By Baldeep Singh, MD, and Rachel Golden, PhD
Commentary
The American Journal of Medicine
February 2006
Despite recent attempts by federal programs to increase access to medical care for uninsured persons, the number
of Americans without insurance has increased since 1994 by an average of one million per year, and 2.4 million in
2002. By 2002, 43 million Americans were uninsured, comprising 17.3% of the nonelderly population (Kaiser
Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000). Even this number may
underestimate the extent of the problem; recent data from the Kaiser Commission found that approximately 30% of
Americans, more than 70 million people, lacked health care for at least 1 month over a 3-year period (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).1
Many Americans have lost coverage throughout the past decade because of the increasing cost of health insurance, which has resulted in larger costs to individuals for premiums and co-pays, and decreased availability of employer-based health insurance.1 For example, in a study by Cooper et al.2 in 1997, two-thirds of those without employer-based insurance cited the high cost of health insurance plans as the main reason they were not covered. Similarly, despite the robust economy of the late 1990s, an increasing percentage of companies cited the high cost of health care plans as the main reason they were dropping medical coverage for or shifting costs to their employees (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).
During the past decade, the U.S. Congress has passed regulatory reforms and enacted new programs in an attempt to increase opportunities for Americans to obtain and maintain health insurance coverage. Two incremental reforms in private health insurance regulation, the Consolidated Omnibus Reconciliation Act and the Health Insurance Portability and Accountability Act, were legislated to increase opportunities for Americans to maintain their insurance coverage, but these regulations have not stopped the numbers of uninsured Americans from continuing to increase. In the public sector, large increases in Medicaid eligibility over the past two decades, as well as the enactment of the State Children痴 Health Insurance Program in 1997, were designed to increase eligibility for public programs, but have also failed to decrease the number of uninsured patients in the United States (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).
The uninsured tend to be young, working poor, minority families. They tend to have worse health, and when they do become ill, have worse outcomes. This article identifies important demographic trends among the uninsured and explores the barriers they face in getting and keeping health care coverage. More importantly, these barriers significantly affect health outcomes and reveal a growing divide in health care access that is affecting the nation痴 health as a whole.
COVERAGE BY TYPE OF HEALTH INSURANCE
In 2002, the uninsured represented 17.3% of the nonelderly, American population. Because almost everyone 65 years of age or more has Medicare, children and adults aged less than 65 years of age make up the majority of the uninsured. Among insured Americans aged less than 65 years of age, employment-based health insurance covers 63.3%, Medicaid covers 12%, and Medicare covers 2%.1
There is a common misperception that the Medicaid program provides health coverage for all low-income Americans, when, in fact, its policy toward low-income adults is quite restrictive. Although the program covers many low-income children, there are only a few eligibility pathways for adults, aside from being significantly disabled or pregnant預nd those that do exist are primarily limited to single parents with very low incomes. Parents working full-time at the minimum wage, for example, are not eligible for Medicaid in the majority of states (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000). Even if one does qualify for Medicaid, strict eligibility makes coverage difficult to keep. At the end of any given year, two-thirds of those who were insured by Medicaid will have lost their coverage.3 The federal welfare reforms enacted in 1996 have affected the Medicaid enrollment process and have been associated with decreases in Medicaid coverage. In addition, these reforms have served to increase the number of uninsured because those leaving welfare move into the workforce to take low-wage positions for which health benefits are less likely to be offered or affordable.
For individuals who are self-employed, work in small companies, or have opted out of their employer痴 health insurance plans, the alternative is private, nongroup insurance. However, private, nongroup insurance covers only 5.3% of the population. The major reason there are not more enrollees is the relatively high cost of such plans compared to family income. For example, the maximum income of families at 200% of the 2004 federal poverty level was $37 700 for a family of 4, whereas the full premium for this family averaged more than $7000 per year. Thus for low-income families, comprising twothirds of the uninsured, premiums remain out of reach.3 Furthermore, workers who have health insurance typically pay one-quarter to one-third of the total cost of family coverage premiums.
COVERAGE BY AGE
Young adults, 19 to 34 years of age, comprise just a quarter of the nonelderly population, but represent 40% of the uninsured.1 Young adults are at higher risk of being uninsured because they are less likely to be married and therefore have only themselves as a link to job-based health benefits. They also earn lower incomes on average and are usually not eligible for Medicaid. Three million young adults are uninsured because they decline to purchase available health insurance because of high premiums and co-pays. But, 11 million young workers are uninsured because their employers do not offer health insurance, and they cannot afford to purchase coverage elsewhere.2 This latter group comprised 75% of the growth in the number of uninsured in recent years (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).
More than half of the uninsured come from families with children, and 1 in 5 of the uninsured is a child. Thanks to recent expansions in Medicaid and the State Children痴 Health Insurance Program, the percentage of children who are uninsured has not increased for the last 3 years. Nevertheless, 10 million children less than 18 years of age in the United States do not have medical insurance even though it is estimated that 95% of them are eligible for public insurance.7 In general, eligible children are more likely to be enrolled in public programs if the rest of the family has coverage. In particular, the insurance status of parents seems to affect whether their children receive care, as well as how much, even if the children have coverage (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).
COVERAGE BY INCOME
In 2002, 27% of the uninsured were from families with incomes below the Federal Poverty Level ($14 348 for a family of 3), 39% had family incomes between 100% and 200% of the Federal Poverty Level, and the remaining 36% of the uninsured were from families with higher incomes. This third group represents the fastest growing segment of the uninsured over the past 3 years.1 Nonetheless, approximately one-third of all members of families living at or below 200% of the Federal Poverty Level, are uninsured, placing an undue burden on this segment of the population as a whole.
Workers with lower incomes are offered employmentbased insurance plans much less often than those with middle to upper incomes. Only 55% of workers whose hourly rate is less than $7 are offered health insurance through their own or a family member痴 job, compared with 96% of workers whose hourly rate is more than $15. 9
COVERAGE BY EMPLOYMENT STATUS
It is a myth that most of the uninsured are unemployed. In fact, 80% of uninsured children and adults less than 65 years of age live in working families. Even members of families with two full-time workers have a 1 in 10 chance of being uninsured.3 Only 19% of the uninsured live in families with just part-time workers or no member working outside the home.1 Nonetheless, members of families without wage earners are much more likely to be uninsured than members of families with wage earners.
Low-wage workers have born the brunt of higher premiums and cost sharing. Thirty-two percent of all low-wage families are not offered health insurance by their employers.10 In fact, rates of employer-sponsored coverage among low-wage workers (making $7/hour) decreased between 1987 and 2000, whereas rates of coverage for high-wage workers actually increased. In fact, 96% of higher-wage workers were offered employerrelated health benefits, and 90% were insured by an employer-sponsored plan.
The highest rate of uninsured workers is found among employees in small firms (25 workers) or self-employed. Thirty-five percent of workers in small firms are uninsured, compared with only 13% in large firms of 100 employees or more.1 However, regardless of firm size, the chances of having job-based coverage are less for those with lower incomes, even for those employees who are full-time.
Blue-collar workers constitute 63% of the work force in the United States, but they represent 81% of the uninsured. This is because they are less likely than white-collar workers to be offered health insurance as a benefit.1
When employers do offer insurance plans, the cost of these programs places a disproportionate burden on low-wage workers. The expense of insurance premiums paid by employees tops the list of reasons why uninsured workers decline to take employment-based insurance when it is offered.11 In 1995, the proportion of workers who paid more than 10% of their family income for health care expenditures increased to 33%.12
COVERAGE BY RACE, ETHNICITY, AND GENDER
Although racial minorities formed one-third of the nonelderly population, they comprised more than half of the uninsured. More than one-third of Latinos are uninsured, and a quarter of both African Americans and Native Americans have no health coverage. African Americans are twice as likely and Latinos are 3 times as likely as non-Hispanic whites to be uninsured.13 The differences in health coverage across racial and ethnic groups are only partially explained by differences in income. Two other factors are evident here. Minority groups are less likely, on average, than non-Hispanic whites to hold jobs that offer health insurance, and they are less able to afford workplace insurance coverage when it is available.
Gender disparities in health coverage are also evident. Adult men are more likely than women to be uninsured. Conversely, women have lower rates of employmentbased coverage. Women are more likely to obtain insurance policies through individual and public programs, usually when they are lower-income and pregnant or with young children. Women with public insurance status, however, tend to have greater instability in their health coverage, providing more opportunities for gaps in coverage.14
COVERAGE BY COUNTRY OF ORIGIN AND IMMIGRATION STATUS
US citizens make up the majority of the uninsured. Although public opinion polls suggest that Americans think most of the uninsured are noncitizens, in fact, noncitizens comprise only 20% of the total uninsured patients. However, this group is at the highest risk (45%) of being uninsured, and immigrant uninsured rates decline with increasing length of residency in the United States.3,15
Recent immigrants are 3 times as likely as members of the general population to be uninsured, but they only comprise 6% of the total uninsured. Disparities in the uninsured rates between immigrants and native-born US residents reflect the lower rates of employer-based coverage among immigrants, as well as their likelihood of employment in lower-waged positions.16 Compounding the problem for immigrants, since 1996, federal welfare and immigration reform legislation have banned legal immigrants arriving after 1996 from eligibility for Medicaid, The State Children痴 Health Insurance Program, and other federal means-tested benefits programs. Except for emergency care, immigrants are not eligible for coverage through these programs during their first 5 years in the United States.17
COVERAGE BY GEOGRAPHIC LOCATION
More than 20% of the nonelderly uninsured population reside in the southwest and south central states, where poverty rates are higher and rates of employer-sponsored coverage are lower than the national average. The amount a state provides in assistance to the uninsured depends on the proportion of families with low incomes, the structure of the state痴 unemployment benefits, and the inclusiveness of the state痴 Medicaid programs. A threefold difference exists between the states with the lowest (9%) and highest (27%) rates of uninsured. Reflecting the predominantly urban locations of the general population, most uninsured persons live in urban areas, although rural and urban residents are equally likely to be uninsured.15
DOES COVERAGE AFFECT MEDICAL OUTCOMES?
There is an association among health insurance coverage, access to health care, and patient outcomes. Although 57% of the public reported they believe that those without health insurance are able to get the care they need, one survey found that the uninsured were less than half as likely as those with insurance to receive medical care for a serious medical condition, as judged by physicians.18
The most important prerequisite for access to care is health insurance coverage. Without it, most people cannot afford medical care. They are more likely to postpone or go without necessary treatment for fear of high medical bills.19 In fact, uninsured adults are at least four times as likely as the insured to report delaying or foregoing needed health services.
Growing evidence from large observational studies reveals the staggering effects of insurance status on general health outcomes. The uninsured poor, for example, are more likely to delay hospitalization compared with those with private health insurance, and when in the hospital, uninsured patients stay longer and experience higher death rates. In addition, hospitalized uninsured patients are 2.3 times more likely than those with insurance to have adverse iatrogenic events.20,21 Uninsured patients are twice as likely to die over 15 years compared with insured patients (18.4% vs 9.6%); even after adjusting for major health risk factors, mortality remains 25% higher among the uninsured.22
The effects of poor access to care for the uninsured are particularly striking for diseases which require early detection. The uninsured receive fewer preventive services such as blood pressure checks, mammograms, and screening for colorectal cancer.2 For example, the loss of Medicaid coverage has been associated with a 10-point increase in diastolic blood pressure and a 15% increase in the hemoglobin A1C in diabetic patients. This has translated into a higher probability of death over 6 months.21 In addition, because regular preventive care is not received, the uninsured are more likely to be diagnosed at advanced stages of cancer. Greater than 40% of uninsured women are more likely to be diagnosed with latestage breast cancer, and 40% to 50% are more likely to
die of breast cancer, compared with insured women, depending on their age.23
In the case of acute care, outcomes are consistently worse for uninsured patients. Among patients with appendicitis, for example, uninsured individuals were 1.5 times more likely than insured patients to present with an
appediceal rupture.24
CONCLUSION
The problem of the uninsured in the United States is rapidly becoming a crisis, affecting a broader crosssection of society with each passing year. Growth in the numbers of uninsured Americans has continued annually for over the past decade, and currently more than 17% of the nonelderly population are uninsured. The poor and members of certain minority groups have historically been excluded by a system of voluntary health insurance in the United States. However, contrary to public perception, most Americans without health insurance today are members of working families and are U.S. citizens. The crisis of the uninsured has increasingly become a problem that reaches all racial, ethnic, and socioeconomic groups, and across a wide spectrum of occupations. Despite recent attempts to improve pediatric insurance coverage, children remain 20% of the total uninsured population.
The uninsured are battling both the decreasing affordability and availability of private health insurance, as well as the increasing restrictions on public health insurance programs. Despite an improved economy, obtaining low-cost health care when needed is becoming more difficult for the uninsured. Fewer employers cover their workers because of the increasing cost of health care, and fewer people can afford to pay. The high cost of private insurance plans themselves clearly affects access to medical services in that fewer people can afford health insurance. In addition, the increasing level of out-of-pocket costs for premiums and co-pays reduces usage of health care services.25,26 Governmental reforms to increase private and public health insurance have made little impact, and in some cases have made the problem worse. Thus, the gap between the increasing cost of health care and the reduced purchasing power of those trying to access health care seems to be the biggest factor in this national crisis.
Furthermore, the uninsured are more likely to have poorer health outcomes than those with health insurance. The high cost of care causes many uninsured people to postpone or forego necessary treatment. As a group, the uninsured are having their diseases detected later, and their morbidity and mortality are higher.
Whether or not one has health insurance affects job decisions, financial security, access to care, and health status. But lack of insurance and gaps in coverage affect all of society. When an uninsured person goes to a public hospital or clinic, an emergency department, or a private physician for care and cannot pay the full cost, some of the bill is passed on to those who do pay, through higher insurance premiums and in the form of taxes supporting our public medical insurance programs. We all pay for having a large and growing uninsured population.
Americans have boasted for years that we have the best health care in the world, but if this is true, it is the case only for those with health insurance. In fact, the clear relationship between insurance status and health outcomes should be considered a national emergency. If access to medical care and health care coverage correlates with improved clinical outcomes, where is the cry from the medical profession to increase both of these? If doctors are entrusted with improving the health care of our patients, we must be at the forefront of moving legislation toward increasing the coverage of all our citizens, thereby increasing the overall health of our nation.4-6,8
Baldeep Singh, MD
UCLA Department of General Internal Medicine
Los Angeles, Calif.
Rachel Golden, DrPh
South Los Angeles Health Projects
Los Angeles Biomedical Research
Institute at Harbor-UCLA
Medical Center, Calif.
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