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Chapter 1 - The uninsured

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Content Last Updated: 8/26/2008 3:36:40 PM
Graphics Last Updated: 9/30/2013 1:29:14 PM
Note: Terms in green will show glossary definitions when clicked.

Key Facts

  • The number of non-elderly uninsured persons in the U.S. shrank in 2007 to 45 million, down from 46.5 million in 2006. a
  • Gains in Medicaid, particularly, and also in employer-sponsored insurance led to more people with coverage. b
  • Overwhelmingly, the uninsured live in working families, but are not offered health benefits through their jobs.  Uninsured workers tend to work for small businesses and tend to have limited incomes. c

  • Lack of coverage and coverage stability is particularly burdensome on the seriously and chronically ill, whose care is often delayed or denied when they cannot pay. d
  • Another 25 million Americans adults are underinsured, with coverage that is inadequate to secure them access to needed care or protect against catastrophic medical bills. e
  • Although the high cost of health insurance is a leading reason why people lack coverage, many inexpensive insurance policies are for sale.  However, the uninsured may not be eligible for low premiums if they are older or in poor health, and covered benefits under low-cost policies may be limited. f

Tens of millions of Americans lack health insurance, and obtaining and keeping health care coverage in America has been a persistent problem.  While health coverage in most economically developed countries is guaranteed or compulsory, it is a choice for most Americans, though high costs force many to forgo it. Lack of coverage, even for relatively short periods, can have devastating clinical and financial consequences.

Because of factors such as rising health care costs, the impact of shorter job tenure on private coverage and the potential for changes in eligibility requirements for public coverage programs, those who have insurance today may not have it tomorrow. Indeed, the number of non-elderly uninsured grew to 43.9 million during the decade ending in 1998.1

Since then, the number has been up and down. According to the U.S. Census Bureau, 45 million Americans under age 65 lacked insurance for all of 2007, compared to 38.2 million in 2000. 2,3 That means 17.1 percent of under-65 population was uninsured in 2007 vs. 15.5 percent in 2000.4 (There are several different ways to  estimate the number of  uninsured. See the box, “Counting the Uninsured – Not As Easy As 1,2,3,” for a discussion of the subject).

The number of people who gained coverage in 2007 (1.5 million) is almost equal to the number of newly insured Medicaid recipients (1.4 million), underscoring the importance of public programs. 5

Where Do People Get Health Insurance?
Employer-sponsored coverage - Almost 63 percent of nonelderly people in the United States – roughly 165 million workers and their dependents in 2005 – get their coverage through employers.6  Large firms (with 200 or more workers) are most likely to offer health coverage. (Only about half of companies with 3 to 9 employees offered any coverage at all in 2006, compared to 98 percent of large firms.7) Workers in manufacturing and government jobs are more likely than others to be offered health benefits. Higher wage firms are more likely than low wage firms to offer health coverage.  Part-time workers, on the other hand, are less likely to be offered health benefits, and temporary workers are rarely offered health benefits.8  

Public programs – 18.5 percent of the non-elderly had health insurance through government programs in 2007.9 Of these, most (36.3 million according to the Census Bureau) were covered by Medicaid. 10 Medicaid is the safety net program for certain low-income populations: children, pregnant women and parents of dependent children, the elderly and people with disabilities.  The federal government and states jointly finance Medicaid and set program eligibility standards, which vary by covered population. Unless one falls into a coverage category like those mentioned above, he or she is not eligible for Medicaid, no matter how poor.11  (For more information on Medicaid, see Chapter 7.)

The State Children's Health Insurance Program (SCHIP), like Medicaid, offers states federal matching funds to expand health care coverage for children. Most states have elected to cover children in families with incomes up to 200 percent of the poverty line or higher.  For parents, however, the income eligibility standards are usually lower, and vary by state.12  (For more information on SCHIP, see Chapter 4, “Children’s Health Coverage.”) 

Other important public programs that provide health coverage for people under 65 include Medicare, which covers certain eligible persons with disabilities (see Chapter 4 for more information about Medicare); TriCare, which covers members of the U.S. military and their families; veteran’s health care administered by the Department of Veterans Affairs; the Indian Health Service, which delivers care to native Americans; and the Federal Employee Health Benefits Program, which provides care to government employees. (See box, “Major Public Coverage Programs at a Glance.”)

Individual health insurance – The individual (or “non-group”) insurance market may be the only alternative for those who do not have access to employer-sponsored coverage, cannot afford their share of the premium for employment-based coverage, or do not qualify for government programs.

Compared to the number of Americans with employment-based coverage, the individual market is small. About 17 million Americans under age 65 – 6.5 percent of that population – had individually purchased health insurance in 2007.13  One study concluded that more than one in four working-age adults bought or considered buying coverage in the individual market over a three-year period.14 

Health insurance in the individual market is more expensive than employer-sponsored coverage for several reasons.  Almost seven out of 10 people (69 percent) who sought individual coverage in 2001 had difficulty finding a plan they could afford, one survey found.15 Marketing and administrative costs per insured person are much higher for policies sold one-by-one rather than to groups.  In addition, people buying individual coverage must pay the full premium. In contrast, those enrolled in employment-based coverage in 2006 paid an average of 16 percent of the total premium for themselves alone or 27 percent for family coverage, with the remainder covered by the employer.16

Individuals with health problems have an additional disadvantage.  Insurance companies in most states are allowed to engage in "medical underwriting.”  This involves setting the premium based on the likelihood that an applicant will need a large amount of health services. Thus, insurance companies usually charge more to those who are older or in ill health, than to younger, healthier people. Also, insurers are typically allowed to deny or delay coverage for particular conditions. For instance, a person with diabetes might be offered a policy covering all medical needs except diabetes and its complications. Or insurers can simply deny coverage altogether.17 

Who Are the Uninsured?
The 45 million uninsured constituted 17.1 percent of the non-elderly population in 2007.18  (For statistics on all uninsured persons, including those age 65 and older, go to The typical uninsured person is a low-wage adult worker for whom coverage is either unavailable or unaffordable.  Certain social and economic characteristics increase the risk of being uninsured.19  (See chart, “Uninsured Population by Age and Income, 2005.”)

Low income – The risk of being uninsured is much greater among low-income people.  For example, one-third of workers earning less than $20,000 were uninsured in 2004 versus 5.6 percent of workers earning $50,000 or more.20 In 2005, 19 percent of children living below the federal poverty level were uninsured, compared to 9.4 percent of children living above the poverty level.21

Age – Eleven percent of children were uninsured in 2007, compared to 19.6 percent of non-elderly adults, reflecting the relatively greater availability of public coverage (Medicaid and S-CHIP) for infants and children.22  Young adults aged 18-24 are most likely to be uninsured (31 percent) of any age group23 as they lose eligibility under either Medicaid or their parents’ health insurance.24

Ethnicity and Citizenship – Eighty-two percent of the non-elderly uninsured in 2005 were U.S. citizens and 48 percent were white.  However, the risk of being uninsured is far higher for non-citizens and non-whites.  More than one-third of Hispanics and 21 percent of African-Americans were uninsured, compared to 13 percent of whites.  Among non-citizens, 40-50 percent lacked health insurance, due to restrictions in eligibility for public coverage and their frequent employment in low wage jobs without health benefits.

Geography – Rates of uninsurance are highest in some southern and southwestern states.  For example, non-elderly residents of Texas (27 percent), New Mexico (23 percent), Florida (24 percent), Arizona (23 percent) and Louisiana (21.5 percent) disproportionately lacked coverage.  By contrast, coverage rates tend to be higher in New England and Midwestern states, for example, Minnesota (10 percent uninsured), New Hampshire (12 percent) and Vermont (13 percent.)25

Working families – Although having a job lowers the risk of being uninsured, more than 80 percent of the non-elderly uninsured in 2004 were in working families.  Almost 70 percent were in families with one or more full-time worker.26  The vast majority of uninsured workers are not offered health benefits; only 20 percent of uninsured workers are offered and decline coverage, most frequently because they don’t have the money to pay their portion of the insurance premium.27

Getting and Keeping Health Insurance
Many who have health insurance today may lose it tomorrow.  One study found 82 million Americans, or 32 percent of the non-elderly population, were uninsured for at least one month over a two-year period from 2002 - 2003.28  Two-thirds (65.3 percent were uninsured for six months or more during this period).29 

Relatively minor fluctuations in income can cause low-income individuals to cycle in and out of Medicaid eligibility.  Those with incomes above 200 percent of the poverty level may experience lapses in private coverage if job changes lead to employers that don’t offer health benefits; or they may encounter waiting periods of several months or longer before they are eligible for health benefits. 30 

Although federal law, commonly known as COBRA, guarantees many workers the right to remain covered temporarily under their former employer’s health plan if they pay the entire premium, most cannot afford to do so.  (For more information about COBRA continuation coverage, see Chapter 2, "Private Health Coverage".)

On average, about 2 million Americans lose health insurance every month.31  Most remain uninsured for less than one year.32 However, research shows people in poor health are twice as likely to encounter a lengthy spell without health insurance compared to people in good health.33 Health problems may make it more difficult to regain coverage after a person is too sick to work.  In addition, people with serious or chronic health conditions can be discouraged from enrolling in new coverage that imposes pre-existing condition exclusions.34

Why Coverage is Important
Not having health insurance can contribute to serious adverse health consequences, including death. 

  • According to the federally chartered Institute of Medicine, about 18,000 deaths among those aged 25 - 64 in 2002 could have been prevented had these individuals had insurance.35
  • Uninsured people are almost twice as likely as the insured to delay getting needed medical care (15.7 percent vs. 8.6 percent).36
  • Even when they have serious symptoms they think need attention, 30 percent of the uninsured report getting no care, compared with 14 percent of the insured.37
  • Cancer patients who don’t have coverage die sooner than those with insurance, largely because of delayed diagnosis.38
  • Twenty-five percent of adult diabetics who were uninsured for a year or more went two years without a checkup, compared to 5 percent of diabetics with insurance.39

Children without coverage often go without medical care for common childhood illnesses. For example, children with insurance are more than twice as likely to get medical help for recurrent ear aches and nearly twice as likely to get asthma treatment as children lacking coverage.40
Lack of coverage can result in health consequences that extend beyond those who are uninsured.  In 1997, New York experienced a large rubella outbreak which started in an area where several uninsured individuals did not receive rubella vaccinations. Subsequently, surrounding communities also became infected.41

In 2002, an article in the journal Science predicted that the less frequent use of health services by the uninsured could hinder the detection and containment of a bioterrorist attack. The researchers reasoned that because of concerns about the costs of seeking care, or worries about deportation for doing so (among undocumented aliens), uninsured people would delay seeking treatment after contracting an infectious illness in a bioterror incident.  As a result, hospitals and other health care providers would be unaware of the full extent of an outbreak.42

The growing number of uninsured also contributes to overcrowding of emergency rooms and increased uncompensated care.  The burden on emergency rooms has prompted more than 400 to close over the past decade and increased the time all patients must wait, even for lifesaving care.43

Not having insurance also has financial consequences. Many people lacking coverage are living from paycheck to paycheck. When they do go to a doctor, they are asked to pay up front. Some nonprofit hospitals, despite requirements that they provide free or reduced-cost charity care to the indigent, pursue aggressive collection practices against uninsured patients by turning their cases over to bill collectors and demanding full payment.44

The uninsured who seek health care may need years to pay off medical expenses, if they can pay at all.45 A study by The Commonwealth Fund found that almost one in three U.S. adults – an estimated 61 million people – reported having trouble paying medical bills in 2003. Especially vulnerable to such problems were the uninsured, blacks, Hispanics, women, and persons reporting a disability, chronic condition or being in fair or poor health. 46 Families where all members are uninsured are about twice as likely to report medical bill problems as insured families – 23.7 percent for uninsured families compared with 11.4 percent for insured families.47

High medical debt can also increase a person’s risk of bankruptcy. Anywhere from to 27 percent to almost half of bankruptcies have medical debt as a triggering factor, depending on who is surveyed and how survey questions are framed.48

The Underinsured
Having insurance does not always guarantee health security.  One analysis estimates that 16 million Americans are under-insured, with coverage that is inadequate to secure them access to needed care or protect against catastrophic medical bills.49 For example, individual health insurance policies often have substantial gaps, imposing high cost sharing and limiting (or not covering) benefits such as prescription drugs, mental health or maternity care.50 
Coverage under job-based health plans has also eroded somewhat. A growing phenomenon today, for example, are “tiered” copayments, especially for prescription drugs, requiring higher cost sharing for more expensive care. (A copayment is the portion of the person’s medical bill that is not covered by insurance, and thus must be paid out-of-pocket.) This trend has been adopted to encourage cost consciousness among consumers. 

However, among chronically ill individuals who need ongoing care, even modest cost sharing can hinder access to care.  For example, modest copayments can make it difficult for diabetics to access insulin and other medications to manage their diabetes.51 

Increasingly, medical debt is also a problem for the under-insured, especially those with serious health conditions and limited incomes.  Between 2001 and 2003, the proportion of low-income, chronically ill people with private insurance who spent more than 5 percent of their income on out-of-pocket health care costs grew from 28 percent to 42 percent.52

State and federal efforts to reduce Medicaid expenses are also adding to the problem of under-insurance. The Deficit Reduction Act allowed states to replace the standard Medicaid benefits package with so-called “benchmark plans” that resemble commercial insurance. This means some Medicaid beneficiaries have lost coverage for certain benefits they had previously, and some beneficiaries new to Medicaid do not have as broad a benefit package as they would have enjoyed in years past. (See Chapter 6, Medicaid, for more information.)

Even before the DRA was passed, states were cutting back on optional acute care benefits to rein in their expanding Medicaid costs. The number of states reducing Medicaid benefits doubled from nine in FY 2002 to 18 in FY 2003, and climbed again to 19 in FY 2004.53

How Much Does Health Insurance Cost?
The cost of coverage is a key reason why individuals and families are uninsured.  Yet the answer to the question, “What does health insurance cost?” can be difficult to pin down.  On average, employer-sponsored health care in the U.S. cost about $4,000 per individual covered in 2005 and almost $11,000 per family covered.54 Premiums for individual coverage ranged from an annual average of $3,767 for Health Maintenance Organizations (HMOs) to $4,150 for Preferred Provider Organizations (PPOs). Premiums for family coverage range from an annual average of $9,979 for a traditional indemnity plan (this would not include the cost of a deductible) to $11,090.55 Employer-sponsored coverage tends to be comprehensive in the benefits covered, and it tends to pool both high and low cost individuals together.

Individual insurance policies can be purchased in many areas for much less.56  But such low premiums apply to policies that limit coverage for key benefits (such as prescription drugs) and impose high deductibles (for example, $5,000). (A deductible is the amount of money a beneficiary must pay directly to a health care provider before costs are covered by the health plan or insurance company.) In addition, lowest premiums are only offered to young adults in excellent health; premiums for older persons with some health conditions can cost many multiples of the lowest-cost plans. And some states regulate insurance rates more strictly than others.57 

Current Policy Debates and Proposals
Despite rising numbers of uninsured, Washington has not enacted significant legislation to expand coverage since 1996, when the State Children’s Health Insurance Program (SCHIP) was passed. With rising deficits (exacerbated in part by the addition of the expansive new prescription drug benefit to the Medicare program), and public attention focused on war, terrorism and the economy, lawmakers have been reluctant to commit funding to covering the uninsured.

But the uninsured are still on policymakers’ “radar screens.”  A 2003 law, passed as part of the new Medicare drug bill, made it possible for uninsured individuals and families to create health savings accounts (HSAs) for out-of-pocket health expenses. Those opening HSAs receive tax breaks if they also purchase qualified high-deductible health insurance policies.  Proponents argued that such policies would be more affordable for the uninsured, while critics worried that low-income uninsured could not afford to fund such accounts, even with tax subsidies.  (See Chapter 2, "Private Health Coverage", for more information.) 

For several years President Bush has proposed a refundable tax credit for Americans who don’t have insurance. The Treasury Department estimates that the credit would extend insurance to 4.5 million Americans.58

Some critics of the Bush tax credits argue that they don’t do enough to cover the more than 46 million people without insurance. A Commonwealth Fund study found that for all but the youngest and healthiest Americans, premiums cost significantly more than the amount of tax credits proposed.59

The president also supports legislation to enable small employers to form Association Health Plans (AHPs), which would allow firms to create large pools of workers. (For more on AHPs, see Chapter 2, "Private Health Coverage".)

Beyond Washington, some states are taking action.  In 2006, Vermont enacted a voluntary program for the uninsured called “Catamount Health,” which provides sliding scale subsidies for premiums and cost sharing under commercial health insurance plans.  The state estimates as many as 25,000 of 60,000 uninsured Vermont residents may enroll in coverage under this program. If coverage goals are not reached by 2010, the legislature may consider coverage mandates. 60

The state of Massachusetts enacted legislation in 2006 establishing a mandate for individuals to have health insurance.  By mid-2007, the state will require all residents to obtain health insurance or pay a penalty.  New, affordable policies and subsidies will be created to enable compliance with the mandate.  In addition, employers will be required to make a “fair and reasonable” contribution to the cost of coverage for their employees.61

Also in 2006, Maryland enacted legislation that required very large employers to either “pay or play,” meaning that they must provide health coverage worth at least eight percent of payroll or pay a tax to the state to help support Medicaid. After the Maryland legislature overrode a gubernatorial veto, a U.S. District Court struck down the law on grounds that it was preempted by federal law. Nonetheless, similar bills were being discussed in several other states as of September 2006.62

Maine began a new health care initiative, called Dirigo Health, in 2005. The voluntary program seeks to ensure access to health care for all of the state’s 1.3 million residents over a five-year period. The program offers health coverage through private insurers to those without access to employer-sponsored coverage, employees of small businesses who work 15 or more hours per week and self-employed persons, as well as dependents of any of those mentioned. Participating employers pay at least 60 percent of the total premium for their participating workers. For those making less than 300 percent of the federal poverty level, premium charges are on a sliding scale based on ability to pay.63,64

One attempt to have the federal government reinforce state efforts like these was the introduction in May 2006 of legislation to offer federal grants to states that propose new efforts to extend health care to their uninsured residents. The Health Partnership Act of 2006, introduced by Senators Jeff Bingaman (D-N. Mex.) and George Voinovich (R- Ohio), would help states try anything from tax credits like those proposed by President Bush to a single-payer (Canadian-style) plan.65 A companion bill in the House was introduced by two Republicans and two Democrats - Tom Price (R-Ga.), Bob Beaupez (R-Colo.), Tammy Baldwin (D-Wisc.) and John Tierney (D-Mass.).66

Since several polls suggest that health coverage for the uninsured is a major concern to voters, policymakers will most likely continue to focus on the issue. A March 2006 Gallup poll found 68 percent of respondents reporting that they worry about this problem a great deal.67 Asked which one issue would be most important in determining their vote for Congress, respondents in an August 2006 Newsweek poll ranked health care #4, behind Iraq, the economy and terrorism.68 In the 2006 and 2008 election cycles, it is likely to garner considerable interest as constituents demand help with the rising costs of coverage and feel threatened with the prospect of losing coverage altogether.

Story Ideas

  • Hospitals across the country have come under attack for charging full prices to people without insurance while offering substantial discounts to large payors, such as insurance companies. More than 4,200 hospitals nationwide have pledged to offer free or reduced-cost care to the uninsured.  Are hospitals in your area among them?  For a listing, see (search for “statement of principles.”)
  •  Despite improving employment conditions, the number of people who are uninsured has grown. Are they still getting needed medical services? How has this affected local community clinics and emergency rooms and their ability to provide services to all residents?
  •  How do chronically ill individuals navigate health insurance transitions?  What do waiting periods, pre-existing condition exclusions, or other coverage lapses mean for people with diabetes, asthma, or hypertension?  How does health insurance, or lack thereof, affect their ability to manage their health conditions and avoid more serious complications?
  •  What efforts have area businesses made to cover workers or reduce health costs?  Some large employers have joined an initiative to offer low-cost coverage options to low wage and part time workers, at the workers’ expense.  What do these low-cost policies cover?  Are uninsured workers signing up?  How do low-cost coverage options compare to the health benefits of other workers (for example, at your job)?
  •  As states continue to experience hard times, what changes have they made or are they contemplating to Medicaid? Most states have attempted to cut costs by reducing eligibility or benefits, though some have since reversed the cuts as revenues revived. What has your state been doing and how has it affected those with Medicaid coverage – or needing it
  •  Companies across the country have increasingly limited retiree medical benefits. What are people between 55-64 doing to get coverage? Talk with employers who may try to help even if they don’t offer coverage.

Experts and Websites
Altman, Stuart, Professor of National Health Policy, Brandeis University, 781/736-3804
Brandt, Edward, Jr., Regents Professor Emeritus, Dept. of Health Admin. and Policy, Univ. of Oklahoma Health Sciences Center, 405/271-2115 x.37089
Budetti, Peter, Edward E. and Helen T. Bartlett Foundation Professor and Chair, Dept. of Health Administration and Policy, Univ. of Oklahoma Health Sciences Center, 405/271-2114
Burton, Alice, Director, State Coverage Initiatives, 202/292.6700
Butler, Stuart, Vice President, The Heritage Foundation, 202/546-4400
Cannon, Michael, Director of Health Policy Studies, Cato Institute, 202/789-5200
Chockley, Nancy, President and CEO, National Institute for Health Care Management, 202/296-4426
Claxton, Gary, Vice President/Director, Health Care Marketplace Project, Kaiser Family Foundation, 202/347-5270
Colby, David, Acting Vice President for Research and Evalution, Robert Wood Johnson Foundation, 609/627-5754
Cunningham, Peter, Senior Health Researcher, Center for Studying Health System Change, 202/484-4242
Curtis, Richard, President, Institute for Health Policy Solutions, 202/789-1491
Davis, Karen, President, The Commonwealth Fund, 212/606-3853
Dorn, Stan, Senior Research Associate, Urban Institute, 202/833-7200
Doty, Michelle, Associate Director of Research, The Commonwealth Fund, 212/606-3860
Etheredge, Lynn, Consultant, Health Insurance Reform Project, George Washington University, 301/654-4185
Feder, Judy, Professor and Dean, Public Policy Institute, Georgetown University, 202/687-8397
Fronstin, Paul, Senior Research Associate, Employee Benefit Research Institute, 202/775-6352
Ginsburg, Paul, President, Center for Studying Health System Change, 202/484-4699
Guyer, Jocelyn, Senior Program Director, Center for Children and Families, Georgetown University, 202-784-4077
Haislmaier, Edmund, Research Fellow, The Heritage Foundation, 202/546-4400
Hellander, Ida, Executive Director, Physicians for a National Health Program, 312/782-6006
Holahan, John, Director of Health Policy Research, Urban Institute, 202/261-5666
Jones, Judith Miller, Director, National Health Policy Forum, 202/872-1469
Lambrew, Jeanne, Associate Professor of Health Policy, George Washington University, 202/416-0479
Lavizzo-Mourey, Risa, President & CEO, Robert Wood Johnson Foundation, 888/631-9989
Loewenson, Jane, Director of Health Policy, National Partnership for Women and Families, 202/986-2600
Lyons, Barbara, Deputy Director, Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 202/347-5270
McDonough, John, Executive Director, Health Care for All, 617/350-7279 x2911
McLaughlin, Catherine, Director, Economic Research Initiative on the Uninsured, 734/615-9586
Meyer, Jack, Health Management Associates, 202/785-3669
Moffit, Robert, Director, Center for Health Policy Studies, The Heritage Foundation, 202/546-4400
Nichols, Len, Director, Health Policy Program, New America Foundation, 202/986-2700
Pollack, Ron, Executive Director, Families USA, 202/628-3030
Pollitz, Karen, Project Director, Health Policy Institute, Georgetown University, 202/687-3003
Reinhardt, Uwe, James Madison Professor of Political Economy, Princeton University, 609/258-4781
Rosenbaum, Sara, Chair, Department of Health Policy, George Washington University, 202/530-2343
Rowland, Diane, Executive Vice President, Kaiser Family Foundation, 202/347-5270
Salo, Matt, Director, Health & Human Services Committee, National Governors Association, 202/624-5336
Scandlen, Greg, President and CEO, Consumers for Health Care Choices, 301/606-7364
Shearer, Gail, Director, Health Policy Analysis, Consumers Union, 202/462-6262
Sheils, John, Vice President, The Lewin Group, 703/269-5610
Short, Pamela Farley, Professor and Director, Center for Health Care and Policy Research, Penn State University, 814/863-8786
Tallon, James, President, United Hospital Fund, 212/494-0700
Thorpe, Ken, Professor and Chair, Rollins School of Public Health, Emory University, 404/727-3373
Turner, Grace-Marie, President, Galen Institute, 703/299-8900
Weil, Alan, Executive Director, National Academy for State Health Policy, 202/903-0101
Wilensky, Gail, Senior Fellow, Project Hope, 301/656-7401
Wilson, Joy Johnson , Federal Affairs Counsel, National Conference of State Legislatures, 202/624-5400
Zuckerman, Steve, Principal Research Associate, The Urban Institute, 202/833-7200

Baiker, Katherine, President's Council of Economic Advisors, 202/456-5333
Kanof, Marjorie
, Managing Director, Health Care, Government Accountability Office, 202/512-7114
Nelson, Charles, Assistant Division Chief, Income, Poverty and Health Statistics, US Census Bureau, 301/763-3183
Redhead, C. Stephen, Head, Health Services, Research and Aging Policy, Congressional Research Service, 202/707-2261

Abernethy, David, Senior Vice President, HIP Health Plans, 202/393-0660
Grealy, Mary, President, Healthcare Leadership Council, 202/452-8700
Halvorson, George, Chairman and CEO, Kaiser Permanente, 510/271-5660
Hunter, Angela, Director of Federal Affairs, Council for Affordable Health Insurance, 703/836-6200 x387
Kahn, Charles, President, Federation of American Hospitals, 202/624-1500
Keehan, Sister Carol, President, Catholic Health Association, 202/296-3993
Lehnhard, Mary Nell, Senior Vice President, Blue Cross Blue Shield Association, 202/626-4781
Lemieux, Jeff, Senior Vice President, Center for Policy and Research, America's Health Insurance Plans, 202/778-3277
Martin, Robyn, Senior Policy Analyst, Service Employees International Union, 202/730-7359
Mongan, James, President and Chief Executive Officer, Partners Healthcare, 617/278-1004
Schmidt, Christy, Senior Director of Public Policy, American Cancer Society, 202/661-5719
Shea, Gerry, Assistant to the President for Government Affairs, AFL-CIO, 202/637-5237
Trueman, Laura, Executive Director, Coalition for Affordable Health Coverage, 202/626-8573

Alliance for Health Reform
Alliance of Community Health Plans
America's Health Insurance Plans
Blue Cross Blue Shield Association
California HealthCare Foundation
Catholic Health Association
Center for Health Care and Policy Research  Penn State University
Center for Studying Health System Change
Citizen's Health Care Working Group
Coalition for Affordable Health Coverage
The Commonwealth Fund
Consumers for Health Care Choice
Consumers Union
Council for Affordable Health Insurance
Cover the Uninsured Week
Divided We Fail coalition
Economic Research Initiative on the Uninsured
Employee Benefit Research Institute
Families USA
Federation of American Hospitals
Galen Institute
George Washington University Department of Health Policy
Georgetown University Center for Children and Families
Georgetown University Health Policy Institute
Government Accountability Office
Health Coverage Coalition for the Uninsured
Health Research and Educational Trust
Healthcare Leadership Council
The Heritage Foundation
Institute for Health Policy Solutions
Kaiser Commission on Medicaid and the Uninsured
Kaiser Family Foundation
The Lewin Group
National Academy for State Health Policy
National Coalition on Health Care
National Conference of State Legislatures
National Governors Association
National Health Policy Forum
National Institute for Health Care Management
National Partnership for Women and Families
National Women's Law Center
New America Foundation
Project HOPE
Robert Wood Johnson Foundation
Rollins School of Public Health    Emory University
State Coverage Initiatives
United Hospital Fund
Urban Institute
U.S. Census Bureau

a  U.S. Census Bureau (2008). "Table HIA-6.  Health Insurance Coverage Status and Type of Coverage by State -- Persons Under 65: 1999 to 2007." August 26. (
b U.S. Census Bureau (2008). "Table HIA-6.  Health Insurance Coverage Status and Type of Coverage by State -- Persons Under 65: 1999 to 2007." August 26. (
c  "The Uninsured: A Primer -- Key Facts About Americans Without Health Insurance," Kaiser Commission on Medicaid and the Uninsured, January 2006."(
d Pollitz, Karen, et al. (2005) "Health Insurance and Diabetes: The Lack of Available, Affordable, Adequate Coverage," Clinical Diabetes 23:88-90.
e  Schoen, Cathy, et al. (2008) "How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007." June 10. (
f  See, for example,  Request a quote for a 22-year-old male, and compare a quote for a 52-year-old man.

1  U.S. Census Bureau (2006). “Table HI-6.  Health Insurance Coverage Status and Type of Coverage by State --People Under 65: 1987 to 2005.” August 31. (
2 U.S. Census Bureau (2008). "Table HIA-6.  Health Insurance Coverage Status and Type of Coverage by State -- Persons Under 65: 1999 to 2007." August 26. (
3  There were 32.4 million uninsured individuals under age 65 in 1988 according to the Current Population Survey (CPS). The CPS methodology was changed in 1988, making comparisons between years before and after this change misleading.  It again revised its methodology in 1999 by adding a question asking respondents to clarify that they had been uninsured for the entire calendar year and not just a portion of the year.  This change in methodology resulted in a somewhat lower figure than would be expected under the pre-1999 methodology.  As a result, it is not possible using CPS data to make completely accurate year to year comparisons between years prior to 1999 and years after that. Comparisons between recent years and years prior to 1988 will considerably overstate the increase in the number of uninsured that has occurred since 1988. See Marc C. Berger, et al., Small Business Research Summary, United States Small Business Administration, 1994. ( downloaded August 7 2006. See also Moyer, Eugene (1989). “A revised look at the number of uninsured Americans.” Health Affairs, Summer. (
4  U.S. Census Bureau (2008). "Table HIA-6.  Health Insurance Coverage Status and Type of Coverage by State -- Persons Under 65: 1999 to 2007." August 26. (
5  U.S. Census Bureau (2008). "Table HIA-6.  Health Insurance Coverage Status and Type of Coverage by State -- Persons Under 65: 1999 to 2007." August 26. (
6  U.S. Census Bureau (2006). “Table HI-6.  Health Insurance Coverage Status and Type of Coverage by State --People Under 65: 1987 to 2005.” August 31. (
7  Kaiser Family Foundation and Health Research and Educational Trust (2006). "Employer Health Benefits: 2006 Annual Survey." Exhibit 2.2. (
8  Kaiser Family Foundation and Health Research and Educational Trust (2005). “Employer Health Benefits 2005.” ( Retrieved on March 17, 2006.
9  U.S. Census Bureau (2008). "Table HIA-6.  Health Insurance Coverage Status and Type of Coverage by State -- Persons Under 65: 1999 to 2007." August 26. (
10  U.S. Census Bureau (2008). "Table HIA-6.  Health Insurance Coverage Status and Type of Coverage by State -- Persons Under 65: 1999 to 2007." August 26. (
11  Kaiser Commission on Medicaid and the Uninsured (2002). “The Medicaid Resource Book.” July, p. 6. ( Retrieved on August 10, 2006.
12  Kaiser Family Foundation “State Health Facts,” at, Retrieved on March 17, 2006.
13 U.S. Census Bureau (2008). "Table HIA-6.  Health Insurance Coverage Status and Type of Coverage by State -- Persons Under 65: 1999 to 2007." August 26. (
14  Duchon, Lisa & Cathy Schoen (2001). “Experience of working-age adults in the individual insurance market: Findings from the Commonwealth Fund 2001 Health Insurance Survey” (Issue Brief No. 514). The Commonwealth Fund, December, p.1. ( Retrieved April 28, 2004.
15  Duchon, Lisa & Cathy Schoen (2001). “Experiences of working-age adults in the individual insurance market: Findings from the Commonwealth Fund 2001 Health Insurance Survey” (Issue Brief No. 514). The Commonwealth Fund, December, p.1. (  Retrieved April 28, 2006.
16  Kaiser Family Foundation and Health Research and Educational Trust (2006). "Employer Health Benefits: 2006 Annual Survey." Exhibit 6.1 (
17 Pollitz, Karen, Richard Sorian, & Kathy Thomas (2001). “How Accessible is Individual Health Insurance for Consumers in Less-Than-Perfect Health?” (Publication No. 3133). The Kaiser Family Foundation, June 20, p.2. ( Retrieved April 28, 2004.
18 U.S. Census Bureau (2008). "Table HIA-6.  Health Insurance Coverage Status and Type of Coverage by State -- Persons Under 65: 1999 to 2007." August 26. (
19 “The Uninsured: A Primer  Key Facts About Americans Without Health Insurance,” Kaiser Commission on Medicaid and the Uninsured, January 2006. ( Retrieved on March 10, 2006. See also Census Bureau, Historical Tables, 
20 Fronstin, Paul, “Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2005 Current Population Survey,” Employee Benefits Research Institute Issue Brief No. 287, November 2005 ( Retrieved on March 17, 2006..
21 Alliance for Health Reform analysis based on: U.S. Census Bureau (2006). “Table HI-9. Health Insurance Coverage Status for Children Under 18 in Poverty:  1987 to 2005.” August 31. (
22 Alliance for Health Reform analysis based on: U.S. Census Bureau (2008). Table HI-5.  Health Insurance Coverage Status and Type of Coverage by State -- Children Under 18: 1987 to 2005.” August 31. ( And U.S. Census Bureau (2006). “Table HI-6.  Health Insurance Coverage Status and Type of Coverage by State --People Under 65: 1987 to 2005.” August 31. (
23 U.S. Census Bureau (2006). “People With and Without Health Insurance Coverage by Selected Characteristics: 2004 and 2005.” August 31. (
24 Collins, Sara,, “Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help,” The Commonwealth Fund, Updated May 4, 2006 ( Retrieved on March 19, 2006.
25 U.S. Census Bureau (2006). “Table HI-6.  Health Insurance Coverage Status and Type of Coverage by State --People Under 65: 1987 to 2005.” August 31. (
26 “The Uninsured: A Primer  Key Facts About Americans Without Health Insurance,” Kaiser Commission on Medicaid and the Uninsured, January 2006.P. 4. ( Retrieved on March 10, 2006.
27 “The Uninsured: A Primer  Key Facts About Americans Without Health Insurance,” Kaiser Commission on Medicaid and the Uninsured, January 2006. ( Retrieved on March 10, 2006.
28 Families USA (2004). “One in Three: Non-Elderly Americans Without Health Insurance, 2002 – 2003.” June. P. 1. (
29 Families USA (2004). “One in Three: Non-Elderly Americans Without Health Insurance, 2002 – 2003.” June. P. 1. (
30 Farley Short, Pamela and Graefe, Deborah, “Battery-Powered Health Insurance? Stability In Coverage of the Uninsured,” Health Affairs, Vol. 22, No. 6, November/December 2003.
31 Farley Short, Pamela, et al., “Churn, Churn, Churn: How Instability of Health Insurance Shapes America’s Uninsured Problem.” (pub. no. 688) New York. Commonwealth Fund, 2003. 
32 Copeland, Craig, “Characteristics of the Nonelderly with Selected Sources of Health Insurance and Lengths of Uninsured Spells,” EBRI Issue Brief no. 198, Employee Benefits Research Institute, June 1998.
33 Haley, J. and Zuckerman, S. “Is Lack of Coverage a Short- or Long-Term Condition?” Kaiser Commission on Medicaid and the Uninsured, August 2003.
34 Pollitz, Karen,, “Health Insurance and Diabetes: The Lack of Available, Affordable, Adequate Coverage,” Clinical Diabetes 23:88-90, 2005
35 Institute of Medicine. (2002). “Care Without Coverage: Too Little, Too Late.” Table D.1, p. 163. ( Retrieved April 27, 2006.
36 Strunk, Bradley C. & Peter J. Cunningham. (2002). “Treading Water: Americans’ Access to Needed Medical Care, 1997-2001.” (Tracking Report No. 1). Center for Studying Health System Change. ( Retrieved March 18, 2006.
37  Baker, David W. et. al. (2000). “Health Insurance and Access to Care for Symptomatic Conditions.” Archives of Internal Medicine, Vol. 160, May 8, p. 1271.
38 Institute of Medicine. (2002). “Care Without Coverage: Too Little, Too Late.” p. 52. ( Retrieved April 27, 2006.
39 Institute of Medicine. (2002). “Care Without Coverage: Too Little, Too Late” D.1, p. 10. ( Retrieved April 27, 2006.
40 American College of Physicians-American Society of Internal Medicine (ACP-ASIM). (2000). “No Health Insurance? It’s Enough to Make You Sick.” (White Paper). p. 2. ( Retrieved April 14, 2006.
41 Schlosberg, Claudia & Dinah Wiley. (1998). “The Impact of INS Public Charge Determinations on Immigrant Access to Health Care.” National Health Law Program. ( Retrieved Nov. 22, 2002.
42 Wynia, Matthew K. & Lawrence Gostin. (2002). “The Bioterrorist Threat and Access to Health Care.” Science, 296:1613.
43 Institute of Medicine.  “Hospital-Based Emergency Care: At the Breaking Point.” June 14, 2006 ( Retrieved June 20, 2006.
44 “Not There When You Need It: The Search for Free Hospital Care,” Community Catalyst, Inc., October 2003, available at
45 “The Consequences of Medical Debt: Evidence from Three Communities,” The Access Project, February 2003, available at
46 Doty, Michelle M. et al. (2005). “Seeing Red: Americans Driven in Debt by Medical Bills.” The Commmonwealth Fund. August. (
47 May, Jessica H. & Peter J. Cunningham. (2004) “Tough Trade-offs: Medical Bills, Family Finances and Access to Care.” (Issue Brief 85). Center for Studying Health System Change. ( Retrieved March 14, 2006.
48 Mathur, Aparna (2006). “Medical bills and bankruptcy filings.” American Enterprise Institute. July 19. (
49 Schoen, Cathy, et. al. “Insured But Not Protected: How Many Adults Are Underinsured?” Health Affairs Web Exclusive, June 14, 2005.
50 Gabel, Jon, et. al., “Individual Insurance: How Much Financial Protection Does It Provide?” Health Affairs Web Exclusive, April 17, 2002
51 Goldman, D., et. al., “Pharmacy Benefits and the Use of Drugs by the Chronically Ill,” JAMA, Volume 291, Number 19, 19 May 19 2004, 2344: 2344–2350.
52 Tu, Ha, “Rising Health Costs, Medical Debt and Chronic Conditions” Center for Studying Health System Change Issue Brief No. 88. September, 2004. ( Retrieved June 20, 2006.
53 Smith, Vernon et al. (2004). “The Continuing Medicaid Budget Challenge: State Medicaid Spending Growth and Cost Containment in Fiscal Years 2004 and 2005: Results of a 50-State Survey.” Health Management Associates and Kaiser Commission on Medicaid and the Uninsured.” October. P. 3, Figure 2. (
54 Kaiser Family Foundation and Health Research and Educational Trust (2005). “Employer Health Benefits 2005.” Chart 4. (
55 Kaiser Family Foundation and Health Research and Educational Trust (2005). “Employer Health Benefits 2005.” Chart 4. (
56 For some representative prices, go to
57 Mila Kofman and Karen Pollitz, “Health Insurance Regulation by States and the Federal Government: A Review of Current Approaches and Proposals for Change,” Georgetown University, Health Policy Institute, April 2006
58 Bush, George W., “State of the Union Address by the President,” January 31, 2006. ( Retrieved June 20, 2006.
59 Gabel, Jon R., Kelley Dhont, & Jeremy Pickreign. (2002). "Are Tax Credits Alone the Solution to Affordable Health Insurance?: Comparing Individual and Group Insurance Costs in 17 U.S. Markets." (Report No. 527). The Commonwealth Fund, May. p. 6-8. ( Retrieved Sept. 11, 2006.
60 “Vermont Moves Toward Universal Coverage,” StateSide newsletter, May 26, 2006. ( Retrieved June 20, 2006.
61 “Massachusetts Passes Landmark Bill,” StateSide newsletter, April 18, 2006. ( Retrieved June 20, 2006.
62 Laborers’ Health and Safety Fund of North America (2006). “Maryland ‘Wal-Mart’ Law Overruled by Court.” (
63 “Profiles in Coverage: Maine Dirigo” State Coverage Initiatives Newsletter, May 2005. ( Retrieved March 20, 2006.
64 Wallack, Victoria “Higher Private Insurance Rates Needed to Cover Dirigo Subsidy” The Lincoln County News, March 20, 2006. ( Retrieved March 20, 2006.
65 “Voinovich, Bingaman Introduce Legislation Aimed at Insuring the Uninsured,” press release from Senator Voinovich, May 9, 2006. (
66 “Baldwin Authors Bipartisan Health Care Bill” (2006). News release from Office of Rep. Tammy Baldwin. July 25. (
67 Gallup Poll. March 13-16, 2006. Polling (  downloaded August 2006.)
68 NBC/Wall Street Journal. Polling ( Retrieved  Aug. 3, 2006.

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Graphics for This Chapter

Uninsured Population by Age and Income, 2005

Number of Non-Elderly Uninsured Americans, 2000 - 2005 (Age<65)

Sources of Health Coverage in the U.S. (Age < 65)


2006 HHS Poverty Guidelines

Counting the Uninsured-Not as Easy as 1, 2, 3

Major Public Coverage Programs at a Glance

2013 Businessman's Regatta V6 Waiver


This sourcebook for journalists was made possible with the support of the Robert Wood Johnson Foundation.

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