INSURANCE

The term uninsured in the United States is most commonly used to refer residents of the United States who do not have health insurance coverage. In 2007, there were 45.7 million people in the US (15.3% of the population) who were without health insurance for at least part of that year, according to the United States Census Bureau. The percentage of the non-elderly population who are uninsured has been generally increasing since the year 2000. However, the 2007 figures were down slightly from the previous year, because 3 million more people received coverage under government programs.

The causes of this rate of uninsurance remain a matter of political debate. Rising insurance costs have contributed to a trend in which fewer employers are offering health insurance, and many employers are managing costs by requiring higher employee contributions. Many of the uninsured are the working poor or are unemployed. Others are healthy and choose to go without it. Some have been rejected by insurance companies and are considered "uninsurable." Some are without health insurance only temporarily.

The number of uninsured Americans is one of the primary concerns raised by advocates of health care reform in the United States.

The US Census Bureau annually reports statistics on the uninsured. According to its most recent figures, in 2007, nearly 37 million of the uninsured were employment-age adults (ages 18 to 64), and more than 27 million worked at least part time. Approximately 61% of the roughly 45 million uninsured live in households with incomes under $50,000 (13.5 million below $25,000 and 14.5 million at $25,000 to $49,000). And 38% live in households with incomes of $50,000 or more (8.5 million at $50,000 to $74,999 and 9.1 million at $75,000 or more.

According to the Census Bureau, people of Hispanic origin were the most affected by being uninsured; nearly a third of Hispanics lack health insurance. However, this rate decreased slightly from 2006 to 2007, from 15.3 to 14.8 million, a decrease of 2 percentage points (34.1% to 32.1%). The state with the highest percentage of uninsured was Texas (24.1% average for three years, 2004-2006). New Mexico has the second highest percentage of residents without health insurance at 22%.

It has been estimated that nearly one fifth of the uninsured population is able to afford insurance, almost one quarter is eligible for public coverage, and the remaining 56% need financial assistance (8.9% of all Americans). An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions. A recent study concluded that 15% of people shopping online for health insurance are considered "uninsurable" because of a pre-existing condition, or for being overweight. This label does not necessarily mean they can never get health insurance, but that they will not qualify for standard individual coverage. People with similar health status can be covered via employer-provided health insurance, Medicare, or Medicaid.

According to the Census Bureau, in 2007, there were 8.1 million uninsured children in the US. Nearly 8 million young adults (those aged 18-24), were uninsured, representing 28.1% of their population. Young adults make up the largest age segment of the uninsured, are the most likely to be uninsured, and are one of the fastest growing segments of the uninsured population. They often lose coverage under their parents' health insurance policies or public programs when they reach age 19. Others lose coverage when they graduate from college. Many young adults do not have the kind of stable employment that would provide ongoing access to health insurance.

Non-citizens are more likely to be uninsured than citizens, with a 43.8% uninsured rate. This is attributable to a higher likelihood of working in a low-wage job that does not offer health benefits, and restrictions on eligibility for public programs. However, most of the uninsured in the US are citizens (78%). The longer a non-citizen immigrant has been in the country, the less likely they are to be uninsured. In 2006, roughly 27% of immigrants entering the country before 1970 were uninsured, compared to 45% of immigrants entering the country in the 1980s and 49% of those entering between 2000 and 2006. Most uninsured non-citizens are recent immigrants; almost half entered the country between 2000 and 2006, and 36% entered during the 1990s. Foreign-born non-citizens accounted for over 40% of the increase in the uninsured between 1990 and 1998, and over 90% of the increase between 1998 and 2003. One reason for the acceleration after 1998 may be restrictions imposed by the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996. Almost six out of ten (68%) of uninsured non-citizens live in California, Texas, Florida, or New York.

A report by the Kaiser Family Foundation in April 2008 found that US economic downturns place a significant strain on state Medicaid and SCHIP programs. The authors estimated that a 1% increase in the unemployment rate increase Medicaid and SCHIP enrollment by 1 million, and increase the number uninsured by 1.1 million. State spending on Medicaid and SCHIP would increase by $1.4 billion (total spending on these programs would increase by $3.4 billion). This increased spending would occur while state government revenues were declining. During the last downturn, the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal assistance to states, which helped states avoid tightening their Medicaid and SCHIP eligibility rules. The authors conclude that Congress should consider similar relief for the current economic downturn.

Americans who are uninsured may be so because: their job does not offer insurance; they are unemployed and cannot pay for insurance; or they may be financially able to buy insurance but may decide to take chances and see what happens without having health coverage.

Low-income workers are less likely than higher income individuals to offered coverage by their employer (or by their spouse's employer), and less able to afford buying it on their own. Even the very poorest adults generally do not qualify for Medicaid if they do not have children.

Historically, most working Americans have received their health insurance from their employer. However, recent trends have shown an ongoing decline in employer-sponsored health insurance benefits. In 2000, 68 percent of small companies with 3 to 199 workers offered health benefits. Since that time, that number has continued to drop to 2007, when 59 percent offered health benefits. For large firms with 200 or more workers, in 2000, 99 percent of employers offered health benefits, and in 2007, that number stayed the same at 99 percent. On average, considering firms of all numbers of employees, in 2000, 69 percent offered health insurance, and that number has fallen nearly every year since, to 2007, when 60 percent of employers offered health insurance.

One study published in 2008 found that people of average health are least likely to become uninsured if they have large group health coverage, more likely to become uninsured if they have small group coverage, and most likely to become uninsured if they have individual health insurance. But, "for people in poor or fair health, the chances of losing coverage are much greater for people who had small-group insurance than for those who had individual insurance." The authors attribute these results to the combination in the individual market of high costs and guaranteed renewability of coverage. Individual coverage costs more if it is purchased after a person becomes unhealthy, but "provides better protection (compared to group insurance) against high premiums for already individually insured people who become high risk." Healthy individuals are more likely to drop individual coverage than less-expensive, subsidized employment-based coverage, but group coverage leaves them "more vulnerable to dropping or losing any and all coverage than does individual insurance" if they become seriously ill.

To strive to properly care for their health while being uninsured, people turn to a variety of resources. This includes: community or nonprofit hospitals or health clinics that charge no or reduced prices for health treatment; asking their health provider for a reduced fee for their healthcare services; turning to medical facilities, pharmacies and hospitals abroad that may charge considerably less than U.S. rates for healthcare; or, going without care altogether.

Additionally, being uninsured impacts American consumers' health in a tangible way, according to a 2008 survey:

• More of the uninsured chose not to see a doctor when were sick or hurt (53 percent) vs 46 percent of the insured.
• Fewer of the uninsured (28 percent) report currently undergoing treatment or participating in a program to help them manage a chronic condition; 37 percent of the insured are receiving such treatment.
• 21 percent of the uninsured, vs. 16 percent of the insured, believe their overall health is below average for people in their age group.

The costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured via cost shifting and higher health insurance premiums, or paid by taxpayers through higher taxes. On average, per capita health care spending on behalf of the uninsured is a bit more than half that for the insured.

A study published in August 2008 in Health Affairs found that covering all of the uninsured in the US would increase national spending on health care by $122.6 billion, which would represent a 5% increase in health care spending and 0.8% of GDP. The impact on government spending could be higher, depending on the details of the plan used to increase coverage and the extent to which new public coverage crowded out existing private coverage.

Emergency Medical Treatment and Active Labor Act (EMTALA), enacted by the federal government in 1986, requires that hospital emergency departments treat emergency conditions of all patients regardless of their ability to pay and is considered a critical element in the "safety net" for the uninsured. However, the federal law established no direct payment mechanism for such care. Indirect payments and reimbursements through federal and state government programs have never fully compensated public and private hospitals for the full cost of care mandated by EMTALA. In fact, more than half of all emergency care in the U.S. now goes uncompensated. According to some analyses, EMTALA is an unfunded mandate that has contributed to financial pressures on hospitals in the last 20 years, causing them to consolidate and close facilities, and contributing to emergency room overcrowding. According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26 percent, while in the same period, the number of emergency departments declined by 425. Hospitals attempt to bill uninsured patients directly under the fee-for-service model, but most such people cannot pay their hospital bills, and escape into bankruptcy when hospitals seek legal process against them.

Mentally ill patients present a unique challenge for emergency departments and hospitals. In accordance with EMTALA, mentally ill patients who enter emergency rooms are evaluated for emergency medical conditions. Once mentally ill patients are medically stable, regional mental health agencies are contacted to evaluate them. Patients are evaluated as to whether they are a danger to themselves or others. Those meeting this criterion are admitted to a mental health facility to be further evaluated by a psychiatrist. Typically, mentally ill patients can be held for up to 72 hours, after which a court order is required.

Below is the estimated percentage and number of uninsured people in the United States organized by state. The information reflects estimated two- and three-year averages as reported by the U.S. Census Bureau in August 2008. The five states with the highest estimated percentage of uninsured between 2005 and 2007 are, in order, Texas, New Mexico, Florida, Arizona, and Mississippi. The five states with the lowest estimated percentage of uninsured for the same period are, in order, Hawaii, Massachusetts, Minnesota, Wisconsin, and Iowa.