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Uninsured people in the united states


The problem of uninsured people in the United States is a major issue. The purpose of this research proposal is to provide information about the uninsured- how many people are uninsured, who are the uninsured, and why are so many Americans uninsured. It also provides an understanding of the difference health insurance makes in people's lives. This research proposal will explain why research is needed to address the uninsured problem.


Healthcare costs continue to rise, making coverage less affordable and increasing the number of people in the United States without health insurance. Affordability of coverage is an important determinant of a family's decision to purchase health insurance. Although affordability depends in part on the price and terms of insurance coverage, it also depends on family income and other basic living expenses. Growth in health care costs and increasing instability in health insurance coverage are creating a crisis of affordability in the U.S. health care system.

Today the uninsured population in the United States is a major problem. Individuals who lack private or public health insurance are referred to as uninsured. Throughout most of the 1990s, when the economy was rapidly growing and competition for workers was high, the number of uninsured increased by about one million a year. Between 2005 and 2006, 2.1 million more people became uninsured (Henry J. Kaiser Family Foundation, 2007). Of those 2.1 million people, more than 700,000 were children. By 2006, 18 percent of the non-elderly lacked health insurance (Henry J. Kaiser Family Foundation, 2007). Enrollment in both Medicaid and SCHIP increased between 2000 and 2004. These programs filled in the gap in private coverage for children, but were not enough to fill in the gap for the adults. Both the high cost of health care and employer-based health insurance affect the number of people who have coverage. Higher premiums discourage people from purchasing insurance-especially those who have lower income. Those who are not employed or who choose to work at a firm not offering insurance have to seek insurance in the individual market. As a result, many people and their family
members are uninsured. Most Americans obtain health insurance through their employers. Job-based coverage is affected by rising health care costs and premiums relative to the growth in wages and the general economy. Since 2001, premiums for family coverage have increased 78 percent, while wages have gone up 19 percent. Low-income Americans have family incomes below 200 percent of the poverty level and run the highest risk of being uninsured (Henry J. Kaiser Family Foundation, 2007). Over a third of the poor and 30 percent of the near poor (100-199 percent of poverty) lack health coverage (Henry J. Kaiser Family Foundation, 2007). In 2003, over 36 percent of those with incomes below the poverty line were uninsured, and 30 percent of those with incomes between 100 and 199 percent of poverty line were uninsured. The poverty level for a family of four in 2006 was $20,614 (Henry J. Kaiser Family Foundation, 2007). More than four out of five (82 percent) of the uninsured are in working families-71percent in households with at least one full-time worker and 11percent with a part-time worker (Henry J. Kaiser Family Foundation, 2007). Low-wage workers are at greater risk of being uninsured, as are those employed in small businesses, service industries, and blue-collar jobs. About two-thirds of the uninsured are in low-income families, and about one-third of the uninsured are low income parents or children (National Coalition on Health Care, 2007). While younger adults are more likely to be uninsured, the majority (61 percent) of uninsured adults is over age 30 (National Coalition on Health Care, 2007). Nearly a quarter of those in fair or poor health are uninsured. Although uninsured rates are higher among legal residents and other non-citizens, almost 80% of the uninsured are U.S. citizens. In 2007, the annual premium for a family of four was $12,106 (Henry J. Kaiser Family Foundation, 2007). Low-income workers-those at greatest risk of being uninsured-are much less likely to be offered coverage through their own or a spouse's job and are less able to afford premiums in the no group market. Medicaid covers many low-income children, but coverage for adults is more limited. Parent income eligibility levels are set much lower than those of children.

Being uninsured in the United States has a major impact on the U.S. health care delivery system. Health insurance is a key that provides access to high quality health care and consequently to better health. People who lack health insurance are more likely to lack a usual source or provider of care, to spend more on health services, and to experience more problems without treatment, quality of care, and continuity of care. Health insurance affects access to health care as well as the financial well-being of families. Delaying or not receiving treatment can lead to more serious illness and avoidable health problems, which makes a difference in how healthy people are. The uninsured are more likely than those with insurance to be hospitalized for conditions that could have been avoided, such as pneumonia and uncontrolled diabetes. Charitable physicians and the safety net of community clinics and public hospitals do not substitute for health insurance. Lack of coverage clearly matters for the millions of uninsured Americans-affecting job decisions, financial security, access to care, and health status. Having health insurance does facilitate access to preventive services, a regular source of care, and better quality care for minority populations. Uninsured adults are less likely than adults to receive recommended health screening services. Some health insurance plans cover preventive health care and others do not. Uninsured cancer patients generally have poorer outcomes and die sooner than persons with insurance. For example, uninsured women with breast cancer have a 30 percent to 50 percent higher risk of dying than women with private health insurance (Estes & Harrington, 2004). Uninsured adults are less likely to have regular checkups and a usual source of care to help manage their disease than is a person with coverage. They receive fewer needed services, worse quality care, and have a greater risk of dying in the hospital or shortly after discharge.

The United States spends nearly $100 billion per year to provide the uninsured with health services (Henry J. Kaiser Family Foundation, 2007). When the uninsured are unable to pay for care they receive, that uncompensated care is paid through federal, state, and private funds. In 2004, the cost of uncompensated care were an estimated 41 billion, but the projected government spending available to pay for the care of the uninsured was 34.6 billion-about 85 percent of the total uncompensated care bill (Henry J. Kaiser Family Foundation, 2007). The increasing dependence of the uninsured on the emergency department has serious economic implications, since the cost of treating patients is higher in the emergency department than in other outpatient clinics and medical practices. This study is guided by the following question: Why are so many working people with incomes less than 20,000 not able to afford health insurance coverage. The purpose of this study is to focus on how to make health care insurance more affordable to low income Americans.

Literature Review

States like Massachusetts, California, Maine, and Vermont enacted reform plans that seek to provide health care coverage to nearly all residents. Nearly two-thirds of the uninsured come from low-income families (families of four earning less than $39,000 a year); most proposals would subsidize the cost of insurance for those in the lowest income groups (Hoffman, 2007).

The campaign for health care reform in Massachusetts launched in November 2004, with the release of the first Blue Cross Blue Shield Foundation of Massachusetts Roadmap to Coverage series (Hart, 2006). The report outlined the costs of the uninsured in Massachusetts-at least $1.1 billion annually. Because so much was already being spent on the uninsured and the state had a relatively low proportion of uninsured residents, it made sense to redirect money to providing health insurance (Hart, 2006). In April the Massachusetts legislature overwhelmingly approved the Health Care Access and Affordability Act, ambitious legislation designed to insure 90% to 95% of the state's uninsured-nearly 515,000 people-within the next three years (Hart, 2006). The new law is the first in the country requiring employers to provide health insurance to their employees and individuals to purchase insurance for themselves and their families. Full implementation is expected by July 1, 2007 (Hart, 2006).The new law requires employers with 11 or more employees to either provide health insurance for their employees or pay $295 per employee per year to the state, requires individuals to purchase health insurance if a comprehensive plan is available at an affordable price or face tax penalties and makes health insurance more affordable for uninsured working people through the new Commonwealth Care Health Insurance Program, which will provide sliding-scale subsidies for adults earning up to 300% of the poverty level ($49,800 for a family of three) to purchase insurance and not have to pay deductibles (Hart,2006). While the new law requires individuals have health insurance or face a tax penalty, it also includes an "affordability clause," which says that an individual won't be penalized if there isn't an "affordable" insurance product on the market (Hart, 2006). Both critics and supporters agree that the success of the new law may rest at least partially on the ability of a new state agency, the Commonwealth Health Insurance Connector, to define "affordable" insurance for different income levels and to sell policies that are of value (Hart, 2006).

Likewise, Governor Schwarzenegger of California recently proposed a similar, but more aggressive plan (Benson, 2007). California may learn from Massachusetts's experience, and both plans can inspire and guide national reformers (Benson, 2007). The central element of the proposal is the individual mandate, which would require all residents of California to purchase health insurance for themselves and their children, or face a penalty that has yet to be determined (Benson, 2007). The minimum acceptable insurance would have a $5,000 deductible, a $7,500 cap on out-of-pocket expenses, and premiums of approximately $100 per month (Benson, 2007). However, the proposal does not include a waiver for individuals who cannot afford insurance. California plans to subsidize insurance for people with incomes between 100 and 250 percent of the FPL, requiring them to contribute between three and six percent of their income (Benson, 2007).

The two states have very different starting points. California has both uninsured residents and a higher rate of uninsurance, making its path to success much longer (Benson, 2007). Massachusetts was spurred to act by advocacy groups, a former governor now running for president, and the threat of losing $770 million in federal matching funds if it did not reform its Medicaid system before its federal waiver expired (Benson, 2007). Massachusetts's government programs are more generous than California's, covering individuals further above the poverty line, requiring lower enrollee contributions, and offering more plan choices (Benson, 2007). Massachusetts's employer requirements have the advantage of equalizing coverage for employees. In contrast, under the California proposal, employers could satisfy the employer assessment by providing high quality products to high income workers, and low quality products to low income workers (Benson, 2007).

A study was done examining subgroups of uninsured Americans uncovering certain patterns of coverage gaps, but affordability remained a key concern (Cook, 2006). The study mentioned that people who lack health insurance fall into three main groups (Cook, 2006). The groups included adults and children who are eligible for Medicaid and SCHIP but do not participate. Another group included people with incomes above Medicaid and SCHIP eligibility levels but finds coverage too costly, and the third group appears to have sufficient income to afford coverage but is uninsured (Cook, 2006). These people are probably not offered employer coverage, since take-up rates of employer offers for higher-income people are very high. Some people in this group may be self-employed and consequently face the purchase of insurance in the nongroup market. Some may be denied coverage or face extremely high premiums because of their poor health status. Others may simply choose to go without coverage.

In this study, it provides a profile of the uninsured that divides the three groups. After the researchers conducted the analysis, they found that 24.7 percent of the uninsured are eligible for pubic health insurance programs, 55.7 percent are in the "need assistance" category, and 19.6 percent are likely to be able to afford coverage on their own (Cook, 2006). There is much variation in this distribution across population groups, with 74 percent of uninsured children being eligible for existing pubic programs and 57 percent and 69 percent of uninsured parents and childless adults, respectively, being in the "need assistance" category (Cook, 2006). The majority of the uninsured have sufficiently low incomes that at least partial financial assistance would be necessary to make coverage affordable. This overall picture masks the variation in the distribution of the eligible, "need assistance," and affordable groups for children, parents, and childless adults (Cook, 2006).

The reviewed literature emphasizes the need for more states to conduct studies concerning how much the cost of caring for the uninsured will cost and how to obtain affordable health insurance to low income families.


Lack of health insurance is a problem in every state and region of the country, but varies from location to location depending on differences in employment patterns and state Medicaid policies. Southern and western states have more workers employed by small firms that do not provide coverage. In addition many states in the South extend Medicaid coverage to fewer children. In 2004, 17 to 18 percent of the people who lived in the west and south were uninsured, while less than 13 percent of those living in the Northeast or Midwest lacked coverage (Gorin& Moniz, 2007). Employees in unionized and manufacturing jobs are more likely to receive health insurance coverage. Full-time employees are far more likely than part-time workers to have coverage, not all full-time workers receive health insurance benefits. In 2004, 18.3 percent of full-time workers had no health insurance (Gorin& Moniz, 2007). Employers also vary in their policies regarding coverage for family dependents.

My population for this study will specifically be targeted to uninsured people in the United States. Young adults (18 to 24 years old) are at greatest risk for lack of coverage. Many young adults are employed in jobs that do not offer health insurance benefits. On the other hand, if their parents are unable to provide them with benefits as family dependents, there is no public insurance program they can turn to. The Medicaid program does not cover young adults over the age of 18 unless they have children or are disabled and meet the income criteria for eligibility. The number of uninsured infants, children, and youth exceeds the number of youth over 18 who lack coverage.

On the other hand, this study will focus on people of color in the United States because they continue to experience inequality in their social and economic well-being. People of color have a significant impact on health status, access to health, and insurance coverage. In 2003, 75 percent of uninsured African Americans and Latinos had incomes below 200 percent of the federal poverty level, compared to 56 percent of uninsured whites (Gorin & Moniz, 2007). People of color represent 34 percent of the nation's population, yet 46 percent of the uninsured population in the United States (Gorin & Moniz, 2007). Income and socioeconomic status play an important role in access to coverage. People of color are disproportionately employed in low-income jobs increases the likelihood that they will not have employment-based insurance.

However, the Hispanic or Latino population is the second-largest and fastest-growing population in the United States. In 2004, one of every three non elderly Latinos lacked insurance coverage (Gorin & Moniz, 2007). Latinos are less likely to have employment-based insurance than are other people of color in the United States. In 2003, 40 percent of Latino workers received coverage through their employers, compared to 48 percent of African American workers and 70 percent of white workers (Gorin & Moniz, 2007). Latino workers with little education and poor English-speaking skills, are more likely to work in low-skill service sector jobs, such as gardeners and restaurant workers with no or few health benefits.
In fact, African Americans have greater access to health insurance coverage than Latinos in the United States, but are nearly twice as likely as whites to go without health insurance (Gorin & Moniz, 2007). They have better access to employment-based insurance that do Hispanics. African Americans are more likely than either whites or Latinos to have government insurance (Medicaid and Medicare). They have greater access to insurance coverage than Latinos do, but are less likely to have private insurance than whites.

African Americans and Latinos are the largest groups of color in the United States; together they make up more than one-quarter (26.4 percent) of the U.S. population (Gorin & Moniz, 2007). On the other hand, Asian Americans and Native Americans consist of less than 5 percent of the population. Asian Americans have better access to health care than other groups of color; 16.8 percent of Asian Americans are uninsured (Gorin & Moniz, 2007). They have achieved higher academic standing and socioeconomic status than African Americans, Latinos, and Native Americans. In 2004, 82.4 percent of Asians attained at least a high school education compared to 84.8 percent of non-Hispanic whites (Gorin & Moniz, 2007).
The research design will consist of a retrospective study on working people with incomes less than 20,000 who can not afford health insurance coverage. Within five years, a prospective study will be done to compare the results. This study will use panel data combining cross-section and time-series data, surveying the uninsured population over time. This study will use secondary data sources to obtain information about the uninsured population. The census data, collected and maintained by the U.S. Bureau of the Census, provide detailed information about the demographic characteristics of the populations of the states, counties, metropolitan areas, cities, towns, neighborhood tracts and blocks. The Current Population Survey (CPS), a monthly survey of a representative sample of households throughout the fifty states used to estimate what share of uninsured Americans are eligible for coverage through Medicaid or the State Children's Health Insurance Program (SCHIP), need financial assistance to purchase health insurance, and who are likely able to afford health care insurance will be used in this study. The Area Resource File will be used to obtain information about individual demographics. For example, age, income, education will be the important factors. This data source pools data from various sources to facilitate health analysis both cross-sectionally and longitudinally. The area resource file is useful in research concerning health status and the relationship between health status and other factors. The Medical Expenditure Panel Survey Household Component will be used in this study. This household survey will provide information about individual household members and their medical providers to collect nationally representative data on demographic characteristics, health conditions, health status, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income, and employment. The sampling frame is drawn from respondents to the National Health Interview Survey, which is conducted by the National Center for Health Statistics. The Medical Expenditure Panel Survey Household Component collects data from a nationally representative sample of households through an overlapping panel design. A new panel of sample households is selected each year, and data for each panel are collected for two calendar years. The two years of data for each panel are collected in five rounds of interviews that take place over a two and a half year period. This provides continuous and current estimates of health care expenditures at both the person and household level for two panels for each calendar year.

In conclusion, In three of the four largest US states (California, Florida, and Texas), more than one out of three non-elderly Americans were uninsured in 2001-02. Ten percent of the Seventy-Four million uninsured were without coverage for two months or less (McLellan, 2003). Fifty-Two were estimated to be uninsured for at least nine months during 2001-02 (McLellan, 2003). Approximately eighty percent of the uninsured were in working families. Fifty-two percent of the uninsured were non-Hispanic whites. However, racial minorities were more likely to be uninsured than whites. The non-elderly age group with the highest likelihood of experiencing an uninsured spell during 2001-02 was 18-24 year olds (49.6%), followed by 25-44 year olds (32.7%) (McLellan, 2003). Health insurance helps improve access to care for low-income adults and lessens the financial impact of health care costs. About 40% of low-income adults are uninsured, and these adults are lower income and in worse health than low-income adults with private coverage (McLellan, 2003).

However, many low-income adults are still burdened with high health costs. Regardless of insurance status, low-income adults in fair or poor health are much more likely to feel the impact of those costs when compared to those in better health. This suggests that low-income adults need comprehensive and continuous health care coverage if they are to be able to afford care when they become sick without jeopardizing their family's finances. With more and more people directly experiencing a lack of health coverage, this problem is already receiving top priority attention from the political candidates running for office in 2008.