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« Norman Rockwell and the Civil Rights Paintings | Main | Compassionate Response to Poverty: Opportunity Creation »

Health Coverage: Why Are People Uninsured?

By Pamela Jean
February 11, 2008

More and more American workers are losing their health coverage in the workplace as employers increasingly refuse to offer it. The Americans most likely to go without insurance now are those earning less than $46,650 a year and the majority of these are fully employed. Most Americans don't buy health insurance if they don't get it at work, regardless of how much they earn.

Four out of five of "uninsured" Americans are employed. Either they are not being offered group health insurance through their employer (the most prevalent problem) or the premiums offered through their employers are priced higher than these employees can afford (this is the smaller group).

The greatest number of uninsured Americans are working and are not offered any group coverage through their jobs. Thus, their choices for health care coverage are very limited. Unable to qualify for group insurance, these working Americans must look to the "non-group insurance" market for their purchases.

Who are these people? Why are these Americans not buying the non-group policies?

The "non-group" policies are notorious for "non coverage" of real medical expenses. The non-group policies generally exploit a lawless frontier, in that most of the patient protections written into law in recent years only apply to those patients that have group insurance. Those with non-group are left, too often, to fend for themselves in a kind of Wild West type of uncertainty.

The two biggest problems in the non-group policy world are these:

1) Non-group policies tend to be unreliable in their reimbursements or payments for routine, usual, customary or necessary medical care. All may seem fine because the fine print may resemble what the subscriber has seen in other policies, however, most policies are written in vague legalese. In truth, the power lies with the insurance company and not the patient.

2) Non-group policies tend to not only have much greater premiums, co-pays, deductibles and co-insurance (what the patient pays) but these policies also are less regulated and their premiums widely vary. Even if a patient (policy subscriber) does his or her level best to try to obtain the best coverage for the best price, he or she may learn, after it's too late, that the coverage just isn't there and the premiums are increasing rapidly.

A mid-November Gallup poll found that the public is more dissatisfied than ever with out-of-control health care costs. An overwhelming 81 percent said they are dissatisfied with the cost of health care in this country, the highest figure recorded on this question since Gallup first started asking it in 2001.

Another recent study, this one by the Kaiser Family Foundation. found that:

Often considered an affordability problem, and for lower income families, the cost of premiums is undoubtedly a factor. Prices for non-group policies vary considerably: for example, over the 2006-2007 period, annual premiums for single coverage varied by age from $1,163 to $5,090, and between $2,325 and $9,201 for family coverage depending on the age and number of family members covered...This finding may be surprising given the potentially large financial and health risks that arise for individuals and families without health insurance coverage.

That same study seeks to assess at what income levels Americans are purchasing the non-group coverage when group coverages are not offered by their employers.

The analysis finds that relatively few people at lower incomes purchase non-group coverage, with one in 20 purchasing it among those with incomes at the federal poverty level ($18,660 for a family of four in 2003 dollars).

As income increases, the coverage rate increases, though even at four times the poverty level, only about a quarter of individuals purchased coverage. And among those with incomes at least 10 times the poverty level, only about half purchased coverage in the non-group market.

The multitude of payers (also called insurance companies) seeking to make profit from the uninsured only contributes to the unaffordability of the non-group policies offered - when they charge extremely high premiums and they do not cover many of the medical services. In some ways, these non-group insurance policies are exploiting people of lower income in the same way that the higher interest rate sub-prime mortgages and predatory lenders exploit people of lesser income. And, like those other industries, the non-group market is not as regulated.

The same Kaiser study, How Non-Group Health Coverage Varies with Income (pdf), examined health benefits and the self-employed. The self-employed were examined separately because they usually do not receive health insurance through an employer, and thus were more likely to purchase insurance directly.

What the study found is that only the upper income folks could afford the insurance purchase - and even then, even at the upper ends, too many were still uninsured. Only when family income was above 450 percent of the poverty line did close to half of the self-employed purchase insurance.

The Kaiser study looked at the percentage of individuals without other coverage options who purchased private non-group health insurance.

Not surprisingly, it found very low coverage rates at lower income levels, suggesting that many people at these incomes were unable to find policies that they felt were affordable.

It also show that while coverage rates rose steadily with income, even at high levels of income, most individuals did not purchase coverage (e.g., at four times the poverty level, only about a quarter of individuals purchased coverage).

Coverage rates were higher for the self-employed at all income levels, but even for the self-employed most remained uninsured until incomes exceeded four times poverty.

As our politicians talk about "health care reform" - few are openly talking about the unaffordability of the non-group coverages that individuals are forced to examine on the market. Some politicians are talking about making it possible for citizens to choose coverages like those offered to senators and congressmen. Are these politicians and candidates talking about non-group or group coverage? It's important to differentiate because non-group coverage is usually not as affordable and not as comprehensive.

These Kaiser findings show that policy makers considering ways to encourage more people to purchase non-group coverage face a daunting challenge.

The current low coverage rates, even at fairly high income levels, suggest that subsidies may need to be fairly substantial in order to encourage a large uptake in purchase, and may need to extend higher up the income scale than some policy makers may prefer. Other proposed market interventions, such as creating purchasing pools or public exchanges to simplify the process of purchasing coverage, could potentially play a role in improving market participation...

The low coverage rates that we find suggest that many people whose coverage option is the non-group market either do not view coverage as attractive or do not feel that they can afford it. The low coverage rates also suggest that policy makers may need to take significant actions if their goal is to substantially increase participation in this market.

Most politicians on the campaign trail say they will not include all our citizens in the national health plan or in health care reform systems. For example, presidential candidate Barack Obama is proposing covering only uninsured children, therefore leaving the uninsured adults (as studied above) out of any plan. Why is Senator Obama is not including uninsured adults in his health care plan? He has said that he does not believe in requiring all Americans to purchase healthcare if they cannot afford to do so. Even so, even after identifying the affordability as a problem, Senator Obama doesn't address the cost problem or explain how health care will be made more comprehensive or more affordable for the people described in this study.

Fewer candidates are insisting that all citizens be covered, such as Hillary Clinton and her comprehensive plan. Senator Clinton has said that she wants to include all Americans in risk pools in order to effectively reduce the costs of premiums for all. In this way, she is at least tackling the affordability problem. The potential advantage of the latter is the inclusion of more citizens in averaging of medical care costs, thereby theoretically making premiums prices more equitable (and affordable) for participants. By including everyone in groups, citizens could gain more of the advantages of participation in regulated plans, thereby avoiding the pitfalls of the non-group plans, as discussed above.

Whose health care plan is right? All of the plans, and all of the candidates, deserve close inspection. Americans voters will want to closely examine the various health care reform ideas presented by the candidates and make up their own minds about what seems fair, reasonable and just. To learn more about the proposed plans of the leading presidential candidates, click here, here, and here, for starters.

No matter what, we have to solve this problem. We cannot just nip around the edges. We will have to really address and resolve the problems of unaffordability of health care and health insurance. In order to accomplish that goal, we've got to get right to the heart of the matter.

Why are people uninsured? The answer seems to rests squarely on the issues of affordability.

Many factors contribute to the unaffordability of health care, including the hodge podge of group plans and non-group plans, the increasing premiums of individual plans, the plummeting incomes of American workers, and the rising costs of every day expenses such as food and gasoline.

Remember, all Americans are harmed by this crisis. Even those that are insured are struggling to pay for their health care - and many of these are facing home foreclosures and bankruptcies due to their cost of medical care. A recent study from Families USA offers these startling insights:

  • More than four out of five people (82.4 percent) in families spending more than 10 percent of their pre-tax income on health care costs are insured.
  • 61.6 million Americans live in families that will spend more than 10% of their pre-tax income on health care costs in 2008
  • Between 2000 and 2008, the number of people in families spending more than 10 percent of their pre-tax income on health care costs will have increased by nearly 19.9 million.
  • 50.7 million non-elderly Americans with insurance are in families that will spend more than 10 percent of their pre-tax income on health care costs in 2008.
  • More than 17.8 million people in families that will spend more than 25 percent of their pre-tax income on health care costs in 2008
  • More than three out of four people (75.8 percent) in families spending more than 25 percent of their pre-tax income on health care costs are insured.
  • 13.5 million Americans with insurance are in families that will spend more than 25 percent of their pre-tax income on health care costs in 2008.

According to that report, these fast-rising health care costs are forcing increasing numbers of people to look for new ways to pay for care. With the majority of doctor’s offices and hospitals now accepting payment by credit card, paying for health services via credit card is becoming increasingly common. Recent data show that more than one in four people with insurance report having trouble paying their medical bills or say that they are in the process of paying off medical debt.

We know that America's health system is in real crisis, leaving out too many and costing too much. 47 million Americans lack health insurance. Millions more are struggling to pay premiums that are growing five times faster than wages, but still seeing their benefits shrink. While some Americans have access to the most sophisticated medical care in the world, others are left to overcrowded emergency rooms, under-funded clinics, or no health care at all - all because they lack the insurance it takes to provide for the care they need. This is wrong. It violates America's deep, long-standing commitment to fairness for all of our citizens.

So, what can we do about it? First we have to honest about this problem. Really honest. Then, we need to seek to increase the size of risk pools and include all Americans in the assessment of costs and affordability.

Very soon, in the coming months, we just have to find a way to make sure that ALL Americans are able to access and afford health care services, including adults, children and the elderly. This problem cannot be allowed to grow. Too many people are suffering! We must solve this problem! What kind of America is this - where only the wealthiest individuals can go see doctors when they get sick?

America’s health care crisis is neither inevitable nor unsolvable. Just as our nation has overcome tough challenges in the past, we can do so again. Ensuring affordable, quality health care is this generation’s great challenge. With conviction and persistence, armed with a practical, fair and responsible plan, this worthy goal can be achieved.

More information about our health care crisis in America:

Comments (1)

John_ Mayer Author Profile Page:

Are you uninsured in America? You should check out the website - John Mayer, California

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The blog post previous to it is titled "Norman Rockwell and the Civil Rights Paintings"

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