What is the Number of Uninsured?
According to the March 2009 CPS, there were 46.3 million uninsured [DeNavas-Walt: Table C-3].
The number of non-elderly who experienced at least one month of being uninsured over a 2-year period (2004-2005) was 82.0 million (31.8%); those who remained uninsured for that entire period numbered 26.1 million (10.1%), while the number uninsured for 4 consecutive years (2002-05) was 17.4 million (6.8%) [Rhoades and Cohen].
- Uninsured trends. According to the CPS, the overall risk of being uninsured rose from 12.9% in 1987 to 15.4% in 2008, with the highest recorded rate (15.8%) occurring in 1998 and 2006 [DeNavas-Walt: Table C-1].
- Institute of Medicine. America’s Uninsured Crisis: Consequences for Health and Health (2009). This report includes an updated review of the research evidence on the dynamics driving downward trends in health insurance coverage.
- SHADAC. Comparing Federal Government Surveys that Count the Uninsured. September 2012. This brief presents trends in national estimates of uninsurance from four federal surveys, presents the most recent available state-level estimates from these surveys, and describes the main reasons for variation in the estimates across the different surveys.
Who Are the Uninsured?
Age. According to the CPS, the risk of being uninsured is highest among young adults (28.6% for 18-24; 26.5% for 25-34) and lowest among the elderly (1.7%) and children under 18 (9.9%) [DeNavas-Walt: Table C-3].
- Race/Ethnicity. According to the CPS, the risk of being uninsured is highest among Hispanics of any race (30.7%) and lowest among non-Hispanic Whites (10.8%), with Blacks (18.9%) falling in between [DeNavas-Walt: Table C-2].
What Access Barriers Are Faced by the Uninsured?
- Relative to the uninsured, insured Americans are more likely to obtain recommended screening and care for chronic conditions (Ayanian, Weissman et al. 2000).
- Relative to the uninsured, insured Americans are less likely to suffer undiagnosed chronic conditions (Ayanian, Zaslavsky et al. 2003).
- Relative to the uninsured, insured Americans are less likely to receive substandard medical care (Institute of Medicine, 2002).
Who Pays for the Uninsured?
- People uninsured for any part of 2008 spend about $30 billion out of pocket and receive approximately $56 billion in uncompensated care while uninsured (Hadley, et al. 2008).
- Government programs finance about 75 percent of uncompensated care (Hadley, et al. 2008).
- If all uninsured people were fully covered, their medical spending would increase by $122.6 billion. The increase represents 5 percent of current national health spending and 0.8 percent of gross domestic product. However, it is neither the cost of a specific plan nor necessarily the same as the government’s costs, which could be higher, depending on plans’ financing structures and the extent of crowd-out (Hadley, et al. 2008).
What Are the Health Consequences of Being Uninsured?
- Mortality Risk
- The Institute of Medicine (2002) calculated 18, 314 excess deaths among uninsured adults age 25-64 in 2000, based on a study showing mortality risk was 25% higher among the uninsured compared with those with private health insurance.
- Using a similar method, a 2009 study calculates that after controlling for age, gender, race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio=1.40; 95% CI=1.06, 1.84) than those with insurance (Wilper: Table 2).
- Using the IOM method of applying age-specific hazard ratios to the number of uninsured adults 18-64 in 2005, this study estimates there were 35,327 excess deaths attributable to lack of coverage. An alternative calculation using the global hazard ratio for uninsured adults rather than age-specific hazard ratios, shows the number of excess deaths may be as high as 44, 789.
- However, in a systematic review of the available evidence, Levy and Meltzer conclude “many of the studies claiming to show a causal effect of health insurance on health do not do so convincingly because the observed correlation between insurance and good health may be driven by other, unobservable factors. Second, convincing evidence demonstrates that health insurance can improve health measures of some population subgroups, some of which, although not all, are the same subgroups that would be the likely targets of coverage expansion policies.”
- A follow-up study in 2009 (still observational, but which was at least able to obtain repeated measures of changes in health insurance status during the follow-up period) found a slightly elevated mortality risk among the uninsured (compared to those with employer-based coverage) that was statistically insignificant (hazard ratio 1.03, 95 percent confidence interval, 0.95–1.12). The author concluded that “the Institute of Medicine’s estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect. It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States” (Kronick 2009).
- See also What is the Impact of Medicaid on Health Outcomes? for a summary of literature that compares the uninsured to those on Medicaid.
Douglas Almond et al., Estimating Marginal Returns to Medical Care: Evidence from At-Risk Newborns. The Quarterly Journal of Economics 125, No. 2 (2010): 591–634, . Infants classified just below threshold for “very low birthweight” have lower mortality rates than infants classified just above the threshold because they tend to receive timely and appropriate medical care.
- Joseph J. Doyle, Health Insurance, Treatment and Outcomes: Using Auto Accidents as Health Shocks. The Review of Economics and Statistics 87, No. 2 (2005): 256–270. Uninsured individuals receive less care and have higher mortality following auto accidents.
Janet Currie and J. Gruber. Health Insurance Eligibility, Utilization of Medical Care, and Child
Health. The Quarterly Journal of Economics 111, No. 2 (1996): 431–466
. Increased eligibility for Medicaid coverage expanded utilization for otherwise uninsured children, resulting in sizeable statistically significant reduction in child mortality.
- David Card, C. Dobkin, and N. Maestas, ‘‘Does Medicare Save Lives?’’ The Quarterly Journal of Economics 124, No. 2 (2009): 597–636. Individuals just old enough to qualify for Medicare have lower mortality rates (despite similar illnesses) than those just too young to qualify.
- Goodman et al. (2009). This NCPA study includes a section on Does Lack of Health Insurance Cause Premature Death?
- Other Impacts on Health
- Institute of Medicine. America’s Uninsured Crisis: Consequences for Health and Health (2009). This report provides an updated review of the research evidence on whether being uninsured is harmful to the health of children and adults.
Hadley, Jack. Sicker and Poorer: The Consequences of Being Uninsured. Medical Care Research and Review 60 (No. 2): 3S–75S, (2003). Lack of coverage is associated with a significant increase in morbidity.
What Are the Economic Consequences of Lack of Coverage?
- Institute of Medicine. America’s Uninsured Crisis: Consequences for Health and Health (2009). This report provides an updated review of the research evidence on how insured people affected by high rates of uninsurance in their communities.
- How Does Insurance Coverage Improve Health Outcomes? (Mathematica, April 2010).
- Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284: 2061–2069.
Ayanian JZ, Zaslavsky AM, Weissman JS, Schneider EC, Ginsburg JA. Undiagnosed hypertension and hypercholesterolemia among uninsured and insured adults in the Third National Health and Nutrition Examination Survey. Am J Public Health. 2003; 93:2051–2054
- DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith. U.S. Census Bureau, Current Population Reports, P60-236, Income, Poverty, and Health Insurance Coverage in the United States: 2008, U.S. Government Printing Office, Washington, DC, 2009.
- Goodman et al. (2009). This NCPA report includes a section on Is the Large Number of Uninsured in the US a Crisis?
- Gruber, J., Covering the Uninsured in the United States, Journal of Economic Literature, American Economic Association, Vol. 46, No. 3, 2008, pp. 517–606.
- Hadley, J., J. Holahan, T. Coughlin, and D. Miller, Covering the Uninsured in 2008: Current Costs, Sources of Payment, and Incremental Costs,” Health Affairs, web exclusive, August 25, 2008, pp. w399–w415.
- Institute of Medicine. Care Without Coverage:Too Little, Too Late. The National Academies Press, 2002.
- Kronick, R. Health Insurance Coverage and Mortality Revisited. Health Services Research, 2009, 44(4), 1211-1231. doi: 10.1111/j.1475-6773.2009.00973.x
- Levy, Helen and David Meltzer. The Impact of Health Insurance on Health. Annual Review of Public Health, 2008; 29: 399-409.
- O’Neill, June E. and Dave M. O’Neill, Who Are the Uninsured? Employment Policies Institute. June, 2009.
- Rhoades, Jeffrey A. and Steven B. Cohen, The Long-Term Uninsured in America, 2002-2005: Estimates for the U.S.
Population under Age 65, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey Statistical Brief #183, August 2007.
Review, August 3, 2012.
- Wilper, Andrew P., Woolhandler, Steffie, Lasser, Karen E., McCormick, Danny, Bor, David H., Himmelstein, David U. Health Insurance and Mortality in US Adults. Am J Public Health December 2009; 99(12). AJPH First Look, published online ahead of print Sep 17, 2009. [Abstract (html)][Full Text (pdf)]
- Model-based Small Area Health Insurance Estimates (SAHIE) for Counties and States. The Census Bureau’s Small Area Health Insurance Estimates (SAHIE) program produces estimates of health insurance coverage for states and all counties. In July 2005, SAHIE released the first nation-wide set of county-level estimates on the number of people without health insurance coverage for all ages and those under 18 years old. In July 2010, SAHIE released 2007 estimates of health insurance coverage by age, sex, race, Hispanic origin, and income categories at the state-level and by age, sex, and income categories at the county-level.
- Kaiser Health News. Uninsured.