VI. Key Issues: Financing & Delivery >> D. Health Insurance Coverage >> Uninsured (last updated 4.25.17)
- 1 Key Questions
- 1.1 What is the Number of Uninsured?
- 1.2 Who Are the Uninsured?
- 1.3 What Access Barriers Are Faced by the Uninsured?
- 1.4 Who Pays for the Uninsured?
- 1.5 What Are the Health Consequences of Being Uninsured?
- 1.6 What Are the Economic Consequences of Lack of Coverage?
- 1.7 Is Universal Coverage Cost-Effective?
- 2 Analysis
- 3 News
What is the Number of Uninsured?
According to the March 2013 CPS, there were 41.953 million uninsured (13.4% of total population) [Table 2].
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].
Because the survey methodology has changed, it is not possible to compare the latest CPS estimates for 2013 and 2014 to prior years. From a constructed time-series based on the National Health Interview Survey, the uninsured rate has declined from a high of 24.3% in 1963 to 11.3% in the second quarter of 2014 (see Table on p. 11).
- Institute of Medicine. America’s Uninsured Crisis: Consequences for Health and Health Care (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 (22.6% for 19-25; 23.5% for 26-34) and lowest among the elderly (1.6%) and children under 18 (7.3%) [Table 2].
- Race/Ethnicity. According to the CPS, the risk of being uninsured is highest among Hispanics of any race (24.3%) and lowest among non-Hispanic Whites (9.8%), with Blacks (15.9%) falling in between [Table 5].
- Geographic Location.
- State Estimates. The Current Population Survey annually reports in the fall estimates of the uninsured by state based on the Annual Social and Economic Supplement (ASEC) to the CPS conducted in March.
- 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. The latest figures are for 2012. A look-up table allows users to retrieve data down to the county level by age (under 19, 18-64, 40-64, 50-64 and under 65), sex, race (White alone, not Hispanic; Black alone, not Hispanic; Hispanic (any race), and income (under 138%, <200%, <250%, <400%, 138-400%).
- Citizenship. In 2013, 8.3 million (or 19.8 percent) of the 41.9 million uninsured were non-citizens and another 3.0 million (or 7.1 percent) were naturalized citizens [Table 5].
- Income. In 2013, low income was a risk factor for being uninsured; 21.6 percent of the uninsured had an annual household income less than $25,000. However, a similar number of the uninsured (21.3 percent) had annual household incomes of $75,000 or more. [Table 4].
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?
- Uncompensated Care.
- People uninsured for any part of 2013 spent about $25.8 billion out of pocket and received approximately $84.9 billion in uncompensated care while uninsured. Thus, of $121 billion in total health spending, 70.2% was uncompensated (Coughlin, et al. 2014).
- In per capita terms, the average uninsured person in 2013 had $2,742 in total health spending, of which $1257 was paid indirectly through implicit subsidies (calculated as the difference between what uninsured patients paid and insured patients paid for the same services) or other public/private sources. In 2008, assuming part-year uninsured people were uninsured an average of 6 months, per capita total spending while uninsured was $1,429, of which $920 was uncompensated.
- People uninsured for any part of 2008 spent (in the period they were uninsured) about $30 billion out of pocket and received $54.3 billion in uncompensated care (the latter=64.4% of total spending) (Hadley, et al. 2008).
- Government-Funded Share of Uncompensated Care.
- 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 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).
Is Universal Coverage Cost-Effective?
- Conover, Christopher J. The Key Obamacare Question: How Much Should Taxpayers Spend to Give Uninsured People More Years of Life? The Agenda. National Review Online. May 9, 2014.
- Duke University, Center for Health Policy and Inequalities Research. Taxpayer Cost to Obtain One Quality-Adjusted Life Year Under Affordable Care Act. Last updated May 26, 2014.
- Miller, Wilhelmine, Elizabeth Richardson Vigdor, and Willard G. Manning. Covering the Uninsured: What Is It Worth? Health Affairs Web Exclusive, no. W4-157 (2004).
- Muennig, Peter, Peter Franks, and Marthe Gold. The Cost Effectiveness of Health Insurance. American Journal of Preventive Medicine 28, no. 1 (2005): 59-64.
- Conover, Christopher J. How Risky Is it to be Uninsured? The American. (7.23.14).
- 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.
- Gianoli, Gerard, MD.
- 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.
- Holtz-Eakin, Douglas. Health Care Spending and the Uninsured. CBO Testimony: Statement before the Committee on Health, Education, Labor, and Pensions, United States Senate, January 28, 2004.
- 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)]
- Kaiser Health News. Uninsured.