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PORTSIDE  January 2011, Week 2

PORTSIDE January 2011, Week 2

Subject:

The Uninsured: A Primer

From:

Portside Moderator <[log in to unmask]>

Reply-To:

[log in to unmask]

Date:

Mon, 10 Jan 2011 01:42:02 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (360 lines)

The Uninsured: A Primer
Key facts about Americans without health insurance
The Kaiser Commission on Medicaid and the Uninsured
December 2010
http://www.kff.org/uninsured/upload/7451-06.pdf


Introduction

The number of nonelderly uninsured Americans rose to
50.0 million in 2009-an increase of 4.3 million people-
amidst rising unemployment rates and an economic
recession. (The Census Bureau reports a total of 50.7
million uninsured in 2009 which includes 676,000 persons
who are elderly (65+ years old). This primer focuses on
the nonelderly uninsured. Our analysis of the Current
Population Survey's ASEC supplement differs from
estimates by the Census Bureau in several other ways
that are outlined in the Data Notes in the back of this
primer.)  Nearly all of the elderly are insured by
Medicare, yet nearly 700,000 of the elderly were
uninsured last year. Because the majority of the non-
elderly still receive their health insurance as a job
benefit, the steady decline in employer-sponsored health
coverage since 2000 and the current weak job market
largely explain the growing numbers of uninsured. The
safety net of Medicaid and the Children's Health
Insurance Program (CHIP) has prevented a larger increase
in the uninsured and, in particular, buffered children
from the full effects of the recession.Almost one in
five (19%) of the nonelderly was uninsured in 2009
(Figure 1).

The gaps in our health care system affect people of all
ages, races and ethnicities, and income levels; however,
those with the lowest income face the greatest risk of
being uninsured. Despite strong ties to the workforce-
more than three-quarters of the uninsured come from
working families-four in ten of the uninsured are
individuals and families who are poor (incomes less than
the federal poverty level or $22,050 for a family of
four in 2009).

Not having health insurance makes a difference in
people's access to needed medical care and their
financial security. The barriers the uninsured face in
getting the care that they need means they are less
likely to receive preventive care, are more likely to be
hospitalized for conditions that could have been
prevented, and are more likely to die in the hospital
than those with insurance. The financial impact can also
be severe. Uninsured families already struggle
financially to meet basic needs, and medical bills, even
for minor problems, can quickly lead to medical debt.

This primer presents basic information about the
uninsured-who they are and why they do not have health
coverage-and provides an understanding of the difference
health insurance makes in people's lives. TheUninsured:
A Primer also discusses how and why the number of
uninsured has changed and ends with a discussion of the
2010 Patient Protection and Affordable Care Act and how
it will expand coverage to the majority of the uninsured
by expanding Medicaid and providing subsidies for
private insurance premiums.

How Do Most Americans Obtain Health Insurance?

More than half (57%) of people in the U.S. under age 65
receive health insurance coverage as an employer
benefit. While Medicare covers virtually all those who
are 65 years or older, the nonelderly who do not have
access to or cannot afford private insurance now go
without health coverage unless they qualify for
insurance through the Medicaid program, Children's
Health Insurance Program (CHIP), or a state- subsidized
program. The gaps in our private and public health
insurance systems leave 50 million nonelderly people in
the U.S.-19% of those under age 65-without health
coverage. The Patient Protection and Affordable Care Act
of 2010 is designed to expand access to health coverage,
and most of the law's key provisions regarding the
affordability of coverage will take effect in 2014. The
risk of being uninsured is greatest for those with the
lowest incomes, and the new health reform law targets
this population through federal subsidies to help
purchase private insurance coverage and expanded
eligibility for Medicaid. (Figure 2)

Private Health Insurance Coverage The majority of
employers offer group health insurance policies to their
employees and to their employees' families. In 2010, 69%
of firms offer coverage to their employees. Among
individuals with employer-sponsored coverage, about half
are covered by their own employer (52%) and half are
covered as an employee's dependent (48%). Health
insurance offer rates vary among businesses, with large
firms and those with more high-wage workers being more
likely to offer coverage.1

Employer-sponsored health insurance is voluntary;
businesses are not legally required to offer a health
benefit, and employees can choose not to participate.
Even when businesses offer health benefits, some
employees are ineligible because they work part-time or
are recent hires and others do not sign up because of
difficulty affording the required employee share of the
premium. Among firms that offer coverage in 2010, an
average of 79% of their workers are eligible for the
health benefits.2The new health reform law aims to
expand access to employer-sponsored coverage through
both temporary subsidies for the smallest firms and
penalties for larger firms that do not offer adequate
coverage.

Private policies directly purchased in the non-group
market (i.e., outside of employer-sponsored benefits)
cover only 5% of people younger than 65. The share of
the nonelderly population with private non-group
insurance has changed very little over time. Non-group
insurance premiums vary by age and health status and can
be more expensive and less comprehensive than group
plans purchased by employers. Obtaining coverage in the
individual market can be difficult, particularly for
those who are older or have had health problems. In
2008, 29% of individuals age 60 to 64 who applied for
non-group insurance were denied coverage based on their
health status.3 Under the current system, applicants who
are offered coverage may find that they are charged a
higher premium due to their medical history, or specific
conditions may be excluded from their policy through an
elimination rider. Starting in 2014, insurers will be
barred from taking pre-existing conditions into account
when issuing policies. And, beginning in September 2010,
the new health reform law prohibits individual and group
health plans from denying children coverage based on
pre-existing medical conditions and from including pre-
existing condition exclusions for children.

Private health insurance coverage is subsidized through
the federal tax system in several ways. The most common
form of private insurance subsidy is the employee tax
exclusion of the health insurance premiums paid for by
employers. In addition, those who are self-employed are
allowed to deduct the costs of their insurance premiums
from their taxes. Tax advantages are also available for
health savings accounts (HSAs) and flexible spending
accounts.

Public Health Insurance Coverage The Medicaid program
and The Children's Health Insurance Program (CHIP)
currently provide coverage to some, but not all, low-
income individuals and people with disabilities.
Medicaid and CHIP cover 20% of the nonelderly population
by primarily covering four main categories of low-income
individuals: children, their parents, pregnant women,
and individuals with disabilities. Individuals who do
not fall into one of these groups-most notably adults
without dependent children-are now generally ineligible
for public coverage regardless of their income. While
some children and parents are still uninsured, adults
without dependent children comprise the majority of the
uninsured largely because they are the least likely to
qualify for Medicaid (Figure 3). The new health reform
law will extend Medicaid to all individuals at or below
138% of poverty starting in 2014.4 This will expand
public coverage to childless adults, and to parents who
were previously ineligible because of low eligibility
thresholds for parents. Undocumented immigrants and
legal immigrants who have been in the U.S. for less than
five years will continue to be ineligible for Medicaid.5

Medicaid and CHIP cover one-third of all children and
more than two-thirds of all children in families below
the poverty level. Medicaid is the largest source of
health insurance for children in the U.S., enrolling 29
million children at some point in the year during 2007
(the most recent year of enrollment data available).
CHIP supplements Medicaid by covering seven million
children who are low or moderate income but whose family
incomes are too high to qualify for Medicaid.Eligibility
levels for parents are generally much lower than for
children.

Medicaid provides health and long-term care coverage for
8.5 million nonelderly people with disabilities (2007
estimates). Its role is more prominent for people with
certain conditions, such as HIV/AIDS. However, Medicaid
eligibility for people with disabilities is limited to
those with very low incomes and few assets. Medicaid
coverage is particularly crucial to this population
because it provides more comprehensive coverage than
most private insurers. For example, Medicaid commonly
pays for medical equipment as well as rehabilitation,
speech therapy and other services that people with
disabilities may need.

Who Are the Uninsured?

In 2009, 50 million people in the U.S. under age 65
lacked health insurance. Most of these individuals come
from working families and have low incomes. The recent
recession has contributed to significant declines in
employer-sponsored coverage. Adults make up more than
their share of the uninsured because they are less
likely than children to be eligible for Medicaid-
especially young adults whose low incomes make it more
it difficult to afford coverage. A high unemployment
rate and increases in the number of individuals living
below poverty put employer-sponsored coverage out of
reach for many individuals.

More than three-quarters of the uninsured are in working
families-sixty-one percent are from families with one or
more full-time workers and 16% are from families with
part-time workers (Figure 4). Workers usually enroll in
employer-sponsored health insurance if they are
eligible.6However, it has become increasingly difficult
for many workers to afford coverage.The average annual
total cost of employer- sponsored family coverage is
$13,770 in 2010, and the share of the premium paid by
workers increased to 30% this year.7

The vast majority of the uninsured are in low- or
moderate-income families. (Figure 4) Individualsbelow
poverty are at the highest risk of being uninsured, and
this group comprises 40% of all the uninsured (the
poverty level for a family of four was $22,050 in 2010).
In total, nine in ten of the uninsured are in low- or
moderate-income families, meaning they are below 400% of
poverty.The new health reform law targets these
individuals through broader Medicaid eligibility and
premium subsidies through health insurance exchanges for
eligible individuals with incomes up to 400% of poverty
who do not have access to employer sponsored insurance.

Adults are more likely to be uninsured than children.
Adults make up 70% of the nonelderly population, but
more than 80% of the uninsured (Figure 4). Most low-
income children qualify for Medicaid or the Children's
Health Insurance Program (CHIP), but low-income adults
under age 65 typically qualify for Medicaid only if they
are disabled, pregnant, or have dependent children.
Income eligibility levels are generally much lower for
parents than for children, and adults without children
are generally ineligible. Under the Patient Protection
and Affordable Care Act (ACA), Medicaid will be expanded
in 2014 to provide eligibility to nearly all people
under age 65 with income under 138%8 of the federal
poverty level.

Young adults, ages 19 to 29, comprise a
disproportionately large share of the uninsured, largely
due to their low incomes. Young adults have the highest
uninsured rate (32%) of any age group. More than half of
uninsured young adults are families with at least one
full-time worker, but their low incomes make it more
difficult for them to afford coverage.9 The median
income of uninsured young adults in 2008 was $15,000.
Starting in September 2010, the health reform law will
let young adults stay on their parent's private health
insurance until they are 26.

More than half (63%) of nonelderly uninsured adults have
no education beyond high school, making them less able
to get higher-skilled jobs that are more likely to
provide health coverage. Thosewith less education are
also more likely to be uninsured for longer periods of
time.10

Minorities are much more likely to be uninsured than
whites. About one third of Hispanics are uninsured
compared to 14% of whites. The uninsured rate among
African-Americans (23%) is also much higher than that of
whites (Figure 5).Because racial and ethnic minority
groups are more likely to come from low- income
families, Medicaid is an important source of health
insurance for them. However, its limited reach leaves
large numbers of minorities uninsured.

The majority of the uninsured (81%) are native or
naturalized U.S. citizens. Although non-citizens (legal
and undocumented) are about three times more likely to
be uninsured than citizens they are not the primary
cause of the uninsured problem. Non-citizens have less
access to employer coverage because they are more likely
to have low-wage jobs and work for firms that do not
offer coverage.Further, until recently, states were
precluded from using federal dollars to provide Medicaid
or CHIP coverage to most recent legal immigrants who
have been in the U.S. less than five years. However, in
2009 states were given the option of extending Medicaid
coverage to children and pregnant women who previously
would have been subject to the five-year ban.
Undocumented immigrants will remain ineligible for
federally funded health coverage under the health reform
law.

The uninsured tend to be in worse health than the
privately insured. Uninsured adults are more than twice
as likely to report being in fair or poor health as
those with private insurance.Almost half of all
uninsured nonelderly adults have a chronic condition.11
Those with such conditions and others who are not in
good health and who do not have access to employer-
sponsored coverage may find non-group coverage to be
unavailable or unaffordable. The ACA addresses this
issue by imposing new regulations on all health plans
that will prevent health insurers from denying coverage
to people for any reason including health status, and
from charging higher premiums based on health status or
gender.12

More than seventy percent of the uninsured have gone
without health coverage for more than a year (Figure 6).
Because health insurance is primarily obtained as an
employment benefit, health coverage is disrupted when
people change or lose their jobs. When people are unable
to obtain employer-sponsored coverage and are ineligible
for Medicaid, they may be left uninsured for long
periods of time if individual coverage is either
unaffordable or unavailable due to their health status.

Insurance coverage varies by state depending on the
share of families with low incomes, the nature of the
state's employment, and the reach of state Medicaid
programs. Insurance market regulations and the
availability of jobs with employer-sponsored coverage
also influence the distribution of health coverage in
each state.13 Uninsured rates tend to be higher in the
southern and western regions of the United States;
however in 2009 the Midwest saw the greatest increase in
uninsured rates of any region in the country. At the
state level uninsured rates vary widely. Massachusetts
has near universal coverage, with an uninsured rate of
less than 5% due to landmark health reform legislation
enacted in 2006. While uninsured rates in states such as
New Mexico, Florida, and Texas exceed 25% (Figure 7).

[moderator: to read the entire report -
http://www.kff.org/uninsured/upload/7451-06.pdf]

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