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Am Fam Physician. 2004;69(6):1357-1360

See editorial on page 1365.

According to figures released by the U.S. Census Bureau in September 2003,1 43.6 million Americans did not have health insurance in 2002, a figure that represents an increase of 2.4 million persons from 2001. A sluggish economy and budget deficits at the state and local government levels are likely to increase the number of uninsured Americans.

Who are “the uninsured”? Approximately 23 million are male, 20 million are female, 21 million are white, 13 million are Hispanic, 7 million are black, and 2 million are Asian or Pacific Islander1,2 (see accompanying table).1 The group least likely to have health insurance comprises adults 18 to 24 years of age; approximately 8.1 million persons (30 percent) in this age group lack health insurance coverage. More than 3 million adults 55 to 64 years of age also lack health insurance. Even more troubling is the fact that 8.5 million children in the United States (12 percent of all children younger than 18) are uninsured.

Why are these people uninsured? Contrary to popular belief, 80 percent of uninsured persons come from working families: 20 million persons who are uninsured work full-time; 6 million work part-time; and 9 million are in families where at least one person is employed. So, why do working families lack health insurance? One reason is that only two thirds of American workers are offered health insurance by their employers.3 In addition, 20 percent of uninsured persons cannot afford employer-based health coverage when it is offered. More than 50 percent of the uninsured are in families that are below 200 percent of the federal poverty level ($34,100 annual income for a family of four)2 and do not have enough extra money to pay the premiums. Ironically, health care workers and their families are more likely not to have health insurance than workers in other industries.4

Fortunately, Medicaid insured approximately 14 million persons in 2002.1 However, 10.5 million persons who were at or below 100 percent of the federal poverty level were not covered. Nondisabled adults are generally not eligible for Medicaid benefits regardless of their health status; the 55- to 64-year-old population, many of whom are developing chronic medical conditions, are particularly at risk.2,5

What are the consequences of being uninsured? For patients, the answer is simple: they do not seek care, they wait until it is too late, or they receive episodic, often “inappropriate,” care. According to the Institute of Medicine’s (IOM’s) May 2002 report,6 uninsured patients have worse clinical outcomes for chronic conditions such as diabetes, cardiovascular disease, end-stage renal disease, human immunodeficiency virus (HIV) infection, and mental illness than insured patients. Furthermore, a large portion of the uninsured are young and lack economic access to preventive health services such as Papanicolaou smears and immunizations.

CharacteristicsTotal U.S. populationUninsured population
Number (in millions)*Number (in millions)*Percentage of total population
Race and ethnicity
White, not Hispanic194.420.810.7
Asian/Pacific Islander12.52.318.7
<18 years73.38.511.6
18 to 24 years27.48.129.6
25 to 34 years39.29.824.9
35 to 44 years44.17.817.7
45 to 65 years67.69.113.5
≥65 years34.20.30.8
Work experience‡
Worked during year142.925.718.0
Worked full-time118.419.916.8
Worked part-time24.55.823.5
Did not work35.59.125.7
Household income
$25,000 to $49,99975.914.619.3
50,000 to $74,99958.66.911.8

The IOM report6 specifically notes that working-age Americans (between 18 and 65 years of age) without health insurance are more likely to have poorer health and die prematurely; receive too little medical care and receive it too late; receive less frequent or no cancer screening tests, resulting in delayed diagnosis and premature death; fail to receive recommended care for chronic diseases; lack regular access to medications to manage conditions such as hypertension or HIV infection; and receive fewer diagnostic and treatment services after a traumatic injury or heart attack, resulting in an increased risk of death when hospitalized.

The IOM’s follow-up September 2002 report7 states that “the financial, physical, and emotional well-being of all members of the family may be in jeopardy if any individual within the family lacks coverage.”7 The report adds that “the health of children and their long-term development would likely be enhanced if the children are covered by insurance.”7

The IOM’s June 2003 report8 states that “communities are at risk of losing health care capacity because high rates of uninsurance result in hospitals reducing services, health providers moving out of the community, and cuts being made in public health programs like communicable disease surveillance. These consequences can affect everyone, not just those who are uninsured.”

The consequences that afflict uninsured persons also are unpleasant for physicians.9,10 All physicians have struggled over issues such as (1) when, or if, to forego a work-up or treatment because of cost, while worrying about liability and obtaining “real” informed consent for the options involved in these “less than standard-of-care” decisions; (2) when, or if, to refer a patient to another care provider or a safety-net clinic (assuming the patient can get an appointment), knowing that the patient may suffer a lapse in care; and (3) when to reduce fees or forego collection for care rendered to the uninsured and trying to decide how much uncompensated care to provide, who should receive it, and at what cost to oneself, one’s practice or institution, one’s family, staff, or other patients. Physicians who work for public health care institutions struggle with these issues, especially the first one, as much as other physicians.

The consequences of being uninsured are financial as well as social. The amount of uncompensated health care delivered in the United States is well over $30 billion annually, including more than $20 billion in care delivered by nonfederal community hospitals, $7 billion delivered by community clinics and health programs, and $5 billion delivered by physicians.11 Other costs include uncompensated care from other sources and the cost of lost days from work because of illness for uninsured workers.2 The uninsured are four times more likely to use the hospital emergency department as their regular source of care than people who have health insurance. This situation means that we all pay, one way or the other.

What can physicians do about this problem? For one thing, we can continue to promote and provide “rescue” care through small, directed programs that address specific subpopulations of the uninsured. The problem with this “bandage” approach is that it postpones definitive solutions and definitive care. In contrast, the IOM endorses “broad-based health insurance strategies” that address the entire uninsured population and that would provide preventive services, out-patient prescription drugs, and specialized mental health care, in addition to general ambulatory and hospital medical care.6

President Bush’s administration is actively endorsing an expansion of the Community Health Center system.12 Although this endorsement of an outstanding model of primary care is a positive step, its usefulness is limited by the following factors: (1) the Community Health Center system cannot provide care for 40 million additional people; (2) it does not provide hospital services; (3) it provides only limited access to specialty or subspecialty care; and (4) it offers limited and variable access to laboratory, pharmacy, and radiology services. The Bush administration plan also does not specifically address other safety-net institutions such as county hospitals and clinics that already are overwhelmed with patients and short on resources.

A plan suggested by the American Academy of Family Physicians (AAFP)13 is one proposal that meets the IOM’s recommendations. The AAFP plan is a strong and clear set of principles that defines who is covered, what is covered, what is not covered, patient cost-sharing and protection, financing, oversight, and the role of the government. It is an extraordinary proposal that should be the foundation of our next national step.

“Covering the Uninsured,”2 a public awareness education campaign sponsored by the Robert Wood Johnson Foundation in conjunction with the California Endowment and fifteen major national organizations, was established in early 2002 to conduct national advertising and sponsor a Web site dedicated to the issue of the uninsured.

In an age where health disparities often are discussed, the issue of lack of health insurance is probably the most concerning issue. One out of every seven people in this country is at risk of not receiving adequate health care because he or she doesn’t have an admission ticket to the health care arena. Unlike other necessities, such as food and clothing, where less-expensive options are available and acceptable, there really is no less-expensive option for basic health care. At least we don’t say that there is, because we don’t want to admit to the existence of health care rationing in this country.

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