How many Americans lack health insurance? How does being uninsured affect access to preventive care?

In 2004, 64 million Americans—26 percent of the nonelderly population—were without health insurance for at least one month during the year, and 34 million of these individuals—14 percent of the nonelderly population—were uninsured all year long. Those without health insurance were less likely than those with coverage to receive preventive care services at appropriate ages.

Why is this important?

Individuals without health insurance or who experience gaps in coverage have generally worse self-reported access to care and quality of care compared with those who are continuously insured (Hadley 2003; Olson et al. 2005; Schoen and DesRoches 2000). In particular, they are:

• less likely to have a regular care provider;
• more likely to delay or forgo needed medical care, preventive services, and prescription drugs;
• more likely to have poor health outcomes; and
• less likely to rate the quality of their care as good or excellent.

Findings

Among nonelderly community-dwelling Americans surveyed during 1996 to 2004 (Rhoades 2006):

• about one of four (24.8 to 27.0 percent, or 58.5 to 63.9 million people) were uninsured for at least one month during a given year;
• about one of eight (12.2 to 13.9 percent, or 28.7 to 34.4 million people) were uninsured for an entire year; and
• both rates and numbers of uninsured generally decreased from 1996 to 1999, then generally increased from 1999 to 2004.

A 2005 national survey found that nonelderly adults without health insurance at some time during the year were generally less likely to receive four preventive services (breast and cervical cancer screening and blood pressure and cholesterol measurement) at recommended ages and intervals than those who were continuously insured (absolute differences of 3 to 32 percentage points) (Collins et al. 2006).

Insurance coverage was associated with higher rates of preventive care use among both lower-income and higher-income individuals. For three of the four services, the absolute differences in rates of preventive care between insured and uninsured individuals were not reduced by higher income. Blood pressure was measured at a high rate among both insured and uninsured high-income individuals.

Implications

These data are consistent with other research finding that insurance coverage encourages greater use of preventive care, primarily by ensuring access to a regular care provider (IOM 2002). For example, formerly uninsured near-elderly individuals who gain Medicare coverage upon reaching age 65 increase their use of preventive care closer to the level of those who were continuously insured before Medicare enrollment (McWilliams et al. 2003).

The failure to ensure universal coverage for all Americans leads to many missed opportunities for prevention, early detection, and optimal treatment of disease, with an annual economic cost to the nation estimated at $65 billion to $130 billion in lost productivity and preventable mortality (IOM 2003).

Improvement Ideas and Resources

The Citizens' Health Care Working Group, a nonpartisan advisory body created by Congress in 2003, has recommended that all Americans should have affordable health care coverage, with a defined set of core benefits guaranteed by law across their lifespan. Universal coverage also has been espoused by the Institute of Medicine, the National Coalition on Health Care, and the Commonwealth Fund Commission on a High Performance Health System.

• The Robert Wood Johnson Foundation's Covering America initiative has created a collection of comprehensive proposals for expanding health insurance coverage using a variety of methods and approaches.
• The Commonwealth Fund has compiled a wide-ranging list of relatively low-cost, incremental coverage reforms (Lambrew and Garson 2003).
• The California HealthCare Foundation has created an online tool for evaluating coverage expansion proposals based on user-specified criteria.

In a 2006 national poll conducted for The Commonwealth Fund, 80 percent of respondents rated "ensuring that all Americans have adequate, reliable health insurance" as a very important policy goal for presidential or congressional action, and 52 percent rated this issue as their first or second priority among health care issues (Schoen et al. 2006).

Measure:

For charts depicting rates and numbers of uninsured, the denominator included community-dwelling, nonelderly individuals under age 65. The numerators included those in the denominator who did not have coverage at any time during the survey year. Respondents were considered uninsured if they were covered only by state-specific programs or private single-service plans such as dental, vision, accident, or specific disease coverage (Rhoades 2006).

For charts depicting receipt of preventive care, each denominator included community-dwelling nonelderly adults of ages at which the particular cancer screening test is recommended by medical experts, classified by insurance status: continuously insured within the past 12 months or uninsured currently or at any time in the past 12 months. Each numerator included those in the denominator who reported receiving the cancer screening test within the recommended time frames (Collins et al. 2006).

Limitations:

These data differ from frequently reported statistics compiled by the U.S. Census Bureau using the Current Population Survey (CPS) Annual Social and Economic Supplements, which more closely approximates the percentage of people who are uninsured at a given point in time. For comparison, the Census Bureau estimated that 45.8 million Americans were uninsured in 2004, representing 15.7 percent of the entire civilian, noninstitutionalized population (DeNavas-Walt et al. 2005).

Source:

Rates and numbers of uninsured were compiled by researchers at the Agency for Healthcare Research and Quality based on responses to the Medical Expenditure Panel Survey, a nationally representative survey of the civilian, noninstitutionalized U.S. population (Rhoades 2006).

Rates of preventive care were compiled by researchers at The Commonwealth Fund based on responses to the 2005 Commonwealth Fund Biennial Health Insurance Survey, a nationally representative telephone survey of civilian, noninstitutionalized adults ages 19 and older living in the continental United States (Collins et al. 2006).

References:

* Indicates source of data used in the chart(s).

* Collins, S. R., K. Davis, M. M. Doty et al. 2006. Gaps in Health Insurance: An All-American Problem. New York: The Commonwealth Fund.

DeNavas-Walt, C., B. D. Proctor, and C. H. Lee. 2005. Income, Poverty, and Health Insurance Coverage the United States: 2004. Current Population Reports, P60-229. Washington, D.C.: U.S. Census Bureau.

Hadley, J. 2003. Sicker and Poorer—The Consequences of Being Uninsured: A Review of the Research on the Relationship between Health Insurance, Medical Care Use, Health, Work, and Income. Medical Care Research and Review 60 (2 Suppl): 3S–75S; discussion 76S–112S.

IOM (Institute of Medicine). 2002. Care Without Coverage: Too Little, Too Late. Washington, D.C.: National Academies Press.

IOM (Institute of Medicine). 2003. Hidden Costs, Value Lost: Uninsurance in America. Washington, D.C.: National Academies Press.

Lambrew, J. M. and A. Garson. 2003. Small but Significant Steps to Help the Uninsured. New York: The Commonwealth Fund.

McWilliams, J. M., A. M. Zaslavsky, E. Meara et al. 2003. Impact of Medicare Coverage on Basic Clinical Services for Previously Uninsured Adults. Journal of the American Medical Associatioin 290 (6): 757–64.

Olson, L. M., S. F. Tang, and P. W. Newacheck. 2005. Children in the United States with Discontinuous Health Insurance Coverage. New England Journal of Medicine 353 (4): 382–91.

* Rhoades, J. A. 2006. The Uninsured in America, 1996–2005: Estimates for the U.S. Civilian Noninstitutionalized Population Under Age 65. Statistical Brief #130. Washington, D.C.: Agency for Healthcare Research and Quality.

Schoen, C., and C. DesRoches. 2000. Uninsured and Unstably Insured: The Importance of Continuous Insurance Coverage. Health Services Research 35 (1 Pt 2): 187–206.

Schoen, C., S. K. H. How, I. Weinbaum et al. 2006. Public Views on Shaping the Future of the U.S. Health Care System. New York: The Commonwealth Fund.