Another focus of Task Force tracking and analysis is employer-sponsored health coverage—the backbone of the U.S. system of health insurance. In recent years, double-digit annual increases in insurance premiums have forced many employers to shift more of their health care costs to employees. According to Fund-supported work by Jon Gabel, small businesses have been particularly hard hit because they face greater costs compared with large employers and higher financial risks from providing benefits to small pools of workers.⁽¹⁵⁾ As a result, workers in small businesses are more likely than their counterparts in larger firms to be uninsured, pay more of their premium costs, and face higher deductibles.

While workers in small firms face more coverage risk, new research supported by the Task Force shows there are growing numbers of uninsured workers at large firms. Columbia University's Sherry Glied and Sarah Little, along with George Washington University's Jeanne Lambrew, have found that the long-term shift away from manufacturing in the U.S. economy, coupled with a declining rate of unionization in the workforce, has led to an increase in the share of uninsured workers employed at large firms. From 1987 to 2001, the proportion of uninsured workers employed by firms with more that 500 employees grew from 25 percent to 32 percent.⁽¹⁶⁾ New work by Peter Fisher and David West of the Iowa Policy Project and the Center for a Changing Workforce is examining the insurance coverage of temporary, part-time, and contingent workers at both small and large firms.

Even so, both small and large employers feel it is important for companies to offer health benefits to their workers, according to a Commonwealth Fund Supplement to the 2003 National Organizations Study.⁽¹⁷⁾ Most employers said they would support a variety of policy options that would expand health insurance coverage and make it more affordable, including requiring employers to offer coverage.

Additional research by the Task Force has broken ground in understanding the dynamics of insurance coverage, in particular showing that insurance coverage is far from static in the U.S. population. While many people remain uninsured for long periods, others cycle on and off coverage. People with gaps in insurance coverage are much more likely to experience health care access problems and difficulty paying medical bills than those with uninterrupted coverage. Task Force-supported research by Pamela Farley Short finds that 85 million Americans were without health insurance at some point between 1996 and 1999. This is more than double the number of uninsured individuals at any point or in any one year during this period.^(18),(19) Fund-supported projects will be examining the effect of this "churning" on access to health care and documenting its cost to public insurance programs across the country.

Hispanics are at particularly high risk of experiencing gaps in their coverage or undergoing long periods without coverage. Task Force staff members Michelle Doty and Alyssa Holmgren found that 37 percent of Hispanic workers with incomes under 200 percent of poverty who had been employed full-time between 1996 and 2000 were uninsured for the entire four years.⁽²⁰⁾ Through a grant to the National Alliance for Hispanic Health, the Task Force supported a working meeting to mobilize Hispanic community leaders in support of expanding insurance coverage for Hispanics and generating agreement on specific ways to tailor major insurance coverage initiatives to the needs of this population.

Young adults also often find themselves in an insurance coverage "limbo." Research by Task Force staff found that substantial churning in young adults' insurance coverage is a result of eligibility changes in both public and private programs as well as leaving high school and college. Policy recommendations presented in the Task Force brief, Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, formed the basis of a bill introduced by Representative Vic Snyder to give states the option to increase the Medicaid and CHIP age limit from age 18 to 23.⁽²¹⁾

Older adults who are nearing retirement but still too young for Medicare are likewise at heightened risk of losing their insurance coverage. In 2005, the Task Force will be examining the insurance experience of older Americans with a new survey of people ages 50 to 70. The survey will shed light on the new Medicare prescription drug discount cards, retiree health benefits, financial security in the later years, and new coverage options for people approaching retirement.