August 1, 2001
Cathy Schoen, Karen Davis, Catherine Hoffman and Diane Rowland
"Gaps in Health Coverage Among Working-Age Americans and the Consequences," Catherine Hoffman, Cathy Schoen, Diane Rowland, and Karen Davis, Journal of Health Care for the Poor and Underserved 12, 3 (August 2001)
This article, published in the Journal of Health Care for the Poor and Underserved, examines health coverage and access to care among working-age adults using the Kaiser/Commonwealth 1997 National Survey of Health Insurance. One of three (52 million) working-age adults were either uninsured at the time of the survey or had a recent gap in their health coverage in the past two years. Having even a temporary gap in health coverage made a significant difference in access to care. Compared with the elderly, who are continuously covered by Medicare, working-age adults have greater problems paying their medical bills and gaining access to care, and are less satisfied with their health insurance coverage.
Gaps in Health Insurance Coverage
While 19 percent of working-age adults were uninsured at the time of the survey, another 13 percent reported that they had a period of time in the past two years when they were not covered by health insurance. Both of these groups were more likely to be young adults (ages 18-34) and to have lower incomes than those who had continuous health coverage over the past two years. Two-thirds of those who had been uninsured anytime in the past two years reported the period lasted a year or longer; 44 percent were uninsured for two years or more. Low-income working families were particularly at risk, as the majority (59%) of adults in low-income working families were or had been uninsured sometime in the past two years (Figure 1). The most common reasons the uninsured cited for not having health insurance were that they couldn't afford it (51%) or lost their job or aren't offered benefits (25%), while only 11% did not want it.
Consequences of Being Uninsured
Being uninsured has serious consequences, as nearly half of uninsured adults said they had either a problem paying their medical bills or a problem getting needed health care in the past year. About one-third of both uninsured working-age adults and those who had a recent gap in coverage reported they had a problem paying for medical bills in the past year-while 17 percent of uninsured adults (and 13% of those with a recent gap) said that their family had to change their way of life signifi-cantly to pay medical bills and nearly half who owed medical bills had been contacted by a collection agency about this debt.
Compared with those with continuous health coverage, the uninsured were three to five times more likely to have problems getting necessary health care. Those who had a recent gap in their insurance coverage were two to three times as likely as adults with continuous coverage to have postponed care, to have had difficulty with or not received needed care, or to have not filled a prescription because of the costs in the past year (Figure 2). Not getting needed care had serious consequences, as 74 percent reported the problem had caused either pain or made it difficult to do their normal activi-ties, and almost half (45%) said they still had the same health problem.Working-Age vs. Elderly Populations
While the insured nonelderly have much lower rates of access and bill problems than their uninsured counterparts, the elderly over age 65-nearly all of whom are insured by the Medicare program-report even fewer problems. Only 10 percent of the elderly reported not getting care or problems paying medical bills compared with 27 percent of working-age adults (Figure 3). The elderly were also more likely to have a consistent source of medical care. Only 10 percent of adults age 65 or older (compared with 30% of younger adults) did not have a regular doctor and over half said they had been seeing the same doctor for at least five years. Given their health care experiences, continuity of coverage and relationship with a regular doctor, it is not surprising that the elderly were considerably more likely to be satisfied with their Medicare coverage than those with either employer-based health coverage or Medicaid (Figure 4).Conclusions and Policy Implications
The impact of being even temporarily uninsured is substantial. This study found that those who were insured at the time of the survey-but who had a recent gap in health coverage in the past two years-were almost as likely as the uninsured to have had problems either getting needed health care and/or paying their medical bills in the past year. Transitions in health coverage undermine the continuity of health care, including preventive check-ups, and jeopardize the financial security of millions of working Americans and their families.
While the enactment and subsequent expansions of the Children's Health Insurance Program have been significant steps toward insuring more Americans, many working-age adults continue to fall outside CHIP's reach and are also not eligible for or not participating in Medicaid. Incremental reforms that target certain age groups fail to recognize the health and financial impacts on the family as a whole when any family member is left uninsured. The experience of states that have expanded their CHIP and/or Medicaid programs to cover the uninsured parents of low-income children will provide important lessons for other policymakers as they weigh incremental steps to expand health insurance to the large majority of uninsured: low-income, working-age adults.