President's Message
Aiming High: Targets for the U.S. Health System
1. Long, Healthy, and Productive Lives
2. The Right Care
3. Coordinated Care over Time
4. Safe Care
5. Patient-Centered Care
6. Efficient, High-Value Care
7. Universal Participation
8. Affordable Care
9. Equitable Care
10. Knowledge and Capacity to Improve Performance

Policy Options for Improving Health System Performance

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Adults ages 19-64 reporting access problems due to cost, by insurance status

Source: C. Schoen, M. M. Doty, S. R. Collins, and A. L. Holmgren, "Insured But Not Protected: How Many Adults Are Underinsured?" Health Affairs Web Exclusive, June 14, 2005.
Despite spending more on health care than any other nation, the United States is the only industrialized nation without universal health insurance coverage. The number of uninsured Americans has increased steadily over the last five years, from 40 million in 2000 to 46 million in 2004.(22) In the absence of federal leadership, some states have responded by adopting programs to expand health insurance coverage. The state of Maine, for example, recently enacted Dirigo Health Care, which enables small businesses to purchase coverage, with workers paying their share of premiums on a sliding-scale basis.(23) The Commonwealth Fund provided funding for technical assistance to design and launch the program, which bears careful monitoring as a possible model for other states and the nation.
Data from 2003 show that, in addition to the 46 million uninsured adults, another 16 million U.S. adults were underinsured—meaning their insurance did not protect them adequately against catastrophic health care expenses.(24) An estimated 35 percent of people ages 19 to 64 had either no insurance, sporadic coverage, or insurance coverage that exposed them to high health care costs and increased the chances they would go without needed medical care.
Recent increases in deductibles-the amount insured individuals must pay before their health benefits begin-will likely place growing numbers of insured patients and their families at risk.(25) Employers are beginning to offer "high-deductible health plans" with minimum deductibles of $1,000 for individuals or $2,000 for families, which qualify for tax-sheltered health savings accounts. These plans are relatively new, but research over the last three decades suggests that high out-of-pocket costs lead to underuse of essential care, failure to fill prescriptions necessary to control chronic conditions, and increased emergency room use and hospitalization.(26) (27)
Instability of health insurance also contributes to another important difference between the United States and other industrialized nations: we are less likely to have lasting relationships with our doctors. Only 37 percent of American adults report that they have been with the same physician for five years or more, compared with more than half of adults in other countries.(28) This lack of continuity has implications for communication, adherence to recommended care, and access to preventive, primary, and specialized care.
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Percent of non-elderly population uninsured by state

Two-year averages 1999-2000 and 2003-2004 from the Census Bureau's March 2000, 2001 and 2004, 2005 Current Population Surveys. Estimates provided by the Employee Benefits Research Institute.