Rising premiums are making coverage in the individual insurance market increasingly expensive—leaving few affordable options for older adults, those with low incomes or preexisting medical conditions, or others without access to job-based coverage. Priced out of the individual market and left out of the employer-based market, some people are turning to discount medical cards. Not true coverage, these cards instead provide discounts to purchasers for certain medical services. As reported by Georgetown University's Mila Kofman, J.D., in a March 2005 Fund issue brief, some of these cards provide a measure of value to purchasers. But others have serious drawbacks, including exaggerated claims of savings, difficulty finding participating doctors, and providers who fail to give cardholders promised discounts. Fund grantees are now examining the proliferation of these cards among temporary and contract workers, who traditionally have had little access to employer-based coverage.

Consumers' medical bill problems and medical debt are other symptoms of the affordability crisis in health insurance coverage. In a Fund publication that received wide attention in the press, Fund senior analyst Michelle Doty, Ph.D., and her colleagues reported that while it is the uninsured who most often experience problems paying medical bills and incur medical debt, even many working-age adults who are continually insured are affected. The study, Seeing Red: Americans Driven into Debt by Medical Bills, also found that working-age adults incur significantly higher rates of medical bills and debt than adults 65 and older. The Washington Post, Chicago Tribune, and Bloomberg.com were among the media outlets that ran stories.

The Future of Health Insurance program also monitors the changing dynamics of insurance coverage in the United States. Fund-supported research has found that, while many people remain uninsured for long periods, others cycle on and off coverage. People with gaps in coverage are as likely to experience difficulty accessing care and paying medical bills as those who are continually uninsured. Fund-supported projects are examining the characteristics of people who "churn" in and out of different sources of insurance coverage, the effect of such churning on their access to health care, and the costs to public insurance programs.

Adults nearing retirement but still too young for Medicare are at risk of losing their insurance coverage, according to the recent Commonwealth Fund Survey of Older Adults.^{(13) (14) (15)} Nearly a quarter of older adults were uninsured just before entering Medicare. Older adults are particularly vulnerable to high medical costs, since 70 percent have at least one chronic health condition. Majorities of older adults who were surveyed expressed interest in new policy options to protect them from the high costs of medical care, both before and after retirement. An option developed by Fund staff would let older adults set aside a percentage of their paychecks in an account within Medicare to use when they became eligible for the program and enabling them to buy into Medicare before age 65.