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Gaps in Health Insurance: An All-American Problem

Middle-Income Uninsured

Executive Summary

National health care spending is climbing by more than 7 percent per year, outpacing economic growth by a substantial margin. As health care costs have climbed, so has the number of people without health insurance in the United States, even during a period of overall economic growth. In 2004, according to U.S. Census data, nearly 46 million people of all ages were uninsured, an increase of 6 million over 2000. This combination of eroding health insurance coverage and rapidly rising health care costs raises concerns about the ability of U.S. families to obtain timely medical care, protect their finances from catastrophic health care costs, and save for retirement.

The Commonwealth Fund Biennial Health Insurance Survey, a nationally representative survey of 4,350 adults age 19 and older, presents new information on the health insurance coverage of Americans and the health and financial consequences families face when they experience breaks in insurance. The survey, conducted between August 2005 and January 2006, finds that while the lowest-income families have always been most at risk of not having insurance coverage, more moderate- and middle-income earners and their families are also in jeopardy. In addition, one of five of all adults under age 65 is currently paying off debt from medical bills incurred in the past. Those who lack insurance are particularly affected by this burden. The survey also finds that uninsured people with chronic health conditions like diabetes and asthma are much more likely to skip medications for their conditions and go to an emergency room or hospital than are those who are insured.

This publication is one in our series on

Biennial Health Insurance Surveys

Previous in the series

Key findings of the survey include:


Rising Numbers of Uninsured Individuals Are in Moderate- and Middle-Income American Families

  • Two of five (41%) working-age Americans with incomes between $20,000 and $40,000 a year were uninsured for at least part of the past year—a dramatic and rapid increase from 2001 when just over one-quarter (28%) of those with moderate incomes were uninsured (Figure ES-1).
  • Adults with incomes under $20,000 were still the most likely to be uninsured: more than half (53%) had spent time uninsured in the past year.



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  • Most people who are uninsured are in working families. Of the estimated 48 million American adults who had any time uninsured in the past year, 67 percent were in families where at least one person was working full time.

Many Americans Report Medical Bill Problems and Medical Debt

  • One-fifth (21%) of working-age adults, both insured and uninsured, currently have medical debt they are paying off over time and more than two of five (44%) of these individuals are carrying $2,000 or more in debt.
  • More than one-third (34%) of adults ages 19 to 64 either had medical bill problems in the past year or were paying off accrued medical debt. Problems include not being able to pay bills, being contacted by a collection agency about unpaid medical bills, or having to change way of life to pay bills.
  • Three of five (62%) of all adults with medical bills or debt problems said they or their family member were insured at the time the debt was incurred.
  • More than half (51%) of uninsured adults reported medical debt or bill problems. Of those, nearly half (49%) used up all their savings to pay their bills. Two of five were unable to pay for basic necessities like food, heat, or rent because of medical bills.
  • Rates of medical bill problems and debt were high among people in both lower-income and higher-income households who experienced a time uninsured. Indeed, rates were highest among those with higher incomes. Nearly three of five (59%) adults with incomes of $40,000 or more reported difficulties with medical bills or accrued debt. Forty-six percent of adults with higher incomes were paying off unpaid medical bills over time, with over half (54%) of these individuals carrying $2,000 or more in medical debt.

People with Gaps in Coverage Have Difficulty Managing Chronic Conditions

  • An alarmingly high proportion—59 percent—of uninsured adults who had a chronic illness, such as diabetes or asthma, did not fill a prescription or skipped their medications because they could not afford them.
  • More than one-third (35%) of uninsured adults who had a chronic condition went to an emergency room or stayed overnight in the hospital in the past year because of their condition—about two times the rate of people with chronic health problems who were insured all year (Figure ES-2).



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Individuals with Gaps in Coverage Are Much Less Likely to Get Preventive Care

  • Only 18 percent of uninsured adults ages 50 to 64 had a colon cancer screen in the past five years, compared with 56 percent of adults insured all year.
  • Less than half (48%) of uninsured women ages 50 to 64 had a mammogram in the past two years, compared with 75 percent of women who were insured all year.
  • Few adults without medical insurance receive dental care: only 35 percent of those uninsured at the time of the survey had a dental exam in the past year, half the rate of those who were insured for the full year.


People with Gaps in Coverage Experience Inefficient Care

  • Nearly one-quarter (23%) of adults who reported spending any time uninsured in the past year said test results or medical records were not available at the time of a scheduled appointment, compared with 15 percent of continuously insured adults.
  • Nearly one of five (19%) adults with any time uninsured said he or she had been given a duplicate test, twice the rate of duplication reported by continuously insured adults.

It is clear from the findings of this survey and from prior research that the health care—and ultimately the health and productivity—of the U.S. population is being damaged as the nation's insurance problem continues to grow. Real solutions that build on group forms of coverage already in place, including employer plans, Medicare, Medicaid, the State Children's Health Insurance Program, and state and federal employee benefits plans, will help to fill insurance gaps with meaningful, affordable coverage that helps link families and providers. Preventive care routines, like cancer screenings, blood pressure and cholesterol tests, dental exams, as well as care for chronic conditions, should be the shared reality of all Americans.

Publication Details



S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, The Commonwealth Fund, April 2006