As we move into "Cover the Uninsured Week," one of the most misunderstood numbers in public policy is the U.S. Census Bureau's estimate that 45 million Americans do not have health insurance. And that's a problem.
There is widespread political support for action that will reduce the number of uninsured. But first we must understand this population. The uninsured are not some monolithic, identical body. The uninsured vary significantly in the amount of time they are uninsured, in their social and economic conditions and even the states where they live. As a result, any legislative attempt to solve the uninsured problem with a broad brush, as elected officials like to do, almost certainly will make matters worse, at least for some. Consider these facts:
- The percentage of uninsured has remained relatively constant over the years: 15 percent. Yes, the number of uninsured has been rising recently, but the uninsured as a percent of the U.S. population has remained relatively constant for many years. So this is a longstanding problem, not a newly arrived "uninsured crisis."
- People are uninsured for relatively short periods of time. There is a common impression that the uninsured have been in that condition for years. But most are uninsured for relatively short periods of time. According to a study by the U.S. Congressional Budget Office, 45 percent are uninsured for four months or less. And only 6 percent are "chronically uninsured" – that is, for two years or longer. Thus, being uninsured is similar to being unemployed: It happens to almost everyone at some point, but for most it's a relatively short period of time.
- Most of the uninsured are workers. The uninsured don't tend to be poor since the poor most often qualify for Medicaid. About 83 percent of the uninsured are workers, with 60 percent of the uninsured working full time all year.
- The uninsured tend to be young and healthy. When pundits are discussing the uninsured, they often imply the uninsured are near- seniors who are sick and can't get health care. In fact, most are young and healthy; and many are recent graduates who are starting their careers in lower-paying jobs. However, as their careers progress most will find jobs that provide health insurance.
- Some of the uninsured have high incomes. While most of the uninsured are lower-income workers, about 25 percent have annual incomes of $50,000 or more – though a recent analysis by the Employment Benefit Research Institute estimates closer to 18 percent.
- The uninsured and the uninsurable are not the same. The uninsured don't have health insurance, but they probably could get it if they could afford it. The uninsurable, by contrast, have been declined health insurance by an insurance company because of a preexisting medical condition. It's an important distinction.
Thirty-two states are providing health coverage for the very small part of the population that is uninsurable by establishing high-risk pools.
Nearly 200,000 Americans currently get their health insurance through a high-risk pool.
- The number of uninsured varies significantly from state to state. Only about 9 percent of Minnesotans are uninsured, and 11 percent of Iowans. By contrast, about 20 percent of Californians are uninsured. And Texas is usually the highest with 28 percent of its population uninsured. There are several reasons for those variations, including the state's workforce and ethnic mix. But a national solution that might help Texas may not help Iowa.
- Being uninsured does not mean no access to health care. People frequently say that 45 million Americans go without health care. That's incorrect. Virtually every American can get health care, even if they have to go to a hospital emergency room. The United States has a public and private safety net patchwork to help those who are uninsured. It isn't perfect, but it does exist, and millions of uninsured Americans get quality care through that system.
Yes, we do need a solution for the 45 million uninsured Americans – or better yet "solutions." But they must be targeted to address the varying problems listed above. What won't work is a single solution. The uninsured are different, and the solutions must be also.
Merrill Matthews is director of the Council for Affordable Health Insurance, a research and advocacy association of insurance carriers.
Grace-Marie Turner is president of the Galen Institute, a research organization that specializes in health policy.