The Overshadowing of the Uninsured

Despite the increased emphasis on health care issues in the 1990s, the number of uninsured Americans continues to steadily rise. While economic growth generally increased family income levels over the past 15 years, the costs of health coverage have risen faster dampening the expansion of health coverage for many working families. Wherein 34.7 million people, about 13.9 percent of the U.S. population, were uninsured in 1990, an estimated 44.3 million Americans, or 16.3 percent of the population, were without health insurance by 1998.^[28]

According to U.S. Census Bureau figures, the total percentage of uninsured Americans moved up to 15.6 percent by 2003, as shown in Figure 1.

Source of Health Funding	2003 U.S.Population (millions)	% of Population
Employer Funded	174.0	60.4
Direct Funded	26.8	9.3
Subtotal Private Coverage	200.8	69.7
Medicare	39.5	13.7
Medicaid	35.7	12.4
Military	10.1	3.5
Subtotal Public Coverage	85.3	29.6
Uninsured	44.4	15.4
TOTAL U.S.Population	288.2	See below
Note: Numbers and percentages do not add up to 100 percent, as many Americans have duplicate coverage or may be covered by more than one source (e.g., retirees who have Medicare coverage and also supplemental private coverage). Source: "Inventory, Poverty and Health Insurance Coverage in the United States: 2003," U.S. Census Bureau; Department of Labor, www.census.gov.

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Figure 1: Sources of Healthcare Funding 2003

The disparity of the uninsured is most evident when the data is examined by race: 10.6 percent of white Americans are uninsured, as compared to 19.6 percent for African Americans, 27.5 percent for native Americans, 18.6 percent for Asian Americans and 32.8 percent for Hispanics (regardless of racial origin). Geography makes a difference, with the highest rates of uninsured in Texas (24.6 percent), New Mexico (21.3 percent), California (18.7 percent), Nevada (18.3 percent) and Wyoming (16.5 percent).

Aggravating the problem is higher costs of health insurance for smaller businesses, which do not have the same ability to spread risks or to self-insure as larger companies. Other concerns deal with employers who feel pressured to pass along additional costs to their employees if health care costs continue to increase faster than general inflation, or if employers face additional costs due to legislation permitting plan members to sue plan sponsors.

Some studies also point to a fundamental structural change in the movement of employment in explaining some of the reduction in employer-based health insurance. Employer funded healthcare accounted for 64.2 percent of healthcare funding in 1987, which dropped to barely 60 percent in 2003 (see above). During the same period there was a similar reduction in the number of Americans working in the manufacturing sector, from 24 percent in 1987 to 18.8 percent in 2002. Many of those workers shifted to the personal services sector, which hosts a significantly lower rate of health insurance coverage; 69.4 percent in manufacturing in 2002 compared to 43.2 percent for the personal services sector.

The growth in public and private initiatives on ways to extend coverage to the uninsured, especially children, underscores the societal importance being placed on tackling this issue. Without consistent health care coverage, medical treatment is often deferred until conditions reach acute stages. Patients lacking health insurance often flood hospital emergency room, many seeking primary care that would normally be delivered in a physician's office. The number of ER visits jumped 23 percent over five years, from 89.8 million visits in 1998 to 110.2 million in 2002, General health also can be further jeopardized without regular preventive care and recommended screening tests.

The apparent correlation between increases in health care costs and the growth in the number of uninsured persons underscores the importance of continuing to evolve managed care in a manner that can continue to control costs and make benefits more affordable. As public policy is shaped to further extend coverage, managed care programs will continue to be an important vehicle used to deliver health coverage.