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Uninsured and Underinsured in America

In America, we not only have the problem of the non-insured but the under insured which causes just about as much problem as the underinsured. Each group has contributed to the vast growing cost of healthcare. Over the last decade or two, the amount of uninsured has risen due to the job market in the economy and the fact that most insurances are tied to employment, which is also a problem as the unemployment rate rises. The purpose of this paper is to explore this issue.

Under insured people can be defined as “people who are insured all year but have one of the following qualifiers: Medical expenses greater than ten percent of annual income; an annual income less than two hundred percent of the poverty level and medical expenses greater than five percent of annual income and health plan deductibles equal to or greater than five percent of annual income” (Nunley, 2008). According to Nunley (2008), several factors contribute to the underinsured.

This might include but are not limited to the unemployment rate that rises every year and low-income wage earners. There are barriers to the Medicaid/Medicare coverage that might be an asset to the underinsured.

Event he more insured people of America may find it hard to access health care due to limited medical professionals available in their area. They may also be burdened with overbearing cost sharing with the employer-based insurance plans. The cost sharing can be burdensome to families that are just making enough to survive. These cost sharing plans do not adjust for lack of income.

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Patients that have little or no health insurance face many difficulties accessing quality care. The drive is to make people more health conscious consumers of health care and therefore if a patient is cost sharing then they will be more apt to do their maintenance care rather than show up in the emergency room as a train wreck.

According to Wayne (2013), “about eighty four million people were uninsured or underinsured, three million more than when two thousand ten health law was signed and twenty million more than in two thousand three…about eighty million adults who had medical conditions said they chose not to see a doctor or fill a prescription because of cost” (Wayne, 2013). Although a reform is needed, the amount of uninsured or underinsured continues to grow. The fact that the reform of the health care relies heavily on state run exchanges that are supposed to help the uninsured and underinsured gain access to health insurance. Medicaid is likely to be expanded in many states for the poor under this program to help disperse the cost of health care from the federal government pocket.

The federal government facing millions of uninsured and underinsured Americans and the fact that there is looming federal debt, it is not just the uninsured and unemployed at risk. Many Americans face the growing concern of unemployment or employed and losing their health care coverage under the current regime. Many Americans face being employed and losing their health care insurance due to the new standards and expense. This puts middle to upper middle class people at risk of losing their insurance for the first time. This trend is contributing to the piling medical debt and eventual bankruptcy claims to put off paying mounting debt that they cannot afford.

The under insurability is figured out by the amount of medical bills per year against that of the mounting medical bills to be paid. Insurance is known to be expensive. Americans usually cannot afford their own, therefor obtain insurance through an employer-based coverage. Some insured cannot afford the amount of premiums charged by their employers. Although there are coverage’s for children, many adults are left without many options, especially if they do not have any children. This leaves many adults with little or no recourse. Since the Obama regime, many Americans have lost jobs, which means their employer-based coverage.

Many of the uninsured or underinsured are low-income or working families. According to the Kaiser foundation, “…adults are more likely to be uninsured than children. People of color are at higher risk of being uninsured than non-Hispanic Whites” See Appendix 1 (Kaiser Foundation, n.d.). Many Americans therefore go without needed health care each year due to the cost alone. These are the people with chronic diseases that need preventative services that may prove to reduce cost in the long run. With the economy failing the added depression and stress helps to hinder good health.

At the current moment, doctors’ offices can refuse care to any uninsured person, whereas an emergency room cannot. The hospital is required by federal law to adequately screen and stabilize a patient. This is where the uninsured tend to show up for care where they tend to seek emergency care for urgent medical conditions that might not have been there due to lack of insurance. This would include the screening tests such as a colonoscopy or a mammogram for preventative care. This can delay the diagnosis of a serious complication that might have easily been taken care of through preventative services. The uninsured and underinsured are generally not as healthy as the insured counterparts. There is also lack of follow up care and medication to make sure the disease is under control. This group of individuals are found to have a higher mortality rate than those who are insured and have preventative services.

According to the Kaiser foundation, “medical bills can put great strain on the uninsured and threaten their physical and financial well-being. The uninsured are almost twice as likely (forty seven percent versus twenty three percent) as those with health insurance coverage to have trouble paying medical bills” see Appendix 2 (Kaiser foundation, n.d.). The emergency department has been a catch all for those without insurance and ability to pay. With the current economy, the newly unemployed and uninsured are turning to them for their basic care. The statistics are staggering. According to the American College of Emergency Physicians, “eight in ten underinsured or non-insured are working families that cannot afford insurance or qualify for public programs; sixty-six percent live in households with a full time worker; twenty percent of African-Americans are uninsured; thirty-three percent of Hispanics are uninsured; and nearly all the uninsured or under insured are under the age of sixty-five” (ACEP, 2013).

The emergency “safety net” are those facilities that are mandated to offer medical care to those that do not have the ability to pay or the status of the patient’s insurance. The people that show up in these safety nets are those that have delayed care of serious medical conditions and are more likely to die before their time compared to their insured counterparts. The overcrowding of the emergency department results from the lack of inpatient beds available for those that need longer term care. These patients are being housed in the emergency room until an available bed opens up. So what are the costs? Hospitals absorb the burden of billions of dollars in uncompensated health care. In the past, compensation was shifted to the insured patients for cost. This option of cost shifting is no longer an option due to regulated prices of the managed health care plans.

The reform is necessary for this to help shift costs. According to DHHS, “employer sponsored insurance covered one hundred seventy four million people or fifty nine percent of the population in two thousand four” See appendix 3 (DHHS, 2005). Not every low-income person is eligible for Medicaid. This is a result of income and other factors. Unfortunately cost is a big issue with being able to afford medical insurance. Most people that had medical debt were paying it off over time. The cost of health care is a substantial obstacle to be able to secure timely health care services. Some people avoid health care costs due to lack of money to pay the bills. As the open enrollment of the Affordable care act has come to a close for the year, people without health insurance or those that are inadequately insured will be able to purchase health care coverage that is supposed to be affordable for the individual and the family. States like Texas have declined to participate in the expansion.

The states will shoulder much of the money to filter into the health care costs after two thousand sixteen. Underinsured or uninsured adults go without needed medical care and struggle with the medical debt that they have. This increases their risk for being uninsured because “while they have health insurance, holes or limits in their plans expose them to often unaffordable medical costs…to reduce the number of underinsured, it will be critical for the plans offered under the Affordable Care Act reforms to keep deductibles and out-of=pocket costs low for essential effective care” (The Commonwealth Fund, n.d). This unnecessarily contributes to added stress that should not be a concern. Sometimes the health insurance that they have does not cover critical medical treatments, leaving one to pay out of pocket for these.

According to Health Well Foundation, “approximately twenty-nine million Americans are underinsured and is an eighty percent increase from two thousand and three” (Health Well Foundation, 2011). Health Well foundation goes on to state that a lot of the underinsured are children and are most likely to be so under private insurance, especially if they are sick. This used to plague lower income families, but in recent years, it has rose up the scale of income and now affects up to the middle to upper middle class. According to the Health Well foundation, “more than one in five patients has been forced to abandon treatment simply because they cannot afford it” (Health Well Foundation, 2011). With this staggering number, especially those that deal with chronic diseases, spend thousands of dollars in out of pocket expenses each month, unfortunately this is more than most people earn. Some adults and some children that are underinsured have admitted to delaying treatment or just completely skipping it all together due to cost.

The economy is not what it used to be and so people tend to focus more on the basic necessities than health care until there is a problem. In Maslow’s hierarchy of needs, there are five stages that one needs for self-actualization. In the case of the economy and many jobless Americans, the first stage is “biological and physiological needs (food, air, water, shelter)” (McLeod, 2011). In this instance, health care is not a priority until something big happens. These are the patients that show up in the emergency room falling apart due to lack of preventative care they missed due to lack of being able to afford it. According to Manag, “the perspective that Maslow’s model brings is an essential element that should be considered as the health care arena is faced with reorganization, re-engineering, mergers, acquisitions, increases in learning demands, and escalating role of technology in training” (Manag, 2003). The uninsured and the underinsured are not the only ones feeling the stress of the health care crisis.

The health care workers are forced to make due with thousands of new patients with less resources. An overwhelming number of bankruptcies are related to health care costs. According to Health Well foundation, “when patients miss their prescriptions, they have higher rates of emergency room visits, doctor visits, and hospitalizations-to the tune of two hundred fifty eight billion to two hundred ninety billion per year” (Health Well foundation, 2011 ). This unfortunate event is having employers pass the cost to their employees. With the cost shift is costing the average family of four and increase from “eight hundred and five dollars a month to one thousand four hundred and twenty dollars a month. Over the same period, total monthly income grew only thirty percent, barely keeping pace with inflation…health insurance premiums and worker contributions for family coverage more than doubled from five thousand two hundred and sixty nine dollars in two thousand and one to ten thousand nine hundred forty four dollars in two thousand and eleven” (Health Well Foundation, 2011 ).

Health Well foundation goes on to state “even with health reform, the trend of increasing copays trend will continue because Patient Protection and Affordable care Act does not address underinsurance…to minimize the risk that the newly insured could become underinsured, designs will need to take a value-based approach that ensures access and financial protection for essential care” (Health Well Foundation, 2011). The Affordable Care Act mandate did two things. The first was the individual mandate. This was to make sure that everyone signed up for the health insurance. This was also to prevent health insurance companies from turning away people based on pre-existing conditions. This was a common place in the insurance realm prior to this being signed into law in two thousand ten. This also prevented them from price gauging and raising the price of insurance so high, that an individual could not really afford it. The second mandate was aimed at the business world.

The purpose was to shift some of the cost to the employer. This is in addition to the regulations on the insurance companies. The employer in this instance would face a fine if one of their employees buys insurance from an exchange and qualifies for the subsidy from the government. The business mandate has been delayed a few times, most recently in February of this year. Unfortunately, this might prove to be a disastrous move as many employers will turn to hiring part time workers so that they do not have to pay for the insurance or the fine. This would decrease the amount of money each worker will make and therefore have a negative effect on an already failing economy. This may force many lower paying jobs to not offer health insurance at all. This will put the heaviest burden on those workers. This will have little to no change on those that are not covered by insurance as there will then be more people uninsured and underinsured which is what the Affordable Care Act was intended to prevent in the first place.

According to Carroll, “the decrease in employer-based coverage would add an expense to the federal cost of the ACA: about four point three billion a year…estimated one hundred thirty billion to cover costs for employers dropping health coverage for employees” (Carroll, 2014). According to Voelker, “an estimated one point one million people who use community health centers for their medical needs will go without health insurance because they live in one of the twenty four states without current plans to expand their Medicaid programs under the Affordable Care Act, according to a new report” (Voelker, 2014). Since these people live in the opt-out states, the citizens may fall into a coverage gap between Medicaid coverage and the low income subsidies from the exchanges. The health centers in the South remain at a loss since many have opted out of Medicaid expansion. According to Voelker, “states should expect more people to use emergency departments after the Affordable Care Act is fully implemented” (Voelker, 2014). Also according to Voelker, more Caucasian patients are apt to seek emergency services in the wake of the ACA than Black.

The study that Voelker speaks about is that the drive toward the emergency room care is driven by the uninsured, which suggests that more Caucasian people will be left uninsured. The article also suggests that other states should expect the same type of trend to happen in their emergency rooms. According to Butler, “any bill designed to transform one-sixth of the economy was bound to have-let us say-a few rough edges” (Butler, 2014). The ACA is already unstable. If the signups of healthy young people continues to lag, this may result in a disaster for the ACA as this was dependent on those age groups signing up for this. This may cause a spike in premiums for next year. We are already shouldering the cost for millions of people that do not have insurance.

This is the combination of uninsured and underinsured. The pickup of the health care tab is being put on to the employers and the federal government. With the recession upon us, this puts bigger restraints on people’s wallets. According to Kavilanz, “twenty five million Americans cannot afford to cover the gap between what their insurance covers and their medical bills demand” (Kavilanz, 2009). This brings us back to the point of people that delay medical care until it is absolutely necessary. Due to the laws that currently exist, emergency rooms are required to treat whatever walks through their door. When the bills are not paid, the hospital eventually writes it off or shifts the costs to any charity program that exists in the hospital. The new trend is to shift the cost to someone who can pay for it. This usually shifts to government insurance and private insurance, thus raising the cost of insurance. The hospitals tend to negotiate higher rates from those insurance companies to help cover the increasing bad debts. This makes the insurance companies charge higher premiums to their clients to cover cost increase. This is a vicious cycle of payments and increases. This leads to poor health outcomes.

The uninsured and under insured are more likely to suffer from chronic diseases. Unfortunately, diabetes is one of the most common end stage diseases that we have. This also does not help when preventative care services are not sought to control the diabetes processes, protect their kidneys and their eyes. Then there are the numerous surgeries for amputations of limbs due to poor control, non-compliance and lack of preventative services. These patients are usually diagnosed in the latter to end stages of the disease, and since they do not seek preventative measures, the lack of adequate care leads to premature death and/or numerous hospitalizations. This accounts for lost days at work and higher premiums for those that have insurance. Lack of insurance gets in the way of needed medical screenings, which can prevent some or all of these diseases.

The very least of which can monitor the diseases. The massive uncompensated health care is putting a burden on a system that is currently struggling to keep its head above water. The health care system also has an impact on physician services. This would include everything from not taking new patients to the number of new doctors that we are getting. There are many physicians that refuse new patients because they are already over burden. However, they are accepting privately insured patients and those that can afford to pay. The decline for physicians accepting Medicaid is slowly declining due to numerous payment issues. This is also true for Medicare patients. There are also not as many physicians coming out of schools any more. That number has been shown to be slowly decreasing which leaves less doctors to care for the growing number of patients.

The health care costs are shown to increase faster than the employee wages. Earnings are lower than the cost of healthcare to them and their employee. This cost is being passed to the employee by higher deductibles and premiums. The insurances are also covering less leaving the employee to make up the rest of the cost. According to Camacho , “ as a result, employees are now bearing thirty five to fifty percent of the cost of healthcare through reduced wages, copayments/coinsurance or higher premiums” ( Camacho, 2004). On the flip side of this, employers are laying people off and reducing hours to help cover their cost, which in turn, affects the economy and the spending of earned dollars. According to Camacho, “inadequate treatment and chronic under-funding of mentally ill patients leads to public leads to public costs related to crime and criminal justice” (Camacho, 2004).

Jails and juvenile facilities have become the treatment of choice and sometimes the only alternative for some people to receive adequate care. This increases the crime rate. The values that we have as a nation. Americans believe in equal opportunity. Americans have the right to an education to further the dream of owning a home and providing for a family. Education is a guaranteed right. Health care is not treated the same way which leads to the risk of financial ruin and poor health outcomes. According to the Declaration of Independence, the citizens of this country enjoy inalienable rights, this includes “life, liberty and the pursuit of happiness” (Declaration of Independence, 1776). If Americans believe in these rights, then the system which is supposed to give us these rights has failed us because health care would be tied into the life and pursuit of happiness. Americans also hold economic efficiency to a high standard, simply stating that we like getting good value for the money.

The US spends almost “twice per capita on health care on average than other countries do…the American Health care system suffers from rampant un insurance, subpar life expectancy and infant mortality rates, and uneven performance on quality…Americans do not need more money for health care; they need more health care for their money” (Casoy, 2005). The lack of health care is become a moral issue. The United States is the only industrialized nation without a universal health care system. Other countries have declared health care a basic right. The US has not done this. They have, in the past, treated health care as a privilege to those that can afford it. This has resulted in a high cost of health care that is being passed on to those that have insurance to help pay the bad debts of the health care bills that are not being paid. According to Casoy, “uninsured have an excess mortality rate of twenty five percent” (Casoy, 2005). This leaves a lot of people that have to choose between basic necessities and pills.

This would also account for those that have been diagnosed with inoperable diseases because they cannot pay for it. There is also an economic gain to a healthier work force. A universal health care system does not seem so far-fetched when the overall cost of health care is looked at to include time lost on a job. Reform of the current system is long over-due. The high cost of insurance and health care as well as price gauging and passing the costs to people that can pay is a thing of the past. The reform should be one of a single or a couple of health care choices where the prices are controlled and the health care spending is not out of control. There are many Americans that are uninsured and more that are being threatened of un- insurance. The reforms that need to be put into place need to cover everyone equally. This would not be based on anything other than the right to be adequately covered without it costing the average person more than they make in a year. The number of the uninsured have grown despite the availability for the new health care exchanges and health insurance that is highly over-priced to begin with.

These people that have become uninsured do not qualify for the lower income insurance because they make too much. The lack of coverage can have not only serious effects to the health of the individual but can have consequences for the workforce and economy. The delay in getting treatment can be costly to not only the patient but everyone involved as the costs have been passed on to people that can pay. People are being able to access health care for the first time but others are losing their health care coverage contributing to the problem that they are trying to solve. The answer seems to be that of one universal health care coverage program that can cover everyone that is a citizen that can set cost limits and reduce the cost to not only the consumer but to the nation as a whole. Reforms are definitely a necessity. Universal health care should be a guaranteed right and not just available to those that can afford it.

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of the 2005n current population survey. Retrieved from Voelker, Rebecca. (2014). Community Health centers and their patients take a big hit in Medicaid opt-out states, report says. Retrieved from Voelker, Rebecca. (2014). Emergency visits up in Massachusetts after reforms enacted. Retrieved from Wayne, Alex. (2013). Uninsured population swells in advance of U.S. health. Retrieved from

Wolf, Richard. (2010 ). Number of uninsured Americans rises to 50.7 million. USA Today. Retrieved from Young, Jeffery. (2013). Uninsured Americans 2012: more than 45 million lacked health insurance last year, CDC reports. Retrieved from

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