Health Policy Center, independent research for better health policy: The Urban Institute


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The Uninsured

The growing number of uninsured in the United States is a major social problem.  There are now 46 million non-elderly Americans (2008) without health insurance, including both children and adults.  Once fully implemented, the new health care reform law – the Patient Protection and Affordable Care Act (PPACA) of 2010 -- is expected to cut the uninsured rate by roughly 60 percent, but the remaining number of uninsured will still be significant.

The uninsured are in all age ranges, though young adults are most likely to be uninsured.  People in the south and west are more likely to be uninsured than those in the northeast and Midwest.  Most uninsured are in families with at least one full time worker.  Hispanics disproportionately have the highest rates of uninsured, but the largest share of the uninsured by far is white Americans. 

The consequences of the lack of health insurance are serious.  The uninsured are less likely to use health services and have poorer health as a consequence.

The number of uninsured has continued to increase each year, primarily reflecting a decline in the rate of employer-sponsored insurance, despite increases in public coverage.  These trends are likely to continue until full implementation of PPACA in 2014. 

While coverage is expected to increase beginning in 2014, success of health care reform in reducing the uninsured will be strongly related to the effectiveness of outreach efforts and strategies designed to make enrollment and retention in subsidized public and private insurance options simple and affordable.

Those remaining outside of the newly expanded systems of coverage will include: undocumented immigrants, those still without affordable coverage options available to them, those choosing to pay tax penalties instead of enrolling in coverage, and those eligible for subsidized coverage but who do not enroll in it for a variety of reasons.  These populations will continue to face the challenges experienced by the uninsured today, and depending upon their numbers and their health status, their lack of coverage may have implications for the sustainability of the federal reforms.

Staff in the Urban Institute’s Health Policy Center have produced detailed data on insurance coverage, including the number and characteristics of the uninsured at the national and state levels.  We have also followed trends in coverage and have written extensively on changes in coverage over many years.  Much of this work has attempted to tie changes in the U.S. economy to the trends in employer-sponsored insurance, public coverage, and the uninsured.  Analyzing the impact of PPACA on the number of uninsured, the characteristics of the uninsured population, and the implications of the remaining uninsured for various aspects of the reforms is a new but central focus for the research group.  Recent analyses include:

  • The costs associated with providing medical care to the uninsured;
  • The likely effects of PPACA on the uninsured, state-by-state;
  • The effects of reforms in Massachusetts on insurance coverage for specific populations;
  • The impact of unemployment on insurance coverage;
  • Estimation of the implications of various subsidization schedules under reform on the number uninsured;
  • Implications of an individual mandate for insurance coverage; and
  • Variation of insurance coverage across Congressional districts.


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