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Makeup of uninsured population unclear

Without an accurate picture of the uninsured, policy designed to expand coverage could go awry.

By Joel B. Finkelstein, amednews staff. April 14, 2003.

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Washington -- The problem of the uninsured has been met with many proposals, but few account for the dynamics of the uninsured, according to several health experts.

They worry that these approaches will give with one hand while taking away with the other.

"There's just a lot of moving in and out of this group of people that we call uninsured," said Pamela Short, PhD, professor of health policy and administration at Penn State University. "We need to think of the uninsured as a moving target."

According to Census Bureau data, the ranks of the uninsured have grown to more than 41 million Americans, but that number does not tell everything.

That's because the number of people who are uninsured during any point in a year remains relatively constant from one year to the next, albeit rising over time. That number looks very different, however, when broken down into groups by how long people are uninsured.

For example, an estimated 80 million people went without insurance for some period in the past two years. But 24 million Americans went without insurance for the entire past two years, while a monthly average revealed 45 million without insurance.

A cross-sectional survey, such as the U.S. Census, "gives you a picture of the uninsured that's skewed toward people who are uninsured for longer periods of time," Dr. Short said.

The risk is that policies designed to help the population of people without insurance for long periods of time can have unintended effects on other populations, said John L. Czajka, PhD, a senior researcher at Mathematica Policy Research Inc., based in Washington, D.C.

Policies that address a long-term lack of insurance may not only fail to address short-term breaks in coverage, but also create perverse incentives that encourage brief gaps in insurance, he said.

For example, states have instituted waiting periods for coverage under the State Children's Health Insurance Program to prevent it from encouraging employers to drop private coverage. That can result in unnecessarily extended periods of going without insurance, Dr. Czajka said.

A recent report from the Institute of Medicine showed that the lack of insurance is associated with Americans getting too little care, too late. Uninsured Americans are sicker, die younger and even receive less care for traumatic injuries than people with health insurance.

Even a few months without insurance is associated with an increased risk to people's health.

Hang on tight

But obtaining coverage for the uninsured in only part of the battle, policy experts said.

"Getting people insured does not keep them insured, and this is something that needs to be addressed," Dr. Czajka said.

A recent report from the Commonwealth Fund suggested that relaxing the requirement for staying in public health programs and easing the transition between work-based coverage and public insurance could put a dent in the problem of the uninsured.

The authors estimated that insurance retention could reduce the number of uninsured, low-income children by nearly 40% and the number of uninsured adults by more than 25%.

While seemingly a good idea, that approach might be difficult to enact.

"Health coverage is a very transient experience for millions of us, actually for most of us, because it's tied to where we work, if we work, if we're part-time, if we're full-time, if we're married, if we have children, and it's even tied to our age," said Cathy Hoffman, ScD, associate director of the Kaiser Commission on Medicaid and the Uninsured, in Washington, D.C.

The Consolidated Omnibus Budget Reconciliation Act was meant to help close this gap. But "COBRA coverage tends to be very expensive to purchase, and a lot of people are determined that they'd rather take a chance than pay for it," Dr. Czajka said.

A study by the Urban Institute showed that only 57% of non-elderly workers were eligible, and only 7% of unemployed adults have coverage through COBRA.

"One of our policy goals should be to try to increase the continuity and stability of coverage to get rid of gaps that people experience over time," Dr. Short said. But care is needed so that federal policies don't introduce new eligibility rules and administrative procedures that widen the gaps.

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