Study: One in Four Americans Without Health Insurance Coverage

A quarter of the adult population ages 19 to 64 experienced a gap in health insurance in 2011, and 69% of those were without coverage for year or more, according to study released Thursday by the nonprofit Commonwealth Fund.

"For people who lose employer-sponsored coverage, the individual market is often the only alternative, but it is a confusing and largely unaffordable option," said Commonwealth Fund Vice President Sara Collins, lead author of the report. "As a result, people are going a year, two years, or more without health care coverage, and as a result going without needed care."

The report concludes that "eliminating gaps in coverage is essential to ensuring that Americans can gain timely access to health services that are necessary to maintain good health over time." It points to the Affordable Care Act as a way to close some of those gaps.

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Commonwealth Fund: Gaps in Health Insurance: Why So Many Americans Experience Breaks in Coverage and How the Affordable Care Act Will Help

A new survey, the Commonwealth Fund Health Insurance Tracking Survey of U.S. Adults, finds that a quarter of the adult population ages 19 to 64 experienced a gap in health insurance in 2011. Nearly seven of 10 (69%) of those with a gap went without coverage for a year or more. Of those who were uninsured at the time of the survey or were insured but had experienced a gap, 41 percent previously had employer-based coverage, 18 percent had been enrolled in Medicaid, 6 percent had a plan purchased in the individual market, 7 percent had been insured through another source, and 27 percent never had health insurance. Among those who had employer-sponsored insurance prior to their gap in coverage, two-thirds (67%) cited a loss or change of a job as the primary reason; nearly six of 10 (58%) were uninsured for a year or more.

The individual market has proven to be a weak stop-gap option for families who lose employer insurance. In the survey, adults who tried to buy a plan on their own in the individual insurance market reported substantial difficulties finding affordable health plans that met their health needs. Of adults who tried to buy a plan in the individual market in the past three years, 60 percent found it very or somewhat difficult to compare the benefits covered by different plans and more than half (55%) found it very or somewhat difficult to compare premium costs. More than two of five (45%) never ended up buying a plan. Cost was the most often cited reason for not purchasing a plan.

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The recession that began in 2008 revealed the degree to which health insurance coverage in the United States depends on whether people have jobs and if those jobs include health benefits. The Commonwealth Fund found that over 2008-2010, more than half of adults--an estimated 9 million people--who lost a job with health benefits became uninsured.2 Very few people enrolled in continuation coverage through COBRA or found a plan on the individual insurance market. The sluggish recovery has meant that millions of those workers remain uninsured: a record 5.3 million people have been searching for a job for longer than six months.

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People who do not have access to employer health benefits and are ineligible for Medicaid are largely limited to purchasing coverage in the individual market. But the individual market for most Americans is neither affordable nor easy to navigate. People buying coverage in the individual market must pay the full premium and, under current laws in most states, are rated on the basis of their health, gender, and age. They can also be denied coverage because of a preexisting condition or have their condition excluded from their health plan.

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In the survey, while nearly all (92%) adults who were continuously insured reported they had a regular doctor, doctors' group, health center, or clinic where they usually went for medical care, those with gaps in coverage were much less likely to have a regular source of care, with rates declining with the length of time uninsured. Among adults who had been uninsured for less than one year, three quarters (76%) reported having a regular doctor. But, of those adults who had spent one year or more without health insurance, fewer than half (46%) reported having a regular source of care.

Similarly, adults with a gap in their health insurance were less likely to be up to date with preventive care tests than were those who were continuously insured. While 83 percent of adults who were insured all year had had their blood pressure checked in the past year, the rate declined to 70 percent among those who had experienced a gap in their health insurance of less than a year and to 51 percent among those who had been without coverage for a year or longer. Likewise, 70 percent of adults who had been continuously insured had their cholesterol checked in the past five years (or in the past year for those with hypertension or heart disease) compared with half of adults who had been uninsured for under a year and one-third (33%) of adults who were uninsured for a year or more.

Recommended cancer screening rates were also far lower among adults who experienced disruptions in their coverage compared with those who were continuously insured. Three-quarters (74%) of women ages 40 to 64 who were insured all year reported that they had a mammogram in the past two years. But only 28 percent of women in that age group who had been uninsured for a year or more said that they had a mammogram in the recommended time frame. Similarly, 72 percent of women who were insured continuously had a Pap test in the recommended time frame compared with fewer than half (46%) who experienced a gap in coverage of a year or longer. Colon cancer screening rates were low among adults who were insured all year, but extremely rare among adults who had long gaps in coverage. Fifty-seven percent of continuously insured adults ages 50 to 64 reported that they had a colon cancer screening in the past five years while fewer than one of 10 (9%) adults who had been uninsured for a year or more reported that they had received the test.