How Many Americans Are Uninsured? It Depends On Whom You Ask

Not having health insurance in America is not so much a single problem, as several problems that may be moving targets.

A new report by the Congressional Budget Office (CBO), “How Many People Lack Health Insurance and For How Long?,” paints a portrait of the uninsured population as a far more fluid group than is generally acknowledged: a significant number are chronically uninsured, but many are without insurance for a short period only.

And one of the problems of “uninsurance”—a term commonly used to denote not having health insurance—appears to be one with legs: some people are likely to be insured, uninsured, then insured again within the same year. Short- and long-term states of uninsurance are separate problems that may require distinct policy approaches, the CBO report suggests.

Notably, the CBO report refutes the widely disseminated figure of 40 million uninsured, saying the number of Americans without health insurance for an entire year is more likely to be between 21 million and 31 million.

The figure of 40 million comes from the Census Bureau’s Current Population Survey, and it more closely approximates the number of people who are uninsured at a specific point in time during the year—not the number who are chronically uninsured, according to the CBO.

“Some people are uninsured for long periods, but more are without coverage for shorter times, such as between jobs,” the CBO states. “For example, about 30 percent of nonelderly people who become uninsured in a given year remain so for more than 12 months, whereas nearly 50 percent regain health insurance within four months.”

Health policy experts familiar with the report say the picture of the uninsured population painted by the report is well known to insiders but less so to the general public, whose opinions may shape pronouncements and policies by legislators.

“The uninsured population is changing in terms of its membership all the time,” said Pamela Short, Ph.D., a professor of health policy and administration at Pennsylvania State University.

She emphasized the CBO’s data showing the discrepancy between those who are uninsured for long periods, those who are uninsured at one point during a year, and the total figure for those who are uninsured at any time during a year.

“What that suggests is that among those who are uninsured, half are either moving into or moving out of being uninsured,” she told Psychiatric News. “There is a lot of turnover.”

Irvin Muszynski, J.D., director of APA’s Office of Healthcare Systems and Financing, said the CBO report lends precision to figures commonly used to describe the problem of Americans who do not have health insurance. He pointed out, however, that the designation “insured” does not necessarily equate with real access to care—particularly when it comes to mental health care.

“The problem of the uninsured is a continuing and serious one,” Muszynski said, “but insurance coverage doesn’t mean you have adequate access to quality psychiatric care.”

Different Surveys Used

The CBO report breaks the uninsured population into three distinct categories, based on the reporting measures used by three federally sponsored national surveys—the Survey of Income and Program Participation, the Medical Expenditure Panel Survey, and the National Health Interview Survey. All of these yield estimates of the number of uninsured at a particular point in time that are similar to the Census Bureau’s Current Population Survey estimate of 40 million.

But the number of people who are uninsured for the entire year is estimated to be 21.1 million by the Survey of Income and Program Participation, and 31.1 million by the Medical Expenditure Panel Survey.

Meanwhile, the number of people who are uninsured at any time during the year—the combination of those who are uninsured all year and those who are uninsured at a particular point in time—is between 56.8 million and 69 million.

The CBO also presents data showing that long spells of uninsurance occur less frequently than short spells, but that they are more likely to be under way at any given time. Looking at spells of uninsurance that began between July 1996 and June 1997, the CBO found, based on data from the Survey of Income and Program Participation, that 45 percent of those spells lasted four or fewer months.

Yet data from the same survey looking at periods of uninsurance that were in progress during March 1998 showed that 78 percent of them had lasted more than 12 months.

“Policies aimed at increasing coverage are most likely to be effective if they consider the distinction between the short-term and long-term uninsured,” the CBO states. “For people with short uninsured spells, policies might have the goal of filling a temporary gap in coverage or of preventing a gap from occurring. For people with longer periods without insurance, policies might seek to provide or facilitate an ongoing source of coverage.”

Numbers Matter

Short agrees that the distinction has important public policy implications, especially given that there is no apparent political will for establishing universal health coverage. “As long as we are stopping short of covering all the people all the time, then we need to think of uninsurance not as a group of people, but as gaps of time when people are without insurance,” she said. This amounts to a “real change of mindset.”

Policies that fail to recognize the distinction between short- and long-term uninsurance are liable to cost more than anticipated by creating secondary, unintended effects. She cited, as an instance, the option of giving tax credits for buying insurance, an approach that has been favored by the Bush administration.

While superficially attractive, Short says tax credits “piggyback” on the tax system, which views time as occurring a calendar year at a time. Yet as the CBO report indicates, many of those who would benefit from a tax credit would not in fact be uninsured for the whole year, Short said.

More constructive would be policies that seek to keep eligible Medicaid enrollees on the Medicaid rolls or that provide ways to make the federal COBRA insurance plan, which covers workers between jobs, more affordable.

Short suggested that precision in the use of numbers is important, since the numbers can be used to support varying perspectives. At one extreme is the figure of 60 million uninsured at any point during a year—a figure that might suggest to the comfortable middle class: “This can happen to you.”

At the other end of the extreme is the figure of 21 million to 31 million people who are uninsured throughout the whole year—more methodologically precise than the widely quoted figure of 40 million, but one that may understate the problem of recurrent lack of access to medical care.

“The size of the problem looks very different depending on how you count the uninsured,” she said.

The report, “How Many People Lack Health Insurance and For How Long?,” is posted on the Web at www.cbo.gov/showdoc.cfm?index=4210&sequence=0. ▪