Uninsured in the United States

# Who are the uninsured?
Among the uninsured population, nearly 38 million were employment-age adults (ages 18 to 64), and more than 27 million worked at least part time. About 37% of the uninsured live in households with incomes over $50,000. According to the Census Bureau, 36.7 million of the uninsured are legal US citizens. Another 10.2 million are non-citizens, but the Census Bureau does not distinguish in its estimate between legal non-citizens and illegal immigrants. It has been estimated that nearly one fifth of the uninsured population is able to afford insurance, almost one quarter is eligible for public coverage, and the remaining 56% need financial assistance (8.9% of all Americans). An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.
According to the U.S. Census, in 2006, there were:
- 8 million uninsured children in the United States
- The state with the highest percentages of uninsured was Texas (24.1% average for three years, 2004-2006.)
- Those of Hispanic origin were the most impacted by being uninsured.  Their numbers grew from 14 million (32.3 percent) in 2005 to 15.3 million (34.1 percent) in 2006.
Young adults make up one of the largest and fastest growing segments of the uninsured population.  They often lose coverage under their parents' health insurance policies or public programs when they reach adulthood at age 19.  Others lose coverage when they graduate from college.  Many young adults do not have the kind of stable employment that would provide ongoing access to health insurance.
A report by the Kaiser Family Foundation in April 2008 found that U.S. economic downturns place a significant strain on state Medicaid and SCHIP programs.  The authors estimated that a 1% increase in the unemployment rate increase Medicaid and SCHIP enrollment by 1 million, and increase the number uninsured by 1.1 million.  State spending on Medicaid and SCHIP would increase by $1.4 billion (total spending on these programs would increase by $3.4 billion).  This increased spending would occur while state government revenues were declining.  During the last downturn, the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal assistance to states, which helped states avoid tightening their Medicaid and SCHIP eligibility rules.  The authors conclude that Congress should consider similar relief for the current economic downturn.

# Causes
Americans who are uninsured may be so because: their job does not offer insurance; they are unemployed and cannot pay for insurance; they may be able to buy insurance but may decide to take chances and see what happens without having health coverage; or, they may be "underinsured," which means they have some level of insurance, but it is insufficient for covering all of their needs.
Historically, most working Americans have received their health insurance from their employer.  However, recent trends have shown an ongoing decline in employer-sponsored health insurance benefits.  In 2000, 68 percent of small companies with 3 to 199 workers offered health benefits.  Since that time, that number has continued to drop to 2007, when 59 percent offered health benefits.  For large firms with 200 or more workers, in 2000, 99 percent of employers offered health benefits, and in 2007, that number stayed the same at 99 percent.  On average, considering firms of all numbers of employees, in 2000, 69 percent offered health insruance, and that number has fallen nearly every year since, to 2007, when 60 percent of employers offered health insurance.

# Consequences
To strive to properly care for their health while being uninsured, people turn to a variety of resources.  This includes: community or nonprofit hospitals or health clinics that charge no or reduced prices for health treatment; asking their health provider for a reduced fee for their healthcare services; turning to medical facilities, pharmacies and hospitals abroad that may charge considerably less than U.S. rates for healthcare; or, going without care altogether.
Additionally, being uninsured impacts American consumers' health in a tangible way, according to a 2008 survey: 
- More of the uninsured chose not to see a doctor when were sick or hurt (53 percent) vs 46 percent of the insured.
- Fewer of the uninsured (28 percent) report currently undergoing treatment or participating in a program to help them manage a chronic condition; 37 percent of the insured are receiving such treatment
- 21 percent of the uninsured, vs. 16 percent of the insured, believe their overall health is below average for people in their age group]
The costs of treating the uninsured must often be absorbed by providers as free care, passed on to the insured via cost shifting and higher health insurance premiums, or paid by taxpayers through higher taxes.

# Emergency Medical Treatment and Active Labor Act (EMTALA)
EMTALA, enacted by the federal government in 1986, requires that hospital emergency departments treat emergency conditions of all patients regardless of their ability to pay and is considered a critical element in the "safety net" for the uninsured. However, the federal law established no direct payment mechanism for such care. Indirect payments and reimbursements through federal and state government programs have never fully compensated public and private hospitals for the full cost of care mandated by EMTALA. In fact, more than half of all emergency care in the U.S. now goes uncompensated. According to some analyses, EMTALA is an unfunded mandate that has contributed to financial pressures on hospitals in the last 20 years, causing them to consolidate and close facilities, and contributing to emergency room overcrowding. According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26 percent, while in the same period, the number of emergency departments declined by 425. Hospitals attempt to bill uninsured patients directly under the fee-for-service model, but most such people cannot pay their hospital bills, and escape into bankruptcy when hospitals seek legal process against them.
Mentally ill patients present a unique challenge for emergency departments and hospitals. In accordance with EMTALA, mentally ill patients who enter emergency rooms are evaluated for emergency medical conditions. Once mentally ill patients are medically stable, regional mental health agencies are contacted to evaluate them. Patients are evaluated as to whether they are a danger to themselves or others. Those meeting this criterion are admitted to a mental health facility to be further evaluated by a psychiatrist. Typically, mentally ill patients can be held for up to 72 hours, after which a court order is required.