The Uninsured Millions in the United States


The lack of health insurance in the United States is one of the major issues grappling the healthcare industry and indeed the American society as a whole. There have been widespread fears that the steady increase in the proportion of uninsured people in the population is a ticking time bomb; that will have devastating effects on society if it goes unchecked.

These fears are not baseless; lack of health insurance has been linked to poor health outcomes ranging from elevated morbidity and mortality; lack of primary prevention services and subsequent increased incidence of preventable diseases; lack of access to essential healthcare services by sections of the population; this leading to the postponement of seeking proper care until the disease has developed into an irreversible or serious state. This results in the stretching of hospital facilities which are forced to admit more people; who would have been treated as simple outpatient cases if the necessary care had been sought earlier.

Children, in particular, are adversely affected by lack of health insurance; poor health has been linked to sub-optimal mental development; and poor academic performance. Indeed, if these effects are not checked in the younger population, then the long-term picture of the country’s workforce is not good vis-à-vis productivity and performance. Poor general health in a population also has the ability to elicit sentiments of abandonment or resentment; which has the effect of creating mistrust and social strife. For a country that is as culturally diverse as the United States, all efforts to create social cohesion will amount to nothing if some sections of the society feel left out by the healthcare industry.

In the face of this challenge; and its potential negative outcomes, it is necessary to analyze the problem of health insurance quickly, thoroughly and objectively so as to come up with a proper solution that will ensure proper healthcare services for the population; and more importantly, that will put in place measures to ensure that the future generations find mechanisms able to cater for their healthcare needs.

Lack of health insurance


The healthcare system in the United States is a complex system of overlapping roles shared between the private and the public sector. While over the years it has evolved to a level that is adequate enough to cater effectively for a large proportion of the population, there still remain gaps in the system through which a significant number of Americans slip through; and find themselves without any insurance; or being inadequately insured (Rowland & Shartzer, 2008).

All the people under the age of 65 are ideally supposed to be covered through job benefits offered by employers as part of the employment package. On the other hand, Medicare covers all people who are 65 years and above in age; and people who are below this age but have severe or permanent conditions that do not allow them to work. As much as this coverage may seem to cover all angles, two crucial groups of people have been omitted; these are people below the age of 65 but that do not have access to employer-sponsored insurance and children. To cater for this segment, two programs Medicaid and the State Children’s Health Insurance Programs (SCHIP) were instituted; access to these services is however regulated by eligibility as determined by the level of income of the candidate. This effectively locks out a large number of people who on one hand cannot afford to pay for their healthcare needs out of their pocket, and on the other hand, are declared ineligible since they do not meet the necessary criteria for income deficits.

The magnitude of the problem

While the figures depicting the state of health insurance cover in the country may be alarming, a more urgent need is to stem the increase in the proportion of the uninsured population. In 2006, about 47 million people were uninsured in the United States (Silverman, 2008; Rowland & Shartzer, 2008); this constitutes about 18 of the population of Americans under the age of 65. However, this is an increase of over 7 million since 2001.

On the other hand, arbitrary figures may not be accurate representations of the situation on the ground. This is due to the fact that the gain or loss in health insurance by the individual and population is determined by the economy of the country, demographic dynamics; and events in the labor market. As such, a one-tie sample of the population will not capture the individuals who lose their cover during the period which affects their ability to do so. This is of particular importance to the non-elderly population; which has been shown to experience about 30% lack of cover for a period of at least one month of the year (Rowland & Shartzer, 2008).

The American healthcare system is supported to a large part by employer-sponsored coverage; this has been put into a severe threat by the double assault of increased costs of healthcare forcing employers to pay higher contributions for their respective employees; and an economic downturn that has severely affected the job market with companies hiring less and laying-off some staff in attempts to reduce their costs of operations. On the other hand, the ability of the federal government to fund public coverage both as an attempt to cover the deficit left by the private sector; and to play its traditional role as the financier of services for senior citizens has been put into question. This is in light of the federal deficits and a rapidly aging American population.

The healthcare industry and the American society are therefore not only faced with a problem that is large but also that is increasing in magnitude and that has a capacity to degenerate into a complete meltdown of the industry. A combination of increasing unemployment rates, increase in healthcare costs and increased federal deficits would leave a majority of people exposed; and unable to pay for any kind of service from their earnings; if this trend was to continue unchecked.

There is also a need to recognize the impact of lack of health insurance on the economy of the United States; the cost stemming from ill health and shorter lifespan in uninsured and underinsured Americans is estimated to range between $65 and $130 billion every year that the people are not insured (Silverman, 2008).

Susceptibility to lack of cover

Americans who are not covered are from diverse social backgrounds; however, they do share certain characteristics which make them more susceptible to inadequate or no cover. The uninsured are characteristically low and moderate-income earners below the age of 65; these are the ones who ideally are supposed to be covered by the employer-sponsored regime (Rowland & Shartzer, 2008). Children, in particular, constitute a significant portion of the uninsured people with 8.7 million accounting for one in every five uninsured people. There however has been an increasing concern over the increase in the proportion of uninsured people in moderate and higher-income families (Silverman, 2008).

The uninsured population is not static and fluctuates depending on the individual affordability of the service at any one time. As such, a large proportion of the non-elderly population suffers a lack of cover for short periods of time ranging up to one month in a year. The key to lack of insurance is the inability to pay for either the premiums or directly paying for the services rendered at the delivery point. The increased premiums in particular have outstripped the inflation and the increase in workers’ wages over the years. On the other hand, the amounts that the employers contribute for the workers have remained relatively stable; this is partly due to the bargaining power of the companies and their benefits of economics of scale. This renders it almost impossible for an average American to either access the premiums or the costs directly.

People from racial or ethnic minorities have been shown to more likely suffer lack of cover; and are disproportionately represented in the uninsured population. For example, in 2006 about 36% of the Hispanic population was uninsured and about 22% of the African-American population; this is in comparison to the 13% of the white population during the same period. This can be liked to the lower incomes earned by minority Americans; and lower eligibility for coverage. Recently arrived immigrants, non-citizens and naturalized citizens also have a higher likelihood of being uninsured.

Gender also plays a role; on average while employer-sponsored coverage is the same for all sexes, women are less likely to be insured through their employer; are more likely to be ineligible due to working part-time; have lower income, and are more likely to depend on the coverage by the husband.

Health insurance and the healthcare sector

The healthcare industry has been cited to have been both adversely affected and as being part of the problem vis-à-vis the lack of health insurance by such a significant proportion of the population. Healthcare providers have had to come up with mechanisms that ensure that an individual in dire need of medical attention will not be turned away from a service point despite having no insurance cover; this involves classification of an uncovered patient either as charity care whereby they are treated for no charge after the assessment of their ability to pay; or as bad debt where the provider has been successful in getting payment for services rendered (Smith, 2008). Such measures have resulted in the providers passing some of these costs to the other consumers in the form of increased costs of services since they (providers) are obliged to bill for any of the services rendered. This has, in part, led to the increase in the premiums due for insurance coverage.

On the other hand, some sectors of the industry have borne the brunt of the trend of increasing lack of insurance among Americans; for example, the emergency departments across the country are increasingly grappling with the challenge of allocating limited resources to insatiable medical needs (Baillargeon et al, 2008); this is primarily due to an increase in the number of people without health insurance who are using hospital emergency departments as their primary source of healthcare services.

This phenomenon has resulted in the crowding of emergency rooms by people presenting problems that would have ideally been handled by other departments and that involve primary care and has left institutions writhing under millions of dollars of uncompensated costs. This has had the effect of making the healthcare system very inefficient; apart from taking up much time and attention from emergency-room staff (which may be crucial for patients brought in with true emergencies); this also results in the underutilization of some of the hospital departments and the net increase in the operation costs of the hospital.

Efforts to decongest emergency rooms have not been successful; this is partly due to the inability of the visitors to pay for the bills that are mandatory for departments other than the emergency ones. As such, the main problem here is affordability.

Implications to nursing

Despite the obvious shortcomings of the healthcare financing and provision systems in the United States, there are measures that individual practitioners and institutions can take to mitigate the effects of lack of insurance both to an individual and at a population level. While some of these measures require policy changes, some only involve modifications to individual paths of practice.

The major question in this area is whether it is possible to provide quality care but at a price where a patient can afford it even without insurance. One of the areas where lack of insurance adversely affects the health of a patient is the lack of compliance to the prescribed regime due to un-affordability. The financial burden, for example, of purchasing medicine may very well be the major obstacle to the recovery of the patient. This in turn results in the increased frequency of readmission; or to severe and potentially fatal outcomes of a disease (Luthy et al, 2008).

The major factor fuelling the high costs of healthcare in the United States is the high cost of medication. On one side, medical practitioners tend to prescribe newer medication for their patients which is significantly more expensive than older medication; on the other, the difference in efficacy between the old and new drugs are not significant to warrant complete denial of a sick person at least one form of treatment. It has been shown that medical practitioners can make healthcare services more affordable for the treatment of hypertension; gastroesophageal reflux disorders (GERD), insomnia, depression and diabetes mellitus (Luthy et al, 2008).

For example, while the treatment for GERD with the proton pump inhibitor Nexium (esomeprazole) may cost as much as $148.00 per month, it would only cost $11.00 to achieve the same outcomes with an older inhibitor Prilosec (omeprazole) (Luthy et al, 2008).

The future of healthcare insurance

The future of health insurance does not look very bright; this is in the face of a slowdown in the economy with its adverse effects on the labor market. This is compounded by an increase in the cost of healthcare and an increased federal deficit. A continuation of this trend will only see an increase in the lack of health insurance cover (Rowland & Shartzer, 2008). There is a general consensus both in the stakeholders and public domain that some form of action is long overdue; there is also recognition that any solution will cost significant amounts of financial resources. Apart from this, there are political and philosophical hurdles to overcome (Silverman, 2008).

However, several states and cities have begun to put in place measures to mitigate the current situation; this includes legislation universal coverage in Massachusetts and Vermont. Other states are also considering adopting this legislation or its variation ensuring coverage for the identified groups. A trend has developed whereby cities have taken the initiative of tackling the issue of health insurance independent of the federal government; which has been viewed a slow to respond to the problem (Silverman, 2008). On the other hand, there have been attempts to make healthcare more affordable by lowering the cost and increasing efficiency. An example of these is the development of ‘medical homes’ and the improvement of diagnostics and treatment to reduce hospital stays and readmissions (Silverman, 2008).


In order to effectively tackle the problem of health insurance in the United States, a concerted effort is necessary for effective reforms to be made. As discussed above, access to medical cover is determined by factors within and without the healthcare setup. As such, if any reversal in the current situation and prevention of its reoccurrence in the future has to take place, it has to involve all the players who affect this situation in one way or another.


  1. Baillargeon Jacques, David Paar, Thomas P. Giordano, Brian Zachariah, Laura L. Rudkin, Z. Helen Wu, and Ben G. Raimer (2008): Emergency department usage by uninsured patients in Galveston County, Texas: Proceedings (Baylor University Medical Center); 21(3):236–242
  2. Luthy E. Karlen, Neil E. Peterson & Joey Wilkinson (2008): Cost-efficient treatment for uninsured or underinsured patients with hypertension, depression, diabetes mellitus, insomnia, and gastroesophageal reflux. Journal of the American Academy of Nurse Practitioners 20; 136–143
  3. Rowland Diane and Adele Shartzer (2008): America’s Uninsured: The Statistics and Back Story. The Journal of Law, Medicine & Ethics. Volume 36 Issue 4, Pages 618 – 628
  4. Silverman D. Ross (2008): Access To Care: Who Pays For Health Care For The Uninsured And Underinsured? A Symposium Introduction and Overview: The Journal of Legal Medicine, 29:1–9
  5. Smith G. Dean (2008): The Uninsured in the U.S. Healthcare System (Covering the Uninsured): Journal Of Healthcare Management 53:2  2008
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