Uninsured in America: problems and possible solutions

doi:10.1136/bmj.39091.493588.BE

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Karen Davis (kd@cmwf.org)

Commonwealth Fund, 1 East 75th Street, New York, NY 10021

Failure to ensure access to health care for all lies at the heart of the US failure to achieve value for money, says Karen Davis

The United States is the only major industrialised nation without universal health insurance, and coverage has deteriorated in the past six years. The consequences are increasingly well known: inequities in access to care, avoidable mortality and poor quality care, financial burdens on people who are uninsured or underinsured, and lost economic productivity. The US spends twice as much on health care as the median industrialised nation but does not systematically achieve the best quality care (table⇓). What are the prospects for reform?

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Healthcare indicators for eight countries

Trends in uninsured and underinsured

The US has a mixed public-private system of health insurance. It comprises:

Federal Medicare programme, covering people aged 65 and over and those who have been disabled for two years or more (12% of population)
State Medicaid programmes—covering children from low income families and in some states their parents as well as providing long term care and cost sharing for acute care for Medicare beneficiaries with low incomes (13%)
Voluntary employer based private insurance—covering many working families (54%), and
Individual insurance (5%)

The remaining 16% of the population is uninsured.1 The number of uninsured people has increased from 40 million in 2000 to nearly 47 million in 2005.2 Coverage varies widely between states and has deteriorated in recent years (fig 1⇓).3

Fig 1 Percentage of people aged 18-64 without insurance by US state3

Nearly all of the growth in the uninsured is among people aged 18 to 64, most of whom are working. The average family premium for employer based cover is $11 480 (£5900; €8800) a year.4 Employers have cut back on coverage and benefits in response to rising healthcare …