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Uninsured Working Poor: In Search of Affordable Quality Healthcare

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Main Street America has been hit hard with the economic downfall that has caused many Americans to dig deeper into their pockets or tighten their belts.  An issue of major concern affected by the tumultuous economy is healthcare.  According to the Center for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS) in 2007 there was an estimated 43.1 million people without health care insurance in the United States.  Amid this figure, 20 million were working but yet without health care coverage.  Over the years, this figure has not changed much and there is a growing fear, that as America wades through the economic crisis, there will undoubtedly be an increase in the number of people working yet uninsured. As the uninsured figures change, so is the health situation of our nation. A health nation is a productive nation. Going by the current trend, the heath of our nation may be deteriorating at alarming rate. An issue of great concern is that we have failed to provide the poor with affordable healthcare. As a nation we are challenged to come up with new models of health care that will address the needs uninsured.

 Just who is the uninsured, working poor?  In this paper, I will define the uninsured, working poor and examine the reasons that persist within this population.  While looking into the health care issues and needs, I will expand upon the areas of access, affordability, and quality health care for the uninsured, working poor.  Lastly, I will review a number of health care models that can provide affordable health care to the uninsured.

Who are the insured?

Under the current United States health care model, most health care providers are for profit. Although there have been strategies to lower the cost of health care, statistic reveal that more than 68% of the uninsured claim that they cannot purchase  insurance premiums because they are too expensive. While it has been argued that ignorance could be one of the factors contributing to a large number of uninsured, we can refute this proposition going by the number of uninsured. Majority of those who are not insured are below 40 years, 29% between 19 and 29, and 25% between 30 and 39 years old. These are grown up individuals who realize the importance of maintaining good health (Robert Wood Johnson Foundation, 2005). Research also reveals that eight out of ten uninsured are the working poor. This further asserts that economic condition could be the leading factor to a large number of uninsured individuals.

Most of the uninsured are poor individual who live below the federal poverty level. Most of these individuals constitute of family of four with income less than $18,400.  Most of the uninsured individuals are barely surviving and their financial concern is the focus on getting basic living like food, shelter, and clothing. This means that health care is not in the list of their priority, not because of ignorance but just because they are constrained financially. Therefore cost is a major barrier for most individuals.

Demographics of the uninsured

The distribution of access to health care is not even in the whole nation. There are some states which have a high number of uninsured individuals while other states have very low percentage of uninsured. The uneven distribution can be attributed to the different strategies which have been taken by different states to come up with appropriate health care models that really address the needs of its citizens. (Acs et al., 2000)

Let us look at the national demographic on the uninsured. By 2006, there were about 47 million people in the country who were without insurance of any kind. The key players in insurance coverage are the public programs, self-purchased insurance policies, and employer purchased policies (SPG staff, 2003). Approximately 47.7 million or 18.2% of the non-elderly population in the United States are covered by public programs. About 17.9 million which is approximately 6.8% of Americans are covered through self-purchased policies. Medicaid and SHIP covers about 36 million Americans while 7.5 million are covered through CHMPV/Tricare.  On age parameters, there are less uninsured elderly compared to the no elderly population.  Majority of those uninsured were less than 65 years with those aged 25-44 comprising of a huge 49%. This should be a concern because this age bracket constitutes the productive population of our nation. If we cannot provide health insurance for our productive segment of the population, then it means the productivity of our nation is at risk. (NCHS data on health insurance and access to care, 2007)

The importance attached to this productive segment of the population can be viewed in term of the model of our health care system where employees have been contributing to the health insurance of their employee. Employer based health care benefits is perhaps the primary source of health care insurance in this country. According to government statistics, it is evident that 31.9% of insurance coverage are employer-based (self) while 30.3% are employer based (dependant). Despite this coverage, the working poor lead in the category of uninsured Americans. According to the United States Census Bureau there are more than 47 million Americans including 9 million children who do not have an insurance cover of any type. States with the lowest percentage of uninsured were Minnesota (7%), Hawaii and Maryland (9%) States with the highest percentage of uninsured were Texas (27%), Louisiana and New Mexico (23%). (U.S Department of Health and Human Services, 2005) The implication of these statistics show that there are more than 6 million individual in our nations who gamble with their life and hopes they will not get sick since this could have far reaching implications on their health and their financial statute.

Since 1994, the percentage of uninsured in our nation has increased due to many factors.  Before the turn of the millennium, there was increased erosion of public coverage which drastically reduced the population that was covered by Medicaid. This was due to the introduction of employer insurance health scheme and the downsizing of the military which reduced those under CHAMPVA/Tricare. In 1994, the percentage of individuals who were insured through employer policies was 64.4% and this number had risen to 68.4% by 2000. Therefore we can say that employer coverage had been important in offsetting the number of uninsured people due to decreased public coverage. (Acs et al., 2000)

What are the healthcare needs and/or issues of this population?

There are many dimensions that we can consider when looking at the issue of uninsured in the country. As we have seen there are many factors that can restrict individual from getting health insurance cover. While many have been arguing that a larger percentage of uninsured individuals are ignorant of purchasing insurance cover, three key factors that are interplay include quality, access and affordability (Hoffman et al., 2004). The more the factor at play, the more difficult it is for individuals to have health insurance policies. In order to understand the situation well, we need to consider each of the factor.


Since the inception of the current for profit health care model, the quality of the health care has been a great concern to the consumers. Further changes which brought about more reduced health care cost came with serious implication on the quality of the health care. In a bid to provide low cost health care, it has been argued that most heath care providers compromised quality in order to lower the cost. The quality of the health care has been one of the greatest factors hindering individual from purchasing health care premiums (ED, 2007). As consumers, we are often concerned of the quality of service we are receiving in exchange for our money. (Ahmed et al., 2001)  Therefore, the issue of quality of care received against the cost of premiums has been one of the major factors forcing some people to prefer direct payment to physicians. Others have opted to pay less for heath care because of their prior experience. There are many uninsured people who are not willing to settle for poor quality health coverage provided by some insurance premiums.


Health care access can be defined in term of availably and eligibility of the needed heath care service within the reach of individuals. Most of the uninsured people don’t have access to the needed health care services due to interplay of many other factors. (Hoffman et al., 2004) In this case, we want to review access to health care insurance as a cause of high number of uninsured individuals. The pegging of eligibility criteria on individual and family income has left many working poor without insurance cover. We have to consider other factors at play for us to arrive at accessibly.

Let us take an example of the public health insurance schemes like Medicaid and SCHIP. There are many individuals who qualify for these service yet they are not benefiting from them. SCHIP which was supposed to provide coverage for all children in the country has come with many eligibility requirements such that many children who are likely to be benefiting from the program are not enrolled. This shows that health insurance coverage may be available in the country but it is not accessible to some segment of the population due to the eligibility criteria. (Ahmed et al., 2001) Other public programs like Medicaid has all kept many qualified individuals due to accessibility criteria. There are individuals who are qualified for the program but they have not been enrolled due to several factors at play. The enrollment process may be rigorous while many people think that they don’t meet the income eligibility limits. (Hoffman et al., 2004)


Affordability is the main factor that is leading to a high number of uninsured individuals in the country. Most uninsured individual are those in low income areas who have priority to meet their basic needs  like food clothing and shelter while a number of them may be  homeless. Most of them have annual income below the federal poverty level they believe they cannot afford health insurance cost.  A current research by Health Insurance Association of America (HIAA) found out that members are selling individual policies at $2,070 for single converge and about $4,000 for family. However this varies from state to state. (Ahmed et al., 2001) Most uninsured working poor are not even covered through employer insurance scheme while for those who are covered, there has been gradual shifting of health are cost from the employer to the employee. The cost of health insurance is the leading factor resulting to high number of uninsured individuals in the country.  As the health care crisis bites, it has been shown that more than half of all Americans are worried about the increasing health care insurance cost and forty two percent acknowledge that they are not in a position to afford health care service.

Due to the high health care cost, most people are opting to pay for physician and prescriptions out of their pocket money.  Others are torn in between paying to see physicians over paying for prescriptions (Ahmed et al., 2001). In some case, individuals do not seek for medical treatment for their condition until they become very serious while many with chronic illness skip their treatments to avoid high costs. Inability to meet the cost of health care has made many individuals to stick to their current employer even when working conditions are not conducive so long as the employer is paying for their health care (Hoffman et al., 2004).

What are some recommendations?

As we stand, there is no short cut to increase the number of uninsured. We have to look at the above factors in detail and determine which one can be addressed fast and which will lead to increased coverage.  The most important factor that has to be addressed is the cost of health care since it is the leading barrier to increased coverage.  In order to understand how they can be worked out, let us review some of the current models which have been advocating for increased number of insured individual in the country through addressing the above three factors.

Current models in healthcare

(i)                 Mass

The Massachusetts model has been considered as one of the most success attempt to provide universal health care to its residents. Since the inception of the program, nearly 97% of its residents are insured. This model requires that all residents in the state must take a health insurance failure to which they will suffer tax penalties. Employers are also supposed to offer insurance coverage for their workers or else provide alternative payment. (Moffit and Owcharenko, 2003)

(ii)               Maryland

Maryland Model is a health care model that seeks to provide affordable health care for all. Under this model there is increased collaboration between health care departments in a bid to provide affordable health care. This model includes a review of the Medicaid program to be more inclusive for mental cases, Children health program, and many others. This model aims at bringing the cost of insurance down (Shi and Singh, 2004

(iii)             Kansas

The Kansa model was developed with and aim of providing and protecting affordable health insurance for all Kansans to increase access to heath care. The model pays for prevention and primary care medical home with an aim of improving health outcomes and reducing the cost of health care (Shi and Singh, 2004).

(iv)             Project access

Project access is a system with coordinated system of donated medical care which is supposed to health the low income and uninsured people to increase their access to heath care and improve health. This is a communal approach where medical professionals also come in to offer their service for the uninsured regardless of whether they will pay or not.

These are some of the alternative programs that are available for implementation to reduce the number of uninsured. However a consideration of all the models shows that the integration of Massachusetts model and project access will be best suited to mitigate our current situation but there need to be some changes. First it has to address the issue of quality of case with heavy penalties imposed on health care providers who fail to provide quality service. If all people will be forced to purchase insurance premium, then they must be assured of quality. The government also needs to come up with a model of subsidizing those who cannot pay. Like in project access, those who have should feel the obligation to provide medical case service for those who cannot pay for the service. (Moffit and Owcharenko, 2003)


Access to affordable health care in the United States has been a thorny issue for along time. The adoption of for profit model has had serious implications on the ability of majority of the people to purchase insurance premiums leaving more than 47 million Americans uninsured including 9 million children. There are three key leading factors to high number of uninsured individuals. First the quality of health care has been compromised such that many people do not want to buy insurance schemes that are not worth the service they receive. The second factor has been inaccessibility of the available programs with strict eligibility criteria which leave many working poor out. The third factor is the escalating cost of health care as compared to the income of most uninsured people. In comparison to the alternative model available, we find that an integration of Massachusetts model where every one is required to have health insurance with subsidized cost of the poor and the projects access model of voluntary communal health service could be best suited to mitigate the current situation.


Acs, G., Phillips, K. R., & McKenzie, D. (2000). Playing by the rules but losing the game: America’s working poor. The urban Institute. Retrieved 26th November 2008 fromhttp://www.urban.org/publications/410404.html

Ahmed, S. M., Lemaku, J., Neahleigh, N., & Mann, B. (2001). Barriers to health access in a non-elderly urban poor American population. Health and Social Care in the Community, Vol. 9(6): 445-453

ED, (2007). Primary care clinic pilot program for uninsured: Working poor are focus of service. Patient Education Management, February 2007

Hoffman, C. Rowland, D. & Carbaugh, A. (2004). Holes in the health insurance system – who lacks coverage and why. The Journal of Law, Medicine and Ethics, Vol. 32(3): 390-396

Moffit, R., & Owcharenko, N. (2003). Covering the uninsured: How states can expand and improve health coverage? The Heritage Foundation

NCHS data on health insurance and access to care,  Center for Disease Control and

            Prevention.  Retrieved on November 12, 2008 from, www.cdc.gov/data/inforsheet/infosheet_haic.pdf

Robert Wood Johnson Foundation, (2005). Study shows million of working Americans have not health coverage, suffer health gaps as a result. RobertWood Johaons Foundation, 2005

Shi, L. & Singh, D.A. (2004).  Delivering Health Care in America: A Systems Approach, 3rd, Sudbury, MA: Jones and Barlett Publishers.

SPG staff, (2003): Texas State planning grant. Texas Department of Insurance

U.S Department of Health and Human Services, (2005). Overview of the uninsured in the united states: An analysis of the 2005 current population survey. ASPE Issue Brief, September 2005

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