In the United States, health insurance is covered by a variety of public and private sources. In 2019, the U.S. population was approximately 330 million people, of which 59 million people age 65 and older were covered by the federal Medicare program. The 273 million non-institutionalized people under age 65 obtained their coverage through employers (159 million) or non-employers (84 million), or were uninsured (30 million). During 2019, 89% of the non-institutionalized population had health insurance. Additionally, approximately 12 million military personnel (considered part of the "institutional" population) received coverage through the Veterans Administration and the Military Health System.
Despite being among the main economic powers, the United States remains the only industrialized country in the world without universal health coverage.
Excessive costs are the main reason Americans give for health care access problems. At approximately 30 million in 2019, more than the entire population of Australia, the number of people without health insurance in the United States is a major concern of health reform advocates. Lack of health insurance is associated with higher mortality, ranging from 30,000 to 90,000 deaths per year, according to the study.
Multiple studies show that the number of uninsured people decreased between 2013 and 2016 due to increased Medicaid eligibility and health insurance exchanges created as a result of the Patient Protection and Affordable Care Act, also known as the "ACA." or "Obamacare." According to the United States Census Bureau, in 2012 there were 45.6 million people in the United States (14.8% of the population under age 65) without health insurance. After the implementation of key provisions of the ACA in 2013, this number fell by 18.3 million, or 40%, to 27.3 million in 2016, or 8.6% of the population under age 65.
However, under President Trump, the improvement in reporting began to reverse. The Census Bureau reported that the number of uninsured people increased from 27.3 million in 2016 to 29.6 million in 2019, an increase of 2.3 million or 8%. The uninsured rate increased from 8.6% in 2016 to 9.2% in 2019. The 2017 increase was the first increase in the number and percentage of uninsured people since 2010. Additionally, the Commonwealth Fund estimated in May 2018 that the number of uninsured people increased. by 4 million it increased. from early 2016 to early 2018. The percentage of uninsured increased from 12.7% in 2016 to 15.5% according to their methodology. The impact was greatest among low-income adults, who had a higher uninsured rate than higher-income adults. The CBO predicted in May 2019 that another 6 million people would become uninsured in 2021 under Trump's policies (33 million), compared to continuing Obama's policies (27 million).
The causes of this percentage of uninsured people continue to be the subject of political debate. In 2018, states that expanded Medicaid under the ACA had an uninsured rate of 8% on average, about half the rate of states that did not do so (15%). Nearly half of those without insurance cite cost as the most important factor. Rising insurance costs have contributed to a trend in which fewer employers offer health insurance and many employers control costs by requiring higher contributions from employees. Many of those without insurance are working poor or unemployed.
Overview
Health insurance coverage is provided by various public and private sources in the United States. Analyzing these statistics is more challenging due to multiple research methods and people with multiple sources of insurance, such as those with coverage through both an employer plan and Medicaid.
For the 273 million non-institutional people under the age of 65 in 2019.
1. There were 159 million with employer coverage, 84 million with other coverage and 30 million without insurance.
2. Of the 159 million people with employer coverage, many have self-funded health insurance: about 60% in 2017.
3. Of the 84 million with other coverage, 57 million were covered by Medicaid and the Children's Health Insurance Program (CHIP), 12 million were covered by the ACA's Medicaid expansion, 9 million were covered by the ACA/Obamacare exchanges, 5 million had different coverage. as private insurance purchased outside the ACA exchanges, and 1 million were covered by the ACA Basic Health Program.
4. Of the 9 million in ACA funds, 8 million received subsidies and 1 million did not.
5. Of the 30 million uninsured, 24 million (80%) were legally present, while 6 million (20%) were not legally present.
6. In 2018, 41% of uninsured people were white, 37% were Hispanic and 14% were black.
7. In 2018, the Veterans Administration covered approximately 12 million institutional (military) personnel.
8. The uninsured rate fell from a high of 18.2% in 2010 to 10.5% in 2015, mainly due to the ACA/Obamacare and improvements in the economy.
9. The inability to pay for insurance was the top reason cited by those without coverage (46%).
10. According to the study, lack of health insurance is associated with increased mortality, ranging from 30,000 to 90,000 deaths per year. This figure is calculated based on 1 additional death per 300 to 800 uninsured people, based on 27 million uninsured people.
The U.S. Centers for Disease Control and Prevention (CDC) reports the number and percentage of uninsured people every year.
The 2010 figure represents the most recent spike caused by the Great Recession. Most of the ACA's key provisions went into effect in 2014, so 2013 reflects pre-ACA levels. After reaching a low point in 2016 at the end of the Obama administration, the number and percentage of uninsured people increased during the first two years of the Trump administration. The New York Times reported in January 2019 that the Trump administration has taken several steps to weaken the ACA, which is negatively impacting reporting. The increase in the number of uninsured people in the first three years of the Trump administration (2017-2019) was reversed in 2020-2021, as coronavirus relief measures expanded eligibility and lowered costs.
Estimates of the number of uninsured people
Various public and private sources report the number and percentage of uninsured people. The Congressional Budget Office (CBO) reported that the actual number of uninsured people was 28.3 million in 2015, 27.5 million in 2016, 27.8 million in 2017 and 28.9 million in 2018. The CBO's 10-year report May 2019 reflected the expectations of the Trump administration. policy. and estimated that the number of uninsured people would rise from 30 million in 2019 to 34 million in 2026 and 35 million in 2029. In an earlier 10-year forecast from March 2016, which reflected Obama administration policies, the CBO projected 27 million uninsured people in 2019 and 28 million in 2026. The primary reason for the increase of 6.5 million (24%) uninsured people between 2016 and 2029 is the repeal of the ACA's individual mandate to purchase health insurance, introduced as part of the Trump tax cuts, with people not purchasing comprehensive insurance due to lack of a mandate or because of higher insurance costs.
Gallup estimated in July 2014 that the uninsured rate for adults (people age 18 and older) was 13.4% in the second quarter of 2014, up from 18.0% in the third quarter of 2013, when health insurance exchanges were created under the Patient Protection Act and The Affordable Care Act (PPACA or "Obamacare") was first opened. "The uninsured rate fell in almost all demographic groups."
The Commonwealth Fund reported that the uninsured rate among adults ages 19 to 64 fell from 20 percent in the third quarter of 2013 to 15 percent in the second quarter of 2014, meaning about 9.5 million more adults had health insurance.
The United States Census Bureau reports statistics on the uninsured annually. The Census Bureau's 2018 Health Insurance Highlights Summary Report states:
In 2018, 8.5 percent of people, or 27.5 million, did not have health insurance at any time during the year. The uninsured rate and number of uninsured people have increased since 2017 (7.9 percent or 25.6 million).
The percentage of people who were fully or partially insured for healthcare in 2018 was lower at 91.5 percent than in 2017 (92.1 percent). Between 2017 and 2018, the percentage of people with public coverage decreased by 0.4 percentage points and the percentage of people with private coverage did not change statistically.
In 2018, private health insurance coverage continued to outweigh public sector coverage, covering 67.3 percent of the population and 34.4 percent of the population, respectively. Among health insurance subtypes, employer-provided insurance remained the most common, covering 55.1 percent of the population for all or part of the calendar year.
Between 2017 and 2018, the percentage of people covered by Medicaid fell 0.7 percentage points to 17.9 percent. The Medicare coverage ratio increased by 0.4 percentage points. The percentage of people with employment-based coverage, direct purchase coverage, TRICARE, and VA or CHAMPVA health care statistically did not change from 2017 to 2018.
The percentage of uninsured children under the age of 19 increased by 0.6 percentage points to 5.5 percent between 2017 and 2018.
Between 2017 and 2018, the percentage of people without health insurance at the time of interview decreased in three states and increased in eight states.
Underinsured
Those who are insured may be so underinsured that they cannot afford adequate medical care. In 2003, an estimated 16 million American adults were underinsured, disproportionately affecting those with lower incomes: 73% of the underinsured in the study population had annual incomes less than 200% of the federal poverty level.
In 2019, Gallup found that 25% of American adults said they or a family member had put off treatment for a serious medical condition during the year because of costs, up from 12% in 2003 and 19 % in 2015. For each condition, 33% reported delaying treatment, compared to 24% in 2003 and 31% in 2015.
There are also differences in coverage among the insured population. Professor Vicente Navarro of Johns Hopkins University stated in 2003: "The problem does not end here with the uninsured. An even bigger problem is the underinsured" and "The most credible estimate of the number of people in the United States that have died as The lack of medical care arose from a study by Professors Himmelstein and Woolhandler of Harvard Medical School, who concluded that almost 100,000 people died annually in the United States due to a lack of necessary medical care. Another study that focused on the effect of not having insurance found that people with private insurance were less likely to be diagnosed with late-stage cancer than the uninsured or Medicaid beneficiaries. Overall health insurance costs showed that Chronically ill patients with higher co- payments sought less care for mild and severe symptoms, while no effect was observed on self-reported health status. The authors concluded that the effect of copayment should be closely monitored.
Coverage gaps and affordability were also highlighted in a 2007 international comparison by the Commonwealth Fund. Of American adults surveyed, 37% reported that they had forgone necessary medical care in the past year due to costs; whether it be skipping medications, avoiding going to the doctor when sick, or avoiding other recommended care. The percentage was higher (42%) among people with chronic diseases. The research shows that these figures were well above those of the other six countries surveyed: Australia, Canada, Germany, the Netherlands, New Zealand and the United Kingdom. The survey also found that 19% of American adults surveyed reported serious problems paying medical bills, more than double the rate in the next highest country.
Coverage trends under President Trump
Gains in health care coverage under President Obama began to be reversed under President Trump. The CDC reported that the number of uninsured people increased from 28.2 million in 2016 (the last year of the Obama administration) to 32.8 million in 2019, an increase of 4.6 million or 16%.
The Commonwealth Fund estimated in May 2018 that the number of uninsured people increased by 4 million between early 2016 and early 2018. The percentage of uninsured people has increased from 12.7% in 2016 to 15.5%. This was due to two factors: 1) failure to address specific weaknesses in the ACA; and 2) actions by the Trump administration that have exacerbated these weaknesses. The impact was greatest among low-income adults, who had a higher uninsured rate than higher-income adults.
About 5.4 million Americans lost their health insurance between February and May 2020 after losing their jobs during the COVID-19 recession. The Independent reported that the Families USA report “found that the increase in the number of uninsured Americans (adding to the estimated 84 million people who are already uninsured or underinsured) is 39 percent larger than any previous annual increase, including the most recent increase at the peak of the US population. crisis. the recession between 2008 and 2009, when nearly four million non-elderly Americans lost their insurance.”
Uninsured demographic
The Kaiser Family Foundation reported in October 2016 that there were 27.2 million uninsured people under age 65, about 10% of the 272 million people in that group. Kaiser reported that:
- 2.6 million were in the “coverage gap” because 19 states chose not to expand the Medicaid program under ACA/Obamacare, meaning their income was above the Medicaid eligibility limit but below the subsidy threshold in the ACA exchanges (~44% at 100% of the federal poverty level or FPL);
- 5.4 million were undocumented immigrants;
- 4.5 million had an offer of employer insurance (making them ineligible for ACA/Obamacare coverage) but turned it down;
- 3.0 million did not qualify for financial assistance under ACA/Obamacare because income was high enough;
- 6.4 million were eligible for Medicaid or another public health program but had not applied; And
- 5.3 million qualified for ACA/Obamacare tax credits but did not enroll in the program.
- An estimated 46% cite cost as a barrier to obtaining insurance coverage.
- Nearly 12 million (43%) people qualified for financial assistance (Medicaid or ACA subsidies) but did not sign up for it.
In 2017, Texas had the highest number of uninsured people at 17%, followed by Oklahoma, Alaska and Georgia.
Uninsured Children and Young Adults
In 2009, the Census Bureau states that 10.0 percent or 7.5 million children under the age of 18 had no health insurance. Children living in poverty are 15.1 percent more likely than other children to have no health insurance. The lower a household's income, the more likely the household is to be uninsured. In 2009, a household with an annual income of $25,000 or less had only a 26.6 percent chance of being uninsured, while households with an annual income of $75,000 or more had only a 9.1 percent chance of being uninsured. According to the Census Bureau, there were 8.1 million uninsured children in the United States in 2007. Nearly 8 million young adults (ages 18 to 24) were uninsured, representing 28.1% of their population. Young adults represent the largest age group of the uninsured, are the most likely to be uninsured, and are one of the fastest growing segments of the uninsured population. They often lose coverage from their parents' health insurance plans or public programs when they turn 19. Others lose coverage when they graduate. Many young adults don't have the kind of stable jobs that would provide them with continued access to health insurance. According to the Congressional Budget Office, the current plan should cover unmarried dependents on their parents' insurance until age 26. These changes also affect large employers, including self-insured companies, causing the company to take on financial responsibility. to provide coverage. The only exception to this is policies that were continuously in effect prior to the enactment of this legislation. That policy would be protected.
Non-citizens
Non-citizens are more likely to be uninsured than citizens, with an uninsured rate of 43.8%. This can be attributed to a greater likelihood of working in a low-wage job that does not provide health benefits and restrictions on eligibility for public programs. The longer a noncitizen immigrant is in the country, the less likely he or she is to be uninsured. In 2006, about 27% of immigrants who entered the country before 1970 were uninsured, compared to 45% of immigrants who entered the country in the 1980s and 49% of those who entered between 2000 and 2006.
Most uninsured noncitizens are recent immigrants; nearly half entered the country between 2000 and 2006, and 36% entered in the 1990s. Foreign-born non-residents were responsible for more than 40% of the increase in the number of uninsured people between 1990 and 1998, and more than 90% of the increase between 1998 and 2006. 2003. One reason for the acceleration after 1998 may be the restrictions imposed by the Department of Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996. Nearly seven in ten ( 68%) of uninsured non-citizens live in California, Texas, Florida or New York.
Effects of slowdown
An April 2008 Kaiser Family Foundation report found that America's economic crises are putting significant pressure on state Medicaid and SCHIP programs. The authors estimate that a 1% increase in the unemployment rate would increase Medicaid and SCHIP enrollment by 1 million, and increase the number of uninsured people by 1.1 million. State spending on Medicaid and SCHIP would rise by $1.4 billion. This increase in spending would occur while state government revenues were declining. During the last recession, the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal aid to states, allowing states to avoid having to tighten their eligibility rules for Medicaid and SCHIP. The authors conclude that Congress should consider similar relief for the current economic crisis.
History
Before the Patient Protection and Affordable Care Act, medical underwriting was common, but after the law went into effect in 2014, it was effectively banned.
Medical underwriting made it difficult for many consumers to purchase coverage in the individual market. Medical underwriting meant that insurance companies screened applicants for pre-existing conditions and rejected those with serious conditions such as arthritis, cancer and heart disease, as well as common ailments like acne, 20-pound weight loss and old sports injuries. In 2008, an estimated 5 million uninsured people were considered "uninsurable" due to pre-existing conditions.
Proponents of medical underwriting claim that this ensures that individual health insurance premiums are kept as low as possible. Critics of medical underwriting believe that it unfairly prevents people with relatively minor and treatable pre-existing conditions from purchasing health insurance.
A major industry survey found that in 2004, 13% of individual health insurance applicants who underwent a medical evaluation were denied coverage. The number of refusals increased significantly with age, from 5% for people under 18 to just under a third for people over 60. age. to 64. The survey found that 76% of those offered coverage received offers with standard premium rates and 22% were offered higher rates.[48] The frequency of premium increases also increased with age, so among applicants over age 40, about half were affected by medical underwriting, either in the form of denials or higher premiums. In contrast, almost 90% of applicants in their 20s were offered coverage, and three-quarters of them were offered standard rates. Seventy percent of applicants ages 60 to 64 were offered coverage, but almost half the time (40%) it was at a higher premium. The study did not address how many applicants who were offered coverage at higher rates chose to decline the policy. A 2001 Commonwealth Fund survey found that among people aged 19 to 64 who applied for individual health insurance in the previous three years, most found it unaffordable and that fewer than a third ultimately purchased insurance. This study did not distinguish between consumers who received higher rates due to medical insurance and consumers who qualified for standard or preferred premiums. Some states have banned medical underwriting as a condition of individually purchased health coverage. These states heed to have the highest premiums for individual health insurance.
Causes
Americans who are uninsured may be uninsured because their jobs do not provide insurance; They are unemployed and cannot afford insurance; or they may be financially able to purchase insurance but find the costs prohibitive. In 2009, persistently low labor participation had negative consequences for those who had previously taken out employment insurance. The Census Bureau claims a 55 percent decline. Other uninsured Americans have elect to join a health care sharing ministry as an alternative to insurance.
Low-income workers are less likely than higher-income earners to get coverage from their employer (or their spouse's employer) and are less able to afford to buy it themselves. Beginning with wage and price controls during World War II, and reinforced by an income tax exemption rule in 1954, most American workers have received their health insurance from their employers. However, recent trends show a steady decline in employer-sponsored health insurance benefits. In 2000, 68% of small businesses with between 3 and 199 employees offered health benefits. Since then, that number has continued to decline until 2007, when 59% offered health benefits. For large companies with 200 or more employees, 99% of employers offered health benefits in 2000; in 2007 that figure remained the same. On average, considering companies of all employee sizes, 69% offered health insurance in 2000, and that number has fallen almost every year since 2007, when 60% of employers offered health insurance.
A study published in 2008 found that people in average health are less likely to be uninsured if they have large group health coverage, more likely to be uninsured if they have small group health coverage, and more likely to be uninsured if they have individual have health insurance. But for people in poor or good health, the likelihood of losing coverage is much greater for people who had small group insurance than for those who had individual insurance. The authors attribute these results to the combination in the individual market of high costs and guaranteed extension of coverage. Individual coverage costs more if purchased after a person becomes ill, but "provides better protection (compared to group insurance) against high premiums for people who already have individual insurance and are at high risk." Healthy people are more likely to drop out of individual coverage than cheaper, subsidized employment-based coverage, but group coverage makes them "more vulnerable to dropping out or losing all coverage than individual insurance" if they become seriously ill.
About a quarter of the uninsured qualify for public coverage but are not enrolled. Possible reasons include a lack of knowledge of the programs or how to enroll, reluctance due to a perceived stigma associated with public reporting, poor retention of enrollees, and burdensome administrative procedures. In addition, some state programs have enrollment limits.
A Kaiser Family Foundation survey published in June 2009 found that 45% of low-income adults under age 65 do not have health insurance. Nearly one-third of non-elderly adults are low-income, with household incomes less than 200% of the federal poverty level. Low-income adults tend to be younger, less educated, and less likely to live in a household with a full-time worker than higher-income adults; These factors contribute to the chance that you are uninsured. Moreover, the chances of being healthy decrease with lower income; 19% of adults with incomes below the federal poverty level describe their health as fair or poor.
Consequences
Insurance coverage helps save lives by exciting early detection and prevention of dangerous medical conditions. According to a 2014 study, the ACA likely prevented about 50,000 preventable patient deaths between 2010 and 2013. Public health professors David Himmelstein and Steffie Woolhandler of City University wrote in January 2017 that rolling back the ACA's Medicaid expansion would cause about 43,956 deaths per year.
The Federal Reserve publishes data on premature death rates by county, defined as those who die before age 74. According to the Kaiser Foundation, expanding Medicaid in the remaining 19 states could reach up to 4.5 million people, reducing the death rate. Texas, Oklahoma, Mississippi, Alabama, Georgia, Tennessee, Missouri and South Carolina, highlighted on the Federal Reserve map (see chart at right) with many counties with high rates of premature death, have not expanded Medicaid.
A study published in 2009 in the American Journal of Public Health found that lack of health insurance is linked to approximately 45,000 preventable deaths per year. One of the authors characterized the results as "someone now dies every 12 minutes." Since then, the number of uninsured people has increased from approximately 46 million in 2009 to 48.6 million in 2012. The number of insurance policies has increased to approximately 48,000 per year.
A 2008 study found that not having insurance affects the health of American consumers in the following ways:
A greater share of uninsured people chose not to see a doctor when they were sick or injured (53%) compared to 46% of insured people.
Fewer uninsured people (28%) report that they are currently receiving treatment or participating in a program to help them manage a chronic disease; 37% of insured people receive this treatment.
21% of uninsured people, compared to 16% of insured people, believe their overall health is below average for people in their age group.
Cost shifting
The costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured through cost shifting and higher health insurance premiums, or paid for by taxpayers through higher taxes.
On the other hand, the uninsured often subsidize the insured because the uninsured use fewer services and are often billed at a higher rate. One study found that in 2009, uninsured patients presenting to U.S. emergency departments were less likely to be admitted for hospital care than patients with Medicare, Medicaid, or private insurance. 60 Minutes reported: “Hospitals are assailing uninsured patients two, three, four or more times what an insurance company would pay for the same treatment.” On average, per capita health care expenditures of the uninsured are just over half those of the insured.
Hospitals and other providers are reimbursed for the costs of providing uncompensated care through a federal matching fund program. Each state enacts legislation regulating the reimbursement of funds to providers. In Missouri, for example, supplier estimates totaling $800 million ($2 for every $1 estimate) are added to create a pool of approximately $2 billion. Under federal law, these funds are transferred to the Missouri Hospital Association for payment to hospitals for costs incurred in providing uncompensated care, including disproportionate share payments (to hospitals with a large number of uninsured patients), Medicaid shortfalls, Medicaid managed care payments to insurance companies. and other costs incurred by hospitals. In New Hampshire, uncompensated care costs reimbursable under the law include: charity care costs, any portion of Medicaid patient care costs not reimbursed by Medicaid payments, and any portion of bad debts that the commissioner determines would meet the criteria set forth in 42 U.S.C. section 1396r-4(g) which governs hospital-specific limits on disproportionate hospital payments under title XIX of the Social Security Act.
A study published in Health Affairs in August 2008 found that covering all uninsured people in the US would increase national health care spending by $122.6 billion, representing a 5% increase in spending in health care and 0.8% of GDP. “From society's prospect, covering the uninsured is still a good investment. “If no action is taken in the short term, it will only be more costly to cover the uninsured in the future, while increasing the productivity missing from not insuring all Americans.” said Professor Jack Hadley, leading author of the study. The impact on government spending could be greater depending on the details of the plan used to increase coverage and the degree to which the new public coverage displaces existing private coverage.
More than 60% of personal bankruptcies are due to medical bills. Most of these people had health insurance.
Effects on the health of the uninsured
From 2000 to 2004, the Institute of Medicine's Committee on the Consequences of Lack of Insurance issued a series of six reports that reviewed and reported the evidence on the consequences of lack of health insurance coverage.
The reports concluded that the committee recommended that the nation implement a strategy to achieve universal health insurance. As of 2011, a comprehensive national plan has yet to be adopted to address what supporters of the universal health care plan call “America's uninsured crisis.” A few states have made progress toward the goal of universal health insurance, such as Maine, Massachusetts, and Vermont, but other states, including California, have failed in their attempts at reform.
The six reports prepared by the Institute of Medicine (IOM) found that the main consequences of not having insurance were: children and adults without health insurance did not receive necessary medical care; They tend to live in poorer health and die earlier than children or adults who have insurance. The financial stability of an entire family can be compromised if just one person is uninsured and needs treatment to cover unexpected healthcare costs. The overall health status of a community can be negatively affected by a higher percentage of uninsured people within the community. The coverage gap between the insured and uninsured has not narrowed, even after recent federal initiatives to expand health insurance coverage.
The last report was published in 2004 and was called Ensuring America's Health: Principles and Recommendations. This report recommended that: The President and Congress should develop a strategy to achieve universal insurance coverage and establish a firm timeline for achieving this goal by the year 2010. The committee also recommended that the federal and state governments provide sufficient resources to Medicaid and the State Children's Health Insurance Program (SCHIP) cover all currently eligible individuals until universal coverage takes effect. They also warned that federal and state governments must avoid erosion of outreach, eligibility, enrollment, and coverage efforts for these specific programs.
Some people believe that not having health insurance will negatively affect the health of the uninsured. On the other hand, some people believe that uninsured children and adults can access needed health care services in hospital emergency rooms, community health centers, or other safety net facilities that provide charity care. . Some observers point out that there is a strong body of evidence showing that a significant portion of US health care spending is spent on care that is ineffective and sometimes can even be harmful. At least for the insured population, increased spending and use of health care services does not always lead to better health outcomes or longer life expectancy.
Children in the United States are generally considered to be in good health compared to adults, because more serious health problems occur later in a person's life. Certain conditions, such as asthma, diabetes, and obesity, have become much more common in children in recent decades. There is also a growing population of vulnerable children with special health care needs who require ongoing medical care, which would not be accessible without health insurance. More than 10 million children in the United States meet the federal demarcation of children with special health care needs "who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require medical care." of high quality and related services." necessary level." type or amount that goes beyond what children generally need." These children call for healthcare-related services that are greater than the average child in the United States. When children purchase health insurance, they are generally much less likely to experience previously unmet health care needs. This includes the average child in America and children with exceptional health care needs. The Committee on the State of Health Insurance and its Impact concluded that the effects of health insurance on children's health outcomes: Children with health insurance are more likely to be diagnosed with serious illnesses. health problems, experience fewer hospitalizations, and miss fewer school days.
The same committee looked at the effects of health insurance on adult health outcomes: Adults who are uninsured and gain Medicare coverage at age 65 experience significantly better health and functional status, especially those who have cardiovascular disease or diabetes. Adults with cardiovascular disease or other heart risk factors who are uninsured are less likely to be aware of their condition, leading to worse health outcomes for these individuals. Without health insurance, adults are more likely to be diagnosed with cancer that would have been discovered earlier through medical tests if they had visited a doctor regularly. As a result, these adults are more likely to die from a cancer diagnosis or have worse health outcomes.
Many towns and cities in the United States have a high concentration of people under age 65 who do not have health insurance. The high uninsured rate affects communities and the insured people in those communities. The Institute of Medicine committee warned of the potential problems of high rates of uninsured community health care, including reduced access to clinical primary care, specialty services, and hospital emergency services.
Emergency Medical Treatment and Active Labor Act (EMTALA)
Enacted by the federal government in 1986, EMTALA requires hospital emergency departments to treat all patient emergencies, regardless of their ability to pay, and is considered a crucial element in the "safety net" for those without sure. However, federal law has not established a 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 required by EMTALA. Materially, more than half of all emergency care in the U.S. is now uncompensated. By some analyses, EMTALA is an unfunded mandate that has contributed to financial pressure on hospitals over the past two decades, forcing them to consolidate and close facilities and contributing to emergency room overcrowding. According to the Institute of Medicine, emergency room visits in the U.S. increased 26% between 1993 and 2003, while the number of emergency departments decreased by 425 during the same period. Hospitals bill uninsured patients directly on a fee-for-service basis. model, which often charges far more than insurers would pay, and patients can go bankrupt if hospitals sue to collect.
Patients with mental illnesses pose unique challenges to emergency departments and hospitals. According to EMTALA, mentally ill patients admitted to the emergency department are evaluated for medical emergencies. Once patients with mental illness are medically stable, regional mental health agencies are contacted to evaluate them. Patients are evaluated to determine if they pose a danger to themselves or others. Those who meet this criteria are admitted to a mental health facility for further evaluation by a psychiatrist. Typically, mentally ill patients can be held for up to 72 hours, after which a court order is necessary.
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