The Underinsured: 45 vs. 17 million

The Underinsured: 45 vs. 17 million
In addition to the uninsured, there is a significant population of underinsured Americans that don’t have adequate coverage to come close to addressing their medical needs. These underinsureds face significant financial burdens and barriers to receiving necessary care, and are a significant problem for health care providers as well.

But a basic problem in examining this population is defining the scope. While identifying the uninsured is pretty straight-forward, "under-insured" is a relative term that can mean different things to different groups of stakeholders. How many underinsured Americans are there? That depends upon how you define underinsured.

If we use a definition advanced by Consumer Reports, the number could be 45.2 million. If we use a definition advanced by AHRQ, the number could be 17.1 million. That’s quite a spread.

Consumer Reports recently released results from a health insurance survey conducted by the Consumer Reports National Research Center in May 2007, which sampled 2,905 Americans between ages 18 and 64 and among other things tackled the issue of the underinsured.

Consumer Reports defines the underinsured as persons with health plan coverage that have two or more of the following complaints about their health plans: "It does not adequately cover costs of prescription drugs; doctor visits; medical tests; surgery or other medical procedures; catastrophic medical conditions; or the deductible is too high."

Applying this definition to their survey respondents, Consumer Reports estimates 24% of the U.S. adult population under age 65, which based on current U.S. census figures of 188.4 million adults in this age group, works out to an estimated 45.2 million people. Consumer Reports indicated the "median household income of respondents who were "underinsured" was $58,950, well above the U.S. median. Twenty-two percent live in households making more than $100,000."

According to the survey, 43% o of the underinsured reported that they postponed going to the doctor because they couldn't afford it, 28% of the underinsured put off filling prescriptions, 27% said they were still in debt to doctors and hospitals, and 3% of the underinsured said medical bills had forced them to declare bankruptcy. Consumer Reports broke out responses to the following circumstances by "Well Insured" vs. Underinsured categories:

Circumstance	Well Insured	Underinsured
Prepared to handle unexpected major medical costs in next 12 months	65%	37%
Postponed needed medical care in past 12 months due to costs	22%	56%
Dug deep into savings to pay medical bills	9%	33%
Made important job-related decisions based mainly on health-care needs	11%	21%
Health plan does not adequately cover prescription-drug costs	7%	63%
Decisions about retirement affected by medical expenses (adults 50+)	12%	34%

Of course, the Consumer Reports definition is entirely subjective. Researchers from the Agency for Healthcare Research and Quality (AHRQ) last year tackled this definition with a more objective measure, and published their findings in JAMA. The AHRQ definition of underinsured?  "insured persons with health care service burdens in excess of 10% of tax-adjusted family income." 

On this basis AHRQ found that in "2003, there were 48.8 million individuals (19.2%) living in families spending more than 10% of family income on health care, an increase of 11.7 million persons since 1996. Of these individuals, about 18.7 million (7.3%) were spending more than 20% of family income. In 2003, individuals with higher-than-average risk of incurring high total burdens included poor and low-income persons and those with nongroup coverage, aged 55 to 64 years, living in a non-metropolitan statistical area, in fair or poor health, having any type of limitation, or having a chronic medical condition. Applying our definition of underinsured to the insured population, an estimated 17.1 million persons younger than 65 years were underinsured in 2003, including 9.3 million persons with private employment-related insurance, 1.3 million persons with private nongroup policies, and 6.6 million persons with public coverage."

Thus the number of underinsured under age 65 Americans might be 45.2 million, according to the Consumer Reports definition, or  17.1 million according to AHRQ. Quite a difference in numbers.