Many Uninsured Are Eligible, Not Enrolled in Gov’t Programs

Published July 1, 2008

A new report by the Washington-based National Institute for Health Care Management (NIHCM) Foundation suggests approximately one in four Americans who have no health coverage–nearly 12 million people, half of whom are children–are eligible for public insurance programs but are not enrolled.

The report, “Understanding the Uninsured: Tailoring Policy Solutions for Different Subpopulations,” suggests several possible reasons people don’t enroll in the State Children’s Health Insurance Program (SCHIP), Medicaid, or similar programs. Those reasons include a lack of awareness about available coverage, the programs’ existence, or how to enroll; difficulty remaining enrolled; and fear of being publicly stigmatized by participation.

Expanding Programs ‘Wasteful’

The report provides the most recent picture of “the complexity and diversity” of the 47 million people in the United States said to be without health insurance at some point during the year. Its authors note, “any solutions [to uninsurance in the U.S.] will need to expand access to public programs or otherwise subsidize coverage for low-income people to make any real difference.”

Experts question the wisdom of forcing more people into public programs, however. “There will always be many people who are uneducated, dysfunctional, or not inclined to anticipate future contingencies,” said John McClaughry, president of the Ethan Allen Institute in Vermont. “If the policy goal is ‘universal coverage,’ only coercive and ultimately punitive measures will achieve it.”

“Expanding costly government programs, at even greater cost to the American worker and taxpayer, when those programs are nowhere near 100 percent enrollment as structured, is a waste of taxpayer dollars,” said Jeff Emanuel, a research fellow for health care policy at The Heartland Institute and managing editor of Health Care News.

“The waste and harm that comes from forcibly growing a program so many eligible people are already refusing to utilize far outweighs any potential good that can come from such proposals,” Emanuel added.

Billing for ‘Free’ Care

According to the report, the 12 million Americans who are eligible for publicly funded coverage but not enrolled are primarily in low-income families.

The 6.1 million children in this group make up 64 percent of the total number of uninsured children in the country. “The vast majority of these children are in families with incomes below 200 percent of the federal poverty level ($41,300 for a family of four or $20,420 for individuals),” the NIHCM Foundation said in a press release.

“The paucity of public coverage for low-income childless adults is really troubling,” said Nancy Chockley, president and CEO of the foundation. “This is a population that really can only be helped by an expansion of public programs or some form of subsidy, yet we don’t see a lot of that out there across the states.”

“A better solution–though not problem-free–could be for governments to bill uninsured persons for the cost of their ‘free’ care, by adding those costs to the patient’s gross income subject to taxation,” countered McClaughry.

“Most poor people would still not have any taxable income, but those who could afford insurance would quickly find themselves motivated to take advantage of various public and private programs to provide it,” McClaughry said.

Reaching the Truly Needy

Childless adults in the United States make up more than 50 percent of the nation’s total uninsured population. Since 2001, states have been allowed to expand coverage to childless adults and others who have been traditionally ineligible for Medicaid or SCHIP.

To date, only seven states–Arizona, Idaho, Indiana, Michigan, New Mexico, Oregon, and Utah–have taken advantage of the newfound ability to expand those programs at taxpayer expense. Most of them have implemented low enrollment caps, cost-sharing requirements, or other eligibility limitations to prevent a massive influx of applicants who are not really needy.

Dr. Sanjit Bagchi ([email protected]) writes from India.

For more information …

“Understanding the Uninsured: Tailoring Policy Solutions for Different Subpopulations,” National Institute for Health Care Management Research and Educational Foundation, April 2008: