A Reporter’s Toolkit: The Uninsured

An Alliance for Health Reform Toolkit - Produced with support from the Robert Wood Johnson Foundation

This toolkit offers links to resources that will help you understand who lacks health coverage in the U.S. and the consequences of being uninsured. We also offer links to proposals for change, including websites that track presidential candidates’ plans, as well as to public opinion polls and updates on state-level reform. This resource also offers story ideas, selected experts with contact information, selected websites and a glossary.

This toolkit was compiled and written by Dinesh Kumar.
Table of Contents

Key Facts

  • Being uninsured makes it more likely that a person will not receive adequate medical care. Lack of coverage and coverage stability is particularly burdensome on the seriously and chronically ill, whose care is often delayed or denied when they cannot pay. 1
  • The number of uninsured persons in the U.S. continues to grow, from 44.8 million in 2005 to 47.0 million in 2006. The percentage of uninsured is also rising, from 15.3 percent of the total population in 2005 to 15.8 percent in 2006. 2, 3
  • Overwhelmingly, the uninsured live in working families, but either are not offered health insurance or cannot afford offered plans. In 2005, over eight in 10 uninsured came from working families. 4
  • A decline in job-based coverage fueled growth in the uninsured. Sixty percent of employers offer benefits in 2007, compared with 69 percent in 2000. This drop is especially due to the decline in small businesses offering coverage. 5
  • One recent study estimated that 29 percent of people who have insurance are “underinsured,” with coverage that is inadequate to secure them access to needed care or protect again catastrophic medical bills. 6
  • Although the high cost of health insurance is a leading reason why people lack coverage, many inexpensive insurance policies are for sale. However, covered benefits under low-cost policies may be limited, out-of-pocket deductibles are often high, and the uninsured may not be eligible for low premiums if they are older or in poor health. 7

Selected Resources

Please email info@allhealth.org if you find that any of the links mentioned in this toolkit no longer work.Statistics on the Uninsured – Where Do People Get Health Coverage and Who is Uninsured?

Consequences of Being Uninsured

The Underinsured

Stories of Real People

  • Video & Story Gallery – Cover the Uninsured
  • Families USA Consumer Story Bank
    Media contact: David Lemmon or others on communications staff, 202/628-3030For more information, go to www.familiesusa.org/tell-us-your-story.html
  • Find-an-Expert Service – Alliance for Health Reform
    www.allhealth.org/reporter_enroll.aspThe Alliance features a database of experts in 36 health policy topics, including the uninsured. Many have contact information for contacting real people. Access is limited to credentialed journalists. Registration required.

Public Opinion Polls

National Proposals for the Future


State-Level Reforms









Story Ideas

  • Maine, Massachusetts and Vermont now have a track record in implementing near-universal health coverage. How are things working out? What lessons learned in these states might apply to your state?
  • What’s different now in debates about helping the uninsured, compared to the last time the nation seriously visited this issue in 1993?
  • What’s the prevailing mood among business leaders about continuing to offer health coverage to their employees (among those who offer coverage now)? Are any seriously considering dropping coverage?
  • Talk with employees of businesses that don’t offer coverage. Do they get coverage through another source, such as a spouse or Medicaid? If not, how do these get their health care? Do they face discrimination from health care providers as a result of being uninsured?
  • Are any area businesses thinking of offering health coverage to uninsured part-time employees?
  • What do providers in your area say about their willingness to care for the uninsured? Is the growing number of uninsured people causing them problems? How has this growing number affected local community clinics and emergency rooms and their ability to provide services to all residents?
  • How do chronically ill individuals navigate the health care system if they’re uninsured? What do waiting periods, pre-existing condition exclusions, or other coverage lapses mean for people with diabetes, asthma, or hypertension? How does a lack of health insurance affect their ability to manage their health conditions and avoid more serious complications?
  • Companies across the country have increasingly limited retiree medical benefits. Are retirees in your area able to get health coverage if they’re younger than 65? Talk with employers who may try to help even if they don’t offer coverage.

Selected Experts

Drawn from the Alliance for Health Reform’s Find-an-Expert Service for reporters. Descriptions in quotes are written by the experts themselves. Credentialed reporters can see full profiles for these and other experts, including after-hours contact numbers, by going to www.allhealth.org/reporter_enroll.asp
Analysts and Advocates

    Senior Fellow, Brookings Institution
    Washington DC 20036
    Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute
    Washington DC 20036
    Vice President, Economic and Domestic Policy Studies, The Heritage Foundation
    Washington DC 20002
    Director of Health Policy Studies, Cato Institute
    Washington DC 20001
    Vice President, Director, Health Care Marketplace Project, Henry J. Kaiser Family Foundation
    Washington DC 20005
    Vice President, Research and Evaluation, Robert Wood Johnson Foundation
    Princeton, NJ
    Assistant Professor, University of Minnesota School of Public Health
    Minneapolis, MN 55414
    President, The Commonwealth Fund
    New York NY 10021
    Consultant, Health Insurance Reform Project, George Washington University.
    Chevy Chase MD 20815
    Director, Health Research Program, Employee Benefit Research Institute
    Washington DC 20037
    President, Center for Studying Health System Change
    Washington DC 20024
    Resident Scholar, Health Policy Studies, American Enterprise Institute
    Washington DC 20036
    Director, Health Policy Center, The Urban Institute
    Washington DC 20037
    Exec V-P, Alliance for Health Reform
    Washington DC 20005
    Senior Program Officer, The Robert Wood Johnson Foundation
    Princeton NJ 08543-2316
    President, Federation of American Hospitals
    Washington DC 20004
    Senior Fellow, Center on Budget and Policy Priorities
    Washington DC 20010
    President and CEO, The Robert Wood Johnson Foundation
    Princeton NJ 08543-2316
    Contact through Gina Ivey, 609-627-5937
    Senior VP, Director Health Care Group, The Robert Wood Johnson Foundation
    Princeton NJ 08543-2316
    Contact through Gina Ivey, 609-627-5937
    Director, State Coverage Initiatives, AcademyHealth
    Washington DC 20006
    Director of Health Policy Program, New America Foundation
    Washington DC 20009
    Executive Director, Families USA
    Washington, D.C. DC 20005
    Project Director, Georgetown University Health Policy Institute
    Washington DC 20007
    President, The Urban Institute
    Washington DC 20037
    Senior Vice President for Advocacy and Public Policy,
    Catholic Health Association of the United States
    Washington, DC
    Director, Policy and Strategy, AARP
    Washington DC 20049
    Chair, Department of Health Policy, George Washington University
    Washington DC 20006
    Executive Vice President, Kaiser Family Foundation
    Washington DC 20005
    Professor of Economics and Public Affairs, Princeton University
    Princeton NJ 08540
    609-258-4781 (Secretary: 609/258-1456)
    Director of Health Legislation, National Governors Association
    Washington DC 20001
    President & CEO, Consumers for Health Care Choices
    Hagerstown MD 21740
    Senior Vice President, Commonwealth Fund
    New York NY 10021
    Director of Public Affairs, National Coalition on Health Care
    Washington DC 20005
    Director, Health Policy Analysis, Consumers Union
    Washington DC 20009
    Vice President, The Lewin Group
    Falls Church VA 22042
    President, United Hospital Fund
    New York NY 10118
    Director, Health & Welfare Studies, Cato Institute
    Washington DC 20001
    Chairman – The Harris Poll, Harris Interactive
    New York NY 10003
    Professor and Chair, Dept Health Policy Mgt, Emory University
    Atlanta GA 30322
    President, Galen Institute
    Alexandria VA 22320
    President, Hamilton PPB
    Washington DC 20008
    Executive Director, National Academy for State Health Policy
    Washington DC 20036


    President & CEO, AHIP
    Washington DC 20036
    Vice President, Media Relations, American Hospital Association
    Washington DC 20004
    Senior Vice President of Consumer Health and Medical Care Advancement, UnitedHealth Group
    Minnetonka MN 55343

Glossary on the Uninsured

ADVANCEABLE TAX CREDIT – A subsidy to help pay for health insurance that is available when the insurance premium is due, without having to wait until a year-end tax return is filed. Also see “tax credit.”

ASSOCIATION HEALTH PLAN (AHP) – Health insurance arrangement sponsored by business coalitions and trade and professional associations. AHPs operate under states’ insurance laws and regulations. Recent legislative proposals would regulate AHPs primarily under federal law. Also see “Small Business Health Plan.”

CAPITATION – Method of payment for health services in which a health care provider is paid a fixed amount for each person on the provider’s patient roster, regardless of the actual number or nature of services provided to each person.

CATASTROPHIC HEALTH INSURANCE – Health insurance which provides protection against the high cost of treating severe or lengthy illnesses. Such policies cover all or most of medical expenses above a relatively high specified amount.

CHERRY PICKING – The practice of insurance companies taking only those businesses or individuals that are good health risks, and avoiding businesses or people that have higher health risks. Also called “skimming.”

CHRONIC CONDITION (CHRONICALLY ILL) – A condition that is not expected to improve, that lasts a year or longer or recurs, and may result in long-term care needs. Chronic illnesses include Alzheimer’s disease, arthritis, diabetes, epilepsy and some mental illnesses.

COINSURANCE – A portion of the bill for a medical service, that is not covered by the patient’s health insurance policy and therefore must be paid out of pocket by the patient. Coinsurance refers to a percentage, e.g., 10 percent of the total charge up to a specified maximum. Contrast with “copayment,” which is stated as a flat amount, e.g., $5 per office visit.

COMMUNITY RATING – A method for setting premiums at the same price for everyone, based on the average cost of providing health services to all. The premium is not adjusted for the individual beneficiary’s medical history or likelihood of using medical services. Contrast with “experience rating.”

COPAYMENT – A flat dollar amount that a patient must pay out of pocket for a medical service, e.g. $5 per office visit.

COST SHARING – Any out-of-pocket payment the patient makes for a portion of the costs of covered services. Deductibles, coinsurance, copayments and balance bills are types of cost sharing.

CROSS-SUBSIDY – The concept of certain purchasers paying more for medical services than they otherwise would so that others can pay less (or nothing at all), or another activity can be funded. In the U.S. health system, this mechanism has been used to pay for medical services for the poor and uninsured, medical education and research.

CROWD-OUT – A phenomenon whereby public programs or expansions of public programs designed to extend coverage to the uninsured encourage some employers to drop health coverage, urging their employees instead to take advantage of the expanded public subsidy.

DEDUCTIBLE – A fixed amount, usually expressed in dollars in the form of an annual fee, that the beneficiary of a health insurance plan must pay directly to the health care provider before a health insurance plan begins to pay for any costs associated with the insured medical service.

DEFINED BENEFIT – A health insurance model used by an employer or government program where specified health services covered under the plan are standardized and guaranteed. The cost of providing the standard benefits may fluctuate. One example of a defined benefit plan is Medicare. Contrast with “defined contribution.”

DEFINED CONTRIBUTION – A health benefit model used by employers or government programs where health services covered may fluctuate based on choice of plan, but the employer or government contributes a set amount (percentage or dollar amount) towards the purchase of the selected health plan. A defined contribution plan limits the financial liability of employers or the government, because the contribution is defined, or fixed. An example of a defined contribution plan is the State Children’s Health Insurance Program. Contrast with “defined benefit.”

EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA) – Enacted in 1974, ERISA was primarily designed to secure workers’ pension rights. The law established federal reporting and disclosure requirements for most private employee health plans. Under ERISA, companies that pay for their workers’ health benefits directly (e.g. by self-insuring and assuming all or most financial risk) are exempt from state insurance regulations and taxes. ERISA also limits workers’ ability to sue their insurer. For more information, see www.dol.gov/dol/topic/health-plans/erisa.htm.

EMPLOYER CONTRIBUTION REQUIREMENT OR “EMPLOYER MANDATE” – A requirement that employers either provide health care benefits to their workers or pay a fee that contributes to the cost of covering their workers under a public (state) plan. Such proposals are also called “pay or play.”

EXPERIENCE RATING – Process of determining insurance premiums for a group that is based wholly or partially on that particular group’s past use of services and expenses incurred. Contrast with “community rating.”

FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM (FEHBP) – Health care plans offered to federal civilian employees who can annually choose among a number of approved, community-rated private health insurance plans. The federal government pays a major portion of the cost of the coverage (on average 72 percent). For more information, see www.opm.gov/insure/health.

FEDERAL POVERTY GUIDELINES – Income amounts set each February by the U.S. Department of Health and Human Services used to determine an individual’s or family’s eligibility for various public programs, including Medicaid and the State Children’s Health Insurance Program. Sometimes called Federal Poverty Level/Line (FPL). (The poverty guidelines are different from the U.S. Census Bureau’s “poverty thresholds,” which are used for Census statistical purposes.) For the 2007 poverty guidelines, see http://aspe.hhs.gov/poverty/07poverty.shtml

GUARANTEED ISSUE – A requirement that health plans cannot reject coverage for an applicant based on medical history. For example, under federal law, small employers that purchase health insurance cannot be denied coverage for sick workers. However, plans can adjust premiums based on medical history or other factors. Health plan policies that operate under a “guaranteed renewability” clause cannot cancel coverage due to a beneficiary’s health status.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) – A 1996 federal law that provides some protection for employed persons and their families against discrimination in health coverage based on past or present health. Generally, the law guarantees the right to renew health coverage, but does not restrict the premiums that insurers may charge. HIPAA does not replace the states’ role as primary regulators of insurance. HIPAA also requires the collection of certain health care information by providers and sets rules designed to protect the privacy of that information. For more information, see www.hhs.gov/ocr/hipaa/.

HEALTH REIMBURSEMENT ARRANGEMENT (HRA) – A type of health insurance plan also known as “health reimbursement account” or “personal care account,” HRAs are tax-preferred accounts with funds established by employers to reimburse employees for qualified medical expenses; often HRAs are paired with a high-deductible health plan. An HRA may be used by an employee to pay for medical coverage until funds are exhausted. Once the deductible is reached, normal coverage begins. Any unused funds are rolled over at the end of the year, but do not follow the employee once he or she changes jobs. Compare to “health savings account.”

HEALTH SAVINGS ACCOUNT (HSA) – A type of health insurance plan similar to HRAs, but which is owned by workers. An HSA is a tax-preferred savings account and is paired with a high-deductible health plan. Any employer can offer an HSA (or a self-employed individual can set one up on his or her own), and both employers and employees can contribute to it. The worker must pay for all services until the amount of the deductible is reached (in 2007, a minimum of $1,100 for an individual and $2,200 for family coverage). The worker can withdraw money from the HSA to pay for medical services under the deductible. Once the deductible is reached, normal coverage begins. Any unused funds are rolled over at the end of the year. Unlike HRAs, HSAs follow an employee when he or she changes jobs. Also see “health reimbursement arrangement” and “medical savings account.”

MANDATE – Used in two senses in health policy discussions. (1) Employer or individual mandate, in which the government imposes a requirement on some or all employers to help pay for insurance coverage for their workers (and perhaps their families), or on individuals to obtain coverage. (2) State mandate, a requirement imposed by states on insurance companies to include, as part of any health insurance policy they sell, coverage for a specific service, such as well baby care, or provider, such as psychologists or optometrists.

MEDICAID – Public health insurance program that provided coverage for an estimated 60 million low-income persons for acute and long-term care at some point during 2006. It is financed jointly by state and federal funds (the federal government pays at least 50 percent of the total cost in each state), and is administered by states within broad federal guidelines. Contrast with “Medicare.”

MEDICAL SAVINGS ACCOUNT (MSA) – A health insurance option consisting of a high-deductible insurance policy coupled with a tax-preferred savings account. MSA policies, put into place by a 1996 law, have been largely replaced by “health savings accounts.”

MEDICARE – Federal health insurance program for virtually all persons age 65 and older, and permanently disabled persons under age 65, who qualify by receiving Social Security Disability Insurance. Contrast with “Medicaid.”

MULTIPLE EMPLOYER WELFARE ASSOCIATION (MEWA) – A group of employers who band together for purposes of purchasing group health insurance, often through a self-funded approach. MEWAs are sometimes exempt from state benefit mandates, taxes and other regulations.

NON-GROUP INSURANCE – Insurance purchased by an individual directly from an insurer, rather than through an employer, union or other third party. Even though this is sometimes called “individual insurance,” it can be purchased for an individual or a family.

PRE-EXISTING CONDITION – A physical or mental condition of an individual which is known to the individual before an insurance policy is issued. Insurers may choose not to cover treatment for such a condition, at least for a period, may raise rates because of it, or may deny coverage altogether.

PREMIUM – The cost of health plan coverage, not including any required deductibles or copayments.

PREMIUM ASSISTANCE – The use of federal funds available through public health coverage programs – especially Medicaid and the State Children’s Health Insurance Program – to purchase or help purchase private insurance.

PREMIUM SUPPORT – A health benefit model that is considered by its designers to be a hybrid of the “defined contribution” and “defined benefit” approaches. This model would require general categories of health services to be covered, but benefits could be added or deleted within limits. The employer or government would then contribute a set amount of the premium for the purchased plan. Plans could set premiums at whatever dollar level they choose, with beneficiaries liable for any costs above the employer or government contribution. A Medicare demonstration designed to test a model similar to premium support is scheduled to begin in 2010.

RATING – The process of evaluating, or underwriting, a group or individual to determine a health insurance premium rate relative to the financial risk of needing healthcare the person or group presents. Key components of the rating formula include age, sex, location and plan design.

RATING BANDS – Amounts by which insurance rates for a specific class of insured individuals may vary. All states have laws regulating insurer rating practices, and many states periodically update these laws with small group market reform proposals to restrict or loosen allowable variations.

REFUNDABLE TAX CREDIT – A way of providing a tax subsidy to an individual or business, even if no taxes are owed (see “tax credit”). If a person owes no tax, the government sends the person (or a third party) a check for the amount of the refundable tax credit.

REINSURANCE/RISK CONTROL INSURANCE – Insurance bought to protect against catastrophic losses by an insurer or self-insured entity.

RISK – The probability of financial loss, relative to the probability of having to provide services to a patient or patient population at a cost that exceeds the payments received. Under capitation payment systems, providers share the risk that is borne by insurers.

RISK ADJUSTMENT – Increases or reductions in payment made to a health plan on behalf of a group of enrollees to compensate for health care expenditures that are expected to be higher or lower than average.

RISK SELECTION – Enrollment choices made by health plans – or by enrollees – on the basis of perceived risk relative to the premium to be paid.

RISK SHARING – A method by which the financial risk of covering a group of enrollees is shared by plan sponsors and purchasers, typically managed care organizations and states. In contrast, indemnity plans assume all risk of providing care paid for through insurance premiums which belong solely to the insurance company.

SINGLE PAYER SYSTEM – As referred to in the U.S., a proposed reorganization of the health care system, either at the national or state level, which would designate one entity (usually the government) to function as the central purchaser of health care services. Canadian provinces operate health insurance coverage for residents under this system.

SMALL BUSINESS HEALTH PLAN (SBHP) – Purchasing pools for small employers that have frequently been the subject of congressional proposals, SBHPs would include trade, industry and professional associations as well as ‘cooperative’ corporations or chambers of commerce. Known in other proposals as association health plans, SBHPs have generated controversy because they would be exempt from some state laws regulating health insurance.

SMALL GROUP MARKET REFORM – Generally refers to laws, regulations and proposals that are designed to simplify rules for small employers (50 workers or fewer) purchasing health insurance. While most regulation of health insurance is done at the state level, the 1996 Health Insurance Portability and Accountability Act made some key reforms.

STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP) – A program enacted by Congress in 1997 that provides federal matching funds for states to spend on health coverage for uninsured kids. The program is designed to reach uninsured children whose families earn too much money to qualify for Medicaid but not enough to afford private coverage.

STATE MANDATE – State coverage laws requiring private insurers to cover specific services (such as well-baby care) or reimbursement for specific providers (such as psychologists). The Employee Retirement Income Security Act (ERISA) generally exempts self-insured companies from these requirements.

TAX CREDIT – A flat amount that can be subtracted from taxes owed. Under some health care reform proposals, tax credits would be given to moderate-income individuals/families to subsidize health insurance premiums. A tax credit is more progressive in its impact than a tax deduction of the same amount, since the value of a deduction is greater for those whose tax rates (and usually incomes) are higher.

TAX DEDUCTION – An amount that can be subtracted from taxable income if spent on a specific purpose. Currently, businesses and the self-employed can deduct the cost of health insurance provided to employees, but health expenses (including insurance) are a deduction for families with group health insurance only after they reach 7.5 percent of income. Contrast with “tax credit.”

TAX PREFERENCE (FOR HEALTH BENEFITS) – Employer-paid health benefits are treated under federal tax law as a deductible business expense for the employer, and excluded from taxable income for the worker. This creates incentives for some employers and workers to prefer extra compensation in the form of more health coverage rather than wages.

UNDERINSURED – People with public or private insurance policies that do not cover all necessary health services, resulting in out-of-pocket expenses that often exceed their ability to pay.

UNDERWRITING – The process by which health insurers decide whether or not to accept an individual’s application for insurance, and, if the applicant is accepted, what conditions to apply. Underwriting is also applied to small employers. If the insurer decides that a particular individual or group poses greater than normal financial risks, it might charge higher premiums, offer more limited benefits, or refuse to pay for services relating to a particular “pre-existing” condition.

VOUCHER – In various health reform proposals, a certificate or fixed dollar amount that is provided to low- or moderate-income persons, which is used to pay all or part of the cost of health insurance or services.


1 Institute of Medicine, “Care Without Coverage: Too Little, Too Late,” May 2002, http://www.iom.edu/Object.File/Master/4/160/Uninsured2FINAL.pdf

2 U.S. Census Bureau, “Health Insurance Coverage: 2006 – Highlights.” August 27, 2007, http://www.census.gov/hhes/www/hlthins/hlthin06/hlth06asc.html

3 For completed, updated Census Bureau tables on health coverage in 2005 and 2006, see http://www.census.gov/hhes/www/hlthins/hlthin06.html (2006) and http://www.census.gov/hhes/www/hlthins/hlthin05.html (2005)

4 Kaiser Commission on Medicaid and the Uninsured, “The Uninsured – A Primer: Key Facts about Americans Without Health Insurance” October 2006, http://www.kff.org/uninsured/7451.cfm

5 Kaiser Commission on Medicaid and the Uninsured, “2007 Employer Health Benefits Survey – Summary of Findings,” September 2007, p. 29, http://www.kff.org/insurance/7672/index.cfm

6 Consumer Reports, “Health Insurance: CR Investigates Health Care,” September 2007, http://www.consumerreports.org/cro/health-fitness/health-care/health-insurance-9-07/overview/0709_health_ov.htm

7 See, for example, www.ehealthinsurance.com. Request a quote for a 22-year-old male, and compare with a quote for a 52-year-old male.

8 Results of ABC News/Washington Post poll, September 4-7, 2007, summarized by The Polling Report — http://www.pollingreport.com/prioriti.htm

9 Kaiser Family Foundation, “Iraq top issue, followed by health care, for the government to address and for presidential candidates to discuss.” August 2007. http://www.kff.org/kaiserpolls/upload/7691.pdf

10 Daniel Costello and Susannah Rosenblatt, “Financial woes jeopardize area hospitals.” Los Angeles Times, September 27, 2007 http://www.latimes.com/news/local/la-fi-hospitals23sep23,1,4466945.story

11 Institute of Medicine, “Care Without Coverage: Too Little, Too Late,” Appendix D, p. 163, May 2002, www.nap.edu/catalog.php?record_id=10367

12 Institute of Medicine, “Report Brief: Care Without Coverage: Too Little, Too Late,” pp. 5-6, May 2002, http://www.iom.edu/Object.File/Master/4/160/Uninsured2FINAL.pdf