Currently, there are approximately 46 million uninsured Americans; nine million of them are children. More than eight out of ten uninsured Americans are in working families (1).  An extensive body of research has demonstrated that health insurance is integral to well-being and health and that being uninsured can harm health for both children and adults.  In addition, according to a recent report from the Institute of Medicine, when adults acquire health insurance, many of the negative health effects of uninsurance are mitigated (2).

In honor of National Cover the Uninsured Week (March 22-28, 2009) and National Public Health Week (April 6-12, 2009) this month the Community Health Data Base examines the current status of the uninsured in Southeastern Pennsylvania (SEPA) based on data from the recently released 2008 SEPA Household Health Survey, a randomized telephone survey of 10,000 households in Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties.  This article examines changes in the prevalence of uninsurance over the past 15 years, demographics of uninsured adults, and the insurance status of children in SEPA.

OVERALL PICTURE: UNINSURED NONELDERLY ADULTS IN SEPA, 1991-2008

According to the 2008 SEPA Household Health Survey, approximately one in ten adults ages 18-64 (9.8%) – representing about 237,400 individuals – have no public or private health insurance.  Similar to the nation, the percentage of the SEPA adult population that has no insurance has been rising steadily – from 7.2% in 1991 to today’s nearly 10% (Figure 1).  Among uninsured adults, nearly half have been uninsured for less than 6 months (47.9%).  However, over one third of the uninsured (34.2%) have been uninsured for over one year, and over half of these have been uninsured for more than two years, representing about 36,400 adults in the region who have not had health insurance in over two years.

There is considerable variation across the 5-county region in the percentage of the population that is uninsured. Currently, Philadelphia has over twice the prevalence of uninsured adults (15.8%) compared to Delaware (7.3%), Bucks (7.0%), Chester (5.8%), and Montgomery (5.4%) Counties. 

CHARACTERISTICS OF THE UNINSURED IN SEPA

The 2008 Household Health Survey findings indicate that six in ten uninsured adults ages 18-64 (60.7%) are employed either full- or part-time; this represents approximately 142,400 nonelderly adults in our region who are currently employed and uninsured  (Figure 2).  Of these 142,400, two thirds (about 90,200) are uninsured and working full-time.

Additional demographic characteristics of uninsured nonelderly adults in SEPA include:

• Young adults are over two times more likely to be uninsured than any other age groups: one in five adults ages 18-29 (19.5%) are uninsured, compared to 8.5% of adults 30-39, 9.1% of adults 40-49, and 6.1% of adults 50-64.  Due to Medicare, about 99% of SEPA adults 65 and older are insured. 
• A higher proportion of men are uninsured than women (11.2% and 8.7%, respectively).
• Racial/ethnic minority adults are at greater risk of being uninsured than white adults in SEPA; 29.8% of Latino adults are uninsured, followed by of Black/African American (14.5%), Other (14.5%), Asian (12.0%), and White (5.9%) adults.
• Those who have completed fewer years of schooling are at greater risk for being uninsured.  That is, over one quarter of adults who do not have a high school diploma/GED are uninsured, compared to 14.6% of adults who have a high school degree, 10.4% of adults with some college, 4.7% of adults with a college degree, and 3.1% of adults with advanced degrees.
• Adults living below 200% of the federal poverty level in 2008 are over four times more likely to be uninsured than those living at or above 200% of the federal poverty level (3).

LACK OF INSURANCE: A CRITICAL BARRIER TO CARE

The 2008 SEPA Household Health Survey also describes ways that uninsured individuals may be limited in their ability to seek health care for themselves and family members. 

• No regular source of care. Having a regular source of care can improve continuity of care, ability to access care when needed, and possibly quality of care.  Uninsured adults (18-64) are more likely to lack a regular source of care than insured adults (37.3% of uninsured adults have no regular source of care, compared to 8.7% of insured adults).  About 88,500 uninsured adults in SEPA have no regular source of care.
• Past year health care visit.  While the vast majority of insured adults in SEPA have visited a medical provider in the previous year (85.1%), only 59.3% of uninsured adults have accessed such a visit in the previous year.
• Not receiving needed care due to cost.  In 2008, 43.8% of uninsured adults (18-64) reported that they did not seek needed care due to the cost (representing about 103,800 adults); this is compared to 10% of insured adults who did not seek care due to cost. 

CHILDREN WITHOUT HEALTH INSURANCE IN SEPA

Although a variety of programs are in place to attempt to provide health coverage for children in the U.S., nine million children in the U.S. are still without health insurance.  According the 2008 Household Health Survey, 4.2% of children, or about 39,000 children under age 18 in the region have no private or public insurance.  While this is a decrease in the proportion of children who are uninsured since 1991 (5.6%), it is an increase from a low of only 2.7% of children uninsured in 2000 (Figure 1).  Across the 5-county region, Philadelphia has the highest proportion of uninsured children (5.1%), followed closely by Bucks (5.0%) and Delaware (4.6%) Counties. Chester (3.5%) and Montgomery (1.8%) Counties have the lowest percentage of uninsured children.

In February 2009, the federally-funded State Children’s Health Insurance Program (SCHIP or CHIP) was reauthorized and expanded.  This expansion may serve to decrease the proportion of children in the region who have no insurance; the Community Health Data Base will track this possible improvement when conducting the next Household Health Survey in 2010.

SUMMARY

The 2008 Household Health Survey indicated that one in ten nonelderly adults in Southeastern Pennsylvania are uninsured, representing 237,400 uninsured adults. Among uninsured adults, one third have been uninsured for more than one year.  About 39,000 children in SEPA are uninsured.  This analysis also demonstrated that the adult uninsured population continued to grow in SEPA in 2008, with no sign of change in this trend.  These findings demonstrate the ongoing need for expanding health coverage to cover all adults and children in Southeastern Pennsylvania and beyond. 

For more information about this article, the Community Health Data Base, or the 2008 Southeastern Pennsylvania Household Health Survey, contact CHDB Associate Allegra Gordon at agordon@phmc.org.

To learn more about Cover the Uninsured Week, visit: http://covertheuninsured.org/.
To learn more about National Public Health Week, visit: http://www.nphw.org/nphw09/default.htm.

NOTES:
(1) Robert Wood Johnson Foundation: http://covertheuninsured.org/the_issue, accessed 3/22/09.
(2) Institute of Medicine. Report Brief: America’s Uninsured Crisis: Consequences for Health and Health Care.  National Academy of Sciences, February 2009. http://www.rwjf.org/pr/product.jsp?id=39069, accessed 3/22/09.
(3) In 2008, federal poverty guidelines defined poverty level as a family of four with an annual household income at or below $21,200.