Bernstein, 2008; Chernew et al., 2005; Dorn et al., 2008; Gould, 2007; Holahan and Cook, 2008; Reschovsky et al., 2006; Smith et al., 2008). This chapter begins with a brief description of the uninsured population and then explores the forces underlying current trends in private and public health coverage.


Sources of Health Insurance

The workplace has been the source of health coverage for several generations of Americans. Today, most privately insured people continue to be insured through their job or the job of a family member (Figures 2-1 and 2-2). However, since around 2000, ESI coverage has been on the decline. Among adults, ESI coverage dropped by 5 percentage points between 2000 and 2007, from 69.3 percent to 64.3 percent. ESI coverage of children also fell during this time period—from to 65.9 to 56.8 percent—but the decline was offset by rising enrollment in Medicaid and the State Children’s Health Insurance Program (SCHIP). During this period, many states expanded eligibility, ramped up outreach, or streamlined application processes to expedite eligible children’s enrollment in these public health insurance programs (Coughlin and Zuckerman, 2008; Smith et al., 2008).

Approximately 2.9 percent of the nonelderly population is insured through the TRICARE or CHAMPVA2 military-related health insurance programs (Fronstin, 2008a).

Only a small proportion of the population purchases private health insurance outside the job setting. In 2007, an estimated 6.8 percent of the nonelderly population had individually purchased health insurance coverage. This percentage has been relatively steady for more than a decade (Fronstin, 2008a).

Who Are the Uninsured?

In 2007, there were 45.7 million people without health insurance in the United States, 5.9 million more than when the IOM issued its initial


Because nearly 98 percent of the U.S. adult population over age 64 has health insurance coverage through Medicare or other sources (DeNavas-Walt et al., 2007), this chapter focuses on trends in coverage for the nonelderly population. References in the text to “adults” refer to 18- to 64-year-olds; “children” refers to the under-18 population.


TRICARE is a health benefits program sponsored by the Department of Defense for military retirees and families of active duty, retired, and deceased service members. CHAMPVA refers to the Civilian Health and Medical Program for the Department of Veterans Affairs, a program for disabled dependents of veterans and certain survivors of veterans.

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