year earlier—is higher than at any time in the 1970s. The most recent high, however, was the 15 percent rate in 1983 (Bureau of the Census, 1991).

The ability to pay for medical care is closely linked to having public or private health care coverage. Financial barriers to health care access may manifest themselves in several ways: eligibility/insurability, benefit coverage, and reimbursement levels. When insurance fails, it is the responsibility of direct service delivery programs to act as a safety net.

The three major surveys that have regularly monitored the size of the uninsured population all have shown an upward trend of about 25 percent over the past 10 or more years even though they differ somewhat on the exact counts. The National Medical Expenditure Survey in 1977 recorded that 12.3 percent of the population under 65 years of age was uninsured, a proportion that increased to 15.5 percent a decade later (Short et al., 1988). The National Health Interview Survey also reported an increase—from 12.5 percent in 1980 to 15.7 percent in 1989. The Current Population Survey (CPS) of the Census Bureau showed increases throughout the 1980s, although a change in the wording of the questionnaire in 1986 makes trend interpretation difficult. Recently, the CPS reported that the proportion of nonelderly uninsured was 16.6 percent of the population. This 1990 figure was an increase from the 1988 level of 15.9 percent with no insurance (Employee Benefits Research Institute, 1992).

The poor and minorities bear a heavy share of the burden of lack of insurance. In 1990, 55 percent of the uninsured were in families with annual incomes of less than $20,000. Although blacks constitute only 12.7 percent of the U.S. population, they represent 17.4 percent of those without health care coverage. The corresponding figures for Hispanics are 9.3 percent and 19.6 percent (Employee Benefits Research Institute, 1992).

The issue of health care coverage is a question not only of the absence or presence of insurance but also underinsurance—the depth or adequacy of coverage. As the cost of medical care relative to income soars, individuals find it increasingly difficult to maintain the breadth of their coverage. Furthermore, employers are likely to shift some proportion of premium cost increases to their employees through the employee contribution route and benefit restrictions. Underinsurance could affect access when policies do not cover preexisting medical conditions, when they require copayments and deductibles that cause delays in necessary care, or when they fail to cover certain categories of benefits (e.g., mental health services). Underinsurance is a difficult concept to gauge operationally because there is an inherent value judgment involved in setting criteria for what services should be covered and how much in out-of-pocket costs should be borne by individuals. In many cases cost sharing has been promoted as a way to reduce overutilization. In terms of access, underinsurance is interpretable only in



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