Curing Americans without health insurance

originally published 9/9/2004

America will spend more than a trillion dollars implementing the Affordable Care Act. Yet in its most recent projection, the Congressional Budget Office estimates that more than 30 million Americans will still lack basic health insurance by 2016 when the law is fully implemented.

While we have reduced the number without health insurance since the peak of the problem around 2009, the reduction has come at a tremendous cost and largely targets groups with minimal health care needs like younger adults.  Virtually all commenters agree that current measures are not sufficient to address the ongoing problem of Americans without health insurance.

Freedom Benefits Association, a provider of employee benefit services for small businesses, endorses the following plan for reducing the estimated 60 million Americans without basic health insurance. Some version of this plan has been promoted with minor variations by the health insurance industry including AHIA1 and various other consumer advocacy groups over the past decade.

The policies2 that will be most effective in reducing the number of Americans without health insurance include:

1) Use wage tax incentives to promote voluntary coverage among an estimated ten million uninsured higher-income workers.
2) Provide refundable tax credits for an estimated 15 million uninsured Americans who are not eligible for public programs or employer plans.
3) Intensify efforts to cover an estimated nine million adults and children who are eligible but not enrolled in Medicaid and the State Children’s Health Insurance Program (SCHIP).
4) Give states the option of expanding Medicaid and SCHIP to provide access to coverage for an estimated two million Americans living below poverty who are not eligible for those programs. (This provision is now part of the ACA).
5) Provide bridge loans or temporary financing to help an estimated four million middle-income workers maintain their coverage when they become unemployed.
6) Create high risk purchasing pools to cover an estimated one million uninsured individuals with especially high health costs.
7) Provide an estimated two million uninsured individuals living near poverty access through public financing of private health coverage.

This chart, based on a pre-reform census, sorts the uninsured groups according to size and summarizes the recommendations. While the size of each component of the uninsured population will change over time, the relative makeup remains mostly unchanged.




Primary Concerns

Approach Most likely to be Effective

Middle income individuals not eligible for employer plans

15 million


Tax incentives and promotion of options

Workers eligible for employer health plans

10 million


Wage tax credits

Eligible for public assistance but not enrolled

9 million


Communication and Outreach

Provide financing to pay for short-term coverage for temporarily unemployed

4 million

Cash Flow

Government-assisted financing

Low income but not eligible for public assistance

4 million


Include in current welfare programs

Individuals with catastrophic health care costs

1 million


Publicly assisted High risk pools


Uninsured people tend to belong to working-class middle-income households. They work, pay taxes and struggle with the cost of health care throughout most of their loves. It appears that relatively simple changes in the tax law would be the most effective means to directly address more than half of the remaining uninsured group. The rest can eventually be addressed through expansion of state Medicaid programs, modifications of state and federal coverage continuity laws (COBRA and other state law), maintenance of high-risk health coverage pools and an ongoing blitz of consumer education and promotion of the existing coverage options. is a Web-based provider of low-cost benefit plan documents, employee communications and designs for small businesses. includes a listing of low-cost health limited benefits or supplemental insurance plans that offer online enrollment. offers employee benefits education programs and service. All of the Freedom Benefits web sites are run by Tony Novak, CPA, financial adviser and health reform activist for more than 25 years.


1 The author was previously an individual member of the group now known as the Association of Healthcare Internal Auditors (AHIA)

2 The 2013 revision or this article largely retains the language of the pre-reform proposals despite modifications by ACA that might otherwise have called for an update in terminology.


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