December 10, 2005


Young and uninsured

A commentary on discusses the large numbers of young adults who do not have health insurance and the need for public policy initiatives to tackle this national problem.  The commentary is written by Holly Beck, a paralegal at a national child welfare advocacy organization in New York City.  Here is what she had to say.

Think about your plans for the next four years. Do they include going without health insurance?

Perhaps they should. A study published by the Commonwealth Fund projects that if past patterns continue, two-thirds of all Americans between the ages of 19 and 29 will lack health insurance at some point in the next four years. In 2003, the most recent year for which data is available, over 30 per cent of 19- to 29-year-olds didn’t have health coverage, almost double the rate of 30-64-year-olds who lacked coverage in the same year.

This makes 20-somethings the age group with the lowest rates of health insurance coverage in the country. While children’s health and retirees’ prescription benefits are often prominently featured in public policy discussions, these groups are in fact covered at far higher rates than young adults. This is often because children and the elderly are eligible for Medicaid and Medicare; young people, considered among the healthiest segments of the population, are more often ineligible for public programs.

They are also the most unstable, a factor that contributes greatly to their difficulty in obtaining insurance coverage. Nationwide, over half of all employers who offer health coverage for employees and their dependents will not cover dependents who are over 18 or 19 and do not go on to post-secondary education. Young people who received public health coverage as children are also likely to age out of the system at 19. Young adults who are able to maintain health coverage through college are often only delaying the loss of coverage until graduation.

Sara Collins, senior program officer at the Commonwealth Fund, points out that within this age group, issues of income and poverty are also very much at play. “This is a relatively low-income group of people that doesn’t have access to health insurance,” she said. “Seventy-two per cent of uninsured young adults are under 200 per cent of the poverty line.” What this means is that even those uninsured young adults who are not below the poverty line are still close enough to poverty to be considered highly vulnerable.

When a young person does not attend college and enters the labor market, the types of jobs they are qualified for tend to not offer benefits. Even young adults who do graduate from college are likely to work temporary or part-time jobs, work for smaller firms, and change jobs more frequently -- all of which lessen their chances of being offered health insurance through work.

Collins says that it is largely due to these factors -- income and employment status -- that young adults find themselves with or without health insurance. A competing theory, which argues that young people view themselves as invincible and don’t see coverage as an important issue, is largely unfounded, says Anthony Wright, executive director of Health Access California.

“There’s a myth of the ‘young immortals,’ people in this age group who believe they’ll live forever so they don’t need coverage,” Wright said. In fact, available statistics counter the presumption that young adults don’t value health insurance. When adults ages 19-29 are offered coverage, they generally accept it at the same rates as people in older age groups.

“If you actually control for income and type of jobs, young people take up coverage as much as any other age group. So if they turn down health coverage, they do it because they can’t afford it,” Wright said.

A Commonwealth Fund survey also found that 70 percent of young workers say that health insurance is an important factor for them when they choose a job, a figure comparable to other age groups. So does the ‘young immortal’ theory carry any weight? Wright believes that while there is some truth to it, it pins the responsibility on individuals, rather than on the system that excludes them. “I’m not saying you can’t find individual people who have this [young immortal] world-view,” he said. “But that’s not the problem with our health system.”

Risky Business

If health insurance is unavailable or too expensive, young people may end up going without coverage while fully aware of the risks involved. But in the event that they require medical attention and don’t have the insurance to cover the expense, they could be faced with an extremely difficult choice between personal health and financial solvency.

“Obviously, health care services are very expensive, and they can mount up,” said Marian Mulkey, senior program officer at the California HealthCare Foundation.

She says that while most young people are healthy, there are always going to be some who will require medical attention. “The odds are low, but they’re not zero,” she said. “We know that a small number of young people will develop those needs and it will be expensive. If they have to pay out of pocket, they may end up making difficult decisions about the care they receive.”

According to a 2003 Commonwealth Fund health survey of young adults ages 19-29 who were uninsured for all or even for part of the year, over half went without medical care, including doctor’s appointments, tests and prescriptions, and had significant trouble paying their medical bills.

Another risk of going without health insurance, even for a short time, is the possibility of being unable to resume coverage.

“Insurance providers can’t turn a company down for coverage, even if the company has sick employees,” Mulkey explained. “With individuals, that’s not the case. If individuals are sick, or even have conditions that aren’t that serious, they could be turned down or charged a higher premium. That’s something most people don’t think about, but it can have long-term repercussions. People may think, ‘I’ll bear the risk for a year, and regain coverage when I find a new job or I’m better off financially.’ But they may be bearing the risks for longer than that.”

The Rugged Individual

Peden Young, 28, spent the first few years after college paying for what he calls “catastrophe insurance.” For just under $100 a month, Young was covered by a high-deductible individual plan that didn’t cover doctors’ visits or prescriptions, but would cover a trip to the emergency room. “It really sucked. I couldn’t go see a doctor unless I paid for it,” he said.

To boot, the policies almost always had a shelf life and limits on renewal. “Every year or so I'd have to look around, get a new temporary policy and pay $75 to $100 a month for no real insurance.”

Real insurance is what the makers of Tonik, a new and growing individual plan geared toward young adults, say they are providing. A product of Blue Cross, Tonik offers coverage in the form of three individual plans: “calculated risk-taker,” “part-time daredevil,” and “thrill-seeker.” Monthly fees, copay, and deductibles vary with each plan. For instance, the “thrill-seeker” plan has the lowest monthly fees and copay, but it also has the highest deductible. Tonik’s web site is a mélange of hipster graphics, bold colors, and Gen-Y slang. The coverage is marketed as “health insurance, straight up.”

Steve Synott, general manager for individual plans at Blue Cross of California, says Tonik is his most successful product launch ever. Currently available in California and Colorado, Blue Cross has plans to expand Tonik into Nevada and other states. The reason for Tonik’s success? Synott says it’s all the research they did on the 19- to 29-year-old demographic before designing the actual health plans. In that research, Synott says it came through loud and clear that young adults want preventive care, dental coverage, and coverage for doctors’ office and emergency room visits.

“Our first tag name for them was ‘young invincibles,” Synott said. “But when we got to know them better, we changed that name to ‘mature mavericks,’ because they did seem to know they should be insured.”

One positive outcome of Tonik’s launch is the extension of health coverage to many who previously lacked any coverage at all. “Seventy per cent of people signing up for Tonik were previously uninsured,” Synott said. “More important than the fact that it’s selling is the fact that it’s selling to people who previously were not covered.”

Synott said the biggest surprise to most young adults is learning the sheer expense of most medical procedures. Tonik’s web site is sprinkled with some of these quotes: $6,797 for an average day in a hospital, $48,302 for knee surgery, and so on. Compared to these scary figures, the Tonik deductibles might not seem so bad.

“Yes, $1,500 is a lot of money to shell out for a deductible,” Synott acknowledged. “But if your appendix bursts and you need surgery, $1,500 is a lot better than the full $48,000 that it would cost to have the surgery.”

Then again, that $1,500 deductible is only for the Tonik plan with the highest copay and monthly fees. Tonik’s other plans carry deductibles of up to $5,000 – a figure that would make many a 20-something’s stomach lurch.

Reactions to Tonik and other options like it have been varied among health care advocates and policy analysts. Some are quick to point out that behind Tonik’s funky, fun-loving lingo and imagery is the same kind of individual coverage that’s been available to young adults for years. “While I think that marketing directly to this population, experimenting with different products, and making people aware of the risks of not having coverage is a really good thing, I think there’s a limit to how far it will go, especially for people in this age segment with really low incomes,” Mulkey said.

Wright points out that Tonik does not cover maternity care, an expensive but necessary form of care for many young women in the 19-29 age group. Synott defended Tonik’s stance, saying that young people consulted during the planning of the benefits structure overwhelmingly said they didn’t want maternity care included. “People said, ‘I don’t want to pay for that.’ If they had, we would have added it to the plan and priced for it.”

Collins said she is skeptical of any new product’s ability to work for the majority of young adults lacking health insurance. The financial burden, she says, is just too high for most uninsured people to bear. “Individual coverage has always been available to this age group, but it’s high cost,” she said. “I’m sure individual coverage works for some families, but for the majority of young adults who are uninsured, it’s not going to work.”

When speaking to experts and analysts for this story, I asked what advice they might give to a young adult hoping to get decent coverage without bankrupting themselves. The fact that I came up short indicates that the options available to this age group are limited indeed. “Find a job that offers health coverage,” one offered. Most seemed to think that the solution must involve a reshaping of public policy, not just placing the burden on young people to individually seek out creative ways to secure insurance.

Looking Ahead

There are a number of policy changes that would expand health coverage to more young adults. Utah already has laws in place that require insurance policies covering dependents to offer coverage for unmarried dependents up to age 26. Last year, California voters were presented with Proposition 72, a referendum that would have expanded employee health coverage throughout the state. “It would have required large employers like McDonald’s or Wal-Mart to offer coverage to their workers,” Wright said.

Proposition 72 was defeated, with 49.2 percent of voters supporting it and 50.8 percent voting against it. Wright says the only reason the measure came so close to passing was the overwhelming support from voters in their twenties. “We lost every other age group by a small amount, and then two-thirds of young people voted for it, which made it nearly a 50-50 split.”

Collins believes that employers who extend health benefits to temporary and part-time workers, and thus to a disproportionate number of young adults, could actually reap benefits for everyone on the group policy. “This is a relatively inexpensive age group to cover,” she said. “Their health costs are lower than other age groups, so pulling this group into an employer group pool could have the effect of lowering premiums for everyone.”