Any attempt to make healthcare more affordable to a greater number of citizens should be based on an accurate accounting of the uninsured.

How many of our citizens are uninsured? Who are these people?

According to the Current Population Survey (CPS) by the U.S. Census Bureau, there were about 47 million in 2006, at the time of the survey. However, only about half of those remained uninsured throughout the entire year. Still, as Thomas P. Miller, resident fellow of the American Enterprise Institute, notes that’s too many.

But to know what should be done, we need to know who these people are and why they are uninsured. Back in the spring, Miller provided a breakdown in a useful Q & A format. A few highlights:

Q: Who tends to be uninsured?

A. They tend to be younger, with those most likely to be uninsured between ages 19 and 24. Almost all adults age 65 and above are covered primarily by Medicare, and many of them have supplemental private insurance. Men are a little bit more likely to be uninsured. Married individuals and persons with more than a high school education are much more likely to be insured. Most of the uninsured (88 percent) are in good to excellent health. The likelihood of being insured rises with income and full-time work status, although nearly half (47 percent) of the uninsured are full-time workers. Hispanics are considerably more likely than those in any other ethnic category to be uninsured (over 30 percent). More than a quarter of the uninsured are foreign-born. By Census Bureau estimates, about 10 million uninsured are not citizens and half of them are illegal immigrants.

Q: Do many higher income people choose to be uninsured, even though they could afford to buy coverage?

A. Surveys suggest that one of the more significant sources for recent annual increases in the number of uninsured Americans involves persons in relatively higher income households. According to the CPS, more than 17.6 million uninsured live in households earning more than $50,000 a year, and household income is above $75,000 for more than 9 million uninsured. However, those numbers overstate the actual income available to those uninsured individuals, because household units are defined more broadly than are insurance purchasing units. As the composition of “households” changes, their income isn’t the same as family income available for spending on health insurance. The rising cost of coverage remains the primary barrier to insurance coverage for the uninsured, and in some cases, its value just may not be “worth it” for those in higher income families. But a more narrow and consistent measure of the higher income uninsured is closer to 2 million, involving people with regular incomes over $50,000 who lack insurance for spells of more than a year.

Q: Isn’t affordability of coverage the main problem, particularly for high-risk individuals?

A. The main reason cited by individuals for why they lack insurance is that it costs too much, but it’s not the only factor. Adults with weak or uncertain preferences for health insurance are less likely than others to obtain job offers with insurance, to enroll in offered coverage, and to be insured. On the other hand, individuals with higher health risks are more likely to seek and obtain health insurance coverage, particularly in the large employer group market. Higher premiums for higher risks are not a significant contributor to the large uninsured population.

Q: Don’t the uninsured obtain healthcare anyway?

A. Yes, but not as much, not as quickly, and not as effectively. People lacking health insurance pay out of pocket, receive uncompensated care, rely on other forms of private and public insurance (such as worker’s compensation), and wait until they have access to health insurance. Overall, the full-year uninsured receive about 50 to 55 percent of the dollar amount of medical care per person of those who have coverage for the entire year. People uninsured for only part of the year average more than 80 percent of the healthcare spending by the full-year insured.

Q: How much uncompensated care is received by the uninsured? Don’t the privately-insured pay higher premiums to make up the difference?

Eghty-eight percent of the uninsured are in good to excellent health.

A. Best estimates indicate that about one-third of the cost of health services received by the uninsured is “uncompensated care”—less than 3 percent of all U.S. healthcare spending. Most of those costs are covered by various taxpayer-funded payments (particularly disproportionate share payments to hospitals likely to treat more uninsured and low-income patients). There isn’t much left in the residual costs of uncompensated care to “shift” to private insurance premium payers. To the extent such cost shifting can occur not just in theory but in practice, it’s due much more to public programs like Medicaid and Medicare that have the legal power to pay much lower “below-market” rates of reimbursement to hospitals and doctors. Expanding low-paying Medicaid coverage might actually make any possible cost shifting to private premium payers worse, not better.

I do hope you’ll read Miller’s entire piece. There are some good bits on the use of the emergency room. It strikes me that quite a few people have simply chosen not to have health insurance—and I don’t see why, if they can afford it and are content with the risk, others should be taxed to provide health care insurance for them. We should not pay for their irresponsibility.

The uninsured who actually can’t afford it are another story. But if you look at the last question, you see that their needs are less dire than we are constantly led to believe. We should look for incremental, modest reforms that address their needs.

But we do not need to radically alter the relationship of government to every single citizen in the United States (minus congressmen, who have tip top policies, and that won’t change!) to address a problem that is smaller and different in character from what we are told by those who desire radical restructuring of society in and for itself.