More than half of the nation’s uninsured residents are ineligible for public programs such as Medicaid but do not have enough resources to purchase coverage themselves, researchers from the Urban Institute report in a Health Affairs Web Exclusive [2-week free access] published November 30.

Of the 44.6 million uninsured Americans, 56 percent are ineligible for public programs and have insufficient incomes to afford coverage on their own, the researchers report. Another 25 percent of the uninsured are eligible for public programs, and the remaining 20 percent have incomes high enough to afford coverage.

“Sometimes you hear arguments that all but a small minority of the uninsured could either purchase coverage or are already eligible for assistance,” said lead author Lisa Dubay, now a research scientist at the Johns Hopkins Bloomberg School of Public Health. “But our study shows that the affordability problem is far more serious than that.”

Barriers For childless adults. Childless adults — who are generally not covered under Medicaid, the State Children’s Health Insurance Program (SCHIP), and other public programs — face the most severe affordability barriers. Of the 25.5 million uninsured childless adults in the United States, 69 percent are ineligible for public programs but cannot afford coverage on their own. By contrast, only 11.3 percent of the country’s 8 million uninsured children can not afford private coverage and have no public options available. “The strikingly different landscapes facing children and childless adults testify to how important the establishment of SCHIP and other coverage expansions have been for the welfare of the nation’s children,” Dubay said.

Affordability: A problem under any measure. As a threshold to determine whether an uninsured person would be able to afford coverage without assistance, Dubay and coauthors used an income level of 300 percent of the federal poverty level (FPL); in 2004, 300 percent of the FPL amounted to $28,935 for a single person and $57,921 for a family of four. Because the concept of “affordability” is subjective, they also looked at several alternative affordability measures. Their conclusion: “Regardless of the affordability threshold used, the bulk of uninsured parents and childless adults are not eligible for public coverage and likely not able to afford private coverage.”