FIGURE 6-1 National expenditures for health services and supplies, 1970 to 1997 and projections for 2002, in billions of dollars (■) and as a percentage of GDP (◊).

SOURCE: Levit et al. (1998).

from 14.2 percent in 1995 (U.S. Census Bureau, 1998). Lack of insurance is closely correlated with low income (Kuttner, 1999a). Many Americans are also underinsured and must either forgo care or pay for it out of pocket. A number of recent studies have documented that the percentage of individuals who lack insurance is rising (Kuttner, 1999a).

Increases in the numbers of uninsured and underinsured individuals appear to be more closely related to a deterioration in employer-based coverage than to unemployment, since they have occurred at a time when the latter is declining (Schoen et al., 1998). Two-thirds of Americans receive their health insurance through an employer (Fronstin, 1998). The rising cost of health care has forced many employers to either drop health insurance coverage for their employees or eliminate some of the benefits that they provide. In addition, trends toward part-time or temporary employment, the growth in the number of self-employed individuals, and the contracting out of certain tasks have left many workers and their families with no or inadequate coverage. Other factors include the loss of Medicaid coverage because of welfare reform and the rising cost of “Medigap” coverage, which results in inadequate insurance coverage for elderly individuals enrolled in the Medicare program (Kuttner, 1999a).

Concerns about the quality of U.S. health care have also been a factor in promoting health care reform (Chassin et al., 1998; Bodenheimer, 1999).