The Nonpoor Uninsured In California , 1998 If those who can afford

Lack of insurance is not solely an issue for the poor. In both California and the nation, approximately 40 percent of the uninsured have family incomes of at least twice the federal poverty level, and one-quarter have family incomes of at least 300 percent of poverty. Examining the issue from this perspective does not detract from the importance of ensuring that those with the least means in our society obtain health insurance and better access to care. However, it does evoke questions about the point at which health insurance is the responsibility of the individual rather than of society. Nationally, the vast majority (80 percent) of the nonpoor (persons with incomes above 200 percent of poverty) obtain health insurance through employment, but a significant minority are self-employed, work for a firm that does not offer coverage, or turn down employer-offered coverage. For these persons (and their dependents), the main options are to purchase individual health insurance or to remain uninsured. About 7 percent purchase individual insurance (35 percent of those not covered through employment); the remainder go without coverage. Interestingly, and somewhat surprisingly, those at 200–299 percent of poverty are just as likely to purchase individual health insurance as are those with incomes above 400 percent of poverty. The nonpoor are not strong candidates for public insurance programs or significant premium subsidies. Only five states have expanded health insurance premium subsidies to adults with incomes greater than 200 percent of the federal poverty level, and there is no serious discussion of doing so at the national level. As a society, we assume that persons at this income level will voluntarily purchase health insurance, and many of them do. Why don’t all of them do so? Are they worried about being uninsured? How do they get access to the medical care system, and at what cost? Would they consider purchasing coverage? Answers to these questions will help to inform the discussion about the potential for expanding coverage within the current voluntary system.