Abstract
IN THE COURSE of our nation's debate about health system reform, the discussion has frequently centered on the 38.9 million Americans who have no health insurance,1 and the insecurity of millions more about their ability to maintain existing coverage in a time when health insurance and health care services costs are increasing rapidly. Indeed, a national survey of Americans conducted in the week following President Clinton's address about health care reform to Congress and the nation, 48% said the cost was their greatest concern about their health insurance, and 21% said they feared losing coverage or benefits.2 In the same survey, one in five Americans (21%) indicated that their greatest concerns about health insurance coverage were related to the inadequacy of benefits they have, including gaps in coverage and lack of catastrophic or stop-loss provisions.2 These kind of data are somewhat frustrating for those concerned about the health care reform debate because they provide measures of who is theoretically at risk for financial catastrophe—people without insurance, without adequate insurance, or concerned about the costs of medical care and health insurance—without providing concrete information about who has actually experienced difficulty paying medical bills. We have read the tragic stories of such individuals in newspapers and heard them presented to the Clintons in several health care forums, but we have yet to see detailed data about how many people in the United States are struggling to pay bills, and who they are. In this article, we use data from a recent national household survey of Americans to look directly, rather than at proxy measures, at who reports actual problems paying medical bills. We examine the insurance status of people in this group and, in addition, ask what other financial stresses they face and how they cope with the realities of illness and disability in their households.