Insured but unable to afford health care

Affordable Care Act will leave tens of millions underinsured, facing choice between ‘life or debt,’ say Journal of General Internal Medicine editorialists

April 25, 2013

Contact: Mark Almberg, PNHP, (312) 782-6006,

In an editorial responding to a new study on skimpy health insurance among low-income, insured Americans, two policy experts review extensive data showing that tens of millions of insured Americans have grossly inadequate coverage, and that the problem of underinsurance is growing.

The editorial in the Journal of General Internal Medicine (JGIM) was approved by the journal's editors for publication on today's date and will appear on its website next week. The text of the editorial is available here.

Paradoxically, the Affordable Care Act (ACA) may actually increase underinsurance, say the editorialists, Drs. Steffie Woolhandler and David Himmelstein.

“Obamacare is lowering the bar for health insurance,” said Dr. Himmelstein, a professor of public health at the City University of New York and primary care doctor. “The new coverage sold through the insurance exchanges will leave many families paying 40 percent of their health costs out-of-pocket even after they’ve laid out thousands for premiums. And the administration is allowing states to institute co-payments under Medicaid, even for the poorest of the poor.”

Himmelstein continued: “Under the ACA a 56-year-old making $46,100 will pay a premium of $10,585 for coverage through the exchange and still face up to $6,250 in co-payments and deductibles.”

Dr. Woolhandler, the lead author of the editorial who is also a physician and professor of public health at CUNY, said: “Over the past 25 years the financial protection offered by health insurance has steadily eroded. The consequences are grave, not only financially but also medically. For instance, we know that heart attack patients who face high co-payments delay coming to the ER, threatening their lives.”

Woolhandler and Himmelstein (who also serve as visiting professors at Harvard Medical School) were co-authors with Elizabeth Warren of a widely cited study that showed that illness and medical bills contribute to 62 percent of personal bankruptcies; most of the medically bankrupt were insured. Sen. Warren played no role in the JGIM editorial.

“Obamacare is making underinsurance the new normal,” said Woolhandler. “It will reduce the number of uninsured from 50 million to 30 million, but the new coverage is full of holes. Americans deserve the kind of first-dollar, comprehensive coverage that Canadians already have. But that’s only affordable under a single-payer system that cuts out the private insurance middlemen.”


“Life or Debt: Underinsurance in America,” Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D. Journal of General Internal Medicine, approved for publication on April 25, 2013. The text of the article is available here.

The related article:

“Prevalence and Predictors of Underinsurance Among Low-Income Adults,” Hema Magge, M.D., M.S., Howard J. Cabral, M.P.H., Ph.D., Lewis E. Kazis, Sc.D., and Benjamin D. Sommers, M.D., Ph.D. Journal of General Internal Medicine, published online Feb. 1, 2013.

Physicians for a National Health Program ( is a nonprofit research and education organization of more than 18,000 doctors who advocate for single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above. To speak with a physician/spokesperson in your area, visit or call (312) 782-6006.