Health Care Financing and Insurance Coverage

Research on the dysfunctional U.S. health care financing system has been a major focus of CHJL’s work for more than 35 years. Our studies have focused on financial barriers that obstruct access to care; medical and financial harms (including medical bankruptcy) caused by current insurance arrangements; health care administrative costs; and the costs of health coverage expansions.

One recent study from our group, published in Health Affairs, examined the effect that high out-of-pocket drug costs has on adherence to prescribed medications, particularly individuals who have low incomes, chronic medical conditions and are from communities of color. Using data from a nationally representative sample of adults in the US in the National Health Interview Survey (NHIS), this study showed that individuals with Veterans Administration (VA) insurance , which provides medications at minimal cost, had much lower medication non-adherence (6.1%) when compared with individuals with non-VA coverage (10.9%), who typically have substantial out of pocket medication costs. This study highlighted the adverse effects of out of pocket costs on medication adherence and showed how a model program with minimal cost sharing can help address the crisis in prescription medication affordability.

Publications in this Area

The effect of the Veterans Health Administration’s low-cost drug coverage on cost-related medication nonadherence among people participating in the system. Gaffney A, Bor DH, Himmelstein DU, Woolhandler S, McCormick D. Health Affairs. 2020 Jan 1;39(1):33-40.

High-deductible health plans and healthcare access, use, and financial strain in those with chronic obstructive pulmonary disease. Gaffney A, White A, Hawks L, Himmelstein DU, Woolhandler S, Christiani DC, McCormick D Annals of the American Thoracic Society. 2020 Jan;17(1):49-56.

Health care administrative costs in the United States and Canada in 2017. Himmelstein DU, Campbell T, Woolhandler S. Annals of Internal Medicine. 2020 Jan 21;172(2):134-42.

Intersecting US epidemics: COVID-19 and lack of health insurance. Woolhandler S, Himmelstein DU.  Annals of Internal Medicine 2020; 172:63-64

Barriers to Primary Care After the Affordable Care Act: A Qualitative Study of Los Angeles Safety-Net Patients’ Experiences. Saluja S, McCormick D, Cousineau MR, Morrison J, Shue L, Joyner K, Hochman M. Health Equity. 2019 Aug 23;3(1):423-430.

US Health Care in the Trump Era: A Data Update. Himmelstein DU, Woolhandler S, Fauke C. International Journal of Health Services. 2019  Apr 8:20731419840178.

The Incidence of Diabetic Ketoacidosis During “Emerging Adulthood” in the USA and Canada: a Population-Based Study. Gaffney A, Christopher A, Katz A, Chateau D, McDougall C, Bor D, Himmelstein D, Woolhandler S, McCormick D Journal of General Internal Medicine. 2019 May 7:1-7.

The effects of household medical expenditures on income inequality in the United States. Christopher AS, Himmelstein DU, Woolhandler S, McCormick D. Am J Public Health. 2018 Mar;108(3):351-4. 

Analysis of Work Requirement Exemptions and Medicaid Spending. Goldman AL, Woolhandler S, Himmelstein DU, Bor DH, McCormick D. JAMA internal medicine. online ahead of print 2018 Sep 10.

The Ongoing US Health Care Crisis: A Data Update. Himmelstein DU, Woolhandler S, Almberg M, Fauke C. International Journal of Health Services. 2018 Apr;48(2):209-22.

The U.S. Health care Crisis Continues: A Data Snapshot. Himmelstein DU, Woolhandler S, Almberg M, Fauke C.  International Journal of Health Services 2018; 48(1):28-41.

Access to Care and Chronic Disease Outcomes among Medicaid-Insured Persons versus the Uninsured.  Christopher AS, McCormick D, Woolhandler S, Himmelstein DU, Bor DH, Wilper AP. American Journal of Public Health 2016; 106(1):63–69. 

Support for National Health Insurance Seven Years into Massachusetts Heallthcare Reform: Views of Populations Targeted by the Reform.  Saluja S, Zallman L, Nardin  R, Bor D, Woolhandler S, Himmelstein DU, McCormick D. International Journal of Health Services 2016; 46(1):185-200. 

Structural Racism and Racial/Ethnic Inequalities in Health

Structural racism is a fundamental cause of large and persistent health inequalities in the United States. Black Americans, for example, have worse access to physicians, worse preventive care, worse access to treatments for common chronic conditions, worse health status and higher mortality than white Americans.  The COVID-19 pandemic and the police killings of George Floyd, Breonna Taylor and others sparked a more intensive examination of disparities in the health care system. Illuminating the many ways in which structural racism causes racial and ethnic disparities–from racial bias in clinical encounters to the lack of health care providers of color—is essential to inform efforts to restructure social arrangements and clinical care, and achieve racial justice in health.

Our research in this area includes a study of the role that physicians of color play in the provision of care for underserved and minority communities. We found that non-white physicians cared for 53.5% of minority and 70.4% of non–English-speaking patients. Patients from underserved groups were significantly more likely to see nonwhite physicians than white physicians. Patients of Black, Hispanic, and Asian physicians were more likely than those served by white physicians to have Medicaid; patients of Hispanic physicians were more likely to be uninsured. Our results demonstrated that non-white physicians provide a disproportionate share of care to people of color and other underserved populations, suggesting that increasing the racial and ethnic diversity of the physician workforce may be key to meeting national goals to eliminate health disparities.

Publications in this Area

Understanding the Role of Past Health Care Discrimination in Help-Seeking and Shared Decision-Making for Depression Treatment Preferences. Progovac A, Cortez D, Chambers C, Delman J, Delman D, McCormick D. Qualitative Health Research. Page 1-18, July 25, 2020.

Depression treatment preferences by race/ethnicity and gender and associations between past healthcare discrimination experiences and present preferences in a nationally representative sample. Sonik RA, Creedon TB, Progovac AM, Carson N, Delman J, Delman D, Lê Cook B; Health Equity Consortium (McCormick). Soc Sci Med. 2020 Apr 1;253:112939.

Racial Disparities in Neurologic Health Care Access and Utilization in the United States. Saadi A, Himmelstein DU, Woolhandler S, Mejia NI.  Neurology 2017; 88(24):2268-2275.

Hospital Payer and Racial/Ethnic Mix at Private Academic Medical Centers in Boston and New York City. Tikkanen RS, Woolhandler S, Himmelstein DU, Kressin NR, Hanchate A, Lin MY, McCormick D, Lasser KE.  International Journal of Health Services 2017; 47(3):460-476.

Racial and Ethnic Disparities in Mental Health Care for Children and Young Adults: A National Study.  Marrast L, Himmelstein DU, Woolhandler S.  International Journal of Health Services 2016; 46(4):810-824. 

Massachusetts Health Reform’s Effect on Hospitals’ Racial Mix of Patients and on Patients’ Use of Safety-net Hospitals. Lasser KE, Hanchate AD, McCormick D, Chu C, Xuan Z, Kressin NR. Med Care. 2016 Sep;54(9):827-36.

Healthcare Reform

Passage of the Affordable Care Act (ACA), the largest US health coverage expansion since 1965, improved access to care, particularly for low income people and communities of color. However, the ACA has fallen far short of providing universal and comprehensive coverage: at least 30 million remain uninsured, underinsurance has actually increased, and medical bankruptcy remains common. Nonetheless, dismantling the ACA would be catastrophic unless a better reform took its place. The CHJL undertakes research to further understanding of the achievements and failures of the ACA in order to inform ongoing debates about health reform options, including a single-payer national health program. 

Our recent research in this area includes a study of 20-year trends in unmet health needs of non-elderly adults in the US. Using a large, nationally representative data source (Behavioral Risk Factor Surveillance System) we found that uninsurance decreased by only 2.1 percentage points (from 16.9% to 14.8%) over the past two decades, despite the implementation of the Affordable Care Act in 2014. Meanwhile, the proportion of non-elderly adults unable to see a physician owing to cost actually increased by 2.7 percentage points overall (from 11.4% to 15.7%) and by 3.6 percentage points among persons with insurance (from 7.1% to 11.5%). This study highlighted that in spite of the many health policy reforms implemented over the last 2 decades, cost-related barriers to care have worsened, suggesting that additional, more robust health care reforms are needed.

Publications in this Area

The effects on hospital utilization of the 1966 and 2014 health insurance coverage expansions in the United States. Gaffney A, McCormick D, Bor DH, Goldman A, Woolhandler S, Himmelstein DU. Annals of internal medicine. 2019 Aug 6;171(3):172-80.

Coverage and Access for Americans with Cardiovascular Disease or Risk Factors After the ACA: a Quasi-experimental Study. Barghi A, Torres H, Kressin NR, McCormick D. J Gen Intern Med. 2019 Sep;34(9):1797-1805.

Effects Of The ACA’s Health Insurance Marketplaces On The Previously Uninsured: A Quasi-Experimental Analysis. Goldman AL, McCormick D, Haas JS, Sommers BD. Health Aff (Millwood). 2018 Apr;37(4):591-599.

Out-of-Pocket Spending and Premium Contributions after Implementation of the Affordable Care Act.  Goldman AL, Woolhandler S, Himmelstein DU, Bor DH, McCormick D.  JAMA Internal Medicine 2018; 178(3):347-355. 

Massachusetts Health Reform’s Effect on Hospitalizations with Substance Use Disorder-Related Diagnoses. Lasser KE, Hanchate AD, McCormick D, Walley AY, Saitz R, Lin MY, Kressin NR. Health Serv Res. 2018 Jun;53(3):1727-1744.

Coverage and Access for Americans With Chronic Disease Under the Affordable Care Act: A Quasi-Experimental Study. Torres H, Poorman E, Tadepalli U, Schoettler C, Fung CH, Mushero N, Campbell L, Basu G, McCormick D. Ann Intern Med. 2017 Apr 4;166(7):472-479.

Affordability of health care under publicly subsidized insurance after Massachusetts health care reform: a qualitative study of safety net patients. Zallman L, Nardin R, Malowney M, Sayah A, McCormick D. Int J Equity Health. 2015 Oct 29;14:112.

Perceived affordability of health insurance and medical financial burdens five years in to Massachusetts health reform. Zallman L, Nardin R, Sayah A, McCormick D. Int J Equity Health. 2015 Oct 29;14:113.

Massachusetts health reform and disparities in joint replacement use: difference in differences study. Hanchate AD, Kapoor A, Katz JN, McCormick D, Lasser KE, Feng C, Manze MG, Kressin NR. BMJ. 2015 Feb 20;350:h440.

Health and Financial Consequences of 24 States’ Decision to Opt Out of Medicaid Expansion.  Dickman SL, Himmelstein DU, McCormick D, Woolhandler S.  International Journal of Health Services 2015; 45(1):133-142.

The Affordable Care Act and Medical Loss Ratios: No Impact in First Three Years. Day B, Himmelstein DU, Broder M, Woolhandler S.  International Journal of Health Services 2015; 45(1):127-131.

Massachusetts reform and disparities in inpatient care utilization. Hanchate AD, Lasser KE, Kapoor A, Rosen J, McCormick D, D’Amore MM, Kressin NR. Med Care. 2012 Jul;50(7):569-77.

Reasons why patients remain uninsured after Massachusetts’ health care reform: a survey of patients at a safety-net hospital. Nardin R, Sayah A, Lokko H, Woolhandler S, McCormick D. J Gen Intern Med. 2012 Feb;27(2):250-6.


The COVID-19 pandemic has taken an enormous toll on the health and financial well-being of Americans, requiring a rapid response from the medical and research communities. The CHJR has undertaken a series of studies that highlight the medical and social vulnerabilities of communities of color and front-line workers.  
For instance, one of our analyses published in the spring of 2020 examined a nationally-representative cohort of individuals who were out of work with symptoms suggestive of COVID-19. We found that individuals out of work with COVID-19 symptoms were more likely to be of minority race/ethnicity and low income, to lack health insurance, and to have other social vulnerabilities such as food insecurity. Another rapidly published study, using national housing data, found that crowded living quarters precluded compliance with recommendations regarding quarantine and isolation for a large share of people of color.

Publications in this Area

Feasibility of Separate Rooms for Home Isolation and Quarantine for COVID-19 in the United States. Sehgal AR, Himmelstein DU, Woolhandler S. Annals of Internal Medicine. 2020, (Online ahead of print)  Jul 21, 2020.

Home Sick with Coronavirus Symptoms: a National Study, April–May 2020. Gaffney AW, Himmelstein DU, Bor D, McCormick D, Woolhandler S. Journal of General Internal Medicine. 2020 Sep 10:1-4.

Health and Social Precarity Among Americans Receiving Unemployment Benefits During the COVID-19 Outbreak. Gaffney AW, Himmelstein DU, McCormick D, Woolhandler S. Journal of General Internal Medicine. 2020 Sep 16:1-4.

18.2 Million Individuals at Increased Risk of Severe COVID-19 Illness Are Un- or Under-insured. Gaffney AW, Hawks L, Bor DH, Woolhandler S, Himmelstein DU, McCormick D Journal of General Internal Medicine. 2020; 35: 2487-9. 

Illness-Related Work Absence in Mid-April Was Highest on Record. Gaffney AW, Himmelstein DU, Woolhandler S. JAMA Internal Medicine. 2020 (On-line ahead of print). 2020 Jul 27.

Risk for Severe COVID-19 Illness Among Teachers and Adults Living With School-Aged Children. Gaffney AW, Himmelstein DU, Woolhandler S. Annals of Internal Medicine. 2020 (Online ahead of Print) 2020 Aug 21.

Intersecting US epidemics: COVID-19 and lack of health insurance. Woolhandler S, Himmelstein DU.  Annals of Internal Medicine 2020; 172:63-64

Immigrant Healthcare

Immigrants to the United States are often portrayed as burdens to the health care system, and politicians have mobilized anti-immigrant sentiment and implemented measures such as “public charge” rules that limit immigrant families’ access to vital programs such as Medicaid and food assistance. Several studies carried out by CHJL have highlighted immigrants’ contributions to the health care workforce, their low use of health services, and the fact that immigrants actually subsidize the health care of native-born persons. These and similar studies help inform the policies to ensure that the human right to health care for immigrants, and for all Americans, is respected.  

Our research in this area includes a study demonstrating that immigrants disproportionately subsidize the Medicare Trust Fund. In this study, we tabulated immigrants’ and others’ Trust Fund contributions and withdrawals using multiple years of data from the Current Population Survey and the Medical Expenditure Panel Survey. In 2009 immigrants made 14.7 percent of Trust Fund contributions but accounted for only 7.9 percent of its expenditures—a net surplus of $13.8 billion. In contrast, US-born people generated a $30.9 billion deficit. Over an eight year period immigrants’ cumulative surplus amounted to $115.2 billion, with non-citizen immigrants accounting for most of the surplus. A subsequent study of private insurance premium payments by immigrants and payouts for their care documented a similar subsidy from immigrants to native born persons.

Publications in this Area

Implications of changing public charge immigration rules for children who need medical care. Zallman L, Finnegan KE, Himmelstein DU, Touw S, Woolhandler S. JAMA pediatrics. 2019 Sep 1;173(9):e191744-.

Care for America’s elderly and disabled people relies on immigrant labor. Zallman L, Finnegan KE, Himmelstein DU, Touw S, Woolhandler S. Health Affairs. 2019 Jun 1;38(6):919-26.

Immigrants Pay More In Private Insurance Premiums Than They Receive In Benefits. Zallman L, Woolhandler S, Touw S, Himmelstein DU, Finnegan KE. Health Affairs. 2018 Oct 1;37(10):1663-8.

Medical Expenditures on and by Immigrant Populations in the United States: A Systematic Review. Flavin L, Zallman L, McCormick D, Wesley Boyd J. Int J Health Serv. 2018 Oct;48(4):601-621.

Affordability of and Access to Information About Health Insurance Among Immigrant and Non-immigrant Residents After Massachusetts Health Reform. Kang YJ, McCormick D, Zallman L. J Immigr Minor Health. 2017 Aug;19(4):929-938.

Unauthorized Immigrants Prolong the Life of Medicare’s Trust Fund.  Zallman L, Wilson FA, Stimpson JP, Bearse A, Arsenault L, Dube B, Himmelstein DU, Woolhandler S Journal of General Internal Medicine 2016; 31(1):122-127. 

Immigrants contributed an estimated 115. Billion more to the Medicare Trust Fund than they took out in 2002-1009. Zallman L, Woolhandler S, Himmelstein D, Bor D, McCormick D.  Health Affairs (Millwood) 2013; 32(6):1153-1160. 

Undiagnosed and Uncontrolled Hypertension and Hyperlipidemia among Immigrants in the US.  Zallman L, Himmelstein DU, Woolhandler S, Bor DH, Ayanian JZ, Wilper AP, McCormick D.  Journal of Immigrant and Minority Health 2013; 15(5):858-865. 

Justice System Involvement and Health

The prison population of the United States has quadrupled in the past 25 years, and the country now incarcerates more people per capita than any other nation. Although the Supreme Court has ruled that the Eighth Amendment guarantees prisoners a constitutional right to health care, prisoners’ access to health care, and the quality of that care, is often deficient. Previous CHJL studies have delineating the specific disease burdens and barriers to accessing care for justice-involved individuals, research undertaken to support efforts to improve care for this vulnerable population.

In a recent study, we compared the health and health care utilization of persons on and not on probation nationally, using the National Survey of Drug Use and Health, a population-based sample of US adults. We compared physical, mental, and substance use disorders and the use of health services of persons aged 18-49 years. We found that those on probation were more likely to have a physical condition (adjusted odds ratio [AOR] = 1.3; 95% confidence interval [CI] = 1.2, 1.4), mental illness (AOR = 2.4; 95% CI = 2.1, 2.8), or substance use disorder (AOR = 4.2; 95% CI = 3.8, 4.5). They were less likely to attend an outpatient visit (AOR = 0.8; 95% CI = 0.7, 0.9) but more likely to have an emergency department visit (AOR = 1.8; 95% CI = 1.6, 2.0) or hospitalization (AOR = 1.7; 95% CI = 1.5, 1.9). This study indicated that persons on probation bear a disproportionate disease burden, and receive less outpatient care but more acute services, suggesting that addressing the health needs of persons with criminal justice involvement should include those on probation, a large population that has received little attention.

Publications in this Area

Health Status and Health Care Utilization of US Adults Under Probation: 2015–2018. Hawks L, Wang E, Howell B, Woolhandler S, Himmelstein D, Bor D, and McCormick D. American Journal of Public Health 0, e1_e7, 

The Health and Health Care of U.S. Prisoners: Results of a Nationwide Survey. Wilper AP, Woolhandler S, Boyd JW, Lasser KE McCormick D, Bor DH, Himmelstein D.  American Journal of Public Health 2009; 99(4):666-672. 

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