Individually purchased health insurance in the United States

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In the United States, individually purchased health insurance is a form of private health care coverage.

According to the US Census Bureau, about 9% of Americans are covered under health insurance purchased directly.[1] The range of products available is similar to those provided through employers. However, average out-of-pocket spending is higher in the individual market, with higher deductibles, co-payments and other cost-sharing provisions.[2][3] Major medical is the most commonly purchased form of individual health insurance.[4]

In the individual market, the consumer pays the entire premium without benefit of an employer contribution.[3][5] While self-employed individuals receive a tax deduction for their health insurance and can buy health insurance with additional tax benefits, most consumers in the individual market do not receive any tax benefit.[6]

Premiums vary significantly by age.[3][7][8] In states that allow individual medical plan underwriting, premiums also vary by health status.[3] However, with the Patient Protection and Affordable Care Act, effective by 2014, all insurers will be fully prohibited from discriminating against or charging higher rates for any individuals based on pre-existing medical conditions.[9][10] For individuals who pass individual medical plan underwriting where it is used, the average premiums they pay are lower than the average paid for employer-sponsored coverage (this comparison is based on the entire premium for employer-sponsored coverage, including both the employee and employer contributions).[3][6][11] Factors that may be contributing to this include: differences in age; less generous coverage in the individual market (higher beneficiary cost sharing); and a tendency for individual consumers to only buy benefits that they expect to need and use while group coverage may provide some benefits that most beneficiaries do not use.[3][6] Individual policyholders are also more likely to report being in excellent health than are people covered by employer-sponsored health insurance, which may be a contributing factor.[11] Premiums in the individual market rose less rapidly over the period 2002 through 2005 than did out-of-pocket premiums in the employer-sponsored market (17.8% versus 34.4%). The increase was larger for family policies than for single policies (25.3% for family policies; the increase for single policies was not statistically significant). Note that these comparisons did not adjust for changes in benefit levels.[5]

Research confirms that consumers in the individual health insurance market are sensitive to price.[12] Estimates of the demand elasticity in this market vary, but generally fall in the range of -0.3 to -0.1. It appears that price sensitivity varies among population subgroups and is generally higher for younger individuals and lower income individuals.[13] One study found that among individuals who lack other sources of health coverage, the percentage purchasing individual insurance increases steadily with income. However, even among those with incomes four times the federal poverty level, only about a fourth buy individual coverage. The self-employed, who can tax-deduct their premiums, are more likely to purchase than other individuals. The researchers concluded that affordability appears to be a key barrier to coverage in this market, and that any premium subsidies would likely have to be substantial to be effective. The researchers note that other factors such as health status and the complexity of the market can also affect the purchase of individual health insurance, but conclude that they are unlikely to be the primary drivers of low coverage rates.[14]

Many states allow medical underwriting of applicants for individually purchased health insurance. An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.[15] A number of proposals have been advanced to limit the effect of underwriting on consumers and improve access to coverage. Each has its own advantages and limitations.[16] One study published in 2008 found that people of average health are least likely to become uninsured if they have large group health coverage, more likely to become uninsured if they have small group coverage, and most likely to become uninsured if they have individual health insurance. But, "for people in poor or fair health, the chances of losing coverage are much greater for people who had small-group insurance than for those who had individual insurance." The authors attribute these results to the combination in the individual market of high costs and guaranteed renewability of coverage. Individual coverage costs more if it is purchased after a person becomes unhealthy, but "provides better protection (compared to group insurance) against high premiums for already individually insured people who become high risk." Healthy individuals are more likely to drop individual coverage than less-expensive, subsidized employment-based coverage, but group coverage leaves them "more vulnerable to dropping or losing any and all coverage than does individual insurance" if they become seriously ill.[17]

In August 2008 the Hartford Courant reported that competition was increasing in the individual health insurance market, with more insurers entering the market, an increased variety of products, and a broader spread of prices.[18]

Individual health insurance is primarily regulated at the state level, consistent with the McCarran-Ferguson Act. Model acts and regulations promulgated by the National Association of Insurance Commissioners (NAIC) provide some degree of uniformity state to state. These models do not have the force of law and have no effect unless they are adopted by a state. They are, however, used as guides by most states, and some states adopt them with little or no change. The primary NAIC models affecting the individual health insurance market are:

  • The Uniform Individual Accident and Sickness Policy Provision Law (UPPL);
  • The Accident and Sickness Insurance Minimum Standards Model Act;
  • The Advertisements of Accident and Sickness Insurance Model Regulation; and
  • The Unfair Trade Practices Act.

All of these models have been implemented in one form or another by most states.

Federal laws affecting individual health insurance include:

See also[edit]


  1. ^ "Income, Poverty, and Health Insurance Coverage in the United States: 2007." U.S. Census Bureau. Issued August 2008.
  2. ^ John Bertko, Hannah Yoo and Jeff Lemieux, An Analysis of the Distribution of Cost-Sharing Levels in Individual and Small-Group Coverage, Policy Report, Changes in Health Care Financing & Organization (HCFO), Robert Wood Johnson Foundation, August 2009
  3. ^ a b c d e f Teresa Chovan, Hannah Yoo and Tom Wildsmith, "Individual Health Insurance: A Comprehensive Survey of Affordability, Access, and Benefits", America’s Health Insurance Plans, August 2005
  4. ^ "Individual Health Insurance: An Overview of Products," America’s Health Insurance Plans (accessed July 28, 2008)
  5. ^ a b Didem Bernard and Jessica Banthin, "Premiums in the Individual Health Insurance Market for Policyholders under Age 65: 2002 and 2005," Statistical Brief #202, Agency for Healthcare Research and Quality, April 2008
  6. ^ a b c "Update on Individual Health Insurance," Kaiser Family Foundation, August 2004, revised, page 5
  7. ^ Risk Segmentation in the Individual Health Insurance Market. National Institutes of Health
  8. ^ Elizabeth M. Tucker & Lindsey Hogan, "The Cost And Benefits Of Individual Health Insurance Plans: 2007," Forrester Research and EHealthInsurance, 2007
  9. ^ Binckes, Jeremy; Nick Wing (2010-03-22). "The Top 18 Immediate Effects Of The Health Care Bill". The Huffington Post. Retrieved 2010-03-22. 
  10. ^ ALONSO-ZALDIVAR, Ricardo (March 24, 2010). "Gap in health care law's protection for children". Associated Press. Retrieved 2010-03-24. 
  11. ^ a b "Comparison of Expenditures in Nongroup and Employer-Sponsored Insurance," the Kaiser Family Foundation, November 2006, Revised: February 2007
  12. ^ "The Price Sensitivity of Demand for Nongroup Health Insurance," Congressional Budget Office, 2005
  13. ^ M. Susan Marquis, Melinda Beeuwkes Buntin, Jose J. Escarce, Kanika Kapur, and Jill M. Yegian, "Subsidies and the Demand for Individual Health Insurance in California," Health Services Research 39:5 (October 2004)
  14. ^ Paul Jacobs and Gary Claxton,"How Non-Group Health Coverage Varies with Income," the Kaiser Family Foundation, February 2008
  15. ^ Marcus, Aliza (2008-05-07). "Baby Kendra's $300,000 Bill Pains Insurers, Inspires Candidates". Bloomberg News. Retrieved 2008-05-10. 
  16. ^ Mark Merlis,"Fundamentals of Underwriting in the Nongroup Health Insurance Market: Access to Coverage and Options for Reform," NHPF Background Paper, National Health Policy Forum, April 13, 2005
  17. ^ Mark V. Pauly and Robert D. Lieberthal, "How Risky Is Individual Health Insurance?," Health Affairs web exclusive, May 6, 2008
  18. ^ Diane Levick, "More Health Insurers Competing In Individual Coverage Market," The Hartford Courant, August 18, 2008
  19. ^ Thomas P. O'Hare, "Individual Medical Expense Insurance," The American College, 2000, Chapter 2 - "Regulation," ISBN 1-57996-025-1