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During the same period, England instituted universal coverage. The reasons we didn't are a complex knot of social and political influences now nearly impossible to untangle. "I think part of it is who's being served here. In more homogeneous societies, like in Scandinavian countries, [universal health care] came as a no-brainer," said David Jones, the president of the Community Services Society, a New York nonprofit. "But we're not homogeneous. There's a sense that 'We've got ours, I'm not sure I want to give it to those guys.' "
As employer-sponsored insurance took hold, the number of uninsured dropped steadily, reaching an all-time low of 23 million in 1976. But the very availability of good care quickly drove premiums up. In the 1980s, health care costs exploded, with annual increases peaking at 18 percent in 1989, before slowing briefly in the 1990s. Increases hit the double digits again in 2001, and reached 13.9 percent last year.
Perhaps not surprising, companies began to balk at providing benefits, leading individualsthe self-employed, the unemployed, the employed but not coveredto go it alone. Reforms designed to help the older and sicker buy private insurance served to further squeeze the able-bodied but vulnerable. Prices today are all over the map. A young, healthy adult in California can find basic catastrophic coverage for under $100 a month, but the same person would have to pay $280 for a similar plan in New York, largely due to differing state regulations.
For Lars Russell, in his early twenties, the cost of health insurance came as a shock. He graduated last year from the University of Michigan and moved to New York. "It's not really anything I can afford," he said in November. "I don't even have car insurance right now."
Russell would get little sympathy from McDonnell, the benefits research analyst. "That's life," he said, when asked about the huge number of uninsured young adults. "If you're young and healthy, you're going to take risks. It's life everywhere."
McDonnell cited an unwillingness to pay for insurance as a big reason young adults go without coverage.
It's a fine line, however, between being unwilling to pay even $100 a month and being unable to. And it's significant that when offered health insurance by an employer in exchange for a deduction from each paycheck, 74 percent of young adults take it, just a hair less than the 79 percent of older adults who do the same. "The argument is that if it's that important to you, then get a job that offers health insurance," said McDonnell, who, like so many experts on health care issues, is over 35 and has long had jobs with good benefits.
Janet Murraywho asked that her name be changed because of pending litigationfollowed McDonnell's advice. Now in her late twenties, she was born with hypothyroidism and takes daily medication. During her first year of college in upstate New York, she contracted Lyme disease. Because she caught it early, she doesn't need constant treatment, though she is prone to exhaustion and respiratory infections like pneumonia. Her health problems don't prevent her from working, but they make it impossible for her to do without good insurance. Murray studied film in college but gave up on her dream of working in movie production. Instead, she took an office job with a media company because it came with benefits.
"I think the biggest thing for me was, if I had the stamina and I didn't have the general expenses of being on a bunch of medication, I would have taken more risks," Murray said. "I feel like I don't really have that luxury."
Maybe her dreams wouldn't have panned out, but the American health care system has made it nearly impossible for her even to try.
Or maybe Murray is lucky. At 21, Pedro Jimenez of South Williamsburg said he has never had health insurance at all. "I don't really know anything about it, to be honest," he said. When necessary, he has gone to the emergency room and tried to pay off the bills in installments. Otherwise, he has avoided going to the doctor. But basically, he has avoided thinking about the dangers, focusing instead on looking for work, getting his GED, and going to college.
It's important to note that degrees of coverage vary greatly by race: African Americans were nearly twice as likely as non-Hispanic white people to be uninsured in 2002, and Latinos three times as likely.
Not having a job with benefits can mean being forced to choose between health insurance and other expenses, some of them critical to building a so-called life. Young adults "are in a stage where people have debts from school, they are trying to buy a house, and that seems more important than paying for health insurance, which might cost multiple thousands each year," said Robert Blendon, a professor of health policy and political analysis at Harvard University.
The types and prices of plans for sale vary dramatically by state, largely according to regulations. Premiums nationwide for those under 35 average about $136 per month, according to eHealthInsurance, a website that sells individual and family insurance. Many states have plans with premiums below $100 for young, healthy adults without any pre-existing conditions. Cheaper plans are usually for emergencies only, don't cover routine doctor visits, and carry four-digit deductibles.