Many people assume that the 47 million Americans who don't have health insurance simply can't afford it.
But the fact is, some don't want it.
Among the 47 million are 9.1 million who earn $75,000 or more a year and 11 million who declined coverage from their employers, according to estimates from the U.S. Census Bureau and the Employment Policies Institute. That also includes many who are young, single and healthy, plus a growing number who rely on alternative and faith-based therapies usually not covered by traditional insurance plans.
These are the voluntarily uninsured, people who may not welcome Washington's efforts to make sure that all Americans have some kind of coverage.
Talk of mandatory health insurance coverage is getting louder. On Thursday, Senate leaders announced that their legislation would require people to carry health insurance or face fines of more than $1,000.
That kind of requirement would directly hit people such as Kelley Michaels, 30, and her fiance, Ken Sharp, 33, of Holiday, who declined employer-sponsored coverage because they felt that their medical needs didn't justify the cost of premiums. And people such as Amy O'Hara, 35, of Indian Shores, a contract paralegal who decided to go without insurance after seeing her premiums rise year after year. Or Robert Clark, 57 of Belleair, a Christian Scientist who believes in healing through prayer and who doesn't have insurance because it doesn't cover faith-based healers.
In other words, it's a diverse group with diverse interests, and that has policy experts concerned about the Senate approach.
"One thing for everybody doesn't make sense," said June O'Neill, a professor of economics at City University of New York and co-author of "Who are the Uninsured?'' The report, issued last week by the Employment Policies Institute, calls the 47 million figure a "relatively coarse measurement" that doesn't help craft effective policy.
O'Neill divides the uninsured population by:
• Income: 43 percent make more than 21/2 times the poverty level, or $55,125 for a family of four.
• Age: half are under 35.
• Marital status: half are single.
Concludes O'Neill: "There are other things they would rather do with their money" than buy insurance.
Not worth it?
Michaels and Sharp both work full time — Michaels for a commercial maintenance company, Sharp for a metal fabrication business. Together, they make about $55,000 a year.
They considered getting health insurance through Sharp's employer (Michaels' doesn't offer it), but premiums would have been about $230 a month.
"Financially, it doesn't balance out for us," Michaels said.
Michaels has had to pay out of pocket for some dental work over the past year, and she went to the emergency room in 2007. But she has learned a few things: Bills can be reduced if you pay cash, some providers offer no-interest payment plans, and health expenses are tax deductible.
Michaels said she doesn't want to be forced to purchase insurance, but she would want to see what her money would buy in a government health plan.
When Robert Clark gets sick, he finds healing through prayer. A Christian Science practitioner, he also helps others who are ill.
He and his wife, Sandy, a Realtor, are voluntarily uninsured, as there are no insurance plans available to them that cover Christian Science care.
"Most Christian Scientists are used to being uninsured," Clark said. "I believe that there's nothing that God can't heal."
There are about 15 Christian Science churches in the Tampa Bay area, and Clark noted that the church doesn't prevent its members from seeking traditional health care.
The church has had a representative in Washington advocating for people who want spiritual treatment covered by insurance. He has company: advocates for acupuncture and for chiropractic, herbal and holistic medicine also would like to see their types of healing covered.
But even if spiritual healing wasn't covered, Clark said he would probably buy insurance, should it be mandated. "We're law-abiding citizens," he said.
But he hopes for a provision similar to that in Massachusetts, the only state with mandatory health insurance. There, individuals can choose not to carry insurance, but they pay a penalty if they don't.
Taking a chance
Amy O'Hara used to have health insurance. The contract paralegal had purchased private coverage since 2005. But her premiums kept increasing, despite the fact that she has generally been healthy and has gone to a doctor no more than once or twice a year. So in January, she joined the ranks of the voluntarily uninsured.
"Insurance was a huge chunk of income that could be going to other things right now," she said.
She's aware of the risks, calling it a sort of Russian roulette. If something catastrophic happens, she hopes she has enough in savings to cover it.
O'Hara considers being uninsured a short-term decision. She hopes the new administration will make insurance a better option for her, perhaps by offering lower rates to those who stay healthy.
'We all pay'
Medical experts, researchers and policymakers point to the many risks of being uninsured. Studies have shown that the uninsured are more likely to postpone or forgo needed care than those with coverage. They are less likely to receive preventative care and more likely to be hospitalized for health problems that could have been avoided.
And when that happens, if they can't pay the bill, the system finds other ways to get paid.
"We all pay for the uninsured," Aetna Insurance CEO Ron Williams said in a 2008 interview in Fortune magazine. "The average employer is paying 12 percent more in premiums today to cover the uninsured than they would pay if we brought those 47 million into the system."
O'Neill, who served as director of the Congressional Budget Office from 1995 to 1999, said one possible solution would be to require every American to have at least catastrophic coverage, which would cover a person in the event that he or she is seriously hurt or needs a costly medical procedure.
"If you're worried about (uninsured people) being a burden on society, requiring some kind of catastrophic coverage" would address that, O'Neill said.
Bay News 9 contributed to this report. Richard Martin can be reached at firstname.lastname@example.org or (727) 893-8330. For the latest in health news, visit tampabay.com/health.