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A third of the nation's workers without health insurance are employed by large companies - the employers traditionally most likely to offer coverage to their workers.
And the numbers are rising, according to a report released Tuesday by the Commonwealth Fund, a private foundation supporting independent research on health and social issues.
Large companies account for a larger portion of uninsured workers than in the past. Workers at large companies comprised 25 percent of the uninsured work force in 1987. Today, they account for 32 percent of all uninsured workers.
The trend has ominous implications at a time when the number of uninsured is rising overall.
Nongovernment employers form the backbone of the nation's private health insurance system with large companies bearing the lion's share of the costs.
Sixty percent of the population under 65 receives health coverage through an employer.
As of 2001, a quarter of uninsured people - nearly 10 million - worked for or were dependents of workers at companies with more than 500 employees.
Between 2000 and 2002, the number of uninsured rose by 10 percent to nearly 44 million people, according to the U.S. Census Bureau. It's likely that the number of uninsured workers also rose.
Surprisingly, researchers found that while the proportion of uninsured at large companies rose between 1987 and 2001, the proportion of uninsured workers in small and midsized employers declined.
In fact, from 1987 to 2001, the rate of uninsured workers has risen faster at large companies than any other size employer, the report found.
"Policy-makers seeking solutions to the growing uninsured problem must look beyond workers in small firms, or they risk leaving out a large group of low-wage uninsured workers," said Jeanne Lambrew, associate professor of health policy at George Washington University and one of three authors of the report.
Among the findings of the report:
-Whether or not a worker is insured depends largely on the access to coverage provided by the employer. More than 70 percent of uninsured workers in large firms reported they lacked access to job-based health coverage.
-In both large and smaller companies that offer health coverage, uninsured workers tended to be low-income employees and were less likely to be married than insured workers.
-Large companies are more likely than small ones to offer health coverage. The largest companies - with more than 1,000 employees - are nearly 10 times more likely than the smallest firms to offer health insurance.
-Large companies with employees scattered over multiple, smaller locations or "establishments" are less likely to offer health coverage than large employers with a concentrated work force.
Researchers cited five factors as the driver of the declining rates of insured workers at large companies:
-Stagnant wage growth in large firms. Low income is strongly tied to lack of health coverage.
-Decline in unionization rates. The rate of workers in unions declined by one-third in large companies between 1987 and 2001, a greater decline than in small and midsize employers.
-Decline in manufacturing jobs. The proportion of workers in manufacturing jobs declined by 2 percentage points in small firms, 8 percentage points in midsize companies and 11 percentage points in large companies.
-Increase in the ratio of establishments per company. Researchers noted that as large companies increasingly moved workers to multiple, smaller establishments, access to coverage declined.
Among the five factors cited, the biggest determinants in the rates and proportions of uninsured workers in large companies are the declines in unionization rates and manufacturing jobs, which are closely linked.
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