the effects of health insurance cost-sharing more generally found that chronically ill patients with higher co-payments sought less care for both minor and serious symptoms while no effect on self-reported health status was observed. the authors concluded that the effect of cost sharing should be carefully monitored. coverage gaps and affordability also surfaced in a 2007 international comparison by the commonwealth fund. among adults surveyed in the u.s., 37% reported that they had foregone needed medical care in the previous year because of cost; either skipping medications, avoiding seeing a doctor when sick, or avoiding other recommended care. the rate was higher – 42% –, among those with chronic conditions. the study reported that these rates were well above those found in the other six countries surveyed: australia, canada, germany, the netherlands, new zealand, and the uk. the study also found that 19% of u.s. adults surveyed reported serious problems paying medical bills, more than double the rate in the next highest country. coverage trends under president trump gains in healthcare coverage under president obama began to reverse under president trump. the cdc reported that the number of uninsured rose from 28.2 million in 2016 (the last year of the obama administration) to 32.8 million in 2019, an increase of 4.6 million or 16%. the commonwealth fund estimated in may 2018 that the number of uninsured increased by 4 million from early 2016 to early 2018. the rate of those uninsured increased from 12.7% in 2016 to 15.5%. this was due to two factors: 1) not addressing specific weaknesses in the aca; and 2) actions by the trump administration that exacerbated those weaknesses. the impact was greater among lower-income adults, who had a higher uninsured rate than higher-income adults. regionally, the south and west had higher uninsured rates than the north and east. further, those 18 states that have not expanded medicaid had a higher uninsured rate than those that did. approximately 5.4 million americans lost their health insurance from february to may 2020 after losing their jobs during the covid-19 recession. the independent reported that families usa report "found that the spike in uninsured americans – adding to an estimated 84 million people who are already uninsured or underinsured – is 39 per cent higher than any previous annual increase, including the most recent surge at the height of the recession between 2008 and 2009 when nearly 4 million non-elderly americans lost insurance." uninsured demographic number u.s. uninsured by reason in 2016 (non-elderly/under 65 years of age). an estimated 43% of the uninsured were eligible for financial assistance. uninsured americans in 2007, by income status the kaiser family foundation reported in october 2016 that there were 27.2 million uninsured under age 65, roughly 10% of the 272 million persons in that group. kaiser reported that: 2.6 million were in the "coverage gap" due to the 19 states that chose not to expand the medicaid program under the aca/obamacare, meaning their income was above the medicaid eligibility limit but below the threshold for subsidies on the aca exchanges (~44% to 100% of the federal poverty level or fpl); 5.4 million were undocumented immigrants; 4.5 million had an employer's insurance offer (making them ineligible for aca/obamacare coverage) but declined it; 3.0 million were ineligible for financial assistance under aca/obamacare due to sufficiently high income; 6.4 million were eligible for medicaid or other public healthcare program but did not pursue it; and 5.3 million were eligible for aca/obamacare tax credits but did not enroll in the program. an estimated 46% cited costs as a barrier to getting insurance coverage. nearly 12 million (43%) of persons were eligible for financial assistance (medicaid or aca subsidies) but did not enroll to obtain it. as of 2017, texas had the highest number of uninsured at 17%, followed by oklahoma, alaska, and georgia. uninsured children and young adults in 2009 the census bureau states that 10.0 percent or 7.5 million children under the age of 18 were medically uninsured. children living in poverty are 15.1 percent more likely than other children to be uninsured. the lower the income of a household the more likely it is they are uninsured. in 2009, a household with an annual income of 25,000 or less was only 26.6 percent likely not to have medical insurance and those with an annual income of 75,000 or more were only 9.1 percent unlikely to be insured. according to the census bureau, in 2007, there were 8.1 million uninsured children in the us. nearly 8 million young adults (those aged 18–24), were uninsured, representing 28.1% of their population. young adults make up the largest age segment of the uninsured, are the most likely to be uninsured, and are one of the fastest growing segments of the uninsured population. they often lose coverage under their parents' health insurance policies or public programs when they reach age 19. others lose coverage when they graduate from college. many young adults do not have the kind of stable employment that would provide ongoing access to health insurance. according to the congressional budget office the plan the way it is now would have to cover unmarried dependents under their parents' insurance up to age 26. these changes also affect large employers, including self-insured firms, so that the firm bears the financial responsibility of providing coverage. the only exception to this is policies that were maintained continuously before the enactment of this legislation. those policies would be grandfathered in. non-citizens non-citizens are more likely to be uninsured than citizens, with a 43.8% uninsured rate. this is attributable to a higher likelihood of working in a low-wage job that does not offer health benefits, and restrictions on eligibility for public programs. the longer a non-citizen immigrant has been in the country, the less likely they are to be uninsured. in 2006, roughly 27% of immigrants entering the country before 1970 were uninsured, compared to 45% of immigrants entering the country in the 1980s and 49% of those entering between 2000 and 2006. most uninsured non-citizens are recent immigrants; almost half entered the country between 2000 and 2006, and 36% entered during the 1990s. foreign-born non-citizens accounted for over 40% of the increase in the uninsured between 1990 and 1998, and over 90% of the increase between 1998 and 2003. one reason for the acceleration after 1998 may be restrictions imposed by the personal responsibility and work opportunity reconciliation act (prwora) of 1996. almost seven out of ten (68%) of uninsured non-citizens live in california, texas, florida, or new york. downturn effects a report by the kaiser family foundation in april 2008 found that us economic downturns place a significant strain on state medicaid and schip programs. the authors estimated that a 1% increase in the unemployment rate increase medicaid and schip enrollment by 1 million, and increase the number uninsured by 1.1 million. state spending on medicaid and schip would increase by $1.4 billion (total spending on these programs would increase by $3.4 billion). this increased spending would occur while state government revenues were declining. during the last downturn, the jobs and growth tax relief reconciliation act of 2003 (jgtrra) included federal assistance to states, which helped states avoid tightening their medicaid and schip eligibility rules. the authors conclude that congress should consider similar relief for the current economic downturn. history prior to the patient protection and affordable care act, medical underwriting was common, but after the law came into effect in 2014 it became effectively prohibited. medical underwriting made difficult for many consumers to purchase coverage on the individual market. medical underwriting meant that insurance companies screen applicants for pre-existing conditions and reject those with serious conditions such as arthritis, cancer, and heart disease, but also such common ailments as acne, being 20 pounds over or under weight, and old sports injuries. in 2008, an estimated 5 million of those without health insurance were considered "uninsurable" because of pre-existing conditions. proponents of medical underwriting argue that it ensures that individual health insurance premiums are kept as low as possible. critics of medical underwriting believe that it unfairly prevents people with relatively minor and treatable pre-existing conditions from obtaining health insurance. one large industry survey found that 13% of applicants for individual health insurance who went through medical underwriting were denied coverage in 2004. declination rates increased significantly with age, rising from 5% for those under 18 to just under one-third for those aged 60 to 64. among those who were offered coverage, the study found that 76% received offers at standard premium rates, and 22% were offered higher rates. the frequency of increased premiums also increased with age, so for applicants over 40, roughly half were affected by medical underwriting, either in the form of denial or increased premiums. in contrast, almost 90% of applicants in their 20s were offered coverage, and three-quarters of those were offered standard rates. seventy percent of applicants age 60–64 were offered coverage, but almost half the time (40%) it was at an increased premium. the study did not address how many applicants who were offered coverage at increased rates chose to decline the policy. a study conducted by the commonwealth fund in 2001 found that, among those aged 19 to 64 who sought individual health insurance during the previous three years, the majority found it unaffordable, and less than a third ended up purchasing insurance. this study did not distinguish between consumers who were quoted increased rates due to medical underwriting and those who qualified for standard or preferred premiums. some states have outlawed medical underwriting as a prerequisite for individually purchased health coverage. these states tend to have the highest premiums for individual health insurance. causes the numbers of uninsured americans and the uninsured rate from 1987 to 2008 the percent of people in us who reported not seeking medical care due to high cost. americans who are uninsured may be so because their job does not offer insurance; they are unemployed and cannot pay for insurance; or they may be financially able to buy insurance but consider the cost prohibitive. during 2009 the continued low employment rate has negatively affected those who had previously been enrolled in employment-based insurance policies. census bureau states a 55 percent drop. other uninsured americans have chosen to join a health care sharing ministry as an alternative to insurance. low-income workers are less likely than higher income individuals to be offered coverage by their employer (or by their spouse's employer) and less able to afford buying it on their own. beginning with wage and price controls during world war ii, and cemented by an income tax exemption ruling in 1954, most working americans have received their health insurance from their employers. however, recent trends have shown an ongoing decline in employer-sponsored health insurance benefits. in 2000, 68% of small companies with 3 to 199 workers offered health benefits. since that time, that number has continued to drop to 2007, when 59% offered health benefits. for large firms with 200 or more workers, in 2000, 99% of employers offered health benefits; in 2007, that number stayed the same. on average, considering firms of all numbers of employees, in 2000, 69% offered health insurance, and that number has fallen nearly every year since, to 2007, when 60% of employers offered health insurance. 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