seriously ill. roughly a quarter of the uninsured are eligible for public coverage but are not enrolled. possible reasons include a lack of awareness of the programs or of how to enroll, reluctance due to a perceived stigma associated with public coverage, poor retention of enrollees, and burdensome administrative procedures. in addition, some state programs have enrollment caps. a study by the kaiser family foundation published in june 2009 found that 45% of low-income adults under age 65 lack health insurance. almost a third of non-elderly adults are low income, with family incomes below 200% of the federal poverty level. low-income adults are generally younger, less well educated, and less likely to live in a household with a full-time worker than are higher income adults; these factors contribute to the likelihood of being uninsured. in addition, the chances of being healthy decline with lower income; 19% of adults with incomes below the federal poverty level describe their health as fair or poor. consequences the map illustrates the frequency of premature deaths (those under age 75) adjusted for the age of persons in the county. insurance coverage helps save lives, by encouraging early detection and prevention of dangerous medical conditions. according to a 2014 study, the aca likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013. city university public health professors david himmelstein and steffie woolhandler wrote in january 2017 that a rollback of the aca's medicaid expansion alone would cause an estimated 43,956 deaths annually. the federal reserve publishes data on premature death rates by county, defined as those dying below age 74. according to the kaiser foundation, expanding medicaid in the remaining 19 states would cover up to 4.5 million persons, thus reducing mortality. texas, oklahoma, mississippi, alabama, georgia, tennessee, missouri and south carolina, indicated on the federal reserve map (see graph at right) as having many counties with high premature mortality rates, did not expand medicaid. a study published in the american journal of public health in 2009 found that lack of health insurance is associated with about 45,000 excess preventable deaths per year. one of the authors characterized the results as "now one dies every 12 minutes." since then, as the number of uninsured has risen from about 46 million in 2009 to 48.6 million in 2012, the number of preventable deaths due to lack of insurance has grown to about 48,000 per year. a survey released in 2008 found that being uninsured impacts american consumers' health in the following ways: more of the uninsured chose not to see a doctor when were sick or hurt (53%) vs 46% of the insured. fewer of the uninsured (28%) report currently undergoing treatment or participating in a program to help them manage a chronic condition; 37% of the insured are receiving such treatment. 21% of the uninsured, vs. 16% of the insured, believe their overall health is below average for people in their age group. cost shifting the costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured via cost-shifting and higher health insurance premiums, or paid by taxpayers through higher taxes. on the other hand, the uninsured often subsidize the insured because the uninsured use fewer services and are often billed at a higher rate. a study found that in 2009, uninsured patients presenting in u.s. emergency departments were less likely to be admitted for inpatient care than those with medicare, medicaid, or private insurance. 60 minutes reported, "hospitals charge uninsured patients two, three, four or more times what an insurance company would pay for the same treatment." on average, per capita health care spending on behalf of the uninsured is a bit more than half that for the insured. hospitals and other providers are reimbursed for the cost of providing uncompensated care via a federal matching fund program. each state enacts legislation governing the reimbursement of funds to providers. in missouri, for example, providers assessments totaling $800 million are matched – $2 for each assessed $1 – to create a pool of approximately $2 billion. by federal law these funds are transferred to the missouri hospital association for disbursement to hospitals for the costs incurred providing uncompensated care including disproportionate share payments (to hospitals with high quantities of uninsured patients), medicaid shortfalls, medicaid managed care payments to insurance companies and other costs incurred by hospitals. in new hampshire, by statute, reimbursable uncompensated care costs shall include: charity care costs, any portion of medicaid patient care costs that are unreimbursed by medicaid payments, and any portion of bad debt costs that the commissioner determines would meet the criteria under 42 u.s.c. section 1396r-4(g) governing hospital-specific limits on disproportionate share hospital payments under title xix of the social security act. a study published in august 2008 in health affairs found that covering all of the uninsured in the us would increase national spending on health care by $122.6 billion, which would represent a 5% increase in health care spending and 0.8% of gdp. "from society’s perspective, covering the uninsured is still a good investment. failure to act in the near term will only make it more expensive to cover the uninsured in the future, while adding to the amount of lost productivity from not insuring all americans," said professor jack hadley, the study's lead author. the impact on government spending could be higher, depending on the details of the plan used to increase coverage and the extent to which new public coverage crowded out existing private coverage. over 60% of personal bankruptcies is caused by medical bills. most of these persons had medical insurance. effects on health of the uninsured from 2000 to 2004, the institute of medicine's committee on the consequences of uninsurance issued a series of six reports that reviewed and reported on the evidence on the effects of the lack of health insurance coverage. the reports concluded that the committee recommended that the nation should implement a strategy to achieve universal health insurance coverage. as of 2011, a comprehensive national plan to address what universal health plan supporters terms "america's uninsured crisis", has yet to be enacted. a few states have achieved progress towards the goal of universal health insurance coverage, such as maine, massachusetts, and vermont, but other states including california, have failed attempts of reforms. the six reports created by the institute of medicine (iom) found that the principal consequences of uninsurance were the following: children and adults without health insurance did not receive needed medical care; they typically live in poorer health and die earlier than children or adults who have insurance. the financial stability of a whole family can be put at risk if only one person is uninsured and needs treatment for unexpected health care costs. the overall health status of a community can be adversely affected by a higher percentage of uninsured people within the community. the coverage gap between the insured and the uninsured has not decreased even after the recent federal initiatives to extend health insurance coverage. the last report was published in 2004 and was named insuring america's health: principles and recommendations. this report recommended the following: the president and congress need to develop a strategy to achieve universal insurance coverage and establish a firm schedule to reach this goal by the year 2010. the committee also recommended that the federal and state governments provide sufficient resources for medicaid and the state children's health insurance program (schip) to cover all persons currently eligible until the universal coverage takes effect. they also warned that the federal and state governments should prevent the erosion of outreach efforts, eligibility, enrollment, and coverage of these specific programs. some people think that not having health insurance will have adverse consequences for the health of the uninsured. on the other hand, some people believe that children and adults without health insurance have access to needed health care services at hospital emergency rooms, community health centers, or other safety net facilities offering charity care. some observers note that there is a solid body of evidence showing that a substantial proportion of u.s. health care expenditures is directed toward care that is not effective and may sometimes even be harmful. at least for the insured population, spending more and using more health care services does not always yield better health outcomes or increase life expectancy. children in america are typically perceived as in good health relative to adults, due to the fact that most serious health problems occur later in one's life. certain conditions including asthma, diabetes, and obesity have become much more prevalent among children in the past few decades. there is also a growing population of vulnerable children with special health care needs that require ongoing medical attention, which would not be accessible without health insurance. more than 10 million children in the united states meet the federal definition of children with special health care needs "who have or are at increased risk for a chronic physical, development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally". these children require health related services of an amount beyond that required by the average children in america. typically when children acquire health insurance, they are much less likely to experience previously unmet health care needs, this includes the average child in america and children with special health care needs. the committee on health insurance status and its consequences concluded that the effects of health insurance on children's health outcomes: children with health insurance receive more timely diagnosis of serious health conditions, experience fewer hospitalizations, and miss fewer days of school. the same committee analyzed the effects of health insurance on adult's health outcomes: adults who do not have health insurance coverage who acquire medicare coverage at age 65, experience substantially improved health and functional status, particularly those who have cardiovascular disease or diabetes. adults who have cardiovascular disease or other cardiac risk factors that are uninsured are less likely to be aware of their condition, which leads to worse health outcomes for those individuals. without health insurance, adults are more likely to be diagnosed with certain cancers that would have been detectable earlier by screening by a clinician if they had regularly visited a doctor. as a consequence, these adults are more likely to die from their diagnosed cancer or suffer poorer health outcomes. many towns and cities in the united states have high concentrations of people under the age of 65 who lack health insurance. there are implications of high rates of uninsurance for communities and for insured people in those communities. institute of medicine committee warned of the potential problems of high rates of uninsurance for local health care, including reduced access to clinic-based primary care, specialty services, and hospital-based emergency services. excess deaths due to 2017-2019 coverage losses in october 2020, health affairs writers summarized the results of several studies that placed the higher death rates for the uninsured between 1 per 278 to 1 per 830 persons without insurance: "based on the acs coverage data, we estimate that between 3,399 and 10,147 excess deaths among non-elderly us adults may have occurred over the 2017-2019 time period due to coverage losses during these years. using the nhis figures for coverage losses yields a higher estimate (between 8,434 and 25,180 non-elderly adult deaths attributable to coverage losses), while the cps figures yield an estimate of 3,528-10,532 excess deaths among non-elderly adults. these figures do not completely capture the population effects of coverage loss, as they exclude the excess deaths that would likely result from coverage losses among children. in 2020 and beyond, we can project even more loss of life if, as expected, millions more lose health coverage due to the economic downturn associated with the pandemic." emergency medical treatment and active labor act (emtala) main article: emergency medical treatment and active labor act emtala, enacted by the federal government in 1986, requires that hospital emergency departments treat emergency conditions of all patients regardless of their ability to pay and is considered a critical element in the "safety net" for the uninsured. however, the federal law established no direct payment mechanism for such care. indirect payments and reimbursements through federal and state government programs have