To offset escalating health insurance costs, employers and insurers have been steadily shifting the burden of paying for medical care to the patients themselves. Higher premiums combined with increasing out-of-pocket expenses have been the primary strategies. The result: More people than ever who have health insurance are considered to be uninsured.

That’s the conclusion of an analysis of health plan data by the Commonwealth Fund. Its study, “The Problem of Underinsurance and How Rising Deductibles Will Make It Worse,” is an extraction from a larger piece of research on health insurance in the U.S. The study is based upon data gathered prior to the launch of Obamacare insurance, so the data offers no comment on how reform act insurance may have affected the numbers. Nonetheless, its implications for the general health of Americans are disturbing.

The report compares those who were considered insured but uninsured in 2003 to those who fit that definition in 2014. The definition is rather subjective; Commonwealth defines it this way: