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Corn
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Coverage
O Lit
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Committee on the Consequences of Uninsuranc
Board on Health Care Services
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C.
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NATIONAL ACADEMY PRESS · 2101 Constitution Avenue, N.W. · Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine. The members of the committee responsible for the report were chosen for
their special competences and with regard for appropriate balance.
Support for this project was provided by The Robert Wood Johnson Foundation. The
views presented in this report are those of the Institute of Medicine Committee on the
Consequences of Uninsurance and are not necessarily those of the funding agencies.
International Standard Book Number 0-309-08343-5
Library of Congress Control Number 2002105905
Additional copies of this report are available for sale from the National Academy Press,
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www.iom.edu.
For more information about the Institute of Medicine, visit the IOM home page at
Copyright 2002 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
The serpent has been a symbol of long life, healing, and knowledge among almost all
cultures and religions since the beginning of recorded history. The serpent adopted as a
logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by
the Staatliche Museen in Berlin.
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"I(n owing is not enough; we invest apply.
Widing is not enough; we must do."
Goethe
..... .....
........ ....... ... -
....... .. . . . .
INSTITUTE OF MEDICINE
Shaping the Future for Health
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National Acaclemy of Sciences
National Acaclemy of Engineering
Institute of Meclicine
National Research Council
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of
distinguished scholars engaged in scientific and engineering research, dedicated to the
furtherance of science and technology and to their use for the general welfare. Upon the
authority of the charter granted to it by the Congress in 1863, the Academy has a mandate
that requires it to advise the federal government on scientific and technical matters. Dr.
Bruce M. Alberts is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of
the National Academy of Sciences, as a parallel organization of outstanding engineers. It
is autonomous in its administration and in the selection of its members, sharing with the
National Academy of Sciences the responsibility for advising the federal government. The
National Academy of Engineering also sponsors engineering programs aimed at meeting
national needs, encourages education and research, and recognizes the superior achieve-
ments of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineer-
ng.
The Institute of Medicine was established in 1970 by the National Academy of Sciences
to secure the services of eminent members of appropriate professions in the examination of
policy matters pertaining to the health of the public. The Institute acts under the responsi-
bility given to the National Academy of Sciences by its congressional charter to be an
adviser to the federal government and, upon its own initiative, to identify issues of medical
care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medi-
c~ne.
The National Research Council was organized by the National Academy of Sciences in
1916 to associate the broad community of science and technology with the Academy's
purposes of furthering knowledge and advising the federal government. Functioning in
accordance with general policies determined by the Academy, the Council has become the
principal operating agency of both the National Academy of Sciences and the National
Academy of Engineering in providing services to the government, the public, and the
scientific and engineering communities. The Council is administered jointly by both Acad-
emies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are
chairman and vice chairman, respectively, of the National Research Council.
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COMMITTEE ON THE CONSEQUENCES OF UNINSURANCE
MARY SUE COLEMAN (Co-chair), President, Iowa Health System and
University of Iowa, Iowa City
ARTHUR L. KELLERMANN (Co-chairJ, Professor and Chairman,
Department of Emergency Medicine, Director, Center for Injury Control,
Emory University School of Medicine, Atlanta, Georgia
RONALD M. ANDERSEN, Wasserman Professor in Health Services, Chair.
Department of Health Services, Professor of Sociology, University of
California, Los Angeles, School of Public Health
JOHN Z. AYANIAN, Associate Professor of Medicine and Health Care
Policy, Harvard Medical School, Brigham and Women's Hospital, Boston,
Massachusetts
ROBERT I. BLENDON, Professor, Health Policy & Political Analysis,
Department of Health Policy and Management, Harvard School of Public
Health and Kennedy School of Government, Boston, Massachusetts
SHEILA P. DAVIS, Associate Professor, The University of Mississippi
Medical Center, School of Nursing, Jackson, Mississippi
GEORGE C. EADS, Charles River Associates, Washington, D.C.
SANDRA R. HERNANDEZ, Chief Executive Officer, San Francisco
Foundation, California
WILLARD G. MANNING, Professor, Department of Health Studies, The
University of Chicago, Illinois
JAMES I. MONGAN, President, Massachusetts General Hospital, Boston,
Massachusetts
CHRISTOPHER QUERAM, Chief Executive Officer, Employer Health
Care Alliance Cooperative, Madison, Wisconsin
SHOSHANNA SOFAER, Robert P. Luciano Professor of Health Care
Policy, School of Public Affairs, Baruch College, New York, New York
STEPHEN I. TREJO, Associate Professor of Economics, Department of
Economics, University of Texas at Austin
REED V. TUCKSON, Senior Vice President, Consumer Health and Medical
Care Advancement, UnitedHealth Group, Minnetonka, Minnesota
EDWARD H. WAGNER, Director, W.A. McColl Institute for Healthcare
Innovation, Group Health Cooperative Puget Sound, Seattle, Washington
LAWRENCE WALLACK, Director, School of Community Health, College
of Urban and Public Affairs, Portland State University, Oregon
v
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IOM Staff
Wilhelmine Miller, Project Co-director
Dianne Miller Wolman, Project Co-director
Lynne Page Snyder, Program Officer
Tracy McKay, Research Associate
Ryan Palugod, Senior Project Assistant
Consultant
Jennifer S. Haas, Assistant Professor of Medicine, San Francisco General
Hospital and University of California, San Francisco
Al
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Reviewers
This report has been reviewed in draft form by individuals chosen for their
diverse perspectives and technical expertise, in accordance with procedures ap-
proved by the NRC's Report Review Committee. The purpose of this indepen-
dent review is to provide candid and critical comments that will assist the institu-
tion in making its published report as sound as possible and to ensure that the
report meets institutional standards for objectivity, evidence, and responsiveness to
the study charge. The review comments and draft manuscript remain confidential
to protect the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report:
GERARD ANDERSON, Director, Center for Hospital Finance and Manage-
ment, Johns Hopkins Health System, Baltimore, MD
JEREMIAH A. BARONDESS, President, New York Academy of Medicine,
New York
ANDREW BINDMAN, Associate Professor, Epidemiology and Biostatistics,
University of California, San Francisco
DANA GOLDMAN, Senior Economist, RAND Health Communications, Di-
rector, UCLA/RAND Health Services Research Postdoctoral Training Program,
Santa Monica
NICOLE LURIE, Senior Natural Scientist and Paul O'Neill Alcoa Professor,
RAND Corporation, Arlington, VA
DIANE MAKUC, Director, Division of Health and Utilization Analysis, Na-
tional Center for Health Statistics, Hyattsville, MD
DAVID MECHANIC, Director, Institute for Health, Health Care Policy, and
Aging Research, Rutgers, The State University of New Jersey - New Brunswick
. .
v''
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V111
RE VIEWERS
THOMAS SCHELLING, Distinguished University Professor, School of Public
Affairs, University of Maryland, College Park
RICHARD SORIAN, Director of Public Affairs and Senior Researcher, Center
for Studying Health System Change, Washington, DC
DAVID R. WILLIAMS, Professor of Sociology and Senior Research Scientist,
Survey Research Center, Institute for Social Research, University of Michigan,
Ann Arbor
Although the reviewers listed above have provided many constructive com-
ments and suggestions, they were not asked to endorse the conclusions or recom-
mendations nor did they see the final draft of the report before its release. The
review of this report was overseen by Hugh H. Tilson, Clinical Professor,
School of Public Health, University of North Carolina, Chapel Hill,
appointed by the Institute of Medicine and Charles E. Phelps, Provost, Uni-
versity of Rochester, appointed by the NRC's Report Review Committee,
who were responsible for making certain that an independent examination of this
report was carried out in accordance with institutional procedures and that all
review comments were carefully considered. Responsibility for the final content
of this report rests entirely with the authoring committee and the institution.
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Foreword
Care Without Coverage: Too Little, Too Late appears at a critical juncture in our
national health policy debate. It comes when, for the first time, legislators and
other policy makers are not disputing the need to help individuals and families
maintain health insurance coverage during economic downturns, but only the best
strategies for doing so. This second report of the Institute of Medicine (IOM)
Committee on the Consequences of Uninsurance confirms what most health care
professionals have long believed and the general American public has acted upon:
health insurance makes a difference in people's lives. The public has acted upon this
premise by taking up workplace health insurance, buying individual policies, and
enrolling in publicly sponsored plans when they qualify for them. This practical
evidence of the value Americans place on having health insurance coexists, para-
doxically, with the commonly held belief (discussed in depth in the Committee's
first report, Coverage Matters: Insurance and Health Care, and briefly in this report)
that Americans without health insurance manage to get the care that they really
need.
Care Without Coverage should disabuse all of us of this overly optimistic view
of how health care operates for the 40 million uninsured Americans. It provides a
critical and comprehensive review of research on the effects of health insurance
coverage or its lack for adults in the United States. The authoring Committee and
its Subcommittee on Health Outcomes for the Uninsured have produced a report
that responds with well-documented evidence to the assumption and assertion
that health insurance is not an essential component of access to quality health care
or to healthy outcomes in America. In this country, we do not see many people
dying in the streets because of inaccessible health care, and it has been easy to
assume that people without health insurance manage to get the care they need.
IX
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x
FOREWORD
The report refutes this assumption by delineating in some detail how the health of
adults who do not have health insurance is compromised by their lack of coverage.
This report constitutes important new information for national and state policy
makers as they deliberate about health, economic, and social welfare policy. What
is at stake is not only the health of those without health insurance but our nation's
reputation and character as a fair and compassionate society.
The Institute of Medicine is grateful to The Robert Wood Johnson Foun-
dation for supporting this series of reports addressing the personal and social
. , .
Impacts ot un~nsurance.
Kenneth I. Shine, M.D.
President, Institute of Medicine
May 2002
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Preface
This is the second report in a series of six that the Institute of Medicine (IOM)
Committee on the Consequences of Uninsurance is issuing. The Committee's
first report, Coverage Matters: Insurance and Health Care, was released in October
2001. It provides an overview of health insurance in the United States, describes
the dynamic and often unstable nature of coverage, identifies the characteristics of
Americans who are likely to lack health insurance, and delineates the scope of the
problem of uninsurance in this country. Coverage Matters is a timely contribution
to the ongoing policy debates about health insurance, and we commend our initial
report to your attention along with this current one.
Care Without Coverage: Too Little, Too Late builds on the foundation of infor-
mation and analysis laid in the first report and examines the question of the health
consequences for adults who lack health insurance. Care Without Coverage is based
on a focused and critical review of clinical and epidemiological research that sheds
light on the question of whether and how having health insurance or lacking it
affects the care adults receive and their health status as a result. The Committee's
work led it to the conclusion that health insurance does, indeed, make a significant
difference in the health of American adults and that uninsured adults experience
worse health as a consequence of their lack of coverage.
The research, analysis, and preparation of Care Without Coverage involved the
committed efforts of Committee members, IOM staff, and consultants to the
project. The Subcommittee on Health Outcomes for the Uninsured, chaired by
Edward Wagner, designed and conducted the critical review of research studies
upon which the Committee based its findings and conclusions. Committee mem-
bers Ronald Andersen, John Ayanian, and Edward Wagner were joined on the
subcommittee by Paula Dichr, David Meltzer, Cynthia Mulrow, and Robin
Xl
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xt!
PREFACE
Weinick, members who enhanced and deepened the expertise available to the
Committee in its work on this study. We are deeply indebted to the intensive
efforts of the Subcommittee in the analysis and drafting of this report. IOM staff
members Wilhelmine Miller, the principal analyst on this report, Tracy McKay,
Lynne Snyder, Dianne Wolman and Ryan Palugod supported the Committee and
Subcommittee in all aspects of their work, and this report reflects their dedication
and initiative. As primary consultant to the Committee, Jennifer Haas helped to
clarify the complex issues of the overlapping influence of race and ethnicity,
socioeconomic status, and health insurance on health outcomes, and we are grate-
ful for her generous participation in the Committee's work.
We hope that Care Without Coverage: Too Little, Too Late will contribute to
the current public examination of options for the stabilization and expansion of
health insurance coverage and improvements in access to care for all of our
nation's people. The Committee's next report, which examines impacts of
uninsurance on the family and health outcomes for children, pregnant women,
and newborns, will be released this fall. The final three Committee reports on
community impacts of uninsured populations, societal economic costs, and mod-
els and criteria for health financing reforms will be released in the winter, spring,
and fall of 2003, respectively. Each of these reports will provide policy makers and
the American public with solid new information and insights to inform decision
making about health insurance coverage at every level.
Finally, we would like to thank The Robert Wood Johnson Foundation for
its continued support of the Committee's work.
Mary Sue Coleman, Ph.D.
Co-chair
Arthur Kellermann, M.D., M.P.H.
Co-chair
May 2002
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Acknowledgments
Care Without Coverage: Too Little, Too Late benefited from the contributions of
many people. The Committee takes this opportunity to recognize those who
helped it develop the analyses on which the report is based.
The Committee particularly acknowledges the members of the Subcommit-
tee on Health Outcomes for the Uninsured, which developed this report: Edward
Wagner (chair), Ronald Andersen, John Ayanian, Paula Dichr, David Meltzer,
Cynthia Mulrow, and Robin Weinick. All members of the Subcommittee con-
tributed much time and advice in designing the critical literature review that
supports this report's findings and conclusions, and in reviewing and critiquing
scores of primary research articles themselves.
Jennifer Haas served as a principal consultant to the Subcommittee and,
with Nancy Adler, professor of medical psychology at the University of California
at San Fransisco (UCSF) and chair of the MacArthur Research Network on
Socioeconomic Status and Health, prepared a background paper that analyzed
how race, ethnicity, and socioeconomic factors contribute to differences in health
outcomes and how these factors should be taken into account in interpreting
findings about health insurance effects. Jennifer generously gave her time for
conference calls and meetings during the preparation of this report, and her
expertise informs it throughout.
Michael Feuerstein, professor of medical and clinical psychology, preventive
medicine and biometrics at the Uniformed Services University of the Health
Sciences, Bethesda, Maryland, contributed his time and expertise to the Commit-
tee by analyzing and synthesizing the research on mental health care and outcomes
and health insurance. Linda Kohn and Elaine Swift, senior program officers in the
Division of Health Care Services, Institute of Medicine, also participated in the
. . .
x'''
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xiv
A CKNO WLED GMENTS
primary literature review and evaluation effort, and advised project staff on its
interpretation. Consulting editor Cheryl Ulmer assisted in preparation of the
Executive Summary.
Highly expert and accomplished consultants were enlisted in the effort to
critically review more than 130 research studies within a six-week time frame last
summer. Consultants to the Committee who served in this capacity were Margot
Kushel, assistant professor of medicine, UCSF; Marcia Polansky, associate profes-
sor of biostatistics, Drexel University; Joshua Sarver, Center for Health Care
Research and Policy, Case Western Reserve University; and Dean Schillinger,
associate professor of medicine, UCSF. The Committee is very grateful for their
thoughtful and thorough critiques and their willingness to contribute to this
prod ect.
The Committee recognizes the hard work of staff at the Institute of Medicine.
This work is conducted under the guidance of Janet Corrigan, director, Board on
Health Care Services. All members of the project team, directed by Wilhelmine
Miller and Dianne Wolman, contributed to this report. Wilhelmine was lead staff
in working with the Subcommittee and Committee in developing and managing
the critical literature review and in drafting Care Without Coverage. Dianne and
Program Officer Lynne Snyder reviewed and edited multiple drafts and back-
ground documents and contributed in many ways to the final report. In addition
to summarizing studies and collecting the large number of articles and references
acquired for this report, Research Associate Tracy McKay resourcefully con-
ducted numerous systematic literature searches under the Subcommittee's direc-
tion and identified many published studies that might otherwise have been missed.
She also prepared the manuscript for publication. Senior Project Assistant Ryan
Palugod efficiently supported communications with Committee members, handled
meeting logistics, and managed the numerous consultancy arrangements related to
the literature review.
Funding for the project comes from The Robert Wood Johnson Foundation
(RW}F). The committee extends special thanks to Steven Schroeder, president,
and Anne Weiss, senior program officer, RW}F, for their continuing support and
. . ~ . .
Interest In t. his project.
Finally, the Committee would like to thank co-chairs Mary Sue Coleman and
Arthur Kellermann for their guidance and Subcommittee Chair Edward Wagner
for his leadership in the research and development of Care Without Coverage.
OCR for page R15
Contents
EXECUTIVE SUMMARY
Assessing the Impact of Health Insurance on Health, 5
Effects of Health Insurance on Specific Health Conditions, 7
General Health Outcomes, 13
The Difference Coverage Could Make to the Health of
Uninsured Adults, 14
INTRODUCTION
Scope of the Report, 19
Definitions, 20
A Conceptual Framework for Understanding the Effects of
Health Insurance Status, 21
Organization of the Report, 24
2 MECHANISMS AND METHODS: LOOKING AT THE
IMPACT OF HEALTH INSURANCE ON HEALTH
Mechanisms and Measures of Access to Health Care, 26
Methodology and Measurement of Health Insurance Effects, 30
Methods of Systematic Literature Review and Synthesis, 40
3 EFFECTS OF HEALTH INSURANCE ON HEALTH
Primary Prevention and Screening Services, 48
Cancer Care and Outcomes, 52
xv
3
17
25
47
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XVI
Chronic Disease Care and Outcomes, 57
Hospital-Based Care, 72
General Health Outcomes, 80
Conclusion, 86
4 THE DIFFERENCE COVERAGE COULD MAKE TO THE
HEALTH OF UNINSURED ADULTS
Adults Most at Risk of Poor Health Outcomes, 92
Features of Health Insurance That Improve Health-Related
Outcomes, 98
Insuring the Uninsured: Improving Health Outcomes, 101
APPENDIXES
A A Conceptual Framework for Evaluating the Consequences of
Uninsurance: A Cascade of Effects
B Primary Research Literature Review
CONTENTS
91
105
109
C Glossary and Acronyms 155
Estimates of Excess Mortality Among Uninsured Adults
E Biographical Sketches
REFERENCES
161
167
177
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