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4 Analytic Plan This chapter describes the Committee's analytic plan to address the impacts and outcomes of our present structure of health insurance, the scope of the five future reports, and the schedule for their release. Each report in turn will focus successively on larger and more complex entities the individual, the family, the local community, and the broader society. By proceeding systematically in this way, the Committee hopes to capture the distinctive effects of the lack of health insurance at each level of analysis. The conceptual framework discussed in Chap- ter 1 and presented in Appendix A will guide the analyses and be developed further in subsequent reports. FUTURE COMMITTEE REPORTS Report 2. Health Outcomes of People Who Lack Health Insurance As already established by more than three decades of health services research, insurance coverage facilitates access to health care. The more that people have to pay out-of-pocket for a physician visit, prescription, or hospitalization, the less likely they are to seek such care. They are also likely to receive fewer services when they do seek care (Newhouse et al., 1993~. In the extreme case ofthose with no insurance, people are less likely to receive health care when they need it compared to those with coverage. The second report will extend the understand- ing of the significance of health insurance coverage by examining personal health outcomes (including self-reported health status, disease-specific morbidity, avoid- 101

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102 CO VERA GE MA TTERS: INSURANCE AND HEALTH CARE able hospitalizations, and mortality) in relation to whether or not a person has health insurance. Studies that distinguish between those without coverage for shorter and longer periods of time and studies of the impact of losing health insurance coverage provide evidence of the effects of coverage on some health outcomes, in addition to the definitive findings regarding access to health care described in Chapter 1. For example, a study by Ayanian and colleagues (2000) identifies both difficulties in obtaining care and deficits in the quality of care for uninsured persons with specific chronic conditions. This study reports that adults who were uninsured for a year or longer were substantially less likely than those with coverage or those who were uninsured for shorter times to be screened for cancers, to receive services that reduce cardiovascular risks (e.g., hypertension, cholesterol screening and counseling about weight and smoking), and to receive regular care for diabe- tes, including foot and eye exams. These specific services are associated with improved longer-term health outcomes (Institute of Medicine, 2001~. Longitudinal studies following the same individuals over time can provide even more definitive evidence of the health effects of being uninsured, because unexamined characteristics of the study population are less likely to account for differences in outcomes between those with and those without insurance. In a study that followed a cohort of adult Medi-Cal beneficiaries who lost coverage in the mid-1980s, Lurie and colleagues found that both six months and one year after losing coverage, these persons reported poorer overall health and were less likely to have a usual source of care or believe that they could obtain care if needed than they had reported when participating in Medi-Cal. Former enrollees with hyper- tension had worse blood pressure control both at six months and one year than they had while enrolled in Medi-Cal (Lurie et al. 1984, 1986~. These are just two of literally hundreds of studies that have taken health insurance status into account as a characteristic that might affect a health outcome of some kind. Not all such studies have found a relationship between health insurance and health outcomes, and not all such studies are methodologically sound. The second report will present and use explicit criteria to assess evidence of the impact of health insurance status on individual adult health outcomes. The conceptual model discussed earlier will guide the analysis. The second report, on health outcomes, will be issued in the spnug of 2002. Report 3. Family Impacts of Lacking Health Insurance In almost a quarter of all American families with children, at least one family member lacks health insurance (Hanson, 2001~. An estimated 10 million children under the age of 18 remain uninsured, despite enactment of the State Children's Health Insurance Program (SCHIP) in 1997. Because children depend on their parents or other adults to obtain health care for them, parents' experiences with the health care system, their beliefs about health care, and their ability to negotiate that system on their children's behalf are important. Providing health insurance to

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ANALYTIC PLAN 103 children removes one barrier to access to care, but it may do little to remove other barriers that spring from the family context. Furthermore, if the health of unin- sured adults suffers as a result of impeded access to care, their ability to care for their children may also be adversely affected. Finally, when one or more family member lacks coverage for health care, the entire family is exposed to potentially catastrophic financial costs. Even when confronted with less catastrophic illness, uninsured families are significantly more likely to have high out-of-pocket medi- cal expenses than are privately insured or Medicaid-enrolled families, although privately insured families are likely to pay more in health insurance premiums (Davidoff et al., 2000~. The Committee will review and document the effects on families when one or more members lack health insurance. It will address the circumstances of and impacts on special populations and various family structures. The report will examine a variety of effects, including measures of family members' health and of . , children's developmental status, access to and use of health services, financial burdens, and family psychosocial stress. Taking the family as the primary unit of analysis, the report will identify patterns of health insurance coverage within families in order to discern relationships between parents' insurance and health status and their children's health insurance status, use of health services, and health. The report will also examine health insurance status in relation to the family's out- of-pocket costs for medical care and its financial well-being and stability. The research literature on health outcomes for children who have gained health insur- ance coverage in recent expansions of Medicaid and with SCHIP will be synthe- sized in the report. The third report, onfamily impacts, will be issued in thefall of 2002. Report 4. Community-wide Effects of Uninsured Populations The presence of substantial numbers of uninsured people may adversely affect communities as well as the uninsured individuals and their families. The "spillover" effects on the insured population and the community at large could be consider- able, although these are not well documented or understood. Faced with a need for health care, some people without health insurance seek the care they need and pay for it out-of-pocket, some try to obtain the care at subsidized rates or at public expense, and some forgo care. The result for the individual is often poorer than that obtained by people with insurance coverage. Several sources estimate that uninsured persons obtain about two-thirds of the care of comparable insured populations (Marquis and Long, 1994-1995~. The fourth report will focus on the often indirect and hidden costs to communities of serving those without insur- ance. Physicians working in private practice, nonprofit clinics such as federally qualified health centers (FQHCs), government-sponsored primary care and spe- cialty clinics, and hospitals all provide significant amounts of subsidized or free care. Institutional providers such as hospitals and clinics must obtain funds to cover the costs of subsidized care from revenue generated from paying patients (cost

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04 CO VERA GE MA TTERS: INSURANCE AND HEALTH CARE shifting), tax-based subsidies, or private philanthropy. Thus, one set of community impacts may include higher prices, higher taxes, or dependence on philanthropy to support care for persons without health insurance. Other community consequences result from the financial burden placed on providers who treat large numbers of uninsured patients. These effects may in- clude cutbacks in service, closure or relocation of services, overcrowded emer- gency rooms, and relocation of physicians' offices or even hospitals from areas of town that have concentrations of uninsured persons. These disruptions may re- duce people's access to care regardless of their insurance status. A third potential impact of uninsured populations on communities follows from the failure to obtain needed health care for communicable diseases, such as treatment for tuber- culosis or diagnosis of HIV infection. Although these effects have not been well documented by published research, the Committee intends to investigate available sources of information to examine whether there are public costs related to pre- ventable disability and an increased incidence of communicable diseases related to uninsured populations. The report will identify the nature and magnitude of effects on geographically defined communities in which differing proportions of the population lack health insurance with a focus on communities (municipalities, metropolitan areas, rural areas, states) that have disproportionately large uninsured populations. Impacts in rural communities may differ from those in urban areas and will be examined in some detail. The Committee will document the relationships of community unin- sured rates to economic and industrial characteristics, public health and welfare programs, population demographics, and health care professional and institutional resources. Specifically, the report may explore the relationship between commu- nity levels of uninsurance and the general availability and quality of physician services, emergency medical services, and highly specialized institutional services such as trauma, burn, and intensive care units. The fourth report, on community impacts, will be issued in the winter of 2003. Report 5. Economic Costs of an Uninsured Population The fifth report will estimate various economic costs incurred by society resulting from the fact that a significant percentage of the U.S. population lacks health insurance. Whereas the previous report on community impacts will exam- ine local costs, both economic and other kinds, the fifth report will consider a broader array of financial impacts on individuals, families, and the national economy. To the extent possible, the analysis will include estimates of selected direct costs of providing health care to the uninsured, increased costs resulting from the inefficient use of health services, and the indirect costs of preventable disability and lost productivity among uninsured persons with specific health conditions. The report will explore how the burden of costs is paid, including out- of-pocket payments by the uninsured and their families, uncompensated care by health care providers and institutions, tax levies by all levels of government, higher

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ANALYTIC PLAN 105 health insurance premiums to support cost shifting, gifts from philanthropies, and the indirect cost of disability on business operations. The report will present a clearer understanding of the extent to which society already pays to care for the uninsured. The fifth report, on economic costs, will be issued in the spring of 2003. Report 6. Strategies and Models for Providing Health Insurance In its final report, the Committee will examine selected state, local, federal, and private-sector policies and programs that have attempted to mitigate the adverse impacts of lack of health insurance on individuals, families, health care providers, and communities by expanding insurance coverage. The report will identify promising prototypes as well as innovative approaches to the problem of uninsurance. A goal of the report will be to identify policy criteria that can be used to assess the merits of alternative reform strategies, rather than to endorse or recommend specific reform approaches. The sixth report, on model programs and policies, will be issued in late summer of 2003.

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