Health Insurance Is a Family Matter

Committee on the Consequences of Uninsurance

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Health Insurance Is a Family Matter Health Insurance Is a Family Matter Committee on the Consequences of Uninsurance Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Health Insurance is a Family Matter THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 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 0-309-08518-7 Library of Congress Control Number 2002111131 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, N.W., Box 285, Washington, D.C. 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. 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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Health Insurance is a Family Matter “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

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Health Insurance is a Family Matter THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine 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 achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. 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 responsibility 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. Harvey V. Fineberg is president of the Institute of Medicine. 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 Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Health Insurance is a Family Matter COMMITTEE ON THE CONSEQUENCES OF UNINSURANCE MARY SUE COLEMAN (Co-chair), President, University of Michigan, Ann Arbor ARTHUR L. KELLERMANN (Co-chair), 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 J. BLENDON, Professor, Health Policy and 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 GEORGE C. EADS, Charles River Associates, Washington, D.C. SANDRA R. HERNÁNDEZ, Chief Executive Officer, San Francisco Foundation, California WILLARD G. MANNING, Professor, Department of Health Studies, The University of Chicago, Illinois JAMES J. MONGAN, President, Massachusetts General Hospital, Boston 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 STEPHEN J. 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, McColl Institute for Healthcare Innovation, Center for Health Studies (CHS), Group Health Cooperative, Seattle, Washington LAWRENCE WALLACK, Director, School of Community Health, College of Urban and Public Affairs, Portland State University, Oregon

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Health Insurance is a Family Matter 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 Consultants Gerry Fairbrother, Research Director, Child Health Forum, New York Academy of Medicine Hanns Kuttner, Senior Research Associate, Economic Research Initiative on the Uninsured, University of Michigan

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Health Insurance is a Family Matter Foreword Health Insurance Is a Family Matter is the third in a series of six reports planned by the Institute of Medicine (IOM) and its Committee on the Consequences of Uninsurance. This series of studies represents a major and sustained commitment by the IOM to contribute to the public debate about the problems associated with having more than 38 million uninsured people in the United States. This very broad research effort also represents a significant contribution from The Robert Wood Johnson Foundation for which we are grateful. Health Insurance Is a Family Matter adds to the IOM’s history of related contributions. Most relevant for this report on families is a consensus report issued by the Committee on Children, Health Insurance, and Access to Care in 1998, America’s Children: Health Insurance and Access to Care. That committee concluded that all children should have health insurance. Because this has not yet become a reality, the Committee on the Consequences of Uninsurance provides further evidence and confirmation of the effects on children of being uninsured, as well as the impact of uninsurance on the whole family. As we prepared to issue the Committee’s first report last fall, Coverage Matters: Insurance and Health Care, two hijacked airliners destroyed the World Trade Center and another severely damaged the Pentagon. After the initial shock and recovery began, attention turned to the families of the victims. Around the country people began asking what could be done for families who had lost their health insurance and their family’s income along with their loved ones. As the economy slowed and more people lost their jobs, the fear of becoming uninsured grew and Congress began debating what to do about the problem of health coverage interrupted by a job loss. These circumstances make this report on the family effects of being

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Health Insurance is a Family Matter uninsured all the more important and relevant to current efforts to understand the problem and find solutions. The members of the Committee on the Consequences of Uninsurance are experts in a wide range of disciplines, including clinical medicine, epidemiology, health services research and delivery of services, economics, strategic planning, small business management, and health communications. They carefully considered the pertinent evidence, and here present a coherent picture of the various effects that being uninsured has upon family well-being. This report shows that a family’s chance of having an uninsured member at some point is significant and that a lack of coverage can have negative effects on the uninsured child or pregnant woman. In addition, some of the ill effects of uninsurance spill over to other family members, even if they have coverage, and can jeopardize the family’s well-being and put the family unit at risk of financial disruption. Children are our nation’s future, and families are the place for raising and protecting them; it is crucial to the strength of the country that we consider the contribution health insurance makes to family well-being. This report will provide much material for reflection by policy experts, decision-makers, and the general public as they consider the various ways that being uninsured can erode the strength of America’s families—and what can be done about it. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine September 2002

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Health Insurance is a Family Matter Preface Health Insurance Is a Family Matter is the third report that the Institute of Medicine (IOM) Committee on the Consequences of Uninsurance is issuing since it began its research efforts in autumn 2000. Three more reports will be issued before the completion of the project in 2003. These reports represent the Committee’s efforts to review and assess the evidence concerning a wide range of causes and effects of being uninsured. The Committee is concerned with both the effects of lacking health insurance for individuals and the broader effects of having more than 38 million uninsured people in our nation. The Committee is following a carefully designed research plan so that each report builds on previous ones and provides a foundation for future reports. The first report, Coverage Matters: Insurance and Health Care, provides essential background information for understanding the dynamics of health insurance, who is uninsured and why, and provides evidence to dispel many public misperceptions. Coverage does indeed matter. The second report, Care Without Coverage: Too Little, Too Late, presents an overwhelming body of evidence documenting the fact that adults without insurance suffer worse health. Now the third report widens the focus from the individual to the family. Health Insurance is a Family Matter analyzes the effects being uninsured can have on the health, finances and general well-being of the family. It also examines the health of uninsured children and pregnant women to see whether they also receive less care and suffer worse health outcomes than do those who are insured. The next report will expand the focus of attention even more to examine how having part of a community’s population uninsured can affect the community as a whole, including those with insurance. Then the Committee looks at the economic costs to society of sustaining an uninsured population of more than

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Health Insurance is a Family Matter 38 million people. The final report will consider aspects of various programs, strategies, and policy options designed to expand coverage and reduce the problems of uninsurance. This report comes at a time when personal concerns about being uninsured and about having such a large uninsured population in the country have fueled public debate yet again. The report echoes the messages of the first two reports that coverage matters and that being uninsured is bad for one’s health. Being uninsured similarly affects the health and well-being of the family. We hope that Health Insurance Is a Family Matter will provide a fresh perspective on the issues and the solid analysis needed to move the discussion further along toward solutions. Mary Sue Coleman, Ph.D. Co-chair Arthur Kellermann, M.D., M.P.H. Co-chair September 2002

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Health Insurance is a Family Matter Acknowledgments Many individuals contributed to Health Insurance Is a Family Matter. The Committee acknowledges the assistance of those who helped with the analyses on which the report is based. The Committee especially recognizes the members of the Subcommittee on Family Impacts of Uninsurance, which developed this report: George Eads, who served as its chair, Sheila Davis, Cathy Schoen, Shoshanna Sofaer, Peter Szilagyi, and Barbara Wolfe. They provided a wide range of expertise, devoted significant amounts of time, and assisted in guiding the development of the critical literature review and analyses of data that form the basis of this report’s findings and conclusions. Gerry Fairbrother, of the New York Academy of Medicine, served as principal consultant to the Subcommittee and prepared background papers on insurance coverage patterns within families and on the interactions within families that are related to insurance coverage and family health. She also conducted a major literature review of the evidence concerning health outcomes for pregnant women, infants, and children. Gerry was always available for advice during preparation of this report, generous with her assistance to staff and the Committee, and her expertise improves the whole report. The Committee is grateful to the New York Academy of Medicine for its generosity with her time and that of her assistants. Hanns Kuttner, of the Economic Research Initiative on the Uninsured at the University of Michigan, assisted the Committee by drafting background papers analyzing and synthesizing the research on the financial effects of health insurance on the family and effects over the life cycle of the family. He also generously provided ongoing economic advice and assistance. Matthew Broaddus provided new tabulations of the latest census data on insurance status, which formed the

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Health Insurance is a Family Matter basis for much of the analysis in the report. The Committee is grateful to the Center on Budget and Policy Priorities and to the David and Lucile Packard Foundation for making Matt’s time and expertise available to us. Consulting editor Cheryl Ulmer assisted in preparation of the literature review on health outcomes for pregnant women, infants, and children and the short summary of the report. 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 Dianne Wolman and Wilhelmine Miller, contributed to this report. Dianne was lead staff in working with the Subcommittee and the Committee in developing and managing the research and drafting of Health Insurance Is a Family Matter. Wilhelmine and Program Officer Lynne Snyder reviewed and edited multiple drafts and background documents and contributed in many ways to the final report. Research Associate Tracy McKay researched and drafted a summary of public insurance programs, conducted systematic literature searches for the Committee’s review, and prepared the whole manuscript for publication. In addition to collecting the large number of articles and references used for this report and maintaining the reference database, Senior Project Assistant Ryan Palugod efficiently supported communications with Committee members and meetings logistics. Funding for the project comes from The Robert Wood Johnson Foundation (RWJF). The Committee extends special thanks to Risa Lavisso-Mourey, senior vice president, and Anne Weiss, senior program officer, RWJF, for their continuing support and interest in this project. Finally, the Committee would like to thank Co-chairs, Mary Sue Coleman and Arthur Kellermann, and Subcommittee Chair George Eads for their guidance in the development of Health Insurance Is a Family Matter.

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Health Insurance is a Family Matter Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution 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: RON J. ANDERSON, President and Chief Executive Officer, Parkland Memorial Hospital, Dallas, TX JANET CURRIE, Professor, Department of Economics, University of California, Los Angeles GARY L. FREED, Professor, Department of Pediatrics, University of Michigan, Ann Arbor JOHN HOLAHAN, Director, Health Policy Center, Urban Institute, Washington, DC EMBRY HOWELL, Principal Research Associate, Health Policy Center, Urban Institute, Washington, DC SARA ROSENBAUM, Director, Center for Health Services Research and Policy, The George Washington University, Washington, DC AMY K. TAYLOR, Senior Economist, Department of Health and Human Services, Rockville, MD

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Health Insurance is a Family Matter Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations 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 Joseph P. Newhouse, John D. MacArthur Professor of Health Policy and Management, Harvard University, 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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Health Insurance is a Family Matter Contents     EXECUTIVE SUMMARY   3     A Family Perspective,   3     Coverage Patterns of Families and Their Significance,   4     Insurance Transitions over the Family Life Cycle,   6     Financial Characteristics and Behavior of Uninsured Families,   7     Health Interactions Within the Family,   8     Health-Related Outcomes for Children, Pregnant Woman, and Newborns,   8     Conclusions,   10 1   A FAMILY MATTER   13     Purpose of the Report,   15     Need for a Family Perspective,   16     How Families Get Health Insurance Coverage,   17     Conceptual Framework,   20     Report Overview,   23 2   INSURANCE COVERAGE OF FAMILIES   25     Overview of Sources of Coverage,   26     Insurance Patterns By Family Characteristics,   27     Summary,   43 3   INSURANCE TRANSITIONS OVER THE FAMILY LIFE CYCLE   47     Age Issues Affecting Insurance Patterns Within Families,   51     Employment Issues Affecting Families,   54

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Health Insurance is a Family Matter     Marital Issues Affecting Families,   59     Summary,   63 4   FINANCIAL CHARACTERISTICS AND BEHAVIOR OF UNINSURED FAMILIES   65     Income, Assets, and Borrowing Power of Uninsured Families,   65     Health Services Costs for Uninsured Families,   69     Financial Burden of Health Care Costs for Uninsured Families and How These Families Cope,   75     Summary,   87 5   FAMILY WELL-BEING AND HEALTH INSURANCE COVERAGE   91     Parents’ Influence on Children’s Access to and Use of Health Services,   91     Effects of Family Health on Child Health and Well-Being,   97     Summary,   103 6   HEALTH-RELATED OUTCOMES FOR CHILDREN, PREGNANT WOMEN, AND NEWBORNS   107     Access to and Use of Health Care by Children,   111     Health Outcomes for Children and Youth,   120     Effect of Health on Children’s Life Chances,   124     Prenatal and Perinatal Care and Outcomes,   127     Summary,   136 7   CONCLUSIONS   141     A Family Perspective,   141     Financial and Health Consequences for Families,   142     Implications of Parental Coverage,   143     Populations at Risk,   144     A Public Policy Perspective,   144     Outlook,   146     APPENDIXES     A   Conceptual Framework for Evaluating the Consequences of Uninsurance for Families   147 B   Overview of Public Health Insurance Programs   153 C   Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants   161 D   Data Tables   213 E   Glossary   241 F   Biographical Sketches   247     REFERENCES   259

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Health Insurance is a Family Matter Health Insurance Is a Family Matter

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