BOX 6.1
Conclusions and Research Agenda

Conclusion 1. A community’s high uninsured rate has adverse consequences for the community’s health care institutions and providers. These consequences reduce access to clinic-based primary care, specialty services, and hospital-based care, particularly emergency medical services and trauma care.

Conclusion 2. Research is needed to more clearly define the size, strength, and scope of adverse community effects that are plausible consequences of uninsurance. These include potentially deleterious effects on access to primary and preventive health care, specialty care, the underlying social and economic vitality of communities, public health capacity, and the overall population health.

Research Agenda

The Context for Community Effects

2.1 What are the unmet needs for care of uninsured persons and families? Do they differ geographically, both within and among states?

2.2 What are the sources of public support for care to uninsured persons? How much does each source contribute and how efficiently are the funds allocated?

2.3 To what extent does uncompensated care by doctors, hospitals, and other entities support care for uninsured persons? To what degree do private cross-subsidies subsidize care of uninsured persons?

Access to Care

3.1 Does the local uninsured rate, independent of other factors, affect residents’ access to care throughout the community?

3.2 How does the local uninsured rate affect the availability of primary and preventive services for the community’s insured as well as uninsured residents?

3.3 How does the local uninsured rate affect the availability of specialty services, including emergency medical services and trauma care for the community’s insured as well as uninsured residents?

3.4 How does the local uninsured rate, in conjunction with public institutional support such as disproportionate share hospital payments, affect hospital service offerings, financial stability, and decisions to close?

3.5 How does uninsurance within communities affect the quality of care available to and provided to all residents, insured and uninsured alike?

Economic and Social Effects

4.1 Does the local uninsured rate, independent of other factors, affect the cost of health services and insurance premiums within the local market area?



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A Shared Destiny: Community Effects of Uninsurance BOX 6.1 Conclusions and Research Agenda Conclusion 1. A community’s high uninsured rate has adverse consequences for the community’s health care institutions and providers. These consequences reduce access to clinic-based primary care, specialty services, and hospital-based care, particularly emergency medical services and trauma care. Conclusion 2. Research is needed to more clearly define the size, strength, and scope of adverse community effects that are plausible consequences of uninsurance. These include potentially deleterious effects on access to primary and preventive health care, specialty care, the underlying social and economic vitality of communities, public health capacity, and the overall population health. Research Agenda The Context for Community Effects 2.1 What are the unmet needs for care of uninsured persons and families? Do they differ geographically, both within and among states? 2.2 What are the sources of public support for care to uninsured persons? How much does each source contribute and how efficiently are the funds allocated? 2.3 To what extent does uncompensated care by doctors, hospitals, and other entities support care for uninsured persons? To what degree do private cross-subsidies subsidize care of uninsured persons? Access to Care 3.1 Does the local uninsured rate, independent of other factors, affect residents’ access to care throughout the community? 3.2 How does the local uninsured rate affect the availability of primary and preventive services for the community’s insured as well as uninsured residents? 3.3 How does the local uninsured rate affect the availability of specialty services, including emergency medical services and trauma care for the community’s insured as well as uninsured residents? 3.4 How does the local uninsured rate, in conjunction with public institutional support such as disproportionate share hospital payments, affect hospital service offerings, financial stability, and decisions to close? 3.5 How does uninsurance within communities affect the quality of care available to and provided to all residents, insured and uninsured alike? Economic and Social Effects 4.1 Does the local uninsured rate, independent of other factors, affect the cost of health services and insurance premiums within the local market area?

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A Shared Destiny: Community Effects of Uninsurance 4.2 What is the burden on local taxpayers of uninsurance within states and localities? How does that burden compare to the tax burden that would be imposed if public insurance programs or subsidized coverage were expanded to reduce uninsured rates? How does the impact of public financing of health care vary across economic cycles? 4.3 Does the adverse financial impact of uninsurance on local health services and institutions extend to the local economy overall? Community Health 5.1 Does the local uninsured rate, independent of other factors, affect the health status of community residents overall? Are particular groups within the general population more affected than others? 5.2 Does demand for personal health care services by uninsured residents adversely affect the availability of public health services within localities and states? Does the presence of substantial uninsured populations within communities adversely affect emergency preparedness and the community’s ability to respond effectively to bioterrorism and other mass casualty events? 5.3 Does the local uninsured rate, independent of other factors, influence the spread or prevalence of communicable diseases?

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A Shared Destiny: Community Effects of Uninsurance 6 Summary: Conclusions and Research Agenda The Committee has presented a series of hypotheses and findings related to the effects that uninsurance may have on a community as a whole. This report has traced connections between health services oriented toward those without health insurance and those who have coverage; among public insurance programs, uninsured rates, and their effects on health care providers and institutions; and between public health activities and personal health care. A Shared Destiny relates a story that is important but not simple. The point of the story is simple, however: over 41 million uninsured persons and 58 million members of uninsured families are spread broadly and widely across communities in the United States, where their uninsured status is likely to have an impact on population health and on the American health care enterprise in which we all participate. The examination of community effects ties together aspects of health policy that are usually compartmentalized, requiring new approaches to research that will clarify the true costs and consequences of uninsurance at the local level. The Committee draws two conclusions based on its expert judgement and its review of illustrative findings from the limited body of relevant evidence that has been identified. Conclusion 1. A community’s high uninsured rate has adverse consequences for the community’s health care institutions and providers. These consequences reduce access to clinic-based primary care, specialty services, and hospital-based care, particularly emergency medical services and trauma care. Conclusion 2. Research is needed to more clearly define the size,

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A Shared Destiny: Community Effects of Uninsurance strength, and scope of adverse community effects that are plausible consequences of uninsurance. These include potentially deleterious effects on access to primary and preventive health care, specialty care, the underlying social and economic vitality of communities, public health capacity and overall population health. Community impacts of uninsurance have rarely been studied directly. As a result, in this report the Committee has worked from its conceptual framework to devise hypotheses about community effects, drawing illustrative inferences from quantitative and, more often, qualitative studies that do not directly address questions about community effects. Much of the research reviewed in this report represents early efforts in new fields of inquiry. This research uses new data sources, research constructs, and models of interactions among people, their health, and structural features of communities and institutions. The limited amount and preliminary nature of much of the evidence considered in this report leads the Committee to its call for further investigations of these impacts. In the sections of the chapter that follow, a research agenda is outlined, pulling together the specific research questions presented at the end of the earlier chapters. Following an initial section about the conceptual framework, the structure of the following research agenda parallels that of Chapters 2 through 5 of the report. A RESEARCH AGENDA FOR COMMUNITY EFFECTS Conceptual Framework for Community Effects The Andersen-Aday behavioral model of access to health care serves as a point of departure for the conceptual framework the Committee has developed for its series of reports. In A Shared Destiny, the conceptual framework highlights the individual, family, and community-level resources, characteristics, and needs that are hypothesized to influence outcomes at the community level and the hypothesized pathways for these effects. The Committee’s framework is a first attempt to theorize and document community effects, and in this report it has served at least as much as a plan for future research as it has the framework within which to assess the limited literature available. Additional conceptual and empirical work is needed to fashion a more useful model, particularly one that can address the following concerns: the validity and explanatory value of the proposed pathways or mechanisms by which uninsurance produces community effects; the role of the framework’s feedback loops, or the process of adaptation to change by community residents, health care providers, and other actors, in modulating or otherwise contributing to the proposed mechanisms for community effects or the effects themselves; and

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A Shared Destiny: Community Effects of Uninsurance the identity and relative influence of individual, family, and community-level factors that may make for different experiences of community effects by different groups within communities. The Context for Community Effects: The Financing and Delivery of Health Services 2.1 Local Patterns of Unmet Need and Utilization by Uninsured Persons What are the unmet needs for care of uninsured persons and families? Do they differ geographically, both within and among states? Basic to much of the proposed research in this report is the need for reliable and current local estimates of uninsured rate and measures of the dispersion or concentration of uninsured persons within local health services markets and among the providers within a market. Until the late 1990s most estimates of uninsured rate, were available only at the national, state, or major metropolitan statistical area (MSA) level, most notably through the U.S. Census Bureau’s March Current Population Survey (CPS).1 In recent years, the Health Resources and Services Administration’s State Planning Grant program, together with the State Health Access Data Assistance Center (SHADAC), has facilitated the creation of uninsured rate surveys at the county or regional level within states, although these estimates tend not to be comparable across surveys. Enhanced data collection and coordination of existing surveys is needed, as well as the development of new methods to allow generation of more precise and reliable local uninsured rates and for the comparison of these estimated rates across jurisdictions. A local uninsured rate can be the basis for estimating the unmet need or health services utilization of uninsured persons, but more direct measures are preferable. Programs to provide and pay for uninsured care are often stretched to their resource limits, with existing dollars outstripped by the perceived health needs of this population (Lewin and Altman, 2000; Felt-Lisk et al., 2001; IOM, forthcoming 2003). Evaluative research is needed to understand how uninsurance at a local level influences the organization and delivery of health care. How have communities that have been substantially effective in meeting the needs for health care of uninsured and other underserved populations met those needs, and what financing and services strategies have they employed? 2.2 Public Subsidy of Health Services Delivered to Uninsured Persons What are the sources of public support for care to uninsured persons? How much does each source contribute and how efficiently are the funds allocated? 1   Appendix B in the Committee’s first report, Coverage Matters, reviews the major surveys that give estimates of uninsured rates (IOM, 2001).

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A Shared Destiny: Community Effects of Uninsurance The Committee relies on Hadley and Holahan’s recent publication (2003) for a working set of rough estimates about the extent of public subsidy. More complete and consistent documentation of existing federal, state, and local supports for the provision of care to uninsured persons is needed. The levels of such payments to hospitals are substantial and may even be adequate to cover the costs of uncompensated hospital care for those completely without health insurance (Hadley and Holahan, 2003). However, more research is needed to identify administrative barriers and inefficiencies in the allocation of funds that result in inadequate or poorly targeted subsidies for the care for uninsured persons. For example, the formulas used to calculate Medicare and Medicaid disproportionate share hospital (DSH) payment rates do not take the number of uninsured patients into account. It is difficult if not impossible to compare Medicaid spending across the states related to DSH payments because many states in effect match the federal grant with monies raised from hospitals themselves (e.g., hospital taxes, intergovernmental transfers from public hospitals) and the states collect and classify data on these payments differently. 2.3 Private Subsidy of Care Delivered to Uninsured Persons To what extent does uncompensated care by doctors, hospitals, and other entities support care for uninsured persons? To what degree do private cross-subsidies subsidize care of uninsured persons? It is widely assumed that private payers (e.g., employers, insurers) and private sector health care providers (e.g., nonprofit hospitals, physician practices) cross-subsidize the costs of care for uninsured patients. However, the size of this subsidy is difficult to estimate and the mechanisms through which this uncompensated care is subsidized are complex and not explicitly addressed or documented in the research literature. To the extent that private cross-subsidies occur, what are the implications for health care costs, for local businesses and employers who offer employment-based coverage, and to economic activity in the community? The literature on hospital cost-shifting presents a useful approach to proposed research on private cross-subsidy. One way to gauge the extent of cross-subsidy, for example, is depicted in Figure 2.1 in Chapter 2, which compares the contributions of uncompensated care, Medicare margins, and private payer surpluses to hospitals’ total margins over time. A longitudinal analysis of changes in payment-to-cost ratios or prices for each payer to an individual provider, correlated with changes in the provider’s total margin and in the cost of unreimbursed care provided to uninsured persons, would yield more precise information about the amount and sources of private subsidy (Dobson, 2002; Morrissey, 2002). Both quantitative and qualitative studies would likely be needed to tease out the extent of private cross-subsidy, with much regional and market variation related to the market position of both insurers and health care providers (e.g., ability to negotiate discounted charges, anticipated revenue from a hospital’s patient case mix, the amount of hospital revenues across which an uncompensated care burden could be spread).

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A Shared Destiny: Community Effects of Uninsurance Effects of Uninsurance on Access to Care Within Communities 3.1 Access to Care Across the Community Does the local uninsured rate, independent of other factors, affect residents’ access to care throughout the community? Existing studies of the relationship between community uninsurance (state or MSA uninsured rate) and access to care offer preliminary evidence that, particularly for lower-income and uninsured populations, higher local uninsured rates are associated with worse access to care. These provocative findings should be corroborated with additional studies that include more refined measures of access as outcome variables. Well-controlled, longitudinal study designs could allow researchers to tease out the difference between the effects of the uninsured population exerting an aggregate influence on local health services (e.g., because the uninsured constitute a large portion of the population being studied) compared with having an ecological impact (e.g., the independent effect of uninsured rate on access to care for insured persons). Is the supply of services in more affluent urban neighborhoods and suburbs affected by proximity to large or small populations of uninsured persons, and how? 3.2 Access to Primary and Preventive Services How does the local uninsured rate affect the availability of primary and preventive services for the community’s insured as well as uninsured residents? Because primary and preventive services are often considered elective by patients (unlike emergency medical services and hospital inpatient care), use of these services may fall off more quickly when patients lack the financial means to pay for care. When the number or proportion of uninsured patients increases within a primary care practice, the combination of decreasing patient utilization and an increasing proportion of uninsured visits may also adversely affect the financial position of the practice. As a result, primary care practices may become financially unviable. A conservative estimate of the amount of charity care that physicians provide annually to uninsured patients is roughly $5 billion (Hadley and Holahan, 2003). Better information about the distribution and impact of the burden of providing uncompensated care among physician practices and its implications for the availability of high-quality, stable primary care services is needed in order to understand the dimensions of the problems that uninsurance poses for communities. 3.3 Access to Specialty Care, Including Emergency Medical Services How does the local uninsured rate affect the availability of specialty services, including emergency medical services and trauma care for a community’s insured as well as uninsured residents?

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A Shared Destiny: Community Effects of Uninsurance The legal duty of hospital emergency departments (EDs) and trauma units to screen and medically stabilize all patients regardless of ability to pay is one source of financial stress on hospitals. What is less clear, however, is how important the financial demands of providing care to uninsured patients are compared with other reasons for emergency department overcrowding and causes of financial strain (Tsai et al., forthcoming 2003). Further study is needed to understand the degree to which ED overcrowding and financial instability could be ameliorated by reductions in the number of uninsured persons, the restructuring of financial subsidies for their care, or the strategic diversion of emergency department patients to alternative sites for primary care. In addition, more research is needed to understand the degree to which administrative and staffing decisions made within hospitals (e.g., the specialized services offered such as psychiatric inpatient care) reduce community access and what alternatives exist to address the problem without jeopardizing the financial health of hospitals. While emergency medical services and trauma care provide some of the strongest evidence about access to specialty care, the Committee’s findings about the difficulty community health center physicians have obtaining referrals for their uninsured and other patients, and about hospital-based specialty services, suggest that further investigation of the availability throughout a community to a wide range of specialty services is merited. How does the institutional setting (e.g., academic health center) influence or moderate the effect of uninsurance on access to other specialty services? And what impacts does uninsurance have on the other related missions of these institutions, for example, medical education in academic health centers? 3.4 Access to Hospital-Based Services How does the local uninsured rate, in conjunction with public institutional support such as disproportionate share hospital payments, affect hospital service offerings, financial stability, and decisions to close? The limitations and preliminary findings of the Committee’s commissioned analyses of hospital services and financial margins suggest a number of ways that community effects on access to care might be explored. Perhaps most important is the examination of strategic or competitive responses of hospital administrators and their boards to local market conditions, including the decisions of competing hospitals to expand or shrink inpatient capacity and boost or trim the provision of services, and the relationship between these responses and individual hospital financial margins. More refined studies, based on market areas smaller than MSAs, are needed to understand better the impacts of uninsured populations on hospital services and operations. For example, findings for rural areas that the concentration of uninsured patients may lessen the size of the effect of local uninsured rate on inpatient capacity, services, and margins of all hospitals in the county, on average, suggest that such concentration of uncompensated care caseload among a few providers may be beneficial to the health care system as a whole. On the other hand, concentrating all care for uninsured persons in one facility, such as a county

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A Shared Destiny: Community Effects of Uninsurance hospital, may both limit access to care, compared with more dispersed safety net arrangements, and lead to poor quality of care. Further research is needed to assess the overall effect of concentration and dispersion on access to hospital-based care. Although there were hundreds of hospital closures during the 1980s and 1990s, there has been little documentation of the role that a community’s uninsured rate may have played in these closures. Most studies of hospital closings do not directly address the influence of uninsurance because of the limited information about local uninsured rates and hospital payer mix. Closures of public hospitals are of particular concern because these hospitals serve as providers of last resort. Studies that examine reasons for these closings and the impacts of these closings or conversions are needed. 3.5 Quality of Care How does uninsurance within communities affect the quality of care available to and provided to all residents, insured and uninsured alike? An important and under-examined potential impact of uninsurance within a community is on the quality of care available and provided to all residents. The Committee’s earlier reports documented problems of quality (based on measures of process and outcomes) in the care of uninsured patients. This report focuses more holistically on the impact on providers’ performance overall when uninsured patients or uncompensated care overwhelm or impair their capacity to provide quality services. No studies have directly assessed the correlation of community uninsured rates with hospital or physician quality of care. There are at least two areas in which high uninsured rates could adversely affect quality of care for all patients. First, if high uninsured rates influence hospital margins, this could lead to cutbacks in nursing staff, which in turn threaten quality of care (Needleman et al., 2002). Second, if high uninsured rates contribute significantly to emergency department overcrowding at certain facilities, these hospitals may deliver poorer quality of care during times of patient overload. Detailed studies at the level of the patient are needed to understand the relationship between overcrowding and quality of care. Economic and Social Implications of Uninsurance Within Communities 4.1 Increases in Local Health Care Costs Does the local uninsured rate, independent of other factors, affect the cost of health services and insurance premiums within the local market area? Cross-sectional studies are the basis for our limited knowledge about whether and how local uninsured rates contribute to the increasing cost of health services in health services markets. Longitudinal small-area studies are needed to look at the hypothesized chains of events at the state and local levels to establish or

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A Shared Destiny: Community Effects of Uninsurance disprove the causal relationship between uninsured rates and health insurance costs and to develop estimates of the size and strength of any such relationships. 4.2 Budget Implications for States and Localities What is the burden on local taxpayers of uninsurance within states and localities? How does that burden compare to the tax burden that would be imposed if public insurance programs or subsidized coverage were expanded to reduce uninsured rates? How does the impact of public financing of health care vary across economic cycles? Public support of care for uninsured persons is substantial, yet documentation is inconsistent and precise estimates are difficult to derive. More consistent reporting is needed across states and localities of revenue and expenditure streams for financing the array of insurance-based and direct health services programs now operating across the nation. Greater knowledge of the budget allocation process and decisions made at the state level between funding Medicaid and the programs that support direct care for uninsured persons, and between health care and other public services, could inform proposals to improve the equity and target efficiency of federal and state health financing programs. Specifically, programs of institutional support for uncompensated care such as the Medicare and Medicaid DSH payments need to be evaluated in light of these goals. A systematic analysis of the existing federal, state, and local tax burdens for financing health care generally and for low-income and uninsured Americans in particular should be undertaken as part of any impact analysis of health financing reform initiatives. 4.3 Economic Base and the Potential for Development Does the adverse financial impact of uninsurance on local health services and institutions extend to the local economy overall? More research is needed to understand the relationship between community uninsurance and the social and economic life of communities. In-depth, longitudinal case studies of communities could be employed to investigate the role played by health insurance coverage or the lack of it. For example, areas that have undergone dramatic social or economic change, such as the economic decline of communities reliant on manufacturing and their subsequent adaptations and economic recovery, might be worthwhile sites to study. If little is known about the role that the health sector plays in rural economies, even less is known about the economic relationships that bind local health services to urban neighborhoods and larger market areas. Research is needed to identify the ways in which a changing uninsured population affects the financial viability of health care providers and institutions, elucidating the complicated series of financial relationships among public and private payers. Can a high uninsured rate trigger a funding or political crisis that leads to the transition of a local health care system toward a more efficient and effective use of limited resources? To what

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A Shared Destiny: Community Effects of Uninsurance extent are an uninsured population’s unreimbursed health care expenses matched by public support with the objective of keeping a local economy afloat? Uninsurance and Community Health 5.1 Health Status Within the Community at Large Does the local uninsured rate, independent of other factors, affect the health status of community residents overall? Are particular groups within the general population more affected than others? A number of cross-sectional studies have documented the worse health status and access to care of lower-income populations in localities and states with relatively high uninsured rates. However, these studies neither confirm nor reject the hypothesis that high rates of uninsurance locally have deleterious effects on the health and access to care among those with coverage. Longitudinal studies could shed some light on this question. Do changes in the uninsured rate over time lead to changes in the health status of insured people as well as to changes in the health of those lacking coverage? Race, ethnicity, and socioeconomic status need to be controlled analytically in such studies, as they influence health outcomes and covary with uninsured status (IOM, 2002a; Smedley et al., 2002). 5.2 Public Health Departments and Services, Including Emergency Preparedness Does demand for personal health care services by uninsured residents adversely affect the availability of public health services within localities and states? Does the presence of substantial uninsured populations within communities adversely affect emergency preparedness and the community’s ability to respond effectively to bioterrorism and other mass casualty events? The Committee’s findings about the relationship between uninsurance and likely reduced access to hospital emergency medical services and trauma care allude to a related community effect on emergency preparedness. Our nation’s capability to respond to casualties on a broad scale, including bioterrorism, is a function of its public health capacity, which depends on adequate and consistent funding for public health activities and health departments at the state and local level nationally. To the extent that uninsurance contributes to the under-funding of public health programs that perform these functions, uninsurance may weaken emergency preparedness. The influence of the presence of many uninsured people on public health preparedness and the ability of the public health programs to contain bioterrorism acts also need to be examined. State and local health department budgets do not now offer a reliable source of information for tracking expenditures for and resources devoted to personal health care and public health services, either for insured or uninsured residents (IOM, forthcoming 2003). The issue of states’ allocations of federal and own-source health dollars between public health activities and personal health services

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A Shared Destiny: Community Effects of Uninsurance merits closer and more regular evaluation. To do this would require more systematic and standardized accounting and reporting of state and local health spending than currently exists (IOM, 2000, forthcoming 2003). In view of the increasing demands being placed upon state and local health departments in the areas of emergency preparedness and disease surveillance in the context of bioterrorism, the need for such information is urgent. 5.3 Population Health (Burden of Disease), Including Spillover Effects of Com municable and Chronic Diseases Does the local uninsured rate, independent of other factors, influence the spread or prevalence of communicable diseases? A lack of information relating local health insurance coverage rates to health indicators precludes definitive statements about the effects of uninsurance on population health. Have preventable infectious disease rates declined in communities that have substantially reduced the number of uninsured? How concentrated or diffused are the spillover effects on population health of uninsurance within the community? Are those who are affected similar to the uninsured population on several social, geographic, or economic dimensions, or is population health affected widely throughout the community? Surveys and statistics that report on both health insurance and health status at the county, city, and neighborhood levels are needed. In order to assess the effects of relatively low insurance coverage rates on the incidence and prevalence of tuberculosis, HIV disease, and other sexually transmitted diseases, for example, one must know local uninsured rates as well as the case rates for at-risk populations at the county and city levels. Any direct relationship cannot be detected with the aggregate statistics for case rates and for uninsured rate that are now available. Chronic diseases can also have spillover effects, and their exacerbation by lack of health insurance has not been examined. For example, research on the interaction of severe mental illness and uninsurance could lead to a better understanding of the social and economic, as well as the health-related, costs that result. In Care Without Coverage, the Committee reported that nearly 20 percent of adults with severe mental illnesses are uninsured and as a result are less likely than insured adults to receive appropriate care (McAlpine and Mechanic, 2000; IOM, 2002). One example of a spillover effect related to the lack of appropriate treatment of severe mental illness is imprisonment (President’s Commission, 2002). The costs associated with the lack of treatment due to lack of coverage are likely to be considerable, and could be estimated. CONCLUSION What we don’t know can hurt us. There is much that is not understood about the relationships between health services delivery and financing mechanisms and even less about how the current structure and performance of the American health care enterprise affect communities’ economies and the quality of social and politi-

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A Shared Destiny: Community Effects of Uninsurance cal life in this country. Because policy makers and researchers have not asked or examined these questions through comprehensive and systematic research and analysis, there is a limited body of evidence of mixed quality on community effects. The Committee believes, however, that it is both mistaken and dangerous to assume that the prevalence of uninsurance in the United States harms only those who are uninsured. It calls for further research to examine the suggested effects of uninsurance at the community level but nonetheless believes there is sufficient evidence to justify the adoption of policies to address the lack of health insurance in the nation (Corrigan et al., 2002). Rather, the call for more research is to say that, as long as we as a nation tolerate the status quo, we should more fully understand the implications and consequences of our stalemated national health policy.