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1
Introduction
The persistence of a large uninsured population in this country, regardless of
the prevailing economic conditions, is remarkable. In 2000, when this three-year
study of the consequences of uninsurance began, 39.4 million people under age 65
in the United States reported having no health insurance during the previous
year.1 The uninsured population had grown by more than 6 million during the
1990s, despite a decade of strong economic growth, when health care inflation
slowed and health spending flattened at just over 13 percent of the gross domestic
product (GDP) between 1992 and 2001.2 Federal and state budgets had experi-
enced surpluses, and states expanded their existing coverage programs and ex-
plored new opportunities to cover more of their uninsured populations. Yet at the
height of this prosperous period, 1998–2000, the number of uninsured dropped
by less than a million; see Figure 1.1. In 2000, the uninsured rate began to grow
once more. Despite fluctuations in economic and demographic trends, which can
affect the numbers and percentage of the population insured, a large uninsured
population has persisted over the past few decades.
1The estimate of 39.4 million uninsured is based on the Census Bureau’s March Current Popula-
tion Survey (CPS) as are all annual estimates of the uninsured population of the United States
presented in this report, unless otherwise noted. See Chapter 2 and Appendix A for a more detailed
discussion of various measures of the uninsured rate and length of time people are uninsured, why
they are uninsured, and characteristics of the uninsured.
2Italicized technical terms are defined in the glossary (Appendix B).
15
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16
17.2%
300 16.5%
16.1%
17.0% 16.2%
16.9%
16.4%
16.1%
15.9%
16.0%
15.7%
15.1%
14.9%
14.5%
14.4%
13.7%
250
200
150
100
Estimated Number (Millions)
50
36.5 37.3
31.7 40.7 39.4 40.9
29.5 32.9 33.6 35.4 36.4 38.3 39.0
31.1 39.9 43.3
0
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
FIGURE 1.1 Uninsured persons under age 65, number and proportion of general population under age 65, 1987–2002.
NOTE: Estimates for 2000, 2001, and 2002 use Census 2000-based weights.
SOURCES: Fronstin, 2002; Mills and Bhandari, 2003.
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17
INTRODUCTION
Now, the uninsured population continues to increase in number, and the
uninsured rate is expected to worsen in the continuing weak economy (Fronstin,
2002). Over 43 million people were reported uninsured in 2002, representing
17.2 percent of the population under the age of 65 (Mills and Bhandari, 2003).3
Unemployment is up now, state budgets are experiencing increased demands for
services, state revenues are less than had been anticipated, and many states have
significant budget shortfalls (National Governors Association, 2003; Rowland,
2003; U.S. Bureau of Labor Statistics, 2003a). The federal budget has returned to
a deficit position as well. Health costs and health insurance premiums are again
increasing faster than general inflation and more quickly than family and business
incomes (Heffler et al., 2003; U.S. Bureau of Labor Statistics, 2003b). Many states
are proposing or implementing cost containment measures for public coverage
programs, although few have yet to cut eligibility substantially or covered services
for their Medicaid and State Children’s Health Insurance Programs (SCHIP) and
some are pursuing significant extensions of coverage as a means to reduce uncom-
pensated care costs (Holahan et al., 2003d; Ross and Cox, 2003; Smith et al.,
2003).
The problem of uninsurance has been growing in urgency, not just because of
the economy and increasing numbers of uninsured Americans. Insurance is so
important now because the effectiveness of medical interventions, particularly
medical technologies and pharmaceuticals, continues to increase, improving health
and longevity (Cutler and Richardson, 1997; Murphy and Topel, 1999;
Heidenreich and McClellan, 2003). Without insurance, people have less access to
these new services and drugs. Thus, the gap between insured and uninsured
people widens and raises questions of equity. This disparity in accesss to health
care violates generally accepted American values of equal consideration and equal
opportunity (IOM, 2003b).
The failure of many attempts throughout the past century to extend health
insurance coverage to everyone is a notable feature of health care in the United
States. The lack of universal health insurance coverage places this nation along
with Mexico and Turkey as the only ones among the developed countries around
the globe with substantial uninsured populations (OECD, 2002). It is time to
rethink the nation’s approach to financing access to health care for its population.
PURPOSE OF THE PROJECT AND THIS REPORT
In 2000, the Institute of Medicine (IOM) formed the Committee on the
Consequences of Uninsurance to examine the evidence concerning the lack of
health insurance for those without coverage, for their families, for their commu-
3Unless otherwise stated, this report will focus on the population under age 65 because the federal
Medicare program provides nearly universal coverage for people at and above that age.
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18 INSURING AMERICA’S HEALTH
nities, and for this country as a whole. Most often, an IOM study is self-contained
in a single report that lays out the evidence leading to the Committee’s findings
and conclusions and then proceeds to make recommendations. This project is
unusual in that it was designed to produce six reports during the course of the
three-year study that examine the issue of uninsurance critically and methodically
from several different perspectives. The first five reports present evidence, find-
ings, and conclusions on their given topics (see following descriptions of each). As
planned from the outset, the Committee has withheld most of its recommenda-
tions until it fully examined the issue. Therefore, this sixth and final report draws
on the findings of the previous five reports, as well as an examination of selected
historical efforts and federal, state, and local programs that were designed to
extend coverage. The Committee uses the term “extend coverage” to mean having more
people gain coverage who previously had had none and reducing the uninsured rate. That
extension of coverage could be achieved through either expansion of existing
insurance programs or creation of new mechanisms.
The findings from the six reports as a whole have convinced the Committee
that uninsurance is a critical problem for the United States that can and should be
eliminated. The Committee believes that leaving over 43 million Americans
uninsured is costly to the country and should no longer be tolerated.
The intent in this final report is to present principles based on the Committee’s
previous research, apply them to potential strategies to extend coverage and elimi-
nate uninsurance, and make a strong case for taking action now. Although the
report examines a wide range of approaches that have been proposed to extend
coverage, it does not recommend a particular proposal. Rather, it presents prin-
ciples and recommendations to guide the public, policy makers, and elected
officials in crafting effective and achievable solutions. This report also provides
examples of how to apply the principles to assess the strengths and weaknesses of
various strategies to extend coverage.
FINDINGS AND CONCLUSIONS FROM PREVIOUS
COMMITTEE REPORTS
The Committee’s first five reports identify the many consequences for the
country of maintaining such a large uninsured population:
• Coverage Matters: Insurance and Health Care (IOM, 2001a) provides an over-
view of how health insurance works in America, and describes the socioeconomic
and demographic characteristics of uninsured populations. It also sets out a con-
ceptual framework for thinking about uninsurance; this framework has guided the
analyses in all the following reports (see Figure 1.2 below).
• Care Without Coverage: Too Little, Too Late (IOM, 2002a) assesses the clin-
ical research concerning health consequences for uninsured adults, including over-
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PANEL 3
PANEL 2
PANEL 1
Process of Obtaining Access to Health Care Consequences of Uninsurance
Determinants of Coverage
Individual and Family Level Individual and Family Level
• Eligibility (either for self or
Resources: financial means,
dependents)
how health policies and health
• Cost to enroll or maintain Health Care
services organization apply to
(including employer • Personal health
the individual and to the family
subsidy) practices
• Administrative process of Characteristics: demographic, • Utilization of health
enrolling or maintaining social, economic, cultural, and services
coverage geographic • Processes of services Health Outcomes for
• Knowledge of eligibility delivery Individuals
Need: health status perceived
Need: Decision to enroll or to • Needs
by the individual or family
maintain • Consumer satisfaction
member and as evaluated by
others
Effects on Families
Community Level
Community Level
• Health outcomes
• Availability of employment- Resources: health policies, • Childhood development
based, public, and private how services are organized, • Economic effects
coverage how services are financed
Characteristics:
demographic, social, economic,
cultural, and geographic Effects on Communities
• Economic effects
Needs: as identified by public
• Population health measures
or population health indicators
• Health care institutions
FIGURE 1.2 A conceptual framework for evaluating the consequences of uninsurance—a cascade of effects.
NOTE: Italics indicate terms that include direct measures of health insurance coverage.
19
SOURCE: IOM, 2001a.
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20 INSURING AMERICA’S HEALTH
all health status, the incidence of specific diseases, avoidable hospitalizations, the
quality of care received, preventable morbidity, and premature mortality.
• Health Insurance Is a Family Matter (IOM, 2002b) examines similar health
effects for children and pregnant women. In addition, it expands the focus beyond
the individual to include the effects of one or more uninsured family members on
others in the family, including those with insurance, and on the family as a unit.
• A Shared Destiny: Community Effects of Uninsurance (IOM, 2003a) looks at
wider “spillover” effects of uninsurance on the local community, insured as well as
uninsured residents, and specifically on its health care providers.
• Hidden Costs, Value Lost: Uninsurance in America (IOM, 2003b) details the
costs to the country of sustaining such a large uninsured population. Many of the
costs identified in the earlier reports are quantified. The costs of additional health
care services likely to be used by those who are now uninsured, if they were to
gain coverage, are also calculated.
The Committee concludes that allowing a sizable uninsured popula-
tion to persist has serious negative consequences for individuals,
families, communities, and the entire nation.
Collectively, these five reports show that current insurance mechanisms have
not eliminated the large, persistent uninsured population and indeed are not
structured to do so. The current system relies on an assortment of private and
public sources to provide coverage, each of which meets the needs of some
people, while leaving millions uncovered. Instead of approaching the problem in
tentative incremental steps, the Committee believes that citizens and policy mak-
ers should begin by setting as an explicit goal that the health insurance system
should include everyone, then determine the private and public policies and
actions necessary to achieve that end, and enact and implement those policies.
The Committee concludes that major, comprehensive reform of the
health insurance system, rather than expansion of the “safety net,” is
essential.
The “safety net” loosely refers to health care facilities and programs that
disproportionately serve needy and uninsured people. If financial access to health
care services were assured, people would be able to choose among providers in
their community and not be dependent upon safety-net institutions, as uninsured
people are now. Also, the availability of payments from insurers could strengthen
the financial stability of those providers and institutions, which are stressed by the
current economy and growing demands for services (IOM, 2003a; KCMU,
2003a). Safety-net services, institutions, and accommodating providers vary widely
from state to state and area to area, have ill-defined responsibilities, are inadequate
to meet current needs of the uninsured, and are unlikely to meet future needs
(Lewin and Altman, 2000; Hadley, 2002; IOM, 2003a).
Strengthening safety-net services would not be an adequate alternative to
expanding health insurance coverage. For example, federally supported primary
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21
INTRODUCTION
care clinics, including community health centers, have a heavy case load of unin-
sured clients but serve only 6.5 to 10 percent of the total uninsured population.
Most uninsured people do not live near a center (Cunningham and Tu, 1997;
IOM, 2003a). Persons receiving primary care in such centers often have difficulty
obtaining specialty, diagnostic, and behavioral health services for which they are
referred (Gusmano et al., 2002). An analysis of 13 states shows that access for
uninsured lower income adults varies depending on local services capacity. How-
ever, even more striking in this analysis are the large gaps in access and use
between the insured and uninsured populations in each state, regardless of the
extent of local safety-net services (Holahan and Spillman, 2002). An analysis of
racial disparities in access to care, based on national data from the Community
Tracking Study (1996–1997 and 1998–1999), showed that lack of insurance is a
significant barrier to access and more important than the supply of medical provid-
ers and services in the community (Hargraves and Hadley, 2003). Thus, the
Committee has concentrated on insurance-based financing mechanisms, not nec-
essarily tied to one provider or facility, to facilitate access to care rather than on
programs that might increase the availability of certain services in selected geo-
graphic areas.
The Committee’s definitions of health insurance and uninsured status are
consistent with those adopted in its previous reports. Health insurance is defined
by the Committee as financial coverage for basic hospital and ambulatory care
services, whether provided through employment-based indemnity, service-ben-
efit, or managed care plans; individually purchased health insurance policies; pub-
lic programs such as Medicare (which covers virtually all persons 65 years of age
and older), Medicaid, and the SCHIP; or other state-sponsored coverage for
specified populations. Uninsured refers to persons without any form of public or
private coverage for hospital and outpatient care, for any given length of time. In
large part this operational definition reflects that used in virtually all studies that
attempt to discern and measure the impact of coverage status on health and other
individual and community outcomes. Although length of time without coverage
almost certainly will make a difference, the information typically available about
individual health insurance status (at baseline or inception of a study) tends to
obscure differences between insured and uninsured populations and thus likely
underestimates the negative effects of being uninsured.
Throughout its series of reports, the Committee has not attempted to address
the condition of underinsurance, by which is meant individuals or families whose
health insurance policy or benefits plan offers less than adequate coverage. The
problems faced by the underinsured are in some respects similar to those faced by
the uninsured, although they are generally less severe (IOM, 2002a, b). Unin-
surance and underinsurance involve some distinctly different policy issues and the
strategies for addressing them may differ. Throughout these reports, the Com-
mittee’s main focus has been on persons with no health insurance and thus no
assistance in paying for health care beyond what is available through charity and
safety-net arrangements.
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22 INSURING AMERICA’S HEALTH
A COMPARISON OF THE UNITED STATES AND
OTHER DEVELOPED COUNTRIES
Having insurance improves access to health services, and access to health care
is associated with better health among the uninsured. (See Figure 1.2, the concep-
tual framework that has guided this project.) The health care provided in America’s
best medical centers is world renowned; many people come from abroad to
benefit from the high-quality care available in this country. Tens of millions of
Americans, however, are uninsured and do not receive the services they need
(IOM, 2002a, b).
In the United States, health insurance has evolved from a mechanism to
protect against only infrequent and serious health events and expenses to one that
also finances routine health care and encourages the use of preventive services
(IOM, 2001a). In addition to lowering financial barriers to care, health insurance
improves the receipt of appropriate care by facilitating the use of a regular source
of care or primary care provider. Coverage is an important determinant of obtain-
ing and maintaining an ongoing relationship with a health care provider (IOM,
2001a; Holahan and Spillman, 2002). Even if uninsured persons receive primary
care, referrals to specialists, ancillary diagnostic and treatment services, and medi-
cations are more difficult to obtain without coverage (Fairbrother et al., 2002).
Both continuity of care and continuity of insurance coverage are important;
breaks in coverage can disrupt care relationships to the detriment of high-quality
health care. Being uninsured for longer periods of time can be expected to have
larger negative effects on utilization of services (and consequently on health) than
being uninsured for shorter periods (IOM, 2002a). The 43 million Americans
who lack health insurance coverage for a year or more are more likely to suffer
worse health and die sooner than Americans with health insurance (IOM, 2002a,
b).
A comparison of the health care system in the United States and the average
health of the U.S. population with that found in other countries highlights the
reason why Americans should be dissatisfied with the status quo. Although the
health care system in this country has accomplished a great deal, it can do much
better in improving the quality of health services and the health of its population.
Lowering financial barriers to needed health services is one important improve-
ment to achieve this goal.
Table 1.1 includes health system and health status indicators of the United
States and several other developed, high-income countries.4 Several conclusions
can be drawn from this table and the comparative international literature re-
viewed:
1. The United States ranks the highest in health care spending per capita and as a
percentage of GDP. In 2000, the United States spent 13 percent of its GDP and
4Much of these comparative data are based on the total population, including persons over age 65.
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TABLE 1.1 Health Care System Indicators in Selected Countries, 1997–2000
1 2 3 4 5
Total Health Health Spending Infant Mortality Disability-Adjusted % Total
Spending as a Per Capita Rate, Deaths per Life Expectancy Population
Percent of GDP in U.S. Dollars 1,000 Live Births in Years Publicly Covered
Country 2000 2000a 2000 1997–1999 2000
United States 13.0 4,631 6.9 70.0 86 b
Australia 8.3 2,211 5.2 73.2 100
Canada 9.1 2,535 5.3 72.0 100
Denmark 8.3 2,420 5.3 69.4 100 c
Finland 6.6 1,664 3.8 70.5 100
France 9.5 2,349 4.6 73.1 99.8
Germany 10.6 2,748 4.4 70.4 92.2 d
Italy 8.1 2,032 4.5 72.7 100
Japan 7.8 2,012 3.2 74.5 100
Luxembourg NA NA 5.1 71.1 100 d
Norway 7.8 2,362 3.8 71.7 100
Sweden NA NA 3.4 73.0 100
Switzerland 10.7 3,222 4.9 72.5 100
United Kingdom 7.3 1,762 5.6 71.7 100
NOTES:
aAdjusted for cost-of-living differences, purchasing power parities.
b86 percent of total population was insured; 24 percent of total population was publicly covered in 2000 (Mills, 2001).
c1999 data.
d1997 data; Germany’s insured rate is close to 99 percent including primary private insurance (Personal communication, Jeremy Hurst, OECD, September 11,
2003).
SOURCES: (Columns 1,2,3,5: OECD, 2002; column 4: WHO, 2000).
23
OCR for page 24
24 INSURING AMERICA’S HEALTH
$4,631 per capita on health care (Table 1.1, columns 1 and 2) (OECD, 2002).
This spending far surpassed the next most expensive health care systems, those of
Switzerland (10.7 percent of GDP) and Germany (10.6 percent of GDP). The per
capita amount spent in the United States is more than twice that of most of the
other countries of similar economic standing. While the U.S. spends substantially
more than the other countries, its measures of use of services, such as physician
visits and hospital days per capita, are below the Organization for Economic
Cooperation and Development (OECD) median (Anderson et al., 2003). The
implication is that the prices of those services are higher in the U.S. (Anderson et
al., 2003).
2. The health care system in the United States is deemed to be the most responsive in
the world to nonhealth aspects of care, such as respect for the individual, protection
of confidentiality, opportunity to participate in choices of treatments and provid-
ers, provision of prompt attention, and clean surroundings (WHO, 2000).5 The
OECD, in a recent assessment of the performance of the U.S. health care system,
similarly found that it is very responsive to consumer preferences. For example,
there is virtually no waiting time for elective procedures in the United States,
unlike many OECD member countries and most Americans are highly satisfied
with the care they receive (Docteur et al., 2003).
3. Comparative international surveys document the high availability of medical tech-
nology in the United States and the fact that it is intensively used (Docteur et al., 2003).
For example, the United States was quicker to adopt and diffuse new technologies
involved with care of heart attack patients than most of the 17 other developed
countries studied (TECH Research Network, 2001). The number of coronary
angioplasties in the United States per 100,000 population is more than two times
that in Germany and even further ahead of Australia, Canada, New Zealand, and
England. While the rates are not adjusted for disease prevalence, the large differ-
ence in rates suggests different patterns of treatment and diffusion of new treat-
ments and technologies (Anderson et al., 2003). Compared with Australia, Canada,
France, Germany, Japan, New Zealand, and the United Kingdom, the United
States is second only to Japan in the availability of magnetic resonance imaging
units: 23.2 in Japan versus 8.1 units in the United States per one million popula-
tion. The United States has 14 computed tomography scanners per million per-
sons, compared with Japan (84), Australia (21), Germany (17), and the OECD
median (12) (Anderson et al., 2002).
4. Although the United States ranks highest in health care spending (in total and as a
percentage of GDP) and ranks high in the availability of medical technology, this spending
has not produced comparably high measures of health status. The health of Americans
5It should be noted that some of the World Health Organization rankings, while innovative, have
been controversial. For the responsiveness ranking, the data were gathered from nearly 2000 key
informants in 35 countries and the distribution of responsiveness for the remaining countries (156)
was estimated using indirect techniques (WHO, 2000; Musgrove, 2003).
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25
INTRODUCTION
consistently ranks poorly relative to that of residents of other industrialized na-
tions. Certainly the health status of a population reflects more than just medical
care and the heterogeneity of the U.S. population distinguishes it from many other
developed countries. Nonetheless, international comparisons provide a useful per-
spective on our own society and indicate areas for improvement.
A comparison of 13 countries based on 16 health indicators conducted by
Barbara Starfield (2000) determined the United States ranked among the worst, on
average twelfth. The countries included in the study were, in order from the top
ranked (best health status) to the lowest, as follows: Japan, Sweden, Canada,
France, Australia, Spain, Finland, the Netherlands, United Kingdom, Denmark,
Belgium, United States, and Germany. The United States came in last for three
indicators (low birth weight; neonatal mortality and infant mortality overall; years
of potential life lost), even after excluding external causes such as motor vehicle
collisions and violence. Also, OECD comparisons ranked the United States
twenty-fifth in male life expectancy and nineteenth in female life expectancy out
of 29 developed countries.
Infant mortality rates and life expectancy, and also disability-adjusted life
expectancy (DALE), are among the most commonly used measures of population
health. They are widely considered valid indicators of the overall effectiveness of
the health care system, although many other factors also affect the health of a
population.6 As of 2000, the infant mortality rate in the United States was 6.9
infant deaths per 1,000 live births (OECD, 2002). Although this number repre-
sented a historic low for the United States, our infant mortality rate is nonetheless
the highest among the listed countries (see Table 1.1, column 3). Even if one
considers the U.S. infant mortality rate (5.7) for white infants only, whose mothers
generally have a higher social and economic status than nonwhite mothers, it is
still a higher rate than all the other countries. The 2000 infant mortality rate for
black infants in the United States (14.1 deaths per 1,000 live births) was more than
twice the white rate of 5.7 (National Center for Health Statistics, 2002).
Starfield found that, among the 13 countries she studied, the United States
came in eleventh for life expectancy of females at age 1 and twelfth for males at age
1. Table 1.1, (column 4), shows that the United States has a DALE of 70 years. Of
those countries listed in Table 1.1, only Denmark had a lower DALE, 69.4 years.
5. The United States is among the few industrialized nations in the world that
does not guarantee access to health care for its population (see Table 1.1, column 5).
Of 30 industrialized countries included in OECD health data, only Mexico and
Turkey have higher uninsured rates. Nearly all the OECD countries provide
public insurance for 99 to 100 percent of their population; Germany has substan-
tially higher coverage than the 92.2 percent publicly covered, when primary
private health insurance is included (OECD, 2002; personal communication,
6Disability-adjusted life expectancy is the number of healthy years of life that can be expected on
average in a given population (WHO, 2000).
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26 INSURING AMERICA’S HEALTH
Jeremy Hurst, OECD, September 11, 2003). In contrast, only 86 percent of the
U.S. population had health insurance in 2000, 24 percent covered by public
programs (Mills, 2001).
The way that health care is organized and delivered in the United States and
the limited access of uninsured persons contribute to our country’s relatively low-
ranking health indicators, despite high levels of spending. The OECD assessment
of the United States concluded that “Incomplete insurance coverage and delayed
access to care adversely affect population health outcomes and possibly economic
performance” (Docteur et al., 2003, p.41). The IOM Committee on Assuring the
Health of the Public in the 21st Century also found that the health of the Ameri-
can population is compromised by the lack of insurance for so many (IOM,
2003c). These findings are clearly consistent with the findings of the first five
reports in this project on uninsurance. The large disparities in access to care and
health outcomes experienced between the insured and the 15 percent of the total
population that is uninsured in the United States may explain, in part, the low
national rankings despite high spending.
HEALTH CARE REFORM AND HEALTH
INSURANCE REFORM
This report distinguishes between the health care delivery system and the health
insurance system. The primary focus of this project is on health insurance.7 Reform
of the health care delivery system is beyond the scope of this Committee’s work,
although other IOM Committees have identified serious problems with the sys-
tem and made recommendations for reform. This report recognizes the work of
those IOM Committees and the problems they have identified, noting the inter-
relatedness of delivery system reform with strategies to reform health insurance
(Field et al, 1993; Edmunds and Coye, 1998; Smedley and Syme, 2000; IOM,
2001b, 2003c; Corrigan et al., 2003; Smedley et al., 2002). Box 1.1 presents some
findings from key IOM reports, listed chronologically by the date of their release.
Reform of the health care delivery system requires attention to issues such as
cost control mechanisms, quality improvement, health workforce training, medi-
7In this country, neither health care nor health insurance can be characterized as a system and the
Committee uses the word “system” with some hesitation. Our previous research makes it clear that
health insurance in this country more closely resembles a hodgepodge or a patchwork quilt than an
organized system. There are numerous ad hoc arrangements that vary from state to state, often leaving
big gaps in coverage. Public coverage programs are targeted to specific subsets of the population;
regulation of private insurance varies substantially by state and is constrained by federal and state laws;
private employment-based coverage depends on the types of businesses in the area as well as economic
conditions; and no single agency or person has responsibility for pulling together the pieces to ensure
coverage for the whole population. Nonetheless, for convenience this report will use the term “health
insurance system” when it refers broadly to the issues, players, and programs mentioned above that
relate to financial access to care.
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27
INTRODUCTION
cal liability compensation systems, and implementation of information technology
systems to promote more effective care patterns and administrative procedures.
After careful examination, the IOM Committee on Quality of Health Care in
America concluded that “The American health care delivery system is in need of
fundamental change” and systemwide reform (IOM, 2001b). Changes in all these
areas could contribute to better and more efficient health care for all and to
improved opportunities for covering those without health insurance. The quality
and cost of health care certainly can be affected by the health insurance system,
and the reverse is also true. The Committee on the Consequences of Uninsurance,
however, did not undertake the scope of research necessary to recommend reform
of the entire care delivery system. It has focused on the effect of financial access to
that system through health insurance. This Committee urges that extension
of health coverage not be delayed until the whole health care delivery
system is reformed first, nor should the transformation of care delivery
be delayed until all Americans are insured. Reform of both the health care
delivery system and the insurance system should move ahead expeditiously and
consider the long-range goals of each as well as the overall evolution of health
care.
ORGANIZATION OF THIS REPORT
The next chapter of this report presents the key findings and conclusions from
all five of this Committee’s previous reports in a systematic way to show the basis
for its recommendations in this report. Because the earlier reports include all the
research supporting each finding, only the most relevant studies are cited in this
chapter.
The third chapter provides a historical overview of selected efforts during the
past century to provide comprehensive coverage to the whole population or to the
uninsured segment of it. It also examines several different approaches to extending
health insurance coverage that have been implemented over the past 15 years,
including examples from federal, state, and local programs in the public and
private sectors.
Chapter 4 presents the Committee’s guiding principles for reforming the
health insurance system. The Committee recognizes as important certain evi-
dence-based principles that describe characteristics of an effective health insurance
system, regardless of its particular structure. The principles can be used to examine
current proposals to extend health insurance coverage and to help develop new
approaches that would combine the best of existing ideas or break new ground.
In Chapter 5 the Committee sketches several prototypical approaches to
fundamental reform that vary quite dramatically in the means they propose to use
to move toward universal coverage. They are drawn from the broad range of
insurance extension options that have been put forth by various interest groups,
policy analysts, and political groups of all persuasions. The wide range of these
proposals demonstrates that there are potentially many pathways to achieving
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28 INSURING AMERICA’S HEALTH
BOX 1.1
Other Institute of Medicine Reports
1. The Committee on Assessing Health Care Reform Proposals concluded in
Assessing Health Care Reform that improved access and health status required
more than just financial access. It should include:
• broad public health and health education initiatives;
• efforts to structure services, systems, and financing to more effectively
reach special populations;
• expanded access to primary and preventive services;
• clinical and health services research; and
• programs of quality assurance (Field et al., 1993).
2. The Committee on Children, Health Insurance, and Access to Care, in Ameri-
ca’s Children, evaluated evidence about the link between coverage and access to
health care for children, with particular attention to the availability of care for unin-
sured and underserved children. It concluded that all children should have health
insurance. In addition, it found a lack of affordable health insurance products that
address the specific needs of children, including those with chronic or special
needs, and it found that inadequate efforts for outreach and enrollment procedures
and insufficient coordination efforts of public programs hinder enrollment (Ed-
munds and Coye, 1998).
3. The Committee on Capitalizing on Social Science and Behavioral Research to
Improve the Public’s Health, in Promoting Health, focused on social and behavior-
al factors, such as smoking, diet, alcohol use, sedentary life style, and accidents,
which influence the health and disease of the American population. It recommend-
ed:
• a better balance between the clinical approach to disease and social and
behavioral determinants of disease, injury, and disability; and
• interventions that link multiple levels—individual, interpersonal, institutional,
community, and policy levels (Smedley and Syme, 2000).
4. The Committee on Quality of Health Care in America, in Crossing the Quality
Chasm, recommended:
• redesigning health care processes to establish continuous healing relation-
ships, evidence-based decision making, patient safety, the reduction of waste in
the health system, and cooperation among clinicians;
• building an information infrastructure to support care delivery; and
fundamental reform. To show how the principles can be used, they are applied to
the prototypes we present so that the strengths and limitations of each approach
are revealed.
In the sixth and last chapter, the Committee presents its recommendations
concerning health insurance. They are based on the findings in Chapter 3 con-
cerning coverage extensions and those enumerated in Chapter 2, and on the
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29
INTRODUCTION
• structuring payment systems to promote quality care, which should be safe,
effective, patient-centered, timely, efficient, and equitable (IOM, 2001b).
5. The Committee on Rapid Advance Demonstration Projects: Health Care Fi-
nance and Delivery Systems, in Fostering Rapid Advances in Health Care, high-
lighted problems of the health care delivery system for coverage of the uninsured,
chronic care, primary care, information and communications technology infrastruc-
ture, and medical liability that could be ameliorated by the establishment of multi-
ple demonstrations to test reform options. It included recommendations that the
federal government commit funds for 10 years for demonstrations in three to five
states to extend stable, affordable coverage through the use of tax credits, or
eligibility expansions of Medicaid and SCHIP, or a combination approach (Corri-
gan et al., 2003).
6. The Committee on Understanding and Eliminating Racial and Ethnic Disparities
in Health Care, in Unequal Treatment, recommended a comprehensive, multilevel
strategy to eliminate disparities, including:
• strengthening of patient-provider relationships in publicly funded health
plans;
• using clinical, evidence-based guidelines to promote consistency and equi-
ty of care;
• providing economic incentives for physician practices to reduce communi-
cations barriers;
• using the payment systems to ensure an adequate supply of services to
minority patients; and
• employing multidisciplinary treatment and preventive care teams (Smedley
et al., 2002).
7. The Committee on Assuring the Health of the Public in the 21st Century, in The
Future of Public Health in the 21st Century, described numerous public health
problems, including:
• an inadequate public health infrastructure;
• lack of knowledge about the determinants of population health; and
• the mismatch between health care spending and health outcomes.
This Committee concluded that adequate population health cannot be achieved if
comprehensive and affordable health care is not available to everyone in the Unit-
ed States (IOM, 2003c).
findings and conclusions in the Committee’s previous five reports. The recom-
mendations also articulate fundamental shared values across the diverse Commit-
tee membership. The Committee’s intention is that this report, and indeed the
whole project, should both encourage and inform public debates about the unin-
sured and make those debates accessible to a wide range of Americans.
Representative terms from entire chapter:
insurance coverage
