In this analysis, Pagán and colleagues found a significant negative relationship between higher rates of uninsurance and physicians’ career satisfaction. They found that high uninsurance was negatively correlated with physicians’ perceptions about quality of care. Higher community-level uninsurance rates were negatively related to the beliefs among physicians that they were able to make clinical decisions in the best interest of their patient without losing income or that they had sufficient communication with their patients’ specialists. Furthermore, patients in communities with higher uninsurance rates were less likely to report trusting their physicians. In-depth site visits by HSC researchers have underscored these findings (Hurley et al., 2005; Lesser et al., 2005).

In a 2008 study, Pagán and colleagues used a multilevel logistic regression model to assess whether higher community-level rates of uninsurance affected mammography screening among insured women age 40 to 69, including not only privately insured women, but also women with Medicare or other sources of coverage (Pagán et al., 2008). They found that higher community-level uninsurance rates were associated with a significant decline in the insured women’s access to care.


Growing economic disparities between U.S. communities with respect to geographic distribution of health care services, including new diagnostic and therapeutic techniques and technology, have been well documented by HSC. As discussed below, the following widespread problems in local health care delivery not necessarily attributable to uninsurance are sensitive to financial pressures and may be exacerbated by higher community-level uninsurance rates:

  • Health care providers and capital investment tend to locate in well-insured areas (and away from high uninsurance communities). It is common for hospitals to focus major investments in more affluent locations with well-insured populations.

  • Physicians and other health care providers are drawn to newer facilities with the most up-to-date technologies. This phenomenon makes it especially challenging for financially stressed hospitals in communities with high uninsurance rates to recruit on-call specialists for emergencies.

  • A range of hospital-based emergency care problems—including limits on inpatient bed capacity, outpatient emergency services, and timeliness of trauma care—have serious implications for the quality and timeliness of care for insured as well as uninsured patients.

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