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A A Conceptual Framework for Evaluating the Consequences of Uninsurance: A Cascade of Effects The Committeeâs general conceptual framework for evaluating the conse- quences of uninsurance is depicted in Figure A.1. This overall conceptualization was the basis of the Committeeâs model for this report on health outcomes, as depicted in Figure 1.1. Both versions of the conceptual framework are based upon a widely employed behavioral model of access to health services that explicates the processes of health care and health-related outcomes for individuals (Andersen and Davidson, 2001). Figure A.1 groups variables into the categories of resources that promote or enable one to obtain health care; personal or community characteristics that favor or predispose action to obtain health care; and needs for health care, as articulated by those in need, determined by health care providers, or identified by researchers and decision makers. Judgments about how susceptible a variable is to change are implicit in the categories of resources, characteristics, and needs. Resources are considered, at least theoretically, as more open to change. Characteristics are less manipulable and needs comprise a heterogeneous grouping, with some needs more changeable than others. The overall model begins with the primarily economic determinants of health insurance status in Panel 1 of the figure. Panel 2 displays, in compressed form, the resources, characteristics, and needs of both individuals and communities that affect the process of obtaining access to health care. Panel 3 displays the conse- quences of uninsurance that are being examined in the Committeeâs various reports. These effects cascade from the smallest unit of analysis, the individual, to increasingly larger units, first that of the family and then the community. Panel 2 and one element of Panel 3, âHealth Outcomes for Individuals,â represent the 105
106 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE focus of Care Without Coverage. These sections of the overall framework are expanded upon in Figure 1.1. The arrows and arrangement of the boxes in Figure A.1 indicate hypothesized causal and temporal relationships. As reflected by the figure, the relationships among factors that determine health insurance status, access to health care, and health, social, and economic outcomes are dynamic with multiple feedbacks. For example, as discussed earlier in this report, health status is both an outcome variable in this model and an important determinant of health insurance status, the individual and family-level resource that is the independent variable of interest in this report.
PANEL 1 PANEL 2 PANEL 3 Determinants of Coverage Process of Obtaining Access to Health Care Consequences of Uninsurance Individual and Family Level Individual and Family Level â¢ Eligibility (either for self or dependents) Resources: financial means, â¢ Cost to enroll or maintain how health policies and health services organization apply to Health Care (including employer â¢ Personal health subsidy) the individual and to the family practices â¢ Administrative process of Characteristics: demographic, â¢ Utilization of health enrolling or maintaining social, economic, cultural, and services coverage geographic â¢ Processes of services Health Outcomes for â¢ Knowledge of eligibility delivery Need: health status perceived Individuals Need: decision to enroll or to by the individual or family â¢ Needs maintain member and as evaluated by â¢ Consumer satisfaction others Community Level Effects on Families Community Level â¢ Health outcomes â¢ Availability of employment- Resources: health policies, â¢ Childhood development based, public, and private how services are organized, â¢ Economic effects coverage how services are financed Characteristics: demographic, social, economic, cultural, and geographic Effects on Communities Needs: as identified by public â¢ Economic effects or population health indicators â¢ Population health measures â¢ Health care institutions FIGURE A.1 A conceptual framework for evaluating the consequences of uninsurance. NOTE: Italics indicate terms that include direct measures of health insurance coverage. Reprinted from Coverage Matters: Insurance and Health Care (IOM, 2001a). 107