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1 Introduction
Pages 15-33

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From page 15...
... That perspective is especially important for this report, in which the Committee develops a series of hypotheses about community effects, assesses the evidence pertaining to these hypotheses, and proposes a research agenda to better document and understand those effects that cannot now be quantified or are poorly documented. The towns, cities, and rural areas of the United States are home to a substantial number of uninsured persons.
From page 16...
... . Uninsured rates show less of a direct relationship with population size; the border state of New Mexico, for example, is home to just 1 percent of the uninsured population nationally (an estimated 400,000 uninsured persons)
From page 17...
... Care Without Coverage and Health Insurance Is a Family Matter have documented the lesser effectiveness of health care received by uninsured persons, notably for those with chronic conditions, which are a major priority for quality improvement efforts. Yet uninsured populations undermine health systems' quality improvement for reasons beyond the kind of care that uninsured persons themselves receive.
From page 18...
... Meeting this first objective engaged a second, more ambitious task, namely, to articulate a new analytic framework that traces plausible causal pathways from uninsurance to a number of effects on population groups or communities. This conceptual work allows the Committee to identify probable steps involved in moving from a hypothesized causal factor, such as a metropolitan area's higher-than-average uninsured rate, to effects such as changes in the area's health services capacity.
From page 19...
... The units in which data about health care utilization, health status, and health resources are collected and reported shape the Committee's approach to assessing community effects. In practical terms, the particular unit of analysis specified as a community also reflects issues of data availability.
From page 20...
... The next section discusses research methods used in this report, and the section following that sets out the working hypotheses about specific community effects that guided the Committee's investigation. The Committee's analysis in each of its reports has been based on a general framework presented in Coverage Matters.2 This framework links individual and collective factors, including health status, financial resources, and health services capacity to the use of health care services and ultimately to a variety of healthrelated and financial outcomes.
From page 21...
... To the extent that uninsured individuals and their families obtain health services, the uncompensated care burden on local providers and facilities (as depicted in the box labeled "lower revenues for providers and facilities") serves as another pathway to community effects because it leads to (1)
From page 23...
... Figure 1.3 presents two graphs for comparison to Illustrate the phenomenon of a community-level effect of the local uninsured rate on individuals' access to care, over and above the effect of personal health insurance status. This pair of diagrams simplifies what is a much more complicated set of relationships among multiple individual and community factors that affect measures of access such as a physician visit within the year (e.g., those shown in Figure 1.2)
From page 25...
... Graph B represents the case in which there is a community effect on the outcome variable because, as the local uninsured rate increases, the percentage of both the Insured and the Uninsured with a physician visit within a year decreases, indicated by the downward-sloping line. METHODS Despite the acknowledged importance of community effects of uninsurance, they have rarely been studied directly.
From page 26...
... The variation in state and local uninsured rates offers one of the best opportunities to detect the effects of uninsurance on community health care services, institutions, and population health. The Committee attempts to identify the nature, size, and significance of these community effects by comparing geographically defined communities in which differing proportions of the population lack health insurance, focusing in particular on areas (municipalities, metropolitan areas, rural counties, states, and regions)
From page 27...
... Availability of Health Care Services in the Community How does uninsurance within a community affect the availability of local health services? As depicted in Figure 1.1, the Committee hypothesizes that when faced with uninsured persons who need care, providers such as physician practices, hospitals, clinics, health departments, and the state and local governments that fund and operate facilities take measures to increase revenues from other sources and to contain their costs in order to balance the effects of uncompensated care.
From page 28...
... Does a heavy uninsured patient load lead hospitals to cut back on emergency and trauma services? The Committee hypothesizes that relatively high or increasing local uninsured rates could result in greater emergency department (ED)
From page 29...
... In the 1980s, for-profit hospitals were less likely to offer unprofitable services viewed as community benefits, such as emergency and trauma services, and certain kinds of specialty care, such as burn units or pediatric intensive care, that are disproportionately used by uninsured patients and are also less likely to be reimbursed fully by insurers (Gray, 1986; Needleman, 1999~. Similar strains on hospitals that disproportionately serve uninsured patients may adversely affect access to care for all community residents, since these hospitals, which are often public facilities or academic health centers, are more likely than other facilities to provide health professions training and specialty services (burn, pediatric neonatal intensive care, trauma, psychiatry, AIDS care)
From page 30...
... As depicted in Figure 1.1, the Committee hypothesizes that communities with relatively high uninsured rates have worse overall population health than those with relatively low uninsured rates. Further, it hypothesizes that these differences can be attributed not only to the worse health status of uninsured persons within the population but also to spillover effects of uninsured populations on those with health insurance.
From page 31...
... For example, the inverse relationship between the funding of public health activities in relation to state and local health departments' provision of personal health services has been documented over several decades (IOM, 1988, forthcoming 2003; Fairbrother et al., 2000) , but the extent of the provision of uncompensated care to medically indigent residents has not necessarily been analyzed as a function of local uninsured rates.
From page 32...
... It assesses the evidence that exists and proposes the research that would be needed to determine the existence and magnitude of other population effects. In Chapter 2, the Committee describes the context for its exploration of potential community effects in the history and present functioning of health care system financing and care for uninsured persons.
From page 33...
... INTRODUCTION 33 analyses of hospital services and financial margins as affected by local uninsured rates are presented here. Chapters 4 and 5 discuss the hypothesized mechanisms for economic impacts on communities and explore likely effects on the health of the community.


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