A Shared Destiny Community Effects of Uninsurance (2003) / Chapter Skim
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6 Summary: Conclusions and Research Agenda
6 Summary: Conclusions and Research Agenda
Pages 162-174
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From page 164... ...
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 an participate.
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From page 165... ...
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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From page 166... ...
, 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.
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From page 167... ...
A longitudinal analysis of changes in paymentto-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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From page 168... ...
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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From page 169... ...
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.
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From page 170... ...
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.
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From page 171... ...
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.
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From page 172... ...
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.
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From page 173... ...
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.
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From page 174... ...
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~.
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