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Executive Summary
Pages 1-14

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From page 1...
... In A Shared Destiny: Community Effects of Uninsurance, the Committee finds that the adverse effects of uninsurance that accrue to uninsured individuals and families in a community, as well as the financial strain placed on the community's health care system, have important spillover effects on community health care institutions and providers. In communities with higher uninsured rates, access to health services and consequent benefits are compromised for persons other than those who lack coverage.
From page 2...
... The Committee hypothesizes a series of spillover effects of uninsurance, effects that extend beyond the adverse health and financial impacts on uninsured individuals and families documented in Coverage Matters, Care Without Coverage, and Health Insurance Is a Family Matter. A Shared Destiny establishes an analytic framework for thinking about the causal pathways hypothesized to lead to the more widespread impacts of uninsurance, assesses the limited empirical evidence that exists about community effects, and proposes a research agenda to better demonstrate the presence or absence of these effects.
From page 3...
... Findings are often based on crosssectional comparisons among states, metropolitan areas, and rural counties with differing uninsured rates as well as on illustrative case studies and other qualitative evidence. Because of the limited data with which to characterize and monitor community effects and the challenges of distinguishing effects that stem from the extent of uninsurance from effects of related community-level characteristics (e.g., income structure)
From page 4...
... CONTEXT FOR COMMUNITY EFFECTS Financing the Delivery of Health Services Over the past 25 years, federal and state policies to control health care costs and an increasingly competitive private market for health care services and coverage have constrained reimbursement rates for care, eroding previous levels of subsidy for uncompensated care costs associated with care delivered to uninsured persons. The effects of this erosion have been felt more strongly in communities with large or growing uninsured populations and by providers (e.g., public hospitals)
From page 5...
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From page 6...
... Local governments operate public clinics and hospitals and frequently provide personal health care services directly or through contracts to uninsured residents. Physicians in solo and group practices, practicing in clinics and in hospital settings, provide an estimated $5.1 billion in free or reduced-price charity care to uninsured patients (Hadley and Holahan, 2003~.
From page 7...
... The Committee finds that low- to moderate-income) and uninsured residents have worse access to health care in communities with high uninsured rates than they do in communities with relatively low rates, although the causal influence of the local uninsured rate on access is unclear.
From page 8...
... In turn this may reduce access to care and the quality of care received, regardless of insurance status. Emergency Medical Services and Trauma Care Emergency departments and trauma centers are key examples of how market pressures and public policies interact in ways that create incentives for hospitals to reduce their exposure to financial losses associated with serving uninsured patients.
From page 9...
... For private AHCs, particularly those that are not located in neighborhoods with high uninsured rates (e.g., central city) , one strategic response of hospitals to such cost pressures has been to eliminate specialty services with relatively poor rates of reimbursement, such as burn units, trauma care, pediatric and neonatal intensive care, emergency psychiatric inpatient services, and HIV/AIDS (Gaskin, 1999; Commonwealth Fund, 2001~.
From page 10...
... Local uninsured rates and the burden of uncompensated care costs to local and state government have contributed to the conversions of some large urban public hospitals (Bovbjerg et al., 2000b)
From page 11...
... Increased public sector support for or reimbursement of providers for uncompensated care delivered to uninsured persons requires that additional public revenues be raised, resources be diverted from other public purposes, or budget cuts be imposed, adversely affecting all members of the community and potentially increasing the number of uninsured persons. State and local governments' capacity to finance health care for uninsured persons tends to be weakest at times when the demand for such care is likely to be highest, namely, during economic recessions.
From page 12...
... Area-wide rates of potentially avoidable hospitalizations serve not only as indicators of access to care but also as measures of the acuity of illness experienced within a population and the efficiency with which health care is provided overall. Uninsured patients are more likely to experience avoidable hospitalizations than are privately insured patients when measured as the proportion of all hospitalizations, and studies consistently report substantially higher rates of these hospitalizations in lower-income areas (Billings et al., 1993, 1996; Millman, 1993; Bindman
From page 13...
... In many parts of the country, health department officials have expressed their perceptions of being caught between the increasing demand and need for care of growing numbers of uninsured persons and diminished budgets (IOM, 1988, forthcoming 2003; Lewin and Altman, 2000~. Efforts to meet the personal health care needs of uninsured residents place considerable demands upon local health department resources and may divert funds from population-based public health activities.
From page 14...
... There is much that is not understood about the relationships between health services delivery and financing mechanisms and even less about how the current structure and performance of the American health care enterprise affect communities' economies and the quality of social and political life in this country. Because policy makers and researchers have not asked or examined these questions through comprehensive and systematic research and analysis, there is a limited body of evidence of mixed quality on community effects.


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