Insuring America's Health Principles and Recommendations (2004) / Chapter Skim
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2. Lessons From Previous Reports
2. Lessons From Previous Reports
Pages 30-65
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From page 30... ...
· The first section examines the scope of uninsurance and current coverage patterns by identifying how many people lack insurance, their basic economic and demographic characteristics, the ways people obtain and lose coverage, current barriers to coverage, and the potential for growth in the uninsured population in the near future. · The second section reports findings on how the lack of coverage affects access to and timely use of appropriate health care services, and adverse health outcomes for children and adults without health insurance.
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From page 31... ...
During 2002, the Current Population Survey (CPS) , conducted annually by the Census Bureau, showed that approximately 43.6 million people in the United States reported being without health insurance coverage for the entire year (Mills and Bhandari, 2003~.3 Some analysts believe that the CPS estimate is closer to a Italicized terms are defined in the glossary (Appendix B)
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From page 32... ...
The CPS, however, provides the most consistent data on health insurance coverage over time and is the most widely used source of information on coverage. The Committee has used this historical series as its basic data set throughout the study for these reasons.
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Therefore, adding together employment-based, individual, and public insurance coverage rates yield more than the 83.5 percent of the U.S. population with some form of coverage during the year.
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When children turn 19 years old, generally the age limit for coverage as a dependent, they must purchase a separate, individual health insurance policy unless they are still in school or become uninsured. While teenagers or those graduating from college may be ready to go to work, they are less likely than their older coworkers to find jobs that include health benefits or to earn enough to purchase insurance independently (Quinn et al., 2000; IOM, 2001a; Collins et al., 2003~.
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From page 35... ...
Although two-thirds of all people without coverage have incomes below 200 percent of FPL, some individuals and families with relatively low incomes do take up employer offers of coverage and some relatively high-income individuals and families forgo coverage (IOM, 2001a; Bundorf and Pauly, 2002~. Nonetheless, unaffordability is the top reason uninsured adults give for why they are uninsured (Hoffman and Schlobohm, 2000)
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36 .~^ Q IL r A E /~ of .
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Is the Uninsured Population Growing7 Over the past 25 years, growth in the number of uninsured Americans has exceeded the rate of growth in the population under 65 years, despite an increasingly tight labor market that expanded employment-based coverage and yielded tax revenues to expand public coverage programs (IOM, 2001a)
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From page 38... ...
When the uninsured receive care in hospitals, their care management, even for trauma or premature birth, differs from that of insured patients, with uninsured patients receiving less intensive services (Hadley, 2002; IOM, 2002b)
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39 c' o =5 i~ s i~ I s I o~ cn C' .c ._ g O U
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They receive, on average, fewer preventive health services, less regular care for management of chronic diseases, and poorer care in the hospital. Lesser Use and Lack of Preventive Health Services for Children and Adults Uninsured children use medical and dental services less frequently and are less likely to get their prescriptions filled than insured children, even after taking into account differences in family income, race and ethnicity, and health status (Newacheck et al., 1998b; McCormick et al., 2001; IOM, 2002b)
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From page 41... ...
Uninsured adults are also less likely to receive preventive health services such as mammograms, clinical breast exams, Pap tests, and colorectal screening (Powell-Griper et al., 1999; Ayanian et al., 2000; Breen et al., 2001~. Less Access to a Regular Source of Care Maintaining an ongoing relationship with a specific provider who keeps records, manages care, and is available for consultation between visits is a key to high-quality care (O'Connor et al., 1998; IOM, 2001b)
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From page 42... ...
. ~ Uninsured patients with acute myocardial infarction who met expert panel criteria for revascularization were less likely to be transferred to a hospital that performed this procedure: 91 percent of Medicare patients, 82 percent of privately insured patients, 75 percent of Medicaid patients, and just 53 percent of uninsured patients received this indicated surgery (Leape et al., 1999~.
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From page 43... ...
For example, uninsured adults with diabetes are less likely to receive regular foot or dilated eye exams that are important in the prevention of foot ulcers and blindness (Beckles et al., 1998~. Uninsured patients with end-stage renal disease began dialysis at a later stage of their disease and with poorer clinical measures (e.g., more likely to be anemic)
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From page 44... ...
Diminished Health-Related Quality of Life Adults in late middle age are more likely to experience declines in function and health status if they lack or lose health insurance coverage (Baker et al., 2001~. Changes in health status might include worsening control of blood pressure, decreased ability to walk or climb stairs, or decline of general self-perceived wellness and functioning.
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From page 45... ...
, uninsured adults have consistently worse clinical outcomes than do insured patients. For example, uncontrolled blood glucose levels, which put diabetics at increased risk of hospitalization and additional complications (e.g., heart and kidney disease)
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From page 46... ...
In one statewide study of hospitalized car crash victims, uninsured patients were found to receive less care and had a 37 percent higher mortality rate than did privately insured patients (Doyle, 2001~. Having health insurance of any kind has been found to reduce mortality in HIV-infected adults by 71 to 85 percent over a 6-month period, with the greater reduction found for a more recent time period during which effective drug therapies were in more widespread use (Goldman et al., 2001~.
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From page 47... ...
Adults with intermittent or no health insurance coverage experience greater declines in health status over time than do adults with continuous coverage. Being uninsured for relatively short periods (1 to 4 years)
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From page 48... ...
Uninsurance can have effects that extend beyond uninsured persons and their families to community health care institutions, providers, and even the insured population. For example, a hospital outpatient department that serves an increasing number of uninsured patients without commensurate increases in financial support for uncompensated care may discontinue costly services, affecting access for everyone in the community.
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From page 49... ...
Even in the healthiest of families, if one member has an accident or a costly hospital stay, the resulting medical bills can affect the economic stability of the whole family. Uninsured patients are likely to be charged more than those with insurance because they do not have a large insurer to negotiate a discount (Miller, 2003~.
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From page 50... ...
Supports for care to uninsured patients come from federal, state, and local programs and grants; from organized philanthropy; and from the donated services and uncompensated care absorbed by providers. There is no uniform public responsibility to subsidize or pay for the care delivered to uninsured persons.
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From page 51... ...
The Committee's exploratory analyses of uninsurance effects on the availability of hospital services and hospital financial margins could not capture and do not reflect differences in the strategic behavior of hospitals in response to uninsured populations, differences that affect the relative shares of uninsured patients at different facilities in the same community. Not all hospitals, even those in communities with high uninsurance rates, serve a high or growing number of uninsured patients, and hospitals that do serve large numbers have varied experiences, depending on corporate resources and the public supports and subsidies available to them (Gaskin, 1999; Catholic Hospital Association, 2002~.
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From page 52... ...
Reduced Availability of Hospital-Based Care Many hospitals operate with financial constraints that leave little room for cross-subsidizing the costs of uninsured patients. In urban areas the adverse financial effects on hospitals are more likely to have an impact on low-income residents (insured and uninsured)
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From page 53... ...
A study of primary care providers in 20 community health centers in 10 states revealed difficulties for practitioners in high uninsured-rate areas in obtaining specialty referrals for all of their patients, not just the uninsured (Fairbrother et al., 2002~. Urban safety-net hospitals and academic health centers also have been affected by increased numbers of uninsured patients.
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From page 54... ...
Alternately, cutting local support can result in more uninsured in the area and reduced service availability for all community residents. During economic downturns, when growth in uninsured populations increases the demand for uncompensated care, state and local reductions in health care spending may reduce the flow of federal dollars (such as Medicaid matching funds)
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From page 55... ...
Does the Size of the Uninsured Population Affect the Physical Health of ~ Community? The sheer number of uninsured persons in an area adds to the community burden of disease and disability because uninsured persons are more likely than their privately insured counterparts to have poorer health, to be at greater risk for some communicable diseases, and to draw on public health resources (IOM, 2003a)
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From page 56... ...
We also spend substantial public resources for direct health care services for those who lack coverage, yet the uninsured continue to have worse health outcomes. By estimating the health services costs now incurred by the tens of millions of uninsured Americans and some of the incremental costs and benefits across society of extending coverage, we provide an economic baseline against which health insurance reform strategies can be measured.
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From page 57... ...
What Are the Costs of Uncompensated Care Used by the Uninsured? The best estimate of the value of uncompensated health care services provided to persons who lack health insurance for some or all of a year is roughly $35 billion annually, about 2.8 percent of total national spending for personal health care services (Hadley and Holahan, 2003b)
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From page 58... ...
Conversely, it is an estimate of the economic value of the better health outcomes that could be realized if the entire population had continuous health insurance coverage. Based on this analysis, the Committee estimates that, in the aggregate, the diminished health and shorter life spans of Americans who lack health insurance are worth between $65 and $130 billion for each year spent without health insurance (IOM, 2003b)
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From page 59... ...
Closing the access gap for the uninsured would mean increased utilization of services. As described earlier, the uninsured population is less likely to use any kind of health service within a given year, and on average the uninsured person uses one-half to two-thirds of the volume and value of services that the privately insured person uses (IOM, 2003b)
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In its previous report, the Committee assessed the individual health and longevity benefits of continuous health insurance coverage for the uninsured population relative to the costs of providing this population with the kind and amount of health care used by comparable insured populations (IOM, 2003b)
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. Even people who receive public insurance coverage may be limited in their job choices because of means testing for public benefits (IOM, 2002b)
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Lower income parents are more likely to lack coverage than are their children because public programs provide coverage for children up to higher family income levels than they do for adults. Public programs also tend to have more generous family income limits for younger children than older ones, with the result that uninsurance rates are higher among older children (Hoffman and Wang, 2003~.
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From page 63... ...
Receipt of appropriate care has been associated with improved functional outcomes for depression and anxiety disorders (Sturm and Wells, 1995; Wang et al., 2000~. Studies also show that uninsured adults with severe mental illnesses receive less appropriate care or medications and experience delays in receiving services until they gain insurance coverage (Rabinowitz et al., 1998, 2001; McAlpine and Mechanic, 2000~.
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From page 64... ...
Local communities with disproportionate populations without coverage are unable to shoulder the burden alone. · Lack of coverage affects access to care across a spectrum of health care services.
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From page 65... ...
· Federal or shared federal-state health insurance programs distribute the burden of financing health care more broadly among taxpayers than the costs of uncompensated care, which fall more heavily on local communities with concentrations of uninsured residents. Insurance-based financing could alleviate some of the financial demands on communities disproportionately affected by uninsurance.
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