Consequences of Uninsurance
Note: In the 2009 report America's Uninsured Crisis: Consequences for Health and Health Care, the IOM provides an updated review of the research evidence on three questions: (1) What are the dynamics driving downward trends in health insurance coverage? (2) Is being uninsured harmful to the health of children and adults? (3) Are insured people affected by high rates of uninsurance in their communities?
Over 43 million U.S. residents, nearly one in six Americans under the age of 65, lack health coverage. With support from the Robert Wood Johnson Foundation, the Institute of Medicine completed a three-year, comprehensive study of Uninsurance and its implications for uninsured individuals, their families, their communities, and the nation. The study had two overarching objectives: to assess and consolidate evidence about the health, economic and social consequences of uninsurance for person without health insurance and their families, health care systems and institutions, and communities and to raise awareness and improve understanding by both the general public policy makers of the magnitude and nature of the consequences of lacking health insurance. In three years, the 16-member Committee issued six reports between September 2001 and January 2004. Six subcommittees drafted these reports and then submitted them to the Steering Committee for review and issuance.
The Subcommittee on the Status of the Uninsured drafted the report, Coverage Matters: Insurance and Health Care. The report disaggregates the uninsured into subpopulations that have distinctive policy-relevant characteristics such as age, gender, ethnicity, income and employment status, health conditions, and health status. In this document, the subcommittee examined any distinctions between the long-term and intermittently uninsured. The geographic concentration or dispersion of the uninsured was studied, and the implications for communities with relatively large uninsured populations outlined. This report served as an introduction to subsequent reports issued by the steering committee, each of focused in depth on a particular type of impact or population.
The Subcommittee on the Health Outcomes of the Uninsured drafted the report, Care Without Coverage: Too Little, Too Late, that evaluates and synthesizes clinical, epidemiological and survey research evidence on the effects of having or lacking health insurance on a variety of personal health-related outcomes. These outcomes include measures of access to health services, the nature of the care received, general and disease-specific measures of health status, including morbidity and mortality rates, and disabilities and functional limitations. This subcommittee developed criteria for assessing the quality of evidence for the effects of health insurance status on individual health outcomes and work with the general conceptual model for assessing impacts of health insurance status that the parent Committee on the Consequences of Uninsurance has developed. The subcommittee synthesized and evaluated studies of general measures of health, such as self-reported health status and mortality, as well as examined evidence of the effects of health insurance coverage or uninsurance on access to care, process of care and outcomes for specific diseases. The impact of health insurance or the lack of it on access to and the quality and timeliness of preventive, acute, emergent and chronic care services was also examined and addressed in the subcommittee's report.
The Subcommittee on the Family Impacts of Lacking Health Insurance drafted the report, Health Insurance is a Family Matter. This report examined and documented the effects on the family, particularly on dependent children, when one or more members lack health insurance. The effects included measures of family members' health and of children's developmental status, access to and use of health services, financial burdens and family psycho-social stress. Taking the family as the primary unit of analysis, the report identified patterns of health insurance coverage within families in order to discern interrelationships between parents' insurance and health status with their children's health insurance status, use of health services, and health. Health insurance status also was examined in relation to the family's out-of-pocket costs for medical care and financial well being and stability.
The Subcommittee on Community Effects of Uninsured Populations drafted the report, A Shared Destiny: Community Effects of Uninsurance. This report identified the nature and magnitude of effects on geographically defined communities where a portion of the population lacks health insurance. The report examined the geographic distribution of the uninsured and focused on communities (municipalities, metropolitan and rural areas, and states) that have large uninsured populations. The interactions of community uninsurance rates with economic and industrial characteristics, public health and welfare program policies, ethnic composition, and health care professional and institutional resources were explored and documented.
The Subcommittee on Societal Costs of Uninsured Populations prepared the report, Hidden Costs, Value Lost: Uninsurance in America. This report identified and estimated various economic costs incurred by society resulting from maintaining a population of roughly 40 million Americans without health insurance. The subcommittee examined financial impacts on individuals, families, and the national economy, using information developed by the main committee in its first four reports. The subcommittee for this report developed a conceptual framework to help identify and estimate the general magnitude of societal economic costs incurred as a result of the incomplete coverage of the U.S. population by health insurance. The subcommittee investigated and reported on the direct costs of providing health care to the uninsured, increased costs resulting from the inefficient use of health services, and the indirect costs of preventable disability and lost productivity among uninsured persons, to the extent that reliable data support such findings. The report explored who bears the costs due to uninsurance, including out-of-pocket payments by the uninsured and their families, uncompensated care by health care providers and institutions, taxes and tax expenditures by all levels of government, higher health insurance premiums to support cost shifting, philanthropic support, indirect costs of disability and reduced productivity on business operations.
The Subcommittee on Strategies and Models for Providing Health Insurance prepared a report that analyzes insurance-based models, policies and programs designed to provide coverage and eliminate the negative consequences of having a large uninsured population in the United States. The main committee's previous reports provided evidence-based findings of the key negative consequences to be eliminated. The Subcommittee examined selected state, local, federal, and private-sector policies and programs that have attempted to mitigate the adverse impacts of lack of health insurance on individuals, families, health care providers, and communities by expanding insurance coverage. The Subcommittee identified promising prototypes, as well as innovative approaches to the problem of uninsurance. A goal of the report was to recommend policy criteria that can be used to assess the merits of various reform strategies.
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