Handout - SGIMimpak.sgim.org/userfiles/file/AMHandouts/AM03Handouts/PW09.pdfHandout SGIM 26th Annual Meeting Wednesday Half Day Precourse PW09 ... Department of Clinical Bioethics

1

Handout SGIM 26th Annual Meeting

Wednesday Half Day Precourse PW09

Marion Danis, MD

The Uninsured: Preparing Internists to Contribute to Change

Wednesday, April 30, 2003 1:00 - 4:30 PM

Vancouver Convention and Exhibition Centre Room 11

2

Overview The United States continues to have a large number of uninsured individuals in its population. The Institute of Medicine is currently preparing a series of reports on the uninsured and its consequences. The Robert Wood Johnson Foundation is actively addressing the problem through various efforts including a technical assistance program entitled Volunteers in Health Care. This pre-course will offer the opportunity to learn about the uninsured and consider how internists can participate in solutions. We will present 1) the latest information on the uninsured from the IOM 2) prospects for policy change 3) efforts to meet the needs of the uninsured through volunteerism and 4) strategies for teaching trainees about care for underserved populations. Educational objectives: 1. To understand the consequences of the lack of universal health insurance for individuals, families, and communities. 2. To be aware of prospects for expanding insurance coverage 3. To become knowledgeable about strategies for caring for the uninsured 4. To become skilled at teaching trainees about caring for the uninsured and other disadvantaged populations

Schedule: 1:00 - 1:10 Introduction - Dr Marion Danis 1:10 - 1:40 Coverage Matters - Dr Wilhelmine Miller 1:40 -2:10 Consequences of Uninsurance for Patients, Families, and Communities Dr John Ayanian 2:10 - 2:30 Prospects for Expanding Coverage - Dr Arlene Bierman 2:30 - 3:00 Break 3:00 - 3:20 Volunteering Care for the Uninsured - Dr Denman Scott 3:20 - 3:40 Teaching about Care of Underserved Populations - Dr James Reuler 3:40 - 4:30 Group discussion

3

Faculty

John Ayanian M.D., M.P.P. Associate Professor of Medicine and Health Care Policy Harvard Medical School

Arlene Bierman, MD., MS Senior Research Physician Agency for Healthcare Research and Quality

Marion Danis, M.D. Head, Section on Ethics and Health Policy Department of Clinical Bioethics National Institutes of Health

Wilhelmine Miller, Ph.D. Project Co-director Committee on Uninsurance Institute of Medicine

James B. Reuler, M.D. Chief, Division of General Medicine Portland Veterans Affairs Medical Center

H. Scott Denman, M.D. Director Volunteers in Health Care

4

Excerpts from the Executive Summaries of the Reports of the Institute of Medicine Committee on the Consequences of Uninsurance1

Coverage Matters

Health care increasingly affects our personal lives and the national economy as its benefits to our health, longevity and quality of life grow. Over the past quarter of a century, clinical medicine has become more sophisticated, technological advances have become more commonplace, and the range of health care interventions has been much expanded. Yet over the same period, the numbers of persons without health insurance to help them purchase health services has increased by about one million per year―faster than the rate of overall population growth. The total number of uninsured Americans grew even during years of economic prosperity (Holahan and Kim, 2000).

In this first report, the Committee provides an overview of health insurance in America, looking specifically at how coverage is gained and lost, why so many people have none, and who lacks insurance, as individuals and as members of groups within the general population. In addition, this report introduces the Committee’s analytic plan for the entire series of reports and presents the conceptual framework that will guide the Committee’s evaluations of specific impacts of uninsurance in its subsequent reports.

RELATING HEALTH INSURANCE TO ACCESS TO HEALTH SERVICES

Health insurance serves multiple constituencies and distinct purposes. For

individuals and families, insurance coverage is one means to promote health and access to care and to protect against exceptional health care costs. Insurance pools the risks and resources of a group of people so that each is protected from financially disruptive medical expenses and each may plan ahead or budget for health care. In contrast with many other insurance products, such as automobile or homeowner’s insurance, health insurance has evolved as a mechanism for financing routine health care expenses and encouraging the use of preventive services, in addition to protecting against uncommon events and expenses. As the scope and effectiveness of health care interventions have grown, so have consumers’ expectations for coverage and benefits through health insurance.

Other constituencies also have a stake in our mechanisms for financing health care. Providers of health care benefit from insurance as a reliable source of payment. Employers offer health benefits to attract and retain workers and to maintain a productive workforce. Governments provide health insurance to special populations as a means to secure health care for them.

Health insurance is neither necessary nor sufficient to obtain health care, yet coverage remains one of the most important ways to obtain access to health services. The level of out-of-pocket costs for care has been demonstrated to have substantial effects on the use of health services (Newhouse et al., 1993; Zweifel and Manning, 2000). Uninsured 1 Coverage Matters: Insurance and Health Care (2001), Care Without Coverage: Too Little, Too Late (2002); Health Insurance Is a Family Matter (2002), and A Shared Destiny: Community Effects of Uninsurance (2003). Copyright by the National Academy of Sciences. All rights reserved.

5

persons may be charged more than patients with coverage, who benefit from discounts negotiated by their insurer (Wielawski, 2000; Kolata, 2001). In addition, uninsured people face 100 percent cost sharing, although some providers are willing to absorb part of the cost for some of their patients some of the time by negotiating a reduced rate. Even though many publicly supported institutions offer free care or reduced fees and many other providers offer some charity care, people without insurance generally have reduced access to care (Cunningham and Kemper 1998; Cunningham and Whitmore, 1998).

Evidence accumulated over the past several decades of health services research has consistently found that persons without insurance are less likely to have any physician visit within a year, have fewer visits annually, and are less likely to have a regular source of care (Andersen and Aday, 1978; Aday et al., 1984; Hafner-Eaton, 1993; Weissman and Epstein, 1994; Newacheck et al., 1998; Zweifel and Manning, 2000). Children without insurance are more than three times as likely as children with Medicaid coverage to have no regular source of care (15 percent of uninsured children do not have a regular provider compared with just 5 percent of children with Medicaid), and uninsured adults are more than three times as likely as either privately or publicly insured adults to lack a regular source of care (35 percent compared with 11 percent) (Haley and Zuckerman, 2000). The likelihood that those without health insurance lack a regular source of care has increased substantially since 1977 (Zuvekas and Weinick, 1999; Weinick et al., 2000).

Uninsured adults are less likely to receive health services, even for certain serious conditions. One nationally representative survey that took into account age, sex, income, and health status found that uninsured people were less than half as likely as those with insurance to receive needed care, as judged by physicians, for a serious medical condition (Baker et al., 2000). People without insurance are also less likely to receive preventive services and appropriate routine care for chronic conditions than those with insurance, even as the importance of preventive care and the prevalence of chronic disease become more prominent elements within health care (Hafner-Eaton, 1993; Burstin et al., 1998; Ayanian et al., 2000; Schoen and DesRoches, 2000; Institute of Medicine, 2001).

HOW COVERAGE IS GAINED AND LOST

In the United States, health insurance is a voluntary matter, yet many people are involuntarily without coverage. There is no guarantee for most people under the age of 65 years that they will be eligible for, or able to afford to purchase or retain, health insurance. The historical tension rooted in American social values, between considering health care as a market commodity and as a social good, has fostered the development of a variegated and complex arrangements for financing the delivery of health care (Stevens, 1989; Stone, 1993). Within the private sector, insurance coverage depends on an employer’s decision to offer a health benefit plan and an employee’s decision to enroll or take up this offer. When workers are not offered the chance to purchase employment-based insurance for themselves and their dependent family members (spouses and minor children), or when they decline to enroll, individual policies and public insurance (Medicaid or the State

6

Children’s Health Insurance Program [SCHIP]) offer limited opportunities for coverage. Poor health status or low income may preclude the purchase of an affordable (or any) individual policy from an insurance company. The combination of strict eligibility requirements and complex enrollment procedures often makes public coverage difficult to obtain and even more difficult to maintain over time.

Opportunities to Purchase Coverage

Almost seven out of every ten Americans under age 65 years (68.5 percent) are covered by employment-based health insurance, from either their job or that of their parent or spouse (Fronstin, 2000b). Among workers 76 percent are offered health insurance by their employers, and 83 percent of those offered insurance decide to purchase or take up the offer of coverage (Fronstin, 2001). The 17 percent of workers that decline an employer’s offer include about 13 percent who are covered through a spouse or elsewhere and 4 percent who remain uninsured. The expense and competing demands on family income are the main reasons given for declining the offer of employment-based insurance (Cooper and Schone, 1997; Rowland et al., 1998; Hoffman and Schlobohm, 2000).

Individually purchased policies and public insurance (primarily Medicaid) both fill some of the coverage gaps created by the employment-based system. Together they account for 21 percent of coverage.2 Self-employed people (about 10 percent of workers) and their families must often rely on individually purchased health insurance. Individual coverage is often a stop-gap measure, however, for adult children who lose their coverage as dependents before they can obtain job-based coverage and for retirees under the age of 65 before they become eligible for Medicare. Medicaid coverage also tends to be transitory, with two-thirds of new enrollees losing coverage within the first year (Carrasquillo et al., 1998; Short and Freedman, 1998).

Limited Coverage Options

Insurance industry underwriting practices, the costs of health services, and the patchwork of public policies regarding insurance coverage all contribute to the economic pressures on employers, insurers, and government programs offering health insurance. Small employers frequently face higher group health insurance premium rates than large employers do. Larger firms can cushion themselves from the financial impact of insurance company medical underwriting and restrictions by choosing to self-insure their employees’ health benefits. Small employers may receive poorer benefits for premiums comparable to those of large firms, because of both a higher risk premium and higher administrative costs per person, and inadequate resources to evaluate and negotiate good coverage. As a result, some small employers may decline to offer coverage altogether. Among a group of 955 small businesses (fewer than 50 employees) surveyed, the most common and the highest-ranking reason for not offering insurance benefits was the expense of coverage (Fronstin and Hellman, 2000).

The expense and competing demands on family income are the main reasons given by individuals for declining an offer of employment-based coverage. Wage-earners who accept or take up an employer’s offer of a subsidized health benefit typically pay between 2 Some people report multiple sources of coverage, so employment-based, individual, and public insurance coverage rates total more than the 82.5 percent of the U.S. population with any coverage during the year.

7

one-quarter and one-third of the total cost of their insurance premium, in addition to deductibles, copayments, and the costs of health services that are not covered or are covered only in part. For families earning less than 200 percent of the federal poverty level (FPL), $33,400 for a family of four in 1999, the cost of an unsubsidized insurance premium may exceed 10 percent of annual income (Gabel et al., 1998).

Coverage Trends over Time

Since the mid-1970s, growth in the cost of health insurance has outpaced the rise in real income, creating a gap in purchasing ability that has added roughly one million persons to the ranks of the uninsured each year. These cost increases result in part from advances in medical and pharmaceutical technology, an aging population, and reduced consumer sensitivity to prices through expanded insurance coverage (Heffler et al., 2001). Despite the economic prosperity of recent years, between 1998 and 1999 there was only a slight drop in the number and proportion of uninsured Americans. Through the early 1990s the rising uninsurance rate reflected a decline in employment-based coverage. Since the mid-1990s increases in employment-based coverage have been offset by steady or declining rates of public and individually purchased coverage (Fronstin, 2000b).

A PORTRAIT OF THE UNINSURED

People lack coverage regardless of education, age, or state of residence. Employment and geographic factors are central because private insurance is closely tied to employment and eligibility for public programs is partly determined by work and income criteria.

Social and Economic Factors Affect Coverage Full-time, full-year employment offers families the best chance of having health

insurance, as does an annual income of at least a moderate level (greater than 200 percent of FPL) (Custer and Ketsche, 2000b). Wage earners in smaller firms, lower-waged firms, nonunionized firms, and nonmanufacturing employment sectors are more likely than average to go without coverage. Members of families without wage earners are more likely to be uninsured than are members of families with wage earners. Two-thirds of all uninsured persons are members of lower-income families (earning less than 200 percent of FPL), and nearly one-third of all members of lower-income families are uninsured. More than one-quarter of all uninsured adults have not earned a high school diploma, and almost four out of every ten adults who have not graduated from high school are uninsured.

Coverage Varies over the Life Cycle The average individual’s chances of being uninsured trace a curve across the life

span, from a lower-than-average likelihood for minor children and a higher-than-average likelihood for young adults to a gradual decline in probability with advancing age and increasing connection to the labor force. People 65 and older have a minimal likelihood of being uninsured because Medicare provides virtually universal coverage to that age group. Marriage and the rearing of infants and young children both decrease the chances, on average, that an adult will be uninsured. Sources of coverage and health status, as well as participation in the work force, also affect one’s chances of lacking coverage.

8

Demographic Disparities in Coverage Higher uninsured rates among members of racial and ethnic minority groups and

among recent immigrants reflect their lower rates of employment-based coverage and lower family incomes, on average, compared to non-Hispanic whites and U.S.-born residents. African Americans are twice as likely as non-Hispanic whites to be uninsured, and Hispanics are three times as likely to be uninsured, although more than half of all uninsured persons are non-Hispanic whites. Foreign-born residents are almost three times as likely to be uninsured as are those born in the United States, and among the foreign born, noncitizens are more than twice as likely as citizens to be uninsured (Mills, 2000).

In addition, there are gender disparities in coverage, reflecting the different experiences of adult men and women in the workplace and with public policies. Although men are more likely than women to be uninsured, women have a lower rate of employment-based coverage. Because women are more likely to obtain coverage through individual policies and public programs, their insurance status tends to be less stable, with more opportunities for gaps in coverage (Miles and Parker, 1997; Fronstin, 2000b).

Geographic Differences Affect Coverage The decentralized labor and health services markets of the United States and the

distinctive public policies of each state and locality together create unique contexts for the patterns of insurance coverage for individuals, families, and population groups. Differences among the states with respect to population characteristics, industrial economic base, eligibility for public insurance, and relative purchasing power of family income shape the geographic disparities in insurance coverage rates (Marsteller et al., 1998; Brown et al., 2000b; Cunningham and Ginsberg, 2001). Residents of the South and West are more likely than average to be uninsured. Reflecting the predominantly urban location of the general population, most uninsured persons live in urban areas, although rural and urban residents are about equally likely to be uninsured.

Care Without Coverage: Too Little, Too Late

In its second report, the Committee examines whether this reduced access to care results in less appropriate care and poor health consequences.

Ascertaining whether health insurance improves health outcomes is critical to shaping public policy about health insurance and the financing of health care more generally. The strongest research studies consistently show that working-age Americans (those between 18 and 65) who do not have health insurance have poorer health and die prematurely. The Committee concludes that if these roughly 30 million working-age Americans were to become insured on a continuous basis, their health would be expected to improve.

Increasingly, clinical and health services research provides evidence that receiving too little medical care or receiving it too late has harmful effects for those without health insurance. These effects could be ameliorated through the enhanced access to care that insurance provides. In this report the Committee weighs the evidence of the effect of being uninsured on health-related outcomes for adults and considers the potential benefits of extending health insurance to adults without it. In a subsequent report, the Committee will examine comparable studies focused on children.

9

Being uninsured is associated with a variety of worse health-related outcomes, including the following:

• less frequent or no use of cancer screening tests resulting in delayed diagnosis

and premature mortality for cancer patients (Ayanian et al.,1993; Roetzheim et al., 1999, 2000a, 2000b; Ferrante, 2000; Breen et al., 2001; Perkins et al., 2001);

• care that does not meet professionally recommended standards for the management of chronic disease, for example, the failure of persons with diabetes to receive timely eye and foot exams to prevent blindness and amputations (Beckles et al., 1998; Ayanian et al., 2000);

• lack of access to and maintenance of appropriate medication regimens for persons with hypertension or HIV infection (Cunningham et al., 1995, 1999, 2000; Shapiro et al., 1999; Huttin et al., 2000; Goldman et al., 2001); and

• fewer diagnostic and treatment services for trauma or heart attacks and an increased risk of death when in the hospital (Haas and Goldman, 1994; Blustein et al., 1995; Canto et al., 1999, 2000; Doyle, 2001).

The health benefits of having insurance are even stronger when continuity of coverage is taken into account. Being uninsured for relatively short periods (one- to four-years) appears to result in a decrease in general health status. When followed over longer periods of time, uninsured adults have been found to be at higher risk of premature death than are persons with private coverage (Lurie et al., 1984, 1986; Franks et al., 1993a; Sorlie et al., 1994; Baker et al., 2001).

Additionally, the potential health benefits of having insurance are magnified when vulnerable populations, already at increased risk of worse health, receive coverage. These vulnerable groups include adults who are

• chronically ill (especially between the ages of 55 and 64 years) • living with severe mental illness • members of racial and ethnic minority groups • of lower socioeconomic status

Based on the preponderance of evidence, the Committee concludes that

• the health of uninsured adults is worse than it would otherwise be if they were insured,

• providing health insurance to uninsured adults would result in improved health, including greater life expectancy, and

• increased rates of health insurance coverage would especially improve the health of those in the poorest health and most disadvantaged in terms of access to care and thus would likely reduce health disparities among racial and ethnic groups.

10

ASSESSING THE IMPACT OF HEALTH INSURANCE ON HEALTH The Committee reached these conclusions after a review that used explicit criteria to

select and evaluate the best-designed research studies investigating the health of working-age adults with and without health insurance. To be selected, studies had to consider (1) an individual’s health insurance status as an independent variable or “predictor,” and (2) the effect of insurance status on one or more health-related outcomes for adults ages 18 through 64. The following report, Health Insurance Is a Family Matter, reviews the effects of health insurance coverage on children and on pregnant women. Studies that focus primarily on adults 65 years and older were excluded because virtually all in this age group have health insurance coverage through the federal Medicare program.3

This report uses specific definitions of insurance and of the terms of coverage. “Insured adults” means those with general medical and hospitalization insurance, while “uninsured adults” are persons without any health insurance. The Committee has not explicitly considered those who may be inadequately insured (“underinsured”). Although the Committee did not examine studies comparing benefit packages among those with insurance or set out to analyze distinctions among kinds of health insurance, the literature led it to consider some features of health insurance that appear to affect health outcomes. For example, distinctive results from studies that compared those with private and public health insurance point to characteristics such as continuity of coverage and coverage of prescription drugs as important factors. The Committee paid particular attention to studies that examined the length of time participants were uninsured to determine whether and how that factor affected health.

Because most of the evidence comes from studies that are observational rather than experimental, interpreting the evidence about the value of coverage for health outcomes requires application of careful standards of analysis and review. Consequently, analytical adjustments are required to account for potential biases related to variation among study subjects in lengths of time uninsured, types of health insurance coverage, and characteristics of study participants that correlate with health insurance status whose effects can be confused or confounded with those of insurance.

Three characteristics of individuals are closely related to health insurance status and, as a result, require analytic adjustment: health status, race and ethnic identity, and socioeconomic status. The strongest observational studies use adjustments to separate the effects of these characteristics from those of health insurance coverage.

The Committee believes that the research literature likely understates the differences in health outcomes between insured and uninsured adults that can be attributed to health insurance. One of the shortcomings in the literature is a lack of information about the experience of those adults who do not seek care, whether insured or uninsured. Research that relies on administrative or clinical documentation of health care use cannot account for the experience of those who do not seek treatment, and uninsured adults are less likely to seek treatment than are insured adults. Thus, studies that rely on health care records to compare groups may actually overstate the utilization of services by uninsured populations. 3 While Medicare covers hospitalizations, physician and other outpatient services including rehabilitative therapies and home health care, it does not cover most outpatient prescription drugs nor does it cover non-rehabilitative long-term care.

11

Finding: Health insurance coverage is associated with better health outcomes for adults. It is also associated with having a regular source of care and with greater and more appropriate use of health services. These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and the effective treatment of acute conditions such as traumatic injury and heart attacks. The ultimate result is improved health outcomes. Health insurance makes a difference in receipt of services and health outcomes.

Direct measures of health examined in studies include self-reported health status, mortality, stage of disease at time of diagnosis and physiologic measures (e.g., controlled blood pressure in persons with hypertension). Because direct measures of health outcomes are often hard to obtain inexpensively in large-scale studies, intermediate measures of health care processes are commonly used as proxies to assess the effect of health insurance on health. This report examines receipt of recommended services, for example, dilated eye exams annually for persons with diabetes and regular blood pressure checks for those with hypertension, that have been validated by professional guidelines and clinical effectiveness research.

Finding: Health insurance is most likely to improve health outcomes if it is continuous and links people to appropriate health care. When health insurance includes preventive and screening services, prescription drugs, and mental health care, it is more strongly associated with the receipt of appropriate care than when insurance does not have these features. Adults without health insurance face serious shortcomings in access to care. The

quality and length of life are distinctly different for insured and uninsured populations, with worse health status and shortened lives among uninsured adults. While having health insurance demonstrably increases use of services, more importantly, it also facilitates more appropriate use of health care services. In prevention and chronic disease management for example, having health insurance greatly increases the likelihood of a regular source of care and of continuity in care, which in turn can improve health outcomes.

Finding: Increased health insurance coverage would likely reduce racial and

ethnic disparities in the use of appropriate health care services and may also reduce disparities in morbidity and mortality among ethnic groups.

Members of different racial and ethnic groups differ in terms of health status, the

likelihood of having health insurance and the care that they receive (Haas and Adler, 2001; IOM, 2001a, 2002; Mills, 2001). Health insurance does not eliminate all disparities among population groups in access to care or remediate all deficits in health status among minority populations. It does, however, facilitate receipt of preventive services, having a regular source of care, and improved quality of care.

12

EFFECTS OF HEALTH INSURANCE ON SPECIFIC HEALTH CONDITIONS

Primary Prevention and Screening Services Finding: Uninsured adults are less likely than adults with any kind of health coverage to receive preventive and screening services and to receive these services on a timely basis. Health insurance that provides more extensive coverage of preventive and screening services is likely to result in greater and more appropriate use of these services. Uninsured adults are less likely than those with health insurance to receive preventive

services such as mammograms, clinical breast exams, Pap tests, and colorectal screening (Powell-Griner, et al., 1999; Ayanian et al., 2000, Breen et al., 2001). The positive effect of having insurance is more evident with relatively costly services such as mammograms (Zambrana et al., 1999; Cummings et al., 2000). Studies of particular ethnic groups find that health insurance is associated with the increased receipt of preventive services and an increased likelihood of having a regular source of care (Mandelblatt et al., 1999).

Generally, insurance benefits are less likely to include preventive and screening services than physician visits for acute care or diagnostic tests for symptomatic conditions. The more extensive the coverage of preventive services, the more likely are health plan enrollees to receive these services (Faulkner and Schauffler, 1997). Yet even if people have health insurance that does not cover preventive services, they are more likely to receive appropriate services than are those without any form of health insurance, partly because they are more likely to have a regular source of care or a primary provider.

Even after adjustments for age, race, education, and regular source of care, uninsured adults are less likely to receive timely screening for breast, cervical, or colorectal cancer. Once discovered, their cancer is likely to be at a more advanced stage.

Cancer Care and Outcomes

Finding: Uninsured cancer patients die sooner, on average, than do persons with insurance, largely because of delayed diagnosis. This finding is supported by population-based studies of breast, cervical, colorectal, and prostate cancer and melanoma. Uninsured cancer patients more often fare poorly than do patients with coverage. A

relatively advanced, often fatal, late stage of disease at the time of diagnosis is more common among persons without insurance coverage, reflecting their reduced use of timely screening services. Uninsured persons with breast, colorectal, or prostate cancer are more likely to die prematurely from their disease than are patients with private health insurance. For example, uninsured women with breast cancer have a risk of dying that is between 30 and 50 percent higher than the risk for women with private health insurance (Ayanian et al., 1993; Lee-Feldstein et al., 2000; Roetzheim et al., 2000a), and uninsured patients with colorectal cancer are about 50 percent more likely to die than are patients with private coverage, even when the cancer is diagnosed at similar stages (Roetzheim et al., 2000b). This evidence comes from research using area or statewide cancer registries.

Uninsured adults with cancer might experience treatment differences. For example, uninsured women with breast cancer are less likely than privately insured women to

13

receive breast-conserving surgery (Roetzheim et al., 2000a). It should be noted, however, that disparities in treatment persist among racial and ethnic groups even if all have insurance (IOM, 2002). Chronic Disease Care and Outcomes

Finding: Uninsured adults living with chronic diseases are less likely to receive appropriate care to manage their health conditions than are those who have health insurance. For all five disease conditions (in addition to cancer) that the Committee examined (diabetes, cardiovascular disease, end-stage renal disease, HIV infection and mental illness), uninsured patients have consistently worse clinical outcomes than do insured patients. For persons living with a chronic illness, health insurance may be most important in

enhancing opportunities to acquire a regular source of care and receive appropriate management of their condition. Identifying chronic conditions early and providing professionally recommended, cost-effective interventions on an ongoing and coordinated basis can improve health outcomes. Yet uninsured adults with chronic conditions are less likely to have a usual source of care or regular check-ups than are chronically ill persons with coverage (Ayanian et al., 2000; Fish-Parcham, 2001). Diabetes. Uninsured persons with diabetes are less likely to receive recommended services. Lacking health insurance for longer periods increases the risk of inadequate care for this condition and can lead to uncontrolled blood sugar levels, which, over time, put diabetics at risk for additional chronic disease and disability. Despite the demanding and costly care regimen that persons with diabetes face, adults with diabetes are almost as likely to be uninsured as adults without this disease (12 percent are uninsured compared to the general population uninsured rate of 15 percent [Harris, 1999].)

Uninsured adults with diabetes are less likely to receive the recommended professional standard of care than those with health insurance. For example, they are less likely to receive regular foot or dilated eye exams that are important in the prevention of foot ulcers and blindness. Twenty-five percent of adults with diabetes who were uninsured for a year or more went without a checkup within the past two years, compared to seven percent of diabetics who were uninsured for less than a year and five percent of diabetics with health insurance (Beckles et al., 1998; Ayanian et al., 2000). Cardiovascular Disease. Uninsured adults with hypertension or high cholesterol have diminished access to care, are less likely to be screened, are less likely to take prescription medication if diagnosed, and experience worse health. According to analyses of national health survey data, 19 percent of uninsured adults with heart disease and 13 percent with hypertension lack a usual source of care, compared to 8 and 4 percent, respectively, of their insured counterparts (Fish-Parcham, 2001). Uninsured adults have less frequent monitoring of blood pressure once they are diagnosed with hypertension and are less likely to stay on drug therapy than are insured adults who have hypertension (Huttin et al., 2000; Fish-Parcham, 2001).

Loss of insurance coverage disrupts therapeutic relationships and worsens blood pressure control (Lurie et al., 1984, 1986). Deficits in care for uninsured adults with hypertension or high cholesterol place them at risk of complications and deterioration of their condition. For example, patients admitted to emergency departments with severe

14

uncontrolled hypertension were more likely to be uninsured than socio-demographically similar patients with any insurance (Shea et al., 1992a, 1992b). End-Stage Renal Disease. Uninsured patients have more severe renal failure when they begin dialysis than insured patients (Kausz et al., 2000). The clinical goals for patients with kidney disease are to slow the progression of renal failure, manage complications, and prevent or manage coexisting disease effectively. Uninsured patients are less likely than insured patients to have received treatment for related anemia before initiating dialysis, and their health status is already compromised by a greater likelihood of more severe anemia (Obrador et al., 1999).

The virtually universal qualification of ESRD patients for Medicare once dialysis or transplantation becomes necessary erases previously existing gender and racial or ethnic disparities in access to hospital-based care for ESRD patients with heart disease (Daumit et al., 1999, 2000). Human Immunodeficiency Virus Infection. Uninsured adults, once diagnosed with HIV, face greater delays in accessing appropriate care than those with health insurance and are more likely to forgo needed care. Persons without health insurance have been shown to wait more than three months after diagnosis to have their first office visit and to wait an average of four months longer than privately insured patients to receive newer drug therapies (Turner et al., 2000). Furthermore, the uninsured with HIV are less likely to be able to maintain a recommended regimen over time (Cunningham et al., 2000). Uninsured adults with HIV infection are less likely to receive highly effective medications that have become the standard of treatment within the past five years and been shown to improve survival (Carpenter et al., 1996, 1998; Goldman et al., 2001). Having health insurance of any kind has been found to reduce mortality in HIV-infected adults by 71–85 percent over a six-month period, with the greater reduction found more recently when effective drug therapies were in more widespread use (Goldman et al., 2001). Mental Illness. Adults with health insurance that covers any mental health treatment are more likely to receive mental health services and care consistent with clinical practice guidelines than are those without any health insurance or with insurance that does not cover mental health conditions.

Mental illness represents a major but often underestimated source of disability and is equivalent to heart disease and cancer in terms of its impact. Depression and anxiety disorders are often treatable in the general medical sector and primarily require outpatient services. Severe mental illnesses (schizophrenia, other psychoses, and bipolar depression) require the attention of specialty mental health professionals and may require more extensive services (e.g., inpatient services, partial or day hospitalization).

Receipt of appropriate care has been associated with improved functional outcomes for depression and anxiety disorders, yet the uninsured are less likely to receive this degree of care. Patients without health insurance for mental health visits who were diagnosed with depression, panic disorder, or generalized anxiety disorder were less likely to receive mental health services (Druss and Rosenheck, 1998; Cooper-Patrick et al., 1999). When they did receive care, it was less likely to be appropriate (concordant with professional practice guidelines) (Wang et al., 2000; Young et al., 2001). Uninsured adults with severe mental illnesses also receive less appropriate care or medications and

15

experience delays in receiving services until they gain public insurance coverage (Rabinowitz et al., 1998, 2001; McAlpine and Mechanic, 2000).

Even when health insurance does not specifically cover mental health services, having it increases the likelihood that someone with depression or anxiety will receive some care for the condition. Persons with a severe mental illness such as schizophrenia or bipolar disorder face difficulties in obtaining and then keeping health insurance after diagnosis. When they do have health insurance, especially public insurance (Medicare or Medicaid), they are more likely to receive specialty mental health services than are severely ill persons without any health insurance or even patients with private insurance.

Hospital-Based Care

Finding: Uninsured patients who are hospitalized for a range of conditions are more likely to die in the hospital, to receive fewer services and, when admitted, are more likely to experience substandard care and resultant injury than are insured patients. Poorer health status for uninsured adults when they are hospitalized is compounded

by their experiences as inpatients. Being uninsured is associated with the receipt of fewer needed services, worse quality care, and greater risk of dying in the hospital or shortly after discharge (Hadley et al., 1991; Burstin et al., 1992; Haas and Goldman, 1994; Blustein et al., 1995; Doyle, 2001). Being uninsured and not having a regular source of care are also associated with delays in seeking care from the emergency department for a variety of conditions, delays that may compromise outcomes (e.g., rupture in acute appendicitis) (Braveman et al., 1994).

Because most hospital-based studies are biased by the inclusion of self-selected patients who “show up” for care, the Committee decided to focus on two conditions—traumatic injuries and acute cardiac events—for which most people receive hospital care whether or not they are insured. Traumatic injuries. Uninsured persons with traumatic injuries are less likely to be admitted to the hospital, receive fewer services when admitted, and are more likely to die than are insured trauma victims. Provider response to traumatic injury can be influenced by insurance status. In one statewide study of uninsured auto accident victims, uninsured patients were found to receive less care and had a 37 percent higher mortality rate than did privately insured accident victims (Doyle, 2001). Another statewide study showed while uninsured trauma patients were as likely to receive intensive care unit services as privately insured patients, they were less likely to undergo operative procedures or receive physical therapy (Haas and Goldman, 1994). Acute Cardiovascular Disease. Uninsured patients with acute cardiovascular disease are less likely to be admitted to a hospital that performs angiography or revascularization procedures, are less likely to receive these diagnostic and treatment procedures, and are more likely to die in the short term. Health insurance reduces the disparity in receipt of these services for women relative to men and for members of racial and ethnic minority groups (Carlisle et al., 1997; Daumit et al., 1999, 2000).

Insurance status influences the receipt of hospital-based treatments for cardiovascular disease (specifically, coronary artery disease). Uninsured patients hospitalized for acute

16

myocardial infarction (heart attack) experience a greater risk of dying during their hospital stay or shortly thereafter than do patients with private insurance (Young and Cohen, 1991; Blustein et al., 1995; Canto et al., 2000).

GENERAL HEALTH OUTCOMES

An uninsured adult’s experiences with ambulatory and hospital care influence his or her health status in important ways over the short term and may lead to a premature death. Health Status

Finding: Relatively short (one- to four-year) longitudinal studies document decreases in general health status measures for uninsured adults and for those who lost insurance coverage compared to persons with continuous coverage.

Like those with chronic health conditions, 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. The effect of being uninsured on self-reported health measures is greater for lower-income persons (Franks et al., 1993b).

Mortality

Finding: Longitudinal population-based studies of the mortality of uninsured and privately insured adults reveal a higher risk of dying for those who were uninsured at the beginning of the study than for those who initially had private coverage.

Longer-term population-based studies (from 5 to 17 years) find a 25 percent higher risk of dying for adults who were uninsured at the beginning of the study (Franks et al., 1993a; Sorlie et al., 1994). These analyses of overall mortality are corroborated by the mortality experience of insured and uninsured patients with heart attack, cancer, traumatic injury, and HIV infection (Blustein et al., 1995; Canto et al., 2000; Ayanian et al., 1993; Roetzheim et al., 2000a; Doyle, 2001; Goldman et al., 2001).

THE DIFFERENCE COVERAGE COULD MAKE TO THE HEALTH OF UNINSURED ADULTS

Particular groups of uninsured adults are more likely to experience poor health or

barriers to care and thus can be expected to benefit more from gaining health insurance. These groups include uninsured adults who are chronically ill, persons with severe mental illness, members of some racial and ethnic minority groups, and persons with lower socioeconomic status. Many of the uninsured belong to one or more of these higher-risk groups.

The Committee bases the following summary conclusions on the substantial consistency of results among the methodologically strongest observational studies in its review and the coherence of these results with the behavioral research that informs the

17

Committee’s conceptual model of mechanisms by which health insurance affects health outcomes:

• Having health insurance is associated with better health outcomes for adults

and with their receipt of appropriate care across a range of preventive, chronic, and acute care services. Adults without health insurance coverage die sooner and experience greater declines in health status over time than do adults with continuous coverage.

• Adults with chronic conditions and those in late middle age stand to benefit the most from health insurance coverage in terms of improved health outcomes because of their high probability of needing health care services.

• Population groups that most often lack stable health insurance coverage and that have worse health status, including racial and ethnic minorities and lower-income adults, would benefit most from increased health insurance coverage. Increased coverage would likely reduce some of the racial and ethnic disparities in the utilization of appropriate health care services and may also reduce disparities in morbidity and mortality among ethnic groups.

• Health insurance that affords access to providers and includes preventive and screening services, outpatient prescription drugs, and specialty mental health care is more likely to facilitate the receipt of appropriate care.

• Broad-based health insurance strategies across the entire uninsured population would be more likely to produce these benefits than would “rescue” programs aimed only at the seriously ill.

Health Insurance Is a Family Matter

In America the family is the basic social unit. Strong families are essential to

America’s future. We all share an interest in the collective well-being of our national community and in providing the conditions for families to succeed in raising the next generation. This report views the consequences of having more than 38 million people in the country lacking health insurance from the perspective of families, in contrast to most research, which examines the impact on individuals. The vast majority of uninsured individuals live in families. Having one or more uninsured individuals in a family can have an impact , even if some or all of the remaining members of the family have health insurance.

In this report the Committee examines two sets of literature, one concerning the relationship between health insurance status and the health of pregnant women, infants, and children and the other, on whether having an uninsured member in the family can have a deleterious effect on the family as a whole.4 The Committee acknowledges that it may take more than simply providing insurance coverage to have a positive health impact. Health insurance is, however, an important factor in reducing barriers to care. The Committee addresses these questions: 4 The Committee’s rigorous evaluation of the literature encompassed a wide range of research; its findings are based on the most methodologically sound studies; and results reported are generally significant at the p< 0.05 or better, unless otherwise specified..

18

• How does the presence of an uninsured family member affect the health of the rest of the family? Even if only one member of the family is uninsured, could that affect the family’s finances and economic stability?

• Because parents act as the health care seekers and decision makers for their children, does being uninsured affect their functioning in that capacity? What if their children have no health coverage?

• Because a family’s health and insurance needs tend to change as its members reach maturity and grow older, how well do the current insurance mechanisms and programs match those needs? Our nation encompasses a rich variety of family structures that reflect how

individuals view themselves, the people they live with, and their emotional, social and economic interrelationships. The Committee purposely chooses to view families as self-defined responsibility units whose members lives are emotionally and economically entwined. It recognizes that the concept is broadly encompassing, not neat and uniform, but it reflects reality. A person’s own definition of family does not necessarily correspond to the definition of family used by employment-based insurance plans for coverage eligibility. As a result, some self-defined family members may not qualify for coverage. In addition, most of the publicly financed health insurance programs provide coverage for individuals rather than for families as a whole, although people generally function economically and socially as part of a family unit. This mismatch between insurers’ eligibility criteria and a family’s definition of itself affects the coverage patterns of families and, ultimately, the family’s well-being. The mismatch and resulting uninsurance within the family also have important implications for the public debate about expanding coverage.

The source of health insurance available to families directly affects whether all members are covered. Employment-based plans are more likely to offer coverage for the entire family than are other types of insurance. The Committee concludes that if all family members are covered, the chances increase that they will get the health care they need in a timely fashion and that the costs of those services would likely have a less destabilizing impact on the family’s finances than if some or all members are uninsured. The Committee also concludes that the health of children and their long-term development would likely be enhanced if the children are covered by insurance. Box ES.1 presents the Committee’s specific findings regarding the nature of the consequences of uninsurance on families.

COVERAGE PATTERNS OF FAMILIES AND THEIR SIGNIFICANCE

There are 85 million families in the United States, and 17 million of them—about one in five—have one or more members who are uninsured. The more than 38 million uninsured people nationally live with roughly 20 million insured family members, which means that 58 million lives may be affected by the consequences of uninsurance. There

19

are more than 38 million families with minor children; 20 percent do not have all their members insured.5

Employment-based insurance is the most common type of coverage. Usually workers purchase coverage when it is offered on the job and buy additional coverage for their dependent family members if they consider it affordable and alternative coverage does not exist. Thus, when parents are insured, whether they are in single- or two-parent families, more than 95 percent of the time all their children are also covered.

Among the almost 20 percent of families with some or all members lacking coverage, specific social and demographic characteristics are more common, including lower income, single parenthood and racial and ethnic minority and immigrant status.

• Family insurance coverage is strongly related to family income; families with lower

incomes are less likely to be fully insured. Similarly, single-parent families are less likely to have all members covered than are two-parent families (71percent compared with 85 percent).

• 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. Nonetheless, many children remain uninsured although they are eligible for public programs. Of the estimated 8 million uninsured children in 2000, most are eligible for Medicaid and SCHIP, but not enrolled (Urban Institute, 2002a). The proportion of uninsured children who are eligible for public programs will likely continue to decrease, if enrollments continue increasing. There are 9.1 million uninsured parents (Lambrew, 2001b). One-third of these

uninsured parents have incomes below the federal poverty level (FPL) and another third have incomes between 100 percent and 200 percent FPL.6 The fact that many of the parents are uninsured is significant because parents obtain health care for their children. Even if their children may be eligible for coverage or are actually enrolled, children are dependent upon their parents’ enrolling them in public programs and taking them for treatment. The parents’ decisions on whether, when, and from whom to seek care for their children may be influenced by their own experiences with and knowledge of the health system. When states have expanded Medicaid coverage broadly to include low-income parents as well as their children, the enrollment of eligible children increases more so than it has in states without the broader parental coverage (Ku and Broaddus, 2000; Dubay and Kenney, 2002). Parents’ lack of knowledge about the programs and their confusion about eligibility, which traditionally are barriers to the enrollment of eligible children, are lower when parents themselves enroll.

A parent’s own use of health services is a strong predictor of their children’s use. Uninsured parents are more likely to have negative experiences with the health system than are those with insurance, and this may affect their perception of the value of health 5 Committee analyses are based on tabulations of the Census Bureau’s 2001 Current Population Survey public use file designed to aggregate data by family units conducted by Matthew Broaddus, Center on Budget and Policy Priorities. Families with heads under age 65 are included as well as children under age 18. 6 For 2000, the FPL is $11,250 for a family of two and $14,150 for a family of three. See Appendix D, Table D.1.

20

care and their willingness to take their children for needed care. Parents without coverage are more likely to report that they are in poorer health than are privately insured parents; they have more trouble gaining access to care when they need it and more often lack a regular source of care. In addition, as the Committee concluded in Care Without Coverage: Too Little, Too Late, uninsured adults are more likely to delay seeking care for themselves and to suffer poorer health and even premature death than are their insured counterparts.

FINANCIAL CHARACTERISTICS AND BEHAVIOR OF UNINSURED

FAMILIES

Even in the healthiest of families, if one member has an accident the resulting medical bills can affect the economic stability of the whole family. The impact depends, in part, on whether the injured person was insured, the size of the bills, and the family’s income and other resources. Families with at least one member lacking insurance predominantly have lower incomes (below 200 percent FPL). Not surprisingly, families with uninsured members also have few if any assets and are unlikely to be able to borrow to pay their medical bills. Often they do not have the budgetary resources to purchase health insurance without a premium subsidy, given the relatively high cost of family coverage outside of group plans.

The annual out-of-pocket expenses for health care for an uninsured family on average are less in actual dollars and less relative to their income than those expenses for families with coverage. Uninsured families do not have the expense of insurance premiums and are less likely to use any health care services; but those who do, generally use fewer services.. Paradoxically, uninsured families are also more likely than insured ones to face health costs that are high relative to their income. At the low end of the spectrum, families without health insurance are more likely to have no health care expenses than are families with health insurance because they are fortunate enough to be healthy or they forgo needed care. In the middle of the spectrum, the average annual out-of-pocket expense for families without health insurance is less than that of families with coverage. However, at the high end of the spectrum, families without health insurance are more likely to have health expenses that exceed 5 or 10 percent of their income than are families with health insurance. For all family types and for single adults, the burden of out-of-pocket expenditures rises as incomes fall. The burden is also greater for uninsured families with members in poorer health compared to those with better health status. More than half of all working-age adults uninsured now or in the recent past report difficulties paying medical bills, compared with less than a quarter of insured adults (Duchon et al., 2001).

How do families cope with the burden of medical bills? Some families delay payment and may be dunned by collections agents. Among all working-age adults with medical bill problems, almost 60 percent of whom are currently or were recently uninsured. Of those with severe bill problems and in those uninsured groups, two-thirds report borrowing from family or a friend and a quarter got a loan or mortgage on their home in order to pay (Duchon et al., 2001). Some families resort to declaring bankruptcy and put their future credit rating in jeopardy. Medical bills are a factor in nearly half of all

21

bankruptcy filings, but it is not known whether bankruptcy is more likely for uninsured families than for those with coverage.

When a family is uninsured, has very limited income, and cannot pay all its medical bills, the financial burden falls on the providers of services and on the broader community, which offer various supports. These supports include charity care, the use of sliding fee schedules based on family income, and the availability of safety-net providers. While uninsured families absorb more than 40 percent of the costs for their medical services on average, the proportion varies widely, depending on the type of service used. For example, prescription costs are unlikely to have subsidies or external support, and families pay 88 percent of that expense. Because of the availability of various subsidies for the care that hospitals provide uninsured people, families ultimately bear only about 7 percent of these expenses. It is difficult to determine the sources of the various supports available to those who cannot afford to pay for their care, who bears the burden financially, and whether free or reduced-cost care is fairly and equitably distributed to needy families and individuals. Some of these issues will be examined in more detail in the Committee’s following reports on community-wide effects and societal costs of uninsured populations.

HEALTH INTERACTIONS WITHIN THE FAMILY

The health of one member of the family can affect the health of the other members and of the unit as a whole. Particularly for children, their early development is dependent on the health and well-being of their parents. Children’s early development can have lifelong consequences for them (Shonkoff and Phillips, 2000). Public health insurance programs have expanded coverage to children, but insuring children alone may not be enough. This is because parents are a key part of the process of obtaining health care for their children.

The Committee’s analyses show that in families with some members uninsured, parents are more likely than the children to lack coverage. The Committee’s previous report shows that uninsured adults are more likely to have poorer health, to receive delayed diagnoses and treatments and to die prematurely. Lower-income parents not only are more likely to be uninsured, but also are more likely to suffer from poorer health compared with wealthier parents. This report presents evidence that parents in poorer physical or mental health have greater difficulty fulfilling their parental roles and responsibilities than do healthy parents. Studies that relate these family circumstances to insurance status do not yet exist.

Family stress, found more frequently in lower-income families than in those with higher incomes, is associated with higher levels of behavioral, emotional, and physical health problems for the children. While there are many contributing factors to the level of stress within the family, uncertainty about health care may be one of them. Research to further clarify the relationships between health insurance, family health, and emotional well-being is needed.

22

HEALTH-RELATED OUTCOMES FOR CHILDREN, PREGNANT WOMEN, AND NEWBORNS

It is important to examine the relationship between the insurance status of children and pregnant women, their use of health care, and ultimately their health outcomes. Uninsured families are parsimonious in their use of health services. Uninsured adults are more likely to report going without care that they feel is needed than are insured adults. Not surprisingly, delaying treatment and not using services can adversely affect health, even though they avoid costs in the short term.

The Committee has reviewed the extensive body of research on the relationship between health insurance and access, use, and outcomes for children, pregnant women, and newborns and concludes that having health insurance coverage improves these health-related outcomes. This conclusion is based on both individual and population-level studies. However, insurance does not guarantee appropriate use of health services and is only one of many factors affecting health, along with poverty, diet, exercise, smoking, and other behavioral factors.

Health insurance promotes children’s use of routine and appropriate care and facilitates a regular source of care, or “medical home.” Well-child care and a regular care provider are very important for monitoring childrens’ development and detecting potential problems early before they can cause long-term health consequences. Uninsured children use medical and dental services less frequently than do insured children, even after taking into account differences in family income, race and ethnicity, and health status. Children with gaps in health insurance coverage are less likely to have a regular source of care and are less likely to see a health care provider when their parents believe they need one than are children with continuous coverage.

Children who are both uninsured and poor or uninsured and a member of a racial or ethnic minority or immigrant group have added difficulties in gaining access to and using primary care services. Although these factors frequently overlap, each independently adds to a child’s likelihood of reduced access and use. Uninsured children with special health needs are particularly disadvantaged since they need considerably more than routine care. Uninsured children with special health needs are less likely to have a usual source of care, less likely to have seen a doctor in the previous year, and less likely to get needed medical, mental health, dental, prescriptions, or vision care than are their insured counterparts.

Adolescents as a group are particularly at risk of not having a regular source of care or any physician visits in the past year. They have the highest uninsured rate of all children even though their need for some kinds of health care services, such as mental health screening and treatment for drinking and other risky behaviors, increases in their late teenage years.

Becasuse uninsured children are more likely to receive no or delayed care, they are at

greater risk of hospitalization for conditions that could have been treated on an outpatient basis. Health conditions that are readily treatable and that could affect a child’s long-term development and life chances if untreated, may be more likely to go undetected when children are not insured. Conditions such as asthma, iron deficiency anemia, and middle-ear infections, if left untreated or improperly controlled, can affect mental development

23

and school performance, language development, and hearing. Although long-term studies linking insurance status to these conditions and later life outcomes have not been conducted, the lack of routine care that would detect these conditions in uninsured children remains a concern.

Being uninsured may affect the health of pregnant women, the care that they receive, and birth outcomes. Uninsured women have greater difficulty in getting the care that they believe they need than do insured women. The differences in the use of medical care between uninsured women and those who are privately insured are larger than those between uninsured and publicly insured women.

Uninsured women and their newborns receive, on average, less prenatal care and fewer expensive perinatal services, such as cesarean sections. Sick newborns average shorter hospital stays.

Uninsured newborns are more likely to have poorer health outcomes than are insured newborns, such as low birth-weight, which is a risk factor for developmental problems. Uninsured babies are also more likely to die prematurely. However evidence of improvements in low birth-weight for newborns based on population studies of Medicaid expansions is not definitive. While uninsured women more frequently have poor outcomes during pregnancy and delivery than do insured women, insurance coverage alone may not be enough to improve maternal outcomes.

24

References – Coverage Matters

Aday, Lu Ann, G.V. Fleming, and Ronald Andersen. 1984. Access to Medical Care in the U.S.: Who Has It, Who Doesn’t. Chicago, IL: Pluribus Press. Andersen, Ronald. 1995. Revisiting the Behavioral Model and Access to Medical Care: Does It Matter? Journal of Health and Social Behavior 36(3):1-10. Andersen, Ronald M., and Lu Ann Aday. 1978. Access to Medical Care in the U.S.: Realized and Potential. Medical Care 16:533–546. Andersen, Ronald, and Pamela Davidson. 2001. Improving Access to Care in America: Individual and Contextual Indictators . In: Ronald Andersen, Thomas Rice, and Gerald Kominski, eds. Changing the U.S. Health Care System: Key Issues in Health Services, Policy and Management. San Francisco, CA: Jossey-Bass. Pp. 3-30. Ayanian, John Z., Joel S. Weissman, Eric C. Schneider, Jack A. Ginsburg, and Alan M. Zaslavsky. 2000. Unmet Health Needs of Uninsured Adults in the United States. Journal of the American Medical Association 284(16):2061-2069. Baker, David W., Martin F. Shapiro, and Claudia L. Schur. 2000. Health Insurance and Access to Care for Symptomatic Conditions. Archives of Internal Medicine 160(9):1269-1274. Bennefield, Robert. 1998. Dynamics of Economic Well-Being: Health Insurance, 1993 to 1995. P70-64. Who Loses Coverage and for How Long? Current Population Reports. Washington, DC: U.S Census Bureau. Blendon, Robert J., John T. Young, and Catherine M. DesRoches. 1999. The Uninsured, the Working Uninsured, and the Public. Health Affairs 18(6):203-11. Brown, E. Richard, Roberta Wyn, and Stephanie Teleki. 2000. Disparities in Health Insurance and Access to Care for Residents Across U.S. Cities, Regents of the University of California, Los Angeles, CA. Burstin, Helen R., Katherine Swartz, Anne C. O’Neill, E.J. Orav, and T.A. Brennan. 1998. The Effect of Change of Health Insurance on Access to Care. Inquiry 35:389–397. Carrasquillo, Olveen, David U. Himmelstein, Steffie Woolhandler, and David N. Bor. 1998. Can Medicaid Mangaged Care Provide Continuity of Care to New Medicaid Enrollees? An Analysis of Tenure on Medicaid. American Journal of Public Health 88(3):464-466. Cooper, Philip F. and Barbara Steinberg Schone. 1997. More Offers, Fewer Takers for Employment Based Health Insurance: 1987 and 1996. Health Affairs 16(6):142-149. Cunningham, Peter, and Paul B. Ginsberg. 2001. What Accounts for Differences in Uninsurance Rates Across Communities? Inquiry 38(10):6-21.

25

Cunningham, Peter J., and Peter Kemper. 1998. Ability to Obtain Medical Care for the Uninsured. How Much Does It Vary Across Communities? Journal of the American Medical Association 280(10):921–927. Cunningham, Peter J., and Heidi Whitmore. 1998. How Well Do Communities Perform on Access to Care for the Uninsured? Washington, DC: Center for Studying Health System Change. Custer, William S. and Pat Ketsche. 2000a. The Changing Sources of Health Insurance,1st Edition. Research Report 1. Washington, DC: Health Insurance Association of America. ———. 2000b. Employment-Based Health Insurance Coverage. Washington, DC: Health Insurance Association of America. Fronstin, Paul. 2001. Employment-Based Health Benefits: Trends and Outlook. EBRI Issue Brief 233. Washington, DC: Employee Benefit Research Institute. ———. 2000a. Counting the Uninsured: A Comparison of National Surveys, EBRI Issue Brief 225. Employment Benefit Research Institute, Washington, DC. ———. 2000b. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2000 Current Population Survey. EBRI Issue Brief 228. Washington, DC: Employee Benefit Research Institute. ———. 1998. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1998. Current Population Survey. EBRI Issue Brief 204. Washington, DC: Employee Benefit Research Institute. Fronstin, Paul and Ruth Helman. 2000. Small Employers and Health Benefits: Findings From the 2000 Small Employer Health Benefits Survey. EBRI Issue Brief 226, Special Report 35. Washington, DC: Employee Benefit Research Institute. Gabel, Jon, Kelly Hunt, and Jean Kim. 1998. The Financial Burden of Self-Paid Health Insurance on the Poor and Near Poor. New York: Commonwealth Fund. Hafner-Eaton, Chris. 1993. Physician Utilization Disparities Between the Uninsured and Insured. Comparisons of the Chronically Ill, Acutely Ill, and Well Nonelderly Populations. Journal of the American Medicial Association 269(6):787-792. Haley, Jennifer M. and Stephen Zuckerman. 2000. Health Insurance, Access, and Use: United States. Tabulations From the 1997 National Survey of America's Families.Washington, DC: The Urban Institute. Hanson, Karla L. 2001. Patterns of Insurance Coverage Within Families With Children. Health Affairs 20(1):240-246. Heffler, Stephen, Katherine Levit, Sheila Smith, Cynthia Smith, C. Cowen, H. Lazenby,

26

and M. Freeland. Health Spending Growth Up in 1999. Faster Growth Expected in the Future. Health Affairs 20(2):193–213. Hoffman, Catherine and Mary Pohl. 2000. Health Insurance Coverage in America. 1999 Data Update. Washington, DC: The Henry J. Kaiser Family Foundation, The Kaiser Commission on Medicaid and the Uninsured. Hoffman, Catherine, and Alan Schlobohm. 2000. Uninsured in America: A Chart Book.Washington, DC: The Henry J. Kaiser Family Foundation, The Kaiser Commission on Medicaid and the Uninsured. Holahan, John, Leighton Ku, and Mary Pohl. 2001. Is Immigration Responsible for the Growth in the Number of Uninsured? Issue Paper 2221. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. Holahan, John, and Johnny Kim. 2000. Why Does the Number of Uninsured Americans Continue to Grow? Health Affairs 19(4):188–196. Institute of Medicine. 2001. Crossing the Quality Chasm; A Health System for the 21st Century. Washington, DC: National Academy Press. Kolata, Gina. 2001. Medical Fees are Often Higher for Patients without Insurance. The New York Times. Accessed July 9, 2001. Available at http://www.nytimes.com.2001/04/02/National/02insu.html. Lewis, Kimball, Marilyn Ellwood, and John L. Czajka. 1998. Counting the Uninsured: A Review of the Literature, Occasional Paper Number 8. Washington, DC: The Urban Institute, Assessing New Federalism. Marsteller, Jill A., Nichols, Len M., Badawi, Adam, Kessler, Bethany, and Rajan, Shruti. 1998. Variations in the Uninsured State and County Level Analyses. Washington, DC: Urban Institute. Available at www.ui.org. Accessed May 1, 2001. McBride, Timothy D. 1997. Uninsured Spells of the Poor. Prevalence and Duration. Health Care Financing Review 19(1):145–160. Miles, Steven, and Kara Parker. 1997. Men, Women and Health Insurance. New England Journal of Medicine 336(3):218-21. Mills, Robert J. 2000. Health Insurance Coverage, 1999. Current Population Reports, P60-211. Washington, DC: U.S. Census Bureau. Newacheck, Paul W., Jeffery J. Stoddard, and Dana C. Hughes. 1998. Health Insurance and Access to Primary Care for Children. New England Journal of Medicine 338(8):513–518. Newhouse, Joseph P. and The Insurance Experiment Group. 1993. Free For All? Lessons From the RAND Health Insurance Experiment. Cambridge, MA: Harvard

27

University Press. News Hour with Jim Lehrer/Kaiser Family Foundation. 2000. National Survey on the Uninsured, Menlo Park, CA: The Henry J. Kaiser Family Foundation. Rowland, Diane, Judith Feder, and Patricia Seliger Keenan. 1998. Uninsured in America: The Causes and Consequences. In: Stuart H. Altman, Reinhart Uwe E., and Alexandra E. Shields, eds. The Future U.S. Healthcare System: Who Will Care for the Poor and Uninsured? Waltham, MA; Chicago, IL: The Council on the Economic Impact of Health System Change/Health Administration Press. Pp. 25-44 Schoen, Cathy, and Catherine DesRoches. 2000. Uninsured and Unstably Insured: The Importance of Continuous Insurance Coverage. Health Services Research 35(1):187-206. Short, Pamela F. and Vicki A. Freedman. 1998. Single Women and the Dynamics of Medicaid. Health Services Research 33(5):1309–1336. Stevens, Rosemary. 1989. In Sickness and In Wealth: America's Hospitals in the Twentieth Century. New York, NY: Basic Books. Stone, Deborah. 1996. The Struggle for the Soul of Health Insurance. Journal of Health Politics Policy and Law 18(2):278-317h. Swartz, Katherine, John Marcotte, and Timothy D. McBride. 1993. Personal Characteristics and Spells Without Health Insurance. Inquiry 30:64–76. Swartz, Katherine. 1986. Interpreting the Estimates from Four National Survey of the Number of People without Health Insurance. Journal of Economic and Social Measurement 14:233-43. Weinick, Robin M., Samuel H. Zuvekas, and Joel W. Cohen. 2000. Racial and Ethnic Differences in Access to and Use of Health Care Services, 1977 to 1996. Medical Care Research Review 57 Suppl. 1:36-54. Weissman, Joel. S., and Arnold. M. Epstein. 1994. Falling Through the Safety Net: Insurance Status and Access to Health Care. Baltimore, MD: Johns Hopkins University Press. Wielawski, Irene. 2000. Gouging the Medically Uninsured: A Tale of Two Bills. Health Affairs 19(5):180-185. Wirthlin Worldwide. 2001. Uninsured Phone Study: January, 12-23, 2001. Princeton, NJ: Unpublished survey conducted for the Robert Wood Johnson Foundation. Zuvekas, Samuel H., and Robin M. Weinick. 1999. Changes in Access to Care, 1977-1996: The Role of Health Insurance. Health Services Research 34(1):271-279. Zweifel, P. J. and Willard G. Manning. 2000. Moral Hazard and Consumer Incentives in

28

Health Care. In: Culyer, A.J., Newhouse, J.P., eds. Handbook of Health Economics. Amsterdam: Elsevier. Pp. 410-459.

REFERENCES – Care Without Coverage Ayanian, John Z., Betsy A. Kohler, Toshi Abe, and Arnold M. Epstein. 1993. The

Relation Between Health Insurance Coverage and Clinical Outcomes Among Women with Breast Cancer. New England Journal of Medicine 329(5):326–331.

Ayanian, John Z., Joel S. Weissman, Eric C. Schneider, Jack A. Ginsburg, and Alan M. Zaslavsky. 2000. Unmet Health Needs of Uninsured Adults in the United States. Journal of the American Medical Association 284(16):2061–2069.

Baker, David W., Joseph J. Sudano, Jeffrey M. Albert, Elaine A. Borawski, et al. 2001. Lack of Health Insurance and Decline in Overall Health in Late Middle Age. New England Journal of Medicine 345(15):1106–1112.

Beckles, Gloria L. A., Michael M. Engelgau, K. M. Venkat Narayan, William H. Herman, et al. 1998. Population-Based Assessment of the Level of Care Among Adults with Diabetes in the U.S. Diabetes Care 21(9):1432–1438.

Blustein, Jan, Raymond R. Arons, and Steven Shea. 1995. Sequential Events Contributing to Variations in Cardiac Revascularization Rates. Medical Care 33(8):864–880.

Braveman, Paula, Mylo Schaaf, Susan Egerter, Trude Bennett et al. 1994. Insurance-Related Differences in the Risk of Ruptured Appendix. New England Journal of Medicine 331(7):444–449.

Breen, Nancy, Diane Wagener, Martin L. Brown, William Davis, et al. 2001. Progress in Cancer Screening Over a Decade. Results of Cancer Screening from the 1987, 1992 and 1998 National Health Interview Surveys. Journal of the National Cancer Institute 93(22):1704–1713.

Burstin, Helen R., Stuart R. Lipsitz, and Troyen A. Brennan. 1992. Socioeconomic Status and Risk for Substandard Medical Care. Journal of the American Medical Association 268(17):2383–2387.

Canto, John G., William J. Rogers, Yuan Zhang, et al. 1999. The Association Between the On-Site Availability of Cardiac Procedures and the Utilization of Those Services for Acute Myocardial Infarction by Payer Group. Clinical Cardiology 22(8):519–524.

Canto, John G., William J. Rogers, William J. French, Joel M. Gore, et al. 2000. Payer Status and the Utilization of Hospital Resources in Acute Myocardial Infarction. Archives of Internal Medicine 160(6):817–823.

Carlisle, David M., Barbara D. Leake, and Martin F. Shapiro. 1997. Racial and Ethnic

29

Disparities in the Use of Cardiovascular Procedures: Associations with Type of Health Insurance. American Journal of Public Health 87(2):263–267.

Carpenter, Charles C. J., Margaret A. Fischl, Scott M. Hammer, Martin S. Hirsch, et al. 1998. Antiretroviral Therapy for HIV Infection in 1998: Updated Recommendations of the International AIDS Society-USA Panel. Journal of the American Medical Association 280(1):78–86.

Cooper-Patrick, Lisa, Rosa M. Crum, Laura A. Pratt, William W. Eaton, et al. 1999. The Psychiatric Profile of Patients with Chronic Disease Who Do Not Receive Regular Medical Care. International Journal of Psychiatry 29(2):165–180.

Cummings, Doyle M., Lauren Whetstone, Amy Shende, and David Weismiller. 2000. Predictors of Screenings Mammography: Implications for Office Practice. Archives of Family Medicine 9(9):870–875.

Cunningham, William E., Ron D. Hays, Kevin W. Williams, K.C. Beck, et al. 1995. Access to Medical Care and Health-Related Quality of Life for Low-Income Persons with Symptomatic Human Immunodeficiency Virus. Medical Care 33(7):739–754.

Cunningham, William E., Ronald M. Andersen, Mitchell H. Katz, Michael D. Stein, et al. 1999. The Impact of Competing Subsistence Needs and Barriers on Access to Medical Care for Persons with Human Immunodeficiency Virus Receiving Care in the United States. Medical Care 37(12): 1270–1281.

Cunningham, William E., Leona E. Markson, Ronald M. Andersen, Stephen Crystal, et al. 2000. Prevalence and Predictors of Highly Active Antiretroviral Therapy Use in Patients with HIV Infection in the United States. Journal of Acquired Immune Deficiency Syndrome 25(2):115–123.

Daumit, Gail, Judith A. Hermann, Josef Coresh, and Neil R. Powe. 1999. Use of Cardiovascular Procedures Among Black Persons and White Persons: A 7-Year Nationwide Study in Patients with Renal Disease. Annals of Internal Medicine 130(3):173–182.

Daumit, Gail L., Judith A. Hermann, and Neil R. Powe. 2000. Relation of Gender and Health Insurance to Cardiovascular Procedure Use in Persons with Progression of Chronic Renal Disease. Medical Care 38(4): 354–365.

Doyle, Joseph J. 2001. Does Health Insurance Affect Treatment Decisions & Patient Outcomes? Using Automobile Accidents as Unexpected Health Shocks. Chicago: University of Chicago, unpublished MS.

Druss, Benjamin G., and Robert A. Rosenheck. 1998. Mental Disorders and Access to Medical Care in the United States. American Journal of Psychiatry 155(12):1775–1777.

30

Faulkner, Lisa A. and Helen Halpin Schauffler. 1997. The Effect of Health Insurance Coverage on the Appropriate Use of Recommended Clinical Preventive Services. American Journal of Preventive Medicine 13(6):453–458.

Franks, Peter, Carolyn M. Clancy, and Marthe R. Gold. 1993a. Health Insurance and Mortality. Evidence from a National Cohort. Journal of the American Medical Association 270(6):737–741.

Franks, Peter, Carolyn M. Clancy, Marthe R. Gold, et al. 1993b. Health Insurance and Subjective Health Status: Data from the 1987 National Medical Expenditure Survey. American Journal of Public Health 83(9):1295–1299.

Ferrante, Jeanne M., Eduardo Gonzalarez, Richard G. Roetzheim, Naazneen Pal, et al. 2000. Clinical and Demographic Predictors of Late-Stage Cervical Cancer. Archives of Family Medicine 9(5):439–445.

Fish-Parcham, Cheryl. 2001. Getting Less Care: The Uninsured with Chronic Health

Conditions. Washington, DC: Families USA Foundation. Goldman, Dana P., Jayanta Bhattcharya, Daniel F. McCaffrey, Naihua Duan, et al. 2001.

Effect of Insurance on Mortality in an HIV-Positive Population in Care. Journal of the American Statistical Association 96(455):883–894.

Haas, Jennifer S., and Lee Goldman. 1994. Acutely Injured Patients with Trauma in Massachusetts: Differences in Care and Mortality by Insurance Status. American Journal of Public Health 84(10):1605–1608.

Haas, Jennifer S., and Nancy E. Adler. 2001. The Causes of Vulnerability: Disentangling the Effects of Race, Socioeconomic Status and Insurance Coverage on Health.Background paper prepared for the Committee on the Consequences of Uninsurance.

Hadley, Jack, Earl P. Steinberg, and Judith Feder. 1991. Comparison of Uninsured and Privately Insured Hospital Patients. Journal of the American Medical Association 265(3):374–379.

Harris, Maureen I. 1999. Racial and Ethnic Differences in Health Insurance Coverage for Adults with Diabetes. Diabetes Care 22(10):1679–1682.

Huttin, Christine, John F. Moeller, and Randall S. Stafford. 2000. Patterns and Costs for Hypertension Treatment in the United States. Clinical Drug Investigation 20(3):181–195.

Institute of Medicine (IOM). 2001a. Coverage Matters: Insurance and Health Care.Washington, DC: National Academies Press.

———. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health

Care. Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson (eds.).

31

Washington, DC: National Academy Press. Kausz, Annamaria T., Gregorio T. Obrador, Pradeep Arora, Robin Ruthazer, et al. 2000.

Late Initiation of Dialysis Among Women and Ethnic Minorities in the United States. Journal of the American Society of Nephrology 11(12):2351–2357.

Leape, Lucian L., Lee H. Hilborne, Robert Bell, Caren Kamberg, et al. 1999. Underuse of Cardiac Procedures: Do Women, Ethnic Minorities, and the Uninsured Fail to Received Needed Revascularization? Annals of Internal Medicine 130(3):183–192.

Lee-Feldstein, Anna, Paul J. Feldstein, Thomas Buchmuller, and Gale Katterhagen. 2000. The Relationship of HMOs, Health Insurance, and Delivery Systems to Breast Cancer Outcomes. Medical Care 38(7):705–718.

Lurie, Nicole, N. B. Ward, Martin F. Shapiro, and Robert H. Brook. 1984. Termination from Medi-Cal: Does It Affect Health? New England Journal of Medicine 311(7):480–484.

Lurie, Nicole, N. B. Ward, M. F. Shapiro, et al. 1986. Termination of Medi-Cal Benefits: A Followup Study One Year Later. New England Journal of Medicine 314(19):1266–1268.

Mandelblatt, Jeanne S., Karen Gold, Ann S. O'Malley, Kathryn Taylor, et al. 1999. Breast and Cervix Cancer Screening Among Multiethnic Women: Role of Age, Health, and Source of Care. Preventive Medicine 28: 418–425.

McAlpine, Donna D., and David Mechanic. 2000. Utilization of Specialty Mental Health Care Among Persons with Severe Mental Illness: The Roles of Demographics, Need, Insurance, and Risk. Health Services Research 35(1):277–282.

Mills, Robert J. 2001. Health Insurance Coverage: 2000. Current Population Reports.Washington, DC: U.S. Census Bureau.

Obrador, Gregorio T., Robin Ruthazer, Arora Pradeep, et al. 1999. Prevalence of and Factors Associated with Suboptimal Care Before Initiation of Dialysis in the United States. Journal of the American Society of Nephrology 10(8):1793–1800.

Perkins, Carin, William E. Wright, Mark Allen, Steven J. Samuels, et al. 2001. Breast Cancer Stage at Diagnosis in Relation to Duration of Medicaid Enrollment. Medical Care 39(11):1224–1233.

Powell-Griner, Eve, Julie Bolen, and Shayne Bland. 1999. Health Care Coverage and Use of Preventive Services Among the Near Elderly in the United States. American Journal of Public Health 89(6):882–886.

32

Rabinowitz, Jonathan, Evelyn Bromet, Janet Lavelle, Kimberly Severance, et al. 1998. Relationship Between Type of Insurance and Care During Early Course of Psychosis. American Journal of Psychiatry 155(10):1392–1397.

Roetzheim, Richard G., Naazneen Pal, Colleen Tennant, Lydia Voti, et al. 1999. Effects

of Health Insurance and Race on Early Detection of Cancer. Journal of the National Cancer Institute 91(16):1409–1415.

Roetzheim, Richard G., Eduardo C. Gonzalez, Jeanne M. Ferrante, Naazneen Pal, et al. 2000a. Effects of Health Insurance and Race on Breast Carcinoma Treatments and Outcomes. Cancer 89(11):2202–2213.

Roetzheim, Richard G., Naazneen Pal, Eduardo C. Gonzalez, Jeanne M. Ferrante, et al. 2000b. Effects of Health Insurance and Race on Colorectal Cancer Treatments and Outcomes. American Journal of Public Health 90(11):1746–1754.

Shapiro, Martin F., Sally C. Morton, Daniel F. McCaffrey, J. Walton Senterfitt, et al. 1999. Variations in the Care of HIV-Infected Adults in the United States. Journal of the American Medical Association 281(24):2305–2315.

Shea, Steven, Dawn Misra, Martin Ehrlich, Lesley S. Field, et al. 1992a. Correlates of Nonadherence to Hypertension Treatment in an Inner-City Minority Population. American Journal of Public Health 82(12):1607–1612.

Shea, Steven, Dawn Misra, Martin H. Ehrlich, Lesley S. Field, et al. 1992b. Predisposing Factors for Severe, Uncontrolled Hypertension in an Inner-City Minority Population. New England Journal of Medicine 327(11):776–781.

Sorlie, Paul D., Norman J. Johnson, Eric Backlund, and Douglas D. Bradham. 1994. Mortality in the Uninsured Compared with That in Persons with Public and Private Health Insurance. Archives of Internal Medicine 154(21):2409–2416.

Turner, Barbara J., William E. Cunningham, Naihua Duan, Ronald M. Andersen, et al. 2000. Delayed Medical Care After Diagnosis in a US National Probability Sample of Persons Infected With Human Immunodeficiency Virus. Archives of Internal Medicine 160(17):2614–2622.

Wang, Philip S., Patricia Berglund, and Ronald C. Kessler. 2000. Recent Care of Common Mental Disorders in the United States. Journal of General Internal Medicine 15:284–292.

Young, Alexander, Ruth Klap, Cathy Sherbourne, and Kenneth B. Wells. 2001. The Quality of Care for Depressive and Anxiety Disorders in the United States. Archives of General Psychiatry 58(1):55–61.

Young, Gary J. and Bruce B. Cohen. 1991. Inequities in Hospital Care, the Massachusetts Experience. Inquiry 28: 255–262.

33

Zambrana, Ruth E., Nancy Breen, Sarah A. Fox, and Mary Lou Gutierrez-Mohamed. 1999. Use of Cancer Screening Services by Hispanic Women: Analyses by Subgroup. Preventive Medicine 29:466–477.

REFERENCES – Health Insurance Is a Family Matter Dubay, Lisa, and Genevieve M. Kenney. 2002. Expanding Public Health Insurance to Parents: Effects on Children's Coverage Under Medicaid. Washington, DC: Urban Institute. Duchon, Lisa, Cathy Schoen, Michelle M. Doty, Karen Davis, et al. 2001. Security

Matters: How Instability in Health Insurance Puts U.S. Workers at Risk. Findings from the 2001 Health Insurance Survey. Publication 512. New York: Commonwealth Fund.

Institute of Medicine (IOM). 2001. Coverage Matters: Insurance and Health Care.Washington, DC: National Academy Press.

Institute of Medicine (IOM). 2002. Care Without Coverage: Too Little, Too Late.Washington, DC: National Academy Press.

Ku, Leighton, and Matthew Broaddus. 2000. The Importance of Family-Based Insurance Expansions: New Research Findings About State Health Reforms. Washington, DC: Center on Budget and Policy Priorities.

Lambrew, Jeanne M. 2001. Health Insurance: A Family Affair. A National Profile and State by State Analysis of Uninsured Parents and Their Children. Publication 464. New York: Commonwealth Fund.

Quinn, Kevin, Cathy Schoen, and Louisa Buatti. 2000. On Their Own: Young Adults Living Without Health Insurance. The Commonwealth Task Force on the Future of Health Insurance 391. New York: Commonwealth Fund.

Shonkoff, Jack P., and Deborah A. Phillips (eds.). 2000. From Neurons to Neighborhoods. The Science of Early Childhood Development. Washington, DC: National Academy Press.

Urban Institute. 2002. Urban Institute Model for Uninsured and Enrollment Estimates. Washington, DC. Available at http://www.coveringkids.org/entrypoints/press/UrbanMethodology.pdf. Accessed August 5, 2002.

34

Volunteering Care for the Uninsured

H. Denman Scott, MD Brown University Center for Primary Care and Prevention

While the Debate on National Health Care Proceeds � What do we do for those who need care today, next month, next year? � What can the private sector do to complement the public safety net? � Specifically what can health professionals do? The Faces of the Uninsured

� Profiles developed by the Massachusetts Blue Cross Foundation � Text by Irene Wielawski � Photos by Jim Harrison

The Consequences of Being Uninsured

� A risk factor like: –Smoking –Hypertension –Obesity –Hyperlipidemia

Reach Out Physicians’ Initiative To Expand Care To Underserved Americans Reach Out Projects

35

Reach Out Projects

Models 1. The Freestanding Clinic 2. The Referral Network 3. Combined Clinic/Referral Network 4. Rural Integrated Primary Care Network 5. Public Health Private Partnership 6. Insurance Look-alike Model 7. Elective Surgical Care

Impact of Reach Out Projects • Almost 200,000 patients enrolled • 5,394 patients enrolled per project • Over 11,000 physicians participated • 289 physicians participated per project

Lessons Learned

• Physician leadership is indispensable. • Physician time required is not excessive. • Projects require a funded administrative structure. • Developing these types of projects is complex and time consuming. • Projects can locate local funding to sustain themselves.

More Lessons • Malpractice concerns were not borne out. • Patients’ problems are sometimes too complex for project resources.

36

• Projects are able to enroll patients in Medicaid, etc. • Collaborations between MDs and public health can be fruitful. • Projects benefit by information sharing.

Reach Out: A Demonstration

� Organized efforts requiring: � Leadership � Administration � Resources

Impact of 1,000 Volunteer Projects

Volunteers in Health Care A National Resource on Caring for the Uninsured Funded by Robert Wood Johnson Foundation Brown University Center for Primary Care and Prevention Identify Universe of Programs •1997 Goal: 1,000 on database •Current Database: 5,400 •Survey of 106 clinics (‘99 Great Lakes survey ) –16,000+ volunteers –201,000+ patients –280,000+ pt. visits VIH supports organized efforts and encourages volunteerism to address the health care needs of the uninsured: � Medical services

5 million patients enrolled (11% of uninsured)

Impact on 44 Million Uninsured if 289,000 physicians (56%)

participate

37

� Dental services � Pharmaceutical access VIH works with: � Community clinics � Federally qualified health centers � Hospital programs � Foundations � Private practices � Professional organizations VIH Programs •Organizational development involving volunteers –Start ups –Expansion •Malpractice/Charitable Immunity •Performance Improvement –Cultural competence –Chronic disease management •RxAssist and Rx Assist Plus VIH Websites •WWW.VOLUNTEERS IN HEALTH CARE.ORG – 120,000 hits per month •WWW.RXASSIST.ORG – 1.7 million hits per month VIH Small Grants � Start/strengthen a free clinic association � Improve pharmaceutical access � Expand dental services � Develop a primary care referral network � Computer scholarships � Evaluating community based programs serving the uninsured VIH Reports and Manuals � Managing medication samples � Creating public private partnerships that work � Fund raising on a shoestring � Providing mental health services to the uninsured

38

RxAssist/RxAssist Plus is one component of VIH’s pharmaceutical access activities and was developed: � To help providers get medication to eligible patients � To alleviate some of the complexity in obtaining medication � To help providers improve their office or clinic productivity RxAssist Patient Assistance Programs � 75 companies � 130+ programs � 800+ medications � 70 forms � 94 forms changed per year Prospects for Universal Health Care

• The US is preoccupied with war, home security, and a weak economy. • While clearly needed, a system of universal health care is unlikely over the next

few years. • Yet the medical needs of the uninsured remain. • Therefore, as we build political support for universal insurance, we must continue

our private initiatives.

39

Teaching About Care of Underserved Populations

James B. Reuler, M.D.

Division of General Medicine & Geriatrics Veterans Affairs Medical Center

Oregon Health & Science University The Wallace Medical Concern

Portland, Oregon

Faculty/Professional Development: • Formal coursework – national/local • National meeting offerings • Readings: medical;policy;lay • Interest groups/professional organization memberships • Local conferences

The ‘Traditional’ Curriculum:

• Small group facilitation: clinic conferences;seminars • One-on-one precepting • Attending/multidisciplinary rounds • Curriculum development: clinic/block experiences • Focus on relation to principles of professionalism

The ‘Subversive’ Curriculum:

• Service-learning concepts • Service-learning initiatives • Service-learning examples • Curriculum development principles • Mentoring in care for the underserved – electives/special experiences

Community Service:

• Community service ledger • Role modeling • Schweitzer Fellowship Program • National service awards

40

‘Special’ Opportunities: • Professional organization involvement • Faculty committees • Campus activities • Invited addresses • Testimony • Publications

Bibliography:

1) Burrows MS, Chauvin S, Lazarus CJ, et al. Required service learning for medical students: program description and student response. Teach Learn Med 1999;11:223-231.

2) Crawshaw R, Rogers DE, Pellegrino E, et al. Patient-Physician Covenant. JAMA 1995;273:1553.

3) Czarnecki C, Crane S, Morley JE, et al. A student-run geriatric home health care program. Acad Med 2001;76:199.

4) Dobie SA, Huffine C. Training medical students in community leadership. Acad Med 1994;69:428.

5) Eckenfels EJ. Contemporary medical students’ quest for self-fulfillment through community service. Acad Med 1997;72:1043-1050.

6) Faulkner LR, McCurdy RL. Teaching medical students social responsibility: the right thing to do. Acad Med 2000;75:346-350.

7) Green AR, Betancourt JR, Carrillo JE. Integrating social factors into cross-cultural medical education. Acad Med 2002;77:193-197.

8) GreenbergJS. Service-learning in health education. J Health Educ 1997;28:345-349.

9) Loxterkamp D. Hearing voices – how should doctors respond to their calling. N Engl J Med 1996;335:1991-1993.

10) Lurie N, Yergan J. Teaching residents to care for vulnerable populations in the outpatient setting. J Gen Intern Med 1990;5(suppl):S27-S34.

11) McCurdy L, Goode LD, Inui TS, et al. Fulfilling the social contract between medical schools and the public. Acad Med 1997;72:1063-1070.

12) Reynolds PP. Reaffirming professionalism through the education community. Ann Intern Med 1994;120:609-614.

13) Seifer SD. Service-learning:community-campus partnerships for health professions education. Acad Med 1998;73:273-277.

14) Seifer SD, Hermanns K, Lewis J, eds. Creating Community-Responsive Physicians: Concepts and Models for Service-Learning in Medical Education. Washington, DC:American Association of Higher Education; 2000.

15) Velezis MJ, Endeshaw Y. Learning through community participation: immunization program at an elementary school. Acad Med 2001;76:195-198.

41

Web Page Resources:

www.acponline.org ACP-ASIM policy/position paper resources www.ncpa.org National Center for Policy Analysis www.pnhp.org Physicians for a National Health Program www.cms.hhs.gov Centers for Medicare and Medicaid Services www.rwjf.org Robert Wood Johnson Foundation initiatives/analyses www.kff.org Henry J. Kaiser Family Foundation; health policy and public education www.schweitzerfellowship.org Schweitzer Fellowship program for medical students www.compact.org Campus Compact coalition committed to civic role of higher ed. www.nationalservice.org Corporation for National+Community Service www.futurehealth.ucsf.edu/ccph Community-Campus Partnerships for Health www.aamc.org/about/awards/cfc Caring for the Community student project grants www.aamc.org/about/awards/ocsa AAMC institutional community service award www.aamc/org/members/orr/communitysvcaward Org. of Resident Representatives