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4
Analytic Plan
This chapter describes the Committee's analytic plan to address the impacts
and outcomes of our present structure of health insurance, the scope of the five
future reports, and the schedule for their release. Each report in turn will focus
successively on larger and more complex entities the individual, the family, the
local community, and the broader society. By proceeding systematically in this
way, the Committee hopes to capture the distinctive effects of the lack of health
insurance at each level of analysis. The conceptual framework discussed in Chap-
ter 1 and presented in Appendix A will guide the analyses and be developed
further in subsequent reports.
FUTURE COMMITTEE REPORTS
Report 2. Health Outcomes of People Who Lack Health
Insurance
As already established by more than three decades of health services research,
insurance coverage facilitates access to health care. The more that people have to
pay out-of-pocket for a physician visit, prescription, or hospitalization, the less
likely they are to seek such care. They are also likely to receive fewer services
when they do seek care (Newhouse et al., 1993~. In the extreme case ofthose with
no insurance, people are less likely to receive health care when they need it
compared to those with coverage. The second report will extend the understand-
ing of the significance of health insurance coverage by examining personal health
outcomes (including self-reported health status, disease-specific morbidity, avoid-
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CO VERA GE MA TTERS: INSURANCE AND HEALTH CARE
able hospitalizations, and mortality) in relation to whether or not a person has
health insurance.
Studies that distinguish between those without coverage for shorter and longer
periods of time and studies of the impact of losing health insurance coverage
provide evidence of the effects of coverage on some health outcomes, in addition
to the definitive findings regarding access to health care described in Chapter 1.
For example, a study by Ayanian and colleagues (2000) identifies both difficulties
in obtaining care and deficits in the quality of care for uninsured persons with
specific chronic conditions. This study reports that adults who were uninsured for
a year or longer were substantially less likely than those with coverage or those
who were uninsured for shorter times to be screened for cancers, to receive
services that reduce cardiovascular risks (e.g., hypertension, cholesterol screening
and counseling about weight and smoking), and to receive regular care for diabe-
tes, including foot and eye exams. These specific services are associated with
improved longer-term health outcomes (Institute of Medicine, 2001~.
Longitudinal studies following the same individuals over time can provide
even more definitive evidence of the health effects of being uninsured, because
unexamined characteristics of the study population are less likely to account for
differences in outcomes between those with and those without insurance. In a
study that followed a cohort of adult Medi-Cal beneficiaries who lost coverage in
the mid-1980s, Lurie and colleagues found that both six months and one year after
losing coverage, these persons reported poorer overall health and were less likely
to have a usual source of care or believe that they could obtain care if needed than
they had reported when participating in Medi-Cal. Former enrollees with hyper-
tension had worse blood pressure control both at six months and one year than
they had while enrolled in Medi-Cal (Lurie et al. 1984, 1986~.
These are just two of literally hundreds of studies that have taken health
insurance status into account as a characteristic that might affect a health outcome
of some kind. Not all such studies have found a relationship between health
insurance and health outcomes, and not all such studies are methodologically
sound. The second report will present and use explicit criteria to assess evidence of
the impact of health insurance status on individual adult health outcomes. The
conceptual model discussed earlier will guide the analysis. The second report, on
health outcomes, will be issued in the spnug of 2002.
Report 3. Family Impacts of Lacking Health Insurance
In almost a quarter of all American families with children, at least one family
member lacks health insurance (Hanson, 2001~. An estimated 10 million children
under the age of 18 remain uninsured, despite enactment of the State Children's
Health Insurance Program (SCHIP) in 1997. Because children depend on their
parents or other adults to obtain health care for them, parents' experiences with
the health care system, their beliefs about health care, and their ability to negotiate
that system on their children's behalf are important. Providing health insurance to
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children removes one barrier to access to care, but it may do little to remove other
barriers that spring from the family context. Furthermore, if the health of unin-
sured adults suffers as a result of impeded access to care, their ability to care for
their children may also be adversely affected. Finally, when one or more family
member lacks coverage for health care, the entire family is exposed to potentially
catastrophic financial costs. Even when confronted with less catastrophic illness,
uninsured families are significantly more likely to have high out-of-pocket medi-
cal expenses than are privately insured or Medicaid-enrolled families, although
privately insured families are likely to pay more in health insurance premiums
(Davidoff et al., 2000~.
The Committee will review and document the effects on families when one
or more members lack health insurance. It will address the circumstances of and
impacts on special populations and various family structures. The report will
examine a variety of effects, including measures of family members' health and of
. ,
children's developmental status, access to and use of health services, financial
burdens, and family psychosocial stress. Taking the family as the primary unit of
analysis, the report will identify patterns of health insurance coverage within
families in order to discern relationships between parents' insurance and health
status and their children's health insurance status, use of health services, and health.
The report will also examine health insurance status in relation to the family's out-
of-pocket costs for medical care and its financial well-being and stability. The
research literature on health outcomes for children who have gained health insur-
ance coverage in recent expansions of Medicaid and with SCHIP will be synthe-
sized in the report. The third report, onfamily impacts, will be issued in thefall of 2002.
Report 4. Community-wide Effects of Uninsured Populations
The presence of substantial numbers of uninsured people may adversely affect
communities as well as the uninsured individuals and their families. The "spillover"
effects on the insured population and the community at large could be consider-
able, although these are not well documented or understood. Faced with a need
for health care, some people without health insurance seek the care they need and
pay for it out-of-pocket, some try to obtain the care at subsidized rates or at public
expense, and some forgo care. The result for the individual is often poorer than
that obtained by people with insurance coverage. Several sources estimate that
uninsured persons obtain about two-thirds of the care of comparable insured
populations (Marquis and Long, 1994-1995~. The fourth report will focus on the
often indirect and hidden costs to communities of serving those without insur-
ance.
Physicians working in private practice, nonprofit clinics such as federally
qualified health centers (FQHCs), government-sponsored primary care and spe-
cialty clinics, and hospitals all provide significant amounts of subsidized or free
care. Institutional providers such as hospitals and clinics must obtain funds to cover
the costs of subsidized care from revenue generated from paying patients (cost
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CO VERA GE MA TTERS: INSURANCE AND HEALTH CARE
shifting), tax-based subsidies, or private philanthropy. Thus, one set of community
impacts may include higher prices, higher taxes, or dependence on philanthropy
to support care for persons without health insurance.
Other community consequences result from the financial burden placed on
providers who treat large numbers of uninsured patients. These effects may in-
clude cutbacks in service, closure or relocation of services, overcrowded emer-
gency rooms, and relocation of physicians' offices or even hospitals from areas of
town that have concentrations of uninsured persons. These disruptions may re-
duce people's access to care regardless of their insurance status. A third potential
impact of uninsured populations on communities follows from the failure to
obtain needed health care for communicable diseases, such as treatment for tuber-
culosis or diagnosis of HIV infection. Although these effects have not been well
documented by published research, the Committee intends to investigate available
sources of information to examine whether there are public costs related to pre-
ventable disability and an increased incidence of communicable diseases related to
uninsured populations.
The report will identify the nature and magnitude of effects on geographically
defined communities in which differing proportions of the population lack health
insurance with a focus on communities (municipalities, metropolitan areas, rural
areas, states) that have disproportionately large uninsured populations. Impacts in
rural communities may differ from those in urban areas and will be examined in
some detail. The Committee will document the relationships of community unin-
sured rates to economic and industrial characteristics, public health and welfare
programs, population demographics, and health care professional and institutional
resources. Specifically, the report may explore the relationship between commu-
nity levels of uninsurance and the general availability and quality of physician
services, emergency medical services, and highly specialized institutional services
such as trauma, burn, and intensive care units. The fourth report, on community
impacts, will be issued in the winter of 2003.
Report 5. Economic Costs of an Uninsured Population
The fifth report will estimate various economic costs incurred by society
resulting from the fact that a significant percentage of the U.S. population lacks
health insurance. Whereas the previous report on community impacts will exam-
ine local costs, both economic and other kinds, the fifth report will consider
a broader array of financial impacts on individuals, families, and the national
economy. To the extent possible, the analysis will include estimates of selected
direct costs of providing health care to the uninsured, increased costs resulting
from the inefficient use of health services, and the indirect costs of preventable
disability and lost productivity among uninsured persons with specific health
conditions. The report will explore how the burden of costs is paid, including out-
of-pocket payments by the uninsured and their families, uncompensated care by
health care providers and institutions, tax levies by all levels of government, higher
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health insurance premiums to support cost shifting, gifts from philanthropies, and
the indirect cost of disability on business operations. The report will present a
clearer understanding of the extent to which society already pays to care for the
uninsured. The fifth report, on economic costs, will be issued in the spring of 2003.
Report 6. Strategies and Models for Providing Health
Insurance
In its final report, the Committee will examine selected state, local, federal,
and private-sector policies and programs that have attempted to mitigate the
adverse impacts of lack of health insurance on individuals, families, health care
providers, and communities by expanding insurance coverage. The report will
identify promising prototypes as well as innovative approaches to the problem of
uninsurance. A goal of the report will be to identify policy criteria that can be used
to assess the merits of alternative reform strategies, rather than to endorse or
recommend specific reform approaches. The sixth report, on model programs and
policies, will be issued in late summer of 2003.
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Representative terms from entire chapter:
insurance coverage
