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Appendixes

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A A Conceptual Framework for Evaluating the Consequences of Uninsurance: A Cascade of Effects The Committee's conceptual framework for evaluating the consequences of uninsurance is depicted in Figure A.1. This three-part framework is based on an economic model of insurance status and the impact of out-of-pocket costs on health care demand. Both have been linked to Andersen's model of access to health services, which incorporates ideas from the behavioral sciences to under- stand the processes of health services delivery and health-related outcomes for individuals (Andersen and Davidson, 2001~. The framework uses the Andersen model's grouping of variables into three categories: (1) resources that foster or enable the process of obtaining health care; (2) personal or community characteristics that favor or predispose action related to obtaining health care; and (3) needs for health care, as articulated by those in need, determined by health care providers, or identified by researchers and deci- sion makers. Arrows and spatial relationships among the boxes indicate hypoth- esized causal and temporal relationships. For example, a woman might have insur- ance coverage for a mammography screening, but if she has no regular source of care and lives 20 miles from the nearest facility offering such service, she could face obstacles to obtaining care. This case can be followed through the model, as shown below. For the purposes of this study, the Committee linked Andersen's model to determinants of health insurance status. These changes to the model allow one to characterize not only individual- and population-level health indicators, but also economic measures of family well-being, institutional viability, and community- level socioeconomic conditions. In addition, depicting the economic consequences of uninsurance allows the Committee to assess hypothesized interactions between 109

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APPENDIX A 111 economics and health and, in particular, the growing literature on the psychoso- cial dimensions of family well-being and childhood development. PANEL 1: DETERMINANTS OF COVERAGE The left third of Figure A. 1 addresses the key determinants that influence the coverage status of individuals and families. Individual- and family- level characteristics include financial resources, categorical eligibility for public health insurance, labor market characteristics associated with employment-based insurance, and the requisite skills to enroll and maintain coverage. In the example, the woman's eligibility for coverage of mammography screening would be an individual determinant of coverage, the top box in Panel 1. In the model, com- munity-level factors include public program eligibility standards, labor market characteristics that determine the availability of employment-based health insur- ance, and the commercial market for individual health insurance. This is a con- densed version of the detailed figure on determinants of eligibility and enrollment (Figure 2.2), and the logic laid out in Chapter 2. PANEL 2: PROCESS OF OBTAINING ACCESS TO HEALTH SERVICES The center third of Figure A.1 is based on Andersen's model of access to health care (Andersen and Davidson, 2001~. The boxes labeled "commu- nity level" and "individual and family level" each contain aggregate and indi- vidual-level variables, respectively, believed to influence how people obtain access to health care. Community-level variables describe the context or environment within which individuals and their families seek and use health care. Because health care services are provided and consumed locally, the term "community" refers to a residential or geographic grouping. The woman discussed earlier lived 20 miles from a mammography site, a factor that would be included in the lower left box of Panel 2. Implicit in grouping variables into the categories of resources, characteristics, and needs are judgments about how much a particular variable may be susceptible to change. Variables labeled as "resources" are considered, at least theoretically, to be more open to change. Those termed "characteristics" are considered less flex- ible or manipulable, and those called "needs" comprise a mixed or heterogeneous grouping, with some needs being more changeable than others. As a whole, community-level and individual- and family-level variables de- scribe many potential scenarios for accessing health care. The variables within the box labeled "health care" describe how these potentials may be realized, with particular attention to the role of health insurance coverage. The process of health care delivery is characterized in terms of three types of variables: (1) personal health practices (e.g., dietary habits, physical exercise), (2) the use of health ser- vices (e.g., number and kind of physician visits within a year), and (3) processes of

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2 CO VERA GE MA TTERS: INSURANCE AND HEALTH CARE care (e.g., adherence to clinical practice guidelines). In the example given, the woman's lack of a regular source of care would fall into this box on the right of Panel 2. The Committee focuses most of its attention on the literature concerning the processes of services delivery and the utilization of health services while recognizing that personal health practices may be influenced by insurance cover- age and access to care. PANEL 3: HOW HEALTH INSU12ANCE INFLUENCES HEALTH OUTCOMES AND AFFECTS FAMILIES AND COMMUNITIES The right side of Figure A.1 describes the ways in which the Committee anticipates that health insurance status may affect the health, eco- nomic, and social characteristics of individuals, families, and communities, by means of access to and utilization of health care. These effects of realized access to health care cascade from the smallest unit of analysis, the individual, to increasingly larger units, first that of the family and then the community. The consequences linked to health insurance influence community-level and individual- and family- level variables that describe the process of obtaining access to health care and also of gaining or losing health insurance coverage. The process is dynamic with multiple feedbacks. Employment status and income influence insurance status, which affects current and future health status. This in turn can influence employ- ment status, bringing us full circle. The woman discussed in the example might have a malignant lump that goes undetected because the obstacles mentioned above deter her from seeking a screening mammogram. She could undergo more extensive surgery and related treatments than would have been necessary if the lump had been detected earlier. This would be a negative health outcome (the top box in Panel 3) that might affect her family in serious ways (middle box of Panel 3) and might also affect her eligibility for health insurance in the future (back to Panel 1, top box). This conceptual framework provides a basis for discussing many variables related to health insurance coverage in this report. It will also serve to guide analyses for the Committee's future reports. As the Committee focuses on specific issues, such as health outcomes or the effects on families, specific pieces of the model will be discussed in more detail.