. "Appendix A: Conceptual Framework for Assessing the Consequences of Uninsurance for Communities." A Shared Destiny: Community Effects of Uninsurance. Washington, DC: The National Academies Press, 2003.
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A Shared Destiny: Community Effects of Uninsurance
the Committee to assess hypothesized interactions between economics and health. The Committee recognizes that insurance is one of many factors that can influence the physical, social, and economic health of communities and their health care arrangements.
CONCEPTUAL FRAMEWORK INTRODUCED IN COVERAGE MATTERS
The left panel of Figure A.1 addresses the main economic forces affecting the insured or uninsured status of individuals and families. Individual- and family-level characteristics include financial resources, categorical eligibility for public health insurance, labor market determinants of employment-based insurance, and the requisite skills to enroll and maintain coverage. Community-level factors include public program eligibility standards, labor market characteristics that determine the availability of employment-based health insurance, and the commercial market for individual health insurance.
The center panel of Figure A.1 is based almost directly on Andersen’s model of access to health care (Andersen and Davidson, 2001). The boxes labeled “individual and family level” and “community level” contain individual- and aggregate-level variables, respectively, believed to influence how people obtain access to health care. Community-level variables are ecologic or aggregate measures to describe the context or environment within which individuals and their families seek and use health care. For example, the community’s morbidity rate for whooping cough might indicate the need for an immunization campaign. Because health care services are provided and consumed locally, the term community refers to a geographic grouping.
Implicit in the categories of resources, characteristics, and needs are judgments about how much a particular variable may be susceptible to change. Variables labeled “resources” are considered, at least theoretically, to be more open to change. Those termed “characteristics” are considered less flexible 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 describe 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) use of health services (e.g., number and kind of physician visits within a year), and (3) processes of care (e.g., adherence to clinical practice guidelines). 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 coverage and access to care.
The right panel of Figure A.1 describes the ways in which the committee