Shared Destiny documents a number of these interactions and presents working hypotheses about many more.

Health care practitioners and institutions are an important part of most local communities, knitting together the lives of individual community residents as providers facilitate access to care, contribute to local economic vitality, and protect and improve the health of community members. Even for healthy community members, having a regular health care provider and more advanced medical services and resources available has real value. These health care relationships and resources enhance the quality of our lives and peace of mind.

The failure to insure all members of American communities can distort and even disrupt these relationships between health care providers and the people they serve. Uninsured persons have much more trouble finding health care providers who will see them, use health care services much less often when they need care than do insured persons, and are more likely to incur high unreimbursed costs when they do obtain care (IOM, 2001a, 2002b). As a result, the presence of a sizable or growing population of uninsured persons may impose destabilizing financial stresses on the health care providers that serve all community members and on the public and private sources that finance local health care. Lack of access to health care results in adverse economic, social, and health consequences for uninsured persons and their family members (IOM, 2001a, 2002a, 2002b). Ripple or spillover effects of these consequences on uninsured persons may be felt by their insured neighbors. For example, an uninsured breadwinner’s lack of health care can lead to disability and loss of income that necessitates public support payments.

This fourth report of the Committee on the Consequences of Uninsurance explores the ways in which many others may be affected by the lack of health insurance of some of us. The Committee hypothesizes a series of spillover effects of uninsurance, effects that extend beyond the adverse health and financial impacts on uninsured individuals and families documented in Coverage Matters, Care Without Coverage, and Health Insurance Is a Family Matter. A Shared Destiny establishes an analytic framework for thinking about the causal pathways hypothesized to lead to the more widespread impacts of uninsurance, assesses the limited empirical evidence that exists about community effects, and proposes a research agenda to better demonstrate the presence or absence of these effects.

Given the large, persisting population of uninsured persons in the United States, the current economic environment and state government fiscal situations make the problems of uninsurance even more urgent and in need of remedy. The national uninsured rate of 16.5 percent among persons under age 65 masks substantial variation in state and local uninsured rates, median durations of uninsured spells of individuals, and the sizes and concentrations of uninsured groups within different populations (Mills, 2002). Uninsured rates vary across the states from 8.7 percent in Iowa to 26 percent in Texas (see Figure ES.1).

Over the past two decades the uninsured rate and total number of uninsured nationally has grown slowly but steadily (with only a slight dip during 1999 and 2000). With the current combination of higher unemployment and rapidly rising



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