ing and providing health care to those without the means to pay (the “medically indigent”), including people without health insurance. The second and third sections describe the current mix of public and private financing and delivery arrangements involved in caring for uninsured persons, including the roles of government, health care institutions and professionals, and philanthropies and the issue of shifting costs to, or getting subsidies from, private payers (insurers and employers). The fourth section is a summary of what is known and what remains to be learned about how the present arrangements for financing and providing health care generally, and uninsured care in particular, have made uninsurance a critical and destabilizing factor in local health care markets and community economies today. Readers who are familiar with this historical background and policy context may want to turn immediately to the fourth section, which identifies research questions and data needs and then to Chapters 3 through 6, which provide the Committee’s findings and conclusions regarding community effects.


Over the past 25 years, federal and state policies to control health care costs and an increasingly competitive private market for health care services and coverage have constrained public payer and commercial reimbursement rates for care. As a result, there has been an erosion of the previous level of public support and private cross-subsidy for the uncompensated care costs associated with providing health services to uninsured persons. The effects of this erosion have been felt more strongly in communities with large or growing uninsured populations and by providers (e.g., public hospitals) that serve a high number or proportion of uninsured persons.

As health insurance has become more central both as a means to access care and to the support of health care providers and institutions, the presence of sizable uninsured populations in communities has become a common explanation for, or the most obvious proximal cause of, health system failings and inefficiencies. Understanding why and how this has happened requires some appreciation of the development of the present public and private structures for financing health services. This historical context also aids an objective appraisal of evidence as to what health system and community-wide effects can validly be attributed to local uninsured rates rather than to other aspects of the overall structure of health care finance.

The public–private amalgam of health insurance mechanisms and the mixed delivery system of private not-for-profit, private for-profit, and public health care institutions and services are a legacy of America’s particular history and notions of the public good. Over the past century in the United States, the concurrent development of private and public approaches to financing health care (and the

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