accumulate uncompensated costs that may impair their ability to continue delivering care.

Governments, health care practitioners and institutions, philanthropies, and private payers all play a part in serving or paying for the care of uninsured Americans. The implicit subsidies are considerable, and their target efficiency and adequacy are difficult to judge. Ultimately, there is no comprehensive or coordinated approach to caring for uninsured persons. The financial implication of this reality—namely, uncompensated care—sets into motion a number of potential community effects of uninsurance.

The growth over the past several decades in the importance of health finance in the U.S. economy and government finances magnifies market distortions and inequities and inefficiencies in the allocation of public resources. Hospital uncompensated care was much easier for both governments and the institutions themselves to address when Medicaid and Medicare together accounted for much less of the national spending on hospital care than the 48 percent that they currently do (Cowan et al., 2001). The DSH payments under those two federal programs, although substantial and essential supports for institutions that are major providers of care to the uninsured, are blunt tools.

Mainstream health services delivery and the provision of care to and financing of care for uninsured Americans are fundamentally interrelated. Although these two components of the health care enterprise are often treated as separate entities with distinct constituencies governed by separate policies, they cannot be understood in isolation from one another. This is especially evident when tracing the funding streams that pay for the care the uninsured receive and the impacts on health care institutions and providers locally when the proportion of uninsured residents is relatively high or increasing. Despite the relatively stable proportion of the national population without health insurance over the past two decades, major changes in the financing and organization of health care services in both the public and the private sectors have changed the significance and impact of uninsured populations for health care providers and governments at all levels.

The next three chapters examine community health care services and access, social and economic institutions, and population health in conjunction with local uninsurance.