sion, the Committee takes the perspective of community residents as consumers of health care and reports on local health services arrangements as typically encountered by someone seeking care. Focusing on the types of services as they may be affected by uninsured rates, rather than on providers and institutions, allows a more systematic perspective on the adequacy of health services throughout the community (see IOM, 2001b). In addition, the mere survival of particular institutions may not be a good proxy for the availability of high-quality care (particularly primary care) or for judging the impacts of uninsurance in a rapidly changing health care system or market. Nonetheless, the value of a hospital or clinic may include contributions to a community’s social and economic base or serve as a source of community identity. Thus, changes related to uninsurance may have additional effects beyond those related to access and quality of care. These values are discussed in the next chapter, which addresses some potential social and economic effects of uninsurance.

While insurance facilitates access to health care by removing or diminishing financial barriers faced by individuals and families, it also secures a revenue stream for health care providers and institutions (IOM, 2001a, 2002a, 2002b). The Committee hypothesizes that when this revenue stream is diminished by higher local uninsured rates, providers may opt to change their patterns of service provision within the community in an effort to preserve revenues. Depending on the local organization of health services, this provider phenomenon would be expected to affect the opportunities of insured residents to obtain health care. Lower-income residents are particularly likely to be affected by loss of access to care because of their limited economic ability, for example, in rural areas to travel long distances to obtain services unavailable locally or to pay higher costs for care.

Three recent studies examine the relationship between self-reported access to care and community uninsurance in urban areas (Cunningham and Kemper, 1998; Brown et al., 2000; Andersen et al., 2002). All of the studies rely on survey data about self-reported access to care, using a number of different measures (e.g., difficulty obtaining care, not having seen a physician in the previous 12 months).

The first study, based on the nationally representative 1996–1997 Community Tracking Study (CTS) Household Survey, examines the differences among metropolitan statistical areas (MSAs) larger than 200,000 population in the rates

Front Matter (R1-R18)

Executive Summary (1-14)

1 Introduction (15-33)

2 Context for Community Effects: Uninsurance and the Financing and Delivery of Health Services (34-81)

3 Community Effects on Access to Care (82-119)

4 Economic and Social Implications of Uninsurance Within Communities (120-137)

5 Community Health and Uninsurance (138-161)

6 Summary: Conclusions and Research Agenda (162-174)

Appendix A: Conceptual Framework for Assessing the Consequences of Uninsurance for Communities (175-179)

Appendix B: Geographic Differences in Uninsured Rates (180-188)

Appendix C: Data Tables (189-202)

Appendix D: Commissioned Papers (203-235)

Appendix E: Glossary (236-241)

Appendix F: Biographical Sketches (242-253)

References (254-276)