Hidden Costs, Value Lost attempts to answer another fundamental question: Who ultimately bears the costs consequent to uninsurance within the U.S. population? Understanding who eventually pays for the health care that uninsured people receive and the economic value lost as a consequence of not receiving adequate care are important to evaluating alternatives for expanding coverage.


This report is the fifth in a series of studies that constitute a systematic assessment of the ramifications of failing to include millions of people each year in the predominant organizational form and financing mechanisms for health care services in the United States, private and public health insurance. The Committee has approached its task in a stepwise fashion. It has analyzed the highly complex and interactive health services and insurance sectors and government health and social welfare programs by focusing on different parts of the overall picture in each of its reports to date. Figure 1.1 displays this sequential and cumulative analytic approach as concentric rings spreading out from individual health outcomes, through families and communities, to the social and economic effects of uninsurance in the aggregate, at the national level. This report “slices” through each of these layers and consolidates information about the costs related to each one.

The rest of this section recaps in broad terms the subjects and general conclusions from the previous four reports and notes how their findings are used in this report.

Coverage Matters: Insurance and Health Care (IOM, 2001a), the Committee’s introductory report, presented an overview of the dynamics of health insurance coverage in the United States and estimates of the number and characteristics of the population that lacks coverage. It also highlighted discrepancies between the Committee’s findings based on empirical research and popular beliefs and understanding of the causes and implications of uninsurance in order to promote greater public awareness of and greater insight into the persistent national problem of uninsurance.

The second report, Care Without Coverage: Too Little, Too Late (IOM, 2002a), was a critical review of clinical and epidemiological health outcomes research that evaluated the effect of health insurance status on a variety of general and condition-specific indicators and outcomes for American adults younger than 65. The Committee concluded in this report that health insurance is associated with better health outcomes for adults and with the receipt of appropriate care across a range of preventive, chronic, and acute care services. Adults without health insurance have shorter lives and greater declines in health status over time than those with continuous coverage. Care Without Coverage developed illustrative estimates of excess deaths associated with being uninsured for the adult population under age 65, both overall and for several specific diseases. Overall, the Committee estimated that the uninsured adult population under age 65 experiences roughly 18,000

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