Second, the estimate of the value of health capital that would result from universal coverage is dependent on the value imputed to a QALY through the stated-preference technique of contingent valuation. Although the value the Committee uses is consistent with current practice in many government agencies reflecting implicit tradeoffs between money and safety, this technique and the value ascribed are both subject to development and revision with further study and application. Again, the Committee believes that the analysis presented here makes reasonably cautious and conservative assumptions.

Third, although the estimate of the direct health care costs now incurred by uninsured Americans has been derived from two independent sources and is well documented and based on reasonable assumptions (see Hadley and Holahan, 2003a), it should not be assumed that these costs necessarily would be offset or eliminated by universal coverage. The extent to which a program of universal coverage would “capture” any of these current subsidies and expenditures depends on the specific provisions of the approach adopted.

Fourth, the resource costs projected in Chapter 5 for increasing the utilization of health care services by uninsured Americans to the level of utilization by those who have coverage should not be construed as the cost of any particular program or set of policies resulting in universal health insurance coverage. Furthermore, the costs of such expansions of insurance coverage are likely to be distributed quite differently from the incidence of costs and burdens associated with the status quo. These projections answer a much narrower question than the questions that would need to be addressed in developing cost estimates for any policy reform proposal. The Committee presents these projections in order to compare the value of statistical healthy life years that would be gained by uninsured individuals if they were to acquire lifelong health insurance coverage in terms of the costs of additional services that would allow them to achieve better health.

Finally, this report and the estimates and analyses it contains are initial efforts at developing an integrated and coherent framework for evaluating a variety of economic costs attributable to the lack of health insurance across the U.S. population. It should not be the last word on the subject. Throughout the report, the Committee notes important questions that cannot be answered adequately because of the lack of data or research. Although this report does not explicitly develop an agenda for further research, the limits of what can be said about the costs due to uninsured populations implicitly point to such an agenda.


This chapter has presented the analytic context, concepts, and approach that the Committee employs in the remainder of the report and acknowledged the limitations of the analysis. The following chapter considers the health care services costs incurred by uninsured Americans and identifies who ultimately bears these costs.

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