increase in costs is predicated on there being no major structural changes or reforms in the way health care is financed and delivered. The forecasts also assume no major differences in the mix of plans that would cover the uninsured from those which now cover the privately or publicly insured populations, in terms of scope of benefits, extent of coverage (levels of deductibles, copayments, stop losses, and other cost-sharing elements), or utilization review and other care management practices.

In addition, the estimates that follow assume that the current capacity of the health care system is sufficient to meet the increased demand without generating additional inflation in health care prices. This assumption may not hold in those localities with particularly large uninsured populations and limited health care delivery resources. In any case, estimates of inflation in health care prices would depend on the particular features of a proposed health care reform, including any explicit cost control elements. The possible alternatives are too numerous to be considered in this report.

In what follows, the Committee presents results from the studies by Long and Marquis (1994), by Miller, Banthin, and Moeller (2003), and by Hadley and Holahan (2003b). We do not review the older literature on comparisons of alternative health plans because the estimates depend on very specific features and are usually targeted at the cost of the entire reform proposal, not just the increase in cost for covering those currently uninsured. Typically, the latter is much smaller than the former. We also do not review studies of the effects of cost sharing on demand for health services because there are a number of reviews in the literature that evaluate the response to out-of-pocket costs; see Zweifel and Manning (2000) for one of the most recent.


Stephen Long and Susan Marquis (1994) predicted the additional ambulatory and hospital care that the population without health insurance could be expected to use if they had health insurance. Their work was based on data from the middle to late 1980s from three nationally representative surveys: the National Medical Expenditure Survey (NMES), the Survey of Income and Program Participation (SIPP), and the Health Interview Survey (HIS). Based on their estimates of differences in use, they predicted the utilization experience that uninsured people would be expected to have if they were in a typical employment-based plan. The 1987 NMES provided the uninsured population sample, updated by the Census Bureau’s Current Population Survey (CPS) to account for changes in the size and mix in the uninsured population between 1987 and 1992. The authors termed the difference in utilization for this standard population in the uninsured and insured states as the “access gap” attributable to lacking coverage. The model assumed that other aspects of health care financing and delivery, such as the mix of prepaid and fee-for-service health plans, cost-sharing provisions, and scope of benefits, re-

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