In addition to geographic variations, racial and ethnic disparities in health care are pervasive (IOM, 2002c). An extensive body of research documents that racial and ethnic minorities receive lower-quality care—both routine and specialty—than nonminorities, and these variations persist after accounting for the patient’s insurance status and income level (Ayanian et al., 1993, 1999; Barker-Cummings et al., 1995; Epstein et al., 2000; Gaylin et al., 1993; Hannan et al., 1999; Herholz et al., 1996; Johnson et al., 1993; Petersen et al., 2002; Williams et al., 1995).

The escalating cost of health insurance not only consumes a sizable proportion of gross national product, but also contributes to rising numbers of uninsured—nearly 45 million people in 2003, or about one in seven Americans (Fronstin, 2004; Kaiser Family Foundation, 2004c). Many other Americans have only minimal insurance coverage and a limited ability to pay for services out of pocket (Collins et al., 2004; Kaiser Family Foundation, 2004a,b). Some of the uninsured and underinsured receive services through safety net providers, such as public and critical access hospitals, community health centers, and rural health clinics, and some providers, such as academic health centers, provide a sizable share of uncompensated services to the uninsured (Moy et al., 1996; Reuter and Gaskin, 1998). But a large gap remains between the services that are available and those that are needed by the uninsured. On the whole, the uninsured are less likely than those with insurance to receive services from which they would likely benefit, and the services that are provided are less timely (IOM, 2002a). This is also the case for insured individuals with high deductibles and copayments and modest financial resources (Rice and Matsuoka, 2004). The lack of insurance for so many Americans results in serious health consequences and economic costs not only for the uninsured, but also for their families, the communities in which they live, and the entire nation (IOM, 2004b). Most families with one or more uninsured members have lower incomes and are more likely to spend a high proportion of family income on health relative to insured families (IOM, 2002b). In communities with high uninsurance rates, even those with insurance may encounter reduced access to clinic-based primary care, specialty services, and hospital-based care, particularly emergency medical services and trauma care (IOM, 2003b). Society as a whole incurs other costs for gaps in health insurance, including lost health and longevity and lost workforce productivity (IOM, 2003c).

The United States is among the few industrialized countries in the world that does not guarantee access to health care and health insurance coverage for its population (IOM, 2004b). Although many factors likely contribute to the nation’s high rates of uninsurance, there is little doubt that rapidly rising health care costs, driven in part by waste in the current health system, hamper efforts to expand coverage.

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