5
Summary of Findings and Recommendation

From 2001 to 2004, the Institute of Medicine (IOM) Committee on the Consequences of Uninsurance issued a comprehensive series of six reports that reviewed and reported on the evidence on the effects of not having health insurance coverage. The final report in the series, Insuring America’s Health: Principles and Recommendations, set out a vision and principles for health insurance coverage in the United States (IOM, 2004). In that 2004 report, the committee recommended action by the President and Congress to achieve universal coverage by 2010.1 It stated:

The benefits of universal coverage would enrich all Americans, whether accounted for in terms of improved health and longer life spans, greater economic productivity, financial security, or the stabilization of communities’ health care systems.

It has now been 5 years since the IOM recommended action to achieve coverage for all Americans, and there has still been no comprehensive national effort to expand coverage to everyone. In 2007, 45.7 million people in the United States—or 17.2 percent of the nonelderly U.S. population—were without health insurance. A severely weakened economy, rising health care and health insurance costs, growing unemployment, and declining employment-based health insurance coverage are all evidence that the U.S. health insurance system is in a state of crisis. There is no evidence to suggest that the trends driving loss of insurance coverage will reverse without concerted action.

1

The executive summary from the report is presented in Appendix A.



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5 Summary of Findings and Recommendation From 2001 to 2004, the Institute of Medicine (IOM) Committee on the Consequences of Uninsurance issued a comprehensive series of six reports that reviewed and reported on the evidence on the effects of not having health insurance coverage. The final report in the series, Insuring America’s Health: Principles and Recommendations, set out a vision and principles for health insurance coverage in the United States (IOM, 2004). In that 2004 report, the committee recommended action by the President and Congress to achieve universal coverage by 2010.1 It stated: The benefits of universal coverage would enrich all Americans, whether accounted for in terms of improved health and longer life spans, greater economic productivity, financial security, or the stabilization of communi- ties’ health care systems. It has now been 5 years since the IOM recommended action to achieve coverage for all Americans, and there has still been no comprehensive na- tional effort to expand coverage to everyone. In 2007, 45.7 million people in the United States—or 17.2 percent of the nonelderly U.S. population— were without health insurance. A severely weakened economy, rising health care and health insurance costs, growing unemployment, and declining employment-based health insurance coverage are all evidence that the U.S. health insurance system is in a state of crisis. There is no evidence to sug- gest that the trends driving loss of insurance coverage will reverse without concerted action. 1 The executive summary from the report is presented in Appendix A. 

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 AMERICA’S UNINSURED CRISIS COMMITTEE’S RESOLuTION AND RECOMMENDATION Resolution of the IOM Committee on Health Insurance Status and Its Consequences In executing its charge, this committee has studied the available data and applied rigorous scientific criteria to set the record straight on the issue of health insurance coverage. The findings presented in the previous chap- ters and summarized below have expanded upon earlier IOM research on the consequences of being uninsured. The body of evidence on the health consequences of health insurance is stronger than ever before. Lack of knowledge is not the problem. Preventable suffering related to uninsurance continues and promises to get worse rather than better. Inaction will lead to further erosion of coverage. There always has been, and will continue to be, uncertainty and disagreement about the best way to address major issues of public policy. The issue of cost, in particular, is daunting. But the nation has been successful with other complex issues that are intertwined with deeply held interests and ideologies. The opportunity to make the necessary difference is never the perfect one. Now is the time to act, emboldened by the knowledge and compassion of a society that truly cares about its members and that has a history of tackling difficult problems. Recommendation The committee recommends that the President work with Congress and other public and private sector leaders on an urgent basis to achieve health insurance coverage for everyone and, in order to make that coverage sustainable, to reduce the costs of health care and the rate of increase in per capita health care spending. There is a compelling case for action. Simply stated: health insurance coverage matters. Expanding health coverage to all Americans is essential and should be done as quickly as possible. It is also of paramount impor- tance that steps be taken to reduce health care expenditures and the rate of increase in per capita health care spending so that health insurance coverage for all can be achieved and sustained in an economically and politically vi- able manner. The committee does not believe that action should be delayed pending the development of a long-term approach to underlying health care costs. Given the demonstrated harms of not having health insurance for children and adults, the committee believes that actions to achieve coverage improvements should proceed immediately.

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 SUMMARY OF FINDINGS AND RECOMMENDATION SuMMARy OF FINDINgS On the basis of a careful review of the scientific literature since 2002, the committee reported findings in three key areas: trends in health insur- ance coverage, the health consequences of uninsurance for children and adults, and the implications of high community-level rates of uninsur- ance on people who have health insurance in affected communities. The committee’s findings, which were discussed at length in previous chapters of this report, are summarized below. Caught in a Downward Spiral: uninsured Rates Are High and getting Worse Over the last decade, health insurance coverage has declined and will continue to decline. Health care costs and insurance premiums are growing at rates greater than the U.S. economy and family incomes. The situation is dire as it affects not only employer-sponsored coverage, the cornerstone of private health coverage in the United States, but also recent expansions in public coverage. Overall, fewer workers, particularly those with lower wages, are of- fered employer-sponsored insurance, and fewer among the workers that are offered such insurance can afford the premiums. And, early retirees are less likely to be offered retiree health insurance benefits than in the past. Employment has shifted away from industries with traditionally high rates of coverage (e.g., manufacturing) to service jobs (e.g., in wholesale and retail trades) with historically lower rates of coverage. In some industries, employers have relied more heavily on jobs without health benefits, includ- ing part-time and shorter term employment, and contract and temporary jobs. Only a small percentage of Americans has nongroup private health insurance purchased in the individual insurance market. For many individu- als and families without employer-sponsored group coverage, nongroup coverage is unaffordable. States and the federal government have substantially increased health coverage among low-income children and, to a lesser degree, among adults in the last decade by expanding eligibility, conducting outreach to people already eligible, and expediting enrollment in Medicaid and State Children’s Health Insurance Program (SCHIP) programs. As this report was being finalized, Congress reauthorized the SCHIP program (P.L. No. 111-3).2 However, some states remain under extreme economic pressures to cut their recent expansions of public programs for low-income children and adults. 2 Under this new legislation, the former SCHIP program is referred to as CHIP, the Chil- dren’s Health Insurance Program.

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 AMERICA’S UNINSURED CRISIS Sharp increases in unemployment will further fuel the decline in the number of people with employer-sponsored coverage and add even greater stress on state health insurance programs. Coverage Matters: Health Insurance Is Integral to Personal Well-being and Health Important new research has emerged since the IOM last studied the question of how health insurance affects health outcomes. This research clearly demonstrates that, despite the availability of care for the uninsured through safety net providers, insurance coverage makes a substantial differ- ence in both access and outcomes. For children, well-designed evaluations of enrollment in Medicaid and SCHIP programs offer important insights into how children benefit when they acquire health insurance. For adults, new research—particularly recent longitudinal analyses of previously unin- sured adults after they acquire Medicare coverage at age 65—has yielded compelling findings about how adults are harmed by not having health insurance. Children with health insurance are more likely to gain access to a usual source of care or medical home, well-child care and immunizations to prevent future illness and monitor developmental milestones, prescription medications, appropriate care for asthma, and basic dental services. Serious childhood health problems are more likely to be identified early in children with health insurance, and insured children with special health care needs are more likely to have access to specialists. Children with health insurance have fewer avoidable hospitalizations, improved asthma outcomes, and fewer missed days of school. Uninsured adults are much less likely to receive clinical preventive services that have the potential to reduce unnecessary morbidity and prema- ture death. Chronically ill adults delay or forgo visits with physicians and clinically effective therapies, including prescription medications. Adults are more likely to be diagnosed with later stage cancers that are detectable by preventive screening or by contact with a clinician who can assess worri- some symptoms. Uninsured adults are more likely to die when hospitalized for trauma or other serious acute conditions, such as heart attack or stroke. Uninsured adults with cancer, cardiovascular disease (including hyperten- sion, coronary heart disease, and congestive heart failure), serious injury, stroke, respiratory failure, chronic obstructive pulmonary disease or asthma exacerbation, hip fracture, seizures, and serious injury are more likely to suffer poorer health outcomes, greater limitations in quality of life, and premature death. New evidence demonstrates that gaining health insurance ameliorates many of these deleterious effects, particularly for adults who are acutely or chronically ill.

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 SUMMARY OF FINDINGS AND RECOMMENDATION Communities at Risk: Higher Levels of uninsurance in Communities May undermine Health Care for the Insured Population There are stark differences in the percentage of people without health insurance in different communities across the country. Many local health care providers in communities with high uninsurance rates bear a dispro- portionate and substantial financial burden due to America’s uninsured crisis. Recent empirical evidence indicates that higher community-level un- insurance rates are negatively associated with several well-validated indica- tors of access to and satisfaction with health care among privately insured adults. Research commissioned by the committee suggests that when local rates of uninsurance are relatively high, insured adults are more likely to have difficulties obtaining needed health care and to be dissatisfied with their care. The precise contribution of uninsurance to this dynamic is not well understood. There are also growing economic disparities between communities with respect to geographic distribution of physician services and other health care resources such as new diagnostic and therapeutic techniques and technology. Well-documented fault lines in local health care delivery—not necessarily attributable to uninsurance—are particularly vulnerable to the financial pressures associated with higher uninsurance and may be intensi- fied by higher uninsurance rates. These include hospital-based emergency care problems, such as limits on inpatient bed capacity, outpatient emer- gency services, and timeliness of trauma care, that have potentially serious implications for the quality and timeliness of care for insured as well as uninsured patients. CONCLuSION For the aforementioned reasons, the committee concludes by joining the challenge put forth by our colleagues in the 2004 IOM report Insuring America’s Health: . . . health insurance contributes essentially to obtaining the kind and qual- ity of health care that can express the equality and dignity of eery person. Unless we can ensure coerage for all, we fail as a nation to delier the great promise of our health care system, as well as of the alues we lie by as a society. It is time for our nation to extend coerage to eeryone. REFERENCE IOM (Institute of Medicine). 2004. Insuring America’s health: Principles and recommenda- tions. Washington, DC: The National Academies Press.

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