reported having been without insurance during the entire previous year.1 In 2000, the Institute of Medicine (IOM) formed an expert Committee on the Consequences of Uninsurance to study the issue comprehensively, examining the effects of the lack of health coverage on individuals, families, communities, and the broader society.2 Now, after a significant economic downturn, 17.2 percent of the population under age 65 is uninsured and the number has grown to over 43 million. One in three Americans were uninsured for a month or more during a two-year period (1996-1997) (Short, 2001). Fewer people have access to coverage at work, more people find the costs of private coverage too expensive, and others lose public coverage because of changed personal circumstances, administrative barriers, and program cutbacks. The situation is even more dire now than when the study began and it is expected to worsen in the foreseeable future because of federal and state budget constraints limiting public coverage programs, increasing costs of health care and insurance premiums, and continuing high rates of unemployment.


The Committee has conducted an exhaustive review of the scientific evidence on the consequences of uninsurance and finds that having no insurance decreases access to health services and reduced access to health care among the uninsured is associated with the poorer health. The lack of coverage is not only associated with negative effects on the uninsured individual but also has implications for the entire family of the uninsured person and the community in which he or she lives, and economic costs to society nationally (IOM, 2001a, 2002a,b, 2003a,b). In short, in a series of five reports the Committee concluded that:


The estimate of the uninsured is based on the Census Bureau’s annual March Current Population Survey (CPS), as all annual estimates of the uninsured population of the United States presented in this report, unless otherwise noted. The CPS may overestimate the number of uninsured for the entire calendar year and does not account for all who are uninsured for shorter time periods (CBO, 2003). See Chapter 2 for a discussion of who is uninsured, why, and for how long.


In this study, the focus is on people with no health insurance, such as “major medical” coverage for hospitalization and outpatient medical services, either for short or long periods. The Committee does not address underinsurance, that is, health plans that offer less than adequate coverage with excessive out-of-pocket payments, maximum benefit limits, or exclusion of specific services, such as mental health treatment. The problems of underinsurance are generally less severe than those of uninsurance, involve different policy issues and require the collection of different types of information. See further discussion in Chapter 2.

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