1
Introduction

Abstract: This chapter describes the objectives, context, scope, and methods of this report. From 2001 to 2004, an earlier Institute of Medicine (IOM) committee undertook an exhaustive examination of the consequences of uninsurance and recommended that the nation move quickly to implement a strategy to achieve universal coverage. Five years later, the IOM Committee on Health Insurance Status and Its Consequences has reexamined the crisis of uninsurance in the United States, albeit with a more narrow focus. The objective of this report is to assess the more recent evidence on three fundamental questions: (1) What are the dynamics driving downward trends in health insurance coverage? (2) Is being uninsured harmful to the health of children and adults? (3) Are insured people affected by high rates of uninsurance in their communities?

In 2007, there were 45.7 million people without health insurance in the United States—nearly 1 in 5 adults under age 65 and more than 1 in 10 children (DeNavas-Walt et al., 2008). The fear of being without health insurance coverage is a growing strain on American families’ sense of health and well-being (Schoen et al., 2008). Family concerns about losing health coverage are well founded.

Figure 1-1 shows changes in the percentage of nonelderly adults in the United States without health insurance from 1999-2000 to 2006-2007. In 2006-2007, in nine states (Arizona, Arkansas, California, Florida, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas)—up from just two states in 1999-2000—the percentage of nonelderly adults who did not have health insurance was 23 percent or more (Commonwealth Fund, 2008). In



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1 Introduction Abstract: This chapter describes the objecties, context, scope, and meth- ods of this report. From 00 to 00, an earlier Institute of Medicine (IOM) committee undertook an exhaustie examination of the conse- quences of uninsurance and recommended that the nation moe quickly to implement a strategy to achiee uniersal coerage. Fie years later, the IOM Committee on Health Insurance Status and Its Consequences has reexamined the crisis of uninsurance in the United States, albeit with a more narrow focus. The objectie of this report is to assess the more recent eidence on three fundamental questions: () What are the dynamics driing downward trends in health insurance coerage? () Is being unin- sured harmful to the health of children and adults? () Are insured people affected by high rates of uninsurance in their communities? In 2007, there were 45.7 million people without health insurance in the United States—nearly 1 in 5 adults under age 65 and more than 1 in 10 children (DeNavas-Walt et al., 2008). The fear of being without health insurance coverage is a growing strain on American families’ sense of health and well-being (Schoen et al., 2008). Family concerns about losing health coverage are well founded. Figure 1-1 shows changes in the percentage of nonelderly adults in the United States without health insurance from 1999-2000 to 2006-2007. In 2006-2007, in nine states (Arizona, Arkansas, California, Florida, Louisi- ana, Mississippi, New Mexico, Oklahoma, and Texas)—up from just two states in 1999-2000—the percentage of nonelderly adults who did not have health insurance was 23 percent or more (Commonwealth Fund, 2008). In 

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 AMERICA’S UNINSURED CRISIS FIguRE 1-1 Comparison in the percentage of nonelderly adults without health insurance, by state, 1999-2000 and 2006-2007. SOURCE: The Commonwealth Fund (2008). Reprinted, with permission, from The Commonwealth Fund, 2008. Copyright 2008 by The Commonwealth Fund (http://www.commonwealthfund.org). 13 states (Alaska, Colorado, Georgia, Kentucky, Montana, Nevada, New Jersey, North Carolina, Oregon, South Carolina, Tennessee, West Virginia, and Wyoming), the percentage of nonelderly adults without health insur- ance ranged from 19 to 23 percent. Only 10 states (Connecticut, Hawaii, Iowa, Maine, Massachusetts, Minnesota, Pennsylvania, Rhode Island, Ver- mont, and Wisconsin) had uninsurance rates for nonelderly adults below 14 percent. As described in this report, rising health care costs, stagnant family incomes, fiscal pressures on state budgets, and increased unemploy- ment are likely to drive further coverage declines (Baicker and Chandra, 2006; Chernew et al., 2005; Cooper and Schone, 1997; Holahan and Cook, 2008). With a new administration and a new Congress, many citizens, policy makers, and opinion leaders anticipate renewed energy and interest in finding a way to reverse the erosion of health insurance coverage and, ultimately, to expand coverage to all in the United States (Blendon et al., 2008; Bodaken, 2008; Lake et al., 2008; McInturff and Weigel, 2008; Oberlander, 2007).

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 INTRODUCTION ObJECTIvE OF THE STuDy The Robert Wood Johnson Foundation (RWJF) asked the Institute of Medicine (IOM) to reexamine America’s uninsured crisis in order to inform the health reform policy debate as it unfolds in 2009 and beyond. The objective of this report is to evaluate the research evidence on the con- sequences of uninsurance that has emerged since the IOM conducted its earlier examination of the issues. The question of whether health insurance matters to health is far more than an academic concern. It is crucial that U.S. health care policy be informed with current and valid evidence, especially for the 45.7 mil- lion individuals without health insurance. In recent years, researchers have considerably strengthened the body of evidence on the consequences of uninsurance, especially the consequences of uninsurance for health out- comes. Better quality longitudinal data and quasi-experimental methods have been used to assess how uninsurance affects the health and mortality of adults (Card et al., 2007; Decker, 2005; Dor et al., 2006; Finkelstein and McKnight, 2007; Hadley and Waidmann, 2006; McWilliams et al., 2007; Polsky et al., 2006; Volpp et al., 2003, 2005). There is also new evidence on the benefits of coverage for children and adolescents from well-designed studies of enrollment in public health insurance programs, such as the State Children’s Health Insurance Program (SCHIP) and Medicaid (Davidoff et al., 2005; Halterman et al., 2008; Howell and Trenholm, 2007; Kempe et al., 2005; Kenney, 2007; Szilagyi et al., 2006; Trenholm et al., 2005). WHAT IS THE PuRPOSE OF HEALTH INSuRANCE? The health insurance system in the United States, in contrast with health insurance in almost all other industrialized nations, is essentially a voluntary one. Most Americans with private health insurance obtain it through the workplace. Employers are free to choose whether and what kind of insurance to offer their employees, and individuals in the United States are usually free to accept or decline their employers’ offer of cover- age, to purchase individual coverage, or if they are eligible, to enroll in public programs such as Medicare, Medicaid, or SCHIP. Health insurance pools risk across groups of individuals or firms and then shares the cost of payouts among them, thereby reducing the burden of catastrophic costs for individual participants. Insurance is most effectively pooled across large groups. When individuals, families, or small employers do not have access to large group coverage, they must apply for coverage in the individual or small group markets. People are more likely to purchase and maintain coverage if they expect to incur high costs—a phenomenon referred to as adverse selection. Insurers protect against adverse selection

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 AMERICA’S UNINSURED CRISIS in the individual and small group health insurance markets by underwrit- ing (i.e., assessment of applicants’ health status and recent use of services). Thus, an insurer may completely deny coverage to applicants, impose permanent or temporary preexisting condition limitations on coverage, or charge a higher premium (depending on state insurance market regulations) on the basis of expected risk. What is the purpose of health insurance? The answer depends on whose perspective is being considered: • For consumers, health insurance often serves two purposes: (1) it provides a gateway to affordable health care through preferential pricing1 of health care services and (2) it offers financial protection from unexpected health care costs. • For clinicians, hospitals, and other health providers, health insur- ance ensures the financial stability of their operations. Indeed, health insurance as we know it today was first developed by Baylor University Hospital for exactly that purpose (Porter and Teisberg, 2006). • With growing concern about the cost and quality of health care services, many large employers and purchasers of health benefits look to health insurance plans to encourage the use of beneficial, evidence-based services, particularly clinical preventive services such as childhood immunizations and certain adult cancer screen- ing tests. Indeed, the quality of health insurance products is often assessed by measuring the extent to which the covered population receives such services (National Committee for Quality Assurance, 2008). PREvIOuS IOM REPORTS ON uNINSuRANCE From 2001 to 2004, with the support of RWJF, the IOM issued a com- prehensive series of six reports on the consequences of uninsurance for chil- dren, adults, families, communities, and the nation (IOM, 2001, 2002a,b, 2003a,b, 2004).2 The series culminated with the publication in 2004 of Insuring America’s Health: Principles and Recommendations (IOM, 2004). This report set out the IOM committee’s vision and principles for health insurance coverage in the United States. It also included the committee’s 1 One recent analysis found that, for the same services, hospitals charge uninsured pa- tients 2.5 times what they charge insurance companies and more than 3 times the hospital’s Medicare-allowable costs (Anderson, 2007). 2 For copies of the previous IOM report series on the consequences of uninsurance, please visit www.nap.edu.

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 INTRODUCTION BOX 1-1 The IOM’s Past Findings and Recommendations Regarding Health Insurance Coverage in the United States, 2001-2004 In 2001, the IOM began a comprehensive 4-year study of the consequences of not having health insurance in the United States at the request of the Robert Wood Johnson Foundation. From 2001 to 2004, the IOM published six reports that assessed the available evidence on how children, adults, families, communities, and the nation were af- fected by uninsurance. Among the principal findings in the earlier series of IOM reports on the consequences of uninsurance were the following: • hildren and adults without health insurance do not receive the care they C need; they suffer from poorer health and development and are more likely to die early than children and adults who have coverage. • ven one uninsured person in a family can put the financial stability and E health of the whole family at risk. • high percentage of uninsured people within a community can adversely A affect the overall health status of the community, its health care institutions and providers, and the access of its residents to key services. • ecent federal initiatives to extend health insurance coverage have not R closed the coverage gap. The series concluded with the publication in 2004 of Insuring America’s Health: Principles and Recommendations. In that report, the IOM Committee on the Con- sequences of Uninsurance recommended the following: • he committee recommends that the President and Congress develop a T strategy to achieve universal insurance coverage and to establish a firm and explicit schedule to reach this goal by 2010. • he committee recommends that, until universal coverage takes effect, the T federal and state governments provide resources sufficient for Medicaid and the State Children’s Health Insurance Program (SCHIP) to cover all persons currently eligible and prevent the erosion of outreach efforts, eligi- bility, enrollment, and coverage. SOURCE: IOM (2004). recommendation that the nation move quickly to implement a strategy to achieve universal health insurance coverage. The key findings and recom- mendations of the 2004 report are provided in Box 1-1; the report’s execu- tive summary is presented in Appendix A. As of early 2009, 5 years since the publication of the IOM’s report Insuring America’s Health, a comprehensive national plan to address Amer- ica’s uninsured crisis has yet to be enacted. A few states—most notably

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 AMERICA’S UNINSURED CRISIS Maine, Massachusetts, and Vermont—have achieved great progress to- wards the goal of universal health insurance coverage. Other states, includ- ing California, have attempted reforms but failed to move forward. SCOPE AND METHODS OF THE STuDy The scope of the earlier IOM series of studies on the consequences of uninsurance was broad and comprehensive: six published volumes assessed then-current evidence on the dynamics of health insurance coverage and the makeup of the uninsured population; effects of health insurance on health; implications for families including health and financial outcomes; impact on communities including the financing and delivery of health services, and community public health; economic and social implications such as spend- ing and sources of spending on health care for the uninsured population including the estimated cost of expanding coverage, other costs including quality of life, family security, workforce participation and productivity; health systems impacts; and principles and strategies for extending cover- age to all. In contrast, the scope of this study is narrow and focuses on three es- sential questions (Box 1-2): (1) What are the dynamics driving downward trends in health insurance coverage? (2) Is being uninsured harmful to the health of children and adults? (3) Are insured people affected by high rates of uninsurance in their communities? BOX 1-2 Charge to the IOM Committee on Health Insurance Status and Its Consequences The overarching objective of this study is to help inform the health reform policy debate as it unfolds in 2009. The committee will assess the research evidence—that has emerged since the IOM’s 2001 to 2004 series of reports on uninsurance—on the consequences of uninsurance. Rather than performing a comprehensive review, the committee is charged with reviewing the literature to identify new insights not yet known or appreciated when the IOM’s earlier reports were developed. The search for new evidence will include the published literature on the conse- quences of uninsurance for individuals, families, communities, specific population groups, and safety net and other providers. The consequences may be related to health outcomes, such as morbidity and mortality; access to health care services; and economic impacts such as affordability of health coverage and its associated financing burden.

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 INTRODUCTION The IOM appointed the Committee on Health Insurance Status and Its Consequences to perform this study in April 2008. The 14-member committee included experts in analytic methods, public policy, vulnerable populations, employment-based health coverage, clinical medicine, health care delivery, health services research, health financing and economics, state health reform, and public health communication. Brief biographies of the committee members are presented in Appendix F. The committee considered but excluded several topics from the study in order to optimize the depth and quality of its 6-month investigation into the three principal questions outlined above. Excluding these topics from this report should not be interpreted to mean they are unimportant. Indeed, these topics are inextricably linked with the nation’s uninsured crisis and merit serious attention by policy makers. The omitted topics include the following: (1) The economic and financial impact of uninsurance. Health insurance has complex economic and financial implications for multiple aspects of American society—the productivity and financial stability of in- dividuals, families, communities, health care systems and providers, Ameri- can business, and local, state, and federal government. Related to these issues and also excluded from this study is the impact of uninsurance on household medical debt, the extent to which uninsurance affects the global competitiveness of American business, and whether providers shift the costs of uninsurance to private payers (a topic with only sparse and inconclusive evidence). (2) The effects of underinsurance. Uninsurance and underinsur- ance involve distinctly different policy issues, and the strategies for address - ing them may differ. Uninsurance—the focus of this study—refers to the lack of health insurance coverage. Underinsurance is defined with respect to health insurance coinsurance requirements and coverage limitations, e.g., excessive out-of-pocket expenditures and/or significant limits on health care benefits perceived as essential to health (Collins et al., 2008; Davis, 2007; Oswald et al., 2007; Schoen et al., 2005, 2008; Wender, 2007). However, there is no agreed upon definition of underinsurance and an inadequate evidence base for assessing its impact (Blewett et al., 2006; Ward, 2006). (3) The impact of discontinuities in health insurance. Employers switch health plans with relative frequency, a new job typically results in different health coverage, and low-income individuals cycle in and out of eligibility for public health insurance. Even minimal disruptions in coverage—such as switching between types of coverage—have been shown to affect use of health care services (Bindman et al., 2008; Federico et al., 2007; Lavarreda et al., 2008; Leininger, 2009). (4) The study sponsor asked the committee not to explore potential approaches to expanding health coverage. As the committee’s work progressed, the committee became aware of considerable misinformation about uninsurance and its consequences, so that setting the record straight became an important concern. Perhaps fore-

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0 AMERICA’S UNINSURED CRISIS most among these misconceptions is that charity care and other safety net services ensure that the health of uninsured individuals is protected—a be- lief that finds no significant support in the research evidence (as Chapter 3 will show). The committee also became aware that the continuing erosion of health insurance coverage was creating urgent difficulties for individu- als, their communities, and public agencies that pay for health insurance coverage. It believes that 2009 will open a window of opportunity for ad- dressing the problem. The committee deliberated during four in-person meetings and seven conference calls between May and November 2008. The committee’s ini- tial deliberations focused on clarifying the scope of its work. The research conducted for this study was accomplished with the assistance of several consultants.3 Once the basic outline for the report was established, the committee commissioned two systematic reviews of research evidence on the consequences of not having health insurance for individuals: one review of the evidence on the consequences for children and adolescents and a second review on the consequences for adults. Both of these reviews of the research evidence focused on research published from 2002 to August 2008 in order to capture the evidence not available during the previous IOM examination of the relationship between health and health insurance. See Chapter 3 for details regarding the literature search strategy. The committee also commissioned original analyses of the Medical Expenditure Panel Sur- vey, the household survey of the Community Tracking Study of the Center for Studying Health System Change, and the health insurance component of the Current Population Survey to examine trends in coverage and assess the impact of high rates of uninsurance on communities. ORgANIZATION OF THE REPORT This introductory chapter has described the context for this report, including the past IOM studies on uninsurance, the purpose of health insur- ance, the committee’s charge, and the objectives, scope, and study methods for this report. Subsequent chapters address the following questions: 3 J. Michael McWilliams, M.D., Ph.D., reviewed the research evidence on the consequences of not having health insurance for adults, and Genevieve Kenney, Ph.D., and Embry Howell, Ph.D., reviewed the child and adolescent literature. Mark Pauly, Ph.D., and José Pagán, Ph.D., conducted an original analysis of the effects of uninsurance on privately insured persons and local communities. Jessica Banthin, Ph.D., Steve Cohen, Ph.D., and Joel Cohen, Ph.D., staff at the Agency for Healthcare Research and Quality, conducted original analyses of how unin- sured families are burdened by the lack of health coverage. Additional details on the literature reviews and analyses commissioned by the committee are provided in subsequent chapters.

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 INTRODUCTION Chapter 2—Caught in a Downward Spiral. What are the dynamics • driving downward trends in health insurance coverage? Chapter 3—Coverage Matters. Is being uninsured harmful to the • health of children and adults? What are the consequences of not having health coverage on access to care and health outcomes? Does the health of individuals without coverage improve when they become insured? Chapter 4—Communities at Risk. Are insured people affected by • high rates of uninsurance in their communities? Chapter 5—Summary of Findings and Recommendation. What are • the committee’s key findings and recommendation? REFERENCES Anderson, G. F. 2007. From “soak the rich” to “soak the poor”: Recent trends in hospital pricing. Health Affairs 26(3):780-789. Baicker, K., and A. Chandra. 2006. The labor market effects of rising health insurance premi- ums. Journal of Labor Economics 24(3):609-634. Bindman, A. B., A. Chattopadhyay, and G. M. Auerback. 2008. Medicaid re-enrollment policies and children’s risk of hospitalizations for ambulatory care sensitive conditions. Medical Care 46(10):1049-1054. Blendon, R. J., D. E. Altman, C. Deane, J. M. Benson, M. Brodie, and T. Buhr. 2008. Health care in the 2008 presidential primaries. New England Journal of Medicine 358(4):414-422. Blewett, L. A., A. Ward, and T. J. Beebe. 2006. How much health insurance is enough? Revisit- ing the concept of underinsurance. Medical Care Research and Reiew 63(6):663-700. Bodaken, B. G. 2008. Where does the insurance industry stand on health reform today? Health Affairs 27(3):667-674. Card, D., C. Dobkin, and N. Maestas. 2007. Does Medicare Save Lives? National Bureau of Economic Research Working Paper 13668 (JEL No. H51,I11). Chernew, M., D. M. Cutler, and P. S. Keenan. 2005. Increasing health insurance costs and the decline in insurance coverage. Health Serices Research 40(4):1021-1039. Collins, S. R., J. L. Kriss, M. M. Doty, and S. D. Rustgi. 2008. Losing ground: How the loss of adequate health insurance is burdening working families, http://www.commonwealthfund. org/usr_doc/Collins_losinggroundbiennialsurvey2007_1163.pdf?section=4039 (accessed August 2008). Commonwealth Fund. 2008 (unpublished). Percent of adults ages – uninsured by state. New York: The Commonwealth Fund. Cooper, P. F., and B. S. Schone. 1997. More offers, fewer takers for employment-based health insurance: 1987 and 1996. Health Affairs 16(6):142-149. Davidoff, A., G. Kenney, and L. Dubay. 2005. Effects of the State Children’s Health Insur- ance Program expansions on children with chronic health conditions. Pediatrics 116(1): e34-e42. Davis, M. M. 2007. Reasons and remedies for underinsurance for child and adolescent vac- cines. JAMA 298(6):680-682. Decker, S. L. 2005. Medicare and the health of women with breast cancer. Journal of Human Resources 40:948-968.

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 INTRODUCTION National Committee for Quality Assurance. 2008. HEDIS & quality measurement, http:// ncqa.org/tabid/59/Default.aspx (accessed July 16, 2008). Oberlander, J. 2007. Learning from failure in health care reform. New England Journal of Medicine 357(17):1677-1679. Oswald, D. P., J. N. Bodurtha, J. H. Willis, and M. B. Moore. 2007. Underinsurance and key health outcomes for children with special health care needs. Pediatrics 119(2): e341-e347. Polsky, D., J. A. Doshi, J. Escarce, W. Manning, S. M. Paddock, L. Cen, and J. Rogowski. 2006. The health effects of Medicare for the near-elderly uninsured. Cambridge, MA: National Bureau of Economic Research. Porter, M. E., and E. O. Teisberg. 2006. Redefining health care: Creating alue-based competi- tion on results. Cambridge, MA: Harvard Business Press. Schoen, C., M. M. Doty, S. R. Collins, and A. L. Holmgren. 2005. Insured but not protected: How many adults are underinsured? Health Affairs w5.289-w5.302. Schoen, C., S. R. Collins, J. L. Kriss, and M. M. Doty. 2008. How many are underinsured? Trends among U.S. adults, 2003 and 2007. Health Affairs 27(4):w298-w309. Szilagyi, P. G., A. W. Dick, J. D. Klein, L. P. Shone, J. Zwanziger, A. Bajorska, and H. L. Yoos. 2006. Improved asthma care after enrollment in the State Children’s Health Insurance Program in New York. Pediatrics 117(2):486-496. Trenholm, C., E. Howell, D. Hughes, and S. Orzol. 2005. The Santa Clara County Healthy Kids Program: Impacts on children’s medical, dental, and vision care. Mathematica Policy Research Report, http://www.mathematica-mpr.com/publications/PDFs/santaclara. pdf (accessed September 2008). Volpp, K. G. M., S. V. Williams, J. Waldfogel, J. H. Silber, J. S. Schwartz, and M. V. Pauly. 2003. Market reform in New Jersey and the effect on mortality from acute myocardial infarction. Health Serices Research 38(2):515-533. Volpp, K. G., J. D. Ketcham, A. J. Epstein, and S. V. Williams. 2005. The effects of price competition and reduced subsidies for uncompensated care on hospital mortality. Health Serices Research 40:1056-1077. Ward, A. 2006. The concept of underinsurance: A general typology. Journal of Medicine & Philosophy 31(5):499-531. Wender, R. C. 2007. The adequacy of the access-to-care debate: Looking through the cancer lens. Cancer 110(2):231-233.

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