growth in unemployment will fuel further decline in the number of people with health insurance and likely intensify financial pressures on local health care delivery.

Many of America’s towns and cities have high concentrations of children and adults under age 65 who lack health insurance (DeNavas-Walt et al., 2008). Thus, two questions arise: What are the implications of high rates of uninsurance for affected communities and for insured people in those communities? Is the financial impact of uninsurance large enough to affect the availability and quality of local health care services for everyone in the community, even for the people who have health insurance?

In 2003, an earlier Institute of Medicine (IOM) committee warned of the potential harms of high rates of uninsurance for local health care, including reduced access to clinic-based primary care, specialty services, and hospital-based emergency medical services and trauma care (Box 4-1) (IOM, 2003). Such consequences reduce access to clinic-based primary care, specialty services, and hospital-based care, particularly emergency medical services and trauma care.

The prior IOM committee also observed that the evidence available in 2003 was observational and largely cross-sectional in design, making it difficult to infer causal relationships between uninsurance and these harms, and that there was a dearth of systematic data to measure the size, strength, and scope of community effects of uninsurance. Thus, the committee called for additional research to measure the size, strength, and scope of potential adverse community effects of uninsurance. As is explained later on in the chapter, sufficient evidence is still lacking and the methodologic obstacles to unraveling the dynamics of community effects remain very challenging.

This chapter reviews what is currently known about the impact of high community-level rates of uninsurance on people who have health insurance in affected communities, using the definition of community used in the 2003 IOM report (Box 4-2). The next section of the chapter provides some context for assessing the consequences of high uninsurance rates in communities. The third section discusses challenges in evaluating the impact of high community-level uninsurance rates and presents findings from recent studies of the spillover effects of uninsurance on communities including an analysis commissioned by the committee. The fourth section reviews recent evidence on a range of well-documented problems in local health care delivery that are vulnerable to financial pressures and may intensify when a large proportion of the community is uninsured. The final section of the chapter summarizes the committee’s overall conclusions.



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