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Pro
-ce and Health Care
Committee on the Consequences of Uninsuranc
Board on Health Care Services
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C.
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NATIONAL ACADEMY PRESS · 2101 Constitution Avenue, N.W. · Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine. The members of the committee responsible for the report were chosen for
their special competences and with regard for appropriate balance.
Support for this project was provided by The Robert Wood Johnson Foundation.
The views presented in this report are those of the Institute of Medicine Committee on the
Consequences of Uninsurance and are not necessarily those of the funding agencies.
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Copyright 2001 by the National Academy of Sciences. All rights reserved.
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the Staatliche Museen in Berlin.
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"I(n owing is not enough; we invest apply.
Widing is not enough; we must do."
Goethe
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INSTITUTE OF MEDICINE
Shaping the Future for Health
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National Acaclemy of Sciences
National Acaclemy of Engineering
Institute of Meclicine
National Research Council
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distinguished scholars engaged in scientific and engineering research, dedicated to the
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ng.
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c~ne.
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chairman and vice chairman, respectively, of the National Research Council.
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COMMITTEE ON THE CONSEQUENCES OF UNINSURANCE
MARY SUE COLEMAN (Co-chair), President, Iowa Health System and
University of Iowa, Iowa City
ARTHUR L. KELLERMANN (Co-chairJ, Professor and Chairman,
Department of Emergency Medicine, Director, Center for Injury Control,
Emory University School of Medicine, Atlanta, Georgia
RONALD M. ANDERSEN, Wasserman Professor in Health Services, Chair.
Department of Health Services, Professor of Sociology, University of
California, Los Angeles, School of Public Health
JOHN Z. AYANIAN, Associate Professor of Medicine and Health Care
Policy, Harvard Medical School, Brigham and Women's Hospital, Boston,
Massachusetts
ROBERT I. BLENDON, Professor, Health Policy & Political Analysis,
Department of Health Policy and Management, Harvard School of Public
Health and Kennedy School of Government, Boston, Massachusetts
SHEILA P. DAVIS, Associate Professor, The University of Mississippi
Medical Center, School of Nursing, Jackson, Mississippi
GEORGE C. EADS, Charles River Associates, Washington, D.C.
SANDRA R. HERNANDEZ, Chief Executive Officer, San Francisco
Foundation, California
WILLARD G. MANNING, Professor, Department of Health Studies, The
University of Chicago, Illinois
JAMES I. MONGAN, President, Massachusetts General Hospital, Boston,
Massachusetts
CHRISTOPHER QUERAM, Chief Executive Officer, Employer Health
Care Alliance Cooperative, Madison, Wisconsin
SHOSHANNA SOFAER, Robert P. Luciano Professor of Health Care
Policy, School of Public Affairs, Baruch College, New York, New York
STEPHEN I. TREJO, Associate Professor of Economics, Department of
Economics, University of Texas at Austin
REED V. TUCKSON, Senior Vice President, Consumer Health and Medical
Care Advancement, UnitedHealth Group, Minnetonka, Minnesota
EDWARD H. WAGNER, Director, W.A. McColl Institute for Healthcare
Innovation, Group Health Cooperative Puget Sound, Seattle, Washington
LAWRENCE WALLACK, Director, School of Community Health, College
of Urban and Public Affairs, Portland State University, Oregon
v
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IOM Staff
Wilhelmine Miller, Project Co-director
Dianne Miller Wolman, Project Co-director
Lynne Page Snyder, Program Officer
Tracy McKay, Research Assistant
Ryan Palugod, Project Assistant
Al
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Reviewers
This report has been reviewed in draft form by individuals chosen for their
diverse perspectives and technical expertise, in accordance with procedures ap-
proved by the NRC's Report Review Committee. The purpose of this indepen-
dent review is to provide candid and critical comments that will assist the institu-
tion in making its published report as sound as possible and to ensure that the
report meets institutional standards for objectivity, evidence, and responsiveness to
the study charge. The review comments and draft manuscript remain confidential
to protect the integrity of the deliberative process. We wish to thank the follow-
ing individuals for their review of this report:
BRUCE BRADLEY, Director, Managed Care Plans, General Motors Health
Care Initiatives, Detroit, Michigan
HARRY P. CAIN, Adjunct Faculty Member, Graduate School of Business,
College of William and Mary, Williamsburg, Virginia
JACOB FELDMAN, Senior Fellow, Center for Health Affairs, Project HOPE,
Bethesda, Maryland
ROBERT L. JOHNSON, Professor of Pediatrics & Clinical Psychiatry, Direc-
tor, Adolescent & Young Adult Medicine, University of Medicine and Dentistry
of New Jersey, New Jersey Medical School, Newark
SCOTT C. RATTAN, Senior Technical Advisor and Population Leadership
Fellow, Center for Population, Health, and Nutrition, U.S. Agency for Interna-
tional Development, Washington, D.C.
DIANE ROWLAND, Executive Vice President, Henry I. Kaiser Family Foun-
dation, Executive Director, The Kaiser Commission on Medicaid and the Unin-
sured, Washington, D.C.
. .
v''
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V111
RE VIEWERS
FRANK A. SLOAN, I. Alexander McMahon Professor of Health Policy and
Management, Professor of Economics, Director, Center for Health Policy, Law &
Management, Duke University, Durham, North Carolina
KATHERINE SWARTZ, Professor of Health Economics, Department of
Health Policy and Management, Harvard School of Public Health, Boston, Mas-
sachusetts
DAVID TAKEUCHI, Professor of Sociology, Indiana University, Bloomington
Although the reviewers listed above have provided many constructive comments
and suggestions, they were not asked to endorse the conclusions or recommenda-
tions nor did they see the final draft of the report before its release. The review of
this report was overseen by Hugh H. Wilson, Adjunct Professor, School of
Public Health, University of North Carolina, Chapel Hill, appointed by the
Institute of Medicine and Joseph P. Newhouse, John D. MacArthur Profes-
sor of Health Policy & Management, Harvard University, appointed by the
NRC's Report Review Committee, who were responsible for making certain
that an independent examination of this report was carried out in accordance with
institutional procedures and that all review comments were carefully considered.
Responsibility for the final content of this report rests entirely with the authoring
committee and the institution.
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Preface
This is the first report in a series of six that the Institute of Medicine (IOM)
Committee on the Consequences of Uninsurance will issue over the next two
years to evaluate and consolidate our knowledge of the causes and consequences
of lacking health insurance. The Committee was established just one year ago with
the charge of reviewing and assessing evidence across a spectrum of disciplines to
expand our understanding of the problem of uninsurance. The Committee agreed
to undertake this formidable task in order to delineate more clearly the personal,
family, community, and economic consequences of the existing public and private
health insurance mechanisms a system that leaves almost one out of six Ameri-
cans without coverage.
This initial report of the Committee establishes both a conceptual framework
and baseline data about the magnitude and extent of the problem nationwide. It
seeks to answer the basic questions of who, when, where, and why so many
Americans lack health insurance. The report provides an overview of health
insurance in America, describes the dynamic and often unstable nature of insur-
ance coverage, profiles populations that frequently lack coverage, and identifies
factors that make it more or less likely that a person will be uninsured at some
point in life. Finally, the report outlines the research agenda that the Committee
will pursue in this series of six reports.
Many people have made substantial contributions to this report. The Sub-
committee on the Status ofthe Uninsured, chaired by Willard Manning, produced
a draft for the full Committee's consideration within an extraordinarily short time
and continued to work with the full Committee in revising the initial draft.
Committee members John Ayanian, Sheila Davis, Willard Manning, and Larry
Wallack were joined on the subcommittee by Peter Cunningham, Paul Fronstin,
IX
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x
PREFACE
and Catherine Hoffman, who generously contributed their expertise to the report
throughout its conceptualization and drafting. Committee member Ron Andersen
advised the subcommittee from the start as it devised the conceptual framework
that will be employed throughout the series of studies. IOM staff under Study Co-
directors Dianne Wolman and Wilhelmine Miller provided excellent research and
writing support to the subcommittee and Committee throughout their delibera-
tions. Program Officer Lynne Snyder served as lead staff analyst on this report.
We hope that this report will stimulate public dialogue and a reexamina-
tion of long-standing issues of health care financing and continuity of coverage.
The Committee's future reports on health outcomes for the uninsured, family
impacts of lacking health insurance, implications for communities, the economic
costs to society as a whole, and models of reform will provide in-depth and closely
considered information that should sustain and hopefully advance policy debates
about health care coverage. We are grateful to The Robert Wood Johnson Foun-
dation for its support of the Committee's work.
Mary Sue Coleman, Ph.D.
Co-chair
Arthur Kellermann, M.D., M.P.H.
Co-chair
September 2001
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Foreword
Coverage Matters: Insurance and Health Care is the first installment of a sustained
effort by the Institute of Medicine (IOM) to inform the debate about a pressing
and persistent challenge to American health care and public policy: lack of health
insurance for about 40 million Americans. In 1999, the IOM determined that this
long-standing problem should be a priority of the Institute's policy research agenda.
We are grateful to The Robert Wood Johnson Foundation for support of a series
of six studies addressing the personal and social impacts of uninsurance. This is the
first report in that series. The 16-member IOM Committee on the Consequences
of Uninsurance brings an exceptional breadth of experience to this project. Its
members have backgrounds in clinical medicine, epidemiology, public health,
nursing, health services organization, health and labor economics, strategic corpo-
rate planning and small businesses, academic health care, and provision of care to
those without coverage and other populations at risk.
This first report of the Committee lays the groundwork for subsequent re-
ports that will identify the costs and consequences for individuals, families, com-
munities, and American society when a large population of individuals does not
have health insurance. Although much of the information in this initial report has
been available before, Coverage Matters integrates findings from an extensive public
policy, economics, and health services research literature to produce a coherent
and comprehensible account of who has and who lacks health insurance, and why.
This report provides the reader with a road map to subsequent reports, outlining
both their content and the analytical framework that the Committee will employ
to look at a wide range of impacts. The second report, which will follow in about
nine months, will examine the evidence accumulated to date about the risks and
health consequences of lacking health insurance, both sporadically and, especially,
Xl
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xt!
FOREWORD
for extended periods of time. Policy makers and general readers alike should find
this initial report and the five to follow a valuable contribution to their under-
standing of a matter of vital concern to us all the consequences of having mil-
lions of uninsured Americans.
Kenneth I. Shine, M.D.
President, Institute of Medicine
September 2001
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Acknowledgments
A project ofthis scale and complexity requires a team effort. Many individuals
have contributed to the quality of this first report. The Committee takes this
opportunity to recognize several of those who have helped.
At the beginning of such an extensive effort, gathering information is crucial.
Many health policy researchers and others contributed to a workshop in Decem-
ber 2000 and to public Committee sessions then and in April 2001. Gerry
Fairbrother, Hanns Kuttner, Edward Maibach, and Jack Needleman, consultants
to the Committee, prepared background papers and served on workshop panels.
Other presenters at the workshop were E. Richard Brown, Thomas Buchmueller,
Peter Cunningham, Darrell Gaskin, Jack Hadley, Karla Hanson, Catherine
Hoffman, Judith Kasper, Genevieve Kenney, Honda Kotelchuck, Nicole Lurie,
Kristin Moore, Keith Mueller, Julie Rovner, Cathy Schoen, Lawrence Wallack,
Ray Werntz, and Charlotte Yeh. William Hall, Catherine McLaughlin, Diane
Rowland, Steven Schroeder, and Anne Weiss addressed the Committee during its
public meetings.
This first report has benefited from the participation of consultants who
provided guidance and technical expertise. Edward Maibach and Diana Rubin of
Porter Novelli provided communications advice, and Hanns Kuttner and Eugene
Moyer provided economic and statistical expertise. Anirban Basu contributed his
time in the preparation of original data analyses presented in this report, and the
Committee extends special thanks to him.
The Committee specifically acknowledges the members of the Subcommittee
on the Status of the Uninsured, which developed this foundational first report:
Willard Manning (chair), John Ayanian, Peter Cunningham, Sheila Davis, Paul
Fronstin, Catherine Hoffman, and Larry Wallack.
. . .
x'''
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xiv
A CKNO WLED GMENTS
The Committee recognizes the hard work of staff at the Institute of Medicine
(IOM). This work is conducted under the guidance of Janet Corrigan, director,
Board on Health Care Services, who planned and developed this project along
with IOM leadership and the sponsor. The project team, directed by Wilhelmine
Miller and Dianne Wolman, worked under a very tight schedule to produce this
first report. Dianne managed the publication process and edited the report.
Wilhelmine guided its substantive development. Program Officer Lynne Snyder
was lead analyst and made sense out of an enormous body of information within
a very short time. Research Assistant Tracy McKay served as sole support staff
during the crucial startup period of the Committee and worked tirelessly and
expertly to organize and prepare background materials for the December work-
shop. She also prepared the manuscript for publication. Project Assistant Ryan
Palugod provided support in the development of databases, managed meeting
logistics, and conducted Web research.
Funding for the project comes from The Robert Wood Johnson Foundation
(RW}F). The committee extends special thanks to Steven Schroeder, president,
and Anne Weiss, senior project officer, RWJF, for their support and thoughtful
attention.
Finally, the Committee would like to thank the chairs, Mary Sue Coleman
and Arthur Kellermann, for their leadership and dedication to the project. The
chairs, in turn, thank the committee members for their commitment and contri-
butions of time and expertise to this report and to those that follow.
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Contents
EXECUTIVE SUMMARY
Myths and Realities, 2
Relating Health Insurance to Access to Health Services, 5
How Coverage Is Gained and Lost, 6
A Portrait of the Uninsured, 11
Analytic Plan for the Committee, 14
Summary, 15
WHY HEALTH INSURANCE MATTERS
Objectives of Health Insurance Coverage, 20
Myths and Realities About Health Insurance, 21
The Committee's Analytic Strategy, 26
Insurance and Access to Health Care, 28
What Follows, 32
19
2 THE DYNAMICS OF HEALTH INSURANCE COVERAGE 35
No Guarantee of Coverage, 35
Opportunities for Obtaining Coverage, 37
How People Gain and Lose Coverage, 46
Constrained Coverage Options, 49
Insurance Trends, 53
Summary, 56
xv
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XVI
3 WHO GOES WITHOUT HEALTH INSURANCE?
WHO IS MOST LIKELY TO BE UNINSURED?
How Social and Economic Factors Affect Coverage, 60
How Coverage Varies Over a Person's Life, 70
Other Demographic Disparities in Coverage, 80
How Geographic Differences Affect Coverage, 90
What Influences an Uninsured Rate the Most?, 96
Summary, 98
4 ANALYTIC PLAN
Future Committee Reports, 101
APPENDIXES
A A Conceptual Framework for Evaluating the Consequences of
Uninsurance: A Cascade of Effects
B Measuring Insurance Coverage and Insurance Rates
C Data Tables
D Multivariate Analysis
E Glossary
F Biographical Sketches
REFERENCES
CONTENTS
59
101
109
113
119
135
143
149
157
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opera
attend
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