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A Shared Destiny: Community Effects Of Uninsurance

by Committee On The Consequences Of Uninsurance


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From the New England Journal of Medicine, August 28, 2003
Insurance inherently involves collective destinies among members of a community -- a sharing of the risk of loss from untoward events. The fourth report from the Institute of Medicine's Committee on the Consequences of Uninsurance, A Shared Destiny: Community Effects of Uninsurance, explores a mirror image of the communal fortunes of those who are insured: the implications for a community of people who share geography and health services when not all of them are insured. It highlights the critical question of what happens to the broader community when the health insurance risk pool is highly fragmented and exclusionary. The report identifies an array of potential societal consequences of uninsurance, beyond the well-known implications for individual persons, families, and uninsured persons as a group. It reviews data on the association between uninsurance levels and community-wide measures of access to care, economic and social conditions, and overall health status; its sources range from sophisticated commissioned studies on uninsurance, hospital services, and financial margins to case studies and anecdotes. The Committee on the Consequences of Uninsurance finds that the adverse effects of uninsurance on the uninsured and the associated financial strain have spillover effects on health care institutions and providers. The committee concludes that indicators of access for persons with low and moderate incomes and those without insurance get worse as rates of uninsurance rise. It finds suggestive evidence of adverse consequences on the availability of primary and preventive services, specialty services, emergency care, and certain hospital services. The committee hypothesizes that uninsurance may also raise health care costs, increase the public tax burden, and hurt the overall local economy. Finally, higher numbers of uninsured persons add to the level of disease and disability within a community, and the provision of care to the uninsured may undermine public health and preparedness activities. Surprisingly, the report skirts the problem of the community-level consequences of personal debt and bankruptcies from sticker-price charges levied and often vigorously enforced on the uninsured, although it acknowledges that the uninsured pay out of pocket for a sizable part of their care. Thus, it sustains the widespread misperception that uncompensated care has adverse consequences mainly for providers and not for the uninsured themselves and their role in the local economy. The committee's own critique of its efforts is that "the picture of community-level impacts . . . , although tentative in some respects, is an important starting point for developing more definitive evidence" and "the picture is clear enough to inform some policy choices now." My conclusion is that the report does indeed provide a well-considered starting point but provides little direction for current policy choices. Reluctant to draw causal connections without teasing out the extraordinarily complex effects of uninsurance on communities, the report provides few answers to these pressing questions and no specific policy recommendations. Rather than providing guidance for policy, which is generally informed by much less rigorous evidence, the report largely calls for the collection of more data and for more research. In the face of a worsening national crisis of uninsurance, one must ask whether our country really needs, or has time to conduct, as the committee suggests, research such as "well-controlled, longitudinal stud[ies] . . . to tease out the difference between the effects of the uninsured population as . . . an aggregate influence" and their effects in terms of "ecological impact." Apparently, the committee shared this frustration, explaining its repeated calls for more research by saying that "as long as we as a nation tolerate the status quo, we should more fully understand the implications and consequences of our stalemated national health policy" and ending the report with a clarion call to action: "[I]t is both mistaken and dangerous to assume that the prevalence of uninsurance in the United States harms only those who are uninsured." Unfortunately, it requires a triumph of optimism over experience to hope that scientific documentation of the communal effects of uninsurance will motivate our society to redress the problem. Peter P. Budetti, M.D., J.D.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Book Description
(Institute of Medicine) Report from the Committee on the Consequences of Uninsurance and the Board on Health Care Services. Fourth in a series of six reports planned on the subject. Text explores the complex interrelationships between populations of insured and uninsured and the effects on total health care in the community. Softcover.

Book Info
(Institute of Medicine) Report from the Committee on the Consequences of Uninsurance and the Board on Health Care Services. Fourth in a series of six reports planned on the subject. Text explores the complex interrelationships between populations of insured and uninsured and the effects on total health care in the community. Softcover.

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