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Spring 2001 Vol. 1 No. 1

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Going Without Health Insurance?
A New Project Looks at the Consequences

Some 42 million people in the United States have no health insurance to cover their medical needs. Although many of the uninsured are poor, the surprising reality is that the majority who are of working-age are employed, and a large proportion of them work for businesses with more than 500 employees. Eight out of every 10 people without health coverage either work or are children of working parents, according to Cathy Schoen, vice president for research and evaluation at the Commonwealth Fund.

In fact, many small businesses do not offer health insurance at all, and those where at least a third of their workers make less than $20,000 a year are far less likely to offer it than firms that pay higher wages. And only 64 percent of workers at larger businesses employing 200 or more receive coverage through their employers. Indeed, as the costs of health insurance plans continue to rise, many businesses are incapable of providing insurance to employees without hurting their bottom line.

Schoen was among 21 experts who presented these and other findings to an Institute of Medicine (IOM) committee during a recent workshop held to review what is known about the uninsured and to identify where research and information gaps persist. The workshop was the first step in a three-year project that is assessing the health, economic, and social consequences of uninsurance.

Despite nearly a decade of national debate on health care reform, little has been done to develop new policies aimed at securing health insurance for all Americans. To help move the discussion closer to action, the committee's study will attempt to raise awareness and improve understanding of the magnitude and nature of uninsurance in the United States.

The facts seem clear. Extensive data exist connecting the lack of insurance with poorer health, lower quality of life, and higher likelihood of premature death. One of the committee's tasks is to consolidate and communicate these and other findings. "The research literature supports what many of us know from clinical practice, that the uninsured often delay medically necessary and life-saving care such as screening and treatment for cancer, high blood pressure, heart disease, asthma, and diabetes," says Steven A. Schroeder, president and chief executive officer of the Robert Wood Johnson Foundation, which is sponsoring the IOM project. "As a result, the uninsured are likely to develop more serious health problems."

And while intermittent coverage may seem better than none at all, even people who only periodically go without health insurance run a higher risk of falling into poor health, said workshop presenter Catherine Hoffman, associate director of the Kaiser Commission on Medicaid and the Uninsured.

Those who have interruptions in health-insurance coverage often fail to receive preventive care and are forced to seek medical attention for emergencies only. Despite the short-term savings that come from not paying for insurance, the overriding consequence for many uninsured families who only receive emergency services is that too much of the family budget ends up being spent on health care.

The Institute of Medicine project will generate six reports on the subject; the first is expected in the fall and will present an overview of who the uninsured are, where they live, and which population subgroups are disproportionately likely to be uninsured. It also will examine the factors that lead to uninsurance. This initial report will offer a conceptual framework for assessing the impact of uninsurance that will be used in the subsequent reports.   -- Cheryl Greenhouse

(See listing in New Projects and Publications for additional project information.)

From top: Catherine Hoffman, Kaiser Commission on Medicaid and the Uninsured, and Keith Mueller, University of Nebraska Medical Center

Edward Wagner, University of Washington School of Public Health and Community Medicine

Julie Rovner, National Public Radio

E. Richard Brown, School of Public Health, University of California, Los Angeles

Jack Hadley, The Urban Institute

Arthur Kellerman (left), Rollins School of Public Health at Emory University, and Reed Tuckson (right), UnitedHealthGroup

Charlotte Yeh (left), National Heritage Insurance Co., Willard Manning (center), University of Chicago School of Medicine and School of Public Policy, and Darrell Gaskin (right), Georgetown University Medical Center

Photographs by Greg Hadley

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Copyright 2001 by the National Academy of Sciences