May 2002
“Sicker and Poorer: The Consequences of Being Uninsured” By Jack Hadley, Ph.D., Principal Research Associate, The Urban Institute
… this report focuses primarily on the relationship between health insurance and health outcomes, which has been addressed by a surprisingly large number of studies over the past 25 years, as well as the link between health and educational attainment and economic opportunity.
This review shows that there is a substantial body of research consistent with a model postulating positive relationships between health insurance, use of medical care, health, income, and education. However, as noted at the outset, none of these studies is definitive, nor are their findings universal. The literature also includes studies that have failed to find a positive relationship between good health and having health insurance or using more medical care.
While all of these studies suffer from methodological flaws of varying degrees, two general observations appear warranted. The first is the fairly remarkable degree of consistency across the studies that support the underlying conceptual model of the relationship between health insurance and health. Studies of different medical conditions, conducted at different times, using different data sets and statistical methods have produced quantitative estimates of the effects of having health insurance or using more medical care that are both consistent with each other and fall within a relatively narrow range. This degree of quantitative agreement across studies reinforces the implications of any single study taken by itself.
The second general observation, holding aside issues of potential methodological weaknesses, is that many of the studies that failed to find a positive association between health insurance or medical care use and health do not obviously generalize to the current population of uninsured nonelderly adults and their families. Casual empirical observations of pre-Medicare/Medicaid data in the U.S., studies of inefficient medical care use by the elderly or privately insured, and studies of birth outcomes may not be directly relevant to assessing the health benefits of extending health insurance to those who are currently without insurance coverage. Even if one accepts as valid the findings of the more methodologically sound studies that suggest little or no health benefit from additional medical care use by well-insured populations, it does not necessarily follow that the uninsured would not benefit both from health insurance coverage and from greater medical care use. Holding both points of view would not be inconsistent. In fact, it would seem to be both inappropriate and unfair to argue on the basis of these studies that the uninsured should be penalized, i.e., denied help in obtaining insurance coverage, because of the inefficient or excessive use of medical care by the well insured.
This report concludes that a compelling case has been made that having health insurance does lead to improved health by means of better access to medical care. Furthermore, the available research on the links between health insurance, health status, and an individual’s productivity begins to provide a reasonable basis for future economic analyses of the benefits of health insurance to the nation as a whole.
The next step for health services research is to estimate the size of the economic benefits of continuous health coverage. Estimates of the size of the potential economic benefits should become a prominent part of policy debates over expanding health insurance coverage. These estimates may help shift the current focus from the direct costs of health insurance expansions to the question of how much is likely to be saved by expanding coverage, and ultimately to policy decisions based on a truer sense of the net cost to the nation to cover all Americans.
(The comments above include excerpts from the Executive Summary and excerpts from the Full Report that have been commingled .)
Comment: This comprehensive review of the extensive research on the consequences of being uninsured is a very valuable resource that confirms that the lack of insurance has major negative impacts. This report can be used to refute the arguments of those that use isolated studies to suggest that the uninsured do receive the care that they really need. They clearly do not.