COVERAGE: A Context for the New Uninsured Estimates

Next week the U.S. Census Bureau will release its updated estimate of the number of uninsured people—now officially at 47 million. David Colby at the Robert Wood Johnson Foundation helpfully assembled some accessible foundation-backed papers and issue briefs on who the uninsured are, what being uninsured means, what the federal environment for change looks like now, and how the states have or have not stepped up. Here's the link to the series "The State of Research on the Uninsured: Putting Census Estimates in Perspective" and we're providing a few of the summaries and abstracts below. We'll post a similar brief guide to some of our own issue briefs and papers on the uninsured before the Census numbers come out.

I personally found the ER paper particularly informative when it came out a few months ago, and my colleague Dr. Guy Clifton has blogged about this topic several times (and explained to me aspects of the ER crisis that I had not previously understood). It's not just the uninsured crowding our ERs, it's everybody. Patients who can't get timely access to primary care, patients who cant' get after-hours routine care if they get sick (or if their physician didn't make time for them during the regular work day), patients whose chronic diseases are not properly controlled so they end up in crisis, or whose pain is not treated well—the list goes on and on. The uninsured, of course, are a big chunk of it, probably about 15 percent of ER visits, and of course as the overall number of uninsured people grows, that means more volume in the ER. The ER is one way of measuring the distress of our health care system, and it's definitely in distress.

Defining the Problem and Potential Solutions

Falling Behind: Americans' Access to Medical Care Deteriorates, 2003-2007
Between 2003 and 2007, the number and proportion of Americans reporting going without or delaying needed medical care increased sharply, according to findings from the Center for Studying Health System Change's nationally representative 2007 Health Tracking Household Survey. People reporting access problems increasingly cited cost as an obstacle to needed care, along with rising rates of health plan and health system barriers.

Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?
The authors analyzed emergency department (ED) visits in the United States to learn whether the rise in ED use could be attributed to uninsured individuals. They conclude that the documented rise in ED visits between 1996 and 2004 cannot be primarily attributed to the uninsured. Instead, major contributors to the rise in number of visits are increased visits by non-poor people and people with other regular sources of care.

Health Insurance Coverage of Young Adults
This Urban Institute analysis looks at why young adults are disproportionately uninsured and what policies could address their coverage gaps. While conventional wisdom suggests that these largely healthy young adults reject coverage because of their youth and vitality, the facts tell a more complicated tale. Large numbers of young adults do not work full time and are not full-time students, leaving them without their own employer-sponsored insurance—or their parents'—and without the income to afford private market coverage.

Knowing What Works in Health Care
Despite unprecedented advances in biomedical knowledge and the highest per capita health care expenditures in the world, the quality and outcomes of health care for Americans vary dramatically across the country. Improved knowledge about which treatments and procedures are effective could lead to less regional differences, stronger consensus on standards and guidelines, and lower costs.

To this end, the Robert Wood Johnson Foundation asked the Institute of Medicine to convene a committee to recommend methods to better identify the most effective health care services. This resultant report provides a blueprint for a national clinical effective assessment program. One of the committee's key recommendations is that the U.S. Department of Health and Human Services create a single entity (the Program) with the authority, resources and capacity to: (1) set priorities for evidence assessment; (2) assess evidence (systematic review); and (3) develop or endorse standards for evidence-based clinical practice guidelines.

The central premise underlying the report is that decisions about the care of individual patients should be based on the current best evidence available, and that having a single body charged with evaluating and sorting information will help to clarify for physicians, health care providers, and patients which evidence is valid.

Igniting Health Care Payment Reform
Health care costs, which are driven by payments to hospitals, physicians and other health care providers, have been steadily increasing across time. The PROMETHEUS Payment® approach is an attempt to address the rise in health care costs while maintaining high quality patient-centered care by developing a new approach to pay for health care services.

PROMETHEUS aims to promote value and quality in health care, decrease the administrative work of providers, and offer reasonable compensation to providers given scientifically—determined treatment for patients with specific conditions.

How Far Can States Take Health Reform?
Expectations for state leadership in health reform have never been higher. States are thought to function as "laboratories of democracy," but they do not fulfill this role effectively because insufficient attention is paid to experimentation and knowledge translation. Congressional proposals to encourage state action cover too narrow a span of state health policy, do not provide states with sufficient authority to tackle major health policy challenges, and supply insufficient funding. This paper concludes with a description of a more robust state-federal partnership that would be more likely to yield substantial health reform.

State Health Access Profile: A Chartbook of Health Care Access Indicators for States
Who is insured? What percentage of employers in a state offer health insurance? Who could get medical care if they needed it? The State Health Access Profile answers those questions, and many more, on a state-by-state basis. The chartbook is published annually by the University of Minnesota's State Health Access Data Assistance Center (SHADAC), with support from RWJF.