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Problems Arising From Lack of Health Insurance Ripple Through Whole Communities

Communities with high rates of uninsurance are more likely to reduce hospital services, divert public resources away from disease prevention, and reallocate tax dollars so says a new report from the Institute of Medicine of the National Academies.

The presence of large numbers of uninsured people can result in reduced access to emergency care, specialty services, and hospital care across the community -- even for those who have health coverage.

"It is misguided and even dangerous to assume that lack of health insurance harms only those who are uninsured," said Arthur Kellermann, co-chair of the committee that wrote the report, and professor and chair of emergency medicine at Emory University School of Medicine, Atlanta.

"The rest of the community pays for uncompensated medical care either directly or indirectly, and high rates of uninsurance can strain community health systems to the point that important services have to be cut or eliminated."

Given current economic conditions -- high unemployment, escalating health care costs, and budget deficits at the federal, state, and local levels -- the uninsurance rate will probably continue to grow and have greater communitywide impact.

There is little evidence that the public funds that pay for the bulk of uncompensated medical care for uninsured patients are being allocated or targeted efficiently, however. If sufficient public funds are not available, resources may have to be diverted from other public purposes to pay for health programs, the committee found.

For example, Hillsborough County in Florida had to reallocate $2.5 million in property taxes that had been earmarked for road construction to help offset a $6.6 million shortfall in a program serving the medical needs of the uninsured and indigent.

Hospitals generally have attempted to control costs by reducing the number of staffed inpatient beds. However, fewer staffed beds can translate into longer wait times before patients who require admission are transferred out of the emergency room. The resulting overcrowded emergency rooms reduce access to emergency and trauma care for everyone in the community.

High rates of uninsurance also take a toll on local public health departments, an important part of the health care safety net. Public health officials across the country report feeling caught between diminishing budgets, demands for populationwide services, and an increasing need to provide medical care to the uninsured.

The result may be a shift of funds toward health care delivery at the expense of disease surveillance, injury control, and other traditional public health programs, the report says. This is a serious concern, given that public health departments play a crucial role in detecting and responding to bioterrorist attacks and naturally occurring disease outbreaks.

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