Research by Author & Topic

Publications by Brenda Spillman on Uninsured/Uncompensated Care

Using data from the 1997 National Survey of America's Families and county-level data on local safety net conditions, the authors find little variation in utilization and access among low-income adults by local safety net conditions, but very large differences by insurance status, after controlling for individual demographic characteristics and health care market characteristics. This suggests that expanding insurance coverage would be a more effective tool for increasing health care use and access among low-income adults than expanding the safety net.

The strength or weakness of a state's safety net does not affect the gap between the insured and uninsured in access to and use of health care services. With few exceptions, the gap in access and use was no larger in states with the most vulnerable safety nets than in states with the least vulnerable safety nets. This report classified 13 states on safety net vulnerability and uses the National Survey of America's Families (NSAF) to measure access and utilization of health coverage. Regardless of the safety net's vulnerability, the uninsured in all states do have access to care and do use services, although the levels are well below those of the insured. While the gaps between the uninsured and the insured show little variation among states, low-income populations are better off in states where they are more likely to be insured.

The author analyzes states' success in covering their uninsured citizens. Nationwide in 1997, the insurance gap, defined as the share of a state's non-elderly adult residents who would be uninsured in the absence of public insurance coverage, was 21 percent. Of the 13 states studied, the insurance gap ranged from 30.4 percent in Texas to 12.2 percent in Wisconsin. States with limited public insurance programs generally covered the smallest proportion of their insurance gap for all income groups. On average, states with comprehensive programs covered twice the proportion of their insurance gap for low-income adults relative to limited program states. Even in comprehensive program states a substantial proportion of low income adults who lacked other insurance were not reached by public coverage.

[© Health Affairs] Policy attention for the uninsured has focused recently on children, despite the fact that nonelderly adults represent about three-quarters of the uninsured. Nationally, adults are 40 percent more likely than children to be uninsured and less than half as likely to have public coverage. Although their approaches differ greatly, all states cover some adults through their Medicaid programs, partially funded by a 50–77 percent federal match. Using data from the National Survey of America's Families (NSAF), this paper examines how different state approaches affected the number of nonelderly adults who obtained public coverage in 1996.