Assessing the New Federalism Discussion Paper No. 03-02
The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.
About the Series
Assessing the New Federalism is a multiyear Urban Institute project designed to analyze the devolution of responsibility for social programs from the federal government to the states. It focuses primarily on health care, income security, employment and training programs, and social services. Researchers monitor program changes and fiscal developments. Alan Weil is the project director. In collaboration with Child Trends, the project studies changes in family well-being. The project provides timely, nonpartisan information to inform public debate and to help state and local decisionmakers carry out their new responsibilities more effectively.
Key components of the project include a household survey, studies of policies in 13 states, and a database with information on all states and the District of Columbia. Publications and database are available free of charge on the Urban Institute's web site: http://www.urban.org. This paper is one in a series of discussion papers analyzing information from these and other sources.
This study was funded primarily by the Kaiser Commission on Medicaid and the Uninsured as part of the Urban Institute's Assessing the New Federalism project. The Assessing the New Federalism project is currently supported by The Annie E. Casey Foundation, The Robert Wood Johnson Foundation, the W. K. Kellogg Foundation, The John D. and Catherine T. MacArthur Foundation, and The Ford Foundation.
BACKGROUND AND LITERATURE
Safety Net Providers
Safety Net Pressures
Previous Safety Net Studies
METHODS AND DATA
Safety Net Variables
Means of Dependent and Safety Net Variables
Do Safety Net Characteristics Affect the Gap?
What is the Role of the Safety Net for Low-income Adults?
Does the Safety Net Affect Uninsured and Insured Adults Differently?
Nearly one in three low income adults lacks health insurance (Zuckerman, Haley, and Holahan 2000). An extensive literature documents that those who lack insurance receive less care and perceive greater barriers to access (American College of Physicians 2000; Hadley 2002; Marquis and Long 1994/95; Monheit 1994). Although much policy focus is on the health needs of children, uninsured adults also represent a vulnerable population, since the prevalence of many serious but treatable diseases rises with age. Ayanian et al. (2000) found that uninsured adults were far more likely to report unmet needs, particularly if they were in fair or poor health, and far less likely to have received preventive or diagnostic services such as breast cancer or hypertension screening, and Baker et al. (2001) found that uninsured or intermittently insured adults aged 50 to 60 were more likely to have a major health decline than those with continuous coverage. The potential consequences of inadequate care for this substantial proportion of the population are a public health concern and may have implications for future Medicare costs.
Policy debates focus on two approaches to address this concern. One is expanding insurance, enhancing individuals' ability to pay for care, wherever received. The second is increasing direct financial support to providers that disproportionately serve the poor and uninsured, collectively the health care "safety net." Both approaches have been reflected in Bush administration budget proposals, which have included tax credits for insurance purchases, by
low-income families and increased support for community health centers (White House 2001). Ample evidence shows that safety net providers primarily serve disadvantaged populations (Forrest and Whelan 2000; IOM 2000), and that changes in health care markets and high uninsurance rates threaten the financial viability of these providers. There is little evidence, however, on how stresses are affecting their ability to serve the uninsured or whether adding safety net capacity would improve access and use for the uninsured or narrow the gap between the uninsured and the insured.
In this paper we examine the relative importance of insurance and the safety net for reducing the magnitude of disparity in health care for adults. We use multivariate models to assess the relationship between specific local safety net conditions and utilization and access by low-income uninsured and insured adults. We also examine the relationship between local safety net conditions and differences in access and use between uninsured and insured adults. Our safety net measures attempt to capture key factors in the performance of the safety net: the capacity of safety net providers and stresses on the safety net system (Norton and Lipson 1998).
Note: This report is available in its entirety in the Portable Document Format (PDF).
The authors wish to thank Emily Greenman for excellent programming and research assistance, Amy Davidoff for providing data and advice for a number of safety net variables, Douglas Wholey of the University of Minnesota for providing private managed care penetration data, and John Holahan for his helpful comments.
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