Expanding coverage to the 47 million Americans who now lack health insurance could greatly improve care for people who already are protected, according to a new study in the September-October issue of the journal Health Affairs. Researchers found that insured adults who live in communities with high uninsurance rates are more likely to face problems with access to care and quality than those who live in communities where more people are covered.

Economists Mark Pauly and José Pagán compared differences in health care access, use, and quality between 9,552 insured adults in 10 communities with the highest and 10 with the lowest proportions of uninsured adults. Communities with high rates of uninsurance had an average of about 27 percent of adults without health insurance. Communities with low rates of uninsurance had an average of nearly 7 percent of adults who lacked coverage.

The authors found that insured adults who live in communities with high proportions of uninsured people were less likely to have a place to go when they were sick or needed health care advice, less likely to visit a doctor, and less likely to have had a physician exam within the last year, compared with their peers in low-uninsurance communities. They also reported more problems getting referred to a specialist and were less likely to report that they were satisfied with their doctor.

"Everyone knows that something needs to be done to cover the uninsured, but the arguments put forth often focus on the potential financial savings to the insured populations that come from providing health care coverage for those who lack it," said Pagán, professor and director of the Institute for Population Health Policy at the University of Texas-Pan American. "By covering the uninsured, we end up with a higher-quality health care system overall, particularly if the uninsured are kept in the same financing and delivery systems as the insured."

Pauly and Pagán also analyzed Community Tracking Survey (CTS) data from almost 5,000 physicians and more than 25,000 adults and found that doctors who practice in communities with high uninsurance rates are more likely to be dissatisfied with their careers and have a lower perception of the quality of care they provide than their peers in communities with lower uninsurance rates. An analysis of another CTS survey of 2,170 physicians showed that primary care doctors who practice in communities with a large uninsured population reported that they were less likely to be able to refer their patients to high-quality specialists. Their analysis also showed that the higher the community uninsurance rate, the less likely it is that specialists are able to deliver high-quality care to their patients.

"It is in the self-interest of those who are less vulnerable to be concerned about the plight of the more vulnerable and be willing to pay to make a change," said study coauthor Pauly, a professor at the Wharton School at the University of Pennsylvania. "Those who live in communities with high rates of uninsurance face not only the higher costs related to uncompensated and charity care, but also lower-quality care as a result of low demand for quality by the uninsured."

This study is part of a series of papers in the September-October issue of Health Affairs that focuses on vulnerable populations. The issue was supported by the Robert Wood Johnson Foundation. Other articles look at how early-life conditions can determine an individual's health over a lifetime, explore policy options for providing health care to immigrants, and examine the most effective strategies for policymakers to address health inequalities and the potential effect of consumer-directed care on vulnerable populations.

Other Issue Highlights:

Early-Life Conditions And Health Status. Scholars have only begun to identify how factors such as socioeconomic status, neighborhood environments, and traumatic events in childhood can affect health over the course of a lifetime. Researchers from the Center for Interdisciplinary Health Disparities Research, University of Chicago, explain that policies and programs are more effective if they target neighborhoods and address multiple factors, including children's physiological and cognitive development and social inequality, rather than focusing exclusively on health. These programs and policies have a greater chance of long-term success if they include input from community stakeholders, said the authors.

"The Katrina disaster exposed the extreme vulnerabilities of a population group defined by poverty, racial discrimination, and geography and focused a global spotlight on the consequences of policies that fail to acknowledge and address those vulnerabilities," write researchers Alice Furumoto-Dawson, Sarah Gehlert, Dana Sohmer, Olufunmilayo Olopade, and Tina Sacks. "When it comes to population-based health vulnerabilities, there is no such thing as 'benign' neglect."

Health Care And Immigrants. Researchers Kathryn Derose and Nicole Lurie of RAND and José Escarce of the University of California, Los Angeles explore the factors that affect immigrants' health status. Although there are differences among immigrant subgroups, immigrants have lower rates of health insurance, use less health care, and receive lower quality of care than those born in the United States. To addresses these issues, the researchers call on policymakers to expand access to health insurance for immigrants, address limited English proficiency, implement policies that strengthen the safety-net infrastructure, and consider easing access to public health insurance.

Policy And Health Inequalities. In a related piece, Tom Miller of the American Enterprise Institute argues that policies designed to reduce health disparities should focus on the degree to which health conditions are "persistent, avoidable, and treatable." He writes that the most effective interventions should address prenatal and early childhood care, as well as destructive lifestyle practices.

Consumer-Directed Health Care And Vulnerable Populations. Gregg Bloche, a professor at the Georgetown University Law Center, argues that consumer-directed health plans -- those that pair high-deductible health plans with health care savings accounts (HSAs) -- could widen socioeconomic, racial, and ethnic disparities in care. Possible fixes to such plans include more-progressive tax subsidies, tiering of cost-sharing schemes to promote high-value care, and reducing deductibles and copayments for the less well-off. "Copayments and deductibles should not force desperate families to choose between high-value health care and life's other basic needs," he writes.

In a related piece, authors Katherine Baicker of the Harvard School of Public Health, William Dow of the University of California, Berkeley, and Jonathan Wolfson of University of Virginia School of Law argue that the movement toward consumer-directed health could increase insurance coverage for all by making lower-cost policies more widely available and by slowing health care cost growth. The authors acknowledge that further examination is needed on the effect of consumer-directed plans on vulnerable populations. However, they write that "leveling the playing field for policies with different degrees of risk sharing and different designs for cost control is a promising avenue for promoting more efficient use of resources and more affordable care."

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at healthaffairs.