What’s Behind It?

The uninsured are more likely to do without needed health care than those who are insured. For example, they are more likely to forgo recommended screening and preventive services and less likely to have regular care for a chronic condition such as hypertension or diabetes. The uninsured are also more likely to be without a regular source of health care and to report worse health status than those with coverage. Being without health insurance also increases the chances of premature death.

Because of these important differences, health insurance is often held up as the key to appropriate access to care. It is sometimes asserted or implied that if only the uninsured had health coverage, they’d get the care they need, when they need it.


The Broader Picture

Health insurance coverage and care are linked, but coverage is neither necessary nor sufficient to assure appropriate access to care. There are many determinants of access to health services, insurance coverage being only one. Other determinants include the availability of providers, cultural and linguistic competence of providers, and affordability of copayments, co-insurance, and deductibles.

In some cases, people who have health insurance nevertheless struggle to gain access to needed care. For example, Medi-Cal reimburses most health care providers considerably below market rates, resulting in low provider participation. As a result, Medi-Cal enrollees often have great difficulty finding participating physicians and other care providers and getting appointments with them, despite their covered status.

In other cases, care can be arranged effectively without insurance coverage. Though this is the exception rather than the rule, some California counties and safety-net facilities are developing programs whereby the populations they serve – often low-income people with chronic diseases – are linked to a regular source of care outside of a traditional insurance arrangement.

Finally, regardless of insurance status, high-quality care is by no means assured. A 2003 RAND study found that adults in the United States — the vast majority of whom have health insurance —receive recommended, evidence-based care only about half of the time.


The Bottom Line

Appropriate, timely, and quality health care services require stable and sufficient financing; access to willing and capable providers; organizational systems to track and manage care; and engaged consumers. Health insurance coverage facilitates, but does not assure, these elements.

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For More Information

• Institute of Medicine, Coverage Matters: Insurance and Health Care, 2001.
• Institute of Medicine, Hidden Costs, Value Lost: Uninsurance in America, 2003.
• McGlynn EA, et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine, Vol. 348, No. 26, 6/26/03, pp. 2635-2645.
• Mathematica Policy Research, Access to Physicians in California’s Public Insurance Programs, 5/04.