Health Care Access for Uninsured Adults

Nearly 43 million Americans were uninsured in 1999. The large number of individuals living without insurance remains a major health and public policy concern. Although these individuals have less health care access and service use, the uninsured do have some sources of care. A health care system, or "safety net," for the poor, comprising public hospitals, community health centers, local clinics, and some primary health care physicians, exists in all communities. However, the capacity of these systems and their sources of financial support vary widely.

States' uninsured rates, marketplace competition, Medicaid payment policies, and state and local financial support all exert pressure on the safety net. As a result, access for the uninsured can vary considerably across states and communities. Cunningham and Kemper (1998), after controlling for personal and health characteristics, find considerable differences across communities in the extent of unmet need and delays in obtaining care among the uninsured.

This brief examines the extent to which differences in the safety-net environment account for differences in the uninsureds' access to and use of health care. After grouping states according to the vulnerability of various aspects of their health care safety nets, we examine whether low-income uninsured adults get less care and have poorer access in states where the safety net is weaker. We then explore whether utilization and access gaps between the uninsured and the insured are narrower in states with stronger safety nets. The brief focuses on low-income adults, who are more likely to be uninsured and therefore dependent on the safety net, and on residents of metropolitan areas, where most states' safety-net resources are concentrated. It draws on representative samples of the population from 13 states—Alabama, California, Colorado, Florida, Massachusets, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin—using data from the Urban Institute's National Survey of America's Families.

The analysis reveals that differences across states in some measures of care access for uninsured adults are consistent with differences in the levels of safety-net vulnerability. More striking, however, is the finding that substantial gaps in service use and care access between the uninsured and the insured are evident in all states and that the vulnerability of a state's safety net does not affect these gaps. Uninsured adults' access to care appears to be no worse where the safety net is more threatened and no better where it is under less pressure.