IOM report: America's Uninsured Crisis

America's Uninsured Crisis: Consequences for Health and Health Care

Institute of Medicine
The National Academies
February 24, 2009

Web briefing

Lawrence S. Lewin, Chair, Committee on Health Insurance Status and Its Consequences (and also founder of The Lewin Group):

We were asked... to basically answer three questions, and this was a follow-on to the IOM studies that were produced in six volumes between 2000 and 2004. The first is what are the dynamics driving an apparently persistent downward trend in health insurance coverage? The second, is being uninsured harmful to the health of children and adults? And third, are insured people affected by high rates of uninsurance in their communities, so called spill-over effect? ...I think that it's important to point out some things that we were not able to cover. The first were a whole series of economic and financial impacts of uninsurance, impact on medical debt and global competitiveness. These are issues where the data are not very sound, and where there is a lot of disagreement in any event. We were not able to, because of the non-availability of data, to look at the impact of different levels of insurance, so in a sense we treated insurance coverage as a binary issue - you either had it or you didn't have it, and we know that there are a lot of shadings in between, but we believe that the research is clear enough - very clear indeed - about even the binary decision. And finally, we were specifically asked not to deal with the potential approaches to solving the problem. There are lots of people doing that - indeed as we speak.


Lawrence S. Lewin:

The conclusions are, yes indeed, health insurance coverage does matter... That question, which I think is at the heart of the debate, really should no longer be an issue... Secondly, particularly given the fact that it does make such a difference, we believe that there is a compelling need to do something to off-set this persistent decline with which we're faced, and that there is an argument to be made that even those who currently have insurance, even if they don't lose it which they are at greater risk of doing, should have an interest in these issues. As a consequence, the committee unanimously adopted the following recommendations... The committee recommends that the president work with Congress and other public and private sector leaders on an urgent basis to achieve health insurance coverage for everyone, and, in order to make that coverage sustainable, to reduce the cost of health care and the rate of increase in per capita health care spending.


A web question from Dr. Don McCanne from Physicians for a National Health Program:

Although this report is limited to the importance of being insured, shouldn't reform efforts also be directed toward adopting policies that would ensure that coverage actually enables access and affordability? Since there are questions about the limits of the private insurance model in accomplishing this, shouldn't all options be on the table, including a single payer national health program?

Lawrence S. Lewin:

Without taking any position implied by the very last point about a particular proposal, I think the answer is yes, of course, all options should be on the table until they're more thoroughly analyzed, and I believe many things are being considered right now. But I think to opine on the question itself is really beyond the scope of the committee.

Links to this audio briefing, the news release, the report in brief, the project web page, and the full report:


By Don McCanne, MD

In six previous reports, published from 2001 to 2004, the Institute of Medicine concluded that "being uninsured was hazardous to people’s health and recommended that the nation move quickly to implement a strategy to achieve health insurance coverage for all."

After a five year lapse, the Institute is issuing an update which concludes, "Health insurance coverage matters. Expanding health coverage to all Americans is essential. Action to reduce health care expenditures and the rate of increase in per capita health care spending is also of paramount importance if health insurance coverage for all is to be achieved and sustained."

Is this earthshaking news or what? Having health insurance can be beneficial for your health, and everyone should have it, especially since it makes communities healthier as well. Uh, I think we all knew that.

What is surprising is Lawrence Lewin's statement that there is "disagreement" on the economic and financial impacts of uninsurance, and the data on this "are not very sound." Is he suggesting that we should discard a couple of decades of extensive, highly credible studies demonstrating that those without health insurance face impaired access to care, financial hardship, and often personal bankruptcy, not to mention physical suffering and perhaps even death?

Just as astounding is his statement that there is a "non-availability of data to look at the impact of different levels of insurance." Again, is he recommending that we discard the plethora of highly credible studies, which demonstrate that the explosion in underinsurance products is also causing much of the same suffering as that experienced by the uninsured?

Lewin's statements provoked me enough to submit the question on whether we should include on the table a consideration of single payer as a financing model that would enable access and affordability. He did let slip out the obvious answer, "yes," before retreating to the position that he should not "opine" on it.

The answer is YES! Single payer definitely needs to be on the table.

Lewin may not want to opine, but that shouldn't stop us from opining that we should remove from the table any reform model that would leave us short of providing all necessary care for everyone without exposing anyone to financial hardship. That would really clear the table. Then we could get serious about working on a single payer national health program.