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Breaking Barriers: Lack of Health Insurance. Introduction. Some say a lack of insurance is not a problem, but what are the more than 40 million people who are uninsured saying? “Sometimes I have to hold off paying a (hospital) bill to keep the gas and electricity on.”

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Breaking Barriers: Lack of Health Insurance

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Breaking barriers lack of health insurance l.jpg

Breaking Barriers:Lack of Health Insurance


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Introduction

Some say a lack of insurance is not a problem, but what are the more than 40 million people who are uninsured saying?

  • “Sometimes I have to hold off paying a (hospital) bill to keep the gas and electricity on.”

  • “I don’t want my children to be held back, because I am worrying about what might happen.”

  • “I barely get finished paying one bill, when the next one comes in.

Source: Shirk M, Trost C, and Schultz S. In Their Own Words. Washington, DC. Kaiser Family Foundation; 2000


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Number of Uninsured in America

In 2001, over 41 million adults under the age of 65 in the United States lacked health insurance. This number is forecasted to increase at about 750,000 people per year.

Source: http://www.kff.org/content/2003/142004/142004.pdf


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The Rise in the Uninsured

Source: US Census Bureau, (2002). Health Insurance Coverage: 2001


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Discussion Question

Who is most likely to be uninsured?


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Characteristics of Uninsured

Work Status

  • Eight out of every ten uninsured people are members of families with at least one wage earner, and six out of every ten uninsured people are wage earners themselves.

    Income Status

  • Two-thirds of all uninsured persons are members of lower-income families (earning less than 200 percent of the federal poverty level).

Source: Fronstin D. 2000. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2000 Current survey. Issue Brief No. 228. Washington, DC: Employee Benefit Research Institute


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2002 Federal Poverty Level

Source: Federal Register, Federal Register: February 14, 2002 Vol 67( 31):Pages 6931-6933


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Income Status of the Uninsured

Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured analysis of March 2002 Current Population Survey. 2002.


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Race and Ethnicity of Uninsured

African Americans are twice as likely, and Hispanics three times as likely, as Caucasians to be uninsured.

Source: Fronstin D. 2000. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2000 Current survey. Issue Brief No. 228. Washington, DC: Employee Benefit Research Institute.


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Race and Ethnicity of Uninsured

Source: Hoffman C, Pohl M. 2000. Health Insurance Coverage in America: 1999 Data Update. Washington, DC:

The Kaiser Commission on Medicaid and the Uninsured.


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Age of Uninsured

Source: Fronstin D. 2000. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2000 Current survey. Issue Brief No. 228. Washington, DC: Employee Benefit Research Institute.


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Age of Uninsured

Three-quarters of the uninsured are adults (ages 18–64 years), while one-quarter of the uninsured are children. Compared with other age groups, young adults are the most likely to go without coverage.

Source: Fronstin D. 2000. Sources of Health Insurance and Characteristics of the Uninsured:

Analysis of the March 2000 Current survey. Issue Brief No. 228. Washington, DC: Employee Benefit Research Institute.


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Geography of Uninsured

  • Most uninsured persons live in urban areas. However, rural and urban residents are about equally likely to be uninsured.

  • Southerners and Westerners are more likely to be uninsured than those who live in the North and Midwest.

Source: Hoffman C, Pohl M. 2000. Health Insurance Coverage in America: 1999 Data Update. Washington, DC:

The Kaiser Commission on Medicaid and the Uninsured.


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Discussion Question

Why are some people denied access to health insurance?


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You Cost too Much to Cover

Poor health

Insurance carriers often decline to cover people with pre-existing medical conditions, and, if coverage is extended to them, it is usually done so with restrictions, and offered at higher costs than people who are healthy. This can price insurance out of the range of individuals with poor health and create more gaps in coverage that could exacerbate the problems of the underinsured.

Source: Pollitz K, Sorian R, Thomas K. 2001. How Accessible is Individual Health Insurance for Consumers in Less-than-Perfect Health?

Washington, DC: The Kaiser Family Foundation.


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Discussion Question

How do people gain and lose coverage?


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Sources of Health Coverage

Source: Institute of Medicine (IOM). 2001. Health Insurance is a Family Matter. Washington, DC: National Academies Press.


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Employment-Based Coverage

  • About 7 out of every 10 Americans under the age of 65 years are covered by employment-based health insurance.

  • Employers are not required to offer employment-based insurance, and, when they don’t, employees and their dependent family members (spouses and minor children) are left uninsured.

  • Loss of employment also means loss of insurance coverage.

Source: Institute of Medicine (IOM). 2001. Health Insurance is a Family Matter. Washington, DC: National Academies Press.


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Employment-Based Coverage

  • Some employees are ineligible because they work part time or temporarily.

  • Some employees cannot afford the premiums.

  • Getting separated, divorced, or being widowed may increase the risk that family members lose their employment-based coverage.

Source: Institute of Medicine (IOM). 2001. Health Insurance is a Family Matter. Washington, DC: National Academies Press.


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Government Assistance Programs

Medicare: A jointly funded insurance program by Federal and State governments to pay for medical assistance for low income and eligible needy persons.

Medicaid: The federal insurance program for people 65 years or older, certain younger people with disabilities, and people with End-Stage Renal Disease.

Source: http://cms.hhs.gov


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Medicaid

  • In 2001, there were about 41 million Americans who relied on Medicaid as their primary source of health insurance.

  • Participation in public insurance such as Medicaid hinges on state eligibility.

Source: Institute of Medicine (IOM). 2001. Health Insurance is a Family Matter. Washington, DC: National Academies Press.


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Medicaid

  • Increasing one's income, even if barely above the eligibility limit, may result in a total loss of Medicaid coverage, even if workplace health benefits are not available or affordable.

  • Low-income, recent immigrants are not eligible for Medicaid.

Source: Institute of Medicine (IOM). 2001. Health Insurance is a Family Matter. Washington, DC: National Academies Press.


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State Children's Health Insurance Program (SCHIP)

SCHIP was enacted to provide states with $40 billion in federal funds to cover low-income children. Children may also be covered through their parent’s insurance plans. When children reach the age of 18, or leave college, they usually lose public benefits or coverage under their parent’s health insurance plan.

Source: Institute of Medicine (IOM). 2001. Health Insurance is a Family Matter. Washington, DC: National Academies Press.


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SCHIP

Nearly 24% of low-income children remain uninsured even after implementation of SCHIP

Source: Salsberry PJ. Why are some children still uninsured? J Pediatr Health Care 2003;17(1):32-8    


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Medicare

Medicare provides coverage to about 35 million Americans aged 65 and older, and to an additional 6 million younger Americans with disabilities.

Source: Institute of Medicine (IOM). 2001. Coverage Matters. Washington, DC: National Academies Press


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Prescription Drug Coverage

However, Medicare offers no prescription drug benefits, leaving 38% of those who need it most either going without the necessary medications, or having to pay out-of-pocket for them.

Source: Kaiser Family Foundation. 2003. Medicare and Prescription Drugs. Fact Sheet.

Washington, DC: The Henry J Kaiser Family Foundation.


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Discussion Question

What are the financial repercussions for the uninsured?


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Financial Repercussions

  • About 70% of the uninsured report depleting their savings to pay off medical bills.

  • In 1999, 500,000 Americans filed for bankruptcy protection due to large medical bills.

Source: Duchon, L., Schoen, C., Doty, M., Davis, K., Strumpf, E., & Bruegman, S. (2001). Security Matters:

How Instability in Health Insurance Puts U.S. Workers at Risk (Report No. 512). New York, NY: The Commonwealth Fund.


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Avoidable Costs

Compared to the privately insured, the rate of avoidable hospitalizations for the uninsured has increased over time from 24.3% in 1980 to 54.6% in 1998 compared to a less than 4% increase for the insured.

Source: Kozak LJ, Hall MJ, Owings MF. Trends in avoidable hospitalizations. Health Affairs. 2001;20(2):225-32.


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Preventative Services

Uninsured adults are less likely than adults with any kind of health coverage to receive preventative and screening services on a timely and periodic basis.

Source: Ayanian JZ, Weissman JS, Schneider EC, et al. Unmet health needs of uninsured adults in the United States.

JAMA 2000;(16)284:2061-69.


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Preventative Services

Source: Ayanian JZ, Weissman JS, Schneider EC, et al. Unmet health needs of uninsured adults in the United States.

JAMA 2000;(16)284:2061-69.


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Medical Advice

Uninsured people are 50% less likely to receive cardiac procedural recommendations from their physician.

Source: Leape LL; Hilborne LH; Bell R; Kamberg C; Brook RH. Underuse of cardiac procedures: do women, ethnic minorities,

and the uninsured fail to receive needed revascularization? Ann Intern Med 1999;2;130(3):183-92.  


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Burden of Suffering

  • Uninsured patients who are hospitalized for their conditions are less likely to receive services and more likely to die in the hospital than are insured patients.

  • Uninsured babies have a 1.5 times greater chance of both neonatal and post-neonatal death.

Source: Sada MJ, French WJ, Carlisle DM, Chandra NC, Gore JM, Rogers WJ. Influence of payer on use of invasive cardiac procedures and

patient outcome after myocardial infarction in the United States. Journal of the American college of Cardiology. 1998;31(7):1474-80.

Source: Dubay L, Joyce T, Kaestner R, Kenney GM. Changes in prenatal care timing and low birth weight by race and socioeconomic status:

implications for the Medicaid expansions for pregnant women. Health Services Research. 2001; June;36(2):373-98.


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Burden of Suffering

  • Uninsured cancer patients are 50% more likely to die prematurely than persons with insurance, largely because of delayed diagnosis.

  • Continuously and/or intermittently uninsured individuals were nearly 2 times more likely to suffer major health declines over a 4-year period, compared to those continuously insured.

Source: Baker DW, Sudano JJ, Albert JM, Borawski EA, Dor A. Lack of health insurance and decline in overall health in late middle age.

The New England Journal of Medicine. 2001; 11;345(15):1106-12.


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Discussion Question

How do the problems of the uninsured affect us all?


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All For One and One For All

  • The presence of a large number of uninsured individuals may adversely affect the health of the entire community due to the transmission of diseases.

  • The uninsured are 50% more likely to be hospitalized for an avoidable condition. The average cost in 2002, for an avoidable condition was $3,300.

Source: Kozak LJ, Hall MJ, Owings MF. Trends in avoidable hospitalizations. Health Affairs. 2001;20(2):225-32.


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Uncompensated Care

In 1999 hospitals incurred $20.8 billion, 6.2 percent of their total expenditures, in costs for patients who did not pay their bills.

Source: Kozak LJ, Hall MJ, Owings MF. Trends in avoidable hospitalizations. Health Affairs. 2001;20(2):225-32.


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Uncompensated Care

Source: A Shared Responsibility: Academic Health Centers and the Provision of Care to the Poor and Underserved,

The Common Wealth Fund, 2001


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Nowhere to Run Nowhere to Hide

  • To compensate the costs of caring for the uninsured, providers must recoup the costs from their paying customers in the form of higher insurance premiums and taxes. These may result in cutbacks in health service delivery and facility closures.

  • As premiums constantly increase, more and more businesses may find it harder to initiate or continue health insurance, as a result adding to the number of uninsured.

Source: Institute of Medicine (IOM). 2001. Coverage Matters. Washington, DC: National Academies Press.


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Productivity

  • Poor health reduces the ability to work; labor force participation is reduced leading to a reduction in productivity. Improvements in health would improve annual earnings by up to 30% .

Source: P Fronstin and AG Holtmann. Productivity gains from employment-based health insurance. EBRI, 2000.


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Vicious Cycle

  • Children in poor health miss more school days and, as a result, are more likely to have less cognitive development. Lower educational attainment due to poor childhood health contributes to lower wages and lower labor force participation, which increase their likelihood of not being insured as an adult.

Source: http://www.kff.org/content/2002/20020510/4051.pdf


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How do Countries with Universal Health Care Compare?

Infant Mortality Rates: Selected Countries, 2000

Source: http://www.oecd.org


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How do Countries with Universal Health Care Compare?

Life Expectancy at Birth: Selected Countries, 1999

Source: http://www.oecd.org


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How do Countries with Universal Health Care Compare?

Percent of Gross Domestic Product (GDP) Spent on Health Care: Selected Countries, 2000

Source: Torrens PR and Williams SJ. 2001. Introduction to Health Services. Delmar Learning.


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How do Countries with Universal Health Care Compare?

Overall the US population does not have anywhere near the best health in the world. Of the 13 countries in a recent comparison, the US ranks an average 12th for 16 available health indicators. Better access to care, including universal health insurance, is widely considered to be the solution.

Source: Barbara Starfield. Is US health really the best in the world? JAMA. 2000;284(4):483-485.


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In A Physician’s Own Words

Dr. Robert Ferrer, MD, MPH talks of his experiences at his clinic:

“A man with a large bandage on his hand. Three days earlier, the fourth and fifth fingers of his left hand had been amputated in a chain saw accident and then reattached at another hospital. Because he had no insurance, he was sent to our walk-in clinic for a follow-up.”


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In A Physician’s Own Words

“A child was sent home from school two weeks earlier with ‘pink eye.’ The child’s school administration would not readmit her without a doctor’s note, and her parents needed two weeks to gather the money for a doctor’s visit so they could obtain the necessary note.”

Source: Ferrer Robert. Within the system of no-system. JAMA. 2001;286(20):2513-14


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Discussion Question

What are some proposals currently being discussed to reduce the uninsured?


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Proposals To Cover The Uninsured

Hear discussions sponsored by the Kaiser Family Foundation that focuses on major health policy issues such as a prescription drug benefit for Medicare beneficiaries, Medicaid reform, and expanded coverage for the uninsured:

http://www.kaisernetwork.org/health_cast/hcast_index.cfm?create=high_windows&linkid=&display=detail&hc=821


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Proposals To Cover the Uninsured

  • The AMA proposes to expand health insurance coverage to all Americans while also increasing health insurance choices:

    http://www.ama-assn.org/ama1/pub/upload/mm/363/expandhealthbro.pdf

  • The Physicians for a National Health Plan support a national health insurance program, where the government finances health care, but keeps health care delivery within private control:

    http://www.pnhp.org/


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Proposals to Cover the Uninsured

  • Find out what individual states are doing to provide universal health care coverage to their constituents:

    http://www.amsa.org/hp/uhcstate.cfm

  • Incremental expansion of current government programs such as Medicare to early retirees, Medicaid and SCHIP (State Children’s Health Insurance Program) to low-income populations:

    http://www.familiesusa.org/BushFY2004Budget.htm


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Proposals To Cover the Uninsured

  • “Creating Consensus on Coverage Choices”A plan to use a variety of options to cover all but 3 million of the uninsured:

    http://www.healthaffairs.org/WebExclusives/Davis_Web_Excl_042303.htm


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Action Points

What proactive steps can medical students take to help address the issues of access by the uninsured population?


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Spread The Word

  • Lobby, call, and write letters to your state legislator. To find out about current issues in Congress and to view sample letters that you can send to congress: http://www.capwiz.com/ams/home/


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Come Together

  • Vigil/rally. Bring coalition of groups to work together to support covering the uninsured. To learn what it takes to start a candlelight vigil: http://www.amsa.org/hp/vigilguide.cfm


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Make A Difference

  • Volunteer at a free clinic for the uninsured. For more information and links to resources on volunteering in clinics for the uninsured. http://www.volunteersinhealthcare.org/links.htm


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Talk Is Not Cheap

  • Issue Forum on Universal Health Care. Start the dialogue at your school with this fun, interactive way to hear many opinions involved in the discussion about universal health care.

    http://www.amsa.org/hp/COCForum_UHC.doc


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Get Involved

  • Join the Covering Kids Initiative http://www.coveringkids.org/

    A National Health Access Initiative for low-income, uninsured children to help states and local communities increase the number of eligible children who benefit from health insurance coverage programs


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Do It For The Kids

  • Find out how you can partner with your community to ensure that all children have access to health care.

    http://www.childrensdefense.org/shout.html


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Knowledge Is Power

  • Learn more about some of the initiatives that are currently help the uninsured http://covertheuninsuredweek.org/

  • Learn how to get your local chapter at your medical school involved in issues of the uninsured

    http://www.amsa.org/hp/uhcprojects.cfm


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Resources

  • Cover the Uninsured Week On Campus Guide - http://covertheuninsuredweek.org/plan/oncampus/

  • AMSA’s UHC website - http://www.amsa.org/hp/uhcinitiative.cfm

  • Institute of Medicine “The Consequences of Uninsurance” - http://www.iom.edu/IOM/IOMHome.nsf/Pages/Consequences+of+Uninsurance#HCs/


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Resources

  • Health Affairs – http://www.healthaffairs.org

  • Kaiser Family Foundation – http://www.kff.org

  • Physicians for National Health Program – http://www.pnhp.org


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Resources

  • Universal Health Care Action Network –brings together diverse groups and activists working for comprehensive health care for all in state and national campaigns across the country.http://www.uhcan.org

  • Families USA- a national nonprofit organization dedicated to the achievement of quality and affordable health care for all Americans.

    http://www.familiesusa.org/site/PageServer


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Resources

  • Understanding Health Policy by Kenneth Bodenheimer & Kevin Grumbach, is the number one selling text in health policy and covers topics of health insurance, managed care, and physician and hospital payment.


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Electronic Library

  • Ayanian JZ, Weissman JS, Schneider EC, et al. Unmet health needs of uninsured adults in the United States. JAMA 2000;(16)284:2061-69.

    http://jama.ama-assn.org/cgi/content/full/284/16/2061

  • A Shared Responsibility: Academic Health Centers and the Provision of Care to the Poor and Underserved, The Commonwealth Fund, 2001

    http://www.cmwf.org/programs/taskforc/AHC_indigentcare_443.pdf


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Electronic Library

  • Baker DW, Sudano JJ, Albert JM, Borawski EA, Dor A. Lack of health insurance and decline in overall health in late middle age. The New England Journal of Medicine. 2001; 11;345(15):1106-12.

    http://content.nejm.org/cgi/content/full/345/15/1106

  • Barbara Starfield. Is US health really the best in the world? JAMA. 2000;284(4):483-485.

    http://jama.ama-assn.org/cgi/content/full/284/4/483


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Electronic Library

  • Ferrer Robert. Within the system of no-system. JAMA. 2001;286(20):2513-14

    http://jama.ama-assn.org/cgi/content/full/286/20/2513

  • Institute of Medicine (IOM). 2001. Care Without Coverage. Washington, DC: National Academies Press.

    http://www.nap.edu/books/0309083435/


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Electronic Library

  • Institute of Medicine (IOM). 2001. Coverage Matters. Washington, DC: National Academies Press.

    http://www.nap.edu/books/0309076099/html/

  • Institute of Medicine (IOM). 2001. Health Insurance is a Family Matter. Washington, DC: National Academies Press.

    http://www.nap.edu/books/0309085187/html/


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Electronic Library

  • Kozak LJ, Hall MJ, Owings MF. Trends in avoidable hospitalizations. Health Affairs. 2001;20(2):225-32.

    http://www.healthaffairs.org/1130_abstract_c.php?ID=/usr/local/apache/sites/healthaffairs.org/htdocs/Library/v20n2/s25.pdf

  • Urban Institute and Kaiser Commission on Medicaid and the Uninsured analysis of March 2002 Current Population Survey. 2002.

    http://www.kff.org/content/2003/142004/142004.pdf


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