The Uninsured Access Gap: Narrowing the Estimates

Author(s): M. Susan Marquis and Stephen H. Long

Source: Inquiry , Winter 1994/95, Vol. 31, No. 4 (Winter 1994/95), pp. 405-414
Published by: Sage Publications, Inc.

Stable URL: https://www.jstor.org/stable/29772498

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M. Susan Marquis The Uninsured Access
Stephen H. Long
Gap: Narrowing the
Estimates

Measuring the cost of universal coverage requires estimates of the uninsured access
gap?the additional care that the uninsured would consume. Estimates of this gap
from existing literature span a wide range. Using databases that are the source of
these estimates, this paper explores differences that might account for the range of
estimates including time, populations, control variables, and definitions. Adjusting for
these differences, estimates of the uninsured access gap are considerably narrowed.
The new estimates indicate that health consumption by the uninsured would increase
50%?implying an increase in total health care spending of about 2%.

Many of the proposals brought before Congress in
the recent debate over national health reform called
for universal coverage. Universal coverage is likely
to increase the use of health care by the uninsured,
thus drawing additional resources into the provision
of health care. Measuring the resource cost of uni?
versal coverage thus requires precise estimates of
the difference in current health care use by the
uninsured and the amount of care that they would
be expected to consume with universal coverage.
This difference often is termed the "access gap."
There is a substantial literature that attempts to
measure the access gap between the uninsured and
the insured. This literature is almost universally
consistent in finding that the uninsured receive less
care than the insured. However, it yields a wide
range of estimates about the actual magnitude of the
access gap. For example, estimates of the propor?
tion of the uninsured who see a physician each year
relative to the proportion of the insured with a visit
range from 62% to 98%, and estimates of the num?
ber of visits by the uninsured relative to the insured
range from 46% to 100% (Wilensky and Berk 1982;
Berk, Bernstein, and Taylor 1983; Yelin, Kramer,
and Epstein 1983; Davis and Rowland 1983; Long
and Settle 1985; Freeman et al. 1987; Long and
Rodgers 1990; Short and Lefkowitz 1992; Spillman
1992).1 Moreover, this research literature reports
hospital admission rates among the uninsured that
range between 25% and 81% of rates among the
insured, and inpatient days of care for the uninsured
relative to the insured that vary between 12% and
81%.
Narrowing the estimate of the access gap is im?
portant because the different estimates have differ?
ent implications for the cost of health care reforms
to equalize coverage for the insured and uninsured.
For example, the range of estimates of the access
gap for seeing a physician implies a difference in the
additional number of currently uninsured individu?
als who would contact a physician under health
reform that guaranteed universal coverage of 9.4
million people. The range in the access gap for the
probability of a hospital admission leads to a differ?
ence in the number of additional hospital admis?
sions for the currently uninsured under reform of
2.1 million.
The purpose of this study is to evaluate a number

M. Susan Marquis, Ph.D., and Stephen H. Long, Ph.D., are senior economists at RAND. Address correspondence
to Dr. Marquis at RAND, 2100 M St., N.W., Washington, DC 20037-1270.

Inquiry 31: 405-414 (Winter 1994/95). ? 1994 Blue Cross and Blue Shield Association and
Blue Cross and Blue Shield of the Rochester Area.
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Inquiry/Volume 31, Winter 1994195

In this paper, we focus on differences in use

of causes that might account for the variation in the
estimates of the access gap and thus to obtain a between those who are uninsured and those who
more precise estimate for policymakers to use in have private employer group insurance coverage.
weighing the costs of reform proposals. Factors that Our estimate of the access gap is the current use by
might account for the variation in estimates among the uninsured relative to what they would use if
past studies include: covered by the mix and distribution of health ben?
efits now provided under employer-sponsored ben?
? change in the access gap over time reflected in efit plans.
data from different years,
The SIPP and NMES are both panel studies that
? different populations or different control vari?
provide information about health insurance cover?
ables in the analysis, age over the full course of the year for which health
? different definitions of insurance and lack of care use is measured. Our measure of the uninsured
insurance, access gap using these data is based on a contrast
? different data collection methods among the sur? between those who were uninsured for the full year
veys. and those who were covered by employer group
We apply standardized methods to many of the coverage for the full year.4
In contrast, the HIS collects information about
databases that have been used in previous studies to
evaluate the role of these factors and to control for insurance only at the time of the interview. Because
them in estimating the access gap and the effect of individuals move into and out of the state of being
universal coverage on resource use. uninsured, a contrast of use in the past year by those
currently uninsured and those currently covered by
Data and Methods an employer group plan will likely understate the
access gap based on the measures of insurance
Data
status over the full year (Long and Rodgers 1990).
The databases that we use in our analysis This was one of the factors that we hypothesized
include
the 1987 National Medical Expenditure Surveywhich might have produced the discrepant
earlier
(NMES), the Survey of Income and Program estimates
Par? of the access gap that we find in the
ticipation (SIPP) for the years 1984 through literature.
1988, We test this by contrasting the estimates
of years
and the Health Interview Survey (HIS) for the the access gap based on the full-year measure in
the NMES and SIPP with the access gap based on
1980,1983,1984,1986, and 1989.2 We have included
a time series from the SIPP and HIS to test ourinsurance measured in all three of our sur?
current
veys.
hypothesis that a change in the access gap over time
Because
might be a source of the different estimates found in the HIS is a very large survey and be?
cause
the literature. The large sample sizes from the we are studying multiple years of data, we
time
series also facilitate more precise estimates have sampled from the full database for our analy?
of the
ses.5 The SIPP sample that we analyze includes all
utilization behavior of the uninsured, particularly
for inpatient hospital services, than would beadults
ob?who completed all waves of their panel and
tained from only one year's sample. All three the sur?
NMES sample includes all persons under age 65
who completed
veys are administered to a representative sample of that full panel. We require data from
all waves of the SIPP and NMES panels to con?
the American population and collect information
struct the measure of insurance throughout the
about each person's health, health care use, insur?
ance status, and economic and demographic year.
char? This exclusion means that newborns are not
acteristics. We restrict our analysis to persons
part who
of our sample.6 This will not bias our estimates
of the access gap as long as the effect of insurance
were age 64 or younger at the time of the survey.3
We examine four different measures of status healthon the quantity of care consumed does not
differ for newborns and other children. Our final
care use: the probability of having an ambulatory
care contact with a medical provider in aanalysis
year,sample sizes for each of the databases are
shown or
including a visit to a doctor's office, a clinic, in Table 1.
hospital emergency room and telephone contacts;
Statistical Methods
the number of such contacts; the probability of
having a hospital admission during the year;We
andusethe
multivariate regressions to estimate the
relationship between insurance status and health
total number of hospital days of care in a year.

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 Uninsured Access Gap

Table 1. Analysis sample sizes coverage is our measure of the uninsur

gap. This measures the marginal effect
Survey Adults Children ance^?that is, the effect of changing insur
SIPP (1984-1988) 54,198 ? tus but holding other characteristics cons
HIS (1980, 1983, 1984, 1986, 1989) 74,895 61,122
We also report differences in the estimat
NMES(1987) 13,196 6,329 gap to investigate whether it has changed
or differs for some subgroups of the unin
care use. For each type of use?ambulatory
estimate thecare
underlying predicted values,
and inpatient hospital care?we fit a two-part model
late use for the sample of the uninsured as i
of use. The first part of each model belonged to the subgroup under study. Fo
is a logit regres?
sion for the probability of receiving ple,
that to investigate
type of care whether the access gap d
during the year. The second equationthose is
inagood
linear
health and in poor health, w
the gap
regression for the logarithm of the total for the
quantity of uninsured sample as if
care for the users of the service?the number
reported that of
they were in good health and
this at
ambulatory contacts for those who have to least
the magnitude
one of the gap that
visit and the number of inpatient hospital
expect ifdays
thefor
uninsured sample all reporte
those with an admission. Because the distribution
poor of measures the marginal e
health. This
visits and days among users is highly skewed,
health on theweaccess gap, controlling for ot
use the logarithmic transformationacteristics that differ between healthy
in this second
part of each model to reduce the skewness
healthy and
uninsured individuals.
provide more efficient parameter estimates.
The predicted value of ambulatory conta
We fit separate utilization models for adults
inpatient days for a sample person in our
(those ages 18 to 64) and for children. In addition
database from to
one of the fitted models is
indicator variables for insurance status, each of our
Predicted
models includes covariates for age, sex, race and Use = P ? (exp[X?]) ? S
ethnicity, income as a percentage of poverty, urban
vs. rural area, and health status. where P is the
For adults, estimated probability of ha
the
use from
estimation models also include education and the
mar? logistic regression; (exp[Z?])
estimate of the conditional quantity of ca
ital status. Indicators to capture time trends (spec?
ified as a 0,1 variable for each year sumed; X? is
in the the product of the ? coeffici
time
the regression for the logarithm of quanti
series) are included in the models fit to the pooled
time-series for the HIS and SIPP. We value
alsoof thefor
test individual's X characteristics
a factor to retransform from the logarithm
some important interactions between insurance sta?
the raw quantity scale. Our retransformati
tus and covariates to investigate whether the gap in
is a nonparametric
use between the insured and uninsured differs estimate developed
(1982) and is equal
among certain population groups, especially groups
to the sample averag
differing in health status and income, and whether
exponentiated least squares residuals
found that the distribution of the errors in
the gap has been changing over time.
We use the fitted model on each titydata
of use equation
set to differs by insurance s
estimate health care use for each so we have
member ofestimated
the and applied separate
formation factors, 5, by insurance status
uninsured population and to predict, or simulate,
for heteroskedasticity.
what each person's use would be if he or she were
covered by a plan typical of those covering persons
Results
with employer group coverage. We use the NMES
sample of uninsured persons as our This section describes
input database the results of our estimation.
in predicting from each fitted model.7 That factors
We investigate is, we that we hypothesized might
accounteach
predict for a standard population using for theofdiscrepant
our estimates in the litera?
fitted utilization models in order to compare
ture?change in thethe
gap over time, sample selection
and control
results from the models. The difference in variables,
the pre? and definitions of insurance
status.
dicted current use for the uninsured Then we present
averaged overour consistent estimates of
our prediction sample and the average predicted
the gap use data sources, correcting
from the different
for that sample if they held employer-sponsored
for the most important of these factors.

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Inquiry/Volume 31, Winter 1994195

Table 2. Increase in uninsured access gap by time and individual characteristics

Increase for adults Increase for children

Characteristic and Ambulatory Hospital Ambulatory Hospital

data source contacts days contacts days
Time: 1984 vs. recent
SIPP (1984 vs. 1988) -.28 NA NA
HIS (1984 vs. 1989) -.01 .2* -.01
Income: below poverty vs.
above 200% of poverty
SIPP .05 NA NA
NMES -.37 1.0* .01
HIS .10 1.0* .03
Health: fair vs. good
SIPP -2.1* -.42* NA NA
NMES -1.5 -.42 -2.6 -.35
HIS -1.0* -.33 -1.8* -.51
Note: A positive value indicates that the uninsured access gap increases with the characteristic, a negative value
indicates that the gap decreases with the characteristic.
* Significantly different from zero, p = .10.

Effects of Time and Individual ambulatory care during the year, rather than in the
Characteristics on the Access Gap number of visits among users of service (Long and
Marquis 1994a).
Estimates of the uninsured access gap from the
The access gap for inpatient hospital care, in
research literature come from different time periods
contrast, appears not to have changed over time.
and some estimates are for special population sub?
We find statistically insignificant changes in the gap
groups?such as those from low-income families or
between the insured and uninsured over time. This
those in poor health. If the access gap varies over
time or among population groups, then this mightis not to say that hospital use has not changed over
account for the variation in the previous estimates. the period. Indeed, both data sets evidenced that
Here we look at whether there is a significant inter?hospital lengths of stay for those with an admission
decreased about 10% from 1984 to the late 1980s.
action between time, income, or health and being
insured on use of services. Table 2 reports ourBut the decrease occurred among both the insured
results. It shows how the measured access gapwith admissions and the uninsured with admissions,
increases as time, income, and health increase. Theand there was no discernible change in the access
estimates are the marginal effect of each character?gap.
istic on the access gap, controlling for other differ? Family income. For adults, we do not find evi?
ences in demographic, economic, and health factorsdence of a difference in the access gap for ambula?
that have changed over time or that distinguishtory care between the uninsured with income below
poverty (who account for about a quarter of the
between low- and high-income or healthy and sickly
individuals. uninsured adults) and those with income above
Time. There is a consistent pattern indicating an 200% of poverty (who account for about 40% of the
increase in the access gap for ambulatory care over uninsured adults). While the HIS data set suggests
the period 1984 to the late 1980s (Table 2). The that there is a significantly different access gap for
increase is statistically significant in the HIS data? the two groups, the other two data sets show access
base, although the magnitude of the increase is gaps that are of similar magnitude for low- and
small in both the SIPP and HIS data. It is about .2 high-income uninsured.
to .4 visits per person per year, or about a 10% to In contrast, our analysis shows that the gap in
25% increase in the magnitude of the gap. (Our best ambulatory care contacts for uninsured children in
estimates of the absolute and relative magnitudes of families with income above 200% of poverty (who
the gap and of actual use rates are given in Tables 4 account for a little more than one-fifth of children
and 5). Most of this increase over time is attribut? who are uninsured) is greater than the gap for the
able to an increase in the gap between the insured uninsured in families with income below poverty
and uninsured in the probability of obtaining any (who account for about two-fifths of the uninsured

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 Uninsured Access Gap

Table 3. Increase In uninsured access gap and control variables

Increase for adults Increase for children
Control variables and AmbulatoryHospital Ambulatory Hospital
data source contacts days contacts days
Marginal to total effect
SIPP .3 -.04 NA NA
NMES .6 -.10 .9 -.01
HIS .1 -.09 .2 -.06
Expanded to limited he
NMES .2 -.02 .1 -.01
Current to last year insurance
SIPP A .09 NA NA
NMES 1.2 .17 .3 .01
Note: A positive value indicates that
to the second in the pair, a negativ

greater
children). This access gap for the uninsured in is
finding fair health as
count
that the lack of
compared insurance
to healthier individuals who lack insur?would
to ance is primarily
receiving care for due to ahigher
greater gap in the number incom
lower income of ambulatory visits per user and in hospital
families. One admis? pos
that we have not
sion rates andcontrolled
not to a greater gap in the likelihood for
ance coverage.
of some The larger
contact with the health care system during gap
the year (Long
income children may and Marquis indicate
1994a). th
insured have That
moreis, the data suggest generous
that the effect of a lack
than the lower income
of insurance insured.
on the patient's decision to initiate care
does notour
consistent with vary by health status. However, lack of
estimates th
insurance appears
insured children haveto have a greater effect on the
about 1.5
contacts intensity of care?as
annually than measured by the do number oflow-i
dren (3.9 vs. 2.4).
visits and referralsThis differe
for hospitalization?delivered to
income effect less
because
healthy patients who dothe differ
contact a medical
low- and provider than to healthier adults.
high-income This may reflect
uninsured
vs. 2.2). differences
Another possible in the way physicians adjust their explan
prac?
employer tice stylescoverage
group to the insurance status of healthycurren
and
tial deductible that
sicker patients, must
or it may reflect less follow-up of be p
before health the insurance
prescribed regimens by the uninsured in poor health pays
A deductible may be
who cannot afford to pay formore
their care. of a
for the low-income insured tha
Control Variables and Estimates
insured.
of the Access Gap
We do not find significant effects of income on the
difference in use of inpatient hospital care by the The studies in the research literature differ in the
insured and uninsured. Moreover, there is no con? variables that are controlled for in comparing the
sistent pattern of difference by income. We con? insured and uninsured. Here we investigate the
clude that income differences in the access gap are effect of some of the most common differences on
not an important factor accounting for the range of the estimate of the gap: the effect of not controlling
estimates of relative hospital use found in the liter? for demographic and economic differences between
ature. the insured and uninsured; the effect of health status
Health status. About 20% of uninsured adults controls on the estimate; and the effect of the def?
and 7% of uninsured children report that their health inition of the insurance variable. Our results are
is fair or poor. The gap between use of health care shown in Table 3, which reports the increase in the
by less healthy uninsured individuals and other estimate of the access gap when not controlling for
similar adults who are insured is greater than the economic and demographic variables, using only a
access gap for healthier individuals (Table 2). The limited measure of health status, and using a mea

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Inquiry/Volume 31, Winter 1994195

sure of insurance in the last year vs. current insur? It compares the estimate of the access gap from
ance. the NMES database including the single health sta?
Total vs. marginal effects. Some studies variable
tus in thein our model with estimates that also
include:
research literature compare actual health care use a measure of whether the individual is
by the insured and the uninsured to measure the any way in his or her activities because of
limited in
access gap. This reflects any differences between
health; a measure of the individual's general per?
the insured and uninsured in demographic, ceptioneco?
of his or her health based on four question
items (three
nomic, or health characteristics that influence ser? for children); and, for adults, a measure
vice use as well as the differences in use due to
of mental health based on five questionnaire items.
A measure of the access gap for ambulatory care
insurance?it measures the total effect of insurance.
Others, as is our practice, measure thecontrolling
gap by only for the simple health rating may
overstate
comparing health service use by the uninsured the gap by about .1 to .2 visits per year,
with
what a population with the same characteristicsof about 10%; that is, the estimated gap
an increase
in ambulatory
could be expected to use if they were insured. That care is smaller when we control for
is, we control and adjust for differences in the
the richer set of health measures. For hospital care,
however,
economic and demographic characteristics of those the estimated gap is slightly higher when
who are observed to be insured and uninsured in additional health measures as control
we include the
measuring the gap?this is the marginal variables. effect of
insurance. Insurance definition. In many surveys, insurance
As Table 3 illustrates, the total estimate of the is measured at the time of the interview, and esti?
access gap for ambulatory care is greater than the mates of the access gap compare use over the
estimate which controls for other characteristics preceding year by those who are uninsured at that
that influence use. The differences reflect primarily time with those who are insured at that time. Such
the lower income and education of the uninsured, is the case with the HIS database. In other surveys
which are characteristics that also influence health insurance corresponds to the period of use, or can
care use and are controlled for in estimating mar? be constructed to do so. Such is the case with the
ginal effects, but not total effects. SIPP and NMES data in which we measure the
For adults, the marginal effect of insurance on access gap as the difference in use among those who
hospital days per year is greater than the total effect. were and were not insured over the full-year period.
This is because a smaller proportion of admissions Because people move into and out of the state of
among the uninsured are for delivering a baby, being uninsured, the first approach is likely to un?
which involves a lower than average length of stay. derstate the access gap. Long and Rodgers (1990)
Health status control variables. Our estimates of demonstrate that this is the case by comparing
the access gap control for a number of important estimates of the access gap from a model fit to the
observed characteristics of individuals that affect 1984 SIPP panel relating last year's insurance status
decisions about health care use. However, there and health care use with estimates from a model
may be unobserved differences between the insured relating current insurance status and last year's
and uninsured that we cannot control for. Our es? health care use.
timates of the access gap assume that these unob? Table 3 also illustrates this result. It compares
served factors do not affect health care use. If these estimates of the access gap from our model fit to the
unobserved factors are differences in health, how? SIPP and NMES sample using a measure of current
ever, such an assumption may be too strong. We insurance with estimates using last year's insurance
have included a measure of health status in our status. Estimates of the access gap are higher when
estimation models; however, it is a fairly simple we use last year's insurance status than when our
rating of the individual's health, which may not insurance variable measures current status. Using
adequately capture all health differences.8 insurance status in the last year, the access gap for
The NMES database, however, includes a much adults for ambulatory care is about .4 to 1.2 visits
richer set of health variables that allows us to in? greater than when current status is used, an increase
vestigate how sensitive the estimate of the access in the estimated gap of about 30% to 50%. For
gap is to the use of only a simple measure of health children the gap is about .3 visits larger, also a 30%
status versus a more comprehensive characteriza? increase in the gap estimate. For hospital care, the
tion of health differences. Table 3 shows the results. access gap for adults is .09 to . 17 days higher using

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 Uninsured Access Gap

Table 4. Uninsured access gap for adults: estimates from three surveys
Ambulatory contacts Hospital days
Adults in Adults in Adults in Adults in
Survey and fair or excellent or All fair or excellent or All
insurance status poor health good health adults poor health good health adults
SIPP
Uninsured 4.5 1.9 2.4 1.07 .30 .45
Insured 7.2 2.8 3.6 1.64 .36 .61
Access gap -2.7 -.9 -1.2 -.57 -.06 -.16
Relative use (%) 63 68 67 65 83 74
NMES
Uninsured 5.0 2.3 2.9 .78 .23 .34
Insured 9.0 4.1 5.1 1.54 .34 .58
Access gap -4.0 -1.8 -2.2 -.76 -.11 -.24
Relative use (%) 56 56 57 51 68 59
HISa
Uninsured 5.2 2.3 2.8 1.23 .32 .50
Insured 8.0 3.4 4.3 1.91 .44 .73
Access gap -2.8 -1.1 -1.5 -.68 -.12 -.23
Relative use (%) 65 68 65 64 73 69
Best estimate13
Uninsured 4.9 2.2 2.7 1.03 .29 .43
Insured 8.1 3.4 4.4 1.70 .38 .64
Access gap -3.2 -1.2 -1.7 -.67 -.11 -.21
Relative use (%) 60 65 61 61 76 67
a Adjusted for different definition of insurance status.
b Average of three estimates.

Status; and the measurement of marginal vs. total

a measure of last year's insurance (a 50% to 70%
effects. In Tables 4 and 5, we present estimates of
increase in the gap estimate); for children the gap is
.01 days higher (a 30% increase). The gap is higherthe access gap from the three surveys that are
when insurance status is defined over the full yearcorrected for these factors. That is, our predictions
rather than the current period, because the lattercome from a model that includes an interaction
definition will include among the uninsured the ex?between health status and insurance, between time
perience of some individuals with periods of insur?and insurance, and a shift in the overall level of use
ance during the year, and will include among the over time to account for declining length of hospital
insured the experience of some individuals with stay. We adjust the estimates of the access gap from
periods of uninsurance during the year?that is,the HIS data based on the measure of current in?
each group will include some part-year uninsured.surance to a measure of the full-year gap as mea?
Other research has shown that people who movesured from the SIPP and NMES data (Long and
from being uninsured to insured use health care Marquis
in 1994a). Our measure of the access gap is
each state at the rate they would if continuously inthe marginal effect of insurance, controlling for
that state (Long and Rodgers 1990; Keeler et al. demographic and economic factors that also differ?
1988) and so the part-year uninsured have interme?entiate between the insured and uninsured.
diate experience to the full-year insured and to the As we have noted, the existing literature provides
full-year uninsured. a range of estimates of relative use that vary by
about 50 percentage points for ambulatory care
A Narrower Range of Gap Estimates
and by about 70 percentage points for inpatient
Our analysis suggests several factors that might be hospital care. Our current estimates on many of
a source of the discrepancies in the estimate of thethese same databases with the adjustments noted
access gap found in the research literature. These substantially narrow this range to a 10 percentage
include: the increase in the gap in ambulatory carepoint spread for ambulatory care, and a 15 percent?
over time; the difference in the gap between those inage point spread for inpatient care. Nonetheless,
some differences remain for which we have no
good and poor health; the concept of insurance

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Inquiry/Volume 31, Winter 1994195

Table 5. Uninsured access gap for children: estimates from two surveys
Ambulatory contacts Hospital days
Children in Children in Children in Children in
Survey and fair or excellent or All fair or excellent or All
insurance status poor health good health children poor health good health children
NMES
Uninsured 3.3 2.4 2.4 .15 .18 .18
Insured 6.5 3.2 3.5 .53 .18 .21
Access gap -3.2 -.8 -1.1 -.38 .00 -.03
Relative use (%) 51 75 69 28 100 85
HISa
Uninsured 3.6 1.9 2.1 .66 .20 .24
Insured 6.2 2.9 3.1 1.14 .24 .31
Access gap -2.6 -1.0 -1.0 -.48 -.04 -.07
Relative use (%) 58 66 68 58 83 77
Best estimateb
Uninsured 3.5 2.1 2.3 .41 .19 .21
Insured 6.4 3.1 3.3 .84 .21 .26
Access gap -2.9 -1.0 -1.0 -.43 -.02 -.05
Relative use (%) 55 68 70 49 90 81
a Adjusted for different definition of insurance status.
b Average of the two estimates.

ready explanation; differences in survey methods
may be a factor.
The three surveys show that uninsured adults
receive about 60% to 75% of the care that they
would if insured. The access gap is about one to two
ambulatory contacts per person per year and about
16 to 25 inpatient days of care per 100 uninsured
adults (Table 4). All three data sources show that
the absolute magnitude of the gap is greater for
adults in poor health than those in good health. The
results for the health subgroups shown in Table 4
are the total effects of health among the uninsured.
In contrast to the marginal effects of health that we
reported earlier that control for other differences in
characteristics between the uninsured in good and
poor health, the measure of the access gap in Table
4 incorporates those differences. It is a comparison
of the incremental care that the population of unin?
sured who are in fair or poor health versus those
in excellent or good health would consume under
universal health coverage. Under such reform, the
additional ambulatory care for an uninsured adult in
good health would be about one to two visits,
whereas an adult in poor health would have about
two to four additional visits per year. Additional
hospital days of care for the uninsured in poor
health would number about 60 to 80 per 100 persons
under universal coverage; for the uninsured in good
health the increased hospital days would average
about six to 12 per 100 persons.
The access gap for children is slightly smaller
than that for adults; uninsured children receive
about 70% as many ambulatory services as other?
wise similarly insured children and have about 75%
to 85% as many inpatient days (Table 5). As with
adults, the gap is greater for the uninsured in poor
health than for those in good health.
Discussion and Implications for
Universal Health Coverage
Although the research literature has produced a
wide range of estimates of the gap, our standardized
methods yield a fairly narrow range of estimates
from the different databases that have been used in
previous work. That is, methodological differences
among the studies rather than differences in the
databases appear to account for most of the dis?
crepancy. Similarly, this would suggest that the
variation in the quantitative estimates of the impact
of various health reform proposals that has been
observed (OTA 1994) is likely to be traced to meth?
odology and assumptions rather than the source of
data used in the estimates.
Our estimates suggest that universal coverage
would increase health care use by the currently
uninsured by about 50%. Using the average esti?
mate of the access gap from the different surveys as
our "best estimate" (see Tables 4 and 5), we esti?
mate that, in the aggregate, the currently uninsured
would have 54.9 million more ambulatory contacts

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 Uninsured Access Gap

than they do currently and 6.1 million more hospital sures of health status. We assume that the currently
days (Long and Marquis 1994b). While this repre? uninsured would use health care at the same rates as
sents a sizable increase in health care for the cur? these insured counterparts under national reform.
rently uninsured, it is a fairly small increase in the However, there may be unobserved characteristics
total resources devoted to health care by the nation. that differentiate the currently uninsured from the
The 54.9 million additional ambulatory contacts insured that would affect health use and for which
represent an increase of 56% in use by the currently we cannot adjust. One random experiment that did
uninsured, but only a 3.8% increase in all such compare health care use by previously uninsured
contacts. The 6.1 million increase in hospital days is individuals once they acquired insurance with those
a 44% increase in hospital care for the currently who were continuously insured suggested that the
uninsured, but a 3.6% increase in inpatient services
uninsured might continue to use at somewhat lower
provided to all patients. Weighting the increases in
rates, even when they acquire insurance (Marquis
visits and hospital days by current prices, total
and Harrison 1992). That study suggested that the
spending by the currently uninsured for ambulatory
currently uninsured might continue to use care at a
care and inpatient hospital care would rise by about
rate equal to only about 85% of use by those cur?
50%, or an increase in total national spending for
rently insured, even under universal coverage. That
all health services of about 2% (Long and Marquis
study was based on small samples and reflects uti?
1994b).
lization patterns of the late 1970s. Nonetheless, the
This estimate is very similar to a recent estimate
results suggest that our estimate of the access gap
by the Congressional Budget Office, based on data
might be as much as 50% too high.
from NMES, of a 56% increase in expenditures by
Our estimate of the access gap is a measure of the
the currently uninsured under universal coverage
quantity of services that the uninsured would use if
(CBO 1993). In contrast, the Lewin-VHI Health
Benefits Simulation Model, which also uses the covered by the mix of insurance plans and benefits

NMES data, produces estimates of an increase in
spending by the uninsured of 74% (Sheils, Lewin,
and Haught 1993). In part, the difference can be
attributed to differences in the assumptions about the
benefits under universal coverage. Our estimates, and
those of CBO, assume that the universal benefit
package would be similar to the typical employ?
ment-based policy offered today. The Lewin-VHI
estimates, however, assume a more generous ben?
efit package (CBO 1993).
There are several other assumptions that are
common to our estimates from all the databases that
policymakers should consider when using our esti?
mates to evaluate the effects of health reform. Our
estimates derive from a comparison of health care
use by the uninsured and insured individuals who
are alike in their demographic and economic char?
acteristics and who are similar on some gross mea
currently held by the insured who hold employer
sponsored coverage. One goal of health reform is to
promote managed care and increased competition
among plans to constrain the growth in health care
spending and to reduce inappropriate and unneces?
sary use of health services. If health reform changes
the norms for insured care, then the newly insured
also would be expected to utilize services differ?
ently than we have assumed in our estimates. We
also assume that prices are unchanged by universal
coverage. Changes in prices also could alter the
demands for care by the newly insured.
Consequently, although this paper has served to
narrow the estimates of the access gap, there are
several other factors that contribute to our uncer?
tainty over the costs of universal health insurance
coverage. These are good candidates for further
research.

Notes
This research was sponsored by the Office of Technology
Assessment, the Congressional Research Service, and the
Robert Wood Johnson Foundation. Any views expressed
herein should not necessarily be attributed to the sponsors
or to RAND. The authors thank Roald Euller and Ellen
Harrison for computer programming assistance, and Jeff
Miller and Audrey Smolkin for research assistance. They
also thank the editor and two referees for helpful com?
ments on an earlier draft of this paper.
1 See Long and Marquis (1994a) for a summary review of
the research literature that measures the gap using data
from one of several major national household surveys.
2 These years of the HIS were selected because the

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 Inquiry/Volume 31, Winter 1994195

survey included questions about health insurance cov? the survey, covered by an employer group plan, covered
erage, our key explanatory variable. by an individually purchased plan, or covered by Med
3 Data about health and health care use in the SIPP are icaid, with insurance status indicator variables to dis?
collected in a special supplement that is administered tinguish among the groups. Again, we exclude those on
only to adults. Therefore, our analyses of the SIPP data Medicare, CHAMPUS or other DOD benefit plans, and
are restricted to people ages 18 to 64. those who are covered by more than one source at a
4 We include other insurance groups in our analysis sam? given time.
ple and our estimation models using indicator variables 6 We also exclude persons who died during the year.
to differentiate among the groups. These include those However, since we are studying the under-65 popula?
on Medicaid for a full year, those with individually tion, this exclusion affects a small proportion of the
purchased insurance for the full year, and those who had observations.
insurance coverage for only part of the year. We ex? 7 Because our model is nonlinear, we require data about
clude those who are covered by both Medicaid and individuals rather than statistics on the average value of
private coverage at any one time, those covered by the characteristic for the population of interest. We
Medicare, CHAMPUS or other Department of Defense selected the NMES as our prediction sample because it
(DOD) insurance, and those who have other combina? provides data for both adults and children who are
tions of coverage over time that are not included in the uninsured and because it provides data on an expanded
list above. These groups are excluded because they set of health status measures needed to evaluate the
comprise only about 15% of the population in total, and effects of using different control variables on estimates
so we have too few observations in any one of these of the access gap as we discuss later.
categories to reliably estimate the effect of these insur? 8 The variable we have used in our models is a measure of
ance status categories. whether individuals rate their health excellent, very
5 See Long and Marquis (1994a) for details. We selected good, good, fair, or poor. In the NMES, the categories
a sample of persons who were uninsured at the time of are limited to excellent, good, fair, or poor.

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