Falling Through the Safety Net

Falling Through the Safety Net: Insurance Status and Access to Health Care
By Joel S. Weissman, Ph.D. and Arnold M. Epstein, M.D., M.A.
2004/12 - Beard Books 
1587982447 - Paperback - Reprint - 206 pp.

This book embodies what everyone should know about the political and social implications of health insurance or the lack thereof.

Publisher Comments

Category: Healthcare

This title is part of the Healthcare Administration list.

Of Interest:

Fundamentals of HMOs

Health Care and Insurance: Distortions in the Financing of Medical Expenditures

Health Care Risk Management: Organization and Claims Administration

Health Plan: The Practical Solution to the Soaring Cost of Medical Care

Introduction to Risk and Insurance

Legal Aspects of Health Care Reimbursement

Management of Hospitals and Health Services: Strategic Issues and Performance

The White Labyrinth: Guide to the Health Care System

Although this book was originally written in 1994, the same problems that inspired the authors still exist and in some measure have been exacerbated. Insurance coverage, its availability, cost, and impact on the medical care Americans receive are still at the center of the national debate on health care reform. Weissman and Epstein offer a look at how insurance status affects a person's health and use of health services and explain why the system is in desperate need of reform. By examining access to health care according to the type -- or the lack -- of insurance, they show how the source of medical payment has a substantial influence on the amount, location, and quality of care received in the U.S. health system.

From Nightingale's Healthcare News, January 15, 2006
Review by Henry Berry:

Falling Through the Safety Net examines the statement, "What services patients get and how well they do depend in part on how they pay for their care." The predicate for this book, which was first published in 1994, is that the source of payment for healthcare - whether out of one's own pocket or through an insurance plan - substantially determines the quality of healthcare received. The inquiry also takes into consideration the type of insurance coverage and the selection of carrier.
When individuals are not covered by insurance, healthcare must be paid for by government programs. So the question of who pays for healthcare is not simply a question of how much individuals pay for it, but rather, of how much businesses or institutions pay for it.

As Falling Through the Safety Net brings to light, the source of payment for healthcare is a major, and often the crucial, question in determining access to healthcare, quality of care, and the effect of this care on particular medical problems and longevity. As Weissman and Epstein's work evidences by abundant statistics and other documentation, the adage "you get what you pay for" is the rule in healthcare. It is not just merely the case that individuals with no health insurance or inferior or patchy insurance have to wait a little longer for healthcare or that they may run into inconveniences such as having to wait in line at clinics or emergency rooms, or being directed to particular healthcare facilities, or being able to see only those doctors who are willing to see them. The consequences are far more serious. According to the authors, "[u]ninsured hospital patients have higher mortality, pregnant uninsured women have worse birth outcomes, and uninsured women with breast cancer have shorter life expectancies."
Weissmann and Epstein take a two-fold approach to presenting and exploring their thesis. First, they offer statistics, references, analyses, and commentary. The statistics are based on work the two authors did for the U.S. Office of Technology Assessment (OTA) in 1992. Their work entailed an extensive, unprecedented review and summarization of academic and government literature on the relationship between healthcare accessibility and insurance coverage. The authors did this work for the OTA as part of a more wide-ranging effort to gather and assess relevant materials for the debate begun by the Clinton Administration over how to improve the nation's healthcare system.

Second, the authors analyze, in essay fashion, sociological, political, and moral issues in healthcare. Their analysis stems from a series of lectures given at Harvard Medical School and the Harvard School of Public Health. These lectures, given over a period of several years, brought central issues of national health policy to the attention of the university's medical students and post-doctoral fellows.

The statistical analyses and essays complement each other and provide a thorough treatment of the subject matter. Nonetheless, the authors advise that readers wishing to "become knowledgeable about health insurance and health system reform without getting steeped in theoretical models and research" can do so by reading chapters two and eight.

An inescapable conclusion of Falling Through the Safety Net is that some of the biggest, seemingly most intractable, problems with healthcare are caused by how healthcare is paid for. Among the remedies posited in the book is a reduction in the number of healthcare payers, who present consumers, doctors, and healthcare organizations with a bewildering, changing, and competing array of policies. The authors realize, however, that both insurance companies and government bureaucracies have a vested interest in keeping their positions as the primary payers for healthcare. Consequently, the authors' recommendations concentrate mainly on bringing better organization and clarification to the present system of payers, which is not only worsening the quality of U.S. healthcare, but also making it considerably more costly than it need be. Among Weissman and Epstein's recommendations in the current circumstances are risk pools for individuals, subsidized insurance for unemployed people, and laws requiring coverage of certain healthcare such as prenatal care.

Bringing together unique, extensive research with firsthand familiarity of the healthcare system and its problems, Falling Through the Safety Net gets to the root cause of many of the system's chronic, widely-recognized problems - namely, the limitless differences in insurance status of individuals seeking healthcare - and puts forward practicable solutions for dealing with these problems.

An associate professor in the Department of Medicine at the Institute for Health Policy at Massachusetts General Hospital, Joel S. Weissman is also a lecturer at Harvard Medical School's Department of Health Care Policy. Arnold M. Epstein is chairman of the Department of Health Policy and Management at Harvard University's School of Public Health, and holds several other prominent positions in the academic and public healthcare fields.

Referring to an earlier version:

Insurance coverage--its availability, cost, and impact on the medical care that Americans receive--is at the center of the national debate on health care reform. In Falling through the Safety Net Joel Weissman and Arnold Epstein, the latter domestic policy advisor for health care to the Clinton administration, offer a timely look at how insurance status affects a person's health and use of health services--and explain why the current system is in desperate need of reform.

From Book News:

Addresses both the general public and the academic/policy communities regarding the large numbers of persons without health insurance and the difficulties they have in obtaining the health care they need. Part of the volume evolved from a report the authors prepared for the Office of Technology Assessment in 1992. The remaining chapters derived largely from a series of lectures they gave at the Harvard Medical School and the Harvard School of Public Health. Annotation copyright Book News, Inc. Portland, Or.

From Book Info:

Harvard University, Boston, Massachusetts. Scholarly look at the relationship between health insurance and access to health care. Forward by Hillary Rodham Clinton.

From Amazon:

This book is the most informative look at health care that I have ever read. It studies the most piercing issues of our time, in an easy-to-read format. Anyone who has any interest in America's health care system should buy this book! Read it, and then recommend it to your friends. I am sure that you will love Falling Through The Safety Net, and when you finish you will be a more informed citizen. Buy this book!

Arnold M. Epstein, M.D., M.A., is Chairman of the Department of Health Policy and Management at Harvard University School of Public Health as well as Chief of the Section on Health Services and Policy Research in the Department of Medicine at Brigham and Women's Hospital. 

Joel S. Weissman, Ph.D., is an Associate Professor in the Department of Medicine and the Institute for Health Policy at Massachusetts General Hospital. He is also a Lecturer in the Department of Health Care Policy, Harvard Medical School.


Foreword by Hillary Rodham Clinton
List of Abbreviations and Statistical Terms
1.  Introduction: A Framework for Thinking about Insurance Status and Access to Care  1
2.  Who Are the Uninsured and How Did They Get That Way? 17
3.  Health Status 49
4.  Intermediate Process Indicators 55
5.  The Quantity and Quality of Care 63
6.  Outcomes of Care 99
7.  Special Cases: Cost-sharing, Changes in or Loss of Insurance and Medicaid Managed Care 113
8.  Insurance, Access, and Health Care Reform: Summary and Policy Implications 133
Appendix A.  National Surveys and Major Studies on Access Included in This Book 155
Appendix B.  Methods Used in Chapters 3-7 159
Notes 161
References 165
Index 185

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