In 2006 there were about 47 million persons in the US without health insurance coverage (18% of the nonelderly population) and improving access to health care services for this vulnerable population is one of the most elusive health policy challenges today . Uninsured persons not only have poorer access to health care than insured persons, but they also have poorer health outcomes over time [2-5]. Recent related research has also argued that the health care access and quality available to the insured population in a local community is likely to be lower in communities with relatively large uninsured populations [6-8]. The provision of uncompensated care to the uninsured population imposes a financial burden in local communities which is absorbed by health care providers as well as insurance payers, insured patients and taxpayers. The quantity and quality of health care services demanded by the uninsured population is lower than the mix of services demanded by the insured population, which reduces the average quality of health care services available and provided in the local health care market . Thus, the local population without health insurance coverage may impose pecuniary (financial) and non-pecuniary (quality) spillovers on everyone else [6-8].
Uninsurance spillovers have been shown to be substantial and unambiguous for the insured population for a wide variety of health care access, use and quality indicators [7,8]. However, it is not entirely obvious that the same result (after considering the individual effect of being uninsured) applies for the uninsured population. That is, does spillover negatively impact the receipt of health care for the uninsured as has been shown for the insured? On the one hand, the uninsured population may impose a very small financial burden in a low uninsurance community. This community would be more willing to fund the local safety net because the fiscal impact of doing so is likely to be relatively small. On the other hand, the existence of few uninsured people in the local community may imply that safety net providers may lack experience providing services to this population, or may not be able to take advantage of economies of scale in the provision of health care services for the uninsured population. In a community with a large uninsured population, mostly-insured taxpayers will be less willing to subsidize a larger volume of health care services for the uninsured population, which would lead to access difficulties. The fact that the uninsured population is large at the local level also means that there could be economies of scale in the provision of services to the uninsured population. Thus, although it is clear that pecuniary (financial) and non-pecuniary (quality) spillovers will be larger for the insured population the larger the local uninsurance rate, this may not be the case for the uninsured population.
This study uses a qualitative approach to explore these ideas by conducting a series of focus groups on health care access and quality with uninsured Latino mothers in two communities that differ substantially by the proportion of the local population that lacks health insurance coverage . Communities in Texas and Minnesota were selected because nationally, Texas has both the highest overall rate of uninsurance (24.2%) and the highest rate among Latinos (60%), while Minnesota has the lowest overall rate of uninsurance (8.4%), and only 18% of Minnesota Latinos are uninsured (see Table 1) [10,11]. Differences in the safety net characteristics between Texas and Minnesota are presented in Table 2 to provide the reader some context on health care availability, eligibility requirements, and coverage differences across these two states [10-15].