Health care

A physician visiting the sick in a hospital. German engraving from 1682.

Health care (sometimes shortened to "healthcare") is the prevention, treatment, and management of illness and the preservation of mental and physical well being through the services offered by the medical, nursing, and allied health professions. According to the World Health Organisation, health care embraces all the goods and services designed to promote health, including “preventive, curative and palliative interventions, whether directed to individuals or to populations”. The organised provision of such services may constitute a health care system. This can include a specific governmental organisation such as, in the UK, the National Health Service or a cooperation across the National Health Service and Social Services as in Shared Care. Before the term "health care" became popular, English-speakers referred to medicine or to the health sector and spoke of the treatment and prevention of illness and disease.

In most developed countries and many developing countries health care is provided to everyone regardless of their ability to pay. The National Health Service in the United Kingdom was the world's first universal health care system provided by government. It was established in 1948 by Clement Atlee's Labour government. Alternatively, compulsory government funded health insurance with nominal fees can be provided, as in France which has the best health system in the world, or Italy which has the second best according to the World Health Organisation. Other examples are Medicare in Australia, established in the 1970s by the Labour government, and by the same name Medicare in Canada, established between 1966 and 1984. Universal health care contrasts to the systems like health care in the United States or South Africa, though South Africa is one of the many countries attempting health care reform.

Health care industry

The health care industry is one of the world's largest and fastest-growing industries. Consuming over 10 percent of gross domestic product of most developed nations, health care can form an enormous part of a country's economy. In 2003, health care costs paid to hospitals, physicians, nursing homes, diagnostic laboratories, pharmacies, medical device manufacturers and other components of the health care system, consumed 15.3 percent of the GDP of the United States, the largest of any country in the world. For United States, the health share of gross domestic product (GDP) is expected to hold steady in 2006 before resuming its historical upward trend, reaching 19.6 percent of GDP by 2016. In 2001, for the OECD countries the average was 8.4 percent with the United States (13.9%), Switzerland (10.9%), and Germany (10.7%) being the top three.

According to Celent, US healthcare expenditures totaled US$2.2 billion in 2006. According to Health Affairs, USD$7,498 will be spent on every woman, man and child in the United States in 2007, 20 percent of all spending. Costs are projected to increase to $12,782 by 2016. The healthcare industry includes the delivery of health services by health care providers. Usually such services receive payment from the patient or from the patient's insurance company; although they may be government-financed (such as the National Health Service in the United Kingdom) or delivered by charities or volunteers, particularly in poorer countries. There are many ways of providing healthcare in the modern world. The most common way is face-to-face delivery, where care provider and patient see each other 'in the flesh'. This is what occurs in general medicine in most countries. However, healthcare is not always face-to-face; with modern telecommunications technology, in absentia health care is becoming more common. This could be when practitioner and patient communicate over the phone, video conferencing, the internet, email, text messages, or any other form of non-face-to-face communication.

Health care systems

Main article: Health care systems

See also: Medical model, Preventive medicine, and Social medicine

Purely private enterprise health care systems are comparatively rare. Where they exist, it is usually for a comparatively well-off subpopulation in a poorer country with a poorer standard of health care–for instance, private clinics for a small, wealthy expatriate population in an otherwise poor country. But there are countries with a majority-private health care system with residual public service (see Medicare, Medicaid). The other major models are public insurance systems. A Social security health care model is where workers and their families are insured by the State. A Publicly funded health care model is where the residents of the country are insured by the State. Within this branch is Single-payer health care, which describes a type of financing system in which a single entity, typically a government run organisation, acts as the administrator (or "payer") to collect all health care fees, and pay out all health care costs. Some advocates of universal health care assert that single-payer systems save money that could be used directly towards health care by reducing administrative waste. In practice this means that the government collects taxes from the public, businesses, etc., creates an entity to administer the supply of health care and then pays health care professionals. Harry Wachtel estimate a single payer universal healthcare system will actually save money through reduced bureaucratic administration costs. Social health insurance is where the whole population or most of the population is a member of a sickness insurance company. Most health services are provided by private enterprises which act as contractors, billing the government for patient care. In almost every country with a government health care system a parallel private system is allowed to operate. This is sometimes referred to as two-tier health care. The scale, extent, and funding of these private systems is very variable.

A traditional view is that improvements in health result from advancements in medical science. The medical model of health focuses on the eradication of illness through diagnosis and effective treatment. In contrast, the social model of health places emphasis on changes that can be made in society and in people's own lifestyles to make the population healthier. It defines illness from the point of view of the individual's functioning within their society rather than by monitoring for changes in biological or physiological signs.

World Health Organisation

Main article: World Health Organisation

See also: Global health

The Flag of the World Health Organization

The World Health Organisation (WHO) is a specialised United Nations agency which acts as a coordinator and researcher for public health around the world. Established on 7 April 1948, and headquartered in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health Organization, which had been an agency of the League of Nations. The WHO's constitution states that its mission "is the attainment by all peoples of the highest possible level of health." Its major task is to combat disease, especially key infectious diseases, and to promote the general health of the peoples of the world. Examples of its work include years of fighting smallpox. In 1979 the WHO declared that the disease had been eradicated - the first disease in history to be completely eliminated by deliberate human design. The WHO is nearing success in developing vaccines against malaria and schistosomiasis and aims to eradicate polio within the next few years. The organization has already endorsed the world's first official HIV/AIDS Toolkit for Zimbabwe from October 3 2006, making it an international standard.

The WHO is financed by contributions from member states and from donors. In recent years the WHO's work has involved more collaboration, currently around 80 such partnerships, with NGOs and the pharmaceutical industry, as well as with foundations such as the Bill and Melinda Gates Foundation and the Rockefeller Foundation. Voluntary contributions to the WHO from national and local governments, foundations and NGOs, other UN organizations, and the private sector (including pharmaceutical companies), now exceed that of assessed contributions (dues) from its 193 member nations.

Health care by country

Map of countries with universal health care

Main article: Health care systems

See also: Category:Healthcare by country

Oceania

Australia and New Zealand both have publicly funded health care systems, though under the Conservative government in Australia, there has been new funding and incentives for people who pay for private health insurance.

Australia

File:Medicare-brand.png

Medicare brand

Main article: Medicare (Australia)

Medicare was introduced by the Whitlam Labor Government on 1 July 1975 through the Health Insurance Act 1973. The Australian Senate rejected the changes multiple times and they were passed only after a joint sitting after the 1974 double dissolution election. Yet Medicare has been supported by subsequent governments and became a key feature of Australia’s public policy landscape. The exact structure of Medicare, in terms of the size of the rebate to doctors and hospitals and the way it has administered, has varied over the years. The original Medicare program proposed a 1.35% levy (with low income exemptions) but these bills were rejected by the Senate, and so Medicare was originally funded from general taxation. In October 1976, the Fraser Government introduced a 2.5% levy. The program is now nominally funded by an income tax surcharge known as the Medicare levy, which is currently set at 1.5% with exemptions for low income earners. In practice the levy raises only a fraction of the money required to pay for the scheme. If the levy was to fully pay for the services provided under the medicare banner then it would need to be set at about 8%. There is an additional levy of 1.0%, known as the Medicare Levy Surcharge, for those on high annual incomes ($50,000) who do not have adequate levels of private hospital coverage. This is part of an effort by the current Coalition Federal Government to encourage people towards private health insurance.

Europe

See also: Directorate-General for Health and Consumer Protection (European Commission)

All of Europe has publicly sponsored and regulated health care. Countries include Austria, Belgium, Denmark, Finland, France Germany, Greece, Hungary, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Spain, Sweden and the United Kingdom.

Ireland

Main article: Health care in the Republic of Ireland

Health care in the Republic of Ireland is governed by the Health Act 2004, which established a new body to govern the national health service in the Republic of Ireland, the Health Service Executive. The new health service came into being officially on 1 January, 2005; however the new structures are in the process of being established. Currently the HSE is continuing to manage the health service under the Health Act 1970 structures. The Health Boards no longer exist as corporate entities, however the structures which existed remain as divisions of the HSE until a plan of reorganisation is complete. Each former health board area operates as a division of the HSE and the former chief executive officer of each health board is now known as a chief officer for the HSE region.

Switzerland

Main article: Healthcare in Switzerland

Healthcare in Switzerland is regulated by the Federal Health Insurance Act. Health insurance is compulsory for all persons resident in Switzerland (within three months of taking up residence or being born in the country). International civil servants, members of permanent missions and their familiy members are exempted from compulsory health insurance. They can, however, apply to join the Swiss health insurance system, within six months of taking up residence in the country. Health insurance covers the costs of medical treatment and hospitalisation of the insured. However, the insured person pays part of the cost of treatment. This is done (a) by means of an annual excess (or deductible, called the franchise), which ranges from CHF 300 to a maximum of CHF 2,500 as chosen by the insured person (premiums are adjusted accordingly) and (b) by a charge of 10% of the costs over and above the excess.

United Kingdom

Main article: National Health Service

The logo of the NHS for Britain. The colour, "NHS Blue" (Pantone 300), is used on signs and leaflets throughout the NHS in the UK.

The NHS is the world's largest, centralised health service, and the world's third largest employer after the Chinese army and the Indian railways. It was created in the aftermath of World War II, by Clement Attlee's Labour government, based on the proposals of the Beveridge Report, prepared in 1942. The structure of the NHS in England and Wales was established by the National Health Service Act 1946 (1946 Act). The current Labour government has pumped billions of new money into the NHS. However, Tony Blair's policy, whilst leaving services free at point of use, was to encourage outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services (such as "surgicentres"), and non-medical services (such as catering) provided under long-term contracts by the private sector. These are more expensive than if the new build was simply funded from the public purse. A study by a consultancy company which works for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced. Even so there is for the first time complete political consensus on the importance of free public health care.

Latin America

Most countries in Latin America have public health care provided. Mexico is planning to launch its own universal health care network though at the moment the standards of health care in Mexico are seriously lacking with large divides between rich and poor. Puerto Rico is planning its own health reform for the poorest of the population. Health care in Venezuela is probably the most extensive and given the country's fortunes in oil wealth, expenditure has recently increased greatly, starting with mass vaccinations under the Plan Bolivar 2000.

Cuba

Main article: Health care in Cuba

Che Guevara, here at Havana airport, made the case for publicly funded health care across Latin America

The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of its citizens. Following the Revolution, the new Cuban government asserted that universal healthcare was to become a priority of state planning. In 1960 revolutionary and physician Che Guevara outlined his aims for the future of Cuban healthcare in an essay entitled "On Revolutionary Medicine", stating: "The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices." These aims were hampered almost immediately by an exodus of almost half of Cuba’s physicians to the United States, leaving the country with only 3,000 doctors and 16 professors in University of Havana’s medical college. Beginning in 1960, the Ministry of Public Health began a program of nationalization and regionalization of medical services. In 1976, Cuba's healthcare program was enshrined in Article 50 of the revised Cuban constitution which states

"Everyone has the right to health protection and care. The state guarantees this right by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, hospitals, preventative and specialized treatment centers; by providing free dental care; by promoting the health publicity campaigns, health education, regular medical examinations, general vaccinations and other measures to prevent the outbreak of disease. All the population cooperates in these activities and plans through the social and mass organizations."

Like the rest of the Cuban economy, Cuban medical care has suffered from severe material shortages following the end of Soviet subsidies and the ongoing United States embargo against Cuba that began after the Cuban Missle Crisis. Data for 2004 show that Cuba has one of the highest life expectancy rates in Latin America. Costa Rica, Chile, Virgin Islands, Guadeloupe, and Martinique now have a higher life expectancy for combined sexes from birth.[6]

North America

Canada

Main articles: Health care in Canada and Medicare (Canada)

The federal government of Lester B. Pearson, pressured by the New Democratic Party (NDP) who held the balance of power, introduced the Medical Care Act in 1966 that extended the HIDS Act cost-sharing to allow each province to establish a universal health care plan. It also set up the Medicare system. In 1984, the Canada Health Act was passed, which prohibited user fees and extra billing by doctors. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility." The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises, private corporations. Most all doctors do not receive an annual salary, but receive a fee per visit or service. About 30% of Canadians' health care is paid for through the private sector. This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and optometry. Many Canadians have private health insurance, often through their employers, that cover these expenses.

United States

Main articles: Health care in the United States and Medicare (United States)

President Johnson signing the Medicare amendment. Harry Truman and his wife, Bess, are on the far right

In the United States, certain publicly funded health care programs help to provide for the elderly, disabled, military service families and veterans, and the poor and federal law ensures public access to emergency services regardless of ability to pay; however, a system of universal health care has not been implemented. The Commonwealth of Massachusetts is attempting to implement a near-universal health care system by mandating that residents purchase health insurance by July 1, 2007. California, Maine, Pennsylvania, and Vermont also are attempting universal systems. Some government health care systems allow private practitioners to provide services, and some do not. In the U.K., doctors are allowed to provide services outside the government system. In Canada, some services are permitted and some are not. The Supreme Court of Quebec ruled, in Chaoulli v. Quebec, that private services must be allowed to compete with the public program.

However, those who are proponents of implementing a universal healthcare system in the United States point out the fact that there are many flaws in the reasoning used against having such a system. Among these flaws, the one that stands out is the fact that the USA has a lower life expectancy than virtually all other countries in a similar economic class, including those with national healthcare systems, such as Australia, the United Kingdom, Canada, and Sweden. Also, infant mortality rates remain higher in the United States as well, despite declines in recent decades, and are in fact higher than the average of the European Union; however, this fails to take into effect that premature births are not counted as live births in most EU nations, potentially resulting in this disparity. </ref> Despite this, only an estimated 84.3% of citizens have some form of health insurance coverage, either through their employer or purchased individually. Employers that do provide insurance, on average, spend between 4.6 and 8.7% of their payroll in health insurance premiums.

Asia

Israel, South Korea, Seychelles and Taiwan have universal health care. Thailand plans to. Health care in India is guaranteed to "improve" for all under the constitution, although the reality does not live up to the vague wording of the article. In Sri Lanka, drugs are provided by a government owned drug manufcaturer called the State Pharmaceuticals Corporation of Sri Lanka. In the Philippines, the Department of Health (Philippines) organises public health for the country, and was established at the initiative of the American governers, before independence. Saudi Arabia has a publicly funded health system, although its levels are lower than the regional average.

Japan

Main article: Health care in Japan

In Japan, payment for personal medical services is offered through a universal insurance system that provides relative equality of access, with fees set by a government committee. People without insurance through employers can participate in a national health insurance program administered by local governments. Since 1973, all elderly persons have been covered by government-sponsored insurance. Patients are free to select physicians or facilities of their choice. In the early 1990s, there were more than 1,000 mental hospitals, 8,700 general hospitals, and 1,000 comprehensive hospitals with a total capacity of 1.5 million beds. Hospitals provided both out-patient and in-patient care. In addition, 79,000 clinics offered primarily out-patient services, and there were 48,000 dental clinics. Most physicians and hospitals sold medicine directly to patients, but there were 36,000 pharmacies where patients could purchase synthetic or herbal medication.

National health expenditures rose from about 1 trillion Yen in 1965 to nearly 20 trillion Yen in 1989, or from slightly more than 5% to more than 6% of Japan's national income. In addition to cost-control problems, the system was troubled with excessive paperwork, long waits to see physicians, assembly-line care for out-patients (because few facilities made appointments), over medication, and abuse of the system because of low out-of-pocket costs to patients. Another problem is an uneven distribution of health personnel, with cities favored over rural areas.

Africa

File:AidsEducationUganda.jpg

AIDS education at a school in Uganda.

Health care in Africa is usually non existent or highly limited and under resourced. The outbreak and spread of HIV/AIDS in Africa has crippled many populations and sent life expectancies plummetting. However some countries have been able to tackle the challenges, for instance health care in Uganda as well as education has reduced HIV/AIDS infections from 13% to 4.1% from 1990 to 2003. This contrasts to some governments' approach, especially that of the South African Health Ministry who until recently denied the link between HIV/AIDS.

Nigeria

Main article: Health care in Nigeria

Health care provision in Nigeria is a concurrent responsibility of the three tiers of government in the country. However, because Nigeria operates a mixed economy, private providers of health care have a visible role to play in health care delivery. The federal government's role is mostly limited to coordinating the affairs of the university teaching hospitals, while the state government manages the various general hospitals and the local government focus on dispensaries. The total expenditure on health care as % of GDP is 4.6, while the percentage of federal government expenditure on health care is about 1.5%. A long run indicator of the ability of the country to provide food sustenance and avoid malnutrition is the rate of growth of per capita food production; from 1970-1990, the rate for Nigeria was 0.25%. Though small, the positive rate of per capita may be due to Nigeria's importation of food products.

Historically, health insurance in Nigeria can be applied to a few instances: free health care provided and financed for all citizens, health care provided by government through a special health insurance scheme for government employees and private firms entering contracts with private health care providers. However, there are few people who fall within the three instances. In May 1999, the government created the National Health Insurance Scheme, the scheme encompasses government employees, the organized private sector and the informal sector. Legislative wise, the scheme also covers children under five, permanently disabled persons and prison inmates. In 2004, the administration of Obasanjo further gave more legislative powers to the scheme with positive amendments to the original 1999 legislative act.

Countries

Click "show" on the right of the templates below to release the drop down menu for health care by country. If your country has no article, please begin it with a short description.

Health care economics

Main article: Health care economics

Medical (health) insurance is subject to the well-known economic problem of adverse selection which may also be referred to as a market failure. Adverse selection in insurance markets occurs because those providing insurance have limited information with which to estimate the risks their clients wish to insure against. In simple terms, those with poor health will apply for insurance, raising the cost of providing insurance; those with good health will find the cost of insurance too expensive, raising costs further. In practical terms, adverse selection means that private insurers are economically incentivized to spend substantial sums on 'weeding out' bad risks in advance by providing medical insurance only to the most healthy. Among the potential solutions posited by economists are forms of universal health insurance, such as requiring all citizens to purchase insurance, limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals. Compulsory universal health insurance is a common thread, although there is no requirement that the insurance or medical services be provided by government.

Country	Life expectancy	Infant mortality rate	Physicians per 1000 people	Nurses per 1000 people	Per capita expenditure on health (USD)	Healthcare costs as a percent of GDP	% of government revenue spent on health	% of health costs paid by government
Australia	80.5	5.0	2.47	9.71	2,519	9.5	17.7	67.5
Canada	80.5	5.0	2.14	9.95	2,669	9.9	16.7	69.9
France	79.5	4.0	3.37	7.24	2,981	10.1	14.2	76.3
Germany	80.0	4.0	3.37	9.72	3,204	11.1	17.6	78.2
Japan	82.5	3.0	1.98	7.79	2,662	7.9	16.8	81.0
Sweden	80.5	3.0	3.28	10.24	3,149	9.4	13.6	85.2
UK	79.5	5.0	2.30	12.12	2,428	8.0	15.8	85.7
USA	77.5	6.0	2.56	9.37	5,711	15.2	18.5	44.6

Most European systems are financed through a mix of public and private contributions. The majority of universal health care systems are funded primarily by tax revenue (e.g. Portugal). Some nations, such as Germany, France and Japan employ a multi-payer system in which health care is funded by private and public contributions. In 2001 Canadians paid $2,163 per capita versus $4,887 U.S., according to the Los Angeles Times (also, see table above). According to Dr. Stephen Bezruchka, a senior lecturer in the School of Public Health at the University of Washington in Seattle, Canadians do better by every health care measure. According to a World Health Organization report published in 2003, life expectancy at birth in Canada is 79.8 years, versus 77.3 in the U.S.

A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, speciality healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and the medications are paid by a state agency. No entirely private health care system exists, although the reform bill in Massachusetts attempts to make private health care more affordable. Bill Frist argued in the New England Journal of Medicine that the free market will keep costs down, because individuals who have to pay for their own health care will make wiser decisions and not spend money on unneeded or inefficient care. A deregulated free market, Frist argues, will also encourage efficiency and innovation.

Health care politics

Main article: Health care politics

The politics of health care depends largely on which country one is in. Current concerns in Britain, for instance, revolve around the use of private finance initiatives to build hospitals or the excessive use of targets in cutting waiting lists. In Germany and France, concerns are more based on the rising cost of drugs to the governments. In Brazil, an important political issue is the breach of intellectual property rights, or patents, for the domestic manufacture of Antiretroviral drugs used in the treatment of HIV/AIDS. The South African government, whose population sets the record for HIV infections, came under pressure for its refusal to admit there is any connection with AIDS because of the cost it would have involved. In the United States, which has some of the most sophisticated, technologically advanced health care in the world, 12% to 16% of the citizens are still unable to afford complete health insurance.

Opponents of universal health care in the United States often argue that it will require higher taxes and a great likelihood of poorly performing health care facilities and physicians. Also, the absence of a market mechanism may slow innovation in treatment and research leading to rationing of care through waiting lists. A statistical comparison shows that it is not universal health care that leads to a doctor shortage, but the payment system to doctors that causes a doctors shortage. In Italy, doctors are paid a fee per patient per year, a per capita salary, and Italy does not have a doctor shortage but has one of the highest doctor per patient ration, 5.8 doctors per 1,000 patients. In Italy though, it should be noted that most physicians subsequently have very limited hours; many only maintaining patient hours 2 days per week. Canada, whose universal health care system pays its doctors a "fee per visit", creates a real market condition, where doctors' salaries are protected, and even increased, by decreasing the supply of doctors. Canada has a low doctor per patient ration of 2.1 doctors per 1,000 patients. A comparative analysis shows that a salaried doctor system, while not perfect, results in more doctors; however, they work substantially fewer hours, while the fee per visit system creates economic pressures to reduce the number of doctors, who subsequently work more hours.

The issue of quality control is an important aspect of any system, and in Canada, the self regulation of the health industry by the doctors union, the Canadian Medical Association, and its self regulatory wing, College of Physicians and Surgeons of Ontario shows that most complaints are swept under the rug, (Toronto Star reports) and very few complaints sent to quality control for study.

See also

• Health
• School health services
• Health care reform
• Health disparities
• Health informatics
• Health promotion

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• Health savings account
• Medical savings account
• Two-tier health care
• Journal of Health Care for the Poor and Underserved
• Massachusetts 2006 Health Reform Statute

External links

• Healthcare Data Depot
• HRC/Eldis Health Resource Guide New research and other resources on health in developing countries
• Medical Updates Breaking Medical NEWS site for doctors and patients
• EU information on Health Care Sector from EU-OSHA
• Health Action by People India.
• Forum of Pakistani Doctors

USA-specific

• Health care company profiles at NNDB.
• Agency for Healthcare Research and Quality.
• Healthy Directory & Resource.
• The Health Care Crisis, Part I - a Pinky Show online video.
• Redefining Healthcare, A Presentation on the Future of Healthcar- January 2007

Supporting universal health care

• American Medical Student Association (AMSA)
• Connecticut Coalition for Universal Health Care
• Physicians for a National Health Program (PNHP)
• Universal Health Care Action Network (UHCAN)
• Universal Health Care / National Health Insurance

Opposing universal health care

• Capitalism Magazine
• The Problems with Socialized Health Care from Mark Valenti's Liberty Page
• British, Canadian Experience Shows Folly of Socialized Medicine, Analyst Says. Press release, Heritage Foundation. Sept. 29, 2000.
• The Heartland Institutes' Health Care Issue Suite
• Dead Meat On The Fence's short film about Canada's socialized healthcare system.

Neutral

• BalancedPolitics.org - "Should the Government Provide Free Universal Health Care for All Americans?"
• Hidden costs, value lost: uninsurance in America. Institute of Medicine Committee on the Consequences of Uninsurance. Washington, DC: National Academies Press, 2003.