For immediate release:
Tuesday, April 11, 2006
12:01 a.m. EDT


Christopher Fleming

Impact Of Community Initiatives On The Uninsured Limited By Economic and Political Obstacles

Bethesda, MD -- Those hoping that community-level initiatives can make significant inroads into the problem of the uninsured may be in for a disappointment. That verdict emerges from a package of five papers published today on the Health Affairs Web site.

By examining many recent community initiatives, the papers demonstrate the creativity and diligence of community officials in seeking to improve care and expand coverage for the uninsured. But the package also illustrates the political, financial, and organizational obstacles communities face in this area, especially when they seek to expand coverage.

Uphill struggle to cover uninsured

One paper by Lawrence Brown and Beth Stevens, which offers case studies of seven sites from the Robert Wood Johnson Foundation’s Communities in Charge (CIC) program, provides this assessment of the program’s results: “Highly intelligent and mission-driven local leaders carefully planned and heroically pursued initiatives that yielded modest results.” In the late 1990s, the nation faced long-stalled federal and state coverage efforts and the inability of a strong economy to reduce the number of uninsured Americans, Brown and Stevens observe. Through the CIC and other, similar programs, reformers sought to use community forces to reignite progress.

But “the mix of modest progress, stalemate, and collapse that we found after four years of tracking suggests that, in brief, even community leaders who are deeply dedicated to addressing the problems of the uninsured face a sharp uphill struggle,” write Brown, a professor at Columbia University’s Mailman School of Public Health, and Stevens, a senior researcher at Mathematica Policy Research. “A few communities engineered small expansions of coverage or care, but nothing in the concatenation of circumstances that supported this modest progress or in the general record of our seven sites argues that US communities have the capacity to make much of a dent in the problem of the uninsured,” the researchers state in “Charge of the Right Brigade? Communities, Coverage, and Care for the Uninsured.”

Reliance on private sector limits scope

A similar message is conveyed in “Community Approaches to Providing Care for the Uninsured,” based on research conducted as part of the Center for Studying Health System Change’s (HSC’s) Community Tracking Study, a longitudinal study of 12 health care markets conducted every two to two and one-half years. Community-based programs “are often invaluable to those who are able to enroll,” but they tend to “serve only a small proportion of their community’s uninsured residents, barely making a dent in the overall problem,” according to the study by Erin Fries Taylor, a researcher at Mathematica and an HSC consulting researcher, HSC senior researcher Peter Cunningham, and HSC research assistant Kelly McKenzie.

The difficulties that local leaders face are the same as those that hinder progress at the federal level: money and politics. “Community programs in the CTS sites increasingly are clustered around private-sector strategies, likely because public resources targeted specifically to programs for the uninsured have become more constrained in recent years,” Taylor, Cunningham, and McKenzie note. “Greater reliance on the private sector seems to be limiting the scope of these programs in terms of the number of uninsured people served, compared with the managed care programs of the 1990s that could tap into substantial public funds and pursue ambitious enrollment goals.”

In “Impermanent Politics: the Hillsborough County Health Care Plan and Community Innovation for the Uninsured,” Brown describes one community’s success in raising the county sales tax to fund a new coverage program in the early 1990s, then maintaining the program in the face of intense political opposition. The CIC program’s “fondest hope,” Brown and Stevens say in “Charge of the Right Brigade,” was “that the funded sites would follow Hillsborough County’s lead by raising new ‘mainstream’ funds for covering the uninsured.”

But replicating the Hillsborough County success proved elusive. In the few CIC sites to try raising new money to expand coverage -- notably three Oregon counties, Brooklyn, and Jacksonville -- “power too widely diffused over too many independent institutions bedevil[ed] the most committed and energetic local leaders,” Brown and Stevens report. “Communities tend to find it ‘easier’ to expand care than to extend coverage,” they say, explaining that “uninsured people morph into ‘patients’ in waiting rooms and EDs.”

Good news for local programs

While much of the package deals with the difficulties faced by community initiatives, one of the papers contains some good news. In “Who Enrolls in Community-Based Programs For The Uninsured, And Why Do They Stay?,” Mathematica’s Taylor and coauthors Catherine McLaughlin, Anne Warren, and Paula Song from the University of Michigan report that local programs could be subject to less adverse selection than some have feared. The researchers studied three CIC sites, and in two of the three, “the majority of participants were in good, very good, or excellent health and did not have chronic or limiting conditions. In these two programs … the majority of respondents were still enrolled one year after enrollment, providing some evidence against the myth that participants join programs for acute care needs and disenroll after those needs are met,” the paper reports. The results also indicate that the programs studied improved access to preventive care and physician care for their enrollees.

Finally, Debbie Chang, a senior vice president at the Nemours Foundation and executive director of the Nemours Division on Health and Preventive Services, offers a Perspective citing the opportunity to learn from both the successes and failures of local initiatives. “Community-based approaches act as a reality check of what is doable and practical: They can provide an actual model of what works; they can help identify promising practices in key areas; and they can provide lessons about how to address political issues,” Chang writes in “Applying Lessons Learned in Communities To Programs and Policies At The Federal Level.”

The articles can be read at:


Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at


©2006 Project HOPE–The People-to-People Health Foundation, Inc.