There is, however, substantial evidence of poor health outcomes associated with being uninsured, which represents an extreme version of cost-sharing ( Weissman, Gatsonis, and Epstein 1992 Ayanian et al. 1989 Solanki, Schauffler, and Miller 2000 Wong et al. 1986 Shapiro, Ware, and Sherbourne 1986 Lurie et al. These and other studies also had limited ability to detect possible changes in unfavorable clinical events associated with ED care (i.e., adverse effects of ED cost-sharing resulting from delayed or avoided ED visits), given the large population sizes needed to assess changes in these typically rare events ( Keeler et al. Previous work by members of our team found that emergency department (ED) copayments reduced ED visits and expenditures, and appeared to decrease ED visits for low severity diagnoses preferentially ( O'Grady et al.
1985 Newhouse and The Insurance Experiment Group 1993 Selby, Fireman, and Swain 1996). Studies including the RAND Health Insurance Experiment (HIE) have found that cost-sharing reduces both health care use and expenditures ( O'Grady et al. Currently, we have limited information on whether cost-sharing has harmful clinical effects. This increased cost-sharing could improve efficiency if patients reduce unnecessary use of resources, but also could result in worse health if patients avoid necessary care ( Phelps 1992 Rubin and Mendelson 1995 Zweifel and Manning 2000). Patients in the United States are paying more for their health care, in part through additional or higher copayments.
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