Health Insurance and Vulnerable Populations

Our charge is to consider the causes of lack of insurance coverage for vulnerable populations. This is a daunting task for many reasons-not least because there are as many kinds of vulnerability as there are bad things that happen to human bodies or to human life. Although the term " vulnerable population " conjures images of a discrete and insular minority, every person's vulnerability to illness, injury, and disease makes health insurance necessary and possible for the vast majority of the U.S. population. Consistent with the ambiguities of "vulnerable populations," a Medline search on this term yielded 191 entries that survey the continent encompassed by that term. A casual list includes: children of immigrants, 1, 2 parents of immigrants, 3 undocumented or recently-documented immigrants, 4 AFDC/TANF recipients, 5 families ineligible for welfare, 6 unattached adults who are ineligible for public cash aid, men and women with psychiatric and substance abuse disorders or developmental disability, 7, 8 race/ethnic minorities, 2 prison inmates and current or former offenders, 6, 9 residents of rural areas, 10 residents of inner-city communities, 11 individuals with chronic illnesses, 8 the disabled poor, the elderly, the near-elderly, foster children, and children with special health care needs. 12-14 Foreign populations noted in the same Medline search include residents of Cuba, Iraq, Guatemala, and other nations subject to U.S. economic sanctions. 1 The diversity of vulnerable populations highlights the many meanings of the term. The range of potential definitions calls into question " vulnerable populations " as an organizing principle of policy analysis. If so many groups are vulnerable, for so many reasons, does the idea of " vulnerability " really provide insight into public policies towards insurance coverage? In our view, it does. The construct of " vulnerable populations, " though admitting many interpretations, highlights an important set of issues for the design and management of health insurance, as well as the essential linkages between health insurance and social policy. 1 While the literature features a diversity of groups under the heading "vulnerable," some analysts have been much more restrictive. For example, the papers in a 1988 edited collection entitled The Vulnerable focused solely on comparing the elderly and children along many dimensions of well-being (Palmer, Smeeding, Torrey, 1988). 2 Roadmap of this Paper To clarify the issues relevant to diverse populations, we start by defining the vulnerable, and by considering components of vulnerability pertinent to health policy …