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"It is mistaken and dangerous to assume that the prevalence of uninsurance in the United States harms only those who are not insured," said Dr. Arthur L. Kellermann of the Emory University School of Medicine in Atlanta.

Providing uncompensated care can put a severe strain on emergency and trauma care and other community health facilities. That can worsen emergency room overcrowding and hospitals may decide to close these facilities in response to financial stress, said Kellermann, co-chairman of the committee that prepared the study.

"The insured and the uninsured have a shared destiny," he said.

The report is the fourth in a series by the Institute looking at the consequences of lacking health insurance. Earlier reports dealt with why people lack insurance and the impact of that on individuals and families. Two more reports are planned, dealing with the problem on a national level and suggesting solutions.

The Institute's report comes just a day after a separate analysis from the Robert Wood Johnson Foundation said about 75 million Americans lacked health insurance at some point during 2001 or 2002.

The sluggish economy and rising health costs are combining to prompt businesses to cut back coverage or charge their workers more for it, and states are trimming their programs for poor and low-income residents. As a result, the ranks of the uninsured now cut deeper into the middle class, that study said.

Dr. Georges C. Benjamin, executive director of the American Public Health Association, said that finding is shocking and shows just how deeply lack of access to health care touches all Americans.

People without health insurance don't get routine preventive health services, receive too little medical care too late, are sicker and die sooner, and receive poorer care when they are hospitalized, Benjamin said.

The Institute's report noted that with current economic conditions, including unemployment, rising health care costs and budget shortfalls at all levels of government, the number of uninsured will probably continue to grow.

And, the study added, there is little evidence that the public funds that pay for most uncompensated medical care are being allocated or targeted efficiently.

With rising costs for providing health care to the uninsured, local governments often have to take resources from other uses, the study said.

For https://www.mvhlvjjtu.online example, facing a $6.9 million shortfall in a program to serve the medical needs of the uninsured, Hillsborough County, Fla., had to reallocate tax funds that had been planned for highway construction.

A number of cities have closed health facilities or converted them from public operation to for-profit ones due, in part, to the burden of uncompensated care, the study added. When this happens both the insured and uninsured may be affected by the reduction in services available.

Last year, for example, Los Angeles County closed 11 of its 18 public health clinics and one of six public hospitals, the report said.

The Institute of Medicine is an arm of the National Academy of Sciences, an independent organization chartered by Congress to advise the government on scientific issues.

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