This chapter examines the literature on the static and dynamic characteristics of uninsured children. Even though estimates of the number and percentage of uninsured children vary by data source and research methodology, the estimates of the characteristics of uninsured children are fairly consistent. Therefore, unless researchers strongly disagree, we simply present the overall findings from one source for key characteristics.
A. STATIC CHARACTERISTICS OF THE UNINSURED
The characteristics presented in this section are all static -- that is, they describe a defined population of the uninsured at a defined time. Although static characteristics provide a useful overall picture of the uninsured, static characteristics can also be deceiving because they can mask the fact that the uninsured are not a homogenous population. For example, the long-term uninsured and the short-term uninsured probably have very different characteristics. Examining these two groups together may provide a picture of the uninsured that does not look like its component parts. For this reason, much of the current literature on the characteristics of the uninsured could be improved by using longitudinal data and examining the short-term and long-term uninsured groups separately.
Most of the discussion which follows is based on EBRI's recent analysis of the March 1996 CPS (Fronstin 1996 and 1997a) because it is timely and presents detailed characteristics of uninsured children. Twelve other sources we reviewed also reported findings on the characteristics of uninsured children: Beauregard et al. (1997); Bennefield (1995); Bennefield (1996a); Bennefield (1996b); Families USA (1997); Holahan (1997); Holahan et al. (1995); Monheit (1994); Reschovsky et al. (1997); Summer et al. (1997); U.S. GAO (1997); and Winterbottom et al. (1995). Their findings were generally consistent with the EBRI results unless otherwise noted.
A summary of EBRI's findings is presented in Table III.1. In this table, the characteristics of the uninsured are presented alongside the characteristics of the privately insured and the publicly insured in order to show how these groups differ.(1) Children with both private and public coverage are included in both the private and public columns. The following characteristics are examined: age, race and ethnicity, citizenship, family structure and poverty level, parents' employment and health insurance status, and parents' education. Except for age characteristics, where the literature includes research done by the Urban Institute using the CPS with the TRIM2 model, all of the estimates we examine in this section are based on the March 1996 CPS and are not adjusted for the underreporting of Medicaid in these data. Therefore, the estimates presented could be biased to the extent that some of the uninsured who are analyzed may actually be receiving Medicaid but not reporting so.
1. Age
As shown in Table III.1, EBRI found that of all uninsured children age 0 to 17 in 1995, 6.7 percent were infants, 26.5 percent were age 1 to 5, 38.4 percent were age 6 to 12, and 28.4 percent were age 13 to 17. As expected, the publicly insured contained a larger percentage of infants and children age 1 to 5 because the poverty-related Medicaid expansions are most generous to these groups.
The Urban Institute also estimated the percentage of children in various age groups that were uninsured (Holahan 1997). The estimates were adjusted for the underreporting of Medicaid in the CPS using the TRIM2 microsimulation model by selecting Medicaid eligible individuals to participate in the program even though they did not report doing so.
The Institute's findings are compared with EBRI's findings in Table III.2. The Institute found that a smaller percentage of children in all age groups were uninsured, but particularly among younger children.(2) They found that 8.3 percent of children age 1 to 5 and 10.2 percent of children age 6 to 12 were uninsured, versus 12.7 percent and 13.8 percent, respectively, according to EBRI. The most likely reason the Institute found a relatively smaller percentage of younger uninsured children compared with EBRI is that younger children were more likely than older children to be eligible for Medicaid under the poverty-related criteria (in 1995, states were required to cover children up to age 6 with family incomes below 133 percent of poverty and children age 6 to 11 in families with incomes below poverty). Thus, the adjustment for underreporting of Medicaid among younger children accounted for much of the 2.9 million difference between The Urban Institute's and EBRI's estimates of the number of uninsured children (6.9 million versus 9.8 million, respectively). Nevertheless, the difference between The Urban Institute's and EBRI's estimates of uninsured older children (age 13 to 17), are still quite high in absolute terms -- about 0.3 million children.
2. Race and Ethnicity
EBRI found that even though most of the uninsured were white (49 percent), the overall uninsurance rate for whites (10.5 percent) was lower than the national average (13.8 percent) and lower than any other race and ethnicity group. Hispanics were, by far, the most likely to be uninsured and the least likely to be covered by private health insurance. Overall, more than one-quarter (26.8 percent) of all Hispanic children were uninsured in 1995, according to EBRI's analysis of the CPS.
Blacks fared quite a bit better than Hispanics -- the uninsurance rate among blacks was 15.3 percent. The lower rate of uninsurance among blacks in comparison to Hispanics was due to the fact that blacks were both more likely to be privately insured and more likely to be publicly insured. The rate of private and public insurance for blacks was 44 percent and 49 percent, respectively, versus 38 percent and 39 percent for Hispanics. Blacks have the highest rates of public coverage.
3. Citizenship
EBRI found that 10 percent of uninsured children were noncitizens versus 4 percent of the publicly insured and 2 percent of the privately insured. That such a high percentage of the uninsured children were noncitizens suggests that their parents disproportionately work at jobs without health benefits or, if they do not work, are less likely than citizens either to be eligible for or to participate in Medicaid.
4. Family Structure and Poverty Level
EBRI found that uninsured children were more likely than the privately insured to be in single-parent families (38 versus 20 percent) but less likely than the publicly insured (56 percent). Similarly, the uninsured were more likely than the privately insured to be in families with incomes below 200 percent of poverty (70 versus 25 percent) but less likely than the publicly insured (79 percent). Thus, in terms of family characteristics, the uninsured seem to represent a middle ground between the privately and publicly insured.
EBRI made the point that the underlying data can explain how so many uninsured children appear to be in families with incomes well above poverty:
"Families with two workers can easily earn $40,000 or more if both parents earned $20,000. However, most parents earning $20,000 do not have access to health insurance. In many cases, their employer does not offer insurance because of the nature of the job. In addition, workers are often asked to pay the full cost of family coverage, which could be very expensive and amount to a relatively high percentage of a worker's $20,000 salary."
5. Parents' Employment and Health Insurance Status
In terms of parents' employment status, EBRI once again found that uninsured children represented a middle ground between the privately and publicly insured. Uninsured children were less likely than the privately insured to have at least one employed parent (89 versus 98 percent) but more likely than the publicly insured (68 percent). EBRI also examined the full-time, full-year employment status of individuals (because private health insurance benefits are typically offered only to full-time, full-year employed) and again found that the uninsured represented a middle ground between the privately and publicly insured -- 64 percent of uninsured children had parents who were employed full-time and full-year, versus 88 percent and 38 percent for the privately and publicly insured, respectively. In terms of health insurance status, EBRI found that 80 percent of uninsured children had at least one uninsured parent and 16 percent had at least one parent with employment-based insurance.
6. Parents' Education
EBRI found that 11 percent of uninsured children's parents had a college degree compared with 32 percent of privately insured children and 8 percent of publicly insured children.
B. DYNAMICS OF THE UNINSURED
In this section, we examine available research on the dynamics of uninsured children, including the length of time they are uninsured, the events leading to loss of coverage, and the events causing them to regain insurance. When examining the dynamics of the uninsured, it is important to understand that researchers' findings may differer markedly because of methodological differences in analyzing longitudinal data. Recall from the discussion on SIPP estimates of the uninsured in Chapter 2 that estimates of the duration of spells without health insurance can vary substantially depending on whether they are based on all spells or spells in progress at a point in time. Spells in progress at a point in time contain a disproportionate number of long spells. Because of this, estimates for all spells, which are often produced using survival analysis techniques, generally give a more accurate picture of the dynamics of the uninsured.
Families USA (1997) used the 1991 SIPP panel to examine how many children were uninsured and how long they were uninsured (see Table II.3A). Families USA did not use survival analysis for these estimates, electing instead to examine all the spells in progress during the 24-month period from February 1991 to January 1993. Of the 20.5 million children uninsured at least one month during that period, 47 percent were uninsured for 12 months or more, 15 percent were uninsured throughout, and only 7 percent were uninsured for less than 3 months.
Bennefield (1996b), using a survival analysis technique on data from the 1992 SIPP panel over a 28-month period, found that the median spell of noncoverage for those under age 18 was only 4.0 months (also shown in Table II.3A).(3) This was considerably shorter than the median spell of 5.8 months or longer for all other age groups. Bennefield's report does not give any further results on length of enrollment for children.
We also looked at research on the events triggering uninsurance for both adults and children. Insurance loss for most individuals is employment-related, according to analysis of SIPP data focusing on calendar year 1994 by The Lewin Group (1997, Draft). Of the two million Americans, on average, who became uninsured each month in 1994, about 58 percent cited changes in employment as their primary reason for losing coverage. Lewin defined a change in employment as loss of employment, loss of employment for a spouse or parent, termination of an employer plan, or a shift from full-time to part-time worker status. In addition, Lewin's analysis of SIPP data from 1991 through 1993 found that only about 8 percent of all persons lost their coverage due to a change in occupation for the same employer or a shift from full-time to part-time status. They also found that those with the lowest incomes were more than twice as likely as those with higher incomes to cite a job change as the reason for losing coverage.
The events triggering uninsurance for children appear to be somewhat different from that of all persons. Using data from a special coverage supplement to the 1993 NHIS, Lewin found that individuals under age 22 who lost their health insurance coverage were less likely to cite job related reasons than all people who lost coverage (44 versus 58 percent). But, they noted that an additional 18 percent indicated that they lost private coverage because they became ineligible as dependents due to age. Therefore, 62 percent of these children became uninsured due to some break in employer coverage. The reasons that children under age 22 lost their health insurance coverage according to Lewin's analysis of the 1993 NHIS are presented in Table III.3 (reproduced from the Lewin report).
Little research has been done on the events that cause uninsured children to regain their health insurance. Blumberg et al. (1997), using data from the 1990 panel of the SIPP, examined theinsurance status of children in wave 8 of the SIPP who were uninsured in wave 1.(4) Blumberg et al. found that of those uninsured in wave 1, 52 percent were uninsured in wave 8, 29 percent were privately insured, and 19 percent were enrolled in Medicaid.
Only somewhat dated research has been done comparing the characteristics of the long-term uninsured with the short-term uninsured. Swartz, Marcotte, and McBride (1993a, 1993b), and Swartz and McBride (1990) measured various distributions of uninsured spell lengths in the 1984 SIPP panel using survival analysis. Swartz, Marcotte, and McBride (1993a) used a hazard model of spell durations to estimate the relative effects of socio-economic and demographic characteristics on the duration of a spell without health insurance. They found that monthly family income, educational attainment, and industry of employment in the month prior to losing health insurance are the characteristics that have the greatest impact on the exit rate from being without health insurance. In particular, a low exit rate is positively correlated with low family income, low educational attainment, and employment in specific industrial sectors (agriculture/forestry/fishing and mining combined, construction, personal services and entertainment services combined, and public administration).
Monheit and Schur (1988) used the 1984 SIPP panel to examine various cohorts of the uninsured population. They did not, however, use survival analysis techniques. They found that the uninsured were heterogenous, consisting of many persons who lost coverage for relatively short periods of time, others who experienced periodic spells without coverage, and those who were persistently uninsured. The persistently uninsured, compared with all persons who lost coverage, were a much more economically disadvantaged group with far less labor market attachment and less access to employment related insurance. Monheit and Schur pointed out that longitudinal analyses of the uninsured are useful because the characteristics of the uninsured differ by spell length.
1. Almost all publicly insured children are insured by Medicaid. A small proportion of children are covered by state only programs.
2. We do not present the uninsured rate for infants because the Urban Institute reported uninsured rates for infants and pregnant women together.
3. That the median is 4 months is due in part to the pronounced "seam effect" in the reporting of health insurance status in the SIPP. Four months is the length of the reference period for each interview. Changes in insurance status are reported to occur disproportionately between interviews. In effect, most spells of fewer than 4 months duration and probably some with 5 or 6 month durations are reported in such a way that they appear to have exactly 4 month durations.
4. Wave 1 of the SIPP covered reference months between November 1989 and April 1990; wave 8 included months between February and August 1992.
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