Analysis of Transition Events in Health Insurance Coverage


Analysis of Transition Events in Health Insurance Coverage

August 2009

By: John L. Czajka and James Mabli Mathematica Policy Research

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The number of people lacking health insurance coverage in the U.S. is sustained by a set of dynamic processes. Comparatively few of the uninsured remain in that state indefinitely, but uninsured persons who gain coverage are offset by insured persons who lose their coverage. In good economic times the balance shifts toward the gainers, and uninsured rates tend to decline. In weak times, the balance shifts in the reverse direction, and uninsured rates tend to rise. Migration plays a role as well. New immigrants have much higher uninsured rates than long-term residents, but so do those who leave the population, which dampens the effect of immigration. Achieving a significant reduction in the number of uninsured persons will require reducing the rate at which people lose coverage or increasing the rate at which people (re)gain coverage  or, ideally, both. From a policy perspective, this should focus attention on the factors that contribute to people losing or gaining coverage, yet true longitudinal analyses of these factors are rare.

The study had four main components: (1) a literature review; (2) methodological work on the 2001 panel of the Survey of Income and Program Participation (SIPP) to identify and address limitations that represent potential sources of bias in estimates of health insurance dynamics; (3) a descriptive (or tabular) analysis of SIPP panel data to document aspects of the dynamics of health insurance coverage and (4) a multivariate analysis of events associated with transitions in health insurance coverage. The literature review and the methodological findings are presented in appendices to the report and not discussed in this summary.

Currently, the only version available of this report is the PDF version. We are working on the HTML version, which will be available shortly. If you need help accessing this report, please contact Don Oellerich, 202-690-8410.


Executive Summary



  1. Introduction
  2. Conceptual Framework and Questions Addressed
    1. Conceptual Framework
      1. Dynamics of Coverage
      2. Why Do People Experience Transitions in Coverage?
    2. Research Questions
      1. Profiling Insurance Coverage in a Longitudinal Context
      2. Understanding the Dynamics of Coverage
      3. Events Associated with Gaining or Losing Coverage
      4. Change in Health Insurance Dynamics Over Time
  3. Data Source
    1. The SIPP Design
    2. Strengths and Limitations of SIPP Panel Data
  4. Health Insurance Coverage Dynamics
    1. Analysis Sample
    2. Lack of Coverage Over Time
      1. How Many People Are Without Coverage?
      2. For How Long Are People Without Coverage?
      3. Change between the 1996 and 2001 Panels 38
      4. Multiple Spells
      5. Relative Income and Coverage Over Time
      6. Differential Coverage by Race and Ethnicity
    3. Transitions in Coverage
      1. Frequencies of Transitions
      2. Retention of Coverage by Source
      3. Coverage Before and After Uninsured Spells
      4. Duration of Insured Spells
    4. Trigger Events and Changes in Coverage
    5. Conclusion
  5. A Multivariate Analysis of Health Insurance Transitions
    1. Obtaining Coverage: Transitions out of the Uninsured State
      1. Sample and Methodology
      2. Empirical Findings
      3. Sensitivity Analyses
    2. Changing and Losing Coverage: Transitions into the Uninsured State
      1. Sample and Methodology
      2. Empirical Findings: Transitions out of the Insured State
      3. Empirical Findings: Transitions into the Uninsured State among Coverage Leavers
      4. Sensitivity Analyses
    3. Conclusion
  6. Conclusion: Policy Implications and Research Priorities
    1. Summary of Key Findings
    2. Policy Implications
    3. Priorities for research



  1. Literature Review
  2. Enhancements to the 2001 SIPP Panel Data


The authors would like to acknowledge the contributions of several individuals to the preparation of this report. We are especially grateful to Julie Sykes, Daisy Ewell, and Sandi Nelson, who constructed the analysis files and produced most of the estimates presented herein. We also wish to acknowledge and express our sincere thanks to James Reschovsky, who reviewed the draft of this report; Laura Castner, who answered numerous questions about the data; and Alfreda Holmes, who prepared the final manuscript.

Finally, we want to thank our Task Order Monitor, Don Oellerich, in the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, and Robert Stewart, his predecessor, now at the Congressional Budget Office, for providing helpful guidance throughout the project.

This report was prepared by Mathematica Policy Research, Inc. under contract to the Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS). The findings and conclusions of this report are those of the authors and do not necessarily represent the views of ASPE or HHS.


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