In this section we examine differentials in children's health insurance coverage by five demographic characteristics: age, race and ethnicity (specifically, Hispanic origin), family composition, metropolitan residence, and region. The findings describe children in September 1994. Before presenting our findings we describe our measurement of the five characteristics and show how the population of children is distributed with respect to each of these characteristics.
a. Distribution of the Population
Table 2 presents the distribution of all children by the demographic characteristics that will be used to examine differentials in insurance coverage.
We divide children 0 through 18 into six age groups, using breaks that are relevant to Medicaid eligibility and, therefore, insurance coverage as well: infant, 1 to 5, 6 to 8, 9 to 10, 11 to 14, and 15 to 18. We separate the 9 to 10 group because these children phased into coverage under the poverty-related criteria over the two fiscal years that we examine. Specifically, none of the children aged 9 to 10 at the end of FY92 qualified for poverty-related coverage under the mandatory federal guidelines whereas all of these children met the age limit for poverty-related coverage by the end of FY94. Children 1 to 5 and 11 to 15 each account for 27 percent of the children under 19 represented by the SIPP panel in September 1994. Infants account for 4 percent while the other age groups include between 10 and 16 percent of all children.
We divide children into four categories on the basis of race and ethnicity. White non-Hispanic children account for 68 percent of the total. Black non-Hispanic children are 15 percent of the total while Hispanic children represent about 13 percent, and children of other racial groups--Asian and Pacific Islander and American Indian, Eskimo, and Aleut account for the remaining 4 to 5 percent.
We define family composition in terms of which parents are present in the household. Children living with both parents account for 72 percent of all children while children with only their mothers present represent 24 percent. The remaining four percent are divided evenly between children living with their fathers and children with no parent present. The latter will include older teens living on their own or with friends as well as younger children being raised by relatives or others who are not their natural or adoptive parents.
The SIPP files do not identify rural residents explicitly, so we have used metropolitan area residence to differentiate between a group including primarily urban children and a group including primarily rural children. The metropolitan category includes 74 percent of children while the non-metropolitan category includes 25 percent. The SIPP files assign 1.2 percent of children to a "not applicable" category, which is a Census Bureau designation that is not defined.
We used the census region classification to break down children by region of the country. The nine census regions and the states they include are:
New England: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut
Middle Atlantic: New York, New Jersey, and Pennsylvania
East North Central: Ohio, Indiana, Illinois, Michigan, and Wisconsin
West North Central: Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas
South Atlantic: Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, and Florida
East South Central: Kentucky, Tennessee, Alabama, and Mississippi
West South Central: Arkansas, Louisiana, Oklahoma, and Texas
Mountain: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, and Nevada
Pacific: Washington, Oregon, California, Alaska, and Hawaii
While the SIPP file does not individually identify nine of the 50 states, leaving us to randomly assign children in each of three groups to individual states, only one of these nine states is not grouped with others from the same region.
Four of the nine regions include between 14 and 18 percent of the child population, with the East North Central region being the largest. Two of the regions--New England and the Mountain region--include less than 5 percent of children under 19. The remaining three account for 7 to 11 percent of all children.
b. Distribution of Insurance Coverage
Table 3 presents for each of the five demographic characteristics the distribution of insurance coverage by subgroup.
The inverse relationship between age and Medicaid coverage and the direct relationship between age and uninsurance are striking, but it is important to keep in mind the generally antecedent role of employer-sponsored and other insurance. The older the child, the more likely that the child is covered by either employer-sponsored or other insurance (generally privately purchased or public insurance other than Medicaid). The 71 percent of children 16 to 18 who are covered by either of these sources contrasts with 64 percent of infants and 65 percent of children 1 to 5. Among those children who might otherwise be uninsured, Medicaid is much more likely to be utilized by younger children (who are more likely to be eligible) than older children. At the extremes, Medicaid covers nearly three-quarters of the infants who lack other coverage but less than half of the 16- to 18-year- olds who, similarly, have no other coverage. The percentage of all children covered by Medicaid in each age group varies from 12 percent among children 16 to 18 to a maximum of 26 percent among infants, with the proportion rising monotonically as age decreases. The frequency of uninsurance, conversely, rises from 9 percent among infants to 16 percent among children 16 to 18.
There are very strong differentials by race and ethnicity (Hispanic origin). Non-Hispanic whites have the highest rate of coverage by employer-sponsored plans at 74 percent and the lowest rates of Medicaid coverage (about 11 percent) and uninsurance (10 percent). Non-Hispanic blacks have the highest rate of Medicaid coverage at 44 percent or four times the rate among whites. Blacks also have the second lowest coverage by employer-sponsored plans at 42 percent, but the rate of uninsurance among blacks is only 2.5 percentage points above that of whites. Hispanics report the highest rate of uninsurance by far at 26 percent, with the lowest rate of coverage by employer-sponsored plans, but 34 percent report Medicaid coverage--a rate that is three times that of non-Hispanic whites. In all coverage groups but other insurance the other races category falls between non-Hispanic whites and Hispanics--generally closer to whites. While coverage by other than employer-sponsored plans or Medicaid is quite low at 4 percent nationally, non-Hispanic whites and other races report much higher coverage--between 5 and 6 percent--than do Hispanics and non-Hispanic blacks.
Differentials by family composition are as great as those by race and ethnicity. Children with both parents present have the highest rates of employer-sponsored and other coverage at 75 percent and 5.0 percent, respectively, and the lowest rates of Medicaid coverage and uninsurance: 8.5 percent and about 12 percent. At the opposite end, children with no parent present have the lowest rate of employer coverage at 27 percent--barely one-third the rate for children with both parents present--and the highest rate of uninsurance at 23 percent or double that of children with both parents present. Children with no parent present share the highest rate of Medicaid coverage with children in mother- only families, at 47 to 48 percent. Children in mother-only families have a much lower rate of uninsurance than children in father-only or no-parent families. Compared to children with no parent present, children in mother-only families have a higher rate of employer-sponsored coverage. Compared to children in father-only families, children in mother-only families are covered by Medicaid at a rate that more than compensates for their lower employer-sponsored coverage.
Differences by metropolitan residence are marginal at best. Children in non-metropolitan areas have a higher rate of uninsurance by two percentage points. Their lower rate of employer-sponsored coverage is partially offset by marginally higher coverage rates for Medicaid and other insurance. Children who could not be classified as metropolitan or not are too few in number for their coverage rates to provide meaningful information, but their rates of employer-sponsored coverage and uninsurance are strikingly similar to those of non-metropolitan children.
Finally, regional differences in rates of uninsurance are quite substantial. New England has the lowest rate at 7.1 percent while the West South Central region has the highest rate at 22 percent or three times the rate observed in New England. In general, rates of uninsurance are highest in the South and the West. Much of the latter, we suspect, can be attributed to the high proportion Hispanic in the Western states. The role of Medicaid in these regional differences in rates of uninsurance is ambiguous--no doubt because higher than average rates of Medicaid participation can reflect either or both the prevalence of poverty and broader eligibility criteria. Employer-sponsored coverage varies over a range of 20 percentage points, with New England having the highest rate of coverage and the Pacific states having the lowest, followed closely by the East and West South Central states.
c. Distribution of Demographic Characteristics within Coverage Groups
Table 4 is a recasting of Table 3 with column percentages instead of row percentages. For each demographic characteristic it shows the percentage distribution of demographic subgroups within each class of insurance coverage. Distributions of demographic subgroups within coverage groups are of interest insofar as they indicate that the members of a particular coverage group--such as the uninsured--have a markedly different demographic composition or profile than other coverage groups. Such distributions are of value in determining how much of a specific deficiency in coverage could be addressed by a targeted strategy focusing on certain subgroups. In general, sizable differentials in coverage by demographic or other characteristics imply sizable differences in the profiles of coverage groups--and vice versa. When coverage differentials are confined to differences between small subgroups and the balance of the population, however, the profiles of different coverage groups may appear very similar. The absence of large differences in the profiles of the various coverage groups does not imply that the differentials are unimportant, necessarily, but it does indicate that a narrowly targeted policy will not have much impact on overall coverage.
Age distributions differ little across the coverage groups except for Medicaid, where children under 6 account for 42 percent of children reporting Medicaid coverage but only 25 to 29 percent of each of the other three insurance classes. Clearly the age profile of Medicaid enrollees is different from that of children with other sources of coverage--or no coverage at all--but these other coverage groups differ little from each other in their age composition. Racial composition varies substantially across the coverage groups, however. Hispanic children represent 26 percent of the uninsured and 23 percent of Medicaid enrollees but only 8 percent of children covered by employer-sponsored plans. Non-Hispanic blacks account for 35 percent of Medicaid enrollees but less than 15 percent of the uninsured and 10 percent of children with employer-sponsored plans. Non-Hispanic white children dominate every group except Medicaid enrollees. They account for more than half of the uninsured and more than three-quarters of those with employer-sponsored coverage but only 38 percent of the Medicaid population.
The impact of group size is evident for family composition as well. While children in two-parent families have the lowest incidence of uninsurance, they nevertheless account for 65 percent of all uninsured children. Children from mother-only families dominate Medicaid due to the eligibility rules for families. They account for 60 percent of Medicaid enrollees compared to only 13 percent of those with employer-sponsored coverage. The father-only and no-parent groups do not account for more than 6 percent of any coverage group.
The only group in which children from non-metropolitan areas account for noticeably more than their share of all children is other insurance, where they represent 34 percent of the total versus 24 to 28 percent for other coverage groups. Finally, while individual regions account for varying shares of the different coverage groups, the variation across coverage groups is generally modest. Perhaps the most notable exception occurs in the West South Central region, which accounts for less than 9 percent of Medicaid enrollees but more than 18 percent of the uninsured.