Other than children who are uninsured at birth, children who begin spells of uninsurance do so by losing previous coverage. What is the source of this coverage? Does it mirror the coverage of all insured children, or do the uninsured come disproportionately from former Medicaid enrollees? Similarly, when children regain coverage do they resemble the rest of the insured population with respect to the sources of this coverage or do they rely on a different mix of sources? And do children tend to return to the same type of coverage that they had prior to their spell of insurance, or do they often end up with another source of coverage? We address these questions by comparing the source of coverage before and after completed spells of uninsurance. We also examine how these answers differ by the duration of spells of uninsurance. After addressing these question with respect to spells of uninsurance, we examine spells of Medicaid-eligible uninsurance to determine what precedes and follows these spells. Here, however, a spell need not be preceded by coverage; instead a child may enter a spell of Medicaid-eligible uninsurance from the state of having been uninsured but not eligible for Medicaid, and may leave a spell of Medicaid-eligible uninsurance by losing Medicaid eligibility without regaining any form of coverage.
1. Spells of Uninsurance
Table 5 presents for spells of uninsurance of various durations a cross-tabulation of insurance coverage in the month before the spell began by insurance coverage in the month after the spell ended (that is, the first month of coverage). Separate tabulations are reported, first, for all spells completed in 1 to 12 months, followed by tabulations of spells completed in 1 to 4 months, 5 to 8 months, and 9 to 12 months. A tabulation of spells completed in 13 to 18 months, derived from spells that started in just the first half of FY93, is reported at the bottom of the table. We did not pool this subset of spells with those completed in 12 months or less because the spells of longer duration would be underrepresented in the pooled tabulation.5
The estimates reported in each subtable are percentages of the total number of spells in each duration group. Thus the percentages in the total column at the right give the distribution of insurance coverage prior to the spell of uninsurance; the percentages in the total row beneath each subtable give the distribution of insurance coverage after the spell of uninsurance; and the percentages inside the row and column margins give the distribution of spells by combinations of prior and subsequent insurance coverage.
For all spells of uninsurance completed in 12 months or less, 54 percent were preceded by employer-sponsored coverage, 39 percent were preceded by Medicaid, 4.5 percent were preceded by another form of coverage, and 2.5 percent were experienced by children who were not in the survey universe prior to the spell. These last would be newborns who were without health insurance at birth. The distribution of sources of coverage following a spell of uninsurance is very similar to the distribution prior to the spell, with 53 percent being covered by an employer-sponsored plan, 40 percent by Medicaid, 5 percent by another type of plan, and 1.6 percent leaving the survey universe.6
In October 1992, based on these same data, about 19 percent of insured children were covered by Medicaid, 76 percent by an employer-sponsored plan, and 5 percent by another type of plan. Thus the frequency of Medicaid as the source of coverage before and after a spell of uninsurance lasting 12 months or less is more than double the frequency of Medicaid among all insured children. Coverage other than Medicaid or an employer-sponsored plan occurs with about the same frequency among all insured children as among those who later or previously experienced spells of uninsurance, while employer-sponsored coverage occurs with lower frequency before or after a spell of uninsurance than it does among all insured children.
The similarity of the distributions of sources of coverage before and after spells of uninsurance does not necessarily mean that children end their spells of uninsurance by returning to the same coverage that they lost to begin their spells, but we see from the cross-tabulation of coverage before and after uninsurance that the two sources are clearly not independent. For all spells of uninsurance completed in 12 months or less, 28 percent were preceded and followed by Medicaid enrollment, and 42 percent were preceded and followed by employer-sponsored coverage. About 9 percent of children changed from employer-sponsored coverage to Medicaid, and somewhat fewer children made the reverse transition.
Among spells completed in 12 months or less, we see little variation in these basic patterns by duration. But spells completed in 13 to 18 months present a very different picture, showing an even greater prominence of Medicaid. Prior to a spell lasting 13 to 18 months, 48 percent of the children were insured by Medicaid and 52 percent by an employer-sponsored plan. We found no incidence of other sources of coverage and no children who remained uninsured for 13 months past their births. Following a spell of 13 to 18 months, 57 percent of children enrolled in Medicaid compared to 32 percent becoming covered by an employer-sponsored plan. Medicaid was the source of coverage both before and after a long spell of uninsurance among 38 percent of the children who experienced such spells. Employer-sponsored coverage preceded and followed 22 percent of these spells--barely half the percentage among shorter spells. Children who left a spell of uninsurance that was preceded by employer-sponsored coverage were almost as likely to end their spells by acquiring Medicaid coverage as employer-sponsored coverage, and other coverage was nearly half as common as Medicaid. A possible explanation for the differential importance of Medicaid by duration is that parents who lose employer-sponsored coverage tend to defer pursuing other coverage for their children because they expect to regain employer-sponsored coverage. If they are unable to regain employer-sponsored coverage within a year or so, they try to obtain Medicaid. It could be, as well, that many of these children did not qualify for Medicaid in the months after employer-sponsored coverage was lost and became eligible only after their parents spent down savings and other resources.
2. Spells of Medicaid-Eligible Uninsurance
A spell of uninsurance in which a child is eligible for Medicaid can begin or end with the child losing Medicaid eligibility without regaining insurance coverage. Table 6 presents cross-tabulations of coverage before and after spells of Medicaid-eligible uninsurance, but it differs from Table 5 in that it includes uninsurance without Medicaid eligibility as a status before and after a spell.
Nearly one-half of children who experienced spells of Medicaid-eligible uninsurance lasting 12 months or less were uninsured but ineligible for Medicaid before beginning their spells, and 31 percent left spells of Medicaid-eligible uninsurance by losing their Medicaid eligibility. Medicaid enrollment preceded 27 percent of the spells of Medicaid-eligible uninsurance and followed 31 percent of them. Only 19 percent of children who experienced spells of Medicaid-eligible uninsurance were covered by employer-sponsored insurance immediately prior to their spells, and just under 15 percent gained employer-sponsored coverage to end their spells. Uninsurance without Medicaid-eligibility bracketed 34 percent of the 1 to 12 month spells of Medicaid-eligible uninsurance while actual Medicaid enrollment bracketed 16 percent of the spells. Employer- sponsored coverage preceded and followed only 6 percent of spells.
As we have seen, spells of Medicaid-eligible uninsurance tend to be quite short, so the spells completed in 12 months or less are dominated by spells completed in 1 to 4 months. The pattern of coverage before and after spells of Medicaid-eligible uninsurance changes dramatically as the duration of these spells increases. Until durations of 13 months or longer the changes are largely confined to the distribution of coverage prior to the spell of Medicaid-eligible uninsurance. Medicaid enrollment becomes more important than Medicaid ineligibility, accounting for more and more of the coverage prior to such spells. Among spells completed in 13 to 18 months, 43 percent began with children leaving Medicaid enrollment compared to 31 percent that started with uninsured children becoming Medicaid-eligible. The reverse trend occurred for the source of coverage following a spell of Medicaid-eligible uninsurance, although there are minimal changes between spells of 1 to 4 month duration and spells of 9 to 12 month duration. Among the longer spells, 65 percent ended with children losing Medicaid eligibility but remaining uninsured. Only 6 percent of the children gained employer-sponsored coverage while 29 percent enrolled in Medicaid.
In looking at the combinations of coverage that precede and follow 13 to 18 month spells of Medicaid-eligible uninsurance, we find that 29 percent of these spells are bracketed by Medicaid enrollment and 31 percent are bracketed by uninsurance without Medicaid eligibility. We found no instances of children having employer-sponsored coverage both before and after a spell of Medicaid- eligible uninsurance. All of the children who lost employer-sponsored coverage to become uninsured but eligible for Medicaid ended their spells by losing their Medicaid eligibility rather than enrolling in Medicaid. This is quite different from what we observed with all spells of uninsurance, but we cannot tell from Table 6 what may have happened to these children after losing Medicaid eligibility. Many of them may have gained employer-sponsored coverage, and some could have regained Medicaid eligibility and become enrolled. Finally, in viewing the bottom panel of Table 6 we need to keep in mind that, according to Table 4, these spells account for less than four percent of all spells of Medicaid-eligible uninsurance that began in FY93.