Analysis of Children's Health Insurance Patterns: Findings from the SIPP. E. Conclusion

05/12/1999

This report has used data from the 1992 panel of the SIPP to examine demographic and socioeconomic differentials in the patterns of health insurance coverage among children under 19. Health insurance coverage among children varies by nearly every demographic and socioeconomic characteristic that we examined. Most of the differentials that we observe in the type of insurance coverage and whether there is any coverage at all are moderately strong to very strong. For example, Hispanic children are more than two-and-a-half times as likely to be uninsured as white non-Hispanic children, and black children are four times as likely as white children to be covered by Medicaid.

Because of Medicaid, coverage patterns are not unidimensional. Groups with low rates of employer-sponsored coverage do not necessarily have high rates of uninsurance. High rates of Medicaid coverage can appear among groups with high uninsurance or moderately low rates of uninsurance. Nevertheless, the strongest differentials by far are those associated with parents' education, and these differentials are strikingly unidimensional.

We estimate that one-third of the children uninsured in September 1994 were eligible for Medicaid, based on a Medicaid eligibility simulation that takes account of most but not all of the ways that children may become eligible. There are sizable differentials in Medicaid eligibility across most of the demographic and socioeconomic characteristics that we examined. Differentials in Medicaid eligibility among the uninsured are strongest by family poverty level, followed by the child's age and parents' employment.

Over all eligible children, the estimated Medicaid participation rate is 65 percent. This participation rate does not reflect any adjustment for the underreporting of Medicaid participation in the SIPP, which in 1994 was on the order of 24 percent. If we exclude from the eligible nonparticipants those who were covered by insurance other than Medicaid, however, the participation rate rises to 79 percent. Differentials by demographic characteristics are largely eliminated when the participation rate is defined in this alternative way, and socioeconomic differentials are greatly reduced.

Generally, differentials in the proportion of children ever uninsured during the year are similar in form to differentials in the percentage uninsured at a point in time. Only for race and ethnicity and region did we find that groups were arrayed differently with respect to their likelihood of being uninsured. Distributions of the uninsured by demographic or socioeconomic characteristics differ very little between the point-in-time and annual-ever measures.

The duration of new spells of uninsurance shows little variation by demographic characteristics or parents' employment. There is modest variation in spell length by poverty level and moderately strong variation by parents' education, however. Spell lengths decline with parents' education.

The current duration of active, or ongoing, spells--that is, how long uninsured children have been without coverage--is of interest recently because a number of states are planning to limit eligibility under their CHIP initiatives to children who have been uninsured for some minimum number of months--as many as 12 months. It appears that such restrictions favor the group that is the principal target of CHIP: children between 100 and 200 percent of poverty. This is the one subgroup whose share of the uninsured clearly increases with duration.

We also examined the insurance coverage of children's parents. Between 18 and 21 percent of uninsured children have an insured parent. This suggests that a nontrivial number of parents may be choosing individual coverage but not family coverage--perhaps because family coverage is not offered or is perceived as too expensive. Measurement error may account for part of this finding as well. Parents may report their own coverage but overlook the coverage that extends to their children. This seems particularly likely for the 7 percent of uninsured children who report that a parent is covered by Medicaid. Among children who are themselves reported to be covered by Medicaid, 10 percent have an uninsured parent. This latter is consistent with the child-only eligibility created by the poverty-related expansions of Medicaid in the late 1980s and 1990s.

Finally, to provide detailed information on life cycle patterns of coverage among children, we estimated the frequency with which children experienced periods of uninsurance, with and without Medicaid-eligibility, during each single year of age. We also estimated the frequency with which children experienced periods of reported Medicaid enrollment. Both the probability of being uninsured and the average number of months uninsured among those with any months of uninsurance increase with age. The likelihood of being uninsured for all 12 months shows a particularly strong relationship with age. The probability of being uninsured and eligible for Medicaid has little relationship with age, however, being relatively constant from infancy through age 9 and then dropping a few percentage points to a level that remains essentially fixed through age 18. The average number of months of Medicaid-eligible uninsurance is relatively constant across the entire age range as well. By contrast, uninsurance without Medicaid eligibility is even more strongly associated with age than uninsurance in general. The estimates of Medicaid participation by single year of age make clear the prominent role of Medicaid as a source of coverage among infants and the increasingly smaller role that Medicaid plays as children grow older. As more children become eligible for the federally mandated coverage for children below the poverty line who were born after September 30, 1983, however, these age differentials will gradually diminish.

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