Children's Health Insurance Patterns: A Review of the Literature. 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.

  Privately Insured

(n=47.0 million)

Publicly Insured

(n=18.8 million)


(n=9.8 million)

  (percentage of children within coverage category)
Age 0 to 1 4.5 7.3 6.7
Age 1 to 5 26.8 35.0 26.5
Age 6 to 12 39.5 36.9 38.4
Age 13 to 17 29.2 20.8 28.4
White 76.3 42.9 49.4
Black 10.5 29.1 17.5
Hispanic 8.4 21.4 28.2
Other 4.8 6.5 4.9
  (percentage of children within race category)
White 77.9 17.5 10.5
Black 44.1 48.7 15.3
Hispanic 38.3 39.0 26.8
Other 62.4 33.8 13.3
  (percentage of children within coverage category)
Noncitizens 2 4 10
Single-parent families 20 56 38
Families with incomes below 200% of poverty 25 79 70
At least one parent employed 98 68 89
At least one parent employed full-time, full-year 88 38 64
At least one uninsured parent - - 80
At least one parent with employment-based insurance 92 - 16
At least one parent with a college degree 32 8 11
Source: Fronstin (1996); Fronstin (1997a).

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.

Age Total Children
Percent Uninsured
Urban Institute EBRI
1 to 5 20.5 8.3 12.7
6 to 12 27.5 10.2 13.8
13 to 17 19.3 13.0 14.5
Source: Holahan (1997) and Fronstin (July 1997).

Note: The Urban Institute's findings are adjusted for Medicaid undercount using the TRIM2 microsimulation model.

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.