The Effects of Trigger Events on Changes in Children's Health Insurance Coverage. 3. Results by Type of Event

04/18/2000

Having reviewed our findings with regard to the overall frequency of possible trigger events, we now examine the frequency of individual types of events for each type of transition and for children whose coverage did not change.

Children Losing ESI. Table 10 presents estimates of the frequency of alternative events occurring in the past month among children who lost ESI--and became uninsured, obtained Medicaid, or obtained other insurance--and children who retained ESI. The cell entries indicate the percentage of children who experienced each event, where the base of the percentage is the total children in that column. 21 For example, in the first row we see that the proportion of children whose fathers lost employment in the past month was 9.2 percent among children who lost ESI and became uninsured, 2.5 percent among children who lost ESI and obtained Medicaid, 3.2 percent among children who lost ESI and obtained other insurance, and only .4 percent among children who remained covered by ESI. At the bottom of the table we have repeated from the first column of Table 8 the percentage of children who experienced any one of a set of events that we defined as relevant to each transition. These events are denoted by asterisks beside the individual event frequencies in the column corresponding to each type of transition. By repeating the summary frequencies here we underscore how the results presented in Table 10 are related to those presented in Table 8. In Table 8 we also reported how often any event from each of the sets identified in the first three columns occurred among children who remained covered by ESI, but those three frequencies are not repeated here.

TABLE 10: CHILDREN LOSING ESI VERSUS CHILDREN REMAINING COVERED BY ESI:
PERCENTAGE OF CHILDREN EXPERIENCING SELECTED EVENTS IN PAST MONTH
Event Coverage After Losing ESI Children
Remaining
Covered
by ESI
Uninsured Medicaid Other
Insurance
 
Father Lost Employment 9.2 * 2.5 * 3.2 * 0.4
Mother Lost Employment 7.9 * 9.3 * 5.0 * 0.9
 
Father Reduced Hours below 30 14.5 * 3.0 * 6.6 * 0.7
Mother Reduced Hours below 30 10.9 * 6.4 * 5.4 * 0.9
 
Father Changed Jobs 7.6 * 1.5   4.6 * 1.3
Mother Changed Jobs 5.1 * 1.6   0.9 * 1.3
 
Father Gained Employment 1.8   0.8   1.8   0.3
Mother Gained Employment 5.2   2.6   1.5   1
 
Father Increased Hours to 30 or More 4.1   0.8   2.6   0.8
Mother Increased Hours to 30 or More 3.6   3.1   2.0   1.3
 
Family Income Fell Markedly 23.1 * 13.6 * 20.9 * 4.2
Family Income Rose Markedly 9.7   11.4   16.7 * 4.3
 
Family Headship Changed 3.3 * 2.9 * 0.0   0.2
Family Size Increased 1.1   3.4   1.8   1.4
Family Size Decreased 6.1 * 4.1 * 3.5 * 0.9
 
Family Obtained AFDC 0.0   13.1 * 0.0   0.0
 
Any Relevant Event (Denoted by *) 46.7   29.3   46.6   --
 
SOURCE: Survey of Income and Program Participation, 1992 Panel.

Nearly all of the event variables occurred with substantially greater frequency among children who made one of the three transitions than among children who remained covered by ESI. Generally, the employment-related events occurred with the greatest frequency among children who moved from ESI to uninsured. This was true of job changes and reductions in the number of hours worked for either parent and a loss of employment for the father. The mother's loss of employment was as common among children who moved from ESI to Medicaid as it was among children who moved from ESI to uninsured.

Table 10 includes not only events that involved a reduction in employment but events that represented either a gain in employment (from unemployed or out of the labor force) or an increase in the hours worked to 30 or more. While it runs counter to expectation that increased employment should be associated with the loss of a child's ESI, employment gains nevertheless did occur more often among children who lost ESI than among children who remained covered by ESI--but not as often as employment losses. In the regression analysis reported later, however, where we looked at the impact of trigger events on changes in children's insurance coverage, we found no significant impact of the employment gains on transitions out of ESI.

The occurrence of marked declines in income among children losing ESI is consistent with the parents' changes in employment, but compared to children who remained covered by ESI the relative frequency of these events is lower than that of losses in employment or reductions in hours worked. Only 4 percent of the children who remained covered by ESI had a marked decline in family income over the preceding month while another 4 percent had a marked rise in income. Between 14 and 23 percent of the children who lost ESI showed marked declines in income while 10 to 17 percent showed marked increases. Again, the occurrence of a marked rise in income appears inconsistent with a loss of ESI, but in the regression analysis we will show that declines in income did not have a significant effect on the likelihood of a child's losing ESI.

Changes in the headship of the family (among one parent, two parents, or no parents) occurred much more often among children who lost ESI and became uninsured or enrolled in Medicaid than they did among children who remained covered by ESI. 22 Reductions in family size also occurred more often among children who became uninsured, enrolled in Medicaid, or obtained other insurance than among children who retained ESI.

Finally, near the bottom of Table 10 we report how often children's families obtained AFDC. To properly interpret these estimates, it is important to understand how the possible occurrence of a change in AFDC coverage is constrained by our limiting the observations to children with particular transitions in health insurance coverage and by the way we simplified the measurement of change over time, described earlier. Theoretically, all children covered by AFDC are covered by Medicaid as well. In the SIPP (and in the CPS), this relationship is forced by the Census Bureau's editing practices, which assign Medicaid coverage to all children who are reported to be receiving AFDC. A child who loses AFDC will not necessarily lose Medicaid, which does not require AFDC, but a child who obtains AFDC and was not already covered by Medicaid will always gain Medicaid coverage along with the AFDC. To be identified in Table 10 as obtaining AFDC, a child had to have had AFDC in month m. The only group for which this can be true is the group that left ESI for Medicaid. 23 We found that 13 percent of the children who made the transition from ESI to Medicaid obtained AFDC at the same time, and for these children it is correct to infer that their enrollment in AFDC explains their transition in insurance coverage. The remaining 87 percent of children who enrolled in Medicaid acquired Medicaid without AFDC. The loss of AFDC, on the other hand, could not have occurred in any of the four groups, since coverage in the prior month was always ESI.

Children Becoming Insured. For children who become insured after a period without insurance, we would expect that the role of parents' employment changes in helping to trigger such transitions would depend on the type of insurance that children acquired. Gains in employment or hours worked may provide access to ESI that did not exist previously, so we would expect to see evidence of recent gains in employment among children who obtained ESI. For children who obtained Medicaid, however, it seems unlikely that we would see much incidence of parents becoming re-employed or increasing their hours. Rather, transitions from uninsured to enrolled in Medicaid would be more likely to be preceded by a loss of employment than a gain--or a reduction in hours rather than an increase. The scenario we imagine is that of a parent whose employer does not offer affordable coverage but pays the parent well enough to make the child ineligible for Medicaid. The parent's subsequent loss of employment or reduction in hours may qualify the child for Medicaid.

The findings presented in Table 11 are generally consistent with these expectations. Among children who made the transition from uninsured to ESI, parents' gains in employment clearly dominated losses. For example, 7 percent of fathers gained employment, and 11 percent increased their hours to 30 or more while only 1 percent lost employment and 1 percent reduced their hours below 30. For children who became covered by Medicaid rather than ESI, gains in employment or hours worked--by either parent--appear to have occurred with somewhat less frequency than among children who obtained ESI. But employment losses or reductions in hours--particularly for the mother--were actually more common than they were among children who obtained ESI, and this is consistent with our speculation that among children who are without insurance, parents' employment losses may help to qualify their children for Medicaid.

Transitions from uninsured to other insurance present something of a puzzle. In this group employment losses by both parents occurred about as often as they did among children who enrolled in Medicaid and much more often than among those who remained uninsured. In these respects, the transitions from uninsured to other insurance resemble what we found for the Medicaid transitions and not what we would expect to find for transitions into privately purchased insurance.

TABLE 11: CHILDREN BECOMING INSURED VERSUS CHILDREN REMAINING UNINSURED:
PERCENTAGE OF CHILDREN EXPERIENCING SELECTED EVENTS IN PAST MONTH
Event Coverage After Becoming Insured
ESI Medicaid Other
Insurance
Children
Remaining
Uninsured
 
Father Lost Employment 1.4   2.4 * 7.9 * 1.1
Mother Lost Employment 1.4   8.1 * 6.0 * 1.5
 
Father Reduced Hours below 30 0.8   4.6 * 4.6 * 1.3
Mother Reduced Hours below 30 4.0   7.2 * 3.2 * 1.4
 
Father Changed Jobs 6.1 * 3.7 * 3.9 * 2.0
Mother Changed Jobs 2.8 * 4.9 * 4.3 * 2.0
 
Father Gained Employment 6.8 * 4.2   0.9   1.1
Mother Gained Employment 5.9 * 4.8   0.9   1.7
 
Father Increased Hours to 30 or More 11.2   4.3   3.8   1.7
Mother Increased Hours to 30 or More 7.2   5.9   2.2   1.9
 
Family Income Fell Markedly 5.8   13.7 * 30.3 * 6.0
Family Income Rose Markedly 22.4 * 13.5   10.4 * 6.6
 
Family Headship Changed 3.2 * 4.8 * 0.7   0.6
Family Size Increased 3.7 * 4.3   0.0   2.1
Family Size Decreased 0.3   5.0 * 0.7   1.8
 
Family Obtained AFDC 0.0   16.6 * 0.0   0.0
 
Any Relevant Event (Denoted by *) 38.6   41.2   49.7   --
 
SOURCE: Survey of Income and Program Participation, 1992 Panel.

Changes in family income differentiate among the transition groups more clearly than changes in parents' employment. Marked increases and decreases in income occurred with about the same frequency among children who remained uninsured--each about 6 percent. But among children who became insured we find distinctly different patterns. Children who obtained ESI were much more likely to show a rise in income (22 percent) than a decline (6 percent) while reductions occurred with the same frequency as increases (about 14 percent) among children who obtained Medicaid. Children who obtained other insurance, however, were three times as likely (30 percent) to have had a marked decline in income as a significant rise (10 percent). Since other insurance presumably costs the purchaser a substantial amount, it is counter-intuitive that a marked reduction in income should trigger exits from uninsured to other insurance.

Changes in family composition occurred more often among uninsured children who gained coverage through ESI or Medicaid than among children who obtained other insurance or remained uninsured. Changes in family headship and increases in family size occurred disproportionately among children who obtained ESI or Medicaid. Reductions in family size occurred with the same frequency as these other events among children who enrolled in Medicaid but not those who enrolled in ESI. Finally, the frequency with which uninsured families obtained AFDC indicates that this path accounted for about 17 percent of the children who enrolled in Medicaid.

Children Leaving Medicaid. The wish to understand why children leave Medicaid--frequently without other coverage--was one of the objectives motivating this research, but the findings presented in Table 12 do little to advance our understanding. About 17 percent of those who became uninsured and 12 percent of those who obtained ESI had left AFDC in the past month, compared to only 1 percent of those who remained covered by Medicaid. We might have expected gains in parents' employment to emerge prominently among children who left Medicaid for ESI, but while such gains were certainly more common among children who made transitions out of Medicaid than among children who remained in Medicaid, employment gains, increased hours, and job changes were no more common among the parents of children who moved from Medicaid to ESI than among those who moved from Medicaid to uninsured. Reflecting the composition of Medicaid families, gains among mothers were more important than gains among fathers, with 6 to 9 percent of the children who left Medicaid for any destination having a mother who gained employment or increased her hours. Job changes by either parent occurred in 3 to 5 percent of the cases. Among children who left Medicaid for ESI, fathers were as likely to have lost employment or reduced hours as to have gained employment or increased hours.

TABLE 12: CHILDREN LEAVING MEDICAID VERSUS CHILDREN REMAINING COVERED BY MEDICAID:
PERCENTAGE OF CHILDREN EXPERIENCING SELECTED EVENTS IN PAST MONTH
Event Coverage After Leaving Medicaid Children
Remaining
Covered
by Medicaid
Uninsured ESI Other
Insurance
 
Father Lost Employment 3.3   1.9   -- 0.6
Mother Lost Employment 3.8   3.4   -- 1.5
 
Father Reduced Hours below 30 3.5   1.4   -- 0.7
Mother Reduced Hours below 30 6.4   3.6   -- 1.1
 
Father Changed Jobs 5.0 * 4.8 * -- 1.2
Mother Changed Jobs 3.1 * 5.3 * -- 1.5
 
Father Gained Employment 3.6 * 2.1 * -- 0.7
Mother Gained Employment 6.6 * 6.5 * -- 1.9
 
Father Increased Hours to 30 or More 6.6 * 1.9 * -- 1.1
Mother Increased Hours to 30 or More 7.2 * 8.7 * -- 1.5
 
Family Income Fell Markedly 13.4   9.9   -- 4.0
Family Income Rose Markedly 12.7 * 18.0 * -- 4.4
 
Family Headship Changed 1.6 * 0.5 * -- 0.5
Family Size Increased 4.0 * 3.5 * -- 1.8
Family Size Decreased 1.9   1.7   -- 1.4
 
Family Lost AFDC 16.7 * 11.7 * -- 1.4
Family Obtained AFDC 0.0   0.0   -- 1.3
 
Any Relevant Event (Denoted by *) 41.6   34.1   -- --
 
SOURCE: Survey of Income and Program Participation, 1992 Panel.

NOTE: The sample size for children leaving Medicaid and obtaining other insurance (see Table 2A) is too small to support these tabulations.

Changes in family income reflected the mixed results of families losing AFDC and families gaining employment. Both losses and gains in income occurred more often among children who left Medicaid than among children who remained, with income gains outpacing losses by 18 to 10 percent among children who obtained ESI while gains and losses occurred with equal frequency--about 13 percent each--among those who became uninsured. Changes in family composition were little more likely among children leaving Medicaid than among those who remained.

Children Leaving Other Insurance. On the assumption that other insurance is generally privately purchased insurance, we would expect that children who leave such coverage tend to do so when their parents gain employment or change jobs, giving them access to ESI, or when their family income falls, making it difficult to sustain the costs of private insurance. The findings presented in Table 13 generally support these expectations, but we see less differentiation than we would have anticipated between children who left other insurance for ESI and those who simply became uninsured. The fathers of children who became uninsured were much more likely to lose employment or reduce their hours of work than the fathers of those who remained covered by other insurance or obtained ESI, but the fathers and especially the mothers of children who became uninsured were also more likely to gain employment than the parents of the other two groups of children. More consistent with our expectations, children who moved from other insurance to ESI were the most likely to have parents who changed jobs or increased their hours of work to 30 or more.

Both increases and reductions in family income were more common among children who left other insurance than those who remained. Children who became uninsured were somewhat more likely to have had marked reductions in income than those who obtained ESI (22 percent versus 15 percent) or retained other insurance (6 percent), but gains were about equally common among children who became uninsured (25 percent) or obtained ESI (22 percent) and much higher than for those who remained covered by other insurance (7 percent). It is difficult to interpret the complete loss of coverage among children who left other insurance despite rising family income. Table 3 showed that 10 percent of the children who made the transition from other insurance to uninsured were covered by ESI shortly thereafter; for these children the loss of coverage was merely transitional and may reflect waiting periods for ESI to become effective. For the others it is simply not clear what may have happened, but understanding such transitions is important to understanding and addressing the problem of uninsurance among children in the United States.

Increases in family size and changes in family headship were marginally more common among children who became uninsured than among those who obtained ESI or retained other insurance. Oddly, when we look back six months (Table A.5) we find that 20 percent of the children who became uninsured had experienced a reduction in family size compared to only 3 percent of those who remained covered by other insurance and less than 1 percent among those who obtained ESI. There is no hint of this in Table 13, which adds to the general ambiguity surrounding the impact of changes in family composition on transitions in children's health insurance coverage.

TABLE 13: CHILDREN LEAVING OTHER INSURANCE VERSUS CHILDREN REMAINING COVERED: PERCENTAGE OF CHILDREN EXPERIENCING SELECTED EVENTS IN PAST MONTH
Event Coverage After Leaving Other Insurance Children
Remaining
Covered
by Other
Insurance
ESI Uninsured Medicaid
 
Father Lost Employment 1.0   5.5 * -- 0.4
Mother Lost Employment 0.9   0.0 * -- 1.0
 
Father Reduced Hours below 30 0.9   7.5 * -- 0.7
Mother Reduced Hours below 30 2.3   3.5 * -- 0.6
 
Father Changed Jobs 6.0 * 2.2 * -- 1.6
Mother Changed Jobs 5.2 * 3.0 * -- 1.0
 
Father Gained Employment 2.7 * 7.2 * -- 0.3
Mother Gained Employment 3.2 * 14.0 * -- 1.1
 
Father Increased Hours to 30 or More 9.7 * 4.8   -- 0.9
Mother Increased Hours to 30 or More 6.8 * 1.2   -- 1.0
 
Family Income Fell Markedly 14.9   22.4 * -- 6.2
Family Income Rose Markedly 22.4 * 24.7 * -- 7.0
 
Family Headship Changed 0.7 * 3.1 * -- 0.3
Family Size Increased 2.8 * 4.0 * -- 1.6
Family Size Decreased 0.4   2.0   -- 1.2
 
Any Relevant Event (Denoted by *) 44.3   48.1   -- --
 
SOURCE: Survey of Income and Program Participation, 1992 Panel.

NOTE: The sample size for children leaving other insurance and enrolling in Medicaid (see Table 2A) is too small to support these tabulations.

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