A Research Focus of the Urban Institute
Broader access to public health insurance programs has kept the number of Americans without coverage from skyrocketing, but uninsurance rates are still rising. Urban Institute health experts explain why.
About the Research
The number of uninsured Americans increased by 2.1 million in 2006, bringing the total number of non-elderly uninsured to 46.5 million. Premiums are rising and employer-based coverage is dropping at all income levels, leaving many Americans in a tough bind.
While Medicaid and the State Children's Health Insurance Program helped to cover low-income children who lost access to employer-sponsored coverage in 2006, the same was not true for children in middle-income families, for whom access to Medicaid and SCHIP is scarce. As a result, almost half of the increase in uninsured children was in families with incomes between 200% and 399% of the federal poverty level (about $40,000 to $80,000 for a family of four).
Employer-sponsored coverage among adults declined most among those with incomes less than 200% of the federal poverty level (less than $40,000 for a family of four). Because public coverage is generally not available to adults, almost half of the increase in uninsured adults occurred among those with low-incomes, leaving their families at greater risk for being uninsured. Read more in What Happened to Health Insurance Coverage of Children and Adults in 2006?
What's New
Massachusetts's legislators passed, and Governor Mitt Romney signed, a law in spring 2006 that requires all state residents to have health insurance coverage by July 2007. The state will subsidize insurance premiums for the poorest residents. The expansion of the government's role was one of the three policy options outlined by UI researchers in Roadmap to Coverage, an initiative to provide universal coverage for Massachusetts' residents.
For some, Medicare is a model of what national health insurance could be in the United States. In Medicare: A Policy Primer (UI Press, 2006), Marilyn Moon explains what Medicare is, how it works, and where it's headed. She examines the problems facing the program and which reform options hold the most promise. She also examines the history of Medicare and how the program works in the broader context of health care, the federal government, and the economy.
Preliminary findings from a survey of parents with children enrolled in the Los Angeles Healthy Kids program reveal that the initiative is improving children's access to primary care and easing parents' concerns about meeting their children's health care needs. The Healthy Kids program, launched in Los Angeles County in July 2003, aims to extend universal coverage to children in families with incomes below 300 percent of the federal poverty level. A July 2006 UI brief offers an early evaluation.
Health Insurance Tax Incentives: The Cure or the Disease?
The United States spends $200 billion each year on tax incentives for health insurance. Yet 46.6 million people lack health coverage. President Bush has proposed tax incentives tied to high-deductable health insurance plans and health savings accounts; critics would retarget tax incentives to favor low-income households and small businesses. Panelists examined the issues to divine the best course of treatment for the nation's failing health care system.
Listen to the audio files
Recent Findings
Below are results from our recent studies, reports, articles, and books.
Hispanics, those without citizenship fare the worst as rates of health insurance coverage decline.
The latest figures show 46.6 million Americans without health insurance. Most are low income. More alarming, the majority of these uninsured people either worked (at least part time) or lived in a working family, which means that a main culprit for no coverage was the drop in employer-sponsored insurance. The rise in uninsurance has also been attributed to rising health care costs, the economic downturn, and public program cutbacks.
The importance of high costs as a reason for being uninsured has risen rapidly, growing steadily for both adults and children. Although cost is an important issue for all populations, costs concerns were most prevalent among Hispanics, noncitizens, and those likely to face the highest cost -- the aging and the disabled.
For more information:
Affording health insurance has become a problem for many American workers.
Even having to pay very small contributions to health insurance policies can deter workers from joining. In fact, about 20 percent of all uninsured people live in families where a worker has declined employer-sponsored insurance coverage, with two-thirds citing cost as the culprit. For many, the decision to purchase health insurance must compete with the need for food and housing.
The costs of private health insurance have risen dramatically relative to both workers' earnings and general inflation. In the past three years, insurance premiums have increased between 10.9 and 13.9 percent annually, while workers' wages have grown between 2 and 3 percent annually. Further, the share of the insurance premium paid by employers has been shrinking.
While the costs of health care are a burden for all adults, it hits those with limited means the hardest. Nearly three-quarters of low-income adults reported some difficulty obtaining health coverage, well above the 31 percent reported by the moderate- and higher-income adults. As a result, 44 percent of low-income adults were uninsured at some point during 2002, compared with only 13 percent of moderate- and higher-income adults.
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The number of children without health insurance declined dramatically between 1999 and 2002.
In sharp contrast to their parents, children—especially those in low-income families—have experienced gains in insurance coverage. In 2002, 7.8 million children were uninsured, a decline of 1.8 million from 1999. More than half of those uninsured children appear eligible for Medicaid or the State Children's Health Insurance Program (SCHIP)—the two public insurance programs responsible for providing coverage to 47.6 percent of low-income children. Employer-sponsored coverage served 32 percent of low-income children.
Despite the gains, nearly one in five children living in poverty lacked insurance coverage in 2002. An uninsured child is more likely to go without proper care. The 2002 National Survey of America's Families, analyzed by Urban Institute health experts, found that uninsured children are missing out on medical treatments they could receive if they were enrolled in Medicaid or SCHIP. The survey shows that over half of all uninsured children have not had a well-child visit in the past year.
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Awareness of public health insurance programs for children is growing.
Established in 1997, the State Children's Health Insurance Program provides states the authority and funding to expand health insurance coverage to low-income children by broadening Medicaid eligibility, developing new child health programs, or a combination of both. Over time, states have streamlined the application process and invested heavily in efforts to publicize the program. Between 1999 and 2002, the share of low-income uninsured children whose parents had heard of their state's separate SCHIP program increased from 47.2 percent to 70.6 percent. There was little change in awareness of the much more established Medicaid program during that time period.
Despite this progress, however, many families remain confused about the relationship between welfare and Medicaid/SCHIP, a finding consistent with other recent data showing that many low-income parents do not know that their uninsured children could qualify for public coverage. Among families familiar with these public health insurance programs, 81.7 percent of low-income uninsured children had parents who said they would enroll their child if told the child was eligible.
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Racial and ethnic disparities in children's health insurance coverage persist, despite overall gains.
Expanded Medicaid eligibility and the creation of the SCHIP program increased public coverage of black, white, and Hispanic children between 1997 and 2002. Yet, during that same time period, Hispanic children were consistently more likely to be uninsured and in fair or poor health than black or white children. Black children, in turn, were more likely to be uninsured and in fair or poor health than white children. In 2002, 20 percent of Hispanic children were uninsured compared with 9 percent of black children and 7 percent of white children.
Further, more than one in five citizen children in low-income mixed-status families remained uninsured in 2002—a rate 74 percent higher than that of children with citizen parents, although the federal government had made it clear that receipt of health benefits would not jeopardize the naturalization of immigrant family members. Indeed, efforts by many health and social service providers across the country to expand their Spanish-speaking staff has led to some gains in public coverage of citizen children in Spanish-speaking families.
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For more Urban Institute research on Immigration, see Immigration Studies.
The Research Team
Many Urban Institute researchers contribute to analyses on health care and the uninsured. They are
- Linda J. Blumberg, senior research associate, an expert in health care fiscal issues, Medicaid, and private health insurance;
- Randall R. Bovbjerg, principal research associate, an expert on private health insurance;
- Teresa A. Coughlin, senior research associate, an expert on Medicaid and uninsured/uncompensated care;
- Lisa C. Dubay, senior research associate, an expert on the State Children's Health Insurance Program;
- Jack Hadley, principal research associate, an expert on the uninsured;
- Ian Hill, senior research associate, an expert on Medicaid and the State Children's Health Insurance Program;
- John F. Holahan, center director, an expert on health care fiscal issues, Medicare, Medicaid, and uninsured/uncompensated care;
- Embry M. Howell, principal research associate, an expert on Medicaid, the State Children's Health Insurance Program, and community-based care;
- Genevieve M. Kenney, principal research associate, an expert on Medicaid and the State Children's Health Insurance Program;
- Sharon K. Long, principal research associate, an expert on Medicaid and state health care reform;
- Stephen Zuckerman, principal research associate, an expert in Medicare, Medicaid, health care fiscal issues, and uninsured/uncompensated care.
Publications
The Urban Institute disseminates many health care research publications.
