Why does the number of uninsured Americans continue to grow?

Health Affairs

Volumn 19, Issue 4, 2000, Pages 188-196

  Holahan, John ^a   Kim, Johnny ^a  

^a URBAN INSTITUTE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; AGED; ARTICLE; CHILD; CLASSIFICATION; ETHNIC GROUP; FEMALE; FORECASTING; HEALTH INSURANCE; HUMAN; INCOME; INSURANCE; MALE; MEDICAID; MIDDLE AGED; PATIENT; POVERTY; STATISTICS; UNITED STATES; UTILIZATION REVIEW;

ADULT; AGED; CHILD; ETHNIC GROUPS; FEMALE; FORECASTING; HEALTH BENEFIT PLANS, EMPLOYEE; HUMANS; INCOME; INSURANCE COVERAGE; MALE; MEDICAID; MEDICALLY UNINSURED; MIDDLE AGED; POVERTY; UNITED STATES;

EID: 0034222908     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.19.4.188     Document Type: Article

References (14)

1. G. Acs, "Trends in Health Insurance Coverage between 1988 and 1991," Inquiry (Spring 1995): 102-110; P. Fronstin, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1996 Current Population Survey, Issue Brief no. 179 (Washington: Employee Benefit Research Institute, November 1996); R. Kronick, "Health Insurance 1979-1989: The Frayed Connection between Employment and Insurance," Inquiry (Winter 1991): 318-332; E. O'Brien and J. Feder, Employment-Based Health Insurance Coverage and Its Decline: The Growing Plight of Low-Wage Workers (Washington: Kaiser Commission on Medicaid and the Uninsured, 1999); R. Kronick and T. Gilmer, "Explaining the Decline in Health Insurance Coverage, 1979-1995," Health Affairs (Mar/Apr 1999): 30-47; and S. Long and J. Rogers, "Do Shifts toward Service Industries, Part Time Work, and Self-Employment Explain the Rising Uninsured Rate?" Inquiry (Spring 1995): 111-117.
2. G. Acs, "Trends in Health Insurance Coverage between 1988 and 1991," Inquiry (Spring 1995): 102-110; P. Fronstin, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1996 Current Population Survey, Issue Brief no. 179 (Washington: Employee Benefit Research Institute, November 1996); R. Kronick, "Health Insurance 1979-1989: The Frayed Connection between Employment and Insurance," Inquiry (Winter 1991): 318-332; E. O'Brien and J. Feder, Employment-Based Health Insurance Coverage and Its Decline: The Growing Plight of Low-Wage Workers (Washington: Kaiser Commission on Medicaid and the Uninsured, 1999); R. Kronick and T. Gilmer, "Explaining the Decline in Health Insurance Coverage, 1979-1995," Health Affairs (Mar/Apr 1999): 30-47; and S. Long and J. Rogers, "Do Shifts toward Service Industries, Part Time Work, and Self-Employment Explain the Rising Uninsured Rate?" Inquiry (Spring 1995): 111-117.
3. G. Acs, "Trends in Health Insurance Coverage between 1988 and 1991," Inquiry (Spring 1995): 102-110; P. Fronstin, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1996 Current Population Survey, Issue Brief no. 179 (Washington: Employee Benefit Research Institute, November 1996); R. Kronick, "Health Insurance 1979-1989: The Frayed Connection between Employment and Insurance," Inquiry (Winter 1991): 318-332; E. O'Brien and J. Feder, Employment-Based Health Insurance Coverage and Its Decline: The Growing Plight of Low-Wage Workers (Washington: Kaiser Commission on Medicaid and the Uninsured, 1999); R. Kronick and T. Gilmer, "Explaining the Decline in Health Insurance Coverage, 1979-1995," Health Affairs (Mar/Apr 1999): 30-47; and S. Long and J. Rogers, "Do Shifts toward Service Industries, Part Time Work, and Self-Employment Explain the Rising Uninsured Rate?" Inquiry (Spring 1995): 111-117.
4. G. Acs, "Trends in Health Insurance Coverage between 1988 and 1991," Inquiry (Spring 1995): 102-110; P. Fronstin, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1996 Current Population Survey, Issue Brief no. 179 (Washington: Employee Benefit Research Institute, November 1996); R. Kronick, "Health Insurance 1979-1989: The Frayed Connection between Employment and Insurance," Inquiry (Winter 1991): 318-332; E. O'Brien and J. Feder, Employment-Based Health Insurance Coverage and Its Decline: The Growing Plight of Low-Wage Workers (Washington: Kaiser Commission on Medicaid and the Uninsured, 1999); R. Kronick and T. Gilmer, "Explaining the Decline in Health Insurance Coverage, 1979-1995," Health Affairs (Mar/Apr 1999): 30-47; and S. Long and J. Rogers, "Do Shifts toward Service Industries, Part Time Work, and Self-Employment Explain the Rising Uninsured Rate?" Inquiry (Spring 1995): 111-117.
5. G. Acs, "Trends in Health Insurance Coverage between 1988 and 1991," Inquiry (Spring 1995): 102-110; P. Fronstin, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1996 Current Population Survey, Issue Brief no. 179 (Washington: Employee Benefit Research Institute, November 1996); R. Kronick, "Health Insurance 1979-1989: The Frayed Connection between Employment and Insurance," Inquiry (Winter 1991): 318-332; E. O'Brien and J. Feder, Employment-Based Health Insurance Coverage and Its Decline: The Growing Plight of Low-Wage Workers (Washington: Kaiser Commission on Medicaid and the Uninsured, 1999); R. Kronick and T. Gilmer, "Explaining the Decline in Health Insurance Coverage, 1979-1995," Health Affairs (Mar/Apr 1999): 30-47; and S. Long and J. Rogers, "Do Shifts toward Service Industries, Part Time Work, and Self-Employment Explain the Rising Uninsured Rate?" Inquiry (Spring 1995): 111-117.
6. G. Acs, "Trends in Health Insurance Coverage between 1988 and 1991," Inquiry (Spring 1995): 102-110; P. Fronstin, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1996 Current Population Survey, Issue Brief no. 179 (Washington: Employee Benefit Research Institute, November 1996); R. Kronick, "Health Insurance 1979-1989: The Frayed Connection between Employment and Insurance," Inquiry (Winter 1991): 318-332; E. O'Brien and J. Feder, Employment-Based Health Insurance Coverage and Its Decline: The Growing Plight of Low-Wage Workers (Washington: Kaiser Commission on Medicaid and the Uninsured, 1999); R. Kronick and T. Gilmer, "Explaining the Decline in Health Insurance Coverage, 1979-1995," Health Affairs (Mar/Apr 1999): 30-47; and S. Long and J. Rogers, "Do Shifts toward Service Industries, Part Time Work, and Self-Employment Explain the Rising Uninsured Rate?" Inquiry (Spring 1995): 111-117.
7. J. Holahan, C. Winterbottom, and S. Rajan, "A Shifting Picture of Health Insurance Coverage," Health Affairs (Winter 1995): 253-264.
8. S. Smith et al., "The Next Decade of Health Spending: A New Outlook," Health Affairs (July/Aug 1999): 86-95.
9. M.R. Ellwood and L. Ku, "Welfare and Immigration Reforms: Unintended Side Effects for Medicaid," Health Affairs (May/June 1998): 137-151.
10. K. Swartz, "Changes in the 1995 Current Population Survey and Estimates of Health Insurance Coverage," Inquiry (Spring 1997): 70-79.
11. K. Lewis et al., "Counting the Uninsured: A Review of the Literature," Occasional Paper no. 8 (Washington: Urban Institute, July 1998).
12. Although survey respondents could choose multiple types of health insurance on the survey, we grouped and classified their responses according to the following hierarchy: employer-own, insurance through a person's own employer-group health plan; employer-other, primary coverage through another's employer-group plan; Medicaid; other public, coverage from other non-Medicaid government insurance programs, such as military-related insurance and Medicare; other private, coverage through a private insurance plan but not as part of an employer-sponsored benefit; and uninsured, the residual category for those who did not report any of the other types of coverage over the course of the year. We examined the effect of using this hierarchial classification approach by comparing it with changes in coverage using data on all types of coverage reported by respondents. The results do not change in significant ways, with one exception: There are no changes, as would be expected in employer coverage when no hierarchy is used, because employer coverage is first in the hierarchial sequence. Nor are there changes in the number of uninsured, since this is a residual category in both approaches. However, we found greater increases in Medicaid, other public, and private nongroup coverage between 1989 and 1993 and greater reductions between 1994 and 1998.
13. These trends have led some to observe that the Medicaid increases were the cause of the decline in employer-sponsored coverage. Research on this issue suggests that the crowding-out effect was small and that the predominant effect was to reduce the number of uninsured. L. Dubay, "Expanding Public Insurance Coverage and Crowd-Out: A Review of the Evidence," in Options for Expanding Health Insurance Coverage: What Difference Do Different Approaches Make?, ed. J. Feder and S. Burke (Washington: Henry J. Kaiser Family Foundation, November 1999). Exhibit 1 suggests this as well. The Medicaid expansions were greater for children than for adults and increases in the uninsured were less for children than for adults, while declines in employer-sponsored coverage were similar.
14. In 1998, 200 percent of the federal poverty level was $16,660 for a family of four; 400 percent of poverty was $33,320.