Children's health insurance coverage and family structure, 1977-1996

Children's Health Insurance Program Expansions: What Works for Families?

We examine the impact of Children’s Health Insurance Program (CHIP) eligibility expansions 1999 to 2012 on child and joint parent/child insurance coverage. We use changes in state CHIP income eligibility levels and data from the Current Population Survey Annual Social and Economic Supplement to create child/parent dyads. We use logistic regression to estimate marginal effects of eligibility expansions on coverage in families with incomes below 300% federal poverty level (FPL) and, in turn, 150% to 300% FPL. The latter is the income range most expansions targeted. We find CHIP expansions increased public coverage among children in families 150% to 300% FPL by 2.5 percentage points (pp). We find increased joint parent/child coverage of 2.3 pp (P = .055) but only in states where the public eligibility levels for parent and child are within 50 pp. In these states, the CHIP expansion increased the probability that both parent/child are publicly insured (2.5 pp) among insured dyads, but where the eligibility levels are further apart (51-150 pp; >150 pp), CHIP expansions increase the probability of mixed coverage—one public, one private—by 0.9 to 1.5 pp. Overall, families made decisions regarding coverage that put the child first but parents took advantage of joint parent/child coverage when eligibility levels were close. Joint public parent/child coverage can have positive care-seeking effects as well as reduced financial burdens for low-income families.

Marital Disruption and Health Insurance

Despite the high levels of marital disruption in the United States and the fact that a significant portion of health insurance coverage for those less than age 65 is based on family membership, surprisingly little research is available on the consequences of marital disruption for the health insurance coverage of men, women, and children. We address this shortfall by examining patterns of coverage surrounding marital disruption for men, women, and children, further subset by educational level. Using the 1996, 2001, and 2004 panels of the Survey of Income and Program Participation (SIPP), we find large differences in health insurance coverage across marital status groups in the cross-section. In longitudinal analyses that focus on within-person change, we find small overall coverage changes but large changes in type of coverage following marital disruption. Both men and women show increases in private coverage in their own names, but offsetting decreases in dependent coverage tend to be larger. One surprising result is that dependent coverage for children also declines after marital dissolution, even though children are still likely to be eligible for that coverage. Children and (to a lesser extent) women show increases in public coverage around the time of divorce or separation. We also find that these patterns differ by education. The most vulnerable group appears to be lower-educated women with children because the increases in private, own-name, and public insurance are not large enough to offset the large decrease in dependent coverage. As the United States implements federal health reform, it is critical that we understand the ways in which life course events—specifically, marital disruption—shape the dynamic patterns of coverage.

The Impact of the Medicaid/CHIP Expansions on Children

This article reviews findings from 38 rigorous studies published in the peer-reviewed literature of the impact of the Medicaid/Children’s Health Insurance Program (CHIP) expansions on children. There is strong evidence for increases in enrollment in public programs and reductions in uninsurance following eligibility expansions. Medicaid enrollment continued to increase during the CHIP era (a “spillover effect”). Evidence for improved access to and use of services, particularly for dental care, is also very strong. There are fewer studies of health status impacts, and the evidence is mixed. There is a very wide range in the size of effects estimated in the studies reviewed because of the methods used and the populations studied. The review identifies several important research gaps on this topic, particularly the small number of studies of the effects on health status. Both research methods and findings from the child expansions can provide insights for evaluating the coming expansions for adults under the Affordable Care Act.

Reexamining the effects of family structure on children's access to care: the single-father family

OBJECTIVE

To examine the effects of family structure, focusing on the single-father family, on children's access to medical care.

DATA SOURCE

The 1999 and 2002 rounds of the National Survey of America's Families (NSAF) including 62,193 children ages 0-17 years.

STUDY DESIGN

We employ a nationally representative sample of children residing in two-parent families, single-mother families, and single-father families. Multivariate logistic regression is used to examine the relationship between family structure and measures of access to care. We estimate stratified models on children below 200 percent of the federal poverty threshold and those above.

DATA COLLECTION/EXTRACTION METHOD

We combine data from the Focal Child and Adult Pair modules of the 1999 and 2002 waves of the NSAF.

PRINCIPAL FINDINGS

Children who reside in single-father families exhibit poorer access to health care than children in other family structures. The stratified models suggest that, unlike residing in a single-mother family, the effects of residence in a single-father family do not vary by poverty status.

CONCLUSIONS

Children in single-father families may be more vulnerable to health shocks than their peers in other family structures.

The impact of SCHIP on insurance coverage of children

In this paper we use the Medical Expenditure Panel Survey between 1996 and 2002 to investigate the impact of the State Children's Health Insurance Program (SCHIP) on insurance coverage for children. We explore a range of alternative estimation strategies, including instrumental variables and difference-in-trends models. We find that SCHIP had a significant impact in decreasing uninsurance and increasing public insurance for both children targeted by SCHIP and those eligible for Medicaid. With respect to changes in private coverage our results are less conclusive: some specifications resulted in no significant effect of SCHIP on private insurance coverage, while others showed significant decreases in private insurance. Associated estimates of SCHIP crowd-out had wide confidence intervals and were sensitive to estimation strategy.

The demand for dependent health insurance: how important is the cost of family coverage?

From the mid-1980s to the mid-1990s, the proportion of non-elderly Americans with employment-based health insurance declined. Roughly 80% of this decline was due to the loss of coverage by dependent family members. During this period, workers became increasingly responsible for the costs of family coverage, while expanded Medicaid coverage provided low-income working families with an alternative to employment-based insurance. We examine the role of out-of-pocket premiums and expanded Medicaid eligibility in households' demand for employment-based family coverage. Cross-sectional results reveal that demand is affected by both factors. We find that between 1987 and 1996, the increase in out-of-pocket premium costs accounted for nearly half of the decline in dependent coverage while expanded Medicaid eligibility represented 14% of the decline.

Children's health coverage: a quarter-century of change

Data from a series of medical spending surveys over the past twenty-five years show that uninsurance rates for children have fallen to levels not seen since the late 1970s (about 8 percent). Rates of uninsurance have fallen in particular for poor children. Deteriorating family economic circumstances, along with a weakened safety net, contributed to the decrease of private insurance coverage and rising uninsurance rates between 1977 and 1987. Although family circumstances have stabilized since the late 1980s, high annual increases in health insurance costs have continued to erode private coverage. Public coverage expansions have reversed the surge in uninsurance rates during 1977-1987.

Tracking Changes In Eligibility And Coverage Among Children, 1996–2002

Data from the 1996 Medical Expenditure Panel Survey (MEPS) reveal that 4.7 million children were eligible for Medicaid but were uninsured. Numerous changes have occurred in the landscape for children's health insurance since then, including welfare reform and implementation of the State Children's Health Insurance Program (SCHIP). We use data from the 1996-2002 MEPS to track changes in the eligibility and coverage of children. As of 2002, uninsurance among children remained as much a problem of participation as one of eligibility. Nevertheless, we find evidence of dramatic improvements in program participation, reflecting the success of efforts to improve outreach, simplify enrollment, and increase retention.

The ABCs of children's health care: how the Medicaid expansions affected access, burdens, and coverage between 1987 and 1996

The Medicaid poverty expansions were among the major health policy initiatives of the late 1980s. This paper examines changes over a nine-year period in access, burdens, and coverage among children eligible for Medicaid through the expansions. Among eligible children, the Medicaid expansions reduced rates of uninsurance, increased access to physicians, and reduced families' risk of bearing a heavy financial burden. Gaps remain, however, and expansion-eligible children are more likely than never-eligible children to have been uninsured, to have gone without a physician office visit, and to have lived in a family that spent at least 20% of family income on medical care.

Health-related quality of life in urban elementary schoolchildren

BACKGROUND

Health disparities between children from urban minority backgrounds and children from more affluent backgrounds are well-recognized. Few studies specifically address urban children's perceptions of their health-related quality of life (HRQOL) or the factors that contribute to these perceptions. Since schools are pivotal to children's intellectual, social, and emotional development, school connectedness may be a factor that contributes to their perception of HRQOL.

OBJECTIVE

To examine children's perceptions of HRQOL in an elementary school-based population of urban children.

METHODS

The study population consisted of 2nd, 3rd, and 5th graders from 6 urban kindergarten to 8th grade schools and their parents. Children completed a survey that included questions on HRQOL and school connectedness. Parents completed a telephone survey that assessed demographics, the child's health, health care usage, and parental health status. Data on school absences and mobility from the computerized school database were linked to survey data. Bivariate analyses were used to evaluate the association between child report of HRQOL and collected variables, including school connectedness. Multivariable linear regression was conducted to identify the factors best predicting HRQOL in these urban children.

RESULTS

Of the 1150 eligible students, parent and child survey data were available for 525 (45.6%). Fifty-one percent of students were male and 89% were black. Ninety-four percent of parents were female, 29% were married, and 62% had family incomes below 20,000 dollars per year. The mean total score for HRQOL was 67.2, with a possible range of 0 to 100 (higher scores reflecting better HRQOL). In the multivariable analysis, child grade, the relationship of the " parent" to the child, employment, family income, type/presence of insurance, and school connectedness were significantly associated with the HRQOL total score.

CONCLUSIONS

Young urban children self-report low HRQOL scores and do so as early as the 2nd grade. These low scores, which reflect children's own perceptions of impaired psychological and physical health, have potential implications for the success of urban children in their learning environments. The association between HRQOL and school connectedness might suggest that health and educational programs that improve a child's attachment to school could result in improved perceptions of health by urban children.

Health insurance and family structure: the case of adolescents in skipped-generation families

Since 1970, both the number and proportion of children being parented by a grandparent without the help of a parent has increased substantially. The increase in skipped-generation households has generated much concern from policy makers because such households are, on average, disadvantaged compared with most other household types. One important challenge facing grandparents with parenting responsibilities is securing health insurance for their dependent grandchildren. In this study, the authors investigate the extent to which grandparents raising their grandchildren were able to secure health insurance for their dependent grandchildren. They find that adolescents living in skipped-generation families in 1995 were more often uninsured, more often publicly insured, and less often privately insured compared with adolescents in other family types. Even after controlling for income, work status, and education, adolescents in skipped-generation families were still more likely to have public insurance and less likely to have private insurance compared with other adolescents.

Parental employment, family structure, and child's health insurance

OBJECTIVE

To examine the impact of family structure on the relationship between parental employment characteristics and employer-sponsored health insurance coverage among children with employed parents in the United States.

METHODS

National Health Interview Survey data for 1993-1995 was used to estimate proportions of children without employer-sponsored health insurance, by family structure, separately according to maternal and paternal employment characteristics. In addition, relative odds of being without employer-sponsored insurance were estimated, controlling for family structure and child's age, race, and poverty status.

RESULTS

Children with 2 employed parents were more likely to have employer-sponsored health insurance coverage than children with 1 employed parent, even among children in 2-parent families. However, among children with employed parents, the percentage with employer-sponsored health insurance coverage varied widely, depending on the hours worked, employment sector, occupation, industry, and firm size.

CONCLUSIONS

Employer-sponsored health insurance coverage for children is extremely variable, depending on employment characteristics and marital status of the parents.

Race/ethnicity and health insurance status: 1987 and 1996

Health insurance confers important private and social benefits. Disparities in coverage among the population remain an important public policy issue. The authors focus on the health insurance status of white, black, and Hispanic Americans in both 1987 and 1996 and identify gaps in minority health care coverage relative to white Americans. They also investigate the access of workers in these groups to employment-based health insurance. Identified are factors underlying changes in the insurance status of workers during the past decade in terms of changes in population characteristics and structural shifts underlying the demand for and supply of health insurance. The authors find that while coverage has declined for workers in most racial/ethnic groups, the experience of Hispanic males appears to be unique in that changes in their characteristics as well as structural shifts account for their decline in employment-related coverage. Structural shifts dominated the changes in coverage rates for other groups.

A comparison of the socioeconomic and health status characteristics of uninsured, state Children's health insurance program-eligible children in the united states with those of other groups of insured children: implications for policy

OBJECTIVES

To describe the sociodemographic and health status characteristics of the national uninsured, State Children's Health Insurance Program (SCHIP)-eligible population, and to compare this population with Medicaid-enrolled children, privately insured children, and privately insured children who have family income in the SCHIP eligibility range.

PROCEDURES

Data were analyzed for 50 950 children 0 to 18 years of age included in the 1993 and 1994 National Health Interview Surveys. The survey obtained information on insurance coverage and sociodemographic and health status measures. Bivariate analyses were conducted to identify the relationships between SCHIP eligibility and sociodemographic and health status characteristics. Multivariate analyses were conducted to assess the independent association of the sociodemographic and health status variables with the likelihood of being uninsured, SCHIP-eligible.

PRIMARY FINDINGS

Results indicate that SCHIP children exhibit markedly different socioeconomic and health status characteristics than do both Medicaid- enrolled and privately insured children, although these differences are less significant in privately insured children. SCHIP children more often live with college- educated (39.4%) and employed adults (91.2%) than do Medicaid-enrolled children (23.0% and 53.9%, respectively). However, SCHIP children live with college-educated and employed adults less than do all privately insured children (66.7% and 96.9%, respectively) and privately insured/same-income children (57.8% and 97.0%, respectively). Parents of SCHIP-eligible children are also disproportionately self-employed or employed in industries (e.g., retail trade) and occupations in which health insurance coverage is less available or affordable. SCHIP-eligible children are also 2 times more likely to be adolescents and 11/2 times more likely to be in excellent health than Medicaid-eligible children. Compared with privately insured children, SCHIP-eligible children are nearly 3 times more likely to be Hispanic and nearly 2 times more likely to be rated in fair or poor health.

CONCLUSIONS

The results demonstrate that uninsured, SCHIP-eligible children are substantially different from children in these groups, particularly compared with Medicaid-enrolled children. These differences need to be taken into account when setting policies and implementing programs intended to increase health insurance coverage and access to health care.