Margaret E.Weigers, Ph.D.

Robin M.Weinick, Ph.D.

Joel W. Cohen, Ph.D.

Health Insurance Access to Care Health Status

1996

Medical Expenditure Panel Survey

Agency for Health Care Policy and Research

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Children’s Health

MEPS Chartbook No. 1
Suggested citation:

Weigers ME,Weinick RM, Cohen JW.

Children’s health, 1996. Rockville (MD):

Agency for Health Care Policy and

Research; 1998. MEPS Chartbook No. 1.

AHCPR Pub. No. 98-0008.
i

Almost two-thirds of all children were

covered by private health insurance (p. 6).

What were we doing

well in 1996?

Most children living with working

parents had employment-related health

insurance (p. 10).

An estimated 9.4 million children who

were eligible for Medicaid in 1996 would

not have qualified for coverage under

the 1987 rules (p. 11).

91% of all children had a usual source of

health care (p. 21).

Less than 12% of American families

experienced barriers to receiving

needed health care (p. 22).

80% of all children were in excellent or

very good health (p. 24).

70% of children in excellent health had

private insurance, while 15% had public

coverage (p. 26).

Nearly 11 million children were

uninsured (p. 7).

On the other

hand...

Of all children who were uninsured,

approximately 90% lived in households

with a working adult (p. 7).

Many children remain uninsured despite

being eligible for Medicaid. MEPS estimates indicate that over 3 million young

children and more than a million older

children were eligible but uninsured (p.12).

20% of uninsured children lacked a usual

source of health care (p. 18).

Of families with barriers to receiving

needed care, 60% said the main reason

they did not get care was because they

could not afford it (p. 22).

2.8 million children were in fair or poor

health (p. 24).

Only 43% of children in fair or poor

health had private insurance, while 42%

had public coverage (p. 26).

Medical Expenditure Panel Survey Agency for Health Care Policy and Research

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executive summar

y

iii

1 Introduction

Health Policy for Children

3 Source of Data for This Report

5 Section 1

Children’s Health Insurance

15 Section 2

Children’s Access to Health Care

23 Section 3

Children’s Health Status

27 Conclusions

28 Looking ahead

Future MEPS Data on Children

29 References

30 Notes

Medical Expenditure Panel Survey Agency for Health Care Policy and Research

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contents

Health Policy

for Children

High-quality health care is

important to the well-being of

America’s children. Recent policy

changes have attempted to increase

children’s health insurance coverage

and access to care so that children

can obtain health care that is

appropriate to their developmental

needs.

In the last decade, the Medicaid

program has been expanded to

decrease the proportion of children

who are uninsured. However, a

substantial number of children still

lack health insurance and adequate

access to care. Consequently, they

risk health problems associated with

not being immunized, not receiving

appropriate well-child care, and not receiving timely treatment for acute

health problems.

In this era of rapid changes in

our health care system, it is

important to assess periodically

where we stand. This report

presents the latest available

information concerning three key

elements related to children’s

health. The first section of the report presents data on the health

insurance status of children in the

United States. Since having health

insurance is just one factor that may

influence children’s health and wellbeing, the second section of the report addresses access to health

care, with a focus on usual source of

care and barriers to care. Finally, the

third section of the report turns to

the motivating force behind our

Nation’s interest in children’s health

insurance and access to care: the

health status of children.

Medical Expenditure Panel Survey Agency for Health Care Policy and Research

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introduction

1

Source of

DataforThis

Report

The estimates presented in this

report are drawn from the Medical

Expenditure Panel Survey (MEPS).

MEPS is the third in a series of

medical expenditure surveys

conducted by the Agency for

Health Care Policy and Research. It

is a nationally representative survey

that collects detailed information on

health status, health care use and

expenses, and health insurance

coverage of individuals and families

in the United States.

These data come from the first

and second rounds of interviewing

for the Household Component of

the 1996 panel of MEPS. (See

Note 1.) The estimates presented

here are nationally representative of

noninstitutionalized children under

age 18. In some cases, totals may

not add precisely to 100 percent as

a consequence of rounding. Where

shown, the racial category “white”

includes children identified as white

as well as a very small number of

children identified as American

Indians, Aleuts, Eskimos, or other

races.

MEPS data are released to the

public in a number of formats,

including public use data files and

the printed MEPS Research Findings

and MEPS Highlights series. The

numbers shown in this chartbook

are drawn from a variety of the

Research Findingsreports, as well as

additional analyses conducted by the

MEPS staff. These sources of

information are listed in the references at the end of this report.

Medical Expenditure Panel Survey Agency for Health Care Policy and Research

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3

Children’s

Health

Insurance

Health insurance plays a critical

role in ensuring that children obtain

timely medical care that is

appropriate to their developmental

needs. In an era of high health care

costs, individuals’ difficulty

affording medical care has made

health insurance essential for

ensuring that children’s health

services are both accessible and

affordable.

Medical Expenditure Panel Survey Agency for Health Care Policy and Research

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section 1

5
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• 15.4% of the Nation’s children

were uninsured throughout the

first half of 1996.

• One-fifth (20.8%) of children

had public coverage.

• Almost two-thirds (63.9%) of the

Nation’s children were covered

by private health insurance.

Agency for Health Care Policy and Research

6

Medical Expenditure Panel Survey

Children’s health insurance:

Where do we stand?

Private

Public

Uninsured

20.8% 63.9%

15.4%

Health insurance status of

children under age 18
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• Nearly 11 million children in

America were uninsured

throughout the first half of

1996. These children represent

15.4% of all children in the

United States.

• Of all children uninsured

throughout the first half of

1996, about 90% were in

households with a working adult.

• Children in families with a

working adult represented over a

fifth (22.1%) of the non-elderly

uninsured population.

7

Medical Expenditure Panel Survey

Who are the uninsured children?

Agency for Health Care Policy and Research
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Hispanic children were the most

likely to be uninsured: 27.7% of

Hispanic children, 17.6% of black

children, and 12.3% of white

children were uninsured.

• White children were far more

likely to have private health

insurance (73.9%) than either

black (41.7%) or Hispanic

children (39.8%).

• Nearly a third (32.5%) of

Hispanic children and 40.8% of

black children had public health

care coverage, compared to only

13.8% of white children.

Agency for Health Care Policy and Research

8

Medical Expenditure Panel Survey

Are minority children at greater risk

of not having health insurance?

0

5

10

15

20

25

30

Hispanic Black White

12.3

17.6

27.7

Percent uninsured
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• Approximately one-quarter of

children in the United States live

in single-parent families.

• Roughly one in five children

(19.8%) in single-parent families

were uninsured during the first

half of 1996, compared with

13.6% of children in two-parent

families.

• Nearly three-quarters (73.7%) of

children in two-parent families

had private insurance, compared

with only 38.7% of children in

single-parent households.

• Children in single-parent families

were three times more likely to

have public insurance than

children in two-parent families

(41.5% compared to 12.7%).

Agency for Health Care Policy and Research

9

Medical Expenditure Panel Survey

Are children in single-parent families at greater

risk of not having private health insurance?

Private

Public

Uninsured

41.5%

38.7% 12.7%

19.8% 13.6%

73.7%

Single-parent families Two-parent families
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Employment

Children living with two

employed parents were the most

likely to have employment-related

private health insurance.

• 79.1% of children living with two

employed parents had health

insurance through an employer.

• 58.8% of children in two-parent

households with one working

parent had health insurance

through an employer.

• 51.1% of children in singleparent households with a

working parent had

employment-related health

insurance.

Education

Adults’ educational level greatly

influenced the probability of children

being insured.

• 27.6% of children living in

families where adults had less

than a high school diploma were

uninsured.

• Only 10.6% of children living in

families where adults had more

than 12 years of education were

uninsured.

Agency for Health Care Policy and Research

10

How do parents’ employment and education

levels affect children’s health insurance?

Medical Expenditure Panel Survey
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• Medicaid expansions between

1987 and 1996 resulted in more

generous eligibility rules for

children. During the same

period, the proportion of

children covered by Medicaid

increased from 12.4% to 20.9%.

• Young children were targeted by

the expansions, and 1996

estimates show that the largest

increase was among that group.

Medicaid enrollment among

children 5 and under nearly

doubled, from 13.8% in 1987 to

25.8% in 1996.

• Approximately 9.4 million

children under the age of 18

who were eligible for Medicaid

in 1996 would not have qualified

for coverage under the 1987

rules.

Agency for Health Care Policy and Research

11

Medical Expenditure Panel Survey

How did recent Medicaid expansions affect

the health insurance status of children?

0

5

10

15

20

25

30

1996

1987

13-17

years

6-12

years

5 years

and under

All children

Percent

12.4

20.9

13.8

25.8

13.1

21.0

9.7

14.8

Medicaid enrollment, 1987 and 1996
The estimates for young children differ from other widely cited

estimates for children age 10 and under, primarily because 11- and 12-

year-olds who became eligible under the Federal expansion rules in

effect in 1996 are included. In addition, children who are eligible under

optional State expansions are included, and eligibility is predicted

using weekly earned income rather than annual income from all

sources.

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Medicaid expansions have

increased access to health insurance

for children. However, many

Medicaid-eligible children still are

not enrolled.

• Of the estimated 16.6 million

children age 12 and under who

were eligible for Medicaid,

approximately 3.3 million

(19.7%) were uninsured during

the first half of 1996, 4.4 million

(26.6%) had private coverage,

and 8.9 million (53.7%) had

public coverage. (See Note 2.)

• In addition, MEPS estimates

indicate that more than 1 million

children age 13 and over were

uninsured despite being eligible

for Medicaid.

Agency for Health Care Policy and Research

12

Are all the children who are eligible

for Medicaid enrolled in the program?

Medical Expenditure Panel Survey

Private

Public

Uninsured

26.6% 19.7%

53.7%

Insurance status of Medicaid-eligible

children age 12 and under
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• 40.1% of Medicaid-enrolled

children under the age of 18

lived with one employed parent.

• An additional 12.7% of

Medicaid-enrolled children

under 18 lived with two

employed parents.

13

Medical Expenditure Panel Survey

What is the employment status of

parents of children on Medicaid?

Agency for Health Care Policy and Research

Parents not employed

One employed parent

Two employed parents

40.1%

47.2%

12.7%

Medicaid-enrolled children

Children’s

Access to

Health Care

Having adequate access to

health care services can significantly

influence health care use and health

outcomes. Consequently, measures

of access to care are an important

tool for evaluating the quality of the

Nation’s health care system.

Limitations in access to care extend

beyond such simple issues as a

shortage of health care providers or

facilities in some areas. Even where

health care services are readily

available, people may not have a

usual source of health care or may

experience barriers to receiving

services because of financial or

insurance restrictions, a lack of

availability of providers at night or

on weekends, or other difficulties.

One extensively studied

indicator of access is having a usual

source of care.

Medical Expenditure Panel Survey Agency for Health Care Policy and Research

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section 2

15
Persons with a usual source of

health care have been shown to be

more likely to receive a variety of

preventive health services than those

without a usual source of care.

However, all usual sources of care

are not the same. Office-based

sources may cost less and provide

better continuity of care.

• Children aged 13-17 were less

likely than younger children to

have a usual source of health

care.

• Children aged 13-17 were also

less likely to have an office-based

usual source of health care.

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Agency for Health Care Policy and Research

16

Medical Expenditure Panel Survey

Do children have a place to go when

they are sick or need health care?

Usual source of care

No usual source

Hospital-based

Office-based

13-17

years

6-12

years

5 years

and under

10.6% 8.9%

10.1%

5.5% 7.6% 14.5%

83.8% 83.6% 75.4%
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Hispanic and black children

were less likely than white children

to have a usual source of care and

less likely to have an office-based

usual source of care.

• Hispanic children were less likely

than children in any other

racial/ethnic group to have a

usual source of health care.

• Black children were less likely

than white children to have a

usual source of health care.

• Hispanic and black children were

less likely than white children to

have an office-based usual source

of care, and were more likely to

have a hospital-based usual

source of care.

Agency for Health Care Policy and Research

17

Medical Expenditure Panel Survey

Are minority children at greater risk

of not having a usual source of care?

Percent

0

20

40

60

80

100

No usual source

Hospital-based

Office-based

Hispanic Black Asian/Pacific Islander White

69.1

17.2 13.7

71.0

12.6 16.4

78.1

8.6 13.4

86.8

7.2 6.0

Usual source of care
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Children with private health

insurance were more likely to have a

usual source of care than those who

had public insurance or were

uninsured.

• 20.2% of uninsured children

lacked a usual source of health

care.

• Children who were uninsured

were 3.6 times more likely to

lack a usual source of care when

compared to children with

private insurance.

• Children who were uninsured

were twice as likely as those with

public insurance to lack a usual

source of care.

Agency for Health Care Policy and Research

18

Does health insurance affect children’s

chances of having a usual source of care?

Medical Expenditure Panel Survey

0

5

10

15

20

25

Uninsured Public Private

20.2

10.0

5.6

Percent with no usual source

of care
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Characteristics of usual sources

of health care that can affect access

to care include having office hours at

times when parents are not working

and being easy to contact by phone.

Among children under age 18 who

had a usual source of care:

• 40.6% had a provider who did

not have night and weekend

office hours.

• 22.1% of these children’s families

found their usual source of care

providers “somewhat” or “very”

difficult to contact by telephone.

19

Medical Expenditure Panel Survey

Do children with a usual source of care

get the care they need when they need it?

Agency for Health Care Policy and Research
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Satisfaction and continuity of

care are important aspects of highquality health care. Families of

children with a usual source of care

reported that:

• 97.5% were “somewhat” or

“very” satisfied with their usual

source of care.

• 96.9% had a usual source of care

provider who generally listened

and gave them needed

information about health and

health care.

• 74.9% had a usual source of care

provider who generally asked

questions about prescription

medicines and treatments from

other doctors.

Agency for Health Care Policy and Research

20

How satisfied are families with their

usual source of care?

Medical Expenditure Panel Survey
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While more than 91% of

children under age 18 had a usual

source of care, 8.8% had no usual

source of health care. Of these:

• 65.9% had no usual source of

care because they seldom or

never got sick.

• 7.8% had no usual source of care

because they recently moved to

the area or did not know where

to receive care.

• 10.0% had no usual source of

care because their families could

not afford medical care.

21

Medical Expenditure Panel Survey

Why don’t some children have a usual

source of care?

Agency for Health Care Policy and Research

{





















yyy

yyy

zzz

zzz

{{{

{{{

{{{

|||

|||

||| Various other reasons

Cannot afford care

Seldom or never sick

Recently moved or

don't know where to go

7.8%

65.9%

10.0%

16.3%

Main reasons for not having a usual source of care
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Approximately 12.8 million

families (11.6% of all American

families) experienced difficulty or

delay in obtaining care, or did not

receive needed health care services.

(See Note 3.) 

• Among these families, inability to

afford health care was cited by

the majority (59.9%) as the main

problem. Another 19.5% cited

insurance-related reasons as the

main obstacle to receiving care.

(See Note 4.)

• Families with a Hispanic head of

household, or with one or more

uninsured members, were

substantially more likely to

report experiencing barriers to

receiving needed health care.

Agency for Health Care Policy and Research

22

Why don’t some families get health

care when they need it?

Medical Expenditure Panel Survey

Other

problems

Unable to

afford care

Insurance

reasons

59.9%

20.7% 19.5%

Reported barriers to receiving

needed care
Children’s

Health Status 

One main objective of our

health care system is to maintain

and improve American children’s

health. Consequently, children’s

health outcomes provide one

indication of how well the system is

functioning.

Answers to simple questions

like the one reported here, which

asked “Would you rate this child’s

health as excellent, very good,

good, fair or poor?” have been

shown to predict both demand for

medical care services and medical

outcomes.

Medical Expenditure Panel Survey Agency for Health Care Policy and Research

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section 3

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• 80.2% of all children under the

age of 18 were in excellent or

very good health.

• Less than 1% of children were in

poor health.

• Although they represent just

under 4% of all American

children under the age of 18,

2.8 million children were in

fair or poor health.

Agency for Health Care Policy and Research

24

Children’s health status:

Where do we stand?

Medical Expenditure Panel Survey





















yy

yy

zz

zz

{{

{{

{{

||

||

||

















yy

yy

z

zz

{{

{

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|

Poor 0.6%

Fair 3.3%

Good

15.9%

Very good

28.2%

Excellent

52.0%

Health status of children
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Children’s health status varies by

racial and ethnic group. This may in

part be explained by differences in

access to adequate health care.

• Hispanic children were more

likely than black or white

children to be in fair or poor

health (7.8% of Hispanic

children, compared with 4.2% of

black children and 2.9% of white

children).

• Black and Hispanic children were

less likely than white children to

be in excellent health (48.1% of

black children and 42.9% of

Hispanic children, compared

with 55.1% of white children).

25

Medical Expenditure Panel Survey

Are minority children at greater risk

of poor health?

Agency for Health Care Policy and Research

0

20

40

60

80

100

yz{|yz{|zyz

z

{|Fair/poor

Good

Very good

Excellent

Asian/ White

Pacific

Islander

Hispanic Black

Percent

7.8

22.7

26.7

42.9

4.2

21.5

26.2

48.1

4.7

10.5

35.2

49.6

2.9

13.3

28.7

55.1

Perceived health status
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. . .

Children in fair or poor health

were far more likely than children in

excellent health to have public

insurance. Children in excellent

health were more likely to have

private insurance. Because of public

health care coverage, children with

health problems were as likely to be

insured as children in excellent

health.

• Of children in fair or poor

health, only 42.8% had private

health insurance and 41.8% had

public health insurance. Of

children in fair or poor health,

15.4% had no insurance

coverage.

• Of children in excellent health,

70.1% had private health

insurance coverage, while 15.1%

had public health insurance and

14.8% were uninsured.

Agency for Health Care Policy and Research

26

Where do children in fair or poor

health get their health insurance?

Medical Expenditure Panel Survey

Private

Public

Uninsured

42.8%

15.4%

41.8%

14.8%

15.1%

70.1%

Children in fair/poor health Children in excellent health
The data presented

in this report

suggest that:

Medical Expenditure Panel Survey Agency for Health Care Policy and Research

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conclusions

27

In spite of various policy

initiatives, a substantial number

of children in America remain

uninsured.

Black and Hispanic children are

at increased risk of adverse

outcomes, including being

uninsured and being in poor

health.

Having a working parent is not

enough to ensure children’s

access to private health

insurance.

The most common reason

children do not get needed

health care is because their

families cannot afford it.

Public coverage is a critical

factor in providing insurance

for children with health

problems.
Medical Expenditure Panel Sur

vey

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Agency for Health Care Policy and Research

28

looking ahead

Future

MEPS Data

on Children

This report presents estimates

of children’s health insurance

coverage, access to health care, and

health status. Future data from

MEPS will address a number of

additional aspects of children’s

health care, including: • The impact of managed care. • Use of specific services. • Use of preventive health

services, including

immunization status.

• Amounts paid for health care

and sources of payment.

• Additional measures of health

status, including health

conditions and functional

limitations.

• Changes in children’s health

insurance status over time.

• Amounts families pay for private

health insurance coverage.

MEPS is a unique data resource

for monitoring our Nation’s health

care system. As an ongoing survey,

MEPS will produce data that can be

used to examine changes over time.
http://www.ahcpr.gov/

Agency for Health Care Policy and

Research. Medical Expenditure Panel

Survey Insurance Status Tables: First

Half of 1996. Rockville (MD); 1997,

AHCPR Pub. No. 97-R052.

Banthin JS, Cohen JW. Changes in the

Medicaid community population, 1987-

1996. Paper presented at the 1997

Annual Meeting of the Association for

Health Services Research.

Monheit AC, Vistnes JP. Health insurance

status of workers and their families:

1996. Rockville (MD): Agency for

Health Care Policy and Research; 1997.

MEPS Research Findings No. 2. AHCPR

Pub. No. 97-0065.

Vistnes JP, Monheit AC. Health insurance

status of the civilian noninstitutionalized

population: 1996. Rockville (MD):

Agency for Health Care Policy and

Research; 1997. MEPS Research

Findings No. 1. AHCPR Pub. No. 97-

0030.

Weinick RM, Zuvekas SH, Drilea SK.

Access to health care—sources and

barriers, 1996. Rockville (MD): Agency

for Health Care Policy and Research;

1997. MEPS Research Findings No. 3.

AHCPR Pub. No. 98-0001. Weinick RM, Monheit AC. Family

structure and children’s health insurance

coverage, 1977-1996. Paper presented

at the 1997 Annual Meeting of the

Association for Health Services

Research.

Medical Expenditure Panel Survey Agency for Health Care Policy and Research

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29

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references

In addition to the sources shown here,

statistics in this chartbook are drawn from

a variety of analyses by the MEPS staff.

Many of these analyses will appear in

future publications. Please consult the

AHCPR Web site at

http://www.ahcpr.gov/

for an updated publications list or contact

the MEPS information coordinator at

AHCPR (301/594-1406) for additional

information.
Medical Expenditure Panel Survey

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. . . Agency for Health Care Policy and Research

30

Note 1: Data collection for Round 1 took place between March and July

1996 and asked about health-related issues for the period from

January 1, 1996, to the date of the Round 1 interview. Round 2

data collection occurred during the period from August to

November 1996 and asked survey respondents to report on

health-related issues between the date of the first interview and

the date of the second interview. All data concerning health

insurance, health status, and demographics presented in this

chartbook come from Round 1 of the survey. Health insurance

and health status estimates should therefore be interpreted as

estimates for experiences during the first half of 1996. Information

on access to care was obtained in Round 2 of the survey; however,

the questions on access to care generally did not ask about a

specific time period.

Note 2: Estimates include children made eligible under both Federal and

State Medicaid expansions. Children age 12 and under are defined

as those born after September 30, 1983. Eligibility was predicted

for each person in Round 1 of MEPS based on age, gender,

pregnancy status, family composition, employment status of

parents, and family earned income. Earned income was computed

using data on wages and hours worked for all jobs as of the

interview week. The Medicaid eligibility measure does not account

for disabled children or adults.

Note 3: The statistics on page 22 are not limited to families with children.

Note 4: Insurance-related reasons include “insurance company wouldn’t

approve, cover, or pay for care,” “pre-existing condition,”

“insurance required a referral but couldn’t get one,” and “doctor

refused to accept family’s insurance plan.” 

notes
AHCPR Publication No. 98-0008

March 1998