Adolescent Health Insurance Status:

Analyses of Trends in Coverage and

Preliminary Estimates of the Effects of an

Employer Mandate and Medicaid

Expansion on the Uninsured

June 1989

NTIS order #PB90-116666
ADOLESCENT

ANALYSES

HEALTH INSURANCE STATUS:

OF TRENDS IN COVERAGE

and

PRELIMINARY ESTIMATES OF THE EFFECTS OF AN

EMPLOYER MANDATE AND MEDICAID EXPANSION ON THE

UNINSURED

July 1989

Background Paper for the Office of Technology Assessment’s

Projecit on Adolescent Health

Prepared under contract by

Richard Kronick

Department of Community and Family Medicine

University of California, San Diego

OTA appreciates the assistance of Carnegie Corporation and

Carnegie Council on Adolescent Development in supporting the work

of Richard Kronick for this background paper

The views expressed in this paper do not

necessarily represent those of the Technology

Assessment Board, the Technology Assessment

Advisory Council, or their individual members.
Recommended citation:

U. S. Congress, Office of Technology Assessment, “Adolescent Health Insurance Status:

Analyses of Trends in Coverage and Preliminary Estimates of the Effects of An Employer

Mandate and Medicaid Expansion on the Uninsured-- Background Paper” (Washington, DC:

U. S. Congress, Office of Technology Assessment, July 1989).

For sale by the Superintendent of Documents

U. S. Government Printing Office, Washington, DC 20402-9325

(order form can be found in the back of the background paper)
FOREWORD

One need only read today’s headlines to know that many of our Nation’s adolescents often

need health care and don’t get it. This Background Paper addresses one important barrier to

access to care--lack of health insurance coverage. This is OTA’s first publication in response to

a request for an assessment of adolescent health. Numerous members of Congress requested the

assessment, including the Chair and/or Ranking Minority Members of the Senate Appropriations

Committee, the Senate Commerce, Science, and Transportation Committee, the Senate

Environment and Public Works Committee, the Senate Finance Committee, the Senate Foreign

Relations Committee, the Senate Labor and Human Resources Committee, the Senate Rules and

Administration Committee, the Senate Small Business Committee, the Senate Veterans’ Affairs

Committee, the House Agriculture Committee, the House Interior and Insular Affairs

Committee, and 7 members of OTA’s Technology Assessment Board, including the Chairman.l

The principal requesters were Senator Daniel K. Inouye, Chairman of the Select Committee on

Indian Affairs, and Senator Nancy Landon Kassebaum, Ranking Minority Member of the

Education, Arts and Humanities Subcommittee of the Senate Labor and Human Resources

Committee. A letter of support was received from the House Select Committee on Children,

Youth, and Families. The main report of the assessment will be released in 1990.

It is important to note that certain of the analyses in this background paper are preliminary,

because certain data are not yet available from the U.S. Census Bureau. Therefore, estimates

have been made of the numbers of adolescents who are currently uninsured and of the potential

impact of the two proposed legislative changes to expand coverage. An updated report will be

released by OTA soon after the necessary data become available.

A special report associated with OTA’s adolescent health project will be released later this

summer on the mental health of American Indian and Alaska Native adolescents.

OTA would like to thank Carnegie Corporation of New York and the Carnegie Council on

Adolescent Development for supporting the work of Richard Kronick of the University of

California, San Diego. OTA is, however, responsible for the paper and its conclusions, as well

as any omissions or errors therein.

1 An additional four Senators requested the assessment (in 1988), but are no longer

members of the Senate.

.
OTA Background Paper--

Adolescent Health Insurance Status:

Preliminary Analyses of Trends in Coverage and

Estimates of the Effects of an

Employer Mandate and Medicaid Expansion on the Uninsured

OTA Project Staff

Roger Herdman, Assistant Director, OTA

Health and Life Sciences Division

Clyde Behney, Health Program Manager

Denise Dougherty, Project Director

Jill Eden, Study Director

Kelly Metcalf, Research Analyst

Karen T. Davis and Carol A. Guntow prepared this paper

for desktop publication.

iv
CONTENTS

Chapter Page

1. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

2. Introduction and Current Number of Uninsured Adolescents ● 0.00.0....0.. ...0.00.00.0.. ● . . . . . . . . . . . . . . . . . 9

3. Sociodemographic Characteristics of Uninsured Adolescents ● 0...0..0.0 ...000000... . . . . . . . . . . . . ● ....0.... 13

4. Trends in Adolescent Health Insurance Coverage, 1979-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

. . 

. . 29

5. Potential Effects of Employer Mandates and Medicaid Expansions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

Appendix

A. Constructing Estimates of the Number of Uninsured Using the Current Population Survey:

Adjustments Made and Interpretation of Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

B. CPS Health Insurance Questions, March 1980-March 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

C. CPS Health Insurance Questions, March 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

D. Bivariate Relationships Among Insurance Status and Selected

Sociodemographic Characteristics of Uninsured Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

E. Federal Poverty Level for a Family of Three, 1979-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

F. Acknowledgments and OTA’s Adolescent Health Advisory Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....................................72

Tables

Table Page

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Health Insurance Status of Adolescents, Age 10-18,

by Family Income, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Health Insurance Status of the 10- to 64-year-old Population,

by Age Group, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Family Income, Race and Ethnicity, and Health Insurance Status

of Adolescents, Age 10-18, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Adolescent’s Living Arrangement by Family Income, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Family Income, Living Arrangement, and Health Insurance Status

of Adolescents, Age 10-18, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Family Income, Education of Family Head, and Health Insurance Status

of Adolescents, Age 10-18, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Family Income, Selected Parental Characteristics, and

Health Insurance Status of Adolescents, Age 10-18, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Region and Adolescent Health Insurance Status, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Health Insurance Status of Adolescents, Age 10-18, by Region

and Family Income, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Estimates of the Effects of Poverty and Rates of Medicaid

and Private Coverage on Regional Differences in Adolescent

Health Insurance Status, 1983-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Trend in the Health Insurance Status of Adolescents, Age 10-18,

1979-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Trend in the Health Insurance Status of Adolescents, Age 10-18,

by Family Income, 1979-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

v
CONTENTS (cent’d)

Tables (cent’d)

Table Page

13.

14.

15.

16.

17.

18.

A-1 .

A-2.

A-3.

A-4.

D-1.

Estimates of the Effects of Changes in Poverty and Rates of

Medicaid and Private Coverage on the Proportion of Adolescents

Without Health Insurance, 1981-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Industry of Parent’s Employers and Health Insurance Status

of Adolescents, 1982-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Trend in Parental and Adolescent Health Insurance Status, 1979-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Potential Effect of Various Employer Mandates on Uninsured Adolescents

by Living Arrangement and Parent’s Work Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Potential Effect of a Medicaid Expansion on Uninsured Adolescents

by Poverty Level and Living Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Potential Effects of Various Combinations of Employer Mandates

and Expansions in Medicaid on Uninsured Adolescents, Age 10-18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Health Insurance Status of Adolescents, Age 15-18, by Year, 1979-1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Health Insurance Status of Adolescents, Age 15-18,

by Type of Family and Year, 1987 vs. 1984-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Trend in the Proportion of Adolescents With and Without Health

Insurance, by Age Group, 1979-1987, Unadjusted Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Health Insurance Status of Adolescents by Age Group, Type of Family,

Parental Insurance Status, and Family Income as a Percentage of

Poverty, 1987, Unadjusted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Health Insurance Status of Adolescents, Age 10-18, by Selected

Demographic and Household Characteristics, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Figures

Figure

1.

2.

3.

4.

5.

6a-d.

7.

8.

D-1.

D-2.

D-3.

D-4.

D-5.

vi

Page

Percent of Adolescents Who Live With Uninsured Parent, Insured Parent,

or No Parent, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Parent’s Insurance Status of Uninsured Adolescents, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Trends in the Proportion of Uninsured Adolescents, Age 10-18, 1979-1986 --..--...--4

Poverty Status of Adolescents, Age 10-18, by Race/Ethnicity, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Map of the U.S., Showing Census Divisions and Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Trends in the Proportion of Insured Adolescents, Age 10-18,

by Type of Coverage, 1979-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

a. Employment-based coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

b. Other private coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

c. Medicaid coverage only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

d. Other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Trends in the Proportion of Adolescents, Age 10-18, Who Live in Poverty,

1979-1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Distribution of Adolescents, Age 10-18, by Parent’s Industry of

Employment Categorized by Rates of Health Insurance Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Living Arrangements of Uninsured Adolescents Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Living Arrangements of All Adolescents, Insured and Uninsured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Race/ethnicity of Adolescents, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Parent’s Work Status of Uninsured Adolescents Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Parent’s Work Status of All Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
1. EXECUTIVE SUMMARY

This paper examines the health insurance

status of adolescents, age 10 to 18 years, and

addresses these questions:

How many adolescents are without

health coverage and why are some

adolescents insured and others not?

Has the number of uninsured adolescents

changed over time? If so, why has this

change occurred?

How many adolescents would be affected by three potential approaches to

reducing the number of uninsured: a

mandate that employers provide health

insurance to their workers (and their dependents); an expansion of the Medicaid

program; or a combination of the two?

Data for this study come from Current

Population Surveys (CPS) fielded in 1980 to

1988 by the U.S. Bureau of the Census. Each

March, a supplement to the survey asks a variety of questions about work history and income during the previous year, and includes a

set of health insurance questions. Responses

to these questions are the basis for the

analyses presented in this paper.

In 1988, new questions were introduced

to the health insurance supplement and others

were changed materially. The March 1988

CPS data that are currently available for public use are incomplete and preliminary.

However, in light of today’s pressing debate

concerning the uninsured, this preliminary

report has been prepared based on currently

available information. An update, incorporating the final results from the 1988

and 19891 March surveys, will be released

1 At the time this Background Paper was published,

data from the March 1989 CPS were not avai lab[e for

ana [ ys is. Because of question wording changes initiated in March 1988, data collected in 1988 ,

1989, and subsequent years uill never be able to be

compared to data C O1 lected from March 1980 through

March 1986. However, when the March 1989 CPS becomes available, some analysis will be able to be

made comparing 1987 and 1988. (Note that the dat a

collected each March pertain to the previou s

calendar year; thus, data collected in March 198 0

pertain to calendar year 1979, and data collected

in March 1989 pertain to calendar year 1988).

before the end of 1989. These final results

may affect OTA’s estimates of the proportion

of adolescents who are currently uninsured,

and, thus, estimates of the effects of an

employer mandate or expanded Medicaid

eligibility, but OTA does not expect these

changes to be significant. They will not affect OTA’s estimate of the increase in

uninsured adolescents between 1979 and 1986.

How Many Adolescents Are

Without Health Insurance and

Who Are They?

Approximately 4.6 million adolescents,

aged 10 to 18, 15 percent overall, were

without public or private health coverage in

1987. Adolescents are slightly more likely to

be uninsured than younger children and

adults aged 25- to 54-years-old.3 Those

adolescents who do have health insurance are

more than twice as likely as 25- to 54-yearolds to be covered by Medicaid.

Sociodemographic Characteristics of

Uninsured Adolescents

Most adolescents, age 10 to 18, live with

their parents. Twelve percent of all adolescents live with uninsured parents (figure 1)

and almost two out of three uninsured

adolescents live with parents who are also

uninsured (figure 2). To a large extent, then,

the problems of uninsured adolescents are the

problems of uninsured parents.

Family income is the most important

determinant of health insurance status for all

age groups. The poor, regardless of other

factors, are the most likely to be uninsured.

Adolescents in poor or near-poor families are

much more likely to be uninsured than

others; approximately 30 percent are without

z 19- to 24-yea r-olds are at greatest risk fo r

being uninsured.

1
2 ■ Preliminary Analyses of Adolescent Health Insurance Status

Figure 1--- Percent of Adolescents Who Live With Uninsured Parent,

Insured Parent, or No Parent, 1987a

Not living

Parent i s

insure d

81%

n o t

aRefers t. the insurance status of the household head un[ess only the spouse ha d

employment-based health coverage.

blW(~es ad~les~ents ~t [ivi~ uith their ~rents and married adolescents living with

their parents.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988

Current Population Survey.

Figure 2--- Parent’s Insurance Status of Uninsured Adolescents, 1987a

Parent no t

insured

6 4 %

n t

b

aRefer~ t. the insurance status of the household head unless only the spouse had

enp[oyment-based hea[th coverage .

blnc(~es adolescents not [iving with their parents and married adolescents living uith

their parents.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988

Current Population Survey.
Preliminary Analyses of Adolescent Health Insurance Status ■ 3

any coverage, public or private (table 1).3 I n

contrast, half as many adolescents whose

family income is between 150 and 299 percent of poverty and less than 5 percent of

adolescents in families at 300 percent of

poverty or above are uninsured.

Despite the strong relationship between

low family income and the likelihood of

being uninsured, it should be recognized that

for adolescents, as for adults, it is by no

means true that all the uninsured are poor.

While 41 percent of uninsured adolescents

live below the Federal poverty level, onethird of uninsured adolescents are between

100 and 199 percent of poverty, and more

than one-quarter are at 200 percent of

poverty or above.

Several other demographic characteristics

have fairly strong relationships with health

insurance status independent of family income. These include Hispanic ethnicity,

parent’s education, parental self-employment,

and region. Hispanic adolescents are much

more likely than others to be uninsured

regardless of family income. This may be

because Hispanics are more likely than others

to work in agriculture and domestic service

where coverage rates are historically low. If

Hispanic families living in poverty are more

likely than others to include both husband

and wife, they will be less likely to be

eligible for Medicaid. In addition, Hispanic

adolescents who are “undocumented aliens”

are not routinely eligible for Medicaid;

eligibility is a State option.

Although black adolescents are much

more likely than whites to live in or near

poverty, and to be uninsured, the correlation

between race and lack of health insurance

coverage almost disappears when family income is taken into account.

3 Poor refers to those with family incomes below

100 percent of the Federal poverty level, and nearpoor describes families living between 100 and 1 5 0

percent of the Federal poverty level .

At each income level, adolescents whose

parents have little formal education are much

more likely to be uninsured than adolescents

whose parents have had more education.

Among adolescents in middle and upperincome families, those whose parents are selfemployed are much more likely than others to

be uninsured. Almost one out of five

Southern and Western adolescents are uninsured while less than one out of ten Northeastern and Midwestern adolescents are

without coverage.

Further analysis shows that regional variations in coverage are due primarily to differences in income-specific rates of Medicaid

and private health coverage. In the South, it

appears that more stringent Medicaid income

eligibility requirements are key to the greater

proportion of uninsured adolescents. If

income-specific Medicaid coverage rates were

as high in the South as in the North, the proportion of Southern adolescents without

health insurance would drop by approximately 25 percent. In the West, lower rates of

private coverage appear to be the most critical factor although lower Medicaid coverage

rates are important as well. If incomespecific rates of private insurance coverage

were as high in the West as in the North, the

proportion of uninsured Western adolescents

would be reduced by about 19 percent.

These results make clear that public policies

designed to expand health coverage, such as

an employer mandate or expansion in

Medicaid, would have markedly different effects in Western and Southern States than in

the North.

Trends in Adolescent Insurance

Coverage, 1979-1986

The proportion of adolescents without

health insurance increased by 25 percent between 1979 and 1986 (figure 3). In the early

1980s, the rise in the uninsured was strongly

associated with increased poverty combined

with a decline in Medicaid coverage of the

poor and near-poor. Later, in the mid-1980s,

as the country recovered from recession,

these trends reversed somewhat. However,
4 ■ Preliminary Analyses of Adolescent Health Insurance Status

Table 1--- Health Insurance Status of Adolescents,

Age 10-18, by Family Income, 1987

Health insurance status

Proportion of

Family income as all adolescents at

a percent of the

No health Insured: private and publi c

the specified insurance Privat e Medicaid

Federal poverty level a

poverty Level bcoverage onl y onl y Othe r

c

Total

less than 50 percent 9.2% 30.9% 16.6% 48.4% 4.2% 100.0%

50 to 99 percent 10.1 32. 2 23. 6 38. 1 6 . 1 100. 0

100 to 149 percent 9 . 5 29. 4 53. 4 10. 7 6 . 5 100. 0

150 to 199 percent 9 . 7 21. 5 69. 2 3 . 1 6 . 2 100. 0

200 to 299 percent 19. 2 10. 3 82. 8 1 . 0 6 . 0 100. 0

300 percent and above & J 4 . 6 90. 7 0 . 2 4 . 6 100. 0

100.0%

~In 1987, the Federal poverty level Has $9,056 for a family of three.

There uere 31.0 million adolescents, age 10-18, in 1987.

cIncludes CHAMPUS, Medicare, or a combination of public and private coverage.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current

Population Survey.

Figure 3---Trends in the Proportion of Uninsured Adolescents,

Age 10-18, 1979-1986a

25

20

15

10

5

Percent uninsure d

25% increase frorn 1978-1986

1 I 1 I 1 I

1979 1881 1982 1883 1984 1985 1986

Yea r

a 1980 and 1988 data are not available; 1987 data are not comparable.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1980

through March 1987 Current Population Surveys.
the proportion of the adolescent population at

each income level with private insurance

declined substantially. It is important to note

that due to a combination of factors (including a decline in the absolute number of 10-

to 18-year-olds from 1979 to 1986), there

was no change in the aggregate number of

uninsured.

The decline in Medicaid coverage was

greatest among adolescents living in or near

poverty and was largely due to regulations

issued under the 1981 Omnibus Reconciliation Act of 1981 (OBRA) that limited the

working poor’s eligibility for Aid to Families

with Dependent Children (AFDC) and

Medicaid benefits. In 1979, 48 percent of

adolescents living in families between 50 to

99 percent of poverty had Medicaid coverage.

By 1983, this had dropped to 38 percent and

rebounded slightly to 42 percent in 1984 and

1986. Meanwhile, almost half of the adolescents in families with incomes from 100 to

149 percent of poverty who were in the

Medicaid program in 1979 had lost coverage

by 1982.

The decline in private coverage was also

most significant among the poor. In 1979, 17

percent of adolescents in households below 50

percent of poverty were covered by some

form of private insurance, but by 1986, only

11 percent were enrolled in a private health

plan. Adolescents in families between 50 to

99 percent of poverty experienced a similar

trend; the proportion with private health

coverage dropped from 27 to 22 percent during the same time period.

A principal reason why more adolescents

were uninsured in 1986 than in 1979 is simply that more lived with uninsured parents in

1986 than in 1979. During this period, the

proportion of adolescents who lived with

uninsured parents increased from 8.8 to 10.5

percent, accounting for 37 percent of the

overall 1979 to 1986 increase in uninsured

adolescents. At the same time, the uninsured

rate among adolescents who lived with

uninsured parents also rose, increasing from

92 to 96 percent (contributing an additional

10 percent to the overall climb in the

uninsured).

Eighteen percent of the overall rise in

the proportion of adolescents without health

coverage was due to a fall in the coverage

rate among adolescents not living with a

parent; in 1979, 61 percent were uninsured,

by 1986 the proportion without coverage

increased to 74 percent. The proportion of

adolescents who obtained health insurance

from their own jobs declined precipitously.

Estimated Effects of Employer

Mandates and Medicaid

Expansions

Two types of proposals have been prominently advanced to reduce the number of

uninsured. So-called “employer mandates” require that employers offer group health insurance policies and pay a significant amount

of the premiums for all employees who work

more than a specified number of hours per

week. Proposals to expand Medicaid require

that categorical eligibility requirements be

relaxed and/or that income eligibility limits

be increased, thereby requiring or encouraging all States to make Medicaid available to

all those eligible below certain income levels.

Numerous factors determine the effects

of an employer mandate: Who is included in

an employer mandate is especially important.

How many hours per week must be worked?

Does coverage begin on the first day of

employment or after awaiting period? Are

the self-employed included? Are employee

dependents covered? Will small firms be exempt? What level of benefits must be provided? How much must the employer contribute to the premium?

Similarly, the effect of an expansion in

Medicaid depends on a number of policy decisions. For example, what is the minimum

eligibility income level? Are the changes in

eligibility mandatory or optional for the

States? Are two-parent families with workers

eligible or must one parent be absent or unemployed?
6 • Preliminary Analyses of Adolescent Health Insurance Status

Estimated Effects of Employer Mandates

The following assumptions were used in

estimating the effect of an employer mandate

on the number of uninsured adolescents:

The self-employed are exempt. All

other “permanent” employees who work

more than the required number of hours

per week are covered (i.e., with no exemptions for firm size or industrial classification).

Employees working 26 weeks or more in

the preceding year are considered

“permanent” workers and would be covered under the mandate.

The effects of the mandate are estimated

using three different assumptions about

the number of hours of work at which

workers are covered: 18 hours, 25 hours,

and 30 hours.

Adolescents who do not live with their

parents are not covered as dependents

under the mandate; however all other

unmarried adolescents age 18 or younger

would be covered by the mandate if

their parents were covered as well.

If employees who worked 30 hours or

more per week were included, approximately

2.55 million uninsured adolescents, or 55 percent of all adolescents currently without

health coverage, would become insured. Although reducing the hourly work threshold

does increase the number of uninsured who

would become covered, its effect is relatively

minimal (at least within the range of 18 to 30

hours per week). For example, if the hourly

work threshold was reduced to 25 hours per

week, an additional 60,000 adolescents ( 1.3

percent of all those uninsured) would be covered. If the threshold was 18 hours per

week, an additional 136,000 adolescents (or 3

percent of all uninsured adolescents) would

be covered.

Estimated Effects of Medicaid Expansion

Proposals to expand Medicaid may

mandate or give States the option to broaden

Medicaid eligibility. Currently States have

the flexibility, within limits, to set their own

eligibility levels for the AFDC and Medicaid

programs. Some States have relatively broad

eligibility policies while others are much

more restrictive. However, with few exceptions, adolescents are eligible for Medicaid

only if they are in a family with a so-called

“deprivation factor”; that is, a family with an

absent parent or one whose principal breadwinner is unemployed.4

If the current categorical requirement of

a “deprivation factor” is maintained, the

potential for an expansion in Medicaid to

cover significant portions of uninsured

adolescents is severely limited. If all adolescents in single-parent households with incomes below 100 percent of poverty were

covered by Medicaid, approximately 707,000

of the 4.6 million uninsured adolescents

would be covered. However, even if States

were required to extend eligibility standards

to all such adolescents, it is doubtful that all

would enroll. In fact, many of the 8 percent

of uninsured adolescents who were in singleparent households in 1987, with incomes below 50 percent of poverty, were already

eligible to receive Medicaid benefits.

If categorical requirements were dropped,

and all adolescents with family income below

a specified standard were eligible for

Medicaid, then significant portions of the

currently uninsured could be covered by a

Medicaid expansion. For example, if

households with family incomes below 100

percent of poverty were included, more than

40 percent of currently uninsured adolescents

would be covered. An additional 19 percent

of uninsured adolescents would be included if

the income standard was raised to 149 percent

of poverty.

Combined Approach: Employer Mandate

With A Medicaid Expansion

If employers were required to cover all

workers who worked 18 hours or more and

A This remains unchanged by the Family Support Act

of 1988 (Public Lau 100-485).
Medicaid was available to all adolescents in

families with income below 200 percent of

poverty, then only 7 percent of adolescents

without health coverage would remain

uninsured. An employer mandate that included employees of at least 30 hours per

week combined with a Medicaid expansion

that included all adolescents below 100 percent of poverty would cover over 80 percent

of uninsured adolescents.

Most of the adolescents left out by the

combination of an employer mandate and

Medicaid expansion are children of the selfemployed. If the self-employed were included under a “combination” mandate, the

vast majority of uninsured adolescents would

become covered.

Of the proposals evaluated, clearly the

single greatest impact would come from an

employer mandate .
2. INTRODUCTION AND CURRENT NUMBER

OF UNINSURED ADOLESCENTS

This paper examines the health insurance

status of adolescents, aged 10 to 18 years, and

addresses the following questions:

How many adolescents are without

health coverage and why are some

adolescents insured and others not?

Has the number of uninsured adolescents

changeover time? If so, why has this

change occurred?

How many adolescents would be affected by three potential approaches to

reducing the number of uninsured: a

mandate that employers provide health

insurance to their workers (and workers’

dependents); an expansion of the

Medicaid program; or a combination of

the two?

The first section of the paper briefly describes its principal data source, the Current

Population Survey (CPS), and important issues

in using the CPS to measure insurance status.

The second section provides a preliminary

analysis of the size and characteristics of the

uninsured adolescent population in 1987 and

also examines the sociodemographic factors

related to health insurance status. Next,

trends in the number of uninsured adolescents

from 1979 to 19861 are assessed. The final

section provides estimates of the potential effects of an employer mandate, Medicaid expansion, or combination approach on the

number of uninsured adolescents.

In light of today’s pressing debate concerning the uninsured, this preliminary report

has been prepared based on currently available information. An update, based on final

results from the 1988 and 1989 March sur1 The year 1987 is not included because as ex -

plained below, questions asked for that year ar e

not comparable to past years.

veys, will be released as soon as possible.2

Data and Related Issues

Current Population Survey

Data for this study come from the CPS, a

household survey that is fielded monthly by

the U.S. Bureau of the Census to approximately 60,000 families (including 160,000 individuals). The chief objective of the CPS is

to provide monthly estimates of the nation’s

unemployment rate and other characteristics

of the labor force. Starting in 1980, a set of

questions about health insurance coverage

during the previous year 3 was added to the

survey in the month of March .

4 The supplement also asks a variety of questions about

work history and income during the previous

year. Responses to questions in the supplement are the basis for the analyses presented

in this paper.

Important Issues in Using the Current

Population Survey

Important adjustments to the 1988 data

were required to estimate and describe uninsured adolescents (see appendix A for

greater detail). Each March from 1980

through 1987,4 the CPS used identical health

z At the time this Background Paper was published,

data from the March 1989 CPS were not avai lab[e for

ana 1 ysis. Note, houever, that because of question

wording changes initiated in March 1988, data collected in 1988, 1989, and subsequent years, wil l

never be able to be cmpared to data C O1 lected from

March 1980 through March 1986. Uhen the March

1989 CPS becomes available, some analysis will b e

able to be made comparing 1987 and 1988. (Not e

further that the data collected each March pertain

to the previous calendar year; thus, data collected

in March 1980 pertain to calendar year 1979, an d

data collected in March 1989 pertain to calenda r

year 1988. )

3 There is some controversy about the way respondents interpret the CPS questions. Some analyst s

have argued that people respond as to their insurance status at the point in time at which the survey is fielded, not for the calendar year preceding

the survey. For discussion of this issue, see ap -

pendix A.

a The March 1981 survey is an exception; the complete set of health insurance questions were no t

asked in that year.

9
insurance questions (see appendix B). In

1988, new questions were introduced and the

others were changed materially. The March

1988 health insurance questions (see appendix

C) provide an improved and more accurate

estimate of the number of adolescents who

are uninsured.

One of the principal problems with the

earlier CPS was that it did not ask if adolescents or other children received health insurance coverage from absent parents (or anyone

outside the household). Thus, any adolescent

or child who was covered under an absent

parent’s health policy was almost always

reported as uninsured. As a result, the

March 1980 to 1987 surveys almost certainly

overestimated the actual number of uninsured

adolescents.

Two changes were made in the March

1988 CPS to fix this problem. First, questions directed to respondents 15 years of age

and older were modified and second, new

questions about children 14 and younger were

introduced .

5 In the 1980 to 1987 surveys,

there was no direct question inquiring

whether each individual in the household was

covered by a health plan; the Census Bureau

had to “infer” coverage when a private insurance subscriber reported that his or her children were covered. Adolescents and other

dependents were counted as insured only if

they resided with a subscriber to a policy or

they themselves were a subscriber to a health

insurance plan. In contrast, the new 1988

questions specifically ask whether each person

in the household, age 15 and above, was covered by a health insurance plan. Those who

answer yes are then asked if the plan is in

their own name or not. Thus, for example,

adolescents (age 15 and older) who reside

with their mother but are enrolled in an absent father’s health insurance policy, would

be reported as insured in the 1988 survey but

uninsured in the 1987 survey. In addition, a

separate set of 1988 questions explicitly ask if

children 14 and younger were covered by a

nonresident parent.

Responses to the new questions aimed at

the 15 and older group are included in OTA’s

preliminary analysis, but answers to the new

questions concerning children 14 and younger

have not yet been provided by the Census

Bureau. The final, complete data will not be

released until later this year.

Before any adjustment, 1988 estimates

indicated that 15 percent of 15- to 18-yearolds and 22 percent of 10- to 14-year-olds

were uninsured in 1987. Yet earlier surveys

found little difference in the health insurance

status of these two age groups. It is most

likely that this discrepancy in coverage rates

is because data for the 10- to 14-year-olds is

not yet complete. It is likely that the final

data will show similar rates of coverage for

these two groups of adolescents. Therefore,

the 1988 CPS data presented in this report assume similar coverage rates among adolescents aged 10 to 14 and 15 to 18 given the

same family income relative to the Federal

poverty level, living arrangement (i.e., twoparent family, one-parent family, or no

parent present), and parent’s insurance status.

Finally, in this report, the March 1980

through March 1987 data serve as the basis

for describing trends in adolescent health insurance status. Keep in mind that because of

the changes in the survey, the 1988 findings

cannot be directly compared with earlier

results.

Number of Uninsured Adolescents,

10- to 18-Years-Old, 19876

Approximately 4.6 million adolescents, 15

percent overall, were without either public or

5 Questions are asked directly of respondents 1 5

years and older and of the parents of those under

15.

6 Throughout this report, adolescents are defined

to be aged 10- to 18-years inclusive.
private health coverage in 1987 (table 2). 7

however, are more than twice as likely as 25-

Adolescents are slightly more likely to be to 54-year-olds to be covered by a public

uninsured than

and adults aged

adolescents who

children aged 9 and younger program, particularly Medicaid. ‘Almost 10

25- to 54-years-old.8 Thos e percent of adolescents have Medicaid

do have health insurance, coverage compared to 4.5 percent of 25- to

54-year-olds. Note also that while about 70

percent of adolescents have private insurance.

7 As noted earlier, preliminary 1988 CPS data hav e 25- to 54-year-olds are privately insured at a

been adjusted to facilitate the analysis . See somewhat higher rate (i.e., 76 percent). llData ad HethodS!l and appendix A fOr details on

the CPS and adjustments to” the data.

8 While earlier CPS data indicate that adolescent s

(and younger children) are significantly more like -

ly to be uninsured than adults (Chollet, 1988), the

preliminary 1988 data suggest little difference in

the proportion of adults and adolescents uho ar e

uninsured . These findings are similar to thos e

from the 1986 National Health Interview Survey and

preliminary results from the 1987 National Medical

expenditure Survey (U.S. Department of Health and

Human Services [USDHHS], 1987; Short, et al. ,

1988).

Table 2--- Health Insurance Status of the 10- to 64-year-old

Population, by Age Group, 1987

No health Insured: private and publi c

a,b

Age Total insurance Privat e Medicaid

group population Number Percent onl y onl y Other

10-1 8

C

31,006,18 9 4,612,36 6 14.9% 69.9% 9.9% 5.3%

19-2 4 22,331,82 3 5,482,49 0 24. 6 63. 1 6 . 3 6 . 0

25-5 4 101,413,81 8 14,134,45 5 13. 9 76. 1 4 . 5 5 . 3

55-6 4 21,635,13 7 2,418,15 4 11. 2 71. 4 4 . 0 13. 4

a

Private onl y includes all with ~loynent-basd coverage from someone in or outside the household and nongroup insurance from hwsehold numbers; Medicaid includes all those with only Medicaid coverage; and other

includes CHAMPUS, Medicare, or a combination of public and private coverage.

b

Row percentages may not total 100 percent &e to rounding.

cHealth insurance status for 10- to 14-year-olds has been estimated based on currently available informa -

tion . See appendix A for details.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current Population

Survey.

19-7570-89-2 : QL 3
3. SOCIODEMOGRAPHIC CHARACTERISTICS OF

UNINSURED ADOLESCENTS

Understanding the sociodemographic factors that are related to adolescent health insurance status is key to unraveling the problem of those who are uninsured. Parent’s insurance status, poverty and family income,

who adolescents live with, race and ethnicity,

parent’s marital status and education, region

and residence, and parent’s work status, and

employment characteristics are all related to

insurance status (see appendix D). However,

many demographic and socioeconomic characteristics of adolescents are highly intercorrelated, and most are correlated with family income. The following examines these relationships and assesses their correlation with

health insurance status independent of family

income. 1

Family Income

Family income is the most important

determinant of health insurance status for all

age groups. The poor, regardless of other

factors, are the most likely to be uninsured.

Adolescents in poor or near-poor families are

much more likely to be uninsured than

others; approximately 30 percent are without

any coverage, public or private (see table 1 in

Executive Summary). In contrast, half as

many adolescents whose family income is between 150 and 299 percent of poverty and

less than 5 percent of adolescents of adolescents in families at 300 percent of poverty or

above are uninsured.

Race and Ethnicity

The correlation between race and lack of

health coverage almost disappears when family income is taken into account. Black

adolescents are much more likely than whites

to live in or near poverty (and thus to be

uninsured); more than half of black adolescents are in families with incomes below 150

percent of poverty compared to 19 percent of

whites (figure 4). Yet, black and white

adolescents who live in families with similar

incomes are insured at similar rates

(table 3). Nonetheless, how black and white

adolescents are covered does differ within the

same income categories, especially among

those living in or near poverty. White

adolescents who live below 150 percent of

poverty are twice as likely as black adolescents in similar economic circumstances to

have private health coverage. Black adolescents in this income category are twice as

likely as whites to be covered by Medicaid.

This is not the case for Hispanic adolescents however. Hispanic adolescents are

much more likely than others to be uninsured

regardless of family income. In families with

incomes below 150 percent of poverty, for

example, 43 percent of Hispanic adolescents

are uninsured, compared to 30 percent of

non-Hispanic whites and 26 percent of nonHispanic blacks (table 3). This may be because Hispanics are more likely than others to

work in agriculture and domestic service

where coverage rates are historically low. In

addition, Hispanic adolescents who are “undocumented aliens” are not routinely eligible

for Medicaid; eligibility is a State option.2

Living Arrangement

It is clear that adolescents who live with

two parents are more likely to be insured

than others. However, a more complicated

1 See appendix E for Federal poverty levels in 1979

to 1988.

z Other contributing factors may be family composition and nunber of uorkers in the fami ly. If

Hispanic fami 1 ies 1 iving in poverty are more likely

than others to inc(ude both husband and uife, the y

will be less likely to be eligible for Medicaid .

Census data indicate that, of famil ies below th e

poverty level, Hispanic fami lies are more likel y

than Black non-Hispanic families, but not mor e

likely than Uhite non-Hispanic families, to includ e

both husband and wife (U.S. Department of Comnerce,

August 1988). In addition, employment-based health

insurance may not be available to a working-poor

Hispanic fami ly if it includes more than one wageearner.

13
Figure 4.--Poverty Status of Adolescents, Age 10-18, by Race/Ethnicity, 1987’

300

151-299 percent n t

than

percent

151-2

pe perc cent

and above 51% 26% and above

less than

150

151

pe

150 percent percent~

28%

. . . . . . . . . . . . . . . percent . . . . . . . . . . . . . . . . . . . . . . . . .

a

Poverty status is expressed in relation to the Federal poverty level. In 1987, the Federal poverty leve l

was $9,056 for a family of three.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current Population Survey.
Preliminary Analyses of Adolescent Health Insurance Status • 15

Table 3--- Family Income, Race and Ethnicity,

and Health Insurance Status of Adolescents, Age 10-18, 1987

Family income No health Insured: private and publi c

as a percentage insurance Privat e Medicaid

of povert y

a

Race/ethnicit y Tota l

b

coverage onl y onl y Othe r

c

less than white, non-Hispanic 100.0% 29.8% 41.0% 22.4% 6.7%

150 percent black, non-Hispanic 100. 0 25. 6 22. 5 46. 0 5 . 8

Hispanic 100. 0 42. 6 22. 3 32. 6 2 . 5

other 100. 0 27. 4 23. 0 43. 9 5 . 7

------ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

150 to white, non-Hispanic 100. 0 12. 6 80. 7 1 . 0 5 . 6

299 percent black, non-Hispanic 100. 0 14.1 74. 4 3 . 6 7 . 9

Hispanic 100. 0 22. 5 67. 9 4 . 3 5 . 3

other 100. 0 19. 7 68. 9 0 . 7 10. 7

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- ------- -- .... . . . . . . . . . . . . . .

More than white, non-Hispanic 100. 0 4 . 0 91. 7 0 . 2 4 . 1

300 percent black, non-Hispanic 100. 0 6 . 6 85. 7 0 . 9 6 . 7

Hispanic 100. 0 7 . 3 84. 1 0 . 1 8 . 5

other 100. 0 10. 5 84. 2 0 . 4 5 . 0

~In 1987, the Federal poverty level was $9,056 for a family of three.

Percentages may not total 100 percent due to romding.

cIncludes adolescents with CHAMPUS, Medicare, or any combination of public and private coverage.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current Population Survey.
16 • Preliminary Analyses of Adolescent Health Insurance Status

picture of the effects of living arrangement

on health insurance status emerges when family income is taken into account. Part of the

reason why adolescents who do not live with

two parents are often uninsured is because

they are also likely to be poor. Most adolescents who live with only one parent live in or

near poverty: 60 percent of adolescents who

live with their mother only are in families

below 150 percent of poverty (table 4).

Adolescents who do not live with a parent at

all are even more likely to live in or near

poverty. In contrast, only 16.2 percent of

adolescents in two-parent families live below

150 percent of poverty.

Almost half of poor or near-poor adolescents who live with their mother only are insured under the Medicaid program (table 5).

In fact, this group of adolescents is more

likely than any others, even two-parent family dependents, to have health coverage. For

adolescents in families at 150 percent of

poverty or above, however, the expected relationship between living arrangement and insurance status is found; those who live with

both parents are much more likely than

others to have health coverage.3

Parent’s Education

The effects of parental education, even

controlling for family income, are quite

strong; at each income level, adolescents

whose parents have little formal education are

much more likely to be uninsured than

adolescents whose parents have had more education (table 6).

The relatively strong relationship between level of education and insurance status

may result from a number of factors: those

with more education are likely to have

3 This result is one of the only findings in thi s

section that is at variance with the findings from

the 1984 National Health Interview Survey (NH IS)

(Ne~acheck and McManus, 1989). Using the 198 4

NH IS, Newacheck and McManus conclude that controlling for family income there is no relationship be -

tween being in a single parent family and lack o f

health insurance.

greater assets to protect and are thus likely to

be more risk averse than those with less education (and also more likely to be able to afford to buy insurance); those with more education are likely to be valued more highly in

the labor market, thus, even controlling for

cash income we would expect their total compensation to be greater; and those with more

education may be inclined to value the consumption of medical care more highly than

those with less education.

But to put the relative importance of education in some perspective, in preliminary

multivariate analyses 4 it appears that, for

adolescents, low family income (i.e., below

150 percent of poverty) is a much stronger

predictor of being uninsured than having a

parent with limited education (i.e., less than a

high school education).

Parent’s Work Status and Employment

Characteristics

Controlling

cents who live

somewhat more

for family income, adoleswith full-time workers are

likely than those living with

x Multivariate analyses were not well enough de -

veloped to report in full here . Correctl y

specified analyses are a nontrivial problem. Al -

though limited dependent variable models can b e

estimated with a O-1 dependent variable measuring

whether or not an adolescent is insured, suc h

models do not correspond direct(y to any choices

being made. Rather, there is a hierarchical decision process. One way of specifying it is as follows: an adult either works at a job with health

benefits offered or not, and if so, decides whether

or not to cover any adolescent children . If n o

benefits are offered, the children may or may no t

be eligible for Medicaid, and if eligible, th e

parent decides whether or not to apply. If ther e

is no employer-provided insurance and no publi c

program, then the parent decides whether or not to

buy nongroup insurance . Rather than one simpl e

model with a yes/no variable for insurance, a t

least three models should be estimated (i.e. ,

yes/no on employer provided insurance, Medicaid

eligibility/coverage , and purchase of nongroup insurance) . It may be, of course, that reasonabl y

accurate estimates of the ~effects” of independen t

variables can be achieved from estimation of th e

sinple combined model, but this is not yet clear.
Preliminary Analyses of Adolescent Health Insurance Status • 17

Table 4--- Adolescent’sLiving Arrangement by Family Income, 1987

Family income

as a percentage Proportion of

of Povert y

a

Living arrangement adolescents

less than 150 percent living with both parents 16.2%

living with father onl y 25. 2

living with mother only b

60. 0

not living with paren t 65. 4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

151 to 299 percent living with both parents 31.0%

living with father onl y 28. 8

living with mother only 24. 7

not living with paren t 19. 9

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300 percent and above living with both parents 52.8%

living with father onl y 46. 0

living with mother only b

15. 2

not living with parent 14. 8

~In 1987, the Federal poverty level uas $9,056 for a family of three.

The CPS category “adolescents not living uith their Parents” includes adolescents who live uith other relatives (i.e. , grandchildren, nieces, nephews, etc.) or unrelated individuals, those living on their o~n

(or with their own spouse and/or children), and married adolescents who reside with their parent(s).

Married adolescents are categorized this way because the Census Bureau assunes that most private health

insurance plans exclude them from their parent’s policies.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current

Population Survey.

Table 5.--Family Income, Living Arrangement,

and Health Insurance Status of Adolescents, Age 10-18, 1987

Family income No health Insured: private and publi c

as a percentage insurance Privat e Medicaid

of Povert y

a

Living arrangement Tota l

b

coverage onl y onl y Othe r

c

less than living with both parents 100.0% 34.0% 41.4% 17.3% 7.3%

150 percent living with father onl y 100. 0 33. 9 32. 8 27. 0 6 . 3

living with mother only d

100. 0 23. 4 23. 0 49. 5 4 . 1

not living with paren t 100. 0 44. 0 27. 8 22. 8 5 . 5

------ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

150 to living with both parents 100. 0 11. 4 80. 9 1 . 0 6 . 9

299 percent living with father onl y 100. 0 18. 2 73. 0 1 . 2 7 . 5

living with mother only d100. 0 18. 5 75. 1 2 . 8 3 . 6

not living with parent 100. 0 37. 0 51. 7 8 . 3 3 . 0

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300 percent living with both parents 100. 0 3 . 2 91. 9 0 . 1 4 . 8

and above living with father onl y 100. 0 10.1 83. 4 0 . 5 6 . 0

living with mother only d100. 0 9 . 5 87. 9 0 . 9 1 . 8

not living with paren t 100. 0 33. 2 64. 0 1 . 6 1 . 2

;In 1987, the Federal poverty level was $9,056 for a family of three.

Percentages may not total 100 percent due to rounding.

~Includes adolescents with CHAMPUS, Medicare, or any combination of @lie and private coverage.

Includes adolescents not living with their parents and married adolescents living ~ith their parents.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current Population Survey.
18 • Preliminary Analyses of Adolescent Health Insurance Status

Table 6--- Family Income, Education of Family Head,

and Health Insurance Status of Adolescents, Age 10-18, 1987

Family income No health Insured: private and publi c

as a percentage Education of b insurance Private Medicai d

of povert y

a

family head Tota l

c

coverage onl y onl y Othe r

d

less than less than 9 years 100.0% 35.8% 21.1% 40.5% 2.5%

150 percent 9 to 11 years 100. 0 27. 2 22. 4 45. 1 5 . 3

high school graduate 100. 0 27. 0 37. 3 29. 7 6 . 0

some college 100. 0 27. 3 39. 9 24. 0 8 . 8

college graduate 100.0 19. 4 52. 5 19. 6 8 . 5

post graduate 100. 0 18.1 58. 9 11. 6 11. 3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

150 to less than 9 years 100. 0 22. 4 67. 0 4 . 3 6 . 3

299 percent 9 to 11 years 100. 0 21. 1 72. 2 2 . 6 4 . 2

high school graduate 100.0 10. 8 82. 2 1 . 3 5 . 7

some college 100.0 12. 3 78. 5 0 . 6 8 . 6

college graduate 100.0 11. 0 83. 7 5 . 4

post graduate 100. 0 6 . 8 86.6 . 6 . 6

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300 percent less than 9 years 100. 0 12. 8 85. 9 1 . 2

and above 9 to 11 years

.

100. 0 7 . 6 84. 8 7 . 7

high school graduate 100. 0 3 . 8 92. 2 0 . 2 3 . 8

some college 100. 0 3 . 7 90. 1 0 . 3 6 . 0

college graduate 100.0 4 . 1 91. 7 0 . 2 4 . 0

post graduate 100. 0 2 . 6 93. 0 0 . 1 4 . 4

~ln 1987, the Federal poverty level uas $9,056 for a family of three.

Refers only to parent(s) uho reside uith uranarried adolescents .

2

ercentages may not total 100 percent due to rounding.

Includes adolescents uith CHAMPUS, Medicare, or any combination of public and private coverage.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current

lation Survey.

Popu-
Preliminary Analyses of Adolescent Health Insurance Status Ž 19

part-time or part-year workers to be insured,

but the relationship is weak (table 7). Given

the same family income, an adolescent whose

parent is a part-time or part-year worker is 3

to 7 percentage points more likely to be

uninsured than an adolescent whose parent is

a full-time, full-year worker.

When family income is held constant, the

relationships between industry of parent’s

employment and lack of insurance are attenuated, but do not disappear. Part of the

reason why adolescents whose parents work in

agriculture or retail trades are more likely

than other adolescents to be uninsured is that

such adolescents are much more likely than

others to be poor; however industry does have

some independent effect on the probability of

being uninsured, particularly among middle

income groups (i.e., 150 to 299 percent of

poverty).

As would be expected given the more favorable tax treatment of employer-sponsored

insurance and the advantages of purchasing

insurance in the large group market, controlling for family income does not substantially

attenuate the relationship between selfemployment and lack of health insurance.

Among adolescents in middle- and upperincome families, adolescents whose parents

are self-employed are much more likely than

others to be uninsured (table 7).

Residences

The bivariate relationship between

residence (i.e., central city, suburban, rural)

and insurance status (see appendix D) virtually disappears when family income is held

constant.

Understanding Why Health

Insurance Status Varies Across

Regions

The proportion of adolescents without

health coverage varies widely across regions

of the country (see figure 5 for a map of

United States census regions; see appendix D).

Almost one out of five Southern and Western

adolescents are uninsured while less than one

out of ten Northeastern and Midwestern

adolescents are without coverage (table 8).

These differences appear to be largely due to

the extent to which adolescents have private

coverage; approximately 76 percent of adolescents in the North are privately insured compared to 65 percent in the South and 54 percent in the West.

6 Medicaid coverage varies

as well, but the regional differences are relatively small (i.e., North, 11 percent; South

and West, 9 percent).

These findings concur with other research (Newacheck and McManus, in press;

Short, et al., 1988). The large difference

across regions in the extent of private insurance coverage has led researchers to conclude

that most of the regional variation in

coverage rates is due to differences in the extent to which employers offer health insurance benefits. In the North, the more

unionized, industrial labor force is more likely to have employment-related benefits than

workers in the South and West. It has also

been noted that more restrictive Medicaid

eligibility policies in the South contribute to

lower coverage rates, but the extent of this

contribution has not been measured before.

This section examines regional differences in coverage rates more closely and

finds that Medicaid eligibility, particularly in

the South and to some degree in the West,

plays a more critical role vis a vis the

uninsured than has been generally recognized.

5 This paper follows Census Bureau terminology for

residence and region.

6 Because insurance status in the Northeast and

Midwest is so similar, in the remainder of thi s

section the two areas are combined and referred to

as the "North."
20 • Preliminary Analyses of Adolescent Health Insurance Status

Table 7.--Family Income, Selected Parental Characteristics, and Health Insurance Status

of Adolescents, Age 10-18, 1987

Family income as No health Insured: private and public

a percentage of Parental insurance Private Medicai d

of povert y

a

characteristic s

b

Tota l

c

coverage onl y onl y Othe r

d

Parental work status :

e,f

less than full-year, full-tim e 100.0% 31.0% 59.0% 6.4% 3.5%

150 percent full-year, part-tim e 100. 0 37. 2 32. 8 23. 3 6 . 8

part-yea r 100. 0 34. 0 24. 5 35. 5 6 . 0

nonworker 100. 0 19. 5 8 . 6 65. 2 6 . 8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

150 to full-year, full-tim e 100. 0 11. 6 84. 9 0 . 4 3 . 1

299 percent full-year, part-tim e 100. 0 16. 2 73. 6 2 . 7 7 . 5

part-yea r 100. 0 18. 7 69. 1 4 . 3 8 . 0

nonworker 100. 0 18. 0 29. 8 8 . 6 43. 6

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300 percent full-year, full-tim e 100. 0 3 . 6 93. 2 0 . 1 3 . 1

and above full-year, part-tim e 100. 0 6 . 1 87. 3 0 . 8 5 . 8

part-yea r 100. 0 6 . 6 90. 4 3 . 0

nonworker 100. 0 7 . 1 29. 1 0 . 9 61. 9

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

less than

Industry of family head :

e

public administration 100. 0 18. 6 55. 2 14. 4 11. 8

150 percent durable goods 100. 0 26. 9 55. 8 12. 5 4 . 9

transportation 100. 0 39. 5 43. 0 13. 3 4 . 1

mining 100. 0 34. 9 54. 4 8 . 6 2 . 0

nondurable goods 100. 0 28. 9 54. 1 12. 3 4 . 7

financ e 100. 0 31. 0 54. 7 7 . 0 7 . 3

wholesale trade 100. 0 28. 7 47. 9 17. 6 5 . 9

professional service s 100. 0 26. 9 50. 7 17. 9 4 . 7

construction 100. 0 42. 6 30. 7 19. 4 7 . 3

retail trad e 100. 0 38. 7 36. 3 19. 8 5 . 2

business services 100. 0 36. 5 32. 9 28. 3 2 . 3

entertainmen t 100. 0 31. 5 54. 9 10. 0 3 . 7

agricultur e 100. 0 38. 4 47. 2 8 . 7 5 . 8

personal services 100. 0 36. 4 34. 3 26. 7 2 . 6

nonworker/other 100. 0 19. 5 8 . 6 65. 2 6 . 8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

150 to public administration 100. 0 4 . 1 87. 3 0 . 6 8 . 1

299 percent durable goods 100. 0 8 . 2 87. 6 0 . 7 3 . 4

transportation 100. 0 9 . 3 86. 9 0 . 2 3 . 6

mining 100. 0 2 . 5 91. 6 6 . 0

nondurable goods 100. 0 8 . 4 86. 4 1 . 4 3 . 9

financ e 100. 0 13. 3 85. 5 0 . 7 . 5

wholesale trade 100. 0 10. 2 87. 9 1 . 9

professional service s 100. 0 11. 5 84. 6 0 . 6 3 . 3

construction 100. 0 24. 0 69. 4 0 . 9 5 . 7

retail trad e 100. 0 16. 0 77. 1 2 . 5 4 . 4

business services 100. 0 22. 3 70. 2 0 . 9 6 . 6

entertainmen t 100. 0 12. 0 76. 6 3 . 3 8 . 1

agricultur e 100. 0 25. 6 69. 9 4 . 5

personal services

.

100. 0 27. 2 69. 5 1.1

nonworker/other 100. 0 18. 0 29. 8 8 . 6 43. 6

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(continued )
Preliminary Analyses of Adolescent Health Insurance Status ■ 21

Table 7--- Family Income, Selected Parental Characteristics, and Health Insurance

Status of Adolescents, Age 10-18, 1987 (Cont’d)

Family income as No health Insured: private and pu bli c

a percentage of Parental insurance Privat e Medicaid

of povert y

a

characteristic s

b

Tota l

c

coverage onl y onl y Othe r

d

300 percent public administration 100. 0 2 . 1 88. 1 9 . 8

and above durable goods

.

100. 0 2 . 1 95. 5 2 . 4

transportation 100. 0 3 . 0 92. 8 0 . 2 4 . 1

mining 100. 0 4 . 6 93.6 . 1 . 8

nondurable goods 100. 0 2 . 5 %.3 . 1 . 2

financ e 100. 0 4 . 1 93. 9 2 . 0

wholesale trade 100. 0 4 . 7 92.7 . 2 . 5

professional service s 100. 0 3 . 9 93. 9 0 . 2 2 . 0

construction 100. 0 8 . 1 86. 8 0 . 3 4 . 9

retail trad e 100. 0 5 . 2 92. 1 0 . 1 2 . 6

business services 100. 0 6 . 1 87. 0 0 . 8 6 . 1

entertainment 100. 0 98. 0 2 . 0

agricultur e 100. 0

.

8 . 3 90. 1 1 . 6

personal services 100. 0 10. 8 86.2 . 2 . 9

nonworker/other 100. 0 7 . 1 29. 1 1 . 9 61. 9

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------ ------ ------ ---- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- ------- --

Parent self-employed: e

less than self-employed 100.0% 36.8% 47.8% 9.6% 5.8%

150 percent not self-employed 100. 0 33. 0 43. 7 18. 4 4 . 9

non worker 100. 0 19. 5 8 . 6 65. 2 6 . 8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------ ------ ------ ------ -- . . . . . . . . . . . . . . . . . . . . . . . . . .

150 to self-employed 100. 0 29. 8 65. 1 0 . 2 4 . 8

299 percent not self-employed 100. 0 11. 2 83. 9 1 . 0 3 . 9

non worker 100. 0 18. 0 29. 8 8 . 6 43. 6

. . . . . . . . . . . . . . . . ------ ------- ------- ------- ------- ------- ------- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300 percent self-employed 100. 0 14. 2 82. 5 3 . 3

and above not self-employed 100. 0 3 . 1 93. 5 0 . 1 3 . 3

non worker 100. 0 7 . 1 29. 1 1 . 9 61. 9

~In 1987, the Federal poverty level uas $9,056 for a family of three.

Characteristics are of household head unless only the spouse had enploynent-based health coverage.

~ercentages ~Y not total 100 percent due to r~if-lg.

Includes adolescents uith CHAMPUS, Medicare, or any combination of public and private coverage.

~Includes only umnarried adolescents living uith their parents.

Full-year, full-time refers to uorkers who worked for at least 35 hours per ueek for at least 50 weeks.

Full-year, cmrt-time refers to workers who were employed for at least 50 weeks and worked less than 35 hours in

a typical week. Part-year workers worked or sought work during the year, but for less than 50 weeks during the

year. Nonworkers neither worked nor sought work during 1987.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current Population Survey.
22 • Preliminary Analyses of Adolescent Health Insurance Status

Figure 5.--Map of the U.S., Showing Census Divisions and Regions

I

‘ - .

s

SD

NE

Tea.

TX

West

r

SOURCE: U.S. Bureau of the Census.
Preliminary Analyses of Adolescent Health Insurance Status • 23

Table 8.-- Region and Adolescent Health Insurance Status, 1987

No health Insured: private and public

insurance Private Medicai d

Region a

Total coverage onl y onl y Othe r

b

Northeas t

c

100.0% 9.2% 76.6X 10.9% 3.3%

Midwes t

c

100. 0 9 . 3 76. 1 11.1 3 . 6

South 100. 0 19. 7 64. 7 8 . 8 6 . 7

West 100. 0 18. 6 65. 4 9 . 4 6 . 7

a

Northeast includes : Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York,

Pennsylvania, Rhode Island, Vermont.

Midwest includes: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska,

North Dakota, Ohio, South Dakota, and Wisconsin.

South includes: Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland,

Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia,

and West Virginia.

West includes: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico,

Oregon, Utah, Washington, and Wyoming.

b

Includes adolescents with CHAMPUS, Medicare, or any combination of public and private coverage.

c

In the text, Northeast and Midwest are combined and referred to as North.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current Population Survey.
24 ■ Preliminary Analyses of Adolescent Health Insurance Status

In order to better understand the regional

differences in coverage rates, it is useful to

examine differences in three key factors

across regions:

the proportion of adolescents who are

poor;

the proportion of adolescents who

receive Medicaid, controlling for family

income; and

the proportion of adolescents with private insurance, controlling for family

income.

It is evident that a greater proportion of

Southern than Northern adolescents live in

poverty (table 9). For example, 12 percent of

Southern adolescents are in families below 50

percent of poverty in contrast to 8 percent in

the North. It follows that, if other things

were equal, Southern adolescents should have

a significantly higher rate of Medicaid

coverage than Northern adolescents. However, only 43 percent of low-income

Southerners are covered by Medicaid compared to 61 percent of those in the North.

Poor Western adolescents are the least likely

to be covered by Medicaid; only 37 percent

in families below 50 percent of poverty have

Medicaid coverage.

Similarly, Medicaid coverage rates for

Northern adolescents are higher than those

for Southern adolescents for all income categories. In the West, however, Medicaid

coverage rates in families at 100 percent of

poverty or above are slightly higher than in

the North.

On average, adolescents are 11 percentage points more likely to be covered by private insurance in the North than in the South

or West (table 8).

The contribution of each factor to the

overall differences across regions in the proportion of adolescents can be measured by

constructing three simulations. The first

simulation computes the rate at which

Southern (or Western) adolescents would be

uninsured if the distribution of Southern (or

Western) adolescents by poverty level equalled

the distribution in the North.

The second simulation computes the rate

at which Southern (or Western) adolescents

would be uninsured if the Medicaid coverage

rates in the South (or West) were equal to

those in the North, controlling for family income.

7

The third simulation computes the rate at

which Southern (or Western) adolescents

would be uninsured if the proportion of

adolescents with private insurance coverage at

each level of family income were the same in

the South (or West) as in the North. To increase the stability of the estimates, data

from the four CPS surveys between 1984 and

1987 are pooled in the analysis.8

Simulation Results

From 1983 through 1986, 25 percent of

Southern adolescents, 23 percent of Western

adolescents, and 16 percent of Northern

adolescents were uninsured (table 10). The

simulation results reported below break down

these differences into their component parts.

These results make clear that public policies

designed to expand health coverage (such as

the Medicaid expansions or employer mandates discussed later in the paper) would have

markedly different effects in Western and in

Southern States than in Northern States.

Southern States--- It appears tha t

Medicaid income eligibility requirements are

key to the greater proportion of uninsured

7 In performing this simulation, a finer breakdown

of family income was used than is shown in table 9,

including: less than 50 percent of poverty, 50 to

74 percent, 75 to 99 percent, 100 to 124 percent,

125 to 149 percent, 150 to 199 percent, 200 to 249

percent, 250 to 299 percent, 300 to 349 percent,

350 to 399 percent, 400 to 449 percent, 450 to 499

percent, and 500 percent and above. In order to

provide more stability to the estimates at thi s

level of detail, an increased sample size, based on

pooled data frcin the March 1984 to March 1987 Current Population Surveys was used.

8 Note that because the data usedare pre-1988, the

absolute proportions of uninsured adolescents shown

in this section will be higher than the estimate s

using the March 1988 CPS. Pre-1988 estimates and

estimates based on the March 1988 are not directly

comparable.
Preliminary Analyses of Adolescent Health Insurance Status • 25

Table 9--- HealthInsuranceStatus of Adolescents, Age 10-18,

by Region and Family Income, 1987

Total Insured:

Family income population, Percent of No health private and publi c

a

as a percentage bage 10-18 the region's dinsurance Privat e Medicaid

of povert y Region c

(in millions) adolescent s Tota l

e

coverage onl y onl y Othe r

f

less than 50 percent North 1.0 6 7.8% 100.0% 19.5% 16.0% 60.5% 4.1%

South 1.31 11. 8 100. 0 36. 2 16. 7 42. 6 4 . 6

West . 4 7 7 . 5 100. 0 41. 8 17. 6 37. 2 3 . 5

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- ------- ------- ------- ------- -------

50 to 99 percent North 1.1 9 8 . 7 100. 0 16. 5 24. 5 53. 8 5 . 2

South 1.25 11. 2 100. 0 45. 1 24. 0 24. 4 6 . 6

West . 7 0 11. 2 100. 0 35. 8 21. 4 36. 2 6 . 5

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- -------

100 to 149 percent North 1.1 9 8 . 7 100. 0 21. 7 59. 8 12. 4 6 . 1

South 1.11 9 . 9 100. 0 37. 2 49. 4 7 . 6 5 . 9

West . 6 6 10. 6 100. 0 30. 3 48. 3 13. 0 8 . 4

. . . . . . . . . . . . . . . . . . . . . . . ------ . . . . . . . . . . . . . . . . . . ------ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------ ------ ----

150 to 199 percent North 1.15 8 . 4 100. 0 13. 9 78. 7 3 . 2 4 . 2

South 1.2 3 11. 0 100. 0 25. 8 66. 2 1 . 8 6 . 2

West .62 9 . 9 100. 0 27. 0 58. 0 5 . 4 9 . 7

----- . . . . . . . . . . . . ------ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------ --c200 to 299 percent North 2.7 9 20. 4 100. 0 7 . 6 87. 8 0 . 8 3 . 8

South 2.0 4 18. 3 100. 0 11. 8 79. 1 0 . 5 8 . 5

West 1.1 4 18. 3 100. 0 14.1 77. 0 2 . 0 7 . 0

....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- -------

300 percent and above North 6.2 8 46. 0 100. 0 3 . 7 93. 9 0 . 2 2 . 3

South 4.2 0 37. 7 100. 0 4 . 4 0 . 1 7 . 0

West 2.6 3 42. 4 100. 0 7 . 0 86. 4 0 . 5 6 . 1

~Health insurance status for 10- to 14-year-olds has been adjusted. See appendix A for details.

In 1987, the Federal poverty leve( was $9,056 for a family of three.

cNorth includes : Connecticut, Illinois, Indiana, Iowa, Kansas, Maine, Massachusetts, Michigan, Minnesota,

Missouri, New Hampshire, New Jersey, New York, North Dakota, Nebraska, Ohio, Pennsylvania,

Rhode Island, South Dakota, Vermont, Uisconsin.

South inc(udes: Alabama, Arkansas, Delauare, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi,

North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and Uest Virginia.

Uest includes : Alaska, Arizona, California, Colorado, Idaho, Hawaii, Montana, New Mexico, Oregon, Nevada,

d

Utah, Washington, and Wyoming.

Percentages refer to the proportion of adolescents in the indicated region who have family income as shown--

e.g., 7.8 percent of adolescents in the North live in families uhose incom is less than 50 percent of th e

poverty level.

~Percentages may not total 100 percent due to rounding.

Includes adolescents with CHAMPUS, Medicare, or any combination of public and private coverage.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current

Population Survey.
26 • Preliminary Analyses of Adolescent Health Insurance Status

Table 10. --Estimates of the Effects of Poverty and Rates of Medicaid and Private

Coverage on Regional Differences in Adolescent Health Insurance Status, 1983-1986

Adolescent Health Insurance Status. 1983-1986

Region

North South West

Proportion

without health insurance 16.0% 25.2% 22.7%

Proportion

with Medicaid coverage 11. 0 7 . 8 9 . 0

Proportion

with private coverage 69. 3 60. 4 61. 3

Estimated effect on the

proportion of adolescents

without health insurance

Factor Simulation South West

Povert y Assume that the region’s -1.8% -0.3%

level distribution of adolescent s

(by poverty level) was

the same as in the North.

Medicaid

coverage

Assume that the region's

rate of Medicaid

coverage (by poverty

level) was the same as

in the North.

Privat e Assume that the region’s

coverage rate of private coverage

(by poverty level) was

the same as in the North.

-6. 2

-1.1

-2. 1

-4. 3

Total All of the above -9. 2 -6. 7

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1984 to March 1987 Current

Population Survey.
Preliminary Analyses of Adolescent Health Insurance Status • 27

adolescents in the South. If income-specific

Medicaid coverage rates were as high in the

South as in the North, 6.2 percent fewer

Southern adolescents would be without health

insurance; this accounts for approximately 66

percent of the Southern vs. Northern gap in

coverage. Given equivalent income-specific

rates of private coverage, 1.l percent fewer

Southern adolescents would be uninsured accounting for 15 percent of the gap. Finally,

if Southern adolescents were no poorer than

those in the North, 1.8 percent fewe r

Southern adolescents would be uninsured accounting for 20 percent of the gap (table 10).

Western States--- Overall, the proportion

of Western adolescents without health insurance exceeds the Northern rate by 6.7 percentage points. Lower rates of private

coverage appear to be the most critical factor

in the coverage gap, although lower Medicaid

coverage rates are important as well. If

income-specific rates of private insurance

coverage were as high in the West as in the

North, 4.3 percent fewer Western adolescents

would be uninsured, reducing the gap between West and North by 65 percent. The

remaining 35 percent differential is due to

lower income-specific rates of Medicaid

coverage.

It is likely that the West’s lower private

coverage rates (relative to the North) are, in

part, due to lower rates of unionization, and

greater employment in the traditionally lowcoverage agriculture and service sectors.

More work is needed to further understand

the extent to which these and other factors

account for regional differences in incomespecific rates of private insurance coverage.9

9 Other hypotheses to explain these regional differences should be explored. For exaWle, coverag e

rates might be lower in the Uest because there are

higher rates of self-employment, greater employment

in small firms , more people in multiple part-time

jobs, the price of insurance is higher, and/or fre e

care is more available.

19-7570-89-3 : QL 3
4. TRENDS IN ADOLESCENT HEALTH INSURANCE

COVERAGE, 1979-1986

The proportion of adolescents without

health insurance increased from 16.7 to 20.8

percent from 1979 to 1986 (table 11).1)2 This

increase of 4.1 percentage points is slightly

larger than the concurrent increase of 3 percentage points in the under-65 population as

a whole (CRS, 1988a). The proportion of

uninsured adolescents increased 1.5 percentage points from 1979 to 1981, by an additional 1.5 percentage points from 1982 to

1983, and by 1 point from 1983 to 1984.

After that, from 1984 through 1986, the proportion of uninsured adolescents remained

relatively stable. Overall, during the period

of 1979 to 1986, the proportion of adolescents

without health coverage grew by 25 percent

to 4.6 million. If, instead, the proportion of

adolescents who were uninsured had remained

stable throughout the period, 800,000 fewer

adolescents would have been uninsured in

1987.

Most of the change in adolescent health

insurance coverage from 1979 to 1986 occurred in employment-based and other private coverage (e. g., nongroup family plans)

1 This analysis uses data from CPS surveys con -

ducted from March 1980 through March 1987; because

of changes in question wording, data from the March

1988 survey are not coo-parable to prior years. The

proportion of adolescents without health coverag e

in 1987 (i. e., 15 percent) is substantially below

the estimate for 1986, apparently because o f

wording changes in the March 1988 questionnaire.

The preliminary March 1988 CPS data provide th e

most accurate estimate of the size and characteristics of the uninsured that is currently availabl e

to the pub[ic. Nonetheless, it remains importan t

to assess the trends in health coverage from 197 9

through 1986 . Because CPS questions were no t

changed from March 1980 through March 1987, such

trend analysis is possible . Note that the trend

estimates presented here are similar to those tha t

have been identified by comparing 1977 to 1987 National Medical Expenditure Survey results (Short,

1988).

z Note that 1980 data are not avai[able because the

U.S. Census Bureau did not field a conplete set of

health insurance questions in its March 1981 survey.

(figure 6). The proportion of adolescents in

employment-based health plans declined from

60.8 to 58.6 percent while other private insurance dropped from 8.1 to 5.7 percent.

Medicaid-only coverage increased slightly

from 8.7 to 9.5 percent (table 11; figure 6c)

although not enough to cover increases in the

proportion of adolescents living in poverty.

These patterns of change parallel that for the

adult population.

Poverty, Medicaid, and Private Insurance

Coverage

In the early 1980s, two events occurred

which were likely to have significant effects

on the prevalence of health insuranc e

coverage. First, the country experienced a

steep recession, with unemployment peaking

at 10.9 percent in December 1982. Second,

the Omnibus Reconciliation Act of 1981

(OBRA) changed the rules that States are required to use in determining eligibility for

the Aid to Families with Dependent Children

(AFDC) and Medicaid programs. The intent

and effect of these rule changes were to make

it more difficult for the so-called working

poor (i.e., people with some earned income

but who are still below the poverty level) to

be eligible for AFDC and Medicaid. The effects of both the recession and the OBRA

changes are clearly seen in the CPS data.

Changes in Poverty and Medicaid.--The

proportion of the adolescent population living

in poverty increased markedly from 1979 to

1983, rising from 14.7 percent to 21 percent,

and then decreasing slightly to 19.4 percent in

1986 (figure 7). Other things being equal,

this rise in adolescent poverty should have led

to an increase in both the proportion of

adolescents who were uninsured as well as

those covered by Medicaid.

However, as can be seen in table 12, the

proportion of the poor and near-poor who

were covered by Medicaid declined dramati29
30 ■ Preliminary Analyses of Adolescent Health Insurance Status

Table 11.--Trend in the Health Insurance Status of Adolescents,

Age 10-18, 1979-1986

Total

population, No health Insured population a

age 10-18 insurance Employment- Other Medicaid

Yea r

b

(in millions ) coverage based privat e onl y Other

1979 33.9 6 16.7% 60.8% 8.1% 8.7% 5.7%

1981 33.5 2 18. 2 60. 2 6 . 4 8 . 8 6 . 4

1982 32.7 8 18. 3 60. 4 6 . 5 8 . 9 5 . 8

1983 32.0 5 19. 8 59. 0 6 . 4 9 . 3 5 . 4

1984 31.8 0 20. 8 58. 6 5 . 9 9 . 6 5 . 2

1985 31.3 6 20. 6 58. 8 5 . 5 9 . 5 5 . 5

1986 31.1 6 20. 8 58. 6 5 . 7 9 . 5 5 . 4

Employment-based includes all with employment-based insurance from someone in the household, and without

public coverage; other private includes nongroup insurance from household members and employment-based insurance from nonhousehold menbers, without public coverage; Medicaid incldes all those with Medicaid but

without private coverage ; other is primarily CHAMPUS, and includes Medicare, and those with both public

and private coverage.

b1980 data are not available.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1980 through March 1987

Current Population Surveys.
Preliminary Analyses of Adolescent Health Insurance Status • 31

Figures 6a-d.--Trends in the Proportion of Insured Adolescents,

Age 10-18, by Type of Coverage, 1979-1986’

Figure 6a

Employment-based b

Percent insured *

4% decline from 1979-198 6

60

60 -

40 -

30 -

20 -

10 -

1 I 1

1979 1981 1982 1983 1984 1986 1988

Figure 6C

Medicaid onlyd

r I

8 -

e -

4 -

2 -

9% increas e from 1979-198 6

1979 1981 1982 1983 1984 1985 1988

10

8

8

4

2

0

Figure 6b

Other privatec

Percent insured *

30% decline from 1979-198 6

1 1

1979 1981 1982 1983 1984 1986 1986

Figure 6d

Other e

Percent insured *

6% decline from 1979-198 6

6 -

5 -

4 -

3 -

2 -

1 -

0 -

1 1 I

*

Note that scales for ‘Percent insured” are not equivalent.

~1980 and 1988 data are not available; 1987 data are not comparable.

Employment-based includes all with e~loyment-based insurance from someone in the household, and without

public coverage.

c

Other private includes nongroup insurance from household members and employment-based insurance from nond household mewbers, without public coverage.

Medicaid includes all those with Medicaid but without private coverage. Note that the increase in Medicaid

did not keep pace uith increases in the proportion of adolescents in poverty.

‘Other is primarily CHAMPUS, and includes Medicare, and those with both public and private coverage.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1980 through March 1987

Current Population Surveys.

1979 -

1981 1982 1983 1984 1986 1988
32 • Preliminary Analyses of Adolescent Health Insurance Status

Figure 7---Trends in the Proportion of Adolescents, Age 10-18,

Who Live in Poverty, 1979-1986’

25

20

15

10

5

0

1978 1981 1982 1983 1984 1886 1986

Year

50-99% of Federal

Poverty Level

Less than 50% of Federal

Poverty Level

~1980 data are not available.

See appendix E for Federal poverty levels from 1979-1988.

SOURCE: Office of Technology Assessment, 1989 based on estimates from the March 1980 to March 1987

Current Population Surveys.
Preliminary Analyses of Adolescent Health Insurance Status ■ 33

Table 12---Trend in the Health Insurance Status of Adolescents, Age 10-18,

by Family Income, 1979-1986

Family income No health

as a percentage Insured: insurance

of povert y

a

Yea r

b

coverage d

Privat e

c Medicai d

less than 50 percent . . . . . . . . 1979 38.4% 17.4% 44.5%

1981 39. 9 15. 4 45. 0

1982 39. 7 18.1 43. 1

1983 40. 6 13. 8 46. 0

1984 42. 6 11. 5 45. 5

1985 41. 1 11. 4 46. 8

1986 42. 4 11. 2 47. 1

50 to 99 percent . . . . . . . . . . . 1979 29. 9 27. 3 47. 8

1981 34. 5 30. 2 38. 9

1982 32. 9 31. 9 39. 4

1983 34. 7 30. 5 38. 4

1984 33. 9 26. 8 42. 0

1985 37. 9 22. 4 40. 3

1986 38. 0 21. 8 41. 9

100 to 149 percent . . . . . . . . . . 1979 28. 7 52. 6 20. 6

1981 29. 6 56. 9 16. 0

1982 29. 8 57. 2 12. 0

1983 32. 7 56. 3 11.1

1984 36. 0 53. 3 11.1

1985 34. 5 51. 8 11. 9

1986 37. 8 49. 8 12. 3

150 to 199 percent . . . . . . . . . . 1979 24. 3 69. 5 6 . 7

1981 22. 1 70. 6 6 . 5

1982 21. 5 72. 8 4 . 5

1983 22. 7 72. 2 3 . 4

1984 26. 2 68. 8 4 . 8

1985 25. 7 67. 3 6 . 0

1986 25. 5 68. 1 4 . 9

200 to 299 percent . . . . . . . . . . 1979 13. 9 81. 5 3 . 7

1981 13. 5 82. 8 2 . 8

1982 13. 3 83. 0 2 . 1

1983 14. 4 82. 1 1 . 2

1984 17. 0 79. 6 1 . 3

1985 16. 4 80. 2 1 . 3

1986 15. 8 80. 1 2 . 0

300 percent and above . . . . . . . 1979 7 . 8 90. 0 1 . 0

1981 7 . 6 90. 1 1 . 0

1982 7 . 6 90. 1 0 . 7

1983 8 . 0 90. 0 0 . 4

1984 7 . 8 90. 2 0 . 3

1985 8 . 6 89. 6 0 . 4

1986 8 . 9 89. 2 0 . 4

In 1987, the Federal poverty level was $9,056 for a family of three. See appendix E for Federal poverty

, levels from 1979-1988.

‘1980 data are not avai[ab[e.

~Includes anyone with private coverage, as well as those who have both private and pub(ic coverage.

Inc[udes anyone with Medicaid coverage, as well as those who have both private and Medicaid coverage.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1980 through March 1987

Current Population Surveys.
34 • Preliminary Analyses of Adolescent Health Insurance Status

cally between 1979 and 1983. In 1979, 48

percent of adolescents living in families between 50 to 99 percent of poverty had

Medicaid coverage. By 1983, this had

dropped to 38 percent, and rebounded slightly to 42 percent in 1984 and 1986.

Medicaid coverage of the near-poor also

dropped significantly during this period. In

1979, 21 percent of adolescents in families

with incomes from 100 to 149 percent of

poverty were covered by Medicaid; in stark

contrast, from 1982 through 1986, Medicaid

covered only 11 to 12 percent of this group.

These declines in Medicaid coverage levels

were clearly due to the 1981 OBRA regulations that limited the working poor’s

eligibility for AFDC and Medicaid benefits.3

Changes in Private Health Insurance---

Income-specific rates of private insurance

coverage were lower in 1986 than in 1979,

but the change was not evenly distributed

across income groups or across time. The

decline in private coverage was much sharper

for lower income than for middle and upper

income groups. Further, income-specific private insurance rates increased slightly from

1979 to 1982, and then decreased sharply,

particularly among the poor, from 1983 to

1986.

The larger decline in private coverage

among the poor is clear. In 1979, nine out of

ten adolescents in families with income at 300

percent or more of poverty had private health

insurance. This had declined only slightly to

89 percent by 1986. During the same period,

private insurance coverage among adolescents

in families with income between 200 and 299

percent of poverty declined by only 1.4 percentage points. The trend among adolescents

in households below 50 percent of poverty

was markedly different; 17 percent were cov3 The relationship to OBRA can be seen clearly b y

noting that Medicaid coverage levels did no t

decline among the very poorest, those below 5 0

percent of poverty. 06RA uas not intended to af -

fect eligibility for those with no (or very small )

earned incomes.

ered by some form of private insurance in

1979, but by 1986, only 11 percent were enrolled in a private health plan. Adolescents

in families between 50 to 99 percent of

poverty experienced a similar trend; the proportion with private health coverage dropped

from 27 to 22 percent from 1979 to 1986.

Although one might have expected a

decline in coverage during the recession and

an increase in income-specific coverage rates

during the recovery, the opposite pattern occurred: coverage rates increased during the

recession and declined, especially for the

poor, during the recovery. In all income categories (except for those below 50 percent of

poverty) the rates of private coverage were

higher from 1981 to 1983 than they were in

1979, and then decreased during the 1984

through 1986 period. The reasons for this

counterintuitive pattern of change are not apparent.

Understanding the Increase in the Uninsured,

1979 to 1986

The following examines why the proportion of adolescents without health insurance

grew from 1979 to 1986. First, four

hypotheses, drawn from two of the most

carefully prepared studies of changes in

coverage at the national level, will be analyzed

1.

2.

3.

4.

(Wilensky, 1988 and CRS, 1988a)

There were more adolescents living in

families at or near the poverty level in

1986 than in 1979.

Given the same family income distribution, fewer adolescents were covered by

Medicaid in 1986 than in 1979.

Given the same family income distribution, fewer adolescents were covered by

private health insurance in 1986 than in

1979.

Employment has shifted from historically high-coverage industries, such as

manufacturing, to low-coverage industries, such as the service sector. (To

the extent that evidence is found for

the hypothesis that income-specific

rates of private coverage have declined,
Preliminary Analyses of Adolescent Health Insurance Status ■ 35

5.

6.

change in the industrial base of the

economy might begin to explain the

rate of decline in private coverage.)

There were more privately insured

parents who did not insure their children in 1986 than 1979 (possibly because employers are requiring greater

contributions for dependent coverage).

There were more adolescents who lived

outside their parents’ homes and were

thus more likely to be uninsured in

1986 than in 1979.

Changes in Poverty, Medicaid Coverage,

and Private Health Insurance: Three Simulations.-- The first three hypotheses can be analyzed by using simulation methods similar to

those used to examine regional differences in

coverage rates. Three simulations are constructed. The first simulation computes the

proportion of adolescents who would have

been insured in each year from 1979 to 1986,

if the family income distribution of adolescents by poverty level had remained at 1979

levels. The difference in each year’s calculated versus actual proportion of uninsured

adolescents reflects the effects of changes in

poverty and family income on the uninsured.

The second simulation computes the percentage of adolescents who would have been

uninsured each year if the income-specific

rates of Medicaid coverage had remained at

1979 levels.

The third simulation is the same as the

second, except that it assumes no change

throughout the period from the 1979 incomespecific rates of private health coverage.

Then, the third simulation is divided into two

parts to determine the individual effects of

changes in private coverage rates for those

above and below 150 percent of poverty.

As noted earlier, from 1979 to 1986, the

proportion of uninsured adolescents rose from

16.7 to 20.8 percent, an increase of 4.1 percentage points. As detailed in table 13, it appears that approximately:

■ 1 percentage point of the increase in the

uninsured (24 percent of the total

change) was due to a growth in adolescent poverty;

1.6 percentage points (39 percent of the

total) were a result of decreases in the

income-specific rates of Medicaid

coverage; and

1.5 percentage points (37 percent of the

total) are accounted for by decreases in

the income-specific rates of private

coverage (principally among adolescents

below 150 percent of poverty).

It is important to look closely at the variations in coverage throughout the period. By

1983, just past the height of the recession,

growth in the number of poor adolescents

could have increased the proportion of

uninsured by 1.9 percentage points, while the

drop in Medicaid coverage might have contributed an additional 2.6 percentage point

rise in the uninsured. This potential total increase of 4.5 points was partially offset, however, by a concurrent rise in private coverage.

Afterward, these trends reversed. Income-specific rates of private coverage

declined every year after 1982; the net effect

reversing from a potential 2.4 percentage

point decrease in the proportion of uninsured

adolescents in 1982, to a potential increase of

1.5 points in 1986 (table 13). At the same

time, after peaking in 1983, a slight decline

in adolescent poverty and small increase in

income-specific Medicaid rates helped reduce

the negative effect of the drop in private

coverage.

In summary, not only were there more

poor adolescents in 1986 than in 1979, but

they were less likely to have Medicaid. Further, decreases in private coverage affected

the poor much more than the nonpoor.4

4 Note that most studies of the grouing gap between

rich and poor in the 1980s focus on cash income and

ignore declines in health coverage; such an ap -

proach understates the disparity in wealth, sinc e

the value of health insurance i s

count (see, for example, Pa(mer

1984).

not taken into acand Sauhil[, eds.,

19-7570-89-4 : QL 3
36 • Preliminary Analyses of Adolescent Health Insurance Status

1

I

9 I - 1

.
Preliminary Analyses of Adolescent Health Insurance Status ■ 37

Private Coverage and Changes in Employment and the Economy .--Why has the

decline in private coverage occurred? It has

been suggested that it may be due, in part,

to sectoral changes in the economy; that is,

fewer job opportunities in manufacturing

(where benefits are traditionally provided)

and more jobs in the relatively low-paying,

low-benefits service sector (Wilensky, 1988).

It makes sense that this might be part of the

explanation, but as can be seen below, relatively straightforward analysis of the data

does not provide much support for this explanation.

From 1982 to 1986, an average of 17.3

percent of adolescents were without any

health coverage. During this period, those

whose parents were employed in public administration, durable goods, transportation,

mining, and nondurable goods industries had

consistently high rates of private health

coverage and a 10.4 percent overall uninsured

rate (table 14). Adolescents with parents in

finance, wholesale trade, and professional

services had an average rate of private

coverage: 16.7 percent were uninsured. Private coverage in construction, retail trade,

business services, and entertainment industries was lower than average; more than

one out of four adolescents with parents in

these industries were uninsured. Finally,

coverage was very low in agriculture and

personal services; 38 percent of adolescents

linked with these industries had no health insurance .

There was relatively little change in the

distribution of the adolescent population

among these four industry groups from 1979

to 1986 (figure 8). The proportion of adolescents with parents in the high coverage industries decreased slightly from 45.4 to 42.8

percent and the proportion of adolescents

linked to industries with an average coverage

rate increased from 25.2 to 27.4 percent.

However, given this relatively small shift in

the adolescent population distribution, the

difference in coverage rates between these

two industry groups was not large enough to

substantially affect the aggregate number of

uninsured. (There was virtually no net increase in the proportion of adolescents whose

parents work in low or very low coverage industries.)

Thus, at least at this fairly aggregate

level of analysis, sectoral change does not appear to account for the observed increases in

the proportion of uninsured adolescents. It is

possible that a more refined analysis which

considers occupational as well as more

detailed industrial classifications would result

in different conclusions. Such an analysis is

beyond the scope of this paper.

Dependent Coverage, Parent’s Insurance

Status, and Adolescent Living Arrangements.-- In 1979, 6.1 percent of adolescents

living with insured parents were without

health coverage (table 15). By 1986, this

proportion had risen to 7.2 percent; an increase of approximately 250,000 uninsured

adolescents that accounted for almost onequarter of the period’s overall 4 percentage

point growth in the proportion of uninsured

adolescents.

This trend is worrisome, but the extent

of the problem and need for a public policy

response are tempered by two observations.

First, it is clear that most of the increase in

adolescents without health coverage (i. e.,

more than three-quarters) was due to other

factors discussed above. Second, analysis of

preliminary 1987 data found that only 3.3

percent of adolescents living with insured

parents were themselves uninsured. This is

less than half the 7.2 percent rate in 1986,

indicating that the wording changes in the

March 1988 CPS may have had a particularly

large effect on this estimate.

The principal reason why more adolescents were uninsured in 1986 than in 1979 is

simply that more lived with uninsured parents

in 1986 than in 1979. During this period, the

proportion of adolescents who lived with

uninsured parents increased from 8.8 to 10.5

percent. This increase accounts for 37 percent of the overall 1979 to 1986 increase in

uninsured adolescents.
38 Ž Preliminary Analyses of Adolescent Health Insurance Status

Table 14---Industry of Parent’s Employers and Health Insurance

Status of Adolescents, 1982-1986’

No health Insured: private and publi c

Rate of Percent insurance Private Medicai d

coverage Industr y

b

of tota l coverage onl y onl y Othe r

c

High public admin. 6.3% 8.6% 82.5% 1.7% 7.3%

durable goods 17. 5 9 . 9 84. 8 1.4 3.9

transportation 9 . 2 10. 5 84. 2 1.5 3.8

mining 1 . 4 11. 7 84. 1 0.8 3.3

nondurable goods 9.7 12. 2 81.6 2.6 3.6

Total 44. 1 10. 4 83. 6 1.7 4.2

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- . . . . . . . ------- ------- . . . .

Average financ e 5 . 1 14. 8 80. 4 1 . 5 3 . 4

wholesale trade 4 . 6 14. 2 79.9 2.0 4.0

prof. service s 16. 8 17. 9 73.4 4.3 4.4

Total 26. 5 16. 7 75.9 3.4 4.1

.... ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . --

construction 8 . 2 24. 5 68.7 2.7 4.1

retail trad e 10. 4 26. 0 62.8 6.4 4.8

business service 4 . 2 27. 6 61.3 5.5 5 . 5

entertainmen t 0 . 6 29. 7 57.4 5.9 7.1

Total 23. 4 25. 9 64.5 4.9 4.7

----- ------ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------ . . . . . . . . . . .

Very Lou agricultur e 3 . 4 36. 7 52.3 6.9 4.1

personal services 2 . 6 39. 4 39. 5 16.7 4.4

Total 6 . 0 37. 9 46. 8 11.1 4 . 2

. . . . . . ------- . . . . . . . . . . . . . . ------- ------- ------- ------- ------- -------

All industries 100.0% 17.3% 74.9% 3.5% 4.3%

~Estimates are based on pooled data from March 1983 to March 1987 Current Populations Surveys.

Refers to the industry of the household head unless only the spouse had employment-based health insurance.

cIncludeS adolescents with CHAMPUS, Medicare, or a ctiination of public and private coverage.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1983 to March 1987

Current Population Surveys.
Preliminary Analyses of Adolescent Health Insurance Status ■ 39

Figure 8.--Distribution of Adolescents, Age 10-18, by Parent’s Industry of Employment

Categorized by Rates of Health Insurance Coveragea,b

100

80

60

40

20

0

1979 1981 1982

Type of Industry

(By Rates of Health

Insurance Coverage)c

1983 1984

Year

198 5 198 6

~1980 data are not available.

bRefers to the industry of the household head unless only the spouse has enploynent-based coverage.

High coverage rates are found in public acininistration, durable goods, transportation, mining, and nondurable goods. Average includes finance, wholesale trade, and professional services. ~ includes construction, retail trade, business services, and entertaimnent. Very Low includes agriculture and personal

services.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1980 to March 1987 Current

Population Surveys.
40 Ž Preliminary Analyses of Adolescent Health Insurance Status

Table 15.--Trend in Parental and Adolescent Health Insurance Status,

1979-1986’

Parent’ s

insurance

status b

1979 1981 1982 1983 1984 1985 1986

not insured 8.8% 9.2% 9.3% 10.2% 10.9% 10.8% 10.5%

Distributio n insured 85. 7 84. 8 85. 0 83. 9 83. 3 83. 5 83. 1

of adolescent

population not livin g

with paren t

c

5.5 6.1 5.7 5.9 5.8 5. 8 6.3 

A l l

d

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- ------- ------- ------- ------- ------- ------- ------- -

not insured 91.9% 95.1% 97.7% 97.4% 97.3% 97.5% 96.4%

Proportion of

adolescents insured 6 . 1 6 . 3 6 . 1 6 . 8 7 . 1 7 . 2 7 . 2

without health

coverage not livin g

with paren t

c

61. 3 67. 7 7 . 7 71. 3 72. 4 71. 5 73. 9

a 1980 data are not available.

b

Refers to the insurance status of the household head unless only the spouse had employment-based health

coverage.

~Includes all adolescents not living with their parents and married adolescents living with their parents.

Percentages may not total 100 percent due to rounding.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1980 through March 1987

Current Population Surveys.
Preliminary Analyses of Adolescent Health Insurance Status • 41

Eighteen percent of the overall rise in

the proportion of adolescents without health

coverage was due to a fall in the coverage

rate among adolescents not living with a

parent. In 1979, 61 percent were uninsured;

by 1986 the proportion without coverage rose

to 74 percent. At the same time, the

uninsured rate among adolescents who lived

with uninsured parents also rose, increasing

from 92 to 96 percent (and contributing to 10

percent of the overall climb in the uninsured). Among both groups the proportion

of adolescents who obtained health insurance

from their own jobs declined precipitously.3

Changes in adolescent living arrangements had a minimal effect on the proportion

of uninsured. From 1979 to 1986, the proportion of adolescents who did not live with a

parent rose from 5.5 to 6.3 percent, accounting for only 11 percent of the overall 4 percentage point increase in uninsured adolescents.

Other Explanations for Increases in

Uninsured Adolescents

Declining rates of health insurance

coverage may also result from increases in

administrative and medical care costs. People

may be less willing to purchase insurance for

themselves or their dependents as the cost of

coverage increases.

4 National health expenditure estimates suggest that insurers’ administrative costs rose by 18 percent per year from

1980 to 1986 (U.S. Dept. of Health and Human Services, 1987).5 Increases in real per

capita health care costs averaged 4.6 percent

per year from 1980 to 1986 and may have

further encouraged the poor and near-poor to

rely on whatever free care is available at the

local hospital or health center rather than use

scarce dollars to purchase (or have their

employer purchase) health coverage. Although not within the scope of this paper, the

affects of rising health care costs on the

prevalence of private health coverage clearly

merit further study.

3 In 1979, a total of 700,178 (4.3 percent) of 15-

to 18-year -olds had their own health insurance; by

1986, this ntier had dropped to 332,106 (2.3 percent ). (It is assumed that only 15- to 18-year01 ds , and not younger adolescents, might hav e

health insurance coverage on their own. ) Of th e

15- to 18-yea r-olds with their own insuranc e

coverage who lived on their own, 11.5 percen t

(161,056 of 15- to 18-yea r-olds) were insured i n

1979; by 1986, this proportion had dropped to 4. 9

percent (68,175 of 15- to 18-year -olds).

4 Cost is defined here as the difference between

expected medical costs and the price of an insurance policy.

5 The 18 percent per year increase occurred in a

category of expenditures including administrativ e

costs for public programs (primarily Medicare and

Medicaid), private insurance administrative costs,

and insurance company profit or loss (or, in th e

case of nonprofit insurers, addition or deletio n

from reserves) . Most of the 18 percent increas e

occurred in private insurance costs.
5. POTENTIAL EFFECTS OF EMPLOYER MANDATES AND

MEDICAID EXPANSIONS

Two types of proposals have been prominently advanced to reduce the number of

uninsured. So-called “employer mandates” require that employers offer group health insurance policies and pay a significant amount

of the premiums for all employees who work

more than a specified number of hours per

week. Proposals to expand Medicaid require

that categorical eligibility requirements be

relaxed and/or that income eligibility limits

be increased (i.e., thereby requiring all States

to make Medicaid available to all those

eligible below certain income levels) (see

CRS, 1988b for a discussion of illustrative

options).

A number of factors determine the effects of an employer mandate. The types of

employees and employers to be included in an

employer mandate are especially important.

How many hours per week must be worked?

Does coverage begin on the first day of

employment or after a waiting period? Are

the self-employed included? Are employee

dependents covered? Will small firms be exempt? What level of benefits must be provided? How much must the employer contribute to the premium?

Similarly, the effect of an expansion in

Medicaid depends on a number of policy decisions. For example, what is the minimum

eligibility income level? Are the changes in

eligibility mandatory or optional for the

States? Are two-parent families with workers

eligible or must one parent be absent or unemployed?

The following presents preliminary

estimates of the effects of an employer

mandate, Medicaid expansion, and combinations of an employer mandate and Medicaid

expansion. The analyses use preliminary data

from the March 1988 CPS supplement.

Employer Mandates

The following assumptions are used in

estimating the effect of an employer mandate

on the number of uninsured adolescents:

The self-employed are exempt. All

other “permanent” employees who work

more than the required number of hours

per week are covered (i.e., with no exemptions for firm size or industrial classification). 1

Employees working 26 weeks or more in

the preceding year are considered

“permanent” workers and would be covered under the mandate.

The effects of the mandate are estimated

using three different assumptions about

the number of hours of work at which

workers are covered: 18 hours, 25 hours,

and 30 hours.

All unmarried adolescents age 18 or

younger would be covered by the

mandate if their parents were covered as

well; however, it is assumed that adolescents who are not heads of household

who do not live with their parents

would not be covered as dependents under the mandate.2

1 The currently available 1988 CPS data do not inc 1 ude f i rm size. As a result , i t is di ff i cult to

do any analysis that excludes smal 1 business even

though many proposed mandates exempt employees in

smal 1 f i rms (often five or feuer employees) . Other

data sources and a set of iwtation rules could be

used to assign sane employees to f i rms of 5 (or 10)

workers or less, but such a process uas beyond the

scope of this paper. Note also that uhen fina l

1988 CPS public use f i [es are available, the smal 1-

est f i rm size coded ui 11 be 1 to 25 enployees thu s

prohibiting any analysis for f i rms ui th less than

25 employees.

2 Most mandate proposals cover some adolescents who

do not live uith their parents; houever, becaus e

the CPS fi le does not report parent[s uork statu s

for adolescents who do not live with their parents,

this analysis takes the conservative approach and

does not impute dependent coverage to thes e

ado 1 escents. Adolescents who are living on their

oun and are eligible for employer-based coverag e

are included as eaployees, not as dependents.

43
44 Ž Preliminary Analyses of Adolescent Health Insurance Status

Table 16 summarizes the effects of an

employer mandate on adolescents given the

above assumptions. If employees who worked

30 hours or more per week were included,

approximately 2.55 million uninsured adolescents, or 55 percent of all adolescents currently without health coverage would become

insured. Although reducing the hourly work

threshold does increase the number of uninsured who would become covered, its effect

is relatively minimal (at least within the range

of 18 to 30 hours per week). For example, if

the hourly work threshold was reduced to 25

hours per week, an additional 60,000 adolescents (1.3 percent of all those uninsured)

would be covered. If the threshold was 18

hours per week, an additional 136,000 adolescents (or 3 percent of all uninsured adolescents) would be covered.

This projection of how many adolescents

would be covered by an employer mandate is

slightly lower than similar analyses of the

adult uninsured because a sizable number of

uninsured adolescents neither live with their

parents nor work full-time. Of the 1.87 million adolescents who would not recovered by

an 18-hour-per-week threshold, 716,000 live

on their own. It is possible that many of

them would, in fact, be covered as a dependent on a parent’s policy, and that actual

coverage under a mandate might be higher

than estimated here. Also not covered by an

18-hour threshold are approximately 379,000

adolescents with self-employed parents;

456,000 who live with nonworking parents;

and 267,000 who live with parents who

worked less than 26 weeks during the preceding year.

While assuring that most workers and

their dependents have health insurance benefits, an employer mandate may have other

labor market effects (see Monheit and Short,

1988; Phelps, 1980; CRS, 1988b). For example, if employers are required to pay for

health benefits for employees who were previously uninsured, they may respond by either raising prices, absorbing reduced profits,

reducing cash wages (or other fringe benefits)

or reducing staff.

It is likely that many employers would

limit the rate of growth of cash wages so that

total employee compensation (i.e., cash plus

health benefits) remains the same. For

uninsured, middle-income workers, this

might be a desirable tradeoff; that is, they

would receive less cash compensation than

before, but would gain access to group health

insurance and reap the benefits of tax-free

employer contributions. However, lowerincome employees may evaluate the tradeoff

differently; they might prefer the cash to the

health benefits. Therefore, in designing a

mandate that includes these workers, it would

be important to consider the feasibility of

subsidizing employer contributions for the required health benefits.

It is also important to consider workers

who earn at or near the minimum wage.

Employers of such workers maybe prohibited

by minimum wage laws from lowering wages,

despite a mandated obligation to provide

health coverage. Consequently, in response to

a mandate, employers of minimum-wage

workers may be less likely to make new jobs

available.

Medicaid Expansions

Proposals to expand Medicaid may

mandate or simply give States the option to

broaden Medicaid eligibility. Currently,

States have the flexibility, within limits, to

set their own eligibility levels for the Aid to

Families with Dependent Children (AFDC)

and Medicaid programs. Some States have

relatively broad eligibility policies while

others are much more restrictive. However,

with few exceptions, adolescents are eligible

for Medicaid only if they are in a family

with a so-called “deprivation factor;” that is,

a family with an absent parent or one whose

principal breadwinner is unemployed (see

CRS, 1988c for an excellent summary of

eligibility rules).3

3 This is unchanged by the passage of the Famil y

Support Act of 1988 (Public Law 100-485).
Preliminary Analyses of Adolescent Health Insurance Status • 45

Table 16--- Potential Effect of Various Employer Mandates on Uninsured

Adolescents by Living Arrangement and Parent’s Work Status

(in thousands)

Additional Additional

Number covered number covered number covered Number not

by mandate by lowering by lowering covered by

on 30 hours mandate to mandate to 18 hours

Living arrangement/ per week 25 hours 18 hours per week

parent’s work status employee s per weeka

per weeka mandate Total s

Living without 75 2 22 716 815

parents

Parent i s 14 6 4 379 403

self-employed

Parent i s 10 2 4 456 472

not working

Parent working 9 0 6 267 282

fewer than

26 weeks

Parent working 2,44 0 51 101 49 2,641

26 weeks or more

----- .... ------ ------ - . . . . . . . . . . . ------ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------ ----

Total 2,54 9 60 136 1,86 8 4,61 3

(55.3%) (1.3%) (3.0%) (40.5%) (100.0%)

a

Entries refer to the number of uninsured adolescents (in 1,000s) who would be covered by th e

employer mandate.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Curren t

Population Survey.
46 • Preliminary Analyses of Adolescent Health Insurance Status

If the current categorical requirement of

a “deprivation factor” is maintained, the

potential for an expansion in Medicaid to

cover significant portions of uninsured

adolescents is severely limited. As can b e

seen in table 17, if all adolescents in singleparent households with incomes below 100

percent of poverty were covered b y

Medicaid, approximately 707,000 of the 4.6

million uninsured adolescents would be covered. However, even if States were required

to extend eligibility standards to all such

adolescents, it is doubtful that all would enroll. In fact, many of the 8 percent of

uninsured adolescents who were in singleparent households in 1987, with incomes below 50 percent of poverty, were already

eligible to receive Medicaid benefits.

If categorical requirements were dropped,

and all adolescents with family income below

a specified standard were eligible for

Medicaid, then significant portions of the

currently uninsured could be covered by a

Medicaid expansion. Over 40 percent of

uninsured adolescents in 1987 lived in

households with family income below 100

percent of poverty, and an additional 19 percent were in households with income between

100 and 149 percent of poverty (table 17).

One concern often raised about expanding Medicaid is that employers may respond

by dropping private health coverage for lowwage workers who would be eligible for

coverage under the expansion. Should this

happen, the pool of eligibles could be much

larger than those who are currently uninsured

and living under the income thresholds In

1987, there were approximately 600,000 pri3 Section 89 of the Internal Revenue Code, the socalled ‘nondiscriminatio n

N section, uill make this

more difficult than previously, but not impossible.

vately insured adolescents in families with incomes between 50 and 99 percent of poverty;

some of these might “leak” from the private

system to Medicaid if Medicaid was available

to all families with incomes below 100 percent of poverty. However, the potential

leakage would be much greater if Medicaid

were available to all adolescents in family incomes below 150 percent of poverty; about

1.7 million additional privately insured

adolescents are in families with incomes between 100 and 149 percent of poverty.

Combined Approach:

Employer Mandate With a

Medicaid Expansion

Table 18 shows the proportion of uninsured adolescents who would be covered by

various combinations of an employer mandate

and Medicaid expansion. The entry in the

bottom right corner of the table shows that if

employers were required to cover all workers

who worked 18 hours or more and Medicaid

was available to all adolescents in families

with income below 200 percent of poverty,

then only 7 percent of adolescents without

health coverage would remain uninsured. An

employer mandate that included employees of

at least 30 hours per week combined with a

Medicaid expansion that included all adolescents below 100 percent of poverty, would

cover over 80 percent of uninsured adolescents (see the center of table 18).

Note that most of the adolescents left out

by the combination of an employer mandate

and Medicaid expansion are children of the

self-employed. If the self-employed were included under a “combination” mandate, the

vast majority of uninsured adolescents would

become covered (even if the expansion included only those up to 100 percent of

poverty).
Preliminary Analyses of Adolescent Health Insurance Status • 47

Table 17. --Potential Effect of a Medicaid Expansion on Uninsured Adolescents

by Poverty Level and Living Arrangements (in thousands)

Estimated number (percent) of uninsured adolescents

covered by the Medicaid expansion

Living arrangement

Medicaid Living with Living with two

eligibility leve l

a,b one parent parents or living alon e Total

Less than 50 percent 354 523 877

of povert y (8%) (11%) (19%)

50 to 99 percent 353 657 1,01 0

of povert y ( 8 ) (14 ) (22 )

100 to 149 percent 288 582 870

of povert y ( 6 ) (13 ) (19 )

150 to 199 percent 212 431 643

of povert y ( 5 ) ( 9 ) (14 )

200 percent of poverty 275 938 1,21 4

and above ( 6 ) (20 ) (26 )

. . . . . . . . . . . . . . . . . . . . ------- . . . . . . . . . . . . . . . . . . . . . . ------- . . . . . . . . . . . . . . . . . . . . . ------- ---

Total number of uninsured

adolescents covered 1,48 2 3,13 1 4,61 4

under expansion

Overall proportion o f

uninsured adolescents (33%) (67%) (loo%)

covered by expansion

aEntries are the proportion of currently uninsured adolescents who uould be insured under the indicatd

~level of Medicaid expansions.

The Medicaid expansions assune that all adolescents in families with incom below the specified amount

would be covered by Medicaid.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current

Population Survey.

Table 18.--Potential Effects of Various Combinations of Employer Mandates

and Expansions in Medicaid on Uninsured Adolescents, Age 10-18

Medicaid

eligibilit y

leve l

a,c

No Employees included in the mandatea,b

employer (no. of hours worked weekly)

mandate 30 hours 25 hours 18 hours

No expansion

Anyone below

50% of poverty

Anyone below

100% of poverty

Anyone below

150% of poverty

Anyone below

200% of poverty

o% 55% 57% 60% 1

19 71 72 75 I

Proportion of

uninsured

41 81 82 84 adolescents who

would become

covered

60 8 7 8 7 8 9

74 92 93 93

aEntries are the proportion of currently uninsured adolescents who would be insured under the indicated combination of an employer mandate and Medicaid expansion.

b

The employer mandates assume that all workers excluding the se[f-enployed (and their dependents), who work

more than the indicated nunber of hours for at least 26 weeks during the preceding year, would be covered.

c

The Medicaid expansions assume that all adolescents in families with income below the specified amount would

be covered by Medicaid.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current

Population Survey.
APPENDIX A.--CONSTRUCTING ESTIMATES OF THE NUMBER OF

UNINSURED USING THE CURRENT POPULATION SURVEY:

ADJUSTMENTS MADE AND INTERPRETATION OF RESULTS

This appendix describes the methods

used to analyze Current Population Survey

(CPS) data on health insurance coverage. The

CPS questions changed materially in March

1988. The material below first considers the

questions as they were asked from March

1980 through March 1987 and then considers

the March 1988 questions.

CPS Questions-- March 1980 to March 1987

In the March supplement to the Current

Population Survey in each year from 1980

through 1987 (with the exception of 1981)

respondents who were in the civilian labor

force in the previous year--that is, civilians

who were 15 or older and who reported at

least some work during the previous year--

were asked whether they were included in a

group health insurance plan at any job they

held during the previous year.1

 Respondents

who reported that they were included in such

a plan were asked who else was included in

the plan, and responses to “who else was included” were coded into the categories: spouse

only; children only; spouse and children; and

other.

Additional questions about public and

private coverage were asked. The question

was asked whether anyone 15 or over was

covered by Medicare at any time in the previous year, and if so, who was covered;

whether anyone 15 or over was covered by

Medicaid at any time in the previous year,

and if so, who was covered; and whether

anyone 15 or over was covered b y

CHAMPUS, VA, or military health care, and

if so, who was covered. Finally, all respondents 15 and over were asked whether they

had any other health insurance plan at any

1 In many fami lies a proxy respondent ui11 respon d

for other family members. Thus, it uould be mor e

accurate to say that a question about employmentbased coverage is asked about (not of) each family

member in the labor force.

time during the preceding year, and if so,

who else was covered.2

It is important to recognize that the

question about other health insurance was far

from comprehensive. The question was asked

“Did anyone in this household have any

(other) health insurance plan at any time during 1986?” Although it sounds comprehensive, it left two gaps. First, the reference to

“anyone” referred only to people 15 and

above. If a respondent under 15 had a health

insurance plan it would not be coded. Second, and more importantly, interviewers were

instructed to interpret the question to mean

“did anyone have a health insurance plan in

their own name”? If the respondent was covered as a dependent then the respondent was

not coded as “having” a health insurance plan;

the respondent was only coded as “having” a

health insurance plan if the respondent was

the primary subscriber (U.S. Department of

Commerce, Bureau of the Census, 1987).

These questions are used to define the

uninsured as a residual category. Those

respondents who did not report coverage

from any source during the preceding year

should, if they were responding accurately,

have been uninsured for the entire previous

year. There are, however, two reasons why

this residual category will be larger than the

true number of people who were uninsured

for the entire previous year. The first reason

is question wording difficulties: in a variety

of situations (discussed further below) people

with health insurance coverage will be

counted as being uncovered. The second reason is recall error: some respondents appear to

forget that they may have been covered at

2 In March 1981 the questions about private health

insurance not related to employment were omitted

from the questionnaire . Thus, March 1981 dat a

cannot be compared to previous or subsequent years.

49
50 • Preliminary Analyses of Adolescent Health Insurance Status

some point during the previous year. Both

sources of error will be discussed below.

Question Wording Problems in the

1980-1987 CPS

There were two main problems with the

wording of the health insurance questions

prior to 1988: first, there was no direct

question inquiring whether each individual in

the household is covered by insurance, and

second, dependents could only be assigned

insurance coverage if the subscriber to the

insurance policy resided in the household.

This created a number of gaps. For one example, if a child was living with his/her

mother and insured by an absent father, the

CPS would count that child as uninsured. As

a second example, if an adolescent was not

living with his/her parents (e.g., a foster

child or a grandchild, or an adolescent living

in his/her own apartment), the adolescent

could never be ascribed coverage as a dependent child, since using the CPS questions

coverage can only be derivative of a parent’s

coverage if the parent lives in the same

household.

Further, the fact that direct questions

about coverage were not asked meant that the

Census Bureau was forced to make inferences

about coverage when a private insurance subscriber reports that his/her children are covered. In such circumstances the Census

Bureau assumed that any children living with

the subscriber who were 21 or younger were

to be covered, unless the child had been

married. 3 This is a reasonable rule, but will

3 On the March 1982 and March 1983 Public Use Files

the Census Bureau did not apply the editing routine

that assigns coverage to spouses and dependen t

children for private insurance coverage. The public use files indicate whether or not an individual

has a private insurance plan in his/her own name,

and who else is covered (spouse only, childre n

only, spouse and children, or other), but in 198 2

and 1983 the census bureau did not follow th e

conventions it followed in 1980 and in subsequen t

years of editing the records for the spouses and

children to show coverage where it existed. For

this paper the Census Bureau’s standard editin g

rules were applied to assign dependent coverage,

where appropriate, to spouses and children. Thus,

the data used here for 1982 and 1983 are consistent

with data for 1980 and 1984-1987.

almost certainly understate the extent of dependent coverage. Some family insurance

policies provide for coverage of dependent

children up to age 23 if they are full-time

college students, some will cover dependents

up to age 21 regardless of the dependent’s

marital status, and some provide for dependent coverage only up to age 18. Thus, for a

variety of reasons the questions asked by the

Current Population Survey from 1980 through

1987 should overestimate the number of

people without insurance. This overestimate

will be greatest for children and adolescents.

Recall Error: Full-Year or Point-in-Time

Estimates?

If respondents were answering without

recall error, respondents who report not being

covered by either private or public sources

should have been uninsured for the entire

previous year. However, as argued by

Swartz, CPS estimates of the number of

uninsured people are approximately the same

as estimates from other surveys of the number of people uninsured at a given point in

time (Swartz, 1986). Swartz argues that the

CPS estimates can be reconciled with

estimates from other surveys if we assume

that CPS respondents are responding to health

insurance questions with reference to their

insurance status at the point in time at which

the questions were asked (March of the given

year), and not with reference to the entire

previous calendar year as the questions were

intended.

This argument is partially correct, but

the case appears to be overstated. There are

a number of potentially anomalous findings if

people are really responding to the CPS questions with respect to their health insurance

status at the point in time at which the questions were fielded. First, for those people for

whom we might expect a difference in insurance status from the previous year to

March--namely for those people who were

employed in the previous year but unemployed in March or vice-versa--insurance status

is more closely aligned with employment

status during the previous year than it is with
Preliminary Analyses of Adolescent Health Insurance Status ● 51

employment status during March (Enthoven

and Kronick, 1988). This suggests that many

people are answering the health insurance

questions with reference to their health insurance status in the preceding year, as requested, and not with reference to the point

in time at which the questions were asked.

Second, preliminary estimates from the 1987

National Medical Care Expenditure survey

show that 37 million people were uninsured

during early 1987 (Short, et al., 1988). This

is 6 million more people uninsured than one

preliminary estimate from the March 1988

CPS (Moyer, 1989). One plausible explanation for a smaller number of uninsured on

the CPS compared to NMES is that NMES is

measuring the number of uninsured at a point

in time, while CPS is, at least for some

people, measuring the number of people who

were uninsured for the entire previous year.

If this is the case, then, we would expect that

the CPS would show a smaller number of

people uninsured than the NMES, as it apparently does. 4 Third, it makes sense that

when people are asked whether they were

covered by insurance during the previous

calendar year that some who are currently

uninsured might forget that they were covered at some point during the preceding year,

but it does not make sense to think that all

(or even most) respondents will forget to

report such coverage.

In summary, because of question wording

difficulties, CPS estimates from 1980 through

1987 certainly overestimate the number of

people who were uninsured for the entire

previous year. As will be discussed below,

the question wording problems were largely

corrected in the March 1988 CPS; however,

because of recall error problems it is likely

A A large remaining puzzle is why the point in time

estimate from NMES of the nunber of people who ar e

uninsured is approximately 6 mi 11 ion greater than

the point in time estimates from either the Health

Interview Survey or from the Survey of Income and

Program Participation (USOHHS, 1987; HcNeil, 1988).

Further work is needed to understand these dif -

ferences, and to further clarify to Aat extent CPS

provides an estimate of the full-year versus pointin-time estimate of the rwber of uninsured.

that the March 1988 estimates will also overestimate the number of people who were

uninsured for the entirety of 1987. The

safest conclusion is that the 1988 estimates

will overestimate the number of people who

were uninsured for the entirety of 1987, but

underestimate the number of people who

were uninsured at any point in time during

1987.

Despite the question wording problems

from March 1980 to March 1987 the CPS

provides a valuable data source for the analysis of the health insurance status of adolescents. It is the only data source that provides

annual measurements to support trend analysis. The CPS has a large sample of respondents, which facilitates analysis of subpopulations. Further, the CPS has a variety

of questions about labor force participation,

which facilitates analysis of the effects of

employer mandates.

Question Wording Changes in March 1988

In an attempt to correct the un -

derestimate of health insurance coverage, the

March 1988 CPS asked different questions

about health insurance from those in previous

years. There are two major changes. First,

for each person in the household age 15 and

above, the March 1988 questionnaire asks

directly whether the respondent was ‘covered

by” a health insurance plan. Anyone covered

by a health insurance plan is then asked

whether the plan is in his/her own name or

not. Thus, a 16-year-old who is covered by

the health insurance of an absent father

should be reported as covered by the March

1988 questions, while the same person would

be reported as uncovered by the March 1987

questions (since such a person did not “have”

a health insurance plan). Second, a set of

“cover sheet” questions ask directly whether

any children in the household under 15 were

covered by health insurance during the

preceding year.

As of this writing, the public use files of

the March 1988 data contain responses to the

new questions for those 15 and above, but do
52 Ž Preliminary Analyses of Adolescent Health Insurance Status

not yet contain responses to the new cover

sheet questions.

As can be seen in table A-1, the new

questions appear to have had a dramatic effect on the reported coverage rates for 15- to

18-year-old adolescents. From 1983-1986

approximately 21 to 21.5 percent of this

group were estimated to be uninsured; the

estimated percentage uninsured drops

dramatically to 15.2 percent in the March

1988 survey. Since the estimated percentage

uninsured changes hardly at all for adults

(data not shown) there is every reason to believe that the change in estimate in 1988 is

due to question wording changes and not to

any real change in the proportion of 15- to

18-year-old adolescents who were uninsured.

Almost all of the reported decrease in the

proportion of 15- to 18-year-olds who are

reported as uninsured is accounted for by an

increase in the proportion with “other private

insurance.” The meaning of this category

changes in 1988 compared to previous years.

Prior to the March 1988 survey, “other private insurance” was equivalent to nongroup

health insurance-- that is, it measured the

number of people covered by insurance that

was not employment-based. However, in the

March 1988 survey this category also includes

employment-based insurance in which the

policyholder was not a household member--

e.g., if a 16-year-old child is covered by the

employment-based policy of an absent father,

this coverage will be counted as “other private

insurance,” and not as employment-based.

Further confirmation of the role of question wording change comes from an examination of changes in coverage rates for those in

single-parent households and those who do

not live with either of their parents. The

1988 questions ask such people directly

whether they are covered, rather than relying

on assigning coverage for such people as the

dependents of other policyholders. Thus, if

these adolescents are covered by a parent

living in another household they will be

reported as uncovered in 1987, but should be

counted as insured in the March 1988 CPS.

As can be seen in table A-2, coverage

rates for 15- to 18-year-old adolescents either living without a parent or living with

only one parent do increase by much more

than coverage rates for adolescents living

with both parents: from 64 percent uninsured

to 43 percent uninsured for those living

alone, from 30-percent to 18-percent for

those living with one parent, but just from

12.5-percent to 10-percent for those living

with both parents. This is further evidence

that the changes are a result of question

wording changes and not of any real change

in the number of adolescents who are

uninsured.5

As mentioned above, the public use files

that are currently available from the March

1988 CPS contain the pre-1987 question

wording for adolescents who are 14 or

younger. As such, estimates of the number

of uninsured people age 14 and younger are

certainly overestimates of the true number of

such people who are uninsured.

An approximation of the

estimation error can be obtained

ination of the data in table A-3,

the estimated percentage of

uninsured, by age group, in each

size of the

from examwhich shows

adolescents

survey from

1980 through 1988. As can be seen there, for

most of the 1980s the proportion of 10- to

14-year-olds who were uninsured was slightly

lower than the proportion of 15- to 18-yearolds who were uninsured. However, in

March 1988 the estimated proportion of 15-

to 18-year-olds who were uninsured

decreased dramatically but the estimated proportion of 10- to 14-year-olds who were

uninsured actually increased slightly.

s A someuhat surprising result in table A-2 is tha t

coverage a~ars to increase among 15- to 18-yearolds living in two-parent households -- from 12. 5

percent in 1983-1986 to 9.9 percent in 1987. Th e

increase occurs primarily in the percentage wit h

“other privat e II suggesting that some 15- to 18-

year-olds report being covered as a dependent when

neither parent in the household reports covering

the adolescent. Some explanations are plausible,

e.g., perhaps these are households uith a stepparent and the coverage of the adolescent is coming

from an absent parent, but further investigation i s

uarranted here.
Preliminary Analyses of Adolescent Health Insurance Status • 53

Table A-1. --Health Insurance Status of Adolescents,

Age 15-18, by Year, 1979-1987

Total

population,

Yea r

a

age 15-18 Total

No health Insured: public and privat e

b

insurance Employment- Other Other Publi c

coverage based privat e Medicaid public and privat e

1979 16,252,30 4 100.0%

1981 15,522,80 2 100. 0

1982 15,054,67 0 100. 0

1983 14,655,51 6 100. 0

1984 14,581,461 100.0

1985 14,733,07 6 100. 0

1986 14,716,50 2 100. 0

1987 14,492,07 7 100. 0

~1980 data are not available.

17.4%

18. 5

19. 5

20. 9

21. 6

21. 5

21. 5

15. 2

58.8%

58. 4

58. 5

56. 7

56. 7

57. 7

57. 2

57. 3

9.0%

7 . 3

7 . 1

7 . 5

6 . 8

6 . 4

7 . 0

12. 7

8.3%

8 . 4

8 . 4

9 . 0

9 . 2

8 . 7

8 . 3

8 . 4

2.2%

2 . 5

2 . 6

2 . 4

2 . 2

2 . 2

2 . 2

2 . 4

4.3%

5 . 0

3 . 8

3 . 5

3 . 5

3 . 6

3 . 8

4 . 0

‘EIIV(O ment-based includes all with employment-based insurance from someone in the household, and without public coverage; other P rivate includes nongroup insurance from household members and employment-based insurance

from nonhousehold metiers, ~ithout public coverage ; Medicaid includes all those with Medicaid but withou t

private coverage ; other Wblic is primarily CHAMPUS, and includes Medicare ; public and ~rivate includes all

those with both public and private coverage.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1980 through March 1988

Current Population Surveys.

Table A-2.--Health Insurance Status of Adolescents,

Age 15-18, by Type of Family and Year, 1987 vs. 1984-1986

No health Insured: public and privat e

b

Type of insurance Employment- Other Other Publi c

famil y Year Total coverage based privat e Medicaid public and privat e

Two-parent 1984-1986 100.0%

1987 100. 0

I

One-parent 1984-1986 100.0

1987 100. 0

No Paren t

b

1984-1986 100. 0

1987 100. 0

12.5% 71.9% 6.5% 2.9% 2.2% 4.0%

9 . 9 72.1 8 . 8 2 . 4 2 . 5 4 . 4

30. 2 33. 9 8 . 0 22. 6 2 . 0 3 . 3

18. 8 36. 0 17. 4 22. 4 1 . 6 3 . 7

64. 6 8 . 6 5 . 5 17. 0 2 . 8 1 . 4

42. 6 6 . 5 28. 2 16. 6 3 . 4 2 . 6

aEm~lovment-based includes all with employment-based insurance from saneone in the household, and without

public coverage; other ~rivate includes nongroup insurance from hwsehold menbers and employment-based insurance from nonhousehold mentws, without public coverage; Medicaid includes all those with Medicaid but

without private coverage; other cnhlic is primarily CHAMPUS, and includes Medicare ; public and Private inbcludes all those with both public and private coverage.

No parent in ftmily includes those adolescents who do not live with their parents and married adolescents

living with their parents.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1985 through March 1988

Current Population Surveys.
54 •Preliminary Analyses of Adolescent Health Insurance Status

Table A-3.--Trend in the Proportion of Adolescents

With and Without Health Insurance

by Age Group, 1979-1987, Unadjusted Data

Age Group

10-14 Years 15-18 Years

Yea r

a

Uninsured Insured b

Uninsured Insure d

b

1979 16.0% 84.0% 17.4% 82.6%

1981 17. 9 82. 1 18. 5 81. 5

1982 17. 3 82. 7 19. 5 80. 5

1983 19. 0 81. 0 20. 9 79. 1

1984 20. 1 79. 9 21. 6 78. 4

1985 19. 8 80. 2 21. 5 78. 5

1986 20. 2 79. 8 21. 5 78. 5

1987 21. 9 78. 1 15. 2 84. 8

~1980 data are not availabte.

Includes adolescents with health coverage from any source, public or private.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1980

through March 1988 Current Population Surveys.
Preliminary Analyses of Adolescent Health Insurance Status ■ 55

It seems likely that when the additional

“cover sheet” questions from the March 1988

survey are available, that the estimated proportion of uninsured 10- to 14-year-olds will

be similar to the estimated proportion for 15-

to 18-year-olds. To anticipate this result, all

analyses of March 1988 CPS data in the body

of this paper use adjusted data for 10- to 14-

year-olds. The adjustment process is described below.

One method of adjustment would be to

simply assume that 15.2 percent of 10- to 14-

year-olds should be uninsured (the same proportion as 15- to 18-year-olds), and that 30.6

percent (i.e., 1-15.2/21.9) of those who currently are counted as uninsured should instead be counted as insured. This change in

count could be accomplished by randomly

changing the health insurance status of 30.6

percent of the currently uninsured 10- to 14-

year-olds from uninsured to “other private

insurance." 6

The data are adjusted using a process

similar to the process described above, but

one slightly more refined. As noted above

the reported increase in coverage in the

March 1988 survey for 15- to 18-year-olds

was larger for adolescents living without their

parents and for adolescents living with one

parent than for adolescents living with both

parents. Further, as shown in table A-4,

parental insurance status and the size of family income also are related to the effect of

the new questions on the estimated percentage

uninsured.

To adjust the data a three-dimensional

table is constructed, where the dimensions

and cell definitions are (i) living arrangement

(alone, one-parent, two-parent), (ii) parental

insurance status (uninsured, privately insured,

6 Alternatively, the file could be reweighed to in -

crease the ueights on 10- to 14-year-olds who ar e

reported as insured and decrease the weights on 10-

to 14-year-olds who are reported as uninsured .

This might be slightly preferable to randoml y

changing responses for some, but is more complicated and not worth the effort for current purposes.

Medicaid, CHAMPUS, Medicare), and (iii)

family income relative to the poverty level

(below 150 percent of poverty, between 150

percent and 300 percent of poverty, and 300

percent and above). For each cell the proportion of 15- to 18-year-olds who are

reported as uninsured is computed, and the

assumption is made that, when adjusted, the

same proportion of 10- to 14-year-olds will

be uninsured.

Define:

P10-14,i,j,k = the reported proportion of 10-14

year olds who are uninsured in the March 1988

CPS among adolescents with living arrangement

"i" (either no parents, one parent, Or two

parents), parental insurance status “j” (either uninsured, private insurance, Medicaid,

CHAMPUS, or Medicare), and family income "k"

(either below 150% of poverty, 150-300% o f

poverty, or 300%+ of poverty); and

P15-18,i,j,k = the same quantity for 15- to 18-

year-olds.

The data are adjusted by picking a random

number from the uniform distribution

from 0 to 1 for each uninsured 10- to 14-

year-old, and changing that individual’s

insurance status from uninsured to insured

if the random number is greater than P15-

18,i,j,k/P10-14,i,j,k. The result of this

process will be, on average, that the adjusted P10-14,i,j,k will be equal to P15-

18,i,j,k for all combinations of living arrangement, parental insurance status, and

family income levels.

This adjustment reduces the estimated

number of uninsured 10- to 14-year-olds

by 1.2 million people: the unadjusted

estimate is that there were 3.6 million

uninsured 10- to 14-year-olds in the

March 1988 survey, or 21.9 percent of the

10- to 14-year-old age group. The adjusted estimate is that there were 2.4 million, or 14.6 percent of the 10- to 14-

year-olds in the survey.

If a similar adjustment were performed for 0- to 9-year-olds, the adjusted

estimate of the number of O- to 9-yearolds would be approximately 2.2 million

less than the unadjusted estimate; thus,

analysis of the new “cover sheet” questions
56 Ž Preliminary Analyses of Adolescent Health Insurance Status

Table A-4.--Health Insurance Status of Adolescents

by Age Group, Type of Family, Parental Insurance Status,

and Family Income as a Percentage of Poverty, 1987, Unadjusted Data

Parental Family income Age Group 

Type of insurance as ● percentage 10-14 years

b

15-18 years

family status of poverty* All Uninsured Insured All Unisure d Insured b

Two-parent uninsured less than 150% 664,105 100.0% -- 395,649 92.2% 7.8%

150 to 300% 396,771 100.0 -- 303,342 82.1 17.9

300% and above177,521 100.0 -- 163,605 69.1 30.9

.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

private less than 150% 936,309 9.8 90.2% 564,070 5.5 94.5

150 to 300% 3,282,186 4.0 96.0 2,152,360 3.5 %.5

300% and above 5,276,34? 2.9 97.1 5,218,866 1.2 98.8

..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAMPUS less than 150% 92,177 -- 100.0 50,451 -- 100.0

150% to 300% 179,671 -- 100.0 176,231 -- 100.0

300% and above 224,273 -“ 100.0 259,729 - - 100.0

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -------- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicaid less than 150% 434.750 -“ 100.0 238,895 -- 100.0

150 to 300% 63,221 -“ 100.0 45,909 -- 100.0

300% and above 15,372 -- 100.0 17,674 -- 100.0

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare less than 150% 62,582 90.3 9.7 61,849 64.8 35.2

150 to 300% 40.643 58.9 41.1 40,035 39.3 60.7

300% and above 5,118 49.5 50.5 28,239 30.3 69.7

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

one-parent uninsured less than 150% 738,309 100.0 -- 482,351 67.9 32.1

150 to 300% 182,513 100.0 -- 182,891 54.6 45.4

300% and above 53,897 100.0 -- 110,759 57.6 42.4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

private less than 150% 469,140 27.5 72.5 266,489 18.0 82.0

150 to 300% 674,814 23.6 76.4 712,547 7.4 92.6

300% and above 527,633 15.4 84.6 696,060 2.7 97.3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAMPUS less than 150% 22.081 -- 100.0 20,944 -“ 100.0

150 to 300% 20,525 -“ 100.0 31,806 “- 100.0

300% and above 10,584 -- 100.0 12,112 -“ 100.0

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicaid less than 150% 1,319,018 0.1 99.9 774,775 -- 100.0

150 to 300% 31,607 “- 100.0 15,430 -- 100.0

300% and above 8,329 “- 100.0 10,767 -- 100.0

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare less than 150% 20,190 86.2 13.8 18,418 69.6 30.4

150 to 300% 11,917 69.3 30.7 18,537 39.0 61.0

300% and above 1,597 100.0 -- 2,570 -- 100.0

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No parent c uninsured less than 150% 139,901 100.0 -- 61O,W1 57.8 42.2

150 to 300% 15,149 100.0 “- 81,317 57.0 43.0

300% and above 18,604 100.0 -- 32,953 41.2 58.8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

private leas than 150% 53,204 100.0 -- 71,373 36.5 63.5

150 to 300% 79,656 97.5 2.5 135,200 36.7 63.2

300% and above 89,972 100.0 “- 106,055 34.2 .65.8

..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAMPUS less than 150% 4,592 100.0 -- 22,750 -- 100.0

150 to 300% 4,632 100.0 -- 11,341 94.4

300% and above 2,205 100.0 -“ 7,933 38.4 61.6

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicaid leas than 150% 90,936 88.6 11.4 206.307 90.6

150 to 300% 14,379 51.9 48.1 14,841 32.7 67.3

300% and above 2,931 74.6 25.4 . . . .

------- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare less than 150% 36,963 100.0 -- 63.236 64.0 36.0

150 to 300% 4,790 100.0 -- 33,751 22.7 77.3

300% and above 12,996 100.0 -- 20,669 17.4 82.6

:In 1987, the Federal poverty level uaa S9,056 for ● f=ily of three.

IIK[udae edo(eacenta with hea(th coverage from my source, IxMic or privete.

CNO permt in family inctudea thoae adolescents *O do not live uith their permts mdmarried addeacenta tiving

with their permts.

SOURCE: Office of Technology Assessment, 1989, based on ● stimates from the March 1988 Current Population Survey.
Preliminary Analyses of Adolescent Health Insurance Status Ž 57

from the March 1988 survey should reduce

the estimate of the number of people

uninsured from the 35.5 million estimate

based on the currently used public use

files to approximately 32 million.7

Respondents Excluded from Analysis

Due to hardware problems, a small

number of records were omitted from the

analysis of each March CPS. The omitted

records are never more than 0.001 percent

of the total (that is, one-tenth of one percent), and for most years are below 0.0005

percent. Nevertheless, tabulations reported

here will be marginally different from

tabulations of the complete data sets.

Further, all unrelated individuals age

14 or below have been excluded from the

analysis because it is likely that the health

insurance status for many is incorrectly

classified. In the pre-1988 surveys all

7 Moyer has analyzed a preliminary March 198 8

CPS fi [e that contains the cover sheet questions

and finds 31.1 million uninsured (Moyer, 1989).

The differences between this 31.1 million and

the 32 million suggested here are relativel y

small but deserve further scrutiny.

such individuals were reported as being

uninsured (since there was no adult present in the household from whom they

could derive coverage), even though many

are probably foster children and likely are

covered by Medicaid. There were 217,000

such individuals in the March 1982 survey,

240,000 in March 1984 and 265,000 in

March 1988.

Analysis of Uninsured Adolescents by Size

of Firm of Parent’s Employer

Finally, a note on methods used to

analyze the May/March merged data in

1983. The March 1988 survey gathers information on the number of workers in

the firm of each respondent in the labor

force, but this information, like the “cover

sheet” health insurance questions for 10-

to 14-year olds has not yet been released

on public use files. The only other CPS

source for such information is the May

1983 CPS which asked questions on firm

size. The Census Bureau has merged the

May 1983 data with March 1983 data to

form the so-called May/March merge; this

file is used to create tabulations of health

insurance coverage by firm size.
APPENDIX B.--CPS HEALTH INSURANCE QUESTIONS

MARCH 1980-MARCH 1987

—

LINE NUUBEff *4 P8JI15 *auIB6 (/fan 18,4)

!4. INTERVIEWEf! CHECK ITEM

Who &d h W? (-YES”h I 29A w2M)

Y6 o No O ■

Yes o

NOc I

Ye5 o

No L ■

Yes o No O

: CnaW&t# 74A—74E ford- n4ti “Y8s”ln 74)

/ 74A. Odnl dun Sakd .Sudty did Ih9 bnv) amPfOYa a Imh

I dut . . . Wtkd fal him m 9 Pauiam Or OthulypOOf

I mimnmlt P19n far anvof it9an@0w@87

L ---------------------------------------- -

! 74a. w . imkukd h Ih91 *?

Yes O (Ad 746) Yes O (Ash 748)

hn”tkn~ g I’(*’P’”7U) DOn’tknZ Z \(Mtpt07u)

Yea (-1 (Ash 74?)

‘

0 0 { (s&@ to 74C) )on’t know O \

Ya$ o NOo y= ~ N o I Yes o No G Yes o No O 1

l---- ––––--------- ––––––– –--- ––––----–-––– .

(a74C. m inchnkd h ● pvup fmlth inwarbm plm

tfw (my) fob W* hdd drinwlma?

Yes O (Ash 740)

Na O 1 (Go to 74A fw nut

Yes J (Ash 740) YeS G (Ad 740)

::: ~(:to74Afwncxt No O ( (Co to 74A fornrxf

rlml Ib+th “Ye!’” DK G ( ~- ‘iffI “’y~”

ti 74 w skip to 75) m 74 Orlk/p to 75)

All c All J

1- I’p’----- ————----- —- —- ——————— — — - — ---- —-----

‘ 740. M . . .“salvkwr or UnkMl WV for ● II, m. or nOm

of* mad Ud# hmflfl pkn?

&

1- - --––--– –––--–-- –––-–--- ––––-––--––––– -

74E. M ..., wfm~ hthim fuMhOfdwswaldby

thb@uPhdtfl Itwntlapkm?

All C All ‘

Pm .,

None ‘

PM! L

I

Part (. ■ Nom O None > None “

Sfwwonly o

Chlld(rm) ontv c

Spoummd Chlldkm) o

self only o

other o

Spc.usn only .

Chdd[renl Otltv “

SPOUS8 and chddkenl

%if only

Otti -

SPam OflIv 0

Chdd(ren) only c

Spcu= and tidd(ren} -

self only G

Other 3

Spouso Cwlly o

Chdd(renl odv )

SpouaB and chdd(ren) (.,

self only c1

other o

1

~ (Go h 74A hxmxtpmwa w#h ‘“Yu’”h 74w9n m 75) #

fll m-d Uwunmml $wVmn Aid! provide nudicd cam

mdkmf bilk

DIM* lma M MyOm in thk houufdd mwrcd by

7“- 6A. (fwtfm d&b&d md8&rly)?

Ya o 7 No “ (s&@tO 7SC)

Yes o No O Yes : No CI ,1

A_------- _________ .___...– _–. ... ----– ––––– .

9-(hwtbenady)?

.__.l------------- ‘=0 7------------:’=!=’::)- : WA Wm wIW?(AIWM Ac?)

Yes c No O Yes “ No Yes . No .

■

Yes No IC 1

1

.–--L---- _--___ ----- –--––-– ––.–. ... .._-- –-–-–

763. C14AWUS, Vk a fwfuy hdlfl m?

Ya o ~ ■ No (Ship m 76A) ■

- _ --, ------------ L---------------------------

I W. M!QMthst? (Anpa8 ● &?)

1 Yes ‘2 NOo Yes c No ‘3

7

No G (Go m tmn 77

~w u

-? (Anymnab?)

8

I

Yes o NOo Yes o No I Yes . NO [, Yea o NOo

1

i*-

L----- --------------------------------- -

,mc ..., **in fhb hOlwhOfdwaccuamd

hSPwle Onlv o

chddhn) Cllly o

SPWmmd chddlran) O

.ssff ally o

Otfw o

SPWsO only Z W= mlv [J

Chdd(rud only Chdd(rml Oflhf O

SPOUS md chld(rml . SW= and cfvld(fen) O

■

Se4f Only . self Onlv o

Dtfw Othef a

Spumonly o

Chddran OdV O

S4muw M-Id d’llid(m) o

■

self only o

Dtfwo

I

! (Go w % hrruxt~ nfti “-yin ”h 766 w!tmn 770n AwP 1)

---------------------- --------------------------------------------------------------------------- ——-—-—— —-. ... —.. ——————— _—__——— -- ——— —---_-—-

58
APPENDIX C.--CPS HEALTH INSURANCE QUESTIONS, MARCH 1988

~

‘RY

I HOUSE

HOLD

NO

1

:

-{

f,

(

‘ORMCPW6S

/ “ \

&

U S DEPARTMENT OF COMMERCE

BUREAU OF THE CENSUS

~%. j

CPS =636 5

UNIW)GM13 WJIPIPREIMEINU

INTERVIEWER CHECK ITEM 2 SAMPLI

A C

L o

LCONTROLNUMBER

1

I

1

Only CPS436510< household

I

(Filldloppfkob{e

F,,$l CPS436!jof cent, nuat,onh,hld (a Item m rhh POfw)

Sm20ml CPS8650f contmuat,onh’hld ‘I (

(Tmnrcribe Itmn

Thwd, fou,th, atc CPS.665 /, ( (3, 6-9, J3)

ffwn first CPS465, 1

‘. SEGMENT 8 SERIAL

O. INTERVIEWER COOE

ABC OEFGHJ KL M

o .-

., , u

O I ~ 3 @ :, (> Y ., [

o I 2 3 “- 5 6 7 .“ 7

b-m APPrOvd -0 M B No &W743S4 MARCH 19S9

13. TYPE INTERVIEW (CPS-5S61 ■ INTRODUCTION

(Ckptlaul)

We hva iuat COtndalad the aueetiorta about emDlovm4mt

Tvpe A Nonmterww (7rm%rf6t Items 1, 3, 6-10

m Iflb Pqe)

a-d unamploy”wt. E&h Mar~, tfte CatuuS Burwu also rmllact$

informs tion dmut the economic situation of Amarwims and the!r

familma for the previous yaer. I am going to esk th- questions

now. We dan’t expect ● ll anawara to be perfect, but please think

about each question ● nd arwwer it the best you can.

13A. DESCRIPTION OF LONGEST JOB (/fcms 46A [)

IN THIS CF’S465

■

S3 During 1987, how many of the children in this

ftoutahtrld usually ate a mmplate hot lunch

Of fart!d at Xhool?

r All

1

-

1 %me, but not all - Mark number

/

T

+

2 @, ~ 6 ? - 9

“ None

Ye5 No

r7. INTERVIEWER CHECK ITEM

TENURE (frun Cmtrd Cardlrem 10)

Chvrted w LWW bouqht ‘

Ffantd

No tirent <

!9, Am you pavIng fowei rent bauta the Federd,

SUte, or local 90vemment IS pavlq part

of the cost?

Yes

S4 The fiowmmant hat ● anargv aantwwa

P-*M Irakpt pay hating mm.

Thit ararttance m IX ramivld directly

by ttta houaahefd or It can be mid dxactly

to ti alatnc company, gm companv

et fud alder

since OctrAmf 1, lim7. hat thb freu@rOld

recaiwd a9isarxe of drls type frm Iha fadaraf

State, w fc4 90wrnrmfIt7

No ●

?S. How manv houamg umtt anm thrr ttrucrum?

1. 5–9

2: 10+ w

~. Oid ertvone in this fw$etwid 9et food -t

at my tune dvring IW7?

S4. Inmvmwr Check Itam

Enrry m Control cord Item 29 h ■

Un&r S32,@13, NA or Ref “. (FII185)

$30.OfXl or more

- End

qumtmm

3 - 4

‘fer (Ask 9fJ

79, INTERvIEwER CHECK ITEM vet (Ask 95)

No L (End Quwhru)

No (Ship to 94)

sum Iwxueho{d KemkMrs uru!u ag8 15 {A,h 80)

11 How many of the people now lrvmq here We

f4.3 hw~ld !710MtWS tmdOr w 15 cowred bv fed atmnm durlw 19S77 (ShlP tO 82)

.)80. urkts 1SS7, how many of tha children m tfvs ftouaaftold

under e@o 15 twm CoverUl by MUJicaraor Medicmd?

. All

“ $xxlw, but not all – Mark rwmber

f

95. Aito@rw, how much anarsv~

fua bean ramtvad smm October 1, 1W77

86. InterviawrChd Item

All C+ scxrm msrked ,n 83 C (Ask S6)

Now marked m 83 w S3 blank C (Sk,P to 87)

@S. During 1SS7, how metty of the children in this

homahom raceiwd tier redufmd Price Iuncfx

bawua they wetif’hd for the Federal SchaoI

Lunch ProFam?

O All

O %ma, but not ail - Mark nurrtbaJ

/+

r . 3 q- ‘j G ? . g

O None

B7. Intel-v- Chl& Imm

&med marked m 77 0 (Sktp m 90) W

Ranted or no cash

rmt mmked m 77 0 (Ask 88)

------ U “ .,

123+56759 +

■

5 Nom

\

al Ins 19S7, fvw many of thachildrart~ m thn

hmJtlhofd Wwa OMard by ● halth i— plan

(fXCktdh9 Madka4dmd Medtir)7

111

?2. h how many mmtht of 1SS7 ware food stamp

reaiwd?

❑ 5 NOIN (sklfJ m 82)

rmnv of tftmt dIildran two ~ by tha health

, — not radding in thm ftmmshld?

2 All

9 Scma, but not all - Mark number

1

All :1

03. Whet WM the value of all the food stamps

racerwd during 1SS7?

(Amarendtlymnewm toobtofnm!mmlfw~)

n

$

. .-

<:2.

3

m

(~ ddfw) : >

SS. IS thn ftousa m ● pubhc ftouahtg proiacr that b,

1$ It W by ● IeCd houtirq mmharity

of other public agmcy?

Yw o (skip to 90)

No O (Ask 89)

.-.5

“>5

- .

(Ask 94/

CODER NkJMSER No f-lmdtold Memban 5-18 ymrt old o (Srw to 84)

ABC OEFGHJKL M

( -) ‘- (- [1 0 0 c) o 0 0 ()

59
60 ■ Preliminary Analyses of Adolescent Health Insurance Status

NtiE(wknnl)

LINE NUMBER (lt@n 18.4) P* 3 Pape 4 Page 5 Pa@ 6

‘A

M. T m lr#wd gwulmnm progl’una tiich PrOvida nmdiwlPDy nwdtd bdb.

Ourifq 1!367 ww anyone m tfws housdwki coverd by.

14A. Madimm (for the dibkdmdetidy)~

Yes o

/

M o (skip !0 74C )

! 748. who wttm7 (Anyan &?) Yes f4~ n Yes - No 1

Yes “ No

l--- __. _..–. -.-- –.-- –––--–– -- -

Yes ‘) No L

>

la. bid (fW the WdY)7

Yes c

7----------------------- -

No D (Sk@ to?4E) ■ ■

._ —---- -__- —— ----

; MO. whn was thstl(Anxm d=?) Ye3 L No L) Yes L No > Yes I

3

No ,> Yes L No L

--- --- —- ——--—-------- —-- —- —-- —- —- ———--—-— —--

ME. AMPUS, VA, or mdttaw health care?

Yes o

7

NO a (sklP to 75A)

_-- T ----------- .-_ —-. ... -.. .-- ——. .-. .-.—.—

~ 74F. Whom dmt?(Anycm *b?) Ye! c’ No O Yes o No : Yes . No o y= (, No C)

1

1

-!

76A. thm Wdkm, MrdKaJ4 w m!l!fary hralth murame)

duffng 1487, -UIWmin this hmndtold mvamd bv

a Itnlth imuranw PW?

Yes o ● m

1

No o (sk$7 to 76) ■

@=”’’’”~-)’) y- II NO f., Yes .1 No Yes No u Yes No O

l----------------------------------------- -

p

&te 7K-F fw #ah PUX.X wffh e “Ya”kt 758)

76C. m..’s hdth inwrma -W from ● @an in . . . “s Yes 3 (Ash 750) Ye 7 (A$k 750) Yes (Ash 750) YOs > (Ask 750)

mm? !40 ~ (Go to IWSlptfSOII No 2 (Go tomxlpenon No - (Go to ocxtwmm No : (Go to nutpmm

wth a “’Yes” tn 758 dth a “Ycs”h 75B w!th a ‘“Yes ’’I.I756 with o “Yes”h 758

or Skip to 76) w ShtP to 76) or Skip (o 76) or Sk@ to 76)

p------------”-------- -

--- -

- ”

------- -

7S0 Wmtfti9 hafth i-mm Pbn ofiemd tfurnJ@ .’* current

of formor Ctnploywr of union? Yes J (Ask 75E) ■ Yes . (Ad 75E) Y= . (Ask 75E) W ‘ies . (Ask 75E)

NO C (Skip to 75F) NO : (~lp t. 75F ) NO ‘J (~tp 10 75F) N O ~ (skip to 7SF )

4-

D

--------------- -

--. —————--—--—.—— —---

, 76E. id. .“s arnpbvar or uttba pay for aif, put. w mm All 1

oftfw aut of this plan7

All C All ,2 All G

\

Part 2 Part o Pact C Part O

None 3 Nom 2 None ‘, None @

I

p

-------------------------------- -

7W. tOtk~w*cmwndbytftkftaalth spouse o Sixuse c

ilwmaplm?(Mwkdthamfiy)

spouse o spouse c

Chdd(ren) m houwhc4d O Ch!ld(ren) m hwselmld : Choldlwnl m household ‘G Ch!ld(mn) ,n household O

(Go m 7SCfwmxt#mmn dth “Yu-h 7W ww to 76) Ch{!d(renl not m the fnxmehold O Ch!ld(renl not m the lwuselwlcl O Chlld(re.) not m lhe hcwsi#mld O Chlld(renl not on the hou~ld C

1

, other o

9

O1hw C Otha o

1 w

other o

NOOnO o N O orw C No one O N001u3 o

t

m Itxavti Cha41 Imm

--W w? IYm tn 29A ar2PB) Yes c NOo y- c No C Ym : No O Yes t> f400

: (Coa#Cm 76.4.748 f~~I=ISM wth “Ycs’”111 76)

[ 76A. othmr tfum .SOCtd %curitv did tha (=Iv) ~pbvw Or unmn Yes O (Ask 76B) Y- O (Ask 766) Yes 3 (Ask 76Ef) Yes C (Ask 768)

1 dmf dd 6X in 1987 ha tmtmiom Wodtw tvpc No O (Go tOIWXIp*lMXl No O (Go tOfUXt~ No C (Go tomxlpcrson No O (Go the nextprmon

I of tdmmwn *for mv of ifs es@ovas? nfti ‘-Yea’,ln 76 w w}th “Yu”/n 76 or with ,,Yes’”In 76 w

I S@ m 770tl Lw@ 1)

wlfh a “Ya”-rn 76 w

■ skip to 77 mpmgc 1) skip to 77mmqc 1) ■ Sktp to 77mpqt 1)

L ---------------------------------------- -

~ 748. wktchldld in tfnt ptml?

c

t

(Go tv ~ formxtm with “Y.””bI )trm 76 Yes o No O Y- o f40 0 Y- o No o

I wSk@ to itm 77011 Pup 1)

Ye$ o No o

t

m:

-------------------------------------------------------------------------------------------------------------------------- -

------------------------------------------------------------------------------------------------------------------------------------------- -

o

‘,

H

7

0

.,.

-3

~

1

SOURCE: U.S. Department of Commerce, Bureau of the Census, Form CPS-665, March 1988.
APPENDIX D.--BIVARIATE RELATIONSHIPS AMONG INSURANCE

STATUS AND SELECTED SOCIODEMOGRAPHIC

CHARACTERISTICS OF UNINSURED ADOLESCENTS

Appendix D analyzes the bivariate relationships between a number of demographic

and household factors and the likelihood of

an adolescent being without health coverage.

These include: parent’s insurance status,

poverty and family income, adolescents’

living arrangements, race and ethnicity,

parent’s marital status, parent’s education

region and residence, and parent’s work status

and other employment characteristics.

Many of these demographic and socioeconomic characteristics of adolescents are

intercorrelated, and most are correlated with

family income. When family income is controlled, the strength of many of the relationships diminishes. Section 3 of this Background Paper assesses the relationships of

these demographic and social characteristics

with health insurance status independent of

family income.

Parent’sl Insurance Status

Virtually all adolescents who have private

health insurance are covered as a dependent

on a parent’s policy. Most adolescents (81

percent) live with an insured parent and almost all such parents insure their adolescent

dependent(s); only 3 percent of adolescents

living with an insured parent are uninsured

(see figure 1 in Executive Summary). To a

large extent, then, the problems of uninsured

adolescents are the problems of uninsured

parents. Twelve percent of all adolescents

live with uninsured parents and more than

three-quarters of those who do are also

uninsured. Almost two out of three uninsured adolescents (64 percent) live with

1 Note that, throughout this paper, references to

the parent reflect the characteristics of th e

household head unless only the spouse ha d

employment-based health coverage. The “household

head” is designated after a discussion bet~een th e

interviewer and the respondent follo~ing certai n

rules (E. Ue[niak, personal comnunication, July 24 ,

1989) .

parents who are also uninsured (figure 1 in

Executive Summary).

Poverty and Family Income2

Family income is closely associated with

adolescent health insurance status. Adolescents in poor or near-poor families 3 (i. e.,

with family incomes below 150 percent of the

Federal poverty level) are much more likely

to be uninsured than others; approximately 29

to 32 percent are without public or private

coverage (table D-l). In contrast, less than 5

percent of adolescents in families at 300 percent of poverty or above are uninsured. Note

also that while the poor and near-poor comprise less than 30 percent of the overall

adolescent population, they account for twice

the proportion (i.e., 60 percent) of all uninsured adolescents.

Despite the strong relationship between

low family income and the likelihood of

being uninsured, it should be recognized that

for adolescents, as for adults, it is by no

means true that all the uninsured are poor.

While 41 percent of uninsured adolescents

live below the Federal poverty level, onethird are between 100 and 199 percent of

poverty, and more than a quarter are at 200

percent of poverty or above.

Although similar proportions of those

below 50 percent of poverty and those between 100 and 149 percent of poverty are

without health insurance (i.e., 31 and 29 perQ Poverty status is expressed in relation to th e

official Federal poverty level . In 1987, the Fed -

eral poverty level was $9,056 for a fami[y o f

three . See appendix E for Federal poverty levels

from 1979 through 1988.

3 “Poor” refers to those whose family incomes ar e

belou the Federal poverty level; “near-poor” de -

scribes fami [y incomes bet~een 100 and 149 percent

of the Federal poverty level; and very poor i s

equal to or less than 50 percent of the Federa l

poverty level.

61
62 ■ Preliminary Analyses of Adolescent Health Insurance Insurance Status

Table D-l --- HealthInsuranceStatus of Adolescents, Age 10-18

by Selected Demographic and Household Characteristics, 1987

Selected demographic No health Insured: private and publi c

and household insurance Private Medicai d

characteristic s Tota l

b

coverage onl y onl y Othe r

c

Parentis insurance status :d

not living with parent s 100.0% 41.0% 37.9% 16.8% 4.4%

parent not insured 100. 0 77. 0 21. 8 0 . 8 0 . 4

parent is insured 100. 0 3 . 3 79. 8 10. 7 6 . 1

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Family income as a

percentage of poverty :

e

less than 50 percent 100. 0 30. 9 16. 6 48. 4 4 . 2

50 to 99 percent 100. 0 32. 2 23. 6 38. 1 6 . 1

100 to 149 percent 100. 0 29. 4 53. 4 10. 7 6 . 5

150 to 199 percent 100. 0 21. 5 69. 2 3 . 1 6 . 2

200 to 299 percent 100. 0 10. 3 82. 8 1 . 0 6 . 0

300 percent and above 100. 0 4 . 6 90. 7 0 . 2 4 . 6

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------ ------ ------ . . . .

Living arrangement:

living with both parents 100.0 10. 7 80.3 3.2 5.8

living with father onl y 100. 0 18. 4 67. 7 7 . 4 6 . 5

living with mother only 100.0 20. 1 45. 8 30. 5 3 . 7

not living with parent d

100. 0 41. 0 37. 9 16. 8 4 . 4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Race/ethnicity :

white, non-Hispanic 100.0 11. 5 78. 7 4 . 7 5 . 1

black: non-Hispanic 100. 0 19. 2 47. 2 27. 1 6 . 5

Hispanic 100. 0 31. 2 46. 2 18. 8 3 . 7

other 100. 0 17. 5 59. 4 14. 9 8 . 1

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- ------- ---

Region :

f

Northeast 100.0 9 . 2 76. 6 10. 9 3 . 3

Midwest 100.0 9 . 3 76. 1 11.1 3 . 6

South 100. 0 19. 7 64. 7 8 . 8 6 . 7

West 100. 0 18. 6 65. 4 9 . 4 6 . 7

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- . . . . . . . . . . . . . . . . . . . . . ------- ------- ------- ---

Residence:

central cit y 100. 0 17. 5 58. 2 19. 2 5 . 0

other MSAg

100. 0 12. 4 77. 7 5 . 1 4 . 7

nonMSAg

100. 0 16. 7 67. 8 10. 3 5 . 2

not identifie d 100. 0 14.1 72. 6 6 . 2 7 . 1

. . . . . . . . . . . . . . . . . . . . ------- . . . . . . . . . . . . . . ------- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sex:

‘mal e 100. 0 14. 3 70. 6 9 . 9 5 . 3

female 100. 0 15. 5 69. 4 9 . 9 5 . 3

.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- . . . . . . . . . . . .

Parent's work status :

h

’

i

full-year, full-tim e 100.0 9 . 5 86. 4 0 . 9 3 . 1

full-year, part-tim e 100.0 22. 9 59. 0 11. 2 6 . 7

part-yea r 100. 0 25. 0 48. 2 20. 8 6 . 0

nonworker 100. 0 18. 2 13. 2 51. 9 16. 7

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Parent self- emloye d

h

self-employed 100.0 25. 8 66.6 3.1 4.5

not self-employed 100. 0 11. 2 81. 2 3 . 8 3 . 8

nonworker 100. 0 18. 2 13. 2 51. 9 16. 7

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Size of parent' s employer j

fewer than 25 emloyees 100. 0 24. 8 64. 7 3 . 7 6 . 8

25 to W employee s 100. 0 17. 0 72. 3 1 . 8 8 . 9

100 to 499 employees 100. 0 13. 3 77. 4 0 . 9 8 . 5

500 to 999 employees 100. 0 12. 5 78. 6 1 . 9 7 . 0

1000 employees or more 100. 0 9 . 8 81. 2 0 . 6 8 . 4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preliminary Analyses of Adolescent Health Insurance Insurance Status • 63

Table D-1.--Health Insurance Status of Adolescents, Age 10-18 by Selected

Demographic and Household Characteristics, 1987 (cont’d)

Selected demographic No health Insured: private and publi c

and household insurance Privat e Medicaid

characteristic s Tota l

b

coverage onl y onl y Othe r

c

Industry of parenti s emloye r

n

public administration 100.0% 4.9% 84.1% 1.5% 9.5%

durable goods 100.0 8 . 1 87. 2 1 . 8 2 . 9

mining 100. 0 8 . 6 87. 3 0 . 9 3 . 1

transportation 100. 0 9 . 0 85. 6 1 . 5 3 . 9

financ e 100. 0 10. 6 86. 2 1.1 2 . 2

professional service s 100. 0 10. 8 82. 4 4 . 0 2 . 9

nondurable goods 100. 0 11.0 83. 2 3 . 0 2 . 8

wholesale trade 100. 0 11. 3 83. 2 2 . 7 2 . 8

entertainment 100. 0 15. 8 74. 3 3 . 4 6 . 4

business services 100. 0 19. 5 66. 7 8 . 7 5 . 1

nonworker/other 100. 0 20. 9 15. 0 49. 1 15. 0

retail trad e 100. 0 21. 1 66. 6 8 . 1 4 . 1

construction 100. 0 22. 5 66. 8 5 . 2 5 . 6

agricultur e 100. 0 29. 4 62. 0 4 . 4 4 . 3

personal services 100. 0 30. 5 52. 8 14.1 2 . 6

----- -- ------ ------ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------ ------ ------ ------ ------ ------ ----

Parentis education :

h

less than 9 years 100. 0 30. 1 39. 3 27. 2 3 . 3

9 to 11 years 100. 0 21. 7 49. 3 23. 6 5 . 3

high school graduate 100.0 12. 5 73. 9 8 . 5 5 . 0

some college 100. 0 10. 5 77. 6 4 . 6 7 . 3

college graduate 100.0 6 . 8 86. 7 1 . 8 4 . 7

post graduate 100. 0 3 . 9 90. 6 0 . 5 5 . 1

. . . . . . . . . . . ------ . . . . . . . . . . . . . . . . . . . . . . . . ------ . . . . . . ------ ------ ------ ------ ------ ------ ----

Parent's marital status :

h

married 100. 0 10. 9 79. 8 3 . 4 5 . 8

widowed 100. 0 29. 2 51. 3 14. 0 5 . 5

divorced 100. 0 18. 9 57. 9 19. 0 4 . 2

separated 100. 0 20. 2 44. 5 33. 0 2 . 3

never married 100. 0 15. 3 24. 6 56. 7 3 . 3

~Characteristics are of household head unless only the spouse had employment-based health coverage.

Percentages may not total 100 percent due to rounding.

~Includes adolescents with CHAMPUS, Medicare, or any combination of public and private coverage.

Includes adolescents not living with their parents and married adolescents living with their parents.

~In 1987, the Federal poverty level was $9,056 for a family of three.

Northeast includes: Connecticut, Maine, Massachusetts, New Jersey, New York, Pennsylvania,

Rhode Island, and Vermont.

Midwest includes: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska,

North Dakota, Ohio, Swth Dakota, and Uisconsin.

South includes: Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, MiSSiSSi~i,

North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and Uest Virginia.

Uest includes : Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon,

Utah, Washington, and Uyoming.

gMSA =

h

Metropolitan Statistical Area.

Includes only mnarried adolescents living with their parents.

‘Full-year, full-time refers to workers who worked for at least 35 hours per week for at least 50 weeks.

Full-year, part-time refers to workers who were employed for at least 50 weeks and worked less than 35

hours in a typical week. Part-year workers worked or sought work during the year, but for less than so

weeks during the year. Nonworkers neither worked nor sought work during 1987.

]Data are frm the 1983 Current population Survey. More current data are not available.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988 Current Population Survey.
64 ■ Preliminary Analyses of Adolescent Health Insurance Insurance Status

cent respectively) the source of coverage differs markedly for these two groups. Those

under 50 percent of poverty who are insured

are most likely to be covered by Medicaid

while those between 100 to 149 percent of

poverty with coverage are more likely to be

enrolled in a private health insurance plan.

Living Arrangement and Parent’s Marital

Status

Whether an adolescent has health coverage is also related to whom he or she lives

with and parent’s marital status. Half of all

uninsured adolescents live in two-parent

families (figure D-1 ), and those who live in

two-parent families are also more likely than

other adolescents to be insured (table D-l).

About 11 percent of adolescents in twoparent families are without health coverage.

In contrast, about 20 percent of adolescents

who live with only one parent are uninsured.

Adolescents living with widowed, divorced,

separated, or never married parents are more

likely to be uninsured than those living with

married parents; 29, 19, 20, and 15 percent,

respectively, do not have health insurance

(table D-l). Those adolescents who do not

live with at least one of their parents, 6 percent overall (figure D-2), are at greatest risk

for being uninsured; 41 percent are without

coverage (table D-1).4

Race and Ethnicity

There are considerable differences in insurance status among white, black, and

4 The category “adolescents not living with their

Parents’t includes adolescents who live with “other

relatives’s (i. e., grandchildren, nieces, nephews,

etc. ) or unrelated individuals, those living o n

their own (or with their own spouse and/or children), and married adolescents who reside wit h

their parent(s) . Married adolescents are categorized this way because the U.S. Census Bureau assumes that most private health insurance plans exclude them from their parent’s policies. Of the 6.4

percent of adolescents ‘not living with thei r

Parent s

n

, approximately half live with “other relatives, 1.1 percent with unrelated individuals, and

the remainder are in other categories.

Hispanic adolescents. 5 More than 30 percent

of Hispanic adolescents, 19 percent of blacks,

and 12 percent of whites do not have health

coverage (table D-l). Race and ethnicity are

also correlated with type of coverage; relative

to whites, insured black and Hispanic adolescents are much more likely to be covered by

Medicaid than by a private health plan.

Parent’s Education

The likelihood of being insured increases

sharply as parent’s education increases. More

than one out of five adolescents whose

parents were not graduated from high school

are uninsured. In contrast, less than 7 percent of adolescent dependents of college

graduates are without coverage (table D-l).

Region and Place of Residence

The proportion of adolescents without

health insurance varies across region. Almost

one out of five Southern and Western adolescents are uninsured while less than one out of

ten Northeastern and Midwestern adolescents

are without coverage.

Note also that urban (i.e., central city)

and rural (i.e., non-metropolitan statistical

area) adolescents are more likely to be

uninsured than those who live in suburban

areas (table D-l).

Parent’s Work Status and Other Employment

Characteristics

Adolescents living with nonworkers,

part-year workers, or part-time workers are

more likely than adolescents living with fullyear, full-time workers to be uninsured (table

D-l). Nevertheless, approximately half of all

the uninsured adolescents who live with a

parent live with a full-year, full-time worker

s The racial and ethnic distribution of adolescent s

in 1987 is shown in figure D-3. Hispanic includes

both black and white adolescents of Hispani c

origin . ~~itell ad Ilblackll are non-Hispanic onlY.
Preliminary Analyses of Adolescent Health Insurance Insurance Status • 65

Figure D-1 --- Living Arrangements of

Living wit h

both P

5

Uninsured Adolescents Only

ng wit h

onl y

18% N o t

wit h

g wit h

fathe r

living

paren t

a

28% mother onl y

alnc[ude~ adolescents not living with their parents and marr

their parents.

SOURCE: office of Technology Assessment, 1989, based on esti

Current Population Survey.

ed adolescents living with

mates from the March 1987

Figure D-2--- Living Arrangements of All Adolescents, Insured and Uninsured

Living with

both parent

70

fathe r

Y

ot living

ith paren t

a

g wit h

er onl y

aInc[udes adolescents not [iving with their parents and married adolescents (iving uith

their parents.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1987

Current Population Survey.
668 Preliminary Analyses of Adolescent Health Insurance Insurance Status

Figure D-3.-- Race/ethnicity of Adolescents, 1987

White, non-Hispanic

71%

pani c

o%

ck, non-Hispanic

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988

Current Population Survey.
Preliminary Analyses of Adolescent Health Insurance Insurance Status ■ 67

(figure D-4). 6 Further, most adolescents (70

percent) live with parents who have a significant attachment to the labor force (i.e.,

full-year, full-time workers) (figure D-5).

More than one-quarter of adolescents

whose parents are self-employed are without

health coverage (table D-1 ). There are two

likely explanations. First, Federal tax treatment of health insurance contributions favors

employees over the self-employed. While no

portion of an employer’s health insurance

contribution is counted as taxable income for

the employee, the self-employed may only

deduct 25 percent of health insurance

premium expenses from taxable income. Second, self-employed parents may not have access to the group health market in which

health plans are typically less costly than

nongroup policies.

Adolescents’ likelihood of being without

health coverage increases as the size of their

parent’s employer decreases. Approximately

6 Fu[ ( -year, full-time is defined as at least 3 5

hours per week for at [east 50 weeks of the year.

one out of four adolescents whose parents

work for small businesses (i.e., fewer than 25

employees) are uninsured, while only 10 percent of those whose parents work in a firm of

1,000 or more employees are uninsured (table

D-1).

7 Although adolescents with parents i n

small firms are more likely than others to be

uninsured, lack of health insurance is not

confined to those whose parents work for

small businesses. Almost 40 percent of

uninsured adolescents have parents who work

in firms with 100 or more employees, and an

additional 12 percent have parents who work

in firms with 25 to 99 employees.

The industry of parent’s employers is

also related to health insurance status.

Coverage rates are lowest in personal services

and agriculture, and highest in public administration (i. e., government), durable goods

manufacturing, and mining (table D-1 ).

7 These data are drawn from the March 1983 CPS

which provides the most current CPS i nf ormat ion on

f i rm size. Al though the March 1988 CPS included

quest ions concerning f i rm size, these data are not

yet available.
68 • Preliminary Analyses of Adolescent Health Insurance Insurance Status

Figure D-4. --Parent’s Work Status of Uninsured Adolescents Onl y

a b

Full-year,

part-tim e

Full year,

full-tim e

51% Nonworke r

17%

t-yea r

aRefers t. the uork status of the household head unless the spouse is providing insuranc e

to the adolescent.

bFu[l-year. full-time refers to uorkers who worked for at least 35 hours per weeks for at (east

50 weeks. Fu(l-year, Part-time refers to workers uho were wp(oyed for at least 50 weeks

and worked less than 35 hours in a typical week. Part-year workers worked or sought work

during the year, but for (ess than 50 weeks during the year. Nonworkers neither worked nor

sought work during 1987.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988

Current Population Survey.

Figure D-5. --Parent’s Work Status of All Adolescents ab

full-year,

full-time

Part-year

%

Full-year

part-tim e

12% Nonworker

aRefers t. the work status of the household head unless the spouse iS providing insuranc e

to the adolescent.

bFu[l-year fu~[-tim refers to workers who worked for at (east 35 hours per weeks for at (east

50 weeks. Ful[-year. part-time refers to workers who were employed for at (east 50 weeks

and worked less than 35 hours in a typica[ week. Part-year workers worked or sought work

during the year, but for less than 50 weeks during the year. Nonworkers neither worked nor

sought work during 1987.

SOURCE: Office of Technology Assessment, 1989, based on estimates from the March 1988

Current Population Survey.
APPENDIX E

Federal Poverty Level for a Family of Three, 1979-1988

Poverty level

Year for a family of three

1979 . . . . . . . . . . . . . . . . . . . . . . .

1980 . . . . . . . . . . . . . . . . . . . . . . . .

1981 . . . . . . . . . . . . . . . . . . . . . . . .

1982 . . . . . . . . . . . . . . . . . . . . . . . .

1983 . . . . . . . . . . . . . . . . . . . . . . . .

1984 . . . . . . . . . . . . . . . . . . . . . . . .

1985 . . . . . . . . . . . . . . . . . . . . . . . .

1986 . . . . . . . . . . . . . . . . . . . . . . . .

1987 . . . . . . . . . . . . . . . . . . . . . . . .

1988 . . . . . . . . . . . . . . . . . . . . . . . .

$5,78 4

6,56 5

7,25 0

7,69 3

7,93 8

8,27 7

8,57 3

8,73 8

9,05 6

9,431

SOURCE: U.S. Department of Commerce, Bureau of the Census, Poverty and Wealth Branch.
APPENDIX F.--ACKNOWLEDGMENTS AND OTA’s ADOLESCENT

HEALTH ADVISORY PANEL

The authors would like to express their appreciation to the following people for providing

information and assistance. Special acknowledgments are due to Michael Grady and

Chuck Nelson.

Amy Bridges

Political Science Department

University of California,

San Diego

Deborah Chollet

Employee Benefits Research Institute

Judy Feder

Bipartisan Commission on Long Term Care

and the Uninsured

Beth Fuchs

Library of Congress

Congressional Research Service

Vince Hutchins

U.S. Department of Health and Human Services

Bureau of Maternal and Child Health

and Resources Development

Carole E. Kitte

Council of Economic Advisors

Peggy McManus

McManus Health Policy, Inc.

Alan Monheit

U.S. Department of Health and Human Services

National Center for Health Services Research

and Health Care Technology Assessment

Gene Moyer

U.S. Department of Health and Human Services

Office of the Assistant Secretary for

Planning and Evaluation

Chuck Nelson

U.S. Department of Commerce

Bureau of the Census

Paul Newacheck

University of California, San Francisco

Institute for Health Policy Studies

School of Medicine

Michael O’Grady

Library of Congress

Congressional Research

Richard Rimkunas

Library of Congress

Congressional Research

Jane Sisk

U.S. Congress

Service

Service

Office of Technology Assessment

Katharine Swartz

Urban Institute

Judith Wagner

U.S. Congress

Office of Technology Assessment

Ed Welniak

U.S. Department of Commerce

Bureau of the Census

70
Preliminary Analyses of Adolescent Health Insurance Insurance Status • 71

U. S. Congress of the United States

Office of Technology Assessment

Advisory Panel

Felton Earls, M.D., Chair

Department of Behavioral Sciences

Harvard School of Public Health

Boston, MA

Drew Altman

Commissioner

New Jersey Dept. of Human Services

Trenton, NJ

Claire Brindis, Dr. P.H.

Co-Director

Center for Population and

Reproductive Health Policy

Institute for Health Policy Studies

San Francisco, CA

Ann W. Burgess, R.N., D.N.SC.

van Amerignen Professor of

Psychiatric Mental Health Nursing

University of Pennsylvania

School of Nursing

Philadelphia, PA

Delores L. Delaney

President

Virginia PTA

Virginia Beach, VA

Abigail English, J.D.

Director, Adolescent Health

Care Project

National Center for Youth Law

San Francisco, CA

Jewelle Taylor Gibbs, Ph.D.

School of Social Welfare

University of California

Berkeley, CA

Michael Graf, Ph.D.

Director, Mental Health

Tanana Chiefs Conference, Inc.

Fairbanks, AK

David E. Hayes-Bautista, Ph.D.

Professor, School of Medicine

Director, Chicano Studies

Research Center

University of California, Los Angeles

Los Angeles, CA

Karen Hein, M.D.

Division of Adolescent Medicine

Department of Pediatrics

Albert Einstein College of Medicine

Montefiore Medical Center

Bronx, NY

Michael I. Cohen, M.D., Vice Chair

Chairman, Department of Pediatrics

Montefiore Hospital

New York, NY

Charles E. Irwin, Jr., M.D.

Division of Adolescent Medicine

Department of Pediatrics

School of Medicine

University of California

San Francisco, CA

Robert Johnson, M.D.

Division of Adolescent Medicine

Department of Pediatrics

New Jersey Medical School

Newark, NJ

Alan Kazdin, Ph.D.

Professor of Child Psychiatry

and Psychology

University of Pittsburgh

School of of Medicine

Research Director

Child Psychiatric Treatment Service

Western Psychiatric Institute & Clinic

Pittsburgh, PA

Teresa LaFromboise, Ph.D.

School of Education

Stanford University

Stanford, CA

Mary Nell Lehnhard

Vice President

Office of Government Relations

Blue Cross and Blue Shield Association

Washington, DC

Barbara D. Matula, M.P.A.

Director

State of North Carolina

Department of Human Resources

Division of Medical Assistance

Raleigh, NC

Robert B. Millman, M.D.

Saul P. Steinberg Distinguished

Professor of Psychiatry

and Public Health

Director, Adolescent Development Program

Daniel Offer, M.D.

Director, Center for the

Study of Adolescence

Michael Reese Hospital

Medical Center

Chicago, IL

Leticia Paez, M.P.A.

Associate Director

Area Health Education Center

Texas Technical University

School of Medicine

El Paso, TX

Cheryl Perry, Ph.D.

Associate Professor

Division of Epidemiology

School of Public Health

University of Minnesota

Minneapolis, MN

Anne C. Petersen, Ph.D.

Dean

College of Health and

Human Development

Pennsylvania State University

104 Henderson Building

University Park, PA

Lee Etta Powell

Superintendent of Schools

Cincinnati, OH

Roxanne Spillett

Director, Program Services

Boys Clubs of America

New York, NY

Myron Thompson

Trustee

Bernice Pauahi Bishop Estate

Honolulu, HI

Director, Alcohol & Substance Abuse Service

Cornell University Medical CollegeNew York Hospital

New York, NY
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