Number 17 n July 1, 2009

Health Insurance Coverage Trends, 1959–2007:
 

Estimates from the National Health Interview Survey
 by Robin A. Cohen, Ph.D., Division of Health Interview Statistics;
 

Diane M. Makuc, Dr.P.H., Amy B. Bernstein, Sc.D., and Linda T. Bilheimer, Ph.D., Office of Analysis and
 

Epidemiology; and Eve Powell-Griner, Ph.D., Division of Health Interview Statistics
 

Abstract

Objectives—This report presents long-term trends in the number and

percentage of persons under age 65 years with different types of health insurance

coverage and with no coverage. It documents changes in how the National

Health Interview Survey (NHIS) has collected information about coverage over

almost 50 years. It also compares recent trends in coverage estimates based on

the NHIS and the U.S. Census Bureau’s Current Population Survey (CPS).

Methods—Estimates were derived from 32 years of the NHIS, from 1959 to

2007. The types of estimates available differ over these years, reflecting changes

in the availability of different types of coverage and changes in the NHIS

questions. Joinpoint regression was used to estimate average annual percent

change over time and to identify statistically significant changes in trends.

Results—The percentage of persons under age 65 years with private

coverage rose between 1959 and 1968, to 79%, remained stable until 1980, and

then declined to 67% by 2007. During the 1980s, the percentage of persons with

no coverage increased, while the percentage with private coverage declined and

the percentage with Medicaid remained stable. Since 1990, the percentage of

nonelderly persons without coverage has remained stable, but the number has

increased by more than 6 million persons, to 43.3 million in 2007. During this

period, the percentage with private coverage has continued to decline, while the

percentage with Medicaid has increased. Recent trends in coverage based on the

NHIS and CPS are similar.

Keywords: private insurance c public coverage c uninsured c Medicaid

Introduction

An extensive body of literature

shows that lack of health insurance

coverage negatively affects both access

to health care and health status (1).

Almost 44 million persons in the United

States lacked health insurance coverage

at a point in time during 2008 (2).

Interest in addressing this longstanding

problem has recently intensified. The

development of programs and policies to

extend coverage to the uninsured

requires accurate and timely information

on the number of persons who lack

health insurance coverage and on the

number with different types of coverage.

The Centers for Disease Control

and Prevention’s National Center for

Health Statistics (NCHS) updates

estimates of the uninsured and those

with private and public coverage

quarterly, based on data from the

National Health Interview Survey

(NHIS). These quarterly reports present

annual trends in health insurance

coverage starting with 1997 and include

estimates for persons of all ages, those

under age 65 years, adults aged 18–64

years, and children (2). NHIS estimates

show that children under age 18 were

less likely than working-age adults to be

uninsured throughout the period

1997–2007. In recent years, the

coverage gap has widened as a result of

substantially greater increases in public

coverage for children than for adults

aged 18–64 years during a period of

declining private coverage for all (2).

Examination of longer trends in

health insurance coverage in the United

States provides a useful perspective for

more recent trends. This report presents

national estimates of health insurance

coverage for persons under age 65 years

from 1959 to 2007, using data from the

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics 
Page 2 National Health Statistics Reports n Number 17 n July 1, 2009

NHIS. This is the first report to present

trends in coverage over the entire span

of years for which such data are

available from the NHIS. The report

also documents major changes in the

provision of health insurance coverage

in the United States over this time

period, as well as changes in the NHIS

approach to collecting data about

coverage. Interpretation of the trends in

coverage estimates requires

consideration of how health insurance

coverage—and the collection of

information on coverage—have changed

over time. Trends in estimates of

coverage may reflect changes in the

design and question content of the

NHIS, as well as actual changes in the

percentage and number of people with

different types of coverage. Finally, this

report compares trends in estimates of

coverage from 1999 through 2007 based

on the NHIS with trends based on the

Current Population Survey (CPS),

another federal survey used for

estimating health insurance coverage.

Trends in coverage based on the NHIS

and CPS are compared for children

under age 18 years, adults aged 18–64

years, and all persons under age 65

years. In this report, adults aged 18–64

are referred to as working-age adults.

Major Health Insurance

Legislation and Events

Since the inception of the NHIS in

1957, numerous changes have occurred

in the health insurance sector. Table I (in

‘‘Technical Notes’’ at the end of this

report) provides a timeline of selected

major legislation and events that

changed the type and scope of private

and public health insurance coverage in

the United States (3–23). Examples of

major legislation include the

establishment in 1965, and subsequent

expansion, of the Medicare and

Medicaid programs, which are now

major payers for elderly, poor, and

disabled people.

The Health Maintenance

Organization Act of 1973 provided

federal subsidies to prepaid group

practices and required all employers

with 25 or more employees that offered

health insurance to offer a federally

qualified health maintenance

organization option upon request, when

such organizations existed in their area.

(This so-called dual choice provision

expired in 1995.)

The Consolidated Omnibus Budget

Reconciliation Act of 1985 (COBRA)

required employers to allow employees

to continue coverage (at their own

expense) for 18 months after they left

employment and allow spouses and

dependents to continue coverage for up

to 3 years after a worker’s death.

The Health Insurance Portability

and Accountability Act of 1996

(HIPAA) set national nondiscrimination

and portability standards for individual

health insurance coverage, HMOs, and

group health plans.

The Balanced Budget Act of 1997

established the State Children’s Health

Insurance Program (CHIP), providing

federal matching funds to states to

expand health insurance coverage for

children above states’ Medicaid

eligibility levels.

Medicare Part D legislation, which

provides the option for prescription drug

coverage to Medicare enrollees, began

in 2006.

These and other events listed in the

timeline may affect trends in estimates

of persons with different types of

coverage and estimates of the uninsured.

Methods

National Health Interview

Survey

Most of the estimates in this report

are based on the NHIS, a continuous,

in-person household survey of the

civilian noninstitutionalized population

of the United States. During 1959–1968,

insurance coverage data were collected

in the NHIS in 3 years (1959, fiscal

year 1963, and 1968). During 1968–

1989, such data were generally collected

every 2 years; and from 1989 on, data

were collected every year.

The NHIS insurance questions have

changed and expanded over time,

reflecting changes in health insurance

coverage and programs as well as in

questionnaire design. There may be a

lag between the introduction of new

health insurance programs, payers, and

regulations and their integration into

ongoing health care surveys. For

example, although Medicaid legislation

was passed in 1965, it was not until

1972 that questions relating to Medicaid

coverage were included in the NHIS.

This may reflect, in part, how quickly

states entered the program. Some states

entered immediately, whereas others

took longer to implement the program

(15). Arkansas did not begin its

Medicaid program until 1970, and

Arizona, the last state to adopt a

Medicaid program, began its program in

1982 (12). All states except Arizona

were participating by 1972.

The NHIS questionnaire

periodically undergoes a major redesign,

during which many questions are added,

dropped, or modified. Major NHIS

questionnaire redesigns occurred in

1967, 1982, and 1997. Fewer questions

are added or modified between redesign

years, to avoid discontinuities in data

trends and the expenses associated with

such modifications. However, as

documented in ‘‘Technical Notes,’’ some

changes to the health insurance

questions have been implemented

between redesign years in response to

emerging issues in health insurance.

Questions about private health

insurance coverage were asked in all

years included in this report, and

questions regarding employer-sponsored

coverage were asked starting in 1970.

Direct questions about Medicaid and

Medicare coverage (for persons under

age 65 years) were asked starting in

1978, and questions about military

coverage starting in 1982. A direct

question asks about coverage, whereas

an indirect question allows coverage to

be inferred from a response to a

question that doesn’t directly ask about

coverage. For example, the following

direct question concerning Medicaid was

asked for the first time in 1978: ‘‘Does

anyone in the family now have a

Medicaid card?’’ Prior to 1978,

information about public coverage could

be inferred in some years through

responses to questions that did not ask

about public coverage directly. For

example, a question on reasons for not

having (private) health insurance

included the following response
National Health Statistics Reports n Number 17 n July 1, 2009 Page 3

categories: ‘‘received care through

Medicaid or welfare’’ (1972–1976) or

‘‘received care through Social Security

Medicare’’ (1976) or military coverage

(1972–1980). Whether a question is

asked directly or indirectly affects the

likelihood of obtaining a positive

response. More positive responses are

usually obtained when a question is

asked in a more direct manner (24,25).

From 1959 to 1980, NHIS asked

questions about hospital insurance and

insurance plans that paid for doctors’ or

surgeons’ bills. In 1982, the separate

associations for Blue Cross (covering

hospitalizations) and Blue Shield

(covering physician care) merged,

making the separation between hospital

and physician insurance less distinct.

Since the inception of the NHIS,

private health insurance plan names

have been collected from those who

report having private coverage. Initially,

private plan names were used for

response verification and to code private

plans as ‘‘Blue plans’’ and ‘‘not Blue

plans.’’ Beginning in 1970, private plan

names were used to edit responses;

initial responses indicating private

coverage could be recoded to no private

coverage based on the private plan name

provided. Beginning in 1976, private

plan names were used to edit responses

concerning coverage to more appropriate

coverage categories or to no coverage

(except in 1990 and 1991, when private

plan names were not collected). In

addition to edits based on plan names,

during 1976–1996, questions on receipt

of Aid to Families with Dependent

Children (AFDC) and Supplemental

Security Income (SSI) were also used to

edit coverage responses; Medicaid

coverage was assigned to recipients of

AFDC or SSI.

From 1997 onward, reported type of

coverage was edited using detailed

verbatim responses to questions on both

private and public insurance plan names

and an external database with

information on the type of coverage

provided by specific plans (e.g.,

Medicaid, comprehensive private,

single-service private). For example, an

initial response of private coverage

would be edited to uninsured if the only

plan name reported was identified as

covering a single service, such as dental

coverage. Coverage for a small number

of people has also been edited based on

verbatim responses to a question on

reasons for no coverage.

‘‘Technical Notes’’ includes a list of

the NHIS insurance questions used to

calculate the estimates shown in this

report.

Current Population Survey

The CPS, conducted by the U.S.

Census Bureau for the Bureau of Labor

Statistics, collects information on health

insurance coverage as part of the Annual

Social and Economic Supplement

(ASEC) (26). The CPS asks separate

questions about major types of health

insurance coverage that the respondent

and family members had during the

calendar year prior to interview. Those

who had no coverage for the entire

calendar year are defined as uninsured.

In 2007, the Census Bureau created a

new historical series from 1999 through

the most recent data year to correct an

editing error in the previous series (27).

During 1999–2007, all CPS insurance

coverage estimates are based on Census

2000-based population control totals and

reflect a follow-up question that verifies

whether people who respond negatively

to all types of coverage are uninsured.

Estimates of the percentage of persons

who lacked coverage, had private

coverage, and had Medicaid coverage

were obtained for persons under age 65

years, aged 18–64 years, and under age

18 years, for comparison with the NHIS.

Estimates based on the CPS may differ

from those based on the NHIS for

several reasons, including differences in

survey design, context, questions, the

length of time that coverage is measured

(e.g., full-year versus point-in-time),

recall periods, response rates, and

post-collection processing. More

complete discussions of the similarities

and differences between federal surveys

that measure insurance coverage have

been published previously (28–31). This

report compares recent trends in

coverage, rather than the levels of

estimates.

Statistical methods

During 1976–2007, persons in the

NHIS were categorized into one or more

of the following health insurance

coverage groups: any private coverage,

employer-sponsored private coverage,

other private coverage, Medicaid,

Medicare, other public coverage, and

uninsured. During 1968–1974, persons

were classified into some but not all of

these groups, based on the questions

available in each year. For more

information on the definitions of these

groups, see Definitions of NHIS

Insurance Coverage Categories in

‘‘Technical Notes.’’ During 1970–2007,

estimates of the percentage of persons in

each category are shown for persons

under age 65 years because almost all

persons aged 65 years and over had

coverage through the Medicare program.

During 1959–1968, persons were

categorized according to whether or not

they had any hospital and surgical

insurance, and estimates are shown for

persons of all ages, for those under age

65 years, and for those aged 65 years

and over.

All percentages and standard errors

for 1968–2007 were calculated using

SUDAAN, to account for the complex

survey design and survey sample

weights of the NHIS (32). Population

counts of persons in coverage categories

were calculated by multiplying weighted

percentages by estimates of the U.S.

civilian noninstitutionalized population

under age 65 years. Percentages for

1959 and for fiscal year 1963 were

extracted from NCHS publications, as

noted in Table A.

Trends in coverage were assessed

by using Joinpoint regression (33,34),

starting in 1968 for private coverage and

in 1978 for public coverage and no

coverage. The regression model for

public coverage and no coverage began

with 1978 because that was the first

year NHIS included direct questions

about Medicaid and Medicare coverage

(for persons under age 65 years).

Joinpoint regression characterizes trends

as joined linear segments on a

logarithmic scale. A joinpoint is the year

when two segments with different slopes

meet. Joinpoint software uses statistical
Page 4 National Health Statistics Reports n Number 17 n July 1, 2009

Table A. Percentage of persons with hospital insurance and surgical insurance, by age group: United States, 1959, 1963, and 1968

Hospital insurance Surgical insurance

Year All ages

Under

65 years

65 years

and over All ages

Under

65 years

65 years

and over

July–December 1959 .........................

July 1962–June 1963 .........................

1968 ...................................

67.1 (0.4 )

70.7 (0.2 )

80.8 (0.36)

69.1 (0.4 )

72.3 (0.2 )

79.3 (0.39)

Percent (standard error)

46.1 (1.4 ) 62.0 (0.4 )

54.2 (0.6 ) 66.2 (0.2 )

96.0 (0.21) 79.4 (0.36)

64.4 (0.4 )

68.3 (0.2 )

77.8 (0.39)

37.1 (1.3 )

46.2 (0.6 )

94.6 (0.25)

SOURCES: The July–December 1959 estimates were extracted from the U.S. National Health Survey, Interim Report on Health Insurance, United States, July–December 1959, series B, no. 26,

Department of Health, Education, and Welfare, Public Health Service, 1960, Tables 19, 24, and 30. Approximate standard errors are from Appendix I, Table I-I.
 

The July 1962–June 1963 estimates are from CDC/NCHS, ‘‘Health Insurance Coverage, United States, July 1962–June 1963,’’ Vital and Health Statistics, series 10, no. 11, 1964. Percentages
 

were calculated from values in Table 6; standard errors were estimated by multiplying relative standard errors in an Appendix I figure by percentages.
 

The estimates for 1968 were calculated from the CDC/NCHS 1968 National Health Interview Survey, Health Insurance Supplement.
 

criteria to determine the fewest number

of segments necessary to characterize a

trend, the year(s) when segments begin

and end, and the annual percent change

for each segment. A 95% confidence

interval around the annual percent

change is used to determine whether the

annual percent change for each segment

is significantly different from zero.

Weighted least squares regression was

used, with the weights defined as the

square of the response variable divided

by the square of the standard error.

Joinpoint regression was also used

to fit lines to the NHIS and CPS

estimates of the percentage of persons

uninsured, with private coverage, and

with Medicaid coverage during 1999–

2007, the years of the new historic

series for CPS. For these more recent

years, estimates are shown for children

under age 18 years and for working-age

adults aged 18–64 years.

For more information on the NHIS,

methods, definitions of terms, and NHIS

questions, see ‘‘Technical Notes.’’

Results

+ Hospital insurance and surgical

insurance increased from 1959 to

1968.

In 1959, three major types of

organizations offered private health

insurance in the United States: (i) Blue

Cross-Blue Shield plans, which were

also called service plans because the

insurer paid the hospital or physician

directly; (ii) private insurance companies

that sold health insurance in a manner

similar to life insurance, with great

variability among plans in the kind and

completeness of coverage; and (iii)

independent, prepaid, comprehensive

plans such as the Health Insurance Plan

of Greater New York and the Kaiser

Foundation Health Plan (35). Between

1959 and 1968, the percentage of

persons under age 65 years with hospital

insurance increased from 69% to 79%,

and the percentage with surgical

insurance increased to a similar level

(Table A).

+ The percentage of persons under

age 65 years with private coverage

remained stable from 1968 to 1980

and then declined from 1980 to

2007.

During 1968–1980, the percentage

of persons under age 65 years who had

private coverage remained stable at

about 79%, while the number with

private coverage increased from 140.5

million to 154.1 million persons

(Tables 1 and 2). During 1980–2007, the

percentage with private coverage

declined steadily, except during

1996–1999. From 1999 to 2007, the

percentage of persons under age 65 with

any private coverage declined at an

average rate of more than 1% per year,

to 67% in 2007; the number of persons

with private coverage remained at about

174 million during this period. The

downward trend in private coverage was

driven in large part by a decline in

employer-sponsored coverage. In 2007,

62% of persons reported employersponsored coverage, down from 71% in

1980.

+ Medicaid coverage among persons

under age 65 years increased

between 1990 and 2007 after

remaining stable from 1978 to

1990.

The percentage of persons with

Medicaid, the most common source of

public coverage for persons under age

65 years, remained stable at about 7%

from 1978 to 1990, while the number of

persons with Medicaid increased

(Tables 1 and 2). Between 1990 and

2007, the percentage of persons with

Medicaid coverage (including other

state-sponsored coverage and CHIP)

increased among persons under age 65,

except from 1994 to 1998. In 1996, the

Personal Responsibility and Work

Opportunity Reconciliation Act

(PRWORA) was enacted that de-linked

Medicaid eligibility and cash assistance

and denied Medicaid benefits (apart

from emergency benefits) to immigrants

who arrived in the United States after

August 1996 for their first 5 years in the

country (Table I). Despite PRWORA,

Medicaid (including other statesponsored coverage and CHIP)

increased at a rate of more than 5% per

year during 1998–2007, from about 9%

in 1998 to 14% in 2007.

Medicare coverage was expanded in

1972 to include certain disabled persons

under age 65 years and persons with

end-stage renal disease (Table I). About

2% of persons under age 65 had

Medicare coverage in 2007, increasing

from about 1% in 1978. Other types of

public coverage in the civilian

noninstitutionalized population include

coverage for veterans and military

dependents and coverage by other

government programs. The percentage
National Health Statistics Reports n Number 17 n July 1, 2009 Page 5

0 

10 

20 

30 

40 

50 

0 

10 

20 

30 

40 

50 

1978 

Percent

Millions 

1982 

Number uninsured 

1986 1990 1994 1998 2002 2007 

SOURCE: CDC/NCHS, National Health Interview Survey, Health Insurance Supplements (prior to 1997) and Family Core 

component (starting with 1997). 

Percent uninsured 

43.3 

16.6 

Figure 1. Number and percentage of persons under age 65 years without insurance:

United States, 1978–2007

reporting coverage in this category was

about 3% in 2007 and fluctuated

between 2% and 3% during most years

from 1972 to 2007.

+ The percentage of persons under

age 65 years with no coverage

remained stable during 1990–2007,

after increasing from 1978 to 1990.

During 1990–2007, the percentage

of persons under age 65 years with no

coverage was stable at approximately

17%, while the number of persons who

were uninsured at the time of interview

increased by 6.1 million to 43.3 million

persons (Tables 1 and 2 and Figure 1).

During the earlier period from 1978 to

1990, the percentage uninsured

increased at a rate of 3% per year: from

12% in 1978 to 17% in 1990. The

number of uninsured rose by 14.2

million persons during this period.

Comparison of trends based

on the NHIS and CPS for

1999–2007

+ Both NHIS and CPS show a decline

in the percentage of persons with

private coverage during 1999–2007.

The average decline in the

percentage of persons under age 65

years with private coverage was about

1% per year during 1999–2007, based

on both the NHIS and CPS. Both

surveys show a significant decline in

private coverage for children during this

period (1.8% and 1.2% per year,

respectively), as well as a significant

decline in private coverage for workingage adults (0.9% per year) (Figure 2).

+ Both NHIS and CPS show an

increase in the percentage of

persons with Medicaid during

1999–2007.

The percentage of children with

Medicaid coverage increased at an

average rate of 6.5% per year based on

the NHIS, and 4.3% per year based on

the CPS, during 1999–2007 (Figure 3).

Both surveys show a change in the trend

for children’s Medicaid coverage during

this period, with greater increases in

Medicaid coverage prior to 2003. The

percentage of adults aged 18–64 years

with Medicaid increased an average of

5.4% per year based on the NHIS and

3.7% per year based on the CPS.

+ Both NHIS and CPS show an

increase in the percentage of adults

without coverage from 1999 to

2007, but the trends for children

differ somewhat between the two

surveys.

The percentage of adults aged

18–64 years without coverage increased

an average of 1.2% per year based on

the NHIS and 2.0% per year based on

the CPS during 1999–2007 (Figure 4).

The percentage of children without

coverage declined an average of 4.2%

per year during 1999–2007 based on the

NHIS, while there was a nonsignificant

decline of 0.8% per year for children

during this period based on the CPS.

The percentage of children without

coverage declined more in the NHIS

than the CPS, despite the somewhat

faster decline in private coverage based

on the NHIS. However, drawing

inferences from these figures regarding

1999 2001 2003 2005 2007 

Percent 

NOTES: National Health Interview Survey (NHIS) estimates are for a point in time; Current Population Survey (CPS) estimates 

are for any coverage in a calendar year. Fitted estimates were calculated using Joinpoint software. 

SOURCES: The observed CPS estimates are from the Historical Health Insurance Tables at 

http://www.census.gov/hhes/www/hlthins/historic/index.html. The observed NHIS estimates were calculated using data from 

the Family Core component of the 1999–2007 NHIS. 

NHIS observed NHIS fitted CPS observed CPS fitted 

Adults 18–64 years 

Children under 18 years 

0 

60 

65 

70 

75 

80 

Figure 2. Percentage of persons under age 65 years with private coverage, by age group

and survey: United States, 1999–2007
Page 6 National Health Statistics Reports n Number 17 n July 1, 2009

Adults 18–64 years 

Children under 18 years 

0 

5 

10 

15 

20 

25 

30 

35 

1999 2001 2003 2005 2007 

Percent 

NHIS observed NHIS fitted CPS observed CPS fitted 

NOTES: National Health Interview Survey (NHIS) estimates are for a point in time; Current Population Survey (CPS) estimates 

are for any coverage in a calendar year. Fitted estimates were calculated using Joinpoint software. 

SOURCES: The observed CPS estimates are from the Historical Health Insurance Tables at 

http://www.census.gov/hhes/www/hlthins/historic/index.html. The observed NHIS estimates were calculated using data from 

the Family Core component of the 1999–2007 NHIS. 

Figure 3. Percentage of persons under age 65 years with Medicaid coverage, by age

group and survey: United States, 1999–2007

0 

5 

10 

15 

20 

25 

Adults 18–64 years 

Children under 18 years 

1999 2001 2003 2005 2007 

NHIS observed NHIS fitted CPS observed CPS fitted 

Percent 

NOTES: National Health Interview Survey (NHIS) estimates are for a point in time; Current Population Survey (CPS) estimates 

are for any coverage in a calendar year. Fitted estimates were calculated using Joinpoint software. 

SOURCES: The observed CPS estimates are from the Historical Health Insurance Tables at 

http://www.census.gov/hhes/www/hlthins/historic/index.html. The observed NHIS estimates were calculated using data from 

the Family Core component of the 1999–2007 NHIS. 

Figure 4. Percentage of persons under age 65 years without health insurance, by age

group and survey: United States, 1999–2007

how differences in private and public

coverage trends between the NHIS and

CPS affect uninsured trends is

complicated by differences between the

two surveys, in particular by their

different reference periods. Private and

public coverage in the NHIS refer to a

point in time, whereas private and

public coverage in the CPS refer to any

coverage in a calendar year, and the

percentage of persons who report both

private and public coverage is higher in

the CPS than the NHIS.

Upon examination of data for all

persons under age 65 years (children

and adults), there was no significant

change on average over this time period

in the percentage of persons without

coverage, based on the NHIS, while the

average change based on the CPS shows

a slow increase of 1.6% per year.

Conclusions

The NHIS has included questions to

estimate the percentage and number of

persons with different types of health

insurance coverage over an almost

50-year period, from 1959 to 2007. The

questions asked and the types of

estimates available differ over these

years, reflecting changes in the

availability of different types of

coverage, issues of interest, and

questionnaire design. For example, in

1959, 1962–1963, and 1968,

respondents were asked whether family

members had hospital and surgical

coverage, rather than about various

types of public coverage, which were

either not yet available or only recently

available. In addition, as documented in

‘‘Technical Notes,’’ changes in the NHIS

survey design and estimation methods

over this long period may affect

estimates of insurance coverage.

Despite changes in the NHIS during

1959–2007, these data can be used to

paint a broad picture of long-term trends

in health insurance coverage for the

population under age 65 years, of whom

43.3 million were uninsured in 2007.

The percentage of the nonelderly

population with private coverage rose

between 1959 and 1968 to about 79%

and remained stable until 1980. During

the 1980s, the percentage with no health

insurance coverage increased, while the

percentage with private coverage

declined and the percentage with

Medicaid remained stable. Since 1990,

the percentage of persons under age 65

who are uninsured has remained stable,

while the percentage with private

coverage continued to decline and the

percentage with Medicaid increased. It

is important to note that although the

percentage has remained stable, the

number of uninsured nonelderly persons

has increased by more than 6 million

since 1990.

Because estimates of health

insurance coverage based on the CPS

are widely cited, we compared trends in

coverage from 1999 to 2007 based on

the NHIS with those based on the CPS.

Consistent with a report from the State

Health Access Data Assistance Center

(31), we conclude that trends based on

these two sources are similar. Both show

declines in the percentage of children

and working-age adults with private

coverage; increases in the percentage of

children and working-age adults with

Medicaid coverage; and increases in the

percentage of working-age adults

without health insurance. However,
National Health Statistics Reports n Number 17 n July 1, 2009	 Page 7

recent trends in the percentage of

children who are uninsured differ

somewhat between the two sources. The

NHIS shows a significant decline in the

percentage of children who are

uninsured during 1999–2007, whereas

the CPS shows a nonsignificant decline.

This difference in trend likely reflects,

in part, the steeper rise in Medicaid (or

CHIP or other state plan) coverage

among children shown in the NHIS than

in the CPS.

As discussed by others (26,31),

survey estimates of health insurance

coverage may differ for many reasons,

including recall period, focus of the

survey, imputation of missing data, and

data editing. In particular, the NHIS

may identify more Medicaid coverage

than the CPS owing to a much shorter

reference period (point-in-time versus

previous calendar year), little item

nonresponse and therefore no imputation

of coverage, insurance questions placed

in the context of a health survey, editing

based on verbatim insurance plan

names, and, starting with the third

quarter of 2004, a question that

explicitly asks persons under age 65

years with no reported coverage about

Medicaid coverage. Despite the

differences in focus and methods

between the NHIS and CPS, overall

both surveys show similar trends in

coverage as well as a large number of

persons under age 65 without health

insurance.

References

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timeline.htm. Accessed May 2009.

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comp2/comp2toc.html. Accessed May

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Accessed May 2009.

22. U.S. Department of Labor. Trade

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2002. Available from: http://

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24. Cohen RA, Martinez ME. Impact of

Medicare and Medicaid probe

questions on health insurance

estimates from the National Health

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E-stats. National Center for Health

Statistics. 2005. Available from:

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impact04.htm.

25. Cohen RA, Martinez ME. Impact of

Medicare and Medicaid probe

questions on health insurance

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E-stats. National Center for Health

Statistics. 2006. Available from:

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impact.htm.

26. DeNavas-Walt C, Proctor BD, Smith

JC. Income, poverty, and health

insurance coverage in the United

States: 2007. U.S. Census Bureau,

Current Population Reports, P60–

235. Washington, DC: U.S.

Government Printing Office. 2008.

27. Lee CH, Stern SM. Health insurance

estimates from the U.S. Census

Bureau: Background for a new

historical series. U.S. Census Bureau.

2007. Available from: http://

www.census.gov/hhes/www/hlthins/

usernote/revhlth_paper.pdf.

28. Office of the Assistant Secretary for

Planning and Evaluation (ASPE).

Understanding estimates of the

uninsured: Putting the differences in

context. ASPE Issue Brief. U.S.

Department of Health and Human

Services. 2005. Available from:

http://aspe.hhs.gov/health/reports/05/

uninsured-understanding-ib/

index.htm.

29. Davern M, Rodin H, Blewett LA,

Thiede Call K. Are the Current

Population Survey uninsurance

estimates too high? An examination

of the imputation process. Health

Serv Res 42(5):2038–54. 2007.

30. Fronstin P. Counting the uninsured:

A comparison of national surveys.

EBRI Issue Brief No. 225.

Washington, DC: Employee Benefit

Research Institute. 2000.

31. State Health Access Data Assistance

Center (SHADAC). Comparing

federal government surveys that

count uninsured people in America.

2008. Available from: http://

www.rwjf.org/files/research/

082608shadac.census.pdf.

32. Research Triangle Institute.

SUDAAN, release 9.1 [computer

software]. Research Triangle Park,

NC: Research Triangle Institute.

2005.

33. Kim HJ, Fay MP, Feuer EJ,

Midthune DN. Permutation tests for

joinpoint regression with applications

to cancer rates. Stat Med 19:335–51.

2000. (Correction. Stat Med 20:655.

2001.)

34. National Cancer Institute, Statistical

Research and Applications Branch.

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3.3 [computer software]. 2008.

Available from: http://srab.cancer.

gov/joinpoint.

35. U.S. National Health Survey. Interim

report on health insurance, United

States, July–December 1959. Series

B, No. 26. Washington, DC: U.S.

Department of Health, Education,

and Welfare, Public Health Service.

1960.

36. Botman SL, Moore TF, Moriarity

CL, Parsons VL. Design and

estimation for the National Health

Interview Survey, 1995–2004.

National Center for Health Statistics.

Vital Health Stat 2(130). 2000.

37. Kovar MG, Poe GS. The National

Health Interview Survey design,

1973–1984, and procedures, 1975–

1983. National Center for Health

Statistics. Vital Health Stat 1(18).

1985.

38. National Center for Health Statistics.

Health Interview Survey procedure,

1957–1974. Vital Health Stat 1(11).

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39. Massey JT, Moore TF, Parsons VL,

Tadros W. Design and estimation for

the National Health Interview

Survey, 1985–94. National Center for

Health Statistics. Vital Health Stat

2(110). 1989.

40. Hoffmann CH. Health insurance

coverage: United States, July

1962–June 1963. National Center for

Health Statistics. Vital Health Stat

10(11). 1964.

41. Gleeson GA. Hospital and surgical

insurance coverage: United States,

1968. National Center for Health

Statistics. Vital Health Stat 10(66).

1972.
National Health Statistics Reports n Number 17 n July 1, 2009 Page 9

Table 1. Percentage of persons under age 65 years with health insurance coverage, by coverage type, and without health insurance:

United States, selected years 1968–2007

Private coverage1 Public coverage2

Sample

Year size Any3 Employer4 Other5 Medicaid6 Medicare7 Other8 Uninsured9

Percent (standard error)

1968 ..................... 120,670 79.3 (0.39) – – – – – – – – – – – – – – – – – –

1970 ..................... 44,373 78.7 (0.53) 68.6 (0.60) 10.0 (0.37) – – – – – – – – – – – –

1972 ..................... 119,939 77.3 (0.39) 69.4 (0.43) 7.8 (0.18) 3.5 (0.14) – – – 2.6 (0.18) 16.7 (0.32)

1974 ..................... 104,727 79.7 (0.31) 70.5 (0.35) 9.6 (0.18) 4.7 (0.16) – – – 2.5 (0.20) 13.1 (0.24)

1976 ..................... 101,594 78.9 (0.31) 68.5 (0.32) 10.3 (0.19) 4.9 (0.16) 0.2 (0.02) 2.6 (0.19) 14.1 (0.24)

1978 ..................... 98,465 79.3 (0.34) 70.2 (0.35) 9.2 (0.19) 6.7 (0.19) 1.2 (0.04) 2.3 (0.16) 12.0 (0.22)

1980 ..................... 91,425 79.4 (0.38) 71.4 (0.40) 8.0 (0.20) 7.1 (0.19) 1.4 (0.05) 2.0 (0.16) 12.0 (0.26)

1982 ..................... 92,489 78.1 (0.53) 70.3 (0.55) 7.9 (0.21) 6.1 (0.29) 1.2 (0.04) 3.7 (0.21) 13.9 (0.36)

1983 ..................... 46,729 76.9 (0.64) 68.4 (0.67) 8.7 (0.27) 6.8 (0.34) 1.1 (0.06) 3.6 (0.26) 14.6 (0.46)

1984 ..................... 93,396 76.7 (0.62) 69.1 (0.62) 7.7 (0.21) 6.8 (0.33) 1.2 (0.04) 3.7 (0.23) 14.5 (0.39)

1986 ..................... 54,860 76.8 (0.71) 69.3 (0.76) 7.6 (0.33) 6.4 (0.35) 1.2 (0.05) 3.3 (0.29) 15.0 (0.43)

1989 ..................... 102,684 75.9 (0.51) 68.3 (0.51) 7.6 (0.19) 7.2 (0.26) 1.4 (0.05) 2.9 (0.24) 15.6 (0.35)

1990 ..................... 105,053 74.2 (0.43) 66.4 (0.47) 7.8 (0.28) 7.1 (0.21) 1.3 (0.04) 3.0 (0.25) 17.2 (0.30)

1991 ..................... 105,316 73.6 (0.48) 62.8 (0.52) 10.8 (0.31) 8.5 (0.27) 1.4 (0.06) 2.9 (0.25) 16.4 (0.29)

1992 ..................... 113,042 72.0 (0.46) 64.9 (0.45) 7.1 (0.18) 9.8 (0.29) 1.4 (0.05) 2.9 (0.25) 16.8 (0.28)

1993 ..................... 53,626 71.0 (0.54) 65.3 (0.53) 5.8 (0.23) 10.7 (0.36) 1.3 (0.06) 2.7 (0.28) 17.4 (0.41)

1994 ..................... 101,608 69.9 (0.50) 64.0 (0.48) 5.9 (0.17) 11.2 (0.34) 1.4 (0.05) 2.8 (0.23) 17.8 (0.32)

1995 ..................... 90,512 71.3 (0.42) 65.6 (0.43) 5.7 (0.16) 11.5 (0.27) 1.6 (0.06) 2.6 (0.17) 16.3 (0.25)

1996 ..................... 56,268 71.2 (0.55) 65.1 (0.57) 6.1 (0.22) 11.1 (0.33) 1.6 (0.07) 2.6 (0.19) 16.7 (0.36)

1997 ..................... 91,275 70.7 (0.36) 66.4 (0.36) 4.2 (0.13) 9.7 (0.23) 1.6 (0.05) 2.7 (0.13) 17.5 (0.24)

1998 ..................... 87,020 72.1 (0.36) 67.5 (0.37) 4.6 (0.14) 8.9 (0.22) 1.7 (0.06) 2.7 (0.15) 16.6 (0.25)

1999 ..................... 85,732 72.8 (0.36) 68.3 (0.37) 4.4 (0.14) 9.1 (0.21) 1.7 (0.06) 2.2 (0.12) 16.1 (0.25)

2000 ..................... 89,149 71.7 (0.35) 67.3 (0.37) 4.2 (0.14) 9.5 (0.22) 1.7 (0.06) 2.2 (0.13) 16.8 (0.25)

2001 ..................... 89,478 71.5 (0.37) 67.2 (0.35) 4.1 (0.12) 10.4 (0.21) 1.8 (0.06) 2.1 (0.12) 16.1 (0.25)

2002 ..................... 82,533 69.7 (0.37) 65.6 (0.37) 3.9 (0.13) 11.8 (0.23) 1.7 (0.06) 2.3 (0.14) 16.5 (0.24)

2003 ..................... 81,596 68.9 (0.40) 64.4 (0.41) 4.0 (0.15) 12.3 (0.25) 1.8 (0.06) 2.4 (0.17) 16.5 (0.26)

2004 ..................... 83,357 68.8 (0.39) 64.0 (0.39) 4.6 (0.14) 12.5 (0.24) 1.8 (0.06) 2.4 (0.12) 16.4 (0.23)

2005 ..................... 87,077 68.2 (0.40) 63.6 (0.40) 4.4 (0.14) 12.9 (0.25) 1.8 (0.06) 2.5 (0.13) 16.4 (0.24)

2006 ..................... 67,066 66.3 (0.48) 61.5 (0.48) 4.6 (0.17) 14.0 (0.32) 2.1 (0.08) 2.5 (0.14) 17.0 (0.29)

2007 ..................... 67,065 66.8 (0.45) 61.6 (0.46) 4.9 (0.17) 13.9 (0.30) 2.1 (0.08) 2.7 (0.17) 16.6 (0.29)

– – – Data not available. 
 1

The category ‘‘private coverage’’ excludes plans that paid for only one type of service, such as accidents or dental care. Private coverage is at the time of interview, except in 1990–1996, when it
 

is for the month prior to interview.
 2

The category ‘‘public coverage’’ includes Medicaid, Children’s Health Insurance Program (CHIP), state-sponsored or other government-sponsored health plan, Medicare (disability), and military
 

plans. Public coverage is at the time of interview, except in 1990–1996, when it is for the month prior to interview.
 3

Includes persons covered by private coverage obtained through an employer, purchased directly, or obtained through any other means.
 4

Employer-sponsored private coverage is private insurance originally obtained through a present or former employer or union; this also includes private insurance obtained through the workplace,
 

self-employment, or a professional association. In 1991, an additional question (‘‘Was — health insurance coverage from a plan in — own name?’’) was asked prior to the question concerning
 

employer-sponsored private coverage, which may have impacted the affirmative responses to the employer-sponsored question and resulted in a lower than expected estimate for employersponsored private coverage.
 5

The category ‘‘other’’ here includes persons covered by private insurance not obtained through a current or former employer, union, or professional association. This includes directly purchased
 

plans, as well as plans obtained through school or other means. See Footnote 4 for an explanation of the estimates for employer and directly purchased coverage for 1991.
 6

The Medicaid category includes persons who reported having Medicaid coverage (1990–2007) or having a Medicaid card (1978–1989) or not carrying health insurance because care was received
 

through Medicaid or welfare (1972–1980). It also includes those who reported coverage by ‘‘any other public assistance program that pays for health care’’ in 1982–1989 and 1992–1996; a
 

state-sponsored health plan in 1997–2007; and CHIP in 1999–2007. In 1976–1996, it also includes persons who reported receiving Aid to Families with Dependent Children (AFDC) or
 

Supplemental Security Income (SSI). Beginning in the third quarter of 2004, a Medicaid probe question was added to reduce potential errors in reporting Medicaid status. Persons under age 65
 

years with no reported coverage were asked explicitly about Medicaid coverage.
 7

In 1968–1974, Medicare coverage was only asked of persons aged 65 years and over. In 1976, Medicare coverage was estimated through reasons for not having health insurance coverage.
 

Beginning in 1978, Medicare coverage was asked of persons of all ages.
 8

The ‘‘other’’ public coverage category includes military coverage (1982–2007), coverage through ‘‘other government programs’’ (1997–2007), and not carrying health insurance because of military
 

coverage (1972–1980). Military coverage includes TRICARE (CHAMPUS), CHAMP-VA, and VA coverage.
 9

A person was defined as uninsured if he or she did not have any private health insurance, Medicare (1976–2007), Medicaid, CHIP (1999–2007), state-sponsored (1982–1989, 1992–2007) or
 

other government-sponsored health plan (1997–2007), or military plan. A person was also defined as uninsured if he or she had only Indian Health Service coverage or had only a private plan that
 

paid for one type of service, such as accidents or dental care.
 

NOTES: Percentages do not add to 100 because a small percentage of persons reported more than one type of coverage. Estimates are based on household interviews of a sample of the civilian
 

noninstitutionalized population. In 1990–1992, approximately 1% of health insurance responses were imputed.
 

DATA SOURCE: CDC/NCHS, National Health Interview Survey, Health Insurance Supplements (prior to 1997) and Family Core component (starting with 1997).
 
Page 10 National Health Statistics Reports n Number 17 n July 1, 2009

Table 2. Number of persons under age 65 years with health insurance coverage, by coverage type, and without health insurance:

United States, selected years 1968–2007

Population under Private coverage1 Public coverage2

age 65 in

Year millions Any3 Employer4 Other5 Medicaid6 Medicare7 Other8 Uninsured9

Number of persons under age 65 in millions

1968 ....................... 177.1 140.5 – – – – – – – – – – – – – – – – – –

1970 ....................... 180.9 142.3 124.1 18.0 – – – – – – – – – – – –

1972 ....................... 184.2 142.3 127.9 14.4 6.5 – – – 4.7 30.7

1974 ....................... 186.6 148.7 131.5 17.9 8.7 – – – 4.6 24.4

1976 ....................... 188.8 148.9 129.4 19.5 9.3 0.5 4.9 26.6

1978 ....................... 191.0 151.6 134.0 17.5 12.8 2.4 4.3 23.0

1980 ....................... 194.0 154.1 138.5 15.6 13.8 2.7 3.9 23.3

1982 ....................... 201.7 157.5 141.8 16.0 12.2 2.5 7.5 28.0

1983 ....................... 203.8 156.7 139.4 17.7 13.9 2.3 7.3 29.7

1984 ....................... 205.2 157.5 141.7 15.7 13.9 2.4 7.6 29.8

1986 ....................... 208.8 160.4 144.6 15.8 13.4 2.5 6.9 31.3

1989 ....................... 214.3 162.7 146.3 16.3 15.4 3.0 6.1 33.4

1990 ....................... 216.3 160.5 143.7 16.8 15.4 2.8 6.5 37.2

1991 ....................... 218.4 160.8 137.1 23.7 18.6 3.0 6.4 35.8

1992 ....................... 220.7 158.9 143.2 15.8 21.6 3.2 6.4 37.1

1993 ....................... 223.6 158.8 145.9 12.9 23.9 3.0 6.1 38.8

1994 ....................... 228.6 159.8 146.2 13.5 25.6 3.1 6.4 40.6

1995 ....................... 230.4 164.4 151.3 13.1 26.6 3.7 5.9 37.7

1996 ....................... 232.5 165.5 151.4 14.2 25.8 3.7 6.0 38.9

1997 ....................... 234.6 165.8 155.9 9.8 22.9 3.8 6.4 41.0

1998 ....................... 236.8 170.8 159.8 10.8 21.1 4.1 6.3 39.2

1999 ....................... 239.2 174.2 163.4 10.5 21.9 4.1 5.2 38.5

2000 ....................... 241.3 173.0 162.5 10.1 22.9 4.0 5.4 40.5

2001 ....................... 243.6 174.1 163.8 10.0 25.2 4.3 5.1 39.2

2002 ....................... 245.7 171.3 161.2 9.7 29.1 4.1 5.6 40.6

2003 ....................... 251.8 173.6 162.1 10.1 30.9 4.5 6.1 41.6

2004 ....................... 253.7 174.5 162.3 11.6 31.6 4.5 6.1 41.6

2005 ....................... 256.1 174.7 162.9 11.1 33.2 4.5 6.4 42.1

2006 ....................... 258.2 171.2 158.8 11.8 36.2 5.4 6.5 43.9

2007 ....................... 260.7 174.1 160.7 12.7 36.2 5.4 7.0 43.3

– – – Data not available. 
 1

The category ‘‘private coverage’’ excludes plans that paid for only one type of service, such as accidents or dental care. Private coverage is at the time of interview, except in 1990–1996, when it
 

is for the month prior to interview.
 2

The category ‘‘public coverage’’ includes Medicaid, Children’s Health Insurance Program (CHIP), state-sponsored or other government-sponsored health plan, Medicare (disability), and military
 

plans. Public coverage is at the time of interview, except in 1990–1996, when it is for the month prior to interview.
 3

Includes persons covered by private coverage obtained through an employer, purchased directly, or obtained through any other means.
 4

Employer-sponsored private coverage is private insurance originally obtained through a present or former employer or union; this also includes private insurance obtained through the workplace,
 

self-employment, or a professional association. In 1991, an additional question (‘‘Was — health insurance coverage from a plan in — own name?’’) was asked prior to the question concerning
 

employer-sponsored private coverage, which may have impacted the affirmative responses to the employer-sponsored question and resulted in a lower than expected estimate for employersponsored private coverage.
 5

The category ‘‘other’’ here includes persons covered by private insurance not obtained through a current or former employer, union, or professional association. This includes directly purchased
 

plans, as well as plans obtained through school or other means. See Footnote 4 for an explanation of the estimates for employer and directly purchased coverage for 1991.
 6

The Medicaid category includes persons who reported having Medicaid coverage (1990–2007) or having a Medicaid card (1978–1989) or not carrying health insurance because care was received
 

through Medicaid or welfare (1972–1980). It also includes those who reported coverage by ‘‘any other public assistance program that pays for health care’’ in 1982–1989 and 1992–1996; a
 

state-sponsored health plan in 1997–2007; and CHIP in 1999–2007. In 1976–1996, it also includes persons who reported receiving Aid to Families with Dependent Children (AFDC) or
 

Supplemental Security Income (SSI). Beginning in the third quarter of 2004, a Medicaid probe question was added to reduce potential errors in reporting Medicaid status. Persons under age 65
 

years with no reported coverage were asked explicitly about Medicaid coverage.
 7

In 1968–1974, Medicare coverage was only asked of persons aged 65 years and over. In 1976, Medicare coverage was estimated through reasons for not having health insurance coverage.
 

Beginning in 1978, Medicare coverage was asked of persons of all ages.
 8

The ‘‘other’’ public coverage category includes military coverage (1982–2007), coverage through ‘‘other government programs’’ (1997–2007), and not carrying health insurance because of military
 

coverage (1972–1980). Military coverage includes TRICARE (CHAMPUS), CHAMP-VA, and VA coverage.
 9

A person was defined as uninsured if he or she did not have any private health insurance, Medicare (1976–2007), Medicaid, CHIP (1999–2007), state-sponsored (1982–1989, 1992–2007) or
 

other government-sponsored health plan (1997–2007), or military plan. A person was also defined as uninsured if he or she had only Indian Health Service coverage or had only a private plan that
 

paid for one type of service, such as accidents or dental care.
 

NOTES: A person may have more than one type of coverage, therefore, individual coverage types may not add up to the population total. Due to rounding, employer-based private coverage and
 

other private coverage may not add up to any private coverage. Estimates are based on household interviews of a sample of the civilian noninstitutionalized population. In 1990–1992,
 

approximately 1% of health insurance responses were imputed.
 

DATA SOURCE: CDC/NCHS, National Health Interview Survey, Health Insurance Supplements (prior to 1997) and Family Core component (starting with 1997).
 
National Health Statistics Reports n Number 17 n July 1, 2009 Page 11

Technical Notes

Data source

The statistics in this report are

based on data from those years in which

the National Health Interview Survey

(NHIS) provided sufficient information

on health insurance coverage to

calculate estimates of the percentage of

the population with coverage. The NHIS

is a continuous multistage probability

sample survey of the civilian

noninstitutionalized population of the

United States. It is a multipurpose health

survey conducted by the Centers for

Disease Control and Prevention’s (CDC)

National Center for Health Statistics

(NCHS). NHIS interviewers are from

the U.S. Census Bureau. Information on

insurance and other socioeconomic

characteristics, and on selected health

topics, is collected for all household

members, by proxy from one family

member if necessary (all household

members aged 17 years and over who

are at home at the time of the interview

are invited to participate and respond for

themselves).

Information on health insurance

status and coverage type has been

collected every year in the NHIS,

starting in 1989. Between 1968 and

1989, health insurance information was

collected every 2–3 years, and between

1959 and 1968 it was collected every

3–4 years.

Starting in 1997, health insurance

status has been collected in the Family

Core component of the NHIS

questionnaire for all members of the

family. Interviews are conducted in the

home, using a computer-assisted

personal interview (CAPI) questionnaire,

with telephone followup permitted if

necessary. Prior to 1997, information on

health insurance status was collected

using paper and pencil. In 1989–1996,

the health insurance section was

administered from a separate booklet of

questions, whereas in 1963–1986 the

health insurance section was included in

the same booklet as the core questions.

In 1959, the health insurance

information was collected at the time of

interview for 52% of respondents. For

the other 48%, all illness and

demographic information was obtained

at the time of interview, and the

information on health insurance was

collected using a special mail-in form

that was left at the household for the

head of the reporting unit to complete

and return.

The sample size of the NHIS has

varied over the years from 1959 to

2007. The sample sizes for the insurance

questions were approximately 62,000

persons in 1959 and 138,000 in fiscal

year 1963. The number of persons under

age 65 years who received the health

insurance questions was 90,000 or

higher in most years from 1968 to 1997.

The largest sample size was 120,670 in

1968. In a few years (1970, 1983, 1986,

1993, and 1996) only a subset of the

sample, or a part-year sample, received

the health insurance questions, resulting

in sample sizes ranging from 44,373 to

56,268. More recently, during 1997–

2007, the sample size under age 65

declined from 91,275 to 67,065.

The sample for the NHIS is

redesigned and redrawn about every 10

years, to better measure the changing

U.S. population and to meet new survey

objectives. For example, a new sample

design for the NHIS was implemented

in 2006. The fundamental structure of

the new design is very similar to the

previous 1995–2005 NHIS sample

design, including state-level

stratification. The new sample design

reduced the NHIS sample size by about

13% compared with the 1995–2005

NHIS. More complete discussions of the

NHIS sampling designs and other

analytic issues prior to 2006 are

available in published reports (36–39).

For information on the 2006 NHIS

sample design and variance estimation,

see http://www.cdc.gov/nchs/data/nhis/

2006_2007var.pdf.

Visit the NCHS website at http://

www.cdc.gov/nchs/nhis.htm for more

information on the design, content, and

use of the NHIS.

Estimation procedures and

significance testing

NCHS creates survey weights for

each calendar quarter of the NHIS

sample. The NHIS data weighting

procedure is described in more detail

elsewhere (36). Estimates were

calculated using the NHIS survey

weights, which are calibrated to census

totals of the U.S. civilian

noninstitutionalized population by sex,

age, and race/ethnicity. The 1959 NHIS

weights were derived from the 1950

census-based population estimates. From

fiscal year 1963 through calendar year

1974, the weights were derived from

1960 census-based population estimates.

The 1976–1980 weights were derived

from 1970 census-based population

estimates; the 1982–1994 weights from

1980 census-based population estimates;

and the 1995–2002 weights from 1990

census-based population estimates.

Starting with 2003, weights were

derived from 2000 census-based

population estimates.

Point estimates and their standard

errors were calculated using SUDAAN

software, to account for the complex

sample design of NHIS. Estimates

shown in the tables meet the NCHS

standard of having a relative standard

error less than or equal to 30%.

Differences between percentages or rates

were evaluated using two-sided

significance tests at the 0.05 level.

Terms such as ‘‘higher than’’ and

‘‘lower than’’ indicate a statistically

significant difference. Terms such as

‘‘similar’’ and ‘‘no difference’’ indicate

that the estimates being compared were

not significantly different. Lack of

comment regarding the difference

between any two estimates does not

necessarily mean that the difference was

tested and found to be not significant.

Furthermore, the tests did not take into

account multiple comparisons.

Response rates

The family response rate for NHIS

data years 1997–2007 ranged from

86.1% to 90.3%. The family response

rate for NHIS data years 1989–1996,

when the insurance questions were in a

separate questionnaire booklet from the

core questions, ranged from 86.4% to

95.7%, which includes adjustment for

nonresponse to the family resource or

health insurance supplements. For
Page 12 National Health Statistics Reports n Number 17 n July 1, 2009

example, in 1993 the overall response

rate for the Health Insurance section

was 88.4%. This response rate was

calculated as follows: the household

response rate for the core questionnaire

for the third and fourth quarters (94.7%)

was multiplied by 93.3% (response to

the Health Insurance section), yielding

an overall response rate of 88.4%. The

family response rate for NHIS data

years 1963–1986 ranged from 95.0% to

97.9%, and the family response rate for

the 1959 NHIS data was 93.1%.

Item nonresponse

In the tables, unknown values

(responses coded as ‘‘refused,’’ ‘‘not

ascertained,’’ or ‘‘don’t know’’) were

not counted in the denominators when

calculating estimates. During 1997–

2007, the item nonresponse rate for the

health insurance items used in this

report was about 1%. During 1972–

1996, it ranged from 0.5% to 3.5%;

during 1963–1968, it ranged from 0.6%

to 1.6%; and in 1959, the item

nonresponse rate was almost 2% for the

hospital insurance question and almost

5% for the surgical insurance question.

Definitions of NHIS

insurance coverage

categories

This section, and the subsequent

section on NHIS questions, provide

detailed information on how the NHIS

data for each year were used to define

the health insurance coverage categories

used in this report. The Description of

Selected Programs section gives an

overview of selected public programs

that are referred to in the NHIS

questions.

Categories for 1968–2007

Private coverage includes

comprehensive health care coverage

obtained through an employer,

purchased directly, or obtained through

any other means. It excludes plans that

pay for only one type of service, such as

accidents or dental care. Private

coverage is at the time of interview,

except in 1990–1996, when it is for the

month prior to interview. During

1968–1980, the NHIS asked separate

questions about private hospital

insurance and private doctor’s or

surgical insurance; persons with private

coverage in those years have hospital

coverage and may also have doctor’s or

surgical coverage.

Employer-sponsored private

coverage is private insurance

originally obtained through the

workplace, that is, through either a

present or former employer or a

union. In 1997–2007, this category

explicitly includes coverage

obtained through self-employment

and professional associations.

Persons who had more than one

private insurance plan were

classified as having employersponsored private coverage if any of

their plans was employer-sponsored.

Other private coverage refers to

private insurance that was not

employer-sponsored. This includes

directly purchased plans, as well as

plans obtained through school or

other means. Persons who had more

than one private insurance plan

were classified as having other

private coverage only if no plans

were employer-sponsored.

Medicaid coverage includes persons

who reported having Medicaid coverage

(1990–2007) or having a Medicaid card

(1978–1989) or not carrying health

insurance because care was received

through Medicaid or welfare (1972–

1980). In addition, the Medicaid

category includes those who reported

coverage by ‘‘any other public

assistance program that pays for health

care’’ in 1982–1989 and 1992–1996; a

state-sponsored health plan in 1997–

2007; and the Children’s Health

Insurance Program (CHIP) in 1999–

2007. In 1976–1996, persons who did

not report Medicaid coverage but did

report receiving AFDC or SSI were

assigned Medicaid coverage because

persons in those programs were

automatically enrolled in Medicaid.

Medicaid coverage is at the time of

interview, except in 1990–1996 when it

is for the month prior to interview. In

1968 and 1970, no information on

Medicaid was collected.

Medicare coverage refers to

coverage at the time of interview, except

in 1990–1996, when it is for the month

prior to interview. In 1976, persons were

assigned Medicare coverage if they

reported not being covered by any

health insurance plan because care was

received through Medicare. In 1968–

1974, no information on Medicare was

collected for persons under age 65

years.

Other public coverage refers to

coverage at the time of interview, except

in 1990–1996, when it is for the month

prior to interview. It includes military

coverage (1982–2007), coverage through

‘‘other government programs’’ (1997–

2007), and not carrying health insurance

because of military coverage (1972–

1980). Military coverage includes

TRICARE (CHAMPUS), CHAMP-VA,

and VA coverage. In 1968 and 1970, no

information on military coverage was

collected.

Uninsured includes persons who

have no private health insurance,

Medicaid, military coverage, Medicare

(1976–2007), or coverage through ‘‘any

other public assistance program that

pays for health care’’ (1982–1989 and

1992–1996), CHIP (1999–2007), or a

state-sponsored health plan or other

government program (1997–2007). In

addition, in 1976–1996, uninsured

includes persons who did not report any

type of public or private health care

coverage and also did not report

receiving AFDC or SSI. A person was

also defined as uninsured if he or she

had only Indian Health Service coverage

or a private plan that paid for one type

of service, such as accidents or dental

care.

Categories for 1959, 1962–1963,

1968, and 1970

Health insurance refers to private

insurance in the 1959, fiscal year 1963,

1968, and 1970 NHIS and is any plan

specifically designed to pay all or part

of the medical or hospital expenses of

the insured individual (35,40,41). The

insurance can be either a group or an

individual policy, with the premiums
National Health Statistics Reports n Number 17 n July 1, 2009 Page 13

paid by the individual, an employer, a

third party, or a combination of these.

Benefits received under the plan can be

in the form of payment to the individual

or to the hospital or doctor. However,

the plan must be a formal one with

defined membership and benefits, rather

than an informal one. For example, an

employer simply paying the hospital bill

for an employee would not constitute a

health insurance plan. For the NHIS in

these years, (private) health insurance

excludes the following kinds of plans:

(i) plans limited to the ‘‘dread diseases’’

such as cancer and polio; (ii) ‘‘free

care’’ such as public assistance or public

welfare or Medicaid (as of 1968), care

given free of charge to veterans, care

given to dependents of military

personnel, care given under the

Uniformed Services Dependents Medical

Care Program, Crippled Children, or

similar programs, and care of persons

admitted for research purposes; (iii)

insurance that pays bills only for

accidents, such as liability insurance

held by a car or property owner,

insurance that covers children for

accidents at school or camp, and

insurance that that covers workers only

for accidents, injuries, or diseases

incurred on the job; and (iv) insurance

that pays only for loss of income

(35,40,41).

Hospital insurance pays all or part

of the hospital bill for the hospitalized

person. ‘‘Hospital bill’’ means only the

bill submitted by the hospital itself, not

the doctor’s or surgeon’s bill or the bill

for special nurses. Such a bill always

includes the cost of room and meals and

may also include the costs of other

services such as operating room,

laboratory tests, and x-rays (35,40,41).

Surgical insurance pays in whole or

part the bill of the doctor or surgeon for

an operation, whether performed in a

hospital or in the doctor’s office.

Insurance that pays the cost of visits to

a doctor’s office for postoperative care

is included as surgical insurance

(35,40,41).

NHIS questions used for

insurance coverage

estimates

NHIS questions that were used to

calculate the estimates in this report are

listed below for each year. (Numerous

additional questions on health insurance

are not used in this report and are not

included.) All questions on health

insurance coverage for each year,

including many questions not listed

below, can be found at http://

www.cdc.gov/nchs/nhis.htm.

The recall period for the insurance

questions is the day of the interview,

except in 1990–1996 when questions

refer to the month prior to interview,

resulting in a recall period of 1–2

months, depending on the time of the

month when the interview occurred.

NHIS questions on health insurance

coverage differ over the time period

1959–2007, reflecting changes in the

availability of different types of

coverage, issues of interest, and

questionnaire design. Starting in 1997,

respondents select the types of coverage

held by all family members from a list

of different types of coverage. During

1972–1996, another approach was used:

respondents were asked a series of

questions on whether family members

had each of several types of coverage.

In 1959, fiscal year 1963, 1968, and

1970, respondents were asked whether

family members had hospital and

surgical coverage, rather than about

various types of public coverage, which

were either not yet available or only

recently available. These differences in

the structure of the questionnaire are

reflected in the organization of the

questions listed below: all insurance

questions are listed together for

1997–2007; insurance questions are

organized by coverage type for 1972–

1996 to make it easier to see changes in

the questions about each type of

coverage; and all questions are again

listed together for 1959–1970.

Following the list of NHIS questions,

the Descriptions of Selected Programs

section gives an overview of

selected public programs that are

referred to in the NHIS questions.

NHIS questions, 1997–2007

Questions on private and public

plan names were used to edit initial

responses to the questions on type of

coverage.

Question FHI.050

The next questions are about health

insurance.

2004–2007

Include health insurance obtained

through employment or purchased

directly, as well as government

programs like Medicare and Medicaid

that provide medical care or help pay

medical bills. {Are you/Is anyone in the

family} covered by any kind of health

insurance or some other kind of health

care plan?

1997–2003

{Are you/Is anyone} covered by any

kind of health insurance or some other

kind of health care plan?

Question FHI.070

What kind of health insurance or health

care coverage {do you/does subject’s

name} have?

2004–2007

INCLUDE those that pay for only one

type of service (nursing home care,

accidents, or dental care). EXCLUDE

private plans that only provide extra

cash while hospitalized.

Enter all that apply from the following

response categories: Private health

insurance, Medicare, Medi-Gap,

Medicaid, SCHIP (CHIP/Children’s

Health Insurance Program), Military

health care (TRICARE/VA/CHAMPVA), Indian Health Service, Statesponsored health plan, Other

government program, Single service

plan (e.g., dental, vision, prescriptions),

No coverage of any type.

1999–2003

INCLUDE those that pay for only one

type of service (nursing home care,

accidents, or dental care); exclude
Page 14 National Health Statistics Reports n Number 17 n July 1, 2009

private plans that only provide extra

cash while hospitalized. Enter all that

apply from the following response

categories: Private health insurance plan

from employer or workplace; Private

health insurance plan purchased directly;

Private health insurance plan through a

state or local government program or

community program; Medicare;

Medi-Gap; Medicaid; CHIP (Children’s

Health Insurance Program); Military

health care/VA; CHAMPUS/TRICARE/

CHAMP-VA (category reordered to

TRICARE/CHAMPUS/CHAMP-VA in

2001–2003); Indian Health Service;

State-sponsored health plan; Other

government program; Single Service

Plan (e.g. dental, vision, prescriptions);

No coverage of any type (added in

2000).

1997–1998

EXCLUDE private plans that only

provide extra cash while hospitalized or

pay for only one type of service

(nursing home care, accidents, or dental

care).

Enter all that apply from the following

response categories: Private health

insurance plan from employer or

workplace; Private health insurance plan

purchased directly; Private health

insurance plan through a State or local

government program or community

program (added in 1998); Medicare;

Medi-Gap; Medicaid; Military health

care/VA; CHAMPUS/TRICARE/

CHAMP-VA; Indian Health Service,

State-sponsored health plan; Other

government program

Question FHI.073 (probe question for

persons under age 65 years with no

coverage of any type)

2004–2007

There is a program called Medicaid that

pays for health care for persons in need.

In this State it is also called (State

name). {Are you/Is subject’s name}

covered by Medicaid?

Question FHI.075 (verification

question)

2000–2007

I have recorded {you are/subject’s name

is} {covered by: refer to FHI.070 / not

covered by health insurance}. Is this

correct?

Question FHI.100 (Medicare HMO and

Medicare HMO plan name questions)

1997–2007

{Are/Is} {you/subject’s name} signed

up with an HMO, that is, a Health

Maintenance Organization? (With an

HMO, you must generally receive care

from HMO doctors, otherwise the

expense is not covered unless you were

referred by the HMO or there was a

medical emergency). If answer is ‘‘yes’’

ask:

Question FHI.110

1997–2007

What is the name of the HMO?

Questions FHI.120 and FHI.130

(Medicaid managed care and plan name

questions)

1997–2007

The next questions are about Medicaid

coverage. In this State it is also called

(state name). {You/Subject’s name}

{are/is} listed as having Medicaid

coverage. Can {you/subject’s name} go

to ANY doctor who will accept

Medicaid or MUST {you/he/she} choose

from a book or list of doctors or is a

doctor assigned?

(1) Any doctor (FHI.140) (2) Select

from book/list (FHI.130) (3) Doctor is

assigned (FHI.130)

[If answer equals 2, ask:]

What is the name of the health plan that

provided the book or list?

[If answer equals 3, ask:]

What is the name of the health plan that

assigned the doctor?

Questions FHI.158–FHI.179

2004–2007

The next questions are about private

health insurance plans. These plans can

be obtained through work, purchased

directly, or through a state or local

government program or community

program.

1998–2003

The next questions are about private

health insurance plans obtained through

work, purchased directly, or through a

state or local government program or

community program.

1997

The next questions are about private

health insurance plans obtained through

work or purchased directly.

1997–2007

It is important that we record the

complete and accurate name of each

health insurance plan. What is the

COMPLETE name of the first plan?

Which family members are covered by

that plan?

Are there any more health insurance

plans (in addition to those already

mentioned)?

What is the name of the next plan?

Now I am going to ask some questions

about the {plan/plans} you just told me

about, {starting with} [plan name].

Question FHI.210

2004–2007

Which one of these categories best

describes how this plan was obtained?

Response categories: Through employer;

Through union; Through workplace, but

don’t know if employer or union;

Through workplace, self-employed or

professional association; Purchased

directly; Through a state/local

government or community program;

Other (specify)

1997–2003

Was this plan originally obtained

through the workplace, such as through

a present or former employer or union?

Response categories: Employer; Union;

Through workplace but don’t know if

employer or union; Through workplace,

self-employed or professional

association; No
National Health Statistics Reports n Number 17 n July 1, 2009 Page 15

Questions FHI.250 (1997–2007),

FHI.251 and FHI.252 (2003), and

FHI.257 and FHI.264 (2004–2007)

2004–2007 (Plan name for CHIP)

Earlier I recorded that {you are/subject’s

name is} covered by the Children’s

Health Insurance Program (CHIP/

SCHIP). What is the name of that plan?

2004–2007 (Plan name for statesponsored program)

Earlier I recorded that {you are/subject’s

name is} covered by a state sponsored

health plan. What is the name of that

plan?

2004–2007 (Plan name for other

government program)

Earlier I recorded that {you are/

subject’s name is} covered by another

government program. What is the name

of that plan?

2003 (Plan name for CHIP)

Earlier I recorded that {you/subject’s

name} {are/is} covered by Children’s

Health Insurance Program (CHIP/

SCHIP). What is the name of that plan?

2003 (Plan name for state-sponsored

program)

Earlier I recorded that {you/subject’s

name} {are/is} covered by a statesponsored health plan. What is the name

of that plan?

2003 (Plan name for other government

program)

Earlier I recorded that {you/subject’s

name} {are/is} covered by another

Government program (other than

Medicaid). What is the name of that

plan?

2000–2002 (Plan name for CHIP,

state-sponsored, or other public

programs)

Earlier I recorded that {you/subject’s

name} {are/is} covered by CHIP, a

state-sponsored or other public program

(other than Medicaid) that pays for

health care. What is the name of the

plan?

1997–1999 (Plan name for statesponsored or other public programs)

Earlier I recorded that {you/subject’s

name} {are/is} covered by a statesponsored or other public program

(other than Medicaid) that pays for

health care. What is the name of the

plan?

Question FHI.260

1999 (uninsured verification question)

Just to verify, other than single service

plans, {do/does} {you/he/she} have

Medicare, Medicaid, CHIP (Children’s

Health Insurance Program), CHAMPUS,

or CHAMPVA or any private insurance?

(READ STATE NAME FOR

MEDICAID AND STATE

SPONSORED HEALTH INSURANCE

PROGRAM)

If yes, go to FHI.070.

1997–1998 (uninsured verification

question)

Earlier I recorded that {you/subject’s

name} {do/does} not have health care

coverage of any kind. {Do/Does}

{you/he/she} have Medicare, Medicaid,

(READ STATE NAME FOR

MEDICAID AND STATE

SPONSORED HEALTH INSURANCE

PROGRAM) CHAMPUS or

CHAMPVA...or any private insurance?

If yes, go to FHI.070.

NHIS questions, 1972–1996

During 1972–1996, respondents

were asked the questions listed below to

determine whether family members had

any of several types of coverage. For

1990–1996, the reference period for

insurance coverage questions was the

month prior to interview; for 1972–

1989, the reference period was the day

of interview. Responses to questions on

private health insurance plan names that

are listed below were used to edit

responses on type of coverage. Private

health insurance plan names were

collected in all years except 1990 and

1991. In some years, information about

different types of public coverage was

obtained through responses to a question

about reasons for not having (private)

health insurance coverage.

Medicare

1990–1996

People covered by Medicare have a card

that looks like this. Show Medicare

Card.

1a. In (month) was anyone in the family

covered by Medicare? Insert ‘‘that is

(read names)’’ after family in 1993–

1994.

1b. Who was covered? (1992–1996)

Who was this? (1990–1991)

1c. Anyone else?

1978, 1980, 1982–1984, 1986, 1989

Medicare is a Social Security health

insurance program for disabled persons

and for persons 65 years old and over.

People covered by Medicare have a card

that looks like this. Show Medicare

Card.

1a. Is anyone in this family, that is (read

names) now covered by Medicare?

1b. Is — now covered?

1976

6a. Which of these statements (Hand

card N) best describes why — is not

covered by any (private) health

insurance plan? Any other reasons?

Response category 1: Care received

through Social Security Medicare

1972, 1974

No information was collected that

enabled assignment of Medicare

coverage for persons under age 65

years. See 1974 Medicaid question

below.

Medicaid and other public assistance

1993–1996

(In 1993 and 1994, questions are

numbered 3a–c.)

There is a program called Medicaid that

pays for health care for persons in need.

In this State it is also called (State

name).

2a. In (month), was anyone in the

family covered by Medicaid?
Page 16 National Health Statistics Reports n Number 17 n July 1, 2009

2b. Who was covered?

2c. Anyone else?

1990–1992

2a. In (month), was anyone in the

family covered by Medicaid or (local

name)?

2b. Who was covered? (1992) Who was

this? (1990–1991)

2c. Anyone else?

1992–1996

(In 1992, questions are numbered 4a–c.)

5a. In (month), was anyone in the

family covered by any OTHER public

assistance program (other than

Medicaid) that pays for health care?

Added in 1993–1996: Do NOT include

use of public or free clinics if that is the

only source of care.

5b. Who was covered?

5c. Anyone else?

1990–1996

(Questions are numbered 10a–c and

13a–d in the 1990–1991 Income section

and 13a–c and 16a–d in the 1992

Family Resources section.)

Income and Assets section

8a. In (month), did anyone in the family

receive Supplemental Security Income

or SSI?

8b. Who was this?

8c. Anyone else?

12a. In (month), did anyone in the

family receive public assistance or

welfare payments from the state or local

welfare office? Do not include SSI.

12b. Who was this?

12c. Anyone else?

12d. Did — receive Aid to Families

with Dependent Children, sometimes

called AFDC or ADC, or some other

type of assistance payments in (month)?

1984, 1986, 1989

(In 1984 and 1986, questions are

numbered 9a, 9b, 10a, 10b, 12a, 12b,

13a, 13b.)

10a. Does anyone in the family (this

family in 1984, 1986) now receive

assistance through the ‘‘Aid to Families

with Dependent Children’’ program,

sometimes called ‘‘AFDC’’ or ‘‘ADC’’?

10b. Does — now receive AFDC or

ADC?

11a. Does anyone in the family (this

family in 1984, 1986) now receive the

‘‘Supplemental Security Income’’ or

‘‘SSI’’ (‘‘SSI’’ gold-colored in 1984)

check?

11b. Does — now receive this check?

13a. Does anyone in the family now

have a Medicaid {or (name)} card?

13b. Does — now have this card?

14a. Is anyone in the family now

covered by any other public assistance

program that pays for health care?

14b. Is — now covered?

1982, 1983

9a. Does anyone in this family now

receive assistance through the ‘‘Aid to

Families with Dependent Children’’

program, sometimes called ‘‘AFDC’’ or

‘‘ADC’’?

9b. Which (other) family members are

included in the AFDC assistance

payment?

9c. Are any other family members

included in this program?

10a. Does anyone in this family now

receive the ‘‘Supplemental Security

Income’’ or ‘‘SSI’’ gold-colored check?

10b. Who (else) receives this check?

10c. Anyone else?

12a. Does anyone in the family now

have a Medicaid (or names) card which

looks like this? Show Medicaid card.

12b. Who is this?

12c. Anyone else?

13a. Is anyone in the family now

covered by any other public assistance

program that pays for health care?

13b. Who is this?

13c. Anyone else?

1980

Ask for each person ‘‘not covered’’ (by

Medicare or private insurance). Many

people do not carry health insurance for

various reasons. (Hand card N)

7a. Which of those statements describes

why — is not covered by any health

insurance plan? Any other reason?

Response: 1. Care received through

Medicaid or Welfare

11a. Does anyone in the family now

have a Medicaid (or ______) card which

looks like this? Show Medicaid card.

11b. Who was this?

11c. Anyone else?

15a. Does anyone in this family now

receive assistance through the ‘‘Aid to

Families with Dependent Children’’

program, sometimes called ‘‘AFDC’’ or

‘‘ADC’’?

15b. Which (other) family members are

included in the AFDC assistance

payment?

15c. Are any other family members

included in this program?

16a. Does anyone in this family now

receive the ‘‘Supplemental Security

Income’’ or ‘‘SSI’’ gold-colored check?

16b. Who (else) receives this check?

16c. Anyone else?

1978

Ask for each person ‘‘not covered’’ (by

Medicare or private insurance). Many

people do not carry health insurance for

various reasons. (Hand card N)

7a. Which of those statements describes

why — is not covered by any health

insurance plan? Any other reasons?

Response: 1. Care received through

Medicaid or Welfare

4a. Does anyone in this family receive

assistance through the ‘‘Aid to Families

with Dependent Children’’ Program,

sometimes called ‘‘AFDC’’ or ‘‘ADC’’?

4b. Which (other) family members are

included in the AFDC assistance

payment?

4c. Are any other family members

included in this program?
National Health Statistics Reports n Number 17 n July 1, 2009 Page 17

5a. Does anyone in this family receive

the ‘‘Supplemental Security Income’’ or

‘‘SSI’’ gold-colored check?

5b. Who receives this check?

5c. Anyone else?

7a. Does anyone in the family now have

a Medicaid (or ______) card which

looks like this? Show Medicaid card.

7b. Who was this?

7c. Anyone else?

1976

Ask for each person ‘‘not covered’’ (by

Medicare or private insurance). Many

people do not carry health insurance for

various reasons. (Hand card N)

6a. Which of those statements describes

why — is not covered by any health

insurance plan? Any other reasons?

Response: 2. Care received through

Medicaid or Welfare

10a. Does anyone in this family receive

assistance through the ‘‘Aid to Families

with Dependent Children’’ Program,

sometimes called ‘‘AFDC’’ or ‘‘ADC’’?

10b. Which (other) family members are

included in the AFDC assistance

payment?

10c. Are any other family members

included in this program?

11a. Does anyone in this family receive

the ‘‘Supplemental Security Income’’ or

‘‘SSI’’ gold-colored check?

11b. Who receives this check?

11c. Anyone else?

1974

Ask for each person ‘‘not covered’’ (by

private insurance). Many people do not

carry health insurance for various

reasons. (Hand card N)

6a. Which of these statements describes

why — is not covered by any health

insurance plan? Any other reason?

Response: 4. Don’t need health

insurance because care received through

Medicare, Medicaid, or welfare.

1972

Ask for each person ‘‘not covered’’ (by

private insurance). Many people do not

carry health insurance for various

reasons.

4. Which of these statements (Hand card

N) best describes why — is not covered

by any health insurance plan? Any other

reason? Response: 4. Don’t need health

insurance because care received through

welfare or Medicaid.

Military coverage

1993–1996

6a. In (month) was anyone in the family

covered by military health care,

including armed forces retirement

benefits, the VA (Department of

Veterans’ Affairs), CHAMPUS or

TRICARE (in 1995 and 1996), or

CHAMP-VA?

6b. Was this CHAMPUS or TRICARE

(in 1995 and 1996), or CHAMP-VA?

6c. Who was covered by CHAMPUS or

TRICARE (in 1995 and 1996) or

CHAMP-VA?

6d. Anyone else?

6e. In (month) was anyone in the family

covered by any other military health

care, including armed forces retirement

benefits or the VA (Department of

Veterans’ Affairs)?

6f. Who was covered by other military

health care?

6g. Anyone else?

1992

3a. In (month), was anyone in the

family covered by military health care,

CHAMPUS, CHAMPVA, or the VA?

3b. Who was covered?

3c. Anyone else?

1990, 1991

3a. In (month), was anyone in the

family covered by CHAMPUS,

CHAMPVA, the VA, or military health

care?

3b. Who was this?

3c. Anyone else?

1984, 1986, 1989

(In 1986, questions are numbered 14a–c,

15a–d, 16a, 16b, 17a, 17b; in 1984,

questions are numbered 14a–c, 15a, 15b,

16a, 16b, 17a, 17b.)

15. Is anyone in this family now

covered by health care benefits from the

Armed Forces or Veterans’

Administration? (1989)

16a. Does anyone in the family now

receive military retirement payments

from any branch of the Armed Forces or

a pension from the Veterans’

Administration? Do not include VA

disability compensation.

16b. Does — now receive military

retirement or a VA pension?

16c. Which does — receive - the Armed

Forces retirement, the VA pension or

both?

17a. Is anyone in the family now

covered by CHAMPUS, which is a

program of medical care for dependents

of military personnel? (1986, 1989)

17b. Is — now covered by CHAMPUS?

(1986, 1989)

17c. Is anyone in the family now

covered by CHAMP-VA, which is

medical insurance for dependents or

survivors of disabled veterans?

17d. Is — now covered?

18a. Is anyone in the family now

covered by any other program that

provides health care for military

dependents or survivors of military

persons?

18b. Is — now covered?

19a. Does — have a disability related to

— service in the Armed Forces of the

United States?

19b. Does — now receive compensation

for this disability from the Veterans’

Administration?

1982, 1983

14a. Does anyone in the family now

receive military retirement payments

from any branch of the Armed Forces or

a pension from the Veterans

Administration? Do not include VA

disability compensation.

14b. Who is this?

14c. Anyone else?
Page 18 National Health Statistics Reports n Number 17 n July 1, 2009

15a. Is anyone in the family covered by

CHAMP-VA, which is medical

insurance for dependents or survivors of

disabled veterans?

15b. Who is this?

15c. Anyone else?

16a. Is anyone in the family now

covered by any other program that

provides health care for military

dependents or survivors of military

persons?

16b. Who is this?

16c. Anyone else?

17a. Does — have a disability related to

— service in the Armed Forces of the

United States?

17b. Does — now receive compensation

for this disability from the Veterans

Administration?

1976, 1978, 1980

(In 1976, question is 6a and response

category is 9.)

Ask for each person ‘‘not covered’’ (by

Medicare or private insurance). Many

people do not carry health insurance for

various reasons. (Hand card N)

7a. Which of those statements describes

why — is not covered by any health

insurance plan? Any other reason?

Response: 8. Military dependent,

(CHAMPUS), veterans’ benefits

1972, 1974

Ask for each person ‘‘not covered’’ (by

Medicare or private insurance). Many

people do not carry health insurance for

various reasons. (Hand card N)

6a. Which of these statements (best in

1972) describes why — is not covered

by any health insurance plan? Any other

reason? Response: 7. Some other reason,

Specify. Responses specifying military

coverage were coded as such on the file.

Private and employer coverage

1993–1996

8a. (Not counting the government health

programs we just mentioned,) In

(month) was anyone in the family

covered by a private health insurance

plan?

8b. It’s important that we have the

complete and accurate name of each

health insurance plan. What is the

COMPLETE name of the plan?

8c. In (month), was anyone in the

family covered by any OTHER private

health insurance plan?

Private Plan and Coverage Detail

section

1a. Now I am going to ask some

questions about the plan(s) you just told

me about, (starting with (plan name).)

Who was covered under this plan?

1b. Anyone else?

3a. Was this plan originally obtained

through the workplace, that is, through a

present or former employer or union?

1992

5a. (Not counting Medicare) In (month)

was anyone in the family covered by a

health insurance plan that pays any part

of hospital or doctors bills? Do NOT

include plans that pay for ONLY ONE

type of service, such as nursing home

care or accidents.

5b. It’s important that we have the

complete and accurate name of each

health insurance plan. What is the

COMPLETE name of the plan?

5c. Is anyone in the family now covered

by any OTHER health insurance plan?

Now I am going to ask some questions

about the plan(s) you just told me about.

6c. Was this plan obtained through an

employer or union?

7. Is — covered under this (name) plan?

1990, 1991

4a. Health insurance can also be

obtained privately or through a current

or former employer or union. Was

anyone in the family covered by private

health insurance or by membership in a

health maintenance organization in

(month)?

4b. Who was this?

4c. Anyone else?

4d. Was any of — health insurance

obtained through an employer or union?

(4e in 1991)

1989

4a. (Not counting Medicare) is anyone

in the family now covered by a health

insurance plan which pays any part of

hospital, doctor, or dental bills? Do

NOT include plans that pay for ONLY

ONE type of service such as nursing

home care or accidents.

4b. It’s important that we have the

complete and accurate name of your

health insurance plan. What is the

COMPLETE name of the plan?

4c. Is anyone in the family now covered

by any OTHER health insurance plan?

Again, do NOT include plans that pay

for ONLY ONE service.

Now I am going to ask some questions

about the plan(s) you just told me about.

5b. Was this plan obtained through an

employer or union?

7. Is — covered under this (name) plan?

1982–1984, 1986

We are interested in all kinds of health

insurance plans except those which pay

only for accidents.

4a. (Not counting Medicare) is anyone

in the family now covered by a health

insurance plan which pays any part of a

hospital, doctor’s, or surgeon’s (or

dentist’s in 1986) bill?

4b. What is the name of the plan?

4c. Is anyone in the family now covered

by any other health insurance plan

which pays any part of a hospital,

doctor’s, or surgeon’s (or dentist’s in

1986) bill?

5b. Was this (name) plan obtained

through an employer or union?

7. Is — covered under this (name) plan?

1980

We are interested in all kinds of health

insurance plans except those which pay

only for accidents.

4a. (Not counting Medicare) Is anyone

in the family covered by hospital
National Health Statistics Reports n Number 17 n July 1, 2009 Page 19

insurance, that is, a health insurance

plan which pays any part of a hospital

bill?

4b. What is the name of the plan?

4c. Is anyone in the family covered by

any other hospital insurance plan?

4d. Is anyone in the family covered by

any (other) health insurance plan which

pays any part of a DOCTOR’s or

SURGEON’s bill?

4e. What is the name of the plan?

5a. Was this (name) plan obtained

through an employer or union?

5b. Was it obtained through some other

group?

6a. Is — covered under this (name)

plan?

1976, 1978

(In 1976, questions are numbered 3–5.)

We are interested in all kinds of health

insurance plans except those which pay

only for accidents.

4a. (Not counting Medicare or Medicaid

in 1976) Is anyone in the family

covered by hospital insurance, that is, a

health insurance plan which pays any

part of a hospital bill?

4b. What is the name of the plan?

4c. Is anyone in the family covered by

any other hospital insurance plan?

4d. Is anyone in the family covered by

any (other) health insurance plan which

pays any part of a DOCTOR’S or

SURGEON’s bill?

4e. What is the name of the plan?

5a. Was this (name) plan obtained

through an employer or union?

5b. Was it obtained through some other

group?

6a. Is — covered under this plan?

We are interested in all kinds of health

insurance plans except those which pay

only for accidents.

3a. (Not counting Medicare) Is anyone

in the family covered by hospital

insurance, that is, a health insurance

plan which pays any part of a hospital

bill?

3b. What is the name of the plan?

3c. Is anyone in the family covered by

any other hospital insurance plan?

3d. Is anyone in the family covered by a

(any other) health insurance plan which

pays any part of a DOCTOR’S or

SURGEON’S bill?

3e. What is the name of the plan?

4. Is — covered under this (name) Plan?

5a. Was this (name) Plan obtained

through an employer, union, or some

other group?

1972

We are interested in all kinds of health

insurance plans except those which pay

only for accidents.

3a. (Not counting Medicare) Is anyone

in the family covered by hospital

insurance, that is, a health insurance

plan which pays any part of a hospital

bill?

3b. What is the name of the plan?

3c. Is anyone in the family covered by

any other hospital insurance plan?

3d. Is anyone in the family covered by a

(any other) health insurance plan which

pays any part of a doctor’s or surgeon’s

bill?

3e. What is the name of the plan?

Table H.I.

(b) Which members of the family

are covered by (name of plan)? Is

anyone else in the family covered

under this policy?

(c) Was this insurance plan obtained

through an employer, union, or

some other group?

NHIS questions, 1959–1970

Questions on plan names for

(private) health insurance were used to

edit responses to hospital and surgical

coverage questions in 1970.

1970

These next questions are about health

insurance. We are interested in all kinds

of health insurance plans except those

which pay only for accidents.

33a. (Not counting Medicare) Is anyone

in the family covered by hospital

insurance, that is, a health insurance

plan which pays any part of a hospital

bill?

33b. What is the name of the plan?

(Record in Table H.I.)

33c. Is anyone in the family covered by

any other hospital insurance plan?

33d. Is anyone in the family covered by

a health insurance plan which pays any

part of a doctor’s or surgeon’s bill?

33e. What is the name of the plan?

(Record in Table H.I.: complete

Table H.I. for each plan)

Table H.I. (2) Which members of the

family are covered by (name of plan)?

Table H.I. (3) Was this insurance plan

obtained through an employer, unions,

or place of work?

Table H.I. (4) Does — pay any part of a

hospital bill?

Table H.I. (5) Does — pay any part of a

surgeon’s bill?

1968

These next questions are about health

insurance. We are interested in all kinds

of HEALTH insurance plans except

those which pay only for accidents.

32a. (Not counting Social Security

Medicare) Is anyone in the family

covered by hospital insurance, that is, a

health insurance plan which pays any

part of a hospital bill?

32b. Who (else) is covered by hospital

insurance?

32c. Is anyone else in the family

covered by a health insurance plan

(besides Medicare) which pays any part

of a hospital bill?

32d. (Besides Medicare) Is anyone in

the family covered by any health

insurance plan which pays any part of a

surgeon’s bill?

1974
1959

Page 20 National Health Statistics Reports n Number 17 n July 1, 2009

32e. Who (else) is covered by surgical

insurance?

32f. Is anyone else in the family

covered by a health insurance plan

(besides Medicare) which pays any part

of a surgical bill?

1962–1963

18a. I have some questions about health

insurance. We don’t want to include

insurance that pays ONLY for accidents,

but we are interested in all other kinds.

Do you, your ... have insurance that

pays all or part of the bill when you go

to the hospital?

If Yes, ask

18b. Who is covered by hospital

insurance?

19a. Excluding insurance that pays

ONLY for accidents, do you, your ...

have insurance that pays all or part of

the surgeon’s bill for an operation?

If Yes, ask:

19b. Who is covered by insurance for

the surgeon’s bills?

The following questions were asked in

the household during the interview:

18a. I have some questions about health

insurance. We don’t want to include

insurance that pays ONLY for accidents,

but we are interested in all other kinds.

Do you, your ... have insurance that

pays all or part of the bill when you go

to the hospital?

If Yes, ask:

18c. Who is covered by this plan (each

plan)?

18d. Does this plan (either plan) pay

any part of the surgeon’s bill for an

operation?

The following questions were asked on

the mail-back part of the survey for

those persons who did not answer the

questions above during the course of the

interview:

Please answer the question in each of

sections A, B, and C below for each

person whose name appears at the top

of the column. Special Note: Do NOT

include insurance that pays ONLY for

accidents.

A1. Does this person have (or is he or

she covered by) any insurance that pays

all or part of the bill when he (she) goes

to the hospital?

B1. Does this person have (or is he or

she covered by) any insurance that pays

any part of the surgeon’s bill for an

operation?

Descriptions of selected

programs

Aid to Families with Dependent

Children (AFDC) was established by the

Social Security Act of 1935 as a grant

program to enable states to provide cash

welfare payments for needy children

who had been deprived of parental

support or care because their father or

mother was absent from the home,

incapacitated, deceased, or unemployed.

Medicaid was automatically linked to

welfare eligibility. The Personal

Responsibility and Work Opportunity

Reconciliation Act of 1996 (PRWORA)

replaced AFDC with a cash welfare

block grant called the Temporary

Assistance for Needy Families (TANF)

program. The new law stipulates that

children and parents who meet AFDC

eligibility standards in effect in their

state in July 1996 qualify for Medicaid,

regardless of whether they are eligible

for aid under the block grant. For more

information, see http://aspe.hhs.gov/

HSP/abbrev/afdc-tanf.htm.

Medicaid was authorized by Title

XIX of the Social Security Act in 1965

as a jointly funded cooperative venture

between the federal and state

governments to assist states in the

provision of adequate medical care to

eligible needy persons. Within broad

federal guidelines, each state establishes

its own eligibility standards; determines

the type, amount, duration, and scope of

services; sets the rate of payment for

services; and administers its own

program. For more information, see

http://www.cms.hhs.gov/home/

medicaid.asp.

Medicare was enacted July 30,

1965, as Title XVIII, Health Insurance

for the Aged, of the Social Security Act,

and became effective on July 1, 1966. It

is a nationwide health insurance

program providing health insurance

protection to people aged 65 years and

over, people entitled to Social Security

disability payments for 2 years or more

(with limited exceptions for people with

specific diagnoses), and people with

end-stage renal disease, regardless of

income. From its inception it has

included two separate but coordinated

programs: hospital insurance (Part A)

and supplementary medical insurance

(Part B). Medicare Advantage

(previously Medicare–2007Choice)

(Part C) is an expanded set of options

for the delivery of health care under

Medicare, created in the Balanced

Budget Act passed by Congress in 1997.

The Medicare Prescription Drug,

Improvement, and Modernization Act

(MMA) was passed on December 8,

2003; it established a voluntary drug

benefit for Medicare beneficiaries and

created a new Medicare Part D. For

more information, see http://

www.medicare.gov/publications/pubs/

pdf/10050.pdf.

Military health care includes

multiple programs serving active duty

personnel and families, retirees and their

families, and eligible veterans.

TRICARE (formerly CHAMPUS)

covers active duty service members,

retirees, activated Guards/Reserves, and

their family members, providing them

with government-subsidized medical and

dental care. Eligibility for Veterans

Administration (VA) health care benefits

depends solely on active military service

in the Army, Navy, Air Force, Marines,

or Coast Guard. Enrolled veterans are

assigned to one of eight priority levels

based on their service-connected

disabilities, income levels, and other

factors. The Secretary of Veterans

Affairs decides each year whether the

VA’s medical budget is adequate to

serve veterans in all priority groups who

seek care. CHAMP-VA (Civilian Health

and Medical Program of the Department

of Veteran Affairs) provides medical

care for spouses and dependent children

of disabled or deceased disabled

veterans who meet the eligibility

requirements of the VA. For more

information, see Kaiser Family

Foundation’s Military and Veterans’

Health Care Background Brief at
National Health Statistics Reports

n Number 17n July 1, 2009 Page 21

http://www.Kaiseredu.org.

Children’s Health Insurance

Program (CHIP), Title XXI of the

Social Security Act, isa program

initiated by the Balanced Budget Act of

1997. CHIP provides additional federal

matching funds for states to provide

health care coverage to low-income,

uninsured children aged 18 years and

under who are ineligible for Medicaid.

Ina few states, CHIP has been

expanded to cover select portions of the

adult population. Within federal

guidelines, each state determines the

design of its CHIP program, eligibility

groups, benefits packages, and payment

levels for coverage. The Children’s

Health Insurance Program

Reauthorization Act of 2009 (CHIPRA,

P.L. 111–3) reauthorized CHIP. For

more information, see http://

www.cms.hhs.gov/home/chip.asp.

Supplemental Security Income (SSI)

was established by Congress in 1972,

with payments beginning in 1974. It

replaced former federal-state programs

in the 50 states and the District of

Columbia. SSI is administered by the

Social Security Administration and

provides income support to persons aged

65 years and older, blind or disabled

adults, and blind or disabled children.

Eligibility requirements and federal

payment standards are nationally

uniform. SSI recipients are eligible for

Medicaid. For more information, see

http://www.ssa.gov/ssi.
Page 22 National Health Statistics Reports

n Number 17n July 1, 2009

on and events relevant to health insurance coverage, 1919–2007

ate coverage Public coverage

ngress. It clarifies that amounts received through

en’s compensation acts, as compensation for personal

e for tax purposes.

Baylor Hospital in Dallas, Texas, to provide room,

ned monthly cost. This plan is considered the

concept of accident and sickness insurance was

management to bargain with labor over ‘‘wages and

alyst for employer-based health benefits.

1935–Social Security Act (P.L. 74–271) is enacted to provide retirement and death benefits for eligiblepersons aged 65 and over who are no longer working and cash benefits to dependent children and theblind. No general health benefits are included.1937–Railroad Retirement Act (45 U.S.C. § 231 et seq.) is enacted, similar to the Social Security Act butamended to include survivors and dependents and to cover maternity and sickness benefits for disabilities.

field to establish prepaid clinic and hospital care for

state. Dr. Garfield had established a prepaid plan to

l and clinic, providing care to workers on the Los

abilization Act, the National War Labor Board rules

lization Act do not apply to fringe benefits such as

contributions for group medical and hospitalization

dified in 1954).

o non-Kaiser groups.

onal organization of Blue Cross plans, is created. 1946–Hospital Survey and Construction Act (Hill-Burton Program) (P.L. 79–725) assists states in

constructing hospitals. Facilities that receive funding are also required to provide a ‘‘reasonable volume’’ offree care each year for those residents in the facility’s area who need care but cannot afford to pay. A1954 amendment adds long-term facilities, rehabilitation centers, and outpatient departments.

t national organization of Blue Shield plans, is

ves states broad power to regulate insurance.

ed as a coordinating mechanism to provide coverage

m home.

t between United States Steel Corporation, the

Western Pennsylvania. The role played by the

t coordinated administration of benefits by local

f the Blue System’s ability to serve large national

1956–Government financing of health services is extended to military dependents in civilian medicalfacilities; expanded and named Civilian Health and Medical Program of the Uniformed Services(CHAMPUS) in 1966 (P.L. 89–614).

s Act (FEHBP) (P.L. 86–382) passes, and the first

1960–Kerr-Mills program (P.L. 86–778) is authorized to provide federal matching funds for medical care ofelderly public assistance recipients; by 1965, all 50 states have such programs. The program also providesfor assistance to ‘‘medically indigent’’ elderly people who are not eligible for public assistance.1965–Medicare and Medicaid legislation is enacted as Title XVIII and Title XIX of the Social Security Act toprovide health coverage for persons aged 65 and over and certain groups of low-income people.1967–Concern about the growing federal costs of the Medicaid program leads Congress to limit Medicaideligibility for the ‘‘medically needy’’ to those with income below 133–1/3% of the Aid to Families withDependent Children (AFDC) maximum payment level for a given family size in a state.
National Health Statistics Reports

n Number 17n July 1, 2009 Page 23

on and events relevant to health insurance coverage, 1919–2007—Con.

ate coverage Public coverage

P.L. 93–222) provides federal subsidies for the

ial and organizational standards. Any employer with

insurance benefits is required to make HMO

MO in the area requests it. (In 1995, the provision

led).

Act of 1974 (ERISA) (P.L. 93–406) places the

g health plans) primarily under federal jurisdiction.

ns, whereas both ERISA and state authority (for

insured health plans.

555, 92 Stat. 2076) amends Title VII of the Civil

reat disabilities and medical conditions associated

her disabilities or medical conditions.

nd Blue Shield plans are merged, forming the Blue

liation Act of 1985 (COBRA) (P.L. 99–272) requires

t employers with 20 or more employees to give

th benefits the right to choose to continue group

plan for limited periods of time under certain

ry job loss, reduction in the hours worked, transition

vents. Qualified individuals may be required to pay

of the cost to the plan.

usted community rating (which permits some variation

health status) by HMOs and to allow employers to

ty plans.

1972–Social Security amendments extend Medicare eligibility to individuals under age 65 with long-termdisabilities and to individuals with end-stage renal disease. Supplemental Security Income (SSI) program iscreated to federalize cash assistance for the aged, blind, and permanently and totally disabled. SSIrecipients are eligible for Medicaid coverage.1981–Omnibus Budget Reconciliation Act of 1981 (OBRA 81) (P.L. 97–35) establishes two new types ofMedicaid waivers to experiment with physician payment under the Medicaid program. The first, section1915(b) freedom-of-choice waivers, allows states to pursue mandatory managed care enrollment of certainMedicaid populations. The second, section 1915(c) home- and community-based services waivers, allowsstates to cover home- and community-based long-term care services for the elderly and individuals withdisabilities at risk of institutional care.1984–Deficit Reduction Act of 1984 (P.L. 98–369) mandates Medicaid coverage of children born afterSeptember 30, 1983, up to age 5, in AFDC-eligible families. Coverage for AFDC-eligible first-time pregnantwomen and pregnant women in two-parent unemployed families also becomes mandatory.1985–Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) (P.L. 99–272) mandatesMedicaid coverage for all remaining AFDC-eligible pregnant women.1986–Omnibus Budget Reconciliation Act of 1986 (OBRA 86) (P.L. 99–509) requires states to covertreatment of emergency medical conditions for illegal immigrants otherwise eligible for Medicaid. OBRA 86also gives states the option of covering pregnant women and infants (up to 1 year of age) with income upto 100% of the federal poverty level (FPL) and allows states to pay for Medicare premiums and costsharing for low-income qualified Medicare beneficiaries (QMBs) with income at or below 100% of FPL.1987–Omnibus Reconciliation Act of 1987 (OBRA 87) (P.L. 100–203) gives states the option of coveringpregnant women and children under the age of 1 in families with income up to 185% of FPL.1988–Medicare Catastrophic Coverage Act of 1988 (MCCA) (P.L. 100–360) requires states to payMedicare premiums and cost-sharing (copayments and deductibles) for Medicare beneficiaries with incomebelow 100% of FPL. MCCA also requires states to phase-in Medicaid coverage for pregnant women andinfants in families with income up to 100% of FPL.1989–Omnibus Budget Reconciliation Act of 1989 (OBRA 1989) (P.L. 101–239) requires states to provideMedicaid coverage to pregnant women and to children up to age 6 in families with income up to 133% ofFPL.1989–Medicare Catastrophic Coverage Repeal Act (P.L. 101–234) repeals most of the 1988 ‘‘catastrophic’’program (except the limits on Medicaid eligibility).
Page 24 National Health Statistics Reports n Number 17 n July 1, 2009 

on and events relevant to health insurance coverage, 1919–2007—Con. 

ate coverage Public coverage 

ntability Act of 1996 (HIPAA) (P.L. 104–191) sets 

andards for individual health insurance coverage, 

y and continuity standards were designed to help 

rance when they change jobs by limiting employers’ 

nditions or health status. HIPAA also provides new 

h coverage when they lose other health coverage, get 

o establishes medical savings accounts (predecessors 

establishes rules for the tax treatment of long-term 

110 Stat. 2874) requires group plans that offer 

vel of coverage for such benefits as they provide for 

ot apply to groups of fewer than 50 or to substance 

e act provides an escape clause for plans in the 

to the act. The provisions of this act expired on 

on Act (P.L. 104–204 110 Stat. 2945) requires plans 

o provide coverage for a minimum 48-hour (for normal 

very) inpatient length of stay for a mother and her 

dates timely post-delivery care when the mother and 

n of these minimum lengths of stay. 

–210) establishes the Health Coverage Tax Credit for 

are eligible for trade adjustment assistance. People 

nefit Guarantee Corporation are also eligible. Credits 

or state-sponsored insurance. 1990–Budget Reconciliation Act of 1990 (P.L. 101–508) includes
 

c Several measures to generate Medicare savings, including an increase in the Part B deductible, which is
 raised from $75 to $100; annual increases in the Part B premium scheduled through 1995 (intended to
 make total premiums equal 25% of Part B expenditures); and severe limits upon annual increases and
 other adjustments to Part A and Part B reimbursement.
 c A requirement that states phase-in Medicaid coverage for all poor children under age 19 born after
 September 30, 1983, by the year 2002.
 c A requirement that the states expand their Part B ‘‘buy-in’’ for poor elderly people.
 c Insurance regulation for Medicare supplementary insurance (MediGap) plans, including limits on
 exclusions for preexisting conditions, requirements for uniformity in policies, civil penalties for duplicative
 services, mandatory rebates if policies failed to return specified ages of each premium dollar, and rules for
 ‘‘simplification’’ and standardization of policies.
 1996–Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) (P.L. 104–193):
 c Repeals the AFDC program and replaces it with block grants to states (Temporary Assistance for Needy
 Families, or TANF), ending the linkage between eligibility for cash assistance and for Medicaid.
 c Establishes ‘‘Section 1931’’ family coverage category requiring states to provide Medicaid coverage to
 families meeting July 16, 1996, AFDC eligibility criteria and allowing higher income eligibility thresholds.
 c Bars Medicaid coverage for legal immigrants who enter the U.S. after August 22, 1996, during their first 5
 years in the country; coverage after the 5-year ban is allowed at state option.
 1997–Balanced Budget Act of 1997 (BBA 97) (P.L. 105–33) includes a broad range of changes in providerpayments to slow the growth in Medicare spending, as part of legislation to balance the federal budget. Italso establishes the Medicare+Choice program, a new structure for Medicare HMOs and other privatehealth plans offered to beneficiaries. The law also provides additional assistance with Medicare Part Bpremiums for beneficiaries with incomes between 120% and 135% of poverty. The law provides for partialassistance with premiums for beneficiaries with income between 135% and 175% of poverty. BBA 97 alsopermits states to require most Medicaid beneficiaries to enroll in managed care plans without obtaining aSection 1915(b) waiver. Congress creates the State Children’s Health Insurance Program (CHIP),providing federal matching funds to states to expand health insurance coverage for children above states’Medicaid eligibility levels.2000–Breast and Cervical Cancer Treatment and Prevention Act of 2000 (P.L. 106–354) allows states toprovide Medicaid coverage to uninsured women with breast or cervical cancer, regardless of income orresources, at enhanced CHIP federal matching rates.2001–The presidential initiative, Health Insurance Flexibility and Accountability (HIFA), to encourage theuse of 1115 waivers with existing Medicaid and CHIP resources, is introduced, with the goal of increasinghealth insurance coverage, primarily among nontraditional groups.
National Health Statistics Reports

n Number 17n July 1, 2009 Page 25

on and events relevant to health insurance coverage, 1919–2007—Con.

ate coverage Public coverage

ent, and Modernization Act of 2003 (MMA) (P.L.

uals with qualified high-deductible plans to establish

ay for qualified medical expenses, including

2003–MMA establishes a new Medicare Part D prescription drug program, beginning in 2006, and requiresthe Social Security Administration (SSA) to make low-income subsidy determinations under Part D, notifyindividuals of availability of Part D subsidies, withhold Part D premiums from monthly benefits for thosebeneficiaries who request such an arrangement, and enroll TRICARE beneficiaries in Medicare Part B.The law also requires, beginning in 2007, that Part B Medicare beneficiaries with modified adjusted grossincome over certain thresholds pay a higher premium than individuals with lower income. SSA is chargedwith making these determinations.2004–A temporary Medicare-Approved Drug Discount Card Program begins, along with a transitionalassistance program to provide a $600 annual credit to low-income Medicare beneficiaries withoutprescription drug coverage in 2004 and 2005.2006–Medicare Part D drug coverage begins.
Page 28 National Health Statistics Reports n Number 17 n July 1, 2009

Suggested citation

Cohen RA, Makuc DM, Bernstein AB,

Bilheimer LT, Powell-Griner E. Health

insurance coverage trends, 1959–2007:

Estimates from the National Health Interview

Survey. National health statistics reports; no

17. Hyattsville, MD: National Center for Health

Statistics. 2009.

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