From Vital and Health Statistics of the National Center for Health Statistics Number 71 � June 29, 1981 ~ 

PROPERWOFTM? 

PLJBLICATIOfljSFJRAfvCh 

Health Care Coverage Under Private Health lns@EWYtmm~Ry 

Medicare, Medicaid, and Military or Veterans 

: Administration Health Benefits: United States, 1978 

Division of Health 

The National Center for Health Statistics included 

a special supplement on health care coverage under 

private health insurance and Medicare as a part of the 

1978 National Health Interview Survey questionnaire. 

While this supplement was not designed to produce 

estimates for all types of health care coverage, it did 

contain a series of items related to eligibility for 

Medicaid and for military and Veterans Administration 

health care benefits. 1 By making certain assumptions 

about how these items relate to the broader concept 

of health care coverage, it is possible to obtain estimates of the number of persons eligibile for these 

pes of benefits. 

This preliminary report presents estimates of the 

@ verage status of persons in the civilian noninstitutionalized population under private health insurance 

and the three types of public programs mentioned in 

the title. There are many other forms of at least 

partial coverage for health care costs, including 

neighborhood health clinics and local philanthropic 

health-service agencies. “Health care coverage” as 

used in this report does not include these forms of 

coverage or insurance restricted to dread diseases, 

accidents, dental care, or protection related to income maintenance during periods of illness. Coverage 

restricted to certain groups is also excluded, such as 

coverage for Indians whose sole source of care is 

through the Indian Health Service. 

The focus of this report is on the extent or scope 

of health care coverage in the population rather than 

on the- question of breadth or depth of that coverage. 

Est@ates are shown fust by cross-classifying the 

coverage status for each person to produce an unduplicated estimate of coverage under the four types 

considered together. This is followed by a presentation of estimates for each of the four types of health 

care coverage and the procedures followed in 

deriving them. 

All of the estimates presented in this report are � Jrage annual point prevalence estimates for the

Interview Statistics 

civilian noninstitutionalized population. They are 

“point prevalence” estimates because they represent 

a person’s health care coverage status only at the 

time of interview, and for no other period during the 

year. They are “average annual” estimates because 

the total annual National Health Interview Survey 

sample consists of summing the results for 52 weekly 

representative samples of the civilian noninstitutionalized population. 

Technical qualifications related to the estimates 

are summarized in the technical notes. For a more 

detailed discussion of these qualifications and for a 

copy of the questionnaire see the 1978 Current 

Estimates (Series 10, No. 130). Additional data on 

health care coverage will be available in future publications from the National Center for Health Services 

Research based on the 1977 National Medical Care 

Expenditure Survey,z and from the National Center 

for Health Statistics and the Health Care Financing 

Administration based on the 1980 Medical Care 

Utilization and Expenditure Survey. 

Coverage status of persons 

under four types of health 

care coverage 

The concept of “coverage” is relatively unambiguous for private health insurance and Medicare, and 

can be approximated for military and/or Veterans 

Administration (VA) health benefits. The closest 

corresponding concept for Medicaid is that of “eligibility.” However, because the criteria for Medicaid 

eligibility vary among the States, because many 

persons only become aware of their eligibility after 

seeking medical aid, and finally because of the added 

complexity in deftig eligibility associated with 

“spenddown” provisions there is no generally agreed 

on criteria for estimating the number of persons 

“covered by” Medicaid. 

The Medicaid estimates shown in this report are 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, ,Office of Health Research, Statistics, and Technology 
2 ackncedata 

operationally defined in terms of responses to three 

items contained on the 1978 National Health Interview Sutiey (NHLS) questionnaire. Persons are 

defined as having “categorical or reported Medicaid 

coverage” if they (1) had a valid Medicaid card at the 

time of interview, (2) were receiving Aid to Families 

with Dependent Children or Supplementary Security 

Income payments, or (3) Medicaid coverage was 

given as a reason for not being covered by any health 

insurance plan. 

Because of the lack of uniformity associated with 

the definitions of Medicaid coverage, the estimates 

for this type of coverage are shown separately in table 

1. The data from the 1978 NHIS indicate that about 

179.5 million persons (83.9 percent) in the civilian 

noninstitutiona.lized population were covered by 

private health insurance, Medicare, or military and/or 

VA health benefits. Among the estimated 31.6 million 

persons (14.8 percent) not covered under any of 

these three and the 2.7 million persons (1.3 percent) 

for whom the coverage status could not be determined, an estimated 10.8 million persons had categorical or reported Medicaid coverage. Combining 

these two groups (represented by the boxed cells in 

table 1) produces estimates of about 190.3 million 

persons (89 percent) in the civilian noninstitutionalized population covered by at least one of the four 

types of coverage and about 23.5 million persons 

(11 percent) who were not identified as being covered 

under private health insurance or any of the three 

public programs.s 

The sum of the estimates in the boxed cells in 

table 1 shows that virtually all persons 65 years of age 

and over (about 99 percent) were covered under at 

least one of the four types of coverage. The corresponding estimate for persons under 65 years of age 

is about 88 percent. 

Table 2 shows estimates of persons in “the civilian 

noninstitutionalized population with combined or 

unique coverage under private health insurance, 

Medicare, and military and/or VA health benefits. 

Because the number of persons actually eligible 

for Medicaid is not known, Medicaid is excluded from 

these estimates of plan combinations. An estimated 

67.3 percent of the civilian noninstitutionalized 

population was covered by private health insurance 

only. The combination of private health insurance 

and Medicare coverage represents 6.2 percent, and 

each of the other plan combinations represents 3.4 

percent or less. 

Not unexpectedly, the patterns of coverage for 

persons under 65 years of age and 65 years of age and 

over are quite different. An estimated 75.0 percent of 

the younger age groups had coverage under private 

health insurance but did not have coverage under 

either of the two pub(ic programs. For persons 

Table 1. Number and percent distribution of persons by age, cover 

status under privete health insurance, Medicare, and milita 

and/or Veterans Administration health benefits, and by Medicai 

coverage status: United States, 1978 

Age and coverage status 7 

All ages, all coverage statuses . . 

Covered . . . . . . . . . . . . . . 

Notcovered . . . . . . . . . . . . 

Unknown if covered . . . . . . . 

Under 65 years, all coverage 

statuses . . . . . . . . . . . . . . 

Covered . . . . . . . . . . . . . . 

Notcovered . . . . . . . . . . . . 

Unknown if covered . . . . . . . 

65 years and over, all coverage 

statuses . . . . . . . . . . . . . . 

Covered . . . . . . . . . . . . . . 

Not covered . . . . . . . . . . . . 

Unknown if covered . . . . . . . 

All ages, all coverage statuses . . 

Covered . . . . . . . . . . . . . . 

Notcovered . . . . . . . . . . . . 

Unknown if covered . . . . . . . 

Under 65 years, all coverage 

statuses . . . . . . . . . . . . . . 

Covered . . . . . . . . . . . . . . 

Notcovered . . . . . . . . . . . . 

Unknown if covered . . . . . . . 

65 years and over, all coverage 

statuses . . . . . . . . . . . . . . 

Covered . . . . . . . . . . . . . . 

Notcovered . . . . . . . . . . . . 

Unknown if covered . . . . . . . 

Has valid Madicaid card, 

receives A FDC or SS1, 

and/or reports Medicaid 

. .. covers.ae as reason for no All heakh insurance plan 

persons 

Reported as Not reportad 

meeting at as meeting 

least one any of these 

critaria2 criteria3 

Numbar of persons in thousands 

213,828 14,846 198,982 

m# 4,022 175,451 

10348 21,295 

2;713 w 476 2,237 

191,041 12,762 178,279 

Ezz# Zflll 155,000 

10204 21,147 

2;579 a 447 2,133 

22,788 2,084 20,703 

q In& 20,451 

149 

133 m 104 

Percent distribution o 

100.0 6.9 93.1 < 

g 82.1 I&l 10.0 

1:3 m 1.0 

100.0 6.7 93.3 

~ 81.1

I&l 11.1 

1:3 m 1.1 

100.0 9.1 90.9 

~ 8.4 89.7 

0.6 0.7 

0;6 AEl * 1 0.5

lSee We sections in this report on “Private Health Insurance Coverag%”


“Medicare Coverage,” and “Military and Veterana Administration


Health Care Coveraga’J for specifications of how the concept of


“coverad” ia defined for each of the three types of health care cover-


age.


‘See the section of this report on “Medicaid Coverage” for the esti­


mates associated with each of the components of this dafin ition.


3“N ot reported” includes negativa responses, refusals, and unknowns


to any one of the components of this concept.


65 years of age and over, 54.5 percent had both private health insurance and Medicare, 26.7 percent had 

Medicare only, and 3.3 percent had private health 

insurance only. 

The following sections show how the estimat 

for each of the four types of health care coverage are e

defined. Also shown are estimates of the mo;e detailed aspects of coverage associated with each type. 
dvm@Ckb 3 

able 2. Number of persons by age and plan combinations of health care coverage under private health insurance, Medicare, and military and/or 

Veterans Administration health benefits’; percent distribution according to age: United States, 1978 

Covers@ status and plan combinations 

All persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

All plan combinations with known coverage status. . . . . . . . . . . . 

Private insurance on/y . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Private insurance and Medicare . . . . . . . . . . . . . . . . . . . . . . . 

Medicare on/y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Priority eligibility or reported military-VA coverage only . . . . . . . . 

Private insurance and priority eligibility or reported military-VA 

coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Allthree types of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . 

Medicare and priority eligibility or reported military-VA coverage . . . 

Notcovered byanyofthe three plans... . . . . . . . . . . . . . . . . 

Unknown covera~ or combination status. . . . . . . . . . . . . . . . . 

All Under 65 years 

agss 65 years and over 

Number of persons in thousands 

213,828 191,041 22,788 

208,023 185,658 22,365 

143,986 143,225 761 

13,296 882 12,414 

7,210 1,121 6,089 

4924 4,79.6 128 

4,142 3,966 176 

1,817 121 1,696 

1,005 196 809 

31,643 31,351 292 

5,805 5,383 423 

All Under 65 years 

egas 65 years and over 

Percent distribution 

100.0 100.0 100.0 

97.3 97.2 98.1 

67.3 75.0 3.3 

6.2 0.5 54.5 

3.4 0.6 26.7 

2.3 2.5 0.6 

1.9 2.1 0.8 

0.8 0.1 7.4 

0.5 0.1 3.6 

14.8 16.4 1.3 

2.7 2.8 1.9 

lExclude~ ~er$on~ not meeting ~ri~ria “=d to define coverage discussed in text who also did nOt rePOrt Militarv or VA cOvera9e as a reason ‘or not 

a 

* 

being covered by any health insurance plan. 

Private health insurance coverage 

Household respondents were asked whether any 

family member was covered by a health insurance 

plan that paid any part of a hospital bill, or a doctor’s 

r surgeon’s bill for operations. The names of all 

lans were listed for which a positive response was 

btained to either or both of these questions. A series 

of questions were then asked for each plan that 

covered at least one family member. Included were 

questions about whether the plan was obtained 

through a group, the type of coverage associated with 

the plan, each family member’s coverage status in 

relation to each of the plans, and whether the plan 

had been used during the past year. In tabulating the 

data, persons were classified as “covered by private 

health insurance” if they were covered by at least 

one plan, and as “not coveged” if they were classified 

as “not covered” under all of the plans listed for 

the family. They were classified as “unknown” if 

their coverage status was not determined for at least 

one plan and they were not covered under any of 

the other plans (if any) listed for the family. 

Table 3 shows that an estimated 166.1 million 

persons (77.7 percent) were covered by private health 

insurance. An estimated 159.0 million persons (74.3 

percent) had both hospital and surgical coverage, 

4.2 million persons had only hospital coverage, and 

323,000 persons had only surgical coverage. About 

325,000 persons classified as covered had neither 

hospital nor surgical coverage, and the type of coverge was not determined for about 2.2 million personsestimated 46.8 million persons (21.9 percent) 

did not have private health insurance coverage and 

the status of about 1.0 million persons (0.5 percent) 

could not be determined. 

Table 3. Number of persons by age and type of private health insurance 

coverage; percent distribution according to age: United States, 1978 

Type of private health All Under 65 years 

insurance coverage ages 65 years and over 

Number of persons in thousands 

All persons. . . . . . . . . . . . . . 213,828 191,041 22,788 

Covered . . . . . . . . . . . . . ..l66.O5O 150,928 15,122 

Hospital and surgical coverage. . 158,978 145,316 13,662 

Hospital, no or unknown 

surgical coverage. . . . . . . . . 4,220 3,192 1,028 

Surgical, no or unknown 

hospital coverage . . . . . . . . 323 243 81 

Neither hospital nor surgical 

coverage . . . . . . . . . . . . . 325 252 74 

Unknown type of coverage . . . 2,203 1$26 278 

Notcovered. . . . . . . . . . . . . 46,791 39,310 7,482 

Unknown if covered . . . . . . . . 987 803 184 

Percent distribution 

Ail persons . . . . . . . . . . . . . . 100.0 100.0 100.0 

Covered . . . . . . . . . . . . . . . 77.7 79.0 66.4 

Hospital and surgical coverage. . 74.3 76.1 60.0 

Hospital, no or unknown 

surgical coverage. . . . . . . . . 2.0 1.7 4.5 

Surgical, no or unknown 

hospital coverage . . . . . . . . 0.2 0.1 0.4 

Neither hospital nor surgical 

coverage . . . . . . . . . . . . . 0.2 0.1 0.3 

Unknown type of coverage . . . 1.0 1.0 1.2 

Notcovered . . . . . . . . . . . . . 21.9 20.6 32.8 

Unknown if covered . . . . . . . . 0.5 0.4 0.8 

Among persons under 65 years of age, the estimated proportion with private health insurance 

coverage was 79.0 percent, while about two-out-ofthree persons (66.4 percent) 65 years of age and over 

were covered by a private health insurance plan. 
4 acimncedata 

If the persons for whom either the coverage under Part B. Distributing the unknown cases in the 

status or the type of coverage was unknown are same proportions as the known cases produces t 

distributed in the same proportions as for persons following adjusted estimates for Medicare coverage, @

with known coverage status and known type of about 23.6 million persons in the civilian noninstitucoverage, the following adjusted estimates result ? tionalized population were covered by Medicare, with 

approximately 166.8 million persons were covered by virtually all of these persons covered by Part A, and 

private health insurance; of these about 166.4 million about 23.1 million of them covered by Part B. 

persons had hospital insurance and about 164.6 The Health Care Financing Administration 

million persons had surgical insurances (HCFA) produces estimates of persons enrolled in 

Medicare. The 1978 estimate is about 26.6 million 

Medicare coverage enrollees. However, HCFA is not able to distinguish 

enrollees on the basis of institutionalization and their 

; 

Household respondents were asked whether estimate is not, therefore, directly comparable to 

anyone in the family was covered by Medicare, and those shown in this report (which represent only the 

if so, to indicate which persons were covered. l%ose noninstitutionalized population). 

classified as covered were then asked whether they 

were covered by the types of benefits that pay for 

hospital bills (Part A), physician care (Part B), or 

both. Table 4 shows either or both of these forms of 

Reason for not being covered 

by any health insurance plan 

coverage for an estimated 23.6 million persons (11.0 

percent). About 21.2 million of these persons were 

An estimated 38.5 million persons were not 

covered by private health insurance or Medicare. 

65 years of age and over and about 2.4 million were Respondents for persons in that category were asked 

under 65 years of age. This represents a coverage rate to select the reasons for this “lack of coverage by any under Medicare of 93.1 percent for the former group health insurance plan” from a flashcard containing and 1.2 percent for the latter group. the reasons shown in table 5. No reason was given An estimated 22.4 million persons had coverage for an estimated 1.5 million persons. An estim-ated 

under both Part A and B of Medicare. An additional 41.7 million reasons were obtained for 36.9 millio 

and another 137,000 persons had coverage only often (15.3 million persons), followed by “Care : 

received through Medicaid or Welfare” (9.1 million 

persons), and by “Military dependent (CHAMPUS) or 

Tabla 4. Number of persons by age and Medicare coverage; percent Veterans benefits” (4.4 million persons). 

713,000 persons had coverage under Part A only, persons. “Too expensive” was the reason chosen mose

distribution according to age: United States, 1978 It should be emphasized that the reasons related 

Type of Medicare covemye	 All Under 65 years to Medicaid and military and/or VA benefits cannot 

ages 65 years and over 

Number of persons in thousands Table 5. Number and percent distribution of reasons for not being 

All persons. . . . . . . . . . . . . . 213,828 191,041 22,788 covered by any health insurance plan for persons who gave at least 

one reason, by type of reason: United States, 1978 

Covered . . . . . . . . . . . . . . . 23,567 2,359 21,207 

Hospital and doctor coverage . . 22,404 2,174 20,230 

Hospital, no or unknown Reason for no health All reasons 

doctor’s coverage . . . . . . . . 713 109 605 insuranca plan 1 i%r%;2s ‘~~~~~~ 

Doctor, no or unknown 

hospital coverage . . . . . . . . 137 *5 132 

Unknown type of coverage . . . 312 72 240 All reasons . . . . . . . . . . . . . . . . . . 41,738 100.0 

Notcovered . . . . . . . . . . . . . 189,733 188,273 1,460 Care received through Medicaid 

Unknown if covered . . . . . . . . 529 409 120 or welfare . . . . . . . . . . . . . . 

Unemployed or reasons related to 

. . . 9,131 21.9 

Percent distribution unemployment . . . . . . . . . . . . . . 3,612 8.7 

Cannot obtain due to poor health, 

All persons . . . . . . . . . . . . . . 100.0 100.0 100.0 illness, or age . . . . . . . . . . . . . . . 632 1.5 

Covered . . . . . . . . . . . . . . . 11.0 1.2 93.1 Tooexpensive . . . . . . . . . . . . . . . . 15,274 36.6 

Hospital and doctor coverage . . 10.5 1.1 88.8 Dissatisfied with previous insurance . . . 727 1.7 

Hospital, no or unknown Don’t believe in insurance . . . . . . . . . 945 2.3 

doctor’s coverage . . . . . . . . 0.3 0.1 2.7 Healthy, not much sickness in family, 

Doctor, no or unknown heven’t needed . . . . . . . . . . . . . . 3,274 7.8 

hospital coverage . . . . . . . . 0.1 *0.O 0.6 Military dependant, (CHAMPUS), 

Some other reason . . . . . . . . . . . . . 3,735 8.9 @ 

Notcovered . . . . . . . . . . . . . 88.7 98.6 6.4 

Unknown if covered . . . . . . . . 0.2 0.2 0.5 ‘This ~ue~tion v,Ias asked of all parsons with neither Private health 

insurance nor Medicare. 

Unknown type of coverage . . . 0.1 0.0 1.1 Veterans benefits . . . . . . . . . . . . . 4,408 10.6 
ackmedm5 

@


by themselves serve as a basis for estimating the 

umber of persons eligible for these two types of 

ealth care benefits: first, persons eligible for these 

types of benefits, who were also covered by Medicare 

or private health insurance, were not shown the card 

and asked to choose a reason; second, a person may 

be aware that he is eligible for either or both of these 

types of benefits but not perceive this as the reason 

he does not have health insurance. An individual 

may, for instance, perceive his unemployment or 

limited income as the real underlying reason for not 

having health insurance and consider his Medicaid 

eligibility as a mere consequence. 

Military and Veterans 

Administration health 

care coverage 

Aside from questions related to coverage under 

private health insurance and Medicare, the 1978 

NHIS questionnaire included items relevant in determining whether persons had priority eligibility to 

receive military and/or VA health care benefits. 

Veterans were asked (1) whether they had a service 

connected disability, . . and (2) whether they were

0 eceiving a pension from any of the military services 

r the VA. 

An estimated 3.0 million veterans had a service 

connected disability. However, respondents were not 

asked whether their disability had been certified by 

the VA as service connected. The estimate, therefore, 

is based on the respondent-assessed claim of such a 

disability.G 

An estimated 3.4 million veterans received a 

pension from the military, VA, or both. Of these 

persons, the VA was the source of the pension for 

about 2.0 million,T and one of the military services 

for about 1.5 million. 

All veterans with other than dishonorable discharges are potentially eligible to receive health care 

benefits from the VA. However, the availability of 

these services is limited and a system of criteria has 

been established to determine which veterans and 

their families qualify for these benefits. The following 

criteria are used to determine priority eligibility 

status: having a service connected disability, receipt 

of a pension from the VA, or being a veteran 65 

years of age or over. A somewhat lower priority is 

afforded to other veterans if they establish that 

they are unable to defray the costs of necessimy 

hospital charges elsewhere. Dependents and survivors 

f certain types of disabled or deceased veterans may 

so qualify for VA health care benefits. These per- e 

sons were not, however, directly identified in the 

1978 NHIS. 

As noted above, an estimated 3.0 million veterans 

had a service connected disability. Additionally, 

about 2.9 million veterans either” received a VA 

pension or were 65 years of age or over. These 

approximately 5.9 million veterans meet the criteria 

discussed above for priority eligibility for VA health 

care benefits.s 

Aside from the VA, the military services themselves offer health care benefits to eligible dependents 

of active military personnel and to military pensioners 

and their eligible dependents. Civilian dependents 

of active military personnel are not directly identified 

in the NHIS. However, it’ is possible to indirectly 

estimate the number of eligible dependents. During 

1978, there were about 1.8 million wives and dependent children under 21 years of age living at home 

with men on active military duty. These persons have 

a very high priority for receiving military health care 

benefits. 

A somewhat lower priority is afforded military 

pensioners and their eligible dependents. Even though 

questions were not asked to identify these dependents, it is possible to indirectly identify about 2.3 

million of them by the family relationship they bear 

to the pensioners. These include the wives and 

dependent children under 21 years of age living at 

home with the military pensioner. Combining the 

above estimates for dependents of active miIitary 

personnel and of military pensioners, and including 

the military pensioners themselves, produces an overall estimate of about 5.6 million persons in the civilian noninstitutionalized population with priority 

eligibility to receive health care benefits from the 

military.g Certain groups, however, (such as eligible 

survivors of military pensioners who have died) 

could not be identified and are, thus, excluded from 

this estimate. 

Among the 5.9 million veterans identified as 

having priority eligibility to receive VA health care 

benefits and the 5.6 million persons identified as 

having priority eligibility for military health care 

benefits, 835,000 were identif__ed as having priority 

eligibility for both types of benefits. However, the 

resulting total of about 10.7 million persons with 

priority eligibility for either or both types of health 

care benefits does not include other persons with 

“military or VA health care coverage” as a reason 

for not being covered by any health insurance plan. 

Table 6 shows the results of cross-classifying 

persons by identtiled priority eligibility status and 

whether or not military and/or VA coverage was 

given as a reason for not having a health insurance 

plan. An estimated 1.3 million persons with this 

reason did not meet the criteria used to identify 

persons with priority eligibility for military or VA 

health benefits. Under the assumption that these 

persons would not claim that their eligibility for these 

health care benefits was a reason for not obtaining 
6 acklncedata 

Table 6. Number of persons by whether military and/or Veterans 

Administration coverage was reportad as reason for no health 

instirance plan, and eligibility six military and/or Veterans Administration health benefits and source of eligibility: United States, 

1978 

Miiitary and/or VA coverage 

Eligibility status 

and sourca of All 

as reason for no -

health insurance plan 

eligibility bane fits persons 

No No re- Not Yas 

sponse asked’ 

Number of persons in thousands 

All eligibility statuses, all 

sources . . . . . . . . . . . 213,828 4,408 32,525 1,544 175,351 

Identified priority eli i3 bility, ail Sources*’ . . . 10,660 3,065 447 69 7,079 

Military and VA2r3. . . 835 159 *22 *2 653 

Military only2. . . . . . 4,773 2,614 137 50 1,972 

VAonly3 . . . . . . . . 5,052 293 288 *I7 4,454 

Priority eligibility status 

not identified . . . . . . . 203,168 1,343 32,079 1,475 168,272 

lNot ~~ked ~eaSOn because person not reported to lack Privata health 

insurance or Medicare coverage. 2Excludes dependents of deceawd or institutionalized military pan­

#oners. 

Excludes veterans who qualify for priority eligibility solely on the 

basis of low income. 

health insurance, unless they had a relatively high 

priority eligibility status for receiving them, it is 

reasonable to include them in the total for persons 

with priority eligibility status for the receipt of 

military or VA health care benefits. This procedure 

produces an overall estimate of about 12.0 million 

persons in the civilian noninstitutionalized population 

with either coverage or priority eligibility status for 

receiving military or VA health care benefits (table, 7). 

Table 7. Number of persons by military and/or Veterans Administration 

health care coverage status’: United States, 1978 

Military andlor VA haalth care coverage 

Number of parsons 

in thousands 

All persons . . . . . . . . . . . . . . . . . . . . . . . . 213,828 

Priority eligibility or reported milita~ 

and/or VAcoveraga’ . . . . . . . . . . . . . . . . . 12,003 

Neither priority eligibility nor reported 

military and/or VA coverage . . . . . . . . . . . . 197,019 

Unknown military :and/or VA health 

benefits coverage . . . . . . . . . . . . . . . . . . . 4,806 

‘Excludes persons not meeting criteria used to define coverage discussed in text who also did not report military or VA coverage as a 

raason for not baing covered by any health insurance plan. 

Medicaid coverage 

As discussed earlier in this report, persons were 

defined as having “categorical or reported Medicaid 

coverage” if they (1) had a valid Medicaid card at the 

time of the interview, or (2) were reported as recei 

a ing Aid to Families with Dependent Children (AFDC) 

or Supplemental Security Income (SS1), or (3) 

Medicaid coverage was given as a reason for not being 

covered by any health insurance plan. 

Based on the number of respondents who presented a valid Medicaid card, it is estimated that 8.2 

million persons were enrolled in the Medicaid program in 1978. An additional estimate of 4.9 million 

persons eligible for Medicaid was obtained based on 

the reports of AFDC or SS1 recipients (often called 

categorical eligibility) who did not show a valid Medi- ~ 

caid card. 10 Together the criteria of a valid Medicaid 

card and/or reported receipt of AFDC or SS1 results 

in an estimate of 13.1 million persons. 

Earlier it was noted that respondents representing 

an estimated 9.1 million persons gave Medicaid coverage as the reason for not having coverage by any 

health insurance plan. As is shown in table 8, an 

estimated 1.7 million (863,000 and 848,000) of 

these persons did not have a valid Medicaid card and 

were not receiving AFDC or SS1. If these 1.7 million 

persons are combined with the 13.1 million cited 

above, an estimate of 14.8 million persons with categorical or reported Medicaid coverage is obtained. 

This figure (14.8 million persons) is an averag 

annual point prevalence estimate. It is not an estimat 

o of the total number of persons covered by or eligible 

for Medicaid during part or all of the 12-month 

period. Data from the National Medical Care Expenditure Survey provide an estimate of 20.8 million 

persons in the civilian noninstitutionalized population 

with Medicaid coverage during part or all of 1977.11 

Table 8. Number of persons by whether 

as a reason for no health insurance 

Medicaid card or receipt of AFDC or 

Possession of valid All Medicaid care card or statuses receives AFDC-SSI Yas 

Medicaid coverage was reported 

plan, and possession of a valid 

SS1: United States, 1978 

Medicaid as reason for no 

healffi insurance plan 

Un- Not No 

known asked’ 

Number of persons in thousands 

All persons . . . . . . . . . . 213,828 9,131 27,803 1,544 175,351 

Has Medicaid card and/or 

receives AFDC or SS1 . . 13,135 7,420 1,670 162 3,883 

Neither has Medicaid card 

nor receives AFDC or 

sS1 . . . . . . . . . . ...198.444 863 25,750 1,337 170,493 

Unknown if meets at least 

one of these criteria. . . 2,250 848 383 45 974 

lNot asked ~aso” becau~ person not reported to lack Private heal 

insurance or Medicare coverage. 

i 
amcedaa7 

iscussion 

An aspect of the debate on national health insurance has been the growing interest in determining 

the extent, breadth, and depth ofhealth care coverage 

among the American population. As noted earlier, 

while the data presented in this report are relevant to 

the issue of the extent of health care coverage, they 

are of limited value regarding the breadth and depth 

of that coverage. As such, the focus of the discussion 

has been on whether or not persons were covered 

under any of the four types of coverage or under at 

least one of them. As discussed in the following 

section, this focus on the question of coverage may 

lead to misinterpretations of the results discussed 

in this xeport. 

Alternative estimates of 

the extent of coverage 

The previous discussions of Medicaid coverage 

and of reported or priority eligibility under military 

or VA health care benefits demonstrate that any 

tirnate of the number of persons not covered under 

y of the four plans derives to a significant degree o from the definition of the concept being measured, 

assumptions made about the data, and the type of 

statistic being estimated. Within this context, the 

following paragraphs briefly indicate some alternative 

estimates that might have been derived from the same 

data. 

Among the approximately 23.5 million persons 

shown in table 1 without identified coverage under 

any of the four types of coverage, about 2.2 million 

were members of families with an annual income of 

less than $3,000, about 2.4 million were veterans, and 

442,000 were unable to perform the usual activity of 

their age-sex group due to chronic health conditions 

or impairments. Among the same 23.5 million persons, an estimated 738,000 received Medicaid benefits 

or VA health benefits during the 12 months preceding the interview. The unduplicated estimate of 

those who meet one or more of these criteria is about 

5.3 million persons. Thus by assuming that these 

persons would have some type of health care coverage, the estimate of those not identified as covered in 

table 1 is reduced by 22.4 percent (or to about 18.3 

million persons). 

m On the other hand, certain assumptions made in 

lassi~ing persons as “covered” in earlier sections of 

his report might be questioned. For example, whether 

or not persons with priority eligibility for VA health 

care benefits actually are able to receive health care 

from the VA depends on a number of factors including their proximity to VA health facilities and 

the ability of these facilities to accommodate them. 

This type of relationship does not provide the usual 

implications for accessibility to health care that 

having private health insurance, Medicare, or even 

military coverage implies. In addition, the data in 

table 6 suggest that persons with VA eligibility do 

not necessarily regard this as an alternative to private 

health insurance. Very few of those persons with only 

VA coverage gave that as a reason for not being 

covered by a health insurance plan. Data are needed 

on the extent to which persons with priority eligibility forVA health benefits actually use VA facilities. 

Such data will be available in the near future from the 

National Center for Health Services Research based 

on the 1977 National Medical Care Expenditure Survey, and from the National Center for Health Statistics and the Health Care Financing Administration, 

based on the 1980 National Medical Care Utilization 

and Expenditure Survey. 

Beyond assumptions related to the data itself, 

different estimates could be derived by choosing to 

use a different and perhaps a more relevant statistic 

to estimate. For instance, compared with the average 

annual point prevalence estimate of a maximum of 

about 23.5 million persons not identified as covered 

under any of the four types of coverage, the average 

point prevalence estimate for a shorter period of 

time (or as of a certain date) might be the more 

appropriate statistic; the estimate of persons not 

identified as covered under any of the four types 

of plans for each of the four qumters of 1978 differ 

by as much as 1.1 million persons. 

Consideration of further issues (including the 

assumptions made in editing the data) and recognition 

of the sampling errors associated with the estimates 

suggests that the 1978 NHIS data fde could reasonably serve as a basis to produce an estimate of anywhere from about 7 to 13 percent as the proportion 

of the civilian noninstitutionalized population not 

covered under any of the four types of health care 

coverage discussed in this report. 

Extent of coverage and the 

financial burden of illness 

There is only a partial association between the 

concepts of coverage and of financially unimpeded 

access to health care services (except perhaps in the 

case of eligibility for full Medicaid benefits or membership in a Health Maintenance Organization). 

For instance, many of the persons classified as 
8 adwncedata 

“covered” in this report may have experienced relatively large out-of-pocket health expenditures even 

though they were covered, while persons classified 

as not being covered may have had no health expenditures during the period they were not covered. As 

such, the concept of coverage is only partially related 

(1) to the issue of the financial burden of illness, 

injury, or impairment; and (2) to the issue of the 

degree to which people fail to seek needed medical 

care because of the potential financial burden associated with obtaining such care. 

In summary, the focus given in this report to th 

question of the extent of health care coverage, 

the limited consideration given to the questio* of the breadth and depth of that coverage, derive 

from the strengths and limitations of the types of 

data collected on these issues in the 1978 NHIS 

and not from the assumption that a mere identification of the so-called “uninsured,” “uncovered,” or 

“unprotected” population is of paramount importance to the major issue of the financial burden of 

illness. 
-achiancedata9 

lBecause these items were not included in the 1976 National Health 

Interview Survey and because different assumptions were made in 

analyzing the data, comparisons of the results of tis study and those 

shown in Health Care Coverage, 1976 (Advance Data No. 44, September 20, 1979) rhould be made with caution. 

2Reports currently available from the National Center for Health 

Services Research include: Data Preview 1: “Who ae the Uninsured?” 

and Data Preview 4: “Health Insurance Coverage of Veterans.” 

3This estimate of about 11 percent of persons irr the civiliti noninstitutionalized population not identitled as having coverage differs 

from the estimate of 12.6 percent shown as “without insurance coverage” in the recent, “Who are the uninsured?” Data Preview 1 (National 

Center for Health Services Research) because: (1) the concept “not 

identified as covered” differs from the concept “without insurance 

coverage,” (2) different criteria were used to define “coverage,” and (3) 

data horn different years and for different time periods were used to 

produce the two estimates. 

41n this and in following sections the estimates based on reported data 

are shown in the tables. When a signifkant number of unknown cases 

are associated with an estimate of major interest, an adjusted population 

estimate wiU be given in the text. The adjusted estimates are derived by 

multiplying the percent of persons covered and not covered (i.e., the 

unknown cases are excluded) by the number of persons in the entire 

civilian noninstitutionrdized population. 

5As of De~mber 31, 1977 the Health Care Fkincing Adminis~ation 

estimates that about 168.2 million persons had hospital coverage and 

about 163.9 million persons had surgical coverage under private health 

“ surance, (Carrel, M.S., Arnett III, R.H., “Private Health Insurance 

s in 1977: Coverage, Enrollment and Financial Experience,” 

th Financing Review, F~ 1979). 

6~e VA estimates that about 4 million veterans have a se~ce connected disability and about 1.7 million of these veterans are classified as having a zero percent seMce connected disability. Presumably, 

many of these veterans with a zero percent duability did not report 

having a seMce connected disability. 

7~e VA estimates that about 1 million veterans were receiving a 

VA pension and abnost 2.3 million veterans were receiving VA compensation during 1978. Presumably, about 1 million persons represented in the NHIS did not distinguish between receipt’ of a pension and 

receipt of compensation payments from the VA8~e VA ~so includes in its priority eligibility fYouP fiose vete-s 

under 65 years of age with an individual income of under $7,000 a 

yeru. It estimates that 11 to 12 million veterans have priority eligiiiliw 

to receive VA health care. Combining the under $7,000 annual income 

group of veterans identiled in the NHIS with the 5.9 million veterans 

who meet the priority eligibility criteria discussed in the text produces 

a NHIS estimate of about 11.1 million veterans in the civilian nonrnstitutionalized population meeting the VA criteria for priority eligibility for VA health care benefits (this estimate is not adjusted for 

unknowns). 

‘The Pentagon estimates 6 to 7 miUion civilians were eligible to receive 

military health care benefits during 1978. 

1‘Based on the number of respondents who reported receipt of AFDC 

or SS1 (regardless of whether or not a valid Medicaid cad was presented), it is estimated that a total of 10.7 million persons had categoricaleligibtity for Medicaid. 

11Wilensky, G., Walden, D., and Kasper, J.: “The Changiug Medicaid 

Population; paper presented at the 1980 Annual Meeting of the 

American Statistical Associatio~ Houston, Texas, Aug. 11,1980. 

@ 
� 

10 acklncedata 

Technical notes 

The estimates shown in this report are based on Table. 1. Standard errors of estimates of aggregates

data obtained in household interviews in a continuing 

nationwide survey. Each week a probability sample Size of estimate Standard 

error in of households is interviewed by personnel of the U.S. in thousands thousand$ Bureau of the Census to obtain information about 

the health and other characteristics of the civilian 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 

noninistitutionalized population of the United States. 100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 

During 1978, interviews were conducted in 300 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 

500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 approximately 41,000 households containing about 1,000. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 

110,000 family members and unrelated individuals. 5,000. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 

The total noninterview rate was about 3.8 percent. 10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 

20,000. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 The weights of intewiewed persons in the segments 30;000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 

containifig households in the sample for whom data 150,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393 

were not obtained were inflated to compensate for 

household nonresponse. 

All persons 17 years of age and over were asked 

to participate in the interview. When this was not Table 11. Standard errors, expressed in percentage points, of estimated 

percentages

possible, proxy responses were accepted from family 

members meeting the NHIS respondent rules. Ap- Estimated percentages 

proximately 63 percent of persons 17 years of age Base of percen teges 2 5 ?0 20 

and over responded for themselves. Proxy responses in thousands 50 

were obtained on the remaining 37 percent of adult :: & % :0


family members. All information on persons under


17 years of age is obtained from adult family members 100 . . . . . . . . . . . . . . . . . . 2.5 3.9 5.4 7.2 9.


or guardians. 500 . . . . . . . . . . . . . . . . . . 1.1 1.8 2.4 3.2 4.0a 

The appendixes of the 1978 Current Estimates 1,000 . . . . . . . . . . . . . . . . . 0.8 1.2 1.7 2.3 2.9 

(Series 10, No. 130) should be consulted for a more 

detailed discussion of the sample design and weighting 

5,000 . . . . . . . . . . . . . . . . . 

10,000. . . . . . . . . . . . . . . . 20,000 . . . . . . . . . . . . . . . . 

0.4 

0.3 

0.2 

0.6 

0.4 

0.3 

0.8 

0.5 

0.4 

1.0 

0.7 

0.5 

1.3 

0.9 

0.6 

procedures (appendix I) and for a copy of the ques- 30,000 . . . . . . . . . . . . . . . . 0.1 0.2 0.3 0.4 0.5 

tionnaire used during 1978. Approximate sampling 150,000 . . . . . . . . . . . . . . . 0.1 0.1 0.1 0.2 0.2 

errors for estimates contained in this report are 

shown in table I (aggregates) and table II (percents). 

300 . . . . . . . . . . . . . . . . . . 1.5 2.3 3.1 4.2 5. 
---

ackmeMa 11 

Recent Issues of Advance Data From Vital and Health Statistics 0 o. 70. Utilization of Short-Stay Hospitals in Treatment of No. 67. Headache as the Reason for Office Vkits, National

Mental Disorders Ambulatory Medical Care Survey: United States, 1977-78 

No. 69. Office Visits for Preventive Care: National Ambulatory (Issued: Januaxy 7, 1981)


Medical Care Survey: United States, 1977-78 (Issued: April 1, No. 66. 1979 Summary, National Ambulatory Medical Care


1981) Survey (Issued: March 2, 1981)


No. 68. Stroke SuMvors Among the Noninstitutionalized Pop­


ulation 20 Years of Age and Over: United States, 1977 (In


Preparation) 

. . . 

0.0 

* 

Symbols 

Data not available 

Category not applicable 

Quantity zero 

Quantity more than O but lessthan 0.05 

Figure does not meet standards of 

reliability or precision