U.S. Department of Commerce Economics and Statistics Administration

Dynamics of Economic Well-Being:

Health Insurance, 1993 to 1995

Who Loses Coverage

and for How Long?

C E N S U S B U R E A U P70-64

Issued August 1998

By Robert L. Bennefield

Current Population Reports

Household Economic Studies

Introduction

Many people are concerned

about the growing number of

Americans who lack health insurance. This report uses data from

the Survey of Income and Program Participation (SIPP) to

examine this issue. It focuses

primarily on the extent to which

people were covered by health insurance over a 36-month period

beginning in early 1993. The

source of this information is the

first nine waves of the 1993 panel

of the SIPP.

During each SIPP interview,

information is collected on health

insurance coverage (along with

other information on income and

labor force and program participation) for each month in the

4–month reference period. It is

therefore possible to classify

people by the number of months

over the 36-month period that they

were covered by one or more

types of health insurance. It is also

possible to measure the number

of months continuously spent without insurance coverage, that is,

spells of noncoverage.

Health insurance in this report

refers to the following types of

coverage: (1) employment-based

insurance, (2) other privately purchased health insurance, (3)

Medicare, (4) Medicaid, and (5)

military health care.

Highlights1

 Estimates for 1994 show that

19.3 (±1.1) million people were

uninsured over the entire

12-month period, not significantly

higher than the 1993 estimate of

19.0 (±1.0) million uninsured

people.

1The figures in parentheses denote the

90–percent confidence intervals.

 Nearly four out of five people or

79.2 (±0.6) percent of all people

had continuous health insurance

coverage during 1994. Thus, 20.8

(±0.6) percent, or 53.2 (±1.6) million people, lacked insurance for

at least 1 month. This percentage

is significantly lower than the 21.9

(±0.6) percent who experienced a

lapse in coverage during calendar

year 1993.

 Over the 36-month period

examined here, 71.0 (±0.7) percent of all people had continuous

health insurance coverage; therefore, 29.0 (±0.7) percent, or 71.5

(±1.9) million people, lacked insurance for at least 1 of those 36

months. Moreover, 3.7 percent

(±0.3) or 9.1 (±0.8) million were

uninsured for the full 36-month

period. Half of all observed spells

without health insurance lasted 5.3

months or longer, which was similar to the 1992-1994 period.

 Young adults (those between

the ages of 18 and 24 years old)

were the most likely of any age

group to lack insurance for at least

1 month—over one–half, or 55.2

percent(±2.6) were not continuously insured during the 36–month

period.

 Work experience has a significant effect on health insurance

coverage: 85.1 (±1.2) percent of

people who worked full time for

the entire period were covered

continuously by health insurance,

compared with 69.9 (±5.3) percent

for full–period, part–time workers,

and 56.1 (±1.4) percent for workers with one or more job

interruptions.

 Those who were poor or near

poor were less likely to have continuous health insurance coverage

than others: 80.4 (±0.8) percent of

those with an income-to-poverty

ratio of 2.0 or greater had continuous coverage, compared with 50.5

(±1.5) percent of those with an income-to-poverty ratio below 2.0.

A Dynamic View of Health

Care Coverage

Health insurance coverage is

commonly associated with other

life circumstances, such as employment, retirement, and

participation in government programs. As a result, there exists

a strong likelihood that, for some

segments of the population, health

insurance status will change over

time. Through the use of longitudinal estimates, it is possible to

examine the dynamics of health

insurance coverage, and the extent to which people experience a

lapse in coverage during a given

time period.

Data from the 1993 SIPP

panel were used to examine the

number of months people were

covered by health insurance during a 36–month period. Interviews

from this panel were conducted

between February 1993 and

January 1996. While data were

collected for every month in 1993,

1994, and 1995, health insurance

estimates were examined for only

two of those years, 1993 and

1994. Calendar year 1995 estimates were not examined

because data were collected for

the entire sample only through

September 1995.

During the 1994 calendar year,

79 percent of all people had

health insurance coverage for the

entire year; 21 percent or 53 million people lacked coverage for at

least 1 month. Eight percent or 19

million people were never covered

in 1994. The corresponding 1993

calendar year estimates were
1 to 11 months

14%

Figure 1.

Percent Covered by Health Insurance: 1993 to 1996

No months

8%

12 months

78%

1 to 11 months

13%

No months

8%

12 months

79%

7 to 35 months

23%

1 to 6 months

2%

36 months

71%

No months

4%

1993

1994

1993 to 1996

Source: U.S. Bureau of the Census, Survey of Income and Program Participation, 1993 Panel.

2 P70-64

U.S. Census Bureau, the Official Statistics TM July 22, 1998

78 percent, 22 percent, and 8

percent.

Between February 1993 and

January 1996, 71 percent of all

people had continuous health insurance coverage over the entire

36–month survey period; 29 percent lacked health insurance for at

least 1 month. Six percent of all

people were covered by insurance

for 6 months or less, of whom 61

percent lacked coverage for the

entire period, and 39 percent were

covered for 1 to 6 months. (See

Figure 1.)

Comparisons Over Time

As time passes more people

lose coverage.

The proportion of people with a

lapse in coverage is greater when

measured over a longer time period, as different people may lose

coverage at different points in

time. For example, proportions of

those with lapses in coverage for

calendar years 1993 and 1994

were 22 and 21 percent, respectively. However, over the full

36–month period, the proportion

of those with a lapse in coverage

increased to 29 percent.

Data from 1992 and 1993 panels

show similar coverage patterns.

An earlier report examined

health care coverage gaps over

a 28–month period between

1992–1994, based on data from

the 1992 SIPP panel. For an appropriate comparison, the 1993

panel was restricted to the first 28

months. The patterns of health

insurance coverage were similar

between the 1992–1994 period

and the 1993–1995 period—74

percent had continuous coverage

in the latter period, compared with

73 percent in the earlier period;

5 percent were never covered in

each case. The remainder of this

report will focus only on information collected for the 36 months

between February 1993 and

January 1996.

Who Loses Coverage . . .

Key factors influencing a lapse

in coverage are:

Gender – As shown in Figure 2,

over the 36–month interview

period, women were less likely

than men to lack continuous

health insurance coverage—27

percent of women compared with

31 percent of men. This difference

is partially attributable to differences in economic status. Women
Figure 2.

Percent Without Health Insurance for

at Least 1 Month in 36: 1993 to 1996

All persons

Suburb

Nonmetropolitan area

Northeast

Midwest

South

West

High school diploma, no college

One or more years of college

Below poverty

Above poverty

Metropolitan area

Central city

25–34

35–44

45–64

65 and over

Under 18

18–24

No high school diploma

Hispanic origin1

White, non-Hispanic

Black

Male

Female

Sex

Race and HIspanic Origin1

Age2

Education2 (adults aged 18 and over)

Poverty

Type of Residence

Region

1 Persons of Hispanic origin may be of any race.

2 Age and education refer to February 1993.

Figure 3.

Percent Covered for 36 Months by

Income-to-Poverty Ratios: 1993 to 1996

Percent

40

50

60

70

80

90

100

Less

than

1.0

1.0 to

1.99

2.0 to

2.99

3.0 to

3.99

4.0 to

4.99

5.0 to

5.99

6.0 and

over

29

31

27

25

37

50

33

55

36

26

22

1

36

30

22

50

27

29

33

26

30

25

24

34

31

Source: U.S. Bureau of the Census, Survey of Income

and Program Participation, 1993 Panel.

Source: U.S. Bureau of the Census, Survey of Income and Program

Participation, 1993 Panel.

P70-64 3

U.S. Census Bureau, the Official StatisticsTM June 22, 1998

are more likely than men to live in

families with incomes below poverty,2 and are more likely to

participate in means–tested government assistance programs.3

This suggest that woman were

more likely than men to take part

in Medicaid.

A second factor contributing to

the difference in health insurance

coverage between men and

women is age. More women than

men are 65 years old and over,

and virtually everyone in that age

group is covered by Medicare.

Race and Hispanic Origin4 –

The relationship between race

and Hispanic origin and health

insurance was a strong one. The

percentages of people who spent

at least 1 month without health

insurance were 25 percent for

Whites (not of Hispanic origin),

37 percent for African Americans,

and 50 percent for Hispanics.

Age – Young adults (those between the ages of 18 and 24)

were the most likely of any age

group to spend at least 1 month

without health insurance coverage—over one–half (55 percent)

lacked insurance for at least 1

month during the 36–month

period, while 9 percent were

covered for less than 7 months.

Moreover, as age increased

among adults, continuous health

insurance coverage became more

common.

2In 1996, the official poverty rate was

12 percent for men and 15 percent for

women. See Current Population Reports, Series P60–198, Poverty in the

United States: 1996.

3For an average month in 1994, 17

percent of all women participated in

means–tested assistance programs,

compared with 13 percent of all men.

(The source of these estimates is the

1993 SIPP panel.) This suggest that

women were more likely than men to

take part in Medicaid.

4Hispanics may be of any race. The

information on the Hispanic population

shown in this report was collected in the

50 states and the District of Columbia,

and therefore, does not include residents of Puerto Rico.
Figure 4.

Duration of Spells Without Health Insurance

Coverage: 1993 to 1996

Median number of months without health insurance coverage

All persons

Suburb

Nonmetropolitan area

Northeast

Midwest

South

West

High school diploma, no college

One or more years of college

Below poverty

Above poverty

Metropolitan area

Central city

25–34

35–44

45–64

65 and over

Under 18

18–24

No high school diploma

Hispanic origin1

White, non-Hispanic

Black

Male

Female

Sex

Race and HIspanic Origin1

Age2

Education2 (adults aged 18 and over)

Poverty

Type of Residence

Region

1 Persons of Hispanic origin may be of any race.

2 Age and education refer to February 1993.

5.3

5.7

4.8

4.5

5.2

7.4

4.0

5.0

6.5

6.8

5.5

7.1

7.6

6.0

4.0

7.0

4.2

5.2

6.4

4.1

5.8

4.8

4.8

6.1

4.9

Source: U.S. Bureau of the Census, Survey of Income and Program Participation, 1993 Panel.

4 P70-64

U.S. Census Bureau, the Official Statistics TM July 22, 1998

Education – People completing at

least 1 year of college were less

likely to spend at least 1 month

without health insurance coverage

than those with lower levels of

educational attainment. For example, about 22 percent of those

(18 years old and over) completing at least 1 year of college were

without health insurance coverage

for at least 1 month, compared

with 30 percent for those who only

completed high school and 36

percent for those with less than a

high school diploma.

Residence5 – People living in suburban areas were more likely to

have continuous health insurance

coverage over the 36–month

period than people living in central

cities or outside of metropolitan

areas—74 percent of those in the

suburbs had continuous coverage

compared with 68 percent in other

areas.

People residing in the South

were more likely to experience 1

or more months without health insurance coverage than those

living in other regions of the country—34 percent of those living in

the South had a lapse in coverage, compared with 31 percent in

the West, 24 percent in the Midwest, and 25 percent in the

Northeast.6 Perhaps the higher

noncoverage rates in the South

can be partially attributed to higher

concentrations of poor people and

African Americans in the South.

These groups generally have

higher noncoverage rates than

those who are not poor or White.

Poverty Status – Income-to-poverty ratios represent one way of

characterizing individuals by their

relative economic status. These

ratios are computed by summing

the individual’s or family’s income

over the entire 36–month period,

and dividing this total by the

5The term “suburban areas” refers to

portions of metropolitan areas outside of

central cities.

6There was no significant difference between the noncoverage rate in the Northeast and in the Midwest.

summed monthly poverty thresholds. Thus, a ratio of less than 1.0

indicates that, on average, an individual’s family income was less

than the sum of that family’s poverty threshold. In the 36–month

period covered here, 11 percent of

all people had an income-to-poverty ratio less than 1.0. One–half

(50 percent) of them lacked continuous health insurance, and 

9 percent were never covered,

compared with 27 and 3 percent,

respectively, for all others.

As would be expected, there

is a strong correlation between

income-to-poverty ratios and the

likelihood of continuous health

insurance. The percentage of

people with health insurance for

the entire 36 months rose from 51

percent for those with an incometo-poverty ratio less than 2.0 to 90

percent for those with ratios of 6.0

and over (See Figure 3).

Employment Status –The relationship between health insurance

coverage and employment is an

important one, given that firms

provide such a large proportion of

coverage for employees and their

dependents. In order to examine

the relationship between health

insurance coverage and employment status, wage and salary

workers 18 to 64 years old were

separated into three groups:

 Those who worked full time for

the entire period.

 Those who worked for the en-
P70-64 5

U.S. Census Bureau, the Official StatisticsTM June 22, 1998

tire period but not always full time

 Those with one or more job interruptions.7

Eighty–five percent of all full-time,

full–period workers were covered

by health insurance for the entire

period, but within this group there

were significant differences for

non–Hispanic Whites, African

Americans, and Hispanics. The

continuous coverage rates for

these groups were 87, 81, and

71 percent, respectively.

Part-time, full-period workers

were twice as likely than their

full-time counterparts to lack

continuous health insurance coverage—30 percent, compared

with 15 percent.

About 44 percent of workers

with one or more job interruptions

experienced 1 or more months

without health insurance coverage. Men in this category were

more likely than women to lack

health coverage for at least

1 month (51 percent versus 39

percent).

Younger full-time, full-period

workers were less likely than their

older counterparts to have been

covered by health insurance continuously—one–third (33 percent)

of those aged 18 to 24 years old

spent 1 or more months without

health insurance, compared with

19 percent of those aged 25 to 34

and 11 percent of those aged 35

to 44.

 . . . and for How Long?

One of the major concerns regarding health insurance is how

long Americans go without coverage. Using a technique known as

survival analysis, it is possible to

estimate the duration of spells

without health insurance. A median spell of 5.3 months without

health insurance was observed for

7Those individuals who did not work

during the period are not included.

people who lost their health insurance after the beginning of the

36–month period of the 1993 panel. In other words, of all spells

without health insurance (experienced by 29 percent of the

people), half of them lasted for 5.3

months or longer. This was not

significantly different from the

5.7–month median duration of

noncoverage for the 1992–1994

period.

People without health care

for long periods of time

share these characteristics—

Education – Attaining a high level

of education appears, on average,

to shorten the time someone goes

without health insurance (See Figure 4). The median spell of 7.6

months without health insurance

coverage for those without a high

school diploma was much longer

than the 4.0 months of noncoverage for those with at least 1 year

of college.

Age – Among the age groups examined, the median spells of 6.5

months and 6.8 months without

coverage for individuals between

25–34 and 35–44 years of age,

respectively, were significantly

longer than spells for children

under 18.8

Employment Status – As expected, full–time workers had a

significantly shorter median spell

without health insurance than

those employed part time, those

unemployed, or those not in the

labor force—a 4.1–month median

spell of noncoverage for full-time

workers, compared with 7.0

months, 7.7 months, and 7.1

months, respectively, for the

others.9

8No significant difference was observed

between the 25–34 and 35–44 age groups.

9The estimates of 7.2 months, 7.6

months, and 7.1 months are not significantly different.

Note: Detailed tables are

available on the Internet at

<http://www.census.gov/hhes/

www/hlth9394.html>

Accuracy Statement

All statistics are subject to

sampling error, as well as nonsampling error such as survey

design flaws, respondent classification and reporting errors, data

processing mistakes, and undercoverage. The Census Bureau

has taken steps to minimize errors

in the form of quality control and

edit procedures to reduce errors

made by respondents, coders,

and interviewers. Ratio estimation

to independent age–race–Hispanic origin–sex population controls

partially corrects for bias attributable to survey undercoverage.

However, biases exist in the estimates when missed persons have

characteristics different from those

of interviewed persons in the

same age-race-Hispanic origin–

sex group.

Analytical statements in this

report have been tested and meet

statistical standards. However,

because of methodological differences, use caution when

comparing these data with data

from other sources. Contact

Donald Keathley, Demographic

Statistical Methods Division, at

301-457-4182 or on the Internet at

dkeathle@census.gov for information on (1) the source of the data,

(2) the accuracy of the estimates,

(3) the use of standard errors, and

(4) the computation of standard

errors.

Contacts:

Health insurance coverage—

Robert Bennefield

301-457-3242

Statistical Methods—

Donald Keathly

301-457-4182
P70-64 6

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