Which children are still uninsured and why.

Summary A strong economy and increased enrollment in employer-sponsored health insurance coverage, together with expansions in Medicaid and State Children's Health Insurance Program (SCHIP) led to reductions in uninsurance among low-income American children between 1998 and 2000 (from 15.6% to 13.3%). Nonetheless, 12% (about 9 million) of children remained uninsured. Identifying these children and understanding the factors that contribute to their continued lack of health coverage is key to providing them access to health care. Using 1994, 1998, and 2000 census data, this article analyzes recent trends in children's health coverage, as well as the groups that make up the population of uninsured children. The picture that emerges from these analyses is one of tremendous variation in coverage for different groups of children, with some groups having a higher risk for lacking health insurance. For example, poor children, Hispanics, adolescents, and children with foreign-born parents (particularly those whose parents are not U.S. citizens) are overrepresented among the uninsured. The authors conclude that the strong economy and concomitant increase in employer-based coverage played a bigger part in reducing uninsurance rates than did expansions in public programs. They also argue that lack of participation by eligible children rather than inadequate eligibility levels is the key policy issue, and conclude with several recommendations to increase program participation. The late 1990s saw an unprecedented federal and state commitment to reducing uninsurance among children, which culminated in 1997 with the enactment of the State Children's Health Insurance Program (SCHIP). The period also wimessed an unparalleled economic boom. Even so, 9.2 million children--12% of all children nationwide--were uninsured in 2000. (1) Given the adverse consequences of going without insurance (2-4)--such as a lower likelihood of having a usual source of care, greater unmet health and dental needs, lower receipt of preventive services, and higher rates of avoidable hospitalizations (see the article by Hughes and Ng in this journal issue)--the lack of insurance coverage for children is a serious problem in this country. This article sheds light on why so many children remain uninsured in spite of Medicaid and SCHIP programs, which could cover 65% to 75% of all uninsured children, and a period of great economic prosperity. (5) It begins with an analysis of recent trends in children's health insurance coverage, (6) and an analysis of the population of uninsured children. These analyses suggest that specific groups of children will need to be targeted if major inroads are to be made in reducing uninsurance among children. The article closes by discussing the major policy changes needed to increase the participation of currently unenrolled children. Recent Trends in Children's Health Insurance Coverage Children's insurance coverage is influenced by a host of factors, including access to public and private coverage, and the sociodemographic characteristics of children and their families. (7-9) The 1990s were characterized by a number of shifts in these underlying factors that combined to produce a decline in the rate of uninsurance among children, from 14.5% in 1994 to 13.3% in 2000. (10) The primary factor in this decfine, however, was the large increase in employer-sponsored insurance (ESI) coverage of children, not expanded access to public insurance programs. Moreover, the decline would have been even greater if not for two important demographic changes: growth in the share of children who are Hispanic or "other" race/ethnicity, and growth in the percentage of children age six and older. Because these groups have higher rates of uninsurance, as the number of children in them increased, more children were at risk of not being covered. Shifts in Reliance on Public and Private Coverage Between 1994 and 2000, ESI coverage of children expanded from 60. …