This Article Abstract Reprint (PDF) Submit a response to this article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to Citation Manager Reprints & Permissions Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (6) Citing Articles via Google Scholar Google Scholar Articles by Hanson, K. L. Search for Related Content PubMed PubMed Citation Articles by Hanson, K. L. Related Collections Access To Care Managed Care - Medicaid Medicaid State/Local Issues

DataWatch

Patterns Of Insurance Coverage Within Families With Children

Abstract

 
This paper examines patterns of health insurance within families with children, using the 1996 Medical Expenditure Panel Survey (MEPS). Four and a half million families (14 percent) had insurance for some, but not all, family members. These partially insured families generally obtained coverage because of one of three situations: (1) A parent earned relatively higher wages and received the concomitant benefits of such jobs but could not afford dependent coverage; (2) the family had young children who were covered by Medicaid through more generous eligibility thresholds for children under age six, while other family members were ineligible; or (3) the family had a member who was eligible for public coverage because of a disability. Each of these situations offers the platform from which incremental policies might efficiently expand coverage to families.

This paper examines the health insurance patterns observed within families with children in 1996, focusing on the partially insured. I first compare family characteristics across groups and then form hypotheses about important attributes associated with partial insurance. Finally, I discuss the implications of various policy options for expanding insurance to more family members.

Study Methods

Top Study Methods Study Findings Avenues For Coverage Expansions NOTES

 
This study used data from the 1996 Medical Expenditure Panel Survey (MEPS), a nationally representative sample of U.S. households. A family is defined as any unit that included a child age eighteen or younger living with at least one parent. Mothers and fathers were identified at the time of the survey and include biological, adoptive, and stepparents. Only children and their parents were included in the analyses. Information from multiple family members was concatenated into one family-level record. The sample included 3,231 families with a total of 6,086 children and 5,417 adults, who represent 32.9 million families nationally.⁶

Insured persons are those with any type of health insurance coverage at any time during the round-one interview process (typically the first three and one-half months of the year). Families were subsequently categorized as being totally insured, completely uninsured, or partially insured. The partially insured group was further refined according to which family members had the coverage: one or two parents only, all of the children only, all of the children and one parent (in two-parent families), or some children and not others, irrespective of parental insurance status. Sources of coverage were placed into three mutually exclusive, hierarchical categories: any private health insurance, Medicaid (with or without other public coverage), and other coverage only. For families, the percentage of insured family members in each coverage category was calculated.

Characteristics were compared across insurance groups using one-way analysis of variance and chi-square analysis. Data were weighted using family-level weights provided with the data.⁷ Standard errors were computed to adjust for complex sample design.⁸

Study Findings

Top Study Methods Study Findings Avenues For Coverage Expansions NOTES

 
The vast majority of families (77 percent) were totally insured (Exhibit 1). However, 10 percent (3.2 million) were completely uninsured, and 14 percent (4.5 million) were partially insured. Overall, totally insured families were most likely to have two parents, with older mothers (age thirty-seven) who had thirteen years of education, on average. Both mothers and fathers in these families were likely to be employed and, if employed, to work full time earning more than $7 per hour. All members of fully insured families tended to be in better health.

I observed no significant differences in the health status of mothers in the two groups. Fathers in the partially insured group were much more likely than those in the completely uninsured group were to be in fair or poor physical and mental health. Likewise, partially insured families were more likely to have a child in fair or poor physical and mental health.

Insurance in partially insured families. The study found four distinct insurance patterns among partially insured families. Most often one or two parents were covered while the children remained uninsured (1.6 million families) (Exhibit 2). In 29 percent (1.3 million) of partially insured families, all of the children were insured but not the parent(s). In the remaining such families, the children and one parent had coverage (18 percent, or almost 800,000, all of which were two-parent families), or some children and not others were insured, irrespective of the parents’ insurance status (17 percent, or 770,000 families).

In contrast, the other types of partially insured families were more likely to have coverage through Medicaid. In families where only the children were covered, 65 percent of the coverage was provided through Medicaid. These families were least likely to have two parents, and working parents in these families earned low wages. Families in which only some children had health insurance also were likely to have Medicaid coverage (66 percent). Most notably, these families were likely to have a child in fair or poor health.

Families with insurance for only one of the two parents and for all of the children were less predictably described. Half of the coverage for this group came from private sources (52 percent) and half from Medicaid (46 percent). In half of these families, both parents were employed, which increased the likelihood of their having some employment-based coverage. These families also were most likely to have young children; this increased their access to Medicaid through its more generous eligibility for pregnant women and young children. These two subgroups of families, with coverage from different sources, could not be separated, because of small sample sizes.

Avenues For Coverage Expansions

Top Study Methods Study Findings Avenues For Coverage Expansions NOTES

 
The limited availability and high cost of employment-based health insurance coverage, as well as the circumscribed nature of public efforts to expand coverage, have created a patchwork of health insurance options; as a result, 4.5 million families are only partially insured. The similarities observed between partially insured and completely uninsured families are not surprising, given the spells that individuals experience with and without health insurance.⁹ The major ways in which partially insured families differed from completely uninsured families reflect the various available routes to health insurance and suggest several incremental policy changes to support whole-family coverage.

Relatively higher wages. To reduce their cost-sharing burden, families with relatively higher wages and the concomitant benefits of such jobs may choose coverage for only the worker, or those with only one child may opt for worker-plus-one-dependent plans (when available) instead of whole-family coverage. Subsidies to employees or employers to assist families in purchasing offered job-based coverage for themselves and their dependents could turn these partially insured families into totally insured families. Furthermore, supporting job-based whole-family coverage may require fewer public funds than would securing coverage through public means for only the children in a family.¹⁰

Young children. While Medicaid eligibility for all children under age nineteen with family incomes below the poverty level will be completely phased in by 2002, federally mandated thresholds still will remain more generous for pregnant women and for children under age six.¹¹ Demonstration project waivers and programs funded only with state funds have allowed many states to expand Medicaid eligibility beyond these minimums. New flexibility in federal welfare law offers states the opportunity to expand Medicaid eligibility to more low-income parents, by allowing broad discretion in defining what counts as income and assets and by extending eligibility to more two-parent families.¹² Similarly, federal SCHIP funds can be used to provide coverage to low-income parents of SCHIP enrollees, in states that can meet some fairly rigorous guidelines.¹³ Such expansions in public coverage could reduce the number of partially insured families, while also easing the enrollment in public coverage for families that may be eligible but haven’t taken up coverage.

Disability. Medicaid eligibility determination for disabled persons is separate from standard income guidelines, often leaving remaining family members uninsured. Furthermore, parents who experienced a job-related disability may continue to receive employer coverage, while cost sharing for dependent coverage may become prohibitively costly because of reduced income.

Families with coverage only for disabled family members pose an interesting problem for expanding coverage to uninsured parents and children. Disabled children or parents clearly need access to the special services necessitated by their impairment. The link of that disabled child or parent with public coverage, however, should not be overlooked as a potential avenue through which to reach other uninsured family members.

Policies that expand partial family insurance into whole-family coverage present opportunities to simplify increasingly complex family insurance arrangements and efficiently use public funds. Such steps may ease enrollment of children and parents into public coverage, provide continuity of benefits and provider networks across family members, and, therefore, take advantage of the inherent link between parents’ and children’s patterns of health care use.

Editor's Notes

 
Karla Hanson is an assistant professor at the Robert J. Milano Graduate School of Management and Urban Policy, New School University, in New York City.

This study was supported by the Commonwealth Fund Findings from this study were presented at the annual meeting of the Association for Health Services Research (AHSR), Los Angeles, June 2000.

NOTES

Top Study Methods Study Findings Avenues For Coverage Expansions NOTES

 

1. Coverage differences between parents and children may present problems in navigating different payment systems or provider networks. Such issues also might arise in families that are fully insured through multiple sources. These subtler issues are not addressed in this paper.
2. P. Newacheck and N. Halfon, "The Association between Mothers’; and Children’s Use of Physician Services," Medical Care 24, no. 1 (1986): 30–38; A.S. Bates et al., "Risk Factors for Underimmunization in Poor Infants," Journal of the American Medical Association 272, no. 14 (1994): 1105–1110; and M. Kogan et al., "The Association between Adequacy of Prenatal Care Utilization and Subsequent Pediatric Utilization in the United States," Pediatrics 102, no. 1 (1998): 25–30.
3. K.L Hanson, "Is Insurance Enough? The Link between Parents’; and Children’s Health Care Use Revisited," Inquiry 35, no. 3 (1998): 294–302.
4. T. Giovannini, "Heterogeneity in Family Health Insurance Coverage: Are There Implications for Access to Care?" (Presentation at the 1999 annual meeting of the AHSR, Chicago, June 1999).
5. L. Ku and M. Broaddus, The Importance of Family-Based Insurance Expansions: New Research Findings about State Health Reforms (Washington: Center on Budget and Policy Priorities, September 2000).
6. Insurance information was unavailable for 115 individuals in 111 families (3.3 percent), who were excluded from the sample.
7. Agency for Health Care Policy and Research, Center for Cost and Financing Studies, MEPS HC-004: 1996 Panel Employment Data and Family-Level Weight for 1996—File Documentation (Washington: AHCPR, January 1999).
8. B. Shah et al., SUDAAN User’s Manual Release 5.50 (Research Triangle Park, N. C.: Research Triangle Institute, 1991).
9. P.P. Short, J. Cantor, and A. Monheit, "The Dynamics of Medicaid Enrollment," Inquiry 25, no. 4 (1988): 504–516; and Linda Bilheimer, Congressional Budget Office, presentation at conference on Coordinating Children’s Health Insurance Programs with Employer-Based Coverage, sponsored by the Institute for Health Policy Solutions and the National Governors’ Association, in Washington, B.C., 5 October 1999.
10. M. Reynolds, Massachusetts Division of Medical Assistance, presentation at 5 October 1999 conference.
11. Center on Budget and Policy Priorities, Medicaid Income Eligibility Guidelines for Children (Washington: CBPP, May 1998).
12. J. Guyer and C. Mann, Taking the Next Step: States Can Now Take Advantage of Federal Medicaid Matching Funds to Expand Health Care Coverage to Low-Income Working Parents (Washington: Center on Budget and Policy Priorities, 1998); and J. Guyer and C. Mann, A New Opportunity to Provide Health Care Coverage for New York’s Low-Income Families (New York: Commonwealth Fund, July 1999).
13. S. Cohan, State Tools to Provide Family Health Insurance Coverage (Washington: National Governors’ Association, January 1999).

                      What's this?

This article has been cited by other articles:

				J. P. Vistnes and B. S. Schone Pathways To Coverage: The Changing Roles Of Public And Private Sources Health Aff., January 1, 2008; 27(1): 44 - 57. [Abstract] [Full Text] [PDF]

				J. B. Mitchell, S. G. Haber, and S. Hoover Premium Subsidy Programs: Who Enrolls, And How Do They Fare? Health Aff., September 1, 2005; 24(5): 1344 - 1355. [Abstract] [Full Text] [PDF]