States vary widely in percentage and composition of uninsured
States vary widely in percentage and composition of uninsured
While much attention is paid to the problems of children without health insurance, there is a higher rate of uninsured adults whose problems do not get nearly as much notice.
According to a recent Urban Institute analysis of 1997 National Survey of America’s Families data, 17% of adults lacked health insurance that year, compared with 12% of children. There were 27 million uninsured adults, nearly three times as many as uninsured children. The Urban Institute is based in Washington, DC.
Of those with incomes below the federal poverty level, 42% of adults lacked health insurance, compared with 21% of children. Of those with incomes between 100% and 199% of the federal poverty level, 34% of adults lacked insurance vs. 21% of children. The Urban Institute policy brief breaks out the adult uninsured population by a variety of demographic characteristics:
• Income and family type. Compared with adults without children, those with children are more likely to be covered by Medicaid and less likely to have employer-sponsored or private, nongroup coverage. As income rises, public coverage is replaced by private coverage, and the number of those who are uninsured declines. A noticeable shift in employer-sponsored coverage occurs at the poverty level, below which only 22% of all adults report employer-provided coverage, compared with 47% of those living in families with incomes between 100% and 199% of the poverty level.
• Age. Adults between the ages of 18 and 34, particularly males, have a higher uninsurance rate (47%) than older age groups. Females in that age group have an uninsurance rate of 38%. The institute report says the lower rate for females is primarily due to the greater likelihood of Medicaid coverage. Older adults ages 55 to 64 are only a small segment of the uninsured. Low-income adults ages 55 to 64 are uninsured at a rate of 23% but account for only 8% of the low-income uninsured population and 5% of all uninsured.
• Race/ethnicity. The Urban Institute says there is a strong relationship between race/ethnicity and lack of health insurance among low-income adults and adults in general. Of low-income white non-Hispanics, 31% are uninsured, accounting for 50% of the low-income uninsured and 31% of the entire uninsured population. Black non-Hispanics have a 34% uninsurance rate, accounting for 16% of the low-income uninsured. The highest rate of uninsurance, 53%, is among low-income Hispanics, who account for 29% of the low-income uninsured and 19% of the total uninsured population.
• Family structure. The likelihood of being uninsured does not vary greatly by family structure for low-income adults. Because they have more public coverage, low-income single parents have the lowest uninsurance rate of the four groups at 33%. Low-income single adults without children have an uninsurance rate of 40%, accounting for 25% of all uninsured adults.
• Work status. The data show that most of the uninsured are in families with at least one full-time worker. Among those with incomes below 200% of the federal poverty level, 39% of families with a full-time worker are uninsured, and those with two or more full-time workers are uninsured at a 37% rate. Low-income adults in families with at least one full-time worker accounted for 65% of the low-income uninsured and 41% of the total uninsured population. By contrast, low-income adults in families with no workers accounted for only 21% of the low-income uninsured and 13% of the uninsured population totally.
• Health status. Those reporting excellent or very good health status have a lower rate of noninsurance (32%) than those who said they were in good, fair, or poor health (41%). The Urban Institute says this is surprising since those in fair or poor health could be assumed to be more willing to pay for coverage.
• Access to care. Even after controlling for a number of factors that might affect health care access and utilization, there is a strong relationship between the lack of health insurance and various measures of access. For instance, the uninsured are more than twice as likely to say they don’t have a usual source of care (even including a hospital emergency department) and to lack confidence in their ability to access health care services. In addition, the uninsured are significantly more likely to be in fair or poor health, to have unmet needs for medical care or surgery, not to have had a physician or other health professional visit, and to lack satisfaction in quality of care received. The Urban Institute says these data show that good health or lack of a need to access health care services are not the reasons why low-income adults lack health insurance and run counter to the perception that the uninsured are able to obtain needed health care.
• Variation across states. The noninsurance rate among low-income adults varies considerably across states, the survey data show.
The proportion of uninsured adults ranged in 1997 from a low of 21% in Minnesota to highs of 44% in California and 50% in Texas. In general, the Urban Institute says, there is an inverse relationship between employer-sponsored coverage and the uninsured rate in each state. Also, coverage by Medicaid and state programs also clearly matters. For example, Minnesota has an above-average, 44% employer-sponsored coverage and 23% Medicaid/state coverage, resulting in a low rate of uninsurance among low-income adults. At the other end, Texas has below-average rates of employer-sponsored and Medicaid/state coverage (32% and 11%), leading to a high uninsurance rate.
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