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3. Who Goes Without Health Insurance? Who Is Most Likely To Be Uninsured?
Pages 58-99

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From page 59...
... In addition to the public surveys and databases conducted and maintained by federal agencies such as the Bureau of the Census and the Department of Health and Human Services, surveys and studies of insurance coverage and uninsured persons are supported by the Employee Benefit Research Institute, the Commonwealth Fund, the Kaiser Commission on Medicaid and the Uninsured, the Urban Institute's Assessing the New Federalism project, and The Robert Wood Johnson Foundation through the Community Tracking Study conducted by the Center for Studying Health System Change.
From page 60...
... Families with at least one full-time, full-year worker are more than twice as likely to have health insurance coverage, compared to families whose wage earners work part-time Hess than 35 hours per week) , as contingent labor (e.g., on a
From page 61...
... The availability of health insurance in the workplace is the most important factor in determining whether wage earners and their families are insured. Yet more than half of the uninsured under age 65 years are members of families with one full-time, full-year worker.
From page 62...
... Most uninsured wage earners are lower income (earning less than 200 percent of FPL) or moderate income (between 200 and 400 percent of FPL)
From page 63...
... Many members of lowerincome families are not eligible for public insurance, yet they are not offered nor can they afford to buy employment-based or individual health insurance. In addition, the number and relative sizes of salaries that make up a family's income may determine whether employment-based health insurance is offered at all.
From page 65...
... between 1977 and 1998. Primary wage earners who did not complete high school experienced an 18 percentage point decline in employment-based coverage rate (from 52 percent to 34 percent)
From page 66...
... FIGURE 3.6 Probability of being uninsured for adults (ages 19-64 years) , by level of educational attainment, 1999.
From page 67...
... In addition to the job characteristics related to work status, the occupation of a family's primary wage earner influences the likelihood that members will be uninsured (McDonnell and Fronstin, 1999~. Uninsured rates vary dramatically with regard to occupation: while almost half of all wage-earners working in private households (maids and domestic laborers)
From page 68...
... Fronstin and Helman, 2000~.4 Of the six out of every ten uninsured persons who are wage earners, 46 percent are self-employed or work for private-sector firms with fewer than 25 employees; the uninsured rate for this subgroup is 28 percent (Figures 3.7 and 3.8) (Fronstin, 2000d)
From page 69...
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From page 70...
... . However, the highest uninsured rate is found among members of families whose primary wage earner works in employment sectors such as agriculture, forestry, fishing, mining, and construction.
From page 71...
... . The age distribution of children without health insurance coverage is similar to the age distribution of children in the general population.
From page 72...
... For young adults who are not wage earners, family income is a key factor affecting their likelihood of being uninsured. Families covered by employment-based health insurance often extend coverage to children who are supported as full-time college students (usually through age 23~.
From page 73...
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From page 74...
... Midlife adults are less likely to go without health insurance than are members of the population overall, yet their risk is of particular concern because of their collective decline in income; their transition in work status from full-time, fullyear work to contingent labor or retirement; and their decline in health status, accompanied by increased spending for health services (GAO, 1998; Brennan, 2000~. During 1996, about one-third of midlife adults with family incomes under $10,000 were uninsured.
From page 75...
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From page 76...
... Wage-earners who retire before age 65 because of a health condition may find themselves uninsured if their employer does not offer retiree coverage, if the cost to continue enrollment in the employer's plan is prohibitive, or if individual insurance coverage is too costly or not available. Children Federal and state policies have given high priority to providing health insurance opportunities for children, yet the uninsured rate for children is almost 14 percent and an estimated two-thirds of all uninsured children are believed to be eligible for public insurance (Broaddus and Ku, 2000; Mills, 2000~.
From page 77...
... Furthermore, the family income of married couples, like that of two-parent families, may reflect the contribution of more than one wage-earner, giving a potential economic advantage in comparison with the family incomes of single people and single parents. As a result, married couples may be more likely to find that health insurance premiums are affordable (Figure 3.14~.
From page 78...
... Between 1976 and 1996, there was little change in children's uninsurance rates among two-parent working families, but there was an 8 percentage point increase in the uninsured rate for children in single-parent working families (Weinick and Monheit, 1999~. Single parents tend to be young adults, which compounds the likelihood that they will lack coverage.
From page 79...
... Single Adults Married Single Living Together Multi- 1 Parent 2 Parents General generational Population and Other Under Age 65 FIGURE 3.16 Probability of being uninsured for population under age 65, by family composition, 1999. SOURCE: Hoffman and Pohl, 2000.
From page 80...
... is significantly more likely than U.S.-born residents to be uninsured, although immigrants' uninsured rates decline with increasing length of residency in the United States. Residency status, family income, and length of residency in the United States are important influences on the likelihood that a person will lack insurance coverage (Carrasquillo et al., 2000~.
From page 81...
... residents reflect the lower rates of employment-based coverage among immigrants, which in turn is linked to greater-than-average likelihood employment in lowerwaged positions (paying $7 or less per hour) and work in employment sectors with lower-than-average coverage rates (Carrasquillo et al., 2000~.7 Among full-time wage earners, 51 percent of noncitizen immigrants had employment-based coverage, compared with 76 percent of naturalized citizens and 81 percent of U.S.-born residents.
From page 82...
... For example, there are concentrations of Mexican immigrant workers in agriculture, which has a higher-than-average uninsured rate, while Filipino immigrants often work in the health care industry, which has a lower-than-average uninsured rate. For members of families headed by foreign-born persons who are not offered employment-based insurance and who are priced out of the individual insurance market, restrictive immigration and welfare policies enacted in the past five years have made public coverage increasingly difficult, if not impossible, to obtain.
From page 83...
... Higher uninsured rates among members of racial and ethnic minority groups are a consequence of lower rates of employment-based coverage and higher proportions of lower-income families within each group (Figures 3.19, 3.20, and 3.21~. These rates are only partially offset by higher rates of public insurance coverage (Gabel, 1999; Brown et al., 2000a; Monheit and Vistnes, 2000; Shi, 2000b)
From page 84...
... 84 CO VERA GE MA TTERS: INSURANCE AND HEALTH CARE Estimated 42.1 Million Uninsured People = 100.0 Asian American American Indian 5.2% 1.8% Non-Hispanic African American 17.1% Hispanic 25.8% Non-Hispanic White 50.2% FIGURE 3.19 Distribution of uninsured population under age 65, by race and ethnicity, 1999. NOTE: Numbers may not add to 100.0 percent due to rounding.
From page 85...
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From page 86...
... For family members of primary wage earners who decline to purchase employment-based coverage, 34 percent receive employment-based coverage through other fancily members, 3 percent purchase individual coverage, 17 percent receive public insurance, and 46 percent remain uninsured (Custer and Ketsche, 2000b)
From page 87...
... . Much of the high uninsured rate for African Americans is a consequence of a lower rate of employment-based coverage, even though primary wage earners in African-American families tend to work for larger-sized firms and in employment sectors with higher coverage (Brown et al., 2000a)
From page 88...
... When a primary wage earner declines job-based coverage, 31 percent of family members obtain employmentbased coverage through another family member, 3 percent purchase individual coverage, 29 percent obtain public insurance, and 37 percent remain uninsured (Custer and Ketsche, 2000b)
From page 89...
... Rates for employment-based health insurance coverage vary considerably, with lower rates for Koreans and Vietnamese (and uninsured rates correspondingly high, greater than 30 percent) and higher rates for Japanese and families with residency extending over multiple generations (Carrasquillo et al., 2000~.
From page 90...
... There is much to be learned about what influences regional variation in uninsurance rates. A multivariate analysis of 60 communities across the United States, whose uninsured rates ranged from 5 to 29 percent, found that "population characteristics, employment, and unexplained or unmeasured geographic variations account for most of the differences" (Cunningham and Ginsburg, 2001~.
From page 93...
... 93 - ~ CD Ct o ~ Aeon (I, ~ ~ U3o ~ .O o U.— a: i ,~.
From page 94...
... The difficulties that small businesses face in purchasing affordable health insurance policies for their employees account for much of the disparity in coverage between rural and urban wage earners (Coburn et al., 1998; Mueller et al., 1998; Pol, 2000~. In addition, rural uninsured workers are more likely to be employed by lower-waged firms, to work on a contingent basis, and to work in particular employment sectors (e.g., agriculture)
From page 95...
... In addition, rates of unionization are lower, and greater proportions of wage earners are in employment sectors with relatively high uninsured rates, such as sales. The immigrant status of residents distinguishes MSAs with high uninsured rates from those with low uninsured rates.
From page 96...
... In the multivariate analysis carried out by the Committee, much of the variation in uninsured rates among individuals and among population groups is associated with the following measured characteristics: income, occupation, employment sector and firm size of employer, education, health status, age, gender, race and ethnicity, citizenship status, and geography. However, large and statistically significant differences in uninsured rates remain after this analysis, and the variation in uninsured rates among population groups is not eliminated completely.
From page 97...
... More than 40 percent of the difference in uninsured rates between families with primary wage earners who have not graduated from high school and families whose primary wage earners have post-college education would be eliminated if these families resembled one another demographically, geographically, and in terms of health status.l3 Immigrant and nativity status have a pronounced influence on differences in uninsured rates among groups. Nearly 60 percent of the difference between uninsured rates for U.S.-born residents and naturalized citizens would disappear if naturalized citizens as a group shared the socioeconomic, demographic, health status, and geographic distribution characteristics of the U.S.-born population.l4 Differences between uninsured rates diminish when multivariate analysis is used to compare the population of long-term residents who are not citizens with persons born in the United States (a 26 percent decrease)
From page 98...
... A snapshot of the uninsured population gives us a portrait that reflects the relative size of population groups within the general population under age 65. More than 80 percent of uninsured persons are wage earners or members of working; families, and two-thirds are members of lower-income families (earning less than 2()
From page 99...
... WHO GOES liVITHOUT HEALTH INSURANCE? 99 for by the commonly measured factors that most directly affect the chances of having health insurance.


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