Children without Health Insurance

Abstract

Data from two nationally representative household surveys—the 1977 National Medical Care Expenditure Survey (NMCES) and the 1987 National Medical Expenditure Survey (NMES)—are used to examine changes in children’s health insurance status over the past decade. The consequences of disparities in children’s health insurance status for their use of health services in each of these years and over time is explored. The data demonstrate that children were more likely to lack health insurance in 1987 than in 1977, that in both years children without insurance were at a disadvantage in their use of health services relative to their insured counterparts, and that over time, health service use by uninsured children declined relative to that by children with private or public coverage. Because of the vulnerable health status of children and the importance of children’s health care, the authors assess how the number of uninsured children might be affected by two frequently discussed policy alternatives: mandated employment-related coverage and incremental Medicaid expansions. They conclude that combining an employer mandate with a Medicaid expansion for some children whose parents are ineligible for an employer mandate appears to have the greatest potential for reducing the number of uninsured children. I n a 1991 report describing the welfare of children in the United States, members of the National Commission on Children observed that “perhaps no set of issues moved members of the National Commission more than the wrenching consequences of poor health and limited access to care.” As has been well documented, the consequences of limited access to health care manifest themselves through a variety of child health problems at all stages of child development. Limited prenatal care increases the risk of low birth weight, premature births, and other adverse outcomes, all of which are associated with infant mortality or contribute to developmental disabilities. Because of poor access to preventive health services, fewer than 70% of white children and less than half of black children 1 to 4 years of age received immunizations against common childhood diseases (DPT, polio, measles, mumps, and rubella) in 1985. The proportion of 2-year-olds immunized has declined from 1980 levels and falls short of the goal established by the Surgeon General of the United States of immunizing 90% of all 2-year-old children by 1990. Finally, limited access to health care services by school-age and adolescent children may reduce the frequency of periodic health assessments and, therefore, the ability of parents and physicians to monitor the physical growth, weight, and By reducing the out-of-pocket costs of health care, nutrition of children; to screen for private and public health insurance coverage possible child abuse and neglect; to play a critical role in improving children’s access detect learning disabilities and poto health care services. tentially debilitating mental health problems; and to provide children with sex education and with education regarding drug and alcohol abuse. (See the article by Perrin, Guyer, and Lawrence in this journal issue.) By reducing the out-of-pocket costs of health care, private and public health insurance coverage play a critical role in improving children’s access to health care services. Depending on the breadth and generosity of coverage, health insurance may enhance access both to preventive care and to services that address acute and chronic health problems. Consequently, concern over disparities in children’s use of health services must necessarily focus on their health insurance status. In this paper, we use data from two nationally representative household surveys, the 1977 National Medical Care Expenditure Survey (NMCES) and the 1987 National Medical Expenditure Survey (NMES), to examine changes in children’s health insurance status over the past decade. We also explore the consequences of disparities in children’s health insurance status for their use of health services in each of these years and examine how their use of health services has changed over time. NMCES and NMES are particularly well suited for this purpose because each survey contains detailed information about the health care use, expenditures, health insurance coverage, and demographic characteristics of the civilian noninstitutionalized population and because each survey has been designed to produce national estimates of health care use and expenditures. These data demonstrate that over this period children were more likely to lack health insurance in 1987 than in 1977, that in both years children without insurance were at a disadvantage in their use of health services relative to their insured counterparts, and that over time, health service use by uninsured children declined relative to that of children with private or public coverage. 156 THE FUTURE OF CHILDREN – WINTER 1992 Children’s Health Insurance Status: 1977 and 1987 In the decade between 1977 and 1987, the likelihood that a child less than 18 years of age would be covered by private or public health insurance declined sharply. Estimates for the first quarter of 1977 and 1987 indicate that the percent of uninsured children increased by some 40%— from 12.7% to 17.8%—or by 3.1 million children. This increase in the number of uninsured children reflects the decline in the percentage covered by private, largely employment-related coverage, and the fact that fewer children in single-parent households were eligible for public insurance programs such as Medicaid. As we have discussed elsewhere, these changes in children’s health insurance status reflect a number of social, legislative, and economic influences over the past 2 decades. In 1987, 25% of all children lived in single-parent households compared to 17% in 1977. Their parents were far less likely to receive an offer of employment-related health insurance than were the parents of children in two-parent households. Figure 1. Annual Health Insurance Status of Children, 1977 and 1987 Uninsured All Year 8.8% Uninsured Part Year 8.7% Public Insurance 10.9% Public and Private Insurance 0.6% Private Insurance 71%