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This is the second of a five-part
series by the Center for Economic and Policy Research (CEPR) on access to health
insurance in the United States. Other Data Briefs in this series examine access
to health insurance generally, changes in the share of Americans receiving
employer-provided health insurance for employees, changes in the share of
Americans receiving employer-provided health insurance as a dependent on another
family member’s plan, and interactions between the private and public
health insurance systems. The first Brief details policy options available to
expand coverage to include the nearly 70 million Americans who did not have
health insurance during all of 2002.
The data used in this series
come from CEPR’s analysis of the Survey of Income and Program
Participation. CEPR creates user-friendly Data Sets from this survey and makes
the data and programs available to the public via our website
(www.cepr.net).
David Maduram provided valuable research assistance
on this project.
This project was funded by a generous grant from the
Rockefeller Foundation.
Nearly 70 million Americans were
without health insurance coverage at some point during 2002. Three-quarters
(75.8 percent) of Americans had health insurance for all of 2002. Two-thirds of
Americans (63.5 percent) had private health insurance for all of 2002 and
one-in-five (18.4 percent) received health insurance from one of the two main
government health programs Medicaid, for low-income individuals, or Medicare,
for those ages 65 and over.
Health insurance coverage varies
across demographic groups. Children and young adults are less likely to have
coverage than are the elderly or older adults. In 2002, only about half (55.4
percent) of young adults (ages 18 to 24) had health insurance all year, compared
to three-quarters (76.0 percent) of adults ages 35 to 44. Latinos are less
likely to have coverage than are other racial/ethnic groups. In 2002,
four-fifths of white adults had health insurance all year, compared to two
Latino adults in five (38.5 percent). Overall, women are slightly more likely
than men to have health insurance, and more likely than men to receive coverage
through Medicaid.
Over the economic boom of the 1990s, health
insurance coverage increased. However, coverage fell back during the most recent
economic contraction. The decline in coverage over the economic contraction was
due to falling private health insurance coverage. Medicaid coverage increased,
especially for children.
The overwhelming majority of those without
health insurance coverage report that they are not covered because it is too
expensive. This is true across demographic groups. Only a small share of those
uncovered – around five to seven percent – report that they either
“don’t want” or “don’t need” health
insurance coverage. Thus, the lack of coverage for so many Americans is indeed
a hardship and most people would prefer to be covered, rather than not.
It is has been reported that
there were “44.6 million people without health insurance coverage during
the entire year in 2002” (Mills and Bhandari 2003). However, since this
figure represents the number of Americans who did not have health insurance
at all during 2002, it leaves open
questions about how many Americans were fully covered by health insurance all
year. The share of Americans with health insurance coverage
all year in 2002 was 75.8 percent,
leaving 69.5 million Americans without health insurance at some point in 2002.
Looked at this way, lack of health insurance coverage is more of a
problem.
This report uses data from the Survey of Income and Program
Participation to address how health insurance coverage varies across demographic
groups and how this has changed from the early 1990s through the early 2000s.
Most people access health insurance through private insurance, except for the
elderly who have nearly universal coverage under Medicare. Health insurance
coverage differs across age groups and along racial/ethnic lines. Children are
less likely to have coverage than are adults, and young adults (ages 18 to 24)
are the least likely adults to have health insurance coverage. Latinos are far
less likely than other groups to have coverage and have been hit especially hard
over the course of the most recent recession. This is true even once we account
for other demographic differences across racial/ethnic groups. For those without
health insurance, the overwhelming majority reports that health
insurance’s high cost is what prohibits them from obtaining coverage.
In the United States, people
receive health insurance from one of three main sources: employer-provided
health insurance, or through one of the two main government programs, Medicare
(for those age 65 and over) or Medicaid (for low-income individuals). While the
vast majority of adults and children receive health insurance through private
plans, Medicare provides nearly universal coverage of the elderly as well as
many disabled Americans. As a result, in 2002, while nearly one-third of
children did not have health insurance all year, nearly all – 98.1 percent
– of the elderly had coverage all year. Nearly two-thirds of the elderly
also have private health insurance, so this age group has a high level of access
to the health care system (Table 1).
Children, however, are not so
lucky. Less than three-quarters (71.4 percent) of children had health insurance
coverage all year in 2002. In 2002, a little over half – 54.5 percent – of children had private health insurance and
14.0 percent had Medicaid all year.
Table 1.
All Year insurance coverage
|
|||||||||||
|
All year |
||||||||||
|
Any
insurance
|
|
Private
insurance
|
|
Medicaid/Medicare
|
||||||
|
1992
|
1999
|
2002
|
|
1992
|
1999
|
2002
|
|
1992
|
1999
|
2002
|
All
|
74.9%
|
79.1%*
|
75.8%*
|
|
63.8%
|
68.3%*
|
63.5%*
|
|
18.2%
|
17.7%*
|
18.4%*
|
Children (under
18)
|
73.9
|
74.9*
|
71.4*
|
|
60.2
|
62.6*
|
54.5*
|
|
12.9
|
10.6*
|
14.0*
|
Adults (18 - 64)
|
70.8
|
77.1*
|
73.3*
|
|
65.2
|
71.3*
|
67.3*
|
|
5.7
|
6.1*
|
5.8*
|
Age group
|
|||||||||||
18
- 24
|
56.5
|
61.2*
|
55.4*
|
|
50.1
|
55.9*
|
55.4*
|
|
5.6
|
4.7*
|
5.0*
|
25
- 34
|
64.6
|
68.5*
|
64.6*
|
|
58.2
|
63.0*
|
59.1*
|
|
6.0
|
5.1*
|
4.4
|
35
- 44
|
75.4
|
80.1*
|
76*
|
|
71.1
|
75.3*
|
70.6*
|
|
4.3
|
4.9*
|
4.7
|
45
- 54
|
77.8
|
85.0*
|
80.6*
|
|
73.2
|
79.8*
|
75.1*
|
|
4.8
|
5.8*
|
5.6
|
55
- 64
|
79.1*
|
86.9*
|
94.1*
|
|
71.8
|
77.9*
|
75.7*
|
|
9.0
|
11.6*
|
10.1*
|
Elderly (over
65)
|
98.7
|
98.3*
|
98.1*
|
|
64.4
|
65.1*
|
63.3*
|
|
95.4
|
93.2*
|
93.4*
|
Source: CEPR analysis of
Survey of Income and Program Participation, 92, 99, and 02 panels.
|
|||||||||||
Note: Universe is all
individuals.
|
|||||||||||
*Indicates that change from
past year is significant at the 5 percent level
|
Adults (ages 18 to 64) are only
slightly more likely than children to have health insurance coverage all year.
In 2002, 73.3 percent of adults were covered, with 67.3 percent covered by a
private plan and 5.8 percent with Medicaid. Young adults (ages 18 to 24) are
less likely to have coverage than are older adults. In 2002, 76.0 percent of
adults ages 35 to 44 had health insurance all year, compared to only 55.4
percent of young adults. The Centers for Disease Control reports that nearly 60
percent of all first births are to mothers aged 18 to 24, underscoring the
importance of health insurance for this age
group.
Table 2.
Partial Year insurance coverage
|
|||
|
At all during year |
||
|
1992
|
1999
|
2002
|
All
|
90.6%
|
91.6%*
|
92.1%*
|
Children (under
18)
|
91.2
|
92.5*
|
94.7*
|
Adults (18 - 64)
|
88.6
|
89.6*
|
89.5*
|
Age group
|
|||
18
- 24
|
86.2
|
85.2*
|
85.1
|
25
- 34
|
85.9
|
86.8*
|
86.3*
|
35
- 44
|
89.6
|
90.3
|
90.0*
|
45
- 54
|
90.7
|
91.9*
|
91.4*
|
55
- 64
|
91.6
|
93.2*
|
93.5*
|
Elderly (over
65)
|
99.6
|
99.5*
|
99.6
|
Source: CEPR analysis of
Survey of Income and Program Participation, 92, 99, and 02 panels.
|
|||
Note: Universe is all
individuals.
|
|||
* Indicates that change from
past year is significant at the 5 percent level
|
Latinos are less likely to have
health insurance coverage than are other racial/ethnic groups. Latino children
had the lowest rates of health insurance coverage among children, with only two
in five (40.9 percent) having coverage all year in 2002 (Table 3). In 2002,
78.2 percent of white children had health insurance all year, compared to 40.9
percent of Latino children and 65.4 percent of African American children.
Latino children were the least likely non-elderly group to have private coverage
(23.7 percent) and yet not as likely as African American children to have
Medicaid coverage. In 2002, 26.3 percent of African American children had
Medicaid, compared to only 12.7 percent of Latino
children.
Table 3.
Health insurance coverage by gender and race/ethnicity
|
|||||||||||
|
All year |
||||||||||
|
Any
insurance
|
|
Private
insurance
|
|
Medicaid/Medicare
|
||||||
|
1992
|
1999
|
2002
|
|
1992
|
1999
|
2002
|
|
1992
|
1999
|
2002
|
(a)
Children (under 18)
|
|||||||||||
Girls
|
73.8%
|
74.8%
|
71.4%*
|
|
60.4%
|
62.2%
|
54.8%*
|
|
12.7%
|
10.9%*
|
13.8%*
|
Boys
|
74.0
|
75.0*
|
71.5*
|
|
60.1
|
62.9*
|
54.3*
|
|
13.2
|
10.5*
|
14.1*
|
White
|
78.5
|
81.8*
|
78.2*
|
|
71.3
|
74.7*
|
67.3*
|
|
6.7
|
6.1*
|
8.9*
|
African-American
|
69.6
|
65.5*
|
65.4*
|
|
35.2
|
40.3*
|
34.0*
|
|
33.0
|
21.1*
|
26.3*
|
Latino
|
49.4
|
45.8*
|
40.9*
|
|
28.1
|
31.6*
|
23.7*
|
|
19.2
|
11.1*
|
12.7*
|
Other
|
67.8
|
73.7*
|
66.5*
|
|
53.9
|
56.6
|
48.6*
|
|
12.8
|
17.0*
|
14.2*
|
(b)
Adults (18 - 64)
|
|||||||||||
Women
|
74.1
|
78.8*
|
75.1*
|
|
66.2
|
71.8*
|
67.8*
|
|
7.8
|
7.1
|
6.8
|
Men
|
67.4
|
75.4*
|
71.5*
|
|
64.1
|
70.9*
|
66.8*
|
|
3.6
|
5.2*
|
4.6*
|
White
|
75.1
|
82.2*
|
80.1*
|
|
71.2
|
78.0*
|
75.6*
|
|
4.1
|
4.7*
|
4.6*
|
African-American
|
61.1
|
69.7*
|
64.6*
|
|
46.1
|
57.2*
|
51.6*
|
|
14.7
|
12.3*
|
11.3*
|
Latino
|
43.0
|
47.3*
|
38.5*
|
|
34.9
|
40.5*
|
32.3*
|
|
7.3
|
5.9*
|
4.5*
|
Other
|
75.1
|
82.2*
|
80.1*
|
|
71.2
|
78.0*
|
75.6*
|
|
4.1
|
4.7*
|
4.6*
|
(c)
Elderly (over 65)
|
|||||||||||
Women
|
98.8
|
98.4*
|
98.2*
|
|
62.9
|
64.1*
|
62.0*
|
|
96.0
|
94.2*
|
93.8*
|
Men
|
98.6
|
98.1*
|
98.0*
|
|
66.6
|
66.5*
|
65.1*
|
|
94.7
|
91.9*
|
92.8*
|
White
|
98.9
|
98.9*
|
99.0
|
|
70.0
|
71.8*
|
70.3*
|
|
95.7
|
93.9*
|
94.5*
|
African-American
|
98.4
|
96.6*
|
96.7*
|
|
25.8
|
35.3*
|
33.5
|
|
95.7
|
91.0*
|
90.5*
|
Latino
|
95.8
|
91.7*
|
87.0*
|
|
24.2
|
17.5*
|
16.0*
|
|
90.0
|
86.2*
|
77.3*
|
Other
|
91.6
|
92.3*
|
91.3*
|
|
37.4
|
33.2*
|
32.3
|
|
89.3
|
83.6*
|
85.1*
|
Source: CEPR analysis of
Survey of Income and Program Participation, 92, 99, and 02 panels.
|
|||||||||||
Note: Universe is all
individuals. To increase sample size, we pooled estimates for Latinos across two
years (92/93, 98/99, 01/02).
|
|||||||||||
* Indicates that change from
past year is significant at the 5 percent level
|
Table 4.
Partial year insurance coverage by gender and race/ethnicity
|
|||
|
At all during year |
||
|
1992
|
1999
|
2002
|
(a)
Children (under 18)
|
|||
Girls
|
91.4%
|
92.3%*
|
94.6%*
|
Boys
|
91.0
|
92.8*
|
94.7*
|
White
|
92.6
|
95.3*
|
96.4*
|
African-American
|
91.8
|
91.8*
|
94.8*
|
Latino
|
89.8
|
85.2*
|
92.0
|
Other
|
85.4
|
93.1*
|
94.3*
|
(b)
Adults (18 - 64)
|
|||
Women
|
90.5
|
91.1
|
91.2
|
Men
|
86.7
|
88.2*
|
87.7*
|
White
|
90.7
|
92.6*
|
92.7
|
African-American
|
85.1
|
86.4
|
87.4*
|
Latino
|
84.0
|
79.8*
|
80.8
|
Other
|
90.7
|
92.6*
|
92.7*
|
(c)
Elderly (over 65)
|
|||
Women
|
99.6
|
99.6*
|
99.7
|
Men
|
99.6
|
99.4*
|
99.6
|
White
|
99.6
|
99.7
|
99.9*
|
African-American
|
100.0
|
99.3*
|
99.5
|
Latino
|
99.6
|
98.4*
|
98.4*
|
Other
|
98.8
|
97.3*
|
97.8
|
Source: CEPR analysis of
Survey of Income and Program Participation, 92, 99, and 02 panels.
|
|||
Note: Universe is all
individuals. To increase sample size, we pooled estimates for Latinos across two
years (92/93, 98/99, 01/02).
|
|||
* Indicates that change from
past year is significant at the 5% level
|
Among
adults, Latinos had the lowest rate of health insurance coverage. In 2002, only
38.5 percent of Latino adults had health insurance coverage all year, compared
to 80.1 percent of whites and 64.6 percent of African Americans. Latino adults
were far less likely than other racial/ethnic groups to have private health
insurance all year: in 2002, 32.3 percent of Latino adults had private health
insurance all year, compared to 51.6 of African Americans and 75.6 percent of
whites. As with Latino children, Latino adults did not access Medicaid in large
numbers: in 2002, 4.5 percent of Latino adults had Medicaid, compared to 11.3
percent of African Americans and 4.6 percent of whites. The gap in health
insurance coverage for Latinos is also evident among the elderly as they are the
least likely racial/ethnic group to supplement Medicare with private
coverage.
The gap in health insurance coverage for Latinos remains
even once we account for differences in personal characteristics between Latinos
and other racial/ethnic groups. Figure 1 shows that Latinos are the least
likely to have health insurance across age, even after controlling for age,
gender, martial status, place of birth (U.S. or abroad), and employment status
and
wage.[2]
Age remains a critical factor across racial/ethnic groups in whether or not
adults have health insurance coverage; younger adults are far less likely to
have coverage compared to older adults.
The gender gap in health
insurance coverage among adults shows up in terms of where men and women get
their health insurance. Overall, women are slightly more likely than men to
have health insurance coverage: in 2002, 71.5 percent of men had health
insurance coverage all year, compared to 75.1 of women. However, women were
more likely to have Medicaid: in 2002, 6.8 percent of women received Medicaid,
compared to only 4.6 percent of men. The gender gap remains even once we
control for other characteristics of women and men (Figure 2).
Over the course of the most recent recession and recovery, the proportion of Americans with health insurance all year fell by 3.3 percentage points, from 79.1 percent in 1999, near the peak of the business cycle, to 75.8 percent in 2002, during the recession.[3] Figures 3 and 4 show the trends in health insurance coverage over the expansion and contraction. Over the expansion, the trend was towards an increase in private health insurance coverage, with the largest increases for adults (a 6.1 percentage point increase). However, during the economic contraction, the share having private health insurance coverage all year fell, especially for children (a 8.1 percentage point decline) and Latinos (a 8.2 percentage point decline among adults and a 7.9 percentage point decline among children).
In 1997, Congress expanded
Medicaid under the State Children’s Health Insurance Program to cover more
children in low-income families. However, Figure 4 shows that this expansion
was not enough to overcome the loss in private health insurance coverage.
Latino children were hurt most over the economic contraction, even though their
gains in coverage over the 1990s economic expansion were about the same as other
groups. In 2002, only 40.9 percent of Latino children had either private health
insurance or Medicaid, down from 45.8 percent in
1999.[4]
Much of the decline for Latino children was due to a decline in private health
insurance coverage of 7.9 percentage points. Over this same period, private
coverage fell by 7.4 percent, down to 67.3 percent, for white children and by
6.3 percent, down to 34.0 percent for African American children.
Most Americans without health insurance report that
it is the high expense of coverage that is the primary reason that they are
uncovered (Table 5). In 2002, 84.3 percent of adults without health insurance
reported that high cost was the reason that they did not have coverage, with more women reporting
this than men. The second-most frequently cited reason is that they are
ineligible for health insurance because they have not been working at their firm
long enough or because of some other employment- related issue. Very few adults
– 6.1 percent overall – report that they do not have health
insurance because they either do not want it or they do not need it.
Table 5.
Reason cited for being without health insurance
|
||||||||
|
Too
expensive
|
|
Ineligible
b/c employment status
|
|
Don't
want/need
|
|||
|
1999
|
2002
|
|
1999
|
2002
|
|
1999
|
2002
|
All adults (18 -
64)
|
84.8%
|
84.3%
|
|
47.4%
|
40.5%*
|
|
5.6%
|
6.1%*
|
Women
|
86.5
|
85.9
|
|
45.8
|
37.8*
|
|
4.8
|
5.0
|
Men
|
83.4
|
82.9*
|
|
48.8
|
42.7*
|
|
6.3
|
7.1*
|
White
|
83.0
|
83.5*
|
|
47.8
|
42.4*
|
|
6.0
|
6.6*
|
African-American
|
87.3
|
87.0
|
|
41.9
|
34.1*
|
|
4.9
|
5.0
|
Latino
|
87.2
|
84.9*
|
|
50.6
|
43.8*
|
|
5.1
|
5.6*
|
Other
|
85.0
|
76.2*
|
|
47.4
|
33.4*
|
|
8.8
|
9.2*
|
18 - 24
|
82.4
|
81.6*
|
|
48.5
|
41.9*
|
|
5.3
|
5.7*
|
25 - 34
|
83.0
|
83.3*
|
|
51.3
|
44.9*
|
|
4.7
|
5.6*
|
35 - 44
|
86.9
|
85.0*
|
|
49.5
|
40.8*
|
|
5.0
|
5.3*
|
45 - 54
|
86.6
|
85.9*
|
|
42.9
|
36.9*
|
|
8.2
|
7.2*
|
55 - 64
|
87.9
|
87.9*
|
|
35.1
|
30.7*
|
|
6.5
|
8.5*
|
Source: CEPR analysis of
Survey of Income and Program Participation, 96 and 02 panels.
|
||||||||
Note: Universe is all adults
(ages 18 to 64) without health insurance. Reasons are not mutually exclusive.
The cumulative means fall from 1999 to 2002. To increase sample size, we pooled
estimates for Latinos across two years (92/93, 98/99, 01/02).
|
||||||||
* Indicates that change from
past year is significant at the 5 percent level
|
|
African-Americans are least
likely to report that they do not have health insurance because of employment
status, while Latinos are most likely. African-Americans and Latinos are also
less likely to report that they do not want or need health insurance than
whites. Older adults (45 to 64) are less likely than younger adults (18 to 44)
to report employment status as the reason for not having health insurance, but
they are more likely to report that they do not want or need it. Adults aged 25
to 34 are also the most likely to report that they do not have health insurance
because of their employment status.
In 2002, there were nearly 70
million Americans without health insurance coverage at some point during the
year. Going without health insurance was more common among Latinos than other
racial/ethnic groups, which is especially important since they are now the
largest ethnic minority in the United States. Since the government chooses to
cover the elderly through the Medicare system, but does not similarly provide
coverage for other Americans, the elderly have nearly universal health insurance
coverage while nearly one-third of children have no coverage at all. Even
though Congress extended Medicaid in the late 1990s to cover more low-income
children, this was not enough to overcome the sharp drops in private coverage.
Since most adults and children get their coverage based on employment, as
unemployment rose and firms cut back on costs, this had led to an even greater
crisis in access to health insurance. The crisis continues for children, but
young adults also struggle to access the health insurance system.
The lower likelihood of younger adults to have health insurance
poses a significant policy problem. Given that most first births occur within
this age demographic, young adults will need a mechanism to opt into the health
insurance system in a way that is affordable. Yet shorter work histories, lower
wages and student status are common impediments to health care coverage for
young adults.
Mills, Robert J., and Shailesh Bhandari. 2003. Health Insurance Coverage in the United States: 2002. Washington, DC: US. Department of Commerce, U.S. Census Bureau.
[1] Heather Boushey is an economist and Joseph Wright a research assistant at the Center for Economic and Policy Research.
[2] See Technical Documentation: Health Insurance Data Briefs for a complete description of the analysis.
[3] The most recent economic boom ended in 2000 and the economy was in a recession throughout most of 2002. However, as late as 2003, the economy continued to shed jobs. Our latest data is for 2002 and, since we do not have 2000 data, we compare it to 1999, which is near the business cycle peak. The year 1992 was chosen because it is the year in which the unemployment rate reached its height, during the contraction of the early years.
[4] Another 2.8 percent of children had health insurance from another source, not Medicaid or private, but possibly through CHAMPUS or another government program.