Table 2. Figure 2. Employer-based coverage for children decreased 8 percent between and see Figure 2. The decrease in employer-based coverage for children was offset by an increase of almost 8 percent in Medicaid coverage between and see Table 2. Trends in health insurance coverage among children, ages , United States, Department of Commerce. There are a variety of interpretations and substantial disagreement, however, about the relationship between the decrease in employer-based coverage and the increase in Medicaid coverage.
At the heart of the issue is the concern that employers and employees might drop private health insurance to take advantage of increasing Medicaid eligibility thresholds to higher levels of income. Others maintain that shifting employment patterns, including the large scale shift from manufacturing to service sector jobs, account for the decline in employer coverage. Thus, the issue of replacement or substitution of coverage, or "crowding out," is controversial.
This issue is discussed later in this chapter. Employer-based coverage decreased for adults as well as for children over the period from to However, the rate of decrease was faster for children, particularly in the s see Tables 2. Trends in health insurance coverage among adults, ages , United States, Comparison of trends in health insurance coverage for adults, ages , and children, ages , United States, During the same period that private coverage for adults was decreasing, the percentage of uninsured adults was increasing Figure 2.
This suggests that adults who lose employer-based coverage are more likely to become uninsured than to enroll in Medicaid Figure 2.
As indicated in Figures 2. However, among children with Medicaid coverage, a disproportionate number approximately 80 percent are in the younger age groups This is true, in part, because families with young children are more likely to be poor and eligible for Medicaid compared with families with older children. Patterns of children's health insurance coverage by age, for employer-based insurance, Medicaid,and children without coverage, United States, Estimates are based on data from the Current Population Survey, more Children's health insurance coverage within age groups, for employer-based insurance, Medicaid, and uninsured children, United States, In addition, the Medicaid expansions enacted in the late s are being phased in by age, with younger children gaining coverage before older children.
Some policy analysts and health services researchers interpret the larger number of Medicaid-insured younger children as evidence that the Medicaid expansions have effectively reached the intended age group. In general, children of color are disproportionately more likely to be uninsured. These figures present national aggregated data; state and regional differences in distribution may be significantly different.
Health insurance coverage among children by race and ethnicity, United States, Patterns of health insurance coverage among children by race andethnicity, United States, Most children with employer-based coverage 76 percent are white; and most white children 69 percent have employer-based coverage. Among black children, fewer than 40 percent have employer-based coverage, close to half 45 percent have Medicaid coverage, and about one in six 15 percent have no insurance.
More than one in four Hispanic children 27 percent are uninsured, whereas 35 percent have private insurance and about 37 percent have Medicaid coverage.
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Among Native Americans, about one third 33 percent have employer-based coverage, almost half 45 percent have Medicaid, and approximately 11 percent are eligible to use the Indian Health Service. On a national basis, Asian-American children make up approximately 4 percent of the total in each. However, in California, Asian-Americans comprise approximately 20 percent of the population and approximately 12 percent of the uninsured children Children Now, Many, but not all, of these differences by race and ethnicity correspond to differences in parental employment and thus relate to family income.
An analysis of the data from the National Medical Expenditure Survey found that poverty, minority status, and absence of insurance each had independent effects on access to and the use of primary care, but that there was overlap among the groups: among children in at least one of these at-risk groups, 40 percent also had another risk factor. In other words, children who are uninsured are more likely to be poor and to be from a racial or ethnic minority Newacheck et al. Along with the growing diversity of the American population throughout all regions of the country, the availability of culturally appropriate health care services also varies.
However, in designing new children's insurance expansions, it will be important to have current information on the racial and ethnic distributions of children by insurance status at the state level and local levels.
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Without such information, it will be more difficult to focus appropriate outreach and enrollment efforts on the communities with the highest concentrations of uninsured children. Figures 2. Characteristics of families of children with employer-based insurance coverage, ages , United States, Characteristics of families of children with Medicaid coverage, ages , United States, Characteristics of families of uninsured children, ages , United States, Not surprisingly, the majority of children with employer-based coverage live in two-parent, working families see Figure 2.
More than half 54 percent live in families with incomes that are percent of the federal poverty level or higher. Children with Medicaid coverage are more likely to live in single-parent families The majority of uninsured children live in two-parent, working families see Figure 2. Thus, parents of most uninsured children have been described as being among the ''working poor. More than half 55 percent of the uninsured children have parents who finished high school.
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The majority of children who are uninsured 64 percent live in families in which someone works full time year-round, typically in service industries, seasonal work, or other low-wage jobs in small businesses. Evidence suggests that the majority of workers who are offered insurance coverage through their employer will enroll Nichols et al. Small employers are less likely to offer health insurance to their workers than are large employers, and small employers tend to provide less-comprehensive benefits than do large employers Nichols et al.
However, the available evidence shows no clear relationship between firm size and the size of employees' contributions for dependent coverage Nichols et al. According to data from the Census Bureau's Survey of Income and Program Participation, millions of children spent several months without coverage between and Only 12 percent of uninsured children lacked coverage for 3 months or less. Nearly 40 percent were without coverage for 4 to 9 months, and half 50 percent were without coverage for 10 months or more see Figure 2. Percentage of children without health insurance coverage, ages , by number of consecutive months without coverage, United States, Taken as a whole, these data suggest that spells without coverage can be substantial and widespread and can involve millions of children.
Indeed, some 20 million children experienced at least one spell when they were uninsured during the period Table 2. If children's episodes without coverage coincide with any major illnesses or injuries, their families face large out-of-pocket expenses for medical treatment. If families choose to forego treatment initially because of the cost, untreated illnesses and injuries can escalate in severity and can become much more costly to treat later on. Much of the care provided to uninsured families becomes bad debt and is thus described by providers as "uncompensated care. The Balanced Budget Act of significantly reduced the amount of DSH funding and also eliminated cost-based reimbursement for community health centers.
For these and other reasons discussed in Chapter 4 , safety net providers need to change the structure of their services and to identify other financial resources to pay for or to offset the costs of uncompensated care. The highest rates greater than 20 percent are in central southeastern, south-central, and southwestern states Mississippi, Louisiana, Oklahoma, Texas, New Mexico, Arizona, and Nevada. The lowest rates less than 10 percent are in the northern tier. Variability occurs because of state and regional differences in the industry and employment base, such as the distribution of large versus small employers, and in the coverage and cost-sharing options they customarily offer Holahan, For example, children and adults in the South traditionally have had lower rates of employer-based coverage and correspondingly higher rates of uninsurance.
Another reason for state and regional differences in rates of uninsured children is because of the variability of state experiments with health insurance for children and state participation in Medicaid options.
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Some states—notably Massachusetts, Minnesota, and Florida—have undertaken successful expansions of children's health insurance coverage. Some private insurance initiatives e. In other states, however, there has been little or no previous activity in the children's health insurance coverage arena. SCHIP was designed to give states flexibility and choice, and the flexibility appeals to most states.
The national patterns of coverage are likely to change as a result of SCHIP, but it is too early to tell whether the states with the highest rates of uninsured children will develop programs that are most successful in expanding insurance coverage. Employer-based coverage is decreasing more rapidly for children than for adults. Although the percentage of children without coverage remained relatively stable between and , the absolute number of uninsured children increased, from 8.
The percentage of uninsured children remained stable over that period primarily because increases in Medicaid enrollments offset declines in employer-based coverage. Among Medicaid enrollees, young children ages 0 to 5 are the largest age group This suggests that Medicaid expansions to younger children have been effective in reaching them. Patterns of coverage differ for racial and ethnic minorities. Black and Hispanic children are more likely than white children to lack coverage. Nationally, one of every six black children and one of every four Hispanic children is uninsured.
Among white children, 1 of every 10 is uninsured. Racial and ethnic variations in coverage have important implications for outreach and enrollment strategies for new insurance programs.
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These strategies should be designed to reach the groups with highest rates of uninsurance, and should be culturally sensitive and culturally appropriate in order to increase the likelihood of participation. Evidence is fairly clear that rates of employer-based health insurance coverage for children declined from to and that rates of Medicaid enrollment increased for children over the same time period.
It is less clear whether the relationship is causal—that is, whether the availability of Medicaid actually caused employers and employees to drop dependent coverage. The available evidence comes from aggregated data reported in national surveys.
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Because data on specific employer and employee decision making about these issues are not readily available, the survey data are subject to different interpretations. Many policymakers are concerned that the availability of public insurance through Medicaid or SCHIP will encourage employers and employees to drop their private coverage, also called substitution or crowding-out of coverage Chollet et al. Substitution can take place in one of two ways: 1 An employer that currently provides coverage for children may stop covering dependents or may continue to offer coverage but increase the amount that employees must pay to receive dependent coverage, making it more likely that they will drop the coverage and try to replace it with public insurance; or 2 employees who are already paying a share of the cost of employer-based insurance might stop participating if, for example, they became eligible for new publicly funded programs.
All of the following will contribute to rising costs:.
While some states including Massachusetts and New York do not allow bare-bones plans on their marketplace, many others plan to do so. The price for the average ACA plan in Illinois would go up According to the Urban Institute, the average plan would go up The analysis showed 94, Illinois residents would be affected. Overall, some , people in the state could end up without the minimum essential coverage.
Georgia residents should brace for premium hikes. The loss of the individual mandate, combined with competition from subpar health insurance plans, would shake the Georgia market even harder. On average, residents will premiums rise Next : In New England, the story is the same, and it gets worse for older Americans. Older Americans will be hit hardest by premium increases.
Up in New Hampshire, insurance markets will respond much like they will in the South and Midwest. On average, premiums would rise Of course, on the ACA exchanges, older Americans get hit the hardest. Anyone who does not yet qualify for Medicare yet must have coverage — mainly, those aged — will feel the most burn.
Indiana residents could be looking at higher healthcare costs in That repeal never happened, and since then Pence and the Trump administration have had to settle for piecemeal efforts to undermine the health care law. Those efforts will give Indiana residents with ACA plans the freedom to pay Next : Rural health care coverage is about to get a lot more expensive. In Montana, people over 50 will see the highest increase. Introducing bare-bones plans that compete with Obamacare will raise premiums yet again in On average, Montana residents will see costs jump Mid-Atlantic states will feel the bite of the Obamacare sabotage as well.
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As many as , West Virginians could end up without minimum essential coverage. As the February teacher strike proved, employee-sponsored health care in West Virginia does not offer a much better alternative. The combination of eliminating individual mandate penalty and introducing cheap, low-coverage insurance will hit Wisconsin hard. The price of ACA plans will increase by The Lone Star State really felt the pinch when Trump ended cost-sharing subsidies for poor residents. Approximately , were affected by that move.