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January 2000-WH: [Health Care Coverage 1-19-00] [1]
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�Draft 01118/00 6:30 pm
Heather Hurlburt
�enrollment to where they and their parents are. That means gomg to day care centers, school
lunch programs, or center for the homeless. My budget will fUiid efforts to do just thatbecause there is just no re· son for any child in America to grow lbp without basic health care.
Third, we are reach\ng out to Americans who cannot geJinsurance through their jobs and
are not ellgible for Medicaif or Mec!Jcmcl- people movmg from welfare to work, 111 between
jobs, or aging out of~IO-w.gr..a.m.s. The fastest-growing group of uninsured is people nearing,_ _ __
retirement. 1 have already proposed that they be allowed to buy into Medicare coverage- and n +~
I}1y-·buc(gct provides a tax credit to help them do it.
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doctors c:u~d .nurses that serve the unmsured, never turnmg a pat~e~1t away. We.shotrltl--nrvest at c._~ ~~:r,, ..JJ;d
]east $1 billion over the next ten years to make sure we're prOVIdmg decent baSIC care-. a health V~
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hard and contributing to our economy- and their children are part of our common future.
Every American knows how hard it is to bear the emotional and financtal burdens of r~f:_~ :#::--'
loved one's illness: But Am.ericans should also know that they don't have to do it alone. When l C~·
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we talk abO Lit moving Amenca forward, we mean a '.Ultio.n of strong, healthy peop~e. ~eady to
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work and contnbute, and confident that they and their children will be cm d for with dig111ty.
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�Draft 01/18/00 3:00pm
Heather Hurlburt
PRESIDENT WILLIAM J. CLINTON
STATEMENT ON HEALTH CARE
THE WHITE HOUSE
WASHINGTON, DC
January 19, 2000
~.~r~ ~or ~~~~r~~wr- ~1~~
Good morning. One ofthe biggestQs facing American families, even in this time of
growing prosperity, is paying for health care. Today I want to talk about two proposals in my
budget for 2001 that will help Americans shoulder the costs of health care- by extending
insurance coverage to millions of people, and helping many others meet the demands of
providing long-term care. These proposals [r~esent the largest investment in America's health
since the creation of Medicare and Medicaid.,Y And theiJare central to making sure every
American has access to high-quality health care in the century ahead.
progre~isease,
more and more of )
As we live longer, and can do more to control the
us face the financial and human costs of providing l?ng-term care for. loved ones - or ourselves.
We announced yesterday that my budget for 2001 mms to help Amen cans face these new
challenges-- by tripling the tax credit for long-term care expenses; by modernizing Medicaid to
assist those in long-term care; and by creating a national program to help caregivers get
information, training and support.
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We need to confront new challenges to America's health, such as long-term care, even as
we continue 'U1fight to expand health care coverage to Americans who lack it. We still have too
many working families ~hoosing between food on the table and ~dricYo~ Too many
children taken to emergency rooms with illnesses that should nev~r have happened. Too many
chances missed to screen for cancer and other deadly diseases. And we are giving our children
too few chances at a healthy start.
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Today I am announcing an initiative\~o expand health insurance options for more than X
million American~building on the pFogrmns we already h<rve it:t placl( My budget ret 2001 will""'rse~ aside $100 billion doll~ver 10 years to reach whole groups of Americans who are falling
through the cracks.
•
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First, we will work with states to reach every child eligible for eFI1P or Medicaid. To
find those children, we've got to take information and enrollment to where they and their parents
are. That means going to day care centers, school lunch programs, or centers for the homeless.
My budget will fund efforts to do just that- because there is just no reason for any child in
America today to grow up without basic: health care.
:,dJ.
SeconE?,one who is concerned about thQealth care costs on our economy and our
~vJ\~~"") society must orry otjust about children, but abo_ut families. That i~ why, as Vice President
~
Gore has urge , e should allow parents to enrollui the same health msurance programs that
:
�cover their children. My budget will give states the money they need to make this change under
one new initiative called Family Care. It will also help families eligible for Family Care
purcha;,tsurance from their employers, when that is the best option.
\ Third, we are reaching out to those Americans who cannot get insurance through their
jobs, &ttfare not eligible for Medicare or Medicaid. Their numbers are growing fastest among --72 ~t~
people nearing retirement, ages 55-65. I have already proposed that they be allowed to buy into
~~
Medicare coverage- and my budget provides a tax credit to help them do it.
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Almost half of uninsured workers are in small businesses. We should help them get
coverage- and help businesses provide quality coverage at affordable prices. My budget
contains a 20 percent tax credit for small businesses that offer health insurance for the first time;
and it provides tax incentives for purchasing coalitions to keep insurance costs down.
My budget will also allow states to continue coverage for 19- and 20-year olds who age
out of insurance plans. It offers a 25 percent tax credit to people between jobs who are paying
the full cost of health insurance from a previous jo~. And it makes our transitional Medicaid
program, for people moving from welfare to work, permanent and easier to join.
Finally, we must strengthen the system of clinics, public hospitals, and dedicated doctors
and nurses that serve the uninsured, never turning a patient away. Last year, we proposed a
program to provide more and better care through such centers, and Congress funded it with $25
million dollars. This year, I propose that we use $125 million dollars to make those centers
places where anyone can get decent basic care. And I propose a $50 million increase in funding
for the community health centers that provide primary cqre for millions of Americans.
Every American knows how hard it is to bear the emotional and financial burdens of a
loved one's illness. But every American should also know,. tha~= ~O!J.~·-·_That there is help
available. And that when we talk about moving a -sti~hg'"'~ · to a ne-t' millennium, we mean
a nation of strong, healthy people~eady to work and contribute, and confident that they and
their children will be cared for with dignity. We have a chance now to make that investment in
our common future - and we ~ not miss it.
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andthe
uninsured
January 2000
THE UNINSURED AND THEIR ACCESS TO HEALTH CARE
Health insurance makes a substantial difference in the
amount and kind of health care people are able to obtain.
The consequences of not getting needed medical care are
not trivial and can result in unnecessary hospitalizations and
serious health problems.
Nearly all of the elderly are covered through Medicare, so
most uninsured Americans are individuals under the age of
65. While the majority of people receive health insurance
coverage through their employers, millions of Americans lack
access to health coverage either because their employer
does not offer it or they cannot afford to pay for it. Medicaid
plays an important role by covering millions of low-income
people, but millions more do not meet its restrictive income
and eligibility criteria and are left uninsured.
WHO ARE THE UNINSURED?
The uninsured are predominantly workers and their families,
many of whom have low incomes.
•
•
•
Nearly 75% of the uninsured are full-time workers or
their dependents. Only 16% of the uninsured are in
families with no connection to the workforce.
Over half of the uninsured (56%) have low incomes,
making less than 200% of the federal poverty level
($32,900 for a family of four in 1998). Over a quarter of
the uninsured population live below the poverty level.
The low-income population runs the highest risk of being
uninsured:-about a third of the poor (36%) and near-poor
(31%) lack insurance (Figure 2).
HOW MANY ARE UNINSURED?
Figure 2
Health Insurance Coverage
by Poverty Level, 1998
Over 44 million Americans are uninsured- over 18% of the
total nonelderly population (Figure 1). The number of
Americanswithout health insurance has grown by nearly 10
million over the past decade. A smaller share of Americans
have health insurance through their jobs today than ten
years ago, and even more would be uninsured were it not for
eligibility expansions and enrollment growth in the Medicaid
program before 1996. Recent declines in Medicaid
enrollment, related in part to changes in welfare and
immigration policy, have also contributed to an increase in
the number of uninsured.
100%
75%
25%
0%
U.S. Total
25
%
Percent of Nonelderly Population
Unlnsu~
20%
15%
14.8%
.....-
.---
18.4%
...---
.
FPL)
10.4%
Medicaid
5%
Near Poor
Moderate
(100·199% (200·299%
FPL)
High
(>300%
FPL)
FPL)
Note: The federal poverty level for a fMlily of four in 1998 was $16,450. D11ta includes non-elderly only
SOURCE: Urban Institute esUmates based on the March 1999 Current Population Survey.
•
Low-income adults are much more likely to be uninsured
than low-income children. Due in part to Medicaid's
eligibility categories and coverage of pregnant women,
among young adults, low-income men are more likely to
be uninsured than women (Figure 3).
Figure 3
/
10%
Poor
(<100%
Figure 1
Growth in Uninsured Americans and
Medicaid Beneficiaries, 1987-1998
0 Private/Othe_r
0 Medicaid
[ill Uninsured
50%
8.6%
Percent of Low-Income Population
Uninsured or with Medicaid, 1998
Children (0·18) • • •
66%
SOURCE: Employee Benefits Research Institute, 1999
Many more Americans who are currently insured have had a
period without health coverage in the recent past. In 1997,
almost a third of nonelderly adults (32%) were uninsured at
some time in the previous two years. Of these, over 40%
were uninsured for more than two years. The majority of the
uninsured say they lack coverage because it is too costly;
few claim that they do not want or need health insurance.
1450
G
PHONE:
STREET
NW,
SUITE
202-347-5270,
WWW.KFF.ORG
Note. Low-Income defined as <200% of FPL; date. lndudes non-elderly only.
SOURCE: Urban lnsbtute estimates bosed on March 1999 Current Population Survey
250, WASHINGTON, DC 20005
202-347-5274, PUBLICATIONS: J-800-656-4533
FAX:
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While the majority (52%) of the~uninsured are white,
Hispanics (25%) and African Americans (17%) are overrepresented among the uninsured population.
Uninsured Workers. Nearly twenty-five million workers18% of the workforce- are uninsured. Over half of uninsured
workers are employed full-time. Where a person works and
the wages paid influence the risk of being uninsured.
•
•
A third (31 %) of workers earning under $20,000/year are
uninsured compared to 5% of workers earning over
$50,000/year.
Part-time and part-year workers are at higher risk of
being uninsured -over 25% are uninsured compared to
15% of full-time workers. ,f:: ~
Workers in businesses with f~~er than 100 employees
are more likely to be uninsured than those in larger firms.
Even in large firms with more than 1,000 employees,
24% of workers earning under $20,000 are uninsured.
WHAT DIFFERENCE DOES HEALTH INSURANCE MAKE?
Health insurance affects access to health care, health
outcomes, and the financial well-being of families.
•
•
•
One in 5 uninsured children have no regular source of
care, and uninsured children are 30% more likely to fall
behind on well-child care and 80% more likely to never
have had routine care.
Uninsured children are at least 70% more likely than
insured children not to have received medical care for
common conditions like asthma and ear aches illnesses that if left untreated can lead to more serious
health problems.
Over half of uninsured adults have no regular source of
care. 55% of uninsured adults say they have postponed
care, and a quarter have not filled a prescription in the
past year because they could not afford it (Figure 5).
gure
Percent of Working-Age Adults Who Postponed
or Did Not Obtain Needed Care in Past Year
Uninsured Children. Over one in 4 (27%) of the uninsured
are children. Though State and Federal Medicaid
expansions in the 1980s and 1990s helped to improve
coverage of low-income children, nearly 12 million children
lack coverage today. It is estimated that two-thirds of
uninsured children are in families with incomes below 200%
of the federal poverty level. Among these children, up to 5
million are potentially eligible for Medicaid but not enrolled
and another 2 million could potentially gain coverage through
the State Children's Health Insurance Program (CHIP).
Over 76% of uninsured children live .in families where at least
one parent is working full-time. Many live in families who
lack access to job-based coverage and others come from
low-income families who cannot afford premium costs. Most
uninsured children have parents'who also are uninsured.
·<~
State Variation. Though 16% of.Jbe national population is
uninsured, the uninsured as a proportion of a state's
population varies widely across the country, ranging from a
low of 9% in Hawaii to over 24% in Texas (Figure 4).1n 5
states, over 20% of the population is uninsured. Some
states have developed programs to extend coverage to the
uninsured, particularly the low-income uninsured, through
Medicaid or with separate state funding.
Figure 4
Uninsured Population by State,
1996-1998 Average
1116% to <20% {14 states*) 0 <12% (15 states}
National Average= 16%
' lndudes the [)strict of Colurrbus
SOURCE: U.S Census Buree.u, March 1997, 1998, and 1999 Current Population Survey
Postponed
Medical Care
• • • • 55%
Did Not Receive
Needed
Medical Care
Did Not Fill
Prescription
SOURCE: Kaiser/COmmonwealth 1997 National Survey of Health Insurance.
•
Uninsured adults are over 4 times more likely than the
privately insured to say they have not received medical
care they believed to be necessary and are less likely to
use preventive services like check-ups and
mammograms.
Because their primary health care needs are not addressed,
the uninsured are more likely than those with insurance to be
hospitalized for conditions that could have been avoided,
such as uncontrolled diabetes. The uninsured are also less
likely to have a procedure that is relatively costly or allows
physicians to exercise a great deal of discretion.
Medical bills mount quickly if a person is uninsured. Over a
third of adults who are uninsured report they have had a
problem paying their medical bills in the past year. Fear of
these debts is an important reason why many of the
uninsured do not get the medical care they need.
Health insurance clearly matters for the millions of
Americans who lack coverage. Decisions made by the
uninsured to delay or forego needed care because of its
cost, coupled with health providers who tend to order less or
different treatments for patients without coverage, ultimately
can lead to poorer health outcomes.
The Kais.er Commission .on Medicaid and the Uninsured was established by the Henry J. Kaiser Family Foundation
to. function as a policy Institute and forum for analyzing health care coverage, financing and access for the lowIncome population and assessing options for reform. The Kaiser Family Foundation is an independent national
health care philanthropy and IS not associated with Kaiser Permanente or Kaiser Industries.
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c;fo;F A~ r~)
and the
uninsured
JANUARY
2000
ENROLLING UNINSURED CHILDREN IN MEDICAID AND CHIP
Nationally, over 11 million, or one in seven, children are
uninsured-two-thirds live in families with incomes below
200% of poverty ($33,400 for a family of four in 1999).
The Medicaid program is a critical health care safety net
for low-income children, covering 21 million children in
1998. The State Children's Health Insurance Program
(CHIP) has extended coverage to an additional 2 million
children who do not qualify for Medicaid. Yet millions of
children are believed to be eligible for these programs
but remain uninsured (Figure 1).
Figure 1
Uninsured Children
Ineligible
(Income >200% FPL)'
JQD/o
Medicaid·
eligible
43%
Lack of insurance coverage negatively affects access to
care among low-income children: 41% of parents of
eligible uninsured children postponed seeking medical
care for their child because they could not afford it.
BARRIERS TO ENROLLMENT
Since its inception, Medicaid has been tied to the welfare
system. Though recently "delinked," Medicaid eligibility
rules and enrollment process are still subject to many of
the requirements for cash assistance.
Lack of knowledge and complex eligibility rules.
Many parents who have never tried to enroll their
children in Medicaid do not know that their children
qualify for the programs, often because of complex
eligibility rules. Others lack basic information on how or
where to enroll (Figure 3). Medicaid and CHIP often
have different eligibility levels depending on a child's
state of residence, age, and family income. Fluctuations
in family income could result in children moving on and
off either program.
Figure 3
27%
Total= 11 million uninsured children In 1998
Reasons Why Parents Have Not Tried
to Enroll Their Child in Medicaid
SOURCE· Urban Institute estimates, 1998
LACK OF KNOWLEDGE & KNOW-HOW
Okln't know how or where to apply
Dkln'tthinkchlld would qualify
ELIGIBLE BUT UNINSURED CHILDREN
Compte.: rutea & forma
Low-income uninsured children typically live in twoparent, working households and have little contact with
the welfare system. Nearly all low-income parents
believe having health insurance coverage for their child
is very important. In fact, two-thirds of low-income
parents (67%) have tried to enroll their child in Medicaid.
However, over half (57%) of these attempts were
unsuccessful (Figure 2).
Figure 2
Past Medicaid Enrollment Experiences
of Eligible Uninsured Children
100%of
.. Ever tried to enroll ..
Status
~=========~'58%
56%
50%
DIFFICULT ENROLLMENT PROCESS
Process is too k)ng
52%
U%
Office is not open
Office Is hard to get to
42'.4
Poor treatment at enrollment omce
42'.4
Didn'twanttogotothewetfareotrlce
38'.4
LANGUAGE ISSUES (asked of Spamsh speakers only)
Materials not in my language
50%
Source National Survey on Barners to Med•caid Enrollment, Kaiser Commission on Med!ca1d and the
Uninsured, 1999.
Difficult enrollment process. Parents who have never
tried to enroll believe the Medicaid enrollment process to
be difficult and inconvenient They cite limited hours and
locations for enrollment and the time required to apply as
important factors that keep them from enrolling (Figure 3).
Past
successful
enrollment
Never tried
to enroll
31%
Tried, but dkl
Tried, but
denied
Tried multiple
times, but
unsuccessful
NOTE: Respondents rnclude tamrlles With rncomes below 133% of poverty
SOURCE: National Survey on Barriers to Medrcard Enrollment, Karser Commission on Medrcaid and the
Umnsured, 1999
1450
G
PHONE:
STREET
NW,
SUITE
202-347-5270,
WWW.KFF.ORG
These perceptions are borne out by actual enrollment
experiences. Many parents who have tried to enroll their
children did not complete the process because it was too
complicated and confusing (62%). Others cited
difficulties in getting all the required documentation
(72%) and the overall hassle of the enrollment process
(66%) as important reasons for not completing the
process.
250, WASHINGTON, DC 20005
202-347-5274, PUBLICATIONS: J-800-656-4533
FAX:
�Other enrollment barriers. Among Spanish-speaking
parents, half (50%) assume that enrollment materials
would not be available in their language, discouraging
them from even trying to enroll their children.
Finally, negative associations with welfare persist and
create barriers to Medicaid enrollment. Over one-third of
parents who have never tried to enroll their children
(38%) do not want to go to the welfare office to enroll in
Medicaid and 42% worry that they will be treated badly
at the enrollment office. In addition, some states have
encountered eligibility systems problems that have led to
the inappropriate disenrollment of eligible children whose
families leave welfare.
Simplified eligibility rules. States can choose to raise
income and age eligibility levels for children beyond
federal minimum standards to provide uninterrupted
coverage as children grow older. States can make
income eligibility determinations easier and more
inclusive by eliminating asset tests and applying income
disregards. Adopting 12-month continuous eligibility can
help families maintain insurance coverage despite small
income fluctuations (Figure 5).
Figure 5
State Strategies for Reducing Barriers
to Medicaid Enrollment for Children
Number of State. Reporting
STRATEGIES TO IMPROVE ENROLLMENT
With few federal requirements for the enrollment
process, states have the flexibility to help families
overcome many of these enrollment barriers (Figure 4).
Fig~re ..
Federal Requirements in the Medicaid
Enrollment Process
Initial Application
Required Documentation
• Social Security Number
• Dedaration of citizenship or immigration
status of child*
State Responsibility
Application without delay, regardless of
status ofT AN F application
Determination in 45 days or less
Prompt notice of reason for denial
Translation services for applicants must
be provided
Redetennination
Roqu/rod Ewl)' 12 MontM
Required Documentation
•
May use initial Medicaid application
State Responsibility
Redetermine Medicaid eligibility
automatically for anyone leaving TANF
Conskler eligibility under all possible
Medicaid categories
Promptly mtorm person of resuhs and
right
to appeal decision
Maintain enrollment throughout
redetermination process, rt person
responds to requests for information in
reasonable time
• Self-declaration under penalty of pe~ury.
SOUCE: HCFA Dear State Med~eaid Director letters
Streamlined enrollment process. By streamlining the
process, states reduce the single greatest barrier to
Medicaid enrollment. States, such as Indiana,
Massachusetts, and Oklahoma, have already
restructured the enrollment process to make it more
accessible and have seen increases in enrollment.
States can make their application forms simpler and
shorter and allow parents to mail them in to the
enrollment office. Expanded enrollment sites and hours
along with the outstationing of eligibility workers and
application assistants can also help to reduce enrollment
barriers. Eliminating unnecessary verification
requirements would ease the burden on families and
eligibility workers alike. Finally, adoption of presumptive
eligibility and/or accelerated Medicaid enrollment of
uninsured children already participating in other incomecomparable public programs such as food stamps or
school lunch would make the enrollment process more
user-friendly (Figure 5).
Dropped
Asset Test
MaiHI
12-month Presumptive Residency Deductions
Income
Application Continuous Eligibility
Eligiblfily
u.. Self.oocw-. lor:
SOURCE: Based on a telephone survey of state MediCaid otftaals conducted by the Center on Budget and
Policy Pnontles for the Ka1ser Corrmission on MediCaid and me Uninsured, 1999
Expanded outreach. States should continue raising
program awareness through public education campaigns
and by contracting with community-based organizations
to conduct outreach and enrollment activities. Different
approaches may be needed to reach different groups,
though printed materials and personal contact are key to
effective outreach. Funding for these activities include
state allocations from the $500 million fund established
to assist states with maintaining Medicaid coverage for
persons affected by welfare reform, Medicaid
administrative funds, and CHIP administrative funds (up
to 10%).
RETENTION AND REDETERMINATION
Greater outreach and enrollment efforts should be
supported with measures to ensure that eligible children
retain their coverage during redetermination.
Unwarranted disenrollment disrupts continuity of care,
decreases access to care, and dilutes state efforts in
increasing enrollment by contributing to the constant
"churn" of children cycling on and off Medicaid and CHIP.
States have much discretion in designing the redetermination process as federal requirements are minimal
for Medicaid and nonexistent for CHIP (Figure 4). States
should apply the same tools used to streamline the initial
enrollment process to make the reenrollment process
more user-friendly. Finally, because redetermination for
children may result in enrollment shifts between
Medicaid and CHIP, coordination between the programs
is critical to ensure seamless coverage.
The Kaiser Commission on Medicaid and the Uninsured was established by the Henry J. Kaiser Family Foundation
to function as a policy institute and forum for analyzing health care coverage, financing and access for the lowincome population and assessing options for reform. The Kaiser Family Foundation is an independent national
health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries.
�KEY
FACTS
November 1999
HEALTH COVERAGE FOR LOW-INCOME CHILDREN
Whether children are publicly or privately insured, having
coverage has been shown to improve their access to
care and ultimately, their health. Nationally, two-thirds of
all children have private insurance (Figure 1). Medicaid
covers one in five children in the U.S., while one in
seven children remain uninsured. Low-income children
are more likely to be covered by Medicaid and to be
uninsured and less likely to have private coverage than
those with higher incomes.
Flgure1
Health Insurance Coverage of Children,
By Income, 1998
Despite the availability of Medicaid coverage for the
poorest children, poor children are as likely (27%) as nearpoor children (24%) to be uninsured. Adolescents are
more likely than younger children to be uninsured, in part
due to lower Medicaid income eligibility levels for older
children. Hispanic children are the most likely to be
uninsured.
The role of insurance in improving access to care is well
documented. Poor uninsured children have markedly
worse access to care than poor children with Medicaid or
private coverage. Medicaid brings poor children closer to
the level of access experienced by nonpoor children with
private insurance coverage (Figure 3).
Figure3
Children's Lack of Access to Care by
Insurance and Income, 1995
0
No Usual
Source of
-
Care
Note: Children under age 19, low-income with family income below 200% of poverty.
SOURCE: Urban Institute calculations from the 1999 Current Population SUTvey, 1999.
No
Physician
Visit in
UNINSURED CHILDREN
Last Year
Over 11 million children under 19 are uninsured today.
Two-thirds of these children - 8 million - live in
families with household incomes below 200% of poverty;
many may be eligible for, but are not enrolled in
Medicaid. Eight out of ten (79%) low-income uninsured
children have parents who work full- or part-time. The
risk of being uninsured varies by income, age, and race
and ethnicity (Figure 2).
Flgure2
Health Insurance Coverage of Low-Income
Children, 1998
Poor
Near-Poor
(100-199% Poverty)
Under 1
1 to 5 years
r------::-=-----,;~...,----::::::-:---,
i==::::::r~~"""'f""'--__::c-"'--_.J
f---'-=.......L-----=-'-"'-_.J
l=r=='~~~:'"=~~_j
E:] Medicaid
D
6 to 12 years !==~~""==~~
13 to 18 years r----=~.....J._....::.:.:c:...._..J
Hispanic
African-American
White
Note: Federal Poverty Level is $13,650 for a family of three in 1998
Uninsured
39.3%
SOURCE: Newacheck eta!., 1998, data from 1995 NHIS
MEDICAID
The Medicaid program is a critical health care safety net
for millions of low-income children. In 1997, 21 million
children were enrolled in Medicaid, at a cost of $24.3
billion. Children represent half of all Medicaid enrollees,
but account for only 16% of program spending. Per-capita
costs for children are the lowest among the groups eligible
for Medicaid, at $1,156, compared to $10,804 for elderly
enrollees in 1997. Medicaid pays for a comprehensive set
of services for low-income children, including physician
and hospital visits, screening and treatment (EPSDT),
well-child care, vision and dental care with no cost sharing.
Being poor does not automatically qualify a child for
Medicaid. In the past, Medicaid primarily served children
who received cash assistance through welfare, with statedetermined eligibility levels well below poverty. In the late
1980s and early 1990s, eligibility was expanded to cover
additional low-income children. Today, Medicaid covers
children based on age and income (Figure 4).
SOURCE: Urban Institute calculations from the March 1999 Current Population Survey, 1999.
1450
G
PHONE:
STREET
NW,
SUITE
202-347-5270,
\VW\i\l.KFF.ORG
Uninsured/Poor
Low-Income Children
31 million
All Children
76 million
(<100% Poverty)
Private/Nonpoor
[}'] Medicaid/Poor
250, WASHINGTON, DC 20005
202-347-5274, PUBLICATIONS: 1-800-656-4533
FAX:
�Figure4
Federal Medicaid Income Eligibility
Standards for Low-Income Children, 1999
Percent of Federal Poverty Level
DState
Option
miii) Federal
Mandate
..... f-~~~-...-"""-"'-,- 0
100%
D
National AFDC
Average (1996)
Phase-in by
2002
Pregnant
Women/
Infants
Ages
1 to 5
Ages
6to 15
Ages
16to 18
States can expand coverage to uninsured low-income
children through either a separate state program or by
broadening Medicaid -or both. If states use the
Medicaid option, children become entitled to full
Medicaid coverage. In implementing CHIP, 22 state
plans expand Medicaid, 16 plans create separate state
programs, and 13 are combination plans (as of 9/99).
The share of low-income children who are uninsured
varies by state, presenting different challenges as states
implement CHIP. In 11 states, 27% or more are
uninsured, compared to 11 states and the District of
Columbia where under 17% are uninsured (Figure 6).
FigureS
Note: Some states have increased eligibility above these levels.
Federal Poverty Level is $16,700 for a family of four in 1999
SOURCE: National Governors' Association, 1999
Low-Income Uninsured Children, 1995 to 1997
Three Year Average
States can choose to expand Medicaid beyond federal
minimum standards by raising age and income levels for
children. As a result, Medicaid coverage varies across
the states, ranging from 13% of children in Colorado to
47% in West Virginia in 1995. Medicaid covered 38% of
births nationally in 1996, ranging from 21% in
Massachusetts and Pennsylvania to 56% in Mississippi.
Despite efforts to broaden coverage, Medicaid coverage
declined from a high of 21.6 million children in 1995 to
21.0 million children in 1997 (Figure 5). The reduction
has been associated with the delinking of Medicaid and
welfare and confusion about eligibility for immigrant
children.
Percent of Low-Income Uninsured Children
0 <17% (12 states*)
riJ 22% to <27% ( 15 states)
0 17% to <22% (13 states) •
27%+ (11 states)
• Includes the District of Columbia
SOURCE: U.S. Bureau of the Census, 1998
ISSUES IN IMPROVING COVERAGE
FJgure5
Medicaid Enrollment of Children,1990-1997
D
1990
1991
1992
1993
Poverty-Related/Other
l!lll Welfare-Related
Millions of Child Medicaid Enrollees
1994
1995
1996
1997
SOURCE: Urban Institute analysis of HCFA 2082 data, 1999.
STATE CHILDREN'S HEALTH INSURANCE PROGRAM
To broaden coverage to low-income uninsured children
who do not qualify for Medicaid, Congress enacted the
State Children's Health Insurance Program (CHIP) as
part of the Balanced Budget Act of 1997. The program
targets uninsured children under 19 with family incomes
below 200% of poverty who are not currently eligible for
Medicaid or covered by private insurance. This matched
block grant program allocates $20.3 billion in federal
funds for five years. As of June 1999, 1.3 million
children were covered through CHIP.
Enrolling uninsured children eligible for Medicaid as well
as CHIP is critical, but it has been challenging. An
estimated 4.7 million uninsured children are potentially
eligible for Medicaid already and an additional 2.6 million
are now eligible under CHIP plans. States can extend
coverage to even more uninsured children than in their
current plans and still receive federal matching funds.
Efforts to conduct outreach and simplify the enrollment
process are greatly needed to improve program
participation. Parents of low-income uninsured children
want coverage for their children, but cannot afford to pay
for private insurance. Many do not think they are eligible
for public coverage, and have difficulties with the
application process. Confusion about welfare and
immigration policy changes have contributed to
enrollment problems.
Effective outreach and streamlined enrollment processes
will be key to the success of both Medicaid and CHIP in
improving coverage for low-income children. In addition,
states will have to focus on simplifying re-enrollment
procedures to ensure that eligible children stay enrolled.
If these efforts are broad and effective, Medicaid and
CHIP together could cover up to two-thirds of the 11
million uninsured children in the United States.
The Kaiser Commission on Medicaid and the Uninsured was established by the Henry J. Kaiser Family Foundation
to function as a policy institute and forum for analyzing health care coverage, financing and access for the low·
income population and assessing options for reform. The Kaiser Family Foundation is an independent national
health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries.
�DRAFT: PP..ESIDENT UNVEILS
MAJOR NEW HEALTH INSURANCE INITIATIVE
January 19, 2000
THE CHALLENGE OF THE UNINSURED AND ITS IMPLICATIONS. Over 44
million Americans lack health insurance. Although there are many causes of this
problem, it generally results from lack of affordability and/or access to coverage. Family
health insurance premiums cost on average $5,700- which represents a large share of
income for a family trying to make ends meet. Purchasing affordable, accessible
insurance is a particular challenge for many older people, workers in transitions between
jobs, and small businesses and their employees. Lacking health insurance has serious
consequences. The uninsured are three times as likely to not receive needed medical
care, 50 to 70 percent more likely to need hospitalization for avoidable hospital
conditions like pneumonia or uncontrolled diabetes, and four times more likely to rely on
an emergency room or have no regular source of care than the privately insured.
The President's four-pronged initiative significantly expands coverage and improves
access by:
I. PROVIDING A NEW, AFFORDABLE HEALTH INSURANCE OPTION FOR
FAMILIES ($76 billion over 10 years, about 4 million uninsured covered). Over 80
percent of parents of uninsured children with incomes below 200 percent of poverty
(about $33,000 for a family of four) are themselves uninsured. Yet, while states have
aggressively expanded insurance options for children through Medicaid and the State
Children's Health Insurance Program (S-CHIP), parents are often left behind. There are
about 6.5 million uninsured parents with income in the Medicaid and S-CHIP eligibility
range for children. These parents frequently do not have access to employer-based
insurance, and when they do, cannot afford it. Recognizing that family coverage not only
helps a large proportion of the nation's uninsured adults but increases the enrollment of
children, the Vice President, the National Governors' Association, and a wide rage of
groups including Families USA and the Health Insurance Association of America have·
called for building on S-CHIP to cover parents. The President's budget adopts this
approach by:
�•
Creating a New "FamilyCare" Program. This proposal would provide higher
Federal matching payments for state coverage of parents of children eligible for
Medicaid or S-CHIP. Under FamilyCare, parents would be covered in the same plan
as their children. States would use the same systems and follow most of the same
rules as they do in Medicaid and S-CHIP today, and the program would be overseen
by the same state agency. State spending for FamilyCare would be matched at the
same higher matching rate asS-CHIP (up to 15 percentage points higher than the
Medicaid rate). To ensure adequate funding, $50 billion over 10 years would be
added to the current state S-CHIP allotments. To access these higher allotments,
states would have to first cover children to 200 percent of poverty as 30 states now
have done. Given states' enthusiastic response to S-CHIP and the NGA support for
this option, we expect strong state responses and significant expansions to parents
under FamilyCare. If after 5 years, some states have not expanded coverage of
parents to at least 100 percent of poverty ($16,700 for a family of four), a fail-safe
mechanism would be triggered to require states to expand coverage to that level.
•
Assisting Families in Affording Private Employer-Based Coverage. FamilyCare
would also facilitate the option to pool state funding with employer contributions
towards private insurance, which can be a cost-effective way to expand coverage.
Under this option, families otherwise eligible for FamilyCare coverage could get
assistance in purchase their employers' health plan if it meets FamilyCare standards
and their employer pays for at least half of the premium. This minimum employer
contribution, along with the S-CHIP crowd-out policies, should discourage employers
from reducing or dropping coverage. This option is supported by the National
Governors' Association as well.
II. ACCELERATING ENROLLMENT OF UNINSURED CHILDREN ELIGIBLE
FOR MEDICAID AND S-CHIP ($5.5 billion over 10 years, an additional400;000
uninsured children covered). The State Children's Health Insurance Program (S-CHIP)
helps children in families with income too high to be eligible for Medicaid but too low to
afford private insurance. Enrollment in S-CHIP doubled to 2 million children in 1999.
However, despite this encouraging trend, millions of children remain eligible but
unenrolled in both S-CHIP and Medicaid. The budget would give states needed tools to
increase coverage by:
•
Allowing School Lunch Programs to Share Information with Medicaid ($345
million over 10 years). Since 60 percent of uninsured children are in the school
lunch program, sharing eligibility information can efficiently help outreach efforts.
•
Expanding Sites Authorized to Enroll Children in S-CHIP and Medicaid ($1.2
billion over 10 years). This includes schools, child care resource and referral
centers, homeless programs, and other sites.
•
Requiring States to Make their Medicaid and S-CHIP Enrollment Equally
Simple ($4.0 billion over 10 years). Most states have carried over theirS-CHIP
simplification strategies like eliminating assets tests and using mail-in applications
and 12-month eligibility redetenninations into the Medicaid program. This proposal
would have all states do so to make enrollment easier for both programs.
2
�III. EXPANDING HEALTH INSURANCE OPTIONS FOR AMERICANS
FACING UNIQUE BARRIERS TO COVERAGE ($28.7 billion over 10 years,
about 600,000 million uninsured people covered). Some vulnerable groups of
Americans often lack access to employer-sponsored insurance and insurance programs
like Medicare or Medicaid. These include older Americans, people in transitions
(between jobs, turning 19 and entering the workforce, leaving welfare for work), and
workers in small businesses. This plan addresses these specific and other problems by:
•
Establishing a Medicare Buy-In Option and Making It More Affordable
Through a Tax Credit ($5.4 billion over 10 years). The rate of uninsured is
growing fastest among people ages 55 to 65 and is expected to increase even faster in
the future. Recognizing this, the President has called on Congress to pass legislation
that allows people ages 62 through 65 and displaced workers ages 55 to 65 to pay
premil.uns to buy into Medicare. The proposal also would require employers who
drop previously promised retiree coverage to allow early retirees with limited
alternatives to have access to COBRA continuation coverage until they reach age 65
and qualify for Medicare. This year, to make this policy more affordable, the
President proposes a tax credit, equal to 25 percent of the premium, for participants in
the Medicare buy-in. Coupled with the tax credit for COBRA (described below), this
policy will address both access to and the affordability of health insurance for this
vulnerable group.
•
Making COBRA Continuation Coverage More Affordable ($10.3 billion over 10
years). Consolidated Omnibus Budget ReconCiliation Act (COBRA), passed in
1985, allows workers in firms with greater than 20 employees to pay a full premium
(1 02 percent of the average cost of group health insurance) to buy into their
employers' health plan for up to 18 months after leaving their job. This policy is
intended to improve the continuity of health coverage as workers change jobs.
However, fewer than 25 percent of people eligible for this coverage participate, in
part due to cost. The President's budget includes a 25 percent tax credit for COBRA
premiums to reduce the number of Americans who experience a gap in coverage due
to job change.
•
Improving Access to Affordable Insurance for Workers in Small Businesses
($313 million over 10 years). Nearly half of uninsured workers are in firms with
fewer than 25 employees. The President proposes to give small firms that have not
previously offered health insurance a tax credit equal to 20 percent their contribution
-twice the credit he proposed last year-- towards health insurance obtained through
purchasing coalitions. In additional, tax incentives would be given to foundations to
help pay for start-up costs of these coalitions, and the Federal Employees' Health
Benefits Program would provide any technical assistance needed.
•
Expanding State Options to Insure Children Through Age 20 ($1.9 billion over
10 years). Nearly one in three people ages 18 to 24 are uninsured mostly because
they age out of Medicaid or S-CHIP or no longer are dependents in private plans.
However, they often do not have jobs that offer affordable coverage. The budget
would gives states the option to cover people ages 19 and 20 through Medicaid and
FamilyCare.
3
�•
Extending Transitional Medicaid ($4.3 billion over 10 years). Many people
leaving welfare for work take first jobs that do not offer affordable health insurance.
Recognizing this, Congress passed a requirement in 1988 that extends Medicaid
coverage for up to a year for those losing it due to increased earnings. This provision
was extended in the welfare reform law to 2001. The President's budget makes this
provision permanent and simplifies the state and family requirements to promote
enrollment.
•
Restoring State Options to Insun~ Legal Immigrants ($6.5 billion over 10 years).
States are prohibited from providing health insurance for certain legal immigrants
who entered the U.S. after the enactment of welfare reform. The uninsured rate for
people of Hispanic origin, some ofwhom are legal immigrants, was 35 percent in
1998 -over twice the national average of 16 percent. The proposal would give states
the option to insure children and pregnant women in Medicaid and S-CHIP regardless
of their date of entry. It would eliminate the 5-year ban, deeming, and affidavit of
support provisions. The proposal would also require states to provide Medicaid
coverage to disabled immigrants who would be made eligible for SSI by the FY 2001
budget's SSI restoration proposal.
IV. STRENGTHENING PROGRAMS THAT PROVIDE HEALTH CARE
DIRECTLY TO THE UNINSURED (At least $1 billion over 10 years). In the
absence of a universal health insurance system, public hospitals, clinics, and thousands of
health care providers give health care of the uninsured and receive inadequate
compensation for doing so. Despite a rising need, reductions in government spending
and aggressive cost cutting by private insurers has left less money in the health care
system to address these needs. The President will renew his commitment to helping these
providers by:
•
Increasing Funding for Increasing Access to Health Care for the Uninsured
(+$100 million for FY 2001, $1 billion over 5 years). Last year, the President and
Secretary Shalala proposed an historic new program to coordinate systems of care,
increase the number of services delivered and establish an accountability system to
assure adequate patient care for the uninsured and low-income. The Congress funded
an initial $25 million investment for this program. This year, the President proposes
funding this initiative at $125 million, a $100 million increase over 2000. This
represents a down payment on the President's proposal to invest $1 billion over 5
year. The Administration will also aggressively pursue an authorization to ensure
that the program is established as a core element of the health care safety net.
•
Investing in Community Health Centers (+$50 million for FY 2001). The budget
proposes an increase of $50 million to support and enhance the network of
community health centers that serve millions of low-income and uninsured
Americans - for total funding of over $1.069 billion in FY 2001.
4
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~
(~
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'
f, i
r• Draft 01118/00 3:00 pm
Heather Hurlburt
PRESIDENT WILLIAM J. CLINTON
STATEMENT ON HEALTH CARE
THE WHITE HOUSE
WASHINGTON, DC
'1ActJ ~ofc!Jd
January 19, 2000
~ fiu.r;t;t'\ .
c .
·. 11s .
ne o f t
1ggest wornes 1acmg Amen. can c. .1.ws, even 111 tl' tlme o f'
tailll
· g fo health care. Today I want to talk about two proposals in my
growing prosperity, is
budget for 2001 that will help Americans shoulder the costs of health care- by extending
insurance coverage to millions of people, and helping many others meet the demands of
providing long-term care. These proposals [represent the largest investment in America's health
since the creation of Medicare and Medicaid.] And they are central to autlcing suf'e every
American ~access to high-quality health care in the century ahead.
.
G oo d mommg.
Via~e..-
Zuf:;'Vof
jJ(O~dais
As we live longer, and can do more to contr l the progress of disease, more and more of
us face the financial and human costs of providing ong-term care for loved ones- or ourselves.
to help Americans face these new
We announced yesterday tbat wy budgst-f ·
challenges -- by tripling the tax credit for long-term care expenses; by modernizing Medicaid to
assist those in long-term care; and by creating a national program to help caregivers get
information, training and support.
We need to confront new challenges to America's health, such as long-term care, even as
we continue to fight to expand health care coverage to Americans who lack it. We still have too (
many working families choosing between food on the table and a doctor's visit. Too many;]
children taken to emergency rooms with illnesses tha.t should never have happened. Too many
chances missed to screen for cancer and other deadly diseases. AJ:id ure are giving our cbildr~
+eo fe ,y chances at a healthy start. •
iiA.J uJP .
.
.
Today I am announcing an initiative kf expand health insurance options for J:l1ore thaR ~
on the programs we already have in place. My budget for 2001 will
set aside $100 billion dollars over 10 years to reach w.hols gFOups of Americans who are falling
through the cracks.
(Vfl!JIL CfUv.-
~building
S;rnJ}
First, we will work with states to reach every child eligible for CHIP or Medicaid. To
find those children, we've got to take information and enrollment to where they and. their parents
are. That means going to day care centers, school lunch programs, or centers for the homeless.
My budget will fund efforts to do just that- because there is just no reason for any child in
America~ to grow up without basic health care.
fa)w_
costs~n
Second, anyone who is concerned about the toll health care
our economy and our
society must worry not just about children, but about families. That is why; as Vice President
Gore has urged, we should allow parents to enroll in the same health insurance programs that
�cover their children. My budget will give states the money they need to make this change under
one new initiative called Family Care. It will also help families eligible for Family Care
purchase insurance from their employers, when that is the best option.
Third, we are reaching out to those Americans who cannot get insurance through their
jobs, but are not eligible for Medicare or Medicaid. Their numbers are growing fastest among
people nearing retirement, ages 55-65. I have already proposed that they be allowed to buy into
Medicare coverage- and my budget provides a tax credit to help them do it.
Almost half of uninsured workers are in small businesses. We should help them get
coverage- and help businesses provide quality coverage at affordable prices. My budget
contains a 20 percent tax credit for small businesses that offer health insurance for the first time;
and it provides tax incentives for purchasing coalitions to keep insurance costs down.
My budget will also allow states to c:ontinue coverage for 19- and 20-year olds who age
out of insurance plans. It offers a 25 percent tax credit to people between jobs who are paying
the full cost of health insurance from a previous job. And it makes our transitional Medicaid
program, for people moving from welfare to work, pem1anent and easier to join.
.
{ld())~
Finally, we must strengthen the~efh of clinics, public hospitals, and dedicated doctors
OCJfi.\'AtM
and nurses that serve the uninsured, never turning a patient away. Last year, we propusecl a
en~~ ck.-J prograr:n te previa~ ft10re aftcl b€:ltter CftfC through such c~mt€:lFS, and Ccmgr€:166 fbmded it '-''ith $2S
'
r. )~ J.-.. ~illign clollars.. This year, I propose that we use $125 million dollars to make tl1Qse centers- J()lli_~~
Jou rfl- LV places where anyone can get decent basic care. And (propose a $50 million increase in funding':/:()' "r
the community health centers that provide primary care for millions of Americans.
~~.
yt:or
~/c.
,0AXJIJ1
. If'·-
Every American knows how hard it is to bear the emotional and financial burdens of a
.
loved one's illness. But every American should also know that it can be done. That there is help t~
available. And that when we talk about moving a strong nation into a new millennium, we mean
... ~
a nation of strong, healthy people. Ready to work and contribute, and confident that they and
their children will be cared for with dignity. We have a chance now to make that investment in
our common future - and we should not miss it.
�Draft 12/30/98 6:00pm
JeffShesol
PRESIDENT WILLIAM J. CLINTON
REMARKS ON LONG-TERM CARE
THE-'WHITE HOUSE
January 4, 1999
Acknowledgments: the First Lady; the VP and Mrs. Gore (via satellite from California);
Sees. Rubin and Shalala; Janice LaChance, OPM; person TBD
, Another new year is upon us -- a time for celebration, and, perhaps, a time to feel a little
bit older. If we do, we are not alone. America may be young in spirit; our nation may have all
the energy and intensity and ambition of youth; but our people are aging. On the verge of the
new century, we are undergoing a profound, seismic demographic shift. Today I want to talk
about the ways we are going to meet the challenges of this new America.
Simply put: The baby boom will soon become the senior boom. And, like the baby
boom did in decades past, the senior boom will change the face of America. During the next
30 years, 76 million baby boomers will join-- and greatly expand-- the ranks of the retired. The
number of elderly Americans will double by 2030. By the middle of the next century, the
·average American will live to 82, six years longer than today.
These changes are underway. Already, longer lives are also stronger, healthier lives,
thanks to medical science. Already, older Americans are redefining retirement. They are
proving that, rather than an ending, it can be a new beginning: a time to learn new ideas, start a
new business, travel to new and distant lands.
Still, aging is inevitable; and so today are the infirmities of age. Nearly half the people
over 85 --one of the fastest-growing segments of the American population-- need help with
everyday tasks. Eating. Dressing. Going to the doctor. We cannot expect all or even most older
Americans to fend for themselves. We cannot expect it and we would never wish it. The real
question is what sort of care is best in each individual case. Millions require the kind of care
only a nursing home can provide, but millions more choose to remain at home, close to family
and friends.
Indeed, the elderly and people with disabilities are remaining at home in record numbers,
cared for by those who care the very most. Today, more than [22 million households] are caring
for elderly relatives and even neighbors. They represent the best of America-- fulfilling, each
and every day, the pledge to our parents' generation that is not often spoken, but resonates deeply
in the American character.
Providing long-term care at home is, more and more often, a common choice, but it is
rarely an easy one. Since this kind of care is rarely covered by private insurance or Medicare,
out-of-pocket expenses can be high. So, too, are the professional costs. Caregivers who hold
�jobs outside the home-- and that is a vast majority-- may have to take unpaid leave or work
fewer hours to fulfill all their responsibilities. Caregiving is, in countless ways, vital, meaningful
work; but it can also be stressful work.
The Vice President just told you what we've been doing to ease the burdens on these
families: by improving nursing homes, strengthening Medicare, and making Medicaid more
flexible. But in 21st-Century America, more will be asked ofus, and so there is more work to be
done.
Today, I am announcing a bold initiative to give care to the caregivers --to help
Americans provide long-term care for aging and ailing loved ones. The size of the senior
boom demands it. The length of our lives makes it more important than ever. And so does
the sacrifice of American families -- 22 million households putting the well-being of
relatives or neighbors above their own.
This is a complicated challenge; it requires a range of responses. Therefore, to improve
long-term care in America, to give it the priority and support these families deserve, there are
four things we must do. First, I am proposing a long-term care tax credit-- $1,000 for people
with long-term care needs or for the families that shelter them. It is far better to devote this
money to help keep the elderly and disabled at home than to spend the same amount to have
them live away from home. Our parents worked and saved and sacrificed to care for us in our
youth. Adult children are working and saving and sacrificing to care for their parents in old age.
It is the cycle of life -- a vital and sacred compact among generations -- and one we should
recognize and reward as a nation.
This targeted tax cut of $1,000, paid for in our balanced budget, would help meet the
individual needs of individual families -- supplementing the care they already provide,
empowering them to do what is best. It would help offset the direct costs oflong-term care, like
home health visits and adult day care, as well as the indirect costs, like the unpaid leave some
caregivers take from work. The care they provide is invaluable; but we can show we value it
very much indeed.
Second, we should create a Family Caregiver Support Program-- a new national network
to support people caring for older Americans. In decades past, families could do little for ailing
relatives but give them shelter and love. Today, due to advances in science, caregivers tend to
everything from dialysis to depression, preparing-intravenous meals and insulin injections. This
initiative enables states to create "one-stop shops" --places caregivers can access the resources of
the community, find technical guidance, and obtain respite and adult day care services. These
families want to provide the best possible care; we want do everything in our power to help them.
That is why, third, we must educate Medicare beneficiaries about long-term care options.
Medicare does not cover most kinds of long-term care, so it is important that beneficiaries
understand their alternatives. This initiative helps answer essential questions efficiently: What
2
�-------..
-
-
- - - - --
""'
are my choices? What should I look for in a private long-term care insurance policy? By
launching a national educational campaign,, we can help ensure that people in need get the
answers -- and the quality care -- they deserve.
Fourth, I am proposing that the federal government use its power as the nation's largest
employer, use its market leverage, to set a national example -- offering private long-term care
insurance to federal employees. By promoting high-quality, affordable care, we can encourage
more people and more companies to invest in long-term care coverage. We can help more
employees -- in every part of our economy -- prepare for the future.
There is no single solution to the challenges of caregiving. But together, these initiatives
represent a powerful force for positive change. To fulfill our fundamental obligation to older
Americans and people with disabilities, we, too, must act together-- members of both parties, of
two branches of government, putting progress above partisanship for the sake of our people.
That means taking these important steps, and I call on Congress to do so. It also means
strengthening Medicare; and, as I have said many times in the past year, it means saving Social
Security for the 21st Century -- for Social Security, too, is a sacred trust between generations.
We now have a remarkable opportunity to strengthen it for the future; we must make the most of
it.
The senior boom is one of the central challenges of the coming century. If we face these
challenges together and make them our top priorities, if we make the efforts I have described
today, then we can prove what no generation in history has had the opportunity to prove -- that
the infirmities of age need not be the indignities of age. Thank you.
3
�'
.)
.
DRAFT: THE PRESIDENT TRIPLES HIS LONG-TERM CARE TAX CREDIT AND
URGES CONGRESS TO PASS A LONG-TERM CARE INITIATIVE IN 2000
January 18,2000
'
Today, the Clinton Administration confirmed that the President's budget will include a $3,000 tax
credit for people with long-tem1 care needs or their caregivers-- tripling the credit over last year's
proposal and increasing the total investment in long-term care to $28 billion over 10 years. This
credit is the centerpiece of the President's historic long-term care initiative that has won praise
from senior groups and health policy experts. The initiative tackles the complex problem of longterm care that affects millions of elderly, people with disabilities and families who care people in
need. In addition to the (l) tax credit, the initiative will (2) create a new National Family Caregiver
Support Program; (3) expand Medicaid eligibility for people in home- and community-based
settings; (4) encourage partnerships between public housing for the elderly and Medicaid; and (5)
encourage the purchase of quality private long-term care insurance by Federal employees. This
initiative complements the Administration's effort, spearheaded by the Vice President, to improve
the quality of care in nursing homes. The President wi II commend Congress on giving this
initiative serious consideration in the last session and urged it to finish the job this year.
MILLIONS OF AMERICANS HAVE LONG-TERM CARE NEEDS
o
An increasing number of Americans have a range of long-term care needs. Over five
million Americans have significant limitations due to illness or disability and thus require longterm care. Approximately, two-thirds are older Americans. Also, millions of adults and a
growing number of children have long-term care needs because of health condition from birth
or a chronic illness developed later in life.
•
The aging of Americans will only increase the need for quality long-term care options.
The number of Americans age 65 years or older will double by 2030 (from 34.3 to 69.4
million), so that one in five Americans will be elderly. The number of people 85 years or older,
nearly halfofwhom need assistance with everyday activities, will grow even faster.
FINANCIAL AS WELL AS NON-FINANCIAL SUPPORTS ARE NEEDED
•
Families, who are the primary caregivet·s for people with long-term care needs, pay a big
price for this care. Although it is difficult to quantify, one study found that the economic
value of caregiving for families ranges from $4,800 to $10,400 per caregiver. As such, this
new $3,000 tax credit could cover from about up to 60 percent of families' costs.
o
Costs are not just financial. Families and friends caring for people with long-term care needs
ctre often need help finding the information and resources necessary for this task. Most of the
primary caregivers for the elderly are elderly themselves, presenting problems since informal
caregiving often requires physical work like he<:tvy lifting, frequent bedding changes, dressing
and bathing. These stresses tend' to be more severe for f~tmilies ofpeople with Alzheimer's
disease. Such caregivers tend to experience greater time demands, family conflict, strain,
mental and physical problems, and financial hardship.
•
Private insurance is an important but relative new and untested option. Only about 4
million Americans-- 1.5 percent of all Americans-- have private long-term care insurance.
Employers are only beginning to learn how to provide these benefits to their workers.
�I
.,
/
PRESIDENT'S LONG-TERM CARE lNITlATlVE. The Clinton Administration's long-term care
initiative, which invests $10 billion over 5 years and $28 billion over 10 years, includes:
•
Supporting families with Iong-tem1 care needs through a $3,000 tax credit. This initiative, for the
first time, acknowledges and supports millions of Americans with long-term care needs or the family
members who care for and house their ill or disabled relatives through a $3,000 tax credit. This credit
would be phased in beginning with $1,000 in 2001 and rising in $500 increments, so eligible people
would receive $3,000 in 2005 and thereafter. The credit would be phased out beginning at $110,000 for
couples and $75,000 for unmarried taxpayers. This new tax credit supports the diverse needs of
!"ami lies by compensating a wide range of f'ormal or Informal long-term care for people ol· all ages with
three or more limitations in activities of daily living (ADLs) or a comparable cognitive Impairment. lt
would provide needed financial support to about 2 million Americans, including 1.2 million older
Americans, over 500,000 non-elderly adults •. and approximately 250,000 children. lt costs about $8.8
billion over five years and $26.6 billion over 10 years.
•
Creating a new National Family C:u·egiver·Support Program. Recent studies have found that
snvices like respite care can relieve caregiver stress and delay nursing home entry, and that support for
!'ami lies of Alzheimer's patients can delay institutionalization for up to a year. This new nationwide
program would support t~1milies who care for elderly relatives with chronic illnesses or disabilities by
enabling states to create "one-stop-shops" that provide: quality respite care and other support services;
Cl"ltiCcll information about community-based long-term services that best meet a families' needs; and
counseling and support, such as teaching model approaches for caregivers that are coping with new
responsibilities and offering training for complex care needs, such as feeding tubes. This program,
which costs $625 million over five years, would assist approximately 250,000 families nationwide.
•
Expanding Medicaid eligibility for people in home- and community-based care settings.
Historically, Medicaid policy and practice has inadvertently discriminated against people with longterm care needs who vvant to live in the community by making it much easier to expand coverage to
nursing homes than community-based services. This proposal would enable states to expand their
programs to cover community-based care as vvell as nursing home residents with income up to 300
percent of the Social Security Income (SSI) limits, without requiring a complicated and frequently timeconsuming Federal waiver. This proposal contributes towards this initiative's goal of giving people
with long-term care needs the choice of remainmg in their homes and communities. It costs $140
million over 5 years, $370 million over 10 years.
•
Encout·aging pal'tnerships between public housing for the elderly and Medicaid. Tliis proposal
would provide $100 million in competitive grant funds to qualified elderly housing facilities (Section
202 l~1ci Iities) to convert to assisted Ii ving f~1ci lities, so long as those facilities provide Medicaid home
and community-based services. As people living these housing facilities age, their need for long-term
care services rises, often leaving them with no choice but to move to a nursing home. This proposal
would allow such people to "age in place" by funding the conversion of their homes into assisted living
I~Icilities. Only sites that agree to bring Medicaid home and community-based services into their
convened assisted living facilities would qualify fm grants, to ensure that low-income elderly have
access to this option.
•
Having the Federal government serve as a model employer by offering quality pl'ivate long-term
care insurance to Federal employees. The Office of Personnel Management (OPM) to use its market
leverage and set a national example by offering non-subsidized, quality private long-term care
insurance to all federal employees, retirees, and their families at group rates. This proposal, which costs
$15 million over five years, will provide employers a nationwide model for offering quality long-term
care msurance. OPM anticipates that approximately 300,000 Federal employees would participate in
this program.
�PRESIDENT UNVEILS MAJOR NEW
HEALTH INSURANCE INITIATIVE
DRAFT:
January x, 2000
Toddy, Presld~iit•Cltnt£nl'}villunveil a f$xj bitlidninitia~ive WtiDJvpuld dtmizatically
expandinsritance cov~rage.:t!)'millfonsofAmerif:~ns.. Tll~propi,si4;.~~j)/ljch'HJ.OillilnuJ,r{!··
than double the fzistpi~lc 199'7,"TO~year ilit!estmeilt.of$48 billion lii•qliildrim1s health · ·
coverage, wotdd pro\,ide ajforAable coverage to~ million ln.ore Aluericans; 1t zs
designed to address the nation's multi-faceted coverage 'clialleng~s by buildiilg on and
complementing curientp1;ivate and public programs. Sjle.cijically, the initidtive.will:
(1) accelerat~ enrolli;teJ~t ojr/nin sured ell if dren ·eligiblejoi: Medicaid and S-CHiP,; ·• (2) ·
provide a ~~.f!~~t·affot:dablq ~~~iilthinsurance opti~nforfajnilies; (3) expand' health
.
1
ii1 sura nee ipti~ns/~i-;Aniericans facing unique barriers. to. coverage; {ill d (4).
strengtlreniiig.progr.,qnzstbatjJ~·ovide health care directly to the. uninsured.
. ,· .. ·.
'.. .,,
. . .
'
·~
·,
'
The Challenge of the Uninsured and Its Implications. Over 44 million Americans
lack health insi.trance. Although there are many causes ofthis problem, it generally
results from lack of affordability and/or access to coverage. Family health insurance
premiums cost on average $5,700 -which represents a large share of income for a family
trying to make ends meet. Purchasing affordable, accessible insurance is a particular
challenge for many older people, workers in transitions between jobs, and small
businesses and their employees. Lacking health insurance has serious consequences. The
uninsured are three times as likely to not receive needed medical care, 50 to 70 percent
more likely to need hospitalization for avoidable hospital conditions like pneumonia or
uncontrolled diabetes, and four times more likely to rely on an emergency room or have
no regular source of care than the privately insured. The President will propose a major
four-pronged initiative designed to significantly expand coverage.
I. providing A NEW, affordable health insurance OPTION FOR families ($76.0
billion over 10 years). Over 80 percent ofparents of uninsured children with incomes
below 200 percent of poverty ($33,000 for a family of four) are themselves uninsured.
Yet, while states have aggressively expanded insurance options for children through
Medicaid and S-CHIP, parents are often left behind. There are about 6.5 million
uninsured parents with income in the Medicaid and S-CHIP eligibility range for children.
These parents frequently do not have access to employer-based insurance, and when they
do, cannot afford it. Recognizing that family coverage not only helps a large proportion
the nation's uninsured adults but increases the enrollment of children, the Vice
President, the National Governors' Association, and a wide rage of groups including
Families USA and the Health Insurance Association of America have called for building
on S-CHlP to cover parents. The President's budget adopts this approach by:
or
�•
Creating a New "FamilyCare" Program. This proposal would provide higher Federal
matching payments for state coverage of parents of children eligible for Medicaid or
S-CHfP. S-CHJP would become "FamilyCare". Under FamilyCare, parents would
be covered in the same plan as their children. States would use the same systems and
follow most of the same rules as they do in Medicaid and S-CHIP today, and the
program would be overseen by the same state agency. State spending for FamilyCare
would be matched at the same higher matching rate asS-CHIP (up to 15 percentage
points higher than the Medicaid rate). To ensure adequate funding, $50 billion over
I 0 years would be added to the current state S-CI-UP allotments. To access these
higher allotments, states would have to first cover children to 200 percent of poverty
as 30 states now have clone. Given the experience of S-CHIP and the strong state
support to extend S-CI-HP to parents, it is likely that most-- if not all-- states will
take up this option. [f after 5 years, however, some states have not expanded
coverage of parents to at least I 00 percent of poverty ($16,000 for a family of four), a
f~1il-safe mechanism would be triggered to require states to expand coverage to at least
that level.
•
Assisting Families in Affording Private Employer-Based Coverage. FamilyCare
would also expand the S-CHIP option to pool state funding with employer
contributions towards private insurance. This would enable families, otherwise
eligible for FamilyCare coverage, to purchase their employers' health plan as long as
it meets FamilyCare standards. Supported by the National Governors' Association,
this option has the potential to cost-effectively use FamilyCare dollars since
_
employers must contribute at least halfofthe premium for the family to be eligible
for assistance. The minimum employer contribution, ~long with the S-CHlP crowdout rules, should discourage employers from reducing or dropping coverage.
H. acceleratiNG enrollment of uninsured children eligible for Medicaid and S-CHlP
($5.5 billion over 10 years). The State Children's Health Insurance Program (S-CHIP)
helps children in families with income too high to be eligible for Medicaid but too low to
afTord private insurance. Enrollment inS-CHIP doubled to 2 million children in 1999.
However, despite this encouraging trend, millions of children remain eligible but
unenrollecl in both S-CHIP and Medicaid. The budget would give states needed tools to
increase coverage by:
•
Allowing School Lunch Programs to Share Information ·with Medicaid ($345 million
over 10 years). Since 60 percent of uninsured children are in the school lunch
program, sharing eligibility information can efficiently help outreach efforts.
•
l~xpanding Sites Authorized to Enroll Children in S-CHIP and Medicaid ($1.2
billion over 10 years). This includes schools, child care resource and referral
centers, homeless programs, and other sites.
o
Requiring States to Make their Medicaid and S-CHIP Enrollment Equally Simple
($4.0 billion over 10 years). Most states have carried over theirS-CHIP
�..
simplification strategies like eliminating assets tests and using mail-in applications
and 12-month eligibility redeterminations. This proposal would have all states do so.
r
III. EXPANDING health insurance options for AMERICANS .facing unique
harriers to coverage ($x billion over 10 years). Some vulnerable groups of peopleolder Americans, workers in small businesses, people in transitions (between jobs,
turning 19 and entering the workforce, leaving welfare for work)- often have access to
neither employer-sponsored insurance nor insurance programs like Medicare or
Medicaid. This plan addresses these specific problems by:
o
Establishing ·a Medic.are Buy-In Option and Making It More Affordable Through a
Tax Credit ($5 billion over 10 years). The rate of uninsured is growing fastest
among people ages 55· to 65 and is expected to increase even faster in the future.
Recognizing this, the President has called on Congress to pass legislation that allows
people ages 62 through 65 and displaced workers ages 55 to 65 to pay premiums to
buy into Medicare. He also would require employers who drop retiree coverage to
allow early retirees with limited alternatives to have access to COBRA continuation
coverage until they reach age 65 and qualify for Medicare. This year, to make this.
policy more affordable, the President proposes a tax credit, equal to 25 percent of the.
premium, for participants in the Medicare buy-in. Coupled with the tax credit for
COBRA (described below), this policy will address both access to and the
afTordability of health insurance for this vulnerable group.
•
Making COBRA Continuation Coverage More Affordable ($x billion over 10 years).
Consolidated Omnibus Budget Reconciliation Act (COBRA), passed in 1985, allows
workers in firms with greater than 20 employees to pay a full premium ( l 02 percent
of the average cost of group health insurance) to buy into their employers' health plan
for up to 18 months after leaving their job. This policy is intended to improve the
continuity of health coverage as workers change jobs. However, fewer than 25
percent of people eligible for this coverage participate, in part due to cost. The
President's budget includes a 25 percent tax credit for COBRA premiums to reduce
the number of Americans who experience a gap in coverage clue to job change.
•
Improving Access to Affordable Insurance for Workers in Small Businesses ($x
billion over I 0 years). Nearly half of uninsured workers are in firms with fewer than
25 employees. The President proposes to give small firms that have not previously
offered health insurance a tax credit equal to 20 percent their contribution- twice the
credit he proposed last year-- towards health insurance obtained through purchasing
coalitions. In additional, tax incentives would be given to foundations to help pay for
start-up costs of these coalitions, and the Federal Employees' 1-lealth Benefits
Program would provide any technical assistance needed.
•
Expanding State Options to Insure Children Through Age 20 ($1.9 billion ov.er I 0
years). Nearly one in three people ages 18 to 24 are uninsured mostly because they
age out of Medicaid or S-CHJP or no longer dependents in private plans. However,
they often do not have jobs that offer affordable coverage. The budget would gives
�states the option to cover people ages 19 and 20 through Medicaid and FamilyCare.
o
Extending Transitional Medicaid ($4.3 billion over l 0 years). Many people leaving
wei fare for work take first jobs that do not offer affordable health insurance.
Recognizing this, Congress passed a requirement in 1988 that extends Medicaid
coverage for up to a year for those losing it clue to increased earnings. This provision
will expire after 2001. The President's budget makes this provision permanent and
simplifies the state and family requirements to promote enrollment.
•
Giving States the Option to Cover Legal Immigrants ($6.5 billion over 10 years).
States are prohibited from providing health insurance for certain legal
immigrants who entered the U.S. after the enactment of welfare reform. The
uninsured rate for people of Hispanic origin, some of whom are legal
immigrants, was 35 percent in 1998- over twice the national average of 16
percent. The proposal would give states the option to insure children and pregnant
women in Medicaid and S-CHTP regardless of their elate of entry. It would eliminate
the 5-year ban, deeming, and affidavit of support provisions. The proposal would
also require states to provide Medicaid coverage to disabled immigrants who vvoulcl
be made eligible for SSI by the FY 200 I budget's SSl restoration proposal. These
proposals are expected to cover 210,000 individuals in FY 2005 and nearly 300,000
in FY 2010 [check]
IV. STRENCTI-lENINC Programs that Provide Health Care Directly to the
Uninsured (+$150 million fot· FY 200 I). In the absence of a universal health insurance
system, public hospitals, clinics, and thousands of health care providers give health care
of the uninsured and receive inadequate compensation for doing so. Despite a rising
need, reductions in government spending and aggressive cost cutting by private insurers
has left less money in the health care system to address these needs. The President will
renew his commitment to helping these providers by:
•
Increasing Funding for Increasing Access to Health Care for the Uninsured (+$100
million for FY 2001). Last year, the President and Secretary Shalala proposed an
historic new program to coordinate systems of care, increase the number of services
cleliverecl and establish an accountability system to assure adequate patient care Cor
the uninsured and low-income. The Congress funded an initial $25 million
investment for this program. This year, the President proposes funding this initiative
at $125 million, a $100 million increase over 2000. The Administration will also
aggressively pursue an authorization to ensure that the program is established as a
core element ofthe health care safety net.
•
Investing in Community Health Centers (+$50 million for FY 2001). The budget
proposes an increase of $50 million to support and enhance the network of
community health centers that serve mi !lions of low-income and uninsured
Americans- Cor total Cuncling of over $1.(J69 billion in FY 200 I.
�http://www.pub. whitehouse.gov/uri- .. ./oma.eop.gov .us/2000/l/Jl/4.text.l
THE WHITE HOOSE
Office of the Press Secretary
For Immediate Release
January 11,
2000
WHITE HOOSE RELEASES NEW REPORT ANNOUNCING TWO MILLION CHILDREN ENROLLED
IN THE STATE CHILDREN'S
HEALTH INSURANCE PROGRAM
Unveils New Initiative to Finish the Job Enrolling Uninsured Children
January 11, 2000
Today, the Clinton-Gore Administration will release a new report by the
Department of Health and Human Services documenting that 2 million
children have now been enrolled in the new State Children's Health
Insurance Program (SCHIP), doubling the program's enrollment in less
than a year.
The White House will also unveil a new, multi-faceted
proposal that will be included in the President's FY 2001 budget to
accelerate enrollment of uninsured children in Medicaid and SCHIP.
This
initiative will invest $2.7 billion over the next five years to: (1)
provide new options to find and enroll uninsured children through
schools; (2) allow additional s~tes such as child care referral ceriters
to immediately enroll low-income, uninsured children while their
applications are formally processed; (3) require states to make their
Medicaid enrollment as simple as that of SCHIP; and (4) expand Medicaid
to include an option to cover children through age 20 and extend the
same option to SCHIP.
Together, these steps will help states finish the
job of enrolling uninsured children in Medicaid and SCHIP.
NEW REPORT SHOWS THAT 2 MILLION CHILDREN ARE NOW ENROLLED IN SCHIP.
Today, HHS is releasing a state-by-state report on SCHIP enrollment and
implementation.
Created in 1997, SCHIP enables states to cover children
from working families whose incomes are too high to qualify for Medicaid
but too low to afford private health insurance.
This expanded coverage
can be achieved through Medicaid expansions, a separate state program,
or a combination of both strategies.
As states continue to expand their programs, this report shows that
great progress has already been made in enrolling children.
Highlights
include:
The number of children enrolled in SCHIP has doubled in less than a
year.
Nearly 2 million children were served by SCHIP between October l,
1998 and September 30, 1999, a doubling in enrollment from December
1998.
The number of states covering children up to 200 percent of poverty has
increased by more than seven fold.
In March 1997, only 4 states covered
children with family incomes up to at least 200 percent of the Federal
poverty level (about $33,000 for a family of 4).
Today, 30 states have.
plans approved to cover children with incomes up to at least this level.
MORE NEEDS TO BE DONE TO FINISH THE JOB.
Despite these positive
enrollment trends, millions of children remain eligible for Medicaid or
SCHIP.
Reasons why children remain uninsured include:
Lack of awareness of eligibility.
Many parents believe that working ot
not receiving welfare disqualifies their children from Medicaid or
SCHIP.
Others do not know about SCHIP, which targets families that
cyp1cally do not qualify for other public programs.
Lack of coordination between programs. A recent
Institute found that approximately 60 percent the uninsured children nationwide are currently
programs.
However, Federal law prohibits these
enrollment information with Medicaid.
I of' J
study by
almost 4
enrolled
programs
the Orban
million - of
in school lunch
from sharing
1/18/2000 9:46AM
�http:/ /ww\v. pub. wh itehouse.gov/uri- .. ./oma.eop.gov .us/2000/ l/ll/4. text.!
(
Uifficult enrollment process.
While states, the Administration and
Congress have made it significantly easier for parents to enroll their
children, barriers remain.
These include confusing applications with
complicated paperwork requirements; some states' requirement for
in-person interviews, often at inconvenient times and places; different
processes within states for Medicaid and SCHIP applications; and Federal
statutory limits on where Medicaid eligibility can be established on a
"presumptive" basis (e.g., most schools are disqualified).
CLINTON ADMINSTRATION UNVEILS NEW INITIATIVE TO HELP STATES FINISH THE
JOB OF ENROLLING UNINSURED CHiLDREN IN MEDICAID AND SCHIP.
Today, The
White House will unveil a new, five year, $2.7 billion investment in
children's health outreach that will be included in the Administration's
FY 2001 budget.
This initiative will:
Provide new options to find and enroll uninsured children through
schools.
This proposal, similar to bipartisan legislation proposed by
Senator Lugar (S. 1570), would allow school lunch programs to share
application information with Medicaid staff for the sole purpose of
outreach and enrollment (this is already allowed for SCHIP).
It would
also allow states to use enrollment in school lunch programs as the
basis for presumptive eligibility for Medicaid and/or SCHIP.
This means
that qualified entities, at the states' discretion, may immediately
enroll potentially eligible children in Medicaid and SCHIP on a
temporary basis while their applications are formally processed.
Allow additional sites, like child care referral centers, to help bring
kids into SCHIP and Medicaid.
The President's proposal also gives
states added flexibility to use additional sites, beyond schools, to
determine presumptive eligibility: child care centers, homeless
shelters, agencies that determine eligibility for Medicaid, TANF, and
SCHIP, and other entities approved by the Secretary.
This option can
help states provide critical health care services to children pending
official enrollment and increases the likelihood that families will
complete the application process.
Require states to make their Medicaid and SCHIP enrollment equally
si1nple . . Complicated, long application processes for Medicaid and SCHIP
discourage enrollment.
While many states have recognized this and have
simplified the process in SCHIP and Medicaid, not all states have
carried over all of their simplification strategies to Medicaid.
To
ensure that children do not fall through the cracks in states that have
different rules and procedures for Medicaid and SCHIP, this proposal
would require that states conform certain Medicaid eligibility rules and
procedures for children to the rules and procedures used in SCHIP.
If a
state, in SCHIP: (1) does not require an assets test; (2) uses simple
eligibility requirements and a mail-in application; and (3) determines
eligibility for SCHIP no more than once a year, it would need to apply
these same rules and procedures for children in Medicaid.
Expand Medicaid to include an option to cover children through age 20
extend the same options to SCHIP.
Currently, states have the option
to extend Medicaid eligibility to some children through age 20.
This
proposal would allow states the same flexibility for SCHIP and for all
other Medicaid children, helping them cover people in one of the most
vulnerable age groups; the highest uninsured rate -- 30 percent -- is
for people ages 18 to 24 years old.
~nd
BUILDS ON THE CLINTON-GORE ADMINISTRATION'S LONGSTANDING COMMITMENT TO
CHILDREN'S HEALTH.
President Clinton and Vice President Gore have a
long standing commitment to children's health -- and to ensuring that
children eligible for insurance know about it.
In 1998, the
Clinton-Gore Administration, together with the National Governors
Association and private sector partners, launched a nationwide ''Insure
2 of3
1/18/2000 9:46AM
�http://www .pub. whitehouse.gov/uri- .. ./oma.eop.gov. us/2000/ I I II /4. text. I
Kids Now" Outreach Campaign that established a national toll-free number
for children's health insurance outreach (1-877-KIDS NOW or
l-877-543-7669) and a website (www.insurekidsnow.gov).
In 1999, the
!\diitinis tration launched a major back-to-school children's health
outreach campaign that enlisted over 1,500 schools to conduct local
outreach activities.
The Administration supported and, with bipartisan
Congressional support, passed an extension of the TANF $500 million fund
for outreach, providing states with resources to conduct aggressive
education campaigns.
It has promoted the use of a single, simple joint
application for Medicaid and SCHIP; encouraged states to make Medicaid
and SCHIP easy to enroll in and user-friendly; and created an
Interagency Task Force on Children's Health Insurance Outreach that
coordinates outreach actions for over 10 Federal agencies.
In addition,
the Administration has targeted hard-to-reach populations like rural
children and legal immigrant children, by clarifying regulations so that
enrolling in Medicaid or SCHIP and receiving other critical benefits
J.l not threaten their immigration status.
###
J orJ
1/18/2000 9:46AM
�2
At a moment when American power is unprecedented, and the world is coming together
around the ideals Americans have lived by and died for, we have a responsibility -- to ourselves,
to our partners around the world, and to the future-- to lead. Let's never forget the Americans
who have struggled to give us this chance: from the marines on Iwo Jima, to the Peace Corps\
volunteers helping others build the future, to Ronald Reagan saying: "Tear clown that wall."
L,et'~ newgr fergot ths:t fttllttlrods ofmilliens ofreorle live in pcctce totlay essaHse oftlte
~Ito IC:'lt in roaee iri gra"e~ marked 'r111Q 'ellllllGFlcetl ull dCJOSS the ,yodd. We have
come too far, sacrificed too much, to stop the world and get off now. We must continue to shape
the world, doing our part to answer the big questions that will decide the character of the 21st
century.
A central question is whether our security will be threatened by regional conflicts,
especially those rooted in ethnic and religious tensions, that pose the risk of wider war. With all
its amazing advances, our modern world is bedeviled by our oldest failing- fear of those who
are different from us. In too many places, that fear is exploited by unscrupulous leaders trying to
cling to power or make brutal war on their neighbors.
America cannot prevent every conflict or stop every outrage. But when our interests and
our values are at stake and we can make a difference, we must be peacemakers. For history
teaches that all big wars start small, and when human beings anywhere are singled out for
destruction because of who they are, it is our common humanity that suffers.
We should be proud that we have helped bring the Middle East closer than ever to
comprehensive peace. [Update on Israel-Syria; essential that America do its share].
We should be proud of the role America played in bringing peace to Northern Ireland; in
helping to end the bloodletting in East Timor; in supporting efforts to end Africa's cruel wars.
.i ti> &J-
0
AtlJit_~J !tfftfD oJt ~tAct
And we should be proud of the men and won~n of our armed forces who turned the tide
against ethnic cleansing in Kosovo. Thanks to them{ a million innocent people are home. And
instead of struggling to defeat something evil, we can focus on building something good: a Europe
uncliviclecl, democratic and at peace for the first time in history.
[Recognize Mitchell and Kosovo soldier in box; need to stay the course.]
A second question is whether our former adversaries, Russia and China, emerge in the
coming century as stable, prosperous, democratic partners of the United States.
oe!~ ~ risl(~
Today, we
a Russia weakened by the legacy of communism, by
economic crisis, by a cruel and futile war in Chechnya. But never forget how much else has
changed: 5,000 former Soviet nuclear weapons dismantled; Russian troops serving with us in
the Balkans; a peaceful, constitutional transfer of power from one leader to another for the first
time in}( I 000 years of Russian history. Russia's long journey to democracy is profoundly
import<int to our future. A generation from now, let no one say that we did not do our part to
help.
�3
As for China, we must promote our interests with firmness, but not with fear. -8o let us
~China cannot buy its stability and stature at the expense of freedom. But let us
not isolate China from the global forces empowering its people to seek a better life. We want to
see China on the inside, playing by the rules, not on the outside denying them.
A third question for the new century is whether terrorists and hostile nations will acquire
the means to undermine our defenses, and force us to live in fear again.
Thanks in part to the biggest counter-terrorism operation in our history, the millennia!
celebrations passed without a violent attack. But this <1ge-olc\ threat, magnified by modern tools
of destruction, remains real.
.Zk {~.ked (Cfl1.Cull!i)).(~
~ ~D~
m?OJn.dcMI
o/ ~vkon~
.
We must work with other nations to destroy terrorist and criminal networks and to targj
the havens t~1at launder their money. This year, l wi II propose a law giving America new tools to
·
protect our financial system from money laundermg.
big~ =~g€l
A
is to, prevent terrorists and potential adversaries from acquiring deadly
weapons. We can do that by w~'rking with Russia to keep nuclear weapons secure and
continuing to reduce our arsenals. By restraining ~r tl! Korea~ nuclear and missile programs :.
~'and continuing to prevent Iraq from threatening its neighbors. And by strengthening
global standards against proliferation. That is why lam committed to working with the Senate
on a bipartisan basis to rebuild a consensus for the Comprehensive Test Ban Treaty.
We are also developing a system to defend America against missile attack, while working to
preserve the Anti-Ballistic Missile Treaty with Russia. And my balanced budget devotes $2
bili'ion to defend America's cyberspace against hacker~riminalse1d potential adversarieiJ
A fourth question is whether the stability of the 21st century world will be threatened by a
growing gap between rich and poor. We just cannot accept a future in which part of humanity
lives on the cutting edge of a new economy, while another lives on the edge of survival. I[;...i..s.&t
r.i..ghl And it isn't jn ou.Httterest.
A large part ofthe answer is freedom. With the hopeful transitions to democracy in Nigeriaand
Indonesia, more people won the right to choose their leaders in 1999 than in 1989, the year the
Berlin Wall fell. Yet even countries making all the right choices must sometimes struggle to
deliver lor their people.
We must stand by democracies like Colombia fighting for their lives-- and for our lives-against narcotics traffickers. I have proposed a two-year, $1.6 billion package to help Colombia ·
and I count on your support.
o,.dc~'l- cflf!J]JJ,
We must stand by impoverished nations held back by debt/ And we must stand by countries
crippled by infectious diseases. AIDS could well kill more people in this decade than all the
wars of the 20 111 century combined. My budget calls for a new $150 million investment to fight
AIDS and the other killer diseases of the developing world. But we can do more. I will call on
~
�4
our partners in the G-7 and around the world to join us in supporting a Millennium Trust Fund
that wi II say to private industry-- if you develop vaccines for diseases like malaria, AIDS and
TB, we will help buy them, and we will lift millions of lives together.
The final question is the most important of all: Will America continue to lead? How do we see
ourselves and our role for next century?
In the 20th century, America was thrust into position of global leadership by circumstance. Now
we have to choose whether to shape the world. But it's really no choice at all, not if we want our
children to know peace and prosperity and the promise of a better clay. We can choose to see our
role as a burden. I choose to see it as a blessing.
That's why we have reversed the decline in defense spending that began in 1985. We must
continue to work together to keep our military the best trained, best equipped in the world.
My budget invests in readiness and in 21st century weapons. And it raises salaries for our men
and women in uniform.
We must also continue to fund the l percent of our budget that supports our international
engagement and keeps our soldiers out of war. Last year, you worked with me to support our top
international priorities and to resume paying our UN clues and arrears. Let's do it again this year.
And let's remember that building the right kind of global community is vital for a strong, secure
American community.
�•
THE
KAISER
COMMISSION
ON
Medicaid and the Uninsured
•
jULIE HUDMAN, MPP
SENIOR POLICY ANALYST
1450 G
STREET
NW,
SUITE
250
WASHINGTON,
DC 20005
PHONE
202 347-5270
FAX
202 347-5274
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ON
Medicaid and the Uninsured
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Uninsured in America
A
C H A R T
JUNE
B 0
0
K
1998
:aJ
II
Prepared by
Catherine Hoffman
A Chirt Book of
II
The Kaiser Commission on
II
Medicaid and the Uninsured
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T A B L E
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PAGE
Foreword
VI
Highlights
X
Introduction
XV
SECTION 1
How Many Are Uninsured?
SECTION 2
Who Are the Uninsured?
Profile of the Nonelderly Uninsured
IS
Profile of Uninsured Workers
23
Profile of Uninsured Children
27
SECTION 3
What Difference Does Health Insurance Make?
Foregoing Needed Medical Care
35
Health Service Use
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Medical Decision-Making and the
Consequences of Going without Care
57
SECTION 4
Detailed Tables
The Nonelderly Uninsured Population
69
Uninsured Workers
76
Uninsured Children
81
State Estimates of the Uninsured
86
Appendix:
A Note about National Estimates of the Uninsured
90
�L
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0
How Many Are Uninsured?
FIGURE 1
4
FIGURE 13
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12
FIGURE 18
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25
26
The Risk of Being Uninsured for Workers Age 18-64,
1995
FIGURE 19
FIGURE 20
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14
Primary Reasons for Not Having Health Insurance,
1996
The Kaiser Commission on Medicaid and the Uninsured • June /998
32
Lack of Health Insurance Within Families. 1996
Health Insurance Coverage in Families With
Uninsured Children, 1996
13
31
The Risk of Being Uninsured for Children. 1995
FIGURE 22
Duration of Periods Without Health Insurance, 1997
FIGURE 11
FIGURE 17
FIGURE 21
Percent of Nonelderly Adults Who Were Either
Currently Uninsured or Had a Recent Gap in
Coverage. 1997
FIGURE 10
FIGURE 16
Profile of Uninsured Children. 1995
Percent of Low-Income Uninsured Children
(Less than Age 19) by State, 1994-1995 Average
FIGURE 9
21
Profile of Uninsured Workers Age 18-64, 1995
Percent of Nonelderly Population With No Health
Insurance by State, 1994-1995 Average
FIGURE 8
FIGURE 15
The Risk of Being Uninsured for Nonelderly Persons,
1995
Trends in Health Coverage for Children. 1987-1995
FIGURE 7
20
Nonelderly Uninsured by Poverty Level and Family
Work Status, 1995
Trends in the Percent of the Nonelderly Who
Are Uninsured, by Poverty Level, 1987-1995
FIGURE 6
19
Americans' Perceptions About the Uninsured
Health Insurance Coverage of the Low-Income
Nonelderly, 1995
FIGURE 5
18
Profile of the Nonelderly Uninsured, 1995
FIGURE 14
Trends in Health Coverage for the Nonelderly
Population,· 1987-1996
FIGURE 4
FIGURE 12
Profile of the Nonelderly Uninsured, 1995
Health Insurance Coverage of the Nonelderly
Population. 1996
FIGURE 3
F I G U R E S
Who Are The Uninsured?
Growth in the Number of Uninsured
Americans. 1987-1996
FIGURE 2
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What Difference Does Health Insurance Make?
FIGURE 23
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Americans' Perceptions about the Uninsured
FIGURE 24
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FIGURE 26
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Families Experiencing Barriers to Medical Care by
Type of Family Coverage. 1996
FIGURE 32
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Site of Usual Source of Care for Adults by Insurance
Status. 1997
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Chances of Uninsured Children NOT Receiving
Medical Care When Sick Compared to Insured
Children. 1987
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Differences in Treatment Decisions by Insurance
Status
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Stage of Breast Cancer at Time of Diagnosis by
Insurance Status
FIGURE 45
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Chances of the Uninsured Undergoing High Cost/High
MD Discretion Procedures Compared to the Insured
FIGURE 44
Percent of Children Without a Usual Source of Care
by Insurance Status, /996
FIGURE 34
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Admission Rates of Avoidable Hospital Conditions
(AHC) for Uninsured vs. Privately Insured in Two
States
FIGURE 43
Percent of None/derly Adults Without a Usual Source
of Care by Insurance Status. 1997
FIGURE 33
FIGURE 40
FIGURE 42
Problems Getting Needed Medical Care by Health
and Insurance Status, 1995
FIGURE 31
FIGURE 39
FIGURE 41
Differences in Access to Care in the Past Year Among
the Recently Uninsured by Income. /997
FIGURE 30
55
Health Consequences of None/derly Adults Who
Did Not Get Needed Care in the Past Year, /997
Differences in Access to Care in the Past Year Among
Nonelderly Adults by Insurance Status. /997
FIGURE 29
FIGURE 38
Chances of Uninsured Children NOT Receiving Routine Health Care Compared to Insured Children, /988
Percent of None/derly Adults With Problems Paying
Medical Bills by Insurance Status, 1997
FIGURE 28
54
Differences in Use of Preventive Services in Past Year
by Insurance Status, 1997
Percent of Children Under 18 With Unmet Health
Needs by Insurance Status, /993
FIGURE 27
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Percent of Children With No Doctor Visits in Past Year
by Insurance Status. /993-/994
FIGURE 37
Percent of Adults Postponing Medical Care and Not
Filling Prescriptions in Past Year Because They Could
Not Afford it, by Insurance Status. 1997
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Percent of Adults With No Doctor Visits in Past Year
by Insurance Status, 1997
FIGURE 36
Percent of Adults Who Did Not Receive Needed
Medical Care in Past Year by Insurance Status, 1997
FIGURE 25
FIGURE 35
65
Selected Studies Examining the Relationship Between
Health Insurance Coverage. Medica/Interventions.
and Health Outcomes
The Kaiser Commission on Medicaid and the Uninsured • June /998
�L
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F
T A B L E S
Nonelderly Uninsured Population
Uninsured Workers
TABLE 1
TABLE 8
69
Characteristics of the Nonelderly Uninsured, 1995
TABLE 2
70
TABLE 9
Characteristics of the Nonelderly Uninsured With
Incomes Less than 200% of Poverty, 1995
TABLE 3
71
TABLE
4
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TABLE 5
73
TABLE 6
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Characteristics of the Nonelderly Uninsured by
Poverty Level and Family Work Status, 1995
TABLE
7
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Characteristics of the Nonelderly Uninsured by
Household Type and Poverty Level, 1995
The Kaiser Commission on Medicaid and the Uninsured • June 1998
79
Characteristics of Uninsured Workers (Age 18-64).
by Gender and Income, 1995
TABLE 12
Characteristics of the Nonelderly Uninsured by
Poverty Level and Race, 1995
78
Characteristics of Uninsured Workers (Age 18-64).
by Work Status and Income, 1995
TABLE 11
Characteristics of the Nonelderly Uninsured by
Poverty Level and Gender, 1995
77
Characteristics of Uninsured Workers (Age 18-64),
With Incomes Less than 200% of Poverty, 1995
TABLE 10
Characteristics of the Nonelderly Uninsured by
Age and Gender, 1995
76
Characteristics of Uninsured Workers (Age 18-64),
1995
Characteristics of Uninsured Workers (Age 18-64).
by Business Size and Workers' Income. 1995
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Uninsured Children
TABLE 13
State Estimates of the Uninsured
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Characteristics of Uninsured Children
(Less than Age 18), 1995
TABLE 14
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Characteristics of Uninsured Children (Less than
Age 18), by Poverty Level and Family Type, 1995
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State Estimates of the Low-Income Nonelderly
Uninsured (Less than 200% of Poverty),
1994-1995
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State Estimates of Uninsured Children (Less than
Age 19), 1994-1995
TABLE 21
Characteristics of Uninsured Children (Less than Age
18), by Poverty Level and Family Work Status, 1995
TABLE 17
TABLE 19
TABLE 20
Characteristics of Uninsured Children (Less than
Age 18), by Poverty Level and Age, 1995
TABLE 16
86
State Estimates of the Nonelderly Uninsured,
1994-1995
Characteristics of Low-Income (Less than 200%
Poverty) Uninsured Children (Less than Age 18), 1995
TABLE 15
TABLE 18
89
State Estimates of Low-Income (Less than 200% of
Poverty) Uninsured Children (Less than Age 19),
1994-1995
The Kaiser Commission on Medicaid and the Uninsured • June /998
�fOREWORD
We are pleased to release this resource book, Uninsured in America: A Chart Book, from the
Kaiser Commission on Medicaid and the Uninsured. The new Commission extends the work
of the Kaiser Commission on the Future of Medicaid, established in 1991, by expanding the
Commission's mandate to address health care coverage for all low-income Americans. In its
work, the Commission conducts analysis, sponsors research, and produces reports and policy
briefs on coverage, service delivery, and financing issues affecting the low-income population,
with a special focus on Medicaid and the uninsured.
This chart book provides a broad overview of the uninsured population: how many and who
they are, who is at greater risk of being uninsured, and the consequences of not having health
insurance. It illustrates some of the simple truths about the uninsured. Contrary to common
beliefs, the majority of uninsured come from families where at least one member is working
full-time; many are not from poor families; and most do not get the same amount or kind of
health care as people who have health insurance.
Uninsured in America: A Chart Book begins by describing the growth over the past decade in
the number and proportion of Americans who are uninsured. It then profiles the uninsuredtheir age, gender, race and ethnicity, and family characteristics, including income, family type,
and the work status of family members. Uninsured workers and uninsured children are separately profiled.
The chart book's third section highlights the difference having health insurance makes in peoples' lives. Not having health insurance affects both the amount and kind of health care people
are able to afford. The consequences of not getting needed medical care are not trivial and can
result in serious health problems and avoidable hospitalizations.
The last section of the chart book contains a series of detailed tables in order to provide a richer
description of the uninsured population. It also includes estimates of the uninsured in each
state reflecting the variation in coverage across states-with uninsured rates ranging from 7%
in Tennessee to 26% in New Mexico.
The Kaiser Commission on Medicaid and the Uninsured • june /998
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We appreciate the contributions of all who helped in the development and preparation of this
chart book. In particular, we recognize the efforts of Catherine Hoffman who managed the
project, drafted the material, and brought this chart book to fruition. We also thank Barbara
Lyons, Alina Salganicoff, and Peter Long for reviewing and editing the chart book, Maryann
Colclasure for graphics support, and Valerie Farnsworth for coordinating its final production .
We also appreciate the contributions of Shruti Rajan, Frank Ullman, and John Holahan at the
Urban Institute whose analyses of the Current Population Survey provided many of the uninsured numbers included in the charts and detailed tables. Finally, we would like
members of the Commission for encouraging our efforts
to
to
thank the
provide objective information
about the lack of health insurance coverage and the implications of being uninsured for the 41
million Americans who are uninsured today.
We hope this chart book will be a useful reference; helping you to better understand who the
uninsured are and the impact not having health coverage has on their lives, as well as aiding
you in the evaluation of policy proposals designed
to
expand health coverage to more Ameri-
cans in the future .
.
James R. Tallon
Diane Rowland, Sc.D.
Chairman
Executive Director
VII
The Kaiser Commission on Medicaid and the Uninsured • june I 998
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THE
KAISER
COMMISSION
ON
Medicaid and the Uninsured
C0
MM I S S I 0 N
James R. Tallon, Jr., Chairman
President
United Hospital Fund
New York, New York
Ron J. Anderson, M.D .
President and Chief Executive Officer
Parkland Memorial Hospital
Dallas, Texas
ME
MB E R S
Sylvia Drew lvie, J.D.
Executive Director
T.H.E. Clinic for Women, Inc.
Los Angeles, California
The Honorable
Charles McC. Mathias, Jr., LL.B.
President and Chairman of the Board
First American Bankshares, Inc.
Washington, D.C.
The Honorable Henry Bellmen
Former Governor of Oklahoma
and U.S. Senator
Billings, Oklahoma
James J. Mongan, M.D.
President
Massachusetts General Hospital
Boston, Massachusetts
Edward Brandt, Jr., M.D., Ph.D.
Professor and Co-Director
University of Oklahoma
Center for Health Policy
Oklahoma City, Oklahoma
Sheila Burke, R.N., M.P.A.
Executive Dean, Lecturer in Public Policy
Kennedy School of Government
Harvard University
Cambridge, Massachusetts
Karen Davis, Ph.D.
President
The Commonwealth Fund
New York, New York
Trish Riley
Executive Director
National Academy for State Health Policy
Portland, Maine
Uwe Reinhardt, Ph.D .
Professor
Woodrow Wilson School
Princeton University
Princeton, New jersey
William Roper, M.D., MPH
Dean
School of Public Health
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Jennifer L. Howse, Ph.D .
President
March of Dimes Birth Defects Foundation
White Plains, New York
The Honorable Kurt Schmoke
Mayor
The City of Baltimore
Baltimore, Maryland
IX
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�HIGHLIGHTS
How Many Are Uninsured?
Who Are the Uninsured?
As many as 41 million Americans were uninsured
in 1996-up to 18% of the total nonelderly
population. While numbers vary depending on
the source, the number of Americans without
health insurance has grown by nearly 10 million
over the past decade. A smaller share of Americans have health insurance today through their
jobs than ten years ago, and ev~n more would be
uninsured were it not for eligibility expansions
and growth in the Medicaid program.
Most uninsured Americans are adults under the
age of 65, with one in five being children. While
low-income Americans represent over half (54%)
of the uninsured, the poorest Americans-those
with incomes under the federal poverty levelcomprise only a fifth of the uninsured population. The near-poor (those with incomes between
100% and 200% of the poverty level) run the
highest risk of being uninsured because while
they may not be eligible for Medicaid in most
cases, they often cannot afford health insurance
premmms.
While most statistics report the number of uninsured on any given day, that snapshot does not
tell the whole story of how many Americans have
experienced being without insurance coverage.
Many people gain or lose insurance during the
course of a year. In 1997, almost one-third of
nonelderly adults (32%) were uninsured at sometime in a two-year period. Of these, over 40%
were uninsured for over two years. The majority
of the uninsured say they are without health coverage because it is too expensive; only a very
small percent say they don't want or need health
msurance.
The Kaiser Commission on Medicaid and the Uninsured • June /998
• Eight out of ten of the uninsured are full-time
workers or dependents of full-time workers.
Only 10% of the uninsured are in families
where there are no connections to the workforce.
• Single adults have the greatest risk of being
uninsured because they have only themselves
as a link to job-based health benefits.
• While the majority (56%) of the uninsured
are white, Hispanics and Mrican Americans
are disproportionately over-represented. The
differences in health coverage across racial and
ethnic groups are only partially explained by
differences in income. Being poor tends to
decrease the differences in health coverage
between minority and white Americans, however at any income level greater than the federal poverty level, minorities are at far greater
risk of being uninsured. Across all income
levels, Hispanics consistently have the highest
risk of being uninsured.
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Uninsured Workers
Uninsured Children
In 1995, 22 million workers-17% of all workers
-were uninsured and over half of them were in
jobs working full-time for the full-year. Where a
person works and how much he/she earns are significant factors in the likelihood-or risk-of
being uninsured .
Medicaid expansions in the 1980s and 1990s
helped decrease the number of uninsured children; still almost one out of ten American children are uninsured. The availability of job-based
coverage is changing and its cost to the family is
increasing, leaving more working families unable
to afford health insurance for their children.
• Employees earning less than $20,000 per year
have a high risk of being uninsured.
• Working any less than full-time for the entire
year also raises the risk of being uninsured substantially.
• Workers in small businesses with fewer than
100 employees are more likely to be uninsured. However, even in large firms lowincome employees have a high risk of being
uninsured. For example, in businesses with
more than 1,000 employees, 20% of those
earning under $20,000 are uninsured .
• The risk of being uninsured also varies by
industry. Workers are less likely to have health
coverage in industries such as agriculture, construction, or the service sector, where businesses tend to employ many part-time or temporary workers .
• More than 85% of uninsured children live in
families where at least one parent is working
full-time.
• More than two-thirds of uninsured children
live in families with two parents.
• Over 60% come from families where every
member is uninsured.
In general, children not eligible for Medicaid have
a higher risk of being uninsured-older teenagers
and children in families with incomes between
100% and 300% of the federal poverty level.
Children in families with one parent have been at
a relatively lower risk being uninsured than
those in two-parent families because of Medicaid's
historic ties to eligibility for welfare which was
targeted to single-parent families.
of
The Kaiser Commission on Medicaid and the Uninsured • June /998
�What Difference Does Health Insurance Make?
Not having health insurance makes a substantial
difference in the amount and kind of health care
people are able to afford and obtain. Medical bills
mount quickly if a person is uninsured.
• Over a third of adults who are uninsured
report they have had a problem paying their
medical bills in the past year.
• · One in six of the uninsured said they had to
change their family's way of life significantly in
order to pay these medical bills.
Contrary to a common belief that the uninsured
are able to get the medical care they need from
doctors and hospitals, in 1997 uninsured adults
were four times more likely than those with private health insurance to say they did not receive
medical care they believed to be necessary.
o
Over half of uninsured adults said they had
postponed getting care and a quarter had not
filled a medical prescription in the past yearbecause they could not afford it.
" Uninsured children are over three times as likely as insured children to have had unmet needs
for health care in the past year.
The Kaiser Commission on Medicaid and the Uninsured • june 1998
People without health coverage are much less likely to have a usual source of health care and use
preventive services.
• One in five uninsured children and over half of
uninsured adults have no regular person or
place where they go for care when they need it.
• When the uninsured have a usual source for
their health care they are far less likely to identify a doctor's office than those with health
coverage.
• Almost 40% of uninsured adults report they
did not see a doctor in the past year-twice the
rate for those with private insurance.
• Uninsured adults are less likely than the
insured to have regular check-ups, mammograms, and other screening tests. Uninsured
children are 30% more likely not to be up-to~
date with well-child care and 80% more likely
to never have had routine care.
Even a temporary lapse in health insurance coverage has an impact on access to care. Persons who
are insured now-but had a "recent gap" in coverage in the past two years-report experiences in
getting needed care that are more similar to the
uninsured than to those who have had continuous
health insurance.
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Because health needs are not addressed, the uninsured are far more likely (50% to 70% more likely) than those with insurance to be hospitalized
for conditions that could have been avoided, such
as uncontrolled diabetes and conditions for which
people can be immunized .
• They are also less likely to have a procedure
that is relatively costly or where physicians
exercise a great deal of discretion. For example, the uninsured are 30% less likely to undergo coronary bypass surgery.
• Uninsured children are treated differently when
they are ill, as well. They are at least 70% more
likely than insured children not to have received
medical care for common childhood conditions
such as sore throats, recurring ear infections, and
asthma-conditions that if left untreated can
lead to more serious health problems .
In summary, whether a person does or does not
have health insurance does makes a substantial
difference. Personal decisions made by uninsured
people to delay or even forego needed care
because of its cost, coupled with providers who
tend to order less or different treatments when a
patient has no health coverage, ultimately can lead
to poorer health outcomes .
XIII
The Kaiser Commission on Medicaid and the Uninsured • June 1998
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INTRODUCTION
Despite a strong economy, several years of lower health insurance premium increases, and health
insurance reforms in nearly all states-the number of Americans who do not have health insurance
has steadily grown. Today over 40 million Americans-more than one in six of the nonelderly
population-are without health insurance. Efforts
to
enact comprehensive health reform were .
unsuccessful in 1994, but improving health insurance coverage remained on the national agenda .
In 1997 the State Children's Health Insurance Program was enacted, providing federal grants to
states that will help finance health insurance coverage for uninsured children. However, the high
proportion of Americans without insurance remains a daunting societal problem.
The purpose of this chart book is to describe the magnitude of the problem, paint a picture of
who the uninsured are, and finally show the difference that health insurance makes, not only
to
a family's financial security, but to individuals' access to care and, ultimately, to their health .
The United States' system of health insurance is one of just a few in the world that is structured
through the workplace. Employers voluntarily decide whether or not to offer health benefits to
their employees, and how much, if anything, their employees must contribute to the cost of
premiums. If employers do not provide health benefits, or the employee share is too high, individuals may have difficulty affording health insurance on their own-particularly individuals
with low- or modest-incomes .
The Medicaid program-this country's "insurance safety net" for the nonelderly who are poor
and disabled-has successfully filled the gap in coverage for many, but not all, low-income
Americans. Poor women and children are the primary beneficiaries of the program, which has
markedly decreased their chances of being uninsured and improved their access
to
health ser-
vices. Poor men, many poor women, and people who are near-poor-most of whom are in
working families-are generally ineligible for Medicaid coverage and thus at high risk of being
uninsured. The uninsured are almost all less than 65 years old because nearly all of the elderly
have health coverage through the Medicare program .
The figures and detailed tables that follow in this chart book are intended to broaden understanding of who the uninsured are, to explain the dimensions of the problem for those who are
uninsured, and to help in evaluating policy proposals designed
to
broaden coverage in the future .
The Kaiser Commission on Medicaid and the Uninsured • June /998
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SECTION
How
1
MANY ARE UNINSURED?
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How
MANY ARE UNINSURED?
• Numbers vary depending on the source, but as many as 41 million were
uninsured in 1996--up to 18% of the nonelderly population .
• The number of uninsured Americans has grown by nearly 10 million over the
past decade.
• The share ofAmericans with job-based health benefits has declined from 69%
in 1987 to 64% in 1996. In contrast, health coverage through the Medicaid
program has grown, particularly among children .
• Health insurance coverage is unstable. In 1997, 113 of nonelderly adults had
a gap in their health coverage sometime in the past two years.
• Nearly 2/3 ofadults with gaps in health coverage go without insurance for
at least a year.
• Southwestern states have larger proportions of uninsured than the rest of the
country-more than 20% of their nonelderly populations are uninsured.
1
The Kaiser Commission on Medicaid and the Uninsured • june /998
�How MANY ARE
Trends
The number of nonelderly Americans without
health insurance has grown over the past decade.
While estimates vary depending on the survey
source of information, as many as 41 million
Americans were uninsured in 1996-up to 18%
of the total nonelderly population. A smaller
share of Americans have health insurance today
through their jobs than ten years ago when 69%
of the nonelderly were covered through a plan
offered by their company. By 1996 that proportion had dropped to 64%.
Many factors possibly contribute to this downward trend:
• high and rising costs of health insurance;
• shifts in American industry that move more
low-income workers into the service sector
(where health benefits have traditionally been
less common);
• increases in employees' share of premium
costs at a time when real wages were declinmg;
• decreased unionization;
• and an increase in the proportion of jobs that
are part-nme or temporary.
2
The Kaiser Commission on Medicaid and the Uninsured • june /998
UNINSURED?
During the same time period, the proportion of
the nonelderly population covered by Medicaid
increased due in large part to expansions in the
program. Because Medicaid expansions primarily targeted low-income children and pregnant
women, the share of children covered by Medicaid grew from 16% in 1987 to 23% in 1995,
while the proportion of children who were uninsured stayed at 13-14% and the proportion with
employer-based coverage declined. The proportion of the poorest Americans (those with
incomes less than the federal poverty level) who
are uninsured has not changed much over time.
However, the percent who are uninsured among
families with incomes higher than the Medicaid
income eligibility levels is growing, particularly
those with incomes between 100% and 300% of
the federal poverty level.
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State Variation
Unstable Health Coverage and Why
Health insurance coverage varies widely by region
and state of the country. State variations in health
coverage occur because of differences in demographics, the nature of employment and employerprovided coverage, the scope of Medicaid coverage, and other state policies. In general, residents
of north central states are least likely to be uninsured and residents of states in the southwest have
the highest likelihood of being uninsured, with
more than one out of five nonelderly with no
health insurance. In 1995, Tennessee had the
highest rate of health coverage (only 7% were
uninsured) and New Mexico had the lowest (26%
of the nonelderly population were uninsured) .
While most statistics report the number of uninsured on any given day, that snapshot does not
tell the whole story of how many Americans have
experienced being without insurance coverage.
Many people gain or lose insurance during the
course of a year. In 1997, in addition to the
19% of nonelderly adults who were without
health insurance at the time they were surveyed,
another 13% of adults reported that they had a
gap in their health coverage for some period in
the past two years. In total, almost one-third of
nonelderly adults (32%) were uninsured at sometime in a two-year period. And most of these
people were uninsured for significant amounts of
time. Two-thirds were uninsured for at least one
year, with 44% of them lacking coverage for over
two years.
Health insurance coverage of children under age
19 varies by state as well. Across states, the share
of low-income children who are uninsured ranges
from 5% in Hawaii to 27% in New Mexico.
The majority of the uninsured say they are without health coverage because it is too expensive;
only a very small percent say they don't want or
need health insurance. While more firms are
now offering health benefits than in the 1980s,
the number of employees electing to enroll in
their firms' health plan has decreased. Increased
employee contributions to premiums at a time
when growth in real wages was declining may
partly explain these trends, particularly for lowincome workers .
3
The Kaiser Commission on Medicaid and the Uninsured • June /998
�FIGURE 1
Growth in the Number of Uninsured Americans,
1987-1996
Millions of N onelderly Uninsured
50
40
30
20
10
0
1987 1988 1989 1990 1991
1992 1993
1994 1995
Source: Employee Benefits Research Institute, Trends in Health Insurance Coverage, Issue Brief (No. 185) 1997.
Data: Current Population Survey, March 1988-1997
4
The Kaiser Commission on Medicaid and the Uninsured • june 1998
1996
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FIGURE 2
Health Insurance Coverage of
the Nonelderly Population, 1996
Insured
82%
Uninsured
18%
234 Million People
Source: Employee Benefits Research Institute, Trends in Health Insurance Coverage, Issue Brief (No. 185) 1997.
Data: Current Population Survey, March 1997 .
5
The Kaiser Commission on Medicaid and the Uninsured • june /998
�FIGURE 3
Trends in Health Coverage
for the None/derly Population, 1987-1996
80%
69.2%
69.0%
68 6o/<
••~---·~--~~~· 671111
o
_.O~o/<-o--6~6-.3%
----.
~63.5%
63.6%
63.8%
64.0%
-·------·r---••~---·
A
Employment-Based
60%
40%
No Health Insurance
¥
20%
8.6%
0%
.
15.5% 15.7% 16.1%
16.3% 17.0%
17.1%
17.4%
17.7%
12.7% 12.5%
12.0%
12.1%
17.3%
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•
• • • ___. • • • • • •
•
• •
14.8%
1987
8.7%
1988
8.8%
1989
10.2%
11.1% A
11.8%
Medicaid
1990
1991
1992
1993
1994
Source: Employee Benefits Research Institute, Trends in Health Insurance Coverage, Issue Brief (No. 185) 1997.
Data: Current Population Survey, March 1988-1997
6
The Kaiser Commission on Medicaid and the Uninsured • June 1998
1995
1996
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FIGURE
4
Health Insurance Coverage
ofthe Low-Income Nonelderly, 1995
Other
EmployerBased
34%
Uninsured
25%
---{,?'\,,,,;,
Individual
4%
76 Million People
Note: Low-income is defined as income <200% of the federal poverty level. The 1995 federal poverty level for a family of 3 was $12,590.
Source: Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1996
7
The Kaiser Commission on Medicaid and the Uninsured • June /998
�FIGURE 5
Trends in the Percent of the Nonelderly
Who Are Uninsured, by Poverty Level, 1987-1995
40%
33.7%
30%
2::--- 4
0-133% ofPoverty
y
32.5%
34.2%
•
25.6% 26.2%-
.-----1----1·-----·
A
28.2%
2
.....
4%
...
_ 7• 011-0A-o_2_.6~
-...
27.6%
27.8%
28.1%
•
134-199%
20%
10%
13.0%
• • • • • • •
7.4%
6.8%
A
300% or More
.---::%
5.4%
6.5%
7.0%
1987
1989
1990
7.9%
7.6%
8.0%
1993
1994
1995
0%
1988
1991
1992
Source: Employee Benefits Research Institute, Trends in Health Insurance Coverage, Issue Brief (No. 185) 1997.
Data: Current Population Survey, March 1988-1996
8
The Kaiser Commission on Medicaid and the Uninsured • june I998
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FIGURE 6
Trends in Health Coverage for Children,
1987-1995
Employment-Based
62~7%
64.0%
60%
50%
40%
30%
Medicaid
y
20.8%
22.0%
20%
10%
• • • • • •
13.6%
13.1%
13.2%
1989
1990
12.9% 12.7%
A
Uninsured
13.7%
14.2% 13.8%
1993
1994
0%
1987
1988
1991
1992
1995
Source: Employee Benefits Research Institute, Trends in Health Insurance Coverage, Issue Brief (No. 185) 1997 .
Data: Current Population Survey, March 1988-1996
9
The Kaiser Commission on Medicaid and the Uninsured • june 1998
�FIGURE 7
Percent of Nonelderly Population
With No Health Insurance by State,
1994-1995 Average
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Data: Current Population Survey, March 1995 and 1996
10
The Kaiser Commiss1on on Medicaid and the Uninsured • June 1998
10 to 14 Percent (26 States)
D
See Table 18
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Source: The Urban Institute, 1997; unpublished
Greater Than 20 Percent (5 States)
Less Than 10 Percent (4 States)
to
20 Percent (15 States and DC)
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FIGURE 8
Percent of Low-Income Uninsured Children
(Less than Age 19) by State, 1994-1995 Average
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Greater Than 20 Percent (6 States)
•
15 to 20 Percent (14 States and DC)
10 to 14 Percent (15 States)
D
Less Than 10 Percent (15 States)
Source: The Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1995-1996
See Table 21
11
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�FIGURE 9
Percent of Nonelderly Adults
Who Were E.ither Currently Uninsured
or Had a Recent Gap in Coverage, /997
Recent Gap*
13%
Currently
Uninsured
19%
Continuously
Insured
68%---!P
164 Million Adults
Age 18-64
*Insured at time ofsurvey but had a period in past 2 years without coverage
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
12
The Kaiser Commission on Medicaid and the Uninsured • June 1998
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FIGURE 10
Duration of Periods Without Health Insurance, 1997
Up to 3 Months
15%
4-11 Months
'.,-----21%
.2 Years or More
44%-12-23 Months
20%
52 million nonelderly adults
currently uninsured or who had a
gap in the past 2 years
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
13
The Kaiser Commission on Medicaid and the Uninsured • June /998
�FIGURE 11
Primary Reasons for Not Having Health Insurance, 1996
Too Expensive
64%
No Employer
Coverage
Change in
Employment
Don't Want
or Need It
Ineligible for
Public Assistance
Pre-existing
Condition
Unemployed
Family Status
Change
0%
10%
20%
30%
40%
50%
60%
70%
Source: Donelan, Ketal., "Whatever Happened to the Health Insurance Crisis in the United States? Voices ftom a National Survey. "
JAMA 276(16):1346-1350.
Data: Getting Behind the Numbers on Access to Care Survey, 1996.
14
The Kaiser Commission on Medicaid and the Uninsured • June 1998
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SECTION
2
WHO ARE THE UNINSURED?
Profile of the Nonelderly Uninsured
Profile of Uninsured Workers
Profile of Uninsured Children
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WHO ARE THE UNINSURED?
PROFILE OF THE NONELDERLY UNINSURED
The majority of uninsured Americans:
• are adults, age 18-64 years old;
• are white, and men;
• have at least one member of their immediate family who works full-time; and
• and over half (54%) have family incomes less than 200% of the poverty level.
:z:
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m
r
t:l
People at greatest risk of being uninsured include:
m
AI
r
-<
• young adults, age 18-34, particularly men;
c:
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en
c
• the near-poor (those with incomes between 100-199% of the federal poverty
level);
AI
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• minority racial and ethnic groups, and Hispanics in particular;
• persons who come from families with only part-time workers;
• single adults; and
• families with children in homes with multiple generations or where adults other
than their parents are raising the children .
15
The Kaiser Commission on Medicaid and the Uninsured • june 1998
�WHO ARE THE UNINSURED?
Profile of the Nonelderly Uninsured
In a representative gathering of uninsured
Americans, you would see:
• mostly adults under the age of 65, but one in
five would be children;
o
men slightly more often than women; and
o
the majority would be white Americans.
The uninsured are almost all less than 65 years
old because nearly all of the elderly have health
coverage through the Medicare program. Children and women make up a much smaller proportion of the uninsured than their proportion
in the total population because they are more
likely to qualify for the Medicaid program. Children are 30% of the total nonelderly population,
but 19% of the uninsured, and women are 51%
of the nonelderly adult population but only 45%
of adults who are uninsured.
(/)
z
>_J
cr:
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Q
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UJ
z
While the majority (56%) of the uninsured are
white, Hispanics and African Americans are disproportionately over-represented, making up the
next largest groups of uninsured. The differences
in health coverage across racial and ethnic groups
are only partially explained by differences in
income. Being poor tends to decrease the differences in health coverage between minority and
white Americans, however at any income level
greater than the federal poverty level, minorities
are at far greater risk of being uninsured. Across
all income levels, Hispanics consistently have the
highest risk of being uninsured.
0
:z:
16
The Kaiser Commission on Medicaid and the Uninsured • june /998
Behind the faces you would learn that:
• low-income Americans (making less than
200% of the poverty level) represent over half
of the uninsured;
• eight out of ten of the uninsured are full-time
workers or dependents of full-time workers.
Only 10% of the uninsured are in families
where there are no connections to the workforce; and
• half come from families with children in their
homes and the majority of these are two-parent families with children.
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In summary, those at greatest risk of being uninThe near-poor run the highest risk of being unin- ~ sured include:
sured (more than one in four are uninsured)
• young adults, age 18-34, particularly men;
because while they may not be eligible for Medicaid in most cases, they often cannot afford health • the near-poor (those with incomes between
100-199% of the federal poverty level);
insurance premiums. Health benefits are also less
common in low-wage jobs. In addition, some• minority racial and ethnic groups, and Hispanwhat larger proportions of low-income people do
ics in particular;
not have any connection to the workforce or work
• persons who come from families with only
only part-time.
part-time workers;
Single adults have the greatest risk of being unin• single adults-living alone or together with
sured because they have only themselves as a link
other single adults;
to job-based health benefits. Two-parent and single-parent families are at about the same risk of
• and families with children in homes with mulbeing uninsured, however families with children
tiple generations or where adults other than the
that have several generations or a mix of relatives
parents are raising the children-both of which
caring for the children are far more likely to be
tend to be lower income families.
uninsured.
Who is at risk of being uninsured?
:z:
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t:l
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The Kaiser Commission on Medicaid and the Uninsured • June /998
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FIGURE 12
Profile of the None/derly Uninsured, 1995
36 Million
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•
<100% ofPoverty
22%
200+%
of Poverty
100-199%
46%
<18 Years Old
Poverty Level
19%
z
::::>
>_J
et::
UJ
Q
_J
18-34
35-64
UJ
z
Years Old
0
:z:
43%
38%
Age
Women
Men
45%
55%
Gender
Source: Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1996
See Table I
18
The Kaiser Commission on Medicaid and the Uninsured • june /998
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FIGURE 13
Profile of the Nonelderly Uninsured, 1995
36 Million
2 or More
Full-Time
29%
No Workers
10%
Only
Part-Time
11%
Only 1
Full-Time
50%
Single Adults
Living Alone
Single Adults
8%
Living Together
23%
Family Work Status
:z:
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z
m
r
t:l
m
;>J
r
-<
c::
z
z
(J)
c
;>J
m
Mrican
American
17%
Asian/S.Pac.
Islander
5%
t:l
32%
Hispanic
22%
White
56%
M ultigeneration
& Others
1 Parent w/Children
7%
w/Children
10%
Household Type
Native
Race/Ethnicity
Source: Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1996
See Table 1
19
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�FIGURE 14
Americans' Perceptions About The Uninsured
I'd like to ask you to think about uninsured Americans ...
that is, people with no health insurance at all.
Would you say that more of them are ...
Employed people and people
from families in which
someone is employed
42%
Q
LJ.J
0::
::::l
en
z
z
:::J
Don't know
8%
>-
...J
Jr--
0::
LJ.J
Q
...J
LJ.J
z
0
:z:
Unemployed people
and people from
families in which
no one is employed
50%
Source: Kaiser-Harvard Program on the Public and Health/Social Policy, July 1996; unpublished.
Data: Survey of Americans on Health Policy
20
The Kaiser Commission on Medicaid and the Uninsured • june /998
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FIGURE 15
Nonelderly Uninsured by Poverty Level
and Family Work Status, 1995
100%
80%
60%
:z
40%
0
z
m
r
t::!
m
;;o
r
20%
-<
c:::
z
.....
z
"'
c
0%
<100%
7.9 Million
100-199%
11.3 Million
;;o
m
200+%
t::!
16.6 Million
Ill 1+ Full-Time Workers
D Part-Time Workers Only
Ill No Workers
Source: Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1996
See Table 6
21
The Kaiser Commission on Medicaid and the Uninsured • June /998
�FIGURE 16
The Risk of Being Uninsured for Nonelderly Persons,
/995
National Average
16%
y
Age:
Gender:
Poverty:
Level :
Q
LJ.J
cr::
::>
CJ)
z
>_J
~--
18 to 34
<18 E555I005Vo
35 to 54
14%
55 to 64
14%
Male~::::::::::::::~~17%
14%
Female~
100-199%
<100%
200-299%
300-399%
>400%
African American
Race/ :
Hispanic
White
Ethnicity : Asian/S.P. Islanders
cr::
LJ.J
Q
_J
LJ.J
z
Native American
0
:z
"
··-------"----·
24%
··---~--~---~-~----·---·
§~~5E::==23o/t~o
27%
18%
11%
' 7%
iiiii1~2%~~=
20%
29%
20%
16%
----·-----
~55555551~2~/c~o:::~-0
Family : Only 1 Full-Time
Work:
2+ Full-Time
Only Part-Time
Status :
No Workers
Homes:
without :
Children :
1 Parent
2 Parents
Other
26%
18%
Single
Married
Other
Homes:
with:
Children :
16%
~::::::::::::::~,~12~0:~~~
Oo/o
11%
5%
Source: Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1996
See Table 1
22
The Kaiser Commission on Medicaid and the Uninsured • June /998
10%
15%
.....
20%
21%
25%
30%
40%
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•
WHO ARE THE UNINSURED?
PROFILE OF UNINSURED WORKERS
• In 1995, 22 million workers-17% ofall workers-were uninsured; over half
of whom worked full-time year round.
• A majority (62%) of uninsured workers are employed by small businesses with
less than 100 employees.
• Almost 314 of uninsured workers earn less than $20,000 annually.
• Even in large firms low-income workers have a high risk of being uninsured.
• Workers in industries such as agriculture, construction or the service sector are
less likely to have health coverage.
<=
z
.....
z
(/)
c
::0
m
0
:::E
0
::0
""
m
::0
(/)
23
The Kaiser Commission on Medicaid and the Uninsured • june /998
�WHO ARE THE UNINSURED?
Profile of Uninsured Workers
Two-thirds of the nonelderly obtain health insurance as a benefit through their employers. A significant number of workers however, do not have
health benefits through their jobs. In 1995, 22
million workers-17% of all workers-were
uninsured and over half of them worked fulltime for the full year.
The connection between income and being uninsured is dear: almost three-quarters of uninsured
workers earn less than $20,000 annually. An
irony of the United States' employer-based system
is that the jobs that may remove families from eligibility for Medicaid often fail to provide health
benefits. Even when health benefits are offered
by employers, low-income workers may have difficulty affording their share of the premium.
en
a::
UJ
"'
a::
0
3:
Q
UJ
a::
A majority (62%) of uninsured workers are
employed by small businesses with less than 100
employees. Disproportionate shares of uninsured
workers come from construction, farming, personal/ entertainment services, and retail and
wholesale trade industries.
:::>
en
z
z
::::>
24
The Kaiser Commission on Medicaid and the Uninsured • June 1998
Who is at risk of being uninsured?
Where a person works and how much he/she
earns are significant factors in the likelihood-or
risk-of being uninsured. Workers earning under
$20,000 per year have a high risk of being uninsured. Hourly rates for these workers range from
the minimum wage to about $10 an hour. Working any less than full-time for the entire year raises
the risk of being uninsured substantially.
Workers in small businesses with fewer than 100
employees also have a higher risk of being uninsured. This is still true despite efforts in nearly
all states to reform group health insurance to better match the needs of small businesses. Interestingly, even in large firms low-income workers
have a high risk of being uninsured. For example, in businesses with more than 1,000 employees, 20% of those earning under $20,000 are
uninsured.
The risk of being uninsured also varies by industry. Workers are less likely to have health coverage in industries such as agriculture, construction,
or the service sector. Businesses in these industries tend to employ many part-time or temporary workers who often do not meet eligibility criteria for insurance coverage through the firm. In
general, firms that are older, have more employees,
are incorporated, or have unionized workers are
more likely to sponsor health insurance.
•
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•
FIGURE
17
Profile of Uninsured Workers Age 18-64, 1995
22 Million Uninsured Workers
Part-Year/Full-Time
23%
Full-Year/
Part-Time
10%
Part-Year/
Part-Time
13%
Full-Year/
Full-Time
53%
=
z
<$20,000
72%
~
z
en
c
;o
Work Status
m
t:l
::E
0
;o
""
m
<25 Workers
48%
;o
en
$40,000+
6%
25-99
14%
$20,000-39,999
21%
Income
100-499
Size of Business
11%
Source: Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1996
See Table 8
25
The Kaiser Commission on Medicaid and the Uninsured • june /998
�FIGURE 18
The Risk of Being Uninsured for Workers Age 18-64,
1995
National Average
17%
y
~30%
Under $10,000
"~'"' _}J 'I 25%
$10,000-$19,999
$20,000-$29,999
Income :
$30,000-$39,999
8%
5%
$40,000-$49,999
$50,000 and Over
5%
I
Work:
Status
Full-Year/Part-Time
Full-Year/Full-Time
!555§551!4°~Jio:
Part-Year/Full-Time
Part-Year/Part-Time
~
55
21%
24%
.. 1 22%
~------------------------+--------------------~--------------------------~
1
Q
UJ
"'
:::>
Business
Size
(/)
z
z
25-99 Employees
<25
iiiiii~~~;~;;[l"·r:E;i""":''
"·.~:Jl
18%
100-499 Employees
14%:
500-999 Employees
::::>
28%
12%
1000+ Employees
1Oo/o
r·-···---·····- ····-·- ·---··-·-----···--···.. - ·
Agriculture
Construction
'.>~1
Business/Repair Services
32%
29%
-~~26%
Personal/Entertain.
Clft1f•, "!"'
26o/o
23%
Type of :
Retail/Wholesale
Business : Trans./Comm./Utilities
13%
Mining/Manufacturing
13%
Professional Services
10%
Fin./lns./Real Estate
10%
Government
0%
5%
5%
Source: Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1996
See Table 8
26
The Kaiser Commission
O'l
Medicaid and the Uninsured • June /998
10%
15%
20%
25%
30%
40%
•
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,
WHO ARE THE UNINSURED? .
PROFILE OF UNINSURED CHILDREN
• One out of ten children are uninsured.
• Nearly 60% of uninsured children live in families with incomes under 200% of
the federal poverty level.
• Children are at greatest risk of being uninsured if they are .from near-poor families (1 00-199% of the federal poverty level) and if they are older than state
Medicaid eligibility age requirements.
• 2/3 of uninsured children live in families with two parents.
c:::
z
~
• 85% of children live in families where at least one parent is working full-time.
z
en
c:
;u
m
t::l
• The majority of uninsured children (61 %) come .from families where everyone is
uninsured.
n
I
r
t::l
;u
m
z
.
27
The Kaiser Commission on Medicaid and the Uninsured • June /998
�WHO ARE THE UNINSURED?
Profile of Uninsured Children
One out of five of the nonelderly uninsured is a
child. Medicaid expansions in the 1980s and
1990s helped decrease the number of uninsured
children so that today children are much more
likely to have health insurance than other groups
of the nonelderly population.
The numbers of uninsured children are expected
to continue to decrease as a result of legislation
passed in the Balanced Budget Act of 1997, creating the State Children's Health Insurance Program. States are given federal funds to help
expand coverage to include children in families
with incomes up to 200% of poverty, with flexibility to design coverage options. Both these
funds and Medicaid target the 60% of uninsured
children from families with incomes less than
200% of the poverty level. However, four out of
ten uninsured children live in families with
incomes greater than 200% of poverty. These
children are not eligible for Medicaid, nor will
they be eligible for the new Children's Health
Insurance Program.
z
U.J
0::
0
_J
I
u
0
U.J
0::
::::l
en
:Z
z
=
28
The Kaiser Commission on Medicaid and the Uninsured • june I 998
Under Medicaid today, states are required to
cover children with incomes below poverty who
are under age 14. Consequently, teenagers make
up a disproportionately high percentage of children who are uninsured.
Two-thirds of uninsured children live in families
with two parents and 85% of them live in families where at least one parent is working fulltime. The availability of job-based coverage is
changing and its cost to the family is increasing,
leaving more working families unable to afford
health insurance for their children.
•
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•
Who is at risk of being uninsured?
Almost one out of ten American children are
uninsured. Some children are more likely than
others to be among the pool of up to 10 million
uninsured children. In general, children not eligible for Medicaid have a higher risk of being uninsured-such as older children and children in
families with incomes between 1OOo/o and 300o/o
of the federal poverty level. On the other hand,
children in families with one parent have been at
a slightly lower risk of being uninsured than those
in two-parent families because of Medicaid's historic ties to eligibility for welfare which was targeted to single-parent families.
One in six families have at least one member who
is uninsured. About half of these families have a
mix of health coverage, meaning some members
have insurance and others do not. Single-parent
families are more likely to have at least one member who is uninsured compared to other types of
families because their children ar~ more likely to
be eligible for Medicaid. The new State Children's Health Insurance Programs will not move
most of the families of uninsured children into
the class of "fully insured families" because the
majority of uninsured children (61 o/o) come from
families where everyone is uninsured.
c:::
z
z
(/)
c
National and state health insurance expansions
have generally focused on children because health
coverage is considered to be especially critical to
children's health and development. For example,
while the Medicaid program has expanded coverage to poor pregnant women and children, adults
in poor families cannot receive the same assistance
with health insurance that their children receive.
As a result, many families don't have uniform coverage-leaving some family members insured
while others are not .
::0
m
t:l
n
::c
r
t:l
::0
m
z
29
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�FIGURE 19
Profile of Uninsured Children, 1995
6. 9 Million Uninsured Children
<100%
21%
<6
30%
400%+
z
LJ.J
0:::
38%
0
...J
31%
:c
39%
Poverty Level
u
Age
31%
0
LJ.J
0:::
:::J
(/)
z
.....
z
::::>
2+
Full-Time
30%
Only
No Workers
Part-Time
6%
8%
Work Status
Only 1
Full-Time
55%
Source: Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1996
See Table 13
30
The Kaiser Commission on Medicaid and the Uninsured • June 1998
M ultigeneration/
1 Parent
21%
Other
Family Type
2 Parents
66%
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FIGURE 20
The Risk of Being Uninsured for Children, /995
National Average
10%
y
Age:
17%
Poverty :
Level :
c:::
z
z
(/)
-·----~~
________
c
_::~-------------------------'
;;o
m
t:l
n
::r:
Family :
r
Type:
t:l
;;o
m
z
: At Least 1 Full- Time
Work:
Status :
,..,.,...,....,,....,..~-="-.,.,-.-~~-=,___,
0%
6%
12%
18%
Source: Urban Institute, 1997; unpublished
Data: Current Population Survey, March 1996
See Table 13
31
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�FIGURE 21
Lack of Health Insurance Within Families, 1996
20%
18%
15%
10%
z
LJ.J
a::
0
_J
5%
:I:
u
0
LJ.J
a::
::::>
(/)
z
z
0% ....___
All
:::::>
Families*
Single
Parent
Families
With
Children
Two
Parent
Families
With
Children
Couples
Without
Children
D
•
*Families with at least 1 member under age 65
Source: J. Kasper, 1997; unpublished
Data: Kaiser Survey of Family Health Experiences, 1996
The Kaiser Commission on Medicaid and the Uninsured • June /998
Some, But Not All
Family Members
Uninsured
All Family Members
Uninsured
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FIGURE 22
Health Insurance Coverage in Families
With Uninsured Children, 1996
Some members uninsured,
others with Medicaid coverage
14%
Some members
uninsured, others
with private
Insurance
25%
All family
members
uninsured
61%
c=
z
z
~
U>
c:
::>J
m
0
n
I
~
r
0
::>J
m
z
6 Million Uninsured
Children
Source: J. Kasper, 1997; unpublished
Data: Kaiser Survey of Family Health Experiences, 1996
33
-
The Kaiser Commission on Medicaid and the Uninsured • June /998
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S E C T I 0 N
3
WHAT DIFFERENCE DOES
HEALTH INSURANCE MAKE?
Foregoing Needed Medical Care
Health Service Use
Medical Decision-Making and
the Consequences of Going without Care
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•
--•
WHAT DIFFERENCE DOES
HEALTH INSURANCE MAKE?
FOREGOING NEEDED MEDICAL CARE
• 30% of uninsured adults went without needed care in 1991.
• Over half (55%) of uninsured adults postponed care due to its cost, compared to
14% of the privately insured.
• Over 114 of uninsured children had unmet needs for health care in 1993, where
medical or dental care, surgery, prescriptions, eyeglasses, and mental health services were needed but not obtained.
• Over 113 of uninsured adults said they have had a problem paying their medical
bills in the past year.
• One in six uninsured adults said they had to change their family's way of life
significantly in order to pay the medical bills.
• One in five persons who were insured-but who had a recent gap in coverage in
the past two years-reported not getting needed medical care in the past year.
""Tl
0
::0
m
Gl
0
~
z
Gl
• 75% ofpeople who are both uninsured and in poor health said they have experienced problems getting needed medical care.
n
)>
::0
m
35
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�WHAT DIFFERENCE DOES
HEALTH INSURANCE MAKE?
Foregoing Needed Medical Care
Not having health insurance makes a substantial
difference in the amount and kind of health care
people are able to afford and obtain. Besides
affecting a person's access to health care, being
uninsured also changes one's financial security.
Having health insurance ultimately makes a difference in how healthy people are and consequently how long they live.
Medical bills mount quickly if a person is uninsured. Over a third of adults who are uninsured
report they have had a problem paying their
medical bills in the past year; one in six of the
uninsured said they had to change their family's
way of life significantly in order to pay these
medical bills.
Contrary to a common belief that the uninsured
are able to get the medical care they need from
doctors and hospitals, in 1997 uninsured adults
were four times more likely than those with private health insurance to say they did not receive
medical care they believed to be necessary. Over
half said they had postponed getting care and a
quarter had not filled a medical prescriptionboth because they could not afford it.
UJ
0::
<(
w
0
(.!)
UJ
0::
0
While children are generally healthier and may not
need as much medical care as adults, differences in
access to care exist nonetheless between children
with and without health coverage. Uninsured children are over three times as likely as insured children to have had an unmet need for health care in
the past year. Depending on the type of health service, (including dental care, prescriptions, and eyeglasses for example) the gap between children who
are insured compared to those with insurance is a
three to six fold difference.
1..1....
36
The Kaiser Commission on Medicaid and the Uninsured • june 1998
Even a temporary lapse in health insurance coverage has an impact on access to care. Persons
who are insured now-but had a "recent gap" in
coverage in the past two years-report experiences getting care that are more similar to the
uninsured than to those who have had continuous health insurance.
In addition to the differences in access to care
between the insured and uninsured, a gradient of
access exists across income levels. Among people
who are uninsured or had a gap in their coverage
in the past two years, those with the lowest
incomes (<$20,000/year) were most likely to
experience problems getting needed care.
Differences in access to care persist even after
adjusting for health status. For example, among·
adults in poor health, 75% of those who are also
uninsured report having had problems getting
medical care in the past year, compared to less
than a quarter of adults who are in poor health
but have health insurance.
How does being uninsured affect access to care for a
family as a whole? Families where everyone is uninsured report they have experienced more barriers to
getting needed care than families where everyone is
privately insured. What about families where some
members are uninsured while other members have
private health insurance? Families where some, but
not all members are uninsured experience barriers to
health services equal to those faced by families where
everyone is uninsured. This suggests that even
though some family members have insurance (and
therefore better financial protection and access to
health providers) this does not necessarily help others
in the family who are uninsured.
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•
�•
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•
FIGURE
23
Americans' Perceptions About the Uninsured
Is it your impression that people in your community without health
insurance are unable to get medical treatment, or that those uninsured people
are still able to get the medical care they need from doctors and hospitals?
Unable to get care
30%
Don't know/
refused
8%
.,
0
::u
m
G"l
Still able to get care
0
62%
z
Gl
n
)>
::u
m
Source: Kaiser-Harvard Program on the Public and Health/Social Policy, July 1996; unpublished
Data: Survey of Americans on Health Policy,
37
The Kaiser Commission on Medicaid and the Uninsured • june 1998
�FIGURE 24
Percent of Adults Who Did Not Receive Needed Medical
Care in Past Year by Insurance Status, 1997
Uninsured
Medicaid
Private
w
Medicare
0:::
~
u
......
0
0%
(.!)
w
5%
10%
0:::
0
LJ...
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
38
The Kaiser Commission on Medicaid and the Uninsured • June 1998
15%
20%
25%
30%
•
•
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•
�•
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•
•
•
•
•
•
•
•
FIGURE 25
Percent of Adults Postponing Medical Care
and Not Filling Prescriptions In Past Year
Because They Could Not Afford It, by Insurance Status, 1997
60%
55%
50%
40%
30%
20%
10%
0%
Postponed Care
"T1
Did Not Fill
Prescription
0
;o
m
G>
0
~
z
G>
n
II
)>
Uninsured
;o
m
~ Medicaid
Private
•
Medicare
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
39
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�FIGURE 26
Percent of Children Under 18 With Unmet Health Needs
by Insurance Status, 1993
30%
26%
25%
20%
15%
10%
5%
0%
AnyUnmet
Needs*
Needed, But
NotAble to
Get Care
Needed
Prescription
Needed
Glasses
(.!)
z
0
(.!)
UJ
0:::
II Uninsured
0
LL..
D Medicaid/Other
Public Insurance
•
Private Insurance
*Needed medical care or surgery, but did not get it; delayed medical care because ofcost; needed dental care, prescription medicine,
eyeglasses or mental health services
Source: Simpson, G., et, al., "Access
to
Health Care, Part 1: Children," National Center for Health Statistics. Vital Health Stat 1997; 10(196).
Data: National Health Interview Survey
40
The Kaiser Commission on Medicaid and the Uninsured • June 1998
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FIGURE 27
Percent of Nonelderly Adults With Problems
Paying Medical Bills by Insurance Status, 1997
40%
36%
30%
20%
10%
0%
Problem Paying
Bills
Had to Change Way
of Life Significantly
to Pay Bills
"'Tl
0
;;o
m
G)
0
•
D
D
Currently
Uninsured
("")
)>
;;o
m
Recent Gap*
Continuously
Insured
*Respondent currently insured, but was uninsured sometime in past 2 years.
Data: The Kaiser/Commonwealth 1997 National Survey of Health Insurance
41
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�FIGURE 28
Differences in Access to Care in the Past Year
Among None/derly Adults by Insurance Status, 1997
60%
55%
50%
40%
30%
20%
10%
0%
UJ
0::
Did Not Get Needed
Medical Care
<(
u
(.!)
z
Postponed Care
Due to Costs
Did Not Fill
Prescription
.....
0
(.!)
UJ
0::
0
I.J....
•
Currently Uninsured
0
Recent Gap*
Ill Continuously Insured
*Respondent currently insured, but was uninsured sometime in past 2 years.
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
42
The Kaiser Commission on Medicaid and the Uninsured • june /998
•
•
•
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•
•
•
•
•
•
•
•
•
�•
•
•
•
•
•
•
•
•
•
•
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•
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•
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•
•
•
•
FIGURE 29
Differences in Access to Care in the Past Year
Among the Recently Uninsured* by Income, 1997
60%
51%
50%
50%
40%
30%
20%
10%
0%
Did Not Get Needed
Medical Care
Postponed Care
Due to Costs
,
Did Not Fill
Prescription
0
;u
m
"'
0
~
z
"'
n
l>
;u
Annual Income
m
~ <$20,000
[J $20,001-$35,000
•
>$35,000
*Person was either uninsured at the time ofthe survey or was insured, but had a period in the past 2 years without health coverage.
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
43
The Kaiser Commission on Medicaid and the Uninsured • june 1998
�FIGURE 30
Problems Getting Needed Medical Care
by Health and Insurance Status, 1995
Percent of Adults Reporting Problems
Getting Needed Care in Past Year
Excellent
Health
Good Health
Fair Health
75%
w
cr:
Poor Health
<t
u
0
(.!)
0%
w
cr:
20%
40%
60%
80%
0
u...
~
Uninsured
D
Insured
Source: Harvard School of Public Health, National Opinion Research Center, Henry J. Kaiser Family Foundation, 1996; unpublished
Data: Getting Behind the Numbers on Access ro Care Survey, 1995.
44
The Kaiser Commission on Medicaid and the Uninsured • june /998
•
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•
�•
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•
•
•
•
FIGURE 31
Families Experiencing Barriers to Medical Care
by Type of Family Coverage, /996
Percent of Families
All MembersPrivate
All MembersMedicaid
All MembersUninsured
Mix of Uninsured
and Private
29%
.,
0
;o
rn
G>
0
Mix of Uninsured
and Medicaid
40%
z
G>
n
l>
0%
10%
20%
30%
40%
50%
Note: At least one family member needed but did not get care or had difficulty getting care in one or more of these services in the past year:
generalist or specialty physician care, emergency medical care, home health care, rehabilitation services, mental health services, and
medications.
Source: J. Kasper, 1997; unpublished
Data: Kaiser Survey of Family Health Experiences, 1996
The Kaiser Commission on Medicaid and the Uninsured • june 1998
;o
rn
�•
•
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•
•
•
•
•
•
•
•
WHAT DIFFERENCE DOES
HEALTH INSURANCE MAKE?
HEALTH SERVICES USE
• Over half of uninsured adults and one in five uninsured children do not have a
usual source ofhealth care.
• Among adults with a usual source of care, 40% of uninsured adults compared to
58% of those with health insurance identify a doctor's office as their usual source
ofcare.
• Adults who are uninsured are over twice as likely as the privately insured not to
have visited a doctor in the past year. One-third of uninsured children did not
see a doctor in the past year compared to only 16% ofinsured children .
• Preventive services are less commonly used by the uninsured-35% report a routine check-up in the past year compared to 61% of the insured. Uninsured children are less likely to be up-to-date with the accepted standard for well-child
care visits.
:::r::
m
)>
r
--f
::J:
(/)
m
;o
<
~
("')
m
en
=
en
m
47
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�WHAT DIFFERENCE DOES
HEALTH INSURANCE MAKE?
Health Services Use
Where people get their health care, whether they
have a usual source of care, how often they have
seen a physician in the course of a year, and if
they have used preventive health services are all
measures of access to care. These measures paint
a consistent picture where the uninsured,
whether they are adults or children, receive fewer
services and different types of care.
People without health coverage are much less
likely to have a usual source of health care. One
in five uninsured children and over half of uninsured adults have no regular person or place
where they go for care when they need it.
Perhaps not surprisingly, given the costs of preventive services, the uninsured are less likely to
have undergone routine check-ups and screening
tests than the insured. While 59% of insured
women had a mammogram in the past year, only
41 o/o of uninsured women had done so. Similarly among men, the uninsured were about half as
likely to have had a prostate exam in the past
year as the insured. Uninsured children also fall
behind those with health insurance in meeting
the accepted standards for well-child care-visits
where health problems are often prevented or
detected early.
When the uninsured have a usual source for their
health care they are far less likely to identify a
doctor's office than those with health coverage.
More than one in six uninsured adults consider a
hospital emergency room their regular source of
care. Almost 40% of uninsured adults report
they did not see a doctor in the past year-twice
the rate for those with private insurance. A third
of uninsured children did not see a doctor in the
past year compared to 16% of children with
health coverage.
(/)
UJ
u
>
0::
UJ
(/)
>
48
The Kaiser Commission on Medicaid and the Uninsured • June 1998
•
•
•
•
•
•
•
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•
•
•
•
•
•
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•
•
•
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•
•
•
•
•
•
•
•
•
�•
•
•
•
•
•
•
•
•
•
•
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•
•
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FIGURE 32
Percent of Nonelderly Adults Without a Usual Source
of Care by Insurance Status, 1997
70%
60%
57%
50%
38%
40%
30%
21%
20%
:::r::
m
)>
10%
r
--1
:I:
(/')
m
::<:1
0%
<
Currently
Uninsured
Recent Gap*
~
Continuously
Insured
("')
m
(/)
c:::
(/)
m
*Respondent currently insured, but was uninsured sometime in past 2 years.
Source: Kaiser Family Foundation and the Commonwealth Fund
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
49
The Kaiser Commission on Medicaid and the Uninsured • june /998
o
�FIGURE 33
Percent of Children Without a Usual Source of Care
by Insurance Status, 1996
Uninsured .
I
.
.
.
Medicaid &
Other Public
Insurance
I
.
I 20%
10%
Private
UJ
(/)
::::>
0%
(/)
5%
10%
15%
20%
UJ
u
~
>
0:::
UJ
U)
Source: Weigers ME, Weinick RM, and CohenJW. "Children's Health, 1996," AHCPR, 1998; (Pub. No 98-0008).
Data: Medical Expenditure Panel Survey, 1996
50
The Kaiser Commission on Medicaid and the Uninsured • june 1998
25%
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FIGURE 34
Site of Usual Source of Care For Adults
by Insurance Status, 1997
Doctor's Office
58%
Clinic or
Health Center
Hospital
Emergency Room
HM 0/0utpatient
Center
:c
m
)>
r
--t
:I:
(/)
Nowhere
m
;o
<
~
("')
m
0%
10%
20%
30%
40%
50%
Vl
60%
c:::
Vl
m
II Uninsured
Iii Insured
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
51
The Kaiser Commission on Medicaid and the Uninsured • June /998
�FIGURE 35
Percent of Adults with No Doctor Visits in Past Year
by Insurance Status, 1997
Uninsured
39%
Private
Medicaid
Medicare
(/)
0%
LJ.J
u
10%
20%
:I:
.....
-'
<
LJ.J
:::r::
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
52
The Kaiser Commission on Medicaid and the Uninsured • June /998
30%
40%
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FIGURE 36
Percent of Children With No Doctor Visits in Past Year
by Insurance Status, 1993-1994
Uninsured
33%
Insured
0%
5%
10%
15%
20%
25%
30%
35%
:::r::
m
)>
r
-I
:I:
(/)
m
::0
<
~
n
m
(/)
c=
(/)
m
Source: Newacheck, PW, eta!., "Health Insurance and Access
to
Primary Care for Children," NEJM 338 (8): 513-519 .
Data: National Health Interview Survey, 1993-94
53
The Kaiser Commission on Medicaid and the Uninsured • june 1998
�FIGURE 37
Differences in Use of Preventive Services in Past Year
by Insurance Status, 1997
Mammogram
59%
48%
Pap Smear
62%
Prostate Exam
Routine Physical
Exam or Check Up
(/)
IJ.J
u
0%
:c
61%
10%
20%
30%
40%
50%
60%
70%
I-
-'
<(
IJ.J
::I::
II Uninsured
D Insured
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
54
The Kaiser Commission on Medicaid and the Uninsured • june /998
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FIGURE 38
Chances of Uninsured Children NOT Receiving Routine
Health Care Compared to Insured Children, 1988
Adjusted Odds Ratio of NOT Receiving Care*
lJninsured/Insured
2.0
1.8
1.3
1.0 ..........
A
Equal chance
of receiving
health care
:X:
m
)>
0
r
L-----
Not lip-to-Date
With Well-Child Care
-I
:I:
Never Had
Routine Care
(./)
m
;;o
<
~
(')
m
(j')
=
(j')
m
Ratios >1.0 indicate uninsured more likely than insured NOT to get care
*Ratios were adjusted for the effects ofage, racelethnicity, region, urban/rural residence, education, family type, poverty status and health status.
Source: Hoi!, JL, et. al., "Profile of Uninsured Children in the United States," Archives ofPediatric and Adolescent Medicine, 1995; 149:398-406.
Data: National Health Interview Survey-Child Health Supplement, 1988
55
The Kaiser Commission on Medicaid and the Uninsured • june 1998
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
WHAT DIFFERENCE DOES
HEALTH INSURANCE MAKE?
MEDICAL DECISION-MAKING AND THE.
CONSE.QUE.NCE.S OF GOING WITHOUT CARE.
~
• 2/3 of nonelderly adults who did not get needed health care in 1997 report the
consequences were serious for them .
• The uninsured are hospitalized at least 50% more often for "avoidable hospital
conditions" like pneumonia and uncontrolled diabetes than the insured.
• The uninsured undergo fewer high cost/high discretion types of medical procedures than the insured.
• Uninsured children are 50% to 100% less likely than insured children to receive
medical care when they are ill with conditions such as recurring ear infections
and asthma .
• Uninsured women with breast cancer are more likely to be diagnosed at a more
severe stage of the disease than women with health coverage.
n
0
z
en
m
0
c:
m
z
("')
m
en
57
The Kaiser Commission on Medicaid and the Uninsured • june /998
�WHAT DIFFERENCE DOES
HEALTH INSURANCE MAKE?
Medical Decision-making and the
Consequences of Going without Care
The consequences of decreased access to health
care are not slight. The large majority of
nonelderly adults reported they experienced serious problems when they did not get the care they
needed in 1997, including living with pain and
activity-limiting conditions. Nearly half (45%)
said they still have the problem for which they
did not get care.
Because health needs are not addressed, the uninsured are more likely to be hospitalized for health
problems that could have been avoided, such as
uncontrolled diabetes and conditions for which
people can be immunized. In a study of two
eastern states, it was found that for these types of
"avoidable hospital conditions" the uninsured
were 50% to 70% more likely to need hospitalization than the privately insured. For some conditions, like diabetes and malignant hypertension
the uninsured were over twice as likely to be hospitalized as the privately insured.
en
w
u
z
w
:::>
The chances of undergoing certain procedures are
also different between the uninsured and those
with insurance. The uninsured are less likely to
have a procedure that is relatively costly or where
physicians exercise a great deal of discretion, (i.e.,
procedures where there is no clinical consensus on
their appropriate use). For example, uninsured
hospitalized patients in 1987 underwent 45%
fewer total hip replacements than those with insurance and 29% fewer coronary bypass surgeries.
CJ
w
en
z
0
u
58
The Kaiser Commission on Medicaid and the Uninsured • June /998
Uninsured children are also treated differently
when they are ill. Common childhood conditions such as sore throats, recurring ear infections,
and asthma, have serious consequences if they are
left untreated. Yet uninsured children are at least
half as likely as insured children to have received
medical care for these types of problems. The
chances of not being treated for chronic ear infections-which if untreated can lead to hearing loss
-were twice as high among the uninsured compared to children with health coverage.
Perhaps of most concern however, are the consequences of inadequate preventive health care
for diseases known to be fatal. Uninsured
women are less likely to have regular physical
exams and mammograms compared to insured
women and the result is that they are far more
likely to have advanced stages of breast cancer
when it is diagnosed.
In summary, whether a person does or does not
have health insurance makes a difference in the
process of medical decision-making. Personal
decisions made by uninsured people to delay or
even forego needed care because of its cost, coupled with providers who tend to order less or different treatments when a patient has no health
coverage, ultimately can lead to poorer health
outcomes, including premature deaths.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
"
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FIGURE 39
Health Consequences of Nonelderly Adults
Who Did Not Get Needed Care in the Past Year, 1997
Percent
Reporting
90%
74%
n
0
z
Problem
Caused Pain
or Difficulties
Consequences
Were Serious
Still Have
Problem
(/)
Went Without
Care More
Than Once
m
0
c:
m
z
n
m
(/)
21 million adults age 18-64 who had a time
they did not get needed care in past year
Data: Kaiser/Commonwealth 1997 National Survey of Health Insurance
59
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�FIGURE
40
Admission Rates of Avoidable Hospital Conditions (AHC)
for Uninsured vs. Privately Insured in Two States
Adjusted Relative Rates*
Uninsured/Privately Insured
3.0
2.8
No difference
between
admission rates
for uninsured
and insured
2.0
v
1.0
0.0
AllAHC
en
Pneumonia
UJ
u
z
UJ
:::>
0
UJ
Relative rates > 1.0 indicate uninsured more likely
than insured to be admitted for AHC
en
z
0
u
•
Massachusetts
0
Maryland
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•,
•
*Rates were all age- and sex-standardized
•
Source: Weissman JS, Gastonis C, and Epstein AM. "Rates of Avoidable Hospitalization by Insurance Status in Massachusetts and Maryland,"
•
JAMA 1992; 268 (17):2388-2394
Data: Maryland and Massachusetts Hospital Discharge Data
60
The Kaiser Commission on Medicaid and the Uninsured • june 1998
•
•
•
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
-·
\
FIGURE 41
Chances of the Uninsured Undergoing High Cost/High
MD Discretion Procedures Compared to the Insured
1.00
Ratio of the Probability of Procedure*
U ninsured/lnsured
........................................
0
•••••••••••••••••••••••••••
Equal chance of
undergoing procedure
0.71
0.50
n
0
z
(J)
0.0
Coronary Artery
Bypass Surgery
Total Hip
Replacement
Total Knee
Replacement
m
Stapedectomy**
0
c
m
z
n
m
(J)
Ratios < 1. 0 indicate uninsured less likely than insured
to undergo procedure
*Ratios were adjusted for the effects ofage, sex and race.
**Surgery for hearing loss
Source: Hadley J, Steinberg EP, and Feder J. "Comparison of Uninsured and Privately Insured Hospital
Patients: Condition on Admission, Resource Use and Outcomes," JAMA 1991; 265(3):374-379
Data: National Hospital Discharge Data
61
The Kaiser Commission on Medicaid and the Uninsured • june /998
�FIGURE 42
Chances of Uninsured Children NOT Receiving Medical Care
When Sick Compared to Insured Children, 1987
I
I.
Adjusted Odds Ratio ofNO Treatment*
Uninsured/Insured
3.0
2.1
2.0
Equal chance
of undergoing
procedure
y
1.0 ....
CJ)
UJ
u
z
0
UJ
Sore
Throat
::::>
0
UJ
Acute
Earache
Recurring
Ear Infection
Asthma
CJ)
z
0
w
Ratios >1.0 indicate uninsured more likely than insured
NOT to be treated
*Ratios were adjusted for the efficts ofage, sex, family size, race!ethnicity, income, region, and urban/rural residence.
Source: Stoddard JJ, et al., "Health Insurance Status and Ambulatory Care for Children," NEJM 1994; 330(20): 1421-1425.
Data: National Medical Expenditures Survey 1987
62
The Kaiser Commission on Medicaid and the Uninsured • June I 998
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FIGURE 43
Differences in Treatment Decisions by Insurance Status
Based on a survey of physicians given clinical scenarios
in which patients were either insured or uninsured .
Percent of Patients for Whom MDs Recommended Services
42%
Discretionary
Services l.c::=========g
Non discretionary
Services
lc:======;;;::::====;:=;;;::::=====;:::::;::=~
93%
n
0%
20%
40%
60%
80%
100%
0
z
en
m
0
•
c:
m
Uninsured
z
("')
0
Insured
m
en
Note: All differences are statistically significant. Discretionary services defined as those for which no clinical consensus exists .
Source: Mort EA, Edwards JN, Emmons DW, et al., "Physician Response to Patient Insurance Status in Ambulatory Care Clinical
Decision-Making." Medical Care, 1996 34 (8): 783-797 .
Data: Primary Care Physician Survey
63
The Kaiser Commission on Medicaid and the Uninsured • june I 998
�FIGURE 44
Stage of Breast Cancer at Time of Diagnosis by Insurance Status
Distribution ofWomen With Breast Cancer by Disease Stage
at Time of Diagnosis
40%
30%
20%
10%
en
LJ.J
u
z
0%
LJ.J
I
::::>
IIA
liB
III
IV
0
LJ.J
Stages of Disease
en
z
0
u
•
Uninsured
Ill Privately Insured
Note: Stage IV is most advanced disease
Source: Ayanian JZ, Kohler BA, AbeT, Epstein AM. "The Relationship Between Health Insurance Coverage and Clinical
Outcomes Among Women with Breast Cancer." NEJM 1993; 329 (5): 326-331.
Data: NJ Hospital Discharge Data and Cancer Registry
64
The Kaiser Commission on Medicaid and the Uninsured • june /998
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FIGURE 45
Selected Studies Examining the Relationship Between
Health Insurance Coverage,
Medical Interventions, and Health Outcomes
Citation
Ayanian JZ, Kohler BA, AbeT,
Epstein AM.
"The Relationship Between Health
Insurance Coverage and Clinical Outcomes Among Women with Breast
Cancer."
Study Population
Major Findings
Matched hospital discharge data and
New Jersey State Cancer Registry for
4,675 women followed for up to seven
years.
Upon diagnosis, uninsured women
had significantly more advanced disease than privately insured women.
Adjusted risk of death was 49o/o higher
for uninsured women than for privately insured women during the four to
seven years following breast cancer
diagnosis.
Hospital discharge data from 15 U.S.
urban areas and 3 urban areas in
Ontario, Canada. Data are from 1990
for all areas except New York City,
which were from 1982-1993.
Across all urban areas in the United
States, low-income patients experienced higher rates of preventable
hospitalizations than patients of higher
incomes. Smaller differences in rates
were found in the urban areas of
Ontario, Canada .
Hospital discharge data on births from
eight counties in the San Francisco
Bay area in California for 1982, 1984,
and 1986.
The uninsured were 30o/o more likely
to have adverse outcomes (prolonged
hospital stay, newborn transfer, or
death) than the privately insured in
1986. Uninsured African Americans
were over twice as likely and Latinos
over 1.5 times as likely to have an
adverse health outcome compared to
those with private coverage .
New England Journal ofMedicine
1993;329(5):326-331 .
Billings J, Anderson GM,
and Newman LS.
"Recent Findings on Preventable
Hospitalizations."
Health Affairs 1996; 15 (3) :239-249.
Braveman P, Oliva G, Miller MG,
eta!.
''Adverse Outcomes and Lack of
Health Insurance Among Newborns
in an Eight-County Area of California,
1982 to 1986."
New England Journal ofMedicine
1989;321 (8):508-513.
The Kaiser Commission on Medicaid and the Uninsured • june /998
�FIGURE 45
(CONTINUED)
Selected Studies Examining the Relationship Between
Health Insurance Coverage,
Medical Interventions, and Health Outcomes
Citation
Franks P, Clancy CM, Gold MR.
"Health Insurance and Mortality:
from a National Cohort.",
journal of the American Medical Association 1993;270(6):737-741.
Hafner-Eaton, C.
"Patterns of Hospital and Physician
Utilization Among the Uninsured."
Study Population
Major Findings
National Health and Nutrition Examination Survey. Epidemiologic study
that followed 6,913 adults from 1971
through 1987.
Adjusted risk of death was 25% higher
for uninsured patients than for privately insured.
1989 National Health Interview
Survey.
The uninsured were 38% less likely to
be hospitalized and 20% less likely to
have a physician visit than the insured.
Hospital discharge abstracts for
emergently hospitalized Massachusetts
residents in 1990.
The uninsured were 39% less likely to
receive physical therapy but as likely to
receive care in an intensive care unit as
the privately insured.
National sample of nearly 600,000
hospital discharge abstracts in 1987.
The uninsured were up to three times
more likely to die in the hospital than
comparable privately insured patients.
The uninsured were 29% less likely to
undergo a Coronary Artery Bypass
Graft (CABG) surgery, and 45% less
likely to undergo a total hip replacement than the privately insured,
procedures subject to high physician
discretion.
journal of Health Care for the Poor and
Underserved 1994;5(4):297-315.
Hass JS, Gold L.
"Acutely Injured Patients with Trauma
in Massachusetts: Differences in Care
and Mortality, by Insurance Status."
American journal ofPublic Health
1994;84(10): 1605-1608.
0
(.!)
UJ,
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0
u_
Hadley J, Steinberg EP, and Feder J.
"Comparison of Uninsured and Privately Insured Hospital Patients: Condition on Admission, Resource Use
and Outcomes."
journal of the American Medical
Association 1991;265(3):374-379.
66
The Kaiser Commission on Medicaid and the Uninsured • june 1998
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FIGURE 45
(CONTINUED)
Selected Studies Examining the Relationship Between
Health Insurance Coverage,
Medical Interventions, and Health Outcomes
Citation
Mort EA, Edwards JN, Emmons OW
et al.
"Physician Response to Patient Insurance Status in Ambulatory Care Clinical Decision-Making."
Medical Care 1996;34(8):783-797 .
Overpeck, MD and Koch, JB.
"The Effect of U.S. Children's Access
to Care on Medical Attention for
Injuries."
American journal ofPublic Health
Study Population
Major Findings
Given the same scenarios, physicians
recommended "discretionary" services
(those with no clearly established
medical protocol) for 50% of insured
patients compared to 42o/o of uninsured patients.
Among children under 18, the uninsured were 27o/o less likely to receive
medical care for nonfatal injuries
and 29o/o less likely to receive care
for serious injuries.
1995;85(3):402-404 .
Stoddard, JJ et al.
"Health Insurance Status and Ambulatory Care for Children."
New England journal ofMedicine
1994;330(20): 1421-1425.
Weissman JS, Gastonis C, Epstein
AM .
"Rates of Avoidable Hospitalization by
Insurance Status in Massachusetts and
Maryland."
journal of the American Medical
Association 1992;268(17):2388-2394 .
Uninsured children were over 70%
more likely to go without a physician
visit for pharyngitis and asthma, 85%
more likely to go without a physician
visit for acute earache, and over twice
as likely to go without a physician visit
for recurrent ear infections compared
to insured children .
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In both states, uninsured patients with
malignant hypertension had twice the
rate of avoidable hospitalizations than
the privately insured. In Massachusetts, uninsured patients with diabetes
had nearly three times the rate of hospitalization than the privately insured.
67
The Kaiser Commission on Medicaid and the Uninsured • june /998
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S E C T I 0 N
4
DETAILED TABLES
The Nonelderly Uninsured Population
Uninsured Workers
Uninsured Children
State Estimates of the Uninsured
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TABLE 1
Characteristics of the Nonelderly Uninsured, /995
69
The Kaiser Commission on Medicaid and the Uninsured • June /998
�TABLE 2
Characteristics of the Nonelderly Uninsured
with Incomes Less than 200% of Poverty, /995
Low-Income
Population
(millions)
Total -- Low-Income Nonelderly
Percent
Distribution
of Low-Income
Po12ulation
Low-Income
Uninsured
(millions)
Percent
Distribution
of Low-Income
Uninsured
Percent
Uninsured
(Rate)
75.9
100.0%
19.3
100.0%
25.4%
<18
18 to 34
35 to 54
55 to 64
31.2
22.9
16.4
5.3
41.1%
30.2%
21.7%
7.0%
4.1
8.3
5.4
1.5
21.1%
43.2%
28.0%
7.7%
13.1%
36.2%
32.9%
28.3%
Male
Female
35.4
40.5
46.7%
53.3%
10.3
8.9
53.7%
46.3%
29.1%
22.0%
White
African American
Hispanic
Asian/S. Pacific Islander
Native American
39.2
16.6
16.4
2.7
1.1
51.6%
21.8%
21.6%
3.6%
1.4%
9.4
3.6
5.3
0.8
0.2
48.8%
18.8%
27.3%
4.0%
1.0%
24.0%
21.9%
32.1%
28.6%
18.3%
Family Work Status
2 or more Full-Time
Only 1 Full-Time
Only Part-Time
No workers
10.6
37.8
10.7
16.8
14.0%
49.8%
14.1%
22.1%
3.1
10.2
3.0
3.0
16.0%
53.1%
15.3%
15.5%
29.0%
27.0%
27.6%
17.8%
Household Type
Adults Only:
Single Adults Living Alone
Married Adults
Sin!:lle Adults Livin!:J To!:Jether
4.6
6.4
9.5
6.0%
8.7%
12.9%
1.6
2.5
4.7
8.7%
13.4%
25.0%
35.2%
38.9%
49.0%
Families with Children:
1 Parent
2 Parents
Multigeneration/Other
19.6
28.0
5.6
26.6%
38.0%
7.6%
2.3
6.6
1.0
12.3%
35.3%
5.3%
11.7%
23.5%
17.7%
Age
Gender
Race!Ethnicity
Notes:
The 1995 federal poverty level for a family of 3 was $12,590.
Multigeneration/Other families with children include families with at least 3 generations in a household;
plus families where adults are caring for children other than their own, e.g., a niece living with her aunt.
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Source: Urban Institute, 1997; unpublished.
Data: Current Population Survey, March 1996
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The Kaiser Commission on Medicaid and the Uninsured • june 1998
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\
TABLE 3
Characteristics of the Nonelderly Uninsured
by Age and Gender, /995
Population
(millions)
Percent
Distribution
of Population
Uninsured
(millions)
Percent
Distribution
of Uninsured
Percent
Uninsured
(Rate)
229.9
100.0%
35.7
100.0%
15.5%
Male
Female
70.1
35.8
34.2
30.5%
15.6%
14.9%
6.9
3.5
3.4
19.3%
9.9%
9.4%
9.8%
9.8%
9.8%
Male
Female
64.7
32.2
32.5
28.1%
14.0%·
14.1%
15.3
9.2
6.1
42.8%
25.7%
17.1%
23.6%
28.5%
18.8%
Male
Female
74.1
36.3
37.8
32.2%
15.8%
16.4%
10.7
5.8
4.9
30.0%
16.2%
13.8%
14.5%
16.0%
13.0%
Male
Female
21.1
10.1
11.0
9.2%
4.4%
4.8%
2.8
1.2
1.6
7.9%
3.5%
4.5%
13.5%
12:3%
14.5%
Total •• Nonelderly
<18
18-34
35-54
55-64
Source: Urban Institute, 1997; unpublished.
Data: Current Population Survey, March 1996
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The Kaiser Commission on Medicaid and the Uninsured • June /998
�TABLE
4
Characteristics of the Nonelderly Uninsured
by Poverty Level and Gender, /995
Population
(millions)
Percent
Distribution
of Population
Uninsured
(millions)
Percent
Distribution
of Uninsured
Percent
Uninsured
(Rate)
Total-- Nonelderly
229.9
100.0%
35.7
100.0%
15.5%
<100%
Male
Female
34.3
15.1
19.2
14.9%
6.6%
8.4%
7.9
4.3
3.6
22.1%
12.0%
10.2%
23.0%
28.3%
18.9%
Male
Female
41.6
20.3
21.2
18.1%
8.8%
9.2%
11.3
6.1
5.3
31.8%
17.0%
14.8%
27.3%
29.8%
24.9%
Male
Female
40.0
19.9
20.0
17.4%
8.7%
8.7%
7.4
4.0
3.3
20.6%
11.2%
9.4%
18.4%
20.1%
16.7%
34.6
17.6
17.0
15.1%
7.7%
7.4%
3.8
Male
Female
2.2
1.6
10.5%
6.1%
4.5%
10.9%
12.3%
9.4%
Male
Female
79.4
41.5
37.9
34.5%
18.0%
16.5%
5.4
3.3
2.1
15.0%
9.1%
5.9%
6.7%
7.9%
5.5%
100-199%
200-299%
300-399%
>400%
Note: The 1995 federal poverty level for a family of 3 was $12,590.
Source: Urban Institute, 1997; unpublished.
Data: Current Population Survey, March 1996
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The Kaiser Commission on Medicaid and the Uninsured • June /998
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TABLE 5
Characteristics of the Nonelderly Uninsured
by Poverty Level and Race, 1995
Population
(millions)
Percent
Distribution
of Po~ulation
Uninsured
(millions)
Percent
Distribution
of Uninsured
Percent
Uninsured
(Rate)
Total -- Nonelderly
229.2
100.0%
35.7
100.0%
15.5%
<100%
White
African American
Hispanic
Other
34.3
14.5
9.6
8.2
2.0
15.0%
6.3%
4.2%
3.6%
0.9%
7.9
3.6
1.7
2.2
0.4
22.0%
10.0%
4.6%
6.3%
1.2%
23.0%
24.6%
17.3%
27.3%
21.9%
White
African American
Hispanic
Other
41.6
24.7
7.0
8.2
1.7
18.2%
10.8%
3.1%
3.6%
0.8%
11.3
5.8
2.0
3.0
0.5
31.7%
16.3%
5.5%
8.5%
1.5%
27.3%
23.6%
28.2%
37.0%
30.2%
White
African American
Hispanic
Other
40.0
28.8
5.0
4.4
1.8
17.5%
12.6%
2.2%
1.9%
0.8%
7.3
4.3
1.1
1.5
0.4
20.5%
12.2%
3.1%
4.1%
1.2%
18.4%
15.1%
22.5%
32.8%
25.3%
White
African American
Hispanic
Other
34.6
27.2
3.4
2.6
1.5
15.1%
11.9%
1.5%
1.1%
0.7%
3.8
2.4
0.5
0.5
0.3
10.5%
6.8%
1.5%
1.5%
0.7%
10.9%
8.9%
15.9%
21.0%
17.8%
White
African American
Hispanic
Other
79.4
67.2
5.3
3.3
3.6
34.6%
29.3%
2.3%
1.5%
1.5%
5.4
3.9
0.7
0.4
0.4
15.0%
10.8%
2.0%
1.2%
1.0%
6.7%
5.7%
13.2%
13.2%
10.1%
100-199%
200-299%
300-399%
>400%
Notes:
To ensure reliable estimates, Asian/S. Pacific Islander and Native American have been combined into
the "Other" category. Note that nonelderly Asian/S.Pacific Islanders as a group have a higher risk
of being uninsured (20.0%) than nonelderly Native Americans (16.3%) .
The 1995 federal poverty level for a family of 3 was $12,590.
Source: Urban Institute, 1997; unpublished .
Data: Current Population Survey, March 1996
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73
The Kaiser Commission on Medicaid and the Uninsured • june I 998
�TABLE 6
Characteristics of the Nonelderly Uninsured
by Poverty Level and Family Work Status, /995
Population
(millions)
Percent
Distribution
of Po~ulation
Uninsured
(millions)
Percent
Distribution
of Uninsured
Percent
Uninsured
(Rate)
229.9
100.0%
35.7
100.0%
15.5%
<100%
2 or more Full-Time
Only 1 Full-Time
Only Part-Time
No workers
34.3
1.9
12.3
6.7
13.4
14.9%
0.8%
5.4%
2.9%
5.8%
7.9
0.5
3.4
1.7
2.3
22.1%
1.4%
9.5%
4.8%
6.4%
23.0%
27.6%
27.3%
25.3%
17.3%
100-199%
2 or more Full-Time
Only 1 Full-Time
Only Part-Time
No workers
41.6
8.7
25.5
4.0
3.4
18.1%
3.8%
11.1%
1.7%
1.5%
11.3
2.6
6.9
1.2
0.7
31.9%
7.3%
19.3%
3.4%
2.0%
27.3%
29.3%
26.9%
31.5%
20.0%
200% +
2 or more Full-Time
Only 1 Full-Time
Only Part-Time
No workers
153.9
74.9
72.3
4.2
2.5
66.9%
32.6%
31.4%
1.8%
1.1%
16.6
7.4
7.7
0.9
0.5
46.2%
20.7%
21.6%
2.5%
1.4%
10.8%
10.0%
10.6%
21.5%
18.3%
Total -- Nonelderly
Notes:
The 1995 federal poverty level for a family of 3 was $12,590.
Part-time workers were defined as working <35 hours per week.
Source: Urban Institute, 1997; unpublished.
Data: Current Population Survey, March 1996
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The Kaiser Commission on Medicaid and the Uninsured • june /998
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•
•
•
•
•
•
•
•
•
•
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•
•
•
•
•
•
•
•
•
•
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TABLE
7
Characteristics of the Nonelderly Uninsured
by Household Type and Poverty Level, 1995
Population
(millions)
Percent
Distribution
of Po(2ulation
Uninsured
(millions)
Percent
Distribution
of Uninsured
Percent
Uninsured
(Rate)
229.9
100.0%
35.7
100.0%
15.5%.
Single Adults Living Alone
<100%
100-199%
200-299%
300-399%
>400%
14.8
2.2
2.4
2.5
2.1
5.5
6.4%
1.0%
1.0%
1.1% .
0.9%
2.4%
2.7
0.8
0.8
0.5
0.2
0.3
7.7%
2.3%
2.3%
1.5%
0.7%
1.0%
18.6%
36.1%
34.3%
21.4%
11.8%
6.2%
Mar~ied
48.9
2.1
4.3
6.0
7.0
29.4
21.3%
0.9%
1.9%
2.6%
3.1%
12.8%
7.2
1.0
1.5
1.5
1.0
2.3
20.3%
2.9%
4.1%
4.1%
2.7%
6.4%
14.8%
49.1%
34.0%
24.3%
13.9%
7.8%
23.9
4.4
5.1
4.8
3.6
6.0
10.4%
1.9%
2.2%
2.1%
1.6%
2.6%
8.3
2.3
2.3
1.7
0.9
1.0
23.1%
6.5%
6.5%
4.7%
2.6%
2.8%
34.6%
52.9%
45.5%
34.7%
26.2%
16.6%
<100%
100-199%
200-299%
300-399%
>400%
28.2
12.1
7.6
4.2
2.2
2.1
12.3%
5.2%
3.3%
1.8%
1.0%
0.9%
3.4
0.9
1.4
0.6
0.3
0.2
9.5%
2.5%
4.0%
1.8%
0.7%
0.5%
12.0%
7.3%
18.7%
15.4%
11.5%
8.8%
<100%
100-199%
200-299%
300-399%
>400%
101.8
9.0
19.0
20.4
18.6
34.8
44.3%
3.9%
8.3%
8.9%
8.1%
15.1%
11.5
2.2
4.4
2.5
1.1
1.3
32.1%
6.0%
12.4%
6.9%
3.1%
3.7%
11.3%
23.9%
23.3%
12.1%
6.0%
3.8%
Multigenerations/Other
<100%
100-199%
200-299%
300-399%
>400%
12.4
4.5
3.2
2.0
1.0
1.6
5.4%
2.0%
1.4%
0.9%
0.5%
0.7%
2.6
0.7
0.9
0.6
0.2
0.2
7.3%
2.0%
2.5%
1.6%
0.6%
0.7%
21.1%
15.5%
28.0%
28.4%
20.7%
14.5%
Total
Adult-Only Households
b)l Povert'j{_ Level:
Couples
<100%
100-199%
200-299%
300-399%
>400%
Single Adults Living Together
<100%
100-199%
200-299%
300-399%
>400%
...-'
Families with Children
by: Povert'j{_ Level:
1 Parent
2 Parents
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Notes:
The 1995 federal poverty level for a family of 3 was $12,590.
Multigeneration/Other families with children include families with at least 3 generations in a household;
plus families where adults are caring for children other than their own, e.g., a niece living with her aunt..
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-<
c::
z
z
(/)
Source: Urban Institute, 1997; unpublished .
Data: Current Population Survey, March 1996
c::
;u
m
t:l
The Kaiser Commission on Medicaid and the Uninsured • june 1998
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
\
TABLE 9
Characteristics of Uninsured Workers (Age 18-64),
with Incomes Less than 200% of Poverty, 1995
Low-Income
Percent
Working
Distribution
Population of Low-Income
(millions)
Working
Po(:2ulation
Low-Income
Percent
Distribution
Uninsured
of Low-Income
Workers
Working
(millions)
Uninsured
Percent
Uninsured
(Rate)
Total-- Low-Income Workers
47.3
100.0%
13.8
100.0%
29.2%
Work Status
Full-Year/Full-Time
Full-Year/Part-Time
Part-Year/Full-Time
Part-Year/Part-Time
16.3
7.6
12.2
11.2
34.4%
16.1%
25.8%
23.7%
5.4
1.9
3.9
2.6
38.8%
13.8%
28.3%
19.1%
32.9%
25.2%
29.2°/q
23.5%
Business Size (# of workers)
<25
25-99
100-499
500-999
1000+
18.5
6.4
5.9
2.4
14.1
39.0%
13.6%
12.5%
5.1%
29.8%
6.5
1.9
1.6
0.6
3.2
47.2%
13.8%
11.3%
4.4%
23.4%
35.3%
29.6%
26.5%
25.3%
22.9%
Female
Male
28.3
19.0
59.8%
40.2%
6.2
7.6
44.8%
55.2%
21.9%
40.1%
Ty_e_e of Business
Agriculture
Business/Repair Services
Construction
Finance/Insurance/Real Estate
Government/Former Military
Mining/Manufacturing
Personal/Entertainment
Professional Services
Retail/Wholesale Trade
Transportation/Comm/Utilities
2.1
3.4
2.7
1.8
0.8
5.5·
4.4
10.6
14.4
1.6
4.4%
7.2%
5.6%
3.8%
1.8%
11.6%
9.2%
22.5%
30.4%
3.4%
0.8
1.3
1.3
0.3
0.2
1.6
1.3
2.0
4.5
0.5
5.9%
9.5%
9.2%
2.4%
1.2%
11.8%
9.7%
14.3%
32.3%
3.6%
38.7%
38.2%
48.1%
18.4%
20.3%
29.6%
30.7%
18.6%
31.1%
31.1%
32.1
6.5
6.6
1.7
0.4
67.9%
13.7%
14.0%
3.5%
0.9%
7.6
2.4
3.2
0.5
55.0%
17.0%
23.4%
3.7%
29.2%
36.5%
48.9%
30.7%
Gender
Race/Ethnicity_
White
African American
Hispanic
Asian/S. Pacific Islander
Native American
c
z
Note: * Insufficient sample for a reliable estimate
z
Source: Urban Institute, 1997; unpublished.
Data: Current Population Survey, March 1996
c
CJ)
::0
m
t:!
:::E
0
::0
;><:
m
::0
CJ)
77
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�------
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
,.
\
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
TABLE 11
Characteristics of Uninsured Workers (Age 18-64),
by Gender and Income, 1995
Population
(miilions)
Percent
Distribution
of Population
Uninsured
(millions)
Percent
Distribution
of Uninsured
Percent
Uninsured
(Rate)
Total-- All Workers
130.0
100.0%
22.0
100.0%
16.9%
Female
Under $10,000
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000 and Over
61.0
17.1
17.4
12.1
7.0
3.7
3.9
46.9%
13.1%
13.4%
9.3%
5.4%
2.8%
3.0%
8.6
3.8
3.1
1.0
0.4
0.1
0.2
39.2%
17.4%
14.3%
4.6%
1.7%
0.5%
0.7%
14.1%
22.4%
18.1%
8.4%
5.2%
3.0%
4.0%
Under $10,000
$10,000-$19,999
$20' 000-$29' 999
$30,000-$39,999
$40,000-$49,999
$50,000 and Over
69.0
10.3
14.0
13.2
10.6
7.2
13.8
53:1%
7.9%
10.7%
10.2%
8.1%
5.5%
10.6%
13.3
4.3
4.6
2.3
1.0
0.4
0.7
60.8%
19.6%
21.1%
10.4%
4.7%
1.8%
3.1%
19.3%
42.0%
33.1%
17.2%
9.7%
5.6%
5.0%
Male
Source: Urban Institute, 1997; unpublished.
Data: Current Population Survey, March 1996
c
z
......
z
(/")
c
::0
m
t:1
::E
0
::0
7<
m
::0
(/")
79
The Kaiser Commission on Medicaid and the Uninsured • june /998
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
\
TABLE 13
Characteristics of Uninsured Children (Less than Age 18), /995
Population
(millions)
Percent
Distribution
of Population
Uninsured
(millions)
Percent
Distribution
of Uninsured
Percent
Uninsured
(Rate)
70.1
100.0%
6.9
100.0%
9.8%
<6
6 to 11
12 to 17
24.0
23.3
22.8
34.2%
33.3%
32.5%
2.0
2.2
2.7
29.6%
31.5%
38.9%
8.5%
9.3%
11.8%
<100%
100-199%
200-299%
300-399%
>400%
15.7
15.5
12.8
10.0
16.1
22.5%
22.1%
18.2%
14.3%
23.0%
1.4
2.6
1.5
0.7
0.7
20.6%
38.5%
21.5%
9.5%
10.0%
9.0%
17.1%
11.6%
6.5%
4.3%
2 Parents
1 Parent
Multigeneration/Other
47.6
16.9
5.6
68.0%
24.1%
8.0%
4.6
1.4
0.9
66.2%
20.7%
13.1%
9.6%
8.5%
16.2%
Famil'f. Work Status
2 or more Full-Time
Only 1 Full-Time
Only Part-Time
No workers
23.0
35.8
4.6
6.7
32.8%
51.1%
6.6%
9.5%
2.1
3.8
0.6
0.4
30.3%
55.2%
8.3%
6.1%
9.1%
10.6%
12.5%
6.3%
45.3
11.0
10.2
2.8
0.7
64.7%
15.8%
14.6%
3.9%
1.0%
3.7
1.1
1.6
0.3
0.1
54.3%
16.0%
23.8%
4.7%
1.1%
8.2%
10.0%
16.0%
11.8%
10.8%
Total --All Children
Ag_e
Poverty Level
Famil'f. T'{_e_e
Race!Ethnicity_
White
African American
Hispanic
Asian/S. Pacific Islander
Native American
c
z
Note: The 1995 federal poverty level for a family of 3 was $12,590.
z
(f)
Source: Urban Institute, 1997; unpublished.
Data: Current Population Survey, March 1996
c
:;o
m
0
(")
::c
r
0
:;o
m
z
81
The Kaiser Commission on Medicaid and the Uninsured • june /998
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
\
TABLE 15
Characteristics of Uninsured Children (Less than Age 18),
by Poverty Level and Age, 1995
Population
(millions)
Percent
Distribution
of PoQulation
Uninsured
(millions)
Percent
Distribution
of Uninsured
Percent
Uninsured
(Rate)
70.1
100.0%
6.9
100.0%
9.8%
<6
6 to 11
12 to 17
15.7
6.5
5.1
4.1
22.5%
9.3%
7.3%
5.9%
1.4
0.3
0.4
0.7
20.6%
4.8%
5.1%
10.6%
9.0%
5.1%
6.9%
17.7%
<6
6 to 11
12 to 17
15.5
5.4
5.3
4.8
22.1%
7.7%
7.6%
6.8%
2.6
0.8
0.9
1.0
38.5%
11.0%
13.6%
13.9%
17.1%
14.0%
17.7%
20.0%
<6
6 to 11
12 to 17
12.8
4.2
4.4
4.2
18.2%
6.0%
6.2%
6.0%
1.5
0.5
0.5
0.5
21.5%
7.3%
6.8%
7.4%
11.6%
11:9%
10.7%
12.1%
<6
6 to 11
12 to 17
10.0
3.1
3.4
3.5
14.3%
4.4%
4.8%
5.1%
0.7
0.2
0.2
0.2
9.5%
3.0%
3.2%
3.4%
6.5%
6.6%
6.4%
6.6%
<6
6 to 11
12 to 17
16.1
4.8
5.2
6.1
23.0%
6.8%
7.4%
8.7%
0.7
0.2
0.2
0.2
10.0%
3.6%
2.8%
3.6%
4.3%
5.2%
3.7%
4.1%
Total-- All Children
<100%
100-199%
200-299%
300-399%
>400%
Note: The 1995 federal poverty level for a family of 3 was $12,590 .
Source: Urban Institute, 1997; unpublished .
Data: Current Population Survey, March.1996
c
z
z
(/)
c
::0
m
0
(")
I
r
0
::0
m
z
The Kaiser Commission on Medicaid and the Uninsured • june I 998
�------------------------------------------------------
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
TABLE 17
Characteristics of Uninsured Children (Less than Age 18),
by Poverty Level and Family Type, 1995
Population
(millions)
Uninsured
(millions)
Percent
Distribution
of Uninsured
Percent
Uninsured
(Rate)
70.1
100.0%
6.9
100.0%
9.8%
2 Parents
1 Parent
Multigenerations/Other
15.7
5.0
8.0
2.8
22.5%
7.1%
11.4%
4.0%
1.4
0.7
0.4
0.4
20.6%
10.4%
5.1%
5.1%
9.0%
14.4%
4.4%.
12.5%
2 Parents
1 Parent
Multigenerations/Other
15.5
9.6
4.4
1.5
22.1%
13.7%
6.3%
2.1%
2.6
1.8
0.5
0.3
38.5%
26.5%
8.0%
4.0%
17.1%
18.9%
12.5%
19.0%
2 Parents
1 Parent
Multigenerations/Other
12.8
9.8
2.3
0.7
18.2%
13.9%
3.3%
1.0%
1.5
1.0
0.3
0.2
21.5%
14.8%
4.4%
2.2%
11.6%
10.5%
13.1%
22.3%
2 Parents
1 Parent
Multigenerations/Other
Total··
Percent
Distribution
of POJ2Uiation
26.1
23.3
2.2
0.6
37.2%
33.2%
3.1%
0.9%
1.3
1.0
0.2
0.1
19.5%
14.5%
3.2%
1.8%
5.1%
4.3%
10.1%
19.3%
All Children
<100%
100-199%
200-299%
>300%
Notes:
To ensure reliable estimates, the 300-399% and >400% groups have been combined .
The 1995 federal poverty level for a family of 3 was $12,590.
Source: Urban Institute, 1997; unpublished .
Data: Current Population Survey, March 1996
c:
z
z
(/)
c:
::0
m
0
n
::c
r
0
::0
m
z
85
The Kaiser Commission on Medicaid and the Uninsured • June 1998
�.---------------------------------------------------------------------------------------------------------------
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
TABLE
19
State Estimates of the Low-Income Nonelderly Uninsured
(Less than 200% of Poverty), 1994-1995
Total Nonelderly Low-Income Population
Low-Income
Population
(thousands)
Percent
Distribution of
Low-Income
Nonelderly Low-Income Uninsured Population
Low-Income
Uninsured
(thousands)
Po~ulation
Percent
Distribution of
Low-Income
Uninsured
Percent
Uninsured
(Rate)
United States
76 321
100.0%
19 331
100.0%
25.3%
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississi
Missouri
Montana
Nebraska
Nevada
New Ham shire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
1.489
176
1.479
857
10 779
891
634
163
221
4 394
2,226
298
370
3,025
1 608
714
745
1,310
1,674
299
1,162
1,238
2,365
1,034
1 027
1.476
271
408
417
223
1,522
769
5,347
1,851
164
2,845
1,086
964
2,986
232
1,326
216
1,724
6,740
586
154
1,573
1.403
605
1,114
140
2.0%
0.2%
1.9%
1.1%
14.1%
1.2%
0.8%
0.2%
0.3%
5.8%
2.9%
0.4%
0.5%
4.0%
2.1%
0.9%
1.0%
1.7%
2.2%
0.4%
1.5%
1.6%
3.1%
1.4%
1.3%
1.9%
0.4%
0.5%
0.5%
0.3%
2.0%
1.0%
7.0%
2.4%
0.2%
3.7%
1.4%
1.3%
3.9%
0.3%
1.7%
0.3%
2.3%
8.8%
0.8%
0.2%
2.1%
1.8%
0.8%
1.5%
0.2%
414
32
421
258
2 929
238
145
48
64
1 242
539
24
92
543
371
153
162
340
518
63
289
248
433
192
275
336
59
84
120
45
421
288
1,342
417
31
626
319
198
556
46
326
33
200
2,593
105
27
415
322
132
214
43
2.1%
0.2%
2.2%
1.3%
15.2%
1.2%
0.7%
0.2%
0.3%
6.4%
2.8%
0.1%
0.5%
2.8%
1.9%
0.8%
0.8%
1.8%
2.7%
0.3%
1.5%
1.3%
2.2%
1.0%
1.4%
1.7%
0.3%
0.4%
0.6%
0.2%
2.2%
1.5%
6.9%
2.2%
0.2%
3.2%
1.6%
1.0%
2.9%
0.2%
1.7%
0.2%
1.0%
13.4%
0.5%
0.1%
2.1%
1.7%
0.7%
1.1%
0.2%
27.8%
18.3%
28.5%
30.1%
27.2%
26.7%
22.8%
29.2%
29.1%
28.3%
24.2%
8.1%
24.9%
18.0%
23.1%
21.4%
21.7%
25.9%
30.9%
20.9%
24.9%
20.0%
18.3%
18.6%
26.8%
22.7%
21.7%
20.6%
28.7%
20.3%
27.7%
37.4%
25.1%
22.5%
19.2%
22.0%
29.3%
20.5%
18.6%
19.7%
24.6%
15.4%
11.6%
38.5%
17.9%
17.8%
26.4%
23.0%
21.8%
19.2%
31.1%
(/)
Note: The 1995 federal poverty level for a family of 3 was $12,590.
-1
)>
Source: Urban Institute, 1997; unpublished.
-1
Data: CPS - March 1995 and March 1996.
m
m
(/)
-1
3
)>
-1
m
(/)
87
The Kaiser Commission on Medicaid and the Uninsured • june /998
�•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
TABLE 21
State Estimates of Low-Income (Less than 200°A> of Poverty)
Uninsured Children (Less than Age 19), 1994-1995
Low-Income Children
Low-Income
Uninsured
Children
(thousands)
Percent
Distribution
of Low-Income
Uninsured
Children
Percent
Uninsured
(Rate)
33,781
United States
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Low-Income Uninsured Children
Percent
Distribution
of Low-Income
Children
100.0%
4,822
100.0%
14.3%
607
77
679
356
5,032
350
314
73
102
1 856
948
141
167
1,463
731
329
315
525
724
114
513
514
1,118
431
475
604
110
180
176
87
639
368
2,345
738
69
1,308
448
413
1,310
98
618
101
746
3,113
290
66
668
541
211
521
58
1.8%
0.2%
2.0%
1.1%
14.9%
1.0%
0.9%
0.2%
0.3%
5.5%
2.8%
0.4%
0.5%
4.3%
2.2%
1.0%
0.9%
1.6%
2.1%
0.3%
1.5%
1.5%
3.3%
1.3%
1.4%
1.8%
0.3%
0.5%
0.5%
0.3%
1.9%
1.1%
6.9%
2.2%
0.2%
3.9%
1.3%
1.2%
3.9%
0.3%
1.8%
0.3%
2.2%
9.2%
0.9%
0.2%
2.0%
1.6%
0.6%
1.5%
0.2%
106
7
105
73
729
60
41
10
17
280
99
7
27
127
117
54
40
95
150
13
70
46
92
35
88
44
11
16
29
13
109
99
231
83
10
153
90
88
124
11
94
8
91
787
32
5
97
44
5
44
11
2.2%
0.1%
2.2%
1.5%
15.1%
1.3%
0.8%
0.2%
0.4%
5.8%
2.1%
0.2%
0.6%
2.6%
2.4%
1.1%
0.8%
2.0%
3.1%
0.3%
1.4%
0.9%
1.9%
0.7%
1.8%
0.9%
0.2%
0.3%
0.6%
0.3%
2.3%
2.1%
4.8%
1.7%
0.2%
3.2%
1.9%
1.8%
2.6%
0.2%
2.0%
0.2%
1.9%
16.3%
0.7%
0.1%
2.0%
0.9%
0.1%
0.9%
0.2%
17.5%
8.7%
15.4%
20.5%
14.5%
17.3%
13.0%
13.7%
16.8%
15.1%
10.4%
5.3%
16.1%
8.7%
16.1%
16.5%
12.8%
18.1%
20.7%
11.9%
13.6%
8.9%
8.2%
8.1%
18.5%
7.3%
10.4%
9.0%
16.7%
14.3%
17.1%
27.0%
9.8%
11.3%
15.2%
11.7%
20.2%
21.3%
9.5%
10.9%
15.3%
7.8%
12.2%
25.3%
10.9%
8.0%
14.5%
8.1%
2.6%
8.5%
19.2%
Population
of Low-Income
Children
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Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Estimates from the CPS are also problematic
because people are believed to under-report their
health insurance, particularly whether or not
they have Medicaid coverage.
This undercounting of the number of people
covered by Medicaid - as evidenced in comparison to known Medicaid enrollee numbers from
the Health Care Financing Administration
(HCFA)-results in a likely over-count of the
number of uninsured.
Several different research institutions (the
Employee Benefits Research Institute, the
Census Bureau, the Congressional Budget Office,
the General Accounting Office and the Urban
Institute) regularly analyze the CPS to generate
information about the numbers of uninsured .
Only the Urban Institute adjusts its estimates
for the under-reporting ofMedicaid and consequent over-count of the number of uninsured.
It does so by applying state Medicaid eligibility
rules to identifY all people in the CPS that are
eligible for Medicaid and then assigns enrollment
randomly to those deemed to be eligible until the
CPS total of Medicaid beneficiaries match the
HCFA enrollment number.
This chart book, Uninsured in America, contains
estimates from a variety of surveys, but primarily
relies on CPS data. In most cases, when the CPS
is the source of the data it has been analyzed by
researchers at the Urban Institute and therefore
adjusted for Medicaid under-reporting as
described here.
Reference: Ullman, F and J Holahan. An Explanation of Estimates of Uninsured Children in
Child Health Facts: National and State Profiles
of Coverage. Report of the Kaiser Commission
on the Future of Medicaid. January 1998 .
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Heather Hurlburt
Creator
An entity primarily responsible for making the resource
Office of Speechwriting
Heather Hurlburt
Date
A point or period of time associated with an event in the lifecycle of the resource
1999-2001
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="http://clinton.presidentiallibraries.us/items/show/36161" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7431953" target="_blank">National Archives Catalog Description</a>
Identifier
An unambiguous reference to the resource within a given context
2008-0700-F
Description
An account of the resource
Heather Hurlburt's speechwriting collection consists of speeches, drafts, correspondence, and background research. Hurlburt worked as Special Assistant and Speechwriter to President Clinton. Her speechwriting files date from 1999-2001. As a speechwriter, Hurlburt prepared remarks on primarily domestic issues ranging from health care to the Special Olympics to the Mississippi Delta Region to the Kennedy Center Awards. She wrote remarks for policy speeches, radio addresses, commencements, taped video remarks, and award ceremonies or tributes. She also prepared a few speeches for the First Lady, and one undelivered speech for Sandy Berger on the topic of military reform.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
128 files in 11 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
January 2000 - WH: [Health Care Coverage 1-19-00] [1]
Creator
An entity primarily responsible for making the resource
Office of Speechwriting
Heather Hurlburt
Identifier
An unambiguous reference to the resource within a given context
2008-0700-F
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 7
<a href="http://www.clintonlibrary.gov/assets/Documents/Finding-Aids/2008/2008-0700-F.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7431953" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
12/15/2014
Source
A related resource from which the described resource is derived
42-t-7431953-20080700F-007-009-2014
7431953