Order Code 97-975 Updated September 2, 2008 Health Insurance Coverage of Children, 2007 Chris L. Peterson and April Grady Domestic Social Policy Division Summary Based on data from the Census Bureau’s Current Population Survey (CPS), 8.9 million children under age 19 were uninsured in 2007 (11.3%), a statistically significant decline compared to 9.4 million in 2006 (12.1%). This decline occurred because of a significant increase in public coverage, from 26.8% in 2006 to 27.9% in 2007. The percentage of children with employment-based health insurance (61%) was unchanged. Only 7.5% of non-Hispanic white children were uninsured in 2007, compared with 20.7% of Hispanic children. Compared to 2006, black and Hispanic children experienced significant increases in 2007 in rates of public coverage, resulting in a drop in their uninsurance rates. Children whose parents worked in a small firm were much more likely to be uninsured (22% in firms with less than 10 workers) than those whose parents worked in a large firm (5% in firms with 1,000 or more workers). Among the 8.9 million uninsured children in 2007, 60% lived in a household with a parent who worked full-time for the entire year. Health Insurance Coverage by Population Characteristics Demographic and Family Characteristics. As shown in Table 1, children1 aged 13 to 18 had higher rates of employment-based coverage than younger children, but were more likely to be uninsured because they were less likely to have public coverage. Uninsured rates were highest among Hispanic children, who had the lowest employmentbased coverage rates of any race/ethnic group. Children who were black or Hispanic were more than twice as likely to have public coverage as white or Asian children. Children in the South and West were more likely to be uninsured than children in the Northeast and Midwest. 1 Census Bureau estimates for children generally refer to individuals under age 18. Most estimates in this report refer to individuals under age 19, which corresponds with the cutoff used for Medicaid poverty-related child eligibility and the State Children’s Health Insurance Program (SCHIP) allotment formula. CRS-2 Table 1. Health Insurance Coverage and Demographic and Family Characteristics of Children Under Age 19, 2007 Type of insurancea Population Employment- Private (thousands) basedb nongroup 78,651 60.7% 5.3% All children under age 19 Age Under 6 6 to 12 13 to 18 Race/ethnicity White Black Hispanic Asian Other Region Northeast Midwest South West Children not living with parent Children living with parentd Family type Two parents Single dad Single mom Family income-to-poverty ratio Under 100% 100% to 149% 150% to 199% 200% to 299% 300%+ Parents’ health insurance coverage Employment-based Private nongroup Public Military or veterans’ Uninsured Military or Public veterans’ 27.9% + 2.8% c Uninsured Percent 11.3% – Thousands 8,872 – 24,944 27,855 25,852 56.1% 61.7% 64.0% 4.6% 5.6% 5.6% 34.0% + 27.7% 22.4% + 2.8% 2.7% 3.0% 10.5% – 10.4% 13.0% – 2,618 2,903 3,351 – 44,736 11,574 16,464 3,094 2,784 72.4% 46.8% 38.4% 65.7% 56.5% 6.4% 3.3% 3.1% + 8.1% 4.9% 18.8% 43.7% + 42.2% + 19.2% 34.2% 3.2% 3.2% 1.5% 1.8% 5.5% 7.5% 12.8% – 20.7% – 11.9% 9.7% – 3,353 1,476 – 3,407 – 367 269 – 13,251 17,168 29,265 18,968 3,473 75,178 66.6% 67.5% 55.4% 58.5% + 27.4% 62.2% 4.1% 4.9% 5.0% 7.0% 2.4% 5.4% 26.7% 27.0% 29.1% 27.9% 44.3% 27.2% 0.9% 2.0% + 4.2% 2.9% 1.1% 2.9% 8.5% 7.2% 14.8% 11.5% – 30.1% 10.4% – 1,127 1,242 4,326 2,177 – 1,047 7,826 – 52,482 4,489 18,207 70.9% 51.7% 39.7% 6.2% 4.6% 3.4% 18.5% 32.5% 50.9% + 3.4% 2.4% 1.6% 8.9% 17.0% – 13.0% – 4,692 – 764 2,370 – 12,871 8,320 7,339 13,591 33,057 15.3% – 33.7% 53.5% 69.8% 86.5% 2.7% 3.9% 4.3% 5.4% 7.1% 69.2% + 52.5% 33.2% 19.4% 6.3% 1.4% 2.0% 3.5% 3.9% 3.2% 17.3% 17.5% 15.2% 11.1% 4.6% – 2,223 1,459 1,119 1,506 1,518 – 49,817 2,961 8,354 788 13,258 91.4% 6.7% 3.2% – 5.7% 5.7% – 11.4% 15.4% 96.4% 6.5% 46.8% + 2.5% 1.6% 1.1% 98.7% 0.4% 2.2% – 3.0% 2.9% 0.3% 48.4% 1,077 – 89 246 3 6,412 3.3% + 81.2% 0.1% 0.2% 0.1% – + + + + Source: Congressional Research Service analysis of data from the March 2008 Current Population Survey. Note: The symbol “+” denotes a statistically significant increase over last year, with “-” denoting a statistically significant decrease. a. People may have more than one source of coverage; percentages may total to more than 100. b. Includes group health insurance through current or former employer or union and all coverage from outside the home (Census Bureau figures are slightly lower because of the exclusion of certain people with outside coverage). Excludes military and veterans’ coverage. c. Includes Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), and other state programs for low-income individuals. Excludes military and veterans’ coverage. d. Includes stepparent. CRS-3 Insurance coverage among children under age 19 also differs by family structure. As shown in Table 1, 30% of children not living with a parent lacked health insurance, compared with 10% of children living with at least one parent. Among children living with a parent, family structure still had an impact on health insurance coverage. Nine percent of children living in a two-parent family were uninsured in 2007. Although children living with a single father were more likely to have employment-based health insurance than those living with a single mother, children living with a single father were more likely to be uninsured because they were less likely to have public coverage. Among children in poverty,2 15% had employment-based coverage, 69% had Medicaid or other public coverage, and 17% were uninsured. As the family income-topoverty ratio increases, the likelihood of children having employment-based coverage increases and the likelihood of having public coverage or being uninsured tends to decrease. Among children in families with family incomes at least three times the poverty threshold, 87% had job-based coverage and 5% were uninsured. A child’s source of health insurance is strongly associated with parents’ coverage. Approximately 91% of children who lived with a parent who had employment-based coverage in 2007 also had employment-based coverage.3 Likewise, 96% of children who lived with a parent who had Medicaid or other public coverage also had public coverage. However, among children who lived with an uninsured parent, 48% were uninsured — but 47% had Medicaid or other public coverage, a significant increase over 2006. Parents’ Employment Characteristics. As shown in Table 2, among children under age 19 who lived with a parent who worked full-time for the entire year, 72.1% had job-based coverage, which was not significantly different from 2006. However, there was a significant increase in public coverage, to 18.3%. As a result, the uninsurance rate among children with a parent who worked full-time for the entire year fell significantly, from 10.0% in 2006 to 9.1% in 2007. Among children who lived with at least one parent who worked, but only part-time or part-year, 34.2% had job-based coverage, a significant decline compared to 2006. Apparent increases in private nongroup and public coverage (though not statistically significant) left the uninsurance rate for these children unchanged between 2006 and 2007, at 14.3%. In cases where no parent worked, 71.0% of children had public coverage and 16.6% were uninsured. Employment-based health insurance coverage is less common for workers in small firms than in larger ones. Job-based coverage rates were lowest and uninsured rates were highest in 2007 among children living with a parent where the primary worker was employed by a firm with less than 10 employees. Health insurance coverage rates also varied substantially by industry. Less than half of children living with a parent where the 2 Among children living with at least one parent. In 2007, the poverty threshold (which is used mainly for statistical purposes and differs slightly from the poverty guideline used for program eligibility and other administrative purposes) for a family with two adults and two children was $21,027. 3 When a parent had more than one source of coverage, the following hierarchy was used to determine “primary” coverage: employment-based, private nongroup, Medicaid/Medicare, CHAMPUS or VA, and other public. Then the parent with the “highest” coverage was used to classify both parents’ insurance coverage. Thus, if one parent had employment-based coverage and the other had private insurance, the parents’ coverage was classified as employment-based. CRS-4 primary worker was in one of four industries (agriculture, construction, other services, and leisure and hospitality) had employment-based coverage. However, more than threequarters of children living with a parent where the primary worker was in one of five (six, including the armed forces) industries (financial activities, information, manufacturing, mining, public administration) had such coverage. Table 2. Health Insurance Coverage and Parents’ Employment Characteristics of Children Under Age 19 Living with at Least One Parent, 2007 Type of insurancea Population Employment(thousands) basedb Children under age 19 living with 75,178 62.2% parent Custodial parents’ work status At least one parent worked full58,799 72.1% time and full-year None full-time and full-year, at 10,771 34.2% – least one part-time or part-year 5,608 12.4% Did not workd Firm size Under 10 11,505 31.5% – 10-24 5,568 46.7% 25-99 8,184 61.5% 100-499 9,366 71.9% 500-999 3,828 75.2% – 1,000+ 27,650 79.1% 9,077 44.5% Not applicablee Industry Agriculture, forestry 931 32.3% Armed forces 691 44.2% Construction 6,240 48.2% Education, health services 12,963 70.5% Financial activities 4,745 76.1% Information 1,605 83.5% Leisure and hospitality 4,187 37.6% Manufacturing 9,113 76.5% Mining 485 78.7% 9,077 44.5% Not applicablee Other services 2,471 39.8% Professional services 6,641 60.3% – Public administration 3,639 88.9% Transportation, utilities 4,188 70.7% Wholesale and retail trade 8,202 60.0% Publicc 27.2% + 5.5% 18.3% + 3.1% 6.0% 52.9% 2.2% 14.3% 1,541 3.3% 71.0% 2.0% 16.6% 931 14.4% 6.3% 5.3% 3.7% 2.9% 2.9% 4.2% 36.6% + 32.9% 28.3% 21.7% 21.3% 17.2% 49.3% 1.6% 1.5% 1.8% 1.7% + 1.3% 4.5% 3.4% 21.9% 17.9% 11.3% – 8.2% – 6.7% 5.1% 10.3% 2,524 999 924 770 256 1,423 931 12.9% 2.2% 7.5% 5.1% 9.2% 4.7% 4.8% 2.5% 2.5% 4.2% 8.0% 7.3% 3.4% 4.5% + 5.9% + 34.7% 1.4% 31.4% 23.3% 13.2% 12.4% 45.4% 19.2% 17.0% 49.3% 38.5% 24.5% 10.2% 18.4% 29.0% 1.0% 100.0% 1.9% + 2.0% 1.4% 1.0% 1.0% 0.9% 2.2% 3.4% 1.9% 2.5% 4.2% 2.3% 1.5% 23.9% 0.0% 18.9% 6.8% – 6.3% – 5.3% 18.3% 7.5% 7.1% 10.3% 17.3% 12.2% 2.8% 11.8% 11.1% – 223 0 1,176 887 299 84 764 683 35 931 427 812 100 494 910 – + + + Military or veterans’ 2.9% Uninsured Private nongroup 5.4% Percent 10.4% – 9.1% – Source: Congressional Research Service analysis of data from the March 2008 Current Population Survey. Note: The symbol “+” denotes a statistically significant increase over last year, with “-” denoting a statistically significant decrease. a. People may have more than one source of coverage; percentages may total to more than 100. b. Includes group health insurance through current or former employer or union and all coverage from outside the home (Census Bureau figures are slightly lower because of the exclusion of certain people with outside coverage). Excludes military and veterans’ coverage. Thousands 7,826 – 5,354 – – – – – – CRS-5 c. Includes Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), and other state programs for low-income individuals. Excludes military and veterans’ coverage. d. Child’s employment-based coverage may be through a parent’s former employer, from someone outside the household (e.g., noncustodial parent), or in the child’s name (e.g., from his or her own job). e. No firm-size or industry information is provided because the parent did not work or because coverage is from outside the household or in the child’s name. Characteristics of Uninsured Children In the preceding discussion, the percentages of various groups of children were compared in terms of their health insurance. For example, 7.5% of non-Hispanic white children were uninsured in 2007, compared with 20.7% of Hispanic children. However, because the United States has many more non-Hispanic white children (45 million) than Hispanic children (16 million), the number of uninsured in each group is similar, as shown in Figure 1. Figure 1. Characteristics of Uninsured Children Under Age 19, 2007 (8.9 million) Source: Congressional Research Service analysis of data from the March 2008 Current Population Survey. Note: Numbers in millions. Totals may not sum to 100% due to rounding. “Full-time and full-year” means at least one parent living with the child was a full-time, full-year worker. “Part-time or part-year” means that at least one parent living with the child worked, but not full-time and full-year. Whites, blacks, and Asians are those who are non-Hispanic and report only one race. Among non-Hispanics, individuals who report any other single race (e.g., American Indian) or multiple races are categorized as “other.” CRS-6 This apparent paradox — that the group least likely to be uninsured makes up a large portion of the uninsured — exists when looking at other characteristics as well. Children who lived with at least one parent who worked full-time for the entire year were least likely to be uninsured (9%) compared with other children, but still composed 60% of all uninsured children in 2007. Similarly, children in two-parent families were least likely to be uninsured (9%) compared with others, yet made up more than half of the population of uninsured children. This raises difficult issues for policy makers who might wish to help uninsured children. For example, should proposals be targeted at those in twoparent families because they are more numerous, or at other uninsured children because they are more likely to be uninsured? Health Insurance Coverage of Children Over Time Health insurance estimates presented in this report thus far have referred to children under age 19. The remainder of this report refers to children under age 18, for whom historical estimates are more readily available.4 Between 1999 and 2007, the number of children under age 18 with employment-based health insurance fell by 2.9 million, while public coverage increased by 6.2 million. These changes, combined with overall child population growth over the period of 2.1 million, led to a smaller but still statistically significant drop in the number of uninsured children (884,000) between 1999 and 2007. Looking at the percentage changes in coverage over the 1999 to 2007 period, children under 18 experienced a 5.7 percentage point decline in employment-based coverage, from 65.2% in 1999 to 59.5% in 2007. Private nongroup coverage also declined significantly, from 5.7% in 1999 to 5.3% in 2007. However, public coverage increased by 7.8 percentage points, from 23.2% in 1999 to 31.0% in 2007, leading to a decline in the percentage of uninsured children of 1.5% percentage points, from 12.5% in 1999 to 11.0% in 2007.5 4 Historical tables for 1999 forward are available at [http://www.census.gov/hhes/www/hlthins/ historic/index.html]. The analysis in this section is based on the table at [http://www.census.gov/ hhes/www/hlthins/historic/hihistt5.xls]. 5 CPS health insurance estimates for years prior to 1999 are available but are not directly comparable to those for later years because of a questionnaire change that increased the number and percentage of people covered by health insurance beginning in 1999, as well as the absence of revised data for years prior to 1996 that would correct a Census Bureau programming error discovered in 2007. Based on unrevised estimates produced using the old questionnaire, the number and percentage of uninsured children under age 18 showed year-to-year fluctuations but grew significantly between 1987 and 1998. As employment-based coverage rates declined in the late 1980s and early 1990s, public coverage rates rose. As employment-based coverage rates rebounded in the mid-1990s, public coverage rates declined. Old historical tables are available at [http://www.census.gov/hhes/www/hlthins/historic/index_old.html].