Health Insurance Coverage of Children, 2010

Contents

• Introduction
• Description of the Data
• Health Insurance Status by Selected Demographic Characteristics
• Age
• Race and Ethnicity
• Citizenship Status
• Health Insurance Status by Selected Family Characteristics
• Poverty Status
• Family Status
• State Estimates of Health Insurance Coverage
• Characteristics of Uninsured Children
• Trends in Health Insurance Coverage of Children

Summary

In 2010, 90% of children had health insurance coverage in the United States, and 10% of children were uninsured. Among children with coverage, private health insurance, including employer-sponsored insurance and nongroup insurance, was the predominant source of coverage, followed by public coverage, including Medicaid and other means-tested public programs (e.g., the State Children's Health Insurance Program—CHIP), as well as Medicare and military health care.

These estimates, and the estimates detailed in this report, are from the U.S. Census Bureau's Annual Social and Economic Supplement to the Current Population Survey (CPS, commonly known as the March Supplement). The CPS is representative of the civilian, noninstitutionalized population of the United States. National-level estimates in this report are created using the most recent CPS data, representing data from 2010, as well as historical data from previous years. State-level estimates are created using a three-year average of CPS data (representing data from 2008 to 2010), which provide reliable state estimates.

The national-level estimates provide only a limited understanding of the health insurance coverage of children under age 19. To better understand this population, the report provides an analysis of the variation in coverage by selected demographic and family characteristics, including age, race, ethnicity, citizenship status, poverty status, and family composition. For example, in 2010, non-citizen children, Hispanic children, and children not living with at least one parent/guardian were more likely to be uninsured compared with other children.

Another important factor affecting uninsurance rates among children is the variation across states. During the 2008-2010 period, the percentage of uninsured children ranged from a high of 17.3% in Texas to a low of 3.2% in Massachusetts. Not only does coverage vary by states, but the source of insurance coverage also varies by states. The percentage of children covered by private health insurance ranged from 80.1% in New Hampshire to 46.9% in Mississippi, and the percentage of children covered by public coverage ranged from 50.6% in the District of Columbia to 18.3% in Utah.

Finally, examining changes in coverage and source of coverage over time provides additional insight into insurance and sources of coverage for children. Between 2000 and 2010, the uninsured rate among children decreased by about 1 percentage point, while the percentage of children with private insurance decreased by more than 11 percentage points and the percentage with public coverage increased by 13.5 percentage points.

As Congress focuses on allocating limited resources to programs such as Medicaid and CHIP, a deeper understanding of the characteristics of uninsured children may prove useful to inform this discussion.

---

Health Insurance Coverage of Children, 2010

Introduction

Over the years, research has consistently shown that children with health insurance coverage have better access to health care services and a regular health care provider, which in turn results in better health outcomes.¹ According to the Annual Social and Economic Supplement to the Current Population Survey (CPS, often called the March Supplement), in 2010, 90.0% of children had health insurance and 10.0% were uninsured. Similarly, in 2009, 10.2% of children were uninsured.²

While overall 10.0% of children are uninsured, the uninsured rate among children varies in different segments of the population. For example, older children are more likely to be uninsured compared with younger children, and Hispanic children have twice the uninsured rate compared with non-Hispanic children.³ State factors, such as eligibility levels for public programs (e.g., Medicaid) and a state's health insurance market, also affect the health insurance status of children. The CPS data show that the uninsured rate among children across the states ranges from 17.3% in Texas to 3.2% in Massachusetts.

Children who have health insurance have either private insurance, public coverage, or both. Private insurance includes employer-sponsored insurance and nongroup insurance (insurance purchased in the individual market); public coverage includes Medicaid, the State Children's Health Insurance Program (CHIP), and any other means-tested public programs, as well as Medicare and military health care (e.g., TRICARE and Veterans Administration [VA] Health Care).⁴ Children may have more than one source of coverage, and those coverage types could be different. For example, a child could have employer-sponsored insurance, a type of private insurance, and Medicaid, a type of public coverage. In 2010, 59.9% of children had private insurance and 37.2% had public coverage.

Sources of health insurance coverage vary according to a child's demographic and family characteristics. For example, in 2010, children living in families with incomes below 100% of the federal poverty level (FPL) were more likely to have public coverage and less likely to have private insurance compared with children living in families with higher incomes.

This report presents estimates of health insurance coverage of children under age 19 in the United States.⁵ Table 1 and Table 2 show children's health insurance coverage by selected demographic and family characteristics at the national level. Table 3 shows state-level estimates of private insurance, public coverage, and the uninsured rate, and Figure 1 is a map showing uninsured rates across states. Figure 2 examines the population of uninsured children at the national level. Figure 3 examines national trends in children's health insurance status from 2000 to 2010.

Description of the Data

The estimates in this report are based on data from the Annual Social and Economic Supplement to the Current Population Survey (CPS).⁶ The CPS is a monthly survey conducted by the U.S. Census Bureau and is representative of the civilian, noninstitutionalized population of the United States. The CPS is used primarily to collect employment data, but it also collects information on health insurance status, income, and poverty. Approximately 100,000 addresses constitute the sample households to be interviewed. The CPS sample is designed to represent the nation, states, and other specified geographies (e.g., regions).⁷

All estimates in this report at the national level are created using the most recent annual CPS data (representing data from 2010), as well as historical annual data from previous years. All estimates in this report at the state level are created using three-year averages of the three most recent years of CPS data (representing data from 2010, 2009, and 2008). The U.S. Census Bureau recommends using three-year averages of CPS data to examine state-level estimates because of the survey's small sample sizes in many states.⁸

Health Insurance Status by Selected Demographic Characteristics

Insurance status differs according to children's demographic characteristics (age, race, ethnicity, and citizenship status). A child's likelihood of being uninsured varies by these demographic characteristics. For example, older children are more likely to be uninsured compared with younger children. As shown in Table 1, while 11.8% of children aged 13 to 18 years were without insurance, 9.1% of children under six years old lacked any source of health insurance. Further, insurance status varies among children of different races, with children who report their race as only black being the most likely to be uninsured, and children who report two or more races the least likely to be uninsured. Hispanics are twice as likely to be uninsured compared with non-Hispanic children, and non-citizen children are almost four times more likely to be uninsured compared with citizen children. For those children who have insurance, the source of coverage also varies by demographic characteristics, as discussed below.

Age

As age increases, children are more likely to have private insurance and less likely to have public coverage. Slightly over half (54.3%) of children under age six had private insurance, and 43.8% had public coverage. In comparison, nearly two-thirds of children aged 13 to 18 had private insurance and under one-third (30.2%) had public coverage. The higher rate of private coverage among older children does not off-set the lower rate of public coverage; children aged 13 to 18 are more likely to be uninsured compared with children under age six and children aged 6 to 12.

Race and Ethnicity

Examining differences in race show that children who report their race as black alone are less likely to have private insurance, and more likely to have public coverage. Children who report their race as white alone or "other alone" (Asian alone, Native American alone, Native Hawaiian/Other Pacific Islander alone, or some other race alone) have similar rates of coverage. In both categories, nearly two-thirds of children have private insurance, and about one-third have public coverage. Among children who report two or more races, over half (55.7%) have private insurance and 46.3% have public coverage.

The only available ethnicity breakdown in the CPS is Hispanic, non-Hispanic, and the question is asked independently of race (i.e., a child who is Hispanic could report any race).⁹ Looking at ethnicity, two-thirds of non-Hispanic children have private insurance compared with 37.9% of Hispanic children; however, only one-third of non-Hispanic children have public coverage, whereas 50.9% of Hispanic children have public coverage.

Citizenship Status

Similar percentages of non-citizen children have private insurance (35.5%), public coverage (33.4%), and are uninsured (34.9%). In contrast, 60.6% of citizen children have private insurance, and 37.3% have public coverage.¹⁰ Compared with citizen children, non-citizen children are almost four times more likely to be uninsured.

Health Insurance Status by Selected Family Characteristics

Whether or not children have insurance is also affected by family characteristics. Table 2 shows health insurance coverage of children by family characteristics at the national level in 2010. Generally, as family income increases, the percentage of uninsured children decreases—the uninsured rate for children in families with income below 100% FPL is over four times the rate for children in families with income equal to or greater than 400% FPL.¹¹ Looking at family composition, children who live in families with two parents have the lowest uninsured rate (8.1%), followed by children who live with a single mother (10.9%) and children who live with a single father (16.0%). A quarter of children who do not live with a parent are uninsured.

Family characteristics can also affect the source of coverage among children with health insurance, as discussed below. For example, whether a child qualifies for a program such as Medicaid is in part dependent on family income.¹²

Poverty Status

As family income increases, the rate of private insurance increases, the rate of public coverage decreases, and the uninsured rate decreases. For example, 16.3% of children in families with income below 100% FPL had private insurance, compared with 92.1% of children in families with income equal to or greater than 400% FPL. The rates of public coverage ranged from 72.7% among children in families with income below 100% FPL to 10.4% among children in families with income equal to or greater than 400% FPL.

Family Status

Among children who live with two parents, 71.1% have private insurance, compared with 47.1% of those who live with a single father and 38.4% of those who live with a single mother. A smaller percentage of children who live with two parents have public coverage compared with children who live either with a single father or a single mother. Overall, children who live with at least one parent are more likely to have private insurance and less likely to have public coverage compared with children who are not living with a parent.

State Estimates of Health Insurance Coverage

Nationwide, health insurance coverage of children is related to children's demographic characteristics and family characteristics. Regional and state variation in coverage of children is likely also affected by these characteristics. Geographic variation may be also affected by a state's health insurance market and by state policies, such as eligibility criteria for a state's Medicaid program or its CHIP.

Figure 1 shows a map of the uninsured by state, and Table 3 show state-level estimates of health insurance coverage of children.¹³ The estimates presented are an average of three years of CPS data, representing data collected in 2008-2010. The U.S. Census Bureau recommends using a three-year average when using the CPS to compare coverage across states because of the survey's small sample size in some states.¹⁴

Figure 1 shows how the uninsured rates compare across states. The four states with the highest uninsured rates, 15.0% or higher, are Texas, Nevada, Florida, and Arizona. The four states with the lowest uninsured rates, less than 5.0%, are Massachusetts, Hawaii, New Hampshire, and Vermont. Generally, states with the lowest uninsured rates for children are located in the Midwest and Northeast; states with the highest uninsured rates are located in the South and West.

Figure 1. Percentage of Uninsured Children Under Age 19, by State, 2008-2010 Average Includes Rank of States from Highest Percentage of Uninsured Children (1) to Lowest Percentage of Uninsured Children (51)

Source: CRS analysis of data from the 2009-2011 Annual Social and Economic Supplement to the CPS (representing data from 2008 to 2010).

Table 3 provides estimates of private insurance, public coverage, and the uninsured for children, with percentage rankings by state. The five states with the highest percentage of children covered by private insurance were New Hampshire (80.1%), Utah (76.8%), Connecticut (74.8%), North Dakota (74.3%), and Wisconsin (74.0%). The five states with the highest percentage of children covered by public coverage were the District of Columbia (50.6%), Mississippi (47.7%), Arkansas (47.4%), New Mexico (44.8%), and Vermont (43.9%).

Characteristics of Uninsured Children

As noted in the preceding discussion, health insurance coverage of children is likely influenced by children's demographic and family characteristics as well as state-specific factors (e.g., eligibility criteria for programs such as Medicaid). Figure 2 shows the characteristics of children who are uninsured and characteristics of all children at the national level in 2010.

Figure 2 illustrates that some characteristics of uninsured children are different from the characteristics of the total population of children ("all children"). ¹⁵ Compared with all children, children who lack health insurance are more likely to be Hispanic, non-citizens, live in families with low income, and not live with a parent. Hispanic children represent 23.1% of all children, but they represent nearly 40% of uninsured children. Non-citizen children represent 2.7% of all children, and 9.7% of uninsured children. Children living in families with income below 100% FPL represent 21.9% of all children, and 35.2% of uninsured children. In contrast, children living in families with income equal to or greater than 400% FPL represent 27.3% of all children and 9.7% of uninsured children. Children not living with at least one parent represent 4.3% of all children and 10.9% of uninsured children.¹⁶

Figure 2. Characteristics of Uninsured Children and of All Children Under Age 19, 2010

Source: CRS analysis of data from the 2011 Annual Social and Economic Supplement to the CPS (representing data from 2010). 1 The only available ethnicity breakdown in the CPS is Hispanic, non-Hispanic, and the question is asked independently of race. 2 Includes both children born in the United States and foreign-born children who are naturalized citizens.

Trends in Health Insurance Coverage of Children

Examining children's health insurance coverage over time is one way to assess how economic conditions and program changes (i.e., changes to CHIP eligibility) affect children's coverage. Figure 3 shows national-level estimates of children who were uninsured and who had private insurance and public coverage between 2000 and 2010. The percentage of children who were uninsured fluctuated slightly during the period, between 2000 and 2010, decreasing 1.1 percentage points, from 11.1% to 10.0%.

The slight fluctuations of the percentage of children who were uninsured were likely affected by the larger changes in the percentage of children who had private health insurance and those who had public coverage over the time period. In 2000, 71.2% of children had private health insurance, but by 2010, the percentage dropped to 59.9%, a nearly 16% decline in private health insurance coverage for children. Over that same period, the percentage of children with public coverage increased from 23.7% in 2000 to 37.2% in 2010, a 57% increase in public coverage for children. Periods of economic recessions, as denoted by the gray bars in Figure 3, may provide additional insight into changes in children's health insurance coverage during those periods.

Figure 3. Health Insurance Status of Children Under Age 19, 2000-2010

Source: 2011 March Supplement to the CPS (representing data from 2010). Notes: Data were downloaded from the State Health Access Data Assistance Center (SHADAC) data center, available at http://www.shadac.org/datacenter. Data were accessed January 4, 2012. Individuals may report more than one source of coverage, and individuals may report both private and public coverage; percentages may therefore total to more than 100. The gray shaded areas represent period of economic recessions, as officially defined by the National Bureau of Economic Research (NBER). For more information, see http://www.nber.org/cycles.html.

Footnotes

1.	See, for example, Kaiser Commission on Medicaid and the Uninsured, "The Uninsured and the Difference Health Insurance Makes," October 2011, http://www.kff.org/uninsured/upload/1420-13.pdf; Jennifer DeVoe, A. Graham, and L. Krois, et al., "Mind the Gap" in Children's Health Insurance Coverage: Does the Length of a Child's Coverage Gap Matter?," Ambulatory Pediatrics, vol. 8, no. 2 (2008); G.D. Stevens, M. Seid, and N. Halfon, "Enrolling Vulnerable, Uninsured but Eligible Children in Public Health Insurance: Association with Health Status and Primary Care Access," Pediatrics, vol. 117, no. 4 (2006).
2.	CRS analysis of data from the 2010 Annual Social and Economic Supplement to the CPS.
3.	In this report, comparisons across various characteristics of children (e.g., older children are more likely to be insured compared with younger children) are comparisons of percentages, not numbers. Comparisons of percentages, or rates, are useful for comparing across groups that do not share a denominator. However, percentages do not provide information about the underlying size of the population, which is why population totals are included in the tables of this report.
4.	For information about these programs, see CRS Report RL32237, Health Insurance: A Primer, by [author name scrubbed]; CRS Report RL33202, Medicaid: A Primer, by [author name scrubbed]; CRS Report R40444, State Children's Health Insurance Program (CHIP): A Brief Overview, by [author name scrubbed] and [author name scrubbed]; CRS Report R40425, Medicare Primer, coordinated by [author name scrubbed]; and CRS Report RL33537, Military Medical Care: Questions and Answers, by [author name scrubbed].
5.	In this report the word "children" will be used to refer to individuals under age 19.
6.	The traditional name of the survey is the March Supplement, but because the supplement has been fielded from February through April for several years, it has been officially renamed the Annual Social and Economic supplement (ASEC) to the CPS. Many analysts continue to refer to it as the March supplement.
7.	Several other surveys also produce health insurance estimates, including the American Community Survey (ACS) and the National Health Institute Survey (NHIS). These surveys, as well as the CPS, have strengths and weaknesses. The CPS is used in this report for two reasons: 1) the CPS has been and continues to be a data source for the State Children's Health Insurance Program (CHIP); 2) the CPS provides a consistent historical time series for health insurance data.
8.	U.S. Census Bureau, Current Population Survey, 2011 Annual Social and Economic (ASEC) Supplement, September 20, 2011, http://www.census.gov/apsd/techdoc/cps/cpsmar11.pdf.
9.	For more information, see CRS Report RL32701, The Changing Demographic Profile of the United States, by [author name scrubbed] and [author name scrubbed].
10.	In this report, "citizen" children include both children born in the United States and foreign-born children who are naturalized citizens of the United States. Because the CPS does not ask about citizenship status (i.e., whether the individual is legally present in the United States), CRS cannot use the CPS to examine the characteristics of children who lack legal authorization to be present in the United States.
11.	In the CPS, poverty levels are created using a "poverty index" that provides a range of income cutoffs adjusted by various factors, including family size. As follows, a family's income is not the only factor that affects a child's poverty status; however, a family's income is one important determinant of a child's poverty status. For more information about how poverty is measured in the United States, see CRS Report R41187, Poverty Measurement in the United States: History, Current Practice, and Proposed Changes, by [author name scrubbed].
12.	For more information on children's eligibility for Medicaid, see CRS Report RL33202, Medicaid: A Primer, by [author name scrubbed].
13.	For the purposes of this report, discussions of states include the District of Columbia.
14.	U.S. Census Bureau, Current Population Survey, 2011 Annual Social and Economic (ASEC) Supplement, September 20, 2011, http://www.census.gov/apsd/techdoc/cps/cpsmar11.pdf.
15.	It should be noted that the 2011 CPS (like previous CPS surveys) asks whether each individual had various types of health insurance at any point 2010. Those who responded that they did not have any health insurance were considered uninsured in 2010. This wording implies that the uninsurance variable measures where an individual lacked health insurance for the entire year; however, researchers have found that the estimates of uninsured in the CPS resemble uninsured estimates from other surveys' point-in-time estimates (i.e., estimates from the American Community Survey). Many researchers have concluded, therefore, that it is reasonable to interpret the CPS uninsurance estimate as a point-in-time estimate. For more information, see Congressional Budget Office, How Many People Lack Health Insurance and for How Long? Economic and Budget Issue Brief, Washington, DC, 2003.
16.	The percentages compared in this section and in Figure 2 are based on numbers found in Table 1 and Table 2.