Number B-22 in Series, "New Federalism: National Survey of America's Families"
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Recent policy debate about the uninsured has focused mostly on the need to expand public coverage of children. However, about three-quarters of Americans without health insurance are nonelderly adults. These adults are 40 percent more likely than children to be uninsured and less than half as likely to have public coverage. Their chances of obtaining public coverage vary widely, however, depending on where they live. States differ in both the degree to which they cover the nonelderly adult population without private insurance and the likelihood of public coverage for different groups within that population: women versus men, parents versus nonparents, healthy versus sick, and poor versus nonpoor.
| Nonelderly adults are 40 percent more likely than children to be uninsured and less than half as likely to have public coverage. |
|
This brief uses data from the 1997 National Survey of America's Families (NSAF)1 to compare the types of medical assistance eligibility a state may provide—Medicaid with little or no expansion beyond federal minimums (limited programs), more generous state options using Medicaid (moderate programs), or even more generous state options using Medicaid and state-only coverage (comprehensive programs)—and that state's relative success in covering its otherwise uninsured adult residents. As expected, states with more comprehensive approaches to medical assistance cover more otherwise uninsured adults than do states with more limited approaches. For example, states with comprehensive approaches are twice as likely as states with limited approaches to cover otherwise uninsured adults, regardless of income. They also reach the largest proportions of low-income adults—whether or not they are in groups that Medicaid traditionally has covered (single parents and disabled adults).
Severing the link between cash welfare and Medicaid, as the 1996 Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) did, could significantly increase states' willingness to provide public health coverage. However, many states have not taken advantage of federally matched expansion options Medicaid has provided since its inception.2 This suggests that major expansion of adult coverage is unlikely without further federal support.
State Differences in Insurance Status and Coverage Gaps
The NSAF, in addition to being nationally representative, contains representative subsamples for 13 states. These focal states are shown in table 1, grouped by the relative comprehensiveness of their policy approaches to providing public coverage for adults in 1997.3 For apparently close cases, such as Massachusetts and New Jersey, which both covered between 2 and 10 percent of their uninsured through state programs beyond Medicaid, the final designation was made by looking at other dimensions—in this case, income eligibility limits and eligibility rates for poor adults, both of which were considerably higher in Massachusetts.
| TABLE 1: Dimensions of the Medical Assistance Approaches of the 13 Focal States |
| |
Medicaid Program Characteristics |
|
| |
Income Eligibility Limits |
|
|
|
| |
Welfare Relateda (% of national average) |
Pregnant Women (% of national minimum) |
Medically Needy Program? |
Poor Adult Eligibility Rateb (% of national average) |
Percentage of Uninsured in State-Only Programsc |
| Limited |
| Alabama |
37 |
100 |
No |
55 |
— |
| Colorado |
96 |
100 |
No |
61 |
— |
| Florida |
69 |
139 |
Yes |
88 |
— |
| Mississippi |
84 |
139 |
No |
80 |
— |
| Texas |
42 |
139 |
Yes |
64 |
— |
| Moderate |
| California |
138 |
150 |
Yes |
124 |
— |
| Michigan |
126 |
139 |
Yes |
125 |
< 2% |
| New Jersey |
101 |
139 |
Yes |
95 |
2%-10% |
| Wisconsin |
118 |
139 |
Yes |
99 |
< 2% |
| Comprehensive |
| Massachusetts |
132 |
139 |
Yes |
113 |
2%-10% |
| Minnesota |
121 |
207 |
Yes |
81 |
over 10% |
| New York |
131 |
139 |
Yes |
119 |
over 10% |
| Washington |
124 |
150 |
Yes |
112 |
over 10% |
Source: Urban Institute tabulations from the 1997 National Survey of America's Families. See Spillman (2000) for details.
Notes:
a. AFDC income limit.
b. Adult eligibility rate is the estimated number of nonelderly poor adults eligible for Medicaid divided by the poor adult population in a given state.
c. Caseload as a percentage of the state's adult uninsured. |
The Coverage Picture
The insurance status of the nonelderly adult population in the United States and in each of the focal states is shown in table 2. The primary determinant of the percentage uninsured is the percentage privately insured, which is mostly employment-related coverage. The four states with the highest percentages of adults uninsured in 1997 (Florida, Mississippi, Texas, and California) had the lowest levels of private coverage, ranging from about 66 percent in Texas to about 70 percent in Florida. The five states with the lowest percentages uninsured (Michigan, New Jersey, Wisconsin, Massachusetts, and Minnesota) all had more than 80 percent of their population privately insured.
TABLE 2: Insurance Status and Coverage Gaps in the 13 Focal States
(Percentage of Nonelderly Adult Population) |
| |
Non-Medical Assistance Coverage |
Coverage Gap |
| |
Private |
Othera |
Total |
Uninsured |
Medical
Assistance |
Total Gap |
| U.S. |
74.8 |
3.9 |
78.7 |
17.0 |
4.3 |
21.3 |
| Limited |
68.8 |
4.8 |
73.6 |
22.9 |
3.5 |
26.4 |
| Alabama |
73.4 |
5.0 |
78.4 |
17.9 |
3.8 |
21.7 |
| Colorado |
76.7 |
4.7 |
81.4 |
16.2 |
2.4 |
18.6 |
| Florida |
69.7 |
5.8 |
75.5 |
21.1 |
3.3 |
24.5 |
| Mississippi |
67.5 |
6.5 |
74.0 |
20.3 |
5.6 |
25.9 |
| Texas |
65.6 |
3.9 |
69.5 |
26.9 |
3.5 |
30.4 |
| Moderate |
74.2b |
3.3b |
77.5b |
17.4b |
5.0b |
22.4b |
| California |
68.2 |
4.3 |
72.5 |
21.6 |
6.0 |
27.6 |
| Michigan |
82.5 |
1.8 |
84.3 |
11.1 |
4.6 |
15.7 |
| New Jersey |
81.3 |
2.3 |
83.6 |
13.1 |
3.3 |
16.4 |
| Wisconsin |
85.7 |
2.0 |
87.7 |
9.9 |
2.4 |
12.2 |
| Comprehensive |
76.8c |
3.0b |
79.8c |
14.1c |
6.1c |
20.2c |
| Massachusetts |
81.8 |
2.7 |
84.5 |
11.5 |
4.0 |
15.5 |
| Minnesota |
83.7 |
1.8 |
85.5 |
8.8 |
5.7 |
14.5 |
| New York |
74.2 |
2.5 |
76.7 |
16.3 |
7.0 |
23.4 |
| Washington |
74.4 |
5.7 |
80.1 |
14.2 |
5.6 |
19.8 |
Source: Urban Institute tabulations from the 1997 National Survey of America's Families.
Notes:
a. Medicare, dual Medicare/Medicaid, and military coverage.
b. Statistically different from group mean for limited states.
c. Statistically different from group mean for limited and moderate states. |
This foundation of private insurance largely defines the magnitude of the health coverage problem states confront. Military-related and Medicare coverage, which together covered about 4 percent of nonelderly adults nationwide, slightly ameliorated the impact of low private coverage because they tended to be higher in states where private coverage was lower.
Bridging the Coverage Gap
Assessing a state's success in covering its otherwise uninsured population requires a measure of the insurance gap it faces. A state's insurance gap is measured here as the share of its adult residents who would be uninsured in the absence of state-provided medical assistance (that is, without Medicaid and any state-funded programs).4 The last column of table 2 shows this coverage gap for the United States and for each of the 13 focal states.
Nationwide in 1997, the coverage gap comprised 21 percent of nonelderly adults. The limited approach states exhibited the largest coverage gaps—averaging 26 percent, compared with 22 percent for the moderate states and 20 percent for the comprehensive states. At the extremes were Texas, with a gap of 30 percent, and Wisconsin, with a gap of slightly over 12 percent.
Table 3 shows the extent to which public coverage filled these gaps. The limited states—by and large those with the largest gaps—tended to cover lower proportions of their gaps than did the moderate states, which, in turn, covered lower proportions of their gaps than did the comprehensive states. In all states, the size of the coverage gap and the percentage of the gap bridged fell as income rose (not shown). In every income group, the moderate states as a group covered larger percentages than the limited states, and the comprehensive states covered even more—twice the percentage for limited states.
TABLE 3: Percentage of Coverage Gap Filled in the 13 Focal States
(Nonelderly Adult Population) |
| |
|
Of Low-Income Gaps |
| |
Of Overall Gap |
Poor |
Near Poora |
| U.S. |
20.2 |
35.1 |
14.5 |
| Limited |
13.3 |
24.2 |
10.1 |
| Alabama |
17.5 |
26.1 |
15.2 |
| Colorado |
13.0 |
23.9 |
8.9 |
| Florida |
13.6 |
26.9 |
10.0 |
| Mississippi |
21.8 |
31.1 |
15.4 |
| Texas |
11.5 |
21.6 |
9.0 |
| Moderate |
22.2b |
37.6b |
14.7b |
| California |
21.6 |
35.2 |
14.2 |
| Michigan |
29.2 |
50.6 |
18.9 |
| New Jersey |
20.0 |
40.6 |
14.6 |
| Wisconsin |
19.3 |
37.3 |
13.6 |
| Comprehensive |
30.2c |
50.4c |
21.0c |
| Massachusetts |
25.7 |
47.5 |
23.5 |
| Minnesota |
39.3 |
61.8 |
40.2 |
| New York |
30.2 |
51.4 |
15.2 |
| Washington |
28.5 |
42.6 |
28.0 |
Source: Urban Institute tabulations from the 1997 National Survey of America's Families.
Notes:
a. Between 100 percent and 200 percent of the federal poverty level.
b. Statistically different from group mean for limited states.
c. Statistically different from group mean for limited and moderate states. |
Texas, California, and New York provide a straightforward comparison of the implications of the three public coverage approaches for the poor. They were similar with respect to percentage of adult population in poverty (14 to 16 percent) and percentage of poor adults otherwise uninsured (about 70 percent). However, Texas reached only about one in five of its otherwise uninsured poorest adults, compared with 35 percent for California and 51 percent for New York.
Coverage Differences within the Low-Income Population
Family Structure
Low-income unmarried parents (income below 200 percent of the federal poverty level) face substantially larger coverage gaps than married parents or adults without children in the home. Nationwide in 1997, for example, 67 percent of unmarried parents lacked private coverage, compared with 46 percent of both married parents and adults with no children in the home. Even in Wisconsin, which has the smallest coverage gap for unmarried parents, more than half of low-income unmarried parents lacked private coverage. In California, the gap for this group was nearly 80 percent. Married parents generally were no more likely to have private coverage than adults without children in this low-income population.
With respect to bridging their insurance gaps, all states do much better for low-income unmarried parents than for other low-income adults (table 4). Nationally in 1997, about half of all low-income unmarried parents without private insurance obtained public coverage, relative to just under 20 percent of both married parents and adults with no children in the home. The limited states on average covered 41 percent of their low-income unmarried parents who lacked other coverage, compared with 58 percent and 67 percent, respectively, in the moderate and comprehensive states. Thus, state disparities in public coverage of low-income unmarried parents, though still large, are not as extreme as disparities for the low-income adult population as a whole.
TABLE 4: Percentage of Low-Incomea Coverage Gap Filled, by Family Structure
(Nonelderly Adult Population) |
| |
Unmarried Parents |
Married Parents |
No Children in Household |
| U.S. |
51.1 |
19.4 |
17.6 |
| State Approach |
| Limited |
40.6 |
10.8 |
12.6 |
| Moderate |
58.2b |
20.4b |
15.7 |
| Comprehensive |
66.6c |
33.3c |
25.9c |
Source: Urban Institute tabulations from the 1997 National Survey of America's Families.
Notes:
a. Income below 200 percent of the federal poverty level.
b. Statistically different from group mean for limited states.
c. Statistically different from group mean for limited and moderate states. |
Low-income adults with no children in the home are twice as likely to obtain public coverage in comprehensive as in limited states. However, their chances of obtaining public coverage are not significantly higher in moderate than in limited states. Thus, on average, only states with state-funded public programs in addition to Medicaid do better in covering this group.
Gender, Health, and Work Status
Gender does not make a large difference in the size of the coverage gap facing low-income adults, but health and work status do. For the country as a whole, the coverage gap for both men and women is about 50 percent, for those in fair or poor health about 60 percent (versus 47 percent for those in excellent or good health), and for those in families with no full-time worker about 58 percent (versus 44 percent for those with at least one full-time worker). These gaps do not vary systematically with the public coverage approach a state chooses.
Whatever their coverage approach, most states bridge larger percentages of their coverage gaps for the groups most closely associated with Medicaid eligibility—women, those in poorer health, and nonworkers. The coverage approach a state chooses, however, does have a major effect on the likelihood of coverage by gender, health, and work status (table 5). Residing in a comprehensive state rather than a limited one nearly doubles the likelihood that a person in only fair or poor health will obtain public coverage—an advantage that is almost as great for women and for nonworkers. However, comprehensive states also bridge the largest percentages of their coverage gaps for the groups less associated with Medicaid eligibility—men, those in better health, and full-time workers and spouses. Indeed, the relative advantage of living in a comprehensive state is greater for these groups than for the Medicaid-favored groups.
TABLE 5: Percentage of Low-Incomea Coverage Gap Filled, by Gender, Health,
and Work Status (Nonelderly Adult Population) |
| |
Gender |
Health |
Full-Time Worker in Home |
| |
Women |
Men |
Fair or
Poor |
Excellent
or Good |
None |
At Least One |
| U.S. |
34.3 |
14.4 |
31.4 |
23.6 |
42.4 |
12.4 |
| State Approach |
| Limited |
26.0 |
7.1 |
23.9 |
15.1 |
31.3 |
8.9 |
| Moderate |
38.8b |
13.6b |
27.0 |
27.6b |
44.5b |
14.1b |
| Comprehensive |
47.5c |
23.3c |
47.3c |
34.6c |
55.6c |
20.5c |
Source: Urban Institute tabulations from the 1997 National Survey of America's Families.
Notes:
a. Income below 200 percent of the federal poverty level.
b. Statistically different from group mean for limited states.
c. Statistically different from group mean for limited and moderate states. |
Notably, the fact that a state has a medically needy component in its Medicaid program does not increase the likelihood that its nonelderly adult residents obtain Medicaid coverage. Of the five limited states, for example, two (Texas and Florida) have medically needy programs. Yet neither bridges a larger proportion of the coverage gap for its less healthy low-income population than do the other three limited states. All four moderate states have medically needy programs, but they do not, as a group, cover a significantly larger percentage of their low-income, less healthy adults without private coverage than do the limited states as a group.
Implications for the Future
By removing the link between cash welfare and Medicaid, PRWORA has significant potential to increase states' willingness to provide health coverage. This legislation provides options for covering additional adults by allowing states to disregard higher levels of earned income and other resources, establish higher limits on hours of work, and provide transitional coverage. In theory, these new opportunities also give states with supplemental programs the ability to shift some additional groups to Medicaid (with its subsidizing federal match) and thus cover more persons with the same level of state funding. As of 1996, however, adult Medicaid enrollment was down in all but five states, with decreases in cash assistanceÐrelated enrollment not generally offset by increases in noncash enrollment (Holahan, Bruen, and Liska 1998). This trend appears to be continuing (Ku and Bruen 1999).
The findings reported here make clear that state approaches do matter in whether and which low-income adults obtain public health coverage. Moderate and comprehensive programs reach substantially larger proportions of those with traditional Medicaid characteristics than limited programs do. In addition, comprehensive programs reach larger proportions of other groups. However, even the most expansive programs still fail to reach substantial proportions of low-income adults who lack other coverage.
| The findings here make clear that state approaches do matter in whether and which low-income adults obtain public health coverage. |
|
Medicaid participation rates are one contributing factor. Eligible persons may perceive Medicaid as a stigma or see little value to coverage in states with shallow benefit packages—a factor that may become more important now that coverage is no longer linked to cash benefits. More recent concerns in the context of welfare reform are burdensome application procedures, lack of information, and rules that vary from group to group. Evidence for children reveals that 22 percent of Medicaid-eligible children remain uninsured and that participation is lower among those in groups newly eligible through the Medicaid expansions (Selden, Banthin, and Cohen 1998).
Even more important than low participation are the income and categorical limits that restrict adult Medicaid eligibility. Among the focal states, the highest income limit for welfare-related eligibility is only about 60 percent of the federal poverty level, and even the poorest of those who do not meet categorical eligibility criteria remain ineligible. Under the current Medicaid structure, expansions of coverage for these groups will remain largely under the purview of state programs. Of the 50 states, 8 have comprehensive programs and 15 have moderate programs. Given that the other 27 states have not taken advantage of the flexibility that has always characterized Medicaid—and only 8 have expanded significantly beyond Medicaid—even the postÐwelfare reform enhancements to flexibility and fiscal incentives will not reduce the substantial state variations in adult access to public health coverage. Barring a federal initiative to set and perhaps underwrite a higher income floor for the Medicaid program, expand or remove categorical requirements, or establish an adult counterpart to the Children's Health Insurance Program, state efforts alone are unlikely to significantly expand health insurance coverage for adults.
Endnotes
This brief is drawn from results in Spillman (2000).
1. The first wave of the NSAF collected economic, health, and social information on 44,000 households between February and November 1997. The survey oversamples households with incomes under 200 percent of the federal poverty level and households in each of 13 targeted states. The NSAF provides information on a nationally representative sample of the civilian, noninstitutionalized population under age 65 and their families. A second wave of this survey was fielded in 1999. For more information, and the survey methods and data reliability, see Kenney, Scheuren, and Wang (1999).
2. The federal matching rate is related to state per capita income. In the richest states, the federal share of Medicaid spending is 50 percent. In Mississippi, the poorest state, the federal share is 77 percent.
3. This typology is modified from one developed by Rajan (1998). The modification excluded factors applying only to children.
4. The impact is net of any substitution of public insurance for private, known as "crowd out." This analysis cannot address crowd out. Large programs tend to be associated here with small gaps, but the counterfactual — "What would the gaps be if the programs were less expansive?"— is not observed.
References
Holahan, John, Brian Bruen, and David Liska. 1998. "The Decline in Medicaid Spending Growth in 1996: Why Did It Happen?" Washington, D.C.: Kaiser Commission on Medicaid and the Uninsured.
Kenney, Genevieve, Fritz Scheuren, and Kevin Wang. 1999. "National Survey of America's Families: Survey Methods and Data Reliability." February.
Ku, Leighton, and Brian Bruen. 1999. "The Continuing Decline in Medicaid Coverage." Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief No. A-37.
Rajan, Shruti. 1998. "Publicly Subsidized Health Insurance: A Typology of State Approaches." Health Affairs 17 (3): 101-17.
Selden, Thomas M., Jessica S. Banthin, and Joel W. Cohen. 1998. "Medicaid's Problem Children: Eligible but Not Enrolled." Health Affairs 17 (3): 192-200.
Spillman, Brenda C. 2000. "Adults without Health Insurance: Do State Policies Matter?" Health Affairs 19 (4): 178-87.
About the Author
Brenda Spillman is a senior research associate in the Urban Institute's Health Policy Center. Her research focuses on access to and utilization of health services for nonelderly adults, including the role of the health care "safety net," as well as projects examining disability trends and long-term care use and financing among the elderly. Dr. Spillman recently published a study projecting service use and cost for the Medicare elderly, and a study of changes over time in the role of informal caregivers for the disabled elderly is forthcoming this fall.
About the Series
This series presents findings from the National Survey of America's Families (NSAF). First administered in 1997, the NSAF is a survey of 44,461 households with and without telephones that are representative of the nation as a whole and of 13 selected states (Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin). As in all surveys, the data are subject to sampling variability and other sources of error. Additional information about the survey is available at the Urban Institute Web site: http://www.urban.org.
The NSAF is part of Assessing the New Federalism, a multiyear project to monitor and assess the devolution of social programs from the federal to the state and local levels. Alan Weil is the project director. The project analyzes changes in income support, social services, and health programs. In collaboration with Child Trends, the project studies child and family well-being.
The project has received funding from The Annie E. Casey
Foundation, the W.K. Kellogg Foundation, The Robert Wood Johnson Foundation, The Henry J. Kaiser Family Foundation, The Ford Foundation, The John D. and Catherine T. MacArthur Foundation, the Charles Stewart Mott Foundation, The David and Lucile Packard Foundation, The McKnight Foundation, The Commonwealth Fund, the Stuart Foundation, the Weingart Foundation, The Fund for New Jersey, The Lynde and Harry Bradley Foundation, the Joyce Foundation, and The Rockefeller Foundation.
