Citation URL: http://www.urban.org/CynthiaPerry

Only 37 percent of adults in low-income working families had employer-sponsored health insurance and 42 percent had no coverage. Health care costs are also rapidly rising out of reach for even middle-income Americans. In this essay, Perry and Blumberg propose comprehensive reform that ensures coverage for everyone at every income level, while still encouraging work. Their proposals include state purchasing pools, individual mandates, and strategies for reducing health care costs.

Only 37 percent of adults in low-income working families had employer-sponsored health insurance and 42 percent had no coverage. Health care costs are also rapidly rising out of reach for even middle-income Americans. In this summary, Perry and Blumberg propose comprehensive reform that ensures coverage for everyone at every income level, while still encouraging work. Their proposals include state purchasing pools, individual mandates and strategies for reducing health care costs.

Child health problems that are caused or exacerbated by health behaviors remain a leading cause of medical spending for children. We examined receipt of clinician advice in a sample of low-income children by insurance coverage. Publicly insured children were more likely than privately insured, full-year–uninsured children, and part-year–uninsured children to have had a preventive care visit in the past year, but regardless of health insurance group, many children went without preventive care. Those who were insured for an entire year through Medicaid or SCHIP did as well as or better than children who were privately insured for the year-and better than children who were not insured for some or all of the year-in terms of receiving preventive counseling. Rates of counseling were universally low, even for children who had a preventive care visit and children who would have particularly benefited from advice.

Cynthia Perry and Genevieve Kenney explore the rates at which providers offer advice on health behaviors and injury prevention during preventive care visits. They find that pediatricians are more likely to advise about healthy eating than other physicians and nonphysicians, and they are also more likely than nonphysicians to advise about exercise, the harmful effects of parental smoking, proper safety restraints in a car, and use of a bicycle helmet. Regardless of provider type, rates of advice were low, leading the authors to conclude that many pediatric providers, particularly those not trained as pediatricians, are missing opportunities to advise about health behaviors and injury prevention.

One of the more prominent concerns in the SCHIP reauthorization debate is that many children enrolling in the program could have been insured through their parents' employers. However, concern about parents dropping employer coverage to enroll their children in SCHIP typically ignores the affordability of that coverage. We show that families' spending burden is, on average, lower under public insurance than under employer-sponsored insurance (ESI), especially for the lowest-income families. For families in which children are covered by Medicaid or SCHIP, out-of-pocket spending is, on average, 4 to 5 percent of their income. However, for families in which children have ESI for a full year, the out-of-pocket spending burden is higher, ranging from 12.9 percent of income for families below 150 percent of the federal poverty level (FPL) to 6.1 percent for families between 250-400 percent of FPL.

Lack of health insurance can affect the health and productivity of workers as well as the health of workers’ families, especially for low-income families, who are more likely to have members in poor health. We show that about half of children in low-income families do not have access to employer-sponsored insurance (ESI). Among the families without access to ESI, public insurance fills some gaps among children, but parents remain uninsured at high rates. For these families, children are twice as likely—and parents are nearly three times as likely—to be uninsured compared to families with an ESI offer.

Return to list of authors