View Research by Author - Mary Beth Pohl

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

Low-income workers face the highest gap in health coverage; 37.3 percent were uninsured in 1999. Although employer-sponsored insurance covered many more low-income workers, state programs are very important to those without private insurance. We examined the wide variations across 13 representative states in public insurance coverage of low-income workers to develop insights into the reasons for the variations and to suggest strategies for encouraging states to expand public insurance coverage. The analysis suggests that expanded and better-targeted federal assistance coupled with greater state flexibility would be needed to achieve this goal. (Health Affairs 21(6): 231–43, November/December 2002.)

The paper provides a typology of innovations which classifies all 50 states into four groups based on the extent to which they expanded coverage beyond required minimums. The policies in the 13 states with the most extensive coverage are described. The most innovative states have higher per capita incomes, higher education levels, larger urban populations, are less politically conservative, have the highest rate of public coverage, and lowest uninsurance rates.

[© Health Affairs] The number of uninsured Americans fell in 2000 for the second consecutive year. The reduction has been attributed to the continued expansion of employer-sponsored insurance. However, the increase in employer coverage among adults was offset by declines of other types of coverage. For children, increases in public coverage plus the growth in employer-sponsored insurance led to the reduction in the number of uninsured children. Over the longer period (1994-2000), one of great economic growth, the uninsurance rate was essentially the same at the end as at the beginning. The rate of employer-sponsored insurance increased sharply, so that more people had employer coverage. However, these increases were offset by reductions in other forms of coverage, particularly Medicaid and state-sponsored insurance and private nongroup coverage, so the overall rate of uninsurance did not change. View the Press Release.

The number of uninsured Americans fell in 2000 for the second consecutive year. The reduction has been attributed to the continued expansion of employer-sponsored insurance. However, the increase in employer coverage among adults was offset by declines of other types of coverage. For children, increases in public coverage plus the growth in employer-sponsored insurance led to the reduction in the number of uninsured children. Over the longer period (1992-2000), one of great economic growth, the uninsurance rate was essentially the same at the end as at the beginning. The rate of employer-sponsored insurance increased sharply, so that more people had employer coverage. However, these increases were offset by reductions in other forms of coverage, particularly Medicaid and state-sponsored insurance and private nongroup coverage, so the overall rate of uninsurance did not change. (Health Affairs Web Exclusive 2002 April: 162-171)

Washington, a leader among states in expanding coverage to the uninsured, now struggles to maintain many of these advances due to spending growth constraints imposed by the I-601 ballot initiative, tax cuts, and revenue shortfalls. Budget problems threaten the ability of Medicaid and the Basic Health Plan to serve those losing employer sponsored coverage during an economic slowdown. Washington solved its 2001-2003 budget dilemma while avoiding dramatic health care spending cuts through expansion of the upper payment limit, or the "ProShare" program. There is a risk that the Centers for Medicare & Medicaid Services may not approve Washington's new ProShare arrangement, which would only exacerbate the state's budget problems. Regardless, ProShare represents a one-time fix, not a solution to the state's health financing and other budget problems.

This paper examines the contribution of immigration to the increase in the number of uninsured Americans between 1994 and 1998. The study found that non-citizens comprised 20 percent of the total uninsured in the U.S. Recent immigrants and their children who lacked health coverage (2.3 million) constitute only 5 percent of the 44 million uninsured. The number of new immigrants entering the U.S. between 1994 and 1998 actually fell, resulting in a decrease of 100,000 in the number of recent immigrants who are uninsured. Thus while recent immigrants have high rates of being uninsured (46 percent), they are not significant reason for the growth in the number of uninsured. Native citizens contributed most of the growth in the number of uninsured, 2.7 million of the 4.2 million increase (or 64 percent) in the number of uninsured between 1994 and 1998. (Published by the Kaiser Commission on Medicaid and the Uninsured; 2001 February.)

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