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Gaps in Insurance Coverage for Children

A Pre-CHIP Baseline

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Document date: May 01, 2000
Released online: May 01, 2000

Number B-19 in Series, "New Federalism: National Survey of America's Families"

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.


Despite the expansions in Medicaid that began in the late 1980s,1 approximately 12 percent of all children ages 17 and under and 21 percent of children in families with incomes below 200 percent of the federal poverty level (FPL) lacked health insurance coverage in 1997 (Brennan, Holahan, and Kenney 1999). Concern about the growing number of children in the United States without health insurance prompted yet another expansion in publicly subsidized coverage that year. In August, the State Children's Health Insurance Program (CHIP) was enacted, which provided states with an additional $40 billion in federal funding over 10 years to expand insurance coverage for low-income children.

CHIP is targeted to low-income children ages 18 and under who are without employer-sponsored coverage and are not eligible for Medicaid. In addition, the Clinton administration has recently proposed expanding Medicaid and CHIP coverage to individuals ages 19 and 20 who previously had limited Medicaid eligibility.2

Prior to CHIP, there was significant variation across states in approaches toward covering children. As of 1997, however, states were mandated to cover infants and children up to age 6 in families with incomes below 133 percent of the FPL and children ages 6 to 14 in families with incomes below 100 percent of the FPL.3  At that time, states had more generous coverage policies toward younger children; the average eligibility threshold was 84 percent of the FPL for children ages 14 through 18, compared with 148 percent for children ages 1 through 5 (Ullman, Hill, and Almeida 1999).

Data from the 1997 National Survey of America's Families (NSAF) are analyzed here to estimate the number and composition of children lacking health insurance prior to the implementation of CHIP. Findings show that 9.2 million children ages 18 and under and 2 million individuals ages 19 and 20 lacked insurance coverage in 1997. Over three-quarters (77 percent) of uninsured children ages 18 and under were in families with incomes below 200 percent of the FPL. Another 14 percent were in families with incomes between 200 and 300 percent of the FPL. Consistent with historic Medicaid coverage policies, older children are more likely than younger children to be uninsured—low-income children ages 14 through 18 were about one and one-half times as likely as low-income children under 5 to lack insurance coverage (29.3 versus 17.6 percent, respectively). Almost half of all low-income individuals ages 19 and 20 were uninsured (47.7 percent). With CHIP, states now have the potential to provide insurance coverage for almost all low-income uninsured children ages 18 and under. The challenge will be to translate that potential into coverage for all eligible but uninsured children.

Data and Methods

The NSAF is a survey of children and adults under the age of 65 in over 44,000 households, conducted as part of the Urban Institute's Assessing the New Federalism (ANF) project.4  It provides representative information on the noninstitutionalized, nonelderly population for 13 focal states5 and for the nation as a whole (Brick et al. 1999). The NSAF oversamples the low-income population (defined as those with incomes below 200 percent of the FPL) and the population in the ANF states.6

Overall, information was collected on 34,439 children. Interviewers asked primary caregivers about children's current and past year's enrollment in private and public insurance coverage and followed up with a confirmation question if respondents did not identify any coverage (Rajan, Zuckerman, and Brennan 1999).7  For this analysis, estimates of coverage at the time the survey was administered are presented.8  The relationship between the demographic and family characteristics of the surveyed children and the child's insurance status is analyzed."Low-income" households are defined as those with incomes below 200 percent of the FPL;"higher-income" households have incomes above 200 percent of the FPL."Poor" households are defined as those with incomes under 100 percent of the FPL;"near-poor" households are those with incomes between 100 and 200 percent of the FPL.

Insurance Coverage Distribution by Income

All Children

Table 1 presents the insurance coverage distribution for children ages 0 through 18 in 1997. Nationally, 9.2 million children were uninsured in 1997, representing 12 percent of the child population. Private insurance coverage, predominantly employer-based dependent coverage, was the primary source of insurance coverage for all children—51.7 million children were covered. Public insurance, predominantly Medicaid, was also an important source of insurance coverage for children, covering 14.4 million children.

Higher-Income Children

Of the 9.2 million uninsured children in 1997, only 2.1 million resided in families with incomes above 200 percent of the FPL. Fully 90 percent of higher-income children had some type of private insurance coverage, while only 2.2 million had public coverage. Within this income group, lack of coverage was concentrated in families living between 200 and 300 percent of the FPL. More than 1 million of the 2.1 million higher-income uninsured children lived in families in this income category.

Table 1
Number and Percentage of Children (Ages 0-18) with Private or Public
Coverage or without Coverage, Nationally and by Income, 1997
 
Income Category
Private
Public
Uninsured
Total
  Millions Percent Millions Percent Millions Percent Millions

All Children 51.7 68.7 14.4 19.2 9.2 12.2 75.3
(.4) (.5) (.3) (.4) (.3) (.4) (.2)

Children in families with incomes:
Below 100% FPL 3.2 21.1 8.8 57.3 3.3 21.6 15.3
(.2) (1.4) (.3) (1.5) (.2) (1.1) (.4)
100-200% FPL 9.5 56.9 3.5 20.8 3.7 22.3 16.6
(.3) (1.1) (.2) (1.0) (.2) (1.1) (.4)
200-300% FPL 12.0 82.4 1.3 8.7 1.3 8.9 14.6
(.4) (1.0) (.1) (.7) (.1) 0.8 (.4)
Above 300% of FPL 26.9 93.9 0.9 3.1 0.8 2.9 28.7
(.4) (.5) (.1) (.4) (.1) (.3) (.4)

Source: Urban Institute tabulations of the 1997 National Survey of America's Families.
Note: Standard errors are in parentheses.

Low-Income Children

As might be expected, the problem of uninsurance is far greater for children living in low-income families. Of the 9.2 million uninsured children in 1997, 7 million lived in families with incomes below 200 percent of the FPL. Over one-fifth (22 percent) of all low-income children lacked insurance coverage.

Poor and Near-Poor Children. Although the same proportion (22 percent) of near-poor children and poor children were uninsured, poor children were less likely to be covered privately and more likely to be covered by Medi-caid. In 1997, 3.3 million poor and 3.7 million near-poor children were uninsured. However, far more near-poor than poor children were covered privately (9.5 million versus 3.2 million). Conversely, 8.8 million poor children had public coverage, compared with just 3.5 million near-poor children. Since most poor children were eligible for Medicaid in 1997, program nonparticipation was the primary reason for uninsurance. Near-poor children were uninsured due both to limited employment-based coverage and limited eligibility for public programs.

Among ANF Focal States. The number and percentage of uninsured low-income children in the 13 ANF focal states are presented in table 2. Among these states, uninsurance rates for low-income children in 1997 ranged from 12 percent in Michigan and Minnesota to 34 percent in Texas. California and Texas each had more than 1 million low-income uninsured children.

Uninsurance rates for low-income children seem to be related both to the extent to which a state has expanded public coverage and the scope of employer-sponsored coverage. In 1997, uninsurance rates for low-income children in Colorado, Florida, Mississippi, and Texas were above 25 percent. At this time, Colorado had not expanded Medicaid beyond the federal eligibility requirements, and Florida, Texas, and Mississippi had only expanded eligibility for infants. Additionally, Florida, Mississippi, and Texas all had private coverage rates below the national average (Brennan et al. 1999).

In contrast, fewer than 15 percent of low-income children were uninsured in Massachusetts, Michigan, Minnesota, Washington, and Wisconsin in 1997. All of these states had either expanded Medicaid beyond federally mandated levels for children in several age categories or implemented a state-funded insurance program for children on a statewide basis. In addition, all but one of these states (Washington) had private coverage rates above the national average (Brennan et al. 1999).

Table 2
Number and Proportion of Low-Income Children (Ages 0-18)
Lacking Insurance Coverage, by State, 1997
 
State
Number
Percentage
Standard Error

United States
7,029,129
22.0
0.8
 
Alabama
141,768
24.5
2.0
California
1,103,081
23.0
2.1
Colorado
114,421
30.0***
2.1
Florida
524,128
28.4***
2.0
Massachusetts
65,122
13.9***
1.7
Michigan
106,860
11.9***
1.3
Minnesota
47,715
12.3***
1.6
Mississippi
148,168
30.0***
2.0
New Jersey
119,269
19.3
1.5
New York
404,393
18.7
1.8
Texas
1,019,506
33.6***
2.0
Washington
77,687
13.6***
1.4
Wisconsin
67,988
14.7***
1.3

Source: Urban Institute tabulations of the 1997 National Survey of America's Families.
*** = significantly different from national average (p < .01).

Uninsurance Rates by Age and Income

Figure 1 shows 1997 rates of uninsurance among poor and near-poor children in different age groups. Within the low-income category, older children had higher rates of uninsurance than younger children, in part reflecting the fact that older children had more restrictive Medicaid coverage in 1997. Low-income individuals ages 19 and 20 had the highest uninsurance rate (47.7 percent), followed by children ages 14 through 18 (29.3 percent), while children ages 6 through 13 and 0 through 5 had 21.6 and 17.6 percent uninsurance rates, respectively (numbers not shown).

Poor and Near-Poor Children

As found in earlier studies (Campbell 1999; Czajka 1999; Newacheck, Hughes, and Cisternas 1995; Weinick, Weigers, and Cohen 1998), among poor children, the youngest children had the lowest rates of uninsurance, and rates increased with age: 16.1 percent of poor children ages 0 through 5 were uninsured, compared with 32.2 percent of children ages 14 through 18. For children under 13, uninsurance rates for near-poor children were higher than rates for poor children. This reflects the fact that, at lower income levels, more of these children were able to qualify for Medicaid in 1997. As income increases, these children tend to lose Medicaid eligibility but do not always obtain private coverage.

19- and 20-Year-Olds

In 1997, 2 million 19- and 20-year-olds were uninsured, of whom 0.8 million were poor and 0.6 million were near poor (numbers not shown). What is particularly notable about this age group is its high rates of uninsurance relative to other children in the same income category, as shown in figure 1. About 53 percent of poor and 42.4 percent of near-poor individuals ages 19 and 20 were uninsured, compared with 21.6 percent of poor children and 22.3 percent of near-poor children ages 0 through 18. Thus, there is considerable room to increase insurance coverage for this group.


Uninsurance Rates by Individual and Family Characteristics

Table 3 shows the proportion of children lacking insurance coverage and the profile of the uninsured across individual and family characteristics in 1997.9  About 30 percent of all low-income Hispanic children and children of "other" ethnic origins were uninsured, which is consistent with previous research (Campbell 1999; Czajka 1999; Newacheck et al. 1995; Weinick et al. 1998). Black and white non-Hispanic children had the lowest rates of uninsurance among all low-income children (17.9 and 19.2 percent, respectively). Half of all foreign-born low-income children were uninsured, compared with 20.3 percent of low-income children born in this country. Even though the immigration status of a parent does not affect the child's eligibility for Medicaid or CHIP so long as the child is eligible, uninsurance rates were much higher for children with foreign-born parents. Almost 42 percent of all children with a foreign-born noncitizen parent and 27 percent of children with a foreign-born naturalized parent were uninsured, compared with 18.4 percent of children with a parent born in the United States.

Children with lower health status were at greater risk of being uninsured. Of all low-income children in fair or poor health, 30.5 percent were uninsured, compared with 20 percent of children in excellent or very good health. Interestingly, the presence of a functional limitation was not associated with a higher rate of uninsurance.

As other studies have shown, having a parent with less than a high school diploma is associated with a higher probability of being uninsured (Czajka 1999; Weinick et al. 1998). Of all low-income families where the primary caregiver did not have a high school diploma or GED, 27.8 percent had an uninsured child, compared with 19.1 percent of children living with a parent with a high school diploma or GED and 13.2 percent of children living with a parent with a bachelor's degree or higher.

Among low-income families, higher rates of uninsurance occurred for children who had parents working full-time compared with those with parents working part-time or parents not working at all. Over one-quarter of all children in low-income families with two full-time workers were uninsured. Similarly, 23.6 percent of children in low-income families with one full-time worker were uninsured. Only 13 percent of children in low-income families where no one was working were uninsured.

Table 3
Rates of Uninsurance and Profile of Uninsured
Low-Income Children, by Individual and Family Characteristics, 1997
 
Characteristics Uninsurance Rate Standard Error Percentage of Low-Income Uninsured Children Standard Error

Child Characteristics (ages 0-18)
Race/Ethnicity
White, non-Hispanica 19.2 0.9 41.2 1.3
Black, non-Hispanic 17.9 1.4 18.9 1.3
Hispanic 29.2*** 1.7 30.6 1.4
Other 31.6*** 3.0 9.2 0.9
Gender
Malea 22.1 1.0 50.6 1.4
Female 21.9 1.0 49.4 1.4
Health Status
Excellent or very gooda 20.0 0.8 65.7 1.4
Good 25.8*** 1.4 22.7 1.3
Fair or poor 30.5*** 3.0 11.6 1.1
Functional limitation
Has health condition that limits activity 22.1 2.4 11.0 1.2
No health condition that limits activitya 22.0 0.8 89.0 1.2
Immigration status
Born in U.S.a 20.3 0.7 87.4 1.1
Foreign-born 50.9*** 4.0 12.6 1.1

Family Characteristics (for children ages 0-17, unless noted)
Educational statusb
No HS diploma or GEDa 27.8 1.5 36.8 1.6
HS diploma or GED, no bachelor's degree 19.1*** 0.9 57.5 1.7
Bachelor's degree or higher 13.2*** 1.4 5.2 0.5
Work status of parent(s)
Two full-time workers 25.3*** 2.5 16.3 1.7
One full-time worker 23.6*** 1.0 59.9 1.5
Part-time worker(s) only, no full-time workers 19.7*** 1.6 10.0 0.9
Not workinga 13.0 1.1 13.8 1.0
Family Structure
Single-parent household 16.8*** 0.9 35.3 1.8
Two-parent householda 24.1 1.1 58.7 1.8
No parents in household 26.6*** 2.9 5.7 0.6
Family Incomeb
Less than 50% FPL 18.7*** 1.9 17.3 1.8
50-100% FPL 23.7 1.3 29.8 1.3
101-150% FPLa 27.4 1.7 32.5 1.9
151-200% FPL 17.3*** 1.0 20.3 1.1
Immigration statusb
Born in U.S.a 18.4 0.7 75.4 1.4
Foreign-born, naturalized citizen 27.0*** 3.5 3.6 0.5
Foreign born, alien 41.6*** 2.5 21.0 1.4

Geographic Location
Regionc
Northeasta 15.1 1.2 11.6 1.0
Midwest 15.9 1.5 14.7 1.4
South 26.0*** 1.3 45.0 1.7
West 25.4*** 1.8 28.7 1.7
Urban/Ruralc
Urbana 20.8 0.8 71.1 1.9
Rural 25.4*** 1.8 28.9 1.9

Source: Urban Institute tabulations of the 1997 National Survey of America's Families.
a. Reference category for significance testing.
b. Represents status of child's primary caregiver.
c. Includes children ages 0 through 18.
*** = significantly different from reference category (p < .01).

Profile of the Uninsured Low-Income Child Population

The low-income uninsured child population is profiled along a number of characteristics in table 3. Findings show that Hispanic children made up about 30 percent of the low-income uninsured child population, and children with a foreign-born parent constituted about one-quarter of uninsured children. Almost two-thirds of uninsured children were in excellent or very good health, roughly 12 percent were in fair or poor health, and about the same proportion had a health condition that limited their activity.

As other studies have shown, the majority of uninsured low-income children lived in families with a working parent (Fronstin 1998; Newacheck et al. 1995; Weigers et al. 1998). Over three-quarters of uninsured low-income children lived in families with at least one full-time worker and 16 percent lived in families with two full-time workers. Most low-income uninsured children (57.5 percent) lived in families where the primary caregiver had a high school diploma or GED but no bachelor's degree. A smaller proportion (36.8 percent) lived in families where the primary caregiver did not complete high school. Most low-income uninsured children lived in families with incomes either between 50 and 100 percent of the FPL (29.8 percent) or between 101 and 150 percent of the FPL (32.5 percent).

Policy Implications

Prior to the enactment of CHIP, more than 9 million children ages 18 and under lacked health insurance coverage. Over three-quarters—or 7 million—lived in families with incomes below 200 percent of the FPL. Many of these uninsured children have since been made eligible for public health insurance coverage under CHIP. As of January 2000, 29 states10 had approved plans to offer coverage to children in families with incomes at least up to 200 percent of the FPL; another 7 offered coverage to children in families with incomes up to 185 percent of the FPL (Health Care Financing Administration 2000).

As CHIP programs mature, the pattern of insurance coverage is expected to shift from what was observed in 1997. Since virtually all states have used CHIP to expand coverage for adolescents ages 14 through 18, greater declines are expected in uninsurance rates occurring among low-income older children, over one-quarter of whom were uninsured in 1997. The Clinton administration's proposal to expand coverage for 19- and 20-year-old low-income individuals—nearly 50 percent of whom are uninsured—could reduce the very high uninsurance rates that prevail for this group. The effectiveness of coverage expansions for this group and for children ages 14 through 18 will depend on how successful states are in finding and enrolling uninsured eligibles many of whom may perceive themselves to be healthy and not in need of health insurance coverage.

Many states have recently taken advantage of the greater flexibility they have regarding income disregards to offer coverage to children whose family incomes are above 200 percent of the FPL. As of January 2000, one state (California) had expanded coverage up to 250 percent of the FPL, five states (Connecticut, Missouri, New Hampshire, Rhode Island, and Vermont) had expanded coverage up to 300 percent of the FPL, and another state (New Jersey) was covering children whose family incomes are up to 350 percent of the FPL. These expansions mean that declines in uninsurance might also be seen among this group of children.

Previous Medicaid expansions demonstrate that expanding eligibility is not enough to ensure that children obtain health insurance coverage (Dubay and Kenney 1996; Selden, Banthin, and Cohen 1999). Substantial numbers of children remained uninsured in 1996 despite being eligible for public coverage (Selden, Banthin, and Cohen 1998). Available information (Lake Snell Perry and Associates 1998; Perry et al. 2000) suggests that there are many reasons that uninsured children are not enrolled in Medicaid. Recent proposals to expand CHIP to cover parents (Dubay et al. forthcoming), use other government programs to reach uninsured eligible children (Kenney et al. 1999), and simplify Medicaid enrollment procedures may be critical to raising participation among children.


Notes

1. Medicaid coverage for young children was expanded in the late 1980s. Congress permitted and eventually mandated states to provide Medicaid coverage for children up to age six in families with incomes up to 133 percent of the FPL and for children born after September 30, 1983, with family incomes up to 100 percent of the FPL. Starting in 1988, Congress also gave states the option to cover infants with family incomes up to 185 percent of the FPL.

2. Medicaid eligibility for individuals ages 19 and 20 is gained primarily through the Ribicoff children provision, pregnancy-related coverage, or a Medically Needy program. This group can also obtain Medicaid through SSI eligibility, as caretaker relatives, or if they were in foster care on their 18th birthday.

3. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) prohibited states from using federal matching funds to cover immigrant children who entered the United States after August 1996 for five years after their arrival. States have the option to cover these children using state-only funds.

4. See Kondratas, Weil, and Goldstein (1998) for a description of the ANF project.

5. The 13 focal states are Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin.

6. The household response rate for the NSAF is 70 percent (Brick et al. 1999). Detailed information was collected on up to two children in each household (one age 5 or under and one between ages 6 and 17). Responses to the interviews are weighted to reflect the design features of the sample, including the oversampling of low-income households in 13 states, and contain adjustments for nonresponse and undercoverage. Variance estimates are computed using a replication method that adjusts for the survey's complex sample design (Flores-Cervantes, Brick, and DiGaetano 1999). Imputed data for health insurance, income, and other variables with missing values are used. Imputed values account for 1.3 percent or less of all observations for health insurance.

7. The inclusion of a confirmation question in the NSAF reduces the number of children identified as uninsured to levels below those identified by the Current Population Survey (CPS). Differences between the NSAF and CPS may also arise because the NSAF collects data on insurance coverage at the time of the survey, but CPS data pertain to insurance coverage during the previous calendar year.

8. Insurance coverage is categorized into one of five groups: employer-sponsored insurance, Medicaid, other public (Medicare, CHAMPUS, or a state-sponsored health insurance program), other private, and uninsured. Because more than one type of insurance coverage was sometimes reported, a hierarchy was imposed through which coverage through an employer-sponsored plan took precedence over all other types of coverage. This is followed by coverage through Medicaid or another public program and then by other private coverage. Like all household surveys, it is likely that Medicaid coverage is underreported. As such, the number and percentage of uninsured children may be overestimated.

9. Multivariate analyses were also performed to examine which characteristics predict uninsurance for children after controlling for other factors (results not presented here). The multivariate analyses confirmed the descriptive findings with one exception. Being Hispanic was a significant predictor of being uninsured when regional factors were controlled for using four regional dummy variables (North, West, Midwest, South); however, this result did not remain when geography was controlled for by using state dummy variables instead. This suggests that Hispanics tend to live in states with higher-than-average uninsurance rates. The logistic regression model controlled for age, race, gender, health and disability status, immigration status of the child and primary caregiver, educational attainment of primary caregiver, work status of parent(s), family structure, family income, urban/rural characteristics, and state. It was found that, after controlling for other factors, age (0-5, 6-13), race (other), child's immigration status (foreign-born), educational attainment of caregiver (high school diploma, bachelor's degree), work status (two full-time, one full-time, one part-time), family income (50-200 percent of FPL), immigration status of primary caregiver (foreign-born), state (Alabama, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, Texas, Washington, and Wisconsin), and geographic location (urban) were significant predictors (p < .05) of uninsurance status.

10. Excluding Puerto Rico.


References

Brennan, Niall, John Holahan, and Genevieve M. Kenney. 1999. Snapshots of America's Families: Health Insurance Coverage of Children. Washington, D.C.: The Urban Institute.

Brick, Pat, Genevieve Kenney, Robin McCullough-Harlin, Shruti Rajan, Fritz Scheuren, Kevin Wang, J. Michael Brick, and Pat Cunningham. 1999. 1997 NSAF Survey Methods and Data Reliability. Washington, D.C.: The Urban Institute. July. National Survey of America's Families Methodology Report No. 1.

Campbell, Jennifer. 1999. Health Insurance Coverage. Washington, D.C.: U.S. Census Bureau. October.

Czajka, John. 1999. Analysis of Children's Health Insurance Patterns: Findings from the SIPP. Washington, D.C.: Mathematica Policy Research. May 12.

Dubay, Lisa, and Genevieve M. Kenney. 1996. "Revisiting the Issues: The Effects of Medicaid Expansions on Insurance Coverage of Children." The Future of Children 6 (1): 152-61.

Dubay, Lisa, Genevieve M. Kenney, and Stephen Zuckerman. Forthcoming. Extending Medicaid to Parents: An Incremental Strategy for Reducing the Uninsured. Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief.

Flores-Cervantes, Ismael, J. Michael Brick, and Ralph DiGaetano. 1999. 1997 NSAF Variance Estimation. Washington, D.C.: The Urban Institute. National Survey of America's Families Methodology Report No. 4.

Fronstin, Paul. 1998. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1998 CPS. Washington, D.C.: Employee Benefit Research Institute. December.

Health Care Financing Administration. 2000. The State Children's Health Insurance Program Annual Enrollment Report, October 1, 1998-September 30, 1999. Washington, D.C.: Health Care Financing Administration. January.

Kenney, Genevieve, Jennifer Haley, and Frank Ullman. 1999. Most Uninsured Children Are in Families Served by Government Programs. Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief No. B-4.

Kondratas, Anna, Alan Weil, and Nancy Goldstein. 1998. "Assessing the New Federalism: An Introduction." Health Affairs 17 (3): 17-24.

Lake Snell Perry and Associates. 1998. Barriers to Medicaid and Medi-Cal Enrollment: Findings from 14 Focus Groups with Parents of Potentially Eligible Children. Menlo Park, Calif.: Kaiser Family Foundation. January.

Newacheck, Paul, Dana Hughes, and Miriam Cisternas. 1995. "Children and Health Insurance: An Overview of Recent Trends." Health Affairs 14 (1): 244-54.

Perry, Michael, Susan Kannel, R. Burciaga Valdez, and Christina Chang. 2000. Medicaid and Children: Overcoming the Barriers to Enrollment. Menlo Park, Calif.: Kaiser Commission on Medicaid and the Uninsured. January.

Rajan, Shruti, Stephen Zuckerman, and Niall Brennan. 1999. Verifying Insurance Coverage: Impact on Measuring the Uninsured within the National Survey of America's Families. Urban Institute Working Paper. Washington, D.C.: The Urban Institute.

Selden, Thomas, Jessica Banthin, and Joel Cohen. 1998."Medicaid's Problem Children: Eligible but Not Enrolled." Health Affairs 17 (3): 192-200.

—— 1999."Waiting in the Wings: Eligibility and Enrollment in the State Children's Health Insurance Program." Health Affairs 18 (2): 126-33.

Ullman, Frank, Ian Hill, and Ruth A. Almeida. 1999. CHIP: A Look at Emerging State Programs. Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief No. A-35.

Weigers, Margaret, Robin Weinick, and Joel Cohen. 1998. Children's Health 1996. MEPS Chartbook No. 1. Rockville, Md.: Agency for Health Care Policy and Research. March.

Weinick, Robin, Margaret Weigers, and Joel Cohen. 1998. "Children's Health Insurance, Access to Care and Health Status: New Findings." Health Affairs 17 (2): 127-36.


Other Selected Publications from the Assessing the New Federalism Project's National Survey of America's Families (NSAF)

Policy Briefs

No. B-8. The Hours That Children under Five Spend in Child Care: Variation across States. Jeffrey Capizzano and Gina Adams. March 2000.

No. B-7. Child Care Arrangements for Children under Five: Variation across States. Jeffrey Capizzano, Gina Adams, and Freya Sonenstein. March 2000.

No. B-6. Income Inequality among America's Children. Gregory Acs and Megan Gallagher. January 2000.

No. B-5. Racial and Ethnic Disparities: Key Findings from the National Survey of America's Families. Sarah Staveteig and Alyssa Wigton. February 2000.


About the Authors

Ruth A. Almeida is a research associate with the Urban Institute's Health Policy Center, where she focuses on insurance coverage for children and the implementation of the state children's health insurance program.

Genevieve M. Kenney is a principal research associate in the Urban Institute's Health Policy Center. Her research focuses on the study of how public policies affect access to care and insurance coverage for pregnant women and children.


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.



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