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Variation and Trends in the Duration of Uninsurance

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Document date: November 30, 2004
Released online: November 30, 2004

Assessing the New Federalism Discussion Paper No. 04-10

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.

Note: This report is available in its entirety in the Portable Document Format (PDF).


A recent study confirmed that lack of health insurance coverage is both a short-term and long-term problem among the uninsured (Haley and Zuckerman 2003). Data from the 1999 round of the National Survey of America's Families (NSAF) showed that, of the 50 million people who lacked coverage at the time of the survey or at some time during the 12 months before the survey, 56 percent were uninsured for 12 months or longer, 24 percent for 6 to 11 months, and 20 percent for 5 months or less.1 The 1999 data also demonstrated that lack of coverage for any period of time was related to diminished access to and use of health care services and that these problems were magnified as the duration of uninsurance increased.

The duration of uninsured spells should play a role in shaping the types of policies that might be considered to address the problems of the uninsured. If people who become uninsured remain so for very short periods, then policies designed to plug gaps in coverage (e.g., subsidies that would make COBRA coverage affordable to more people or efforts to keep eligible people enrolled in public programs) might seem sensible. However, if people tend to be without coverage for longer periods of time, then policies aimed at making structural changes in health insurance to enhance accessibility and affordability over the long run (e.g., permanent tax credits, insurance market reforms and/or broader expansions of public coverage beyond low-income groups) might be needed. Haley and Zuckerman (2003) concluded that policymakers who want to tackle the problem of uninsurance and the associated health risks will need to consider approaches that meet the needs of both the short-term and long-term uninsured, but that the long-term uninsured are at a greater disadvantage and should be a higher priority.

This paper updates the 1999 analysis with data from the 2002 round of NSAF.2 In addition to re-examining some earlier findings, it also shows how the distribution of the duration of uninsurance changed over time for the entire nonelderly population as well as for age and income subgroups. In particular, the paper addresses four questions:

  1. What is the distribution of the duration of uninsurance in 2001-02?
  2. How does the duration of uninsurance vary by subgroup?
  3. What is the relationship between duration of uninsurance and health care access and use?
  4. How has the distribution of the duration of uninsurance changed over time?


Notes from this section

1 The original Haley and Zuckerman paper reported that 49 million people lacked coverage at the time of the survey or at some time during the 12 months before the survey. That number has been revised as a result of reweighting that took place when data from the 2000 Census became available.

2 This analysis uses the 1999 and 2002 National Survey of America's Families (NSAF), conducted by the Urban Institute as part of its Assessing the New Federalism (ANF) project. The NSAF is a nationally representative survey of nonelderly adults and children in over 40,000 households that represents the noninstitutionalized civilian population under age 65. It oversamples the low-income population (those with family incomes below 200 percent of the federal poverty level) and populations in 13 states. The survey contains detailed information on health insurance coverage, access, and use for up to two sampled children (one age 5 or under and one between ages 6 and 17) and one sampled adult in each household. The sample was weighted to population totals, and weights adjust for the design features of the sample, including oversampling low-income households and those in the 13 study states, as well as nonresponse and under-coverage. Variances used for tests of statistical significance were adjusted to account for the complex sample design.

Respondents were asked about selected family members' health insurance coverage, including a question that confirmed uninsurance for those not originally identified as having any type of coverage (Rajan, Zuckerman, and Brennan 2000). The health insurance coverage sequence allows for assessment of coverage at the time of the survey and in the 12 months before the survey.

Individuals identified as having no health insurance coverage at the time of the survey are classified as uninsured at a point in time. Those uninsured either at the time of the survey or at any time in the prior 12 months are classified as uninsured during the previous 12 months. Among those with any uninsurance during the 12-month period, long-term uninsurance was defined as uninsured for a full year or more (that is, at the time of the survey and for all of the prior 12 months), while individuals with less than 12 months without coverage were the shorter-term uninsured.


Note: This report is available in its entirety in the Portable Document Format (PDF).



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