This brief focuses on the health insurance coverage experiences under the Affordable Care Act (ACA) of fathers living with dependent children. Using 1997-2014 data from the National Health Interview Survey, we examine trends in uninsurance among custodial fathers nationally and in states that did and did not expand Medicaid under the ACA by May 2014. We also assess changes between 2013 and 2014 in the characteristics of uninsured custodial fathers and uninsurance rates for various subgroups of fathers as well as reasons for being uninsured among those without coverage in 2014. We find an increase in uninsurance among custodial fathers between 1997 and 2013, followed by a decline between 2013 and 2014, with larger reductions found in Medicaid expansion states compared to states that did not expand Medicaid. More than five million custodial fathers remained uninsured in 2014.
This brief examines the health insurance coverage experiences of fathers living with dependent children before and after implementation of the major coverage provisions of the Affordable Care Act (ACA) in 2014. Among these provisions were an expansion of Medicaid eligibility, new tax credits for plans purchased in ACA Marketplaces, and an individual mandate to maintain coverage. Our recent analysis showed that mothers who were living with dependent children experienced substantial declines in uninsurance between 2013 and 2014 (Karpman, Gates, Kenney, et al. 2016a). Although the share of children living with their fathers is lower than the share living with their mothers—just over 70 percent compared with 90 percent, respectively—there is still substantial potential for fathers’ coverage changes to have spillover effects on their children’s health and well-being (Davidoff et al. 2003; Dubay and Kenney 2003).
No published research has yet focused on coverage changes for custodial fathers (hereafter referred to as fathers) under the ACA. For this brief, we use data from the National Health Interview Survey (NHIS) to look at trends in uninsurance for fathers between 1997 and 2014, the most recent year for which parental status data are available from the NHIS. We focus exclusively on fathers living with dependent children ages 18 and under because we cannot identify noncustodial fathers from the NHIS. In addition to showing the overall change in uninsurance for fathers, this brief provides estimates of changes in the uninsurance rate for fathers with family incomes above and below the new Medicaid eligibility threshold of 138 percent of the federal poverty level (FPL). It also examines changes in the characteristics of uninsured fathers between 2013 and 2014, as well as changes in uninsurance rates for fathers in specific subgroups, including fathers in states that did and did not expand Medicaid as of May 2014. Companion briefs show parental outcomes for both mothers and fathers under the ACA, including coverage, access, and affordability (Karpman, Gates, Kenney, et al. 2016b; Karpman, Gates, McMorrow, et al. 2016).
Data and Methods
This analysis uses nationally representative data for the civilian noninstitutionalized population obtained from the NHIS, which is conducted annually by the National Center for Health Statistics. The NHIS includes three main sections: the family core, the sample adult core, and the sample child core. Family core questions are answered for each member of the family by a knowledgeable adult and ask for information on basic demographics, educational attainment, employment status, general health status, and health insurance coverage. For each family, sample child core questions are asked of one randomly selected child age 17 or under (if present and excluding emancipated minors), and sample adult core questions are asked of one randomly selected adult age 18 or over. The questions solicit extensive information on health status and details on health care access, use, and affordability. The NHIS is fielded continuously throughout the year and can be used to provide nationally representative annual or quarterly estimates. We use public data from the 1997–2014 Integrated Health Interview Series, which provides harmonized versions of NHIS variables across years.1
We use data from 1997 to 2014 to track uninsurance rates for fathers ages 19 to 64, both overall and by income as a percentage of FPL. We use 1997 as a starting point because that year marked the introduction of a redesigned NHIS, thereby rendering data from earlier years incomparable for the purposes of our study. We construct health insurance units (HIUs), which reflect the units used to determine health insurance eligibility more accurately than does the definition of family provided on the NHIS. In this brief, family and HIU are used interchangeably, but all analysis of changes in uninsurance by income uses HIUs as the relevant units for determining income as a percentage of FPL. A father is defined as a man between the ages of 19 and 64 who was identified as the father of a child age 18 or under in the household. Using this definition, the 2014 NHIS contains data on approximately 11,000 fathers in the family core file and approximately 4,000 fathers in the sample adult core file.
In addition to observing trends in uninsurance among fathers during this 18-year period, we more closely examine changes that occurred between 2013 and 2014 both in rates of uninsurance and in the composition of the remaining uninsured group, according to the following demographic and health characteristics: age (19 to 25, 26 to 34, 35 to 49, or 50 to 64); race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other race, or Hispanic); self-reported general health status (excellent or very good, good, or fair or poor); activity limitations; psychological distress (severe or moderate distress, or no or mild distress); citizenship status; HIU income (138 percent of FPL or less, above 138 percent but equal to or below 400 percent of FPL, or above 400 percent of FPL); work status (full-time worker, part-time worker, or not working); education level (less than high school, high school, some college, or college graduate); HIU citizenship (any noncitizen in HIU or no noncitizen in HIU); census region (Northeast, Midwest, South, or West); marital status (married, widowed, divorced or separated, or never married); and whether the father has at least one child age 5 or under living in the same household. We also examine changes in the uninsurance rate for fathers between 2013 and 2014 by state Medicaid expansion status. As of May 2016, 30 states and the District of Columbia had expanded Medicaid eligibility to include parents and childless adults with incomes up to 138 percent of FPL. For this analysis, we focus on changes in uninsurance among fathers, both overall and by family income, based on their states’ Medicaid expansion status as of May 2014, indicating whether expanded eligibility was available to them for the majority of that year.
We also provide estimates for the stated reasons for being uninsured among those fathers who lacked coverage. For this question, respondents provided up to five reasons for being uninsured. Possible responses include the loss of a job or a change of employer by the person in the family with coverage; divorce, separation, or death of a spouse or parent; the loss of eligibility because of age or leaving school; coverage not being offered by an employer either generally or because the employee is not eligible for coverage; cost for coverage being too high; insurance company refusing coverage; the loss of Medicaid or medical plan because of a new job or an increase in income; the loss of Medicaid for other reasons; and any other reason. Many respondents had been uninsured for more than 12 months; therefore, when answering this question, they described why they lost coverage years before the survey was administered.
Long-Term Trends and Changes
Between 1997 and 2013, the uninsurance rate among fathers rose 25 percent, increasing 4.2 percentage points from 16.4 percent to 20.6 percent (figure 1). This trend reversed between 2013 and 2014, when the uninsurance rate for fathers declined 3.3 percentage points, a drop almost twice as large as any other yearly change during the 18-year period and a change significant at the 0.01 level.
Fathers with incomes at or below 138 percent of FPL had similar uninsurance rates in 1997 and 2013 (51.2 percent and 50.6 percent, respectively) but experienced periods of rising and falling uninsurance in the intervening years (figure 2). Between 2013 and 2014, however, the uninsurance rate for low-income fathers fell 6.1 percentage points. Fathers with moderate family incomes (above 138 percent but at or below 400 percent of FPL) experienced a rise of over 50 percent in their uninsurance rate between 1997 and 2013, which increased from 15.7 percent to 23.7 percent. Like their low-income counterparts, moderate-income fathers then saw a sharp drop in their uninsurance rate in 2014 (to 18.5 percent). The changes from 2013 to 2014 for both low-income and moderate-income fathers were significant at the 0.01 level. Fathers with family incomes greater than 400 percent of FPL saw no statistically significant change in their uninsurance rate over the period, with rates close to 3 percent throughout the 18-year period.
Fathers living in states that expanded Medicaid under the ACA had lower uninsurance rates in 2013 and saw greater declines in uninsurance in 2014 than did their counterparts in nonexpansion states (figure 3). The decline in uninsurance was statistically significant for those both above and below 138 percent of FPL in expansion states, but only for those in the higher-income group in nonexpansion states. By 2014, the uninsurance rate in nonexpansion states was 54 percent higher than in expansion states for low-income fathers (54.5 percent versus 35.5 percent) and 51 percent higher for fathers with incomes above 138 percent of FPL (13.3 percent versus 8.8 percent).
In all, approximately 1.1 million fathers gained insurance coverage between 2013 and 2014, including 300,000 living in low-income families (figure 4). The larger total gains among those in higher-income families means that, as of 2014, the number of uninsured custodial fathers is roughly equally divided among those in higher- and lower-income families.
A Look at Those Who Remain Uninsured
As the number of fathers with coverage increased between 2013 and 2014, several shifts occurred in the composition of the group of fathers that were uninsured. The share of uninsured fathers residing in the West declined, as did the share of uninsured fathers who are college graduates (table 1). The share of uninsured fathers with family incomes less than or equal to 138 percent of FPL rose, while the share of uninsured fathers with moderate incomes (above 138 but at or below 400 percent of FPL) fell. Compared with 2013, uninsured fathers in 2014 also were less likely to be in fair or poor health and were less likely to report moderate or severe psychological distress.
Of the remaining uninsured fathers in 2014, over 50 percent were Hispanic, and more than two-fifths were noncitizens. Almost three-quarters of uninsured fathers were married, and nearly half lived in the South. Although almost 50 percent of uninsured fathers had family incomes at or below 138 percent of FPL, more than 70 percent were full-time workers in 2014.
More than half (51.9 percent) of uninsured fathers cited the cost of coverage as a reason for being uninsured in 2014, and around one-quarter cited changes in their employment as a reason for lacking coverage (figure 5). Other reported reasons for being uninsured included lack of access to employer-sponsored insurance (12.8 percent) and loss in coverage because of a new job or change in income (3.3 percent). A host of other reasons—including divorce, separation, or death of a spouse or parent; becoming ineligible because of age or leaving school; denial of coverage from an insurance company; and not needing insurance—were reported by 20.4 percent of custodial fathers.
Changes in Uninsurance by Subgroup
Most subgroups of fathers saw a statistically significant drop in their uninsurance rate between 2013 and 2014 (table 2). Exceptions included fathers ages 50 to 64, those living in the Northeast and the Midwest, and those with incomes above 400 percent of FPL. Groups reporting declines in uninsurance of at least 5 percentage points included younger fathers (ages 19 to 25), those who are black, Hispanic, noncitizens, or nonworkers, and those with low or moderate incomes or with less than a high school degree. Fathers in fair or poor self-reported health and those reporting moderate or severe psychological distress experienced declines in uninsurance of more than 9 percentage points.
Despite those improvements, uninsurance rates remained disproportionately high for fathers who were ages 19 to 25 (36.1 percent), noncitizens (47.8 percent), or part-time workers (34.5 percent), as well as those in low-income families (44.5 percent).
After more than a decade of few coverage increases for fathers, the uninsurance rate fell sharply from 2013 to 2014, with more than 1 million fathers gaining coverage. Fathers in low- and moderate-income families in states that chose to expand Medicaid under the ACA experienced particularly large declines. These coverage gains for fathers were broadly shared, with most of the subgroups we examined seeing declines in uninsurance from 2013 to 2014. These increases in coverage coincide with implementation of the major coverage provisions of the ACA in 2014, but the improving economy and other factors also may have contributed to the observed declines in uninsurance for fathers during this period.
Even with this progress, more than 5 million fathers remained uninsured in 2014. These uninsured fathers were disproportionately likely to be low income, less educated, Hispanic, noncitizens, and living in the South. These findings are similar to those for uninsured mothers. Compared with uninsured custodial mothers, however, uninsured custodial fathers were significantly more likely to be married (74.2 percent of fathers versus 58.6 percent of mothers) and were also much more likely to be working full time (73.9 percent of fathers versus 33.6 percent of mothers). These differences imply that outreach efforts to enroll eligible uninsured mothers and fathers may require targeted approaches that account for differences in family structure and employment status.
Uninsured custodial fathers were also less likely to have incomes at or below 138 percent of FPL than were uninsured custodial mothers (48.9 percent versus 61.1 percent), which suggests that Medicaid and Marketplace expansions are likely to play somewhat different roles for these groups of mothers and fathers. In addition, from 1997 to 2014, low-income fathers (those with incomes at or below 138 percent of FPL) consistently had uninsurance rates that were roughly 10 percentage points higher than those of low-income mothers. Although this gap likely reflects a combination of more limited Medicaid eligibility and lower Medicaid participation among low-income fathers, it also demonstrates that outreach to Medicaid-eligible fathers may require additional attention.
As indicated earlier, this brief focuses exclusively on custodial fathers. However, the ACA has also changed the coverage options available for noncustodial fathers, which could affect both their own financial well-being and the health and health insurance coverage of their children.
Our earlier work found that children have also experienced declines in uninsurance under the ACA, especially those living in low- and moderate-income families (Gates et al. 2016). Because many uninsured children were already eligible for insurance coverage before 2013, it is possible that the progress in covering both mothers and fathers has contributed to the continued reduction in children’s uninsurance rates. Thus, it will be important to continue to monitor family coverage patterns for parents—including noncustodial parents, where possible—and their children to fully assess coverage changes under the ACA.
- We used version 6.12 of the Integrated Health Interview Series, published online by the Minnesota Population Center, University of Minnesota and State Health Access Data Assistance Center, accessed April 7, 2016, http://www.ihis.us.↩
Davidoff, Amy, Lisa Dubay, Genevieve M. Kenney, and Alshadye Yemane. 2003. “The Effect of Parents’ Insurance Coverage on Access to Care for Low-income Children.” Inquiry 40: 254–68.
Dubay, Lisa, and Genevieve M. Kenney. 2003. “Expanding Public Health Insurance to Parents: Effects on Children’s Coverage under Medicaid.” Health Services Research 38 (5): 1283–301.
Gates, Jason A., Michael Karpman, Genevieve M. Kenney, and Stacey McMorrow. 2016. Uninsurance among Children, 1997–2015: Long-Term Trends and Recent Patterns. Washington, DC: Urban Institute.
Karpman, Michael, Jason A. Gates, Genevieve M. Kenney, and Stacey McMorrow. 2016a. How Are Moms Faring under the Affordable Care Act? Evidence through 2014. Washington, DC: Urban Institute.
Karpman, Michael, Jason A. Gates, Genevieve M. Kenney, and Stacey McMorrow. 2016b. Uninsurance among Parents, 1997–2014: Long-Term Trends and Recent Patterns. Washington, DC: Urban Institute.
Karpman, Michael, Jason A. Gates, Stacey McMorrow, and Genevieve M. Kenney. 2016. Uninsurance among Parents of Young Children, 1997–2014: Long-Term Trends and Recent Patterns. Washington, DC: Urban Institute.
About the Authors
Jason A. Gates is a research assistant in the Health Policy Center at the Urban Institute. His current work focuses on the effects of expanding coverage on low-income populations, children, and families. His expertise is with the National Health Interview Survey, and he has experience analyzing the American Community Survey and Behavioral Risk Factor Surveillance System. He received his BA from Dickinson College.
Stacey McMorrow is a health economist with extensive experience using quantitative methods to study the factors that affect individual health insurance coverage and access to care as well as the impacts of state and national health reforms on employers and individuals. Her current work uses the Affordable Care Act and past Medicaid expansions to explore the effects of expanding insurance coverage on access to care, service use, and health outcomes for various populations. Through this and other work, McMorrow has developed substantial expertise in analyzing data from several federal surveys, including the National Health Interview Survey and the Medical Expenditure Panel Survey. Other research interests include the role of community health centers and safety net providers under health reform, receipt of preventive and reproductive health services among women, barriers to care for low-income children, and the market-level effects of insurance expansions. McMorrow received her PhD in health economics from the University of Pennsylvania in 2009.
Genevieve M. Kenney is a senior fellow and codirector of the Health Policy Center at the Urban Institute. She has been conducting policy research for over 25 years and is a nationally renowned expert on Medicaid, the Children's Health Insurance Program (CHIP), and broader health insurance coverage and health issues facing low-income children and families. Kenney has led a number of Medicaid and CHIP evaluations and has published more than 100 peer-reviewed journal articles and scores of briefs on insurance coverage, access to care, and related outcomes for low-income children, pregnant women, and other adults. In her current research, she is examining implications of the Affordable Care Act, how access to primary care varies across states and insurance groups, and emerging policy questions related to Medicaid and CHIP. She received a master’s degree in statistics and a PhD in economics from the University of Michigan.
Michael Karpman is a research associate in the Health Policy Center at the Urban Institute. His work focuses on the implications of the Affordable Care Act, including quantitative analysis related to health insurance coverage, access to and affordability of health care, use of health care services, and health status. This work includes efforts to help coordinate and analyze data from the Urban Institute’s Health Reform Monitoring Survey. Before joining Urban in 2013, Karpman was a senior associate at the National League of Cities Institute for Youth, Education, and Families. He received his MPP from Georgetown University.
This brief was funded by the David and Lucile Packard Foundation and an anonymous donor. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission.
Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute’s funding principles is available at www.urban.org/support.
The authors are grateful to Patricia Barnes and the staff at the National Center for Health Statistics Research Data Center for their help with this study. The views expressed are those of the authors and should not be attributed to the Research Data Center, the National Center for Health Statistics, the Centers for Disease Control and Prevention, or to the Urban Institute, its trustees, or its funders. The authors also appreciate the helpful suggestions of Stephen Zuckerman.