The key health insurance coverage provisions of the Affordable Care Act (ACA) were designed to reduce uninsurance primarily among nonelderly adults, including parents living with dependent children. In the years leading up to the ACA’s passage in 2010, the share of adults without coverage had been rising steadily as uninsurance among children had been falling (Rosenbaum and Kenney 2014). Early estimates from the Urban Institute’s Health Reform Monitoring Survey (HRMS) show a break in this trend following implementation of the ACA’s key coverage provisions, a period when the uninsurance rate for adults fell steeply (Karpman, Long, and Zuckerman 2016). HRMS data indicate that the gap in uninsurance between parents and children narrowed between September 2013 and March 2015 (Karpman et al. 2015). In addition, related work shows that mothers living with dependent children had substantial declines in their uninsurance rates between 2013 and 2014 (Karpman, Gates, Kenney et al. 2016).
The health insurance provisions of the ACA, including broader eligibility for Medicaid, tax credits to purchase health plans through the new health insurance Marketplaces, insurance market reforms that prohibit denials of coverage or premium rates based on pre-existing conditions, and a tax penalty for not having coverage, have the potential to improve not only parents’ access to health insurance coverage and care and their financial stability but also their children’s coverage and well-being. Several studies have found that previous coverage expansions for parents were associated with increased coverage for children (Aizer and Grogger 2003; Dubay and Kenney 2003; Ku and Broaddus 2000) and suggest that children have greater access to care when their parents are insured (Davidoff et al. 2003; Guendelman and Pearl 2004; Gifford, Weech-Maldonado, and Farley Short 2005).
In this brief, we use data from the National Health Interview Survey (NHIS) to examine trends in uninsurance for custodial parents between 1997 and 2014, the most recent full year for which NHIS data on parents’ coverage status are available. We focus on custodial parents living in a household with their dependent children age 18 and under because noncustodial parents are not identifiable on the NHIS. We provide estimates of uninsurance among custodial parents (subsequently referred to as parents) overall and among those with family incomes above and below 138 percent of the federal poverty level (FPL), which is the new Medicaid eligibility level established for adults under the ACA. As of June 2016, 31 states and the District of Columbia had expanded Medicaid to 138 percent of FPL for parents and childless adults. We also explore differences in health care access, service use, and health care affordability between insured parents and the remaining uninsured as of 2014, changes in the characteristics of uninsured parents between 2013 and 2014, and uninsurance rates for various subgroups of parents in 2013 and 2014. This analysis provides context for recent changes in coverage among parents and offers new information on the access and affordability challenges facing both insured and uninsured parents. Related briefs examine outcomes under the ACA separately for mothers, fathers, and parents of young children (Gates, McMorrow, Kenney et al. 2016; Karpman, Gates, Kenney et al. 2016; Karpman, Gates, McMorrow et al. 2016).
Data and Methods
This analysis uses nationally representative data for the civilian noninstitutionalized population from the NHIS, which is conducted annually by the National Center for Health Statistics. The NHIS consists of three main sections: the family core, sample adult core, and sample child core. Questions on the family core are answered for each member of the family by a knowledgeable adult and include basic demographic information, educational attainment, employment status, general health status, and detailed information on health insurance coverage. Questions on the sample child and sample adult core are asked of one random child age 17 or under (if present; excluding emancipated minors) and one random adult over age 17 in each family; 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 use 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 counts and rates for parents ages 19 to 64. For our analysis, we construct health insurance units (HIUs) to better reflect the units used to determine health insurance eligibility relative to the broader family definition available on the NHIS. Hereafter, we use the terms “family” and “HIU” interchangeably, but all analysis of changes in uninsurance by income uses the HIU as the relevant unit for determining income as a percentage of FPL. Parents are defined as adults ages 19 to 64 who were identified as the mother or father of a child age 18 or under living in their household. Based on this definition, in 2014 the NHIS included data on approximately 25,000 parents from the family core file and 10,000 parents from the sample adult file. Parents are considered uninsured if they do not have coverage through private health insurance, Medicare, Medicaid, military health insurance, or other public insurance at the time of the survey. We examine changes between 2013 and 2014 in the composition of uninsured parents and rates of uninsurance among parents by 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); sex; health status (excellent or very good, good, or fair or poor); disability status (has any activity limitation or has no activity limitation); citizenship status; HIU income (138 percent of FPL or less, above 138 percent and 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 graduated college); HIU citizenship (any noncitizen in HIU or no noncitizen in HIU); census region (Northeast, Midwest, South, or West); and state Medicaid expansion status as of May 2014, indicating whether expanded eligibility was available for the majority of the year.
We also compare health care access, service use, and affordability experiences for uninsured parents in 2014 to those for insured parents. For these analyses, we define uninsured parents as those who lacked health insurance coverage for all of the previous 12 months and insured parents as those who had health insurance coverage for all of the previous 12 months. We construct four measures of access and service use including having a usual source of care other than the emergency department, having seen a general doctor in the past 12 months, and indicators for having seen a specialist and a dentist in the past 12 months. We also generate four measures of affordability. Using information reported by a family respondent, we identify parents whose families had trouble paying medical bills in the past 12 months as well as a subset whose families were unable to pay their medical bills. We also measure the share of parents who had any unmet need because of affordability in the past 12 months (including unmet needs for medical care, dental care, prescription drugs, eyeglasses, mental health care, specialist care and follow-up care), and the share of parents for whom medical care was delayed because of the cost in the past 12 months. When assessing differences in these measures between uninsured and insured parents, we adjust for individual and HIU characteristics including age, sex, race/ethnicity, education level, work status, HIU income, citizenship, region, reported health status, and activity limitations.
Changes in Uninsuracne among Parents
Although uninsurance among parents rose and fell with the fluctuations of the economy between 1997 and 2013, on balance their uninsurance rate drifted upward 3.1 percentage points, increasing from 16.9 to 20.0 percent (figure 1). In contrast, between 2013 and 2014, the uninsurance rate for parents fell 3.6 percentage points, a decline that was more than three times larger than any other year-to-year change since 1997. Though some of the decline between 2013 and 2014 may be caused by the economic recovery, the uninsurance rate for parents had fallen only 1 percentage point between its peak in 2010 (21.0 percent) and 2013 (20.0 percent), just before implementation of the ACA’s major coverage provisions.
Figure 2 shows that uninsurance fell among parents with family incomes above and below 138 percent of FPL between 1997 and 2014. There was a larger percentage-point decline in uninsurance for lower-income parents, from 43.4 percent to 35.7 percent, compared with the decline from 10.3 percent to 9.8 percent for parents with incomes above 138 percent of FPL. In 2014, however, lower-income parents remained nearly four times as likely to be uninsured as moderate- and higher-income parents, a ratio that has decreased only slightly since 1997.
Approximately 2.6 million parents gained coverage between 2013 and 2014, including nearly 1 million parents with incomes at or below 138 percent of FPL and nearly 1.7 million parents with incomes above that level (figure 3). More than 11 million parents remained uninsured in 2014, and parents with incomes below 138 percent of FPL constituted more than 55 percent of remaining uninsured parents, a slightly higher share than in 1997 or 2013.
Composition of Parents Remaining Uninsured in 2014
The characteristics of uninsured parents shifted between 2013 and 2014. A greater proportion of the remaining uninsured were noncitizens in 2014 relative to 2013 (40.2 percent versus 35.7 percent), potentially reflecting the exclusion of undocumented noncitizens from the ACA’s new coverage options or a lack of awareness of new coverage options among lawfully present noncitizens (table 1). Nearly half (48.9 percent) of parents who were uninsured in 2014 were Hispanic; this is not statistically different from the share who were Hispanic in 2013. More than 40 percent of uninsured parents had at least one noncitizen in the family. Between 2013 and 2014, the remaining uninsured parents became increasingly concentrated in states that chose not to expand Medicaid, with 59.4 percent residing in those states in 2014.
Parents who were uninsured in 2014 were also slightly less likely to be in fair or poor health (8.9 versus 10.6 percent) or to have a limitation on their activities (3.7 versus 4.6 percent) than those who were uninsured in 2013, suggesting that uninsured parents with health problems or disabilities may have been more likely to seek coverage under the ACA than parents in better health. The regional composition of uninsured parents also changed, with more uninsured parents in the South (50.0 percent versus 46.6 percent) and fewer in the West (23.8 percent versus 27.5 percent) in 2014 than in 2013. In addition, a somewhat smaller share of uninsured parents had some college education short of a bachelor’s degree in 2014 compared with 2013. Although the share of uninsured parents with incomes at or below 138 percent of FPL increased, there was a moderate decrease in the share of uninsured parents with incomes between 138 and 400 percent of FPL, the income range targeted by the ACA’s premium tax credits for Marketplace coverage. In 2014 as in 2013, nearly 95 percent of uninsured parents had incomes below 400 percent of FPL.
Other characteristics of uninsured parents remained stable between 2013 and 2014. For instance, the age and racial/ethnic distributions and patterns in employment status of uninsured parents have not changed. Over two-thirds (67.2 percent) of parents who were uninsured in 2014 worked either full-time or part-time.
Variation in Uninsured Rates among Parents
Between 2013 and 2014, the uninsurance rate fell for every demographic, socioeconomic, and geographic subgroup of parents examined except for those in the Northeast, where parents already had a lower uninsurance rate than their peers in other regions (table 2). The largest declines in uninsurance were found among parents with low or moderate incomes: a 6.2 percentage-point decrease for parents with incomes at or below 138 percent of FPL and a 5.0 percentage-point decrease for parents with incomes between 138 and 400 percent of FPL. Parents with incomes above 400 percent of FPL continued to have the lowest uninsurance rate of any income group at 2.6 percent compared with 16.2 percent for moderate-income parents and 35.7 percent for lower-income parents. Uninsurance rates also fell most sharply among parents with other characteristics associated with low or moderate incomes, including those who were ages 19 to 25 (5.6 percentage points), were non-Hispanic black (5.0 percentage points), were Hispanic (6.9 percentage points), were in fair or poor health (6.7 percentage points), or had less than a high school education (6.0 percentage points).
Uninsurance rates in 2014 varied significantly by age, race/ethnicity, gender, and citizenship status. Parents were more than twice as likely to be uninsured if they were ages 19 to 25 (26.2 percent) than if they were ages 50 to 64 (10.9 percent). Hispanic parents continued to have the highest uninsurance rate of any racial/ethnic group (36.5 percent), over twice as high as the uninsurance rate for non-Hispanic black parents (15.3 percent) and over three times as high as the rate for non-Hispanic white parents (9.8 percent). Fathers had higher uninsurance rates than mothers (17.3 percent versus 15.7 percent), and nearly half of noncitizen parents were uninsured (46.4 percent) compared with 11.4 percent of parents who were citizens.
Parents who reported being in excellent or very good health were less likely to be uninsured (14.0 percent) than those in worse health. However, parents with at least one activity limitation were less likely to be uninsured than parents with no activity limitations (11.2 percent versus 16.7 percent), perhaps because of Medicaid’s historic role in providing coverage for low-income individuals with disabilities.
Despite coverage gains in the South and West, these two regions continued to have higher uninsurance rates for parents than the Northeast (21.6 percent and 16.3 percent versus 10.2 percent, respectively). Not surprisingly, parents remain more likely to be uninsured if they do not work full time, have lower educational attainment, or live in families with at least one noncitizen.
Access, Service Use, and Afordability for Uninsured Parents
Parents who were uninsured for all 12 months before the 2014 survey were more likely to report problems affording health care than parents who were insured for all 12 months (figure 4). They were six times as likely to report delaying care because of the cost, over twice as likely to report problems paying family medical bills or being unable to pay bills at all, and more than three times as likely to say they had an unmet need for health care because it was not affordable.
Parents without coverage were also less likely to report having a usual source of care than insured parents (44.9 percent versus 91.8 percent) and had lower use of health care services (figure 5). Insured parents were more likely than their uninsured peers to have seen a general doctor, dentist, or specialist in the previous 12 months. These differences in health care affordability, access, and service use persist even when we account for differences in the characteristics of insured and uninsured parents. Figure 6 shows that, controlling for observable characteristics of the parents and their families, uninsured parents were 19.8 percentage points more likely to delay care because of the cost, 28.3 percentage points more likely to go without care for affordability reasons, and 12.4 percentage points more likely to have problems paying family medical bills. Similarly, figure 7 shows that uninsured parents were 41.9 percentage points less likely to have a usual source of care and continued to be less likely than insured parents to have seen a general doctor, a dentist, or a specialist in the previous year, although the differences between insured and uninsured parents are somewhat smaller with the regression adjustment.
The share of nonelderly parents without health insurance increased from 16.9 percent in 1997 to 20.0 percent in 2013, just before the implementation of the ACA’s Medicaid expansion, Marketplaces, and several of the law’s major insurance market reforms. Between 2013 and 2014, the uninsurance rate for parents fell 3.6 percentage points, representing a decline in the uninsured population of 2.6 million. A separate analysis of NHIS data shows that children have also experienced declines in uninsurance under the ACA (Gates, Karpman, Kenney et al. 2016). Although these coverage improvements for parents and children coincide with the implementation of the ACA’s major coverage provisions, some of these gains may also be attributed to other changes, such as an improving economy.
Uninsurance fell between 2013 and 2014 for almost every subgroup of parents we examined with particularly sharp declines for low- and moderate-income parents, those in poor or fair health, those living in families with noncitizens, and Hispanic parents; simultaneously, those same groups still had high rates of uninsurance in 2014 compared with their peers. Over one-third of parents with incomes at or below 138 percent of FPL and over one-third of Hispanic parents did not have coverage, and uninsurance rates were relatively high among parents who were young, less educated, not working, or in less than very good health. Some parents, such as undocumented immigrants and parents with incomes below 100 percent of FPL in states that have not expanded Medicaid, continue to have few viable pathways to coverage. In many of the largest nonexpansion states, parents must have very low incomes to qualify for Medicaid. For instance, parents seeking Medicaid are not eligible unless their incomes are less than 39 percent of FPL in Virginia, 37 percent of FPL in Georgia, 34 percent of FPL in Florida, and 18 percent of FPL in Texas.2 Moreover, even among parents who are likely to have access to financial assistance, many do not think they can afford coverage and often face difficulties paying for such basic needs as food and housing (Karpman, Gates, and Kenney 2016).
Parents who do not have coverage are less likely than insured parents to have a usual source of care and to see doctors and dentists and are more likely to forgo care for affordability reasons and have problems paying family medical bills. These differences in access, service use, and affordability remain after controlling for the demographic and socioeconomic characteristics of parents. Uninsured parents’ disconnection from the health care system could have adverse spillover effects for children, who may be less likely to get needed health care and more likely to experience hardships if their parents’ health or finances deteriorate.
Given that 55 percent of uninsured parents had incomes below 138 percent of FPL and were disproportionately likely to live in the South and West in 2014, further reductions in uninsurance among parents may depend on additional state expansions of Medicaid, increased take up of Medicaid and Marketplace coverage among those who are eligible, and on tackling affordability issues facing noncitizen parents. Targeted outreach to young parents and Hispanic parents may also be needed to further raise awareness of options for obtaining coverage.
Moreover, even as coverage continues to expand, 14.5 percent of parents who had coverage for a full year before the 2014 survey reported problems paying medical bills, and 13.1 percent reported going without care because it was not affordable in the previous year. Underinsurance in the employer and nongroup markets, driven by increasing deductibles and other forms of cost sharing, continues to pose challenges, particularly for those with low incomes or high health needs (Collins et al. 2015). Further, provider capacity may not be sufficient to support the influx of newly insured in all areas. Thus, additional monitoring of access and affordability is critical to ensure that parents with health insurance coverage are able to access needed care and are receiving adequate protection from high medical bills.
- “Integrated Health Interview Series: Version 6.12” 2016, Minnesota Population Center, University of Minnesota and State Health Access Data Assistance Center, accessed April 7, 2016, http://www.ihis.us.↩
- “Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level,” Kaiser Family Foundation, last updated January 1, 2016, http://kff.org/health-reform/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/.↩
Aizer, Anna, and Jeffrey Grogger. 2003. “Parental Medicaid Expansions and Health Insurance Coverage.” Working Paper No. 9907. Cambridge, MA: National Bureau of Economic Research.
Collins, Sara R., Petra W. Rasmussen, Sophie Beutel, and Michelle M. Doty. 2015. The Problem of Underinsurance and How Rising Deductibles Will Make It Worse. New York: Commonwealth Fund.
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): 1283–1301.
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.
Gates, Jason A., Stacey McMorrow, Genevieve M. Kenney, and Michael Karpman. 2016. How Are Custodial Fathers Faring under the Affordable Care Act? Evidence through 2014. Washington DC: Urban Institute.
Gifford, Elizabeth J., Robert Weech-Maldonado, and Pamela Farley Short. 2005. “Low-Income Children’s Preventive Services Use: Implications of Parents’ Medicaid Status.” Health Care Financing Review 26 (4): 81–94.
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Karpman, Michael, Jason A. Gates, and Genevieve M. Kenney. 2016. QuickTake: Further Reducing Uninsurance among Parents Will Require Tackling Affordability Concerns. Washington, DC: Urban Institute.
Karpman, Michael, Genevieve M. Kenney, Nathaniel Anderson, and Sharon K. Long. 2015. QuickTake: The Gap in Uninsurance Rates for Parents and Children Narrowed Between September 2013 and March 2015. Washington, DC: Urban Institute.
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About the Authors
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.
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.
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 published over 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.
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.
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.