National Health Interview Survey (NHIS) data show that the share of nonelderly parents without health insurance fell from 20.0 percent in 2013 to 16.4 percent in 2014 following implementation of the major coverage provisions of the Affordable Care Act, or ACA (Karpman, Gates, Kenney, et al. 2016). The estimated uninsurance rate for parents in 2014 is lower than the uninsurance rate in 1997, when major changes to the NHIS health insurance questions and other aspects of this survey were made.
Coverage expansions for parents that took place before the ACA’s passage were associated with reductions in uninsurance for children (Aizer and Grogger 2003; Dubay and Kenney 2003; Ku and Broaddus 2000), and children are more likely to visit medical providers and receive well-child visits when their parents are insured (Davidoff et al. 2003; Gifford, Weech-Maldonado, and Farley Short 2005). In addition, children who have a usual source of care are more likely to have unmet health care needs if their parents do not have a usual source of care, suggesting that parents’ connection to health insurance and the health care system have implications for their children’s health care access (DeVoe et al. 2011). The ACA’s Medicaid expansion and new premium tax credits for purchasing Marketplace coverage could narrow the gap in uninsurance between young children and their parents, which has been driven largely by the higher income thresholds at which children are eligible for public coverage relative to such thresholds for parents.
For this analysis, we used NHIS data from 1997 to 2014 to examine long-term trends in uninsurance for nonelderly parents of young children (age 5 and under); differences by coverage status in access to health care, service use, and health care affordability in 2014;1 and changes in the composition of uninsured parents of young children and uninsurance rates for various subgroups of these parents between 2013 and 2014. This analysis supplements findings from and uses the same methods as a related brief focused on all parents ages 19 to 64 who are living with their dependent children (Karpman, Gates, Kenney, et al. 2016).2
We find that the share of parents with young children who did not have health insurance increased from 19.4 percent in 1997 to 22.8 percent in 2013 and then fell to 18.8 percent in 2014 (figure 1). Changes in uninsurance among parents of young children have largely tracked changes in the overall uninsurance rate for parents. However, the uninsurance rate for parents of young children has been consistently higher than the uninsurance rate among all parents, in part because young children are more likely to live in low-income families than older children (Jiang, Ekono, and Skinner 2015). As of 2014, 5.6 million parents of young children were uninsured (data not shown).
Uninsured parents of young children are less likely to use the health care system than their insured peers (figure 2). Only 39.4 percent of parents who were uninsured for the entire year before the 2014 survey have a usual source of health care outside of a hospital emergency department compared with 89.3 percent of full-year insured parents. Uninsured parents are less than half as likely as insured parents to have seen a general doctor or dentist in the past year and are much less likely to have seen a specialist (4.9 percent versus 18.5 percent).
Uninsured parents of young children also experience more health care affordability problems than insured parents; 19.5 percent of the uninsured had delayed health care because of the cost and 41.9 percent had gone without care for affordability reasons compared with 3.4 percent of insured parents who delayed care because of cost and 11.7 percent of insured parents who had an unmet need for care (figure 3). Uninsured parents were over twice as likely as insured parents to report problems paying family medical bills and being unable to pay medical bills at all in the past year. Differences between uninsured and insured parents in health care access, service use, and affordability were consistent, though typically somewhat smaller, after controlling for their observable characteristics (data not shown).
Table 1 shows changes in the characteristics of uninsured parents of young children between 2013 and 2014. A larger share of uninsured parents of young children were noncitizens in 2014 (43.6 percent) than in 2013 (37.7 percent), and there were increases in the shares of uninsured parents who were Hispanic (48.2 percent to 52.2 percent) or had at least one noncitizen in the family. A smaller share of the uninsured had some college education short of a bachelor’s degree in 2014 relative to 2013. There were no statistically significant changes in the disproportionate share of uninsured parents with young children who were mothers (50.3 percent in 2014), ages 19 to 25 (20.4 percent), not working (35.4 percent), or living in the South or West (73.1 percent). All but 3.6 percent of uninsured parents of young children have incomes below 400 percent of the federal poverty level, suggesting many may be eligible for financial assistance to obtain coverage under the ACA.
Table 2 shows that between 2013 and 2014, uninsurance fell significantly for most subgroups of parents of young children, with the largest declines among parents that historically have had higher uninsurance rates, such as those with incomes below 400 percent of the federal poverty level, Hispanic parents, and parents in the South and West. However, uninsurance rates for many of these groups of parents remained disproportionately high in 2014: 36.3 percent of those with incomes below 138 percent of the federal poverty level, 40.4 percent of Hispanic parents, and 24.8 percent of those in the South were uninsured. Other groups with young children that continue to have high uninsurance rates are noncitizen parents (47.9 percent), parents with at least one noncitizen in the family (42.2 percent), parents with less than a high school education (47.0 percent), young parents ages 19 to 25 (26.3 percent), parents who are not working full time, and parents who are in less than excellent or very good health.
Together, these results indicate that the uninsurance rate for parents of young children, including many of the most vulnerable parents from minority backgrounds or with low incomes, fell sharply following implementation of the ACA’s key coverage provisions. An improving economy and other factors may also have contributed to these coverage gains. However, nearly one in five parents of young children remained uninsured in 2014, and uninsurance rates were disproportionately high among parents who had lower incomes or who were Hispanic, young, or not citizens. The results also show that parents without coverage are much less likely to use the health care system, more likely to go without needed care because of the cost, and more likely to have problems paying medical bills, all of which could jeopardize their health and financial well-being and negatively affect their children. Given the small share of young children who are uninsured (Karpman, Gates, McMorrow, et al. 2016), further reductions in uninsurance among parents may depend on outreach to those whose children are covered and who are themselves eligible for Medicaid or subsidized Marketplace coverage. In addition to targeted outreach and enrollment efforts, it will also be important both to assess how many uninsured parents of young children remain ineligible for financial assistance because they are undocumented immigrants, because their states have not expanded Medicaid, or because they have an offer of employer-based coverage that disqualifies them from receiving premium tax credits for Marketplace coverage and to consider policies to close those gaps.
- For the analysis of differences in access, service use, and affordability, we focus on the insurance coverage status of parents of young children in the year before the survey. We analyze differences in these measures between parents of young children who were insured for the entire previous year and those who were uninsured for the entire previous year.↩
- We focus on custodial parents—those living in a household with their dependent children age 18 and under—because noncustodial parents cannot be identified on the NHIS.↩
Aizer, Anna, and Jeffrey Grogger. 2003. “Parental Medicaid Expansions and Health Insurance Coverage.” Working Paper No. 9907. Cambridge, MA: National Bureau of Economic Research.
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.
DeVoe, Jennifer E., Carrie J. Tillotson, Lorraine S. Wallace, Heather Angier, Matthew J. Carlson, and Rachel Gold. 2011. “Parent and Child Usual Source of Care and Children’s Receipt of Health Care Services.” Annals of Family Medicine 9 (6): 504–13.
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.
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.
Jiang, Yang, Mercedes Ekono, and Curtis Skinner. 2015. Basic Facts about Low-Income Children: Children Under 18 Years, 2013. New York: National Center for Children in Poverty.
Karpman, Michael, Jason Gates, Genevieve M. Kenney, and Stacey McMorrow. 2016. Uninsurance among Parents, 1997–2014: Long-Term Trends and Recent Patterns. Washington, DC: Urban Institute.
Karpman, Michael, Jason Gates, Stacey McMorrow, and Genevieve M. Kenney. 2016. Uninsurance among Young Children, 1997–2015: Long-Term Trends and Recent Patterns. Washington, DC: Urban Institute.
Ku, Leighton, and Matthew Broaddus. 2000. The Importance of Family-Based Insurance Expansions: New Research Findings about State Health Reforms. Washington, DC: Center on Budget and Policy Priorities.
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.
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 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.
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.