This brief uses data collected in 2008 and 2009 from the U.S. Census Bureau\u27s American Community Survey (ACS) to examine changes in overall insurance coverage rates, as well as changes in types of coverage, and differences by region, state, and place type. The data show that together with new and more inclusive parameters for children\u27s health insurance coverage, rates of children\u27s health insurance have grown during the final year of the recession. Authors Jessica Bean and Michael Staley of the Carsey Institute discuss the complex factors contributing to the shift from private to public health insurance among children. The authors conclude that, because those who have health insurance are healthier overall and, more importantly, because healthy children are more likely to become healthy adults, focusing on covering eligible children should remain at the forefront of the nation\u27s agenda

Bean, Jessica A.

Staley, Michael J.

English

UNH Scholars' Repository

CARSEYI N S T I T U T EISSUE BRIEF NO. 34SUMMER 2011		 Key	Findings• Health insurance coverage among children increased 1.4 percentage points from 2008 to 2009 in the United States, with the most growth in central cities and rural places.• The Northeast continues to have the highest rate of coverage, with more than 95 percent of children covered. The South has the lowest coverage rate, at 89 percent.• Forty-three states plus Washington, DC and Puerto Rico had a significant increase in the number of children covered by public health insurance.• Forty states saw a decrease in private health insurance coverage for children. • Children in Midwestern central cities experienced the largest shift from private to public insurers in 2009; private insurance coverage fell 4.3 percentage points, while public coverage rose by 6.5 percentage points.Total	Children	Covered	by	Health	Insurance		Increased	in	2009	Significant	Shifts	from	Private	to	Public	Plans	in	Many	States	J E S S I C A 	 A . 	 B E AN 	 AND 	M I CHA E L 	 J . 	 S T A L E YSince	the	introduction	of	Medicaid	in	the	1960s,	the	per-centage	of	young	Americans	with	health	insurance	has	steadily	increased.1	Ensuring	that	children	are	covered	remains	at	the	forefront	of	national	policy	concerns.	Presi-dent	Obama	signed	the	Children’s	Health	Insurance	Program	Reauthorization	Act	(CHIPRA)	of	2009	in	February	of	that	year.2	In	addition,	the	President	sent	a	memorandum	to	state	health	officials	requesting	that	previous	restrictions	on	pro-viding	health	insurance	to	children	be	repealed3	in	order	to	cover	additional	uninsured	children	in	a	struggling	economy.This	brief	uses	data	collected	in	2008	and	2009	from	the	U.S.	Census	Bureau’s	American	Community	Survey	(ACS)—the	most	recent	data	available—to	examine	changes	in	overall	insurance	coverage	rates,	increases	in	public	insurance,	and	differences	by	region,	state,	and	place	type.	The	data	show	that	together	with	new	and	more	inclusive	parameters	for	children’s	health	insurance	coverage,	rates	of	children’s	health	insurance	have	grown	during	the	final	year	of	the	recession.	Overall,	coverage	among	children	rose	1.4	percentage	points	in	that	one-year	period.	In	the	context	of	this	overall	growth,	however,	there	were	some	important	shifts	in	the	types	of	insurance	coverage	reported.	For	example,	those	reporting	private	health	insurance	decreased	by	2.6	percentage	points,	while	public	insurance	rates	grew	by	4.9	percentage	points	over	that	year.	Coverage	Increases	Between		2008	and	2009Of	the	areas	examined	(all	fifty	states	plus	Washington,	DC	and	Puerto	Rico),	twenty-nine	experienced	significant	in-creases	in	children’s	health	insurance	coverage.Health	insurance	coverage	among	children	increased	in	all	regions	from	2008	to	2009.	The	largest	gains	in	coverage	were	realized	in	the	regions	that	had	the	lowest	coverage	rates	in	2008,	namely	the	South	and	West	(see	Table	1).	Regions	with	higher	initial	coverage	(the	Northeast	and	Midwest)	experi-enced	smaller	gains	in	coverage.While	rural,	suburban,	and	central	city	areas	all	experienced	significant	growth	in	coverage	between	2008	and	2009,	growth	was	highest	in	rural	places	and	central	cities.	Rural	places	and	central	cities,	with	traditionally	lower	coverage	than	suburban	places,4	have	experienced	the	largest	increases	in	coverage.REVISED  November 2011*Table 1. Percentage Point Change in Health Insurance Coverage for  Persons Under Age 18, 2008-2009N/A= Not applicable.1. The bold and faded font indicates statistical significance (p<0.05).2. Levels of urbanization are defined as follows: Rural consists of American Community Survey geographic components “not in metropolitan or micropolitan statistical area” and “in micropolitan statistical area”; suburban includes “in metropolitan statistical area—not in principal city” and central city includes “in metropolitan statistical area—in principal city.”Source: American Community Survey, 2008 and 2009		 2	 C A R S E Y 	 I N S T I T U T EPublic	Insurance	Increases	While	Private	Insurance	Coverage	DeclinesMore	children	were	covered	in	2009	than	in	2008,	and	though	private	insurance	rates	are	declining	and	public	rates	are	increasing,	it	is	not	at	the	same	rate.	Increases	in	public	insurance	are	likely	due	to	the	enrollment	of	children	whose	parents	experienced	job	loss	or	changes	to	benefits	(result-ing	in	loss	of	adequate	insurance	coverage)	and	because	of	increasing	participation	rates	among	children	who	were	previously	uninsured.	In	other	words,	not	all	of	the	increases	in	public	insurance	are	due	to	children	transitioning	from	private	insurance—a	phenomenon	known	as	“crowd	out.”5	This	is	most	evident	in	the	dark	shaded	states	on	the	map	(see	Figure	1),	where	public	insurance	has	increased	with	no	discernible	declines	in	private	insurance.Understanding	Trends	in	Children’s	Health	Insurance	Because	health	insurance	data	from	the	ACS	first	became	available	in	2008,	it	is	not	possible	to	examine	these	changes	in	a	broader	historical	context.7	However,	these	increases	in	coverage	and	shifts	in	insurance	type	are	large	enough	to	signify	that	these	data	capture,	at	least	in	part,	an	interesting	trend	in	children’s	coverage.Figure 1. Change in Children’s Health Insurance Coverage Type, 2008-2009Source: U. S. Census Bureau, American Community Survey, 2008 and 2009In	forty-three	states,	plus	Washington,	DC	and	Puerto	Rico,	significant	increases	in	the	percentage	of	publicly	insured	children	were	reported,	and	in	twenty	of	those	states	and	Washington,	DC,	the	increase	was	5	percent-age	points	or	more.	All	place	types	(rural,	suburban,	and	central	city),	in	all	regions,	reported	significant	increases	in	public	insurance.	Private	insurance	decreased	in	forty	states,	though	only	one	of	these	states	(Nebraska)	reached	a	decline	as	high	as	5	percentage	points.	Rural,	suburban,	and	central	city	areas	in	nearly	all	regions	experienced	declines	in	the	percentage	of	children	covered	by	private	insurance	(the	rural	West	was	the	lone	exception;	see	Table	2).	Case	Study:	Wisconsin	and		BadgerCare	PlusWisconsin	has	one	of	the	highest	rates	of	health	insur-ance	coverage	among	children.	In	2009,	the	state	saw	a	marked	shift	from	private	health	insurance	coverage	to	public	coverage	for	youth:	private	insurance	declined	4.8	percentage	points	and	by	8.1	percentage	points	in	central	cities.	Meanwhile,	public	insurance	increased	substan-tially,	rising	6.4	percentage	points	statewide,	and	10.3	percentage	points	in	central	cities.	Few	other	states	saw	such	drastic	changes	in	both	types	of	insurance	in	2009.Unlike	many	other	states,	where	declining	rates	of	private	health	insurance	coverage	and	rising	rates	of	public	health	coverage	may	be	due	to	downturns	in	the	U.S.	economy,	Wisconsin	has	made	recent	policy	changes	that	contribute	to	these	shifts.	Policymakers	in	Wisconsin	implemented	BadgerCare	Plus	in	2008,	one	of	the	most	comprehensive	public	health	insur-ance	programs	in	the	United	States.	BadgerCare	Plus	provides	health	insurance	coverage	to	parents	and	children	at	or	below	300	percent	of	the	federal	pov-erty	level	(FPL),	and	childless	adults	at	or	below	200	percent	of	the	FPL.	All	children,	regardless	of	income,	are	eligible	for	BadgerCare;	those	who	are	defined	as	low	income	draw	from	federal	CHIP	and	Medicare	funds,	while	those	who	are	not	low	income	are	insured	using	state-only	funds.	Additionally,	BadgerCare	Plus	provides	expanded	eligibility	for	pregnant	women,	offering	coverage	to	those	whose	income	is	at	or	below	300	percent	of	the	FPL	(federal	law	only	allows	Medic-aid	funds	for	pregnant	women	at	or	below	250	percent	of	the	FPL).6	In 2011, the Wisconsin legislature cut $500 million from Medicaid funds in order to reduce their budget deficit. It is too soon to know exactly how these cuts will affect those who are covered under BadgerCare Plus.	 C A R S E Y 	 I N S T I T U T E 	 3Table 2. Percentage Point Change in Public and Private Health Insurance Coverage, for Persons  Under Age 18, 2008-2009N/A= Not applicable.1. The bold and faded font indicates statistical significance (p<0.05).2. Levels of urbanization are defined as follows: Rural consists of American Community Survey geographic components “not in metropolitan or micropolitan statistical area” and “in micropolitan statistical area”; suburban includes “in metropolitan statistical area—not in principal city” and central city includes “in metropolitan statistical area—in principal city.”Source: American Community Survey, 2008 and 2009		 4	 C A R S E Y 	 I N S T I T U T EE NDNOT E S1.	National	Academy	for	State	Health	Policy,	“Children’s	Health	Insurance”	(Washington,	DC:	National	Academy	for	State	Health	Policy,	2011).	Available	at	http://www.nashp.org/childrens-health-insurance.2.	National	Conference	of	State	Legislatures,	“Children’s	Health	Insurance	Program	(CHIP)”	(Washington,	DC:	Na-tional	Conference	of	State	Legislatures,	2010).	3.	Ibid.4.	Marybeth	J.	Mattingly	and	Michelle	L.	Stransky,	“Rural	and	Urban	Children	Have	Lower	Rates	of	Health	Insurance	Coverage	and	Are	More	Often	Covered	by	Public	Plans,”	Is-sue Brief No. 8	(Durham,	NH:	Carsey	Institute,	2011).	5.	“Crowd	out”	can	be	described	as	incidents	when	public	insurance	is	expanded,	leaving	individuals	or	families	to:	(1)	drop	private	coverage	in	lieu	of	public	coverage	that	is	more	affordable	or	has	better	benefits,	(2)	refuse	an	offer	of	private	coverage,	or	(3)	be	subjected	to	actions	by	their	employer,	such	as	increasing	premiums	or	not	providing	coverage,	that	encourage	individuals	to	drop	private	coverage	and	enroll	in	public	plans.	See	Gestur	Davidson,	Lynn	A.	Blewett,	and	Kathleen	Thiede	Call,	“Public	Program	Crowd-Out	of	Pri-vate	Coverage:	What	Are	the	Issues?”	The Synthesis Project,	Research Synthesis Report No. 5, June (Princeton,	NJ:	The	Robert	Wood	Johnson	Foundation,	2004).	6.	Wisconsin	Department	of	Health	Services,	“Badgercare	Plus	For	Pregnant	Women”	(Madison,	WI:	Department	of	Health	Services,	2011).	Available	at	http://www.dhs.wiscon-sin.gov/badgercareplus/pregnantwomen.htm.	The	shift	from	private	to	public	health	insurance	among	children	is	likely	the	result	of	several	complex	(and	perhaps	interrelated)	factors.	For	example,	of	the	fifteen	states	that	had	unemployment	rates	higher	than	the	national	average	in	June	2009,	fourteen	experienced	shifts	from	private	to	public	insurance.	Further,	the	four	states	with	no	significant	shift	from	private	to	public	insurance	(see	Figure	1)	all	had	unem-ployment	rates	lower	than	the	national	average.8	As	nearly	two-thirds	of	the	population	under	age	65	receives	health	insurance	through	an	employment-based	plan,9	this	link	is	not	surprising.	When	people	become	unemployed,	not	only	do	they	lose	their	employment-based	private	insurance,	but,	with	the	loss	of	income,	families	may	become	newly	eligible	for	public	plans.	In	addition,	the	generally	poor	economy	and	expanded	eligibility	for	public	plans	may	also	play	less	direct	roles	in	the	shifting	rates	of	health	insurance	among	children.Though	rising	coverage	rates	are	beneficial	to	children	na-tionwide,	still	just	over	nine	percent	of	children	are	not	covered	by	any	form	of	insurance.	More	than	half	of	these	children	are	eligible	for	coverage	through	Medicaid	or	Children’s	Health	Insurance	Programs	(CHIP);	research	demonstrates	that	most	of	these	eligible	children	come	from	states	with	low	participa-tion	rates	and	are	disproportionately	Hispanic.10	Because	those	who	have	health	insurance	are	healthier	overall11	and,	more	importantly,	because	healthy	children	are	more	likely	to	become	healthy	adults,12	focusing	on	covering	eligible	children	should	remain	at	the	forefront	of	the	nation’s	agenda.	With	the	recent	passage	of	the	Patient	Protection	and	Affordable	Care	Act	(PPACA),	insurance	rates	are	predicted	to	continue	to	rise,	in	part	because	of	new	regulations	in	place	allowing	children	to	remain	on	their	parents’	insurance	until	their	twenty-seventh	birthday	and	making	it	illegal	for	insurance	companies	to	reject	children	with	pre-existing	health	conditions.13	However,	states	will	still	have	a	great	deal	of	latitude	in	implementing	insurance	regulations	for	their	constituencies,	meaning	that	state-to-state	variation	in	rates	of	coverage	will	likely	persist.	It is likely that increasing coverage and shifts from pri-vate to public insurance have continued as the country has continued to move out of the recession, trends likely driven by an infusion of federal dollars and “maintenance of effort” requirements—requirements that preserved eligibility for pub-lic health insurance—which occurred throughout 2009 and 2010.14 The authors will publish 2010 figures later in 2011 as they become available.DataThis	analysis	is	based	on	U.S.	Census	Bureau	estimates	from	the	2008	and	2009	American	Community	Survey	released	in	September	2009	and	2010,	respectively,	and	on	Bureau	of	Labor	Statistics	data	from	2009.	For	more	details	or	information,	please	refer	to	the	U.S.	Census	American	Community	Survey.15	Tables	were	produced	by	aggregating	information	from	detailed	tables	available	on	American	FactFinder	(http://factfinder.census.gov/home/saff/main.html?_lang=en).	These	estimates	are	meant	to	give	perspec-tive	on	children’s	health	insurance,	but	since	they	are	based	on	survey	data,	caution	must	be	used	in	comparing	across	years	or	places,	as	the	margin	of	error	may	indicate	that	seemingly	disparate	numbers	fall	within	sampling	error.16	All	differences	highlighted	in	this	brief	are	statistically	significant	(p<0.05).	 C A R S E Y 	 I N S T I T U T E 	 57.	Data	from	other	sources,	such	as	the	Current	Population	Survey	(CPS),	are	not	directly	comparable	to	ACS	estimates.	For	example,	the	CPS	questionnaire	only	asks	children’s	health	insurance	items	of	children	under	age	15.	8.	Bureau	of	Labor	Statistics,	“The	Employment	Situation:	June	2009,”	News, Bureau of Labor Statistics,	June 2 (Wash-ington,	DC:	U.S.	Department	of	Labor,	2009)	and	Bureau	of	Labor	Statistics,	“Regional	and	State	Employment	and	Unemployment:	June	2009,”	News, Bureau of Labor Statistics,	June 2 (Washington,	DC:	U.S.	Department	of	Labor,	2009).	9.	Agency	for	Healthcare	Research	and	Quality,	“Employer-Sponsored	Health	Insurance:	Trends	in	Cost	and	Access,”	Research in Action, Issue 17	(Washington,	DC:	U.S.	Depart-ment	of	Health,	2004).	10.	Genevieve	M.	Kenney	et	al.,	“Who	and	Where	Are	the	Children	Yet	to	Enroll	in	Medicaid	and	the	Children’s	Health	Insurance	Program?”	Health	Affairs	29	(2010):1920-1929.11.	C.H.	Brouse,	“Gaps	in	Children’s	Health	Insurance:	Mag-nitude,	Consequences,	Barriers,	and	Implications	for	Policy	and	Research,”	International Journal of Health Promotions and Education 48	(2010):	129-133.12.	World	Health	Organisation,	“The	Closing	Gap	in	a	Generation:	Health	Equity	Through	Health,”	Commission on Social Determinants of Health	(Geneva:	World	Health	Organisation,	2008).13.	HealthCare.gov,	“Understand	the	Law:	Provisions”	(Washington,	DC:	U.S.	Department	of	Health	and	Human	Services,	2011).	Available	at	http://www.healthcare.gov/law/provisions/ChildrensPCIP/childrenspcip.html	and	http://www.healthcare.gov/law/provisions/youngadult/index.html.	14.	Center	for	Children	and	Families	and	Center	on	Bud-get	and	Policy	Priorities,	“Holding	the	Line	on	Medicaid	and	CHIP:	Key	Questions	and	Answers	About	Health	Care	Reform’s	Maintenance-of-Effort	Requirements,”	March	26	Memo,	Washington,	DC,	Georgetown	University	Health	Poli-cy	Institute	and	Center	on	Budget	and	Policy	Priorities,	2010.	Available	at	http://www.cbpp.org/files/4-7-10health3.pdf.15.	See	http://factfinder.census.gov/servlet/DTGeoSearchByListServlet?ds_name=ACS_2009_1YR_G00_&_lang=en&_ts=306335491183.	16.	Refer	to	the	Census	Bureau’s	published	tables	for	detailed	margins	of	error.Building	knowledge	for	families	and	communitiesThe	Carsey	Institute	conducts	policy	research	on	vulnerable		children,	youth,	and	families	and	on	sustainable	community		development.	We	give	policy	makers	and	practitioners	timely,		independent	resources	to	effect	change	in	their	communities.	This	work	was	supported	by	the	Annie	E.	Casey	Foundation,	theW.	K.	Kellogg	Foundation,	and	an	anonymous	donor.Huddleston	Hall73	Main	Street	Durham,	NH	03824(603)	862-2821www.carseyinstitute.unh.eduA B OU T 	 T H E 	 AU THOR SJessica	A.	Bean	is	a	research	associate	at	the	Carsey	Institute	(jessica.bean@unh.edu).	Michael	Staley	is	a	research	assistant	at	the	Carsey	Institute	and	a	graduate	student	in	the	Department	of	Sociology	at	the	University	of	New	Hampshire	(michael.staley@unh.edu).AC KNOWL ED GMEN T SThe	authors	thank	Beth	Mattingly,	Curt	Grimm,	Amy	Sterndale,	Michelle	Stransky,	Jessica	Ulrich,	and	Laurel	Lloyd	Earnshaw	at	the	Carsey	Institute	and	Judy	Solomon	at	the	Center	on	Budget	and	Policy	Priorities	for	their	helpful	edits	and	comments.	Special	thanks	to	Barb	Cook	and	Luke	Rogers	at	the	Carsey	Institute	for	creating	the	map.	*This brief was revised to correct underestimates of significant inter-year changes in coverage.		 6	 C A R S E Y 	 I N S T I T U T E

Total children covered by health insurance increased in 2009

https://scholars.unh.edu/cgi/viewcontent.cgi?article=1141&amp;context=carsey

Total children covered by health insurance increased in 2009

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