Objective. To assess the health insurance status of adolescents, the trends in adolescent health care coverage, the demographic and socioeconomic correlates of insurance coverage, and the role that insurance coverage plays in influencing access to and use of health care. Together, the results provide a current and comprehensive profile of adolescent health insurance coverage.
Methods. We analyzed data on 14 252 adolescents, ages 10 to 18 years, included in the 1995 National Health Interview Survey. The survey obtained information on insurance coverage and several measures of access and utilization, including usual source of care, site of the usual source of care, indications of missed or delayed care, and use of ambulatory physician services by adolescents. We conducted multivariate analyses to assess the independent association of age, sex, race, poverty status, family structure, family size, region of residence, metropolitan resident status, and health status on the likelihood of insurance coverage. We conducted bivariate and multivariate analyses to ascertain how insurance coverage was related to each of the access and utilization measures obtained in the survey. We also examined trends in health insurance coverage using the 1984, 1989, and 1995 editions of the National Health Interview Survey.
Results. An estimated 14.1% of adolescents were uninsured in 1995. Risk of being uninsured was higher for older adolescents, minorities, adolescents in low-income families, and adolescents in single parent households. Compared with their insured counterparts, uninsured adolescents were five times as likely to lack a usual source of care, four times as likely to have unmet health needs, and twice as likely to go without a physician contact during the course of a year. Between 1984 and 1995 the percentage of adolescents with some form of health insurance coverage remained essentially unchanged. During this period, the prevalence of private health insurance decreased, while the prevalence of public health insurance increased.
Conclusions. This study demonstrates the critical importance of health insurance as a determinant of access to and use of health services among adolescents. It also shows that little progress has been made during the past 15 years in reducing the size of the uninsured adolescent population. The new State Children's Health Insurance Program could lead to substantial improvements in access to care for adolescents, but only if states implement effective outreach and enrollment strategies for uninsured adolescents. adolescents, health insurance, access, Medicaid, SCHIP.
- SCHIP =
- State Children's Health Insurance Program •
- NHIS =
- National Health Interview Survey
Access to health care is critical to the well-being of adolescents. Insurance can play a crucial role in ensuring that adolescents access the health care they need. Analyses have shown that insured children and adolescents as a group are more likely to receive recommended preventive visits, have fewer unmet health needs, and have a relationship with a primary care physician than their uninsured counterparts.1–6 Insured children and adolescents are also less likely to go without medical attention when they have symptoms of a variety of illnesses for which office visits are warranted.7 Unfortunately, adolescents are more likely to be uninsured than younger children, putting them at risk for under-utilization of health care services.8
The availability of health insurance for children and adolescents, both private and public, has changed dramatically during the last 15 years. There has been a substantial decline in private health insurance coverage, especially employer-based coverage. At the same time, public coverage has grown rapidly. In fact, a series of congressionally enacted Medicaid expansions beginning in the mid-1980s primarily offset the decline in private coverage, with the result that the total number of uninsured children and adolescents has been relatively constant.9
Adolescents, however, have been slow to benefit from Medicaid expansions. The early expansions exclusively benefitted infants and young children. Later expansions, culminating with the Omnibus Budget Reconciliation Act of 1990, included adolescents; however, because coverage is phased-in by age, the effect on adolescents has only recently begun to be felt. Under current law, states are not required to phase-in coverage for adolescents who live in families with incomes below the federal poverty level until the year 2002. Although many states have accelerated Medicaid coverage of adolescents, as of 1999 the law only mandates coverage of adolescents up to 16 years of age with family incomes up to 100% of the federal poverty level.
Provisions of the Balanced Budget Act of 1997 offer promise for insuring more children and adolescents through new federal grants to states. This legislation, by creating the State Children's Health Insurance Program (SCHIP), provides an additional source of federal funding for states that want to expand health insurance coverage of children and adolescents from low-income families through Medicaid or other insurance programs.
Given the rapid pace of change occurring in the health insurance arena, the present analysis was conducted to ascertain the current scope of adolescent health insurance coverage. The profile of adolescent health insurance provided here can serve as a basis for gauging progress during the last several years and for assessing the effects of the new insurance expansion efforts. This is particularly important because there have been few recent studies of adolescent health insurance coverage or its impact on access to care, using nationally representative data.10 ,11 In this article, we present new data on the health insurance characteristics of adolescents, 10 to 18 years of age, from the 1995 National Health Interview Survey (NHIS), the most current nationally representative data set available at the time of the study. In the first section, we assess the health insurance status of adolescents and the demographic and socioeconomic correlates of insurance coverage. We then examine the role that health insurance plays in influencing access to and use of health care services, including presence of usual source of care, unmet health care needs, and use of physician services. Finally, we examine trends in adolescent health care coverage during the period spanning 1984 to 1995. Together, the results provide a current and comprehensive profile of adolescent health insurance coverage and a baseline for measuring future changes.
The NHIS is a continuing household survey of the civilian noninstitutionalized population of the United States.12The survey is sponsored by the National Center for Health Statistics and field operations are conducted by trained personnel from the US Bureau of the Census. The survey instrument consists of a core questionnaire and supplemental questionnaires on selected topics of interest to the public health community. During 1995, supplemental questionnaires on access to health care and health insurance coverage were included in the NHIS. We used data from the core survey and these supplements for our analysis.
The NHIS conducts field interviews in ∼40 000 households annually. The 1995 NHIS sample used in our analysis included 14 252 adolescents 10 to 18 years of age. An adult member of the household serves as the respondent for adolescents younger than 17 years of age; adolescents ages 17 or 18 years are permitted to respond for themselves. The combined response rate for the core and supplemental questionnaires used in our analysis was 86%. Although the NHIS is designed to provide nationally representative estimates, adolescents living outside of households, including homeless and institutionalized adolescents, are excluded from the survey.
Description of Variables Used
We used the questionnaire on health insurance to determine insurance status for adolescents. Adolescents in the sample were classified as insured if they were reported to be covered by CHAMPUS, Medicare, Medicaid, the Indian Health Service, other public assistance programs, or private health insurance during the month before the interview date. Adolescents with no coverage from these sources were classified as uninsured. Adolescents with unknown insurance status (n = 1688) were excluded from the insurance comparisons, but included in the table totals for all adolescents. It should be noted that by defining insurance status based on coverage during the previous month, a somewhat higher proportion of adolescents are classified as insured in the NHIS than in surveys in which a full year of coverage is used as the criterion for establishing insurance status.
Access and Utilization Measures
We used the questionnaire on access to obtain information on the presence of a usual source of care, the site of the usual source of care, and indications of missed or delayed care. Using the core questionnaire, we obtained data on the frequency of ambulatory physician services received by adolescents. Two indicators were used: whether the adolescent had a physician contact in the past year and the volume of contacts during the previous year. These measures of physician contacts include telephone consultations and exclude physician services provided during inpatient hospital episodes. Item nonresponse rates for each of the access and utilization measures in the survey were <10%.
Data analyses were conducted using SUDAAN, a statistical analysis program that incorporates the complex survey design used in the NHIS, including household and intrafamilial clustering of sample observations.13 Most of our results are presented in the form of simple bivariate comparisons of insured and uninsured children. However, we also conducted multivariate analyses to assess the independent association of age, sex, race, poverty status, family structure, family size, region of residence, metropolitan resident status, and several measures of health status with the likelihood of insurance coverage. We also used multivariate analysis to account for confounding in our analysis of the impact of insurance on access and use of health services. Unless otherwise noted, only differences significant at the .05 level (two-tailed test) are discussed in the text.
Limitations of the Data
As indicated previously, the NHIS uses adult household members as proxy respondents for adolescents <17 years of age. Although not ideal for some reporting purposes, adult respondents (principally parents) are likely be more knowledgeable about adolescent health insurance status than the adolescent family member. Moreover, we have no reason to believe that proxy reporting would result in systematic bias in our comparisons of access and utilization outcomes for insured and uninsured adolescents.
Health Insurance Status of Adolescents
Data from the NHIS indicate that 85.9% of adolescents, 10 through 18 years of age, had some kind of health insurance coverage in 1995 (Table 1). Most of these children (69.1%) were covered by private health insurance but a substantial minority (14.8%) were covered through public insurance plans such as Medicaid or CHAMPUS. A much smaller proportion of adolescents (2.1%) had both private and public insurance coverage. The remaining 14.1% of adolescents had no health insurance coverage at all. Translated into population terms, 4.2 million adolescents had no health insurance coverage in 1995.
Characteristics of Insured and Uninsured Adolescents
Health insurance coverage was far from uniform among US adolescents in 1995. Indeed, the results shown in Table 1 indicate that there were substantial differences in the likelihood of health insurance coverage based on demographic and socioeconomic characteristics of adolescents and their families. Older adolescents (15–18 years) were more likely to be uninsured than younger adolescents (10–14 years) (15.7% vs 12.8%; P < .01). This difference was primarily attributable to the higher prevalence of public health insurance among younger adolescents. Although there was little difference in health insurance coverage of males and females, there were significant differences according to race and ethnicity. Black adolescents were much more likely than white adolescents to have public coverage (36.1% vs 10.5%;P < .00l) and were ∼40% more likely than white adolescents to be uninsured (14.9% vs 10.7%; P < .001). Hispanic adolescents faced the greatest disadvantage; they were more than twice as likely as blacks (31.6% vs 14.9%;P < .001) and three times more likely than whites to be uninsured (31.6% vs 10.7%; P < .001).
Large differences in coverage related to poverty status of adolescents are shown in Table 1. Adolescents living in low-income families, especially those with incomes below the federal poverty level, were much more likely to have public coverage but also much less likely to have private insurance when compared with adolescents in families with higher incomes. Even with the higher prevalence of public insurance coverage, adolescents in low-income families were much more likely to be uninsured than their higher income counterparts. Both poor (<100% of the federal poverty level) and near poor (100% to 199% of the federal poverty level) adolescents were about six times as likely to be uninsured as adolescents living in families with incomes ≥200% of the federal poverty level (all comparisons P < .001).
Educational attainment of the family reference person (generally the father or mother) was closely related to insurance status. In fact, there was a fivefold difference in the likelihood of being uninsured for adolescents in families in which the reference person had attained less than a high school education when compared with those in families in which the reference person had completed at least some college level education (35.4% vs 7.1%; P < .001).
Substantial differences in type of coverage are shown for adolescents with different living arrangements in Table 1. Adolescents living in families with five or more persons were more likely to be uninsured than adolescents living in smaller families (15.9% vs 12.9%;P < .01). In addition, adolescents living with one or neither parent were ∼50% more likely to be uninsured as adolescents living with both parents (18.1% vs 12.2%; P < .001). Those living with both parents were far more likely to have private health insurance coverage than adolescents living with one or neither parent (79.4% vs 49.5%; P < .00l), but much less likely to have public health insurance coverage (10.4% vs 34.9%;P < .00l).
Although there was little difference in likelihood or type of coverage for adolescents in metropolitan and nonmetropolitan areas, there were substantial differences by region of the country. Adolescents living in the South were twice as likely as adolescents living in the Northeast or Midwest to be without health insurance coverage in 1995 (19.5% vs 9.2% and 9.3%, respectively; both P < .001). Adolescents living in the West were also more likely than adolescents in the Northeast and Midwest to be uninsured (15.2% vs 9.2% and 9.3%, respectively; both P < .001) but less likely than adolescents in the South to be without insurance coverage (15.2% vs 19.5%; P < .001). Only small differences were found in patterns of insurance coverage for adolescents living in metropolitan and nonmetropolitan areas.
Multivariate Analysis of Predictors of Insurance Coverage
Many of the demographic and socioeconomic variables presented inTable 1 are highly correlated. This is especially true for the socioeconomic status indicators, such as poverty status and educational attainment. In addition, there are also less obvious correlations between some of the socioeconomic and demographic variables. For example, incomes in the Northeast and Midwest are generally higher than those in the South and West; consequently, some of the differences shown in Table 1 by region may be explained by differences in family income. To adjust for such confounding we conducted a multivariate analysis of predictors of insurance coverage among adolescents. All the variables shown in Table 1 were entered into a logistic regression equation predicting presence or absence of insurance coverage.
The results of this analysis are presented in the form of unadjusted and adjusted odds ratios in Table 2. The findings indicate that a substantial degree of confounding exists, as indicated by the attenuated odds ratios after adjustment. However, the key findings from the bivariate analysis remain intact; that is, there are substantial and statistically significant differences in health insurance coverage of adolescents according to age, race and ethnicity, poverty status, educational attainment, and region of the country.
Reasons for Absence of Insurance Coverage
During the interview, families of uninsured adolescents were asked to identify the principle reason their adolescent child did not have health insurance coverage. Based on our earlier findings concerning the powerful role of socioeconomic status as a determinant of health insurance coverage, it is not surprising to learn that the expense of coverage is the primary reason for absence of health insurance among adolescents (Table 3). Fully 7 out of 10 respondents indicated that health insurance was too expensive and that they could not afford to purchase it. One in 8 respondents indicated that a job layoff or job loss was the primary reason for absence of coverage. A small but disturbing 3.3% of respondents reported that their adolescent child was healthy and did not need health insurance coverage. Another 2% of respondents indicated that uninsured adolescent family members were unable to obtain coverage because of poor health or illness (ie, preexisting conditions).
Usual Source of Care
Approximately 92% of adolescents had a usual source of care or place to go for routine health care or treatment of illness in 1995 (Table 4). As expected, insured adolescents were far more likely than uninsured adolescents to have a usual source of care (95.6% vs 71.0%; P < .00l). Among adolescents with a usual source of care, 14% did not identify a regular physician, and uninsured adolescents were nearly twice as likely as their insured counterparts to lack a regular clinician (20.5% vs 12.9%; P < .01).
Most adolescents with a usual source of care received their care in physician's offices or health maintenance organizations (77.2%). A substantially smaller proportion received their care in community health centers and other clinics (16.2%). Very few adolescents overall received their care in emergency rooms or urgent care settings (2.4%). There were substantial differences in the distributions of usual sites of care for insured and uninsured adolescents. Insured adolescents were more likely than uninsured adolescents to receive their care in physician's offices or health maintenance organizations (79.3% vs 62.3%; P < .001), and much less likely to receive their care in health centers and other clinics (15.1% vs 26.1%;P < .001) or emergency department/urgent care settings (2.0% vs 5.9%; P < .001).
Inability to Obtain Needed Health Care
The NHIS asked respondents a series of questions about whether adolescents were able to obtain needed medical care, dental care, prescriptions, eyeglasses, and mental health care (Table 5). Overall, 1 in 12 adolescents (8.5%) was unable to access at least one of the health services shown in Table 5. The most common type of unmet need was for dental care (6.3%), followed by prescriptions and/or eyeglasses (2.7%), and medical care (1.7%). Table 5 also indicates that 1.9% of adolescents had multiple types of unmet needs in 1995.
As might be expected, insured and uninsured adolescents differed substantially in unmet needs. Uninsured adolescents were nearly four times more likely than insured adolescents to have at least one unmet need (23.1% vs 6.2%; P < .001). Four- to sixfold differences existed for each of the services shown in Table 5. Uninsured adolescents were also six times more likely to have multiple unmet needs as insured adolescents (7.2% vs 1.2%; P< .001).
Use of Physician Services
Table 6 describes use of ambulatory physician services for adolescents in 1995. As seen in Table 6, 73% of adolescents had at least one physician contact in the year before the interview, with an average of 2.5 contacts per year. These measures of utilization, although useful, tell us little about use relative to need. The remaining three measures indicate use of physician services in the context of adolescent health needs. The first of these shows that on a population basis, adolescents had ∼88 physician contacts per 100 bed days. This aggregate measure, sometimes termed the use-disability ratio, provides a means for assessing the use of physician services adjusted for the number of days when adolescents spent all or most of the day confined to bed because of illness or injury. The absolute value of the use-disability ratio has little inherent meaning; its primary value is in comparing use rates across population subgroups, such as insured and uninsured youth. Two other measures of health status are used to account for need in Table 6. Adolescents reported in fair or poor health had four times as many contacts as those reported to be in good, very good, or excellent health (12.9 vs 3.0; P < .001), although adolescents with limitation of activity (disability) because of chronic conditions had more than three times as many contacts as those with no limitation (9.0 vs 2.8; P < .001).
Insured adolescents were significantly more likely than their uninsured counterparts to have had at least one physician contact in the past year (89.8% vs 74.9%; P < .001). They also had more contacts per year on average (2.8 vs 1.5 contacts;P < .001) and nearly two times as many physician contacts per 100 bed days in the past year (94.5 vs 52.2;P < .001) as uninsured adolescents. Similar differences in the volume of physician contacts are visible for insured and uninsured adolescents when grouped by perceived health status and limitation of activity status.
Multivariate Analysis of the Impact of Insurance on Access and Utilization
Although our results show a consistent and statistically significant effect of insurance on the access and utilization outcome measures included in Tables 4, 5, and 6, the insurance effect observed may be confounded by other factors. In particular, past studies have demonstrated that children's access to and use of care are also associated with family income and race/ethnicity.4–7 ,10We assessed whether such confounding was present for each of the dependent variables in Tables 4, 5, and 6 by conducting a series of regression analysis that controlled for family income and race/ethnicity. The results of these analyses (not shown) were consistent with those identified in the simple bivariate presentation. That is, insurance coverage status remained a statistically significant predictor of all access and utilization outcome indicators.
Trends in Adolescent Health Insurance Coverage
Trend data on adolescent health insurance for 1984, 1989, and 1995 are presented in Table 7. These data indicate that, despite some intermediate movement, the proportion of adolescents with some type of coverage remained essentially unchanged between 1984 and 1995. Closer inspection of the data reveals that substantial changes in the composition of insurance coverage occurred during this 12-year period. Specifically, the proportion of adolescents with private insurance declined from 75.9% to 71.2%, while the proportion of those with public coverage increased from 11.9% to 16.9%. Hence, the substantial decline in private insurance was effectively offset by an increase in public insurance, leaving the total proportion of adolescents without insurance essentially unchanged during the 1984 to 1995 period. Data inTable 7 also indicate that although both younger and older adolescents were subject to losses of private health insurance coverage, younger adolescents were the primary beneficiaries of expanded public coverage.
Results from our study demonstrate the key role health insurance plays as a determinant of access to health care for adolescents. The presence of health insurance was independently associated with an increased likelihood of having a usual source of care, fewer unmet health care needs, and increased use of physician services. These findings are consistent with the findings of a large body of current literature on health insurance and access to care for children.2–8 However, they are unique in that they provide the first comprehensive look at adolescent health insurance using nationally representative data from the 1990s. The last such assessment of adolescent health insurance used data from the 1980s.10 ,11
Our results also provide new information on trends in health insurance coverage among adolescents. Most importantly, there has been no significant progress in expanding health insurance coverage for adolescents, with the percentage of adolescents with insurance remaining essentially unchanged since 1984. Despite expanded Medicaid enrollment, a substantial number of adolescents remain uninsured because of a sharp decline in private insurance coverage. Experts have offered a number of explanations for the decline in private insurance coverage. First, some portion of the shift from private to public coverage may be attributable to “crowd-out” or the substitution of newly available public coverage for existing employer-based private insurance.14–16 However, the extent to which crowd-out explains the decline in private coverage remains unclear and controversial. Additional explanations for the decline include the long-term shift of jobs from the manufacturing sector to the service sector, where health insurance is less likely to be offered as a fringe benefit to employees and their dependents; a shift on the part of employers toward covering only employees and not their dependents; a growing contingency work force of temporary and contract workers who do not receive employer-based coverage; and rising premiums because of increased medical care costs.2 15–18
Despite the clear importance of health insurance, results from our study also indicate that insurance is not evenly distributed within the adolescent population. In particular, adolescents from low-income families were found to be at substantially increased risk of being uninsured. Specifically, adolescents living in families with incomes <200% of the poverty level were six times more likely to be uninsured than adolescents in more affluent families. In fact, four of every five uninsured adolescents live in families with incomes <200% of poverty level. Consequently, policies aimed at expanding insurance coverage for adolescents in low-income families should help to alleviate existing inequities in coverage and ultimately in access to care.
SCHIP provides a powerful new tool for this purpose. Under this program, states can collectively access up to $4 billion annually in federal matching funds to provide insurance for children and adolescents up to age 19 living in families with incomes <200% of the federal poverty level. States have the option of using the new funds to expand their existing Medicaid programs, establish a new insurance program, or pursue a combination of the two approaches. Federal matching rates were purposely set at more generous levels than previously available under the Medicaid program to make the program more attractive to states. This strategy seems to have been met with some success; at press time, all but 2 states had applied for SCHIP funding.
This new law has particular value in redressing past inequities experienced by adolescents. Because the Medicaid expansions legislated in the late 1980s were initially targeted at younger children, adolescents in low-income families have lagged behind their younger counterparts in gaining access to expanded Medicaid coverage. For example, as of October 1, 1997, all states provided Medicaid coverage to children and adolescents younger than 14 years of age living below the federal poverty level as required by federal law; however, only half of the states extended coverage to adolescents 14 years of age or older living in impoverished families. Many states are using their SCHIP grants to immediately broaden Medicaid coverage for adolescents.
Although a large number of adolescents are expected to gain coverage under SCHIP, aggressive outreach and enrollment efforts will be required to fully realize the potential of the new program. Adolescents are a particularly challenging population to attract, enroll, and retain. Newly eligible adolescents may be difficult to enroll given that they traditionally have fewer contacts with health care providers than younger children.19 Moreover, SCHIP is a new program and primarily unknown to families. Even in a well-established program like Medicaid, large numbers of eligible children and adolescents fail to enroll.20 Practicing pediatricians can be helpful here by informing potentially eligible adolescents and their families about the program and by working in their states to encourage development of effective outreach and enrollment strategies.
This study has demonstrated the critical importance of health insurance for adolescents. Insurance was found to play a critical role in influencing adolescent's access to care and use of health services. Government sponsored programs, including Medicaid and SCHIP, provide important mechanisms for expanding access to insurance. These programs have taken on even greater importance with the continued erosion of private health insurance of adolescents.
This work was supported by federal Maternal and Child Health Bureau Grants MCU-069384, MCU-000978, MCJ-063A80, and MCU-06MCP1; Robert Wood Johnson Foundation Grant 31009; and Center for Studying Health System Change Grant 6004–96-13.
Yun-Yi Hung provided programming assistance and Chellene Wood provided manuscript preparation assistance. We also appreciate the helpful comments of Tracy Macdonald and the anonymous reviewers on an earlier version of this manuscript.
- Received September 28, 1998.
- Accepted January 28, 1999.
Reprint requests to (P.W.N.) Institute for Health Policy Studies, 1388 Sutter St, Suite 1100, San Francisco, CA 94109.
Data were provided by the National Center for Health Statistics. Interpretation and conclusions are those of the authors and do not necessarily reflect the views of the data collection and funding agencies.
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- Copyright © 1999 American Academy of Pediatrics