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Health Insurance Coverage — United States, 2008 and 2010

Ramal Moonesinghe, PhD1

Man-huei Chang, MPH2

Benedict I. Truman, MD3

1Office of Minority Health and Health Equity, Office of the Director, CDC

2Center for Surveillance, Epidemiology, and Laboratory Services, CDC

3National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC


Corresponding author: Ramal Moonesinghe, PhD, Office of Minority Health and Health Equity, Office of the Director, CDC. Telephone: 770-488-8203; E-mail: zor7@cdc.gov.

Introduction

One out of four adults aged 19–64 years reported not having health insurance at some time during 2011, with a majority remaining uninsured for ≥1 year (1). In the first quarter of 2010, an estimated 59.1 million persons had no health insurance for at least part of the year, an increase from 58.7 million in 2009 and 56.4 million in 2008 (2). The unemployment rate increased from 5.8% to 9.3% from 2008 to 2009, the largest 1-year increase on record (3). Losing or changing jobs was the primary reason persons experienced a gap in health insurance (1). Employment-based coverage for persons aged <65 years continued to erode for the ninth year in a row, falling 3.0 percentage points from 61.9% in 2008 to 58.9% in 2009 (3). Persons aged 18–64 years with no health insurance during the preceding year were seven times as likely as those continuously insured to forgo needed health care because of cost (2).

This report is part of the second CDC Health Disparities and Inequalities Report (CHDIR). The 2011 CHDIR (4) was the first CDC report to assess disparities across a wide range of diseases, behavioral risk factors, environmental exposures, social determinants, and health-care access. The topic presented in this report is based on criteria that are described in the 2013 CHDIR Introduction (5). This report provides updated information that complements the health insurance coverage data published in the 2011 CHDIR (6). This report on health insurance coverage discusses and raises awareness of differences in the characteristics of persons who lack health insurance coverage, and prompts actions to reduce these disparities.

Methods

To identify disparities in the lack of health insurance coverage for adults aged 18–64 years for different demographic and socioeconomic groups over time, CDC analyzed data from the 2008 and 2010 National Health Interview Survey (NHIS). NHIS is a cross-sectional survey of a representative sample of the civilian, noninstitutionalized U.S. household population. NHIS includes various questions on family health insurance (ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Survey_Questionnaires/NHIS/2010/English/qfamily.pdf). The 2010 NHIS included 27,157 respondents, of whom a total of 80 were excluded because of unknown insurance status. The overall response rate was 60.8%. The questionnaire begins with the question "are you/is anyone in the family covered by any kind of health insurance or some kind of health-care plan?" Respondents were considered uninsured if they did not have any private health insurance, Medicare, Medicaid, State Children's Health Insurance Program coverage, state-sponsored or other government-sponsored health plan, or a military health-care plan at the time of the interview. Persons also were considered uninsured if they reported having only Indian Health Service coverage or a private plan that paid for only one type of service (e.g., unintentional injuries or dental care). Rate of uninsured is the percentage of adults aged 18–64 who did not have health insurance.

Disparities were examined by characteristics that included race and ethnicity, sex, age (adults aged 18–64 years), household income, disability status, and educational attainment. Poverty status was defined by using the ratio of income to the federal poverty level (FPL), in which "poor" is <1.0 times FPL, "near poor" is 1.0–2.9 times FPL, and "nonpoor" is ≥3.0 times FPL. Educational attainment was defined as less than high school, high school graduate or equivalent, some college, and college graduate or higher. Disability was defined as limitations in a person's activity because of a health condition or impairment. Race was defined as white, black, American Indian/ Alaska Native, and other and multiple race. Ethnicity was defined as Hispanic or non-Hispanic.

Disparities were measured as deviations from a "referent" category for an uninsured rate; defined as the lowest percentage for a population group-specific without health insurance. Absolute difference was measured as the simple difference between an estimate for a population subgroup and the estimate for the referent category rate. The relative difference, a percentage, was calculated by dividing the absolute difference by the value in the referent category and multiplying by 100. The 95% confidence intervals for uninsured rates were estimated using statistical software (7). Pair-wise differences by sex, age group, race/ethnicity, disability status, educational achievement, and differences between 2008 and 2010 were tested by the z-statistic (one-tailed) at the 0.05 level of significance. A covariance of zero between estimates in conducting these tests was assumed. When testing differences within demographic groups, the Bonferroni method was used to account for multiple comparisons. If κ comparisons existed within a group, the level of significance was set to 0.05/κ. Estimates with a relative standard error of >20% were considered unreliable.

Results

During 2010, substantial disparities persisted in uninsured rates for all demographic and socioeconomic groups. Statistically significant disparities by sex (p<0.001) also continued during 2010, with a higher percentage of males (24.1%) than females (18.8%) being uninsured (Table 1). The uninsured rate for young adults aged 18–34 years was approximately double the uninsured rate for adults aged 45–64 years (aged 18–34 years, 28.5%; aged 45–64 years, 15.4%). Uninsured rates for all the age groups analyzed were significantly higher (p<0.001) than with adults aged 45–64 years.

During 2010, among adults aged 18–64 years, approximately two out of five persons of Hispanic ethnicity and one out of four non-Hispanic blacks were classified as uninsured. Both these groups had significantly higher (p<0.001) uninsured rates (41.0% and 26.2%, respectively), compared with Asians/Pacific Islanders and non-Hispanic whites (17.3% and 16.1%, respectively). No significant difference in uninsured rates existed between non-Hispanic whites and Asians/Pacific Islanders. During 2010, approximately half of uninsured adults were non-Hispanic whites (Table 2). Hispanics accounted for 29.3% of the uninsured population. The estimate of uninsured rate for non-Hispanic American Indian and Alaska Native persons was not reliable enough to make comparisons with estimates from other subpopulations.

During 2010, among persons aged 18–64 years, uninsured rates for poor (those living at the federal poverty level [FPL]) and near poor persons (those at <3.0 times FPL) ranged from 34.2% to 41.2%, and these rates were significantly higher (p<0.001) than the uninsured rate among the nonpoor (those at ≥3.0 FPL) (Table 1). Approximately half (50.7%) of uninsured adults were near poor (Table 2). During 2010, income for the near poor ranged from $22,314 to $66,942 per year for a family of four. Uninsured rates for persons in the poor and near poor categories increased significantly (p<0.014) from 2008 (37.0% and 30.5%, respectively) to 2010 (41.2% and 34.2%, respectively). The uninsured rate for non-Hispanic blacks also increased significantly (p<0.002) from 22.1% in 2008 to 26.2% in 2010. No significant difference existed in the uninsured rate between 2008 (41.6%) and 2010 (41.0%) for the Hispanic population (Table 1).

Regarding educational attainment, when compared with college graduates, all groups continued to have significantly higher uninsured rates (p<0.001). From 2008 to 2010, uninsured rates for graduates from high school and with some college education increased significantly (p<0.003). The uninsured rate for persons without a disability (22.3%) also remained significantly higher (p<0.001) than persons with a disability (19.6%).

Discussion

During 2010, similar to the disparities observed in 2004 and 2008 (6), substantial disparities persisted in uninsured rates for all demographic and socioeconomic groups. From 2008 to 2010, uninsured rates increased significantly (p<0.05) for all groups considered in this report with the exception of persons with less than a high school diploma, college graduates, highest income group considered, Hispanics, and persons in age group 18–34 years. However, those with less than a high school diploma and Hispanics were groups with the highest uninsured rates. Chronically ill patients without insurance are more likely than those with coverage 1) not to have visited a health-care professional, and 2) either not to have a standard site for care or to identify their standard site of care as an emergency department (8). Because minority populations and the poor have high uninsured rates, these populations tend to visit the emergency department for nonurgent health care. Costly emergency department care could be saved if primary care were available to these populations (9).

Limitations

The findings in this report are subject to at least two limitations. First, health insurance coverage information in NHIS is self-reported and subject to recall bias. Second, because NHIS does not include institutionalized persons, the results are not generalizable to segments of the population that include prison inmates, military personnel, and adults in nursing homes and other long-term care facilities.

Conclusion

Disparities in health insurance coverage continue among all demographic and socioeconomic groups. Coverage expansion resulting from current or future reform of health insurance policies is likely to reduce disparities in uninsured rates. For example, after implementation of the 2010 Affordable Care Act, an estimated 6.6 million adults aged 19–25 years who might have been uninsured stayed on or joined their parents' health plans between November 2010 and November 2011 (10).

References

  1. Collins SR, Robertson R, Garber T, Doty MM. Gaps in health insurance: why so many Americans experience breaks in coverage and how the Affordable Care Act will help. Issue Brief (Commonwealth Fund) 2012 April. Available at http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Apr/Gaps-in-Health-Insurance.aspx.
  2. CDC. Vital signs: health insurance coverage and health care utilization—United States, 2006—2009 and January-March 2010. MMWR 2010;59:1448–54.
  3. Gould E. Decline in employer-sponsored health coverage accelerated three times as fast in 2009. Economic Policy Institute. Available at http://www.epi.org/publication/decline_in_employer-sponsored_health_coverage_accelerated.
  4. CDC. CDC health disparities and inequalities report—United States, 2011. MMWR 2011, 60;(Suppl; January 14, 2011).
  5. CDC. Introduction. In: CDC health disparities and inequalities report—United States, 2013. MMWR 2013; 62 (No. Suppl 3).
  6. CDC. Health insurance coverage—United States, 2004 and 2008. In: CDC health disparities and inequalities report—United States, 2011. MMWR 2011; (Suppl; January 14, 2011).
  7. SAS Institute, Inc. SAS version 9.02. Cary, NC: SAS Institute, Inc.; 2.
  8. Wilper AP, Woolhandler S, Lasser KE, et al. A national study of chronic disease prevalence and access to care in uninsured US adults. Ann Intern Med 2008;149:170–6.
  9. Gill JM, Arch GM, Musa N. The effect of continuity of care on emergency department use. Arch Fam Med 2000;9:333–8.
  10. Collins SR, Robertson R, Garber T, Doty MM. Young, uninsured, and in debt: why young adults lack health insurance and how the Affordable Care Act is helping. Issue Brief (Commonwealth Fund) 2012. Available at http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Jun/Young-Adults-2012.aspx.

TABLE 1. Percentage* of adults aged 18–64 years without health insurance, by selected demographic characteristics — National Health Interview Survey, United States, 2008 and 2010

Characteristic

2008

2010

%

(95% CI)

Absolute
difference (percentage
points)

Relative difference
(%)

%

(95% CI)

Absolute
difference (percentage
points)

Relative
difference
(%)

Sex

Male

22.2

(21.0–23.5)

4.9

28.3

24.1

(23.0–25.2)

5.3

28.5

Female

17.3

(16.2–18.3.)

Ref.

18.8

(17.8–19.7)

Ref.

Ref.

Age group (yrs)

18–24

27.9

(25.4–30.4)

14.3

105.1

29.8

(27.6–31.9)

14.4

93.5

25–34

26.6

(24.7–28.5)

13.0

95.6

27.2

(25.6–28.9)

11.8

76.6

35–44

18.7

(17.3–20.2)

5.1

37.5

21.4

(20.1–22.7)

6.0

39.0

45–64

13.6

(12.6–14.6)

Ref.

15.4

(14.5.–16.2)

Ref.

Ref.

Poverty status

Poor

37.0

(34.0–40.0)

28.1

315.1

41.2

(38.9–43.5)

33.1

410.5

Near poor

30.5

(28.8–32.2)

21.6

242.2

34.2

(32.8–35.6)

26.1

323.6

Nonpoor

8.9

(8.1–9.8)

Ref.

8.1

(7.4–8.7)

Ref.

Ref.

Race/Ethnicity

Hispanic§

41.6

(38.8–44.4)

27.6

197.1

41.0

(39.0–43.0)

24.9

154.2

White, non-Hispanic

14.6

(13.7–15.5)

0.6

4.3

16.1

(15.3–17.0)

Ref.

Black, non-Hispanic

22.1

(20.3–23.9)

8.1

57.9

26.2

(24.2–28.3)

10.1

62.6

American Indian/Alaska Native

33.7

33.5

Asian/Pacific Islander

14.0

(11.2–16.9)

Ref.

17.3

(14.7–19.8)

1.2

7.1

Other, non-Hispanic other, and multiple race

20.1

21.5

Disability status

Persons with a disability

17.7

(16.4–19.0)

Ref.

19.6

(18.4–20.7)

Ref.

Persons without a disability

20.5

(19.4–21.5)

2.8

15.8

22.3

(21.4–23.1)

2.7

13.7

Educational attainment

Less than high school

40.5

(37.6–43.3)

32.4

400.0

42.8

(40.6–45.0)

34.8

432.2

High school graduate or equivalent

24.4

(22.8–26.1)

16.3

201.2

27.5

(26.1–28.9)

19.5

242.5

Some college

16.6

(15.4–17.7)

8.5

104.9

20.0

(18.8–21.2)

12.0

148.8

College graduate or higher

8.1

(7.1–9.0)

Ref.

Ref.

8.0

(7.2–8.8)

Ref.

Abbreviations: 95% CI = 95% confidence interval; Ref. = referent.

* Rate of uninsured is the percentage of adults aged 18–64 who did not have health insurance.

Poor = ≤1.0 times the federal poverty level (FPL), near poor = 1.0–2.9 times FPL, and nonpoor = ≥3.0 times FPL. FPL was based on U.S. Census Bureau poverty thresholds, available at http://www.census.gov/hhes/www/poverty/html.

§ Persons of Hispanic ethnicity might be of any race or combination of races.

Estimates are considered unreliable because the relative standard errors are >20%.


TABLE 2. Number and percentage of adults aged 18–64 years without health insurance, by poverty status and race/ethnicity — National Health Interview Survey, United States, 2010

Characteristic

No.

(% of total)

% without health insurance

Poverty status*

Poor

11,078,526

(30.8)

41.2

Near poor

18,246,425

(50.7)

34.2

Nonpoor

6,641,720

(18.5)

8.1

Total

35,966,671§

(100.0)

Race/Ethnicity

Hispanic

11,957,253

(29.3)

41.0

White, non-Hispanic

20,130,159

(49.5)

16.1

Black, non-Hispanic

6,097,277

(15.0)

26.2

American Indian/Alaska Native

363,140

(0.9)

33.5

Asian/Pacific Islander

1,575,972

(3.9)

17.3

Other, non-Hispanic and multiple race

560,459

(1.4)

21.5

Total

40,684,260§

(100.0)

* Poor = ≤1.0 time the federal poverty level (FPL), near poor = 1.0 2.9 times FPL, and nonpoor = ≥3.0 times FPL. FPL was based on U.S. Census Bureau poverty thresholds, available at http://www.census.gov/hhes/www/poverty/html.

Persons of Hispanic ethnicity might be of any race or combination of races.

§ Totals are different because of unknown poverty status.


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