Research Findings #11: Health Insurance Status of the Civilian Noninstitutionalized Population, 1998

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Jeffrey A. Rhoades, Ph.D., Erwin Brown, Jr., B.S., and Jessica P. Vistnes, Ph.D., Agency for Healthcare Research and Quality

On this page: Abstract - Introduction - Overview - Characteristics of Uninsured Americans - Conclusions - Tables - References - Appendix

Abstract

This report from the 1998 Medical Expenditure Panel Survey (MEPS) provides preliminary estimates of the health insurance status of the civilian noninstitutionalized U.S. population during the first half of 1998, including the size and characteristics of the population with private health insurance, with public insurance, and without any health care coverage. During this period, 84.2 percent of all Americans were covered by private or public health insurance, leaving 15.8 percent of the population, some 42.3 million people, uninsured. Among the non-elderly population, 82.2 percent of Americans had either private or public coverage and 17.8 percent of the population (42 million people) lacked health care coverage. Among the elderly population, there was a significant drop in private health insurance coverage and a significant increase in coverage by only public health insurance when compared to 1997 estimates. The probability that an individual would be uninsured during this period was especially high for young adults aged 19-24 and members of racial and ethnic minorities (especially Hispanic males). Public health insurance continues to play an important role in ensuring that children, black Americans, and Hispanic Americans obtain health care coverage.

Introduction

This report is the third in a series of yearly reports on the health insurance status of the U.S. population. The first report (Vistnes and Monheit, 1997) presented health insurance estimates for the first half of 1996, and the second (Vistnes and Zuvekas, 1999) presented health insurance estimates for the first half of 1997. The yearly reports all have the same format but give the most recent statistics and point out noteworthy changes from the previous year.

The health insurance status of the U.S. population, especially the size and composition of the uninsured population, has become an issue of perennial public policy concern for several reasons. First, health insurance is viewed as essential to ensure that individuals obtain timely access to medical care and protection against the risk of expensive and unanticipated medical events. Compared to people without health care coverage, insured individuals are more likely to have a usual source of medical care, to spend less out of pocket on health services, and to experience different treatment patterns, quality, and continuity in their health care (Lefkowitz and Monheit, 1991; U.S. Congress, Office of Technology Assessment, 1992).

Second, concern over the population's health insurance status reflects a variety of equity and efficiency considerations. These include the magnitude and appropriate mix of private and public sector responsibility for financing health care, the impact of health insurance on the efficient use of health care, and the manner in which health insurance affects the distribution of health care among the general population and across groups of specific policy interest.

Third, timely and reliable estimates of the population's health insurance status are essential to evaluate the costs and expected impact of public policy interventions to expand coverage or to alter the manner in which private and public insurance is financed. Identification of how individual and household demographic characteristics, health status, and economic circumstances are associated with the population's health insurance status is of critical importance in developing efficient and targeted policy interventions. This is especially relevant given the current emphasis on incremental health care reform that is focused on particular health care markets and population groups.

Finally, comparisons of the characteristics of insured and uninsured populations over time provide information on whether greater equity has been achieved in the ability of specific population groups to obtain health insurance or whether serious gaps remain. In this regard, estimates of the population's health insurance status from the Medical Expenditure Panel Survey (MEPS), which is conducted annually, provide critical data for evaluating the health insurance implications of recent legislative initiatives: the 1996 Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191; welfare reform under the 1996 Personal Responsibility and Work Opportunity Reconciliation Act, Public Law 104-193; and the 1997 State Children's Health Insurance Program (SCHIP). A primary goal of HIPAA is to reduce the impact of preexisting health conditions on the continuity of health insurance during employment transitions. Under welfare reform, mandated work requirements and time limitations governing the receipt of public assistance may have consequences for a recipient's health insurance status. The goal of the SCHIP program is to provide health insurance coverage to low-income children who are not eligible for Medicaid.

This report presents preliminary estimates of the number and characteristics of people with private and public health insurance at any time during the first half of 1998, on average. Particular emphasis is directed toward estimating the size of the population that was uninsured throughout the first half of 1998 and identifying groups especially at risk of lacking health insurance.

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Overview

During the first half of 1998, on average, 84.2 percent of all Americans in the civilian noninstitutionalized population had some type of private or public health insurance coverage (Table 1). Nearly 69 percent of Americans obtained health insurance from private sources. Another 15.6 percent obtained public sources of coverage, primarily from the Medicare and Medicaid programs. The remaining 15.8 percent of Americans, 42.3 million people, were without health insurance throughout the first half of 1998. Among the non-elderly population, 70.4 percent were covered by private insurance and 11.8 percent by public insurance. Among the non-elderly population, an estimated 42.0 million people (17.8 percent) were uninsured. Table 2 gives more detailed information on the health insurance status of the non-elderly population.

Overall these health insurance estimates do not differ significantly from the 1997 MEPS figures for the non-elderly population reported in Vistnes and Zuvekas, 1999. However, there were differences between the two years for the elderly population. These differences are discussed below.

Tables 1-3 provide estimates of the population's health insurance status according to selected demographic characteristics, perceived health status, employment status, and residential location. Table 4 provides estimates of the distribution of the uninsured population by selected characteristics. Table A in the Technical Appendix provides estimates of the number of people by health insurance status. Some of the key findings and relationships revealed by these data are discussed below.

Age

MEPS data reveal that, in general, children are more likely than non-elderly adults to have health insurance coverage. The main findings among age groups are described next.

Children

There has been considerable interest in the health insurance status of children. This interest stems from the role health care coverage plays in ensuring that children obtain the medical care appropriate to their specific stage of development. To help ensure such coverage, Congress passed the State Children's Health Insurance Program in 1997, allocating approximately $24 billion over 5 years to provide health insurance coverage to low-income children who are not eligible for Medicaid. The SCHIP program follows on Medicaid expansions beginning in the late 1980s that focused attention on the role of the public and private sectors in financing health care for low-income children.

MEPS data indicate that public health insurance covered a substantial proportion of children in the first half of 1998: Nearly 30 percent of children under age 4, one in four children ages 4-6, and close to one in five children ages 7-12 had public coverage, primarily through Medicaid. As a result, children under age 18 were less likely to be uninsured than were non-elderly adults in general. Despite this finding, about 10.6 million children lacked health care coverage.

Adults

Young adults ages 19-24 were the age group most likely to lack health insurance. Nearly a third of young adults (31.8 percent) were uninsured, twice the rate at which all Americans lacked coverage. Young adults ages 19-24 also had the lowest rate of private health insurance coverage among the non-elderly adult population.

On the other hand, over half of elderly Americans (55.3 percent) were covered by private health insurance. More than 4 out of 10 elderly Americans (43.8 percent) held only public coverage (Medicare alone or in conjunction with Medicaid). These estimates differ significantly from estimates for 1997, when 60.5 percent of the elderly were covered by private health insurance and 38.4 percent were covered by public health insurance only. Presently there are insufficient data to determine why these changes have occurred between the two years.

Employment Status

Since most private health insurance in the United States is provided through the workplace, employment status is an important indicator of access to private health insurance. MEPS data reveal the following for the population ages 16-64 (Table 2):

Over three-quarters (79.9 percent) of workers were covered by private health insurance, compared to half (51.2 percent) of individuals who were not employed.
People who were not employed were more likely than workers to be covered by public insurance (23.1 and 3.4 percent, respectively).
Workers were less likely than people who were not employed to be uninsured (16.6 and 25.6 percent, respectively).

Race/Ethnicity

MEPS data indicate that significant disparities exist in the rate at which racial and ethnic minorities are covered by private and public health insurance compared to white Americans (Table 1). For example:

Less than half of all Hispanic Americans (46.9 percent) and half of black Americans (50.2 percent) were covered by private health insurance, compared to three-quarters of whites (75.7 percent). Close to a third of Hispanics (31.8 percent) and a fifth of blacks (20.6 percent) were uninsured. In contrast, 12.2 percent of white Americans were uninsured.
Among all racial/ethnic groups, Hispanic males were the most likely to be uninsured; 33.9 percent lacked coverage.
Hispanic and black Americans were more likely than white Americans to be covered by public health insurance (21.3 percent and 29.2 percent, respectively, compared to 12.1 percent).

Marital Status

Married individuals were more likely than others to have private health insurance (Table 1). As shown in Table 2, among people ages 16-64, married individuals were more likely than others to have private health insurance (81.8 percent) and less likely to have public insurance (4.5 percent) or be uninsured (13.7 percent). Of people ages 16-64 who were not married at the time of the survey:

Almost one-quarter of widowed persons were uninsured (23.1 percent).
Over a fifth of all divorced persons (21.7 percent) were uninsured.
Over one-quarter of Americans who were separated were uninsured (28.8 percent).
More than one-quarter of Americans who never married were uninsured (26.3 percent).

Residential Location

The type of health care coverage obtained by Americans and the likelihood of being uninsured also varied by region and whether they lived in a metropolitan statistical area (MSA). MEPS data show that:

People living in the South and West were less likely than residents of other regions to have private health insurance (64.8 percent and 65.0 percent in the South and West, respectively, compared to 70.8 percent and 76.1 percent of residents in the Northeast and Midwest). Nearly one out of five persons in the South and West were uninsured (18.8 percent and 18.1 percent, respectively), compared to 12.7 and 11.4 percent in the Northeast and Midwest, respectively.
People living outside MSAs were less likely than those living within MSAs to be covered by private health insurance (64.0 percent vs. 69.8 percent).

Health Status

There is considerable public policy interest in determining whether people with health problems are able to obtain health insurance and, if so, the source of such coverage. MEPS respondents were asked to rate their health and family members' health as excellent, very good, good, fair, or poor. The data in Table 3 reveal the relationships described below between health status and insurance coverage.

Non-Elderly People

More than one in five non-elderly Americans in good health (20.8 percent), fair health (23.2 percent), or poor health (22.8 percent) were uninsured throughout the first half of 1998. Among the non-elderly:

People in fair or poor health were less likely than those in better health to have private health insurance. Only 41.2 percent of those in poor health and 53.8 percent of those in fair health had any private coverage.
Public insurance helped to reduce the health-related disparities in private coverage. Over 20 percent of people in fair health and over one-third of people in poor health had public coverage. Nevertheless, those in only good or fair health were more likely than people in very good or excellent health to be uninsured.

Elderly People

Elderly Americans in poor health were less likely to have private coverage than those in good or better health. As a result, those in poor health were more likely to be covered by insurance from public sources only (55.9 percent) than other elderly Americans. Medicare, either alone or with Medicaid, was the main public source of coverage. There were significant differences between the 1997 and 1998 estimates for elderly people in good health. The percent covered by private health insurance decreased significantly, from 63.3 in 1997 to 55.5 percent in 1998. There was a corresponding significant increase in the percent covered by public health insurance only, from 35.9 in 1997 to 43.3 percent in 1998. Presently there are insufficient data to determine why these changes have occurred between the two years.

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Characteristics of Uninsured Americans

Previous sections of this report have described the health insurance status of Americans by focusing on demographic, health status, and geographic characteristics associated with the likelihood that particular groups obtained private or public health insurance or were more at risk of being uninsured. To put this discussion in perspective, data displayed in Table 4 characterize the uninsured population in terms of the representation of specific groups in the general population of non-elderly Americans relative to their representation among the uninsured population. In this way, one can assess whether certain population groups are disproportionately represented among the uninsured. Such information can be useful in formulating targeted policy interventions on behalf of people without health insurance.

Age

Children under age 18 comprised just over one-quarter (25.2 percent) of the uninsured population. Young adults ages 19-24 composed 8.8 percent of the non-elderly population but 15.7 percent of the uninsured population. Young adults had the greatest risk of being uninsured of any age group.

Sex

While males made up slightly less than half of the non-elderly population, they represented 54.0 percent of the uninsured population.

Race/Ethnicity

Racial and ethnic minorities were more at risk of lacking health insurance than white Americans were. As a result, minority representation among the uninsured exceeded their representation among the general population. For example:

Although Hispanics represented only 12.3 percent of the non-elderly U.S. population, they accounted for 23.1 percent of the uninsured population.
Hispanic males were the racial/ethnic group most likely to be uninsured. They represented only 6.4 percent of all non-elderly Americans but 12.6 percent of the uninsured population.
Although 7 out of 10 non-elderly Americans were white, whites accounted for less than 6 out of 10 uninsured persons.
When the uninsured are categorized by race/ethnicity and sex, white males represent the largest proportion of the uninsured population.

Other Factors

People with specific residential locations and marital status were also disproportionately represented among the uninsured:

People living in the South represented about a third (35.0 percent) of all non-elderly Americans but 42.0 percent of all uninsured Americans. Nearly 70 percent of the uninsured population, but less than 60 percent of non-elderly Americans, resided in the South or West.
People who never married accounted for over a fifth of the non-elderly population but over a third of the uninsured population.

Finally, more than 1 out of 10 uninsured people (11.5 percent of the uninsured population) were in fair or poor health. These individuals are of particular policy concern because of the importance of health insurance in assuring timely access to needed health care services.

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Conclusions

Preliminary estimates from the 1998 MEPS reveal that, during the first half of 1998, 68.6 percent of Americans obtained health insurance from private sources, 15.6 percent obtained coverage through public programs, and 15.8 percent of the population (42.3 million people) lacked any health care coverage. Among the non-elderly population, over one person in six was uninsured.

In general, there was no difference between the 1997 and 1998 estimates. However, among the elderly population there was a significant drop in the rate of private health insurance coverage and a significant increase in public health insurance coverage only.

The tabulations presented in this report indicate that the health insurance status of the U.S. population is strongly associated with specific demographic characteristics, health status, and employment status. Important disparities in health care coverage exist for particular groups. Among the groups especially at risk of lacking health care coverage are young adults ages 19-24 and members of racial and ethnic minorities (especially Hispanic males). Public health insurance continues to play an important role in insuring children, black Americans, and Hispanic Americans. Disparities in rates of insurance coverage also exist by health status, with non-elderly people in good or fair health more likely than people in better health to be uninsured.

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Tables

1. Health insurance coverage and population characteristics--all ages

2. Health insurance coverage and population characteristics--under age 65

3. Health insurance coverage and perceived health status--all ages

4. Population characteristics--total population and the uninsured, under age 65

Table 1. Health insurance coverage of the civilian noninstitutionalized population: Percent by type of coverage and selected population characteristics, United States, first half of 1998

Population characteristic	Total population in thousands	Private	Public only	Uninsured
Percent distribution
Total^a	268,297	68.6	15.6	15.8
Total under age 65^a	236,214	70.4	11.8	17.8
Age in years
Under 4	15,817	59.4	27.6	13.1
4-6	11,843	61.6	24.3	14.1
7-12	24,467	66.6	18.7	14.7
13-17	20,032	69.7	14.1	16.2
Total under 18	72,160	65.1	20.3	14.7
18	3,729	67.6	12.3	20.1
19-24	20,779	59.1	9.1	31.8
25-29	18,881	64.5	8.1	27.4
30-34	20,123	71.1	8.1	20.8
35-54	78,598	78.2	6.8	15.1
55-64	21,944	76.2	10.9	12.9
18-64	164,055	72.8	8.1	19.1
65 and over	32,082	55.3	43.8	0.9
Employment status^b
Employed	133,653	79.4	4.5	16.1
Not employed	70,133	52.4	31.7	15.9
Sex
Male	130,999	68.9	13.7	17.4
Female	137,298	68.4	17.4	14.2
Total Hispanic	30,726	46.9	21.3	31.8
Total black	33,643	50.2	29.2	20.6
Total white	193,489	75.7	12.1	12.2
Total other	10,439	61.0	19.8	19.2
Hispanic male	15,700	47.1	19.0	33.9
Black male	15,679	50.0	26.8	23.2
White male	94,638	76.1	10.4	13.6
Other male	4,983	61.0	19.3	19.7
Hispanic female	15,026	46.7	23.7	29.6
Black female	17,964	50.4	31.3	18.3
White female	98,851	75.4	13.8	10.9
Other female	5,456	60.9	20.3	18.8
Marital status^b
Married	110,197	78.8	9.6	11.6
Widowed	13,544	50.7	43.1	6.2
Divorced	20,859	62.2	18.2	19.6
Separated	4,900	50.6	22.1	27.2
Never married	54,933	61.6	12.8	25.7
Metropolitan statistical area (MSA)
MSA	215,524	69.8	15.0	15.3
Non-MSA	52,772	64.0	18.2	17.8
Census region
Northeast	51,205	70.8	16.5	12.7
Midwest	62,723	76.1	12.4	11.4
South	94,014	64.8	16.4	18.8
West	60,355	65.0	17.0	18.1

^aIncludes persons with unknown employment status and marital status.
^b For individuals age 16 and over.

Note: Percents may not add to 100 because of rounding.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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Table 2. Health insurance coverage of the civilian noninstitutionalized population under age 65: Percent by type of coverage and selected population characteristics, United States, first half of 1998

Population characteristic	Total population in thousands	Private	Public only	Uninsured
Percent distribution
Total^a	236,214	70.4	11.8	17.8
Employment status^b
Employed	129,333	79.9	3.4	16.6
Not employed	42,453	51.2	23.1	25.6
Sex
Male	117,475	70.0	10.8	19.3
Female	118,740	70.9	12.8	16.3
Race/ethnicity
Total Hispanic	29,108	48.2	18.5	33.3
Total black	30,999	51.8	26.1	22.1
Total white	166,299	78.2	7.7	14.1
Total other	9,808	63.5	16.4	20.1
Hispanic male	15,019	47.9	16.8	35.3
Black male	14,623	50.7	24.8	24.6
White male	83,064	77.8	6.8	15.4
Other male	4,768	62.3	17.4	20.2
Hispanic female	14,089	48.6	20.2	31.2
Black female	16,375	52.9	27.2	19.9
White female	83,235	78.6	8.5	12.8
Other female	5,040	64.7	15.4	19.9
Marital status^b
Married	92,575	81.8	4.5	13.7
Widowed	3,071	60.1	16.8	23.1
Divorced	18,655	64.5	13.8	21.7
Separated	4,638	51.8	19.4	28.8
Never married	53,414	62.2	11.4	26.3
Metropolitan statistical area (MSA)
MSA	191,011	71.6	11.3	17.1
Non-MSA	45,203	65.5	13.8	20.7
Census region
Northeast	44,517	73.3	12.4	14.3
Midwest	55,004	77.6	9.4	13.0
South	82,594	66.8	11.9	21.4
West	54,100	66.5	13.5	20.0

^a Includes persons with unknown employment status and marital status.
^b For individuals age 16 and over.

Note: Percents may not add to 100 because of rounding.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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Table 3. Health insurance coverage of the civilian noninstitutionalized population: Percent by type of coverage and perceived health status, United States, first half of 1998

Population characteristic	Total population in thousands	Private	Public only	Uninsured
Percent distribution
Total under age 65^a	236,214	70.4	11.8	17.8
Total age 65 and over^a	32,082	55.3	43.8	0.9
Perceived health status, under age 65
Excellent	88,319	74.8	9.3	15.9
Very good	74,463	74.5	9.1	16.3
Good	52,443	65.3	13.8	20.8
Fair	15,459	53.8	23.1	23.2
Poor	5,283	41.2	36.0	22.8
Perceived health status, age 65 and over
Excellent	5,724	59.1	40.1	*0.8
Very good	8,213	61.4	37.6	*1.0
Good	9,597	55.5	43.3	*1.2
Fair	5,419	49.0	50.7	*0.3
Poor	2,567	42.7	55.9	*1.4

^a Includes persons with unknown perceived health status.
*Relative standard error is greater than or equal to 30 percent.

Note: Percents may not add to 100 because of rounding.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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Table 4. Total population and uninsured persons under age 65: Percent by selected population characteristics, United States, first half of 1998

Population characteristic	Total population in thousands	Percent distribution of population		Percent uninsured	Percent distribution of uninsured population
Percent distribution
Total^a	236,214	100.0	17.8		100.0
Age in years
Under 4	15,817	6.7	13.1		4.9
4-6	11,843	5.0	14.1		4.0
7-12	24,467	10.4	14.7		8.6
13-17	20,032	8.5	16.2		7.7
Total under 18	72,160	30.5	14.7		25.2
18	3,729	1.6	20.1		1.8
19-24	20,779	8.8	31.8		15.7
25-29	18,881	8.0	27.4		12.3
30-34	20,123	8.5	20.8		10.0
35-54	78,598	33.3	15.1		28.2
55-64	21,944	9.3	12.9		6.8
Sex
Male	117,475	49.7	19.3		54.0
Female	118,740	50.3	16.3		46.0
Race/ethnicity
Total Hispanic	29,108	12.3	33.3		23.1
Total black	30,999	13.1	22.1		16.3
Total white	166,299	70.4	14.1		55.9
Total other	9,808	4.2	20.5		4.7
Hispanic male	15,019	6.4	35.3		12.6
Black male	14,623	6.2	24.6		8.6
White male	83,064	35.2	15.4		30.5
Other male	4,768	2.0	20.2		2.3
Hispanic female	14,089	6.0	31.2		10.5
Black female	16,375	6.9	19.9		7.8
White female	83,235	35.2	12.8		25.4
Other female	5,040	2.1	19.9		2.4
Marital status^b
Married	92,575	39.2	13.7		30.3
Widowed	3,071	1.3	23.1		1.7
Divorced	18,655	7.9	21.7		9.7
Separated	4,638	2.0	28.8		3.2
Never married	53,414	22.6	26.3		33.5
Census region
Northeast	44,517	18.8	14.3		15.2
Midwest	55,004	23.3	13.0		17.0
South	82,594	35.0	21.4		42.0
West	54,100	22.9	20.0		25.8
Perceived health status
Excellent	88,319	37.4	15.9		33.5
Very good	74,463	31.6	16.3		29.0
Good	52,443	22.2	20.8		26.0
Fair	15,459	6.6	23.2		8.6
Poor	5,283	2.2	22.8		2.9

^a Includes persons with unknown employment status and marital status.
^bFor individuals age 16 and over.

Note: Percents may not add to 100 because of rounding.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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References

Cohen JW, Monheit AC, Beauregard KM, et al. The Medical Expenditure Panel Survey: a national health information resource. Inquiry 1996;33:373-89.

Cohen S. Sample design of the 1996 Medical Expenditure Panel Survey Household Component. Rockville (MD): Agency for Health Care Policy and Research; 1997. MEPS Methodology Report No. 2. AHCPR Pub. No. 97-0027.

Lefkowitz D, Monheit AC. Health insurance, use of health services, and health care expenditures. Rockville (MD): Agency for Health Care Policy and Research; 1991. National Medical Expenditure Survey Research Findings 14. AHCPR Pub. No. 92-0017.

U.S. Congress, Office of Technology Assessment. Does health insurance make a difference? Background paper. Washington: U.S. Government Printing Office; 1992. Report No. OTA-BP-H-99.

Vistnes JP, Monheit AC. Health insurance status of the civilian noninstitutionalized population: 1996. Rockville (MD): Agency for Health Care Policy and Research; 1997. MEPS Research Findings No. 1. AHCPR Pub. No. 97-0030.

Vistnes JP, Zuvekas SH. Health insurance status of the civilian noninstitutionalized population: 1997. Rockville (MD): Agency for Health Care Policy and Research; 1999. MEPS Research Findings No. 8. AHCPR Pub. No. 99-0030.

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Appendix

Derivation of Insurance Status Information		Rounding
Health Insurance Edits		Comparisons With Other Data Sources
Population Characteristics		Population and Standard Error Tables
Sample Design and Accuracy of Estimates

This data in this report were obtained in the third round of interviews for the Household Component (HC) of the 1997 Medical Expenditure Panel Survey (MEPS) and the first round of interviews from the 1998 MEPS HC. MEPS is cosponsored by the Agency for Healthcare Research and Quality (AHRQ) and the National Center for Health Statistics (NCHS). The MEPS HC is a nationally representative survey of the U.S. civilian noninstitutionalized population that collects medical expenditure data at both the person and household levels. The focus of the MEPS HC is to collect detailed data on demographic characteristics, health conditions, health status, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income, and employment. In other components of MEPS, data are collected on the use, charges, and payments reported by providers; residents of licensed or certified nursing homes; and the supply side of the health insurance market.

The sample for the MEPS HC was selected from respondents to the National Health Interview Survey (NHIS), which was conducted by NCHS. NHIS provides a nationally representative sample of the U.S. civilian noninstitutionalized population and reflects an oversampling of Hispanics and blacks. The MEPS HC collects data through an overlapping panel design. In this design, data are collected through a precontact interview that is followed by a series of five rounds of interviews over 2 1/2 years. Two calendar years of medical expenditure and utilization data are collected from each household and captured using computer-assisted personal interviewing (CAPI). This series of data collection rounds is launched again each subsequent year on a new sample of households to provide overlapping panels of survey data which, when combined with other ongoing panels, will provide continuous and current estimates of health care expenditures. The reference period for Round 3 of the 1997 MEPS HC (Panel 2) was from the Round 2 interview date to the Round 3 interview date. The reference period for Round 1 of the 1998 MEPS HC (Panel 3) was from January 1, 1998, to the date of the Round 1 interview. Interviews for Panel 2 (Round 3) and Panel 3 (Round 1) were conducted from March to July 1998.

Derivation of Insurance Status Information

The household respondent was asked if during the interview period anyone in the family was covered by any of the sources of public and private health insurance coverage discussed in the following paragraphs. For respondents in their third MEPS interview (Panel 2), previously reported insurance was reviewed to determine whether it was still in effect and when changes in insurance status had occurred. Although Panel 2 survey respondents were asked about their insurance information for part of 1997 as well as 1998, the insurance information in this report refers to coverage only in 1998. Medicare and TRICARE coverage were measured at the time of the interview. (TRICARE, the present military coverage, replaced CHAMPUS and CHAMPVA.) All other sources of insurance were measured for any time between January 1998 and the interview. Persons counted as uninsured were uninsured throughout this time period.

Public Coverage

For this report, individuals were considered to have public coverage only if they met both of the following criteria:

They were not covered by private insurance.
They were covered by one of the public programs discussed below.

Medicare

Medicare is a federally financed health insurance plan for the elderly, persons receiving Social Security disability payments, and most persons with end-stage renal disease. Medicare Part A, which provides hospital insurance, is automatically given to those who are eligible for Social Security. Medicare Part B provides supplementary medical insurance that pays for medical expenses and can be purchased for a monthly premium.

Tricare

TRICARE covers active-duty and retired members of the Uniformed Services and the spouses and children of active-duty, retired, and deceased members. Spouses and children of veterans who died from a service-connected disability or who are permanently disabled and not eligible for Medicare are covered by TRICARE. In this report, TRICARE coverage is considered to be public coverage. When persons covered by TRICARE reach age 65, their coverage generally ends and enrollees are eligible for Medicare.

Medicaid

Medicaid is a means-tested government program jointly financed by Federal and State funds that provides health care to those who are eligible. Program eligibility criteria vary significantly by State, but the program is designed to provide health coverage to families and individuals who are unable to afford necessary medical care.

Other Public Hospital/Physician Coverage

Respondents who did not report Medicaid coverage were asked if they were covered by any other public hospital/physician coverage. These questions were asked in an attempt to identify Medicaid recipients who might not have recognized their coverage as Medicaid as well as to identify children covered by the State Children's Health Insurance Program (SCHIP). In this report, all coverage reported in this manner is considered public coverage.

Private Health Insurance

Private health insurance was defined for this report as insurance that provides coverage for hospital and physician care (including Medigap coverage). Insurance that provides coverage for a single service only, such as dental or vision coverage, was not counted. Private health insurance could have been obtained through an employer, union, self-employed business, directly from an insurance company or a health maintenance organization (HMO), through a group or association, or from someone outside the household.

Uninsured

The uninsured were defined as persons not covered by Medicare, TRICARE, Medicaid, other public hospital/physician programs, or private hospital/physician insurance (including Medigap coverage) during the period from January 1998 through the time of the interview. Individuals covered only by noncomprehensive State-specific programs (e.g., Maryland Kidney Disease Program) or private single-service plans (e.g., coverage for dental or vision care only, coverage for accidents or specific diseases) were not considered to be insured.

Health Insurance Edits

For the Round 1 (Panel 3) sample, minimal editing was performed on sources of public coverage and no edits were performed on the private coverage variables. For Round 3 (Panel 2), most of the insurance variables were logically edited to address issues that arose during Rounds 2 and 3 when reviewing insurance reported in earlier rounds. The health insurance data were edited as described below.

Medicare

Medicare coverage was edited for persons age 65 and over but not for persons under age 65. Persons age 65 and over were assigned Medicare coverage if they met one of the following criteria:

They answered "yes" to a follow-up question on whether they had received Social Security benefits.
They were covered by Medicaid, other public hospital/physician coverage, or Medigap coverage.
Their spouse was age 65 or over and covered by Medicare.
They were covered by TRICARE.

Medicaid

This report does not distinguish among sources of public insurance. Medicaid or other public hospital/physician coverage was included when considering whether an individual was covered only by public insurance.

Tricare

Respondents age 65 and over who reported TRICARE coverage were instead classified as covered by Medicare.

Private Health Insurance

Private insurance coverage was unedited and unimputed for Round 1 (Panel 3). For Round 3 (Panel 2), most of the insurance variables were logically edited to address issues that arose during Rounds 2 and 3 when reviewing insurance reported in earlier rounds. One edit to the private insurance variables corrected for a problem concerning covered benefits when respondents reported a change in any of their health insurance plan names. Additional edits addressed issues of missing data on the time period of coverage.

Individuals were considered to be covered by private insurance if the insurance provided coverage for hospital/physician care. Medigap plans were included. Individuals covered by single-service plans only (e.g., dental, vision, or drug plans) were not considered to be privately insured. Sources of insurance with missing information regarding the type of coverage were assumed to contain hospital/physician coverage.

Population Characteristics

Place of Residence

Individuals were identified as residing either inside or outside a metropolitan statistical area (MSA) as designated by the U.S. Office of Management and Budget (OMB), which applied 1990 standards using population counts from the 1990 U.S. census. An MSA is a large population nucleus combined with adjacent communities that have a high degree of economic and social integration within the nucleus. Each MSA has one or more central counties containing the area's main population concentration. In New England, metropolitan areas consist of cities and towns rather than whole counties. Regions of residence are in accordance with the U.S. Bureau of the Census definition.

Race/Ethnicity

Classification by race and ethnicity was based on information reported for each household member. Respondents were asked if their race was best described as American Indian, Alaska Native, Asian or Pacific Islander, black, white, or other. They were also asked if their main national origin or ancestry was Puerto Rican; Cuban; Mexican, Mexicano, Mexican American, or Chicano; other Latin American; or other Spanish. All persons who claimed main national origin or ancestry in one of these Hispanic groups, regardless of racial background, were classified as Hispanic. Since the Hispanic grouping can include black Hispanic, white Hispanic, and other Hispanic, the race categories of black, white, and other do not include Hispanic.

Employment Status

Persons were considered to be employed if they were age 16 and over, and had a job for pay, owned a business, or worked without pay in a family business at the time of the Round 1 or Round 3 interview.

Sample Design and Accuracy of Estimates

MEPS is designed to produce estimates at the national and regional level over time for the civilian noninstitutionalized population of the United States and some subpopulations of interest. Each MEPS panel collects data covering a 2-year period, with the first three MEPS panels spanning 1996-97, 1997-98 and 1998-99, respectively. In this report, data from the 1998 portion of the third round of data collection for the MEPS Panel 2 sample are pooled with data from the first round of data collection for the MEPS Panel 3 sample (far right portion of Figure A).

The statistics presented in this report are affected by both sampling error and sources of nonsampling error, which include nonresponse bias, respondent reporting errors, interviewer effects, and data processing misspecifications. For a detailed description of the MEPS survey design, the adopted sample design, and methods used to minimize sources of nonsampling error, see Cohen (1997) and Cohen, Monheit, Beauregard, et al. (1996). The MEPS person-level estimation weights include nonresponse adjustments and poststratification adjustments to population estimates derived from the March 1998 Current Population Survey (CPS) based on cross-classifications by region, MSA status, age, race/ethnicity, and sex.

Tests of statistical significance were used to determine whether the differences between populations exist at specified levels of confidence or whether they occurred by chance. Differences were tested using Z-scores having asymptotic normal properties at the 0.05 level of significance. Unless otherwise noted, only statistical differences between estimates are discussed in the text.

Figure A. Overlapping panel design of the Medical Expenditure Panel Survey

Figure A. Overlapping panel design of the MEPS

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Panel 2

At its beginning in 1997, MEPS Panel 2 consisted of a sample of 6,281 households, a nationally representative subsample of the households responding to the 1996 National Health Interview Survey. The 1996 NHIS sampled Hispanic and black households at approximately 2.0 and 1.5 times the rate of other households, respectively. These oversampling rates are also reflected in the MEPS sample of households. The sample design for Panel 2 also oversampled the following policy-relevant groups (classified based on 1996 NHIS data) to produce more reliable estimates for these groups:

Adults (age 18 and over) with functional impairments (difficulty with one or more activities of daily living).
Children (under age 18) with limitations in activity.
Individuals ages 18-64 expected to incur high medical expenditures in 1997.
Individuals predicted to reside in low-income households (below 200 percent of poverty level).
Adults (age 18 and over) with health limitations other than functional impairments (difficulty with one or more instrumental activities of daily living).

More specifically, a hierarchical sampling scheme was used to select the MEPS sample. Among the NHIS households that were candidates for the MEPS sample, all those having at least one member in groups 1-3 were selected. Among the remaining households, those that contained at least one member in groups 4 or 5 were subsampled at a rate of .6. Finally, households that were not in any of the five groups were subsampled at a rate of .3.

The overall MEPS Panel 2 response rate at the end of Round 3 (when data were collected for the first part of 1998) was 67.9 percent. This overall rate reflects response to both the 1996 NHIS interview and the MEPS interviews for Rounds 1-3.

Panel 3

At the beginning in 1998, MEPS Panel 3 consisted of a sample of 5,166 households, a nationally representative subsample of the households responding to the 1997 National Health Interview Survey. Like the first MEPS sample for 1997 (Panel 2), the Panel 3 sample reflects the oversampling of Hispanic and black households.

The overall MEPS Panel 3 response rate at the end of Round 1 (when data were collected for the first part of 1998) was 75.3 percent. This overall rate reflects response to the 1997 NHIS interview and the MEPS Round 1 interview.

Combined Panel Response

Each panel was given approximately equal weight in the development of sampling weights to produce national estimates. Therefore, a pooled response rate for the survey respondents in this data set can be obtained by taking an average of the panel-specific response rates. This pooled response rate for the combined panels is 71.6 percent.

Rounding

Estimates presented in the tables were rounded to the nearest 0.1 percent. Standard errors, presented in Tables B-F, were rounded to the nearest 0.01. Population estimates in Tables 1-4 and Table A were rounded to the nearest thousand. Therefore, some of the estimates presented in the tables for population totals of subgroups will not add exactly to the overall estimated population total.

Comparisons With Other Data Sources

Other Surveys

Because of methodological differences, caution should be used when comparing these data with data from other sources. For example, CPS measures persons who are uninsured for a full year; NHIS measures persons who lack insurance at a given point in time--the month before the interview. The CPS interview that contains information on the health insurance status of the population is conducted annually, and NHIS collects insurance data on a continuous basis each year. In addition, unlike MEPS, CPS counts as insured military veterans whose source of health care is the Department of Veterans Affairs. CPS also counts children of adults covered by Medicaid as insured. For these preliminary estimates, MEPS did not consider these children insured unless their families reported them as such.

1997 MEPS Data

Users interested in comparing the 1997 and 1998 MEPS health insurance estimates should be aware that the standard errors presented in the tables do not account for the fact that the estimates are not independent. By design, the 1997 MEPS panel respondents are present in both the 1997 and 1998 sample populations. Users should also be aware of questionnaire wording differences in the Rounds 1 and 3 MEPS interviews. The questionnaire for the Round 3 interviews includes reviews of previously reported sources of health insurance coverage.

Table A. Health insurance coverage of the civilian noninstitutionalized population: Population estimates by type of coverage and selected population characteristics, United States, first half of 1998

Population characteristic	Total population	Any coverage	Any private coverage	Public only	Uninsured
Number in thousands
Total^a	268,297	226,032	184,144	41,888	42,264
Total under age 65^a	236,214	194,249	166,400	27,848	41,966
Age in years
Under 4	15,817	13,752	9,393	4,359	2,066
4-6	11,843	10,170	7,292	2,878	1,673
7-12	24,467	20,870	16,295	4,575	3,597
13-17	20,032	16,787	13,972	2,815	3,245
Total under 18	72,160	61,579	46,953	14,626	10,580
18	3,729	2,978	2,520	^c-	c-
19-24	20,779	14,180	12,279	1,900	6,600
25-29	18,881	13,703	12,172	1,531	5,178
30-34	20,123	15,945	14,314	1,631	4,178
35-54	78,598	66,753	61,453	5,317	11,846
55-64	21,944	19,111	16,726	2,384	2,834
65 and over	32,082	31,783	17,744	14,040	^c-
Employment status^b
Employed	133,653	112,074	106,106	5,969	21,578
Not employed	70,133	58,994	36,737	22,257	11,139
Sex
Male	130,999	108,235	90,260	17,975	22,764
Female	137,298	117,797	93,884	23,913	19,501
Race/ethnicity
Total Hispanic	30,726	20,960	14,420	6,540	9,766
Total black	33,643	26,724	16,897	9,827	6,919
Total white	193,489	169,915	146,461	23,454	23,573
Total other	10,439	8,433	6,367	2,067	2,006
Census region
Northeast	51,205	44,703	36,257	8,446	6,502
Midwest	62,723	55,543	47,746	7,797	7,180
South	94,014	76,336	60,931	15,405	17,678
West	60,355	49,450	39,211	10,239	10,905

^a Includes persons with unknown employment status.
^bFor individuals age 16 and over.
^cSample size too small to produce reliable estimates.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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Table B. Health insurance coverage of the civilian noninstitutionalized population: Standard errors by type of coverage and selected population characteristics, United States, first half of 1998 Corresponds to Table 1

Population characteristic	Private	Public only	Uninsured
Standard error
Total^a	0.71	0.51	0.46
Total under age 65^a	0.74	0.51	0.51
Age in years
Under 4	1.78	1.55	1.12
4-6	1.87	1.79	1.17
7-12	1.44	1.24	0.98
13-17	1.65	1.12	1.27
Total under 18	1.10	0.97	0.71
18	3.03	2.00	2.46
19-24	1.60	0.85	1.40
25-29	1.65	0.82	1.31
30-34	1.28	0.81	1.18
35-54	0.76	0.40	0.59
55-64	1.20	0.78	0.96
65 and over	1.39	1.38	0.18
Employment status^b
Employed	0.63	0.27	0.54
Not employed	1.04	0.91	0.64
Sex
Male	0.78	0.57	0.50
Female	0.75	0.55	0.49
Race/ethnicity
Total Hispanic	1.52	1.13	1.31
Total black	1.59	1.60	0.98
Total white	0.68	0.46	0.51
Total other	3.59	3.02	2.80
Hispanic male	1.67	1.26	1.42
Black male	2.15	1.94	1.25
White male	0.76	0.52	0.56
Other male	4.03	3.40	3.13
Hispanic female	1.80	1.37	1.51
Black female	1.61	1.65	1.24
White female	0.77	0.55	0.56
Other female	3.90	3.32	2.99
Marital status^b
Married	0.77	0.44	0.56
Widowed	1.82	1.75	0.81
Divorced	1.27	1.10	1.11
Separated	3.00	2.18	2.39
Never married	1.09	0.71	0.87
Metropolitan statistical area (MSA)
MSA	0.82	0.57	0.52
Non-MSA	1.54	0.97	1.23
Census region
Northeast	1.47	0.97	0.90
Midwest	1.49	0.88	0.96
South	1.22	0.90	0.85
West	1.44	1.15	0.90

^a Includes persons with unknown employment status and marital status.
^bFor individuals age 16 and over.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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Table C. Health insurance coverage of the civilian noninstitutionalized population under age 65: Standard errors by type of coverage and selected population characteristics, United States, first half of 1998 Corresponds to Table 2

Population characteristic	Private	Public only	Uninsured
Standard error
Total^a	0.74	0.51	0.51
Employment status^b
Employed	0.62	0.25	0.55
Not employed	1.28	1.02	0.93
Sex
Male	0.81	0.56	0.55
Female	0.78	0.56	0.55
Race/ethnicity
Total Hispanic	1.60	1.17	1.37
Total black	1.65	1.62	1.04
Total white	0.71	0.43	0.58
Total other	3.71	3.07	2.89
Hispanic male	1.71	1.25	1.47
Black male	2.21	2.01	1.35
White male	0.80	0.47	0.62
Other male	4.22	3.56	3.28
Hispanic female	1.90	1.41	1.60
Black female	1.70	1.61	1.30
White female	0.78	0.52	0.66
Other female	3.96	3.18	3.10
Marital status^b
Married	0.77	0.34	0.65
Widowed	3.69	2.40	2.88
Divorced	1.32	1.05	1.22
Separated	3.11	2.15	2.50
Never married	1.09	0.66	0.88
Metropolitan statistical area (MSA)
MSA	0.86	0.57	0.56
Non-MSA	1.61	0.99	1.43
Census region
Northeast	1.57	1.02	1.01
Midwest	1.51	0.90	1.11
South	1.33	0.93	0.91
West	1.46	1.11	0.98

^a Includes persons with unknown employment status and marital status.
^bFor individuals age 16 and over.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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Table D. Health insurance coverage of the civilian noninstitutionalized population: Standard errors by type of coverage and perceived health status, United States, first half of 1998 Corresponds to Table 3

Population characteristic	Private	Public only	Uninsured
Standard error
Total under age 65^a	0.74	0.51	0.51
Total age 65 and over^a	1.39	1.38	0.18
Perceived health status, under age 65
Excellent	0.91	0.60	0.67
Very good	0.88	0.57	0.76
Good	1.14	0.80	0.88
Fair	1.75	1.37	1.56
Poor	2.52	2.48	2.09
Perceived health status, age 65 and over
Excellent	3.19	3.22	*0.48
Very good	2.42	2.40	*0.40
Good	2.28	2.27	*0.39
Fair	3.01	3.02	*0.23
Poor	2.94	2.92	*0.67

^a Includes persons with unknown perceived health status.
^*Relative standard error is greater than or equal to 30 percent.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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Table E. Total population and uninsured persons under age 65: Standard errors by selected population characteristics, United States, first half of 1998 Corresponds to Table 4

Population characteristic	Percent distribution of population	Percent uninsured	Percent distribution of uninsured population
Standard error
Total^a	--	0.51	--
Age in Years
Under 4	0.20	1.12	0.39
4-6	0.17	1.17	0.32
7-12	0.24	0.98	0.54
13-17	0.23	1.27	0.58
Total under 18	0.39	0.71	0.89
18	0.12	2.46	0.24
19-24	0.26	1.40	0.75
25-29	0.31	1.31	0.65
30-34	0.26	1.18	0.57
35-54	0.40	0.59	0.79
55-64	0.35	0.96	0.52
Sex
Male	0.33	0.55	0.72
Female	0.33	0.55	0.72
Race/ethnicity
Total Hispanic	0.57	1.37	1.32
Total black	0.82	1.04	1.24
Total white	0.99	0.58	1.62
Total other	0.38	2.89	0.76
Hispanic male	0.31	1.47	0.77
Black male	0.39	1.35	0.73
White male	0.58	0.62	1.09
Other male	0.22	3.28	0.41
Hispanic female	0.28	1.60	0.67
Black female	0.46	1.30	0.69
White female	0.59	0.66	1.00
Other female	0.20	3.10	0.44
Marital status^b
Married	0.45	0.65	1.00
Widowed	0.10	2.88	0.23
Divorced	0.26	1.22	0.65
Separated	0.14	2.50	0.33
Never married	0.39	0.88	1.05
Census region
Northeast	1.09	1.01	1.37
Midwest	0.96	1.11	1.42
South	1.22	0.91	1.78
West	1.08	0.98	1.33
Perceived health status
Excellent	0.64	0.67	1.16
Very good	0.51	0.76	1.07
Good	0.48	0.88	1.09
Fair	0.19	1.56	0.64
Poor	0.12	2.09	0.31

^a Includes persons with unknown marital status and perceived health status.
^bFor individuals age 16 and over.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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Table F. Health insurance coverage of the civilian noninstitutionalized population: Standard errors by type of coverage and selected population characteristics, United States, first half of 1998 Corresponds to Table A

Population characteristic	Any coverage	Any private coverage	Public only	Uninsured
Standard error in thousands
Total^a	5,654	5,221	1,447	1,469
Total under age 65^a	5,093	4,845	1,249	1,461
Age in years
Under 4	577	499	278	184
4-6	498	416	246	157
7-12	708	675	311	261
13-17	656	621	236	267
Total under 18	1,814	1,635	756	555
18	258	235	-	-
19-24	634	612	181	385
25-29	771	743	161	332
30-34	704	657	173	277
35-54	1,899	1,840	329	532
55-64	874	804	191	221
65 and over	1,149	822	632	-
Employment status^b
Employed	3,271	3,192	373	833
Not employed	1,623	1,251	837	520
Sex
Male	2,905	2,723	783	812
Female	2,933	2,662	825	775
Race/ethnicity
Total Hispanic	1,061	740	521	591
Total black	1,669	1,089	867	579
Total white	5,216	4,689	1,080	1,122
Total other	832	727	349	344
Census region
Northeast	2,921	2,506	699	644
Midwest	2,499	2,331	619	658
South	3,114	2,919	850	1,002
West	2,913	2,714	674	602

^a Includes persons with unknown employment status.
^bFor individuals age 16 and over.
Sample size too small to produce reliable estimates.

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 1998.

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Suggested Citation:
Rhoades, J. A., Brown, Jr., E., and Vistnes, J. P. Research Findings #11: Health Insurance Status of the Civilian Noninstitutionalized Population,1998. April 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/data_files/publications/rf11/rf11.shtml

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