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1 Shifting Health Insurance Coverage, Economic expansion, welfare reform, and SCHIP have changed who has insurance coverage, but not across the board. b y S t e ph e n Z u c k e r m a n, Ge n e v i e v e M. K e n n e y, L i s a D u b a y, Je n n i f e r H a l e y, an d Jo h n Ho l ah a n Th e f o r c e s t h a t a f f e c t private and public health insurance coverage have been shifting over the past several years. During the 1990s unprecedented economic expansion brought increased employment and higher incomes, which should have raised access to job-based coverage. 1 Nevertheless, evidence on how employer offer rates have been changing is mixed. 2 There is consistent evidence, however, that employee takeup rates have been falling, and the costs of coverage may be changing differently for different types of coverage. 3 Public health insurance programs also have been in transition. Federal welfare reform may have had the unintended side effect of reducing Medicaid participation among eligible children and adults. 4 At the same time, the State Children s Health Insurance Program (SCHIP) has expanded coverage to children with higher family incomes than traditionally covered under public programs. However, most states SCHIP programs were not yet mature in A few states have taken advantage of new policy options to expand Medicaid coverage to low-income parents and other nonelderly adults. 6 This paper uses the National Survey of America s Families (NSAF) to assess how health insurance coverage is changing for children and adults in various income groups and states. This analysis was done as part of the Urban Institute s Assessing the New Federalism (ANF) project. 7 Data And Methods We used the 1997 and 1999 rounds of NSAF to examine changes in insurance coverage over those two years. 8 NSAF is a household survey that provides information on more than 100,000 children and nonelderly adults in each round and is representative of the noninstitutionalized civilian population under age sixty-five. Interviews were conducted in households with and without telephones using computer-assisted telephone interviewing technology. NSAF oversamples lowincome families (defined as having incomes below 200 percent of the federal poverty level, $33,400 for a family of four in 1999). In addition, it has large enough samples to provide reliable estimates for each of thirteen states intensively studied as part of the ANF project and an additional sample drawn from the other states to make estimates that are representative of the nation as a whole. 9 The data are weighted to provide reliable national and state estimates. 10 Detailed information was collected on up to two children in each family from the adult who knew the most about the child s education and health care. The response rates for the 1997 and 1999 rounds were about 70 and 64 percent, respectively. 11 Standard errors 169 Stephen Zuckerman and Genevieve Kenney are principal research associates, Lisa Dubay is a senior research associate, and Jennifer Haley is a research associate at the Urban Institute s Health Policy Center in Washington, D.C. John Holahan is director of the center Project HOPE ThePeople-to-PeopleHealth Foundation, Inc.

2 170 used to conduct the tests of statistical significance on changes over time and differences across subgroups are based on the balanced repeated replication method to account for the complex nature of the sample design. 12 n Categorization. Respondents were asked about their family s health insurance coverage at the time of the survey, including a question that confirmed the absence of coverage for household members who were not originally identified as having any type of coverage. 13 Responses were categorized into one of the following groups: (1) employer coverage (includes coverage from a current or former employer or union or under a military program); (2) Medicaid/SCHIP/state; (3) other (includes Medicare, private coverage, and other coverage that is not classifiable elsewhere); and (4) uninsured. 14 Health insurance is defined using a hierarchy; persons with both employer coverage and some other form of coverage were classified as having employer coverage. 15 n NSAF versus CPS. The approach to measuring insurance coverage in NSAF differs from that used in the Current Population Survey (CPS) the most widely cited source of health insurance information in several important ways. These differences were designed to address some of the concerns that have been expressed about the CPS related to potential recall problems, the treatment of uninsurance as a residual, and identification of coverage through state programs. 16 First, we measured insurance coverage at the time of the survey as opposed to the CPS approach of asking about coverage from the previous calendar year. Second, we used a question to confirm that people for whom no coverage has been reported during the main battery of questions were actually uninsured. 17 Finally, we included separate questions that asked about coverage related to SCHIP or state programs. 18 All of these features are designed to avoid missing insurance coverage. Despite potential problems in using the CPS to estimate the level of uninsurance, there is an extensive literature that relies on the CPS to track insurance coverage trends. 19 Although national trends covering a period comparable to, and much longer than, NSAF could be derived from the CPS, we feel that it is still appropriate to consider the national estimates of change based on NSAF in this paper. These estimates provide a consistent context for considering the NSAF state estimates, which are, with the exception of California, based on much larger samples than are available from the CPS. n Population groups. We present separate analyses for children (age eighteen and under) and nonelderly adults (ages nineteen to sixty-four) nationally and by state. 20 We also examine national patterns of change for low-income adults by race/ethnicity, selfreported health status, and parental status. Parents are defined as adults who live in a household with their biological, step, or adoptive child under age eighteen; all other adults are classified as nonparents. Findings n Levels of and changes in insurance coverage. Nationally, 9.6 million children and 26.5 million adults 13 percent of all children and 16 percent of all adults lacked health insurance coverage in 1999 (Exhibit 1). Overall, rates of uninsurance did not change significantly between 1997 and 1999 for either adults or children, but trends did differ between income groups. Higher-income children experienced a one-percentage-point increase in their uninsurance rate, while rates remained steady for low-income children. 21 In contrast, uninsurance rates for higher-income adults did not change. The uninsurance rate of low-income adults decreased by almost two percentage points (from 37 percent to 35 percent) but this change was not statistically significant. While the disparity between the uninsurance rates of the lower and higher income groups narrowed slightly for both adults and children between 1997 and 1999, the low-income population remained much more likely than the higher-income population was to lack insurance coverage. Patterns of coverage varied widely by fam- H E A L T H A F F A I R S ~ V o l u m e 2 0, N u m b e r 1

3 EXHIBIT 1 Changes In Health Insurance Coverage Of U.S. Children And Adults, By Poverty Level, Chidren (ages 0 18) Total < 200% of poverty > 200% of poverty Adults (ages 19 64) Total < 200% of poverty > 200% of poverty 66.7% % *** 1.2** 3.2*** % % 1.0*** * 4.5% % * 12.5% SOURCE: Urban Institute tabulations from the 1997 and 1999 National Survey of America s Families (NSAF). NOTES: Changes between 1997 and 1999 are presented in percentage points. SCHIP is State Children s Health Insurance Program. * p <.10 ** p <.05 *** p < % ** ily income for both children and adults. More than 80 percent of children and adults with family incomes above 200 percent of poverty had employer coverage, compared with 39 percent of low-income children and 42 percent of low-income adults. At the same time, 35 percent of low-income children and 15 percent of low-income adults received coverage through Medicaid/SCHIP/state programs, compared with 4 percent of children and about 1 percent of adults with family incomes above 200 percent of poverty. Over this period, changes in types of coverage among children differed across income groups, which may partially reflect the effects of federal welfare reform and SCHIP. Although Medicaid/SCHIP/state coverage did not change significantly across all lowincome children, it fell for poor children relative to other children (data not shown), a likely consequence of welfare reform. 22 At the same time, Medicaid/SCHIP/state coverage increased for children with family incomes between 100 and 200 percent of poverty the group primarily targeted by SCHIP during the period. In addition, children with family incomes between 200 and 300 percent of poverty also gained Medicaid/SCHIP/state coverage, but still only 7 percent relied on this source. Changes in employer coverage varied between adults and children and across income groups. Among children, those in families with incomes above 200 percent of poverty lost employer coverage; these children were 2.8 percentage points less likely to rely on employer coverage in 1999 than they were in These declines appear to be responsible for the rising rates of uninsurance among these children. Over this same period, the rate of employer coverage increased by 3.2 percentage points among low-income adults. However, this did not translate into a significant decrease in uninsurance because of small and statistically insignificant decreases in Medicaid/state and other coverage. Insurance Coverage Among Low-Income Adults Although the uninsurance rate for lowincome adults was not significantly lower in 1999 than in 1997, there were significant gains in coverage for certain subgroups of lowincome adults (Exhibit 2). Similar analysis was also performed for different subgroups of low-income children, but very little change was found, and the results are not reported here. 23 n Race and ethnicity. Across racial/ ethnic groups, the gain in employer coverage for low-income adults in seems to be concentrated among whites. 24 They started out with a higher rate of employer coverage in 1997 than either blacks or Hispanics, and the coverage gap between whites and Hispanics 171

4 EXHIBIT 2 Changes In Health Insurance Coverage Of Low-Income Adults, By Selected Characteristics, All low-income adults 41.7% 3.2% 14.7% 0.6% 8.8% % 34.9% 1.6% Race/ethnicity a White non-hispanic Black non-hispanic Hispanic Fair/poor health Excellent/very good/good health Parent Nonparent *** *** 2.5** ** *** * * * ** ** SOURCE: Urban Institute tabulations from the 1997 and 1999 National Survey of America s Families (NSAF). NOTES: Changes between 1997 and 1999 are presented in percentage points. Adults are persons ages nineteen to sixty-four. a Those classified in other race/ethnicity groups were excluded from this exhibit, because of insufficient sample size. * p <.10 ** p <.05 *** p < appears to have expanded by Almost half of white low-income adults had employer coverage in 1999, up from 43 percent in In comparison, the employer coverage rate in 1999 for blacks was 36 percent and for Hispanics, almost 30 percent. The gains among low-income whites were sufficient to lead to a significant reduction in their uninsurance rate, from 31 percent to 29 percent. n Health status. Employer coverage rates among low-income adults increased over the period, regardless of health status. For those in fair or poor health, the coverage rate increased from 23 percent to 28 percent, resulting in a reduction in their uninsurance rate from 41 percent to 35 percent. This suggests that the expansion in employer coverage among low-income adults was helping persons for whom nongroup coverage might be expensive and possibly unavailable. Nevertheless, low-income adults in fair or poor health remained much more dependent on coverage through Medicaid or a state program than did other low-income adults. The gains in employer coverage were not large enough to lower the uninsurance rate of healthier low-income adults, because of small reductions in other types of health insurance. n Parents and nonparents. The national patterns of change in insurance coverage are quite different for low-income parents than for other low-income adults. Low-income parents did not see a significant gain in employer coverage, but Medicaid/state coverage declined significantly, from 19 percent to 16 percent. Despite this loss, the small but statistically insignificant gains in employer coverage resulted in a fairly stable uninsurance rate for parents (36 percent). Data not shown indicate that most of this statistically significant loss in Medicaid/state coverage was concentrated among parents with incomes below the poverty level and occurred in seven of the thirteen ANF states. This is consistent with other studies showing that adults leaving welfare have lost Medicaid coverage, possibly due to welfare reform. 25 As a result of gains in employer and public coverage, uninsurance rates for low-income nonparents fell from 38 percent to 34 percent. Thus, low-income nonparents moved from being slightly worse off than low-income parents in 1997 to being slightly better off in Variation Across States As shown in Exhibit 3, there was substantial cross-state variation in the 1999 uninsurance rates for both children and adults, a pattern similar to that observed in Among children and adults at all income levels, uninsurance rates were well below average in Massachusetts and Minnesota and well above H E A L T H A F F A I R S ~ V o l u m e 2 0, N u m b e r 1

5 EXHIBIT 3 Changes In Uninsurance Rates Of U.S. Children And Adults In Thirteen States, By State And Poverty Level, U.S. total 12.5% % % % 1.6 AL CA CO FL MA MI MN MS NJ NY TX WA WI *** ** *** 1.7* ** 2.0* *** * *** ** *** ** * *** SOURCE: Urban Institute tabulations from the 1997 and 1999 National Survey of America s Families (NSAF). NOTES: Children are persons from birth to age eighteen. Adults are persons ages nineteen to sixty-four. Changes between 1997 and 1999 are presented in percentage points. * p <.10 ** p <.05 *** p < average in California and Texas. Among lowincome children, uninsurance rates ranged from 7 percent in Massachusetts to 37 percent in Texas. For low-income adults, uninsurance rates ranged from 19 percent in Massachusetts and 20 percent in Minnesota to 41 percent in California and 47 percent in Texas. n States with uninsurance declines. Alabama, Colorado, and Massachusetts were the only states in Exhibit 3 that had significant declines in uninsurance rates for all children and adults as well as for those in lowincome families. 27 Focusing on low-income adults and children (Exhibit 4), we see that the reasons for the decrease in uninsurance rates varied across the three states. For the discussion of changes in types of insurance coverage at the state level, we combined the employer and other coverage categories. In Colorado and Alabama the gains in employer/other coverage were sufficient to lower uninsurance rates by between five and ten percentage points. In fact, for low-income adults in Colorado the group with the smallest improvement the gains were large enough to overcome a small but significant decrease in Medicaid/state coverage. In Alabama, low-income children gained both employer/other coverage and Medicaid/SCHIP/ state coverage, which together led to a 9.7- percentage-point reduction in their uninsurance rate. The gains in public coverage among low-income children in Alabama may be traced to the implementation of ALL Kids, one of the first SCHIP programs in the nation to be approved. Alabama s separate SCHIP program was layered on top of a limited Medicaid program. The ALL Kids launch was accompanied by broad-based outreach and a simplified joint Medicaid/SCHIP application. 28 In contrast to Colorado and Alabama, there were three states Michigan, Texas, and Washington in which low-income adults or children, or both, experienced statistically significant gains in employer/other coverage without a reduction in uninsurance rates (data not shown). 29 In each of these cases, a decrease in public coverage (sometimes not statistically significant) offset the employer/other gains. In Colorado and Alabama, on the other hand, public coverage held steady, declined by much less than the gains in employer/other coverage, or actually increased (Exhibit 4). 173

6 EXHIBIT 4 Changes In Health Insurance Coverage Of Low-Income Populations, In Three States With Falling Uninsurance Rates, Children (ages 0 18) AL CO MA Adults (ages 19 64) AL CO MA 45.9% * 5.9* 6.7** 7.3*** 7.8** % * *** 2.9** 7.9*** 14.7% *** 7.0** 7.3*** 6.3** 4.9* 10.7*** SOURCE: Urban Institute tabulations from the 1997 and 1999 National Survey of America s Families (NSAF). NOTES: Changes between 1997 and 1999 are presented in percentage points. SCHIP is State Children s Health Insurance Program. *p <.10 **p <.05 ***p < In Massachusetts, low-income children experienced a 7.3-percentage-point reduction in the rate of uninsurance, while low-income adults experienced a 10.7-percentage-point reduction (Exhibit 4). This growth in coverage appears to be associated with a substantial expansion of the Massachusetts Medicaid program and the consolidation of it and other state health insurance programs into a single seamless system called MassHealth. 30 The increases in Medicaid/SCHIP/state coverage in were fourteen percentage points for children and 7.9 percentage points for adults. Public coverage in Massachusetts expanded among both low-income parents and nonparents (data not shown). These increases were all occurring at a time when Medicaid/ SCHIP/state coverage was flat for the nation as a whole. 31 The expansion of public coverage to nonparents is particularly notable because typically this group is excluded from public programs unless they are disabled. While the increase in public coverage in Massachusetts seemed to lower the rate of uninsurance, it is possible that these expansions reduced the rate of employer coverage. To address this policy concern, we conducted a separate analysis (not shown in the exhibits) of changes in employer coverage in Massachusetts and the rest of the nation. The data present a mixed picture on this issue. On the one hand, the rate of employer coverage for low-income children fell in Massachusetts while increasing in the rest of the United States. However, significant declines in employer coverage were also experienced by children with family incomes between 200 and 300 percent of poverty in Massachusetts, which suggests that there may have been forces at work, other than MassHealth, that led to this erosion in employer coverage. In addition, for low-income adults the changes in employer coverage were not statistically different from those in the rest of the nation. Thus, while some drop in employer coverage because of the MassHealth expansions cannot be ruled out completely, the predominant effect of MassHealth appears to have been to reduce dramatically the number of uninsured persons in the state. Discussion This paper shows that even over a period as short as two years, the ongoing economic expansion, welfare reform, and SCHIP have been changing who has insurance coverage as well as the relative importance of various types of coverage. However, the influence of these forces is not being felt uniformly among all adults and children or across all states. The economic expansion, for example, seems to be associated with increased employer coverage among low-income adults but not among higher-income adults or chil- H E A L T H A F F A I R S ~ V o l u m e 2 0, N u m b e r 1

7 dren. In fact, the gains were not experienced by all low-income adults. Significant gains among whites are widening the coverage gap between them and Hispanics. For higherincome children, employer coverage actually decreased. Although higher-income children are about half as likely to be uninsured as lowincome children are, they may become more of a policy concern than they are now if this downward trend continues. Variations in the apparent influence of policy changes are more predictable, given that many policies are targeted at specific types of persons. Reductions in Medicaid coverage resulting from welfare reform should have affected poor children and parents, because families with children were much more likely to receive cash assistance and be covered by Medicaid before reform. This is precisely the pattern observed in this study. In fact, the reduction in Medicaid coverage among parents increased their risk of being uninsured in 1999 to a level above that of nonparents. In terms of SCHIP, the recent experiences in Massachusetts and Alabama two states that implemented the program relatively quickly suggests that SCHIP may be starting to expand coverage among low-income children. Despite these positive signs, SCHIP does not appear to be lowering uninsurance rates for low-income children in other states or nationally. However, it would be premature to judge SCHIP on that basis. Given the time it takes to implement major new programs, large declines in uninsurance rates for lowincome children should not have been expected by Within the next few years, SCHIP programs will mature. Ultimately, the program s success will depend upon its ability to make large inroads into the population of low-income uninsured children over time. MassHealth s apparent success in increasing coverage may be a signal that a broadbased seamless approach that covers whole families is more likely to succeed than programs that only cover children. Future research should explore whether the success of this approach is limited to Massachusetts or if other states with similar approaches, such as Wisconsin, also have large reductions in uninsurance. Despite the changes we observe in insurance coverage, large differences persist between low-income and higher-income groups and across states. In 1999 low-income children and adults were more than three times more likely than their higher-income counterparts to lack health insurance. In addition, the states that had low rates of employer coverage and high rates of uninsurance in 1997 remained the same in Over time, as the full effects of SCHIP are felt and if more policies that extend eligibility to parents of already-eligible children are adopted, some of these coverage gaps could narrow. States now have the flexibility to cover low-income parents under Medicaid, but these new provisions still leave many uninsured parents ineligible for coverage. 33 In addition, finding the appropriate incentives to encourage states to cover parents and getting them to enroll in the programs may be difficult. Moreover, current Medicaid rules constrain states in their options for covering nonparents. Overlaid on these policy challenges is the sobering reality that the economic expansion that appears to have helped some subgroups of the population has not really changed the overall patterns of coverage and cannot be expected to continue indefinitely. This paper is part of the Assessing the New Federalism project, which has received funding from the Annie E. Casey, W.K. Kellogg, Robert Wood Johnson, Henry J. Kaiser Family, Ford, John D. and Katherine T. MacArthur, Charles Stewart Mott, and David and Lucile Packard Foundations and several other foundations. The authors thank Alan Weil, Alyssa Wigton, and three anonymous reviewers for their helpful comments. The opinions expressed are those of the authors and do not represent those of the Urban Institute, its trustees, or its sponsors. 175

8 176 NOTES 1. Economic Report of the President (Washington: U.S. Government Printing Office, February 2000). 2. H. Farber and H. Levy, Recent Trends in Employer-Sponsored Health Insurance Coverage: Are Bad Jobs Getting Worse? Journal of Health Economics 19, no. 1 (2000): ; and P. Cooper and B.S. Schone, More Offers, Fewer Takers for Employment-Based Health Insurance: 1987 and 1996, Health Affairs (Nov/Dec 1997): Ibid.; and P.B. Ginsburg, Tracking Health Care Costs: Long-Predicted Upturn Appears, Issue Brief no. 23 (Washington: Center for Studying Health System Change, November 1999). 4. M.R. Ellwood, The Medicaid Eligibility Maze: Coverage Expands, but Enrollment Problems Persist: Findings from a Five-State Study, Assessing the New Federalism Occasional Paper no. 30 (Washington: Urban Institute, December 1999); M.R. Ellwood and K. Lewis, On and Off Medicaid: Enrollment Patterns for California and Florida in 1995, Assessing the New Federalism Occasional Paper no. 27 (Washington: Urban Institute, July 1999); B. Garrett and J. Holahan, Health Insurance Coverage after Welfare, Health Affairs (Jan/Feb 2000): ; and Families USA, Go Directly to Work, Do Not Collect Health Insurance: Low-Income Parents Lose Medicaid, (Washington: Families USA, June 2000). 5. F. Ullman, I. Hill, and R. Almeida, CHIP: A Look at Emerging State Programs, Assessing the New Federalism Policy Brief no. A-35 (Washington: Urban Institute, 1999); Children s Defense Fund, All Over the Map: A Progress Report on the State Children s Health Insurance Program (SCHIP) (Washington: Children s Defense Fund, 2000); and G.M. Kenney, F.C. Ullman, and A. Weil, Three Yearsinto SCHIP: What States Areand Are Not Spending, Assessing the New Federalism Policy Brief no. A-44 (Washington: Urban Institute, September 2000). 6. M. Krebs-Carter and J. Holahan, State Strategies for Covering Uninsured Adults, Assessing the New Federalism Discussion Paper no (Washington: Urban Institute, 2000). 7. A. Kondratas, A. Weil, and N. Goldstein, Assessing the New Federalism: An Introduction, Health Affairs (May/June 1998): ANF is a multiyear research project to analyze the devolution of responsibility for social programs from the federal government. 8. G. Kenney et al., The National Survey of America s Families: An Overview of the Health Policy Component, Inquiry (Fall 1999): ; and P.D. Brick et al., 1997 NSAF Data Editing and Imputation, National Survey of America s Families Methodology Report no. 10 (Washington: Urban Institute, 1999). 9. In the ANF project, thirteen states were selected for intensive study because they represented a mixture of approaches to health and social policy and because they were diverse geographically and economically. These thirteen states are Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin. 10. The weights adjust for design features of the survey, including oversampling low-income households and the study states, as well as nonresponse and undercoverage. See J.M. Brick et al., 1997 NSAF Snapshot Survey Weights, National Survey of America s Families Methodology Series Report no. 3 (Washington: Urban Institute, March 1999). 11. A. Safir, F. Scheuren, and K. Wang, National Survey of America s Families: Survey Methods and Data Reliability, 1997 and 1999, 2000, <newfederalism. urban.org/nsaf/survey-methods.html> (9 November 2000). 12. I. Flores- Cervantes, J.M. Brick, and R. DiGaetano, 1997 NSAF Variance Estimation, NSAF Methodology Series Report no. 3 (Washington: Urban Institute, March 1999). 13. S. Rajan, S. Zuckerman, and N. Brennan, Confirming Insurance Coverage in a Telephone Survey: Evidence from the National Survey of America s Families, Inquiry (Fall 2000): To have clearly delineated employer and Medicaid/state categories of insurance coverage, we included Medicare coverage with other coverage. Recall that Medicare is not a major source of coverage among the nonelderly population. 15. The impact of this hierarchy on our results should be minimal; only approximately 2 percent of the weighted sample in both years reported coverage in more than one of these four insurance categories. 16. K. Lewis, M. Ellwood, and J. Czajka, Counting the Uninsured: A Review of the Literature, Occasional Paper no. 8 (Washington: Urban Institute, July 1998); and P. Fronstin, Counting the Uninsured: A Comparison of National Surveys, Issue Brief no. 225 (Washington: Employee Benefit Research Institute, September 2000). 17. Rajan et al., Confirming Insurance Coverage. The CPS added a question to confirm lack of insurance coverage in the March 2000 survey. Results based on this new question are expected by the time of this publication. 18. In these questions, we used state-specific program names to enhance respondents recognition. The CPS is planning to move to a separate question related to SCHIP in its March 2001 survey. 19. J. Holahan and J. Kim, Why Does the Number of Uninsured Continue to Grow? Health Affairs (July/Aug 2000): ; and EBRI, Source of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1999 Current Population Survey, H E A L T H A F F A I R S ~ V o l u m e 2 0, N u m b e r 1

9 EBRI Issue Brief no. 217 (Washington: EBRI, January 2000). 20. We treat eighteen-year-olds as children in this analysis because they are eligible as children under both Medicaid and SCHIP. 21. Throughout this paper, all changes that we highlight are significant with p values of less than or equal to G. Kenney, L. Dubay, and J. Haley, Health Insurance, Access, and Health Status of Children, Snapshots of America s Families II: A View of the Nation and Thirteen States from the NSAF (Washington: Urban Institute, October 2000). We found that the changes between 1997 and 1999 in Medicaid/ SCHIP/state and employer coverage for poor children were significantly different from the changes for children in the other income groups. 23. Among the subgroups we examined, only Hispanic children experienced significant changes in coverage. The rate of employer coverage increased significantly by 3.2 percentage points, and the rate of Medicaid/SCHIP/state coverage decreased significantly by 5.4 percentage points. However, the uninsurance rate did not significantly change. 24. We classified adults into four mutually exclusive groups based on race and ethnicity: white non- Hispanic (white), black non-hispanic (black), Hispanic, and other non-hispanics (Asian and Pacific Islanders, Native Americans, and Aleutian or Eskimo). 25. Garrett and Holahan, Health Insurance Coverage after Welfare ; and Families USA, Go Directly to Work. 26. S. Zuckerman et al., Snapshots of America s Families: Variations in Health Care across States, Assessing the New Federalism Discussion Paper no (Washington: Urban Institute, 1999). 27. Only one state, Michigan, had a significant increase for all children, but the increase was small and still left uninsurance rates for children in Michigan far below the national average. A complete set of tabulations by state are available on the Web, <newfederalism.urban.org/nsaf/snapshots_ index.html>; and in S. Zuckerman, J. Haley, and J. Holahan, Health Insurance, Access, and Health Status of Nonelderly Adults, Snapshots of America s Families II (Washington: Urban Institute, October 2000); and Kenney et al., Health Insurance, Access, and Health Status of Children. 28. Alabama s ALL Kids SCHIP program expanded coverage to 200 percent of poverty; prior to SCHIP, Medicaid covered younger children at federally mandated minimums and older children at just 15 percent of poverty. ALL Kids use of the state s Blue Cross/Blue Shield organization for service delivery seems to be very popular among both consumers and providers. I. Hill and A. Westpfahl, Reaching and Enrolling Children: An Analysis of Outreach and Enrollment Strategies under SCHIP, Assessing the New Federalism Discussion Paper (Washington: Urban Institute, forthcoming). The large increases in Medicaid/SCHIP/state coverage in Alabama may be related to eligibility expansions under SCHIP, but they may also reflect rising enrollment in Medicaid among poor children. V.K. Smith, Enrollment Increases in State CHIP Programs: December 1998 to June 1999 (Washington: Kaiser Commission on Medicaid and the Uninsured, July 1999). 29. Kenney et al., Health Insurance, Access, and Health Status of Children ; and Zuckerman et al., Health Insurance, Access, and Health Status of Nonelderly Adults. 30. Using a Section 1115 Medicaid waiver starting in July 1997, Massachusetts extended coverage to children and parents with incomes up to 133 percent of poverty, long-term unemployed adults up to 133 percent of poverty, disabled adults above 133 percent of poverty, and adults up to 200 percent of poverty receiving unemployment benefits. The program was expanded incrementally over the next two years. By July 1999 eligibility for MassHealth had been expanded to include children with incomes up to 200 percent of poverty under SCHIP, the parents of these children, and nonparents with incomes up to 200 percent of poverty working for certain types of employers. For some of these children and parents, eligibility depends on their access to employer coverage and the type of coverage provided. Throughout this period, substantial investments were made to raise awareness about MassHealth and to streamline the enrollment system. 31. Consistent with this were large reported increases in Medicaid enrollment for families, adults, and children in Massachusetts relative to other states for which comparable administrative data were available. Kaiser Commission on Medicaid and the Uninsured, Medicaid Enrollment in 21 States: June 1997 to June 1999 (Washington: Kaiser Commission, April 2000). 32. Kenney et al., Three Years into SCHIP. 33. L. Dubay, G. Kenney, and S. Zuckerman, Extending Medicaid to Parents: An Incremental Strategy for Reducing the Number of Uninsured, Assessing the New Federalism Policy Brief no. B-20 (Washington: Urban Institute, June 2000). 177