The Purchase of Health Insurance by California s Non-Poor Uninsured: How Can It Be Increased?
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1 Policy Analysis Brief May 2004 C Series No. 1 The Purchase of Health Insurance by California s Non-Poor Uninsured: How Can It Be Increased? Claudia L. Schur, Jacob J. Feldman, and Lan Zhao Why Focus on the Non-Poor? Because the uninsured population is so heterogeneous, policy initiatives aimed at decreasing its size need to focus on particular segments of the uninsured. Persons who may be able or willing to purchase insurance coverage on their own are one segment of the population that has received relatively little attention and may be worth examining. We focus on uninsured persons toward the higher end of the income distribution who, therefore, may be more amenable to private coverage options. Our research shows that there are a substantial number of uninsured persons who would be considered non-poor, using a definition of twice the poverty level and above. During the four-year period 1996 through 1999, there were over 5 million non-poor Overview Policy initiatives aimed at decreasing the size of the uninsured population tend to focus on poor and low-income persons; in fact, approximately one-third of the uninsured have incomes at or above two times the poverty level. These non-poor uninsured have shorter periods without coverage than their poor counterparts, with almost half being uninsured for four months or less, probably during job or other transitions. A substantial number of the non-poor uninsured lack access to employer-sponsored health insurance through their workplace; others are the spouses and children of insured workers who may find family coverage too costly. Despite having incomes of more than twice the poverty level, the non-poor uninsured have lower incomes and fewer assets than their privately insured counterparts, and they report that lack of affordability is the primary reason that they are uninsured. In this brief, we provide more background on the heterogeneity of the non-poor uninsured and discuss targeted policy options that could expand coverage. persons uninsured at some time in California. Almost 30 percent of them were children less than 18 years of age, another 23 percent 1 were 18 to 24 years old, and 37 percent were Latinos (of all ages). Both of these latter groups tend to have high rates of uninsurance. (continued on page 2)
2 The non-poor uninsured have shorter uninsured spells than their poor counterparts; probably related to their higher incomes, they are more likely to be working and more likely to acquire private coverage after being uninsured. Compared to persons with private insurance, however, the non-poor uninsured have lower incomes and are somewhat less likely to be working. Still, 84 percent of the non-poor uninsured are in a family with at least one employed member (compared to 97 percent of the non-poor privately insured). Among the non-poor, the uninsured are, on average, no more likely to be in poor health than the privately insured. While there are certainly some individuals who face difficulties purchasing insurance because of their health, or who think they are so healthy that they don t need insurance, neither of these explanations for the lack of insurance applies to a large number of persons. What Do Policymakers Need to Know about the Non-Poor Uninsured? Policies to increase coverage among the uninsured need to consider the following pieces of information culled from this study: Half of the non-poor uninsured are without coverage for four months or less. Another one-third have uninsured spells lasting twelve months or more, and just over half of the non-poor uninsured had more than one time without coverage during the study period. From our analysis, it is clear that a substantial number of the non-poor uninsured are only temporarily without coverage. Those uninsured for shorter periods of time are somewhat better off, while those who remain uninsured for longer periods generally have lower means. For persons who lost insurance, half of all spells were less than four months. Even a brief period without coverage may put an individual or family at health and financial risk since a serious illness or injury can occur without warning. And the large number of persons with multiple uninsured spells indicates a somewhat tenuous connection to health insurance. Still, for many individuals, the problem of lack of coverage does get resolved. Children under 18 years of age, females, whites, and those with higher incomes were more likely to re-acquire coverage and least likely to have had long spells without insurance. From a policy perspective, a four-month period without coverage requires a different solution than persistent lack of coverage. Perhaps most importantly, these are people accustomed to having health insurance coverage and are likely to have a stronger inclination toward maintaining health insurance coverage. And they have slightly higher incomes than their counterparts with longer spells so they may be more able to purchase coverage on their own or with limited financial assistance. Most of the non-poor uninsured are working; even so, lack of availability of health insurance at the workplace remains a substantial barrier to coverage. The vast majority of persons nationally and in California obtain coverage through an employer. Obtaining health insurance coverage through the workplace is a tremendous benefit, not only because there is usually an employer contribution to the cost of the premium but also because group purchasers face substantially lower premium costs. It follows, then, that persons who do not have health coverage available at the workplace face a considerable financial disadvantage in buying insurance. 2 (continued on page 3)
3 The Purchase of Health Insurance by California s Non-Poor Uninsured: How Can It Be Increased? Among non-poor uninsured workers in California, 68 percent or 760,000 people were working but were not offered insurance from their employer. This does not include family members who also remain uninsured because of the lack of availability of employer-provided health benefits. Of those who were not offered coverage, approximately half worked for small firms with fewer than 25 employees. And about one in three were self-employed. Additionally, approximately one-fifth of non-poor uninsured workers were ineligible for the coverage offered to other workers at their place of employment. Of these ineligible workers, three-fifths were in a probationary period (e.g., had recently started a new job and were not yet eligible for coverage), onefifth were part-time workers, and one-fifth were contract or temporary employees. Health insurance is difficult to afford even for the nonpoor, and family coverage is particularly costly. Among the non-poor uninsured, the most frequent response when asked why they don t have health insurance is that they cannot afford it. Over two-thirds of our study group responded this way, while only a small proportion of persons (7%) said they didn t believe in insurance or didn t need coverage. Even with access to employerprovided health insurance, health insurance premiums are expensive. In 2003, the annual premium for a typical family policy was about $9, For those who don t have a substantial employer contribution available or don t have employerprovided coverage at all, this can represent a significant financial burden. Even for those with jobrelated coverage, the average annual employee contribution for family coverage was $2,400 in 2003, representing about 5 percent of annual income before taxes for a family with earnings just at the non-poor cut-off of two times poverty. Workers in smaller firms-- where the non-poor uninsured are disproportionately employed--are more likely to have to pay more than 50 percent of the family premium. Of all California non-poor uninsured children, about sixty percent had at least one parent with health insurance coverage. It is possible that a family option was not offered or, more likely, that the family premiums were substantially 1 The Kaiser Family Foundation and Health Research and Educational Trust Employer Health Benefits 2003 Summary of Findings, at 3 more costly than the employee-only premium, with little or no employer contribution. Many firms are beginning to increase premiums for larger families, and the proportion of employers that fully subsidize family coverage is falling; as a result, the percentage of employees choosing family coverage has fallen from 39 to 33 percent since Most of the non-poor uninsured are far from affluent. For this study, we defined nonpoor as having a family income of at least two times the federal poverty level. For a family of four in 2001, this meant an annual income of approximately $35,000. While these families are not poor by federal standards, they are far from well-off or even financially secure. And only 30 percent of the non-poor uninsured (less than 10% of all uninsured) had incomes higher than four times poverty, or more than $70,600 per year for a family of four.
4 The non-poor uninsured have less accumulated wealth or assets than the non-poor with private health insurance. The ability to purchase insurance depends not only on income and other family needs or circumstances, but on wealth or assets. Assets include the value of home equity and traditional savings accounts as well as financial investments such as stock ownership or savings plans such as IRAs. The median level of assets held by the non-poor privately insured was three to five times that for the non-poor uninsured. The discrepancy in assets between the insured and uninsured was greatest for the chronically uninsured (persons who went the entire study period without insurance) and somewhat less for those who lost their insurance but had coverage at some time during the period. While there was also some variation among the uninsured in the level of assets by age (young persons tend not to have accumulated as much wealth as those at the height of their earning potential) and by poverty status, the asset gap between the insured and uninsured was always sizeable. This means that when circumstances such as a job loss threaten health insurance coverage, even those classified as non-poor have few resources to tide them over or to help them in maintaining coverage. How Do We Increase Coverage of the Non-Poor Uninsured Even within the non-poor uninsured, policymakers will need to adopt targeted initiatives to increase coverage. Workable solutions are likely to involve some government intervention, at the very least in the form of administrative support, such as standardizing or vetting of products and, very possibly, in terms of financial subsidies. While many state and local initiatives have tended to focus on low-income workers, usually defined as those with incomes of less than 200 percent of poverty, our findings indicate that workers with incomes above this level may also need support. Because of the financial and administrative benefits of employer-provided health insurance, it is critical that 4
5 Policy Analysis Brief May 2004 barriers to job-related coverage are lowered. The California Health Insurance Act of 2003 (Senate Bill 2) takes some steps forward in this regard, but substantial gaps remain and there is a referendum on the November ballot for its repeal. While the requirements of SB2 may increase the availability of insurance to some workers that were formerly shut out, many part-time workers, contract or temporary workers, those with limited job tenure, or workers employed by small firms will still face obstacles to employer-sponsored coverage. The selfemployed, in particular, face a large financial burden because of their lack of access to an employer group The availability and cost of family coverage presents a major barrier to the coverage of children. The majority of California s non-poor uninsured children had at least one parent with private coverage. While the non-poor uninsured should require less financial assistance in purchasing coverage than the poor, they may still need financial support in the form of subsidies or tax incentives to assist them in making the purchase especially for family coverage. As part of SB2, employees contributions to health insurance premiums would be limited to 20 percent of total premium costs; while this is certainly a step in the right direction, even this amount (for example, $1,800 on an average family policy premium of $9,000) could be a burden for some uninsured and government subsidies may be needed. There need to be policy initiatives focused on the short-term uninsured. Our estimates suggest that there were approximately 1.3 million persons in California during the period from 1996 through 1999 who experienced an uninsured spell of less than four months. While there are a range of short-term individual policies currently available, there appears to be a broader market that is not being reached. Public policymakers and private decision-makers need to better understand how to reach these individuals, whether it is through a sparer benefits package at a lower premium, increased education about what is available, or some other strategy to increase purchasing incentives. At the same time, COBRA may meet some of the need for this type of short-term solution, though enrollment through COBRA can be expensive and the benefits package is inflexible. 2 In order to better reach persons in need of a gap-filling policy, the design and marketing of short-term policies as well as the issues surrounding COBRA enrollment may need to be re-visited. METHODS This study uses data from the 1996 panel of the Survey of Income and Program Participation (SIPP), a governmentsponsored household survey that interviewed individuals once every four months over a four-year period, beginning in December 1995 and running through February Household members were asked about their socio-demographic characteristics, their health insurance, their jobs, and a variety of other topics. We limited the analysis to persons less than 65 years of age and defined uninsured persons as those who were not covered by private insurance policies, Medicare, or Medicaid. We identified persons who had a period without insurance coverage but were covered at some time during the four years. These are people who were insured when they started the survey and then lost coverage, or were uninsured at the outset, acquired insurance and then subsequently lost it. Many estimates of the length of uninsured periods rely on individuals to recall how long they ve been without coverage and are often limited to a 12-month period overall. Other surveys--such as the one on which this study is based--follow people over a longer period of time while collecting information frequently. This allows a more accurate assessment of the length of time without coverage as well as the ways that people lose and acquire health insurance. Persons are classified as non-poor if they were part of a family with an income that was 200 percent or more of the federal poverty level. The measure of income used was based on reported income in their first month without health insurance coverage; we multiplied this monthly income by 12 before comparing it to the poverty level. The federal poverty level was $17,650 in annual income for a family of four in The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires most employers with group health plans to offer employees the opportunity to continue temporarily their group health care coverage under their employer's plan if their coverage otherwise would cease due to termination, layoff, or other change in employment status (referred to as "qualifying events"). 3 Federal Register, Vol. 66, No. 33, pp , 5 Friday, February 16, 2001.
6 Policy Analysis Brief May 2004 Even among the non-poor, increasing the voluntary purchase of health insurance coverage is a difficult proposition. The non-poor may have a hard time affording health insurance, especially if it s not available from their employers. On the more positive side, many non-poor uninsured find their own way to becoming insured after a brief period without coverage. To help in this process, policymakers need to find ways to lower barriers to employerrelated coverage especially for part-time workers or those with little job tenure. Where employers can t be induced to offer coverage or for the selfemployed or those not in the labor force, other approaches are needed. Possibilities include federal, state, or local community assistance with standardizing benefits packages or premiums made more affordable through re-insurance mechanisms or subsidized pools. However, as medical care costs and health insurance premiums continue to rise dramatically, even these steps may not be sufficient. This study was supported by a grant from the California HealthCare Foundation (Grant Number ). The California HealthCare Foundation (CHCF), based in Oakland, is an independent philanthropy committed to improving California s health care delivery and financing systems. For more information, visit NORC is a social science research organization affiliated with the University of Chicago. The conclusions and opinions expressed are the authors alone; no endorsement by NORC or CHCF is intended or should be inferred. A copy of the full report from this study is available from Claudia L. Schur Principal Research Scientist NORC at the University of Chicago, 7500 Old Georgetown Road, Suite 620, Bethesda, MD , Tel: , Fax: Schur-claudia@norc.net Old Georgetown Road, Suite 620, Bethesda, MD
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