PEDIATRICS Vol. 119 No. 5 May 2007, pp. e1033-e1039 (doi:10.1542/peds.2006-1730)
ARTICLE |
Health Insurance Across Vulnerable Ages: Patterns and Disparities From Adolescence to the Early 30s
a Department of Pediatrics
b Institute for Health Policy Studies
c Center on Social Disparities in Health, University of California, San Francisco, California
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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OBJECTIVE. Young adults have the lowest rate of insurance coverage of any age group. Little is known about insurance patterns from adolescence through the early 30s. The objective of this study was to assess patterns and disparities in health insurance from adolescence through the early 30s.
DESIGN. We analyzed data from the 2002 and 2003 National Health Interview Survey (ages 13–32; N = 48827). We examined public and private insurance coverage and conducted logistic regression to evaluate racial/ethnic and income disparities in coverage. Outcomes were insurance coverage at ages 13 to 32.
RESULTS. Insurance patterns follow a U-shaped curve across the age categories. Rates are highest at ages 13 to 14, lowest at ages 23 to 24, and then increase gradually. Private rate patterns are similar; however, public coverage decreases across ages. In bivariate analyses, black and Hispanic groups had lower coverage rates than the white group, and the low- and middle-income groups had lower rates than the high-income group. After adjustment for confounding variables, all disparities remained significant except for differences between the black and white groups.
CONCLUSIONS. After age 18, all groups are vulnerable to lack of insurance. Rate increases beyond age 25 to 26 years are attributable to increases in private coverage, whereas decreases in public coverage account for the lack of a full recovery to the higher rates seen in adolescence. The safety net of public programs that cover adolescents disappears in young adulthood, leaving young adults vulnerable, a problem that persists into the 30s for those who are in poverty and those who are of Hispanic origin.
Key Words: health insurance coverage gaps • young adults
Abbreviations: NHIS—National Health Interview Survey • FPL—federal poverty level • OR—odds ratio • aOR—adjusted odds ratio
Lack of health insurance is a critical issue during young adulthood. Young adults without health insurance, compared with their insured counterparts, are more likely to have unmet medical needs, to have no usual source of care,1 and to report fair or poor health.2 Young adults have the lowest insurance rate of any age group, with 32.5% of men and 26.9% of women aged 18 to 24 years uninsured in 1998–2000.3 Adults aged 19 to 29 years compose 17% of the population that is younger than 65 years but 30% of uninsured.4 Furthermore, 19- to 29-year-olds accounted for 40% of the growth in the uninsured population since 2000.4
Recognizing the importance of continuous insurance coverage for this age group, the American Academy of Pediatrics5 and the Society for Adolescent Medicine6 issued policy/position papers emphasizing health insurance coverage and affordable health care for children, adolescents, and young adults. The Society for Adolescent Medicine also issued a position paper that spells out specific responsibilities for pediatric and other health care providers and addresses the transition to adult care for adolescents with chronic conditions.7 Among these is the elimination of policies, protocols, and restrictions of third-party payers that impede the timely transition to adult services for this population.
Changes in family and legal status that occur in the early 20s shape young adults' ability to secure insurance. Coverage for adolescents has increased in the past 10 years, as declines in family-based employer coverage have been offset by increases in coverage under public programs, notably Medicaid and the State Children's Health Insurance Program.8 In the transition into young adulthood, however, many young people lose eligibility under their parents' private insurance coverage, and coverage generally ends at 21 years of age for the public programs that cover poor and near-poor adolescents.9 Those in the workforce are less likely to have employer-sponsored insurance, in part because young adults are more likely to be employed in low-wage positions and in settings with few employees.10
Recent research has identified several factors that are associated with health insurance status among young adults. Women have slightly higher insurance rates than men. This may be because public programs are available to single mothers, although this has not been studied extensively.1,10 Rates of insurance coverage are lower among low-income and middle-income young adults. White individuals have the highest insurance coverage rates, followed by black and Hispanic individuals.1 Insurance rates are higher among young adults who are enrolled in school, especially those who are enrolled full time. In 2003, 39% of young adults who were aged 19 to 23 years and not enrolled in school full time were uninsured.9
Traditionally, insurance is measured dichotomously, comparing those with any insurance at a point in time or during a specific period with those with no insurance. However, for many, insurance coverage may be intermittent or discontinuous. Therefore, recent research examined insurance status in a more comprehensive manner, by assessing coverage for a particular time frame, often 1 year, and taking into account intermittent insurance coverage as separate from having or lacking insurance for that time frame.9,11,12 A growing literature suggests that unstable or intermittent insurance also affects access to care. Children and adults with gaps in coverage experience substantially reduced access to care, compared with those with continuous coverage.11,13 Similarly, those who experience "insurance churning" (ie, losing and gaining coverage multiple times) are less likely to receive follow-up care and preventive services.12 Young adults have the highest rates of intermittent insurance and churning of any age group.12,13
Most research on young adult health insurance either focuses exclusively on young adults or compares young adults with older age groups. Although these analyses have yielded important information, they have not examined how insurance status changes during the course of young adulthood. Although it is clear that adults who are older than 30 years have higher insurance rates than those who are in their 20s, we are not aware of any studies that have examined the dynamics of insurance during this period of the life span, as young people transition from adolescence into young adulthood and adults reach their late 20s and early 30s.
In this article we present a new analysis of patterns of health insurance, both public and privately funded, among young people from early adolescence through their early 30s. Our main objective was to describe the changes that take place in insurance coverage during this period of the life span. Our analysis demonstrates trends in private and public coverage, as well as full-year and part-year coverage. We also document differences in insurance patterns by socioeconomic status and among racial and ethnic groups during this period of transition. Our analysis uses data from the 2002 and 2003 editions of the National Health Interview Survey (NHIS).
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Sample and Population Characteristics
We used data from the 2002 and 2003 NHIS to conduct this study. The NHIS is a continuing nationwide household survey that is designed to collect information on the demographic characteristics, health status, and health care use patterns of the US civilian noninstitutionalized population. The survey has 3 modules: a basic module, a periodic module, and a topical module. The basic module contains 3 components: the family core, the sample adult core, and the sample child core. The family core includes a short set of questions that are administered for all family members, and the variables that were used for the analyses herein were taken from the family core. The NHIS was selected for these analyses because it includes the pertinent variables of interest and has sufficient sample size to allow for analyses of narrow age groupings.
A total of 48827 respondents who were aged 13 to 32 years were included in this study (24559 from 2002 and 24268 from 2003). A knowledgeable adult (typically a parent or guardian) answered questions about health insurance for adolescents who were younger than 17. When present, individuals who were 17 years and older answered the questions for themselves. The response rate for the NHIS family core questionnaires was 88.1% in 2002 and 87.9% in 2003.
Variable Construction
The family core includes information on sociodemographic characteristics, health insurance coverage, and family income. We constructed the health insurance variable on the basis of NHIS questions regarding health insurance coverage in the past 12 months. Respondents were asked whether they were currently insured. Furthermore, the NHIS asked those who were currently insured about the type of insurance that they had and whether they had been uninsured at any time in the past 12 months. Similarly, those who were currently uninsured were asked how many months it had been since they had been insured. From these NHIS responses, we constructed an insurance variable that consisted of 3 categories: (1) full-year insured, consisting of private and/or public insurance; (2) full-year uninsured; and (3) partial-year uninsured.11
We examined health insurance status from ages 13 through 32 years, using 2-year age intervals (eg, 13–14, 15–16) to improve the statistical precision of our estimates. This 20-year age range was selected because it shows the insurance patterns of adolescence, young adulthood, and the years after young adulthood into the early 30s.
The family questionnaire provided information about family income and the ratio of annual family income for the past year to the federal poverty thresholds, which are adjusted for family size. For example, the poverty threshold for a family of 4 was $18392 in 2002 and $18810 in 2003.14 In this study, a poverty status index was used to create 3 income categories: below the poverty level and near poor (<200% federal poverty level [FPL]), moderate income (200%–399% FPL), and middle/high income (
400% FPL). The nonresponse rate for income data, including missing and unknown responses, was 27%. Because >1 in 4 respondents did not report income, we used multiply imputed income values that were made available from the National Center for Health Statistics.15 We used SUDAAN statistical programs to analyze the multiply imputed data.16
Data Analysis and Presentation
Estimates that are presented here were statistically weighted to reflect national population totals. The weights, provided by the data collection agency, are equal to the inverse of the sampling probability for each case, adjusted for nonresponse. Estimates, SEs, and test statistics were derived using SUDAAN software that takes into account the complex sample design of the survey, including household and intrafamilial clustering of sample observations.16
The results are presented in graphic and tabular form. All analyses were conducted separately for each of the 2-year age groups, and all results are presented by age group. First, we present rates of insurance status in 3 categories: full-year insured, full-year uninsured, and partial-year uninsured. Second, we present rates for the full-year insured category separately according to whether the source of coverage was private or public. Third, we present rates of full-year insurance for white, black, and Hispanic groups. We conducted a bivariate logistic regression by using a dichotomous insurance outcome variable for each age group (full-year insured versus full- or partial-year uninsured), with race/ethnicity as the independent variable. This yielded unadjusted odds ratios (ORs) for the white, black, and Hispanic groups on the insurance variable. We also conducted a multivariate logistic regression for each age group that yielded adjusted ORs (aORs) for the racial/ethnic groups, controlling for income group, gender, and region of residence as independent variables. Fourth, we present rates of full-year insurance by the 3 income levels. We conducted a bivariate logistic regression using the dichotomous insurance outcome variable for each age group, with income level as the independent variable. This yielded unadjusted ORs for the income groups on the dichotomous insurance outcome. Using results of the multivariate logistic regressions described, we report the aORs for the income groups, controlling for race/ethnicity, gender, and region of residence.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Health Insurance Coverage Across Age Categories
Insurance coverage follows a U-shaped curve across the age categories (Fig 1). Rates of full-year insurance are highest among adolescents aged 13 to 14 years (87%) and lowest among 23- to 24-year-olds (61%). Rates then increase to 75% in the 31- to 32-year-old group, 12 percentage points lower than the rate for the 13- to 14-year-old group. The corresponding inverted U-curves indicate that full-year uninsurance rates are highest at ages 21 to 22 years and partial-year uninsurance rates are highest at ages 23 to 24 years. Taken together, the highest rate of any uninsurance occurs at ages 23 to 24 years.
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Public and Private Health Insurance Coverage
Rates of private insurance coverage follow a U-shaped curve similar to that of the overall full-year coverage (Fig 2). Private coverage rates are stable from 13 to 18 years of age; they then decline to their lowest rates at ages 21 to 22 years and then increase to reach their highest levels at ages 31 to 32 years. Coverage rates for public insurance are highest at ages 13 to 14 years; they then decline most sharply between ages 17 to 18 and 19 to 20 years and then continue to decline gradually to a low of 7% by ages 31 to 32 years. The loss of public insurance throughout the late adolescent and young adult years accounts for the lack of a complete restoration of overall insured rates by ages 31 to 32 years to equal those at ages 13 to 14 years (Fig 1).
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Racial/Ethnic Disparities in Health Insurance Coverage
Patterns of health insurance within the different racial/ethnic groups tend to follow a similar U-shaped curve across the age range (Table 1). The white group has the highest insured rates, and the Hispanic group has the lowest rates at each age. The gap between the white and the Hispanic groups increases from 16 percentage points at ages 13 to 14 years to a maximum of a 32–percentage point difference at ages 19 to 20 years and then fluctuates between 25 and 31 percentage points across the remaining age groups. The rate differences are statistically significant within each 2-year age interval. Although the differences between the white and Hispanic rates were somewhat attenuated when gender, income, and region of residence were controlled using multivariate analysis, they remained significant at each age.
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Overall, our analyses found few significant differences between the white and black groups. When confounding variables of gender, poverty level, and region of residence are controlled, the rate differences remain significant in only 2 of the groups: ages 19 to 20 and 21 to 22 years. This suggests that the majority of the difference between the white and the black groups is accounted for by the confounding factors. The gap between the white and black groups is 3 percentage points at ages 13 to 14 years, widens during the early young adult years, and then diminishes to a 4–percentage point gap at ages 31 to 32 years.
Income Disparities in Health Insurance Coverage
Table 2 presents the rates of insurance for the 3 income groups and illustrates that the highest and middle-income group rates follow a U-shaped pattern most clearly. The lowest income group shows the drop in coverage from ages 13 to 14 years through ages 25 to 26 years and then demonstrates very little recovery of rates after that. The gap between the lowest and highest income groups grows from 19 percentage points at ages 13 to 14 years to a maximum of 39 percentage points at ages 27 to 28 years and remains throughout subsequent ages. The insurance rate differences between the highest and both the middle and lowest income groups are significant at each age. When confounding factors of gender, race/ethnicity, and region of residence are controlled, the differences remain significant and show very little attenuation. This suggests that income has a strong independent effect on rates of insurance coverage.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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In this article we have described the insurance patterns of Americans from adolescence through the early 30s. The analyses update and expand previous research that addressed insurance for adolescents and young adults. This study makes several unique contributions regarding health insurance patterns. First, showing changes across 2-year age increments allows us not only to highlight differences between the young adult years and adolescence and the early 30s but also to illustrate differences within the young adult years. Second, the presentation of insurance rates broken into full-year coverage and both partial- and full-year uninsurance allows us to present estimates and ORs that differentiate between those with or without stable coverage. This is important because previous research has shown that those with partial-year uninsurance were more similar to full-year uninsured groups in terms of decreased access to care9,11,13 and because a broad goal is continuous insurance for all. Finally, we examine insurance patterns for an expanded age range, spanning the major transitions from adolescence through the early 30s. Previous articles have documented coverage rates for adolescents or young adults (typically ages 18 through 24 or 25 years), but no analysis has followed rates past young adulthood through the early 30s.
Our results show a steep decline in insurance rates after 18 years of age that continues through the mid-20s. More than 10.7 million young adults who were aged 19 to 26 were uninsured for all or part of the previous year. This was followed by a gradual increase in coverage that continued into the 30s. Rates in the early 30s do not recover to their earlier adolescent levels. The weak recovery in the late 20s and early 30s is directly related to the loss of public coverage, which diminishes steadily from adolescence onward.
Our analyses show that racial and ethnic disparities in coverage are present during adolescence and persist into young adulthood and the early 30s. Whereas disparities that are present in the black group are largely accounted for by income level, those that are observed in the Hispanic group, relative to the white group, remain significant when income level is controlled, indicating that additional factors account for some of the disparities in the Hispanic group. Income disparities in coverage continue to persist when we control for confounding factors, highlighting the importance of income in having coverage.
Several factors may account for the drop in coverage that was noted after age 18, regardless of income level. Although some employer-based insurance programs now provide coverage to dependents beyond age 18 or 19 years of age, regardless of student status, the majority of programs still do not provide extended coverage for nonstudents.4 In addition, public programs cover adolescents only until age 18 or 21 years, and for many who use the public programs, there are no affordable alternative sources for coverage. Our finding that public coverage decreases steadily after adolescence supports this. We also found that the largest drop-off in coverage occurred for traditionally disadvantaged groups, including Hispanic individuals and those with low incomes. Individuals in these groups are more likely to be employed in low-wage, part-time or temporary jobs or in jobs in small businesses that either do not offer insurance coverage or offer coverage that includes employee premiums that are unaffordable for many.17–20 Our analyses suggest that for those groups, the gaps in coverage are likely to extend beyond young adulthood, into the 30s.
In the past few years, policy makers at the federal and local levels have initiated programs and legislation to expand coverage to the young adult population.1,4,21–23 As many as 9 states passed or considered legislation to increase the age limit (ranging from 24 to 30 years) for dependent coverage on family policies.4 However, the effect of state insurance regulations may be limited because many large employers choose to self-insure and are exempt from state regulation. Several private insurers offer coverage for young adults now, either through individual or family plans.24 Several states mandate that colleges and universities require that students have health insurance and in some cases require that institutions make coverage available.4
Although insurance gaps for young adults are being addressed at many levels, we lack an organized approach at the national level to address the problem. The drop-off in public coverage that we showed across each age group primarily affects lower income groups and those with special health care needs. Three regulatory changes would help to increase coverage: (1) increases in the age limit for State Children's Health Insurance Program coverage; (2) provision of incentives for affordable employer-sponsored programs in low-wage job settings; and (3) changes in Medicaid eligibility criteria so that young adults with special health care needs qualify for coverage with broader allowances for the ability to work.
Pediatric health care providers can work at an individual level to help families and patients strategize options to maintain coverage as teens finish high school and plan future activities and can work at the policy level to publicize the importance of insurance coverage for all. Providers can help families and patients with special health conditions to plan and to minimize insurance gaps and can work at the policy level for the redefinition of criteria for young adults with health conditions to increase eligibility.
The primary limitation of this analysis is that the data are cross-sectional, not longitudinal. As a consequence, our analysis provides provisional information about how insurance status may change from adolescence through the early adult years. To be definitive, these findings need to be replicated using a longitudinal design.
Our analysis shows that lack of insurance is a problem for higher income young adults, as well the poor and near poor. We also show that the problem of lack of coverage persists into the late 20s, with the period between ages 19 and 28 years particularly at risk, and continues even into the 30s for those in poverty and those of Hispanic origin. We argue that in addition to increasing the age for dependents who are covered in private programs, increasing coverage for all must include improvements in publicly funded programs and improvements in coverage that is offered in low-wage employment settings. Improving coverage will result in measurable improvements in health and productivity during this transitional period for America's young adults.
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ACKNOWLEDGMENTS |
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This study was supported by Federal Maternal and Child Health Bureau grants U45 MC00023 and U45 MC00002.
We acknowledge the help of Michael Berlin, Tina Paul Mulye, Elizabeth Valitchka, and Jennifer Yu in the preparation of the manuscript.
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FOOTNOTES |
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Accepted Oct 31, 2006.
Address correspondence to Sally H. Adams, RN, PhD, University of California, Department of Pediatrics, 3333 California St, Suite 245, San Francisco, CA 94143-0503. E-mail: adamss{at}peds.ucsf.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
Data were provided by the National Center for Health Statistics. The analyses, interpretation, and conclusions are solely those of the authors and do not necessarily reflect the views of the data collection and funding agencies.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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