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Recent Health Insurance Trends for US Families: Children Gain While Parents Lose


In the past decade, political and economic changes in the United States (US) have affected health insurance coverage for children and their parents. Most likely these policies have differentially affected coverage patterns for children (versus parents) and for low-income (versus high-income) families. We aimed to examine—qualitatively and quantitatively—the impact of changing health insurance coverage on US families. Primary data from interviews with Oregon families (2008–2010) were analyzed using an iterative process. Qualitative findings guided quantitative analyses of secondary data from the nationally-representative Medical Expenditure Panel Survey (MEPS) (1998–2009); we used Joinpoint Regression to assess average annual percent changes (AAPC) in health insurance trends, examining child and parent status and type of coverage stratified by income. Interviewees reported that although children gained coverage, parents lost coverage. MEPS analyses confirmed this trend; the percentage of children uninsured all year decreased from 9.6 % in 1998 to 6.1 % in 2009; AAPC = −3.1 % (95 % confidence interval [CI] from −5.1 to −1.0), while the percentage of parents uninsured all year rose from 13.6 % in 1998 to 17.1 % in 2009, AAPC = 2.7 % (95 % CI 1.8–3.7). Low-income families experienced the most significant changes in coverage. Between 1998 and 2009, as US children gained health insurance, their parents lost coverage. Children’s health is adversely affected when parents are uninsured. Investigation beyond children’s coverage rates is needed to understand how health insurance policies and changing health insurance coverage trends are impacting children’s health.

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  1. 1.

    US Department of Health and Human Services. SCHIP Evaluation (2001). http://aspe.hhs.gov/health/schip/pl105-33.htm. Accessed 11 Oct 2012.

  2. 2.

    Oberlander, J. B., & Lyons, B. (2009). Beyond Incrementalism? SCHIP and the politics of health reform. Health Affairs, 28(3), w399–w410.

  3. 3.

    Ryan, J. (2009). The children’s health insurance program (CHIP): The fundamentals. Washtington, DC: The George Washington University.

  4. 4.

    The Henry J. Kaiser Family Foundation. Children’s Coverage and SCHIP Reauthorization (2009). http://www.kaiseredu.org/Issue-Modules/Childrens-Coverage-and-SCHIP-Reauthorization/Background-Brief.aspx. Accessed 11 Oct 2012.

  5. 5.

    111th Congress. Compilation of Patient Protection and Affordable Care Act (2010). http://docs.house.gov/energycommerce/ppacacon.pdf. Accessed 16 Dec 2011.

  6. 6.

    Kaiser Commission on Medicaid and the Uninsured. Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). Kaiser Family Foundation, Washington, DC (2009). http://www.kff.org/medicaid/upload/7863.pdf. Accessed 14 Jan 2011.

  7. 7.

    US Department of Health and Human Services (2012). The health care law & you: What’s changing when. http://www.healthcare.gov/law/timeline/index.html. Accessed 2 Feb 2012.

  8. 8.

    Zhang, W., & Cresswell, J. (2012). The use of “mixing” procedure of mixed methods in health services research. Medical Care. 13 Jan 2012 (Epub ahead of print).

  9. 9.

    Fronstin, P. (2008). Sources of health insurance and characteristics of the uninsured: analysis of the March 2008 current population survey. EBRI Issue Brief, 321, 1–33.

  10. 10.

    Angier, H., DeVoe, J. E., Tillotson, C.J., Wallace, L., & Gold, R. (2012). Trends in Health Insurance Status of US Children and their Parents, 1998–2008. Maternal and Child Health Journal. 27 Sep 2012. (Epub ahead of print).

  11. 11.

    Cohen, R. A., Makuc, D. M., Bernstein, A. B., Bilheimer, L. T., & Powell-Griner, E. (2009). Health insurance coverage trends, 1959–2007: Estimates from the National Health Interview Survey. National health statistics reports, 17, 1–25.

  12. 12.

    Choi, M., Sommers, B. D., & McWilliams, J. M. (2011). Children’s Health Insurance and Access to Care During and After the CHIP Expansion Period. Journal of Health Care for the Poor and Underserved, 22(2), 576–589.

  13. 13.

    DeVoe, J. E., Graham, A., Krois, L., Smith, J., & Fairbrother, G. L. (2008). “Mind the gap” in Children’s health insurance coverage: Does the length of a child’s coverage gap matter? Ambulatory Pediatrics, 8(2), 129–134.

  14. 14.

    DeVoe, J. E., Krois, L., Edlund, C., Smith, J., & Carlson, N. E. (2008). Uninsured but eligible children: Are their parents insured? Recent findings from Oregon. Medical Care, 46(1), 3–8.

  15. 15.

    DeVoe, J. E., Lisa, K., Tina, E., Jeanene, S., & Nichole, E. C. (2008). Uninsurance among children whose parents are losing medicaid coverage: Results from a statewide survey of Oregon families. Health Services Research, 43(1p2), 401–418.

  16. 16.

    Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability. Field Methods, 18(1), 59–82.

  17. 17.

    Cohen, D. J., & Crabtree, B. F. (2008). Evaluative criteria for qualitative research in health care: controversies and recommendations. Annals of Family Medicine, 6(4), 331–339.

  18. 18.

    Crestwell, J. W. (2007). Qualitative inquiry & research design: Choosing among five approaches (2nd ed.). Thousand Oaks, California: Sage Publications, Inc.

  19. 19.

    Aday, L. A., & Andersen, R. (1974). A framework for the study of access to medical care. Health Services Research, 9, 208–220.

  20. 20.

    Andersen, R. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36, 1–10.

  21. 21.

    Carillo, J. E., Carillo, V. A., Perez, H. R., Salas-Lopez, D., Natale-Pereira, A., & Byron, A. T. (2011). Defining and targeting health care access barriers. Journal of Health Care for the Poor and Underserved, 22(2), 562–575.

  22. 22.

    Penchansky, R., & Thomas, W. J. (1981). The concept of access definition and relationship to consumer satisfaction. Medical Care, X1X(2), 127–140.

  23. 23.

    Gulliford, M., Figueroa-Munoz, J., Morgan, M., et al. (2002). What does ‘access to health care’ mean? Journal of Health Services Research and Policy, 7(3), 186–188.

  24. 24.

    MacQueen, K. M., et al. (1998). Codebook development for team-based qualitative analysis. Cultural Anthropology Methods Journal, 10(12), 31–36.

  25. 25.

    Agency for Healthcare Research and Quality (2004). MEPS HC-089: 2004 Full Year Consolidated Data File. http://www.meps.ahrq.gov/mepsweb/data_stats/download_data/pufs/h89/h89doc.pdf. Accessed 10 Jan 2008.

  26. 26.

    Cohen, J.W., Monheit, A.C., Beauregard, K.M., et al. (1996). The Medical Expenditure Panel Survey: a national health information resource. Inquiry, Winter:373-89.

  27. 27.

    Kim, H. J., Fay, M. P., Feuer, E. J., & Midthune, D. N. (2000). Permutation tests for joinpoint regression with applications to cancer rates. Statistics in Medicine, 19, 335–351.

  28. 28.

    Kim, H. J., Fay, M. P., Feuer, E. J., & Midthune, D. N. (2001). Permutation tests for joinpoint regression with applications to cancer rates: correction. Statistics in Medicine, 20, 655.

  29. 29.

    Blakely, S. (2010). Employers, workers, and the future of employment-based health benefits. EBRI Issue Brief, 339, 1–23.

  30. 30.

    DeVoe, J. E., Dodoo, M. S., Phillips, R. L., & Green, L. A. (2005). Graham Center one-pager: Who will have health insurance in 2025? American Family Physician, 72(10), 1989.

  31. 31.

    Kaiser Family Foundation and Health Research & Educational Trust. Employer health benefits 2012 annual survey (2012). http://ehbs.kff.org/?page=abstract&id=1. Accessed 11 Oct 2012.

  32. 32.

    Lavarreda, S. A., Brown, E. R., Cabezas, L., & Roby, D. H. (2010). Number of uninsured jumped to more than eight million from 2007 to 2009. Policy Brief UCLA. Center for Health Policy Research, (PB2010-4):1–6.

  33. 33.

    Christanson, J. B., Tu, H. T., & Samuel, D. R. (2011). Employer-sponsored health insurance: down but not out. Issue Brief (Center for Studying Health System Change), 137, 1–5.

  34. 34.

    Holahan, J. (2011). The 2007–2009 recession and health insurance coverage. Health Affairs, 30(1), 145–152.

  35. 35.

    Roehr, B. (2011). Nine million Americans have lost health insurance in recession. BMJ, 342, d1645.

  36. 36.

    Kaiser Commission on Medicaid and the Uninsured (2003). States Respond to Fiscal Pressure: State Medicaid Spending Growth and Cost Containment in Fiscal Years 2003 and 2004. Results from a 50-State Survey. http://www.kff.org/medicaid/upload/States-Respond-to-Fiscal-Pressure-State-Medicaid-Spending-Growth-and-Cost-Containment.pdf. Accessed 3 Aug 2011.

  37. 37.

    Dubay, L., Guyer, J., Mann, C., & Odeh, M. (2007). Medicaid at the ten-year anniversary of SCHIP: Looking back and moving forward. Health Affairs, 26(2), 370–381.

  38. 38.

    Dubay, L., & Kenney, G. (2009). The impact of CHIP on children’s insurance coverage: An analysis using the National Survey of America’s Families. Health Services Research, 44(6), 2040–2059.

  39. 39.

    Hudson, J. L., & Selden, T. M. (2007). Children’s eligibility and coverage: recent trends and a look ahead. Health Affairs, 26(5), W618–W629.

  40. 40.

    Davidoff, A., Dubay, L., Kenney, G., & Yemane, A. (2003). The effect of parents’ insurance coverage on access to care for low-income children. Inquiry, 40(3), 254–268.

  41. 41.

    Cogan, L. W., Josberger, R. E., Gesten, F. C., & Roohan, P. J. (2012). Can prenatal care impact future well-child visits? The experience of a low income population in New York State Medicaid managed care. Maternal and Child Health Journal, 16(1), 92–99.

  42. 42.

    Sarnoff, R., & Hughes, D. (2005). Increasing health insurance coverage in the first year of life. Maternal and Child Health Journal, 9(4), 343–350.

  43. 43.

    DeVoe, J. E., Ray, M., & Graham, A. (2011). Public health insurance in Oregon: Underenrollment of eligible children and parental confusion about children’s enrollment status. American Journal of Public Health, 101(5), 891–898.

  44. 44.

    DeVoe, J. E., Tillotson, C. J., & Wallace, L. S. (2009). Children’s receipt of health care services and family health insurance patterns. Annals of Family Medicine, 7(5), 406–413.

  45. 45.

    Yamauchi, M., Carlson, M. J., Wright, B. J., Angier, H., & Devoe, J. E. (2012). Does health insurance continuity among low-income adults impact their children’s insurance coverage? Maternal and Child Health Journal, 17(2), 248–255.

  46. 46.

    Kenney, G., Buettgens, M., Guyer, J., & Heberlein, M. (2011). Improving coverage for children under health reform will require maintaining current eligibility standards for Medicaid and CHIP. Health Affairs, 30(12), 2371–2381.

  47. 47.

    Shoen, C., Doty, M. M., Robertson, R. H., & Collins, S. R. (2011). Affordable care act reforms could reduce the number of uninsured US adults by 70 percent. Health Affairs, 30(9), 1762–1771.

  48. 48.

    Kenney G, Dubay L, Zuckerman S, Huntress M. Making the Medicaid Expansion an ACA Option: How Many Low-Income Americans Could Remain Uninsured 2012; June 29.

  49. 49.

    McDonough, J. E. (2012). The Road Ahead for the Affordable Care Act. New England Journal of Medicine, 367(3), 199–201.

  50. 50.

    The Henry J. Kaiser Family Foundation. (2012, August). Implementing the ACA’s medicaid-related health reform provisions after the supreme court’s decision. Focus on Reform (8348).

  51. 51.

    US Department of Health and Human Services (1998). Annual Update of the HHS Poverty Guidelines. Federal Register, 63(36): 9235–9238.

  52. 52.

    US Department of Health and Human Services (2009). Annual Update of the HHS Poverty Guidelines. Federal Register, 74(14): 4199–4201.

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This project received direct support from Grant Number R01 HS018569 from the Agency for Healthcare Research and Quality (AHRQ) and the Oregon Health & Science University Department of Family Medicine. We also wish to thank our colleagues in the Oregon Office for Health Policy and Research and the Division of Medical Assistance Programs. We are also extremely grateful to the parents who shared their time and insights with us. The authors are grateful for editing and publication assistance from Ms. LeNeva Spires, Publications Manager, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.

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Correspondence to Heather Angier.

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DeVoe, J.E., Tillotson, C.J., Angier, H. et al. Recent Health Insurance Trends for US Families: Children Gain While Parents Lose. Matern Child Health J 18, 1007–1016 (2014). https://doi.org/10.1007/s10995-013-1329-3

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  • Health insurance
  • Access to care
  • Health services research
  • Health policy
  • Health care disparities
  • Children’s health care