Health Insurance in the San Antonio Metropolitan Statistical Area

Richard J. Harris, Ph.D.
Juanita M. Firestone, Ph.D.
MRPI Faculty Associates

ISSUE: Bexar County and the City of San Antonio are part of a vital regional environment with unique strengths, but with pervasive urban problems that are common to many major metropolitan areas. The City is fortunate to have resources such as near full employment, clean air, a local water supply, superior highway system, affordable housing, good public transportation, and a population that is generally happy to live here. However, despite full employment, one-quarter of adults and one-third of children live in poverty and a disproportionate number of San Antonio families confront the many ancillary problems associated with living in poverty. High among the issues of importance to those living in poverty is access to health care. One important reason for lack of satisfactory health care is the large proportion of individuals and families that have inadequate or no health insurance coverage.

Among Hispanics, the lack of health insurance is particularly high. In 1998, for example, the U.S. Census Bureau estimated that 35 % of Hispanics nationwide lacked health insurance. One report estimates that U.S. Hispanics are "nearly twice as likely to be uninsured as the general population," and that the number of uninsured Hispanics nearly doubled from 1987 to 1998 (Quinn 2000). Additionally, the uninsured rate among Hispanics varies regionally. In Los Angeles County, for example, one estimate places the rate at nearly 50 % (Lopez 2000). Here in San Antonio, we find the rate among Hispanics lacking health insurance to be 31 %.

DATA AND METHODS: This analysis compares results from two local surveys conducted by UTSA's Metropolitan Policy and Research Institute (MRPI) to data from the March Annual Demographic Files of the Current Population Surveys (CPS) conducted by the U. S. Bureau of Labor Statistics and the Bureau of the Census. The MRPI surveys were conducted in May 1999, in conjunction with the City of San Antonio's Department of Community Initiatives (D.C.I.), and in November 1999, in conjunction with the Community Revitalization Action Committee (C.R.A.G.), also of the City of San Antonio.

LOCAL SURVEYS: Local surveys of the adult population with telephones in the San Antonio City area consistently indicate that about 12 percent of the respondents report having no insurance (see Table 1). This figure, however, underestimates the extent of the uninsured population. A particular adult respondent may indeed have some form of insurance, but there is no assurance that all members of the household are insured. Furthermore, those least likely to have telephones may be among those most likely to have no insurance.

In addition, those in the center of the city are more likely to be uninsured than those in the predominantly more affluent suburban areas. The C.R.A.G. survey also asked the question on coverage "to take care of your family." The family insurance results are nearly identical to those reported above, with 12.6% of those inside Loop 410 reporting no insurance compared to 5.1% outside Loop 410.

Table 1: Health Insurance among Respondents to Local Telephone Surveys

 

D.C.I.		C.R.A.G. (11/99)
		Inside Loop 410	Outside Loop 410
Employer	51.3	51.4	65.6
Private	17.6	18.2	17.3
Medicaid	10.2	5.6	1.9
Medicare	8.5	5.8	5.0
Local	-	6.3	3.7
None	12.0	12.7	6.5
Total	100.0	100.0	100.0
Sample Size (N)	1148	537	462

As stated earlier, however, it is likely that these surveys underestimate the percent with no insurance, partly due to the single question approach and partly by excluding those without telephones. Asking a separate question for each type of insurance and focusing on each household member would provide a more accurate assessment.

CURRENT POPULATION SURVEYS: Recently, detailed questions have been included in the March Annual Demographic Files of the Current Population Surveys (CPS) conducted by the U. S. Bureau of Labor Statistics and the Bureau of the Census. These files provide relatively small samples of households for the San Antonio Metropolitan Area each year from 1996 to 1999. However, data are gathered for each member of the interview household. This report provides detailed information from the Current Population Surveys in order to focus on the issue of lack of health insurance as a household as well as a community problem.

As shown in Figure 1, CPS data estimated the percentage of total household members with no insurance has varied from a high of 25.4% to a low of 21.7%, with an average for 1996-1999 of 23%. The consistency of findings over the years lends credibility to the overall estimate. In this measurement approach, respondents are asked a series of questions about specific forms of health insurance that they or other household members have available. The classification of "no insurance" is based on negative answers to all of the possibilities covered by the questions.

Figure 2 illustrates the prevailing forms of health insurance in the San Antonio Metropolitan Area from the 1996 through 1999 CPS. Not surprisingly, job related insurance is the most prevalent. Champus/VA/Military, Medicaid and Medicare about equal and next in prevalence, followed by private sources of insurance and finally by insurance provided from someone outside the household. Given that employer or union based health insurance is so prominent, it is important to observe that there is a close link to age. Few young adults have such health insurance. Interestingly, in the peak age group of 35-39 only 52.3% report employment based insurance. Young adults are the least likely to have insurance. Notably, however, substantial proportions with no insurance are found for all age groups under age 65. Those aged 65 and over are typically covered by Medicare (95.3% of the persons in the 1996-1999 CPS data). Among those aged 65 and over, 15.9% are reported to have Medicaid. The overlap between these programs reflects the fact that they often provide limited coverage and recipients often need supplementary support to meet medical needs. CPS data also demonstrates that the lack of insurance is also related to race and ethnicity. Hispanics (almost totally Mexican origin) are least likely to have insurance, closely followed by Asians. Household type is also related to availability of health insurance. Female-headed households are the most likely to have no insurance at 30.1%. However, all household types except those in the Armed Forces have twenty percent or more with no insurance.

One of the research possibilities with the CPS is the aggregation of information about all of the individuals in each household. This allows the identification of the proportion of people in each household with insurance. These results are displayed below in Figure 3. Interestingly, only 4.6% of households have no one with insurance. On the other hand, only 46.7% of the households have all household members covered. The largest category (48.7%) is households with some insured members and some with no insurance.

DISCUSSION: Both the MRPI Surveys and the Current Population Surveys provide strong evidence for concluding that there is a large unmet need for health insurance in the San Antonio Metropolitan Area. Over twenty percent of individuals have no insurance. Even this large figure may understate the extent of the problem. Over half of all households have one or more members with no insurance.

Access to health insurance also varies by location, age, race and ethnicity, family size, household composition and other factors related to social and economic status. Even though they tend to underestimate the lack of health insurance, further analyses of local telephone surveys may help to identify patterns of insurance access by socioeconomic status, geographic location, race and ethnicity, age and other variables. The larger sample sizes allow for more detailed analyses of different subgroups of the population, and the patterns of such differences may help to identify subgroups at greatest risk.

RECOMMENDATIONS: Access to health insurance is an important part of insuring that San Antonio's community agencies are more effectively managing the health needs of citizens. Accurate information about the groups who lack insurance is a critical step in creating and funding programs to provide unmet health care needs. Using base line data from a variety of sources to compare more recent figures could, in the long term, improve overall access to health care in San Antonio, particularly among high-risk groups.

Notes:
Lopez, Eduardo. "Latino Health in the New Millennium," LatinoLink, March 3, 2000. Harris, Richard J. and Juanita M. Firestone. Forthcoming 2000. "Health Insurance in the San Antonio Metropolitan Area: Different Findings from Different Sources," Metropolitan Research and Policy Institute Report, University of Texas at San Antonio. Quinn, Kevin. 2000. "Working without Benefits: The Health Insurance Crisis Confronting Hispanic Americans"