MRPI Working Paper Series No. 2:

Working Hard but Remaining Uninsured: A Report on then Lack of Health Insurance in the San Antonio Metropolitan Area

Richard J. Harris, Ph.D.
Juanita M. Firestone, Ph.D.
Faculty Associates,
Metropolitan Research and Policy Institute

Executive Summary

• The Current Population Surveys provide a strong basis 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.
• Over half of all households have one or more members with no insurance.
• Access to health insurance varies by location, age, race and ethnicity, family size, household composition and other factors related to social and economic status.
• Those families whose incomes fall well below the poverty level are at high risk for being without health insurance.
• Full time employment does not guarantee adequate insurance coverage, although unemployment is associated with higher percentages without 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.
• Uninsured individuals are likely to be substantially worse off than those with insurance on measures of health access and health status.
• Individuals who lack insurance are very likely faced with unmet medical needs when sick and an inability to pay medical bills.
• The high proportion of individuals who live at or below the poverty line and the high proportion of individuals who are seasonally employed or unemployed contribute to the challenge of meeting San Antonio's health insurance needs.
• The profile of individuals most likely to be without insurance mirrors that of the "working poor" and is far different from the stereotype that those without health insurance are homeless or otherwise indigent.
• Policies focused solely on providing health services to homeless or other indigent populations are not enough to meet health care concerns in the community.
• Since a large proportion of the uninsured are employed, a part of the challenge for San Antonio leaders will be to craft solutions to lack of health insurance that fit the reality of the San Antonio workforce.
• Lack of health insurance is likely worse among the majority Mexican American population, which has higher rates of poverty.
• Mexican Americans are more likely to work for employers that do not provide insurance than the white, non-Hispanic population.

Introduction:

Background Literature:

This problem is not unique to the San Antonio area. Using data from the 1998 Current Population Surveys, Campbell (1998) reported that

• 16.4% of the U.S. population were without health insurance during 1997
• 15.4 % of children under 18 in the U.S. were uninsured in 1997
• 31.3% of all poor people in the U.S. had no health insurance in 1997
• The uninsured rate was higher among Hispanics (35.3%) than white, non-Hispanics (11.9%)
• Among the poor, those employed were less likely to be insured than those unemployed
• 53.3% of poor immigrants were uninsured
• 30% of people 18 - 24 years old lacked health insurance.

These figures on the percentages of uninsured are supported by other research (Rowland & Seliger, 1998; Sloan, Conover & Hall, 1999). Employment does not guarantee health insurance coverage. Low income employed parents are at high risk of being uninsured because they have limited access to publicly-funded insurance, but often hold the types of jobs in which their employers do not provide insurance coverage (Acs, Phillips & McKenzie, 2000; Holahan & Brennan, 2000). According to Guyer & Mann (1999), Texas has among the highest proportion of low-income employed without insurance coverage at 61.1%. Budetti, Chikles, Duchon, and Schoen, (1999) reported that among workers with annual incomes below $35,000, 32% were uninsured and 37% went without needed medical care. Recent welfare to work programs exacerbate the problem of uninsured or underinsured families. Garrett & Holahan (2000) report that about half of women and a third of children are uninsured after leaving welfare programs (see also Ellwood, 1999; Employee Benefit Research Institute, 1997).

Several researchers indicate that women and children and race and ethnic minorities are among those most likely to be uninsured (Arndorfer, 1998; Brown 7 Rice, 1999; Ellwood, 1999; Ford, Will & Mokdad, 1998; Harris, 1999; Holahan & Brennan, 2000; Short, 1998). According to a report based on The Commonwealth Fund 1998 Survey of Women's Health, during 1998, one in four women were uninsured at the time of the survey or had been uninsured at some time during the past year. Overall, 31 % of minority Americans, aged 18-64 lack basic health insurance (The Commonwealth Fund, 2000). In addition, minority adults are less likely than white adults to receive health insurance through their own employers (The Commonwealth Fund, 2000). Hispanics across the U.S. have a high proportion without health insurance coverage (State of Hispanic Health, 1999). While younger, low-income adults, particularly African Americans and Hispanics, have the highest uninsurance rates, half of all low-income uninsured adults are white (Holahan & Brennan, 2000). In addition changes in welfare eligibility standards have impacted uninsurance rates. About 33% of women who leave welfare are uninsured within six months of leaving, and after twelve months close to 50% have no health insurance (Bowen & Holahan, 2000).

Among Hispanics, the sub-population of Mexican Americans typically have higher percentages with no health insurance (State of Hispanic Health, 1999). Only 43% of Hispanic adults and children are insured through employer-sponsored coverage (Quinn, 2000). Texas is one of the four states that account for 73% of all uninsured Hispanics (Quinn, 2000). Furthermore, half of Hispanics with family incomes below the federal poverty level are uninsured (Quinn, 2000). Investigating health insurance coverage among Hispanic women, de la Torre, Friis, Hunter, and Garcia (1996) reported that Mexican American and Cuban women had the lowest percentage of any health insurance coverage. It is likely that Dominican Americans and various Central American groups residing in the United States could be added to this list. As with the white non-Hispanic population, the proportions of Hispanics with no insurance increased with poverty status. Immigrant status can further impact the proportions of people uninsured, especially among the Mexican American populations. Immigrants often lack access to insurance, which is compounded by other factors such as language skills, knowledge of health resources, and poverty that increase their risk for not receiving necessary health care (see for example, Flaskerud, & Kim 1999; Quinn, 1999).

Local Surveys:

Local surveys of the adult population with telephones in the San Antonio City area consistently indicate that about 12 % of the respondents report having no insurance (see Table 1). This figure, however, underestimates the size 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. As noted in Figure 1, data from the Current Population Survey indicates that the percentage of individuals without health insurance (45.5%) is twice as high as among those without telephones compared to those with telephones (21.8%).

Table 1: Health Insurance among Respondents to Local Telephone Surveys*

Profile of Uninsured in Bexar County:

Our research indicates that the "typical" uninsured person in San Antonio is most likely to be Hispanic, male, married living with his spouse and children, employed full time, between the ages of 40 and 64, and have not completed high school. These characteristics are similar to those of the "working poor ," and different from stereotyped ideas that those without health insurance are homeless, unemployed or otherwise indigent.

Current Population Surveys:

Recently, detailed questions have been included in the March Annual Demographic Files of the Current Population Surveys 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 2, the estimated 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 gives a high degree of 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 3 illustrates the prevailing forms of health insurance in the San Antonio Metropolitan Area from the 1996 through 1999 Current Population Surveys. Not surprisingly, job related insurance is the most prevalent. Champus/VA/Military, Medicaid and Medicare are 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 (see Figure 4). Interestingly, in the peak age group of 35-39 only 52.3% report employment based insurance.

As established in other research, there is a close correspondence between health insurance and age (Campbell 1998; Rowland & Seliger, 1998; Sloan, Conover & Hall, 1999). Young adults are the least likely to have insurance. Notably, however, substantial proportions of the population with no health insurance found for all age groups under age 65 (see Figure 5). Those aged 65 and over are typically covered by Medicare (95.3% of the persons in the 1996-1999 C.P.S. data).

As established in other research, there is a close correspondence between health insurance and age (Arndorfer, 1998; Brown 7 Rice, 1999; Ellwood, 1999; Ford, Will & Mokdad, 1998; Harris, 1999; Holahan & Brennan, 2000; Short, 1998). Young adults are the least likely to have insurance. Notably, however, substantial proportions of the population with no insurance are found for all age groups under age 65 (see Figure 5).

Those aged 65 and over are typically covered by Medicare (95.3% of the persons in the 1996-1999 C.P.S. 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. In addition, changes in welfare supplements such as Medicaid coverage have created a decline in children covered by health insurance (Lee, 1999). According to Lee (1999), more children lost Medicaid health insurance coverage during the last three years in Texas than in any other state. Results indicate that San Antonio mirrors the data for Texas as a whole. In a column published in the San Antonio Express-News on May 11, 2000, Carlos Guerra wrote that Texas ranks number one in the percentage of uninsured children. As shown above, over 20% of children under 17 were without health insurance coverage.

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 (see Figure 6).

As seen in Figure 7, 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 20% or more with no insurance.

One of the research possibilities with the Current Population Surveys 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 in Figure 8 below. 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.

Table 3: Any Health Insurance by Ratio of Family Income to Poverty Level (in %)

N=2334
Source CPS 1996-1999.

Table 3 shows the relationship between the ratio of family income to the poverty level as defined by the Department of Labor. Those families with lowest ratio are the most poor and have the highest percentages with no insurance. Between 30% and 40% of families with income ratios between 0.5 and 1.74 of the poverty level report no health insurance. Between 25% and 30% of those with family incomes ranging between three quarters and one and one half times the poverty level report being uninsured. At the other end of the spectrum, families whose income ratio is 5 times the poverty rate have slightly less than 8% with no health insurance. The percent uninsured for all families in the analysis was 23%. While higher incomes do not guarantee adequate health insurance, clearly those families living closest to or below the poverty level are most likely to have no health insurance.

Figure 9 depicts the link between health insurance coverage and employment status. Focusing on those who are typically employed full time, we see that about 22.7% report no health insurance. Among those typically employed part time about 28.1% report no health insurance. About 20% of those not in the labor force do not have health insurance coverage, and about 45.5% of those unemployed do not have health insurance. Importantly, even being employed full time does not guarantee health insurance for over one fifth of the population. This reinforces findings by the Center for Public Policy Priorities that more than one third of Texas children in poor working families lack health insurance. This same report states that this proportion is one third higher than the average for other states.

One interesting observation is that self-reported health status is not related to whether or not an individual has health insurance (see Figure 10). Among those who report their health as excellent, 21.5% say they have no health insurance. On the other end of the health spectrum, 20% of those saying their health is poor report having no health insurance. This finding may be related to the age structure of those with and without insurance. Younger people are less likely to have insurance but also have superior health status.

Conclusion:

The Current Population Surveys provide a strong basis 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. Even though telephone surveys tend to underestimate the lack of health insurance, data from these surveys 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.

Access to health insurance varies by location, age, race and ethnicity, family size, household composition and other factors related to social and economic status. Those families whose incomes fall well below the poverty level are at high risk for being without health insurance. And, importantly, while unemployment is associated with higher percentages without health insurance, even full time employment does not guarantee adequate insurance coverage. The profile of individuals most likely to be without insurance mirrors that of the "working poor" and is far different from the stereotype that those without health insurance are unemployed, on welfare, or indigent. Clearly, policies focused solely on providing health services to homeless or other indigent populations are not enough to meet health care needs in the community.

Furthermore, uninsured individuals are likely to be substantially worse off than those with insurance on measures of health access and health status. Individuals who lack insurance are very likely faced with unmet medical needs when sick and an inability to pay medical bills. An important challenge for the San Antonio Metropolitan Area will be to continue to find strategies that will improve access to affordable health insurance coverage. Importantly, since a large proportion of the uninsured are employed, a part of the challenge will be to craft solutions that fit the reality of the San Antonio workforce. The high proportion of individuals who live at or below the poverty line and the high proportion of individuals who are seasonally employed or unemployed further contribute to the challenge of meeting San Antonio's health insurance needs.

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