QuickTake: Further Reducing Uninsurance among Parents Will Require Tackling Affordability Concerns


Michael Karpman, Jason Gates, and Genevieve M. Kenney

January 6, 2016


Despite large gains in coverage since 2013, many parents remained uninsured in 2015 (Karpman, Gates and Kenney 2015).1 Lack of coverage for parents not only could affect their access to health care and increase their vulnerability to high medical bills, but also has implications for their children's coverage and health care. For example, previous studies have shown that children are more likely to have coverage if their parents are insured (Aizer and Grogger 2003; Dubay and Kenney 2003).


We used data from the March and September 2015 rounds of the Urban Institute's Health Reform Monitoring Survey (HRMS) to examine the reasons parents living with dependent children ages 17 and under remain uninsured in the wake of coverage expansions implemented under the Affordable Care Act (ACA).2 We found that in March and September 2015, nearly two-thirds of uninsured parents (65.2 percent) cited the cost of insurance or their inability to afford insurance as a reason for not having coverage (figure 1). The next most frequently cited reason was that parents were in transition between different types of coverage (13.7 percent); another 7.1 percent said they did not know how to find information about available options. About 13.0 percent of uninsured parents reported that they do not want coverage. These findings are consistent with data from earlier rounds of the HRMS for nonelderly adults more generally and with other analyses of survey data from the same Internet panel underlying the HRMS that have found perceived affordability problems to be the most significant barrier to coverage for the remaining uninsured adults (PerryUndem 2015; Shartzer et al. 2015).



Uninsured parents also report experiencing significant financial hardship and difficulty meeting basic needs in the previous year, and these hardships may help explain why they have been unable to purchase coverage. For instance, in September 2015 nearly 6 in 10 uninsured parents (58.4 percent; figure 2) reported that their family often or sometimes ran out of food in the previous 12 months, nearly twice the proportion of insured parents (30.1 percent; data not shown).3 In addition, 45.0 percent of uninsured parents reported that they often or sometimes were unable to pay the rent, mortgage, or other housing costs; 69.3 percent had problems with unexpected bills, such as car repairs or home repairs; and 44.7 percent were unable to make the minimum payment on a credit card bill or loan.



About one-third (31.9 percent; figure 3) of uninsured parents have family incomes at or below the federal poverty level (FPL)4 and live in states that did not expand Medicaid before September 1, 20155—many of these parents are likely in the "assistance gap," having incomes that are too high to qualify for Medicaid but not high enough to qualify for tax credits to purchase coverage in the health insurance Marketplaces.6 Another quarter of uninsured parents (24.0 percent) have incomes at or below 138 percent of FPL and live in Medicaid expansion states.7 Some of these parents may be eligible for Medicaid, though others may be ineligible because of their immigration or documentation status.



Other parents may be eligible for tax credits to purchase a Marketplace health plan but may still find that coverage unaffordable. Four in 10 uninsured parents (39.9 percent) are in the income range targeted by the Marketplace tax credits (139–399 percent of FPL in Medicaid expansion states and 100–399 percent of FPL in nonexpansion states), though not all of these parents will qualify for tax credits because, for example, some may have offers of employer-sponsored insurance that are deemed affordable under the ACA. Only 4.2 percent of uninsured parents in the HRMS were found to have incomes at or above 400 percent of FPL.


Overall, these results indicate that many uninsured parents feel that affordable coverage is still beyond their reach and that a large share struggles to meet their families' basic needs or pay off debt. As noted, children are historically less likely to be covered when their parents are uninsured, a pattern that is visible in the HRMS data from 2015. For instance, among the sampled children and parents in the September 2015 HRMS, just 1.7 percent of insured parents reported that their child is uninsured (data not shown). In contrast, 25.2 percent of uninsured parents reported that their child is uninsured.8 Steps to make coverage more affordable, either through expansions of Medicaid in the 20 states that have not yet expanded eligibility or increased financial assistance for Marketplace coverage (Blumberg and Holahan 2015), are likely to be critical to building on the gains in health insurance coverage that parents have experienced since the ACA's major coverage provisions took effect. Furthermore, with about 20 percent of uninsured parents reporting an inability to find information about coverage options or no desire for insurance, efforts to increase awareness and understanding of the value of insurance and how to obtain it will also be important.


Methods: For this analysis, we used HRMS data from quarters 1 and 3 2015 to examine reasons for being uninsured among parents ages 18 to 64. In each round of the HRMS, approximately 7,500 adults ages 18 to 64 complete the survey. The child supplement (HRMS-Kids) was added to the HRMS in quarter 2 2013 to ask questions about a randomly selected child in respondents' households. HRMS-Kids yields information on approximately 2,400 randomly selected children each round. Our definition of parents, which is based on information provided in the HRMS-Kids, includes all parents and guardians living with a dependent child age 17 or under. Each round of the HRMS and HRMS-Kids is weighted to be nationally representative.




Aizer, Anna, and Jeffrey Grogger. 2003. "Parental Medicaid Expansions and Health Insurance Coverage." NBER Working Paper No. 9907. Cambridge, MA: National Bureau of Economic Research.


Blumberg, Linda J., and John Holahan. 2015. After King v. Burwell: Next Steps for the Affordable Care Act. Washington, DC: Urban Institute.


Dubay, Lisa, and Genevieve M. Kenney. 2003. "Expanding Public Health Insurance to Parents: Effects on Children's Coverage under Medicaid." Health Services Research 38 (5): 1283–1301.


Karpman, Michael, Jason Gates, and Genevieve M. Kenney. 2015. Time for a Checkup: Changes in Health Insurance Coverage, Health Care Access and Affordability, and Plan Satisfaction among Parents and Children between 2013 and 2015. Washington, DC: Urban Institute.


PerryUndem. 2015. Understanding the Uninsured Now. Princeton, NJ: Robert Wood Johnson Foundation.


Shartzer, Adele, Genevieve M. Kenney, Sharon K. Long, and Yvette Odu. 2015. A Look at Remaining Uninsured Adults as of March 2015. Washington, DC: Urban Institute.


About the Series

This QuickTake is part of a series drawing on the HRMS, a quarterly survey of the nonelderly population that explores the value of cutting-edge Internet-based survey methods to monitor the ACA before data from federal government surveys are available. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute. This QuickTake was funded by the David and Lucile Packard Foundation and funding from an anonymous donor. It draws on the HRMS-Kids, which was conducted in partnership with the Center for Children and Families at Georgetown University and is currently funded by the David and Lucile Packard Foundation and an anonymous donor. The authors are grateful to Sharon K. Long, Douglas Wissoker, Nathaniel Anderson, Stacey McMorrow, Lisa Clemans-Cope, Lisa Dubay, Joan Alker, Tricia Brooks, and Liane Wong for their input on the HRMS-Kids and to Stacey McMorrow for helpful comments on this QuickTake.


For more information on the HRMS and for other QuickTakes in this series, visit www.urban.org/hrms.


About the Authors


Michael Karpman is a research associate, Jason Gates is a research assistant, and Genevieve M. Kenney is a senior fellow and codirector with the Urban Institute's Health Policy Center.



1 Unpublished Urban Institute tabulations of the National Health Interview Survey data find that 15.7 percent of parents and guardians were uninsured in 2014.

2In this QuickTake, we focus on parents and other legal guardians of children ages 17 and under living in the household and refer to them throughout as parents. In some cases, adults who are not parents or guardians (e.g., other relatives or nonrelatives) respond to the HRMS child supplement questions on behalf of a randomly selected child in the household—those cases are excluded from analyses of parents/guardians but included in those that pertain to children. In the September 2015 HRMS, 94.4 percent of adults reporting on behalf of children were parents or guardians.

3 Though these estimates are based on a relatively small sample of 234 uninsured parents in September 2015, responses to similar questions on difficulty affording food and housing costs March 2015 show similar patterns for uninsured parents. For example, in March 2015, 49.8 percent of uninsured parents reported running out of food in the past 12 months compared with 58.4 percent of uninsured parents in September 2015, and this difference is not statistically significant. The two rounds of data could not be combined because of changes to the wording of the question on housing costs between the two rounds and because questions on unexpected bills and inability to make minimum payments on a credit card or loan were not asked in March 2015.

4 The income measure used in the HRMS is not the same as the measure of modified adjusted gross income used to determine eligibility for Medicaid and Marketplace tax credits; therefore, estimated levels of family income as a percentage of FPL only provide an approximation of whether respondents are in the income ranges targeted by the Medicaid expansion and Marketplace tax credits.

5 States that expanded Medicaid before September 1, 2015, are AZ, AR, CA, CO, CT, DE, DC, HI, IL, IN, IA, KY, MD, MA, MI, MN, NV, NH, NJ, NM, NY, ND, OH, OR, PA, RI, VT, WA, and WV.

6 Matthew Buettgens, "Medicaid Expansion Could Make Health Insurance Affordable for 5.6 Million," Urban Wire, October 2, 2015.

7 Alaska, Connecticut, and the District of Columbia have income eligibility thresholds for parents that are above 138 percent of FPL. See "Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level," Kaiser Family Foundation, last updated November 2015.

8 The estimated uninsurance rates for children are similar if we include all adults reporting on behalf of children, including those who are not parents or guardians. For instance, among all insured adults reporting on behalf of a child in the household, 1.9 percent of the children for whom they are reporting are uninsured. Among asll uninsured adults reporting on behalf of a child, 25.2 percent of the children for whom they are reporting are uninsured. In addition, a small number of HRMS respondents identified themselves as parents of children living in the household but did not respond to other child supplement questions, such as questions on the child's coverage, and are therefore not included in these estimates.

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