Low-income teenagers are more likely to lack health insurance than younger children. Using data from the 2006, 2007, and 2008 rounds' of the National Health Interview Survey, we examine whether differences between teens and younger children in socioeconomic factors, public health insurance eligibility, and observable family characteristics explain this apparent age-related coverage gap. Somewhat surprisingly, they do not. We find a highly robust age-coverage gradient among poor and near-poor children. Our results suggest the need to examine teen-specific insurance enrollment dynamics, particularly in families with no younger siblings, to optimize the effect of the newly enacted Patient Protection and Affordable Care Act on teens' insurance coverage.
Uninsurance rates among teenagers continue to outpace those observed in younger children despite a decade of public health insurance expansions that focused largely on older children (DeNavas-Walt, Proctor, and Smith 2009). The creation of the State Children's Health Insurance Program (now called the Children's Health Insurance Program or CHIP) in concert with expansions to Medicaid decreased the proportion of uninsured teenagers, while simultaneously increasing the proportion of publicly insured teenagers (Currie, Decker, and Lin 2008; Leininger 2009; Lurie 2009; Newacheck et al. 2003). Yet, among low-income children who are eligible for public health insurance, approximately 16% of teenagers are uninsured relative to 12% of younger children nationwide (Kenney, Cook, and Dubay 2009). It is important to identify the factors that may explain teens' relatively high uninsurance rates to maximize the effectiveness of the recently passed Patient Protection and Affordable Care Act (ACA) in increasing teens' health insurance coverage (Public Law 111-148).
Health policymakers have long viewed health insurance coverage as a necessary, if insufficient, resource to improve access to health care for low-income children. For teenagers in particular, there is considerable room for improvement. Relative to younger children, teens are more likely to lack a usual source of care (Burns and Leininger 2010) and experience lower levels of compliance with well-care recommendations (Selden 2006). Additionally, teens' receipt of preventive and problem-focused care consistently falls short of clinical recommendations (Irwin et al. 2009; Dempsey and Freed 2010). Moreover, teenagers suffer high rates of morbidity from conditions that are preventable and/or amenable to medical care. Illustratively, one study has documented that 16% of adolescents ages 12 to 17 have a chronic condition that requires the intensive use of medical services (van Dyck et al. 2004). Chronic conditions faced by adolescents are disproportionately borne by the low-income members of this age group (Brindis, Morreale, and English 2003), further motivating the relevance of focusing on enabling factors--of which insurance coverage is a notable example--that facilitate access to medical care for low-income teens (Goodman, Slap, and Huang 2003; Andersen 1995; Andersen and Aday 1978).
Historically, the primary explanation for low-income teenagers' high rates of uninsurance was the stringent eligibility criteria that they faced in order to obtain public health insurance relative to younger children (Brindis, Morreale, and English 2003: Morreale and English 2003). Beginning in the late 1980s and continuing through the late 1990s, a series of federal mandates extended Medicaid eligibility, first to all children ages 0 to 5 living in families with incomes below 133% of the federal poverty level (FPL), and subsequently phased in eligibility for most children ages 6 through 18 living in families at or below 100% FPL. The creation of CHIP in the 1997 Balanced Budget Act further expanded public insurance eligibility for nearpoor children of all ages, who generally were defined as children living in families with incomes between 100% and 200% FPL. …