1. Declining Access of Adolescents and Young Adults to Both Public and Private Sources of Health Insurance Niev J. Duffy, PhD Mount Sinai Adolescent Health Center The Mount Sinai Medical Center New York, New York

2. Objective To explore the impact of the restructuring of health care markets on the health insurance status of adolescents and young adults, taking into consideration changes in both public and private sources of insurance. To evaluate the potential public health implications of these trends.

3. Methods The author analyzed data from eleven years of the March Supplement of the Current Population Survey in order to identify trends in Medicaid and private insurance coverage.

4. Introduction  Health insurance coverage among children fell dramatically during the recession of the early 1990s. Between 1994 and 1998 levels of private insurance coverage among children recovered only slightly.

6. A Few Words of Caution  Data before and after 1994 are not directly comparable because of a change in the ordering of CPS questions that dramatically increased reporting of private insurance among children.  Data before and after 1999 are not directly comparable due to a change in the composition of CPS questions that dramatically increased reporting of private health insurance among children. Thus the apparent rise in insurance in the following diagrams in 1999 and 2000 is largely or entirely due to coding changes.

9. Medicaid  Medicaid coverage among children rose until 1995, and then began a downward slide.

11. Uninsurance among Children  As a consequence of these two trends uninsurance among children rose both during the recession of the early 1990s and during the long economic recovery. The apparent decline in rates of uninsured between 1998-2000 was largely or entirely due to changes in the structure of Survey questions and therefore does not necessarily reflect improvements in the health insurance status of children.

14. Health Insurance Status of Parents and Children  The health insurance status of children is largely determined by that of their parents. Declining private employer provided health insurance among parents, particularly those working full-time year-round leads to an erosion of coverage among children. Younger children are less likely to have private coverage because their parents, who are also younger, are less likely to have coverage.

15. Rates of Private Insurance All Among Children Aged 0-18 Source: Author’s Calculations Using March Supplement of the Current Population Survey, 1990-2001

21. RESULTS  Declining access in the U.S. to both public and private sources of health insurance among children and young adults.  Declines in rates of private employer provided coverage among fulltime year-round workers during 1990s sharpest for adults in their peak childbearing years, 19-29.  Younger children/younger parents have lower rates of private insurance.

22. RESULTS  Recent partial recovery of private health insurance benefits among children is due to extraordinarily high rates of fulltime labor force participation among spouses in households with children.  Growing gap in private health care coverage between older adolescents/young adults and other age groups.

23. IMPLICATIONS FOR COMMUNITY HEALTH  The rising share of uninsured among adolescents imposes a strain on the resources of health care institutions providing services to this population, at a time when cost-shifting is increasingly difficult.  Financial difficulties are worsened by cuts in health care subsidies and declining reimbursement rates, as well as declining funding for reproductive health care.

24. IMPLICATIONS FOR COMMUNITY HEALTH  The current economic downturn is likely to accelerate the decline in private health insurance leading to rising rates of uninsurance.  The loss of Medicaid coverage may accelerate as recipients of public assistance reach the 5 year welfare reform limit.

25. IMPLICATIONS FOR COMMUNITY HEALTH  Ultimately, continued financial difficulties lead to declining quality of care or denial of services to the uninsured.  Rising uninsurance leads to rising demands on the resources of Medicaid and CHIP.  Financially troubled health care institutions cut community services.