Children Living With Uninsured Family Members: Differences by Family Structure
| Author | Sharon Bzostek,Christine Percheski |
| DOI | http://doi.org/10.1111/jomf.12309 |
| Date | 01 October 2016 |
| Published date | 01 October 2016 |
S B Rutgers University
C P Northwestern University∗
Children Living With Uninsured Family Members:
Differences by Family Structure
Despite increased access to insurance through
the Patient Protection and Affordable Care
Act of 2010, uninsurance rates are expected
to remain relatively high. Having uninsured
family members may expose children to nan-
cial hardships. Eligibility rules governing
both private and public health insurance are
based on outdated expectations about family
structure. Using 2009–2011 data from the
National Health Interview Survey (N=65,038),
the authors investigated family structure dif-
ferences in family-level insurance coverage
of households with children. Children living
with married biological parents were the least
likely to have uninsured family members and
most likely to have all family members covered
by private insurance. Controlling for demo-
graphic characteristics and income, children
in single-mother families had the same risk
of having an uninsured family member as
children in married-parent families. Children
with cohabiting biological parents had higher
rates of family uninsurance than children with
married biological parents, even accounting for
other characteristics.
Department of Sociology and Institute for Health, Health
Care Policy and Aging Research, Rutgers University,26
Nichol Ave., NewBrunswick, NJ 08901
(sbzostek@sociology.rutgers.edu).
∗Department of Sociology and Institute for Policy
Research, 1810 Chicago Ave., Evanston,IL 60208.
Key Words: cohabiting couples with children, family health,
family policy, inequality,marriage, single-parent families.
Current estimates suggest that more than half of
all children in the United States will spend part
of their childhood living in a family that is not
headed by married biological or adoptive parents
(Bumpass & Lu, 2000). Family scholars have
documented a number of ways through which
the increasing prevalence of “nontraditional”
family structures may be linked with widening
inequalities in children’s access to material,
social, and emotional resources (McLanahan &
Percheski, 2008), but this body of research has
largely neglected to consider health insurance
coverage. This omission is notable because
living with uninsured family members may
adversely affect children in numerous ways, and
the relationship between family structure and
health insurance coverage may differ from that
between family structure and other resources.
Prior to the passage of the Patient Pro-
tection and Affordable Care Act of 2010
(ACA), the share of the U.S. population without
health insurance was high, at 16.3% in 2010
(DeNavas-Walt, Proctor, & Smith, 2011). The
ACA promises (and has already begun) to
substantially reduce the number of uninsured
people in the United States by increasing access
to nongroup private insurance through health
insurance exchanges and providing premium
subsidies for low- and middle-income families
(ACA, 2010, p. 124). In a number of states,
Medicaid will also become available to more
adults under the ACA. Political resistance
to expansions of Medicaid and implementa-
tion problems, however, make it likely that
1208 Journal of Marriage and Family 78 (October 2016): 1208–1223
DOI:10.1111/jomf.12309
Family Structure and Family Insurance Coverage 1209
uninsurance will continue to be a problem for
the foreseeable future. Indeed, early reports have
suggested that as many as 30 million people
were still uninsured at the end of 2014, the rst
year of full ACA implementation (Gareld &
Young, 2015).
Inequalities in health insurance coverage
are important because of the effects of health
insurance on the well-being of individuals and
families. Numerous studies have shown strong
correlations between lack of insurance and
poor health or health care access (Institute of
Medicine, 2009), and studies with experimental
designs have found that health insurance has
causal effects on health (Currie, Decker, & Lin,
2008; Currie & Gruber, 1996; Finkelstein et al.,
2012; Sommers, Baicker, & Epstein, 2012).
In addition, studies of public health insurance
expansions have found that access to public
health insurance reduced families’ medical
debts and expenditures on health (Finkelstein
et al., 2012; Leininger, Levy, & Schanzenbach,
2010).
Living with uninsured family members may
affect even insured family members’ health.
Studies have found, for example, that adults liv-
ing with an uninsured family member reported
worse self-rated health than those living with
insured family members (Nielsen & Garasky,
2008) and that children with uninsured parents
had different health care utilization patterns than
those with insured parents (DeVoe, Tillotson, &
Wallace, 2009; Gifford, Weech-Maldonado, &
Short, 2005; Hanson, 1998). This research has
not focused on the mechanisms by which expo-
sure to uninsured family members may affect
insured individuals’ health, but some researchers
have suggested that parental experience with the
health care system may affect parents’ willing-
ness and ability to seek health care for their chil-
dren (Gifford et al., 2005; Hanson, 1998).
Having uninsured family members may
also affect other aspects of child and family
well-being. For example, parents without health
insurance may face more obstacles to getting
mental health care, and research has suggested
that parents’ untreated depression may nega-
tively affect children (e.g., Turney, 2011). Also,
residing with an uninsured family member may
expose the entire family to nancial risk and
higher out-of-pocket health expenses. Thus,
health insurance is a valuable resource that
affects both health and economic well-being,
and individuals are likely affected by both their
own insurance coverage status as well as that of
other family members.
Expansions of public health insurance for
children throughout the 1990s and 2000s sub-
stantially reduced the number and percentage
of children who are uninsured (Howell & Ken-
ney, 2012), and a considerable body of research
has examined the characteristics of children
who remain uninsured. Although the question
of which children are uninsured is important,
we argue that the neglected question of whether
children have uninsured family members is also
crucial. The uninsurance rate for nonelderly
adults was more than twice the rate for children
in 2010 (DeNavas-Walt et al., 2011).
We are particularly interested in howa child’s
family structure relates to insurance coverage
within the household. Because the predictors of
uninsurance among adults are different from the
predictors among children, we cannot assume
that the associations between family structure
and children’s insurance coverage found in pre-
vious research (see, e.g., Bass & Warehime,
2011; Cunningham & Kirby, 2004; Weinick &
Monheit, 1999) will be the same for parents or
for the whole family.
T R F S H
I C
In the United States, the two most common
sources of health insurance (prior to the pas-
sage of the ACA, and still today) are (a) pri-
vate, employer-sponsored health insurance and
(b) public insurance programs, which both have
rules about eligibility that are based on family
relationships and marital status. Until the cre-
ation of the health insurance exchanges in 2014
as part of the ACA, fewfamilies had health insur-
ance that was purchased on the individual market
(DeNavas-Walt et al., 2011).
F S P H
I C
The eligibility rules for most private,
employer-sponsored plans covering families
assume a nuclear, married-couple family with
children, and these plans typically provide
coverage only for an employee’s legal spouse
and biological, adopted, or legally recognized
stepchildren. A recent report based on the
Bureau of Labor Statistics’ 2013 Survey of
Employers found that only 26% of civilian
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