March 1996, Vol. 30, No. 1

In Missouri, 630,000 non-elderly citizens had no health insurance coverage in 1993. These uninsured residents accounted for 14 percent of Missouri's children and adults under age 65.

Almost two thirds of non-elderly Missourians had health-care coverage provided through employers, according to analyses of U.S. Census Bureau Current Populations Surveys (CPS) with data on 1990 - 1992 as shown in Graph 1. Thirty-three percent were employees covered by their employers, and 32 percent were dependents covered by employers. Other private insurance plans covered 9 percent and included individually purchased non group coverage. Medicaid provided coverage for 10 percent of non-elderly Missourians. Other public insurance programs involved CHAMPUS (military) and Medicare for some non-elderly. Uninsured Missourians encompassed the remaining 14 percent without health-care coverage. For comparison, 16 percent of non-elderly U.S. citizens were uninsured in 1993, while only 12 percent were uninsured among non-elderly residents in the West North Central region, including the states of Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota and South Dakota combined.

Seventy-seven percent of uninsured adults were employed, with 56 percent working full time (35 hours or more per week) and 21 percent having part-time employment. Only 23 percent were not working. Eighty-eight percent of uninsured families had at least one working adult (Graph 2). Seventy-one percent had one or two full-time workers, and 17 percent had someone working part-time. Only 12 percent of families without health care coverage had no working adult. Forty-three percent of uninsured workers were employed by large firms with 100 or more workers, and 41 percent worked for small firms with under 25 workers. Almost three quarters of uninsured workers were in wholesale/retail and service industries, and 85 percent worked in the private sector.

Fifty two percent of uninsured households were headed by a single adult, with or without children. In 36 percent of households without coverage, adults were married with children.

Almost half the uninsured families had income (relative to poverty) in the 100 to 199 percent range. Thirty-four percent were below 100 percent. Medicaid covered many households in this lower income group in 1993. Fifteen percent of uninsured non-elderly Missourians were in the 200 to 399 percent range, and 4 percent had income above 400 percent. According to 1993 federal poverty guidelines, a family of four with an income of about $14,000 was at 100 percent of the Federal Poverty Level. Guidelines vary for families of other sizes.

Estimates about Missouri's uninsured were made using Census statistics on demographic characteristics of Missourians and information developed about the uninsured in the State. Table 1 shows that 36.3 percent of non-elderly Missourians below 100 percent of poverty and 35.8 percent of those in the 100 to 199 percent range did not have health care coverage. Less than 4 percent of persons with incomes of 200 percent or more of poverty were uninsured.

Twenty-six percent of the uninsured were children less than 18-years-old, and 44 percent were ages 18 through 34. Uninsured adults 55 through 64 years old comprised the smallest group.

Table 1 displays percents of non-elderly uninsured Missourians by age classes. One fifth of young adults, 18 to 34 years of age did not have health care coverage. This group had a much higher proportion of their number who were uninsured, when compared to those in other age categories.

Slightly more of the uninsured were males. Females, especially pregnant women, had higher rates of Medicaid coverage. Table 1 shows that overall 16 percent of males and 13 percent of females were uninsured.

Seventy-nine percent of the uninsured were white. Missourians without health-care coverage were found across demographic groupings. However, residents were more likely to lack health insurance coverage if they had low income or were young adults and single. Though 79 percent of the uninsured were white, many African-Americans and other nonwhites are at higher risk of being uninsured because of employment and income. Table 1 shows that 13 percent of whites were uninsured, while over 22 percent of blacks and others did not have health care coverage.

In 1993 hospital use rate differences existed between uninsured Missourians and state residents with health-care coverage. The emergency room use rate was higher for the uninsured than for those with coverage. The uninsured had 425 visits per thousand population, and residents with health-care coverage made 276 visits per thousand statewide.

In contrast, inpatient admission rates and per capita hospital charges were less for the uninsured than for those with health-care coverage. The uninsured were hospitalized at the rate of 56 per thousand uninsured, while those with health-care coverage had 105 hospitalizations per thousand population. Charges for uninsured inpatient hospital care averaged $603 per uninsured Missourian, while charges averaged $1,063 per Missourian with health-care coverage.

Percents of 1993 outpatient and inpatient hospital encounters by uninsured non-elderly residents of Missouri's counties are displayed in Map 1. Percentages vary among counties, and counties were divided into quartiles according to the percents. Visits to the hospital were influenced by not only the characteristics of those living in each county but by availability and accessibility of primary care providers, hospitals and other health services. Numbers of encounters varied between counties of residence. Emergency room visits are about 90 percent of all outpatient encounters.

Health-care charges in Missouri hospitals for non-elderly uninsured patients totaled $430 million in 1993, or about 8.2 percent of all hospital charges. This included 300,000 outpatient and 36,000 inpatient encounters by uninsured non-elderly Missourians. No private insurance or public health-care coverage was available in 18 percent of outpatient visits and 8 percent of inpatient hospitalizations. Total 1993 health-care charges (hospital, physician, pharmacy, etc.) for uninsured non-elderly Missourians were over $1 billion (assuming health care fees in Missouri are similar to the rest of the nation).

Studies of health insurance in the United States show that, compared with the insured, the uninsured are less likely to use health services, including physicians, emergency rooms, prescriptions and hospitals and have lower average health expenditures. The uninsured have more avoidable hospitalizations, higher inpatient mortality, higher overall mortality (even adjusting for income), more diagnoses indicating later stages of life-threatening diseases and lower levels of subjective health status. "Spells" without insurance are likely to be shorter if a person is employed, has higher income, is educated, is married and/or is 18 to 24 years old. About half the "spells" last at least six months, 28 percent last at least 12 months, and 15 through 18 percent last at least 24 months.

Statewide baseline data on health insurance coverage and characteristics of uninsured Missourians were analyzed as part of a State Health Initiative Project under a grant from the Robert Wood Johnson (RWJ) Foundation. Data used for this Focus article are from (1) combined March 1991-1993 Current Population Surveys (CPS), U.S. Bureau of Census analyzed by the Urban Institute, Washington, D.C., and (2) analyses of 1993 Hospital Patient Abstract Records at the Missouri Department of Health. Each March, CPS collect data on health insurance coverage, work status, income, demographics and other populations characteristics. Sampling is nationwide, but Missouri respondents can be analyzed separately. Merging three consecutive annual surveys provides more reliable estimates of population characteristics. The CPS analyses cited here represent average values for the 1990-1992 period, weighted toward the most recent year. Data analyzed for Table 1 were weighted in a similar fashion. During analyses, the Urban Institute adjusted the percent of Medicaid coverage estimated through CPS responses.