Embargoed Until:
February 20, 2008
12:00 a.m. Eastern Time



Christopher Fleming

Coverage Losses Continued Even As The Economy Improved From 2004 Through 2006

Continuing Declines In Employer-Sponsored Coverage Plus Slower Growth In Medicaid And SCHIP Reversed Coverage Gains For Children

Bethesda, MD -- The number of uninsured people in the United States grew by 3.4 million from 2004 to 2006, even as a resurgent economy raised incomes and lowered poverty rates, Urban Institute researchers say in a Health Affairs Web Exclusive study published today. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.2.w135

The economy’s emergence from recession did not interrupt the rise in uninsurance dating back to 2000. In fact, on an annual basis, the ranks of the uninsured grew faster in 2005 and 2006 than they did during the four years from 2000 through 2004, when a total of 6 million people became uninsured. The study is based on data from the 2000, 2005, and 2007 March supplements to the Current Population Survey conducted by the U.S. Census Bureau.

“In good economic times and bad, the dominant factor behind the growing number of uninsured was the decline in employer-sponsored health coverage,” said lead author John Holahan, the director of the Health Policy Center at the non-partisan Urban Institute. From 2000 to 2004, the rate of employer coverage fell dramatically: In 2000, 67.8 percent of the nonelderly were covered by employer-sponsored insurance (ESI), but by 2004, only 63.3 percent had ESI.

From 2004 to 2006, the rate of ESI dropped another percentage point, from 64.0 percent to 63.0 percent. (The 2000-04 and 2004-06 coverage statistics are not strictly comparable because the 2004 and 2006 data reflect revisions the Census Bureau made to the assignment of dependent coverage.)

“The decline in the rate of employer coverage was much greater during the first part of the decade, but it is disturbing that ESI rates continued to decline even as the economy improved. What’s more, from 2000 to 2004, Medicaid and the State Children’s Health Insurance Program were able to compensate for ESI losses among children, but in the 2004-06 period the deteriorating budget picture caught up with states and Medicaid and SCHIP growth slowed,” said Holahan. As a result, the number of uninsured children rose 1.0 million from 2004 to 2006, after having fallen by 400,000 from 2000 to 2004. Over the two periods, the number of adults without coverage increased by 8.7 million.

Declines In Employer-Sponsored Coverage
Were Largest For Those At Lower Incomes

Declines in ESI rates occurred at all income levels but were most pronounced for the low-income, note Holahan and coauthor Allison Cook, a research associate at the Urban Institute. ESI rates for low-income adults -- those with family incomes below 200 percent of the federal poverty level (FPL) -- dropped 4.2 percentage points in 2000-04 and 1.6 points in 2004-06. By contrast, the decreases in ESI rates for higher-income adults -- those with family incomes above 400 percent of the FPL – were only 2.0 points in 2000-04 and 0.5 points in 2004-06.

For children, the pattern was similar. The percentage of low-income children with ESI dropped 5.5 percentage points in 2000-04 and 2.5 points in 2004-06, while the corresponding decreases for higher-income children were only 2.2 points in 2000-04 and 0.5 points in 2004-06. For both adults and children, the decline in ESI rates for middle-income people -- those with family incomes between 200 percent and 400 percent of the FPL -- fell between the declines for low-income people and those for higher-income people.

To the extent that firms cannot shift rising insurance premiums “back to workers in the form of lower wages, they become less likely to offer coverage. At the low end of the income scale, premiums add much more to compensation and often cannot be shifted back to workers. Nor are the tax benefits at the low end of the income distribution particularly great, which weakens the incentive to give up wages for health insurance,” Holahan and Cook write.

The authors warn that the erosion of ESI is likely to continue, particularly for low-income people, “because the basic factors underlying it seem unlikely to change.” In addition to rising health care costs, those factors include the shift in employment to industries such as services and construction, where ESI rates have traditionally been relatively low, and away from industries such as manufacturing, where ESI rates have been relatively high; and the movement of the population to the South and West, again away from the large manufacturing centers of the North and Midwest.

Holahan and Cook say that the increase in the number of noncitizens has also contributed to the decline in ESI, but “in a relatively minor way,” accounting for about 20 percent of the growth in the number of uninsured people from 2000 to 2006.

After the embargo lifts, you can read the article by Holahan and Cook at


Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.


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