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Over the last fifteen years, the nation has placed an increasing emphasis on ensuring that children with a parent living elsewhere have access to the private health care coverage available to their nonresident parent. Since 1985, state child support agencies have been required to request that health care coverage be included in the child support order when the custodial parent does not have private coverage and coverage is available to the nonresident parent through his employer. The Omnibus Budget Reconciliation Act of 1993 addressed some of the barriers to coverage of children with a nonresident parent by requiring states to pass laws to prevent insurers from denying coverage on the basis of residency or dependency requirements. The Child Support Performance and Incentive Act of 1998 aims to facilitate the process of obtaining health care coverage from a nonresident parent's employer through development of a National Medical Support Notice that employers will be required to accept and respond to within a specified time frame.
The emphasis on securing access to private health care coverage has arisen in part from the disparity in private health care coverage between custodial children (children with a nonresident parent) and children in intact families. In 1997, 77 percent of children in intact families had private health care coverage, compared to 51 percent of children in custodial families. As a result, custodial children are much more likely to rely on public health care coverage such as Medicaid than are other children. Thirty-six percent of custodial children are covered by publicly funded benefits compared to twelve percent of children in intact families. Thirteen percent of custodial children and 11 percent of children in in-tact families are uninsured. (1)
The recent legislative efforts may improve custodial children's access to private health care coverage, but only to the extent that nonresident parents, the majority of whom are fathers, have access to health care coverage. The purpose of this paper is to develop a national estimate of the extent to which nonresident fathers have access to employment-based health care coverage, and to consider the potential for extending additional coverage to custodial children.
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There has been little research into the extent of nonresident parents' access to private health care coverage, and much of what exists is of health care coverage status during the 1980s. Three studies have examined this issue using state or county level data. Using data from 2,700 child support cases in Wisconsin in the mid-1980s, Meyer (1997) estimated that fathers could provide health care coverage to between 4 and 28 percent of children covered only by Medicaid, and to between 9 and 35 percent of uninsured children. Similar results were obtained by Sonenstein and Calhoun (1988) in an analysis of 86 child support cases in Florida and Ohio, also in the mid-1980s. Although their sample size was too small to produce generalizable results, they found that the nonresident parents in their sample could provide health care coverage to between 10 and 29 percent of children covered only by Medicaid, and to between 9 and 20 percent of uninsured children.
More recent data are available from a 1998 study by the Department of Health and Human Services, Office of the Inspector General (OIG). The study covered 200 Child Support Enforcement (IV-D) program cases in Connecticut in 1996 and 1997 in which the child was eligible for Medicaid and the nonresident parent paid child support and was required to provide health care coverage. The study found that 63 percent of the nonresident parents did not provide health care coverage as required under the medical support order because health care coverage from an employer was not available at all or was not available at reasonable cost (relative to the nonresident parent's income). Another 23 percent of the nonresident parents provided health care coverage to their children and, in 11 percent of the cases, the state agency was in the process of enforcing the medical support order.
Two prior studies, Nightingale, et al. (1986) and GAO (1992), produced national estimates of the potential for additional health care coverage from nonresident parents, but both studies relied on assumptions about nonresident parents' work and health care coverage status. Nightingale, et al. analyzed data on single-parent families from the March 1984 Current Population Survey and estimated that less than 10 percent of the children receiving Medicaid and 30 percent of the uninsured children could be covered by a nonresident parent's private health care plan. The estimate relied on two assumptions: first, that health care coverage could only be provided by nonresident parents currently paying child support or alimony and, second, that most nonresident parents with orders were employed and had access to health care coverage.
The more recent GAO study used data from the 1990 child support and alimony supplement to the Current Population Survey (CPS). GAO examined custodial families in which the children were covered by Medicaid, and the nonresident father paid child support and was required to provide health care coverage. About half of these nonresident fathers provided health care coverage as required (in which case the health care coverage took precedence over the child's Medicaid coverage or helped to reimburse the Medicaid program for the costs of treatment). Another 30 percent were estimated to be able to provide health care coverage, based on the assumption that they worked full-time and were as likely as other full-time workers to have access to health care coverage from an employer.
The study presented here fills a gap in prior research by creating a national estimate of nonresident fathers' access to private health care coverage. Whereas the studies by Nightingale, et. al. and GAO relied on assumptions about the work and health care coverage characteristics of nonresident fathers, this study directly observes these characteristics using data from a nationally representative survey. Data from the same source provide information on the health care coverage status of custodial children, although children's and nonresident fathers' data are not linked.
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Data for this analysis come from the 1993 Survey of Income and Program Participation (SIPP), a longitudinal survey containing detailed income and demographic information on a nationally representative sample of approximately 20,000 households. Households are interviewed once every four months over the course of a three year period. In each interview, the household is asked questions about the prior four months. The four month period required to interview all of the households is referred to as a "wave." This analysis uses data from the first three waves of the 1993 SIPP panel. Nonresident fathers and custodial mothers not interviewed in all three waves are excluded from the analysis, but custodial children do not have to be present in all three waves for their mothers to be included. The months covered by the first three waves range from October 1992 to September 1993 for the first households interviewed and from January 1993 to December 1993 for the last households interviewed. (2) In this report, results from the first three waves are referred to as results for 1993, and results from the first wave are referred to as results from the first four months of 1993.
Custodial mothers can be readily identified through child support questions included in the Wave 3 topical module of the SIPP. Mothers who have split custody or joint legal and physical custody with the fathers of their children are excluded from the analysis (about 3 percent of the unweighted sample). Identification of nonresident fathers is more difficult and is based on the approach developed by Elaine Sorensen using the 1990 SIPP (Sorensen 1997). A man is assumed to be a nonresident father if he reports paying child support or providing health care coverage to a nonresident child in the prior 12 months. Additional nonresident fathers are identified using Wave 2 topical module questions about marital and fertility history and household composition. In general, a man is considered to be a nonresident father if he reports having fathered more children than are currently living with him and his age and marital history suggest that the nonresident children are minor children from a prior relationship.
The methods described above identify 1,758 of the sampled women as custodial mothers, and 1,285 of the sampled men as nonresident fathers. Applying the 1993 population weights supplied by the SIPP produces an estimate of 10.2 million custodial mothers and 8 million nonresident fathers. Assuming an equal number of custodial mothers and nonresident fathers, the above methods identify 78 percent of the nonresident father population using the SIPP.
To produce a more realistic profile of nonresident fathers that reflects the entire population of nonresident fathers rather than just those identified in the SIPP, new weights are created for the identified nonresident fathers. The reweighted data represent the entire population of nonresident fathers, including those who are absent from the SIPP as a result of the Census undercount, incarceration or other institutionalization, or military service. Additional adjustments are made to compensate for the apparent underreporting of fertility by nonresident fathers on the SIPP. See Appendix A for further information about the development of the new weights, and of the effect that reweighting has on the estimates.
The SIPP includes detailed information on the health care coverage status of each member of the household in each month of the year. Of particular relevance to this analysis are nonresident fathers' reports of provision of health care coverage to children living elsewhere, and custodial families' reports of receipt of coverage from outside the household. Unfortunately, the SIPP does not ask whether a father without health care coverage works for an employer that offers coverage. Therefore, the employer offer of dependent coverage is imputed based on data from the April 1993 Current Population Survey Employee Benefits Supplement (CPS). The imputation controls for the father's demographic characteristics, weekly earnings, firm size, industry of employment, and coverage under a spouse's health care plan. Appendix B provides additional information on the imputation.
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Table 1 presents information about income, child support, and the provision of health care coverage by the nonresident father as reported by custodial mothers and nonresident fathers in 1993. There are approximately 10.2 million custodial mothers with at least one child under 18 who has an absent father. The adjustments to the nonresident father estimates assume an equal number of nonresident fathers. Although approximately 15 percent of custodial parents are fathers (U.S. Bureau of the Census 1995), they are excluded from the analysis due to small sample size.
| Custodial Mothers | Nonresident Fathers | |
|---|---|---|
| Sample Size | 1,758 | 1,285 |
| Number (thousands) | 10,227 | 10,227 |
| Income Level | ||
|
37% | 20% |
|
28% | 20% |
|
35% | 60% |
| Receives/Pays Child Support | 46% | 45% |
| Receives/Provides Health Care Coverage in year | 24% | 30% |
| Receives/Provides Health Care Coverage in first four months | 16% | 22% |
| Families with formal written order or agreement (thousands) | 5,102 | na |
|
76% | na |
|
35% | na |
|
25% | na |
|
Note: The population weights of nonresident fathers are
adjusted to account for all nonresident fathers, including those missing
from the SIPP due to the Census undercount, incarceration or other
institutionalization, and military residence in barracks or overseas.
Source: Author's analysis of the 1993 Survey of Income and Program Participation. |
||
Custodial mothers are more likely to be poor or low-income than are nonresident fathers. More than one in three custodial mothers is officially poor, compared to one in five nonresident fathers. Sixty-five percent of custodial families have incomes of less than 200 percent of the poverty threshold, compared to 40 percent of nonresident fathers. (4)
Nearly half (46 percent) of custodial mothers report receiving child support in at least one month of the year. The adjustments to the estimates for nonresident fathers assume that virtually the same percentage of nonresident fathers pays child support. Of the 5.1 million custodial mothers with a formal written child support order or agreement, 76 percent report receiving child support in at least one month of the year. (5)
More nonresident fathers report providing health care coverage to their nonresident children than is reportedly received by custodial mothers. Thirty percent of nonresident fathers report providing, and 24 percent of custodial mothers report receiving, health care coverage for at least one child in at least one month of the year. The percentage of children receiving health care coverage is less when viewed in the context of a shorter time frame, but the discrepancy between fathers' and mothers' reports remains. Twenty-two percent of nonresident fathers report providing, while 16 percent of custodial mothers report receiving, health care coverage in at least one month in the first four months of 1993. Custodial mothers with a formal written child support order or agreement are more likely to receive health care coverage from the nonresident parent. Thirty-five percent of those with a written order or agreement report receiving health care coverage in at least one month of the year, and 25 percent report receiving health care coverage in at least one of the first four months of 1993.
The discrepancy between fathers' and mothers' reports is not necessarily due to reporting error. Anecdotal evidence suggests that some custodial mothers may be unaware that the father of her child has secured health care coverage. Alternatively, the mother may know of the coverage, but not be able to take advantage of it, due to geographic or other barriers to access. Although provisions of the Omnibus Budget Reconciliation Act of 1993 aimed to remove such barriers, implementation has been gradual and any changes brought about by this legislation would not be reflected in the 1993 data used in this analysis. In this paper, results pertaining to custodial families reflect mothers' reports, and those pertaining to nonresident fathers reflect fathers' reports.
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According to reports by custodial mothers, over 60 percent of child support orders and agreements in effect in 1993 made some provision for medical costs (Table 2). Thirty-seven percent required the nonresident parent to provide health care coverage, and 16 percent required the custodial parent to provide coverage. Nine percent made some other provision for medical costs such as requiring the nonresident parent to pay medical costs directly or including cash medical support in the child support award. Child support orders of low-income custodial families were equally likely as those of higher-income custodial families to require the nonresident father to provide health care coverage. Higher-income families' child support orders were more likely than those of lower-income families to require the custodial parent to provide health care coverage and less likely to make no provision for medical costs.
| Custodial Family Income Level | |||
|---|---|---|---|
| <200% Poverty | 200% Poverty+ | Total | |
| Families with a Formal Child Support Award or Agreement | 2,858 | 2,244 | 5,102 |
| Provision for Health Costs in Award: | (100%) | (100%) | (100%) |
|
37% | 38% | 37% |
|
11% | 21% | 16% |
|
9% | 9% | 9% |
|
43% | 32% | 38% |
| Source: Author's analysis of the 1993 Survey of Income and Program Participation | |||
Table 3 examines the health care coverage status of custodial children by whether the nonresident father is required to provide health care coverage. (6) If at least one custodial child receives health care coverage from a given source in at least one month of the year, then the family is considered to have received health care coverage from that source. The family is placed into the first of the following categories that applies to it: coverage from the nonresident father, coverage from the custodial family, and Medicaid coverage. If none of the custodial children has health care coverage in at least one month of the year, the family is categorized as uninsured. Coverage by the nonresident father and custodial family includes private employer-based or other group coverage, individually purchased private (nongroup) coverage, and coverage obtained through employment in the government or military. A small number of families have children receiving Medicare and are grouped with the Medicaid recipients.
The top panel of Table 3 provides detailed information about the health care coverage status of all custodial families, regardless of whether there is a child support order. Twenty-four percent of the custodial families report receiving health care coverage from the nonresident father in at least one month of 1993, another 35 percent report covering the children from within the household, 35 percent rely exclusively on Medicaid, and 6 percent are uninsured. Less than half (43 percent) have private coverage from the nonresident father or custodial family for all 12 months of the year.
| Custodial Family Income Level | |||
|---|---|---|---|
| <200% Poverty | 200% Poverty+ | Total | |
|
All Custodial Families (thousands) |
6,636 | 3,591 | 10,227 |
|
(100%) | (100%) | (100%) |
|
21% | 30% | 24% |
|
21% | 61% | 35% |
|
50% | 5% | 35% |
|
8% | 4% | 6% |
| With Private Coverage Entire Year | 23% | 79% | 43% |
|
Father Required to Provide Health Care Coverage Under Award or Agreement |
1,062 | 846 | 1,908 |
|
(100%) | (100%) | (100%) |
|
66% | 71% | 68% |
|
12% | 24% | 17% |
|
18% | 2% | 11% |
|
4% | 3% | 4% |
| With Private Coverage Entire Year | 48% | 87% | 65% |
| Award or Agreement, but Father Not Required to Provide Health Care Coverage | 1,795 | 1,398 | 3,193 |
|
(100%) | (100%) | (100%) |
|
15% | 16% | 15% |
|
26% | 77% | 49% |
|
52% | 3% | 30% |
|
7% | 4% | 6% |
| With Private Coverage Entire Year | 22% | 83% | 49% |
| No Award or Agreement | 3,779 | 1,346 | 5,125 |
|
(100%) | (100%) | (100%) |
|
10% | 18% | 12% |
|
21% | 68% | 33% |
|
59% | 10% | 46% |
|
10% | 4% | 8% |
| With Private Coverage Entire Year | 16% | 69% | 30% |
|
* If at least one custodial child receives health care coverage
from a given source in at least one month of the year, then the family is
considered to have received health care coverage from that source. The family
is placed into the first of the categories that applies to it.
Source: Author's Analysis of the 1993 Survey of Income and Program Participation. |
|||
Children's health care coverage varies by the income level of the custodial family. Seventy-nine percent of higher-income custodial families have private coverage from either the father or the custodial family in every month of the year, compared to 23 percent of lower-income custodial families. Higher-income custodial families are somewhat more likely to receive health care coverage from the nonresident father, with 30 percent of higher-income and 21 percent of lower-income families receiving health care coverage from the nonresident father in at least one month of the year. But most of the difference in coverage arises from the custodial family. Sixty-one percent of higher-income custodial families don't receive health care coverage from the nonresident father in any month, but provide coverage in at least one month themselves, compared to only 21 percent of lower-income custodial families. As a result, fewer than 10 percent of higher-income custodial families experience the entire year without private health care coverage, compared to 58 percent of lower-income custodial families. Without private health care coverage from the nonresident father or custodial family, half of lower-income families rely on Medicaid and 8 percent are uninsured for the entire year.
The remaining three panels of Table 3 display the health care coverage status of custodial families, by whether or not there is a child support award or written agreement, and whether or not the award or agreement requires the nonresident father to provide health care coverage. Sixty-eight percent of nonresident fathers who are required to provide health care coverage do so in at least one month of the year, compared to 15 percent of those with an award that does not require the father to provide health care coverage, and 12 percent of those without an award.
There are two reasons to expect higher rates of health care coverage provision by nonresident fathers who are required to provide coverage. First, some nonresident fathers who would not otherwise provide coverage are induced to do so. Second, since state child support agencies are required to request that health care coverage be included in the child support order when the custodial parent does not have private coverage and the nonresident parent has access to employment-based coverage, the absence of such a requirement suggests that the nonresident father may not have access to affordable coverage, or that the children are better off covered through the custodial family's health care plan. It is unclear how much of the higher rates of provision of health care coverage by nonresident fathers who are required to provide coverage is due to the inducement effect of the health care coverage order, and how much simply reflects a greater ability to provide health care coverage. But it is highly unlikely that simply requiring all nonresident fathers to provide health care coverage would result in as high a coverage rate as experienced by those currently required to provide coverage, since the very reason that some nonresident fathers are not required to provide health care coverage is that they do not have access to employment-based coverage.
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Nearly a third of nonresident fathers report providing health care coverage to a child outside the household in at least one month of 1993. This includes all nonresident fathers, regardless of whether or not they have a child support order or are required to provide health care coverage. Of the nonresident fathers who report providing health care coverage in at least one month, less than half (44 percent) report providing health care coverage to their children for all twelve months of the year.
As shown in Table 4, the nonresident fathers who provide health care coverage for all of the year (full-year providers) appear somewhat better off financially than nonresident fathers who provide coverage for only part of the year (part-year providers). But both groups are far better off financially than nonresident fathers who do not provide any health care coverage during the year (nonproviders). Twenty-nine percent of nonproviders are officially poor, compared to only 2 percent of part-year providers and 1 percent of full-year providers. Sixty-seven percent of nonproviders have personal income of less than $20,000 (in 1998 dollars), compared to 24 percent of part-year providers and 9 percent of full-year providers. Less than half of nonproviders work full-time all year, compared to nearly 90 percent of part-year and full-year providers. A quarter of nonproviders do not work at all or are incarcerated. (7)
Nonproviders differ demographically from part-year and full-year providers, tending to be younger and less educated, and more likely to have fathered their children out-of-wedlock. Fifteen percent of nonproviders are under age 25, compared to 5 percent of part-year providers and 2 percent of full-year providers. Nearly a third of nonproviders do not have a high school degree or GED, compared to 10 percent of part-year and full-year providers. Fifty-three percent of nonproviders have never been married or are in their first marriage, suggesting that their children were born out-of-wedlock, compared to 29 percent of part-year providers and 10 percent of full-year providers. Thirty-three percent of nonproviders paid at least some child support during 1993, compared to 62 percent of part-year providers and 86 percent of full-year providers. The difference in child support payments may arise in part from a lower rate of child support orders among nonproviders, but this cannot be ascertained from the data.
|
Months Provided Health Care Coverage to Nonresident Children in 1993 |
Total | |||
|---|---|---|---|---|
| All | Some | None | ||
| Nonresident Fathers (1,000s) | 1,377 | 1,720 | 7,130 | 10,227 |
| % Officially Poor | 1% | 2% | 29% | 20.5% |
| Father's Own Income (1998 dollars) | (100%) | (100%) | (100%) | (100%) |
|
0% | 4% | 43% | 30% |
|
9% | 20% | 24% | 22% |
|
54% | 48% | 23% | 31% |
|
38% | 29% | 10% | 17% |
| Work Status During Year | (100%) | (100%) | (100%) | (100%) |
|
88% | 87% | 43% | 56% |
|
12% | 11% | 31% | 25% |
|
0% | 2% | 26% | 19% |
| Work Status By Income Level | (100%) | (100%) | (100%) | (100%) |
|
85% | 75% | 32% | 46% |
|
4% | 12% | 11% | 10% |
|
10% | 8% | 16% | 14% |
|
1% | 5% | 41% | 30% |
| Education | (100%) | (100%) | (100%) | (100%) |
|
10% | 10% | 32% | 25% |
|
44% | 55% | 43% | 45% |
|
46% | 35% | 25% | 30% |
| Marital Status | (100%) | (100%) | (100%) | (100%) |
|
6% | 10% | 31% | 24% |
|
4% | 19% | 22% | 19% |
|
41% | 28% | 18% | 23% |
|
49% | 43% | 29% | 34% |
| Age | (100%) | (100%) | (100%) | (100%) |
|
2% | 5% | 15% | 11% |
|
32% | 34% | 35% | 35% |
|
66% | 61% | 50% | 54% |
| Race/Ethnic Composition | (100%) | (100%) | (100%) | (100%) |
|
14% | 20% | 31% | 27% |
|
8% | 8% | 16% | 13% |
|
77% | 72% | 51% | 58% |
|
1% | 0% | 2% | 2% |
| % Pay Child Support During Year | 86% | 62% | 33% | 45% |
| Source: Author's analysis of the 1993 Survey of Income and Program Participation. | ||||
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Table 5 presents estimates of the extent to which nonproviders have access to employment-based health care coverage. Unfortunately, it is not possible for the estimates to reflect all of the barriers that might prevent a nonresident parent from extending coverage to his nonresident children. For example, the estimates do not control for the fact that the worker's share of the dependent premium may be unaffordable, or that the child lives outside the service area of the father's health plan. Furthermore, the estimates do not control for the necessity of coverage. Many of the nonproviders are the fathers of children covered by the custodial family's health plan. Finally, while it would be preferable to estimate the extent to which nonresident fathers have access to health care coverage continuously throughout the year, the data used to impute the employer's offer of health care coverage are only available for the first four months of 1993. What the table does provide is an outer estimate of fathers' access to dependent health coverage in the first four months of 1993. The issues of continuity of coverage and geographic barriers to coverage are addressed in following sections, to the extent allowed by the data.
| Nonresident Father Income Level | |||
|---|---|---|---|
| <200% Poverty | 200% Poverty+ | Total | |
| Total (thousands) | 3,863 | 4,137 | 8,000 |
| (100%) | (100%) | (100%) | |
|
19% | 55% | 38% |
|
8% | 12% | 10% |
|
73% | 33% | 52% |
| Has Access (thousands) | 722 | 2,292 | 3,014 |
| (100%) | (100%) | (100%) | |
|
40% | 44% | 43% |
|
60% | 56% | 57% |
| Possibly Has Access (thousands) | 316 | 481 | 797 |
| Does Not Have Access (thousands) | 2,824 | 1,365 | 4,189 |
| (100%) | (100%) | (100%) | |
|
5% | 14% | 8% |
|
1% | 2% | 1% |
|
25% | 38% | 29% |
|
6% | 18% | 10% |
|
43% | 27% | 38% |
|
21% | - | 14% |
| Source: Author's analysis of the 1993 Survey of Income and Program Participation. | |||
Eight million nonresident fathers do not provide health care coverage to their nonresident children in any of the first four months of 1993. Of these, an estimated 38 percent have access to dependent health care coverage, meaning that they either cover their resident family or have individual coverage and work for a firm that offers dependent coverage. Another 10 percent possibly have access to dependent health care coverage, given that they work for a firm that offers dependent coverage, but don't have coverage themselves. Some of these men are undoubtedly ineligible for the firm's coverage, due to part-time or temporary status, not enough time on the job, or other factors. (8) Over half of the nonproviders are estimated to be without access to dependent health care coverage, due to the fact that they work for a firm that doesn't offer dependent coverage, or are self-employed, not working, or incarcerated.
Low-income fathers account for almost half of all nonproviders and are much less likely to have access to dependent health coverage than are higher-income nonproviders. At most, only about one quarter of low-income nonproviders have access to dependent coverage, compared to as many as 67 percent of higher-income nonproviders.
The second panel of Table 5 provides greater detail on nonproviders with access to dependent health care coverage. Of these, 43 percent provide dependent coverage to their resident family. This group may include some fathers who would be willing to extend coverage to their nonresident children, but are unable to overcome employer, health plan provider, or geographic barriers to coverage, (9) and some who do not cover their nonresident children because the children have sufficient coverage from the custodial family. The remaining 57 percent of nonproviders with access to dependent health care coverage have individual coverage. Although these fathers are able to afford the worker share of the premium for individual coverage (if any), some may be unable to afford the premium for family coverage.
The bottom panel of Table 5 provides additional information on nonproviders without access to dependent health care coverage. Thirty-eight percent of these fathers work for a firm that doesn't offer dependent coverage. While some have individual coverage or work in a firm that offers individual coverage, most work in firms that do not offer any coverage at all. Ten percent of these fathers are self-employed, 38 percent did not work during the first four months of 1993, and 14 percent are incarcerated.
About two-thirds of fathers without access to dependent health coverage have low family incomes, and a majority of these fathers either do not work or are incarcerated, making it unlikely that many will obtain access to health care coverage in the foreseeable future or be able to provide substantial cash contributions toward their children's medical support.
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While many nonresident fathers do not have access to employment-based dependent coverage, coverage is available to as many as half of those who do not provide health care coverage to their nonresident children. But how much of this coverage, if provided, would go to children who receive Medicaid or are uninsured? It is likely that most of the coverage would go to children who are already covered by the custodial family's health care plan, resulting in only a small reduction in Medicaid utilization and the number of uninsured children.
Since the SIPP does not provide information linking a child's custodial and nonresident parents, it is not possible to directly measure the extent to which increased health care coverage from nonresident fathers would benefit children who receive Medicaid or are uninsured. Some insight may be provided, however, by comparing the extent to which nonresident fathers could cover their children with the extent to which children are already covered by custodial families.
Adjusting for the discrepancy in fathers' reports of provision of health care coverage, and custodial families' reports of receipt, between 42 and 51 percent (3.6 and 4.4 million) of nonresident fathers who do not provide health care coverage have access to dependent coverage (Table 6).(10) Of custodial families who do not receive health care coverage from the nonresident father, 41 percent (3.5 million) provide health care coverage themselves, 41 percent (3.5 million) rely on Medicaid alone, and 18 percent (1.6 million) are uninsured.
| Number (Thousands) | Percent of Total | |
| Total Without Coverage from the Nonresident Father | 8,562 | 100% |
| Source of Custodial Family's Health Care Coverage | ||
|
3,484 | 41% |
|
3,499 | 41% |
|
1,579 | 18% |
| Nonresident Father's Access to Dependent Coverage* | ||
|
3,576 | 42% |
|
797 | 9% |
|
4,189 | 49% |
|
* The number of fathers with access to dependent coverage
is higher than shown in Table 5 because this table adjusts
for the discrepancy between the number of nonresident fathers reporting provision
of coverage and the number of custodial families reporting receipt of
coverage. The extra fathers reporting provision of health care coverage
are assumed to have access to health care coverage.
Source: Author's Analysis of the 1993 Survey of Income and Program Participation. |
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The potential for reduction in the number of children without private coverage depends on the extent to which the additional coverage from nonresident fathers would duplicate the coverage of the 3.5 million custodial families who provide private health care coverage (and do not receive coverage from the nonresident father) rather than add new coverage for the 5.1 million custodial families who are covered by Medicaid or uninsured. (11) It is reasonable to expect a large amount of overlap between these two groups. Assuming that women tend to partner with men of a similar or higher socioeconomic status, a custodial family that is able to provide private health care coverage probably corresponds to a nonresident father who could do the same. Furthermore, the very reason that a nonresident father might not provide health care coverage is that the children are covered under the custodial family's health care plan.
A minimum estimate of the potential reduction in the number of children without private coverage can be made by assuming that all custodial families who provide health care coverage to their children correspond to a nonresident father who has access to dependent coverage. Under this assumption, between 100,000 and 900,000 additional custodial families without private coverage could receive coverage from a nonresident father, accounting for between 2 and 18 percent of all custodial families without private coverage.
This is only a rough estimate. To the extent that some custodial families who provide private coverage correspond to a nonresident father who lacks access to coverage, the estimate is too low. On the other hand, the estimate of the number of nonresident fathers who could extend coverage to their nonresident children is probably too high since it does not capture all of the barriers to extending coverage to nonresident children. Without additional data, it is not possible to determine the net effect of these offsetting biases.
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Even more important than whether a father can provide health care coverage, is whether he can provide it on a continuous and reliable basis. If fathers cannot continuously cover their children for extended periods of time, then some other provision for health care coverage may be in the children's best interest, such as coverage from Medicaid, the new State Children's Health Insurance Program (CHIP), or private health care coverage from the custodial family. Under CHIP, which was established in 1997, low-income children may be better off without any coverage from the nonresident father, if the father is unable to provide continuous coverage, since some states do not grant CHIP eligibility until children have been uninsured for a waiting period of three or more months. (12) Table 7 and Table 8 examine the work and health care coverage status of fathers over the months of the year and the impact of disruption in fathers' health care coverage on the health care coverage status of custodial children.
Table 7 compares the work and health care coverage status of fathers who provide health care coverage to a nonresident child in at least one month of 1993 to those who do not. Providers are much more likely to be continuously employed than are nonproviders. Virtually all of the providers work in at least one month of the year, and 91 percent work in every month. But only three-quarters of the nonproviders work at all during the year, and only half work in every month. Higher-income nonproviders are much more likely than lower-income nonproviders to work continuously throughout the year. Only a quarter of lower-income nonproviders work in each month of the year, compared to three quarters of higher-income nonproviders.
| Providers | NonProviders, By Income Level | Total | |||
|---|---|---|---|---|---|
| Total | Total | <200% Poverty | 200% Poverty + | ||
| Total | 3,097 | 7,130 | 3,723 | 3,406 | 10,227 |
| Percentage Working | (100%) | (100%) | (100%) | (100%) | (100%) |
|
91% | 50% | 28% | 75% | 62% |
|
8% | 23% | 29% | 17% | 19% |
|
1% | 27% | 43% | 8% | 19% |
| Percentage Covered in Own Name | (100%) | (100%) | (100%) | (100%) | (100%) |
|
86% | 26% | 10% | 44% | 44% |
|
14% | 19% | 17% | 21% | 17% |
|
- | 55% | 73% | 36% | 39% |
| Percentage Covering Nonresident Children | (100%) | (100%) | (100%) | (100%) | (100%) |
|
44% | - | - | - | 13% |
|
56% | - | - | - | 17% |
|
- | 100% | 100% | 100% | 70% |
| Source: Author's analysis of the 1993 Survey of Income and Program Participation. | |||||
The disparity between providers and nonproviders is even greater when it comes to continuity in health care coverage throughout the year. Eighty-six percent of the providers have an employment related or privately purchased health care plan in all months of the year, compared to only 26 percent of nonproviders. Over half of nonproviders do not have their own health care coverage in any month of the year. Low-income nonproviders fare worse than higher-income nonproviders, with 10 percent of low-income and 44 percent of higher-income nonproviders having their own health care coverage in every month.
Less than half (44 percent) of fathers providing health care coverage to their nonresident children provide coverage in every month even though 86 percent of the providers have health care coverage in every month of the year. Possible sources of discrepancy between having and providing coverage include imprecision in the data (13) and fathers' reactions to changes in the circumstances of the custodial family. Recently divorced or separated families may be in the process of switching health care coverage from the nonresident father to the custodial mother's employer plan. Some fathers may start covering the children midway through the year, either in response to medical support enforcement or loss of coverage by the custodial mother.
Table 8 presents the health care coverage status of custodial children in the month preceding a gain in health care coverage from the father and the month following a loss. Unlike Table 7, Table 8 is based on reports from the custodial family. More fathers report providing health care coverage than custodial families report receiving it, but the reports are consistent as to the percentage of providers who provide health care coverage for the full year (44 percent according to nonresident fathers, and 42 percent according to custodial families). Part-year recipients are almost equally divided into those who gain health care coverage, those who lose and do not regain it, and those who lose and regain it during the year.
| Custodial Family Income | |||
|---|---|---|---|
| <200% of Poverty | 200% Poverty+ | Total | |
| Families Where Father Provides Health Care Coverage in at Least One Month | 1,356 | 1,070 | 2,426 |
| (100%) | (100%) | (100%) | |
|
40% | 46% | 42% |
|
23% | 18% | 21% |
|
15% | 21% | 18% |
|
22% | 15% | 19% |
| Families Gaining Health Care Coverage from the Father During the Year | 618 | 350 | 968 |
| (100%) | (100%) | (100%) | |
|
34% | 86% | 53% |
|
33% | 3% | 22% |
|
33% | 11% | 25% |
| Families Losing Health Care Coverage from the Father During the Year | 505 | 393 | 897 |
| (100%) | (100%) | (100%) | |
|
21% | 90% | 51% |
|
36% | 0% | 20% |
|
43% | 10% | 29% |
| Source: Author's analysis of the 1993 Survey of Income and Program Participation. | |||
Coverage in the month preceding a gain in fathers' health care coverage or the month following a loss varies considerably by custodial family income level. Nearly all of the higher-income custodial families provide health care coverage to the children in the month preceding the gain or the month following the loss. But only a third of low-income families provide health care coverage in the month preceding a gain in fathers' health care coverage, and only a fifth provide coverage in the month following a loss. About a third of low-income families are covered by Medicaid in the month preceding the gain or following the loss. Low-income families are particularly susceptible to periods of uninsurance when continuous health care coverage from the nonresident father is unavailable. A third are uninsured in the month preceding the gain in fathers' health care coverage, and 43 percent are uninsured in the month following the loss of the fathers' health care coverage.
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A father with access to dependent health care coverage may not be able to extend coverage to his nonresident children if he is enrolled in a Health Maintenance Organization (HMO) and his children reside outside the plan's service area. Enrollment in other types of managed care plans such as Preferred Provider Organizations (PPOs) and Point-of-Service (POS) plans does not necessarily preclude coverage of nonresident children living outside of the area, since services can be obtained from out-of-network medical providers. However, reliance on out-of-network medical providers generally results in higher out-of-pocket costs and/or restricted benefits. Unfortunately, the SIPP does not contain information on the father's health care plan type or service area, but some insight can be provided by examining the location of the father relative to the custodial family, by whether or not the father provides health care coverage.
According to custodial mothers, nearly two-thirds of fathers live in the same state as the custodial family, with 42 percent living in the same county or city (Table 9). Nineteen percent of fathers live in a different state, 5 percent live somewhere else (presumably in another country) and the location of 13 percent is unknown. Fathers whose location is known and who live in the same state as their children are somewhat more likely to pay child support and provide health care coverage than are fathers living in a different state. Of families in which the father lives in the same state, 55 percent receive child support in at least one month of the year, compared to 44 percent in which the father lives in a different state. Health care coverage is received in at least one month of the year by 29 percent of families with fathers in the same state, and 23 percent of those with fathers in a different state.(14)
| Custodial Family Income | |||
|---|---|---|---|
| <200% Poverty | 200% Poverty+ | Total | |
| All Custodial Families (thousands) | 6,636 | 3,591 | 10,227 |
|
(100%) | (100%) | (100%) |
|
43% | 39% | 42% |
|
19% | 25% | 21% |
|
18% | 21% | 19% |
|
6% | 4% | 5% |
|
14% | 10% | 13% |
| Percentage Receiving Child Support in at Least One Month of the Year | |||
|
50% | 64% | 55% |
|
38% | 53% | 44% |
| Percentage Receiving Health Care Coverage From Father in at Least One Month of the Year | |||
|
24% | 37% | 29% |
|
22% | 24% | 23% |
| Source: Author's analysis of the 1993 Survey of Income and Program Participation. | |||
Custodial families are less likely to receive health care coverage from fathers living in a different state than from those living in the same state, but the magnitude of the difference is not great. However, for custodial parent families with incomes above 200 percent of poverty, nonresident fathers in the same state are fifty percent more likely to provide coverage (37 percent versus 24 percent), but only 20 percent more likely to be required to provide coverage (41 percent versus 34 percent) (Table 10). This contrasts with poorer custodial families where there is less difference between fathers' location in either the order to provide health care coverage (39 percent same state, 36 percent different state) or in the actual provision of coverage (24 percent same state, 22 percent different state).
|
Custodial Families with an Award or Written Agreement |
Provision for Health Costs in the Child Support Award or Agreement | |||
|---|---|---|---|---|
| Nonresident Father to Provide Health Care Coverage | Custodial Family to Provide Health Care Coverage | Other Provision For Health Costs | No Provision for Health Costs | |
| Total (thousands)* | 37% | 16% | 9% | 38% |
| Location of Nonresident Father | ||||
|
40% | 16% | 8% | 36% |
|
35% | 14% | 9% | 42% |
| Custodial Families <200% Poverty* | 37% | 11% | 9% | 43% |
| Location of Nonresident Father | ||||
|
39% | 12% | 8% | 41% |
|
36% | 11% | 11% | 42% |
| Custodial Families 200% Poverty+* | 38% | 21% | 9% | 32% |
| Location of Nonresident Father | ||||
|
41% | 22% | 9% | 28% |
|
34% | 17% | 7% | 41% |
|
* The total includes a small number of fathers living outside
the United States and some whose location is unknown.
Source: Author's analysis of the 1993 Survey of Income and Program Participation. |
||||
One should use caution in drawing any conclusions from these findings. One major limitation of this analysis is that the data do not indicate the timing of the child support and medical support order relative to one or both parent's decision to move. It is likely that many of the orders were established when the parents were living in the same state. A second major limitation of this analysis is that geographic barriers to health care coverage do not necessarily follow state lines. Custodial families living a few miles from the father, but in a different state, may find it easier to participate in the father's health care plan than those living hundreds of miles away in the same state. Nevertheless, the fact that only forty percent of nonresident fathers live in the same county or city as their children suggests the importance of taking fathers' location into consideration in determining how best to provide for the medical costs of custodial children.
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The results presented in this paper are based on data from 1993, the most recent year for which information on nonresident fathers is readily available. To what extent have changes since 1993 affected nonresident fathers' ability to provide health care coverage? If nonresident fathers have experienced the same health care coverage trends as the overall workforce, then the flattening out of several health care coverage trends since 1993 suggests that the findings are still relevant.
Many of the notable recent shifts in health care coverage trends occurred before 1993. After dropping six percentage points between 1987 and 1993, the percentage of the population with employment-based health care coverage has remained fairly stable. (15) Rapid growth in health plan premiums in the early 1990s has given way to modest annual increases of two to three percent. (16) The average employee share of the employment-based health care coverage premium rose somewhat between 1993 and 1995, but has since fallen nearly to the 1993 levels. (17) The percentage of workers offered health care coverage remained fairly stable from 1987 to 1996, increasing by a few percentage points. (18)
One change that may adversely affect nonresident fathers' ability to provide health care coverage is the rapid expansion of managed care during the 1990s. Between 1993 and 1999 the percentage of workers enrolled in conventional plans declined from 46 to 9 percent, while enrollment in HMOs increased from 21 to 28 percent, and enrollment in other managed care plans such as PPO and POS plans increased from 33 to 63 percent (Kaiser Family Foundation and Health Research and Educational Trust 1999). Nonresident fathers enrolled in HMOs face barriers to extending coverage to children living outside the plan's service area. Those enrolled in PPO and POS plans should be able to extend coverage to children living elsewhere, since these plans allow the use of out-of-network medical providers. However, reliance on out-of-network medical providers generally results in higher out-of-pocket costs and/or restricted benefits.
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Provision of employment-based health care coverage by nonresident parents is one tool with which to address the medical costs of children in custodial families, but only in cases in which the nonresident parent has access to affordable coverage through an employer and this coverage is preferable to private coverage available to the custodial family. For these cases, provision of employment-based health care coverage by the nonresident parent can work well. Of families with a child support order requiring the father to provide health care coverage, nearly 70 percent received health care coverage in at least one month of 1993. This is not to suggest that simply requiring all nonresident parents to provide health care coverage would result in such high rates of coverage. Indeed, the very existence of a health care coverage requirement in the child support order suggests that the nonresident parent has access to health care coverage, and that this coverage is preferable to coverage available to the custodial parent.
Although as many as half of fathers who do not provide health care coverage to their nonresident children have access to employment-based dependent coverage, such coverage offers only limited potential for further reduction in the number of custodial families without private coverage. Much of the health care coverage, if provided, would go to children who already have private coverage through the custodial family. The number of custodial families without private coverage would be reduced by only about 2 to 18 percent. This estimate is similar to the findings of previous studies, none of which found potential for more than a third of custodial families without private coverage to receive employment-based coverage from the nonresident parent. To the extent that some custodial families who provide private coverage correspond to nonresident fathers who lack access to coverage, the 2 to 18 percent estimate is too low. On the other hand, the estimate may be too high since it does not capture all of the barriers to extending fathers' health care coverage to their nonresident children.
Geographic barriers are an example of one barrier not captured in this analysis. The shift from conventional to managed care health plans over the last decade underscores the need to address problems that result when children live outside the service area of the nonresident parent's health plan. By 1999, more than a quarter of all workers were enrolled in HMOs and almost two-thirds were enrolled in other managed care plans such as PPO and POS plans. Children living outside the service areas of these plans may be unable to obtain coverage from the plan (HMOs) or may face higher out-of-pocket costs and reduced benefits (PPO and POS plans). Thus, for children living far from their nonresident father, managed care reduces the attractiveness of coverage under the nonresident father's plan relative to other options for health care coverage.
Perhaps more important than a nonresident father's ability to provide health care coverage at a single point in time is his ability to provide it on a continuous and reliable basis. Of nonresident fathers who did not provide health care coverage to their children in any month of 1993, only half worked for the full year and only about one quarter had a private health care plan all year. Of those who provided health care coverage in at least one month of 1993, fewer than half provided coverage for all of the months of the year. Nearly all higher-income custodial families who lost health care coverage from the nonresident father in 1993 were able to provide coverage in the following month. But almost half of children in low-income custodial families were uninsured in the month following the loss of the father's coverage.
What is the best source of coverage for a child whose nonresident parent has access to employment-based health care coverage on an irregular basis? This depends, in part, on how seamlessly a child can move back and forth between the nonresident parent's health care plan and an alternative source of coverage. Transitions to and from Medicaid can be quite seamless, since children can remain enrolled in Medicaid even when they are also covered by the nonresident parent's health care plan (in which case, the nonresident parent's health care plan takes precedence). However, if the alternative source of coverage is CHIP, then the transition may not be seamless, since some states require a child to be uninsured for three or more months before gaining eligibility. Unless some exemption can be made for children losing coverage from a nonresident parent, CHIP-eligible children whose nonresident parent can provide only irregular access to employment-based health care coverage may be better off if some other form of medical support is required, such as a contribution to the health plan premiums paid by the custodial family, or contributions toward copayments and deductibles.
Clearly, provision of employment-based health care coverage by nonresident parents can be only one of several tools for ensuring adequate health care coverage for custodial children. About half of nonresident fathers who do not provide health care coverage to their nonresident children do not have access to dependent coverage, primarily because they do not work, work for a firm that does not offer coverage, or are incarcerated. They tend to be poorer and have less attachment to the work force than those who provide coverage. Nearly one third are officially poor and less than half work full-time for the entire year. For the children of many of these poor fathers, government programs such as Medicaid and CHIP may provide the only viable source of health care coverage.
To the extent that nonresident parents are able to pay, the problem of lack of access can be partially addressed by requiring nonresident parents to make cash contributions toward their children's health care coverage costs. Options that have been proposed or implemented in various states and localities include allowing the nonresident parent to "buy-in" to the government's Medicaid program, to contribute to the custodial parent's private health care coverage premiums, or to enroll the child in state programs set up to cover uninsured children. (19) Further efforts in these areas, as well as alleviating geographic barriers to access and coordinating seamless transitions between nonresident parents' health plans and government health care coverage programs, can yield greater opportunities for nonresident parents to contribute to consistent and reliable health care coverage for their children.
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Cooper, Philip F. and Barbara Steinberg Schone. 1997. "More Offers, Fewer Takers For Employment-Based Health Insurance: 1987 And 1996." Health Affairs 16:6 (November/December): pgs 142-149.
Ginsburg, Paul B. And Jon R. Gabel. 1998. "Tracking Health Care Costs: What's New in 1998?" Health Affairs 17:5 (September/October): pgs. 141-146.
Kaiser Family Foundation and Health Research and Educational Trust. 1999. Employer Health Benefits 1999 Annual Survey. Chicago.
Meyer, Daniel M. 1997. "Health Insurance and Child Support." Health Affairs 16:2 (March/April): pgs. 207-217.
National Academy for State Health Policy. 1998. CHIP Implementation Brief: Early Lessons Learned: Crowd-Out. September.
Nightingale, Demetra S. and Katherine Swartz, Larry Beyna, Sue Poppink, Marry Christman, and Susan Kessler Beck. 1986. The Inclusion of Medical Coverage in Child Support Cases: Current Status and Options for the Future. The Urban Institute, May.
O'Brien, Ellen and Judith Feder. 1999. Employment-Based Health Insurance Coverage and its Decline: The Growing Plight of Low-Wage Workers. The Kaiser Commission on Medicaid and the Uninsured.
Roberts, Paula. 1997. Improving Health Care Coverage in the Child Support System. Center for Law and Social Policy, April.
Sonenstein, Freya L. and Charles A. Calhoun. 1988. Survey of Absent Parents: Pilot Results. The Urban Institute, July.
Sorensen, Elaine. 1997. "A National Profile of Nonresident Fathers and Their Ability to Pay Child Support." Journal of Marriage and the Family 59 (November 1997): 785-797.
Sorensen, Elaine and Laura Wheaton. 2000. "Income and Demographic Characteristics of Nonresident Fathers in 1993." Report Submitted to the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services.
Thorpe, Kenneth E. and Curtis S. Florence. 1999. "Why are Workers Uninsured? Employer-Sponsored Health Insurance in 1997." Health Affairs 18:2 (March/April): pgs. 213-218.
U.S. Bureau of the Census, 1995. Current Population Reports, Series P60-187, Child Support for Custodial Mothers and Fathers: 1991, U.S. Government Printing Office, Washington, DC.
U.S. Department of Health and Human Services, Office of Inspector General (OIG). 1998. Review of Availability of Health Insurance for Title IV-D Children. June, A-01-97-02506.
U.S. General Accounting Office (GAO). 1992. Medicaid: Ensuring That Noncustodial Parents Provide Health Insurance Can Save Costs. GAO/HRD-92-80.
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1. These data are from the Urban Institute's 1997 National Survey of Americas' Families (NSAF). Health care coverage is the coverage that was in effect at the time of the interview. Children who have both private and public coverage are classified as being privately covered.
2. Households interviewed in the SIPP are not all interviewed in the same month, but instead are divided into four rotation groups which are interviewed in consecutive months. The first rotation group to be interviewed for the 1993 SIPP had its first interview in February 1993, and the last rotation group to be interviewed had its first interview in May 1993.
3. Additional demographic information about nonresident fathers and custodial mothers is provided in Sorensen and Wheaton (2000).
4. In 1993, the poverty threshold for a family of three was $11,522 and the poverty threshold for a single individual was $7,518. So an unmarried custodial parent with two children would have to have an annual income of less than $11,522 to be considered officially poor, and less than $23,044 to be considered low-income. A nonresident father living alone would have to have an annual income of less than $7,518 to be considered officially poor, and less than $15,036 to be considered low-income.
5. Similar data are unavailable for nonresident fathers, since nonresident fathers who do not pay child support are not asked whether or not they have a child support order or agreement.
6. The counts are of families, rather than children, since the SIPP data do not specifically identify the custodial children in some custodial families. The analysis is restricted to actual custodial children in the families where custodial children are identified, and likely custodial children in families in which they are not.
7. The incarcerated estimates reflect the entire population of institutionalized nonresident fathers, most of whom are presumably incarcerated.
8. An analysis of data from the 1997 Contingent Worker Supplement (CWS) to the February 1997 Current Population Survey (CPS) found that nearly half of workers in firms offering health care coverage who were not covered by the employer's plan were ineligible for coverage (Thorpe and Florence 1999). Fifty-three percent of the workers did not work enough hours per week or weeks per year to be eligible for coverage, 27 percent had not worked for long enough to qualify for benefits, 8 percent were ineligible because they were contract or temporary employees, 1 percent were ineligible due to a pre-existing condition, and the remaining 11 percent were ineligible for some other reason.
9. As noted previously, the Omnibus Budget Reconciliation Act of 1993 aimed to remove such barriers to coverage, but implementation has been gradual and any changes brought about by this legislation will not be reflected in the 1993 data used in this analysis.
10. The 42 to 51 percent estimate is calculated as follows. According to the nonresident father estimates, 3.014 million nonproviders have access to dependent coverage, and .797 million possibly have access. About .562 million more fathers report providing, than mothers report receiving, health care coverage in the first four months of 1993. Assuming all of these have access to dependent coverage, then between 3.576 million (3.014+.562) and 4.373 million (3.014+.562+.797) custodial families have a nonresident father who has access to dependent health care coverage. There are 8.562 million custodial families who don't receive health care coverage from the nonresident father in the first four months of 1993, so between 42 and 51 percent of these nonrecipients have a nonresident father with access to dependent health care coverage.
11. Appendix Table D.1 takes a closer look at these numbers by race and payment/receipt of child support.
12. CHIP was established by the Balanced Budget Act of 1997 as Title XXI of the Social Security Act to provide states with block grants to expand health insurance to low-income uninsured children who are ineligible for Medicaid. CHIP can be used to expand Medicaid to cover children at higher income levels, or to set up separate state health insurance programs. In order to avoid "crowd-out" of private health insurance, in which families with private health insurance drop coverage in favor of CHIP, some states do not grant eligibility until children have been uninsured for a "waiting period" of three or more months. According to the National Academy for State Health Policy (1998), 9 of 47 surveyed states are imposing three month waiting periods, 10 are imposing six month waiting periods, and 4 are imposing twelve month waiting periods. Additional states are monitoring the situation before making a final decision about waiting periods.
13. A father who provides health care coverage to a child in all relevant months of the year will be classified as providing coverage in only some months if the child is born during the year, reaches adulthood, or lives with the father for part of the year.
14. There is no significant difference in rates of receipt of child support and health care coverage for fathers living in the same city or county as the custodial family versus those living elsewhere in the state (not shown).
15. The percentage of the population covered by employment-based health care coverage dropped from 69.2% in 1987 to 63.5 percent in 1993, from where it rose slightly to 64.2 percent in 1997 (O'Brien and Feder 1999).
16. The annual percentage increase in private health plan premiums was 10.9 percent in 1992, dropping to 8 percent in 1993 and 4.8 percent in 1994. Between 1995 and 1998 the rates of increase were in the range of 2 to 3 percent, below the rate of growth in hourly earnings (Ginsburg and Gabel 1998).
17. The average employee share of the health care premium for family coverage rose from about 26 percent in 1993 to about 33 percent in 1995, falling to about 28 percent in 1998 (Ginsburg and Gabel 1998).
18. In 1987, 72.5 percent of workers were offered health care coverage by their employers, compared to 75.4 percent in 1996. The fact that the percentage of workers with employment-based coverage dropped between 1987 and 1996 is attributable to lower take-up rates, possibly in reaction to declining real incomes, increasing health plan premiums, and expansions in Medicaid (Cooper and Schone 1997).
19. See Roberts (1997) and OIG (1998) for a discussion of methods for increasing opportunities for nonresident parents to provide health care coverage to their children. The Medical Child Support Working Group, established by Child Support Performance and Incentive Act of 1998, is currently reviewing this issue and will be submitting a report with their recommendations in the year 2000.
20. TRIM3 uses a slightly different version of this model that includes a separate dummy variable for firms with fewer than 10 employees. Since the smallest firm size category in the SIPP includes all firms with fewer than 25 employees, this analysis uses an older version of the equation that does not have a separate dummy variable for firms with fewer than 10 employees.
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