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Nearly one-fifth (18 percent) of the nonelderly people in the nation's largest metropolitan areas have no health insurance, with minorities being those most likely to have no coverage, according to a study by the UCLA Center for Health Policy Research.
The uninsured rates varied widely among the 85 largest metropolitan areas nationally studied by researchers. With 39 percent of its residents uninsured, El Paso, Texas, had the highest number, while Knoxville, Tenn., with 7 percent of its residents uninsured, had the lowest rate.
Job-based health insurance remains the most common type of coverage, with 67 percent of the nonelderly in the nation's largest cities receiving their coverage from their job or that of a family member. About 9 percent of the people were covered by Medicaid, the federal and state insurance plan for the poor and disabled. Additionally, 4 percent of the nonelderly purchased their own insurance while another 2 percent received coverage through other government programs (Medicare, CHAMPUS, Indian Health service).
"The major factor that determines the number of uninsured people in a region is the rate of job-based health insurance coverage," said Rebecka Levan, the report's lead author. "That number tends to depend on a region's economy. Areas with relatively large numbers of smaller employers and low-paying jobs tend to have more people who do not have job-based health insurance."
The UCLA study examines health insurance trends in more cities than have other efforts to analyze the number of people without health insurance in the United States. Brown and his colleagues studied the nation's 85 largest metropolitan areas by analyzing the March 1996 and March 1997 Current Population Survey, a large Census Bureau poll that addresses a number of issues.
Researchers found that the areas with higher-than-average numbers of uninsured all tended to have large numbers of minority residents, particularly Latinos. Latinos made up 33 percent of the population in areas with high uninsurance rates, while they comprised just 4 percent of the population in areas with low uninsurance rates.
In addition to El Paso, cities with high uninsurance rates include Los Angeles (31 percent), Houston (31 percent), Tucson, Ariz. (29 percent), Miami (28 percent), San Antonio (27 percent), New York (25 percent), and Jersey City, N.J. (25 percent).
Cities that had low levels of the uninsured included Knoxville, Ann Arbor, Mich. (8 percent), Allentown, Penn. (9 percent), Omaha, Neb. (9 percent), Minneapolis (10 percent), Milwaukee (11 percent), Akron, Ohio (11 percent) and Pittsburgh (11 percent).
Researchers found a number of trends that probably are not surprising. Areas with larger numbers of the uninsured tend to have more poor residents and a higher number of residents who did not graduate from high school.
Areas with more uninsured tend to have more small employers, who are less likely to offer their workers health benefits than are large employers. In areas with low rates of health insurance coverage, 21 percent of the families have a breadwinner who works for a company with fewer than 10 employees, compared with 14 percent in areas with high rates of health coverage.
The study did find evidence that efforts states have taken to extend health coverage to more low-income residents seem to be paying off. States such as Tennessee, Minnesota, Washington, Massachusetts and Hawaii have established programs that expand coverage under Medicaid.
"Increasing the generosity of Medicaid programs is one way that states can aid their urban areas," said E. Richard Brown, director of the UCLA Center for Health Policy Research and another author of the report.
For example, Memphis, Tenn., benefits from Tennessee's expansion of its Medicaid program (TennCare). While 63 percent of the city's nonelderly residents have job-based insurance coverage, another 18 percent are covered under TennCare. That helps keep the region's uninsurance rate at 17 percent, just below the national average.
By contrast, Ft. Lauderdale, Fla., has a similar job-based insurance rate, with 61 percent of its residents having work-related coverage. But Florida's Medicaid program is not as generous, with just 6 percent of Ft. Lauderdale residents receiving coverage through the program. That leaves 23 percent of the city's residents with no insurance, significantly above the national average.
"One way to lower the uninsured rates is for states to do more to expand Medicaid coverage or create alternative programs," said Brown, a professor at the UCLA School of Public Health. "One good sign are the programs many states have put into place to expand insurance coverage for children."
Funding for the report was provided by The Commonwealth Fund, a private foundation supporting independent research on health and social issues. Other authors of the report are Rebecka Levan, Lisa Lara and Roberta Wyn, all of the UCLA Center for Health Policy Research.