The politics of reform

Racial and ethnic disparities in the purchase of nongroup health insurance: the roles of community and family-level factors

OBJECTIVE

To evaluate the influence of community- and family-level factors on racial/ethnic disparities in the uptake of nongroup (individual) health insurance.

DATA SOURCES

Responses to the 1996-1997 Community Tracking Study Household Survey plus community-level descriptors from several sources including census data, the Area Resource File, and community and migrant health center Medicare cost reports.

STUDY DESIGN

Logistic regression was used to compare families in which at least one person had nongroup health insurance to families without nongroup insurance in which at least one person was uninsured. Sequential models were constructed examining family- and community-level factors.

RESULTS

Twenty-three percent of families with otherwise-uninsured persons purchased nongroup insurance, ranging from 11% to 41% among the 60 communities sampled. Disadvantaged minority group members, especially Spanish-speaking Hispanics, had half or less the odds of whites of purchasing nongroup insurance. Education had a weaker association with purchasing nongroup insurance among minority group members than among whites. Community-level factors had minimal effect on disparities in uptake, although greater housing segregation was associated with lower uptake among blacks.

CONCLUSIONS

Minority group members are much less likely to purchase nongroup insurance than whites. Family income and community factors do not explain this gap. Programs aimed at stimulating voluntary insurance purchase will continue to underenroll disadvantaged minorities if nonfinancial barriers to acquiring insurance coverage, including the interplay between race/ethnicity and education, are not better understood and addressed.

Window shopping: state health reform politics in the 1990s

Throughout the 1990s states sought politically acceptable policies to reduce the ranks of the uninsured. Visions of comprehensive health reform and universal coverage yielded by mid-decade to more modest measures to repair private health insurance markets, and to these enactments were added several new public programs (state and federal) to expand coverage for lower-income children and, in some cases, adults. Because governments remain ill equipped to counter the power of business, insurers, and providers in conflicts fought on private turf, reform agendas have been more readily set, moved, and cleared in public-sector arenas. Although the number of uninsured rose steadily until 1999, "catalytic federalism"--the accelerating interplay between state and federal reform forces and funds--may be putting the programmatic foundations for broader coverage incrementally into place.