Public insurance is increasingly crucial to American families even as employer-sponsored health insurance coverage ends its steady decline.

Americans under age 65 rely on a healthy labor market for almost all facets of economic security. While 2012 marked the first year in more than a decade that the employer-sponsored health insurance (ESI) coverage rate for the under-65 population did not decline, employer-sponsored health insurance continues to fail American families. If the coverage rate had not fallen 10.8 percentage points as it did from 2000 to 2012, as many as 29 million more people under age 65 would have had ESI in 2012. Even with the end of its longstanding decline, ESI coverage rates among men and women, white and non-white, high and low income, white and blue collar, young and old remain far lower than they were in 2000. Over this period, the increase in uninsured Americans was not as steep as the fall in ESI because of increases in public coverage, including Medicaid, the Children's Health Insurance Program, and Medicare. These programs were particularly effective in reducing the share of children uninsured over the 2000s. Additionally, key components in the Patient Protection and Affordable Care Act shielded young adults from further coverage losses.

Large repayments of premium subsidies may be owed to the IRS if family income changes are not promptly reported.

Subsidies for health insurance premiums under the Affordable Care Act are refundable tax credits. They can be taken when taxes are filed or in advance, as reductions in monthly premiums that must be reconciled at tax filing. Recipients who take subsidies in advance will receive tax refunds if their subsidies were too small but will have to make repayments if their subsidies were too high. We analyzed predicted repayments and refunds for people receiving subsidies, using California as a case study. We found that many families could owe large repayments to the Internal Revenue Service at their next tax filing. If income changes were reported and credits adjusted in a timely manner throughout the tax year, the number of filers owing repayments would be reduced by 7-41 percent and the median size of repayments reduced by as much as 61 percent (depending on the level of changes reported and the method used to adjust the subsidy amounts). We recommend that the health insurance exchanges mandated by the Affordable Care Act educate consumers about how the subsidies work and the need to promptly report income changes. We also recommend that they provide tools and assistance to determine the amount of subsidies that enrollees should take in advance.

Employer-sponsored health insurance coverage continues to decline in a new decade.

Most Americans, particularly those under age 65, rely on health insurance offered through the workplace. Given continuing high unemployment, it comes as no surprise that the share of Americans under age 65 covered by employer-sponsored health insurance (ESI) eroded for the 11th year in a row in 2011, falling from 58.6 percent in 2010 to 58.3 percent. The situation started deteriorating long before the Great Recession: the share of Americans under age 65 covered by ESI eroded every year from 2000 to 2011, decreasing by a total of 10.9 percentage points. As many as 29 million more people under age 65 would have had ESI in 2011 if the coverage rate had remained at the 2000 level. The decline in ESI coverage has been accompanied by an overall decline in health insurance coverage. The number of uninsured non-elderly Americans was 47.9 million in 2011--11.7 million higher than in 2000. Increasing public insurance coverage, particularly among children, is the only reason the uninsured rate did not rise one-for-one with losses in ESI. In addition, key components in the Patient Protection and Affordable Care Act took effect in 2010, shielding young adults from further coverage losses.

Employer-sponsored health insurance erosion accelerates in the recession.

From 2000 to 2009, the share of non-elderly Americans covered by employer-sponsored health insurance (ESI) fell 9.4 percentage points. Although the economy was already in a recession in 2008, it continued to dramatically deteriorate in 2009. From 2008 to 2009, the unemployment rate rose 3.5 percentage points, the largest one-year increase on record. As most Americans under age 65 rely on health insurance obtained through the workplace, it is no surprise that ESI fell sharply from 2008 to 2009 at a rate three times as high as in the first year of the recession. Over the 2000s, no demographic or socioeconomic group has been spared from the erosion of job-based insurance. Both genders and people of all ages, races, education, and income levels have suffered declines in coverage. Workers across the wage distribution, in small and large firms alike, and even those working full-time and in white-collar jobs have experienced losses. Along with sharp declines in ESI, the share of those under age 65 without any insurance increased 3.3 percentage points from 2000 to 2009. Increasing public insurance coverage, particularly among children, is the only reason the uninsured rate did not rise one-for-one with losses in ESI.

Employer-sponsored health insurance erosion continues in 2008 and is expected to worsen.

Although employer-sponsored health insurance (ESI) is the primary source of health coverage in the United States, at 61.9 percent of the under-65 population, the rate of this coverage has decreased every year since 2000, when 68.3 percent had ESI. By 2008, the rate of ESI coverage had fallen 6.4 percentage points, and 5 million fewer people under the age of 65 had ESI in 2008 than in 2000. Because of these large declines in ESI, workers and their families have become uninsured at alarming rates; more than 7.5 million more Americans became uninsured after 2000. Uninsured workers are disproportionately young, Hispanic, lower educated, and lower income; however, workers across all socioeconomic groups have experienced declines in coverage since 2000. Children's coverage also fell 7.0 percentage points over the 2000s, and the gap in ESI access by income substantially widened over this period. The only reason the drop in ESI did not translate into a larger increase in the overall number of uninsured is that 3.4 million additional non-elderly people were covered by public insurance from 2007 to 2008. Because of the rise in unemployment between 2008 and 2010, the number without ESI and without any coverage at all is likely to swell in the coming years.

Early retiree and near-elderly health insurance in recession.

This paper examines recent trends in health insurance cost and coverage for the near-elderly population (aged 55 to 64), with particular attention directed toward the implications of the 2007 recession. We examine coverage by demographic and socioeconomic characteristics from the Current Population Survey and the Medical Expenditure Panel Survey. We also estimate the effects of projected increases in the unemployment rate for employer-sponsored insurance coverage of the near elderly in 2009 and 2010. Erosion in coverage is likely to be exacerbated in the short run by the 2007 recession, given rapidly rising unemployment among this age cohort, and in the long-run, given the inability of the labor market to support increased labor market participation of older Americans in jobs that would have traditionally provided health insurance coverage.

The erosion of employer-sponsored health insurance: declines continue for the seventh year running.

Employer-sponsored health insurance (ESI) remains the most prominent form of health coverage in the United States, at 62.9 percent of the under-65 population; however, the rate of this coverage has fallen every year since 2000, when 68.3 percent had ESI. By 2007, this rate had fallen 5.4 percentage points, and 3 million fewer people under the age of 65 had ESI in 2007 than in 2000. Because of these large declines in ESI, workers and their families have become uninsured at alarming rates. Despite a small gain in overall coverage for workers from 2006 to 2007, there were over 4 million more uninsured workers in 2007 than in 2000. Uninsured workers are disproportionately young, nonwhite, less educated, and low wage; however, workers across the socioeconomic spectrum experienced losses in coverage over the 2000-2007 period. Even the most highly educated and highest-wage workers had lower rates of insurance coverage in 2007 than in 2000. As with workers, the downward trend in ESI coverage for children (through their parents' employers) continued into 2007: 3.4 million fewer children had ESI in 2007 than in 2000, cutting across all race and income groups. Even as employment-based coverage has declined, the share of Americans who receive coverage through private purchase (non-group market) has also declined. The safety net programs--Medicaid and the State Children's Health Insurance Program--have kept millions of families insured as employment-based coverage fell.

Childhood lead poisoning: conservative estimates of the social and economic benefits of lead hazard control.

BACKGROUND: This study is a cost-benefit analysis that quantifies the social and economic benefits to household lead paint hazard control compared with the investments needed to minimize exposure to these hazards. OBJECTIVES: This research updates estimates of elevated blood lead levels among a cohort of children < or = 6 years of age and compiles recent research to determine a range of the costs of lead paint hazard control ($1-$11 billion) and the benefits of reduction attributed to each cohort for health care ($11-$53 billion), lifetime earnings ($165-$233 billion), tax revenue ($25-$35 billion), special education ($30-$146 million), attention deficit-hyperactivity disorder ($267 million), and the direct costs of crime ($1.7 billion). RESULTS: Each dollar invested in lead paint hazard control results in a return of $17-$221 or a net savings of $181-269 billion. CONCLUSIONS: There are substantial returns to investing in lead hazard control, particularly targeted at early intervention in communities most likely at risk. Given the high societal costs of inaction, lead hazard control appears to be well worth the price.

Rite of passage? Why young adults become uninsured and how new policies can help, 2009 update.

Young adults ages 19 to 29 are one of the largest segments of the U.S. population without health insurance: 13.2 million, or 29 percent, lacked coverage in 2007. They often lose coverage at age 19 or upon high school or college graduation: nearly two of five (38%) high school graduates who do not enroll in college and one-third of college graduates are uninsured for a time during the first year after graduation. Twenty-six states have passed laws to expand coverage of dependents to young adults under parents' insurance policies. Congressional proposals to reform the health system could help uninsured young adults gain coverage and prevent others from losing it. This is the seventh edition of Rite of Passage, first published by The Commonwealth Fund in 2003.

Rite of passage? Why young adults become uninsured and how new policies can help, 2008 update.

Young adults, ages 19 to 29, are one of the largest segments of the U.S. population without health insurance: 13.7 million lacked coverage in 2006. They often lose coverage at age 19 or upon high school or college graduation--most two of five (38%) high school graduates who do not enroll in college and one-third of college graduates are uninsured for a time during the first year after graduation. Several states have passed laws to expand coverage of dependents up to age 24 or 25 under parents' insurance policies. This policy change, in addition to two others--extending eligibility for public insurance programs beyond age 18 and ensuring that colleges require and offer coverage to full- and part-time students to have coverage--could help uninsured young adults gain coverage and prevent others from losing it. This issue brief, the sixth in a series, updates an earlier version of Rite of Passage

The erosion of employment-based insurance: more working families left uninsured.

The number of Americans without health insurance rose from 38.4 million in 2000 to 47.0 million in 2006, primarily due to the precipitous decline in employer-provided health coverage for workers and their families. Nearly 3.9 million fewer Americans under 65 had employer-provided coverage in 2006 than in 2000. The downward trend in the rate of employer-provided insurance continued for the sixth year in a row, falling from 68.3 to 62.9 percent. Individuals among the bottom 20 percent of household income were the least likely to have employer coverage. Jobholders experienced a significant decline in health insurance coverage, from 74.8 percent of workers in 2000 to 70.8 percent in 2006. No category of workers was insulated from loss of coverage. Children experienced declines in employer-provided health insurance coverage (through their parents) in each of the past five years, the rate falling from 65.9 percent of children in 2000 to 59.7 percent in 2006. Public health insurance (Medicaid and the State Children's Health Insurance Program) is no longer offsetting these losses. The decline in employer-provided coverage was felt throughout the country. Between the 2000-2001 and 2005-2006 periods, 38 states experienced significant losses in employment-based coverage for the under-65 population. No state experienced a significant increase in the coverage rate.

Health insurance eroding for working families: employer-provided coverage declines for fifth consecutive year.

In 2005, the percentage of Americans with employer-provided health insurance fell for the fifth year in a row. Workers and their families have been falling into the ranks of the uninsured at alarming rates. The downward trend in employer-provided coverage for children also continued into 2005. In the previous four years, children were less likely to become uninsured as public sector health coverage expanded, but in 2005 the rate of uninsured children increased. While Medicaid and SCHIP still work for many, the government has not picked up coverage for everybody who lost insurance. The weakening of this system-notably for children-is particularly difficult for workers and their families in a time of stagnating incomes. Furthermore, these programs are not designed to prevent low-income adults or middle- or high-income families from becoming uninsured. Government at the federal and state levels has responded to medical inflation with policy changes that reduce public insurance eligibility or with proposals to reduce government costs. Federal policy proposals to lessen the tax advantage of workplace insurance or to encourage a private purchase system could further destabilize the employer-provided system. Now is a critical time to consider health insurance reform. Several promising solutions could increase access to affordable health care. The key is to create large, varied, and stable risk pools.

A prescription for more retirement income security: retiree health insurance coverage in an era of declining access to employer-sponsored insurance.

As health care costs have been rising, especially for prescription drugs, employers have curtailed access to employer-sponsored retiree health insurance, especially for future retirees. This paper studies the question whether declining access has already translated into measurable loss of coverage for retirees. Based on data from the Current Population Survey and the Medical Expenditures Panel Survey, we find that retirees have lost health insurance and prescription drug coverage since 1996. The declines are especially pronounced for men before age 65 and for all Medicare-eligible retirees between the ages of 65 and 74. Our results also suggest that coverage will decline in the future.

Decomposing the effects of children's health on mother's labor supply: is it time or money?

In this paper, I explore how children's health influences the wages and work hours of their mother. Some children have illnesses that require expensive medicine or treatment, but demand little parental time. Others require extraordinary amounts of time; and still others require care at unpredictable times of the day. I construct a theoretical model of mother's labor supply that explicitly incorporates the financial and time costs associated with the presence of unhealthy children. The model predicts that children with time-intensive illnesses and those with unpredictable illnesses negatively influence mother's labor supply, whereas children with illnesses with a strong financial component have a positive effect on mother's labor supply. In order to empirically test this, I organize a focus group of doctors to categorize illnesses and disabilities by the type of resources they require. Using the 1997 PSID Child Development Supplement, I estimate the effects of these requirements on mother's decision to work and work hours. After controlling for the financial burden of the illness, single mothers work fewer hours if their child has a time-intensive illness and married mothers are less likely to work and work fewer hours if their child has a severe condition with an unpredictable time component. These findings are consistent with the theoretical model and highlight the need to decompose the effects of child health on mother's work status. Model specifications that aggregate across illnesses are incapable of disentangling these effects and may therefore underestimate the welfare costs of having a sick child in the family.