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Maximizing Health Care Enrollment through Seamless Coverage for Families in Transition: Current Trends and Policy Implications

Introduction

The Affordable Care Act (ACA) builds on our country’s employment-based health insurance system which is the bedrock of health insurance coverage for most Americans. When these Americans experience a change in their work lives or their family lives, they are at risk for losing their job-based health insurance coverage. The health insurance exchanges established by the ACA 1 provide an unprecedented opportunity to address one of the major sources of gaps in health insurance coverage: transitions in life that result in the loss of health insurance.

The uninsured population is not static. Many people who are uninsured cycle in and out of coverage over a short period of time. One-half to two-thirds of those who are uninsured in any given year move into or out of coverage in that year. 2 Even short bouts of uninsurance can have important health impacts due to lack of needed care. 3 Many of those who are intermittently uninsured are experienc- ing a work or life transition that also involves a loss of income, such as the loss of or change in a job in the family, a reduction in work hours, divorce or legal separation, loss of dependent status, a disability, or the death of a family member.

These individuals in transition are likely to make up a significant portion of those eligible for the new health insurance exchanges. In Massachusetts, approximately one-quarter of individual market participants in the “Health Connector,” the state’s health exchange, enrolled and terminated their coverage within 12 months. 4 How transitional coverage is handled will play a major role in whether the ACA is successful in expanding and stabilizing health coverage. In order to be successful in enrolling the uninsured, the exchange should be designed to maintain continuous coverage for individuals undergoing life transitions. Understanding the triggers to uninsurance provides an important window into how people who are in life transitions can be reached and enrolled into the exchange before or at the time they lose other sources of coverage.

Background

Under the recently enacted federal health law, the Affordable Care Act, Americans will continue to receive health coverage from multiple sources: employer-based coverage, public programs such as Medicare or Medicaid, individually purchased insurance, and the newly created exchanges. Many Americans, especially those who would have been uninsured prior to reform, will move between sources of coverage.

The vast majority of Americans under age 65 have health coverage through an employer, either through their own job or through a parent or spouse. 5 That is not expected to change under the ACA. While most analysts predict only a small net decline in job-based coverage under the ACA, there are likely to be significant transitions on and off of employer-sponsored coverage in the early years: more individuals will take-up employer-based coverage in response to the mandate, and some lower-wage employers will elect to drop coverage. Long and Gruber (2011) estimate that 1.5 million Californians will lose employer-sponsored insurance as their employers cease to offer coverage, while an estimated 630,000 would gain or newly take-up job-based coverage through their own, or a spouse’s, employer. 6

After initial implementation, we can anticipate the continuation of the existing cycling in and out of job-based coverage. The difference under the ACA will be that individuals who lose their job-based coverage will now have the ability to seek transitional coverage through the exchanges.

For more than two-thirds of the uninsured, uninsurance is not typically a static situation. 7 Rather, for many individuals uninsurance is a condition precipitated by a work or life change such as loss of job, reduction in work hours, job change, divorce, early retirement, or graduation. As shown in Figure 1, Short and Graefe (2003) found that over a four-year period, 24 percent of the uninsured spent one to four months uninsured, 22 percent spent five to twelve months, 19 percent spent thirteen to twenty-four months, and 35 percent spent twenty-five to forty-eight months uninsured. 8 Some of the uninsured cycled in and out of coverage multiple times.

Figure 1: Distribution of Uninsured by Duration of Gap in Coverage, U.S. Population Under Age of 65

Cyclical periods of high unemployment lead to greater uninsurance during economic downturns. 9 Nearly 30 percent of non-elderly adults in California were uninsured for all or part of 2009, when unemployment averaged 12.3 percent, up from 24 percent uninsured in 2007 when the unemployment rate averaged 5.3 percent. 10 Even when unemployment is low, the American workforce is highly mobile; at any given time, 20 percent of the workforce is estimated to have been at the present job for less than one year. 11

Intermittent periods of non-coverage are correlated with negative care experiences and potentially adverse health outcomes, according to research by Sudano and Baker (2003). Those lacking continuous health insurance underutilize clinical preventive services and have difficulty in accessing care. Being continuously or intermittently uninsured is a marker for health decline in late middle age. The catch-up period for preventive care after a period of continuous or intermittent uninsurance is in excess of two years. 12

Uninsured Americans have a higher mortality rate overall 13 and are more likely to die after trauma than insured Americans. 14 The uninsured are more likely to go without care. A Commonwealth Fund survey (2009) found that among working adults who were uninsured for at least part of the year:

  • 56 percent did not visit a doctor or clinic when sick because of cost;
  • 62 percent experienced at least one cost-related access problem, including failing to fill prescriptions or get recommended tests or treatment, and forgoing care from a specialist and other doctors when sick; and
  • 35 percent delayed or did not get preventive screenings because of cost. 15

Another study by McWilliams and colleagues (2007) found that adults who were uninsured and then enrolled in Medicare at age 65 had more doctor visits, hospitalizations, and total medical expenditures than those who were previously insured. 16

Until the exchanges are implemented in 2014, COBRA coverage is the primary back-up option for those who lose coverage due to a life or work transition. COBRA allows individuals to continue to access an employer-based group health plan that they otherwise would have lost due to unemployment, reduction in work hours, or divorce. But COBRA coverage has some significant limitations.

Only about 20 percent of those eligible actually enroll in COBRA, absent any federal premium subsidies. 17 Low enrollment is partly due to lack of affordability. COBRA allows individuals to continue to access their group health plan, but most individuals will have to pay the entire premium (where previously an employer may have covered a portion of the premium) at a time when the individual has less income. Families USA (2009) found that the average unemployed worker would need to spend 30 percent of his/her unemployment check on COBRA premiums to maintain single coverage and 84 percent to maintain family coverage. 18

In addition, not all workers are eligible for COBRA. Only workers employed by firms with at least 20 employees are eligible under the federal COBRA law, though California has expanded COBRA to smaller businesses with 2 to 19 employees. According to the Commonwealth Fund (2009), 5 percent of current workers would not be eligible for federal COBRA benefits upon loss of their job because they work for a small business. 19 Additionally, eligibility for COBRA coverage is time limited, expiring after 18 to 36 months, depending on the qualifying event.

Purchasing coverage in the individual market is also not currently an option for many individuals going through a life or work transition. A survey by the Commonwealth Fund (2011) found that 71 percent of adults who attempted to buy a health plan in the individual market in the last three years found it very difficult or impossible to find an afford able plan with coverage that fit their needs, were denied coverage or charged a higher rate due to a health problem, or had a specific health problem excluded from coverage. 20 Beginning in 2014, the ACA will reduce these barriers by offering subsidies for eligible individuals, setting minimum benefits standards for health plans, and banning denial of coverage and rate variation based on pre-existing conditions.

Work and Life Transitions Prompting Insurance Loss

Many individuals and families lose insurance as a result of work or life transitions that also often result in income loss, such as job loss or change, divorce, widowhood, loss of dependent status, disability, or moving. Given the concomitant loss of income typically seen in these circumstances, it should not be surprising that cost is the single most common reason cited by individuals for lack of coverage. 21

Change of Employment

Aside from cost, the most common reason cited by individuals for a lack of coverage is a change in employment in the family, whether due to the loss of a job or a job change. 22 A survey by the Centers for Disease Control and Prevention (CDC, 2006) found that 27 percent of the uninsured identified change in employment as one of the reasons for lack of coverage. 23 A recent survey by the Commonwealth Fund (2011) found that nearly three out of five individuals who had been receiving coverage through their jobs and lost their jobs became uninsured. 24

Newly unemployed workers are just one group that loses coverage as a result of a change in employment. Switching jobs or leaving the labor market altogether can also have a significant impact on insurance coverage. Gruber (2001) analyzed individuals who had moved from privately insured to uninsured at a point in time and had lost or left a job in the previous four months. Among these, less than a quarter moved from employment to unemployment, while more than half moved to a new job and nearly a quarter left the labor market. 25 One reason for loss of coverage when moving to a new job is that nearly three-quarters of covered workers are employed by firms that require a waiting period for health benefits. The most common waiting period length is one month, affecting 31 percent of covered workers. 26 In California, 6 percent of covered workers were employed by a firm with a waiting period of more than 90 days in 2009. 27 The ACA will limit waiting periods to 90 days starting in January 2014.

The longer one is out of work, the more likely one is to lose private coverage. This can be explained in part by the fact that the longer one is unemployed, the more likely one is to lose COBRA coverage either due to expiration of eligibility or due to exhaustion of financial resources to dedicate to COBRA coverage. 28

A reduction in work hours can also increase the likelihood of uninsurance. Fairlie and London (2005) found that full-time, full-year workers who become employed only part-year are 5.0 percentage points more likely to lose health insurance than those who continue to work a full year, and full-time, full-year workers who become employed only part time are 5.7 percentage points more likely to lose health insurance than those who continue to work full time. 29 Research by the Commonwealth Fund (2005) found that temporary workers (defined as temporary agency workers, contract company workers, leased employees, on-call workers, day laborers, or direct-hire temporary workers) are more likely to be uninsured than the population as a whole. 30 Because the employer obligation in the ACA applies to full-time, full-year employees, a reduction in work hours or work year may continue to result in the loss of job-based coverage in the future.

Children’s coverage is also tied to employment changes. Fairbrother and colleagues (2010) found that children whose parent loses a job are almost four times as likely to lose insurance as are children whose parent experiences no job loss. Nearly one-third of children with private insurance lose coverage when a parent loses a job, and for low-income children among this group the odds of becoming uninsured are even higher: 46 percent. The high rate of uninsurance for these low-income children is partly due to the lower ability to afford COBRA coverage. 31

Divorce and Widowhood

Divorce and widowhood are also correlated with losing health insurance, especially for women and the near-elderly. 32 In 2008, almost 40 percent of married women ages 18 through 64 received employer-sponsored insurance as a dependent, 33 compared to 25 percent of all women ages 18 through 64. 34 One-quarter of women offered health insurance through their own employers decline in favor of dependent coverage through a spouse. 35 Even women with insurance through their own employers are at risk of losing insurance after a divorce because a major loss of financial resources post-divorce decreases the ability to afford the employee portion of a premium. 36

Over three-quarters of women who remain married are continuously insured, compared to just over half of women who divorce. 37 Marital disruption, including widowhood, separation, and divorce, increases the risk of insurance loss significantly more for women than for men. 38 The chances of becoming uninsured in the eight months after the loss of a spouse (widowhood, separation, divorce) are 23 percent for married women and 14 percent for married men. 39 Persons who are widowed, divorced, or separated account for one-third of the uninsured near-elderly. 40 Approximately 3 percent of the non-elderly uninsured report that a change in marital status or the death of a parent are reasons for uninsurance. 41

Aging Out

Another trigger for losing health insurance is aging out of a plan. The ACA allows young adults under age 26 to enroll in a parent’s plan, potentially reducing the number of young adults who lose coverage due to age, but data is not yet available to indicate how coverage trends are likely to change for this group. In 2006, 6 percent of the non-elderly uninsured cited ineligibility due to age or leaving school as reasons for uninsurance. 42 Currently, turning 19 increases the risk of being uninsured by more than twofold: the uninsured rate rises from 12 percent among children age 18 and under to 31 percent among those ages 19 to 29. 43 High school and college graduations are also milestones at which young adults tend to lose coverage. Among all young adults graduating from high school, 30 percent were uninsured for some time in the subsequent year, while the rate is much higher (51 percent) for those who do not go on to college and lower (23 percent) for young adults who attended college that year. 44 Nearly two of five college graduates are uninsured for a period during the first year after graduation. 45

Young adults comprise 29 percent of the uninsured and have the highest rate of uninsurance of any age group. Working young adults have lower access to job-based coverage than other working adults because they are more likely to work for small firms and in industries with low offer rates. 46 Young adults face higher unemployment rates than other age groups 47 and are also less likely to be married, 48 thereby decreasing the odds of receiving coverage through their own job or that of a spouse.

Another reason for the higher rate of uninsurance among young adults is that more than four in ten young adults who were previously enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) become uninsured after turning 19. 49 Beginning in 2014, some of these young adults will be eligible to continue their Medicaid coverage due to the ACA expansion of coverage to adults below 133 percent of the federal poverty level. In the 10 states in which Medicaid eligibility for children ages 6 through 18 is above 133 percent of the federal poverty level, young adults will continue to age off of Medicaid. 50 Due to their low income, uninsured young adults who age out of Medicaid or CHIP are unlikely to be able to afford job-based coverage even if it is offered through their own job. In addition, more than half of these uninsured young adults are in families below the federal poverty level, making enrollment in a parent’s plan unlikely. 51

The ACA will result in a significant expansion of coverage for those young adults who have access to a parent’s job-based plan, but many currently uninsured young adults will not benefit from this expansion and are likely to access coverage through the exchanges. Young adults who become ineligible for Medicaid and CHIP due to age are also likely to access coverage through the exchanges.

Disability

Disability is another cause of uninsurance. Two percent of employees who take leave due to their own temporary disability (including pregnancy, child birth, and recovery from child birth) or to care for an ill family member lose their health insurance, according to a study by the Department of Labor (2001). 52 A 2003 survey of non-elderly adults with permanent disabilities found that 5 percent were uninsured. 53

Some employees with short-term disabilities will continue to have access to their employer-based coverage as mandated by the Family and Medical Leave Act (FMLA), which requires employers to maintain group coverage for employees on certain kinds of leave. But half of all workers in the country are not covered by FMLA either because they work for a small business or they haven’t met the eligibility requirements. 54

Private short-term disability insurance typically replaces wages only and does not address health insurance.

Some disabled individuals may qualify for Medicaid if their income and assets are low enough. Those with short-term disabilities are typically ineligible for Medicaid because eligibility rules may require being unable to work for a year or more. The ACA eliminates the asset test for some Medicaid eligibility categories, reducing a significant barrier to eligibility, but the asset test will continue for individuals with disabilities.

Individuals with long-term disabilities (expected to last more than one year) are eligible for Medicare, even prior to reaching age 65, but only after a waiting period that typically lasts 29 months. (The 29-month waiting period includes a five-month waiting period from the start of disability to the start of Social Security Disability Insurance [SSDI] plus a 24-month waiting period from the start of SSDI to the start of Medicare.) Short and Weaver (2008) estimate that at any point in time 1.3 to 1.5 million newly eligible SSDI recipients are waiting to qualify for Medicare. Nearly one-quarter of new Medicare enrollees were uninsured at the point at which they were surveyed during the waiting period. 55

Moving

Moving is also associated with loss of insurance. Nationally, 13.1 percent of children who have moved in the last 12 months were uninsured compared to 8.6 percent among the children who did not move. 56 Moving is also strongly correlated with other factors such as job loss and divorce, which are often precipitating events for a move as well as income loss. Because moving is often the result of a change in employment or a change in family situation, moving is not necessarily the cause of the loss of coverage. Assuring that individuals continue to be covered even after a move presents a policy challenge.

Policy Considerations

The ACA establishes mechanisms for ensuring seamless coverage between public programs and the exchanges. Each state will be required to have a single, streamlined form which an individual would fill out regardless of whether they enter the system through an exchange, the Medicaid program, or CHIP. That form will be used to determine eligibility for health insurance in any of the other programs. Individuals eligible for Medicaid or CHIP who apply for coverage in the exchanges will be automatically enrolled in the appropriate public program. 57 The enrollment data will be shared between the exchanges, Medicaid, and CHIP.

As the ACA is implemented through federal regulations and state law and regulations, similar strategies should be implemented to create seamless coverage for individuals transitioning between job-based coverage and the exchange. The strategies should focus on trigger events that lead to coverage gaps. Accomplishing seamless coverage transitions will require significant intentionality in designing the exchanges. In an upcoming policy brief, we will further analyze the ways in which federal and state policy can help ensure that individuals maintain coverage as they experience life transitions, but in this brief we raise some initial considerations for policymakers.

First and foremost, it is important that the architects of the state health exchanges recognize that many of the consumers of health plans under the exchange will be seeking temporary health coverage and may enter and exit the exchange multiple times.

Each of the trigger events discussed in this brief creates a potential point of intervention to connect individuals to the health insurance exchanges. Information about potential eligibility for the exchanges and the opportunity to enroll should be provided to individuals going through work or life transitions at certain contact points: COBRA notification, application for unemployment insurance, application for state disability and paid family leave insurance, dissolution or nullification of a marriage, or legal adoption of a child. Enrollment should be as streamlined and automatic as possible.

In order to simplify the transition between job-based coverage and the exchanges and to maximize continuity of care, exchanges should seek to offer plans with networks that are similar to those of the largest employer plans.

The work and life transitions discussed in this brief are often associated with significant changes in income. Under the ACA, subsidies and credits for both employment-based coverage and the exchanges are determined annually based on the previous year’s taxable income. The Secretary of Health and Human Services may create procedures for determining eligibility based on factors other than most recent taxable year income if an individual applicant has submitted information that “demonstrates substantial changes” in income, family size, filing status, or other significant changes affecting eligibility, or if the individual applicant files for unemployment benefits. To ensure that health care remains affordable during periods of lost income, the guidelines developed by the Secretary and the practices put in place must be responsive to these dips in income. Federal regulations will have important implications for the level of uncertainty and financial hardship individuals may face in utilizing exchange subsidies and will have an impact on public support for the law.

States should consider what role exchanges and other organizations will play in helping individuals make informed choices about the level of subsidies they accept in the exchanges, factoring in the projected income changes throughout the year while acknowledging the eventual reconciliation of projected and actual household income.

This brief sets the groundwork for an upcoming policy brief in which we will make more detailed recommendations for state and federal policymakers on how best to ensure seamless health coverage under the Affordable Care Act for individuals and families who lose health insurance because of a work or life transition.

Endnotes

  1. The ACA will create health insurance “exchanges:” state-based marketplaces that will offer a choice of plans that meet standards for coverage and that will provide information to consumers to help them make educated choices about the policies they are purchasing. Some individuals and families will be eligible for subsidized coverage through the exchanges.
  2. Pamela Farley Short and D.R. Graefe, “Battery-Powered Health Insurance? Stability In Coverage Of The Uninsured,” Health Affairs, Volume 22, Number 6 (2003): p. 244-255.
  3. Joseph Sudano and D. Baker, “Intermittent Lack of Health Insurance Coverage and Use of Preventive Services,” American Journal of Public Health, Volume 93, Number 1 (2003): p. 130-137. Andrew P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.H. Bor, and D.U. Himmelstein, “Health Insurance and Mortality in U.S. Adults,” American Journal of Public Health, Volume 99, Number 12 (2009): p. 2289-2295. Heather Rosen, F. Saleh, S. Lipsitz, S.O. Rogers, A. Gawande, “Downwardly Mobile: The Accidental Cost of Being Uninsured,” Archives of Surgery, Volume 144, Number 11, November 2009. J. Michael McWilliams, E. Meara, A.M. Zaslavsky, and J.Z. Ayanian, “Use of Health Services by Previously Uninsured Medicare Beneficiaries,” The New England Journal of Medicine, Volume 357 (2007): p. 143-53.
  4. Dianna K. Welch and K. Giesa, “Analysis of Individual Health Coverage in Massachusetts Before and After the July 1, 2007 Merger of the Small Group and Nongroup Health Insurance Markets,” Report to the Health Care Access Bureau within the Massachusetts Division of Insurance, June 2010, http://www.mass.gov/Eoca/docs/doi/Companies/adverse_selection_report.pdf, accessed February 28, 2011.
  5. Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2010 CPS.
  6. Peter Long and J. Gruber, “Predicting the Impact of the Affordable Care Act on California,” Health Affairs, Volume 30, Number 1, (January 2011): p. 63-70.
  7. Sixty-five percent of the uninsured are without coverage for less than two years, according to Short and Graefe (2003).
  8. Pamela Farley Short and D.R. Graefe, “Battery-Powered Health Insurance? Stability in Coverage of The Uninsured,” Health Affairs, Volume 22, Number 6 (2003): p. 244-255.
  9. Ken Jacobs and D. Graham-Squire. “No Recovery in Sight: Health Coverage for Working-Age Adults in the United States and California,” UC Berkeley Center for Labor Research and Education Policy Brief, April 2009.
  10. Shana Lavarreda, R.E. Brown, L. Cabezas and D.H. Roby, “Number of Uninsured Jumped to More Than Eight Million from 2007 to 2009,” University of California Los Angeles Center for Health Policy Research—Research Brief, March 2010. California Employment Development Department, “Historical Civilian Labor Force,” March 2010 Benchmark, data not seasonally adjusted.
  11. Jonathan Gruber, “Transitional Subsidies for Health Insurance Coverage,” Inquiry, Volume 37, Number 2 (2001): p. 225-231.
  12. Joseph Sudano and David Baker, “Intermittent Lack of Health Insurance Coverage and Use of Preventive Services,”American Journal of Public Health, Volume 93, Number 1 (2003): p. 130-137.
  13. Andrew P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.H. Bor, and D.U. Himmelstein, “Health Insurance and Mortality in U.S. Adults,” American Journal of Public Health, Volume 99, Number 12 (2009): p. 2289-2295.
  14. Heather Rosen, F. Saleh, S. Lipsitz, S.O. Rogers, A Gawande, “Downwardly Mobile: The Accidental Cost of Being Uninsured,” Archives of Surgery, Volume 144, Number 11, November 2009.
  15. Michelle M. Doty, S.D. Rustgi, C. Schoen, and S.R. Collins, “Maintaining Health Insurance During a Recession: Likely COBRA Eligibility,” The Commonwealth Fund Issue Brief, January 2009.
  16. J. Michael McWilliams, E. Meara, A.M. Zaslavsky, and J.Z. Ayanian, “Use of Health Services by Previously Uninsured Medicare Beneficiaries,” The New England Journal of Medicine, Volume 357 (2007): p. 143-53.
  17. Randall R. Bovbjerg, S. Dorn, J. Macri, and J.A. Meyer. “COBRA Subsidies for Laid-Off Workers: An Initial Report Card.” Commonwealth Fund Issue Brief, December 2009.
  18. Families USA Foundation, “Squeezed! Caught between Unemployment Benefits And Health Care Costs,” 2009.
  19. Michelle M. Doty, S.D. Rustgi, C. Schoen, and S.R. Collins, “Maintaining Health Insurance During a Recession: Likely COBRA Eligibility,” The Commonwealth Fund Issue Brief, January 2009.
  20. Sara R. Collins, M.M. Doty, R. Robertson, and T. Garber, “Help on the Horizon: How the Recession Has Left Millions of Workers Without Health Insurance, and How Health Reform Will Bring Relief,” Findings from The Commonwealth Fund Biennial Health Insurance Survey of 2010, March 2011.
  21. Centers for Disease Control and Prevention, “Summary Health Statistics for the U.S. Population: National Health Interview Survey, 2004,” Vital and Health Statistics, Series 10, Number 229, Table 25 (August 2006).
  22. Ibid.
  23. Ibid.
  24. Sara R. Collins, M.M. Doty, R. Robertson, and T. Garber, “Help on the Horizon: How the Recession Has Left Millions of
    Workers Without Health Insurance, and How Health Reform Will Bring Relief,” Findings from The Commonwealth Fund Biennial Health Insurance Survey of 2010, March 2011.
  25. Jonathan Gruber, “Transitional Subsidies for Health Insurance Coverage,” Inquiry, Volume 37, Number 2 (2001): p. 225-231.
  26. Kaiser Family Foundation/Health Research and Educational Trust, “Employer Health Benefits 2010 Annual Survey,” Exhibit 3.8: Distribution of Covered Workers with the Following Waiting Periods for Coverage, 2010.
  27. Jon Gabel, K. Jacobs, L. Tan, R. McDevitt, J. Pickreign, and S. KC, “National Health Reform Requirements and California Employers,” UC Berkeley Center for Labor Research and Education Issue Brief, December 2009.
  28. Jonathan Gruber, “Transitional Subsidies for Health Insurance Coverage,” Inquiry, Volume 37, Number 2 (2001): p. 225-231.
  29. Robert W. Fairlie and R.A. London, “The Dynamics of Health Insurance Coverage: Factors Correlated with Insurance Gain and Loss among Adults,” Final Report Submitted to U.S. Department of Labor, August 31, 2005.
  30. Elaine Ditsler, P. Fischer, and C. Gordon, “On the Fringe: The Substandard Benefits of Workers in Part-Time Temporary, and Contract Jobs,” Commonwealth Fund Publication Number 879, December 2005.
  31. Gerry L. Fairbrother, A.C. Carle, A. Cassedy, and P.W. Newacheck, “The Impact of Parental Job Loss on Children’s Health Insurance Coverage,” Health Affairs, Volume 29, Number 7 (2010): p. 1343-1349.
  32. Robert W. Fairlie and R. A. London, “The Dynamics of Health Insurance Coverage: Identifying Trigger Events for Insurance Loss and Gain,” Health Services and Outcomes Research Methodology, Volume 8 (2008): p. 159-185.
  33. Liz Weiss, E. Whelan, and J. Arons, “Unmarried and Uninsured: Single Women Face Additional Health Insurance Barriers,” Center for American Progress, 2009.
  34. Kaiser Family Foundation, “Women’s Health Insurance Coverage,” October 2009.
  35. T.C. Buchmueller, “Marital Status, Spousal Coverage, and the Gender Gap in Employer-Sponsored Health Insurance,” Inquiry, Volume 33 (1996-1997): p. 308-316.
  36. Bridget J. Lavelle and P.J. Smock, “Divorce and Women’s Risk of Health Insurance Loss in the U.S.,” National Poverty Center Working Paper Number 2011-4, March 18, 2011.
  37. Ibid.
  38. Robert G. Wood, B. Goesling, and S. Avellar, “The Effects of Marriage on Health: A Synthesis of Recent Research Evidence,” Mathematic Policy Research, 2007.
  39. Ibid.
  40. Gail Jensen, “The Dynamics of Health Insurance Among the New Elderly,” Medical Care , Volume 30, Number 7 (July 1992): p. 598-614.
  41. Centers for Disease Control and Prevention, “Summary Health Statistics for the U.S. Population: National Health Interview Survey, 2004,” Vital and Health Statistics, Series 10, Number 229, Table 25 (August 2006).
  42. Ibid.
  43. Sara R.Collins, C. Schoen, J.L. Kriss, M.M. Doty, and B. Mahato, “Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help,” The Commonwealth Fund Issue Brief, May 2006.
  44. Ibid.
  45. Ibid.
  46. Karyn Schwartz and T. Schwartz, “Uninsured Young Adults: A Profile and Overview of Coverage Options,” Kaiser Commission on Medicaid and the Uninsured, June 2008.
  47. Katherine Anne Edwards and A. Hertel-Fernandez, “The Kids Aren’t Alright—A Labor Market Analysis of Young Workers,” Economic Policy Institute Briefing Paper Number 258, April 7, 2010.
  48. Karyn Schwartz and T. Schwartz, “Uninsured Young Adults: A Profile and Overview of Coverage Options,” Kaiser Commission on Medicaid and the Uninsured, June 2008.
  49. Kaiser Commission on Medicaid and the Uninsured, “Aging Out of Medicaid: What Is the Risk of Becoming Uninsured?” March 2010.
  50. The ten states with Medicaid eligibility limits above 133 percent of federal poverty level for children ages 6 through 19 are Alaska, Connecticut, Michigan, Minnesota, New Hampshire, New Mexico, Ohio, South Carolina, Vermont and Washington. Kaiser Family Foundation, “Income Eligibility Limits for Children’s Regular Medicaid and Children’s CHIP-funded Medicaid Expansions as a Percent of Federal Poverty Level (FPL), January 2011.”
  51. Kaiser Commission on Medicaid and the Uninsured, “Aging Out of Medicaid: What Is the Risk of Becoming Uninsured?” March 2010.
  52. David Cantol et. al, “Balancing the Needs of Families and Employers: Family and Medical Leave Surveys,” Department of Labor (2001).
  53. Kristina W. Hanson, P. Neuman, D. Dutwin, and J.D. Kasper, “Uncovering The Health Challenges Facing People With Disabilities: The Role Of Health Insurance,” Health Affairs Web Exclusive W3- 553, November 19, 2003.
  54. Jane Waldfogel, “Family and Medical Leave: Evidence from the 2000 Surveys,” Monthly Labor Review, Volume 124, Number 9 (2001): p. 19–20.
  55. Pamela Farley Short and F.M. Weaver, “Transitioning to Medicare Before Age Sixty-Five,” Health Affairs Web Exclusive w177, March 25, 2008.
  56. Victoria Lynch, S. Phong, G. Kenney, and J. Macri, “Uninsured Children: Who Are They and Where Do They Live?” Urban Institute and Robert Wood Johnson Foundation, August 2010.
  57. Affordable Care Act Section 1413.