Why are low-income working-aged men so vulnerable to uninsurance? One reason is that the United States has minimal public health insurance for men. For working-aged adult men, there are two major pathways for eligibility for public insurance: having a disability that is severe enough to qualify for Social Security disability benefits, or living in a household in which one’s own dependent children reside and being poor enough to meet state eligibility requirements for Medicaid or the State Children’s Health Insurance Program (SCHIP), which are much stricter for parents than for children. Another reason that so many low-income working-age men are uninsured is that private insurance is often unavailable to individuals in low-paying low-skilled jobs.⁵

Being uninsured can have adverse effects on health,^6,7,8 and men’s high uninsurance rates may provide a partial explanation for their poor health status relative to women. Death rates at every age are higher for men than for women, as are the prevalence rates of hypertension, high serum cholesterol, unhealthy weight, and other health conditions.⁹ Gender differences in health status are substantial among young and middle-aged adults. For example, in the U.S. in 2001–2004, 7.0% of men aged 20–34 had hypertension, compared with 2.7% of women in the same age group, and 21.2% of men aged 35–44 had high serum cholesterol, compared with 11.4% among women aged 35–44.⁹ Men with low socioeconomic status are particularly disadvantaged in terms of health.¹⁰ In 2004, death rates for men with less than a high school education were over three times those of men with at least some college education.⁹ Employed men in the lowest income quartile are over three times more likely to die from chronic obstructive pulmonary disease, and over twice as likely to die from diabetes or stroke, as employed men in the highest income quartile.¹¹

Fathers’ health insurance can improve family health and well-being in many ways. It can foster men’s health and potentially reduce gender health disparities by increasing men’s use of preventive care, resulting in earlier diagnosis and treatment of serious health conditions.^12,13,14 Compared with those who are uninsured, insured men have higher rates of screening for prostate-specific antigens,¹⁵ cholesterol,¹⁶ and blood pressure.¹⁶ Health insurance also is an important financial resource, particularly for low-income families. In 2004, uninsured individuals in the U.S. were about twice as likely as those with insurance to report having problems paying medical bills in the past year, with about one-third of the uninsured reportedly having spent less on other basic needs such as food and heat in order to pay medical bills.¹⁷ Medical expenses are a leading cause of bankruptcy, and parental health insurance has been identified as an important means of avoiding impoverishment from medical out-of-pocket expenses for families.¹⁸ Finally, parents’ health insurance coverage improves children’s continuity of coverage^19,20 and utilization of health services.^21,22

The importance of fathers’ contributions (financial, social, and emotional) to their children’s development and well being is increasingly being recognized.²³ Fathers with low earnings potential may have difficulty contributing to the family’s material circumstances. Fathers with few job skills may be obliged to work long hours in low-paying jobs that involve emotional stress or health hazards. They are unlikely to have access to employer-sponsored health insurance and, unless seriously disabled, are unlikely to qualify for public health insurance. Uninsurance can compound existing financial difficulties and have adverse health consequences, which may result in reduced work activity. During such cycles, few financial, social, and emotional resources may be available for their children.

Little is known about the health insurance status of fathers, particularly those who are financially disadvantaged. A key reason is that most information on health insurance status comes from surveys, which generally provide incomplete information about non-resident fathers, who are disproportionately poor.²⁴ In this study, we redress this knowledge gap by presenting data on the insurance status of fathers who participated in a national birth cohort study and examining the prevalence and correlates of public, private, and no insurance in this population. The distinction between public and private insurance is important, as potential policy solutions are different for the two types of coverage.

Of the 1,653 fathers, 474 (29%) had private insurance, 228 (14%) had public insurance, and 951 (58%) had no insurance. The last figure is slightly higher than the national figure for low-income young men cited earlier (54%). In contrast, 20% of the 1,653 mothers in this sample had private insurance (either through the father or themselves), 44% were publicly insured, and 37% were uninsured; 20% of the children had private insurance, 66% were publicly insured, and 14% were uninsured (most of these figures not shown in tables). Thus, fathers had much higher rates of uninsurance than the mothers and children. Notably, fathers’ uninsurance is a risk factor for children not having insurance. Of the 228 children who were uninsured at follow-up, 68% had fathers without insurance and the other 32% had fathers who had health insurance (not shown in tables).

Table 1 includes the results from t-tests that indicate significant differences between pairs of the three insurance groups (fathers with private, public, and no insurance). While past research indicates that uninsured and insured men differ in many ways, it has not generally distinguished between privately and publicly insured men.³¹ As expected, we find that there are many differences between the private and uninsured groups and between the private and public groups. We also find that the public group more closely resembles the uninsured group than it does the group of privately insured fathers.

Compared with privately insured fathers, uninsured fathers tend to report poorer health, are more likely to be disabled, and have lower levels of human capital (they are younger, less educated, less likely to have served in the military, less likely to have been offered health insurance at baseline, more likely to have a history of incarceration, more likely to have income below 100% of the FPL, less likely to be employed, and less likely to be married to the child’s mother). Also, they are more likely to be Hispanic. The mothers are more likely to be on public insurance, less likely to be employed, and less likely to have their own private health insurance. Finally, they are more likely to have a child in suboptimal health. Thus, uninsured fathers have greater immediate health needs than privately insured fathers, and they also have much lower earnings capacity.

Compared with publicly insured fathers, uninsured fathers are younger, less educated, less likely to be disabled, more likely to be foreign-born, less likely to be Black, more likely to be Hispanic, and less likely to live with the child’s mother. The results for disability, nativity, Hispanic ethnicity, and living arrangements are consistent with lack of eligibility for Medicaid. Additionally, the mothers are more likely to have suboptimal physical or mental health and less likely to be on public insurance. This last finding highlights interdependency in parents’ insurance status.

Even in this low-income sample, fathers with private insurance differ significantly from those with public insurance in many ways. They tend to have greater levels of human capital (they are older, more educated, more likely to have had an offer of employer insurance at baseline, less likely to have an incarceration history, less likely to have income below the FPL, more likely to be employed, and more likely to be married). They are also less likely to be disabled or depressed. Finally, they are less likely to be Black and more likely to be foreign-born, and the mother is less likely to have public insurance and more likely to have her own private insurance.

In the cases where both privately and publicly insured fathers differ significantly from those who are uninsured, we find that uninsured fathers are younger and less educated than insured fathers; that uninsured fathers are less likely than publicly insured fathers, but more likely than privately insured fathers, to be disabled; and that uninsured fathers and publicly insured fathers are more likely to be associated with mothers who have public insurance, compared with fathers who are privately insured.

Additional analyses (results not shown) indicate that fathers with multiple risk factors for being uninsured (unmarried, unemployed, and less than a high school education) constitute a substantial proportion of the uninsured. Seventy-eight percent of the 167 fathers who were unmarried, unemployed, and had a low level of education were uninsured. Even among low-income fathers who are better positioned to have coverage, many do not. Of the 230 fathers who were married, employed, and graduates of high school, over one third (35%) were uninsured. For the uninsured fathers in the last group, there is evidence of considerable unmet need: 62% reported having suboptimal health, 57% were disabled, and 59% were depressed.

Table 2 presents the results of a multinomial logistic regression model that assesses the association of each characteristic with the father’s insurance status, controlling for all of the other characteristics. The analysis indicates whether the bivariate associations persist taking all other variables into account, and indicates the magnitude of those effects. Results are presented for the likelihood of private insurance and for the likelihood of public insurance, with no insurance as the reference outcome in both cases. Because no insurance is the reference outcome, the RRRs represent the change in private (or public) insurance status relative to no insurance for a unit change in a given characteristic, holding the others constant. For example, being disabled more than the doubles the probability that a father will have public rather than no insurance coverage. Having suboptimal rather than excellent or very good health makes a father 35% less likely to have public insurance coverage than to be uninsured. In keeping with the bivariate associations from Table 1, many paternal and family characteristics differ significantly (using p<.05 unless indicated otherwise) between fathers with private rather than no insurance and between fathers with public rather than no insurance. However, education, race/ethnicity, military service, depression, and the child’s physical health, which were significant in some of the bivariate comparisons in Table 1, are not independently associated with the father’s insurance status in the multivariate context (although some of these factors may operate through the father’s employment). The characteristics that differentiate privately insured fathers from uninsured fathers are not necessarily the same characteristics that differentiate publicly insured fathers from uninsured fathers. These differences again highlight the importance of separately analyzing privately and public insured fathers rather than pooling them together to contrast them with those who are uninsured.

Age, employment (full- or part-time), having had (at baseline) an employer offer health insurance, being married to the focal child’s mother, and the mother having her own private insurance all increase the likelihood that the father had private (vs. no) insurance. Being foreign-born, being very poor, ever having been incarcerated, and having a child whose mother has public health insurance all decrease the likelihood that the father had private (vs. no) insurance. The strongest associations were for employment (RRR=4.61, p<.001 for full-time; RRR=3.12, p<.001 for part-time). The majority of these results are consistent with the corresponding bivariate associations from Table 1.

The scant previous research on health insurance coverage among economically disadvantaged men has focused on any insurance coverage and studied small geographic areas.³¹ Such an analysis, while informative, may not be generalizable and obscures the different pathways by which low-income men obtain coverage. We found some notable differences in correlates of public versus private health insurance, compared with no insurance. Consistent with previous research that did not use low-income samples, we found that being older, having previously had a job that offered health benefits, and being employed are positively associated,³⁵ and that being an immigrant is negatively associated,^36,37 with private insurance coverage among men. We also found that even among low-income men, the poorest and those with incarceration histories are less likely than their counterparts to have private insurance, which is consistent with findings by others vis-à-vis labor market outcomes.^38,39 The key correlates of public health insurance among low-income fathers are disability (one of the eligibility characteristics for public insurance for men) and the mother having public insurance. Interestingly, a self-report of suboptimal physical health (net of disability) decreases the likelihood of public insurance, suggesting that many low-income men with health problems obtain public insurance only when they reach the point of being disabled enough to qualify.

We took a preliminary look at associations between health status of family members and the fathers’ insurance coverage. We found that reported child physical health is not independently associated with the father’s private (vs. no) insurance coverage. We also found that the mother’s poor physical or mental health reduces the likelihood that the father has public (vs. no) insurance. Past research has found that men are more likely to be labor force participants when they have a family member who has both a physical and mental illness.⁴⁰ This could reduce the likelihood that they are eligible for public insurance. Further research is needed to explore interdependencies between the health of family members and insurance status.

This study has several limitations. The sample was based on urban births. Patterns in health insurance status for non-urban fathers may look different. Follow-up survey non-response was associated with lower educational attainment, suggesting that the rate of private insurance we found among low-income fathers may be an overestimate and that our findings may not be fully representative of the population of urban low-income fathers. Our measures capture health insurance coverage at one point in time, rather than the duration of time spent in each insurance status or the dynamics of changes in insurance status. Finally, this is a descriptive study, which depicts correlations between the variables but does not identify causal factors.

Prospects for insurance coverage have worsened since 2000. The fraction of employers offering health benefits has decreased sharply, from 69% to 60%.⁴¹ The decline has been driven to a large extent by reductions in coverage offered by smaller and lower-wage firms, where low-income individuals tend to work.³³ As the economy stalls, state Medicaid programs will face challenges as the eligible population grows and tax revenues decline.⁴¹ Compounding the problem are federal rule changes taking place in 2008 that are expected to reduce federal Medicaid spending by limiting reimbursement to certain providers and restricting the scope of services eligible for federal matching funds.These trends do not bode well for low-income fathers’ ability to maintain or obtain health insurance.

The findings from this study have broad policy implications. Our finding of significant state differentials in coverage for fathers suggests that the public sector has the capacity to address the high rate of uninsurance among low-income men. Expanding public insurance eligibility for parents and encouraging take-up among men would increase coverage rates for fathers. Because uninsured and publicly insured fathers share many of the same characteristics, outreach efforts to encourage take-up among those who are already eligible for public coverage and those newly eligible under an expansion can be targeted largely to the same groups. This strategy may also result in increased enrollment among children.^43,44 Our findings also suggest that making employer-sponsored coverage more widely available and improving employment opportunities, both of which may require government involvement, are necessary for increasing health insurance coverage among low-income fathers.