The impact of demographic and perceptual variables on a young adults decision to be covered by private health insurance | BMC Health Services Research | Full Text


Rising health care costs and insurance premiums are making health care unaffordable and unaffordable for many Americans. a recent usa The Census Bureau report indicated that there were 42 million uninsured Americans living in the United States in 2013 [1]. The consequences of such a large uninsured population are great, affecting those who do not purchase health insurance, as well as the rest of society, through cost transfer, increased insurance premiums, and taxes. Taller. this is the main reason for the urgency of the obama administration to pass the health insurance reform in 2010.

The existing literature clearly reveals that the uninsured rate varies by age. Young adults represent the largest percentage of Americans who are not covered by a health insurance plan [2]. young adults between the ages of 18 and 24 are 30% less likely to be insured than the rest of the population [3]. the chances of being insured increase as a person ages. About 25% of people ages 25-34 are uninsured, compared to 18% between ages 35-44 and 13% between ages 45-65.

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The primary goal of this study is to determine why so many young adults lack private health insurance coverage through a detailed examination of demographic and perception variables that affect a young adult’s opportunity to obtain insurance. Perceived health status, perceived need, perceived worth, socioeconomic status, and other demographics have been identified in the existing literature as determinants of health insurance status for both young adults and the general US population. structural equation modeling is used to examine the impact of these variables on health insurance coverage.

The landscape of the health insurance industry changed with the passage of the Affordable Care Act (ACA) in March 2010 and the Supreme Court decision in June 2012 upholding the individual mandate for insurance coverage. of health associated with it. the aca now allows young students to stay on their parents’ insurance plans until they are 26, which will allow more young adults to access needed health care services. For a variety of reasons, many young adults today choose not to purchase health insurance when they turn 18 or graduate from college. In addition, in 2014 the ACA allowed an expansion in Medicaid. this allowed adults below 133% of the federal poverty level to be insured by medicaid, covering approximately 7.1 million more adults than were previously covered by health insurance[4].

Premium subsidies may cover an additional 6 million young adults [4]. young adults above 133% of the poverty level will be eligible for subsidized health insurance coverage. The passage of the aca creates penalties for people who do not purchase health insurance if they qualify to do so. penalties for opting out will vary from year to year, but will cap at $695.00 or 2.5% of a person’s income, whichever is less, for the year 2016 [5]. Young adults who can’t afford to be covered by their parents’ plans or who won’t qualify for subsidized plans will still need to purchase health insurance or risk a penalty. young adults will be required to pay this penalty if they decline coverage and qualify for a health insurance plan that offers coverage premiums for less than 8% of their income.

In massachusetts, where health insurance has already been made mandatory with tax penalties for those who don’t buy it, most young adults have bought a plan. despite this, young adults remain the number one demographic group least likely to be insured in the state [5]. The massachusetts health insurance mandate has shown that putting more people in the risk pool while lowering health insurance premiums increases the likelihood that a young adult will purchase health insurance.

An analysis of why young adults don’t buy health insurance can provide insight into whether young adults will choose to buy insurance or pay the penalty when the ACA is fully implemented. Will young people across the country follow this trend of not buying health insurance? various subsidies are supposed to reduce the cost of insurance for many young people, thus removing an impediment to being insured. the subsidies are also supposed to significantly increase the proportion of young adults insured; perhaps the national trends will follow the trends in massachusetts. More research is needed to predict how young adults across the country will act.

This study examines the determinants of health insurance coverage for young adults by measuring respondents’ perceptions of their health status, the need for health care services, and the value of those services. we examine the impact of traditional demographic factors typically studied in previous research. structural equation modeling, a powerful empirical technique, is used to determine relationships between variables. Structural equation modeling is appropriate for situations where you want to measure the influence of several different factors on a dependent variable, such as the different determinants of health insurance coverage for population subgroups. An advantage of using structural equation models in empirical studies is that it allows the inclusion of latent variables. the inclusion of latent variables and directly measured variables distinguishes this study from other health insurance studies.

conceptual framework

kahneman and tversky’s perspective theory postulates that the immediate financial investment associated with the purchase of a product (health insurance in this case) is an important factor in deciding whether or not to buy it [6] . Other decision theories take into account the likely financial loss that may arise from serious illness or injury in the future. however, prospective theory allows for the sure loss associated with paying a monthly premium and up-front costs, rather than the possibility of a large future medical bill, to be the primary deciding factor when it comes to purchasing a car. health insurance. by young adults. a major study outlines the main argument in prospect theory: when it comes to deciding between potential gains, people avoid risk, but when it comes to potential losses, people seek risk [6,7]. As the amount of loss associated with a decision increases, the less likely a person will decide to accept that loss.

While prospect theory is useful for understanding how young adults make health insurance decisions, we argue that this conceptual framework should not be applied in isolation. The social ecological model developed by Stokols proposes that “behaviors are influenced by intrapersonal, sociocultural, political, and physical environmental factors. these variables are likely to interact, and multiple levels of environmental variables are described that are relevant to understanding and changing health behaviors” [8]. In the context of this situation, the lack of certain environmental resources (eg, money, education) may prevent people from seeking necessary health care services or the insurance to pay for them. in the same context, other environmental factors may impede the adoption of insurance.

There are four levels of determinants of health behavior in the social ecological framework: individual, organization, community and population. At the individual level, a person’s behavior is influenced by their knowledge of the risks associated with not having health insurance and their individual income (socioeconomic and demographic status). Socioeconomic status also comes into play at the organizational level. whether one is employed or not theoretically plays a role in one’s decision-making process. In addition, whether or not part-time employment opportunities allow the adoption of insurance may be a factor. at the community level, social norms and beliefs influence behavior (perceived need). At the population level, perceived value is a variable that dictates who chooses to be covered by health insurance and who does not.

Perceived health status, perceived need for health insurance, perceived value of health insurance, socioeconomic status, and other demographics have a theoretical effect on individual health insurance coverage based on the structural equation model for the study. . The main variables of interest in this study (perceived need, perceived value, and socioeconomic status) will be examined through the perspective of prospect theory. The model used in this study is consistent with prospective theory in that it measures whether socioeconomic status and the price of insurance have more influence on the decision to purchase health insurance than perceived health status, perceived need, and the perceived value.

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The social ecological model explains that personal behaviors are influenced by a series of different factors that interact with each other. this provides a framework that illustrates that the different variables included in this study are likely to interact with each other at different levels [8]. the final model used in this study was based on a combination of published literature and the two main theories discussed in this section. these two theories fit well together and, when combined, form a theoretical framework that helped guide our study. prospect theory describes why individuals make certain decisions, and the social ecological model explains how different social variables interact with each other and affect the individual [8].

literature review

actual and perceived health status

There is a popular belief that young adults do not buy health insurance because they are generally in very good health. Although many young adults are healthy, those with disabilities and chronic illnesses need significant medical care. if these people do not have health insurance, the consequences can be deadly. young Americans with disabilities and long-term health problems often have public or private health insurance coverage through their parents [9].

Once young adults turn nineteen, they face enormous challenges when it comes to purchasing health insurance, unless they are students and still covered by their parents’ insurance plans [9]. Medicaid is thought by many to act as a safety net for all people with disabilities; However, this is not always the case. there is a growing number of young adults with long-term health problems who cannot get private health insurance and cannot be covered by medicaid because they are not classified as functionally disabled [9]. This means that there are sick people in our country (young and old) who are unable to work and are left with limited or no options to purchase health insurance.

a study conducted in 2000 found no strong association between health status and health insurance coverage [10]. however, another 2003 study comparing two timely national surveys found that the ability to purchase private health insurance coverage is about 50% lower for people in fair or poor health compared to people who are considered to be in excellent health [11]. the researchers also found that premiums are actually 13-16% higher for people experiencing moderate health difficulties and 43-50% higher for people experiencing major health difficulties compared to people in excellent health.

Americans with private health insurance are very healthy because those in good health can generally afford coverage [12]. This conclusion was reached after examining data collected from the Medical Spending Panel Survey, which showed that being in good health is associated with a higher likelihood that a person will purchase health insurance. the United States. Using data from the 2001 Survey of Income and Program Participation, the Census Bureau found that people in excellent health had higher rates of health insurance than people in poorer health.

perceived need

One of the reasons some young adults do not purchase health insurance may be that they feel immortal or invincible to serious illness or injury, especially young adult men [13]. It’s certainly not hard to understand that this feeling of invincibility may be a contributing factor to the lack of health insurance coverage among young adults. many young adults simply don’t seek regular care, don’t fully appreciate health insurance, and choose to spend their income on rent, food, and transportation [13].

Young adults are generally healthier and fitter than older adults, and they heal faster from injuries than older adults. however, this does not necessarily mean that they do not place any value on health insurance.

some young adults may not recognize the importance of being insured or see it as a benefit [14]. many young adults have not yet had a serious medical problem and do not see the possibility of serious injury in the near future. While some young adults may realize there are risks associated with being uninsured, they are generally willing to accept the risks.


contrary to popular belief, many young adults do consider health insurance to be important [15]. As the author of the biennial survey on health insurance explains, when young workers were asked about their desire for health insurance, seven out of ten of those between the ages of 19 and 29 said that health insurance was very important for them when deciding whether to take out health insurance. work, a rate similar to that of older workers (p. 5). the survey found that 71% of working young adults accept health insurance. furthermore, it is reported that 70% of young adults believe that the existence of a company health insurance plan is an important factor when deciding to accept a job [16]. however, only 42% of employed young adults are covered by an employer-sponsored health plan, compared to 62% of working older adults. One possible explanation for this low insurance take-up rate among young adults is that they are more likely to be employed part-time or temporary by an employer that simply offers health benefits [16]. These studies raise questions about the conventional wisdom that young adults feel they don’t need or want health insurance.

perceived value

Previous literature indicates that people choose to invest in health insurance if the perceived benefits exceed out-of-pocket costs. In many cases, a perceived value is attached to having health insurance. Lack of affordability is a major reason people do not buy health insurance, and Monheit (2008) argues that some people prefer a steady income without health insurance coverage to the unquantifiable value associated with having health insurance. health (that is, the perceived value does not exceed the cost of coverage) [17].

The rising cost of health insurance is one of the main reasons so many young adults don’t buy health insurance. approximately 50% of respondents in a survey on human health insurance indicated that their main reason for not purchasing health insurance is that they cannot afford it [13]. the price of health insurance is number one on the list of explanations for why young adults choose not to have insurance [14]. a study by markowitz et al indicated that 40% of the uninsured population between the ages of 18 and 24 stated that expense was the main reason for not being covered by health insurance [18]. this reason was classified as the highest percentage among the categories of socioeconomic status, demographic status, and health status. the variables in their study closely resemble those examined in the present study and illustrate the importance of including a variable related to perceived value in any study of health insurance.

the henry j. The Kaiser Family Foundation also reports that the number one reason people of any age are uninsured is the high cost of health insurance in the United States [19]. The Wisconsin Department of Health and Family Services found that the high cost of health insurance prevents young Wisconsin adults from also purchasing health insurance [20]. Specifically, 67% of young adults in the Wisconsin study said they couldn’t buy health insurance because they simply couldn’t afford it.

socioeconomic status

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While many different issues contribute to a person’s lack of health insurance coverage, the literature makes it clear that low income is one of the reasons people are unwilling to purchase health insurance plans [twenty-one]. Socioeconomic status can be measured by multiple variables, including educational level. The literature shows that there is a positive relationship between years of education and socioeconomic status with health insurance coverage. those with the least education are nearly five times less likely to have health insurance than their more educated peers [22].

People with incomes below the poverty level are twice as likely to be insured [23]. The Kaiser Commission on Medicaid and the Uninsured reports that low-income adults are at significant risk of being uninsured, accounting for about 50% of the uninsured population [24]. another empirical investigation found a positive relationship between age, race (Caucasian), income, and employment with insured status [25].

2003 research analyzed the 1997 and 1999 National Survey of American Families (NSAF) to determine what financial hardships uninsured adults face [21]. the study reported that “more than 40% of all adults in the sample were found to have reported food, housing, or health care difficulties in the past year” [21] and that “overall, 38% of adults without moderate- and high-income uninsured and 70% of low-income uninsured adults were unable to afford health insurance because they struggle to pay for food and housing” [21]. Socioeconomic status appears to play an integral role in whether or not a person of any age purchases health insurance.

demographic data

Any discussion of demographics and the state of health insurance must include an examination of minorities. the kaiser commission on medicaid and the uninsured report explained that minorities make up approximately 34% of the non-elderly population, but 52% of the uninsured population [24]. other studies also indicate that minority status has a negative relationship with health insurance coverage.

Members of minority groups are more likely to be uninsured, and this is especially true if their income is at or below the federal poverty level [26]. one researcher stated that “African American youth are the least likely to have health insurance” [14] (p.5). furthermore, Hispanics are more likely to be uninsured than other racial and ethnic groups [27]. Although a large number of white young adults (31%) are uninsured, they are more likely to be covered by some type of health insurance plan than African Americans or Hispanics.

another researcher stated that young men are more likely to be uninsured than young women [14]. In general, young men have the lowest rate of health insurance coverage. Historically, health insurance coverage rates for younger men have been lower than corresponding rates among older men, but gaps in coverage have widened in recent years [28].

Researchers have found that Caucasians and women in general have health insurance at higher rates than others [29]. The National Center for Health Statistics (2003) supported this finding, reporting that women are more likely to have health insurance.

In summary, previous research indicates that actual and perceived health status, perceived need, perceived worth, socioeconomic status, and demographic factors are all related to a person’s health insurance status. The present study will more specifically aim to determine the extent to which they are predictors of health insurance status in young adults.


The following hypotheses are based on the established conceptual framework and the results of the literature discussed above. These hypotheses guided our study of the health insurance status of young Americans:

h1: the perceived health status of an individual is negatively related to the probability of being insured.

h2: The perception of health insurance as something valuable (worth the cost) is positively related to the probability of being insured.

h3: a person’s perception of the need for health insurance is positively related to the probability of being insured.

h4: The socioeconomic status of an individual is positively related to the probability of being insured.

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