Which Factors Affect Why Some People Have Health Insurance While Others Have None?

Several million people are uninsured and suffer as a result. Over 15 percent of individuals, or over 46 million people, in the U.S. are uninsured, according to the U.S. Census Bureau (2008, p. 20). The U.S. Census Bureau also stated that the number of uninsured individuals has gone up from 2007 to 2008 (2008). As the number of people who are uninsured increases, financial issues increase for those people who have health conditions which result in medical bills which must be paid for out-of-pocket. In a study on lower-income Oregon families, researchers found that those who lacked health insurance or who had low levels of health insurance were not accepted into some non-emergency medical establishments which only accepted those with insurance (DeVoe, et al., 2007, p. 515). As a result, lower levels of medical care were sometimes received (2007).

Individuals may have the need for medical care at some point in life. Health insurance, whatever the level of coverage, is beneficial to individuals. However, individuals with higher levels of health insurance coverage have the added potential for having more preventative care and having emergency care at significantly lower costs.

According to Department of Labor research by Fairlie and London (2004), Institute of Medicine of the National Academies (2003), billions of dollars have been lost in recent years due to individuals without health insurance coverage (p. 1). Health insurance clearly impacts individuals and costs for society as a whole.

If as many individuals as possible have health insurance, sick or injured individuals will gain improvements in quality of health care received and long-term cost savings. Individuals who do not have health insurance cause higher costs for those with health insurance, when those individuals without insurance go to the emergency room for free treatment. Health insured individuals, who are able to receive relatively low-cost preventative medical care, may gain higher levels of overall health care and overall lower health care expenses.

Purpose

The reason for this study is to determine and study some factors which affect levels of health insurance for adult residents of Anytown, GA. This project will help identify some of the strongest factors which affect whether or not individuals carry health insurance, and what levels of health insurance individuals carry. This will allow administrators and community leaders of Anytown, GA to learn more about which factors influence levels of health insurance for Anytown, GA residents. The study will provide information to these community leaders and administrators so that changes might be made within local organizations and within the community. After reading the results of this study, organization leaders and administrators in Anytown, GA may be able to tailor health insurance options so that more people may have higher levels of health insurance coverage. This is important because not having health insurance can impact a person's entire financial well-being, and can affect quality of health care received. Age, income level, whether an employer offers health insurance, and levels of employment will be the factors this study tries to show affect health insurance coverage.

A secondary reason for this project is to determine how insurers, including government and private insurers can target their insurance towards a larger percentage of the population. For instance, if the study finds that certain groups of people are uninsured at a high rate, insurers could use this data to determine ways to offer insurance coverage to those individuals. If younger people, for example, tend not to carry insurance as frequently as older people, insures could look at ways to market insurance products to younger people or to otherwise encourage younger people to obtain insurance. If the study finds that unemployed or part-time workers tend not to carry insurance, then insurers could find ways to offer insurance products to these workers at levels they could possibly afford.

A final purpose of this study is to add to existing empirical data from previous studies which have been done on levels of health insurance coverage and on other studies regarding health insurance situations which affect individuals.

Problem Statement

The problem to be addressed in this research study is why some individuals have low or no levels of health insurance coverage while other individuals have high levels of health insurance coverage. In an attempt to answer that question, research will be done to identify factors which may affect levels of health insurance coverage for individuals. The findings regarding these factors could lead to ideas on how higher health insurance levels could be provided for a larger portion of individuals. If fewer people are uninsured, then fewer people will be devastated financially due to medical costs which come from not being insured. If more people have higher levels of health insurance, then more people will have better financial well-being and receive higher levels of health care. If more individuals have health care insurance which covers preventative care, then more individuals will be able to receive preventative care rather than waiting until a problem becomes severe enough to have to go to the emergency room.

The information from this study also could be used by organization employers to gain ideas and possibly determine ways to make health insurance available for more individuals within their organizations.

Research Questions

study will focus on numerous research questions which will help to show certain factors which influence levels of health insurance (dependent variable) for individuals. The main question which will be asked is, "What factors directly impact individuals' level of health insurance coverage?" These next questions that will be researched that may influence levels of health insurance coverage (independent variables) are: 1) Do ages of individuals influence levels of health insurance coverage? 2) Does income level influence levels of health insurance coverage? 3) Does whether an employer offers health insurance influence levels of health insurance coverage? 4) Do levels of employment influence levels of health insurance? It is important to describe the independent variables used to study levels of health insurance coverage.

Age: People of all ages may benefit from having health insurance. However, as people get older they may, on average, have more need for health insurance due to increased visits to the doctor. Still, health insurance is a valuable benefit to people of all ages, because health emergencies and other health problems can happen to anyone at any age. For this study, ages considered will be adults 18 and older. However, in many statistical studies regarding health insurance, ages are grouped into categories up to age 65. This is likely because people 65 and older typically receive government-provided Medicare which they use for their health insurance. The U.S. Census Bureau showed that in 2008 only 1.7 percent of adults 65 and older did not have health insurance (p. 21). The U.S Census Bureau also found that in 2008, for groups younger than age 65, the numbers of uninsured rose greatly from that 1.7 percent. So, although adults over 65 will be included in this study, much of the research for this project will focus on adults who are from ages 18 to 64.

Income: Whether individuals purchase any product or service, including medical insurance, is affected by the law of supply and demand and whether one can afford it. If health insurance costs too much for an individual to pay for, that individual will choose to buy other items with his or her limited resources. Even if an individual is in dire need of health insurance he or she will not buy it, if the cost is prohibitive or the person's income is too low to be able to purchase it. In a 2005 Oregon study of lower-income families on food stamps, just over 35 percent of adult respondents stated that they did not have health insurance (DeVoe, et al., pp. 512-513). In comparison, the U.S. Census Bureau reported that in 2007 around 15 percent of people nationwide did not have health insurance, and that percent has not significantly changed recently (2008, p. 20).

Whether an employer offers health insurance: For employed individuals, whether an employer offers health insurance can make a difference as to whether employees working there are insured. However, some individuals, regardless of whether an employer offers insurance, may go elsewhere to buy insurance. Whether through a spouse's insurance plan or on the open market, individuals may be able to buy insurance regardless of whether an employer carries it. However, some individuals with certain preexisting conditions, or who have chronic illnesses which make them difficult to insure at an affordable cost, may only be able to get insurance if an employer offers it. In national surveys which were between 1996-1999 by the Community Tracking Study Household Survey, researchers found that the expenses to buy insurance and the types of insurance plans offered by employers affected whether or not employees chose to be covered by those insurance policies (Polsky, Stein., Nicholson, & Bundorf, 2005, p. 1259). Individuals who would have been uninsured without the employer's offered health coverage plans would have been more likely to be insured if their employer offered health insurance (p. 1275). However, those who had alternative sources of obtaining health insurance were not significantly more or less likely to have health insurance if their employer offered it (2005).

Levels of employment: Individuals working part-time, full time, or not at all, could benefit from having health insurance coverage. However, individuals working full-time may have the ability to obtain health insurance through their place of employment, whereas individuals working part-time or not at all may not. Additionally, individuals working part-time or not at all may not have the financial resources to purchase health insurance. On the other hand, lower-income individuals who have a spouse making a good income may be able to obtain health insurance even if they don't make enough money to purchase it themselves. Regardless of whether an employer offers health insurance, or if a person isn't employed at all, alternative sources of health insurance are often available to those with few preexisting and no serious chronic health conditions. However, for those with many or serious health issues, insurance may be unavailable to them if they are not working full-time. The U.S. Census Bureau reported that in 2008 17.2 percent of adults ages 18-64 working full-time were not covered by any health insurance plan, while 25.4 percent working part-time were not covered by any health insurance plan and 26 percent not working were not covered by any health insurance plan (2008, p. 21).

Scope

After the initial research is completed, a survey will be done. This project will only focus on items which influence levels of health insurance coverage for adults. If a portion of a study focuses on health insurance coverage for children, it will not be studied except as that study may relate to adults. Although health insurance coverage for adults will be the focus of this project, the information might be applicable to study health insurance coverage for children.

The study results may be of benefit mainly to administrators of organizations within the community, but others may benefit as well. Individuals may benefit from learning factors which may affect their levels of health insurance coverage.

The project also will not exclude any adults based on health conditions. Also, no adult will be excluded based on race, age, sexual orientation, disability, etc.

The population size will include adult residents of Anytown, GA. According to the City of Anytown website, the results of the US census showed that the population of Anytown, as of the year 2000, was 21,675.Literature Review

Dependent variable: Health insurance.

In this project the dependent variable will be health insurance. Health insurance, as defined by the U.S. Census Bureau, includes all health insurance coverage obtained by individuals through an employer or union, through the government, or through a private insurance company (2008, p. 20). Health insurance plans offered by the government include military health plans, Medicare, Medicaid, and individual plans offered by state governments. "Uninsured" refers to individuals who were not insured by any type of health insurance at all during the previous calendar year. "Insured" refers to individuals who been insured under some type of health insurance plan during at least part of the last calendar year. Since health insurance coverage can change throughout an individual year, some statistics on health insurance may not be completely accurate. For instance, some U.S. Census Bureau respondents surveyed may have reported that they do not have health insurance. However, those same individuals, for the definition and purpose of the U.S. Census Bureau, actually did have health insurance if they actually had it during part of the last year. Nonetheless, the U.S. Census Bureau data is considered to be a close estimate of the number of people who are uninsured according to age, income levels, and other factors (2008).

In a report on the Department of Labor website, Fairley and London found that failure to have health insurance results in substandard levels of health care for individuals (2005, p. 1). They also found that individuals without health insurance are less likely to be seen by a physician at an office, and more likely to be seen at an emergency medical facility. Also, not having health insurance increases individual risks which causes some people to have financial problems (2005). Having health insurance, on the other hand, increases financial stability in that if an expensive medical emergency arises insurance may cover a large part of the cost.

Another organization which concerns itself with levels of health insurance coverage for individuals is the National Coalition on Health Care. According to the National Coalition on Health Care's website, this organization is located in Washington, D.C., was founded in 1990, and is made up of over 70 various organizations (2009). Over 150 million individuals in the U.S. are represented by the National Coalition on Health Care. Ex-presidents Jimmy Carter and George Bush are honorary co-chairmen. The organization seeks ways to improve affordability of health care for individuals, so that more people may be insured. They also try to find ways to improve health care without it becoming inaccessible to certain individuals who may not be able to obtain it (2009).

The ways in which people should be able to obtain health insurance coverage has been argued by U.S. lawmakers for years (Glied & Borzi, 2004, p. 404). Whether or not health insurance coverage should be tied to an employer has been a debate since health insurance tied to employers began in the 1930's. Regardless of critics' views, most people who have private health insurance got it through an employer. However, since 1987 fewer individuals who are not elderly have health insurance partly because it is not available to them through an employer (2004).

Health insurance is not easily obtained by everyone, but certain factors make mean that people are more likely to be able to obtain it, according to Glied and Borzi (2004, p. 405). They found that as health insurance costs go up, the number of people who obtain health insurance goes down (2004, p. 405). Also, they found that people who work full-time and in professions such as manufacturing, managerial and other certain types of jobs were more likely to have health insurance. According to Glied and Borzi, the private health insurance systems which are so prevalent in the U.S. are not perfect, but are the next best alternative when health insurance is not available to individuals through the government (2004, p. 404).

First independent variable: Age.

Age may affect health insurance coverage because many younger people may not be insured due to various factors. For instance, a younger person may have fewer health concerns than an older person so the younger person may not see health insurance as a priority. An older person may have more experience and knowledge about potential healthcare issues which may arise, and higher income, making purchasing health insurance a priority.

The Center for Disease Control (CDC) stated that in 2008 older individuals were less likely to be uninsured than younger individuals (2009, p. 8). The US Census website statistics concur, with older individuals having health insurance more often than younger individuals (2008, p. 21).

Older individuals have been increasingly obtaining health insurance coverage while younger individuals have been increasingly going with no health insurance coverage (Keenan, Cutler, & Chernew, 2006, p. 1497). Data from the March Current Population study, from 1988 through 2004 showed that health insurance coverage rates for those ages 18-29 were lower than health insurance coverage rates amongst those ages 45-64. The oldest groups have been consistently better insured than the younger groups (p. 1499). Furthermore, the gap between how many older individuals are insured and how many younger individuals are insured continues has grown each year recently (p. 1500). Older people also have had private insurance and higher levels of coverage than have younger people (2006, p. 1504).

In a longitudinal Survey of Income and Program Participation (SIPP) study using information gathered from 1996-2000, people older than 55 had a three times greater likelihood of having health insurance than those under the age of 35 (Ziller, Coburn, McBride, & Andrews, 2004, p. 212). In that study, individuals in groups of ages 18-24, 25-34, 35-44, 45-54, and 55-64 had progressively higher rates of insurance coverage as age increased. Furthermore, younger people had an increased likelihood of being uninsured after exiting an individual insurance coverage plan, than did older individuals (p. 215). Even after losing coverage for a time, older individuals studied in the same 1996-2000 study were not uninsured at nearly the rate as were younger individuals. In that study, age, rather than health status, was shown as a predictor of the probability that an individual would be insured by a health plan (2004).

Second independent variable: Income level.

An individual's increased income level may increase the likelihood that he or she has health insurance. High costs of obtaining health insurance may be a barrier to lower-income individuals. Individuals who have a low income may be less likely to purchase health insurance when basic needs such as food, clothing, and shelter are more critical. Individuals with lower incomes will not purchase health insurance, even if it is a priority and even if they can obtain it inexpensively, if they do not have the money to do so.

Socio-economic level is a major factor in health even among people who are insured (Ruffin, 2008, p. 4). However, being poor and having no health insurance can lead to lack of preventative care and can decrease the quality of health services rendered (DeVoe, et al., 2007, p. 515).

Being poor combined with other factors can affect whether individuals have health insurance (Angel, Frias & Hill, 2005, p. 1344). For example, in a research project studying residents of Boston, Chicago and San Antonio, researchers found that poorer households were more likely to have health insurance if individuals in those households had certain factors such as having more than a high school education or being American citizens (2005).

In a 2005 study of 722 Oregon families, expense was cited by participants as one of the most critical reasons for lack of health insurance (DeVoe, et al., 2007, pp. 514-517). Furthermore, having no access to health insurance was also a hindrance faced by many lower-income individuals. Issues raised by many lower-income individuals in the study included not being able to afford the co-pay required for a doctor's visit, not having enough money for basic needs such as toilet paper and other household items, and not being able to find medical facilities that were easily accessible and that would allow them to be treated without insurance (2007).

The vast majority (87 percent) of the subjects without health insurance cited lack of being able to easily obtain it as a primary reason (DeVoe, et al., 2007, p. 514). Although cost was a huge concern, some individuals in the study said that not having access to insurance they could utilize at a reasonable cost was also a cause for lack of insurance. In addition, participants said that some medical offices would not accept certain types of insurance, thus limiting access to medical care (2007, p. 515).

Many people studied in the 2005 Oregon project also said that they had insurance but could not use it without significant cost which they could not afford (DeVoe, et al., 2007, p. 515). High deductibles stopped many from using their insurance at all. Family physicians sometimes only take certain types of health insurance plans which are not as available to individuals living close to or below the poverty line. So the poor, even when they have insurance, are left without the benefit of medical care in many situations (2007).

Third independent variable: Employer offers health insurance.

Whether an employer offers health insurance determines whether individuals have access to health insurance through their workplace. However, individuals who do not work for employers who offer health insurance may sometimes, depending on their situation, obtain health insurance elsewhere. The health insurance industry offers policies for sale to individuals outside their workplace, although some individuals with severe health issues or certain preexisting conditions may find these non-employer plans cost prohibitive or possibly even unavailable to them. Individuals who are not able to obtain health insurance through an employer or other source may face financial ruin due to high medical bills, and subprime health care due to fewer healthcare options.

Individuals who work for employers who don't offer health insurance may be able to purchase health insurance through a private plan outside an employer, or receive coverage through a spouse's employer. However, individuals who have access to health insurance through an employer, but due to health issues don't qualify for a non-employer plan, may be more likely to have health insurance than those same types of people who don't have access through their employer.

Less numbers of employers offer health insurance plans to their workers, and those employers who do carry health insurance have, in recent years, tended to offer it at higher costs to employees than in the past (Shields, McGinn-Shapiro, & Fronstin, 2008, p.138). Due to economic situations, employees have more often been lowering overall pay and benefits, including health plans offered to employees (DerGurahian, 2009, p. 14). Health insurance expense for employers has lowered the rates of growth for many of those organizations (2009).

Individuals who work for employers who offer health insurance may be more likely to have health insurance in certain cases, such as when the employer offers a certain type of plan or the plan cost is not too high for the individual (Polsky, et al., 2005, p. 1273). This is especially true for individuals who have no access to other health insurance plans, such as through a spouse's employer or another private insurer. However, when employers often certain types of insurance benefit plans, like HMOs, employees who are able to obtain insurance benefit plans which are not HMO's by means other than through their employer may obtain insurance coverage somewhere else (2005).

Typically, higher levels of health insurance and lower costs of those plans to individuals will increase the probability of employees being covered by an employer's health insurance plan (Polsky, et al., 2005, p. 1262). In deciding to sign up with an employer's plan, the employee weighs these costs and benefits. Often, if the employee has alternative, cheaper and/or higher levels of health insurance available outside the employer, the employee will be covered regardless of whether the employer offers coverage (2005).

Therefore, whether or not an employer offers health insurance affects some employees who do not have another option for health insurance coverage other than through where they work. However, if the cost of employer insurance is very expensive, some workers will see the added health benefits as outweighed by the expense, and not sign up for health insurance (Polsky, et al., 2005, p. 1263).

Fourth independent variable: Employment.

For people who do not have to opportunity to obtain health insurance through either a spouse or through an individual policy, employment may determine whether health insurance is even available for them. Whether employment affects health insurance coverage may be affected by several factors: the individual's type of employment, whether an individual works in a large or small organization, whether the income from that employment is sufficient to pay for health insurance, whether the organization pays much or all of the cost of health insurance, and whether an individual works full or part-time.

Individuals who are employed making an income may be more likely to be able to afford to carry health insurance than those who are unemployed with no income. However, this is not the case for everyone who is not employed because many people choose to be unemployed, such as when one spouse chooses to stay home to raise children while the other spouse works to support the family. Coverage which is available for an unemployed spouse through the spouse's workplace is often offered at very expensive costs (Glied & Borzi, 2004, p. 406). Even if a non-working spouse is eligible for health insurance coverage through the spouse's workplace, the non-working spouse might be more likely to have health insurance coverage if he or she were employed.

Individuals who are employed less than full-time (not more than 35 hours each week) may have access to health insurance, but may not be able to afford it making less money than full time employees. However, again if a part-time worker's spouse provides enough income, the whole family might be covered by health insurance regardless of the part-time individual's employment status.

In a project involving small businesses in San Diego County, CA, researchers found that most workers in smaller business organizations did have health insurance coverage even though many of those organizations did not offer health insurance (Kronick & Olsen, 2006, p.40). Businesses in the county of San Diego which did not provide health insurance but had many uninsured people working there were rare. Over half the small business organizations that did not offer health insurance had one employee or less who did not have health insurance (2006).

In a study done in Jamaica, type of employment such as urban or rural, as well as whether employment provides enough income, also determined levels of health insurance coverage (Bourne, 2009, p. 206). Workers on farms, for example, tended to have lower levels of insurance, or no insurance, more often than workers in many other types of employment. Individuals who were self-employed or poor, even if they had employment, were more likely to count on over-the-counter remedies and other self-care for health issues rather than relying on health insurance. Individuals who had jobs often had higher levels of available money to spend, so they were more likely to have health insurance than individuals with no jobs (2009).

Individuals who change work status from full to part-time often lose their health insurance coverage (Glied & Borzi, 2004, p. 406). Even though Federal law says that those who lose their jobs are eligible for health insurance coverage, the high costs of keeping health insurance means many who lose their jobs go without health insurance. Being employed means, for many, having health insurance which is paid for in part by an employer. In turn, this means that those who are employed, where health insurance is offered through the employer, are more likely to be able to pay for the cost of health insurance and thus more likely to have health insurance than those who are not (2004).

Those who work full time who have poor health face much higher costs to buy health insuance if they don't get health insurance through their workplace (Glied & Borzi, 2004, p. 407). Also, bigger firms which offer health insurance are more likely to have lower costs, so employees of those firms are more likely to be able to afford health insurance when those lower costs are passed on to them (2004). Hypothesis

Based on the information that has been collected and reviewed, the following hypothesis will be made for this research project:

H₁: An individual's increased age directly impacts the level of health insurance coverage. Increased age is the independent variable that has a direct relationship with the dependent variable of health insurance coverage. H₂: Increased income level directly increases the level of health insurance coverage. Increased income level is the independent variable that has a direct relationship with the dependent variable of health insurance coverage.

H₃: An individual's employer offering health insurance directly increases the level of health insurance coverage. An employer offering health insurance is the independent variable that has a direct relationship with the dependent variable of health insurance coverage.

H₄: If an individual is employed full-time as opposed to part-time or not at all, the level of health insurance coverage is directly impacted. Full-time employment is the independent variable that has a direct relationship with the dependent variable of health insurance coverage.

Chapter 2: Methodology

Design

This research project will study the levels of health insurance coverage for individuals in Anytown, GA. Certain variables which impact the levels of health insurance coverage for individuals will be shown and discussed for this survey. The information obtained for this project will be used by government administrators to determine ways more people might be able to obtain health insurance coverage. The following research questions will be asked for this study: 1) "Does age influence levels of health insurance coverage for individuals?" 2) "Does income level affect levels of health insurance coverage for individuals?" 3) "Does whether or not an employer offers health insurance influence levels of health insurance coverage for individuals?" 4) "Do levels of employment influence levels of health insurance coverage for individuals?" "Does whether or not an employer offers health insurance influence levels of health insurance coverage for individuals?" (See Appendix A). Based on the review of literature in this research, the following hypothesis are predicted: H₁: Increased age increases levels of health insurance coverage. H₂: Increased income levels increase levels of health insurance coverage. H₃: An individual's employer offering health insurance increases levels of health insurance coverage. H₄: If an individual is employed full-time as opposed to part-time or not at all, levels of health insurance coverage increase. A carefully implemented survey will be used to make sure the variables stated in the project are measured reliably.

Validity

Making sure that the results of the study are valid will be a top priority. Internal validity is evidence that an action, policy, or program (independent variable) resulted in a difference in a dependent variable which has been observed (O'Sullivan, Rassel & Berner, 2008, p. 58). To make sure this study has internal validity, a smaller sample of the study population (who were not picked to be sampling units in the formal study) will be chosen to receive the survey. The sample population will be picked in a random sample. The sample survey should also help to check for operational validity, by making sure the independent variables are accurately and appropriately measured. External validity means the results of a study are generalized past the cases that are specifically involved (O'Sullivan, et al., 2008, p. 59). To make sure the survey has external validity, a random sample which has heterogeneous sampling units will be taken.

My project will consist of a systematic sampling design with skip intervals. This means each unit chosen will have an equal and known probability. Using this method, a sufficient sample taken from the huge population should easily result. Nonetheless, the skip interval chosen must be verified to ensure it has no hidden bias patterns. If bias patterns are present, then periodicity could be used to minimize or remove them.

Population and Sample

The population for this project will include adult residents of Anytown, GA. Since everyone may potentially obtain health insurance, a large number of demographics or characteristics could exist in the population for this survey. Individuals from all income levels, ages, races, education levels, and cultures could have health insurance. Also, there will be no exclusions made based on whether a person has pre-existing health conditions, or disabilities. The study will include residents who both own and rent their homes, or who live with family or friends. The individuals in Anytown, GA are residents who have lived in that town all their lives, and who have lived there for a day. No differentiations will be made in the survey based on how long a person has lived in Anytown, GA. Similarities may be found in study participants who could potentially be taken from surrounding areas. However, due to cost constraints, parameters have been put in place to limit the study to adult residents of Anytown, GA.

This project's sampling frame will consist of all adult residents of Anytown, GA on the day the survey is distributed. The residents include all individuals who reside in Anytown, GA regardless of whether they receive health care or have health insurance. Individuals include those who have and have not received medical care for a medical condition. The sampling frame includes residents of Anytown, GA at the time the survey is given. Any individuals who become residents after the survey is given, or who were residents but who cease to become residents at the time the survey is given, will not be included. There will always be some fluctuations in the population characteristics due to people moving in and out of Anytown, GA.

According to the Anytown, GA website, the U.S. Census showed that the population of Anytown, GA was 21,675 in 2000. There were 10,593 males and 11,082 females, and of those there were 15,662 adult residents, according to the U.S. Census Bureau (see Appendix C and Appendix D). Race was primarily Caucasian, and African-American was the second largest representation in the race category (see Appendix E). Education levels varied significantly amongst residents of Anytown, GA (see Appendix F). About three-fourths of the Anytown, GA population was in the labor force in the year 2000 (see Appendix G). The U.S. Census Bureau did not show recent income characteristics (before the year 1999) for residents of Anytown, GA.

This project's sample size will be 860 individuals. The systematic sampling design method will be used with a skip interval of 25. To eliminate or reduce bias for this sample, a computer software program will randomly pick a starting point individual, and then will select every 25^th person for the survey. If a person younger than 18 is chosen, the computer will discard that sampling unit and will continue choosing every 25^th person until a total of 860 individuals have been selected.

Variables

An operational definition defines each of the variables in the project. The exact meaning of each of these variables in the study is specifically measured by this definition and and are measured by using the survey instrument. As stated earlier, health insurance may benefit any person. Not having health insurance, or having low levels of health insurance, can impact individuals' levels of care and financial well-being. Factors which may impact levels of health insurance will be noted and discussed with a specific survey (see appendix B graphical model). It is important that these independent variable factors be discussed with an operational, functional definition.

A hypothesis has been made that age can influence levels of health insurance coverage. Age as an independent variable will be included in questions 2 and 3. These two questions will ask the individual's exact age and birth date. Since the exact age at the time the survey is mailed may differ from the exact age on the day the survey is received back by the researchers, birth date will clear up any age discrepancies. These two questions will be compared with the dependent variable of health insurance to see whether older people tend to have health insurance more or less often.

A hypothesis has been made that income can influence levels of health insurance coverage. Question 11 will cover this independent variable. The overall household income, before taxes, of individuals will be studied to determine if income affects whether or not an individual has health insurance coverage.

A hypothesis has been made that whether or not an employer offers health insurance can influence levels of health insurance coverage. This independent variable will be addressed in question 8c. Question 8a asks an employment question leading up to question 8c. If an individual is not employed, then question 8c will not apply and "n/a" will be the response. If an individual works for an employer who offers health insurance, then health insurance as an individual variable will be studied to determine whether it affects health insurance coverage.

A hypothesis has been made that levels of employment can influence levels of health insurance coverage. Questions 8a and 8b ask about this independent variable. If a person is employed full-time, part-time, or not at all is asked. Also, the type of company (private or public) where an employed individual works is determined. Levels of employment can thus be compared with the dependent variable of health insurance to see if there is a relationship.

Several control variables that could impact the results of the survey will also be covered in this project. Individuals will be asked for their sex. This will aid in testing to see if there are other relationships among variables and if those relationships are changed by the control variable. Individuals will be asked their race, levels of education, and whether they are married or not. These variables will also test to see if relationships among other variables exist, and if they are affected by the control variable. The first question asks if the individual filling out the survey is a resident of Anytown, GA. Since the survey is for only residents of Anytown, GA, anyone answering "no" to this question will have his or her survey discarded. Also, individuals will be asked if their spouse works for an employer that offers health insurance coverage and whether they are covered by their spouse's employer for health insurance coverage. For situations where the individual filling out the survey form is unable to write for some reason, there is a place for the person filling out the form to identify their relationship to the individual whose answers are on the form.Data Collection

Measuring Instrument

This project's measuring instrument will consist of a basic survey consisting of 15 questions (including the extra sections of some questions with more than one part), that will show how the independent variables impact health insurance coverage. The number of questions in the survey was limited as to prevent a low response rate. By not having too many questions, the respondents would be less likely not to complete the entire survey, and would not be overwhelmed and tend to throw out the survey without completing it. The questions, although some such as income level were personal in nature, were designed to only gather information needed for the research. A cover letter (see Appendix H) will be included with each survey to let participants know the information they provided will be confidential and anonymous. These actions have been done to increase a higher rate of response. If a low rate of response is received, and the budget allows, then a follow-up reminder may be sent to participants. The follow-up reminder would be sent to individuals who were sent the survey but did not respond.

A Likert scaling method will be used for the survey questions. This method was chosen partly because the responses of individuals taking the questionnaire can be represented easily. A secondary reason this method was used is that it is easier for the data to be input into a computer to find out the results. Five answers will consist of yes or no choices, with three of those having a "n/a" choice. Bias possibility will be reduced since there will be the same number of positive and negative choices in these questions. At the end of the survey a section for comments will allow respondents to elaborate on any answers they have given.

Materials

For the sample size of 860 individuals, the following materials are to be used for the mail-out survey. To estimate the costs of office supplies, the Staples website was used. Other costs which are not stated are costs which may occur if a second mailing is needed due to low response rate. Costs of employees doing the work, printer and ink supplies, and other resources potentially needed are also not included. The possibility exists that damage to items used in the survey may cause additional expenses which were not factored in to the materials costs. For example, paper and envelopes may be damaged due to unforeseen circumstances. These potential issues should be taken into consideration and allowances should be made for when a budget is being made for this survey project.

For each mailed survey, two pieces of paper will be used. The survey itself will be printed on the front and back of one of the pages. The cover letter will take up the other sheet of paper. The number of pieces of paper needed will total 1,720 sheets. To cover this need, four reams of 500 pages each could be bought for $7 each (allows a few cents extra per ream to cover tax and/or shipping), or a total of approximately $28. This will allow for extra paper to be used if some is inadvertently destroyed or wasted.

For each survey mailed, two letter-sized envelopes will be used. The one envelope to be returned will be folded, addressed, stamped and placed inside the other envelope which will be mailed to the survey respondents. The number of envelopes needed, in total, will be 1,720. The cost of 500 envelopes, standard letter size, is about $12. Therefore, the cost of four boxes of 500 envelopes is about $48. Buying four boxes totaling 2,000 envelopes will allow for extra envelopes if some are inadvertently wasted or destroyed. Instead of using labels to mail the surveys, the addresses will be printed on the envelopes using a computer and printer. This will save money from not having to use labels, and time by not having to hand-write information on the envelopes. 860 stamps will be needed at a cost of 44 cents each. The total stamp cost will be $378.40.

Also, a computer, printer, printer ink, and manpower will be needed. The cost of these resources will be variable and thus difficult to calculate or even predict. It is hard to tell how much ink a printer will need to print out all the addresses on the envelopes and all the surveys and cover letters. It is also hard to know how much manpower will be needed to perform the process of mailing out surveys. Nonetheless, based on the calculations which are known, a rough estimate of the cost for this survey is $454.40.

Delivery method

As already determined, the sample size will be composed of the more than 21,000 residents of Anytown, GA. First, a computer software program will randomly choose one person from the population of Anytown, GA. This will be where the skip interval will begin. Next, the computer will select one out of every 25^th person in a systematic way, until 860 adult individuals have been chosen from the entire sampling frame. For those individuals chosen who are less than age 18, the computer will discard those choices and continue selecting every 25^th individual until 860 who are at least age 18 have been chosen.

When the final sample units have been chosen, a random sample which is smaller will be taken from those. The sample size will be small enough so that they can be called on the phone to see if they are willing to participate. Each of these individuals will be called on the phone to make sure they agree, and those who do agree will be mailed the questionnaire. The official sampling units will also be sent the questionnaire by mail. This will be done in order to lower expenses, so that people who have no intention of participating in the project will not be sent questionnaires. The process will go on after these questionnaires are sent back.

The envelope addresses will be printed according to information provided by the City of Anytown. The stamped envelope, survey (front and back) and cover letter will be sent by mail to the sampling units. A wait time of 30 days, which will be stated in the cover letter as the time limit, will be taken into consideration before any follow-up surveys are sent out.

Once the questionnaires have been sent back, each response will receive a number value. Each number value will be input into a computer software program and coded. The statistical software program SPSS will be used to manage and analyze the data.

Data Analysis

Since a lot of information will be analyzed, the program SPSS will be used. By using this program, the data will be analyzed more quickly and more efficiently. Also, correlation among variables will be more easily shown by using SPSS. The researcher will use multiple regression analysis to determine which relationships occur between the dependent and independent variables. By using the multiple regression analysis, the person analyzing the data can correlate the various variables in comparison with one another at one time. In addition, the SPSS program lets the person doing the research isolate each variable in relation to the dependent variable. The program will show whether the independent variables significantly correlate with the dependent variable.

A variance table will be utilized to show the results of the computer's analysis of the variables. The researcher will then give each correlation a numerical value, which will help show who strong each correlation is. The number 1.0 stands for a perfect correlation. Any numerical value of .25 or greater might be considered as a correlation which is significant.

Chapter 3: Anticipated Findings

The anticipated findings of this study, based on the research and the methodology, is that levels of health insurance coverage will be affected by age, income, whether or not an individual's employer offers health insurance, and levels of employment. Upon completion of the study, the results will be presented in chart form with a style similar to that of the charts in appendices I-L.

It is thought that the independent variables will correlate with a positive slope for survey questions 2 and 3. That is, as age increases, levels of health insurance will increase. Affirmative answers for questions 8a and 8c are also expected to yield a positive slope correlation. That is, levels of health insurance will increase if a person's employer offers insurance, and they will also increase if a person is employed full-time rather than part-time or not at all. In question 11, the higher income levels are expected to correlate with higher levels of health insurance coverage.

Chapter 4: Conclusions

Health insurance coverage is an important issue in Anytown, GA and one which must be researched in order to provide information administrators can use to increase health insurance coverage options for more people. Additionally, if studies can find ways to increase the number of people who have higher levels of health insurance, a lot of money can be saved for individuals who have little or no health insurance coverage and require costly medical procedures to be paid out-of-pocket. Some benefits of the study results will be providing information to administrators which will improve access to health insurance for those of all ages, whether or not they are employed full-time, part-time, or not at all, and whether they have high or low incomes.

The literature review provided information which resulted in hypothesis in regards to the dependent variable of health insurance coverage and the influence of independent variables of age, levels of employment, whether or not an employer offers coverage, and income. It is believed that each of these independent variables will correlate positively and directly with the dependent variable.

This study's results can add to empirical data from past and future studies regarding health insurance coverage. The results of the study will be generalized to the Anytown, GA population of adults. The results will be shown to administrators in the Anytown government so that they may develop a plan to increase public awareness on how individuals may improve their health insurance coverage options. In addition, administrators at insurance companies may use the information provided by the study to find ways to offer health insurance to more people. The results will be available on the internet for individuals to read as well, so that they may learn factors which may limit or improve their ability to obtain health insurance coverage.

Implications

The outcome of this project is thought to be of value to the Anytown, GA government officials working to improve the lives of residents of Anytown, GA. By making health insurance coverage available to more people, the health care options for Anytown, GA residents will be increased. Even though the results might not be generalized beyond the parameters of the target population, similar organizations can use the research to find ways to increase levels of health insurance coverage for individuals. Also, the data found can be utilized to add to other studies which contain empirical evidence regarding health insurance coverage.

Recommendations

This research study was not able to include all the variables which might impact health insurance coverage. Thus, it is recommended to study more variables which might influence levels of health insurance coverage for adult residents of Anytown, GA. Administrators at governmental or private organizations may wish to conduct further studies using variables such as personal priorities, education levels, and whether or not individuals are married or not. These variables, if found to correlate with levels of health insurance coverage, could help administrators find more ways in which more individuals could obtain health insurance coverage. Administrators may want to repeat the survey once every few years to see if factors determining health insurance coverage change significantly over time. Also, this will allow administrators to have a better picture of reasons some individuals have no health insurance while other individuals have health insurance. References

(2008). Income, Poverty, and Health Insurance Coverage in the United States, 20-21, Retrieved November 7, 2009 from the U.S. Census Bureau Web site: http://www.census.gov/prod/2009pubs/p60-236.pdf

(2009). About Us. Retrieved November 7, 2009 from the National Coalition on Health Care Web site: http://www.nchc.org/about/

(2009). Demographics. Retrieved November 7, 2009 from the City of Anytown Web site: http://www.Anytown-ga.gov/index.aspx?NID=38

(2009, June). Lack of Health Care and Type of Coverage, 8, Retrieved November 7, 2009 from the Centers for Disease Control Web site: http://www.cdc.gov/nchs/data/nhis/earlyrelease/200906_01.pdf

Angel, R., Frias, S. & Hill, T. (2005, December). Determinants of Household InsuranceCoverage Among Low-Income Families from Boston, Chicago, and San Antonio: Evidence from the Three-City Study. Social Science Quarterly (Blackwell Publishing Limited), 86, 1344, Retrieved November 2, 2009 from http://search.ebscohost.com.libproxy.troy.edu/login.aspx?direct=true&db=a9h&AN=19493483&loginpage=Login.asp&site=ehost-live

Bourne, P. (2009, October).Health insurance coverage in Jamaica: Multivariate Analyses using two cross-sectional survey data for 2002 and 2007.International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH), 1(8), 206, Retrieved November 3, 2009 from http://search.ebscohost.com.libproxy.troy.edu/login.aspx?direct=true&db=a9h&AN=44704794&loginpage=Login.asp&site=ehost-live

DerGurahian, J. (2009, July). Too much to bear; Study calls health insurance crippling for employers. Modern Healthcare, 39(30), 14, Retrieved November 7, 2009 from http://search.ebscohost.com.libproxy.troy.edu/login.aspx?direct=true&db=a9h&AN=43700804&loginpage=Login.asp&site=ehost-live

DeVoe, J., Baez, A., Angier, H., Krois, L., Edlund, C. & Carney, P. (2007, November/December). Insurance + Access ? Health Care: Typology of Barriers to Health Care Access for Low-Income Families. Annals of Family Medicine, 5(6), 512-517, Retrieved November 7, 2009 from http://search.ebscohost.com.libproxy.troy.edu/login.aspx?direct=true&db=a9h&AN=27563675&loginpage=Login.asp&site=ehost-live

Fairley, R. & London, R. (2005, August). The Dynamics of Health Insurance Coverage: Factors Correlated With Insurance Gain and Loss among Adults, Retrieved November 7, 2009 from the Department of Labor Web site: http://www.dol.gov/ebsa/pdf/DOLHealthDynamics.pdf

Glied, S. & Borzi, P. (2004, Fall). The Current State of Employment- Based Health Coverage.

Journal of Law, Medicine & Ethics, 32(3), 404-407, Retrieved November 7, 2009 from http://search.ebscohost.com.libproxy.troy.edu/login.aspx?direct=true&db=a9h&AN=14841743&loginpage=Login.asp&site=ehost-live

Keenan, P., Cutler, D. & Chernew, M. (2006, November/December). The 'Graying' Of Group Health Insurance, Health Affairs, 25(6), 1497, 1499, 1500, 1504, Retrieved November 7, 2009 from http://search.ebscohost.com.libproxy.troy.edu/login.aspx?direct=true&db=a9h&AN=23124795&loginpage=Login.asp&site=ehost-live

Kronick, R. & Olsen, L. (2006, February). A Needle in a Haystack? Uninsured Workers in Small Businesses That Do Not Offer Coverage. Health Services Research, 41(1)1, 40, Retrieved November 4, 2009 from http://search.ebscohost.com.libproxy.troy.edu/login.aspx?direct=true&db=a9h&AN=19427790&loginpage=Login.asp&site=ehost-live

O'Sullivan, E., Rassel, G. & Berner, M. (2008). Research Methods for Public Administration (5^th ed.). N.Y., N.Y.: Pearson Education, Inc.

Polsky, D., Stein, R., Nicholson, S. & Bundorf, K. (2005, October). Employer Health Insurance Offerings and Employee Enrollment Decisions.Health Services Research, 40(5P1), 1259, 1262-1263, 1273, 1275, Retrieved November 5, 2009 from http://search.ebscohost.com.libproxy.troy.edu/login.aspx?direct=true&db=a9h&AN=18139413&loginpage=Login.asp&site=ehost-live

Ruffin, J. (2008, March). Department of Health and Human Services National Institute of Health (NIH), Fiscal Year 2009 Budget Request, Retrieved November 7, 2009 from the National Institute of Health Web site: http://www.ncmhd.nih.gov/NCMHD%20-%20FY2009%20Budget%20Request%20(2).pdf

Shields, A., McGinn-Shapiro, M. & Fronstin, P. (2008, June). Trends in Private Insurance, Medicaid/State Children's Health Insurance Program, and the Healthcare Safety Net. Annals of the New York Academy of Sciences, 1136, 138, Retrieved November 7, 2009 from http://search.ebscohost.com.libproxy.troy.edu/login.aspx?direct=true&db=a9h&AN=32677472&loginpage=Login.asp&site=ehost-live

Ziller, E., Coburn, A., McBride, T. & Andrews, C. (2004, November/December). Patterns Of Individual Health Insurance Coverage, 1996-2000. Health Affairs, 23(6), 212-214, Retrieved November 7, 2009 from http://web.ebscohost.com.libproxy.troy.edu/ehost/pdf?vid=2&hid=104&sid=a6c96b9e-9537-44b7-b188-b142eada378e%40sessionmgr104

APPENDIX A (graph omitted)

Dependent variable:

• Health insurance

Independent variables:

• whether employer offers health insurance - direct relationship

• employment levels - direct relationship

• age - direct relationship

• income - direct relationship

APPENDIX BHealth Insurance Survey

Thank you for taking the time to complete this survey. When you are finished, please mail it back in the enclosed stamped envelope.

Instructions: For multiple choice questions, place an X on the line which most applies to you. Please try to answer every question. If you are not sure of a response, choose what you think is the best response or skip to the next question.

Questions

1. Are you a resident of Anytown, GA? ______Yes ______No

2. What is your date of birth? Month: ________ Day ___________ Year __________

3. What is your age in years? _____

4. Who is filling out this form? ______self ______ friend or relative

5. Are you married ___yes ___no

6. What race do you consider yourself to be?

___Caucasian

___African-American

___other or two or more races mixed

7. If married, does your spouse work for an employer who offers health insurance coverage as an option?

____yes ___no ___n/a

8a. Are you employed (check all that apply):

____full-time (35 or more hours a week)

____part-time (less than 35 hours a week)

____unemployed

8b. If employed, is your employer (check all that apply):__government

___private company ___n/a

8c. If employed, does your employer offer health insurance? ____yes _____no ____n/a

9a. Do you have any type of health insurance? ____yes ____no

9b. If yes, is the health insurance you have provided by:

____your employer (OVER)

____your spouse's employer

____a private company not through an employer

____Medicare or Medicaid

____n/a

10. What is your highest level of education received?

____less than high school diploma

____high school diploma or GED

____some college or associate's degree

____Bachelor's degree

____Graduate or professional degree

11. What is your annual household income level, before taxes?

____less than $24000

____$24001 to $49999

____$50000 to $74999

____$75000 to $100000

____$100000 to $124999

____$125000 to $149999

____$150000 and above

12. Are you: ____male ____female

Do you have anything else you would like to add or comment on? If so please comment here.

APPENDIX C Anytown, GA Population, year 2000 number percent Male

10,593

48.9 Female

11,082

51.1

APPENDIX D Adult Population of Anytown, GA, year 2000

number

percent Adults 18 and older 15,662

72.3% Male adults 18 and older 7,481

34.5% Female adults 18 and older 8,181

37.7% APPENDIX E Race of Residents of Anytown, GA, year 2000

number

percent White 17,767 82.0% Black 2,146 9.9% Other, or two or more races 1,232 8.1%

APPENDIX F Education of Anytown, GA Residents, year 2000

number

percent Less than high school diploma

1,222 8.5% High school diploma (includes equivalency)

3,394 23.8% Some college, or associates degree

4,746 33.3% Bachelor's degree

3,685 25.8% Graduate or Professional degree

1,242 8.7% APPENDIX G Employment status of Anytown, GA Residents, year 2000

number

percent In labor force

12,265

75.4% Not in labor force 3,994

24.6% APPENDIX H (Health Insurance Survey Cover Letter)

City of Anytown, GA

Today's Date

Dear:

Thank you for taking the time to fill out this survey.

Our goal at the City of Anytown is to give our residents the very best opportunities for health care. We believe that having health insurance can affect levels of health care received, as well as financial well-being of those who receive medical care. Your opinion is important, as the results of this survey can lead to new ways to provide health insurance for residents of Anytown, GA.

Providing information about your health insurance experiences gives us valuable information we can use for the future of health insurance needs for residents of Anytown. If you have any further comments regarding this study, please provide them at the end of the survey or on a separate piece of paper. We will be sure to review all the responses.

Enclosed you will find the health insurance survey. Please send it back in the enclosed stamped envelope, within 30 days of receiving it.

The information you provide will be kept completely anonymous and confidential.

Once again, we appreciate your time and are happy you have chosen your home as Anytown, GA.

Sincerely,

xxxxxxxxxxxxxx

APPENDIX ISample Results Graph

For the following charts in Appendices I-L, "Yes" indicates health insurance coverage and "No" indicates no health insurance coverage.

Percent of Individuals in Anytown, GA Who Have Health Insurance By Age

%

(graph omitted)

APPENDIX JSample Results Graph

Percent of Individuals in Anytown, GA Who Have Health Insurance By Income Level

%

(graph omitted)APPENDIX KSample Results GraphPercent of Individuals in Anytown, GA Who Have Health InsuranceBy Employment Level

(graph omitted)

%

APPENDIX LSample Results Graph

Percent of Individuals in Anytown, GA Who Have Health Insurance By Whether an Employer Offers Coverage

% (graph omitted)

Note: This chart only includes figures based on total percentages of the employed respondents. Unemployed respondents are not included in this graph, since it does not apply to them.