A Senior Researcher Studies Why Workers Accept or Refuse Health Insurance

    • March 17, 2010

The Problem: Low levels of responsiveness to health coverage options offered to uninsured people over the past two decades have perplexed researchers and policy-makers alike.

This prompted questions such as: To what extent do uninsured workers value health insurance? Do they find it too costly? Do they believe they are healthy enough not to need coverage? Are workers who value coverage more likely to seek jobs that offer coverage? What are other factors that influence decisions to enroll in health insurance?

Grantee Background: Alan C. Monheit, PhD, professor of health economics at the University of Medicine & Dentistry of New Jersey and research associate at the National Bureau of Economic Research, wanted to answer those questions and understand the factors that lead workers to accept or refuse health insurance when it is available to them.

The Robert Wood Johnson Foundation's Economic Research Initiative on the Uninsured (originally the Research Initiative on Health Insurance) provided Monheit that opportunity. It also gave him a chance to discuss his ideas with colleagues from different backgrounds and orientations: "We had researchers who had not necessarily worked in the areas of health, insurance or health reform. They had a different perspective and brought different tools to the research."

The Project: In his study, "Health Insurance Enrollment Decisions: Preferences for Coverage, Worker Sorting, and Insurance Take-Up," Monheit examined the health insurance preferences of single workers and their level of comfort with taking risks.

Alan Monheit and Jessica Primoff Vistnes, PhD, a senior economist at the federal Agency for Healthcare Research and Quality, analyzed demographic and health data of 2,987 single workers participating in the 2001 Medical Expenditure Panel Survey (MEPS). MEPS is a nationally representative survey of people's access to, use of and expenditures for health care, their health coverage status and their demographic characteristics.

Monheit and Vistnes also analyzed responses to four preference statements included in a separate self-administered questionnaire within MEPS. Respondents indicated how strongly or weakly they agreed or disagreed with the statements below. The first two statements measure preferences and the last two provide measures indirectly associated with attitudes toward health insurance:

  • I'm healthy enough that I really don't need health insurance.
  • Health insurance is not worth the money it costs.
  • I'm more likely to take risks than the average person.
  • I can overcome illness without help from a medically trained person.


In an article published in the Summer 2008 issue of Inquiry, Monheit and Vistnes reported specific findings, including:

  • Workers with weak or uncertain preferences for health insurance coverage are not only less likely to have jobs with coverage, they are less likely to enroll in offered coverage than workers with strong coverage preferences.

  • Self-described higher risk takers are less likely to have a job with health insurance than lower risk takers, though the difference is not statistically significant. Other measures of risk are also associated with not obtaining a job with health insurance. In particular, smokers and people who seldom or nearly always use seatbelts are significantly less likely to have jobs with insurance than nonsmokers or people who always use seatbelts.

  • There is only an imperfect match between worker preferences for health insurance coverage and the jobs they have. About 28 percent of workers are mismatched: 18.7 percent have strong preferences for coverage but have jobs that do not provide coverage, and 9.4 percent have weak preferences but have jobs that do offer coverage.

  • Other factors are associated with the likelihood of finding a job that offers health insurance. Workers facing higher costs to look for jobs with insurance, such as those in fair or poor health, are less likely to find jobs with coverage. Workers potentially eligible for Medicaid or the State Children's Health Insurance Program and, thus, expected to have lower out-of-pocket medical expenses, are up to 25 percentage points less likely to have jobs with insurance than workers not potentially eligible for these programs.

  • Several demographic factors are associated with how people decide whether to enroll in insurance offered to them at work. For example, workers age 40 to 54 are more likely to enroll than workers age 18 to 24. People with incomes less than 125 percent of the federal poverty level are 27.1 percent less likely to enroll than workers with incomes four times the federal poverty level.

Reflecting on the findings of the study, Monheit observes, "Having data on preferences for insurance is important because demographic data often used as proxies, such as gender or race, do not do a good job of helping us understand preferences."

Monheit concluded that "preferences do matter in whether people seek or accept health insurance and workers will seek employment situations that are consistent with their preferences."

He further states, "There may be a considerable gap between the perceptions of policy-makers and some of the uninsured regarding the social and private value of health insurance. We think both voluntary and mandatory approaches to coverage are important. These may need to involve educational efforts to help people understand the protection they get from coverage."

In looking back, Monheit says: "I was senior in my field when I came to the program, but it did get me thinking about other areas. I am now more interested in issues related to socioeconomic status and health than I was."

RWJF Perspective: RWJF established the Economic Research Initiative on the Uninsured in 2000 to generate information on the relationship between the labor market and health insurance coverage. RWJF also wanted to elicit new ideas about these relationships by attracting applied economists who had not previously focused on health concerns and by drawing upon new analytical frameworks.

"Given the number of uninsured people, the fragility of insurance for those who have it and the spiraling costs of care to individuals, businesses and the government, we needed the best information and the best ideas about ways to address the connections between work and health insurance. The Economic Research Initiative on the Uninsured was designed to fill gaps in our knowledge and understanding of these complicated relationships," said David C. Colby, PhD, RWJF's Vice President for Research and Evaluation and program officer for the initiative.