William F. Tate IV holds the Edward Mallinckrodt Distinguished University Professor in Arts & Sciences at Washington University in St. Louis. His academic appointments are in education, public health, urban studies, African and African American Studies, and American Culture Studies. He serves as Dean of the Graduate School and Vice Provost for Graduate Education. Tate has a particular interest in STEM attainment. Ongoing research projects include understanding the distal and social factors that predict STEM doctoral degree attainment broadly defined to include highly quantitative social sciences disciplines. His co-edited book titled, Beyond Stock Stories and Folktales: African Americans’ Paths to STEM Fields captures the direction of this research program. Also, his research has focused on the development of epidemiological and geospatial models to explain the social determinants of education, health, and developmental outcomes. His book project titled, Research on Schools, Neighborhoods, and Communities: Toward Civic Responsibility reflects his interest in the geography of opportunity in metropolitan America. He served as president of the American Educational Research Association and is a fellow of the association. In 2016, he was elected to membership in the National Academy of Education.

“Where did you graduate from high school?” Health Insurance as Education Reform [1]

“My ear hurts.” “It’s hard to breathe.” “I feel afraid and it won’t go away.” 

Imagine learning to read or doing a science project with otitis media or asthma. Picture taking a major exam while experiencing the symptoms of a crippling anxiety disorder. Many students miss classes, experience increased difficulties with illness, and go untreated because they lack the resources to secure a health care provider. Too many students do not have health care coverage. The 2011 US Census Bureau estimates indicate 9.4% of young persons under 18 (7 million) have no health insurance (DeNavas-Walt, Proctor, Smith, 2012). Nearly 14% of children living in poverty are uninsured. The uninsured rates for African American and Hispanic children are 10.2% and 15.1%, respectively.

National health insurance trends for children suggest the need for careful examination of regions where underserved racial groups concentrate. St. Louis City, the only majority African American county outside of the traditional South (e.g., Georgia, Florida, North Carolina, South Carolina, Virginia), presents an instructive starting point for a discussion of health insurance coverage as St. Louis City and St. Louis County contribute more than 13,000 youth to this national problem (Jones, Harris, and Tate, 2015). This may seem an insignificant number; however, consider it in relation to the famous St. Louis question, “Where did you attend high school?”[2] Some locals use this crudely veiled question as a heuristic to quickly evaluate family social status. In a region severely bound in terms of upward income mobility[3], the question offers a powerful sociological lens since the response provides a gross approximation of family resources and residential status.

Transform the health insurance coverage problem to the scale of three noteworthy local St Louis area high schools. Part of school districts ranked among the best in the region, these three high schools offer quality academic opportunities. The uninsured figure equals roughly the enrollment of 6.5 Lafayette High Schools, 7 Mehlville High Schools, or 13 Clayton High Schools. None of these communities would consider this acceptable. Our region should not accept this state of affairs, either. Other regions across the country face similar challenges.

Access to health insurance coverage varies across the St. Louis region. As Figure 1 indicates, the largest percentages of youth with health insurance live in affluent central and western St. Louis County, while northern and southern St. Louis City had the smallest percentages of youth with health insurance coverage. Historically, the latter areas experience greater poverty and racial isolation.


According to an Institute of Medicine (2002) report, uninsured children have less access to health care, are less likely to have a regular source of primary care, and use medical and dental care less often than children with insurance coverage. Like families, educators are on the front lines of child and adolescent health. Uninsured children may experience adverse consequences on cognitive tasks and in social interactions, and ultimately educational attainment.

Investing in insurance coverage for children living in poverty has the potential to be a powerful form of education reform.

We know that insured children do better in school. In a May 2014 National Bureau of Economic Research working paper, Sarah Cohodes and her colleagues reported that the expansion of public health care in the form of Medicaid reduced high school drop out rates, increased college attendance, and improved the rate of college degrees earned. This research suggests that investing in insurance coverage for children living in poverty represents a potentially powerful form of education reform.

To date, Missouri has not expanded Medicaid (MO HealthNet) under the Affordable Care Act. Non-disabled adults without children remain ineligible for Medicaid regardless of their income status [4]. In addition, eligibility status for parents with dependent children requires incomes that don’t exceed 18 percent of the poverty level. With a 15 percent cap, only the state of Texas maintains a lower Medicaid eligibility level. Fortunately, Missouri considers children eligible for Medicaid or Children’s Health Insurance Program (CHIP) if they live in households with incomes up to 300% of the federal poverty level. However, research has found that the enrollment of eligible children improves with parent coverage in public programs. Children benefit when their parents’ coverage exists. Garfield and Damicco (2016) reported nationally that nearly a quarter of million people in coverage gap represent poor parents with income above Medicaid eligibility levels. This problem exists for children living in states such as Missouri without Medicaid expansion, which puts these children at risk for falling into a coverage gap.

The relationship between high school completion and insurance coverage is of particular concern for African Americans in the St. Louis region. In 2012, Missouri Department of Elementary and Secondary data indicated over two thousand African American 9-12 graders as high school dropouts in St. Louis City and St. Louis County (Tate, 2013). This data classified one in ten African American 9-12 graders as high school dropouts in the region. Unless they resume their education, this places them at high risk for both lower incomes and poorer health. These students are likely to earn about $7,000 less per year than high school graduates.

Figure 2 illustrates that less than 5% of students dropped out of high school in most St. Louis-area school districts during the 2012 school year. In contrast, approximately 22% of students dropped out of high school in the Normandy district, which served part of Ferguson, Missouri. In St. Louis Public School district (SLPS) and in adjoining University City School district, at least 10% of students dropped out in 2012. All of these districts are majority Black school districts. The comparatively high drop out rate in these school districts aligns with the trend of racial disparities in the region (Jones, Harris, and Tate, 2015)



Setting up children to succeed at the youngest ages has powerful health, education, and societal effects.

Recall that Cohodes, Grossman, Kleiner, and Lovenheim reported expanded Medicaid increases the education attainment of children living in poverty. Increased education attainment fosters additional societal benefits. As stated in the For Sake of All report (Purnell, Camberos, and Fields, 2015), envision a St. Louis region with increased purchasing power (ranging from $347,000 to $739,410 per graduate), higher tax receipts to support services and schools, and lower costs for social services and unemployment assistance. Using earnings estimates alone, St. Louis gains $694 million to $1.5 billion across a generation, if the 2012 African American cohort completed high school. Consider the year after year effect. For many of these students, health insurance would have been an important protective factor supporting their high school completion. It is not too late for future cohorts of students.

Solutions exist. Setting up children to succeed at the youngest ages has powerful health, education, and societal effects. Expanding Medicaid in Missouri and other states represents a start. The state of Missouri has an opportunity to expand Medicaid to many more working families experiencing the stresses of limited resources. There has been progress. Medicaid and CHIP have provided needed coverage for many children.

Visualize thirteen Clayton High Schools worth of children with health insurance coverage. Many more St. Louisans will live longer and get to answer a different question, “Where did you graduate from high school?”

[1] The figures in the brief are part of a larger study of metropolitan St. Louis (Jones, Harris, & Tate, 2015). An earlier version of this essay was published in a blog hosted by the Washington University in St. Louis, Institute for Public Health.

[2] For additional discussion on this topic, see http://mohistory.org/highschool.

[3] Income mobility estimates for St. Louis and other regions provided at http://www.nytimes.com/2013/07/22/business/in-climbing-income-ladder-location-matters.html?pagewanted=all&_r=0

[4] For a more expansive discussion, see https://www.healthinsurance.org/missouri-medicaid/


Cohodes, S., Grossman, D., Kleiner, S., & Lovenheim, M. F. (2014).  The effect of child health insurance access on schooling: Evidence from public insurance expansions

DeNavas-Walt, C., Proctor, B.D., Smith, J. C. (2012, September). Income, poverty, and health insurance coverage in the United States: 2011. Washington, DC: U.S. Department of Commerce. Retrieved from https://www.census.gov/prod/2012pubs/p60-243.pdf

Garfield, R., & Damico, A. (2016, January).  The coverage gap: Uninsured poor adults in states that do not expand Medicaid-An update (issue brief). The Kaiser Commission on Medicaid and the uninsured.  Retrieved from http://files.kff.org/attachment/issue-brief-the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update-2.

Jones, B. D., Harris, K. M., & Tate, W. F. (2015). Ferguson and beyond: A descriptive epidemiological study using geospatial analysis. Journal of Negro Education, 84(3), 231-253.

Purnell, J., Camberos, G., & Fields, R. (Eds.) (2015). For the sake of all. A report on the health and well-being of African Americans in St. Louis and why it matters for everyone (revised edition). Retrieved from https://forthesakeofall.files.wordpress.com/2015/08/for-the-sake-of-all-report-2.pdf

Institute of Medicine. (2002). Health insurance is a family matter. Washington, DC: National Academies Press.

Sommers, B. D. (2006).  Insuring children or insuring families: Do parental and sibling coverage lead to improved retention in children in Medicaid and CHIP? Journal of Health Economics, 25(6), 1154-1169.

Tate, W. F. (2013, September).  How does health influence school dropout?  Retrieved from https://forthesakeofall.files.wordpress.com/2013/09/policy-brief-2.pdf


The author thanks Equity Alliance reviewers and Edna Cash for their instructive feedback on this essay.

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