VISIT STATE HEALTH COMPARE
Blog & News
SHADAC Comments on Proposed 2025 American Community Survey Health Insurance Coverage Instrument Changes
January 07, 2024:The U.S. Census Bureau has released a request for comments regarding proposed revisions and changes for the 2025 American Community Survey. Based on information gained from the 2022 Content Test, proposed changes would affect a variety of topics and questions, including educational attainment, disability, household roster, and, most notably for the State Health Access Data Assistance Center (SHADAC), health insurance coverage.
See an excerpt regarding ACS health insurance coverage question changes below. You can find the full request for comments here in a notice from October 20, 2023.
| Health Insurance Coverage - Since implementation in 2008, research has found that Medicaid and other means-tested programs are underreported in the ACS and the PRCS and that direct-purchase coverage is overreported, in part due to misreporting of non-comprehensive health plans and reporting multiple coverage types for the same plan (Mach & O'Hara, 2011; Lynch et al., 2011; Boudreaux et al., 2014; O'Hara, 2010; Boudreaux et al., 2011; Boudreaux et al., 2013). Moreover, revisions to the health insurance question would help capture changes to the health insurance landscape that occurred with and since the passage of the Patient Protection and Affordable Care Act. Changes to the health insurance coverage question include a change in formatting of the question that adds an explicit response category for those who are uninsured, reordering some response options and rewording response options for direct purchase, Medicaid, employer, and veteran's health care. |
Researchers at SHADAC have reviewed the proposed changes regarding health insurance coverage data collection for the American Community Survey 2025 data year. We have crafted the following response letter discussing our opinion that the implementation of these changes be postponed in order to further investigate causes of Medicaid underreporting, and to allow for the ACS 2025 to adequately reflect effects of the Medicaid unwinding.
SHADAC’s Comments
We appreciate the opportunity to comment on Census’ proposed changes to the 2025 American Community Survey questionnaire. For more than twenty years, the State Health Access Data Assistance Center (SHADAC) has used the American Community Survey (ACS) to provide state officials and other stakeholders with data to inform health policy. Since the health insurance question was added in 2008, we have used the ACS to monitor changes in health insurance coverage.
As frequent and knowledgeable users of the survey, we have a particularly vested interest in the continued ability of the ACS to produce a high-quality measurement of health insurance coverage. With that in mind, we submit the following comments on the proposed changes to the health insurance coverage instrument. We strongly urge postponing the implementation of the proposed changes to the ACS’ health insurance coverage instrument with reasons provided below:
Medicaid Underreporting
While heartened by the commitment to improvements in the measurement of health insurance coverage, we are very concerned that the most recent content test showed significantly reduced reporting of Medicaid coverage in both versions of the test questions.
Given that this request for comment specifically mentions addressing the long-standing problem of Medicaid underreporting as a goal of the new instrument, we view this increase in Medicaid underreporting as disqualifying. In our view, Census needs to conduct further investigation to determine the cause for this demonstrated decrease in Medicaid reporting and use that information to revise the test questions to address this substantial problem.
Timing and Medicaid Unwinding Data
Though we understand that the timing for this change is driven by Census’ standard process for adding or changing survey content, we view the proposed timing of this change as inappropriate because of the ongoing, large-scale redetermination of Medicaid eligibility (“unwinding”) that began in April 2023 with the end of the pandemic-era continuous coverage requirement. This unwinding will continue into 2024.
The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act, and there is significant interest in monitoring the impacts. ACS data year 2025 will be the first full year of data after the completion of the unwinding.
If changes to health insurance coverage questions are implemented in 2025, we will never be able to reliably learn about the full impacts of the unwinding on health insurance coverage. Postponing revisions would allow us to better compare data and understand the impacts of the unwinding on key populations in the first full year post-unwinding completion. This is especially important for state-level populations of interest (including those relevant to furthering critical health equity goals) and for substate geographies, as the ACS is the only source of this information.
Thank you for your consideration. We know you face many important decisions and appreciate the chance to comment on this important and impactful data collection change.
See SHADAC’s comments on the newly proposed Sexual Orientation and Gender Identity (SOGI) questions on our blog here.
