Using Enrollment Records to Evaluate Self-Reports of Monthly Coverage in the Redesigned Current Population Survey Health Insurance Module

This journal article was originally published on January 23, 2024, in Health Services Research.

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Introduction

This article, authored by SHADAC Investigator Dr. Kathleen T. Call alongside colleagues from the U.S. Census Bureau Angela R. Fertig and Joanne Pascale, explores the veracity of self-reports of month-level health insurance coverage in the Current Population Survey Annual Social and Economic Supplement (CPS ASEC). 

The CHIME (Comparing Health Insurance Measurement Error) study used health insurance enrollment records from a large regional Midwest insurer as the sample for primary data collection in spring of 2015. In this study, a sample of individuals enrolled in a range of public and private coverage types (including Medicaid and marketplace) was administered the CPS health insurance module, which included questions about month-level coverage, by type, over a 17–18-month time span. Survey data was then matched to enrollment records covering that same time frame, and concordance between the records and self-reports was assessed.

Principal Findings

For 91% of the overall sample, coverage status and type were reported accurately for at least 75% of observed months.

Among those who were continuously covered throughout the 17–18 month observation period (64% of the overall sample), that level of reporting accuracy was observed for 94% of the sample. For those who had censored spells (34% of the overall sample), the figure was 87%. Among those with gaps and/or changes according to the records (2% of the overall sample), for 82% of the group at least 75% of months were reported accurately.

These findings suggest that reporting accuracy of month-level coverage is high - thus, this survey could become a new data source for studying overall dynamics of health insurance coverage, namely the Medicaid unwinding.

To read the full article, visit this link.

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Learn more about:

• The Medicaid Unwinding
• Current Population Survey data
• Other CHIME products

An Annual Conversation with the U.S. Census Bureau: 2022 Health Insurance Coverage Estimates from the ACS and CPS

 

On Thursday, September 28th at 1:00 PM CST, SHADAC hosted a webinar covering the release of new 2022 health insurance coverage estimates from two key, large-scale federal data sources: The American Community Survey (ACS) and the Current Population Survey (CPS).

Estimates from both surveys were presented at: the national and state levels, as well as by coverage type, and a range of other demographic categories (age, geography, poverty level, and more), during the webinar. Technical and analytic insight was provided from experts at the U.S. Census Bureau, which administers both the ACS and CPS, and SHADAC researchers joined with our special guests from the Census Bureau to answer questions from attendees after the presentation.

Attendees were able to learn about:

• New 2022 health insurance coverage estimates
• When to use which estimates from the ACS vs the CPS
• How to access the estimates via Census reports and the data.census.gov website
• How to access state-level estimates from the ACS using SHADAC tables and State Health Compare web tool

Speakers

Kathleen T. Call, Moderator Principal Investigator SHADAC Dr. Call has been an Investigator with SHADAC since its launch in 2001. She is also a Professor in the Division of Health Policy and Management at the University of Minnesota (UMN), School of Public Health (SPH). She demonstrates her commitment to community-engaged scholarship through her leadership in the Clinical and Translational Science Institute, and the Interdisciplinary Research Leaders (IRL) program, and by co-chairing the UMN, SPH Health Equity Work Group.

Katherine Keisler-Starkey, Speaker Economist in Health and Disability Statistics Branch United States Census Bureau Katherine Keisler-Starkey is an economist in the Health and Disability Statistics Branch in the U.S. Census Bureau’s Social, Economic and Housing Statistics Division. In her position, Ms. Starkey provides subject matter expertise on health topics for the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) and has authored the Census Bureau’s Health Insurance Coverage in the United States report for the last four years. Her research interests focus on Applied Microeconomics, including Health Economics, Public Finance, and Labor Economics, and she is the author of several topically focused Census working papers and blogs in these areas.

Robert Hest, Speaker Senior Research Fellow SHADAC Robert Hest joined SHADAC in 2017 and was recently made Senior Research Fellow. Mr. Hest provides expertise in survey data, data analysis and processing, and project management. Mr. Hest also manages SHADAC’s State Health Compare website, coordinating data processing, quality assurance, dissemination, and documentation of data.

Sharon Stern, Speaker Assistant Division Chief United States Census Bureau Sharon Stern is the Assistant Division Chief for employment characteristics in the U.S. Census Bureau’s Social, Economic and Housing Statistics Division. In her position, Ms. Stern oversees statistics on the labor force, health insurance and disability from several Census Bureau surveys. She has authored a wide variety of Census Bureau reports and papers on topics related to poverty, disability, and health insurance.

Related Resources

SHADAC

• Webinar slides from SHADAC
• CPS ASEC: 2022 National Health Insurance Coverage Estimates Show Falling Rates of Uninsurance and Direct-Purchase Coverage (Infographic) (Blog)
• 2022 ACS: Declining Uninsured Rates for the U.S. and States are Supported by Private and Public Coverage Increases (Blog)

​​U.S. Census Bureau

• Webinar slides from Census Bureau
• Health Insurance Coverage in the United States: 2022 (Report)
• Health Insurance Coverage of U.S. Workers Increased in 2022: Health Insurance Rates for Working-Age Adults Higher by Race, Hispanic Origin, Region (Blog)
• Uninsured Rates Decreased in Over Half of U.S. States in 2022: Changes in Types of Health Insurance Coverage Contributed to Declines in Uninsured Rates From 2021 to 2022 (Blog)

Hest, Robert
Theis, Lindsey
Stewart, Andrea

CPS ASEC: 2022 National Health Insurance Coverage Estimates Show Falling Rates of Uninsurance and Direct-Purchase Coverage (Infographic)

The U.S. Census Bureau has released an initial report detailing the state of health insurance coverage in the United States for 2022.

Drawing on data from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC), the report highlights good news overall as the percentage of the population without health insurance coverage at any point in 2022 fell to 7.9% from 8.3% in 2021—a decrease of 0.4 percentage points or approximately 1.3 million people (25.9 million in 2022 vs. 27.2 million in 2021). 

The following blog post explores changes in national-level coverage rates by demographic characteristics - such as age, employment, race and ethnicity, immigration status, poverty status, and Medicaid expansion status - for nonelderly adults (age 19-64) and for children (age 0-18). While neither group saw an overall significant change in uninsured rates, both experienced shifts across demographic subgroups.

Additionally of note, though not within the scope of this blog to explore further, elderly adults (age 65+) saw a significant increase in Medicare rates, which the Census Bureau notes is due to a larger elderly population overall, not a larger share of those adults having Medicare. The continued growth of an aging population will continue to have ramifications for a number of health-related measures, including health insurance coverage rates, and bears following in future research.

Changes in Uninsurance by Age (Nonelderly Adults age 19-64, and Children age 0-18) and Characteristics

Among nonelderly adults, the overall rate of uninsurance fell to 10.8% in 2022, a 0.8 percentage point (PP) decrease from 2021.

Comparatively, the uninsured rate among children remained statistically unchanged from 2021 (5.0%) at 5.4% in 2022.

Race and ethnicity
In 2022, rates of uninsurance fell among nonelderly Black, Hispanic, and White adults, declining to 11.4%, 23.4%, and 6.8% (versus 12.7%, 25.1%, and 7.5%), respectively. Rates of uninsurance among nonelderly Asian adults were unchanged at 7.4%.

Similarly, while uninsurance rates remained stable for children of several racial and ethnic groups in 2022 - 4.1% for Asian children, 4.7% for Black children, and 8.6% for Hispanic children - the rate of uninsurance rose significantly among White children, increasing to 4.1% in 2022 from 3.4% in 2021.

Immigration status
The rate of uninsurance among native-born nonelderly adults fell to 8.2% in 2022 from 9.1% in 2021, while the uninsurance rate among foreign-born adults remained statistically unchanged at 22.1% in 2022 compared to 22.8% in 2021.

Rates of uninsurance were unchanged among native-born children at 4.7% in 2022 and among foreign-born children at 20.6% in 2022.

Poverty level
When examining coverage by poverty level, rates of uninsurance were unchanged at 24.2% among nonelderly adults with incomes below 100% poverty, decreased to 15.2% from 16.8% for those between 100%-399% poverty, and decreased to 3.9% from 4.5% for those living at or above 400% poverty.

In 2022, rates of uninsurance were unchanged for children in the two lower poverty level categories—8.9% for those in families with incomes below 100% poverty and 6.1% for those living in families with incomes between 100%-399% poverty. However, uninsured rates rose to 2.6% among children in families with incomes at or above 400% of poverty, an increase of 0.9 PP from 2021.

Medicaid expansion status
As of January 1, 2022, 38 states and the District of Columbia have chosen to act on the option provided by the Affordable Care Act (ACA) and expand Medicaid eligibility requirements, with the additions of Missouri and Oklahoma last year. Comparing rates of uninsurance by expansion and nonexpansion states revealed divergent trends for nonelderly adults and children.

In 2022, the uninsured rate fell to 8.4% in 2022 from 9.2% in 2021 for nonelderly adults living in expansion states and fell to 16.2% in 2022 from 17.0% in 2021 for those in nonexpansion states.

However, children in expansion and nonexpansion states saw no significant change in uninsured rates for 2022 compared to 2021 at 4.1% and 8.1%, respectively.

Notable Public and Private Coverage Changes

Among nonelderly adults, rates of public coverage and private coverage were unchanged at 19.1% and 72.9%, respectively. Rates of employer-based coverage increased to 63.5% in 2022 among nonelderly adults, up 0.6 PP from 2021. Rates of Medicare coverage fell to 3.6% among nonelderly adults in 2022, down from 3.8% in 2021.

By Race and Ethnicity (Total Population)
Rates of private and public coverage were statistically unchanged among Asian (72.2% and 27.8%, respectively) and Hispanic individuals (49.4% and 37.7%, respectively).

Among Black persons, the percentage with private coverage rose to 56.6% in 2022, up from 55.1% in 2021, and the percentage with public coverage fell to 41.2% in 2022, down from 42.7% in 2021.

Among White individuals, the percentage with private coverage fell to 72.3% in 2022, down from 73.2% in 2021, and the percentage with public coverage rose to 35.4% in 2022, up from 34.6% in 2021.

Immigration Status (Total Population)
Rates of private and public coverage were unchanged among the native-born population at 67.6% and 36.7%, respectively. Among the foreign-born population, the percent with private coverage was unchanged at 54.4% while the percentage with public coverage rose to 32.8% in 2022 from 31.7% in 2021.

Medicaid Expansion Status (Total Population)
In expansion states, the share with private coverage fell to 66.6% in 2022 from 67.1% in 2021 while the share with public coverage rose to 37.6% in 2022 from 36.9% in 2021. In nonexpansion states, the share of the population with private coverage and public coverage were unchanged at 63.6% and 32.9%, respectively.

Employment Status (Nonelderly Adults)
Public coverage rose among working nonelderly adults in 2022 to 12.6% from 11.8% in 2021 while the share with private coverage was stable at 80.0%. Public coverage rose among those who worked full-time year round and those who worked less than full-time, year round, rising to 8.9% and 23.5%, respectively. Private coverage was unchanged among these groups at 84.8% and 66.0%, respectively. Private and public coverage were unchanged among those who did not work, at 47.5% and 42.6%, respectively.

More on the insurance coverage changes among working-age adults can be found in a topically focused blog released today by the Census Bureau.

Notes
All changes are tested at the 90% confidence level.
All estimates come from the 2022 and 2023 Current Population Survey Annual Social and Economic Supplements, which provide data for years 2021 and 2022, respectively.
Uninsured estimates represent individuals with no health insurance coverage for the entire calendar year.
Estimates of health insurance coverage type represent individuals with that type of coverage at any point during the calendar year. Types of health insurance coverage are not mutually exclusive.

COVID-19 Public Health Emergency Impacts

Continuous Coverage Requirement

The continuous coverage requirement that prevented states from terminating individuals’ Medicaid coverage during the pandemic ended on March 31, 2023. The resumption of Medicaid eligibility redeterminations and renewals (and potential disenrollments), a process commonly referred to as the “unwinding,” began on April 1, 2023, and each state has a year to navigate a return to normal operations while also meeting reporting requirements set by CMS for publicly sharing coverage transitions and outcomes data during this time. While the health insurance estimates released by the US Census Bureau for 2022 precede the beginning of the unwinding process, the data will provide an essential baseline for understanding how health insurance coverage is distributed across the U.S. and among the states prior to the unwinding, as well as marker to measure the impacts of this seismic coverage transition as potentially millions of individuals, both adults and children, are poised to lose Medicaid and must either find another form of coverage (e.g., state-based marketplace or employer-sponsored insurance [ESI]), or risk becoming uninsured.

Several resources have been compiled by SHADAC to track the unwinding process in a variety of avenues, falling under several broader categories:

Guidance for States

• Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement
• Best Practices for Publicly Reporting State Unwinding Data

Health Insurance Coverage Data Tracking

• State-Based Marketplace Transition Data During the Unwinding
• State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement
• Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey

Data Collection and Dissemination - Nonresponse Bias

While Census Bureau researchers have not cited any concerns with CPS ASEC data collection or release processes, an ongoing issue of persistently lower response rates and resultant nonresponse bias has been documented for the past few years, coinciding with the beginning of the COVID-19 pandemic. In March 2023 (the point in time that the CPS is administered), the response rate fell to its lowest point yet, at 68.9%, compared to a pre-pandemic rate of 82% (March 2019). This lower response rate particularly affects the CPS measures of income, and since 2020, the Census Bureau has been working to address the bias in higher reported earnings using new weighting methods to create adjusted income and poverty estimates. More detail on this methodology can be found in a companion blog released today by Census Bureau researchers.

Stewart, Andrea
Research Fellow

p 612-624-4850
e astewart@umn.edu

Review of Health Insurance Coverage Data in 2021: Releases and Resources

Each year, SHADAC covers the releases of health insurance coverage data from major federal surveys such as the American Community Survey (ACS) and Current Population Survey (CPS), both of which are overseen by the U.S. Census Bureau.¹ Not only do these data provide an understanding of trends for the millions of individuals in the United States who lack any type of coverage, but they also give indications of changes in other major forms of health insurance, like public coverage, private coverage, and employer-sponsored coverage.

SHADAC researchers work to provide insights into these data in a variety of formats (including reports, blog posts, and webinars) and analyze a multitude of important demographic groups (children, families living below poverty levels, and for communities of color). We also know that to truly understand the trends and vagaries of health insurance coverage, it’s important to look beyond national-level statistics, to see what’s happening at the state level.

That’s why we recently updated one of the longest-running measures on SHADAC’s data tool, State Health Compare, “Health Insurance Coverage Type” with the latest data for 2021. Users can take a look at estimates of health insurance coverage across all 50 states by type (uninsured, employer-sponsored, Medicaid/CHIP, etc.), by categories (age, education level, race/ethnicity, marital status, poverty level, etc.),² over time (from 2008-2021),³ and can even examine estimates using color-coded maps, trend and bar charts, or by ranking states in terms highest and lowest rates for any coverage type.

2021 Key Findings

After multiple disruptions to data collection efforts resulted in data quality issues for 2020 ACS estimates, SHADAC is excited that data for 2021 are able to be used with confidence once again—though users are cautioned not to compare data to the prior year. Nationally, the U.S. saw a near-record low rate of uninsurance in 2021, at 8.6%, second only to a rate of 8.5% in 2016.

Looking at the state level, however, shows much wider variation in uninsured rates, from a low of 2.4% in Massachusetts to a high of 17.9% in Texas. By larger demographic groups:

• Among children (age 0-18), 5.4% were uninsured in 2021; however, by state, this ranged from 1.1% in Massachusetts to 11.8% in Texas.
• Among those below the poverty level, 15.6% were uninsured in 2021; however, by state, this ranged from 4.4% in Vermont to 30.5% in Texas.
• Among individuals with less than a high school degree, 22.2% were uninsured in 2021; however, by state, this ranged from 5.9% in Massachusetts to 41.4% in Texas.
• Among people reporting “Fair” or “Poor” health status, 25.9% were uninsured in 2021; however, by state, this ranged from 17.9% in Louisiana to 44.7% in Utah.

SHADAC Publications

For a full range of available products from SHADAC’s coverage of the 2022 health insurance data release (2021 estimates) please see below.

• CPS ASEC: 2021 National Health Insurance Coverage Estimates Show Falling Uninsured and Private Coverage Rates Across Population Demographics (Blog & Infographic)
• 2021 ACS: Estimates Show Declining Uninsurance Rates Across 28 States, Driven by Rise in Public Coverage and Fall in Private Coverage (Blog & Interactive Maps)
• An Annual Conversation with the U.S. Census Bureau: Coverage Estimates from the 2021 ACS and CPS (Webinar Recording)
• 2021 ACS Data: State and County Uninsured Rates, with Comparison Year 2019 (Blog, Interactive Map, & Data Tables)
• Comparing Federal Government Surveys That Count the Uninsured: 2022 (Issue Brief)
• 2017-2021 ACS: 5-year Combined State and County Uninsured Rates (Blog, Interactive Map, & Data Tables)

For more detailed estimates on health insurance coverage in 2021, please visit State Health Compare. Be sure to also check out our helpful guide to Navigating Data on State Health Compare for more on what users can do with this unique data tool!

Medicaid Undercount Doubles, Likely Tied to Enrollee Misreporting of Coverage

December 2022:

Medicaid and Children’s Health Insurance Plan (CHIP) programs have played a key role in responding to the COVID-19 pandemic, providing an important safety net for health insurance coverage for millions of people during this unprecedented public health crisis. The Families First Coronavirus Response Act enacted the continuous coverage requirement, which provides a 6.2 percentage point increase in federal matching funds for states that maintain continuous Medicaid enrollment until the end of the public health emergency. Subsequently, administrative records show that enrollment in Medicaid and CHIP has grown substantially.

However, key federal surveys such as the American Community Survey have failed to show the extent of this growth in the population with Medicaid/CHIP coverage. This brief describes our analysis of these estimates, focused on the size of the “Medicaid undercount”, the misalignment between survey estimates of self-reported Medicaid coverage, and enrollment counts obtained from Medicaid/CHIP administrative data.

The Medicaid undercount in the 2021 American Community Survey (ACS) was larger than in earlier years, which we believe was tied, at least in part, to the Medicaid continuous coverage requirement. In the brief, we also present analysis of two years of linked data from the Current Population Survey Annual Social and Economic and Supplement (CPS ASEC). Our results suggest that despite having continuous coverage, many enrollees may not have known they were still covered by Medicaid.

Related Resources

• SHADAC Blog: Understanding the Undercount of Medicaid Enrollees in the 2020 Current Population Survey Health Insurance Coverage Data
• Research Article: Medicaid Expansion and the Medicaid Undercount in the American Community Survey
• Past SHADAC Project: Medicaid Undercount Project