Hest, Robert
Senior Research Fellow

p 612-624-5507
e hestx005@umn.edu

Current Population Survey Shows 2020 National Uninsured Rate Stable, Rising in Three States

On September 14, the U.S. Census Bureau released 2020 national health insurance estimates from the Current Population Survey along with public use microdata. These data will serve as one of very few sources of information on 2020 state-level health insurance as the U.S. Census Bureau will not release its normal set of 1-year estimates from the 2020 American Community Survey (ACS), due to impacts of the pandemic that resulted in nonresponse bias and substantially lower response rates.

Given its large sample size, SHADAC typically relies on the ACS to study state and sub-state (e.g., county-level or state-level coverage by race) health insurance trends and posts detailed state estimates on State Health Compare. However, because the ACS data are not being released as usual this year, we recommend that analysts use the CPS, and have posted 2020 estimates from this survey on State Health Compare for analysts and policymakers that need 2020 state-level information on coverage. Differences between the ACS and CPS and considerations for their use are summarized here.

This post presents highlights from the 2020 state-level coverage estimates on State Health Compare and compares 2020 estimates to 2018, a pre-COVID baseline unaffected by pandemic-related data collection challenges.

Uninsurance was stable nationally and in most states
In 2020, 8.6 percent of Americans (nearly 28 million people) were uninsured all year, statistically unchanged from a pre-pandemic baseline of 8.5 percent in 2018. Rates of uninsurance were unchanged in most states, though three states (Arizona, Missouri, and Tennessee) saw increases and five states (Florida, Maryland, Oregon, Vermont, and Virginia) experienced decreases. Tennessee had the largest increase at 4.1 percentage points (PP) (11.4 percent vs. 7.3 percent), and Virginia had the largest decrease at 3.3 PP (5.5 percent vs. 8.8 percent).

More Americans had public coverage and fewer had private coverage
The percent of Americans with public coverage at some point during 2020 increased to 32.8 percent from 32.3 percent in 2018. This equates to 2.4 million more people with public coverage at some point in 2020 as compared to 2018. At the state level, seven states had increases in rates of private coverage (Maryland, Massachusetts, Michigan, New Hampshire, Ohio, Oklahoma, and Wyoming), and only Virginia had a decrease in rates of private coverage. Of these states, Maryland had the largest increase in public coverage at 6.2 PP (31.2 percent vs. 25.0 percent) and Virginia had the largest and only decrease in public coverage at 3.4 PP (25.1 percent vs. 28.5 percent).

The percent of Americans with private coverage at some point during 2020 fell to 58.6 percent from 59.2 percent in 2018, which represents 934,000 fewer people with private coverage. In most states, however, the percent with private coverage remained stable. Just two states (Virginia and West Virginia) saw increases in private coverage, and five states (Colorado, Delaware, Massachusetts, Ohio and Tennessee) saw decreases. Of these states, Virginia had the largest increase at 6.7 PP (69.5 percent vs. 62.7 percent), and Tennessee had the largest decrease at 7.1 PP (54.7 percent vs. 61.7 percent).

2020 coverage estimates available on State Health Compare
In addition to state-level estimates by both broad coverage types (Insured, Private, Public, and Uninsured) and more detailed (Employer, Individual, Medicaid/CHIP, Medicare, and Uninsured), state-level coverage estimates are available by age group (0-18, 0-64, 19-64, and 65+) and health status (Good/Very Good/Excellent and Fair/Poor). Estimates by poverty level will likely be forthcoming. However, coverage estimates by race/ethnicity for most states do not meet our standards for statistical reliability and precision due to the relatively small sample size of the CPS.

Data users should also note that the 2020 State Health Compare coverage estimates from the CPS are not comparable to estimates from the ACS, since the two surveys use different concepts of health insurance coverage and uninsurance. The CPS asks respondents if they had a particular type of coverage at any point during the previous year or if they were uninsured for the entire year. The ACS asks respondents about their health insurance coverage at the time of the interview. More information on this topic will be available in a forthcoming related brief.

Stewart, Andrea
Research Fellow

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

2021 CPS ASEC Release: Fewer Americans Had Health Insurance Coverage in 2020 — Private Coverage Fell while Public Coverage Rose

National Story
The U.S. Census Bureau has released 1-year health insurance coverage estimates for 2020 from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC). The Census report, “Health Insurance Coverage in the United States: 2020,” showed that the national uninsured rate was 8.6 percent in 2020, which represented a significant increase from 8.0 percent in 2019.¹

No state-level estimates were published in the report, which in the past has drawn on data from the Census Bureau’s American Community Survey (ACS) for information on health insurance coverage by state. Estimates from the 2020 1-Year ACS will not be released as usual this year due to substantial COVID-19-pandemic-related disruptions to data collection operations and resulting issues with data quality. However, the CPS ASEC does provide important breakdowns of available health insurance coverage estimates at the national level, which are explored in this blog, and SHADAC plans to soon release state-level 2020 health insurance coverage estimates from the CPS ASEC.

Public/Private
In 2020, 66.5 percent of the United States population had private coverage, which represented a 1.6 percentage-point (PP) decrease from 68.0 percent in 2019. Conversely, the portion of the U.S. population with a public plan increased by 0.7PP to 34.8 percent in 2020 from 34.1 percent in 2019.

Among categories of private-based insurance coverage…

… employer-sponsored insurance (ESI) continued to be the most common form of coverage at 54.4 percent, followed by direct-purchase coverage (including marketplace coverage) at 10.5 percent, individual marketplace coverage at 3.3 percent, and TRICARE at 2.8 percent.

Among categories of public-based insurance coverage…

… Medicare and Medicaid were split nearly evenly at 18.4 percent and 17.8 percent, respectively. Individuals who had the Department of Veterans Affairs (VA) or Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) made up 0.9 percent of public coverage.

Medicaid Expansion Status
Differences in uninsured rates were also apparent when examined by state Medicaid expansion status. In 2020, the rate of uninsured for states that expanded Medicaid was 6.4 percent, and in non-expansion states the uninsured rate for 2020 measured at 12.6 percent.

Age
Looking at rates of uninsured individuals by age, children age 19 and younger measured at 5.6 percent in 2020. Adults under age 65 had an uninsured rate of 10.2 percent in 2020, while uninsured rates for adults over the age of 65 measured at just 1.0 percent in 2020.

Race/Ethnicity
Estimates of uninsurance by race/ethnicity were also included within the CPS ASEC report. For 2020, the portion of the population who identified as White had an uninsured rate of 8.3 percent, those who identified as Black had an uninsured rate of 10.4 percent, the uninsured rate for those who identified as Asian was 5.9 percent, and those who identified as Hispanic regardless of their race had a rate of 18.3 percent who were uninsured.

Income
The report also provided health insurance coverage data by poverty levels. The rate of uninsured for 2020 for those below 100 percent of poverty measured at 17.2 percent and individuals below 138 percent of poverty saw a similar rate of 16.1 percent in 2020. Conversely, individuals at or above 400 percent of poverty had an uninsured rate of 3.4 percent.

Access the full report on “Health Insurance Coverage in the United States: 2020.”

Current and Future Data Releases and Products
In addition to their health insurance coverage report, the Census Bureau also published two new companion blogs to the CPS ASEC release.

The first post discusses the way in which the CPS has changed its measure of health insurance coverage within a particular year as a result of the 2014 questionnaire redesign, as well as providing an overview of subannual coverage in the CPS from 2018 to 2020, and whether and how these measures may be compared with estimates from other surveys such as the Medical Expenditure Panel Survey (MEPS) and the Survey of Income and Program Participation (SIPP).

The second blog takes a deeper dive into the effects of the COVID pandemic on response rates for the 2021 CPS ASEC and the extent that nonresponse bias played a factor in the outcome of the 2020 estimates for income, poverty, and health insurance coverage.

Experimental data from the 2020 ACS 1-Year Estimates are expected to be published by the Census Bureau in November 2021, and 2016-2020 ACS 5-Year Estimates are planned for release in December 2021 (though Census is still evaluating whether the 5-Year ACS estimates meet their standards for data quality).

SHADAC will monitor these planned ACS releases and will assess whether and how any of these products could be used to produce state-level health insurance coverage and related estimates. We will also assess if and which other data sources may be useful for producing the coverage estimates we typically get from the ACS.

Factors associated with accurate reporting of public and private health insurance type (HSR)

August 2021:

This Journal article was originally published on August 26, 2021, in Health Services Research.

---

Introduction

This article authored by SHADAC Investigator Dr. Kathleen T. Call, and colleagues from the U.S. Census Bureau Angela R. Fertig and Joanne Pascale, explores factors associated with accurate reporting of private and public health insurance coverage. It moves beyond the usual focus on Medicaid reporting accuracy to examine reporting accuracy for private insurance; because the study occurred after the implementation of the Affordable Care Act (ACA) Marketplace enrollees are included. Additionally, we contrast factors associated with reporting accuracy for two federal surveys commonly used to measure health insurance coverage: the American Community Survey (ACS) and the redesigned Current Population Survey's Annual Social and Economic Supplement (CPS). Results from this study can inform data editing and modeling routines that account for measurement error.

Principal findings

Reporting accuracy across treatment and coverage type is high (77%–84%). As with past research, accurate reporting of public insurance is higher for people with characteristics consistent with eligibility for public insurance for both survey treatments. For the ACS treatment, reports of direct purchase insurance are more accurate for enrollees who receive a premium subsidy.

Read the full article in Health Services Research or download it here. 

Stewart, Andrea
Research Fellow

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

Census Bureau Announces Major Changes to 2020 American Community Survey (ACS) Data Release

*Update (November 30, 2021): On November 30, the U.S. Census Bureau announced the official release of the 2020 ACS 1-year "experimental" estimates, along with the Public Use Microdata Sample (PUMS) file and a working paper. 

On July 29, the U.S. Census Bureau announced during a special webinar that due to impacts of the COVID-19 pandemic on the American Community Survey (ACS), the 2020 1-Year estimates will not be released as usual in September, nor will 2020 ACS data be included in related products (e.g., the CPS Health Insurance Report). This change comes as the pandemic resulted in substantially lower response rates and non-response bias that could affect the accuracy of estimates. Instead of the usual data products, the Census Bureau plans to release a set of 2020 ACS “Experimental” 1-year estimates for a more limited set of geographies, scheduled to be available in November 2021.

Resources available from the Census Bureau include:

• Slides from the webinar
• A press release detailing the impacts of COVID on the ACS data
• Revised release schedule and explanation of the experimental estimates
• A short informational guide to understanding how your work may be impacted by the change in the 2020 ACS data

SHADAC will continue to closely monitor future announcements and data releases related to the ACS, and we will assess whether and how any 2020 ACS data products can be used to produce state-level health insurance coverage and related estimates. We will also assess if and which other data sources may be useful for producing the coverage estimates we typically get from the ACS.

Archived Updates

September 22, 2021: The Census Bureau has released national estimates of health insurance coverage from the Current Population Survey (CPS), which they recommend for use this year instead of data from the ACS. SHADAC has published two separate blogs using the CPS, with the first post detailing how the CPS will serve as the primary data source for health insurance coverage this year and how it differs from the ACS and the second blog providing an overview of national-level insurance coverage trends and public and private insurance coverage data from the CPS.

October 6, 2021: Using estimates from the CPS, SHADAC researchers have produced a special, 2020-only Health Insurance Coverage measure for all 50 states on State Health Compare. 

October 27, 2021: A new analytic report further detailing the impact of the COVID-19 pandemic on the 2020 ACS 1-year data has been published by the Census Bureau. The report details several different data category responses that confirm initial concerns of over-representation of more economically advantaged respondents.

November 10, 2021: The Census Bureau announced that, in an effort to preserve data quality in the estimates from the ACS, the 2016-2020 5-year data will now be released in March 2022 rather than as initially planned in December 2021.

November 17, 2021: The Census Bureau confirmed that the 2020 ACS 1-year "experimental" estimates will be released on November 30, 2021, along with the Public Use Microdata Sample (PUMS) file and a working paper. Census will also be hosting a webinar accompanying the release in order to explain and answer questions about the estimates.

Comparing Federal Government Surveys That Count the Uninsured: 2020

October 2020:

With the release of new insurance coverage estimates from surveys conducted by the U.S. Census Bureau, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention (CDC), SHADAC has updated our annual “Comparing Federal Government Surveys that Count the Uninsured” brief.

The brief provides an annual update to comparisons of uninsurance estimates from four federal surveys:

• The American Community Survey (ACS)
• The Current Population Survey (CPS)
• The Medical Expenditure Panel Survey - Household Component (MEPS-HC)
• The National Health Interview Survey (NHIS)

In this brief, SHADAC presents current and historical national estimates of uninsurance along with the most recent available state-level estimates from these surveys. We also discuss the main reasons for variation in the estimates across the different surveys as well as possible reasons for incomparability of estimates across and within the surveys.

Download a PDF of the Comparing Federal Government Surveys Brief.

Last year’s brief with data from 2019, and certain 2018 data, can be accessed here.