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Key Resources and 2022 Updates: SHADAC's Health Insurance Unit

Updated April 2023

In the years following the passage of the Patient Protection and Affordable Care Act (ACA), SHADAC developed and introduced its Health Insurance Unit, or “HIU,” a tool to aid in defining family interrelationships in federal population surveys for the purpose of analyzing health insurance coverage.

Since the inception of this tool, SHADAC has regularly produced updated HIU variables, including in fall 2022 following the release of the 2021 American Community Survey (ACS) and 2022 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). These variables were recently made available via IPUMS-CPS (October 19, 2022) and IPUMS-USA (March 10, 2023). These HIU variables use the updated HIU methodology introduced in 2020 and incorporate the latest years of survey data and federal poverty guidelines, as relevant.

What is the SHADAC HIU?
First released in 2012, one of the goals of the SHADAC HIU is to establish a common definition of a “family unit” to help ensure consistent and comparative research across major national surveys when analyzing health insurance coverage.

Most federal surveys define a “family” differently from the way it is defined by most private and public insurance programs. For instance, the definition of "family" or "household" in U.S. Census Bureau surveys includes all related members of a household, no matter the degree of relationship, and does not necessarily align with dependent coverage or public program eligibility.

The SHADAC HIU attempts to more closely align with a definition of family used for private and public health insurance coverage eligibility. The SHADAC HIU uses a narrower definition of family that looks at specific interrelationships between individuals within a household and excludes all non-dependent relatives (grandparents, adult siblings, aunts/uncles, etc.) who may be household members but are unlikely to be considered as part of the “family unit” as defined for the purposes of determining eligibility for health insurance.

The SHADAC HIU, then, is defined as an economic unit that consists of those members of a household who would likely be eligible as a group for family health insurance coverage, or whose resources (i.e., income) would be considered in determining eligibility for public coverage.

Related Resources

• Defining Family for Studies of Health Insurance Coverage (August 2021): A brief that outlines the impacts of using the SHADAC HIU in analysis—specifically, analysis showing how the population distribution of family income changes using three different definitions of family: all members in the same household (Census definition), the definition used by the IPUMS (described below), and the SHADAC HIU (described in detail in a companion brief). Researchers can use this brief to assess whether the SHADAC HIU is suitable for their analysis and what the potential impacts of its use might be.
• Stata Code (January 2021): Technical documentation of statistical code in STATA to help researchers to employ the SHADAC HIU in their own analysis using ACS microdata downloaded from IPUMS USA.

Comparing Federal Government Surveys That Count the Uninsured: 2022

October 2022:

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 (where possible). 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 the 2020 collection year, and certain 2019 collection-year data, can be accessed here.

An Annual Conversation with the U.S. Census Bureau: Health Insurance Coverage Estimates from the 2021 ACS and CPS (Webinar)

SHADAC hosted a webinar on Thursday, September 29, 2022 that provided an overview of 2011 health insurance coverage estimates from two key, large-scale federal data sources: The American Community Survey (ACS) and the Current Population Survey (CPS).

This webinar examined the new estimates at both the national and state levels, as well as by coverage type, with technical insight from experts at the U.S. Census Bureau, which administers both the ACS and CPS, and from SHADAC researchers.

Attendees learned about:

• The new 2021 national and state coverage estimates
• When to use which estimates from which survey
• 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

SHADAC researchers and Census experts also answered questions from attendees after the presentation.

 

Download the slide deck from this webinar here.

Speakers

Kathleen T. Call, Moderator 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.	Sharon Stern, Speaker Assistant Division Chief United States Census Bureau Sharon Stern is assistant division chief for employment characteristics in the U.S. Census Bureau’s Social, Economic and Housing Statistics Division. In her position, Stern oversees statistics on the labor force, health insurance and disability from several Census Bureau surveys. She has authored Census Bureau reports and papers on topics related to poverty, disability and health insurance.
Robert Hest, Speaker Research Fellow SHADAC Robert Hest joined SHADAC in 2017 as a Research Fellow. Mr. Hest provides expertise in survey data, data analysis and processing, and project management and tracking. Mr. Hest manages SHADAC’s State Health Compare website, coordinating data processing, quality assurance, dissemination, and documentation of data.	Laryssa Mykyta, Speaker Chief of Health and Disability Statistics Branch United States Census Bureau Laryssa Mykyta is chief of the Health and Disability Statistics Branch in the Social, Economic, and Housing Statistics Division at the U.S. Census Bureau. The Health and Disability Statistics Branch is responsible for analyzing and publishing data collected on health insurance coverage, health status and health care utilization, and disability.
	Katherine Keisler-Starkey, Speaker Economist in Health and Disability Statistics Branch United States Census Bureau Katherine Keisler-Starkey is an economist in Health and Disability Statistics Branch in the U.S. Census Bureau’s Social, Economic and Housing Statistics Division. In her position, Starkey performs research and works as a subject matter expert on health topics for the Current Population Survey Annual Social and Economic Supplement. She has authored the Census Bureau’s Health Insurance Coverage in the United States report for the last three years.

 

 

Room to Grow: Inequities in Children's Health Insurance Coverage

September 2022:

Health insurance is a linchpin in the United States’ health care system. It can insulate families from deep financial strain and medical debt, as costs for health care services have grown increasingly unaffordable in recent decades. For children, the doorway to health care offered by insurance is uniquely important—ensuring their opportunity to develop into healthy adults by providing access to regular health screenings, routine services, vaccinations, and vital treatments when health issues are identified.

Children’s health insurance coverage rates in the United States have improved since the 1990s, largely due to policy initiatives designed to provide kids with affordable health insurance options, such as the long-running Children’s Health Insurance Program (CHIP) established twenty-five years ago.¹ However, while overall uninsured rates remain low, disparities among select groups of children have persisted, with wide gaps in coverage found across the states and certain demographic categories.

In this issue brief and accompanying 50-state profiles, SHADAC researchers explore rates of uninsurance among children in the U.S. using 2016-2020 estimates from the U.S. Census Bureau’s American Community Survey (ACS). Aiming to quantify coverage disparities in the states, this analysis looks at rates of uninsurance by race and ethnicity, income as measured by poverty level, citizenship status, age, and metropolitan status. These products can be used to identify health equity gaps and develop policies and initiatives to ensure children have needed access to health insurance and health care.

Uninsured Children by State, 2016-2020

Click on a state in the graphic below to view its kid's coverage profile. Click here to download all 50-state profiles.

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¹ Gates, J.A., Karpman, M., Kenney, G.M., & McMorrow, S. (2016). Uninsurance among children, 1997–2015: Long-term trends and recent patterns. Urban Institute. https://www.urban.org/sites/default/files/publication/79316/2000732-Uninsurance-among-Children-Long-Term-Trends-and-Recent-Patterns.pdf

Hest, Robert
Theis, Lindsey
Stewart, Andrea

2021 ACS: Estimates Show Declining Uninsurance Rates Across 28 States, Driven by Rise in Public Coverage and Fall in Private Coverage

In a slight departure from their normal process, the U.S. Census Bureau released all 2021 estimates from the American Community Survey (ACS) today, which included state-level information about health insurance coverage by coverage type as well by certain demographic categories. The Census Bureau also released an accompanying report and blog post highlighting many of the changes seen from 2019 to 2021.*

Overall, the data showed a decrease in the number of people who were uninsured at the time of the survey: 8.6% in 2021, down 0.5 percentage points (PP) from 9.2% of the population in 2019. This echoes the drops in uninsurance shown by the recently released Current Population Survey (CPS) estimates (8.3% in 2021 from 8.6% in 2020), as well as the NHIS (9.2% in 2021 from 9.7% in 2020, though this change was not statistically significant).

This blog post highlights some of the national and state-level changes in the broadest categories of insurance (uninsurance, public coverage, and private coverage), and takes a look at the changes in rates by two age groups, nonelderly adults (age 19-64) and children (age 0-18), across the states.

Key Findings from the 2021 ACS: Uninsurance, Public Coverage, and Private Coverage

Alongside the national decline in uninsurance, 28 states also experienced significant decreases in their rates of uninsured. Maine saw the largest decrease, falling 2.3 PP from 8.0% in 2019 to 5.7% in 2021. North Dakota was the only state to experience an increase in its uninsured rate, which rose by 1.0 PP from 6.9% in 2019 to 7.9% in 2021. Uninsured rates ranged from a low of 2.5% in Massachusetts to a high of 18.0% in Texas. Though we are unable to compare to estimates in 2020, these states continued a trend of having the lowest and highest rates of uninsurance from 2018 and 2019.

When looking at public coverage, rates increased to 36.8% in 2021 from 35.4% in 2019—a 1.4 PP increase. This trend was echoed by rising rates of public coverage across 36 states, and no states saw decreases in public coverage in 2021 as compared to 2019. Rates of public coverage ranged from a low of 22.3% in Utah to a high of 50.9% in New Mexico. Idaho saw the largest increase in public coverage from 2019 to 2021, rising 4.3 PP to 36.8% last year.

Conversely, rates of private coverage declined across the nation and among 18 states in 2021. The percentage of individuals with private coverage decreased 0.4 PP from 67.4% in 2019 to 67.0% last year. Private coverage rates ranged from a low of 53.3% in New Mexico to a high of 77.8% in Utah. Rhode Island experienced the largest drop in private coverage, falling 4.2 PP to 69.2% in 2021 from 73.3% in 2019. Florida was the only state to see an increase in private coverage, rising 0.7 PP to 63.1% in 2021 from 62.5% in 2019.

State-Level Uninsurance by Age

Uninsurance fell among nonelderly adults in 2021, declining by 0.7 PP to 12.2% from 12.9% in 2019. 26 states also saw decreases in their uninsured rates for nonelderly adults, and only North Dakota saw an increase, rising 1.9 PP to 10.1%. The largest decrease in uninsurance was seen in Idaho, whose rate of uninsured nonelderly adults dropped precipitously by 4.4 PP to 12.1% in 2021 from 16.5% in 2019.

Children also saw an overall decrease in uninsurance last year, falling 0.3 PP to just 5.4% in 2021. This was echoed by falling uninsured rates in ten states, with increases seen in just two—Idaho and Maryland. Oklahoma had the largest decrease in the rate of uninsured children, falling 1.2 PP from 8.6% in 2019 to 7.4% in 2021.

Changes in State-Level Uninsurance Rates by Age, 2019 vs. 2021

State-Level Public Coverage by Age

Examining rates of public coverage for nonelderly adults showed an overall increase of 1.4 PP from 2019 to 2021, rising from 17.7% to 19.1%. 35 states also saw public coverage increase among nonelderly adults, with no states reporting decreases. Once again, Idaho was the state to report the largest increase in public coverage for nonelderly adults, rising 7.1 PP to 19.4% in 2021.

Similarly, rates of public coverage rose by 1.4 PP for children from 2019 to 2021—an increase reflected across 23 states. Just one state, Montana, saw a decrease in public coverage among children from 2019 to 2021 (42.0% to 37.7%, a difference of 4.3 PP). Rhode Island saw the largest increase from 2019 to 2021, rising 7.1 PP to 40.3% of children covered by public insurance in the state.

Changes in State-Level Public Coverage by Age, 2019 vs. 2021

State-Level Private Coverage by Age

Overall, rates of private coverage remained unchanged for nonelderly adults in 2021, likely due to a mix of states reporting rate changes (7 increased and 11 decreased) in this type of coverage. Nonelderly adults in Maine saw the largest increase in public coverage, rising 1.9 PP to 75.9% in 2021. Rhode Island reported the largest decrease, dropping 3.3 PP to 74.4% in 2021.

Children also saw fewer changes in private coverage rates, both at the national level (rate of 60.5% coverage was statistically unchanged from 2019 to 2021) and across the states, with 5 reporting increases and 3 reporting significant decreases. Pennsylvania and Tennessee both reported the largest increase in private coverage for children, rising 1.9 PP to 65.4% and 60.6%, respectively. Rhode Island’s rate of private coverage among children saw a large drop from 2019 to 2021, falling 8.4 PP to 64.6%.

Changes in State-Level Private Coverage by Age, 2019 vs. 2021

Future Data Releases and Products

Supplemental tables for the 2021 ACS 1-Year Estimates will be released from the U.S. Census Bureau on October 20, 2021, and 2017-2021 ACS 5-Year Estimates will be available on December 8, 2021.

Stay tuned for more granular details about insurance coverage changes in the states from 2019 to 2021 via customized SHADAC tables examining coverage at the state and county level.

As this blog noted, changing rates of public and private coverage in 2021 drove overall declines in uninsured rates. Further analysis shows that these changes were, in turn, driven by shifts in Medicaid, employer-sponsored insurance (ESI), and direct-purchase coverage. A SHADAC blog post taking a deep dive into these trends will be published next week. In the meantime, to learn more about our latest research on ESI trends, check out our recent narrative report and 50-state comparison tables.

Related Materials
Recent Blog: CPS ASEC: 2021 National Health Insurance Coverage Estimates Show Falling Uninsured and Private Coverage Rates Across Population Demographics (Infographic)

Upcoming Webinar: SHADAC Hosting An Annual Conversation with the U.S. Census Bureau to talk Health Insurance Coverage Estimates from the 2021 ACS and CPS

On Thursday, September 29th at 1:00 PM Central Time (2:00 PM Eastern), SHADAC will host a webinar to examine the new 2021 coverage estimates from the ACS as well as from the Current Population Survey (CPS), with technical insight provided by researchers from SHADAC and special guests Sharon Stern and Laryssa Mykyta from the U.S. Census Bureau, which administers both surveys.

Speakers will discuss the new national and state-level estimates, and attendees will learn when to use which estimates from which survey, how to access the estimates via the data.census.gov site and the new ACS table formats, and there will be an opportunity to ask questions after the speaker presentations.

Register for the webinar here!

*Comparisons with 2020 ACS Data
As has been extensively documented by both SHADAC and the Census Bureau, disruptions to data collection and dissemination efforts—as well as the presence of significant nonresponse bias—due to the COVID-19 pandemic heavily impacted estimates for 2020. As such, the Census Bureau released 2020 ACS 1-year data in an “experimental-only” format and cautioned against their use. Similarly, the Census Bureau recommends that data users do not compare 2020 ACS 1-year experimental estimates with any other data.

Notes
All changes described in this document are significant at the 90% level. Private coverage includes individually purchased and employer-sponsored coverage.

Overarching estimates of uninsurance and public and private coverage are for all ages, except where noted for children (age 0-18) and nonelderly adults (19-64).