SHADAC Staff

p 612.624.4802
e shadac@umn.edu

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

The U.S. Census Bureau has released an initial report detailing the state of health insurance coverage in the United States for 2021. 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 2021 fell to 8.3% from 8.6% in 2020—a decrease of 0.4 percentage points (PP) or approximately 1.1 million people (27.2 million in 2021 vs. 28.3 million in 2020).

While this year marks a return to a more standard release of health insurance coverage estimates after COVID-related factors impacted the release of 2020 from the CPS and, to a larger degree, the American Community Survey (ACS), the report did not include any state-level estimates from the ACS, as have been provided in past years. Instead, the Census Bureau plans to release all data relating to the ACS on Thursday, September 15, 2022.

The CPS ASEC does provide important breakdowns of available health insurance coverage estimates at the national level, including by age, race and ethnicity, immigration status, marital status, geographic region, employment, poverty status, and Medicaid expansion status.

The following blog and infographic explore changes in coverage rates by demographic for nonelderly adults (age 19-64) and for children (age 0-18), who experienced a greater number of changes in insurance coverage both overall and across categories than their adult counterparts.

Changes in Uninsurance by Age and Characteristics

Among nonelderly adults (age 19-64), the overall rate of uninsurance remained statistically unchanged from the previous year, reported at 11.6% in 2021 compared to 11.9% in 2020.

Comparatively, children (age 0-18) had an uninsured rate of 5.0% in 2021, a decrease from 5.6% the previous year.

Race and ethnicity
While uninsurance rates also remained unchanged across a number of racial and ethnic groups in 2021—7.5% for White adults, 7.7% for Asian adults, and 25.1% for Hispanic adults—the rate of uninsurance fell significantly among Black nonelderly adults, decreasing to 12.7% in 2021 from 14.2% in 2020.

Similarly, while uninsurance rates remained stable for children of several racial and ethnic groups in 2021—3.4% for White children and 8.6% for Hispanic children—the rate of uninsurance dropped significantly among Black children, falling to 4.3% in 2021 from 5.9% in 2020. Asian children, however, saw an increase in rates of uninsurance, rising to 4.6% in 2021 from 2.8% in 2020.

Immigration status
The rate of uninsurance among native-born nonelderly adults fell to 9.1% in 2021 from 9.6% in 2020, while the uninsurance rate among foreign-born adults remained statistically unchanged at 22.8% in 2021 compared to 22.9% in 2020.

Rates of uninsurance also fell among native-born children, decreasing to 4.5% in 2021 from 5.2% in 2020, while again, the uninsurance rate for foreign-born children was statistically unchanged at 18.6% in 2021.

Poverty level
When examining coverage by poverty level, rates of uninsurance among nonelderly adults were broadly unchanged for each measurable category: 24.0% among those with incomes below 100% poverty, 16.7% for those between 100%-399% poverty, and 4.5% for those living at or above 400% poverty.

In 2021, rates of uninsurance were unchanged for children in the two lower poverty level categories—8.3% for those in families with incomes below 100% poverty and 6.4% for those living in families with incomes between 100%-399% poverty. However, uninsured rates fell to 1.7% among children in families with incomes at or above 400% of poverty, a decrease of 0.4 PP from 2020.

Medicaid expansion status
As of January 1, 2021, 36 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. Comparing rates of uninsurance by expansion and nonexpansion states revealed parallel trends for both nonelderly adults and children.

In 2021, the overall uninsured rate remained statistically unchanged from 2020 (9.0% in both years) for adults living in expansion states. However, uninsurance dropped from 17.7% in 2020 to 16.7% in 2021 for adults living in nonexpansion states.

Similarly, children in expansion states saw no change in uninsured rates for 2021 compared to 2020 (4.0% in both years). And again, uninsurance fell in nonexpansion states, falling to 7.1% in 2021 from 8.6% in 2020.

Other Notable Coverage Changes

Public and private coverage
Other notable overarching trends included a higher percentage of the population with public coverage, increasing 1.2 PP to 35.7% in 2021 from 34.5% in 2020, and a consequent decrease in the percentage of the population with private coverage, measuring at 66.0% in 2021, a decrease of 0.6 PP from 2020 (66.5%). The largest drivers of public and private coverage changes were a 0.9 PP increase in Medicaid coverage (18.9% in 2021, up from 17.9% in 2020) and a 0.2 PP drop in employment-based coverage (54.3% in 2021, down from 54.6% in 2020).

Poverty level
Of particular note in the report was a consistent correlation between poverty level for both adults and children and changes in rates of public and private insurance coverage between 2020 and 2021.

Rates of public coverage rose among adults in all poverty categories, increasing 2.4 PP to 51.8% among those with incomes below 100% of poverty, 0.8 PP to 25.4% for those between 100%-399% of poverty, and 0.5 PP to 5.7% among those living at or above 400% of poverty.

Rates of public coverage also increased by 2.0 PP to 44.2% among children in families with incomes between 100%-399% and by 1.2 PP to 7.2% for children in families at or above 400% of poverty. Rates of public coverage were unchanged among children below 100% of poverty (79.7%).

Looking at private coverage changes, uninsurance rates remained unchanged among adults in all poverty categories at 27.1%, 61.8%, and 91.8% for those with incomes below 100% of poverty, between 100%-399% of poverty, and at or above 400% of poverty, respectively.

Similarly, rates of private coverage were largely unchanged among children in families with incomes below 100% of poverty and those in families at or above 400% of poverty at 15.5% and 93.2%, respectively. Rates of private coverage did decrease in one category: children in families with incomes between 100%-399% of poverty, dropping by 1.5 PP to 53.4% in 2021.

Employment
Overall, rates of uninsurance fell amongst workers, decreasing to 10.7% in 2021 from 11.2% in 2020, driven by a decrease in adults who worked less than full-time year-round (15.1% in 2021 vs. 16.4% in 2020). Among those who worked full-time year-round, uninsurance did increase to 9.1% in 2021 from 8.4% in 2020, and among those who did not work in 2021, the rate of uninsurance remained unchanged at 14.8%.

Access the U.S. Census Bureau's "Health Insurance Coverage in the United States: 2021 - Current Population Reports".

As previously mentioned, the Census Bureau will be releasing the full roster of 2021 estimates from the American Community Survey (ACS) on Thursday, September 15. SHADAC will be monitoring this release and providing updates, along with several blog posts analyzing the estimates, as soon as they are available.

In a follow-up to several blogs and reports released in 2021 that detailed the effects of COVID-19 on the 2020 CPS and ACS health insurance coverage data estimates, a new blog from the Census Bureau looks at the continuing impact of the pandemic on survey data collection and release processes and nonresponse bias.

Though data collection operations were mostly able to resume as normal, lower-than-usual response rates persisted into 2022, measuring at 72% compared to 76% in 2021. Prior to the pandemic (2018 and earlier), the CPS enjoyed some of the highest response rates across a number of federal surveys, consistently recording percentages in the high 80s and low 90s.

Additionally, the blog notes the continued presence of measurable nonresponse bias, particularly in categories of income statistics and poverty rates. While the CPS standard weighting methodology (described fully in the ASEC technical documentation) was able to account for differences in survey estimates and administrative data prior to 2019, figures in the blog show that both standard and even alternative weights employed by the Census Bureau have not been able to fully adjust for differences between respondents and nonrespondents since 2020, highlighting the fact that certain pandemic-era challenges still persist.

Notes
All changes are statistically significant at the 90 percent confidence level.

All estimates come from the 2021 and 2022 Current Population Survey Annual Social and Economic Supplement, which provide data for years 2020 and 2021, respectively.

Both the 2020 and 2021 estimates use 2020 Census-based population controls, meaning that estimates for 2020 listed in the current report may not always match those listed in the report published in September 2021, which used 2010 Census-based population controls.

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.

State-Level Trends in Employer-Sponsored Health Insurance, 2019-2021

August 2022:

The COVID-19 pandemic has altered long-standing patterns of life and work in the United States and internationally. The pandemic, along with the associated policy response, led to (at least temporary) changes in Americans’ primary source of health insurance coverage, with more Americans enrolled in public coverage and fewer in private. Despite these shifts, employ­er-sponsored health insurance (ESI) remains the largest single source of coverage for most Americans, with 62.2 million private-sector workers enrolled in ESI in 2021. This report considers how trends in ESI coverage and cost have evolved over the past three years, since the pre-pan­demic baseline (2019), since the first year of the pandemic (2020), and in 2021, as the country emerges from pandemic-related restrictions and economic dislocation. These analyses use estimates from the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC), recently produced by the Agency for Healthcare Research and Quality (AHRQ).

This narrative also provides an overview of the 2021 MEPS-IC private-sector ESI estimates, cov­ering changes in market composition, ESI access, and cost. Because changes in the labor market caused by COVID-19 likely had a large influence on measures of ESI access in 2020, the analysis of ESI access will compare 2021 estimates against a pre-pandemic baseline of 2019. However, the pandemic likely had a smaller impact on long-running cost trends, so the analysis of ESI costs will compare 2021 estimates against 2020.

Accompanying this narrative are detailed 50-state comparison tables that allow for easy cross-state analysis of ESI trends from 2017 to 2021, significant changes in ESI rates from 2019 to 2021 and 2020 to 2021, and state vs national average comparisons for 2021 estimates.

   

For more detailed information on ESI findings from SHADAC, see the following products:

• Printable version of this ESI Report Narrative
• Companion Blog and Infographic highlighting key findings in ESI coverage at the national level
• 50-State Comparison Tables including 2017-2021 ESI estimates  
• 2020 ESI Blog covering pandemic-era trends

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Employer-Sponsored Insurance (2019-2021): A National-Level Look at Cost and Coverage Rates (Infographic)

Throughout the United States, a majority of Americans and their families receive health insurance coverage through their employer. In 2021, the number of individuals enrolled in this type of coverage–known as employer-sponsored insurance or ESI–exceeded 62.2 million. In this blog, infographic, and companion documents, SHADAC researchers use data from the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC) to analyze the private-sector ESI landscape in 2021 on a national level and within the states. As discussed in SHADAC’s 2020 ESI coverage blog, the COVID-19 pandemic complicated the collection and analysis of data throughout recent years, leading our researchers to compare 2021 ESI access data against pre-pandemic (2019) estimates and 2021 ESI cost data against 2020 estimates.

Key Findings

Employee Access to Coverage (2019 vs. 2021)

Establishment
Not all private sector establishments offer their employees health insurance coverage. In fact, slightly less than half of establishments in the U.S. offered coverage in 2021 (49.2%). This was a significant increase from 47.4% in 2019.

Offer
The offer of employer-sponsored insurance coverage was extended to the majority of private-sector employees. In 2021, 85.7% of employees in the U.S. worked in establishments that offered health insurance coverage, a rate that remained statistically unchanged from 2019 (85.3%).

Eligibility
Among employees working at establishments that offered coverage, the percent eligible for coverage was 80.3% in 2021; an increase from 77.7% in 2019.

Take-Up
The take-up rate of ESI-eligible employees has varied over the years, and in 2021, 69.8% of eligible employees enrolled in coverage. This represented a 2.1 percentage-point decrease from 2019 (71.9%).

Employee Coverage Costs (2020 vs. 2021)

Premiums and contributions

• The average annual premium for single coverage rose to $7,380 in 2021, a $231 or 3.2% increase from 2020.
   
• For those enrolled in family coverage, average annual premiums also rose. In this case, premiums climbed to $21,381 in 2021, a $623 or 3.0% increase from 2020.

Deductibles

• For single coverage, the 2021 average individual deductible was $2,004. This represented a significant increase of 3.0% from 2020 ($1,945).
   
• Among those enrolled in family coverage, the average deductible per employee enrolled was $3,868 in 2021. This was also a significant increase of 3.9% from 2020 ($3,722).

High-Deductible Health Plans

• In 2021, the share of employees enrolled in high-deductible health plans (HDHPs) increased substantially in 2021 to 55.7% – an increase of 5.3 percentage points from 2020.

Key Takeaways

With so many Americans relying on their employers for health insurance coverage, ESI findings remain an important indicator of the financial and health burdens many individuals and families face. In 2021, the U.S. experienced several continuing ESI trends, including rising costs across employee premiums, premium contributions, and deductibles. Additionally, the share of private sector employees enrolled in high-deductible plans increased substantially. In regards to coverage, more employers offered ESI to their employees in 2021 when compared to pre-pandemic levels. Meanwhile, the rate of ESI-eligible employees enrolling in offered coverage was down overall from pre-pandemic, though unchanged from 2020.

For more detailed information on ESI findings from SHADAC, see the following products:

Report Narrative
The report narrative provides an in-depth look at 2019-2021 ESI estimates including state-level changes and trends.

50-State Comparison Tables
The 50-state tables include 2017-2021 ESI estimates and allow for easy cross-state and state vs. national analysis.

Other related resources
   • 2021 ESI Blog (2019-2020 data) 
   • 2020 ESI Report, Blog, and Infographic (2015-2019 data) 
   • 2019 ESI Report, Blog, and Infographic (2014-2018 data)

Stewart, Andrea
Research Fellow

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

2022 NHIS Early Release: Estimates from Quarter 1 (January-March) show potential post-pandemic rebounds in health insurance coverage

The National Center for Health Statistics (NCHS) has released quarterly estimates of health insurance coverage beginning in January 2021 through March 2022 from the National Health Interview Survey (NHIS) as part of the NHIS Early Release Program.

After disruptions to data collection operations due to COVID-19 in 2020 and 2021, NHIS quarterly estimates for 2022 were able to collect and produced as usual.¹ Estimates for each included category of insurance coverage (uninsured, public, and private) have been disaggregated by age group and family incomes as a percentage of the federal poverty level (FPL), reported race and ethnicity categories, and by geographic region.²

Uninsured rate saw significant decreases while public and private coverage remain stable

As the United States emerges from the height of the COVID-19 pandemic, estimates from the NHIS indicate positive trends for health insurance rates across coverage types thus far in 2022.

The uninsured rate dropped significantly across all age groups, decreasing by an incredible 1.5 percentage points (PP) from 9.5% during Q1 2021 to a historic low of just 8.0% during Q1 2022.

While public and private insurance coverage rates showed no statistically significant changes between the Quarter 1 time periods (measuring at 40.0% in 2021 and 39.1% in 2022 and 59.7% in 2021 and 61.8% in 2022, respectively), the potential shifts in coverage that are hinted at by the NHIS data offer hope toward a continuing post-pandemic recovery. A possible rise in private insurance coverage would indicate the potential for a resurgence in employer-sponsored insurance (ESI) due to a prospective rise in employment (unemployment rates fell sharply to 5.3% in 2021 from 8.1% in 2020).³ Consequently, this potential rise in private insurance coverage appears to be possibly offset by a reduction in public insurance coverage, indicating a consequent reduction in the portion of the national population needing to rely on safety net public insurance programs such as Medicaid. Again, our analysis of the NHIS insurance estimates did not find the year-to-year changes in public and private coverage to be statistically significant; therefore, these data will require further monitoring to see if these possible trends bear out.

Falling uninsured rates across demographic groups

Examining the NHIS  coverage estimates for Q1 (January-March) 2022 revealed further good news in that a number of demographic subgroups saw a significant reduction in uninsured rates: by age, by race and ethnicity, and by geographic region.

Findings by age group

Our analysis showed not only a significant drop in uninsurance across all age groups from 2021 to 2022 (9.5% to 8.0%, respectively), but this decrease was underscored by rates for individuals under 65 (11.3% to 9.6%) and for nonelderly adults age 18-64 (13.8% to 11.8%). Rates for children (age 0-17) remained stable between the two years’ first quarters.

Findings by race and ethnicity

Uninsured rates also decreased significantly for Hispanic nonelderly adults (age 18-64)—dropping from 31.1% in Q1 2021 to 25.7% in Q1 2022—and for Non-Hispanic, White nonelderly adults (age 18-64) —dropping from 8.7% in Q1 2021 to 6.9% in Q1 2022.

Findings by geographic region

While uninsured rates in most regions remained stable between January-March of 2021 and 2022, NHIS data showed a significant drop in uninsurance for nonelderly adults (age 18-64) in the South, a region that traditionally has seen higher rates of uninsurance, falling to 15.7% in 2022 from 20.1% in 2021.⁴

Overall, data from Q1 of 2022 indicated positive trends in health insurance coverage, with uninsured rates falling significantly for a number of population subgroups and a potential (though not significant) recovery for private insurance and a lessening of public insurance coverage.

About the Numbers
The above estimates provide a point-in-time measure of health insurance coverage, indicating the percent of individuals with (or without) a specific type of coverage at the time of the interview. The estimates discussed in this blog are only from Q1 (January-March) 2022 and the same period in 2021.

Differences in estimates are statistically significant at the 95% confidence level unless otherwise specified.

Hest, Emily
Communications Associate

e hestx008@umn.edu

Pandemic-Era Trends in Employer-Sponsored Health Insurance (ESI), 2019-2020

The COVID-19 pandemic continues to disrupt many patterns of life and work in the United States and internationally, while exacerbating many long-standing concerns regarding health care affordability, access, and utilization as well as rates of health insurance coverage for Americans. In this regard, one area of potential pandemic-related impact to consider is coverage rates for employer-sponsored health insurance (ESI), which remains the largest source of coverage for Americans, with 60.1 million private-sector employees enrolled in ESI in 2020.¹

In anticipation of the release of the 2021 Medical Expenditure Panel Survey Insurance Component (MEPS-IC) data, SHADAC researchers analyzed private-sector ESI estimates from the 2020 MEPS-IC to better contextualize the forthcoming 2021 estimates. Understanding 2020 coverage data will supply a pandemic-era baseline, while providing a critical vantage point from which to observe and interpret trends in ESI composition, affordability, and access in this critical market.

This narrative provides an overview of the 2020 MEPS-IC private-sector ESI estimates, covering firm size, ESI cost, and access. It’s important to note that the overlay of COVID-19 on this data makes it difficult to interpret the cause of certain changes when compared to pre-pandemic estimates. One area where this is evident is within the composition of private-sector employees by employer firm size.

Small firms declined significantly in 2020
Many employers offer ESI to their employees, regardless of the number of individuals they employ. However, while ESI remains the most common source of coverage for Americans, the composition of private sector employees enrolled in ESI shifted significantly from 2019 to 2020. Specifically, the number of employees in small firms (defined here as <50 employees) experienced a 19 percent decline over this timeframe, leaving a greater proportion of medium and large firms (defined here as >50 employees) to drive trends in ESI access to coverage and cost.

With larger firms comprising an increasingly significant portion of the private sector, trends among this subset of firms are driving overall changes between 2020 and 2019. For this reason, it is difficult to analyze changes in ESI estimates from 2020 to 2019, as these changes could be attributed to actual trends in access, cost, and affordability, or they could be directly tied to this shift in composition of employers and employees.

Number of private-sector employees in the United States, by firm size: 2019—2020

Source: SHADAC analysis of the Medical Expenditure Panel Survey—Insurance Component, 2019, 2020.

ESI costs and premiums remain mostly stable
Monitoring costs associated with ESI is essential for understanding health care-related financial burdens for employees. Nationally, 2020 premiums and cost sharing remained relatively stable for employees enrolled in ESI. While premiums for single coverage increased slightly by 2.5 percent ($177), family premiums, employee contributions, and deductibles (for both single and family coverage) remained steady when compared to 2019.

When examined on a state-level, 2020 ESI costs are more varied. Nationally, the average premium for single coverage was $7,149. Certain states exceeded that average in 2020, with Alaska and New York monthly premiums surpassing $8,000 ($8,635 and $8,177 respectively). Meanwhile, Alabama had the lowest premium for single coverage at $6,393. There was also a great deal of variation across states in the size of deductibles. Nationally, the average deducible for single coverage was just under $2,000 in 2020. However, deductibles ranged from an average of $2,500 in Montana to less than $1,500 in Hawaii.

High-deductible health plans (HDHP) represent one common form of ESI. Nationwide, the percent of employees enrolled in a HDHP increased in 2020, rising from 50.5 to 52.9 percent. Moreover, the majority of private-sector employees were enrolled in a HDHP across 36 states in 2020. North Carolina had the highest percentage of HDHP-enrolled employees at 69.5 percent, and Hawaii was at the other end of the spectrum with only 17.6 percent of employees enrolled in HDHPs.

Access to coverage varies by state
Employee access to ESI has three components:

Employee Offer: An employee must work in an establishment that offers coverage.
Employee Eligibility: An employee must meet the criteria established by the employer to be eligible for coverage that is offered.
Employee Take-Up: The employee must decide to enroll in (“take up”) the offer of ESI coverage.

The decision to offer ESI to employees is determined by the employer, with 51.1 percent of private sector firms choosing to offer coverage in 2020 (compared to 47.4 percent in 2019). However, although over half of employers provided optional ESI, not all of their employees were eligible to enroll in that coverage. Meaning, while 86.9 percent of employees worked for an employer offering ESI coverage in 2020, only 80.5 percent were eligible for that coverage; eligibility could be based on a minimum number of hours worked per pay period or a minimum length of service with an employer, for example. Among employees eligible for ESI, overall enrollment declined in 2020, dropping from 71.9 percent to 70.8 percent—a difference of 1.745 million employees.

ESI access also varied across states in 2020. In Hawaii, Tennessee, Massachusetts, Illinois, Pennsylvania, New Jersey, and the District of Columbia (D.C.), more than 90 percent of employees worked at a firm that offered ESI. Meanwhile, less than 75 percent of Montana and Wyoming employees worked for an employer that offered ESI (73.8 percent and 70.6 percent, respectively).

It’s important to note that trends in access are particularly difficult to interpret due to the sharp decline in employees who work in firms with <50 employees, as small firms are much less likely to offer coverage. 

To revisit 2019 ESI findings from SHADAC, see the following products:

• Printable version of 2019 ESI Report Narrative
• Companion Blog and Infographic highlighting key findings at the national level regarding ESI coverage affordability and access
• Two-Page Profiles on ESI trends for each state
• 50-State Interactive Map showing levels of, and changes in, average annual premiums for single and family coverage in 2019, with links to state profile pages
• 50-State Comparison Tables including 2015-2019 ESI data

Notes and Sources
Hawaii has a broad employer mandate that preceded the ACA. The Hawaii Prepaid Health Care Act, enacted in 1974, requires private employers to provide health insurance for employees who work at least 20 hours (some exceptions apply).

High-deductible health plans (HDHP) are defined as plans that meet the minimum deductible amount required for Health Savings Account (HSA) eligibility (e.g., $1,400 for an individual and $2,800 for a family in 2020).

The labor market changed significantly between 2019 and 2020 with a dramatic reduction in small firm employment. It is difficult to determine whether 2020 changes in ESI were driven by this change in the labor force or reflect actual changes in ESI access and cost. 

Data are from the 2019–2020 Medical Expenditure Panel Survey–Insurance Component (MEPS-IC), produced by the Agency for Healthcare Research and Quality (AHRQ), and are available on SHADAC’s State Health Compare web tool at statehealthcompare.shadac.org.

¹ State Health Access Data Assistance Center. (n.d.). Health Insurance Coverage Type (2020)*  http://statehealthcompare.shadac.org/bar/279/health-insurance-coverage-type-2020-by-total#0/1/5,4,1,10,86,9,8,6/32/325