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.

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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. 

Bernard, Sydney
Research Assistant

e hoffe108@umn.edu

Minnesota Medicaid Enrollment Grew More than the U.S. Average during COVID-19

The Minnesota Medicaid program has served as an important safety net program during the COVID-19 crisis. As a countercyclical program, Medicaid enrollment/spending increases when the economy is in decline (such as during a pandemic or a recession), as employer-sponsored insurance decreases and the low-income population increases.¹

The additional enrollment of 166,364 individuals in Minnesota from February 2020 to January 2021 provided important and needed coverage during this unprecedented time.² The COVID-19 public health emergency declaration has supported this growth with the moratorium on disenrollment and extended open enrollment sessions.

Medicaid in Minnesota
Minnesota was an early Medicaid expansion state through the options provided by the Affordable Care Act. Minnesota extended eligibility for Medicaid (called Medical Assistance in the state) to childless adults at or below 75% of the Federal Poverty Guideline (FPG) in 2011 and adopted the full expansion to 138% FPG in 2014.^3,4 In 2019, Medical Assistance in Minnesota provided health insurance coverage to approximately 13.1% of the state’s population._⁵

Minnesota’s Medicaid expansion was a crucial resource during the COVID-19 pandemic for those who lost their jobs and/or their employer-sponsored health insurance coverage. It is estimated that approximately 29,500 Minnesotans lost their private health insurance coverage between April 2020-July 2020.⁶ Despite these changes, data from the 2019 Minnesota Health Access Survey and the state’s 2020 Health Insurance Enrollment Survey show that Minnesota’s uninsured population has stayed relatively stable during COVID-19, with increases in Medicaid enrollment making up for some of the losses experienced in the private insurance market.⁶

Minnesota in Context
SHADAC analyzed a recently released 50-state review of Medicaid growth during COVID-19 from Manatt Health to explore how Medicaid enrollment in Minnesota during COVID-19 compares to the rest of the United States.¹ Manatt Health utilized state-specific sources to gather data from February 2020 through January 2021. These data show that Minnesota’s Medicaid program has not only stabilized the state’s coverage landscape but has also grown at a faster pace than many other state Medicaid programs. A total of 21 states have reported data from February 2020 to January 2021, and they are included in this analysis.

Key Findings¹

From February 2020 to January 2021, enrollment in Medical Assistance grew by 19.7 percent in Minnesota, from 844,467 to 1,010,831. This increase was higher than the national median growth rate of 14.5 percent in expansion states and 15.7 percent in non-expansion states.

Only 3 of the 21 states that provided Medicaid enrollment data for this time period experienced larger growth: Florida, Indiana, and Missouri. The highest percentage growth among states was 22.6% in Missouri, and the lowest growth was 8.2% in Tennessee.

When comparing Medicaid expansion adults with non-expansion adults, Minnesota saw a growth in enrollment of 33.4% vs 28.7%, respectively. Minnesota’s enrollment growth was above the median for reporting states for expansion adults (31.0%) but below the 37.1% median for non-expansion adults (Exhibits 1 and 2).¹

Conclusion
While Minnesota’s Medicaid growth during COVID-19 has helped to offset private health insurance coverage losses and the state’s program has done well with respect to coverage relative to many other states, the eventual end of the federal public health emergency will bring with it an end to special emergency Medicaid rules such as the moratorium on disenrollment. The public health emergency’s mandate of continuous eligibility was vital in the growth of Medicaid as a safety net. As the economy continues to recover and the federal public health emergency concludes as soon as the end of the year, we should see an increase in employer-sponsored insurance and a decrease in Medicaid enrollment due to the countercyclical nature of the program. It will be important to track Medicaid enrollment as these emergency rules are phased out to evaluate the impact of returning to standard enrollment and retention practices.

Further Reading
Pandemic’s Impact on Health Insurance Coverage in Minnesota was Modest by Summer 2020. (Minnesota Department of Health, May 2021)
Tracking Medicaid Enrollment Growth during COVID-19. (State Health and Value Strategies, February 2021)

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Minnesota Health Access Survey (MNHA) Data Show Minimal Impact from COVID Pandemic on 2020 Insurance Coverage

A new report released by the Minnesota Department of Health (MDH) shows that Minnesota’s uninsured rate for the first half of 2020—as well as the first known period of the coronavirus pandemic—was relatively unchanged from the fall of 2019, at 4.6% and 4.7%, respectively. The report uses data from the biennial Minnesota Health Access Survey (MNHA), conducted collaboratively between the Minnesota Department of Health (MDH) and the State Health Access Data Assistance Center (SHADAC), to examine changes in health insurance coverage across the state from 2017 to 2019, as well as preliminary coverage estimates from 2020 to measure changes to the insurance landscapr from fall 2019 to spring and summer of 2020.

Pre-Pandemic Coverage Conditions

Prior to the COVID-19 pandemic, the state of Minnesota was enjoying historic levels of health insurance coverage among the overall population. From 2017, the last time the MNHA Survey was conducted, statewide coverage grew significantly to 95.3% in 2019, propelled by gains in employer-sponsored insurance coverage (51.9% in 2017 to 53.6% in 2019), relatively unchanging numbers of public health insurance coverage enrollment, and stabilization of the individual market.

Impacts on Health Insurance Coverage, 2019 to 2020

Using data from the 2019 Minnesota Health Access Survey and the 2020 Health Insurance Enrollment Survey, the report looks at the changes wrought by the COVID-19 pandemic on the insurance coverage landscape from October 2019 to April 2020 and October 2019 to July 2020.

From October 2019…

• …the number of uninsured individuals increased by 600 people in April 2020 and 5,800 people in July 2020.
• …enrollment in public coverage increased by 16,000 individuals in April 2020 and 60,500 individuals in July 2020.
• …enrollment in private insurance fell for both group (i.e., employer-sponsored) coverage—14,400 by April 2020 and 40,100 by July 2020—and individual coverage—15,600 by April 2020 and 13,000 by July 2020.

Health Insurance Coverage Costs, 2017 to 2019

Regardless of the pandemic, a frequently cited issue among Minnesotans with health insurance coverage was the high cost of care, which led to issues of both foregone care as well as reports of trouble paying medical bills, or trouble paying other basic bills (food, housing, etc.) due to high medical bills.

Estimates from the MNHA survey revealed that:

• 25.0% of Minnesotans overall reported having to forgo needed health care due to cost (up from 21.1% in 2017)
• 27.1% of Minnesotans with public insurance reported having to forgo needed health care due to cost (up from 23.7% in 2017)
• 21.0% of Minnesotans with group coverage reported having to forgo needed health care due to cost (up from 16.5% in 2017)

Estimates from the MNHA survey revealed that when it came to experiencing financial burden due to medical bills:

• 22.0% of Minnesotans overall reported experiencing high medical burden (up from 19.8% in 2017)
• 22.5% of Minnesotans with group coverage reported experiencing high medical burden (up from 19.9% in 2017)

Read the full brief detailing these findings, from SHADAC and the Minnesota Department of Health’s Health Economics Program.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

SHADAC Researchers Continue to Make Updates to State Uninsured Population Profile Tool at Crucial Time

More than a year after their initial release of an interactive tool that provides a way to identify and characterize communities with high uninsurance rates in the state of Minnesota, a research team at SHADAC is continuing to provide general users, health insurance navigators, policymakers, and outreach teams with updates aimed at refining the tool, providing new data, and improving usability.

All of the original features of the Minnesota Uninsured Profile Tool— the ability to compare characteristics of the total population to the uninsured population by state, region, county, economic development region (EDR), MNSure rating area, and specific ZIP code, as well as an in-depth profile of community characteristics—have remained as part of the resource since its first release; however, an update in the fall of 2020 added the ability to sort and view the uninsured population by state legislative district (both House and Senate), and this latest update pulls estimates from the U.S. Census Bureau’s American Community Survey (ACS) to populate the profile with the latest available data from 2019.

Recent studies have suggested that many Minnesotans, along with workers and dependents across the rest of the nation, have suffered pandemic-related coverage losses such as from employer-sponsored insurance, and may be unaware of possible options for new coverage.¹ Tools such as the Minnesota Uninsured Profile, then, may offer some assistance in outreach efforts for both the historically uninsured as well as those newly uninsured.

Three other accompanying resources have also been developed alongside the profile tool: The first; an infographic series featuring color-coded state legislative district maps categorized by four levels of need for coverage assistance: Needs Most Assistance; Needs Significant Assistance; Needs Some Assistance; and Needs Less Assistance; with detailed socioeconomic data about that respective district's uninsured population, such as race, ethnicity, income, and age. The second is a brand-new video tutorial, narrated by profile development team member and SHADAC PhD student Cynthia Pando, offering a step-by-step walkthrough of how to access the uninsured profile, and how to use the downloadable data spreadsheet.

Information presented in the profile tool is also supplemented by the third resource, an interactive map that shows users the geographic makeup of each ZIP code in relation to schools, hospitals, native reservations, and other important or distinctive landmarks. 

Continuing to make timely and relevant updates has always been a goal of the project, according to Principal Investigator Dr. Kathleen Call, who noted that her team is working “to meet the changing needs of navigators and other data users” by making changes to the profile that will “matter most in the decisions they are making to learn more about their communities and those who lack health insurance coverage.”

For additional information on the uninsured profile tool, or to request the development of a similar tool for another state, users can access the Uninsured Profile Resource Page on SHADAC’s website where the tool is available for download in Excel spreadsheet format, the interactive map can be accessed, and an option to provide Dr. Call with feedback on their user experience is located.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Minnesota's coverage dynamics shifted prior to pandemic

Growth in ESI could pose vulnerability for nonelderly adults leading into 2020 crisis
Trends in health insurance coverage for nonelderly adults (age 19 and older) are similar to the overall population during this time, though more exaggerated. The uninsurance rate for nonelderly adults was even higher than the overall population in 2019, and it represents a larger, statistically significant increase since 2016 (from 5.7 percent to 6.6 percent in 2019) (Figure 2).

Figure 2. Minnesota health insurance rates by coverage type, 2013-2019 (Nonelderly adult population)

That increase in uninsurance occurred alongside significant declines in Medicaid coverage, from 12.3 percent in 2016 to 11.3 percent in 2019, and individual-market coverage, from 9.4 percent in 2016 to 6.9 percent in 2019. Meanwhile, employer-sponsored insurance for nonelderly adults increased significantly, from 69.7 percent in 2016 to 72.5 percent in 2019. Though, as noted earlier, those improvements were likely undermined or eliminated by pandemic-related job losses.

Stability in public coverage may serve as a buffer for kids
The coverage dynamics of the past few years may provide more insulation against loss of health insurance for children leading into the pandemic. Unlike for nonelderly adults, the uninsurance rate for Minnesota kids did not change significantly from 2016, remaining effectively steady at 3.4 percent in 2019.

Figure 3. Minnesota health insurance rates by coverage type, 2013-2019 (Child population)

Additionally, kids did not see the same statistically significant increase in employer-sponsored insurance that nonelderly adults experienced. Their 2019 rate of ESI was 66.2 percent, which was not significantly different from 2013 (65.0 percent). While that lack of increase may have been disappointing at the time, it also means that children’s ESI rates don’t have as far to fall due to fallout from the COVID pandemic. Meanwhile, the rate of Medicaid and CHIP coverage for Minnesota kids remained statistically unchanged since 2016, at 26.0 percent in 2019. Children did, however, see a significant decline in individual market insurance, from 6.4 percent in 2016 to 4.4 percent in 2019.

Conclusions
During the first few years of the ACA, Minnesota uninsurance rates declined significantly. That coincided with significant increases in Medicaid (and CHIP) coverage as the state adopted the ACA’s Medicaid expansion. But more recently, that reduction in uninsurance has been partially reversed—posing a serious challenge going into the public health and economic crises of 2020 that are believed to have caused health insurance losses for potentially millions of people.

In the coming months of 2021, it will be important to monitor coverage patterns and work to ensure that those who have lost insurance due to the coronavirus are aware of their options to regain coverage. ACA policies that were designed to increase access to health coverage—such as Medicaid expansion and tax credits to make individual market coverage more affordable—could help to soften the blow of ESI lost due to the pandemic recession.

Some early research using the Minnesota Health Access Survey (MNHA) and Health Insurance Enrollment Survey found evidence that Minnesota’s uninsured rate has remained relatively steady through the first half of 2020, at roughly 4.6 percent.² The survey found that while ESI declined during that time, coverage through public programs like Medicaid and Minnesota Care (the state’s Basic Health Program) increased in early 2020. However, the extent to which those patterns persisted in later 2020 and into 2021 is not yet known.