Lukanen, Elizabeth
Stewart, Andrea

2023 NHIS Early Release: Estimates from Quarter 3 (July to September) Hold Steady

The National Center for Health Statistics (NCHS) has released quarterly estimates of health insurance coverage beginning in July 2022 through September 2023 from the National Health Interview Survey (NHIS) as part of the NHIS Early Release Program. Each quarter covers a three-month span, and this blog specifically looks at survey data from the most recent quarter (Q3 - July to September 2023) and notes any differences compared to the same time period in 2022.

Between Q3 of 2022 and Q3 of 2023, rates of uninsurance, public coverage, and private coverage for adults (age 18-64) remained mostly unchanged. There was a small increase in the rate of public coverage for all ages and a small decrease in the rate of uninsurance overall, but these changes were not statistically significant.

Figure 1: Health Insurance Coverage Rates by Type (Adults Age 18-64), Q3 2022 vs. Q3 2023

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Household Pulse Survey (HPS) Insurance Coverage Trend Analysis: How Does It Compare?

Introduction

The U.S. Census Bureau’s Household Pulse Survey (HPS) is an online survey that provides up-to-date monthly data on emergent issues and the social and economic wellbeing of U.S. adults. As one of the only sources of publicly available rapid response data, the HPS is a critical tool for monitoring how policies such as the “unwinding” of the Medicaid continuous coverage requirement are affecting the landscape of health insurance coverage in near real time, hopefully providing actionable information for those making and implementing policy.

However, data validation of the Household Pulse Survey is crucial, especially given its short track record and novel methods. Even while offering near-real-time data, the HPS also faces several other challenges, including a notably low response rate (6.8% as of September 2023); underrepresentation of harder-to-reach demographic groups, such as adults with lower levels of education and young adults; a lack of editing and imputation for most variables; and likely some degree of nonresponse bias.

As researchers at the State Health Access Data Assistance Center (SHADAC) utilize the subannual HPS data to monitor changes in insurance coverage, we wanted to compare the HPS’ ability to detect insurance coverage changes over time against other more established surveys that also provide subannual estimates.

To this end, we compared subannual estimates of Medicaid/CHIP coverage, private coverage, and uninsurance among U.S. civilian noninstitutionalized nonelderly adults (age 18–64) in the HPS to similar estimates in the National Health Interview Survey (NHIS) [quarterly estimates from 2021–2022] and the Behavioral Risk Factor Surveillance System (BRFSS) [monthly estimates from 2022]. Below you'll find our insurance trend analysis findings using survey data.

Key Findings

Our analysis reveals that HPS estimates of coverage among adults follow similar trends as found with BRFSS and NHIS estimates. However, the exact estimates tend to deviate from each other.

Medicaid/CHIP

HPS estimates of Medicaid coverage almost exactly follow the trend of NHIS estimates of Medicaid coverage. The HPS estimates were consistently greater than the NHIS estimates with the HPS estimating that around 18% of adults were covered by Medicaid in 2021 and around 19% in 2022. The NHIS estimates were approximately 4 percentage points lower at around 14% in 2021 and 15% in 2022.

Private

Similar to estimates of Medicaid coverage among adults, the HPS estimates of private insurance coverage among adults were consistently higher than NHIS estimates, but both followed the same overall trend. HPS estimates for private insurance coverage hovered around 75% in 2021 and 2022. The gap between HPS estimates and NHIS estimates widened slightly between 2021 and 2022, increasing from an approximately 6 percentage point difference to an approximately 8 percentage point difference – NHIS estimates were around 69% in 2021 and 67% in 2022.

Uninsured

Similarly to both Medicaid and private coverage estimates, HPS estimates of uninsurance among adults closely mirrored the trends observed in both NHIS and BRFSS data. In a change from Medicaid and private coverage estimates, though, HPS estimates of uninsurance consistently fall between the estimates from BRFSS and NHIS, with HPS figures consistently greater than those from BRFSS but lower than NHIS’. This pattern persists through the first quarter of 2022.

Following this point, HPS estimates of uninsurance among adults decrease while BRFSS estimates increase and NHIS estimates stay more or less consistent.

Data and Methods

This analysis utilizes publicly available data from three household surveys: the Household Pulse Survey (HPS), the National Health Interview Survey (NHIS), and the Behavioral Risk Factor Surveillance System (BRFSS). All three surveys provide national representation of the civilian, noninstitutionalized population, with data collected on either a quarterly basis (NHIS) or a monthly basis (HPS and BRFSS). In order to have comparable time periods, HPS data was pooled both at the quarterly level and at the monthly level prior to analysis.

In the Household Pulse Survey, coverage was defined as having any sort of coverage (e.g. Medicaid or private) at the time of the survey. Uninsured was allocated to those that did not answer yes to being currently covered by some sort of health insurance or health coverage plan.

In the National Health Interview Survey (NHIS), Medicaid coverage among adults was defined as currently having either Medicaid coverage or CHIP coverage. Private coverage was defined as currently having any private coverage. Uninsurance was designated to those who answered they did not currently have health insurance.

The Behavioral Risk Factor Surveillance System (BRFSS) has a unique method of ascertaining health insurance coverage. As opposed to asking which health insurance coverage an individual has, BRFSS only has asks for a primary source of insurance, and individuals are only allowed to select one type of coverage. So, while BRFSS does include data on Medicaid coverage and private coverage, these estimates were not provided in this analysis as this type of instrument is not sufficiently comparable with the questions used by the HPS and NHIS to include estimates of coverage. Uninsurance among adults in BRFSS was defined as not having coverage of any type at the time of survey or being covered by Indian Health Service. 

Theis, Lindsey
Senior Communications Specialist

p 612-625-5062
e lani0058@umn.edu

Now Available on State Health Compare: One Brand New Measure and Five Updated Measures

Estimates for five measures of health care access, affordability, and use have now been updated on SHADAC’s State Health Compare. One new measure, Had Telehealth Visit, has also been added to State Health Compare. The new and updated measures are all produced using data from the National Health Interview Survey (NHIS), conducted by the National Center for Health Statistics (NCHS). SHADAC produces these state-level measures using restricted-access data through the Minnesota Research Data Center (MnRDC). SHADAC’s State Health Compare is the only source of state-specific data for these measures which are essential for monitoring individuals’ access to and use of medical care, along with their ability to afford care.

These measures now contain data through 2021, using two-year pooled periods (i.e., 2019-2020, 2020-2021). The measures can be broken down by Total, Age, and Coverage Type (Public, Private, Uninsured).

Updated and new measures include:

NEW: Had Telehealth Visit
This measure describes the percent of individuals who had a medical appointment by video or phone during the past twelve months.

Had Usual Source of Medical Care
This measure captures rates of individuals who had a usual place of medical care other than an emergency department during the past twelve months.

Had General Doctor or Provider Visit
This measure provides rates of individuals who had any visit to a general doctor or provider within the last year.

Had Emergency Department Visit
This measure looks at rates of individuals who had any type of visit to an emergency department in the past twelve months.

​Trouble Paying Medical Bills
This measure examines rates of individuals who had trouble paying off medical bills during past twelve months.

Made Changes to Medical Drugs
This measure highlights rates of individuals who were prescribed medication in the past twelve months who made changes to their medical drugs due to cost during the past twelve months. This includes delaying filling a prescription, taking less medicine, or skipping doses to save money.

Click here to explore these measures on State Health Compare!
 

Notes: Data for State Health Compare’s Had Dental Visit measure is only asked in the NHIS rotating core and thus was not asked in the 2021 survey. We will be able to update that measure with new data after both the 2022 and 2023 data are out in mid-2024.

All measures are representative of the civilian noninstitutionalized population.

Data Source: The estimates were produced using restricted NHIS data in the MnRDC. Measures have been updated with data through 2021 using two-year pooled periods, including (a) 2011–2012 through 2017–2018 and (b) 2019-2020 through 2020-2021, except in the case of the telehealth measure for which data is only available from 2020-2021.

Stewart, Andrea
Research Fellow

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

2022 NHIS Early Release: Estimates for First Half of the Year Show Continued Fall of Uninsured Rates

As part of the National Health Interview Survey (NHIS) Early Release Program, the National Center for Health Statistics (NCHS) recently published a second round of health insurance coverage estimates for the first half of 2022, covering the months of January to June.

Uninsurance was again measured at historic lows, with just 8.3% of all ages reporting being uninsured compared to 9.6% in the first half of 2021. This significant decrease represents 3.7 million fewer people without insurance through June 2022 (27.4 million as opposed to 31.1 million in 2021).

Other overarching comparisons between January-June estimates in 2022 and 2021 showed:

• The rate of individuals without health insurance coverage was significantly lower among those under 65, particularly for nonelderly adults (age 18-64), who saw a 1.9 percentage-point (PP) drop in their uninsured rate, from 14.0% in 2021 to 12.1% in 2022.
• Rates of public and private coverage remained statistically unchanged for all age groups.

Much like in our analysis of the NHIS Q1 estimates, no measure of statistical significance in either public or private coverage changes was able to account for the large drop in uninsurance rates. Therefore, we can only surmise that the potential shifts in coverage shown by the data—nearly unchanged among public coverage and slight indications of increasing private coverage—may in time point to confirmations of a post-pandemic recovery.

Coverage Changes for All Ages and Nonelderly Adults (18-64)

*Statistically significant at the 95% confidence level.

Important Findings by Demographic Groups

Analyzing coverage rates by more granular population levels revealed few significant changes between January to June of 2022 and the same time in 2021. However, we did note sizeable drops in uninsured rates for nonelderly adults with an income less than 100% of the federal poverty level (down from 19.5% in 2021 to 14.9% in 2022) and nonelderly adults living in states that have not yet expanded Medicaid (decreasing from 17.1% in 2021 to 14.5% in 2022).

While it is heartening to see persistently low overall rates of uninsurance, to anticipate that any perceived gains in private coverage^ have been potentially driven by employer-sponsored insurance and thus by rising post-pandemic employment levels, and improvements in coverage for those experiencing greater levels of poverty, it is also important to understand where there are still opportunities to improve coverage rates. For instance, Hispanic/Latino individuals were more than twice as likely to be uninsured compared with all nonelderly individuals under 65 (20.5% versus 9.9%) for the third year in a row.

Examining uninsured rates for individuals of other races/ethnicities showed that uninsurance decreased to 6.4% from 7.5% between 2022 and 2021 for nonelderly White individuals, but was stable among Black individuals (10.0%), Asian individuals (6.9%), and persons who identified as being of multiple races and other races (8.6%).

Much like overarching national trends, no racial or ethnic groups experienced any significant differences in rates of public coverage; however, White individuals saw gains in private coverage, rising from 72.7% in 2021 to 75.1% in 2022, while Hispanic individuals, Black individuals, Asian individuals, and individuals who reported being of multiple races and other races remained statistically unchanged between the first half of 2021 and 2022, at 44.7%, 49.7%, 72.4%, and 53.2%, respectively.

Impact of COVID-19 on NHIS 2021 Data

While federal survey data collection has recovered greatly from pandemic-related disruptions in 2020, it’s important to note that the presence of COVID-19 did impact collection operations in 2021 to a lesser degree. From January through April 2021, NHIS interviews continued to be attempted by telephone first, with personal visits used only to follow up on nonresponse, deliver recruitment materials, and conduct interviews when telephone numbers were unknown. Starting in May, field representatives were given the discretion to resume personal visits based on their assessment of risks and conditions in the area.

As such, differences between early estimate reports may contain greater variation than in years past; however, all data presented in this report continues to meet NCHS standards of reliability.¹

For further details on the impacts of the COVID pandemic on federal surveys in 2020 and 2021, see SHADAC briefs: “Comparing Federal Government Surveys That Count the Uninsured: 2022” and “Changes in Federal Surveys Due to and During COVID-19.”

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.