Survey Data on Health Insurance Coverage for 2013 and 2014

Publication Date

Oct 30, 2014

By: Kenneth Finegold and Munira Z. Gunja

The Affordable Care Act’s Health Insurance Marketplace coverage became available on January 1, 2014, and its Federally-financed, state-optional, Medicaid expansion started on the same day. Since then, millions of Americans have gained coverage through each of these sources, and total insurance coverage has expanded markedly. All told, estimates based on data from the Gallup-Healthways Well-Being Index (WBI) suggest that 10.3 million previously uninsured nonelderly adults (ages 18 to 64) gained coverage under the Affordable Care Act through June 2014.¹ This estimate includes the effect of the surge in Marketplace enrollment in late March, at the end of the open enrollment period, as well as Medicaid/CHIP growth through June.

Key Findings:

As of June 2014, 10.3 million nonelderly adults (ages 18-64) gained health insurance coverage since the start of the Affordable Care Act initial open enrollment period in October 2013.
The uninsured rate among nonelderly adults fell by more than a quarter (26 percent), from 20.3 percent to 15.1 percent, comparing numbers as of June 2014 with the January 2012-September 2013 baseline period. African Americans and Latinos saw particularly large drops in their uninsured rates of 6.8 percentage points and 7.7 percentage points, respectively.
Government and private surveys offer a consistent picture of expansions in insurance coverage.

The 2014 reduction in the number of uninsured adults builds on earlier effects of the Affordable Care Act on health insurance coverage. Nearly 950,000 individuals in six states (California, Colorado, Connecticut, Minnesota, New Jersey, and Washington) and the District of Columbia gained coverage before January 1, 2014 from early Medicaid expansions under the Affordable Care Act.² And an estimated 3.1 million young adults gained coverage under a parent’s employer-sponsored or individual market plan under the Affordable Care Act’s expansion of dependent coverage, which was effective for plan years beginning on or after September 23, 2010.³

The Gallup-Healthways WBI survey data represent the most up-to-date information on insurance coverage since the start of the Affordable Care Act’s coverage expansion. However, federal surveys have also recently released estimates on insurance coverage; in September, the National Center for Health Statistics (NCHS) released data for January-March 2014, and the Census Bureau released data for Calendar Year (CY) 2013. These surveys provide the best information available to date on health insurance coverage during the periods they cover.⁴ The federal surveys have large sample sizes, high response rates, rigorous quality assurance procedures, and methodologies that are continually being improved through statistical analyses, cognitive interviewing, and field tests of alternative approaches.

Unfortunately, the data from government surveys released to date either provide no information on 2014 or end too early in 2014 to capture the surge in enrollment that occurred at the end of the first Marketplace open enrollment period. When federal survey data for the whole of 2014 become available, it will be possible to more fully assess the impact of the Affordable Care Act’s coverage expansion.

¹Benjamin D. Sommers, Thomas Musco, Kenneth Finegold, Munira Z. Gunja, Amy Burke, and Audrey McDowell, “Health Reform and Changes in Health Insurance Coverage in 2014,” New England Journal of Medicine, July 23, 2014 (http://www.nejm.org/doi/full/10.1056/NEJMsr1406753, accessed October 27, 2014).

² Centers for Medicare & Medicaid Services, Center for Medicaid & CHIP Services, Medicaid & CHIP: August 2014 Monthly Applications, Eligibility Determinations and Enrollment Report, October 17, 2014 (http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/…, accessed October 27, 2014). See also Benjamin D. Sommers, Emily Arnston, Genevieve M. Kenney, and Arnold M. Epstein, “Lessons from Early Medicaid Expansions Under Health Reform: Interviews with Medicaid Officials,” Medicare & Medicaid Research Review 3:4 (2013) (http://www.cms.gov/mmrr/Downloads/MMRR2013_003_04_a02.pdf, accessed October 27, 2014); and Benjamin D. Sommers, Genevieve M. Kenney, and Arnold M. Epstein, “New Evidence on the Affordable Care Act: Coverage Impacts of Early Medicaid Expansions,” Health Affairs 33, no. 1 (2014): 78-87.

³ Benjamin D. Sommers, “Number of Young Adults Gaining Insurance Due to the Affordable Care Act Now Tops 3 Million,” ASPE Issue Brief, June 19, 2012 (http://aspe.hhs.gov/aspe/gaininginsurance/rb.pdf, accessed October 27, 2014). See also Andrew Mulcahy, Katherine Harris, Kenneth Finegold, Arthur Kellermann,, Laurel Edelman, and Benjamin D. Sommers, “Insurance Coverage of Emergency Care for Young Adults under Health Reform,” New England Journal of Medicine 368:2105-2112 (May 30, 2013), DOI: 10.1056/NEJMsa1212779; Brett O’Hara and Matthew W. Brault, “The Disparate Impact of the ACA-Dependent Expansion across Population Subgroups,” Health Services Research 48:5 (October 2013), pp. 1581-92, DOI: 10.1111/1475-6773.12067.

⁴Robin A. Cohen and Michael E. Martinez, Health insurance coverage: Early release of estimates from the National Health Interview Survey, January–March 2014. National Center for Health Statistics. September 2014; (http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201406.pdf, accessed October 27, 2014); Jessica C. Smith and Carla Medalia, U.S. Census Bureau, Current Population Reports, P60-250, Health Insurance Coverage in the United States: 2013, U.S. Government Printing Office, Washington, DC, 2014 (http://www.census.gov/content/dam/Census/library/publications/2014/demo…, accessed October 27, 2014).

Current Estimates of the Uninsured

Mid-2014: Gallup-Healthways Well-Being Index (WBI)

Analysis of data from the Gallup-Healthways WBI by Sommers et al. shows a decline of 26 percent in the uninsured rate for nonelderly adults. The study estimated a 5.2 percentage point reduction in the uninsured rate for 18 to 64 year olds in the second quarter of 2014, compared to the base period from the first quarter of 2012 through the third quarter of 2013.⁵ This decrease in the uninsured rate translates to 10.3 million additional adults becoming insured since the start of the open enrollment period on October 1, 2013 (see Table 1). These estimates are adjusted for the prior trend and for changes in income and employment, and so provide a reasonable estimate of the impact of the Affordable Care Act on insurance coverage.

</p><p><small><strong>Note:</strong> Other/Unknown includes Asian American, American Indian and Alaska Native, and Native Hawaiian and Other Pacific Islander, who are not broken out separately due to sample sizes.</small></p><p><small><strong>Source:</strong> ASPE analysis of Gallup-Healthways Well-Being Index (WBI) data, adapting the basic approach used in Benjamin D. Sommers, Thomas Musco, Kenneth Finegold, Munira Z. Gunja, Amy Burke, and Audrey McDowell, “Health Reform and Changes in Health Insurance Coverage in 2014,” New England Journal of Medicine, July 23, 2014 (<a href="http://www.nejm.org/doi/full/10.1056/NEJMsr1406753">http://www.nejm.org/doi/full/10.1056/NEJMsr1406753</a>, accessed October 27, 2014).</small></p><hr /><p>The January 2012-September 2013 uninsured rate for Whites was 14.3 percent, with a 4.0 percentage point reduction in the second quarter of 2014, translating to a 28 percent relative decline (Table 1). For African Americans there was a 30 percent relative decline (22.4 percent uninsured baseline rate and a 6.8 percentage point reduction in the second quarter of 2014) and for Hispanics there was an 18 percent relative decline (a 41.8 percent uninsured baseline rate and a 7.7 percentage point reduction in the second quarter of 2014).<sup>6</sup> The Commonwealth Fund found that among Latinos living in states that did not expand their Medicaid programs, the uninsured rate remained statistically unchanged (33 percent).<sup>7</sup> Some large states with substantial Latino populations, including Florida and Texas, did not take part in the Medicaid Expansion.</p><p>Skopec, Musco, and Sommers found that unadjusted Gallup-Healthways WBI annual estimates of the share of 18-64 year olds without health insurance tracked those from multiple federal surveys for 2008-2011.<sup>8</sup> Similarly, Figure 1 shows that the unadjusted Gallup-Healthways WBI quarterly estimates closely track NHIS quarterly data for the period covered by both datasets. Annual data on the percentage of 18 to 64 year olds who were uninsured are also similar, with Gallup-Healthways WBI estimates of 20.2 percent uninsured in 2012 and 20.7 percent uninsured in 2013, compared with NHIS estimates of 20.9 percent uninsured in 2012 and 20.4 percent uninsured in 2013.<sup>9</sup></p><p><img alt="Figure 1. Percentage of Adults ages 18-64 who were Uninsured by Year and Quarter, 2010-2014. NHIS and Gallup-Healthways Well-Being Index" src="/sites/default/files/private/images-reports/survey-data-health-insurance-coverage-2013-and-2014/Figure%201.PNG" /></p><p><small><strong>Sources:</strong> Robin A. Cohen and Michael E. Martinez, <em>Health insurance coverage: Early release of estimates from the National Health Interview Survey, January–March 2014</em>. National Center for Health Statistics. September 2014 (<a href="http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201409.pdf">http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201409.pdf</a>, accessed October 27, 2014); ASPE analysis of Gallup-Healthways Well-Being Index data.</small></p><hr /><p>A limitation of nongovernmental surveys such as the Gallup-Healthways WBI is that their response rates are low compared with federal surveys. The Gallup-Healthways WBI response rate, measured according to the American Association for Public Opinion Research (AAPOR)’s criteria for complex surveys, stood at 7 percent for the Gallup-Healthways Well-Being portion of the survey, which includes the health insurance question. The Urban Institute reports a lower response rate of 5 percent for its Health Reform Monitoring Survey.<sup>10</sup></p><p>Production estimates for federal surveys, which have more resources to convert non-respondents to respondents through incentives and follow-up interviews—and in which participation may be mandatory, or thought to be so—are based on higher, though not perfect, response rates. Skopec, Musco, and Sommers report a 91-93 percent response rate for the CPS-ASEC, 93-98 percent for the ACS, 80-90 percent for NHIS, 63-71 percent for the Medical Expenditure Panel Survey (MEPS), and 50-58 percent for the Behavioral Risk Factor Surveillance System (BRFSS).<sup>11</sup> Even among federal surveys, however, response rates may be lower for content tests than for production estimates: Brault reports an unweighted response rate of 43.1 percent for the 2013 CPS-ASEC Content Test.<sup>12</sup></p><p>Survey methodologists are, however, increasingly arguing that survey response rates may be a poor indicator of the level of bias in survey estimates<sup>13</sup> Substantial efforts by federal and academic researchers over the last decade or so have concluded that low response rates do not necessarily indicate bias, and that scarce survey resources are better devoted to analysis of potential biases and correction of them through reweighting than to pushing response rates slightly higher, which does not appear to reduce survey response bias as much as had previously been thought. As Brault suggests, “While little can be done ex post to address the problems of small sample size, adjustment can be done to minimize the effect of non-response bias.”<sup>14</sup></p><hr /><p><sup>5</sup> Benjamin D. Sommers, Thomas Musco, Kenneth Finegold, Munira Z. Gunja, Amy Burke, and Audrey McDowell, “Health Reform and Changes in Health Insurance Coverage in 2014,” <em>New England Journal of Medicine</em>, July 23, 2014 (<a href="http://www.nejm.org/doi/full/10.1056/NEJMsr1406753">http://www.nejm.org/doi/full/10.1056/NEJMsr1406753</a>, accessed October 27, 2014).</p><div><sup>6</sup> Benjamin D. Sommers, Thomas Musco, Kenneth Finegold, Munira Z. Gunja, Amy Burke, and Audrey McDowell, “Health Reform and Changes in Health Insurance Coverage in 2014,”<em> New England Journal of Medicine</em>, July 23, 2014 (<a href="http://www.nejm.org/doi/full/10.1056/NEJMsr1406753">http://www.nejm.org/doi/full/10.1056/NEJMsr1406753</a>, accessed October 27, 2014).</div><div><sup>7</sup> Michelle M. Doty, Petra W. Rasmussen, and Sara R. Collins, “Catching Up: Latino Health Coverage Gains and Challenges Under the Affordable Care Act,” <em>The Commonwealth Fund</em>, September 2014. (<a href="http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/sep/1775_doty_catching_up_latino_hlt_coverage_aca_tb_v3.pdf">http://www.commonwealthfund.org/~/media/files/publications/issue-brief/…</a>, accessed October 27, 2014).</div><div><sup>8</sup> Laura Skopec, Thomas Musco, and Benjamin D. Sommers. 2014. “A potential new data source for assessing the impacts of health reform: Evaluating the Gallup-Healthways Well-Being Index.” <em>Healthcare</em>: <a href="http://dx.doi.org/10.1016/j.hjdsi.2014.03.001">http://dx.doi.org/10.1016/j.hjdsi.2014.03.001</a> (accessed October 27, 2014).</div><div><sup>9</sup> ASPE calculations from Gallup-Healthways WBI data; Robin A. Cohen and Michael E. Martinez, <em>Health insurance coverage: Early release of estimates from the National Health Interview Survey, January–March 2014</em>. National Center for Health Statistics. September 2014. (<a href="http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201406.pdf">http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201406.pdf</a>, accessed October 27, 2014).</div><div><div><sup>10</sup> Urban Institute. N.D. “Health Reform Monitoring Survey, “HRMS Frequently Asked Questions, 8) What is the response rate for the HRMS?” (<a href="http://hrms.urban.org/faq.html">http://hrms.urban.org/faq.html</a>, accessed October 27, 2014).</div><div><sup>11</sup> Laura Skopec, Thomas Musco, and Benjamin D. Sommers. 2014. “A potential new data source for assessing the impacts of health reform: Evaluating the Gallup-Healthways Well-Being Index.” <em>Healthcare</em>: <a href="http://dx.doi.org/10.1016/j.hjdsi.2014.03.001">http://dx.doi.org/10.1016/j.hjdsi.2014.03.001</a> (accessed October 27, 2014).</div><div><div><sup>12</sup> Matthew W. Brault, “Non-response Bias in the 2013 CPS ASEC Content Test.” Proceedings of the 2013 Federal Committee on Statistical Methodology (FCSM) Research Conference, November 6. SEHSD Working Paper Number 2014-17. (<a href="https://www.census.gov/hhes/www/hlthins/publications/sehsd_wp_2014-17.pdf">https://www.census.gov/hhes/www/hlthins/publications/sehsd_wp_2014-17.p…</a>, accessed October 27, 2014).</div><div><sup>13</sup> Michael Davern, “Nonresponse Rates are a Problematic Indicator of Nonresponse Bias in Survey Research,” <em>Health Services Research </em>48:3 (2013): 905-912.</div><div><sup>14</sup> Matthew W. Brault, “Non-response Bias in the 2013 CPS ASEC Content Test.” Proceedings of the 2013 Federal Committee on Statistical Methodology (FCSM) Research Conference, November 6. SEHSD Working Paper Number 2014-17. (<a href="https://www.census.gov/hhes/www/hlthins/publications/sehsd_wp_2014-17.pdf">https://www.census.gov/hhes/www/hlthins/publications/sehsd_wp_2014-17.p…</a>, accessed October 27, 2014).</div></div></div><h3>Early 2014: National Health Interview Survey (NHIS)</h3><p>In September, the National Health Interview Survey (NHIS) released data for the first quarter of 2014 that provide estimates of the number of people without insurance and the sources of coverage. These data represent averages over the first quarter.</p> <p>The new NHIS data lag behind the data from nonfederal surveys on health insurance status and administrative data on enrollment, which is particularly important during a period of unusually rapid change in health insurance coverage. In particular, because the NHIS estimates reflect interviews conducted continuously during January, February, and March, they do not reflect the full impact of the surge in Marketplace enrollment in late March at the end of the open enrollment period, as reported in HHS enrollment statistics.<sup>15</sup> Medicaid and CHIP enrollment were not directly affected by the end of open enrollment and have continued to grow since March: the latest administrative data suggest that by August 2014, enrollment in these two programs was up by 8.7 million compared with the June-September 2013 base period.<sup>16</sup></p> <p>Estimates of the percentage of people that were uninsured during January-March 2014 and their sociodemographic characteristics are available from the NHIS quarterly data released on September 16 and summarized in Table 2. Table 2 also shows the comparable NHIS estimates of the percentage uninsured, overall and by selected subgroups, in CY 2013, and whether the change over this period was statistically significant.</p> <p>Because most low-income children were eligible for Medicaid or CHIP before the Affordable Care Act and most seniors were already enrolled in Medicare, the early 2014 gains were concentrated among 18 to 64 year olds, particularly young adults. And because eligibility for Medicaid coverage and Marketplace subsidies is based on income, the reduction in the number of people that were uninsured was significant for the poor and near-poor, but not for those with higher incomes, who were less likely to be uninsured before this year’s coverage expansion. The first quarter change was statistically significant for men, but not for women. The new NHIS estimates, like the adjusted Gallup-Healthways WBI estimates presented by Sommers et al. and the unadjusted estimates presented by Long et al. for similar periods, suggest that Latinos and African Americans were particularly likely to gain coverage in early 2014.<sup>17</sup></p> <p>The data reported in Table 2 are for coverage at the time of interview, and thus represent point-in-time estimates averaged over the three-month period in which the data was collected. Estimates of the percentage uninsured for at least part of the previous year (January-December 2013) and the percentage uninsured for more than a year are also available in the NCHS September 2014 report.<sup>18</sup> Those data show statistically significant reductions in the percentage of nonelderly adults who were uninsured for more than a year, suggesting that the coverage expansion is reaching the long-term uninsured. These data also represent averages over the three-month collection period.</p> <p><strong>Table 2. National Health Interview Survey. Estimated Percentage Uninsured, January-December 2013 and January-March 2014, Under 65 Only</strong></p> <div class="table-responsive"><table border="1" class="footable table-align-left table"><thead><tr><th>Group</th> <th> <div>January-December 2013</div> <div>(%)</div> </th> <th> <div>January-March 2014</div> <div>(%)</div> </th> <th> <div>Change</div> <div>(%)</div> </th> </tr></thead><tbody><tr><td><em>Total Population</em></td> <td>16.6</td> <td>15.2</td> <td>-1.4*</td> </tr><tr><td colspan="4">By Age</td> </tr><tr><td>0-17</td> <td>6.5</td> <td>6.6</td> <td>0.1</td> </tr><tr><td>18-64</td> <td>20.4</td> <td>18.4</td> <td>-2.0*</td> </tr><tr><td>19-25</td> <td>26.5</td> <td>20.9</td> <td>-5.6*</td> </tr><tr><td colspan="4"><em>By Income</em></td> </tr><tr><td>Poor (<100% FPL)</td> <td>27.3</td> <td>24.1</td> <td>3.2*</td> </tr><tr><td>Near-Poor (>=100% FPL and <200% FPL)</td> <td>29.3</td> <td>26.2</td> <td>-3.1*</td> </tr><tr><td>Not Poor (>=200% FPL)</td> <td>9.6</td> <td>9.0</td> <td>-0.6</td> </tr><tr><td>Unknown</td> <td>20.5</td> <td>16.5</td> <td>-4.0</td> </tr><tr><td colspan="4"><em>By Gender</em></td> </tr><tr><td>Male</td> <td>18.0</td> <td>16.2</td> <td>-1.8*</td> </tr><tr><td>Female</td> <td>15.1</td> <td>14.2</td> <td>-0.9</td> </tr><tr><td colspan="4"><em>By Race/Ethnicity</em></td> </tr><tr><td>Latino (all races)</td> <td>30.3</td> <td>27.2</td> <td>-3.1*</td> </tr><tr><td>White Non-Latino (single race)</td> <td>12.1</td> <td>11.5</td> <td>-0.6</td> </tr><tr><td>Black Non-Latino (single race)</td> <td>18.9</td> <td>15.1</td> <td>-3.8*</td> </tr><tr><td>Asian Non-Latino (single race)</td> <td>13.8</td> <td>13.3</td> <td>-0.5</td> </tr><tr><td>Other Non-Latino (other/multiple race)</td> <td>16.0</td> <td>16.7</td> <td>0.7</td> </tr></tbody></table></div><p><small>* Change is statistically significant at the .05 level.</small></p> <p><small><strong>Sources:</strong> ASPE calculations from Robin A. Cohen and Michael E. Martinez, <em>Health insurance coverage: Early release of estimates from the National Health Interview Survey, January–March 2014</em>. National Center for Health Statistics. September 2014 (<a href="http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201409.pdf">http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201409.pdf</a>, accessed October 27, 2014) and Robin A. Cohen and Michael E. Martinez, <em>Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2013</em>. National Center for Health Statistics. June 2014 (<a href="http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201406.pdf">http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201406.pdf</a>, accessed October 27, 2014).</small></p> <hr /><p>As noted above, because the NHIS first quarter estimates in Table 2 represent averages over the three months from January to March 2014, they do not reflect the full coverage gains that have occurred under the Affordable Care Act in 2014. This means that NHIS data for the second quarter of 2014, based on averages for April-June, will likely show larger enrollment gains than the first quarter data shown in Table 2. The second quarter NHIS data, to be released in December 2014, will capture the full late-March/SEP Marketplace surge, and more of the continuing growth in Medicaid and CHIP.</p> <p>The second quarter NHIS data may also suggest different conclusions about the distribution of those gains across the subgroups shown in Table 2. Marketplace enrollment data, for example, indicate that younger enrollees were particularly likely to sign up late in the 2014 enrollment period.<sup>19</sup> The estimates for 19 to 25 year olds in Table 2 may not reflect the full impact of coverage gains among this age group.</p> <hr /><div><sup>15</sup> Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period, ASPE Issue Brief, May 1, 2014 (<a href="http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf">http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib...</a>, accessed October 27, 2014).</div> <div><sup>16</sup> Centers for Medicare & Medicaid Services, Center for Medicaid & CHIP Services, <em>Medicaid & CHIP: August 2014 Monthly Applications, Eligibility Determinations and Enrollment Report</em>, October 17, 2014 (<a href="http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/August-2014-Enrollment-Report.pdf">http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/D...</a>, accessed October 27, 2014).</div> <div> <div><sup>17</sup> Benjamin D. Sommers, Thomas Musco, Kenneth Finegold, Munira Z. Gunja, Amy Burke, and Audrey McDowell, “Health Reform and Changes in Health Insurance Coverage in 2014,” <em>New England Journal of Medicine</em>, July 23, 2014 (<a href="http://www.nejm.org/doi/full/10.1056/NEJMsr1406753">http://www.nejm.org/doi/full/10.1056/NEJMsr1406753</a>, accessed October 27, 2014); Sharon K. Long, Genevieve M. Kenney, Stephen Zuckerman, Douglas Wissoker, Dana Goin, Katherine Hempstead, Michael Karpman, and Nathaniel Anderson, <em>Early Estimates Indicate Rapid Increase in Health Insurance Coverage under the ACA: A Promising Start</em>, Urban Institute, April 15, 2014 (<a href="http://hrms.urban.org/briefs/early-estimates-indicate-rapid-increase.html">http://hrms.urban.org/briefs/early-estimates-indicate-rapid-increase.html</a>, accessed October 27, 2014).</div> <div><sup>18</sup> Robin A. Cohen and Michael E. Martinez, Health insurance coverage: <em>Early release of estimates from the National Health Interview Survey, January–March 2014</em>. National Center for Health Statistics. September 2014; (<a href="http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201409.pdf">http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201409.pdf</a>, accessed October 27, 2014).</div> <div><sup>19</sup> Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period, ASPE Issue Brief, May 1, 2014 (<a href="http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf">http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib...</a>, accessed October 27, 2014).</div> </div> <p> </p> <h2>2013: Current Population Survey Annual Social and Economic Supplement (CPS-ASEC) and American Community Survey (ACS)</h2><p>The CPS-ASEC and ACS estimates released on September 16, 2014 cover CY 2013.<sup>20</sup> These data thus provide a baseline for future analyses of changes in health insurance coverage under the Affordable Care Act.</p> <p>The new CPS-ASEC data were the first collected using a new battery of health insurance questions, long under development, that aim to provide more accurate estimates of the uninsured and sources of coverage.<sup>21</sup> The Census Bureau regards these changes as a break-in-series, meaning that this year’s CPS-ASEC estimates are not comparable to past years’ estimates.<sup>22</sup></p> <p>The new CPS-ASEC estimates suggest that 42 million Americans (13.4 percent of the population) were uninsured for all of CY 2013 and 271.4 million Americans had coverage for all or at least part of the year.<sup>23</sup> The likelihood of being uninsured varies according to age, race/ethnicity, employment status, and household income. Although the break-in-series in the CPS-ASEC precludes direct comparison of these data with data for earlier years, the new data and methodology suggest conclusions about who is uninsured and who is insured that are similar to those based on last year’s CPS-ASEC data and methodology.<sup>24</sup> Table 3, for example, suggests that, in 2013, as in 2012, young adults were more likely to be uninsured than children or seniors.</p> <p><strong>Table 3. Profile of the Uninsured vs. Total Population by Age, 2013</strong></p> <table border="1" class="footable table-align-left"><thead><tr><th>Age</th> <th>Uninsured (N = 42.0 million) (%)</th> <th>Total Population (N = 313.4 million) (%)</th> </tr></thead><tfoot><tr><td>Total</td> <td>100.0</td> <td>100.0</td> </tr></tfoot><tbody><tr><td>0-18</td> <td>14.1</td> <td>24.9</td> </tr><tr><td>19-25</td> <td>16.4</td> <td>9.7</td> </tr><tr><td>26-34</td> <td>21.3</td> <td>12.1</td> </tr><tr><td>35-44</td> <td>18.0</td> <td>12.7</td> </tr><tr><td>45-64</td> <td>28.6</td> <td>26.3</td> </tr><tr><td>65 and older</td> <td>1.7</td> <td>14.2</td> </tr></tbody></table><p><small><strong>Source:</strong> ASPE calculations from Jessica C. Smith and Carla Medalia, U.S. Census Bureau, Current Population Reports, P60-250, <em>Health Insurance Coverage in the United States: 2013</em>, U.S. Government Printing Office, Washington, DC, 2014 (<a href="http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf">http://www.census.gov/content/dam/Census/library/publications/2014/demo/...</a>, accessed October 27, 2014).</small></p> <hr /><p>The ACS began to measure health insurance coverage in 2008, and due to its large sample size (approximately 3 million), the Census Bureau has recommended that it be used for state- and local-level analyses. The point-in-time ACS estimate for all age groups is that 45.2 million people (14.5 percent) were uninsured in Calendar Year 2013.<sup>25</sup></p> <p>With the break in the CPS-ASEC time series due to the introduction of the new methodology, the Census Bureau recommends use of the ACS for trend analysis as well. O’Hara and Medalia found that the two Census surveys suggested similar trends between 2009 and 2012.<sup>26</sup></p> <hr /><div><sup>20</sup> Jessica C. Smith and Carla Medalia, U.S. Census Bureau, Current Population Reports, P60-250, <em>Health Insurance Coverage in the United States: 2013</em>, U.S. Government Printing Office, Washington, DC, 2014 (<a href="http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf">http://www.census.gov/content/dam/Census/library/publications/2014/demo/...</a>, accessed October 27, 2014). Additional ACS estimates were released on September 18, 2014.</div> <div><sup>21</sup> The NHIS data described in the last section also underwent changes in data processing to permit them to reliably identify different types of private coverage, particularly new Marketplace coverage. These changes do not affect overall coverage trends, nor does NCHS believe that they have generated a break-in-series for the share of individuals with different types of coverage.</div> <div><sup>22</sup> Jessica C. Smith and Carla Medalia, U.S. Census Bureau, Current Population Reports, P60-250, <em>Health Insurance Coverage in the United States: 2013</em>, U.S. Government Printing Office, Washington, DC, 2014 (<a href="http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf">http://www.census.gov/content/dam/Census/library/publications/2014/demo/...</a>, accessed October 27, 2014); Brett O’Hara and Carla Medalia, <em>CPS and ACS Health Insurance Estimates: Consistent Trends from 2009-2012</em> , U.S. Census Bureau, SEHSD Working Paper 2014, September 15, 2014 (<a href="http://www.census.gov/hhes/www/hlthins/data/incpovhlth/2013/CPS_ACS_Trends.pdf">http://www.census.gov/hhes/www/hlthins/data/incpovhlth/2013/CPS_ACS_Tren...</a>, accessed October 27, 2014).</div> <div> <div><sup>23 </sup>Jessica C. Smith and Carla Medalia, U.S. Census Bureau, Current Population Reports, P60-250, <em>Health Insurance Coverage in the United States: 2013</em>, U.S. Government Printing Office, Washington, DC, 2014 (<a href="http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf">http://www.census.gov/content/dam/Census/library/publications/2014/demo/...</a>, accessed October 27, 2014).</div> <div><sup>24</sup> Carmen DeNavas-Walt, Bernadette D. Proctor, and Jessica C. Smith, U.S. Census Bureau, Current Population Reports, P60-245,<em> Income, Poverty, and Health Insurance Coverage in the United States: 2012</em>, U.S. Government Printing Office, Washington, DC, 2013 (<a href="http://www.census.gov/prod/2013pubs/p60-245.pdf">http://www.census.gov/prod/2013pubs/p60-245.pdf</a>, accessed October 27, 2014); Kenneth Finegold, <em>New Census Estimates Show 3 Million More Americans Had Health Insurance Coverage in 2012</em>, ASPE Issue Brief, November 23, 2013 (<a href="http://aspe.hhs.gov/health/reports/2013/CPSIssueBrief/ib_cps.pdf">http://aspe.hhs.gov/health/reports/2013/CPSIssueBrief/ib_cps.pdf</a>, accessed October 27, 2014).</div> </div> <div> <div><sup>25</sup> Jessica C. Smith and Carla Medalia, U.S. Census Bureau, Current Population Reports, P60-250, <em>Health Insurance Coverage in the United States: 2013</em>, U.S. Government Printing Office, Washington, DC, 2014 (<a href="http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf">http://www.census.gov/content/dam/Census/library/publications/2014/demo/...</a>, accessed October 27, 2014).</div> <div><sup>26</sup> Brett O’Hara and Carla Medalia, <em>CPS and ACS Health Insurance Estimates: Consistent Trends from 2009-2012</em>, U.S. Census Bureau, SEHSD Working Paper 2014, September 15, 2014 (<a href="http://www.census.gov/hhes/www/hlthins/data/incpovhlth/2013/CPS_ACS_Trends.pdf">http://www.census.gov/hhes/www/hlthins/data/incpovhlth/2013/CPS_ACS_Tren...</a>, accessed October 27, 2014).</div> </div> <p> </p> <h2>Conclusion: Looking AHEAD to the Present</h2><p>Gallup-Healthways WBI health insurance survey data provide the most up-to-date data on insurance coverage so far in 2014. An analysis of these data published by the <em>New England Journal of Medicine</em> shows that 10.3 million adults had gained coverage through June 2014.<sup>27</sup></p> <p>The new NHIS quarterly data for January through March 2014 represent the first federal survey data for any part of the current year. The data corroborate earlier findings from administrative data and from nongovernmental household surveys suggesting substantial reductions in the uninsured, substantial increases in Medicaid and CHIP coverage, and substantial enrollment in private insurance through the Marketplace.<sup>28</sup> The NHIS data demonstrate that in the first few months of the year, the Affordable Care Act was already achieving its intended outcome. The new CPS-ASEC and ACS data offer a baseline view of health insurance coverage in 2013, the last year before implementation of the Affordable Care Act’s coverage expansion.</p> <p>Yet even the new NHIS data are only for the first few months of 2014—and represent averages over that period, rather than coverage as of March 31. For this reason, these new health insurance data likely understate the changes in coverage that have occurred at the end of the first quarter of 2014. Marketplace and Medicaid/CHIP enrollment data, and data from nongovernmental surveys, suggest that the next round of NHIS data for April-June 2014 will show even larger gains.</p> <p>With Medicaid and CHIP continuing to grow each month, and open enrollment for the Marketplace beginning again on November 15, 2014 (<a href="https://www.healthcare.gov/">https://www.healthcare.gov/</a>), it seems likely that future data will show that the Affordable Care Act is continuing to provide health insurance coverage to a large and growing group of Americans.</p> <hr /><div><sup>27</sup> Benjamin D. Sommers, Thomas Musco, Kenneth Finegold, Munira Z. Gunja, Amy Burke, and Audrey McDowell, “Health Reform and Changes in Health Insurance Coverage in 2014,” <em>New England Journal of Medicine</em>, July 23, 2014 (<a href="http://www.nejm.org/doi/full/10.1056/NEJMsr1406753">http://www.nejm.org/doi/full/10.1056/NEJMsr1406753</a>, accessed October 27, 2014).</div> <div><sup>28</sup> Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period, ASPE Issue Brief, May 1, 2014 (<a href="http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf">http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib...</a>, accessed October 27, 2014); Centers for Medicare & Medicaid Services, Center for Medicaid & CHIP Services, <em>Medicaid & CHIP: August 2014 Monthly Applications, Eligibility Determinations and Enrollment Report</em>, October 17, 2014 (<a href="http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/August-2014-Enrollment-Report.pdf">http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/D...</a>, accessed October 27, 2014); Benjamin D. Sommers, Thomas Musco, Kenneth Finegold, Munira Z. Gunja, Amy Burke, and Audrey McDowell, “Health Reform and Changes in Health Insurance Coverage in 2014,” <em>New England Journal of Medicine</em>, July 23, 2014 (<a href="http://www.nejm.org/doi/full/10.1056/NEJMsr1406753">http://www.nejm.org/doi/full/10.1056/NEJMsr1406753</a>, accessed October 27, 2014); Sharon K. Long, Genevieve M. Kenney, Stephen Zuckerman, Douglas Wissoker, Adele Shartzer, Michael Karpman, Nathaniel Anderson, and Katherine Hempstead, <em>Taking Stock at Mid-Year: Health Insurance Coverage under the ACA as of June 2014</em>, Urban Institute, July 29, 2014 (<a href="http://hrms.urban.org/briefs/taking-stock-at-mid-year.pdf">http://hrms.urban.org/briefs/taking-stock-at-mid-year.pdf</a>, accessed October 27, 2014); Katherine Grace Carman and Christine Eibner, <em>Changes in Health Insurance Enrollment Since 2013: Evidence from the RAND Health Reform Opinion Study</em>, RAND Research Report RR-656-RC, April 2014 (<a href="http://www.rand.org/content/dam/rand/pubs/research_reports/RR600/RR656/RAND_RR656.pdf">http://www.rand.org/content/dam/rand/pubs/research_reports/RR600/RR656/R...</a>, accessed October 27, 2014); Sara R. Collins, Petra W. Rasmussen, and Michelle M. Doty, <em>Gaining Ground: Americans’ Health Insurance Coverage and Access to Care After the Affordable Care Act’s First Open Enrollment Period</em>, Commonwealth Fund, July 2014 (<a href="http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/jul/1760_collins_gaining_ground_tracking_survey.pdf">http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2...</a>, accessed October 27, 2014); Liz Hamel, Mira Rao, Larry Levitt, Gary Claxton, Cynthia Cox, Karen Pollitz, and Mollyann Brodie, Survey of Non-Group Health Insurance Enrollees, Kaiser Family Foundation, June 19, 2014 (<a href="http://kff.org/health-reform/report/survey-of-non-group-health-insurance-enrollees/">http://kff.org/health-reform/report/survey-of-non-group-health-insurance...</a>, accessed October 27, 2014); Bianca DiJulio, Jamie Firth, Larry Levitt, Gary Claxton, Rachel Garfield, and Mollyann Brodie, <em>Where are California's Uninsured Now? Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey</em>, Kaiser Family Foundation, July 30, 2014 (<a href="http://kff.org/uninsured/report/where-are-californias-uninsured-now-wave-2-of-the-kaiser-family-foundation-california-longitudinal-panel-survey/">http://kff.org/uninsured/report/where-are-californias-uninsured-now-wave...</a>, accessed October 27, 2014).</div> <h2>Appendix 1: National Health Interview Survey (nhis): Additional Information on Correlates of Uninsurance in 2013 and Early 2014</h2><p><strong>Table A-1. Estimated Percentage Uninsured, January-December 2013 and January-March 2014, Under 65 Only</strong></p> <div class="table-responsive"><table border="1" class="footable table-align-left table"><thead><tr><th>Group</th> <th>January- December 2013 (%)</th> <th>January- March 2014 (%)</th> <th>Change (%)</th> </tr></thead><tbody><tr><td><em>Total Population</em></td> <td>16.6</td> <td>15.2</td> <td>-1.4*</td> </tr><tr><td colspan="4"><em>By Region</em></td> </tr><tr><td>New England</td> <td>8.1</td> <td>6.8</td> <td>-1.3</td> </tr><tr><td>Middle Atlantic</td> <td>12.4</td> <td>12.0</td> <td>-0.4</td> </tr><tr><td>East North Central</td> <td>13.2</td> <td>10.8</td> <td>-2.4*</td> </tr><tr><td>West North Central</td> <td>12.3</td> <td>11.8</td> <td>-0.5</td> </tr><tr><td>South Atlantic</td> <td>20.9</td> <td>18.1</td> <td>-2.8</td> </tr><tr><td>East South Central</td> <td>15.0</td> <td>15.8</td> <td>0.8</td> </tr><tr><td>West South Central</td> <td>21.9</td> <td>23.3</td> <td>1.4</td> </tr><tr><td>Mountain</td> <td>18.7</td> <td>17.4</td> <td>-1.3</td> </tr><tr><td>Pacific</td> <td>18.7</td> <td>15.5</td> <td>-3.2*</td> </tr><tr><td colspan="4"><em>By Employment Status**</em></td> </tr><tr><td>Employed</td> <td>18.4</td> <td>16.3</td> <td>-2.1*</td> </tr><tr><td>Not Employed</td> <td>47.7</td> <td>46.4</td> <td>-1.3</td> </tr><tr><td>Not in Workforce</td> <td>19.4</td> <td>17.5</td> <td>-1.9</td> </tr><tr><td colspan="4"><em>By Marital Status**</em></td> </tr><tr><td>Married</td> <td>15.1</td> <td>13.8</td> <td>-1.3</td> </tr><tr><td>Widowed</td> <td>21.0</td> <td>23.7</td> <td>2.7</td> </tr><tr><td>Divorced/Separated</td> <td>24.5</td> <td>23.1</td> <td>-1.4</td> </tr><tr><td>Living with Partner</td> <td>31.8</td> <td>31.1</td> <td>-0.7</td> </tr><tr><td>Never Married</td> <td>25.9</td> <td>21.8</td> <td>-4.1*</td> </tr><tr><td colspan="4"><em>By State Medicaid Expansion Status</em></td> </tr><tr><td>Expanded</td> <td>14.9</td> <td>13.0</td> <td>-1.9*</td> </tr><tr><td>Did Not Expand</td> <td>18.4</td> <td>17.7</td> <td>-0.7</td> </tr><tr><td colspan="4"><em>By State Marketplace Type</em></td> </tr><tr><td>Federally-facilitated Marketplace</td> <td>17.9</td> <td>16.9</td> <td>-1.0</td> </tr><tr><td>State Partnership Marketplace</td> <td>14.2</td> <td>10.5</td> <td>-3.7*</td> </tr><tr><td>State-Based Marketplace</td> <td>15.2</td> <td>14.0</td> <td>-1.2</td> </tr></tbody></table></div><p><small>* Change is statistically significant at the .05 level.</small></p> <p><small>** Consists of persons ages of 18-64 years only.</small></p> <p><strong><small>Notes:</small></strong></p> <p><small>States moving forward with Medicaid expansion include AZ, AR, CA, CO, CT, DE, DC, HI, IL, IA, KY, MD, MA, MI, MN, NV, NJ, NM, NY, ND, OH, OR, RI, VT, WA, and WV (as of October 31, 2013).</small></p> <p><small>States not moving forward with Medicaid expansion include AL, AK, FL, GA, ID, IN, KS, LA, ME, MS, MO, MT, NE, NH, NC, OK, PA, SC, SD, TN, TX, UT, VA, WI, and WY (as of October 31, 2013).</small></p> <p><small>Federally Facilitated Marketplace states are AL, AK, AZ, FL, GA, IN, KS, LA, ME, MS, MO, MT, NE, NJ, NC, ND, OH, OK, PA, SC, SD, TN, TX, UT, VA, WI, and WY (as of October 31, 2013).</small></p> <p><small>Partnership Marketplace states are AR, DE, IL, IA, MI, NH, and WV (as of October 31, 2013).</small></p> <p><small>State-based Marketplace states are CA, CO, CT, DC, HI, ID, KY, MD, MA, MN, NV, NM, NY, OR, RI, VT, and WA (as of October 31, 2013).</small></p> <p><small><strong>Sources:</strong> ASPE calculations from Robin A. Cohen and Michael E. Martinez, <em>Health insurance coverage: Early release of estimates from the National Health Interview Survey, January–March 2014</em>. National Center for Health Statistics. September 2014 (<a href="http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201406.pdf">http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201406.pdf</a>, accessed October 27, 2014) and Robin A. Cohen and Michael E. Martinez, <em>Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2013</em>. National Center for Health Statistics. June 2014 (<a href="http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201406.pdf">http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201406.pdf</a>, accessed October 27, 2014).</small></p> <h2>Appendix 2: Cps-asec: Sources of Health Insurance Coverage in 2013</h2><p>The estimates shown in Table A-2 are based on the percentage of people for whom each source of coverage was reported in the CPE-ASEC for CY 2013. These percentages sum to more than 100 percent because some people report multiple forms of coverage. Some of the elderly and disabled, for example, are “dual eligibles” enrolled in both Medicare and Medicaid.<sup>29</sup> Many Medicare enrollees, moreover, purchase Medicare Supplemental Health Insurance policies, also known as “Medigap,” to cover costs they would otherwise bear out-of-pocket, <sup>30</sup> and some respondents may have reported such policies in their CPS-ASEC interviews. Because the CPS-ASEC asks about coverage in the prior calendar year, people who had different types of coverage in different parts of the year (for example, people who directly purchased individual market coverage and then obtained jobs providing employer-sponsored coverage) may also report multiple sources of coverage.</p> <p><strong>Table A-2: Sources of Health Insurance Coverage in 2013</strong></p> <div class="table-responsive"><table border="1" class="footable table-align-left table"><thead><tr><th rowspan="2">Source</th> <th colspan="2">Number</th> </tr><tr><th>(in millions)</th> <th>(percentage)</th> </tr></thead><tfoot><tr><td>Total</td> <td>313.4</td> <td>115.7%</td> </tr></tfoot><tbody><tr><td>Medicare</td> <td>49.0</td> <td>15.6%</td> </tr><tr><td>Military</td> <td>14.1</td> <td>4.5%</td> </tr><tr><td>Medicaid/CHIP</td> <td>54.1</td> <td>17.3%</td> </tr><tr><td>Employer-Sponsored</td> <td>169.0</td> <td>53.9%</td> </tr><tr><td>Direct Purchase</td> <td>34.5</td> <td>11.0%</td> </tr><tr><td>Uninsured</td> <td>42.0</td> <td>13.4%</td> </tr></tbody></table></div><p><small><strong>Note:</strong> Percentages total more than 100 because more than one type of coverage was reported or imputed for some respondents.</small></p> <p><small><strong>Source:</strong> ASPE calculations from Jessica C. Smith and Carla Medalia, U.S. Census Bureau, Current Population Reports, P60-250, <em>Health Insurance Coverage in the United States: 2013</em>, U.S. Government Printing Office, Washington, DC, 2014 (<a href="http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf">http://www.census.gov/content/dam/Census/library/publications/2014/demo/...</a>, accessed October 27, 2014).</small></p> <hr /><p><sup>29</sup> Centers for Medicare & Medicaid Services, Center for Medicaid & CHIP Services, “Seniors & Medicare and Medicaid Enrollees” (<a href="http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Population/Medicare-Medicaid-Enrollees-Dual-Eligibles/Seniors-and-Medicare-and-Medicaid-Enrollees.html">http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Population/...</a>, accessed October 27, 2014).</p> <p><sup>30</sup> Steven Sheingold, Adele Shartzer, and Dan Ly, <em>Variation and Trends in Medigap Premiums</em>, ASPE Report, December 2011 (<a href="http://aspe.hhs.gov/health/reports/2011/MedigapPremiums/">http://aspe.hhs.gov/health/reports/2011/MedigapPremiums/</a>, accessed October 27, 2014).</p>

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Survey Data on Health Insurance Coverage for 2013 and 2014

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