Thursday, September 17, 2015

The Census on health insurance gains: who got what and how?

This week the Census reported on changes in Americans' health insurance rates from 2013 to 2014, based on results of its two yearly surveys, the Current Population Survey and the American Community Survey. The two together show what is probably the most dramatic drop in the percentage of people without insurance since Medicare and Medicaid were implemented. The drop in the ranks of uninsured was steepest among the roughly one third of the population living in households with incomes under 200% of the Federal Poverty Level (FPL) -- where lack of insurance is most concentrated.

In my grand personal tradition of burying the lead, I discuss an apparent oddity in the data under the second subhead below. Feel free to skip! If you're well-versed in these matters, it may be no mystery to you.

The near-poor gain most

The ranks of the uninsured dropped more steeply for the near-poor than for those below the poverty line, and for the part-time employed than for the nonworking population,  The pattern does not hold for educational level: the uninsured rate dropped most for those without a high school diploma and next most for high school grads, with smaller drops at each level of educational attainment.

More specifically, the uninsurance rate dropped 6.3 percentage points for those who worked less than full-time year round, vs, 4,9 points for those who did not work at least one week in the year, and 2.7 points for full-time workers. It dropped 5.3 percentage points for those with incomes between 100% and 199% of the Federal Poverty Level (FPL), vs. 4.2 points for those below the poverty line. The drop was 7.6 percentage points for non-high school grads 5.0 points for high school grads, 4.4 points for those with some college but no degree, and 3.3 points for those with associate degrees.

More people in the 100-199% FPL income band gained insurance (3.12 million) than in the 0-100% FPL range (1.86 million). In 2013, the ranks of the uninsured in those two income bands were fairly comparable -- there were 10.88 million uninsured under 100 % FPL, and 11.98 million between 100% and 199% FPL. By 2014, there were fewer uninsured in the 100-199% band, 8.85 million, than among those below 100% FPL, 9.02 million.

Why did the near-poor apparently gain insurance at greater rates than the poor?  The difference may be partly (or mainly?) explained by the refusal of nearly half the states to enact the Medicaid expansion in 2014, shutting about 4 million people with incomes under 100% FPL out of Medicaid eligibility. Conversely, the refusal to expand Medicaid would not have cut off access to aid to those in the 100-199% FPL band, since in nonexpansion states, eligibility for private plan subsidies begins at 100% FPL rather than 138% FPL, as in expansion states. A fair chunk of beneficiaries of the Medicaid expansion are in the 100-199% FPL band (that is, between 100% and 138% FPL). Perhaps there were also more gains in employer-sponsored insurance among those in the 100-199% FPL band than for those below 100% FPL.

More government insurance for the not-poor? More private insurance for the poor?

With respect to how the poor and near-poor obtained new insurance, there is an apparent anomaly in the tables on p. 12 and p. 29. The data shows greater percentage increases in private insurance among those below 100% FPL (or below 138% FPL) than for those between 100% and 199% FPL or 200% and 299% FPL. Conversely, there are greater increases in government health insurance among those in those in the higher two ranges cited above than in the lower two. That seems counterintuitive, as those under 100% FPL (or 138% FPL in Medicaid expansion states) are ineligible for subsidized private coverage, and those over 138% FPL gained no new access to government insurance. Private insurance does include employer-sponsored insurance, but it seems unlikely that large numbers of people in households under 100% FPL would have gained access to that.

Specifically, the Census reports that government-provided insurance increased 2.6 percentage points for people with incomes from 100-199% FPL and 2.7 points for those in the 200-299% FPL range, compared to just 1.3 points for people under 100% FPL and 1.4 for those under 138% FPL. Conversely, private insurance is reported to have increased 3.7 percentage points for those under 100% FPL and 3.6 points for those under 138% FPL,but just 3.2 for the 100-199 % income band and 2.9% for those between 200 and 299% FPL.

The apparent discrepancy is reflected in raw numbers: almost as many people under 100% FPL gained private insurance as did those in the 100-199% FPL range (1.81 million vs. 1.87 million), while the number of people who gained government insurance in the 100-199% FPL income band (1.47 million)  exceeded the number of people below 138% FPL who did so (1.30 million)* -- despite starting from a lower 2013 baseline (29.2 million vs 40.4 million).

What gives? I don't think increases in Medicare enrollment explain this: of the 7.2 million people said to gain government insurance, just 1.3 million were over 65 -- and their ranks would presumably be spread fairly evenly among income groups. Adults under 65 who gained public insurance through disability could be a factor. I'd be grateful for any insights as to how those below the poverty line gained private insurance -- and those well above it gained public.

Update, 9/18: Ruminating on the oddities a bit further: According to the census, the net gain in public insurance from 2013 to 2014 for people with incomes under 100% FPL was just 820,000 (as noted above, the total was 1.3 million for those under 138% FPL). In November 2014, HHS announced that thanks to the ACA, Medicaid and CHIP enrollment had increased by 9.1 million from September 2013 to September 2014. By the end of 2014, Charles Gaba had tracked about 11 million Medicaid signups reported by the states, including close to 8 million made eligible by the ACA Medicaid expansion. I realize these are not apples-to-apples comparisons. The census surveys define household income differently; they also count anyone who had a given type of insurance for any portion of the year (even, say, a week) as part of the total for that insurance type -- though you'd think that would make census totals larger. Still, something does not compute here,

Update, 9/20: In response to the Census data, Robert Greenstein, president of the Center for Budget and Policy Priorities, highlights the centrality of the Medicaid expansion to the reduction in the ranks of the uninsured:
Today’s data underscore the importance of state participation in health reform’s Medicaid expansion.  As a group, the 25 states (including the District of Columbia) that expanded Medicaid by January 2014 had much larger declines in their uninsured populations than the other 26.  If the uninsured rate had fallen in non-expansion states at the same rate as in expansion states, an additional 2.6 million uninsured Americans would have gained coverage last year.
That estimate further underscores the question: how could the net gain in public insurance among those under 138% FPL be so low? Perhaps the difference in methods of calculating household size and income is key.  Another possibility: Charles Gaba and I were ruminating on Twitter about the possibility that many who have benefited from the Medicaid expansion don't recognize their coverage as Medicaid. Charles went on to note in a post that just 12 states call their Medicaid programs "Medicaid." On the other hand, the CPS and ACS surveys go to some length to verify the types of insurance respondents say they have (or had).  CPS has redesigned its questionnaire to capture respondents' insurance status and recent insurance history more accurately.

Update 9/23: I just happened on a post of my own from this past June which reminds me that the NHIS survey, which came out that month, found that the percentage of  adults with household incomes under 100% FPL who had public insurance increased 4.2 percentage from 2013 to 2014, from 42.4% to 46.6%, while private insurance for the poor increased from 19.0% to 21.9%. For the near-poor (100-199% FPL), according to the NHIS, public insurance increased 3 percentage points, from 26.6% to 29.6%, while private insurance increased 4.8 points, from 36.4% to 41.2%.  These results seem more in line with HHS enrollment reports.
* Corrected, 9/18.

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