Thursday, August 26, 2021

Is the uninsured rate flat since 2019, or down a bit?

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See 8/31 update from NHIS survey at bottom

The Urban Institute, in an analysis of results from its own ongoing Heath Reform Monitoring Survey, found that the uninsured rate among adults aged 19-64 did not change significantly from March 2019 to April 2021. 

That's at least a backhanded tribute to the U.S.'s kludgy health insurance safety net as bolstered by the Affordable Care Act. Big picture: in Urban's estimate, as a result of the pandemic, employer-sponsored insurance  fell by 3 percentage points (from 65% to 62.3%) in the survey period, while insurance through public programs (mainly Medicaid) increased by 4 percentage points (from 13.6% to 17.5%). 

You could read these results as a paean to the ACA Medicaid expansion (which Republicans almost repealed in 2017). In states that have expanded Medicaid, Urban found that the uninsured rate actually dropped two percentage points for people with incomes below 138% FPL, the Medicaid eligibility threshold. According to CMS, total Medicaid enrollment (including children) increased by 11 million -- 15.6% -- from February 2020 to March 2021.  Enrollment among adults rendered eligible by the expansion increased by about double that rate.

Urban recorded a much more modest and ambiguous impact for the ACA marketplace -- though the huge enrollment surge during the emergency Special Enrollment Period open from February 15 through August 15 of this year, turbo-charged by subsidy increases enacted in the American Rescue Plan, which appeared on on April, was mainly missed by Urban's study period. I'll return to that in a bit.

I speculated in May that the U.S. uninsurance rate might be at an all-time low, powered by huge gains in Medicaid enrollment, significant gains in marketplace enrollment, and relatively modest losses in employer-sponsored insurance during the pandemic. My methods (and math) are far less sophisticated than Urban's, and this is not to question their results (no source ever has a really complete picture of insurance in the U.S.).  That said, a few comments and caveats below.

  • By Urban's own estimate, the gains in public insurance (7.9 million) outstripped the losses in ESI (5.5 million). Urban did not find the difference (thinned slightly by a slight drop in individual market enrollment) statistically significant, but it's a data point.

  • In December, the Kaiser Family Foundation estimated a smaller drop than Urban in ESI, at least through September of last year (2-3 million). That's based on administrative data. Urban does not provide mid-pandemic estimates, however.

  • As I noted in my May post, the experimental, real-time Household Pulse Survey fielded by the Census Bureau and the National Center for Health Statistics indicates a lower uninsured rate for adults aged 18-64 at present (10.8% from Aug. 4 to Aug. 16, 2021) -- and through much of the pandemic -- than that recorded for adults 18-64 in the better-established National Health Interview Survey, or NHIS (13.4% in Jan-June 2020, down slightly from 13.7% in Jan-June 2019). The Pulse survey is conducted online only, and results are volatile, but on balance, they have fallen since the pandemic struck.  A new NHIS report is due next week, on Aug. 31.

  • According to the NHIS, Medicare enrollment increased by about 2 million from 2019 to 2020. Presumably Medicare enrollment has increased further this year. That doesn't affect the uninsured rate for adults 18-64 tracked by Urban, unless disability Medicare enrollment is also increasing significantly. But with an aging population, it probably pushes down the uninsured rate for all ages.

  • Urban finds a slight drop in the overall percentage of the adult population insured through the individual market, from 8.0% in March 2019 to 7.7% in April 2021 (essentially flat). That could be the case, if unsubsidized off-exchange enrollment dropped during the pandemic. In the ACA marketplace, however, enrollment from February 2019 to February 2021 increased by over 700,000 (6.7%). Then came the surge in emergency SEP enrollment -- more than 2.5 million new enrollments from February 15 through July 31 this year. Most of that was outside the Urban survey period. But marketplace enrollment is probably up by about 20% year-over-year since 2020 and 26% since 2019. Surely marketplace enrollment in the current month exceeds enrollment in August 2019 (9.6 million*) by more than 2 million, and likely by more than 2.5 million -- though those gains may be partly offset by off-exchange enrollees switching to on-exchange after the American Rescue Plan removed the income cap on subsidies.
Urban's survey results do show the marketplace picking up significant slack in nonexpansion states -- insuring 12.9% of adults in those states with incomes in pre-ARPA subsidy range, 138-400% FPL, in 2021, compared to 10.9% in 2019. But Urban also finds that individual market enrollment dropped in those states at incomes below 138% FPL, from insuring 8.8% of the adult population in 2019 to 7.6% in 2021. I find that a bit anomalous, given huge surges in marketplace enrollment in nonexpansion states, both before and during the 2021 emergency SEP. 

Income at low levels often fluctuates and is difficult to estimate. That said...

In nonexpansion states, more than a third of enrollment is at incomes below 138% FPL. From February 2019 to February 2021, total enrollment in nonexpansion states** increased by 15.5%. 

At incomes in the 100-150% FPL range -- about 85% of which is under 138% FPL in these states -- enrollment in nonexpansion states during Open Enrollment for 2021 was up 16.7%  over OE for 2020, an increase of 425,000. 

These states subsequently accounted for half of all emergency SEP enrollment this spring and summer (though again, most SEP enrollment would not be reflected in the Urban report). By my estimate, as of June of this year, enrollment in nonexpansion states was up 41% since June 2019. Enrollment during the 2021 SEP at the 100-150% FPL level likely totaled slightly less than 600,000 through June -- about 360,000 above SEP enrollment in the same period in 2020, which was itself elevated.

All this is to say I would expect individual market enrollment at incomes below 138% FPL in nonexpansion states to be up -- already as of March of this year, and all the more so now. I would also expect growth in individual market enrollment at all income levels to have shaved maybe 1% off the uninsured rate since early 2019 -- though the just-ended SEP would account for a chunk of that.

In short, I would venture that enrollment data, which is different from survey data, points toward at least a slight drop in the uninsured rate since early 2019. We'll see what the NHIS (also survey data) suggests next week -- and again, when all of 2021 is accounted for.

UPDATE, 8/31: The NHIS survey for 2020 is out. Top line:

In 2020, 31.6 million persons of all ages (9.7%) were uninsured at the time of interview. This is lower than, but not significantly different from, 2019 where 33.2 million persons of all ages (10.3%) were uninsured

Among adults aged 18-64, NHIS found that the uninsured rate dropped from 14.7% in 2019 to 13.9% in 2020. That drop is also deemed not statistically significant. The NHIS findings are thus pretty much in line with Urban's.


* See monthly effectuated enrollment, 2019, p. 11

** Excluding Wisconsin, which has no 'coverage gap,' providing Medicaid to adults up to the 100% FPL threshold for marketplace subsidy eligibility. 

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