Tuesday, August 31, 2021

NHIS: No shift from private to public insurance?

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The annual early release estimates from the National Health Interview Survey (NHIS) came out today. The NHIS recorded a decrease in the uninsured rate for all ages from 2019 to 2020, from 10.3% to 9.7%, but deemed the change statistically insignificant. Among adults aged 18-64, the uninsured rate  dropped from 14.7% to 13.9% -- also deemed not significant. Similarly, the Urban Institute survey report that I wrote about last week found essentially no change in the uninsured rate from March 2019 to April 2021 -- but also recorded a statistically insignificant drop. 

Directionally, as I noted last week, most surveys, including the Census's experimental Household Pulse Survey, point to a modest drop in the uninsured population during the pandemic. Big picture: huge gains in Medicaid enrollment, driven largely by a pause in disenrollments effectively mandated by pandemic relief legislation, appear to have outstripped drops in access to employer-sponsored insurance (ESI), which according to various sources fell less than the massive job losses triggered by the pandemic might have led one to expect. But there are a lot of moving parts that may have canceled one another out. 

This year's NHIS report cites more than usual uncertainty in the results, driven by the pandemic:

Due to the COVID-19 pandemic, National Health Interview Survey data collection switched to a telephone-only mode beginning March 19, 2020. Personal visits resumed in all areas in September 2020, but cases were still attempted by telephone first. These changes resulted in lower response rates and differences in respondent characteristics for April–December 2020. Differences observed in estimates between 2020 and earlier time periods may still be impacted by these changes.

I'd like to point to one oddity in this year's results: the NHIS found essentially no difference from 2019 to 2020 in the percentages of the population with public and private insurance. Among 18-64 year-olds, 20.4% of respondents said they had public coverage in 2019 at the time of interview -- and 20.5% in 2020.  66.8% reported private coverage in 2019, and 67.5% in 2020, a statistically insignificant increase. Among the entire under-65 population (including children) both public and private coverage among respondents ticked up 0.4 percentage points, also statistically insignificant.

In apparent contrast, the Urban Institute's ongoing survey found that 5.5 million fewer people had employer-sponsored coverage in March 2021 than in March 2019, and that basically all of that drop occurred between March 2020 and March 2021. (Private nongroup coverage also downticked slightly, according to Urban.) As of September 2020,  KFF estimated a smaller but still substantial drop in ESI coverage, between 2 and 3 million. That analysis was based on insurer data.

At the same time, based on state enrollment reports sent to CMS, Medicaid enrollment increased by 9 million (12.6%) nationally from December 2019 to December 2020 (and by a bit more than 8 million from January 2019 to December 2020).  Medicaid enrollment growth was faster among adults than among children, rising 16.8% from February 2020 to December 2020. Urban estimated an increase in public insurance (7.9 million) larger than the drop in employer-sponsored insurance. Yet the NHIS finds no significant change in either public or private insurance from 2019 to 2020. 

Emily Gee of the Center for American Progress points out that "private" insurance includes the individual market, which could have made up some of the loss in ESI. True, but only a silver of it. Average monthly enrollment in the ACA's Health Insurance Marketplace increased from 9.8 million in 2019 (p. 7) to 10.4 million in 2020 (p. 6), an increase of 600,000. (In 2021, the flood of new ACA marketplace enrollment in the emergency Special Enrollment Period that ran from Feb. 15 to Aug. 15 -- more than 2.5 million newly enrolled  -- may make a real dent in the uninsured rate, while Medicaid enrollment continues to grow during the ongoing moratorium for disenrollments.)

It's a persistent problem for survey-based health insurance estimates that many Medicaid enrollees tend to identify their coverage as "private" -- as most enrollees are now in branded managed care plans (and insurance behemoths like UHC and  CVS Aetna are major players). Perhaps a large number of NHIS respondents identified newly acquired Medicaid coverage as private. Perhaps not. Results in the "early release" are preliminary.  But the flat year-over-year results for public and private insurance seem odd. One would think there would have been a shift from private to public insurance in 2020. 

Another point worth noting. Among people under 65 and adults aged 18-64, while the results from January to June barely budged from full-year 2019 to full-year 2020, the uninsured rate dropped by more than a percentage point from July through December: from 13.0% to 11.9% for all people under age 65, and from 15.6% to 14.3% for the 18-64 age group. Pandemic effects did not take hold until April.  On the other hand, NHIS quarterly estimates, which run through Q1 2021, show the overall uninsured rate barely budging from Q1 2020 to Q1 2021. Quarterly estimates are more volatile, though. Both the early release and the quarterly estimates are published "prior to final data editing and final weighting."

One more note. The income group that shows a real jump in public insurance is the 100-200% FPL bracket: from 35.4% in 2019 to 38.8% in 2020 among 18-64 year-olds. (full year). In the quarterly tables,  public insurance from ages 18-64 jumped from 36.4% in Q1 2020 to 42.3% in Q1 2021. 

In states that have enacted the ACA Medicaid expansion, Medicaid eligibility for adults extends to 138% FPL -- based on monthly income. For the extent of the public health emergency, beginning in March 2020 and still ongoing, there are no income checks or "redeterminations."  Some people who earned a fair amount through much of 2020 may have qualified for Medicaid after a sudden drop in monthly income, and some whose income rose above the eligibility threshold once they were enrolled may be able to stay enrolled.

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