U.S. uninsured rate hits an all-time low; Biden's HHS takes a victory lap; xpostfactoid claims prepostfactoid credit

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Record broken!

Biden's HHS took something of a victory lap yesterday, announcing that the national uninsured rate -- 8.0% for all ages --  was at an all-time low in the first quarter of 2022. Since the fourth quarter of 2020, the uninsured rate has dropped by 2.7 percentage both for ages 18-64 and for children, according to the ASPE* brief.

The brief is based on quarterly updates from the National Health Interview Survey. Those updates are notoriously bouncy, but the change over the time frame selected is clearly statistically significant. 

The brief asserts: "These gains in health insurance coverage are concurrent with [mustn't claim causality, now...] the implementation of the American Rescue Plan’s enhanced Marketplace subsidies, the continuous enrollment provision in Medicaid, several recent state Medicaid expansions, and substantial enrollment outreach by the Biden-Harris Administration in 2021- 2022."

I must note that I've been something of a canary in the coal mine on this front, first speculating that we might be approaching an uninsured low in April 2021; wondering whether the 2021 Special Enrollment Period coupled with the ARPA subsidy boosts might have got us there by late August 2021; and parsing the NHIS quarterly data in light of the 2022 marketplace enrollment surge in January 2022.

Ultimately, I noted in the January post, the enrollment math, if not the survey data, told a fairly simple story:

On climbing out of the ACA coverage gap

The latest quarterly estimates of health insurance coverage from the National Health Interview Survey (NHIS) show a drop in the uninsured rate for all ages from 9.7% in Q2 2021 to 8.9% in Q3. That's probably not statistically significant. The confidence intervals largely overlap;  quarterly rates bounce around quite a bit; they are "published prior to final data editing and final weighting"; and response rates have been affected by the pandemic.

That said, the changes among adults aged 18-64 in the lowest income segment -- those with incomes below the Federal Poverty Level -- may be worth pausing over:

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. 

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 HealthCare.gov 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.

NHIS puts individual market angst in perspective

The Kaiser Family Foundation reports that individual market enrollment dropped by about 2 million from the first quarter of 2017 to the first quarter of 2018. Medicaid/CHIP enrollment is down by about 1 million in the same period, to 73.8 million in April of this year (preliminary count*).

Together those reported drops, if accurate, would account for about 1% of the U.S. population under age 65.  Yet according to the preliminary results of the National Health Interview Survey (NHIS) for the first quarter of 2018, released this week, the uninsured population has not changed significantly since 2017.  In fact, the percentage of the total population that is uninsured has downticked from 9.1% to 8.8%, and among the under-65 population from 10.7% to 10.3%, though those changes are not deemed statistically significant.

Who are the "20 million" insured via the ACA?

In references to the roughly 20 million people the ACA has said to have insured, three things tend to be conflated: 1) the net increase in the insured population since ACA enactment (roughly 20 million), 2) the number insured through the ACA marketplace (10-11 million at present), and 3) the number insured through the individual market (18-20 million, about half of them subsidized).

Below, a few points aiming to clarify who's benefiting and to what degree. Teaser: don't miss my slicing of CPS data in the chart below.

1. The contributing streams to the 20 million increase in insured Americans include  a) an increase of 17 million in Medicaid enrollment since July-Sept. 2013, including nearly 12 million categorized by states as rendered newly eligible by the ACA; b) 8-9 million subsidized enrollees in the ACA marketplace, contributing to an increase in overall individual market enrollment of roughly the same size;c)  2-3 million adults under age 26 added to their parents' health plans; and 4) a possible moderate increase in enrollment in employer-sponsored plans.

Is employer-sponsored insurance superior to ACA marketplace plans? For whom?

So far, the Affordable Care Act has not curtailed the availability of employer-sponsored insurance (though it may have curtailed its growth). On the front page of today's New York Times, Reed Abelson reports that "health care remains an important recruitment and retention tool as the labor market has tightened in recent years." One part of her explanation is "mostly true," as the fact-checkers say -- but hides an important fact about what kind of insurance is available to whom:

The law has resulted in more coverage for low-income people, as expected. But...the plans on the exchanges remain less generous than those offered by many employers, with significantly higher deductibles and a significantly narrower choice of hospitals and networks.

That's probably true for most workers whose employers offer them insurance. It's not true, however, with respect to out-of-pocket costs for workers whose household income is below 201% of the Federal Poverty Level (FPL). As I noted last Friday, for ACA enrollees with incomes below that threshold, the average weighted actuarial value (AV) of the plans they obtain -- that is, the percentage of the average user's costs that the plan will cover -- is 86%.  The average AV in employer-sponsored insurance was estimated by the Kaiser Family Foundation at 82% back in 2011 -- and it's probably dropped since then.  It's likely to be still lower for lower income workers.

How the ACA reversed two decades of insurance bleeding for the near-poor (and cut uninsurance for the poor too)

I've noted before that while the ACA works best for uninsured people with incomes under 200% of the Federal Poverty Level (FPL),* that's also where the uninsured are concentrated. While just about exactly one third of the U.S. population is below 200% FPL,  55% of the uninsured were below that level in 2013,  according to the Census Bureau's  Census' Current Population Survey 2015 Annual Social and Economic Supplement.**

A Health Affairs article by Nicole Huberfeld and Jessica Roberts spotlights one reason for the concentration of the uninsured at low income levels. While the availability (or affordability) of employer-sponsored insurance has dropped for all income levels since early this century,

The decreases in coverage were measurably greater for middle- to low-income workers; for example, those earning more than 400 percent of the federal poverty level (FPL) experienced a 2.8 percent drop in employer-sponsored coverage from 2000 to 2011, but people earning less than 200 percent of the FPL experienced a 10.1 percent drop in employer-sponsored coverage.

That snippet sent me to the most recent National Health Interview Survey  (NHIS) update, which indicates that the ACA has plugged this gap by making both private and public insurance available to lower income workers. (Stats for 1997-2010 are here.)

The Counter-Upshot: Obamacare is quite as egalitarian as it appears

Tyler Cowen draws a rather odd conclusion from the spike this year in premiums for health plans sold in the nongroup market: The ACA is not as egalitarian as it appears.

Cowen legitimately spotlights the weakness of the ACA value proposition for uninsured people with incomes above 250% of the Federal Poverty Level (FPL) and so for a large group of the remaining uninsured. But his discussion of its "egalitarian" impact is limited by his leaving the Medicaid expansion out of the equation (if not entirely out of the discussion).

Cowen bases his case that "by some measures, the Affordable Care Act has had only a limited impact on economic inequality" mainly on a recent study* by Wharton School researchers led by health economist Mark Pauly.* Pauly et al found that slightly less than half of the still-uninsured who are eligible to buy health plans on the ACA exchanges would not experience "welfare improvements" if they buy health plans. Cowen summarizes:

An NHIS non sequitur

Back in February, I complained that Gallup had conflated the effects of a state expanding Medicaid with the effects of a state running its own ACA exchange. All states running their own exchanges but one (Idaho) accepted the Medicaid expansion, making the conflation easy. But their superior performance in reducing the uninsurance rate was due entirely to the Medicaid expansion, not the decision to create their own exchanges. State-run exchanges got good press early on because most were not as dysfunctional as healthcare.gov in fall 2013. But some were even worse, and by the end of open season 2015 they had not collectively outperformed the federal exchange with regard to enrolling their potentially eligible populations.

CDC today released results of the National Health Interview Survey for the first 6 months of 2015. It's a trove of information about who's gained insurance over the last two years and who's still uninsured. But it contains one apparent non sequitur that recalls Gallup's:

Stat shots of the unsubsidized uninsured

Barring any slip between cup and lip, I should have an article coming out soon that recounts the experiences of several people who do not qualify for ACA subsidies but who have bought insurance plans for 2014 in the new ACA-enacted universe.  A preview is here. In the process, I've tried to get a grip on just how many such people there may be and how they're likely to fare under the ACA.

A Health Affairs post by Urban Institute researchers Lisa Clemans-Cope and Nathaniel Anderson has helped me bring the statistical picture into focus. I should say into relative focus, because there's a good deal of uncertainty in every stat shot. With that caveat, here goes:

• Estimates based on 2009 surveys conducted by different federal agencies as to how many Americans were buying insurance in the individual market vary widely, from 9.1 million in the Medical Expenditure Panels Survey to 25.3 million in the American Community Survey. A mid-range estimate from the National Health Interview Survey (NHIS) conducted by the CDC is 14.0 million.


• In December 2013, the Health Reform Monitoring Survey found that 18.6% of those insured in the individual market received cancellation notices attributing cancellation to the ACA, and  another 6% had their policies cancelled for other stated reasons.  Using that data, and the NHIS estimate of 14 million in in the individual market, Clemans-Cope and Anderson  estimate that 2.6 million people received policy cancellations that their insurers blamed on the ACA (and one might infer another 840,000 cancelled for other stated reasons).


• According to a March 2013 Urban Institute study, 48.6% of those currently in the individual market are ineligible for subsidies. If that ratio is right, and the estimate of 2.6 million cancellations attributed to the ACA is on target, about 1.2 million people who received cancellation notices blamed on the ACA would be ineligible for subsidies.  Of those, some probably had pre-existing conditions and will do better under the ACA.
  


• The Urban Institute study estimates the current individual market at 12.8 million, 6.2 million of whom would be subsidy-ineligible.