HRMS Issue Brief #12: Change in Insurance Status of Adult Texans by Demographic Group as of March 2015
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Elena M. Marks
Senior Fellow in Health PolicyVivian Ho
James A. Baker III Institute Chair in Health EconomicsPhilomene Balihe
Data Analyst, Episcopal Health FoundationShare this Publication
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Marks E, Ho V, Balihe P. James A. Baker III Institute for Public Policy, Rice University, The Episcopal Health Foundation, Health Reform Monitoring Survey – Texas, Issue Brief #12: Change in Insurance Status of Adult Texans by Demographic Group as of March 2015. Houston Texas: 2015.
In March 2015, as the second open enrollment period of the Affordable Care Act’s (ACA) Health Insurance Marketplace was drawing to a close, we surveyed adult Texans ages 18 to 64 to examine changes in insurance status since the opening of the Marketplace. As we reported in Issue Brief #11, the overall rate of uninsured adult Texans fell by more than 30%, from 24.6% to 16.9%. In this brief, we examine the change in uninsured rates based on eight demographic characteristics to understand the relative changes among groups. We also compare the Texas data to the national HRMS data and report on similarities and differences between Texas and the US.
About the Survey
The Health Reform Monitoring Survey (HRMS) is a quarterly survey of adults ages 18-64 that began in 2013. It is designed to provide timely information on implementation issues under the ACA and to document changes in health insurance coverage and related health outcomes. HRMS provides quarterly data on health insurance coverage, access, use of health care, health care affordability, and self-reported health status. The HRMS was developed by the Urban Institute, conducted by GfK, and jointly funded by the Robert Wood Johnson Foundation, the Ford Foundation, and the Urban Institute. Rice University’s Baker Institute and The Episcopal Health Foundation are partnering to fund and report on key factors about Texans obtained from an expanded, representative sample of Texas residents (HRMS-Texas). The analyses and conclusions based on HRMS-Texas are those of the authors and do not represent the view of the Urban Institute, the Robert Wood Johnson Foundation or the Ford Foundation. Information about the sample demographics of the cohort is available in Issue Brief #1. This Issue Brief is a summary of data extracted from the HRMS Surveys in Texas administered between September 2013 and March 2015. We will continue to report on survey data through additional Issue Briefs and future surveys.
Characteristics and Changes in Rates of the Uninsured in Texas, September 2013 to March 2015
We wanted to know how the reductions in the rate of uninsured adult Texans as a whole were experienced by various demographic groups and, if so, whether some groups experienced greater reductions than others. Table 1 below shows the rates of uninsured Texans among eight demographic groups and the rates of reduction for each group. We were especially interested to examine how the groups with the lowest rates of coverage pre-Marketplace, who stood the most to gain from the ACA, were impacted.
Table 1 — Uninsured Rates by Group, Texas Adults 18–64
Hispanics had the most to gain from the ACA. Before the Marketplace, Hispanics had the highest rates of uninsured (39.1%), and as of March 2015, this group still had the highest rates of uninsured (24.3%). The survey shows that Hispanics achieved the largest reduction in uninsured between September 2013 and March 2015 with a 37.8% decrease in the percent uninsured compared to the reductions achieved by Whites (24.8%) and Blacks (4.5%). These results are consistent with the Department of Health and Human Services’ decision to boost resources aimed at increasing enrollment among Latinos during the most recent enrollment period.
The change in insurance status of women follows a similar pattern. Women were more likely than men to be uninsured in 2013, and while they still had higher rates of uninsurance than men in 2015, they experienced a more significant decrease in uninsurance (31.8% compared to 22.8%) and are closing the gap (from 6 to 2.2 percentage points).
In the case of Texans with the lowest incomes and educational attainment, who had the highest rates of uninsurance in 2013 and therefore the greatest opportunity for improvement, the data showed the opposite outcome. Those who did not complete high school and those with incomes at or below 138% of the federal poverty level (FPL) did experience reductions in the rate of uninsured, but the rates of reduction were substantially lower than those with higher educational attainment and higher incomes. For example, the percentage uninsured dropped by more than 9 percentage points for all persons in households earning up to 399% of FPL. However, the proportion uninsured dropped by almost one-half for those between 139 and 399% of FPL, while the fraction of uninsured dropped by less than one quarter for those under 139% of FPL. Similarly, while those who were not employed saw reductions in the rate of uninsurance from 2013 to 2015, the reductions were only a fraction of those experienced by employed persons. Because educational attainment, employment and earning power are closely associated, it is not surprising to see the same patterns among these groups.
In the case of Texans living in urban versus rural areas, the survey shows that both groups made steady and substantially the same reductions in the portion of uninsured (28% and 27.2%, respectively). While those living in urban areas had and have higher rates of coverage, those outside of urban areas are succeeding in gaining coverage.
Comparisons Between Texas and the United States
Table 2 below shows the rates of uninsured adults ages 18-64 throughout the United States among eight demographic groups and the decreases in the rates of uninsurance for each group as reported in the national HRMS survey. As the data show, Texas and the US followed similar patterns with respect to some groups, but not others.
Table 2 — Uninsured Rates by Group, U.S. Adults 18–64
As in Texas, Hispanics had the highest rates of uninsurance in 2013 and 2015 and, as in Texas this group made substantial gains in coverage. However, while in Texas Hispanics showed the greatest decreases in rates of uninsurance, they did not do so in the US as a whole. Because Texas has a higher percentage of Hispanic adults than the US as a whole, it is more important here than in most states that this population become insured to increase the overall rate of coverage.
At the national level, Blacks had the greatest reduction in the percent of uninsured (46.7% compared to 40.7% for Whites and 41.6% for Hispanics), while in Texas, Blacks experienced the smallest decrease among all races/ethnicities and among all demographic groups examined. The rate of uninsurance for Blacks in Texas was lower than for the US in 2013 (16.5% vs. 19.4%) but is now higher in 2015 (15.8% vs. 10.4%). Further analysis is needed to understand why Texas is not seeing more significant decreases in uninsured rates for Blacks as compared to the US as a whole and to other groups in Texas.
Across the US, as in Texas, those at or below 138% of the FPL and those who did not complete high school experienced the lowest decreases in rates of uninsurance. The rate of uninsurance for those at or below 138% of the FPL is nearly twice as high in Texas as in the US as a whole, likely because most states, unlike Texas, have expanded their Medicaid programs to include this population. Medicaid expansion is likely the reason that the national survey shows that those who were unemployed experienced significant decreases in rates of unisurance, while unemployed Texans did not.
Looking Ahead
We will continue to analyze and report on the March 2015 data to understand the characteristics and experiences of newly insured Texans and those who remain uninsured.
Methodology
Each quarter’s HRMS sample of nonelderly adults is drawn from active KnowledgePanel® members to be representative of the US population. In the first quarter of 2013, the HRMS provided an analysis sample of about 3,000 nonelderly (age 18–64) adults. After that, the HRMS sample was expanded to provide analysis samples of roughly 7,500 nonelderly adults, with oversamples added to better track low-income adults and adults in selected state groups based on (1) the potential for gains in insurance coverage in the state under the ACA (as estimated by the Urban Institute’s microsimulation model) and (2) states of specific interest to the HRMS funders.
Although fresh samples are drawn each quarter, the same individuals may be selected for different rounds of the survey. Because each panel member has a unique identifier, it is possible to control for the overlap in samples across quarters.
For surveys based on Internet panels, the overall response rate incorporates the survey completion rate as well as the rates of panel recruitment and panel participation over time. The American Association for Public Opinion Research (AAPOR) cumulative response rate for the HRMS is the product of the panel household recruitment rate, the panel household profile rate, and the HRMS completion rate—roughly 5 percent each quarter.
While low, this response rate does not necessarily imply inaccurate estimates; a survey with a low response rate can still be representative of the sample population, although the risk of nonresponse bias is, of course, higher.
All tabulations from the HRMS are based on weighted estimates. The HRMS weights reflect the probability of sample selection from the KnowledgePanel® and post-stratification to the characteristics of nonelderly adults and children in the United States based on benchmarks from the Current Population Survey and the Pew Hispanic Center Survey. Because the KnowledgePanel® collects in-depth information on panel members, the post-stratification weights can be based on a rich set of measures, including gender, age, race/ethnicity, education, household income, homeownership, Internet access, primary language (English/Spanish), residence in a metropolitan area, and region. Given the many potential sources of bias in survey data in general, and in data from Internet-based surveys in particular, the survey weights for the HRMS likely reduce, but do not eliminate, potential biases.
The design effect for the Texas data in March 2015 is 2.184 and the MOE is +/- 3.7. The survey fielded from March 5-30.