QuickTake: Health Insurance Coverage for Parents under the ACA as of September 2014
Michael Karpman, Genevieve M. Kenney, Sharon K. Long, Nathaniel Anderson, Douglas Wissoker, and Stacey McMorrow
March 5, 2015
The Urban Institute has been using the Health Reform Monitoring Survey (HRMS) to examine trends in health insurance coverage for nonelderly adults (ages 18 to 64) and their families under the Affordable Care Act (ACA) since the first quarter of 2013 (Long, Kenney, et al. 2014). An earlier analysis of HRMS data showed that the uninsurance rate for parents with children from birth to age 17 in their households fell 14.4 percent between September 2013, just before the first open enrollment period for the ACA’s health insurance Marketplaces, and June 2014, after the first open enrollment period ended (Kenney et al. 2014). This QuickTake provides an update of that analysis, assessing coverage changes for parents between September 2013 and September 2014, just before the second open enrollment period began, and comparing coverage changes for parents to those for childless adults as context. A previous HRMS policy brief shows that the uninsurance rate for all nonelderly adults fell an estimated 30.1 percent in that period (Long, Karpman, et al. 2014).
We find that the uninsurance rate for parents fell significantly between September 2013 and September 2014, with particularly large declines in states that expanded Medicaid under the ACA, among low-income parents, and among parents who are married or living with a partner. Coverage also increased among childless adults between September 2013 and September 2014. For more detail on the coverage changes found for childless adults, see Karpman et al. (2015).
Between September 2013 and September 2014, the uninsurance rate fell 20.0 percent for parents, as compared with 35.2 percent for childless adults.
The uninsurance rate for parents fell 3.3 percentage points (95% CI [1.6, 5.0]), from 16.5 percent in September 2013 to 13.2 percent in September 2014, a decline of 20.0 percent (figure 1). In comparison, childless adults experienced a 6.5 percentage point (95% CI [5.0, 7.9]) reduction in their uninsurance rate, from 18.4 percent to 11.9 percent, a decline of 35.2 percent. This large decline found among childless adults likely reflects that eligibility for Medicaid was more limited for childless adults than for parents before the ACA’s Medicaid expansion.
Among parents, gains in insurance coverage were larger for those with low income, those living in Medicaid expansion states, and those who are married or living with a partner.
The share of low-income parents—those with family income at or below 138 percent of the federal poverty level (FPL)—with insurance increased 7.5 percentage points (95% CI [3.1, 11.9]) between September 2013 and September 2014 (figure 2), from 62.6 percent to 70.1 percent (data not shown). Estimated changes in insurance coverage for parents in middle- and higher-income families (those with income between 139 percent and 399 percent of FPL and those with income at or above 400 percent of FPL, respectively) were not statistically significant.
Though parents in Medicaid nonexpansion states experienced a 2.1 percentage-point increase in coverage (95% CI [0.3, 3.8]), parents living in Medicaid expansion states experienced a 4.2 percentage-point increase in coverage (95% CI [1.3, 7.1]). The uninsurance rate among parents in Medicaid expansion states fell from 14.5 percent to 10.2 percent, a decline of 29.3 percent (data not shown). In nonexpansion states, the uninsurance rate for parents fell from 19.1 percent to 17.1 percent, a decline of 10.8 percent (data not shown). Insurance coverage increased an estimated 4.4 percentage points for parents who are married or living with a partner (95% CI [2.3, 6.5]), but no significant change was found among single parents.
Methods: Each round of the HRMS is weighted to be nationally representative. We use these weights along with a regression adjustment to control for differences in the demographic and socioeconomic characteristics of the respondents across the different rounds of the survey. This allows us to remove any variation in insurance coverage caused by changes in the types of people responding to the survey over time rather than by changes in the health insurance landscape. The basic patterns shown for the regression-adjusted measures are similar to those based solely on simple weighted estimates. In presenting the regression-adjusted estimates, we use the predicted rate of each coverage type in each quarter for the same nationally representative population. For this analysis, we base the nationally representative sample on survey respondents from the most recent 12-month period from the HRMS (i.e., quarters 4 of 2013 and quarters 1–3 of 2014). We focus on statistically significant changes in insurance coverage over time (defined as differences that are significantly different from zero at the 5 percent level or lower) and highlight changes relative to September 2013, just before the open enrollment period for the Marketplaces began. We provide a 95 percent confidence interval for key estimates. In some rounds of the survey, the interview month starts a few days before or lasts a few days after the target month.
Our definition of parents is based on information provided in the child supplement to the HRMS. The child supplement was added to the HRMS in the second quarter of 2013 to ask questions about a randomly selected child in respondents’ households if the household included children. We have updated our definition of parents for this QuickTake. In a previous analysis (Kenney et al. 2014), we defined parents to include all adults who identified themselves as parents or guardians living with a dependent child age 17 or under who were willing and able to answer questions about their child’s health and health care, based on information provided in the child supplement to the HRMS. In this QuickTake, we focus on all parents and guardians living with a dependent child age 17 or under whether or not they were willing to answer questions about their child’s health and health care. This update has little effect on our estimates, which typically change by 0.1 to 0.2 percentage points. Our definition of childless adults includes all adults who are not parents or guardians living with a dependent child age 17 or under. It includes noncustodial parents whose children live outside of the household. Our definition of single parents includes those who are widowed, divorced, separated, or never married, and excludes those who are married or living with a partner. In discussing changes by state Medicaid expansion status, we focus on expansion status as of September 1, 2014. States that had expanded Medicaid by this date are AZ, AR, CA, CO, CT, DE, DC, HI, IL, IA, KY, MD, MA, MI, MN, NH, NV, NJ, NM, NY, ND, OH, OR, RI, VT, WA, and WV. New Hampshire had begun its expansion just before this date, but Indiana and Pennsylvania have expanded since that time and are therefore not classified as expanding for this analysis.
Limitations to the analysis: The HRMS is designed to provide early feedback on ACA implementation to complement the more robust assessments that will be possible as more federal survey data become available. Though these HRMS estimates capture the changes in insurance coverage under the first open enrollment period of the ACA, the estimates understate the full effects of the ACA because the estimates do not reflect the effects of some important ACA provisions (such as the ability to keep dependents on health plans until age 26 and early state Medicaid expansions) that were implemented before 2013. In addition, these estimates will reflect changes beyond the effects of the ACA because they do not control for long-term trends in health insurance coverage that predate the ACA nor do they control for changes in the business cycle. Further, the difference in coverage gains between the states that did and did not expand Medicaid should not be entirely attributed to the Medicaid expansion; there were other policy choices that likely affected enrollment. For example, many of the nonexpansion states did not set up their own Marketplaces and therefore did not get the same access to outreach and enrollment assistance funding.
Karpman, Michael, Genevieve M. Kenney, Sharon K. Long, Nathaniel Anderson, Douglas Wissoker, and Stacey McMorrow. 2015. “QuickTake: Taking Stock: Health Insurance Coverage for Childless Adults under the Affordable Care Act as of September 2014.” Washington, DC: Urban Institute.
Kenney, Genevieve M., Nathaniel Anderson, Sharon K. Long, Lisa Dubay, Stacey McMorrow, Lisa Clemans-Cope, Michael Karpman, and Douglas Wissoker. 2014. “Taking Stock: Health Insurance Coverage for Parents under the ACA in 2014.” Washington, DC: Urban Institute.
Long, Sharon K., Michael Karpman, Adele Shartzer, Douglas Wissoker, Genevieve M. Kenney, Stephen Zuckerman, Nathaniel Anderson, and Katherine Hempstead. 2014. “Taking Stock: Health Insurance Coverage under the ACA as of September 2014.” Washington, DC: Urban Institute.
Long, Sharon K., Genevieve M. Kenney, Stephen Zuckerman, Dana E. Goin, Douglas Wissoker, Fredric Blavin, Linda J. Blumberg, Lisa Clemans-Cope, John Holahan, and Katherine Hempstead. 2014. “The Health Reform Monitoring Survey: Addressing Data Gaps to Provide Timely Insights into the Affordable Care Act.” Health Affairs 33 (1): 161–67.
About the Series
This QuickTake is part of a series drawing on the HRMS, a quarterly survey of the nonelderly population that is exploring the value of cutting-edge Internet-based survey methods to monitor the ACA before data from federal government surveys are available. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute. This quick take was funded by the David and Lucile Packard Foundation. It draws on the HRMS-Kids which was conducted in partnership with the Center for Children and Families at Georgetown University and is currently funded by the David and Lucile Packard Foundation. The authors are grateful to Lisa Clemans-Cope, Lisa Dubay, Joan Alker, Tricia Brooks, and Liane Wong for their input on the HRMS-Kids.
For more information on the HRMS and for other QuickTakes in this series, visit www.urban.org/hrms.