QuickTake: Uninsurance Rate Halved for Adults with Chronic Conditions
Adele Shartzer, Genevieve M. Kenney, Stephen Zuckerman
April 16, 2015
The Urban Institute has been using the Health Reform Monitoring Survey (HRMS) to examine trends in health insurance coverage since the first quarter of 2013. Recent HRMS data show an estimated 15.0 million adults ages 18 to 64 gained coverage between September 2013 (95% CI [11.9 million, 18.1 million]), just before the first open enrollment period for the Affordable Care Act’s (ACA) health insurance Marketplaces, and March 2015, just after the close of the second open enrollment period (Long et al 2015). This QuickTake explores how coverage changed between September 2013 and March 2015 for nonelderly adults with chronic conditions,1 overall and by family income and state Medicaid expansion status. Though historically, adults with chronic conditions have been less likely to be uninsured than their healthier counterparts, research suggests that gaining insurance coverage may be particularly beneficial for uninsured adults with chronic conditions, leading to better access to needed care (Davidoff and Kenney 2005; Johnson et al. 2012; McWilliams et al. 2007). Improved care management for adults with some chronic conditions can reduce potentially preventable and costly hospitalizations (Moy, Chang, and Barrett 2013). The ACA includes several provisions that should expand the availability of insurance coverage for adults with chronic conditions, including the Medicaid expansion, subsidized coverage available through the Marketplaces, and the elimination of preexisting conditions exclusions in private coverage.
We find that the share of nonelderly adults with chronic conditions who are uninsured decreased 6.7 percentage points (95% CI [5.3, 8.1]; figure 1) between September 2013 and March 2015, from 13.2 percent to 6.5 percent (data not shown).2 This represents a 50.7 percent decline in uninsurance for these adults following the implementation of key ACA provisions. The decrease in uninsurance is particularly large among low-income adults with chronic conditions targeted by the ACA’s Medicaid expansion (those with family income at or below 138 percent of the federal poverty level [FPL]): 14.0 percentage points (95% CI [9.5, 18.5]) representing a 52 percent reduction in uninsurance. Simultaneously, adults with chronic conditions targeted by the ACA’s Marketplace subsidies (those with family income between 139 and 399 percent of FPL) experienced a 7.0 percentage point (53 percent) decline in uninsurance (95% CI [3.7, 10.3]). Adults with chronic conditions in states expanding Medicaid saw a 7.1 percentage-point decline in uninsurance (which represents a decline of 64 percent); adults with chronic conditions in states that had not expanded Medicaid saw a 6.2 percentage-point (38 percent) decline. The reductions in uninsurance found for adults with chronic conditions, particularly those with low incomes, suggests that the ACA may be improving access to care and affording greater financial protections to vulnerable groups of adults, for whom having health insurance coverage may be vital.
Methods: Each round of the HRMS is weighted to be nationally representative. We use these weights and 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 uninsurance 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., quarter 1 of 2015 and quarters 2–4 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.
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 HRMS estimates capture the changes in insurance coverage from the first open enrollment period under 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 change estimates might not reflect only 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 ACA; 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.
Sharon K. Long, Michael Karpman, Genevieve M. Kenney, Stephen Zuckerman, Douglas Wissoker, Adele Shartzer, Nathaniel Anderson, and Katherine Hempstead. 2015. “Taking Stock: Health Insurance Coverage under the ACA as of March 2015.” Washington, DC: Urban Institute.
Canadian Institute for Health Information. 2013. Health Indicators 2013: Definitions, Data Sources and Rationale, May 2013. Ottawa, Ontario: Canadian Institute for Health Information.
Davidoff, Amy, and Genevieve M. Kenney. 2005. “Uninsured Americans with Chronic Health Conditions: Key Findings from the National Health Interview Survey.” Princeton, New Jersey: Robert Wood Johnson Foundation.
GfK. 2013. KnowledgePanel Design Summary. Palo Alto, CA: GfK.
Johnson, Pamela Jo, Neha Ghildayal, Andrew C. Ward, Bjorn C. Westgard, Lori L. Boland, and Jon S. Hokanson. 2012. “Disparities in Potentially Avoidable Emergency Department (ED) Care: ED Visits for Ambulatory Care Sensitive Conditions.” Medical Care 50 (12): 1020–28.
McWilliams, J. Michael, Ellen Meara, Alan M. Zaslavsky, and John Z. Ayanian. 2007. “Health of Previously Uninsured Adults After Acquiring Medicare Coverage.” Journal of the American Medical Association 298 (24): 2886–94.
Moy, Ernest, Eva Chang, and Marguerite Barrett. 2013. “Potentially Preventable Hospitalizations — United States, 2001–2009.” Morbidity and Mortality Weekly Report 62 (3): 139–43.
About the Series
This QuickTake is part of a series drawing on the HRMS, a quarterly survey of the nonelderly population that explores the value of cutting-edge Internet-based survey methods to monitor the Affordable Care Act before data from federal government surveys are available. The QuickTakes provide information on health insurance coverage, access to and use of health care, health care affordability, and self-reported health status, as well as timely data on important implementation issues under the ACA. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute.
For more information on the HRMS and for other QuickTakes in this series, visit www.urban.org/hrms.
1 We limit our sample to adults who, while completing their household demographic profile (part of becoming a member of GfK’s KnowledgePanel, the Internet-based panel that underlies the HRMS [GfK 2013]), identified themselves as having ever been told by a doctor they have one of the following conditions: asthma, chronic bronchitis, or chronic obstructive pulmonary disorder; diabetes; epilepsy; heart attack; heart disease; and high blood pressure. We base our definition of chronic conditions on ambulatory care sensitive conditions used by the Canadian Institute for Health Information, which assess the rate of hospitalizations for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital (Canadian Institute for Health Information 2013). Among respondents in the March 2015 HRMS, 30.9 percent had been diagnosed with one or more of these chronic conditions based on their GfK profile data.