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Household Pulse Survey (HPS) Insurance Coverage Trend Analysis: How Does It Compare?January 10, 2024:
The U.S. Census Bureau’s Household Pulse Survey (HPS) is an online survey that provides up-to-date monthly data on emergent issues and the social and economic wellbeing of U.S. adults. As one of the only sources of publicly available rapid response data, the HPS is a critical tool for monitoring how policies such as the “unwinding” of the Medicaid continuous coverage requirement are affecting the landscape of health insurance coverage in near real time, hopefully providing actionable information for those making and implementing policy.
However, data validation of the Household Pulse Survey is crucial, especially given its short track record and novel methods. Even while offering near-real-time data, the HPS also faces several other challenges, including a notably low response rate (6.8% as of September 2023); underrepresentation of harder-to-reach demographic groups, such as adults with lower levels of education and young adults; a lack of editing and imputation for most variables; and likely some degree of nonresponse bias.
As researchers at the State Health Access Data Assistance Center (SHADAC) utilize the subannual HPS data to monitor changes in insurance coverage, we wanted to compare the HPS’ ability to detect insurance coverage changes over time against other more established surveys that also provide subannual estimates.
To this end, we compared subannual estimates of Medicaid/CHIP coverage, private coverage, and uninsurance among U.S. civilian noninstitutionalized nonelderly adults (age 18–64) in the HPS to similar estimates in the National Health Interview Survey (NHIS) [quarterly estimates from 2021–2022] and the Behavioral Risk Factor Surveillance System (BRFSS) [monthly estimates from 2022]. Below you'll find our insurance trend analysis findings using survey data.
Our analysis reveals that HPS estimates of coverage among adults follow similar trends as found with BRFSS and NHIS estimates. However, the exact estimates tend to deviate from each other.
HPS estimates of Medicaid coverage almost exactly follow the trend of NHIS estimates of Medicaid coverage. The HPS estimates were consistently greater than the NHIS estimates with the HPS estimating that around 18% of adults were covered by Medicaid in 2021 and around 19% in 2022. The NHIS estimates were approximately 4 percentage points lower at around 14% in 2021 and 15% in 2022.
Similar to estimates of Medicaid coverage among adults, the HPS estimates of private insurance coverage among adults were consistently higher than NHIS estimates, but both followed the same overall trend. HPS estimates for private insurance coverage hovered around 75% in 2021 and 2022. The gap between HPS estimates and NHIS estimates widened slightly between 2021 and 2022, increasing from an approximately 6 percentage point difference to an approximately 8 percentage point difference – NHIS estimates were around 69% in 2021 and 67% in 2022.
Similarly to both Medicaid and private coverage estimates, HPS estimates of uninsurance among adults closely mirrored the trends observed in both NHIS and BRFSS data. In a change from Medicaid and private coverage estimates, though, HPS estimates of uninsurance consistently fall between the estimates from BRFSS and NHIS, with HPS figures consistently greater than those from BRFSS but lower than NHIS’. This pattern persists through the first quarter of 2022.
Following this point, HPS estimates of uninsurance among adults decrease while BRFSS estimates increase and NHIS estimates stay more or less consistent.
Data and Methods
This analysis utilizes publicly available data from three household surveys: the Household Pulse Survey (HPS), the National Health Interview Survey (NHIS), and the Behavioral Risk Factor Surveillance System (BRFSS). All three surveys provide national representation of the civilian, noninstitutionalized population, with data collected on either a quarterly basis (NHIS) or a monthly basis (HPS and BRFSS). In order to have comparable time periods, HPS data was pooled both at the quarterly level and at the monthly level prior to analysis.
In the Household Pulse Survey, coverage was defined as having any sort of coverage (e.g. Medicaid or private) at the time of the survey. Uninsured was allocated to those that did not answer yes to being currently covered by some sort of health insurance or health coverage plan.
In the National Health Interview Survey (NHIS), Medicaid coverage among adults was defined as currently having either Medicaid coverage or CHIP coverage. Private coverage was defined as currently having any private coverage. Uninsurance was designated to those who answered they did not currently have health insurance.
The Behavioral Risk Factor Surveillance System (BRFSS) has a unique method of ascertaining health insurance coverage. As opposed to asking which health insurance coverage an individual has, BRFSS only has asks for a primary source of insurance, and individuals are only allowed to select one type of coverage. So, while BRFSS does include data on Medicaid coverage and private coverage, these estimates were not provided in this analysis as this type of instrument is not sufficiently comparable with the questions used by the HPS and NHIS to include estimates of coverage. Uninsurance among adults in BRFSS was defined as not having coverage of any type at the time of survey or being covered by Indian Health Service.