Blog & News
New Brief details 2020 update for the SHADAC Health Insurance Unit (HIU)
July 31, 2020:In the years following the passage of the Patient Protection and Affordable Care Act (ACA), SHADAC developed and introduced its Health Insurance Unit, or “HIU,” a tool to aid in defining family interrelationships in federal population surveys for the purpose of analyzing health insurance coverage.
Now, SHADAC has revised its HIU in response to recent policy shifts, such as changes to eligibility for public and private insurance programs and changes to how relationships are coded in the federal surveys. A new brief from SHADAC researchers describes the revisions to the HIU, details the associated updates and improvements made to the data parameters used to create the HIU, and shows how this new HIU can be applied to federal survey research.
What is the SHADAC HIU?
Originally released in 2012, one of the goals of the SHADAC HIU is to establish a common definition of a “family unit” to help ensure consistent and comparative research across major national surveys when analyzing health insurance coverage.
Most federal surveys define a “family” differently from the way it is defined by most private and public insurance programs. For instance, the definition of "family" or "household" in U.S. Census Bureau surveys includes all related members of a household, no matter the degree of relationship, and does not necessarily align with dependent coverage or public program eligibility.
The SHADAC HIU attempts to more closely align with a definition of family used for private and public health insurance coverage eligibility. The SHADAC HIU uses a narrower definition of family that looks at specific interrelationships between individuals within a household and excludes all non-dependent relatives (grandparents, adult siblings, aunts/uncles, etc.) who may be household members but are unlikely to be considered as part of the “family unit” as defined for the purposes of determining eligibility for health insurance.
The SHADAC HIU, then, is defined as an economic unit that consists of those members of a household who would likely be eligible as a group for family health insurance coverage, or whose resources (i.e., income) would be considered in determining eligibility for public coverage.
Original vs. Revised: How the SHADAC HIU is constructed
The SHADAC HIU is constructed based on a set of rules for assigning individuals within a household into family groups based on their familial relationships. The updates to the revised SHADAC HIU center around changes to these assignment rules.
The original version of the HIU created “family units” using the following assignment rules:
- single adults with no children of their own living with them are assigned to their own HIU
- married couples with no children of their own living with them are placed together in an HIU
- single or married parents and their eligible children (i.e., children 18 years of age or younger, who do not have a spouse in the household and have no children of their own) are assigned to an HIU
- eligible children with no parent in their household, but who are related to the household reference person are placed in the reference person’s HIU
- eligible children with no parent in the household and who are not related to the household reference person are placed in their own HIU
As a result of recent policy and health landscape changes, the revised version of the HIU creates “family units” using the following assignment rules:
- single adults with no children of their own living with them are placed in their own HIU
- married couples with no children of their own living with them, now including same-sex couples as well as couples who report being separated but still live together, are placed together in an HIU1
- single or married parents and their eligible children (i.e., children 18 years of age or younger, who do not have a spouse in the household and have no children of their own), now including same-sex couples as well as couples who report being separated but still live together are placed together in an HIU1
- eligible children with more than one unmarried parent in the household are now placed in the HIU of the parent with the highest income
- eligible children with no parent in their household, but who are related to the household reference person are placed in the reference person’s HIU
- eligible children with no parent in the household and who are not related to the household reference person are placed in their own HIU
- eligible married children who live apart from their spouse but in the same household as one or more of their parents are now incorporated into the HIU of the parent(s)
Click on the brief to download a PDF and learn more about the revisions to the SHADAC HIU.
Explore current and upcoming data using the SHADAC HIU
While SHADAC’s HIU was originally constructed with the intention to be broadly consistent with the family unit that is relevant for public and private insurance, it is able to be tailored to specific criteria used in individual states, for specific programs, or for specific types of analysis.
Our State Health Compare web tool currently houses estimates produced using the original SHADAC HIU, including breakdowns from the Health Insurance Coverage measure such as income and poverty level.
For more on the original version of the HIU, see our issue brief with more on creation and definitions of the HIU and our technical brief with information, and example STATA and SAS code for using the HIU. Estimates and code using the revised HIU will be available following this year’s U.S. Census Bureau American Community Survey (ACS) and Current Population Survey (CPS) release in September.
NOTES
1 Same-sex couples are now included as of the 2015 ruling by the Supreme Court in Obergefell v. Hodges granting their legal right to marry.
Couples who report being separated but still live together are considered legally married and therefore still considered eligible for coverage under their spouse’s insurance.
Blog & News
Updates to Minnesota's Uninsured Profile Data Tool that Identifies and Characterizes the Uninsured Population
July 21, 2020:After a successful initial release of a new, interactive data tool that provides a way to identify and characterize communities with high uninsurance rates in Minnesota, Dr. Kathleen Call and her team at SHADAC have continued their partnership with the Blue Cross Blue Shield Foundation of Minnesota through a just-released update to the profile tool, which incorporates new geography by which users can now view the state’s uninsured population—MNsure rating areas, the geographic regions health insurers use to set premiums on MNsure.
The original version of this profile tool provided rates and counts of the uninsured in Minnesota that were focused specifically on classification by ZIP code level (i.e., Census-defined ZIP code), allowing users to compare characteristics of the total population to the uninsured population in a specific ZIP code as well as providing an in-depth profile of community characteristics. An interactive map that accompanies this tool also shows users the geographic makeup of each ZIP code in relation to schools, hospitals, native reservations, and other important or distinctive landmarks.
In the updated version, users are able to look at rates and characteristics of the uninsured not only by their ZIP code area of interest—or by the state as a whole, or by region, or by county, by state legislative district—but also by MNsure rating areas. By adding this layer of definition, Dr. Call hopes to continue the work of refining the tool and making it more useful in supporting targeted outreach and enrollment activities of health insurance navigators.
To download the Uninsured Profile, access additional information, or to request the development of a similar tool for another state, visit the "Minnesota's Uninsured Profile Resource" page.
Blog & News
NHIS: 2.4 million more uninsured working-aged adults in first six months of 2019
May 28, 2020:The number of nonelderly adults (age 18-64) without health insurance coverage increased to 27.2 million in the first six months of 2019 (January-June), up from 24.8 million in the same period in 2018. This put the uninsured rate for the first half of 2019 at 13.7%, an increase from 12.5% in the same period in 2018.
This finding comes from new health insurance coverage estimates for Q1-Q2 2019 from the National Health Interview Survey (NHIS). These estimates were released by the National Center for Health Statistics (NCHS) as part of the NHIS Early Release Program and are the first available coverage estimates for 2019 from a federal survey and the first estimates since the NHIS was redesigned for 2019. Though this post compares the 2019 estimates from the redesigned NHIS to 2018 NHIS estimates from the prior version of the survey, readers should take caution in making this comparison, as the survey redesign and co-occurrent changes to survey weighting may have affected estimates of health insurance coverage. A short summary of the NHIS redesign is provided at the end of this post.
Though current rates of health insurance coverage have been substantially altered by the ongoing coronavirus pandemic and resulting economic upheaval, estimates of health insurance coverage in 2019 are an important baseline and provide information about changes to the coverage landscape that were ongoing before COVID-19.
Uninsurance Increased, Public and Private Coverage Remained Stable in First Half of 2019
The new NHIS estimates show that overall rates of uninsurance among the nonelderly adult population increased to 13.7%. Rates of private and public health insurance coverage among this same population remained statistically unchanged from 2018, a trend echoed among all other age groups, none of which experienced statistically significant changes in rates of uninsurance or public or private coverage.
Uninsurance Increased among Other Subpopulations (Income and Race/Ethnicity)
Among nonelderly adults above 200% of the Federal Poverty Level (FPL), the uninsured rate increased to 8.5% in January-June 2019 from 7.6% in the same period in 2018. Rates of public and private coverage were stable for this income group, and no other income group saw significant changes in either rates of uninsurance or public or private coverage over the same period.
The uninsured rate for non-Hispanic, White nonelderly adults rose to 9.8% in the first half of 2019, up from 8.6% in the same period of 2018. This increase in uninsurance among White adults was accompanied by a decrease in private coverage, falling to 74.8% in the first six months of 2019 from 76.9% in the first half of 2018. The rate of public coverage among Whites was stable, as was uninsurance and private coverage for all other reported racial/ethnic groups in the report.
Changes in Coverage Type among Children by Income
Uninsurance Fell among Children in Poverty
Among children (age 0-17) below 100% FPL, the percent without health insurance coverage decreased to 3.4% during January-June 2019 from 6.4% in the same period in 2018. Rates of public and private coverage for this group were statistically unchanged during the same period.
Public Coverage Decreased among Children 100-200% FPL
Among children with family incomes of 100-200% FPL, rates of public coverage decreased to 69.8% in the first half of 2019 from 75.7% during the same period in 2018. The percent uninsured and with private coverage were statistically stable for this group at 6.1% and 27.1%, respectively, during the first six months of 2019.
Shift from Public to Private Coverage among Children above 200% FPL
For children in families with incomes above 200% FPL, rates of private coverage rose by 2.8 percentage points from 78.7% to 81.5% in the first halves of 2018 and 2019, respectively—an increase which mostly offset the 2.5 percentage-point drop in public coverage from 18.6% to 16.1% over the same period. The percent of uninsured children in this income category remained stable, however, at 3.7%.
2019 NHIS Redesign
The NHIS recently underwent a substantial redesign of its content and structure, culminating in the launch of the redesigned survey instrument in January 2019. Per the survey overview page from NCHS, the goals of the redesign were to “improve the measurement of covered health topics, reduce respondent burden by shortening the length of the questionnaire, harmonize overlapping content with other federal health surveys, establish a long-term structure of ongoing and periodic topics, and incorporate advances in survey methodology and measurement.”1
One of the largest changes made under the redesign is the elimination of the family questionnaire, which previously asked questions about the family as a whole as well as separately of each member of the family. Most of the family questionnaire content was moved to revised sample adult and sample child questionnaires, which are asked of one adult and one selected at random from members of the household and has the effect of substantially reducing the available sample size. For example, the January-June 2019 early release report had a total sample of 21,902 persons, whereas the same report in 2018 was based on a sample size of 39,112 persons. This also appears to have resulted in a substantial decrease in the number of available estimates of health insurance coverage by subpopulation and geography published in the January-June Early Release report. However, NCHS anticipates that the redesign’s reduction in respondent burden will result in more sample adult and sample child interviews due to higher response rates.
About the Numbers
The above estimates provide a point-in-time measure of health insurance coverage, indicating the percent of persons with that type of coverage at the time of the interview. The 2019 estimates are for the months of January to June 2019 (Q1 and Q2) and are based on a sample of 21,902 persons from the civilian noninstitutionalized population.
Differences described in this post are statistically significant at the 95% confidence level unless otherwise specified.
For more information about the early 2019 NHIS health insurance coverage estimates, read the National Center for Health Statistics brief.
Citation
Cohen, R.A., Terlizzi, E.P., Martinez, M.E., & Cha, A.E. (2020). Health insurance coverage: Early release of estimates from the National Health Interview Survey, January–June 2019. Available from https://www.cdc.gov/nchs/nhis/healthinsurancecoverage.htm
1 National Center for Health Statistics (NCHS). (2019, November 27). 2019 Questionnaire Redesign. Available from https://www.cdc.gov/nchs/nhis/2019_quest_redesign.htm
Publication
SHADAC COVID-19 Survey Results
The SHADAC COVID-19 Survey on the impacts of the coronavirus pandemic on health care access and insurance coverage was conducted as part of the AmeriSpeak omnibus survey conducted by NORC at the University of Chicago. The survey was conducted using a mix of phone and online modes from April 24 and 26, 2020, among a nationally representative sample of 1,007 respondents age 18 and older.
These briefs highlight key results from the survey, relating to loss of health insurance coverage, delayed medical care due to cost, and increased stress due to the coronavirus pandemic, for a nationally representative sample of U.S. adults (age 18 and older).