Hest, Robert
Lanigan, Lindsey

Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey

This update uses data from the September release of the Household Pulse Survey, collected from August 23 – September 4, 2023.

Introduction

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act. Since February 2020, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has increased by 23 million enrollees and analysis indicates that as many as 15 million individuals will exit Medicaid to other coverage or become uninsured. This blog uses data from the U.S. Census Bureau’s Household Pulse Survey (HPS) to track trends in adult health insurance coverage rates as states “unwind” the Medicaid continuous coverage requirement and restart standard redetermination procedures.

Given the intense interest from policymakers and the media in monitoring coverage transitions during the unwinding, many states have released Medicaid administrative data showing their progress, with some State-based Marketplaces also reporting transition data. Though administrative data can show the number of successful Medicaid renewals and coverage terminations along with transitions to Marketplace coverage, they cannot provide information on transitions to other sources of coverage, such as employer-sponsored insurance or provide an estimate of changing rates of uninsured individuals. 

As states continue the process of redetermining beneficiaries’ Medicaid eligibility, this resource will help track transitions in coverage. Specifically, it will present rates of primary source of health insurance coverage by type (Employer/Military, Direct Purchase, Medicaid/CHIP) and rates of no insurance as they are observed in the HPS. Estimates will be presented at the state and national level by selected individual and geographic characteristics. The survey does not include children, so the analysis is limited to adults 18 and older.

This blog will be updated on a monthly basis as new HPS data are released and compare the latest monthly coverage estimates (reference above in the subtitle) to estimates from March 2023, the last month before the unwinding began.

Highlighted Findings

Limited to statistically significant changes at the 95% confidence level.

• There were no observed changes in coverage among all adults at the national level
• Though unchanged nationally, a small number of states saw changes in the share of adults who had employer-sponsored insurance as their primary source of coverage
• The share of adults with Direct Purchase coverage saw small but significant changes, such as declines in three states (Delaware, Illinois, and Kansas) and among those with previous year household incomes at or above $100,000 as well as increases in two states (Maryland and Wyoming)
• The share of adults with no coverage saw modest changes among subpopulations (non-Hispanic White individuals, those age 65+) and in a few states (Alaska, D.C., and Kansas)
• There were few significant state-level changes in the share of adults with Any Medicaid/CHIP, or Medicaid/CHIP as primary source of coverage

Select a coverage type from the orange box on the right in the dashboard below to filter the visualizations. 

Methods and Data

This analysis uses public use microdata from the Household Pulse Survey (HPS), a monthly, nationally representative, quick-turnaround survey that collects data on topics including household demographics, education, employment, food sufficiency, financial spending, housing security, and physical and mental health, in addition to current health insurance coverage.

The survey has a typical monthly sample size of 60,000 to 80,000 U.S. adults and is designed to produce state-level (and a select number of metropolitan-level) estimates of the civilian noninstitutionalized adult population. The survey does not include children (those age 17 or younger).

Data is collected for approximately two weeks each month from adults (age 18 or older) via a short, online survey and is released on a monthly basis. Readers should keep in mind that the HPS emphasis on producing near-real-time data comes with the tradeoff of lower levels of data quality compared with “gold standard” surveys such as the American Community Survey (ACS). These data quality issues include very low response rates (e.g., 6.7% response rate in the March 2023 survey), underrepresentation of harder-to-reach groups (e.g., adults with lower levels of education, young adults), a lack of editing and imputation for most variables, and likely some degree of nonresponse bias. For these reasons, HPS estimates should be treated with a greater degree of caution than estimates from other federal surveys.

Further, like other surveys, the HPS relies on respondents’ self-reporting their coverage, which is often associated with known biases such as the Medicaid Undercount and reflects respondents’ (sometimes imperfect) knowledge of their own coverage rather than the reality reflected in administrative data sources. 

The HPS’ health insurance coverage measure is similar to that used in the ACS and asks respondents: “Are you currently covered by any of the following types of health insurance or health coverage plans?” Respondents are allowed to select “Yes” or “No” from among the following coverage types:

1.  “Insurance through a current or former employer or union (through yourself or another family member)”; 
2.  “Insurance purchased directly from an insurance company, including marketplace coverage (through yourself or another family member)”;
3.  “Medicare, for people 65 and older, or people with certain disabilities”;
4.  “Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability”;
5.  “TRICARE or other military health care”;
6.  “VA (including those who have ever used or enrolled for VA health care)”;
7.  “Indian Health Service”; or 
8.  “Other”

The response options for employer coverage [1], TRICARE [5], and VA [6] were combined into one Employer/Military coverage category, and respondents were considered uninsured if they didn’t affirmatively report any coverage under options 1-6.

SHADAC’s primary source of coverage hierarchy was applied to determine which payer was likely primary when a respondent reported multiple sources of coverage (see SHADAC brief for more information).

For example, the hierarchy would classify a respondent reporting both Medicaid/CHIP coverage and Employer/Military coverage as having Employer/Military as a primary source of coverage, as Employer coverage typically acts as the primary payer for individuals with Employer and Medicaid coverage.

Estimates with a relative standard error (standard error divided by the percentage estimate) of 30% or greater, based on an unweighted denominator count of less than 50, based on an unweighted numerator count of less than five, or with a weighted estimate of exactly 0% or 100% were considered statistically unreliable and were suppressed.

Two-sided t-tests were used to assess statistically significant differences between the most recent data month and the baseline month (i.e., March). A lack of statistically significant difference does not affirmatively establish that there was no significant difference but rather that the data presented here are not sufficient to show a significant difference.

Hest, Robert
Lanigan, Lindsey
Stewart, Andrea

CPS ASEC: 2022 National Health Insurance Coverage Estimates Show Falling Rates of Uninsurance and Direct-Purchase Coverage (Infographic)

The U.S. Census Bureau has released an initial report detailing the state of health insurance coverage in the United States for 2022.

Drawing on data from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC), the report highlights good news overall as the percentage of the population without health insurance coverage at any point in 2022 fell to 7.9% from 8.3% in 2021—a decrease of 0.4 percentage points or approximately 1.3 million people (25.9 million in 2022 vs. 27.2 million in 2021). 

The following blog post explores changes in national-level coverage rates by demographic characteristics - such as age, employment, race and ethnicity, immigration status, poverty status, and Medicaid expansion status - for nonelderly adults (age 19-64) and for children (age 0-18). While neither group saw an overall significant change in uninsured rates, both experienced shifts across demographic subgroups.

Additionally of note, though not within the scope of this blog to explore further, elderly adults (age 65+) saw a significant increase in Medicare rates, which the Census Bureau notes is due to a larger elderly population overall, not a larger share of those adults having Medicare. The continued growth of an aging population will continue to have ramifications for a number of health-related measures, including health insurance coverage rates, and bears following in future research.

Changes in Uninsurance by Age (Nonelderly Adults age 19-64, and Children age 0-18) and Characteristics

Among nonelderly adults, the overall rate of uninsurance fell to 10.8% in 2022, a 0.8 percentage point (PP) decrease from 2021.

Comparatively, the uninsured rate among children remained statistically unchanged from 2021 (5.0%) at 5.4% in 2022.

Race and ethnicity
In 2022, rates of uninsurance fell among nonelderly Black, Hispanic, and White adults, declining to 11.4%, 23.4%, and 6.8% (versus 12.7%, 25.1%, and 7.5%), respectively. Rates of uninsurance among nonelderly Asian adults were unchanged at 7.4%.

Similarly, while uninsurance rates remained stable for children of several racial and ethnic groups in 2022 - 4.1% for Asian children, 4.7% for Black children, and 8.6% for Hispanic children - the rate of uninsurance rose significantly among White children, increasing to 4.1% in 2022 from 3.4% in 2021.

Immigration status
The rate of uninsurance among native-born nonelderly adults fell to 8.2% in 2022 from 9.1% in 2021, while the uninsurance rate among foreign-born adults remained statistically unchanged at 22.1% in 2022 compared to 22.8% in 2021.

Rates of uninsurance were unchanged among native-born children at 4.7% in 2022 and among foreign-born children at 20.6% in 2022.

Poverty level
When examining coverage by poverty level, rates of uninsurance were unchanged at 24.2% among nonelderly adults with incomes below 100% poverty, decreased to 15.2% from 16.8% for those between 100%-399% poverty, and decreased to 3.9% from 4.5% for those living at or above 400% poverty.

In 2022, rates of uninsurance were unchanged for children in the two lower poverty level categories—8.9% for those in families with incomes below 100% poverty and 6.1% for those living in families with incomes between 100%-399% poverty. However, uninsured rates rose to 2.6% among children in families with incomes at or above 400% of poverty, an increase of 0.9 PP from 2021.

Medicaid expansion status
As of January 1, 2022, 38 states and the District of Columbia have chosen to act on the option provided by the Affordable Care Act (ACA) and expand Medicaid eligibility requirements, with the additions of Missouri and Oklahoma last year. Comparing rates of uninsurance by expansion and nonexpansion states revealed divergent trends for nonelderly adults and children.

In 2022, the uninsured rate fell to 8.4% in 2022 from 9.2% in 2021 for nonelderly adults living in expansion states and fell to 16.2% in 2022 from 17.0% in 2021 for those in nonexpansion states.

However, children in expansion and nonexpansion states saw no significant change in uninsured rates for 2022 compared to 2021 at 4.1% and 8.1%, respectively.

Notable Public and Private Coverage Changes

Among nonelderly adults, rates of public coverage and private coverage were unchanged at 19.1% and 72.9%, respectively. Rates of employer-based coverage increased to 63.5% in 2022 among nonelderly adults, up 0.6 PP from 2021. Rates of Medicare coverage fell to 3.6% among nonelderly adults in 2022, down from 3.8% in 2021.

By Race and Ethnicity (Total Population)
Rates of private and public coverage were statistically unchanged among Asian (72.2% and 27.8%, respectively) and Hispanic individuals (49.4% and 37.7%, respectively).

Among Black persons, the percentage with private coverage rose to 56.6% in 2022, up from 55.1% in 2021, and the percentage with public coverage fell to 41.2% in 2022, down from 42.7% in 2021.

Among White individuals, the percentage with private coverage fell to 72.3% in 2022, down from 73.2% in 2021, and the percentage with public coverage rose to 35.4% in 2022, up from 34.6% in 2021.

Immigration Status (Total Population)
Rates of private and public coverage were unchanged among the native-born population at 67.6% and 36.7%, respectively. Among the foreign-born population, the percent with private coverage was unchanged at 54.4% while the percentage with public coverage rose to 32.8% in 2022 from 31.7% in 2021.

Medicaid Expansion Status (Total Population)
In expansion states, the share with private coverage fell to 66.6% in 2022 from 67.1% in 2021 while the share with public coverage rose to 37.6% in 2022 from 36.9% in 2021. In nonexpansion states, the share of the population with private coverage and public coverage were unchanged at 63.6% and 32.9%, respectively.

Employment Status (Nonelderly Adults)
Public coverage rose among working nonelderly adults in 2022 to 12.6% from 11.8% in 2021 while the share with private coverage was stable at 80.0%. Public coverage rose among those who worked full-time year round and those who worked less than full-time, year round, rising to 8.9% and 23.5%, respectively. Private coverage was unchanged among these groups at 84.8% and 66.0%, respectively. Private and public coverage were unchanged among those who did not work, at 47.5% and 42.6%, respectively.

More on the insurance coverage changes among working-age adults can be found in a topically focused blog released today by the Census Bureau.

Notes
All changes are tested at the 90% confidence level.
All estimates come from the 2022 and 2023 Current Population Survey Annual Social and Economic Supplements, which provide data for years 2021 and 2022, respectively.
Uninsured estimates represent individuals with no health insurance coverage for the entire calendar year.
Estimates of health insurance coverage type represent individuals with that type of coverage at any point during the calendar year. Types of health insurance coverage are not mutually exclusive.

COVID-19 Public Health Emergency Impacts

Continuous Coverage Requirement

The continuous coverage requirement that prevented states from terminating individuals’ Medicaid coverage during the pandemic ended on March 31, 2023. The resumption of Medicaid eligibility redeterminations and renewals (and potential disenrollments), a process commonly referred to as the “unwinding,” began on April 1, 2023, and each state has a year to navigate a return to normal operations while also meeting reporting requirements set by CMS for publicly sharing coverage transitions and outcomes data during this time. While the health insurance estimates released by the US Census Bureau for 2022 precede the beginning of the unwinding process, the data will provide an essential baseline for understanding how health insurance coverage is distributed across the U.S. and among the states prior to the unwinding, as well as marker to measure the impacts of this seismic coverage transition as potentially millions of individuals, both adults and children, are poised to lose Medicaid and must either find another form of coverage (e.g., state-based marketplace or employer-sponsored insurance [ESI]), or risk becoming uninsured.

Several resources have been compiled by SHADAC to track the unwinding process in a variety of avenues, falling under several broader categories:

Guidance for States

• Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement
• Best Practices for Publicly Reporting State Unwinding Data

Health Insurance Coverage Data Tracking

• State-Based Marketplace Transition Data During the Unwinding
• State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement
• Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey

Data Collection and Dissemination - Nonresponse Bias

While Census Bureau researchers have not cited any concerns with CPS ASEC data collection or release processes, an ongoing issue of persistently lower response rates and resultant nonresponse bias has been documented for the past few years, coinciding with the beginning of the COVID-19 pandemic. In March 2023 (the point in time that the CPS is administered), the response rate fell to its lowest point yet, at 68.9%, compared to a pre-pandemic rate of 82% (March 2019). This lower response rate particularly affects the CPS measures of income, and since 2020, the Census Bureau has been working to address the bias in higher reported earnings using new weighting methods to create adjusted income and poverty estimates. More detail on this methodology can be found in a companion blog released today by Census Bureau researchers.

Lanigan, Lindsey
Lukanen, Elizabeth
Zylla, Emily

State-Based Marketplace Transition Data During the Unwinding (Cross-Post)

The following content is cross-posted from State Health & Value Strategies. 
Authors: Elizabeth Lukanen, Emily Zylla, and Lindsey Theis, SHADAC

This expert perspective (EP) will be updated by SHADAC experts as additional dashboards/reports go live. Please visit the State Health & Values Strategies webpage for the most recent version of this EP.

Original publication date: August 16, 2023. Updated: September 9, 2023.

The unwinding of the Medicaid continuous coverage requirement is currently underway in all states and the District of Columbia. While state Medicaid agencies are responsible for processing the eligibility redeterminations of the more than 94 million enrollees in the program as of April 2023, State-Based Marketplaces (SBMs) are also playing a significant role. SBMs are coordinating with Medicaid agencies using a number of different strategies to ensure a smooth transition for people who no longer qualify for Medicaid, but might be eligible for a qualified health plan (QHP) offered through the Marketplace. This work is critically important to keeping people insured, as estimates suggest that of those individuals moving off Medicaid, 2.7 million likely qualify for premium tax credits through the Marketplace and of these, 60% or 1.7 million are eligible for zero-premium plans. 

Given the potential to reduce coverage losses, there is intense interest in data that monitors transitions between Medicaid and Marketplace coverage and, more importantly, the outcomes of those transitions. In an effort to promote transparency, the Centers for Medicare & Medicaid Services (CMS) requires states to report related metrics. CMS released the first batch of this data on July 28, 2023 and additional data on August 31, but information related to transitions was very limited and included many caveats. In September, CMS plans to release more comprehensive data on transitions from Medicaid and Children’s Health Insurance Program (CHIP) to Marketplace coverage in states that operate on HealthCare.gov, along with more recent transition data for SBMs that use their own eligibility platform. Given data concerns and cautions regarding state comparisons, SBMs that use their own eligibility platform should consider releasing their own data on Marketplace transitions and the outcomes of those transitions. This will allow the state to present the most current data available in the context of their broader unwinding efforts. Key considerations for presenting outcomes data include:

• Draw on existing reporting requirements. Because timeliness of this data is so important, SBMs should start by releasing the CMS-required Marketplace indicators—the number of individuals determined eligible for a QHP and the number who selected a plan. Beyond that, SBMs could release additional data related to process—such as whether the enrollment was active or passive—and outcomes—such as whether people qualified for financial assistance or whether they qualified for a zero-dollar plan.  
• Present Marketplace and Medicaid data together. The best data dashboards present Medicaid and Marketplace data side-by-side, offering a wholistic view of the impact of unwinding. Several of the states who are currently reporting do this well, including Pennsylvania, featured below.
• Publish disaggregated data. There is a great interest in understanding who is being impacted by the unwinding. At a minimum, we recommend displaying data breakdowns by:
  • Program type
  • Age (children versus adults)
  • Race/Ethnicity
  • Language
  • Geography (ZIP code is best, but by county or any other level lower than statewide is helpful)
  • Eligibility for or receipt of financial assistance (e.g., advance premium tax credit or cost-sharing reduction payments)
• Provide context and transparency. There are many reasons that Marketplace transition outcome data reported by different states might be difficult to compare. CMS has outlined these data limitations and specifically cautioned against comparing data from HealthCare.gov to data from SBMs. States should address this in their reporting by clearly labeling data time periods and documenting data revisions, providing clear data labels and definitions, and including both proportions and counts so it easy to understand the group being reported on.
• Make the data easy to find. Many SBMs release information and data via materials such as board meeting minutes (e.g. California, Colorado and Minnesota). Unless you know where to look, these materials can be hard to find and often do not appear in a cursory Google search. If a state does plan to release unwinding data in this way, consider cross-posting in order to increase visibility. For example, data could also be released as a blog post, highlighted in an SBM newsletter, or put out as a press release. Alternatively, the state could post links to the materials on a highly trafficked part of the SBM or Medicaid website for more permanency.

Outside of the required federal reporting, many states are releasing their own data related to unwinding, including a handful of states who are reporting the number of individuals deemed ineligible for Medicaid and were sent to the Marketplace. Given their important role in facilitating these coverage transitions, SBMs that use their own eligibility platform are well positioned to share crucial and coveted data on Marketplace transitions and outcomes in a timely manner. Below is detailed information on which of the 18 SBM states are reporting data on Marketplace transition outcomes.  

SHADAC will continue to update this expert perspective as more states publish their unwinding data.

SBMs Reporting Marketplace Transition Outcome Data
 

Note: In some cases, SBMs publish Marketplace transition outcome data in a more ad-hoc way (e.g., in a legislative report) or in administrative documents that are hard to access (e.g., board meeting minutes—examples include California, Colorado and Minnesota). Because these data are not being systematically reported and are more difficult to access, they are not represented in the map above.

Variation in State Reporting

To date, seven of the 18 SBMs that use their own eligibility platform are reporting outcomes for individuals who exited Medicaid and were transitioned to the Marketplace. (California has indicated that they will start reporting transition data in October 2023.)

• Three states are reporting whether individuals were eligible for a QHP.
• Seven states are reporting whether individuals selected a plan.
• Three states are reporting enrollment and/or eligibility broken down by whether the individual received financial assistance (e.g., advance premium tax credit or cost-sharing reduction payments).

Select Data Highlights

In addition to general information on transition outcomes, most states reporting outcome measures are providing additional information of interest, though this detail differs by state. Visit the SHVS Expert Perspective for a selection of data highlights from the following states: Massachusetts, New York, Pennsylvania, and Rhode Island. 

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement (Cross-Post)

The following content is cross-posted from State Health & Value Strategies. 
Authors: Elizabeth Lukanen, Emily Zylla, and Lindsey Theis, SHADAC

This expert perspective (EP) will be updated by SHADAC experts as additional dashboards/reports go live. Please visit the State Health & Values Strategies webpage for the most recent version of this EP.

Original publication date: March 16, 2023. Updated September 9, 2023.

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act, with significant health equity implications. As states restart eligibility redeterminations, millions of Medicaid enrollees will be at risk of losing their coverage with some portion exiting because they are no longer eligible, some losing coverage due to administrative challenges despite continued eligibility, and some transitioning to another source of coverage. As part of this process, the Centers for Medicare & Medicaid Services (CMS) requires states to closely track and monitor the impacts of the resumption of eligibility redeterminations and disenrollments, and on July 28, 2023, CMS released the first batch of these data. CMS’ commitment to transparency is mirrored by calls from advocates and researchers eager to see how progress is being made as people enrolled in Medicaid have their eligibility redetermined. 

Given the intense focus on coverage transitions during the unwinding and the delays and caveats of the CMS data, many states have published their own state data dashboards to monitor progress. Data dashboards are useful for publishing dynamic data that is in high demand. They allow states to make proactive decisions about what data to release and on what schedule and then organize that data in an easy-to-digest visual format that facilitates the interpretation of key trends and patterns at a glance. Given the intense interest in unwinding data to monitor the impact of coverage transitions, releasing data in this format also allows states to follow some specific best practices, including providing additional detail about definitions, timeframes, and state context that will be important for communicating the unique and specific circumstances that states are experiencing during unwinding. An SHVS expert perspective highlights best practices for states to follow when publicly reporting unwinding data.

States Publicly Posting Unwinding Data
 

To date, 42 states including the District of Columbia (D.C.) have publicly published unwinding data in some format (this does not include states with pre-existing enrollment dashboards that don’t specifically identify unwinding cohorts). In most cases, state Medicaid departments are releasing those data, although some State-Based Marketplaces (SBMs) are also publishing unwinding data (see the SHVS expert perspective on SBM Marketplace Transition Data During the Unwinding). Of the 42 states currently reporting data:

• 21 are releasing state unwinding data online in either an interactive dashboard or static pdf format.
• Two states have only released copies of their required CMS Monthly Unwinding Data.
• 19 states are releasing both state data and their CMS Monthly Unwinding Data reports.

In some cases states are publishing unwinding information in an ad-hoc way—such as in a report to a legislature. Because these data are not being systematically reported, they are not represented in the map above. 

SHADAC will continue to update this expert perspective as more states publish their unwinding data.

Variation in States’ Reporting of Indicators

There is a wide variation in the indicators that states are reporting on their state data dashboards and reports. Of the 42 states reporting publicly, most are now reporting renewal and termination data. Some states are also reporting other interesting indicators such as:

• Reasons for procedural denials 
• Number of cases terminated that are re-enrolled or reinstated in Medicaid 
• Number of Medicaid cases sent to the Marketplace 
• Enrollment in CHIP 

It’s important to note that states use different terminology, definitions, population denominators, and timeframes on their dashboards making it difficult to compare one state’s data to another. In some instances, the data displayed on state dashboards also varies from what states include in their monthly reports to CMS (see Georgetown’s State Unwinding Renewal Data Tracker for a summary of states’ monthly CMS reports). Another cause of variation in the types of indicators reported across states is that states began disenrolling people from Medicaid in different months; for example, five states began disenrollments in April and another 14 states began disenrollments in May. Also, CMS has allowed states to delay terminations for one month and conduct additional outreach.

Unwinding Indicators & Disaggregated Data Reported by States
 

Few states are reporting disaggregated data on their dashboards. The most common breakdowns that states are providing are by program and geography (typically by county). Although CMS only asks states to report data by modified adjusted gross income (MAGI) and non-disability applications, versus disability applications, additional data breakdowns by age, race, ethnicity, and program type can elucidate important trends about the disproportionate impact of unwinding on groups that have been economically or socially marginalized.

Visit the SHVS Expert perspective for a selection of state dashboard examples including: Arizona, Colorado, Massachusetts, Minnesota, New Hampshire, Ohio, Oregon, Utah, and Washington.

Lukanen, Elizabeth
Planalp, Colin

Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement (Cross-Post)

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The following content is cross-posted from State Health & Value Strategies. 
Authors: Elizabeth Lukanen and Colin Planalp, SHADAC, and Kevin Caudill, GMMB

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act. Not surprisingly, policymakers, advocates and the media are watching coverage transitions closely and many states have released Medicaid administrative data documenting their progress. While state and federal administrative data can quantify the number of successful Medicaid renewals and coverage terminations, they typically cannot provide details on what happens to people leaving Medicaid. For instance, are people gaining employer-sponsored insurance (ESI) upon leaving Medicaid coverage, or are they becoming uninsured? Those administrative data also are limited in their ability to tell us why patterns are occurring. For instance, among people who remained eligible for Medicaid coverage, why were some successfully renewed while others were not?

Individual-level surveys of people who were enrolled in Medicaid during the continuous coverage requirement can help to answer such questions. The federal government’s Household Pulse Survey, which the U.S. Census Bureau established during the COVID-19 pandemic, serves as one key example of how surveys can fill critical data gaps to answer questions during unique circumstances. Similarly, states may consider conducting their own survey of consumers.

Motivation for Conducting a Medicaid Consumer Survey

Targeted surveys of people who have been enrolled in health coverage (referred to as “consumers” in this expert perspective), can be a relatively inexpensive and quick way for states to obtain information on coverage transitions and consumer experiences. In the context of unwinding, surveys would target Medicaid enrollees who recently went through the redetermination process. These surveys could be leveraged by officials in Medicaid or the Marketplace to:

• Better understand coverage transitions.
  • Did an enrollee transition to employer-sponsored coverage, some other source of coverage, or become uninsured?
  • Why did the enrollee exit Medicaid if they were still eligible?
  • If they were eligible for a qualified health plan (QHP) but didn’t enroll, why?
• Gather information on what messages and message strategies resonated with consumers.
• Assess what shopping, assistance and customer service tools were used.
• Educate people on tools, resources, or coverage options available to them.
• Serve as a final nudge to consumers that they need to take action to stay covered or transition to new coverage.
• Inform future research, such as longer targeted surveys, user experience testing or consumer focus groups.

Survey Mode

Given the dynamic nature of the unwinding, surveying consumers quickly is important. For this reason, states should consider short surveys that are distributed by email or text message using a convenience sample (i.e., Medicaid disenrollees for whom the state has contact information). For the sake of administrative ease, states could work with a web survey vendor that offers a user-friendly interface and (if possible) with whom they have an existing subscription or contract.

Many web-based vendors can send surveys via email or text. When sent via email, these surveys can typically be distributed in two ways: 1) consumers are sent a generic survey—the same survey link goes to everyone on the distribution list; 2) consumers are sent a unique survey link—a unique survey link is distributed individually to everyone on the distribution list. These options entail trade-offs. A benefit of a generic link is that it can be sent using the state’s existing communication platform. This avoids the need to import consumer contact information into the survey vendor platform, which might raise privacy and other legal concerns. Alternatively, a benefit of using a unique, individualized survey link is the ability to connect survey responses to state administrative data on the respondent, notably, characteristics (e.g. income, age, race, household type, etc.). This reduces the need to collect demographic data via the survey, can result in richer demographic detail about survey respondents, and provides insights into those who did not respond to the survey.  

Text or SMS surveys can also be distributed in two ways. One option is to send a “2-way” survey, where respondents text their replies to each question (best suited for a one question survey). The second option is to distribute a link to the survey which is sent to the consumer’s phone and can be opened in a mobile browser. During the unwinding, states are often focused on very short surveys. In some cases, they might ask a single question (typically focused on assessing coverage transitions) or other very brief surveys (3 to 10 questions). In some cases, states might attempt both—starting with a single question survey to assess coverage transition, followed up by a longer survey that captures information about the consumer experience. While there is wide concern that state Medicaid programs might not have up-to-date contact information for Medicaid enrollees, especially in a time-sensitive situation such as the unwinding, it is likely most practical to reach out to people using contact information already on file—often including a cell phone number or email address.

The primary benefits of web-based surveys sent via text or email are speed and cost. If a state has in-house expertise, funding, and can leverage an existing partnership (e.g., a state–university partnership) or an existing survey effort, they could also consider a more robust, mixed-methods survey that supplements a mailed survey (and online option) with interviews. For example, New Mexico recently fielded the New Mexico 2023 Office of the Superintendent of Insurance (OSI) Health Access Survey, commissioned by the New Mexico OSI and conducted by the University of New Mexico. This was a larger and sophisticated effort—a statewide survey of 1,900 adults, conducted by a survey firm in both English and Spanish using multiple modes (telephone and online). While the focus of the survey was broad, to better understand the opinions and attitudes New Mexicans have regarding health insurance, the state recognized the opportunity to use this vehicle to gain insights into unwinding. The survey found that residents were generally aware that pandemic funding for Medicaid was ending, but this awareness was lower for Latino/a, Native American, Spanish-speaking and lower-income New Mexicans, which highlighted the importance of targeted messaging and outreach.

Target Population and Timing

During the unwinding, states should focus on consumers who are scheduled to be redetermined for Medicaid. Logistically, states could consider sending the survey in waves, aligning with unwinding cohorts. If state systems allow them to target more granular groups, the state could send slightly different surveys to different groups. For example, if a state is targeting those who exited Medicaid and shopped for plans in the Marketplace, they could send slightly different questions to those who ultimately selected a plan than to those who did not select a plan.

States should also carefully consider the timing of any consumer survey as they finalize their questions.  For example, questions about shopping and plan selection should happen fairly quickly, ideally within a couple of weeks of when consumers should have engaged in these activities. If a consumer can still submit redetermination paperwork or sign-up for a QHP, the questions and wording should make that clear and not imply the consumer has no option to take action. As mentioned above, given the nature of many states’ phased unwinding approach, states should consider sending surveys weekly or monthly based on renewal cohorts.

Questions of Interest

States considering consumer surveys related to the unwinding tend to be interested in a fairly narrow set of questions. They want to understand coverage transitions, specifically whether people enrolled in employer-sponsored or Marketplace coverage after leaving Medicaid, and the enrollee’s experience navigating the process. States might use these surveys to assess specific outreach methods (e.g. the impact of mailing campaigns to send people letters on colored paper). And for states with available customer service resources, they could use the survey to connect people with a customer service channel (for instance, asking respondents if they would like assistance with the application and enrollment process). By collecting demographic information along with these questions, states can also get a sense for whether there are population differences between those who successfully transitioned to another source of coverage and those who remain uninsured. 

Common survey question domains include:
(A list of sample questions is included at the end)

• Current coverage/coverage transitions
• Reasons/motivations to have or not have coverage
• Experience shopping for insurance
• Establish who shopped (if this cannot be identified using administrative data)
• Outreach and assistance
• Impacts of uninsurance
• Demographics
• Did an enrollee transition to employer-sponsored

As states consider what questions to ask, they should take care to tailor their surveys to the strengths and limitations of this data collection method. Surveys are good at collecting information on people’s experience and impressions, but they are less useful for collecting specific, detailed and nuanced information (e.g. specific information about ESI cost-sharing, specific detail on what programs consumers qualified for). 

Another best practice is to ask questions that only require the respondent to reflect on one concept at a time. For example, when constructing questions about the shopping process, avoid phrasing questions that conflate opinions about the shopping experience and plan choice, which could pose a challenge to respondents if they found the online interface easy to use but the plan options to be underwhelming, or vice versa.

Finally, states should consider the goals of the survey and tailor the questions to those goals. Especially in the unique circumstances of the unwinding, states may be looking for ways to make their redetermination processes more user-friendly for Medicaid in the near-term, so they can maximize the number of eligible individuals reenrolled in the program. In that case, states should prioritize questions that are likely to yield data that are actionable in the coming weeks or months, rather than years. Relatedly, states should take care in how they interpret survey data collected during the unwinding and temper their expectations for the generalizability of the survey findings into the future. Because the current circumstances are so unusual, it is possible that the experiences of Medicaid enrollees going through the redetermination process today may not resemble the experience of people going through the redetermination process in a couple of years. However, if states find these survey data useful, they could incorporate similar surveys even after the unwinding, as part of their ongoing, regular course of business.

Communications Best Practices

As states are developing survey instruments, it is important to also keep in mind the surrounding communications to potential respondents to maximize participation, reinforce validity, and mitigate against concern about scams. Below are some helpful tips that states should consider when developing communications to support consumer research. While these apply primarily to email, they can also be applied to other mediums such as text messages. 

Establish your tone/voice. The tone of your subject line and email should reflect your Marketplace or Medicaid agency brand. Reinforcing your role as an official program is key. Determine where you will fall on the spectrum of conversational (e.g. “A few minutes to share your feedback?”) versus professional (e.g. “We’d appreciate your feedback to help us serve you better.”)

Personalize as much as possible. Personalizing is more than a name; it’s reflecting the experience you want feedback on. For example: “How did we do with Medicaid/Marketplace enrollment?” or “Did you have all the enrollment information you needed?”

Talk about the benefits of completing the survey. Explain up front why their participation matters. For example: “Help us make Medicaid enrollment better” or “Your feedback will make Marketplace enrollment better.” Within the body of the email itself, briefly explain how their feedback will be used and express appreciation for their time and input.

Ask a question in the subject line.

Try to keep subject lines under 50 characters. This is so participants can get the full headline on their mobile device.

States should consider these recommendations as they develop customized messaging for survey communications. These steps can help states get the most helpful information from their survey efforts. Ultimately, communications should reflect the unique goals that each state will determine for its research effort so there is no one size fits all approach.

Interpreting the Results

This type of consumer survey can be very useful to gather information on consumers’ experiences, identify areas where they are struggling with the process and which resources or outreach methods are resonating. In this case, it can also be useful for gaining some insights into coverage transitions outside of Medicaid or the Marketplace. That said, it will rely on a convenience sample, it is likely to have a low response rate and the results will not be representative of the target population as a whole. When interpreting the results, these limitations should be considered. States shouldn’t assume that survey results collected using a convenience sample during the unwinding represent everyone who experiences the Medicaid redetermination process. For example, consumers’ experiences might be different during a more typical renewal period and might be different for those who did not respond to the survey.

Agency Coordination

States considering these surveys should work closely with their legal, marketing, customer service and other relevant teams. Support and guidance from a legal team can be critical as states consider specific details about how the surveys are sent and distributed. For example, can the state send text messages to consumers and with what limitations? Can the state upload consumer contact information into survey vendor platforms for the purposes of distributing a survey? Involving the marketing and public relations team is also a good idea as they can ensure the terminology is consistent and that messages are aligned with what is being sent regarding redeterminations. And it is important to let customer service teams know when these surveys are going out, particularly if they are designed to spur final action or are directing enrollees to specific supports.

Sample Questions

A list of sample survey questions can be downloaded using the link below. The sample questions can be customized and used by states interested in conducting a consumer survey during the unwinding.

SHVS_Sample Consumer Unwinding Survey