Hest, Robert
Stewart, Andrea

2023 ACS: After Two Years of Decline, Uninsured Rates Increased for Children; Public and Private Coverage Rates See Variations Across the States

This post is a part of our Survey Data Season series where we examine data from various surveys that are released annually from the summer through early fall. Find all of the Survey Data Season series posts on our Survey Data Season 2024 page here.

The U.S. Census Bureau released 2023 health insurance coverage estimates from the American Community Survey (ACS) yesterday, September 12, 2024. These estimates include both national- and state-level information about health insurance coverage by type, as well by certain demographic categories. 

Overall, 2023 ACS data and findings at the national level echoed those from the Current Population Survey (CPS ASEC), which was released this past Tuesday, September 10, 2024. According to new ACS data, among the total U.S. population, the 7.9% uninsured rate in 2023 remained statistically unchanged from the previous year (8.0%). 

Also like the 2023 CPS data, the newly released ACS data show a significant increase in the uninsured rate among children (age 0-18) in 2023, rising to 5.4% from 5.1% in 2022.

The rest of the blog will walk through state-level findings regarding different types of health insurance coverage (public, private, and uninsurance) in 2023. We will also discuss changes by age category for nonelderly adults (age 19-64) and children (age 0-18). 

Key Findings from the 2023 ACS by Health Insurance Coverage Types

Uninsurance

The stability of the national uninsurance rate from 2022 to 2023 was supported by little change among the states between these two years as well. 

The uninsured rate fell in 11 states, and increased in Iowa, New Jersey, and New Mexico. North Dakota saw the largest decrease in uninsurance at 1.9 percentage points (PP), moving from 6.4% in 2022 to 4.5% in 2023. New Mexico saw the largest percentage point increase in uninsurance at 0.9 PP, rising from 8.2% in 2022 to 9.1% in 2023. Across the states, Texas and Massachusetts continued their long-running trend as the states with the highest and lowest rates of uninsurance, at 16.4% and 2.6%, respectively. 

Private Coverage

2023 ACS data show that rates of private coverage fell slightly to 67.0% in 2023 from 67.2% in 2022. Rates of employer-sponsored insurance coverage (ESI) and direct purchase coverage were unchanged at 54.7% and 13.9%, respectively. 

Private insurance coverage rates decreased in nine states in 2023, and increased in four - Florida, North Dakota, Texas, and West Virginia. Delaware saw the largest decrease in private coverage with a 2.7PP decrease from 71.8% in 2022 to 69.1% in 2023. North Dakota saw the largest increase in private coverage, rising 2.4PP from 78.4% in 2022 to 80.8% in 2023. Rates of private coverage across the states ranged from a high of 80.8% in North Dakota to a low of 54.1% in New Mexico.

Public Coverage 

Nationally, the rate of public insurance coverage rose significantly in 2023, increasing to 37.4% from 37.2% the previous year. Surprisingly, the rate of Medicaid coverage was unchanged at 21.3% (21.2% in 2022), while the rate of Medicare coverage rose to 18.8% in 2023 from 18.5% the year prior. 

Public coverage saw the most change of all insurance types across the states in 2023, increasing in 13 and decreasing only in Arkansas, Idaho, Texas, and West Virginia. Arkansas saw the largest decrease in public coverage, falling by exactly 2.0PP from 45.0% in 2022 to 43.0% in 2023. Wyoming experienced the largest increase in public coverage, rising also by exactly 2.0PP from 31.2% in 2022 to 33.2% in 2023. Across the states, rates of public coverage ranged from a high of 52.2% in New Mexico to a low of 22.6% in Idaho in 2023.

Key State-Level Findings from the 2023 ACS by Age: Nonelderly Adults (19-64)

Uninsurance

The uninsured rate among nonelderly adults decreased 0.3PP from 11.3% in 2022 to 11.0% in 2023, representing the third year of falling uninsured rates for this group. Twelve states saw decreases in their uninsured rates while only Connecticut, Iowa, New Jersey, and Ohio saw increases in their uninsured rates. As with the overall population, North Dakota saw the largest decrease in uninsured rates among nonelderly adults, decreasing 2.2PP to 6.1% in 2023. Iowa saw the largest increase in uninsured rates, rising 1.0PP to 7.1% in 2023.

Private Coverage

The rate of private coverage among nonelderly adults was unchanged at 73.5% in 2023 (73.4% in 2022). Across the states, nearly the same number experienced increases (eight) in private coverage rates for nonelderly adults as experienced decreases (six). North Dakota had the largest increase at 3.3PP, with private coverage rates rising to 85.1% in 2023 from 81.8% in 2022. Delaware saw the largest decrease at 2.3PP, with private coverage rates falling to 74.0% in 2023 from 76.3% in 2022.

Public Coverage 

The rate of public coverage among nonelderly adults was also unchanged in 2023, holding steady at 19.5% (19.4% in 2022). Looking at the states, this rate stability was supported by a nearly equal number of states that experienced increases (six) as did those that experienced decreases (five). Delaware had the largest increase in public coverage, rising 2.1PP to 21.4% in 2023 from 19.3% in 2022. Arkansas had the largest decrease in public coverage, falling by 2.1PP to 24.1% in 2023 from 26.2% in 2022.

Key State-Level Findings from the 2023 ACS by Age: Children (0-18)

Uninsurance

The uninsured rate among children rose 0.3PP to 5.4% in 2023 from 5.1% in 2022. This change represents the first year of increased uninsurance among children after two years of falling rates. Five states saw an increase in their uninsured rate while three states — Colorado, Kentucky, and North Dakota — saw a decrease in their uninsured rate. As with nonelderly adults, North Dakota had the largest decrease in uninsured rates for children, falling 1.9PP from 5.5% in 2022 to 3.6% in 2023. New Mexico saw the largest increase in uninsurance, rising 2.1PP from 3.8% in 2022 to 5.9% in 2023. Rates of uninsurance among children ranged from a low of just 1.3% in the District of Columbia to a high of 11.9% in Texas.

Private Coverage

The rate of private coverage among children in 2023 was 60.6%, unchanged from the same recorded rate in 2022. Nearly as many states — Florida, Illinois, Maryland, and West Virginia — saw increases in rates of private coverage as those that saw decreases — New Mexico, Ohio, Pennsylvania, Tennessee, and Wyoming — from 2022 to 2023. West Virginia has the largest increase in private coverage, rising 4.8PP to 57.3% while Wyoming had the largest decrease in private coverage, falling 6.4PP to 65.2%.

Public Coverage 

The rate of public coverage among children in 2023 was 39.4%, statistically unchanged from the previous year at 39.6%. Five states — Iowa, Missouri, New Mexico, Tennessee, and Wyoming — saw an increase in public coverage while seven saw a decrease in public coverage. Wyoming had the largest increase in public coverage, rising 9.5PP to 33.6% while West Virginia had the largest decrease in public coverage, falling 5.0PP to 46.0% in 2023.

Future Data Releases and Products

Supplemental tables for the 2023 ACS 1-Year Estimates will be released from the U.S. Census Bureau on October 17, 2024, and 2019-2023 ACS 5-Year Estimates will be available on December 12, 2024. Stay up to date with the latest Survey Data Season releases and resources on the archive page here.

We will also soon be releasing more granular details about insurance coverage changes in the states from 2022 to 2023 via customized SHADAC tables examining coverage at the state and county level, along with an announcement of updated health insurance coverage measures available on State Health Compare.

Concluding the Continuous Coverage Requirement and the Medicaid Unwinding

The continuous coverage requirement that prevented states from terminating individuals’ Medicaid coverage during the COVID-19 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 has since ended on June 30, 2024. 

Each state was given a 14-month period to navigate returning to normal operations while also meeting reporting requirements set by the Centers for Medicare & Medicaid Services (CMS), such as submitting monthly “Unwinding Data Reports,” in order to publicly share coverage transitions and outcomes data during this time. Though the unwinding period has come to a close, a May 30, 2024, State Health Official (SHO) letter announced that CMS will extend these requirements for the foreseeable future. Beginning on July 1, 2024, all states are expected to continue to submit certain metrics contained in the Unwinding Data Report, now referred to as an “Eligibility Processing Report,” on an ongoing basis.

For more information on the post-unwinding period and reporting process, see a recent blog written by SHADAC researchers for State Health & Value Strategies:

Unwinding Ends, but States’ Reporting of Medicaid Renewal Data Continues (SHVS Cross-Post)

It is important to note that full-year 2023 estimates from all surveys, including the ACS and CPS, will not be fully reflective of a Medicaid unwinding process that began mid-year. However, provisional data from sources like the Census Bureau’s Household Pulse Survey, can give us an indicator of coverage trends during this time.

If you are interested in learning more, SHADAC researchers have compiled a clear, concise, and informative data resource that can be found here:

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

Related Releases and Materials

Recent Data Release: Current Population Survey ASEC: 2023 National Health Insurance Coverage Estimates Remain Steady for Adults but Rise for Children

We just released a new blog and accompanying infographic from SHADAC researchers covering the release of 2023 health insurance coverage data across the United States. Drawing from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC), the blog looks at uninsured rates at the national level, as well as by select demographic categories.

Upcoming Webinar: U.S. Census Bureau Data Explained: Breaking Down 2023 Health Insurance Coverage Estimates from the ACS & CPS - featuring a Q&A with a Census Bureau Expert

On Thursday, September 26th at 1:00 PM CST, SHADAC will host a webinar covering the release of new Census data on health insurance coverage estimates for 2023. The estimates come from two key federal surveys conducted by the U.S. Census Bureau: The American Community Survey (ACS) and the Current Population Survey (CPS).

SHADAC researchers and presenters Robert Hest and Andrea Stewart will discuss the 2023 health insurance data at national and state levels, as well as by coverage type, and a range of other demographic categories (age, geography, poverty level, and more).

In addition, SHADAC will walk through how to access the data and examples of how to use it to answer research questions. We are also pleased to once again welcome a special guest from the Census Bureau, Sharon Stern, who will join us to answer questions from attendees after the presentation.

Notes

All changes described in this document are significant at the 90% level. Private coverage includes individually purchased, employer-sponsored coverage, and TRICARE military health coverage. Public coverage includes Medicare, Medicaid/CHIP, and VA health care. Public and private coverage types are not exclusive and include individuals with those types of coverage alone or in combination with other coverage. Estimates represent the civilian noninstitutionalized population. 

Overarching estimates of uninsurance and public and private coverage are for all ages, except where noted for children (age 0-18) and nonelderly adults (19-64).

Hest, Robert
Stewart, Andrea

CPS ASEC: 2023 National Health Insurance Coverage Estimates Remain Steady for Adults but Rise for Children

This post is a part of our Survey Data Season series where we examine data from various surveys that are released annually from the summer through early fall. Find all of the Survey Data Season series posts on our Survey Data Season 2024 page here.

Today, September 10, 2024, the U.S. Census Bureau released an initial report containing data on health insurance coverage across the United States in 2023, drawn from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC). This latest issue in the long-running line of Current Population Reports did not include any state-level estimates, as the Census Bureau plans to release those data from the American Community Survey (ACS) on Thursday, September 12, 2024. 

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. 

Uninsured Rates Across the Nation in 2023

Overall, data from the “Health Insurance Coverage in the United States” report highlights good news for 2023: the share of the total population without health insurance coverage remained statistically unchanged from 2022 at 8.0%, representing 26.4 million people. Nonelderly adults (age 19-64) similarly did not see any statistically significant change in their uninsurance rate from 2022 (10.8%) to 2023 (10.9%).

However, the report does note that the rate of uninsurance among children (age 0-18) rose significantly to 5.8% in 2023 from 5.4% in 2022.

The overarching stability of uninsured rates in 2023 for the total U.S. population held mostly true when looking across demographic groups, as well. The data show no significant changes for uninsurance among nonelderly adults and children for all measured racial and ethnic groups and by immigration status.

There were some slight changes in uninsurance by region, with both nonelderly adults and children in the Midwest seeing rate increases from 7.2% to 8.1% for the former and from 3.3% to 4.6% for the latter. Children in the West also experienced increasing uninsured rates from 4.2% in 2022 to 5.1% in 2023.

Changes in Uninsurance by Medicaid Expansion Status and Poverty Level

The one subcategory to experience any larger changes in 2023 was uninsurance for individuals in states that have or have not expanded Medicaid.

The rate of uninsurance among nonelderly adults in Medicaid expansion states rose to 8.9% in 2023 from 8.4% in 2022. The rate among those in nonexpansion states remained statistically unchanged at 15.5%. Among children, the rate of uninsurance rose to 4.6% in expansion states (from 4.1%) and was unchanged in nonexpansion states at 8.3%.

Rate of Uninsurance for Nonelderly Adults in Expansion States by Income Level

The rate of uninsurance among nonelderly adults in expansion states with incomes between 100% and 399% of the poverty level rose to 13.3% in 2023 from 12.4% in 2022. The rate of uninsurance among nonelderly adults in expansion states was unchanged among those with incomes below 100% of the poverty level (18.7%) and among those at or above 400% of the poverty level (3.5%).

Rate of Uninsurance for Nonelderly Adults in Nonexpansion States By Income Level

The rate of uninsurance among nonelderly adults in nonexpansion states with incomes below 100% of the poverty level fell to 32.5% in 2023 from 37.9% in 2022. The rate of uninsurance among nonelderly adults in nonexpansion states was unchanged among those with incomes between 100% and 399% of the poverty level (21.4%) and at or above 400% of the poverty level (5.4%).

Public and Private Coverage Across the Nation in 2023

Among all persons, overall rates of public coverage and private coverage in 2023 remained unchanged at 36.4% and 65.4%, respectively. Much like uninsured rates, rates of public and private coverage remained steady across demographic groups by race and ethnicity, immigration status, and even mostly across Medicaid expansion status. 

The only exception of note was in expansion states, which saw a decrease in rates of private coverage, falling 0.7 percentage points to 65.9% in 2023. (The rate of public coverage remained unchanged at 37.8%.)

Changes in Employment-Based, Medicaid, and Medicare Coverage 

However, there was more change in coverage when looking at specific types of private and public coverage. 

Within private coverage types, the rate of employment-based coverage fell 0.7 percentage points to 53.7% in 2023 while the rate of direct purchase and Marketplace coverage each increased to 10.2% (0.3 percentage point increase) and 4.0% (0.4 percentage point increase), respectively. 

Within public coverage types, the rate of Medicare coverage increased 0.2 percentage points to 18.9% while the rate of Medicaid coverage was unchanged at 18.9%.

Image Text: Health Insurance Coverage by Employment Status for Nonelderly Adults in 2023: Among nonelderly adults who worked full-time, year-round, the rate of uninsurance increased to 8.9% in 2023 from 8.4% in 2022. However, the rate of uninsurance actually decreased to 12.9% from 13.8% among those who worked less than full-time, year-round. Rates were unchanged among those who did not work (14.7%) and among all workers (10.0%). There was no change in rates of either private or public coverage among all workers; those who worked full-time, year-round; those who worked less than full-time, year-round; and those who did not work.

COVID-19 Public Health Emergency, Medicaid Unwinding, and Related Impacts

Concluding the Continuous Coverage Requirement and the Medicaid Unwinding

The continuous coverage requirement that prevented states from terminating individuals’ Medicaid coverage during the COVID-19 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 has since ended on June 30, 2024. 

Each state was given a 14-month period to navigate returning to normal operations while also meeting reporting requirements set by the Centers for Medicare & Medicaid Services (CMS), such as submitting monthly “Unwinding Data Reports,” in order to publicly share coverage transitions and outcomes data during this time. Though the unwinding period has come to a close, a May 30, 2024, State Health Official (SHO) letter announced that CMS will extend these requirements for the foreseeable future. Beginning on July 1, 2024, all states are expected to continue to submit certain metrics contained in the Unwinding Data Report, now referred to as an “Eligibility Processing Report,” on an ongoing basis.

For more information on the post-unwinding period and reporting process, see a recent blog written by SHADAC researchers for State Health & Value Strategies:

Unwinding Ends, but States’ Reporting of Medicaid Renewal Data Continues (SHVS Cross-Post)

It is important to note that full-year 2023 estimates from all surveys, including the CPS and ACS, will not be fully reflective of a Medicaid unwinding process that began mid-year. However, provisional data from sources like the Census Bureau’s Household Pulse Survey, can give us an indicator of coverage trends during this time.

If you are interested in learning more, SHADAC researchers have compiled a clear, concise, and informative data resource that can be found here:

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

CPS ASEC Data Collection - Response Rates and Nonresponse Bias

Continuing a trend that began in 2020 during the COVID-19 pandemic, Census Bureau researchers once again noted an issue of lower response rates for the CPS ASEC this year (67.2% in March 2024 compared to 81.5% in March 2019). While a newly published CPS companion blog from Census points out that low response rates in and of themselves are not inherently problematic, issues can arise when certain types of respondents are overrepresented in the data as compared to nonrespondents.

For example, starting in 2020, the CPS ASEC began to see more respondents with reported higher earnings than in years prior, and Census researchers have found that differences in median earnings between respondents and nonrespondents were statistically significant in each year since 2019 (2020-2024). This difference has the potential to, in turn, affect overall income and poverty estimates.

The Census Bureau has continued to monitor these issues since they first arose during the COVID-19 pandemic, and has begun to develop a number of methods to address them, including combining data from different sources to produce improved estimates of the income distribution as well as creating and employing an alternative weighting scheme.

Related Releases and Materials

Recent Data Release: After Two Years of Decline, Uninsured Rates Increased for Children; Public and Private Coverage Rates See Variations Across the States

As previously mentioned, the Census Bureau will be releasing 2023 estimates from the American Community Survey (ACS) - including coverage rates at the state level - on Thursday, September 12, 2024. SHADAC has now created and released a blog post analyzing the new ACS data.

You can check for other updates on our Survey Data Season 2024 Resource Page.

Upcoming Webinar: U.S. Census Bureau Data Explained: Breaking Down 2023 Health Insurance Coverage Estimates from the ACS & CPS - featuring a Q&A with a Census Bureau Expert

On Thursday, September 26th at 1:00 PM CST, SHADAC will host a webinar covering the release of new Census data on health insurance coverage estimates for 2023. The estimates come from two key federal surveys conducted by the U.S. Census Bureau: The American Community Survey (ACS) and the Current Population Survey (CPS).

SHADAC researchers and presenters Robert Hest and Andrea Stewart will discuss the 2023 health insurance data at national and state levels, as well as by coverage type, and a range of other demographic categories (age, geography, poverty level, and more).

In addition, SHADAC will walk through how to access the data and examples of how to use it to answer research questions. We are also pleased to once again welcome a special guest from the Census Bureau, Sharon Stern, who will join us to answer questions from attendees after the presentation.

Notes

• All changes are tested at the 90% confidence level.
• All estimates come from the 2023 and 2024 Current Population Survey Annual Social and Economic Supplements, which provide data for years 2022 and 2023, 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.

Lukanen, Elizabeth
Zylla, Emily

Unwinding Ends, but States’ Reporting of Medicaid Renewal Data Continues (SHVS Cross-Post)

The following Expert Perspective (EP) is cross-posted from State Health & Value Strategies. Authors: Emily Zylla and Elizabeth Lukanen, SHADAC

Original posting date August 13, 2024. Find the original post here on the SHVS website.

States have resumed their regular processes for renewing individuals’ Medicaid and Children’s Health Insurance Program (CHIP) coverage due to the end of the continuous coverage requirement set in place during the COVID-19 pandemic. During this unwinding period, advocates, policymakers, and the media have been keenly interested in understanding how this work has impacted coverage for Medicaid enrollees.     

One key source of data has been the monthly Unwinding Data Reports that state Medicaid agencies were required to submit to the Centers for Medicare & Medicaid Services (CMS). These reports include indicators about activities related to eligibility renewals, call center operations, and transitions to Marketplace coverage; CMS began publicly reporting monthly snapshots of these data in August 2023. However, well before the federal government began reporting this unwinding data, many states began publishing their own state dashboards, publicly detailing their progress in restarting renewals.

The public release of renewal data, at both the federal and state level, has proven to be a valuable tool in understanding who lost Medicaid coverage and why during the unwinding. States have successfully used the data to both monitor renewal outcomes and adjust outreach and administrative enrollment policies. This data has also provided new transparency into state eligibility and enrollment processes that had previously been lacking.

CMS initially indicated it would report unwinding data only through June 2024 (the official end of the unwinding period). However, many states received CMS approval to extend timelines to complete their unwinding-related renewals. Subsequently, a May 30, 2024, State Health Official (SHO) letter announced that starting July 1, 2024, CMS will expect all states to continue to submit certain metrics contained in the Unwinding Data Report on an ongoing basis, now referred to as an “Eligibility Processing Report.” 

These reports will include monthly data on:

• Renewals initiated.
• Renewals due.
• Successful renewals, including the number renewed on an ex parte basis and through pre-populated renewal forms.
• Coverage terminations due to both ineligibility and procedural reasons.
• Pending renewals and renewal backlogs.
• Fair hearing requests pending for more than 90 days.

In the SHO letter CMS also explicitly encourages states to continue state-level transparency processes, including public dashboards that “can support ongoing state-level efforts to ensure timely processing of applications and renewals.”

States Publicizing Medicaid Renewal Data

During the unwinding period, the State Health Access Data Assistance Center (SHADAC) tracked which states were publicly reporting unwinding data (separate from their required CMS monthly report). Over the course of the official unwinding period, from April 2023 through June 2024, 45 state Medicaid agencies (including the District of Columbia) regularly published their own renewal data (reflected in the map above), either in an interactive dashboard or a static PDF format. Two states, Mississippi and West Virginia, made copies of their monthly CMS data unwinding reports available on their state websites, but did not publish any additional state-level renewal or unwinding data. Four states, Alabama, Florida, Hawaii, and Wyoming, did not publish any state-level data.

Although some states, such as Arkansas, Idaho, Montana, and Utah, have indicated that they will no longer be updating their state unwinding dashboards, the majority of states appear to be maintaining and posting regular data updates. Other states, such as Virginia, have indicated that they plan to incorporate some of the information from their unwinding dashboard into an ongoing dashboard to track enrollment as a whole. 

Medicaid Reporting Bright Spots

Given the time-lags and caveats of the CMS data, state-level dashboards and/or reports became valuable sources of timely, up-to-date information for states, policymakers, and other stakeholders, allowing them to better understand how the unwinding progressed. States that published their own data also had the ability to provide additional detail about definitions, varying timeframes, and state-specific context important for communicating the unique circumstances that they experienced during unwinding.

In addition, although CMS only required states to report data broken down by modified adjusted gross income (MAGI) and non-disability applications versus disability applications, many states were able to supplement their federal reporting with both state-specific data analysis and data broken down by eligibility group and other demographic characteristics (e.g., age, race, ethnicity, language, geography). These types of additional data breakdowns helped elucidate important trends about the disproportionate impact of the unwinding on groups that have been economically or socially marginalized.

Several states also reported how many individuals were reinstated in Medicaid after a termination, thus providing a more complete story about what happened to individuals after they were disenrolled from Medicaid.

Among state Medicaid agencies’ unwinding dashboards or reports, several stood out.

Indiana Family and Social Services Administration – Medicaid Renewals and Outcomes Dashboard

Indiana’s dashboard provided a highly visual and interactive interface for the user. Renewal outcome data was filterable by geography, race and ethnicity, gender, age, program type, and managed care entity. Renewal outcomes were displayed both as total counts and percentages.

Kentucky Cabinet for Health and Family Services – Medicaid Unwinding Demographic Reports

Kentucky was one of the earliest reporters of state-level unwinding data, publishing data snapshots beginning in April 2023. Kentucky additionally began publishing Data Demographic Reports on a monthly basis beginning in September 2023, which provided breakdowns by race, ethnicity, age, gender, and county of residence, of Medicaid renewals, pending cases, and terminated cases.

Massachusetts Executive Office of Health and Human Services – MassHealth Eligibility Redetermination Dashboard

Massachusetts’ dashboard, updated on a monthly basis, provided data on member renewals and departures, filterable by age, program type, disability status, and whether the member resides in a “priority community” (i.e., one of the top 15 towns or cities where the most MassHealth members were at risk of losing coverage). Massachusetts also reported the number of terminated members who re-enrolled in Medicaid after a specific period of time.

Nevada Department of Health and Human Services – Monitoring Medicaid Enrollments, Disenrollments, and Renewals in Nevada Dashboard

Nevada’s dashboard displayed historical enrollment data both prior to and during the public health emergency (PHE). It also contained detailed metrics of the demographic characteristics for individuals disenrolled from Medicaid, including a comparison of the distribution of the disenrolled population versus the enrolled population. This visual display of differences between the two groups made it especially clear to see how disenrollments were affecting certain demographic groups more than others. 

Oregon Department of Human Services – Medical Redeterminations Dashboard

Oregon’s dashboard displayed the number of renewals due each month as well as the number of renewals that were completed, initiated, or not started. The dashboard also presented data disaggregated by written language, gender identity, race and ethnicity, age, disability status, housing status, county, and reason for closure. Oregon also published a separate dashboard for call center data, including a daily average customer service score.

State-Based Marketplace Reporting

State-Based Marketplaces (SBMs) also played a significant role during the unwinding by coordinating with Medicaid agencies and using a number of different strategies to ensure a smooth transition for people who no longer qualified for Medicaid and were eligible for a qualified health plan (QHP) offered through the Marketplace. Given this, policymakers, advocates, and the media have also been keenly interested in unwinding data on the outcomes of transitions from Medicaid to the Marketplace.

By the end of the unwinding, 16 of the 19 states that operate an SBM had reported some data on Marketplace transition outcomes (see Table 1 below). In some states, this information was reported by the SBM itself, and in other states, Marketplace transition outcomes were included within the state’s Medicaid renewals dashboard. In 11 states, this meant ongoing reporting as part of a formal and easy to find data dashboard or data repository. In five states, Colorado, Idaho, Kentucky, Maine, and Washington, data was reported less consistently – examples include reporting as a part of SBM board meeting minutes or administrative documents, or as a part of a one-time or sporadic release of information. Three SBMs, the District of Columbia, New Mexico and Virginia, did not publicly report Marketplace transition data. Virginia, however, launched its SBM on November 1, 2023 and while the state was using the Federally-Facilitated Marketplace (FFM) at the beginning of the unwinding, CMS was responsible for the states’ reporting of transition data.

Table 1. Reporting of State-Based Marketplace Transition Data

Generally, reporting of SBM data was more limited and less consistent across states than Medicaid reporting. All of the states listed in the table above reported enrollment in a QHP by people no longer enrolled in Medicaid. Only one SBM, Idaho, reported a conversion rate (i.e., Marketplace enrollment among those disenrolled from Medicaid) and about half of the SBM states reported elements allowing for this calculation (however, it is important to note that often these data points were hard to find). Six SBM states reported information about whether transitioners received premium assistance, and only two states, California and Washington, reported transitioner demographics. 

Along with this data reported by SBMs, CMS also released state Marketplace enrollment transition data. These data included information on consumers who:

• Were transferred to or applied for Marketplace coverage.
• Were eligible for a QHP or Basic Health Plan (BHP) coverage (disaggregated by those eligible for financial assistance).
• Had a QHP selection or BHP enrollment.

CMS data was reported differently for FFM states that use HealthCare.gov, and for SBM states with an integrated system versus those who transfer accounts between Medicaid and the Marketplace.

While CMS data offered a somewhat parallel view of progress in all states, it was released at a lag (compared with state reported data) and comparability was complicated by data concerns and cautions regarding state comparisons, differences in how states managed changes to ex parte renewals, and potential confusion regarding the use of different denominators. Although CMS is requiring states to report ongoing Medicaid enrollment and renewal metrics beyond the unwinding period, the May 2024 SHO letter indicated that states will no longer have to report SBM transitions starting June 30, 2024, or once the state has completed all unwinding-related renewals (whichever is later).

SBM Reporting Bright Spots

While most SBM states offered transparency regarding unwinding transitions by releasing outcomes data beyond required CMS reporting, variation in how data were reported, their specific definitions, reporting timelines, and disaggregation made it very difficult to compare similar measures across states.

That said, like the Medicaid unwinding dashboards, individual SBM reporting allowed states to present the most current data available in the context of their broader unwinding efforts – controlling the narrative and storyline. In other words, states could report more quickly, and they could present Marketplace and Medicaid data together offering a holistic view of the impact of the unwinding. States could also publish disaggregated data, beyond the requirements, such as transitioner race/ethnicity and geography. States were also able to provide more detail on the metrics being released, providing clear data labels and definitions, methodologies and documenting data revisions. Among the SBM states reporting robust Marketplace transition data, several stood out.

Covered California Medi-Cal Transitioner Profile

California provided detailed data on Californians who transitioned from Medi-Cal to Covered California (the state’s official health insurance Marketplace) in the form of an Excel file. The Excel file has multiple tabs and contains counts, percentages, and detailed methodological and definitional information. It starts with a tab containing summary information on transitions by month (called “key performance indicators”). The tabs that follow contain detailed demographic information for: individuals who lost Medi-Cal and who were eligible for Covered California; those who lost Medi-Cal, were eligible for Covered California, and received an automatic plan selection; and those who effectuated QHP coverage. Demographic data available for those categories includes:

• Age
• Gender (including transgender identification)
• Income
• Race and ethnicity (in combination and separately)
• Written language
• Service channel used (i.e., Certified Insurance Agent, Certified Enrollment Counselor)
• Geography (i.e., region, county)
• Financial assistance

Pennsylvania Medicaid Continuous Coverage Unwinding Data Tracker

Pennsylvania had one of the earliest unwinding dashboards featuring Marketplace renewal outcome metrics. The dashboard presented side-by-side renewal outcome metrics for Medicaid and the Marketplace, providing a holistic view of coverage transitions across the state. In addition, the state provided information on the outcomes of transitions to Pennie (the state’s official health insurance Marketplace) by county and ZIP code. 

Washington Keeping People Covered During the Medicaid Unwind: Data Snapshot Reports

Washington released robust data snapshots in October 2023 and January 2024 (each available as a PDF). These reports started with summary information (called “data top lines”), a personalized coverage transition example illustrating an individual’s cost under a QHP, and detailed information on coverage transitions such as the geographic distribution, carrier transitions, receipt of financial assistance, and demographics of transitioners (i.e., age, sex, race, and ethnicity). Washington provided both counts and percentages for most data points and provides a detailed appendix with information on data sources and definitions.

Conclusion

Timely, accessible, state-level data on Medicaid renewal outcomes will continue to be important for understanding the impact of various policies on Medicaid enrollees, even after the unwinding period ends. Given the ongoing reporting requirement from CMS, and states’ success setting up these new public reporting capabilities, there is hope that states will continue to make detailed disenrollment, renewal, call center, and Marketplace transition data publicly available on an ongoing basis.

Stewart, Andrea
Research Fellow

p 612-624-4850
e astewart@umn.edu

2023 NHIS Full-Year Health Insurance Estimates Early Release: Decreasing Uninsured Rates Overall and for Certain Groups of Nonelderly Adults

Hest, Robert
Liu, Grace
Theis, Lindsey

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

This update was posted on September 12, 2024 and uses data from the September 2024 release of the Household Pulse Survey, collected June 25 - August 19, 2024. 

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.

• Compared to March 2023, ESI/Military coverage fell 1.6 percentage points (PP) to 52.2% among all adults in August. This decrease was reflected across several groups: 
  • Adults age 65 or older (2.5PP),
  • White adults (1.8PP),
  • Adults with prior year household incomes of $50,000–$74,999 (3.8PP),
  • Adults living in Medicaid nonexpansion states (2.5PP)
• Consequently, the uninsured rate rose 1.0PP to 8.8% among all adults and was also echoed among several groups that saw significant increases in uninsurance:
  • Nonelderly adults (1.6PP),
  • White adults (1.0PP),
  • Adults with prior year household incomes of $50,000–$74,999 (4.0PP),
  • Adults living in Medicaid nonexpansion states (2.2PP)
• Rates of any Medicaid coverage rose 4.1PP among Black adults to 31.0% and fell 4.8PP among Asian adults to 13.0%. Rates among all adults held steady at 18.5%.
• There were few meaningful changes in rates of Direct Purchase or Medicaid/CHIP primary source coverage types.
  

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).

As of January 2024, data is collected for approximately four weeks each month from adults age 18 or older via a short, online survey and is released on a monthly basis. Prior to this, data was collected for approximately two weeks each month and 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 (95% confidence level) 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.