VISIT STATE HEALTH COMPARE
Publication
2018 State-level Estimates of Medical Out-of-Pocket Spending for Individuals with Employer-sponsored Insurance Coverage
U.S. health care spending continues to grow, reaching $3.6 trillion and 17.7% of the GDP in 2018.[i] Unfortunately, a significant share of these costs are increasingly born by Americans in the form of increased deductibles, copayment, and coinsurance—commonly referred to as patient “out-of-pocket” (OOP) costs. Even for the 52% of Americans who have private health insurance through their own or their spouse’s employer, affordability of health care is a pressing issue. Nationally, the average deductible for families in 2018 was $3,392, and almost half (49.1%) of all Americans were enrolled in high-deductible health plans with a deductible of at least $2,700 for family coverage.[ii],[iii]
The State Health Access Data Assistance Center (SHADAC) at the University of Minnesota continues to monitor trends in coverage, access, and affordability. This brief highlights the affordability of coverage for those with employer-sponsored health insurance (ESI). Using data from the Annual Social and Economic Supplement (ASEC) of the 2019 Current Population Survey (CPS; data year 2018), we estimated family out-of-pocket costs for people with employer coverage across all 50 states and the District of Columbia (D.C.). For individuals with ESI, we looked at: (1) the family median out-of-pocket costs by state, and (2) an estimate of the high medical cost burden where family out-of-pocket spending is greater than 10% of household income. For additional estimates, please visit SHADAC’s State Health Compare web tool.
[i] Centers for Medicare & Medicaid Services (CMS). (2019, December 5). NHE Fact Sheet. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet/
[ii] State Health Access Data Assistance Center analysis of the 2018 American Community Survey microdata.
[iii] State Health Access Data Assistance Center, State-level Trends in Employer-Sponsored Health Insurance, 2014-2018. Available at: https://www.shadac.org/ESIReport2019
SHADAC Expertise
Medicaid and CHIP Policy
SHADAC has worked both independently and under contract to the Robert Wood Johnson Foundation (RWJF) and the Medicaid and CHIP Payment Access Commission (MACPAC) to monitor and analyze changes in the Medicaid and CHIP policy landscape such as Medicaid expansion, eligibility, enrollment, and renewal, quality measurement, as well as states’ waiver application, implementation, and evaluation. SHADAC faculty and staff have exceptional knowledge of Medicaid and CHIP, including knowledge from the perspective of state policymakers and program administrators, as well as operational issues at the federal and state levels.
Related SHADAC work
Click on any title below to learn more about the project.
SHADAC Advocates a Data-based Approach to Advancing Medicaid and CHIP Access Monitoring Plan
On February 17, 2022, the Centers for Medicare & Medicaid Services (CMS) released a request for information (RFI) regarding access to coverage and care in Medicaid and the Children’s Health Insurance Program (CHIP). SHADAC researchers focused our response on Objective 4: Question 1, which asked researchers to consider how CMS might develop a stronger Medicaid and CHIP access monitoring approach through data reporting and analysis. These comments are based on SHADAC’s experience providing data and evaluation technical assistance (TA) to states, and mirror recent testimony to the Medicaid and CHIP Payment Access Commission (MACPAC) provided by SHADAC’s Deputy Director.
Tracking the Data on Medicaid’s Continuous Coverage Unwinding (State Health & Value Strategies)
A lack of publicly available data on Medicaid enrollment, renewal, and disenrollment makes it difficult to understand exactly who is losing Medicaid coverage and for what reasons. This issue brief lays out a phased set of priority measures and provides a model enrollment and retention dashboard template that states can use to monitor both the short-term impacts of phasing out public health emergency (PHE) protections and continuous coverage requirements, as well as longer-term enrollment and retention trends.
Assessment and Synthesis of Selected Medicaid Eligibility, Enrollment, and Renewal Processes and Systems in Six States
SHADAC worked as a contractor for the Medicaid and CHIP Payment Access Commission (MACPAC) to conduct an assessment of Medicaid eligibility, enrollment, and renewal processes and systems in six study states—Arizona, Colorado, Florida, Idaho, New York, and North Carolina. Utilizing a multi-case study methodology as well as key informant interviews with state and local agency staff and advocacy organizations, SHADAC collected and synthesized data on Medicaid enrollment processes and systems for individuals whose income eligibility is based on Modified Adjusted Gross Income (MAGI) in order to assess the extent to which states were achieving desired goals such as program efficiency and a simplified beneficiary experience. As a follow up, SHADAC identified the risks that remain for both individuals and state agencies that cause eligible individuals to remain uninsured or lose Medicaid coverage and conducted interviews with key stakeholders nationally and in four states to obtain additional input on potential risk points and strategies to improve eligibility determination and renewal accuracy.
Addressing Social Determinants of Health through Behavioral Health-focused 1115 Waivers: Implementation Lessons from Three States
Through the Robert Wood Johnson Foundation’s (RWJF) “Research in Transforming Health” program, SHADAC researchers conducted a study to understand how three states—Illinois, Texas, and Washington—were addressing the needs of justice-involved populations through implementation of Section 1115 Medicaid waiver programs. The specific aim of the study was to identify promising practices and lessons learned related to the development, implementation, and management of these innovative behavioral health policies with the purpose of informing policy development in states considering similar 1115 waivers.
Blog & News
Evaluations of Integrated Care Models for Dually Eligible Beneficiaries: Key Findings and Research Gaps from MACPAC
August 08, 2019:Under contract to the Medicaid and CHIP Payment and Access Commission (MACPAC), researchers at SHADAC recently compiled an inventory of evaluations of integrated care models for beneficiaries enrolled in both Medicare and Medicaid, for which both the inventory itself and a related issue brief have now been published.
About the Study
Currently, both the federal government and numerous states are testing a variety of models to integrate care for beneficiaries enrolled in both Medicare and Medicaid, including the Program of All-Inclusive Care for the Elderly, the Financial Alignment Initiative (FAI), Medicare Advantage dual eligible special needs plans and fully integrated dual eligible special needs plans, managed long-term services and supports programs, and demonstrations that pre-dated the FAI.
There is a limited but growing body of evidence examining the effects of these models on Medicare and Medicaid spending, health outcomes, and access to care. Broadly, studies to date have generally found a decrease in hospitalizations and readmissions for enrollees in the different models relative to those not enrolled in integrated models. Findings regarding the use of other services, such as use of the emergency department and long-term services and supports, were mixed—as are reports on beneficiary experience. It is often difficult to generalize from evaluations of specific models about the effects of integrated care more broadly.
This new inventory details a total of 51 studies, including those published between 2004 to November 2018 and formal evaluations on the FAI updated through July 2019, and gathers all available evidence on how programs have affected spending, quality, health outcomes, and access.
Access the Inventory of Evaluations of Integrated Care Programs for Dually Eligible Beneficiaries to read and download the full literature review and inventory compiled by SHADAC.
For a high-level summary on data methods and sources used for the review and inventory, see the companion brief, Evaluations of Integrated Care Models for Dually Eligible Beneficiaries: Key Findings and Research Gaps.
SHADAC Expertise
Federal Survey Data Release Schedule
American Community Survey (ACS)
An ongoing general household survey conducted by the U.S. Census Bureau provides annual estimates of health insurance coverage at the national, state, and sub-state geographies. For a full range of available products from SHADAC’s coverage of the 2022 health insurance data release (2021 estimates) click here.
Upcoming
September 14, 2023
• 2022 ACS 1-year data file
Released
January 2023
• 2017-2021 5-Year Public Use Microdata Sample (PUMS) file
October 2022
• 2021 ACS 1-Year Public Use Microdata Sample (PUMS) file
September 2022
• 2021 ACS 1-year data file (i.e., on data.census.gov)
Other Resources
• An Assessment of the COVID-19 Pandemic’s Impact on the 2020 ACS 1-Year Data Analytic Paper
• Introduction to the American Community Survey Public Use Microdata Sample (PUMS) file
Current Population Survey (CPS)
A monthly household survey conducted by the U.S. Census Bureau for the Bureau of Labor Statistics. Data on income and health insurance coverage is collected in its Annual Social and Economic Supplement administered in February through April. Annual health insurance estimates are provided for the nation and states.
Upcoming
September 12, 2023
• 2022 Income, Poverty and Health Insurance statistics from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC)
Released
September 2022
• 2021 Income, Poverty and Health Insurance statistics from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC)
Medical Expenditure Panel Survey (MEPS)
MEPS is a two-component survey sponsored by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality. The MEPS-Insurance Component (IC) is a survey of employers that provide data on employer-based health insurance. The MEPS-Household Component (HC) is a panel household survey that is supplemented with data from the respondents' medical providers.
Released
July 2023
• 2022 MEPS-IC Private Sector Tables - National Estimates
• 2022 MEPS-IC Private Sector Tables - State Estimates
• 2022 MEPS-IC Private Sector Tables -Metro Estimates
National Health Interview Survey (NHIS)
A continuous cross-sectional household interview survey conducted by the National Center for Health Statistics (NCHS) which is part of the Centers for Disease Control and Prevention (CDC). It provides information on the health of the U.S. population and includes questions about health insurance coverage, health care utilization and access, and health conditions and behaviors, in addition to demographic and socioeconomic characteristics.
Upcoming
Estimates for sub-annual time periods are released through the NHIS Early Release Program in September, November/December, and February/March each year.
Released
June 2023
• 2022 NHIS Public Use Files
Behavioral Risk Factor Surveillance System (BRFSS)
A state-based survey sponsored by the Centers for Disease Control and Prevention that focuses on population health, risk factors, and health behaviors for the adult population.
Released
August 2023
• 2022 Annual Survey Data
Household Pulse Survey
A near-real-time experimental survey from the U.S. Census Bureau. Typically released on a monthly basis.
Note: Based on previous data release calendars.
Page last updated September 2023
Publication
Mental Health and Substance Use Disorder Parity under the ACA: National and State Estimates of Parity Gains as of 2017
In addition to expanding access to health insurance coverage for millions of Americans through subsidized individual market coverage and state Medicaid expansions, the federal Affordable Care Act (ACA) applied Mental Health (MH) and Substance Use Disorder (SUD) coverage and parity mandates to beneficiaries in the individual and small-group markets and to Medicaid expansion beneficiaries. The following brief details the mechanisms by which the ACA applied these mandates and presents national and state-level estimates of the number of people with insurance coverage that must newly provide MH/SUD parity under the ACA. These estimates provide important context for policymakers and others engaged in the ongoing debate about repealing, modifying, or replacing the ACA.
Background
Before the ACA, national legislation regarding equitable coverage for MH/SUD treatments applied only to large-group (i.e., employer-sponsored) health plans, as a result of the Mental Health Parity Act of 1996 (MHPA) and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The ACA extended these MH/SUD parity protections beyond the large-group market to the individual and small-group markets and to Medicaid expansion beneficiaries by making MH/SUD treatments an essential health benefit (EHB). Before this change, coverage and parity for MH/ SUD treatment in these markets were addressed unevenly across states through a patchwork of state laws.
Expanding Equitable Coverage of Mental Health and Substance Use Disorder Treatment under the ACA: Key Provisions
Findings
Mental Health
In total, an estimated 39 million individuals nationwide had health insurance that was subject to the ACA’s expanded MH parity requirements as of 2017. Of these, 12.1 million were enrolled in individual plans, 14.4 million were enrolled in small-group plans, and almost 13 million were newly eligible Medicaid expansion enrollees.
At the state level, California saw the greatest number of individuals affected at approximately 8.6 million. Other states that had high estimates of affected populations included New York with 2.1 million, Florida with 2.08 million*, Texas with 1.9 million*, and Pennsylvania with 1.87 million.
Vermont, which had pre-ACA parity in both the individual and small-group market and had expanded Medicaid in advance of the ACA, was the only state that saw no effect. Other states such as Wyoming*, Alaska, and Delaware, all had affected populations of less than 100,000 (44,000; 67,000; and 80,000, respectively).
Substance Use Disorder
In total, an estimated 36.4 million individuals nationwide had health insurance that was subject to the ACA’s expanded SUD parity requirements as of 2017. Of these, 9.8 million were enrolled in individual plans, 14 million were enrolled in small-group plans, and almost 12 million were newly eligible Medicaid expansion enrollees.
At the state level, California saw the greatest number of individuals affected at approximately 8.26 million, followed by New York (2.09 million), Florida* (1.79 million), Pennsylvania (1.79 million) and Texas* (1.7 million).
Massachusetts, which had pre-ACA parity in both the individual and small-group market and had expanded Medicaid in advance of the ACA, was the only state that saw no effect. Other states such as Delaware, Wyoming*, Maine*, and Alaska all had affected populations of less than 100,000 (12,000; 39,000; 52,000; and 64,000, respectively).
Discussion
Though the ACA mandated access to health insurance coverage with parity for treatment of mental health and substance use disorders for new groups, it is important to note that the expansion of coverage parity legislation does not guarantee access to equitable MH/SUD services unless the legislation is enforced. Responsibility for parity enforcement falls primarily to states, and the nature and extent of enforcement is consequently inconsistent across the country, with many parity violations continuing to occur as state regulators face limitations in their enforcement capacities.
Further Reading
Access and Cost Barriers to Mental Health Care, by Insurance Status, 1999-2010
Kathleen Rowan, Donna McAlpine, and Lynn Blewett
Section 1115 Waivers and ACA Medicaid Expansions: A Review of Policies and Evidence from Five States: May 2016
SHADAC Special Issue Brief
Medicaid Expansion: Comparing State Choices in Alternative Benefit Plan Design
Colin Planalp
To learn more about mental health and state-level estimates for the affected population who report mentally unhealthy days, see our recent blog post, and visit State Health Compare to learn more about the measure and its data sources.
[1] National estimates do not include a Medicaid expansion breakdown because expansion has only occurred at the state level.
* No Medicaid expansion
