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# 

State Health Access Data Assistance Center (SHADAC) University of
Minnesota School of Public Health

612-624-4802 fax: 612-624-1493 [www.shadac.org](http://www.shadac.org/)

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#### A State Perspective on National Survey Data on the Uninsured

The following paper presents background information on the national
resources available to states and a summary of the strengths and
weaknesses of each survey for state policy purposes. Descriptions of
surveys are organized by the way in which they are funded: 1) federally
sponsored surveys, and 2) privately sponsored surveys.

**Behavioral Risk Factor Surveillance System (BRFSS)**

<http://www.cdc.gov/nccdphp/brfss/>

The BRFSS was established to provide previously unavailable national
data collected on health status and risk behaviors to states. States
have the primary role of targeting resources to address behavioral risks
and state and local agency participation is essential to achieve
national health goals^1^. The BRFSS is conducted by states using rolling
monthly telephone surveys based on a common sampling methodology and
list of core questions, which allow comparisons across states. The core
survey instrument includes questions on health insurance coverage,
however, states have the option of including a "health insurance module"
to collect more specific information on the length of people's episodes
of uninsurance and to determine how satisfied insured people were with
their insurance plans. In addition to the health insurance module,
states may add their own questions to the survey to address
state-specific issues regarding health insurance coverage. Table 1 lists
the states who have included the health insurance module and/or their
own questions about health coverage in their 1998, 1999, and/or 2000
BRFSS survey.

[State Perspective:]{.underline} An advantage for state analysts is that
they conduct the surveys, maintain control over the questions in the
state-specific modules, and have access to the person-level survey data
for ongoing state analysis. Some states have pursued additional sample
and developed a stratification that allows them to estimate prevalence
for regions within a state. In this regard, the BRFSS is perhaps one
model for future federal-state household survey initiatives.

For state health coverage policy, however, the principal drawbacks are
the public health focus on working-aged adults; there are no children
sampled. Given the federal focus on children through the SCHIP program,
BRFSS has not been used to monitor or evaluate national or state health
access initiatives. Though the time lag is less than other national
surveys, it still takes one year to collect the data and one year to
create estimates. Concerns about the telephone

survey's potential for under sampling low-income households have also
been voiced, leading to criticism that the BRFSS lacks sufficient data
on special populations, populations of color, and city- and
county-specific data needed for state health policy initiatives^2^.
There is also concern about lack of quality control in the data
collection methods as it is difficult to oversee 50 state data
collection processes and assess the impact that varied methods have on
population estimates.

Table 1. States' Use of the BRFSS Health Insurance Module and/or the
Addition of Their Own Survey Questions

+----------------------------------+-----------------------------------+
| **States That Used the BRFSS     | **States that Added Their Own     |
| Health Insurance Module (1998,   | Health Coverage Questions to      |
| 1999, and/or 2000)**             | BRFSS (1998, 1999, and/or 2000)** |
+----------------------------------+-----------------------------------+
| Arizona                          | Alabama                           |
|                                  |                                   |
| Idaho                            | Alaska                            |
|                                  |                                   |
| Indiana                          | California                        |
|                                  |                                   |
| Nebraska                         | Florida                           |
|                                  |                                   |
| Rhode Island                     | Hawaii                            |
|                                  |                                   |
| Virginia                         | Idaho                             |
|                                  |                                   |
| Washington                       | Illinois                          |
|                                  |                                   |
|                                  | Kansas                            |
|                                  |                                   |
|                                  | Louisiana                         |
|                                  |                                   |
|                                  | Massachusetts                     |
|                                  |                                   |
|                                  | Michigan                          |
|                                  |                                   |
|                                  | Minnesota                         |
|                                  |                                   |
|                                  | Missouri                          |
|                                  |                                   |
|                                  | Nevada                            |
|                                  |                                   |
|                                  | New Hampshire                     |
|                                  |                                   |
|                                  | New Mexico                        |
|                                  |                                   |
|                                  | Oklahoma                          |
|                                  |                                   |
|                                  | Oregon                            |
|                                  |                                   |
|                                  | South Dakota                      |
|                                  |                                   |
|                                  | Tennessee                         |
|                                  |                                   |
|                                  | Texas                             |
|                                  |                                   |
|                                  | Vermont                           |
|                                  |                                   |
|                                  | Virginia                          |
|                                  |                                   |
|                                  | Washington                        |
|                                  |                                   |
|                                  | West Virginia                     |
|                                  |                                   |
|                                  | Wisconsin                         |
|                                  |                                   |
|                                  | Wyoming                           |
+----------------------------------+-----------------------------------+

**Current Population Survey (CPS)**

<http://www.bls.census.gov/cps/cpsmain.htm>

The U.S. Census Bureau has conducted the CPS for more than 50 years. Its
primary purpose is to collect labor force data on the civilian
noninstitutional population 16 years of age and over. The primary intent
of the CPS is to provide government statistics on labor force
participation, as well as collect income and employment information.
However, each year the March Supplement includes questions concerning
health insurance coverage. These questions are asked toward the end of
the survey. The March Supplement of the Current Population Survey (CPS)
is the most commonly used data source for estimating rates of
uninsurance. While the CPS was intended to provide *national* estimates
and trends over time, policy analysts began using the CPS to derive
*state* estimates of insurance participation.

[State Perspective:]{.underline} The CPS sample was not initially
designed to produce state estimates for uninsurance rates. For many
states, the sample size of the survey is small and the sampling frame
includes only a limited number of counties within each state. When
states started using the CPS to determine state level estimates of the
uninsured, the Census Bureau responded by creating an algorithm for
states to use that takes the sample frame into account and recommends
using a three year rolling average rather than the rate in any given
year. The Census has also responded to states needs by increasing the
size of the sample within some states. While increasing the CPS sample
has improved the confidence intervals of some of its state estimates,
the sample is still too small for detailed state-level policy research
(e.g., rates of uninsurance by age, race, geographic region, etc.)

The downsides of CPS are widely known and efforts to fix some of the
methodological issues appear to be underway given the new resources
allocated with the changes to the Balanced Budget Act included in the
omnibus appropriations bill for FY 2000 (P.L.106-113). The federal
government has mandated that States report on an annual basis the effect
of their State Children's Health Insurance Program (SCHIP) on the number
of uninsured children. To help states with this task, the Treasury
appropriated \$10,000,000 to the Bureau of the Census to make
adjustments to the CPS so that it will produce statistically reliable
annual state data on the number of low-income children without health
insurance.

Recognizing the inadequacies of the present CPS sample in providing
state estimates, the expected adjustments to the CPS include: expanding
the sample size used in state sampling units, increasing the number of
sampling units in a state, and changing the way the survey determines
health insurance status. CPS used to measure health insurance status by
asking respondents whether they had coverage from a specified list of
sources at any time during the prior year. Those who respond "no" to
each source were considered uninsured by default. The new version of the
CPS will include an appropriate verification element (i.e., "At anytime
during the prior year were you without any form of health insurance?")
^3^.

Despite its drawbacks, CPS provides routine and timely estimates of the
uninsured by state providing the only source of comparative information
on the uninsured for broad categories of a state's population.

**Medical Expenditure Panel Survey-Household Component (MEPS-HC)**

<http://www.meps.ahrq.gov/>

The Medical Expenditure Panel Survey (MEPS) is a national survey
conducted by the Agency for Healthcare Research and Quality (AHRQ) on
the financing and utilization of medical care in the United States. The
Household Component (HC) -- one of four components of the MEPS --
collects data on the specific health services that Americans use, how
frequently they use them, the cost of these services, and how they are
paid for. In addition, information is collected on health insurance
coverage, as well as household income, assets and employment.

The panel design of the survey, which features several rounds of
interviewing covering 2 full calendar years, makes it possible to
determine how changes in respondents\' health status, income,
employment, eligibility for public and private insurance coverage, use
of services, and payment for care are related. Because the data are
comparable to those from earlier medical expenditure surveys, it is
possible to analyze long-term trends.

[State Perspective:]{.underline} The MEPS-HC is a well-designed and
tested household survey. Unfortunately, there is not enough sample to
produce state estimates of the uninsured. National data on medical
expenditures may be used to model state expenditures in select
categories, but states, in general, are reluctant to use data that do
not reflect the unique characteristics of their state and its
population. Access to the micro-data (i.e., individual household data)
is hindered by a complex process designed to provide data privacy
protections. Details on how to access the data through Census Research
Data Centers are discussed in more detail in the following section.

**Medical Expenditure Panel Survey-Insurance Component (MEPS-IC)**

<http://www.meps.ahrq.gov/>

The MEPS Insurance Component (IC) consists of two subcomponents, the
household sample and the list sample. The household sample collects
detailed information on the health insurance held by and offered to
respondents to the MEPS-HC. The number of employers and union officials
interviewed varies from year to year, as the number of respondents in
the previous year\'s HC varies. These data, when linked back to the
original household respondent, allow for the analysis of individual
behavior and choices made with respect to health care use and spending.
The list sample consists of a sample of business establishments and
governments throughout the United States. Cost constraints prevent the
fielding of a sufficiently large sample to provide state estimates for
all 50 states and the District of Columbia every year. In 1996,
estimates were made for the forty most populated states. Beginning in
1997, a sample rotation strategy was implemented so that the 20 least
populated states will receive an adequate sample size to make
state-level estimates at least once every four years. (For additional
information on the sample rotation, please see:
<http://www.meps.ahrq.gov/MEPSDATA/ic/1999/technote.pdf>). MEPS-IC may
be used to produce national, regional, and state-level estimates of the
amount, types, and costs of health insurance available to Americans
through the workplace.

[State Perspective:]{.underline} Like the Household Component, the
MEPS-IC is a well-designed and tested survey. It includes state
identifiers and sufficient sample size to produce state estimates for
most states. The cross tabs that have been published for a subset of
states represent a good start in making the survey results available.
However, more analysis could be done with these data. For instance,
states are interested in employee offerings in rural versus urban areas,
by firm size, cost sharing requirements, availability and amounts of
preventive services and prescription drug coverage. These data are
collected but are not included in the public tables. It should be noted
that AHRQ has provided additional one-time runs for states by request,
but time and resources may limit their ability to respond to
state-specific data needs. Perhaps a more important issue for states is
that the data currently released are for 1996, which may not adequately
represent a state's current employment-based health insurance trends. In
addition, the use of MEPS for state analysis is not well publicized. Our
state analyst interviews revealed that many state analysts were unaware
of MEPS or that state tables had been released with descriptive results
for the Insurance Component.

## Access to MEPS-IC Data through Census Research Data Centers 

The possibilities for state policy research are largely untapped by
states that are aware of MEPS because access to micro-data analysis is
too costly and cumbersome for state policy needs. Researchers who would
like to conduct their own analyses of the MEPS IC data must: (1) submit
a proposal for review by the Office of the Chief Economist at the
Census, the AHRQ; (2) receive security clearance to access Census data;
and (3) physically go to a Census Research Data Center (RDC)^4^. There
are six RDCs across the country: Washington DC, Boston, Pittsburgh, Los
Angeles, Berkeley and a newly established center at Duke University in
North Carolina. The proposal review process takes approximately two
months and is conducted concurrently by Census and AHRQ.

Once a proposal has been accepted, the researcher must "buy time" on an
RDC computer to run analyses or pay a programmer consultant to run
programs. Anyone who enters an RDC must obtain "Special Sworn Status"
(SSS) which includes a background check, security clearance, and
analysts must sign and make a sworn statement about preserving the
confidentiality of the data^4^. Individuals who violate this agreement
are subject to the same criminal penalties as Census Bureau employees
who violate the confidentiality of the data. The time and money required
to use MEPS-IC make it infeasible for many states. Only three of the
fifteen states we interviewed have used MEPS-IC. Furthermore, it is not
clear that the detailed analyses states want could be generated and
released given Census concerns of data privacy and confidentiality.

**National Health Interview Survey (NHIS)**

<http://www.cdc.gov/nchs/nhis.htm>

The National Health Interview Survey (NHIS) is a continuing nationwide
survey of the U.S. population. The sample includes 36,000 to 47,000
households each year. Interviews are conducted by trained personnel of
the U.S. Bureau of the Census to obtain information about the health and
other characteristics of each living member of the sample household.
Data collected includes the number of work- or school-loss or
restricted-activity days, as well as all physician visits occurring
during the 2-week period prior to the week of the interview.

[State Perspective:]{.underline} The advantage of NHIS data is that it
is an established ongoing survey with federal funding. It includes
surveys of households with and without telephones so it is more Likely
to reach low-income populations. Public use files are available and easy
to obtain. The NHIS micro-data is now available through NCHS\' own
Research Data Center, which was modeled after the Census RDCs and has a
similar process as Census for accessing data^5^. Release of data is
comparable to other federal surveys, which appears to be on average two
years from data collection.

The disadvantages of NHIS are that it is not specifically designed to
produce state estimates and because it is such a comprehensive survey,
it would be costly to add enough sample to do so. At least one state
(CA) considered buying into NHIS but for specific issues related to the
sampling frame for NHIS, decided to conduct their own household survey
and try to build in some of the NHIS questions. It is not impossible to
produce state estimates from NHIS but it is not easy to do. States may
apply their own demographic population counts to the NCHS published
weights to produce state-level estimates and directions for this process
are published with the 1994 public use file. The process used to compute
these calculations takes time and a certain level of statistical
knowledge and expertise. Another disadvantage of NHIS is that prior to
1997, the uninsured are counted as those who do not report any other
type of coverage, like the CPS and SIPP^6^. That is, uninsured status
serves as a residual category, which may lead to overestimating the
number of uninsured.

**State and Local Area Integrated Telephone Survey (SLAITS)**

<http://www.cdc.gov/nchs/slaits.htm>

The State and Local Area Integrated Telephone Survey (SLAITS) is a
mechanism for government agencies and nonprofit organizations to sponsor
or "buy into" for data collection in areas ranging from health insurance
coverage and access to care to perceived health status and utilization
of services to measures of child well being. SLAITS uses the same
random-digit-dial telephone design approach and sampling frame as the
ongoing National Immunization Survey conducted by the Centers for
Disease Control and Prevention (CDC.) It allows researchers to collect
data using customized questionnaires and the National Immunization
Survey sampling frame of nearly one million households (NCHS 2001).
There are presently four existing SLAITS survey modules including:
Health (Iowa and Washington State, 1997), Child Well-Being and Welfare
(Texas and Minnesota, 1998-99), National Survey of Early Childhood
Health (national sample, 2000), and Children with Special Health Care
Needs (national and state samples, 2000-01).

[State Perspective:]{.underline} SLAITS has the potential to provide a
mechanism for state and national comparisons of data and for
customization to accommodate state-specific needs. Data collection for
three pilot states (MN, IA, NM) was conducted in 1997 and it has gone
through significant design work and statistical modifications. For
example, to correct for under-reporting of public programs typically
seen in household surveys, NCHS developed a study in two states using
people they knew had recently left Medicaid and to produce a
statistically sound correction for this under reporting. They have also
developed methods to correct for bias inherent in telephone surveys for
low-income respondents. (Edward L. Hunter, Associate Director for
Planning, Budget and Legislation, National Center for Health Statistics,
Center for Disease Control, personal conversation, January 14, 2000.)

The present downside to SLAITS is that it has not secured ongoing
funding and future funding is uncertain. It appears that SLAITS may seek
project-specific funding from outside sources as opposed to ongoing core
NCHS federal funds. For example, the Health Resources and Services
Administration (HRSA) is currently using some portions of the SLAITS
survey and a modified sampling frame to conduct a large study of
children with special health needs in all 50 states. Access to the
micro-data, if and when collected, will be available through NCHS' own
Research Data Center, which may present issues for states unless the
discussions of off-site access are feasible. The SLAITS project must
compete with other NCHS activities in the federal budget process and it
is not clear that a state-focused survey can successfully compete in a
federal budget context.

**Survey of Income And Program Participation (SIPP)**

<http://www.sipp.census.gov/sipp/>

The Survey of Income And Program Participation (SIPP) is conducted by
the U.S. Census Bureau to collect information about the labor force
behavior, income, participation in public programs, basic demographic
characteristics to measure the effectiveness of existing federal, state,
and local programs. In addition, the data are used to estimate future
costs and coverage for government programs, such as food stamps, as well
as to provide improved statistics on the distribution of income in the
country. The survey is a continuous series of national panels, with
sample size ranging from approximately 14,000 to 36,700 interviewed
households. The duration of each panel ranges from 2 1/2 years to 4
years.

[State Perspective:]{.underline} SIPP does not allow for state-level
estimates and increasing the sample has significant cost
implications^7^. In addition, the release of SIPP data is 18+ months
from data collection. This time period may be more reasonable from a
federal survey perspective, than it is from a state policy perspective
where decisions often need to be made in a short time frame. Another
downside to SIPP, which is consistent with other general population
surveys, is that it may under-report Medicaid^8^. SIPP is presently the
best data set for analyzing the dynamics of the uninsured over a long
period of time, which may provide a starting point for states interested
in learning more about the episodic nature of uninsurance^9^. However,
its inability to furnish state-level estimates makes its practical
application limited.

# Community Tracking Study Household Survey

<http://www.hschange.com/index.cgi?data=01>

The Community Tracking Study (CTS) is a longitudinal study of health
system change and its effects on people. One component of the CTS is the
Household Survey, which is a biennial, national telephone survey in 60
randomly selected communities stratified by region, community size and
type (metropolitan and non-metropolitan). Table 2 lists the 60
communities by state and highlights 12 communities where more in-depth
data collection and analysis is being conducted. The Household Survey
sample includes 60,000 individuals in 33,000 families. The survey
focuses on assessing whether consumer access to the health care system
is improving or declining over time, nationally and at the community
level. Particular areas of inquiry include access, satisfaction, use of
services and insurance coverage. Information about health status and
sociodemographic characteristics is also collected.

[State Perspective:]{.underline} The concern, from a state perspective,
is how the community-level data ties to state trends or informs state
policy. The data collected for the communities in CTS information may be
compared to other communities in the sample, but the broader state
applications are not clear. States may be less interested in local and
regional estimates of uninsurance coverage, but they are generally
interested in the context of broader state policy and in identifying
pockets of concern or needed local interventions. In addition, like many
surveys, it under reports Medicaid participation^6^.

Table 2. Communities Included in the Community Tracking Study by State

  ----------------------------- -----------------------------------------
  State                         Sites/Geographic Regions

  ALABAMA                       Dothan, W-Cen Alabama

  ARKANSAS                      Cen Arkansas, Little Rock

  ARIZONA                       Phoenix

  CALIFORNIA                    Los Angeles, Modesto, Orange County,
                                Riverside, San Francisco, Santa Rosa

  COLORADO                      Denver

  CONNECTICUT                   Bridgeport

  FLORIDA                       Miami, Tampa, W Palm Beach

  GEORGIA                       Atlanta, Augusta, N Georgia

  ILLINOIS                      Chicago, NE Illinois

  INDIANA                       Indianapolis, NE Indiana, Terre Haute

  LOUISIANA                     Shreveport

  MASSACHUSETTS                 Boston, Worcester

  MARYLAND                      Baltimore

  MAINE                         E Maine

  MICHIGAN                      Detroit, Lansing

  MINNESOTA                     Minneapolis

  MISSOURI                      St. Louis

  NORTH CAROLINA                E North Carolina, Greensboro, Wilmington

  NEW JERSEY                    Middlesex, Newark

  NEVADA                        Las Vegas

  NEW YORK                      Nassau, New York City, Rochester,
                                Syracuse

  OHIO                          Cleveland, Columbus

  OKLAHOMA                      Tulsa

  OREGON                        Portland

  PENNSYLVANIA                  Philadelphia, Pittsburgh

  SOUTH CAROLINA                Greenville

  TENNESSEE                     Knoxville

  TEXAS                         Houston, Killeen, San Antonio

  UTAH                          N Utah

  WASHINGTON                    NW Washington, Seattle

  WASHINGTON, DC                Washington DC

  WISCONSIN                     Milwaukee

  WEST VIRGINIA                 Huntington
  ----------------------------- -----------------------------------------

**National Survey of American Families (NSAF)**

<http://newfederalism.urban.org/nsaf/>

The **National Survey of America\'s Families** produces quantitative
measures of quality of life for people under age 65 in 13 states:
Alabama, California, Colorado, Florida, Massachusetts, Michigan,
Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and
Wisconsin. These states were chosen because they represent a broad range
of fiscal capacity, child well being, and approaches to government
programs. The survey provides a particular focus on health insurance
coverage.

[State Perspective:]{.underline} The 13 states where the NSAF is fielded
benefit from a well-designed survey focusing on health coverage issues.
In addition, low-income households have been oversampled and efforts to
include households without telephones have generated enough sample to
provide estimates of some populations of color and immigrants. The Urban
Institute has made the micro-data for the 1997 and 1999 NSAF available
to states for additional analyses. The usefulness of privately funded
surveys in the long run is essentially tied to the availability of funds
for additional follow-up surveys. There have been discussions between
Urban and several states to effectively "buy-in" to NSAF in place of a
state's own household survey. To date, no states have signed on to a
"buy-in" proposal. The usefulness of privately funded surveys in the
long run is essentially tied to the availability of funds for additional
follow-up surveys.

1993 Robert Wood Johnson Foundation Family and Employer Health Insurance
Surveys

The 1993 Robert Wood Johnson Foundation (RWJF) household survey was
conducted in 10 states and provided new, detailed data on the uninsured
in those states. It was one of a few household surveys that went
door-to-door in an effort to reach individuals without phones, thus
potentially increasing the accuracy of its uninsurance estimates. It was
also one of the only sources of state-level data on insurance coverage
for populations of color. Like the household survey, the employer survey
was a well-designed survey that provided invaluable information to the
10 participating states. Several states pursued adding state sample to
the next iteration, which was a nationally representative sample, and
now have two points in time to measure change. For example, the State of
Minnesota used these data to take a comprehensive look at changes in the
employer market between 1993 and 1997^10^.

[State Perspective:]{.underline} These surveys provided a wealth of
information about the uninsured, as well as about the insurance offered
by employers for individuals in the 10 states in which the surveys were
conducted. Several years later, one of the states included in the
survey, was still using the estimates from this survey for its insurance
coverage for populations of color, as its own state-initiated survey did
not have the sample size needed for sub-population estimates. Several
states were able to obtain the RWJF survey micro-data as long as data
confidentiality requirements were met. For most states, there were no
follow-ups to the 1993 survey and it became a point-in-time look at
insurance coverage with no ability to measure or monitor change over
time in insurance estimates. It is unlikely that a national organization
or the federal government would perform this level of detailed analysis.
The drawbacks of the employer survey are that there is no planned
follow-up survey and it was conducted initially in only 10 states.

1\. CDC. About the BRFSS. Centers for Disease Control and Prevention;
1999.

2\. Figgs LW, Bloom, Y., Dugbatey, K., Stanwyck, C.A., Nelson, D.E.,
Brownson, R.C. Uses of Behavioral Risk Factor Surveillance System Data,
1993-1997. *American Journal of Public Healt*h. 2000;90:774-776.

3\. Nelson CT. Current Population Survey. *Obtaining State Estimates on
the Uninsure*d. Annapolis, MD. Robert Wood Johnson Foundation; 2000.

4\. Census. The Research Data Center (RDC) Program, U.S. Bureau of the
Census; 1999.

5\. NCHS. NCHS Research Data Center. NCHS; 2000.

6\. Lewis K, Ellwood, M., Czajka, J.L., Mathematica Policy Research,
Inc. Counting the Uninsured: A Review of the Literature. Washington,
D.C.: The Urban Institute; 1998:1-31.

7\. Kalton G. SIPP Quality Profile 3rd Edition. Washington, D.C. U.S.
Bureau of the Census; 1998:1-1 through 11-6.

8\. Bennefield RL. A Comparative Analysis of Health Insurance Coverage
Estimates: Data from CPS and SIPP. *1996 Joint Statistical Meetings of
the American Statistical Associatio*n; 1996.

9\. Swartz K. Dynamics of People Without Health Insurance: Don\'t Let
the Numbers Fool You. *JAM*A. 1994; 271:64-66.

10\. Sonier J. Employer-Based Health Insurance in Minnesota. St. Paul:
Minnesota Department of Health, Health Economics Program; 2000:1-69.
<http://www.shadac.org/publications/pubs.htm>