Two Times a Charm? Verifying Reports ofUninsurance in a National Survey

Paul D. Jacobs

Patricia Keenan

Disclaimer

The views expressed in this presentation are those of the authors, and no official endorsement by the Department of Health and Human Services or the Agency for Healthcare Research and Quality is intended or should be inferred.

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Overview

Survey respondents may not recognize or report sources of health insurance coverage, leading to downward estimates of coverage

Federal surveys tend to underreport public coverage, based on comparisons to administrative data

Many household surveys have added a health insurance verification question 

National Health Interview Survey (NHIS), Current Population Survey (CPS), Medical Expenditure Panel Survey (MEPS)

One analysis of CPS (Nelson and Mills, 2001) showed that verification questions primarily identified new reports of private insurance

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Research Questions

What is the impact of adding a verification question on the uninsured rate? 

What are the characteristics of people whose coverage is reported in verification? 

What types and sources of coverage are reported in verification?

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Data

Medical Expenditure Panel Survey, Household Component, 2018-19

Some analyses focus on 2019; others pool 2018-19

One adult in the household aged 18 or over is responsible for answering about all others in a Respondent Unit (RU).

Sample

All MEPS-HC in-scope respondents 

One analysis limited to non-elderly adults ages 18-64

Insurance coverage status as of December 31 of each year obtained from MEPS-HC Rounds 3 and 5.

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MEPS Insurance Coverage Verification 

Added in 2018

Administered after initial health insurance questions

Goal to capture those individuals misreported as uninsured up through that point in the interview

Loosely based on CPS insurance questions:

“Were you covered...even if just for one day, by any kind of health plan...that included hospital and physician benefits?”

If yes: “For that coverage, do you get it through a job, the government or state, is it privately purchased...or did you get it some other way?”

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Classifying Verification Responses

Responses are flagged as verification if 

The response was in verification in that survey round

If coverage was reported in verification in a prior survey round and the coverage continued 

No other sources of coverage were reported outside of verification

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Methods

Compare differences in the uninsurance rate with and without verification

Compare percent reporting insurance coverage in verification

By demographics, health spending, family arrangements in RU

Compare distribution of sources of coverage in verification

Sources of ESI

Marketplace and Medicaid coverage for non-elderly adults

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Reports of Coverage, by Whether Coverage Was Reported in Verification

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|                                                                                                        | Number (millions) | Percent |
|--------------------------------------------------------------------------------------------------------|-------------------|---------|
| Reporting coverage during main interview, before verification                                          | 285.5             | 87.9%   |
| Those who did not report coverage during main interview, and asked to verify whether they had coverage | 39.3              | 12.1%   |
| Those reporting coverage in verification module                                                        | 11.3              | 3.5%    |
| Uninsured after verification section of survey                                                         | 28.0              | 8.6%    |

 Source: Analysis of 2019 MEPS-HC, rounds 3/5.

Percent of Coverage Reported in Verification, by Education and Race/Ethnicity

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Source: Analysis of 2019 MEPS-HC, rounds 3/5.

Notes: ^ reference category. * p<0.05.

[VALUE] *[VALUE] *Hispanic^	Black, non-Hispanic	White, non-Hispanic	Other race, non-Hispanic	No degree^	Bach/Master/Other	Race/Ethnicity	Education	4.6916786193575449E-2	4.1828317020045115E-2	3.3709628078097416E-2	4.9576383490518593E-2	4.4602388210452738E-2	3.2087868376697852E-2	
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Source: Analysis of 2019 MEPS-HC, rounds 3/5.

Notes: ^ reference category. * p<0.05.

Percent of Coverage Reported in Verification, by Age and Health Spending
<	18	18-44^	45-64	65+	>	$0	=$0^	Age	Health spending	<	18	18-44^	45-64	65+	>	$0	=$0^	Age	Health spending	
[VALUE]*[VALUE]*[VALUE]*<	18	18-44^	45-64	65+	>	$0	=$0^	Age	Health spending	3.3303576695189754E-2	5.046762963680191E-2	5.0720274486003761E-2	3.5702151415514766E-3	3.5088487886169847E-2	6.1826834736219867E-2	
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Percent of Coverage Reported in Verification, by Family Characteristics

Source: Analysis of 2018-19 MEPS-HC, rounds 3/5.

Notes: ^ reference category. * p<0.05 †Direct relatives included: either the spouse or partner of the respondent and any children of either the respondent or the respondent's spouse/partner.

^
Only has direct relatives living together†	Other relatives living together^	Reference person	Spouse	Unmarried partner	Child	Child of partner 	Grandchild	Parent	Sibling	Grandparent	Aunt/uncle	Niece/nephew	Other related	Family arrangement	Relationship to reference person	
[VALUE]*[VALUE]*[VALUE]*[VALUE]*[VALUE]*[VALUE]*Only has direct relatives living together†	Other relatives living together^	Reference person	Spouse	Unmarried partner	Child	Child of partner 	Grandchild	Parent	Sibling	Grandparent	Aunt/uncle	Niece/nephew	Other related	Family arrangement	Relationship to reference person	3.538065416583127E-2	5.6789521822813646E-2	3.1519271947632793E-2	2.4634419869872051E-2	5.3341885642691454E-2	3.9392327810832017E-2	1.2863966021940969E-2	9.8485899284090808E-2	5.9417386339843788E-2	8.5117028315109408E-2	0	1.8327390563343239E-2	7.4422061449737273E-2	4.6800649947680531E-2	
Distribution of Sources of Coverage, by Verification Status

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Source: Analysis of pooled 2018 and 2019 MEPS-HC, rounds 3/5.
Medicaid	Verification Module	Main Module	0.14852678527702909	0.21095293074740945	Medicare	Verification Module	Main Module	4.085596352578013E-2	0.18396824565474718	Other Public	Verification Module	Main Module	3.3238166935125012E-2	3.4077230528264654E-2	Employer-based coverage	Verification Module	Main Module	0.34026379957246711	0.52945756147252621	Non-group or Marketplace coverage	Verification Module	Main Module	0.30446450191666974	2.9444437544204671E-2	Other private coverage	Verification Module	Main Module	0.13265078277292885	1.209959405284813E-2	
Distribution of Sources of Employer-related Coverage, by Verification Status

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Source: Analysis of pooled 2018 and 2019 MEPS-HC, rounds 3/5.
Policyholder, coverage through current main job	Verification Module	Main Module	4.213177729551007E-2	0.44504985792276452	Policyholder, coverage through former/misc. job	Verification Module	Main Module	0.20569408753425883	7.7591804125933986E-2	Dependent, policyholder in RU	Verification Module	Main Module	0.45021655114318654	0.4616708789073608	Dependent, policyholder outside RU	Verification Module	Main Module	0.3019575840270447	1.5687459043940862E-2	
Medicaid and Marketplace by Family Income Relative to FPL and Verification Status

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Source: Analysis of pooled 2018 and 2019 MEPS-HC, rounds 3/5. Note: Sample restricted to those ages 18-64.
main coverage module	Medicaid	Marketplace	Medicaid	Marketplace	<	125% FPL	>	125% FPL	0.97	0.68	0.96	0.76	verification module	Medicaid	Marketplace	Medicaid	Marketplace	<	125% FPL	>	125% FPL	0.03	0.32	0.04	0.24	
Conclusions

Verification reduced the percentage uninsured in December 2019 from 12.1% to 8.6%, a 3.5 pp decline

People more likely to report in verification when:

Have no health expenditures

Reporting for a more distant family member

ESI Policyholder is outside RU, or ESI not from main job

Verification is a high percent of Marketplace coverage 

Although administering redundant questions in an instrument is burdensome to respondents, appears to reduce chances of underestimating coverage

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