The Errors in Reporting Medicare Coverage: A Comparison of Survey Data and Administrative Records.

Objectives: We examine survey reporting of Medicare coverage of the older population by evaluating discordance between survey responses and administrative records. Method: We link data from the 2014 Current Population Survey Annual Social and Economic Supplement (CPS ASEC) and 2014 Medicare Enrollment Database to evaluate the extent to which individuals misreport Medicare coverage in the CPS ASEC. Using regression analyses, we assess factors associated with misreporting. Results: We find the CPS ASEC undercounts the population aged 65 years and older with Medicare by 4.5%. Misreporting of Medicare coverage is associated with citizenship status, immigration year of entry, employment, coverage of other household members, and imputation of Medicare responses. Adjusting for misreporting, Medicare coverage among older individuals increases from 93.4% to 95.6%. Discussion: The CPS ASEC underestimates Medicare coverage for the older population. Administrative records may be useful to evaluate and improve survey imputation of Medicare coverage when missing.

Indian Health Service Coverage among American Indians and Alaska Natives in Federal Tribal Areas.

Compared with other racial/ethnic groups, American Indians and Alaska Natives (AIANs) have higher uninsured rates and worse health outcomes. Using data from the 2010-2014 American Community Survey, we employ logistic regression techniques to assess the characteristics associated with Indian Health Service (IHS) coverage among working-age AIANs who have health insurance or are uninsured. Across all insurance categories, geographic residence is a factor in IHS coverage. Among the uninsured, those with and without IHS coverage are more dissimilar than similar across socioeconomic characteristics. When controlling for confounding characteristics, people who are uninsured or have Medicaid have a much higher IHS coverage rate compared with those with employer-sponsored insurance. This indicates IHS coverage is an important component for the uninsured and it complements Medicaid services. This work identifies a need for increased outreach to eligible AIANs about IHS programs, particularly those without comprehensive care.

Risking Life and Limb: Estimating a Measure of Medical Care Economic Risk and Considering its Implications.

This paper considers the risk of incurring future medical expenditures in light of a family's resources available to pay for those expenditures as well as their choice of health insurance. We model non-premium medical out-of-pocket expenditures and use the estimates from our model to develop a prospective measure of medical care economic risk estimating the proportion of families who are at risk of incurring high non-premium out-of-pocket medical care expenses in relation to its resources. We further use the estimates from our model to compare the extent to which different types of insurance mitigate the risk of incurring non-premium expenditures by providing for increased utilization of medical care. We find that while 21.3% of families lack the resources to pay for the median expenditures for their insurance type, 42.4% lack the resources to pay for the 99th percentile of expenditures for their insurance type. We also find the mediating effect of insurance on non-premium expenditures to outweigh the associated premium expense for expenditures above $1804 for employer-sponsored insurance and $4337 for direct purchase insurance for those younger than age 65; and above $12 118 of expenditures for Medicare supplementary plans for those aged 65 or older. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

New Estimates of Offer and Take-Up of Employer-Sponsored Insurance.

This analysis uses new questions in the Current Population Survey Annual Social and Economic Supplement to examine rates of offer and take-up of employer-sponsored health insurance over early 2014 and early 2015, as well as reasons reported for why individuals did not enroll. We find increases in offer and eligible rates of 0.5 and 0.9 percentage points, respectively, and a decrease in the take-up rate of 1.5 percentage points, while the coverage rate remained stable. We further find an increase in the proportion of workers covered by another plan and decreases in the proportions eligible for coverage but having a preexisting condition, employed as contract or temporary employees not allowed in the plan, and who have not yet worked for an employer long enough.

Measurement Error in Public Health Insurance Reporting in the American Community Survey: Evidence from Record Linkage.

OBJECTIVE: Examine measurement error to public health insurance in the American Community Survey (ACS). DATA SOURCES/STUDY SETTING: The ACS and the Medicaid Statistical Information System (MSIS). STUDY DESIGN: We tabulated the two data sources separately and then merged the data and examined health insurance reports among ACS cases known to be enrolled in Medicaid or expansion Children's Health Insurance Program (CHIP) benefits. DATA COLLECTION/EXTRACTION METHODS: The two data sources were merged using protected identification keys. ACS respondents were considered enrolled if they had full benefit Medicaid or expansion CHIP coverage on the date of interview. PRINCIPAL FINDINGS: On an aggregated basis, the ACS overcounts the MSIS. After merging the data, we estimate a false-negative rate in the 2009 ACS of 21.6 percent. The false-negative rate varies across states, demographic groups, and year. Of known Medicaid and expansion CHIP enrollees, 12.5 percent were coded to some other coverage and 9.1 percent were coded as uninsured. CONCLUSIONS: The false-negative rate in the ACS is on par with other federal surveys. However, unlike other surveys, the ACS overcounts the MSIS on an aggregated basis. Future work is needed to disentangle the causes of the ACS overcount.

Data sources for identifying low-income, uninsured populations: application to public health-National Breast and Cervical Cancer Early Detection Program.

OBJECTIVE: To provide information on the sources of data for estimating low-income, uninsured populations. To recommend uses of these data sources. To demonstrate the application of these data sources in the public health field, using the National Breast and Cervical Cancer Early Detection Program as an example. METHODS: We describe U.S. Census Bureau data sources for identifying low-income, uninsured populations using two population surveys: the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC) and the American Community Survey (ACS), and using one model-based estimation program, the Small Area Health Insurance Estimates (SAHIE). We provide recommendations for use of these data sources, and we use CPS ASEC and SAHIE to estimate the percent of U.S. women eligible for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). RESULTS: CPS ASEC, ACS, and SAHIE are produced by the U.S. Census Bureau, and they are reliable sources for estimates of the low-income, uninsured populations in the USA. Key characteristics of these three data sources were presented to highlight the strengths of each to meet the needs of various programs at national and local levels. Recommendations are made on the use of the data sources. Based on these three data sources, estimates of NBCCEDP eligibility showed substantial variation over time at the national and state levels, and across states and counties. CONCLUSIONS: Publicly funded programs that are directed toward low-income, uninsured individuals require information on their eligible populations to make decisions about program policy and resource allocation, and to monitor and evaluate the effectiveness of the programs. The U.S. Census Bureau produces three data sources (CPS ASEC, ACS, and SAHIE) for these estimates. The percent of U.S. women eligible for NBCCEDP varies over time and across states and counties. The data sources for these estimates are changing in order to measure key dimensions of the Affordable Care Act (ACA) and can provide helpful information for assessing the legislation's impact.

Cervical cancer screening of underserved women in the United States: results from the National Breast and Cervical Cancer Early Detection Program, 1997-2012.

OBJECTIVE: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast and cervical cancer screens to low-income, uninsured, and underinsured women. We describe the number and proportion of women eligible for cervical cancer screening services and the proportion of eligible women screened over the period 1997-2012. METHODS: Low-income, uninsured, and underinsured women aged 18-64 years who have not had a hysterectomy are eligible for cervical cancer screening through the NBCCEDP. We estimated the number of low-income, uninsured women using data from the US Census Bureau. We adjusted our estimates for hysterectomy status using the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. We used data from the NBCCEDP to describe the number of women receiving NBCCEDP-funded screening and calculated the proportion of eligible women who received screening through the NBCCEDP at the national level (by age group, race/ethnicity) and at the state level by age group. We used the Medical Expenditure Panel Survey to estimate the proportion of NBCCEDP-eligible women who were screened outside the NBCCEDP and the proportion that are not screened. RESULTS: We estimate that in 2010-2012, 705,970 women aged 18-64 years, 6.5 % (705,970 of 9.8 million) of the eligible population, received NBCCEDP-funded Pap tests. We estimate that 60.2 % of eligible women aged 18-64 years were screened outside the NBCCEDP and 33.3 % were not screened. The NBCCEDP provided 623,603 screens to women aged 40-64 years, an estimated 16.5 % of the eligible population, and 83,660 screens to women aged 18-39 years, representing an estimated 1.2 % of the eligible population. The estimated proportions of eligible women screened in each state ranged from 1.5 to 32.7 % and 5 % to 73.2 % among the 18-64 and 40-64 years age groups, respectively. Changes in the proportion of eligible women screened over the study period were nonsignificant. CONCLUSIONS: Although the program provided cervical screening to over 700,000 women between 2010 and 2012, it served a small percent of those eligible. The proportion of women screened varied substantially across age groups, racial/ethnic groups, and states. Many low-income, uninsured women are not being screened.

Breast cancer screening of underserved women in the USA: results from the National Breast and Cervical Cancer Early Detection Program, 1998-2012.

OBJECTIVE: To describe the number and proportion of eligible women receiving mammograms funded by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: Low-income, uninsured, and underinsured women aged 40-64 are eligible for mammography screening through the NBCCEDP. We used data from the NBCCEDP, the Current Population Survey, and Medical Expenditure Panel Survey to describe the number and proportion of women screened by the NBCCEDP and overall. RESULTS: In 2011 and 2012, the NBCCEDP screened 549,043 women aged 40-64, an estimated 10.6 % (90 % confidence interval [CI] 10.4-10.9 %) of the eligible population. We estimate that 30.6 % (90 % CI 26.4-34.8 %) of eligible women aged 40-64 were screened outside the NBCCEDP, and 58.8 % (90 % CI 54.6-63.0 %) were not screened. The proportion of eligible women screened by the NBCCEDP varied across states, with an estimated range of 3.2 % (90 % CI 2.9-3.5 %) to 52.8 % (90 % CI 36.1-69.6 %) and a median of 13.7 % (90 % CI 11.0-16.4 %). The estimated proportion of eligible women aged 40-64 who received mammograms through the NBCCEDP was relatively constant over time, 11.1 % (90 % CI 10.2-11.9 %) in 1998-1999 and 10.6 % (90 % CI 10.4-11.9 %) in 2011-2012 (p = 0.23), even as the number of women screened increased from 343,692 to 549,043. CONCLUSIONS: Although the NBCCEDP provided screening services to over a half million low-income uninsured women for mammography, it served a small percentage of those eligible. The majority of low-income, uninsured women were not screened.

The financial burden of medical spending: estimates and implications for evaluating the impact of ACA reforms.

This article uses the 2013 Current Population Survey Annual Social and Economic Supplement to estimate the financial burden of medical out-of-pocket costs by comparing medical out-of-pocket expenditures to income. This measure is important for evaluating the magnitude of burden, better understanding who bears it, and establishing a baseline to assess the impact of the Patient Protection and Affordable Care Act. We examine the distribution of burden and the incidence of high burden across all families and by individuals' health insurance status and demographic and socioeconomic characteristics. We look more closely at one group vulnerable to having high burden: those younger than age 65 with incomes between 138% and 200% of the federal poverty line. We find that 18.5% of these individuals have incomes below the threshold of expansion Medicaid eligibility after accounting for non-over-the-counter medical expenses and examine the characteristics associated with being classified below this threshold.

The disparate impact of the ACA-dependent expansion across population subgroups.

OBJECTIVE: This study presents evidence on how the dependent provision in the Affordable Care Act (ACA) differentially affected coverage for young adults across states and population subgroups. STUDY DESIGN/METHODS/DATA: The data derive from the American Community Survey. Using a difference-in-difference design, we compare the target population (ages 19-25) with a control group (ages 26-29). PRINCIPAL FINDINGS: Net private health insurance coverage increased by 4.6 percentage points and overall coverage increased by 4.2 percentage points for people aged 19-25; more for Whites than non-White subgroups. CONCLUSIONS AND IMPLICATIONS: Changes in coverage for states appear driven by demographics rather than the existence of prior dependent expansions by the state. Disparities in health care coverage remain, but the absolute level of coverage is improving.

Uninsurance and its correlates among poor adults with disabilities.

States must offer Medicaid coverage to low-income adults with disabilities; however, they have discretion in the design of eligibility criteria and enrollment processes. Using the American Community Survey, we examined the health insurance status of adults enrolled in the Supplemental Security Income (SSI) disability program including (1) the national rate of health insurance coverage; (2) state rates of uninsurance and Medicaid; and (3) the correlates of uninsurance. Uninsurance and Medicaid rates varied across states from 1% to 12% and from 63% to 91%, respectively. Nationally, 5% of the SSI population was uninsured; 77% was enrolled in Medicaid. Limited English proficiency, Black race, lack of U.S. citizenship, and residence in a state that used an enrollment process and/or eligibility criteria distinct from the SSI program were associated with uninsurance. As states streamline Medicaid enrollment processes to meet requirements of the Affordable Care Act, they should consider the needs of this vulnerable population.

Meeting the cervical cancer screening needs of underserved women: the National Breast and Cervical Cancer Early Detection Program, 2004-2006.

OBJECTIVE: To examine the extent to which the only national organized screening program in the US, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), has helped to meet the cervical cancer screening needs of underserved women. METHODS: Low-income, uninsured women 18-64 years of age are eligible for free cervical cancer screening services through NBCCEDP. We used data from the US Census Bureau to estimate the number of eligible women, based on insurance status and income. The estimates were adjusted for hysterectomy status using the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. We used administrative data from NBCCEDP to obtain the number of women receiving NBCCEDP-funded Papanicolaou (Pap) tests. We then calculated the percentage of NBCCEDP-eligible women who received free cervical cancer screening through NBCCEDP. We also used the NHIS to calculate the percentage of NBCCEDP-eligible women screened nationally and the percentage unscreened. RESULTS: In 2004-2006, nearly 9% (775,312 of 8.9 million) of NBCCEDP-eligible women, received NBCCEDP-funded Pap test. Rates varied substantially by age groups, race, and ethnicity. NBCCEDP-eligible women 40-64 years of age had a higher screening rate (22.6%) than eligible women 18-39 years of age (2.3%). Non-Hispanic women had a higher screening rate (9.3%) than Hispanic women (7.3%). Among non-Hispanics, the screening rate was highest among American Indian and Alaska Native (AIAN) women (36.1%) and lowest among women of different race combinations (4.6%), The percentage of eligible women screened in each state ranged from 2.0 to 38.4%. CONCLUSIONS: Although NBCCEDP provided cervical cancer screening services to 775,312 low-income, uninsured women, this number represented a small percentage of those eligible. In 2005, more than 34% of NBCCEDP-eligible women (3.1 million women) did not receive recommended Pap tests from either NBCCEDP or other sources.

Experimental health insurance estimates for low-income and demographic groups by state.

OBJECTIVE: To assess the quality of new modeled estimates of health insurance based on a federal survey. DATA SOURCES/STUDY SETTING: The study uses data from the Annual Social and Economic Supplements to the Current Population Survey (CPS ASEC), calendar years 2001-2003. Health insurance estimates for low-income populations are analyzed. STUDY DESIGN: To assess a method for making estimates for uninsured low-income persons, survey estimates of low-income children are compared with modeled estimates. Inferences can be drawn from this comparison and the method is extended to account for demographic groups. DATA COLLECTION: Data for 2001-2002 CPS ASEC were self-tabulated for low-income children aged 0-17. A special tabulation of the CPS ASEC was used to categorize the numbers of uninsured by age, race, sex, and Hispanic origin by low income at the state level. This special tabulation was the underlying data for the model. Principal Findings. The modeled estimates reduce the variance and margin of error substantially compared with the survey estimates. CONCLUSIONS: These health insurance estimates are credible and increase the precision for the low-income uninsured population. They have broad uses for policy makers and program administrators who focus on the uninsured in special populations.

Do medical out-of-pocket expenses thrust families into poverty?

This paper estimates the impact of medical out-of-pocket expenses on families' well-being using the Survey of Income and Program Participation. Medical out-of-pocket expenses include the out-of-pocket costs from medical services and the family's share of health insurance premiums. Demographic characteristics, insurance status, and medical usage of the family are analyzed to determine which characteristics are most likely to impoverish a family. Families impoverished because of medical out-of-pocket expenses are far more likely to have older heads of the family, at least one family member in poor health, or some adults without health insurance. Families without at least one person who worked full time for the entire year were also likely to be impoverished. However, children in the family had little effect on the probability that the family became impoverished. This odd result is probably due to the high correlation between parental health insurance coverage and the health insurance coverage of their children.