In September 2015, just before the third open enrollment period of the Affordable Care Act’s (ACA) Health Insurance Marketplace was about to open, we surveyed adult Texans ages 18 to 64 to examine changes in insurance status since the opening of the Marketplace. We then compared their responses to those of the United States population as a whole, as reported by the Urban Institute. We also looked at the changes for various demographic groups based on age, gender, race/ethnicity and income. The data show that Texans, like all Americans, experienced meaningful drops in the rates of the uninsured. As of September 2015, the uninsured rate among adults ages 18 to 64 in Texas and the U.S. was 18.5% (a 21.4% drop) and 10.4% (a 40.9% drop), respectively.
About the Survey
The Health Reform Monitoring Survey (HRMS) is a quarterly survey of adults ages 18-64 that began in 2013. It is designed to provide timely information on implementation issues under the ACA and to document changes in health insurance coverage and related health outcomes. HRMS provides quarterly data on health insurance coverage, access, use of health care, health care affordability, and self-reported health status. The HRMS was developed by the Urban Institute, conducted by GfK, and jointly funded by the Robert Wood Johnson Foundation, the Ford Foundation, and the Urban Institute. Rice University’s Baker Institute and The Episcopal Health Foundation are partnering to fund and report on key factors about Texans obtained from an expanded, representative sample of Texas residents (HRMS-Texas). The analyses and conclusions based on HRMS-Texas are those of the authors and do not represent the view of the Urban Institute, the Robert Wood Johnson Foundation or the Ford Foundation. Information about the sample demographics of the cohort is available in Issue Brief #1. This Issue Brief is a summary of data extracted from the HRMS Surveys in Texas administered between September 2013 and September 2015. We will continue to report on survey data through additional Issue Briefs and future surveys.
Characteristics and Changes in Rates of the Uninsured in Texas, September 2013 to September 2015
We wanted to know how the reductions in the rate of uninsured adult Texans as a whole were experienced by various demographic groups and, if so, whether some groups experienced greater reductions than others. Table 1 below shows the rates of uninsured Texans as a whole and among four demographic groups and the rates of reduction for each group. We were especially interested to examine how the groups with the lowest rates of coverage pre-Marketplace, who stood the most to gain from the ACA, were impacted.
Table 1 — Uninsured Rates by Group, Texas Adults 18-64
Adult Texans as a group experienced a decrease of 5 percentage points in the rate of uninsurance, from 23.5% in September 2013 to 18.5% in September 2015. This is an important development for Texas which has had a stubbornly high rate of uninsured residents for many years. When we look at where the gains were made, we see that all groups experienced improvements. In particular, older Texans, ages 50-64 experienced a 36.6% decrease in the rate of uninsurance. This is likely due to the premium rate bands prescribed by the ACA which limit the variability in premiums based on age. This change in pricing resulted in cost reductions for health plans for older adults in many cases.
Hispanics had the most to gain from the ACA, and they have done relatively well compared to other groups. Before the Marketplace, Hispanics had the highest uninsured rates (39.1%) in Texas. By September 2015, that rate had decreased by 10 percentage points (a 25.7% drop) to 29%. This was a larger decrease than that experienced by Whites (1.8 percentage points, or a 12.9% drop) and Blacks (3.7 percentage points, or a 22.4% drop). These results are consistent with the Department of Health and Human Services’ decision to boost resources aimed at increasing enrollment among Latinos and good news for this growing population.
In the case of Texans with the lowest incomes, the group with the highest uninsured rates in 2013 (49.7%), the data showed relatively meager gains compared to those with higher incomes. Those with incomes below 138% of the federal poverty level did experience reductions in the rate of uninsured (15.5%), but the rates of reduction were substantially lower than those with higher incomes (25%). This is not surprising because of the differences in opportunities for affordable coverage. Those with incomes between 139% and 399% of the federal poverty level (household income of approximately $27,000 to $80,000 for a family of three) were eligible to buy subsidized health plans on the Marketplace, which offers subsidies to those with household incomes between 100% and 400% of the federal poverty level. For the lowest income Texans, most were too poor to obtain Marketplace subsidies. The ACA’s plan for covering the poorest Americans was through Medicaid expansion, but because Texas opted not to expand Medicaid, this population, estimated to be around one million people, is in a coverage gap without access to affordable coverage. Unless Texas expands Medicaid or devises an alternative system of coverage for this population, they will remain uninsured.
Comparisons Between Texas and the United States
Table 2 below shows the rates of uninsured adults ages 18-64 throughout the United States among four demographic groups and the decreases in the rates of uninsurance for each group as reported in the national HRMS survey.
Overall, the U.S. as a whole experienced a reduction of 7.2 percentage points in the rate of the uninsured between 2013 and 2015, a 40.9% drop, while Texas experienced a reduction of 5.0 percentage points, a 21.4% drop.
The relative rates of uninsurance in 2015 among various demographic groups nationally and in Texas follow similar patterns in most cases. Older adults, Whites, and higher income people were less likely to be uninsured than young adults, Blacks, Hispanics, and the lowest income people. In the case of gender, there is virtually no difference in the rate of uinsurance nationally; however, in Texas, women are much more likely to be uninsured than men (21.1% vs. 15.8%).
As in Texas, nationally Hispanics had the highest rates of uninsurance in 2013 and 2015 but have made substantial gains in coverage. However, Texas Hispanics showed the greatest decreases in rates of uninsurance, but they did not do so in the US as a whole. Because Texas has a higher percentage of Hispanic adults than the US as a whole, it is more important here than in most states that this population become insured to increase the overall rate of coverage. Despite this progress, in September 2015, 29% of Hispanic adults in Texas remained uninsured, compared to 23.5% nationally.
Table 2 — Uninsured Rates by Group, U.S. Adults 18-64
Looking Ahead
We will continue to analyze and report on the 2015 data to understand the characteristics and experiences of newly insured Texans and those who remain uninsured. In 2016, we will survey again and gain knowledge about the impact of the third open enrollment period and the experiences of Texans with their Marketplace plans.
Methodology
Each quarter’s HRMS sample of nonelderly adults is drawn from active KnowledgePanel® members to be representative of the US population. In the first quarter of 2013, the HRMS provided an analysis sample of about 3,000 nonelderly (age 18–64) adults. After that, the HRMS sample was expanded to provide analysis samples of roughly 7,500 nonelderly adults, with oversamples added to better track low-income adults and adults in selected state groups based on (1) the potential for gains in insurance coverage in the state under the ACA (as estimated by the Urban Institute’s microsimulation model) and (2) states of specific interest to the HRMS funders.
Although fresh samples are drawn each quarter, the same individuals may be selected for different rounds of the survey. Because each panel member has a unique identifier, it is possible to control for the overlap in samples across quarters.
For surveys based on Internet panels, the overall response rate incorporates the survey completion rate as well as the rates of panel recruitment and panel participation over time. The American Association for Public Opinion Research (AAPOR) cumulative response rate for the HRMS is the product of the panel household recruitment rate, the panel household profile rate, and the HRMS completion rate—roughly 5 percent each quarter.
While low, this response rate does not necessarily imply inaccurate estimates; a survey with a low response rate can still be representative of the sample population, although the risk of nonresponse bias is, of course, higher.
All tabulations from the HRMS are based on weighted estimates. The HRMS weights reflect the probability of sample selection from the KnowledgePanel® and post-stratification to the characteristics of nonelderly adults and children in the United States based on benchmarks from the Current Population Survey and the Pew Hispanic Center Survey. Because the KnowledgePanel® collects in-depth information on panel members, the post-stratification weights can be based on a rich set of measures, including gender, age, race/ethnicity, education, household income, homeownership, Internet access, primary language (English/Spanish), residence in a metropolitan area, and region. Given the many potential sources of bias in survey data in general, and in data from Internet-based surveys in particular, the survey weights for the HRMS likely reduce, but do not eliminate, potential biases.
The design effect for the Texas data in March 2015 is 2.243 and the MOE is +/- 3.7. The survey fielded from September 1-25.
