The significant increase in health insurance coverage among adult Texans ages 18-64 since the implementation of the Affordable Care Act (ACA) has reversed a trend that was decades in the making. Relative to September 2013, just before the opening of the ACA’s Health Insurance Marketplace (Marketplace), the rate of uninsured adult Texans dropped by 30%, from 25.5% to 17.9%, meaning that an additional 1.3 million people were enrolled in health insurance plans. The availability of new coverage opportunities, including Marketplace plans and mandated coverage by large employers, gave many Texans new options for coverage and, in some cases, may have led insured Texans to change health plans. Some may have done so by choice while others may have experienced a change in coverage for other reasons, including a change in residence, income, employment, or marital status.
As reported by the Urban Institute, transitions in coverage can be welcome and smooth or unwelcome and disruptive. Smooth transitions, especially when made to a better plan, can be beneficial. Disruptive transitions, however, can cause people to delay or forego care, lose continuity of care, or incur expenses in finding and enrolling in a new plan. Insurance coverage transitions could be beneficial for individuals who gain insurance after being uninsured or switch to a health plan that better meets their needs.
In this brief, we examine the stability of coverage for adult Texans. For purposes of this brief, we define coverage as “stable” if a person had health insurance for all twelve months of the previous year. We compare stability of coverage for adult Texans to US adults, and we then stratify the data among sub-groups of the population. Our data show that almost two-thirds of adult Texans (64.5%) had stable coverage, which is slightly less than the national data for all US adults (73.9%). While the stability of coverage is good news for those who have coverage, our research also shows the stubbornly high rate of uninsurance in Texas (16.6%), which is more than twice that of the US population as a whole (7.7%).
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 March 2016. We will continue to report on survey data through additional Issue Briefs and future surveys.
Stability in Coverage Among Texas and US Adults
To assess the stability of coverage over the preceding twelve-month period, the Health Reform Monitoring Survey asked respondents whether they were insured for all of the previous twelve months (“stable coverage”), for some but not all of the previous twelve months (“unstable coverage”), or for none of the previous twelve months (“uninsured”).
As Chart 1 on page 4 indicates, as of March 2016, almost two-thirds of adult Texans (64.5%) had stable coverage, meaning that they were insured all of the prior year. At the national level, almost three-quarters (73.9%) of adults had stable coverage. The percentage of adult Texans without coverage for any part of the previous year (16.6%) is more than twice that of the US population as a whole (7.7%).1 These differences are due in part to the failure of Texas to expand Medicaid, which accounts for a 37%2 gap between insurance coverage rates for adult Texans as compared to the US population as a whole.
Chart 1 — Health Insurance Coverage Stability in Texas and the United States, Adults Ages 18-64
Notes Estimates are regression-adjusted. Adults who refused to report their coverage status over the previous 12 months are not shown.
Among Texans and all US adults who were insured at all during the year, coverage was substantially stable for both groups. Among all adult Texans with any coverage during the year, 77% had coverage for all twelve months, as did 81% of all US adults. The high rates of stability for both groups indicate that once a person is in coverage, they are very likely to retain coverage consistently throughout the year. This is good news for these individuals, because it improves their access to care; and good news for the insurance providers, because most people are staying in the markets continuously.
Stability in Coverage Among Demographic Groups in Texas
We stratified the Texas respondents by various demographic groups to see whether there were differences in stability of coverage among the groups. As shown in Table 1 on page 5, there are significant differences in the percent of Texans with stable coverage by age, ethnicity, income, employment, education, and health status.
Table 1 reveals that only half (50.5%) of Hispanic Texans had stable coverage, significantly less than that of Whites (72.7%). Also, Texans ages 18-34 and 35-49 reported stable coverage rates of 55% and 59%, respectively, significantly less than 81% stability rate reported for Texans ages 50- 64. Similarly, almost two-thirds (65.6%) of Texans with moderate incomes had stable coverage, significantly higher than that of Texans with the lowest incomes (37.7%).
The data indicate that the lower rates of stable coverage for adults ages 18-49 versus adults 50- 64 is due to higher rates of both unstable coverage and uninsurance in the younger age groups. In contrast, lower rates of stable coverage for Hispanics, lower-income Texans, those not working, the less educated and the less healthy is solely attributable to higher rates of uninsurance. Therefore, coverage stability differs only by age for Texans, while other disadvantaged socioeconomic groups are unable to obtain even partial coverage.
Table 1 — Insurance Coverage Status by Demographic Characteristics (March 2016)
The HRMS survey asked all respondents whether or not they had trouble accessing or paying for medical care during the preceding year. We examined their responses to these questions in light of whether they had stable, unstable, or no health insurance coverage in the previous year. As shown in Table 2 below, respondents with stable coverage were significantly less likely to report trouble accessing or paying for health care and mental health care as compared to those with unstable coverage. This finding is consistent with previous research showing that consistent coverage improves access to care, which is a core premise underlying the ACA’s insurance provisions.
Table 2 — Percent of Texans Ages 18–64 Who Reported Trouble Accessing or Paying for Health Care in Previous Year, March 2016
Note The 11.7% “trouble accessing care” reported by only 11.7% of uninsured Texas adults is puzzling and is contradicted by the statistically significantly higher rates of “trouble” they reported in the categories of “skipped care,” “paying bills,” and “mental health.”
Conclusions
Our data show that almost two-thirds of adult Texans had stable coverage, meaning that they were insured all of the prior year. This is slightly below the national data produced by the Urban Institute showing that almost three-quarters of US adults had stable coverage. The high rate of coverage stability suggests that when Texans are insured, they tend to retain their coverage for a full year once enrolled in a plan.
Texans with stable coverage were significantly less likely to report trouble accessing or paying for health care and mental health care as compared to those with unstable coverage. Our subgroup analysis also reveals a significantly lower level of coverage stability among Hispanics, adult Texans younger than 50 and those with the lowest incomes, which is attributable to higher rates of uninsurance. These populations may also lack sufficient understanding of the health insurance options available to them. As enrollment assistance organizations are preparing for the upcoming open enrollment period in November, they should continue to look for ways to strengthen their outreach and educational efforts to these subgroups.
While our research shows that most Texans are experiencing coverage stability, the data once again highlight the stubbornly high rate of uninsurance in Texas (16.6%), which is more than twice that of the US population as a whole (7.7%). As the recently released census data shows, despite these gains, Texas remains the state with the highest rate of uninsurance and the largest number of uninsured residents. We can change these dismal statistics through enhanced outreach and enrollment as well as Medicaid expansion.
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 2016 is 2.7005 and the MOE is +/- 4.1% at the 95% CI. The survey fielded from March 1-22, 2016.
Endnotes
1. It should be noted that the uninsured estimates reported in this Issue Brief are slightly different from IB #21 as we analyzed different survey questions for the two briefs. In Issue Brief #21, we analyzed a question that asked whether the respondent was insured at the time of the survey, while in this Issue Brief we analyzed a question that asked specifically about the respondent’s coverage over the past twelve months. This approach is consistent with the national analysis that Urban Institute published previously.
2. This estimate is derived from the following steps: First, the gap between U.S. uninsured rate and Texas uninsured rate was 8.9%. Based on previous research produced by Kaiser Family Foundation, the estimated coverage gap population in Texas was 766,000. If Texas agreed to expand Medicaid, it would have reduced the state uninsured rate to 13.3% - reflecting a decrease of 3.3%. This 3.3% represents 37% of the 8.9% gap between national and Texas uninsured rate data.
