Health Reform Monitoring Survey -- Texas

April 30, 2015

Vivian Ho, PhD and Elena Marks, JD, MPH

The major insurance coverage expansionprovisionsoftheAffordableCareAct—theHealthInsuranceMarketplaceandMedicaidexpansion—went into effect in January 2014. At that time,individuals inall50stateswereable topurchasehealth plans during two open enrollmentperiods, with subsidies for those with incomesbetween 100% and 400% of the federal povertylevel. Individuals with incomes below 139% ofthe federal poverty level were able to enroll inMedicaid in the 31 states that opted to expandMedicaid.ThisissuebrieffocusesonthechangesinhealthinsurancecoverageamongTexansages18-64asofMarch2015,followingtheACA’ssecondopenenrollmentperiod.

BecauseTexashashad thehighestpercentageofuninsuredresidentsamong the50states formanyyears,thecoverageprovisionsoftheACAwereexpectedtoplayasignificantroleinprovidingcoveragetothemorethan4millionadultsages18-64whopreviously lackedhealthinsurance.BasedontheHRMS-TexasMarch2015survey,wefindthattheACAhashadasubstantialpositiveimpactontherateofhealthinsurancecoverageamongTexans.TherateofuninsuredTexansages18-64droppedbynearlyone-third,from24.6%inSeptember2013to16.9%inMarch2015.Thedropisalmostentirelyattributabletonewlyinsuredindividualswhopurchasedtheirownplans.Thereductionintherateofuninsuredindividualsoccurredacrossallagegroups,includingyoungeradults.

Despite thisprogress,Texas remains the statewith thehighestpercentageofuninsured residentsand,forthefirsttime,Texasnowhasthelargestnumberofuninsuredresidents.ThepercentofuninsuredTexanswith incomes above 138%of the federalpoverty leveldroppedby44.5%whilethosewiththelowestincomeonlydroppedby19.7%.AsofMarch2015,thelowestincomeTexansarealmost four timesmore likely tobeuninsuredthanhigher incomeindividuals.Thiscoveragegaphasgrown since2013because theMarketplaceenabled thehigher incomegroup topurchasehealthinsurancewithsubsidiesnotavailabletolowerincomeTexans.UnlessTexasparticipatesinanexpandedMedicaidprogramordevelopssomeothermechanismforcoveringthelowestincomeTexans,thisisnotlikelytochange.

Issue Brief #11: Effects of the Affordable Care Acton health insurance coverage in Texas as of March 2015

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AT A GLANCE

The percent of adult Texans without health insurance fell from 24.6% in September 2013 to 16.9% in March 2015

The decrease in the uninsured is almost entirely attributable to a rise in individually purchased health plans

Had Texas opted to expand Medicaid, the gains

in coverage would have been more substantial

ABOUT THE SURVEY

TheHealthReformMonitoringSurvey(HRMS)isaquarterlysurveyofadultsages18-64thatbeganin2013.ItisdesignedtoprovidetimelyinformationonimplementationissuesundertheACAandto document changes in health insurance coverage and related health outcomes. HRMS providesquarterlydataonhealthinsurancecoverage,access,useofhealthcare,healthcareaffordability,andself-reportedhealthstatus.TheHRMSwasdevelopedbytheUrbanInstitute,conductedbyGfK,andjointlyfundedbytheRobertWoodJohnsonFoundation,theFordFoundation,andtheUrbanInstitute. Rice University’s Baker Institute and The Episcopal Health Foundation are partneringtofundandreportonkeyfactorsaboutTexansobtainedfromanexpanded,representativesampleofTexasresidents(HRMS-Texas).TheanalysesandconclusionsbasedonHRMS-Texasare thoseof the authors and do not represent the view of the Urban Institute, the Robert Wood JohnsonFoundationortheFordFoundation.InformationaboutthesampledemographicsofthecohortisavailableinIssueBrief#1.ThisIssueBriefisasummaryofdataextractedfromtheHRMSSurveysinTexasadministeredbetweenSeptember2013andMarch2015.WewillcontinuetoreportonsurveydatathroughadditionalIssueBriefsandfuturesurveys.

CHANGES IN INSURANCE STATUS AND TYPES OF INSURANCE

The rate of uninsured Texans has dropped substantially since the opening of the ACA’s HealthInsuranceMarketplaceinlate2013.Figure1showsthatfromSeptember2013toMarch2015,Texasexperiencedanoverallreductionintherateofuninsuredresidentsof7.7percentagepoints,from24.6%to16.9%,accordingtotheMarch2015HRMS-Texassurvey.This31%decreaseintherateofuninsuredissimilartotherateofchangereportedbytheUrbanInstituteforotherstatesthatdidnotexpandMedicaid(30%decrease),butlowerthantherateofchangefortheUSasawhole(43%decrease)andwellbelowtherateofchangeforstatesthatexpandedMedicaid(53%decrease).

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Figure 1:Trends in Uninsurance Rates for Texas Adults Ages 18 to 64

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Figure2showsthechangeincoveragebytypeofinsurancecoveragefromimmediatelybeforetheopeningof theMarketplace through the secondopenenrollmentperiod.Thedata show that thedecrease in thepercentofuninsuredTexans is almost entirely attributable to the increase in thepercentofTexanscoveredbyindividuallypurchasedplans.Whilethepercentofindividualscoveredby public and employer sponsored insurance was relatively unchanged, the percent covered byindividualplansroseby7.4percentagepoints,whichaccountsforalmostallofthedecreaseof7.7percentagepointsinthosewithnoinsurance.

ThisisanimportantchangeintheindividualmarketinTexas.PriortotheenactmentoftheACA,theindividualhealthinsurancemarkethadrelativelylittlepenetrationinTexas.Whilethestatehasalwayshadalargenumberofcarriersofferingdozensofdifferentplans,individualplanswereoftenunaffordableorunavailabletomany.ThecoverageprovisionsoftheACAmodifiedaspectsoftheindividualmarkettoaddresstheseproblemsforallTexansand,throughtheMarketplace,reducedthe cost of insurance for low to moderate income families. Texans now enjoy a markedly morerobustindividualinsurancemarket,asevidencedbythe72%increaseinpenetration.

Figure 2: Net Changes in Insurance Coverage between September 2013 and March 2015, Texans Ages 18-64

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Figure 3: Rate of Uninsured by Age Group, September 2013 to March 2015

CHANGES IN INSURANCE STATUS BY AGE AND INCOME LEVEL

Ratesofuninsurancedroppedforallagegroupsandincomelevels.Figure3shows thedecreasebyagegroup.Thedecreaseacrosstheboardispromising,becauseofconcernthatyoungerpeoplewouldnotbuyhealthinsurance.BetweenSeptemberof2013andMarchof2015,theratesofuninsurancedropped19.4%for18-44yearoldsand55%for45-64yearolds.While thedecline in therateofuninsurancefortheyoungerrespondentsissmallerthanfortheoldergroup,thisisamoveintherightdirectionindicatingthatyoungerTexanswantandarewillingtopayforhealthinsurance.

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TEXAS AND THE HEALTH INSURANCE MARKETPLACE

Atotalof83.1%ofthosesurveyedinHRMS-TexasinMarch2015respondedthattheywerecoveredbyhealthinsuranceand13.8%ofinsuredrespondentsstatedthattheyobtainedinsurancethroughtheMarketplace.U.S.Censusdataindicatethattherewere16.8millionadultsinTexasages18-64in2014.Applyingthesurveyresponseratestothispopulationindicatesthatapproximately1.9millionTexansenrolledinaplanthroughtheMarketplacebyMarch2015.TheUSDepartmentofHealthandHumanServicesreportedthat1.2millionTexanshadenrolledinMarketplaceplansasofFebruary15,2015.OursurveywasconductedthroughoutMarchandislikelytohavecapturednewenrollments,whichwereexpectedtoescalateastheopenenrollmentperioddrewtoaclose.

Figure4showsadecreaseinratesofuninsuredforallthosebelow400%ofthefederalpovertylevel.Thepercentofindividualswithincomesbetween139-399%ofthefederalpovertyleveldecreasedby44.5%.Therateofuninsureddecreasedforthoseatorbelow138%ofthefederalpovertylevelby19.8%.

WhilebothgroupsshowedimprovedratesofcoveragesincetheopeningoftheMarketplace,Texas’decisionnottoexpandMedicaidleavesthoseatthelowestincomelevelswithfewcoverageoptions.Asoursurveydatashow,thoseinthe100%to400%incomegrouppurchasedsubsidizedcoveragethrough the Marketplace thereby substantially increasing their rates of coverage. The ACA wasintended to provide coverage opportunities to the lowest income Americans through Medicaidexpansionandwithoutsuch,theseTexansarelikelytoremainuninsured.

Figure 4: Uninsured Rates by Federal Poverty Level

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LOOKING AHEAD

In subsequent issue briefs, we will report on additional data from the March 2015 HRMS-TexassurveyincludingadditionalcharacteristicsofinsuredanduninsuredTexansandtheexperienceofTexanswiththeMarketplaceandMarketplaceplans.

ABOUT THE AUTHORS

Vivian Ho, PhD,istheJamesA.BakerIIIInstituteChairinHealthEconomics,aprofessorintheDepartmentofEconomicsatRiceUniversity,andaprofessorintheDepartmentofMedicineatBaylorCollegeofMedicine.

Elena Marks, JD, MPH,isthePresidentandChiefExecutiveOfficerofTheEpiscopalHealthFoundationandanonresidentHealthPolicyFellowatRiceUniversity’sBakerInstituteforPublicPolicy.

TheauthorsgratefullyacknowledgetheassistanceofPhilomeneBalihe,MPH,MeeiHsiangKu-Goto, and Alithea McFarlane and the financial support of the Episcopal HealthFoundationandmembersoftheBakerInstitute’sHealthPolicyForum.ThecoreHRMSissupportedbytheRobertWoodJohnsonFoundation,theFordFoundation,andtheUrbanInstitute.Weappreciate theUrbanInstitute’swillingness tocollaborateonexpandingtheHRMSsampletosupportestimatesforTexas.

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METHODOLOGY

Eachquarter’sHRMSsampleofnonelderlyadultsisdrawnfromactiveKnowledgePanel®membersto be representative of the US population. In the first quarter of 2013, the HRMS provided ananalysis sampleofabout3,000nonelderly (age 18–64)adults.After that, theHRMSsamplewasexpandedtoprovideanalysissamplesofroughly7,500nonelderlyadults,withoversamplesaddedto better track low-income adults and adults in selected state groups based on (1) the potentialforgainsininsurancecoverageinthestateundertheACA(asestimatedbytheUrbanInstitute’smicrosimulationmodel)and(2)statesofspecificinteresttotheHRMSfunders.

Althoughfreshsamplesaredrawneachquarter,thesameindividualsmaybeselectedfordifferentroundsofthesurvey.Becauseeachpanelmemberhasauniqueidentifier,itispossibletocontrolfortheoverlapinsamplesacrossquarters.

ForsurveysbasedonInternetpanels,theoverallresponserateincorporatesthesurveycompletionrate as well as the rates of panel recruitment and panel participation over time. The AmericanAssociationforPublicOpinionResearch(AAPOR)cumulativeresponseratefortheHRMSistheproductofthepanelhouseholdrecruitmentrate,thepanelhouseholdprofilerate,andtheHRMScompletionrate—roughly5percenteachquarter.

While low, this response ratedoesnotnecessarily imply inaccurate estimates; a surveywith a lowresponseratecanstillberepresentativeofthesamplepopulation,althoughtheriskofnonresponsebiasis,ofcourse,higher.

All tabulations from the HRMS are based on weighted estimates. The HRMS weights reflectthe probability of sample selection from the KnowledgePanel® and post-stratification to thecharacteristicsofnonelderlyadultsandchildren in theUnitedStatesbasedonbenchmarks fromtheCurrentPopulationSurveyandthePewHispanicCenterSurvey.BecausetheKnowledgePanel®collects in-depth information on panel members, the post-stratification weights can be basedon a rich set of measures, including gender, age, race/ethnicity, education, household income,homeownership,Internetaccess,primarylanguage(English/Spanish),residenceinametropolitanarea,andregion.Giventhemanypotential sourcesofbias insurveydata ingeneral,and indatafromInternet-basedsurveys inparticular, thesurveyweightsfortheHRMSlikelyreduce,butdonoteliminate,potentialbiases.

ThedesigneffectfortheTexasdatainMarch2015is2.184andtheMOEis+/-3.7.ThesurveyfieldedfromMarch5-30.

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Foundedin1993,the JAMES A. BAKER III INSTITUTE FOR PUBLIC POLICYhasestablisheditselfasoneofthepremiernonpartisanpublicpolicythinktanksinthecountry.Theinstituteranks11thamonguniversity-affiliatedthinktanksworldwide,20thamongU.S.thinktanksandfifthamongenergyresource think tanks, according to a2013 studyby theUniversityofPennsylvania’sThinkTanks andCivilSocietiesProgram.AsanintegralpartofRiceUniversity,oneofthenation’smostdistinguishedinstitutionsofhighereducation,theBakerInstitutehasastrongtrackrecordofachievementbasedontheworkofitsendowedfellows,Ricefacultyscholarsandstaff.LocatedinHouston,Texas,thenation’sfourth-largestcityandtheenergycapitaloftheUnitedStates,aswellasadynamicinternationalbusinessandculturalcenter,theBakerInstitutebringsauniqueperspectivetosomeofthemostimportantpublicpolicychallengesofourtime.

Contact information can be found at: http://bakerinstitute.org

THE EPISCOPAL HEALTH FOUNDATION isanewlyestablishedentitywith$1billioninassetsdedicated to improving thehealthandwell-beingof thepeople andcommunities in theEpiscopalDioceseofTexas.TheFoundationembracestheWorldHealthOrganization’sbroad,holisticdefinitionofhealth:a stateofcompletephysical,mentalandsocialwell-beingandnotmerely theabsenceofdisease. The Foundation’s work includes research, grant-making and other initiatives aimed attransformationalchange.

Contact information can be found at: http://www.episcopalhealth.org

SuggestedCitation:

HoV,MarksE.

JamesA.BakerIIIInstituteforPublicPolicy,RiceUniversity,

TheEpiscopalHealthFoundation,

Health Reform Monitoring Survey – Texas,

Issue Brief #11:

Effects of the Affordable Care Act on health insurance coverage in Texas as of March 2015. Houston Texas: 2015

©2015JamesABakerIIIInstituteforPublicPolicy,EpiscopalHealthFoundation