Upcoming Census Estimates Expected to Show Continued Major Gains in Health Coverage
On September 13, the Census Bureau will issue its estimates of health coverage for 2015, based on its Current Population Survey (CPS) and American Community Survey (ACS). Data already available from other reputable surveys suggest that the Census data will show significant coverage gains.Last year’s results showed historic coverage gains between 2013 and 2014 as a result of full implementation of the Affordable Care Act’s (ACA) major coverage expansions, which took effect January 1, 2014. Data already available for 2015 from other reputable surveys suggest that the Census data will show further significant coverage gains.
Preliminary results from the Centers for Disease Control and Prevention’s National Health Interview Survey (NHIS) show that in 2015, both the share (9.1 percent) and number (28.6 million) of Americans without health coverage were the lowest on record. The number of uninsured fell by 7.4 million in 2015 after falling by nearly 9 million the year before. Since health reform was enacted in 2010, the number of uninsured Americans has fallen by 20 million, according to this survey, with the uninsured rate declining from 16 percent to 9.1 percent. These coverage gains resulted from significant increases in both private and public health coverage.
Surveys that the Urban Institute, RAND, the Commonwealth Fund, and Gallup have conducted similarly show that the share of Americans without coverage declined substantially in 2015. For example, the share of adults aged 18-64 without insurance fell from 17.6 percent to 10.5 percent between September 2013 and September 2015 — with 9.7 million fewer uninsured people — according to survey results from the Urban Institute’s Health Reform Monitoring Study.
CPS Data Permit Coverage Comparisons to 2013, But ACS Data Needed to Compare to Prior Years
The 2015 estimates from the Census Bureau’s Current Population Survey will be based on the same survey questions as Census used for the previous two years. The estimates that Census issued for 2013 were the first to reflect changes in the survey questions, which the Census Bureau made to improve the reliability and accuracy of the CPS health coverage estimates.a
Before 2013, the CPS asked respondents to report their source of health coverage over the previous calendar year. The Census Bureau concluded, however, that some respondents misinterpreted the question, leading them to indicate their coverage status at the time they were asked the question, rather than whether they had coverage for the entire year.b
In 2013, the CPS began asking about the respondent’s source of coverage at the time of the interview and then asking additional questions to determine whether that coverage had changed over the previous 12 to 15 months (depending on the month in which the interview is conducted). This allows the Census Bureau to generate accurate coverage estimates on both a point-in-time and entire-year basis, as well as to estimate how long respondents retain a particular source of coverage.
The CPS estimates for 2015 thus will be directly comparable to the Census Bureau’s 2013 and 2014 estimates, and analysts will be able to measure accurately the effects of the ACA’s major coverage expansions that took effect in 2014, including the Medicaid expansion to low-income adults and subsidized private marketplace coverage for low- and moderate-income families.
But because of the change in CPS questions, a historical comparison of 2015 CPS data to CPS data for any year before 2013 is not possible. Fortunately, the Census Bureau’s American Community Survey has not changed its health insurance questions, so the ACS data, which are the most widely used source of state-level coverage data, can also be used to make comparisons of the 2015 national data to national data for years back to 2008, when Census first included health insurance questions in the ACS.
a For further information on the Census Bureau survey changes, please see Matt Broaddus and Edwin Park, “Understanding the Census Bureau’s Upcoming Health Insurance Coverage Estimates,” Center on Budget and Policy Priorities, September 11, 2014, https://www.cbpp.org/research/understanding-the-census-bureaus-upcoming-health-insurance-coverage-estimates.
b Census Bureau, “Income, Poverty, and Health Insurance Coverage in the United States: 2005,” August 2006, http://www.census.gov/prod/2006pubs/p60-231.pdf.
Other Surveys Provide Clues About Forthcoming Census Data
As noted, preliminary results from the Centers for Disease Control and Prevention’s National Health Interview Survey (NHIS) indicate what the upcoming CPS estimate of the change in health coverage may show for 2015. The NHIS data show that the share of Americans without health coverage fell from 11.5 percent in 2014 to 9.1 percent in 2015. This 2.4 percentage-point decline follows a 2.9 percentage-point decline from 2013 to 2014. These are by far the two largest single-year declines in the uninsured rate on record.
The 2015 NHIS data also reveal several other trends that the forthcoming CPS and ACS data will likely reflect:
Since the ACA took effect, the share of Americans without health coverage has fallen substantially. The uninsured rate fell from a peak of 16.0 percent in 2010 to 9.1 percent in 2015, according to the NHIS data. The number of uninsured declined by 20 million, or more than 40 percent, over that time period.
The decline has been especially significant among young adults, who since 2010 have been able to stay on their parents’ private insurance plans up to age 26. Moreover, because young adults tend to have relatively low incomes, they tend to qualify for the ACA’s Medicaid expansion (in the states that have adopted it) and the most generous level of marketplace subsidies. Their uninsured rate fell by more than half between 2010 and 2015, from 33.9 percent to 15.8 percent. Similarly, the share of children without health insurance coverage has declined more than 40 percent since 2010.
- Both private and public health coverage grew in 2015. Between 2014 and 2015, the share of Americans with public coverage edged up from 34.6 percent to 35.6 percent, while the share with private coverage rose from 61.8 percent to 63.2 percent, according to the NHIS data. The year 2015 is only the second year — with 2014 being the first — since NHIS data were first collected in 1997 in which both public and private coverage grew by statistically significant amounts. This reflects the impact of the ACA’s major coverage expansions in 2014.
- Coverage rates differ significantly among states. States that have adopted the ACA’s Medicaid expansion had lower uninsured rates in 2015 among non-elderly adults than other states. The gap between the two groups of states grew from 4.3 percentage points to 6.3 percentage points between 2013 and 2014, as expansion states reduced their uninsured rate by twice as much as non-expansion states. That gap widened further in 2015 to 7.7 percentage points.
Coverage gains among poor adults would have been even greater if more states had adopted the Medicaid expansion. The uninsured rate among poor adults fell from 32.3 percent in 2014 to 25.2 percent in 2015 — a 22 percent reduction. This was the biggest coverage gain for this group, exceeding the 2014 gain, since the CDC began collecting these data in 1997. This reflects the fact that Indiana, New Hampshire, and Pennsylvania expanded Medicaid in 2015. Coverage gains for this group would have been roughly twice as large if every state had adopted the Medicaid expansion. So far, 31 states and the District of Columbia have expanded Medicaid.
Public coverage is particularly important for poor Americans, 51.7 percent of whom were enrolled in public coverage in 2015, the NHIS estimates show. Low-income workers are much less likely to be offered and enroll in employer-sponsored coverage than higher-income workers.
Significant coverage gains accrued across population sub-groups. The NHIS data provide health coverage estimates across a wide array of demographic characteristics, including gender, age, family income, working status, and race/ethnicity. Among every such group, the uninsured rate fell by at least 10 percent in 2015, following at least a 15 percent decline among all groups in 2014.
Certain groups experienced larger gains. The share of high school graduates without coverage fell by nearly one-fourth in 2015, from 22.2 percent in 2014 to 17.1 percent last year. People living in the Northeast and West, African Americans and Asian Americans, and those between 100 percent and 138 percent of poverty experienced similarly large reductions.
 Robin Cohen and Michael Martinez, “Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2015,” Centers for Disease Control and Prevention, May 2016, https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201605.pdf.
 Sharon Long et al., “Taking Stock: Health Insurance Coverage Under the ACA as of March 2016,” Urban Institute, May 2016, http://hrms.urban.org/briefs/health-insurance-coverage-ACA-March-2016.pdf.
 This number includes Alaska, Louisiana, and Montana — all of which implemented their Medicaid expansion in late 2015 or 2016 and so are not counted by the CDC as Medicaid expansion states for the purpose of the 2015 analysis.