The Capacity of MEPS to Inform Provisions of the Patient Protection and Affordable Care Act Statistics and Public Policy, ASA Steven B. Cohen PhD.

The Capacity of MEPS to Inform Provisions The Capacity of MEPS to Inform Provisions of the Patient Protection and Affordable Care of the Patient Protection and Affordable Care

ActAct

Statistics and Public Policy, ASAStatistics and Public Policy, ASA

Steven B. Cohen PhD Steven B. Cohen PhD

Presentation Presentation

AHRQ MissionAHRQ Mission MEPS overview MEPS overview Research Infrastructure and Analytic CapacityResearch Infrastructure and Analytic Capacity Informing Provisions of the Affordable Care Informing Provisions of the Affordable Care

ActAct Modeling EffortsModeling Efforts

AHRQ Mission StatementAHRQ Mission Statement

To improve the quality, safety, efficiency, To improve the quality, safety, efficiency, and effectiveness of health care for all and effectiveness of health care for all Americans.Americans.

AHRQ ActivitiesAHRQ Activities

Knowledge CreationKnowledge Creation– Creating data, research findings and tools Creating data, research findings and tools

Synthesis and DisseminationSynthesis and Dissemination– Disseminating information to multiple Disseminating information to multiple

stakeholders to improve the systemstakeholders to improve the system

ImplementationImplementation– Partnering with stakeholders to implement Partnering with stakeholders to implement

proven strategies for health care improvementproven strategies for health care improvement

MEPS ComponentsMEPS Components

Household Component (HC)Household Component (HC)

Medical Provider Component (MPC)Medical Provider Component (MPC)

Insurance Component (IC)Insurance Component (IC)

Medical Expenditure Panel Medical Expenditure Panel Survey (MEPS)Survey (MEPS)

Data resources:Data resources:Annual Survey of 14,000 households:Annual Survey of 14,000 households:

provides national and provides national and state estimates (most state estimates (most populous)populous) of health care use, expenditures, of health care use, expenditures, insurance coverage, sources of payment, insurance coverage, sources of payment, access to care and health care qualityaccess to care and health care quality

Permits studies of:Permits studies of: Distribution of expenditures and sources of Distribution of expenditures and sources of

paymentpayment Role of demographics, family structure, Role of demographics, family structure,

insuranceinsurance Expenditures for specific conditionsExpenditures for specific conditions Trends over timeTrends over time

HC - PurposeHC - Purpose

Estimates annual health care use and expendituresEstimates annual health care use and expenditures Provides distributional estimatesProvides distributional estimates Supports person and family level analysisSupports person and family level analysis Tracks changes in insurance coverage and Tracks changes in insurance coverage and

employmentemployment Longitudinal design; linkage to National Health Longitudinal design; linkage to National Health

Interview Survey (NHIS)Interview Survey (NHIS)

Key Features of MEPS-HCKey Features of MEPS-HC

Survey of U.S. civilian noninstitutionalized populationSurvey of U.S. civilian noninstitutionalized population Sub-sample of respondents to the National Health Interview Survey Sub-sample of respondents to the National Health Interview Survey

(NHIS)(NHIS) Oversample of minorities and other target groupsOversample of minorities and other target groups Panel Survey – new panel introduced each yearPanel Survey – new panel introduced each year

– Continuous data collection over 2 ½ year periodContinuous data collection over 2 ½ year period

– 5 in-person interviews (CAPI) 5 in-person interviews (CAPI)

– Data from 1st year of new panel combined with data from 2nd Data from 1st year of new panel combined with data from 2nd year of previous panelyear of previous panel

MEPS Overlapping PanelsMEPS Overlapping Panels(Panels 13 and 14)(Panels 13 and 14)

MEPS Household Component MEPS Panel 13

2008-2009

Round 2

Round 3 Round 4 Round 5

Round 1 Round 2 Round 3

MEPS Panel 142009-2010

1/1/2008 1/1/2009

Round 1

NHISNHIS20072007

NHISNHIS20082008 Round 4 Round 5

MEPSMEPSDefinition and estimation of uninsuredDefinition and estimation of uninsured

Types of estimates of uninsured – calendar year Types of estimates of uninsured – calendar year focus:focus:1. First half of calendar year 1. First half of calendar year 2. Annual profiles2. Annual profiles3. Two consecutive years3. Two consecutive years4.4. Point in timePoint in time5.5. Long-term uninsured: 4 consecutive years Long-term uninsured: 4 consecutive years

As a longitudinal survey MEPS can examine health As a longitudinal survey MEPS can examine health insurance dynamics, changes in coverage, and spells insurance dynamics, changes in coverage, and spells without insurancewithout insurance

Research on Health InsuranceResearch on Health Insurance

Tracks overall health insurance status of the Tracks overall health insurance status of the U.S. populationU.S. population– Estimates of uninsured by population characteristicsEstimates of uninsured by population characteristics

– Duration of spells of uninsuranceDuration of spells of uninsurance

– Trends in estimates of the uninsuredTrends in estimates of the uninsured

More focused research examinesMore focused research examines– Factors associated with insurance take upFactors associated with insurance take up

– Financial consequences of being uninsuredFinancial consequences of being uninsured

– Relationship between uninsurance and health statusRelationship between uninsurance and health status

Trends in medical care costs, Trends in medical care costs, coverage and use coverage and use

Impact of economic and behavioral factors, payment and Impact of economic and behavioral factors, payment and individual demand on health care service utilization individual demand on health care service utilization and expendituresand expenditures

Distribution of expenditures, concentration and Distribution of expenditures, concentration and persistence of high levelspersistence of high levels

Expenditures for chronic conditions: Expenditures for chronic conditions: focus on patients focus on patients with multiple chronic conditionswith multiple chronic conditions

Trends in prescription medications by drug classTrends in prescription medications by drug class

Medical Provider Medical Provider Component Component

Targeted SampleTargeted Sample All associated hospitals and associated All associated hospitals and associated

physiciansphysicians Sample of associated office-based physiciansSample of associated office-based physicians All associated home health agenciesAll associated home health agencies All associated pharmaciesAll associated pharmacies

Data CollectedData Collected Dates of visitsDates of visits Diagnosis and procedure codesDiagnosis and procedure codes Charges (except Rx) and paymentsCharges (except Rx) and payments

MEPS Insurance MEPS Insurance Component Component

Annual survey of 40,000 establishmentsAnnual survey of 40,000 establishmentsNational and sNational and state Level estimates of employer tate Level estimates of employer

sponsored coveragesponsored coverage:: Availability of health insuranceAvailability of health insurance Access to health insuranceAccess to health insurance Cost of health insuranceCost of health insurance Benefit and payment provisions of private Benefit and payment provisions of private

health insurancehealth insurance

Significance of the IssueSignificance of the Issue

Health care expenditures:Health care expenditures: Over one-sixth of the U. S. GDP Over one-sixth of the U. S. GDP Rate of growth exceeds other sectors of the economyRate of growth exceeds other sectors of the economy Recent moderation in rate of growthRecent moderation in rate of growth Expenditure distribution is highly concentrated Expenditure distribution is highly concentrated Among the largest components of the Federal and states’ Among the largest components of the Federal and states’

budgetsbudgets Cost containment of continuing concern to private and public Cost containment of continuing concern to private and public

payerspayers

Most Recent Cost StatisticsMost Recent Cost Statistics

In 2010 total expenditures = $2.6 trillionIn 2010 total expenditures = $2.6 trillion– 17.9% of GDP17.9% of GDP

– 3.9% increase over 20093.9% increase over 2009

– growth remained slow growth remained slow

– $8,402 per capita$8,402 per capita

Projected to be $4.4 trillion in 2018 Projected to be $4.4 trillion in 2018 20.3% of GDP20.3% of GDP

1.Source: Anne B. Martin, David Lassman, Benjamin Washington 2.Aaron Catlin and the National Health Expenditure Accounts Team, Health Affairs, January 2012

Affordable Care ActAffordable Care Act

2010 Initiatives2010 Initiatives– dependent coverage up to age 26dependent coverage up to age 26– employer tax credits for contributions toward their employer tax credits for contributions toward their

employees' health insurance premiums employees' health insurance premiums – temporary reinsurance program to offset costs of temporary reinsurance program to offset costs of

employer provided retiree benefitsemployer provided retiree benefits– High-risk pools for uninsured with preexisting High-risk pools for uninsured with preexisting

conditionsconditions– greater availability of consumer insurance information greater availability of consumer insurance information

on coverage choiceson coverage choices

Affordable Care ActAffordable Care Act

2011 Initiatives2011 Initiatives– New payment and delivery approaches: New payment and delivery approaches:

CMS Center for InnovationCMS Center for Innovation

– Physician Quality Reporting: physician Physician Quality Reporting: physician compare websitecompare website

– Medicare doughnut hole discountsMedicare doughnut hole discounts

2012 Initiatives2012 Initiatives

Medicare value-based purchasingMedicare value-based purchasing

Affordable Care ActAffordable Care Act

2013 Initiatives2013 Initiatives– Flexible spending limits Flexible spending limits

2014 Initiatives2014 InitiativesMedicaid expansionsMedicaid expansions

Insurance exchangesInsurance exchanges

Premium subsidiesPremium subsidies

Shared Responsibility for coverageShared Responsibility for coverage

2018 Initiatives2018 Initiatives

High cost insurance plansHigh cost insurance plans

2013 Initiatives2013 Initiatives

2012 Initiatives2012 Initiatives

Medicare value-based purchasingMedicare value-based purchasing

Capacity of MEPS to Inform Provisions Capacity of MEPS to Inform Provisions of the Patient Protection and Affordable of the Patient Protection and Affordable

Care ActCare Act

Assess trends in health care spending by source of payment Assess trends in health insurance coverage, ESI, insurance

take-up, eligibility for subsidies Evaluations of the health insurance status of young adults and

their health care use and costs, ages 22-26 Analysis of trends in the health insurance status of high risk

individuals and their health care use and costs Inform allocation of Federal Medical Assistance Percentages

(FMAP) matching funds for state Medicaid programs Determination of the amount of the small employer health

insurance tax credit Evaluations of the impact of the planned excise tax on the most

expensive employer sponsored health plans

Assess Trends in Concentration of Assess Trends in Concentration of Healthcare $s and Distributional Cost Healthcare $s and Distributional Cost

Estimates Estimates

27

38

55

70

97

28

39

56

70

97

28

38

56

69

97

20

30

47

64

97

0102030405060708090

100

Top 1% Top 2% Top 5% Top 10% Top 50%Population ranked by expenditures

1977 1987 1996 2008

Per

cent

age

of e

xpen

ditu

res

Source: National Medical Care Expenditure Survey, 1977; National Medical Expenditure Survey, 1987; Medical Expenditure Panel Survey, 1996 and 2008.

Factors for Cost Factors for Cost Projection ModelsProjection Models

Demographic/economic characteristics: Age; sex; race/ethnicity; marital status; Demographic/economic characteristics: Age; sex; race/ethnicity; marital status; region; MSA classification, family size, poverty status region; MSA classification, family size, poverty status

Health status measures: health status; activity limitations Health status measures: health status; activity limitations Health insurance coverage: full year insured; part year insured; uninsuredHealth insurance coverage: full year insured; part year insured; uninsured Health conditions: Diagnosis of arthritis; cancer; BMI; cerebrovascular disease; Health conditions: Diagnosis of arthritis; cancer; BMI; cerebrovascular disease;

diabetes; heart disease; high blood pressure; high cholesterol; mental health; diabetes; heart disease; high blood pressure; high cholesterol; mental health; back pain; pregnancy back pain; pregnancy

Accidental events: traumaAccidental events: trauma Utilization measures: inpatient events; ambulatory visits; number of prescribed Utilization measures: inpatient events; ambulatory visits; number of prescribed

medicine purchasesmedicine purchases

Expenditure measures: prior yr. total health care spendingExpenditure measures: prior yr. total health care spending

Conditional Distributions by Percentile for Persistence of Expenditures

90-100%

80-90%

70-80%

60-70%

50-60%

40-50%

30-40%

20-30%

10-20%

0-10%0-10%

20-30%

40-50%

60-70%

80-90%

0.05.0

10.015.020.025.030.035.040.045.050.0

55.060.0

Perc

ent

Expenditure Group 2007

Expenditure Group 2008

Persistence of Level of Health Care Expenditures: 2007-08

Assess Trends in Healthcare Burdens Pre and Post ACA:Percent of individuals with high out of pocket health care burdens, elderly &

non-elderly, 2008 (MEPS).Burden=out of pocket medical expenditures +premiums/

family income

Poverty Group 10% of family income 20% of family income

All Elderly 52.5 26.1

Non-elderly 17.0 7.7

Poor Elderly 54.1 43.5

Non-Elderly 33.2 24.5

Low Income Elderly 70.8 40.7

Non-Elderly 22.4 10.2

Middle Income Elderly 63.5 26.0

Non-elderly 18.8 5.9

High Income Elderly 27.4 7.8

Non-elderly 7.5 2.1Banthin and Bernard, 2009, CFACT

MEPS, 2009:Percentage uninsured by age

15.5

6.3

21.6

28.826.6

20.917.2

13.4

26.9

16.7

40.9

48.7

42.5

33.2

26.9

19.9

0

10

20

30

40

50

60

Age 0-64 0-17 18-21 22-26 27-29 30-34 35-54 55-64

Percent full year uninsured Percent ever uninsured

Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2009 Full- Year File

Assess Trends in Cost of Employer Sponsored Coverage:Annual premiums and employee contributions for

employer-sponsored health insurance by coverage type, private industry,2001 & 2009

Cumulative percent change in total premiums by coverage type for employer-sponsored health insurance,

private industry, 2001-2009

Insurance Component estimates are not available for

2007.

Cumulative percent change in employee contributions by coverage type for employer-sponsored health insurance,

private industry, 2001-2009

Insurance Component estimates are not available for 2007

Source: Center for Financing, Access, and Cost Trends, AHRQ, Insurance Component of the Medical Expenditure Panel Survey

MEPS-IC State-Level Premiums Key To Tax Credit for Small Employers

• The Affordable Care Act offers a tax credit for small employers providing health insurance

• Credit effective beginning in 2010

• Amount of credit limited by the average premium paid by small employers by State

•Treasury & HHS have begun joint effort to define these limits

• MEPS-IC is only source of State-level premium data for all States

• In later years, sub-State small group markets may be designated by HHS secretary

•Research underway to improve MEPS-IC sub-State estimates of health insurance premiums

Tax Credit FormTax Credit Form

MEPS-based DataMEPS-based Data

2010 MEPS-IC Family Premium Estimates Now Available 2010 MEPS-IC Family Premium Estimates Now Available For Use in Setting State Tax Credits for Small, Private For Use in Setting State Tax Credits for Small, Private

Sector Firms under Health Care ReformSector Firms under Health Care Reform

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w H

am

ps

hir

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15

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6

$5,000

$7,500

$10,000

$12,500

$15,000

Small firms have fewer than 50 employees; Source: Center for Financing, Access, and Cost Trends, AHRQ, Insurance Component of the Medical Expenditure Panel Survey, 2010

Source: Center for Financing, Access, and Cost Trends, AHRQ, Insurance Component of the Medical Expenditure Panel Survey, 2009

Trends for Employers that Self-Insure

Provisions in the Affordable Care Act impact on self-insured plans

• Impact on plan design

• Implications on preventive care coverage

• Assess trends in offers of employment-based group coverage and self insured plans, their cost and benefit provisions

Source: Center for Financing, Access, and Cost Trends, AHRQ, Insurance Component of the Medical Expenditure Panel Survey, 2009

Percent of enrollees with employer-sponsored coverage in self-insured plans, private sector by firm size, 2000 and 2010

Modeling and Simulation EffortsModeling and Simulation Efforts

MEPS survey data used to model costs and MEPS survey data used to model costs and impacts of various proposed reforms impacts of various proposed reforms – Costs of reform to householdsCosts of reform to households

– Costs to nationCosts to nation

– Changes in coverageChanges in coverage

– Tax impactsTax impacts

Research QuestionResearch Question

How much lower would out-of-pocket How much lower would out-of-pocket expenditures for care for adults with expenditures for care for adults with individual insurance be if they had individual insurance be if they had more generous benefits typical of more generous benefits typical of employment-related insurance?employment-related insurance?

– Small employersSmall employers

– Large employersLarge employers

Annual Out-of-Pocket Spending Annual Out-of-Pocket Spending for Medical Care and Drugsfor Medical Care and Drugs

EmployerEmployer

IndividualIndividual SmallSmall LargeLarge

MeanMean $1,005$1,005 $583**$583** $517**$517**

Percent positivePercent positive 80.480.4 80.280.2 82.5**82.5**

Percent > $3,000Percent > $3,000 7.47.4 3.7**3.7** 2.2**2.2**

Source: Medical Expenditure Panel Survey, 2001-2008, insured for calendar year .Source: Medical Expenditure Panel Survey, 2001-2008, insured for calendar year . Inflated to 2008 dollars using CPI-medical care.Inflated to 2008 dollars using CPI-medical care.

** Significant difference at 1% level.** Significant difference at 1% level.

Characteristics Controlled for:Characteristics Controlled for: Socioeconomic factorsSocioeconomic factors

– Education and demographicsEducation and demographics

– Income, asset income, home ownershipIncome, asset income, home ownership

Geographic factorsGeographic factors

– Providers per capita, region, urbanicityProviders per capita, region, urbanicity

Health: SF-12, chronic conditions Health: SF-12, chronic conditions

Attitudes and health behaviorsAttitudes and health behaviors

– Smoking, regular exerciseSmoking, regular exercise

– Family members’ attitudesFamily members’ attitudes

ResultsResults If adults with individual insurance gained benefits typical of small If adults with individual insurance gained benefits typical of small

employers:employers:

– Mean out-of-pocket expenditures for medical care and drugs would Mean out-of-pocket expenditures for medical care and drugs would likely decrease by over 30% from $1,005 per year in 2008 $slikely decrease by over 30% from $1,005 per year in 2008 $s

– The probability of out-of-pocket expenditures exceeding $3,000 The probability of out-of-pocket expenditures exceeding $3,000 would likely fall by a thirdwould likely fall by a third

If adults with individual insurance gained benefits typical of large If adults with individual insurance gained benefits typical of large employers:employers:

– Mean out-of-pocket expenditures for medical care and drugs would Mean out-of-pocket expenditures for medical care and drugs would likely decrease by over 40% from $1,005 per year in 2008 $slikely decrease by over 40% from $1,005 per year in 2008 $s

– The probability of out-of-pocket expenditures exceeding $3,000 The probability of out-of-pocket expenditures exceeding $3,000 would likely fall by two-thirdswould likely fall by two-thirds

Out-of-Pocket Spending for Health Care and Individual Insurance, Steve Hill AHRQOut-of-Pocket Spending for Health Care and Individual Insurance, Steve Hill AHRQ

MEPS-Based SimulationMEPS-Based Simulation

MEPS widely used inside and outside government in MEPS widely used inside and outside government in models to simulate ACA effectsmodels to simulate ACA effects

Some ways we support these efforts:Some ways we support these efforts:– Detailed reconciliation of MEPS with NHEADetailed reconciliation of MEPS with NHEA– Publishing projected micro datafiles aligned with CMS Publishing projected micro datafiles aligned with CMS

projectionsprojections– Tax simulations for MEPS-HCTax simulations for MEPS-HC– Tax expenditure benchmarks from synthetically linked MEPS-ICTax expenditure benchmarks from synthetically linked MEPS-IC

Economic Research Economic Research Infrastructure Infrastructure

Data infrastructure to support intramural, extramural Data infrastructure to support intramural, extramural work on cost and financing, efficiency and quality, work on cost and financing, efficiency and quality, access, disparities. access, disparities.

– Significant intramural expertise and activitySignificant intramural expertise and activity

– Large and growing use by extramural researchersLarge and growing use by extramural researchers Data Center on-site for work with MEPSData Center on-site for work with MEPS

The link between research and dataThe link between research and data– Substantive expertise reflected in design of AHRQ-Substantive expertise reflected in design of AHRQ-

sponsored data resources and toolssponsored data resources and tools– Maintain and increase quality, integrity, and relevanceMaintain and increase quality, integrity, and relevance

through researcher-informed data improvements, through researcher-informed data improvements, substantive and technical assistancesubstantive and technical assistance

Assistance to Congress on Coverage Assistance to Congress on Coverage Trends and CostTrends and Cost

Provision of AHRQ research findings to inform Provision of AHRQ research findings to inform health policyhealth policy

– national estimates of the long term uninsured national estimates of the long term uninsured

– estimates of the number of uninsured children estimates of the number of uninsured children eligible for SCHIPeligible for SCHIP

– state estimates of the availability and cost of state estimates of the availability and cost of employer sponsored coverageemployer sponsored coverage

– concentration of health care expendituresconcentration of health care expenditures

– premium percentiles of high-cost health plans premium percentiles of high-cost health plans by state by state

Fast-track responses to requests from Fast-track responses to requests from CBO, CRS, CBO, CRS, Senate and House Committees Senate and House Committees andand Congressional Congressional staffstaff

Future EffortsFuture Efforts

Co-ordination within DHHS in terms of adding new Co-ordination within DHHS in terms of adding new content to evaluate components of the ACAcontent to evaluate components of the ACA

Planning for Pre/Post analyses of new program Planning for Pre/Post analyses of new program initiativesinitiatives

Attention to enhanced linkages to administrative Attention to enhanced linkages to administrative data and greater capacity for longitudinal analysesdata and greater capacity for longitudinal analyses

Topics CoveredTopics Covered

MEPS OverviewMEPS Overview Informing trends in health care costs, Informing trends in health care costs,

coverage, and access coverage, and access Affordable Care Act provisionsAffordable Care Act provisions MEPS and the ACAMEPS and the ACA Ongoing health care initiativesOngoing health care initiatives