Uninsured New Yorkers After Full Implementation of the Affordable ... - NY State of Healthinfo.nystateofhealth.ny.gov/sites/default/files/Uninsured... · 2013-06-05 · Characteristics
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Uninsured New Yorkers After Full Implementation of the Affordable Care Act: Source of Health Insurance Coverage by Individual Characteristics
and Sub-State Geographic Area Revised, May 2013
Fred Blavin, Linda Blumberg, Matthew Buettgens
The Urban Institute developed a New York state-specific version of its Health Insurance Reform Simulation Model (HIPSM) for use in providing analytic support to the state in its effort to assess the implications of the implementation of the Patient Protection and Affordable Care Act of 2010 (ACA). Initial findings from this work were made available in March of 2012.1 As the state develops and designs its health benefits exchange consistent with the requirements of the ACA and stakeholders prepare for the full implementation of the reforms, the need arose for additional detail on the characteristics and areas of residence of those that are likely to be gaining coverage.
The tables presented here provide sub-state analyses, consistent with our previous findings, focusing on those without insurance coverage of any kind prior to reform, the baseline uninsured. We show the share of uninsured expected to gain coverage under the ACA, whether through public insurance (Medicaid or the Children’s Health Insurance Program, CHIP) or through private coverage (via the new exchange or outside it). The tables include the distribution of characteristics (age, income, race/ethnicity, health insurance unit type,2 health status, language, gender, and education) for those anticipated to gain insurance of each type whenever sample sizes allow.
For these results, we assume the small employer size threshold is set to 100 employees and the small group and direct pay markets remain separate for premium rating purposes. The 100 employee threshold is consistent with the fully phased-in federal requirement, and the separate markets are consistent with the state’s most recent policy decision. Together, these design features are consistent with the “Alternative #1” assumptions in our March 2012 report.
The post-reform estimates of the uninsured in the March 2012 report differ somewhat form those presented here. The estimates in the earlier report are the net effects of many uninsured New Yorkers gaining coverage and a small number of other New Yorkers becoming uninsured post-reform. The estimates in the present analysis focus exclusively on those uninsured prior to reform, thus they do not include any adjustment for the small share of individuals expected to go from insured to uninsured post-reform.
Methods The HIPSM-NY model that we have used to analyze the effects of the ACA in earlier reports was based on two years of the Current Population Survey (CPS).3 There were enough observations of New Yorkers in the two-year merged CPS data for statewide analysis, but not for analysis of detailed areas within the state. For that, we reproduced the results of our model on three years (2008-2010) of the American Community Survey (ACS), which yielded a far larger sample size.
We augmented the ACS with several data elements that are important in simulating the effects of the ACA: • Modified Adjusted Gross Income (MAGI) was computed as specified in the ACA. This required the
imputation of unemployment compensation, which was not directly available on the survey. • Immigration status was imputed following a methodology originally developed by Passel.4 • Eligibility for Medicaid and CHIP was imputed using current state rules.5 • The presence of an offer of employer-sponsored insurance was imputed using the methodology
We used the previously published results of HIPSM-NY to predict changes in coverage on our enhanced ACS data. The New York ACS records were reweighted to simultaneously achieve two objectives. First, in developing HIPSM-NY, we had access to state-specific data that allowed us to determine enrollment in various types of health insurance coverage more accurately than survey responses could. This was particularly true of Medicaid, CHIP and individual (nongroup) market enrollment. Second, effects of the ACA, such as Medicaid and exchange enrollment, were calibrated to be consistent with earlier HIPSM-NY results. This multi-constraint reweighting was based on entropy maximization.7
We were then able to tabulate the results by sub-state area. The smallest geographic areas available on the public-use ACS are Public Use Microdata Areas (PUMAs) created by Census. These do not necessarily follow county boundaries, so we were not able to separate results for all counties. We present results for those counties that we could separate and divide the rest of the state into aggregations of PUMAs (Super-PUMAs). In cases where we provide separate tables with county specific estimates, observations for that county are omitted from the tables with Super-PUMA estimates to avoid double-counting.
For each area, we considered three populations, corresponding to the three columns of each table: those simulated to gain Medicaid or CHIP, those simulated to gain private coverage, and those simulated to remain uninsured under full implementation of the ACA. If the unweighted sample count of a column was less than 90, we suppressed the entire column except for the total due to concerns with the reliability of estimates based upon small samples. If the count was greater than 200, we did not suppress estimates.
For columns based on 90 to 200 observations, we tested each variable to determine whether estimates of its distribution should be suppressed. This allowed us to show estimates for many variables in these sub-state areas. The basic idea behind our test is as follows. Note that these are simulated results, not survey responses, so there is no computed standard error. Instead, we check the consistency of our estimates with other estimates in which we have confidence. Estimates in this sample size range are not shown if they were significantly different than that for a large sample. For example:
Take the age distribution of Medicaid coverage in County X: 1. Statewide, we computed the Kullback-Liebler divergence of age distributions among the eligible,
unenrolled population and the population gaining Medicaid/CHIP. This summarizes take-up behavior related to age at the state level.
2. We computed the same divergence for County X. 3. We computed the difference between these two (1. and 2., above). A difference of zero means that the
estimate was perfectly compatible with what we know about take-up of various age groups at the state level, combined with the distribution of age groups among the eligible population in the county. If the difference was greater than 0.01, age group estimates were suppressed. That does not necessarily mean that the estimates are wrong, just that they diverge from other estimates in which we have more confidence, and because the sample size was somewhat questionable, those estimates are not shown. We analyzed several areas manually, looking at the unweighted counts and comparisons with larger, but similar populations. The threshold value of 0.01 was set low enough to suppress at least those variables in whose distributions we were not confident.
For language, a different method was used. Even in areas with relatively large samples there could be individual languages with unreliably small samples. We suppressed estimates for individual languages with low sample size, and also suppressed the “other” category if any individual language was suppressed. For consistency with our prior estimates, the simulations assume fully phased-in implementation of the Affordable Care Act in the year 2012.
Notes 1. Fredric Blavin, Linda J. Blumberg, Matthew Buettgens, Jeremy Roth, The Coverage and Cost Effects of
Implementation of the Affordable Care Act in New York State, (Washington, DC; The Urban Institute; 2012) http://www.urban.org/health_policy/url.cfm?ID=412534
2. A health insurance unit (HIU) is a group of individuals who would normally be eligible to enroll on a common health insurance plan and includes adult children ages 18 to 22 that do not work the entire year, attend school and live with their parents. A HIU is similar to, yet more restrictive than, the typical survey family definition which includes all related persons in the household.
3. Fredric Blavin, Linda J. Blumberg, Matthew Buettgens, Jeremy Roth, 2012, op cit.
4. Passel, J. and D. Cohen. A Portrait of Unauthorized Immigrants in the United States. Washington, DC: Pew Hispanic Center. 2009.
5. Genevieve M. Kenney, Victoria Lynch, Jennifer Haley, and Michael Huntress (2012) Variation in Medicaid Eligibility and Participation among Adults: Implications for the Affordable Care Act. Inquiry: Fall 2012, Vol. 49, No. 3, pp. 231-253. http://dx.doi.org/10.5034/inquiryjrnl_49.03.08
6. Matthew Buettgens, HIPSM Methodology, 2011 National Version, http://www.urban.org/UploadedPDF/412471-Health-Insurance-Policy-Simulation-Model-Methodology-Documentation.pdf
7. Wittenberg, "An introduction to maximum entropy and minimum cross-entropy estimation using Stata," The Stata Journal (2010) 10, Number 3, pp. 315-330.
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Characteristics of the Uninsured in New York by Insurance Status under the Affordable Care ActAll NY State
N % N % N % N % N %Total Nonelderly 469,000 100.0% 327,000 100.0% 82,000 100.0% 170,000 100.0% 1,676,000 100.0%
Less than High School 64,000 13.6% 53,000 16.2% 17,000 20.4% 31,000 18.2% 364,000 21.7%High School 170,000 36.2% 133,000 40.8% 32,000 38.5% 61,000 36.1% 531,000 31.7%Some College 63,000 13.4% 75,000 23.0% 14,000 16.7% 31,000 18.2% 309,000 18.4%College Graduate 36,000 7.7% 55,000 16.8% 13,000 15.5% 35,000 20.4% 278,000 16.6%
Source: UI Analysis of ACS NY Records1: For adults only.
Baseline Uninsured gaining: Baseline Uninsured:Medicaid or CHIP Remaining UninsuredNon-Group Exchange Small-Firm ESI Other Private
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Characteristics of the Uninsured in New York by Insurance Status under the Affordable Care ActNew York City - Counties 50, 470, 610, 810, 850Bronx, Kings, New York, Queens, Richmond
N % N % N %Total Nonelderly 219,000 100.0% 289,000 100.0% 927,000 100.0%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Less than High School 1,000 9.8% * 2,000 14.0%High School 2,000 34.2% * 5,000 31.6%Some College 1,000 11.0% * 3,000 20.0%College Graduate 1,000 15.0% * 3,000 19.7%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Baseline Uninsured gaining:Medicaid or CHIP Private Coverage Remaining Uninsured
Baseline Uninsured:
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Characteristics of the Uninsured in New York by Insurance Status under the Affordable Care ActCounty: 50 - Bronx
N % N % N %Total Nonelderly 44,000 100.0% 47,000 100.0% 177,000 100.0%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Single, No Dependents * * 4,000 43.7%Single, With Dependents * * 1,000 7.6%Married, No Dependents * * 1,000 11.8%Married, With Dependents * * 3,000 32.8%
Health StatusBetter than Fair/Poor 3,000 88.0% * 8,000 84.8%Fair/Poor * * 1,000 15.2%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Single, No Dependents * * 8,000 40.7%Single, With Dependents * * 3,000 16.7%Married, No Dependents * * 2,000 9.8%Married, With Dependents * * 6,000 29.9%
Health StatusBetter than Fair/Poor 5,000 92.9% 7,000 89.6% 19,000 93.3%Fair/Poor 1,000 10.4% 1,000 6.7%
Less than High School * 1,000 9.3% 3,000 14.3%High School * 3,000 41.5% 7,000 35.8%Some College * 2,000 24.3% 5,000 23.5%College Graduate * 1,000 13.4% 2,000 12.0%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Single, No Dependents * * 7,000 47.1%Single, With Dependents * * 2,000 14.2%Married, No Dependents * * 2,000 13.1%Married, With Dependents * * 3,000 23.1%
Health StatusBetter than Fair/Poor * 5,000 91.6% 13,000 89.6%Fair/Poor * * 2,000 10.4%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Less than High School * 3,000 22.2% 6,000 21.6%High School * 4,000 35.7% 10,000 33.7%Some College * 2,000 19.4% 4,000 15.0%College Graduate * 2,000 12.9% 3,000 11.0%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Single, No Dependents * * 4,000 52.6%Single, With Dependents * * 1,000 19.3%Married, No Dependents * * 1,000 9.8%Married, With Dependents * * 1,000 18.3%
Health StatusBetter than Fair/Poor * * 7,000 90.9%Fair/Poor * * 1,000 9.1%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Single, No Dependents * * 9,000 36.8%Single, With Dependents * * 4,000 15.8%Married, No Dependents * * 2,000 10.7%Married, With Dependents * * 8,000 35.2%
Health StatusBetter than Fair/Poor 5,000 88.6% 8,000 92.1% 21,000 91.1%Fair/Poor 1,000 11.4% 1,000 7.9% 2,000 8.9%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Single, No Dependents * * 7,000 51.4%Single, With Dependents * * 2,000 16.9%Married, No Dependents * * 1,000 5.2%Married, With Dependents * * 3,000 22.4%
Health StatusBetter than Fair/Poor * * 11,000 85.9%Fair/Poor * * 2,000 14.1%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Single, No Dependents * * 5,000 44.5%Single, With Dependents * * 2,000 15.5%Married, No Dependents * * 1,000 12.8%Married, With Dependents * * 3,000 24.5%
Health StatusBetter than Fair/Poor * * 11,000 93.5%Fair/Poor * * 1,000 6.5%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Less than High School 1,000 12.1% 1,000 9.3% 5,000 17.3%High School 3,000 32.4% 6,000 53.8% 11,000 38.5%Some College 1,000 13.2% 3,000 23.1% 5,000 18.0%College Graduate * 1,000 9.6% 3,000 9.1%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Medicaid or CHIP Private Coverage Remaining UninsuredBaseline Uninsured:Baseline Uninsured gaining:
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Characteristics of the Uninsured in New York by Insurance Status under the Affordable Care ActSuper PUMA: 36030Syracuse/ Auburn/ Oneida Area
N % N % N %Total Nonelderly 19,000 100.0% 20,000 100.0% 44,000 100.0%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Less than High School 1,000 8.7% * 6,000 20.7%High School 4,000 32.1% * 10,000 34.3%Some College 2,000 18.0% * 5,000 16.9%College Graduate 1,000 9.7% * 4,000 14.8%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Less than High School 1,000 9.6% 2,000 18.1% 4,000 17.5%High School 4,000 29.2% 5,000 45.1% 9,000 34.9%Some College 1,000 10.0% 2,000 21.2% 4,000 16.6%College Graduate * * 2,000 9.3%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Characteristics of the Uninsured in New York by Insurance Status under the Affordable Care ActSuper PUMA: 36082Ossining/ Peekskill/ Jefferson Valley‐Yorktown Area
N % N % N %Total Nonelderly 8,000 100.0% 9,000 100.0% 27,000 100.0%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Single, No Dependents * * 5,000 44.6%Single, With Dependents * * 1,000 13.6%Married, No Dependents * * 2,000 19.1%Married, With Dependents * * 2,000 18.9%
Health StatusBetter than Fair/Poor 4,000 90.9% 5,000 84.7% 9,000 89.2%Fair/Poor * 1,000 15.3% 1,000 10.8%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size
Characteristics of the Uninsured in New York by Insurance Status under the Affordable Care ActSuper PUMA: 36085New Rochelle/ Mount Vernon/ White Plains Area
N % N % N %Total Nonelderly 14,000 100.0% 20,000 100.0% 65,000 100.0%
Source: UI Analysis of ACS NY Records1: Small number of HIU units are child-only HIUs.2: For adults only.*: estimates suppressed due to small sample size