Academic journal article Inquiry

Preparing to Measure Health Coverage in Federal Surveys Post-Reform: Lessons from Massachusetts

Academic journal article Inquiry

Preparing to Measure Health Coverage in Federal Surveys Post-Reform: Lessons from Massachusetts

Article excerpt


In preparation for health reform in 2014, qualitative research was conducted with Massachusetts residents to explore how to adapt surveys to accommodate reporting information about health exchanges. Questions about exchange participation were effective when state-specific exchange program names were offered, but generic terms such as "marketplace" and "exchange" did not resonate with respondents. However, respondents were able to understand new questions about premiums and subsidies and to answer with a high degree of accuracy. These questions, taken in tandem with answers on plan type, were sufficient to distinguish among Medicaid, subsidized exchange coverage, and unsubsidized coverage, even without the benefit of state-specific exchange program names.


health reform, survey measurement, exchange


The Affordable Care Act (ACA) of 2010 established a series of reforms to be introduced over the course of four years, with nearly full implementation set for January 1, 2014. With the goal of reducing racial, ethnic, and language-based disparities in health care in the United States, many of the provisions of the ACA target historically uninsured populations such as young adults, low-income individuals, and people with limited English proficiency (LEP). In the service of those goals, one of the predominant features of the ACA is the requirement for each state to maintain an "American Health Benefit Exchange," a competitive state-based marketplace of standardized and vetted insurance plans for individuals and small businesses (Patient Protection and Affordable Care Act [PPACA] 2010a). In addition, the ACA states that

any federally conducted or supported health care or public health program, activity or survey (including Current Population Surveys and American Community Surveys conducted by the Bureau of Labor Statistics and the Bureau of the Census) collects and reports, to the extent practicable--(A) data on race, ethnicity, sex, primary language, and disability status for applicants, recipients, or participants.... (PPACA 2010b)

As such, in August 2011, the Census Bureau began a course of research to adapt both the Current Population Survey Annual Social and Economic Supplement (CPS ASEC, commonly called the CPS) and the American Community Survey (ACS) by including questions on exchange participation and subsidization to have these measurement methods in place when the exchanges go into effect in 2014.

Currently, the ACS and CPS both measure whether a person is covered by health insurance and, more specifically, the type of coverage. The ACS is a mixed-mode survey with a current sample size of more than three million households annually; its full implementation began in 2005. Because of the large sample, the ACS is unique in its ability to provide estimates at county, city, and other substate geographic levels on a variety of person and household characteristics. Health insurance coverage items first appeared on the ACS in 2008 and are used by federal and local agencies to allocate funds and evaluate health care programs. The CPS, based on a sample size of about one hundred thousand addresses, is the most often-cited source of estimates on health insurance (Blewett et al. 2004). First appearing on the CPS in 1980 as a mandate to collect information on noncash benefits, the CPS health insurance series provides a source for historical trends in coverage. Given the extensive income module, the CPS can provide a more substantive analysis of health insurance within the scope of poverty, and the Census Bureau derives its supplemental poverty measure (SPM) partly from health insurance coverage and health care costs measured in the CPS.

Since the passage of the AC A in 2010, states have gone about planning for health reform in a variety of ways. Many states waited out results of the Supreme Court ruling in June 2012 and the presidential election in November 2012 before taking any legislative action on their exchange program designs or implementation. …

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