1. Joanne Pascale, US Census Bureau
Thursday, January 23, 2014
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Kathleen Thiede Call
Second levelInvestigator, SHADAC
Third levelProfessor, University of Minnesota, School of Public Health
Fourth level
Fifth level
Joanne Pascale,
Research Social Science Analyst, Research & Methodology
Directorate, US Census Bureau
3
4. Adapting State Surveys to Measure
Health Coverage Post-Reform
Joanne Pascale
US Census Bureau
State Health Access Data Assistance Center
January 23, 2014
1
5. Outline
• Massachusetts project: 2011-2012
– Research on measuring exchange coverage
– Test questions embedded in CPS Redesign, ACS
General approach for survey adaptation
• Current implementation plans
• Outstanding measurement issues
– Medicaid/CHIP/subsidized exchange overlap
– Question on subsidized premiums
2
6. Research Goals
Adapt federal surveys to:
1. Identify coverage thru the exchange
2. Determine whether it was subsidized
3. Enable analysis of shifts in conventional
(non-exchange-related) sources of
coverage post-reform
3
7. Massachusetts Project
• Expert consultation
1.
2.
Research on state surveys measuring exchange in
Massachusetts post-2006
Monitoring other states’ plans for implementation
• Focus groups with exchange enrollees
• Cognitive interviews with exchange and
Medicaid enrollees
4
9. Expert Consultation Methods
• Series of conference calls with 12 experts
• Expertise in:
– Health care administration and finance
– Health policy, research, advocacy
– Survey measurement
• Agencies included:
–
–
–
–
Health Connector Board
Urban Institute
SHADAC
Harvard University
-- BC/BS Foundation
-- Health Care for All
-- Community Catalyst
-- Social Science Research Solutions
6
10. Mechanics of Exchange
Two-step process:
1. Eligibility screening:
– Apply to Medicaid first
– If ineligible, apply to subsidized exchange
2. Enrollment: multiple pathways including:
–
–
–
–
Connector website
Community-based organizations
Hospitals and clinics
Phone, mail
11. State-level Surveys post-2006
• Two surveys at state-level:
– Massachusetts Health Interview Survey
– BRFSS/Massachusetts
• Method: embedded exchange program
names in “laundry list” of plan types
• Results of interview monitoring, data review:
– Concurrent Medicaid, subsidized & unsubsidized exchange
– Little correlation between income and subsidization level
– Under-reporting of exchange estimated at 50%
Data on plan type not used; only insured/uninsured
8
12. Focus Group Methods
•
•
•
•
•
•
4 groups; all subsidized (CommCare)
2 groups in English; 2 in Spanish
8-12 participants per group; 39 total
Recruited via ads, flyers
Held December 2012-January 2013
Conducted in Boston, central Mass,
Lowell/Lawrence
9
13. Programs, Plans, Levels
Good news: most participants had fairly clear
understanding of distinctions:
•“I have NHP thru CommCare…plan II.”
•“Eligibility is getting accepted into CommCare, then enrollment
is which plan. Do I want Celticare, do I want Network Health
Plan.”
•“They sent me various plans…one with no copay, one that
covered less…I picked the so-so one – the one I thought I
could pay for.”
10
14. Medicaid vs CommCare
Bad news: many conflated Medicaid with
CommCare (subsidied exchange):
•“I used to have MassHealth. Now I have CommCare
but it is the same thing, the only thing is that I work and
that’s why the coverage changed.”
•“I still call it MassHealth…because of so many years,
prior to being CommCare it was MassHealth.”
11
15. Premium and Subsidies
Could-be-worse news: premiums and cost
• Participants had solid understanding of
whether the plan carried a premium
• Little knowledge of absolute cost of
premium, only the portion they pay
• Good understanding of link between
income/employment and premium cost
12
16. “Government” vs “State”
Introduced standardized question from CPS
Redesign on general source of coverage:
“Do you get that coverage through a job, the government or some
other way?”
General reactions:
•“…you should differentiate between state and federal. In my mind that’s a big
difference, and it didn’t surprise me that choosing the word government led me to
Medicaid, military, VA, things like that I associate with a level of federal government.”
•“…confused…it doesn’t say state or US…so people assume…US government. I
think of it as a state thing. I would say the state provided me with insurance.”
•“I don’t think of it as government. I think of it as a state thing.”
13
17. Cognitive Interview Methods
• N=134 subjects total
– 101 in exchange (68% subsidized)
– 28 in Medicaid
– 5 in ESI
•
•
•
•
•
6 rounds of iterative testing (4 in CPS; 2 in ACS)
14-30 subjects/round
Recruited via Connector; known coverage status
54% English; 46% Spanish
Semi-scripted protocol; retrospective probing
14
18. “Downstream” Adaptation
of Surveys for Exchange
• Exchange is not (arguably) a new source
of coverage
• It is a new mechanism for accessing
existing sources of coverage
• Use existing methods to determine source
• Use follow-up questions to find out:
– If obtained thru the exchange
– If subsidized
15
19. CPS Redesign Baseline
Questions on Plan Type
Any coverage?
yes
General source: job, government, other?
job
Who is policyholder?
govt
Type of govt plan?
•
•
•
•
Medicaid
Medicare
VA/miitary
Other
other
Buy it?
16
20. CPS Downstream Adaptations
Any coverage?
yes
General source: job, government or state, other?
job
other
govt
Type of govt plan?
Who is policyholder?
(non-mil)
Thru SHOP?
mil
•
•
•
•
Medicaid
Medicare
VA/miitary
Other
Buy it?
Mcaid,
Other,
DK, Ref
On the exchange?
17
21. Results Overview
• Cross-cutting findings
• CPS redesign plan type reporting among
– Subsidized exchange enrollees
– Unsubsidized exchange enrollees
– Medicaid recipients
• ACS plan type reporting
• Premium and subsidy questions
18
22. Cross-Cutting Results
Covered, yes/no:
•all exchange enrollees said ‘yes’
General source of coverage:
•Some gave insurance plan name
•Probe was effective: “OK, so that would be the plan
name. What do you call the program? Some examples of programs in
[STATE] are [fill state names for govt programs and exchange].”
19
23. CPS Subsidized Exchange (1)
Any coverage?
yes
General source: job, government or state, other?
job
other
govt
Type of govt plan?
Who is policyholder?
(non-mil)
Thru SHOP?
mil
•
•
•
•
Medicaid
Medicare
VA/miitary
Other
Buy it?
Mcaid,
Other,
DK, Ref
On the exchange=YES
20
24. CPS Subsidized Exchange (2)
Any coverage?
yes
General source: job, government or state, other?
job
other
govt
Type of govt plan?
Who is policyholder?
(non-mil)
Thru SHOP?
mil
•
•
•
•
Medicaid
Medicare
VA/miitary
Other
Buy it?
Mcaid,
Other,
DK, Ref
On the exchange=YES
21
25. CPS Subsidized Exchange (3)
Any coverage?
yes
General source: job, government or state, other?
job
other
govt
Type of govt plan?
Who is policyholder?
(non-mil)
Thru SHOP?
mil
•
•
•
•
Medicaid
Medicare
VA/miitary
Other
Buy it = YES
Mcaid,
Other,
DK, Ref
On the exchange=YES
22
26. CPS Unsubsidized Exchange (1)
Any coverage?
yes
General source: job, government or state, other?
job
other
govt
Type of govt plan?
Who is policyholder?
(non-mil)
Thru SHOP?
mil
•
•
•
•
Medicaid
Medicare
VA/miitary
Other
Buy it?
Mcaid,
Other,
DK, Ref
On the exchange=YES
23
27. CPS Unsubsidized Exchange (2)
Any coverage?
yes
General source: job, government or state, other?
job
other
govt
Type of govt plan?
Who is policyholder?
(non-mil)
Thru SHOP?
mil
•
•
•
•
Medicaid
Medicare
VA/miitary
Other
Buy it = YES
Mcaid,
Other,
DK, Ref
On the exchange=YES
24
28. CPS Medicaid Enrolles
Any coverage?
yes
General source: job, government or state, other?
job
other
govt
Type of govt plan?
Who is policyholder?
(non-mil)
Thru SHOP?
mil
•
•
•
•
Medicaid
Medicare
VA/miitary
Other
Buy it?
Mcaid,
Other,
DK, Ref
On the exchange =
No, DK
25
29. CPS: Exchange Source of
Coverage Summary
• Questionnaire accommodates multiple
characterizations of the coverage:
–
–
–
–
–
Federal or state government
Medicaid
Direct-purchase
Insurance plan name
Other/DK/Refused
• Few false-positive reports of exchange from
Medicaid enrollees
26
30. CPS Exchange Participation
Final Question Wording
•
Is that coverage through the Health
Connector, such as Commonwealth Care
or Commonwealth Choice?
•
[if yes] Which plan is it -- Commonwealth
Care or Commonwealth Choice?
27
31. ACS Baseline Questionnaire
1.
2.
3.
4.
ESI?
Direct purchase?
Medicare?
Medicaid?
5.
6.
7.
8.
Military?
VA?
IHS?
Other (specify)?
Issues:
1.ACS mail form can’t accommodate state-specific exchange names
2.Adding exchange program name to laundry list was problematic in
Massachusetts state surveys
3.Exchange not mutually-exclusive with other categories of coverage
28
32. Generic Terms for Exchange
Tested generic terms for yes/no question on
exchange:
•
•
•
•
Exchange, Marketplace
State-sponsored program
Low- and moderate-income cost is reduced
Insurance thru website to compare plans, apply,
purchase coverage
all failed in Massachusetts, in 2011/12
29
33. ACS Work-Around Strategy
• Abandon exchange yes/no question
• Ask two follow-up questions:
1. Is there a monthly premium?
[premise: all exchange plans would have at least a modest premium]
• Yes = Exchange
• No = Medicaid
2. [If yes]: Is the premium subsidized?
• Yes = subsidized exchange
• No = unsubsidized exchange OR non-exchange direct-purchase
coverage
30
34. ACS: Exchange Source of
Coverage Summary
• No natural “home” for exchange plans in
laundry list of plan types
• Subsidized exchange tended toward:
– Medicaid or Other
• Unsubsidized exchange tended toward:
– Direct or Other
• Some chose multiple plan types
• Some didn’t choose any plan type
31
35. Premium & Subsidy Testing
• Premium question unproblematic in CPS and ACS:
– “Is there a monthly premium for this plan?”
• Premium subsidy question:
– “Is the cost of the premium [reduced/subsidized] based
on [your/family] income?”
• Testing results: “Reduced” problematic:
–
–
–
–
Sometimes premium went up based on income
Premium goes up every year, even if subsidized
“Reduced” b/c they chose lesser plan, not due to subsidy
Benefits are reduced due to income, not premiums
32
36. Premium & Subsidy
Final Question Wording
“Is there a monthly premium for this plan?”
Read if Necessary: A monthly premium is a fixed amount of money people pay each
month to have health coverage. It does not include copays or other expenses such
as prescription costs.
“Is the cost of the premium subsidized based on
[your/family] income?”
Read if Necessary: A monthly premium is a fixed amount of money people pay each
month to have health coverage. It does not include copays or other expenses such
as prescription costs.
Read if Necessary: Subsidized health coverage is insurance with a reduced
premium. Low and middle income families are eligible to receive tax credits that
allow them to pay lower premiums for insurance bought through healthcare
exchanges or marketplaces.
33
37. Recap: CPS ASEC 2014
Downstream Adaptations
Any coverage?
yes
General source: job, government or state, other?
other
govt
job
Buy it?
Type of govt plan?
Who is policyholder?
(non-mil)
mil
•
•
•
•
Medicaid
Medicare
VA/miitary
Other
Mcaid,
Other,
DK,
Ref
On the exchange?
Is there a premium?
Thru SHOP?
Is premium subsidized?
34
38. Known Reporting Problems
Respondents’ inevitable mis-reporting of plan type:
•Exchange gets mis-reported as Medicaid: application
process went thru Medicaid but enrollee income too high
to qualify for Medicaid
•Medicaid/CHIP gets mis-reported as exchange b/c
enrollee started with state exchange portal but qualified
for Medicaid (‘woodwork effect’)
35
39. Evolving Complications:
Medicaid vs Subs Exchange
•
•
•
Some states charge Medicaid/CHIP premium
Some bronze exchange plans may be fullysubsidized
Can’t rely on premium yes/no question to
distinguish Medicaid from exchange:
Is there a monthly premium?
–Yes = Exchange [or Medicaid/CHIP, if state charges premium]
–No = Medicaid [or bronze exchange, if state fully subsidizes
premium]
36
40. Modified Strategy
• “Preponderance of Evidence”
• Rely on multiple data points to classify plan type:
– Respondent reports
• source of coverage
• premium yes/no
• premium subsidization
– State eligibility rules on Medicaid/CHIP premiums
– State eligibility rules for premium-free bronze
exchange plans
37
41. Ongoing Testing of Q Wording
• Premium Subsidy Question:
– Tax credits did not exist as a form of
subsidy in Massachusetts pre-2014
– Testing on tax credit wording may not
be effective until next year when
enrollees receive/pay back subsidies
• Some premiums are annual, quarterly
38
42. Harmonization Across Surveys
• Downstream logic:
– Maintain existing methods to identify conventional
source of coverage
– Use follow-up questions about:
• Exchange (yes/no)
• Premium (yes/no)
• Subsidized premium (yes/no)
• Use preponderance of evidence scheme
• Coordinate editing schemes across surveys
39
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44. Kathleen Thiede text
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SHADAC
Second level
callx001@umn.edu
Third level
Joanne Pascale
US Census Bureau
joanne.pascale@census.gov
Fourth level
Webinar recording will be posted at:
Fifth level
http://www.shadac.org/AdaptingStateSurveysWebinar
What are state surveys measuring to evaluate health reform? Visit the State
Reform Survey Item Matrix (SRSIM). We welcome your updates.
http://www.shadac.org/content/SRSIM
www.shadac.org
@shadac
