Profiles residents still uninsured after the individual mandate was implemented: young, single, urban, male racial/ethnic minorities and non-citizens with limited English proficiency. Outlines lessons on outreach to those eligible for public coverage

Lokendra Phadera

Sharon K. Long

Victoria Lynch

English

IssueLab

 State Health Access Reform Evaluation, a national program of the Robert Wood Johnson Foundation® Urban Institute • Washington, D.C.   August 2010  Massachusetts Health Reform in 2008: Who are the Remaining Uninsured Adults? ‒Sharon K. Long Ph.D. ^, Lokendra Phadera*, Victoria Lynch M.S. *  ^University of Minnesota, *The Urban Institute   INTRODUCTION  In 2006, Massachusetts passed comprehensive health reform legislation with the goal of achieving near-universal health insurance coverage in the state. 1  The most recent na-tional data show that Massachusetts’ overall uninsurance rate was 4.1 percent by 2008—the lowest among all states and well below the national average of 15.1 percent. 2  Nonel-derly adults represent much of the remaining uninsured in Massachusetts, with 5.7 per-cent of adults ages 19 to 64 estimated to be lacking insurance in 2008.  This equates to approximately 223,000—or 85.4%—of  the state’s 261,000 uninsured residents. 3    In order to reach the remaining uninsured nonelderly adults in Massachusetts, we need a better understanding of who they are and where they live.  Until recently, information about the characteristics of this group has been constrained by relatively small sample sizes in existing surveys—a problem that has intensified as the uninsurance rate in Massa-chusetts has dropped. 4  However, the American Community Survey (ACS) began collecting information on health in-surance status in 2008, providing a valuable new resource for understanding insurance coverage in the United States.  This brief provides a new assessment of the nonelderly uninsured population in Massachusetts using the ACS.    DATA & METHODS  The ACS, which is conducted by the U.S. Census Bureau, provides annual information on the economic, social, demo-graphic and housing circumstances of U.S. residents. Each year the ACS samples approximately 2.5 percent of U.S. households, yielding data on about two million households. This sample size far exceeds that of other national surveys, and the response rate for the survey in 2008 was very high, at 97.9 percent.5 Of particular relevance to this study, the 2008 ACS added a question on the health insurance status of each individual in the household.6  For the present analysis, the authors used the Integrated Public Use Microdata Series (IPUMS)-USA file of the 2008 ACS, a very large subset of the full survey that is made available by the Minnesota Population Center.7,8 The focus of the analysis was nonelderly adults aged 19 to 64 in Massachusetts. The final sample size was 38,207, which represents 3.9 million nonelderly adults in the state.  The uninsurance rate for this sample was 5.7 percent in 2008.9  The smallest geographical unit provided in the ACS 2008 IPUMS-USA file is the “Public Use Microdata Area” (PUMA). PUMAs are defined within states, generally based on counties, to identify areas with a population size of roughly 100,000 residents. For this analysis, information from PUMAs was used as the geographic unit to map the distribution of uninsurance across Massachusetts, focusing on six geographic regions of the state: Western, Central, Metro West, Northeast, Boston and Southeast.    Who are  the  Remain ing Uninsured ?    2 This analysis relied on descriptive methods, comparing insured and uninsured adults in the state in 2008. All analyses use weighted data, with estimates of standard errors obtained using replicate weights and successive differences repli-cation methods.10,11  FINDINGS  The Remaining Uninsured  Consistent with earlier work on the characteristics of uninsured adults in Massachusetts12 and in the nation as a whole,13 we find that the adults who remained uninsured under health reform in Massachusetts in 2008 were more likely than those with insurance coverage to be    Male, young, and single   Racial/ethnic minorities and non-citizens   Unable to speak English well or very well  Living in a household in which there was no adult able to speak English well or very well  Compared with insured respondents, uninsured adults also reported substantially lower educational attainment and less employment and had lower family income and greater financial stress.  With respect to location, pockets of higher-than-average uninsurance were reported in each of the six regions of Mas-sachussets-- Western, Central, Metro West, Northeast, Boston and Southeast (Figure 1). The places with the highest levels of uninsurance were in urban areas, around Boston and in the Southeast region of the state.  Areas with the low-est uninsurance were largely concentrated in the Metro West and Central regions of Massachusetts. When we look at the distribution of uninsured adults across the state, we find, not surprisingly, the greatest concentration of uninsured residents in the Boston area, where much of the population of the state is concentrated. However, there are large pock-ets of uninsured adults in each of the other regions of the state as well.       The Uninsured Who Qualify for Public or Subsidized Coverage    Who are  the  Remain ing Uninsured ?    3 As part of Massachusetts’ health reform initiative, many lower-income adults have access to either direct public cover-age via the state’s Medicaid program (MassHealth) or subsidized coverage via the new Commonwealth Care program.14 MassHealth is available to pregnant women and parents living with dependent children with family income at or below 200 percent of the FPL, as well as to some other special coverage categories (e.g., disabled adults, long-term unem-ployed adults). Subject to some restrictions, Commonwealth Care is available with a full subsidy to adults with family income below 150 percent of the FPL. Adults with family income between 150 percent and 300 percent of the FPL are also eligible for Commonwealth Care but must contribute toward the cost of that coverage.  Among the adults who are not eligible for Commonwealth Care are undocumented immigrants, some groups of legal immigrants, and adults who have access to ESI coverage.  While we do not have the data needed to determine eligibility for MassHealth or the Commonwealth Care program with certainty, we can identify a subset of those who are potentially eligible—that is, with family income less than 300 percent of the FPL and U.S. citizenship. Based on this criterion, at least 42 percent of uninsured adults in Massachusetts were potentially eligible for MassHealth or Commonwealth Care in 2008. Of those potentially eligible for MassHealth or Commonwealth Care, half had family income less than 150 percent of the FPL and thus were potentially eligible for coverage with a full subsidy.  In 2008, the uninsurance rate among those potentially eligible for MassHealth or Com-monwealth Care was 9.2 percent.   Like uninsured adults overall, the uninsured adults who were potentially eligible for MassHealth or Commonwealth Care were more likely than insured adults to be   Male, young, and single  Hispanic   Facing substantial financial stress   Uninsurance among potentially-eligible nonelderly adults was highest in parts of the Boston, MetroWest, Southeast and Northeast regions of the state. Above-average uninsurance for these adults was also reported in much of the Western region of Massachusetts. When we look at the distribution of this population across the state, we find the highest num-ber of potentially-eligible uninsured adults in the Boston area and in pockets across the Western and Southeast regions of the state.  LESSONS FOR REFORM: TARGETING THE UNINSURED  With its benchmark 2006 health reform effort, Massachusetts has achieved near-universal health insurance coverage. Nonetheless, some residents remain uninsured, including the estimated 223,000 uninsured nonelderly adults who are the focus of this study.  Policy initiatives and outreach efforts should address the particular characteristics of this group that act as barriers to taking up insurance.  Age  The adults who have remained uninsured under health reform are often from population groups that can be hard to convince of the need for health insurance coverage, including those often referred to as the “young invincibles”—adults age 18 to 26. In an effort to reach this group, Massachusetts’ reform effort incorporated special provisions targeting them, including an expansion in eligibility for dependent coverage and the creation of special benefit packages under the Commonwealth Choice program. While the available evidence suggests that those strategies have been quite suc-cessful at expanding coverage among young adults,15 young adults continue to represent a disproportionate share of the uninsured in Massachusetts, highlighting the need for continued outreach to this population.  Ethnicity, Language, Citizenship  Targeted policy initiatives are also needed to address the higher levels of uninsurance among Hispanic adults, adults with limited English-proficiency, and those who are not U.S. citizens. That latter is particularly important since nearly one in three of the remaining uninsured adults in Massachusetts in 2008 were non-citizens. While undocumented im-migrants are not eligible for coverage under MassHealth or Commonwealth Care, many legal immigrants do qualify. Reaching the eligible-but-uninsured immigrant population is likely to be challenging, however, given both language issues and potential concerns about being a public charge.16 Additionally, bringing undocumented immigrants and oth- Who are  the  Remain ing Uninsured ?    4 er immigrants who do not qualify for MassHealth or Commonwealth Care into health insurance coverage is likely to require new programs. One strategy would build on the new Commonwealth Care Bridge program, a state-subsidized health insurance program for special-status legal immigrants who no longer qualify for Commonwealth Care, to expand coverage to additional immigrant groups.  Literacy  Outreach efforts to all nonelderly uninsured populations will need to take literacy issues into account, as nearly one-quarter of uninsured adults lack a high school education. Health insurance coverage is a complicated issue that can be difficult to communicate to those with limited literacy skills. A check on the reading level for introductory materials on the web pages for MassHealth and Commonwealth Care highlights this challenge: The materials on “What is Mas-sHealth?” are rated at a 10.5 grade level, while the “Welcome to Commonwealth Care: Overview” materials are rated at a 12.1 grade level.17 Materials that address the criteria for eligibility for both programs are rated at even higher grade levels for reading (11.6 and 12.9, respectively). The National Institutes of Health recommends a reading level of 4th to 8th grade for materials meant for the general public, so many of those who are eligible for but not enrolled in Mas-sHealth and Commonwealth Care may have difficulty understanding program materials.18  Region  While much of the uninsurance in Massachusetts is—like much of the state’s population—concentrated in the Boston area, there are areas throughout the state with high levels of uninsurance. It may be that different strategies are needed to address the remaining uninsurance in different regions of the state. This would include areas around Boston and parts of the Metro West, Southeast and Northeast regions, where uninsurance is particularly high, as well as much of the Western region, where uninsurance is above the state average in nearly all of the region.   CONCLUSION  Massachusetts has achieved historic levels of insurance coverage through an ambitious coverage initiative and sub-stantial outreach and enrollment efforts.19 The findings reported here suggest that reaching the remaining uninsured in Massachusetts will require expanded efforts that focus on key constituencies among the uninsured, including young adults, immigrants (both documented and undocumented), and communities across the state.    These findings carry lessons for the implementation of federal reform as well, indicating that broad-based policy initia-tives and outreach under federal reform may be less effective at stimulating take-up among certain demographic groups than among the population as a whole.  These hard-to-reach groups will require targeted policy and outreach efforts that address their particular barriers to health insurance take-up.  NOTES                                                           1  “Chapter 58 of the Acts of 2006: An Act Providing Access to Affordable, Quality, Accountable Health Care.” The Commonwealth of Massachusetts, 2006.  http://www.mass.gov/legis/laws/seslaw06/sl060058.htm 2  Turner, Joanna, Michel Boudreaux, and Victoria Lynch. “A Preliminary Evaluation of Health Insurance Coverage in the 2008 American Community Survey.” US Census Bureau, 22 Sept. 2009.  http://www.census.gov/hhes/www/hlthins/acs08paper/index.html 3  Urban Institute analysis of American Community Survey (ACS) 2008; data from the Integrated Public Use Microdata Series (IPUMS) USA.. 4  For example, the sample size for uninsured adults in Massachusetts in 2008 was 120 in the Current Population Survey, 94 in the Massachusetts Health Insurance Survey and 448 in the Massachusetts Health Reform Survey. The latter survey oversamples uninsured adults so as to track changes in the unin-sured population in Massachusetts over time. Findings from that survey for 2008 are reported in: Long, Sharon K., and Karen Stockley. “Health Reform in Massachusetts: An Update on Insurance Coverage and Support for Reform as of Fall 2008.” Urban Institute, 11 Sept. 2009.  http://www.urban.org/health_policy/url.cfm?ID=411958 5  “How to use the Data: Quality Measures.” American Community Survey (ACS), U.S. Census Bureau, 2009.  http://www.census.gov/acs/www/UseData/sse/ 6  For details about this new ACS question, see http://www.census.gov/acs/www/SBasics/Information/health_ins.htm 7  The IPUMS-USA file for the 2008 ACS contains approximately 3 million individual records. 8  Ruggles, Steven, J. Trent Alexander, Katie Genadek, Ronald Goeken, Matthew B. Schroeder, and Matthew Sobek. Integrated Public Use Microdata Se-ries: Version 5.0 [Machine-readable database]. Minneapolis: University of Minnesota, 2010.  http://usa.ipums.org/usa/index.shtml 9   Because of these exclusions, our estimates for non-elderly adults in Massachusetts will differ slightly from those reported by the Census Bureau.  Who are  the  Remain ing Uninsured ?    5                                                                                                                                                                                                            10  “Replicate Weights in the American Community Survey / Puerto Rican Community Survey.” IPUMS USA, Minnesota Population Center, 2010.  http://usa.ipums.org/usa/repwt.shtml 11  Fay, Robert E., and George F. Train. “Aspects of Survey and Model-Based Postcensal Estimation of Income and Poverty characteristics For States and Counties.” Proceedings of the Section on Government Statistics, American Statistical Association, Alexandria, VA. 1995: 154-159 12  See, for example, Long, Sharon K., and Karen Stockley. “Health Reform in Massachusetts: An Update on Insurance Coverage and Support for Reform as   of Fall 2008.” Urban Institute, 11 Sept. 2009.  http://www.urban.org/health_policy/url.cfm?ID=411958. 13  See, for example, Kriss, Jennifer L., Sara R. Collins, Bisundev Mahato, Elise Gould, and Cathy Schoen. “Rite of Passage? Why Young Adults Become  Uninsured and How New Policies Can Help, 2008 Update.” Issue Brief, The Commonwealth Fund, May 2008. http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/May/Rite-of-Passage--Why-Young-Adults-Become-Uninsured-and-How-New-Policies-Can-Help--2008-Update.aspx. 14  “Commonwealth Care Eligibility.” Health Connector, 2009. https://www.mahealthconnector.org/portal/site/connector/ 15  Long, Sharon K., Alshadye Yemane, and Karen Stockley. “Disentangling the Effects of Health Reform in Massachusetts: How Important are the Special  Provisions for Young Adults?” American Economic Review, Papers and Proceedings, 2010, forthcoming. 16  A person can be labeled a “public charge” if he or she relies on government assistance for support or to pay for long-term care in an institution. Being ruled a public charge can affect an individual’s immigration status and ability to become a citizen. With the exception of receiving long-term care under MassHealth, enrollment in MassHealth or Commonwealth Care will not affect immigration status or ability to become a citizen. 17  The grade level calculation is from the Flesch-Kincaid Grade Level score in Microsoft Word. The MassHealth materials are from http://www.massresources.org/pages.cfm?contentID=35&pageID=13&subpages=yes&dynamicID=558. The Commonwealth Care materials are from https://www.mahealthconnector.org/portal/site/connector/template.MAXIMIZE/menuitem.3ef8fb03b7fa1ae4a7ca7738e6468a0c/?javax.portlet.tpst=2fdfb140904d489c8781176033468a0c_ws_MX&javax.portlet.prp_2fdfb140904d489c8781176033468a0c_viewID=content&javax.portlet.prp_2fdfb140904d489c8781176033468a0c_docName=CommCareOverview&javax.portlet.prp_2fdfb140904d489c8781176033468a0c_folderPath=/Aboutpercent20Us/CommonwealthCare/&javax.portlet.begCacheTok=com.vignette.cachetoken&javax.portlet.endCacheTok=com.vignette.cachetoken  18  “Clear and to the Point: Guidelines for Using Plain Language at NIH.” Harvard School of Public Health: Health Literacy Studies, 2007. http://www.hsph.harvard.edu/healthliteracy/how_to/clear.html 19  Dorn, Stan, Ian Hill and Sara Hogan. “The Secrets of Massachusetts Success: Why 97 Percent of State Residents Have Health Coverage,” SHARE, SHADAC, November 2009.  http://www.shadac.org/files/shadac/publications/SecretsOfMassSuccessLongPaper.pdf    Who are  the  Remain ing Uninsured ?    6 ABOUT THE SHARE INITIATIVE  SHARE is a national program of the Robert Wood Johnson Foundation and is located at the University of Minnesota’s State Health Access Data Assistance Center (SHADAC).   The SHARE project has the following key goals:   1. Coordinate evaluations of state reform efforts in a way that establishes a body of evidence to inform state and national policy makers on the mechanisms required for successful health reform. 2. Identify and address gaps in research on state health reform activities from a state and national policy perspective. 3. Disseminate findings in a manner that is meaningful and user-friendly for state and national policy makers, state agencies, and researchers alike.  To accomplish these goals, SHARE has funded 16 projects covering 29 states.    CONTACTING SHARE The State Health Access Reform Evaluation (SHARE) is a Robert Wood Johnson Foundation (RWJF) program that aims to provide evidence to state policy makers on specific mechanisms that contribute to successful state health reform efforts. The program operates out of the State Health Access Data Assistance Center (SHADAC), an RWJF-funded research center in the Division of Health Policy and Management, School of Public Health, University of Minnesota. Information is available at www.statereformevaluation.org.  State Health Access Data Assistance Center 2221 University Avenue, Suite 345 Minneapolis, MN 55414 Phone (612) 624-4802 

Massachusetts Health Reform in 2008: Who Are the Remaining Uninsured Adults?

https://www.issuelab.org/resources/10200/10200.pdf

Massachusetts Health Reform in 2008: Who Are the Remaining Uninsured Adults?

Abstract

Similar works

Full text

Available Versions

IssueLab