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Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
Adapting statesurveyswebinar jan2014
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Adapting statesurveyswebinar jan2014

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  • 1. Joanne Pascale, US Census Bureau Thursday, January 23, 2014 You will be connected to broadcast audio through your computer. You can also connect via telephone: 800-916-9263
  • 2. • For those dialing in: All phone lines are muted Click to edit Master text styles • Submit questions via the chat feature at any time during the Second level webinar level Third Fourth level • Troubleshooting: • • • • • Fifth level ReadyTalk help line: 800-843-9166 ReadyTalk chat feature Download slides at http://www.shadac.org/AdaptingStateSurveysWebinar Webinar recording will be posted on this page as well E-mail notice will be sent to registrants when recording is available 2
  • 3. Click to edit Master text styles 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
  • 8. Massachusetts Exchange • Exchange portal = “Health Connector” • Two programs: – CommonwealthCare (CommCare): subsidized – CommonwealthChoice (CommChoice): unsubsidized 5
  • 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
  • 43. Click to edit Master text styles Second level Third level Fourth level Fifth level Submit questions via the chat feature on the left-hand side of the screen. 4
  • 44. Kathleen Thiede text Click to edit MasterCall styles 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

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