Another item in this month’s issue of the ASAHP newsletter highlights the importance that data play in developing effective health policy. Data from the jointly administered federal-state Medicaid program frequently are used to investigate racial and ethnic disparities in health. Unfortunately, there is considerable variation in the completeness of such information across the United States. For example, according to the U.S. Census Bureau, about 19% of Medicaid beneficiaries were missing race/ethnicity information, a rate that varies considerably across states. Approximately one-third of states (18) were missing less than 10% of beneficiaries’ race/ethnicity information. Three states (Nebraska, Rhode Island, and Tennessee) did not have race/ethnicity information for any of their Medicaid beneficiaries.
To address these gaps, the U.S. Census Bureau’s Enhancing Health Data (EHealth) Program assessed the feasibility, benefit, and effectiveness of linking Medicaid enrollment data (T-MSIS) with Census Bureau microdata (i.e., Decennial Census, American Community Survey [ACS], Census Numident) to enable researchers to document and track racial/ethnic disparities in health more effectively. Also, this research evaluated whether and to what degree bias was introduced into mortality estimates when Medicaid beneficiaries with missing race/ethnicity information were omitted from analysis. Results demonstrate significant potential for using Census Bureau data to complement existing health records that commonly lack important demographic characteristics, such as race/ethnicity. Overall, enhancing this information in Medicaid data with restricted Census Bureau microdata is feasible and can advance an understanding of population health.
Growth In Health Care Costs
In 2020, lower use of health care services led to the first decline in per person health care spending that was seen in 12 years. That decline in utilization, however, was concentrated in the early months of the pandemic. By mid-2020, data from a report in April 2023 from the Health Care Cost Institute, a research group that has partnerships with insurers (CVS Health/Aetna, Humana, and Blue Health Intelligence) to gauge the health care market, show that use (and spending) had largely returned to pre-pandemic levels. In 2021, there was a full rebound in per person health care spending, which was nearly $6,500 (15% higher than in 2020). A 13% increase in utilization from 2020 to 2021 contributed to this growth, following the 7.5% decline in use in 2020. Average prices grew 2% from 2020 to 2021. This lower growth rate than in previous years reflects that the overall mix of care was less expensive in 2021 than in 2020 when many lower cost preventive services were delayed. Overall, prices grew close to 14% over the 2017-2021 period while use grew just over 7%. The largest growth in prices was for inpatient hospital services, which grew 28% even as use declined over the five–year period. Growth in health care prices, and particularly in hospital prices, remains a persistent challenge to access and affordability.
The Risk Of Losing Health Insurance
Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID period, it is estimated that while 12.5% of individuals under 65 are uninsured, twice as many are uninsured at some point over a two-year period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA according to an article in the May 2, 2023 issue of the journal Proceedings of the National Academy of Sciences of the USA. Data from the Medical Expenditure Panel Survey were used that cover the time period after the landmark Affordable Care Act (ACA) and before the COVID-19 pandemic—from 2014 to 2019—as well as the period 2007 to 2013 prior to the ACA.
Risk of insurance loss is particularly high for those with health coverage through Medicaid or private exchanges. They have a 20% chance of losing coverage at some point over a two-year period, compared to 8.5% for those with employer-provided coverage. Individuals who lose insurance can experience prolonged periods without coverage. Approximately one-half of them still are uninsured six months later. Almost one-quarter are uninsured for the subsequent two years. Health insurance coverage, whose purpose is to provide a measure of certainty in an uncertain world, is itself highly uncertain. The risk of losing it reduces its value for risk-averse individuals. It also creates the potential for suboptimal medical choices as individuals suboptimally may shift the timing of their medical treatments to align with when they have insurance coverage.