SEPTEMBER 2009

Comparing Federal
Government Surveys
that Count Uninsured
People in America


UPDATEDSEPTEMBER22,2009

Comparing Federal Government Surveys that Count

Uninsured People in America

ThenumberofuninsuredAmericansislargeandgrowingovertime,yettherecontinuestobedebateabout
exactlyhowmanyAmericansareuninsured.Researchersusedatafromseveraldifferentnationalsurveysto
estimatethenumberofuninsuredpeopleinAmericaanddiscrepanciesintheirestimatesarecommon.This
briefcomparesestimatesofhealthinsurancecoveragefromfournationalhealthsurveyssponsoredbythe
federalgovernment,identifiesthedifferencesintheirestimatesofuninsurance,andidentifiesthreecommon
themes:(1)allthesurveysreportverylargenumbersofAmericanslivingwithouthealthinsurance;(2)all
surveysshowthatthesenumbershaverisenoverthedecade,particularlyforadults;and(3)childrensrates
ofuninsurancedeclinedearlierinthedecade,largelyduetogrowthofpublicprogramssuchastheState
ChildrensHealthInsuranceProgram(SCHIP),butinrecentyearshasstayedsteadyorgrownslightly
(dependingonthesurvey).

Federal Government Surveys Used to Measure the Uninsured

TheAnnualSocialandEconomicSupplement(ASEC)totheU.S.CensusBureausCurrentPopulation
Survey(CPS)producesthemostvisibleestimateofthenumberofuninsuredintheUnitedStates.TheCPS
estimatesofhealthinsurancecoverageareusedtomonitorstateandnationaltrendsinhealthinsurance
coverageandtoallocatefederalfundstostatestoimplementtheStateChildrensHealthInsuranceProgram.
TheCPSdatatendtoproduceestimatesofhealthinsurancecoveragethatdiffersignificantlyfromother
majorsurveyestimatesofcoverage.1TheseotherfederalgovernmentsurveysincludetheNationalHealth
InterviewSurvey(NHIS),andtheMedicalExpenditurePanelSurveyHouseholdComponent(MEPS).Detailed
descriptionsofthesesurveysareavailableelsewhere. 2,3Anewsourceofhealthinsurancecoverage
estimatesisbeingreleasedthisyear,theAmericanCommunitySurvey(ACS).TheACSbegancollecting
healthinsurancedatain2008andispoisedtobecomeanimportantsourceofestimatesinthefuture.

Thesefourfederalsurveys,CPS,NHIS,MEPS,andACSwereeachdesignedtocollectspecificinformationfor
differentresearchandpolicypurposes.TheCPSisamonthlylaborforcesurveyandthehealthinsurance
questionsareaddedattheendofanannualsupplementtothemonthlyCPS.Conversely,theNHISandMEPS
aredesignedspecificallytocollecthealthinformationfromtheU.S.population.Collectinginformationon
healthinsurancecoverage,thetypeofcoverage,andlackofcoveragearehighpriorityquestionsinthese
surveys.TheACSisdesignedtoprovidecommunitiesthroughouttheU.S.withuptodateinformationonkey
demographicsandpolicyrelevantdata.TheACSisanongoingsurveythattheCensusBureauhasusedto
replacetheformerlongformdecennialquestionnaire.

Comparison of National Estimates from Different Federal Surveys

Table1showsthedifferencesbetweenthenationallevelestimatesfromthethreemajorfederal
surveysthatmeasurehealthinsurancecoveragefor2007(themostrecentyearavailableacrossallsources),
forpeopleunder65yearsofage.TheCPSprovidesthehighestestimateofthenumberofpeoplewithout
healthinsurancecoveragefortheentireyearat45.0millionpeopleandNHISproducesthatthelowestat30.4
million.


UPDATEDSEPTEMBER22,2009
TABLE 1: Trends among the Surveys in the Number of People under 65 Years of
Age Who are Uninsured for Entire Year and Point in Time (in millions): 2007
Survey

Uninsured for the Entire Year

Uninsured at a Specific Point-in-Time

CPS

45.0

N/A

CPS Adjusted*

42.9

N/A

NHIS

30.4

43.3

MEPS

39.9

53.5

Source:CurrentPopulationSurvey,2008withestimatestabulatedbytheStateHealthAccessDataAssistanceCenter;Cohenetal.,2009,
HealthInsuranceCoverageTrends,19592007:EstimatesfromtheNationalHealthInterviewSurvey;ChuandRhoades,2009,The
UninsuredinAmerica,19962008:EstimatesfortheU.S.CivilianNoninstitutionalizedPopulationunderAge65,StatisticalBrief#259,
AHRQ.

*TheseadjustedestimateshavebeendevelopedbySHADACtoaccountforhistoricalmethodologicalchanges.TheCPSdataare
reweightedandadjustedtoaccountforhistoricalchangesinthesurveysmethodology.Theseestimatesdonotcorrespondcompletelyto
estimatespublishedbytheCensusBureau,however,theycanprovideamoreaccurateassessmentofcoverageestimatesovertime.

Therangeofthepointintimeestimatesismuchsmaller(from43.3to53.5people)relativetothefullyear
estimates.ThefactthattheCPSfullyearuninsuredestimatefallswithintherangeoftheothertwosurveys
pointintimeestimatesmakesittemptingtointerprettheCPSestimateasactuallyapointintime
measure.4TreatingtheCPSaspointintimemeasureorasafullyearuninsuredmeasurecanleadtovastly
differentestimatesofthesizeofimportantpolicyrelevantgroupssuchasthenumberuninsuredpeoplewho
areeligibleforpublichealthinsurancecoverage.Thispartiallyexplainsvariationsinestimatesofthenumber
ofeligiblebutuninsuredkidsintheU.S.5

Reasons for the Discrepancies

Researchershavesuggestedmanyexplanationsforwhyhealthinsuranceestimatesdifferacross
surveys.Weexploreseveralofthemostimportantpossibleexplanationsbelow.6

REFERENCE PERIOD

CPSrespondentsareexpectedtoremembercoveragetheyhadupto15monthspriortotheinterview,
whereastheACSaskscurrent(pointintime)coverage.TheNHISandMEPShaveamuchshorterrecall
periodaswellasapointintimemeasure.Asaresult,CPSrespondentstendtohavemorerecallerror(e.g.,
theyforgetaboutcoveragetheymayhavehadandtheymayreportcoveragetheyhaveatthetimeofthe
interviewratherthanthepriorcalendaryear).7

MISREPORTING BY RESPONDENTS AND THE MEDICAID UNDERCOUNT

MisreportingofuninsurancebyMedicaidenrolleesisamajorconcernforpolicymakers.Misreportingcan
impactuninsuranceestimatesintwoways:thosewithinsurancemayfalselyreporttheyareuninsuredand
thosewithoutinsurancemaymistakenlyreporttheyhaveinsurance.
Incomparisontoadministrativedata,mostsurveysundercountthenumberofpeoplethoughttobeenrolled
inMedicaid.Researchersspeculatethatthiscouldbeduetoavarietyoffactorssuchasunderreportingof
Medicaidcoverageduetosocialstigma,lackofawarenessofenrollment,orconfusionaboutthetypeof
coveragerespondentshave(e.g.,MedicareorMedicaid). 8Theextenttowhichuninsuranceestimatesare
overestimatedvariesbythereferenceperiodthelongertherecallperiod,themorelikelyaknownMedicaid
enrolleewillerroneouslysaytheyareuninsured.TheCPS,withitslongreferenceperiod,demonstratesthe


UPDATEDSEPTEMBER22,2009
mostsignificantamountofrecallerrorwithMedicaidenrolleesreportingasuninsured.Surveysusingpoint
intimemeasuresofcoverageresultinmodestupwardbiastouninsuranceestimates.8

Second,whilesomepeoplewithcoveragemayreportthattheyareuninsured,itisalsopossiblethatsome
uninsuredpeoplereporthavingcoverage.Therearetwolikelyreasonsforthesefalsereports.Firstisthe
tendencyofrespondentstochooseasociallyacceptableresponse.Havinghealthinsuranceisasocially
acceptableanswer,anduninsuredpeoplemayfeelpressuretoansweryestohavingcoverage.Second,
codingerrorsfavorareportofcoveragebecauseitonlytakesonepositiveresponsetoatypeofhealth
insuranceforarespondenttobeconsideredinsured.Itispossiblethatanyerrorsduetounderreportingare
offsetsomewhatbythepotentialcorrespondingtendencytofalselyreportcoverage.

DIFFERENCES IN HANDLING MISSING DATA

Dataprocessingconductedbeforethecoverageratesareestimatedaccountsforsomeofthediscrepancy
betweentheCPSandtheothersurveys.Between10and15percentoftheCPSsamplearemissinghealth
insurancedataandtheCensusBureauimputes(orestimates)thesemissingvalues.Recentresearchshows
thattheCensusBureausmethodforimputinghealthinsurancecoveragemayleadtoanundercountof
peoplewithemployersponsoredcoverageandresultinanoverestimateofthenumberofpeoplewhoare
uninsured.9Bycontrast,theothersurveyshaveverylittlemissinghealthinsurancecoveragedataand,
therefore,fewercasestoimpute.

DIFFERENCES IN DATA EDITING

TheNHISistheonlysurveythatcollectsdetailedverbatimresponsesonhealthinsurancecoverageand
analystsusethisinformationtohelpeditthereportedhealthinsurancedata.Theyuseverbatimreportsof
plannamesanddescriptionstodetermineifthereportedhealthinsuranceispublicorprivateinsurance,orif
thecoveragereportedisnotactuallycomprehensivehealthinsurancecoverage(e.g.,IndianHealthService,
VeteransAdministrationorsingleserviceplancoverage,seriousanddreaddisease,workerscompensation,
accidentanddisabilitypolicies).10Thisrecodingofhealthinsurancemainlyaffectsestimatesofprivate
insurancecoverage(whichdrop)anduninsurance(whichincrease),asmanypeoplewhoreportprivate
healthinsurancecoverageareeditedtobeuninsured.Forexample,thesedataeditsincreasedtheNHIS
uninsuranceratefrom15.6to16.8percentin1998.11

Conclusion
ThenumberofuninsuredintheU.S.willneverbeexactlydetermined.Surveysproducedifferent
estimatesbecausetheyeachhandlecomplexsurveyandestimationissuesinslightlydifferentways.While
researchcanfocusonimprovingsurveysandestimationmethodologies,westillareleftwithjustthat:
estimates.Nonetheless,thesesurveysaretheonlytoolsavailabletoestimatethenumberofuninsured.The
bottomlineisthattherearetensofmillionsofuninsuredpeopleinthiscountry.Thenumberofuninsured
childrendeclinedearlierinthedecadeinallofthesurveys,butinrecentyearshasstayedsteadyinNHIS,
droppedintheCPS,andgrownintheMEPS.ThefirstyearofACSestimates,reflectingcalendaryear2008,
areconsistentwiththeCPS.

Graph1showsestimatesofchildrenunder18yearsofageinAmericawhoareuninsuredforanentireyear
fromtheCPS,CPSestimatesadjustedtoaccountforhistoricalchangesinthesurveysmethodology,andthe
pointintimeestimatesfromMEPSandNHIS.Theindividualestimatesvaryforreasonsdiscussedabove,yet


UPDATEDSEPTEMBER22,2009
theyallshowsimilartrends.Thenumberofuninsuredchildrenshowsadropinallthesurveysfrom2001
2004whilethenumberofuninsuredadultsisincreasingrapidlyinallthreesurveys(seeGraph2).For
children,theMEPSsurveyshowsanincreaseinthenumberofuninsuredthrough2008,whiletheNHIS
showsthenumberholdingsteadyandtheCPSshowsarecentdecline.Weareconductingfurtheranalysis
intowhythethreesurveysaredivergingforestimatesofcoverageamongchildren.

Asdetailedanalyseshavedemonstratedelsewhere,thedecreaseincoverageamongadultsismainlydueto
droppingprivatehealthinsurancecoverage.Forchildrenoverthistimeframe,therehasbeenbothan
increaseinthenumberenrolledinpublicprogramsandadecreaseinthenumberenrolledinprivate
coverage,sotheoverallnumberofuninsuredhasnotchangedsignificantlyordroppedslightly.12Focusingon
thedifferencesandmethodsusedtoproducethosenumbersisimportant,butshouldnotdistractpolicy
makersfromtheneedtoaddressissuesofcostandaccessforthosewithouthealthinsurancecoverageinthe
UnitedStates.

GRAPH 1: Trends among the Surveys in the Number of Children (under 18 years) who are
Uninsured at All Year (CPS) and Point-in-Time (MEPS and NHIS) (in millions)

12

CPS
CPSAdjusted*

10

MEPS
NHIS

ACS
6
2000

2001

2002

2003

2004

2005

2006

2007

2008

Note:SlightlynewmethodswereimposedintheNHISandCPS2005uninsuredestimates,resultinginfeweruninsured.
Source:CurrentPopulationSurvey,20012009withestimatestabulatedbytheStateHealthAccessDataAssistanceCenter;Cohenetal.,Health
InsuranceCoverage:EarlyReleaseofEstimatesfromtheNationalHealthInterviewSurvey,2008;andMEPSHConlinetables,Table5(multiple
years),http://www.meps.ahrq.gov/mepsweb/data_stats/quick_tables_results.jsp?component=1&subcomponent=0&year=
1&tableSeries=4&searchText=&searchMethod=1&Action=Search
*TheseadjustedestimateshavebeendevelopedbySHADACtoaccountforhistoricalmethodologicalchanges.TheCPSdataare
reweightedandadjustedtoaccountforhistoricalchangesinthesurveysmethodology.Theseestimatesdonotcorrespondcompletelyto
estimatespublishedbytheCensusBureau;however,theycanprovideamoreaccurateassessmentofcoverageestimatesovertime.2008
adjustedestimatesarenotyetavailable.


UPDATEDSEPTEMBER22,2009

GRAPH 2: Trends among the Surveys in the Number of Adults (18-64 years of age) who are
Uninsured at all Year (CPS) and Point-in-Time (MEPS and NHIS) (in millions)
50

CPS

45

CPSAdjusted*
40

MEPS

35

NHIS

30

ACS

25
2000

2001

2002

2003

2004

2005

2006

2007

2008

Note:SlightlynewmethodswereimposedintheNHISandCPS2005uninsuredestimates,resultinginfeweruninsured.
Source:CurrentPopulationSurvey,20012009withestimatestabulatedbytheStateHealthAccessDataAssistanceCenter;Cohenetal.,Health
InsuranceCoverage:EarlyReleaseofEstimatesfromtheNationalHealthInterviewSurvey,2008;andMEPSHConlinetables,Table5(multiple
years),http://www.meps.ahrq.gov/mepsweb/data_stats/quick_tables_results.jsp?component=1&subcomponent=0&year=
1&tableSeries=4&searchText=&searchMethod=1&Action=Search
*TheseadjustedestimateshavebeendevelopedbySHADACtoaccountforhistoricalmethodologicalchanges.TheCPSdataare
reweightedandadjustedtoaccountforhistoricalchangesinthesurveysmethodology.Theseestimatesdonotcorrespondcompletelyto
estimatespublishedbytheCensusBureau;however,theycanprovideamoreaccurateassessmentofcoverageestimatesovertime.2008
adjustedestimatesarenotyetavailable.

Acknowledgements
SupportforthisresearchcamefromtheRobertWoodJohnsonFoundation,theAgencyforHealthcare
ResearchandQuality,andtheAssistantSecretaryforPlanningandEvaluationattheU.S.Departmentof
HealthandHumanServices.Theviewsexpressedinthispaperarethoseoftheauthors,andnoofficial
endorsementbytheAgencyforHealthcareResearchandQualityortheDepartmentofHealthandHuman
Servicesisintendedorshouldbeinferred.

About SHADAC
TheUniversityofMinnestotasStateHealthAccessDataAssistanceCenter(SHADAC)helpsstatesmonitor
ratesofhealthinsurancecoverageandunderstandfactorsassociatedwithuninsurance.SHADACprovides
targetedpolicyanalysisandtechnicalassistancetostatesthatareconductingtheirownhealthinsurance
surveysand/orusingdatafromnationalsurveys.SHADACsworkisfundedbytheRobertWoodJohnson
Foundation.Informationisavailableatwww.shadac.org.

StateHealthAccessDataAssistanceCenter
2221UniversityAvenue,Suite345
Minneapolis,MN55414
Phone(612)6244802


UPDATEDSEPTEMBER22,2009

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