October 2011 Small Area Health Insurance Estimates from the Census Bureau: 2008 and 2009 Introduction TheU.S.CensusBureau’sSmallAreaHealthInsuranceEstimates(SAHIE)programproducesmodel‐based estimatesofhealthinsurancecoverageforallcountiesandstates.Estimatesforcalendaryears2008and 2009werereleasedonOctober13,2011.1Currently,theSAHIEprogramistheonlysourceofhealth insurancecoverageestimatesforallcountiesintheUnitedStates.Thisbriefhighlightswhatisnewforthis release,providesanoverviewofhowtheSAHIEestimatesaredeveloped,andcomparestheSAHIEmodel‐ basedmethodologytotheAmericanCommunitySurvey. What is New for the 2008 and 2009 SAHIE Modeled Estimates TheSAHIEprogrammodelshealthinsurancecoveragebycombiningsurveyestimateswithadministrative records,populationestimates,anddecennialCensusdata.The2008and2009estimatesmodelhealth insurancecoveragebasedontheAmericanCommunitySurvey(ACS).PreviousyearsofSAHIEestimatesused theCurrentPopulationSurvey’sAnnualSocialandEconomicSupplement(CPS).ComparedtoCPS,thelarger samplesizeoftheACSproducesestimateswithgreaterprecisionandallowsforadditionalincomecategories. TheSAHIEcountyestimatesareavailablebyage,income,andsexcategories;race/ethnicityestimatesare producedatthestatelevelonly.Beginningwiththisreleasetheincomecategorieshavebeenmodifiedto reflectbreakpointsthatareimportantforestimatingtheimpactsoftheAffordableCareAct(138and400 percentoftheFederalPovertyLevel(FPL),inadditiontoexistingcategoriesforpeoplewithincomesator below200and250percentoftheFPL). Finally,theCensusBureauintroducednewinteractivemappingandtabletoolswiththeseestimatesthat allowuserstoeasilycustomizemapsandtablesofuninsuranceratesbytheavailabledemographic categories. 1Estimatesareavailableathttp://www.census.gov/did/www/sahie/index.html. 1 Background on the SAHIE Program TheSAHIEprogramreleasedthefirstnationwidesetofcounty‐leveluninsuranceestimatesin2005, reflectingthepopulationasawholeandchildrenforcalendaryear2000.2Developmentofthesemodeled estimateswasanimportantsteptobetterinformthepublicabouthealthinsurancecoverageandprovide healthpolicyanalystsatooltomonitorsub‐stateestimatesofhealthinsurancecoverage.Overtime,the SAHIEprogramhasmadeenhancementstothemodels;thisbrieffocusesontheSAHIEestimatesand methodologyfor2008and2009,themostrecentestimatesavailable.3 TheSAHIEprogramuninsuranceestimatesareavailableforstatesandcountiesbythefollowing demographiccategories:  Age:Under65years,18to64years,40to64years,50to64years(stateonly),andunder19years  Race/ethnicity(stateonly):WhitealonenotHispanic,BlackalonenotHispanic,andHispanic(anyrace)  Income:atorbelow138,200,250,or400percentofpoverty  Sex Table1summarizesthelevelofdetailavailableforeachagegroup.Forexample,county‐levelestimatesare availableforfemalesages40to64withincomesatorbelow138percentofpoverty.Incontrast,onlystate‐ levelestimatesareavailableforthe50to64agecategory,andforchildrentherearenorace/ethnicityorsex estimatesavailable. Table1.LevelofDetailAvailableinSAHIEEstimates,byAgeGroup Age  Race/Ethnicity  Income  Sex  Under 65 years  State  State, County  State, County  18 to 64 years  State  State, County  State, County  40 to 64 years  State  State, County  State, County  50 to 64 years  State  State  State  Under 19 years  None   State, County  None  Modeling Approach TheSAHIEprogrammodelshealthinsurancecoverageestimatesbycombiningsurveydatafromtheACSwith administrativerecords,populationestimatesfromtheCensusBureau’sPopulationEstimatesProgram,and decennialCensusdata.Modelingestimatesallowsthe“borrowing”ofinformationfromavarietyofdata sourcestoachievemorereliableestimatesforareaswithsmalldirectsurveysamplesizes. Thereareseparatestateandcountymodels.Thestateestimatesarecontrolledsotheyareconsistentwith ACSnationalestimates.SummingoverthestateswillequalACSnationalestimatesforkeysub‐groups. Similarly,thecountyestimatesarecontrolledtosumtotheSAHIEstate‐levelestimates.4Thedatausedinthe modelsaredescribedbelow. 2SHADACparticipatedinthemethodologicalreviewoftheseestimatesandthereportisavailableat http://www.census.gov/did/www/sahie/methods/review/index.html. 3TheprogramenhancementswerepartiallyfundedbytheCentersforDiseaseControlandPrevention,NationalBreast andCervicalCancerEarlyDetectionProgram(NBCCEDP).TheNBCCEDPhasacongressionalmandatetoprovide screeningservicesforbreastandcervicalcancertolow‐income,uninsured,andunderinsuredwomen.Thedemographic variablesavailableintheSAHIEestimatespartiallyreflectthismandate. 4Adetaileddescriptionofthemethodologyisavailableat http://www.census.gov/did/www/sahie/methods/20082009/index.html. 2 AmericanCommunitySurvey(ACS) TheACSisconductedbytheCensusBureautoprovidecommunitieswithup‐to‐dateinformationonkey demographicsandpolicy‐relevantdata,andin2008beganaskingabouthealthinsurancecoverageusinga point‐in‐timemeasureofcoverage.TheSAHIEprogrammodelusessingle‐yearACSdirectestimatesforall statesandallcounties,regardlessofpopulationsize.Forexample,the2009ACSwasusedtomodelthe2009 SAHIEprogramestimates. TheACSsampleincludespeoplelivinginbothinstitutionalizedandnon‐institutionalizedgroupquarters,but thepublishedhealthinsurancetabulationsarerestrictedtotheciviliannon‐institutionalizedpopulation.The SAHIEprogramestimatesfurtherrestrictthepopulationtothoseforwhomincomeisreported(thepoverty universe).Assuch,theSAHIEestimatesexcludeactive‐dutymilitary,peopleinprisons,peoplelivingin nursinghomes,childrenunderage15whoarenotrelatedtothehouseholder,andpeoplelivingincollege dormitories. InadditiontoACShealthinsurancecoverageestimates,theSAHIEprogramusesACSincomedatatoestimate thenumbersofpeopleinthespecificincomecategories. AdministrativeData Theadministrativedatausedinthemodelsareaggregatedtothestateandcountylevels.Sourcesofdataused inthemodelinclude:  Federaltaxreturns:numberofexemptionsfromtheInternalRevenueService,totalcountsforthe areapartitionedbychildversusadultandbyincomegroup;  SupplementalNutritionAssistanceProgram(SNAP),formerlyFoodStamps:numberofpeople participatinginSNAPfromtheUnitedStatesDepartmentofAgriculture;  MedicaidandtheChildren’sHealthInsuranceProgram(CHIP):numberofpeoplecoveredby MedicaidandCHIPfromtheCentersforMedicareandMedicaidServices;  CountyBusinessPatterns:establishmentdatafromtheCensusBureau’sBusinessRegister. PopulationEstimates TheCensusBureau’sPopulationEstimatesProgrampublishesintercensalestimatesoftheresident populationforthenation,states,andcounties,byage,sex,race,andHispanicorigin.TheSAHIEprogram adjuststheseestimatessotheyhaveauniversesimilartotheciviliannon‐institutionalizedpopulation.In additiontothenumberofpeopleineachoftheage,race,sex,Hispanicorigin(ARSH)groups,themodel incorporatestheproportionAmericanIndianandAlaskaNativeandtheproportionHispanic. Census2000 Census2000sampledataareusedinthemodels.Thesample(longform)2000questionnairewassentto aboutoneinsixhouseholdsandincludedquestionsonsocialandeconomiccharacteristicsofthepopulation andphysicalandfinancialcharacteristicsofhousing.InadditiontothenumberofpeopleineachoftheARSH groups,theSAHIEmodelsalsoincludetheproportionwhoarenon‐citizens,theproportionofowner occupiedhousingunits,andtheproportionofhouseholdsinruralareas. 3 Comparison of SAHIE and ACS AnimportantfeatureoftheACSisthatithasalargeenoughsampleforstate‐levelandsub‐statehealth insurancecoverageestimates.TheCensusBureauwillpublishACSestimatesofhealthinsurancecoveragefor allcountieswhen5‐yearestimates(2008‐2012)areavailablein2013,butthesewillonlybeavailablefrom thesummarytablesonAmericanFactFinder.Countyestimateswillnotbeavailableinthemicrodataexcept forthelargestcounties.5 Atthistime,1‐yearhealthinsurancecoverageestimatesarecurrentlyavailableforareaswithpopulationsof 65,000ormoreand3‐yearpooledestimateswillbeavailableinlateOctober2011forareaswithpopulations of20,000ormore,includingestimatesfor59percentofcounties.6Table2summarizeskeyinformationabout theSAHIEprogramandtheACS. Table2.ComparisonofSAHIEandACSHealthInsuranceEstimates   SAHIE Modeled Estimates  ACS Direct Estimates  Years available   2000, 2001 (states only), 2005, 2006, 2007,  1‐year estimates: 2008, 2009, 2010  2008, 2009  3‐year pooled estimates: 2008‐2010 available in late  October 2011 with microdata one to two months later  Geography available  All states and all counties  All states, all congressional districts, some counties,  7 and various sub‐state geographies   Estimates available  Uninsured and insured  Uninsured and insured by coverage type: private  coverage, employer‐based, direct‐purchase,  TRICARE/military health care, public coverage,  Medicare, Medicaid, VA  Summary vs.  Summary tabulations available in pre‐ Summary tabulations available in pre‐defined tables  microdata  defined tables  on American FactFinder; microdata available in public  use files for custom analysis  Comparability across  Estimates are comparable across  Estimates are comparable across geographies and over  geographies and  geographies and over time with an  time9  over time  approximation, but it is recommended to  only compare 2008 and 2009 due to the  8 model change from CPS ASEC to ACS   Uncertainty of  Margins of error are published for the 90  Margins of error are published for the 90 percent  estimates  percent confidence interval  confidence interval      Estimates have more precision due to the  Microdata users can calculate standard errors to  use of additional information from  measure precision at other confidence intervals  administrative records  5Thelowestlevelofgeographyavailableinthe1‐year,3‐year,and5‐yearACSmicrodatafilesarethePublicUse MicrodataArea(PUMA);areaswithatleast100,000people. 6Thepublicusemicrodataforthe3‐yearestimateswillbeavailableonetotwomonthsaftertheAFFrelease. 7Seehttp://www.census.gov/acs/www/data_documentation/areas_published/foracompletelistingofgeographic areasavailableinthe1‐year,3‐year,and5‐yearACSestimates. 8DetailsoncomparingSAHIEestimatesareavailableathttp://www.census.gov/did/www/sahie/about/faq.html#q12. 9RecommendationsforcomparingACSestimatesareavailableat http://www.census.gov/acs/www/guidance_for_data_users/comparing_data. 4 BoththeSAHIEandACScanbeusedforcounty‐levelhealthinsurancecoverageestimatesandbothhave strengthsandlimitations.TheSAHIEestimateshaveseveraladvantages.Foranalystsinterestedinall countieswithinastate,theSAHIEestimatesarecurrentlytheonlyavailablesource.TheSAHIEestimatesare forasingleyearsothereisnoneedtopooloraveragemultipleyearsofdata,andtheyhavegreaterprecision duetotheincorporationofadditionalinformationinthemodels. TheSAHIEestimatesalsohavesomelimitations.ThereleaseofSAHIEestimateslagstheACSdirectestimates bymorethanayear.(Forexample,SAHIEestimatesfor2009werereleasedshortlyaftertheACSestimates for2010.)AnotherlimitationisthattheSAHIEestimatesareonlyavailablebyinsurancestatus (uninsured/insured)andnotbytypeofhealthinsurancecoverage.TheSAHIEestimatesareavailablefor relevantdemographicgroups,butunliketheACS,microdataarenotavailablesoanalystsarenotableto conductcustomanalyses. ComparisontoEstimatesfromStateSurveys Severalstatesconducttheirownhouseholdhealthaccesssurveysthathavelargeenoughsampletoprovide estimatesforatleasttheirlargercounties.Someofthesestatesmayalsoconducttheirownsmallarea estimation.WhencomparingestimatesfromindividualstatesurveyswiththeSAHIEprogramestimates, differencesmaybeobservedforavarietyofreasons.Forexample,theremaybedifferencesduetothe survey’sdesign,thehealthinsurancecoveragequestionsasked,modeofadministration,anddataprocessing. Conclusions TheSAHIEestimatesareavaluablesourceofinformationonlocalhealthinsurancecoverage,andformost statestheyaretheonlycompletesourceofcounty‐levelestimatesavailable.Therearetradeoffsbetween usingtheSAHIEmodeledestimatesandtheACSdirectestimates,buttheprecisionandsingle‐yearestimation oftheSAHIEestimatesprovidesausefulbasisforunderstandingchangesovertime.TheACSwilleventually produceestimatesforallcountiesusing5‐yearpooleddata,butthe5‐yearestimateswillbeoflimitedusefor trendanalysis. The2010SAHIEreleaseisplannedforsummer2012. Suggested Citation StateHealthAccessDataAssistanceCenter.2011.“SmallAreaHealthInsuranceEstimatesfromtheCensus Bureau:2008and2009.”IssueBrief#26.Minneapolis,MN:UniversityofMinnesota. About SHADAC TheUniversityofMinnesota’sStateHealthAccessDataAssistanceCenter(SHADAC)isfundedbytheRobert WoodJohnsonFoundationtocollectandanalyzedatatoinformstatehealthpolicydecisionsrelatingto healthinsurancecoverageandaccesstocare.ForinformationonhowSHADACcanassistyourstatewith smallareaestimationorotherdataissuesrelevanttostatehealthpolicy,pleasecontactusat shadac@umn.eduorcall612‐624‐4802. 5