March 2011 Monitoring the Impac ts of Health R eform at the S tate L evel: Us ing F ederal S urvey Data The 2010 federal Patient Protection and Affordable Care Act (also referred to as the Affordable Care Introduction Act or ACA) will have far-reaching impacts on health insurance coverage, health care financing, and health care delivery in the United States. Given that states are responsible for implementing many of the core elements of the legislation, understanding the state-level impacts of the ACA will contribute to better understanding the overall impact of the law on the nation, identifying and addressing any unintended effects, and ensuring that the reforms included in the law are sustainable over time. There are several reasons to expect that the impacts of the ACA will vary by state. First, states have significant flexibility in how they choose to implement the law, especially with regard to health insurance coverage. Second, existing variation across states in health insurance coverage, health care financing, and health care delivery systems will play a role in determining the impact of the law in each state. Finally, existing variation across states in the economic, demographic and socioeconomic characteristics of their populations (for example, the share of the population that will be newly eligible for Medicaid in 2014) and in their economic environments (for example, the share of workers at firms that currently offer health insurance) will also affect the impacts of the ACA in the state. The purpose of this brief is to identify the state-level information currently available from federal surveys that states can use to monitor the impact of health reform and to compare the impacts of reform across states. We examine seven federal surveys that include questions on health insurance coverage and health access. While many states also conduct their own health surveys—and many of these state surveys include a richness of detail not available from federal surveys—our focus in this brief is on data that can be used to make comparisons across all 50 states and the District of Columbia. We provide an overview of survey design, survey content, and sample sizes, including sample sizes by state, for the following federal surveys: • American Community Survey (ACS) • Current Population Survey (CPS) • National Health Interview Survey (NHIS) • Medical Expenditure Panel Survey–Household Component (MEPS-HC) • Behavioral Risk Factor Surveillance System (BRFSS) • National Survey of Children’s Health (NSCH) • Survey of Income and Program Participation (SIPP) This brief describes each of these surveys, addressing survey design, sample, content relating to coverage and access, and how to obtain estimates and data. This discussion is followed by a series of tables summarizing the information provided, with source notes included at the end of the brief. This section provides a brief overview of each of the surveys, with a more detailed comparison of the S urvey Des ign surveys provided in Table 1. The American Community Survey (ACS), conducted by the U.S. Census Bureau, is an ongoing general household survey of the entire population (including persons living in group quarters). This mandatory survey (persons are required to respond under law) replaced the long form of the decennial census and provides annual estimates of health insurance coverage for the nation, states, and sub-state geographies. The Current Population Survey (CPS), conducted by the U.S. Census Bureau for the Bureau of Labor Statistics, is designed to provide monthly data on labor force participation and unemployment for the civilian non-institutionalized population. Data on income and health insurance coverage are collected once each year through the Annual Social and Economic Supplement (ASEC), which is administered February through April. This survey provides annual estimates of health insurance coverage for the nation and states. The National Health Interview Survey (NHIS), sponsored by the Centers for Disease Control and Prevention’s National Center for Health Statistics, is a survey of the health of the civilian non- institutionalized population. This annual survey provides national-level estimates for a variety of health and access indicators, with selected estimates available for the 20 largest states. The Medical Expenditure Panel Survey – Household Component (MEPS-HC), sponsored by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality, is a survey of health care access, utilization, and cost for the civilian non-institutionalized population. MEPS-HC is a panel survey including several interviews over two calendar years. This survey provides annual estimates at the national level with selected estimates available for about 30 to 35 states. The Behavioral Risk Factor Surveillance System (BRFSS), sponsored by the Centers for Disease Control and Prevention, is a state-based survey of population health, risk factors, and health behaviors for the adult civilian non-institutionalized population. States may add optional modules to the standardized questionnaire. This survey provides annual estimates for the nation and states. The National Survey of Children’s Health (NSCH), sponsored by the U.S. Department of Health and Human Services’ Maternal and Child Health Bureau of the Health Resources and Services Administration, is a survey of the health and well-being for the civilian non-institutionalized population of children under age 18. The NSCH is conducted every four years and provides national and state-level estimates. The Survey of Income and Program Participation (SIPP), conducted by the U.S. Census Bureau, collects longitudinal data on income and public program participation for the civilian non- institutionalized population. SIPP is a panel survey with the entire panel being interviewed at four month intervals (called waves). The survey includes core questions that are asked during each wave as well as topical modules that vary by wave. Each panel varies in duration from 2 ½ to 4 years. SIPP provides national and state-level estimates by month and year and is designed to be representative of the 20 largest states (2008 panel). 2 This section provides an overview of sample sizes for each of the surveys. Table 2 lists each survey’s S urvey S ample S izes sample size by age and income categories, and Table 3 lists sample sizes for each state by survey. Four of the surveys—the ACS, CPS, BRFSS, and NSCH—are designed to provide state-representative estimates for all states. The ACS has the largest sample size of the federal surveys, at approximately 3 million in 2009, which allows for analysis at both the state and sub-state levels. The BRFSS, with a sample size of 424,592 adults in 2009, provides the next largest sample sizes to the ACS and can also support both state and sub-state analysis. The sample size of the CPS is smaller, at 209,802 for calendar year 2009. Because of the smaller state sample sizes in the CPS, the Census Bureau recommends using 3-year averages to compare measures across states and 2-year averages to evaluate changes within a state over time. Finally, the NSCH, with a sample size of 91,642 children in 2007, supports state-level analyses but not analyses at sub-state geographies. The NHIS, MEPS-HC, and SIPP do not have sufficient sample size to produce annual estimates for all states, although each survey produces estimates for a limited number of states. Additionally, it may be possible to pool data from multiple years of these surveys to get reliable state estimates, as is commonly done with the CPS. The public use files for the NHIS and MEPS-HC do not include state identifiers, so any state-level analyses would need to be conducted using a Research Data Center. In contrast, the SIPP includes state identifiers for all states on its public use files. S urvey C ontent R elated to Health Ins urance C overage and Health C are Acces s , This section provides an overview of the health insurance coverage and the health care access, use Us e, and C os t and cost questions included in each of the surveys. Table 4 provides a more detailed description of these questions. The ACS asks a single question about current (i.e., “point in time”) health insurance coverage that includes seven coverage types as response categories. This question was added in 2008, so researchers and policymakers are still learning about the data. The ACS uninsurance rate is consistent with the CPS and NHIS uninsurance rates overall as well as for key population subgroups, including children (National Research Council 2010). The ACS does not include any questions on health care access, use, or cost. The CPS asks a series of questions about insurance coverage for the prior calendar year. The question series has been asked since 1988; as such a long time trend is available and researchers and policymakers are familiar with the data. There are concerns about the accuracy of reported coverage for the CPS because it asks respondents to recall coverage they had up to 16 months prior to the interview. In fact, research has shown that the CPS tends to look more like a point in time estimate than the full year measure of coverage that it is intended to measure (Congressional Budget Office 2003; Davern et al. 2007). SHADAC has developed an enhanced CPS series to account for question changes over time and to make some additional adjustments that result in a more accurate measure of trends in coverage (Ziegenfuss and Davern 2011; State Health Access Data Assistance Center 2009). The CPS does not include any questions on health care access or use. Limited questions on health care cost were added to the 2010 ASEC supplement. The NHIS has been conducted since 1957 and asks questions on current (point in time) coverage and coverage over the past year, followed by a series of questions about coverage types. The NHIS 3 includes questions on usual source of care, use of health services, unmet need for health care services, barriers to obtaining care, and health care cost, among other topics. Health insurance coverage and some basic access, use and cost questions are asked for all household members. Detailed measures are only asked about a random adult and, if children are present, a random child within the household. In collaboration with the Minnesota Population Center (MPC) at the University of Minnesota, SHADAC has developed the Integrated Health Interview Series (IHIS, see www.ihis.us). IHIS is a unique initiative that has harmonized and documented the NHIS from 1969 forward, making data downloads and documentation freely available to data users. The MEPS-HC asks a series of questions about current (point in time) coverage and coverage over the months included in each round of interviewing, along with questions on type of coverage. The MEPS-HC includes detailed questions on usual source of care, use of health services, unmet need for health care, barriers to obtaining care, and health care cost, among other topics. Household information is supplemented by information collected from respondents’ health care providers. The MEPS-HC supports longitudinal data analysis. The BRFSS asks adults a single question about current (point in time) coverage status and does not ask about coverage type. The BRFSS includes questions on usual source of care, use of health services (particularly preventive care), and unmet need for health care, among other topics. The NSCH asks a single question about current (point in time) coverage status and, if the child is insured, follows up with a question about Medicaid/Children’s Health Insurance Program (CHIP) coverage. The NSCH includes questions on usual source of care, use of health services, unmet need for health care, barriers to obtaining care, and health care cost/affordability, among other topics. The SIPP asks a series of questions about current (point in time) coverage and coverage over the months included in each round of interviewing, along with questions on coverage types. The SIPP includes questions on use of health services and health care cost, among many other topics. The SIPP supports longitudinal data analysis. Table 5 provides the web site links for summary tabulations of estimates and lists the locations of the Obtaining S tate-Level E s timates public use microdata files for each of the surveys. Summary tabulations are pre-tabulated estimates available to the public through published reports and/or tables. Microdata files containing individual records and detailed variable information are available directly through the sponsoring agency or from a few third party data access sites. Microdata files are generally available as public use files and as non-public files. The public use files have undergone disclosure avoidance techniques prior to being released. They may also have other edits such as limited variables or reduced sample size. The non-public data files, on the other hand, may allow a researcher to analyze using more variables and/or sample, but these can only be accessed through a Research Data Center (RDC). As an example, state identifiers are available on the public use files for ACS, CPS, BRFSS, NSCH, and SIPP. For the NHIS and MEPS-HC, access to state identifiers is only available on restricted data files at a designated RDC. As another example, the ACS public use file contains about two-thirds of the records available on the non-public files. SHADAC can provide support to state health policy analysts who are interested in accessing the full data files through an RDC. 4 Table 1: Federal Health Survey Design Elements ACS CPS NHIS MEPS-HC BRFSS NSCH SIPP Target population Total population Civilian non- Civilian non- Civilian non- Civilian non- Non- Civilian non- including persons in institutionalized institutionalized institutionalized institutionalized institutionalized institutionalized group quarters population population population adult population child population (0 population to 17 years) Primary focus of General household Labor force Population health Health care access, Population health, Children’s health Longitudinal data on survey survey, replacement participation and utilization, and cost risk factors, and and well-being income and program for the “long form” unemployment health behaviors participation decennial census Sample frame National Master Census 2000 Census 2000 Respondents to the Households with Households with Census 2000 1 Address File (MAF) sampling frame sampling frame NHIS landline telephones landline telephones sampling frame updated with new updated with new updated with new housing housing housing construction construction construction Sample designed to be Yes Yes No, but No, but Yes Yes Yes, for the 20 state representative? representative for representative for largest states (2008 some states some states panel) Survey mode Mail, phone, and in Phone and in person In person In person Phone Phone In person and phone person 2 Response rate 98.0% in 2009 85.9% in 2009 82.2% in 2009 59.3% for full panel 38.9% (average of 46.7% in 2007 63.4% by wave 12 of in 2008 state response the 2004 panel rates) in 2009 State-level estimates Yes Yes Releases selected Releases selected Yes Yes No, but state available? estimates for 20 state estimates for identifiers are largest states. Public about 30-35 states. available on the use file does not Public use file does public use file include state not include state identifiers identifiers State-level analysis of Yes Yes, but limited by Potentially, but Potentially, but Yes Yes Potentially, but subpopulations state sample size; limited by state limited by state limited by state possible (e.g., by recommended to sample size and sample size and sample size and income or insurance use 2- or 3- year survey design survey design survey design type)? averages Notes: 1 The National Master Address File (MAF) is the Census Bureau’s official inventory of known addresses. 2 The CPS response rate represents 2009 calendar year data collected from the 2010 Annual Social and Economic Supplement See pages 12-13 of this brief for source information. 5 Table 2: Federal Health Survey Sample Size by Age, Income, and States for the Most Recent Year Available ACS CPS NHIS MEPS-HC BRFSS NSCH SIPP 2009 2009 2009 2008 2009 2007 2008 1 Total 3,030,728 209,802 88,446 33,066 424,592 91,642 91,219 Children (ages 0 to 18) 735,486 64,128 25,158 10,437 0 91,642 24,115 Adults (ages 19 to 64) 1,815,272 123,818 53,170 19,245 290,491 0 54,326 2 Low-Income 964,336 71,742 28,772 14,095 NA 26,562 33,439 Children (ages 0 to 18) 285,437 26,565 11,085 5,649 NA 26,562 11,286 Adults (ages 19 to 64) 503,533 36,641 14,971 7,040 NA 0 17,883 3 Sample size by state 352,875 20,190 12,971 4,800 20,294 1,932 8,557 High (CA) (CA) (CA) (CA) (WA) (IL) (CA) Median 44,191 3,246 1,092 400 6,828 1,788 1,038 (KY) (SD) (SC) (AR, CO, CT, IN, LA, (SD) (MT) (KY) MA, MS, OK, SC) Low 5,538 1,800 117 < 100 2,432 1,725 163 (WY) (MT) (AK) (AK, DC, MT, ND, VT) (AK) (VT) (WY) Notes: 1 The BRFSS includes adults ages 18 and older; the adult tabulations are ages 18 to 64. The NSCH includes children ages 0 to 17. 2 Low-income is defined as family income below 200% of the Department of Health and Human Services federal poverty guidelines for ACS, CPS, MEPS-HC and NSCH. Low-income is defined as family income below 200% of the Census Bureau’s poverty thresholds for NHIS. The SIPP counts for low income also use the Census Bureau poverty thresholds, and exclude children under 15 years old who are not related to the household head. 3 The state tabulations for the NHIS are based on average sample size from 2004 to 2006, and the state tabulations for the MEPS-HC are based on average sample size from 2004 to 2008. NA: BRFSS only has categorical household income so poverty calculations are not available. See pages 12-13 of this brief for source information. 6 Table 3: Federal Health Survey Sample Sizes by State for Most Recent Year Available ACS CPS NHIS MEPS-HC BRFSS NSCH SIPP 2009 2009 2004-2006 2004-2008 2009 2007 2008 Alabama 48,319 2,272 1,391 500 6,789 1,761 1,331 Alaska 6,457 2,776 117 <100 2,432 1,739 215 Arizona 61,915 2,719 1,864 900 5,475 1,769 2,319 Arkansas 28,919 2,014 791 400 4,009 1,765 820 California 352,875 20,190 12,971 4,800 17,392 1,751 8,664 Colorado 49,434 4,569 1,393 400 11,956 1,801 1,278 Connecticut 35,272 4,598 1,024 400 6,496 1,889 944 Delaware 8,425 3,192 242 100 4,361 1,805 282 District of Columbia 5,580 2,611 157 <100 3,904 1,801 201 Florida 186,047 8,464 5,639 1,700 12,055 1,797 4,578 Georgia 95,400 4,618 2,210 900 5,896 1,782 2,859 Hawaii 13,517 3,691 434 200 6,683 1,822 401 Idaho 15,755 2,493 457 200 5,390 1,768 529 Illinois 126,758 6,473 3,924 1,200 5,845 1,932 3,491 Indiana 65,850 2,981 1,869 400 9,288 1,764 3,332 Iowa 30,748 3,790 781 200 6,024 1,757 996 Kansas 28,327 2,968 887 200 18,912 1,803 760 Kentucky 44,191 2,931 1,124 600 9,652 1,803 1,060 Louisiana 44,325 1,980 1,309 400 8,882 1,868 1,206 Maine 12,535 3,576 387 100 8,082 1,752 438 Maryland 56,406 4,920 1,548 600 8,591 1,773 2,234 Massachusetts 64,856 3,098 1,711 400 16,731 1,786 2,593 Michigan 100,064 4,816 2,797 1,000 9,255 1,861 2,465 Minnesota 53,140 4,801 1,548 500 5,611 1,767 1,560 Mississippi 28,958 2,011 653 400 11,194 1,918 901 Missouri 60,303 3,523 1,701 500 5,057 1,847 2,603 Montana 8,958 1,800 256 <100 7,618 1,788 278 7 Nebraska 18,109 3,101 573 300 15,988 1,827 535 ACS CPS NHIS MEPS-HC BRFSS NSCH SIPP 2009 2009 2004-2006 2004-2008 2009 2007 2008 Nevada 26,145 3,302 707 200 3,840 1,821 617 New Hampshire 13,021 4,013 254 100 5,989 1,773 442 New Jersey 86,356 4,525 2,591 800 12,390 1,827 3,499 New Mexico 18,816 2,108 742 300 8,837 1,826 633 New York 188,767 9,059 5,607 1,800 6,927 1,793 4,654 North Carolina 94,278 4,128 2,336 1,000 13,277 1,782 2,382 North Dakota 6,798 2,425 120 <100 4,767 1,800 225 Ohio 117,386 5,549 3,161 1,000 9,774 1,765 3,241 Oklahoma 37,026 2,541 1,074 400 7,846 1,816 1,036 Oregon 37,792 2,914 989 500 4,297 1,794 1,060 Pennsylvania 125,505 5,907 3,308 1,000 9,178 1,767 3,408 Rhode Island 10,436 3,299 287 100 6,296 1,756 268 South Carolina 45,877 2,768 1,092 400 9,860 1,885 1,258 South Dakota 8,280 3,246 163 100 6,828 1,740 206 Tennessee 63,282 2,695 1,493 500 5,579 1,840 2,407 Texas 238,301 12,436 8,457 3,600 11,608 1,805 6,432 Utah 27,276 2,711 739 200 10,161 1,747 775 Vermont 6,148 2,643 145 <100 6,664 1,725 180 Virginia 78,548 4,413 2,236 700 5,184 1,774 3,897 Washington 66,407 3,544 1,843 800 20,294 1,736 3,363 West Virginia 18,253 2,095 432 100 4,817 1,766 566 Wisconsin 59,049 3,844 1,638 600 4,553 1,860 2,830 Wyoming 5,538 2,661 124 100 6,058 1,748 166 U.S. Total 3,030,728 209,802 89,296 33,066 424,592 91,642 92,418 See pages 12- 13 of this brief for source information. 8 Table 4: Federal Health Survey Access and Coverage Topics 1 2 ACS CPS NHIS MEPS-HC BRFSS NSCH SIPP Health insurance Single question Series of questions Question about Series of questions Single question Single question Series of questions coverage status about coverage about coverage coverage status, about coverage about coverage about coverage about coverage (insured/uninsured) status that includes types followed by a series types; questions on status; no status; if insured, status and coverage and type of coverage different coverage of questions about availability of health information on asked if coverage is type for each types as response coverage types; insurance through coverage type through Medicaid or month; question on categories question on employer; questions CHIP availability of health availability of health on scope of insurance through insurance through coverage employer employer Health insurance No Yes Yes Yes No No Yes coverage: verification question for uninsured Type of uninsurance Point in time All of prior calendar Point in time; all of Point in time; all of Point in time Point in time; Point in time; all of 3 3 measures year prior year; if prior year ; length whether uninsured prior year ; whether uninsured at time of of time uninsured; at some point in uninsured at some survey, length of uninsured at some past year; if point in past year; if time uninsured; if point in the past uninsured at survey, uninsured, length of insured at survey, year any coverage in past time uninsured; whether uninsured year reasons for being at some point in the uninsured past year State-specific program No Yes Yes Yes No Yes Yes names included Health and disability Disability status Health and disability Health and disability Health and disability Health and disability Health and disability Health and disability status (limited) status (limited) status; medical status, medical status, medical status, medical status conditions, conditions, conditions conditions pregnancy pregnancy Usual source of care No No Whether Whether Whether Whether child has a No respondent has respondent has respondent has a usual source of care; usual source of care; usual source of care; personal doctor or type of place for type of place for reason for no usual health care provider usual source of care; usual source of care source of care; type whether child has a of place/provider of personal doctor or usual source of care nurse; medical home/care coordination 9 1 2 ACS CPS NHIS MEPS-HC BRFSS NSCH SIPP Use of health services No No Use of services in Detailed Length of time since Medical/dental Hospitalizations; past 2 weeks and information on use last doctor visit for visits in past year; number of medical past year, by of services by routine checkup; preventive provider visits; provider type; more provider type and specific preventive medical/dental prescription drugs; detailed is asked of reason care services visits in past year; use of care while the sample adult services from uninsured and sample child. specialists and mental health providers Unmet need for health No No Unmet needs due to In past year, unable Any time in past 12 Any time in past 12 No care cost for specific to obtain necessary months when months when child types of medical or dental couldn’t go to needed health care care/services care or prescription doctor due to cost but it was delayed drugs; reasons or not received couldn’t obtain care; how much of a problem it was that care was not received Barriers to obtaining No No Delayed care; Delayed care; No Delayed care (see No health care reasons for delayed reasons for delayed above); difficulty care care; how much of a obtaining referrals problem it was that care was delayed; how often was it easy to get necessary care Health care No Limited set of Premiums and out- Premium cost; No Any out-of-pocket Premiums and out- costs/affordability questions about of-pocket detailed information expenses for care; of-pocket annual out-of- expenditures on health care how often that expenditures pocket expenditures expenditures and amount is sources of payment reasonable (including self-pay) Notes: 1 This comparison focuses on questions that are common across all states. 2 The SIPP is administered in panels, with each panel consisting of waves and rotation groups. Each wave contains core questions that are asked each time, along with questions that vary from one wave to the next (topical modules). This table includes questions in both the core and topical modules. 3 Since MEPS-HC and SIPP are longitudinal surveys, it is also possible to construct uninsurance measures over the complete time period of the panel. 10 See pages 12-13 of this brief for source information. Table 5: Federal Health Survey Resources and Internet Links Survey Estimates Web Site ACS Summary Tabulations American FactFinder (full sample): http://factfinder.census.gov/ SHADAC’s Data Center (public use sample): http://www.shadac.org/datacenter Public Use Files American FactFinder: http://factfinder.census.gov/ Census Bureau DataFerret: http://dataferrett.census.gov/ IPUMS: http://www.ipums.org/ (IPUMS-USA) CPS Summary Tabulations Census Bureau web site (follow “Tables” link): http://www.census.gov/hhes/www/hlthins/hlthins.html Census Bureau CPS table creator: http://www.census.gov/hhes/www/cpstc/cps_table_creator.html SHADAC’s Data Center (public use sample): http://www.shadac.org/datacenter Public Use Files Census Bureau DataFerret: http://dataferrett.census.gov/ IPUMS: http://www.ipums.org/ (IPUMS-CPS) SHADAC- Summary Tabulations SHADAC’s Data Center (public use sample): http://www.shadac.org/datacenter Enhanced CPS Public Use Files IPUMS: http://www.ipums.org/ (IPUMS-CPS) NHIS Summary Tabulations NHIS Early Release program: http://www.cdc.gov/nchs/nhis/releases.htm Public Use Files http://www.cdc.gov/nchs/nhis/nhis_questionnaires.htm IHIS Summary Tabulations http://www.ihis.us Public Use Files http://www.ihis.us MEPS-HC Summary Tabulations MEPS-HC Summary tables: http://www.meps.ahrq.gov/mepsweb/data_stats/quick_tables.jsp Public Use Files http://www.meps.ahrq.gov/mepsweb/about_meps/releaseschedule.jsp BRFSS Summary Tabulations BRFSS web site: http://apps.nccd.cdc.gov/BRFSS/index.asp BRFSS web site: http://www.cdc.gov/brfss/pubs/index.htm Public Use Files http://www.cdc.gov/brfss/technical_infodata/surveydata.htm NSCH Summary Tabulations http://www.nschdata.org/Content/Default.aspx Public Use Files NSCH web site (follow “View/Download”) http://www.cdc.gov/nchs/slaits/nsch.htm SIPP Summary Tabulations Census Bureau SIPP web site http://www.census.gov/sipp/pubs.html Public Use Files Census Bureau DataFerret: http://dataferrett.census.gov/ 11 T able S ources Table 1 Source Information ACS design and methodology available at http://www.census.gov/acs/www/methodology/methodology_main/ and response rate available at http://www.census.gov/acs/www/methodology/response_rates_data/index.php. CPS design and methodology available at http://www.census.gov/prod/2006pubs/tp-66.pdf and response rate available at http://www.census.gov/hhes/www/p60_238sa.pdf. NHIS design and methodology and response rate available at ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2009/srvydesc.pdf. MEPS-HC design and methodology available at http://www.meps.ahrq.gov/mepsweb/survey_comp/hc_data_collection.jsp and response rate available at http://www.meps.ahrq.gov/mepsweb/survey_comp/hc_response_rate.jsp. BRFFS design and methodology available from “Overview: BRFFS 2009” at http://www.cdc.gov/brfss/technical_infodata/surveydata/2009.htm and response rate available at ftp://ftp.cdc.gov/pub/Data/Brfss/2009_Summary_Data_Quality_Report.pdf. NSCH design and methodology and response rate available at ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/slaits/nsch07/2_Methodology_Report/NSCH_Design_and_Oper ations_052109.pdf. SIPP design and methodology available at http://www.census.gov/sipp/usrguide.html and response rate available at http://www.census.gov/sipp/sourceac/S&A04_W1toW12%28S&A-9%29.pdf. Table 2 Source Information ACS data tabulated from the 2009 public use file. CPS data tabulated from the 2010 Annual Social and Economic Supplement public use file, representing calendar year 2009. NHIS data tabulated from the 2009 public use file. Data for states obtained from Cohen RA, Makuc DM. State, regional, and national estimates of health insurance coverage for people under 65 years of age: National Health Interview Survey, 2004–2006. National health statistics reports; no1. Hyattsville, MD: National Center for Health Statistics. 2008. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr001.pdf. Three-year totals for states divided by three to estimate annual sample size. MEPS-HC data tabulated from the 2008 public use file. Data for states is a special tabulation provided by the Agency for Healthcare Research and Quality. Data represents average state sample size from 2004-2008, rounded to the nearest hundred. BRFSS data tabulated from the 2009 public use file. Data for states obtained from the Behavioral Risk Factor Surveillance System 2009 Codebook Report. 2010. Available at http://www.cdc.gov/brfss/technical_infodata/surveydata/2009.htm. NSCH data from the 2007 public use file available in tables from the Data Resource Center for Child and Adolescent Health at http://www.childhealthdata.org. Data for states obtained from Stephen Blumberg, et al. Design and Operation of the National Survey of Children’s Health, 2007. 2009. Available at: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/slaits/nsch07/2_Methodology_Report/NSCH_Design_and_Oper ations_052109.pdf. SIPP data tabulated from wave 4 of the 2008 panel from the public use file. Tabulations by age are number of people in month 4. Data for states is number of people in wave 4. Because people may change age over the months in a wave it is not straightforward to calculate a person number by age for a wave. Table 3 Source Information ACS data tabulated from the 2009 public use file. CPS data tabulated from the 2010 Annual Social and Economic Supplement public use file, representing calendar year 2009. NHIS data obtained from Cohen RA, Makuc DM. State, regional, and national estimates of health insurance coverage for people under 65 years of age: National Health Interview Survey, 2004–2006. National health statistics reports; no1. Hyattsville, MD: National Center for Health Statistics. 2008. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr001.pdf. Three-year totals for states divided by three to estimate annual sample size. 12 MEPS-HC data source is a special tabulation provided by the Agency for Healthcare Research and Quality. Data represents average state sample size from 2004-2008, rounded to the nearest hundred. BRFSS data obtained from the Behavioral Risk Factor Surveillance System 2009 Codebook Report. 2010. Available at http://www.cdc.gov/brfss/technical_infodata/surveydata/2009.htm. NSCH data obtained from Stephen Blumberg, et al. Design and Operation of the National Survey of Children’s Health, 2007. 2009. Available at: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/slaits/nsch07/2_Methodology_Report/NSCH_Design_and_Oper ations_052109.pdf. SIPP data tabulated from wave 4 of the 2008 panel from the public use file, number of people. Table 4 Source Information ACS questions available at http://www.census.gov/acs/www/methodology/questionnaire_archive/. CPS questions available at http://www.census.gov/apsd/techdoc/cps/cpsmar10.pdf. NHIS questions available at ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Survey_Questionnaires/NHIS/2009/English/. MEPS-HC questions available at http://www.meps.ahrq.gov/mepsweb/survey_comp/survey.jsp. BRFSS questions available at http://www.cdc.gov/brfss/questionnaires/english.htm. NSCH questions available at http://www.nschdata.org/Content/Guide2007.aspx. SIPP questions available at http://www.census.gov/sipp/questionnaires.html. State Health Access Data Assistance Center. 2011. “Monitoring the Impacts of Health Reform at the S ugges ted C itation State Level: Using Federal Survey Data.” Brief #24. Minneapolis, MN: University of Minnesota. Congressional Budget Office. 2003. "How many people lack health insurance and for how long?" R eferences Economic and Budget Issue Brief. Washington DC: Congressional Budget Office. Davern , M., G. Davidson, J. Ziegenfuss, et al. 2007. "A Comparison of the Health Insurance Coverage Estimates from Four National Surveys and Six State Surveys: A Discussion of Measurement Issues and Policy Implications." Final report for U.S. DHHS Assistant Secretary for Planning and Evaluation, Task 7.2. Minneapolis, MN: University of Minnesota. Available at: http://www.shadac.org/files/shadac/publications/ASPE_FinalRpt_Dec2007_Task7_2_rev.pdf National Research Council. 2010. Databases for Estimating Health Insurance Coverage for Children: A Workshop Summary. Thomas J. Plewes, Rapporteur. Committee on National Statistics, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. State Health Access Data Assistance Center. 2009. "SHADAC-Enhanced CPS Health Insurance Coverage Estimates: A Summary of Historical Adjustments." SHADAC Technical Brief. Minneapolis, MN: University of Minnesota. Available at http://www.shadac.org/files/shadac/publications/TechBrief_CPSEnhanced.pdf Ziegenfuss, J.Y. and M.E. Davern. 2011. “Twenty years of coverage: an enhanced current population survey-1989-2008.” Health Services Research 46(1 Pt 1):199-209. 13