Individual and Market Factors Predicing Insurance Coverage under the Affordable Care Act

Background and Objective: Prior to the implementation of the major insurance provisions of the ACA, Texas had the highest rate of uninsured adults under age 65 in the U.S. Previous reports have documented large numbers of individuals gaining insurance coverage in Texas since 2013. However, prior studies have not determined which factors were most significant in increasing coverage. We also do not know the relative importance of individual characteristics versus market level factors. This study uses regression analysis to identify the most important determinants of changes in insurance coverage and tests the role of insurance market factors in predicting observed changes in Texas.

Methods: We analyzed data from the Health Reform Monitoring Survey of Texas for the periods September 2013, March and June 2014, and March and September 2015. The Urban Institute conducts a nationwide quarterly survey of roughly 7,500 adults ages 18-64 regarding health insurance coverage. We used the Urban Institute’s survey instrument to collect information on an expanded sample of 1,500 Texans per period. We used regression analysis to test which individual characteristics were associated with significantly higher rates of insurance coverage between 2013 and 2015. We are in the process of merging the survey data with insurance market characteristics for each surveyed individual.

Results: The percent insured in Texas rose from 76.6% in 2013 to 83.1% in 2015. Preliminary results indicate that only individuals age 50 to 64 experienced significant increases in insurance coverage (79.2 to 91.5%). Persons in families earning between 138 and 400% of the poverty level experienced a significant increase in percent insured, from 79.2% in 2013 to 88.6% in 2015. Coverage rates for persons in families above and below this income category did not have significant changes in coverage. Coverage rates increased significantly for adults in excellent or very good health between 2013 and 2015 (from 75.5% to 86.0%), but not for adults reporting good, fair, or poor health. There was also a significant increase in coverage between 2013 and 2015 for those with a high school degree (74.2% to 83.7%) and Hispanics (71.7% to 83.0%).

Conclusion: Although Texas has experienced a significant rise in coverage since 2013, the increases are uneven across sociodemographic groups. Individuals in families earning between 138 and 400% of the FPL experienced a significant rise, suggesting that Marketplace subsidies boosted coverage. Texas did not elect a Medicaid expansion, which is consistent with an insignificant rise in coverage for lower income Texans. Further research is needed to determine why blacks have not benefited as much from the ACA in Texas as Hispanics have. We will update these results prior to the conference when we have added to the dataset information on the availability of insurance policies and their plan characteristics in each Texas rating area.