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

NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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Thomas J. Plewes, Rapporteur Committee on National Statistics Division of Behavioral and Social Sciences and Education

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi- neering, and the Institute of Medicine. The members of the Steering Committee for the workshop were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHSP23320042509XI between the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, and the National Academy of Sciences. Support of the work of the Committee on National Statistics is provided by a consortium of federal agen- cies through a grant from the National Science Foundation (No. SES-0453930). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organiza- tions or agencies that provided support for the project. International Standard Book Number-13: 978-0-309-16240-1 International Standard Book Number-10: 0-309-16240-8 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: 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.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal govern - ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem - bers, sharing with the National Academy of Sciences the responsibility for advis- ing the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro - viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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STEERING COMMITTEE FOR A WORKSHOP ON EVALUATING DATABASES FOR USE IN THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) ALLOCATION FORMULA V. JOSEPH HOTz (Chair), Department of Economics, Duke University LyNN A. BLEWETT, School of Public Health, University of Minnesota, and State Health Access Data Assistance Center MICHAEL DAVERN, National Opinion Research Center and University of Chicago LISA C. DUBAy, Bloomberg School of Public Health, Johns Hopkins University JOAN HENNEBERRy, Colorado Department of Health Care Policy and Financing, Denver CHRIS L. PETERSON, Medicaid and CHIP Payment and Access Commission, Washington, DC ERIC V. SLUD, Department of Mathematics, University of Maryland THOMAS J. PLEWES, Study Director ANTHONy S. MANN, Program Associate v

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COMMITTEE ON NATIONAL STATISTICS 2010 LAWRENCE D. BROWN (Chair), Department of Statistics, The Wharton School, University of Pennsylvania JOHN M. ABOWD, School of Industrial and Labor Relations, Cornell University ALICIA CARRIQUIRy, Department of Statistics, Iowa State University WILLIAM DuMOUCHEL, Oracle, Phase Forward, Waltham, Massachusetts V. JOSEPH HOTz, Department of Economics, Duke University MICHAEL HOUT, Department of Sociology, University of California, Berkeley KAREN KAFADAR, Department of Statistics, Indiana University SALLIE KELLER, Director, Science and Technology Policy Institute, Washington, DC LISA LyNCH, The Heller School for Social Policy and Management, Brandeis University SALLy C. MORTON, Department of Biostatistics, University of Pittsburgh JOSEPH NEWHOUSE, Division of Health Policy Research and Education, Harvard University SAMUEL H. PRESTON, Population Studies Center, University of Pennsylvania HAL STERN, Department of Statistics, University of California, Irvine ROGER TOURANGEAU, Joint Program in Survey Methodology, University of Maryland, and Survey Research Center, University of Michigan ALAN zASLAVSKy, Department of Health Care Policy, Harvard Medical School CONSTANCE F. CITRO, Director vi

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Preface This report summarizes the proceedings of a workshop convened in June 2010 to critically examine the various databases that could provide national and state-level estimates of low-income uninsured children and could be effectively used as criteria for monitoring children’s health insur- ance coverage. The workshop was sponsored by the Office of the Assis - tant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services, and convened by the Committee on National Statistics (CNSTAT), Division of Behavioral and Social Sciences and Edu - cation (DBASSE) of the National Research Council (NRC). The workshop was organized by a steering committee composed of experts in administering and assessing the Children’s Health Insurance Program (CHIP) at the national and state levels, as well as experts in survey methodology and modeling. The committee provided invaluable guidance in developing the workshop, securing expert presentations, and facilitating the conduct of the workshop. Although the steering committee played a central role in designing and conducting the workshop, the mem- bers did not actively participate in writing this workshop summary. The staff of ASPE and of the U.S. Census Bureau played an important role in preparing for and conducting the workshop. The work of Don Oellerich of ASPE and David Johnson of the Census Bureau in this prepa- ration phase is especially recognized, as are the important information and comments they provided that enhanced the value of the event. As the person responsible for supervising the grant that supported this activity, Oellerich also served as the primary point of coordination between the steering committee and the Department of Health and Human Services. vii

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viii PrEfACE The presentations in the workshop were designed to shed light on various aspects of the issues involved in evaluating the adequacy and appropriateness of databases for estimating health insurance coverage for children. The task of describing the overall context for the consideration of these issues fell to Chris Peterson of the Medicaid and CHIP Payment and Access Commission, a member of the steering committee. He discussed the evolution of the CHIP legislation and the more recent change in emphasis from use of coverage estimates for allocating funds to states to the purpose of assessing progress and performance overall that came with the reauthorization of CHIP in 2009. He described how the new health care reform legislation, known as the Patient Protection and Affordable Care Act, sets a new standard for the coverage data. Michael Davern, also a member of the steering committee, discussed the background of the major surveys that have been used to measure the health insurance coverage of children. The first panel discussion focused on the use of administrative data for estimating the coverage of health insurance for children. David Baugh, who has responsibility for the Medicaid and CHIP databases at the Cen- ters for Medicare & Medicaid Services (CMS), discussed the status of the major administrative data collections and a summary of recent programs to improve those key databases. A user’s perspective on the quality of the administrative data on CHIP was provided by David Rousseau of the Kaiser Family Foundation. Richard Strauss, of CMS, discussed the quality of the administrative and survey data used for programmatic purposes, including the allocation of funds to states, which was a major use of the data prior to the passage of the CHIP reauthorization in 2009. In the second panel, Sharon Long of the Urban Institute, John McInerney of the Commonwealth Institute, and Lynn Blewett of the Uni- versity of Minnesota (also a member of the steering committee) discussed the important state uses of administrative and survey data for state pur- poses, such as program management and evaluation. The third panel focused on modeling strategies for improving estimates, with presenta- tions by Mark Bauder and Brett O’Hara summarizing the Census Bureau’s Small Area Health Insurance Estimation program and William Bell dis- cussing the Census Bureau’s Small Area Income and Poverty Estimation model. Nathaniel Schenker of the National Center for Health Statistics discussed joint modeling of survey and administrative record data, using health-related data collections. On the second day, workshop participants heard from John Czajka of Mathematica Policy Research, Inc., who discussed measuring income; Joanna Turner of the University of Minnesota, who discussed measuring health insurance coverage; and Genevieve Kenney and Victoria Lynch of the Urban Institute, who gave an overview of survey characteristics that

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ix PrEfACE would commend or limit their use in estimating coverage of health insur- ance for children. Finally, we heard from Cindy Mann, director of Medic- aid and state operations at CMS, who put the work of the committee into an overall perspective and provided the workshop with a provocative wish list of data needs from the viewpoint of the administrator of CHIP. These presentations were uniformly well prepared, well presented, and provocative. In the course of the workshop, several important issues were raised on the scope and content of the surveys and administrative databases, which are ancillary to coverage issues. Those topics included the need to collect data on the health and other socioeconomic characteristics of children by insurance status, and the benefits available to children within their insurance coverage (e.g., dental and mental health coverage), special therapies, and the like. In view of the concentrated focus of the workshop on means of estimating coverage, these issues were not explored in any depth. However, these important issues of scope and content should be considered in any future review of these data sources. The steering committee also acknowledges the excellent work of the staff members of CNSTAT and the NRC for their support in developing and organizing the workshop and preparing this report. This report was prepared under the direction of Constance Citro, director of CNSTAT. Tom Plewes served as study director as well as rapporteur for the workshop. The steering committee was ably assisted in all administrative arrange - ments by Anthony Mann, also on the CNSTAT staff. Anthony played a major role in preparation of this workshop summary. This workshop summary was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accor- dance with procedures approved by the Report Review Committee of the NRC. The purpose of this independent review is to provide candid and critical comments that assist the institution in making its report as sound as possible, and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integ- rity of the deliberative process. The panel thanks the following individuals for their review of this report: Martha Heberlein, Georgetown Center for Children and Families; Leighton Ku, Center for Health Policy Research, School of Public Health and Health Services, The George Washington Uni- versity; and Paul W. Newacheck, Department of Pediatrics and Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco. Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the con-

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x PrEfACE clusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Lisa Lynch, The Heller School for Social Policy and Management, Brandeis University. Appointed by the NRC, she was responsible for making certain that the independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests entirely with the author and the NRC. V. Joseph Hotz, Chair Steering Committee for a Workshop on Evaluating Databases for Use in the Children’s Health Insurance Program (CHIP) Allocation Formula

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Contents PART I WORKSHOP SUMMARy 1 Introduction 3 2 The Changing Policy Context 7 3 Federal Surveys 14 4 Administrative Databases 32 5 State Data Collections 38 6 Modeling Strategies for Improving Estimates 47 7 Looking Ahead 56 References 60 PART II BACKGROUND PAPERS 8 Monitoring Children’s Health Insurance Coverage Under CHIPRA Using Federal Surveys 65 Genevieve Kenney and Victoria Lynch xi

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xii ContEntS 9 Health Insurance Coverage in the American Community Survey: A Comparison to Two Other Federal Surveys 83 Joanna turner and Michel Boudreaux 10 Income and Poverty Measurement in Surveys of Health Insurance Coverage 109 John L. Czajka 11 Using Uninsured Data to Track State CHIP Programs 141 John McInerney 12 The Massachusetts Experience: Using Survey Data to Evaluate State Health Care Reform 154 Sharon K. Long 13 Small-Domain Estimation of Health Insurance Coverage 165 Brett o’Hara and Mark Bauder Appendixes A Workshop Agenda and Participants 183 B Biographical Sketches of Steering Committee Members 188