Recommendations for Using Surveys to Measure Health Coverage Post-Reform

Two young women fill out an enrollment form.

The Issue:

Soon after the Affordable Care Act (ACA) was signed in 2010, the US Census Bureau began exploring ways of adapting surveys that measure insurance coverage to accommodate the new law, focusing on the Current Population Survey (CPS) and the American Community Survey (ACS). At the time, Massachusetts, with its ACA-like 2006 reforms, was the only place in the country with real-world experience offering coverage through an insurance exchange (or “marketplace”). So in 2011 the Census Bureau collaborated with Research Support Services (RSS) and the University of Massachusetts Center for Survey Research (CSR) to carry out a research project. Methods included expert consultation with individuals involved in the state’s implementation of health reform since 2006, focus groups (four in total) and one-on-one cognitive interviews (134 in total) with marketplace enrollees to explore how to adapt questionnaires to capture coverage obtained through the new marketplaces.

Test subjects were recruited with the help of the state marketplace (“The Massachusetts Connector”) and in most cases the enrollees’ coverage and subsidization status were known going in to the testing. The purpose of the focus groups was to flesh out general perceptions of the marketplace, terminology enrollees used for the coverage, and pathways to enrollment. The purpose of the cognitive interviews was to go through the experimental adaptations to the CPS and ACS standardized surveys to explore whether the questions on marketplace participation and subsidization were understood as intended and prompted accurate reporting. Focus groups and cognitive interviews were conducted in English and Spanish.

This brief summarizes the results of this research and outlines recommendations for measuring health insurance coverage following the introduction of marketplace plans.


State Health Access Data Assistance Center

The State Health Access Data Assistance Center (SHADAC) is an independent health policy research center located at the University of Minnesota School of Public Health. SHADAC is a resource for helping states collect and use data for health policy, with a particular focus on monitoring rates of health insurance coverage and understanding factors associated with uninsurance.