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well, good morning, andthank you for coming. today is an eventthat we are co-holding with our fellow fiscalagency, the national center for health statistics. i'm john thompson, thedirector of the census bureau. and we are going to be -- there's a little bit of areal strange feedback here. is the -- [ inaudible speaker ]

is it good? so, anyway, on september 16th,we are going to be releasing, we and our colleague agency, are going to be releasingestimates of health insurance. and today we're reallypleased to talk to you about the methodologythat we're using to collect these statisticsand how we're going to be producing them, andwhat the estimates will mean when you see themon september 16th.

we have -- at the census bureau, we will be discussingthe methodology in our current population survey and the national [inaudible]statistics will be discussing the methodology they use in thenational health interview survey to collect and producethese estimates. so, as i said, we arejust delighted to be here and i will let charlie rothwell,the head of nchs, present. good morning all.

it's good to be here and it'sgood to see you all here. and, again, as john said,my name's charlie rothwell and i'm proud to be thedirector of the national center and we're here today to discusstwo premier federal surveys: the current populationsurvey, or cps, run by the census bureau, and the nationalhealth interview survey of the national centerfor health statistics, and how these surveys can beused to monitor the changes

in health insurancecoverage in our nation. monitoring healthinsurance is nothing new for the census or nchs. we've been very carefullydoing so for decades to effectively measure changes as the health insurancelandscape has changed. and we have done thisthrough a variety of surveys. these two surveys specificallythat we'll be concentrating on today are veryall-encompassing surveys

which cover much more thanjust health insurance. so why now have this technicalbriefing on these two surveys and strictly on healthinsurance? as you know there have beenrecent findings published by various private surveys on health insurancecoverage changes in the first months of 2014. and in mid-september,as john mentioned, both these two major federalsurveys will be releasing

statistics on healthinsurance coverage. while the cps report will be for the 2013 health insuranceestimates before coverages under aca went intoeffect, the nhis or it national health interviewsurvey will be producing the first federal survey statisticson health insurance coverage for the first few months of2014, and thus they also, together, can beused to monitor, i believe in more detail,the evolving impact

of the affordable care acton health insurance coverage. we hope through this briefing to help you better utilize theinformation you'll be receiving from these surveys. and so, today, we're here todiscuss these surveys' strengths and how they can be usedto monitor the changes in our health insurancecoverage as well as provide you with an overview of futurereporting, because there's going to be future reporting

from these surveys beyond justthe releases in september. now, both these surveys arevery large in-person surveys which are representative of thenon-institutional population of the u.s. and arereally the gold standard in measuring health statusand income in our nation. and by the way, have also beencollecting health insurance for decades. the cps, and specificallyits , it annual social and economic supplement, theasec, is a survey administered

by trained, highly-trained,field staff with the census and includes health insurancequestions and is conducted over three months every spring, and the statistics arereleased each fall as a part of the annual release on income,poverty, and health insurance in the prior calendar year. no other survey provides thesame level of detail on income. now, in september, census willalso be providing insurance coverage rates for the periodof february through march

to augment what will bepublished by the national center now the it national healthinterview survey is the principle source ofinformation on health of the civiliannon-institutional population of the u.s. and providescurrent statistical information on the amount, the distribution,and the effects of illness and disability in healthcarein the united states as well as health insurance coverage. and, by the way, it'sbeen doing so since 1959.

now beginning in 2011with the funding provided by the public health preventionfund of the affordable care act, we were able to expand thecontent collected in the his and expand the surveysample size to allow for more detailed nationalmonitoring of the impact of aca as well as providestate-level changes in health insurance coverage. now as you look at your agenda, you can see that the upcomingspeakers will providing much

more detailed and specificinformation on these surveys as well as what can beexpected to be made available, not just in september, butthroughout the next year and, i might add, theyears to follow. it's my pleasure now tointroduce both jennifer day of the census bureau andstephen blumberg of nchs who will provide you with thespecifics on these two surveys as they relate to healthinsurance coverage. jennifer, pleaselead off the cps.

[waiting for speaker] the census bureau collectslots of data about many topics. today our focus is onhealth insurance coverage. i will provide a primer on thethree census bureau surveys that collect data onhealth insurance coverage. then i will cover thehistory of improvements in the current populationsurvey measurement of health insurance coverageand discuss our research and testing efforts toimprove our survey questions,

and end with explainingthe changes that we have made recently to better measure healthinsurance coverage. the census bureau collectsand produces estimates of health insurancefrom three surveys: the current population survey;the american communities survey; and the survey of incomeand program participation. so why do we have three surveysto measure health insurance? well, it depends onwhat you need to know

as each has its ownunique strengths. let's take a closer look. the current population surveyis a monthly survey focused on determining who is employedand unemployed and has been used to calculate theofficial unemployment rate since the late 1940s. in february, march, and april,we have a special supplement to the current populationsurvey called the "annual social and economic supplement."

this contains a slew of detailedquestions on income sources and is the source of theofficial poverty rate. along with thesequestions we also ask about health insurance coverage. these questions ask aboutthe previous calendar year, so the estimates for 2012,as shown here in the figure, were collected in the 2013 cps. the purpose of collecting thehealth insurance information in the cps is toobtain a measure

of health insurancecoverage to be used along with the previous calendar yearincome and poverty estimates, thus providing an assessment ofnon-cash benefits and its impact on economic well-being. the american communities surveyis one of the largest surveys in the world with a sample size of 3.4 million householdsannually. it is collected continuouslythroughout the year. because of this largesample size,

the acs can provide reliablehealth insurance estimates for the nation, state, andlocal levels of geography. in 2008 we added thehealth insurance question as shown here. this question provides a list of health insurance typesplus a write-in for response to check yes or no if they havethat kind of health insurance. people who do notcheck any yes boxes and do not provide a write-inare counted as uninsured.

one of the advantagesof this list in the acs paper questionnaireis respondents can see all the answer possibilities at once. the survey of income and programparticipation is a longitudinal survey that interviewsrespondents multiple times over several years. the strength of the sip isits measurement of transitions in a broader context ofmany events; for example, on and off programs, in and outof the labor force, and so on.

beginning this year, wecompletely redesigned the survey to reduce respondentburden and reduce costs. in this new sip, we visithouseholds just once a year, but ask respondents about events for each month during theprevious year using the event history calendar toaid their memories. every year the census bureauproduces health insurance estimates for boththe cps and the acs. however, these twosurveys produce their

estimates differently. the cps providesestimates of the population without health insurance for theentire previous calendar year. that means if they hadinsurance, even for one day, they are not includedin this uninsured count. this year we asked aboutjanuary through december of 2013 and we'll provide nextmonth the estimates of how many people didnot have health insurance for all of last year.

the benefit of thecps is the combination of detailed employmentand detailed income with a time series thatstretches back decades at the national level, whichproduces an excellent picture of economic well-beingof our nation. similar to the cps, the americancommunities survey produces annual estimates ofthe uninsured rate. however, they arebased on the average of responses collectedduring the whole year,

with respondents providing theirhealth insurance coverage status at the time of their interview. we publish estimates in thefall of the following year. so this fall, next month, we will publish ratesreflecting 2013. the strength of the acsis its large sample size, and we can drill downto smaller geographies and provide health insuranceestimates for most communities. the sip collectsmonthly estimates

and can provide a fullcontext of transitions for many topics includinghealth insurance. the focus today is on cps. we began over 30years ago asking about health insurancecoverage on cps for only part of the population when congressdirected the census bureau to collect data onnon-cash benefits such as the government-providedhealth insurance to show its impact on poverty.

the following year at hhs'srequest, we added all types of private insuranceto our collection. a few years later, in1988, we redesigned and expanded the questions to collect prior year insurancestatus of all household members. this is the first populationestimate of health insurance in the cps, and reflectedhealth insurance coverage status in the calendar year 1987. since then we havereleased estimates

of health insurance coverage inthe fall of the collection year with the officialpoverty report. during the 1990s, researcherscould see that the cps estimates of uninsured seemed higher thanthose of other major surveys, indicating that under-reportingmight be a larger problem for the cps. in response, we addeda verification question at the end of the supplement. this asked respondents whohad not reported any health

insurance coveragewhether they were, in fact, uninsured duringthe previous year. this resulted in an 8% declinethe uninsured rate as shown here in the slide in the circle withthe two estimates for 1999, thus moving the cps closerto other published estimates. for the 2000 estimateswe added a new question about the state children'shealth insurance program, chip. and in order to provide newreliable state-level estimates of health insurance coverage,we added 28,000 more households

to the sample to enable us to measure the effectsof the new program. in 2011 we enhanced ourdata processing methods and released revised estimates on health insurancecoverage back to 1999. in addition to questionchanges, sample changes, processing changes thatdirectly affect health insurance estimates, we are continuouslyimproving our survey collections to provide the most accurate

and up-to-date informationfor us all estimates. footnoted here are severalimprovements to the survey and estimates, including changesfrom when we went from paper to computer-assistedinterviewing, waiting improvements and others. all of these are noted inour annual published reports. even after adding theverification question and the chip question,research suggested that cps needed furtherimprovement

as the estimates still werenot in line with other sources. we confirmed someof our concerns with the estimates'differences between the cps and other national surveys, with the medicaidundercount projects. we also researched reportingproblems in the survey itself, considering, for example, whether a questionorder matters. we held focus groups, cognitivetesting, and field tests.

we conducted expert reviews,interview debriefings, record-check studies, andother kinds of research, working to find any potentialsource of measurement error. our goal was to makeevery reasonable effort to produce the best healthinsurance coverage estimates with the cps. this research in the medicaidundercount project was conducted through a joint program with thecensus bureau, several agencies within hhs including nchsand shadac, the university

of minnesota's state healthaccess data assistance center. it found that cpsundercounted medicaid enrollees by at least one quarter compared to the medicaid administratorrecord counts even after adjusting for differences in the two data sourceshow they counted enrollees. an undercount of medicaidenrollment by cps would tend to lower overall healthinsurance coverage estimates. an existence of a medicaidundercount suggested

that the cps healthinsurance questions needed improvement overall. other research we did suggested that the cps healthinsurance estimates had some reporting problems. the questions were retrospective about health insurance duringthe previous calendar year, that is january to december. and the health insurancecoverage status can change

over a course of the year. so questions about this longreference period may lead to response errors. for example, some people mayreport their insurance coverage status at the time oftheir interview rather than the coverage statusthe previous calendar year. research also showed, in addition to the calendaryear reference issue, the health insurance questionswere designed to be read

where each type of coverage isasked of everyone regardless of prior answers or information. the cps provides no visual clueas to the whole array of choices as it is conducted with a fieldrepresentative reading the questions out loud with onequestion after the other. respondents may say yes tothe first type of coverage that sounds close to whatthey had which can lead to over-reporting of some typesand under-reporting of others that appeared furtherdown on the list.

respondents struggle withthe meaning of the questions and get confusedamong plan types, especially public programs. moreover, the health insurancequestions on cps are asked in a household level design where household membersmay be forgotten if they are not mentionedby name. after a final round ofcognitive testing in 2009, we ran a field test calledthe survey of health insurance

and program participationor ship. this tested a new approach tomeasuring health insurance. the aim was to capturecoverage in a more intuitive way and make it easierfor respondents to correctly identifytheir coverage. the questions wereshorter and simpler. the first question was asimple yes or no to determine if the respondentcurrently had any coverage. the questions then drilled down,as needed, and were designed

to clarify areas of ambiguityand reroute respondents to the correct coverage path. the instrument used previousanswers about age, income, and other coveragewithin the household to present appropriatefollow-up questions that could captureunreported plans. and, finally, the new questiondesign used a hybrid flow of both household andperson-level questions. it began by asking personone about his or her coverage

and then fill in theinformation where appropriate for other household members. so the questions don't haveto repeat for each person. we compared this new methodwith that as currently on cps and acs, and this newformat provided the basis for the proposedstyle of questions for the full-scale nationalcontent test in 2013. while all this researchwas going on, the affordable care act healthreform law passed in 2010.

we realized at thetime that several of its provisions would changehow people answered their health insurance questions. people would have new waysto obtain health insurance, including through stateinsurance exchanges, now called the "marketplace,"and the number of people who would be eligible for subsidized health insurancepremiums would increase. we started to considerhow we were going

to measure health insurancein this new climate. two states already had healthinsurance exchange-type programs, utah andmassachusetts. the utah program was focusedprimarily on businesses, and since the affordablecare act was modeled after the programin massachusetts, we focused on researchin massachusetts. we had three phases of research, starting with expertconsultation, focus groups

with exchange participants, andfinally, cognitive interviews with people who were enrolled in the massachusetts healthcaresystem and those who were not. in march, 2013, weran a national test that combined the lessonslearned from the 2010 ship test and the cognitiveresearch in massachusetts. it included a redesigned list ofhealth insurance coverage types, new questions about the exchangemarketplace participation, and additional questions

on employer-offeredhealth insurance. this was an operational test for both the newhealth insurance section and a revised income section. the tests included all the samesections as the production cps, something that shiphad not done. this would allow us to makesure the test questions worked in a context of the fullarray, a full survey where the healthinsurance section appears

after a full panel ofquestions on labor force and another one on income. we wanted to be surethe addition of the new health insuranceitems would not slow down the instrument, and wewanted to ensure that the flow within the health insurancesection worked well. moreover, the timing thetest provided an opportunity to provide the test questions,to compare the test questions with the production cps.

with a sample size in the testhealth insurance questions of 16,000 people, we could makestatistically valid comparisons between the test estimates and the full productioncps estimates. our goal was to see whetherthe test questions produced estimates that would be closerto the other national surveys, and whether the current coverageestimates of the uninsured were, as expected, higherthan the prior january through decembercalendar year estimates.

we found that the content testestimates of uninsured was lower by 1.4 percentage points in theproduction cps, bringing it more in line with othernational survey estimates. we also found that the currentcoverage uninsured rate exceeded the rate for theprevious calendar year. both findings confirmedour expectations. so we implemented thisnew set of questions for the productioncps this year. our goal was to provide improvedhealth insurance coverage

estimates for calendaryear 2013. this is prior tothe major changes from the affordable care act andthus provides a baseline year for accurately measuringfuture year changes. the redesigned health insurancecoverage questions differ from the old questionnairein three ways; the reference period;coverage types; and household level design. that is, the newquestionnaire asks

about current coverage questionsto improve the responses about healthcare coverage inthe previous calendar year. it starts with generalcoverage questions and drills down to specific types ofcoverage via different paths, depending on previous answers. and this approach is cognitivelyeasier for respondents which should result inmore correct answers. and, finally, we changed froma household level design to one that helps us capturehealth insurance coverage

for all members ofthe household. we ask, "who else in thehousehold had that plan type," and ask about all householdmembers by name to address gaps in household coverage. further, the cpsincludes new questions to measure marketplaceparticipation as well as additional questions on employer-sponsoredinsurance offers and take-up. and we revised the questions

on the medical out-of-pocketexpenses. the general flow of thequestionnaire begins with determiningcurrent coverage, then moves through sections onplan type, months of coverage, and additional householdmembers covered by the plan, iterating throughthese questions, checking for gapsin additional plans. once the instrument hasdetermined the insurance status of a person for the entireprevious calendar year

and all the insurancetypes, it then moves on to the remaining questionsin the health insurance section. rather than going through theentire instrument mechanics now, i'll just highlight howthe beginning works. as i mentioned, the newquestions capture both current coverage as well aspast year coverage. they begin by askingthe respondent about his or her own coverage. this is most salient

as the respondent ishopefully knowledgeable and it's easier toremember coverage you have at the time of the interview. this acts as an anchor beforeasking about past coverage. if they have current coveragethey're then asked what type of coverage and thenif it started before or after the prior yearsuch as january 1, 2013, with follow-up questions to determine themonths of coverage.

if they don't have any coverageat the time of the interview, they are asked ifthey had any coverage in the previous calendar year. then we ask who elseis covered by the plan, at what months theywere covered, whether they had the samemonths as the other people in the household ordifferent months. we also ask if anyone outsidethe household is covered by their plan, such as a childliving with another parent.

this is a simplifiedillustration of the complex and detailed surveyinstrument we have implemented to measure a very complex and changing healthinsurance environment. in summary, the cps providesmore than three decades of health insurance measurement. multiple surveys offer healthinsurance coverage measures with different uses such asanalysis by economic well-being, by geography, by transitions.

federal statisticalagencies work continuously to improve data collection,to improve our understanding of these data, and toimprove the reliability of our estimates. changing a survey takes yearsof research and testing. we are very cautiousabout making changes. these cps improvements willbetter measure health insurance coverage for theprevious calendar year, thus providing astrong 2013 baseline

to measure future changes inhealth insurance coverage due to the affordable care act. and here is my contactinformation. and now we'll hear fromdr. stephen blumberg from the national centerfor health statistics. [waiting on next speaker] well, good morning. and now we turn to the nationalhealth interview survey. to reiterate a little bit aboutwhat charlie rothwell said

when he initiallydescribed the nhis, the national health interviewsurvey is the principle source of information on the healthof the u.s. population. it provides estimates for monitoring progresstoward public health goals and for addressingspecific issues of current public healthconcern including, of course, the health insurance coverageof the u.s. population and its relationshipwith health status

and healthcare access and use. like the cps, the nhisis a household survey of the civiliannon-institutionalized population conducted by interviewersfrom the u.s. census bureau. the nhis, however, is across-sectional survey which means that we generallyinterview each family only once. interviewing is continuousthroughout the year with the goal ofcompleting interviews in at least 35,000households annually

and often more iffunding permits. the basic structure of the nhisconsists of three components: a core family questionnaire,and then questionnaires for one randomly-selected adult and one randomly-selectedchild from each family. the family core questionnaireis where all of the questions about health insurancecoverage are located. these questions are askedfor all family members and the respondent is a familymember who is knowledgeable

about the general health andhealth insurance coverage of all family members. the sample adult and samplechild questionnaires then are used to collect the majority ofinformation about health status, access, and utilizationthat can be linked with the health insurancecoverage data. now the nhis has been collectingdata continuously since 1957. questions about thehealth insurance coverage of family members havebeen included since 1959.

now back then, of course, the coverage options were morelimited than they are today. remember, back then, medicareand medicaid had not yet come into existence as we knowthem, so the questions asked about insurance that pays thebills for hospital visits, house calls, and office visits. yet even then there was concern that health insurancewas not well understood by some respondents.

so, yes answers were followedby questions about the name of the health insurance plan. there were two reasons thatnhis asked for plan names. first, the intent was touse the question to identify and exclude single-serviceplans such as those that covered onlydental or vision care or workplace accidents. second, the goalwas to distinguish between persons covered by bluecross and blue shield plans

and those not coveredby blue plans. the nhis has continued to monitor health insurancecoverage since 1959. the monitoring was periodicuntil 1968, then every two years until 1986, and annuallysince 1989. now, of course, the coverageoptions have expanded over the years from medicareand medicaid to hmo's, tricare, and other managed care plans, to the children'shealth insurance program,

and most recently, theaffordable care act. . but the basic approachof the nhis, that is asking about coverage types and thenasking about plan names in order to properly categorizecoverage types or to correct the initialresponse, remained the same. the last time that the nhiswas redesigned, was 1997. since 1997, the healthinsurance section of the family core has begunwith a general question about whether anyone in thefamily is covered by any kind

of health insurance or someother kind of healthcare plan. if so, then we ask whatkind of health insurance or healthcare coverageeach family member has. on this slide you can seethe various coverage types in the right-hand column. at the bottom of that columnis no coverage of any type which helps to identifyuninsured persons who live with family members whodo have health insurance. for each type of coveragethe nhis then asks a series

of detailed questionsabout the coverage. these questions are asked on aperson basis for public plans, and on a plan basisfor private plans. examples include questionsabout how the plan was obtained, who pays for it, whether it'sa high deductible health plan, and whether it hasmanaged care features. and just as was done back in1959, we collect the full name of all private and public plans, preferably from ahealth plan card

or other communicationfrom the health plan. finally, for thosewithout coverage, we confirm that they don'thave coverage and then ask about how long it has beensince they last had coverage, and why they do not havehealth insurance coverage now. now, as was the casemore than 50 years ago, we still recognize today that health insuranceis a complex topic. some inconsistencies insurvey response are expected.

therefore, before producingstatistics on coverage, the nhis looks at theresponses to the entire battery of insurance questions. if follow-up questionsclearly suggest that the original coveragetype reported was incorrect, the follow-up questions are usedto assign the coverage type. this evaluation generallyleads to corrections for only a few percentof respondents. where it does, it is generallythe plan name that leads

to a reclassificationfrom insured to uninsured or from one coveragetype to another. we use automated string searchesof the private plan names to identify and exclude singleservice plans from coverage. we then use manualcoding of the plan names to correct the dataon type of coverage. this coding is facilitatedby a list of plan names that is developed, maintained,and updated annually by nchs. this slide lists the manysources of information

that are consultedto maintain this list which today includes morethan 4000 plan names. following the evaluationand coding process, persons are classified into oneor more of 10 coverage types. the variable namesand descriptions on this slide are drawn straightfrom the final data files. it is possible for thissame person to be covered by both private andpublic plans. and you will see inmost of our reports

that if you add togetherthe percentages of persons uninsured, privatelyinsured, and publicly insured, the sum will slightlyexceed a hundred percent. now, 2014 brought a new sourceof coverage, the private plans that were obtained through thehealth insurance marketplace or state-based exchanges. yet among our potentialrespondents we expected that there wouldbe much confusion about whether exchange-basedcoverage was private or public.

at the end of last year andthe beginning of this year, nchs fielded an online survey that was called the healthinsurance terminology survey. it was fielded usingan opt-in online panel. and i'm not suggestingthat any specific estimates from this survey area precise reflection of any specific population. but the survey madeit clear that plenty of people were confused.

so we asked whetherit was true or false that the affordable care actcreates a new government-run insurance plan. the correct answer is false. the aca does not create a newgovernment-run insurance plan. but only about a third ofrespondents gave us that answer. another third incorrectlythought that the aca does createa new government-run plan. and a third were not sureof the correct answer.

. if some people think that their exchange coverage isa government-run insurance plan, then we expected that on oursurvey they would misclassify themselves as havingpublic coverage. therefore, we recognizedthat new questions to capture exchange-basedcoverage would have to be asked not only for persons with non-employment-basedprivate coverage, but also for persons whowere said to have coverage

through state-sponsoredprograms, other government programs,and other public sources. an inter-agency group, includinghhs and census bureau staff, developed the new questions. the primary question that wasadded to the nhis is at the top of this slide: was the planobtained through healthcare.gov or at the healthinsurance marketplace? and in states where the exchangewas given a specific name, that name was includedin the question.

follow-up questions askedwhether there was a premium paid by the family and whether thepremium was based on income. now we recognized that thesequestions still would not be clear to everyone. in the health insuranceterminology survey one in four respondentshad not heard of the health insurancemarketplace. in fact, one in three could notpick the definition of the word "premium" from a listof possible definitions.

so, just as the nhis hasalways used the entire battery of insurance questions tocategorize coverage types, the same was needed forcategorizing exchange coverage. now we worked withthe inter-agency group to develop a strategy fordoing this, and the plan that we developed is based onone major guiding principle: we trust what the respondenttells us about whether or not their plan was obtained through the exchanges unlessthere is clear evidence

from other questions thatthe respondent's answer was in error. so, if a person is reported tohave exchange-based coverage, that will be considered accurateunless the plan name provided identifies a company thatwe know does not offer exchange-based coverage, orif the plan name is unknown, the coverage is saidto be state sponsored or from another governmentprogram, but there is no premium.

similarly, if a personis reported to not have exchange-basedcoverage, that will be consideredaccurate unless the plan name specifically identifies aknown exchange plan name or exchange portal name. as you can see, the name of the plan is animportant consideration when classifying people ashaving exchange-based coverage. now, i realize that thisis a bit complicated,

so here's another way tolook at the same method for determining exchangecoverage. for all persons, regardlessof the coverage type that they tell usthat they have, if the specific plan name theygave us is an exchange plan, they will be assignedto exchange coverage. so, if they tell us thatthey've got kaiser permanente: bronze 60 hmo in californiaor blue cross/blue shield of idaho silver choiceppo, they will be assigned

to exchange coverage regardlessof what else they might say. similarly, they will beassigned to exchange coverage if they said they had adirectly purchased private plan or a state-sponsored orother government plan, and they provided anexchange portal name or they said they obtainedthe plan from the exchange and provided the nameof a company known to offer exchange plans. but if the plan name isunknown or not collected,

then we don't haveas much information to drive decision-making. if the plan was directlypurchased and was said to have been obtained from thehealth insurance marketplace, then it was assigned as such. but if the plan was saidto be state-sponsored or from another governmentprogram, then there had to be a premium associatedwith the plan for it to be assigned asexchange coverage.

now this decision was made outof an abundance of caution. most medicaid and other publicplans do not have premiums; but most exchange-basedplans do. now, because we do notassign exchange coverage to public plans that donot have premiums and for which the plan name was unknown, we limited how often we mightincorrectly reclassify public coverage to private coverage. in the nhis all individualswho are classified

as having exchange-basedcoverage will be considered to have private healthinsurance coverage regardless of whether they were reportedto have obtained that coverage from a private or public source. so, as you can probablytell, this process for determining exchangecoverage is complicated yet conservative, andwe've posted more details about this plan online inthe special topics section of the nhis website,and i encourage you

to go take a look at it there. well, my time's almost up. let me close by highlightinga few strengths of the nhis healthinsurance data. as charlie rothwellnoted earlier, the nhis data are collected inthe context of extensive data on the health andhealthcare of the individual. these coverage data reflectcurrent coverage at the time of the survey and becausethey've been collected using the

same general approach since 1997observed changes in coverage over time can beconsidered reliable. we collect extensive follow-updata including plan names to help us verify publicand private coverage. and, finally, as jennifer madanswill soon explain, we produce and release our nationalhealth insurance estimates on a quarterly basis. and we have sufficientsample sizes to permit annualcoverage estimates

for a majority of states. but, before jenniferdoes that, tori velkoff from the census bureau will talk about data releaseplans for the cps. [waiting for next speaker] thank you, stephen. good morning. i'm going to giveyou a quick preview of what the censusbureau plans to release

from the 2014 cps asec. this year, the cps asecincluded summary designed income questions as well as the redesigned healthinsurance questions. i'm going to review what willbe coming out using the old and new questions and when. before i talk aboutthe releases, i need to explain a bitabout the implementation of both the redesignedincome questions

and the redesigned houseinsurance questions in the cps asec. after that, i'll talk aboutour upcoming releases. as jennifer said, the censusbureau did a lot of research and testing on thehealth insurance questions over the last several years. we were also testing someredesigned income questions around the same time period. in 2011, we did a cognitivetest of these income questions.

we tested both theredesigned income and the redesignedhealth insurance questions in the 2013 asec content test. after that test, weincorporated the new questions into the 2014 cps asec whichhas a reference year of 2013. how we implemented thenew income questions and the new healthinsurance questions differed. for income, we used asplit sample approach. in 2014 we had about98,000 addresses

in the full cps asec sample. we asked the newincome questions of about 30,000 ofthose addresses. the remaining 68,000addresses received the standard income questions. we needed the splitpanel design for income because it preserves the timeseries and provides a bridge between the old andthe new series. the cps asec is the source

of the official u.s.poverty estimate, so a consistent timeseries is a necessity. and the best way tomake improvements and create a bridge is totake a split panel approach. the time series for healthinsurance is also important, but knowing there wereother data sources out there in health insurance, specifically theamerican community survey, and knowing we needed avery solid baseline for 2013

with the new healthinsurance questions, we decided to ask the redesignedhealth insurance questions for the full sample. we needed to establisha baseline in 2013 and we wanted this baseline inplace before the major effects of the affordablecare act took effect. and we can use this2013 baseline for comparisons withfuture years. and only a full asec sampleprovides reliable estimates

for small groups, some ofwhich may be most affected by the affordable care act. this slide gives you a visualof how this was implemented. again, 68,000 addresseswere selected to receive the standardincome questions, and about 30,000 received theredesigned income questions. the redesigned healthinsurance questions went out to the full sample ofaround 98,000 addresses. again, the splitpanel for income

and poverty preserves the timeseries and provides a bridge and the full asec sample for health insuranceprovides reliable estimates for small groups and establishesa 2013 baseline before the major provisions of the affordablecare act take effect. this fall we'll be releasingtwo reports: an income and poverty report and areport on health insurance. these two reports, the sourceof which is the 2014 cps asec which refers to calendaryear 2013.

for the reports on income andpoverty and health insurance that we're releasingin september, we chose to use the samplebased on the 68,000 addresses. we did this for acouple of reasons.income and health insurance are veryclosely related so we wanted to have a consistentset of income questions for the health insurance report. and were still evaluating theredesigned income questions. so were taking aconservative approach

and using the sample based on the 68,000 addressesfor both reports. this sample is nationallyrepresentative of the total u.s. population. as i said, we'recurrently evaluating the new note that health insurance andincome are processed together, so we have completedthat evaluation. we will put out apublic use file that will be basedon the full sample.

this file will be releasedin january of 2015. for next year, when we releasethe 2015 health insurance, we will plan to use thefull sample as the baseline for the 2013 partof that report. when we release the healthinsurance report in the fall of 2015 for calendar year 2014,we will have the full sample for both the baseline2013 and 2014. the comparisons of thesetwo years will enable us to show the impact ofthe affordable care act.

next month, on september 16th,we'll be releasing two reports. both reports will bebased on the sample of approximately68,000 households. for income and poverty, the report will be verysimilar to last year. we'll look at income and povertyby characteristics such as age, sex, race, and hispanic origin. we will continue to presentthe time series for income and poverty in this report.

for health insurance, we'lllook mainly at 2013 data. as this is a new baseline year,there will not be comparisons to previous years of cps. we will, however, look athealth insurance coverage, coverage by type, and examinehealth insurance by age, race, and hispanic origin, andother characteristics. we will use data from theamerican community survey to provide trends inhealth insurance coverage, and we will also usethe acs data to look

at health insurancecoverage at the state level. we also plan to have a webinaron the 16th when the reports and data are released. in that webinar we will goover the results of the income and poverty report and thehealth insurance report. we will have subject matterexperts in the webinar who can answer questionsabout the release. we also plan to releasedetailed tables on our website for income, poverty,and health insurance.

we will release a publicuse microdata sample file that will be based on thesample of 68,000 addresses. this file will havethe same variables as last year's public use file. as jennifer mentioned, as part of the redesigned healthinsurance questions, we begin by asking if theperson is currently covered by health insurancebefore we begin asking about coverage inthe prior year.

we will be releasing a measure of current coveragebased on this question. these estimates of currentcoverage will be included with nchs' release of data fromthe health interview survey. nchs will release theseestimates on september 16th. we are releasing theseestimates with nchs to provide a comparison to theirfirst quarter health insurance coverage release. in addition to the itemsthat we're releasing

on september 16th, wehave many related releases and events later thisfall and next year. the week of september 8th, we'll be having ourpre-release webinar for the acs one-yearestimates release. we will have peopleparticipating in that webinar to talk a bit aboutthe new cps questions. on september 18th, the one-yearacs estimates will be released. these data will beembargoed on september 16th.

in mid-october we will releasethe supplemental poverty measure, also basedon the 68,000-sample which is the same data used inthe income and poverty report and the health insurance report. we will continue our evaluation of the redesignedincome questions and plan to release some results from this evaluationin january of 2015. at the same time,january of 2015,

we plan to release aresearch public use file which will be basedon the full sample. we will also continue to evaluate the redesignedhealth insurance questions and plan to release theresults of this work in the summer of 2015. you can find more informationon income and poverty at our website, census.gov. income and poverty are very easyto get to from our home page

as they have a topic page andthis is simply a screenshot of the income andpoverty topic page. you can also findmore information on health insuranceon census.gov. again, this is a screenshotof the topic page for health. here's my contact information. i thank you very much. i'm now going to turn it overto jennifer madans from nchs, and she will talk abouttheir upcoming releases.

thank you, torrey. okay. so i'm going to giveyou a very brief overview of the planned nchs releasesof health insurance information from the health interviewsurvey. as stephen mentioned, the hisis in the field continuously with the final data for the yearbeing released about six months after the end ofdata collection. so the 2013 data releaseat the end of last june. but in addition to beingin the field continuously,

the his is also based onrandom monthly samples. and this has given us theability to analyze data for months or combinationsof months. in 1997 the his changed froma paper and pencil interview to a computer-assistedpersonal interview. and the processingchanges that accompanied that switch allowedus to take advantage of these monthly random samples,so we were actually able to release the estimatesbased on part of a year.

and this was done through anew data dissemination program called the earlyrelease program. the quarterly earlyrelease reports and the preliminary microdatafiles that are produced through this mechanismsare done prior to final processingand weighting. and so they are consideredpreliminary estimates, but they do allow us to providevery early access to our users on these key indicatorsincluding health insurance.

there are various componentsof the early release program. every three months the earlyrelease program produces two reports. one report has informationon 15 key health indicators. health insuranceis one of these. the report was first releasedin early 2001 and had data from 1997 through june of 2000. then there's a secondseparate report on health insurance coveragewhich is much more detailed.

that was first released inearly 2002 and had information from 1997 throughseptember, 2001. now, along with that release,we also have a set of web tables that are releasedat the same time which includes thequarterly estimates that are not in the report. and i'll say a little bitmore about that later. and actually throughout the yearwe sometimes post some special tabulations on the web aswell, but not quarterly.

and also along with theearly release reports, there's a preliminarymicrodata file that is released that contains the elements thatare used to create that report. there are also someperiodic reports on special health-related topics that are releasedthroughout the year that are based on sub-year data. in the past we've done reports on problems paying medicalbills, sources of coverage,

and healthcare access andutilization for young adults, and emergency departmentuse for adults. we intend to update someor all of these reports over the next several years. and, finally, thereis a bi-annual report on wireless substitutionfor landline service. now, other nchs dataproducts such as data briefs and national health statisticsreports also provide information on health insuranceand healthcare.

those tend to only be basedon the full final year data, and those will come out atvarious times over the year. now, all early releaseproducts are only web-based. we don't print any ofthem, but they're easy to find on the website. the easiest thing to do is to go to the health interview surveywebsite and the link is here. go down to the earlyrelease program where the arrow is pointed.

it will take you to thepage for early release where it lists all thedifferent products. just link on the insurance one. that will take you to a list ofall of the insurance reports. pick the one you want, andyou'll get to the report. the format and thecontent of the report -- we try to keep thempretty constant. we think that's easierfor the users. they'll kind of look like this.

there's a highlight section,some introductory material, a lot of results,tables, and some graphs. so in terms of therelease schedule. as we said, the quarter releasecomes out about six months after the end of datacollection, so they come out in september,december, march, and june. after the first releasein september, the reports become cumulative, so the december reporthas information

from january through june. and the march report, fromjanuary through september, and then the finalreport has the full year. however, if you want aspecific quarterly estimate, so for example, in december, ifyou want the january to march and the april to june estimates,those are what you can find on those web tables thataccompany the report. so you can actuallylook a quarterly change on a quarterly basis over time.

we do the cumulative -- our reports, could weget larger sample size, estimates become morereliable, and we can say more about change over time. now, because the survey againis in the field all the time, it's in the field for thatentire quarter, any estimate for that quarter is really someaverage over that time period. when things don't changemuch over time, that's nice. that kind of tells you somethingabout the whole period.

when things are changing,you really need to think of that estimateas kind of focused or centered on the midpoint. so for the september release,which is going from january to march, we think of it as being centeredaround mid-february. again, the content ispretty standard across all of the health insurance reports. you get the percent and countsof persons who are uninsured

at the time of the interviewwho were uninsured at least part of the year and who areuninsured for more than a year. . and this is done by age group and this is a time trendtable in the report. however, not all year since1997 are in every report. the tables were gettingvery, very big, so we started selecting certainyears, but the old reports are on the web, and you canalways go in and fill in the years thatyou might want.

also get the percent of personswho were uninsured at the time of the interview, the percentwith public health coverage, the percent withprivate health coverage, by age and poverty status. again, over time. and by race ethnicity over time. and by age and sex, butthat's just for the period of that release, so it'sjust for that quarter or for the cumulative quarter.

and then the percent ofadults uninsured at the time of the interview with publiccoverage, with private coverage, by education, by employmentstatus, and by marital status, again, for the time periodcovered by that report. there's also informationon the percent of persons in high deductible health plans, both without a healthsavings account and in a consumer-directed plan. and while the estimates areprimarily for the whole nation,

some sub-nationalestimates are provided. estimates are providedfor nine expanded regions which are very similar to thecensus divisions, by state, medicaid expansion status, andby health marketplace type. so whether it's a statemarketplace or the federal. and starting in december,we start releasing estimates for selected states andthe number of states that we have enoughsample to release estimates on increases over the year.

and, of course, starting withthe september, 2014 report, we will give you the percent andcount of persons under the age of 65 who have exchangebase coverage. and, again, that's centeredon the february, mid-february, and so does not coverthe entire time of the enrollmentperiod for the exchanges. the next release, which willcome three months later, will cover that entireenrollment period. and, again, as the yearprogresses, we'll be able

to make estimates forpopulation sub-groups as sample size increases. we mentioned that the estimates out of the early releaseprogram are preliminary, primarily because they'rebased on a streamlined version of processing procedures. the procedures arequite automated. we don't do anywhere near asmuch of the manual evaluation as we do on the final report.

and it's based onthe prior year's list of health insurance plannames, so it's 4000 names that stephen mentioned. however, we did update the listwith the latest exchange plans for the september release. the early release alsodoes not distinguish between the individualtypes of public programs. that comes with thefinal release. and we continuallymonitor the differences

between the preliminaryestimates and the final estimates whenthe final report comes out. and they tend to be small. it's usually within.1 percentage points for the percent uninsured. and .1 or .3 percentage pointsfor estimates of private and public coverage and thisis something that's [inaudible] on every year. and the final product is themicro data file that's released

along with the reportson a quarterly basis. in order to get these reportsout quickly and the file out quickly, we have todo it before the files go through the very rigorousdisclosure review processes that we have to do beforewe release any micro data to the public. and because of that, we canonly release these files through our researchdata center. there are multiple waysto access these files.

there is the datacenter in hyattsville. there is one in atlanta. but there are also the 12census burea data centers where you can getaccess to nchs data. but there is alsoremote access system. we actually don'teven have to come to lovely downtown hyattsville. you can access the datafrom your own office. the website listed here willgive you information about how

to make proposals to get accessto the data through the rdc. if you're interestedin announcements about the early release programor any of the his data releases or any of the data collectionactivities, i encourage you to go to the website and get on the list serve.ithink we're now going to take a very short break --yes, maybe five to 10 minutes? say five to 10 minutes? fifteen! get back at 11:15and then we will hear

from our distinguisheddiscussants and then there will be aquestion and answer period. thank you very muchfor all of us. [ applause ] [break until ] okay, i think we'll get started. it is my pleasure tointroduce our two distinguished discussants both of whom havea long history of expertise

and work in this area. the first speaker willbe michael j. o'grady, who is the principal ofo'grady health policy, llc which is a privatehealth consulting firm and he's also a seniorfellow at norc at the university of chicago. dr. o'grady's work concentrateson health policy research and analysis for publicand private organizations. his current research isconcentrated on the interaction

between scientificdevelopment and health economics with a particular concentrationon diabetes and obesity. he served as the chair of thenational academies of sciences, institute of medicine panelmeasuring medical care risk in conjunction with the newsupplemental income poverty measure and is currently amember of the national academy of sciences policy round table of the behavioraland social sciences. from 2003 to 2005, he was theassistant secretary for planning

and evaluation, aspe, at hhs where he directedboth policy development and policy researchacross the full array of issues confrontingthe department. prior to his role asassistant secretary, he served as the senior healtheconomist on the majority staff of the joint economiccommittee of the us congress. and for several years, hewas the senior health adviser to the chairman of thesenate finance committee

and helped seniorstaff physicians with the medicare paymentadvisory commission and the congressionalresearch service. now, in order to kind of giveus enough time for questions, i'm going to also introduce oursecond discussant, gary claxton. gary is vice president ofkaiser family foundation. he is also the director of thehealthcare marketplace project and co-director of the programfor the study of health reform and private insuranceat the foundation.

mr. claxton, oh i'm sorry, the healthcare marketplaceproject provides information, research and analysis abouttrends in the healthcare market and about policyproposals that relate to health insurance reform andour changing healthcare system. the program for thestudy of health reform and private insuranceexamines changes in the private insurance marketunder the affordable care act as federal and state policymakers implement provisions

of the health reform. prior to joining thefoundation, mr. claxton worked as a senior researcherat the institute for healthcare research andpolicy at georgetown university. from march 1997 untiljanuary 2001, he served as the deputyassistant secretary for health policyat the department of health and human services. previous positions includeserving as a consultant

for the lumen group,a special assistant to the deputy assistantsecretary for health policy, at the assistant secretary forplanning and education, planning and evaluation, aninsurance analyst for the national associationof insurance commissioners, and a health policy analyst for the american associationof retired persons. we thank both of themfor joining us today and i'll hand this over to mike.

thank you very much. i'd like to give you a littlebit of the policy context here and a little bit ofthe history as well. it's important to knowabout kind of, you know, those of us who get into thetechnical aspects of this, it's important we want to getthe most accurate numbers. we want to see these go forward. but it's also important to know that this is notthe end in itself.

this is the means to an end. that this data, this sort ofinformation is used very heavily in very serious policy-making. and the accuracy ofit is very important, beyond simply youwant to do a good job and have an accurate survey. so i want to give you a little,as i say, a little political and policy historyof what's going on. back up 10 years ago,in 2004, this is --

i was an assistant secretaryin the bush administration. we had successfully passedthe medicare drug benefit. it was on its wayto being implemented and the bush administration waskind of turning, exploring kind of where did theywant to move next. they were comingup on the election. it was going fairlywell for them. they wanted to think about what if they got a second term wouldbe one of their big pushers?

and this question ofreducing the number of uninsured was being pushed bythen secretary tommy thompson. so the approach was much moreincremental, i would say, in terms of what we saw laterwith the coming out of the aca. we had in the medicaredrug benefit, been given first thebudge that we had to work with, 400 billion. and so we had built,designed kind of benefits and who was going to be coveredand how you were going to do it,

kind of, you know, kindof working in to that. we couldn't go over 400billion without really a hell of a good reason to go over it. really, that was sortof our marching orders. so as we approached thisone on the uninsured, what were the options youwanted to take to the president? what did you want totake to the secretary? how did you want to thinkabout those sorts of things? we would -- we're thinking ina very incremental approach.

our political judgmentat that point was that there wasn't enoughconsensus either on the amount of money or on who shouldget government coverage, that it would coverall the uninsured, whatever that numberhappened to be. but whatever that happenedto be, we didn't see that it would be all there. and we wanted thesemore accurate estimates so we could sliceand dice and think

about different subpopulationswho were the greatest need. not that if you hadenough money, you wouldn't cover everybodybut you had people who were sort of at the front of the line, those most desperatein many ways. so this is basicallythe way we were sort of conceptualizing things in apolicy context at that point. we were trying to identifykind of what your variables and what your keysubpopulations.

you weren't really sure kind ofhow much money you would have and how far it would go intothat matrix but you had -- we were looking at it mostly interms of time without insurance. we knew that there were somepeople who were just, you know, i mean the college kid whograduates and is uninsured for three months before hestarts his first job, a concern but not top of the list,if you have limited money, and limited time, andlimited political currency to get them covered.

the chronically-ill personwho's been uninsured for months, if not years, that's somebodyprobably moves up to the front of the line in termsof thinking about this. people who were or some peoplewho weren't seeking insurance as we've kind of seennow as well, can afford, didn't necessarily butit was a pricing thing and they were peoplewho were desperate. again, that kind of triaging. you're going to prioritizewho you are and then in terms

of citizens, non-citizens herelegally and then illegal aliens who are kind of third in line,if you want to think about that. so meeting in the white house. this is 2004, exactly10 years ago. you have a fellow at that point, the white house staffer was afellow named doug badger who has to start his -- thisis the roosevelt room. it's got all this history to itand his first slide comes up, he comes up and thisis what it is.

mr. president, thereare four surveys. the numbers range from19 million to 45 million. the percentage of americansuninsured or people living in the united states uninsuredis roughly 7% up to 15, 16%. now, policy makers are usedto dealing with uncertainty. this is not physics. they understand that. but this sort of arange of a double or more is really a heavy lift

for most policy makersto kind of go with. if you told me thatthere were, you know, it was 30 to 28, no problem. they can live with that. so that notion of what wasgoing on, he went on further to explain that the medianormally uses the $45 million number because it's a bignumber and they like it and they know cps more than theyknow things like naps and some of these other surveysthat are going on.

and this situation,our ability to think about how we would sliceand dice and kind of get down to these key subpopulationsif we would put priorities for some and not -- you know,kind of second range for others, kind of shaky, pretty shaky. now, as i sat there,it was clear in my mind because i was kind of, you know,what we call in the business, the whisper dweeb, the guywho sits behind the secretary and kind of, you know,whispers in his ear and slides

in pieces of paper and whatnot. i'm thinking, i bet some poordevil sat here in 1993-1994 and said, "president clinton,there are four surveys out there and it goes, you know, andthe numbers were different but the problem wasstill there." and so part of that ideaof what the thinking was at that point was this, youknow, this has got to change. we can't keep goingin this direction. there's got to at leastbe some move to think

about how these thingsgo forward. so step one, you heardit mentioned before. i think jennifer brought up themedicaid undercount problem. so what we were also seeingsimultaneously was states -- for any of you who have everworked in medicaid data, the states for decades had theworse data that you can imagine. it was just horrible,their administrative files, their claims, who waseligible, et cetera. they finally, by about 10years ago, they were starting

to get a little more modernized,better systems and we started to see this pattern wherethe states were telling us, you know, you would seea cps member that said, "2.3 million -- " and i'm makingthat up, "medicaid in the state of california," andyou get this call from sacramento going,"i don't think so." you know, it's not, you know,they had much different numbers and it was pointing in thedirection of undercount. and any of these things whenyou're trying to improve,

you don't necessarilyknow going in. is this an over count,an undercount, what it's going to be. we also heard thingswhich i'm not going to talk tons about today. same kind of thing about employment-based healthinsurance and not, again, was that being overcounted, undercounted? but it's all a question ofgetting to more rigorous data,

more accurate datathe best you can. so what happened waswe did fund with acf. acf, who don't -- for those ofyou who don't speak hhs speak, it's the agency forchildren and families, basically the welfareside of hhs. and aspe which ihad, we funded -- i ran to kind of gothrough the california data, go through the administrativerecords and find. and certainly, we foundthat problem was there.

we then took the next step andwe funded two different teams. you know, one of theproblems in terms of government policy making and policy research isyou really don't have a clinical trial. you know, you don't have acontrol in an experimental -- one thing you cando to kind of proxy for that is you taketwo independent teams of researchers.

you send them off. they know about each otherbut you have a little bit of a firewall between themand you see what they have. much of policy debate,certainly in healthcare policy, is often it comes down toa methodological food fight between actuaries andhealth economists. if you remember thedrug benefit, the aca, anything going backthere, the cms actuaries, the medicare actuaries kind ofgo, "i think it's 500 billion,"

and the health economistat cv are going, "i think it's 400billion," and you know, they go over everythingbut it comes out to that. so this was my thinking at thetime was i'd set up one team that was actuaries, one teamthat was health economist. actuary research corporationis actually the consulting actuaries to cms, tothe medicare actuaries and the urban scienceinstitute had kind of the top micro simulationmodel in terms of thinking

about these sorts of things. so they both went out totry and make estimates of what this undercount was. and as you can tell frommy earlier comments, we were interested notonly in the overall number but could you identifykey policy importance of populations. the actuaries cameup with an estimate of 9.1 million was thesize of the undercount;

3.6 coming out of the economistsout of the urban institute. we didn't take that as gospelor gold standard but at least, it felt like it gave us a range of what we thoughtwe were dealing with. non-citizens, theywere pretty close. you can see in termsof what was going on. eligible for medicaid, anotherproblem with this is where, you know, was there a certainpercentage of people who, if they went in and applied,

would be eligible,could be signed up. so that was a different problem than offering themhealth insurance. they were already beingoffered health insurance. you just couldn'tget them in the door. 300% of poverty candidly in ourdiscussions, we weren't thinking of subsidizing anyonereally over 300% of poverty so that was sort of anotherkey population to sort of think about what was going on this.

childless adults, that wassort of the key population at that point because theway medicaid was being done, they didn't reallycover childless adults. that got changed during the aca. and then the remaininguninsured. so we were trying to get thatfeel but they were saying that the estimates that hadbeen 45 million were maybe 35, maybe 37 in that range. now, we didn't stop there.

i mean, because as you can tellfrom the earlier presenters, there's all thesedifferent things that go on. you want to make sureyou've got it right. so part of it wasjust as convenient. we brought the staffs to thefour different surveys together. candidly, that was somethingthat i kind of hosted at aspe and i expected it to be quitea herding catch, sort of, i have to say, goinginto the first meeting. and i found that iwas absolutely wrong.

the staffs of the four surveyswere kind of dying to talk to each other and comparenotes and how do you do this and the conversation was good. and so, it was much more -- i thought it would be kindof just protect my turf. and that's not what i found. outside survey and health policyexperts, we brought them in. there was a number of thingsthat were kind of going on out there in the academicliterature that candidly,

i was not convinced by, youknow, and it kind of fell into the category of well, census probably didn'tdo the question right. and the people answering,well, the american people kind of don't know how toanswer the question. it did seem a little dismissiveto both the census bureau and to the americanpeople candidly. but you know, i wantedto hear what they said, wanted to see what they hadwhen they got a chance to talk

to these staff who said,"well, maybe it's maybe but maybe it's re-waiting. maybe it's kind ofquestion wording. maybe it's length of recall,some of these other things." and also brought in the main --and this is you have to make -- my focus at this point was whatcould be used in policy making? so i brought in themain audiences for this, the actuaries atcms, the tax people at treasury, omb, cbo, crs.

and again, how did theydeal with this uncertainty? what were they doing? and what was going on to sum up quickly was these were verysophisticated users of this data and they would pick and choose. so you would see hopefullynobody from treasury here but you'd see a treasurydocument but you understood. they would sort of say, ifthey needed to know something as they do with filing andthe way these things work

because there were a numberof tax credit provisions for the uninsured at thatpoint, they needed to look back. so they would use the maps because they gota two-year panel. so they would take the percentexchange off the maps and like, apply it to a cpsnumber or apply it to, you know, a his number. but they were sort ofthis, i mean, you know, as the methodologyi'm sure you know,

but if the president is askingand you'd say what happens if we did an 18-month look backand then decided, you have, you know, you're expectedto come up with a number. so consensus and cooperation,certainly, you know, the main thing that i found wasthat there was a lack of funding for much of this kind ofmethodological research to allow you to do that. and that was certainly somethingthat aspe could provide. so you heard mention ofshadac before, the university

of minnesota folks that do this. they were doing it. they started out with onecomparison of questions of methodologiesacross the four majors on the health insuranceestimates. snacc was a project; ithink it stands for shadac, nchs, aspe, census and cms? so just getting a littlecute with the names there. but that was basically togo out and start to figure

out could you methodologicallyactually link survey individuals -- you know, individuals in -- who took a survey with theiradministrative records? so you would see how theyanswered the questions but you would say, "no, the state of maryland saidthey did have medicaid for the last 18 months." and how are they doingthat in getting to that? and there's at least five or sixdifferent kind of sets of that

and it's a greatkind of resource now. it's getting a littleold but that idea of if you really wantedto see these linked files, it's a very powerful tool. mathematica, dr. chika heredid a great one on income. again, going across the four. now one thing tokeep in mind here, we were talking about uninsured. we were talking aboutquestions of subsidies.

we were talking about whowas already really eligible for medicaid. if you either had an over countor [inaudible] on your income, you were again going to beinto not as much trouble as if you had an over or anunder on health insurance, but you were not in a strongposition on policy making. if you went forward witha provision that said, "we think it's going to workand can cover everybody 300% of poverty with a slidingscale," and you've got

that number wrong and theincomes are really much higher, the bill ends up being muchcheaper than you thought it was. which in many ways we had withthe medicare drug benefit. that turned out on someof this, not so much. i mean, there were moreseniors that's turned out to be much more aggressiveconsumers than we had predicted. but that sort ofthing, so income is -- if it's not yourfirst priority, boy, it's a close secondon these ones.

conclusions, it was quiteclear from the start that this might takea very long time. we were a part of it. we were going to outsideacademics and you know when you go to academics,don't hold your breath. it's going to be a year or two or whatever beforethey get back to you. it takes them a while but it wasalso clear and so this notion that much of this stuffhas taken a decade to come,

i don't think any of us, who started at that pointare wildly surprised by some of those things. but as i said, as i satthere in the roosevelt room, i was sure my colleagues fromthe clinton administration, my counterparts had probablyfaced that and i know that much had beendone in between. and so it was timeto get started, at least to get started.

and on this question about kind of there's always this notionespecially if you're not that familiar with thepolicy in political world, to be a little concernedabout kind of political heat you might get. and candidly, in arepublican administration, we were already being accusedthat is this sort of an attempt to define away our problemand sort of say, "you know, if you came away with it,"so we were sensitive to that.

but if you do see thatthere's a more accurate, a more rigorous way to measurethese important questions, to get this data better,and you don't do it because of your concernabout political heat. it is, i would say,professionally irresponsible, close to professionalmalpractice if you sit there and you know thenumber is wrong, and you know you couldget a better number, and you don't do anything.

that's, you know, you geta little political heat. it'll go away in a week. but if, you know,if you sit there, we've got to improve this data. it's just too vital tothe policy questions that are out there today. thank you. [applause] i'm gary claxton with thekaiser family foundation.

i actually just havea few comments to make before there's timefor questions and discussion. the first comment iwant to make is i want to compliment the agenciesfor doing such a great job for not only making thechanges that needed to be made for all the research thatwent into getting ready to make the changesfor all of their care. but also for at leastwith respect to us, how open they have been andwe've been asking them questions

about this for anumber of months. we did a paper a littlewhile back to describe when information would beavailable to look at changes in the aca and all theagencies were very helpful in helping us understandthings, explaining things. so i think it's been areally transparent process and a really openand good process and obviously the resultslook very promising. in particular, i want to saythat the added focus in the aca

to transitions so we don't thinkabout coverage as a static thing but it's something that changesduring the year is really important and will help usunderstand things better. i mean, we had someof this with sip. sip is a wonderful survey. we use it a lot butcps is bigger and it provides state estimates and that'll be animportant addition. another important additionwhich i don't think has gotten

as much discussion today isthe addition of questions about x offers of employercoverage to the cps. a number of importantpolicy questions do revolve around whether or not someonehas access to coverage. in particular, whether or notyou're tax credit eligible. or -- and we also want tolook more at both the offers of employer coverage and thewage and hour information from the cps as we try to evaluate how the employerresponsibility provisions change

what's going on inemployer practices both for health insuranceand for work. this is an importantpolicy question. it starts next year and thiswill be helpful information. as i'll say in a moment, i'm notsure it's everything you need to know and sip willbe important there too. but it is a good addition. since it's a technical meeting, i thought i'd do a coupleof technical things.

mike was sort ofbig and i'm going to think small for a minute. i think the first, somechallenges still that remain -- and i don't know howmuch time i have -- the first relates to the fact that the initial openenrollment period extended late into march and into april. and that the big surge wasend of march and in april. and this was before --and this was after much

of the data collectionfor the 2014 sip and cps and also the firstthree months of nhis. in addition, for people whoapplied for coverage during that surge period, itprobably wasn't effective until may, maybe later. i'm not sure we know how well,how people who had applied for coverage butthey don't have it yet would answer someof these questions. i think we believe fromsome of the gallup results

that people are reportingthemselves as covered probably even beforetheir coverage took effect. but we don't know that soit's going to be a source of some ambiguity and thenprobably one will never actually know the answer to or maybea couple of years in 2016 when we can look back two years and said we'll maybe have somedata and i'll get back to that. so what's been -- so oneof the important additions to the cps is obviouslybeing able to look back

and track coverage to the prioryear because and in particular, you know, for 2013 to 2014,people really want to know, policy makers really wantto know how people changed. what did they do? what kind of coveragedid they used to have? are the new peoplewho got covered, you know, previously uninsured? did they move fromone non-group policy? did they drop employer-basedinsurance?

and unfortunately, we're notgoing to know that right away because many of the peoplewe can tie back will -- are the ones who were surveyedin january, in february and beginning of march. we're not going to be able to know how their ultimate2014 coverage ties back to 2013 through the cps. we will know that a yearlater when the sip comes out because we'll be able totie back two years of coverage.

but it's going to take a while. the other -- i mean, obviously,we're going to learn a lot when the his information,the early release comes out. from the private surveysthat are out there, i think we already knowa good deal about changes in overall levels of coverage. the private surveys are prettyconsistent in having, you know, changes that are of a magnitudeof some percentage points to make us think of seven,eight, nine million people.

they're all pretty different -- many of them aredifferent in terms of where they startand where they end. but their changes arepretty consistent. but what they're not verygood at is telling us about the coveragethat people have. there -- a matter of fact, some of them are notvery good at that at all. in terms of public versusprivate and types of public

and types of private, i know theearly releases will only sort of separate it intopublic and private but that will be a nice -- thatstill will be a nice addition to our understanding of what'sgoing on and the ability to look at states that expand inmedicaid and didn't just to separate groups will also bereally helpful in that regard. second point i want tomake and then i'll stop and let people ask questionsis that and which was pointed out earlier, and we take it fromsome of the surveys we've done.

we do a fair number ofsurveys of people as well, is that people don't understandtheir coverage very well and that particularly appliesto some of the newly insured because some of them havenever been covered before. they really haven't been coveredby anything private before. quite frankly, all this isreally complicated for us and for a person who can go to some place called themarketplace, it's brand new and when they come out of it,

some of them havepublic coverage and some of them have private coverage. it's not really surprisingthat they don't know sort of what box theyfit into very well. we also found thatthere are people who say that they have private coverage,that they don't have a subsidy or a premium or premiumtax credit but if you look at their income and you lookat their coverage history like they've neverhad coverage before

and they don't have any money. it's highly unlikelythat that's true. and it's not surprisingreally because you can go into a marketplace and they'llsort of tell you what you owe to enroll in somethingbased on your income and you may not understandall of the dynamics of that. so we're finding that peopledon't always understand that they're subsidized. i think the approach of askingthem whether their premium was

calculated based on theirincome is another approach that might work out andi believe that's one of the things that'sbeing done here. it also made me very happyto hear about all the editing that was happeningand the collecting of information offof insurance cards. and the fact that so much of these surveys collectinformation in person and are able to lookat documents

and use insurance names isa good way to help correct for some of these errors. the only and asking whether or not people pay a premium isalso an additional good piece of information. i just wanted to pointout -- make two points. one is the way that taxcredits work, there are people who can enroll in bronze plansand not have any premium. so for them, we're still goingto have some source of ambiguity

because their taxcredit is large enough that it covers the entirecost of the private premium. also some of the editingthat's being done based on planning makesa lot of sense. but i've spent a fair amountof time recently looking at rate filings frominsurers more than i ever wantedto again [laughter]. and i will say a lot of insurersare for the same plan both on and off the exchange and sousing the name may not be

as helpful as we firstthink it will be. well, we'll justhave to wait and see. final point i wantedto make was, as i said, adding the questions about-- to the cps about whether or not someone who is workingbut does not have insurance from that employer whetherthey were offered coverage is a good addition. for the policy reasons imentioned before, it's important to start to know that.

but i do think we need toknow more which is whether or not the spouse wasoffered coverage, whether or not the childrenwere offered coverage. now luckily, sip has thator used to have that. and hopefully, it still will. you may not know it quite asquickly and you can't tie it up to state estimates and do asmuch as you can with the cps. that's an important questionthat we're going to need to know more about and hopefullywe can figure out ways working

with these surveystogether to inform that. but overall, i think this wasreally an exciting meeting and i appreciate it. hi, my name is michael cook fromthe public information office of the us census bureau. we are now going to begin ourfloor discussions and questions. just some quick reminders, somehousekeeping notes for people who are watchingthis via ustream or listening on the phone.

if you could please dial1-800-857-4620 to ask a question and remember that your pass codewhich is the pass code is cenchs and we ask that youstay on the line until the operatorasks for the pass code. do not key in thepass code, okay? so, also another quick note. if you were lookingfor an electronic copy of the materials,if you navigate to the census bureau'swebsite, on the home page,

you'll see media advisoryfor today's event. on that advisory,you would click on it and that will directyou directly to the electronic press kit. inside the electronic press kit,you'll find all the materials from today's event aswell an archive version of this video, this event. so without further ado, goahead and commence and begin with today's questions.

and i'll take any questions fromthe floor first and for those in attendance today, we dohave a mike over to your right where you can askyour questions. i please ask thatyou use the mike so that the people listeningvia ustream can hear you and be part of the conversation. and we have our firstquestion and also i'd ask that you note youraffiliation if you could please. my name is sarah wheaton.

i'm a healthcarereporter at politico. and as far as the discussionabout figuring out what -- whether people have apublic or a private plan. how are you characterizing, mr.bloomberg, people who might be in the states that didalternative medicaid expansions where they are getting premiumassistance to buy health plans on the marketplace andthen in some cases, those people do actuallyhave a small premium payment. yeah, some of the moretechnical questions,

i may have trouble with, as i haven't been the onereally getting my hands dirty in the data. however, when it comes tosuch plans in those states, even though some of thatpremium assistance may be coming from public plan, if the planitself is private and obtained through the marketplace,it'll be classified as private with our survey. hi, my name is kitty smith.

i'm with the council ofprofessional associations on federal statistics. and the guy behind me may be thebest one to answer my question but for the sake of the-- it wasn't planned. this wasn't planned [laughter]. for the sake of the group, i'm aware that the medicalexpenditures panel survey, conducted by arc, is a subsample of the national healthinterview survey.

and what i'm curious about iswhether the questions asked of the panel, the meps panel about health insurance coverageare the same as what are asked on the nhis or different? and i could answer thatquestion [laughter]. i'm steve cohen from the agency for healthcare researchand quality. there has been tremendouscoordination in terms of trying to bring harmonization

to the questionsparticularly the enhancements to address the affordablecare act. but there is a bit moredifferences in terms of the venue of gettingthe data in terms of we're first asking questionsin our employment section and it's a panel survey as wellto get detailed information on all the household members. but there's been a number ofresearch pieces that we've done over the years, nchand arc looking

at coverage estimates going fromyear one to year two his to meps versus meps to meps because mepsis an overlapping panel design and generally, the trendsare incredibly resonant but they're not explicitlythe same questions. so in many ways, that's whyyou saw what mike o'grady put up in terms of amodest differential between the two surveys as well as there was a timedifferential. so hopefully thatanswered that question.

but to get to my question now[laughter], gary claxton pointed out the surge that came abouttowards the end of march and early april and the cpswill coordinate with nchs on the march estimates. cps, i'm sorry, his isvery rich in sample as well and in the first quarter, you do many socio-demographicbreakdowns. so it might be quite informative if you did a monthlyestimate for march.

i know you're going tohave all the estimates in another three months for,you know, the half-year period. but that would beincredibly helpful. is that somethingyou're planning? you're talking about a monthlyhealth insurance coverage estimate or simply amonthly exchange-based coverage estimate? well, both. if you could putout -- [laughter].

if you could have -- ifyou could put both of that, you could actuallycombine, you know, january and february and then do march. i think it would bequite informative. you probably getquestions on that front. >> i'm fairly certainthat a monthly estimate of exchange-based coverage at this point would notbe stable given the sample sizes available.

as for a monthly estimate of health insurance coverage,that may be possible. it's not part of our currentrelease plans but, you know, remembering that we dorelease the micro data file from which we producethe quarterly estimate, it would be possiblefor somebody to produce them amonthly estimate. i kind of agree with steven. i think it's probably notgoing to be stable enough

to really say anything about it. we certainly can look atit and if it turns out, it's worth putting out,that's where we would put -- we could put thoseestimates out on the website under that special tabulation. but the sample size islarge but not that large and when you breakit down to the month which is why we never put out months before,it's pretty small.

we can take a look at it. what we do going forward, ithink is pretty much open. well, that's very helpful. if i could just make onemore addition to the comments that gary made in termsof information coming on the changes that people havegiven what their coverage status was in 2013 and 2014, while mepswon't be there in september, by the winter, we will haveestimates from the first half of 2013 for the panelgoing into 2014.

so we could see whatthose transitions are and i know ren put out areport a couple of months ago but we'll be having nationalestimates on that front. so thank you. and one quick reminder beforewe have another question from the floor, for thosecallers that are on the line, if you could please pressone, please press one if you are desirousof asking a question. and our next questionfrom the floor.

hi, thanks. i'm bill o'hare with theannie casey foundation. and first of all, let mecongratulate all the presenters on a very informative andengaging presentation. my question is probablyto jennifer but anybody else whowants to jump in. i think you did a good jobexplaining how the new cps healthcare questions aredifferent from the old ones and that would result

in slightly differentnumbers and rates. my question is about whether youhave any evidence or any reason to believe that thatrelationship between old and new questions willvary by geographic areas? i'm particularlyinterested in people inside and outside metropolitan areasor urban-rural or states. i guess another way ofkind of asking it is that the differential we'veseen in the past likely to be true in the future?

well, it's very hardto tell at this point. as i mentioned that the, astory mentioned it in our report, this fall, we are going toconcentrate just on the nation with the new cps assessmentsand we'll use acs to look at the state andlower geographies. so these changes that we didto the cps questionnaire, we really wouldn't beable to see any effect, the year to yearchanges until next year. ken finegold from aspe, i havea question for jennifer day

and this goes back to, i think, to slide 21 which is theresults of cps content test. in a way, this kind of -- it'sa combination of my 10 years, my greatest 10 yearsof work is the result with the new improved test. i just want to make sure i wasunderstanding the signs right on that slide. so on the left side, that withthe wording that was tested, the uninsured rate isdown 1.4 percentage points

than what it was in production, the production versionat that time. and that's for -- is thatfor the full population? that is correct. per stage. and that is the previousyear question as it had been askedall along right? okay, then if you go below that,you have the bars for changes in private coverageand public coverage,

government coverageit's called here. and the government coverageis down 2.4 points so does that mean that with the new,the new question that was tested that fewer people reportgovernment coverage? >> that is, in this comparisonhere and as you remember, this is a comparison ofa test to the production. right. and that'swhat we were seeing in this particular comparison between these twodifferent surveys.

i don't -- this was a samplesize of about 16,000 people in the health insurancepart of this questionnaire. it gave us enoughconfidence that we could see that these numbers were going in the directionthat we would expect. but i don't knowif this is going to indicate exactly what we'regoing to see in the future with the currentpopulation survey. okay, but i mean, i think thedirection is still surprising

for that. i would think that given thatthere was a medicaid undercount which the snacc researchdemonstrated, that we would haveexpected that the change in questions might pick upmedicaid better, in which case, it didn't work onthe other direction. but it is what thecontext showed you. it does seem a littlecounterintuitive. okay, and then the lastpart on that slide is

that the privatecoverage, what -- i think private coveragewas picked up more than more peoplereported private coverage in the new methodology. yes. okay, thanks. again, a quick reminderfor those people that are on the phones. if you want to ask a question,please press star one. star one for questionson the phone.

any other questions in the room? operator, do we have anyquestions on the phone? yes, we do have a questionfrom joanna turner from saaca. hi, this is joanna [inaudible]. two questions, socps [inaudible] on with the nchs [inaudible]? i can answer that. oh, this is jennifer day. okay [laughter], igot parts and pieces.

she was asking arewe releasing -- i believe, the current coveragestatus in the cps on the 16th which tory covered that we wouldbe releasing some preliminary estimates along withnchs when they put out their release on the 16th. and would it be availableon the public use file? our public use file variableswill be exactly the same as what we had lastyear so they will not be on the public use file.

>> any other questions, joanna? no, thank you. and operator, do we have anyother questions on the phone? no, there are no otherquestions on the phone for you. do we have any otherquestions in the room? any comments in the room? yes. this is charlie rothwell. i'm going to say justa general comment.

i think this is a good example of what federal statisticalagencies are all about, independence and cooperation. and i think this is a goodexample of it at its best. we have 13 federalstatistical agencies throughout in various departmentsin justice, in education, obviously bls. we collect information thatcomes together many times to really paint a pictureof the american people

and our country in general. and i think health insuranceis just one of those activities that obviously rightnow is at the forefront. but there are many others. and our job is to say it as itis and let other folks decide where the policy should be. so thank you all for coming andi hope this has met your needs. and with that, that concludestoday's federal statistics on health insurancecoverage technical meeting

on methods used inhousehold surveys. thank you, everyone.