The Health Insurance section of the NHIS Family Core (FHI) has a full range of data items addressing health insurance. A family respondent answers these questions about all family members. However, individual members present can also respond to the questions as well. Although the questions are asked on the Family Core component of the questionnaire, health insurance coverage status is collected for each family member. The flow of the questions pertaining to health insurance programs in this section has been similar since 1997. The FHI section begins by asking an overall question of whether anyone in the family has health insurance coverage. If there is a positive response to this initial overall question, then the types of coverage are collected for each family member. The types include “no coverage of any type,” in case one or more family members are uninsured but others are not. The questions about types of coverage are followed by detailed questions about each coverage type collected on a person basis, with an exception of detailed questions about private plans which are asked by plan, for up to four plans per family. If there is a negative response to the initial overall question, then all family members are marked as not having health insurance coverage and the appropriate follow-up questions for those who lack coverage are asked. The FHI section ends with a series of family-level questions about out-of-pocket expenses, flexible spending accounts, and problems paying medical bills.
In summary, since 1997 the FHI core section included questions on several different topic areas:
- Type of health care coverage (Medicare, Medicaid, Children’s Health Insurance Program (CHIP), military (TRICARE, VA, CHAMP-VA), other state-sponsored health plans, Indian Health Service, other government programs, private insurance and single service plans);
- Characteristics of managed care arrangements for those covered by Medicare, Medicaid, Children’s Health Insurance Program, other state-sponsored health plans and other government programs;
- Enrollment in a Medicare managed care;
- Enrollment in the Medicare Part D prescription drug program;
- Characteristics of private insurance
- covered individuals’ relationships to the policyholder
- coverage of individuals outside the household
- Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Point-of-Service (POS) status
- enrollment in high deductible health plans (deductible amount adjusted annually for inflation)
- enrollment in health savings accounts or health reimbursement agreements for high deductible plans
- how private plans were obtained
- existence of employer subsidies for premiums
- amount paid by employer
- amount paid by individual/family
- need for a referral (1997-2014)
- prescription drug benefit
- dental coverage
- Types of single service plans;
- Type of TRICARE coverage;
- Beginning in 2018, for veterans who have not indicated their Veteran’s Administration (VA) coverage in the health insurance section, a question was added specifically asking those who had ever served in the armed forces if they had ever enrolled in or used VA health care.
- Periods of time without health insurance and reasons for no health insurance;
- Out-of-pocket costs in the past year for medical expenses (excluding health insurance premiums); and
- Enrollment in a flexible spending account (FSA) for medical expenses.
A new question was added to the FHI core section beginning with Quarter 4 of 2013 to ascertain if premiums paid by an individual or family for their private health insurance plans were based on income (PLNPRE1 and PLNPRE2). This question is intended to provide a baseline estimate of the number of persons covered by private health insurance plans that are tiered by their employers, prior to the availability of private health insurance through the Federal Health Insurance Marketplace or state-based exchanges.
In 2014, to take into account the Affordable Care Act of 2010 (P.L. 111-148, P.L. 111-152) (ACA), several new questions were added to the FHI section to capture health care coverage obtained through the Health Insurance Marketplace or state-based exchanges. These new questions were asked for persons covered by public plans (Medicaid, CHIP, state-sponsored health plans, and other government programs) as well as for those on private health insurance. This acknowledges that some respondents perceive exchange coverage as a public program, and other respondents perceive exchange coverage as private health insurance. For persons who indicate Medicaid, CHIP, state-sponsored health plans, other government programs, they were asked if they obtained this coverage through Healthcare.gov, the Health Insurance Marketplace, or the name of their state’s exchange. This was followed by a question that asked if there was a premium or enrollment fee associated with the plan. If this was the case, the respondents were asked if this premium was based on income. For persons covered by private insurance plans that were not employment-based, respondents were asked if the plan was obtained through Healthcare.gov, the Health Insurance Marketplace, or the name of their state’s exchange. In addition, for any plan where the family is paying a portion of the premium, an additional question was added to ascertain whether the premium was based on income (added October 2013).
In addition to the core health insurance questions, additional supplemental questions have been included since 2011. The purpose of the FHI supplemental questions is to provide additional information about the following topic areas:
- Relationship of the covered individual to the policyholder;
- Employer contributions to private plan premiums and if premiums were based on income;
- Primary care provider requirement;
- Confidence in purchasing affordable private health insurance on one’s own;
- Previous health insurance coverage for persons who are either uninsured or who have had a change in insurance coverage within the past year;
- Difficulty paying medical bills, paying medical bills over time, and having medical bills that cannot be paid at all.
Coverage variables are available on the Person File, which enables analysts to look at coverage for each family member. In addition, selected insurance coverage summary variables are created for the Family File. The inclusion of the FHI section on the Family File is intended to make it easier to analyze insurance data on a family basis.