User Note - Variables to Monitor the Affordable Care Act
Using NHIS to Monitor Health Care Reform
With the passage of the Patient Protection and Affordable Care Act (ACA) in March 2010, new data will need to be collected to understand the effects of the law. The NHIS already has many relevant questions that are useful for monitoring access and use of health care and that can be used to monitor the effects of the new law. Beginning with the 2011 survey, around 85 new questions about health insurance coverage, healthcare access and utilization, and poverty were added to the survey. These were explicitly designed to track the effects of the ACA and more extensively capture health care access and use as compared to existing variables. This user note provides analysts a description of these variables.
- I. Affordability
- II. Employer Sponsored Insurance
- III. Use of Services
- IV. Computer Knowledge and Use
- V. Emergency Room Use
- VI. Preventive Care
- VII. Long Term Care
- VIII. Food Insecurity
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I. Affordability A key goal of the ACA is to increase the number of persons with health insurance coverage. It is important to understand how uninsurance changes with the full implementation of the ACA and the reasons for uninsurance among those remaining without insurance, such as the percentage of people who indicate they are uninsured because of difficulty enrolling in public programs, do not enroll because of cost, or cannot find coverage due to pre-existing conditions. |
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| Variable name | Variable description |
| HITRYDIR3Y | Whether person tried to purchase health insurance directly (not through any employer, union, or government program), in the past 3 years |
| HIBUYDIR3Y | For persons who tried to purchase health insurance directly in the past 3 years, if plan was purchased. |
| HIBUYDIRSF3Y | For persons purchased health insurance directly in the past 3 years, for whom the plans was purchased |
| HIBUYHAPP3Y | How difficult it was to find a plan with the type of coverage the person needed. |
| HIBUYHAFF3Y | How difficult was it to find a plan the person could afford |
| HIDENYCOV3Y | Whether a company turned down someone when they tried to buy coverage directly |
| HICOSTMOR3Y | Whether a company charged a higher price because of person's health |
| HIEXCLUDE3Y | Whether a company excluded a specific health problem from the coverage |
| HIBUYNODENY | Reason for not buying a plan: turned down by insurance company |
| HIBUYNOCOND | Reason for not buying a plan: pre-existing condition |
| HIBUYNOCOST | Reason for not buying a plan: cost |
| HIBUYNOSORC | Reason for not buying a plan: got health insurance from other source |
| HIBUYNOOTHR | Reason for not buying a plan: Other reason |
| HICHANGEYR | Whether currently insured persons had a change in coverage in the past year |
| HIHOWGOTPAST | How private insurance plan was obtained (asked of those who had private coverage and experienced a change in coverage) |
| HIPRIVYR | Had private health insurance coverage in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HIMEDICRYR | Had Medicare coverage in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HIMEDICAIDYR | Had Medicaid coverage in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HIMEDIGAPYR | Had Medi-Gap coverage in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HISCHIPYR | Had SCHIP in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HIMILITYR | Had Military coverage in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HIINDYR | Had Indian Health Insurance coverage in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HISTATEYR | Had State Insurance coverage in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HIOTHGOVYR | Had other government insurance coverage in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HISINGLEYR | Had a single service plan in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| HINONEYR | Had no health insurance in the past 12 months, (asked of those currently uninsured, those who had a period of uninsurance, or who had a change in coverage type in the past year) |
| WORMEDBILL | How worried the respondent is about being able to pay medical bills if he or she got sick or had an accident |
| HICOMPARE1Y | How the respondent rates current health insurance coverage, compared with one year ago |
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II. Employer Sponsored Insurance One way in which the ACA will reduce uninsurance is through improved employer-sponsored health insurance (ESI) coverage. It requires employers with more than 200 employees to automatically enroll employees into health insurance plans offered by the employer. Employers with more 50 employees that do not offer coverage will be assessed a tax. The ACA will create state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges, through which individuals and small businesses with up to 100 employees can purchase coverage. In addition, as of September 2010, young adults up to age 26 are allowed to stay on their parent's plan if they are not offered insurance at work. The ACA also has policies to make insurance more affordable: it will provide insurance premium credits to eligible individuals and families with incomes between 133-400% FPL to purchase insurance through the Exchanges. The law (as of September 23, 2010) prohibits insurance companies from imposing lifetime limits on benefits, has provisions that preclude insurance companies from raising the cost of premiums with no accountability, and other measures, such as prohibiting iinsurance companies from denying coverage to persons because of pre-existing conditions or health status. Important indicators to monitor include trends related to ESI coverage and coverage for young adults, premium contributions as a percentage of income, and the percent of families with a high cost burden for health care (this is typically assessed as health care costs of more than 10% of family income). The variables below with a "1" in the name indicate information on the person's first private health insurance plan. Similar variables, with a "2" in the variable name, are available for persons who have a second private health insurance plan. |
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| Variable name | Variable description |
| HIP1EMPAYKNO | Whether respondent knows how much the employer or union is paying for the health plan |
| HIP1EMPAYPRM | The amount the employer or union pays on health insurance premiums, including payroll deduction |
| HIP1EMPAYPCT | Percent of the premium paid by the employer or union |
| HIP1RELPOLICY | How the person(s) covered by the plan is related to the policyholder |
| HIP1POLCOUT | Plan covers persons outside the household |
| HIP1POLCOUTN | Number of persons covered by plan who live outside the household |
| HIP1SPOUT | Spouse who lives outside the household covered by plan |
| HIP1EXSPOUT | Former spouse who lives outside the household covered by plan |
| HIP1KIDOUT | Child who live outsides the household covered by plan |
| HIP1OTHOUT | Other relative who lives outside the household covered by plan |
| HIP1KIDNOOUT | Number of children who live outside the household covered by plan |
| HIP1KID26OUT | Number of children age 26 and older who live outside the household covered by plan |
| HIP1KID25OUT | Number of children age 19 to 25 and older who live outside the household covered by plan |
| HIP1KID18OUT | Number of children age 0 to 18 and older who live outside the household covered by plan |
| HIP1MDREQ | Plan requires members to have primary care physician for all routine care |
| HIPCONAFFORD | Confidence in affording private health insurance plan |
| HIPCONAFFORDR | Confidence in affording private health insurance plan (recode) |
| HIPROBPAYR | Whether the family has problems paying or unable to pay medical bills, past 12 months |
| HIPAYMEDBIL | Whether person/family is currently paying medical bills over time, from earlier years as well as current year |
| HIUNABLEPAY | Whether person/family currently has any medical bills unable to pay at all |
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III. Use of Services With the improved affordability of health care and expanded efforts to improve the use of services, it is important to understand how access to quality care changes. It will be important to monitor the availability of timely and acceptable care, reasons for no usual source of care, and barriers to care. The ACA also aims to improve system-level access to primary and specialty services; indicators such as the percent of physicians accepting new patients (by payer) and the percentage of physicians participating in public programs can help monitor these efforts. |
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| Variable name | Variable description |
| NOUSLYNONEED | Why no usual source of care: Doesn't need doctor |
| NOUSLYNOLIKE | Why no usual source of care: Doesn't like doctors |
| NOUSLYLANG | Why no usual source of care: Speak a different language |
| NOUSLYFAR | Why no usual source of care: Care too far away |
| NOUSLYDKWHER | Why no usual source of care: Doesn't know where to go |
| NOUSLYDRMOV | Why no usual source of care: Previous doctor moved or is unavailable |
| NOUSLYDELAY | Why no usual source of care: Didn't get around to it |
| NOUSLYCOST | Why no usual source of care: Too expensive or no insurance |
| NOUSLYOTH | Why no usual source of care: Other reason |
| CHANGEIN | For respondents who changed their usual source of care in the past 12 months, this reports that the reason for the change was health insurance |
| LVISPLACE | For sample adults aged 18+ years who have ever seen/talked to a doctor, this reports the place of their last medical visit |
| LVISGENSPEC | For sample adults aged 18+ years who have ever seen/talked to a doctor, this reports that the person saw a general doctor or specialist at last visit |
| LVISGENERAL | For sample adults aged 18+ years who visited a clinic, doctor's office/HMO, hospital outpatient department, or someplace else (but not ER or urgent care) on their last visit, this reports that the person saw a general doctor at last visit |
| LVISPECIAL | For sample adults aged 18+ years who visited a clinic, doctor's office/HMO, hospital outpatient department, or someplace else (but not ER or urgent care) on their last visit, this reports that the person saw a specialist at last visit |
| LVISNURSE | For sample adults aged 18+ years who visited a clinic, doctor's office/HMO, hospital outpatient department, or someplace else (but not ER or urgent care) on their last visit, this reports that the person saw a nurse practitioner or physician assistant at last visit |
| LVISOTHER | For sample adults aged 18+ years who visited a clinic, doctor's office/HMO, hospital outpatient department, or someplace else (but not ER or urgent care) on their last visit, this reports that the person saw another health provider at last visit |
| LVISAPTWATNO | For sample adults aged 18+ years who have ever seen/talked to a doctor, this reports the waiting time between appointment and care at the last visit (number) |
| LVISAPTWATTP | For sample adults aged 18+ years who have ever seen/talked to a doctor, this reports the waiting time between appointment and care at the last visit (time period) |
| LVISRMWATNO | For sample adults aged 18+ years who have ever seen/talked to a doctor, this reports the waiting time in the waiting room at the last visit (number) |
| LVISRMWATTP | For sample adults aged 18+ years who have ever seen/talked to a doctor, this reports the waiting time in the waiting room at the last visit (time period) |
| TRUBFINDRYR | Whether the person had trouble finding a general doctor or provider who would see him or her, past 12 months |
| ABLEFINDRYR | Despite having trouble, whether the person was able to find doctor or provider, past 12 months |
| NONEWPATYR | Whether the person was told by a doctor’s office or clinic that he/she would not be accepted as a new patient, past 12 months |
| NOHCTAKEYR | Whether the person was told by a doctor’s office or clinic that they would not accept person's health care coverage, past 12 months |
| YBARSPECL | Whether the person needed but couldn't afford to see a specialist, past 12 months |
| YBARFOLLOW | Whether the person needed but couldn't afford follow-up care, past 12 months |
| YSKIPMEDYR | Whether the person skipped medication doses to save money, past 12 months |
| YSKIMPMEDYR | Whether the person took less medicine to save money, past 12 months |
| YDELAYMEDYR | Whether the person delayed filling a prescription to save money, past 12 months |
| YCHEAPMEDYR | Whether the person asked their doctor for a lower cost medication to save money, past 12 months |
| YFORNMEDYR | Whether the person bought prescription drugs from another country to save money, past 12 months |
| YALTMEDYR | Whether person used alternative therapies to save money, past 12 months |
| For sample children | |
| NOUSLYNONEED | Reason child has no usual source of medical care: did not need a doctor or did not have any problems. |
| NOUSLYCOST | Reason child has no usual source of medical care: too expensive or no insurance. |
| NOUSLYNOLIKE | Reason child has no usual source of medical care: doesn't trust or believe in doctors. |
| NOUSLYDKWHER | Reason child has no usual source of medical care: doesn't know where to go. |
| NOUSLYDRMOV | Reason child has no usual source of medical care: previous doctor is not available/moved. |
| NOUSLYLANG | Reason child has no usual source of medical care: speak a different language (than health care staff) |
| NOUSLYFAR | Reason child has no usual source of medical care: no care available or care is too far away |
| NOUSLYDELAY | Reason child has no usual source of medical care: put it off/didn't get around to it |
| NOUSLYOTH | Reason child has no usual source of medical care: some other reason |
| TRUBFINDRYR | Whether the person had trouble finding a general doctor or provider who would see their child, past 12 months |
| ABLEFINDRYR | If person was able find a general doctor or provider for their child |
| NONEWPATYR | Whether the person was told by a doctor’s office or clinic that their child would not be accepted as a new patient, past 12 months |
| NOHCTAKEYR | Whether the person was told by a doctor’s office or clinic that they would not accept child's health care coverage, past 12 months |
| For sample children under 2 years of age: | |
| YBARSPECL | If child needed to see a specialist but parent couldn't afford it, past 12 months |
| YBARFOLLOW | Needed but couldn't afford follow-up care, past 12 months |
| For sample children older than 2 years: | |
| YBARFOLLOW | Needed but couldn't afford follow-up care, past 12 months |
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IV. Computer Knowledge and Use As health information is increasingly available online and virtual communiation with health care providers becomes increasingly possible, it is important to monitor computer use and and knowledge as it pertains to health services use. The following variables were added as part of the Health Information Technology (HIT) supplement, which was first introduced in 2009 and they will be useful for monitoring how people gather health information and interact with health care providers as ACA expansion continues. |
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| PCLOOKHELYR | Whether the sample adult looked up health information on the internet in the past 12 months |
| PCRXFILLYR | Whether the sample adult refilled a prescription on the internet in the past 12 months |
| PCAPPTHPYR | Whether the sample adult looked up helath information on the internet in the past 12 months |
| PCEMAILHPYR | Whether the sample adult scheduled an appointment with a health care provider on the internet in the past 12 months |
| PCCHATHELYR | Whether the sample adult used online chat gropus to learn about health topics in the past 12 months |
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V. Emergency Room Use To assess the Affordable Care Act's effects on the overall quality of the health care system, it is important to monitor the quality of emergency room (ER) care. Research shows that newly covered individuals are less likely to use the emergency room for care compared to the uninsured which can reduce health care costs. Important indicators available through the NHIS allow users to track emergency room use rates and monitor potentially preventable emergency room visits. |
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| ERLNIGHT | Whether the person's most recent ER visit was at night or on the weekend |
| ERLHOSPADM | Whether the person's most recent ER visit resulted in a hospital admission |
| ERLNOTHER | For sample adults and children who had at least one ER visit that did not result in a hospital admission: Reason for most recent ER visit: didn't have another place to go |
| ERLDRCLOSED | For sample adults and children who had at least one ER visit that did not result in a hospital admission: Reason for most recent ER visit: doctor's office was not open |
| ERLDRSENT | For sample adults and children who had at least one ER visit that did not result in a hospital admission: Reason for most recent ER visit: provider said to go |
| ERLSERIOUS | For sample adults and children who had at least one ER visit that did not result in a hospital admission: Reason for most recent ER visit: problem was too serious for doctor’s office/clinic |
| ERLHOSPHELP | For sample adults and children who had at least one ER visit that did not result in a hospital admission: Reason for most recent ER visit: only a hospital could help the person |
| ERLCLOSEST | For sample adults and children who had at least one ER visit that did not result in a hospital admission: Reason for most recent ER visit: the emergency room was the person's closest provider |
| ERLUSUALPL | For sample adults and children who had at least one ER visit that did not result in a hospital admission: Reason for most recent ER visit: the emergency room is where the person gets most of his or her care |
| ERLAMBUL | For sample adults and children who had at least one ER visit that did not result in a hospital admission: Reason for most recent ER visit: the person arrived by ambulance or other emergency vehicle |
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VI. Preventive Care The ACA provisions established the National Prevention, Health Promotion and Public Health Council to coordinate federal prevention, wellness, and public health activities. A national strategy was developed to improve the nation's health and the Prevention and Public Health Fund was expanded to improve prevention and public health programs. In addition, the ACA has other measures to improve preventive services, expand the administration of immunizations, and reduce tobacco use. As of September 2010, all new insurance plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. The ACA will also improve preventive services for everyone on Medicare (for example, they will be able to get preventive services like mammograms for free). | |
| For sample adults | |
| HYPCHEK1YR | Whether the person has had blood pressure checked by a doctor, nurse, or other health professional, past 12 months |
| CHOLCHEK1YR | Whether the person has cholesterol checked by a doctor, nurse, or other health professional, past 12 months |
| PAPHAD1YR | Whether a woman had a Pap smear or Pap test, past 12 months |
| COLTANY1YR | Whether the person has had any test done for colon cancer, past 12 months |
| GLUCCHEK1YR | Whether the person had a fasting blood glucose test, past 12 months |
| MAMHAD1YR | Whether the person had a mammogram, past 12 months |
| MDIETALK | Whether a doctor or other health professional advised person on their diet, past 12 months |
| MDSMOKTALK | Whether a doctor or other health professional advised person against smoking, past 12 months |
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VII. Long Term Care The ACA establishes a national, voluntary insurance program for purchasing community living assistance services and supports (the CLASS program). Effective January 2011, the program provides individuals with functional limitations a cash benefit (an average of $50 per day) to purchase non-medical services and supports necessary to maintain residence in the community. The NHIS will collect indicators that will be used to monitor need and interest in this program. |
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| LTCFAMNEED | Whether parent, spouse, sibling, or adult child has needed help for at least a year with everyday needs like bathing, dressing or eating due to a long term condition |
| LTCSELFNEED | Extent to which person may someday need help with daily activities like bathing, dressing, eating, or using the toilet due to a long term condition (and LTCSELFWHO, who would help them) |
| LTCHELPFAM | Who would help person with daily activities: Family |
| LTCHELPHOMC | Who would help person with daily activities: Home health care organization |
| LTCHELPHIRE | Who would help person with daily activities: Person would hire someone |
| LTCHELPNHOM | Who would help person with daily activities: Nursing home or assisted living would provide ADL help |
| LTCHELPOTHR | Who would help person with daily activities: Some other person or organization |
| LTCWANTBUY | Whether person would be interested in purchasing long-term care insurance (purchasing into the CLASS program) |
| LTCPAYMO | How much person would be willing to pay per month (at the time of the survey) to receive benefits from CLASS later |
| LTCPAY100 | How likely person is to pay $100 per month for this insurance |
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VIII. Food Insecurity Under the ACA, every state will be required to provide food and nutrition services as part of their Essential Benefits Package. The Medicaid expansion will also help reduce food insecurity by easing poverty and improving access to better quality food. The NHIS allows users interested in evaluating the impact of the ACA on food insecurity to monitor trends in the percentage of families who forgo meals or face hunger. |
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| FSRUNOUT | If the person/family worried their food would run out before having enough money to buy more |
| FSNOTLAST | If the food purchased didn’t last and person/family didn’t have money to get more. |
| FSBALANC | If person/family could not afford to eat balanced meals |
| If families reported that it was often or sometimes true that, in the last 30 days, they worried that food would run out, or they couldn't afford to eat balanced meals, they were asked the following: | |
| FSSKIP | If any of the adults ever cut the size of meals or skipped meals because there wasn't enough money for food (and FSSKDAYS, how many days in the past 30 days this happened) |
| FSATELESS | In the last 30 days, how often person ate less than they felt they should because there wasn't enough money for food |
| FSHUNGRY | In the last 30 days, how often person was hungry because there wasn't enough money for food |
| FSWEIGHT | In the last 30 days, if person lost weight because there wasn't enough money for food |
| FSNOTEAT | In the last 30 days, if any adults ever did not eat for a whole day because there wasn't enough money for food (and FSNEDAYS, how many days in the last 30 days this happened). |
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