Since the effective date of the ACA market changes in January of 2014, people with pre-existing health conditions have not had to worry about their health conditions affecting their access to health insurance or increasing the premiums that they pay. The legislation assures people access to individual market coverage with comprehensive benefits through a variety of changes in their work and life circumstances. This could change quite quickly if the ACA market protections for people with pre-existing conditions were invalidated. While many adults with pre-existing conditions have Medicaid or employer coverage that would still provide protection, over a quarter of nonelderly adults have a health condition that would jeopardize their access to non-group coverage without the ACA market protections, potentially affecting almost one-half of non-elderly families in the country. For these families, an invalidated ACA could fundamentally affect future access to health care.
Methods
To calculate nationwide prevalence rates of declinable health conditions, we reviewed the survey responses of nonelderly adults for all question items shown in Methods Table 1 using the CDC’s 2018 National Health Interview Survey (NHIS). Approximately 27% of 18-64 year olds, or 54 million nonelderly adults, reported having at least one of these declinable conditions in response to the 2018 survey. The CDC’s National Center for Health Statistics (NCHS) relies on the medical condition modules of the annual NHIS for many of its core publications on the topic; therefore, we consider this survey to be the most accurate means to estimate both the nationwide rate and weighted population.
Since the NHIS does not include state identifiers nor sufficient sample size for most state-based estimates, we constructed a regression model for the CDC’s 2018 Behavioral Risk Factor Surveillance System (BRFSS) to estimate the prevalence of any of the declinable conditions shown in Methods Table 1 at the state level. This model relied on three highly significant predictors: (a) respondent age; (b) self-reported fair or poor health status; (c) self-report of any of the overlapping variables shown in the left-hand column of Methods Table 1. Across the two data sets, the prevalence rate calculated using the analogous questions (i.e. the left-hand column of Methods Table 1) lined up closely, with 21% of 18-64 year old survey respondents reporting at least one of those declinable conditions in the 2018 NHIS and 23% of 18-64 year olds in the 2018 BRFSS. Applying this prediction model directly to the 2018 BRFSS microdata yielded a nationwide prevalence of any declinable condition of 29%, a near match to the NHIS nationwide estimate of 27%.
In order to align BRFSS to NHIS overall statistics, we then applied a Generalized Regression Estimator (GREG) to scale down the BRFSS microdata’s prevalence rate and population estimate to the equivalent estimates from NHIS, 27% and 54 million. Since the regression described in the previous paragraph already predicted the prevalence rate of declinable conditions in BRFSS by using survey variables shared across the two datasets, this secondary calibration solely served to produce a more conservative estimate of declinable conditions by calibrating BRFSS estimates to the NHIS. After applying this calibration, we calculated state-specific prevalence rates and population estimates off of this post-stratified BRFSS sample.
Methods Table 1: Declinable Medical Conditions Available in Survey Microdata | |
Declinable Condition Questions Available in both the 2018 National Health Interview Survey and also the 2018 Behavioral Risk Factor Surveillance System | Declinable Condition Questions Available in only the 2018 National Health Interview Survey |
Ever had CHD | Melanoma Skin Cancer |
Ever had Angina | Any Other Heart Condition |
Ever had Heart Attack | Stomach Duodenal or Peptic Ulcer |
Ever had Stroke | Difficulty Due to Mental Retardation |
Ever had COPD | Difficulty Due to Cerebral Palsy |
Ever had Emphysema | Difficulty Due to Senility |
Chronic Bronchitis in past 12 months | Difficulty Due to Depression |
Ever had Non-Skin Cancer | Difficulty Due to Endocrine Problem |
Ever had Diabetes | Difficulty Due to Blood Forming Organ Problem |
Weak or Failing Kidneys | Difficulty Due to Drug / Alcohol / Substance Abuse |
BMI > 40 | Difficulty Due to Schizophrenia, ADD, or Bipolar Disorder |
Pregnant |
To calculate nationwide prevalence rates of declinable health conditions at the family-level, we imputed person-level presence of any condition onto the NHIS person file using the main 2018 NHIS sample adult estimate. This model relied on three highly significant predictors: (a) respondent age; (b) self-reported fair or poor health status; (c) self-report of any health-related activity limitation, disability, hospitalization, or high rate of physician visits. Since all individuals responding to the NHIS sample adult questionnaire also respond to the NHIS person component of the survey, these factors produced a reasonably predictive estimate, matching 27% of non-elderly adults with pre-existing conditions for all individuals participating in the survey. Unlike the NHIS sample adult file, the NHIS person file allows for analyses of family-wide characteristics. This prediction yielded 53% of non-elderly adults having a declinable condition themselves or co-habiting with a non-elderly adult family member with a declinable condition; using the NHIS family weights, this results in 45% of non-elderly families (families having at least one non-elderly adult family member) having one or more adults with a declinable condition. In total, approximately 54 million non-elderly adults may have a pre-existing condition and almost as many non-elderly adults without pre-existing conditions live with a family member that does.
The programming code, written using the statistical computing package R v.3.6.1, is available upon request for people interested in replicating this approach for their own analysis.
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