Updated November 2, 2017
Coverage in the Private Health Insurance Market
Americans obtain health insurance through a variety of
methods and from different sources. People may get
insurance through the private sector or from a government
source, or individuals may go uninsured.
Private Health Insurance Market
The private health insurance market includes both the group
market (largely made up of employer-sponsored insurance,
or ESI) and the non-group market (commonly referred to as
the individual market, see Figure 1). Private health
insurance does not include government sources of coverage,
such as Medicare or Medicaid.
Private Health Insurance Coverage
Private health insurance is the predominant source of health
insurance coverage in the United States. In 2016, 67.5% of
the U.S. population (216.2 million people) had private
coverage through either the group or the non-group market
during all or part of the year (see Figure 2).
Figure 2. Private Health Insurance Coverage in the
United States, 2013-2016
Figure 1. Private Health Insurance Sources of
Coverage
Source: U.S. Census Bureau, Current Population Survey, 2014,
2015, 2016 and 2017 Annual Social and Economic Supplements.
Notes: Coverage is measured during all or part of the year. The
estimates by type of coverage are not mutually exclusive; people can
be covered by more than one type of health insurance during the
year.
Source: Congressional Research Service (CRS).
Notes: SHOP = Small Business Health Options Program. A SHOP
exchange is where small businesses can purchase small-group
insurance and apply for small business health insurance tax credits.
The dynamic nature of health insurance coverage results in
nuanced estimates of coverage, which often depend on the
time frame being measured. For example, at the time of the
measurement, an individual may indicate having Medicare
coverage only. However, when measuring coverage in the
past year, that same individual may indicate having had
private insurance coverage for part of the year and
Medicare for part of the year. People also may have
multiple sources of coverage simultaneously within a time
frame (e.g., Medicare and supplemental private health
insurance at the time of interview); thus, estimates by type
of coverage are not always mutually exclusive.
This In Focus primarily uses estimates from the Census
Bureau’s Current Population Survey Annual Social and
Economic Supplement (CPS ASEC) to provide estimates of
coverage in the private health insurance market for 20132016. The CPS ASEC measures any coverage and type of
health insurance coverage for all or part of the year.
Group Insurance
Group health insurance is typically offered by employers
and is divided into small-group and large-group segments.
The distinction between the small-group and large-group
markets is defined by the size of the employer or other
organization purchasing a group plan. Most states define
small group as businesses having 50 or fewer employees
and large group as businesses having more than 50
employees.
A majority of Americans obtain health coverage through
the group market. In 2016, 55.7% of the U.S. population
(178.5 million people) had group coverage during all or part
of the year (see Figure 2). The CPS ASEC does not further
differentiate between small-group and large-group
coverage.
Non-group Insurance
Consumers who are not associated with a group can obtain
health coverage by purchasing it directly from an insurer in
the non-group insurance market. In general, the non-group
market enrolls many people who do not receive coverage
from an employer and who are otherwise ineligible for
public insurance programs, such as Medicare or Medicaid.
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Coverage in the Private Health Insurance Market
In 2016, 16.2% of the U.S. population (52.0 million people)
had non-group coverage during all or part of the year (see
Figure 2).
Health Insurance Exchanges
The Patient Protection and Affordable Care Act’s (ACA’s;
P.L. 111-148, as amended) individual health insurance
exchanges (marketplaces where individuals may purchase
coverage for themselves or their families) are part of the
non-group health insurance market. Generally, plans
offered in the exchanges are known as Qualified Health
Plans (QHPs). QHPs undergo an additional certification
process compared to other plans in the non-group market.
Accordingly, non-group plans often are categorized as
either “inside the exchanges” or “outside the exchanges”
(see Figure 1). QHPs can, however, be offered both inside
the exchanges and outside the exchanges.
This In Focus uses administrative data from the Department
of Health and Human Services (HHS) and the Centers for
Medicare & Medicaid Services (CMS) to provide estimates
of coverage inside the individual exchanges (see Figure 3).
Data on exchange enrollment often are released in stages,
pre-effectuated and effectuated enrollment. Pre-effectuated
enrollment is the number of individuals who have selected a
plan. Effectuated enrollment is the number of individuals
who have selected a plan and have submitted the first
premium payment for a plan. Pre-effectuated enrollment
estimates are generally provided at the end of an Open
Enrollment Period (OEP) but may include enrollment
associated with a Special Enrollment Period (SEP) that
directly follows an OEP. Effectuated enrollment estimates
are generally provided throughout the year.
Figure 3. Enrollment in the Health Insurance
Exchanges, 2014-2017
Source: Administrative data from HHS and CMS.
Notes: The pre-effectuated enrollment estimate for 2014 is during
the 2014 OEP (October 1, 2013-March 31, 2014) and an SEP that ran
through April 19, 2014. The effectuated enrollment estimate for 2014
is as of October 15, 2014. The pre-effectuated enrollment estimate
for 2015 is during the 2015 OEP (November 15, 2014-February 15,
2015) and an SEP that ran through February 22, 2015. The
effectuated enrollment estimate for 2015 is as of December 31, 2015.
The pre-effectuated enrollment estimate for 2016 is during the 2016
OEP (November 1, 2015-February 1, 2016). The effectuated
enrollment estimate for 2016 is for the “end of the year.” The preeffectuated enrollment estimate for 2017 is during the 2017 OEP
(November 1, 2016-January 31, 2017). The effectuated enrollment
estimate for 2017 is as of March 15, 2017, for individuals with
effectuated coverage for February 2017.
During the 2017 OEP, pre-effectuated enrollment in the
exchanges was 12.2 million individuals (see Figure 3).
Effectuated enrollment for February 2017 coverage in the
exchanges was 10.3 million individuals (see Figure 3).
The 2018 OEP is currently underway and is to run from
November 1, 2017 to December 15, 2017. CMS will likely
provide enrollment estimates during OEP.
Other Data Estimates of Private Health
Insurance Coverage
Estimates of private health insurance coverage can be
obtained from a number of reputable data sources. Data
sources may focus on particular aspects of the private
health insurance market. Data sources also may produce
different estimates because they may vary in terms of
methodology, questions, and time frames. Table 1 provides
summary information for selected data sources.
Table 1. Selected Data Sources for Coverage
Estimates in the Private Health Insurance Market
Data Source
Summary
Agency for Healthcare
Research and Quality’s
(AHRQ’s) Medical
Expenditure Panel
Survey–Insurance
Component (IC)
Provides estimates on the number and types
of ESI plans offered by employers, benefits
associated with these plans, annual
premiums, annual contributions by employers
and employees, eligibility requirements, and
employer characteristics in a calendar year at
the state and national level.
Centers for Disease
Control and
Prevention’s National
Health Interview Survey
(NHIS)
Provides estimates of private health
insurance coverage averaged throughout a
calendar year. Early estimates do not
differentiate between group and non-group
coverage. Provides estimates of exchange
coverage.
Centers for Medicare
and Medicaid Services
(CMS)
Provides pre-effectuated and effectuated
enrollment estimates for the health insurance
exchanges.
Kaiser Family
Foundation/Health
Research and Education
Trust (KFF/HRET)
Employer Health
Benefits Survey
Provides detailed look at trends in ESI
coverage. Provides estimates of large(defined as 200+ employees) and small-group
(defined as 3-199 employees) markets in a
calendar year.
U.S. Census Bureau’s
American Community
Survey (ACS)
Provides estimates of private health
insurance coverage averaged over the past 1
year, 3 years, or 5 years. Provides estimates
at state, county, and congressional district
levels.
U.S. Census Bureau’s
Current Population
Survey Annual Social
and Economic
Supplement (CPS
ASEC)
Provides estimates of private health
insurance coverage during the last calendar
year. Differentiates between group and nongroup coverage.
Source: CRS compilation of data sources.
Notes: This is not a comprehensive list of data sources for coverage
estimates in the private health insurance market or a comprehensive
discussion of the advantages and disadvantages of each data source.
Vanessa C. Forsberg, Analyst in Health Care Financing
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IF10558
Coverage in the Private Health Insurance Market
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