HEALTH INSURANCE COVERAGE IN MINNESOTA · 3/29/2012 · HEALTH INSURANCE COVERAGE IN MINNESOTA Early Results from the 2011 Minnesota Health Access Survey Access Workgroup - Governor’s

HEALTH INSURANCE COVERAGE IN MINNESOTA Early Results from the 2011 Minnesota Health Access Survey Access Workgroup - Governor’s Health Reform Task Force March 29, 2012 Jessie Kemmick-Pintor Stefan Gildemeister Researcher, SHADAC/School of Public Health Director, Health Economics Program

Overview • Background on the Minnesota Health Access Survey • Access to health insurance

• Sources of insurance coverage • Rates of uninsurance (age, race/ethnicity, income) • Demographics and employment characteristics of the uninsured • Potential sources for coverage & barriers to coverage

• Access to care • People with a usual source of care • Rates of confidence about receiving needed care • Experienced discrimination • Affordability of care

• Conclusion

2

BACKGROUND

3

Survey Objectives • Monitor the distribution of health insurance coverage in Minnesota

• Describe the characteristics of the uninsured • Identify economic and demographic factors associated with lack of health insurance

• Inform state level policy and decisions • Establish baseline data for evaluating health reform implementation (coverage, access to care, barriers to care, etc.)

4

Survey Overview • Stratified area probability survey designed to produce reliable health

access estimates for: • Regions of the state; and • Most populous racial/ethnic groups

• Survey conducted in partnership between Minnesota Department of Health and University of Minnesota School of Public Health

• Previous surveys in 2001, 2004, 2007, and 2009

• 2011 MNHA Survey: • Over 11,000 telephone interviews were conducted between

August and November 2011 • Certain populations were oversampled; others were screened to

lower probability of selection; a surname sample was conducted • About 40 percent of survey respondents were reached on a cell

phone

5

ACCESS TO INSURANCE COVERAGE

6

Uninsurance Rate Trends in Minnesota

6.1%

7.7%* 7.2%

9.0%* 9.1%

0%

2%

4%

6%

8%

10%

2001 2004 2007 2009 2011

7

*Indicates statistically significant difference (95% level) from prior year shown. Source: 2001, 2004, 2007, 2009, and 2011 Minnesota Health Access Surveys

Estimated Number of Uninsured in Minnesota, 2001 to 2011

304,000

392,000* 375,000

478,000* 489,000

0

100,000

200,000

300,000

400,000

500,000

600,000

2001 2004 2007 2009 2011

8

*Indicates statistically significant difference (95% level) from prior year shown. Source: 2001, 2004, 2007, 2009, and 2011 Minnesota Health Access Surveys

Sources of Insurance Coverage in Minnesota, Select Years

*Indicates statistically significant difference to year shown (95% level). Estimates that rely solely on household survey data differ slightly from annual estimates that include both survey and administrative data. Source: Minnesota Health Access Surveys, 2009 and 2011.

9

Trends in ESI Coverage, Select Years (Minnesota’s Non-elderly Population)

10

*Indicates statistically significant difference (95% level) from prior year shown. Source: 2001, 2009, and 2011 Minnesota Health Access Surveys

Other Measures of Uninsurance

11

Measures of Uninsurance in Minnesota, 2007 to 2011

12

*Indicates statistically significant difference (95% level) from prior year shown. Source: 2007, 2009, and 2011 Minnesota Health Access Surveys.

Minnesotans With an Episode of Uninsurance, 2011 (about 12.6 percent of population)

unin

sure

d no

w

uninsured at som

e point in the year

Sh

ort-t

erm

Long-term

Insu

red

now

episode of uninsurance in past 12 months

13

Long-term uninsured means uninsured for 12 months or longer. Source: 2011 Minnesota Health Access Survey

Age Distribution of the Long-Term Uninsured and the Total Population, 2011

14

Îndicates statistically significant difference in the rates to the overall population (95% level) Source: Minnesota Health Access Survey.

Rates for Specific Populations

15

Disparities in Rates of Coverage in 2011 Remain Largely Unchanged • Disparities in coverage

• Age & income • Race/Ethnicity • Education

• Differences in coverage also exist by • Region • Marital status & health status • Nativity

• In 2011, rates of uninsurance between Greater Minnesota and Twin Cities do not differ from each other (but metro rate rose)

16

Uninsurance Rates by Age, Select Years

4.7%^

14.4%^

10.0%^

5.9%

2.8%^

0.6%^

6.1% 6.6%#^

21.8%*^

15.0%*^

8.4%*

6.0%*^

1.6%^

9.0%*

5.4%^

16.7%#^ 18.6%^

10.1%

7.5%

0.7%^

9.1%

0%

5%

10%

15%

20%

25%

0 to 17 18 to 25 26 to 34 35 to 54 55 to 64 65+ All Ages

2001 2009 2011

Source: Minnesota Health Access Surveys *Indicates statistically significant difference from previous year shown (95% confidence level). #Indicates statistically significant difference from previous year shown (90% confidence level). Îndicates statistically significant difference from statewide rate (95% confidence level).

17

Presenter

Presentation Notes

Should I remove the symbols for comparison to overall rate? Or maybe just the 90% significance…makes it a bit distracting. -Only age group with a significant DECREASE in the % of uninsured from 2009 to 2011 (90% level). - Because I talk about the 2008 health reform law at the state level, should I include 2007 as well? Take out 2001?

Uninsurance Rate Among Young Adults (ages 18 to 25 years), Select Years

18

*Indicates statistically significant difference (95% level) from prior year shown. Source: 2001, 2009, and 2011 Minnesota Health Access Surveys

Young Adults with Group Coverage, 2011

19

*Indicates statistically significant difference (95% level) from prior year shown. Source: 2009 and 2011 Minnesota Health Access Surveys

Sources of Children’s Health Insurance Coverage in Minnesota by Age, 2011

Îndicates statistically significant difference (95% level) from all children. Source: Minnesota Health Access Surveys, 2011

20

Presenter

Presentation Notes

Uninsured children: 2011: 69,739 2009: 84,633 Rate for Kids: 2011 - 0 to 5 years/6 to 17 years: 5.1%/5.5% 2009 - 0 to 5 years/6 to 17 years: 7.8%/6.6%

Minnesota Uninsurance Rates by Income, Select Years

15.2%^ 13.7%^

7.2%

3.6% 2.0%^

6.1%

16.9%^ 17.1%^

12.4%^

7.2%*

2.9%*^

9.0%*

16.4%^ 15.8%^

13.0%^

6.4%^

2.6%^

9.1%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

0 to 100% 101 to 200%201 to 300%301 to 400% 401%+ All Income

Income as % of Federal Poverty Guidelines 2001 2009 2011

21

*Indicates statistical difference to previous year shown (95% level). Îndicates statistically significant difference (95% level) from all incomes within year. Source: 2001, 2009, and 2011 Minnesota Health Access Surveys

Uninsurance Rates by Race/Ethnicity, Select Years

22

Source: 2001, 2009, and 2011 Minnesota Health Access Surveys. *Indicates statistically significant difference from previous year shown (95% confidence level). Îndicates statistically significant difference from statewide rate (95% confidence level).

Presenter

Presentation Notes

American Indians the only group with a large decrease in uninsurance (20.7% to 14.3%) – although not significant. All other racial groups experienced about the same or increased rates of uninsurance. Add if significantly different from the statewide rate. Why? – Significant increase in public coverage among American Indians (and not other groups). ADD SLIDE ABOUT THAT?

Insurance Distribution among American Indians and Minnesotans Overall

35.7%^ 29.4%^

57.4% 56.4%

3.4%

1.5%^

5.1% 5.2% 40.2%^ 54.8%*^

28.5% 29.2%

20.7%^ 14.3%

9.0% 9.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009 2011 2009 2011

American Indians Total

UninsuredPublicIndividualGroup

23

Source: 2009 and 2011 Minnesota Health Access Surveys * Indicates a statistically significant difference from previous year shown at the 95% level. ^ Indicates a statistically significant difference from statewide rate within year at the 95% level.

Presenter

Presentation Notes

Note from Stefan: I think your slide #2 is probably most clear, but what do you think about this way of presenting it? Jessie: I agree, looks great The rate of uninsurance declined for American Indians in 2011 however, this decline is not significant. Preliminary analysis indicate that sig. increase in public coverage is distributed across a variety of programs including Medical Assistance and VA benefits due to a service related disability. Consistent with prior years, group coverage is lower and public coverage is higher among American Indians than is true for the state population as a whole.

Potential sources of change from 2009 to 2011 among American Indians • Shift toward the lower levels of the income distribution from 2009 to 2011 • 46% are at or below 200% FPL in 2009 compared to

60% in 2011 • American Indian community more concentrated at lower end of age spectrum than total population • 45% age 0-17 compared to 25%

• Proportion unemployed in American Indian community is higher than population overall, restricting access to private coverage

• 43% vs. 28%

24

Presenter

Presentation Notes

Note from Stefan: this is just background information or do you plan on showing this slide? Jessie: we were planning to show this slide, just to add some context Shift toward the lower levels of the income distribution from 2009 to 2011, helping to explain higher rates of public program eligibility. Children enjoy higher rates of coverage than non-elderly adults; this may be driving down overall uninsurance rate for American Indians. Unemployment increased in 2011 for AIs, but not significantly

Insurance Coverage for Minnesotans Born in the US and Not Born in US

25

Source: 2009 and 2011 Minnesota Health Access Surveys * Indicates a statistically significant difference from previous year shown at the 95% level. ^ Indicates a statistically significant difference from statewide rate within year at the 95% level.

Why lower rates of group coverage among non-US born?

• Employment rates are same for US and non-US born both years • However, significantly fewer non-US born population work 31 hours

per week or more in 2011 than in 2009 (81% vs 84% respectively)

• Although no change from 2009 to 2011, factors associated with lower group coverage include: • Temporary and seasonal employment more common among non-US

born than US born (e.g., 16% and 9% respectively in 2011). • Non-US born are more likely than US born Minnesotans to live in

greater MN (83% vs 52% in 2011) where group coverage less common

26

Presenter

Presentation Notes

Significantly lower % of non-US born population work 31 hours per week or more in 2011 than in 2009 (81% vs 84% respectively), which is also associated with offer of, and eligibility for, employer based insurance.

Why higher rates of uninsurance among non-US born?

• The following are related to higher uninsurance rates: • Non-US born more concentrated among adults age 26-54 • Non-US born more highly concentrated in the lower income

groups • In 2011, 46% of non-US born had household incomes at or below

200% FPL compared to 29% of US born

• A significantly larger percentage of non-US born Minnesotans report living in the US 11 years or more (64% vs 52%) and 6 years or more (82% vs 77%) in 2011 than in 2009 • Meet 5 year eligibility for public program enrollment

27

Presenter

Presentation Notes

While does not explain an increase in uninsurance between 2009 and 2011 the following are related to higher uninsurance rates: Age composition of Non-US born is more concentrated among adults age 26-54 than true of US born; these age groups are more likely to be uninsured than children and older adults. In 2011, 46% of non-US born had household incomes at or below 200% FPL compared to 29% of US born. Although their low incomes would indicate eligibility for public programs, this is also dependent on the length of time they have been in the US and other factors associated with immigration. A significantly larger percentage of non-US born Minnesotans report living in the US 11 years or more (64% vs 52%) and 6 years or more (82% vs 77%) in 2011 than in 2009, which is an indicator or their potential eligibility for public programs and familiarity with the US health care system. The race and ethnic composition of the Non-US born uninsured subpopulation shifted slightly, but not significantly, between 2009 and 2011. Specifically, a greater proportion identify as Black and a smaller proportion identify as Hispanic (lower panel of Exhibit 3). However, non-US born Hispanics continue to make up the largest share of the non-US born uninsured (almost 50% in 2009 and 40% in 2011) followed by non-US born Blacks (19% in 2009 and 27% in 2011). If question asked: about ¼ - 1/3 of foreign-born in MN would not be categorically eligible for Medicaid due to immigration status

Characteristics of the Uninsured

28

Demographic Characteristics of the Uninsured

• Compared to the Minnesota population overall, Minnesota’s uninsured in 2011 were more likely to be: • Between 26 and 34 years of age • African American and Hispanic/Latino • Not born in the U.S. • Of middle and low income (300% of FPG or less) • Not married • In good or fair health (vs. excellent, very good or poor).

• Unlike in 2009, the uninsured in 2011 were demographically comparable to the overall population by • Gender • Region (Twin Cities/Greater Minnesota)

29

Employment Characteristics

• Compared to the Minnesota population overall, Minnesota’s the uninsured in 2011 were more likely to: • Be self employed • Work between 21 and 30 hours (as compared to fewer or more

hours) • Hold more than one job • Work for firms with fewer than 50 employees, and • Hold temporary or seasonal jobs

• The uninsured in 2011 were as likely to be employed as the general population (68 percent compared with 72 percent)

30

Potential Sources of Coverage

31

Potential Sources of Health Insurance Coverage for Minnesota Uninsured, 2011

32

Differences to previous years (not shown) are not statistically significant. Source: Minnesota Health Access Survey, 2011

Main 4 Reasons for Lack of Coverage Among the Uninsured, 2011

33

Did not Take-up of ESI When Offered

Did Not Purchase Coverage Directly

Reason for Loss of Coverage

Too expensive/ could not afford 47.6%

73.6%

Too much hassle/ paperwork 3.6%

Not eligible for reason other than health 5.5% 3.4%

Don’t like benefits package 6.9%

Expect to be covered shortly 2.9%

18 or older so does not qualify as dependent

5.2%

Job that provided coverage ended 32.7%

No longer eligible for public insurance 14.9%

Did not get information to stay on coverage 11.6%

Just moved to state, haven’t gotten coverage

8.1%

Main Reason For Not Enrolling in Public Health Care Programs

34

Category “other” includes among other responses: response refused, confusion over next steps/ enrollment, rarely sick, too much paperwork, don’t want government involved in health care. Source: Minnesota Health Access Survey, 2011

Interaction of the Uninsured with Minnesota Public Programs, 2011

35

Source: 2011 Minnesota Health Access Survey

ACCESS TO CARE

36

Percent of Minnesotans Who Did Not Have a Usual Source of Care

*Indicates a statistically significant difference from previous year shown at the 95% level. #Indicates statistically significant difference from previous year shown at 90% level. Îndicates a statistically significant difference from statewide rate within year at the 95% level.

6.0%^

18.6%^

7.3%^

39.9%^

10.0% 8.8%*^ 9.3%* 8.1%^

46.7%^#

12.1%*

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Group Individual Public Uninsured Total

2009 2011

37

Presenter

Presentation Notes

Notes from Stefan: can you add notes of significance on the bottom? Also, is the difference for uninsured significant? I assume not, because it isn’t marked. Jessie: It was only significant at 90%, we’re only including 95% here, right? The proportion of people with a USC decreased significantly from 2009 to 2011, for the total sample (90.0% to 87.9%) and or those with group coverage (94.0% to 91.2%) Significant change at .1 level for the uninsured (60.1% to 53.3%).

Percent of Minnesota Children Who Did Not Have a Usual Source of Care

38

*Indicates a statistically significant difference from previous year shown at the 95% level. Îndicates a statistically significant difference from statewide rate within year at the 95% level. Source: 2009 and 2011 Minnesota Health Access Surveys

Place of Usual Source of Care, 2011

39

*Indicates a statistically significant difference from 2009 at the 95% level. Îndicates a statistically significant difference from statewide rate within year at the 95% level. Source: 2009 and 2011 Minnesota Health Access Surveys

Presenter

Presentation Notes

There was no change from 2009 to 2011 in type of USC for the total sample. Use of the ER as USC increased for those with group (1.3% to 2.0%) and decreased for those with individual (2.8% to 1.3%) coverage. The % of uninsured reporting a sliding fee/free clinic as USC increased from 2009 to 2011 (17.9% to 28.9%). In 2009 and 2011, the uninsured report highest use of ER as usual source of care (7.5%), followed by those with public (2.8%), group (2.0%), and individual (1.3%) coverage.

Barriers to Care Due to Cost & Other Factors

40

Barriers to Care Because of Costs, 2011

41

*Indicates statistically significant difference between insured & uninsured Source: 2011 Minnesota Health Access Survey

Percent of Minnesotans with Some Delay in Care in 2011, by Type of Coverage

42

Îndicates statistically significant difference to rate for all. Source: 2011 Minnesota Health Access Survey

Percent of Minnesotans with Some Delay in Care in 2011, by Type of Coverage

43

Îndicates statistically significant difference to rate for all. Source: 2011 Minnesota Health Access Survey

Percent of Minnesotans Reporting Provider Discrimination, by Insurance Status

4.5%^

9.0%

17.3%^

32.7%^

10.7%

3.2%*^ 4.8%*^

14.1%*^

26.3%^

8.4%

0%

5%

10%

15%

20%

25%

30%

35%

Group Individual Public Uninsured Total2009 2011

44

Change in item wording in 2011 may, in part, explain change in estimates over time. *Indicates a statistically significant difference from previous year shown at the 95% level. Îndicates a statistically significant difference from statewide rate within year at the 95% level. Source: 2009 and 2011 Minnesota Health Access Surveys

Presenter

Presentation Notes

For the total sample, report of discrimination decreased among all types of coverage from 2009 to 2011. For the total sample, the uninsured are most likley to report discrimination due to type of insurance/because uninsured (26.3%), followed by public (14.1%), individual (4.8%), and group (3.2%).

Percent of Parents Reporting Perceived Provider Discrimination, by Insurance Status

2.3%^ 4.3%

23.9%^

30.7%^

8.9%

1.6%*^

7.1%

22.1%*^ 21.6%^

7.8%

0%

5%

10%

15%

20%

25%

30%

35%

Group Individual Public Uninsured Total2009 2011

45

Change in item wording in 2011 may, in part, explain change in estimates over time. *Indicates a statistically significant difference from previous year shown at the 95% level. Îndicates a statistically significant difference from statewide rate within year at the 95% level. Source: 2009 and 2011 Minnesota Health Access Surveys

Presenter

Presentation Notes

However, among children, those with public coverage are the most likely to report discrimination (22.1%), compared to 21.6% of the uninsured, 7.1% of those with ind. coverage, and 1.6% of those with group coverage. This pattern was not observed among children in 2009 (where the uninsured were most likely to report discrimination). Difference between public and uninsured not significant interesting that > % of adults reporting for children report discrim than adults reporting for self

Confidence in Being Able to Obtain Needed Care

46

Percent of Minnesotans “very confident” They Can Get Care When Needed

80.0%^

65.4%^

70.0%

35.9%^

72.6% 80.7%^

74.6%^ 69.3%^

30.9%^

72.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


2009 2011

47


Presenter

Presentation Notes

Those with group coverage are most likely to report being "very confident" (80.7%), compared to 74.6% of those with ind. coverage, 69.3% of those with public, and only 30.9% of the uninsured. There was no change in confidence in getting care for the total sample from 2009 to 2011. The only change was seen among those with individual coverage, where more individuals reported feeling "very confident" (65.4% to 74.6%).

Percent of Parents Who Are “very confident” They Can Get Care When Needed for Their Child

87.9%^

65.4%^

77.0%

56.6%^

82.9% 86.8%^ 86.5%^

75.7%^

45.0%^

81.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


2009 2011

48


Presenter

Presentation Notes

Notes from Stefan: would agree, unless the drop for kids is significant (at .9 maybe)? Jessie: no significant drop for kids, even at 90% Kathleen: Guess it depends on the message could emphasize that parents are more confident about getting care for kids than themselves, yet preventive care is important for both. Guess you could say that with slide 14 and drop 15 and 16. However, I agree that the statewide results are interesting and plenty to talk about. IF you like this strategy, could do the same for the discrim results too (report only total pop and point out interesting results by age – however the bigger story is how confidence and discrim vary by COVTYPE).

Conclusions • Rates of health insurance coverage in 2011 have largely

remained unchanged compared to 2009 • Coverage through employer-sponsored insured did not

improve two years after the end of the recession • Sizable disparities in coverage by age, income, and race

& ethnicity remain • For a variety of reasons, many uninsured do not take

advantage of coverage options available to them • Lack of insurance coverage presents barriers to

accessing care (usual source of care, confidence) • Even Minnesotans who have insurance coverage face

barriers to care, particularly related to cost

49

50

Additional Information from the Health Economics Program Available Online • Health Economics Program Home Page

• www.health.state.mn.us/healtheconomics

• Publications • www.health.state.mn.us/divs/hpsc/hep/publications/

• Health Care Market Statistics (Chartbook Updates) • www.health.state.mn.us/divs/hpsc/hep/chartbook/

• Interactive Health Insurance Statistics • pqc.health.state.mn.us/mnha/Welcome.action

• Contact:

Stefan Gildemeister, 651-201-3550 [email protected]

http://www.health.state.mn.us/healtheconomics

http://www.health.state.mn.us/divs/hpsc/hep/publications/yearly/2010.html

http://www.health.state.mn.us/divs/hpsc/hep/chartbook/index.html

https://pqc.health.state.mn.us/mnha/Welcome.action




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HEALTH INSURANCE COVERAGE IN MINNESOTA · 3/29/2012 · HEALTH INSURANCE COVERAGE IN MINNESOTA Early Results from the 2011 Minnesota Health Access Survey Access Workgroup - Governor’s