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Health Insurance and Health Care in Wyoming. Rex E. Gantenbein, Ph.D., Center for Rural Health Research and Education Mary E. Burman, Ph.D., Fay W. Whitney School of Nursing. Consequences of being uninsured How does a lack of insurance affect people? Why aren’t more people covered?

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health insurance and health care in wyoming

Health Insurance and Health Care in Wyoming

Rex E. Gantenbein, Ph.D., Center for Rural Health Research and Education

Mary E. Burman, Ph.D., Fay W. Whitney School of Nursing

overview
Consequences of being uninsured

How does a lack of insurance affect people?

Why aren’t more people covered?

Aren’t there public programs for health care?

Research findings

Who are the uninsured in America, and in Wyoming?

What are the reasons for being uninsured?

What can be done?

Special interest population: Young adults

Overview
slide3

Does lack of insurance affect access to health care?

  • Lack of coverage means decreased access to care and increased risk
    • The uninsured are more likely to postpone or forego treatment, even for serious conditions
    • Many uninsured cannot follow recommended treatments or fill prescriptions
    • Uninsured are less likely to have a regular source of care
slide4

How do the uninsured pay for medical care?

  • Uninsured are often low-income, so medical bills can have a serious impact on family finances
    • Only about 35% of uninsured care costs are paid by uninsured
    • Most of remainder is “uncompensated care”
      • Estimated $41,000,000,000 in 2004
      • 85% of this paid by government sources
slide5

Is the problem getting worse?

  • Number of uninsured has grown in the last five years
    • Rates were stable (and even declined briefly) in mid-to-late 1990s
      • Increased employer coverage due to good economy
      • Medicare enrollment stabilized due to welfare reform
    • Stalling of economic growth has resulted in increases
      • Over five million more Americans became uninsured between 2000 and 2003
slide6

Why aren’t more working people covered?

  • 27,000,000 workers were not covered in 2003 (increase of 1,000,000 over previous year)
    • Not all businesses offer health benefits to workers or their families
    • Not all workers qualify for coverage
    • Many employees cannot afford their share of the premiums
slide7

Why aren’t more working people covered?

  • Small businesses are less likely to offer insurance to their employees
    • Fewer than 2/3 of businesses with fewer than 200 employees offer health insurance
    • Small businesses often require a higher share of premium cost from employees
  • Part-time workers are usually not eligible for benefits
slide8

Why aren’t more working people covered?

  • Health coverage varies by industry and type of occupation
    • Uninsured rate among agriculture and construction is around 38%
    • Public administration (government) rate is around 6%
    • Over 80% of uninsured workers are in blue-collar jobs
slide9

What is Medicaid’s role?

  • Medicaid covers three main groups of non-elderly, low-income people
    • Children (over half of beneficiaries)
    • Parents (if eligible under state guidelines)
    • People with disabilities
  • Most single or childless adults are not eligible for Medicaid, no matter how poor
slide10

What can be done?

  • If we can understand the nature of the problem, we may be able to develop policy to address it
    • Who are the uninsured?
    • Why are they uninsured?
    • What solutions might help?
slide11

2002-2003 Wyoming Insurance Study (State Planning Grant)

  • Wyoming Department of Health received funding from Health Resources and Services Administration to undertake a Wyoming-specific study of uninsured
    • UW was subcontractor for research and strategic planning
    • Mission was to understand Wyoming’s uninsured population and develop a strategic plan to reduce their number
research plan
Research Plan

The Wyoming insurance study was designed to answer these questions:

  • Who are the uninsured in Wyoming and how do they compare to national demographics?
  • Why are they uninsured and how long have they been uninsured?
  • What might enable employers to offer insurance to more employees and their dependents?
  • What is the economic impact on individual communities and the State as a result of lack of coverage?
  • What options would result in the highest number of people being able to afford coverage?
research activities
Research Activities
  • Data Collection & Analysis
    • Baseline data from national research
    • Statewide household and employer surveys (with comments)
    • Focus groups
    • Interviews with “key informants”
    • Group quarters interviews
slide15

Who are the uninsured?

  • Most Americans under 65 who have health insurance coverage receive it as an employer benefit
    • Americans over 65 are covered by Medicare
    • Some non-elderly, low-income people qualify for Medicaid, SCHIP or other state-subsidized programs
slide16

Who are the uninsured?

  • 45,000,000 Americans were without health insurance coverage in 2003!
    • 18% of the nonelderly population (1% increase from 2002)
  • More than 80% of the uninsured came from working families
    • Most of these have one or more full-time workers in the household
slide17

Who are the uninsured?

  • Among poor people, the uninsured rate is 36% (twice the average)
    • “Poor” is defined as under 100% of the federal poverty level -- $14,348 for a family of 3 in 2002)
  • The near-poor (100-200% of FPL) are also at risk (30% uninsured)
    • Often ineligible for Medicaid
  • These two income groups account for two-thirds of uninsured
slide18

Who are the uninsured?

  • Majority of uninsured adults (59%) have gone without coverage for two years or longer
  • Adults are more likely to be uninsured than children
    • Most low-income children qualify for Medicaid or SCHIP (State Children’s Insurance Program)
    • Adults do not qualify for Medicaid unless they are pregnant, disabled, or have dependent children
slide19

Table 5.5

Race and Incidence of Uninsured, 1987-2000

Minorities are more likely than whites to be uninsured.

Hispanic

Non-Hispanic American Indian

Non-Hispanic Asian

Non-Hispanic Black

Total

Non-Hispanic White

Note: Under 65 population.

Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments.

slide20

Rural uninsured

  • 17% of non-elderly rural population are uninsured
    • Remote rural areas (not adjacent to an urban county) have even higher risk (24%)
    • Rural residents tend to be uninsured for longer periods than urbanites
slide21

Rural uninsured

  • Why are risks higher in rural areas?
    • More remote rural residents come from low-income families
    • Rural residents are less likely to be offered health benefits through employment
      • Rural/remote rural residents are just as likely as urban workers to enroll in programs if offered, however
initial findings from household survey late 2002
Initial findings from household survey (late 2002)
  • 5,511 responses to survey (mail and phone)
  • 14.1% of Wyoming’s residents are uninsured: 70,217 people
    • 14.5% of adults: about 53,000
    • 13.1% of children (18 and under): about 17,000
uninsured percentage by county
Uninsured percentage by county

County Mean = 12.08%

The counties in gray have above mean % of uninsured, representing about 1/3 of Wyoming’s population.

uninsured individuals takeup of employer coverage
Uninsured individuals takeup of employer coverage
  • 9.2% of households reported someone in the household is eligible for employer coverage but is not enrolled
    • 38.9% of those said reason is they cannot afford it
uninsured individuals takeup of employer coverage1
Uninsured individuals takeup of employer coverage
  • 19.4% of uninsured report someone in the household is eligible for employer coverage but is not enrolled
    • 61.4% of these people say reason is they cannot afford it
slide34

% of uninsured individuals by size of firm where employed(from household surveys)

focus groups key informant interviews and survey comments
Focus Groups, Key Informant Interviews and Survey Comments
  • 13 focus groups (with physicians interviewed individually)
    • Uninsured persons, small employers and health care providers
    • Statewide with 82 different people
  • 16 Key informant interviews
    • Insurance industry leaders, safety net providers, business and health leaders, professional organization directors/officers.
  • Mail and telephone survey comments
  • 610 pages of transcribed data!
themes
Root Causes of Uninsurance: Health Care Costs and Low Wages

Solutions: No Silver Bullet

Themes

Uninsured Persons/Families

  • Meeting Health Needs: Between and Rock and a Hard Place
  • Barriers to Purchase of Health Insurance: Money, money, money
  • Participation in Public Programs: Falling Through the Cracks
  • Employer-based Coverage
  • Decisions about Offering Insurance: Salary Vs. Benefits
  • Decisions about Type of Coverage: Playing Around with Deductible and Premiums
  • Response to Economic Downtown: Increased Employee Cost-Sharing
root causes health care costs
Root Causes: Health Care Costs

Back in 1981 . . . a single policy generally ran about $45, for a family about $95, which at the time seemed rather expensive. However, now we are in 2003 and a single policy has gone from $45 to $358 and family has gone from 95 to $828, so we’ve almost seen a 10-fold increase in cost increase in the cost, total cost of health insurance in roughly21, 22 years. (Ralph Hayes, Employees Group Insurance Program)

root causes low wages
Root Causes: Low Wages

[At 185% poverty], their actual income. . . ends up being around . . . $2000 to $2400 a month. Now you think of raising a family . . . on that and all the expenses of rent and insurance on your car and the whole bit. It really does not leave money for people to have insurance.(Key Informant)

slide42

2006 HHS Poverty Guidelines

Size ofFamily Unit

48 ContiguousStates and D.C.

Alaska

Hawaii

1

$ 9,800

$12,250

$11,270

2

13,200

16,500

15,180

3

16,600

20,750

19,090

4

20,000

25,000

23,000

5

23,400

29,250

26,910

6

26,800

33,500

30,820

7

30,200

37,750

34,730

8

33,600

42,000

38,640

For each additional person, add

3,400

4,250

3,910

SOURCE:Federal Register, Vol. 71, No. 15, January 24, 2006, pp. 3848-3849 .

According to US Census, official poverty rate is 12.5%

slide43

Table 5.6

The Uninsured by Age, 1987-2000

Most of the uninsured are adults 18-54.

Note: Under 65 population.

Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments.

meeting health needs between a rock and a hard place
Impact of Being Uninsured:

You live paycheck to paycheck.

(Uninsured Person)

Illness Behavior:

I take 3 aspirin and if I’m still alive 3 days later… (Uninsured Person)

I started taking medication for bipolar… But I weaned myself off of it because I know I’m not going to be able to get it… And I’m just winging it… Just do each day as it comes. (Uninsured Person)

Meeting Health Needs: Between a Rock and a Hard Place
slide45

Table 5.4

Income and Incidence of Uninsured, 1987-2000

Lower-income groups are more likely to be uninsured than higher-income groups.

<100% of Federal Poverty Level

100-200% of Federal Poverty Level

Total

200+% of Federal Poverty Level

Note: Under 65 population.

Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments.

slide46

Table 5.10

Impact on Non-Elderly Adults of Being Uninsured, 2000

The uninsured face financial and other barriers to health care.

Note: Among adults under age 65.

Source: NewsHour with Jim Lehrer/Kaiser Family Foundation, National Survey on the Uninsured, April 2000.

admission rates for avoidable hospital conditions by uninsured vs privately insured
Admission Rates forAvoidable Hospital Conditions by Uninsured vs. Privately Insured

Adjusted Relative Rates

managing care for the uninsured
Managing Care for the Uninsured

It impacts me… limiting the number of laboratory tests and x-rays that I might order to just the bare essentials… choosing the medication based on what I have available for samples… rather than based on what I think is the best drug clinically. (Physician)

If someone comes in with cardiac chest pain who may need a stress test or cardiac cath, there’s no way to pay for that. (Nurse Practitioner)

local safety nets
Local Safety Nets
  • Hospitals
  • Community clinics
  • Private physician offices
  • Other agencies

“Intact, but endangered” (IOM, 2000)

barriers to purchase of health insurance money
Barriers to Purchase of Health Insurance: Money

Moderator: I’d like for you to tell me the main reason you do not have insurance?

Margie: Money

Bob: Money

Kathy: Money

Richard: Money

Veronica: No money

Susan: Money

barriers to purchase of health insurance cont
Barriers to Purchase of Health Insurance (Cont.)

I only had one job ever in this town where I had benefits included in the job. (Uninsured Person)

But see even my pay at $7.50 an hour, 40 hours a week, I couldn’t afford $80 every two weeks [for the premium]. (Uninsured Person)

slide55

Table 5.1

Out-of-Pocket Spending by the Under 65 Population by

Insurance Status by Income, 1996-1998

The percent of health spending from out-of-pocket sources by the uninsured is significantly higher than for those with insurance.

Uninsured

Insured

Percent of Health Spending Out-of-Pocket

Percent of Health Spending Out-of-Pocket

Note: Insured includes all types of insurance coverage.

Source: Actuarial Research Corporation tabulations of Medical Expenditure Panel Survey.

employees
Employees

SPG, 2003

participation in public programs falling through the cracks
Participation in Public Programs: Falling Through the Cracks

When I had all this problem going on with my teeth, I had gone to the Welfare Department and asked them, “Isn’t there anybody that can help me?” And they said, “Helen, we would pay for everything if you had your children living with you.” But because my children live with my ex-husband they wouldn’t. And I don’t know what difference that makes. My income doesn’t go up any more. (Uninsured Person)

significant gaps in medicaid coverage
Significant Gaps in Medicaid Coverage
  • In over half of states, woman working full-time at minimum wage job with 2 children would have too much income to be eligible for Medicaid.
  • Women without children not eligible in 40 states, despite being low-income.
employers decisions about insurance salary vs benefits
Employers Decisions about Insurance: Salary Vs. Benefits

An employee lives on what he makes and.. If it costs him $8 an hour to live and he’s making $8 an hour, and then… we’re going to take $.25 an hour out of your paycheck to cover the overage of insurance, all the sudden he’s in the negative. He can’t make his house payment, or he can’t make this or that and then… It ends up coming out of the employer’s pocket one way or the other. (Small Employer)

employers decisions about insurance salary vs benefits1
Employers Decisions about Insurance: Salary Vs. Benefits

We have also seen that as a company we battle the premium war trying to decide. Those decisions are made at the corporate level, but still our company battles what percentage of cost to pass on to our employees to still be offering a benefit that’s meaningful to our employees, yet doesn’t bankrupt our organization or keep us from doing other things. (Employer – Key Informant)

employers from employer survey
Employers (from employer survey)
  • 72.2% of state’s employers offer health insurance to their full-time employees
    • Fewer than 10% offer it to part-time
    • 64.3% offer it to dependents of full-time
    • Fewer than 9% pay all or part of insurance costs for retirees

SPG, 2003

employers not providing insurance
Employers Not Providing Insurance

Cost was so excessive for a few employees. (Small Employer)

A lot of employers opt out because . . . if you’ve got 20 employees, my paperwork that I would submit would be that thick because I have to do a census on every employee and each of their dependents and their health conditions, who they see, and what medication they’re on . . . Some employers don’t want to go through the hassle. (Small Employer)

employers
Employers

SPG, 2003

employers1
Employers

SPG, 2003

decisions about types of coverage deductibles and premiums
Decisions about Types of Coverage: Deductibles and Premiums

We have a $250 deductible and a $500 deductible. . . This year we offered to do a $1000 deductible but after the employee uses the first $500 of the deductible, we will pay the second $500. . . We really felt that would save us rather than . . . paying for the $500 deductible.(Small Employer)

responses to economic downturns increase employee cost sharing
Responses to Economic Downturns: Increase Employee Cost-sharing

I agree. . . with everyone else that I will offer benefits as long as I can. With us, we have a separate dental that might go first, or I would ask the employees to pay all of the premiums, but that would be before the health insurance. (Small Employer)

slide67

Table 1.4

Sources of Health Insurance Coverage for the

Under 65 Population, 1980-2000

Over the last two decades, private coverage has declined, public coverage has stayed about the same, and the uninsured have grown.

Any Private

74%

ESI

69%

Uninsured

16%

Any Government

14%

9%

Medicaid

Notes: ESI - Employer Sponsored Insurance. Any Private includes ESI and individually purchased insurance. Any government includes Medicare for the disabled population.

Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments.

slide68

Table 4.6

Employee Contributions to Health Insurance Premiums, 1988-2001

Employees are paying a higher dollar value, but smaller share of theirhealth insurance premiums.

Average Monthly Employee Contribution, 1988-2001

Percentage of Premium Paid by Covered Employees, 1988-2001

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2000, 2001; KPMG Survey of Employer-Sponsored Health Benefits: 1988, 1993, 1996.

solutions across the political spectrum
Solutions: Across the Political Spectrum

The problem of out-of-control drug and medical services which were caused by the government meddling in the first place. All this is heading to is more socialist programs to have the taxpayer subsidize the health program. Where in our constitution does it guarantee all our medical needs will be paid by the government? (Survey participant)

solutions across the political spectrum1
Solutions: Across the Political Spectrum

We firmly believe something must be done statewide or nationally. We are farmers and ranchers. . . We, a couple, pay $788 a month for a policy with a $5,000 per person deductible. They tell us it’s going up another 20 some percent next year. . . The insurance company we had dropped all policies in WY, at least that’s what they told us, so we were picked up by another company. Being upper middle aged and having some medical problems no other company will give us insurance without putting riders on it. . . We are at the mercy of Mother Nature and the grain and cattle markets. . . We need the state or nation to address this problem. Why can’t we be put into a statewide group policy to help get reduced rates? It is not fair for us to be subsidizing government employees, teachers, and the poor and have no help in getting reasonable rates for the rest of us. (Survey participant)

solutions across the political spectrum2
Solutions: Across the Political Spectrum

I think the USA should socialize medicine. There should be free insurance for everybody. (Survey participant)

solutions no silver bullet
Solutions: No Silver Bullet
  • Expansion of public programs (Medicaid, SCHIP (KidCare)
  • New public programs, e.g., national health insurance
  • Supporting, developing and expanding safety net
  • Expanding employer-based coverage: purchasing alliances, tax credits, subsidies
  • Increasing personal responsibility
  • Control costs and address HCP shortages
  • Tort reform
  • Restructuring insurance
slide74

Young adults

  • Young adults (19-29) are one of the largest and fastest-growing segments of the uninsured
    • Uninsured rate nearly 30%,
    • Up by 2,000,000 in past decade
slide75

Young adults

  • Why are rates higher among young adults?
    • Many insurance programs terminate dependent coverage at 19
    • Life transitions change coverage options (graduation, independence)
    • Young people have lower incomes, families
slide76

Young adults

  • Why is health insurance important to this age group?
    • Disrupts access to health care system
    • Puts uninsured at risk for high costs in case of severe illness or injury
    • Increases risk of problems with acute care
      • Pregnancy
      • HIV
      • Injury
      • Chronic diseases (heart, cancer, etc.)
slide77

Young adults

  • What can be done to help?
    • Extend private insurance eligibility for dependents through age 23
    • Extend eligibility for Medicaid/SCHIP through age 23
    • Require that all college students have health insurance (and that colleges offer it to both full- and part-time students)
slide78

Questions?

For more information, contact the CRHRE

http://www.health.uwyo.edu

references and further reading
References and further reading
  • Kaiser Commission on Medicaid and the Uninsured report, “The Uninsured: A Primer – Key Facts about Americans Without Health Insurance,” November 2004. http://www.kff.org/uninsured/7216.cfm
  • Kaiser Commission on Medicaid and the Uninsured fact sheet, “The Uninsured in Rural America,” April 2003. http://www.kff.org/uninsured/kcmu225202factsheet.cfm
  • S.R. Collins, et al., “Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help,” The Commonwealth Fund, May 2004. http://www.cmwf.org/usr_doc/collins_ritepassage.pdf
  • T.D. Rowley, “The Rural Uninsured: Highlights from Recent Research,” Health Resources and Services Administration, January 2003. http://ruralhealth.hrsa.gov/policy/uninsured.htm
  • Kaiser Commission on Medicaid and the Uninsured report, “Sicker and Poorer: The Consequences of Being Uninsured,” May 2002. http://www.kff.org/uninsured/20020510-index.cfm