Health Insurance and Health Care in Wyoming

1
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
2
Overview

• Consequences of being uninsured
• How does a lack of insurance affect people?
• Why arent more people covered?
• Arent 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

3
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

4
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

5
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

6
Why arent 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

7
Why arent 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

8
Why arent 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

9
What is Medicaids 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

10
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?

11
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 Wyomings uninsured
  population and develop a strategic plan to reduce
  their number

12
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?

13
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

14
National baseline data
15
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

16
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

17
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

18
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 Childrens Insurance Program)
• Adults do not qualify for Medicaid unless they
  are pregnant, disabled, or have dependent children

19
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.
20
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

21
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

22
Results from Wyoming research
23
Initial findings from household survey (late 2002)

• 5,511 responses to survey (mail and phone)
• 14.1 of Wyomings residents are uninsured
  70,217 people
• 14.5 of adults about 53,000
• 13.1 of children (18 and under) about 17,000

24
Uninsured percentage by county
County Mean 12.08
The counties in gray have above mean of
uninsured, representing about 1/3 of Wyomings
population.
25
Uninsured individuals by age(from household
survey)
26
Uninsured by household income
27
Uninsured individualsLength of time Since last
insured
28
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

29
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

30
of uninsured individuals by household per
capita incomeAge 0 to 4 years
31
of uninsured individuals by household per
capita income Age 19 to 24 years
32
of uninsured individuals by household per
capita income Age 25 to 34 years
33
of uninsured individuals by household per
capita income Age 35 to 44 years
34
of uninsured individuals by size of firm where
employed(from household surveys)
35
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!

36
(No Transcript)
37
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

• Root Causes of Uninsurance Health Care Costs and
  Low Wages
• Solutions No Silver Bullet

• 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

38
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
  weve almost seen a 10-fold increase in cost
  increase in the cost, total cost of health
  insurance in roughly 21, 22 years. (Ralph Hayes,
  Employees Group Insurance Program)

39
Borger, Smith, Truffer, Keehan, Sisko, Poisal
Clemens, 2006.
40
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)

41
Wyoming Wages, 2004
42
2006 HHS Poverty Guidelines
SOURCE  Federal Register, Vol. 71, No. 15,
January 24, 2006, pp. 3848-3849 .
According to US Census, official poverty rate is
12.5
43
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.
44
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 Im still alive 3 days
  later (Uninsured Person)
• I started taking medication for bipolar But I
  weaned myself off of it because I know Im not
  going to be able to get it And Im just winging
  it Just do each day as it comes. (Uninsured
  Person)

45
Table 5.4 Income and Incidence of Uninsured,
1987-2000
Lower-income groups are more likely to be
uninsured than higher-income groups.
lt100 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.
46
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.
47
Admission Rates for Avoidable Hospital Conditions
by Uninsured vs. Privately Insured
Adjusted Relative Rates
48
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, theres
  no way to pay for that. (Nurse Practitioner)

49
Local Safety Nets

• Hospitals
• Community clinics
• Private physician offices
• Other agencies
• Intact, but endangered (IOM, 2000)

50
Patients by Revenue Source Physicians and
Federally Qualified Health Centers
51
Dobie, Hagopian, Kirlin Hart, 2005.
52
Dobie, Hagopian, Kirlin Hart, 2005.
53
Barriers to Purchase of Health Insurance Money

• Moderator Id 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

54
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 couldnt afford 80 every two weeks for
  the premium. (Uninsured Person)

55
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.
56
Employees
SPG, 2003
57
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, Isnt 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 wouldnt. And I dont know what
  difference that makes. My income doesnt go up
  any more. (Uninsured Person)

58
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.

59
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 hes making 8
  an hour, and then were going to take .25 an
  hour out of your paycheck to cover the overage of
  insurance, all the sudden hes in the negative.
  He cant make his house payment, or he cant make
  this or that and then It ends up coming out of
  the employers pocket one way or the other.
  (Small Employer)

60
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 thats meaningful to our employees, yet
  doesnt bankrupt our organization or keep us from
  doing other things. (Employer Key Informant)

61
Employers (from employer survey)

• 72.2 of states 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
62
Employers Not Providing Insurance

• Cost was so excessive for a few employees.
  (Small Employer)
• A lot of employers opt out because . . . if
  youve 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 theyre on . . .
  Some employers dont want to go through the
  hassle. (Small Employer)

63
Employers
SPG, 2003
64
Employers
SPG, 2003
65
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)

66
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)

67
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.
68
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.
Percentage of Premium Paid by Covered Employees,
1988-2001
Average Monthly Employee Contribution, 1988-2001
Source Kaiser/HRET Survey of Employer-Sponsored
Health Benefits 2000, 2001 KPMG Survey of
Employer-Sponsored Health Benefits 1988, 1993,
1996.
69
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)

70
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 its going up another 20 some
  percent next year. . . The insurance company we
  had dropped all policies in WY, at least thats
  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
  cant 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)

71
Solutions Across the Political Spectrum

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

72
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

73
Populations of special interest young adults
74
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

75
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

76
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.)

77
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)

78
Questions?
For more information, contact the CRHRE
http//www.health.uwyo.edu
79
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.c
  fm
• Kaiser Commission on Medicaid and the Uninsured
  fact sheet, The Uninsured in Rural America,
  April 2003. http//www.kff.org/uninsured/kcmu22520
  2factsheet.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.pd
  f
• 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/uni
  nsured/20020510-index.cfm