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Health Insurance and Health Care in Wyoming


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Title: 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
  • 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

Does lack of insurance affect access to health
  • 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

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

Is the problem getting worse?
  • Number of uninsured has grown in the last five
  • 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
  • Stalling of economic growth has resulted in
  • Over five million more Americans became uninsured
    between 2000 and 2003

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

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

Why arent more working people covered?
  • Health coverage varies by industry and type of
  • Uninsured rate among agriculture and construction
    is around 38
  • Public administration (government) rate is around
  • Over 80 of uninsured workers are in blue-collar

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

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?

2002-2003 Wyoming Insurance Study (State Planning
  • Wyoming Department of Health received funding
    from Health Resources and Services Administration
    to undertake a Wyoming-specific study of
  • UW was subcontractor for research and strategic
  • Mission was to understand Wyomings uninsured
    population and develop a strategic plan to reduce
    their number

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
  • What options would result in the highest number
    of people being able to afford coverage?

Research Activities
  • Data Collection Analysis
  • Baseline data from national research
  • Statewide household and employer surveys (with
  • Focus groups
  • Interviews with key informants
  • Group quarters interviews

National baseline data
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

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
  • Most of these have one or more full-time workers
    in the household

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
  • 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

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
  • 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

Table 5.5 Race and Incidence of Uninsured,
Minorities are more likely than whites to be
Non-Hispanic American Indian
Non-Hispanic Asian
Non-Hispanic Black
Non-Hispanic White
Note Under 65 population. Source Tabulations
of the March Current Population Survey files by
Actuarial Research Corporation, incorporating
their historical adjustments.
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

Rural uninsured
  • Why are risks higher in rural areas?
  • More remote rural residents come from low-income
  • 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

Results from Wyoming research
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

Uninsured percentage by county
County Mean 12.08
The counties in gray have above mean of
uninsured, representing about 1/3 of Wyomings
Uninsured individuals by age(from household
Uninsured by household income
Uninsured individualsLength of time Since last
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

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

of uninsured individuals by household per
capita incomeAge 0 to 4 years
of uninsured individuals by household per
capita income Age 19 to 24 years
of uninsured individuals by household per
capita income Age 25 to 34 years
of uninsured individuals by household per
capita income Age 35 to 44 years
of uninsured individuals by size of firm where
employed(from household surveys)
Focus Groups, Key Informant Interviews and Survey
  • 13 focus groups (with physicians interviewed
  • 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!

(No Transcript)
  • Uninsured Persons/Families
  • Meeting Health Needs Between and Rock and a Hard
  • 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.
  • Decisions about Type of Coverage Playing Around
    with Deductible and Premiums
  • Response to Economic Downtown Increased Employee

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)

Borger, Smith, Truffer, Keehan, Sisko, Poisal
Clemens, 2006.
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

Wyoming Wages, 2004
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
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
  • 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

Table 5.4 Income and Incidence of Uninsured,
Lower-income groups are more likely to be
uninsured than higher-income groups.
lt100 of Federal Poverty Level
100-200 of Federal Poverty Level
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.
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
Adjusted Relative Rates
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)

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

Patients by Revenue Source Physicians and
Federally Qualified Health Centers
Dobie, Hagopian, Kirlin Hart, 2005.
Dobie, Hagopian, Kirlin Hart, 2005.
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

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)

Table 5.1 Out-of-Pocket Spending by the Under 65
Population by Insurance Status by Income,
The percent of health spending from out-of-pocket
sources by the uninsured is significantly higher
than for those with insurance.
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.
SPG, 2003
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)

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.
  • 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)

Employers Decisions about Insurance Salary Vs.
  • 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)

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
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)

SPG, 2003
SPG, 2003
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
  • 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)

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
Any Government
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.
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,
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,
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 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

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
  • Expansion of public programs (Medicaid, SCHIP
  • New public programs, e.g., national health
  • 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

Populations of special interest young adults
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

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

Young adults
  • Why is health insurance important to this age
  • 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.)

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

For more information, contact the CRHRE
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//
  • Kaiser Commission on Medicaid and the Uninsured
    fact sheet, The Uninsured in Rural America,
    April 2003. http//
  • S.R. Collins, et al., Rite of Passage? Why Young
    Adults Become Uninsured and How New Policies Can
    Help, The Commonwealth Fund, May 2004.
  • T.D. Rowley, The Rural Uninsured Highlights
    from Recent Research, Health Resources and
    Services Administration, January 2003.
  • Kaiser Commission on Medicaid and the Uninsured
    report, Sicker and Poorer The Consequences of
    Being Uninsured, May 2002. http//