PROFILE OF MINNESOTA S UNINSURED SUMMARY OF KEY FINDINGS Kathleen T. Call, Elizabeth Lukanen, Jessie Kemmick Pintor, Giovann Alarcón April 29, 2014 Funded by NASHP, MDH, DHS and the Robert Wood Johnson Foundation
Overview This profile is designed to provide information about uninsured Minnesotans that can aid policy Second development level as well as outreach and enrollment efforts. It includes information about the characteristics of the uninsured, their access to insurance, access to and Third of health level care, and reasons they lack insurance. We estimate their eligibility for insurance options Fourth available level through the Affordable Care Act (ACA), as well as those who are not eligible Fifth for ACA level expansions. We also provide a summary of the projected impact of the ACA in Minnesota provided by Gruber and Gorman, followed by documented results of health reform efforts in Massachusetts and Oregon to foreshadow what might be expected in Minnesota. We close with a series of maps that indicate where rates of uninsurance are highest in the state, estimated location of the uninsured eligible for Medicaid, MinnesotaCare, and MNsure with a subsidy along with overlays of other information that aid outreach efforts such as the location of schools, churches and hospitals. We focus on the non-elderly population who are the primary target of ACA provisions. We draw on a variety of data sources to tell this story. The compilation of the information presented in this chart book was funded by the National Academy for State Health Policy (NASHP). 2
Slide 4 Slides 5-24 uninsured in Minnesota? Slides Third 25-35 level Access to and of care for the uninsured Slides 36-46 Slides 47-52 Slides 53-70 Slides 71-126 Data sources used among the uninsured Table of Contents Estimates of populations not expansions What we know about take-up from prior research of uninsured across Minnesota 3
Data sources 2013 Minnesota Health Access Survey (MNHA) American Community Survey (ACS): 2011 Fourth Small level Area Health Insurance Estimates (SAHIE) 2011 & 2012 1-year file 2010-2012 3-year file 2008-2012 5-year file Minnesota Gruber-Gorman simulation model 2011 MNHA, health plan data, and MEPS-HC 4
WHO ARE THE UNINSURED IN MINNESOTA? 5
Section overview of coverage among non-elderly (0-64) Summary characteristics of uninsured Minnesotans Measures Fourth of level uninsurance (point-in-time, long- and short-term uninsured) Uninsurance rates by demographic characteristics Demographic and employment characteristics of the uninsured Reasons for uninsurance 6
Preview: Nonelderly uninsured, 2013 9.4% at time of survey, or 13.7% uninsured at some time in 2013 Uninsurance rates highest among: 18-34 year-olds; Blacks, Hispanics, and American Indians; non US-born, and those under 200% FPG Uninsured are less likely to be employed than MNs overall And were more likely to be self-employed, work fewer hours, and work for smaller firms Most report lack of coverage due to cost, and loss of coverage due to job termination Source: 2013 Minnesota Health Access Survey 7
Sources of insurance coverage among nonelderly, Click to edit Master 2013 text styles 70.0% 60.0% 50.0% 63.2% 40.0% 30.0% 20.0% 21.3% 10.0% 6.1% 9.4% 0.0% Group Coverage Public Coverage Individual Coverage Uninsured Source: 2013 Minnesota Health Access Survey 8
Measures of uninsurance among nonelderly, Click to edit 2013 Master text styles Some episode of uninsurance in year 13.7% Uninsurance, all year 7.0% Uninsurance, point in time 9.4% NOTE: Unless otherwise indicated, estimates are based on those uninsured at the time of the survey or a point in time 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% Source: 2013 Minnesota Health Access Survey 9
Nonelderly Minnesotans with an episode of uninsurance, Click to edit Master 2013 text styles (13.7%) Uninsured now (9.4%) Insured now Uninsured now, but was insured at some point in the year (short-term) (2.4%) Uninsured for 12 months or longer (long-term) (7.0%) Insured now, but had episode of uninsurance in past 12 months (4.3%) Uninsured at some point in the year (13.7%) Long-term uninsured means uninsured for 12 months or longer Source: 2013 Minnesota Health Access Survey 10
Age distribution of nonelderly long-term uninsured Click to edit and Master total text nonelderly styles population, 2013 35.0% 30.0% 25.0% 20.0% 19.0% 21.0%^ 24.2%^ 31.1% 30.2% 15.0% 10.0% 9.3% 8.7%^ 12.5% 13.2% 10.6%^ 15.0% 5.0% 5.3%^ 0.0% 0-5 6-17 18-25 26-34 35-54 55-64 Long-term uninsured Total Long-term uninsured means uninsured for 12 months or longer ^Indicates statistically significant difference in the rates to the overall population (95% level) Source: 2013 Minnesota Health Access Survey 11
Uninsurance rates by age among nonelderly, Click to edit Master 2013 text styles 20.0% 18.0% 16.0% 14.0% 12.0% 13.9%^ 17.3%^ 10.0% 8.8% 9.4% 8.0% 6.0% 7.4% 5.6%^ 6.2%^ 4.0% 2.0% 0.0% 0-5 6-17 18-25 26-34 35-54 55-64 Overall ^Indicates statistically significant difference in the rates to the overall population (95% level) Source: 2013 Minnesota Health Access Survey 12
Uninsurance rates by race/ethnicity among nonelderly, Click to edit Master 2013 text styles 40.0% 35.0% 30.0% 25.0% 35.4%^ 20.0% 19.2%^ 15.0% 15.0%^ 13.5% 10.0% 7.0%^ 10.6% 9.4% 5.0% 0.0% White Black Hispanic American Indian Asian Other Overall ^Indicates statistically significant difference in the rates to the overall population (95% level) Respondents were able to choose more than one race/ethnicity Source: 2013 Minnesota Health Access Survey 13
Uninsurance rates for nonelderly Minnesotans Click to edit Master born text and styles not born in US, 2013 30.0% 25.0% 20.0% 27.3%^ 15.0% 10.0% 7.7%^ 9.4% 5.0% 0.0% Not US born US born Overall ^Indicates statistically significant difference between US-born and non US-born (95% level) Reported for individuals 3 years and older Source: 2013 Minnesota Health Access Survey 14
Uninsurance rates by FPG* among nonelderly, Click to edit Master 2013 text styles 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 18.3%^ 17.5%^ 10.7% 9.4% 8.0% 6.0% 5.3%^ 4.0% 2.0% 2.0%^ 0.0% FPG <= 100% FPG 101-200% FPG 201-300% FPG 301-400% FPG >400% Overall ^Indicates statistically significant difference in the rates to the overall population (95% level) *2012 Federal Poverty Guidelines (FPG) Source: 2013 Minnesota Health Access Survey 15
Comparing demographic characteristics of the nonelderly Click to edit Master uninsured text styles to overall population, 2013 Compared to the nonelderly MN population overall Minnesota s uninsured were more likely to be: Male, between 18 and 34 years of age; African American, American Indian, or Hispanic/Latino; not born in the U.S. Not married, lower-income (200% of FPG or less); in good or fair/poor health (vs. excellent or very good) There were no regional differences (Twin Cities/Greater MN) between the nonelderly uninsured and overall nonelderly Source: 2013 Minnesota Health Access Survey 16
Comparing employment characteristics of the nonelderly Click to edit Master uninsured text styles to overall population, 2013 Second The nonelderly level uninsured were less likely to be employed than Third the level overall nonelderly population (74% compared with 82%) Minnesota s nonelderly uninsured were more likely to: Be self employed Work between 11-20 hours (as compared to fewer or more) Work for firms with fewer than 100 employees, and Hold temporary or seasonal jobs Source: 2013 Minnesota Health Access Survey 17
Potential sources of coverage among nonelderly Click to edit Master uninsured, text styles 2013 70.0% 60.0% 50.0% 62.4% 40.0% 37.0% 30.0% 20.0% 19.7% 10.0% 0.0% Connection to employer that offers coverage Eligible for employer coverage Potentially eligible for public programs Source: 2013 Minnesota Health Access Survey 18
Measures of reasons for uninsurance Second Primary level reasons for lack of coverage Main reasons for not enrolling in public health care programs Interaction of the uninsured with public health care programs 19
Primary four reasons for lack of coverage among Click to edit non-elderly Master text styles uninsured, 2013 Did not take-up ESI when offered* Did not purchase coverage directly Too expensive/ could not afford 44.5% 60.5% Not eligible for reason other than health 31.0% 7.6% Expect to be covered shortly 15.5% 4.8% Unemployed/not working 6.2% Receives services through IHS 1.2% Reason for loss of coverage Among shortterm uninsured Among longterm uninsured Job that provided coverage ended 34.4% 40.7% No longer eligible for public insurance 21.2% 18.8% Did not provide info to stay on public program 10.2% Could no longer afford employer coverage/cobra 5.2% 8.1% No longer eligible for parents policy 7.9% Could no longer afford to buy own coverage Source: 2013 Minnesota Health Access Survey 20
Primary reasons for lack of coverage by age Click group, to edit Master 2013 text styles Second Sample level size does not support separate analysis for adults and children, yet it appears that: The most Fifth common level reason for not taking up ESI for nonelderly adults is not being eligible for reasons unrelated to health whereas cost and of coverage is most important for children Loss of coverage is tied to job loss for non-elderly adults, whereas for children, not providing information to stay on a public program is most common 21
Main reasons for not enrolling in public health care Click programs to edit Master among text uninsured styles children*, 2013 1.2% 1.6% Do now need or want insurance right now 15.2% 3.0% 9.7% 0.0% 9.4% 10.7% Rarely sick Do not know what to do/where to go/how to enroll Too much hassle/paperwork Too expensive Do not think the care or benefits through these programs are good Applied but is not eligible Do not think is eligible 0.1% 5.9% 18.4% Is embarrased or do not want other to know Do not think government should pay for their health care Do not want government involved in their health care 0.9% 3.7% Will get insurance soon or has applied and is waiting Gets care through IHS 20.3% *Reports by parents or guardians Source: Minnesota Health Access Survey, 2013 0.0% Never looked into it Other 22
Main reasons for not enrolling in public health care programs Click to edit among Master uninsured text styles nonelderly adults, 2013 Do now need or want insurance right now 1.1% 0.3% 4.5% 3.3% 14.1% 0.7% 7.0% 5.4% 6.0% 2.7% 14.9% 6.4% Rarely sick Do not know what to do/where to go/how to enroll Too much hassle/paperwork Too expensive Do not think the care or benefits through these programs are good Applied but is not eligible Do not think is eligible Is embarrased or do not want other to know Do not think government should pay for their health care Do not want government involved in their health care Will get insurance soon or has applied and is waiting 11.7% 21.6% Gets care through IHS Never looked into it 0.2% Other Source: Minnesota Health Access Survey, 2013 23
Interaction with public health care programs among Click to edit eligible Master nonelderly text styles uninsured, 2013 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 75.9% 52.4% 88.1% 87.8% 83.0% 84.1% 73.6% Children NE Adults 30.0% 20.0% 10.0% * 0.0% Asked/given information about public programs Would enroll if eligible Of those who say no or do not know: would enroll if coverage was free Would participate in a premium assistance program *Insufficient sample for children Source: 2013 Minnesota Health Access Survey 24
ACCESS TO AND AFFORDABILITY OF CARE FOR THE UNINSURED 25
Measures of access and Usual source of care, and type of usual source of care Confidence in care Forgone care due to cost Financial burden Problems paying medical bills Payment plan with clinic to cover medical bills Trouble paying for other living costs due to medical bills 26
Preview: Access to care Most Minnesotans have a usual source of care; this is less Second true for the level uninsured, especially uninsured non-elderly adults The most common source of care is a doctors office, however, the uninsured also use safety net clinics and ED services Most Minnesotans are confident in getting care when needed; this is less true for the uninsured, especially uninsured non-elderly adults 27
Preview: Affordability Compared to those with insurance, uninsured children and Second non-elderly level adults are significantly more likely to Report forgone care due to cost Experience financial burden Forgone care due to cost and experiences of financial burden appear more prominent among uninsured non-elderly adults than uninsured children 28
Percent of nonelderly uninsured without a usual source Click to edit of care, Master 2013 text styles 100.0% 90.0% 80.0% 70.0% 60.0% 94.5% 79.2%^ 87.2% 50.0% 40.0% 30.0% 48.5%^ Insured Uninsured 20.0% 10.0% 0.0% Children NE Adults ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 29
Place of usual source of care among nonelderly uninsured, Click to edit Master 2013 text styles 1.0% 100% 0.1%^ 0.6% 0.5% Second 0.0% 1.5% level 2.2% 8.4% 3.6% 90% 80% 70% 60% 50% 40% 30% 20% 10% 7.6% 90.0% 0.0% 5.5% 25.2%^ 60.7%^ 7.5% 86.2% 0.0% 15.6%^ 4.1% 0.7% 21.4%^ 57.7%^ Some place else An emergency room or urgent care center A VA hospital/clinic A An Indian Indian Health Health Care Care provider provider A sliding fee scale, public health, or free clinic A private clinic or doctor s office 0% Insured - Children Uninsured - Children Insured - Adults Uninsured - Adults ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 30
Percent of nonelderly uninsured very or somewhat Click confident to edit they Master can text get styles care when needed, 2013 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 96.8% 77.6%^ 93.3% 53.6%^ Insured Uninsured 0.0% Children NE Adults ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 31
Percent of uninsured children* with forgone care due to worry about cost, 2013 50% 45% 40% 35% 30% 28.1%^ 25% 20% 16.6%^ 21.8%^ Insured Uninsured 15% 10% 5% 10.9% 4.3% 9.6% 5.9% 8.0%^ 8.8%^ 2.0% 1.5% 1.7% 0% Any Care Presciption Dental Care Routine Care Mental Health Specialist Care Care *Reports by parents or guardians ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 32
Percent of uninsured nonelderly adults with forgone Click to edit care Master due to text worry styles about cost, 2013 50% Second 48.7%^ level 45% 40% 35% 30% 36.2%^ 34.8%^ 25% 20% 18.7% 19.6%^ 19.4%^ 19.7%^ Insured Uninsured 15% 12.4% 10% 5% 7.1% 5.4% 3.4% 4.5% 0% Any Care Presciption Dental Care Routine Care Mental Health Care Specialist Care ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 33
Percent of uninsured children* experiencing financial Click to edit burden, Master 2013 text styles 70% 60% 50% 40% 30% 20% 10% 21.0% 51.1%^ 12.6% 32.1%^ 16.3% 40.7%^ 7.7% 24.5%^ Insured Uninsured 0% Any Financial Burden Problem paying medical bills Set up a payment plan for medical bills Had trouble with basic bills due to medical costs *Reports by parents or guardians ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 34
Percent of uninsured nonelderly adults experiencing Click to edit Master financial text styles burden, 2013 70% 60% 50% 40% 30% 23.8% 63.4%^ 52.4%^ 48.1%^ 34.1%^ Insured Uninsured 20% 15.3% 17.5% 10% 8.4% 0% Any Financial Burden Problem paying medical bills Set up a payment plan for medical bills Had trouble with basic bills due to medical costs ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 35
ACA ELIGIBILITY AMONG THE UNINSURED: APPLYING 2014 ELIGIBILITY CRITERIA TO 2013 MNHA DATA 36
Method for estimating 2014 Click Medicaid to edit eligible Master includes: text styles Adults (19 or older) with family income of 138% FPG or less Children (18 or younger) with family income of 275% FPG or less Infants (23 months or younger) with family income of 280% FPG or less MNCare/BHP eligibility includes: Adults (19 or older) who are not eligible to get coverage through their employer (or their spouse s/parents employer) and report a family income between 139 200% of FPG Exchange subsidy eligibility includes: Everyone with family income of 400% FPG or lower who do not meet the eligibility criteria presented above and are not eligible to get coverage through their employer (or their spouse s or parents employer) 37
Insurance coverage among nonelderly by ACA eligibility 100% 90% 80% 70% 60% 50% 40% 30% 16.7% 5.4% 37.7% 44.4% 16.5% 0.0% 33.7% 24.5% 0.0% 2.3% 4.7% 84.1% Uninsured Individual Coverage Group Coverage Public Coverage 20% 40.3% 39.2% 41.8% 10% 0% 8.8% MA-eligible MNCare/BHP-eligible Exchange-eligible Not Source: 2013 Minnesota Health Access Survey 38
among nonelderly uninsured 16.2% 15.1% 58.0% Eligible for MA Eligible for MinnesotaCare/BHP Eligible for Exchange with subsidies Not coverage 10.8% Source: 2013 Minnesota Health Access Survey 39
What do we know about Medicaid-eligible nonelderly? Second Children level are overrepresented among those eligible for Medicaid, whereas we observe the opposite for nonelderly Fourth adults level 35 years of age or older MA-eligible are more likely to be Hispanic, and less likely to be white, in comparison to the overall MN nonelderly population MA-eligible are less likely to live in non-core rural areas and to have completed some years of college than the overall MN nonelderly population 40
What do we know about MinnesotaCare/BHP- Click eligible to edit non-elderly? Master text styles Those eligible for MNCare or BHP are less likely to be college Third graduates level or have completed postgraduate studies Fourth than level the overall MN nonelderly population 41
What do we know about MNSure subsidy-eligible Click non-elderly? to edit Master text styles Children and young adults (18-25) are underrepresented among Third people level eligible for subsidies or tax credits, whereas people 35 years of age or older are overrepresented Those eligible Fifth for level subsidies or tax credits are more likely to be white, and less likely to be black or Hispanic than the overall MN nonelderly population Those eligible for subsidies or tax credits are less likely to live in micropolitan rural areas People who do not have a high school diploma are underrepresented among those eligible for subsidies 42
Age distribution among nonelderly uninsured by 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 29.2%^ 0.0% 6.0%* 3.8%* 23.5% 10.6% 8.5%* 15.6% 21.7% 35.3% 17.9% 32.6% 19.4%* 39.1% 52.4%^ 33.5% 6.2%* 17.4%^ 15.0% 12.4% 0-17 18-25 26-34 35-54 55-64 ^Indicates that this estimate is statistically significantly higher than the estimate for the overall population (95% level) *Indicates that this estimate is statistically significantly lower than the estimate for the overall population (95% level) Source: 2013 Minnesota Health Access Survey MA-eligible MNCare/BHP-eligible Exchange-eligible Not 43
Race/ethnicity among nonelderly uninsured by 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 73.7%^ 53.4%* 62.9% 75.5%^ 15.1% 11.5% 4.6%* 13.4% 27.8%^ 22.0% 6.5%* 5.1%* Sample size is insufficient for reporting Asian and other race estimates 4.0% 3.6% 4.1% 2.6% White Black Hispanic American Indian ^Indicates that this estimate is statistically significantly higher than the estimate for the overall population (95% level) *Indicates that this estimate is statistically significantly lower than the estimate for the overall population (95% level) Source: 2013 Minnesota Health Access Survey MA-eligible MNCare/BHP-eligible Exchange-eligible Not 44
Geographic distribution among nonelderly uninsured by 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 72.3% 64.8% 75.5% 61.1% 16.7% 16.2% 7.5%* 13.5% 10.9%* 22.8% 27.8% 11.1% MA-eligible MNCare/BHP-eligible Exchange-eligible Not 0.0% Metropolitan Urban Micropolitan Rural Non-core Rural ^Indicates that this estimate is statistically significantly higher than the estimate for the overall population (95% level) *Indicates that this estimate is statistically significantly lower than the estimate for the overall population (95% level) Source: 2013 Minnesota Health Access Survey 45
Level of education among nonelderly uninsured by 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 22.7% 21.2% 34.8% 32.0% 29.9% 23.3% 27.1%* 36.3% 41.1% 42.3% 15.4% 27.6% 24.7% MA-eligible MNCare/BHP-eligible Exchange-eligible Not 10.0% 5.0% 8.0%* 3.1%* 10.4%* 0.0% Less than HS HS Some college College grad/postgrad ^Indicates that this estimate is statistically significantly higher than the estimate for the overall population (95% level) *Indicates that this estimate is statistically significantly lower than the estimate for the overall population (95% level) Source: 2013 Minnesota Health Access Survey 46
ESTIMATES OF POPULATIONS NOT ELIGIBLE FOR ACA EXPANSIONS 47
Low-income uninsured not eligible for ACA Click to expansions edit Master text due styles to immigration status Medicaid eligibility by immigration status unauthorized immigrants and legal permanent residents (LPRs) who have resided legally in the U.S. for < five years are not eligible Exchange (tax credit) eligibility by immigration status unauthorized immigrants are not eligible 48
Estimates of Medicaid eligibility by immigration status % unauthorized or legal permanent residents of <5 years 7% 10% 3% NE Adults Low Income NE Adults Low Income Uninsured NE Adults 49
Estimates of Exchange (tax credit) eligibility by immigration status 10,170, or 5.9% of all uninsured non-elderly adults with incomes between 139 and 400% FPG are unauthorized 50
Family glitch Second Non-elderly level adults (19-64) between 138-400% FPG with Third an level employed spouse and access to coverage through Fourth that level spouse, but not eligible for coverage through own work Children (0-18) between 275-400% FPG with an employed parent and access to coverage through that parent 51
Total number in the glitch, 2013 (uninsured and those with individual coverage) Current Coverage Adults Second with Children level Individual Uninsured 138-200% FPL 298 5,830 >200-275% Third FPL level 4,277 0 >275-400% FPL 1,249 0 Adults without Children 138-200% FPL 0 1,323 >200-275% FPL 264 1,959 >275-400% FPL 1,791 2,660 All Adults 138-200% FPL 298 7,153 >200-275% FPL 4,541 1,959 >275-400% FPL 3,040 2,660 Adults (subtotal) Children >275-400% FPL 8,234 881 Total 16,113 12,653 52
WHAT WE KNOW ABOUT TAKE-UP AND ACCESS TO CARE FROM PRIOR RESEARCH 53
Take-up in Minnesota and other states 2011 Gruber-Gorman estimates of ACA impact in 2016 across markets (ESI, unreformed/reformed individual market, MNCare, Medical Assistance, BHP) and on number of remaining uninsured Take-up rates and the impact of coverage on access to care: Lessons from other states (MA, OR) 54
Estimate of ACA effect, 2016 (BHP/Wrap) Source: Gruber and Gorman MNsure Analysis, 2011 as presented January 2013 55
Estimated ACA effect on MNCare, 2016 Source: Gruber and Gorman MNsure Analysis, 2011 as presented January 2013 56
Predicting the size of MNsure, 2016 Source: Gruber and Gorman MNsure Analysis, 2011 as presented January 2013 57
Predicting remaining uninsured, 2016 Projected number uninsured in 2016: 210,000 43% 12% 9% Undocumented Newly Uninsured 36% Documented, Exempt from Mandate Subject to Mandage, Choose Not to Insure Source: Gruber and Gorman MNsure Analysis, 2011 as published April 2012 58
Massachusetts (MA) introduction MA Health Reform Initiative enacted in 2006 Serves as an important benchmark for take-up, access to care, and the welcome mat effect because it was used as a template for the structure of the ACA 59
Preview: Lessons from Massachusetts Take-up Second increased level for all types of insurance, though higher for public programs Medicaid Fourth enrollment level increased between 16 and 19 percentage points among those previously eligible but not enrolled Access improved: having a usual source of care and utilization increased and the inability to get care when needed and forgone care decreased Use of inpatient and ED services decreased Catastrophic health expenditures decreased 60
Take-up 2 years after MA reform enacted Click (Long to edit & Stockley, Master text 2011) styles Among lower-income adults (<350% FPL): 6 to Fourth 10 percentage level point (pp) increase in public coverage 4 to 6 pp increase for any coverage Among all adults: 2 to 4 pp increase in public coverage 2 to 3 pp increase for any coverage 61
Access to care 4 Years after MA reform Click enacted to edit (Long Master et text al., styles 2012) Outcome Usual source of care Preventive visit in past 12 months Multiple doctor visits in past 12 months Specialist visit in past 12 months Direction Magnitude 5 percentage points 6 percentage points 5 percentage points 4 percentage points Dental visit in past 12 months Any hospital stay Any ED visit in past 12 months 5 percentage points 2 percentage points 4 percentage points 3 or more ED visits 2 percentage points Most recent ED visit was for nonemergency condition 4 percentage points 62
Access to care 4 years after MA reform enacted Click to edit (Long Master et text al., styles 2012) Outcome Did not get needed care in past 12 months Doctor care Medical tests, treatment, follow-up care Direction Magnitude 2 percentage points 2 percentage points Preventive care screening 3 percentage points 63
Affordability of care 4 years after MA Click reform to edit enacted Master text (Long styles et al., 2012) Outcome Out-of pocket spending over past 12 months at >= 10% of Fourth family level income Did not get needed care because of costs in past 12 months Any care Direction Magnitude 4 percentage points 3 percentage points Doctor care Specialist care Medical tests, treatment, follow-up care Preventive care screening 3 percentage points 2 percentage points 2 percentage points 1 percentage points 64
MA reform and the Welcome Mat Effect Click (Sonier to edit et Master al., 2013) text styles Second The welcome level mat effect refers to an increase in Medicaid participation for populations that were previously eligible (prior to reform) but not enrolled Sonier et al. use MA as a case study to measure the potential effect of the ACA on the previously eligible, but not enrolled population They find an increase in Medicaid enrollment between 16 and 19 percentage points among those previously eligible but not enrolled 65
Preview: Lessons from Oregon 2008 Medicaid experiment based Medicaid expansion on a lottery from a waiting list of lowincome adults Baicker et al., 2013 evaluated the effect of Medicaid coverage on a range of outcomes Findings: Improved clinical outcomes, access to care, self-reported health, increased use of preventive care, and reduction of costs and financial strain 66
Effect of Medicaid enrollment after 2 years: health Click to edit care Master utilization text styles (Baicker et al., 2013) Outcome Direction Magnitude Usual source of care Office visit past month Received all needed care past 12 months 24 percentage points 3 percentage points 11 percentage points High quality care in past months Cholesterol screening Pap smear (women) Mammography (women) PSA test (men) 10 percentage points 15 percentage points 14 percentage points 30 percentage points 19 percentage points 67
Effect of Medicaid enrollment after 2 Years: Click health to edit outcomes Master text (Baicker styles et al., 2013) Outcome Direction Magnitude Self-reported health Self-reported depression 8 percentage points 2 percentage points Diagnosis of diabetes Prescription for management of diabetes 4 percentage points 5 percentage points 68
Effect of Medicaid enrollment after 2 years: financial Click to edit strain Master (Baicker text styles et al., 2013) Outcome Any out-of-pocket (OOP) spending Direction Magnitude Amount of annual OOP spending $215 12 percentage points Catastrophic expenditures (OOP>30% income) Any medical debt Borrowed $ to pay bills or skipped payment 4 percentage points 13 percentage points 14 percentage points 69
Literature cited Baicker, K., Taubman, S.L., Allen, H.L., Bernstein, M., Gruber, J.H., Newhouse, J.P., et al. (2013). The Oregon Experiment Effects of Medicaid on Clinical Outcomes. The New Third England level Journal of Medicine, 368: 1713-1722. doi: 10.1056/NEJMsa1212321 Long, S.K. & Stockley, K. (2011). The Impacts of State Health Reform Initiatives on Adults in New York and Massachusetts. Health Services Research, 46: 365 387. doi: 10.1111/j.1475-6773.2010.01211.x Long, S.K., Stockley, K., & Dahlen, H. (2012). Massachusetts Health Reforms: Uninsurance Remains Low, Self-Reported Health Status Improves As State Prepares To Tackle Costs. Health Affairs, 31(2): 444-451. doi:10.1377/hlthaff.2011.0653 Sonier, J., Boudreaux, M.H., & Blewett, L.A. (2013). Medicaid Welcome-Mat Effect Of Affordable Care Act Implementation Could Be Substantial. Health Affairs, 32(7): 1319-1325. doi:10.1377/hlthaff.2013.0360 70
DISTRIBUTION OF UNINSURED ACROSS MN 71
Exploring the distribution of uninsured Mapping the geography of the uninsured provides useful Second information level to guide outreach efforts Third Identify level concentrations of populations that are likely eligible for various Fourth coverage level options (e.g., MNCPs versus QHP subsidies) Comparing different geographies can confirm uniformity or highlight hotspots not seen in geographic roll ups (e.g., should a program be regional or county-based?) Layering on points of interest can inform potential outreach approaches (e.g., hospitals, schools) 72
Measures of the distribution of uninsured of uninsured across Minnesota counties of uninsured by zip code Estimates of uninsured eligible for Medicaid, MinnesotaCare/BHP and the Exchange with a subsidy, with overlays of cities, churches, hospitals, Federally Qualified Health Centers (FQHCs), and schools 73
DISTRIBUTION OF UNINSURED ACROSS MINNESOTA COUNTIES 74
Number of nonelderly uninsured, by county, 2011 Source: SHADAC Analysis of the US Census Bureau, Model- Based Small Area Health Insurance Estimates (SAHIE) for Counties and States, 75
Additional small area health insurance estimates (SAHIE) U.S. Third Census level Bureau s interactive data/map tool allows users to Fourth estimate level uninsurance at the county-level by a number of demographic groups, including: Age group (0-18, 18-64, 40-64, 50-64, 0-64) Sex Income (<=139% FPL*, <=200%, <=250%, <=400%) SAHIE Interactive Data Tool: https://www.census.gov/did/www/sahie/data/interactive/ *Federal Poverty Level 76
DISTRIBUTION OF UNINSURED BY ZIP CODE 77
Percent uninsured, by zip code tabulation area, 2008-2012 Source: SHADAC Analysis of the 2008-2012 American Community Survey. 78
ESTIMATES OF UNINSURED ELIGIBLE FOR MEDICAID, WITH OVERLAYS OF CITIES, CHURCHES, HOSPITALS AND SCHOOLS 79
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by region, 2011 Source: SHADAC analysis of 2011 American Community Survey (ACS). 80
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by region, 2011 - cities Source: SHADAC analysis of 2011 American Community Survey (ACS). 81
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by region, 2011 - churches Source: SHADAC analysis of 2011 American Community Survey (ACS). 82
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by region, 2011 - hospitals Source: SHADAC analysis of 2011 American Community Survey (ACS). 83
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by region, 2011 - schools Source: SHADAC analysis of 2011 American Community Survey (ACS). 84
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by PUMA, 2011 Source: SHADAC analysis of 2011 American Community Survey (ACS). 85
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by PUMA, 2011 - cities Source: SHADAC analysis of 2011 American Community Survey (ACS). 86
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by PUMA, 2011 - churches Source: SHADAC analysis of 2011 American Community Survey (ACS). 87
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by PUMA, 2011 - hospitals Source: SHADAC analysis of 2011 American Community Survey (ACS). 88
Number of nonelderly citizens who are uninsured and between 0-138% FPG, by PUMA, 2011 - schools Source: SHADAC analysis of 2011 American Community Survey (ACS). 89
Number of nonelderly citizens who are uninsured and between 0-138% FPG, metro, 2011 Source: SHADAC analysis of 2011 American Community Survey (ACS). 90
Number of nonelderly citizens who are uninsured and between 0-138% FPG, metro, 2011 cities Source: SHADAC analysis of 2011 American Community Survey (ACS). 91
Number of nonelderly citizens who are uninsured and between 0-138% FPG, metro, 2011 - churches Source: SHADAC analysis of 2011 American Community Survey (ACS). 92
Number of nonelderly citizens who are uninsured and between 0-138% FPG, metro, 2011 - hospitals Source: SHADAC analysis of 2011 American Community Survey (ACS). 93
Number of nonelderly citizens who are uninsured and between 0-138% FPG, metro, 2011 - schools Source: SHADAC analysis of 2011 American Community Survey (ACS). 94
ESTIMATES OF UNINSURED ELIGIBLE FOR MNCARE/BHP, WITH OVERLAYS OF CITIES, CHURCHES, HOSPITALS AND SCHOOLS 95
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by region, 2011 Source: SHADAC analysis of 2011 American Community Survey (ACS). 96
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by region, 2011 - cities Source: SHADAC analysis of 2011 American Community Survey (ACS). 97
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by region, 2011 - churches Source: SHADAC analysis of 2011 American Community Survey (ACS). 98
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by region, 2011 - hospitals Source: SHADAC analysis of 2011 American Community Survey (ACS). 99
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by region, 2011 - schools Source: SHADAC analysis of 2011 American Community Survey (ACS). 100
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by PUMA, 2011 Source: SHADAC analysis of 2011 American Community Survey (ACS). 101
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by PUMA, 2011 - cities Source: SHADAC analysis of 2011 American Community Survey (ACS). 102
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by PUMA, 2011 - churches Source: SHADAC analysis of 2011 American Community Survey (ACS). 103
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by PUMA, 2011 - hospitals Source: SHADAC analysis of 2011 American Community Survey (ACS). 104
Number of nonelderly citizens who are uninsured and between 139-250% FPG, by PUMA, 2011 - schools Source: SHADAC analysis of 2011 American Community Survey (ACS). 105
Number of nonelderly citizens who are uninsured and between 139-250% FPG, metro, 2011 Source: SHADAC analysis of 2011 American Community Survey (ACS). 106
Number of nonelderly citizens who are uninsured and between 139-250% FPG, metro, 2011 - cities Source: SHADAC analysis of 2011 American Community Survey (ACS). 107
Number of nonelderly citizens who are uninsured and between 139-250% FPG, metro, 2011 - churches Source: SHADAC analysis of 2011 American Community Survey (ACS). 108
Number of nonelderly citizens who are uninsured and between 139-250% FPG, metro, 2011 - hospitals Source: SHADAC analysis of 2011 American Community Survey (ACS). 109
Number of nonelderly citizens who are uninsured and between 139-250% FPG, metro, 2011 - schools Source: SHADAC analysis of 2011 American Community Survey (ACS). 110
ESTIMATES OF UNINSURED ELIGIBLE FOR EXCHANGE WITH SUBSIDY, WITH OVERLAYS OF CITIES, CHURCHES, HOSPITALS AND SCHOOLS 111
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by region, 2011 Source: SHADAC analysis of 2011 American Community Survey (ACS). 112
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by region, 2011 cities Source: SHADAC analysis of 2011 American Community Survey (ACS). 113
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by region, 2011 - churches Source: SHADAC analysis of 2011 American Community Survey (ACS). 114
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by region, 2011 - hospitals Source: SHADAC analysis of 2011 American Community Survey (ACS). 115
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by region, 2011 - schools Source: SHADAC analysis of 2011 American Community Survey (ACS). 116
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by PUMA, 2011 Source: SHADAC analysis of 2011 American Community Survey (ACS). 117
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by PUMA, 2011 - cities Source: SHADAC analysis of 2011 American Community Survey (ACS). 118
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by PUMA, 2011 - churches Source: SHADAC analysis of 2011 American Community Survey (ACS). 119
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by PUMA, 2011 - hospitals Source: SHADAC analysis of 2011 American Community Survey (ACS). 120
Number of nonelderly citizens who are uninsured and between 251-400% FPG, by PUMA, 2011 - schools Source: SHADAC analysis of 2011 American Community Survey (ACS). 121
Number of nonelderly citizens who are uninsured and between 251-400% FPG, metro, 2011 Source: SHADAC analysis of 2011 American Community Survey (ACS). 122
Number of nonelderly citizens who are uninsured and between 251-400% FPG, metro, 2011 - cities Source: SHADAC analysis of 2011 American Community Survey (ACS). 123
Number of nonelderly citizens who are uninsured and between 251-400% FPG, metro, 2011 - churches Source: SHADAC analysis of 2011 American Community Survey (ACS). 124
Number of nonelderly citizens who are uninsured and between 251-400% FPG, metro, 2011 - hospitals Source: SHADAC analysis of 2011 American Community Survey (ACS). 125
Number of nonelderly citizens who are uninsured and between 251-400% FPG, metro, 2011 - schools Source: SHADAC analysis of 2011 American Community Survey (ACS). 126
Click to edit Contact Master information title style shadac@umn.edu 612.624.4802 Kathleen Thiede Call callx001@umn.edu www.shadac.org @shadac