Health Insurance Coverage Among North Dakotans

1. Health Insurance Coverage Among North Dakotans Dakota Conference March 25, 2004 Alana Knudson, PhD Mike Cogan, MA John Baird, MD Kyle Muus, PhD Garth Kruger, MS

2. Overview of Presentation • National Perspective on Uninsured • State Perspective on Uninsured • Estimates of uninsured (national surveys) • State Planning Grant • Research • Policy

3. September 30, 2003 Headlines Big Increase Seen in People Lacking Health Insurance The New York Times Census Finds Many More Lack Health Insurance Washington Post

4. What is the increase in uninsured? • 5.7% increase in 2002 • Translates to 2.4 million people • About 4 times the population of North Dakota

5. What is the total uninsured? • 43.6 million people • Translates to the aggregate population of 24 states • 15.2% of Americans are uninsured

6. Who are the uninsured by age? Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured, March 2002 CPS

7. Who are the uninsured by income? Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured, March 2002 CPS

8. Who are the uninsured by work status? Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured, March 2002 CPS

9. Cost of Being Uninsured % of adults not receiving preventive services (uninsured, insured) • Mammography in past 2 yrs (32%, 11%) • Pap test in past 3 yrs (20%, 6%) • Hypertension screening (20%, 6%) • Cholesterol screening (40%, 18%) • Diabetics’ dilated eye exam (44%, 27%) • Diabetics’ foot exam (64%, 40%) Source: Hadley, 2003; Ayanian, 2000

10. Cost of Being UninsuredLess Preventive Care • % increase in probability of late-stage diagnosis--uninsured compared to insured • colorectal cancer--70% • melanoma--160% • breast cancer--40% • prostate cancer--50% Source: Hadley, 2003; Canto, 2000

11. Cost of Being Uninsured Household Finances and Work • 44% of uninsured had serious problem paying medical bills; nearly a third were contacted by a collection agency • Poor health reduces annual earnings: • Earnings lost: white men, 21%, black men, 22%, white women, 12%, black women, 28% • States also incur costs in areas such as mental health and safety net spending Source: Kaiser, January 2003; Hadley, 2003

12. Who are the uninsured in North Dakota?

13. North Dakota’s Uninsured Source: Current Population Survey • *Total Population • 72,000 uninsured, 11.4% • *Children Under 18 • 12,000 uninsured, 8.5% • ** Low-Income Children Under 19 • 10,000 uninsured, 6.4% • Below 200% FPL Source: *3 Year Average of 2000, 2001, and 2002 CPS Data, ** 3 Year Average of 1999, 2000 , and 2001 CPS Data

14. North DakotaBehavioral Risk Factor Surveillance Survey • 11.8% indicated they did not have any kind of health care coverage • 7.1% indicated they could not see a doctor because of the cost • 58.2% indicated they used health care coverage from their employer to cover medical care • 13.2% indicated they bought their own health care coverage

15. State Planning Grant • Awarded to North Dakota Department of Health by the Health Resources Service Administration, HHS • Fall 2003 • 44 states have received funding since 1999 • Provides funding to explore uninsured issues • Research to examine uninsured (state surveys) • Develop policy options to explore options to decrease uninsured • UND Center for Rural Health ~ Research • Household Surveys • Employer Surveys • North Dakota Department of Health ~ Policy • Governor’s Advisory Committee on Health Insurance

16. Research

17. Research Components • Household Focus Groups • Report available • Household Survey • Report available ~ June 2004 • Uninsured Focus Groups • May 2004 • Employer Focus Groups • April 2004 • Employer Survey • Fall 2004

18. Household Focus Groups • Four focus groups were conducted in Valley City, Hettinger, Tioga, and Grand Forks • Cost matters • Purchasing health insurance • Seeking health care • Many issues contribute to health insurance costs • Some participants had not had a routine checkup in three years

19. Household Telephone Survey • Who are North Dakota’s insured and uninsured? • Telephone survey • Conducted by SSRI, UND • 3,199 households • Demographics • Urban, large rural, small rural • Gender • Age • Income • Employment Status • Health Status

20. North Dakota Household Designations Urban-17,000+ Large Rural-5,000 to 16,999 Small Rural-< than 5,000

21. Household Survey Preliminary Results • 1,978 surveys completed • 1,059 Urban • 775 Small Rural • 144 Large Rural

22. Preliminary Results - Gender

23. Preliminary Results Regular Place for Healthcare

24. Preliminary Results - What type of facility do you normally visit for health care?

25. Preliminary Results - Do you have a regular Dr.?

26. Preliminary Results - Self-reported Health Status

27. Policy

28. Governor’s Advisory Committee on Health Insurance • Established to identify options to decrease the number of uninsured in North Dakota • Members appointed in October 2003 • Advisory Committee Meetings • November 2003 • February 2004 • April 30, 2004 • Advisory Committee Report • October 2004

29. Biron Baker Larry Bernhardt Carol Berntson William Butcher Tim Cox Sherlyn Dahl Dick Hedahl Lonna Milburn Kristi Pfliger-Keller Jon Rice Chip Thomas Pat Traynor Governor’s Advisory Committee on Health Insurance

32. What are other states doing? • Expanding public coverage • Medicaid & SCHIP waivers • Section 1115 & HIFA (Health Insurance Flexibility and Accountability) • Premium assistance for employer-sponsored insurance • Bolstering the Safety Net

33. Maine – Dirigo Health • Voluntary program addressing cost, quality, and access • Insurance plan – offered to small business (<50 workers), self-employed, low-income in large firms • Cost containment measures • “Savings offset payment” on carriers from uncompensated care savings (capped at 4%)

34. Utah – Primary Care Network • Primary and preventive care services • Provide coverage of single adults and couples w/o children • 150% of poverty (do not qualify for Medicaid) • No access to employer sponsored health insurance • Enrollment fee, cost sharing with annual cap • Specialist & hospital care through community donated care alliances

35. What are other states doing? • Partnering with the Private Sector • Subsidizing employees (UT) • Subsidizing insurance market (NY) • Pooled purchasing (WV) • Mandates (CA)

36. Utah – Covered at Work Program • Part of Primary Care Network • Employees who have not taken employer sponsored insurance • Receive a voucher for the value of the Primary Care Network benefits

37. New York – Healthy NY • Commercial insurance product • For small firms with low-wage workers, low-income self-employed, uninsured workers • Reduced premiums through: • Stop-loss fund: state pays 90% claims $5K-75K • In-network benefits only • High cost-sharing

38. West Virginia • Pool based on Public Employees Insurance • Small employers (<50 workers) • Cost-sharing, crowd-out rules

39. California – “Pay or Play” • Businesses pay into State Health Purchasing Fund for each worker • Receive credit for providing acceptable coverage • Employer must cover >80% of premium • >200 employees from 2006 • 50-199 employees from 2007 • 20-49 only if state passes 20% tax credit for employers

40. North Dakota • CHAND (Comprehensive Health Association of North Dakota) • Healthy Communities Access Project (HCAP) – Northland & DMF • Community Resource Coordinators • Caring Program • Community Health Center (CHC) expansions • Uncompensated care

41. Next steps… • Review North Dakota research • Where are the gaps in health insurance coverage? • Identify options that may decrease the number of uninsured • Present to Governor in Fall 2004 • Present to Legislative Interim Committees in Fall 2004

42. Health care for all…

43. For more information contact:Center for Rural HealthUND School of Medicine and Health SciencesGrand Forks, ND 58202-9037701-777-3848http://medicine.nodak.edu/crh Comments, questions, and ideas: spg@state.nd.us