2003 Alabama Health Care Insurance and Access Survey

Montgomery, AL

May 2, 2003

Ashley Alvord, MPHAlabama Department of Public HealthChildren’s Health Insurance Program

Survey funded by a grant from the US Health Resources and Services Administration

Overview of Session

• Why conduct health insurance surveys?• Why the CSCS survey platform?• What populations were identified as important

for policy makers in Alabama?• What unique questions did Alabama ask in the

2003 Health Care Insurance and Access Survey?• Review of selected results.• Summary and conclusions.

Why do states conduct health insurance surveys?

• State survey sample size is typically much larger than Federal sample – providing better estimates for both statewide and subpopulations

• Allows for details on sub-populations of interest– Geographic areas (urban, rural)

– By race and ethnicity

• Allows for hands-on work with the data– State-specific policy development

– Simulation of policy options

Coordinated State Coverage Survey (CSCS)

• CSCS is a household telephone survey developed by the State Health Access Data Assistance Center (SHADAC)

• Flexible design captures:– Overall level of uninsurance in the state– Characteristics of the uninsured– Additional questions of local policy interest

• CSCS can provide rates by geographic region and sub-group (e.g., racial and ethnic groups)

Why Alabama Chose the Coordinated Sate Coverage Survey (CSCS) Platform

• Proven Results - Other states that received previous planning grants had used the CSCS platform successfully.

• Timeliness – The survey instrument was available quickly which fit with the grant’s one year timeline.

• Comparability – GA and SC are using the basic CSCS as a platform for their state surveys, therefore we would have common data elements to compare among our states.

• Relevance - The CSCS platform was easily tailored to Alabama’s policy interests.

• Experience – Both the University of Minnesota Survey Center and the State Health Access Data Assistance Center (SHADAC) had experience with fielding the survey as well as analysis of the survey findings.

Populations Studied in the 2003 Alabama Health Care Insurance

and Access Survey• Insured – having current health insurance through an

employer group, public program, or individually purchased policy.

• Uninsured – having no insurance coverage at the time of survey.

• Underinsured – insured but indicating difficulty in accessing needed medical services

• Unstably Insured – insured but worried this coverage will end within the next twelve months.

Additional Items of Interest

• Geography –Twelve geographic regions were evaluated: 9 Metropolitan Statistical Areas, Northern Rural Counties, Black Belt Counties and Southern Rural Counties.

• Special Populations – Children and Hispanics were over sampled in order to provide more detailed data on these groups.

Unique Questions from Alabama’s Survey

• Dental / Mental Health –Respondents (both insured and uninsured) were asked about dental and mental health insurance coverage and utilization of dental health and mental health services. Of particular interest were barriers to receiving care.

• Confidence in ability to receive needed care – Respondents (both insured and uninsured) were asked about their comfort level in obtaining needed medical and pharmacy services including what barriers they perceived to obtaining these services. In addition, the insured population was asked to rate their confidence level in maintaining their current health insurance for the next 12 months.

Selected Data from Alabama’s Survey

• Sources of Health Insurance • Uninsurance Rates by age, race, income level, employment

status and educational attainment• Geographic Regions of Interest• Items of Statistical Significance• Potential Access to Health Insurance Coverage– Employer-

sponsored and Public Programs• Utilization of Health Care Services • Barriers to Accessing Care – Dental and Mental Health

Services

What are the sources of health insurance coverage in Alabama?

Coverage AL RateUS Rate

(CPS 2001)

Uninsured 11.2% 14.6%

Employer Sponsored Coverage

53.7% 62.6%

Public Program 31.4% 25.3%

Individual Coverage 3.7% UNK

Definitions of Uninsurance Used in the Survey

• Uninsured at Point in Time – survey respondents that reported being uninsured at the time of the survey.

• Uninsured All Year – survey respondents that were uninsured at the time of the survey and reported no insurance coverage in past year.

• Uninsured Part Year – survey respondents that were insured at the time of the survey but reported being uninsured at some point in the past year.

• Uninsured at Some Point During the Year – a combination of those uninsured all year and uninsured part of the year.

Current Alabama Uninsurance Rates

Definition AL Rate

Uninsured at Point in Time

11.2%

Uninsured All Year 8.8%

Uninsured Part Year 5.8%

Uninsured at Some Point During Year

14.6%

How does Alabama Compare?

Definition AL RateUS Rate

(MEPS 1999)

Uninsured : Point in Time 11.2% 17.3%

Uninsured All Year 8.8% 12.2%

Uninsured Part Year 5.8% -

Uninsured at some point During Year

14.6% 25.0%

AL Uninsurance Rates by Age

11.2

4.3

7.6

20.5

23.1

13.0 11.6

1.10.00

5.00

10.00

15.00

20.00

25.00

All Ages 0-5 6-18 19-24 25-34 35-54 55-64 65+

All rates reflect point in time data.

AL Uninsurance Rates by Race

11.213.2

10.9

5.5

22.0

10.2

0.10.0

5.0

10.0

15.0

20.0

25.0

Total Population African American American Indian Asian

Hispanic Whie Other

All rates reflect point in time data.

AL Uninsurance Rates by Income Level

11.2

18.918.1

20.9

17.114.9

8.17.6

3.00.00

5.00

10.00

15.00

20.00

25.00

Total Population <15% FPL 15 - 100% FPL

101-133% FPL 134-150% FPL 151 - 200% FPL

201 - 250% FPL 251 - 300% FPL >300% FPL

All rates reflect point in time data.

AL Uninsurance Rates by Employment Status

11.2

17.3

8.4

25.7

2.2

14.3

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Total Population Self Employed

Employed by Someone Else Not employed / unpaid worker

retired Student

All rates reflect point in time data.

AL Uninsurance Rates by Educational Attainment

11.2

21.3

13.3

10.2

3.83.4

0.00

5.00

10.00

15.00

20.00

25.00

Total Population Less than High School High School graduate

Some College College graduate Postgraduate

All rates reflect point in time data.

AL Uninsurance Rates by Geographic Region

8.413.3

9.110.9

15.614.9

11.8

11.213.0

10.77.7

10.013.6

0.00 5.00 10.00 15.00 20.00

Tuscaloose MSA

Southern Rural

Northern Rural

Montgomery MSA

Mobile MSA

Huntsville MSA

Florence MSA

Dothan MSA

Black Belt

Birmingham MSA

Auburn MSA

Anniston MSA

ALL Regions

All rates reflect point in time data.

Items of Statistical Significance

• Compared to the survey population as a whole, the following populations were more likely to be uninsured:– Adults aged 19 to 34 years of age , specifically 25 to 34 years of

age.

– Individuals living in families with incomes of less than 133% FPL, specifically between 15% and 100% FPL.

– Adults with less than a high school education

– Unemployed adults

– Individuals working for firms with less than 10 employees.

What are some potential sources of coverage for the uninsured*?

• Some uninsured appear to have potential access to coverage:

– 20.8% indicated they were eligible for Employer Sponsored Coverage

– 21.9% are potentially eligible for public health care program

– 62.0% are eligible for neither

*Data adds to over 100% due to individuals that are eligible for both an employer sponsored insurance Program and potentially eligible for a pubic program.

Uninsured People Whose Employer Offers Coverage: Reasons For Not Enrolling

Expensive61%

Don't Qualify25%

Desire Adequacy

3%Other10%

Covered Soon1%

Uninsured People Who Are Potentially Eligible for Public Programs:

Willingness to Enroll

Yes77%

Don't Know/ Refused

20%No3%

Do the Uninsured have a Regular Source of Care?

90.293.1

71.1

0

10

20

30

40

50

60

70

80

90

100

Uninsured Insured Publicly Insured Privately

Perc

enta

ge w

ith

regu

lar

sour

ce o

f ca

re

Where do those with a regular source of care access their health care?

Source Type of Insurance

Uninsured Public Private Emergency Room

13.5% 2.3% 2.1%

Doctor’s Office 58.5% 72.9% 85.7%

Clinic 25.9% 21.2% 10.9%

Other 2.1% 3.6% 1.3%

TOTAL 100% 100% 100%

Types of Clinics used by those with a regular source of care

Source Type of Insurance

Uninsured Public Private

Free Clinic 71.0% 44.9% 26.7%

Hospital Clinic 16.3% 24.5% 24.1%

Private Clinic 9.1% 23.7% 45.8%

Other 3.7% 6.9% 3.5%

TOTAL 100% 100% 100%

How to Measure “Unmet Need”?

7.2

11.2

54.6

0

10

20

30

40

50

60

Public Private Uninsured

Health Insurance Status

“Was there any time over the past twelve months when you needed to see a doctor but could not because of cost?

Access to Preventive Dental Care in Alabama?

• 77.0% of those individuals with private insurance coverage indicated that this coverage included preventive dental care. 46.6% of publicly insured individuals reported this type of coverage and 3.0% of those without medical insurance coverage indicated that they had some coverage for preventive dental health care.

• Of those that indicated they had received dental treatment in the past 12 months (30% of the uninsured, 50.4% of the publicly insured and 68.7% of the privately insured), many reported having problems finding a convenient dental office (30.3%, 15.2% and 8.1% respectively).

Main Reason for Not Receiving Dental Care or Problem Finding a Dentist

Don't Need It40%

Too expensive22%

No dentist in area

9%

Not important12%

Other4%

Not accepting my insurance

5%

Child too young

8%

Access to Mental Health Care in Alabama?

• 76.8% of those individuals with private insurance coverage indicated that this coverage included mental health care coverage. 50.6% of publicly insured individuals reported this type of coverage and 0.6% of those without medical insurance coverage indicated that they had some coverage for mental health care.

• Of those that indicated they had received mental health services in the past 12 months (13.4% of the uninsured, 8.6% of the publicly insured and 4.3% of the privately insured), many reported having problems obtaining mental health treatment or counseling (76.0%, 34.8% and 20.6% respectively).

Main Reason for Problem in Obtaining Mental Health Treatment or Counseling

Too expensive53%

Other26%

Don't know w here to go

4%

Insurance does not pay for

mental health care12%

No providers in my area

5%

Other includes: No Insurance, hard to get an appointment, transportation issues and language barriers.

How Worried Are Alabamians About Health Care?

0

10

20

30

40

50

60

70

80

90

100

w on't affordprescription

drugs

w on't affordhealth careservices

healthinsurance w illbecome tooexpensive

benefits w ill becut back

substantially

w ill lose healthinsurancebenefits

Private

Public

Uninsured

Reasons for Worries About Loss of Current Benefits?

22.0%

31.8%

6.1% 6.0%7.5%

27.4%

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

PremiumIncrease

Loss of Job Job Change No EmployerOffer

FamilyComposition

Change

Other (Divorce,COBRA ends)

Summary and Conclusions

• While the rate of uninsurance reported in this survey is lower than previous estimates, there is still much work to be done.

• Success in covering children is apparent and may be used as a guide for policy makers as we move forward.

• Policy makers must consider the uninsured population’s access to employer sponsored insurance and willingness to enroll in public programs as they move forward.

• Further examination of public / private partnerships may expose ways to increase offer rates of insurance in small / micro businesses.

Next Steps

• Application for no-cost grant extension to further examine options for increased health coverage in AL.

• Application for additional funds to further model options determined for additional study.

• Importing survey data into the Multi-state integrated Database for use in further grant activities and policy discussions.

• Option of repeating the survey at a specified tie in the future?