Idahoans Without. Health Insurance. A Data Report

Idahoans Without Health Insurance A Data Report

Idahoans Without Health Insurance A Data Report Data analysis conducted by Boise State University under contract to the Idaho Department of Commerce as part of the Idaho State Planning Grant project, funded through the Health Resources and Services Administration, U.S. Department of Health and Human Services. Idaho State Planning Grant Idaho Department of Commerce October 1 Medicare 11% Uninsured 18% Medicaid 8% Idaho Health Coverage Private Individual Coverage 7% Employer Sponsored 56%

Of Idaho s Uninsured between ages 18 and 64: 69%are younger than 45 6%have incomes less than $25, 89%have less than a college education 42%live in rural or frontier counties AND NEARLY 8%are part of working families 1

The number of Americans living without health insurance has been a major topic of discussion both in the media and of policy makers at all levels of government. With the number of uninsured having grown to over 44 million Americans, the issue has received even greater process. It covers the demographic and economic characteristics of the uninsured. It discloses that nearly 8% of Idaho s uninsured are in working families and it examines the business decisions that determine whether or not employees are provided health coverage. attention recently. While Idaho s rates of uninsurance generally reflect the national averages, This lack of health insurance by so many of our citizens carries heavy personal cost to them and major financial costs to all of us (insured or uninsured) as taxpayers. they mask pockets of uninsured among Idahoans employed by small business, Idaho s Hispanic populations and poor children. This is partially driven by a growing split in population between large population areas and rural and frontier areas. This grant is intended to define the gaps The Idaho State Planning Grant is one of twenty national state planning grants funded in the past two years by the Health Resources existing in the state and hopefully may contribute to finding solutions for our state s citizens. and Services Administration, U.S. Department of Health and Human Services. As part of Idaho s grant we are conducting a coordinated process of data collection, policy analysis and evaluation of potential Gary Mahn Director, Department of Commerce Co-chair Sandra Bruce President & CEO, St. Alphonsus Regional Medical Center Co-chair insurance strategies in conjunction with a structured dialogue among Idaho political, health care and business leaders about policy options Idaho State Planning Grant Steering Committee in order to develop a comprehensive plan for providing access to insurance for all Idahoans. This report is the first step in that 2

The people who are most at risk today are those who have no health insurance at all. They re at risk of not getting regular care when they need it. They re at risk of not catching real problems before they get serious enough not to be treatable. They could lose everything that they ve saved in their lives because of some even fairly minor health problem. Sherry Glied, Ph.D. Associate Professor and Chair Department of Health Policy and Management Columbia University New York, NY They re at risk of not getting the best treatment when they actually do get sick. And they re at tremendous financial risk. 3

Boundary Sample interpretation: Bonner 3% + of people in Boundary County are uninsured. Kootenai Uninsured Rates by County Benewah Latah Nez Perce Lewis Shoshone Clearwater County Rate of Uninsured 3%+ 25-29% - 24% Idaho s individual county rates of uninsured range from a low of approximately 15% to a high of over 3%. It should be remembered, however, that in the case of some counties while rates are high the county population may be quite small. Idaho s counties are designated Idaho 15-19% urban, rural or frontier. Urban counties are those with a population No Data Available center of greater than or equal to,. Rural counties are defined Adams Lemhi as those that have greater than or equal to 6 people per square mile Valley and which include no population centers that would qualify as urban. Washington Payette Gem Canyon Boise Custer Butte Clark Jefferson Fremont Madison Teton Frontier counties are those with less than 6 people per square mile. Forty-two percent (42.1%) of the uninsured live in rural or frontier counties. Ada Elmore Camas Gooding Blaine Lincoln Bingham Bonneville Owyhee Jerome Minnedoka Power Bannock Caribou Twin Falls Cassia Oneida Franklin Bear Lake 4

Boundary Bonner Sample interpretation: Boundary County contains less than 2% of Idaho's uninsured Kootenai Concentration of Uninsured by County Benewah Shoshone County as % of Idaho Total % of Idaho Total Latah Clearwater 1%+ 28.4% Nez Perce Lewis 5-1% 15.4% Adams Idaho Lemhi 2-5% < 2% Total 27.8% 28.7 1% Looking at concentrations of Idaho s uninsured by county shows that 13 counties represent over 7% of the total number of uninsured. These counties are those that surround the state s larger population centers (Boise, Twin Falls, Pocatello, Idaho Falls, Moscow Valley and Coeur d Alene). Washington Payette Boise Gem Canyon Ada Elmore Owyhee Camas Gooding Twin Falls Custer Blaine Lincoln Jerome Minnedoka Cassia Butte Power Clark Jefferson Bingham Oneida Bannock Fremont Madison Teton Bonneville Franklin Caribou Bear Lake 5

Uninsured Idahoans by Age The highest rate of uninsured falls in the 18-24 age group (29.1%) and drops to 16.6% by age 55-64. Idahoans age 65 and over are virtually all covered with Medicare. Data sources for the numbers of uninsured children (under age 18) estimate the rate at 13-19%. The institution of the Children s Health Insurance Program (CHIP) has resulted in reduced rates of uninsured children over the past 2-3 years, however, it is estimated that there are still 3, children not enrolled but currently qualified for CHIP or Medicaid. 25 15 1 5 Idaho Uninsured by Age Compared With % of Population (age 18-64) 22 16 23 18 22 21 % of Total Uninsured % of Total Population 18-24 25-34 35-44 45-54 55-64 65+ 18 19 7 12 21 2 Insurance Status by Age Age Group 1 1 8 Setting aside the under 18 population, a comparison of the percentage 6 4 Uninsured < 18 16 18-24 29.1 25-34 22.4 35-44 18.5 45-54 17.2 55-64 16.6 65+ 1.6 of total uninsured within each age group to the age groups percent of total population shows that there is a disproportionate number of uninsured among all the age groups from 18 to 64. However, the 18 to 24 and 25 to 34 have the largest imbalance. Insured 84 7.9 77.6 81.5 82.8 83.4 98.4 Age 6

Idaho Uninsured Trends (1991-) Idaho Uninsured (age 18-64) Trend Examining Idaho s uninsured between the ages of 18-64, the primary working population, it can be seen that the percentage of uninsured has remained fairly constant in the past ten years (between 15 and 25 15 1.9.1.4 17.9 16.9 18.2 18.3.1 16.9 15.4 percent). However, it is important to note that as the population has 5 grown, so have the number of uninsured. 199 1992 1994 1996 1998 2 Based on recent population growth rates in Idaho, there are approximately Income 635 new Idahoans without health insurance each month. 7

Uninsured Idahoans by Income Of the approximately 15, uninsured between ages 18-64, over 4% have incomes of between $15, and $25,. As might be expected, the higher an individual s or household s income, the less chance they have of being uninsured. However, those with incomes of less than $15, show a slightly lower rate because of access for some family members to programs such as Medicaid or CHIP. At the same time it should be noted that there are still almost 4% uninsured with family income below $15,. Those at highest Uninsured Idahoans by Income (age 18-64) $35-49.9K 16% $5K+ 6% < $15K 19% risk for being uninsured are those with incomes of less than $25,, having more than double the rate of those with incomes higher than $25,. % Uninsured by Income $25-34.9K 18% $15-24.9K 41% 1 1 8 6 4 Uninsured Insured < $15K 39.6 6.4 $15- $25- $35-24.9K 34.9K 49.9K $5K+ 43.6 19.8 13.9 4 56.4 8.2 86.1 96 Income 8

Eligibility for Public Programs Idaho has several Medicaid health programs for children, adults with dependent children and pregnant women. Each program has different eligibility levels. with an income level of 133% of FPG or less. Coverage ends two months after the birth of the child unless she qualifies for the TAFI program. Children in families with household income of 15% of FPG or less may also qualify for coverage under the Children s Health Insurance Program (CHIP). Idaho National Average Highest State Lowest State % < 65 Population Receiving Medicaid Benefits (1997-1999) 9.64% 47th of 51 in U.S. ranking (includes D.C.) Total Federal & State Medicaid Spending per Capita $34.66 5th of 51 in U.S. ranking (includes D.C.) Median Household Income $35,96 (4th in U.S. ranking) 13.43% $659.26 $4,816 27.1% (TN) 7.79% (NV) $1,71.7 (NY) $3.89 (UT) In addition to Medicaid coverage for various special populations FPG% 1% 133% 15% TAFI PWC CHIP Family Size Monthly Annual Monthly Annual Monthly Annual 1 $716 $8,592 $952 $11,427 $1,74 $12,888 2 968 11,616 1,287 15,449 1,452 17,424 3 1,219 14,628 1,621 19,455 1,829 21,942 4 1,471 17,652 1,956 3,477 2,7 26,478 5 1,723,676 2,292 27,499 2,585 31,14 6 1,974 23,688 2,625 31,55 2,961 35,532 7 2,226 26,712 2,961 35,527 3,339 4,68 8 2,478 29,736 3,296 39,549 3,717 44,64 Add'l 252 3,24 252 4,22 378 4,536 (disabled, blind, etc.), families with dependent children may qualify for Temporary Assistance for Families in Idaho (TAFI) and Medicaid coverage if family income is below a state established fixed rate of approximately $4 a month. Pregnant women may qualify for only pregnancy- related coverage through the Pregnant Women and Children program (PWC) 9

Uninsured by FPG% When the rates of the uninsured are examined against the Federal Poverty Guidelines (FPG) it can be seen that among children under age 18 and in families under 15% of the FPG there are almost 3, children (59.6% of uninsured children) that may be qualified for CHIP or Medicaid. of Children 4 3 1 Uninsured Children Under 18 35.3 24.3 21.3 19.1 < = 1% 11-15% 151-% 1% This represents an immediate opportunity for coverage without any FPG% changes to existing programs. In addition, if CHIP eligibility were raised to % of FPG then almost 1, more children might be covered. The numbers of uninsured actually increase as individual or family incomes increase within the ranges in the table below. This is simply because there are more individuals and families earning incomes of those amounts. 4 3 1 Uninsured Adults 18-64 35.5 3.5 17.5 16.5 < = 1% 11-15% 151-% 1% FPG% Uninsured Population Children < 18 < = 1% 17,5 (35.3%) Household Income as Federal Poverty Guidelines 11-15% 151-% 1% + 11,74 (24.3%) 9,23 (19.1%) 1,3 (21.3%) Total 48,31 (1%) 6 5 Uninsured Adults by FPG% (with and without children) Adults w/children Adults w/o Children 51.5 Adults 18-64 w/children Adults 18-64 w/o children Total Adults 31,44 (38.3%) 13,97 (21%) 45,4 (3.5%) 16,11 (19.6%) 8,5 (12.8%) 24,59 (16.5%) 16,16 (19.7%) 9,9 (51.5%) 26,6 (17.5%) 18,51 (22.5%) 34,31 (51.5%) 52,85 (35.5%) 82,2 (1%) 66,7 (1%) 148,9 (1%) 4 3 1 38.2 21 19.6 19.7 12.8 14.9 22.5 < = 1% 11-15% 151-% 1% FPG% 1

Employment Status of Idaho s Uninsured Employment Status of Idaho Uninsured Over 7% of Idaho s uninsured are self employed or employed by others. Almost 1% more are members of working families. AGAIN... Nearly8%of uninsured are in working families. Student 4% Homemaker in Working Household 7% Retired 11% 3% Self Employed % Unemployed Unable to work 4% Employed 51% 11

Idaho Businesses by Number of Employees Business Health Coverage Idaho has over 5, businesses, excluding government and schools. 1-249 5-99 1.6%.9% -49 1-19 9.5% 5.5% 5-9 19.4% 5+.1% 1-4 62.9% 25-499.2% Almost 92% of Idaho businesses have fewer than employees, and over 97% have fewer than 5 employees. About 35% of Idaho s (non-governmental) workforce is employed in businesses with fewer than employees and almost 5% in businesses with fewer than 5 employees. Idaho Business Offering Health Insurance Coverage Health coverage is offered by 48.5% of business in Idaho. No Coverage 51% Offers Coverage 49% 12

Reasons for Working Uninsured Reasons for Not Offering Health Insurance When businesses were asked why they did not offer health care insurance, over 6% of those employers listed cost. Other responses 1 9 8 were identified far less often, including employee coverage through other sources, complexity and fear of premium increases. (Total percentages total more than 1% due to multiple answers) 7 6 5 4 3 1 6.4 1.8 11.2 4.2 5.4 18.3 16 Cost Complexity Premium increase Business fears Employees not interested Reason Employees have other insurance Other 13

Health Care Coverage of Employees Several factors determine which employees are covered for health care and which are not. Examining employer-based coverage by size and type of business shows that smaller retail, service and construction businesses have the lowest percentage offering coverage. When the salaries of employees are examined it also demonstrates that the lower the average salary level in a business, the less likely the business Businesses Offering Health Coverage by Size Offering Coverage Health Care Coverage by Type of Business 1 9 8 7.4 7 61 61.6 61 63.4 6 49.4 5 43.4 46.1 46.7 4 33.9 3 1 Aviation/Transportation Construction Financial/Banking Health Care Law Manufacturing Retail Business Focus Services Wholesale Other is to offer health coverage. The decline in coverage at the higher average salary levels probably represents sole proprietors with at most one other Offering Coverage 1 9 8 7 6 5 4 3 1 29.9 83.8 75.3 66.3-5 6-1 11-15 16-98.3 95.1 9.7 9.3 84.4 21-3 31-5 5-1 11-25 25+ employee. There are very few businesses in this category. 1 9 8 7 6 5 4 3 1 Insurance Status by Average Employee Salary 89.5 <$1K 1.5 76.9 $1-15K 23.1 56.1 58.9 43.9 41.1 $15-K $-25K 26.9 $25-3K 73.1 19.7 $3-35K 8.3 32.1 $35-4K 67.6 39.8 $4K+ 6.7 Uninsured Insured Number of FTEs Salary 14

Perceived Importance of Health Coverage When employers were asked how important they felt health insurance is to their employees over 6% identified it as very important. When those who also identified important are added, almost 87% recognize When employers were asked about what they feel is the most important reason to offer health coverage, 44% identified recruitment and retention of employees and 43% said it was the right thing to do. Among other answers were the importance of having healthy employees, supporting families, and employee s inability to afford health insurance without business support. their employees value for health coverage. 1 8 6 4 Employers' Perceived Importance of Health Insurance to Employees 62.5 Very important 24.2 9 Important Somewhat important 4.3 Not important Not Important 5% Most Important Reason to Offer Insurance Other 8% Right Thing To Do 43% Recruitment/ Retention 44% 15

The Cost of Uninsurance The cost of Idaho s uninsured can be measured in personal, social and economic terms. National findings show that those who are uninsured: There is a personal financial cost for the uninsured when they do seek care. It has been demonstrated that because of negotiated discounts between insurers and health care providers the uninsured are often charged more than the insured for the same care. Are more likely to be hospitalized for avoidable medical conditions. Are more likely to be diagnosed with late stage cancer. Have significantly higher mortality rates in women with breast cancer. From: Key Facts About the Uninsured, Families USA Going Without Care And Are 3% less likely to receive preventative care. Nearly 4% of uninsured adults skipped recommended medical tests or treatment. Nearly % said they needed care for a serious problem, and didn t receive it. 1 8 6 4 Heart disease 26 23.7 34.1 25.5 7 5.6 7.5 7.6 Hypertension Arthritis Condition Chronic back pain Uninsured Insured From: Getting Less Care: The Uninsured with Chronic Health Conditions, Families USA, 1 16

Personal Costs Problems Paying Medical Bills There can also be a serious financial cost to the uninsured. When medical costs are incurred there are often significant problems paying 5 4 Major Impact those bills which can impact a family s or individual s credit. 3 1 7 9 2 27 1 2 Insured Uninsured Minor Impact No Impact Level of Impact From: The Uninsured: A Primer, Kaiser Commission on Medicaid and the Uninsured, March 1 17

Social and Economic Costs When the uninsured receive health care and are not able to pay, those costs must be covered by the facilities providing the care and ultimately by other businesses, individuals and taxpayers. In Idaho medically indigent patients who do not quality for state or federal programs receive county and state assistance through County Indigency Funds and the State Catastrophic Funds. Counties are responsible for the first $1, of medical bills and the state funds for amounts over $1,. County costs are funded through property taxes and the state costs funded by state general fund. Idaho hospitals incur millions of dollars in Charity Care and Bad Debt, much of it from uninsured patients. These costs must be covered by Idaho Government Costs for Uninsured other sources (cost-shifting to paying patients and insurance companies). Amount in Millions ($M) 1 8 6 4 Idaho Hospitals Cost of Unpaid Care 37.8 47.2 51.3 17.3 22.2 1996 1997 1998 Charity Care Bad Debt Amount in Millions ($M) 3 25 15 1 5 $11 44.4 M $14 M Government Costs for Uninsured County and State Expenses State Catastrophic Health Care Funds (General Fund) County Indigency Funds (Property Taxes) Year 18

Affordability In a survey of businesses, employers providing health coverage identified what they currently are spending as a percentage of payroll and also what they believe is reasonable. Most employers, not surprisingly, are paying more than they would like. In the same survey, employers providing health coverage reported a median premium cost per employee per month of approximately $225. Of those employers not currently offering coverage only 2% of those responding stated they would be willing to pay over $ and only 11.8% indicated a willingness to pay over $1. It is clear that the current system is not meeting the need and a new solution needs to be sought to reconcile these differences. Almost 8% of businesses cover 2/3 or more of their employee s premiums and 65% pay 1%. Less than 3% use a sliding scale, paying more for lower salary employees. Almost 9% allow dependent enrollment Premium Level Willing to Pay but not all employees use this, citing other coverage available or inability due to cost. of Business 5 4 3 1 23.7 of Total Budgeted Payroll Spent on Health Care 41.4 44.4 39.1 9.9 9.9 7.2 3.5.8 < 5% 6-1% 11-15% 16-% %+ % of Payroll Actual % of Payroll Believed Reasonable 3 25 15 1 5 27.6 17.1 21.2 22.3 None Up to $25 $26-5 $51-1 $11-15 7.4 2.6 1.8 $151- Premium Per Employee Per Month Over $ of Payroll Spent On Premiums 19

[Appendix A] 1 Income Limits Based on Federal Poverty Guidelines FPG% 1% 133% 15% 175% % Family Size Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual 1 $ 716 8,592 952 11,427 1,74 12,888 1,253 15,36 1,436 17,184 2 968 11,616 1,287 15,449 1,452 17,424 1,694,328 1,936 23,232 3 1,219 14,628 1,621 19,455 1,829 21,942 2,133 25,599 2,438 29,256 4 1,471 17,652 1,956 3,477 2,7 26,478 2,574 3,891 2,942 35,34 5 1,723,676 2,292 27,499 2,585 31,14 3,15 36,183 3,446 41,352 6 1,974 23,688 2,625 31,55 2,961 35,532 3,455 41,454 3,948 47,376 7 2,226 26,712 2,961 35,527 3,339 4,68 3,896 46,746 4,452 53,424 8 2,478 29,736 3,296 39,549 3,717 44,64 4,337 52,38 4,956 59,472 Add l 252 3,24 335 4,22 378 4,536 441 5,292 54 6,48 A

[Appendix B] Data Sources: Idaho Behavioral Risk Factor Surveillance System Report (BRFSS), Idaho Department of Health and Welfare. Employer Health Care Benefit Survey, Idaho State Planning Grant U.S. Census (), U.S. Census Bureau The Uninsured: A Primer, Kaiser Commission on Medicaid and the Uninsured, March 1 Key Facts About the Uninsured, Families USA Getting Less Care: The Uninsured with Chronic Health Conditions, Families USA, 1 A full data report may be examined online at: www.idahouninsured.org Idaho State Planning Grant A one-year planning project 91 N. Curtis Road #42 Boise, ID 8376 Phone (8) 367-4855 Fax (8) 367-768 www.idahouninsured.org A