2003 Alabama Health Care Insurance and Access Survey Montgomery, AL May 2, 2003 Ashley Alvord, MPH Alabama Department of Public Health Children’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. CSCS – Coordinated State Coverage Survey

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 Even states who have NSAF and community tracking and other surveys, MA and MN, still continue to do their own surveys. They want the data and use the data…

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. Survey designed to gather detail through 7200 member, random digit dial household survey. Roughly the same number of interviews per geographic region to promote comparability across the state. Results weighted to match the known population distributions in AL Survey fielded October 2002 – February 2003 with 7299 completed surveys.

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? AL Rate US 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 CPS can code a person as being insured by both an ESI plan and a public plan, therefore these data show > 100% The questions asked may point to the difference in rates .. CPS asks the respondent to recall their insurance status for the previous year, while the AL rates are based on a question asking the current insurance status of the respondent. Also, timeframe … questions asked at a different time would most liekly yield different results 11.2% rate corresponds to approximately 500,000 individuals.

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 Rate US 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 When we look at children specifically – and the characteristics of uninsured children as a group: Approximately 6.6% of Alabama’s child population is uninsured (78,800) 20.3% of uninsured kids are aged 0-5 79.7% of uninsured kids are aged 6-18 Most report that their health status is Excellent or Very Good (69.3%) 52% of uninsured children are living in families with incomes below 100% FPL ($18,400 for a family of 4) All rates reflect point in time data.

AL Uninsurance Rates by Race All rates reflect point in time data.

AL Uninsurance Rates by Income Level All rates reflect point in time data.

AL Uninsurance Rates by Employment Status All rates reflect point in time data.

AL Uninsurance Rates by Educational Attainment All rates reflect point in time data.

AL Uninsurance Rates by Geographic Region When these rates are applied to the population estimates you see that while the rate is lower in the B’ham MSA there are still significant number of uninsured in that area of the state: B’ham (928,108 * 7.7%) = 71,464 Northern Rural (647,265 * 15.6%) = 100,973 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. Employer offer rates in AL Overall 77% <10 employees – 44.9% 10-50 employees - 71.3% >50 employees - 84.3% Industry with the highest offer rate = Transportation / Warehousing (86.6%) Industry with the lowest offer rate – Arts & Entertainment, Recreation, Accommodation and Food Service (53.7%) Permanent or Full Time employees report increased access to health insurance through their employer (78.8 and 81.6% respectively) while temporary or seasonal workers report the lowest offer rates from employers (35.6 and 49.6)

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

Uninsured People Who Are Potentially Eligible for Public Programs: Willingness to Enroll When asked if the program as free if that would influence their wilingness to enroll – 86% said they would enroll if it was free. However –Many reported never requesting and / or receiving information from public programs in AL (58%).

Do the Uninsured have a Regular Source of Care?

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

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

How to Measure “Unmet Need”? “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

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

How Worried Are Alabamians About Health Care?

Reasons for Worries About Loss of Current Benefits?

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?