Access to Health Care in Wyoming Information from BRFSS Menlo Futa, WY Department of Health Mary Adams, On Target Health Data LLC Contact: Menlo Futa, BRFSS Coordinator, WY Dept. of Health, 6101 Yellowstone Road, Suite 510, Cheyenne, WY 82002, 307-777-6012, menlo.futa@health.wyo.gov

What is BRFSS? Behavioral Risk Factor Surveillance System Random digit dial telephone survey of WY adults age 18 and older Topics include health behaviors, health conditions, health care access, preventive health services Examples: tobacco/alcohol use, physical activity, diabetes, obesity, lack of health insurance, mammograms/Pap smears

What is BRFSS? (cont) Primary purpose is to support WDH programs, especially in chronic disease and health promotion Data is collected every month and analyzed on calendar year basis All 50 states conduct BRFSS Wyoming participation since 1994 Annual sample size between 2,000 and 5,000

Methods 4,993 BRFSS interviews in 2006 Main Access Measures: Adults with no health care coverage Adults without a regular doctor Adults who needed to see an MD in the past year but could not due to cost (“cost issue”) Underinsured: includes uninsured plus those with insurance who had a cost issue

Other Access Measures Children’s health care coverage Recent checkup Health care visit in past year Dental visit in past year

Results: Health Care Access 2006 WY BRFSS Access to health care is very different for adults age 65 and over compared with 18-64 year olds Numbers (est): 70,400 total uninsured, 69,400 of whom are 18-64. An est 52,000 had a cost issue, 105,000 had no MD, and 96,000 were underinsured and 156,000 had one or more of the health access issues. Issues did tend to be associated so persons often had more than one issue. 3.5% of all adults reported all three separates access issues (no insurance, no MD, and a cost issue) while 16.5% of the working poor, 9.0% of the out of work, and 11.5% of those with FMD reported all three.

Access Measures by Age Group, 2006 WY BRFSS Health care access is also different for younger adults compared to those in the middle age groups.

Number of WY Adults at Risk Data from BRFSS are weighted to be generalizable to the adult WY population. We can convert weighted percentages to the number of WY adults.

Health Care Access by Group 2006 WY BRFSS Note that the working poor are even more likely than the out of work to report issues with health care access. Working poor = employed for wages and annual household income less than $25,000. FMD = frequent mental distress or 14 or more days when mental health was not good in the past month.

Who Are the “Working Poor”? By definition: employed for wages and annual household income under $25,000 About 34,000 in 2006 (20,000 women) 8.6% of all WY adults, but: 17% of adults age 18-24 21% of the minority population 18% of those with less than high school education 18% of the unmarried Working poor is defined here in very simplified terms – employed for wages and annual household income less than $25,000. According to this definition, there were about 34,000 working poor in 2006, or about 8.6% of all WY adults.

Make-up of Uninsured 2006 WY BRFSS This shows the percent of all the uninsured that are in certain groups. Even though the rate of uninsured is extremely high for the working poor and the out of work, employed persons still make up 71% of the uninsured and more than half (55.6%) of the uninsured have household incomes above $25,000. Just like minorities are MORE likely to be uninsured, but there are more non-Hispanic whites in WY, so they make up the majority (82%) of the uninsured.

Health Care Access by Group 2006 WY BRFSS Some population subgroups report far fewer problems with health care access.

Comparison of groups with poor and good access Poor access groups Good access groups These are the same charts drawn to the same scale but placed side by side to illustrate the differences between subgroups in their access to health care.

Results by Race/Ethnicity WY BRFSS 2001-2005 No Health Care Coverage Estimates for very small populations are possible with BRFSS, but it may be necessary to combine multiple years of data. To get estimates by race/ethnicity and county, we combined 5 years of data from 2001-2005. Even though the numbers of blacks, Asians, and American Indians in the sample were still small, the data do show disparities in health care access. Brackets indicate the 95% confidence interval, red bars indicate groups showing disparity. Non-overlapping confidence intervals indicate that there is a statistically significant difference between the groups being compared. N=18,139 N=73 N=893 N=72 N=261 Source: WY BRFSS 2001-2005

Cost Issue by Race/Ethnicity WY BRFSS 2003-2005 Source: WY BRFSS 2001-2005

No Personal Doctor by Race/Ethnicity WY BRFSS 2001-2005 Source: WY BRFSS 2001-2005

Uninsured by County 2001-2005 WY BRFSS Range from 10.0-24.4% adults uninsured Highest rates in: Park 19.9% Carbon 20.3% Weston 20.5% Sheridan 21.1% Big Horn 21.9% Hot Springs 24.4% Highest numbers of uninsured in: Sheridan 4,579 Fremont 5,265 Campbell 4,736 Natrona 9,554 Sweetwater 4,839 Laramie 9,892 Similar results for other measures….but not exactly the same.

Uninsured by County, Sorted by %, 2001-2005 WY BRFSS Percent 95% CI Number Sample Size Teton 10.0 7.6 - 13.1 64 690 Albany 14.7 12.1 - 17.6 153 1,154 Crook 14.9 10.3 - 20.9 35 282 Sublette 15.1 11.1 - 20.3 47 325 Laramie 15.2 13.6 - 16.9 416 3,111 Goshen 16.0 12.6 - 20.2 71 550 Johnson 16.2 12.3 - 21.0 55 321 Washakie 11.7 - 22.0 334 Sweetwater 16.9 14.6 - 19.6 192 1,330 Campbell 17.0 195 1,238 Converse 17.4 13.6 - 22.0 74 498 Natrona 17.8 16.0 - 19.7 396 2,489 Uinta 18.4 15.2 - 22.1 120 760 Platte 18.8 12.9 - 26.7 59 365 Fremont 18.9 16.4 - 21.7 242 1,404 Lincoln 15.5 - 22.9 114 648 Niobrara 19.3 11.9 - 29.6 27 154 Park 19.9 17.2 - 22.9 203 1,145 Carbon 20.3 16.7 - 24.5 103 607 Weston 20.5 15.5 - 26.7 56 301 Sheridan 21.1 18.3 - 24.1 211 Big Horn 21.9 17.5 - 27.1 90 487 Hot Springs 24.4 18.2 - 32.0 50 220 These rates by county may be difficult to see, but they are available on the website and in the spreadsheet for all 3 access indicators.

Health Care Access Comparison with US, 2006 BRFSS Now that we have seen what health care access looks like in WY, how does this compare with the nation? With other states? With past years? This slide compares WY with the national median for the 3 major access indicators for 2006. WY’s rates are higher (worse) than the national median for all 3 and much higher for 2 of the 3.

Uninsured by State, 2006 BRFSS Rank State % 1 MN 8.2 2 HI 8.3 3 MA 8.5 4 DC 8.7 5 DE 9.6 6 WI 9.7 7 CT 10.1 8 MD 9 VA 10.3 10 ME 10.4 11 IA 10.5 12 PA 13 RI 11.3 14 NH 11.4 15 VT 11.5 16 ND 11.6 17 OH 12.4 18 MI 12.9 19 KS 13.0 20 MO 13.2 21 TN 13.3 22 NY 13.5 23 SD 24 NE 14.2 25 NJ 26 WA 14.5 Rank State % 27 UT 15.0 28 IL 15.1 29 WV 15.4 30 IN 15.6 31 GA 15.8 32 AL 16.0 33 OR 16.3 34 MT 16.6 35 SC 36 CO 17.0 37 KY 38 AK 17.5 39 CA 40 NC 17.8 41 WY 17.9 42 ID 18.8 43 AZ 19.6 44 FL 20.4 45 AR 20.6 46 OK 20.8 47 MS 20.9 48 NM 21.7 49 NV 22.2 50 LA 22.9 51 TX 25.2 In order to determine the national medians, we have to determine the rate for each state, rank order them, and find the middle value. The intermediate step of the state by state rankings are often of interest and are included in the spreadsheet. This is state ranking for uninsured.

BRFSS has measured the percentage of uninsured in WY every year since 1994. After a sharp rise in the mid 90s, this rate has remained fairly level over the past 10 years. The Healthy People 2010 objective is 0%.

WY does not appear to be showing progress on any of the 3 access indicators. WY’s rates for all 3 indicators are also consistently worse than the national medians.

Health Care Access and Preventive Health 2006 WY BRFSS Results were similar for the other measures of health access (especially having an MD) and for other preventive health services. Pap test is among women who have not had a hysterectomy.

Health Care Access and Preventive Health 2006 WY BRFSS (cont.) The only preventive service we looked at that wasn’t positively associated with insurance status was HIV test. Since WY appears to have worse access to care than other states, does this also mean that we do worse on these preventive health services? Generally speaking, this does appear to be the case. WY rates for colonoscopy, FOBT, mammograms, Paps, DRE, HIV test, dental visit, and dental cleaning, are all worse than the national median. Our rate is about the same as the national median for cholesterol check. And tour rates are better than the national median for flu shots and PSA tests.

Health Care Access for People With Chronic Disease, 2006 WY BRFSS Having access to the health care system is especially important for people with chronic disease conditions which must often be medically managed to avoid costly complications, disability, and early death. The good news is that most people with chronic disease conditions appear to have better access to health care than adults in general. Medicare plays a significant role in this. The bad news is that a significant portion of adults with chronic disease still report not having insurance, a personal doctor, or were recently unable to pay for needed care.

Health Care Access for People With Chronic Disease, 2005 WY BRFSS

Number of WY Adults with Chronic Conditions Lacking Health Care Access Because we know the percentages of WY adults with these chronic conditions and the percentages of these groups that lack health care access, we can convert the percentages into the estimated number of adults with chronic conditions lacking health care access.

Children’s health insurance Method: for households with children, the selected adult respondent was asked questions about a randomly selected child within the household. 2006 WY BRFSS included 1,512 household with children. Uninsured rate for children = 6.4%. About 7,800 uninsured children in 2006. Although BRFSS is designed as a survey of adults, it is possible to get information on children.

Children’s Health Insurance, 2006 WY BRFSS For children, we do ask the type of insurance for the randomly selected child.

Children’s Insurance Status, WY BRFSS 1998-2006 We collected children’s health insurance information since the beginning of Kid Care in 1998 for 5 consecutive years and then again in 2006. Kid Care’s growth can be seen in this chart as well as a decline in the rate of uninsured.

Limitations People without phones or only cell phones are not included Data are self-reported Response rates declining People living in institutions not included

Conclusions Health care access appears to be an issue for a number of Wyoming adults, especially for those ages <65 yrs WY rates for these measures tend to be worse than other states and are steady over time Receipt of recommended preventive health services appears to be affected by the health access measures addressed here A significant number of people with chronic conditions appear to have health care access problems