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?
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 Uninsured Less 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 Dakota Behavioral 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 Household Survey
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, Large Rural-5,000 to 16, 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. Regular Place for Healthcare
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. Governor’s Advisory Committee on Health Insurance
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

31. 2004 HHS Poverty Guidelines
48 Contiguous States & D.C.
Size of Family Unit
100%
133%
200%
300% 1
$9,310
$12,382
$18,620
$27,930 2
12,490
$16,612
$24,980
$37,470 3
15,670
$20,841
$31,340
$47,010 4
18,850
$25,071
$37,700
$56,550 5
22,030
$29,300
$44,060
$66,090 6
25,210
$33,529
$50,420
$75,630 7
28,390
$37,759
$56,780
$85,170 8
31,570
$41,988
$63,140
$94,710
For each additional person, add
3,180
$4,229
$6,360
$9,540
Source: Federal Register, Vol. 69, No. 30, February 13, 2004, pp

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
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. Comments, questions, and ideas: spg@state.nd.us
For more information contact: Center for Rural Health UND School of Medicine and Health Sciences Grand Forks, ND
Comments, questions, and ideas: