1.SUMMARY OF KEY FINDINGS Funded by NASHP, MDH, DHS and the Robert Wood Johnson Foundation PROFILE OF MINNESOTAS UNINSURED Kathleen T. Call, Elizabeth Lukanen, Jessie Kemmick Pintor, Giovann Alarcn April 29, 2014

2. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level This profile is designed to provide information about uninsured Minnesotans that can aid policy development as well as outreach and enrollment efforts. It includes information about the characteristics of the uninsured, their access to insurance, access to and affordability of health care, and reasons they lack insurance. We estimate their eligibility for insurance options available through the Affordable Care Act (ACA), as well as those who are not eligible for ACA expansions. We also provide a summary of the projected impact of the ACA in Minnesota provided by Gruber and Gorman, followed by documented results of health reform efforts in Massachusetts and Oregon to foreshadow what might be expected in Minnesota. We close with a series of maps that indicate where rates of uninsurance are highest in the state, estimated location of the uninsured eligible for Medicaid, MinnesotaCare, and MNsure with a subsidy along with overlays of other information that aid outreach efforts such as the location of schools, churches and hospitals. We focus on the non-elderly population who are the primary target of ACA provisions. We draw on a variety of data sources to tell this story. The compilation of the information presented in this chart book was funded by the National Academy for State Health Policy (NASHP). 2 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN Overview 3. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Slide 4 Data sources used Slides 5-24 Who are the uninsured in Minnesota? Slides 25-35 Access to and affordability of care for the uninsured Slides 36-46 ACA eligibility among the uninsured Slides 47-52 Estimates of populations not eligible for ACA expansions Slides 53-70 What we know about take-up from prior research Slides 71-126 Distribution of uninsured across Minnesota 3 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN Table of Contents 4. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Data sources 2013 Minnesota Health Access Survey (MNHA) American Community Survey (ACS): 2011 Small Area Health Insurance Estimates (SAHIE) 2011 & 2012 1-year file 2010-2012 3-year file 2008-2012 5-year file Minnesota Gruber-Gorman simulation model 2011 MNHA, health plan data, and MEPS-HC 4 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 5. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level WHO ARE THE UNINSURED IN MINNESOTA? 5 6. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Section overview Distribution of coverage among non-elderly (0-64) Summary characteristics of uninsured Minnesotans Measures of uninsurance (point-in-time, long- and short-term uninsured) Uninsurance rates by demographic characteristics Demographic and employment characteristics of the uninsured Reasons for uninsurance 6 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 7. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Preview: Nonelderly uninsured, 2013 9.4% at time of survey, or 13.7% uninsured at some time in 2013 Uninsurance rates highest among: 18-34 year-olds; Blacks, Hispanics, and American Indians; non US-born, and those under 200% FPG Uninsured are less likely to be employed than MNs overall And were more likely to be self-employed, work fewer hours, and work for smaller firms Most report lack of coverage due to cost, and loss of coverage due to job termination 7 Source: 2013 Minnesota Health Access Survey Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 8. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Sources of insurance coverage among nonelderly, 2013 8 63.2% 21.3% 6.1% 9.4% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% Group Coverage Public Coverage Individual Coverage Uninsured Source: 2013 Minnesota Health Access Survey Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 9. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Measures of uninsurance among non- elderly, 2013 9 9.4% 7.0% 13.7% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% Uninsurance, point in time Uninsurance, all year Some episode of uninsurance in year Source: 2013 Minnesota Health Access Survey NOTE: Unless otherwise indicated, estimates are based on those uninsured at the time of the survey or a point in time Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 10. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Nonelderly Minnesotans with an episode of uninsurance, 2013 (13.7%) 10 Long-term uninsured means uninsured for 12 months or longer Source: 2013 Minnesota Health Access Survey Uninsurednow(9.4%) Uninsuredatsomepointintheyear(13.7%) Uninsurednow,but wasinsuredat somepointinthe year(short-term) (2.4%) Uninsured for 12 months or longer (long-term) (7.0%) Insurednow Insured now, but had episode of uninsurance in past 12 months (4.3%) Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 11. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Age distribution of nonelderly long-term uninsured and total nonelderly population, 2013 11 Long-term uninsured means uninsured for 12 months or longer ^Indicates statistically significant difference in the rates to the overall population (95% level) Source: 2013 Minnesota Health Access Survey 5.3%^ 8.7%^ 21.0%^ 24.2%^ 30.2% 10.6%^ 9.3% 19.0% 12.5% 13.2% 31.1% 15.0% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 0-5 6-17 18-25 26-34 35-54 55-64 Long-term uninsured Total Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 12. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Uninsurance rates by age among nonelderly, 2013 12 ^Indicates statistically significant difference in the rates to the overall population (95% level) Source: 2013 Minnesota Health Access Survey 7.4% 5.6%^ 13.9%^ 17.3%^ 8.8% 6.2%^ 9.4% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0% 0-5 6-17 18-25 26-34 35-54 55-64 Overall Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 13. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Uninsurance rates by race/ethnicity among nonelderly, 2013 13 ^Indicates statistically significant difference in the rates to the overall population (95% level) Respondents were able to choose more than one race/ethnicity Source: 2013 Minnesota Health Access Survey 7.0%^ 15.0%^ 35.4%^ 19.2%^ 13.5% 10.6% 9.4% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% White Black Hispanic American Indian Asian Other Overall Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 14. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Uninsurance rates for nonelderly Minnesotans born and not born in US, 2013 14 ^Indicates statistically significant difference between US-born and non US-born (95% level) Reported for individuals 3 years and older Source: 2013 Minnesota Health Access Survey 27.3%^ 7.7%^ 9.4% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Not US born US born Overall Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 15. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Uninsurance rates by FPG* among nonelderly, 2013 15 ^Indicates statistically significant difference in the rates to the overall population (95% level) *2012 Federal Poverty Guidelines (FPG) Source: 2013 Minnesota Health Access Survey 18.3%^ 17.5%^ 10.7% 5.3%^ 2.0%^ 9.4% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0% FPG 400% Overall Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 16. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Comparing demographic characteristics of the nonelderly uninsured to overall population, 2013 16 Source: 2013 Minnesota Health Access Survey Compared to the nonelderly MN population overall Minnesotas uninsured were more likely to be: Male, between 18 and 34 years of age; African American, American Indian, or Hispanic/Latino; not born in the U.S. Not married, lower-income (200% of FPG or less); in good or fair/poor health (vs. excellent or very good) There were no regional differences (Twin Cities/Greater MN) between the nonelderly uninsured and overall nonelderly Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 17. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Comparing employment characteristics of the nonelderly uninsured to overall population, 2013 17 Source: 2013 Minnesota Health Access Survey The nonelderly uninsured were less likely to be employed than the overall nonelderly population (74% compared with 82%) Minnesotas nonelderly uninsured were more likely to: Be self employed Work between 11-20 hours (as compared to fewer or more) Work for firms with fewer than 100 employees, and Hold temporary or seasonal jobs Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 18. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Potential sources of coverage among nonelderly uninsured, 2013 18 Source: 2013 Minnesota Health Access Survey 37.0% 19.7% 62.4% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% Connection to employer that offers coverage Eligible for employer coverage Potentially eligible for public programs Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 19. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Measures of reasons for uninsurance Primary reasons for lack of coverage Main reasons for not enrolling in public health care programs Interaction of the uninsured with public health care programs 19 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 20. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Primary four reasons for lack of coverage among non-elderly uninsured, 2013 20 Did not take-up ESI when offered* Did not purchase coverage directly Reason for loss of coverage Among short- term uninsured Among long- term uninsured Too expensive/ could not afford 44.5% 60.5% Not eligible for reason other than health 31.0% 7.6% Expect to be covered shortly 15.5% 4.8% Unemployed/not working 6.2% Receives services through IHS 1.2% Job that provided coverage ended 34.4% 40.7% No longer eligible for public insurance 21.2% 18.8% Did not provide info to stay on public program 10.2% Could no longer afford employer coverage/COBRA 5.2% 8.1% No longer eligible for parents policy 7.9% Could no longer afford to buy own coverage Source: 2013 Minnesota Health Access Survey Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 21. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Primary reasons for lack of coverage by age group, 2013 Sample size does not support separate analysis for adults and children, yet it appears that: The most common reason for not taking up ESI for non- elderly adults is not being eligible for reasons unrelated to health whereas cost and affordability of coverage is most important for children Loss of coverage is tied to job loss for non-elderly adults, whereas for children, not providing information to stay on a public program is most common 21 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 22. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Main reasons for not enrolling in public health care programs among uninsured children*, 2013 22 *Reports by parents or guardians Source: Minnesota Health Access Survey, 2013 1.2% 1.6% 9.4% 10.7% 18.4% 0.0%20.3% 3.7%0.9% 5.9% 0.1% 15.2% 0.0% 3.0% 9.7% Do now need or want insurance right now Rarely sick Do not know what to do/where to go/how to enroll Too much hassle/paperwork Too expensive Do not think the care or benefits through these programs are good Applied but is not eligible Do not think is eligible Is embarrased or do not want other to know Do not think government should pay for their health care Do not want government involved in their health care Will get insurance soon or has applied and is waiting Gets care through IHS Never looked into it Other Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 23. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Main reasons for not enrolling in public health care programs among uninsured nonelderly adults, 2013 23 Source: Minnesota Health Access Survey, 2013 6.0% 2.7% 14.9% 6.4% 21.6% 0.2% 11.7% 14.1% 0.3% 3.3% 1.1% 7.0% 0.7% 4.5% 5.4% Do now need or want insurance right now Rarely sick Do not know what to do/where to go/how to enroll Too much hassle/paperwork Too expensive Do not think the care or benefits through these programs are good Applied but is not eligible Do not think is eligible Is embarrased or do not want other to know Do not think government should pay for their health care Do not want government involved in their health care Will get insurance soon or has applied and is waiting Gets care through IHS Never looked into it Other Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 24. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Interaction with public health care programs among eligible nonelderly uninsured, 2013 24 * *Insufficient sample for children Source: 2013 Minnesota Health Access Survey 75.9% 88.1% 87.8% 52.4% 83.0% 73.6% 84.1% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Asked/given information about public programs Would enroll if eligible Of those who say no or do not know: would enroll if coverage was free Would participate in a premium assistance program Children NE Adults Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 25. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level ACCESS TO AND AFFORDABILITY OF CARE FOR THE UNINSURED 25 26. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Measures of access and affordability Usual source of care, and type of usual source of care Confidence in care Forgone care due to cost Financial burden Problems paying medical bills Payment plan with clinic to cover medical bills Trouble paying for other living costs due to medical bills 26 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 27. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Preview: Access to care Most Minnesotans have a usual source of care; this is less true for the uninsured, especially uninsured non-elderly adults The most common source of care is a doctors office, however, the uninsured also use safety net clinics and ED services Most Minnesotans are confident in getting care when needed; this is less true for the uninsured, especially uninsured non-elderly adults 27 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 28. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Preview: Affordability Compared to those with insurance, uninsured children and non-elderly adults are significantly more likely to Report forgone care due to cost Experience financial burden Forgone care due to cost and experiences of financial burden appear more prominent among uninsured non-elderly adults than uninsured children 28 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 29. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Percent of nonelderly uninsured without a usual source of care, 2013 29 94.5% 87.2% 79.2%^ 48.5%^ 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Children NE Adults Insured Uninsured ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 30. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Place of usual source of care among nonelderly uninsured, 2013 30 ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 90.0% 60.7%^ 86.2% 57.7%^ 7.6% 25.2%^ 7.5% 21.4%^ 0.0% 5.5% 0.0% 0.7% 0.0% 0.0% 3.6% 4.1% 1.5% 8.4% 2.2% 15.6%^ 1.0% 0.1%^ 0.6% 0.5% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Insured - Children Uninsured - Children Insured - Adults Uninsured - Adults Some place else An emergency room or urgent care center A VA hospital/clinic A Indian Health Care provider A sliding fee scale, public health, or free clinic A private clinic or doctors office An Indian Health Care provider Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 31. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Percent of nonelderly uninsured very or somewhat confident they can get care when needed, 2013 31 96.8% 93.3% 77.6%^ 53.6%^ 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Children NE Adults Insured Uninsured ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 32. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Percent of uninsured children* with forgone care due to worry about cost, 2013 32 *Reports by parents or guardians ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 10.9% 4.3% 5.9% 2.0% 1.5% 1.7% 28.1%^ 9.6% 16.6%^ 21.8%^ 8.0%^ 8.8%^ 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Any Care Presciption Dental Care Routine Care Mental Health Care Specialist Care Insured Uninsured Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 33. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Percent of uninsured nonelderly adults with forgone care due to worry about cost, 2013 33 ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 18.7% 7.1% 12.4% 5.4% 3.4% 4.5% 48.7%^ 19.6%^ 36.2%^ 34.8%^ 19.4%^ 19.7%^ 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Any Care Presciption Dental Care Routine Care Mental Health Care Specialist Care Insured Uninsured Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 34. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Percent of uninsured children* experiencing financial burden, 2013 34 *Reports by parents or guardians ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey 21.0% 12.6% 16.3% 7.7% 51.1%^ 32.1%^ 40.7%^ 24.5%^ 0% 10% 20% 30% 40% 50% 60% 70% Any Financial Burden Problem paying medical bills Set up a payment plan for medical bills Had trouble with basic bills due to medical costs Insured Uninsured Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 35. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Percent of uninsured nonelderly adults experiencing financial burden, 2013 35 ^Indicates statistically significant difference between the nonelderly uninsured and insured population (95% level) Source: 2013 Minnesota Health Access Survey Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 23.8% 15.3% 17.5% 8.4% 63.4%^ 52.4%^ 48.1%^ 34.1%^ 0% 10% 20% 30% 40% 50% 60% 70% Any Financial Burden Problem paying medical bills Set up a payment plan for medical bills Had trouble with basic bills due to medical costs Insured Uninsured 36. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level ACA ELIGIBILITY AMONG THE UNINSURED: APPLYING 2014 ELIGIBILITY CRITERIA TO 2013 MNHA DATA 36 37. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Method for estimating 2014 ACA eligibility Medicaid eligible includes: Adults (19 or older) with family income of 138% FPG or less Children (18 or younger) with family income of 275% FPG or less Infants (23 months or younger) with family income of 280% FPG or less MNCare/BHP eligibility includes: Adults (19 or older) who are not eligible to get coverage through their employer (or their spouses/parents employer) and report a family income between 139 200% of FPG Exchange subsidy eligibility includes: Everyone with family income of 400% FPG or lower who do not meet the eligibility criteria presented above and are not eligible to get coverage through their employer (or their spouses or parents employer) 37 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 38. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Insurance coverage among nonelderly by ACA eligibility 38 Source: 2013 Minnesota Health Access Survey 40.3% 39.2% 41.8% 8.8% 37.7% 0.0% 0.0% 84.1% 5.4% 16.5% 24.5% 4.7% 16.7% 44.4% 33.7% 2.3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% MA-eligible MNCare/BHP-eligible Exchange-eligible Not eligible for ACA Uninsured Individual Coverage Group Coverage Public Coverage Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 39. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level ACA eligibility among nonelderly uninsured 39 Source: 2013 Minnesota Health Access Survey 58.0% 10.8% 16.2% 15.1% Eligible for MA Eligible for MinnesotaCare/BHP Eligible for Exchange with subsidies Not eligible for ACA coverage Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 40. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level What do we know about Medicaid-eligible non- elderly? Children are overrepresented among those eligible for Medicaid, whereas we observe the opposite for nonelderly adults 35 years of age or older MA-eligible are more likely to be Hispanic, and less likely to be white, in comparison to the overall MN nonelderly population MA-eligible are less likely to live in non-core rural areas and to have completed some years of college than the overall MN nonelderly population 40 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 41. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level What do we know about MinnesotaCare/BHP- eligible non-elderly? Those eligible for MNCare or BHP are less likely to be college graduates or have completed postgraduate studies than the overall MN nonelderly population 41 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 42. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level What do we know about MNSure subsidy-eligible non-elderly? Children and young adults (18-25) are underrepresented among people eligible for subsidies or tax credits, whereas people 35 years of age or older are overrepresented Those eligible for subsidies or tax credits are more likely to be white, and less likely to be black or Hispanic than the overall MN nonelderly population Those eligible for subsidies or tax credits are less likely to live in micropolitan rural areas People who do not have a high school diploma are underrepresented among those eligible for subsidies 42 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 43. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Age distribution among nonelderly uninsured by ACA eligibility 43 ^Indicates that this estimate is statistically significantly higher than the estimate for the overall population (95% level) *Indicates that this estimate is statistically significantly lower than the estimate for the overall population (95% level) Source: 2013 Minnesota Health Access Survey 29.2%^ 23.5% 21.7% 19.4%* 6.2%* 0.0% 10.6% 35.3% 39.1% 15.0% 3.8%* 8.5%* 17.9% 52.4%^ 17.4%^ 6.0%* 15.6% 32.6% 33.5% 12.4% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 0-17 18-25 26-34 35-54 55-64 MA-eligible MNCare/BHP-eligible Exchange-eligible Not eligible for ACA Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 44. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Race/ethnicity among nonelderly uninsured by ACA eligibility 44 Sample size is insufficient for reporting Asian and other race estimates 53.4%* 11.5% 27.8%^ 3.6% 62.9% 15.1% 22.0% 4.0% 75.5%^ 4.6%* 6.5%* 4.1% 73.7%^ 13.4% 5.1%* 2.6% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% White Black Hispanic American Indian MA-eligible MNCare/BHP-eligible Exchange-eligible Not eligible for ACA ^Indicates that this estimate is statistically significantly higher than the estimate for the overall population (95% level) *Indicates that this estimate is statistically significantly lower than the estimate for the overall population (95% level) Source: 2013 Minnesota Health Access Survey Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 45. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Geographic distribution among nonelderly uninsured by ACA eligibility 45 72.3% 16.7% 10.9%* 61.1% 16.2% 22.8% 64.8% 7.5%* 27.8% 75.5% 13.5% 11.1% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% Metropolitan Urban Micropolitan Rural Non-core Rural MA-eligible MNCare/BHP-eligible Exchange-eligible Not eligible for ACA ^Indicates that this estimate is statistically significantly higher than the estimate for the overall population (95% level) *Indicates that this estimate is statistically significantly lower than the estimate for the overall population (95% level) Source: 2013 Minnesota Health Access Survey Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 46. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Level of education among nonelderly uninsured by ACA eligibility 46 22.7% 34.8% 27.1%* 15.4% 21.2% 32.0% 36.3% 10.4%* 8.0%* 23.3% 41.1% 27.6% 3.1%* 29.9% 42.3% 24.7% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% Less than HS HS Some college College grad/postgrad MA-eligible MNCare/BHP-eligible Exchange-eligible Not eligible for ACA ^Indicates that this estimate is statistically significantly higher than the estimate for the overall population (95% level) *Indicates that this estimate is statistically significantly lower than the estimate for the overall population (95% level) Source: 2013 Minnesota Health Access Survey Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 47. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level ESTIMATES OF POPULATIONS NOT ELIGIBLE FOR ACA EXPANSIONS 47 48. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Low-income uninsured not eligible for ACA expansions due to immigration status Medicaid eligibility by immigration status unauthorized immigrants and legal permanent residents (LPRs) who have resided legally in the U.S. for < five years are not eligible Exchange (tax credit) eligibility by immigration status unauthorized immigrants are not eligible 48 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 49. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Estimates of Medicaid eligibility by immigration status 49 % unauthorized or legal permanent residents of 200-275% FPL 4,277 0 >275-400% FPL 1,249 0 Adults without Children 138-200% FPL 0 1,323 >200-275% FPL 264 1,959 >275-400% FPL 1,791 2,660 All Adults 138-200% FPL 298 7,153 >200-275% FPL 4,541 1,959 >275-400% FPL 3,040 2,660 Adults (subtotal) Children >275-400% FPL 8,234 881 Total 16,113 12,653 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 53. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level WHAT WE KNOW ABOUT TAKE-UP AND ACCESS TO CARE FROM PRIOR RESEARCH 53 54. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Take-up in Minnesota and other states 2011 Gruber-Gorman estimates of ACA impact in 2016 across markets (ESI, unreformed/reformed individual market, MNCare, Medical Assistance, BHP) and on number of remaining uninsured Take-up rates and the impact of coverage on access to care: Lessons from other states (MA, OR) 54 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 55. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Estimate of ACA effect, 2016 (BHP/Wrap) 55 Source: Gruber and Gorman MNsure Analysis, 2011 as presented January 2013 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 56. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Estimated ACA effect on MNCare, 2016 56 Source: Gruber and Gorman MNsure Analysis, 2011 as presented January 2013 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 57. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Predicting the size of MNsure, 2016 57 Source: Gruber and Gorman MNsure Analysis, 2011 as presented January 2013 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 58. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Predicting remaining uninsured, 2016 58 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN Source: Gruber and Gorman MNsure Analysis, 2011 as published April 2012 12% 9% 36% 43% Undocumented Newly Uninsured Documented, Exempt from Mandate Subject to Mandage, Choose Not to Insure Projected number uninsured in 2016: 210,000 59. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Massachusetts (MA) introduction MA Health Reform Initiative enacted in 2006 Serves as an important benchmark for take-up, access to care, and the welcome mat effect because it was used as a template for the structure of the ACA 59 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 60. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Preview: Lessons from Massachusetts Take-up increased for all types of insurance, though higher for public programs Medicaid enrollment increased between 16 and 19 percentage points among those previously eligible but not enrolled Access improved: having a usual source of care and utilization increased and the inability to get care when needed and forgone care decreased Use of inpatient and ED services decreased Catastrophic health expenditures decreased 60 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 61. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Take-up 2 years after MA reform enacted (Long & Stockley, 2011) Among lower-income adults (= 10% of family income 4 percentage points Did not get needed care because of costs in past 12 months Any care 3 percentage points Doctor care 3 percentage points Specialist care 2 percentage points Medical tests, treatment, follow-up care 2 percentage points Preventive care screening 1 percentage points Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 65. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level MA reform and the Welcome Mat Effect (Sonier et al., 2013) The welcome mat effect refers to an increase in Medicaid participation for populations that were previously eligible (prior to reform) but not enrolled Sonier et al. use MA as a case study to measure the potential effect of the ACA on the previously eligible, but not enrolled population They find an increase in Medicaid enrollment between 16 and 19 percentage points among those previously eligible but not enrolled 65 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 66. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Preview: Lessons from Oregon 2008 Medicaid experiment based Medicaid expansion on a lottery from a waiting list of low- income adults Baicker et al., 2013 evaluated the effect of Medicaid coverage on a range of outcomes Findings: Improved clinical outcomes, access to care, self-reported health, increased use of preventive care, and reduction of costs and financial strain 66 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 67. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Effect of Medicaid enrollment after 2 years: health care utilization (Baicker et al., 2013) Outcome Direction Magnitude Usual source of care 24 percentage points Office visit past month 3 percentage points Received all needed care past 12 months 11 percentage points High quality care in past months 10 percentage points Cholesterol screening 15 percentage points Pap smear (women) 14 percentage points Mammography (women) 30 percentage points PSA test (men) 19 percentage points 67 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 68. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Effect of Medicaid enrollment after 2 Years: health outcomes (Baicker et al., 2013) Outcome Direction Magnitude Self-reported health 8 percentage points Self-reported depression 2 percentage points Diagnosis of diabetes 4 percentage points Prescription for management of diabetes 5 percentage points 68 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 69. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Effect of Medicaid enrollment after 2 years: financial strain (Baicker et al., 2013) Outcome Direction Magnitude Any out-of-pocket (OOP) spending 12 percentage points Amount of annual OOP spending $215 Catastrophic expenditures (OOP>30% income) 4 percentage points Any medical debt 13 percentage points Borrowed $ to pay bills or skipped payment 14 percentage points 69 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 70. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Literature cited Baicker, K., Taubman, S.L., Allen, H.L., Bernstein, M., Gruber, J.H., Newhouse, J.P., et al. (2013). The Oregon Experiment Effects of Medicaid on Clinical Outcomes. The New England Journal of Medicine, 368: 1713-1722. doi: 10.1056/NEJMsa1212321 Long, S.K. & Stockley, K. (2011). The Impacts of State Health Reform Initiatives on Adults in New York and Massachusetts. Health Services Research, 46: 365387. doi: 10.1111/j.1475-6773.2010.01211.x Long, S.K., Stockley, K., & Dahlen, H. (2012). Massachusetts Health Reforms: Uninsurance Remains Low, Self-Reported Health Status Improves As State Prepares To Tackle Costs. Health Affairs, 31(2): 444-451. doi:10.1377/hlthaff.2011.0653 Sonier, J., Boudreaux, M.H., & Blewett, L.A. (2013). Medicaid Welcome-Mat Effect Of Affordable Care Act Implementation Could Be Substantial. Health Affairs, 32(7): 1319-1325. doi:10.1377/hlthaff.2013.0360 70 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 71. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level DISTRIBUTION OF UNINSURED ACROSS MN 71 72. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Exploring the distribution of uninsured Mapping the geography of the uninsured provides useful information to guide outreach efforts Identify concentrations of populations that are likely eligible for various coverage options (e.g., MNCPs versus QHP subsidies) Comparing different geographies can confirm uniformity or highlight hotspots not seen in geographic roll ups (e.g., should a program be regional or county-based?) Layering on points of interest can inform potential outreach approaches (e.g., hospitals, schools) 72 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 73. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Measures of the distribution of uninsured Distribution of uninsured across Minnesota counties Distribution of uninsured by zip code Estimates of uninsured eligible for Medicaid, MinnesotaCare/BHP and the Exchange with a subsidy, with overlays of cities, churches, hospitals, Federally Qualified Health Centers (FQHCs), and schools 73 Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 74. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level 74 DISTRIBUTION OF UNINSURED ACROSS MINNESOTA COUNTIES 75. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Number of nonelderly uninsured, by county, 2011 75 Source: SHADAC Analysis of the US Census Bureau, Model- Based Small Area Health Insurance Estimates (SAHIE) for Counties and States, Overview Who are the uninsured? Access and affordability ACA eligibility Populations not eligible for ACA Take-up under state reforms Distribution across MN 76. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Additional small area health insurance estimates (SAHIE) U.S. Census Bureaus interactive data/map tool allows users to estimate uninsurance at the county-level by a number of demographic groups, including: Age group (0-18, 18-64, 40-64, 50-64, 0-64) Sex Income (