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.
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
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.
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– Employersponsored 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
Coverage
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
Uninsured All Year
11.2%
Uninsured Part Year
5.8%
Uninsured at Some
Point During Year
14.6%
8.8%
How does Alabama Compare?
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%
Definition
AL Uninsurance Rates
by Age
25.00
23.1
20.00
20.5
15.00
10.00
13.0
11.2
11.6
7.6
5.00
4.3
1.1
0.00
All Ages
0-5
6-18
All rates reflect point in time data.
19-24
25-34
35-54
55-64
65+
AL Uninsurance Rates
by Race
25.0
22.0
20.0
15.0
10.0
13.2
11.2
10.9
10.2
5.0
5.5
0.1
0.0
Total Population
African Ame rican
Ame rican Indian
Hispanic
Whie
Othe r
All rates reflect point in time data.
Asian
AL Uninsurance Rates
by Income Level
25.00
20.00
18.9
20.9
18.1
15.00
10.00
17.1
14.9
11.2
8.1
7.6
5.00
3.0
0.00
Total Population
<15% FPL
15 - 100% FPL
101-133% FPL
201 - 250% FPL
134-150% FPL
251 - 300% FPL
151 - 200% FPL
>300% FPL
All rates reflect point in time data.
AL Uninsurance Rates
by Employment Status
30.00
25.00
25.7
20.00
15.00
10.00
17.3
14.3
11.2
8.4
5.00
2.2
0.00
Total Population
Self Employed
Employed by Someone Else
retired
Not employed / unpaid worker
Student
All rates reflect point in time data.
AL Uninsurance Rates
by Educational Attainment
25.00
20.00
21.3
15.00
10.00
13.3
11.2
10.2
5.00
3.8
0.00
3.4
Total Population
Less than High School
High School graduate
Some College
College graduate
Postgraduate
All rates reflect point in time data.
AL Uninsurance Rates
by Geographic Region
Tuscaloose MSA
11.8
Southern Rural
14.9
15.6
Northern Rural
Montgomery MSA
10.9
Mobile MSA
9.1
Huntsville MSA
13.3
8.4
Florence MSA
13.6
Dothan MSA
10.0
Black Belt
7.7
Birmingham MSA
10.7
Auburn MSA
13.0
Anniston MSA
11.2
ALL Regions
0.00
All rates reflect point in time data.
5.00
10.00
15.00
20.00
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.
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
Other
10%
Desire
Adequacy
3%
Don't Qualify
25%
Expensive
61%
Covered Soon
1%
Uninsured People Who Are Potentially
Eligible for Public Programs:
Willingness to Enroll
Don't Know/
Refused
20%
No
3%
Yes
77%
Percentage w ith
regular source of care
Do the Uninsured have a
Regular Source of Care?
100
90
80
70
60
93.1
90.2
Insured Publicly
Insured Privately
71.1
50
40
30
20
10
0
Uninsured
Where do those with a regular source of care
access their health care?
Source
Type of Insurance
Uninsured
Public
Private
Emergency
Room
13.5%
2.3%
2.1%
Doctor’s Office
58.5%
72.9%
85.7%
Clinic
25.9%
21.2%
10.9%
Other
2.1%
3.6%
1.3%
TOTAL
100%
100%
100%
Types of Clinics used by those with a regular
source of care
Source
Type of Insurance
Uninsured
Public
Private
Free Clinic
71.0%
44.9%
26.7%
Hospital Clinic
16.3%
24.5%
24.1%
Private Clinic
9.1%
23.7%
45.8%
Other
3.7%
6.9%
3.5%
TOTAL
100%
100%
100%
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?
60
54.6
50
40
30
20
11.2
10
7.2
0
Public
Private
Health Insurance Status
Uninsured
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
Too expensive
22%
Don't Need It
40%
No
dentist in area
9%
Not accepting
my insurance
5%
Child too
young
8%
Other
4%
Not important
12%
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
No providers in
my area
5%
Don't know
w here to go
4%
Other includes:
No Insurance,
hard to get an
appointment,
transportation issues
and
language barriers.
Other
26%
Insurance does
not pay for
mental health
care
12%
Too expensive
53%
How Worried Are Alabamians
About Health Care?
100
90
80
70
60
Private
50
40
Public
30
Uninsured
20
10
0
w on't afford
prescription
drugs
w on't afford
health care
services
health
insurance w ill
become too
expensive
benefits w ill be w ill lose health
cut back
insurance
substantially
benefits
Reasons for Worries About
Loss of Current Benefits?
0.35
31.8%
0.3
27.4%
0.25
22.0%
0.2
0.15
0.1
7.5%
6.1%
6.0%
Job Change
No Employer
Of f er
0.05
0
Premium
Increase
Loss of Job
Family
Composition
Change
Other (Divorce,
COBRA ends)
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?