Affording Insurance

North Dakota's Uninsured -
Who are they and where do they live?
By Mary Schieve

• He is a young man who works three part-time jobs to support his wife and two children. None provides benefits, and he can’t afford to pay for health coverage on his own. There are more immediate needs such as paying the rent and buying food and clothes.
• She is a single parent and works full time. She’s eligible for benefits through her employer, but her wages aren’t adequate to allow her to purchase family insurance coverage.
• He is a farmer who has seen his income drastically reduced by low commodity prices and the rising cost of doing business. He doesn’t want to drop his family’s health coverage, but he may not have a choice if he wants to keep the farm.

Contrary to common belief, the uninsured in North Dakota are more likely to fit profiles such as those above than stereotypical images of the homeless. A high percentage are the “working poor.” Quite often, they are young adults who either are not offered health insurance through their employers or cannot afford to pay for it.

It’s a trend that tracks with other state and national surveys. According to a 1999 report issued by the Center on Budget and Policy Priorities, children in low-income working families receive assistance through Medicaid and, in some states, through newly established child health programs, but the parents who head these families remain at a high risk of being uninsured. The same report revealed that working poor parents are twice as likely to be uninsured as their unemployed counterparts.

Dr. Alana Knudson-Buresh, until recently data director for the North Dakota Department of Health, explained that while Medicaid exists primarily for children and caretakers, and Medicare is designed for the elderly, few government programs provide a safety net for low-income working adults. These people are making a contribution to our state, she said, yet in many cases, it is difficult for them to pay the cost of health insurance.

A longtime advocate for those who have access barriers to health care, Sherlyn Dahl believes this is an issue people need to start discussing. “There is a great deal of concern about access to health care in rural communities in North Dakota,” she said, “but I would like to push the dialogue further and talk about the issue of the uninsured. We need to recognize that this is a problem.”
Dahl is executive director of the Family HealthCare Center in Fargo, a federally funded community health center whose mission is to deliver primary health care to anyone regardless of ability to pay. One of 700 such facilities across the country, it is the only one of its kind in North Dakota and has been in operation since 1993.

“I feel strongly about our role,” she said, “but I don’t think we’re the answer to the problem. We need to support programs like ours, but we also have to look at the larger issues of insurance and affordability. How can we make insurance more affordable for low-income families? We need to engage employers and small businesses, legislators, insurance companies and all the different providers in the discussion. The answers will be found when people start to talk about the problems.”

A closer look at North Dakota’s uninsured
Focus on Children
Focus on Farmers and Ranchers
What Difference Does Health Insurance Make
Fargo’s Family Health Care Center
America’s Uninsured: the national picture
Working Parents

A closer look at North Dakota’s uninsured
In North Dakota, quite a bit is known about the uninsured and why they lack health coverage.
While many states rely on national surveys to gather information about their uninsured, North Dakota is able to draw extensive data from two comprehensive statewide health insurance surveys completed in the last six years, one in 1994 and another in 1998. Conducted for the North Dakota Department of Health and funded by the Robert Wood Johnson Foundation, both surveys assess the percentage of uninsured in the state and access to health care.

In 1994, an estimated 9.9 percent of North Dakotans were uninsured. By 1998 that number had actually declined to 8.6 percent, or an estimated 55,000 uninsured out of a total population of 638,244. That figure is lower than the national average of 16 percent and lower than that of other states.

Knudson-Buresh noted several factors that may have contributed to the decrease, among them a strong economy in North Dakota between 1994 and 1998. “Our unemployment rate is so low,” she said, “that many employers have had to offer insurance to be competitive in the market.” Also, she pointed out, some health insurance reforms seem to have had a positive impact on reducing the number of unemployed in the state.

What else do we know about uninsured adults in North Dakota from the 1998 survey? We know this:

• The highest percentage of the state’s uninsured are 25 to 34. In 1998, 51 percent of the people in this age group reported they were uninsured.
  
• There is very little difference in terms of gender – 8.2 percent of women are uninsured compared to 9 percent of men.
  
• Of uninsured adults, half live alone, and one in five is married.
  
• The uninsured in North Dakota do not include only those with minimal education. Forty percent of uninsured adults have a high school diploma or GED, 30.8 percent have some college or an associate degree, 9.4 percent have a bachelor’s degree and 1.5 percent have a graduate degree.
  
• Of the uninsured adults, 4 percent are full-time students;
  3 out of 4 are employed. Two-thirds of the 3 out of 4 work for a private company, while 15 percent are self-employed.
  
• Sixty percent of the uninsured said they worked at firms that offered health insurance, but only 50 percent of them were eligible to apply. Their ineligibility, said Knudson-Buresh, is mostly due to their part-time status.
  
• One out of 10 work at more than one job.
  
• Uninsured adults in North Dakota are more likely to be employed in construction, farming, retail, restaurants and nursing homes.
  
• Of the adults with insurance who responded to the survey, 31.6 percent felt they had excellent health compared to 25.4 percent of the uninsured. Typically, the uninsured rate their personal health as slightly less than their insured counterparts. There are many theories that account for this, said Knudson-Buresh. “One is that insured people, by virtue of being healthy, have an easier time getting health insurance, while the uninsured may have had some pre-existing condition that precluded them from being eligible,” she said. Also, she notes, no matter where you live, a person’s socio-economic status has a great impact on health. People on the lower end are often the most challenged with their health and have poorer health outcomes.

Focus on children
According to the 1998 Robert Wood Johnson survey, 14,663 of North Dakota’s 175,822 children are uninsured. That number may improve with the latest federal effort to insure more of America’s children.

An effort proposed by President Clinton and launched in 1997 to provide coverage to more uninsured children, the State Children’s Health Insurance Program (SCHIP) is the largest single expansion of health insurance coverage for children in more than 30 years and is already having an effect, not only in North Dakota, but also across the country.

Just one month after North Dakota launched its version of the program, Healthy Steps, the governor announced that 620 previously uninsured children had health coverage through the plan. As was intended by federal legislation, the Healthy Steps plan is projected to meet the needs of working families who cannot afford health insurance coverage for their children, yet earn too much to qualify for Medicaid. The 1999 Legislature budgeted funds to cover an average of 2,000 children per month during the biennium, and Blue Cross Blue Shield of North Dakota (BCBSND) was chosen to administer the program. Healthy Steps is expected to reach its goal by the end of the year. As of September 30, 2000, there were already 2,022 children enrolled, according to Camille Eisenmann, Healthy Steps outreach coordinator.

Applicants who do not meet the income guidelines are referred to BCBSND’s Caring Program for Children, an older program also designed to reach children who fall between
the cracks and are uninsured.

Focus on farmers and ranchers
A downturn in the agricultural economy prompted a more recent survey on North Dakota’s uninsured, this time with a focus on the state’s farmers and ranchers. Concerned about anecdotal information that indicated farm and ranch families were having a difficult time maintaining their health insurance coverage due to low crop and cattle prices, legislators wanted to know more about the situation. The Health Department and Community HealthCare Association partnered with the North Dakota Agricultural Statistics Service to examine coverage of the group and released the findings of their work last June. Surprisingly, only six percent of households surveyed reported having no health insurance—a relatively low number.

Knudson-Buresh cautioned, however, that rural health coverage problems have not lessened. “We found that the six percent reflects the number of uninsured, but it doesn’t tell us the number of underinsured,” she said. She suspects that many farmers and ranchers buy coverage at the catastrophic level, which is less expensive but carries a higher deductible. It is really more of a safety net for the operators who believe their ability to farm is dependent upon their health in an occupation that carries a high risk of injury. These farm families who can’t afford more coverage may not be receiving regular or preventive care, she said.

Also, she noted, many farmers have received significant disaster payments over the last couple of years that may have helped them maintain their health insurance. “If we have another bad year and don’t receive the level of disaster payments we’ve had in the past, that six percent could change dramatically,” she added.

Clearly, she said, farm and ranch operators are concerned about health insurance based on the volume of the comments and the 90 percent response rate to the survey. Other survey findings include the following:

• Forty-two percent of the respondents were at least 55. Twenty percent lived in households where the head of the household was over 64 – a percentage consistent with other studies that estimate 21 percent of North Dakota’s farm and ranch operators are over 64.
  
• Younger farmers and ranchers were more likely to go without health insurance. Of the farmers younger than 34, about 10 percent did not have coverage – a figure consistent with other state and national surveys that show younger workers are more likely to be uninsured than older workers.
  
• “Too expensive” or “cannot afford it” were listed by 86 percent as the primary reasons for not having health insurance. Nearly half who responded offered comments related to financial issues, such as the cost of premiums, high deductibles and the need to seek off-farm employment to secure health insurance coverage.

What difference does health insurance make?
Literature on the uninsured suggests that there are negative consequences to living without health insurance. The Kaiser Commission on Medicaid and the Uninsured, a
program of the Henry J. Kaiser Family Foundation, reported that nationally:

• More than half of uninsured adults and one in five uninsured children do not have a usual source of health care.
  
• Preventive services are less commonly used by the uninsured. Thirty-five percent reported a routine check-up in the past year compared to 61 percent of the insured. Uninsured children are less likely to be up-to-date with the accepted standard for well-child visits.

Dr. Deb Walker, a family physician at the Fargo Family HealthCare Center, understands the dilemmas faced by her uninsured patients. “We have family practitioners here,” she said. “If someone comes in and needs a general surgeon, computerized tomography (CT) scan or magnetic resonance imaging (MRI), it can cost $1,200. That’s pretty prohibitive for people who don’t have money. Uninsured people are very careful about costs. They don’t want to run up bills they can’t pay. They’re very reluctant to have workups they can’t afford.”

Therefore, the center’s physicians try to obtain discounts for their patients. “I’ve become really good at begging,” said Walker, who often asks specialists to donate or discount their services. But even then, she says, people may elect to go without treatment. Some people can’t afford half the cost of a $1,200 MRI.

Dahl agrees that both adults and children who are uninsured are less likely than those who are insured to receive preventive care and more likely to require emergency services for conditions that may have been avoided.

“The difference in treatment occurs,” she said, “before they show up at our door. The uninsured have a tendency to take care of a problem themselves or to ignore it, so we see people seeking care late in an illness. They use the emergency room to access care, which is probably the most expensive way to do it.”

With that in mind, the center takes a preventive approach to health care, integrating it into the system. “If we have a child in for an ear infection, we check on immunizations. We ask if the child has had a well-child exam. We try to address the full spectrum of health care, not just deal with the sickness,” Dahl said. She explained that the center is currently involved in an effort to help its patients better manage diabetes, making sure their feet are checked and their blood sugars are maintained appropriately.

“Having a provider like us that focuses on this population is a way of saying, ‘We understand that you’re concerned about the cost. It’s OK for you to come in. We can help you. We can take care of your illness before you get really sick,’” she said.

“We’re paying for that care, anyway – the providers, the insurance companies, the businesses who buy health insurance, the taxpayers – so we might as well deal with it,” said Dahl.

She noted that while it is primarily federal dollars now that pay for the uninsured, more states are beginning to look at their role and developing grant programs for providers serving higher percentages of low income people.

In late 1998, Jenny Withum was hired as director of the state’s Primary Care Association. She is working with communities across North Dakota to determine the need for health centers and working on health care solutions for their uninsured populations.

Dahl also pointed to progress in other North Dakota communities – the Third Street Clinic in Grand Forks; a free clinic, staffed with volunteer physicians, in Minot to reach out to farm families in western North Dakota; and a recently developed health care facility for the homeless in Bismarck.

“Just in the last couple of years, I have seen the development of health care programs for the homeless in each of our four centers of population,” said Dahl. “This is an issue that is starting to play out across the state.”

Fargo’s Family HealthCare Center
Designed to meet the health care needs of anyone in the community, regardless of ability to pay, Fargo’s Family HealthCare Center served 9,884 people with more than 32,000 visits in 1999. Thirty-two percent of its patients are uninsured. Seventy-five percent are low income. Sherlyn Dahl, the center’s executive director, noted a 60 percent increase in the number of uninsured patients from 1995 to 1999, and pointed out that most of that growth occurred from 1998 to 1999, mostly among uninsured racial and ethnic minority groups.

While the center has not yet analyzed its data to determine where the growth is coming from, Dahl said, “My sense is that the uninsured we see tend to be a little more weighted to those who are Caucasian and working in jobs where employers don’t provide health insurance. They are the working poor.”

By far, the majority of the uninsured who apply to participate on the center’s sliding fee scale are young people, according to the center’s eligibility worker. They are young families, with one or two parents and a couple of kids. They’re working part-time jobs or full-time jobs where there is no provision for health insurance, or if there is, they don’t make enough money to afford it. They are also young single people just entering the work world, who often work at one or two part-time jobs where no insurance is provided.

While the center serves a large number of minorities, they are often insured primarily through medical assistance.
The center has about 140 requests for applications to its sliding scale each month, but center staff are quick to point out that “some may think people take advantage of our sliding fee scale, but that is not the case. Most of these families are working hard and really need the help.”

America’s uninsured: a national picture
According to the Health Insurance Association of America, more than 44 million Americans currently lack health insurance coverage. More than 11 million of those are children. The following information is taken from “Uninsured in America: A Chart Book,” published in June 1998 by the Kaiser Commission on Medicaid and the Uninsured.

• The number of Americans without health insurance has grown by nearly 10 million over the last decade.
  
• The near-poor (those with incomes from 100 to 200 percent of the poverty level) run the highest risk of being uninsured because while they may not be eligible for Medicaid, in most cases, they often cannot afford health insurance premiums.
  
• Eight out of 10 of the uninsured are full-time workers or dependents of full-time workers. Only 10 percent of the uninsured are in families where there are no connections to the work-force. Working any less than full-time for the entire year also raises risk substantially.
  
• Employees earning less than $20,000 per year have a high risk of being uninsured.
  
• The risk of being uninsured varies by industry. Workers are less likely to have health coverage in industries such as agriculture, construction or the service sector, where businesses tend to employ many part-time or temporary workers.
  
• More than a third of uninsured adults reported problems paying their medical bills in the past year. One in six said they had to change their family’s way of life significantly in order to pay these medical bills.
  
• People without health coverage are much less likely to have a usual source of health care and use preventive services.

Working parents
The following information on working parents was taken from “Employed But Not Insured: A State-by-State Analysis of the Number of Low-Income Working Parents Who Lack Health Insurance,” 1999, Center on Budget and Policy Priorities:

• Nationwide, more than one out of three working parents with income below 200 percent of the poverty level ($27,300 a year for a family of three in 1998) are uninsured.
  
• The uninsured rate among working parents with income below 100 percent of the federal poverty level is even higher. Nationwide, close to half of all poor working parents are uninsured.
  
• In 1997, some 23 percent of poor parents who had no earnings throughout the year were uninsured compared to 46 percent of poor parents who worked for 13 weeks or more during the year.

Reprinted with permission from Blue Cross Blue Shield ND Health Care Discussions, Fall 2000 issue. Mary Schieve is a copywriter with Simmons Advertising, Grand Forks, ND

Funding for Life Support is provided by a grant from USDA Rural Development