American Community Survey for
Analysis for the Bemidji Area of the Indian
Health Services: Comparison of Michigan,
Minnesota, and Wisconsin.
How many American Indians are eligible for
the Affordability Programs of the Affordable
Care Act?
Turning Data into Information for Analysis
Edward Fox, Ph.D.,
Director, Health Services, Port Gamble S’Klallam Tribe
With assistance of Phil Norgaard, Director, Health and Social Services,
Fond du Lac Band of Lake Superior Chippewa
July 2013
1
Research Note
The data source for this report is a dataset developed from the output of downloads
from the American Community Survey (2009-2010-2011) using the US Census
research tool Dataferret. This exploratory analysis of 2012 ACS 3-year pooled data
(year of release for surveys conducted in 2009, 2010, 2011) is an attempt to
describe significant characteristics of Uninsured American Indians and Alaska
Natives in the Bemidji Area that might be useful for planning outreach and
enrollment activities for health care reform.1 In addition, variations in insurance
and income status with comparisons between the national, state, and sub-state level
are described with an eye toward future research. A word of caution when using
ACS data for small geographies and small populations is that the error rate increases
dramatically for populations under 1,000. Fortunately, pooling three years of data
extends the ‘n’ or number, lowers the error rate, and allows for more reliable
estimates for nearly every state including the three examined in this research brief:
Minnesota, Michigan, and Wisconsin.2
Income and Insurance Estimates for American Indians and Alaska Natives
Approximately 1.2 million American Indians and Alaska Natives3 are uninsured.
About 900,000 of the 2.8 million AIANs between 19 and 65 (inclusive) are
uninsured. The uninsurance rate of 32% is more than double the non-Indian
population. Most AIANs do not access IHS-funded health programs. Nationally,
about 38% of uninsured AIAN respondents report they have access to Indian Health
Services-funded programs and 62% report that they do not have access to IHS. In
the Bemidji Area, with approximately 60,000 uninsured, 40% of the uninsured
(24,000) report access to IHS and 60% (36,000) report they do not have access to
IHS essentially the same as the national average.
While it is true that most of those who report they do not have access to IHS services
are Urban Indians, there are hundreds of thousands of Urban Indians nationally who
do have reasonable access to IHS-funded programs ( albeit underfunded Tribal, IHS
or Title V Urban Programs) in cities such as Oklahoma City, Tulsa, Anchorage,
Albuquerque, and Phoenix. Much more common for Urban Indians, however, is the
situation in cities in states like California, Michigan, Minnesota, Oregon, Washington,
Wisconsin where IHS-funded programs cannot meet the demand for services for
their uninsured AIAN urban population.
50 States Uninsured American Indians / Alaska Natives by Access to IHS
Access to IHS?
Total
Yes
No
38%
62%
1,232,264
465,825
766,439
Suggested citation: American Community Survey 2009-2011 Ed Fox ACS 2013
Dataset
2 Using the ACS for Policy Analysis, Ed Fox, 2012, PowerPoint presentation.
3 American Indian Alaska Native alone and in combination with two or more races.
1
2
Source: American Community Survey 2009-2011 Ed Fox ACS 2013 Dataset
Estimates for Medicaid and Marketplace Tax subsidies
AIANs, like the general population, have nearly equal numbers uninsured in the two
main categories for the affordability programs, Medicaid and Marketplace Qualified
Health Plans: 526,000 of uninsured AIANs are under 139% of FPL and 511,000 are
between 139 and 400% of FPL. Medicaid is far more beneficial in terms of
enrollment uptake rate that far exceeds expected enrollment in Marketplace plans
due to premium cost, complications due to the definition of Indian, and a general
reluctance to purchase health plans with uncertain costs and tax liabilities.4
50 States Uninsured American Indians / Alaska Natives by Access to IHS
0-138%
139-400%
Access to IHS?
Access to IHS?
Total
Yes
No
Total
Yes
No
526,112
201,067
325,045
511,961
199,868
312,093
Source: American Community Survey 2009-2011 Ed Fox ACS 2013 Dataset
About 70,000 uninsured AIANs are in states where Medicaid will not expand to
138% and will be eligible for the Marketplace tax credits raising the number eligible
to 580,000 compared to 450,000 for Medicaid.
50 States Uninsured AIANs by age and
access to Indian Health Service funded program
IHS
IHS
Total
Yes
No
Yes
No
50 states
1,232,264
465,825
766,439
38%
62%
0-18
241,150
129,744
111,406
54%
46%
19 and older
991,114
336,081
655,033
34%
66%
Source ACS 2009-2010-2011 pooled data, Ed Fox 2013 ACS dataset.
Provider access in Qualified Health Plans, however, could be better than Medicaid
provider access for specialists.
4
3
The Bemidji Area is located in the three upper Midwest States of Minnesota,
Wisconsin, and Michigan. Although the three states have above average income,
when compared to the Nation, their Indian populations are less well off.
Minnesota’s Indian population, unfortunately, has very low income when compared
to the state average. While all three states have long traditions of progressive health
care policies, recessions and concern about state and federal budget deficits have
constrained these programs in the past two decades.
The Bemidji Area has 3 Direct Service Programs at Cass Lake, White Earth, and Red
Lake; all located in Northern Minnesota. Most programs, however, are tribal
programs (under 638 authority) and four urban programs exist in Chicago, Illinois,
Milwaukee, Wisconsin, Minneapolis, Minnesota, and Detroit, Michigan.
Bemidji Area Uninsured AIANs
Totals
0-18
IHS Access
Yes
No
60,654
24,483
36,171
13,060
6,844
6,216
19 and
older
47,594
17,639
29,955
There are an estimated 60,654 uninsured in the Bemidji Area. Nearly 48,000 are
adults and 13,000 children under 19 years old. It appears that children, most of
whom are likely Medicaid eligible, are less likely to be enrolled if they have ‘access
to IHS’. This is a lost opportunity to secure insurance coverage at no cost to the
Tribe or families and a lost opportunity for revenue to health programs. It is easily
explained: most prefer not to enroll in Medicaid until a referral to a specialist or a
hospital visit is required since there is no charge for direct care services at IHSfunded health programs.
Bemidji Area Uninsured AIANs by income level
Totals
0-18
19 and
older
Between 0 and 138 % of FPL
26,056
10,875
15,181
8,697
3,322
5,375
9,312
3,644
5,668
5,710
3,156
5,810
3,237
2,573
2,554
1,127
1,427
2,005
778
1,227
1,218
1,035
20,246
7,638
12,608
6,143
2,195
3,948
7,307
2,866
4,441
4,492
2,121
Between 139 and 200
Between 201 and 300
Between 301 and 399
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
Yes
4
Between 400 and 500
Not Elsewhere Classified (nec.)
No
Total
Yes
No
Total
Yes
No
2,554
2,955
1,460
1,495
7,924
2,026
5,898
183
673
403
270
800
264
536
2,371
2,282
1,057
1,225
7,124
1,762
5,362
43% of the uninsured are under 139% of the federal poverty level (26,000).
Another 39% are between 139% and 400% of FPL, with a total of 83% eligible for
the affordability programs of the Affordable Care Act (Medicaid or Tax Subsidies).
Note: Wisconsin and Michigan have not agree to expand Medicaid
The Three States of the Bemidji Area: Uninsured by age and access to IHS.
Michigan
Access to IHS
Total
Yes
No
21,902
6,744
15,158
0-18
2,856
1,334
1,522
0-18
Access to IHS
Access to IHS
Minnesota
Total
21,288
Yes
8,581
No
12,707
6,399
3,040
3,359
Wisconsin
0-18
17,464
9,158
8,306
3,805
2,470
1,335
Total
Yes
No
19 and
older
19,046
5,410
13,636
19 and
older
14,889
5,541
9,348
19 and
older
13,659
6,688
6,971
Michigan has the largest number of uninsured, but all three states have similar sized
uninsured populations with Minnesota’s 21,300 essentially that same as Michigan’s
21, 900, and Wisconsin’s just 4,000 less at 17,500. Minnesota has proportionally
more uninsured children than the other two states---nearly the same number as
Michigan and Wisconsin combined (see discussion below).
The states do vary by ‘access to IHS’ with Wisconsin have the largest uninsured
population reporting they feel they have access to IHS services followed by
Minnesota and then Michigan. Each state has large Urban populations that may not
5
have easy access to an Urban Indian health program as evidence by the fact that
36,000 of the 60,000 uninsured in the area do not have access to IHS paid services
and just 24, 000 saying they do have access.
Minnesota
Access to IHS
Between 0 and 138
Access to IHS
Between 139 and 200
Access to IHS
Between 201 and 300
Access to IHS
Between 301 and 399
Access to IHS
Between 400 and 500
Access to IHS
Not Elsewhere Classified
(nec.)
0-18
19 and older
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
Minnesota
21,288
8,581
12,707
9,693
4,002
5,691
2,527
907
1,620
3,686
1,676
2,010
1,636
795
841
1,252
652
600
2,494
6,399
3,040
3,359
3,324
1,644
1,680
888
235
653
1,043
380
663
386
365
21
352
337
15
406
14,889
5,541
9,348
6,369
2,358
4,011
1,639
672
967
2,643
1,296
1,347
1,250
430
820
900
315
585
2,088
Yes
No
549
1,945
79
327
470
1,618
Minnesota’s Indian population is poorer than the national average and this is
reflected in the high percentage who are under 139% of the federal poverty level
and thus eligible for the state’s Medicaid program.
19 and older
Minnesota
Between 0 and 138
Between 139 and 200
Between 201 and 300
Between 301 and 399
Between 400 and 500
Not Elsewhere Classified
(nec.)
Total
14,889
6,369
1,639
2,643
1,250
900
2,088
IHS Access
5,541
2,358
672
1,296
430
315
470
No IHS
9,348
4,011
967
1,347
820
585
1,618
6
14,889
Minnesota’s Indian population that indicates they do have access to IHS funded
programs are poorer than the state average income for all AIANs. This is also
reflected in the high percentage who are between 139% and 300% of the federal
poverty level and thus eligible for tax subsidies AND the cost sharing exemption (if
an enrolled tribal member) in the Marketplace. Another way to look at this: those
without access to IHS services are far less likely to have incomes over 300% FPL
than those who do have access to IHS (800 compared to 2,200).
19 and older
Minnesota
Between 0 and 138
Between 139 and 200
Between 201 and 300
Between 301 and 399
Total
IHS Access
43%
11%
18%
8%
80%
No IHS
43%
12%
23%
8%
86%
43%
10%
14%
9%
76%
In Minnesota, affordability programs (Medicaid and Marketplace tax subsidies)
reach 80% of Minnesota’s Uninsured AIANs, 86% of those with access to IHS and
about 76% of those without access to IHS. This means 12,000 of the 15,000
uninsured adults would have either Medicaid eligibility or tax subsidy eligibility in
the Marketplace. This means about 3,000 uninsured AIANs have incomes over
400% of the federal poverty level.
Access to IHS
Between 0 and 138
Between 139 and 200
Between 201 and 300
Between 301 and 399
Between 400 and 500
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
Wisconsin
0-18
17,464
9,158
8,306
6,602
3,776
2,826
2,835
1,143
1,692
2,410
1,141
1,269
2,279
1,789
490
906
3,805
2,470
1,335
1,226
1,078
148
928
485
443
702
273
429
553
459
94
118
19 and
older
13,659
6,688
6,971
5,376
2,698
2,678
1,907
658
1,249
1,708
868
840
1,726
1,330
396
788
7
Not Elsewhere Classified
(nec.)
Yes
No
Total
453
453
2,432
39
79
278
414
374
2,154
Yes
No
856
1,576
136
142
720
1,434
As noted above, Wisconsin has the highest percentage of Uninsured Indians who
indicate that they have ‘access to IHS’. Over half (52%) of the state’s uninsured
AIANs have access to IHS, higher than the area or national average. 38% are under
139% of FPL and 43% are between 139 and 400% of FPL. Unfortunately, Wisconsin
has yet to expand Medicaid fully and a closer analysis is needed to determine the
impact of this decision on the state’s uninsured as the state explore’s its options to
expand insurance under the ACA.
Wisconsin Income distribution with 100% Federal Poverty Level
AGE
0-18
19-28
29-38 39-48 49-58 59-64 65+
Total
Between 0 and 99
100 and 200
201 and 300
301 and 399
400 and 500
Not Elsewhere
Classified
17,464
4,938
4,499
2,410
2,279
906
3,805
900
1,254
702
553
118
4,894
1,188
1,768
472
353
336
2,720
741
383
591
438
11
2,741
1,256
403
154
247
124
2,283
666
485
345
307
216
875
109
206
110
372
78
146
78
36
9
23
2,432
278
777
556
557
264
-
-
Michigan
Between 0 and 138
Between 139 and 200
Between 201 and 300
Between 301 and 399
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
Yes
No
Total
0-18
21,902
6,744
15,158
9,761
3,097
6,664
3,335
1,272
2,063
3,216
827
2,389
1,795
2,856
1,334
1,522
1,260
515
745
738
407
331
260
125
135
279
19 and
older
19,046
5,410
13,636
8,501
2,582
5,919
2,597
865
1,732
2,956
702
2,254
1,516
8
Between 400 and 500
Not Elsewhere Classified
(nec.)
Yes
No
Total
Yes
No
Total
572
1,223
797
355
442
2,998
211
68
203
27
176
116
361
1,155
594
328
266
2,882
Yes
No
621
2,377
49
67
572
2,310
Michigan has the largest number of uninsured of the three states with 22,000
uninsured. It has by far the largest number of uninsured who do not have access to
IHS services with 15,000. A closer analysis would likely reveal that these uninsured
live in urban areas. The state legislature and governor continue the heated debate
over whether or not it will take full advantage of the opportunity to cover uninsured
up to 139% of the federal poverty level.
Regions within States
The ACS’s lowest unit of analysis is the PUMA. It is beyond the scope of this paper to
analyze sub-state regions of the Bemidji area, but a cursory examination of
Minnesota’s regional variation is instructive and suggests that a within state
regional analysis can highlight significant characteristics of a state’s uninsured AIAN
population. One Minnesota Census Public Use Microdata Area5, PUMA 200, includes
all three of the Bemidji Area Direct Service Tribes. This PUMA includes 25% of the
state’s uninsured and 58% of those who indicate they have access to IHS-funded
services. One can combine the nearby PUMAs (300 and 400) and find that 6,000 of
Minnesota’s 9,700 uninsured AIANs reside in Northern Minnesota. Similarly 4,200
of the 6,400 adults under 139% of FPL reside there. These findings, while not
surprising to Minnesota’s Indian leadership, may be useful in planning for outreach
and education initiatives and informing these efforts, guiding implementation and
measuring progress in expanding insurance coverage.
Findings from analysis of PUMA 200 (home of Cass Lake, White Earth and Red
Lake Service Units of the Indian Health Service):
Minnesota’s PUMA 200 (with less than 100,000 population) contains the following
percentages (of uninsured) for its American Indian and Alaska Native Population:
1. 25% of the states uninsured.
2. 32% of the states’ uninsured children, 22% of the states uninsured adults
3. 58% of the states’ uninsured who report that they have access to Indian
Health Service-funded services.
5
Geographical unit of about 100,000, typically made up of counties or parts of counties.
9
4.
5.
6.
7.
27% of the states uninsured who are eligible for Medicaid (under 139% )
Only 15% of the states uninsured who are between 139 and 200% of FPL
34% of the states uninsured who are between 200% and 300% of FPL.
Only 7% of the states uninsured who have incomes over 500% of FPL.
10
Minnesota Compared to PUMA 200
0-18
All income
Access to IHS
0 and 138
Access to IHS
139 and 200
Access to IHS
201 and 300
Access to IHS
301 and 399
Access to IHS
400 and 500
Access to IHS
Not
Elsewhere
Classified
Access to IHS
Minne
sota
Total 21,288
Yes 8,581
No
12,707
Total 9,693
Yes 4,002
No 5,691
Total 2,527
Yes
907
No 1,620
Total 3,686
Yes 1,676
No 2,010
Total 1,636
Yes
795
No
841
Total 1,252
Yes
652
No
600
Total 2,494
Yes
No
549
1,945
Puma#
200,
0-18
6,399
3,040
3,359
19
and
older
14,889
5,541
9,348
2,051
1,954
97
19
and Puma#
older
200,
3,346
25%
3,052
58%
294
3%
5,397
5,006
391
3,324
1,644
1,680
888
235
653
1,043
380
663
386
365
21
352
337
15
406
6,369
2,358
4,011
1,639
672
967
2,643
1,296
1,347
1,250
430
820
900
315
585
2,088
79
327
470
1,618
018
32%
64%
3%
19
and
older
22%
55%
3%
2,587
2,348
239
388
367
21
1,244
1,168
76
622
605
17
381
381
175
1,042
970
72
157
157
311
297
14
285
285
245
245
11
1,545
1,378
167
231
210
21
933
871
62
337
320
17
136
136
164
27%
59%
4%
15%
40%
1%
34%
70%
4%
38%
76%
2%
30%
58%
0%
7%
31%
59%
4%
18%
67%
0%
30%
78%
2%
74%
78%
0%
70%
73%
0%
3%
24%
58%
4%
14%
31%
2%
35%
67%
5%
27%
74%
2%
15%
43%
0%
8%
137
38
11
137
27
25%
2%
0%
3%
29%
2%
Conclusion
The ACS provides useful information about the uninsured that can be used to target
outreach and enrollment efforts and measure progress in expanding health
insurance coverage to the uninsured.
11