TRENDS IN RURAL HEALTH
INSURANCE ENROLLMENT,
POST-ACA IMPLEMENTATION
Preliminary findings
Presentation to Rural Health Advisory Committee
September 22, 2015
Counties as metro, micro or rural
Metropolitan statistical areas
Micropolitan statistical areas
Source: MN Dept of Employment and Economic Development, Metropolitan Statistical Areas and Micro Statistical Areas.
Why it’s important to break out rural when
talking health insurance
Share of uninsured nonelderly
adults v population, 2013
Share of pop 18-64
Uninsurance rate, nonelderly
adults, 2013
Share of uninsured 18-64
12.9%
78.3%
75.7%
12.3%
10.8%
10.0%
11.5%
Rural
11.7%
12.8%
Micro
Metro
Rural
Micro
Metro
Source: American Community Survey, U.S. Census, 5-year estimates, 2013.
Sources of Insurance Coverage in MN, 2009 to 2013
9.0%
9.0%
8.2%
28.3%
29.2%
31.1%
5.1%
5.2%
5.4%
57.6%
56.6%
55.2%
2009
2011
2013
Group
Individual
Public
Uninsured
Estimates that rely solely on household survey data differ slightly from annual estimates that include both survey and administrative data.
Source: Minnesota Health Access Surveys, 2009, 2011 and 2013. Summary of graph
Employer-sponsored insurance:
Greater MN v Twin Cities metro, 2010-2014
Rural
2011
Urban
*Uncompensated care figures are adjusted to reflect costs of providing services.
Source: MDH Health Economics Program analysis of data from the Health Care Cost Information System.
Summary of graph
2.1%
2.4%
2.2%
2.5%
2010
2.1%
2009
2.5%
2008
2.5%
2.3%
2007
2.1%
2006
2.2%
2005
2.2%
2.2%
2.0%
2.0%
2004
1.9%
2.0%
2003
1.7%
1.8%
1.6%
1.6%
Percent Hospital Operating Expenses
2.5%
2.6%
Uncompensated Care Trends for Rural and Urban
Minnesota Hospitals
2012
2013
Affordable Care Act (ACA)
implementation in Minnesota
Key ACA milestones in MN
March 2010
Affordable Care Act signed
March 2011
Medical Assistance (MA)
expanded to childless adults
75% FPL
Jan 2014
• MA expanded further, to
childless adults 138% FPL
• MinnesotaCare converted to
a Basic Health Plan, which
expanded benefits and
reduced max. income to
200% FPL
Nov 2013-March 2014
MNsure 1st enrollment period
Nov 2014-March 2015
MNsure 2nd enrollment period
Source: State Health Access Data Assistance Center, Early Impacts of the Affordable Care Act on Health Insurance Coverage in Minnesota, June 2014.
Source: Manatt, Phelps & Phillips for the Minnesota Task Force on Health Care Financing. Presentation at August 7, 2015 task force meeting.
http://mn.gov/dhs/images/Minnesota_Task_Force_on_Health_Care_Financing_8-7-15_Meeting_handout.pdf
What we know from MN studies so far
• Betw Sept 2013 and May 2014, the number of uninsured
Minnesotans fell by 40.6%, to 4.9% of the population.
• Coverage has increased in both public programs and private
insurance, with the greatest increases in MA and
MinnesotaCare.
• MA enrollment grew by about 1/3 from Sept 2013 to May
2014: From 11.5% to 15.3%.
• Just over 1/4 of those in commercial insurance through MNsure
were uninsured immediately before they were enrolled, and
29% of these had been uninsured for 5 years or more.
Sources:
State Health Access Data Assistance Center, Early Impacts of the Affordable Care Act on Health Insurance Coverage in Minnesota, June 2014.
Minnesota Office of the Legislative Auditor, Evaluation Report: Minnesota Health Insurance Exchange (MNsure), February 2015.
What we don’t know yet
• Rural-urban differences at the sub-county level.
• Current levels of uninsurance and underinsurance in rural sub-
county areas.
• Changes in access and use of health services, including
remaining financial barriers to care.
• Impacts on rural providers.
• Changes in the non-MNsure private insurance market.
Initial analysis for RHAC
Parameters
High-level rural vs urban distribution
• Distribution of public program enrollment, pre-ACA to 2015
• Distribution of MNsure’s 1st round of enrollment
• Regional distribution and subsidy levels of MNsure QHP
enrollment, 2015
Limitations
• Still only county- or regional-level, so “rural” or “metro”
categories obscure differences within areas (e.g., “metro”
includes counties like Fillmore, Mille Lacs and St. Louis)
• Only part of the picture: Public programs are the only complete,
current data available
Medical Assistance enrollees, 2011-2015
1,302,753
Rural
1,193,667
Micro
Metro
882,361
336,423
64,543
58,560
Oct-10
907,107
339,469
64,895
59,500
Feb-11
162,523
160,098
151,667
145,426
Jun-11
Sep-13
Source: Enrollment data from MN Department of Human Services.
Metro
+287%
213,675
193,723
Jun-14
240,334
204,625
Apr-14
Micro
+272%
Rural
+249%
Share of MA enrollees v population,
2010-2015
MA 2010
73.2%
MA 2010
12.7%
MA 2015
11.7%
MA 2010
14.0%
Share of
population
78.6%
MA 2015
74.3%
MA 2015
13.7%
Share of
population
9.9%
Share of
population
11.5%
Rural
Micro
Metro
Source: Enrollment data from MN Department of Human Services. Population data from U.S. Census Bureau, Decennial Census and Population Estimates via MN Compass.
MA childless adults, 2011-2015
Rural
Micro
Metro
159,672
130,106
68,421
53,455
22,758
17,817
8,654
Oct-10
Feb-11
8,323
9,033
Jun-11
Sep-13
18,987
Jun-14
21,199
23,428
4/2015
Source: Enrollment data from MN Department of Human Services.
MinnesotaCare enrollment, 2011-2015
Rural
Micro
Metro
118,009
107,187
94,967
83,102
Metro
- 22.5%
62,538
25,385
26,313
22,259
23,624
Micro
- 39.4%
20,549
18,864
10,486
10,352
Oct-10
Feb-11
Sep-13
Jun-14
12,776
13,492
Rural
- 49.7%
Apr-15
Source: Enrollment data from MN Department of Human Services.
Share of MinnesotaCare enrollment v
population, 2010-2015
MNCare
2010
69.2%
MNCare 2010
16.4%
MNCare 2015
11.7%
MNCare 2010
14.4%
MNCare
2015
76.0%
Share of
population
78.6%
MNCare 2015
12.3%
Share of
population
9.9%
Share of
population
11.5%
Rural
Micro
Metro
Source: Enrollment data from MN Department of Human Services. Population data from U.S. Census Bureau, Decennial Census and Population Estimates via MN Compass.
MNsure-specific data
Office of Legislative Auditor study
• Issued evaluation of
MNsure in Feb 2015.
• One of the few post-ACA
studies to break out QHP
enrollment by
geographic area of the
state.
• Provided MDH countylevel data where
available for this analysis.
Share of MNsure enrollees v nonelderly
population, 1st enrollment period
Share of
MN pop
78.6%
Share of
MN pop
9.9%
Share of
QHP
enrollees
9.8%
Rural
Share of
MN pop
11.5%
Share of
QHP
enrollees
74.3%
Share of
QHP
enrollees
10.6%
Micro
Metro
Source: Enrollment data from Office of the Legislative Auditor, analysis of data provided by the Office of MN.IT Services. Population data from U.S. Census
Bureau, Decennial Census and Population Estimates via MN Compass
Share of QHP enrollees with tax credit,
1st enrollment period
Share of
MN pop
78.6%
Share of
MN pop
9.9%
Share with
tax credit
14.6%
Rural
Share of
MN pop
11.5%
Share with
tax credit
68.0%
Share with
tax credit
17.4%
Micro
Metro
Source: Enrollment data from Office of the Legislative Auditor, analysis of data provided by the Office of MN.IT Services. Population data from U.S. Census
Bureau, Decennial Census and Population Estimates via MN Compass
Share of QHP enrollees vs population, by
MNsure rating region
Percent of state's population in region
60.0%
Average share of QHP enrollees, Jan-July
2015
0.9%
Area 9
(NW)
1.9%
Area 4
(SW)
3.5%
Area 5
(SW)
4.2%
4.6%
Area 6
Area 3
(west central) (south central)
Source: MNsure, Metrics dashboard reports provided to Board of Directors, January-July 2015.
6.4%
Area 2
(NE)
9.1%
Area 7
(north central)
9.5%
Area 1
(SE)
Area 8
(TC metro)
Initial conclusions
• MinnesotaCare remains disproportionately rural, though not to
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the degree that it was pre-ACA.
Medical Assistance (MA) enrollment is also disproportionately
rural relative to population share.
Rural counties experienced a greater relative drop in
MinnesotaCare enrollment (50% compared to 23% in metro
areas and 39% in micropolitan counties).
It is not yet clear where the 12,609 rural enrollees formerly on
MinnesotaCare landed, but our hypothesis is a combination of
MA and MNsure QHPs.
Tax credits under ACA appear to be used disproportionately in
rural areas.
Possible next steps for RHAC
• More from MNsure and CMS on QHP enrollees and subsidies
• 2015 Minnesota Health Access Survey – now in field, results
available early 2016
• Uninsurance rates by age, race/ethnicity, income and other
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characteristics.
Sources of health insurance coverage.
Access to employer coverage.
Employment characteristics of the uninsured.
Potential sources of health insurance coverage.
Discussion