Health Economics Program
The Health Economics Program of the Minnesota
Department of Health (MDH) conducted a study to
assess certain effects of the 2014 implementation of
the Patient Protection and Affordable Care Act
(ACA) in Minnesota. This study, the Health Reform
Monitoring Survey – Minnesota (HRMS-MN), is a
component of a larger national survey1. One major
purpose of this survey was to obtain a 2014
uninsurance rate for Minnesota adults ages 18 to 64,
and to provide insight about how adult Minnesotans
view and understand their health insurance.
This issue brief presents new estimates of
uninsurance for non-elderly Minnesotans, estimates
of satisfaction with aspects of health insurance
coverage, confidence with insurance terms and
navigating insurance coverage, and forgone care
among adults ages 18 to 64 in September 2014.
Results of the HRMS-MN indicate that an estimated
135,000 more Minnesota adults ages 18 to 64 had
health insurance in 2014 than in 2013, for an adult
uninsured rate of 6.7 percent. This is lower than the
2013 rate of 10.7 percent found by the Minnesota
Health Access Survey2, and lower than the national
rate from the September 2014 Health Reform
Monitoring Survey of 12.4 percent3.
A previous study from June 2014 estimated the
uninsurance rate for all Minnesota residents at 4.9
percent 4. Although the two rates are not directly
comparable, because the rate from the HRMS-MN
only includes adults ages 18 to 64, and does not
include children and elderly adults over age 65, the
downward trends in uninsurance appear consistent5.
Adults aged 65 and over are nearly universally
covered by Medicare; children are more likely to be
eligible for public health insurance programs.
National results on coverage for children indicate
Issue Brief
December 2014
little change in the first half of 20146. As a result, if
this new estimate included these groups, at the
coverage rates that they experienced in 2013, we
estimate that the overall rate of uninsurance for all
Minnesotans would be between four and six
percent.
One major change in the health insurance market in
2014 was the addition of MNsure, a health
insurance marketplace that allowed Minnesotans to
enroll in either state public programs (Medical
Assistance or MinnesotaCare) or private non-group
coverage7. Those with incomes below 400 percent
of the Federal Poverty Guidelines8 could also
qualify for subsidies to reduce the cost of premiums
and cost-sharing based on their family income.
Approximately 10 percent of insured survey
respondents reported that they had obtained their
coverage, both private and public, through
MNsure9. This is slightly higher than overall
enrollment estimates published by MNsure of
around 350,000 in October 201410.
As part of the study, we were interested in assessing
insured Minnesotans’ satisfaction with and
understanding of health insurance. In general,
Minnesotans who have health insurance in 2014 are
satisfied with their coverage (Table 1). When it
comes to choice of providers and access to those
providers about four out of five Minnesotans report
that they are very or somewhat satisfied.
Satisfaction was also high for services provided,
with all levels of satisfaction around 80 percent.
There are no statistically significant differences
across public or private coverage, although people
with non-group coverage coverage11showed slightly
lower rates of satisfaction.
Minnesota Department of Health
More Adults in Minnesota Have Health Insurance –
Challenges Persist with Satisfaction and Understanding of Coverage
Satisfaction
Range of health
care services
Choice of providers
Ability to get
specialist care
Premium
Copayments
Deductible
Protection against
high medical bills
Quality of care
available
Overall
Private1 Public2

79.0%
82.2%
70.3%
83.3%
85.5%
77.5%
79.6%
79.9%
78.8%
58.3%
59.0%
66.3%
53.8%*
55.6%
65.9%
70.4%
68.1%
67.3%

80.3%
81.9%
75.9%

51.8%
50.6%
55.1%



Satisfaction with costs of coverage was more
mixed. While 80.3 percent feel satisfied that
insurance gives them protection from high medical
bills, only three out of five non-elderly Minnesotans
are satisfied with their premiums and copayments
(58.3 percent and 59.0 percent respectively), and
about two-thirds are satisfied with their deductibles
(66.3 percent). People with public coverage tend to
have higher satisfaction with costs of coverage than
those with private coverage, likely due to the fact
that coverage is often available at no charge (such
as with Medical Assistance), or subsidized.
Satisfaction with costs among enrollees in nongroup coverage tends to be lower than for either
group or publicly insured.

Minnesota added a larger sample of
Minnesota residents to the national Health
Reform Monitoring Survey (HRMS) to
generate state-specific uninsured rates for
adults ages 18 to 64 in September 2014. This
is called the HRMS-MN.
Minnesota decided to do this because
statewide estimates of uninsurance rates in
2014 will not be available from federal
surveys until summer or fall of 2015.
Results are for Minnesota adults ages 18-64,
not all Minnesotans.
Uninsurance rate estimates were constructed
based on respondents who said they gained or
lost coverage in the past year.
Children (ages 0-17) or adults aged 65 or
older were not included.
Respondents to this survey were chosen from
an internet panel designed to produce
Minnesota-specific rates, called
KnowledgePanel®.
499 Minnesotans participated in the survey in
September 2014; the survey has a margin of
error of 6.8 percent.
and understanding of tradeoffs resulting from
differences in premiums and cost sharing amounts.
To study this, we asked respondents about their
understanding of seven health insurance terms:
premium, deductible, copayments, coinsurance,
maximum annual out-of-pocket spending, provider
network and covered services.
Only three in five insured Minnesotans felt
confident in their ability to understand all seven
health insurance terms (61.5 percent). Health
insurance literacy for all five financial terms
(premium, deductible, copayments, coinsurance and
maximum annual out-of-pocket spending) was 64.4
percent, while understanding of coverage terms
(provider network and covered services) was
higher, at 77.5 percent.
Selecting and navigating health insurance coverage
is complex, because it requires knowledge of
special terms, familiarity with how coverage works,
2
More Adults in Minnesota Have Health Insurance –
Challenges Persist with Satisfaction and Understanding of Coverage
All Insured
Income <=400% FPG
Income 400%+ FPG
100%
86.6%*^
76.1%*^
80%
77.5%
69.9%
64.4%
61.5%
60%
78.5%*^
52.8%
49.5%
40%
20%
0%
All Terms Combined
Financial Terms Only1
Coverage Terms Only
2
% Confident with Health Insurance Terms
People with higher incomes12 were more confident
in their understanding of health insurance terms
than people with lower incomes 12, at 76.1 percent
and 49.5 percent, respectively (Figure 1). Health
insurance literacy was highest for people with group
coverage, as compared to those with public
coverage, non-group coverage, or the uninsured.
Among the insured, health insurance literacy was
lowest for people who held non-group coverage.
are covered by your plan; calculating costs of a
health care visit or service; estimating how much a
prescription will cost; assessing which health care
costs will count toward an annual deductible; and
determining the maximum amount paid out of
pocket for services covered by a health plan in a
given year.
Only 54.6 percent of insured Minnesotans feel
confident they have all seven skills required for
effectively navigating the use of health insurance
(Figure 2). Similarly, understanding costs (Cost
Navigation) was difficult, with only 55.4 percent of
insured Minnesota adults confident they could
calculate all costs associated with their coverage.
Conversely, more than two-thirds of insured
Minnesota adults (70.3 percent) were confident in
their ability to identify covered services and
providers (Covered Services Navigation). The vast
majority (91.5 percent) were confident they could
find a provider in their network.
Familiarity with common health insurance terms is
critical to understanding how your health insurance
works. Beyond understanding the terms, there are
specific skills that individuals need to gain in order
to effectively navigate coverage decisions,
including finding providers covered by your
insurance policy, understanding which services are
covered, and figuring out how much health care
services or prescriptions will cost.
We asked insured Minnesota adults about how
confident they were with seven different insurance
navigation activities, including: finding a doctor or
other health provider who is in their health plan
network; determining whether a service is covered
by their plan; identifying which prescription drugs
There were limited differences in ability to
understand insurance by income and coverage type.
In general, people with lower incomes had the
lowest levels of confidence. Adults with non-group
coverage were less confident in their ability to
navigate covered services than those with group
3
More Adults in Minnesota Have Health Insurance –
Challenges Persist with Satisfaction and Understanding of Coverage
1
All
All Terms
Terms
54.6%
2
Cost Navigation
Navigation
55.4%
Visit Copay
66.4%
Rx Copay
68.4%
Deductible Costs
67.0%
Maximum Annual OOP
72.1%
3
Covered Services Navigation
Navigation
70.3%
Find Provider in Network
91.5%
Service Covered by Plan
76.7%
RX Covered by Plan
74.1%
0%
20%
40%
coverage; however, these differences were not
present for ability to navigate costs of health
insurance (data not shown).
60%
80%
100%
The findings on health insurance coverage for
Minnesota adults ages 18 to 64 are in many ways
encouraging. They indicate that the rate of health
insurance coverage has increased among nonelderly adults, leaving fewer uninsured
Minnesotans. In light of national results from a
similar survey, Minnesota continues to have lower
rates of uninsurance than the nation as a whole.
Previous research has indicated that even with
health insurance, affording care can be difficult.
Despite the increase in the number of people
insured, a sizable share of Minnesota adults ages 18
to 64, 27.0 percent, or around 900,000 people
repored that in the previous 12 months they did not
get some type of needed health care due to cost. A
plurality of these adults (43.0 percent) knew the
cost of care and determined they could not afford it.
The remaining adults reported they they were either
unsure of the cost, but were afraid it was too high
(20.1 percent), or felt cost didn’t matter, they just
knew they could not afford the services (36.9
percent). The majority of people who do not get
needed care due to cost have health insurance
coverage.
Along with the increase in insurance coverage, this
research shows a complex relationship with health
insurance among insured adults in Minnesota.
While people who are insured indicate their
insurance gives them protection against high
medical bills, they are still not satisfied with the
cost of health insurance. This finding is consistent
across all types of insurance coverage, but is highest
among people who hold non-group coverage.
While the ability to understand and navigate
insurance is critical to efficient and effective use of
4
More Adults in Minnesota Have Health Insurance –
Challenges Persist with Satisfaction and Understanding of Coverage
health insurance, fewer than two-thirds of
Minnesota adults ages 18 to 64 are confident they
understand all seven insurance navigation terms
presented to them. In addition, slightly more than
half of insured Minnesota adults were confident
they could navigate their insurance successfully.
MDH’s Health Economics Program will continue
its analysis of the effect of health care reform in
Minnesota to help guide policymakers in their work.
MDH has partnered with the University of
Minnesota, State Health Access Data Assistance
Center (SHADAC) to study the experiences of
populations most likely affected by health care
reform changes in Minnesota: the uninsured and
those who held non-group coverage or were
covered by the state’s high risk pool in 2013. In
2015, MDH will release additional information
about the impact of the ACA on insurance coverage
in the small group and non-group markets in 2013
and 2014. Finally, robust statewide insurance rates
from 2015, including information about
demographic subgroups, will be available from the
2015 Minnesota Health Access Survey in early
2016.
This research indicates that insurance is performing
a critical function for covered Minnesotans:
protecting people from catastrophic medical costs.
However, there remains a need for increased
education on how insurance works and how to
navigate coverage options. Increased understanding
of health insurance will also help people identify an
insurance product most suited to their needs and the
needs of their family when a choice is available. For
those who do not have a choice of product, it will
allow them to more efficiently use their coverage.
5
More Adults in Minnesota Have Health Insurance –
Challenges Persist with Satisfaction and Understanding of Coverage
1
The Health Reform Monitoring Survey (HRMS) is
conducted by the Urban Institute in partnership with GfK
using the KnowlegePanel® internet panel. Funding for the
national survey was provided by the Robert Wood Johnson
Foundation, the Ford Foundation and the Urban Institute;
MDH funded the purchase of additional Minnesota sample.
For more information, see “About the Health Reform
Monitoring Survey” and “About KnowledgePanel®” at the
end of this issue brief.
2
For more information about the Minnesota Health Access
Survey, see
http://www.health.state.mn.us/divs/hpsc/hep/hasurvey/about.ht
ml
3
For more information on the Health Reform Monitoring
Survey results, see http://hrms.urban.org
4
See University of Minnesota, State Health Access Data
Assistance Center (SHADAC), “Early Impacts of the
Affordable Care Act on Health Insurance Coverage in
Minnesota.” June 2014.
http://www.shadac.org/MinnesotaCoverageReport
5
For this issue brief, we are comparing multiple studies and
surveys, which use different methods to estimate the rate of
uninsurance in Minnesota or the nation in 2014. Because of
the methodological differences, the estimates are not directly
comparable, rather we are looking for consistent trends across
estimates, which would indicate an overall decrease or
increase in uninsurance between 2013 and 2014.
6
See Cohen RA, Martinez ME. “Health insurance coverage:
Early release of estimates from the National Health Interview
Survey, January – March 2014.” National Center for Health
Statistics. September 2014. Available from:
http://www.cdc.gov/nchs/nhis/releases.htm and Kenney, GM,
Alker, J, Anderson, N, McMorrow, S, Long, SK, Wissoker, D,
Clemans-Cope, L, Dubay, L, Karpman, M and Brooks, T. “A
first look at children’s health insurance coverage under the
ACA in 2014.” The Urban Institute, September, 2014.
Available from: http://hrms.urban.org/briefs/Childrens-HealthInsurance-Coverage-under-the-ACA-in-2014.html
7
Coverage purchased in the individual market, generally
without the aid of an employer.
8
FPG is Federal Poverty Guidelines. In 2014, 400% FPG was
$46,680 for a single person and $95,400 for a family of 4. See
http://aspe.hhs.gov/poverty/14poverty.cfm
9
Survey participants struggle with clearly distinguishing the
pathways through which they obtained coverage, and
questions to obtain that information differ between surveys.
10
Data from the MNsure Dashboard, October 15, 2014 board
meeting. See https://www.mnsure.org/images/bd-2014-10-15dashboard.pdf, accessed 12/12/2014.
11
Given small sample sizes and high variability in estimates,
data that separates group and non-group coverage are not
shown.
12
Unless otherwise noted, “lower income” refers to people
with incomes at or below 400 percent FPG, and “higher
income” refers to people with incomes higher than 400 percent
FPG.
The Health Reform Monitoring Survey (HRMS), a quarterly
survey designed to support timely monitoring of the
Affordable Care Act (ACA) for the nation and selected groups
of states, was developed by the Urban Institute
(hrms.urban.org), fielded by GfK (www.gfk.com), and jointly
funded by the Robert Wood Johnson Foundation
(www.rwjf.org), the Ford Foundation (www.fordfound.org),
and the Urban Institute (www.urban.org). The Urban Institute
has allowed other organizations to fund supplemental surveys
with state-specific oversamples based on the HRMS, including
the oversample for Minnesota that is used in this work. The
analyses and conclusions based on HRMS-Minnesota are
those of the authors and do not represent the views of the
Urban Institute, the Robert Wood Johnson Foundation, or the
Ford Foundation.
This survey was conducted using the web-enabled
KnowledgePanel®, a probability-based panel designed to be
representative of the U.S. population. Initially, participants are
chosen scientifically by a random selection of telephone
numbers and residential addresses. Persons in selected
households are then invited by telephone or by mail to
participate in the web-enabled KnowledgePanel®. For those
who agree to participate, but do not already have Internet
access, GfK provides at no cost a laptop and ISP connection.
People who already have computers and Internet service are
permitted to participate using their own equipment. Panelists
then receive unique log-in information for accessing surveys
online, and then are sent emails throughout each month
inviting them to participate in research.
The Health Economics Program conducts research and
applied policy analysis to monitor changes in the health care
marketplace; to understand factors influencing health care
cost, quality and access; and to provide technical assistance
in the development of state health care policy.
For more information, contact the Health Economics Program at
(651) 201-3550 or [email protected]. This issue brief, as well
as other Health Economics Program publications, can be found on
our website at http://www.health.state.mn.us/healtheconomics
Minnesota Department of Health
Health Economics Program
85 East Seventh Place, PO Box 64882
St. Paul, MN 55164-0882
(651) 201-3550
6