Issue Brief
2004-01
Health Economics Program
February 2004
Variations in the Use of Health Services in
Minnesota by Insurance Status: Results from the
2001 Minnesota Health Access Survey
There are many types of barriers that can prevent people from having access to appropriate and timely
health care. Of these barriers, a lack of health insurance coverage is one of the most significant. The purpose of this issue brief is to present findings on access
and the use of health care services among uninsured
Minnesotans compared to people with private health
insurance coverage.
The analysis in this issue brief is based on data from
the 2001 Minnesota Health Access Survey that was
conducted by the Minnesota Department of Health
in collaboration with the University of Minnesota,
School of Public Health, Division of Health Services
Research and Policy. The 2001 Minnesota Health
Access Survey is the largest and most comprehensive
health insurance survey conducted in Minnesota to
date. This survey was funded by a grant from the U.S.
Department of Health and Human Services, Health
Resources and Services Administration (HRSA).1
Usual Source of Care
Having a usual source of care - a place that a person
goes to with new health problems requiring a doctor’s
attention - is a key indicator of access to primary care
and whether a person is likely to have continuity of
care.2 As Table 1 shows, the likelihood of having a
usual source of care varies significantly by health
insurance status. Uninsured Minnesotans are between
three and five times more likely to lack a usual source
of care than people with private insurance.3 Nearly
half (44 percent) of people uninsured for a year or
more, i.e., the long-term uninsured, did not have a
usual source of care, compared to about one quarter
(24 percent) of people uninsured for less than a year.
In contrast, fewer than 8 percent of the privately
insured lacked a usual source of care.
Table 1
Percentage of Minnesotans With a Usual Source
of Care, by Health Insurance Status
Have a Usual Source of Care?
Yes
No
Private Coverage Overall
Group Coverage
92.1%
92.3%
7.9%
7.7%
Individual Coverage
89.1%
10.9%
Uninsured at the Time of Survey 62.7%
56.3%
Uninsured 1 Year or More
Uninsured Less than 1 Year 75.9%
37.4%
43.7%
24.1%
Numbers in bold indicate a statistically significant difference (95%
level) from the rate of the privately insured overall.
Group coverage is coverage through an employer. Individual coverage
is purchased in the individual market.
Since having health insurance coverage is a strong
determinant of having a usual source of care, we
expect the main reasons for lacking a usual source of
care to be related to whether or not a person has
health insurance coverage. Table 2 shows that this is
in fact the case. Of those uninsured and lacking a
usual source of care, nearly 25 percent reported being
uninsured as one of the main reasons for not having a
usual source of care. An additional 20 percent of the
h ealth e conomics p rog ram
Minnesota Department of Health
uninsured reported other financial reasons for lacking
a usual source of care; it is likely that for some people
this answer referred to the cost of health insurance.
For both the insured and the uninsured, the most
common reason given for not having a usual source of
care was that they felt they did not have a need for
one because they were rarely sick (63 percent of people with private insurance and 39 percent of the uninsured). In summary, while it is common for people
who do not have a usual source of care to report that
they have no need for one, it is more likely among the
uninsured that the reason for lacking a usual source of
care is not voluntary.
Just as the rates of insurance coverage vary by demographic category,5 so does the likelihood of lacking a
usual source of care. Table 3 shows those variations by
age, gender, race, and income and compares the rates
for different demographic groups to the overall population of the uninsured and the privately insured.
While the percent of Minnesotans who lack a usual
source of care varies significantly by insurance type,
some consistent patterns across demographic groups
are evident, as shown in Table 3. Among the uninsured, children younger than 18 are the least likely,
and males the most likely, to lack a usual source of
care. Among the privately insured, females are least
likely, and adults between 25 and 34 are most likely
to lack a usual source of care.
Table 2 also shows an interesting variation between
the responses of those with group insurance and those
with insurance coverage purchased in the individual
market. A significantly higher proportion of the individually insured (7 percent) than those with group
insurance (0.2 percent) report lacking a usual source
of care because they cannot afford one. One reason
for this difference is likely the fact that people with
individual coverage have less comprehensive insurance
benefits than people with group coverage – for example, they usually have policies with higher
deductibles.4 Consequently, the up-front cost that the
individually insured have to pay out of pocket may
potentially act as a deterrent to maintaining a usual
source of care.
Table 3
Percentage of Minnesotans Without a Usual
Source of Care, by Insurance Type and
Demographic Group
Table 2
Main Reason for Not Having a Usual Source of
Care
Private Coverage
Uninsured All Private
Group
Coverage Coverage
Individual
Coverage
Financial reasons/not affordable
19.9%
0.7%
0.0%
7.1%
No insurance coverage
24.3%
4.7%
4.9%
2.9%
No need, because rarely get sick
38.7%
62.9%
62.6%
65.6%
Time and transportation barriers
0.3%
2.5%
2.6%
0.4%
Language and trust barriers
Recent changes with doctors or
health plan
2.6%
7.6%
7.9%
4.5%
11.5%
19.0%
19.5%
14.6%
2.7%
2.6%
2.4%
4.9%
100.0%
100.0%
100.0%
100.0%
Other reasons
Numbers in bold indicate a statistically significant difference (95%
level) from the distribution of the privately insured overall.
Uninsured
Private
Coverage
Overall Rate
37.4%
7.9%
Age
0-17
18-24
25-34
35-49
50-64
21.0%
46.1%
48.1%
35.8%
26.5%
2.5%
15.7%
16.1%
9.4%
3.8%
Gender
Male
Female
46.9%
27.1%
11.4%
3.9%
Income
Low income
Higher income
35.5%
39.3%
4.4%
8.2%
Race
White
Non-White
35.6%
43.4%
7.6%
8.7%
Country of Origin
U.S.
Not U.S.
35.0%
52.5%
7.6%
12.1%
Region
Greater Minnesota
Twin Cities
30.3%
43.4%
5.1%
9.7%
Numbers in bold indicate a statistically significant difference (95%
level) from the overall rates of the uninsured or the privately insured.
“Low income” is defined as 200% of poverty or below. (This is $17,650
for a family of four according to the 2001 Federal Poverty Guideline.)
“Higher income” is above 200% of poverty.
2
Sources of Care
Table 4
Location Where Minnesotans With a Usual
Source of Care Obtain Health Care Services
In addition to being less likely to have a usual source
of care, the uninsured also report being less healthy
than the population as a whole. About 12 percent of
the uninsured report being in fair or poor health,
compared with only 5 percent of the privately
insured, a difference that is statistically significant.
Despite being less healthy on average, the uninsured
use fewer health services.
Uninsured
ER/ Urgent Care
Clinic/Doctor's office
Public health/community cinic
Hospital outpatient clinc
Private clinic/doctor's office
Other
Hospital
Some other place
There are some significant differences in the ways that
the uninsured access health care services compared to
people with private coverage. Those differences for
people who have a usual source of care are shown in
Table 4. While both population groups rely mostly on
clinics and doctors’ offices to obtain care (92 percent
of the uninsured and 98 percent of those with private
coverage), the uninsured are more likely to use public
health or community clinics (37 percent compared
with 20 percent) and less likely to use private clinics
than those with private health insurance coverage (39
percent compared with 55 percent). Further, the
uninsured are also more likely than the privately
insured to rely on emergency room and urgent care
settings (7 percent compared with 2 percent).
Total
Private
Coverage
6.5%
92.4%
36.5%
24.6%
38.7%
0.2%
0.7%
0.4%
1.8%
98.0%
19.8%
25.3%
54.9%
0.1%
0.1%
0.1%
100.0%
100.0%
Numbers in bold indicate a statistically significant difference (95%
level) from the distribution for the privately insured respondents.
Confidence in Ability to Get Care
Table 5 depicts the relative confidence of survey
respondents in being able to obtain care when needed. As expected, people with private health insurance
coverage are more confident in their ability to obtain
needed care than the uninsured. About 96 percent of
people with private coverage are either strongly or
somewhat confident that they can obtain care when
needed. In contrast, only about two-thirds of the
uninsured (69 percent) are similarly confident in their
ability to get needed care. Table 5 also shows another
distinction between the responses of the uninsured
and the privately insured. The privately insured are
much more likely to be strongly confident of their
ability to obtain care than the uninsured. About 70
percent of the privately insured respondents are
strongly confident, compared with only one-third of
the uninsured.
There are two primary implications of the greater
reliance of the uninsured on emergency rooms and
urgent care. First, services delivered in these settings
are more expensive than comparable services provided
at physician clinics.6 This higher cost is either borne
by the uninsured themselves or shows up as uncompensated care for health care providers. Some of this
uncompensated care is paid for through higher prices
charged for other patients, some is absorbed by the
provider as forgone income, and some is paid for by
taxpayers through public subsidies.
Second, patients who rely on the emergency room for
their primary care needs are less likely to receive preventive care services and more likely to lack continuity of care. As a result, they may delay seeking needed
care and present with greater complications or at an
advanced point in their illness.7
3
Table 5
nificantly greater proportion of the uninsured did not
have any physician visit in the three months prior to
the survey, compared to the privately insured (73 percent and 51 percent, respectively). This result is consistent with other research that shows that the uninsured use fewer health services, despite their less favorable health status.9 It is unclear to what extent this
difference is the result of financial barriers the uninsured face or of higher utilization of services by people with insurance coverage.
Confidence in Ability to Obtain Care8
(“I am confident that I can get the care I need when I need it”)
Private Coverage
Uninsured
All Private
Coverage
Group
Coverage
Individual
Coverage
Agree
strongly agree
somewhat agree
33.9%
34.9%
66.8%
29.6%
67.2%
29.3%
59.7%
34.9%
Disagree
somewhat disagree
strongly disagree
14.8%
16.3%
2.8%
0.8%
2.8%
0.7%
2.8%
2.6%
100.0%
100.0%
100.0%
100.0%
Figure 1
Number of Physician Visits In the Last Three
Months by Insurance Type
Numbers in bold indicate a statistically significant difference (95%
level) from the distribution for the privately insured overall.
When studying reported confidence in being able to
obtain care by age group, one category stands out –
respondents on behalf of uninsured children are,
when compared with uninsured overall, more confident in their ability to obtain care when the children
need it. Despite significant barriers to obtaining
health services, 81 percent of caretakers of uninsured
children are confident about being able to get needed
care for their children, compared to 69 percent for the
uninsured overall. Still, this level of confidence is
lower than for privately insured children (97 percent).
100%
0.2%
3.0%
90%
9.1%*
80%
14.1%*
0.4%
0.2%
4.0%
1.4%
15.9%
70%
more than 15 visits
27.1%
9 to 15 visits
60%
4 to 8 visits
50%
2 to 3 visits
40%
1 visit
73.3%*
30%
51.4%
No visits
20%
10%
0%
Uninsured
Private Insurance
* Indicates a statistically significant difference (95% level) from the distribution for the privately insured.
Use of Services
As shown in Table 6, there is no statistically significant difference between the use of inpatient care and
emergency room services of the uninsured and the
privately insured.10 This may be because the use of
emergency rooms and inpatient hospitalizations are
usually not discretionary services, and therefore we
expect to see smaller differences. In addition, a hospitalization or serious illness would likely be an event
that would cause uninsured people to seek coverage
options. Given that a large share of the uninsured
(about two thirds) are potentially eligible for insurance coverage,11 it is at least somewhat likely that people who are uninsured and experience an illness
requiring hospitalization will be able to obtain insurance coverage.
This section provides an overview of the use of health
services among the privately insured and the uninsured by reporting the number of doctor visits, the
number of inpatient visits and the volume of emergency room use.
Figure 1 depicts the variation in the number of physician visits in the three months prior to the survey by
type of insurance coverage. Despite the fact that the
uninsured report poorer health status, they are significantly less likely to indicate that they have seen a
physician than people with private insurance. A sig-
4
Endnotes
Table 6
A subset of respondents to this household survey, conducted by
telephone, were asked about the availability of a usual source of
care, the location of that care, and the volume of inpatient and
outpatient visits. Specifically, populations who received these use
questions included: all of the uninsured paticipated in the survey
(1,477), all those with individual coverage (1,374), and a subset
of Minnesotans with group coverage (1,841). For more detail on
the survey methodology, see: MDH, Health Economics Program
(2002). “Minnesota’s Uninsured: Findings from the 2001 Health
Access Survey,” Appendix A.
1
Proportion of Population Using Hospital Services
by Insurance Type
Uninsured
Inpatient Care
One or more visits
No inpatient visits
Private
Coverage
5.1%
94.9%
6.3%
93.7%
100.0%
100.0%
Emergency Room Use
One or more visits
15.2%
No emergency room use 84.8%
13.1%
86.9%
100.0%
100.0%
Starfield B. (1998). Primary Care, Balancing Health Needs,
Services, and Technology, Oxford University Press, New York.
2
Results pertaining to responses from people with individual or
group coverage are, unless noted otherwise, reported in a “private
coverage” category. This is done because results for people with
individual coverage, in most cases, track closely those for people
with group coverage.
3
Differences between the privately insured and the uninsured are not
statistically significant.
A forthcoming study by the Health Economics Program
reports that the median deductibles for Minnesotans with individual coverage was $1,000 per person. This compares to recently published national data, showing the average annual
deductible for employer-based single coverage to be $270 (The
Kaiser Family Foundation and Health Research and Educational
Trust. Employer Health Benefit, 2002 Annual Survey, p.93).
4
Summary
This issue brief shows that the uninsured are less likely to have a usual source of care, less likely to use
health care services, more likely to receive care in an
urgent care setting, and less confident in their ability
to get care when they need it. All of these issues have
potential consequences for the health status of the
uninsured and health outcomes when they do receive
care. In a recent summary of research on this topic,
the Institute of Medicine noted that working-age
Americans without health insurance are more likely
to:
See for more detail: Minnesota Department of Health, Health
Economics Program (2002).
5
6 The Kaiser Commission on Medicaid and the Uninsured
(2002). “Sicker and Poorer: The Consequences of Being
Uninsured,” p.80.
Institute of Medicine, Committee on the Consequences of
Uninsurance (2002). Care Without Coverage: Too Little, Too
Late, National Academy Press, Washington D.C., p.8.
7
Where the targeted respondent was a child, a parent was asked
about his or her confidence with being able to get needed care
for the child.
8
z
receive too little medical care and receive it
too late;
z
be sicker and die sooner; and
z
receive poorer care when they are in the hospital even for acute situations like a motor vehicle crash.12
Institute of Medicine, Committee on the Consequences of
Uninsurance (2002). Studies also report that the uninsured are
more likely to delay needed care. However, we cannot test this
for Minnesota as we did not ask that question in our 2001 survey.
9
Note, the greater reliance on emergency room and urgent care
setting reported in Table 4 refers only to uninsured who have a
usual source of care. In contrast, this analysis includes every
uninsured person.
10
Given that health insurance and having a usual source
of care are associated with better health and improved
health outcomes, policy makers should continue to
explore ways to ensure that Minnesotans have access
to affordable, high quality health insurance coverage.
Minnesota Department of Health, Health Economics
Program (2002), p.66.
11
Institute of Medicine, Committee on the Consequences of
Uninsurance (2002). Report Summary, p.1
12
5
The Health Economics Program conducts research and applied poli cy 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)
282-6367. This issue brief, as well as other Health Economics
Program publications, can be found on our website at:
http://www.health.state.mn.us/divs/hpsc/hep/index.htm
Health Economics Program
121 East Seventh Place, P.O. Box 64975
St. Paul, MN 55164-0975
(651) 282-6367
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