In January of 2009, CHRT released the first edition of Cover Michigan, a report designed to provide a comprehensive picture of health care coverage in the U.S. and Michigan. In August 2009, to better understand the impact of coverage trends on the people behind the statistics, CHRT commissioned a survey of 1,022 Michigan adults about their sources of coverage, perceived health status, ability to pay for insurance and care, and decisions about seeking—or not seeking—needed health care services.
- Income—not coverage status—was the single most important factor influencing self- perceptions of health. Seventy-two percent of those with incomes of $150,000 or more reported excellent or good health, compared to just 14 percent of those with incomes of less than $10,000 per year. Coverage status, however, wasn’t key to self-perceptions of health, with 49 percent of those who were insured reporting excellent or very good health, compared to 47 percent of the uninsured.
- Cost was an issue for both the uninsured and the insured. Of those who were uninsured, 29 percent reported they lacked coverage because they could not afford to pay for it; only 4 percent said they did not have coverage because they were in good health. Forty percent of those who were uninsured reported delaying needed medical care in the six months preceding the survey. Seventeen percent of those with insurance delayed seeking needed medical care—a lower percentage than the uninsured but substantial nevertheless. For both groups, cost was cited as the number one reason for delaying needed medical care.
- Urban dwellers, despite having the lowest average incomes, reported fewer problems with access to care than all but suburban dwellers with the highest average incomes. Sixteen percent of urban dwellers reported delaying needed medical care in the past year, compared to 10 percent of suburban dwellers. This finding is likely related to the fact that urban communities generally have more safety net providers than other geographic settings.
- More than one-third of all Medicaid recipients reported having a hard time finding health care providers. Thirty-five percent of those covered by Medicaid or Healthy Kids said they had difficulty finding providers who would accept their coverage. In contrast, only 12 percent of those with MIChild coverage reported difficulty accessing needed care. (Medicaid/Healthy Kids recipients receive their care through the Medicaid managed care or fee for service system while most MiChild recipients receive their care through Blue Cross Blue Shield of Michigan’s PPO network).
- Those with jobs in manufacturing expressed considerable worry that they might lose health insurance coverage, joining those in the retail and service sectors, who have traditionally expressed such concerns. Those with jobs in manufacturing, services, the arts, and the wholesale/retail trade were the most worried about losing health insurance; those with jobs in information technology, government, construction, and education were the least worried.
Taken together, these findings paint an important picture for those seeking to expand access to care in Michigan and the U.S. While health insurance coverage for all is an important goal, this survey reveals that coverage alone will not guarantee access to care. Other barriers to access—such as cost and availability of providers—must be addressed by policy makers in all sectors in order to close the gap between coverage and care. And, factors beyond medical care—such as income and education—must be considered if the focus is on achieving the ultimate goal: improved health status for all Michiganders.
The Center for Healthcare Research & Transformation commissioned this survey to provide a more complete picture of the issues facing the insured and uninsured in Michigan, and gain a deeper understanding of the lives behind the statistics. The survey was designed to address the following questions:
- What is the association between health insurance coverage and health status?
- What is the impact of coverage on access to care?
- How secure do Michiganders feel about their health insurance status?
The results presented in this report were produced from a series of survey questions added to the quarterly State of the State Survey conducted by Michigan State University’s Institute for Public Policy and Social Research (IPPSR). IPPSR fielded the survey in August 2009 to a random stratified sample of 1,022 Michigan adults. The margin of error for the entire sample is +/- 3.1 percent. For analyses involving sub-populations, the margin of error will be higher.
For analytical purposes, survey data were weighted to adjust for unequal probabilities of selection for each stratum of the survey sample (e.g., region of the state, listed vs. unlisted telephones, etc.). Additionally, data were weighted to adjust for non-response based on age, gender, and race within the survey sample according to population distributions from the 2000 Census. Statistical significance was tested using a Chi-Square test for independence. All results reported here as statistically significant are at least significant at the p<.05 level. Due to rounding errors, some frequencies may not total to 100 percent.
A full report of IPPSR’s SOSS methodology can be found at: http://ippsr.msu.edu/SoSS/default.asp.
FIGURE 1: Characteristics of the survey sample
|Gender||58 percent of respondents were female; 42 percent were male.|
|Children||45 percent of respondent households had at least one child under the age of 19.|
|Marital Status||60 percent of respondents were either married or remarried.|
|Education||29 percent of respondents reported having a high school diploma or a GED, 21 percent reported having a four year college degree, and 11 percent reported having a graduate level degree.|
|Employment||40 percent of respondents were employed full-time, 13 percent were employed part time, 8 percent were unemployed, and 16 percent were retired.|
|Income||Median income range reported by respondents was $50,000 to $60,000.|
|Race||89 percent of respondents reported their race as white, 9 percent African American, and 2 percent “other.”|
|Community||36 percent of respondents lived in small towns or communities, 30 percent in rural areas, 24 percent in suburban communities, and 10 percent in urban areas.|
|Age||19 percent of respondents were 18–29 years of age, 30 percent were 30–44 years old, 32 percent were 45–64 years old, and 18 percent were 65 years or older.|
The survey sample was generally representative of the adult population in Michigan (18 and older) with the exception of age. The sample was slightly older than the general population of Michigan: According to Census 2000, 14 percent of the Michigan population is age 65 or older, compared to 18 percent in our sample.
|Do you have health insurance?|
|Yes||88%||No||12%||Of the insured, what is the source of insurance?||Medicare||20%|
|Employer or union based||63%|
|Of the uninsured, did you lose your insurance in past 12 months?||Yes||31%|
|Are your child(ren) covered by MIChild or Medicaid/Healthy Kids?||No||79%|
General Health Status
Almost half of respondents reported their health was either “excellent” (18 percent) or “very good” (31 percent); one third rated their health as ”good,” and one in five Michiganders reported their health as only “fair” (14 percent) or “poor” (five percent). This is consistent with national survey data. The Centers for Disease Control and Prevention (CDC) reports that 21 percent of respondents in the United States rate their health as “excellent,” 32 percent as “very good,” 30 percent as “good,” 12 percent as “fair,” and four percent as “poor” (CDC, 2008).
There were some significant variations in levels of self-reported health by demographics. These differences are not surprising, but underscore that in Michigan, as in the U.S., health can be as much impacted by social determinants as it is by health care coverage and access to care. The survey found significant differences by:
Self Rated Health by Insurance Status
Forty-nine percent of insured respondents reported “excellent” or “very good” health compared to 47 percent of the uninsured. Eighteen percent of the insured and one-fourth of the uninsured report reported “fair” or “poor” health. These differences were not statistically significant.
FIGURE 5: Self rated health by insurance status
|Have Insurance||No Insurance|
Self Rated Health by Insurance Source
Sixteen percent of respondents with Medicaid reported their health as “excellent” or “very good” compared to 61 percent of those with individually purchased health plans, 54 percent of those with employer-based insurance coverage, 38 percent of those with Medicare, and 36 percent of those with another government source of insurance (such as the military). When adjusted for income, however, there were no statistically significant differences in self-perceived health based on insurance source.
Reason for Lack of Coverage
Respondents who reported being uninsured were asked an open-ended question about the reason they lacked health care coverage. Among those respondents, almost 30 percent reported they lacked insurance because they simply could not afford it. The next most common response was “other/non-specified.” After that responses varied but with a common theme: lack of access to employer-sponsored insurance and the cost of individually-purchased insurance are key factors for being uninsured in Michigan. These results are consistent with national survey data that demonstrate affordability is a major consideration for lack of insurance in a household (Pickens, 2009).
Respondents were also asked how they would pay for their medical care if they lost their main source of insurance. Forty-four percent indicated they would pay for their medical care out of pocket using their own funds or savings. Twenty-one percent indicated they would not be able to pay for their medical care or were simply unsure of how they would do so. Ten percent indicated that they would turn to Medicaid or Medicare.
The impact of cost on decisions to seek—or not seek—needed care is further illustrated when looking at differences by insurance status. Forty percent of uninsured respondents reported they did not seek needed medical care in the past year, compared to 17 percent of the insured.
FIGURE 9: Did you not seek needed medical care in the past six months? (by insurance status)
|Have Insurance||No Insurance|
Among those who reported delaying care, cost was the number one reason reported for both the uninsured and the insured—52 percent of those with insurance and 76 percent without insurance cited cost-related issues as the reason they avoided seeking medical care in the six months preceding the survey.
FIGURE 10: Why did you not seek medical care in the past six months? (by insurance status)
|Have Insurance||No Insurance|
|Cost/Could not afford care/Money||29%||55%|
|No health insurance/Too expensive to use health insurance||23%||21%|
|Don’t like/trust doctors/Fear||9%||2%|
|Thought get better on own/Problem not severe||6%||2%|
|Don’t believe in doctors/Believe in self-healing||0%||11%|
|Don’t have doctor/clinic/etc.||1%||0%|
Of those with coverage, Medicare beneficiaries were the least likely to delay care (11 percent), followed by those with employer-based insurance (17 percent), and those with individually purchased health plans (22 percent). Almost thirty percent of Medicaid beneficiaries reported not seeking needed medical care in the six months prior to the survey, which is likely to be associated with limited access to providers (see “Access Issues” below).
FIGURE 11: Did you not seek needed medical care in past six months? (by source of health insurance)
|Medicare||Medicaid||Employer or Union||Individually purchased private plan|
Community of residence by type was not associated with delays in seeking care once adjusted for income. Indeed, while urban community respondents had the lowest mean income they had the second-highest level of access,2 suggesting they actually had better access to care than those many in other types of communities. One possible explanation for this apparent contradiction is the higher concentration of health care facilities and community health centers in urban areas, which provides a health care “safety net” for this population.
FIGURE 12: Income by community type compared to access by community type
Having insurance coverage does not necessarily guarantee access to care. The survey asked respondents with coverage through Medicaid and/or children with coverage through Medicaid or MIChild whether or not they had experienced difficulty finding providers who would accept their insurance. Thirty-five percent of respondents with coverage through Medicaid—either for themselves or their children—reported having trouble finding providers who accept their coverage. Only 12 percent of MIChild families reported such difficulty. These differences are statistically significant.
FIGURE 13: Ever had difficulty finding a provider that accepts Medicaid, Healthy Kids or MIChild?
In 2009, 63 percent of Medicaid beneficiaries received care through a managed care provider, and 37 percent received care through the Medicaid fee-for-service system. By contrast, Blue Cross Blue Shield of Michigan provided coverage for 88 percent of MIChild beneficiaries through its PPO network (MDCH, 2009).
Sixty-seven percent of those who said they were worried about their jobs were also very worried about their health insurance, 59 percent of those who said they were somewhat worried about their jobs were also somewhat worried about their health insurance, 66 percent who say they were not too worried about losing their job were also not too worried about their insurance, and finally 69 percent of those who were not at all worried about losing their jobs were also not at all worried about losing their health insurance.
FIGURE 16: Correlation between employment insecurity and health insurance insecurity
|How worried are you about losing your health insurance?|
|Very worried||Somewhat worried||Not too worried||Not at all worried|
|How worried are you about losing your job?||Very worried||67%||18%||5%||9%||100%|
|Not too worried||9%||11%||66%||14%||100%|
|Not at all worried||4%||14%||13%||69%||100%|
Grouping responses by employment sector further demonstrates the connection between worries about job loss and worries about loss of health insurance. The figure below illustrates the average level of worry for respondents overall by employment sectors (where 100 percent would indicate all respondents were “very worried” about losing health insurance). As noted in the figure, those with jobs in leisure, manufacturing, arts, services, and retail were the most worried about losing health insurance.
The findings from this survey dispel some commonly held beliefs about health insurance. Many have assumed that having health insurance is necessary to both improved health and access to health care. Data from this survey, however, provides a more nuanced picture of these issues. While the survey does not test actual health status, self-perceptions of health status did not significantly differ between the insured and uninsured. And, at least for those with Medicaid coverage, access to care was not assured simply by virtue of having health insurance.
Even those with insurance and those who have historically had good health benefits are experiencing issues with health care. These issues were apparent in this survey both in terms of the relatively high percentage of those with insurance who delayed needed care and with the high percentages of those with jobs that typically provide health coverage expressing worry about the loss of that coverage.
These findings create a convincing—and too often overlooked—case for the importance of socio-demographic factors in self-perceptions of health status and delays in seeking need care. In particular, those with low income and low levels of education report significantly poorer health status and forgoing needed medical care. These critical issues must not get lost in the policy discussions about health reform in this state and country.
Centers for Disease Control and Prevention (CDC), (2008). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, GA: U.S. Department of Health and Human Services, Center for Disease Control and Prevention.
Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality (AHRQ). (2006). Medical Expenditure Panel Survey.
Michigan Department of Community Health (MDCH), (2009). MIChild November 2009 Executive Summary.
Pickens, G. P. (2009). The Current Recession and Healthcare Consumers. Ann Arbor, MI: Thomson Reuters.
U.S. Census Bureau. (2008). Current Population Survey.
U.S. Census Bureau. (2009). Current Population Survey.
Suggested citation: Riba, Melissa, Nathaniel Ehrlich, Marianne Udow-Phillips, Karen Clark, and Jody Myers. Cover Michigan Survey 2010. Ann Arbor, MI; Center for Healthcare Research & Transformation, 2010.
Photo Credits: Daymon J. Hartley © 2010 daymonjhartley.com Special thanks to Natasha, Jayden, Zack, and Connie for sharing their health care stories and agreeing to be photographed for our publication.
The staff of the Center for Health Care Research & Transformation (CHRT) would like to thank the staff of the Institute for Public Policy and Social Research (IPPSR) at Michigan State University for their assistance with the design and analysis of the survey.
© 2010 Center for Healthcare Research & Transformation. Any part of this survey may be duplicated and distributed for non-profit educational purposes provided the source is credited.