Hest, Robert
Senior Research Fellow

p 612-624-5507
e hestx005@umn.edu

Analyzing Forgone Care by Coverage Type: New on State Health Compare

For most Americans, having health insurance is an important first step to being able to access and afford health care when it is needed.

As shown in recent data published on SHADAC’s State Health Compare, adults with health insurance coverage were at least 79% less likely to report having forgone (gone without) medical care when they needed it because of cost than adults without health insurance coverage. Whereas 63 percent of adults without health coverage reported forgone care, no more than 14 percent of those with coverage reported forgone care. This statistic illustrates the ability of health insurance coverage to protect against unexpected health care costs.

However, these data indicate that health insurance coverage’s ability to protect against unexpected health care costs varies by state and by type of health insurance coverage. The chart below shows the percent of adults (age 18+) who could not get medical care when needed due to cost by state and source of health insurance coverage. In the U.S., adults with some types of coverage such as Medicare (5 percent) or employer/military coverage (6 percent) were less likely to have gone without care because of cost compared with other types of coverage, such as individual coverage (10 percent) or Medicaid/CHIP coverage (14 percent).

It is important to note that the size of these differences in the protective power of health insurance coverage varied substantially by state. For example, where 11 percent of Georgia adults with employer coverage went without care, just 3 percent of employer-covered adults in the District of Columbia went without care. And similar state differences existed for other types of coverage:

• For adults with Medicare coverage, 9 percent of Louisianans had forgone care versus 3 percent of Vermonters.
   
• For adults with individual coverage, 16 percent of Nevadans had forgone care versus 3 percent of Vermonters.
   
• For adults with Medicaid/CHIP coverage, 25 percent of Oklahomans had forgone care versus 7 percent of South Dakotans.
   
• For adults with no health insurance coverage, 77 percent of Nevadans had forgone care versus 44 percent of South Dakotans.

These state differences highlight the inconsistency in the quality of health insurance coverage across the U.S., often related to differences in states’ markets for private health insurance coverage (e.g., individual coverage or employer coverage), differences in state Medicaid and CHIP programs, and differences in health care costs across the states.

Differences by coverage type call attention to variation in the ability of different types of health insurance coverage to protect covered adults from the risks of expensive or unexpected health care needs. However, these differences also highlight disparities in the underlying economic and health vulnerabilities of adults covered by different types of coverage.

Accessing BRFSS Coverage Data on State Health Compare

The data presented here come from SHADAC analysis of the 2021 Behavioral Risk Factor Surveillance System (BRFSS), a survey conducted in partnership between states and the Centers for Disease Control, and are available on SHADAC’s State Health Compare web tool. 

Data on detailed health insurance coverage types were collected among all participating states in the BRFSS for the first time in 2021. These new data have allowed State Health Compare to include breakdowns by detailed coverage type for all eight BRFSS measures that feature 2021 data and are the first source of information about these important measures of access and affordability of care, outcomes, and health behaviors for adults with specific types of coverage (e.g., Medicaid/CHIP).

BRFSS measures to explore further:

Notes: All differences described in this analysis are statistically significant at the 95% confidence level. Estimates are representative of the civilian non-institutionalized population 18 years and over and are based on SHADAC analysis of the 2021 Behavioral Risk Factor Surveillance System public use files. Florida data are not available in 2021 because the state was unable to collect sufficient data, and 2021 national data do not include Florida. Other state-level data were not available due to suppression where the number of sample cases was too small.

Theis, Lindsey
Senior Communications Specialist

p 612-625-5062
e lani0058@umn.edu

Now Available on State Health Compare: One Brand New Measure and Five Updated Measures

Estimates for five measures of health care access, affordability, and use have now been updated on SHADAC’s State Health Compare. One new measure, Had Telehealth Visit, has also been added to State Health Compare. The new and updated measures are all produced using data from the National Health Interview Survey (NHIS), conducted by the National Center for Health Statistics (NCHS). SHADAC produces these state-level measures using restricted-access data through the Minnesota Research Data Center (MnRDC). SHADAC’s State Health Compare is the only source of state-specific data for these measures which are essential for monitoring individuals’ access to and use of medical care, along with their ability to afford care.

These measures now contain data through 2021, using two-year pooled periods (i.e., 2019-2020, 2020-2021). The measures can be broken down by Total, Age, and Coverage Type (Public, Private, Uninsured).

Updated and new measures include:

NEW: Had Telehealth Visit
This measure describes the percent of individuals who had a medical appointment by video or phone during the past twelve months.

Had Usual Source of Medical Care
This measure captures rates of individuals who had a usual place of medical care other than an emergency department during the past twelve months.

Had General Doctor or Provider Visit
This measure provides rates of individuals who had any visit to a general doctor or provider within the last year.

Had Emergency Department Visit
This measure looks at rates of individuals who had any type of visit to an emergency department in the past twelve months.

​Trouble Paying Medical Bills
This measure examines rates of individuals who had trouble paying off medical bills during past twelve months.

Made Changes to Medical Drugs
This measure highlights rates of individuals who were prescribed medication in the past twelve months who made changes to their medical drugs due to cost during the past twelve months. This includes delaying filling a prescription, taking less medicine, or skipping doses to save money.

Click here to explore these measures on State Health Compare!
 

Notes: Data for State Health Compare’s Had Dental Visit measure is only asked in the NHIS rotating core and thus was not asked in the 2021 survey. We will be able to update that measure with new data after both the 2022 and 2023 data are out in mid-2024.

All measures are representative of the civilian noninstitutionalized population.

Data Source: The estimates were produced using restricted NHIS data in the MnRDC. Measures have been updated with data through 2021 using two-year pooled periods, including (a) 2011–2012 through 2017–2018 and (b) 2019-2020 through 2020-2021, except in the case of the telehealth measure for which data is only available from 2020-2021.

Benedict, Maya
Research Assistant

e bened099@umn.edu

Monitoring Broadband Expansion and Disparities using Data from State Health Compare

Introduction

The onset of the COVID-19 pandemic underscored the importance of telehealth services to people across the U.S. and the crucial role of broadband internet access in providing those services. Telehealth continues to be a popular and often necessary way for patients to access care, and federal and state governments are now making significant investments to expand and ensure affordable access to broadband internet.¹

For these reasons, it is important to monitor changes in the share of the population with broadband internet as an indicator of access to care. SHADAC analysis of 2021 American Community Survey (ACS) data indicates households’ access to broadband internet has increased by 3.8 percentage points (PP) since 2019, rising to 90.1% (from 86.3%).

State Broadband Efforts

The percentage of households with broadband access varies across the states, ranging from a low of 81.8% in Mississippi to a high of 93.4% in Washington. Though every state experienced some increase in household broadband access, a few states showed larger expansions in access.

Out of all states, Arkansas saw the largest increase at 5.4PP, rising to 85.7% from 80.3%. Former Arkansas Governor Asa Hutchinson and the Arkansas General Assembly had made broadband a “top priority,” working to expand the state Broadband Office by increasing staffing and enhancing services.^2, 3 The state also developed the Arkansas Rural Connect (ARC) grant program to expand broadband access in rural communities, and they recently announced a first-in-the-nation partnership with national non-profit EducationSuperHighway to develop best practices and programs to address broadband affordability.⁴

Rates of broadband access increased by similar amounts in South Carolina, rising to 87.8% from 82.4%. South Carolina has engaged in significant broadband expansion initiatives over the past few years, approving nearly $30 million in broadband expansion projects in early 2021 and spending nearly $50 million in CARES Act funding on broadband-related projects in 2020.⁵

Despite gains in access, disparities by income level remain

Despite overall growth in broadband internet access, there are still sizable disparities in access between households of different income levels.

For example, though 91.1% of Minnesota households have broadband access (higher than the national average), only 73.1% of low-income households in Minnesota (under $25,000 per year) have broadband internet (below the national average of 74.7%).

In general, households with an income under $25,000 per year have the lowest percentage of broadband access, and households with an income over $50,000 per year have the highest percentage, though that difference varies by state. South Dakota shows the largest gap at 26.2PP: only 67.8% of low-income households have broadband access, compared to 94% of high-income households. Mississippi has a sizable disparity between income levels as well, with a 25.4PP difference between high- and low-income households.

Delaware and Oregon see the smallest disparities between income levels, showing a gap of only 15.8PP and 15.9PP between high- and low-income households, respectively. Those two states have some of the highest percentages of broadband access for low-income households as well, with 79.7% of low-income households in Delaware reporting broadband access and 79.5% in Oregon.

Considering these disparities, some states are taking steps to address broadband affordability;

The 2022 Virginia Telecommunication Initiative guidelines include grant scoring criteria that encourage applicants to be aligned with the state’s efforts to bring low-income households affordable access to broadband internet.⁶ 

The Minnesota Office of Broadband Development recently began the process of establishing a statewide digital equity plan which would focus on addressing internet service affordability and reducing gaps in device access, and digital skills.⁷ 

In 2021, California passed a historic law directing $6 billion toward improving broadband access and affordability, with multiple provisions intended to improve internet speed, increase access, and lower internet costs for consumers.^8, 9

Conclusion

On both national and state levels, access to broadband internet improved from 2019 to 2021. States have begun several promising broadband expansion initiatives and are using available federal and state grant funding to bolster broadband infrastructure and affordability. However, as states continue working toward greater broadband access and navigating an influx of funding for expansion projects, it is necessary to ensure those improvements are specifically targeted to address existing disparities in access.

About the Data
The data cited here can be accessed through SHADAC’s online data tool, State Health Compare, using the measure “Percent of households with a broadband internet subscription” for the years 2019-2021. The estimates come from SHADAC’s analysis of the American Community Survey (ACS) Public Use Microdata Sample (PUMS). All differences described are statistically significant at the 95% confidence level unless otherwise specified.

Significance Testing Using State Health Compare

Originally published December 2016. Updated March 2023 by SHADAC Research Assistant Adey Fentaw. 

Updated August 2024 by SHADAC Research Assistant Annie Gowlovech.

This technical brief provides guidance on how to run tests for statistically significant differences using estimates and their associated margins of error from SHADAC’s State Health Compare web tool.

The brief first explains how to conduct a quick visual scan for statistically significant differences using the margins of error (MOE) output in State Health Compare's state ranking charts, and then goes on to provide step-by-step instructions for using margins of error to conduct a more robust test of statistical significance through a type of hypothesis testing known as a “t-test.” Download a PDF of the brief.

 

 

Stewart, Andrea
Research Fellow

p 612-624-4850
e astewart@umn.edu

Review of Health Insurance Coverage Data in 2021: Releases and Resources

Each year, SHADAC covers the releases of health insurance coverage data from major federal surveys such as the American Community Survey (ACS) and Current Population Survey (CPS), both of which are overseen by the U.S. Census Bureau.¹ Not only do these data provide an understanding of trends for the millions of individuals in the United States who lack any type of coverage, but they also give indications of changes in other major forms of health insurance, like public coverage, private coverage, and employer-sponsored coverage.

SHADAC researchers work to provide insights into these data in a variety of formats (including reports, blog posts, and webinars) and analyze a multitude of important demographic groups (children, families living below poverty levels, and for communities of color). We also know that to truly understand the trends and vagaries of health insurance coverage, it’s important to look beyond national-level statistics, to see what’s happening at the state level.

That’s why we recently updated one of the longest-running measures on SHADAC’s data tool, State Health Compare, “Health Insurance Coverage Type” with the latest data for 2021. Users can take a look at estimates of health insurance coverage across all 50 states by type (uninsured, employer-sponsored, Medicaid/CHIP, etc.), by categories (age, education level, race/ethnicity, marital status, poverty level, etc.),² over time (from 2008-2021),³ and can even examine estimates using color-coded maps, trend and bar charts, or by ranking states in terms highest and lowest rates for any coverage type.

2021 Key Findings

After multiple disruptions to data collection efforts resulted in data quality issues for 2020 ACS estimates, SHADAC is excited that data for 2021 are able to be used with confidence once again—though users are cautioned not to compare data to the prior year. Nationally, the U.S. saw a near-record low rate of uninsurance in 2021, at 8.6%, second only to a rate of 8.5% in 2016.

Looking at the state level, however, shows much wider variation in uninsured rates, from a low of 2.4% in Massachusetts to a high of 17.9% in Texas. By larger demographic groups:

• Among children (age 0-18), 5.4% were uninsured in 2021; however, by state, this ranged from 1.1% in Massachusetts to 11.8% in Texas.
• Among those below the poverty level, 15.6% were uninsured in 2021; however, by state, this ranged from 4.4% in Vermont to 30.5% in Texas.
• Among individuals with less than a high school degree, 22.2% were uninsured in 2021; however, by state, this ranged from 5.9% in Massachusetts to 41.4% in Texas.
• Among people reporting “Fair” or “Poor” health status, 25.9% were uninsured in 2021; however, by state, this ranged from 17.9% in Louisiana to 44.7% in Utah.

SHADAC Publications

For a full range of available products from SHADAC’s coverage of the 2022 health insurance data release (2021 estimates) please see below.

• CPS ASEC: 2021 National Health Insurance Coverage Estimates Show Falling Uninsured and Private Coverage Rates Across Population Demographics (Blog & Infographic)
• 2021 ACS: Estimates Show Declining Uninsurance Rates Across 28 States, Driven by Rise in Public Coverage and Fall in Private Coverage (Blog & Interactive Maps)
• An Annual Conversation with the U.S. Census Bureau: Coverage Estimates from the 2021 ACS and CPS (Webinar Recording)
• 2021 ACS Data: State and County Uninsured Rates, with Comparison Year 2019 (Blog, Interactive Map, & Data Tables)
• Comparing Federal Government Surveys That Count the Uninsured: 2022 (Issue Brief)
• 2017-2021 ACS: 5-year Combined State and County Uninsured Rates (Blog, Interactive Map, & Data Tables)

For more detailed estimates on health insurance coverage in 2021, please visit State Health Compare. Be sure to also check out our helpful guide to Navigating Data on State Health Compare for more on what users can do with this unique data tool!