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Health care issues among Montanans.

The health care industry is certainly an important, growing, and in some respects controversial part of our national and state economies. And there are many ways to analyze its impact. This article discusses the industry from the perspective of health care consumers--the general public.

Our findings are the result of a statewide telephone survey, conducted in August 1992, with a random sample of adult Montanans. As with all the Bureau's surveys, we used a two-stage random sampling procedure to assure a representative cross-section of Montana's adult population.

The research was done for a committee established by former Governor Stephens to study health care in Montana and was only one part of that committee's work.

Health Insurance Coverage--Generally

We needn't look at the survey data to know that Montanans--like Americans generally--are deeply concerned about affordable and accessible health care. And, from consumers' perspective, their access to and ability to pay for health care can be significantly affected by the existence and extent of health insurance coverage.

Fortunately, most Montanans apparently are covered by health insurance, and many have been continuously covered throughout their adult lives, according to the survey findings. However, some Montanans remain uninsured, and many more have had to deal with lapses in their coverage.

As noted in Figure 1, about eight respondents in ten reported being insured at the time of the survey, and five in ten said they had been continuously covered throughout their adult lives. However, almost a third reported lapses in coverage at some time in the past, although they were insured at the time of the survey. And another 16 percent--almost two in ten--were not insured at the time of the survey. While this may seem a relatively small proportion of the adult population, it translates to over 90,000 adults in the state. Moreover, it is likely that at least some of these uninsured adults have one or more children who are also uninsured.

A similar pattern holds at the national level where an estimated 13 to 14 percent of the total population (including children) are uninsured. Four states (Connecticut, Pennsylvania, Wisconsin, and Hawaii) are particularly well covered with under 10 percent uninsured. Eleven states and the District of Columbia estimate 20 percent or more of their populations are without health insurance. Thus, Montana falls in the middle of this range.

Insurance Coverage among Segments of the Population

Overall, patterns of coverage in Montana are similar to those found generally in the United States. In both, some segments of the population are more likely than others to have coverage.

Specifically, among our Montana respondents, those with health insurance were more likely:

* To be older Montanans,

* To have more education, and

* To have higher incomes.

The coverage patterns for our sample population are summarized in Table 1. As might be expected, insurance coverage increased noticeably with age, peaking at 95 percent TABULAR DATA OMITTED among the elderly, aged sixty-five and older. It also increased with education and with income. However, income is likely the more influential factor of the two, since it generally accompanies increased education.

Marital status also affected insurance coverage. Ninety-one percent of the married respondents were covered by health insurance; among the unmarried, only 74 percent were covered. Those living in households headed by men were also more likely to have coverage than were those in households headed by women. These differences reflect the predominance of husband-wife households in Montana. Most Montana households headed by men are, in fact, husband-wife households, and many are dual-earner households. Most Montana households headed by women are not dual-earner households.

By contrast, segments of the Montana population less likely to have insurance include:

* Young adults,

* Those with less education, and

* Those with lower incomes.

In Montana, as nationally, insurance coverage tends to be particularly correlated with employment. So it comes as no surprise that, among our respondents, the unemployed were the least likely to have health insurance.

We looked also at the small subgroup (68 out of 402 respondents) of employers and self-employed persons in our sample. Collectively, their situation mirrored that of the overall sample--about 85 percent were insured.

Coverage for their employees, however, was less extensive. Of the employers in our sample, slightly less than half had provided or arranged for insurance for their own employees. Among those employers who had, the coverage tended to follow traditional patterns. Their full-time employees were much more likely to be covered than were their part-time employees. Also, employers with larger numbers of employees were somewhat more likely to provide insurance than were those with just a few employees.

Nature of Insurance Coverage

Among insured respondents, about a fourth reported coverage through Medicare or Medicaid. The vast majority of insured respondents had private coverage.

Almost half the insured respondents had obtained coverage through their employment. For a few, their unions were the conduit, but in most of the cases, their employers had arranged for the insurance. About a third reported arranging their own coverage.

Three out of four insured respondents paid all or part of the insurance premiums themselves. In most cases where the premium was paid by someone else, the respondent was covered by a spouse's or parent's policy.

About two-thirds of the insured respondents reported that dependents in their household were also covered; two dependents was the median among this group.

Going Without Health Insurance

Slightly more than half the survey respondents reported continuous coverage throughout their adult lives. The remainder were either uninsured at the time of the survey or had experienced periods--often quite long periods--without any health insurance. Only about one in five of these respondents had gone without insurance for a year or less. The median was five years without coverage, with about a fourth reporting being uninsured for over ten years.

As Figure 2 shows, affordability and employment circumstances were most often cited as reasons for not having health insurance. About nine in ten indicated they could not afford to carry the insurance themselves. About five in ten indicated that health insurance was not available to them through their employment. In almost half the cases, both cost and employment factors were cited. Once again, the connection between employment and insurance coverage is obvious.

At the same time, though, roughly one in ten said that their coverage had been canceled by the insurance company because of a medical problem or condition.

Access to Health Care

We also asked all our respondents about their own access to health care. The survey results suggest that most Montanans, though not all, have access to what they consider basic health care services.

About eight respondents in ten said they have their own doctor, and in most cases that doctor was in their own community.

Over three-fourths said they live within ten miles of a hospital or medical facility of some sort. About one in ten lived more than twenty-five miles away; this would account for almost 60,000 adults in this state, along with any children in their households.

Eighty-nine (89) percent of the respondents--almost all--said that most "basic services" are available to them in their own communities. Still, about one in five also indicated a need or desire for other services.

These "other" services pertained mostly to more specialized treatment services--such as for cancer, cardiac care, head injuries, trauma, obstetrics-gynecology, and so on. Or they pertained to the need for expanded equipment and services--such as having a full-time doctor rather than a part-time doctor, or another doctor, or more emergency equipment, and so on. Such services typically are associated with larger or more urban areas.

Use of Health Care Services

The survey findings, summarized in Table 3, indicate that Montanans, not unlike Americans overall, make considerable use generally of health care services.

The vast majority of respondents reported consulting with at least one type of health care professional in 1991--most often with a medical doctor (83 percent) or with a nurse or nurse practitioner (42 percent). Most had five or fewer consultations during the year. Not unexpectedly, given the impact of insurance coverage, insured respondents were noticeably more likely to report such consultations than were uninsured respondents.

Roughly six respondents in ten overall reported that someone in their household was using prescription medicines at the time of the survey. Since use of prescription medicines implies consultation with a doctor, and uninsured respondents reported less consultation, it's not surprising that they also reported less use of prescription medicines by household members.

Twenty-nine percent overall reported that someone in their household had been hospitalized during 1991. Interestingly, the uninsured respondents reported a somewhat higher-than-average incidence of hospitalization. This is perhaps at least partially reflective of a reported tendency that people who don't have their own doctors go without routine attention or put off early treatment and end up using a hospital emergency room for medical attention.
Table 2

Access to Basic Health Care among Adult Montanans, August 1992

Have a regular doctor

All respondents (n=402) 78%
Insured persons (n=337) 82%
Uninsured persons (n=65) 57%

Have a regular doctor in own community

All respondents (n=402) 62%
Insured persons (n=337) 66%
Uninsured persons (n=65) 43%

Proximity to hospital or medical assistance facility of some
type (n=402)

Within 10 miles of residence 79%
11 to 25 miles from residence 12%
Over 25 miles from residence 8%

Believe most basic health care services are available
in own community (n=402) 89%

Need or would like to have other health care services
in own community (n=402) 20%

Source: Bureau of Business and Economic Research, The
University of Montana.
Table 3

Use of Health Care Services among Montanans

Consulted with a health care professional during 1991

All respondents (n=402) 78%
Insured persons (n=337) 80%
Uninsured persons (n=65) 65%

Types of professionals consulted (n=313):

Medical doctor 83%
Nurse or nurse practitioner 42%
Chiropractor 19%
Physical therapist 16%
Counselor, psychologist 11%
Other types (naturopath, dentist,
optometrist, etc.) 35%

Prescription medicines used (currently) by someone in household

All respondent households (n=402) 57%
Insured households (n=337) 59%
Uninsured households (n=65) 45%

Hospitalization of anyone in household during 1991

All respondent households (n=402) 29%
Insured households (n=337) 28%
Uninsured households (n=65) 37%

Source: Bureau of Business and Economic Research, The
University of Montana.


Health Care Expenditures

We also asked respondents to estimate their total out-of-pocket household expenditures for prescription medicines, TABULAR DATA OMITTED doctor services, and hospital services. Table 4 summarizes this information, noting first the percentage of households having such out-of-pocket expenditures and the median estimated expenditure for those households. The median reflects the "middle" figure in the data--that is, presumably half the households spent less, and presumably half spent more.

Most respondent households overall apparently had out-of-pocket expenditures for medicines during 1991 and for doctor services during 1990-1991. Roughly half had hospital expenditures during the two-year period.

By comparison, though--among just the uninsured respondents--fewer reported household expenditures for medicines and doctors, which would be expected, especially since such expenditures would reflect some routine or preventive care or early treatment. However, more uninsured respondents reported having hospital expenditures--roughly seven in ten. Since our data showed they were less likely to have their own doctor or any doctor consultations, this again may reflect a tendency among some to turn more often to hospital emergency rooms for treatment, especially when it has become a necessity.

Health-Related Lifestyle Practices

An increasing body of evidence shows that lifestyle practices--such as smoking, drinking, and exercise--can have a profound impact on health and consequently on the need for health care. TABULAR DATA OMITTED The survey findings suggest that Montanans have some pretty respectable lifestyle practices.

Most Montanans apparently exercise or engage in physical activity somewhat regularly, don't smoke, drink only moderately or not at all, use seat belts, and have consciously improved dietary habits.

While this picture might seem too good to be true, similar patterns have shown up at the national level, and there's no reason to believe the experience reported by Montanans is an aberration.

Table 5 summarizes these findings. Roughly eight respondents in ten said they engage in exercise or some other form of strenuous activity. Most said they did so regularly, three or four times a week or more; walking was, by far, the single most frequently cited activity (54 percent). Other frequently mentioned activities were use of weight training or exercise equipment or aerobics (20 percent total), and jogging (11 percent).

Only about a fourth of all respondents admitted to being smokers or other users of tobacco. About a third said they had used tobacco in the past. Compared with insured persons, the uninsured respondents were nearly twice as likely to report current tobacco use.

A similar pattern appeared in reported use of alcohol. Overall, roughly one respondent in four (26 percent) claimed to be a nondrinker, while the majority said they drink only moderately or infrequently. Among the uninsured, about as many (28 percent) said they were nondrinkers, but more of those who did drink reported drinking often.

The uninsured also reported using seat belts with less frequency than did insured persons, although few respondents overall would admit to never buckling up.

Overall, about six respondents in ten claimed to have improved their eating habits, citing concerns about fat and cholesterol as influential factors in their changes. Here as with other lifestyle measures, uninsured persons were somewhat less likely to practice the healthier alternative.

Overall, uninsured respondents as a group were slightly less likely to use their seat belts or to have improved their diets. Moreover, they showed a somewhat higher propensity for tobacco and alcohol use. All of these practices could certainly lead to needing health care--care for which they have no insurance.

Options for Dealing with Health Care

In addition to queries about lifestyle, expenditures, insurance status, and so on, we also asked Montanans how they felt about several important health care policy issues, especially those that would impact access and cost containment. Table 6 summarizes the public support for the various options or issues.

Health Care Access. Overall, there was generally less public support for options that would reduce health care access. In fact, respondents favored more, rather than less, access to health care, and only one in ten did not agree with the notion that access to basic health care is a fundamental right for all citizens.

Of all the explicit access-related options in the survey, employer-provided health insurance garnered the most public support. A substantial majority (83 percent) favored incentives for employers to offer (though not necessarily pay for) coverage. Nearly that many respondents (72 percent) thought employers should be required to offer coverage.

Almost three-fourths (72 percent) supported adopting a national health care plan as a means of improving overall access; about six in ten favored expanding Medicare and Medicaid to achieve that goal.

Interestingly, when offered three related options, nearly half the respondents (46 percent) said they would pay higher taxes for increased access, rather than leave things as they are (34 percent) or reduce access (3 percent).

Health Care Costs. Human nature being what it is, respondents tended to support options that would provide the greatest access while putting less burden directly on the average consumer--i.e., themselves.

Thus, the biggest majority (80 percent) endorsed limits on malpractice liability, which is more often seen as benefitting doctors and other providers rather than affecting consumer access. Almost as many (79 percent) favored limits on providers' fees--i.e., what they and other consumers could be charged for health care services. By contrast, many fewer respondents (45 percent) supported limiting insurance reimbursements on behalf of the insured consumers.

Once again, the general idea of a national health care system received majority support; 68 percent favored it as a cost-cutting measure, compared with 72 percent who saw it as a means of improving access.

However, support was mixed for health care systems at the state level. When asked about a Montana-operated health care system as a means of controlling costs, only 46 percent indicated support. Yet nearly three-fourths (73 percent) endorsed the general idea of a state-level "safety net" or trust fund to provide coverage for uninsured or underinsured Montanans.

Here again strategies that limited access garnered little support. In fact, only 15 percent of respondents endorsed the idea of limiting access to control costs. But two cost control measures with some impact on access did receive majority support. Just over half (55 percent) thought Medicare benefits should be denied on the basis of need or income. Slightly more respondents (57 percent) favored setting priorities on federally funded health care services.


It's always tempting to reach for a few succinct concluding comments and recommendations. However, as our survey suggests, health care reform is a deeply complex issue involving difficult tradeoffs, apparently contradictory public demands, and no pat answers.

While important policy matters should not be dictated by public opinion, neither can we afford to develop policy without acknowledging the complexity and power of public opinion. Thus we hope our survey findings may serve decision makers as they tackle this crucial issue.

Susan Selig Wallwork is director of survey research at the Bureau of Business and Economic Research, The University of Montana, Missoula, MT.
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Author:Wallwork, Susan Selig
Publication:Montana Business Quarterly
Article Type:Cover Story
Date:Jun 22, 1993
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