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Understanding Barriers to Health Insurance of Uninsured and Sporadically Insured Alaskans Summary of Focus Groups with Individuals, Small-Business Employers, and Health-Insurance Representatives P REPARED FOR Alaska Department of Health and Social Services Office of the Commissioner Health Planning and Systems Development F UNDED BY Health Resources and Services Administration Grant #P09HS05505 P REPARED BY Rosyland Frazier Virgene Hanna Meghan Wilson
April 2007 Institute of Social and Economic Research University of Alaska Anchorage 3211 Providence Drive Anchorage, Alaska 99508 T ABLE OF C ONTENTS
E XECUTIVE S UMMARY ...................................................................................................... ix I NTRODUCTION ....................................................................................................................1 Questions for Focus Groups........................................................................................2 M ETHODOLOGY AND P ROCEDURES FOR F OCUS G ROUPS FOR I NDIVIDUALS ....................7 Recruitment.................................................................................................................7
Screening and Selection with Demographic Questionnaire .......................................7
Insurance and Employment Questionnaire .................................................................8
Discussion Guides ......................................................................................................8
Institutional Review Board .........................................................................................8
Special Consideration .................................................................................................9
Data Analysis..............................................................................................................9 F OCUS G ROUP C OMPOSITION : T ARGET C OMMUNITIES AND P OPULATIONS ..................11 Demographics ...........................................................................................................11
Insurance and Employment ......................................................................................12 Q UESTIONS AND F INDINGS FOR I NDIVIDUALS ..................................................................15 What is Affordable? How Much Are the Uninsured Willing to Pay? ......................15 Why do Uninsured Individuals and Families Not Participate in Public Programs for which They are Eligible? ................................................17 Why do Uninsured Individuals and Families Disenroll from Public Programs? .....20 Why do Individuals and Families Not Participate in Employer-sponsored Coverage for Which They Are Eligible? .........................................................20 Do Workers Want their Employers to Play a Role in Providing Insurance or Would Some other Method be Preferable?..................................................21 How Likely Are Individuals To Be Influenced by Availability of Subsidies and/or Tax Credits or Other Incentives?..........................................................25 What Other Barriers, Besides Affordability, Prevent the Purchase of Health Insurance?.............................................................................................25 How Do the Uninsured Get Their Medical Needs Met? ..........................................27
What Are the Features of an Adequate, Barebones Benefits Package?....................31 How Should “Underinsured” Be Defined? How Many of Those Defined as “Insured” Are Underinsured? ........................................................33 F OCUS GROUPS FOR A LASKA N ATIVES .............................................................................37 Methodology and Procedures for Focus Groups with Alaska Natives.....................37
Alaska Native Focus Groups Composition...............................................................39
Findings from Alaska Native Focus Groups.............................................................40 M ETHODOLOGY AND P ROCEDURES FOR F OCUS G ROUPS FOR S MALL -B USINESS E MPLOYERS AND H EALTH -I NSURANCE R EPRESENTATIVES ............................................47 Recruitment...............................................................................................................47
Screening and Selection with Demographic Questionnaire .....................................47
Understanding Barriers to Health Insurance: Table of Contents Page v Health-Insurance Questionnaire ...............................................................................48
Discussion Guide ......................................................................................................48
Institutional Review Board .......................................................................................49
Special Consideration ...............................................................................................49
Data Analysis............................................................................................................49 F OCUS G ROUP C OMPOSITION FOR S MALL -B USINESS E MPLOYERS AND H EALTH -I NSURANCE R EPRESENTATIVES ................................................................51 Composition of Small-Business Employers Focus Groups......................................51
Information from Demographic Questionnaire ........................................................51
Small-Business Employers’ Insurance Status in Response to Health Insurance Questionnaire.......................................................................52 Composition of Health-Insurance Representatives Focus Group.............................53 Q UESTIONS AND F INDINGS FOR S MALL -B USINESS E MPLOYERS AND H EALTH I NSURANCE R EPRESENTATIVES ..................................................................55 What Influences the Employer’s Decision about Whether or Not to Offer Coverage?...............................................................................................55 What Are the Primary Reasons Employers Give for Electing Not to Provide Coverage?.......................................................................................57 How Do Employers Make Decisions about the Health Insurance They Will Offer to their Employees?...............................................................60 What Factors Go into their Decisions Regarding Premium Contributions, Benefits Package, and Other Features of the Coverage? .................................61 What Would Be the Likely Response of Employers to an Economic Downturn or Continued Increases in Costs?....................................................63 Which Employer and Employee Groups Are Most Susceptible to Crowd-Out? .....64 How Likely Are Employers Who Do Not Offer Coverage to be Influenced by Expansion/Development of Purchasing Alliances; Additional
Tax Incentives; and Individual Employer Subsidies?......................................65 What Other Alternatives Might be Available to Motivate Employers Not Now Providing or Contributing to Coverage?..........................................................67 C ONCLUSION .....................................................................................................................73 A PPENDIXES A. R ECRUITMENT A CTIVITIES Focus Groups for Individuals
Focus Groups for Small-Business Employers B. Q UESTIONS FROM A LASKA ’ S D EPARTMENT OF H EALTH AND S OCIAL S ERVICES C. D ISCUSSION G UIDES Uninsured or Intermittently Insured Individuals
Alaska Natives
Small-Business Employers
Health-Insurance Representatives
Understanding Barriers to Health Insurance: Table of Contents Page vi D. D EMOGRAPHIC Q UESTIONNAIRES Individuals
Small-Business Employers
Health-Insurance Representatives E. C ONSENT F ORMS Individuals
Small-Business Employers
Health-Insurance Representatives F. I NSURANCE AND E MPLOYMENT Q UESTIONNAIRES Individuals
Small-Business Employers G. R ESPONSES TO I NSURANCE AND E MPLOYMENT Q UESTIONNAIRE FOR I NDIVIDUALS Individuals
Alaska Natives H. R ESPONSES TO S URVEY Q UESTIONNAIRE FOR S MALL -B USINESS E MPLOYERS I. “M EASURING THE A DEQUACY OF C OVERAGE OR U NDERINSURANCE ,” S TATE H EALTH A CCESS D ATA A SSISTANCE C ENTER J. T ABLES Individuals
Table 1 Community, Insurance Status, and Subcategories of Individuals in Focus
Groups Table 2. Number of Participants in Focus Groups for Individuals who Completed Demographic Questionnaire by Place of Focus Group Table 3. Participants in Focus Groups for Individuals by Years of Age
Table 4. Race and Ethnicity of Participants in Focus Groups for Individuals
Table 5. Gender of Participants in Focus Groups for Individuals
Table 6. Education Level of Participants in Focus Groups for Individuals
Table 7. Marital Status of Participants in Focus Groups for Individuals
Table 8. Number of Participants in Focus Groups for Individuals Who Are Below Poverty Line Based on Annual Income and Number of Household Members Table 9. Number of Participants in Focus Groups by Number of Years They Have Lived in the United States Table 10. Number of Individuals Called, Contacted, Scheduled, and Attended each Focus Group of Individuals Alaska Natives
Table 11. Participants in Focus Groups for Alaska Natives by Years of Age
Table 12. Race and Ethnicity of Participants in Alaska Native Focus Groups
Table 13. Martial Status of Participants in Alaska Native Focus Groups
Understanding Barriers to Health Insurance: Table of Contents Page vii Table 14. Gender of Participants in Alaska Native Focus Groups
Table 15. Education Level of Participants of Alaska Native Focus Groups
Health-Insurance Representatives
Table 16. Do You Currently Sell Health-Care Benefits to Companies with Fewer than 10, 11 to 50, or More than 50 Employees? Table 17. Percentage of Health-insurance Representatives’ Health-insurance Clients that Are Small Businesses with 2 to 50 Employees Table 18. Which Health Plans Does Your Organization Currently Represent to Small-Business Clients? Table 19. Number of Years Selling Health-Care Plans
Small-Business Employers
Table 20. Number of Participants in Focus Groups for Small-Business Employers who Completed Demographic Questionnaire by Place of Focus Group Table 21. Number of Small-Business Employers by Years in Business
Table 22. Number of Small-Business Employers by Type of Industry
Table 23. Including both Part-time and Full-time Employees at All of Your Locations, How Many Employees in Total Does Your Company or
Organization Employ? Table 24. Defining Full-time as Working at Least 30 Hours per Week, How Many People Are Employed Full-time, Including Those in Remote Locations? Table 25. What Is Your Role in the Decision-Making Process for Your Company when Selecting Which Health Plans Are Made Available to Your
Employees? Table 26. Have You, in the Last Few Years, Contacted Insurance Carriers and/or Brokers to Obtain Information about Providing Health Insurance to Your
Employees? Table 27. Number of Calls, Contacted, Scheduled, and Attending each Focus Group of Small-Business Employers and Health-Insurance Representatives Table 28. “Which of the Following Best Describes the Majority of Your Employees?
Table 29. Has Your Organization or Company Ever Offered Health Insurance to Its Employees? Table 30. Which Health Plan Does Your Company or Organization Currently Offer?

Understanding Barriers to Health Insurance: Table of Contents Page viii

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