Just who are the uninsured in Minnesota?

By Casey Selix

This is not a question that theater major Laura Zabel expected to be fielding when she became head of an arts service organization: Where can an uninsured artist get a low-cost colonoscopy?

But as executive director of St. Paul-based Springboard for the Arts, Zabel has learned that health care is top of mind for the self-employed artists her nonprofit group serves. About 14 percent of artists in Minnesota are uninsured, according to Artists Count, a 2007 survey of about 20,000 artists conducted by Minnesota Citizens for the Arts.

Fourteen percent might not sound like much statistically, but it's nearly double the 7.2 percent rate of the state's overall uninsured population, according to the latest Fact Sheet (PDF) prepared by the Minnesota Department of Health and the University of Minnesota's School of Public Health.

High self-employment, low income

"It's a huge issue for artists because of their high rate of self-employment plus their low income, which makes health insurance really, really difficult to afford," says Zabel, whose staff eventually found the answer to the colonoscopy question through Springboard's Artists' Access to Health Care program.

The self-employed — from artists to other entrepreneurs — make up 20.6 percent of Minnesota's estimated 374,000 uninsured residents, according to the state's 2007 survey.

Another survey (PDF), [Page 32] conducted by the U.S. Census Bureau, estimates Minnesota's uninsured population could be even larger — 439,000 or 8.5 percent of the total population. Given that 45 million Americans or 15.3 percent of the U.S. population lack health insurance, Minnesota's stats look decidedly healthier no matter which survey is used. But for health-care policy and funding purposes, Minnesota lawmakers have relied on the state survey since the early 1990s.

Bottom line: Minnesota's uninsured residents could fill a city close to the population of Minneapolis. Who lives in this big city? Get ready: We're going to knock down some stereotypes about the uninsured.

No. 1: The uninsured are not slackers.

"There used to be the popular perception that uninsured people weren't hard-working and employed people," says Julie Sonier, director of the health economics program for the Minnesota Department of Health which tracks the uninsured through surveys.

In fact, most of Minnesota's uninsured are working — 71.3 percent are employed vs. 28.7 unemployed. Of those who are employed, 79.4 percent work for someone else. About 44 percent of those folks work for employers with two to 50 employees, pointing up evidence that small businesses might be hard-pressed to afford and/or offer health insurance. Yet another 23 percent of the uninsured work for employers with 51 to 500 workers. And about 18 percent work for companies with more than 500 employees.

Though 31 percent of the uninsured say they log fewer than 30 hours per week, 44.5 percent report working 31 to 40 hours weekly and 24.5 percent say they work more than 40 hours.

No. 2: They're not primarily people of color and immigrants. "Even though populations of color and immigrants are disproportionately likely to be uninsured, most of the uninsured (88.5 percent) in Minnesota are people who were born here (in the U.S.) and 78.2 percent are white," Sonier says. Whites also make up 88.5 percent of the state's population.

The two minority groups with the highest proportions of uninsured are blacks and Hispanic/Latinos; 14.7 percent of blacks are uninsured, and 19 percent of Hispanic/Latinos are uninsured.

No. 3: They're not all low-income.

While low-income people certainly dominate the ranks of the uninsured, increasing numbers of the so-called middle class are joining them, says Kathleen Call, an associate professor in the University of Minnesota's School of Public Health/Division of Public Policy and Management who has worked on the state surveys since the mid-1990s.

"The middle class is having a lot of difficulty affording health care coverage, and it's getting harder for employers to offer it," Call says. "We've seen a drop in the number of people (in the state and U.S.) who are covered by employer-based health coverage. We know people are getting squeezed. It's more and more expensive. It's not just a low-income issue anymore, but people with low incomes are suffering more — particularly minorities and young adults just coming out of school who haven't gotten into positions that offer health care."

Health economists use federal poverty guidelines in studying the uninsured and determining eligibility for public assistance programs. A household of one with an income of $10,400 is considered to be living in poverty and at 100 percent of the poverty guideline — in government parlance. A family of four with an income of $21,200 meets the same threshold.

In the 2007 state survey, Call and Sonier found higher percentages of uninsured in households with incomes 201 percent to 300 percent of the poverty guideline: 28.2 percent vs. 21.9 percent in 2004. Singles earning $20,800 to $31,200 and families of four bringing in $42,400 to $63,600 were among the 28.2 percent going without health insurance in the state.

The survey also detected a bump in the percentage of uninsured in the 401 percent-plus level: 12.7 percent in 2007 vs. 9.5 percent in 2004. Translation: Singles with an income of $41,600 and families of four with $84,800 are going without insurance.

What gives?

"There are different problems for different groups," Sonier said, "but we do know that for the 20 percent of uninsured who have access to employer-based insurance, the overwhelming reason they don't take it is because of the cost."

No. 4: They're young, yes, but not necessarily invincible.

The 18- to 24-year-old age group, including those out of high school and college, accounts for the second-biggest percentage of uninsured (24.4 percent) by age in Minnesota. If you add in groups younger than they are (6 to 17) and those slightly older (25 to 34), ages 6 to 34 represent 60 percent of the uninsured population in the state and 38 percent of the state's residents.

"A number of people in the policy arena and the public have the vision of young people as being 'young invincibles' who are making a foolish choice," Call said.

But those just out of high school are likely working in jobs that don't offer insurance or even full-time employment, she said. Think of the kids busing tables or working the espresso machine at the corner coffee shop. They're likely making minimum wage or low pay that won't cover private-market insurance as well as rent, food and transportation.

Although 16.8 percent of the uninsured didn't finish high school, 34 percent are high-school graduates and 37.9 percent have some college or tech school. Another 7.5 percent have advanced degrees.

Ed Stych, CEO and owner of Sir Speedy Printing in downtown Minneapolis, says he has run into a few "young invincibles" in his 15-year-old business and believes they're making "lifestyle choices" when they turn down his company insurance plan in favor of discretionary spending. His lowest-paid worker makes $12 an hour, but the average wage is $18 to $19 among 20 employees. He figures his younger workers should be able to afford a plan in which he contributes $200 per month per employee.

"Younger people will say to me, 'Gee, I hardly ever go to the doctor, I'm young and healthy … I don't need health insurance. Let me back up: Younger men say to me, 'Gee, I hardly ever go to the doctor … I don't need health insurance.' Women, for birth control reasons or others, know they need to go to the doctor. They seem to understand that. But men 18 to 30 don't see any reason to go to the doctor, so they think, 'Why should I spend money on health insurance?' "

Stych is willing to tick off all the reasons they need insurance — an accident, cancer, what have you. Sometimes they listen.

For other young workers, however, employer-based health insurance isn't an option, the state survey found. (See related story at right.)

"For young adults it's more often a lack of access to employer coverage than not signing up for it when it's available," Sonier said. "They are just as likely (as older workers) to sign up when they have access to it, but they're much less likely to have access to that coverage. It could be because of the kinds of jobs they have."

The good news: A change in Minnesota law this year is expected to reduce the numbers of uninsured in the 18- to 24-year-old population, Sonier said. Insurers are now required to cover dependents under their parents' policies until they are 25 years old.

No. 5: MinnesotaCare and public assistance aren't sure bets.

About 49 percent of Minnesota's uninsured are either living in poverty or at 200 percent of the poverty guideline, which prompts the question: Why aren't they enrolled in the low-cost MinnesotaCare plan (PDF) or another public medical-assistance program?

The state survey found that more than half of the uninsured were potentially eligible for public coverage in 2007 but didn't have it.

"We've found that with the public programs there's either a lack of awareness (about their eligibility and the programs) or a lack of willingness to enroll in what's perceived as public assistance," said Sonier of the state Health Department.

The health-care reform bill passed in May includes some provisions to spread the news about MinnesotaCare and public-assistance programs, Sonier says.

Still, fewer people have been eligible for MinnesotaCare in recent years since the Health Care Access Fund, which pays for MinnesotaCare through a tax on health-care providers, has been tapped by Gov. Tim Pawlenty to help erase the projected state deficit.

Meanwhile, about one-third of the uninsured in Minnesota are stuck. They either aren't eligible for public assistance or don't have access to employer-based insurance. "They're making enough that they don't qualify for public programs, but they still can't afford what's on the private market," says Call of the U.

Finding health care vs. health insurance

Which brings us back to the uninsured artist who recently asked Springboard for the Arts where to get a low-cost colonoscopy.

Since its founding in 1991, Springboard has been in the business of advising artists on the "nuts and bolts" of making a living as an artist, including financial planning, marketing and networking, says Zabel, the executive director.

But when the nonprofit asked clients a few years ago what other programs they wanted from Springboard, the No. 1 answer was "health care, health care, health care," she says.

At first, Springboard looked into forming an insurance pool consisting of artists. It was too unwieldy and expensive. The Artists Count survey in 2007 found that 46 percent of artists are insured under individual policies with high deductibles designed for catastrophic illness or injury. Other artists are covered through their spouses' or significant others' policies or through another employer. And 14 percent, as mentioned previously, are uninsured.

But through all that data emerged one common denominator: Even those artists who could get high-deductible policies are having trouble paying for basic preventive health care, Zabel said. They are considered "underinsured."

Springboard's focus shifted from health insurance to finding low-cost health care for the uninsured as well as the underinsured.

Vouchers for artist discounts

With a slight bump in operating funding from the McKnight and Ecolab foundations, Springboard was able to create the Artists' Access to Health Care program, which teams up with the Neighborhood Involvement Program clinic in Minneapolis to provide vouchers for discounts on medical appointments for artists.

Springboard also co-sponsors health fairs where artists can get flu shots and other preventive screenings. And, finally, the group publishes the "Guide to Healthcare for Minnesota Artists," which involved plodding through the health-care information maze to find low-cost services. If an artist's question can't be answered in the guide, then Springboard will spring into action with more fancy footwork.

"There are a lot of great resources and low-cost clinics, but it's a really complicated system to navigate," Zabel says.

Still, she knows these aren't long-term solutions.

"It's a Band-Aid to help artists with their immediate needs so they can get care to prevent major health disasters," Zabel says. "The five of us who work here aren't going to be able to address everything, so that's why we've chosen to focus on health care — how artists can get help today to go to the doctor today ... and not when it gets to the emergency stage."

So, how much does a colonoscopy cost? $800 to $2,000, according to Zabel. But it turns out Springboard was able to track down a free screening for the uninsured artist through a pilot program between the Minnesota Department of Health and the American Cancer Society.

"This wasn't an ongoing program, but it's a good example of how finding these resources is a moving target," she says.

Question for readers: Leave it to artists to come up with a creative solution — focusing more on obtaining health care than health insurance. Could a similar system work for the general population?

Casey Selix is a news editor and writer for MinnPost.com. She can be reached at cselix [at] minnpost [dot] com.