Association for Public Policy Analysis & Management

Evidence shows sharp reductions in uninsurance rates at the national and state levels. These accomplishments could be eclipsed if some sub-groups of the population did not benefit equally from the provisions provided by the Affordable Care Act (ACA). Moreover, while gaining access to health insurance is a necessary first step in protecting financial assets, it is important to monitor how well that insurance translates into affordable healthcare services. Minnesota has historically been one of the states with the lowest uninsurance rates, but has also had large disparities that some underprivileged sub-groups have had to bear. Thus, it provides a good setting to analyze pre- and post-ACA changes in coverage and affordability indicators for the non-elderly population, as well as changes in disparities across key policy relevant sub-groups (i.e., age, race and ethnicity, and income).

We use the Minnesota Health Access Survey (MNHA), a state focused survey that provides timely information on changes in health insurance coverage and uninsurance over time as well as a look at remaining barriers to insurance coverage. These data also provide a comprehensive picture of how well insurance meets the goals of financial protection and providing access to healthcare services. We use the 2013 and 2015 MNHA, each with a representative sample of 9,000+ non-elderly Minnesotans. This survey provides information on reports of forgone care due to costs (for five different types of care), problems paying medical bills, needing to establish a payment plan with a provider, or having trouble paying other basic bills (e.g., food, heat, or rent) due to healthcare costs.

Despite having an already low uninsurance rate in 2013, at 9.4%, non-elderly Minnesotans experienced further gains in coverage that dropped this rate to a historical low on record of 4.9%. Similarly, the percentage of Minnesotans experiencing a medical financial burden fell by 2.5 percentage points, to 22.6% in 2015. However, there was no significant change in the percentage of individuals reporting any forgone care (19.3% in 2015), with the exception of routine and mental care.

In 2013, many sub-groups of the non-elderly population were overrepresented among those experiencing forgone care or medical financial burden (e.g., children, African-Americans, Hispanics, low-income people). This changed in 2015 as these disparities were eliminated for some of these sub-groups. Adults aged 26-37, African-Americans, Hispanics, Asians, and Minnesotans with incomes below 200% of the Federal Poverty Guidelines (FPG) overcame these disparities in forgone care by 2015. Sub-groups that surmounted medical financial burden by 2015 are: children aged 6-17, African-Americans, Hispanics, Asians, and individuals with incomes below 138% FPG.

These results show that post-ACA healthcare became more accessible and affordable in Minnesota. Gains in coverage seem to have translated to declines in forgone care and medical financial burden, but more importantly to an elimination of some disparities that were observed in 2013. Underprivileged sub-groups now face more affordable healthcare, although disparities prevail for some sub-groups (e.g., middle-income class).