2018 Minnesota Racial & Ethnic Populations Survey of Attitudes and Outlook Regarding Healthcare Services and Costs Minnesota Governor's Council on Developmental Disabilities Quantitative Research Study Addendum Report #2418 20 June 2018 MarketResponse International 1304 University Ave NE Suite 304 Minneapolis, MN 55413 612-379-1645 marketresponse.com CONTENTS Research Overview 3 Executive Summary 6 Detailed Findings I. Healthcare Satisfaction, Outlook and Concerns Personal Health Insurance and Attitudes 9 Healthcare Outlook and Concerns 15 II. Healthcare System Beliefs and Opinions Attitudes Towards the Healthcare System 18 Opinions Regarding Government Policy 30 Appendix 40 2 RESEARCH OVERVIEW 3 BACKGROUND OBJECTIVES In 2004 MarketResponse conducted a survey of Minnesotans regarding a wide range of healthcare issues. This survey was conducted in cooperation with former U.S. Senator David Durenberger's Minnesota Citizens Forum on Healthcare Costs. MarketResponse International was commissioned by The Minnesota Governor's Council on Developmental Disabilities (GCDD) to repeat and update the Minnesota Healthcare Attitudes Study in 2018. An on-line survey was conducted, with demographic quotas as needed, to achieve a representative sample of the Minnesota general population. Report addendum: The survey was repeated with in-person, hard-copy surveys among Minnesota's racial and ethnic minority communities: American Indian, East African and Southeast Asian. The purpose was to understand perspectives of these often overlooked minority communities, compared to other racial/ethnic groups. Analysis of Minnesota's racial and ethnic minority communities, vs. the general population, regarding: • Current healthcare insurance coverage, and related attitudes and satisfaction • Future outlook and concerns regarding healthcare • Measures of attitudes and values that are relevant and related to today's healthcare -- Identify attitudinal segments, groups of like-minded people, based on consistency of answers across a range of attitudes towards healthcare • Perceptions regarding the healthcare system in the U.S. as a whole, and Minnesota • Opinions regarding role of government in: -- Ensuring coverage for all -- Drug pricing and public programs -- MA/Medicaid funding RESEARCH OVERVIEW 4 RESPONDENT PROFILE - MINNESOTA RACIAL AND ETHNIC COMMUNITIES 5 There were some demographic differences between the samples of respondents representing the various racial/ethnic groups of Minnesotans: FEMALE/MALE There were higher proportions of females in the samples representing South East Asians (79% female) and American Indians (68% female), vs. East African respondents (52% female) AVERAGE AGE Average age was highest among American Indians (53 years old) Average age of East Africans (44 years old) and South East Asians (49 years old) were similar to the respondents who represented the white/Caucasian population (48 years old) EMPLOYMENT One-third (34%) of American Indian respondents were retired, and 20% unemployed; leaving 40% employed either full or part-time (lowest employment of all respondent groups Employment rate was highest among East African respondents (72%), and 62% among South East Asian respondents EDUCATION Higher portion of college graduates among South East Asian respondents (58%), vs. 35% among East Africans, and 19% among American Indians (lowest of all racial/ethnic groups) INCOME Annual household income was lowest among East African respondents ($18,670), somewhat higher among American Indians ($29,155), and much higher among South East Asians ($61,912) EXECUTIVE SUMMARY 6 EXECUTIVE SUMMARY 7 Among the minority communities, rates of health insurance or healthcare coverage ranged from 81% (among East Africans) to 92% (among American Indians and South East Asians): • Highest rates of uninsured people: -- Hispanic 13% -- East African 12% • Highest enrollment in Medicaid/MA or Minnesota Care: -- East African 51% -- American Indian 48% -- African American 36% • Highest rates of health insurance through an employer: -- Asian/Pacific Islander 72% -- South East Asian 71% Approximately 6-out-of-10 respondents rate their overall health coverage and care as good or better: • Hispanic and American Indians had slightly lower ratings, as compared to other minority communities. Regarding future outlooks for good quality and affordable healthcare, there were some differences between the various ethnic groups: • 47% African Americans believe they will be better off • 32% Hispanics and American Indians believe they will be worse off All of the minority communities differed from the white/Caucasians by their preference for a government-run healthcare system versus a system based mostly on private health insurance. EXECUTIVE SUMMARY 8 Some demographic and attitudinal differences were found between the minority communities: African American African American respondents were most concerned about rising costs related to healthcare, and they most strongly believe healthcare should be available to all citizens regardless of their income, employment status or ability to pay. Hispanic The Hispanic community is most concerned about rising costs related to healthcare premiums and Federal cuts to Medicaid; and they most strongly believe healthcare should be available to all citizens regardless of their income or employment status. Over half (58%) believe the government needs more involvement in healthcare education, and incentives for wise health choices. Native American American Indians feel our current healthcare system relies too heavily on drugs as opposed to more holistic management of health and wellbeing. They have the highest concern of rising costs of premiums, deductibles and co-pays and potential Federal cuts to Medicaid. Asian/Pacific Islander Asian/Pacific Islander respondents are the youngest, highest educated and have the highest income of all minority communities. They have the highest rates of health insurance through an employer (72%) and compared to all other minority communities, are least concerned about future potential Federal cuts to Medicaid. South East Asian All of the respondents representing the South East Asian community were born in Thailand. As a group they feel strongly that it's the government's responsibility to make sure that patients receive safe, high quality medical care, and have a choice in the care provider, physician and hospital. Their main future concerns are centered around rising costs of healthcare related services for an aging population. East African Minnesota's East Africans have the lowest income of all minority communities, half are enrolled in Medicaid/MA, and they most strongly believe that government should insure access to healthcare for low income populations. They also feel strongly that children's needs should take a priority in healthcare cost decisions, and they are most concerned about access to medical services for people with disabilities, and access to mental health coverage. DETAILED FINDINGS I. Healthcare Satisfaction, Outlook and Concerns • Personal Health Insurance and Attitudes 9 CURRENT HEALTH INSURANCE COVERAGE 10 Do you have some form of health insurance? (Q1) White Caucasian (n=729) African American (n=79) HiNspanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=48) Yes 94% 89% 82% 92% 91% 92% 81% No 6% 8% 13% 7% 8% 8% 12% Don't Know 1% 4% 5% 1% 1% -- 6% Type of Health Insurance (Q2) (n=682) (n=70) (n=51) (n=69) (n=78) (n=49) (n=39) Medicare 23% 27% 8% 26% 8% 14% 28% Medicaid, Medical Assistance or MinnesotaCare 16% 36% 27% 48% 18% 12% 51% Health insurance through an employer 56% 46% 47% 22% 72% 71% 18% Health insurance purchased through the Exchange 9% 1% 10% 6% 4% 2% -- Other 6% 4% 8% 7% 4% 4% 5% Hispanic and East African communities had the highest rates of uninsured people, 13% and 12% respectively. Highest enrollment in Medicaid/MA or Minnesota Care is found among East Africans (51%), American Indians (48%) and African Americans (36%). Highest rates of health insurance through an employer is found among Asian/Pacific Islanders (72%) and South East Asians (71%). Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. HEALTH INSURANCE PREMIUMS AND ADDITIONAL COSTS American Indians and East Africans were least likely to believe their costs for health insurance premiums have been going up over the past couple of years, as compared to the other communities. 11 Does it seem to you that your cost for deductibles, co-insurance and co-payments have been… (Q7) (n=682) (n=70) (n=51) (n=69) (n=78) (n=49) (n=37) Going up 62% 61% 55% 49% 60% 67% 59% Staying the same 37% 39% 45% 51% 38% 33% 41% Going down 1% -- -- -- 1% -- -- Over the past couple of years, does it seem to you that your costs for health insurance premiums have been…. (Q5) White Caucasian (n=682) African American (n=70) Hispanic (n=51) Native American (n=67)* Asian/Pacific Islander (n=78) South East Asian (n=48) East African (n=39) Going up 68% 60% 65% 37% 53% 77% 38% Staying the same 24% 30% 25% 28% 37% 12% 33% Going down 2% 3% -- 3% 1% -- -- Don't know 5% 7% 10% 31% 9% 10% 28% Have they gone up…. (Q6) (n=464) (n=42) (n=33) (n=25) (n=41) (n=37) (n=15) A lot 38% 29% 39% 56% 20% 32% 53% Somewhat 62% 71% 61% 44% 80% 68% 47% Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. MEDICAL TREATMENT COSTS African Americans and Hispanics were more likely than other communities to have delayed medical treatment because of cost. Over half of those delayed treatments were for serious conditions or illnesses. 12 Within the last 12 months, have you or a member of your family delayed any sort of medical treatment because of the cost you would have to pay? (Q8) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=51) East African (n=47) Yes 37% 44% 47% 25% 34% 20% 32% No 63% 56% 53% 75% 66% 80% 68% When this medical treatment was delayed, how serious was the condition or illness? (Q9) (n=272) (n=35) (n=29) (n=19) (n=29) (n=10) (n=15) Very serious 6% 17% 14% 11% 17% 30% 33% Somewhat serious 40% 40% 38% 58% 38% 30% 53% Not very serious 47% 34% 41% 21% 38% 30% -- Not at all serious 7% 9% 7% 11% 7% 10% 13% Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. OVERALL HEALTH COVERAGE AND CARE 13 All things considered, how would you rate your overall health coverage and care? (Q11) Average Ratings Total (n=1156) A White Caucasian (n=729) B African American (n=79) C Hispanic (n=62) D Native American (n=74) E Asian/Pacific Islander (n=86) F South East Asian (n=51) G East African (n=47) 6.4 6.5 CD 6.5 6.1 AE 6.1 AE 6.7 CD 6.5 6.4 ABCDEFG Indicates statistically significantly higher than other figures in the row, at 95% confidence level Hispanic and American Indian respondents had slightly lower ratings regarding their overall health coverage and care, as compared to other minority communities. Healthcare Related Experiences (TOP BOX) Very Satisfied: (Q10) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=48) The whole process of pricing, billing and reimbursement for medical services provided to me and/or my family 14% 14% 13% 15% 15% 16% 21% The total amount I pay for health insurance 14% 19% 13% 18% 15% 14% 24% The process and ease of finding the insurance plan that best meet my (or my family's) needs 17% 18% 13% 15% 22% 14% 21% My ability to see medical specialists if I ever need one 30% 23% 26% 32% 21% 20% 38% My ability to choose the doctors and other healthcare providers I want 31% 24% 26% 23% 22% 33% 40% The amount I have to pay for prescription drugs 17% 23% 24% 22% 19% 12% 36% My ability to get a doctor's appointment when I want 29% 24% 39% 24% 22% 25% 47% The amount of time I am able to spend with my doctor 28% 20% 32% 26% 23% 27% 38% The kind of advice I get from my doctor regarding actions I can take to help improve my health 26% 27% 29% 31% 28% 20% 36% My ability to get the newest drugs and medical treatments 16% 19% 13% 15% 14% 18% 26% My ability to have an interpreter at doctors appointments -- -- -- -- -- 27% 36% The shaded statements below were determined from the Minnesota General Population Survey to be relatively more impactful in predicting overall health coverage and care ratings. HEALTH CARE RELATED EXPERIENCES Very Dissatisfied Somewhat Dissatisfied Neither Somewhat Satisfied Very Satisfied 14 Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. DETAILED FINDINGS I. Healthcare Satisfaction, Outlook and Concerns • Personal Health Insurance and Attitudes • Healthcare Outlook and Concerns 15 With regards to your access to good quality and affordable healthcare, I believe in 3 years we will be…. (Q13) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=51) East African (n=44) Worse off 27% 28% 32% 32% 16% 16% 18% Better off 20% 47% 29% 15% 33% 37% 39% About the same 53% 25% 39% 53% 51% 47% 43% Almost half of African Americans (47%) believe in three years they will be better off with regards to their access to good quality and affordable healthcare. Approximately one third of Hispanics and American Indians (32%) believe they will be worse off in three years with regards to their access to good quality and affordable healthcare. HEALTHCARE OUTLOOK 16 Most differences in proportions of 15% or more are statistically significant at 95% confidence level * Sample includes n=25 from general population survey, plus additional n=50 oversampling. Healthcare Concerns (TOP BOX) Very Concerned: (Q14) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=48) Rising costs of healthcare premiums 49% 44% 60% 65% 47% 56% 43% Rising cost of insurance deductible and co-pay fees for medical services 42% 41% 50% 49% 38% 42% 41% Rising cost of drugs and other medical services, as our country's medical system is strained by an aging population 40% 44% 45% 51% 44% 51% 46% Potential Federal cuts to Medicaid, which could lead to more uninsured people and higher premiums 37% 39% 53% 60% 38% 42% 47% Delaying treatment due to high annual deductible out of pocket costs 33% 39% 37% 43% 42% 33% 57% Access to affordable health insurance for people with preexisting conditions 32% 37% 45% 47% 34% 39% 22% Cost of long term services, supports, and care 33% 28% 42% 52% 37% 54% 51% Access to mental health coverage 30% 37% 44% 47% 28% 41% 54% People taking advantage of government-provided health insurance, when they can afford it on their own 30% 27% 26% 43% 35% 42% 30% Access to all of the medical services needed for people with disabilities 27% 34% 40% 59% 33% 43% 57% People over-using healthcare services, raising the cost for the rest of us 29% 24% 27% 39% 26% 37% 26% Being forced to buy health insurance or pay a fine, even if I don't want it 21% 27% 23% 48% 21% 33% 40% HEALTHCARE CONCERNS 17 Most differences in proportions of 15% or more are statistically significant at 95% confidence level Not at all Concerned Somewhat Concerned Very Concerned * Sample includes n=25 from general population survey, plus additional n=50 oversampling. 18 DETAILED FINDINGS I. Healthcare Satisfaction, Outlook and Concerns • Personal Health Insurance and Attitudes • Healthcare Outlook and Concerns II. Healthcare System Beliefs and Opinions • Attitudes Towards the Healthcare System ATTITUDINAL SEGMENTATION ANALYSIS 19 The survey questionnaire included 24 statements reflecting a variety of attitudes related to health care services, costs, access and responsibilities. The respondents indicated the degree to which they agreed or disagreed with each statement using this scale: Strongly Disagree Somewhat Disagree Neither Somewhat Agree Strongly Agree A multivariate statistical analysis procedure was used to group like-minded people together based on consistency of answers across all 24 statements. Four different attitudinal segments were thus identified: 1) Self Reliance 2) Social Balance 3) Social Protection 4) Total Entitlement ATTITUDINAL LANDSCAPE SUMMARY 20 The correspondence map shows the relative sizes and positions of the 4 segments within the attitudinal landscape. The horizontal and vertical axes were subjectively labeled based on the relative positions of all the defining attitudinal variables ATTITUDINAL LANDSCAPE SUMMARY 21 The vertical axis differentiates those who believe government involvement in healthcare should be minimized (Free Market), from those who believe government should have a more active role (Government Controlled). The horizontal axis differentiates those who seek or feel more independence from the group (Independence) from those with a greater sense of Social Responsibility. INDEPENDENCE SOCIAL RESPONSIBILITY FREE MARKET GOVERNMENT CONTROLLED The Self-Reliant people are more likely to believe in personal freedom and responsibility over one's own healthcare, where government is less involved and the market plays a role in determining levels of health coverage and care. Suspicions that some people take advantage of the system, and don't pay their fair share, appear to reside in the Self-Reliant belief system. The Social Balance segment believes that both personal and social responsibilities need to be taken into account in all healthcare decisions and policies. And it goes both ways: individuals are responsible for not abusing healthcare services; and society should reward individuals who make healthy lifestyle choices with lower insurance premiums. The Total Entitlement segment believes most strongly in the importance of government managed healthcare. To ensure that all citizens have access to high quality health coverage and care, regardless of where they live or their ability to pay; and no one should be penalized with higher premiums if they need higher levels of care. Both of the 2 lower half segments believe strongly that healthcare should be available to all citizens regardless of their income or employment status; and they would prefer a government run healthcare system over a system based on private health insurance. What differentiates the Social Protection segment is a stronger sense of personal responsibility in healthcare decisions, for the good of the whole society. FOUR HEALTHCARE ATTITUDINAL SEGMENTS WERE IDENTIFIED 22 SOCIAL RESPONSIBILITY FREE MARKET GOVERNMENT CONTROLLED INDEPENDENCE ATTITUDINAL LANDSCAPE - RACIAL AND ETHNIC COMMUNITIES SOCIAL RESPONSIBILITY FREE MARKET GOVERNMENT CONTROLLED Self-Reliant 36% Social Protection 25% Social Balance 27% White, Caucasian American Indian Asian/Pacific Islander Black, African American Hispanic Total Entitlement 11% 23 INDEPENDENCE South East Asian East African Each racial/ethnic group's position within the attitudinal landscape is determined by the summation of their health-care attitudes. For example, American Indians were positioned in the lower-right quadrant of the attitudinal landscape, largely because their responses aligned most with the attitudes that define the Social Protection segment. ATTITUDINAL LANDSCAPE - AFRICAN AMERICAN COMMUNITY 24 Attitudes with which they generally agree strongly: • Healthcare should be available to all citizens regardless of their income or employment status • People should not be turned away from necessary medical treatment, even if they are uninsured and cannot afford the treatment Future health concerns: • Rising costs of healthcare premiums • Rising cost of drugs and other medical services, as our country's medical system is strained by an aging population • Rising cost of insurance deductible and co-pay fees for medical services Demographics: (n=79) Gender: Male 41% Employed: Full/Part time 77% Female 59% Retired 11% Average Age: 38 Average Household Income: $54,335 Education: < HS graduate -- High school graduate 20% Trade/Vocational 3% Some college 37% College graduate 29% Grad school/Post grad work 12% Marital Status: Single 41% Children in Household: Yes No 59% 41% Married/living with 46% Political party: Democrat 51% Know someone with a developmental disability: Yes 9% No/Don't know 42% Republican 58% Independent 14% African American respondents were most concerned about rising costs related to healthcare, and they most strongly believe healthcare should be available to all citizens regardless of their income or employment status. Statistically significant difference, higher or lower, vs. other minority communities ATTITUDINAL LANDSCAPE - HISPANIC COMMUNITY 25 Demographics: (n=62) Gender: Male 24% Employed: Full/Part time 71% Female 74% Retired 6% Average Age: 37 Average Household Income: $65,403 Education: < HS graduate 8% High school graduate 18% Trade/Vocational 3% Some college 21% College graduate 31% Grad school/Post grad work 20% Marital Status: Single 32% Children in Household: Yes No 56% 44% Married/living with 58% Political party: Democrat 45% Know someone with a developmental disability: 16% Republican 50% Yes 16% Independent No/Don't know 50% Attitudes with which they generally agree strongly: • Healthcare should be available to all citizens regardless of their income or employment status • The government should provide education and incentives to help people make wise choices regarding their health • People should not be turned away from necessary medical treatment, even if they are uninsured and cannot afford the treatment Future health concerns: • Rising costs of healthcare premiums • Potential federal cuts to Medicaid, which could lead to more uninsured people and higher premiums • Rising cost of insurance deductible and co-pay fees for medical services The Hispanic community is most concerned about rising costs related to healthcare premiums and federal cuts to Medicaid; and they most strongly believe healthcare should be available to all citizens regardless of their income or employment status. Over half (58%) believe the government needs more involvement in healthcare education, and incentives for wise health choices. Statistically significant difference, higher or lower, vs. other ethnic communities ATTITUDINAL LANDSCAPE - AMERICAN INDIAN COMMUNITY 26 Demographics: (n=75) Gender: Male 31% Employed: Full/Part time 40% Female 68% Retired 34% Average Age: 53 Average Household Income: $29,155 Education: < HS graduate 11% High school graduate 25% Trade/Vocational 6% Some college 37% College graduate 15% Grad school/Post grad work 4% Marital Status: Single 43% Children in Household: Yes No 35% 65% Married/living with 26% Political party: Democrat 48% Know someone with a developmental disability: Republican 8% Yes 73% Independent 12% No/Don't know 27% American Indians feel our current healthcare system relies too heavily on drugs as opposed to more holistic management of health and wellbeing. They have the highest concern of rising costs of premiums, deductibles and co-pays and potential Federal cuts to Medicaid. Attitudes with which they generally agree strongly: • Healthcare should be available to all citizens regardless of their income or employment status • Our healthcare system needs to be more focused on prevention and early detection of disease, as opposed to treatment after a patient gets sick • People, such as the elderly and people with disabilities, who need more services than others, should get them without paying more • People should not be turned away from necessary medical treatment, even if they are uninsured and cannot afford the treatment Future health concerns: • Rising costs of healthcare premiums • Potential federal cuts to Medicaid, which could lead to more uninsured people and higher premiums • Access to all of the medical services needed for people with disabilities • Cost of long term services, supports, and care Statistically significant difference, higher or lower, vs. other ethnic communities ATTITUDINAL LANDSCAPE - ASIAN/PACIFIC ISLANDER COMMUNITY 27 Demographics: (n=86) Gender: Male 29% Employed: Full/Part time 70% Female 70% Retired 8% Average Age: 36 Average Household Income: $68,430 Education: < HS graduate 5% High school graduate 9% Trade/Vocational 3% Some college 14% College graduate 43% Grad school/Post grad work 25% Marital Status: Single 33% Children in Household: Yes No 47% 53% Married/living with 61% Political party: Democrat 36% Know someone with a developmental disability: Republican 15% Yes 33% Independent 20% No/Don't know 67% Asian/Pacific Islander respondents are the youngest, highest educated and have the highest income of all minority communities. They have the highest rates of health insurance through an employer (72%) and compared to all other minority communities, are least concerned about future potential Federal cuts to Medicaid. Attitudes with which they generally agree strongly: • Healthcare should be available to all citizens regardless of their income or employment status • I should be able to choose any health care provider I want, including physicians and hospitals • People should pay lower premiums for making healthy choices, such as exercising frequently Future health concerns: • Rising costs of healthcare premiums • Rising cost of drugs and other medical services, as our country's medical system is strained by an aging population Statistically significant difference, higher or lower, vs. other ethnic communities ATTITUDINAL LANDSCAPE - SOUTH EAST ASIAN COMMUNITY 28 Demographics: (n=53) Gender: Male 21% Employed: Full/Part time 62% Female 79% Retired 15% Average Age: 49 Average Household Income: $61,912 Education: < HS graduate 21% High school graduate 14% Trade/Vocational -- Some college 7% College graduate 49% Grad school/Post grad work 9% Marital Status: Single 27% Children in Household: Yes No 34% 66% Married/living with 62% Place of birth: Thailand 100% Know someone with a developmental disability: Political party: Democrat 53% Republican 15% Yes 47% Independent 4% No/Don't know 53% All of the respondents representing the South East Asian community were born in Thailand. As a group they feel strongly that it's the government's responsibility to make sure that patients receive safe, high quality medical care, and have a choice in the care provider, physician and hospital. Their main future concerns are centered around rising costs of healthcare related services for an aging population. Attitudes with which they generally agree strongly: • It is the government's responsibility to make sure that patients receive safe, high quality medical care • I should be able to choose any health care provider I want, including physicians and hospitals • The government should provide education and incentives to help people make wise choices regarding their health Future health concerns: • Rising costs of healthcare premiums • Cost of long term services, supports, and care • Rising cost of drugs and other medical services, as our country's medical system is strained by an aging population Statistically significant difference, higher or lower, vs. other ethnic communities Minnesota's East Africans have the lowest income of all minority communities, half are enrolled in Medicaid/MA, and they most strongly believe that government should insure access to healthcare for low income populations. They also feel strongly that children's needs should take a priority in healthcare cost decisions, and they are most concerned about access to medical services for people with disabilities, and access to mental health coverage. ATTITUDINAL LANDSCAPE - EAST AFRICAN COMMUNITY 29 Demographics: (n=48) Gender: Male 48% Employed: Full/Part time 72% Female 52% Retired 9% Average Age: 44 Average Household Income: $18,670 Education: < HS graduate 28% High school graduate 14% Trade/Vocational 14% Some college 9% College graduate 28% Grad school/Post grad work 7% Marital Status: Single 30% Children in Household: Yes No 44% 56% Married/living with 55% Place of birth: Somalia Kenya 31% 2% Ethiopia Other 50% 13% Political party: Democrat Republican Independent 61% 11% 4% Know someone with developmental disability: Yes No/Don't know 44% 56% Attitudes with which they generally agree strongly: • The government should insure access to healthcare for low income populations, people with disabilities and those who live in rural areas • The government should provide education and incentives to help people make wise choices regarding their health • People, such as the elderly and people with disabilities, who need more services than others, should get them without paying more Future health concerns: • Access to all of the medical services needed for people with disabilities • Access to mental health coverage • Delaying treatment due to high annual deductible out of pocket costs • Cost of long term services, supports, and care Statistically significant difference, higher or lower, vs. other ethnic communities DETAILED FINDINGS I. Healthcare Satisfaction, Outlook and Concerns • Personal Health Insurance and Attitudes • Healthcare Outlook and Concerns II. Healthcare System Beliefs and Opinions • Attitudes Towards the Healthcare System • Opinions Regarding Government Policy 30 Average Ratings Total (n=1,160) A White Caucasian (n=729) B African American (n=79) C Hispanic (n=62) D Native American (n=75) E Asian/Pacific Islander (n=86) F South East Asian (n=53) G East African (n=48) U.S. 5.1 5.1 CFG 5.1 C 4.3 ABDEFG 5.4 C 5.2 C 5.8 AC 5.8 AC Minnesota 6.1 6.1 6 C 5.6 ABEFG 5.8 6.2 C 6.3 C 6.4 C All things considered, how would you rate the overall quality of the healthcare system in Minnesota and the US? (Q19) OVERALL QUALITY HEALTHCARE SYSTEM 31 Respondents from every community gave Minnesota higher ratings for overall quality of the healthcare system, as compared to the healthcare system for the U.S. as a whole. Hispanics gave lower ratings compared to all other communities. ABCDEFG Indicates statistically significantly higher than other figures in the row, at 95% confidence level Total n=1,160 Do you think it is the responsibility of the federal government to make sure all Americans have healthcare coverage, or is that not the responsibility of the federal government? (Q15) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=47) Yes, it is the responsibility of the federal government to ensure that all Americans have healthcare coverage 49% 68% 74% 67% 60% 77% 83% No, ensuring healthcare coverage is not the responsibility of the federal government 35% 19% 21% 21% 23% 11% 13% I don't know; I don't have an opinion either way 16% 13% 5% 12% 16% 11% 4% The majority of respondents believe the federal government is responsible for ensuring that all Americans have healthcare coverage. The East African community (83%) are most aligned with this belief compared to Caucasians, of whom 35% believe it is not the responsibility of the federal government. GOVERNMENT HEALTHCARE POLICIES 32 Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. APPROACH FOR PROVIDING HEALTHCARE 33 All of the minority communities differed from white/Caucasians by their preference for a government-run healthcare system versus a system based mostly on private health insurance. Which of the following approaches for providing healthcare in the United States do you prefer? (Q16) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=48) A government-run healthcare system 40% 62% 55% 48% 48% 64% 62% A system based mostly on private health insurance 44% 19% 32% 27% 28% 15% 17% No opinion 16% 19% 13% 25% 24% 21% 21% Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. Should Congress deal with healthcare reform on a…. (Q17) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=52) East African (n=47) Gradual basis 58% 61% 50% 57% 64% 69% 68% Comprehensive, repeal and replace 42% 39% 50% 43% 36% 31% 32% A majority of respondents believe Congress should deal with healthcare reform on a gradual basis, as opposed to a comprehensive, repeal and replace approach to the Affordable Care Act. The Hispanic community was the only group that had an evenly split opinion in this topic. APPROACH FOR PROVIDING HEALTHCARE 34 Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. Compared to white/Caucasians, all but one of the minority communities (Asian/Pacific Islanders) were more likely to believe that government should be very involved in controlling drug prices. Just over half (51%) of Asian/Pacific Islanders believe that government should monitor the drug industry and enforce price controls only if an important drug is priced excessively high. GOVERNMENT ROLE IN DRUG PRICING 35 What do you believe is the role of government in drug pricing? (Q18) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=46) Government should be very involved in controlling prices, to ensure that drugs are affordable for the people who need them 39% 49% 47% 49% 35% 72% 65% Government should monitor the drug industry and enforce price controls only if an important drug is priced excessively high 45% 34% 37% 33% 51% 23% 20% Government has no role in controlling drug prices. Drug prices should be determined by the market, to encourage competition, which will ultimately lead to lower prices 9% 8% 10% 8% 6% 2% 9% I really don't know 7% 9% 6% 9% 8% 4% 7% Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. The United States primarily has a third-party payer system of healthcare, which means that a health insurance plan (the third party) reimburses hospitals and doctors for the bulk of the cost of healthcare services provided to patients. The nation uses a mixed system of public and private insurance. The two major public programs are: Medicare, for People 65 years or older Individuals on disability income or with ALS Medicaid, for Low-income people Individuals with disabilities 36 MEDICARE AND MEDICAID DESCRIPTIONS Congress and the current administration are proposing to put a cap on the amount of money the federal government pays to states for Medicaid. If this policy is adopted, Minnesota is projected to lose over $34 billion over 10 years, and the Minnesota state government would need to choose among the following options: • Reduce rates paid to service providers who are paid with Medicaid dollars • Draw funds from other state priorities • Raise state taxes to pay for the growth in Medicaid costs • Cut services that are currently being offered through Minnesota's Medicaid program • Cover fewer people 37 MEDICAID FUNDING PROPOSAL DESCRIPTION Medicaid funding proposals that are being considered by Congress and the current administration: All communities believe the federal government should continue to "honor the commitment"”" to match the states spending for Medicaid, as opposed to putting a limit on federal Medicaid spending. The African American and Hispanic communities are most aligned with this recommendation. RECOMMENDATIONS FOR MEDICAID 38 If you were in a position to advise both state and national government leaders on what should be done regarding Medicaid, what would you recommend? (Q20) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=48) Federal government should cap Medicaid spending and force the states to find ways to cut costs and/or find other sources of funding 24% 18% 19% 19% 33% 29% 27% Federal government should continue to "honor the commitment" to match the states spending for Medicaid 60% 71% 71% 56% 48% 48% 51% Don't know 16% 11% 10% 25% 20% 23% 22% Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. RECOMMENDATIONS FOR MEDICAID 39 Respondents' relative preferences for response to possible Medicaid funding cut: (Q21) a White Caucasian (n=729) b African American (n=79) c Hispanic (n=62) d Native American (n=75)* e Asian/Pacific Islander (n=86) f South East Asian (n=53) g East African (n=48) Reduce rates paid to service providers who are paid with Medicaid dollars 33% 36% 38% 40% g 34% 29% 28% d Draw funds from other state priorities 25% d 24% 25% 33% ae 22% d 23% 25% Raise state taxes to pay for the growth in Medicaid costs 20% 24% 24% 20% 20% 18% 25% Cut services that are currently being offered through Minnesota's Medicaid program 19% 17% 14% 15% 17% 21% 21% Cover fewer people 17% 15% 14% 20% 16% 19% 17% abcdefg Indicates that the mean percent is statistically significantly higher or lower than the means of other communities, at the 90% confidence level. Respondents from all communities expressed similar actions in response to a possible Medicaid funding cut. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. 40 APPENDIX • Respondent Profile • Familiarity with Developmental Disability • Overall National Healthcare Attitudes • Attitudinal Landscape Demographic Variables: a White Caucasian (n=729) b African American (n=79) c Hispanic (n=62) d Native American (n=75)* e Asian/Pacific Islander (n=86) f South East Asian (n=53) g East African (n=48) Gender: Male 44% 41% 24% 31% 29% 21% 48% Female 55% 59% 74% 68% 70% 79% 52% Average Age: 48 bcde 38 adg 37 adfgh 53 abcefh 36 adfgh 49 bce 44 cde Education: < High school grad 1% -- 8% 11% 5% 21% 28% High school grad 13% 20% 18% 25% 9% 14% 14% Some college/Trade 35% 40% 24% 43% 17% 7% 23% College Grad + 51% 41% 51% 19% 68% 58% 35% Employment: Full time 49% 54% 48% 22% 57% 49% 34% Part time 16% 23% 23% 18% 13% 13% 38% Unemployed 8% 11% 10% 20% 16% 21% 19% Retired 24% 11% 6% 34% 8% 15% 9% Average Income: $74,883 bdh $54,335 adeh $65,403 dh $29,155 abcefgh $68,430 bdh $61,912 dh $18,670 abcdefg RESPONDENT PROFILE - MINNESOTA RACIAL AND ETHNIC COMMUNITIES 41 abcdefgh Indicates that mean numbers (age and income) are statistically significantly higher or lower than those of other communities, at the 90% confidence level. Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. Do you know someone with a developmental disability? (Q30) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=75)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=48) Yes 60% 58% 50% 73% 33% 47% 44% No 34% 38% 44% 15% 60% 47% 50% Don't Know 5% 4% 6% 12% 7% 6% 6% How would you characterize the closet relationship you have with that person? (Q31) (n=441) (n=46) (n=31) (n=55) (n=28) (n=25) (n=21) Myself, I have a developmental disability 5% 9% -- 11% 4% -- -- Immediate family member, living in my household 7% 9% 6% 18% 11% 16% 14% Immediate family member, not living in my household 10% 20% 10% 31% 25% -- 5% Other relative 24% 17% 16% 20% 21% 4% 24% Friend 21% 15% 19% 16% 25% 64% 29% Other 32% 31% 49% 20% 15% 28% 30% FAMILIARITY WITH DEVELOPMENTAL DISABILITY 42 Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. 43 (TOP BOX) Agree Strongly: (Q12) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=74)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=48) Healthcare should be available to all citizens regardless of their income or employment status 49% 63% 61% 62% 57% 49% 57% If they can afford it, some people should be able to have a health care plan that covers more medical services than other health care plans 24% 37% 29% 42% 33% 31% 22% Everyone should pay something for their health care, with people paying varying amounts depending on what they can afford 24% 22% 19% 20% 26% 34% 26% People, such as the elderly and people with disabilities, who need more services than others, should get them without paying more 35% 47% 47% 57% 43% 33% 60% Individuals or households who are likely to use more health care, should be expected to pay higher premiums than others 10% 13% 18% 12% 10% 10% 20% Health insurance should pay for any kind of medical treatment, regardless of the cost 31% 47% 45% 48% 44% 37% 52% Our current healthcare system relies too heavily on drugs as opposed to more holistic management of health and wellbeing 26% 32% 21% 41% 22% 25% 33% People should pay lower premiums for making healthy choices, such as exercising frequently 28% 35% 34% 35% 44% 39% 37% People should be denied health care if they make unhealthy lifestyle or behavior choices 4% 11% 11% 5% 9% 12% 9% OVERALL NATIONAL HEALTHCARE ATTITUDES Disagree Strongly Disagree Somewhat Neither Agree Somewhat Agree Strongly Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. 44 (TOP BOX) Agree Strongly: (Q12) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=74)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African (n=48) Individuals whose health has been impacted through no fault of their own should not have to pay higher premiums than others 37% 39% 47% 36% 33% 26% 38% People should not be turned away from necessary medical treatment, even if they are uninsured and cannot afford the treatment 43% 53% 56% 57% 43% 52% 45% I should be able to choose any health care provider I want, including physicians and hospitals 45% 47% 42% 55% 50% 55% 47% Employers should give employees a choice of more than one health plan 35% 42% 39% 45% 37% 51% 52% We all have a personal responsibility not to use more healthcare services than we need in order to keep healthcare affordable 33% 37% 31% 30% 33% 30% 27% Our healthcare system needs to be more focused on prevention and early detection of disease, as opposed to treatment after a patient gets sick 37% 47% 44% 59% 38% 55% 46% It is the government's responsibility to make sure that patients receive safe, high quality medical care 21% 22% 39% 39% 30% 62% 55% Our healthcare system should spend as much money as necessary to try to save a person's life 20% 35% 35% 42% 30% 52% 53% Children's healthcare needs should take a priority in healthcare cost decisions 28% 43% 39% 44% 28% 38% 60% Disagree Strongly Disagree Somewhat Neither Agree Somewhat Agree Strongly OVERALL NATIONAL HEALTHCARE ATTITUDES Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. 45 (TOP BOX) Agree Strongly: (Q12) White Caucasian (n=729) African American (n=79) Hispanic (n=62) Native American (n=74)* Asian/Pacific Islander (n=86) South East Asian (n=53) East African(n=48) The government should insure access to healthcare for people who live in rural areas 28% 42% 47% 45% 29% 48% 63% The government should insure access to healthcare for low income populations 31% 49% 50% 54% 41% 45% 70% The government should provide education and incentives to help people make wise choices regarding their health 29% 43% 58% 54% 40% 55% 64% If I want to smoke, drink or just not take good care of my health, that's my business; I shouldn't be penalized with higher healthcare costs 11% 24% 5% 26% 13% 19% 21% The cost of treatment, along with the chance of success, is a factor that should be considered in decisions regarding treatment 11% 16% 18% 22% 14% 26% 31% The whole process of pricing and billing for medical services is too complex and difficult to understand 33% 28% 21% 34% 28% 38% 36% We all have a personal responsibility not to use more healthcare services than we need in order to keep healthcare accessible -- -- -- -- -- -- 43% The government should insure access to healthcare for senior citizens -- -- -- -- -- -- 60% The government should insure access to healthcare for people with disabilities -- -- -- -- -- -- 71% Disagree Strongly Disagree Somewhat Neither Agree Somewhat Agree Strongly OVERALL NATIONAL HEALTHCARE ATTITUDES Most differences in proportions of 15% or more are statistically significant at 95% confidence level. * Sample includes n=25 from general population survey, plus additional n=50 oversampling. ATTITUDINAL LANDSCAPE - RACIAL AND ETHNIC COMMUNITIES SOCIAL RESPONSIBILITY FREE MARKET GOVERNMENT CONTROLLED Self-Reliant 36% Social Protection 25% Social Balance 27% Male Female White, Caucasian American Indian Asian/Pacific Islander Black, African American Republican Libertarian Independent Democrat Hispanic Total Entitlement 11% 46 INDEPENDENCE South East Asian East African TWO DIMENSIONAL ATTITUDINAL LANDSCAPE - GENERAL POPULATION The correspondence map below shows the relative sizes and positions of the 4 segments within the attitudinal landscape based on answers across 24 agree/disagree statements describing various attitudes towards healthcare. Higher premiums for those who use more healthcare Denied healthcare for unhealthy choices If I want to smoke or drink, that's my business I shouldn't be penalized with higher costs If you can afford it; have a plan that covers more medical services Everyone should pay something Current healthcare relies too heavily on drugs Insurance should pay for any kind of medical treatment, regardless of costs Healthcare system should spend as much money as necessary to try to save a life Children's healthcare needs should take priority Those who need more services than others should get them without paying more Healthcare available to all Should not pay high premiums for those whose health has impacted through no fault of their own Government provides education & incentives to help people make wise health choices Government assures access to healthcare in rural areas Government is responsible to assure patients receive safe, quality healthcare Government assures access to healthcare for low income populations Should not be turned away if uninsured or can't afford the treatment Employers should offer more than one health plan Healthcare system needs to focus on prevention & early detection I should be able to choose any healthcare provider Pricing & billing for medical services is too complex Lower premiums for those making healthy choices Personal responsibility not to use more services than needed to keep healthcare affordable Treatment cost & success rate should both be considered Self-Reliant 36% Social Protection 25% Total Entitlement 11% Social Balance 27% 47 SOCIAL RESPONSIBILITY FREE MARKET GOVERNMENT CONTROLLED INDEPENDENCE ATTITUDINAL SEGMENTS 48 White, Caucasian Black, African American Hispanic American Indian Asian/Pacific Islander South East Asian East African Self-Reliant SOCIAL RESPONSIBILITY FREE MARKET GOVERNMENT CONTROLLED INDEPENDENCE Total Entitlement Social Balance Social Protection This chart shows how the respondents representing each racial/ethnic community were distributed across the attitudinal landscape, based on how their attitudes aligned with each of the 4 quadrants. Thank you Your MarketResponse contacts: Tom Pearson, Managing Director t.pearson@marketresponse.com Lynn Schreifels, Research Analyst l.schreifels@marketresponse.com Derek Pearson, Senior Research Manager d.pearson@marketresponse.com MarketResponse International 1304 University Ave NE Suite 304 Minneapolis, MN 55413 612-379-1645 marketresponse.com