2018 Minnesota General Population Survey of Attitudes and Outlook Regarding Healthcare Services and Costs Minnesota Governor's Council on Developmental Disabilities Quantitative Research Study Report #2395 2 April 2018 Research Overview Detailed Findings I. Healthcare Satisfaction, Outlook and Concerns Personal Health Insurance and Attitudes Satisfaction with Current Health Coverage and Care Healthcare Outlook and Concerns Summary: Satisfaction, Outlook and Concerns II. Healthcare System Beliefs and Opinions Attitudes Towards the Healthcare System Opinions Regarding Government Policy Appendix Research Overview BACKGROUND In 2003 MarketResponse conducted a survey of Minnesotans regarding a wide range of healthcare issues. This survey was conducted in cooperation with 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. OBJECTIVES • Identify current healthcare insurance coverage, and related attitudes and satisfaction • Uncover future outlook and concerns regarding healthcare • Measure attitudes and values that are relevant and related to today's healthcare o Identify attitudinal segments, groups of like-minded people, based on consistency of answers across a range of attitudes towards healthcare • Gage perceptions regarding the healthcare system in the U.S. as a whole, and Minnesota • Measure opinions regarding role of government in: o Ensuring coverage for all o Drug pricing and public programs o MA/Medicaid funding Research Design Phase 1: Qualitative Exploration: a) MarketResponse interviewed healthcare policy experts (including U.S. Senator David Durenberger), to ensure that all relevant and timely issues and policy considerations are covered in the survey. b) On-line qualitative interviews were conducted among Minnesota citizens from across the state, to reveal current attitudes, concerns and outlook related to healthcare: • The interviews were conducted using an on-line Bulletin Board method, enabling the moderator to have an interactive dialog with dozens of individuals from across the state, via the internet. • We included a total of n=30 participants, divided into 2, 3-day sessions, each with n=15 participants. • Some volunteer respondent names and contact information were provided to MarketResponse by the GCDD to assure that people with developmental disabilities and/or their advocates were included and their perspectives represented in the qualitative research. Insights gained from the qualitative Bulletin Board discussions was used to guide the necessary changes and additions to the Phase 2, Quantitative Attitudinal Survey. Research Design Phase 2: Quantitative Attitudinal Survey: Methodology: An on-line survey was conducted, with demographic quotas as needed, to achieve a representative sample of the Minnesota general population. Sampling Plan: A total sample of n= 1,009 was achieved, representing the adult population of the state of Minnesota. The sample closely matches geographic dispersion and other demographics of the state's population (age, income, ethnicity/race). Efforts were made to ensure representation from American Indian, African American, and Hispanic communities. Questionnaire: MarketResponse updated and refined the survey instrument for the 2018 study by: • Reviewing the previous attitudinal survey conducted in 2003 and determining the extent to which the previous survey questions were still relevant for the 2018 survey. • Developing additional questions as needed to measure attitudes related to new issues and experiences that have emerged over the past 15 years (i.e., Affordable Care Act, efforts to repeal and replace, etc.) • The final instrument is a 20-minute structured questionnaire. Respondent Profile The geographic dispersion of respondents of the survey closely matched that of the general population of Minnesota. Which region of the state do you currently live in? (QA) Total Sample (n=1009) 2018 Census Parameters Northeast 8% 7% Northwest 4% 4% Central 6% 6% West Central 7% 8% Metro 65% 61% Southwest 3% 3% Southeast 8% 11% Type of geographic location: Rural 28% Small Town 34% Small City 38% Suburban 69% MPLS/STP 31% Respondent Profile 2018 study among the general population of Minnesotans (n=1,009) Great efforts were taken while implementing the survey to ensure that the final sample of n=1,009 respondents closely matched the age, gender and race/ethnic diversity of the Minnesota adult population, as much as possible. Age 2018 Census 18-24 12% 11% 25-34 22% 19% 35-44 19% 16% 45-54 14% 19% 55-64 18% 17% 65-74 11% 11% 75+ 4% 8% Race/Ethnicity 2018 Census White, Caucasian 72% 81% Black, African American 8% 6% Hispanic 6% 5% Asian/Pacific Islander 9% 1% Native American 2% 5% Other 3% 2% Gender Male 41% Female 59% Know someone with a developmental disability Immediate Family/Self 24% Acquaintance 38% No 38% Respondent Profile Demographics Demographic Variables: A White Caucasian (n=729) Gender: Male 44% CE Female 55% Average Age: 48 BCE Insurance coverage: Medicare 21% CE MA/Medicaid 15% CDEF Through employer 53% B Exchange 8% No Insurance 6% Average Income: $74,883 BCD B African American (n=79) Gender: Male 41% C Female 59% Average Age: 38 Insurance coverage: Medicare 24% C MA/Medicaid 32% AE Through employer 41% Exchange 1% No Insurance 8% Average Income: $54,335 C Hispanic (n=62) Gender: Male 24% Female 74% Average Age: 37 Insurance coverage: Medicare 6% MA/Medicaid 23% Through employer 39% Exchange 8% No Insurance 13% A Average Income: $65,403 D Native American (n=25) Gender: Male 36% Female 60% Average Age: 47 BCE Insurance coverage: Medicare 4% MA/Medicaid 24% Through employer 44% Exchange 8% No Insurance 12% Average Income: $49,000 E Asian/Pacific Islander (n=86) Gender: Male 29% Female 70% Average Age: 36 Insurance coverage: Medicare 7% MA/Medicaid 16% Through employer 65% ABCDF Exchange 3% No Insurance 8% Average Income: $68,430 BD F Other (n=28) Gender: Male 32% Female 64% Average Age: 45 Insurance coverage: Medicare 25% CE MA/Medicaid 21% Through employer 36% Exchange 0% No Insurance 4% Average Income: $69,554 DETAILED FINDINGS I. Healthcare Satisfaction, Outlook and Concerns • Personal Health Insurance and Attitudes Current Health Insurance Coverage Ninety-two percent of the survey respondents report having some kind of health insurance coverage; just over half (56%) have private health insurance through their employer, and another 8% purchased insurance through the Exchange. Forty percent (40%) have some kind of government provided healthcare coverage (21% Medicare, 19% MA/Medicaid). MA/Medicaid insurance has grown from 7% in 2004 to 19% in 2018. Do you have some form of health insurance or healthcare coverage? (Q1) (n=1,009) Yes 92% No 7% Don't know 2% What type of coverage do you have? (Q2) 2018 2004 Medicare 21% 20% Medicaid, Medical Assistance or MnCare 19% 7% Health Insurance through an employer 56% 83% Health Insurance purchased on Exchange 8% --- Other 6% Current Health Insurance Coverage & Perceptions Among the 64% of Minnesotans who have private insurance, 14% of them have an employer that covers all their insurance costs; for 69% of them their employer pays some of the costs. Among those privately insured: (Q3) (n=587) Employee pays all 17% Employer pays all 14% Employer pays some 69% Thinking about the last few years, do you think your employer is paying…. (Q4) 2018 2004 (n=489) (n=489) More 23% 24% About the same 45% 37% Less 24% 32% Don't know 9% 8% Health Insurance Premiums & Additional Costs Two-thirds of Minnesotans who have any kind of health insurance coverage believe their cost for premiums and additional costs have been going up over the past couple of years; however, these perceptions of rising costs are not as severe as they were in 2004. Over the past couple of years, does it seem to you that your costs for health insurance premiums have been: (Q5) 2018 (n=926) 2004 (n=758) Going up 65% 89% Staying the same 26% 9% Going down 2% 1% Don't know 7% -- Have they gone up… (Q6) A lot 36% 58% Somewhat 64% 42% Does it seem to you that your cost for deductibles, co-insurance and co-payments have been: (Q7) (n=926) Going up 62% Staying the same 38% Going down 1% Medical Treatment Just over one-third of Minnesotans (38%) have delayed medical treatment because of the cost they would have to pay; over one-half of those who delayed treatment had a serious condition or illness. 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) (n=1,009) Yes 38% No 62% When this medical treatment was delayed, how serious was the condition or illness? (Q9) (n=384) Very serious 9% Somewhat serious 40% Not very serious 44% Not at all serious 8% DETAILED FINDINGS I. Healthcare Satisfaction, Outlook and Concerns • Personal Health Insurance and Attitudes • Satisfaction with Current Health Coverage and Care Overall Health Coverage and Care Thirty-nine percent (39%) of Minnesotans give their overall health coverage and care a less than good rating; one-third (32%) gave a good rating, and 28% gave better than good ratings. All things considered, how would you rate your overall health coverage and care? (Q11) (n=1,009) Overall Average Rating = 6.4 9 = Excellent 10% 8= 18% 7= Good 32% 6= 10% 5 = Fair 17% 4= 4% 3 = Subpar 5% 2= 1% 1 = Poor 2% Negative Experience: In my personal experience, the quality of healthcare has drastically declined due to the rising cost of premiums and deductibles, along with the downfall of personal care and attention given by doctors' "treat them & street them" mentality. Few doctors actually have the time or the allowance from insurance companies to actually sit with a patient for an extended period of time to really get to know them and their health situation. Positive Experience: Over the last year I've developed significant health issues and have seen many doctors and specialists. I've never felt like it was a "cattle drive," I've been fortunate enough to have doctors who spend a lot of time listening and working together to come up with a diagnosis and treatment plans. Health Care Related Experiences Minnesotans expressed a range of satisfaction and dissatisfaction with various aspects of their healthcare experiences. How satisfied are you with each of the following aspects of your healthcare related experiences? (Q10) (n=1,009) My ability to choose the doctors and other healthcare providers I want Very Dissatisfied 5% Somewhat Dissatisfied 11% Somewhat Satisfied 32% Very Satisfied 29% My ability to see medical specialists iIf I ever need one Very Dissatisfied 6% Somewhat Dissatisfied 12% Somewhat Satisfied 34% Very Satisfied 29% My ability to get a doctor's appt when I want Very Dissatisfied 4% Somewhat Dissatisfied 10% Somewhat Satisfied 39% Very Satisfied 28% The amount of time I am able to spend with my doctor Very Dissatisfied 4% Somewhat Dissatisfied 10% Somewhat Satisfied 36% Very Satisfied 27% The kind of advice I get from my doctor regarding actions I can take to help improve my health Very Dissatisfied 4% Somewhat Dissatisfied 9% Somewhat Satisfied 37% Very Satisfied 26% The amount I have to pay for prescription drugs Very Dissatisfied 12% Somewhat Dissatisfied 19% Somewhat Satisfied 27% Very Satisfied 18% The process and ease of finding the insurance plan that best meet my (or my family's) needs Very Dissatisfied 9% Somewhat Dissatisfied 14% Somewhat Satisfied 28% Very Satisfied 17% My ability to get the newest drugs and medical treatment Very Dissatisfied 5% Somewhat Dissatisfied 10% Somewhat Satisfied 27% Very Satisfied 16% The total amount I pay for health insurance Very Dissatisfied 18% Somewhat Dissatisfied 21% Somewhat Satisfied 23% Very Satisfied 15% The whole process of pricing, billing And reimbursement for medical services provided to me and/or my family Very Dissatisfied 13% Somewhat Dissatisfied 21% Somewhat Satisfied 27% Very Satisfied 14% Attitudes That Drive Satisfaction SATISFACTION WITH HEALTHCARE EXPERIENCES… My ability to choose the doctors and other healthcare providers I want My ability to see medical specialists if I ever need one My ability to get a doctor's appointment when I want The amount of time I am able to spend with my doctor The kind of advice I get from my doctor regarding actions I can take to help improve my health The amount I have to pay for prescription drugs The process and ease of finding the insurance plan that best meet my (or my family's) needs My ability to get the newest drugs and medical treatments.. The total amount I pay for health insurance The whole process of pricing, billing and reimbursement for medical services provided to me and/or my family DETERMINES OVERALL HEATH CARE RATINGS All things considered, how would you rate your overall health coverage and care? 1 Poor 2 3 Below Average 4 5 Average 6 7 Good 8 9 Excellent HealthCare Experiences Statements regarding 'health coverage' related subjects (i.e. pricing, ease of choosing an insurance plan, freedom to choose doctors, etc.) were more likely to be predictors of overall healthcare quality ratings, as compared to statements more directly related to quality of healthcare. Statements with the most impact in predicting health coverage and care ratings: Relative Impact on Overall Ratings The whole process of pricing, billing and reimbursement for medical services provided to me and/or my family 23% The total amount I pay for health insurance 23% The process and ease of finding the insurance plan that best meet my (or my family's) needs 18% My ability to see medical specialists if I ever need one 15% My ability to choose the doctors and other healthcare providers I want 12% The amount I have to pay for prescription drugs 8% Quotes from qualitative: Frustration over billing process: Medical bills are hard to understand. It's so easy for them to overcharge for things. Not everyone takes the time to review every line item. We have this certain trust that we won't be taken advantage of, and yet I think healthcare systems thrive on that. Difficulty finding optimal insurance: I'm baffled by all the plans out there, what you can and can't get covered and who can or who can't have that same coverage. It's all confusing and rather stupid to me. If my husband were to lose his job and we lost our insurance, I wouldn't know how or where to begin to navigate the options, or how we would pay for it. Overall Health Coverage and Care On average Minnesotans with government provided healthcare coverage (Medicare or Medicaid) had more positive perceptions of their overall health coverage and care, as compared to Minnesotans with private insurance. The care a patient receives can be all too easily determined by whether or not they chose the correct insurance plan. This is a nightmare in and of itself, combined with the insurmountable premium costs that are nearly unaffordable to most people having to purchase their insurance privately. All things considered, how would you rate your overall health coverage and care? (Q11) (n=1,009) Average Ratings Total (n=1009) 6.4 A Medicare (n=191) 7.2 ABCD B Medicaid (n=176) 6.7 CD C Employer (n=518) 6.4 D Exchange (n=71) 6.0 ABC ABCD Indicates statistically significantly higher than other figures in the row, at 95% confidence level 9 = Excellent 10% 8= 18% 7 = Good 32% 6= 10% 5 = Fair 17% 4= 4% 3 = Subpar 5% 2= 1% 1 = Poor 2% Satisfaction by Insurance Type Medicare recipients are generally more satisfied than those with private health insurance on all aspects of healthcare experiences. HealthCare Experiences, Satisfaction Ratings (Q21) Top 2-Box Satisfaction Ratings (Very or Somewhat Satisfied) The whole process of pricing, Billing and reimbursement for Medical services provided to me and/or my family Total (n=1009) 41% Medicare (n=191) 56% Medicaid (n=176) 54% Employer (n=518) 36% Exchange (n=71) 29% The total amount I pay for health insurance Total (n=1009) 38% Medicare (n=191) 48% Medicaid (n=176) 53% Employer (n=518) 35% Exchange (n=71) 20% The process and ease of finding the insurance plan that best meet my (or my family's) needs Total (n=1009) 45% Medicare (n=191) 57% Medicaid (n=176) 45% Employer (n=518) 46% Exchange (n=71) 42% My ability to see medical specialists if I ever need one Total (n=1009) 61% Medicare (n=191) 76% Medicaid (n=176) 59% Employer (n=518) 62% Exchange (n=71) 59% My ability to choose the doctors and other healthcare providers I want Total (n=1009) 63% Medicare (n=191) 73% Medicaid (n=176) 55% Employer (n=518) 59% Exchange (n=71) 66% The amount I have to pay for prescription drugs Total (n=1009) 45% Medicare (n=191) 58% Medicaid (n=176) 58% Employer (n=518) 45% Exchange (n=71) 34% My ability to get a doctor's appt when I want Total (n=1009) 67% Medicare (n=191) 78% Medicaid (n=176) 60% Employer (n=518) 68% Exchange (n=71) 78% The amount of time I am able to spend with my doctor\Total (n=1009) Medicare (n=191) 63% Medicaid (n=176) 72% Employer (n=518) 59% Exchange (n=71) 65% My ability to get the newest drug and medical treatments and medical treatments Total (n=1009) 43% Medicare (n=191) 50% Medicaid (n=176) 56% Employer (n=518) 46% Exchange (n=71) 32% The kind of advice I get from my doctor regarding actions I can take to help improve my health Total (n=1009) 63% Medicare (n=191) 76% Medicaid (n=176) 65% Employer (n=518) 62% Exchange (n=71) 67% HEALTHCARE OUTLOOK One-out-of-four Minnesota adults (27%) believe they will be worse off in 3 years regarding access to good quality, affordable healthcare. With regards to your access to good quality and affordable healthcare, I believe in 3 years we will be… (Q13) (n=1,009) Worse off 27% Better off 24% About the same 49% Do you know someone with a developmental disability? Yes, Immediate Family/Self (n=143) Worse off 38% Better off 27% About the same 40% Yes, Acquaintance (n=433) Worse off 27% Better off 23% About the same 50% No (n=433) Worse off 23% Better off 26% About the same 51% Households with a person with a developmental disability are more likely to have a pessimistic near future outlook regarding healthcare quality and affordability, as compared to all other households. HEALTHCARE CONCERNS Minnesotans are most concerned about rising costs related to healthcare coverage and care. How concerned are you with each of the following statements? (Q14) (n=1,009) Rising costs of healthcare premiums Top 2-Box Concern 74% Rising cost of insurance deductible and co-pay fees for medical services Top 2-Box Concern 70% Rising cost of drugs and other medical services, as our country's medical system is strained by an aging population Top 2-Box Concern 67% Potential Federal cuts to Medicaid, which could lead to more uninsured people and higher premiums Top 2-Box Concern 58% Delaying treatment due to high annual deductible out of pocket costs Top 2-Box Concern 57% Access to affordable health insurance for people with preexisting conditions Top 2-Box Concern 57% Cost of long term services, supports, and care Top 2-Box Concern 52% Access to mental health coverage Top 2-Box Concern 51% People taking advantage of government-provided health insurance, when they can afford it on their own Top 2-Box Concern 50% Access to all of the medical services needed for people with disabilities Top 2-Box Concern 52% People over-using healthcare services, raising the cost for the rest of us Top 2-Box Concern 53% Being forced to buy health insurance or pay a fine, even if I don't want it Top 2-Box Concern 33% HEALTHCARE CONCERNS People who have a person in their household with a developmental disability are more likely to be very concerned about federal cuts to Medicaid, and access to medical services in general for people with developmental disabilities. Do you know someone with a developmental disability? (TOP BOX) Very concerned: (Q14) Yes, Immediate Family/Self (n=143) Yes, Acquaintance (n=433) No (n=433) Rising costs of healthcare premiums 46% 53% 45% Rising cost of insurance deductible and co-pay fees for medical services 41% 45% 39% Rising cost of drugs and other medical services, as our country's medical system is strained by an aging population 44% 45% 36% Potential Federal cuts to Medicaid, which could lead to more uninsured people and higher premiums 46% 40% 33% Delaying treatment due to high annual deductible out of pocket costs 37% 36% 32% Access to affordable health insurance for people with preexisting conditions 41% 33% 30% Cost of long term services, supports, and care 41% 32% 32% Access to mental health coverage 38% 33% 27% People taking advantage of government-provided health insurance, when they can afford it on their own 29% 30% 30% Access to all of the medical services needed for people with disabilities 38% 30% 25% People over-using healthcare services, raising the cost for the rest of us 29% 27% 28% Being forced to buy health insurance or pay a fine, even if I don't want it 30% 20% 23% HEALTHCARE CONCERNS People, who expect to be worse off in 3 years, are more concerned about aspects of healthcare coverage and costs, as compared to those who believe they'll be better off or about the same. Very concerned: (Q14) Worse off (n=269) Better off (n=244) About the same (n=496) Rising costs of healthcare premiums 64% 43% 44% Rising cost of insurance deductible and co-pay fees for medical services 54% 35% 38% Rising cost of drugs and other medical services, as our country's medical system is strained by an aging population 52% 31% 40% Potential Federal cuts to Medicaid, which could lead to more uninsured people and higher premiums 53% 29% 35% Delaying treatment due to high annual deductible out of pocket costs 43% 33% 30% Access to affordable health insurance for people with preexisting conditions 49% 27% 27% Cost of long term services, supports, and care 45% 30% 29% Access to mental health coverage 39% 29% 28% People taking advantage of government-provided health insurance, when they can afford it on their own 29% 30% 31% Access to all of the medical services needed for people with disabilities 38% 26% 26% People over-using healthcare services, raising the cost for the rest of us 28% 28% 28% Being forced to buy health insurance or pay a fine, even if I don't want it 25% 25% 20% SUMMARY: HEALTHCARE SATISFACTION, OUTLOOK AND CONCERNS 92% of the survey respondents report having some kind of health insurance or healthcare coverage: • 56% have private health insurance through their employer and 8% purchased through the Exchange. • 40% have some kind of government-provided healthcare coverage. o 21% Medicare o 19% MA/Medicaid 28% rate their overall health coverage and care as better than good; while 39% gave less than good ratings. • Satisfaction with the following aspects of healthcare had the most impact on impressions of overall quality of health coverage and care: o The whole process of pricing, billing and reimbursement for medical services provided to me and/or my family. o The total amount I pay for health insurance. 27% of Minnesota adults believe they will be worse off in 3 years regarding access to good quality, affordable healthcare. • Minnesotans are most concerned about rising costs related to healthcare coverage and care. • Households with a person with a developmental disability are more likely to have a pessimistic near future outlook regarding healthcare quality and affordability, as compared to all other households. o People who have a person in their household with a developmental disability are more likely to be very concerned about federal cuts to Medicaid, and access to healthcare in general. ATTITUDINAL SEGMENTATION ANALYSIS 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: Disagree Strongly Disagree Somewhat Neither Agree Somewhat Agree Strongly 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 The correspondence map below 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 FOUR SEGMENTS SELF-RELIANT SEGMENT: 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. That sentiment may best be captured in these quotes from qualitative research: Quote from qualitative research: I have a relative (with a disability) who is capable of working, however, he chose to take Medicaid or whatever was available and never saw a medical bill. Those of us who are working are paying premiums, co-pays and hefty deductibles at least. Healthcare is not a handout. Social security payments to individuals who have NEVER paid premiums IS a handout. Welfare for individuals who are capable of working IS a handout. Money for this does not grow on trees. It comes out of our taxes, insurance premiums, etc. Gender: Male 45% Employed: Full/Part time 70% Female 54% Retired 17% Average Age: 43 Average Income: $70,079 Marital Status: Single 28% Children in Household: Yes 40% No 60% Married/living with 59% Political party: Democrat 32% Know someone with a developmental disability: Republican 32% Yes 46% Independent 17% No/Don't know 54% ATTITUDES: SELF-RELIANT SEGMENT The Self-Reliant segment is defined and differentiate from other segments by its higher levels of agreement with the first three statements below, and lower levels of agreement with the other four statements. PERCENT SAYING AGREE STRONGLY or SOMEWHAT A SELF-RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) 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. 43% 6% 33% 39% Individuals or families, who are likely to use more health care, should be expected to pay higher premiums than others. 42% 58% 15% 11% People should be denied health care if they make unhealthy lifestyle or behavior choices. 29% 30% 4% 8% People should pay lower premiums for making healthy choices, such as exercising frequently. 58% 84% 74% 65% People should not be turned away from necessary medical treatment, even if they are uninsured and cannot afford the treatment. 59% 76% 99% 100% Healthcare should be available to all citizens regardless of their income or employment status. 70% 71% 97% 100% Children's healthcare needs should take a priority in healthcare cost decisions. 60% 64% 80% 80% SOCIAL BALANCE SEGMENT: 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. Quote from qualitative research: I want everyone to have coverage and I want everyone to be taken care of and have everything they need available to them Ð but I don't think it should be given to them. We need to set up our society and our future to allow people to afford and be able to care for their care. Let people feel good about being able to contribute to their healthcare Ð they might take some pride in that and take better care of themselves. Gender: Male 50% Employed: Full/Part time 63% Female 50% Retired 27% Average Age: 51 Average Income: $84,574 Marital Status: Single 17% Children in Household: Yes No 31% 69% Married/living with 70% Political party: Democrat 14% Know someone with a developmental disability: Republican 36% Yes 69% Independent 31% No/Don't know 31% ATTITUDES: SOCIAL BALANCE SEGMENT The Social Balance segment believes in the importance of accounting for both personal and societal needs in healthcare decisions and policies. PERCENT SAYING AGREE STRONGLY A SELF-RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) We all have a personal responsibility not to use more healthcare services than we need in order to keep healthcare affordable. 18% 53% 34% 38% Everyone should pay something for their health care, with people paying varying amounts depending on what they can afford. 16% 36% 21% 24% People should pay lower premiums for making healthy choices, such as exercising frequently. 23% 37% 39% 19% Our current healthcare system relies too heavily on drugs as opposed to more holistic management of health and wellbeing. 18% 35% 30% 26% The cost of treatment, along with the chance of success, is a factor that should be considered in decisions regarding treatment. (Top 2-Box)* 46% 67% 49% 40% PERCENT WHO DISAGREE STRONGLY or SOMEWHAT 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. 24% 82% 44% 37% SOCIAL PROTECTION SEGMENT: 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, while the Total Entitlement segment believes everyone should get optimal care regardless of their income level or personal healthcare/lifestyle choices. Quote from qualitative research: I think we're on track when we have a more universal coverage for all people. Everyone needs to be part of the pie. If everyone is not paying in then it is harder to help those that are sick too. I think the problem would be to find affordability for the young people starting out and the older people who may need more care. Gender: Male 28% Employed: Full/Part time 70% Female 72% Retired 17% Average Age: 44 Average Income: $65,305 Marital Status: Single 26% Children in Household: Yes No 39% 61% Married/living with 59% Political party: Democrat 48% Know someone with a developmental disability: Republican 13% Yes 59% Independent 20% No/Don't know 41% ATTITUDES: SOCIAL PROTECTION SEGMENT The belief that people should be rewarded with lower premiums for making healthy choices is an attitude that most differentiates the lower right Social Protection segment from the lower left Total Entitlement segment. PERCENT SAYING AGREE STRONGLY A SELF-RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) Healthcare should be available to all citizens regardless of their income or employment status. 35% 32% 82% 96% People should not be turned away from necessary medical treatment, even if they are uninsured and cannot afford the treatment. 24% 26% 75% 96% Employers should give employees a choice of more than one health plan. 24% 34% 52% 46% Our healthcare system needs to be more focused on prevention and early detection of disease, as opposed to treatment after a patient gets sick. 20% 45% 52% 59% People should pay lower premiums for making healthy choices, such as exercising frequently. 23% 37% 39% 18% PERCENT WHO DISAGREE STRONGLY or SOMEWHAT People should be denied health care if they make unhealthy lifestyle or behavior choices. 41% 46% 84% 85% Individuals or families who are likely to use more healthcare, should be expected to pay higher premiums than others. 22% 19% 65% 66% TOTAL ENTITLEMENT SEGMENT: 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. Quote from qualitative research: In other countries government helps make sure that things necessary, not profitable, still happen. It's for the collective good. Pure capitalism means that lifesaving medications are super expensive because the demand is high, not because they are expensive. And I think that we (in the U.S.) have different ideas of what "deserves" and "earns" means, when we've grown up in this culture. (We see this in that it's legal to pay certain people with disabilities less than minimum wage.) And taking away programs that ensure people's abilities to work and live independently does not keep them from being lazy, it means that they are forced into poverty and are even more dependent. This is bad for them, and bad for the community as a whole. Gender: Male 34% Employed: Full/Part time 59% Female 66% Retired 24% Average Age: 47 Average Income: $64,679 Marital Status: Single 26% Children in Household: Yes No 32% 68% Married/living with 58% Political party: Democrat 68% Know someone with a developmental disability: Republican 4% Yes 71% Independent 11% No/Don't know 29% ATTITUDES: TOTAL ENTITLEMENT SEGMENT: The Total Entitlement segment is most differentiated from all other segments by its belief that government should be responsible for ensuring that all citizens have access to all healthcare services they need. PERCENT SAYING AGREE STRONGLY A SELF-RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) Individuals whose health has been impacted through no fault of their own should not have to pay higher premiums than others. 20% 27% 49% 96% The government should insure access to healthcare for people who live in rural areas. 12% 13% 49% 96% The government should insure access to healthcare for low income populations. 16% 10% 63% 96% People should not be turned away from necessary medical treatment, even if they are uninsured and cannot afford the treatment. 24% 26% 75% 96% Healthcare should be available to all citizens regardless of their income or employment status. 35% 32% 82% 96% People, such as the elderly and people with disabilities, who need more services than others, should get them without paying more. 26% 19% 52% 87% The government should provide education and incentives to help people make wise choices regarding their health. 22% 24% 46% 66% OVERALL QUALITY OF THE HEALTHCARE SYSTEM Minnesotans give their state higher ratings for the overall quality of Minnesota's healthcare system, as compared to the healthcare system for the U.S. as a whole. Qualitative Quotes: The quality of care itself is pretty great to be honest. I know that we continue to lead the world in quality of care, but the problem is getting access to that care. As a result we're falling behind in health as a nation. Healthcare for me unfortunately has a negative connotation associated with greed, red tape and massive overcharging, all at the expense of someone's well-being during a time of need. It is a bureaucracy of regulations and agreements between the hospitals, clinics, doctors and the health insurance companies designed to keep money at the highest levels of the system. All things considered, how would you rate your overall quality healthcare system? (Q19) (n=1,009) Average Rating for Minnesota 6.1 Average Rating for U.S. 5.1 MINNESOTA U.S. 9 = Excellent 8% 5% 8= 14% 4% 7 = Good 28% 19% 6= 13% 13% 5 = Fair 17% 26% 4= 7% 10% 3 = Subpar 7% 14% 2= 3% 4% 1 = Poor 3% 5% GOVERNMENT HEALTHCARE POLICIES Just over half (54%) of all adults in Minnesota believe the federal government is responsible for ensuring that all Americans have healthcare coverage. The two lower half segments are most aligned with that belief. 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) (n=1,009) A SELF-RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) Yes, it is the responsibility of the federal government to ensure that all Americans have healthcare coverage 54% 47% 28% 76% 86% No, ensuring healthcare coverage is not the responsibility of the federal government 32% 38% 56% 10% 6% I don't know; I don't have an opinion either way 15% 16% 15% 13% 8% QUOTES FROM QUALITATIVE RESPONDENTS: Yes: Healthcare companies, insurance companies and healthcare providers are not properly incentivized to provide care for everyone. It is expensive and logistically hard to provide healthcare to poor and disabled people. The government needs to make sure that everyone, regardless of whether they need high or low levels of care, have continued access at a price that is not going to make them lose their financial freedom. No: Healthcare you don't pay for is a handout. Social security payments to individuals who have never paid premiums is a handout. Welfare for individuals who are capable of working is a handout. Money for this does not grow on trees. It comes out of our taxes, insurance premiums, etc. APPROACH FOR PROVIDING HEALTHCARE Minnesotans as a whole are evenly split in terms of preference for a government-run healthcare system versus a system based mostly on private health insurance. However, the 2 lower-half segments would prefer a government-run system, whereas the Self-Reliant and Social Balance segments prefer a system based mostly on private insurance. Which of the following approaches for providing healthcare in the United States do you prefer? (Q16) (n=1,009) A SELF-RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) A government-run healthcare system 43% 36% 25% 61% 75% A system based mostly on private health insurance 40% 45% 62% 20% 10% No opinion 17% 19% 12% 20% 15% A majority of Minnesotans (58%) 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. Should Congress deal with healthcare reform on a….(Q17) (n=1,009) A SELF-RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) Gradual basis 58% 58% 58% 57% 55% Comprehensive, repeal and replace 42% 42% 42% 43% 45% Quotes in support of gradual reform: They should reform the healthcare system gradually so that they can experiment and see what will work and won't work in the future. All the answers will not be uncovered immediately and there will be some loopholes that will need to be filled. Problems will arise, they will need time to be addressed. Trial and error until we get it right. GOVERNMENT ROLE IN DRUG PRICING The majority of Minnesotans (83%) believe the government should play a role in drug pricing, with 39% believing the government should be very involved in controlling prices. What do you believe is the role of government in drug pricing? (Q18) (n=1,009) A SELF-RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) Government should be very involved in controlling prices, to ensure that drugs are affordable for the people who need them 39% 40% 23% 48% 64% Government should monitor the drug industry and enforce price controls only if an important drug is priced excessively high 44% 43% 54% 42% 31% 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% 10% 16% 3% 1% I really don't know 8% 7% 7% 7% 4% MEDICARE AND MEDICAID The survey respondents were asked to read this description of Medicare and Medicaid: 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 MEDICAID Next, the respondents were shown and asked to read this description of Medicaid funding proposals that are being considered by Congress and the current administration: Congress and the current administration are proposing to put a cap on the amount of money the federal government pays to states for Medicaid.Ê 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 RECOMMENDATIONS FOR MEDICAID The majority of Minnesotans (60%) 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. 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) (n=1,009) A SELF-RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) Federal government should cap Medicaid spending and force the states to find ways to cut costs and/or find other sources of funding 24% 32% 36% 9% 3% Federal government should continue to "honor the commitment" to match the states spending for Medicaid 60% 50% 45% 80% 92% Don't know 16% 18% 19% 10% 6% RECOMMENDATIONS FOR MEDICAID Minnesotans would prefer to reduce rates paid to service providers, as a way of offsetting federal cuts to Medicaid. Cutting services and covering fewer people were least preferred. Respondents' relative preferences for response to possible Medicaid funding cut: (Q21) Total (n=1,009) A SELF- RELIANT 36% (n=348) B SOCIAL BALANCE 27% (n=264) C SOCIAL PROTECTION 25% (n=246) D TOTAL ENTITLEMENT 11% (n=109) Reduce rates paid to service providers who are paid with Medicaid dollars 33% 34% 30% 37% 33% Draw funds from other state priorities 25% 24% 21% 29% 33% Raise state taxes to pay for the growth in Medicaid costs 20% 17% 15% 26% 33% Cut services that are currently being offered through Minnesota's Medicaid program 18% 19% 23% 14% 11% Cover fewer people 16% 17% 23% 11% 8% SEGMENT PROFILE DEMOGRAPHICS Demographic Variables: Total (n=1,009) A SELF RELIANT (n=348) B SOCIAL BALANCE (n=264) C SOCIAL PROTECTION (n=246) D TOTAL ENTITLEMENT (n=109) Gender: Male 41% 45% 50% 28% 34% Female 59% 54% 50% 72% 66% Average Age: 45 43 51 44 47 Employed: Full/Part time 67% 70% 63% 70% 59% Retired 20% 17% 27% 17% 24% Average Income: $71,353 $70,079 $84,574 $65,305 $64,679 Marital Status: Single 24% 28% 17% 26% 26% Married/living with 61% 59% 70% 59% 58% Children in HH: Yes 36% 40% 31% 39% 32% No 64% 60% 69% 61% 68% Know someone with a developmental dis.: Yes 57% 46% 69% 59% 71% No/Don't know 43% 54% 31% 41% 29% Political party: Democrat 34% 32% 14% 48% 68% Republican 25% 32% 36% 13% 4% Independent 21% 17% 31% 20% 11% Libertarian 3% 3% 5% 1% 0% 43