Insurance coverage in the workplace the spread of community health care centers college education and exercise heart disease cancer and asthma rates

Under coverage

Massachusetts has one of the lowest percentages of people without health insurance, but it might do even better if more private employers picked up the tab. According to a recent report in Governing magazine, almost 72 percent of adults under 65 working in the Bay State receive insurance at their workplace (as of two years ago), but that’s significantly lower than the rate in next-door New Hampshire—where 78 percent of the workforce gets insurance from employers, the highest rate in the country. Because the state government in New Hampshire moves relatively few people into the ranks of the insured, its overall coverage rate is still lower than that in Massachusetts. But three of the four states that do better than the Bay State at insuring its citizens—Delaware, Minnesota, and Wisconsin—also have higher percentages of people receiving insurance through employers.

In addition to the figures below, Governing also calculated that Massachusetts ranks 14th in the percentage of adults receiving insurance through public programs including Medicaid — 11.2 percent versus the national average of 9.2 percent. Tennessee ranks first in this category, with 16.6 percent insured through government programs (see Innovations sidebar), an effort that greatly compensates for the relatively high number of jobs that don’t offer coverage. Maryland ranks last, with only 4.9 percent of adults insured through government programs—a fact that explains why this relatively wealthy state has a mediocre standing (24th) in terms of the percentage of its population with any health insurance at all.

Self-financed health insurance is most popular—or, at least, necessary—in western states. In Montana, which ranks first by this measure, 12.7 percent of all adults over 65 pay for health insurance completely out of their own pockets. Massachusetts ranks 35th in the percentage of adults with individual plans (4.9 percent), somewhat below the national average of 5.7. percent.

Rank

State

% of adults under 65 with health insurance

% of adults under 65 with health insurance through an employer (rank)

1

Minnesota

90.0

75.5 (2)

2

Delaware

88.4

74.1 (3)

3

Iowa

88.3

72.4 (9)

4

Wisconsin

88.0

73.1 (6)

5

Massachusetts

87.9

71.7 (13)

6

Rhode Island

87.7

70.5 (15)

7

Hawaii

87.4

71.4 (14)

8

New Hampshire

86.9

78.1 (1)

8

Pennsylvania

86.9

72.8 (8)

10

Nebraska

86.7

68.3 (22)

11

North Dakota

86.3

67.5 (25)

11

South Dakota

86.3

65.3 (32)

13

Connecticut

86.2

73.5 (4)

14

Vermont

86.1

67.1 (27)

15

Michigan

85.6

72.4 (9)

16

Tennessee

85.4

63.2 (37)

17

Maine

85.0

66.6 (29)

18

Kansas

84.9

69.9 (17)

19

Missouri

84.6

72.3 (11)

19

Ohio

84.6

70.3 (16)

19

Virginia

84.6

69.5 (18)

22

Indiana

84.1

73.1 (6)

23

Kentucky

83.6

68.3 (22)

24

Maryland

83.4

73.3 (5)

25

South Carolina

83.3

66.1 (31)

26

Oregon

83.1

63.3 (36)

27

Washington

83.0

66.3 (30)

28

Alabama

82.9

67.8 (24)

29

New Jersey

82.6

71.8 (12)

30

Illinois

82.4

69.4 (19)

31

Utah

81.9

69.2 (20)

32

Montana

81.4

56.7 (49)

33

Colorado

80.8

66.9 (28)

34

West Virginia

80.7

61.6 (40)

35

Georgia

80.3

67.2 (26)

36

North Carolina

79.7

64.7 (34)

37

New York

79.0

63.4 (35)

38

Nevada

78.8

68.9 (21)

39

Arizona

78.7

61.1 (42)

40

Wyoming

78.3

65.0 (33)

41

Mississippi

77.9

58.7 (46)

42

Alaska

77.8

63.2 (37)

42

Idaho

77.8

62.4 (39)

44

Arkansas

77.5

58.8 (45)

45

Florida

77.2

60.9 (43)

46

California

76.5

61.4 (41)

46

Oklahoma

76.5

59.7 (44)

48

Louisiana

74.4

57.9 (48)

49

New Mexico

71.7

55.0 (50)

50

Texas

70.3

58.6 (47)

US total

80.9

66.1

Source: Governing Magazine (www.governing.com), using 2001-02 data from the Kaiser Commission on Medicaid and the Uninsured.

Community care

The 43 million Americans without health insurance get newspaper headlines and the attention of political candidates. But there are 36 million Americans who have insurance but lack access to health care because they live in communities without enough providers. That’s the conclusion of A Nation’s Health at Risk, a study released in March by the National Association of Community Health Centers. Not surprisingly, the study recommends community health centers as a relatively inexpensive way to reach underserved populations.

Massachusetts has already taken this idea to heart. According to the NACHC, the Bay State is one of a handful where more than 95 percent of residents have adequate health care services in their communities, thanks, in part, to an extensive network of community health centers. This abundance of community-based providers seems also to help those without health insurance. Massachusetts ranks highly (sixth place) in the percentage of low-income, uninsured individuals who use such centers as their regular providers, as well.

But the two—access and health centers—don’t always go together. Though Massachusetts ranks in the top 10 in both categories, it’s bested by a totally different set of states in each instance. Several states have achieved near-universal proximity to adequate health care without much reliance on community health centers—mostly northeastern states such as Maine, Maryland, and New Hampshire. Other states have relatively low populations that are “medically served” even though their community health centers care for most of their uninsured—particularly rural states such as Montana, South Dakota, and West Virginia. Only Alaska, Hawaii, and Rhode Island are comparable to Massachusetts in relying so much on community health centers to achieve near-total health care service.

Cambridge may be the best-served city in the Bay State; it has 12 community health centers, or almost half the number (27) in five-times-larger Boston. The smallest towns with such clinics, Worthington and Huntington, are right next to each other in Hampshire County. The largest cities without community health centers are Newton and Waltham, which are right next to each other in the Metrowest region. While most of the Bay State’s centers are in urban areas, the NACHC notes that, at the national level, one-fifth of all adults living in rural areas get their primary care through community health centers—which is about twice the rate as that of urban residents.

% of population that is “medically served” (2003)

1.

Hawaii

99

2.

New Hampshire

98

2.

Rhode Island

98

4.

Alaska

97

4.

Connecticut

97

4.

Maryland

97

7.

Maine

96
7.

Massachusetts

96

9.

Illinois

95

9.

Washington

95

11.

Arizona

94

11.

Colorado

94

11.

Delaware

94

11.

New Jersey

94

11.

Vermont

94

16.

California

93

17.

Minnesota

91

17.

Oregon

91

17.

Pennsylvania

91

20.

Ohio

90

21.

Michigan

89

21.

New York

89

23.

Iowa

88

23.

Wisconsin

88

25.

Indiana

87

25.

Kansas

87

25.

Virginia

87

28.

Florida

87

28.

West Virginia

87

30.

North Dakota

85

31.

Montana

84

32.

Missouri

82

32.

New Mexico

82

32.

Oklahoma

82

32.

South Carolina

82

32.

Texas

82

37.

South Dakota

81

37.

Utah

81

39.

Idaho

80

39.

Kentucky

80

39.

Nebraska

80

39.

Nevada

80

39.

North Carolina

80

44.

Tennessee

79

45.

Georgia

78

46.

Arkansas

77

47.

Wyoming

76

48.

Alabama

71

49.

Mississippi

67

50.

Louisiana

64

 

US total

88

 
% of low-income uninsured served by community health centers (2003)

1.

Alaska

62

2.

West Virginia

55

3.

South Dakota

53

4.

Colorado

47

4.

Montana

47

6.

Massachusetts

44

7.

Mississippi

43

8.

Hawaii

42

9.

New Mexico

40

9.

Rhode Island

40

11.

Washington

38

12.

Connecticut

35

13.

North Dakota

32

14.

Iowa

29

14.

Oregon

29

16.

Missouri

28

16.

South Carolina

28

18.

Alabama

27

18.

Kentucky

27

20.

California

26

20.

Idaho

26

20.

Utah

26

23.

Illinois

24

23.

New Hampshire

24

23.

Vermont

24

26.

Kansas

22

26.

Nebraska

22

28.

Arkansas

21

28.

Maine

21

30.

Minnesota

20

31.

Pennsylvania

19

32.

Michigan

18

33.

North Carolina

17

34.

Florida

16

34.

New York

16

34.

Tennessee

16

37.

Wyoming

16

38.

Delaware

15

38.

New Jersey

15

40.

Arizona

14

40.

Indiana

14

40.

Maryland

14

40.

Nevada

14

44.

Georgia

13

44.

Virginia

13

46.

Oklahoma

12

46.

Wisconsin

12

48.

Ohio

11

49.

Texas

10

50.

Louisiana

9

 

US total

20

Association of Community Health Centers (www.nachc.com), Massachusetts League of Community Health Centers (www.massleague.org).

Physical education

By several criteria, Massachusetts is in the vanguard of healthy living. According to the Centers for Disease Control, we have among the country’s lowest rates of obesity and smoking, and we rank among the highest in seeing our doctors on a regular basis. But our healthy rankings are at least partly attributable to our demographics. Massachusetts is a relatively affluent and well-educated state, and people with more money and more degrees tend to have healthy habits wherever they live. When you look at members of specific groups, the Bay State isn’t always at the doctor-recommended end of the spectrum. For example, Massachusetts ranks 48th in the percentage of adults who are current smokers (18.9, considerably below the national average of 23.0). But we’re 38th in the percentage of residents without high school diplomas who smoke (30.7, versus 34.6 at the national level and barely below North Carolina’s 32.0). And we’re 43rd in the percentage of college graduates who smoke (10.5, versus the national average of 12.6).

Massachusetts ranks third in the percentage of adults who have had their teeth cleaned in the past year (78.9 percent, versus the national average of 69.2 percent) but ninth in the percentage of college graduates who have had their teeth cleaned (85.0 percent versus 79.2 percent).

Educational differences are especially noticeable in the percentage of individuals who claim no leisure-time physical activity—and thus may be at greater risk for heart disease and diabetes, among other conditions. Overall, Massachusetts ranks 35th by this measure, and its 22.7 percent of citizens who are sedentary is well below the 26.3 percent at the national level. But while Bay State college graduates are more physically active than their counterparts elsewhere (with only 12.8 percent abstaining from exercise, compared with 14.5 percent nationally), residents who have not advanced beyond high school match up almost exactly with the national sample, with 32.6 percent in both groups admitting that they have no leisure-time physical activity.

At least in this case, climate may play a role in minimizing or exaggerating differences by educational level. Blue Hawaii has the smallest gap between high school graduates and college graduates in terms of exercise rates, and often-snowy Nebraska has the greatest gap. While most states with high rates of inactivity are in the South, it’s notable that New York has high inactivity rates at all educational levels—but the survey didn’t determine whether New Yorkers lack time, proximity to green space, or affordably priced health clubs.

% of adults with no leisure-time
physical activity

% of HS graduates with no leisure-time physical activity

% of college graduates with no leisure-time physical activity

1

Louisiana

35.8

40.6 (3)

21.0 (1)

2

Tennessee

34.7

41.0 (2)

17.9 (6)

3

Mississippi

33.5

38.0 (5)

20.0 (2)

4

Kentucky

33.3

35.9 (9)

16.6 (11)

5

Oklahoma

32.5

36.3 (8)

19.3 (4)

6

West Virginia

31.3

34.2 (14)

19.5 (3)

7

Nebraska

31.2

43.1 (1)

17.8 (7)

8

Alabama

31.1

36.3 (7)

15.9 (12)

9

Arkansas

31.1

38.2 (4)

18.8 (5)

10

New York

28.6

34.8 (10)

17.3 (8)

11

Georgia

27.6

34.6 (12)

13.6 (23)

12

Texas

27.3

31.4 (26)

14.0 (21)

13

Missouri

27.2

31.2 (28)

14.5 (19)

14

Florida

27.1

33.3 (18)

17.3 (9)

15

California

26.6

32.1 (25)

15.0 (17)

16

Illinois

26.6

37.7 (6)

15.7 (13)

17

South Carolina

26.6

33.3 (19)

13.6 (24)

18

Kansas

26.4

33.5 (17)

17.0 (10)

19

New Jersey

26.4

34.1 (15)

15.4 (15)

20

North Carolina

26.3

34.6 (13)

13.2 (28)

21

Indiana

26.1

33.0 (20)

13.1 (29)

22

Ohio

26.1

32.9 (22)

13.1 (30)

23

New Mexico

25.9

33.8 (16)

11.3 (42)

24

Delaware

25.6

34.7 (11)

15.4 (16)

25

Iowa

25.5

32.3 (24)

14.7 (18)

26

South Dakota

25

30.5 (32)

13.5 (25)

27

Rhode Island

24.6

30.7 (29)

12.5 (34)

28

Maryland

24.3

31.2 (27)

15.7 (14)

29

Pennsylvania

24.1

28.0 (37)

14.2 (20)

30

Connecticut

23.8

32.9 (21)

13.6 (22)

31

Virginia

23.4

30.6 (30)

13.3 (26)

32

Michigan

23.3

29.1 (34)

11.6 (39)

33

North Dakota

23

27.6 (40)

12.2 (36)

34

Maine

22.9

28.1 (36)

11.7 (38)

35

Massachusetts

22.7

32.6 (23)

12.8 (32)

36

Alaska

22.4

30.5 (31)

11.7 (37)

37

Arizona

21.9

26.0 (42)

10.6 (43)

38

Montana

21.5

27.6 (38)

10.4 (44)

39

Wyoming

21.3

25.5 (43)

13.3 (27)

40

Idaho

20.9

25.4 (45)

12.8 (33)

41

Oregon

20.6

25.4 (46)

10.0 (46)

42

Wisconsin

20.6

25.4 (47)

11.5 (40)

43

Nevada

20.4

29.4 (33)

12.4 (35)

44

Vermont

20.4

28.4 (35)

8.5 (48)

45

New Hampshire

19.6

27.6 (39)

9.8 (47)

46

Colorado

19.4

26.5 (41)

11.3 (41)

47

Hawaii

18.8

25.4 (44)

13.1 (31)

48

Minnesota

17.1

24.3 (49)

8.4 (50)

49

Utah

17.1

24.5 (48)

10.4 (45)

50

Washington

17.1

24.3 (50)

8.4 (49)

US Total

26.3

32.6

14.5

Source: 2002 Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention (www.cdc.gov/brfss).

Death takes a holiday

Perhaps because of better diets and more exercise, Massachusetts has outpaced the nation in reducing the number of deaths from heart disease. Based on a three-year average of age-adjusted data from 1998 through 2000, the Bay State ranks 38th in the number of heart-related deaths per 100,000—down from 26th in 1990. While the national rate dropped from 321.8 to 268.7, the decline was considerably sharper in Massachusetts: from 309.1 to 226.7.

Deaths from cancer have been tougher to reduce. Nationally, the death rate is at 205.3 per 100,000, a slight drop from 216.7 in 1990. In the Bay State, the rate of cancer deaths has actually risen, from 209.1 to 211.4, placing us 19th highest in the nation. At this rate, Massachusetts may soon join Minnesota, which is now the only state where one is more likely to die from cancer than from heart disease.

Overall, Massachusetts has the third lowest rate of “premature death” (based on the number of years lost by individuals who die before the age of 75) according to 2000 figures, behind only Minnesota and New Hampshire. On that count, we were helped not only by our low rate of heart disease but also by our ranking of 44th in deaths attributed to strokes and 50th in occupational fatalities.

But on some other ailments, Massachusetts doesn’t do as well. In 2002, the Bay State ranked 19th in the rate of AIDS cases, and 18th in the rate of infectious disease. And Massachusetts makes a rare appearance at the wrong end of a health chart when it comes to asthma. Though there is no consensus on why the rate here is so high, there seems to be a geographical pattern to this respiratory ailment: Every New England state except Connecticut is in the top 10 for asthma rates, and almost all of the states in the bottom 10 are in the South.

State

Heart deaths per 100,000 population (rank)

Cancer deaths per 100,000 population (rank)

Percentage of adults diagnosed with asthma (rank)

Alabama

299.5 (7)

213.3 (18)

6.3 (43)

Alaska

211.8 (45)

189.0 (42)

7.3 (24)

Arizona

231.8 (36)

186.1 (44)

8.3 (8)

Arkansas

291.1 (10)

214.5 (13)

7.0 (32)

California

264.4 (22)

191.9 (40)

7.2 (29)

Colorado

202.1 (47)

177.2 (48)

8.0 (15)

Connecticut

244.5 (31)

196.1 (37)

7.9 (18)

Delaware

265.3 (21)

219.1 (5)

7.5 (22)

Florida

250.4 (28)

196.0 (38)

5.8 (46)

Georgia

282.5 (14)

203.8 (28)

7.2 (30)

Hawaii

194.0 (48)

162.3 (50)

7.3 (25)

Idaho

222.8 (40)

183.7 (45)

8.0 (16)

Illinois

274.4 (16)

214.3 (14)

7.9 (19)

Indiana

283.1 (13)

221.9 (4)

7.5 (23)

Iowa

252.7 (26)

203.3 (31)

6.7 (38)

Kansas

243.8 (32)

197.3 (36)

8.1 (13)

Kentucky

310.9 (4)

231.6 (1)

8.3 (9)

Louisiana

290.3 (11)

224.8 (3)

5.3(49)

Maine

249.6 (29)

216.7 (10)

9.4 (2)

Maryland

256.7 (24)

210.8 (20)

7.1 (31)

Massachusetts

226.7 (38)

211.4 (19)

9.5 (1)

Michigan

291.5 (9)

206.0 (23)

9.0 (5)

Minnesota

189.7 (50)

198.2 (34)

6.6 (39)

Mississippi

338.9 (1)

217.7 (9)

5.5 (48)

Missouri

299.0 (8)

214.6 (11)

8.2 (12)

Montana

217.1 (42)

203.7 (29)

8.0 (17)

Nebraska

238.9 (34)

194.0 (39)

5.8 (47)

Nevada

274.1 (17)

218.6 (7)

8.3 (10)

New Hampshire

227.4 (37)

210.3 (21)

8.4 (7)

New Jersey

271.3 (19)

214.3 (14)

6.2 (44)

New Mexico

215.5 (43)

178.7 (47)

6.9 (34)

New York

303.9 (5)

197.8 (35)

7.3 (26)

North Carolina

262.2 (23)

204.9 (27)

6.4 (41)

North Dakota

208.9 (46)

188.9 (43)

6.8 (37)

Ohio

286.5 (12)

218.5 (8)

7.3 (27)

Oklahoma

324.2 (2)

214.1 (16)

6.9 (35)

Oregon

212.6 (44)

205.1 (25)

8.1 (14)

Pennsylvania

280.6 (15)

214.6 (11)

7.3 (28)

Rhode Island

250.6 (27)

213.6 (17)

9.4 (3)

South Carolina

270.5 (20)

205.1 (25)

6.5 (40)

South Dakota

236.2 (35)

179.7 (46)

5.3 (50)

Tennessee

302.2 (6)

219.1 (5)

6.9 (36)

Texas

273.3 (18)

201.0 (32)

6.1 (45)

Utah

191.8 (49)

164.5 (49)

7.0 (33)

Vermont

241.8 (33)

200.4 (33)

8.8 (6)

Virginia

254.4 (25)

209.0 (22)

6.4 (42)

Washington

221.0 (41)

203.4 (30)

7.7 (21)

West Virginia

321.3 (3)

228.4 (2)

9.3 (4)

Wisconsin

244.6 (30)

205.7 (24)

7.8 (20)

Meet the Author

Wyoming

226.3 (39)

191.1 (41)

8.3 (11)

US total

268.7

205.3

7.2

Sources: the United Health Foundation (www.unitedhealthfoundation.org) and the Henry J. Kaiser Family Foundation (http://statehealthfacts.kff.org), both using data from the Centers for Disease Control and Prevention.