More than one in three Minnesota and Wisconsin residents struggle to pay for health care.

So says a “health care affordability policy checklist” released on Tuesday by a national nonprofit.

The report, by Washington-based health policy think tank Altarum, notes that health care costs emerge in surveys as a major national policy concern, regardless of political perspectives.

That makes sense because even in the best-performing state — Maryland — nearly one in four people face “affordability burdens,” according to the report. That means people are delaying or forgoing care because of concern about paying for it, or they get the care but struggle to pay. In Mississippi, the state that fares worst, well over half of the population is in that category.

Minnesota and Wisconsin are toward the middle of the pack, at 34% and 37%, respectively. In Minnesota, the top affordability concession was “made changes to medical drugs because of cost,” applicable to 23% of adults. In Wisconsin, it was “trouble paying medical bills,” which applied to 28% of adults.

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The per-person cost of health care in 2018 was $8,615 in Minnesota and $8,097, in Wisconsin, compared to a national mean of $7,191, according to the Bureau of Economic Analysis, a U.S. government agency. But those numbers can be misleading, said Lynn Quincy, author of the Altarum report. A lower per-person cost could mean residents of a state are getting a better deal, but it also could mean they’re paying for and getting less health care than they need.

But the prices paid for “health care units” — such as a day in the hospital or a 30-day prescription — are high in both states, according to the report. Wisconsin was the third most expensive behind Alabama and California, and Minnesota ninth. (The ranking includes the District of Columbia, but eight states are left out because key data were unavailable.)

Jean Abraham, a health economist and professor at the University of Minnesota School of Public Health, said the data the report used were “pretty incomplete, in my opinion.”

They were drawn from the Health Care Costs Institute, which compiles its numbers from insurers that aren’t well-represented in Minnesota, Abraham said.

Nonetheless, she said, concerns about health care prices in Minnesota are relevant.

“We have had a lot of consolidation in health care providers over time,” Abraham said. “And we also don’t have a very large number of insurers, particularly in areas that are more rural. And so we end up with potentially a situation with higher prices, and those prices get passed on to consumers.”

Quincy, who directs Altarum’s Healthcare Value Hub, said she finds the providers — such as health systems — carry more weight than the insurers. “It is hard for health plans to counteract provider market power,” she said. “And often, honestly, they’re not terribly incentivized … because at the end of the day, what do they have to do? They just have to pass those charges along.”

Nearly every state can point to measures in place to help control health care prices, Quincy said. But every state also could take steps that have been effective elsewhere. Minnesota, she said, could strengthen protections against so-called surprise medical bills and regarding short-term limited duration health plans. The latter do not have to follow Affordable Care Act guidelines. Although inexpensive at the front end, they can result in very large medical bills if not well-regulated, Quincy said. As much as 50% of the premium can go to the health plan’s overhead rather than to medical care, she added.

Wisconsin could expand its Medicaid coverage for childless adults from up to 100% of federal poverty level to as high as 138%, Quincy suggested. People in that bracket would get much more affordable care than they could through a private plan purchased on the marketplace, she said.

Both Minnesota and Wisconsin, the report said, need strong price transparency measures, a health-spending oversight entity and health-spending targets.

Minnesota does have some transparency measures, Abraham said. For example, MN Health Scores, produced by the nonprofit MN Community Measurement, gives consumers access online to clinic and medical group quality ratings, cost of services and procedures and other data.

Minnesota also also has an All Payer Claims Database that allows analysis of where money paid by public and private insurers goes. But it provides too much privacy for providers and payers, said Lynn A. Blewett, also a professor focusing on health care policy with the University of Minnesota’s School of Public Health.

“MN absolutely needs to have providers and health plans identified in our All Payer Claims Database,” Blewett wrote in an email.

Nationally, orders President Donald Trump has signed to make health prices more transparent have been “really bold,” Abraham said. “And of course, they’ll be sued by the providers as a result of that.”