Medicaid & SCHIP
Call For Papers
The Impact of SCHIP & Medicaid Expansion on Children
Chair: Cindy Brach, Agency for Healthcare Research
and Quality
Sunday, June 26 • 10:30 am – 12:00 pm
●Dynamics of Children’s Enrollment in Public Health
Insurance: A Three-State Comparison
Susan Haber, Sc.D., Andrew Allison, Ph.D., Elizabeth
Shenkman, Ph.D.
Presented By: Susan Haber, Sc.D., Senior Economist, RTI
International, 411 Waverley Oaks Road, Suite 330, Waltham,
MA 02452; Tel: (781) 788-8100; Fax: (781) 788-8101; Email:
shaber@rti.org
Research Objective: Although Medicaid and SCHIP can be
viewed as complementary programs as families’ incomes
fluctuate, few studies have looked at enrollment in public
health insurance (PHI) generally. Previous studies have
mainly looked at Medicaid and SCHIP separately and have
found that many children receive only episodic coverage
through these programs. We examine children’s patterns of
coverage in PHI to understand the relationship between
SCHIP and Medicaid, and to compare children’s coverage
based on type of eligibility (SCHIP, TANF, and poverty-level
Medicaid).
Study Design: We linked SCHIP and Medicaid eligibility
records for children in Kansas, Oregon, and Texas to create
complete records of enrollment in PHI. Transitions between
different types of eligibility, as well as patterns of enrollment in
and disenrollment from PHI, are analyzed using descriptive
and multivariate methods.
Population Studied: Children in Kansas, Oregon, and Texas
enrolled in SCHIP or in Medicaid through TANF or povertylevel eligibility during the first 3-4 years of SCHIP operation.
Principal Findings: While, a large proportion of SCHIP
children in Kansas and Oregon move between SCHIP and
Medicaid eligibility, these transitions are rarer in Texas. Onethird of SCHIP children in Kansas and two-fifths in Oregon
move directly into Medicaid when they leave SCHIP,
compared to 11% in Texas. Transitions between different
types of Medicaid eligibility are common in all three states.
Most children in all of our study states are covered by PHI for
relatively brief periods of time, although length of coverage in
Texas differed for Medicaid and SCHIP. Less than 60% the
children in Kansas remain in some type of PHI 12 months
after their initial enrollment, while in Oregon less than half
were still enrolled at this point. In Texas, less than 30% of
Medicaid children and 55% of SCHIP children still had PHI
after 12 months. However, there is considerably more
churning in Texas’ programs, particularly Medicaid, compared
to Oregon and Kansas. In Texas, 49% of TANF children and
38% of poverty-level Medicaid children disenroll from PHI and
subsequently re-enroll within a year after their initial
enrollment, compared to 15% or less of the children in Oregon
and Kansas.
Conclusions: There are considerable differences in continuity
of PHI coverage among the states in our study. Oregon’s
SCHIP is fully integrated with Medicaid, which likely explains
the high rate of transition between programs. While SCHIP is
free-standing in both Texas and Kansas, Kansas has moved to
integrate some aspects of the eligibility process. Texas shows
very high rates of churning, particularly in Medicaid,
suggesting that children may be disenrolled for administrative
reasons rather than true changes in eligibility status.
Implications for Policy, Delivery, or Practice: Policymakers
need to understand the extent to which SCHIP operates as a
complement to Medicaid, both to accurately assess the
continuity of PHI coverage provided to low-income children
and to design appropriate policies to educate families and
coordinate coverage as they move between programs and
across eligibility categories. High rates of churning suggest
there may be a need to modify administrative procedures in
order to avoid disruptions in continuity of coverage.
Primary Funding Source: David and Lucile Packard
Foundation
●The Impacts of the State Children’s Health Insurance
Program (SCHIP) on Access to Care and Use of Services:
Findings from Ten States
Genevieve Kenney, Ph.D.
Presented By: Genevieve Kenney, Ph.D., Principal Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street NW, Washington, DC 20037; Tel: (202) 261-5568; Fax:
(202) 223-1149; Email: jkenney@ui.urban.org
Research Objective: Together, SCHIP and Medicaid provide
insurance coverage to roughly four in ten low-income children.
In the current budget climate, it is important to understand
the impacts of these programs on the children who enroll and
their families. We assess the effects of SCHIP on access to
care and use of health services among children who enroll in
SCHIP for 10 states that account for over 60 percent of all
SCHIP enrollees nationwide. Impacts were also estimated for
Medicaid enrollees in 2 of the 10 states.
Study Design: Impact estimates are derived by contrasting
the access and use experiences of SCHIP enrollees who have
been enrolled in the program for at least five months to the
pre-SCHIP experiences of a separate sample of children who
had just enrolled in SCHIP. Regression models are used to
estimate impacts, controlling for county of residence and a
host of child and parent characteristics. Data are from a 2002
Survey of SCHIP and Medicaid enrollees. The access and use
measures include five different types of indicators related to 1)
service use; 2) unmet need; 3) attitudes and stress; 4) usual
source of care, and 5) provider communication and
accessibility.
Population Studied: Analytic samples include over 8,500
SCHIP enrollees ages 0 to 18 in 10 states: California,
Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey,
New York, North Carolina, and Texas and 1,500 Medicaid
enrollees ages 0 to 18 in California and North Carolina. The
10 states represent a mix of SCHIP program types (including
separate SCHIP programs, combination programs, and
Medicaid expansions) and are diverse geographically and with
respect to the composition of the enrollee population served
by the program.
Principal Findings: Under SCHIP, enrollees have fewer
unmet health needs and are more likely to have a usual source
for both health and dental care and their parents have less
stress and worry about meeting their children’s health care
needs compared to the experiences children have before
enrolling, other things equal. The greatest improvements are
found relative to new enrollees who were uninsured prior to
enrolling in SCHIP, where improvements are also found
related to the receipt of preventive and other health care
services and with respect to provider communication and
accessibility. These positive effects were found in each of the
10 study states and for all the subgroups of children. Positive
impacts of Medicaid enrollment were also found in analyses
for California and North Carolina.
Conclusions: This study indicates that Medicaid and SCHIP
are having positive impacts on the lives of the children who
enroll. The benefits of SCHIP enrollment are not limited to
one type of program or state or to a particular subgroup of
children.
Implications for Policy, Delivery, or Practice: Cutbacks in
public programs will likely lead to access problems for lowincome children. Additional analysis is needed to assess
quality of care under both Medicaid and SCHIP and impacts
on the health and functioning of children.
Primary Funding Source: The Assistant Secretary for
Planning and Evaluation, United States Department of Health
and Human Services
●Deterring Crowd-out in State Children's Health Insurance
(SCHIP) Programs: How Would Waiting Periods Affect
Children in New York?
Laura Shone, MSW, DrPH, Michael E. Chernew, Ph.D.,
Andrew W. Dick, Ph.D., Peter G. Szilagyi, M.D., MPH, Paula
M. Lantz, Ph.D., MS
Presented By: Laura Shone, MSW, DrPH, Assistant Professor,
General Pediatrics, University of Rochester, 601 Elmwood
Avenue, Box 777, Rochester, NY 14642; Tel: (585) 273-4084;
Fax: (585) 756-4132; Email:
Laura_Shone@URMC.Rochester.edu
Research Objective: Rationale: The State Children's Health
Insurance Program (SCHIP) provides public coverage to lowincome US children who are ineligible for Medicaid. Families
may substitute or “crowd-out” of private plans to enroll in
SCHIP. Waiting periods require a specified uninsured period
before SCHIP to deter substitution. Waiting periods in most
states preclude objective measurement, and substitution in
SCHIP is poorly understood. New York monitors substitution
and may impose a 6-month waiting period depending on
incidence. Objective: To determine the incidence and costs of
substitution; describe characteristics, health status, and health
care experiences of “substituters” versus “non-substituters”
before SCHIP; identify differences in access, service use, and
health status during SCHIP to determine the potential impact
of waiting periods on children and effects of substitution on
program impact measures.
Study Design: Design: Retrospective analysis of crosssectional survey data collected via parent telephone interview
six months after SCHIP enrollment. Methods: Substitution
was assessed using questions identical to the application form
questions used for ongoing monitoring in NYS. Substitution
occurred if the reason for joining SCHIP was cost/SCHIP is
cheaper or SCHIP has better benefits than prior insurance.
Bivariate analyses and multivariate logistic regression
calculated incidence of substitution, described
sociodemographic characteristics and experiences of
“substituters” before SCHIP (usual source of care (USC),
service use, unmet need, health status) and during SCHIP
(USC, USC use, health status), and determined the degree to
which experiences before and during SCHIP were associated
with substitution versus other factors. STATA was used to
provide weighted statewide estimates.
Population Studied: Random sample, stratified by race, age,
and NYS region, of 2644 children ages 0-17 who enrolled in
New York's SCHIP between 11/00 and 3/01.
Principal Findings: Incidence of substitution was 7.5%, (SE
1.1), thus, six-month premium costs for “substituters”
represented 7% of total premiums for all enrollees. Health
status and prior health care experiences did not differ by
substitution status, but greater parental worry was associated
with less substitution. Differences in health status and service
use during SCHIP were associated with factors other than
substitution.
Conclusions: Substitution is not occurring frequently in NY,
is consistent with NYS monitoring, is not associated with
differences in prior health status or service use during SCHIP,
and is therefore unlikely to have significant impact on
premium costs or assessment of program performance.
Implications for Policy, Delivery, or Practice: Substitution in
NYS SCHIP is minimal and has been stable since monitoring
of its precursor program began more than a decade ago. The
absence of substitution-related differences in health status or
service use should alleviate concerns that substitution would
result in higher program costs (possibly enrolling sicker
children) or dilution of program effects (possibly enrolling
healthier children who had less room to demonstrate
improvement relative to uninsured children). In the context of
others’ research about the medical and financial risks of
coverage gaps and costs of enrollment relative to coverage
(the existing enrollment process in NY takes roughly two
months at a monthly cost nearly equivalent to the monthly
premium cost for coverage), these results suggest that
unintended consequences of waiting periods, if implemented
in New York, may overshadow intended consequences.
Primary Funding Source: AHRQ, David and Lucile Packard
Foundation; Health Resources and Services Administration
(HRSA)
●Substitution of SCHIP for Private Coverage: Findings
from Ten States
Anna Sommers, Ph.D., Stephen Zuckerman, Ph.D.
Presented By: Anna Sommers, Ph.D., Research Associate,
Health Policy Center, The Urban Institute, 2100 M Street NW,
Washington, DC 20037; Tel: (202)261-5265; Fax: (202)2231149; Email: asommers@ui.urban.org
Research Objective: From the program’s inception, there
were concerns that parents of some children would substitute
SCHIP for private coverage. This paper assesses the extent to
which SCHIP is serving the target population of low-income
children who would have otherwise been uninsured in 10
states that account for over 60 percent of all SCHIP enrollees
nationwide.
Study Design: We measure substitution at the time of
enrollment as the share of new enrollees who moved from
private coverage to SCHIP and had the option of retaining
their private coverage. We then measure potential substitution
among established enrollees by estimating the share whose
parents are covered by an employer plan at the time of survey
and who might be foregoing the option of enrolling their child.
We refer to this as potential substitution, because the child
was not actually covered by an employer plan. We apply a
range of assumptions throughout this paper to produce
alternative substitution estimates.
Population Studied: Analytic samples include over 8,500
SCHIP enrollees ages 0 to 18 surveyed in 10 states: California,
Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey,
New York, and North Carolina Texas.
Principal Findings: Only 28 percent of recent SCHIP
enrollees had private coverage during the 6 months before
they enrolled. However, 14 percent of these children lost their
private coverage involuntarily (not substitution) and another 8
percent had parents who said their coverage was not
affordable. Affordability is a legitimate reason for families to
drop a child’s coverage in some states and treating it as such
would reduce the percent of recent enrollees had substituted
SCHIP for private coverage to 7 percent. Among established
enrollees, 39 percent had parents covered by an employer
plan. Taking into account those with no premium contribution
by an employer, only 36 percent may be substituting coverage
for their children. Since policymakers in some states are
willing to make exceptions for children with significant health
care needs, we can exclude these children, reducing the
estimate of potential substitution to 28 percent.
Conclusions: SCHIP is serving the target population of lowincome children who would otherwise have been uninsured
and that a relatively small share is substituting SCHIP for
employer coverage. Our higher estimates of potential
substitution are similar to the Congressional Budget Office
assumption that 40 percent of SCHIP enrollees would
substitute SCHIP for employer coverage.
Implications for Policy, Delivery, or Practice: States may
want to give attention to better the coordination between
SCHIP and employer coverage, possibly using premium
assistance programs, even though a small share of enrollees
has the option of private coverage. However, given the
number of children eligible for SCHIP but covered by an
employer plan, greater coordination with employer coverage
could lead to greater public outlays on behalf of these
children.
Primary Funding Source: United States Department of
Health and Human Services Assistant Secretary for Planning
and Evaluation
●Does a Patchwork Approach to Health Insurance
Expansion Exacerbate Public Insurance Drop-Out?
Benjamin Sommers, Ph.D.
Presented By: Benjamin Sommers, Ph.D., Ph.D. Program in
Health Policy, Harvard University, 90 Brainerd Road,
Apartment 7, Allston, MA 02134; Tel: (617) 734-6580; Email:
sommers@fas.harvard.edu
Research Objective: To determine if a fragmented approach
to expanding insurance access leads to higher drop-out rates
among children in CHIP and Medicaid. More specifically,
does having multiple separately-run public programs for
different age groups and different income groups lead to
problems with public insurance retention?
Study Design: Using the 2001-2003 March Supplements from
the Current Population Survey, two-year linked files were
assembled for children initially enrolled in Medicaid or CHIP.
Multivariate logistic regression was used to explore
demographics and policies predictive of drop-out from the
program. State and year fixed effects, in addition to
instrumental variable regression, were used to control for
omitted parameters and the endogeneity of key variables.
Population Studied: The study used a nationally
representative sample of 4957 children (age 0 -18) enrolled in
Medicaid or CHIP during the years 2001-2003.
Principal Findings: Roughly one million children a year
switched back and forth between the two programs. One in 8
children in Medicaid and one in 6 CHIP enrollees left public
insurance and became uninsured each year, despite ongoing
eligibility. Insurance drop-out was much lower among
children whose parents or siblings were also covered by public
insurance. Drop-out was lower among children living in states
with a single combined public insurance program, rather than
separate CHIP and Medicaid programs. Lastly, drop-out was
lower in states with more generous enrollment options for
adults.
Conclusions: Both CHIP and Medicaid experience high rates
of drop-out among needy and still-eligible children. A
patchwork approach to expanding health insurance appears to
be counterproductive in terms of public insurance retention.
Children are at a higher risk for drop-out when their parents or
siblings are not enrolled in the same program that they are,
and running multiple public programs within the same state
exacerbates drop-out.
Implications for Policy, Delivery, or Practice: Current
policies in the realm of health insurance expansion could be
markedly improved through two steps towards greater
coordination: We should be targeting families rather than
individuals for coverage, and we should be bringing disparate
programs together under coordinated administration. In
addition, there is a clear need for increased efforts to improve
Medicaid/CHIP retention through streamlining the eligibility
redetermination process and increasing outreach by providers
and government.
Primary Funding Source: National Science Foundation
Graduate Research Fellowship
Call for Papers
Medicaid Cost, Growth & Program Design Issues
Chair: Genevieve Kenny, The Urban Institute
Sunday, June 26 • 5:30 pm – 7:00 pm
●The Effect of Public Subsidies for Community-Based
Services on Eldercare Decisions
Joanna Campbell, Ph.D.
Presented By: Joanna Campbell, Ph.D., Asstistant Professor,
Preventive Medicine and Community Health, University of
Texas Medical Branch, 301 University Boulevard, Galveston,
TX 77550; Tel: (409)772-2551; Email: jhcampbe@utmb.edu
Research Objective: Issues concerning the Care of the Elderly
have moved to the forefront of the public’s consciousness as
the baby boom generation ages. In this paper, I examine the
role of publicly funded, community-based health services;
specifically services provided under the Medicaid 1915(c)
Waiver Program, in elder care decisions. Using a multinomial
logit framework, I analyze the effects of specified services on
the likelihood of institutionalization, and the likelihood of
receiving Medicaid assistance within the community. In
addition, I look for evidence of a “Woodwork Effect”
associated with these services.
Study Design: For each respondent, I calculate their eligibility
for 4 types of Medicaid funded services: Residential Care /
Adult Foster Care, Skilled Nursing Services, Adult Day Care,
and Personal Assistance/Home Health Aides/ Respite Care.
After demonstrating the exogeneity of the policy instruments, I
correlate respondent’s eligibility for different types of services
with their institutionalization status and receipt of Medicaid
assistance using multinomial logits. I also look at subpopulations of the elderly including respondents with mental
health problems and chronic medical ailments.
Population Studied: I use the 1998 wave of the merged
Health and Retirement and Asset and Health Dynamics of the
Oldest Old surveys. I restrict the sample to respondents aged
65 years and older who report at least one limitation in either
Activities of Daily Living, or Instrumental Activities of Daily
Living. I merge the survey data with state-level data on the
Medicaid 1915(c) programs, detailing the differences in
services offered and eligibility requirements.
Principal Findings: I find that the effects of subsidized
community services are masked in the general elder
population. By expanding the nature of the services under
consideration, and focusing on sub-groups of respondents
with varying levels of infirmities, I am able to identify
responses to program incentives. In particular, I find evidence
that subsidies for Residential Care significantly decrease the
conditional probability of nursing home entrance for severely
impaired respondents. I also find weaker evidence that
subsidies for Adult Day Care may also divert relatively less frail
individuals from nursing home placements. I find no
evidence that subsidies for personal care attendants have any
effect on institutionalization rates. Finally, I note that personal
and\or respite care services are the services most prone to the
Woodwork Effect.
Conclusions: There is empirical evidence of the potential for
publicly funded community-based elder care programs to
reduce the incidence of nursing home placements, while
managing the scope of any “Woodwork Effect”. Careful
targeting of both potential clients and the services offered are
required.
Implications for Policy, Delivery, or Practice: There is
empirical evidence of the potential for publicly funded
community-based elder care programs to reduce the incidence
of nursing home placements, while managing the scope of
any “Woodwork Effect”. Careful targeting of both potential
clients and the services offered are required.
Primary Funding Source: The John M. Olin Foundation
Dissertation Fellowship - Stanford Institute for Economic
Policy Research
●Medicaid Cost Containment and Access to Prescription
Drugs
Peter Cunningham, Ph.D.
Presented By: Peter Cunningham, Ph.D., Senior Health
Researcher, Center for Studying Health System Change, 600
Maryland Avenue, SW, Suite 550, Washington, DC 20024; Tel:
(202)484-4242; Fax: (202)484-9258; Email:
pcunningham@hschange.org
Research Objective: While states have been intensifying
efforts to control rising prescription drug costs in their
Medicaid programs, the effects of these cost containment
efforts on enrollee access is largely unknown. This study
examines the effects of Medicaid cost containment policies on
enrollees’ perceptions of their ability to get prescription drugs.
Study Design: Data are based on the 2000-01 and 2003
Community Tracking Study household surveys, linked to statelevel data on Medicaid prescription drug policies. The CTS
survey data are representative of the nation, as well as 60
randomly selected communities spread across 35 states. The
dependent variable is the probability of not getting
prescription drugs in the past 12 months due to cost (asked in
the survey). Five Medicaid cost containment policies are
examined: prior authorization, copayments, dispensing limits,
generic drug requirements, and step therapy. Pooling
subsamples of Medicaid enrollees from the 2000-01 and 2003
surveys, multivariate analysis is used to examine whether
living in states with the various cost containment policies is
associated with lower access to prescription drugs. Control
variables include a variety of socioeconomic, demographic,
and health characteristics of Medicaid beneficiaries, and
dummy variables for states and survey year.
Population Studied: Adult Medicaid enrollees (age 18 and
over).
Principal Findings: Almost one-fourth of adult Medicaid
enrollees reported problems getting prescription drugs in
2003, a rate that is similar to uninsured persons and three
times higher than privately insured persons. The results of
multivariate regression analysis show that Medicaid policies
that require prior authorization and generic substitutes
increase problems with access to prescription drugs, while
policies for copayments, dispensing limits, and step-therapy
showed no significant effects. Also, Medicaid enrollees in
states that have implemented at least 4 of the 5 policies have
greater problems getting prescription drugs than enrollees in
states that have implemented fewer policies. The large
increase in the percentage of Medicaid enrollees in states with
cost containment policies between 2000-01 and 2003 led to a
net increase in prescription drug access problems of about 5
percentage points. However, other changes during this
period largely offset this increase in prescription drug access
problems.
Conclusions: From the perspective of Medicaid enrollees,
state efforts to contain the rising costs of prescription drugs
are having negative effects on their access to prescription
drugs. While it’s possible that these results reflect greater
difficulty in getting medications that are ineffective or
nonessential, other research implies that these policies also
affect essential drug use.
Implications for Policy, Delivery, or Practice: Continued
increases in Medicaid program costs—including prescription
drugs—mean that cost containment policies will likely
continue and even increase in intensity in the coming years.
While a complete rollback of these policies is probably
unrealistic, policymakers should monitor the effects of these
policies on enrollee access in order to identify unnecessary
obstacles that prevent enrollees from getting needed drugs.
Greater awareness among both providers and enrollees as to
how to navigate the increasingly complex set of rules for
obtaining prescription drugs may also help to reduce access
problems.
Primary Funding Source: RWJF
●What Explains the Recent Dramatic Growth in Adult
Medicaid Enrollment?
Amy Davidoff, Ph.D., Alshadye Yemane, BA, Emerald Adams,
BA
Presented By: Amy Davidoff, Ph.D., Assistant Professor,
Public Policy, University of Maryland Baltimore County, 1000
Hilltop Circle, Baltimore, MD 21250; Tel: (410)455-6561; Fax:
(410)455-1172; Email: davidoff@umbc.edu
Research Objective: Between 1999 and 2002 Medicaid
enrollment among non-elderly adults grew by 2.3 million, an
increase of 25%. The economic downturn began in 2000,
reducing employment and incomes, and increasing the
likelihood that adults met Medicaid eligibility criteria.
Concurrently, several states expanded eligibility for adults in
an effort to address the problem of the uninsured, and most
states were actively engaged in outreach and enrollment
simplification for children, which may have had positive
spillover effects on adult enrollment. This analysis explores the
relative contribution of these factors to the growth in
enrollment, enhancing our understanding of the role played by
the Medicaid program in cushioning the losses of private
insurance.
Study Design: We specify a mathematical model where
Medicaid enrollment is a function of population size,
characteristics, Medicaid eligibility policy, and Medicaid
enrollment behavior among eligible adults or takeup. Using
data from the National Survey of America’s Families from
1999 and 2002, we decompose changes in enrollment by
examining the effects associated with stepwise changes in
these four factors. We use two analytic tools, detailed
algorithms that apply state and year specific Medicaid
eligibility policies to identify likely eligible adults; and
multivariate models of Medicaid takeup. The decomposition
employs a series of counterfactual calculations, where we
simulate the effects of selected changes on enrollment.
Population Studied: Nonelderly adults, U.S.
Principal Findings: Of the growth in enrollment during this
period, 4.2% would have occurred due to population growth
alone, with an additional 43.1% associated with changes in
population characteristics, 49.7% due to changes in eligibility
policy and 3.0% due to changing takeup. For parents,
population growth was flat, but changes in characteristics
such as income accounted for 42% of enrollment growth.
Expanded eligibility rules would have increased enrollment by
an additional 83.5%, while simulated declines in takeup would
have decreased enrollment by 24%. For adults without
dependent children, changes associated with population
growth, characteristics, eligibility policy and takeup behavior
accounted for 11%, 44%, 10% and 34% respectively.
Conclusions: Population growth and changes in
characteristics of adults between 1999 and 2002 would have
resulted in substantial growth in Medicaid enrollment, even in
the absence of eligibility expansions. More generous eligibility
thresholds resulted in even more parents becoming eligible
for and enrolled in Medicaid. For adults without dependent
children, the eligibility expansions played a much smaller role,
as change in population characteristics and takeup behavior
were the dominant factor contributing to enrollment growth.
Implications for Policy, Delivery, or Practice: The Medicaid
program played an important part in covering low income
adults during a period of economic downturn. As a result,
many states face pressure to reduce Medicaid spending, as
they grapple with reduced revenues associated with the poor
economy. Some states have responded by rolling back
previous eligibility expansions, capping enrollment or reducing
benefits. This analysis demonstrates that some strategies,
such as eligibility rollbacks, may be less effective in controlling
costs associated with increased enrollment. However, all of
these strategies to reduce Medicaid enrollment will likely leave
many low income adults without a critical insurance safety
net.
Primary Funding Source: Kaiser Family Foundation
●Lapses in Medicaid Coverage: Impact on Cost and
Utilization Among Diabetics Enrolled in Medicaid
Allyson Hall, Ph.D., Jeffrey Harman, Ph.D., Jianyi Zhang, Ph.D.
Presented By: Allyson Hall, Ph.D., Research Director, Florida
Center for Medicaid and the Uninsured, University of Florida,
Health Science Center, PO Box 10185, Gainesville, FL 32607;
Tel: (352)273-5129; Fax: (352) 273-5061; Email:
ahall@phhp.ufl.edu
Research Objective: To assess whether a lapse in Medicaid
coverage is associated with differences in expenditures,
inpatient episodes, and emergency room visits among
beneficiaries with diabetes.
Study Design: Florida Medicaid claims and eligibility data for
the period January 1999 to December 2002 were used in the
analysis. Using multivariate regression models, we compared
each enrollees' inpatient utilization, emergency room use, and
total cost for the three months prior to an interruption in
Medicaid to the three months immediately following the
coverage lapse.
Population Studied: Florida Medicaid beneficiaries with
diabetes who experienced at least one one-month gap in their
Medicaid coverage between January 1999 and December
2002.
Principal Findings: The presence of a coverage lapse was
found to be associated with a 264% increase in the
hospitalization rate (p<. 001) and a 155 fold increase in the
rate of emergency room visits (p<. 001) in the period
immediately following a coverage lapse. Overall total
expenditures were estimated to increase by $259 per member
per month for the three-month period following a Medicaid
coverage lapse compared to the three-month period before a
lapse. The total number of hospital admissions, length of stay
and total number of emergency room visits were also found to
be higher in the three months after a coverage lapse.
Conclusions: The results from this study suggest that
interruptions in Medicaid coverage is associated with greater
utilization of acute care services and may lead to greater
Medicaid expenditures among beneficiaries with diabetes, at
least for the time period immediately following the lapse.
Implications for Policy, Delivery, or Practice: Findings from
this study provide direction for Medicaid and general health
system reform. Assuring seamless health insurance coverage
is an obvious recommendation. Under Medicaid, this would
entail a reexamination of eligibility and enrollment policies,
particularly for those suffering from a chronic disease.
Primary Funding Source: Florida Agency for Health Care
Administration
●Effects of Medicaid Benefit Changes on Expenditures for
Persons with Chronic Conditions
Neal Wallace, Ph.D., K. John McConnell, Ph.D., Charles Gallia
Presented By: Neal Wallace, Ph.D., Assistant Professor,
Public Administration, Portland State University, P.O. Box 751,
Portland, OR 97207; Tel: (503)725-8248; Fax: (503)725-8250;
Email: nwallace@pdx.edu
Research Objective: In February 2003, the Oregon Health
Plan (OHP) imposed cost sharing and discrete benefit
reductions for its adult “expansion” enrollees. The objective of
this study was to determine the extent to which these program
changes influenced treatment expenditures (net of copayments) for benefits consistently covered over time for
persons with identified chronic conditions versus those
without.
Study Design: The study employed a quasi-experimental
design with non-equivalent control groups. We compare
average expenditures per member per month (PMPM) before
and after the policy change for the expansion group in
comparison to those for adult categorical enrollees who do
not experience this policy change. Using administrative data
from 2002 and 2003, we identified individuals with chronic
conditions. Groupings include chronic coronary disease,
diabetes, asthma, chronic obstructive pulmonary disease,
serious and persistent mental illness, and drug/alcohol abuse.
Persons with multiple chronic conditions were grouped
separately. We estimated expenditure change using a multilevel difference-in-difference specification. The unit of
observation was PMPM expenditures by chronic condition (or
its absence) aggregated to the level of 130 medical market
areas. Expenditures were calculated as the value of services at
the prevailing Medicaid maximum allowable rates (i.e. without
regard to co-payment levels). Expenditures were measured for
inpatient care, hospital outpatient care, physician services,
emergency department (ED) services, and in total in each of
three nine-month periods, two prior to the policy change and
one after. Fixed effects estimation was used in all models. We
adjusted for income, age, language, gender, ethnicity, enrolled
as a couple/single, managed care enrollment, and if the adult
enrollee had children.
Population Studied: Approximately 100,000 Oregon Health
Plan beneficiaries enrolled in 2002. This was reduced by
almost 50% after the policy change. These beneficiaries were
part of the ‘expanded’ Oregon Health Plan population and
comprise poor individuals (<100% FPL) who would not have
been `categorically eligible’ for traditional Medicaid.
Principal Findings: In the nine months following the changes
in benefit structure, we found that total PMPM expenditures
for expansion enrollees decreased relative to controls, but at
the same rate for chronic conditions vs. others. While
inpatient PMPM expenditures were decreasing for non-chronic
expansion enrollees, they increased significantly for all chronic
conditions among the expansion enrollees, except coronary, in
relative and absolute terms. ED PMPM expenditures
decreased among the expansion enrollees, while increasing in
relative terms for persons with diabetes and severe and
persistent mental illness. Hospital outpatient PMPM
expenditures increased for the expansion group as a whole,
while physician PMPM expenditures decreased.
Conclusions: The introduction of co-payments and discrete
benefit elimination did not lead to different rates of change in
PMPM expenditures for persons with chronic conditions
versus others, but did shift treatment towards inpatient care.
Increases in ED expenditures for some chronic conditions also
occurred.
Implications for Policy, Delivery, or Practice: Co-payments
and/or specific benefit reductions are typical methods states
can consider in their attempt to decrease the cost of public
programs. These policies may reduce costs overall but may
have unintended distributional effects related to enrollee
health status.
Primary Funding Source: RWJF
Related Posters
Poster Session B
Monday, June 27 • 6:15 pm – 7:30 pm
●Medicaid HMO Penetration and Market-Level Physician
Participation
E. Kathleen Adams, Ph.D., Bradley Herring, Ph.D.
Presented By: E. Kathleen Adams, Ph.D., Professor, Health
Policy and Management, Rollins School of Public Health, 1518
Clifton Road NE, Atlanta, GA 30322; Tel: (404) 727-9370; Fax:
(404) 727-9198; Email: eadam01@sph.emory.edu
Research Objective: To use changes in Medicaid HMO
penetration across markets to test their effect on the level and
extent of participation in Medicaid among primary and
specialty care physicians. Markets have most recently
witnessed declines in participation by commercial plans (with
both private and Medicaid insured) and increases in Medicaid
dominated plans (with 75% or more Medicaid insured).
Study Design: We use the Community Tracking Study’s
Physician Survey administered in 60 nationally-representative
markets for three periods (1996, 1998 and 2000) to examine
the effects of variation in Medicaid HMO penetration over
time on the likelihood that physicians are willing to see
Medicaid patients, using logit models that account for
physician firm characteristics, Medicaid payment levels, and
market-level fixed effects. We test three measures of
participation: 1) accepting any Medicaid patients; 2) accepting
all new Medicaid patients; and 3) if accepting any Medicaid
patients, accepting all new patients. We test for differential
effects of penetration by commercial versus Medicaiddominated plans and adjust Medicaid/Medicare fees by
geographic practice costs.
Population Studied: A sample of 29,991 physicians across
the 51 urban CTS markets was studied. We split this sample
into primary versus specialty care, office-based versus nonoffice- based and higher versus lower-quality physicians. We
define higher quality physicians as those that are board
certified and graduates of neither a foreign nor osteopathic
medical school.
Principal Findings: The primary effect of commercial
Medicaid HMO penetration is not on the overall number of
participating office-based physicians but rather, on whether
some of these physicians have ‘open’ Medicaid practices,
accepting all new Medicaid patients. The number of officebased physicians with ‘open’ practices increases among lowerquality specialists as the percentage commercial Medicaid
HMOs in a market increases. Increases in Medicaiddominated plans were associated only with increases in the
total number of non office-based physicians. In contrast,
increases in cost-adjusted Medicaid fees, relative to Medicare
levels, were associated with increases in higher quality officebased primary care physicians with ‘open’ practices. Firm
characteristics that consistently lower participation among all
physicians include being older, board certified, a US graduate,
primary care and a solo or group- owned practice. Market
characteristics, such as racial mix and extreme poverty also
influence overall participation rates.
Conclusions: The effects of Medicaid HMO penetration vary
by the type of plan and physician. The results indicate that in
markets where commercial Medicaid penetration increased
1996-2000 access for Medicaid enrollees to lower-quality
office-based specialists increased. Higher Medicaid payment
levels, on the other hand, were associated with increased
access for enrollees to primary office-based physicians as
HMOs of either type entered the Medicaid market.
Implications for Policy, Delivery, or Practice: States may not
have seen the anticipated increase in access to office-based
primary care physicians with increased commercial HMO
plans. Rather, these plans may have filled unmet needs for
specialty care by increasing access to specialists, albeit of
lower-quality. States will need to consider whether these
changes are consistent with improved efficiency and lower
costs as well as the implications of exits by commercial plans
in recent periods.
Primary Funding Source: RWJF
●Forecasting Eligibility Caseload in Medicaid Population
Groups
Shaun Alfreds, MBA, Aniko Laszlo, Michael Tutty, Steven
Banks
Presented By: Shaun Alfreds, MBA, State Health Policy
Analysis Unit, Center for Health Policy and Research, 222
Maple Avenue Higgins Building, Shrewsbury, MA 01545; Tel:
(508) 856-8634; Email: shaun.alfreds@umassmed.edu
Research Objective: Budgetary shortages in state
governments have forced many state Medicaid programs to
reduce costs through eligibility cuts and reductions in services
provided. Due to these shortfalls, accurately projecting future
costs has become even more important, and caseload growth
plays a pivotal role in determining costs. The purpose of this
analysis was to recommend and assess mathematical tools
for forecasting caseload that increase budgetary forecast
accuracy and can be easily implemented.
Study Design: A retrospective quantitative analysis of the
Massachusetts Medicaid (MassHealth) eligibility caseload
forecasting methodology was conducted. The impact of
system and policy effects on data reliability for the most recent
time periods were assessed through an evaluation of historical
data. The actual eligibility caseload growth was then compared
to the projected growth developed by two different
methodologies for two separate time periods. Differences in
estimated caseload growth and Medicaid expenditures were
then compared for each method.
Population Studied: The MassHealth population
(n=~950,000) subdivided into age, disability, and coverage
type / aid categories for two separate time periods; quarter
three of FY03 and quarter one of FY04.
Principal Findings: Variations in Medicaid enrollment and
eligibility determination policies require MassHealth to
forecast each population group separately. The most recent
eligibility data however, was not accurate due to system and
policy effects. Because historical behavior is often the best
predictor of future behavior, it was necessary to increase the
accuracy of the most recent historical eligibility data. From
these findings four principal methodological
recommendations were made: 1) Utilize multipliers
(“completion factors”) based on historical data to increase the
accuracy of data for the most recent time periods, 2)
Determine the number of historical months to forecast for
each population group based on minute changes in the
compounded monthly growth behavior of these groups over
time, 3) Forecast all population groups for the time period
chosen in step 2, utilizing least-squares trending, 4) Assign
population groups into age and disability clusters to check
trends for logical consistency. A new method incorporating
these recommendations was compared, on two separate data
sets, to a methodology whereby the most recent three months
of data was excluded and all population groups were trended
for the same time periods. The recommended methodology
increased forecast accuracy from 92.5 to 96.6 and from 93.7 to
98.1 percent respectively when compared to actual eligibility
for those time periods, with each step providing incremental
improvement. The increased accuracy in caseload
represented a reduction in projected spending by greater than
$225 million for each data set over the comparative
methodology.
Conclusions: Simple mathematical tools can be utilized to
forecast Medicaid eligibility and to increase the accuracy of the
budgetary process. Utilizing completion factors and assessing
the most relevant time periods for each budget group
increases the data reliability and allows for simple linear
trends to produce accurate forecasts.
●Commercial Health Plan Exits and Involuntary Plan
Switching Among Children in Medicaid
Sema K. Aydede, Ph.D., Andrew Dick, Ph.D., Bruce Vogel,
PhD, David Sappington, PhD, Elizabeth A. Shenkman, PhD, ,
Presented By: Sema K. Aydede, Ph.D., Associate Research
Scientist, Institute for Child Health Policy, University of
Florida, PO Box 100147, Gainesville, FL 32610; Tel: (352)2657220 x86335; Fax: (352)265-7221; Email: ska@ichp.ufl.edu
Research Objective: Commercial health plan exits have
increased the rate of plan turnover in Medicaid markets.
When plans exit the market, their enrollees must transfer to
remaining health plans. We employed data from a large
state’s Medicaid Managed Care program to examine the
health status of children involuntarily transferring from health
plans exiting the Medicaid market and the short term impact
of these transfers on the children’s health care expenditures.
Study Design: A pre-post design with a comparison group
was used to examine health status and health care
expenditures for children involuntarily switching health plans
relative to children already enrolled for 12 months or longer in
the plan accepting the transfers. Overall health care
expenditures as well as inpatient, emergency department, and
outpatient expenditures were examined. Enrollment and
claims data on 127,185 children (9,924 in the experiment
group and 117,261 in the comparison group) from a state’s
Medicaid program were employed. Children were grouped
into nine Clinical Risk Group categories (such as healthy,
malignancies, and catastrophic conditions) to characterize
their health status.
Population Studied: Children involuntarily transferring to
existing health plans due to the exit of their old plan and the
established enrollees of existing plans.
Principal Findings: In the experiment (comparison) group,
83% (81%) were healthy, 10% (12%) had chronic conditions,
and 7 % (7%) had significant acute conditions. Multivariate
models based on a difference-in-differences approach revealed
that children who switched health plans involuntarily incurred
higher total expenditures ($48.39 per member per month,
PMPM) immediately following their transfer than established
enrollees ($36.78 PMPM). Among children who switched
health plans involuntarily, relative changes in post-transfer
expenditures were larger for children with chronic conditions
($44.26 PMPM) than for healthy children ($5.36 PMPM).
Expenditures related to emergency department and outpatient
visits contributed to the higher post-transfer expenditures for
children involuntarily switching plans. Health care
expenditures incurred in the inpatient settings, however, were
not different for the two groups of children.
Conclusions: This study shows that enrollees who
involuntarily switched health plans did not disproportionately
have chronic conditions relative to the group of established
enrollees in the health plans accepting the transferring
children. However, expenditures on children who switched
plans involuntarily were relatively high. The higher emergency
department and outpatient expenditures may arise because
the children change their usual source of care when they
change health plan. The emergency department may provide
the only immediate access to the health care system as
families try to identify a new primary care provider (PCP) and
learn new required procedures for accessing health care
services. After the child and family identify a new PCP, the
PCP may order additional health care services to assess the
child and/or to address any unmet needs, leading to higher
outpatient expenditures.
Implications for Policy, Delivery, or Practice: States
experiencing substantial exit of health plan might reduce
health care costs and increase health care quality by
implementing policies that help families to preserve familiar
sources of care or to identify new PCPs promptly.
Primary Funding Source: US Department of Health and
Human Services, Maternal and Child Health Bureau
●Why Do Eligible Children Fail to Take-up Medicaid or
SCHIP?
Jessica Banthin, Ph.D., Thomas M. Selden, Ph.D., Julie
Hudson, Ph.D.
Presented By: Jessica Banthin, Ph.D., Director of Division of
Modeling and Simulation, Center for Financing, Access, and
Cost Trends, Agency for Healthcare Research and Quality, 540
Gaither Road, Rockville, MD 20850; Tel: (301)427-1678; Fax:
(301)427-1277; Email: jbanthin@ahrq.gov
Research Objective: Research Objective:
Medicaid poverty expansions in the late 1980s and the
creation of SCHIP in 1997 greatly expanded the number of
children eligible for free or highly subsidized public coverage.
As of 2002 nearly half of all children in the U.S. were income
eligible for Medicaid or SCHIP. Take-up rates among eligible
children increased between 1996 and 2002 and by 2002 about
79 percent of Medicaid-eligible children, not covered by private
insurance, were enrolled in the program. About 60 percent of
SCHIP-eligible children were enrolled. Yet some children
eligible for these programs remained uninsured. Recent
research estimates that 6.2 million uninsured children were
eligible for Medicaid or SCHIP in 2002. In this paper we
identify which eligible children are most likely to enroll and
which children are most likely to remain uninsured. We test
several hypotheses on which children would be less likely to
enroll using logistic regression and controlling for a variety of
factors. Specifically, we examine the hypothesis that some
neighborhoods may be more efficient than other
neighborhoods in sharing information on Medicaid and
SCHIP programs.
Study Design: Our analysis includes detailed information on
child and family characteristics as well as neighborhood
factors. We test whether the addition of neighborhood level
data on poverty, race, language, immigration status, and
education have a significant effect in our take-up models. We
use nationally representative data from the Medical
Expenditure Panel Survey which collects information on health
care utilization, expenditures, and health insurance status, in
addition to detailed measures of health status, family
structure, income, education, employment, and more. We
also link to geo-coded data at the Census block group level
and add information on neighborhood characteristics such as
race, prevalence of English, foreign born, education, and
poverty. We pool together several years of data in order to
increase our samples of subgroups of interest.
Population Studied: Our study includes a nationally
representative sample of children age 0 through 18 who have
been simulated to be eligible for Medicaid or SCHIP. The
simulation model takes account of state specific eligibility
rules, family structure, income, citizenship and other relevant
rules.
Principal Findings: In preliminary work that did not include
neighborhood characteristics we find that black and Hispanic
children are more likely to enroll than are white children.
Children with health problems or limitations were also more
likely to enroll. Enrollment was also more likely when there
was another child in the family or when the entire family was
eligible for coverage. Finally, children with single parents or
unemployed parents were more likely to enroll.
Implications for Policy, Delivery, or Practice: This analysis
will be useful to Medicaid and SCHIP programs in refining
their outreach efforts. The addition of neighborhood factors
to the analysis will potentially allow more precise targeting of
resources by geographic areas.
Primary Funding Source: AHRQ
●Simplifying Medicaid/SCHIP Enrollment Forms
Mercedes Blano, Christina Zarcadoolas, Ph.D., Penny Lane,
MA, Holly Smith, BA, John F. Boyer, Ph.D.
Presented By: Mercedes Blano, Cultural Literacy Expert,
Center for Health Literacy, Maximus Inc., 719 Hope Street,
Bristol, RI 02809; Tel: (401) 254-8949; Email:
MercedesBlanco@maximus.com
Research Objective: We will present results of a one year
CMS funded research project during which the Center for
Health Literacy analyzed Medicaid and SCHIP applications
and notices from almost 50 states, and developed simplified
template for states to use. The Health Care Financing
Administration (HCFA – now the Center for Medicare and
Medicaid Services - CMS) awarded the MAXIMUS Center for
Health Literacy two related contracts to improve State
government communications with Medicaid and SCHIP
applicants and beneficiaries. The Medicaid and SCHIP
programs are Federal/State partnerships that together serve
over 38 million individuals. Internal program reviews and
independent studies by DHHS have determined that lengthy
and complicated applications and notices are barriers to the
enrollment and reenrollment of eligible individuals. Medicaid
and SCHIP applicants and beneficiaries are racially and
ethnically diverse, and many have low literacy skills and speak
languages other than English.
Study Design: The Center’s researchers analyzed the
linguistic and design complexity of the applications and
notices, identified the high barrier elements in them that
made them more difficult to read and/or use, and then
developed simplified models. The Center field tested the
models extensively throughout the country with almost 300
English and Spanish consumers, and also developed best
practices guidelines for writing and designing easy-to-read
applications and notices. Using a text element grid designed
by the project, we coded applications and notices on an
extensive list of vocabulary, syntax, composition and design
factors as well as the quality of the translation into Spanish.
We then interviewed Medicaid and SCHIP consumers in four
states to confirm the elements of complexity. Using a threeround process of revision and field testing we derived
templates for more readable applications and notices and
created a Best Practice Guidelines document available in CD
and pdf version for distribution to all states and interested
individuals.
Population Studied: Low literate, low income clients enrolled
in federally funded Medicaid and SCHIP programs.
Principal Findings: Findings revealed that while a few states
have written and designed these documents with fundamental
literacy principles in mind, the vast majority have not—and
thus documents are written at 10th-12th grade reading level
and much higher. For example, clients are sometimes faced
with (and cannot read and understand) complex sentence
structure with multiple, embedded clauses such as the
following: “20% of earned income (including self-employment
income) is not counted when comparing family income to the
limits. The 20% deduction does not apply to unearned income
such as child support, social security disability, or
unemployment insurance benefits.” The Center rewrote the
documents to simplify vocabulary and sentence structure and
reformatted using clear and consistent designs. These efforts
greatly improved the readability of materials and instilled
confidence in clients.
Conclusions: As a result of this research, the Center rewrote
the documents to simplify vocabulary and sentence structure
and reformatted using clear and consistent designs. These
efforts greatly improved the readability of materials and
instilled confidence in clients.
Implications for Policy, Delivery, or Practice: This research
resulted in the report, The Notices & Applications Handbook Best Practice Guidelines. Other recommendations include (1)
support training for call center staff in understanding and
communicating with low literate and culturally diverse
consumers; and, (2) support training for state staff in
understanding issues of translation and cultural
appropriateness, including how to find/hire high quality
translators and how to approach adaptations, and how to
assure the quality of completed translations.
Primary Funding Source: CMS
●Implications of Medicaid Cuts on Podiatric Foot Care for
Diabetics in Texas
Martha Conkling, MSPH, Graciela Castillo, MPH, Susan
Fenton, MBA, RHIA, Patricia Moore, MEd, Bita Kash, MBA,
Aelia Akhtar, MS
Presented By: Martha Conkling, MSPH, Graduate Assistant,
Health Policy and Management, School of Rural Public
Health, 3000 Briarcrest, Suite 300, Bryan, TX 77802; Tel:
(979)822-4380; Email: mctromp@srph.tamhsc.edu
Research Objective: To explain the repercussions of the 2003
Medicaid cuts for diabetics needing podiatric foot care. There
are 1.06 million people with diabetes in Texas which is the
State’s fifth leading cause of death. Healthcare costs for
diabetics in Texas are over 5 billion dollars each year. Lower
leg amputations are expected for 8000 diabetic Texans this
year (2004) at a cost of 210 million dollars.
Study Design: In the interest of doing practical work in an
academic setting, a PhD health policy class examined this
issue. Research was undertaken to describe the problem
facing Texans by examining legislative actions, costs of and
populations affected by diabetes, clinical problems associated
with diabetes, and a policy strategy to appropriately deal with
the findings. Direct costs for people with diabetes in 2003
were determined using the medical services inflation rates
from the Consumer Price Index. The Consumer Price Index
inflation calculator for all services was used to determine the
2003 indirect costs for this population.
Population Studied: Diabetics in Texas who have lost their
Medicaid coverage as a result of HB2292 in the Texas State
Legislature passed in 2003 and signed into law by the
Governor on June 10, 2003.
Principal Findings: The prevalence of diabetes among adults
in Texas aged 65-74 is 13 times higher than that for people
aged 45. Diabetics have a 15 percent chance of developing a
foot ulcer. Of these people, 25 precent will have an
amputation. Up to 85 percent of these amputations can be
prevented with appropriate medical care. The chance of
another amputation within 5 years is as high as 50 percent.
The risk of dying within 5 years of an amputation ranges from
39-68 percent. Appropriate foot care for diabetics could save
Texas 210 million dollars in health care costs. The indirect
costs of diabetes due to disability, work loss and premature
mortality are estimated to exceed 2 billion dollars annually in
Texas.
Conclusions: The elderly in Texas and Texans of Hispanic and
African-American origin are disadvantaged by the elimination
of podiatric foot care. The Texas Legislature has increased
health care costs to the State with the 2003 Medicaid cuts.
With diabetes and resultant amputations on the rise
nationwide, Texas must act now to avert staggering and
unnecessary costs to its health care system. Without these
services, mobility and quality of life for diabetics are
jeopardized.
Implications for Policy, Delivery, or Practice: After being
invited to share our cost data with a legislator on the State
Public Health Committee, we were asked to present our
findings at a State Public Health Committee hearing last
February 2004. We have been given assurances that coverage
will be restored, during the 2005 Texas legislative session, as a
result of the analysis and empirical data we were able to
assemble and present.
Primary Funding Source: No Funding Source
●The Effect of Medicaid Managed Care on Racial
Disparities in Health Care Access
Benjamin Cook, BA, MPH
Presented By: Benjamin Cook, BA, MPH, Ph.D. Candidate in
Health Policy, Department of Health Policy, Harvard
University, 180 Longwood Avenue, 2nd floor, Boston, MA
02115; Email: bcook@fas.harvard.edu
Research Objective: To evaluate the impact of Medicaid
Managed Care on racial disparities in access to care using the
IOM definition of racial disparity.
Study Design: I estimate multivariate regression models to
compare racial disparities in doctor visits, ER use and having a
usual source of care between enrollees in Medicaid Managed
Care and Medicaid Fee for Service plans. To overcome
potential selection bias, I additionally assess the impact of an
increase in MMC penetration at the MSA level on Medicaid
enrollees’ access measures. I implement the IOM definition
of racial disparity by transforming the distribution of health
status for minority populations to approximate the white
distribution, and compare results to other commonly used
methods of disparities measurement.
Population Studied: 1997-2000 Hispanic, Black, and nonHispanic White Medicaid enrollees living in large Metropolitan
Statistical Areas, as identified by the 1997-2000 National
Health Interview Surveys.
Principal Findings: Using the IOM definition of disparity, I
find that Medicaid Managed Care has led to an amelioration
of disparities in having a doctor visit in the last year and
having a usual source of care, and an exacerbation of disparity
in having any ER Use in the last year.
Conclusions: Medicaid Managed care programs’
amelioration of racial disparities in seeing a doctor and having
a usual source of care provides evidence that recent shifts in
Medicaid policy towards managed care plans have been
beneficial for minority enrollees. However, an exacerbation of
disparity in ER use raises questions about the appropriateness
and efficiency of care that is being received.
Implications for Policy, Delivery, or Practice: State Medicaid
agencies that increase managed care penetration in their
Medicaid programs should take steps to prevent inappropriate
ER use among Black and Hispanic enrollees. Using the IOM
definition of disparity to guide multivariate racial disparities
analyses aligns analytical methods with a definition accepted
by the health policy discipline, and will provide a consistent
measure for tracking disparities into the future.
Primary Funding Source: National Institute of Mental Health
●The Effect of Insurance Disruption on Immunization
Rates
Gerry Fairbrother, Ph.D., John Stevenson, MA
Presented By: Gerry Fairbrother, Ph.D., Senior Scientist,
Health and Science Policy, The New York Academy of
Medicine, 1216 Fifth Avenue, New York, NY 10029; Tel: (212)
822-7398; Fax: (212) 822-7369; Email:
gerry.fairbrother@cchmc.org
Research Objective: Prior studies have examined the effect of
length of insurance coverage on access and use, but the effect
on oucomes is less well researched. The purpose of this study
was to begin examining the relationship of duration of
coverage for low-income children to quality of care, using
immunization coverage rates as the measure of quality. The
purpose of this study is to relate up-to-date (UTD) coverage
for two-year-olds to length of enrollment in Medicaid.
Study Design: Data were collected from Medicaid databases
and immunization registries in Michigan and Oregon, for
children who turned two-years-old in 2001. Children were
grouped according to length of time in Medicaid: those
enrolled in Medicaid for less than 6 months, enrolled for 6
months and less than 9, enrolled for 9 months and less than
12, and enrolled for 12 months or more. The Medicaid
enrollment files were matched with files from the state
immunization registries. UTD coverage was calculated for
children overall and for children in each enrollment group.
Population Studied: Two-year-old children enrolled in
Medicaid.
Principal Findings: Children enrolled for shorter periods of
time were less likely to be UTD than children enrolled for 12
months or more in both states, with UTD rates comparable in
each enrollment grouping. Of the children who were enrolled
less than 6 months months, 44% were UTD in Michigan and
46% were UTD in Oregon. Of the children enrolled for 12
months or more, 63% were UTD in Michigan and 62% were
UTD in Oregon. Of note, children were enrolled for longer
periods in Michigan than in Oregon. Michigan also had
higher overall UTD rates than Oregon (62% vs. 56%).
Michigan’s higher coverage rates were due to the fact that
more children were enrolled for 12 months or more.
Conclusions: There appears to be a strong relationship
between length of enrollment in Medicaid and UTD
immunization coverage rates.
Implications for Policy, Delivery, or Practice: The data
suggest that outcomes may improve with the longer a child is
insured. These data are suggestive that state enrollment
policies that affect tenure may also affect quality.
Primary Funding Source: CDC
●Does Disabling Condition Predict Participation in
Employment Among Enrollees in a Medicaid Buy-In
Program?
Alexis Henry, Sc.D., Fred Hooven, Ph.D. (cand), Lobat
Hashemi, MS, Steven Banks, Ph.D., Robin Clark, Ph.D., Jay
Himmelstein, M.D., MPH
Presented By: Alexis Henry, Sc.D., Research Assistant
Professor, Center for Health Policy and Research, University of
Massachusetts Medical School, 222 Maple Avenue,
Shrewsbury, MA 01545; Tel: (508) 856-8833; Fax: (508) 8564456; Email: alexis.henry@umassmed.edu
Research Objective: Adults with disabilities face many
employment barriers. One important policy-related barrier is
the fear that working will result in a loss of health insurance.
Medicaid buy-in programs address this barrier by allowing
people with disabilities with income too high to qualify for
standard Medicaid to purchase Medicaid through premiums
or other cost sharing. The goal of this study was to examine
the extent to which type of disabling condition predicts
participation in employment among enrollees in the
Massachusetts Medicaid buy-in program (known as
MassHealth CommonHealth).
Study Design: Data were collected using the MassHealth
Employment and Disability Survey (MHEDS), which gathered
information on disability, health and employment status, and
use of health care services from working age adults Medicaid
(MassHealth) enrollees with disabilities. A sample of 1952
adults with disabilities, enrolled in CommonHealth for at least
six months, was randomly selected from a population of
8,095. The survey was administered by mail and phone
during the summer and fall of 2003.
Population Studied: Respondents included 1166
CommonHealth enrollees: 49% male; 28% married; 92%
Caucasian; 4% Latino; and 93% English-speaking.
Respondents had a mean age of 45.5 year; 52% had a high
school education or less and 48% were currently employed.
Disabling conditions reported by respondents included: 57%
psychiatric disabilities; 51% physical disabilities; 35% longterm illnesses; 8% head injury; 8% developmental disabilities;
and 5% sensory disorders.
Principal Findings: Most working respondents worked part
time and reported low earnings; 78% of workers earned less
that $20,000 in the past year. Most unemployed respondents
worked in the past, and 38% reported intending to work in the
future. Those with physical disabilities and with psychiatric
disabilities were significantly less likely to be employed than
those with other condition, while those with developmental
disabilities were significantly more likely to be employed.
Workers with psychiatric and developmental disabilities
worked fewest hours and had lowest earnings; those with
psychiatric disabilities also had shorter job tenure than other
respondents. Unemployed respondents with developmental
disabilities were the least likely to have worked in the past; yet,
if they had worked, they were more likely to have recently
worked than those with other conditions. Unemployed
respondents with physical disabilities were the least likely to
have recently worked and to intend to work in the future.
Conclusions: Participation in employment varied among
CommonHealth enrollees by disabling conditions. Few
respondents had earnings at levels consistent with economic
self-sufficiency. Those with psychiatric and developmental
disabilities appear the least likely to achieve economic selfsufficiency (i.e. earnings over $20,000). Enrollees with
higher earnings cannot become "medically self-sufficient"
because the health services they need are not often covered by
insurance (e.g. employer-sponsored insurance) other than
Medicaid.
Implications for Policy, Delivery, or Practice: People with
differing types of disabling conditions likely need specialized
services to support their employment efforts; access to
employment services should be ensured for anyone with a
disability who desires work. Medicaid buy-in programs allow
people with disabilities to retain health insurance and increase
earnings. However, it seems unlikely that many buy-in
program participants will become both economically and
medically self-sufficient, allowing them to move off Medicaid.
Primary Funding Source: CMS
●Bending But Not Breaking: SCHIP Responds to Three
Years of Budget Pressure
Ian Hill, MPA, MSW, Brigette Courtot, BA, Jennifer Sullivan,
MHS
Presented By: Ian Hill, MPA, MSW, Senior Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street NW, Washington, DC 20037; Tel: (202) 261-5374; Fax:
(202) 223-1149; Email: ihill@ui.urban.org
Research Objective: To examine how a representative sample
of SCHIP programs responded to the ongoing economic
downturn during fiscal years 2002-2004, and identify the
extent of cuts and range of policy strategies used in response
to budget pressures.
Study Design: As one component of the Urban Institute’s
SCHIP Evaluation, conducted under the Assessing the New
Federalism project, researchers completed three rounds of indepth telephone interviews with SCHIP directors in 13 states
which account for nearly two-thirds of SCHIP enrollment
nationally (Alabama, California, Colorado, Florida,
Massachusetts, Michigan, Minnesota, Mississippi, New
Jersey, New York, Texas, Washington, and Wisconsin). During
the interviews—conducted in autumn 2002, 2003, and
2004—researchers discussed SCHIP policy changes in the
areas of eligibility, enrollment procedures, outreach, benefits,
cost sharing, provider reimbursement, and crowd-out. In
addition, we queried officials on the extent to which SCHIP,
relative to other state programs, was targeted for (or protected
from) cuts.
Population Studied: State SCHIP programs.
Principal Findings: During the first round of interviews
(2002), SCHIP seemed largely immune to cuts, despite
growing state budget pressures. Several states actually
enhanced their programs by simplifying enrollment
procedures or bolstering benefits packages. Six states did,
however, reduce outreach budgets and two increased costsharing requirements. Continuing budget pressures forced
many more states to cut SCHIP in 2003. Three states enacted
enrollment caps, effectively freezing growth in program roles.
Over half the states reduced or eliminated their outreach
budgets, six increased cost-sharing requirements, and four
imposed stricter enrollment procedures. Compared to other
state programs, however, SCHIP fared relatively well, and
eight states even took actions to further simplify enrollment
for families. In 2004, researchers found a blend of state
actions. Improving economic conditions, coupled with strong
political desire to restore SCHIP cuts, permitted all three
states that capped enrollment to lift those caps. Three states
liberalized cost sharing policies, while one reinstated outreach
funding. However, continued tight budgets forced four other
states to increase cost sharing.
Conclusions: SCHIP continues to enjoy notable levels of
support from policymakers, providers, and consumers. This
support has allowed the program to fare well, relative to other
state programs, during periods of budget tightness.
Persistent budget pressures forced many states to use the
flexibility provided in the Title XXI statute to elect the
combination of cuts that best suited their unique political and
economic circumstances. Overall, however, states were
reluctant to drastically scale back this program, which has
proven successful in reducing the number of uninsured
children.
Implications for Policy, Delivery, or Practice: Separate state
SCHIP programs, since they are not entitlements, possess
significant policy flexibility to control costs during an
economic downturn. Still, a review of experiences in 13 states
suggests that policymakers made prudent use of this
flexibility. SCHIP rules appear to have given state
policymakers the tools they needed to modify policies to meet
their fiscal needs while allowing them to quickly reverse the
most stringent cuts when budget conditions improved. This
has enabled states to retain their overall commitment to
protecting children’s coverage.
Primary Funding Source: RWJF
●Coping with Enrollment Caps: The Experiences of Seven
SCHIP Programs
Ian Hill, MPA, MSW, Brigette Courtot, BA, Jennifer Sullivan,
MHS
Presented By: Ian Hill, MPA, MSW, Senior Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street, NW, Washington, DC 20037; Tel: (202) 261-5374; Fax:
(202) 223-1149; Email: ihill@ui.urban.org
Research Objective: Separate state SCHIP programs, since
they are not entitlements, possess significant policy flexibility
to control costs during an economic downturn. One of the
more drastic steps such programs can take is to “cap”
enrollment and, between 2001 and 2004, seven states did so.
This research set out to: assess the experiences of states that
imposed enrollment caps; gain an understanding of the
effects of caps on enrollment, outreach, and support for
SCHIP; and identify strategies that mitigate the negative
effects of enrollment caps.
Study Design: During the fall of 2004, researchers conducted
telephone interviews with SCHIP officials and child and family
health advocates in the seven states that imposed caps
(Alabama, Colorado, Florida, Maryland, Montana, North
Carolina, and Utah). Both sets of key informants were asked
about factors that led to the imposition of caps, key policies
surrounding cap implementation, duration of caps and effects
on enrollment, and factors leading to the lifting of caps.
Advocates were asked about their roles in attempting to
forestall caps and/or mitigate the negative impacts of caps.
Population Studied: State SCHIP programs.
Principal Findings: States were reluctant to cap enrollment
under SCHIP, but severe budget pressures forced these
actions. Four of the seven study states maintained waiting
lists while caps were in place (to track need and facilitate
enrollment when slots opened), while three did not (citing
administrative challenges). Five states exempted certain
children from their caps (such as children transitioning off of
Medicaid due to income increases). Most states continued to
accept applications during their caps, but all dramatically
curtailed outreach efforts. Attrition took a heavier toll on
SCHIP enrollment in some states than others—ranging from
300 to 20,000 children—while caps were in place. This was
true despite the fact that rates of retention improved
significantly in most states during these periods. Of note,
every state was able to lift its cap and reopen enrollment in
less than a year. Four returned to normal enrollment
procedures, while three switched to policies of time-limited
“open enrollment” periods. Advocates were able to exert little
influence on cap policies, yet worked hard to continue
outreach, promote renewal, and facilitate enrollment as
programs reopened.
Conclusions: SCHIP officials and advocates in the majority of
states indicated that enrollment caps, while painful, were
preferable to cuts in other areas, reasoning that it was better
to maintain simplified enrollment, comprehensive benefits,
and low cost sharing, even if it meant having to endure a
short-term enrollment freeze.
Implications for Policy, Delivery, or Practice: During a time
of severe budget pressure, just seven of 39 states with
separate SCHIP programs instituted enrollment caps. Yet in
those states, key informants valued the flexibility granted by
SCHIP to use this “tool” as a means of controlling costs.
Caps, which were in place for relatively short periods of time,
resulted in quick cost savings, at the expense of steep declines
in enrollment in some states due to attrition.
Primary Funding Source: RWJF
●Families with Mixed Eligibility - Navigating both
Medicaid and SCHIP
Julie Hudson, Ph.D.
Presented By: Julie Hudson, Ph.D., Economist, CFACT,
AHRQ, 540 Giather Road, Rockville, MD 20817; Tel: (301)4271683; Email: jhudson@ahrq.gov
Research Objective: Families with children with mixed public
insurance eligiblity often face different rules concerning levels
of coverage, choice of providers and administrative
(application) rules. In recent years concerns have been raised
over the complications of providing two separate public
insurance programs for children. This paper focuses on the
impact this may have on families with children eligible for
different types of coverage. I measure the incidence of mixed
eligibility in HIEU's in the Medical Expenditure Survey
between 1998 and 2002 and provide descriptive statistics on
demographic characteristics, take-up and use for these
families.
Study Design: Eligibility for Medicaid and SCHIP is simulated
using families and income from the Medical Expenditure
Panel Survey combined with detailed state level rules. HIEU's,
coverage and use from MEPS are used to report descriptive
statistics.
Population Studied: Children in Health Insurance Eligibility
Units in the Medical Expenditure Panel Survey between 1996
and 2002.
Principal Findings: To be determined
Conclusions: To be determined
Implications for Policy, Delivery, or Practice: This paper is
intended to inform researchers and policy makers who are
concerned that families with children with mixed public
coverage face additional burdens in navigating both the
Medicaid and SCHIP systems.
Primary Funding Source: AHRQ
●The Effect of Exclusion of State Employee Dependents
from S-CHIP Eligibility
Patricia Ketsche, Ph.D., MHA, Joan T. Gabel, JD, Nancy
Mansfield, JD
Presented By: Patricia Ketsche, Ph.D., MHA, Assistant
Professor, Institute of Health Administration, Georgia State
University, MSC 4A1473, 33 Gilmer Street, SE, Unit 4, Atlanta,
GA 30303-3084; Tel: (404)651-2993; Fax: (404)651-1230; Email:
pketsche@gsu.edu
Research Objective: A provision in the legislation that created
the S-CHIP program excludes children whose families are
eligible for participation in a state employee benefits plan from
eligibility. This applies regardless of whether that parent
actually participates in the state employee health benefits
program, and even if the children would otherwise be eligible
for S-CHIP based on family income and the relevant look-back
period for health insurance coverage. This paper analyzes the
effect of this policy on current health insurance coverage
among children of state employees and the potential for an
increasing effect on these children in the future.
Study Design: We use combined data from the Annual
Demographic Supplement to the Current Population Survey
(CPS) from the March 2002, 2003 and 2004 surveys to
identify children of full-time state employees. State level data
are used to classify these children as income-eligible for S-
CHIP if their reported family income as a percent of the
federal poverty level is at or below the state established cut-off
for S-CHIP.
Population Studied: Coverage status of low-income children
with a parent employed full-time in state government are
compared to similarly situated children who are dependents of
federal workers and with children who are dependents of
workers at large, private sector firms using bi- and multivariate
approach.
Principal Findings: Dependents of full time state workers in
low- and moderate income families are more likely to have
private coverage, less likely to have any public coverage, and
less likely to be uninsured than their private sector
counterparts. Dependents of state workers are also less likely
to have public coverage or be uninsured than dependents of
federal workers. The results indicate that a small but
significant number of dependents of state workers are
reporting S-CHIP coverage despite the provision limiting
eligibility. While some of this may be explained by job
transitions during a given year, it is also likely that states vary
in their ability enforce the exclusionary policy. The S-CHIP
coverage rates for children of state- and federal workers are
similar. The required contribution for enrolling in a group
plan has a significantly greater impact on the likelihood of
lacking coverage for dependents of state workers than for
other children studied.
Conclusions: At this time there is no evidence that children
who are dependents of a state worker are more likely to be
uninsured because of their ineligibility for S-CHIP, even after
controlling for family income, wages, and the premium
required for coverage. However, as states face increasing
budgetary constraints and reassess their state health benefit
plan design, it is likely that one of the remedies states will
consider will be to increase the required contributions for
dependent coverage. In that event, it is likely that more
dependent children of state workers will lack coverage but will
be ineligible for their public coverage program.
Implications for Policy, Delivery, or Practice: The results
suggest a need to monitor this group of children over time to
determine if the effect of their differential treatment with
respect to S-CHIP begins to affect aggregate coverage levels,
particularly if states make changes to the existing state health
benefit plans.
Primary Funding Source: No Funding Source
●The Impact of an Increase in KCHIP Premiums on
Insurance Coverage of Kentucky Children
Jim Marton, Ph.D.
Presented By: Jim Marton, Ph.D., Assistant Professor, Martin
School of Public Policy and Administration, University of
Ketucky, 433 Patterson Office Tower, Lexington, KY 40506; Tel:
(859)257-4387; Fax: (859)323-1937; Email: marton@uky.edu
Research Objective: My objective is to measure the impact of
increasing premiums on enrollment in CHIP programs. I will
do this using date from the state of Kentucky.
Study Design: The state of Ketucky began charging a monthly
family premium for parts of their CHIP program in December
2003. I follow the families enrolled in the premium paying
catagory from July 2003 to August 2004 and observe changes
in their enrollment status, as well as demographic information
about the children and several indicators of their health.
In addition to analysis of enrollment data, families who lost
coverage due to non-payment are also surveyed.
Population Studied: Low income children in the state of
Kentucky.
Principal Findings: I find that the premium has a statistically
significant negative impact on the probability that a child
remains in the premium paying part of KCHIP. I also find that
less health children are more likely to move into other state
insurance programs, such as the non premium paying part of
KCHIP and Ketucky Medicaid.
Conclusions: These results show that a small monthly
premium does have a statistically significant impact on
enrollment. Further work will be done to quantify the size of
the change in monthly enrollment.
Implications for Policy, Delivery, or Practice: From a policy
perspective it may be useful to know that the relatively less
healthy kids find their way into the non premium paying part
of KCHIP and / or Medicaid.
Primary Funding Source: UK Center for Poverty Research
through the U.S. Department of Health and Human Services
●Adverse Selection with Changes in Benefit Structure in a
Public Insurance Program
K. John McConnell, Ph.D., Neal Wallace, Ph.D., Charles A.
Gallia, MS
Presented By: K. John McConnell, Ph.D., Assistant Professor,
Center for Policy and Research in Emergency Medicine,
Oregon Health & Science University, 3181 Sam Jakcson Park
Road Mail Code CR-114, Portland, OR 97239; Tel: (503)494
1989; Fax: (503) 494 4640; Email: mcconnjo@ohsu.edu
Research Objective: In an effort to cut Medicaid program
costs, many states have recently reduced benefits or required
certain beneficiaries to pay higher premiums and copayments. The objective of this study was to determine the
extent to which cost-sharing and similar benefit reductions led
healthier individuals to leave the Oregon Health Plan at a
higher rate than the chronically ill.
Study Design: Our empirical approach used a natural
experimental design arising from the imposition of copayments, increased premiums, and other exogenous benefit
changes in the Oregon Health Plan in 2003. Using
administrative data from 2002 and 2003, we classified
individuals in terms of chronic diseases (including, e.g.,
diabetes, asthma, COPD, selected mental health disorders).
Individuals were considered ‘non-chronic’ if they did not have
a claim for any chronic condition during their period of
enrollment. We estimated two separate models to measure
the extent of adverse selection: (1) a difference-in-difference
approach; and (2) a discrete-choice model. In the differencein-difference model, we compared changes in enrollment
among chronic and non-chronic enrollees at the level of 130
medical market areas. In the discrete-choice model, we
examined the individual decisions to maintain enrollment
after the changes in the benefit plan. We adjusted for income,
age, language, and location of residence. Individual and
market area fixed effects were used to control for unobserved
heterogeneity.
Population Studied: Approximately 100,000 Oregon Health
Plan beneficiaries enrolled in 2002. These beneficiaries were
part of the ‘expanded’ Oregon Health Plan population and
comprise poor individuals (<100% FPL) who would not have
been `categorically eligible’ for traditional Medicaid. Medical
market areas were developed by the Oregon Office of Rural
Health and were based on topography, social/political
boundaries, and travel patterns.
Principal Findings: In the six months following the increased
premiums, co-payments, and changes in the benefit structure
of the Oregon Health Plan, approximately 50% of the
beneficiaries in the ‘expanded’ population were still enrolled.
We find that individuals with chronic diseases had a much
higher likelihood of continuing enrollment. For example,
compared to patients with no history of chronic disease,
patients with diabetes were 3 times more likely to stay
enrolled. This pattern existed for patients with asthma, COPD,
and other chornic illnesses. Surprisingly, some patients with
chronic mental illness also showed a higher likelihood of
maintaining enrollment even though benefits for outpatient
mental health services were eliminated as part of the change
in the benefit structure. These results were robust to different
modeling approaches and specifications.
Conclusions: The introduction of co-payments, higher
premiums, and reduced benefits led to high rates of
disenrollment among all Oregon Health Plan beneficiaries.
However, this rate of disenrollment was much higher among
beneficiaries without chronic diseases.
Implications for Policy, Delivery, or Practice: Higher
premiums and co-payments are likely to be one method states
consider in their attempt to decrease the cost of public
programs. However, the actuarial estimates of the effects of
cost-sharing may be biased if healthier patients leave and the
program serves primarily the chronically ill.
Primary Funding Source: RWJF
●Disenrollment from SCHIP: The Role of Health Status,
Program Experiences, and Beliefs
Jane Miller, Ph.D., Dorothy Gaboda, Ph.D., Thomas Trail, Joel
C. Cantor, Sc.D.
Presented By: Jane Miller, Ph.D., Associate Professor,
Institute for Health, Health Care Policy & Aging Research,
Rutgers University, 30 College Avenue, New Brunswick, NJ
08901; Tel: (732)932-6730; Fax: (732)932-6872; Email:
jem@rci.rutgers.edu
Research Objective: To determine the demographic, health,
beliefs and program experiences in children’s transition from
SCHIP to uninsured status in New Jersey.
Study Design: A 2003 telephone survey of the most
knowledgeable adult in 679 families of children enrolled in
New Jersey’s State Children’s Health Insurance Program (NJ
FamilyCare) in May 2002 (response rate 52%). The survey
sample was stratified by program eligibility category and
enrollment status as of January 2003. Weights are used to
adjust for differential probabilities of selection. Data for
children from low income families who were not enrolled in
NJ FamilyCare are taken from a similar survey of the NJ
general population (response rate 59%). Groups are
compared using bivariate statistical tests, confirmed using
multinomial logistic regression.
Population Studied: Children enrolled in NJ FamilyCare in
both May 2002 and January 2003 compared to those enrolled
in May 2002 but disenrolled in January 2003 and to other lowincome children.
Principal Findings: NJ FamilyCare enrollees from the lowest
income families were more likely to be uninsured following
disenrollment than children in moderate income families (e.g.,
200% to 350% of the Federal Poverty Level), who were more
likely to obtain private coverage. Survey data on family income
suggest that most of the children who became uninsured after
leaving the program remained eligible. Compared to children
who remained in NJ FamilyCare or obtained private coverage,
those who became disenrolled and uninsured were: (1) twice
as likely to be reported in fair or poor health; (2) more likely to
be from larger families; (3) more likely to worry about health
needs, be willing to use public/free clinics, believe that care
should be sought only when a problem “gets bad”, express
difficulty finding time to see a doctor, and believe that most
health problems go away by themselves; (4) less likely to
express that they can control their own health or that they are
more risk-taking than the average person; (5) more than twice
as likely to report having difficulty paying the premium every
month; (6) less likely to recall needing to submit renewal
information prior to re-determination time; and (7) much
more likely to suggest more assistance should be available
during renewal.
Conclusions: Patterns of disenrollment from NJ FamilyCare
do not suggest adverse health risk retention. Rather,
comparatively unhealthy children appear most likely to
become uninsured. Respondents for disenrolled-anduninsured children are more likely to express beliefs that
would make them reluctant to seek care, which raise serious
challenges for program administrators seeking to prevent
children from becoming uninsured.
Implications for Policy, Delivery, or Practice: Our findings
suggest important challenges for retaining children in SCHIP,
but in-depth qualitative interviews or focus groups are needed
to develop specific retention messages and strategies.
Despite extensive efforts by NJ FamilyCare to keep families
informed about renewal, survey responses suggest that
parents with large families or very ill children may require
additional assistance with their renewal applications.
Moreover, our findings are limited to New Jersey, which has
higher income-eligibility thresholds than any other state, and
is one of the few states that enroll parents in SCHIP.
Primary Funding Source: HRSA
●A Survey-based Assessment of Children with Special
Health Care Needs Enrolled in Medicaid & SCHIP
Managed Care Plans
Susan Milner, Ph.D., MPH, Jonathan P. Weiner, DrPH,
Cynthia S. Minkovitz, M.D., MPP, Anne Riley, Ph.D., Brian
Caffo, Ph.D.
Presented By: Susan Milner, Ph.D., MPH, Health Policy
Analyst, Office of Planning, Maryland Department of Health
and Mental Hygiene, c/o 3811 Canterbury Road #510,
Baltimore, MD 21218; Tel: (610)664-2306; Email:
smilner@jhsph.edu
Research Objective: Children with special health care needs
constitute at least one-fifth of children enrolled in state
Medicaid and SCHIP programs. Few studies have addressed
experiences with care among children with special health care
needs enrolled in Medicaid and SCHIP capitated managed
care plans. The objectives of this study were threefold: (1) to
identify factors associated with negative experiences with care
among children enrolled in Maryland’s Medicaid/SCHIP
managed care plans; (2) to examine differences in experiences
with care between special needs children and healthier
children, paying particular attention to children requiring the
use of mental health and therapy services that have been
“carved out” of health plan capitations; and (3) to examine
differences between respondents and non-respondents.
Study Design: The study’s primary data source was
Maryland’s 2001 Medicaid Child 2.0H Consumer Assessment
of Health Plans Survey (CAHPS). Health status, coverage
group and geographic information from Maryland’s
Medicaid/SCHIP encounter/claims data file were appended to
the CAHPS survey respondent and sample frame data.
Individual level scores were calculated for each respondent for
each of the five global CAHPS experience with care measures.
Logistic regression was used to assess the effects of child,
caregiver, health plan, and regional characteristics on these
five CAHPS measures and on survey response. The
relationship between children’s experiences with care and their
health and chronic condition status was modeled using both
variables derived from the survey instrument and variables
derived from Maryland’s 2001 encounter/claims data file.
Population Studied: The sampling frame consisted of 13,422
children enrolled in Maryland’s Medicaid/SCHIP capitated
managed care plans in 2001, including an over-sample of
5,648 children with chronic conditions. Survey respondents
included 4,664 Medicaid/SCHIP enrolled children, 1,820 with
special health care needs.
Principal Findings: After controlling for demographic,
caregiver, health status, plan, and regional factors, children
requiring mental health services and occupational, physical or
speech therapy services (i.e., carve-out services) reported
greater problems with access to and timeliness of care than
other children; this was largely true regardless of whether
special needs children were defined using claims/encounter
data or using caregiver reported information. After controlling
for other factors, children with caregivers who did not speak
English were more than twice as likely to report problems on
all reporting measures except plan customer service. Regional
differences proved more important than health plans in
explaining problems with care, after controlling for other
factors. Survey non-respondents were more likely than
respondents to be urban, non-white, younger, Medicaid
(opposed to SCHIP) enrollees, and healthy.
Conclusions: Maryland should consider eliminating the
special therapy carve-out, conducting additional quality
monitoring activities for children with mental health problems,
and targeting linguistic minorities in its quality improvement
efforts. Additionally, thought should be given to tracking and
trending CAHPS data regionally.
Implications for Policy, Delivery, or Practice: Conducting an
in-depth, individual-level analysis of CAHPS measures can
provide state Medicaid/SCHIP programs with additional
information for quality assessment and improvement.
Because caregivers of sicker children are more likely to report
negative experiences with care, the study provides some
evidence that unadjusted plan-level scores may be biased in a
negative direction.
Primary Funding Source: AHRQ, Heath Resources &
Services Administration (HRSA)
●Effect of HMO on Ambulatory/Emergency Care Use
Among Medicaid/SCHIP Beneficiaries Under 18: A FixedEffects Panel Regression Analysis
Sangho Moon, Ph.D, Jaeun Shin, Ph.D.
Presented By: Sangho Moon, Ph.D., Professor, Graduate
School of Governance, Sungkyunkwan University, 3-53
Myeongryun-dong Chongno-gu, Seoul, 110-745; Tel: (+82-2)
760-0367; Fax: (+82-2) 766-8856; Email: smoon@skku.edu
Research Objective: As Medicaid/SCHIP programs expand
coverage upon children under 18, the low-income children
with Medicaid/SCHIP benefits receive special attention.
Despite growing concern on potential consequences of
Medicaid/SCHIP HMO, relatively little is known about how
the managed care revolution in Medicaid relates to patterns of
ambulatory / emergency care use among children
beneficiaries under 18. The purpose of this study is to
understand differences in utilization of ambulatory /
emergency care use among Medicaid/SCHIP beneficiaries
under 18 by HMO status; to identify factors associated with
HMO coverage; to examine effects of HMO (relative to nonHMO) on use and spending on ambulatory / emergency care;
and to assess health policy implications of the findings for
HMO coverage and its impact on its beneficiaries.
Study Design: Medicaid HMO status is identified for
respondents to the Medical Expenditure Panel Survey (MEPS)
from 2000 through 2002. The primary outcome variables are
total number of outpatient physician visits (OPDRV),
emergency room visits (ERTOT), total / out-of-pocket
expenditures for ER physician services (ERDEXP / ERDSLF)
per year. Statistical significance of the differences in means is
calculated using t-tests. Race, gender, marital status, region of
residence, educational attainment, employment status,
poverty level, family size, and health conditions are included in
the logistic regression as predictors of whether or not an
individual has Medicaid HMO (as opposed to Medicaid nonHMO). To control for unobservable, individual-specific
characteristics, we perform a fixed-effects panel regression
analysis of two-year appended panel data from 2000 through
2002 (MEPS panel 5 and 6). Goal of analysis is to understand
relationship between Medicaid HMO and utilization of
ambulatory / emergency care among Medicaid beneficiaries
under 18.
Population Studied: The population studied includes full-year
Medicaid/SCHIP enrollees ages 18 or less from MEPS 20002002. Sample enrollees are restricted to those without private
health plans in a given year (N=3,114). Individuas are divided
into two groups, children (<18) with Medicaid/SCHIP HMO
plans (N1=1,759) and children (<18) with Medicaid/SCHIP
non-HMO plans (N2=1,271).
Principal Findings: Being Hispanic or non-Hispanic AfroAmerican, being unemployed and living in a larger family are
associated with significantly higher probability of being
enrolled in Medicaid HMO plans, while higher family income
decreases the probability. The family income effect (200% or
higher than the Federal Poverty Level) is stronger than the
effect of race/ethnicity. Medicaid HMO plan has no
significant relationship with level of utilization and
expenditures for ambulatory visits. However, it shows a
positive and significant (p<0.1) association with total number
of ER visits (b=0.326, t=2.26, ERTOT); total / out-of-pocket
spending for ER physician services (b=22.535, t=2.13, ERDEXP
/ b=8.416, t=2.25, ERDSLF). Being in poor self-rated health
status, having at least one chronic disease, having larger
number of co-morbidities show significantly (p<0.05) positive
associations with the utilization of and expenditures for ER
visits among Medicaid beneficiaries under 18.
Conclusions: This study provides preliminary evidence that
children with Medicaid HMO plans demand more use and
higher costs for ER visits compared to those with Medicaid
non-HMO plans. Medicaid HMO plans, however, are not
correlated with level of utilization and total expenditures for
ambulatory visits.
Implications for Policy, Delivery, or Practice:
Medicaid/SCHIP HMO pans are equivalent with non-HMO
plans in providing children access to ambulatory care.
However, as shown in increased ER visits, quality concerns
about HMO plans may be addressed over children under 18.
Primary Funding Source: University Research Funds from
Sungkyunkwan University
●Comprehensive Service Coordination Organizations
Susan Palsbo, Ph.D., Margaret Fisk Mastal, Ph.D., MS
Presented By: Susan Palsbo, Ph.D., Principal Research
Associate, Center for Health Research, Policy & Ethics, George
Mason University, 4400 University Drive MS 3C4, Fairfax, VA
22030; Tel: (703)993-2173; Email: spalsbo@gmu.edu
Research Objective: Describe innovative delivery systems of
medical and social services, as well as community-based
services, for Medicaid adults of working age with physical or
behavioral disabilities.
Study Design: This was a qualitative case study design. We
visited 7 care coordination programs in 6 states during 2004.
Using a semi-structured interview, we spoke with clinicians,
beneficiaries, and health plan personnel about the care
coordination process. We also compiled organizational
charts, mission statements, and newsletters. We asked
questions on governance, consumer involvement, financing
and sustainability, quality improvement initiatives, and
management information systems.
Population Studied: Adults with severe and persistent mental
illness; adults with impaired mobility caused by spinal cord
injury, multiple sclerosis, cerebral palsy; adults and children
with asthma or complex medical needs (including HIV/AIDS).
Principal Findings: Nearly a dozen states are piloting
coordination programs for Medicaid adults with disabilities.
About half of the programs capitate a risk-bearing entity for
some or all Medicaid covered services; the others use a
PCCM. Some states also capitate Medicare-covered services
for dual eligibles, integrating dual funding bases to
incorporate the full continuum of services and settings.
Regardless of financing method, the coordinator works across
the entire spectrum of health and social services and has
financial incentives to keep the beneficiary healthy and out of a
nursing home. These pilot programs are a new breed of social
services delivery system. We suggest calling them
Comprehensive Service Coordination Organizations (CSCOs)
to describe the medical and social services domains they
encompass, as well as the various sources of funding. Each of
the pilot CSCOs we visited is unique, with different target
populations, different financial incentives, different missions
and different staffing. Despite these differences, they have
many similarities: --Use advance practice or specialized
nurses;--Use social workers;--Coordinate medical and
behavioral health services;--Coordinate social services
(housing, transportation, personal care assistance);-Emphasize patient-centered, planned health care;--Carefully
select a disability-literate provider panel;--A commitment to
help the individual move beyond day-to-day management of
the consequences of disability, so the individual can
participate in higher-order life activities (personal
relationships, parenting, community involvement,
employment, etc).--A commitment to quality.Participants in
the pilot programs are uniformly enthusiastic. In our
interviews, participants use phrases such as “This plan saved
my life”; “I’m in charge of my health instead of my health
being in charge of me”; “I’m much happier”; “I know what’s
going on when I go to the doctor;” “I get the services and
supplies I need, when I need them.” Participating physicians
support the programs because they see improvement in their
patients and because they know the coordinators will help the
patient follow through on referrals and prescriptions.
Physicians also appreciate having a single person (the
coordinator) who knows everything going on about that
patient and community resources that might be available.
Conclusions: CSCOs can organize person-centered medical
and social services that improve the psycho-social well-being
of adult Medicaid beneficiaries with physical or behavioral
disabilities.
Implications for Policy, Delivery, or Practice: States and
CMS should continue to explore CSCOs as a mechanism to
blend financing and services for vulnerable populations.
Formal licensure programs to certify nurses and social
workers as “Comprehensive Service Coordinators” should be
developed. The CSCOs should develop common measures of
cost and quality to compare their performance against each
other and standard Medicaid delivery systems.
Primary Funding Source: RWJF, Center for Health Care
Strategies
●How Medicaid Adults with Disabilities Determine Health
Plan Quality: A Hierarchy of Needs
Susan Palsbo, Ph.D., Thilo Kroll, Ph.D.
Presented By: Susan Palsbo, Ph.D., Principal Research
Associate, Center for Health Policy, Research & Ethics, George
Mason University, 4400 University Drive, MS 3C4, Fairfax, VA
22030; Tel: (703)993-2173; Email: spalsbo@gmu.edu
Research Objective: A growing number of states offer
Medicaid insured adults with disabilities a choice of health
plans and delivery systems. Few, if any, states issue a
Medicaid report card geared specifically to adults with
disabilities. This project builds on our prior research that
queried adults with MS, CP, or SCI. In that study, we found
little difference across states and greater differences between
impairment origins. We wanted to learn how people with
cognitive-behavioral, sensory and physical disabilities resulting
from other high incidence conditions assess health plan
quality.
Study Design: Using a semi-structured topic guide, we
conducted eight focus groups in 2003-2004. All focus groups
were conducted by an experienced moderator and cofacilitator. The co-facilitator took notes which were used in the
debriefing following after each interview. Transcripts of
audiotapes were independently read and coded by two
analysts. We used constant comparative analysis for within
and between state coding. We also presented Medicaid Report
Cards for Michigan, California, and Maryland for discussion.
Population Studied: 49 Medicaid insured adults with various
physical, sensory, and cognitive disabilities in Oregon,
California, Virginia, Maryland, and the District of Columbia.
Principal Findings: Participants’ mean age was 49 years
(SD=11.53). The sample was ethnically diverse. The most
common primary medical diagnoses were arthritis (10%),
stroke (8.1%), epilepsy (6.1%), cerebral palsy (6.1%), posttraumatic stress disorder (6.1%), or blindness (6.1%).
Oregon respondents felt that major cutbacks jeopardized
access to providers and prescription drugs. They defined
quality in terms of access to and coordination of receipt of
basic healthcare services. It is relatively easier to find
Medicaid providers in southern California; Californians
defined quality in terms of care coordination and low out-ofpocket expenses. Maryland Medicaid participants were
surprised to hear that they had a choice of health plans and
providers. The beneficiaries in DC and Virginia highlighted the
need for a positive doctor-patient relationship with sensitive
and knowledgeable providers. All respondents liked the
Medicaid Report Cards but wanted more information about
responses from people with disabilities.
Conclusions: Unlike our previous findings, we found
substantial variation across states in how people with
disabilities define a quality health plan. We designed a
hierarchical system of health care quality indicators grounded
in the perspective of Medicaid adults with disabilities. At the
bottom of this hierarchy is access to benefits and services.
People in states with severe access problems measure quality
by the ease of seeing clinicians and obtaining medications or
supplies. At the second level (states where these basic needs
are met), beneficiaries measure quality by focusing on the
access to needed specialist services and coordination between
clinicians. At the third level, beneficiaries focus on preferred
provider characteristics (e.g. knowledge and disability
competence). In states with well-developed and adequately
funded Medicaid programs, beneficiaries use the same
domains and indicators of health plan quality as the private
sector market.
Implications for Policy, Delivery, or Practice: Unlike multistate employer Report Cards, it is likely that each state will
need to develop a Medicaid Report Card content unique to
people with disabilities in its state. People with disabilities
should be included in the design of content, items, and
dissemination strategies.
Primary Funding Source: NIDRR/US Dept of Education
●Identifying Persons with Mobility Impairment
Susan Palsbo, Ph.D., Nancy Latham, Ph.D., PT, Vickie
Stringfellow, BSc, Ann Lawthers, Ph.D., Patricia Gallagher,
Ph.D., Kathleen Brody, BSN, PHN
Presented By: Susan Palsbo, Ph.D., Principal Research
Associate, Center for Health Policy, Research & Ethics, George
Mason University, 4400 University Drive, Fairfax, VA 22030;
Tel: (703)993-2173; Fax: (703)993-1953; Email:
spalsbo@gmu.edu
Research Objective: Develop a short set of screening
questions to accurately identify people with mobility
impairments (PWMI). People who self-identify as having a
mobility impairment will be asked to complete CAHPS
questions targeted to them.
Study Design: An initial set of 6 questions was developed by
the CAHPS-PWMI team. Cognitive testing was conducted at
Rand (n=6), Harvard (n=7), and National Rehabilitation
Hospital (n=6). In 2004, MassHealth included these
questions in a telephone survey of approximately 1000
Medicaid adults in Massachusetts. We also received 1000
mail responses to a survey of 11,000 Medicaid adults in
California. Responses on the screeners were compared to
presence/absence of chronic conditions (Massachusetts), use
of medication (Massachusetts and California), all diagnoses,
and self-reported responses to the OARS mobility scale, IADL
and ADLs (California). The California survey included an openended question asking respondents to list the “top three
problems that bother you”. These data (300 characters) will
be scrutinized and recoded to specify pain issues to form an
interaction variable with levels of mobility impairment.
Population Studied: Medicaid adults of working age with
physical disabilities enrolled in MassHealth (Massachusetts)
or Inland Empire Health Plan (southern California).
Principal Findings: We evaluated 6 questions: In the past 12
months, did you use any mobility equipment? In the past 12
months, how much difficulty did you have standing, walking
¼-mile, climbing 10 stairs, moving around the house, or
getting out of bed? In Massachusetts, over half the people
reporting a chronic condition did not report having a mobility
impairment. About two-thirds of people reporting mobility
problems did not use mobility equipment. Analysis of the
California data (including sensitivity and specificity analysis) is
underway.
Conclusions: Mobility screeners identify a population of
people distinct from people with chronic conditions. A
question about mobility equipment, alone, is not sufficient to
identify PWMI. A combination of two questions (walking and
use of mobility equipment) identify most PWMI.
Implications for Policy, Delivery, or Practice: Just two or
three questions on a telephone or mail survey will accurately
identify people with mobility impairments. These people can
then be asked additional questions in a CAHPS survey about
their experiences with health care.
Primary Funding Source: No Funding Source
●Challenges and Innovations in Improving Appropriate
Utilization of Primary and Preventive Services by Children
Enrolled in Medicaid and SCHIP through CommunityBased Organizations
MaryAnn Phillips, MPH, Bernette McColley, BA, MPA
Candidate, Mark Rivera, Ph.D.
Presented By: MaryAnn Phillips, MPH, Senior Research
Associate, Georgia Health Policy Center, 14 Marietta Street,
Atlanta, GA 30303; Tel: (404)651-1643; Fax: (404)651-3147;
Email: mphillips2@gsu.edu
Research Objective: Determine the key challenges faced by
community-based organizations and the innovations they
create in improving appropriate utilization of primary and
preventive services by SCHIP and Medicaid children.
Study Design: Retrospective qualitative and quantitative
analysis of six community-based organizations awarded
competitive grants to improve the utilization of primary and
preventive care services by children enrolled in Georgia’s
Medicaid and PeachCare for Kids programs. Analyses
included written and telephone interviews of key grant staff
and project document and record review.
Population Studied: Six community-based organizations in
Georgia working with Medicaid and PeachCare for Kids
members and health care providers.
Principal Findings: Key innovations during the one-year
project included:1.The development of new data systems
(4,890 new or potential enrollees were identified; 5,149
telephone appointment reminders were made; 77% of
appointments were kept; 2,308 referrals to other services were
made); 2. Innovative staffing patterns (Dedicated outreach
staffing increased member response; Sharing resources
across organizations extended the reach of the outreach
efforts; Strategically located staff within partner organizations
improved access to enrollees); 3. Collaboration (Forging new
partnerships with provider organizations strengthened the
bonds between members and outreach organizations; New
partnerships created new referral sources and strengthened
continuity of care across providers; Provider partnerships
increased rapport between community-based organizations
and members. Key challenges included:Limited
funding;HIPPA requirements; Transportation; Length of startup time; Staff turnover; Lack of IT integration; and Systemlevel administrative changes.
Conclusions: While grantees varied considerably in size of the
enrollee population served, size and type of staffing and
services, and rural/urban setting, key challenges and
innovations were similar. By identifying key challenges and
innovations and understanding the activities undertaken by
each grantee to meet its program objectives, Georgia has a
better understanding of what is needed to improve
appropriate utilization of services at the community level.
Implications for Policy, Delivery, or Practice: Policymakers
are concerned that children enrolled in the State Medicaid and
PeachCare for Kids programs appropriately utilize the services
that are available to them. However, individuals and families
fail to use services due to lack of awareness of the need for
preventive care, fear or discomfort with health professionals,
or poor knowledge about the health care system. Communitybased organizations may help bridge the gap between families
and the health care provider community. This paper provides
state agencies wishing to work with community-based
organizations to increase appropriate service utilization tested
programmatic recommendations and guidance.
Primary Funding Source: Georgia Department of
Community Health
●Do Physician Organizations Use Managed Care Tools to
Influence PCP Adherence to Chlamydia Screening?
Nadereh Pourat, Ph.D., Patricia Parkerton, Ph.D., Jas Nihalani,
MPH
Presented By: Nadereh Pourat, Ph.D., Senior research
scientist, UCLA Center for Health Policy Research, 10911
Weyburn Avenue, # 300, Los Angeles, CA 90024; Tel:
(310)794-2201; Fax: (310)794-2686; Email: pourat@ucla.edu
Research Objective: Annual chlamydia screening of young
females is a 1999/2000 HEDIS® measure incorporated into
quality improvement activities of some physician
organizations (POs). However, little is known on the potential
impact of such activities on physician behavior. We explored
the extent to which POs used managed care tools aimed at
influencing primary care physicians’ (PCPs) adherence to
chlamydia screening guidelines.
Study Design: A cross-section of PCPs that contracted with
Medicaid HMOs in California were surveyed on the phone on
their delivery of sexually transmitted services (STD) services
consistent with Centers for Disease Control and Prevention
clinical guidelines and the HEDIS® chlamydia measure. The
PO providing the majority of Medicaid patients to each PCP
was identified from the PCP survey and PO medical directors
were mailed a similar questionnaire that also included use of
STD specific managed care tools including review of screening
practices of PCPs, feedback to PCP on screening, PCP
education, patient education, and guideline promotion. The
dependent variable measured the PCP reported frequency of
annually screening females 15-19 years of age for chlamydia. A
logistic model identified the probability of physician adherence
given the POs’ reported use of these managed care tools. The
model controlled for both PCP (gender, specialty, experience,
practice setting, Medicaid patient load) and PO (total and
Medicaid enrollment, number of contracted PCPs, number of
contracted Medicaid HMOs, method of PCP payment)
characteristics.
Population Studied: All PCPs, contracting with Medicaid
HMO plans in the eight California counties with the highest
rates of chlamydia infection and of Medicaid recipients, were
identified. Overall, 948 PCPs participated in the telephone
survey, with a response rate of 40%. A third of these PCPs did
not identify their physician organization and 60% belonged to
a PO that was unreachable or did not respond to the PO
survey. Therefore, complete data was available for 25% of
PCPs (n = 234). Further analysis did not identify significant
differences in characteristics of included and excluded PCPs.
Non-response analysis of POs did not reveal significant
differences among respondent and non-respondents.
Principal Findings: Preliminary analyses showed that POs
surveyed were primarily individual practice associations
(66%), with a mean patient enrollment of 37,700 and an
average of 3 Medicaid HMO contracts. The majority reported
promoting annual chlamydia screening of females 15-19 years
(65%), reviewing physicians’ STD screening practices (82%),
and educating their patients on STD prevention and control
(78%). Far fewer (24%) reported providing feedback to PCPs
on their STD screening or training the PCPs on STD
prevention and control (10%). Examining the impact of these
managed care tools did not reveal a measurable impact on
PCP adherence to chlamydia screening guidelines.
Conclusions: Although most physician organizations
reported employing managed care tools directed at prevention
and control of chlamydia, no evidence was found on the
potential influence of these efforts on PCP adherence to the
chlamydia screening guideline.
Implications for Policy, Delivery, or Practice: Evaluating the
impact of POs’ use of managed care tools can illuminate their
strengths and weaknesses and identify the future direction of
such activities. Establishing clinical guidelines, providing
patient education, and examining physician performance may
not be adequate to influence PCP adherence to chlamydia
screening by POs. Specifics of the managed care tools or
other management practices actually employed and the
potential impacts of physician training and direct feedback on
physician performance need further exploration to identify
effective mechanisms to improve quality of care.
Primary Funding Source: California DHS STD Control
Branch
●Secondary Diagnoses and Procedures for the 0-19
Inpatient Hospital Population in Florida: a Comparison of
Medicaid Expansions and Separate State Children
Insurance Programs
Etienne Pracht, Ph.D., Barbara Orban, Ph.D., Peter Gorski,
M.D.
Presented By: Etienne Pracht, Ph.D., Assistant Professor,
Health Policy and Management, University of South Florida,
13201 Bruce B. Downs Boulevard, MDC 56, Tampa, FL 336123805; Tel: (813) 974-7609; Fax: (813) 974-6741; Email:
epracht@hsc.usf.edu
Research Objective: We hypothesize that, as a direct result of
the differences in the federal-state cost sharing arrangement,
the provision of health care services under separate state child
health Insurance programs (SCHIP) is subject to a stricter
cost-containment environment, compared to Medicaid
expansions.
Study Design: The Florida inpatient hospital discharge data,
available through the Agency for Health Care Administration
allows testing of our hypothesis, for example, based on the
utilization of diagnoses and procedures associated with
individual hospitalizations. Poisson regression techniques will
be used to control for the type of program, illness severity,
age, sex, race, hospital characteristics, and diagnostic related
group (DRG) case mix. Illness severity will be accounted for
using the 3M All Patient Refined DRG Software package.
Population Studied: All children, ages 0 to 19, admitted to a
Florida hospital in the 2003 calendar year, falling in three
payer categories: Medicaid, Florida’s SCHIP, and uninsured.
Principal Findings: Compared to Medicaid fee-for-service
(FFS) beneficiaries, Medicaid Health Maintenance
Organization (HMO), KidCare, and uninsured hospitalized
children receive, respectively, 11.3, 14.5, and 15.6 percent fewer
diagnoses on average. The corresponding reductions in
procedures are, respectively, 9.1, 19.3, and 16 percent. The
differentials were found to be larger, on average, for higher
DRG weight groups.
Conclusions: The findings presented here suggest that
children receive a higher level of services when enrolled in
traditional Medicaid programs, particularly under FFS
approaches, as opposed to separate children’s public health
programs. Differences in state/federal cost sharing
arrangements for Medicaid and non-Medicaid children
insurance programs, as well as illness severity, may explain
the variation.
Implications for Policy, Delivery, or Practice: The results
indicate important differences between different public
insurance programs intended to serve similar populations.
From a health policy perspective, the 1997 Balanced Budget
Act provided states with federal grants to create children’s
health insurance programs either by expanding their existing
Medicaid programs or creating separate child health
programs. The results of this study indicate that children may
not be equally served by each alternative.
Primary Funding Source: No Funding Source
●Comparability of Children Enrolled in Medicaid and
SCHIP: Feasibility of Program Integration in a Two System
State
Meryl Price, MHSA, Daniel Gilden, Ph.D.
Presented By: Meryl Price, MHSA, President, Health Policy
Matters, 146 Allston Street, Medford, MA 02155; Tel: (781)3930120; Email: meryl@healthpolicymatters.com
Research Objective: The objective of the study is to
determine the comparability of Medicaid and SCHIP children
and to assess the potential for program integration in a state
with separate administration, benefit design and provider
networks.
Study Design: The study design included the review of
program documentation, best practices nationally and service
level utilization data from the state of Colorado for the period
of 1999-2002. Comparative analyses were performed on
benefit design, provider network scope, enrollee
demographics, disability, morbidity, geographic distribution,
costs of care and rates of utilization of key services. A risk
categorization method was developed based on administrative
status, age, disability, morbidity and pregnancy in year. We
estimate the comparability of the programs by modeling
utilization and expenditures using a two-stage multivariate
regression.
Population Studied: SCHIP and Medicaid children under the
age of 20 are compared in three exclusive sub-groups: special
needs, under-one, pregnant and low-risk. The populations
include income-eligible Medicaid children covered under feefor-service financing and SCHIP enrolled children. Medicaid
children with SSI eligibility, users of waivered services and
with severe behavioral health conditions are excluded from the
analysis. The claims and program eligibility data used for the
analyses included service and enrollment dates between 1999
and 2002. The comparability model focused on the most
recent year of available data (2002).
Principal Findings: All risk groups are substantially present in
both programs. The greatest comparability between the
populations is in the children identified as low risk, i.e. nondisabled, over one year of age and eligibility not apparently
linked to pregnancy. The low risk population represents
approximately 75% of non-SSI Medicaid children in Colorado.
Payment differences between the programs are concentrated
in inpatient acute care with Medicaid utilization significantly
higher for respiratory and other conditions. Benefit limitations
and program design in the Colorado SCHIP program would
not materially restrict access to care for Medicaid children.
Conclusions: The Colorado SCHIP program has sufficient
experience with providing care to a diverse population of
children to support Medicaid program integration for low-risk
Medicaid children into the CHP+ program. Provider network
characteristics and benefit design would not need to be
substantially altered to accommodate integration. There is
evidence that Medicaid integration with the SCHIP provider
network and administrative structure would result in cost
savings from reduced inpatient acute care for respiratory and
other conditions. Economies of scale exist that could improve
care and cost-effectiveness for both populations.
Implications for Policy, Delivery, or Practice: The policy
implications of the findings directly relate to the problem of
streamlining and financing the provision of health care
services to low income children. The integration of programs
could address the recognized problems of cross-program
migration, retention, benefit design and costs efficiencies.
Primary Funding Source: Government
●How Much Is Enough? A Suggested Framework for
Setting Medicaid Payment Levels
Kevin Quinn, MA, EMT-P
Presented By: Kevin Quinn, MA, EMT-P, Director, Payment
Method Development, ACS State Healthcare LLC, 34 Norht
Last Chance Gulch, Helena, MT 59601; Tel: (406) 457-9550;
Fax: (406) 442-2819; Email: kevin.quinn@acs-inc.com
Research Objective: To arrive at an evidence-based, policyrelevant framework for setting Medicaid payment levels to
healthcare providers
Study Design: Literature review and policy analysis
Principal Findings: A strong policy argument can be made
that the sole purpose of Medicaid payments to providers is to
ensure access for beneficiaries to appropriate and quality
services. To put this goal into operation, a framework was
developed that considers, first, evidence on access and, only if
measurement of access is problematic, evidence on
comparative payment rates. HIPAA data standardization and
improved technology such as decision support systems and
the Internet mean that such evidence is more readily available
than ever before. Nationwide and state-specific data on
access and payment rates are used to illustrate the framework.
If access is found to be inadequate, the framework focuses on
the best "return on investment" for Medicaid among four
options. If rate increases offer the best return, then Medicaid
must keep in mind its role in the market. For some provider
types, such as hospitals, Medicaid is one player IN the market.
For other provider types, such as personal care providers,
Medicaid is so important it almost IS the market. The analysis
includes detailed estimates by provider type of Medicaid
market share nationwide as well as application of economic
principles to Medicaid's ratesetting decisions.
Conclusions: Use of the best available evidence within a
coherent policy framework can make a Medicaid program's
ratesetting decisions more consistent and defensible.
Implications for Policy, Delivery, or Practice: The paper has
direct relevance to the approximately $310 billion that
Medicaid programs are expected to spend this year to
purchase health care. Moreover, these expenditures affect the
organization and effectiveness of the health care system,
especially in areas such as long-term care where Medicaid is
the major source of funding.
Primary Funding Source: No Funding Source
●Evaluating the Arkansas Medicaid Expansion Program for
Pregnant Women and Older Medicare Beneficiaries
Lisa R. Shugarman, Ph.D., Julie Brown, BA, David Dausey,
Ph.D., Donna Farley, Ph.D.
Presented By: Lisa R. Shugarman, Ph.D., Associate Health
Policy Researcher, RAND Corporation, 1776 Main Street, PO
Box 2138, Santa Monica, CA 90407; Tel: (310) 393-0411 x7701;
Fax: (310)393-4818; Email: Lisa_Shugarman@rand.org
Research Objective: Using funds from the tobacco master
settlement agreement, Arkansas expanded Medicaid services
to cover pregnant women who have incomes at or below
200% of the federal poverty level (FPL) and to cover aged
Medicare beneficiaries (65+) with incomes less than 80% of
the FPL (AR-Seniors Program). This paper reports on the
evaluation of the Medicaid expansion programs during their
first years of operation.
Study Design: The evaluation examined the progress of the
Medicaid program in expanding health care coverage for the
selected populations. We tracked expansion program
enrollment trends, and we conducted focus groups with
pregnant women and older adults enrolled in the programs.
In the focus groups, we asked enrollees about their
understanding of the program and the services for which they
are eligible, and what they saw as the programs’ strengths and
weaknesses.
Population Studied: Individuals enrolled in the Arkansas
Medicaid expansion program for pregnant women and in the
Arkansas Medicaid AR-Seniors program.
Principal Findings: Despite a steady increase in enrollment
for the pregnant women’s Medicaid expansion program, the
program has only reached about 47% of its enrollment
targets. Similarly, enrollment rates for the AR-Seniors
program have been lower than planned. Based on the
agency’s own estimates, enrollment has reached 82% of the
target population. However, Census Bureau estimates of the
total number of older adults who have incomes below 80% of
the FPL suggest that the state has reached only 8% of the
eligible population. The focus groups revealed concerns
regarding how well the enrollment process informed eligible
populations about available coverage. The AR-Seniors
enrollees did not recognize the name of the program. When
asked whether they received educational materials, none could
recall any. Some focus group members were still paying out
of pocket for Medicare supplemental insurance for pharmacy
coverage, even though it is part of the expanded Medicaid
benefit. The participants in the pregnant women’s focus
group were much more familiar with the Medicaid expansion
program, although none of them were aware that the program
was funded by the Tobacco Settlement. Most of the women
were enrolled through their local health department.
However, all of them stated that they were uncertain about
what services were covered by Medicaid, and many were
unsure of what kind of insurance coverage they or their child
would have after the birth.
Conclusions: Both Medicaid expansion programs are
experiencing increasing enrollments, but they are still not
reaching all eligible populations, and enrolled members may
be under-using services because they do not understand what
services are covered. As a result, the programs are under-
spending the Tobacco Settlement funds that are available to
support health care for these low-income populations.
Implications for Policy, Delivery, or Practice: The rapid
implementation of these Arkansas Medicaid expansion
programs was possible because the programs built upon
existing organizational, staffing, and system structures.
However, there is still a substantial need for the enrollment
process to undertake more education and outreach so the
enrolled and general populations can be reached and
informed about the available programs.
Primary Funding Source: Arkansas Tobacco Settlement
Commission
●Managed Care in New York City's Public Coverage
Programs
Denise Soffel, Ph.D., Chris Molnar, MPH, Denise Soffel, Ph.D.,
Susan Kannel, BA
Presented By: Denise Soffel, Ph.D., Senior Policy Analyst,
Policy Research, Community Service Society, 105 East 22nd
Street, New York, NY 10010; Tel: (212)614-5308; Fax: (212)6149441; Email: dsoffel@cssny.org
Research Objective: Because the majority of low-income
people covered through public programs in New York receive
their care through managed care organizations, we surveyed
the enrolled population to understand their utilization
patterns and their awareness of how to navigate managed
care systems. Questions were asked about access to and use
of primary care and of specialty care, satisfaction with care
and with the health plan, and knowledge of managed care
rules and member responsibilities. Particular attention was
paid to identifying vulnerable subgroups.
Study Design: During the summer of 2004, CSS
commissioned a random-digit dial telephone survey of New
York City residents enrolled in public coverage programs
(Medicaid, Family Health Plus, and Child Health Plus). The
18-minute survey was conducted in English and Spanish.
Population Studied: We surveyed 1047 individuals. The
survey included 385 parents of children in CHP A (Medicaid),
312 parents of children in CHP B (SCHIP), 257 adults in
Medicaid managed care, and 93 adults in Family Health Plus.
278 interviews were conducted in Spanish.
Principal Findings: 1. Access to Primary Care: 85 percent of
respondents have a primary care provider; 81 percent have
had a physical since they joined their plan; 82 percent say they
can get a primary care appointment easily. 2. Access to
Specialty Care: People are more likely to report difficulty
finding a specialist within their plan (20 percent); and that
they have to wait too long to get an appointment with a
specialist (30 percent) compared to primary care (17 percent).
In addition, 46 percent have not seen a dentist in the last year.
3. Knowledge: Despite many years of experience with managed
care, people do not know the basics. Few people knew the
name of their plan or the type of coverage they had; only 25
percent could accurately answer three questions about how
managed care plans operate; half the respondents did not
know whether their plan provided mental health services. 4.
Access for Vulnerable Populations: Vulnerable populations are
less likely to have a PCP; more likely to have used the
emergency department; and more likely to report a time they
did not get medical care when they needed it .
Conclusions: 1. The managed care system is working
reasonably well for most low-income people covered through
public programs. On most indicators of access, a large
majority are doing well. 2. Access to primary care is better
than access to specialty care for this population. 3. Vulnerable
populations (immigrants, those with chronic health
conditions, and those with unstable coverage) do not do as
well at accessing care across the board.
Implications for Policy, Delivery, or Practice: 1. While most
low-income enrollees have access to primary care, certain
vulnerable populations are having a more difficult time getting
care. Outreach and education efforts need to target these
vulnerable populations. 2. Stability of coverage and
connection to a health care home make a difference. 23
percent of respondents had been uninsured at some time
during the last year. Maintaining eligibility through simplifying
the recertification process, and extending eligibility for a longer
time, especially for children, would reduce access barriers.
Primary Funding Source: No Funding Source
●A Comparison of Costs for Medicaid Long-Term Care
Clients in the Community and in Nursing Facilities in
Texas
Anna S. Sommers, Ph.D., Barbara A. Ormond, Ph.D.
Presented By: Anna S. Sommers, Ph.D., Research Associate,
Health Policy Center, The Urban Institute, 2100 M Street NW,
Washington, DC 20037; Tel: (202) 261-5265; Fax: (202) 2231149; Email: asommers@ui.urban.org
Research Objective: The Community Based Alternatives
program (CBA) is a Medicaid waiver program with a
substantial waiting list. The Rider 37 initiative allows Texas
Medicaid recipients who are in nursing facilities to move back
to the community and receive services under the CBA
program without joining the waiting list or supplanting
someone on it. This study examines the role of Rider 37 in
meeting the long-term care needs of Texas Medicaid
recipients and its likely effect on the overall costs of the
Medicaid long-term care program.
Study Design: Using Texas Medicaid long-term care
administrative data, we compare clients who have moved
from a nursing facility to the CBA program (Rider participants)
to a sample of clients who remain in the nursing facility and a
sample of clients who entered the CBA program directly from
the community rather than from a nursing facility (CBA
clients). We examine service mix and costs associated with
sociodemographic characteristics, primary diagnosis,
prevalence of mental/behavioral conditions, and assigned
level of care (TILE score) across samples.
Population Studied: Participants in the Rider 37 initiative
(n=4,868), CBA clients entering after the inception of Rider 37
(n=16,571), and a representative sample of nursing facility
residents (n=66,475); all restricted at those age 21 and over.
Principal Findings: The analysis suggests that Rider
participants use more assisted living services and have a
higher rate of personal assistance services than CBA clients
but are otherwise comparable in service mix and costs. These
differences appear to be due to a higher prevalence of
dementia and behavioral conditions among Rider participants,
greater medical instability, and a lack of informal support
networks. There are large differences in service mix across
racial and ethnic groups.
Conclusions: Observed differences in costs between Rider
participants and non-Rider CBA clients are likely attributable to
differences in the characteristics of the populations rather
than in their service use profiles.
Implications for Policy, Delivery, or Practice: By providing a
mechanism for Medicaid recipients to move out of the
nursing facility with supportive care in the community, the
Rider establishes a nursing facility stay as a potentially shortterm option rather than only as end-of-life care. In this way, it
provides access to a more culturally acceptable range of care
for populations that find long-term nursing facility placement
anathema. There is little evidence that the Rider increases
overall costs of the Medicaid long-term care program.
Primary Funding Source: Assistant Secretary for Planning
and Evaluation
●Effects of the State Children’s Health Insurance Program
(SCHIP) on Health Insurance, Access to Care, Health
Services Use, and Health Outcomes
Hua Wang, Ph.D. Candidate
Presented By: Hua Wang, Ph.D. Candidate, Health Policy and
Administration, University of North Carolina at Chapel Hill,
3311 Cleveland Avenue NW, Washington, DC 20008; Tel:
(301)458-4734; Fax: (301)458-4038; Email:
wang1@email.unc.edu
Research Objective: Health insurance is a primary
determinant of access to care and strongly associated with
health services use and health outcomes. The SCHIP
program, established by Congress in 1997 as the single largest
expansion of health insurance in the past 40 years, aims to
reduce the uninsured rate and improve access, health services
use and health outcomes for children. This study estimates
effects of SCHIP implementation on these goals at the
national level. It differs from other studies as follows: It
provides the first national estimate of SCHIP’s spillover effect
on Medicaid enrollment; when estimating SCHIP’s effects on
access, services use, and health outcomes for newly insured
children, it uses the instrumental variables approach to correct
endogeneity of insurance, and estimates changes among
children who would otherwise be uninsured instead of newly
enrolled SCHIP children, because many of them had either
private or public coverage before switching to SCHIP.
Study Design: As different states implemented SCHIP at
different times from 1997 to 2000, there is considerable
variation in timing of program implementation across states.
This exogenous variation is used to identify SCHIP’s effects on
health insurance controlling for state and time fixed effects.
The same variation and state programs’ income thresholds
are selected as instruments for insurance coverage in
estimating SCHIP’s effects on access, services use, and health
outcomes with control of county fixed effects. To minimize
misclassification between Medicaid and SCHIP coverage, I
estimate SCHIP’s spillover on Medicaid enrollment among
children under age 6 and with family income lower than the
Federal Poverty Level because they are eligible for Medicaid
but not for SCHIP.
Population Studied: A nationally representative sample of
over 213,000 children aged 0–18 years from the 1995–2002
National Health Interview Survey (NHIS).
Principal Findings: Results indicate that 3.3% children
enrolled in either SCHIP or Medicaid nationwide since SCHIP
implementation; due to its spillover on Medicaid enrollment,
5.5% of the youngest and poorest children enrolled in
Medicaid. Overall, because of SCHIP availability, 2.7%
children obtained public coverage, 1.4% lost private insurance,
and eventually 1.1% children gained health insurance–about
10% of children without insurance in 2004. SCHIP also had
sizable effects on most indicators of access and services use
for children who gained insurance from SCHIP
implementation. For example, they were 47% more likely to
have usual source of care, 93% more likely to use
hospitalization services, and 90% less likely to have the last
dental visit more than one year ago, compared to their
uninsured counterparts. Most effects are greater for older and
lower–income children, and states that implemented separate
programs only.
Conclusions: SCHIP sizably enhanced public coverage
(including both Medicaid and SCHIP), reduced the uninsured
rate, and improved access to care and health services use for
children. The program crowded out private coverage only by a
small amount. However, its effect on health outcomes could
not be determined yet.
Implications for Policy, Delivery, or Practice: The federal
and state governments should continue their support of the
SCHIP program. Many of the innovative and effective SCHIP
policies can be a valuable model for other public programs.
Primary Funding Source: NCHS/AcademyHealth Fellowship
Program