Losing Insurance and
Using the Emergency
Department:
Critical Effect of the
Transition to Adulthood
Peter Scal, MD MPH* Robert Town, PhD**
University of Minnesota
Departments of Pediatrics, Medical School
*
Health Policy and Management, School of Public Health & National
Bureau of Economic Research
**
Funded by the Agency for Healthcare Research and Quality
K08 HS015511-01A1
Background

In the US, young adults with chronic
conditions:



High rates of uninsurance
Poor access to care
Both of which are remarkably different than it is for
children and adolescents
Study Questions and Hypotheses
Goal: Evaluate impact of loss of insurance on
utilization and expenditures
Hypothesis: Losing insurance will lead to:
1.
2.
3.
Increase in ED use
Decrease in routine utilization (Office Visits,
Rx)
Decrease in total $, but increase in out-ofpocket
Data Source/Study Population

Pooled 7 panels of MEPS (1996-2003)

2 years of observation for each subject

Selected young adults ages 18 -19 during the
first year of observation

Limited to those with:
 chronic conditions
 health insurance
Key Variables

Insurance Status:



Maintain: (any insurance in both years, n=800)
Lose: (insurance in 1st year, none in 2nd; n=81)
Utilization:




Emergency Department Visits ( # )
Office Visits ( # )
Prescription fills ( # )
Expenditures for these services ( $ ) both total and
out-of-pocket
Analytic Strategy

Difference in Difference to estimate the
effects of losing insurance.


Calculate the change in utilization between
the years
Compare the change between the two
groups (maintain vs. lose ins.)
Results: Loosing insurance
By logistic regression, factors significantly
associated with losing insurance:

Public insurance (OR 2.29; 95% CI 1.23 - 4.27)

Age 19 (OR 1.87; 95% CI 1.14 – 3.07)
With sex, employment, income, race/ethnicity, msa
health status, student status not significant predictors
Results: Counts
Simple Difference in Differences
Lose Insurance
Year 1
Year 2
Maintain Ins
Year 1
Year 2
Treatment Effect
Emergency
Department
Use
(mean)
Office
Visits
Prescription
Fills
(mean)
(mean)
.30
.57
.27
2.3
1.1
-1.2
4.5
2.9
-1.6
.29
.29
.00
3.3
3.5
0.2
5.6
5.4
-0.3
.27
-1.4
-1.3
Results: Counts
Regression Based Treatment Effect
Emergency Office
Department Visits
Use
(mean) (mean)
Treatment Effect
p value
+ 100.5% - 50.8%
.05
.01
Prescription
Fills
(mean)
- 32.9%
.03
(Models include: age, sex, race/ethnicity,
health status, student status, employment
status, msa, and region of country)
Results: Total Payments for 3 services ($)
Simple Difference in Differences
Lose Insurance
Year 1
Year 2
Maintain Ins
Year 1
Year 2
Treatment Effect
Emergency
Department
$
(mean)
Office
Visits
$
(mean)
Prescription Expenditures
Fills
(Sum)
$
(mean)
(mean)
59.8
284.1
224.3
268.0
108.3
-159.7
193.8
164.3
-29.5
521.7
556.7
35.1
109.7
126.4
16.7
428.2
330.8
-97.5
302.7
285.8
-17.0
840.6
742.9
-97.7
207.6
-62.2
-12.5
132.8
Results: Total Payments for 3 services
Regression Based Treatment Effect
Emergency Office
Department Visits
$
$
(mean) (mean)
Treatment Effect
p value
238.8%
.08
-44.9%
.16
Prescription Expenditures
Fills
( Sum )
$
$
(mean)
(mean)
-14.0%
.60
32.3 %
.07
(Models include: age, sex, race/ethnicity,
health status, student status, employment
status, msa, and region of country)
Results: Out of Pocket Payments ($)
Simple Difference in Differences
Lose Insurance
Year 1
Year 2
Maintain Ins
Year 1
Year 2
Treatment Effect
Emergency
Department
$
(mean)
Office
Visits
$
(mean)
Prescription Expenditures
Fills
(Sum)
$
(mean)
(mean)
11.3
151.5
140.1
44.0
25.2
-18.8
94.6
129.5
34.9
150.0
306.2
156.1
12.3
16.4
4.1
64.4
56.3
-8.2
98.0
111.5
13.5
174.7
184.2
9.4
136.0
-10.6
21.3
146.7
Results: Out of Pocket Payments
Regression Based Treatment Effect
Emergency Office
Department Visits
$
$
(mean) (mean)
Treatment Effect
p value
1161%
.04
-25%
.46
Prescription Expenditures
Fills
( Sum )
$
$
(mean)
(mean)
13%
.64
150.4 %
.07
(Models include: age, sex, race/ethnicity,
health status, student status, employment
status, msa, and region of country)
Summary of findings

Scope: 9 % of 18-19 y.o. lose insurance

Selection: Those with private coverage, and higher
utilization tend to maintain coverage

Impact: Loss of insurance leads to:
 More ED visits
 Fewer office visits
 No difference in total expenditures but
 Increase in out-of-pocket burden but this is not
stat. sig.
Implications

Even without health insurance, YACC
continue to use health care services

Shift from office visits to ED is in contrast
with best clinical practice

Opportunity for clinical practice and
policy based interventions
Losing Insurance and
Using the Emergency
Department:
Critical Effect of the
Transition to Adulthood
Peter Scal, MD MPH* Robert Town, PhD**
University of Minnesota
Departments of Pediatrics, Medical School
*
Health Policy and Management, School of Public Health & National
Bureau of Economic Research
**
Funded by the Agency for Healthcare Research and Quality
K08 HS015511-01A1