Is Insurance Stability an Overlooked Aspect of Quality?: What we know about Stability for in Medicaid? Gerry Fairbrother, Ph.D. Cincinnati Children’s Hospital Medical Center Presented at Child Health Services Research Meeting June 25, 2005 This research was supported by The Commonwealth Fund, the California Endowment, the Jewish Healthcare Foundation and Blue Cross/Blue Shield of Michigan. I thank Medicaid officials in the participating states for their assistance.
Transcript
Is Insurance Stability an Overlooked Aspect of Quality?: What we know
about Stability for in Medicaid?
Gerry Fairbrother, Ph.D.Cincinnati Children’s Hospital Medical Center
Presented atChild Health Services Research Meeting
June 25, 2005
This research was supported by The Commonwealth Fund, the California Endowment, the Jewish Healthcare Foundation and Blue Cross/Blue Shield of Michigan. I thank Medicaid officials in the participating states for their assistance.
Background: Insurance Instability
• Recent studies have highlighted high levels of instability in coverage, for both adults and children
– Short PF and Graefe DR. Battery-powered health insurance? Stability in coverage of the uninsured. Health affairs. 2003. 22(6):244-255.
– Tang SS, Olson LM, Yudkowsky BK. Uninsured children: how we count matters: Pediatrics 2003;112:168-73.
• Problems of instability are particularly acute for low income and minority populations, who move– In and out of coverage– Between public and private coverage– Short PF and Graefe DR. Battery-powered health insurance? Stability in coverage of the
uninsured. Health affairs. 2003. 22(6):244-255.
Stability affects Quality of Care
• Individuals with unstable coverage have poorer access to and use of services
– Adults who had any time without health insurance during a year were two to four times more likely to have gone without needed medical care than adults insured all year long
– Duchon L et al. Security matters: How instability in health insurance puts U.S. workers at risk. 2001. The Commonwealth Fund; New York , NY.
– Individuals currently insured, but with gaps in coverage during the year were more likely to report that they had no usual source of care or that they used the ER as a usual source of care and that they had no doctor visit in the past year
– Schoen C and DesRoches C. Uninsured and unstably insured: the importance of continuous coverage. Health Services Research. 2000. 35(1 Pt 2: 187-206
Coverage Gaps Harm Children’s Care as Well as Adults
• Children with a recent gap in coverage are more likely
• To lack a usual source of care, and• Kogan MD, et al. The effect of gaps in health insurance on continuity of a regular
source of care among preschool-aged children in the United States. JAMA. 1995. 274(18):1429-1435.
• To delay seeking needed medical care and filling prescriptions for drugs
• Aiken KD, Freed GL and Davis MM. When insurance status is not static: insurance transitions of low-income children and implications for health and health care. Amb. Ped. 2004. 4:3):237-243.
Stability and Quality
• Discussions of quality improvement strategies usually do not include– Insurance infrastructure and its impact on stability– Strategies to improve stability among the quality-
related interventions
• Yet, these may be important, particularly so for low-income and minority children, who experience greater instability– Thus it is important to know more about instability in
public insurance programs for the low-income
The purpose of this study is to
• Assess the level of stability of coverage for children enrolled in Medicaid;
• Describe level of churning and the length of the breaks for children who leave and return;
• Describe the costs of churning (forthcoming)
Study Methods
• We examined Medicaid eligibility files in five states– California, Michigan, Ohio, Oregon, Pennsylvania
• We took children 5-18 enrolled in Medicaid as of December 2003
• We described enrollment patterns for these children during the three prior years (January 2001 – December 2003), including– Proportion of children enrolled continuously for 1, 2, and 3 years– Proportion of children with breaks in enrollment– Length of the breaks in enrollment
State/Medicaid Characteristics
US CA OH PA MI OR
Population (millions) 287.3 35.5 11.4 12.4 10.1 3.6
Medicaid enrollees June 2003 (millions)
40.6 6.4 1.6 1.6 1.3 .4
% population below 100% FPL, millions
17% 19% 15% 14% 16% 16%
% Uninsured
(children <18)
12% 14% 8% 10% 7% 13%
% on Medicaid
(children <18)
27% 29% 21% 20% 26% 25%
MMC penetration 60% 51% 30% 80% 75% 80%
From Kaiser Family Foundation; State Health Facts. http://www.statehealthfacts.org. 2003 data.
Features of the Medicaid Program that may Affect Enrollment/Renewal
CA OH PA MI OR
Income eligibility threshold, % FPL
(children 6-19)
100% 200% 100% 150% 100%
Separate SCHIP program
income eligibility threshold, %FPL
Yes
250%
No Yes
200%
Yes
200%
Yes
185%
Renewal period 12 m 12 m 12 m 12 m 6 m
12 mo Continuous eligibility yes no no yes no
Self-declaration of income no no no yes no
No face-to-face/No asset test yes yes yes yes yes
Donna Cohen Ross and Laura Cox. Beneath the Surface: Barriers threaten to slow progress on expanding health coverage of children and families. Kaiser Family Foundation. October 2004. (Based on data as of July 2004)
Figure 1: States Vary in Proportion of Children Stably
Insured for 3 Years
52 46 4734
25
13 15 12
1312
15 17 1721
21
21 21 24 3142
0%
20%
40%
60%
80%
100%
CA OH PA MI OR
3 Years 2 Years 1 Year <1 YearYears Continuously Enrolled:
Data Source: State Medicaid Enrollment Files. Note: Continuous enrollment over the three prior years for children enrolled in Medicaid in December 2003.Data includes children ages 5-18.
Percent of Children Enrolled for Specific Number of Years
• A substantial proportion of children are stably insured through Medicaid in some states (approximately 60% insured for two years for CA, OR, and PA), and
• Stably enrolled in a managed care plan, at least in some states, for their care to be managed;
• This means that Medicaid (and Medicaid managed care) have opportunity to affect quality of care.
Conclusions
• Still, from 18% to 44% of children leave the rolls, only to return after a short time
• This suggests that many (possibly most) of these children were eligible for coverage when they fell off the rolls
• The strong implication is that these children had problems with Medicaid renewal, rather than had a change in eligibility status
Limitations
• The results are five states only
• Our data do not permit an examination of causal links – between state policies and reasons for churning– Between churning or short tenures and quality
• We do not know why children left and came back on the rolls or what their insurance status was during the breaks
• We do not know the characteristics of the children who churn vs. those who are stably insured
Policy Implications
• Policymakers need to think about stability as a contributor to quality of care
• Strategies to improve stability need to be “on the table,” along with more traditional quality improvement interventions
• Research is needed on the relationship between stability and– Access– Use– Outcomes
