Medicare, Medicaid, and SCHIP Extension Act of 2007 and the Medicare Secondary Payer Act (MSP)
Expansion of Public Insurance for Adults: SCHIP and Medicaid/QUEST
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Transcript of Expansion of Public Insurance for Adults: SCHIP and Medicaid/QUEST
This research is funded in part through a U.S. Health Resources and Services Administration, State Planning Grant to the Hawaii State Department of Health, Prime Contract No. 1 P09 OA 00046-01. Sub-Contract Research Corporation of the University of Hawaii, Project No. 659075. Research conducted by the University of Hawaii, Social Science Research Institute in collaboration with the Hawaii State Department
of Health, Hawaii Institute for Public Affairs/Hawaii Uninsured Project and the Hawaii Health Information Corporation.
Expansion of Public Insurance for Adults:
SCHIP and Medicaid/QUEST
Gerard RussoSang-Hyop Lee
Lawrence NitzUniversity of Hawai`i at Mānoa
Hawai`i Coverage for All ProjectTechnical Workshop III
23 May 2003
This research is funded in part through a U.S. Health Resources and Services Administration, State Planning Grant to the Hawaii State Department of Health, Prime Contract No. 1 P09 OA 00046-01. Sub-Contract Research Corporation of the University of Hawaii, Project No. 659075. Research conducted by the University of Hawaii, Social Science Research Institute in collaboration with the Hawaii State Department
of Health, Hawaii Institute for Public Affairs/Hawaii Uninsured Project and the Hawaii Health Information Corporation.
POLICY SCENARIO:SCHIP Adults
Extend State Children’s Health Insurance Program eligibility to the
parents of children aged 0-18 years residing in households with incomes
less than or equal to 200% of the Federal Poverty Line.
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Social Security Amendments
Medicare: Title XVIII of the Social Security Act 1965
Medicaid: Title XIX of the Social Security Act 1965
SCHIP: Title XXI of the Social Security Act 1997
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
SCHIP FMAP
Federal Medical Assistance Percentage (FMAP)
FFY 2002 69.44% FFY 2003 71.14%
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Adult SCHIP Demonstration States
Arizona Minnesota New Jersey Rhode Island Wisconsin
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Econometric Model: Multinomial Logit Mutinomial Logit to Estimate the Probability of Coverage Three Categories
Uninsured Private Insurance & Other Medicaid QUEST
Predictor Variables Age Sex Income County Race/Ethnicity Health Status (some models) Employment Status (some models)
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Methodology for Predicting the Effect of Changing Eligibility
Step I: Estimate multinomial logit model on a sample of adults with eligible children where the adults are also eligible (i.e., 0-100% FPL).
Step II: Estimate multinomial logit model on a sample of adults with eligible children where the adults are ineligible (i.e., 100-200% FPL).
Step III: Predict with Model I and Model II with the characteristics of the target population (i.e., adults with SCHIP children 100-200% FPL).
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Economic-Demographic Analysis of Adult SCHIP Expansion
How many additional adults are potentially eligible for free medical assistance under the SCHIP Expansion from 100% to 200% FPL? 35,756 adults based on CPS 1996-2002
Of the newly eligible adults, how many are expected to be enrolled in SCHIP? (Take-Up) 7831 adults based on model estimate CPS 1996-2002
Of the newly enrolled SCHIP beneficiaries, how many are expected to have switched from private to public insurance? (Crowd-Out) 4255 adults based on model estimates CPS 1996-2002
How many adults will become newly insured? 3576 adults based on model estimates CPS 1996-2002
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Econometric Prediction of Insurance Coverage Change due to Adult SCHIP Expansion: CPS 1996-2002
Prediction
Ineligible
Prediction
Eligible
Change
Uninsured 14.0% 4.0% -10.0%
Private Insurance
80.2% 68.3% -11.9%
Public Insurance
5.8% 27.7% +21.9%
Total 100% 100% 0%
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Econometric Prediction of Insurance Coverage Change due to Adult SCHIP Expansion: CPS 1996-2002
Prediction
Ineligible
Prediction
Eligible
Change
Uninsured 5006 1430 -3576
Private Insurance
28,676 24,421 -4255
Public Insurance
2074 9905 +7831
Total 35,756 35,756 0
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Incurred Per Capita Expenses 2001: Uninsured SCHIP Adults Age 19-64, 100-200% FPL
Emergency Room & Hospital Discharge
$388
Private Physician Offices ?
Primary Care Facilities ?
Pharmaceuticals, etc. ?
TOTAL $388
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Economic Cost Analysis
What is the expected direct expenditure per newly enrolled beneficiary? $3000 Burden to Federal Taxpayers $2134 Burden to State Taxpayers $866
What is the current total medical expenditure by all sources per uninsured adult residing in SCHIP households 100-200% of FPL? $388
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Economic Cost Analysis (cont.)
What is the cost per newly insured adult? Cost to Federal Taxpayers Cost to State Taxpayers Cost to Society as a Whole
What is the total cost of the SCHIP expansion? Cost to Federal Taxpayers Cost to State Taxpayers Cost to Society as a Whole
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Burden to Federal and State Taxpayers
Direct Cost of SCHIP Expansion $3000*7831=$24,493,000 Federal Share 71.14%: $2134*7831=$16,711,354 State Share 28.86%: $866*7831=$6,781,646
Direct Cost per Newly Insured Adult $6849 Federal Cost per Newly Insured Adult $4873 State Cost per Newly Insured Adult $1976
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Net Cost to Society as a Whole
Cost of Newly Insured Adults $3000*3576.
$10,728,000
Less Current Medical Expenses $388*3576.
$1,387,488
Net Cost $9,340,522
This research is funded in part through a U.S. Health Resources and Services Administration, State Planning Grant to the Hawaii State Department of Health, Prime Contract No. 1 P09 OA 00046-01. Sub-Contract Research Corporation of the University of Hawaii, Project No. 659075. Research conducted by the University of Hawaii, Social Science Research Institute in collaboration with the Hawaii State Department
of Health, Hawaii Institute for Public Affairs/Hawaii Uninsured Project and the Hawaii Health Information Corporation.
Policy Scenario:Medicaid/QUEST Adults
Extend Quest eligibility to adults with incomes less than or equal to 200% of the Federal Poverty
Line
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Medicaid/QUEST FMAP
Federal Medical Assistance Percentage (FMAP)
FFY 2003 58.77%
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Where we are now: Distribution of Insurance in 2001, BRFSS Survey
Class Num. Percent
Uninsured 134 7.84
Insured 1470 85.96
Medicaid 106 6.2
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Two models
Test Case: Compute a predictive equation on the 0% to 100% FPL population Estimate the distribution of insured among the
100%-200% FPL population using this equation Base Case: Compute a predictive Equation
on the entire sample Estimate the distribution of insured among the
100% -200% FPL population
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Predictions of changing Medicaid ceiling to 200% of FPL
Predicted vs. Actual Rates of Coverage
(pooled 2000 and 2001 data, BRFSS)
Coverage Method:Prediction
Eligible*PredictionIneligible^ Actual
Uninsured 8.9 3 7.84
Insured 81.2 92 85.96
Medicaid 9.9 5 6.2
*Prediction Target Group Eligible: Fit model over the population <100% FPL, then predict over the means of the 100%-200% FPL population.
^Prediction Target Group Ineligible: Fit model over the entire population and predict over the means of the 100%-200% FPL population.
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Implications for Changing Adult Eligibility
From the ideal base case, raising the eligibility floor to 200% FPL brings the Medicaid coverage from 5% to 9.9%
The same change in eligibility also raises the percentage of uninsured from 3% to 8.9%
10.8% of the target population will switch from private or other health insurance to Medicaid
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Problematic Issues
The whole population model may not be the best indicator of the base case for the 100% to 200% FPL household’s insurance decision
The multivariate logistic regression for the 0% to 100% FPL population may identify behavioral patterns unrelated to the policy difference—the zero monetary cost of Medicaid coverage
Rev. 22 May 2003 Preliminary results. Not for quotation, citation nor further dissemination.
Open Questions
How can we more cleanly separate the economic decision to acquire a particular health insurance coverage from other motivations or experiences in the target population?
Do systematic differences in the underlying surveys lead to different results in the CPS and BRFSS?