The Effects of Expanding Public Insurance to Childless Adults
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Transcript of The Effects of Expanding Public Insurance to Childless Adults
The Effects of Expanding Public Insurance to Childless Adults
Marguerite Burns, Ph.D. University of Wisconsin-Madison APPAM Fall Research Conference November 12, 2015
Acknowledgments
• Co-authors Laura Dague, Ph.D., Texas A&M University Thomas DeLeire, Ph.D., Georgetown University Lindsey Leininger, Ph.D., Mathematica Policy Research, Inc. Gaston Palmucci, Ph.D., Fiscalia Nacional Economica Donna Friedsam, MPH, University of Wisconsin-Madison Kristen Voskuil, MA, University of Wisconsin-Madison John Schmelzer, Ph.D., Marshfield Clinic Mary Dorsch, RN, Marshfield Clinic
• Funding
NIH NCATS Grant UL1TR000427 to the UW ICTR NIMH K01 092338 Robert Wood Johnson Foundation SHARE program WI Department of Health Services
What Do We Know About the Effects on Use of Care of Expanding Medicaid to Childless
Adult Populations?
Recent Studies
Massachusetts [Long and Dahlen, 2014] • Increased likelihood of usual source of care
Oregon [Finkelstein et al.,2012; Baicker et al.,2013; Taubman et al., 2014]
• Increased outpatient visits • Mixed effects on ED use • Initial increase in inpatient use that did not persist
Background: Prior to ACA Wisconsin sought to insure 98% of citizens
• In 2008, program simplification and coverage
expansion to all children and low-income caretaker adults – BadgerCare Plus
• In 2009 a coverage expansion to low-income childless adults – BC+ Core Plan • Medicaid-like plan for uninsured adults w/out
dependent children with incomes < 200%FPL
6
How did the Core Plan for childless adults affect the use of health care?
Marshfield
Milwaukee County
Poor individuals in Milwaukee County • 9,619 prior users of the county safety net system who
were automatically enrolled on 1/1/09 Low-income individuals in Marshfield Clinic’s 28-county service area in central & northern WI
• Prior users of Marshfield Clinic safety net system
Two Populations
The Challenge in Studying the Effect of Health Insurance on Utilization
Participation or enrollment is a choice
vs. Attempt to find quasi-random changes in enrollment into public insurance
BC+ Core Plan Auto-Enrollment
GAMP BC+ Core Plan
January 1, 2009
Indigent care program for poor uninsured adults in Milwaukee County
12,941 individuals were auto-enrolled into BC+ Core Plan
BC+ Core Plan Enrollment Freeze
BC+ Core Waitlist
October 9, 2009
Statewide open enrollment begins for childless adults with incomes below 200% FPL.
Enrollment suddenly closed. Subsequent eligible applicants placed on a waitlist.
July 1, 2009
Our approach: Quasi-experimental design
Examine two populations 1. Poor individuals who were automatically
enrolled into BC Core on January 1, 2009 (GAMP population, Milwaukee County)
2. Low-income individuals who applied around
the time the enrollment cap was imposed (Marshfield Clinic)
Method 1: Pre-Post Comparison
12-months of pre-enrollment utilization
12-months of post-enrollment utilization
Auto-enrollment into BC+ Core
Method 2: Regression Discontinuity
October 9, 2009
Last Individuals enrolled
First individuals placed on the waitlist
Data: Wisconsin Medicaid
Data: Marshfield Clinic
Outcomes
Outpatient Visits
Emergency Department Visits
Hospitalizations
Results from Milwaukee County
40% Increase No Change 140% Increase
Results from Marshfield Area
Summary of Main Results
AnyOutpa*ent Preven*ve
MentalHealthorSubstanceAbuse Emergency Inpa*ent
Baseline 2.783 0.275 0.297 0.056 0.034
Coef 1.076 0.256 -0.064 0.060 0.042
P-Value 0.026 0.000 0.655 0.086 0.081Notes:Allresultses,matedatabandwidthof14daysexcludingoneweekpriortoandfollowingtheclosingdate.
Outpatient Visits 0
24
6
Avg.
Num
ber o
f Out
patie
nt V
isits
-20 -10 0 10 20Days from Oct 5th (left) or Oct 14th (right)
Panel A. Outpatient
Preventive Care Visits 0
.2.4
.6.8
Avg.
Num
ber o
f Pre
vent
ive C
are
Visit
s
-20 -10 0 10 20Days from Oct 5th (left) or Oct 14th (right)
Panel B. Preventive Care
Mental Health or Substance Use 0
.51
1.5
2
Avg.
Num
ber o
f MHS
UD V
isits
-20 -10 0 10 20Days from Oct 5th (left) or Oct 14th (right)
Panel C. Mental Health or Substance Abuse
ED Visits 0
.1.2
.3.4
Avg.
Num
ber o
f Em
erge
ncy V
isits
-20 -10 0 10 20Days from Oct 5th (left) or Oct 14th (right)
Panel D. Emergency
Inpatient Visits 0
.05
.1.1
5
Avg.
Num
ber o
f Inp
atien
t Visi
ts
-20 -10 0 10 20Days from Oct 5th (left) or Oct 14th (right)
Panel E. Inpatient
Outpatient visits • Increase in Milwaukee sample • Increase in Marshfield sample
ED visits
• Increase in Milwaukee sample • No change in Marshfield sample
Hospitalizations • Decrease in Milwaukee • Increase in Marshfield sample
Differences don’t seem to be due to differences in enrollee case mix
Heterogeneous Impacts
The impacts likely depend on the characteristics of the area health system Growing numbers of studies with credible designs; need to begin to focus on representativeness, and be attentive to variable effects across & within states.
Conclusions
Extra Slides
Local Linear Regression For outcome Yi, date Xi cutoff date x0, threshold indicator Wi
where the weights are given by h is the bandwidth in days, and τ is the treatment effect of interest.
Sharp Regression Discontinuity
( ) ( ) iiiiii WxXWxXY εγτβα +−++−+= 00
0xXh i −−
Demographic Characteristics
Core Enrollees
(All)
Core Enrollees (Within 30
Days)
Waitlisted Applicants
(All)
Waitlisted Applicants (Within 30
Days)
Number of enrollees 4,280 658 3,262 351
Male 41% 44% 48% 45%
Age, years 43.78 41.00 39.91 39.84
Age<35 30% 39% 45% 44%
Age 35-54 43% 39% 37% 40%
Age 55 + 26% 22% 18% 16%
Inpatient Visits
-0.2
-0.1
0.0
0.1
0.2
0.3
0.4
0.5
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Coe
ffici
ent a
nd 9
5% C
I
Bandwidth in Days
Panel E. Inpatient
ED Visits
-0.6
-0.4
-0.2
0.0
0.2
0.4
0.6
0.8
1.0
1.2
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Coe
ffici
ent a
nd 9
5% C
I
Bandwidth in Days
Panel D. Emergency