1. Capstone 2011 Kisha Davis, M.D.

2.  Created in 1965 to provide medical coverage to the poor  Children, the disabled, pregnant women, very low income parents and the elderly poor are eligible  Federally funded, state administered  Income limits range from 17% (AK) to 215% (MN) of FPL

3.  In 2007 Maryland passed the Working Families and Small Business Health Coverage Act  The Medical Assistance to Families program increased Medicaid eligibility for parents from 36% to 116% (FPL)  Covered an additional 65,000 people  Similar to the coming Affordable Care Act Medicaid expansion

4.  The purpose of this study is to examine the characteristics of the expansion population in comparison to the non-expansion population to determine if there are differences in health care costs and utilization. ◦ Sicker or healthier? ◦ More expensive or less? ◦ Pent up demand?

5.  Claims data from a Managed Care Organization (MCO) FY 2009 & 2010  Newly enrolled individuals aged 19 to 64  Remained enrolled for at least six months  Study groups ◦ Expansion ◦ Previously Eligible ◦ Continuous- enrolled last 6 months of FY 2008

6.  Identified by the state as expansion or not  Excluded disabled persons, pregnant women, persons with substance abuse diagnosis  Each member followed for maximum of 12 months after start of experience period

7. Categorical variables: chi-square Continuous Variables: ANOVA with Tukey’s test for adjustment for multiple comparison Multivariate analysis done using proc genmod All analyses done in SAS

8. Expansion (N = 13,987) Previously Eligible (N=7,922) Continuously Enrolled (N= 1,159) P-Value Mean months enrolled (SD) 10.410.210.0p < 0.0001 for all Mean age (SD)34.531.833.3E v P p < 0.0001 E v C p=0.0002 P v C p=0.0001 Female, %71.4%74.2%82.1%p < 0.0001 Race, % White37.2%33.0%33.1%p < 0.0001 Black/Hispanic/ Asian/Indian 40.2%46.5%61.9% Unknown22.6%20.5%5.1% Region*, % Urban14.0%21.6%33.7%p < 0.0001 Suburban38.6%42.1%35.0% Rural47.4%36.4%31.3%

9. Expansion (N = 13,987) Previously Eligible (N=7,922) Continuously Enrolled (N= 1,159) P-Value Number of Chronic Conditions p < 0.0001 061.3%64.2%46.1% 117.7%17.2%21.7% 29.1%8.3%12.7% 3+11.9%10.3%19.6% Mean ACG- (prob. of being high cost in the next year) 0.07 0.11E v P p=0.0122 E v C p<0.0001 P v C p <0.0001 RUB Score (morbidity)p < 0.0001 Non-users11.7%14.6%11.0% Very low12.2%12.3%4.5% Low12.7%12.0%10.4% Moderate44.1%40.9%45.5% High15.2%15.9%19.3% Very high4.2%4.3%9.2%

11. Mean Total Costs Mean Inpatient Costs

12. Regression Analysis P-Value Expansion0 Previously Eligible $55P<0.0001 Continuous-$74P=0.0001

13.  Limitations ◦ Time frame continuous vs newly enrolled ◦ Drop outs  Implications for Affordable Care Act ◦ Predictions on health status of new enrollees ◦ Cost considerations ◦ Continuous coverage  Future Directions

14.  Dr. Jonathan Weiner  Alyson Schuster  Dr. Peter Fagan  Priority Partners

15.  Hadley, J. (2003). Sicker and Poorer- the consequences of being uninsured:. Medical Care Research Review, 60 (2 suppl) 3S-75S.  Institute of Medicine. (2003). Hidden Costs, Value lost, uninsurance in America. Washington, DC: National Academies Press.  JM McWilliams, E. M. (2007). Health of previously uninsured adults after acquiring Medicare coverage. JAMA, 298(24):2886–94.  JM McWilliams, E. M. (2007). Use of health services by previously uninsured Medicare beneficiaries. NEJM, 357(2):143–53.  Kaiser Family Foundation. (2010). Medicaid and children's health insurance program provisions. Focus on Health Reform, Publication #7952-03.  Kaiser Family Foundation. (2010). Medicaid Facts. Kaiser Commission on Medicaid and the Uninsured, Publication #7235-04.  Kaiser Family Foundation. (2011). State Medicaid Fact Sheet. Kaiser Commission on Medicaid and the Uninsured, http://www.kff.org/MFS/.  Ku, L. (2010). Ready, Set, Plan, Implement: Executing The Expansion of Medicaid. Health Affairs, 29(6):1173-1177.  Maryland DHMH. (2011, March 4). Maryland Medical Assistance for Families. Retrieved April 21, 2011, from http://www.dhmh.state.md.us/ma4families/html/faqs.htm  State Coverage Initiatives. (2010). State Coverage Initiatives. Retrieved January 26, 2011, from State Specific Strategies: http://www.statecoverage.org/node/50/cs_states  Tilford, J., Robbins, J., Shema, S., & Farmer, F. (1999). Response to health insurance by previously uninsured rural children. Health Services Research, 34(3):761-775.