1. Churning: Disenrollment and Reenrollment in Wisconsin’s Medicaid and BadgerCare Programs Presented to: AcademyHealth Annual Research Meeting San Diego, CA June 8, 2004 Presented by: Nancy Lenfestey, M.H.A. Contributors: Norma I. Gavin, Ph.D. Nathan West, M.P.A. Funded by the Centers for Medicare and Medicaid Services (CMS). This presentation does not necessarily reflect CMS views or policies.

2. 2 BadgerCare is A Medicaid demonstration program in Wisconsin designed to bridge the gap between Medicaid and private insurance for the working poor. Supported by a combination of federal and state matching funds under: l Section 1115 Medicaid Waiver, and l State Children’s Health Insurance Program. A Medicaid expansion program—enrollment system, benefit structure and health care delivery system for Medicaid and BadgerCare are one and the same.

3. 3 Enrollment Source: Wisconsin Department of Health and Family Services. BadgerCare at a Glance: March 2004. http://www.dhfs.state.wi.us/badgercare/pdfs/BadgerCareAtaGlance-March2004.pdf

4. 4 BadgerCare and Medicaid Eligibility Categories

5. 5 Churning Process of repeatedly coming into and out of a health insurance program l Disruptive to continuity of care l Negative health outcomes l Costly

6. 6 Research Questions l Did the length of enrollment and the probability of disenrolling from public coverage differ for: u BC enrollees compared to individuals in traditional Medicaid eligibility categories? u Individuals in traditional Medicaid eligibility categories pre- to post- BC? l For Medicaid/BC disenrollees, did the length of time that they remained off public coverage and the probability of re- enrolling differ for: u BC enrollees compared to individuals in traditional Medicaid eligibility categories? u Individuals in traditional Medicaid eligibility categories pre- to post- BC l Do the probabilities of enrolling and re-enrolling vary by race/ethnicity?

7. 7 Enrollment patterns: Length of enrollment episodes Defined pre- and post BadgerCare periods: l Pre: All episodes beginning from Jan. 1, 1997 through Dec. 31, 1998 (n=339,955 episodes) l Post: All episodes beginning from Jan. 1, 2000 through Dec. 31, 2001 (n=394,197 episodes) Defined eligibility category as that in which individuals were enrolled at the start of the episode. Ran Kaplan-Meier survival curves on the length of enrollment by age group, eligibility category, and time period.

8. 8 Enrollment Duration—Adults Pre- and Post- Probability of Remaining Enrolled among Adults Pre- and Post- BadgerCare

9. 9 Enrollment Duration--Pregnant Women Pre- and Post- Probability of Remaining Enrolled Among Adult Healthy Start Pregnant Women Pre- and Post- BadgerCare

10. 10 Enrollment Duration— Children Pre- and Post- Probability of Remaining Enrolled among Children Aged 6 to 18 Pre- and Post- BadgerCare Probability of Remaining Enrolled among Children Aged 0 to 5 Pre- and Post- BadgerCare

11. 11 Enrollment patterns: Length of time between episodes Defined pre- and post-BadgerCare periods as: l Pre: All episodes ending from Jan. 1, 1997 through Dec. 31, 1998 (n=320,461) l Post: All episodes ending from Jan. 1, 2000 through Dec. 31, 2001 (n=294,822) Defined eligibility category as that in which individuals were enrolled at the time of disenrollment. Ran Kaplan-Meier survival curves of the length of time out of public coverage by age group, eligibility category, and time period.

12. 12 Months Between Episodes- Adults Pre- and Post- Probability of Remaining Disenrolled among Adults Pre- and Post- BadgerCare

13. 13 Months Between Episodes-Children Post- Period by Eligibility Category Probability of Remaining Disenrolled among Children Aged 6 to 18 Probability of Remaining Disenrolled among Children Aged 0 to 5

14. 14 Probability of Reenrolling at 12 months Post-Period 0-5 years6-18 yearsAdult BadgerCare52%44%43% AFDC59%53%51% Healthy Start46%52%43%

15. 15 Race/Ethnicity Post-Period Adult Enrollment Duration by Race/Ethnicity Child Enrollment Duration by Race/Ethnicity

16. 16 Race/Ethnicity— Months Between Episodes Post-Period Probability of Remaining Disenrolled among Adult Enrollees Post- BadgerCare Probability of Remaining Disenrolled among Child Enrollees Post- BadgerCare

17. 17 Conclusions Besides increasing the number of publicly insured low-income adults and children, BC also increased the lengths of enrollment in public coverage. Greater likelihood of continued eligibility and enrollment of Healthy Start pregnant women--12% pre-BC versus 40% post-BC at 12 months postpartum.

18. 18 Conclusions Churning was particularly high among Medicaid and BC children. l As many as 15%-20% of children re- enrolled after only 1 month l 60%-70% had reenrolled within the first 2.5 years after disenrolling Black NH enrollees were more likely to remain enrolled longer and to re-enroll earlier once disenrolled relative to enrollees of other races/ethnicities. Effects of churning on well-child visit and immunization schedules?