1. 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. Hawai `i ’s Uninsured Population: Adults Age 19-64 Lawrence Nitz Gerard Russo Sang-Hyop Lee University of Hawai`i at Mānoa Hawai`i Coverage for All Project IV Technical Workshop 26 September 2003

2. Preliminary results. Please do not quote. Counting the Uninsured— Fixing the Problem Who are the uninsured? We have to ask them  Counting everyone—a census  Counting a sample—and estimating Who are we counting? Each major survey defines a purposeful population Each survey has a policy goal—but potential additional uses How do we count? Who should we exclude? Who is excluded inadvertently or by the initial study design?

3. 26 September 2003 Preliminary results. Please do not quote. Example: Uninsured by Age Group Partitioning population by policy initiative (source of funds) Exclusion of segments adequately covered elsewhere (65-year-olds and older residents)

4. 26 September 2003 Preliminary results. Please do not quote. Do we focus on everyone—or can we omit elders with Medicare?

5. 26 September 2003 Preliminary results. Please do not quote. Shorthand for data selection Recognize policy purpose of initial study Identify sampling frame and intended population Do these match our needs? Must we adjust the population [by removing elders, for example] Understand how sample size bounds the precision of any reported number Restrict inference to the time, geographical scope, and population justified by sample Combine years or waves of survey to increase sample size

6. 26 September 2003 Preliminary results. Please do not quote. The pragmatic boundaries Whichever data source, whatever level of the specified problem we must ask: How much will it cost to serve everyone? How much slippage is likely in the process? Will persons now served by self-paid plans drop them in favor of a free governmental service? Will external actors be rewarded for tactics that ultimately increase the size of the group to be helped?

7. 26 September 2003 Preliminary results. Please do not quote. Looking at estimates of the uninsured: Policy Options, Test Data and Side Effects Assessment Strategy Policy Option Mechanism Required Data Side-Effects

8. 26 September 2003 Preliminary results. Please do not quote. Expand Medicaid for adults to a 200% of poverty eligibility ceiling. Substitution of free public program for former participatory or paid program. Movement from stable enrollment to program with tested re-enrollment and or disqualifications

9. 26 September 2003 Preliminary results. Please do not quote. Expand Medicaid for adults to 300% of poverty eligibility ceiling Substitution of free public program for former participatory or paid program. Movement from stable enrollment to program with tested re-enrollment and or disqualifications. Test for actions by employers to move workers from company to public plan.

10. 26 September 2003 Preliminary results. Please do not quote. Reduce application and re-enrollment documentation and requirements for Medicaid Some persons ineligible on income grounds in the short run may be granted benefits. It is difficult to tally the cost or savings of work not done on forms not filed. Assured enrollment status will increase the level of usage, since persons will not be in the disenrolled-not-yet- re-enrolled status.

11. 26 September 2003 Preliminary results. Please do not quote. Take parents of SCHIP children into Medicaid program Movement of parents out of eligibility status while children retain benefits. Creates re-enrollment issues for family

12. 26 September 2003 Preliminary results. Please do not quote. Create ERISA compliant employment based program for persons working under 20 hrs per week. Costs associated with low initial sales. Administrative costs, medical costs associated with moving in and out of program. Inability of clients to pay their non- employer segments in times of short work; variance in employer contributions due to changes in working hours.

13. 26 September 2003 Preliminary results. Please do not quote. Create program blending some groups of employed but uninsured with unemployed, uninsured who are not currently Medicaid eligible Displacement of some currently insured workers into the new program. Unanticipated cost shifts or subsidy requirements because of random events in work experience (short hours, layoffs, etc.)

14. 26 September 2003 Preliminary results. Please do not quote. A Profile of Hawaii’s Uninsured Uninsured from the sources cited above Edited for simplicity One year out of several

15. 26 September 2003 Preliminary results. Please do not quote. Age Distribution of Uninsured

16. 26 September 2003 Preliminary results. Please do not quote. Life-stage and insured status

17. 26 September 2003 Preliminary results. Please do not quote. Income Distribution of Uninsured

18. 26 September 2003 Preliminary results. Please do not quote. What is going on? Surveys tend to use income categories in the direct questions to respondents BRFSS asks initially for a knowledgeable person in the household Broader definitions may elicit different responses than definitions which focus on wages and salaries Apparent differences level out when using per- capita income within the household, or poverty indicators

19. 26 September 2003 Preliminary results. Please do not quote. Poverty Status

20. 26 September 2003 Preliminary results. Please do not quote. Employment Status and Uninsurance

21. 26 September 2003 Preliminary results. Please do not quote. Population employment

22. 26 September 2003 Preliminary results. Please do not quote. Employment status from HHS

23. 26 September 2003 Preliminary results. Please do not quote. Risk of being uninsured Labor Force StatusUninsuredPopulation Odds Ratio Unable to Work0.78%1%0.78 Retired1.58%20%0.08 Student12.73%4%3.18 Homemaker7.53%6%1.26 Unemployed> 1 year10.04%2%5.02 Unemployed<1 year15.66%2%7.83 Self-employed25.68%8%3.21 Employed26%58%0.45

24. 26 September 2003 Preliminary results. Please do not quote. Quest Eligibility among Uninsured

25. 26 September 2003 Preliminary results. Please do not quote. For any group, such as the 26,000 to 29,000 uninsured between 100% and 200% of FPL, at any typical cost of coverage, how many do we wish to cover? –Remember 29,000 times $2,000/year is $58 million. --Shall we go for $3,000 in annual insurance premiums? Critical Questions

26. 26 September 2003 Preliminary results. Please do not quote. Employee /Employer responses Creation of the public program by no means assures that those currently covered privately will continue to be so covered. What is our tolerance for shifting people from a privately or employer-paid program to a publicly paid program? What level of distortion are we willing to tolerate in the labor market, should a proposed program shift costs for employers?

27. 26 September 2003 Preliminary results. Please do not quote. Distortions & Unintended consequences What level of distortion are we willing to tolerate in the labor market, should a proposed program shift costs for employers? What degree of inaccuracy in estimates of Quest or Medicaid qualification are we willing to tolerate in order to bring any substantial number of the currently eligible into the Quest program? What inaccuracy will we tolerate to reduce paperwork and increase retention in of the qualified poor in the Quest program? How much can we save by assuring continuous enrollment for a year or two or three for Quest adults, mothers with children, children, and the like?

28. 26 September 2003 Preliminary results. Please do not quote. End question How much of any defined problem can be fixed—accounting for unforeseen consequences, events and the like How much do we want to pay—and from which other programs are we willing to take the funds?