1. Is Insurance Stability an Overlooked Aspect of Quality?: What we know about Stability for in Medicaid? Gerry Fairbrother, Ph.D. Cincinnati Childrens Hospital Medical Center Presented at Child Health Services Research Meeting June 25, 2005 This research was supported by The Commonwealth Fund, the California Endowment, the Jewish Healthcare Foundation and Blue Cross/Blue Shield of Michigan. I thank Medicaid officials in the participating states for their assistance.

2. Background: Insurance Instability Recent studies have highlighted high levels of instability in coverage, for both adults and children –Short PF and Graefe DR. Battery-powered health insurance? Stability in coverage of the uninsured. Health affairs. 2003. 22(6):244-255. –Tang SS, Olson LM, Yudkowsky BK. Uninsured children: how we count matters: Pediatrics 2003;112:168-73. Problems of instability are particularly acute for low income and minority populations, who move –In and out of coverage –Between public and private coverage –Short PF and Graefe DR. Battery-powered health insurance? Stability in coverage of the uninsured. Health affairs. 2003. 22(6):244-255.

3. Stability affects Quality of Care Individuals with unstable coverage have poorer access to and use of services –Adults who had any time without health insurance during a year were two to four times more likely to have gone without needed medical care than adults insured all year long –Duchon L et al. Security matters: How instability in health insurance puts U.S. workers at risk. 2001. The Commonwealth Fund; New York, NY. –Individuals currently insured, but with gaps in coverage during the year were more likely to report that they had no usual source of care or that they used the ER as a usual source of care and that they had no doctor visit in the past year –Schoen C and DesRoches C. Uninsured and unstably insured: the importance of continuous coverage. Health Services Research. 2000. 35(1 Pt 2: 187-206

4. Coverage Gaps Harm Childrens Care as Well as Adults Children with a recent gap in coverage are more likely To lack a usual source of care, and Kogan MD, et al. The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States. JAMA. 1995. 274(18):1429-1435. To delay seeking needed medical care and filling prescriptions for drugs Aiken KD, Freed GL and Davis MM. When insurance status is not static: insurance transitions of low-income children and implications for health and health care. Amb. Ped. 2004. 4:3):237-243.

5. Stability and Quality Discussions of quality improvement strategies usually do not include –Insurance infrastructure and its impact on stability –Strategies to improve stability among the quality- related interventions Yet, these may be important, particularly so for low-income and minority children, who experience greater instability –Thus it is important to know more about instability in public insurance programs for the low-income

6. The purpose of this study is to Assess the level of stability of coverage for children enrolled in Medicaid; Describe level of churning and the length of the breaks for children who leave and return; Describe the costs of churning (forthcoming)

7. Study Methods We examined Medicaid eligibility files in five states –California, Michigan, Ohio, Oregon, Pennsylvania We took children 5-18 enrolled in Medicaid as of December 2003 We described enrollment patterns for these children during the three prior years (January 2001 – December 2003), including –Proportion of children enrolled continuously for 1, 2, and 3 years –Proportion of children with breaks in enrollment –Length of the breaks in enrollment

8. State/Medicaid Characteristics USCAOHPAMIOR Population (millions)287.335.511.412.410.13.6 Medicaid enrollees June 2003 (millions) 40.66.41.6 1.3.4 % population below 100% FPL, millions 17%19%15%14%16% % Uninsured (children <18) 12%14%8%10%7%13% % on Medicaid (children <18) 27%29%21%20%26%25% MMC penetration60%51%30%80%75%80% From Kaiser Family Foundation; State Health Facts. http://www.statehealthfacts.org. 2003 data.http://www.statehealthfacts.org

9. Features of the Medicaid Program that may Affect Enrollment/Renewal CAOHPAMIOR Income eligibility threshold, % FPL (children 6-19) 100%200%100%150%100% Separate SCHIP program income eligibility threshold, %FPL Yes 250% NoYes 200% Yes 200% Yes 185% Renewal period12 m 6 m 12 mo Continuous eligibilityyesno yesno Self-declaration of incomeno yesno No face-to-face/No asset testyes Donna Cohen Ross and Laura Cox. Beneath the Surface: Barriers threaten to slow progress on expanding health coverage of children and families. Kaiser Family Foundation. October 2004. (Based on data as of July 2004)

10. Figure 1: States Vary in Proportion of Children Stably Insured for 3 Years Years Continuously Enrolled: Data Source: State Medicaid Enrollment Files. Note: Continuous enrollment over the three prior years for children enrolled in Medicaid in December 2003. Data includes children ages 5-18. Percent of Children Enrolled for Specific Number of Years % N=1,838,672 N=525,057N=179,476N=416,693 N=90,800

11. Figure 2: Churning Also Varies Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18. N=1,838,672 N=525,057 N=179,476 N=416,693N=90,800

12. Figure 3: Among those who Experience Breaks, Most Breaks Are Short Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18. N=332,484 N=116,609 N=34,542 N=164,118 N=39,985

13. Mean Number and Length of Breaks in Medicaid Coverage Among Children with Enrollment Breaks CAOHPAMIOR Mean Number of Breaks in Coverage* 1.14 1.101.291.33 Mean Length of Break (Months) 5.685.818.074.746.24 Median Length of Break (Months) 33624 *Includes only those who were in Medicaid in Dec 03 and had at least 1 break during the 3 years. Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18.

14. Figure 4: Children are Enrolled in Medicaid Longer than in MMC Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18. CAOHPAMI OR N=1,272,212 N=224,337 N=159,895N=330,424 N=67,442

15. Figure 5: Proportion of Children Enrolled in a Medicaid Managed Care Plan for 1 or More Years Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18. N=1,272,212N=224,337 N=159,895N=330,424N=67,442

16. Conclusions A substantial proportion of children are stably insured through Medicaid in some states (approximately 60% insured for two years for CA, OR, and PA), and Stably enrolled in a managed care plan, at least in some states, for their care to be managed; This means that Medicaid (and Medicaid managed care) have opportunity to affect quality of care.

17. Conclusions Still, from 18% to 44% of children leave the rolls, only to return after a short time This suggests that many (possibly most) of these children were eligible for coverage when they fell off the rolls The strong implication is that these children had problems with Medicaid renewal, rather than had a change in eligibility status

18. Limitations The results are five states only Our data do not permit an examination of causal links –between state policies and reasons for churning –Between churning or short tenures and quality We do not know why children left and came back on the rolls or what their insurance status was during the breaks We do not know the characteristics of the children who churn vs. those who are stably insured

19. Policy Implications Policymakers need to think about stability as a contributor to quality of care Strategies to improve stability need to be on the table, along with more traditional quality improvement interventions Research is needed on the relationship between stability and –Access –Use –Outcomes