the effects of expanding public insurance to childless adults
TRANSCRIPT
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The Effects of Expanding Public Insurance to Childless Adults
Marguerite Burns, Ph.D. University of Wisconsin-Madison APPAM Fall Research Conference November 12, 2015
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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
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What Do We Know About the Effects on Use of Care of Expanding Medicaid to Childless
Adult Populations?
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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
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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
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How did the Core Plan for childless adults affect the use of health care?
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Marshfield
Milwaukee County
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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
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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
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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
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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
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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)
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Method 1: Pre-Post Comparison
12-months of pre-enrollment utilization
12-months of post-enrollment utilization
Auto-enrollment into BC+ Core
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Method 2: Regression Discontinuity
October 9, 2009
Last Individuals enrolled
First individuals placed on the waitlist
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Data: Wisconsin Medicaid
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Data: Marshfield Clinic
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Outcomes
Outpatient Visits
Emergency Department Visits
Hospitalizations
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Results from Milwaukee County
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40% Increase No Change 140% Increase
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Results from Marshfield Area
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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.
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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
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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
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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
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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
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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
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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
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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
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Extra Slides
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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 −−
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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%
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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
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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