James Marton

The Effects of Medicaid and CHIP Policy Changes on Receipt of Preventive Care among Children

OBJECTIVE To examine changes in childrens receipt of well-child and preventive dental care in Medicaid/Childrens Health Insurance Program (CHIP) in two states that adopted policies aimed at promoting greater preventive care receipt. DATA SOURCES The 2004-2008 Medicaid/CHIP claims and enrollment data from Idaho and Kentucky. STUDY DESIGN Logistic and hazard pre-post regression models, controlling for age, gender, race/ethnicity, and eligibility category. DATA EXTRACTION METHODS Claims and enrollment data were de-identified and merged. PRINCIPAL FINDINGS Increased reimbursement had a small, positive association with well-child care in Idaho, but no consistent effects were found in Kentucky. A premium forgiveness program in Idaho was associated with a substantial increase (between 20 and 113 percent) in receipt of any well-child care and quicker receipt of well-child care following enrollment. In Kentucky, children saw modest increases in receipt of preventive dental care and received such care more quickly following increased dental reimbursement, while the move to managed care in Idaho was associated with a small increase in receipt of preventive dental care. CONCLUSIONS Policy changes such as reimbursement increases, incentives, and delivery system changes can lead to increases in preventive care use among children in Medicaid and CHIP, but reported preventive care receipt still falls short of recommended levels.

Effects of Premium Increases on Enrollment in SCHIP: Findings from Three States

This study examines the effects of new and higher premiums on SCHIP enrollment in Kansas, Kentucky, and New Hampshire—three states that implemented premium changes in 2003. We used state administrative enrollment records from 2001 to 2004–2005 to track changes in total caseloads, new enrollments, and disenrollment timing in premium-paying categories of SCHIP before and after the premium changes were implemented. Premium hikes were associated with lower caseloads in all three states and with earlier disenrollment in Kentucky and New Hampshire. Premium increases appeared to have greater disenrollment effects for lower-income children in New Hampshire and for nonwhite children in Kentucky.

SCHIP premiums, enrollment, and expenditures: a two state, competing risk analysis

Faced with state budget troubles, policymakers may introduce or increase State Childrens Health Insurance Program (SCHIP) premiums for children in the highest program income eligibility categories. In this paper we compare the responses of SCHIP recipients in a state (Kentucky) that introduced SCHIP premiums for the first time at the end of 2003 with the responses of recipients in a state (Georgia) that increased existing SCHIP premiums in mid-2004. We start with a theoretical examination of how these different policies create different changes to family budget constraints and produce somewhat different financial incentives for recipients. Next we empirically model the impact of these policies using a competing risk approach to differentiate exits due to transfers to other eligibility categories of public coverage from exiting the public health insurance system. In both states we find a short-run increase in the likelihood that children transfer to lower- income eligibility/lower-premium categories of SCHIP. We also find a short-run increase in the rate at which children transfer from SCHIP to Medicaid in Kentucky, which is consistent with our theoretical model. These findings have important financial implications for state budgets, as the matching rates and premium levels are different for different eligibility categories of public coverage.

Who Gained Insurance Coverage in 2014, the First Year of Full ACA Implementation?

Abstract The most significant pieces of the Affordable Care Act (exchanges, subsidies, Medicaid expansion, and individual mandate), implemented in 2014, were associated with sizable gains in coverage nationally that were divided equally between gains in Medicaid and private coverage. These national trends mask heterogeneity in gains by state Medicaid expansion status, age, income level, and source of coverage.

Health insurance generosity and conditional coverage: Evidence from medicaid managed care in Kentucky

This paper estimates the impact of the introduction of Medicaid managed care (MMC) on the formal Medicaid participation of children. We employ a quasi-experimental approach exploiting the location-specific timing of MMC implementation in Kentucky. Using data from the March Current Population Survey from 1995-2003, our findings suggest that the introduction of MMC increases the likelihood of being uninsured and decreases formal Medicaid participation. This finding is consistent with an increase in “conditional coverage” – waiting until medical care is needed to sign up or re-enroll in Medicaid. These effects are concentrated among low-income children and absent for high-income children. We find no evidence of “crowd-in” – substituting private coverage for Medicaid. These results are robust to multiple placebo tests and imply the potential for less formal participation (i.e. more conditional coverage) among the ACA Medicaid expansion population (which is likely to be primarily covered under MMC) than is typically predicted.

CHIP Premiums, Health Status, and the Insurance Coverage of Children

This study uses the introduction of premiums into Kentuckys Childrens Health Insurance Program (KCHIP) to examine whether the enrollment impact of new premiums varies by child health type. We also examine the extent to which children find alternative coverage after premium nonpayment. Public insurance claims data suggest that those with chronic health conditions are less likely to leave public coverage. We find little evidence of a differential impact of premiums on enrollment among the chronically ill. Our survey of nonpayers shows that 56% of responding families found alternative private or public health coverage for their children after losing CHIP.

Does Medicaid Managed Care Help Equalize Racial and Ethnic Disparities in Utilization

Objective To estimate the impact of different forms of Medicaid managed care (MMC) delivery on racial and ethnic disparities in utilization. Data Source Longitudinal, administrative data on 101,649 children in Kentucky continuously enrolled in Medicaid between January 1997 and June 1999. Outcomes considered are monthly professional, outpatient, and inpatient utilization. Study Design We apply an intent‐to‐treat, instrumental variables analysis using the staggered geographic implementation of MMC to create treatment and control groups of children. Principal Findings The implementation of MMC reduced monthly professional visits by a smaller degree for non‐whites than whites (3.8 percentage points vs. 6.2 percentage points), thereby helping to equalize the initial racial/ethnic disparity in utilization. The Passport MMC program in the Louisville‐centered region statistically significantly reduced disparities for professional visits (closing the gap by 8.0 percentage points), while the Kentucky Health Select MMC program in the Lexington‐centered region did not. No substantive impact on disparities was found for either outpatient or inpatient utilization in either program. Conclusions We find evidence that MMC has the possibility to reduce racial/ethnic disparities in professional utilization. More work is needed to determine which managed care program characteristics drive this result.

Does More Public Health Spending Buy Better Health

Background: In this article, we attempt to address a persistent question in the health policy literature: Does more public health spending buy better health? This is a difficult question to answer due to unobserved differences in public health across regions as well as the potential for an endogenous relationship between public health spending and public health outcomes. Methods: We take advantage of the unique way in which public health is funded in Georgia to avoid this endogeneity problem, using a twelve year panel dataset of Georgia county public health expenditures and outcomes in order to address the “unobservables” problem. Results: We find that increases in public health spending lead to increases in mortality by several different causes, including early deaths and heart disease deaths. We also find that increases in such spending leads to increases in morbidity from heart disease. Conclusions: Our results suggest that more public health funding may not always lead to improvements in health outcomes at the county level.

Retiree Health Benefit Coverage and Retirement

Employer-provided health benefits for workers who retire before age 65 has fallen over the last decade. We examine a cohort of male workers from the Health and Retirement Survey to explore the dynamics of retiree health benefits and the relationship between retiree health benefits and retirement behavior. A better understanding of this relationship is important to the policy debate over the best way to increase health coverage for older Americans without reducing work incentives. Concerning the dynamics at work, we find that, between 1992 and 1996, 24 percent of full-time workers who had retiree health benefits lost their coverage, while 15 percent of full-time workers who lacked coverage gained it. Also, of the full-time employed men who were covered by retiree health benefits in 1992 and had retired by 1996, 3 percent were uninsured, and 15 percent were covered by health insurance other than employer-provided insurance. On the relationship between retiree health benefits and retirement, we find that workers with retiree benefits were 29 to 55 percent more likely to retire than those without. We also find that workers who are eligible for retiree health benefits tend to take advantage of them when they are relatively young.

Estimating Premium Sensitivity for Children's Public Health Insurance Coverage: Selection but No Death Spiral

OBJECTIVE To estimate the effect of premium increases on the probability that near-poor and moderate-income children disenroll from public coverage. DATA SOURCES Enrollment, eligibility, and claims data for Georgias PeachCare for Kids(™) (CHIP) program for multiple years. STUDY DESIGN We exploited policy-induced variation in premiums generated by cross-sectional differences and changes over time in enrollee age, family size, and income to estimate the duration of enrollment as a function of the effective (per child) premium. We classify children as being of low, medium, or high illness severity. PRINCIPAL FINDINGS A dollar increase in the per-child premium is associated with a slight increase in a typical childs monthly probability of exiting coverage from 7.70 to 7.83 percent. Children with low illness severity have a significantly higher monthly baseline probability of exiting than children with medium or high illness severity, but the enrollment response to premium increases is similar across all three groups. CONCLUSIONS Success in achieving coverage gains through public programs is tempered by persistent problems in maintaining enrollment, which is modestly affected by premium increases. Retention is subject to adverse selection problems, but premium increases do not appear to significantly magnify the selection problem in this case.