Lindsey Leininger

Wisconsin Experience Indicates That Expanding Public Insurance To Low-Income Childless Adults Has Health Care Impacts

As states consider expanding Medicaid to low-income childless adults under the Affordable Care Act, their decisions will depend, in part, on how such coverage may affect the use of medical care. In 2009 Wisconsin created a new public insurance program for low-income uninsured childless adults. We analyzed administrative claims data spanning 2008 and 2009 using a case-crossover study design on a population of 9,619 Wisconsin residents with very low incomes who were automatically enrolled in this program in January 2009. In the twelve months following enrollment in public insurance, outpatient visits for the study population increased 29 percent, and emergency department visits increased 46 percent. Inpatient hospitalizations declined 59 percent, and preventable hospitalizations fell 48 percent. These results demonstrate that public insurance coverage expansions to childless adults have the potential to improve health and reduce costs by increasing access to outpatient care and reducing hospitalizations.

Reexamining the Effects of Family Structure on Children's Access to Care: The Single-Father Family

OBJECTIVE To examine the effects of family structure, focusing on the single-father family, on childrens access to medical care. DATA SOURCE The 1999 and 2002 rounds of the National Survey of Americas Families (NSAF) including 62,193 children ages 0-17 years. STUDY DESIGN We employ a nationally representative sample of children residing in two-parent families, single-mother families, and single-father families. Multivariate logistic regression is used to examine the relationship between family structure and measures of access to care. We estimate stratified models on children below 200 percent of the federal poverty threshold and those above. DATA COLLECTION/EXTRACTION METHOD We combine data from the Focal Child and Adult Pair modules of the 1999 and 2002 waves of the NSAF. PRINCIPAL FINDINGS Children who reside in single-father families exhibit poorer access to health care than children in other family structures. The stratified models suggest that, unlike residing in a single-mother family, the effects of residence in a single-father family do not vary by poverty status. CONCLUSIONS Children in single-father families may be more vulnerable to health shocks than their peers in other family structures.

Wisconsin's BadgerCare Plus Reform: Impact on Low-Income Families' Enrollment and Retention in Public Coverage

OBJECTIVES To examine the impact of a Wisconsin health care reform enacted in early 2008 on public insurance enrollment and retention. DATA SOURCES Administrative data covering the period January 2007 to November 2009. STUDY DESIGN We calculate unadjusted enrollment trends and exit rates stratified by age, income group, and enrollment mode. Kaplan-Meier curves and Cox proportional hazards models are estimated to assess the impact of the reform on program exits. PRINCIPAL FINDINGS Overall enrollment increased by approximately one-third and exit rates decreased by approximately one-fifth. The majority of new enrollment came from the previously income eligible. CONCLUSIONS Wisconsins enactment of eligibility expansions coupled with administrative simplification and targeted marketing and outreach efforts were successful in enrolling and retaining low-income children and families in public coverage.

Using self-reported health measures to predict high-need cases among Medicaid-eligible adults.

OBJECTIVE To assess the ability of different self-reported health (SRH) measures to prospectively identify individuals with high future health care needs among adults eligible for Medicaid. DATA SOURCES The 1997-2008 rounds of the National Health Interview Survey linked to the 1998-2009 rounds of the Medical Expenditure Panel Survey (n = 6,725). STUDY DESIGN Multivariate logistic regression models are fitted for the following outcomes: having an inpatient visit; membership in the top decile of emergency room utilization; and membership in the top cost decile. We examine the incremental predictive ability of six different SRH domains (health conditions, mental health, access to care, health behaviors, health-related quality of life [HRQOL], and prior utilization) over a baseline model with sociodemographic characteristics. Models are evaluated using the c-statistic, integrated discrimination improvement, sensitivity, specificity, and predictive values. PRINCIPAL FINDINGS Self-reports of prior utilization provide the greatest predictive improvement, followed by information on health conditions and HRQOL. Models including these three domains meet the standard threshold of acceptability (c-statistics range from 0.703 to 0.751). CONCLUSIONS SRH measures provide a promising way to prospectively profile Medicaid-eligible adults by likely health care needs.

Partial-year insurance coverage and the health care utilization of children.

A large literature examines the effects of health insurance on the health care utilization of children; however, most existing studies conceptualize coverage as a point-in-time measure rather than as a dynamic phenomenon. The major contribution of this article is its provision of estimates on the relationship between the duration of coverage over the course of a calendar year and health care utilization among children. Using child-level fixed-effects regression, we find that an incremental uninsured month is associated with a 0.7 percentage point decline in the probability of receiving a visit over the course of a year and a 3% decrease in the number of visits received. Children with intrayear coverage losses are more likely than those with continuous coverage to lose their usual source of care, which serves as a potential mechanism through which short gaps in coverage may lead to longer-term decrements in utilization.

Child Health and Access to Medical Care.

Summary:It might seem strange to ask whether increasing access to medical care can improve children’s health. Yet Lindsey Leininger and Helen Levy begin by pointing out that access to care plays smaller role than we might think, and that many other factors, such as those discussed elsewhere in this issue, strongly influence children’s health.Nonetheless, they find that, on the whole, policies to improve access indeed improve children’ health, with the caveat that context plays a big role—medical care “matters more at some times, or for some children, than others.” Focusing on studies that can plausibly show a causal effect between policies to increase access and better health for children, and starting from an economic framework, they consider both the demand for and the supply of health care. On the demand side, they examine what happens when the government expands public insurance programs (such as Medicaid), or when parents are offered financial incentives to take their children to preventive appointments. On the supply side, they look at what happens when public insurance programs increase the payments that they offer to health-care providers, or when health-care providers are placed directly in schools where children spend their days. They also examine how the Affordable Care Act is likely to affect children’s access to medical care.Leininger and Levy reach three main conclusions. First, despite tremendous progress in recent decades, not all children have insurance coverage, and immigrant children are especially vulnerable. Second, insurance coverage alone doesn’t guarantee access to care, and insured children may still face barriers to getting the care they need. Finally, as this issue of Future of Children demonstrates, access to care is only one of the factors that policy makers should consider as they seek to make the nation’s children healthier.

Predicting high-cost pediatric patients: derivation and validation of a population-based model.

Background:Health care administrators often lack feasible methods to prospectively identify new pediatric patients with high health care needs, precluding the ability to proactively target appropriate population health management programs to these children. Objective:To develop and validate a predictive model identifying high-cost pediatric patients using parent-reported health (PRH) measures that can be easily collected in clinical and administrative settings. Design:Retrospective cohort study using 2-year panel data from the 2001 to 2011 rounds of the Medical Expenditure Panel Survey. Subjects:A total of 24,163 children aged 5–17 with family incomes below 400% of the federal poverty line were included in this study. Measures:Predictive performance, including the c-statistic, sensitivity, specificity, and predictive values, of multivariate logistic regression models predicting top-decile health care expenditures over a 1-year period. Results:Seven independent domains of PRH measures were tested for predictive capacity relative to basic sociodemographic information: the Children with Special Health Care Needs (CSHCN) Screener; subjectively rated health status; prior year health care utilization; behavioral problems; asthma diagnosis; access to health care; and parental health status and access to care. The CSHCN screener and prior year utilization domains exhibited the highest incremental predictive gains over the baseline model. A model including sociodemographic characteristics, the CSHCN screener, and prior year utilization had a c-statistic of 0.73 (95% confidence interval, 0.70–0.74), surpassing the commonly used threshold to establish sufficient predictive capacity (c-statistic>0.70). Conclusions:The proposed prediction tool, comprising a simple series of PRH measures, accurately stratifies pediatric populations by their risk of incurring high health care costs.

Understanding the Gap in Primary Care Access and Use Between Teens and Younger Children

Primary health care use among teenagers falls short of clinical recommendations and consistently lags behind that of younger children. Using the Medical Expenditure Panel Survey, the authors explore three explanations for this age-related gap: family composition, parental awareness of children’s health care needs, and the relative role of predisposing, enabling, and need-based factors for teens and younger children. Teenagers are 64% more likely to have no usual source of care and 25% more likely to have had no health care visit in the prior year relative to younger children. The gap narrows in families with children from both age-groups and among children with special health care needs. The largest disparity in primary care access exists between teens in families with no younger sibling(s) and younger children in families with no teen(s). A resolution to the age-related access gap will likely require understanding of, and intervention into, family-level determinants of poor access.

What Fraction of Medicaid Enrollees Have Private Insurance Coverage at the Time of Enrollment? Estimates from Administrative Data

We use administrative data from Wisconsin to determine the fraction of new Medicaid enrollees who have private health insurance at the time of enrollment in the program. Through the linkage of several administrative data sources not previously used for research, we are able to observe coverage status directly for a large fraction of enrollees and indirectly for the remainder. We provide strict bounds for the percentages in each status and find that the percentage of new enrollees with private insurance coverage at the time of enrollment lies between 16 percent and 29 percent, and the percentage that dropped private coverage in favor of public insurance lies between 4 percent and 18 percent. Our point estimates indicate that, among all new enrollees, 21 percent had private health insurance at the time of enrollment and that 10 percent dropped this coverage. Our results show substantially lower rates than previous studies of crowd-out following public health insurance expansions and significant rates of dual coverage, whereby new enrollees into public insurance retain their previously held private insurance coverage.