Public Insurance Enrollment Research Articles

Medicare, Medicaid, and dual enrollment for adults with intellectual and developmental disabilities.

Given high rates of un- and underemployment among disabled people, adults with intellectual and developmental disabilities rely on Medicaid, Medicare, or both to pay for healthcare. Many disabled adults are Medicare eligible before the age of 65 but little is known as to why some receive Medicare services while others do not. We described the duration of Medicare enrollment for adults with intellectual and developmental disabilities in 2019 and then compared demographics by enrollment type (Medicare-only, Medicaid-only, dual-enrolled). Additionally, we examined the percent in each enrollment type by state, and differences in enrollment type for those with Down syndrome. 2019 Medicare and Medicaid claims data for all adults (≥18 years) in the US with claim codes for intellectual disability, Down syndrome, or autism at any time between 2011 and 2019. Administrative claims cohort. Data were from the Transformed Medicaid Statistical Information System Analytic Files and Medicare Beneficiary Summary files. In 2019, Medicare insured 582,868 adults with identified intellectual disability, autism, or Down syndrome. Of 582,868 Medicare beneficiaries, 149,172 were Medicare only and 433,396 were dual-enrolled. Most Medicare enrollees were enrolled as child dependents (61.5%) Medicaid-only enrollees (N = 819,256) were less likely to be white non-Hispanic (58.5% white non-Hispanic vs. 72.9% white non-Hispanic in dual-enrolled), more likely to be Hispanic (19.6% Hispanic vs. 9.2% Hispanic in dual-enrolled) and were younger (mean 34.2 years vs. 50.5 years dual-enrolled). There is heterogeneity in public insurance enrollment which is associated with state and disability type. Action is needed to ensure all are insured in the program that works for their healthcare needs.

Effects of the Children's Health Insurance Reauthorization Act on immigrant children's healthcare access.

To estimate the effects of Children's Health Insurance Reauthorization Act (CHIPRA), a policy that provided states the option to extend Medicaid/CHIP eligibility to immigrant children who have not been legal residents for five years or more, on insurance coverage, access, utilization, and health outcomes among immigrant children. Restricted use 2000-2016 National Health Interview Survey (NHIS). We used a difference-in-differences design that compared changes in CHIPRA expansion states to changes in non-expansion states. Our sample included immigrant children who were born outside the US, aged 0-18 with family income below 300% of the Federal Poverty Level (FPL). Subgroup analyses were conducted across states that did and did not have a similar state-funded option prior to CHIPRA (state-funded vs. not state-funded), by the length of time in the US (5 years vs. 5-14 years), and global region of birth (Latin American vs. Asian countries). We found that CHIPRA was associated with a significant 6.35 percentage point decrease in uninsured rates (95% CI: -11.25, -1.45) and an 8.1 percentage point increase in public insurance enrollment for immigrant children (95% CI: 1.26, 14.98). However, the effects of CHIPRA became small and statistically not significant 3 years after adoption. Effects on public insurance coverage were significant in states without state-funded programs prior to CHIPRA (15.50 percentage points; 95% CI:8.05, 22.95) and for children born in Asian countries (12.80 percentage points; 95% CI: 1.04, 24.56). We found no significant changes in health care access and utilization, and health outcomes, overall and across subgroups due to CHIPRA. CHIPRA's eligibility expansion was associated with increases in public insurance coverage for low-income children, especially in states where CHIPRA represented a new source of coverage versus a substitute for state-funded coverage. However, we found evidence of crowd-out in certain subgroups and no effect of CHIPRA on access to care and health. Our results suggest that public coverage may be an important tool for promoting the well-being of immigrant children but other investments are still needed.

Public and Commercial Medical Insurance Enrollment Rates of Rural-to-Urban Migrants in China.

Objectives: Large-scale rural-to-urban migration of China has provoked heated discussion about the health of migrants and whether they have equal access to the health resources. This article aimed to compare the public and commercial medical insurance enrollment rates between temporary, permanent migrants and urban natives.Methods: Average marginal effects (AME) of the weighted logistic regression models using 2017 China General Social Survey from 2,068 urban natives, 1,285 temporary migrants, and 1,295 permanent migrants.Results: After controlling for the demographic and socio-economic characteristics, our results show that while the temporary and permanent migrants have a similar public insurance enrollment rate compared with the urban natives, both temporary and permanent migrants have significantly lower commercial insurance enrollment rates (7.5 and 5.3%, respectively) compared with the urban natives.Conclusions: The results highlight significant institutional barriers preventing the temporary migrants from gaining access to public medical insurance and the adverse impact of disadvantaged socio-economic backgrounds on the access of temporary migrants to both public and commercial insurance.

Growth Of Public Coverage Among Working Families In The Private Sector.

Working families have increasingly enrolled their children in Medicaid or the Children's Health Insurance Program in recent years. Parents' place of employment affects the availability and cost of family health insurance, making it a determinant of pediatric public insurance enrollment. We examined that enrollment in the period 2008-16 in families working full time and earning more than 100percent of the federal poverty level at three types of employers. Among low-income families (100-199percent of poverty), children's public health insurance coverage was highest for those with parents employed at small private firms, increasing from 53percent to 79percent, while the public insurance coverage rate also increased among children with parents working for large private firms (from 45percent to 69percent). Among moderate-income families (200-299percent of poverty) working at small private firms, public coverage increased from 21percent to 64percent. Increases in the number of working families with pediatric public insurance were driven by employees of large private firms. Maintaining high pediatric insurance coverage rates will require policies that recognize the changing role of public insurance for working families as the cost of employer-based coverage grows.

Family planning service provision in Illinois religious hospitals: Racial/ethnic variation in access to non-religious hospitals for publicly insured women

ObjectivesTo identify religious affiliations of hospitals and access to family planning (FP) care available to publicly insured women in Cook County, Illinois. DesignWe analyzed Illinois public insurance enrollment data and family planning service claims (2015–2018) for women 18–45. ResultsEighty-five percent of Black/Hispanic women were enrolled in Medicaid managed care plans with a higher percentage of Catholic healthcare than Cook County as a whole compared to 75% of White women (p<0.0001). There were fewer FP services at Catholic (IRR 0.072, 95% CI 0.068–0.076) and Christian non-Catholic (IRR 0.55, 95% CI 0.53–0.56) compared to non-religious hospitals. ConclusionsMedicaid managed care plans may restrict family planning care by limiting patients to religious hospitals.

Expedited Medicaid Enrollment, Mental Health Service Use, and Criminal Recidivism Among Released Prisoners With Severe Mental Illness.

This study investigated whether Washington State's 2006 policy of expediting Medicaid enrollment for offenders with severe mental illness released from state prisons increased Medicaid access and use of community mental health services while decreasing criminal recidivism. A quasi-experimental design with linked administrative data was used to select all prisoners with a severe mental illness (schizophrenia or bipolar disorder) released during the policy's first two years (January 1, 2006, through December 31, 2007), and those referred for expedited Medicaid (N=895) were separated from a propensity-weighted control group of those not referred (N=2,191). Measures included binary indicators of Medicaid enrollment, other public insurance enrollment, postrelease use of inpatient and outpatient health services, and any postrelease criminal justice contacts. All data were collapsed to person-level observations during the 12 months after the index release, and outcomes were estimated via propensity-weighted logit models. Referral for expedited Medicaid on release from prison greatly increased Medicaid enrollment (p<.01) and use of community mental health and general medical services (p<.01) for persons with severe mental illness. No evidence was found that expediting Medicaid reduced criminal recidivism. Expediting Medicaid was associated with increased Medicaid enrollment and both mental health and general medical service use, but study findings strongly suggest that rather than relying on indirect spillover effects from Medicaid to reduce criminal recidivism, advocates and policy makers would better address the needs of offenders with severe mental illness through direct interventions targeted at underlying causes of recidivism.

Medicaid and CHIP Premiums and Access to Care: A Systematic Review.

Premiums are required in Medicaid and the Children's Health Insurance Program in many states. Effects of premiums are raised in policy debates. Our objective was to review effects of premiums on children's coverage and access. PubMed was used to search academic literature from 1995 to 2014. Two reviewers initially screened studies by using abstracts and titles, and 1 additional reviewer screened proposed studies. Included studies focused on publicly insured children, evaluated premium changes in at least 1 state/local program, and used longitudinal or repeated cross-sectional data with pre/postchange measures. We identified 263 studies of which 17 met inclusion criteria. Four studies examined population-level coverage effects by using national survey data, 11 studies examined trends in disenrollment and reenrollment by using administrative data, and 2 studies measured additional outcomes. No eligible studies evaluated health status effects. Increases in premiums were associated with increased disenrollment rates in 7 studies that permitted comparison. Larger premium increases and stringent enforcement tended to have larger effects on disenrollment. At a population level, premiums reduce public insurance enrollment and may increase the uninsured rate for lower-income children. Little is known about effects of premiums on spending or access to care, but 1 study reveals premiums are unlikely to yield substantial revenue. Effect sizes were difficult to compare across studies with administrative data. Public insurance premiums often increase disenrollment from public insurance and may have unintended consequences on overall coverage for low-income children.

Insuring the Uninsured: Reducing the Barriers to Public Insurance

Health insurance is one of the essential enabling resources to gain access to medical care and ultimately increase health status. Over 11 million or one quarter of the nation’s uninsured individuals are eligible for Medicaid or the State Children’s Health Insurance Program (SCHIP), but are not enrolled. Interviews with 368 individuals from 1999 through 2003 identify eight primary barriers to enrollment in public insurance. These include: economic aspects of qualifying, lack of knowledge, benefit design of public programs, poor experiences and stigma, complexity and literacy, immigration status, poor customer service, and fear of fraud. These results suggest policy options alone are unlikely to result in reaching eligible uninsured individuals unless knowledge and instrumental support are offered to them about insurance.

The effects of expanding public insurance to rural low-income childless adults.

This study measures the change in health care use after enrollment into a new public insurance program for low-income childless adults. The data sources include claims from a large integrated health system in rural Wisconsin and Medicaid enrollment files, January 2007-September 2012. We employ a regression discontinuity design to measure the causal effect of public insurance enrollment on counts of outpatient, emergency department, and inpatient events for 2years following enrollment for a sample of previously uninsured low-income adults in rural Wisconsin. Public insurance enrollment led to substantial increases in outpatient visits including preventive visits, but not mental health visits. Public insurance enrollment also led to increases in inpatient stays, but the study is inconclusive on whether it led to an increase in ED visits. Public insurance expansions to childless adults have the potential to impact the use of health care. The large increase in Medicaid coverage and reduction in rates of uninsurance anticipated to result from the Affordable Care Act should increase the use of inpatient and outpatient services, but they will have an uncertain impact on the use of ED among rural populations.

Coverage for low-income immigrant children increased 24.5 percent in states that expanded CHIPRA eligibility.

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 provided states with the option of expanding eligibility for federally funded public insurance to low-income immigrant children within their first five years of legal residence in the United States. By 2011 twenty states and the District of Columbia had adopted that option. Using cross-sectional data from the 2003, 2007, and 2011-12 National Survey of Children's Health, we compared trends in coverage and access to care among immigrant children in states that did expand eligibility to children in states that did not. Compared to immigrant children in states that did not expand eligibility, children in states expanding eligibility experienced a 24.5 percent increase in insurance coverage, largely due to greater enrollment in public insurance. Immigrant children in states that expanded eligibility also experienced significant reductions in unmet health care needs, compared to their counterparts in nonexpansion states. Disparities relative to children in nonimmigrant families were substantially reduced in states that expanded eligibility, compared to states that did not. Expanding eligibility for federally funded public insurance to immigrant children within their first five years of legal residence in other states could improve coverage for immigrant children and might also increase access to care.

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.

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis

Generational Status, Health Insurance, and Public Benefit Participation Among Low-Income Latino Children

The objectives of this study were to (1) measure health insurance coverage and continuity across generational subgroups of Latino children, and (2) determine if participation in public benefit programs is associated with increased health insurance coverage and continuity. We analyzed data on 25,388 children income-eligible for public insurance from the 2003 to 2004 National Survey of Children's Health and stratified Latinos by generational status. First- and second-generation Latino children were more likely to be uninsured (58 and 19%, respectively) than third-generation children (9.5%). Second-generation Latino children were similarly likely to be currently insured by public insurance as third-generation children (61 and 62%, respectively), but less likely to have private insurance (19 and 29%, respectively). Second-generation Latino children were slightly more likely than third-generation children to have discontinuous insurance during the year (19 and 15%, respectively). Compared with children in families where English was the primary home language, children in families where English was not the primary home language had higher odds of being uninsured versus having continuous insurance coverage (OR: 2.19; 95% CI [1.33-3.62]). Among second-generation Latino children, participation in the Food Stamp (OR 0.26; 95% CI [0.14-0.48]) or Women, Infants, and Children (OR 0.40; 95% CI [0.25-0.66]) programs was associated with reduced odds of being uninsured. Insurance disparities are concentrated among first- and second-generation Latino children. For second-generation Latino children, connection to other public benefit programs may promote enrollment in public insurance.

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

To examine the impact of a Wisconsin health care reform enacted in early 2008 on public insurance enrollment and retention. Administrative data covering the period January 2007 to November 2009. 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. 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. Wisconsin's 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.