Finding Uninsured But Eligible Children in Oregon After Major Medicaid Reforms Results from a Statewide Survey of Oregon’s Food Stamp Population Jen DeVoe, MD, DPhil Department of Family Medicine Oregon Health and Science University

Research Team Jen DeVoe Oregon Health and Science University F32 Fellowship Funding from the Agency for Healthcare Research and Quality (AHRQ) Lisa Krois Office for Oregon Health Policy and Research Tina Edlund Office for Oregon Health Policy and Research Jeanene Smith Office for Oregon Health Policy and Research **Oregon Health Research and Evaluation Collaborative (OHREC)

Oregon’s Uninsured

Changes in the OREGON HEALTH PLAN (OHP) The initial intent was to expand coverage; however, thousands of Oregon adults lost OHP STANDARD coverage shortly after February OHP prior to February 2003 After February 2003: OHP PLUS Benefits similar to original OHP No premiums or co-pays WHO QUALIFIES? All eligible children “Categorical” adults After February 2003: OHP STANDARD Leaner benefit package Stricter rules Requires premiums and co- pays WHO QUALIFIES? Low-income adults who do not qualify for OHP PLUS

The recent loss of Medicaid coverage for many Oregon adults may have impacted children’s access to health insurance coverage. We conducted a survey of Oregon’s food stamp families to find out why many eligible children lack insurance coverage and to identify factors impacting their access to healthcare services. Photo by Jamie Francis, The Oregonian

Methods Random sample (n=10,175) of all families with children ages 1-18 enrolled in the food stamp program as of January 31, Mail return, self-report survey with 31% response rate. Respondents were demographically similar to non-respondents. We weighted the data back to the original food stamp population (n=84,087 families), and we used a raking ratio estimation process to adjust for non-response.

Nearly 11% of the children in this population, presumed eligible for Oregon Health Plan, were uninsured.

Among children in Oregon’s food stamp population, higher rates of uninsurance were associated with being: Hispanic Older than 14 years of age Living in a household earning between % of the Federal Poverty Level Having an employed parent Having an uninsured parent Having an adult in the household who recently lost OHP coverage

Over 26% of the children had a health insurance coverage gap in the 12 months prior to the survey.

Why did children in this population have coverage gaps? Family lost or could not afford employer-sponsored coverage. Parent did not think their child was eligible for OHP due to income. Family missed the OHP re-certification window.

Why was your child uninsured? “Because I owe money to OHP for back premiums when they dropped adults from the health plans…” “We own our own business and could not afford insurance premiums…had to wait 6 months to apply for OHP” “My employer does not offer insurance, and I don’t make enough to get it on my own, and OHP denied us…” “Their dad was supposed to get them covered through his work, but the cost was too much, and it didn’t happen…”

The most commonly reported suggestions for improving the OHP application process to minimize children’s coverage gaps: Extend the time between re-enrollment from 6 to 12 months. Decrease the amount of paperwork needed to enroll. Shorten the 6 month waiting period, thus decreasing the amount of time children must go without coverage prior to enrollment.

“Healthy Kids” Process Governor’s Pledge to Cover All Kids Medicaid Advisory Committee –Hearings –Statewide public meetings –Recommendations to the Governor Legislative Committee Hearings Media Attention Legislation Introduced

“Healthy Kids” Proposal Expand eligibility – fluidity of coverage, with cost-sharing for families earning >200% FPL Extend re-enrollment window to 12 months Decrease waiting period to 60 days Simplify enrollment Aggressive outreach to uninsured kids Continue to focus on access to care

Political Realities Need funding! –Tobacco tax increase not universally accepted, will likely go to voters. –Revenue legislation requires 3/5 majority. Citizenship concerns Opposition to government social programs Perception that all children have access to safety net clinics and emergency department Partisan politics

Refusal to vote derails Ore. Healthy Kids proposal 4/26/2007, 5:21 p.m. PT By JULIA SILVERMAN The Associated Press SALEM, Ore. (AP) — A Democratic plan to pay for an expansion of children's health insurance programs by hiking the state's cigarette tax died an ignominious death in the Oregon House Thursday, but only after the chamber's brand of political theater had spiraled into out-and-out farce.

What is Happening With Healthy Kids Now?

Research and Policy Continuum Policy- Relevant Questions Exploratory Research Policy Proposals POLITICS! Revised Policy Implemented Research and Evaluation

For Further Discussion… State/Academic collaborations Dissemination of results –Different time-lines (policy vs. academic) –Multi-State comparisons Writing for a diverse audience What is the researcher’s role?

Acknowledgements This study was funded by a HRSA grant through the Office for Oregon Health Policy and Research. Jen DeVoe was funded by a fellowship grant from the Agency for Healthcare Research and Quality. Thank you to the Office for Oregon Health Policy and Research (OHPR), the Oregon Department of Children, Adults and Families (CAF - food stamp office), the Oregon Office of Medical Assistance Programs, and the Oregon Department of Education. A special thanks to Janne Boone, Jessica Miller and James Oliver (OHPR); Rebecca Ramsey and Pooya Naderi (PSU); additionally, our appreciation for the efforts of Ron Taylor and Jeff Tharpe (CAF)

“I hope that people "in charge" can get this all figured out for the health and safety of our children – they are our future – please help all of them to survive until then.” In The Words of One Parent…