Survey of CIC Program Participants: Who Joined and How Did They Change Their Care-Seeking Behavior? Catherine McLaughlin University of Michigan Erin Fries Taylor Mathematica Policy Research WebCast Presentation CIC programs June 23, 2004

Alameda County: Family Care Insurance product for parents of children enrolled in Alameda Alliance for Health 300% FPL or less Austin: I-Care Not an insurance product, collaboration of area hospitals and charity care organizations 250% FPL or less Southern Maine: CarePartners Donated care model 150% FPL or less Survey in 3 CIC Sites

Research Questions Who joined? Changes in care-seeking behavior? Changes in satisfaction and perceived access? Differences by race/ethnicity? Alameda and Austin Differences by chronic illness? Southern Maine Who stays and who leaves?

Survey Content Household information Demographics Income and employment Previous health insurance coverage (asked at baseline) Health status and utilization Usual source of care, unmet need Satisfaction, attitudes

Wave 1 Details Site provided contact information on all new enrollees over a period of 4-6 months Completed interviews in Wave 1 Alameda - Alameda: 471 adults (Aug 01–Jan 02) 88% response rate Austin -Austin: 347 adults (Feb–Aug 02) 87% response rate S Maine -S Maine: 300 adults (Nov 01–June 02) 93% response rate

Baseline Survey Data Who participates in each CIC program? Were there differences in characteristics by race/ethnicity? Were there differences in characteristics by chronic illness?

Selected Socio-Demographics AlamedaAustin S. Maine Female63%60%66% Married78%48%20% Median age34 43 Median hshld size442 Homeowners34%29%43% Born outside US89%64%3%

Income, Employment, and Previous Insurance Status AlamedaAustin S. Maine Median hshld income $23k$17k$13k Currently employed 52%69%50% Avg. hours worked (among workers) Some coverage in previous year 49%25%47% Never had coverage before CIC program 31%54%15%

Race/Ethnic/Language Composition: Alameda County Latinos Asians Others Spanish-speaking (48%) English-speaking (5%) English-speaking (7%)Cantonese-speaking (30%) English-speaking (10%)

Selected Socio-demographics by Race/Ethnicity: Alameda County LatinoAsianOther Average Age % Married75%87%63% Avg. Household Size Avg. Education (yrs.) Avg. Annual Household Income $23K$34K % Born Outside US93%97%11%

Race/Ethnic/Language Composition: Austin Latinos Spanish-speaking (50%) English-speaking (22%) Whites English-speaking (16%) Others English-speaking (12%)

Selected Socio-demographics by Race/Ethnicity: Austin Span-sp Latino (n=174) Eng-sp Latino (n=75) Other (n=42) White, NH (n=56) Avg. Age % Married63%32%50%21% Avg. Household Size Avg. Education (yrs.) Avg. Annual Hshld. Income (2001) $17K$18K$25K$18K % Born Outside US97%33%57%7%

Baseline Health Status and Care- Seeking Behavior AlamedaAustin S. Maine Fair or poor health status22%35%30% Chronic or limiting condition12%22%53% No health care utilization (previous 12 months) 35%32%10% Median out-of-pocket costs (previous 12 months) <$50$ $

Preventive Services in Previous Year AlamedaAustin S. Maine Physical Exam Blood Pressure Check Breast Exam (among women) Pap Smear (among women) 38% 59% 30% 44% 31% 61% 22% 34% 53% 84% 55% 50%

36% 6% 43% 12% 3% 36% 23% 38% 2% 1% 62% 9% 20% 8% 1% Doctor's Office Hospital Outpatient Other Clinic or Health Hospital ER or Urgent Some Other Place Alameda Austin S. Maine Usual Source of Care:

Alameda: Health and Care-Seeking Behaviors: Themes by Race/Ethnicity Asians and Latinas reported worse health status, but fewer chronic conditions Cantonese-speaking Asians rated health status lower than English-speaking Asians Latinas and Other were more likely to have an ER visit or a doctor visit Asians reported lowest out-of pocket costs and Other reported the highest

More on Baseline Health in Alameda: Themes by Race/Ethnicity Cantonese-speaking Asians were most likely to have no health care utilization Those in Other category were most likely to report unmet need

Austin: Utilization Rates By Race/Ethnicity White, Non- Latino English Speaking Latino Spanish Speaking Latino Other ER Visit36%39%24%36% Hospital Stay9% 6%5% Doctor Visit68%61%52%62% No Utilization18%27%39%29% Median Out-of- Pocket Costs $200 $75$200

Baseline Health and Care-Seeking Behaviors: Themes by Race/Ethnicity Alameda County Cantonese-speaking Asians were most likely to have no health care utilization, but also report worse health status than English-speaking AsiansAustin Spanish-speaking Latinos were most likely to have no health care utilization, but also report worse health status than English-speaking Latinos In both Alameda and Austin, Latinos report worse health status and, at the same time, fewer report chronic or limiting condition(s) than other participants

Self-Reported Health Status by Race/Ethnicity Alameda Austin

S. Maine: Baseline Utilization Rates by Presence of Chronic Condition Those with limiting or chronic condition(s) Those without condition(s) PercentAverage number (among those with visits) PercentAverage number (among those with visits) Hospital Stay23%2.212%1.4 ER Visit58%3.544%2.4 Doctor Visit86%9.077%5.3

S. Maine: Out-of-Pocket Health Care Costs in Previous Year (if Costs>0)

Having a Usual Source of Care Made a Difference in: Having any physician visits, ER visits, or hospital stays Receiving preventive care – –Physical exam – –Blood pressure check – –Breast exam (among females) – –Pap smear (among females) Having a personal health care provider

Having Insurance Coverage in Last 12 Months Made a Difference in : Having any physician visits Receiving preventive care: –Physical exam –Blood pressure check –Breast exam (among females) –Pap smear (among females) Having a usual source of care and a personal health care provider

Research Questions: Changes Changes in health status, health care utilization, and care-seeking behavior? –e.g., decrease ED use, increase preventive care Changes in satisfaction and perceived access? –e.g., less self-reported unmet need Are there race/ethnic differences in these changes? Are there differences in changes for those with a chronic condition?

Use Pre/Post Comparison: Wave I vs. Wave II + Wave III Utilization data for the 12 months before and for the 12 months post-enrolling –Continuous enrollees and those who disenrolled –Possible “seam bias” (doublecounting), so rely more on “Yes/No used” than the count data of how many visits –Change = used only before or used only after enrolling

Number of Respondents by Wave Wave 1Wave 2*Wave 3* Alameda enrollees enrollees Austin enrollees enrollees S. Maine enrollees enrollees *Continued high response rates (>80%)

Alameda: Comparisons of Medical Care Use Before and After Enrollment Doc use ED use Hosp use After enrollment only 33% 12% 4% Before enrollment only Both before and after enrollment Neither before or after enrollment change no change N=330, survey respondents who were continuously enrolled in CIC

Alameda: Comparisons of ED Use Before and After Enrollment by Race/Ethnicity AsianLatinoOther After enrollment only10%15%12% Before enrollment only7136 Both before and after enrollment 2***10***21*** Neither before or after enrollment 81***62*** change no change Note: there are no statistically significant differences for hospital use

Austin: Comparisons of Medical Care Use Before and After Enrollment 01552Both before and after enrollment 6163Before enrollment only 9% 16% 32% After enrollment only Neither before or after enrollment Hosp use ED use Doc use change no change N=164, survey respondents who were continuously enrolled in CIC

Austin: Comparisons of Use Before and After Enrollment by Ethnicity 4**16**Neither before nor after enrollment 48116Number of respondents OtherLatino 63*48*Both before and after enrollment 43Before enrollment only 29%32%After enrollment only Doctor Use change no change %19% OtherLatino ED use 48116

S. Maine: Comparisons of Medical Care Use Before and After Enrollment Both before and after enrollment 6180Before enrollment only 9%12%17%After enrollment only 73270Neither before or after enrollment Hosp use ED use Doc use change no change N = 99, survey respondents who were continuously enrolled in CIC

S. Maine: Comparisons of Use Before and After by Presence of Chronic Illness Doctor UseED Use ChronicNotChronicNot After enrollment only9%**25%**13%11% Before enrollment only0018 Both before and after enrollment 91**75**5134 Neither before nor after enrollment 0018**36** Number of Respondents change no change *p<0.10, **p<0.05, ***p<0.01, significantly different by presence of chronic illness

Alameda: Comparisons in Preventive Care Use Before and After Enrollment, Enrollees Physical exam Blood pressure After enrollment only 38% 29% Before enrollment only 7 7 Both before and after enrollment 3151 Neither before or after enrollment 2414 no change change

Austin: Comparisons in Preventive Care Use Before and After Enrollment 5523Both before and after enrollment 5 5Before enrollment only 27% 36%After enrollment only 1235Neither before or after enrollment Blood pressure Physical exam no change change

S. Maine: Changes in Preventive Care Use Before and After Enrollment, Enrollees 8246Both before and after enrollment 3 4Before enrollment only 15% 34%After enrollment only 116Neither before or after enrollment Blood pressure Physical exam no change change

Women’s Preventive Care in Alameda: Comparisons Before and After Enrollment Breast examPap smear After enrollment only 38% 35% Before enrollment only1011 Both before and after enrollment 1933 Neither before or after enrollment 3221 change no change N = 220 women

Women’s Preventive Care in Austin: Comparisons Before and After Enrollment 2737Neither before or after enrollment 2416Both before and after enrollment 85Before enrollment only 41% After enrollment only Pap smearBreast exam change no change N = 98 women

Women’s Preventive Care in S. Maine: Comparisons Before and After Enrollment 2322Neither before or after enrollment 40 Both before and after enrollment 10 Before enrollment only 27% After enrollment only Pap smearBreast exam change no change N = 62 women

S. Maine: Comparisons of Breast Exams Before and After by Presence of Chronic Illness ChronicNot After enrollment only13%**41%** Before enrollment only136 Both before and after enrollment 3744 Neither before or after enrollment 37**9** Number of Respondents3032 no change change

Were There Changes Over Time in Medical Care Use? In all 3 sites, there was a noticeable increase in physician visits and an even larger increase in the number receiving physical exams, PAP smears, and breast exams. Only S. Maine showed a noticeable, although statistically insignificant, decrease in ED use No site showed a noticeable change in hospital use

Do Changes Over Time Differ in Different Populations? In Alameda, changes in ED use varied significantly by race/ethnicity: Latinos were the most likely to go only before enrollment In S. Maine, those without a chronic condition were more likely to increase use of physician services and to have a breast exam

Different Use by Different Populations Most of the differences in utilization by race/ethnicity and by the presence of a chronic condition are differences in level of use, not change in use after enrolling –Asians were less likely to use physician, ED, and hospital services both before and after enrollment –Latinos were more likely than Asians, but less likely than “other” to use physician, ED, and hospital services both before and after –Those with a chronic condition were more likely to use ED and hospital services both before and after

Caveats Results are based on self-reported utilization data -Utilization (e.g., visits) tend to be under- reported -Procedures (e.g., pap smears) tend to be over-reported -Errors of omission increase with length of recall

Disenrollment There were varying levels of disenrollment across the 3 sites, the highest in S. Maine What were the reasons given for leaving? Were disenrollees “different” from continuous enrollees? What happened to disenrollees in terms of coverage, utilization, satisfaction?

Possible Sample Transitions Wave 1 CarePartners Wave 2 CarePartners ESI Medicaid Uninsured Wave 3 CarePartners ESI Medicaid Uninsured N = 182 N = 84 N = 73 N = 89 N = 266 Example and numbers presented are for S. Maine

Possible Sample Transitions Wave 1Wave 2Wave 3 CarePartners ESI Medicaid Uninsured N = 6 N = 266 N = 84 N = 182 N = 89

Possible Sample Transitions Wave 1Wave 2Wave 3 CarePartners ESI Medicaid Uninsured ESI Medicaid Uninsured N = 71 N = 266 N = 84 N = 182 N = 89

Reasons for Disenrolling: S. Maine Became eligible for another program37%72% R or spouse got job that offered coverage 3114 Income too high to remain eligible 21 8 Didn’t complete program paperwork 8 4 Didn’t think needed care 7 1 Couldn’t afford to remain in program 6 3 Moved away from area 5 4 Was unhappy with program 2 3 Some other reason 2 6 W2W3

% of Participants by Insurance Status, Waves 2 and 3 Wave Wave ESI Medicaid Uninsured EnrolledDisenrolled

Comparisons of Enrollees and Disenrollees by Insurance Status, Wave 2 % Female % Married % Employed Hsehold Income $15k 32k 13k 19k % ESI before % Medicaid before Enrolled Disenrolled ESI Medicaid Uninsured

Comparisons of Enrollees and Disenrollees by Health Status and Utilization, Wave 2 % Fair or Poor HS % with Condition % Physician visit % Hospital stay % ED visit Enrolled Disenrolled ESI Medicaid Uninsured

Emerging Patterns One group staying in program as long term source of coverage: –Part-time or self-employed workers who lack access to ESI

Emerging Patterns Two groups tend to be using CarePartners as stopgap measure: –Relatively healthy full-time workers who (re)gained access to ESI –Relatively sicker unemployed persons who became eligible for Medicaid

Emerging Patterns Fourth group: –Those leaving the program who lost eligibility or failed to fill in the proper paperwork and remain uninsured

Next Steps Investigate further how utilization changes across time (pent-up demand?) Continue to explore differences in use, access, and attitudes by race/ethnicity Explore differences in use, access, and attitudes by presence of a chronic or limiting condition Continue analysis of factors that predict retention in the program Analyze changes in use and attitudes for disenrollees