1. Do Gaps in Insurance Coverage Increase Ambulatory-sensitive ER/Inpatient Visits? Who Pays? Hsou Mei Hu 1, Emily C. Shelton 1, David M. Cutler 2, Allison B. Rosen 1 1 University of Michigan 2 Harvard University Funded by NIA, the Harvard Interfaculty Program for Health Systems Improvement, the Lasker Foundation

2. AcademyHealth ARM, 6/27/2006 Background Gaps in insurance coverage lead to the same level of barriers to care and financial difficulties as uninsurance (Schoen & DesRoches, 2000). People with chronic conditions experience barriers to medical care due to lack of insurance coverage (Pollitz, 2005; Beckles, 1998; Ayanian, 2000).

3. AcademyHealth ARM, 6/27/2006 Study Objectives To study the effect of gaps in insurance coverage on the use and spending of ER and inpatient care for adults (age 18 to 64) with diabetes or asthma. To examine who pays for the care, third party payers or patients?

4. AcademyHealth ARM, 6/27/2006 Data Source Three 2-year panels of the Medical Expenditure Panel Survey (MEPS), spanning from 2000 to 2003. A survey of civilian non-institutionalized U.S. population: health status, insurance coverage, health care use and expenditures for health services. 5 rounds of interview. Adults (age 18 to 64) reporting diabetes or asthma (n=4,408).

5. AcademyHealth ARM, 6/27/2006 Insurance Status Definition: Continuous Insurance Coverage: insurance coverage all 5 rounds during the two-year survey. (n=3,160) Gaps in Coverage: at least one round without insurance coverage (n=795) Adults with no coverage (n=453) were excluded.

6. AcademyHealth ARM, 6/27/2006 Data Analysis Descriptive statistics: ER/inpatient visits and spending in 2003 dollars. Payment by source Regression analyses Odds of having any ER visit, inpatient stay adjusted ER visits, hospitalization, and spending.

7. AcademyHealth ARM, 6/27/2006 Findings: I ndividual Characteristics Compared with adults having continuous coverage, the group with gaps in coverage were younger, lower income, more likely to be minority, healthier.

8. AcademyHealth ARM, 6/27/2006 Finding II: ER/Hospitalization Controlling for individual characteristics, health status: Adults having gaps in coverage were more likely to have any ER visits than those with continuous coverage (OR=1.22, p=0.062) No significant difference in the likelihood of having any hospitalization (OR=1.10, p=0.447)

9. AcademyHealth ARM, 6/27/2006 Finding III: Mean ER/Inpatient Stays per Person Significant at =0.05 Significant at =0.10.

10. AcademyHealth ARM, 6/27/2006 Finding IV: Mean Spending per ER/Inpatient Event Continuous Coverage: $3,327 per event Gaps in Coverage: $1,960 per event Having coverage: $2,042 per event No coverage: $958 per event mean spending during the period having insurance coverage. mean spending during the period with no reported health insurance.

11. AcademyHealth ARM, 6/27/2006 Finding V: ER/Inpatient Payment per Event by Source Gaps in coverage mean spending during the period having insurance coverage. mean spending during the period with no reported health insurance.

12. AcademyHealth ARM, 6/27/2006 Conclusions Gaps in insurance coverage is associated with increased ER visits. Public programs and patients bear the most financial burden for each ambulatory-sensitive ER/inpatient visit for those without continuous insurance coverage.

13. AcademyHealth ARM, 6/27/2006 Limitations Self-reported information Not causal effect

14. AcademyHealth ARM, 6/27/2006 Policy Implication Policies to fill insurance gaps may improve health and potentially even save money if applied in subpopulation, such as those with diabetes or asthma.