1. Losing Insurance and Using the Emergency Department: Critical Effect of the Transition to Adulthood Peter Scal, MD MPH * Robert Town, PhD ** University of Minnesota * Departments of Pediatrics, Medical School ** Health Policy and Management, School of Public Health & National Bureau of Economic Research Funded by the Agency for Healthcare Research and Quality K08 HS015511-01A1

2. Background In the US, young adults with chronic conditions: High rates of uninsurance Poor access to care Both of which are remarkably different than it is for children and adolescents

3. Study Questions and Hypotheses Goal: Evaluate impact of loss of insurance on utilization and expenditures Hypothesis: Losing insurance will lead to: 1. Increase in ED use 2. Decrease in routine utilization (Office Visits, Rx) 3. Decrease in total $, but increase in out-of- pocket

4. Data Source/Study Population Pooled 7 panels of MEPS (1996-2003) 2 years of observation for each subject Selected young adults ages 18 -19 during the first year of observation Limited to those with: chronic conditions health insurance

5. Key Variables Insurance Status: Maintain: (any insurance in both years, n=800) Lose: (insurance in 1 st year, none in 2 nd ; n=81) Utilization: Emergency Department Visits ( # ) Office Visits ( # ) Prescription fills ( # ) Expenditures for these services ( $ ) both total and out-of-pocket

6. Analytic Strategy Difference in Difference to estimate the effects of losing insurance. Calculate the change in utilization between the years Compare the change between the two groups (maintain vs. lose ins.)

7. Results: Loosing insurance By logistic regression, factors significantly associated with losing insurance: Public insurance (OR 2.29; 95% CI 1.23 - 4.27) Age 19 (OR 1.87; 95% CI 1.14 – 3.07) With sex, employment, income, race/ethnicity, msa health status, student status not significant predictors

8. Results: Counts Simple Difference in Differences Lose Insurance Year 1 Year 2 Maintain Ins Year 1 Year 2 Treatment Effect EmergencyOfficePrescription DepartmentVisitsFills Use (mean)(mean)(mean).302.34.5.571.12.9.27-1.2-1.6.293.35.6.293.55.4.000.2-0.3.27-1.4-1.3

9. (Models include: age, sex, race/ethnicity, health status, student status, employment status, msa, and region of country) Results: Counts Regression Based Treatment Effect EmergencyOfficePrescription DepartmentVisitsFills Use (mean)(mean)(mean) + 100.5%- 50.8%- 32.9%.05.01.03 Treatment Effect p value

10. Results: Total Payments for 3 services ($) Simple Difference in Differences Lose Insurance Year 1 Year 2 Maintain Ins Year 1 Year 2 Treatment Effect EmergencyOfficePrescriptionExpenditures DepartmentVisitsFills(Sum) $$$ (mean)(mean)(mean)(mean) 59.8268.0193.8 521.7 284.1108.3164.3 556.7 224.3-159.7-29.5 35.1 109.7428.2302.7 840.6 126.4330.8285.8 742.9 16.7-97.5-17.0-97.7 207.6-62.2-12.5 132.8

11. (Models include: age, sex, race/ethnicity, health status, student status, employment status, msa, and region of country) Results: Total Payments for 3 services Regression Based Treatment Effect EmergencyOfficePrescription Expenditures DepartmentVisitsFills( Sum ) $$$$ (mean)(mean)(mean)(mean) 238.8% -44.9% -14.0% 32.3 %.08.16.60.07 Treatment Effect p value

12. Results: Out of Pocket Payments ($) Simple Difference in Differences Lose Insurance Year 1 Year 2 Maintain Ins Year 1 Year 2 Treatment Effect EmergencyOfficePrescriptionExpenditures DepartmentVisitsFills(Sum) $$$ (mean)(mean)(mean)(mean) 11.344.094.6 150.0 151.525.2129.5 306.2 140.1-18.834.9 156.1 12.364.498.0 174.7 16.456.3111.5 184.2 4.1-8.213.5 9.4 136.0-10.621.3 146.7

13. (Models include: age, sex, race/ethnicity, health status, student status, employment status, msa, and region of country) Results: Out of Pocket Payments Regression Based Treatment Effect EmergencyOfficePrescription Expenditures DepartmentVisitsFills( Sum ) $$$$ (mean)(mean)(mean)(mean) 1161% -25% 13% 150.4 %.04.46.64.07 Treatment Effect p value

14. Summary of findings Scope: 9 % of 18-19 y.o. lose insurance Selection: Those with private coverage, and higher utilization tend to maintain coverage Impact: Loss of insurance leads to: More ED visits Fewer office visits No difference in total expenditures but Increase in out-of-pocket burden but this is not stat. sig.

15. Implications Even without health insurance, YACC continue to use health care services Shift from office visits to ED is in contrast with best clinical practice Opportunity for clinical practice and policy based interventions

16. Losing Insurance and Using the Emergency Department: Critical Effect of the Transition to Adulthood Peter Scal, MD MPH * Robert Town, PhD ** University of Minnesota * Departments of Pediatrics, Medical School ** Health Policy and Management, School of Public Health & National Bureau of Economic Research Funded by the Agency for Healthcare Research and Quality K08 HS015511-01A1