1. Does a Patchwork Approach to Health Insurance Expansion Exacerbate Public Insurance Drop-Out? Benjamin D. Sommers, Ph.D. Harvard University AcademyHealth Annual Meeting June 26, 2005

2. Background: Children Without Health Insurance * 8.4 million children (11.4%) in U.S. have no health insurance * Over 6 million uninsured children are eligible for Medicaid/CHIP * 1 in 8 children “drops out” of Medicaid/CHIP annually – becoming uninsured, despite still being eligible Sources: Census Bureau 2004, Selden et al. 2004, Sommers 2005

3. Conceptual Framework: Why Do Kids Disenroll? ☑ Acquiring Other Health Insurance ☑ Loss of Eligibility ☑ ‘Drop-Out’: Uninsured & Still Eligible Parents must reenroll annually to prove eligibility. Why might they not do so? - Only “drop-out” is a program failure.

4. Motivation & Objectives * Incrementalism is the current approach to health insurance expansion: Does this exacerbate the drop-out problem? Question 1: Do separate CHIP's (vs. combined Mcaid/CHIP programs) fare differently in retention? Question 2: Does covering parents improve the retention of children?

5. Is This A Problem? Mom & Dad need not apply... Is this Medicaid, CHIP, or both?

6. Data & Methods Child & household data from the CPS March Supplement (2000-2004), using two-year linked samples Since 2001, CPS asks about CHIP separately from Medicaid State-specific eligibility rules from the National Governors Association State policies for Medicaid/CHIP from state welfare offices and previous studies

7. Results: Key Descriptive Statistics As of 2001, 17 states + D.C. ran combined CHIP/Medicaid programs, and 33 ran separate CHIP's. 23% of CHIP kids had a parent in public insurance, vs. 61% of Medicaid kids Roughly 2 million children switched back & forth between Medicaid & CHIP each year Drop-Out: CHIP 15.6%, Medicaid 12.5%

8. Effect of Combined vs. Separate Medicaid/CHIP Program on Drop-Out Adjusted for + UnadjustedDemographics* Policies** Odds Ratio for 'Combined' 0.690.680.64 95% CI: (0.51-0.92)(0.49-0.93)(0.43-0.95) N = 6526 % Reduced Risk = 31% * Adjusted for gender, age, race, parental education, family income, parental & sibling insurance coverage, health status, urban residence, state & year. ** Adjusted for demographics + the following Medicaid policies: frequency of renewal, face-to-face interview at renewal, presumptive eligibility, state renewal outreach, 12-month continuous eligibility, monthly premium, physician reimbursement rate, physician participation rate, MCO penetration, spending per child, charity care availability, & state political ideology.

9. Effect of Family Coverage in Medicaid on Drop-Out Among Children* Logistic 2-Stage IV Logistic** VariableOdds RatioOdds Ratio Parent in0.650.19 Mcaid/CHIP (p<.01) (p<.01) % Reduced Risk 28%72% Sibling in0.60 0.74 Mcaid/CHIP (p<.01) (p<.10) % Reduced Risk 32%20% n = 9020 NOTES: * Adjusted for gender, age, race, parental education, family income, number of children, health status, urban residence, state & year. ** Instrumented for parental and sibling Medicaid/CHIP coverage using parental and sibling Medicaid/CHIP eligibility.

10. Limitations Correlational only, for the combined vs. separate programs 12 month snapshots don’t let us see: –How long children stay enrolled –If drop-outs ever return to Medicaid Technical issues for CPS data: –Medicaid /CHIP Undercount –Monthly vs. Annual Income Data –Attrition Bias

11. Policy Implications Separate programs are administratively costly (2 million kids switching annually) and exacerbate drop-out → States should consider combining Medicaid & CHIP, or at least streamline transitions between programs. Covering parents and kids separately doesn’t make sense in terms of retention → Cover families, not individuals.

12. Acknowledgments This research was conducted with the support of a fellowship from the National Science Foundation. Many thanks to Joe Newhouse, David Cutler, Kathy Swartz, and Melissa Wachterman for excellent advice throughout this project.