Churning: Disenrollment and Reenrollment in Wisconsin’s Medicaid and BadgerCare Programs

Presented to:

AcademyHealth Annual Research Meeting

San Diego, CA

June 8, 2004

Presented by: Nancy Lenfestey, M.H.A.

Contributors:Norma I. Gavin, Ph.D.Nathan West, M.P.A.

Funded by the Centers for Medicare and Medicaid Services (CMS). This presentation does not necessarily reflect CMS views or policies.

2

BadgerCare is

A Medicaid demonstration program in Wisconsin designed to bridge the gap between Medicaid and private insurance for the working poor.

Supported by a combination of federal and state matching funds under: Section 1115 Medicaid Waiver, and State Children’s Health Insurance Program.

A Medicaid expansion program—enrollment system, benefit structure and health care delivery system for Medicaid and BadgerCare are one and the same.

3

Enrollment

Source: Wisconsin Department of Health and Family Services. BadgerCare at a Glance: March 2004. http://www.dhfs.state.wi.us/badgercare/pdfs/BadgerCareAtaGlance-March2004.pdf

BadgerCare Enrollment July 1999-March 2004

0

20000

40000

60000

80000

100000

1999 2000 2001 2002 2003 2004

Year

En

roll

men

t

BC Children BC Parents Additional Medicaid Children Covered

4

BadgerCare and Medicaid Eligibility Categories

100% 150% 200%185%55%0% 68%

Medicaid(Title XIX)

BadgerCarewith Premium

(Title XXI)

Healthy Start(Title XIX)

BadgerCarewithout Premium

(Title XXI)

Healthy Start:OBRA 90Expansion(Title XXI)

BadgerCarewith Premium

(Title XIX)

BadgerCarewithout Premium

(Title XIX)

Medicaid(Title XIX)

Healthy Start:Pregnant Women

(Title XIX)

Source: Framework for state evaluation of children’s health insurance plans under Title XXI of the Social Security Act developed by the NationalAcademy for State Health Policy.

Children (Age)Custodial Parents

6–140–5

15–18

Federal Poverty Level (Percent)

Figure 1: BadgerCare and Medicaid EligibilityRequirements

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Churning

Process of repeatedly coming into and out of a health insurance program Disruptive to continuity of care Negative health outcomes Costly

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Research Questions

Did the length of enrollment and the probability of disenrolling from public coverage differ for: BC enrollees compared to individuals in traditional

Medicaid eligibility categories? Individuals in traditional Medicaid eligibility categories pre-

to post- BC?

For Medicaid/BC disenrollees, did the length of time that they remained off public coverage and the probability of re-enrolling differ for: BC enrollees compared to individuals in traditional

Medicaid eligibility categories? Individuals in traditional Medicaid eligibility categories pre-

to post- BC

Do the probabilities of enrolling and re-enrolling vary by race/ethnicity?

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Enrollment patterns: Length of enrollment episodes

Defined pre- and post BadgerCare periods: Pre: All episodes beginning from Jan. 1, 1997

through Dec. 31, 1998 (n=339,955 episodes) Post: All episodes beginning from Jan. 1, 2000

through Dec. 31, 2001 (n=394,197 episodes)

Defined eligibility category as that in which individuals were enrolled at the start of the episode.

Ran Kaplan-Meier survival curves on the length of enrollment by age group, eligibility category, and time period.

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Enrollment Duration—Adults Pre- and Post-

Probability of Remaining Enrolled among Adults Pre- and Post- BadgerCare

0.00.10.20.30.40.50.60.70.80.91.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Months Since Enrolled

AFDC Post AFDC Pre BadgerCare

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Enrollment Duration--Pregnant Women Pre- and Post-

Probability of Remaining Enrolled Among Adult Healthy Start Pregnant Women Pre- and Post- BadgerCare

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Months

Healthy Start Post Healthy Start Pre

10

Enrollment Duration—Children Pre- and Post-

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Months Since Enrolled

AFDC Post HS Post AFDC Pre HS Pre

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Months Since Enrolled

AFDC Post HS Post AFDC Pre HS Pre

Probability of Remaining Enrolled among Children Aged 6 to 18 Pre-

and Post- BadgerCare

Probability of Remaining Enrolled among Children Aged 0 to 5 Pre-

and Post- BadgerCare

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Enrollment patterns: Length of time between episodes

Defined pre- and post-BadgerCare periods as: Pre: All episodes ending from Jan. 1, 1997

through Dec. 31, 1998 (n=320,461) Post: All episodes ending from Jan. 1, 2000

through Dec. 31, 2001 (n=294,822)

Defined eligibility category as that in which individuals were enrolled at the time of disenrollment.

Ran Kaplan-Meier survival curves of the length of time out of public coverage by age group, eligibility category, and time period.

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Months Between Episodes-Adults Pre- and Post-

Probability of Remaining Disenrolled among Adults Pre- and Post- BadgerCare

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Months Since Disenrolled

AFDC Post AFDC Pre BadgerCare

13

Months Between Episodes-Children Post- Period by Eligibility Category

0.00.10.20.30.40.50.60.70.80.91.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Months Since Disenrolled

AFDC-Related Healthy Start BadgerCare

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Months Since Disenrolled

AFDC-Related Healthy Start BadgerCare

Probability of Remaining Disenrolled among Children Aged 6 to 18

Probability of Remaining Disenrolled among Children Aged 0 to 5

14

Probability of Reenrolling at 12 months Post-Period

0-5 years 6-18 years Adult

BadgerCare 52% 44% 43%

AFDC 59% 53% 51%

Healthy Start 46% 52% 43%

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Race/Ethnicity Post-Period

Adult Enrollment Duration by Race/Ethnicity

Child Enrollment Duration by Race/Ethnicity

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Months

Black NH Hispanic White NH

0

0.10.2

0.30.4

0.5

0.60.7

0.80.9

1

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31Months

Black NH Hispanic White NH

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Race/Ethnicity—Months Between Episodes

Post-Period

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Black NH Post Hispanic Post White NH Post

00.1

0.20.30.40.5

0.60.70.8

0.91

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Black NH Post Hispanic Post White NH Post

Probability of Remaining Disenrolled among Adult Enrollees Post-

BadgerCare

Probability of Remaining Disenrolled among Child Enrollees Post-

BadgerCare

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Conclusions

Besides increasing the number of publicly insured low-income adults and children, BC also increased the lengths of enrollment in public coverage.

Greater likelihood of continued eligibility and enrollment of Healthy Start pregnant women--12% pre-BC versus 40% post-BC at 12 months postpartum.

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Conclusions

Churning was particularly high among Medicaid and BC children. As many as 15%-20% of children re-

enrolled after only 1 month 60%-70% had reenrolled within the first 2.5

years after disenrolling Black NH enrollees were more likely to remain

enrolled longer and to re-enroll earlier once disenrolled relative to enrollees of other races/ethnicities.

Effects of churning on well-child visit and immunization schedules?