Gaps in Supplemental Health Insurance for Disabled Medicare Beneficiaries Jill Klingner MS RN Rural...
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![Page 1: Gaps in Supplemental Health Insurance for Disabled Medicare Beneficiaries Jill Klingner MS RN Rural Health Research Center University of Minnesota AcademyHealth.](https://reader035.fdocuments.us/reader035/viewer/2022062716/56649dd25503460f94ac842b/html5/thumbnails/1.jpg)
Gaps in Supplemental Health Insurance for Disabled Medicare
BeneficiariesJill Klingner MS RN
Rural Health Research CenterUniversity of Minnesota
AcademyHealthState Health Research and Policy Interest Group Meeting
June 24, 2006Seattle Washington
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Research Questions
• For the disabled under-65 Medicare Beneficiaries– Do state Medicaid and Medigap policies affect
their enrollment in Medicaid or Medigap?– Does enrollment in supplemental Medicare
insurance affect their health status?
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Medicare Overview
• Established in 1965 for the elderly
• Expanded in 1972 for the disabled
• Medicare out of pocket expenses– Co-pays– Deductibles– Non-Covered items
• Supplemental coverage often sought
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Distribution of Supplemental Policies by Source
Aged
Medigap25%
Medicare HMO16%
Employer sponsor
39%
Medicaid10%
No supplement10%
Disabled Under-65
Medigap5%
No supplement24%
Medicaid39%
Employer sponsor
23%
Medicare HMO9%
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Disabled Access to Supplemental Policies
• State Medicaid policies differ for disabled
• Disabled not included in federal Medigap guarantee-offer policy
• Medigap guarantee-offer policies for the disabled vary by state
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Disabled Medicare Beneficiaries
• Nearly 7 million people or over 15% of Medicare beneficiaries (2005)
• Social Security Disability Insurance (SSDI) Eligibility
• Paid FICA taxes for 5 of the previous 10 years• Specialty eligibility rules for some conditions
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Disabled vs. Aged Beneficiaries
• Poorer self-reported health status– More health needs– Higher health costs
• Lower incomes– Less able to purchase supplemental policy– Less able to purchase health care
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Data Sources
• Medicare Current Beneficiary Survey (MCBS) 1997-2001– Longitudinal– Self-report and claims
• State Policy : AARP Public Policy Institute Oct 1999 #9915.
• Area Resource File (ARF)
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Sample
• Disabled observations from 1997-2001– 8000+
• Sample for insurance estimation– Unique observations =4254
• Sample for outcomes estimation– Individuals with more than one year =2746
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Sample DemographicsCharacteristic Sample Disabled Aged
Single 68% 59% 44%
White 75% 67% 81%
Male 58% 55% 43%
Rural 30% 26% 23%
Income < $10,000 40% NA 17%
Education
Less than HS
HS Grad
More than HS
38%
37%
25%
34%
31%
34%
30%
30%
40%
Health Status
Fair/Poor
Good
V. good/Excellent
53%
29%
18%
62%
24%
13%
22%
32%
45%
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Model for Supplemental Insurance Choice and Outcomes
Personal Characteristics
State Policies
Market Factors
Available Supplements
Dependent Variable 2=
Health StatusChange
Choice Characteristics
Dependent
Variable 1= Choice
Provider supply
State FE
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State Policies of Interest
• Medicaid income limits
• Medicaid buy-in option
• Medically needy option
• Medigap guarantee-offer– # of plans required
– # of prescription plans required
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Supplemental Insurance Estimation Equations
• Utility
• Multinomial Logit equationPr(y=1|x)= exp(α+βx)
1+ exp(α+βx)
EffectsStateFixedPolicyJ jijii )1(Pr
J=1, 2, 3, 4, 5
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Results: Effect of State Policies on Enrollment in Medicaid or Medigap R2=.2361 (N=3074)
Policy MedicaidCoef (se) p value
(Marginal Effect)
MedigapCoef (se) p value(Marginal Effects)
Ln of # of firms that offer Medigap plans in state
-.067 (.050) .175 -.718 (.184) 0.0(-.003)
# of Mandated Medigap RX plans
-.589 (.381) .122 3.67 (1.39) .008
(.020)
Ln of # of type of mandated Medigap plans
.688 (.400) .085(.067)
-2.33 (1.21) .054(-.006)
LN of # of Medicare HMO by county
-.11 (.988) .209 -.134 (.134) .318
Medicaid buy-in in place -.419 (.247) .090(-.093)
.891 (.819) .277
FPL%*income -.575 (.168) .011(-.149)
-.056 (.150) .709
Medically needy plan in place .206 (.518) .691 -1.63 (2.04) .425
Medically needy*income .037 (.103) .721 .098 (.102) .338
State prescription drug program for disabled
-.224 (.100) .025(-.051)
-.201 (.211) .342
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Other Significant Variables
Significant Control Variables
Medicaid Veterans eligibility (-), Age (-), White (-),
Single (+), Mental illness (+), Mobility limitations (+), Cognitive limitations (+),
Live alone (+), Male (-), Education level (-), State FE
Medigap Veteran eligibility (-), Age (+), White (+), Ever smoked (+), Education Level (+), State FE
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State Policies that Affect Medicaid Enrollment
• Increase Medicaid enrollment– # of Medigap plans required by the state’s
guarantee-offer policy
• Decrease Medicaid enrollment– Medicaid buy-in– FPL% * income– State prescription drug program for disabled
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State Policies that Affect Medigap Enrollment
• Increase Medigap enrollment– # of Medigap prescription drug plans required
by the state’s guarantee-offer policy
• Decrease Medigap enrollment– # of Medigap plans required by the state’s
guarantee-offer policy– # of Medigap firms
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Estimates for Rural DisabledR2=.3019 (N=954)
Policy MedicaidCoef (se) p value
(Marginal Effect)
MedigapCoef (se) p value(Marginal Effects)
Ln of # of firms that offer Medigap plans in state
11.38 (.231) 0.0(1.46)
-4.28 (.233) 0.0(-.004)
# of Mandated Medigap RX plans
96.76 (2.89) 0.0(24.08)
47.95 (.529) 0.0(.002)
Ln of # of type of mandated Medigap plans
-204.63 (2.58) 0.0
(-15.72)
-75.96 (.595) 0.0(.005)
LN of # of Medicare HMO by county
.111 (.219) .613 -.288 (.440) .513
Medicaid buy-in in place -.329 (.424) .438 42.15 (.453) 0.0(.034)
FPL%*income -.580 (.404) .151 -.015 (.341) .965
Medically needy plan in place 220.81 (1.27 ) 0.0(1)
87.17 (5.08) 0.0
(2.34 e-24)
Medically needy*income -.050 (.254) .843 .032 (.289) .913
State prescription drug program for disabled
-.207 (.214) .334 -17.59 (.210) 0.0(-.014)
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Does enrollment in supplemental policies affect health status?
• Outcome Equation
• Estimation challenges– Insurance variable may be correlated with
unobserved variables, selection conserns and error term
stateFESupplyinsOUi jijiji
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Solution :Instrumental Variables
• Variables that are correlated with the original independent variable but not the errors (Like random assignment)
• Instruments used are the predicted probability from the supplemental insurance estimation
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Outcome DefinitionsVariable Calculation Mean (sd) Interpretation
Health status ∆
First year-most recent yr *(-1)
-.023 (1.002)
Positive number = improvement
Func status ∆
First year-most recent yr
.003 (1.631) Positive number = improvement
Func ∆
Consumer wts
First year-most recent yr
8.052
(490.846)
Positive number = improvement
Func ∆ expert wts
First year-most recent yr
1.482 (445.888)
Positive number = improvement
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Significant Health Status Effects
Supplement Type Sample Health Outcome Coef (se) p value
Any Supplement Full Func ∆
Consumer wts
-305.23 (166.07) .066
Any Supplement Full Func ∆
Expert wts
-314.29 (171.41) .067
Any Supplement MI Health ∆ -.901 (.358) .012
Any Supplement MI Func ∆ -1.18 (.710) .096
Medigap Mob Health ∆ -1.72 (.933) .065
Medigap Cog Func ∆ 4.57 (1.76) .009
HMO Supplement Mob Func ∆ Consumer wts
-438.33 (56.77).087
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Significant Control Variables
• Health ∆ affected by:– Male, Vet elig, Single, PCI, Chronic condition, Some State FE
• Func ∆ affected by:– Some State FE
• Func ∆ with consumer wts affected by:– Single, White, Metro, Year 2000, Vet elig, Some State FE
• Func ∆ with expert wts affected by:– White, Vet elig, Single, Some State FE
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Rural Health Effects
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Conclusions
• Identified state policies affect Medicaid and Medigap enrollment.
• Supplemental coverage affects health outcomes for subgroups of the disabled.
• State fixed effects are significant in both the estimation of enrollment and the estimation of health outcomes. This needs additional research.