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
5
Churning
Process of repeatedly coming into and out of a health insurance program Disruptive to continuity of care Negative health outcomes Costly
6
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?
7
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.
8
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
9
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
11
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.
12
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%
15
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
16
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
17
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.
18
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?
Top Related