Oregon received approval for a Medicaid waiver program earlier this week. There are a lot of moving parts but I want to highlight one of them:
Very exciting! Oregon #Medicaid will now continuously cover children from birth to age 6. I wonder if other states will follow? https://t.co/BYYDxzAoXK
— Akeiisa Coleman (@ACintheDC) September 28, 2022
Once a kid qualifies for Medicaid from birth to age 6, they will be presumed to be eligible for Medicaid until they are six. This will significantly reduce enrollment churn caused by administrative burden. People routinely fall off of coverage that they are likely eligible for because of paperwork. My friend and colleague, Dr. Rushina Cholera was the lead author on a study by a Duke team that looked at churn in North Carolina Medicaid for kids, and we found it was a fairly frequent occurrence. We hypothesized that there are significant negative effects of short periods of uninsurance.
The second thing that I found interesting was a job market paper by Eran Politzer. He looked at what happened to people on Medicaid whose insurers’ contracts were not renewed by a state:
Throughout the year after the switch, the share of switchers with any filled prescription is lower by about 15% relative to the baseline mean and comparing to the control group (3.7 percentage points lower). The use of prescription drugs decreases even among patients with chronic conditions such as diabetes or depression. Switchers have 6% to 8% fewer visits to primary care physicians throughout most of the post-exit year, and they use emergency departments (ED) up to 5% more in the beginning of that year. Towards the end of the switching year, switchers are admitted more often to hospitals (they have 11% more inpatient admissions) and spend more time hospitalized (14% to 21% more inpatient days). In addition to utilization, I estimate insurers’ spending using prices from Medicaid’s fee-for-service (FFS) program. After the exit, insurers’ spending on switchers is 9.7% lower than their baseline spending, comparing to beneficiaries in remaining plans. This amounts to $348 annual savings per switcher. The total Medicaid spending on switchers (including spending through the FFS program) is lower during the switching year by $151 (4%). Section 5 examines heterogeneity. The results suggest that children are more sensitive to disruptions after an involuntary switch. The number of children’s hospital admissions due to Ambulatory Care Sensitive Conditions (ACSC), deemed preventable with appropriate community care, is higher by 17% during the second quarter after the exit, relative to the baseline. For adults, the number of ACSC-related admissions decreases. In a similar result, Lavarred a et al. (2008) find that children in fair or poorhealth, that switch to another health insurance, have much higher odds of reporting a delay in care than adults.
Those are big results due to a transition in which insurer held a person’s coverage. It was not a loss of coverage. It was just a switch from Big Blue to Mayhew Insurance companies. People lose the learning that they picked up on the switch. They lose the relationships. They lose the understanding that an insurer will cover something.
There has been a good literature on the costs of transitions from being insured to uninsured. Now there is an emerging literature of the costs of transiting from one insurer to another within the same program. Oregon is taking steps to reduce these costs.
Ohio Mom
Continuous health coverage through age six should help in the discovery of developmental delays and disorders — I say “should” because it depends on how observant the doctor is, and how willing they are to follow-up on deviations from typical developmental milestones.
Are they going to wave off any symptoms (“he’s just a late talker/walker/whatever”), or order the necessary evaluations? I would guess that depending on how the coverage is structured, it may encourage or discourage the necessary referrals.
Early intervention can make a huge difference in development and get young children back on track or at least closer “to track” (I might have made that expression up).
It would take a lot of long term data collection to prove that Oregon’s expansion of Medicaid coverage was having this effect though.
jonas
I know nothing about OR’s healthcare infrastructure, but how easy is it to actually access a pediatrician who accepts Medicaid?
Ohio Mom
@jonas: That question is everything.
Here in Hamilton County, Ohio, we have a special tax levy (the Indigent Care levy) that makes up the difference for patients seen at our children’s hospital and our university-based medical system. Because of this, Ohio Son has had, and continues to have, fabulous care (he has a Medicaid Waiver because of his disability).
After years of reading David Anderson’s posts, I wonder if this tax support is responsible at least in part for both medical systems having good-sized disability-focused departments. For example, the UC Health system has a new center for disabled adult care, which I gather is somewhat unusual.
jonas
@Ohio Mom: That’s good to hear. My impression is that Medicaid can be pretty good for things like hospitalization and long term care, but virtually no primary care physicians take it.
Ohio Mom
@jonas: When Ohio Son was younger and had primary coverage through Ohio Dad’s job, with Medicaid covering the deductibles and co-pays, he saw a lovely pediatrician who also had a son on the autism spectrum. She wasn’t in a health system covered by the levy but with the private coverage, it didn’t matter.
When he aged out of pediatrics, she had some suggestions for adult practitioners but warned they may have already “enough” Medicaid patients — apparently, practices set a number of Medicaid patients they calculate they can afford the loss on. She shrugged her shoulders and said something along the lines of, You gotta be able to stay in business.
But then the adult disability group opened at the University Hospital and that was the obvious choice.
I don’t know how families with disabled members manage in areas that don’t have the supports we do here.
dnfree
@Ohio Mom: Both Medicare and Medicaid seem to underpay for providers and procedures. This seems unsustainable and unfair to me. I look at my Medicare EOB and I see a charge for $500 that Medicare paid $100 for, or a blood test for $100 that Medicare paid $12 for. It seems to me that private insurers greatly overpay because of how little Medicare pays. Why don’t the government programs pay closer to what the service actually costs, considering the expense of an office, a staff, supplies, etc.?
I’m glad your son has access to good services.
dnfree
Thanks again. I always appreciate information on what’s going on in the states, and the real-world consequences.
Ohio Mom
@dnfree:
I am also on Medicare and have noticed the same thing. It’s all just another example of our nation’s health system dysfunction. What is the actual value/cost of anything, no one knows because of all the cost-shifting.
Even within Medicare there is cost-shifting. Ohio Dad’s endocrinologist gave him a very involved blood sugar level test (took hours) that he failed? passed? I don’t know what the right word is, the result was that his diabetes was shown to be severe enough that he now gets his insulin under Part B, which is a lot cheaper for us.
dnfree
@Ohio Mom: I had my shingles shots in my primary care provider’s office several years ago when they were fairly new. I didn’t get the bill for the first one until I had the second one. They charged me more than $500 for each shot. Turns out the shingles shots are covered under Part D, not Part B, and I should have had them at a pharmacy. Well, I didn’t know that and neither did my doctor. After months of wrangling I got them to drop the charges because how was I supposed to know? But it’s a stupid setup. Some shots you get from your doctor and some you don’t. Why the difference?
raven
@dnfree: Yea, we’re trying to figure out Proliva injections for my wife and, damn, it’s confusing.
Ohio Mom
@dnfree: I am inbetween my shingles shots, due for the second next month. If only I had waited —next year Medicare makes them free!
@raven: Do you mean Prolea, the bone-strengthening injection — I took that for a while, worked well for me. If so, make sure you go to the dentist before you start. Twice now I’ve had to delay my osteoporosis treatment to get dental surgery done.
David Anderson
@dnfree: Posting a reply to this comment tomorrow….