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How Will Health Reform Affect Churning in States?
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Transcript of How Will Health Reform Affect Churning in States?
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Funded by a grant from the Robert Wood Johnson Foundation
How will health reform affect churning in
states?
Brett Fried, MS
State Health Research and Policy
Interest Group Meeting (SHRP)
June 22, 2013
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Acknowledgements
• Supported by a grant from the Robert Wood
Johnson Foundation to the State Health
Access Data Assistance Center (SHADAC)
at the University of Minnesota
• Co-Author
– Julie Sonier, SHADAC
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Overview
• Background on Churn
• Methods
• Results
• Discussion
• Implications
• Future Research
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Churn: Background
What is it?
Churning in this presentation is the percent of
individuals who are income-eligible for Medicaid at a
point in time, but no longer eligible 12 months later
Why does it matter?
– Can disrupt continuity of care
– Can increase administrative costs for plans,
providers and government entities
– Knowledge about the degree of churn can help
states, providers and plans reduce the costs and
impacts of churning
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Churning for Medicaid Enrollees
Eligibility changes due to:
• Changes in income
• Changes in family size
What happens to people who lose Medicaid
eligibility?
• Uninsured
• ESI or Direct Purchase
• Post ACA Implementation: Subsidies in the
Exchange
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Data Source – The SIPP
• The Survey of Income and Program Participation (SIPP) is a
Census Bureau panel survey that is done in four month waves with
each wave split into four groups (rotations) and asked to recall
information over four months (reference months)
• The purpose of the SIPP is to provide information on income and
government program participation
• Here we are using reference month April 2010 from wave 6 and
April 2011 from wave 9 of the 2008 panel which includes about
90,000 observations
• Not designed to be state representative
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Analytic Approach
• Sample was limited to people who were present in both
waves of the survey
• Adjusted for attrition using a simple logistic regression
• The focus of this research is change in Medicaid
eligibility after 12 months as a result of changes in
income volatility and family size
• State Medicaid eligibility for jobless parents of dependent
children and jobless other adults is from Kaiser (2013)
survey of Medicaid eligibility
• National data but tested weighting to states
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RESULTS
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Income Distribution by Eligibility Group
22% 22%
26% 26%
20% 19%
41% 42% 44% 44%
40% 41%
36% 37%
30% 31%
40% 40%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2010 2011 2010 2011 2010 2011
0-138% FPG 139-400% FPG 401%+ FPG
9
Nonelderly Adults Parents Childless Adults
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Starting at 0-138% FPG: Where are they
after 12 months?
68% 73%
64%
27% 24%
29%
5% 3%
7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Nonelderly Adults Parents Childless Adults
0-138% FPG
139-400% FPG
401%+ FPG
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Starting at 139-400% FPG: Where are they
after 12 months?
13% 14% 13%
72% 73% 71%
15% 13% 16%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Nonelderly Adults Parents Childless Adults
0-138% FPG
139-400% FPG
401%+ FPG
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Starting at 401%+ FPG: Where are they
after 12 months?
3% 3% 3%
16% 16% 16%
81% 81% 81%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Nonelderly Adults Parents Childless Adults
0-138% FPG
139-400% FPG
401%+ FPG
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As the Medicaid Eligibility Threshold increases,
“churn” decreases for parents and childless adults
62% 60%
57% 55%
52% 50%
45%
42%
38% 36%
33% 32%
29% 27%
57% 56% 55% 54%
53% 52%
49% 47%
45% 43%
41% 39%
37% 36%
0%
10%
20%
30%
40%
50%
60%
70%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% 120% 130% 138%
Perc
en
t ch
urn
aft
er
12 m
on
ths
Medicaid Eligibility Threshold
Parents
Childless Adults
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Percent of parents who are income eligible for
Medicaid but are ineligible after 12 months
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Reduction in “churn” as a result of change from
state to ACA Medicaid eligibility threshold: Parents
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Discussion
Other reasons why people “churn” into or out of Medicaid:
• Changes in family status
• Changes in assets
• Changes to program administration
• Change in awareness or ability to renew coverage
The ACA will reduce some of this churn because of the
following:
• Streamlined application process
• Requiring the use of existing state information
• Increased awareness of renewal process
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Implications
For every increase in the Medicaid eligibility threshold by 10
percentage points, “churn” decreases on average by 3
percentage points for parents and on average by about 1.5
percentage points for childless adults.
Consequently, states that have a current eligibility threshold
for parents and/or childless adults that is less than 138% of
poverty should see a decrease in churn (as defined here) if
they choose the ACA Medicaid expansion.
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Future Research
• Estimate the characteristics of people that churn
at the state level
• Estimate churning over different time periods
• Estimate churning into and out of subsidies in
the exchange.
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www.shadac.org
@shadac
Brett Fried Senior Research Fellow
612-624-1406