Table Of Content•
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ChildrenintheOregonHealthPlan: HowHaveTheyFared?
CMSLibrary
Writtenby: C2-07-13
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JanetB.Mitchell,Ph.D.,SeniorVicePresident
HealthEconomicsResearch,Inc.
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Co-Authors:
SusanG.Haber,Sc.D.,SeniorEconomist
HealthEconomicsResearch,Inc.
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- GalinaKhatutsky,M.S.,Analyst
HealthEconomicsResearch,Inc.
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(781)788-8100
(781)788-8101(fax)
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SuzanneDonoghue,B.A.,JuniorAnalyst
HealthEconomicsResearch,Inc.
411WWaavletrhlaemy,OMaAks0R2o4a5d2,-S8u4i1t4e330
(781)788-8100
(781)788-8101(fax)
[email protected]
Keywords: Medicaidmanagedcare,accesstocare,children'shealthinsurance
Words:4,732
AbstractWords: 250
ChildrenintheOregonHealthPlan:HowHaveTheyFared?
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ChildrenintheOregonHealthPlan: HowHaveTheyFared?
Abstract
Background. TheOregonHealthPlan(OHP)isaninnovativeMedicaiddemonstrationthat
bothenrollsbeneficiariesinmanagedcare,andusesaprioritylisttodefinethebenefitpackage.
Objectives. ThisstudyseekstoevaluatetheimpactofOHPonchildren'saccesstocare.
ResearchDesign. Atelephonesurveywasconductedin1998oftwogroupsofchildren:OHP
enrolleesandFoodStamprecipientsnotenrolledinOHP. TheFoodStampsampleincluded
bothprivatelyinsuredanduninsuredchildren. Thisallowedustodisentangletheinsurance
effectsofOHPfromothereffectssuchasitsrelianceonmanagedcareandtheprioritylist.
Comparisonsincluded:usualsourceofcare,travelandwaitingtimes,utilizationonhealthcare
services,unmetneedandsatisfactionwithcare.
Results. MuchofOHP'simpacthasbeenrealizedbythesimpleextensionofhealthinsurance
coveragetoOregon'slow-incomechildren. Theavailabilityofinsurancesignificantlyincreased
theuseofphysicianvisitsanddentalcare. OHPchildrenweremorelikelytoreportanunmet
needforprescriptiondrugs,however,largelyduetomanagedcareplans'formularies. The
prioritylisthadlittleeffectonchildren,affectingonly2percentofchildrensurveyed,mostof
whomsucceededingettingtheserviceanyway.
Conclusions. Despitethenegativepublicitypriortoitsimplementation,thereisnoevidencethat
"rationing"underOHPhassubstantiallyrestrictedaccesstoneededservicesforchildren. OHP
childrenappeartoenjoyaccessequaltothatoflow-incomechildrenwithprivateinsurance,and
fargreateraccessthantheuninsured.
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ChildrenintheOregonHealthPlan: HowHaveTheyFared?
TheOregonHealthPlan(OHP),Oregon'sinnovativeMedicaid 1115waiverprogram,
wasimplementedoversixyearsagoinFebruary 1994.Ithadbeenprecededbyconsiderable
controversyoveritsuseofaprioritizedlistofservicestodefinetheprogram'sbenefitpackage.
Infact,thecontroversyhadbeensogreatthatapprovalofOregon'swaiverwasdelayedfortwo
years. Ofparticularconcernwasthenotionthatthe"rationing"ofservicesviatheprioritylist
wouldbeappliedonlytosomeofthemostvulnerableresidentsoftheState,e.g.,poorwomen
andchildren.1"5 Under Oregon'sprioritylist, pairedmedical conditions andtreatments are
rankedhierarchicallyfrommosttoleastmedicallynecessary. Coveredservicesarethoseator
aboveacut-offlinethatisestablishedbasedontheState'sbudgetaryresources.Criticsworried
whetherMedicaidbeneficiariesinOregonwouldreceivethecaretheyneeded,orwhetherthey
wouldbedeniedmedicallynecessaryservicesbecausetheserviceswere"belowtheline".
Despitetheconsiderablepublicitythatprecededitsimplementation,littleisknownabout
howtheOregonHealthPlanhasimpactedtheservicesthatMedicaidbeneficiariesreceiveinthe
State. Inthispaper,wefocusspecificallyonaccesstocareforchildren. (Acompanionpaper
examinesaccesstocareforadults.) Thisfocusisparticularlyappropriateasitwasa7-yearold
boyneedingabonemarrowtransplantwhotriggeredthestate-widediscussionsthateventually
resultedintheOregonHealthPlan. Facedwithabudgetcrisisin1987,theOregonMedicaid
programhadearlierrescindedcoveragefororgantransplants(anoptionalMedicaidserviceunder
federalregulations),andtheboydiedasaresult.1
Underitswaiver,theOregonHealthPlannotonlyintroducedtheprioritylist,buttwo
otherinnovationsthatmayimpactaccesstocare.First,OHPexpandedMedicaideligibilityto
coveralluninsuredresidentsupto 100percentoftheFederalPovertyLevel(FPL). Thevast
majority ofthese expansion beneficiaries are adults, as the earlier SOBRA expansions had
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alreadycoveredmostchildrenunderthepovertylevel. However,olderteen-agers(childrenborn
priortoSeptember30,1983),whowerenoteligibleunderSOBRA,couldnowbecoveredunder
OHP. Second,nearlyallOHPchildrenhavebeenenrolledincapitatedmanagedcareplans.
Sinceeachoneofthesethree OHP componentsmayhave aneffectonaccessto care, any
evaluationofOHPmustideallytrytodisentanglethedifferentialeffects.
HowmightthesedifferentcomponentsofOHPaffectaccess? Eligibilityexpansionis
expectedto improve access, aspreviouslyuninsuredteenagers presumably faced difficulties
obtainingcare. Previousresearch has clearly shownthat extending health insuranceto the
uninsuredincreasesutilizationofphysicianandotherservices.6"10 Theneteffectsofmanaged
careandthepriority listare lessclear. OHP childrenenrolledinmanaged careplansmay
encounterbarrierstoservicesrequiringpriorauthorizationbytheirprimarycarephysician,such
asspecialistreferrals. StudiesconductedduringtheearlyyearsofMedicaidmanagedcaredid
findevidenceofreducedspecialistvisits,11"12althoughamorerecentstudyinruralMinnesota
foundnodifferencesinuseofspecialists(oranyotherservices)betweenchildrenenrolledin
managedcarevs.fee-for-service.13 Ontheotherhand,enrollmentinaplanandassignmenttoa
primarycareprovidermayassureaccesstoausualsourceofcare,atleastforadults. " The
impactoftheprioritylistissimilarlydifficulttopredictapriori.Whileimplementationofthe
prioritylistmayrestrictaccesstothoseservicesthatarebelowtheline,thelistitselfisbasedona
farmoreexpansivelistofservicesthanhadbeencoveredunderOregon'straditionalMedicaid
program.Newlycoveredservicesforchildrenincludeorgantransplantsandarichersetofmental
healthbenefits.
Inthispaper,weevaluateOHP'simpactonaccessfortraditionalAFDC(nowTANF)
andSOBRAchildrenaswellasthosechildrencoveredundertheexpansionprogram. These
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eligibilitygroupswereamongthefirsttobeenrolledinOHPinFebruary1994. Thus,bythe
timeofoursurvey(1998),OHPwasamaturehealthprogram,havingservedtheseeligibility
groupsforfouryears.
Methods
EvaluationDesign
Theidealquasi-experimentaldesignwouldconsistofpreandpost-OHP measuresof
accessforbothOHPchildrenandacomparisongroupofnon-OHPchildren. Unfortunately,it
wasnotpossibletocollectbaselinemeasuresofaccesspriortoimplementationofOHP.Instead,
weadoptedasimplepointintimecomparisonofOHPchildrenandacomparisongroup. Our
OHPsampleofchildrenlivedinfamilieswithincomesupto 100percentofFPL,exceptfor
thoseaged5yearsandunderwhocouldhaveincomesupto133percentofFPL. (TheSOBRA
legislationraised the eligibility ceiling for pre-school children.) Our comparison group of
childrenwereFoodStamprecipients,excludingthosealsoenrolledinOHP. TheFoodStamp
eligibilityceiling is 130 percent ofFPL, so ourcomparison group presumably has average
incomesreasonablysimilartothoseofOHPchildren.
SampleSelection
Samplesofchildrenaged 1 to 17wereselectedfromboththeOHPandFoodStamp
populations. Stateeligibilityfilesforbothprogramswereusedtoconstructthesamplingframes.
TherewereconsiderabledifficultiesandtwelvemonthsofnegotiationsbeforegainingtheState's
permissiontousetheFoodStampeligibilityfileforsamplingpurposes. Overthecourseofthis
year,theFoodStampsofficeinOregonswitchedfromthetraditionalmethodofmailingfood
stampstorecipientseachmonthtoanautomateddebitcardsystemthatkepttrackofrecipients'
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"accounts". Underthe debitcard system, arecipientno longerneededto maintaincurrent
addressinformationwiththeStateinordertoreceivefoodstampbenefits. Thismadeitmuch
moredifficulttolocatetheFoodStampsampleaswillbeseenbelow.
DataCollectionandSampleSizes
Thesurveywasconductedbytelephone,usingcomputer-assistedtelephoneinterviewing
(CATI)techniquesin1998. Allinterviewswereconductedwithanadultinformant,usuallythe
child'sparent.
Atotalof351 OHPchildrenand137FoodStamprecipientsrespondedtothesurvey,
withresponseratesof67.2percentand38.2percent,respectively. Despiteextensivetracing,
manyFoodStampsamplememberscouldnotbelocated. Low-incomepopulationsgenerally
tendtobehighlymobileandoftendonotleaveforwardingaddressinformation.
TheresponseratefortheOHPsampleisashigh(orhigher)thanthoseachievedinother
publishedsurveysofMedicaidpopulations,14"15 whilethe response rate forthe Food Stamp
sampleisonlytwo-thirdsashigh. BecausedatacollectionandtracingproceduresfortheOHP
andFoodStampsampleswereidentical,itwouldseemthatthedifferenceintheirresponserates
can be attributed to the poorer quality ofthe addresses in the Food Stamp eligibility file.
Furthermore,whenlocated,almostalleligiblerespondentsparticipatedinthesurvey; only3
percentofsampledparentsrefusedtoparticipate. Forthesereasons,wedonotbelievethatany
systematicbiashasbeenintroducedasaresultofthislowresponserate.
Amongthe 137 FoodStamprecipients,themajority(62%or97)oftheFoodStamp
comparisongrouphadprivatehealthinsurance,almostalwaysthroughaparent'semployer. The
remaining40childrenwereuninsured,andmostoftheirparentsreportedthattheysimplycould
notaffordhealthinsurance.
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TheavailabilityofbothinsuredanduninsuredFoodStampchildreneffectivelyprovides
uswithtwo comparisongroups. ComparisonofOHPchildrenwithuninsuredFood Stamp
recipients allows us to evaluate the impact of OHP on access, relative to no insurance
whatsoever. Because ofthe small number ofuninsured children, however, we may have
insufficientpowerforsomeanalyses. ComparisonwithinsuredFoodStamprecipientsallowsus
toevaluateOHP'simpact,relativetothatofprivateinsurance. This lattercomparisonwill
capturedifferencesbetweenOHPandcommercialhealthinsurance,suchastheprioritylistand
theuseofmanagedcare.
StatisticalTests
Chi-square tests were used to determine the statistical significance ofall categorical
variables,andt-testsforcontinuousvariables. LogisticregressionwasusedtoevaluateOHP
impacts,whileadjustingforconfoundingvariableslikehealthstatus. Duetothecomplexsample
design,weightingandstandarderroradjustmentsweremadeusingSUDAANforallanalyses.
Results
DescriptiveFindings
SociodemographicCharacteristicsandHealthStatus
Table 1 comparessociodemographiccharacteristicsandhealthstatusofOHPchildren
withinsuredanduninsuredFoodStamprecipients. OHPchildrenweresignificantlyyoungeron
averagethanFood Stamp children, reflectingthe expandedMedicaideligibility forchildren
under6(upto133%ofFPL). Almosttwo-fifthsofOHPchildren(39%)were5yearsofageor
under,comparedwithonly25percentofFoodStampchildren.Therewerenodifferencesin
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gender.ReflectingthepopulationoftheStateasawhole,thevastmajorityofparentsofboth
OHPandFoodStampchildrenreportedthattheirchildrenwerewhiteandnon-Hispanic.
There were no significant differences in marital status between the parents ofOHP
childrenandthoseofFoodStampchildren. ParentsofFoodStampchildrenweresignificantly
morelikelytobe"currentlyemployedinajobforpay"andwerebettereducated,however,
comparedwiththeparentsofOHPchildren.
Therewerefewdifferences inhealthstatusbetween OHP andFood Stampchildren,
althoughparentsofinsuredFoodStampchildrenweremorelikelytoreporttheirchild'shealthas
"excellent". (Onlyasinglechildwasreportedasbeinginpoorhealth;hencethe"fair"and
"poor"categorieshavebeencombined.)
UsualSourceofCareandTravel/WaitingTimes
OHP childrenwere significantlymore likelythanuninsured Food Stamp childrento
reportthattheyhadausualsourceofcare,i.e."aplacetheyusuallygotowhentheyaresickor
needadviceabouttheirhealth" (Table2). Theveryhighrateamonginsured Food Stamp
childrenofhavingausualsourceofcareissomewhatsurprising,aswehadhypothesizedthat
rateswouldbehighestforOHPchildrengiventheirgreaterenrollmentinmanagedcareplans.
AlmostalloftheOHPchildren(94%)wereenrolledinamanagedcareplan,comparedwithless
thantwo-thirds(62%)oftheinsuredFoodStampchildren(datanotshown). Amongthosewitha
usualsourceofcare,themajorityofallchildrenwenttoadoctor'sofficeorHMO.However,
uninsuredFoodStamprecipientsweresignificantlymorelikelytogotoahospitalemergency
roomor"other"typeofsetting,generallyapublichealthorcommunityhealthclinic. Among
thosewithausualsourceofcare,OHPchildrenweresignificantlymorelikelythanuninsured
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FoodStampchildrentoreportthattheyhadausualhealthcareprovider,i.e.,"aparticulardoctor
orothermedicalpersonthattheyusuallyseeatthisplace".
Allrespondentswithausualsourceofcarewerealsoaskedabouttravelandwaiting
timestothisusualsource. Asarule,therewerefewdifferencesbetweenOHPchildrenandthose
inthetwocomparisongroups. UninsuredFoodStampchildrendid reportsomewhatlonger
waits inthe waitingroomandexamroombefore seeingadoctororothermedicalperson,
presumablybecausetheyweremorelikelytousethehospitalERastheirusualsourceofcare.
UtilizationofHealthCareServices
Asarule,utilizationofhealthcareservicesbyOHPchildrenissimilartothatofinsured
Food Stamp children, and higher than that ofuninsured children (see Table 3). In some
instances,suchasphysicianvisits,thismayreflecttherelativelylargernumberofveryyoung
childrenintheOHPsample. Youngchildrengenerallyusemorehealthcareservicesthanolder
children,becauseoftheneedtoreceiveimmunizationsandthelike.Regressionanalysesshown
laterwill allowusto holdageconstant,aswell ashealthstatusandotherfactors affecting
utilization.
ThemajorityofOHPandinsuredFoodStampchildrenhadseenaphysicianinthepast
threemonths(60%and64%,respectively),comparedwithonly35percentofuninsuredchildren.
Forthosewithatleastonevisit,therewerenodifferencesinthenumberofphysicianvisits
duringthisthree-monthperiod(datanotshown).
Onceimmunizationsarecomplete,healthychildrenareunlikelytovisitthephysician
morethanonceayear,however,andthepercentwithaphysicianvisitinthepasttwelvemonths
maybeamorereasonablemeasureforcomparison. Althoughtheutilizationgapisdefinitely
narrowed,OHPandinsuredFoodStampchildrenwerestillsignificantlymorelikelytohaveseen
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