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Who Enrolls In Community-Based Programs For The Uninsured, And Why Do They Stay?

Abstract

 
Faced with growing numbers of uninsured people, many communities are developing local programs to provide coverage or improve access. Some might predict that only those with health problems would participate; however, little is known about who enrolls. This paper examines participation and retention in three different community programs aimed at low-income uninsured adults. In two of the three programs, the typical participant had no health problems. Improved access to preventive and routine physician care, and increased security about getting access to care should the need arise, appeared to be the primary benefits of both initial and continued enrollment.

There are some common perceptions and myths among community leaders and policy-makers about the types of patients community-based initiatives will attract. Some worry that such programs will attract people with acute care needs who remain enrolled only until their needs are met and then exit until they once again have a short-term need for medical care.³ Others express concern that they will attract chronically ill people who remain enrolled as long as they are eligible. The combination of these two nonrandom selection processes could result in covering a pool of participants with high health care needs. To better inform policy surrounding coverage expansions, empirical evidence is needed on how a program’s eligibility criteria and target population affect who joins, who stays, and for how long. Similarly, data on how enrollees use services while in these programs also represent useful information to policymakers and program administrators.

This paper examines how the myths surrounding participation and retention play out in three local programs from the CIC initiative. Using a survey of program participants, we describe the ebb and flow of participants in these programs, noting the characteristics of those who enroll, which enrollees remain and which leave, and why. Examination of participants’ health status, utilization, and disenrollment patterns provides important information on the value of community-based programs to their participants.

Background On Communities In Charge

Top Background On Communities In... Data And Methods Key Findings Concluding Comments NOTES

 
In 2001 the RWJF funded fourteen sites across the country to develop community programs aimed at improving access to care for low-income, uninsured adults. This study examines results from the three sites chosen for a participant survey. Although all three programs provide fairly comprehensive benefits and aim to coordinate care in some fashion, they differ greatly in their approach, target population, financing, and geography.

Alameda County, California. Alliance Family Care was a coverage product administered by Alameda Alliance for Health, a not-for-profit health maintenance organization (HMO) in Alameda County. The program targeted low-income parents and their children. To be eligible, a person had to be an uninsured resident of Alameda County with a household income under 300 percent of the federal poverty level and ineligible for public coverage. Adults also had to have one or more children enrolled in the Alliance.⁴ Citizenship status was not considered. Alliance Family Care is the only program of the three studied here that charged a monthly premium; however, premiums were highly subsidized, ranging from $20 to $120 per month, depending on age. Benefits included physician care, inpatient and outpatient hospital care, laboratory services, and prescription drugs. Some services required small copayments. Recertification of eligibility occurred every twelve months.

Financing for Family Care came primarily through the Alliance’s reserve fund, with additional funding through the California Endowment and the California HealthCare Foundation (CHCF). The program also received some tobacco settlement money from the State of California.⁵

Austin, Texas. Seton Care Plus is an access program that provides health care to low-income uninsured adults in Austin. The Seton Health Care Network, a large nonprofit health system, administers the program. Enrollees receive care at one of three Seton community health centers (CHCs). To be eligible, a person must have a household income under 250 percent of poverty and be ineligible for Medicaid and the local Medical Assistance Program (a program offered by the county). Citizenship status is not considered. Upon enrollment, participants are assigned a primary care provider (PCP), given an access card to use when seeking medical services, and assessed sliding-fee copayments for various services based on income. Benefits include physician care, inpatient hospital care, lab services, prescription drugs, and (if approved as appropriate) emergency and urgent care. Seton generally recertifies eligibility every twelve months; however, the program does recertify at six months for a small number of people expected to become eligible for public programs. Seton Care Plus is financed by the Seton HealthCare Network as part of its mission to serve the poor.

Southern Maine. CarePartners offers access to health care services (including care management) for low-income adults in three counties in southern Maine. MaineHealth, an integrated delivery system serving southern and central Maine, initiated the program and continues to provide substantial financial and other support. All hospitals in the three-county area (including those outside the MaineHealth system) and approximately 950 local physicians have volunteered to provide free care under the program. Although the criteria have since changed, at the time of our survey, eligibility criteria required that a person be a nonelderly adult with an annual household income under 150 percent of poverty and ineligible for either government or employer-sponsored health coverage. In addition, a person must have resided within the program’s service area for at least six months and must not have assets exceeding $10,000 (or $12,000 for a family). Enrollees are assigned a PCP and given a membership card. For specialty care, enrollees must get a referral from their PCP. Benefits include physician care, inpatient hospital care, outpatient surgery, home care, and prescription drugs. Copayments are required for certain services. CarePartners recertifies eligibility every six months.

Health care for CarePartners enrollees is provided through the donated in-kind services of physicians and hospitals. However, CarePartners differs from many other donated care programs in that a local health system (MaineHealth) also provides substantial funding for administrative and support services (such as staff salaries). The program has also received a HRSA CAP grant and grants from local foundations.

Data And Methods

Top Background On Communities In... Data And Methods Key Findings Concluding Comments NOTES

 
Data for this analysis come from a multi-wave telephone survey of program participants in each of the three sites. Wave 1 was conducted within six to eight weeks of enrollment (on a rolling basis between August 2001 and August 2002); wave 2 occurred approximately six months after enrollment; and wave 3, at about twelve months after enrollment. We attempted to interview everyone who participated in the wave 1 survey in waves 2 and 3, regardless of their enrollment status at that time. Only adult enrollees were eligible for the survey. If more than one person per household joined the program, one person per household was randomly chosen for inclusion in the sample frame, to maintain independence.

The survey used a pretested, structured interview format. Many questions were similar to those of national surveys such as the Community Tracking Study (CTS) household survey and the Urban Institute’s National Survey of America’s Families (NSAF). The wave 1 survey included questions about health insurance coverage, health care use, access, and unmet need during the previous year; satisfaction with and opinions about health care; and current health status, employment, and sociodemographic information. The survey instrument for waves 2 and 3 included many of the same questions but also incorporated additional satisfaction questions and, for those who were no longer participating, questions on reasons for disenrolling.

Response rates to the survey were high for each site and in each wave. Alameda’s response rate ranged from 88 percent to 93 percent, depending on the wave. In Austin, the wave 1 response was 76 percent, but response increased to 85–86 percent in waves 2 and 3. In southern Maine, the response rate was 87–89 percent.

Key Findings

Top Background On Communities In... Data And Methods Key Findings Concluding Comments NOTES

 
Baseline characteristics of program enrollees. Enrollees’ sociodemographic characteristics at the time of enrollment varied greatly across the three programs studied (Exhibit 1). Alameda’s Family Care program, which targeted parents, attracted the youngest adults, most of whom were married. In contrast, enrollees in southern Maine’s program were older and more likely to be unmarried. All three programs attracted more females than males. After household size was accounted for, average income of enrollees across the three sites was fairly comparable, ranging from an average 117 percent of poverty in Austin to 139 percent in both Alameda County and southern Maine. The programs in Alameda and Austin both had large proportions of Hispanic enrollees; in contrast, 88 percent of enrollees in southern Maine were white. The large proportion of Hispanic enrollees in the Alameda and Austin programs (and Asian enrollees in Alameda) reflects both the broader population and the programs’ enrollment activities at CHCs serving the Latino and Asian communities. At least half of the enrollees in all three sites were working at the time of enrollment.

Who stays enrolled, and why? At six months after enrollment, at least two-thirds of respondents at all three sites were still enrolled in the program (Exhibit 3).⁶ Retention was highest among participants in Alameda’s Family Care program, an interesting finding given that this was the only program of the three studied that required a monthly premium. It appears that one important factor driving the difference in retention might be the programmatic features of each site—specifically, the eligibility criteria and the frequency of recertification. Alameda, which had the highest retention, recertified eligibility every twelve months and had the highest income-eligibility threshold of the three sites. Austin, with a slightly lower income-eligibility threshold, also recertified every twelve months.⁷ And southern Maine, which recertified every six months and had the lowest income threshold, had the lowest retention rates.

A small percentage in all three programs reported disenrolling because they were no longer eligible for the program (16 percent in southern Maine, which had the lowest income threshold for eligibility, and 3 percent in each of the other two sites). Indeed, the most common reason cited for losing eligibility was that household income had become too high. In terms of program affordability, 22 percent of disenrollees said that they could not afford to remain in the program in Alameda—the only program studied that charged enrollees a monthly premium—compared with 5–8 percent in the other two sites. Although the samples of disenrollees are too small to detect any significant differences, this suggests that premiums might have affected continued enrollment.

Health status, use patterns, and differences over time. To determine whether health care needs might have played a role in why continuous enrollees remained in these community-based programs, we examined (1) health status and use patterns for continuous enrollees versus disenrollees, and (2) use patterns for continuous enrollees over time. The first set of analyses informs our understanding of who remains in these programs by comparing and contrasting characteristics of continuous enrollees with those of disenrollees. The second provides information on how continuous enrollees use these programs, offering some important insights into the value of these programs for participants who took the time (in terms of eligibility paperwork) to remain enrolled and, in Alameda, continued to pay the premium.

We first examined how continuous enrollees and disenrollees differed in health status and health care use at the time of enrollment (Exhibit 4). There were few significant differences in health status and use between these groups, and no consistent patterns. In Alameda, where there were very few disenrollees, those with chronic or limiting conditions were significantly more likely than others to disenroll. In the other two sites, there was no significant difference. Nor were there significant changes in self-reported health status over the year of participation between continuous enrollees and disenrollees (data not shown). About half of continuous enrollees and disenrollees in each site reported no change in their health status over time. Among those who did report a change, continuous enrollees were no more likely than disenrollees to report an improvement or decline.

To determine whether usage patterns might help reveal enrollees’ reasons for remaining enrolled in their respective programs, we examined differences in use levels among continuous enrollees for the year before versus the year after enrollment (Exhibit 5). A significantly higher proportion of continuous enrollees in all three sites reported physician use in the year after enrollment, relative to the year before, with the largest increase occurring in Alameda. Moreover, all measures of preventive care included exhibited a statistically significant increase between the year before and the year after enrollment. Over the same period, continuous enrollees’ satisfaction with health care increased significantly in all sites.

Top Background On Communities In... Data And Methods Key Findings Concluding Comments NOTES

The majority of enrollees in all three sites used the programs largely for physician and preventive care. Self-reported rates of preventive cares increased dramatically after enrollment in all three sites. Getting preventive and physician care seems to be an important aspect of participation for those who stay enrolled. In addition, program enrollees appear to derive value from the fact that these programs help them avoid the financial risk associated with getting health care when they need it. Almost all enrollees reported that they felt more secure knowing that they had health care coverage or access after enrolling in the program. And although each of the three programs targeted and attracted different subgroups of uninsured people, the reasons for enrolling and staying enrolled were fairly consistent across the three programs.

Less than 5 percent of disenrollees reported leaving the program because they did not think they needed health care. Although some left because they became eligible for other sources of coverage, many were disenrolled because they no longer met the program’s eligibility criteria or failed to complete the necessary paperwork. The relatively high disenrollment rates in southern Maine largely reflect CarePartners’ recertification of eligibility every six months.

There are several important limitations to this work. The results are based on a small survey of enrollees in each site, which limited our ability to detect statistically significant differences, particularly when comparing subgroups such as continuous enrollees versus disenrollees. The data reflect self-reported use, health status, and other measures, which are subject to recall bias and other respondent error. Moreover, comparisons across the three sites are made with the caveat that these programs used different models of care and intended to attract different segments of the uninsured population from the start. The environmental context of each site clearly plays an important role in determining who joins these programs. Similar programs elsewhere might attract a very different set of enrollees, depending on the generosity of a state’s Medicaid program, the sociodemographic makeup of the general population, local charity-care efforts, and other factors.

OUR RESULTS SUGGEST that although community programs do not uniformly attract high-use, high-cost enrollees, their eligibility, recruitment, and re-enrollment strategies do influence who they attract. Further, the programs we studied all offer their participants the security of knowing they can get costly care when they need it. However, in all sites, physician care, rather than more costly hospital or emergency department services, was the primary driver behind the increased use observed after enrollment. The value of community programs to most participants does not appear to stem from the provision of acute medical care for a short-term need.

Editor's Notes

 
Erin Fries Taylor (etaylor{at}mathematica-mpr.com) is a health researcher at Mathematica Policy Research in Washington, D.C. Catherine McLaughlin is a professor in the Department of Health Management and Policy, University of Michigan, in Ann Arbor. Anne Warren is a research assistant in the Department of Economics, University of Michigan. Paula Song is a research assistant in the Department of Health Management and Policy.

This research was funded by the Robert Wood Johnson Foundation and the California HealthCare Foundation as part of the evaluation of the Communities in Charge initiative. The authors thank the program staff from the three sites profiled here for their cooperation in the study. Any errors in this research are attributable solely to the authors.

NOTES

Top Background On Communities In... Data And Methods Key Findings Concluding Comments NOTES

 

1. C. DeNavas-Walt, B.D. Proctor, and C.H. Lee, Income, Poverty, and Health Insurance Coverage in the United States: 2004, Current Population Reports no. P60-229, August 2005, http://www.census.gov/prod/2005pubs/p60-229.pdf (accessed 15 March 2006); and R.J. Mills, "Health Insurance Coverage—2000," Current Population Reports no. P60-215, September 2001, http://www.census.gov/prod/2001pubs/p60-215.pdf (accessed 15 March 2006).
2. For information on employees’ take-up of coverage offered, see H.S. Farber and H. Levy, "Recent Trends in Employer-Sponsored Health Insurance: Are Bad Jobs Getting Worse?" Journal of Health Economics 19, no. 1 (2000): 93–119[CrossRef][Web of Science][Medline]; and P.F. Cooper and B.S. Schone, "More Offers, Fewer Takers for Employment-based Health Insurance: 1987 and 1996," Health Affairs 16, no. 6 (1997): 142–149.[Medline]For information on employers’ offers of coverage, see J. Gabel et al., "Health Benefits in 2005: Premium Increases Slow Down, Coverage Continues to Erode," Health Affairs 24, no. 5 (2005): 1273–1280.[Abstract/Free Full Text]
3. E.H. Kilbreth et al., "State-Sponsored Programs for the Uninsured: Is There Adverse Selection?" Inquiry 35, no. 3 (1998): 250–265.[Web of Science][Medline]
4. These children could be enrolled in the Alliance through MediCal (the state’s Medicaid program), the State Children’s Health Insurance Program (SCHIP), or Alliance Family Care if the child(ren) was not eligible for public coverage.
5. Because of internal financial problems, the Alliance contracted Family Care enrollment by several thousand people in July 2004 and then terminated the program in June 2005.
6. Because we have no information on nonrespondents, we can only report on the enrollment status of people responding to the survey in waves 2 and 3. Nonrespondents might be more likely than respondents to have disenrolled from the program (for example, moved away from the area, left the program, and were lost to follow-up). If retention is calculated as a percentage of baseline enrollment (which likely overstates disenrollment), retention rates are 62 percent, 47 percent, and 30 percent at twelve months after initial enrollment for Alameda, Austin, and southern Maine, respectively.
7. Austin’s Seton Care Plus program did recertify eligibility at six months for a small subset of enrollees whose income was close to the threshold for public coverage, although eligibility for most enrollees was recertified annually.

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