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Gaps in Supplemental Health Insurance for Disabled Medicare Beneficiaries. Jill Klingner MS RN Rural Health Research Center University of Minnesota AcademyHealth State Health Research and Policy Interest Group Meeting June 24, 2006 Seattle Washington. Research Questions. - PowerPoint PPT Presentation
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Gaps in Supplemental Health Insurance for Disabled Medicare
BeneficiariesJill Klingner MS RN
Rural Health Research CenterUniversity of Minnesota
AcademyHealthState Health Research and Policy Interest Group Meeting
June 24, 2006Seattle Washington
Research Questions
• For the disabled under-65 Medicare Beneficiaries– Do state Medicaid and Medigap policies affect
their enrollment in Medicaid or Medigap?– Does enrollment in supplemental Medicare
insurance affect their health status?
Medicare Overview
• Established in 1965 for the elderly• Expanded in 1972 for the disabled• Medicare out of pocket expenses
– Co-pays– Deductibles– Non-Covered items
• Supplemental coverage often sought
Distribution of Supplemental Policies by Source
Aged
Medigap25%
Medicare HMO16%
Employer sponsor
39%
Medicaid10%
No supplement10%
Disabled Under-65
Medigap5%
No supplement24%
Medicaid39%
Employer sponsor
23%
Medicare HMO9%
Disabled Access to Supplemental Policies
• State Medicaid policies differ for disabled• Disabled not included in federal Medigap
guarantee-offer policy• Medigap guarantee-offer policies for the
disabled vary by state
Disabled Medicare Beneficiaries
• Nearly 7 million people or over 15% of Medicare beneficiaries (2005)
• Social Security Disability Insurance (SSDI) Eligibility
• Paid FICA taxes for 5 of the previous 10 years• Specialty eligibility rules for some conditions
Disabled vs. Aged Beneficiaries
• Poorer self-reported health status– More health needs– Higher health costs
• Lower incomes– Less able to purchase supplemental policy– Less able to purchase health care
Data Sources
• Medicare Current Beneficiary Survey (MCBS) 1997-2001– Longitudinal– Self-report and claims
• State Policy : AARP Public Policy Institute Oct 1999 #9915.
• Area Resource File (ARF)
Sample
• Disabled observations from 1997-2001– 8000+
• Sample for insurance estimation– Unique observations =4254
• Sample for outcomes estimation– Individuals with more than one year =2746
Sample DemographicsCharacteristic Sample Disabled Aged
Single 68% 59% 44%
White 75% 67% 81%
Male 58% 55% 43%
Rural 30% 26% 23%
Income < $10,000 40% NA 17%
Education Less than HS HS Grad More than HS
38%37%25%
34%31%34%
30%30%40%
Health Status Fair/Poor Good V. good/Excellent
53%29%18%
62%24%13%
22%32%45%
Model for Supplemental Insurance Choice and Outcomes
Personal Characteristics
State Policies
Market Factors
Available Supplements
Dependent Variable 2=
Health StatusChange
Choice Characteristics
DependentVariable 1= Choice
Provider supply
State FE
State Policies of Interest
• Medicaid income limits• Medicaid buy-in option• Medically needy option• Medigap guarantee-offer
– # of plans required– # of prescription plans required
Supplemental Insurance Estimation Equations
• Utility
• Multinomial Logit equationPr(y=1|x)= exp(α+βx)
1+ exp(α+βx)
EffectsStateFixedPolicyJ jijii )1(PrJ=1, 2, 3, 4, 5
Results: Effect of State Policies on Enrollment in Medicaid or Medigap R2=.2361 (N=3074)
Policy MedicaidCoef (se) p value
(Marginal Effect)
MedigapCoef (se) p value(Marginal Effects)
Ln of # of firms that offer Medigap plans in state
-.067 (.050) .175 -.718 (.184) 0.0(-.003)
# of Mandated Medigap RX plans
-.589 (.381) .122 3.67 (1.39) .008(.020)
Ln of # of type of mandated Medigap plans
.688 (.400) .085(.067)
-2.33 (1.21) .054(-.006)
LN of # of Medicare HMO by county
-.11 (.988) .209 -.134 (.134) .318
Medicaid buy-in in place -.419 (.247) .090(-.093)
.891 (.819) .277
FPL%*income -.575 (.168) .011(-.149)
-.056 (.150) .709
Medically needy plan in place .206 (.518) .691 -1.63 (2.04) .425
Medically needy*income .037 (.103) .721 .098 (.102) .338
State prescription drug program for disabled
-.224 (.100) .025(-.051)
-.201 (.211) .342
Other Significant Variables
Significant Control Variables
Medicaid Veterans eligibility (-), Age (-), White (-),Single (+), Mental illness (+), Mobility limitations (+), Cognitive limitations (+), Live alone (+), Male (-), Education level (-), State FE
Medigap Veteran eligibility (-), Age (+), White (+), Ever smoked (+), Education Level (+), State FE
State Policies that Affect Medicaid Enrollment
• Increase Medicaid enrollment– # of Medigap plans required by the state’s
guarantee-offer policy
• Decrease Medicaid enrollment– Medicaid buy-in– FPL% * income– State prescription drug program for disabled
State Policies that Affect Medigap Enrollment
• Increase Medigap enrollment– # of Medigap prescription drug plans required
by the state’s guarantee-offer policy
• Decrease Medigap enrollment– # of Medigap plans required by the state’s
guarantee-offer policy– # of Medigap firms
Estimates for Rural DisabledR2=.3019 (N=954)
Policy MedicaidCoef (se) p value
(Marginal Effect)
MedigapCoef (se) p value(Marginal Effects)
Ln of # of firms that offer Medigap plans in state
11.38 (.231) 0.0(1.46)
-4.28 (.233) 0.0(-.004)
# of Mandated Medigap RX plans
96.76 (2.89) 0.0(24.08)
47.95 (.529) 0.0(.002)
Ln of # of type of mandated Medigap plans
-204.63 (2.58) 0.0(-15.72)
-75.96 (.595) 0.0(.005)
LN of # of Medicare HMO by county
.111 (.219) .613 -.288 (.440) .513
Medicaid buy-in in place -.329 (.424) .438 42.15 (.453) 0.0(.034)
FPL%*income -.580 (.404) .151 -.015 (.341) .965
Medically needy plan in place 220.81 (1.27 ) 0.0(1)
87.17 (5.08) 0.0(2.34 e-24)
Medically needy*income -.050 (.254) .843 .032 (.289) .913
State prescription drug program for disabled
-.207 (.214) .334 -17.59 (.210) 0.0(-.014)
Does enrollment in supplemental policies affect health status?
• Outcome Equation
• Estimation challenges– Insurance variable may be correlated with
unobserved variables, selection conserns and error term
stateFESupplyinsOUi jijiji
Solution :Instrumental Variables
• Variables that are correlated with the original independent variable but not the errors (Like random assignment)
• Instruments used are the predicted probability from the supplemental insurance estimation
Outcome DefinitionsVariable Calculation Mean (sd) InterpretationHealth status ∆
First year-most recent yr *(-1)
-.023 (1.002)
Positive number = improvement
Func status ∆
First year-most recent yr
.003 (1.631) Positive number = improvement
Func ∆Consumer wts
First year-most recent yr
8.052(490.846)
Positive number = improvement
Func ∆ expert wts
First year-most recent yr
1.482 (445.888)
Positive number = improvement
Significant Health Status EffectsSupplement Type Sample Health Outcome Coef (se) p value
Any Supplement Full Func ∆ Consumer wts
-305.23 (166.07) .066
Any Supplement Full Func ∆Expert wts
-314.29 (171.41) .067
Any Supplement MI Health ∆ -.901 (.358) .012
Any Supplement MI Func ∆ -1.18 (.710) .096
Medigap Mob Health ∆ -1.72 (.933) .065
Medigap Cog Func ∆ 4.57 (1.76) .009
HMO Supplement Mob Func ∆ Consumer wts
-438.33 (56.77).087
Significant Control Variables
• Health ∆ affected by:– Male, Vet elig, Single, PCI, Chronic condition, Some State FE
• Func ∆ affected by:– Some State FE
• Func ∆ with consumer wts affected by:– Single, White, Metro, Year 2000, Vet elig, Some State FE
• Func ∆ with expert wts affected by:– White, Vet elig, Single, Some State FE
Rural Health Effects
Conclusions• Identified state policies affect Medicaid
and Medigap enrollment.• Supplemental coverage affects health
outcomes for subgroups of the disabled.• State fixed effects are significant in both
the estimation of enrollment and the estimation of health outcomes. This needs additional research.