Trends in Medicaid Enrollment and Disenrollment During the Early Phase of the COVID-19 Pandemic in Wisconsin.

Importance: After the federal public health emergency was declared in March 2020, states could qualify for increased federal Medicaid funding if they agreed to maintenance of eligibility (MOE) provisions, including a continuous coverage provision. The implications of MOE provisions for total Medicaid enrollment are unknown. Objective: To examine observed increases in Medicaid enrollment and identify the underlying roots of that growth during the first 7 months of the COVID-19 public health emergency in Wisconsin. Design Setting and Participants: This population-based cohort study compared changes in Wisconsin Medicaid enrollment from March through September 2020 with predicted changes based on previous enrollment patterns (January 2015-September 2019) and early pandemic employment shocks. The participants included enrollees in full-benefit Medicaid programs for nonelderly, nondisabled beneficiaries in Wisconsin from March through September 2020. Individuals were followed up monthly as they enrolled in, continued in, and disenrolled from Medicaid. Participants were considered to be newly enrolled if they enrolled in the program after being not enrolled for at least 1 month, and they were considered disenrolled if they left and were not reenrolled within the next month. Exposures: Continuous coverage provision beginning in March 2020; economic disruption from pandemic between first and second quarters of 2020. Main Outcomes and Measures: Actual vs predicted Medicaid enrollment, new enrollment, disenrollment, and reenrollment. Three models were created (Medicaid enrollment with no pandemic, Medicaid enrollment with pandemic economic circumstances, and longer Medicaid enrollment with a pandemic-induced recession), and a 95% prediction interval was used to express uncertainty in enrollment predictions. Results: The study estimated ongoing Medicaid enrollment in March 2020 for 792 777 enrollees (mean [SD] age, 20.6 [16.5] years; 431 054 [54.4%] women; 213 904 [27.0%] experiencing an employment shock) and compared that estimate with actual enrollment totals. Compared with a model of enrollment based on past data and incorporating the role of recent employment shocks, most ongoing excess enrollment was associated with MOE provisions rather than enrollment of newly eligible beneficiaries owing to employment shocks. After 7 months, overall enrollment had increased to 894 619, 11.1% higher than predicted (predicted enrollment 805 130; 95% prediction interval 767 991-843 086). Decomposing higher-than-predicted retention, most enrollment was among beneficiaries who, before the pandemic, likely would have disenrolled within 6 months, although a substantial fraction (30.4%) was from reduced short-term disenrollment. Conclusions and Relevance: In this cohort study, observed increases in Medicaid enrollment were largely associated with MOE rather than new enrollment after employment shocks. Expiration of MOE may leave many beneficiaries without insurance coverage.

The Line between Medicaid and Marketplace: Coverage Effects from Wisconsin's Partial Expansion.

CONTEXT: States have experimented with the income eligibility threshold between Medicaid coverage and access to subsidized Marketplace plans in an effort to increase coverage for low-income adults while meeting other state priorities, particularly a balanced budget. In 2014, Wisconsin opted against adopting an ACA Medicaid expansion, instead setting the Medicaid eligibility threshold at 100% of the poverty level-a state-funded partial expansion. Childless adults gained new eligibility, while parents and caregivers with incomes between 101-200% of poverty lost existing eligibility. METHODS: We used Wisconsin's all-payer claims database to assess health insurance gains, losses, and transitions among low-income adults affected by this partial expansion. FINDINGS: We found that less than one third of adults who lost Medicaid eligibility definitely took up commercial coverage, and many returned to Medicaid. Among those newly eligible for Medicaid, there was little evidence of crowd-out. Both groups experienced limited continuity of coverage. Overall, new Medicaid enrollment of childless adults was offset by coverage losses among parents and caregivers, rendering Wisconsin's overall coverage gains similar to nonexpansion states. CONCLUSIONS: Wisconsin's experience demonstrates the difficulty in relying on the Marketplace to cover the near poor and suggests that full Medicaid expansion more effectively increases coverage.

Predicting high-need cases among new Medicaid enrollees.

OBJECTIVES: To assess the ability of a short, self-reported health needs assessment (HNA) collected at the time of Medicaid enrollment to predict subsequent utilization and costs. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed individual-level data that included self-reported HNAs, medical care encounter records, and administrative eligibility records for 34,087 childless adult Medicaid enrollees in Wisconsin, covering the period 2009-2010. High need was operationalized using the following outcome variables measured over the first year of program enrollment: having an inpatient admission; membership in the top decile of emergency department (ED) utilization; and membership in the top cost decile. We assessed the ability of the HNA to predict high-need cases using several complementary methods: the C-statistic; integrated discrimination improvement; and sensitivity, specificity, and positive predictive value resulting from multivariate logistic regression estimates. RESULTS: Using the HNA along with sociodemographic measures met the Hosmer-Lemeshow criterion for adequate predictive performance for the high ED and high cost outcomes (C-statistics of 0.74 and 0.72, respectively). The HNA was associated with large improvements in predictive performance over sociodemographic measures alone for all 3 dependent variables (integrated discrimination improvement of 182%, 413%, and 300% for ED, cost, and inpatient variables, respectively). The HNA also led to considerable improvements in sensitivity and positive predictive value with no resulting decreases in specificity or negative predictive value. CONCLUSIONS: Collecting self-reported health measures for a Medicaid expansion population can yield data of sufficient quality for predicting high-need cases.

What fraction of Medicaid enrollees have private insurance coverage at the time of enrollment? Estimates from administrative data.

We use administrative data from Wisconsin to determine the fraction of new Medicaid enrollees who have private health insurance at the time of enrollment in the program. Through the linkage of several administrative data sources not previously used for research, we are able to observe coverage status directly for a large fraction of enrollees and indirectly for the remainder. We provide strict bounds for the percentages in each status and find that the percentage of new enrollees with private insurance coverage at the time of enrollment lies between 16 percent and 29 percent, and the percentage that dropped private coverage in favor of public insurance lies between 4 percent and 18 percent. Our point estimates indicate that, among all new enrollees, 21 percent had private health insurance at the time of enrollment and that 10 percent dropped this coverage. Our results show substantially lower rates than previous studies of crowd-out following public health insurance expansions and significant rates of dual coverage, whereby new enrollees into public insurance retain their previously held private insurance coverage.

The effects of expanding public insurance to rural low-income childless adults.

OBJECTIVE: This study measures the change in health care use after enrollment into a new public insurance program for low-income childless adults. DATA SOURCES/STUDY SETTING: The data sources include claims from a large integrated health system in rural Wisconsin and Medicaid enrollment files, January 2007-September 2012. STUDY DESIGN: We employ a regression discontinuity design to measure the causal effect of public insurance enrollment on counts of outpatient, emergency department, and inpatient events for 2 years following enrollment for a sample of previously uninsured low-income adults in rural Wisconsin. PRINCIPAL FINDINGS: Public insurance enrollment led to substantial increases in outpatient visits including preventive visits, but not mental health visits. Public insurance enrollment also led to increases in inpatient stays, but the study is inconclusive on whether it led to an increase in ED visits. CONCLUSIONS: Public insurance expansions to childless adults have the potential to impact the use of health care. The large increase in Medicaid coverage and reduction in rates of uninsurance anticipated to result from the Affordable Care Act should increase the use of inpatient and outpatient services, but they will have an uncertain impact on the use of ED among rural populations.

Wisconsin experience indicates that expanding public insurance to low-income childless adults has health care impacts.

As states consider expanding Medicaid to low-income childless adults under the Affordable Care Act, their decisions will depend, in part, on how such coverage may affect the use of medical care. In 2009 Wisconsin created a new public insurance program for low-income uninsured childless adults. We analyzed administrative claims data spanning 2008 and 2009 using a case-crossover study design on a population of 9,619 Wisconsin residents with very low incomes who were automatically enrolled in this program in January 2009. In the twelve months following enrollment in public insurance, outpatient visits for the study population increased 29 percent, and emergency department visits increased 46 percent. Inpatient hospitalizations declined 59 percent, and preventable hospitalizations fell 48 percent. These results demonstrate that public insurance coverage expansions to childless adults have the potential to improve health and reduce costs by increasing access to outpatient care and reducing hospitalizations.

Wisconsin's experience with Medicaid auto-enrollment: lessons for other states.

The Patient Protection and Affordable Care Act (ACA) relies heavily on the expansion of Medicaid eligibility to cover uninsured populations. In February 2008, Wisconsin expanded and reformed its Medicaid/CHIP program and, as part of program implementation, automatically enrolled a set of newly eligible parents and children. This process of "auto-enrollment" targeted newly eligible parents and older children whose children/siblings were already enrolled in the state's Medicaid/CHIP program. Auto-enrollment brought over 44,000 individuals into the program, representing more than 60% of all enrollees in the first month of the reformed program. Individuals who were auto-enrolled were modestly more likely to leave the program relative to other individuals who enrolled in February 2008, unless their incomes were high enough to be required to pay premiums; these auto-enrollees were much more likely to exit relative to other enrollees subject to premium payments. The higher exit rates exhibited by non-premium paying auto-enrollees were likely due to the fact that over 40% of auto-enrollees were covered by a private insurance policy in the month of their enrollment, compared to approximately 30% for regular enrollees. A national simulation of an auto-enrollment process similar to Wisconsin's, including the expansion of adult Medicaid eligibility to 133% of the federal poverty level under the ACA, suggests that 2.5 million of the 5.6 million newly eligible parents could be auto-enrolled, and approximately 25% of this population would be privately insured. These results suggest that auto-enrollment may be appropriate for other states, especially in their efforts to enroll eligible populations who are not subject to premium requirements.

Wisconsin's BadgerCare Plus reform: impact on low-income families' enrollment and retention in public coverage.

OBJECTIVES: To examine the impact of a Wisconsin health care reform enacted in early 2008 on public insurance enrollment and retention. DATA SOURCES: Administrative data covering the period January 2007 to November 2009. STUDY DESIGN: We calculate unadjusted enrollment trends and exit rates stratified by age, income group, and enrollment mode. Kaplan-Meier curves and Cox proportional hazards models are estimated to assess the impact of the reform on program exits. PRINCIPAL FINDINGS: Overall enrollment increased by approximately one-third and exit rates decreased by approximately one-fifth. The majority of new enrollment came from the previously income eligible. CONCLUSIONS: Wisconsin's enactment of eligibility expansions coupled with administrative simplification and targeted marketing and outreach efforts were successful in enrolling and retaining low-income children and families in public coverage.

Wisconsin physician opinions on health care reform.

OBJECTIVE: To determine Wisconsin physicians' opinions regarding health care reform. METHODS: The University of Wisconsin Survey Research Center performed a 46-question mail survey of 2500 randomly selected physicians from the Wisconsin Medical Society master list of practicing physicians. Respondents rated opinions on a 5-point Likert scale. Demographics of respondents (sex practice type, geographic location, age) were compared to non-responders and the overall Wisconsin physician population. Data analysis quantified opinions regarding the health care system in Wisconsin and nationally, elements of health care reform proposals, and the role of public policy and government in health care. The analysis emphasized a comparison of primary care versus specialist physician responses. RESULTS: The survey yielded a 38% response rate. Respondent demographics were representative of Wisconsin physicians and very similar to nonresponders. Respondents revealed support for several topics, regardless of the respondent's practice type. Respondents also were in agreement on which elements of reform were most frequently favored and most frequently opposed. Nevertheless, there were many areas where primary care physicians strongly differed from specialists, such as favoring legislation for national health insurance (65.6% primary care versus 46.2% specialist). CONCLUSIONS: Wisconsin physicians responding to this survey expressed dissatisfaction with the health care system in which they currently practice and noted a clear desire for system reform. While most respondents agree on a few key priorities, primary care physicians significantly differ in their preferred strategies for reform and, in particular, the role of government in a reformed system. These results indicate a need for more dialogue and education among physicians in order to achieve a consensus that might help promote reform.

Dissemination research: the University of Wisconsin Population Health Institute.

Despite significant accomplishments in basic, clinical, and population health research, a wide gap persists between research discoveries (ie, what we know) and actual practice (ie, what we do). The University of Wisconsin Population Health Institute (Institute) researchers study the process and outcomes of disseminating evidence-based public health programs and policies into practice. This paper briefly describes the approach and experience of the Institute's programs in population health assessment, health policy, program evaluation, and education and training. An essential component of this dissemination research program is the active engagement of the practitioners and policymakers. Each of the Institute's programs conducts data collection, analysis, education, and dialogue with practitioners that is closely tied to the planning, implementation, and evaluation of programs and policies. Our approach involves a reciprocal exchange of knowledge with non-academic partners, such that research informs practice and practice informs research. Dissemination research serves an important role along the continuum of research and is increasingly recognized as an important way to improve population health by accelerating the translation of research into practice.

Short report: factors that affect specialty choice and career plans of Wisconsin's medical students.

OBJECTIVE: To identify factors that influence specialty choice among Wisconsin medical students and provide insight into approaches to encourage more students to pursue careers in primary care. METHODS: The importance of several factors in medical student career choice was surveyed using a Web survey convenience sample of all Wisconsin medical students. Students intending to pursue a career in primary care and in other specialties were compared. RESULTS: Respondents, regardless of specialty choice or gender, identified a similar group of factors as highly influential, and similar group of factors as non-influential in their decision-making. However, significantly more primary care students than other specialty students considered interest in underserved populations, relationships with patients, scope of practice, and role models important in their career choice. Significantly more primary care students than other specialty students responded that salary and competitiveness were "not at all" important. A greater number of other specialty students than primary care students stated that interest in scope of practice, role models, and training years were "not at all" important. Debt-related factors were reported as "not at all" important by nearly one-third of respondents. CONCLUSIONS: Although primary care and other specialty students report making their career plans based on the impact of similar factors, significant differences between primary care and other specialty students were reported in key areas. These results validate many previously reported factors, and indicate that salary and years of training may have been overemphasized in understanding student career choice. The results of this survey may be useful for Wisconsin medical schools in order to sustain, support, and foster student interest in primary care.

The state of quality reports: comparing states by their rankings.

BACKGROUND: Public reports ranking physician competence and quality often yield conflicting results and create confusion. METHODS: Bivariate Pearson correlation analyses were performed to compare states' rankings of physician discipline and physician quality, as reported by the Medicare program and National Practitioner Data Bank. Medical boards were surveyed on their rates of complaints against physicians and ratio of actions to complaints. RESULTS: For all states, there was a poor to negative correlation between state rankings of disciplinary rates and quality, as well as rates of complaints against physicians. As an example, Wisconsin ranked 50th out of the 50 states plus the District of Columbia (where 1 is most desirable and 51 is worst) in rates of "serious" licensure sanctions, but did well when ranked by Medicare quality (eighth out of 51) and the rate of NPDB adverse reports (second out of 51). Wisconsin had a low rate of complaints per physician, ranking second out of 35 responding states, and a high ratio of actions to complaints, ranking fourth out of 35. CONCLUSION: Conflicting conclusions among public reports on physician discipline and quality raise questions about their methods and validity. State rankings of physician discipline and quality should be viewed with caution.

Tribal benefits counseling program: expanding health care opportunities for tribal members.

American Indian tribal clinics hired benefits counselors to increase the number of patients with public and private insurance coverage, expand the range of health care options available to tribal members, and increase third-party revenues for tribal clinics. Benefits counselors received intensive training, technical assistance, and evaluation over a 2-year period. Six tribal clinics participated in the full training program, including follow-up, process evaluation, and outcomes reporting. Participating tribal sites experienced a 78% increase in Medicaid enrollment among pregnant women and children, compared with a 26% enrollment increase statewide during the same period. Trained benefits counselors on-site at tribal clinics can substantially increase third-party insurance coverage among patients.