Strategies to Expand
  Insurance Coverage for Adults
Preliminary Findings for New York,
    Illinois, and Massachusetts
  ...
Study Overview

• NY, IL, and MA have implemented reforms
  designed to expand health insurance coverage
  for adults
• Th...
The Health Reform Initiatives
• New York (2000)
   – Expansion of public coverage for lower-income adults; new
      premi...
Overview of Key Changes in Eligibility for
Adults under the Health Reform Initiatives *
                             NY   ...
Methods
• “Natural experiments” in the three study states
• Estimate difference-in-differences models
  – Use comparison g...
Difference-in-Differences Model
   Y = ß0 + ß1 StudyState + ß2 Post + ß3 StudyState * Post + ε


                         ...
Data

• Current Population Survey’s Annual Social and
  Economic Supplement (CPS ASEC)
• Years: 1999 – 2007 (2000 – 2008 C...
Estimation Issues
• Use SVY procedures in Stata to adjust for
  complex survey design of CPS
• Sensitivity analyses
  – Al...
Populations of Interest
• Target populations for public and subsidized
  coverage expansions
• Overall and lower-income ad...
Estimates of Impacts for
     Target Populations for
     Public and Subsidized
     Coverage Expansions




             ...
Pre-Post Changes in Insurance Coverage
    for Target Populations as of 2007
                  100%                       ...
DD Estimates of Impacts for
    Target Population: Illinois

     Target Population                                       ...
DD Estimates of Impacts for
  Target Population: New York

    Target Population                                          ...
DD Estimates of Impacts for
Target Population: Massachusetts

    Target Population                                       ...
Estimates of Impacts for
    Overall Population and
   Lower-income Population




                              15



THE...
Pre-Post Changes in Insurance Coverage
                            for Adults as of 2007

                  100%          ...
DD Estimates of Impacts for
                   Total Population as of 2007

Population                                    ...
Summary of Results
• Illinois
   – No increase in insurance coverage
• New York
  – Significant increase in insurance cove...
Lessons for National Reform

• Illinois
   – Program design and implementation matter
• New York
   – Relatively modest ex...
Next Steps
• Add 2008 to the analysis when 2009 CPS data
  become available

• Examine impacts for different time periods ...
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Strategies to Expand Insurance Coverage for Adults: Preliminary Findings for New York, Illinois, and Massachusetts

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Presentation by Sharon Long at the AcademyHealth Annual Research Meeting session, "The Lab Reports: Evaluating State's Actions to Expand Access and Coverage," Chicago, IL, June 30 2009.

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Strategies to Expand Insurance Coverage for Adults: Preliminary Findings for New York, Illinois, and Massachusetts

  1. 1. Strategies to Expand Insurance Coverage for Adults Preliminary Findings for New York, Illinois, and Massachusetts Sharon K. Long, Alshadye Yemane, and Karen Stockley AcademyHealth Annual Research Meeting June 30, 2009 Funded by the State Health Access Reform Evaluation, a national program of the Robert Wood Johnson Foundation THE URBAN INSTITUTE
  2. 2. Study Overview • NY, IL, and MA have implemented reforms designed to expand health insurance coverage for adults • This study: Evaluate the impacts of the reform efforts on insurance coverage • Future work: Evaluate the of the reform efforts on access to care, use of care and affordability of care 2 THE URBAN INSTITUTE
  3. 3. The Health Reform Initiatives • New York (2000) – Expansion of public coverage for lower-income adults; new premium support program for working adults • Illinois (2002) – Expansion of public coverage for lower-income parents, with a premium assistance program option for some • Massachusetts (2006) – Goal of near universal coverage for all adults, with expansion of public coverage, subsidized private coverage, purchasing pool, requirements for employers, and individual mandate, among other changes 3 THE URBAN INSTITUTE
  4. 4. Overview of Key Changes in Eligibility for Adults under the Health Reform Initiatives * NY IL MA Parents Pre-reform Public coverage <100% FPL <39% FPL <133% FPL Premium assistance -- -- <200% FPL Post-reform Public coverage <150% FPL <185% FPL <300% FPL Premium assistance <250% FPL <300% FPL Subsidized coverage -- -- <300% FPL Purchasing pool -- -- >300% FPL Childless Adults Pre-reform Public coverage <~50% FPL -- -- Premium assistance -- -- <200% FPL Post-reform Public coverage <100% FPL -- <300% FPL Premium assistance <250% FPL -- <300% FPL Subsidized coverage -- -- <300% FPL 4 Purchasing pool -- -- >300% FPL THE URBAN INSTITUTE
  5. 5. Methods • “Natural experiments” in the three study states • Estimate difference-in-differences models – Use comparison groups to control for other changes (beyond health reform) over time – Include rich set of covariates to control for differences between study state samples and comparison groups – Use propensity score matching to reweight comparison groups to look like study state samples 5 THE URBAN INSTITUTE
  6. 6. Difference-in-Differences Model Y = ß0 + ß1 StudyState + ß2 Post + ß3 StudyState * Post + ε Study Comparison Time Period State Group Pre-reform Period ß0 + ß1 ß0 Post-reform Period ß0 + ß1 + ß2 + ß3 ß0 + ß2 Pre-Post Difference ß2 + ß3 ß2 Difference-in-Differences ß3 6 THE URBAN INSTITUTE
  7. 7. Data • Current Population Survey’s Annual Social and Economic Supplement (CPS ASEC) • Years: 1999 – 2007 (2000 – 2008 CPS) • Sample: Adults ages 19 to 64 • Comparison groups: Higher-income adults in other large states in same region as study state • Sample sizes: – Target populations: IL=2,903; MA = 2,228; NY= 15,405 – Comparison groups ranged from 10,269 to 27,292 7 THE URBAN INSTITUTE
  8. 8. Estimation Issues • Use SVY procedures in Stata to adjust for complex survey design of CPS • Sensitivity analyses – Alternate comparison groups – Alternate pre-reform periods – With and without propensity score weighting – With and without non-citizens 8 THE URBAN INSTITUTE
  9. 9. Populations of Interest • Target populations for public and subsidized coverage expansions • Overall and lower-income adult population 9 THE URBAN INSTITUTE
  10. 10. Estimates of Impacts for Target Populations for Public and Subsidized Coverage Expansions 10 THE URBAN INSTITUTE
  11. 11. Pre-Post Changes in Insurance Coverage for Target Populations as of 2007 100% 97%*** 88%*** 86% 80% *** 80% 70% 69% 69% *** Percent Insured 66% 65% 60% 54% Pre-Period 2007 40% 20% 0% IL NY MA NY MA ----------------------Parents------------------- ----Childless Adults---- * (**) (***) Pre-post change is significantly different from zero at the 10% (5%) (1%) level. 11 THE URBAN INSTITUTE
  12. 12. DD Estimates of Impacts for Target Population: Illinois Target Population Estimate Parents <= 185% FPL Uninsured -0.031 ESI 0.015 Public/Other Coverage 0.017 * (**) (***) Significantly different from zero at the 10% (5%) (1%) level. 12 THE URBAN INSTITUTE
  13. 13. DD Estimates of Impacts for Target Population: New York Target Population Estimate Parents <= 250% FPL Uninsured -0.094*** ESI 0.042 Public/Other Coverage 0.052*** Childless Adults <= 250% FPL Uninsured -0.136*** ESI 0.090*** Public/Other Coverage 0.046** * (**) (***) Significantly different from zero at the 10% (5%) (1%) level. 13 THE URBAN INSTITUTE
  14. 14. DD Estimates of Impacts for Target Population: Massachusetts Target Population Estimate Parents <= 300% FPL Uninsured -0.108*** ESI -0.007 Public/Other Coverage 0.115*** Childless Adults <= 300% FPL Uninsured -0.214*** ESI 0.079** Public/Other Coverage 0.135*** * (**) (***) Significantly different from zero at the 10% (5%) (1%) level. 14 THE URBAN INSTITUTE
  15. 15. Estimates of Impacts for Overall Population and Lower-income Population 15 THE URBAN INSTITUTE
  16. 16. Pre-Post Changes in Insurance Coverage for Adults as of 2007 100% 95% *** 91% *** 88% 84% *** 79% 80% 75% 72%*** Percent Insured 63% 60% Pre-Period 2007 40% 20% 0% NY MA NY MA -----------------All Adults-------------- ------Lower-Income Adults------ * (**) (***) Pre-post change is significantly different from zero at the 10% (5%) (1%) level. 16 THE URBAN INSTITUTE
  17. 17. DD Estimates of Impacts for Total Population as of 2007 Population NY MA All Adults Uninsured -0.034*** -0.066*** ESI 0.018* 0.031* Public/Other Coverage 0.016** 0.035** Adults <= 300% FPL Uninsured -0.080*** -0.173*** ESI 0.039** 0.056* Public/Other Coverage 0.041*** 0.117*** * (**) (***) Significantly different from zero at the 10% (5%) (1%) level. 17 THE URBAN INSTITUTE
  18. 18. Summary of Results • Illinois – No increase in insurance coverage • New York – Significant increase in insurance coverage, especially for lower-income adults and childless adults – No crowd-out of ESI • Massachusetts – Significant increase in insurance coverage, especially for lower-income adults and childless adults – No crowd-out of ESI – Still in implementation phase of reform in 2007 18 THE URBAN INSTITUTE
  19. 19. Lessons for National Reform • Illinois – Program design and implementation matter • New York – Relatively modest expansions in eligibility for public coverage and reductions in the cost of private premiums can have an impact on coverage • Massachusetts – More comprehensive reform efforts yield more substantial gains in coverage 19 THE URBAN INSTITUTE
  20. 20. Next Steps • Add 2008 to the analysis when 2009 CPS data become available • Examine impacts for different time periods to address the phasing in of health reform initiatives • Examine impacts on access, use and affordability of care using the National Health Interview Survey when 2008 data become available 20 THE URBAN INSTITUTE

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