Insights from Survey of CIC Program Participants in Alameda, Austin, and Southern Maine

1. Survey of CIC Program Participants: Who Joined and How Did They Change Their Care-Seeking Behavior? • Catherine McLaughlinUniversity of MichiganErin Fries Taylor • Mathematica Policy Research • WebCast Presentation • CIC programs • June 23, 2004

2. Survey in 3 CIC Sites • Alameda County: Family Care • Insurance product for parents of children enrolled in Alameda Alliance for Health • 300% FPL or less • Austin: I-Care • Not an insurance product, collaboration of area hospitals and charity care organizations • 250% FPL or less • Southern Maine: CarePartners • Donated care model • 150% FPL or less

3. Research Questions • Who joined? • Changes in care-seeking behavior? • Changes in satisfaction and perceived access? • Differences by race/ethnicity? • Alameda and Austin • Differences by chronic illness? • Southern Maine • Who stays and who leaves?

4. Survey Content • Household information • Demographics • Income and employment • Previous health insurance coverage (asked at baseline) • Health status and utilization • Usual source of care, unmet need • Satisfaction, attitudes

5. Wave 1 Details • Site provided contact information on all new enrollees over a period of 4-6 months • Completed interviews in Wave 1 • -Alameda: 471 adults (Aug 01–Jan 02) • 88% response rate • -Austin: 347 adults (Feb–Aug 02) • 87% response rate • -S Maine: 300 adults (Nov 01–June 02) • 93% response rate

6. Baseline Survey Data • Who participates in each CIC program? • Were there differences in characteristics by race/ethnicity? • Were there differences in characteristics by chronic illness?

7. Selected Socio-Demographics

8. Income, Employment, and Previous Insurance Status

9. Race/Ethnic/Language Composition: Alameda County English-speaking (7%) Asians Cantonese-speaking (30%) English-speaking (5%) Others English-speaking (10%) Latinos Spanish-speaking (48%)

10. Selected Socio-demographics by Race/Ethnicity: Alameda County

11. Race/Ethnic/Language Composition: Austin Whites English-speaking (16%) English-speaking (22%) Others English-speaking (12%) Latinos Spanish-speaking (50%)

12. Selected Socio-demographics by Race/Ethnicity: Austin

13. Baseline Health Status and Care-Seeking Behavior

14. Preventive Services in Previous Year Alameda Austin S. Maine Physical Exam 38% 31% 53% 84% 59% 61% Blood Pressure Check Breast Exam (among women) 30% 22% 55% Pap Smear (among women) 50% 44% 34%

15. Doctor's Office Hospital Outpatient 1% 1% 8% 2% Other Clinic or Health 3% 12% 36% 20% 38% 36% Hospital ER or Urgent 62% 9% Some Other Place 23% 43% 6% Alameda Usual Source of Care: S. Maine Austin

16. Alameda: Health and Care-Seeking Behaviors: Themes by Race/Ethnicity • Asians and Latinas reported worse health status, but fewer chronic conditions • Cantonese-speaking Asians rated health status lower than English-speaking Asians • Latinas and Other were more likely to have an ER visit or a doctor visit • Asians reported lowest out-of pocket costs and Other reported the highest

17. More on Baseline Health in Alameda: Themes by Race/Ethnicity • Cantonese-speaking Asians were most likely to have no health care utilization • Those in Other category were most likely to report unmet need

18. Austin: Utilization Rates By Race/Ethnicity

19. Baseline Health and Care-Seeking Behaviors: Themes by Race/Ethnicity In both Alameda and Austin, Latinos report worse health status and, at the same time, fewer report chronic or limiting condition(s) than other participants • Alameda County • Cantonese-speaking Asians were most likely to have no health care utilization, but also report worse health status than English-speaking Asians • Austin • Spanish-speaking Latinos were most likely to have no health care utilization, but also report worse health status than English-speaking Latinos

20. Self-Reported Health Status by Race/Ethnicity Austin Alameda

21. S. Maine: Baseline Utilization Rates by Presence of Chronic Condition

22. S. Maine: Out-of-Pocket Health Care Costs in Previous Year (if Costs>0)

23. Having a Usual Source of Care Made a Difference in: • Having any physician visits, ER visits, or hospital stays • Receiving preventive care • Physical exam • Blood pressure check • Breast exam (among females) • Pap smear (among females) • Having a personal health care provider

24. Having Insurance Coverage in Last 12 Months Made a Difference in: • Having any physician visits • Receiving preventive care: • Physical exam • Blood pressure check • Breast exam (among females) • Pap smear (among females) • Having a usual source of care and a personal health care provider

25. Research Questions: Changes • Changes in health status, health care utilization, and care-seeking behavior? • e.g., decrease ED use, increase preventive care • Changes in satisfaction and perceived access? • e.g., less self-reported unmet need • Are there race/ethnic differences in these changes? • Are there differences in changes for those with a chronic condition?

26. Use Pre/Post Comparison: Wave I vs. Wave II + Wave III • Utilization data for the 12 months before and for the 12 months post-enrolling • Continuous enrollees and those who disenrolled • Possible “seam bias” (doublecounting), so rely more on “Yes/No used” than the count data of how many visits • Change = used only before or used only after enrolling

27. Number of Respondents by Wave *Continued high response rates (>80%)

28. Alameda: Comparisons of Medical Care UseBefore and After Enrollment change no change N=330, survey respondents who were continuously enrolled in CIC

29. Alameda: Comparisons of ED Use Before and After Enrollment by Race/Ethnicity change no change Note: there are no statistically significant differences for hospital use

30. Doc use ED use Hosp use After enrollment only 32% 16% 9% Before enrollment only 3 16 6 Both before and after enrollment 52 15 0 Neither before or after enrollment 13 52 85 Austin: Comparisons of Medical Care UseBefore and After Enrollment change no change N=164, survey respondents who were continuously enrolled in CIC

31. Doctor Use ED use Latino Other Latino Other 19% 10% After enrollment only 32% 29% Before enrollment only 3 4 16 17 Both before and after enrollment 48* 63* 13 21 53 52 Neither before nor after enrollment 16** 4** 116 48 Number of respondents 116 48 Austin: Comparisons of Use Before and After Enrollment by Ethnicity change no change

32. Doc use ED use Hosp use After enrollment only 17% 12% 9% Before enrollment only 0 18 6 Both before and after enrollment 83 43 12 Neither before or after enrollment 0 27 73 S. Maine: Comparisons of Medical Care UseBefore and After Enrollment change no change N = 99, survey respondents who were continuously enrolled in CIC

33. S. Maine: Comparisons of Use Before and After by Presence of Chronic Illness change no change *p<0.10, **p<0.05, ***p<0.01, significantly different by presence of chronic illness

34. Alameda: Comparisons in Preventive Care Use Before and After Enrollment, Enrollees change no change

35. Physical exam Blood pressure After enrollment only 36% 27% Before enrollment only 5 5 Both before and after enrollment 23 55 Neither before or after enrollment 35 12 Austin: Comparisons in Preventive Care Use Before and After Enrollment change no change

36. Physical exam Blood pressure After enrollment only 34% 15% Before enrollment only 4 3 Both before and after enrollment 46 82 Neither before or after enrollment 16 1 S. Maine: Changes in Preventive Care Use Before and After Enrollment, Enrollees change no change

37. Women’s Preventive Care in Alameda: Comparisons Before and After Enrollment change no change N = 220 women

38. Breast exam Pap smear After enrollment only 41% 41% Before enrollment only 5 8 Both before and after enrollment 16 24 Neither before or after enrollment 37 27 Women’s Preventive Care in Austin: Comparisons Before and After Enrollment change no change N = 98 women

39. Breast exam Pap smear After enrollment only 27% 27% Before enrollment only 10 10 Both before and after enrollment 40 40 Neither before or after enrollment 22 23 Women’s Preventive Care in S. Maine: Comparisons Before and After Enrollment change no change N = 62 women

40. S. Maine: Comparisons of Breast Exams Before and After by Presence of Chronic Illness change no change

41. Were There Changes Over Time in Medical Care Use? • In all 3 sites, there was a noticeable increase in physician visits and an even larger increase in the number receiving physical exams, PAP smears, and breast exams. • Only S. Maine showed a noticeable, although statistically insignificant, decrease in ED use • No site showed a noticeable change in hospital use

42. Do Changes Over Time Differ in Different Populations? • In Alameda, changes in ED use varied significantly by race/ethnicity: Latinos were the most likely to go only before enrollment • In S. Maine, those without a chronic condition were more likely to increase use of physician services and to have a breast exam

43. Different Use by Different Populations • Most of the differences in utilization by race/ethnicity and by the presence of a chronic condition are differences in level of use, not change in use after enrolling • Asians were less likely to use physician, ED, and hospital services both before and after enrollment • Latinos were more likely than Asians, but less likely than “other” to use physician, ED, and hospital services both before and after • Those with a chronic condition were more likely to use ED and hospital services both before and after

44. Caveats • Results are based on self-reported utilization data -Utilization (e.g., visits) tend to be under-reported -Procedures (e.g., pap smears) tend to be over-reported -Errors of omission increase with length of recall

45. Disenrollment • There were varying levels of disenrollment across the 3 sites, the highest in S. Maine • What were the reasons given for leaving? • Were disenrollees “different” from continuous enrollees? • What happened to disenrollees in terms of coverage, utilization, satisfaction?

46. ESI ESI Medicaid Medicaid Uninsured Uninsured CarePartners CarePartners Possible Sample Transitions Wave 1 Wave 2 Wave 3 N = 73 N = 84 N = 266 N = 89 N = 182 CarePartners Example and numbers presented are for S. Maine

47. Possible Sample Transitions Wave 1 Wave 2 Wave 3 N = 6 ESI N = 84 Medicaid Uninsured N = 266 N = 89 N = 182 CarePartners CarePartners CarePartners

48. Possible Sample Transitions Wave 1 Wave 2 Wave 3 N = 71 ESI ESI N = 84 Medicaid Medicaid Uninsured Uninsured N = 266 N = 89 N = 182 CarePartners CarePartners CarePartners

49. Reasons for Disenrolling: S. Maine W2 W3 • Became eligible for another program 37% 72% • R or spouse got job that offered coverage 31 14 • Income too high to remain eligible 21 8 • Didn’t complete program paperwork 8 4 • Didn’t think needed care 7 1 • Couldn’t afford to remain in program 6 3 • Moved away from area 5 4 • Was unhappy with program 2 3 • Some other reason 2 6

50. % of Participants by Insurance Status, Waves 2 and 3 • Wave 2 69 5 5 21 • Wave 369 4 8 18 Enrolled Disenrolled ESI Medicaid Uninsured