142nd APHA Annual Meeting and Exposition

Annual Meeting Recordings are now available for purchase

Disenrollment under ACA: Lessons learned from a health care coverage initiative in California

142nd APHA Annual Meeting and Exposition (November 15 - November 19, 2014): http://www.apha.org/events-and-meetings/annual
Monday, November 17, 2014 : 8:50 AM - 9:10 AM

Ying-Ying Meng, Dr Ph , Center for Health Policy Research, University of California, Los Angeles, Los Angeles, CA
Dimiter Milev, BA , UCLA School of Public Health, UCLA Center for Health Policy Research, Los Angeles, CA
Ana Martinez, MPH , UCLA Center for Health Policy Research, | Los Angeles,, CA
Xiao Chen, PhD , UCLA Center for Health Policy Research, University of California, Los Angeles, Los Angeles, CA
Nadereh Pourat, PhD , Department of Health Policy and Management, UCLA Fielding School of Public Health/UCLA Center for Health Policy Research, Los Angeles, CA
Gerald Kominski, PhD , UCLA Center for Health Policy Research, University of California, Los Angeles, Los Angeles, CA

This study examined factors associated with disenrollment, specifically the role of service utilization under the Health Care Coverage Initiative (HCCI) program. HCCI was implemented under a California §1115 Medicaid Waiver from September 2007 to August 2010. HCCI was later expanded statewide as the early implementation of the Affordable Care Act (ACA).

HCCI enrollees were low-income (up to 200% of the federal poverty level) adults ages 18-64, legally residing in ten participating counties, had lived more than 5 years in the U.S., and did not qualify for other public programs. The sample (N=57,000) included program enrollees (ages 18-62) who enrolled during the first year of the program in seven HCCI counties with comprehensive enrollment and utilization data.

Disenrollment was defined as: (1) dropping-out completely; or (2) “churning,” or enrollment interruptions. We applied a random-effect logistic regression model to evaluate the likelihood of disenrollment (both churn and drop-out) after controlling for individual-level characteristics (including age, gender, race, language, federal poverty level and chronic conditions) and service utilization (including annual rates of primary care provider (PCP) visits, emergency department (ED) visits or hospitalizations) in the first 12 months of the program year. We then compared the differences in rates of drop-out vs. churn to identify which populations are more likely to churn.

Half (50%) of enrollees in year 1 remained enrolled for all three program years. The odds of continuous enrollment in the second and third program years were 23% higher for enrollees who had a higher rate of PCP visits in year 1. The odds of disenrollment were higher if enrollees had higher rates of ED visits (42%) or hospitalizations (71%) in year 1. Also, the odds of continuous enrollment were higher for older and female enrollees as well as those with chronic conditions (asthma, diabetes, heart disease, hyperlipidemia, hypertension, osteoarthritis or a mental health condition). Those who dropped out and those who churned were similar in most characteristics and utilization patterns, except more individuals with at least three chronic conditions were in drop-out group.  

Our findings have important implications for retention efforts for Medicaid and exchanges under the Affordable Care Act (ACA). Retention efforts should include linking enrollees to primary care services. Retention efforts should also focus on younger, male, and healthier enrollees who are more likely to disenroll. Targeted retention policies and programs for newly covered individuals in Medicaid and exchanges will ultimately enhance the success of the ACA.


Learning Areas:

Chronic disease management and prevention
Conduct evaluation related to programs, research, and other areas of practice
Provision of health care to the public
Public health or related public policy

Learning Objectives:
Describe factors associated with disenrollment under the Health Care Coverage Initiative (HCCI) program in California with emphasis on primary care utilization

Keyword(s): Affordable Care Act, Primary Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I made substantial contributions to conception and design, to the data analyses and interpretation of data.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.