title: Medicaid Expansions and Crowd-Out: Evidence from HIFA Premium Assistance Programs.
abstract: OBJECTIVE
  To evaluate the effect of the Oregon and New Mexico Health Insurance Flexibility and Accountability (HIFA) demonstrations. HIFA is an optional state Medicaid expansion targeted at adults and children with incomes below 200 percent of the federal poverty level (FPL). The study has five research questions: What type of health insurance do HIFA enrollees self report in surveys? What are the demographic characteristics of these enrollees? What type of health insurance coverage, if any, did HIFA enrollees have just prior to enrollment in the HIFA program? Among those with prior coverage, what prompted participation in the HIFA program? What type of health insurance, if any, would HIFA enrollees have in the absence of HIFA?
  
  
  METHODS
  Data were collected via telephone interviews with a total of 406 enrollees from Oregon and 409 enrollees from New Mexico. The survey was conducted between July 7 and September 20, 2009, for both states. The sample frame for the survey was based on administrative records of adults enrolled in June 2009. After completion of the survey, active enrollment status as of the date the telephone interview was confirmed. Respondents no longer enrolled at the time of the survey (7 cases in NM and 14 in OR) were excluded from the analysis. The final sample size was 794 verified HIFA enrollees.
  
  
  RESULTS
  HIFA enrollees tended to be middle-aged, male, and relatively unhealthy. Employment status varied tremendously from the self-employed to retired to unable to work. HIFA enrollees were reasonably well educated with 80 percent having at least a high school education. Most HIFA enrollees (90 percent) reported being uninsured just prior to participation in HIFA. Of those who were uninsured, most reported having been uninsured for an extended time-a year or more. Most enrollees joined HIFA because they lacked access to health insurance or could not afford insurance on the private market. The overwhelming majority (76 percent) of respondents believed that they would be uninsured in the absence of HIFA, with few considering either an employer plan or private purchase to be a viable option. Over 90 percent of enrollees correctly indicated they had insurance coverage. However, characterization of the type of coverage was problematic, particularly in the absence of the program-specific name.
  
  
  CONCLUSIONS
  HIFA enrolled a relatively sick, male, middle-aged population that tended to have been long-term uninsured--the kind of enrollees for which the programs were designed--with little apparent crowd-out of private insurance. The reported health status coupled with low incomes suggests that individual purchase is unlikely, a sentiment echoed by the respondents. In the absence of HIFA, most enrollees believed they would rejoin the ranks of the uninsured from where they came.
authors.affiliation: Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado, Aurora, CO.
authors.forename: Adam
authors.initials: A
authors.lastname: Atherly
authors.affiliation: Department of Health Policy and Management, University of Minnesota, Minneapolis, MN.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Call
authors.affiliation: School of Management, Simmons College, Boston, MA.
authors.forename: Robert
authors.initials: R
authors.lastname: Coulam
authors.affiliation: Department of Health Policy and Management, University of Minnesota, Minneapolis, MN.
authors.forename: Bryan
authors.initials: B
authors.lastname: Dowd
mesh_terms: D000328:Adult; D017677:Age Distribution; D004608:Eligibility Determination; D005260:Female; D006304:Health Status; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data; D007348:Insurance, Health / Q000706:statistics & numerical data; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data*; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008603:Mental Health; D008875:Middle Aged; D009516:New Mexico; D009922:Oregon; D017678:Sex Distribution; D012959:Socioeconomic Factors; D014481:United States
keywords: HIFA waivers; Medicaid; Medicaid expansion; crowd-out; uninsured