This study will use the experience of two state health coverage demonstration programs to examine how policy choices with regard to program structure and eligibility criteria impact on attrition from program enrollment. The two programs included in this analysis are both initiatives offering subsidized insurance to low-income individuals. The programs provide contrasting target populations: in one, eligibility is determined by income and the other limits participation to uninsured small business groups. Involuntary, eligibility-driven disenrollment in this analysis will be assessed to contrast the success of these two program strategies in meeting the long-term access needs of previously medically indigent program participants. The study will be composed of a quantitative analysis supported by a qualitative case study. A linked file of survey data and claims records for program participants in each state will be used to compare program and enrollee characteristics and the relationship of these characteristics to length of enrollment and reasons for disenrollment. The goal of this portion of the study is to evaluate the impact of eligibility-driven enrollee characteristics (employment status, income and age) on disenrollment decisions and to contrast the experience of an individual enrollment plan with an employment-based plan. The model developed will be one accommodating a multinomial categorical dependent variable (disenrolled to an alternative plan; disenrolled to no plan; still enrolled). Strategies being considered include: I) a nested logit model that distinguishes between factors contributing to involuntary disenrollment (eg., threshold changes in employment or income) and factors contributing to consumer choice; and 2) a hazard model that adjusts for the differing time period of participants' risk of disenrollment between entry into the program and the study interview. A case study, involving interviews and document review in the two states, will be used to put the findings from the quantitative analysis into a broader policy framework. This analysis will compare the political and institutional frameworks that led to the decisions regarding program structure and eligibility; will review the implementation process; and will draw lessons from these early state experiments relevant to the on- going health reform policy debate.
