Transitions in health insurance among continuously insured patients with schizophrenia

Abstract

Changes in health insurance coverage may disrupt access to and continuity of care, even for those who remain insured. Continuity of care is especially important in schizophrenia, which requires ongoing medical and pharmaceutical treatment. However, little is known about continuity of insurance coverage among those with schizophrenia. The objective was to examine the probability of insurance transitions for individuals with schizophrenia who were continuously insured and whether this varied across insurance types. The Massachusetts All-Payer Claims Database identified individuals with schizophrenia aged 18-64 who were continuously insured during a two-year period between 2014 and 2018. A logistic regression estimated the association of having an insurance transition - defined as having a change in insurance type - with insurance type at the start of the period, adjusting for age, sex, ZIP code in the lowest quartile of median income, and ZIP code with concentrated poverty. Overall, 15.1% had at least one insurance transition across a 24-month period. Insurance transitions were most frequent among those with plans from the Marketplace. In regression adjusted results, individuals covered by the traditional Medicaid program were 20.2 percentage points [pp] (95% confidence interval [CI]: 24.6 pp, 15.9 pp) less likely to have an insurance transition than those who were insured by a Marketplace plan. Insurance transitions among individuals with schizophrenia were common, with more than one in six people having at least one transition in insurance type during a two-year period. Given that even continuously insured individuals with schizophrenia commonly experience insurance transitions, attention to insurance transitions as a barrier to care access and continuity is warranted.

Fig. 1. Adjusted rates of health insurance transition for individuals with schizophrenia by health insurance type at start of period.

N = 36,754 person-period observations. Adjusted results control for age, sex, residence in a ZIP code in the lowest quartile of median income, and residence in a ZIP code with concentrated poverty. Standard errors are clustered at the 5-digit ZIP code level. *Indicates a statistically significant difference in predicted probability from the reference group (Marketplace insurance) at the 5% level. 95% Confidence intervals for each group are shown with vertical bars.

Fig. 2. Adjusted rates of health insurance transition for individuals with schizophrenia by age.

N = 36,754 person-period observations. Adjusted results control for insurance type at the start of the period, sex, residence in a ZIP code in the lowest quartile of median income, and residence in a ZIP code with concentrated poverty. Standard errors are clustered at the 5-digit ZIP code level. *Indicates a statistically significant difference in predicted probability from the reference group (age 18–25 years) at the 5% level. 95% Confidence intervals for each group are shown with vertical bars.

Fig. 3. Health insurance transitions over the study period.

For display purposes, all combinations with fewer than 11 observations were dropped (N = 467; 1.3%). Among those with Marketplace and Health Safety Net insurance at month 1, 7.7% and 11.4% were dropped, respectively.

Fig. 4. Adjusted rates of health insurance transition for sensitivity analysis combining Traditional Medicaid and Medicaid Managed Care for individuals with schizophrenia by health insurance type at start of period.

N = 36,754 person-period observations. Adjusted results control for age, sex, residence in a ZIP code in the lowest quartile of median income, and residence in a ZIP code with concentrated poverty. Standard errors are clustered at the 5-digit ZIP code level. *Indicates a statistically significant difference in predicted probability from the reference group (Marketplace insurance) at the 5% level. 95% Confidence intervals for each group are shown with vertical bars.