Can telehealth expansion boost health care utilization specifically for patients with substance use disorders relative to patients with other types of chronic disease?

OBJECTIVE: Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high risk of poor outcomes. Telehealth expansion may boost utilization, but it is unclear whether telehealth can increase utilization for patients with SUDs beyond that expected for other chronic diseases amenable to remote treatment, like type 2 diabetes. This information is needed by health systems striving to improve SUD outcomes, specifically. This study compared the impact of telehealth expansion during the COVID-19 public health emergency (PHE) on utilization for patients with SUDs and diabetes. METHODS: Using Wisconsin Medicaid administrative, enrollment and claims data 12/1/2018-12/31/2020, this cohort study included nonpregnant, nondisabled adults 19-64 years with SUDs (N = 17,336) or diabetes (N = 8,499). Outcomes included having a primary care visit in the week (any, and telehealth) for any diagnosis, or a SUD or diabetes diagnosis; and the weekly fraction of visits completed by telehealth. Logistic and fractional regression examined outcomes pre- and post-PHE. Covariates included age, sex, race, ethnicity, income, geography, and comorbid medical and psychotic disorders. RESULTS: Post-PHE, patients with SUDs exhibited greater likelihood of telehealth utilization (percentage point difference (PPD) per person-week: 0.2; 95% CI: 0.001-0.003; p<0.001) and greater fractional telehealth use (PPD: 1.8; 95%CI: 0.002-0.033; p = 0.025) than patients with diabetes despite a larger overall drop in visits (PPD: -0.5; 95%CI: -0.007- -0.003; p<0.001). CONCLUSIONS: Following telehealth expansion, patients with SUDs exhibited greater likelihood of telehealth utilization than patients with diabetes. This advantage lessened the substantial PHE-induced healthcare disruption experienced by patients with SUDs. Telehealth may boost utilization for patients with SUDs.

How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders?

BACKGROUND: Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown. METHODS: Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share"). RESULTS: The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only. CONCLUSIONS: Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.

Health and Healthcare Access for Essential, Nonessential, and Nonworkers During the COVID-19 Pandemic.

OBJECTIVE: The aim of the study is to describe sociodemographic characteristics, healthcare access, and health status of low-income essential, nonessential, and nonworkers during the COVID-19 pandemic. METHODS: Using survey data (2020-2021) from Wisconsin Medicaid enrollees ( N = 2528), we compared sociodemographics, healthcare access, and health status between essential, nonessential, and nonworkers. RESULTS: Essential workers had less consistent health insurance coverage and more problems paying medical bills than nonessential and nonworkers. They reported better health than nonessential and nonworkers. They reported fewer work-limiting conditions and less outpatient healthcare utilization than nonworkers but similar rates as nonessential workers. Essential workers reported masking less frequently than nonworkers but similar frequency to nonessential workers, and lower COVID-19 vaccine willingness than nonessential and nonworkers. CONCLUSIONS: Essential workers report better health, fewer protective behaviors, and more healthcare barriers than nonessential and nonworkers. Findings indicate essential worker status may be a social determinant of health.

Trends in Medicaid Enrollment and Disenrollment During the Early Phase of the COVID-19 Pandemic in Wisconsin.

Importance: After the federal public health emergency was declared in March 2020, states could qualify for increased federal Medicaid funding if they agreed to maintenance of eligibility (MOE) provisions, including a continuous coverage provision. The implications of MOE provisions for total Medicaid enrollment are unknown. Objective: To examine observed increases in Medicaid enrollment and identify the underlying roots of that growth during the first 7 months of the COVID-19 public health emergency in Wisconsin. Design Setting and Participants: This population-based cohort study compared changes in Wisconsin Medicaid enrollment from March through September 2020 with predicted changes based on previous enrollment patterns (January 2015-September 2019) and early pandemic employment shocks. The participants included enrollees in full-benefit Medicaid programs for nonelderly, nondisabled beneficiaries in Wisconsin from March through September 2020. Individuals were followed up monthly as they enrolled in, continued in, and disenrolled from Medicaid. Participants were considered to be newly enrolled if they enrolled in the program after being not enrolled for at least 1 month, and they were considered disenrolled if they left and were not reenrolled within the next month. Exposures: Continuous coverage provision beginning in March 2020; economic disruption from pandemic between first and second quarters of 2020. Main Outcomes and Measures: Actual vs predicted Medicaid enrollment, new enrollment, disenrollment, and reenrollment. Three models were created (Medicaid enrollment with no pandemic, Medicaid enrollment with pandemic economic circumstances, and longer Medicaid enrollment with a pandemic-induced recession), and a 95% prediction interval was used to express uncertainty in enrollment predictions. Results: The study estimated ongoing Medicaid enrollment in March 2020 for 792 777 enrollees (mean [SD] age, 20.6 [16.5] years; 431 054 [54.4%] women; 213 904 [27.0%] experiencing an employment shock) and compared that estimate with actual enrollment totals. Compared with a model of enrollment based on past data and incorporating the role of recent employment shocks, most ongoing excess enrollment was associated with MOE provisions rather than enrollment of newly eligible beneficiaries owing to employment shocks. After 7 months, overall enrollment had increased to 894 619, 11.1% higher than predicted (predicted enrollment 805 130; 95% prediction interval 767 991-843 086). Decomposing higher-than-predicted retention, most enrollment was among beneficiaries who, before the pandemic, likely would have disenrolled within 6 months, although a substantial fraction (30.4%) was from reduced short-term disenrollment. Conclusions and Relevance: In this cohort study, observed increases in Medicaid enrollment were largely associated with MOE rather than new enrollment after employment shocks. Expiration of MOE may leave many beneficiaries without insurance coverage.

Trends in Engagement With Opioid Use Disorder Treatment Among Medicaid Beneficiaries During the COVID-19 Pandemic.

Importance: Disruptions in care during the COVID-19 pandemic may have decreased access to care for patients with opioid use disorder. Objective: To examine trends in opioid use disorder treatment including buprenorphine possession, urine drug testing, and opioid treatment program services during the COVID-19 public health emergency. Design Setting and Participants: This cohort study included 6453 parent and childless adult Medicaid beneficiaries, aged 18 to 64 years, with opioid use disorder and continuous enrollment from December 1, 2018, to September 30, 2020, in Wisconsin. Logistic regression compared differences in study outcomes before, early, and later in the COVID-19 public health emergency. Analyses were conducted from January 2021 to October 2021. Exposures: Early (March 16, 2020, to May 15, 2020) and later (May 16, 2020, to September 30, 2020) in the public health emergency. Main Outcomes and Measures: Person-week outcomes included possession of buprenorphine, completion of outpatient urine drug testing, and receipt of opioid treatment program services. Results: The final cohort of 6453 participants included 3986 (61.8%) childless adults; 5741 (89%) were younger than 50 years, 3435 (53.2%) were women, 5036 (78.0%) White, and 22.0% were racial and ethnic minority groups (American Indian, 269 [4.2%]; Asian, 26 [0.4%]; Black, 458 [7.1%]; Hispanic, 292 [4.5%]; Pacific Islander, 1 [.02%]; Multiracial, 238 [3.7%]). Overall, 2858 (44.3%), 5074 (78.6%), and 2928 (45.4%) received buprenorphine, urine drug testing, or opioid treatment program services during the study period, respectively. Probability of buprenorphine possession did not change in the early or later part of the public health emergency. Probability of urine drug testing initially decreased (marginal effect [ME], -0.04; 95% CI, -0.04 to -0.03; P < .001) and then partially recovered in the later public health emergency (ME, -0.02; 95% CI, -0.03 to -0.02; P < .001). Probability of opioid treatment program services followed a similar pattern, with an early decrease (ME, -0.05; 95% CI, -0.05 to -0.04; P < .001) followed by partial recovery (ME, -0.02; 95% CI, -0.03 to -0.02; P < .001). Conclusions and Relevance: In a sample of continuously enrolled adult Medicaid beneficiaries, the COVID-19 public health emergency was not associated with decreased probability of buprenorphine possession, but was associated with decreased probability of urine drug testing and opioid treatment program services. These findings suggest patients in office-based settings retained access to buprenorphine despite decreased on-site services like urine drug tests, whereas patients at opioid treatment programs experienced greater disruption in care. Given the importance of medications for opioid use disorder in preventing overdose, policy makers should consider permanent policy changes based on lessons learned from the public health emergency to enable ongoing enhanced access to these medications.

The role of paid family leave in labor supply responses to a spouse's disability or health shock.

Disability onset and major health shocks can affect the labor supply of those experiencing the event and their family members, who face a tradeoff between time spent earning income and providing care. This decision could be affected by the availability of paid family leave. We examine the role of paid leave mandates in caregiving and labor supply decisions after a spouse's disability or health shock. Using data from the Survey of Income and Program Participation, we show that paid leave mandates reduce the likelihood that potential caregivers report decreasing their paid work hours to provide caregiving after a spouse's health shock. However, if caregivers are unlikely to have access to job protection, paid leave mandates also increase the likelihood of leaving the labor market to provide caregiving and working fewer weeks. There is limited evidence of an effect of paid leave on other employment outcomes. Our findings demonstrate that paid leave has some influence on household labor supply decisions after spousal health shocks, but its role should be considered together with the availability of job protection.

Association Between Assistance With Medicaid Enrollment and Use of Health Care After Incarceration Among Adults With a History of Substance Use.

Importance: The transition from prison to community is characterized by elevated morbidity and mortality, particularly owing to drug overdose. However, most formerly incarcerated adults with substance use disorders do not use any health care, including treatment for substance use disorders, during the initial months after incarceration. Objective: To evaluate whether a prerelease Medicaid enrollment assistance program is associated with increased health care use within 30 days after release from prison. Design, Setting, and Participants: This retrospective cohort study included 16 307 adults aged 19 to 64 years with a history of substance use who were released from state prison between April 1, 2014, and December 31, 2016. The Wisconsin Department of Corrections implemented prerelease Medicaid enrollment assistance in January 2015. Statistical analysis was performed from January 1 to August 31, 2021. Exposure: A statewide Medicaid prerelease enrollment assistance program. Main Outcomes and Measures: The main outcome was Medicaid-reimbursed health care, associated with substance use disorders and for any cause, within 30 days of prison release, including outpatient, emergency department, and inpatient care. Mean outcomes were compared for those released before and after implementation of prerelease Medicaid enrollment assistance using an intention-to-treat analysis and person-level data from the Wisconsin Department of Corrections and Medicaid. Results: The sample included 16 307 individuals with 18 265 eligible releases (men accounted for 16 320 of 18 265 total releases, and 6213 of 18 265 releases were among Black individuals; mean [SD] age at release, 35.5 [10.7] years). The likelihood of outpatient care use within 30 days of release increased after implementation of enrollment assistance relative to baseline by 7.7 percentage points for any visit (95% CI, 6.4-8.9 percentage points; P < .001), by 0.7 percentage points for an opioid use disorder visit (95% CI, 0.4-1.0 percentage points; P < .001), by 1.0 percentage point for any substance use disorder visit (95% CI, 0.5-1.6 percentage points; P < .001), and by 0.4 percentage points for receipt of medication for opioid use disorder (95% CI, 0.2-0.6 percentage points; P < .001). There was no significant change in use of the emergency department (0.7 percentage points [95% CI, -0.15 to 1.4 percentage points]). The probability of an inpatient stay increased by 0.4 percentage points (95% CI, 0.03-0.7 percentage points; P = .03). Conclusions and Relevance: The results of this cohort study suggest that prerelease Medicaid enrollment assistance was associated with increased use of outpatient health care after incarceration and highlights the value of making this assistance universally available within correctional settings. More tailored interventions may be needed to increase the receipt of treatment for substance use disorders.

The Line between Medicaid and Marketplace: Coverage Effects from Wisconsin's Partial Expansion.

CONTEXT: States have experimented with the income eligibility threshold between Medicaid coverage and access to subsidized Marketplace plans in an effort to increase coverage for low-income adults while meeting other state priorities, particularly a balanced budget. In 2014, Wisconsin opted against adopting an ACA Medicaid expansion, instead setting the Medicaid eligibility threshold at 100% of the poverty level-a state-funded partial expansion. Childless adults gained new eligibility, while parents and caregivers with incomes between 101-200% of poverty lost existing eligibility. METHODS: We used Wisconsin's all-payer claims database to assess health insurance gains, losses, and transitions among low-income adults affected by this partial expansion. FINDINGS: We found that less than one third of adults who lost Medicaid eligibility definitely took up commercial coverage, and many returned to Medicaid. Among those newly eligible for Medicaid, there was little evidence of crowd-out. Both groups experienced limited continuity of coverage. Overall, new Medicaid enrollment of childless adults was offset by coverage losses among parents and caregivers, rendering Wisconsin's overall coverage gains similar to nonexpansion states. CONCLUSIONS: Wisconsin's experience demonstrates the difficulty in relying on the Marketplace to cover the near poor and suggests that full Medicaid expansion more effectively increases coverage.

Financial burden and medication adherence among near-poor older adults in a pharmaceutical assistance program.

BACKGROUND: With increasing drug prices in the past decade, affordability and medication adherence are a growing concern for near-poor older adults, especially for those who are not receiving Low-Income Subsidy in Medicare Part D. SeniorCare is a pharmaceutical assistance program in Wisconsin for near-poor older adults, providing comprehensive prescription coverage with flat copayments. OBJECTIVES: To evaluate five-year trends in financial hardship and medication adherence and to examine factors associated with these outcomes in SeniorCare members. METHODS: SeniorCare program enrollment and pharmacy claims data from 2014 to 2018 were used. The study population was near-poor older adults in SeniorCare with annual family income ≤200% of the federal poverty level. Financial burden was assessed using the proportion of total annual out-of-pocket costs to total annual income. Medication adherence was assessed by adapting the measures endorsed by the Pharmacy Quality Alliance and National Quality Forum. Descriptive statistics and independent t-tests were used to evaluate the trends, and multivariate logistic regressions were conducted to examine factors associated with financial burden and medication adherence. RESULTS: From 2014 to 2018, mean annual out-of-pocket costs per member declined by 3.7% (p < 0.001) for all drugs, while those for specialty drugs increased by 31.2% (p < 0.05). Around 3.3% spent more than 5% of their income for prescription drugs in 2014, which decreased to 2.4% in 2018 (p < 0.001). The proportions of adherent patients increased from 78.1% to 81.2% (p < 0.001) for diabetes medications (excluding insulins), from 77.3% to 79.5% (p < 0.001) for statins, and from 79.8% to 80.8% (p < 0.05) for RASA. Members subject to a $500 annual deductible were more likely to experience high financial burden (adjusted odds ratio (AOR) = 1.677, p < 0.001) and less likely to be adherent to diabetes medications (AOR = 0.484, p < 0.001). CONCLUSIONS: The near-poor older adults enrolled in Wisconsin SeniorCare program had low financial burden and good medication adherence within the program.

Implementing parity for mental health and substance use treatment in Medicaid.

OBJECTIVE: To estimate the association between the implementation of parity in coverage for mental health and substance use disorder (MHSUD) services within the Medicaid program and MHSUD service use. DATA SOURCES/STUDY SETTING: Wisconsin Medicaid enrollment and claims data from 2013 to 2015. In April 2014, Wisconsin Medicaid transitioned childless adult beneficiaries from coverage with limited MHSUD services to parity-consistent coverage. Preparity, they only had Medicaid coverage for MHSUD visits to psychiatrists and the emergency department, while parent beneficiaries had parity-consistent coverage. STUDY DESIGN: The study uses a difference-in-differences design to compare outcome changes for childless adult and parent beneficiaries. DATA COLLECTION/EXTRACTION METHODS: We identified 76, 569 childless adult and parent beneficiaries aged 18-64 who were continuously enrolled for the 2-year study period. PRINCIPAL FINDINGS: Introducing parity-consistent coverage within Medicaid was associated with increased utilization of Medicaid-reimbursed MHSUD services: outpatient, prescription medication, ED, and inpatient. Increased MHSUD outpatient visits were driven by increased visits to nonpsychiatrists. CONCLUSIONS: Parity's effects on MHSUD service use have been studied in the context of private insurance, but its impact among Medicaid beneficiaries has not. Our findings suggest that parity implementation in Medicaid could increase access to effective MHSUD services in a high-need population.

Trends in a State Pharmaceutical Assistance Program for Low-income Older Adults in Wisconsin.

INTRODUCTION: Many older adults face difficulty in affording their prescription drugs, despite having coverage available through Medicare Part D. SeniorCare is Wisconsin's pharmaceutical assistance program that provides comprehensive drug coverage for low-income older adults who are not eligible for full Medicaid benefits. METHODS: We analyzed SeniorCare enrollment and pharmacy claims data from 2014 to 2018. RESULTS: Total drug expenditures increased by 19.3%, with the proportion of expenditures paid by SeniorCare and members decreasing while the proportion paid by other payers increased. Specialty drugs accounted for a substantial and growing proportion of total expenditures (20.4% in 2018) despite accounting for <0.2% of all claims. CONCLUSIONS: Total drug expenditures in SeniorCare have steadily increased over time, primarily due to rising average expenditures per drug fill and increased use of specialty drugs. However, SeniorCare members have been largely protected from these increases and have paid a decreasing proportion of costs over time.

Medicaid Expansion And State Trends In Supplemental Security Income Program Participation.

The Affordable Care Act made low-income nonelderly adults eligible for Medicaid in 2014 without requiring them to obtain disabled status through the Supplemental Security Income (SSI) program. In states that participated in the Medicaid expansion, we found that SSI participation decreased by about 3 percent after 2014.

What fraction of Medicaid enrollees have private insurance coverage at the time of enrollment? Estimates from administrative data.

We use administrative data from Wisconsin to determine the fraction of new Medicaid enrollees who have private health insurance at the time of enrollment in the program. Through the linkage of several administrative data sources not previously used for research, we are able to observe coverage status directly for a large fraction of enrollees and indirectly for the remainder. We provide strict bounds for the percentages in each status and find that the percentage of new enrollees with private insurance coverage at the time of enrollment lies between 16 percent and 29 percent, and the percentage that dropped private coverage in favor of public insurance lies between 4 percent and 18 percent. Our point estimates indicate that, among all new enrollees, 21 percent had private health insurance at the time of enrollment and that 10 percent dropped this coverage. Our results show substantially lower rates than previous studies of crowd-out following public health insurance expansions and significant rates of dual coverage, whereby new enrollees into public insurance retain their previously held private insurance coverage.

The effects of expanding public insurance to rural low-income childless adults.

OBJECTIVE: This study measures the change in health care use after enrollment into a new public insurance program for low-income childless adults. DATA SOURCES/STUDY SETTING: The data sources include claims from a large integrated health system in rural Wisconsin and Medicaid enrollment files, January 2007-September 2012. STUDY DESIGN: We employ a regression discontinuity design to measure the causal effect of public insurance enrollment on counts of outpatient, emergency department, and inpatient events for 2 years following enrollment for a sample of previously uninsured low-income adults in rural Wisconsin. PRINCIPAL FINDINGS: Public insurance enrollment led to substantial increases in outpatient visits including preventive visits, but not mental health visits. Public insurance enrollment also led to increases in inpatient stays, but the study is inconclusive on whether it led to an increase in ED visits. CONCLUSIONS: Public insurance expansions to childless adults have the potential to impact the use of health care. The large increase in Medicaid coverage and reduction in rates of uninsurance anticipated to result from the Affordable Care Act should increase the use of inpatient and outpatient services, but they will have an uncertain impact on the use of ED among rural populations.

The effect of Medicaid premiums on enrollment: a regression discontinuity approach.

This paper estimates the effect that premiums in Medicaid have on the length of enrollment of program beneficiaries. Whether and how low income-families will participate in the exchanges and in states' Medicaid programs depends crucially on the structure and amounts of the premiums they will face. I take advantage of discontinuities in the structure of Wisconsin's Medicaid program to identify the effects of premiums on enrollment for low-income families. I use a 3-year administrative panel of enrollment data to estimate these effects. I find an increase in the premium from 0 to 10 dollars per month results in 1.4 fewer months enrolled and reduces the probability of remaining enrolled for a full year by 12 percentage points, but other discrete changes in premium amounts do not affect enrollment or have a much smaller effect. I find no evidence of program enrollees intentionally decreasing labor supply in order to avoid the premiums.

Wisconsin experience indicates that expanding public insurance to low-income childless adults has health care impacts.

As states consider expanding Medicaid to low-income childless adults under the Affordable Care Act, their decisions will depend, in part, on how such coverage may affect the use of medical care. In 2009 Wisconsin created a new public insurance program for low-income uninsured childless adults. We analyzed administrative claims data spanning 2008 and 2009 using a case-crossover study design on a population of 9,619 Wisconsin residents with very low incomes who were automatically enrolled in this program in January 2009. In the twelve months following enrollment in public insurance, outpatient visits for the study population increased 29 percent, and emergency department visits increased 46 percent. Inpatient hospitalizations declined 59 percent, and preventable hospitalizations fell 48 percent. These results demonstrate that public insurance coverage expansions to childless adults have the potential to improve health and reduce costs by increasing access to outpatient care and reducing hospitalizations.

Wisconsin's experience with Medicaid auto-enrollment: lessons for other states.

The Patient Protection and Affordable Care Act (ACA) relies heavily on the expansion of Medicaid eligibility to cover uninsured populations. In February 2008, Wisconsin expanded and reformed its Medicaid/CHIP program and, as part of program implementation, automatically enrolled a set of newly eligible parents and children. This process of "auto-enrollment" targeted newly eligible parents and older children whose children/siblings were already enrolled in the state's Medicaid/CHIP program. Auto-enrollment brought over 44,000 individuals into the program, representing more than 60% of all enrollees in the first month of the reformed program. Individuals who were auto-enrolled were modestly more likely to leave the program relative to other individuals who enrolled in February 2008, unless their incomes were high enough to be required to pay premiums; these auto-enrollees were much more likely to exit relative to other enrollees subject to premium payments. The higher exit rates exhibited by non-premium paying auto-enrollees were likely due to the fact that over 40% of auto-enrollees were covered by a private insurance policy in the month of their enrollment, compared to approximately 30% for regular enrollees. A national simulation of an auto-enrollment process similar to Wisconsin's, including the expansion of adult Medicaid eligibility to 133% of the federal poverty level under the ACA, suggests that 2.5 million of the 5.6 million newly eligible parents could be auto-enrolled, and approximately 25% of this population would be privately insured. These results suggest that auto-enrollment may be appropriate for other states, especially in their efforts to enroll eligible populations who are not subject to premium requirements.

Wisconsin's BadgerCare Plus reform: impact on low-income families' enrollment and retention in public coverage.

OBJECTIVES: To examine the impact of a Wisconsin health care reform enacted in early 2008 on public insurance enrollment and retention. DATA SOURCES: Administrative data covering the period January 2007 to November 2009. STUDY DESIGN: We calculate unadjusted enrollment trends and exit rates stratified by age, income group, and enrollment mode. Kaplan-Meier curves and Cox proportional hazards models are estimated to assess the impact of the reform on program exits. PRINCIPAL FINDINGS: Overall enrollment increased by approximately one-third and exit rates decreased by approximately one-fifth. The majority of new enrollment came from the previously income eligible. CONCLUSIONS: Wisconsin's enactment of eligibility expansions coupled with administrative simplification and targeted marketing and outreach efforts were successful in enrolling and retaining low-income children and families in public coverage.