A Healthy Blog

Massachusetts health care — wonky, with a healthy dose of reality

What do other 33 states have for children that Massachusetts does not?

What do other 33 states have for children that Massachusetts does not?

July 26, 2010

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Justin is a six year old boy with asthma. He stays healthy and out of the hospital as long as he takes his medications. One morning, Justin’s mom called the Health Care For All's HelpLine in a panic. She went to refill her son’s prescriptions and was told she would have to pay out-of-pocket because her son’s MassHealth coverage was shut off. The medications would cost hundreds of dollars that she did not have. The HCFA HelpLine helped her to reinstate her coverage that was terminated due to a small fluctuation in her income. But it was too late; in the interim Justin had an asthma attack and had to be rushed to the emergency room where he received the same breathing treatment he could have had at home if his MassHealth coverage was continuous.

This is not only Justin’s story. This is the story of thousands of other children. Many families whose income fluctuates close to the 300% of povery level eligibility cut-off find themselves constantly becoming ineligible and then re-eligible for MassHealth and as a result their children are paying the price, by missing doctor’s appointments not being able to get prescriptions filled and ending up in the emergency room.

Now, Massachusetts has a unique opportunity to paint a very different picture and make sure children like Justin have the care they deserve when they need it.

As part of the effort to increase health coverage retention among children, the Massachusetts legislature passed 12-month continuous eligibility for children as an outside section to the budget. Unfortunately Governor Deval Patrick vetoed this language in the budget. We understand the challenges in this fiscal year and the difficulty choices legislators need to make. Now the legislature can make a real improvement for kids' health by overriding the veto of section 71 and putting this provision back in the FY2011 budget. 12-month continuous eligibility is crucial to make sure children receive the care they need and the 33 states who have successfully implemented this policy are projecting to save administrative costs.

The 12-month continuous eligibility policy allows children under the age of 19 who enroll in Medicaid or CHIP to retain coverage for a full 12 months, regardless of changes in family income over that one year period. This ensures continuous coverage and helps children get their health care needs met on an ongoing basis with fewer disruptions due to administrative barriers.

The Obama Administration has cited 12-month continuous eligibility policy as one of the 8 central measures to simplify Medicaid enrollment and renewal, as well as decrease churning. Why 12 month continuous eligibility is a wise decision?

According to the Office of Medicaid there are about 16,000 children in Massachusetts, whose coverage fluctuates during the year. This means that children become ineligible and fall off of coverage during a particular month due to income fluctuations or paper work and then become eligible again the next month or so. This cycling on and off are detrimental to the health of the child as well as to the State Budget.

Children who experience a coverage gap of any length face substantial barriers to accessing affordable, quality care. Research shows that even brief gaps in health coverage cause people to skip or delay care, while uninterrupted coverage can reduce avoidable hospitalizations for children by 25 percent. Studies also show that children with gaps in health insurance coverage commonly do not seek medical care, including preventive visits, and do not get prescriptions filled.

On the financial side, the Enrollment and Disenrollment in MassHealth and Commonwealth Care report (pdf) by the Center for Health Law and Economics, states that in Massachusetts the administrative costs associated with each enrollment in Medicaid/CHIP are estimated to be about $200 per enrollee, per enrollment cycle. This cost multiplies every time an eligible recipient loses coverage and must be re-enrolled. Therefore, savings for preventing churning for one child is 200 dollars per re-enrollment. Since there are potentially 16,000 children annually who fall off coverage, this means that for one re-enrollment cycle this policy would save the state about 3.2 million dollars in administrative costs, and for two re-enrollment cycles, the state would save 6.4 million dollars.

A report by the Center for Children and Families at Georgetown University's Health Policy Institute, shows that health costs could decrease as acute episodes are prevented or treated at an earlier stage and the management of chronic conditions is improved. The study shows that payment per child and payment per enrollee per month could drop by about 3 percent. Here's the details:

A 2007 report from the University of California studied hospitalizations of millions of California Medicaid enrollees from 1998 to 2002, and presented two key findings. First, children with interruptions in Medicaid coverage were far more likely to be hospitalized for “ambulatory-sensitive conditions”— hospital stays that could be avoided with proper ongoing care. Second, when California children’s Medicaid enrollment was increased from six to 12 months in 2001, avoidable hospitalizations fell by 25 percent, enrollment of children increased, and eligible children had fewer gaps in coverage.


Let’s paint a different picture and color Massachusetts with 12-month continuous eligibility!