How Long do Children Stay in Medicaid and What is their Level of Churning? Gerry Fairbrother, Ph.D. Cincinnati Children’s Hospital Medical Center Presented at AcademyHealth June 27, 2005 This research was supported by The Commonwealth Fund, the California Endowment, the Jewish Healthcare Foundation and Blue Cross/Blue Shield of Michigan. I thank Medicaid officials in the participating states for their assistance.

Why is churning important? If the same eligible beneficiaries are being processed and re-processed, then inefficiencies are introduced in the system Children may forgo needed care during gaps Breaks in care may adversely affect quality Re-instating eligible children a short time after they fall off the rolls causes unnecessary costs

The purpose of this study is to Assess the level of stability of coverage for children enrolled in Medicaid; Describe level of churning and the length of the breaks for children who leave and return; Describe the costs of churning (forthcoming)

Study Methods We examined Medicaid eligibility files in five states –California, Michigan, Ohio, Oregon, Pennsylvania We took children 5-18 enrolled in Medicaid as of December 2003 We described enrollment patterns for these children during the three prior years (January 2001 – December 2003), including –Proportion of children enrolled continuously for 1, 2, and 3 years –Proportion of children with breaks in enrollment –Length of the breaks in enrollment

State/Medicaid Characteristics USCAOHPAMIOR Population (millions) Medicaid enrollees June 2003 (millions) % population below 100% FPL, millions 17%19%15%14%16% % Uninsured (children <18) 12%14%8%10%7%13% % on Medicaid (children <18) 27%29%21%20%26%25% MMC penetration60%51%30%80%99%80% From Kaiser Family Foundation; State Health Facts data.

Features of the Medicaid Program that may Affect Enrollment/Renewal CAOHPAMIOR Income eligibility threshold, % FPL (children 6-19) 100%200%100%150%100% Separate SCHIP program income eligibility threshold, %FPL Yes 250% NoYes 200% Yes 200% Yes 185% Renewal period12 m 6 m 12 mo Continuous eligibilityyesno yesno Self-declaration of incomeno yesno No face-to-face/No asset testyes Donna Cohen Ross and Laura Cox. Beneath the Surface: Barriers threaten to slow progress on expanding health coverage of children and families. Kaiser Family Foundation. October (Based on data as of July 2004)

Figure 1: States Vary in Proportion of Children Stably Insured for 3 Years Years Continuously Enrolled: Data Source: State Medicaid Enrollment Files. Note: Continuous enrollment over the three prior years for children enrolled in Medicaid in December Data includes children ages Percent of Children Enrolled for Specific Number of Years % N=1,838,672 N=525,057N=179,476N=416,693 N=90,800

Figure 2: Churning Also Varies Data Source: State Medicaid Enrollment Files. Data includes children ages N=1,838,672 N=525,057 N=179,476 N=416,693N=90,800

Figure 3: Among those who Experience Breaks, Most Breaks Are Short Data Source: State Medicaid Enrollment Files. Data includes children ages N=332,484 N=116,609 N=34,542 N=164,118 N=39,985

Mean Number and Length of Breaks in Medicaid Coverage Among Children with Enrollment Breaks CAOHPAMIOR Mean Number of Breaks in Coverage* Mean Length of Break (Months) Median Length of Break (Months) *Includes only those who were in Medicaid in Dec 03 and had at least 1 break during the 3 years. Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18.

Figure 4: Children are Enrolled in Medicaid Longer than in MMC Data Source: State Medicaid Enrollment Files. Data includes children ages CAOHPAMI OR N=1,272,212 N=224,337 N=159,895N=330,424 N=67,442

Figure 5: Proportion of Children Enrolled in a Medicaid Managed Care Plan for 1 or More Years Data Source: State Medicaid Enrollment Files. Data includes children ages N=1,272,212N=224,337 N=159,895N=330,424N=67,442

Conclusions A substantial proportion of children are stably insured through Medicaid in some states (approximately 60% insured for two years for CA, OR, and PA) and Stably enrolled in a managed care plan, at least in some states, to be part for their care to be managed; This means that Medicaid (and Medicaid managed care) have opportunity to affect quality of care.

Conclusions Still, from 18% to 44% of children leave the rolls, only to return after a short time This suggests that many (possibly most) of these children were eligible for coverage when they fell off the rolls The strong implication is that these children had problems with Medicaid renewal, rather than had a change in eligibility status

Limitations We do not know why children left and came back on the rolls We do not know the characteristics of the children who churn vs. those that are stably insured We need more information about state policies and reasons for churning

Policy Implications States need to take action to reduce churning, since many children are effected; At the same time, states also can more aggressively seek quality improvements in care, since a sizeable portion of children are enrolled “long enough” (from 76% to 41% were enrolled in a MMC for one or more years) States that rely on managed care need to maximize time children’s care is managed, by accelerating enrollment in a health plan.