How Long do Children Stay in Medicaid and What is their Level of Churning?

1. 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.

2. 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

3. 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)

4. 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

5. State/Medicaid Characteristics From Kaiser Family Foundation; State Health Facts. http://www.statehealthfacts.org. 2003 data.

6. Features of the Medicaid Program that may Affect Enrollment/Renewal 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 2004. (Based on data as of July 2004)

7. Figure 1: States Vary in Proportion of Children Stably Insured for 3 Years Percent of Children Enrolled for Specific Number of Years Years Continuously Enrolled: % N=1,838,672 N=90,800 N=525,057 N=179,476 N=416,693 Data Source: State Medicaid Enrollment Files. Note: Continuous enrollment over the three prior years for children enrolled in Medicaid in December 2003. Data includes children ages 5-18.

8. Figure 2: Churning Also Varies N=1,838,672 N=179,476 N=416,693 N=90,800 N=525,057 Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18.

9. Figure 3: Among those who Experience Breaks, Most Breaks Are Short N=332,484 N=34,542 N=164,118 N=39,985 N=116,609 Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18.

10. Mean Number and Length of Breaks in Medicaid Coverage Among Children with Enrollment Breaks *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.

11. Figure 4: Children are Enrolled in Medicaid Longer than in MMC CA OH PA MI OR N=1,272,212 N=224,337 N=159,895 N=330,424 N=67,442 Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18.

12. Figure 5: Proportion of Children Enrolled in a Medicaid Managed Care Plan for 1 or More Years N=1,272,212 N=224,337 N=159,895 N=330,424 N=67,442 Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18.

13. 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.

14. 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

15. 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

16. 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.