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 atAcademyHealthJune 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

US CA OH PA MI OR

Population (millions) 287.3 35.5 11.4 12.4 10.1 3.6

Medicaid enrollees June 2003 (millions)

40.6 6.4 1.6 1.6 1.3 .4

% population below 100% FPL, millions

17% 19% 15% 14% 16% 16%

% Uninsured(children <18)

12% 14% 8% 10% 7% 13%

% on Medicaid(children <18)

27% 29% 21% 20% 26% 25%

MMC penetration 60% 51% 30% 80% 99% 80%

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

Features of the Medicaid Program that may Affect Enrollment/Renewal

CA OH PA MI OR

Income eligibility threshold, % FPL (children 6-19)

100% 200% 100% 150% 100%

Separate SCHIP programincome eligibility threshold, %FPL

Yes250%

No Yes200%

Yes200%

Yes185%

Renewal period 12 m 12 m 12 m 12 m 6 m

12 mo Continuous eligibility yes no no yes no

Self-declaration of income no no no yes no

No face-to-face/No asset test yes yes yes yes yes

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)

Figure 1: States Vary in Proportion of Children Stably

Insured for 3 Years

52 46 4734 25

13 15 1213

12

15 17 1721

21

21 21 24 31 42

0%

20%

40%

60%

80%

100%

CA OH PA MI OR

3 Years 2 Years 1 Year <1 YearYears Continuously Enrolled:

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.

Percent of Children Enrolled for Specific Number of Years

%

N=1,838,672 N=525,057 N=179,476 N=416,693 N=90,800

Figure 2: Churning Also Varies

52 46 4734 25

30 31 34

2731

18 22 1939 44

0%10%20%30%40%50%60%70%80%90%

100%

CA OH PA MI OR

Enrolled Continuously for 3 Years Came On the Rolls During the 3 YearsFell Off the Rolls and Came Back

Data Source: State Medicaid Enrollment Files. Data includes children ages 5-18.

N=1,838,672 N=525,057 N=179,476 N=416,693 N=90,800

Figure 3: Among those who Experience Breaks,

Most Breaks Are Short

27 2615

3421

32 3227

35

31

14 16

16

1221

26 2741

20 28

0%10%20%30%40%50%60%70%80%90%

100%

CA OH PA MI OR

1 Month 2-4 Months 5-7 Months >7 Months

Data Source: State Medicaid Enrollment Files.Data includes children ages 5-18.

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

CA OH PA MI OR

Mean Number of Breaks in Coverage*

1.14 1.14 1.10 1.29 1.33

Mean Length of Break (Months)

5.68 5.81 8.07 4.74 6.24

Median Length of Break (Months)

3 3 6 2 4

*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

6044 54

1746 35 38

24 2613

3232

45

2933 36

33 33

28

13 24 1337 25 32 26

43 405927

0%

20%

40%

60%

80%

100%

Covered 3 Years Covered Between 1 and 3 Years Covered Less Than 1 Year

Data Source: State Medicaid Enrollment Files.Data includes children ages 5-18.

CA OH PA MI ORN=1,272,212 N=224,337 N=159,895 N=330,424 N=67,442

Figure 5: Proportion of Children Enrolled in a Medicaid Managed Care Plan for 1 or More Years

7663 68

5741

2437 32

4359

0%10%20%30%40%50%60%70%80%90%

100%

CA OH PA MI OR

1 or More Years Less Than 1 Year

Data Source: State Medicaid Enrollment Files.Data includes children ages 5-18.

N=1,272,212 N=224,337 N=159,895 N=330,424 N=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.