Stability and Churning in Medi-Cal and Healthy Families

Gerry Fairbrother, PhD

Joseph Schuchter, MPH

Presented atCalifornia State Legislature

SacramentoApril 29, 2008

Why is Stability Important?

• Studies have shown that children with stable coverage

– More likely to have a usual source of care – and to use it for most care

– Less likely to have unmet needs– Less likely to experience delays in care

Why is Stability Important?

• Stable is needed to manage care.

• Health Plans need time to:– Monitor care– Institute corrective action, if needed

• Stable promotes attachment to a regular provider and a medical home

In this study we:

• Followed newly-enrolled children in Medi-Cal and Healthy Families to see patterns of enrollment

• Examined cost after a gap

5251

40

60

80

100

0 3 6 9 12 15 18

Months after initial enrollment

% o

f ch

ildre

n s

till

enro

lled

Healthy Fam

Medi-Cal

Retention is Poor in both Medi-Cal and Healthy Families

Different Eligibility Groupings have Different Patterns

82

61

52

40

60

80

100

0 3 6 9 12 15 18

Months after initial enrollment

% o

f ch

ildre

n s

till

enro

lled

SSI

CALWORKS

1931(B)

100 PERCENT

133 PERCENT4039

Healthy Families Shows Sharp Drop-Off at Renewal

505455

40

60

80

100

0 3 6 9 12 15 18

Months after inital enrollment

% o

f ch

ildre

n s

till

enro

lled

100-149

150-199

200-249

One Child in Three Back on Medi-Cal in a Year

back on the program within 6

months after being

dropped

back on the program within 12

months after being

dropped

100 PERCENT 20 28

133 PERCENT 20 30

1931 26 37

CALWORKS 29 40

Overall 25 35

Children continue to come back on the program even after a year. After three years half to two-thirds are back on.

National data shows children are still eligible

• Two uninsured children in three are eligible for coverage

• 42% of uninsured, eligible children had been enrolled in Medicaid in the prior year

– Therefore, states could reduce uninsured by 42% by just retaining eligible children

Somers BD. Why millions of children eligible for Medicaid and SCHIP are uninsured: poor retention vs. poor take-up. Health Affairs 2007;26(5):w560-67.

• COSTS OF CHURNING

Medical Costs are Substantial After a Gap

0.0

4.0

8.0

12.0

16.0

20.0

6 5 4 3 2 1 1 2 3 4 5 6

Months before gap - Months after gap

To

tal c

ost

s (m

illio

ns

$)

_

OTHER

medical equip

lab

prescriptions

psychiatric

provider visits

inpatient

• Gap>= 3 months (n=164,520)

Costs are Higher After 6 mo

0.0

4.0

8.0

12.0

16.0

20.0

6 5 4 3 2 1 1 2 3 4 5 6

Months before gap - Months after gap

To

tal c

ost

s (m

illio

ns

$)

_

OTHER

medical equip

lab

prescriptions

psychiatric

provider visits

inpatient

• Gap>= 6 months (n=83,058)

And Highest After 12 mo

0.0

4.0

8.0

12.0

16.0

20.0

6 5 4 3 2 1 1 2 3 4 5 6

Months before gap - Months after gap

To

tal c

ost

s (m

illio

ns

$)

_

OTHER

medical equip

lab

prescriptions

psychiatric

provider visits

inpatient

• Gap>= 12 months (n=23,492)

There are also administrative costs

Elements of Cost PA CA OH MI OR

State/County costs for Outreach and

Eligibility Determination

$95 $68 $47 $58 $69

Enrollment Broker $34 $28 $7 $13 No

broker

Health Plan (approximate)

$20 $26 $17 $15 $20

TOTAL $149 $122 $ 71 $ 86 $ 89

Level of Churning Varies

53 52 4634

25

31 3031

2731

16 18 2239 44

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

100%

PA CA OH MI OR

Enrolled Continuously for 3 Years Came On the Rolls During the 3 Years

Fell Off the Rolls and Came Back

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

N=319,636 N=1,838,672 N=525,057 N=414,868 N=90,800

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 program

income eligibility threshold, %FPL

Yes

250%

No Yes

200%

Yes

200%

Yes

185%

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)

Conclusions

• Only half newly-enrolled children “survive” after 21 months

• Sharpest drop occurs at the 12-month renewal period

• Drop is more gradual for children in families receiving cash assistance or food stamps

Conclusions

• More frequent renewals will hit hardest children in 1931(B) and percentage programs

• These families are teetering on the brink of poverty and may need to support health care provides

• Costs are higher after a gap; the longer the gap the higher the cost when children return to coverage