Many families live in rural areas without easy access to local government offices. These families would benefit from the remote access offered by online applications. Making applications available online would also reduce the potential for incomplete and misplaced submissions. Through questions, prompts and blocks that do not allow incomplete forms to be submitted, online applications provide useful feedback in a way paper applications cannot.

Given the high tech business sector in many New England states and with all the efforts states have put into achieving such high enrollment numbers, it is surprising that they have not taken advantage of this common-sense extra push. Online applications, along with other streamlined application and renewal procedures may be just what New England needs to get to 100 percent enrollment of eligible children in health coverage. Hopefully New England will make 2012 a year of great advances in coverage and consumer access starting with online applications and renewal for health benefits.

– Nicole Tambouret, Project Director
New England Alliance for Children’ Health

Please note, this blog was updated to reflect Maine’s policy on electronic applications, which was not originally reflected in the report.

The new report from our partners at the Georgetown University Health Policy Institute’s Center for Children and Families (CCF) (click here for the executive summary) provides strong evidence that the uninsured rate for children decreased in the midst of the worst recession in decades because Medicaid and the Children’s Health Insurance Program (CHIP) were in place to prevent children from failing through the cracks.

CCF found that private insurance coverage of children eroded during this period—dropping by 4.5 percent. This is no surprise, since the recession cost millions of families their jobs and their employer-sponsored insurance (ESI). But public insurance coverage of children increased by 5.8 percent during this same time, filling the gap left by declining ESI. This is simple, hard evidence that public coverage programs are irreplaceable sources of coverage that protect children’s access to care when the economy falters.

Ironically—maybe only in the Alanis Morissette meaning of the word—it’s during these hard economic times, when Medicaid and CHIP are most needed as a safety net, that their funding is most at risk. As policy makers scramble to fill state budget gaps, they too often turn to harmful Medicaid and CHIP cuts such as reductions in provider payments, restrictions on covered services, and increased premiums and co-payments. The findings in the report emphasize why it’s essential that policy makers turn instead to the dozens of delivery and payment system reform options that can achieve savings in Medicaid and CHIP without undermining—and often by actually strengthening—these programs. (See our Medicaid Report Card for ideas on how your state can save money in Medicaid.)

The report also highlights the importance of the maintenance of effort requirement in the Affordable Care Act, which prohibits state policymakers from cutting eligibility for children on Medicaid and CHIP until 2019. The heartening findings in the CCF report would simply not have been possible had states been permitted to slash eligibility in these programs.

The full report includes state-specific data on children’s insurance rates, so check it out and see how your state did (only one state, Minnesota, had a statistically significant increase in uninsured children). With our economic woes likely to continue for some time, this report should renew our commitment to protecting Medicaid and CHIP. The health of our children depends on it.

—Katherine Howitt, Senior Policy Analyst
and Patrick M. Tigue, Senior Policy Analyst

And that’s why here at the New England Alliance for Children’s Health, a program of Community Catalyst, we were excited to see that the CDC recently announced a new initiative aimed at addressing childhood obesity. The Childhood Obesity Demonstration Project was created by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and funded through the Affordable Care Act (ACA). It will provide $25 million over a four year period to comprehensively identify effective health care and community approaches to reduce childhood obesity in the areas of supporting healthy dietary choices and promoting active living. Children aged two to twelve who are enrolled in CHIP are the target population for the project.

CDC chose only four grantees to participate in the project. Three grantees will serve as research facilities (the University of Texas Health Science Center at Houston, San Diego State University, and the Massachusetts Department of Public Health) that will identify strategies that are effective means to reduce childhood obesity and one grantee (the University of Houston) will serve as the evaluation center for the project and share lessons learned across identified strategies. The project will conclude in September 2015 at which time CDC will widely share the findings from the initiative and make recommendations about effective strategies to prevent childhood obesity among undeserved children.

What we learn from this project needs to inform policy choices at the federal, state and local level if we are going to make much needed progress on the childhood obesity epidemic. And thanks to CHIPRA and the ACA, we now have an even better chance of doing so.

—Patrick M. Tigue, Senior Policy Analyst

To conduct the study, research staff posed as parents and called specialty practices in Illinois to schedule appointments for their children. The two major findings from the study were:

• – More than 66 percent of callers who said they had a child on Medicaid or CHIP were denied an appointment, compared to only 11 percent of callers who said they had a child on private insurance.
• – The average wait time to see a specialist who accepted both public and private insurance was 22 days longer for Medicaid and CHIP children than for children with private insurance.

This study’s findings are consistent with the United States Department of Health and Human Services’ (HHS) 2010 literature review on access to care for Medicaid and CHIP children. HHS succinctly summarized its findings this way: “. . . access could be improved substantially for specialty care services (e.g., dental, mental health).” Reasons cited in the NEJM article for providers’ decisions not to treat patients covered by Medicaid and CHIP include: disparities in insurance reimbursement rates, delays in payment, and cumbersome payment procedures.

Access to specialty care for children on Medicaid and CHIP is clearly an issue that needs to be addressed. This begs the question of what effect current Congressional proposals to turn Medicaid into a block grant program, cap federal expenditures, or allow states to cut Medicaid and CHIP eligibility through repealing the Affordable Care Act’s maintenance of effort requirements (MOE) would have. The short answer is that all of these proposals would make this problem even worse. Block granting or a spending cap would result in reductions in Medicaid and CHIP spending, which would inevitably lead to provider rate cuts. Repealing the MOE provisions would result in reductions in overall coverage levels—leading to more uninsured children. Either way, these proposals would result in even less access to specialty care (not to mention to other essential health services as well).

Overall, Medicaid and CHIP serve our country’s children immensely well by providing cost-effective coverage for children that improves health outcomes and protects low-income families from financial ruin. For example, Medicaid and CHIP children actually fare very well when it comes to access to primary care. According to HHS, “Considerable evidence indicates that children enrolled in Medicaid/CHIP have much better access to primary care services than uninsured children and comparable access relative to privately insured children.”

In areas like access to specialty care, where further progress needs to be made, the answer is not to undermine these programs by reducing our investment in them. Instead, we need to implement innovative policy proposals that create savings in Medicaid by improving the health care delivery system, and that can be used to address outstanding issues like access to specialty care as well as for deficit reduction. And it’s up to all of us to make sure that members of Congress understand that we need thoughtful solutions to our nation’s problems, not mindless cuts.

—Patrick M. Tigue, Children’s Health Care Coordinator
New England Alliance for Children’s Health

Chairman Ryan would cut Medicaid and CHIP by a staggering $2 trillion over the next 10 years by doing the following:

1. Slashing the Medicaid Budget: Ryan’s proposal would cut $771 billion in federal spending from the Medicaid program. According to the Congressional Budget Office, “federal spending for Medicaid would be 35 percent lower in 2022 and 49 percent lower in 2030 than currently projected.”
2. Transforming Medicaid into a Block Grant: Under a block grant, states that use up their federal Medicaid allotment will no longer be able to receive additional federal funds when costs go up or enrollment increases. Cash-strapped states will be left high and dry, and will have to make up the difference by raising taxes, cutting other spending, or shrinking their Medicaid programs.
3. Repealing the Affordable Care Act: Ryan’s blueprint repeals most of the new health law’s major provisions, including its language extending CHIP through 2019 and fully funding the program through 2015. This means that CHIP would not receive any federal funding past 2013, its reauthorization date prior to the Affordable Care Act’s (ACA) two-year funding extension. Repealing the ACA would also cut an additional $627 billion from Medicaid—bringing total Medicaid cuts to $1.4 trillion—and would have a host of other detrimental effects on children’s access to quality health care.

States will have to fill in these funding gaps somehow, which could mean cutting reimbursement rates to providers and hospitals, limiting benefits, or reducing eligibility levels. No matter how states work to fill in these gaps, children are likely to lose out. Children represent half of all Medicaid enrollees, but account for only 20 percent of Medicaid spending—meaning that huge numbers of children could be adversely affected by program cuts yet save the federal government comparatively little money.

The impact of limiting benefits is particularly concerning for children. As Jocelyn Guyer from the Georgetown Center for Children and Families points out in a recent Say Ahhh! blog post, families rely on these programs “for hearing tests and glasses so their children can grow and learn, as well as for physicals so they can play sports. In many families, Medicaid provides children with the medical care that they need so they can thrive in the face of common medical conditions such as asthma and ADHD.”

While Ryan’s budget proposal may be a path to prosperity if you’re a wealthy individual or corporation in line to receive some $1.8 trillion in tax cuts, it certainly isn’t a path to prosperity if you’re a family who depends on Medicaid or CHIP for your child’s asthma medications, eye tests, or flu shots. Our nation cannot afford to ignore the needs of its children. We can and should do better.

—Maia Fedyszyn, Program Associate, New England Alliance for Children’s Health

CHIPRA provides states with incentives (in the form of bonus payments) to enact enrollment and retention simplification measures to improve coverage rates, offers grants for conducting innovative outreach, enrollment and quality-improvement activities. It also authorizes new policy options like Express Lane Eligibility, coverage of pregnant women in CHIP, and removal of the five-year waiting period for lawfully residing immigrant children and pregnant women to enroll in public insurance.

All of these new financial resources and policy options have enabled states to make significant improvements to their children’s health programs in a very short amount of time. In 2010 alone, 13 states expanded eligibility, 14 states made improvements in enrollment and renewal procedures, and 15 states qualified for bonus payments. Nationwide, Medicaid and CHIP programs for children are more comprehensive and efficient than ever. According to the recently-released 2010 CHIPRA Annual Report:

– 46 states and the District of Columbia now cover children with incomes up to 200 percent of the Federal Poverty Level (FPL) ($44,700 for a family of four).
– 22 states now offer coverage to lawfully residing immigrant children and/or pregnant women.
– 48 states and the District of Columbia have a 12 month eligibility period for Medicaid and CHIP and 23 states offer 12 months of continuous eligibility.
– 32 states have an on-line application that can be submitted electronically and 29 states allow electronic signatures on applications.
– 33 states and the District of Columbia are utilizing the data matching process provided by the Social Security Administration to confirm U.S. citizenship for children in Medicaid.

Thanks in part to these program enhancements and eligibility improvements, over two million children gained Medicaid or CHIP coverage during federal fiscal year 2010, with the programs serving more than 42 million children during this timeframe. These numbers should continue to rise in the years to come, as outreach, enrollment and retention efforts ramp up thanks to a new round of outreach and enrollment grants and U.S. Department of Health and Human Services Secretary Kathleen Sebelius’ Connecting Kids to Coverage Challenge, which aims to enroll five million eligible but uninsured children in Medicaid and CHIP by 2015.

Yet there is a chance that coverage for children will not continue to move in the right direction. If Republican governors get their way and states no longer have to comply with the Affordable Care Act’s Maintenance of Effort (MoE) requirement, coverage for millions of children in CHIP and optional Medicaid expansions could be eliminated. States could also impose “back door” cuts by using red tape barriers to make it harder for children to sign up for coverage. For example, programs could reinstate face-to-face interviews or shorten eligibility periods.

We cannot afford to let this happen. We need strong Medicaid and CHIP programs to create a solid foundation for the full implementation of the Affordable Care Act in 2014 and to ensure that our nation’s children have the coverage they need to stay healthy. Eliminating the MoE requirement would be a penny-wise and pound-foolish way to address budget shortfalls. After all, let’s not forget about what’s at stake here: the health and well-being of our nation’s children.

—Maia Fedyszyn, Program Associate
New England Alliance for Children’s Health

Why were Medicaid and CHIP eligibility policies so stable? Well, primarily because provisions in the American Recovery and Reinvestment Act of 2009 required states to maintain their Medicaid eligibility rules and enrollment procedures as a condition of receiving a boost in funding from a temporary increase in the federal Medicaid matching rate. It’s also worth noting here that the Affordable Care Act (ACA) includes a similar requirement to maintain both Medicaid and CHIP eligibility rules and procedures for children until 2019 (and for adults until 2014 when the ACA makes subsidies to purchase coverage available).

Additional key findings from the report include:

• – Thirteen states implemented targeted Medicaid and CHIP eligibility expansions for children, pregnant women, and adults in 2010. Most of these expansions were aimed at providing coverage to uninsured children and some produced state savings because states were able to draw down federal matching funds to help pay for coverage that was previously paid for solely with state dollars.
• – Three states (Colorado, Kansas, and Oregon) increased Medicaid and CHIP income eligibility levels for children. Twenty-five states now cover children in families with income at least up to 250 percent of the federal poverty level (FPL), or $45,775 for a family of three in 2010.
• – Six states (Delaware, Minnesota, Montana, Nebraska, North Carolina, and Wisconsin) took advantage of the option to cover lawfully residing immigrant children and pregnant women during their first five years residing in the country. As of the end of 2010, this means that twenty-one states have eliminated this barrier for children.
• – While meaningful progress continues to be made in expanding coverage for children, parent eligibility for Medicaid and CHIP continues to lag far behind. Only Colorado expanded eligibility for parents in 2010. Thirty-three states do not cover parents up to 100 percent of the FPL. This was $18,310 in 2010 for a family of three.
• – Low-income adults without dependent children remain ineligible for Medicaid in the vast majority of states. Just seven states (Arizona, Connecticut, Delaware, the District of Columbia, Hawaii, New York, and Vermont) provide Medicaid or (Medicaid-like) benefits to adults without dependent children.
• – States have moved forward with making improvements to their Medicaid and CHIP enrollment and renewal procedures in 2010. For example, twenty-nine states took advantage of the Children’s Health Insurance Program Reauthorization Act of 2009 option to verify citizenship by using an electronic data match with the Social Security Administration.
• – States continued to focus on making technological improvements to their Medicaid and CHIP systems in 2010. For instance, every state posts its Medicaid application online. However, only thirty-two states accept the electronic submission of the application.

Looking back at 2010, this report reminds us of the importance of keeping Medicaid and CHIP strong in order to ensure that coverage remains available during the most difficult times. Going forward, the report paints a clear picture of the work that still lies ahead to continue to make the promise of the ACA a reality for our children and families.

—Patrick M. Tigue, Children’s Health Care Coordinator
New England Alliance for Children’s Health

Here at the New England Alliance for Children Health (NEACH), an initiative of Community Catalyst, we congratulate the 15 states that collectively received a total of more than $206 million in bonuses: Alabama, Alaska, Colorado, Illinois, Iowa, Kansas, Louisiana, Maryland, Michigan, New Jersey, New Mexico, Ohio, Oregon, Washington, and Wisconsin. Awards ranged from a high of nearly $55 million in Alaska to a low of just over $2.5 million in Kansas. Cindy Mann, the Deputy Administrator of CMS and Director of the Center for Medicaid, CHIP and Survey & Certification (CMCS), put it best when she pointed out that the “increase in both the number of states receiving awards and the amount distributed is particularly encouraging given the difficult economic times states are facing.” For more details about what these states did to qualify for an award, check out this terrific post by Vikki Wachino, the Director of Family and Children’s Health Programs Group at CMS over at Say Ahhh!, the children’s health policy blog run by NEACH’s close partners at the Georgetown University Center for Children and Families.

We encourage every state to work to increase the enrollment of eligible but unenrolled children in Medicaid and CHIP. As we’ve blogged about in the past, Secretary Sebelius has initiated the Connecting Kids to Coverage Challenge to enroll the nearly five million uninsured children eligible for Medicaid and CHIP over the next five years. These 15 states show that it’s possible to make significant progress in the world of children’s health, even in the face of challenging economic circumstances.

—Patrick M. Tigue, Children’s Health Care Coordinator,
New England Alliance for Children’s Health

Just last August, Texas advocates chuckled and sighed along with our Arizona colleagues when the Onion ran the headline, “Texas Vows to Reclaim Title of Most Regressive State from Arizona.” That satire piece included references to our Governor Rick Perry’s very real 2009 statements about the possibility of Texas’ secession option. Perry distanced himself from his secession comments then, but recently kicked up a whole new flurry of media attention when he suggested on national television (CNN 11/7 /2010; Daily Show 11/8) that Texas might consider shutting down its Medicaid program entirely, and claimed a potential state savings of $60 billion dollars over several years. The interviews were part of the book promotion tour Perry launched immediately following the November election, and were in keeping with the states’ rights theme of that book, entitled “Fed Up”.

The Governor based his projections on a December 2009 memo from the Heritage Foundation, prior to the March 2010 passage of the Affordable Care Act. That memo speculated that the bill eventually passed might allow states to shut down their Medicaid programs in 2014, and send their former Medicaid enrollees to the new health insurance Exchange where their costs would be entirely borne by the federal budget. (Perry also complained about CMS not having approved a Texas 1115 waiver submitted in 2008. CMS authorities told Texas in August 2008 that Texas’ proposal covered too few adults, too slowly, and with too limited benefits — waiver request examples included a benefit package capped at $25,000 a year — to justify the significant departures from federal minimum standards Texas had requested.)

Of course, rhetoric like this is enough to make a policy analyst/health access advocate want to tear her hair out, but a funny thing has happened over the last six weeks since that first story: a whole lot of Texans have learned a whole lot about Medicaid and the critical role it plays in our state’s health care system and economy. News story after story drummed these facts home: leaving Medicaid would cause Texas to lose over $16 billion a year (at 2009 levels) in our federal matching funds — the number one source of federal dollars in our state budget. We would lose federal funding for over two-thirds of Texans in nursing homes, over 55 percent of Texas births, for virtually all residential services and community services and supports for Texans with disabilities, and health coverage for the nearly 3 million Texas children covered today by Medicaid and CHIP.

News coverage also quickly reflected the alarm of Texas health care leaders at the notion of a Medicaid apocalypse including the president of the Texas Medical Association, and the heads of state associations representing nursing facilities, community health centers, family physicians, and hospitals. Most colorfully, Dr. Ron Anderson, President and Chief Executive Officer of Parkland Hospital System, went on Dallas radio to call the concept “so bizarre as to be unworthy of consideration.”

The Governor’s book tour comments were followed a few weeks later — coincidentally it appears — by the scheduled release of a report mandated under 2009 state law which directed the Texas Health and Human Services Commission (THHSC) to study “the effect on the health care infrastructure in the state if the state Medicaid program is abolished, or a severe reduction in federal matching money under the program occurs.” That report underwent some late revisions to directly address the new question of a state-initiated, (rather than federally-driven) Medicaid withdrawal.

The report from our state Medicaid agency is a very good and helpful compilation of important information. Like earlier reports by Wyoming and Nevada, the Texas report lays out in detail the critical role of the federal-state Medicaid partnership in caring for poor and low-income Texans who have disabilities or are over age 65, providing prenatal care and delivery services, supporting safety-net hospitals in managing the burden of Texas’ 6.4 million uninsured, and providing comprehensive health care for millions of Texas children. The report details the expected “down sides” to shutting down Texas Medicaid, among them:

– The loss of a significant chunk of our state’s health care economy — with no offsetting reduction in federal taxes. Medicaid and CHIP spending accounts for over 15 percent of Texas health care.
– Most former Texas Medicaid enrollees would be uninsured. Seniors and other Medicare dual eligibles would remain insured by Medicare but would lose their Medicaid wrap-around coverage or assistance with out-of-pocket costs; the relatively small share of Texas Medicaid enrollees with incomes above 133 percent FPL (largely long-term care recipients) plus children in Texas CHIP could enroll in the Exchange. (The agency expects that interpretation of ACA will not allow for persons defined as Medicaid eligible in that law to qualify for Exchange premium tax credits.)
– THHSC estimates an annual increase of $4 billion or more in uncompensated hospital care due to emergency admissions to former Medicaid enrollees. Substantial cost-shifting to county governments and hospitals for care to these newly-uninsured would occur.
– The addition of such a large group of uninsured (another 2.6 million or more) to Texas already-huge 6.4 million uninsured (2009 Census CPS) could trigger a serious adverse selection crisis in Texas’ commercial insurance market, by adding to the estimated $1,551 in annual excess premium costs already being borne by insured Texas families.
– The state’s share of Medicaid spending would be just enough to continue longer-term care (community and institutional) and coverage for children in foster care, with no net savings and all of the negative effects and risks described above.

The report doesn’t neglect the conservative point of view. The agency proposes several scenarios for major future changes to Medicaid, most of which would require major federal law changes. They include:

– A “consolidated annual funding” approach to Medicaid, much like the per-capita cap proposals of the 1990s, would be a block grant that would growth annually based on inflation, population growth, “and other factors.” The agency envisions that states would have fewer floors on who is covered and what services they get than in today’s federal Medicaid law.
– The current formula for “FMAP” is criticized for failing to take into account relative poverty and uninsured rates across the country.
–Texas could pursue an 1115 waiver to allow clients to buy high-deductible coverage linked to a health savings account.
– Texas could pursue federal law changes to allow states to provide more limited “benchmark” benefits to low-income children and pregnant women.
– The federal government should pay 100 percent of the costs of Medicaid emergency care as well as other uncompensated care provided to undocumented residents.
–The Affordable Care Act’s maintenance of effort that prevent Medicaid and CHIP eligibility rollbacks should be waived or eliminated

Affordable Care Act impact revisited.
The report also revisits THHSC’s early (and high!) estimates of the Medicaid-related state budget costs expected to accompany Affordable Care Act implementation. The agency notes that excluding some of their earlier worst-case assumptions (e.g., assuming the state will assume 100 percent of the costs of Medicaid primary care rate increases from 2015 forward) reduces their net state-dollar cost projection to $5 billion for 2014 to 2019. The report notes that THHSC’s $5 billion net cost estimate (which assumes 91-94 percent take-up rates in the expanded Medicaid coverage of adults, offset by $760 million in additional Medicaid managed care premium tax collections) is still higher than the Kaiser Foundation-Urban Institute analysis that projected a high-end state cost from 2014-2019 of $4.5 billion — largely due to the latter’s much lower 75 percent take-up assumption.

THHSC’s report did not mention the over $74 billion in federal matching funds that would accompany the new Texas Medicaid spending, and declined to assume any economic multiplier effect from those dollars. They did note that short-term multipliers (such as the 3.64 used by Families USA) are assumed by some economic models, but they also note an unpublished report from two economists which asserts that “every $200 million in federal matching funds reduces gross state product by $1.8 billion, a multiplier of -9.0.”

Medicaid Red Herring?
The report points to the need for Medicaid’s “unsustainable” growth rate to be controlled to keep it within population, general inflation, and GDP growth. This argument, while not without merit, points to perhaps the most serious problem with this highly politicized discourse around state Medicaid spending. The “Medicaid Opt-out” talking point is based on and reinforces a misperception; namely, that Medicaid is uniquely troubled by rising care costs. In reality, the CBO reports that growth rates for Medicare, Medicaid, and “All Other” U.S. health spending have out-stripped GDP growth consistently since 1975. Medicare logged the highest cost growth in excess of GDP, and Medicaid “tied” with All Other health spending over that entire period, despite having grown at a much slower rate than the rest of the system since 1990.

As a nation, we face a serious challenge of reining in health spending growth across our entire population and economy, not just in Medicaid. The “adult conversation” we need to have on reducing federal deficits and debt can’t take place as long key leaders believe they can solve the nation’s health care and debt challenges simply by cutting or eliminating Medicaid.

What we are Learning.
Perhaps the experiences of Wyoming, Nevada and Texas will be enough to dissuade other states from traveling too far down the Opt-Out road. But if those too-good-to-be-true talking points (Drop Medicaid! Save Money!, Nobody Gets Hurt!) do arrive in your state, be prepared to seize the teachable moment and help tell the real story of Medicaid and CHIP. It is so important that the new round of freshman lawmakers get the facts about Medicaid and CHIP’s critical role in caring for Americans. In the process, you can not only protect your state’s most vulnerable citizens, but also raise critical awareness that real solutions to our country’s health care spending woes will only come from hard work that looks across all populations and sources of coverage.

– Anne Dunkelberg, guest blogger
Center for Public Policy Priorities, Texas

But even more extraordinary was the finding on coverage for children. For kids, the 2010 insurance rate is an astonishing 99.8 percent — essentially universal coverage. Children’s health advocates in Massachusetts, who have been steadily working on step-by-step improvements to kids coverage programs, cheered the unprecedented results. We also reflected on how we achieved such success, and how our lessons can apply nationally.

We would identify three critical factors to the growth in children’s coverage:

1. A strong base of public programs: Massachusetts has long been among the leaders in state public programs for children. Our 1996 legislation that expanded Medicaid eligibility for children up to 200 percent of the federal poverty level (FPL) inspired Senator Kennedy to introduce the federal CHIP law. Then in 2006, the state went further and expanded MassHealth, the state’s combined Medicaid and CHIP program, to all children in families earning up to 300 percent FPL. As a result, children’s enrollment grew from 435,000 in June 2006, to 529,000 today. In addition to MassHealth, the state also operates the Children’s Medical Security Plan, which provides basic pediatric primary care to all uninsured children ineligible for MassHealth due to immigration status or income. As a result, all children in Massachusetts are eligible for a public health care program.
2. Extensive Community-based Outreach: Massachusetts put significant resources into outreach and enrollment assistance, using both a top-down and bottom-up approach. The top-down effort included mass media ads and partnerships with local icons such as the Boston Red Sox. These were somewhat targeted to the low-income and minority community; for example, bus and subway ads were placed on urban lines. The ads were augmented by grants to dozens of community organizations, focusing in areas of high uninsurance, particularly minority and non-English speaking communities. Urban Institute researcher Stan Dorn evaluated the program and found that “these ‘mini-grants’ helped develop a cadre of agencies and individuals who were knowledgeable about the state’s health coverage programs, trained in using the Virtual Gateway [online enrollment system] to complete applications on behalf of consumers, and skilled in culturally and linguistically competent strategies for working with diverse, low-income families.” We learned that having a trusted advisor from one’s own community is critical to build the confidence required to enter the enrollment process.
3. Spill-Over from the Individual Mandate: While children are not included under the Massachusetts mandate, the extensive attention paid to the need for insurance coverage led many parents to enroll their children. The mandate sets up a social expectation that everyone in the Commonwealth should have health insurance coverage — kids, too. While much of the growth in coverage in Massachusetts was among groups exempt from the mandate — low-income adults and children, the cultural force of the mandate provided the backdrop to encourage enrollment.

We still have more to do to improve children’s health in Massachusetts. The enrollment system could be made accessible, notices could be simpler, and gaps in coverage filled. But this week, kids advocates basked in the knowledge that universal coverage for children is not a dream. If we can do it, the rest of the nation can too. Let’s get to work.

– Brian Rosman, Guest Blogger
Research Director, Health Care for All Massachusetts