"The Cycle of Uninsurance" by Christina Severin

8-21-2008 - Statement from Network Health:

"Unfortunately, Network Health has determined that a recent a survey of former Network Health Commonwealth Care members, which was administered by a third party, was not conducted in a statistically valid manner.

As a result, Network Health can no longer stand behind the article listed below or the survey upon which it was based.

Network Health apologizes to the readers of this blog for publishing a flawed article.

Network Health remains committed to working with MassHealth and the Commonwealth Connector on the continued successful implementation of the state’s historic health reform law."

7-29-2008 - Original Post:As you know from my previous posts, the “churn” of still-eligible MassHealth and Commonwealth Care members on and off their coverage is a topic of great interest and concern of mine. I focus on it because it’s antithetical to what our commonwealth has embraced in creating the health reform law and mandating insurance coverage for all Massachusetts residents. And, not only does churn self-perpetuate the problem of the uninsured in Massachusetts, I also believe that it creates lost opportunities for care management and critical gaps in care, and is a waste of time, energy, and money for the state, for members, for health care providers, for health plans, and for taxpayers. In the words of one recently disenrolled Commonwealth Care member, “If the state is going to insist that you have health insurance, they should make it easier to keep it.”

The goal of reform efforts is continuous insurance coverage of nearly all Massachusetts residents. Yet, in a recent survey we conducted of nearly 400 recently disenrolled Network Health Commonwealth Care members, more than 40 percent told us they do not have health insurance since losing Commonwealth Care (!!). Of that 40 percent without coverage, nearly 20 percent said they did not know why they lost their Commonwealth Care coverage. As one survey respondent said, “I am very interested in knowing why I was cut from the plan. I never got a reason.”

Nearly 45 percent of respondents reported they did not receive paperwork from the state asking for information prior to their disenrollment. Of those who did receive paperwork, nearly one in 10 said they did not understand it. Illustrating the numerous points of confusion that can occur, one respondent told us, “It was a mistake in my paperwork; they thought I had insurance through my job, but it’s a temp position.”

And, some additional comments from disenrolled members who are now without any coverage, in their own voices:
• ”I don’t have care and can’t afford to make a doctor’s appointment.”
• “I went out of my way to return the paperwork on time, and I am very frustrated that they say they didn’t get it.”
• “We called them because we had no insurance, and we had to re-apply again.”
• ”I am in the hospital right now, and I am not able to pay the bill.”
• “I was in the hospital and missed the deadline.”
• “I sent in the paperwork, and they said I have access to other insurance when I don’t.”
• “They said I had access to other insurance, but I don’t work enough hours a week to get their insurance.”

In this survey, we heard some predictably unfortunate results about the consequences of missed coverage. More than 20 percent missed doctors’ appointments and nearly that many missed medical treatments; 28 percent had problems getting or paying for medicine. Most disturbing as we think about the broader context of rising health care costs is that 13 percent went to the emergency room for care.

Again, in their own voices, here are a few anecdotes about what those numbers mean for some of these folks:
• “I have a $500 expense for medications that I still owe to the pharmacy.”
• “I have chronic liver disease and now I am unable to receive treatment.”
• “I was too afraid of what it cost so when I got sick, I didn’t even go to the doctor’s.”
• “My doctor treated me without charging me for the visit.”
• “Prescriptions were the biggest problem. I still owe the pharmacy money.”
• ”I could not afford birth control pills — now I am pregnant, and I lost my PCP.”
• “I owe money; I am not able to afford medicine.”

We know churn is an established problem; what about solutions? There are some that would make a difference.

• Better communication
First and foremost, the Connector may want to look again at any opportunities to further simplify and clarify the language they use in any critical notices, and to produce them in members’ own languages. Several disenrolled individuals reported they couldn’t read or understand English well enough to respond. It also may mean trying additional communication methods; nearly 52 percent of those we talked to said they had an e-mail account, and the vast majority of those (91 percent) said they check e-mail daily or weekly. Let’s try communicating with people in the methods they want to use!

• Allow more time for paperwork and documentation completion and submission
Recently, the time frame for members to respond was changed from 60 days to 45. This was done for budgetary purposes, as it would knowingly increase the volume of involuntary disenrollments; let’s change it back.

• Let more people help
Health plans know their members and are eager to keep them, so why don’t we partner with providers and the state to keep eligible members continuously covered? With 43 percent of those surveyed saying they didn’t receive information — and this is undoubtedly a tough group to keep connected, as some move and change phone numbers frequently — it will require multiple attempts in multiple ways to keep this vulnerable population covered. The Connector could also dedicate resources to disenrolled members to ensure that disenrolled people get the help they need to ensure continuity of health care coverage. Since they are currently doing the work to reinstate these members who never should have been disenrolled in the first place, why not invest that work upfront to reduce hassle and unintended costs of disrupted coverage?

There’s a lot of heated debate right now about the plan to come up with additional dollars in the state budget to fund the Commonwealth Care program for FY09. The state is looking to assess health plans and employers $71 million more to fund health reform. Part of the funding need is based on FY09 Commonwealth Care membership projections of 225,000; however, is this really a reasonable projection given the level of churn we are seeing right now? The Commonwealth Care program has not grown in more than seven months, as ever slightly more members get terminated from the program than enrolled in the program.

Whatever the methods, we must work toward solutions that keep the people truly eligible engaged in coverage. That is the mandate of health care reform.

Christina Severin is executive director of Network Health, a health plan with nearly 160,000 MassHealth and Commonwealth Care members across Massachusetts.