Background: Retaining eligible children in public insurance is of rising concern as pediatric Medicaid/CHIP enrollment has declined in recent years. Any gaps in coverage, even short ones, lead to unmet healthcare needs for children. This coverage “churning” is also costly for public programs. Understanding program churning will be critical to prevent widening of health disparities as North Carolina (NC) is poised to implement dramatic payment and care delivery reforms, including the value-based Integrated Care for Kids model.
Objectives: To describe rates and disparities in Medicaid coverage churning among NC children.
Methods: Children enrolled in NC Medicaid on January 1, 2016 (N=1,196,127) were included and followed until December 31, 2018. We used the Kaplan-Meier estimator to calculate the probability of continuous enrollment and the time to reenrollment among those with a coverage gap of ≥1 month. Children who reenrolled within 6 months of disenrollment were assumed to have been continuously eligible for coverage and were classified as having experienced churning. Disparities in churning were assessed by demographic characteristics.
Results: 90.4% of children remained continuously enrolled for 1 year, 81.3% for 2 years, and 73.6% for three years. Adolescents ages 16-18 were less likely to remain continuously enrolled for 2 or 3 years (60.2-73.4%) compared to younger children. Among children who experienced a coverage gap (N= 315,217), 17.0% churned (i.e., reenrolled within 6 months), 9.2% reenrolled within 7-11 months, and 73.8% did not reenroll for one year or more. Of the White children who experienced a coverage gap, 13.8% (95% CI: 13.6, 14.0) reenrolled within 6 months compared to 17.7% (95% CI: 17.4, 18.0) of Black children and 23.0% (95% CI: 22.7, 23.3) of Hispanic/Latinx children. Program churning was higher in children living in urban areas (20.4% [95% CI: 20.1, 20.7]) compared to those living in rural (17.4% [95% CI: 17.1, 17.6]) and suburban (17.8% [95% CI: 17.5, 18.2]) areas.
Conclusions: Most Medicaid insured children remained continuously enrolled for at least a year with almost 75% experiencing 3 years of continuous enrollment. Among children who experienced a coverage gap, 17% churned with reenrollment within 6 months. Higher rates of churn among minority children and children living in urban areas can inform how the allocation of limited resources to reduce coverage instability.