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Psychiatr Serv. 2013 Apr 1;64(4):360-5. doi: 10.1176/

Sustaining enrollment in health insurance for vulnerable populations: lessons from Massachusetts.

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Since 2008 Massachusetts has had universal health insurance with an individual mandate. As a result, only about 3% of the population is uninsured. However, patients who use behavioral health services are uninsured at much higher rates. This 2011 study sought to understand reasons for the discrepancy and identify approaches to reduce disenrollment and sustain coverage.


The qualitative study was based on structured interviews and focus groups. Structured interviews were conducted with 15 policy makers, consumer advocates, and chief executive officers of provider organizations, and three focus groups were held with 33 patient volunteers.


The interviews and focus groups identified several disenrollment opportunities, all of which contribute to "churn" (the process by which disenrolled persons who remain eligible are reenrolled in the same or a different plan): missing and incomplete documentation, acute and chronic conditions and long-term disabilities that interfere with a patient's ability to respond to program communications, and lack of awareness among beneficiaries of the consequences of changes that trigger termination and the need to transfer to another program. Although safeguards are built into the system to avoid some disenrollments, the policies and procedures that drive the system are built on a default assumption of ineligibility or disenrollment until the individual establishes eligibility and completes requirements. Practices that can sustain enrollment include real-time Web-based prepopulated enrollment and redetermination processes, redetermination flexibility for designated chronic illnesses, and standardized performance metrics for churn and associated costs.


Changes in the information system infrastructure and in outreach, enrollment, disenrollment, and reenrollment procedures can improve continuity and retention of health insurance coverage.

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