Coverage of children not required in health law

The state's landmark health insurance law contains a little-known loophole: The mandate that all residents have coverage by next summer does not include children.

As a key aspect of the program starts today, some advocates for the uninsured are worried that some of the state's 40,000 to 78,000 uninsured children will remain uncovered if parents cannot afford health plans that cover their entire family.

Lower-income families can purchase inexpensive coverage for their children through Medicaid. But middle-class parents, faced with financial penalties if they go uninsured, could forgo coverage for their children that can cost hundreds of dollars extra a month.

The state Executive Office of Health and Human Services has asked the Legislature to make ``technical corrections" to the law that would, among other changes, expand the coverage mandate to children.

``Our goal is for everyone in the Commonwealth to have insurance, adults and kids," said Timothy Murphy, secretary of health and human services. ``We believed this is best accomplished with a variety of approaches, including a mandate."

Romney administration officials said it was an oversight that they did not push to expand the mandate previously. Legislative leaders said they are willing to review the issue, but that forcing parents to insure their children may be unenforceable and unnecessary, because most parents voluntarily insure their children when they buy coverage for themselves.

The law requires residents age 18 and over to have coverage by July 1 or face income tax penalties. It expands Medicaid coverage to children in families with incomes up to 300 percent of the federal poverty level -- about $60,000 annually for a family of four -- more generous than the previous limit of 200 percent. But parents are not obligated to cover their children.

The first wave of uninsured residents, 60,000 adults who earn less than the federal poverty level -- about $9,800 annually for a single person -- can start enrolling today in a fully subsidized insurance program called Commonwealth Care. Many of these residents get medical care now through the state's free-care pool, a fund that reimburses hospitals and community health centers for treating the uninsured.

On Jan. 1, the state expects to make Commonwealth Care plans available to about 150,000 residents who earn between 100 percent and 300 percent of the poverty level; for this group, subsidies will fall as income rises.

In addition to exempting children from the insurance mandate, advocates said the law leaves out several groups entirely, which could make it difficult for the state to reach its goal of insuring all residents. One of the largest groups is immigrants who are living here illegally. Legislative leaders and Murphy said undocumented immigrants cannot enroll in Commonwealth Care plans because the federal government, which is helping fund the state's program, generally does not allow federal money to be used to cover healthcare for illegal immigrants. Though illegal immigrants can continue getting emergency care through the free-care pool, the pool is expected to shrink as the state gradually shifts dollars to pay for health plan subsidies.

While state officials said they do not know the number of illegal immigrants, groups that track the population say it is large. The Pew Hispanic Center, a nonpartisan research organization in Washington, D.C., estimates that 150,000 to 250,000 undocumented Hispanic immigrants alone were living in Massachusetts in 2005.

``People come into the health center and they're ill; they have a high temperature or an injury that has to be attended," said Zoila Feldman, chief executive of the Great Brook Valley Health Center in Worcester. ``I hope the Legislature and the governor's office will be prudent enough to provide a safety net pool" of money to cover them.

Some legal residents also could find themselves without access to state-offered affordable health plans.

Workers offered health insurance subsidized by their employer in a company with 50 or more employees will not qualify for coverage through the Commonwealth Health Insurance Connector, the agency implementing the law , even though the connector's plans are likely to be cheaper than the employers'.

The exemption of children from the mandate has drawn little notice -- even some Connector executives and board members said they were unfamiliar with it.

``No one has taken responsibility for figuring out this problem, and it needs to be figured out," said Neil Cronin, a health policy analyst with Massachusetts Law Reform Institute, an advocacy organization for the poor. ``A family pushed to the wall," and faced with the threat of tax penalties, ``might be forced to say we have to buy the adults insurance but we're not legally required to cover the children."

The cost difference can be significant. A 30-year-old couple living in the Boston area, for example, would pay $827 a month for Blue Cross and Blue Shield of Massachusetts' HMO Blue, a standard plan. The plan costs $1,086 for a family with children.

John Holahan, a health policy analyst at the Urban Institute, a nonpartisan policy research organization in Washington, said he was surprised that the state did not mandate that parents cover their children. ``I thought it would have been politically easy to say that you cover your children."

But, he said, he still expects the number of uninsured children will fall, because many parents also insure their children when they buy coverage for themselves.

Representative Patricia A. Walrath, a Stow Democrat who cochaired the legislative committee that crafted the final bill, said legislators had very little discussion about whether to extend the mandate to children.

The state, she said, already offers plans that cover some children who do not qualify for Medicaid, such as a program for disabled children with large medical bills, and has a relatively low rate of uninsured children.

Just under 5 percent of Massachusetts children are uninsured, or 78,000 youngsters, compared with 11.6 percent nationally, according to Holahan, who used federal data to calculate the rate. He said most of those children live in families earning less than 300 percent of poverty level. The state uses a different methodology to count uninsured residents, and its numbers are traditionally lower than those published by the federal government. According to state figures, 2.5 percent of children, or about 40,000, are uninsured .

``Normally, parents insure their kids before they insure themselves, so it didn't seem to be at the time one of those big issues we needed to address," Walrath said. If many parents do not end up voluntarily covering their children, she added, the Legislature will have to reexamine the issue.

Brian Rossman, research director for Health Care for All, an advocacy group in Boston that pushed for passage of the law, said the group does not favor expanding the mandate to children now. He said such a change would be a burden on workers whose employers do not offer family coverage. ``Just getting the adults covered is going to be hard enough," he said.

Information on applying for Commonwealth Care is available at www.mass.gov/connector, or by calling 1-877-623-6765. Liz Kowalczyk can be reached at kowalczyk@globe.com.