time, the Medicaid program had been increasing by 22 percent annually for the previous 4 years. In the late 1980s, an estimated 90,000 children were uninsured, and by 1995, that number had grown to 160,000 despite Medicaid expansions for children (Greenberg and Zuckerman, 1997).

In 1996, the Massachusetts legislature passed the Access to Health Law, expanding Medicaid coverage for children and modifying CMSP to reach low-income children not covered by Medicaid. Previous legislation mandating that employers provide coverage or contribute to a state fund was scheduled for implementation in August 1996, and pressure from businesses had generated interest in either repealing the mandate or replacing it with an alternative, more limited program (Greenberg and Zuckerman, 1997).

Children's health insurance expansions in Massachusetts have been financed through a reallocation of the state's pool of money for uncompensated care and through a 25-cent increase in the cigarette tax (Greenberg and Zuckerman, 1997). In Massachusetts, the Medicaid program is available to uninsured children and adults with incomes up to 133 percent of the federal poverty level. All other children are eligible for CMSP, which provides a limited package of primary and preventive care services. Inpatient hospital care is not covered, and coverage for prescription drugs and mental health is limited.

We found extraordinary political salience in linking children's health and tobacco taxes. People generally look at tobacco taxes differently than any other kind of tax, and most of the public generally like raising cigarette taxes. When you link it with using the funds to buy health care for children, the support just simply goes through the roof.

John McDonough

Massachusetts House of Representatives, Boston, MA

Public Workshop, June 2, 1997

CMSP is partly supported by participant cost-sharing. For families with incomes of up to 200 percent of the poverty level, participation is free. Families with incomes of between 200 and 400 percent of the federal poverty level may buy into CMSP for a monthly premium of $10.50 per child. Families with incomes higher than 400 percent of the federal poverty level pay the full cost of about $52.50 per month (Johnson and McDonough, 1998).

Through 1997, CMSP had covered 31,000 children up to age 19. The program is administered separately from the Medicaid program, and the application, enrollment determination, and outreach staff are different. Because families must apply to different agencies to enroll in the two programs, it is difficult for families to make transitions between the programs when their financial circumstances change. However, the separation of programs has made CMSP more appealing to families who prefer to avoid a welfare program, even though the Medicaid benefits are much more extensive and cost-sharing is greater with CMSP (McDonough, 1997).

Minnesota Care and Children's Health Plan

Minnesota's Children's Health Plan was one of the first state-financed programs to subsidize coverage for children. In 1987, the Minnesota legislature allocated a 1-cent increase in the cigarette tax to help finance the development of the Children's Health Plan. The program was implemented in July 1988, and in 1992, it was incorporated into Minnesota Care, the state's subsidized health insurance program for individuals who are not eligible for Medicaid. As of March 1997, Minnesota Care covered 53,000 children under the age of 21, or approximately 40 percent of the uninsured children in Minnesota (Gauthier and Schrodel, 1997).

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