Dr. Kiame Mahaniah, Secretary
Executive Office of Health and Human Services
1 Ashburton Place
Boston, MA 02108
Re: PUBLIC NOTICE: Termination of MassHealth’s “TANF and EAEDC Recipients” 1115 Demonstration Expenditure Authority and the Transition and Phase-Out Plan
Dear Secretary Mahaniah:
On behalf of Children’s HealthWatch, we write in strong opposition to MassHealth’s proposal to end automatic eligibility for TAFDC and EAEDC recipients effective December 31, 2027. This change will affect children and families across the Commonwealth, jeopardizing healthcare continuity and coverage for approximately 120,000 of our lowest-income residents.
Children’s HealthWatch is a nonpartisan network of pediatricians, public health researchers, and policy experts who examine how policy decisions affect the health and well-being of young children and their families. We accomplish this by interviewing caregivers of young children under age four in emergency departments and primary care clinics in four U.S. cities: Boston, MA; Minneapolis, MN; Little Rock, AR; and Philadelphia, PA. Headquartered at Boston Medical Center, since 1998, we have interviewed more than 80,000 caregivers, and have analyzed those data to determine the impact of policy decisions on the health and development of young children.
Access to Healthcare is Essential for Child and Family Health
Research has repeatedly demonstrated that access to affordable, comprehensive health care is critical for young children and their parents’ overall health. As pediatricians and child health researchers, we are acutely aware of this.i When health care services are affordable and accessible, children are more able to access needed care, including preventive services such as well child visits and immunizations. Research shows that Medicaid coverage in childhood is associated with improved health, educational, and financial outcomes throughout the life course.
Conversely, when families are unable to afford care, they may be forced to forgo needed healthcare or prescriptions, or sacrifice paying for other basic needs – such as rent, food, or utilities – in order to pay for medical care or prescriptions (known as “health cost sacrifices”). Children’s HealthWatch research shows that an experience of health care hardship – forgone health care and/or health cost sacrifices – is associated with worse health for both parents and children, greater risk for child developmental delays, and a greater likelihood of child hospitalizations. Moreover, immigrant families and Black and Latine families are more likely to face health care hardships than US-born or white immigrant families. Families who experience health care hardships also frequently report other material hardships – including food insecurity, housing instability, and energy insecurity – which, in turn, are known risk factors for poor child and adult health with consequences across the lifespan.
Administrative Burdens Make our Safety Net Less Effective
Programs like MassHealth and TANF serve complementary roles in meeting families’ needs. However, applying and recertifying for these essential programs can be extremely intensive, requiring families to repeatedly submit personal details to multiple state offices throughout the year. Black and Latine parents, those who have immigrated to the US, and those whose primary language is not English face additional barriers to enrollment, with roots in structural racism.ii As a result, only a fraction of those eligible for programs like MassHealth and TANF are enrolled, and many families experience enrollment gaps, where they do not enroll in the full suite of programs for which they are eligible.
This gap is well-documented, and results in severe consequences.iii, iv For families, not participating in programs for which they are eligible increases risk of experiencing economic hardship, which contributes to poor health outcomes across the lifespan.v Research, including from Children’s HealthWatch, has demonstrated that experiencing poverty in childhood increases risks of infant mortality, impaired cognitive and socioemotional development, chronic disease, and reduced academic readiness. Due to critical windows of human development, poverty is especially consequential if experienced in the first 1,000 days of life, when 80% of the brain develops.
For the healthcare system, when patients arrive in the emergency room with health complications that can arise from economic hardship, such as worsened hypertension due to lack of ability to pay for medication or healthcare visits, the level of care needed to treat and stabilize the patient is high. The cost of increased staffing, more advanced medical interventions, and potential
hospital stays are considered “avoidable” costs because they are preventable if the condition is addressed before the symptoms of disease progress. Estimates suggest economic hardship drives billions of dollars in avoidable costs annually in just the Commonwealth alone. These costs do not just affect patients experiencing economic hardship, but everyone. Healthcare is inherently a system of pooled risk, with the cost of care needed to care for sicker patients passed onto all patients via increased health insurance premiums and increased cost at point of service. And for society at large and our communities, when families do not get the economic supports they need, our communities lose the human capital and productive capacity of both parents unable to participate fully in the workforce and children whose health and development are compromised.
Common applications help to overcome some of the administrative burdens families experience when enrolling and accessing programs like MassHealth and TANF. Successful common application systems require sustained investment across agencies, and feedback mechanisms with staff, nonprofits, and participants. Implementation succeeds when states secure leadership buy-in, allow adequate time for iteration and testing, establish clear accountability structures, and engage dedicated technology, policy, and program experts. This coordinated approach helps reduce the complex burden families face when enrolling in programs like MassHealth and TANF.
We urge MassHealth and DTA to adopt the following measures to protect continuity of healthcare coverage during this transition:
- First, the Commonwealth must allocate additional resources to the Department of Transitional Assistance (DTA) to serve the children and families at risk of losing MassHealth coverage. The DTA workforce is already under immense strain due to added complexities from H.R. 1, and not enough caseworkers to serve TAFDC and EAEDC participants.
- Second, to overcome some of these staffing shortages, MassHealth should establish a dedicated unit of staff and a specific phone line exclusively for TAFDC and EAEDC participants who need to reapply for MassHealth coverage.
- Third, DTA should implement a formal “warm handoff” process connecting residents directly — in real time, while on the phone with a DTA caseworker — to a MassHealth caseworker to initiate the application process.
- Finally, DTA must communicate clearly, proactively, and in multiple languages about these changes and available resources across all channels, including notices, website, text, email, and application and reevaluation materials. Research demonstrates institutional outreach that meets participants where they are may be effective in improving trust in government overall and in governmental services.
Ending Automatic Enrollment Poses Significant Future Health and Economic Costs
We understand the intense fiscal challenges states are facing in the aftermath of H.R. 1. The current federal administration has made policy choices that will harm millions of children and families across the United States, while furthering wealth and income inequality at the behest of corporate interests. However, while state budgets are tight, families’ budgets are even tighter. We need state leadership to step into these challenges with the health and well-being of our children at the forefront.
Families participating in TAFDC are our Commonwealth’s lowest-income residents. Removing automatic enrollment for these families will add additional bureaucratic hurdles to a population already experiencing economic hardship, and, as research demonstrates, a population at increased risk of poor health outcomes. Should families fall off of MassHealth due to these increased burdens, health outcomes will worsen, and become more expensive to care for and treat, and their quality of life will decrease.
Pediatricians alone cannot prevent or treat the health consequences that derive from inconsistent access to healthcare. We need to work in partnership with state leadership to ensure all children and families in Massachusetts are able to access the healthcare they need to grow and thrive.
Sincerely,
Stephanie Ettinger de Cuba, PhD, MPH, Executive Director, Children’s HealthWatch
Richard Sheward, MPP, Director of System Implementation Strategies Children’s HealthWatch
Carley Ruemmele, MPH, Research and Policy Analyst Children’s HealthWatch
i Cook JT, Frank DA, Berkowitz C, et al. Welfare reform and the health of young children: a sentinel survey in 6 US cities. Arch Pediatr Adolesc Med. 2002;156(7):678-68
ii Bovell-Ammon A, Ettinger de Cuba S, Lê-Scherban F, Rateau L, Heeren T, Cantave C, Green KA, Frank DA, Cutts D, Ochoa E, Sandel M. Changes in Economic Hardships Arising During the COVID-19 Pandemic: Differences by Nativity and Race. J Immigr Minor Health. 2023 Apr;25(2):483-488. doi: 10.1007/s10903-022-01410-z. Epub 2022 Nov 5. PMID: 36334182; PMCID: PMC9638452.
iii Yamauchi M, Carlson MJ, Wright BJ, Angier H, DeVoe JE. Does health insurance continuity among low-income adults impact their children’s insurance coverage? Matern Child Health J. 2013;17(2):248-255.
iv Shen Y, Sommers BD, Hatfield LA, Hayes C, Pandya A, Menzies NA. Insurance Dynamics During Childhood in the Fragmented US Health System. JAMA. 2025;334(17):1533–1540. doi:10.1001/jama.2025.15488
v Black MM, Cutts DB, Frank DA, et al. Special Supplemental Nutrition Program for Women, Infants, and Children Participation and Infants’ Growth and Health: A Multisite Surveillance Study. Pediatrics. 2004;114(1):169-176.