Medicaid's Problem Children: Eligible but Not Enrolled

Health Affairs

Volumn 17, Issue 3, 1998, Pages 192-200

  Selden, Thomas M ^a   Banthin, Jessica S ^a   Cohen, Joel W ^a  

^a AGENCY FOR HEALTHCARE RESEARCH AND QUALITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADOLESCENT; ARTICLE; CHILD; CHILD HEALTH CARE; ECONOMICS; FEMALE; HEALTH CARE DELIVERY; HEALTH CARE PLANNING; HEALTH CARE POLICY; HEALTH INSURANCE; HUMAN; INFANT; INSURANCE; LEGAL ASPECT; MALE; MEDICAID; ORGANIZATION AND MANAGEMENT; PATIENT; PRESCHOOL CHILD; PUBLIC RELATIONS; STATISTICS; UNITED STATES;

ADOLESCENT; CHILD; CHILD HEALTH SERVICES; CHILD, PRESCHOOL; COMMUNITY-INSTITUTIONAL RELATIONS; ELIGIBILITY DETERMINATION; FEMALE; HEALTH POLICY; HEALTH PRIORITIES; HEALTH SERVICES ACCESSIBILITY; HUMANS; INFANT; INSURANCE COVERAGE; INSURANCE, HEALTH; MALE; MEDICAID; MEDICALLY UNINSURED; UNITED STATES;

EID: 0032062045     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.17.3.192     Document Type: Article

References (37)

1. J. Vistnes and A. Monheit, Health Insurance Status of the Civilian Noninstitutionalized Population: 1996, MEPS Research Finding no. 1, Pub. no. 97-0030 (Rockville, Md: Agency for Health Care Policy and Research, 1997).
2. R. Pear, "Clinton Ordering Effort to Sign Up Medicaid Children," New York Times, 29 December 1997, A1.
3. S. Rosenbaum et al., "The Children's Hour: The State Children's Health Insurance Program," Health Affairs (January/February 1998): 75-89.
4. L. Dubay and G. Kenney, "The Effects of Medicaid Expansions on Insurance Coverage of Children," The Future of Children 6, no. 1 (1996): 152-161; P. Purcell, "Medicaid Enrollment of Children Not Receiving Cash Welfare Payments" (Unpublished manuscript, AHCPR, Rockville, Maryland, 1996); and L. Shore-Sheppard, "Stemming the Tide? The Effect of Expanding Medicaid Eligibility on Health Insurance Coverage," Working Paper 361 (Princeton, N.J.: Industrial Relations Section, Princeton University, 1995).
5. L. Dubay and G. Kenney, "The Effects of Medicaid Expansions on Insurance Coverage of Children," The Future of Children 6, no. 1 (1996): 152-161; P. Purcell, "Medicaid Enrollment of Children Not Receiving Cash Welfare Payments" (Unpublished manuscript, AHCPR, Rockville, Maryland, 1996); and L. Shore-Sheppard, "Stemming the Tide? The Effect of Expanding Medicaid Eligibility on Health Insurance Coverage," Working Paper 361 (Princeton, N.J.: Industrial Relations Section, Princeton University, 1995).
6. L. Dubay and G. Kenney, "The Effects of Medicaid Expansions on Insurance Coverage of Children," The Future of Children 6, no. 1 (1996): 152-161; P. Purcell, "Medicaid Enrollment of Children Not Receiving Cash Welfare Payments" (Unpublished manuscript, AHCPR, Rockville, Maryland, 1996); and L. Shore-Sheppard, "Stemming the Tide? The Effect of Expanding Medicaid Eligibility on Health Insurance Coverage," Working Paper 361 (Princeton, N.J.: Industrial Relations Section, Princeton University, 1995).
7. L. Summer, S. Parrott, and C. Mann, Millions of Uninsured and Underinsured Children Are Eligible for Medicaid (Washington: Center on Budget and Policy Priorities, 1997). The authors use data from the Current Population Survey (CPS) to estimate that there were 2.7 million Medicaid-eligible but uninsured children age ten and under in 1994. The corresponding estimate by the U.S. General Accounting Office, Health Insurance for Children: Private Insurance Coverage Continues to Deteriorate, Pub. no. HEHS-96-129 (Washington: GAO, 1996), is 2.9 million eligible but uninsured children.
8. L. Summer, S. Parrott, and C. Mann, Millions of Uninsured and Underinsured Children Are Eligible for Medicaid (Washington: Center on Budget and Policy Priorities, 1997). The authors use data from the Current Population Survey (CPS) to estimate that there were 2.7 million Medicaid-eligible but uninsured children age ten and under in 1994. The corresponding estimate by the U.S. General Accounting Office, Health Insurance for Children: Private Insurance Coverage Continues to Deteriorate, Pub. no. HEHS-96-129 (Washington: GAO, 1996), is 2.9 million eligible but uninsured children.
9. S. Rosenbaum and J. Darnell, An Analysis of the Medicaid and Health-Related Provisions of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Washington: Kaiser Commission on the Future of Medicaid, 1997).
10. The Family Support Act of 1988 mandated that all states implement the AFDC-Unemployed Parents provision, granting cash assistance and Medicaid coverage to intact families in which income is below the AFDC payment threshold and the primary wage earner is unemployed. This act also extended Medicaid coverage for twelve months to families that lose AFDC assistance because of increased earnings.
11. Round 1 began 1 January 1996 and ended at the interview date (between March and July 1996).
12. See J. Cohen et al., "The Medical Expenditure Panel Survey: A National Health Information Resource," Inquiry (Winter 1996/97): 373-389; and S. Cohen, "Sample Design of the 1996 Medical Expenditure Panel Survey Household Component," MEPS Methodology Report no. 2, Pub. no. 97-0027 (Rockville, Md.: AHCPR, 1997).
13. See J. Cohen et al., "The Medical Expenditure Panel Survey: A National Health Information Resource," Inquiry (Winter 1996/97): 373-389; and S. Cohen, "Sample Design of the 1996 Medical Expenditure Panel Survey Household Component," MEPS Methodology Report no. 2, Pub. no. 97-0027 (Rockville, Md.: AHCPR, 1997).
14. Although some Medicaid-eligible children may be in families headed by elderly persons, we do not yet have access to the pension data that would enable eligibility simulation. We excluded children in military families because they would be covered by military health insurance and thus were unlikely to have been eligible for Medicaid.
15. We use wage and self-employment earnings from all jobs as of the interview week, imputing values for self-employed adults and for cases in which earnings data were missing for other employed adults. Data on unearned income will not be available until fall 1998. Ignoring unearned income may tend to increase the number of children deemed eligible, but we do not believe that the magnitude of this bias is large, since cash transfers and earned income tax credits, the largest sources of unearned income among the population of interest, are disregarded for determining eligibility (as is a portion of child support payments). To examine the magnitude of the bias from ignoring the remaining unearned income components, we simulated eligibility using data from the 1987 National Medical Expenditure Survey (NMES) with and without unearned income, finding only a 3 percent difference in the total estimate of Medicaid-eligible children. We used earnings as of the interview week rather than full-year earnings measures. This approach may have advantages over full-year measures (as in studies using the March Current Population Surveys), since Medicaid eligibility can change during the year.
16. We assumed that child care payments were $100 (1996 dollars) per month per child age ten and under in families in which the family head and all other members over age eighteen were employed (up to a maximum of $250 per family). Similarly, we subtracted from earned income $90 per month of employment-related expense for each employed adult.
17. We do not yet have the MEPS asset data and thus could not apply asset tests to determine eligibility. Experiments with random assignment of assets revealed that this is unlikely to be a significant source of bias.
18. We focused on Medicaid programs, ignoring state-only plans.
19. Note that the three eligibility categories constitute a hierarchy, so that eligibility definitions do not overlap. Also, as in any attempt to simulate Medicaid eligibility, some children who were simulated to be ineligible for Medicaid were nevertheless observed to have Medicaid coverage at some point during the round (see Exhibit 3). Some children may be in families that had low earnings at the beginning of the round but higher earnings by the interview date, which led us to deem them ineligible. Misclassifications can also occur because our eligibility simulator does not account for continuation of benefits. Nor did we simulate eligibility based on disability status or medically needy spend-down provisions.
20. J. Holohan, C. Winterbottom, and S. Rajan, "A Shifting Picture of Health Insurance Coverage," Health Affairs (Winter 1995): 253-264; L. Ku, M. Ellwood, and J. Klemm, "Deciphering Medicaid Data: Issues and Needs," Health Care Financing Review (Annual Supplement 1990): 35-45; Dubay and Kenney, "The Effects of Medicaid Expansions on Insurance Coverage of Children;" and Shore-Sheppard, "Stemming the Tide?"
21. J. Holohan, C. Winterbottom, and S. Rajan, "A Shifting Picture of Health Insurance Coverage," Health Affairs (Winter 1995): 253-264; L. Ku, M. Ellwood, and J. Klemm, "Deciphering Medicaid Data: Issues and Needs," Health Care Financing Review (Annual Supplement 1990): 35-45; Dubay and Kenney, "The Effects of Medicaid Expansions on Insurance Coverage of Children;" and Shore-Sheppard, "Stemming the Tide?"
22. J. Holohan, C. Winterbottom, and S. Rajan, "A Shifting Picture of Health Insurance Coverage," Health Affairs (Winter 1995): 253-264; L. Ku, M. Ellwood, and J. Klemm, "Deciphering Medicaid Data: Issues and Needs," Health Care Financing Review (Annual Supplement 1990): 35-45; Dubay and Kenney, "The Effects of Medicaid Expansions on Insurance Coverage of Children;" and Shore-Sheppard, "Stemming the Tide?"
23. See, for instance, K. Swartz, "Interpreting the Estimates from Four National Surveys of the Number of People without Health Insurance," Journal of Economic and Social Measurement 14, no. 3 (1986): 233-256; and A. Monheit, "Underinsured Americans: A Review,"Annual Review of Public Health 15 (1994): 461-485. Additional sources of error may include stigma in reporting Medicaid participation and/or the possibility that respondents simply did not know about the insurance coverage of other household members.
24. See, for instance, K. Swartz, "Interpreting the Estimates from Four National Surveys of the Number of People without Health Insurance," Journal of Economic and Social Measurement 14, no. 3 (1986): 233-256; and A. Monheit, "Underinsured Americans: A Review,"Annual Review of Public Health 15 (1994): 461-485. Additional sources of error may include stigma in reporting Medicaid participation and/or the possibility that respondents simply did not know about the insurance coverage of other household members.
25. We calculated the 4.7 percent error rate using estimates of the total number of Medicaid enrollees in 1987 from Table 2.4 in T. Coughlin, L. Ku, and J. Holahan, Medicaid since 1980: Costs, Coverage, and the Shifting Alliance between the Federal Government and the States (Washington: Urban Institute Press, 1994). We adjusted their estimates to exclude the institutionalized population using recipient counts from the Medicaid 2082 reports.
26. All results are weighted by the inverse of the probability of selection into the MEPS sample. In addition, all standard errors are corrected for the complex design of the MEPS sample and for the possibility of intrafamily correlation.
27. Only those children who were continuously without coverage for the entire round are included in the uninsured category. To offer a more complete perspective on this issue, we also calculated estimates of the number of children who were uninsured at the interview date. Our overall estimate of uninsured but Medicaid-eligible children rises to 5.5 million, with a disproportionate share of the difference between 4.7 and 5.5 million attributable to expansion-eligible children. Results are available upon request from Thomas M. Selden, Agency for Health Care Policy and Research, Center for Cost and Finance Studies, Suite 500, 2101 E. Jefferson Street, Rockville, Maryland 20852.
28. GAO, Health Insurance for Children; and Summer et al., Millions of Uninsured and Underinsured Children Are Eligible for Medicaid.
29. GAO, Health Insurance for Children; and Summer et al., Millions of Uninsured and Underinsured Children Are Eligible for Medicaid.
30. As discussed in the data and methods section, CPS estimates of uninsured children align most closely with round-level MEPS estimates. The fact that our MEPS estimates of the eligible uninsured align closely to corresponding estimates from the CPS confirms the reliability of our eligibility simulation.
31. These results parallel findings in Dubay and Kenney, "The Effects of Medicaid Expansions on Insurance Coverage of Children," and Shore-Sheppard, "Stemming the Tide?"
32. These results parallel findings in Dubay and Kenney, "The Effects of Medicaid Expansions on Insurance Coverage of Children," and Shore-Sheppard, "Stemming the Tide?"
33. R.M. Weinick, M.E. Weigers, and J.W. Cohen, "Children's Health Insurance, Access to Care, and Health Status: New Findings," Health Affairs (March/April 1998): 127-136.
34. A. Monheit and P. Cunningham, "Children without Health Insurance," The Future of Children 2, no. 2 (1992): 154-170; and G. Simpson et al., "Access to Health Care, Part I: Children," Vital and Health Statistics 10, no. 196 (Hyattsville, Md.: National Center for Health Statistics, 1997).
35. A. Monheit and P. Cunningham, "Children without Health Insurance," The Future of Children 2, no. 2 (1992): 154-170; and G. Simpson et al., "Access to Health Care, Part I: Children," Vital and Health Statistics 10, no. 196 (Hyattsville, Md.: National Center for Health Statistics, 1997).
36. Monheit and Cunningham, "Children without Health Insurance."
37. Bureau of National Affairs, "Clinton Budget Includes Outreach Funds, Cuts Federal Match for Administrative Costs," BNA's Health Care Policy Report (9 February 1998): 251-252.