Waiting in the wings: Eligibility and enrollment in the state children's health insurance program

Health Affairs

Volumn 18, Issue 2, 1999, Pages 126-133

  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; HEALTH CARE PLANNING; HEALTH CARE POLICY; HUMAN; INCOME; INFANT; INSURANCE; NEWBORN; ORGANIZATION AND MANAGEMENT; PATIENT; PRESCHOOL CHILD; STATISTICS; UNITED STATES; UTILIZATION REVIEW;

ADOLESCENT; CHILD; CHILD HEALTH SERVICES; CHILD, PRESCHOOL; ELIGIBILITY DETERMINATION; HEALTH POLICY; HEALTH PRIORITIES; HUMANS; INCOME; INFANT; INFANT, NEWBORN; INSURANCE COVERAGE; MEDICALLY UNINSURED; STATE HEALTH PLANS; UNITED STATES;

EID: 0033089143     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.18.2.126     Document Type: Article

References (38)

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. For additional details regarding the design of CHIP, see F. Ullman, B. Bruen, andj. Holahan, The State Children's Health Insurance Program: A Look at the Numbers, Occasional Paper no. 4 (Washington: Urban Institute Press, 1998) and S. Rosenbaum et al., "The Children's Hour The State Children's Health Insurance Program," Health Affairs (January/February 1998): 75-89.
3. For additional details regarding the design of CHIP, see F. Ullman, B. Bruen, andj. Holahan, The State Children's Health Insurance Program: A Look at the Numbers, Occasional Paper no. 4 (Washington: Urban Institute Press, 1998) and S. Rosenbaum et al., "The Children's Hour The State Children's Health Insurance Program," Health Affairs (January/February 1998): 75-89.
4. States allow certain amounts to be netted out of income before testing for program eligibility. Amounts disregarded in this way typically include child care costs, transportation to and from work, and child-support receipts.
5. White House, Implementation of the Children's Health Insurance Program: Six Month Progress Report, a report of the National Economic Council/Domestic Policy Council (Washington: U.S. Government Printing Office, 1998);
6. CHIP Check-Up: A Healthy Start for Children (Washington: Children's Defense Fund, 1998);
7. and National Governors' Association, Implementation of Title XXI (www. nga.org/MCH/Implementation.htm, 21 August 1998).
8. American Healthline, "Statelines-Washington: Turns Down Federal Kiddiecare Funds" (10 March 1998).
9. For full details of our methodology, see T. Selden, J. Banthin, and J. Cohen, Projecting Eligibility and Enrollment for the State Children's Health Insurance Program, Pub. no. 99-R025 (Rockville, Md.: AHCPR, 1998), available from the authors or the AHCPR Web site (www.meps.ahcpr.gov/ nmes/papers). We subset the sample to exclude children in families with elderly members or active-duty military personnel, where we define families as the household members who would be eligible for coverage under most family health insurance policies. Although some CHIP-eligible children may be in families headed by elderly persons, we do not yet have access to the pension and other retirement income data that would enable eligibility simulation for these cases. In total, we exclude observations representing approximately 0.5 million uninsured children nationwide, some of whom may be eligible for MedicaidorCHIP.
10. 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).
11. 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).
12. U.S. Bureau of the Census, Population Projections of the United States, by Age, Sex, Race, and Hispanic Origin: 1995 to 2050, Current Population Reports, P25-1130 (Washington: U.S. GPO, 1996).
13. T.M. Selden, J.S. Banthin, and J.W. Cohen, "Medicaid's Problem Children: Eligible but Not Enrolled," Health Affairs (May/June 1998): 192-200.
14. Throughout the analysis we treat family income as exogenous, whereas families may in reality adjust their incomes to gain CHIP eligibility. On the one hand, CHIP may free the families of some Medicaid-enrolled children to earn more income without losing access to publicly subsidized coverage for their children. On the other hand, some higher-income families may reduce their earnings if by doing so they are able to gain eligibility to CHIP. In both cases, the number of CHIP-eligible children would increase relative to our projections. The implicit assumption in our analysis, however, is that the value of the CHIP benefit would be too small to induce substantial numbers of additional families to respond in these ways.
15. In the first scenario we disregard child care payments of $100 (1996 dollars) per month per child age ten and under in families where the family head and all other members over age eighteen are employed (up to a maximum of $250 per family). Also, we subtract from earned income 590 per month of employment-related expense for each employed adult.
16. State plans are from NGA, Implementation of TitleXXI. In total, forty-seven states plus the District of Columbia had plans that were sufficiently developed to be included (including Wyoming and Washington, which decided not to participate in CHIP in the first year). The remaining three states were assigned the modal plan, whereby CHIP eligibility was simulated for all Medicaid-ineligible children age eighteen and under in families with incomes (net of standard disregards) below 185 percent of the poverty guidelines. For states where income disregards were not specified, we applied the same disregards that we used to simulate the federal CHIP program.
17. General Accounting Office, Health Insurance for Children: Private Insurance Coverage Continues to Deteriorate, GAO/HEHS-96-129 (Washington: GAO, 1996).
18. Also, Medicaid allows retroactive enrollment (thereby covering the preenrollment expenditures for a particular episode of care), whereas non-Medicaid CHIP programs typically do not. This might induce some families to enroll in CHIP, whereas they might not have enrolled in a plan with retroactivity.
19. CHIP Check-Up; P. Diehr et al., "Will Uninsured People Volunteer for Voluntary Health Insurance? Experience from Washington State," American Journal of Public Health 86, no. 4 (1996): 529-532; A. Gauthier and S. Schrodel, Expanding Children's Coverage: Lessons from State Initiatives in Health Care Reform (Washington: Alpha Center, 1997); L Ku and T. Coughlin, The Use of Sliding Scale Premiums in Subsidized Insurance Programs (Washington: Urban Institute, 1997); and K. Thomas, "Are Subsidies Enough to Encourage the Uninsured to Purchase Health Insurance? An Analysis of Underlying Behavior," Inquiry, 31, no. 4 (1994): 415-425.
20. CHIP Check-Up; P. Diehr et al., "Will Uninsured People Volunteer for Voluntary Health Insurance? Experience from Washington State," American Journal of Public Health 86, no. 4 (1996): 529-532; A. Gauthier and S. Schrodel, Expanding Children's Coverage: Lessons from State Initiatives in Health Care Reform (Washington: Alpha Center, 1997); L Ku and T. Coughlin, The Use of Sliding Scale Premiums in Subsidized Insurance Programs (Washington: Urban Institute, 1997); and K. Thomas, "Are Subsidies Enough to Encourage the Uninsured to Purchase Health Insurance? An Analysis of Underlying Behavior," Inquiry, 31, no. 4 (1994): 415-425.
21. CHIP Check-Up; P. Diehr et al., "Will Uninsured People Volunteer for Voluntary Health Insurance? Experience from Washington State," American Journal of Public Health 86, no. 4 (1996): 529-532; A. Gauthier and S. Schrodel, Expanding Children's Coverage: Lessons from State Initiatives in Health Care Reform (Washington: Alpha Center, 1997); L Ku and T. Coughlin, The Use of Sliding Scale Premiums in Subsidized Insurance Programs (Washington: Urban Institute, 1997); and K. Thomas, "Are Subsidies Enough to Encourage the Uninsured to Purchase Health Insurance? An Analysis of Underlying Behavior," Inquiry, 31, no. 4 (1994): 415-425.
22. CHIP Check-Up; P. Diehr et al., "Will Uninsured People Volunteer for Voluntary Health Insurance? Experience from Washington State," American Journal of Public Health 86, no. 4 (1996): 529-532; A. Gauthier and S. Schrodel, Expanding Children's Coverage: Lessons from State Initiatives in Health Care Reform (Washington: Alpha Center, 1997); L Ku and T. Coughlin, The Use of Sliding Scale Premiums in Subsidized Insurance Programs (Washington: Urban Institute, 1997); and K. Thomas, "Are Subsidies Enough to Encourage the Uninsured to Purchase Health Insurance? An Analysis of Underlying Behavior," Inquiry, 31, no. 4 (1994): 415-425.
23. L. Blumberg, L. Dubay, and S. Norton, "Did the Medicaid Expansions for Children Displace Private Insurance?" Working Paper (Washington: Urban Institute, 1997).
24. All standard errors in this paper are corrected for the complex design of the MEPS sample.
25. Ullman et al., The State Children's Health Insurance Program; S. Flint, S. Tang, and B. Yudkowsky, Medicaid Eligibility and Implications for SCHIP Participation (Washington: American Academy of Pediatrics, 1998); and K. Thorpe and C. Florence, Covering Uninsured Children and Their Parents: Estimated Costs and Number of Newly Insured (New York: Commonwealth Fund, 1998).
26. Ullman et al., The State Children's Health Insurance Program; S. Flint, S. Tang, and B. Yudkowsky, Medicaid Eligibility and Implications for SCHIP Participation (Washington: American Academy of Pediatrics, 1998); and K. Thorpe and C. Florence, Covering Uninsured Children and Their Parents: Estimated Costs and Number of Newly Insured (New York: Commonwealth Fund, 1998).
27. Ullman et al., The State Children's Health Insurance Program; S. Flint, S. Tang, and B. Yudkowsky, Medicaid Eligibility and Implications for SCHIP Participation (Washington: American Academy of Pediatrics, 1998); and K. Thorpe and C. Florence, Covering Uninsured Children and Their Parents: Estimated Costs and Number of Newly Insured (New York: Commonwealth Fund, 1998).
28. Exhibit 2 uses the CHIP population defined by applying the federal income thresholds to family incomes net of the standard disregards defined in Note 11.
29. This is a very rough estimate obtained from data on the number of medically needy children (Health Care Financing Administration, Medicaid Program Statistics, HCFA 2082 Report, www.hcfa. gov/medicaid/mstats.htm, 1998) with the MEPS distribution by family income of children with health problems and/or disabilities. For additional details, see Selden et al.. Projecting Eligibility and Enrollment.
30. This is a very rough estimate obtained from data on the number of medically needy children (Health Care Financing Administration, Medicaid Program Statistics, HCFA 2082 Report, www.hcfa. gov/medicaid/mstats.htm, 1998) with the MEPS distribution by family income of children with health problems and/or disabilities. For additional details, see Selden et al.. Projecting Eligibility and Enrollment.
31. To compute implied take-up rates, we use the enrollment projections from Exhibit 3 to divide (1) the total number of CHIP enrollees by (2) total CHIP enrollees plus CHIP-eligible children who remain uninsured (2.04 million). An alternative approach would be to calculate the take-up rate as the percentage of otherwise uninsured children who enroll. That approach, however, would ignore children switching from other sources of insurance and would be inconsistent with take-up rate estimates for the Medicaid population. The 59 percent enrollment rate for Medicaid expansion-eligible children is reported in Selden et al., "Medicaid's Problem Children."
32. Similar results can be found in L. Dubay and G. Kenney, "The Effects of Medicaid Expansions on Insurance Coverage of Children," Future of Children 6, no. 1 (1996): 152-161;
33. and L. Shore-Sheppard, "Stemming the Tide? The Effect of Expanding Medicaid Eligibility on Health Insurance Coverage," Working Paper no. 361 (Princeton: Industrial Relations Section, Princeton University, 1995).
34. Selden et al., "Medicaid's Problem Children."
35. To compute the crowd-out rate, we use the simulated enrollment figures presented in Exhibit 3 to divide (1) the change in the number of children covered by private insurance (0.44 million) by (2) the total number of CHIP enrollees (1.83 million).
36. See J. Holahan, "Crowding Out: How Big a Problem?" Health Affairs (January/February 1997): 204-206.
37. White House, Implementation of the Children's, Health Insurance Program, and White House, Budget of the United States Government, Fiscal Year 1999 (Washington: U.S. GPO, 1998).
38. For more on the effect that CHIP may have on Medicaid take-up, see Ullmanet al., TheStateChildren's Health Insurance Program.