Medicaid for children: Federal mandates, welfare reform, and policy backsliding

Health Affairs

Volumn 20, Issue 1, 2001, Pages 97-111

  Kronebusch, Karl ^a  

^a YALE UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CHILD; CHILD HEALTH CARE; CHILD WELFARE; ECONOMICS; EVALUATION; HEALTH CARE DELIVERY; HEALTH CARE PLANNING; HUMAN; INCOME; LEGAL ASPECT; MEDICAID; POLICY; POVERTY; STATISTICS; UNITED STATES; UTILIZATION REVIEW;

CHILD; CHILD HEALTH SERVICES; CHILD WELFARE; HEALTH SERVICES ACCESSIBILITY; HUMANS; INCOME; MEDICAID; POVERTY; PUBLIC POLICY; STATE HEALTH PLANS; UNITED STATES;

EID: 0035234377     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.20.1.97     Document Type: Article

References (26)

1. A more extensive discussion of the analytic model and estimation strategy are provided in K. Kronebusch, "Medicaid and Children: Enrollment Trends and the Impact of Federal Policy Mandates" (Working Paper, Yale University, 2000).
2. Data extracts were constructed using the uniform CPS file distributed by CPS Utilities. The sample sizes for the nation as a whole are as follows: 1980-82, 87,249; 1983-85, 80,332; 1986-88, 72,509; 1988-90, 69,209; 1991-93, 74,333; 1994-96,68,243; 1997-99,59,906; 1980-99 total, 511,781. State-specific samples for 1994-96, for example, range from 8,005 in California to 442 in New Hampshire. In some years and for some states the sample size is insufficient to create reliable maximum likelihood estimates. These reliability problems arise in the jurisdictions with relatively small sample sizes that also have Medicaid/welfare recipient pools that are nearly all white (Maine, New Hampshire, Vermont) or nearly all nonwhite (District of Columbia). In most years only a few states are affected by this. For the 1997-99 period this issue arises for a larger number of states, generally for the estimates of TANF enrollment probabilities but not for Medicaid. Corresponding to the steep decline in welfare rolls, there are now many fewer CPS respondents who report receipt of welfare, which reduces the reliability of statistical estimation.
3. U.S. Bureau of the Census, Poverty in the United States, Pub. no. P60-207 (Washington: U.S. Government Printing Office, 1998).
4. Only thirty-five states are included in Exhibit 4. For the remaining states, the estimates are potentially unreliable for the change in AFDC/TANF enrollment, largely because the number of families with welfare receipt has fallen dramatically, thereby reducing the available sample sizes. This problem does not generally affect the change in Medicaid enrollment.
5. In 1995 the ratio of welfare-related enrollment to Medicaid enrollment for children with no income ranged from 0.45 to 0.99, depending on the state.
6. R. Mills, Health Insurance Coverage, 1999, Current Population Reports P60-211 (Washington: U.S. GPO, September 2000).
7. There are empirical uncertainties about how people respond to health insurance and program participation survey questions. See 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): 233-242; and J.C. Ham and L Shore-Sheppard, "The Effect of Medicaid Expansions for Low-Income Children on Medicaid Participation and Insurance Coverage: Evidence from the SIPP" (Unpublished paper, March 2000).
8. There are empirical uncertainties about how people respond to health insurance and program participation survey questions. See 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): 233-242; and J.C. Ham and L Shore-Sheppard, "The Effect of Medicaid Expansions for Low-Income Children on Medicaid Participation and Insurance Coverage: Evidence from the SIPP" (Unpublished paper, March 2000).
9. This more complex model includes income, income squared, race, age, eligibility for the Medicaid mandates, year-specific intercepts, year-specific mandate coefficients, as well as whether the family head is a single female (versus two-parent families and those headed by a single male), the age of the family head, the educational attainment of the family head, the presence of children under age six in the family, and whether the family head is employed full time (defined as thirty-five or more hours per week).
10. 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.
11. M.R. Ellwood and L. Ku, "Welfare and Immigration Reforms: Unintended Side Effects for Medicaid," Health Affairs (May/June 1998): 137-151.
12. L. Ku and B. Bruen, The Continuing Decline in Medicaid Coverage, New Federalism: Issues and Options for States, no. A-37 (Washington: Urban Institute, 1999); V. Pulos and P. Denker, One Step Forward, One Step Back: Children's Health Coverage after CHIP and Welfare Reform, Pub. no. 99-106 (Washington: Families USA Foundation, 1999); and E.R. Ellis and V.K. Smith, Medicaid Enrollment in Twenty-one States, June 1997 to June 1999 (Washington: Kaiser Commission on Medicaid and the Uninsured, April 2000).
13. L. Ku and B. Bruen, The Continuing Decline in Medicaid Coverage, New Federalism: Issues and Options for States, no. A-37 (Washington: Urban Institute, 1999); V. Pulos and P. Denker, One Step Forward, One Step Back: Children's Health Coverage after CHIP and Welfare Reform, Pub. no. 99-106 (Washington: Families USA Foundation, 1999); and E.R. Ellis and V.K. Smith, Medicaid Enrollment in Twenty-one States, June 1997 to June 1999 (Washington: Kaiser Commission on Medicaid and the Uninsured, April 2000).
14. L. Ku and B. Bruen, The Continuing Decline in Medicaid Coverage, New Federalism: Issues and Options for States, no. A-37 (Washington: Urban Institute, 1999); V. Pulos and P. Denker, One Step Forward, One Step Back: Children's Health Coverage after CHIP and Welfare Reform, Pub. no. 99-106 (Washington: Families USA Foundation, 1999); and E.R. Ellis and V.K. Smith, Medicaid Enrollment in Twenty-one States, June 1997 to June 1999 (Washington: Kaiser Commission on Medicaid and the Uninsured, April 2000).
15. Ku and Bruen, The Continuing Decline In Medicaid Coverage.
16. L. Ku and B. Garrett, "How Welfare Reform and Economic Factors Affected Medicaid Participation: 1984-96," Urban Institute Discussion Paper (Washington: Urban Institute, 2000); and R. Klein and C. Fish-Parcham, Losing Health Insurance: The Unintended Consequences of Welfare Reform, Pub. no. 99-103 (Washington: Families USA Foundation, 1999).
17. L. Ku and B. Garrett, "How Welfare Reform and Economic Factors Affected Medicaid Participation: 1984-96," Urban Institute Discussion Paper (Washington: Urban Institute, 2000); and R. Klein and C. Fish-Parcham, Losing Health Insurance: The Unintended Consequences of Welfare Reform, Pub. no. 99-103 (Washington: Families USA Foundation, 1999).
18. J.P. Stuber et al., "Beyond Stigma: What Barriers Actually Affect the Decisions of Low-Income Families to Enroll in Medicaid?" Issue Brief (Washington: George Washington University Medical Center, School of Public Health and Health Services, Center for Health Services Research and Policy, 2000); and M. Perry et al., Medicaid and Children; Overcoming Barriers to Enrollment, Findings from a National Survey (Washington: Kaiser Commission on Medicaid and the Uninsured, 2000).
19. J.P. Stuber et al., "Beyond Stigma: What Barriers Actually Affect the Decisions of Low-Income Families to Enroll in Medicaid?" Issue Brief (Washington: George Washington University Medical Center, School of Public Health and Health Services, Center for Health Services Research and Policy, 2000); and M. Perry et al., Medicaid and Children; Overcoming Barriers to Enrollment, Findings from a National Survey (Washington: Kaiser Commission on Medicaid and the Uninsured, 2000).
20. M. Ellwood, "The Medicaid Eligibility Maze: Coverage Expands, but Enrollment Problems Persist, Findings from a Five-State Study," Assessing the New Federalism, Occasional Paper no. 30 (Washington: Urban Institute, 1999).
21. The SCHIP limit in Massachusetts is 400 percent of poverty, while the limit for Connecticut is 300 percent. In addition, two other states with small declines or even increases in children's Medicaid enrollment (Vermont and Missouri) set their Medicaid/SCHIP limits at 300 percent of poverty.
22. L. Cox and D.C. Ross, Medicaid for Children and CHIP: Income Eligibility Guidelines and Enrollment Procedures, Findings from a Fifty-State Survey (Washington: Center on Budget and Policy Priorities, 2000); Center for Law and Social Policy and Center on Budget and Policy Priorities, States' Implementation of Selected Medicaid Provisions of the Personal Responsibility and Work Opportunities Reconciliation Act of 1996, State Policy Documentation Project (Washington: Center for Law and Social Policy and Center on Budget and Policy Priorities, 2000); U.S. General Accounting Office, Medicaid Enrollment: Amid Declines, State Efforts to Ensure Cover-age after Welfare Reform Vary (Washington: GAO, 1999); and Children's Health Council, Ensuring Husky Coverage for Children (Hartford, Conn.: Children's Health Council, 1999).
23. L. Cox and D.C. Ross, Medicaid for Children and CHIP: Income Eligibility Guidelines and Enrollment Procedures, Findings from a Fifty-State Survey (Washington: Center on Budget and Policy Priorities, 2000); Center for Law and Social Policy and Center on Budget and Policy Priorities, States' Implementation of Selected Medicaid Provisions of the Personal Responsibility and Work Opportunities Reconciliation Act of 1996, State Policy Documentation Project (Washington: Center for Law and Social Policy and Center on Budget and Policy Priorities, 2000); U.S. General Accounting Office, Medicaid Enrollment: Amid Declines, State Efforts to Ensure Cover-age after Welfare Reform Vary (Washington: GAO, 1999); and Children's Health Council, Ensuring Husky Coverage for Children (Hartford, Conn.: Children's Health Council, 1999).
24. L. Cox and D.C. Ross, Medicaid for Children and CHIP: Income Eligibility Guidelines and Enrollment Procedures, Findings from a Fifty-State Survey (Washington: Center on Budget and Policy Priorities, 2000); Center for Law and Social Policy and Center on Budget and Policy Priorities, States' Implementation of Selected Medicaid Provisions of the Personal Responsibility and Work Opportunities Reconciliation Act of 1996, State Policy Documentation Project (Washington: Center for Law and Social Policy and Center on Budget and Policy Priorities, 2000); U.S. General Accounting Office, Medicaid Enrollment: Amid Declines, State Efforts to Ensure Cover-age after Welfare Reform Vary (Washington: GAO, 1999); and Children's Health Council, Ensuring Husky Coverage for Children (Hartford, Conn.: Children's Health Council, 1999).
25. L. Cox and D.C. Ross, Medicaid for Children and CHIP: Income Eligibility Guidelines and Enrollment Procedures, Findings from a Fifty-State Survey (Washington: Center on Budget and Policy Priorities, 2000); Center for Law and Social Policy and Center on Budget and Policy Priorities, States' Implementation of Selected Medicaid Provisions of the Personal Responsibility and Work Opportunities Reconciliation Act of 1996, State Policy Documentation Project (Washington: Center for Law and Social Policy and Center on Budget and Policy Priorities, 2000); U.S. General Accounting Office, Medicaid Enrollment: Amid Declines, State Efforts to Ensure Cover-age after Welfare Reform Vary (Washington: GAO, 1999); and Children's Health Council, Ensuring Husky Coverage for Children (Hartford, Conn.: Children's Health Council, 1999).
26. T. Westmorland, "Dear State Medicaid Director," letter on improper terminations, federal requirements for redetermining Medicaid eligibility, and operation of computerized eligibility systems, 7 April 2000, (29 October 2000).