CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings

Mathematica Policy Research

Suggested citation: Harrington and Kenney, et al. 2014. “CHIPRA Mandated Evaluation of the Children’s Health Insurance Program: Final Findings.” Report submitted to the Office of the Assistant Secretary for Planning and Evaluation. Ann Arbor, MI: Mathematica Policy Research, August 2014.

This report presents findings from an evaluation of CHIP mandated by CHIPRA and patterned after an earlier evaluation. Some of the evaluation findings are at the national level, while others focus on the 10 states selected for more intensive study: Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia. The evaluation included a large survey conducted in 2012 of CHIP enrollees and disenrollees in the 10 states, and Medicaid enrollees and disenrollees in three of these states. It also included case studies conducted in each of the 10 survey states in 2012 and a national telephone survey of CHIP administrators conducted in early 2013. Data from the Current Population Survey and the American Community Survey were analyzed to document national coverage trends from 1997 to 2012. Together with Medicaid, CHIP has helped fuel a decline in the number of uninsured children from 11.4 million (15 percent of children) in 1997 to 6.6 million (9 percent of children) in 2012. As of March 2014, 8.13 million children were enrolled in CHIP at some point in FFY 2013.

Executive Summary

Passed with bipartisan support in the Balanced Budget Act of 1997, the Children’s Health Insurance Program (CHIP) celebrated its 16th anniversary in August 2013. Legislation reauthorizing CHIP, the Children’s Health Insurance Program Reauthorization Act (CHIPRA), was signed into law on February 4, 2009, providing significant new financial support for the program and introducing various initiatives to increase enrollment, improve retention, and strengthen access and quality of care in Medicaid and CHIP. A total of 8.13 million children were enrolled in CHIP at some point in FFY 2013.

Congress mandated in CHIPRA that the Secretary of the U.S. Department of Health and Human Services conduct an independent comprehensive evaluation of CHIP patterned after an earlier evaluation Congress mandated in the Balanced Budget Refinement Act (BBRA) of 1999.¹ Mathematica Policy Research and its partner the Urban Institute were awarded the contract in 2010 to conduct the current evaluation, which is being overseen by the Office of the Assistant Secretary for Planning and Evaluation (ASPE). An interim report was sent to Congress in 2011 that described the status and evolution of state CHIP programs throughout the United States as of 2010 and summarized the evidence available at that time about the role and impacts of CHIP. This final report synthesizes evidence collected through the CHIPRA evaluation of CHIP.

¹ Appendix A contains copies of the relevant sections of the CHIPRA (P.L. 111-3) and BBRA (H.R. 3426) legislation.

What Did the Evaluation Find?

As summarized in Table ES.1, the evaluation found CHIP to be successful in nearly every area examined. CHIP succeeded in expanding health insurance coverage to the population it is intended to serve, particularly children who would otherwise be uninsured, increasing their access to needed health care, and reducing the financial burdens and stress on families associated with meeting children’s health care needs. These positive impacts were found for children and families in states with different CHIP program structures and features, across demographic and socioeconomic groups, and for children with different health needs. Medicaid and CHIP have worked as intended to provide an insurance safety net for low-income children during economic hard times. Awareness of both Medicaid and CHIP was high among low-income families, most newly enrolling families found the application process at least somewhat easy, and the vast majority of children remained enrolled through the annual renewal period.

The evaluation also identified a few areas where there is room for improvement. One in four children in CHIP had some type of unmet need, and although most CHIP enrollees received annual well-child checkups, fewer than half received key preventive services such as immunizations and health screenings during those visits, and fewer than 40 percent had after-hours access to a usual source of care provider. While most CHIP enrollees received annual dental checkups, a significant share of them did not get recommended follow-up dental treatment. There is also room for improvement in reducing the percentage of children who cycle off and back on to Medicaid and CHIP, and reducing gaps in coverage associated with moving between Medicaid and separate CHIP programs. And while participation rates have grown to high levels in most states, further effort could be targeted to the 3.7 million children who are eligible for Medicaid or CHIP but remain uninsured.

Table ES.1.

What Problem is CHIP Trying to Solve?

A series of Medicaid expansions passed by Congress beginning in the mid-1980’s aimed to address the problem of rising uninsured rates throughout the 1970s and early 1980s among children in families with incomes below the federal poverty level (FPL). As these expansions unfolded during the following decade, attention began to turn toward rising uninsured rates among children with family incomes between 100 and 200 percent of the FPL, due largely to declines in private insurance coverage (Cunningham and Kirby 2004). Although attempts at national health care reform failed in 1994, Congressional leaders of both political parties supported development of legislation to help children who fell into this coverage gap. The State Children’s Health Insurance Program (previously known as SCHIP, now called CHIP) passed with bipartisan support as part of the Balanced Budget Act of 1997 and became law on August 5, 1997, as Title XXI of the Social Security Act (P.L. 105-33).

How Does CHIP Work?

Congress designed CHIP to give states more control over program design compared with Medicaid so that states might experiment with providing coverage that more closely resembles options available in the commercial insurance market (Ryan 2009). States can (1) expand their existing Medicaid program (this is called a Medicaid expansion CHIP program), (2) create a separate program, or (3) blend the two approaches to create a combination program. While many states initially implemented a Medicaid expansion CHIP program, in part because that approach could be implemented quickly, over time more states began administering separate CHIP and combination programs, which offer greater flexibility in program design. Table ES.2 summarizes characteristics of each program type and the number of states with each type in 2001 and in 2013.

Table ES.2. Characteristics of CHIP Programs, FFYs 2001 and 2013