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

Publication Date
Jul 31, 2014

Mathematica Policy Research

Mary Harrington
Kimberly Smith
Christopher Trenholm
Sean Orzol
Sheila Hoag
Joseph Zickafoose
Claire Dye
Connie Qian
Tyler Fisher
Lauren Hula

Kenneth Finegold

The Urban Institute
Genevieve M. Kenney
Lisa Clemans-Cope
Ian Hill
Stacey McMorrow
Jennifer Haley
Timothy Waidmann
Sarah Benatar
Matthew Buettgens
Victoria Lynch
Nathanial Anderson

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.

Submitted to:
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation
200 Independence Avenue, SW
Washington, DC 20201
Project Officer: Rose Chu Contract Number: HHSP23320095642WC/HHSP23337021T

Submitted by:
Mathematica Policy Research
220 East Huron Street Suite 300 Ann Arbor, MI 48104-1912 Telephone: (734) 794-1120 Facsimile: (734) 794-0241
Project Director: Mary Harrington Reference Number: 06873.140



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.

Major Findings from the CHIPRA Mandated Evaluation of CHIP
1. CHIP contributed greatly to the decline in uninsured rates among low-income children, which fell from 25 percent in 1997 to 13 percent in 2012. Since CHIP was enacted, coverage rates improved for all ethnic and income groups and coverage disparities narrowed significantly for Hispanic children.
2. Medicaid and CHIP participation rates increased even as the number of eligible children has grown. The number of children eligible for Medicaid or CHIP yet uninsured fell from 4.9 million in 2008 to 3.7 million in 2012, and 68 percent of all remaining uninsured children are eligible for Medicaid or CHIP.
3. Relatively few low-income children in CHIP have access to private insurance coverage, and direct substitution of private for public coverage at the time of CHIP enrollment was estimated to be as low as 4 percent. Even when dependent coverage is available to families with children enrolled in CHIP, affordability is likely an important barrier many parents face in accessing employer sponsored insurance coverage for their children.
4. Medicaid and CHIP programs worked as intended to provide an insurance safety net for low-income children, especially during times of economic hardship.
5. Most new CHIP enrollees stayed enrolled in public coverage for at least 28 months, and the vast majority exited because they were no longer eligible. Many children moved between Medicaid and CHIP; while most transitioned seamlessly, coverage gaps occurred for as many as 44 percent depending on the type of transition.
6. Children in Medicaid and CHIP experienced better access to care, fewer unmet needs, and greater financial protection than children who were uninsured. Compared to children with private insurance, CHIP enrollees had better access to dental benefits and their families experienced much lower financial burden and stress in meeting the child’s health care needs. However, CHIP enrollees were less likely than children with private insurance to have a regular source of medical care and nighttime or weekend access to a provider at that source of care.
7. Most low-income families knew about Medicaid and CHIP, and those with children enrolled in the programs reported positive application experiences. Some barriers to enrollment remain for eligible uninsured children.


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

Program Type Summary Number of States 2001 Number of States 2013
Medicaid Expansion CHIP Required to follow all Medicaid program rules, including benefits and cost–sharing; prohibited from capping or freezing enrollment 17 8
Separate CHIP Allows increased flexibility in program design. Benefits must be equivalent to a “benchmark” benefit package. Typically, a commercial plan or the state employees’ health benefit package is used as the benchmark, although it can also be a benchmark equivalent package or a plan approved by the Secretary of the Department of Health and Human Services. Cost-sharing (premiums, copayments, and deductibles) must be nominal for children from families with incomes below 150 percent of the federal poverty level; for families with higher incomes, cost-sharing cannot exceed 5 percent of total family income. Provides no federal entitlement to coverage. Prior to maintenance of effort (MOE) rules established by the American Recovery and Reinvestment Act of 2009 (and extended and broadened by the Affordable Care Act), states could cap or freeze enrollment and maintain waiting lists at any time to limit costs and coverage. Option to impose waiting periods. 16 15
Combination States operate both Medicaid expansion CHIP and separate CHIP programs; each covers a different population based on income threshold 18 28
Children's Health Insurance Program (CHIP)