Analysis of Children's Health Insurance Patterns: Findings from the SIPP. 2. Medicaid Participation Rates

05/12/1999

Tables 10 and 11 present Medicaid participation rates in September 1994 by demographic and socioeconomic characteristics among all eligible children and among children with no other

TABLE 10: MEDICAID PARTICIPATION RATES BY DEMOGRAPHIC CHARACTERISTICS: SEPTEMBER 1994
Demographic Characteristic All Eligible Children Children with No Other Insurance
All Children 64.7 79
Age of Child    
    Infant (0) 57.5 78.2
    1 to 5 64.8 81.9
    6 to 8 65.9 77.5
    9 to 10 57.9 71
    11 to 15 70.3 81
    16 to 18 64.9 75.8
Race/Ethnicity of Child    
    White Non-Hispanic 53.7 75
    Black Non-Hispanic 78.6 87.8
    Hispanic 67.1 74.1
    Other 59.4 71.1
Family Composition    
    Both Parents Present 46 65.2
    Mother Only Present 75.7 85.6
    Father Only Present 55 69
    No Parent Present 87.3 90.3
Metropolitan Residence    
    Metro 65.8 78.8
    Non-Metro 61.8 79.5
    Not Applicable 62.9 77.6
Region    
    New England 51.4 75.3
    Middle Atlantic 73.3 85.7
    East North Central 69.5 80.4
    West North Central 52 78.3
    South Atlantic 62.4 80.5
    East South Central 65.6 78
    West South Central 57.3 66.7
    Mountain 63.2 77.1
    Pacific 66.8 78.7
SOURCE: Survey of Income and Program Participation, 1992 Panel.

 

TABLE 11: MEDICAID PARTICIPATION RATES BY SOCIOECONOMIC CHARACTERISTICS: SEPTEMBER 1994
Socioeconomic Characteristic All Eligible Children Children with No Other Insurance
Poverty Level    
    Less than 50% FPL 75.4 84.2
    50% to < 100% FPL 67.3 79.6
    100% to < 200% FPL 50.2 68.6
    200% to < 300% FPL 45 78.7
    300% FPL or Greater 52 86.5
Parents' Employment    
    1 or More Full Time 40.7 63.7
    Part Time Only 64.4 78.9
    No Working Parent 82.2 86.2
    No Parent Present 87.3 90.3
Parents' Education    
    No Parent Present 87.3 90.3
    6 Years or Less 65.7 69.6
    7 to 11 Years 75.7 82.7
    12 Years 65.7 78.9
    Attended College 55.3 78.3
    4-Year College Degree 27.4 56.7
    Graduate Work 31.3 62.6
SOURCE: Survey of Income and Program Participation, 1992 Panel.

insurance coverage. The first participation rate is defined as the number of Medicaid-enrolled children who were simulated to be eligible divided by the number of all children who were simulated to be eligible.7 The second participation rate is defined as the number of Medicaid-enrolled children who were simulated to be eligible divided by the number of children who were simulated to be eligible and had no other source of insurance. That is, the participation rate is calculated as the number of Medicaid-enrolled children who are simulated to be eligible divided by the sum of these same Medicaid-enrolled children and Medicaid-eligible uninsured children.

Calculated over all eligible children, the estimated Medicaid participation rate is about 65 percent. When we exclude from the denominator those eligible children who are covered by insurance other than Medicaid, the estimated participation rate rises by 14 percentage points to 79 percent.8 Neither rate includes an adjustment for the underreporting of Medicaid participation in the SIPP, and, as explained above, neither rate includes reported participants who were simulated to be ineligible. Even with these caveats, which imply that the rates may be understated, the participation rate among children who would otherwise be uninsured is quite high. While the participation rate among all eligible children is significantly lower, the fact that the difference between the two rates is attributable solely to children who were reported to have other coverage puts the overall participation rate in a new light. Certainly we should not assume that this other coverage was necessarily more comprehensive than Medicaid, and in many cases almost surely it was not. But for a significant number of children who were Medicaid-eligible but not participating the choice faced by their parents appears to have been between Medicaid and another source of coverage rather than between Medicaid and no insurance at all. Why parents in this situation may have elected not to enroll their children in Medicaid is a question whose answer may have implications for Medicaid and CHIP outreach as well as for strategies to minimize the potential crowd-out effects of CHIP.

Comparison of the two columns of Table 10 shows that in addition to raising the participation rate by 14 percentage points, on average, the effect of excluding children with other insurance from a Medicaid participation rate is to render the rates much more equal across demographic subgroups. This is most striking for race and ethnicity, where non-Hispanic whites lag behind Hispanics by 13 percentage points and behind non-Hispanic blacks by 25 percentage points when the participation rate is calculated among all Medicaid-eligible children. When children with other insurance are excluded from the participation rate, whites show effectively the same participation rate as Hispanics (75 percent versus 74 percent) and lag behind blacks by only 13 percentage points. Puzzling age differences are largely eliminated when the rate is calculated just among children who would otherwise be uninsured, and differentials by family composition are reduced as well. A small metropolitan/non-metropolitan difference is eliminated, and the surprisingly low participation rate in New England is increased by 24 percentage points with the alternative measure. While regional differences remain, only one region--the West South Central--is very far out of line with the rest with a participation rate of 69 percent or 19 percentage points below the highest participation rate. In fact, if these two regions are eliminated, the remaining seven regions fall within a 5 percentage point range.

The story is much the same for socioeconomic differentials (Table 11). When all eligible children are included in the calculation, the range of participation rates among poverty classes is 31 percentage points. This drops to 20 percentage points when children with other insurance are excluded, and the relationship between poverty and Medicaid participation becomes U-shaped, with the lowest participation rate found in the middle poverty group and the highest rates found at the ends. Parents' employment shows a similar equalizing of rates with the alternative measure of participation. There remains a monotonic, inverse relationship between the level of parents' employment and their children's participation rate in Medicaid, but the range of participation rates is reduced from 46 percentage points to 26 percentage points. Finally, differentials in children's participation rates by parents' education level are reduced as well, with a 20 point differential across the middle three levels being reduced to 4 percentage points. The children of college graduates (including those who did graduate work) remain much less likely to participate than the children of less educated parents, but instead of being 45 percentage points below the group with the highest participation rate they are less than 25 percentage points below this group. Nevertheless, we continue to see evidence suggesting that the education differential reflects more than just access to health insurance. The 70 percent participation rate for children whose parents have no more than an elementary school education contrasts with participation rates of 84 percent for children below 50 percent of poverty and 86 percent for children with no working parent. The comparatively low participation rate of children in this lowest parents' education category underscores the need for further research on the relationship between education and insurance coverage.

Why do the differentials in participation rates decline when we exclude children with other coverage, and what does this tell us about participation in Medicaid? Some compression of the differentials may have occurred simply because we reduced the variance of participation by removing a group of nonparticipants from the rates. The dominant reason for the reduction, however, is that in removing children with other sources of coverage we have removed one source of the original differentials. That is, differences in Medicaid participation rates exist in part because children in different demographic and socioeconomic groups are differentially likely to have other coverage. That we observe these reductions in differential participation rates also suggest that it is unlikely that most of this other coverage is misreported Medicaid coverage. If it were largely Medicaid, then participation rates would be boosted more uniformly--unless, of course, the misreporting itself occurred disproportionately among groups that were least likely to participate. This is not implausible--particularly if the perceived stigma attached to Medicaid contributed to the misreporting, as well it might. The Medicaid stigma might also contribute to parents' decisions to choose an alternative source of coverage over Medicaid if such coverage is available. Clearly, we have identified an area where further research would be beneficial, as there could be important policy implications in the reasons why parents may have and choose alternatives to Medicaid, as we noted previously.

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