Analysis of Children's Health Insurance Patterns: Findings from the SIPP. What Do Medicaid Participation Rates Tell Us about Strategies for Outreach?

05/12/1999

Medicaid participation rates among children vary widely by the basis of eligibility. In September 1994, we observed the following participation rates:

  • 100 percent among AFDC participants, who are automatically enrolled
  • 75 percent among reported SSI recipients and foster children
  • 54 percent among children in families that appeared to be eligible for AFDC but did not report that they were receiving cash assistance
  • 37 percent among children eligible under the poverty-related expansions
  • 23 percent among other eligibility groups3

As the number of families receiving cash assistance diminishes under welfare reform, we would expect the overall Medicaid participation rate to drop significantly unless there is a sizable increase in participation rates among children in these other eligibility categories.

The overall pattern of participation and the nature of changes in the cash assistance caseload post-welfare reform carry implications for CHIP. First, it is clear that outreach efforts will have to be very strong to achieve high participation rates in both the Medicaid expansions and the state programs. In the absence of strong outreach, we might expect to see participation rates that are no better than what we observed in the populations eligible for Medicaid without cash assistance. Second, to the extent that CHIP extends eligibility to families and children who were not eligible previously, participation rates could be even lower than we have seen for non-cash families and their children historically. Many newly eligible families may not perceive that a public program is truly for them; they may not even be aware that they are eligible and, lacking experience with public programs, may not think to inquire. They may also hesitate because of the stigma that they believe accompanies participation in such programs. Third, different outreach strategies may prove to be differentially effective with different eligibility groups and different subgroups of the population. At a minimum, strategies should be designed to deal with three different types of eligibles, who will be found in different proportions in different eligibility groups and population subgroups:

  • Children who have been eligible for Medicaid but resisted participation
  • Children who have already participated
  • Children who are becoming eligible for the first time

It may be relatively easy to enroll children who have already participated, but it is likely to be much more difficult to enroll children who have resisted participation or who have become eligible for the first time. For the newly eligible, outreach will have to communicate basic information about the program and allay the concerns of prospective new clients. For those who have been eligible but have not participated, we may need to understand the reasons for their behavior in order to design effective outreach programs.

Another factor that plays into this issue of outreach is the role of coverage for the parent. The differences in participation by eligibility group provide at least a suggestion that children are more likely to participate if a parent is eligible as well. Some states have begun to consider strategies that would allow them to use CHIP funds to partially fund coverage for the parents of eligible children. Further research into the importance of parents' access to coverage in determining their children's likelihood of participating in public insurance programs is clearly in order and may lend additional support to efforts intended to increase the coverage that is available to parents.

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