CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. Children’s Health Insurance Coverage In The CHIP Era, 1997–2012

08/01/2014

Medicaid and CHIP coverage offset declines in employment-based coverage, fueling a substantial decline in uninsurance among children.

Between 1997 and 2012, most children (all incomes) had coverage from a parent’s employer, although the proportion with such coverage dropped from 63 to 55 percent over the period (Figure III.1).26Meanwhile, Medicaid and CHIP coverage among all children increased from 20 to 35 percent over the same period.27 Increased public coverage more than offset the loss of employer-sponsored coverage so that the percentage of all children who were uninsured fell by 6 percentage points (from 15 to 9 percent) despite recession conditions that separated many families from their connection to employer-sponsored coverage and left families with fewer resources to purchase coverage on their own.

Figure III.1. Percentage with Medicaid/CHIP, Employer-Sponsored Insurance, and Uninsured: All Children, 1997–2012

Figure III.1. Percentage with Medicaid/CHIP, Employer-Sponsored Insurance, and Uninsured: All Children, 1997–2012

Source: CPS-ASEC.

Notes: Children are ages 0 to 18.


Given that both CHIP and Medicaid are means-tested programs, their impact is even more visible when low-income children (in families with income below 200 percent of the FPL) are the focus, as in Figure III.2. Among low-income children, Medicaid and CHIP coverage exceeded employer-sponsored coverage throughout the period, rising from 41 percent in 1997 to 63 percent in 2012. The proportion of low-income children who were uninsured fell from 25 percent in 1997 to 13 percent in 2012.

Figure III.2. Percentage with Medicaid/CHIP, Employer-Sponsored Insurance, and Uninsured: Low-Income Children, 1997–2012

Figure III.2. Percentage with Medicaid/CHIP, Employer-Sponsored Insurance, and Uninsured: Low-Income Children, 1997–2012

Source: CPS-ASEC.

Notes: Children are ages 0 to 18. Low income is below 200 percent of the FPL.


Although public coverage rates are consistently highest among children with the lowest incomes, the gains in public coverage among children in families with incomes in the range targeted by CHIP—between 100 and 300 percent of the FPL—were even greater (Figure III.3). Over the 15-year period since CHIP’s inception, public coverage rates for children in families with income between 100 and 200 percent of the FPL increased by 26 percentage points; rates for children in families with income between 200 and 300 percent of the FPL increased by 18 percentage points; and rates for children with income in the Medicaid range of under 100 percent of the FPL increased by 15 percentage points.

Figure III.3. Percentage of Children Covered by Medicaid/CHIP, by Poverty Level: 1997–2012

Figure III.3. Percentage of Children Covered by Medicaid/CHIP, by Poverty Level: 1997–2012

Source: CPS-ASEC.

Note: Children are ages 0 to 18.


The coverage gains for low-income children were not matched by similar gains for low-income adults, pointing to the importance of public coverage in driving the decline in uninsurance among children.

Throughout the 15-year period, uninsured rates were substantially higher among low-income adults than among children (Figure III.4). Uninsured rates were consistently highest among adults without children, who were less likely to be eligible for public coverage. Uninsurance among low-income adults without children remained fairly constant during the period, while rates for adult parents increased from 33 to 38 percent. In contrast, rates for children declined steadily, falling from 25 to 13 percent over the 15-year period.

Figure III.4. Percentage Uninsured: Low-Income Children and Adults, 1997–2012

Figure III.4. Percentage Uninsured: Low-Income Children and Adults, 1997–2012

Source: CPS-ASEC.

Notes: Children are ages 0 to 18. Low income is below 200 percent of the FPL.


Public coverage gains were similar across groups of children defined by race and ethnicity, helping to narrow disparities in uninsured rates, especially for Hispanic children.

The coverage trends for low-income children show similar patterns across racial and ethnic groups. Medicaid and CHIP coverage increased (Figure III.5), and uninsurance fell (Figure III.6) for Hispanics, non-Hispanic whites, non-Hispanic blacks, and other groups of children (which includes Asian-Americans, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives). The trends among low-income Hispanic children are particularly striking: the uninsured rate was cut in half, falling from 34 percent in 1997 to 17 percent in 2012. The improvement was driven by the increase in Medicaid and CHIP coverage, from 42 percent in 1997 to 65 percent in 2012.

Figure III.5. Percentage of Low-Income Children Covered by Medicaid/CHIP Coverage, by Race and Ethnicity, 1997–2012

Figure III.5. Percentage of Low-Income Children Covered by Medicaid/CHIP Coverage, by Race and Ethnicity, 1997–2012

Source: CPS-ASEC.

Notes: Children are ages 0 to 18. Low income is below 200 percent of the FPL. Hispanic includes all races. Other includes Asian-American, Native-Hawaiian and Other Pacific Islander, and American Indian and Alaska Native. Non-Hispanic respondents indicating more than one race are assigned to a primary race based on a hierarchy originally developed for ASPE’s TRIM3 microsimulation model. Prior to March 2003, individuals could only report one race.


By 2012, the uninsured rate had fallen by 10 percentage points for non-Hispanic black and non-Hispanic white children and by 17 percentage points for Hispanic children (Figure III.5). Disparities in coverage for Hispanic children also declined sharply; the differential between non-Hispanic white and Hispanic children narrowed from a 13 percentage points in 1997 to 5 percentage points in 2012.

Figure III.6. Percentage of Low-Income Children Uninsured, by Race and Ethnicity, 1997–2012

Figure III.6. Percentage of Low-Income Children Uninsured, by Race and Ethnicity, 1997–2012

Source: CPS-ASEC.

Notes: Children are ages 0 to 18. Low income is below 200 percent of the FPL. Hispanic includes all races. Other includes Asian-American, Native-Hawaiian and Other Pacific Islander, and American Indian and Alaska Native. Non-Hispanic respondents indicating more than one race are assigned to a primary race.


26 Interpretation of CPS-ASEC health insurance data is subject to several caveats. Research matching CPS-ASEC responses with Medicaid and CHIP administrative data shows that significant percentages of respondents in all age groups who are enrolled in Medicaid or CHIP do not report such coverage on the survey. Consequently, coverage reported through the survey is lower than totals in administrative data, and uninsurance estimates from survey data are inflated. Introduction of verification questions in the survey, in which respondents who said no when asked about all coverage types were asked to confirm that they were uninsured, increased reported coverage rates beginning with the data for 1999, as did retroactive improvements in procedures for imputing responses among those who did not provide answers to the health insurance questions. A portion of the increase in coverage since 1997 is thus attributable to changes in CPS-ASEC methods. See U.S. Census Bureau (2008) and U.S. Census Bureau (2011).

27 The CPS-ASEC asks separate questions about Medicaid and CHIP coverage. Many analysts, however, believe that respondents do not always distinguish accurately between the two programs. It is particularly difficult to do so in states where the programs have the same name.

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