States quickly implemented CHIP programs; in the first three program years, enrollment tripled, from about 1.0 million in 1998 to 3.3 million in FFY 2000 (Ellwood et al. 2003; Wooldridge et al. 2003). The program has continued to grow, albeit at a slower pace, in the past decade. For example, between 2006 and 2012, CHIP enrollment increased by about 20 percent (Appendix Tables B.2 and B.3 provide trend data on the number of children ever enrolled by state from 1998 through 2012).
Even before CHIPRA passed, Congress made changes to various aspects of CHIP. For example, states identified problems early on with the formula for the allotments; the formula did not consider state expenditures, leading to imbalances where some states had surplus CHIP funds while others experienced shortfalls (Congressional Research Service 2006 and 2008).16 The Balanced Budget Refinement Act of 1999 revised aspects of the state allotment formulas, provided additional funding for CHIP in U.S. territories, and required an evaluation of the program. CHIP remained largely untouched until passage of the Deficit Reduction Act of 2005 [P.L. 109-171] (signed into law in February 2006), which increased funds available for CHIP to avoid state CHIP deficits. This legislation also eliminated coverage of childless adults in CHIP.
Attempts to reauthorize CHIP failed in the fall of 2007 and Congress instead extended it through March 2009, funding it at $5 billion per year and appropriating some additional funds to help states with projected funding shortfalls. CHIPRA then passed in February 2009, providing $44 billion in new funding (in addition to the $25 billion in baseline funding appropriated through September 2013), establishing a performance bonus fund to encourage states to pursue innovations in enrolling children and keeping them enrolled, providing $100 million in new outreach grant funding, and establishing an enhanced match rate for translation and interpretation services (Kaiser Commission on Medicaid and the Uninsured 2009b; PL 111-3, Section 104). CHIPRA also made several policy changes: requiring states to offer dental services and mental health parity in CHIP, giving them the option to cover legal immigrant children and pregnant women (who previously were prohibited from obtaining CHIP or Medicaid during their first five years in the United States), permitting states to provide premium assistance to children and families with employer-sponsored coverage, prohibiting states from covering parents in CHIP unless a waiver was approved by HHS to provide such coverage, and requiring documentation of citizenship for children enrolled in CHIP (as in Medicaid) (Hoag et al 2011). CHIPRA also provided funds to study and improve access and quality of care for children and address other issues, and gave states new tools, new funds, and a new funding formula to use in their CHIP programs to address shortfalls in both enrollment and access to and quality of care.17
Among other things, the Affordable Care Act extended CHIP funding through September 2015 and MOE provisions through September 2019, gave states the option to cover low-income children of state employees if certain conditions are met, and specified a new “no wrong door policy” effective in 2014 that requires CHIP, Medicaid, and new Marketplaces to screen each child and adult who applies for coverage and enroll them in the insurance appropriate for their income (Medicaid, CHIP, or the Marketplace).
17 This included $225 million for child health quality initiatives, including developing child health quality measures and electronic health records, and $20 million for the U.S. Census Bureau to improve state-specific estimates of children, as well as funding for this CHIP evaluation (P.L. 111-3).