CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. I. Background and Context for the Evaluation


This report presents findings from an evaluation of the Children’s Health Insurance Program (CHIP) mandated by the Children’s Health Insurance Program Reauthorization Act (CHIPRA) passed in February 2009. Initially authorized through the Balanced Budget Act of 1997, CHIP celebrated its 16th anniversary in August 2013. CHIPRA reauthorized the program and funded it through September 2013. The Patient Protection and Affordable Care Act of 2010 and the Health Education Reconciliation Act of 2010 (collectively referred to hereafter as the Affordable Care Act) authorized CHIP through September 2019 and extended funding for the program through September 2015. Moreover, the Affordable Care Act stipulated that states must maintain minimum eligibility and enrollment standards (known as maintenance of effort [MOE] requirements) in CHIP (as well as in Medicaid) that are at least as generous as those in place when the legislation was enacted on March 23, 2010 (P.L. 111-148).7

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

Congress stipulated in CHIPRA that the evaluation include 10 states with varied geographical and urban/rural representation, diverse approaches to program design, and a large proportion of the low-income, uninsured children in the United States.

Congress also stipulated that the evaluation survey families of CHIP enrollees and disenrollees, study low-income children likely to be eligible for Medicaid or CHIP but not enrolled, and address numerous questions related to the effectiveness of Medicaid and CHIP in finding, enrolling, and retaining eligible children and how Medicaid and CHIP work together to meet the health and health care needs of low-income children.

The enabling legislation for the current evaluation is contained in CHIPRA (P.L. 111-3), and the relevant legislation referenced in CHIPRA for the prior evaluation is contained in the BBRA of 1999 (H.R. 3426). (Appendix A contains copies of the relevant sections of the legislation).

Mathematica Policy Research and its partner the Urban Institute were awarded the contract in 2010 to conduct the CHIPRA evaluation of CHIP, 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 describes the status and evolution of state CHIP programs throughout the United States as of 2010 and summarizes the evidence available at that time about the role and impacts of CHIP (Hoag et al., 2011). This final report synthesizes evidence collected through the CHIPRA evaluation of CHIP. The evaluation comes at an important juncture for CHIP because funding after September 2015 is not assured. Findings from the evaluation will help Congress and the nation better understand CHIP and its value as the future of the program is debated.

Some of the evaluation findings are at the national level, while others focus on 10 states selected for more intensive study: Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia. As required by Congress, the evaluation included a large survey conducted in 2012 of CHIP enrollees and disenrollees in 10 states, and Medicaid enrollees and disenrollees in 3 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. Insight into the experiences of children eligible for CHIP and Medicaid but not enrolled came from an analysis of data from the 2011/2012 National Survey of Children’s Health (NSCH). Finally, the evaluation used data from the Current Population Survey to document national coverage trends from 1997 to 2012, and data from the American Community Survey (ACS) to estimate how coverage would be influenced in the future by different assumptions about the funding of CHIP after implementation of the Affordable Care Act.

7 The American Recovery and Reinvestment Act, passed in February 2009, first established the Medicaid MOE requirements and made them retroactive to Medicaid eligibility standards in place as of July 1, 2008. The Affordable Care Act extended the Medicaid MOE requirements for adults to January 2014, when coverage through the Marketplaces went into effect (Hoag et al., 2011). MOE requirements for children were extended through September 2019.

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