CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. Participation in Medicaid and CHIP, 2008 and 2012

08/01/2014

Medicaid and CHIP participation rates for children increased substantially overall and in most states and for all major subpopulations examined.

Nationally, the estimated number of uninsured children and the proportion of children uninsured fell between 2008 and 201228, from 7.2 to 5.4 million and from 9.2 to 7.0 percent, respectively, according to data from the ACS (Table III.1).29 Decreases in uninsured rates were widespread among children, with statistically significant declines in 33 states. As a result, the distribution of uninsured rates narrowed across states, although a differential of 14.5 percentage points persisted in the uninsured rates among children; in 2012, Nevada had an uninsured rate of 15.8 percent among children compared to a rate of 1.3 percent among children in Massachusetts. In 2008, a differential of 18 percentage points existed between Nevada and Massachusetts, the states with the highest and lowest uninsured rates for children, respectively.

Table III.1. Medicaid/CHIP Eligibility, Participation, and Uninsurance of Children (Ages 0 to 18) by State, 2008 and 2012

  Uninsured Medicaid/CHIP Eligibles Medicaid/CHIP Participation
  2008 2012 2008 2012 2008 2012
  Rate (%) Rate (%) Number (1,000s) Number (1,000s) Rate (%) Rate (%)
Nation 9.2 7.0 ++ 41,548 46,025 81.7 88.1 ++
Alabama 7.6** 4.0**++ 651 855 85.4** 92.6**++
Alaska 12.1** 12.8** 86 93 70.4** 81.7**++
Arizona 14.8** 12.5**++ 909 976 76.3** 81.8**++
Arkansas 8.3 5.5**++ 444 452 87.8** 93.9**++
California 10.0** 7.8**++ 5,687 6,010 81.4 87.0**++
Colorado 12.9** 8.1**++ 519 681 69.3** 85.0**++
Connecticut 5.0** 3.6**++ 389 419 85.8** 93.0**++
Delaware 8.0 3.6**++ 101 110 81.2 93.9**++
District of Columbia 2.8** 2.7** 78 74 95.6** 97.1**
Florida 16.6** 10.6**++ 2,082 2,385 69.8** 85.5**++
Georgia 10.7** 8.6**++ 1,538 1,644 81.0 85.8**++
Hawaii 2.9** 2.9** 200 230 91.5** 92.6**
Idaho 12.6** 7.6 ++ 216 237 73.6** 86.3 ++
Illinois 5.4** 4.0**++ 2,004 2,012 88.0** 93.8**++
Indiana 9.1 7.6**++ 981 1,032 78.5** 84.4**++
Iowa 4.7** 4.1** 545 587 85.9** 89.8 +
Kansas 7.8** 6.8 342 431 81.4 86.4++
Kentucky 5.7** 5.9** 579 613 89.5** 90.2**
Louisiana 7.4** 5.5**++ 747 773 88.3** 92.5**++
Maine 5.4** 4.7** 136 149 91.0** 94.0**
Maryland 5.2** 3.8**++ 704 749 86.3** 91.9**++
Massachusetts 1.6** 1.3** 685 723 95.0** 97.4**++
Michigan 4.9** 4.2**++ 1,230 1,299 89.6** 92.2**++
Minnesota 5.6** 5.5** 646 687 81.3 85.3**++
Mississippi 12.0** 7.2 ++ 514 537 81.4 90.3**++
Missouri 6.6** 7.1 968 1,002 85.3** 85.5**
Montana 14.1** 11.2** 114 150 67.9** 81.0**++
Nebraska 6.9** 5.4** + 205 238 80.8 88.4 +
Nevada 20.0** 15.8**++ 318 392 56.1** 70.6**++
New Hampshire 5.0** 4.1** 146 149 85.5 89.7
New Jersey 6.8** 5.0**++ 1,089 1,159 82.4 88.7++
New Mexico 12.8** 8.2++ 344 389 81.6 89.3++
New York 5.3** 3.9**++ 2,432 3,214 89.2** 92.4**++
North Carolina 9.5 7.1++ 1,181 1,368 84.6** 89.6**++
North Dakota 7.3 7.4 47 44 75.9 84.5
Ohio 6.7** 5.4**++ 1,366 1,494 83.3** 89.5++
Oklahoma 11.8** 10.0**++ 542 579 81.2 85.8**++
Oregon 11.7** 5.4**++ 402 621 74.9** 90.2**++
Pennsylvania 5.7** 4.8**++ 1,757 1,828 86.1** 89.4**++
Rhode Island 5.3** 5.7** 111 120 85.1 90.4 +
South Carolina 10.9** 7.9*++ 596 686 79.4** 87.5++
South Dakota 8.4 3.9**++ 106 102 83.2 92.1**++
Tennessee 6.7** 5.6**+ 945 1019 86.3** 90.3**++
Texas 16.3** 12.2**++ 3,756 4,142 74.6** 84.3**++
Utah 12.0** 9.4** 362 446 65.8** 95.8**++
Vermont 3.7** 2.9** 81 84 93.5** 95.2**
Virginia 7.2** 5.5**++ 752 824 80.0** 87.5++
Washington 7.7** 5.4**++ 831 1,025 82.5 89.4*++
West Virginia 6.1** 4.1**++ 241 288 89.3** 91.1**
Wisconsin 4.7** 4.7** 784 839 86.2** 88.7
Wyoming 8.9 9.3* 58 65 76.4 81.5+

Source: Analysis of the Urban Institute's Health Policy Center's ACS Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2008 and 2012.

Notes: See text for definitions of eligibility, participation, and uninsurance. Since eligibility estimates reflect potential eligibility based on meeting the income, asset, and immigration requirements, they include some children with ESI coverage who do not necessarily qualify for Medicaid/CHIP coverage. Eligibility estimates do not take into account waiting periods which vary by state.

**(*) indicates estimate is statistically different from national estimate at the 0.05 (0.1) level.
++(+) indicates 2012 estimate is statistically different from 2008 estimate at the 0.05 (0.1) level


Increased take-up of Medicaid and CHIP coverage among eligible children was associated with a decrease in the number of uninsured children eligible for but not enrolled in Medicaid or CHIP (Table III.I). The decline in the number of uninsured children who were eligible for Medicaid or CHIP but not enrolled occurred even as states expanded eligibility to additional groups of children over that period and as more children became eligible for public coverage due to the economic downturn. Of the ten states that saw the largest decreases in uninsured rates for children between 2008 to 2012, seven saw the largest increases in Medicaid and CHIP participation rates for children over the same period (Colorado, Delaware, Florida, Idaho, Nevada, Oregon, and Texas) and seven were one of the ten states in 2008 with the highest uninsured rates (Colorado, Florida, Idaho, Mississippi, New Mexico, Nevada, and Texas).

Between 2008 and 2012, participation in Medicaid and CHIP rose nationally among eligible children, with statistically significant increases in 37 states.30 Nationwide, Medicaid and CHIP participation rates among children increased from 82 percent in 2008 to 88 percent in 2012; by 2012, 21 states had participation rates of 90 percent or higher and just two states had rates of 80 percent or lower (Table III.1).31 The 21 states that had participation rates above 90 percent draw from all four regions and include states that differ in terms of the demographic and socioeconomic composition of the children who are targeted by Medicaid and CHIP. Over the four-year period, many states implemented changes in their enrollment and re-enrollment processes and adopted new outreach strategies aimed at increasing the take-up and retention of Medicaid and CHIP coverage among eligible children (Heberlein et al. 2013; Hoag et al. 2013). Participation rates increased in Medicaid programs as well as in separate CHIP and Medicaid expansion CHIP programs (data not shown).32

Medicaid and CHIP participation rates increased across many subpopulations but still vary across groups.

Medicaid and CHIP participation rates increased among children across subgroups defined by income, age, race and ethnicity, immigration status, and functional status (Table III.2).33 In 2012, participation rates exceeded 85 percent across most subgroups, with the exception of American Indian children (78 percent), children with income above 138 percent of the FPL (80 to 81 percent depending on the income group), children ages 13 to 18 (83 percent), noncitizen children (83 percent), and citizen children with no parents in the household (83 percent). Participation rates exceeded 90 percent for children under age six (92 percent), children with income below 138% percent of the FPL (90 percent), black non-Hispanic children (92 percent), non-Hispanic children with multiple or other race (90 percent), and children with functional limitations (94 percent). Despite these gains, participation rates remained lower for some groups of children--for adolescents compared to younger children; for non-citizen compared to citizen children, and for children without functional limitations compared to children with functional limitations. For example, children ages 13 to 18 had participation rates that were nearly ten percentage points lower than children under age six.

Table III.2. Medicaid/CHIP Participation Rates for Children by Subgroup, 2008 and 2012

  Participation Rates
  2008 2012
Nation 81.7% 88.1%
Income
Less than 138 percent of FPL 84.4%** 90.1%**++
Between 138 and 200 percent of FPL 74.2%** 81.2%**++
Greater than 200 percent of FPL 71.6%** 79.8%**++
Age
0 to 5 85.6%** 91.5%**++
5 to 12 82.4%** 88.9%**++
13 to 18 75.5%** 82.8%**++
Sex    
Male 81.6% 88.0%++
Female 81.7% 88.2%++
Race/Ethnicity
Hispanic 78.8%** 87.2%**++
White, non-Hispanic 81.4% 87.0%**++
Black, non-Hispanic 86.8%** 92.2%**++
Asian, non-Hispanic 79.2%** 85.8%**++
American Indian, non-Hispanic 68.4%** 78.4%**++
Other/multiple, non-Hispanic 86.4%** 90.3%**++
Citizenship
Citizen with no citizen parents 78.5%** 88.8%**++
Citizen with at least one citizen parent 83.3%** 88.8%**++
Noncitizen 78.5%** 82.9%**++
Citizen with no parents in household 75.5%** 82.8%**++
Functional Limitation
Yes 91.0%** 94.2%**++
No 78.2%** 85.6%**++

Source: Analysis of the Urban Institute's Health Policy Center's ACS Medicaid/CHIP Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2008 and 2012.

Notes: See text for definitions of eligibility, participation, and uninsurance.

**(*) indicates estimate is statistically different from national estimate at the 0.05 (0.1) level.

++(+) indicates 2012 estimate is statistically different from 2008 estimate at the 0.05 (0.1) level.


The number of uninsured children eligible for public coverage has been declining but most remaining uninsured children are eligible for Medicaid or CHIP.

Between 2008 and 2012, the number of children eligible for Medicaid or CHIP but uninsured fell by about 1.2 million to 3.7 million and the estimated number of uninsured children fell from 7.2 to 5.4 million (Figure III.7). Over that period, more than a third of the states expanded coverage to new groups of children.34 Altogether, an additional 4.5 million children became eligible for Medicaid or CHIP between 2008 and 2012 as a consequence of a combination of the following: expansions of eligibility to new groups of children, increases in the total number of children, and shifts in the income distribution that made more children eligible for public coverage.

Figure III.7. Estimated Number of Uninsured Children (Ages 0 to18), 2008 and 2012 (in millions)

Figure III.7. Estimated Number of Uninsured Children (Ages 0 to18), 2008 and 2012 (in millions)

Source: Urban Institute’s Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS) from 2008 and 2012.

Notes: Estimates reflect an adjustment for the misreporting of coverage on the ACS (see Footnote 28).


As of 2012, an estimated 68 percent of uninsured children were eligible for Medicaid or CHIP but not enrolled in either program (Figure III.8). The remaining 32 percent of uninsured children were not eligible for Medicaid or CHIP coverage because of their immigration status (7 percent of all uninsured children, and 22 percent of the uninsured children who are not eligible for Medicaid or CHIP) or because their income levels exceeded Medicaid and CHIP eligibility levels (25 percent of all uninsured children, and 78 percent of the uninsured children who are not eligible for Medicaid or CHIP).

Figure III.8. Profile of Medicaid and CHIP Eligibility Among Uninsured Children, 2012

Figure III.8. Profile of Medicaid and CHIP Eligibility Among Uninsured Children, 2012

Source: Analysis of the Urban Institute’s Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model based on data from the Integrated Public Use Microdata Series (IPUMS).

Notes: Estimates reflect an adjustment for the misreporting of coverage on the ACS.


The high participation rates achieved in a large and growing number of states and for many subgroups of children suggest that there is the potential for additional increases in Medicaid and CHIP coverage among the remaining 3.7 million eligible but uninsured children, particularly among the states and groups that are lagging behind. As discussed later in Chapter IX, the vast majority of low-income parents reported that they would enroll their uninsured child in Medicaid or CHIP if told their child was eligible, but many of these families did not know that their child was eligible or how to apply for coverage, or they thought the enrollment and renewal processes were difficult to navigate. Moreover, evidence presented in Chapter VI on the extent of churning in public coverage and gaps in coverage between Medicaid and separate CHIP programs suggests that state policy choices can have substantial effects on how successful states are at enrolling and retaining children in Medicaid and CHIP and transferring them seamlessly between programs.


28 We analyze trends between 2008 and 2012 because 2008 is the first year that the American Community Survey included questions on health insurance coverage and 2012 was the most recent year that was available when these analyses were being performed.

29 Reported estimates of uninsurance from the ACS are lower than the CPS estimates of uninsurance presented earlier in this chapter (Figure III.1). Even though the ACS coverage estimates released by the Census Bureau are generally considered reliable and align fairly well with those from other surveys, the estimates presented here reflect a set of logical coverage edits that are applied if other information collected in the ACS implies that coverage for a sample case likely has been misclassified (Lynch et al. 2011). The edits bring the ACS estimates closer to distributions reported in other national surveys, such as the National Health Interview Survey (NHIS), and bring the Medicaid/CHIP coverage estimates from the ACS more in line with administrative totals. For more details, see Kenney et al. (2011).

30 Participation rates are the ratio of eligible children enrolled in Medicaid or CHIP to that number plus eligible children not enrolled in Medicaid or CHIP. We exclude the small number of children with both Medicaid/CHIP and employer-provided/union-based, military, or private nongroup coverage; we also exclude the children with Medicaid/CHIP coverage without a known eligibility pathway since we cannot include them in a consistent way.

31 Although six states showed a slight increase in uninsured rates for children over this period (AK, KY, MO, ND, RI and WY), the increases were not statistically significant.

32 There is substantial error in the measurement of program type based on the information available on the ACS which is why we do not provide participation rates for children who are eligible for different types of programs.

33 The Indian Health Service (IHS) is not typically counted as health insurance coverage because of limitations in the scope of available services and the geographic reach of IHS facilities. For most states, the participation rates do not change in a meaningful way when IHS was considered a source of health insurance coverage; however, in six states—Alaska, Montana, New Mexico, North Dakota, Oklahoma, and South Dakota—the participation rate increased by more than 2 percentage points when IHS was reclassified as insurance coverage when using data from 2009, with a particularly noticeable impact in Alaska. The other estimate sensitive to how IHS was treated was the participation rate among American Indian/Alaska Native children, which increased from 74.5 to 91.8 percent when the IHS was classified as health insurance coverage.

34 By 2011, 25 states and the District of Columbia had eligibility levels at or above 250 percent of the FPL; of those, 17 had thresholds of 300 percent of the FPL or higher, and nearly half of states covered lawfully residing immigrant children who had been in the country fewer than five years. See Heberlein et al. (2013) for more information.

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