CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. Summary of Major Findings

08/01/2014

Together, CHIP and Medicaid have contributed to declines in uninsurance among children.

From 1997, when CHIP was enacted, to 2012, the uninsured rate among all children declined by six percentage points and by even more (12 percentage points) among children with incomes below 200 percent of the FPL--the target population for Medicaid and CHIP. Racial and ethnic differences in uninsured rates for children also narrowed. In contrast, uninsured rates did not decline for low-income adults and increased for some groups, including low-income parents. Underlying the reductions in uninsurance among children were increases in Medicaid and CHIP coverage. Private coverage decreased among children since 1997, but the increases in public coverage more than offset those declines.

Participation in Medicaid and CHIP among eligible children increased under CHIPRA.

CHIP programs continued to evolve and innovate under CHIPRA, leading to streamlined enrollment and renewal procedures, expanded eligibility and outreach efforts, and new investments in quality measurement and care improvements for children. Despite declines in employer-sponsored insurance among children and adults during the most recent recession, rates of children’s health insurance coverage continued to increase since 2008, and the number of uninsured children who are eligible for Medicaid or CHIP but not enrolled fell from 4.9 to 3.7 million. Participation in Medicaid and CHIP increased nationwide from 82 to 88 percent between 2008 and 2012, and 21 states had participation rates at or above 90 percent in 2012. These states draw from all four census regions and vary in their racial and ethnic composition and other factors such as the degree of urbanicity, indicating it is possible to achieve high participation rates in Medicaid and CHIP under different local circumstances. The parents of over 80 percent of new CHIP enrollees reported that the application process was easy or very easy, and a third said they had received assistance with their application.

CHIP and Medicaid improved children’s access to needed care and reduced financial burdens and stress on their families.

Overall, CHIP programs were meeting the health care needs of most of the children who enroll based on information provided by parents surveyed in the 10 study states. Fully 96 percent of the parents of CHIP enrollees reported feeling confident that their children will be able to get the health care they need and 86 percent of children enrolled in CHIP had seen a doctor or other health provider in the past year. Moreover, enrollment in CHIP and Medicaid had clear benefits for children, particularly relative to going without coverage. For nearly every health care access, use, care, and cost measure examined, CHIP enrollees fared better than uninsured children--their parents reported less stress and substantially more confidence in their ability to get needed health care for their children, less trouble paying medical bills and substantially lower out of pocket spending on health care for their child, greater access to health and dental providers, fewer unmet health needs, and greater receipt of screenings, anticipatory guidance, and health care. Similar patterns were found for Medicaid enrollees in the three study states.

Access to care was similar for children with public and private coverage for most measures, but financial burdens were substantially lower under public coverage, and access to weekend and nighttime care was not as good.

Overall, children with Medicaid and CHIP coverage have similar service-use patterns and unmet needs relative to comparable children with private health insurance coverage, but on a few measures, Medicaid and CHIP differ from private insurance. CHIP and Medicaid enrollees are more likely to have access to dental benefits and much more likely to be protected from financial burdens associated with meeting their children’s health care needs, as reflected in lower out-of-pocket spending levels and fewer problems paying medical bills as reported by their families. The greater financial protection provided by Medicaid and CHIP coverage compared with private insurance likely also contributes to findings that parents reported being more confident that they will be able to meet their children’s health care needs and feeling less stress about doing so with Medicaid and CHIP coverage as opposed to private insurance. Relative to privately insured children, however, CHIP enrollees were less likely to have a regular source of medical care or a regular provider, and nighttime or weekend access at their usual source of care.

Relatively few low-income children with CHIP coverage have access to private insurance coverage, and the direct substitution of private for public coverage at the time of enrollment was estimated to be as low as 4 percent.

Just 13 percent of children enrolling in CHIP had private coverage in the prior 12-month period, according to their parents, and only 4 percent were estimated to have dropped private coverage in order to enroll in CHIP. Reported access to dependent coverage was limited among CHIP enrollees and even more so among Medicaid enrollees and the remaining low-income uninsured children—reportedly just 20 percent of CHIP enrollees, 16 percent of low-income uninsured children, and 5 percent of Medicaid enrollees could be covered on a parent’s ESI policy. Although some of the reduction in private coverage among children that has occurred since the inception of CHIP has been found to be the result of the expansions in Medicaid and CHIP coverage, many different studies have found that the majority appears to be the result of secular declines in ESI that also led to reductions in private coverage and rising rates of uninsurance among adults (Howell and Kenney 2012). An estimated 57 percent of CHIP enrollees in the ten study states had a parent who was uninsured; similarly, approximately 54 percent of children enrolled in Medicaid in the three study states of California, Florida, and Texas had an uninsured parent.

Despite progress, 3.7 million children who are eligible for Medicaid or CHIP remain uninsured. Variable retention across the study states suggests that efforts to streamline the renewal process through such things as automatic renewals and less frequent redeterminations have been more successful in some states.

Despite increasing Medicaid and CHIP participation rates and declining numbers of uninsured children in recent years, approximately four million children who are eligible for public coverage remain uninsured. Overall, 68 percent of all uninsured children are eligible for Medicaid/CHIP coverage but not enrolled. While over 90 percent of parents said they would enroll their uninsured child in public coverage if told their child was eligible, many did not believe that their child was eligible or know how to enroll them or where to go for more information. Moreover, 59 percent of low-income uninsured children had been enrolled in Medicaid or CHIP at some point in the past, many within the prior year. As a consequence, retention of eligible children who are enrolled in Medicaid and CHIP is critical to achieving further reductions in uninsurance among eligible children.

Some children cycled in and out of Medicaid and CHIP and had gaps in coverage in between.

Between 10 and 20 percent of the children who disenrolled from Medicaid and CHIP in the study states returned to the same program within seven months, experiencing periods of uninsurance in between. Transitions between Medicaid and CHIP were also common as income and other family circumstances changed, and while transitions between Medicaid and Medicaid expansion CHIP programs was nearly always seamless, children were more likely to experience temporary gaps in coverage of between two and six months when moving between Medicaid and separate CHIP programs. In terms of the median percentage across states, 40 percent of transitions from Medicaid to separate CHIP programs and 33 percent of those from Medicaid expansion to separate CHIP programs resulted in such a coverage gap; gaps were less common for transitions in the other direction, occurring for 16 and 11 percent of transitions from separate CHIP to Medicaid or Medicaid expansion programs, respectively. These findings suggest that coordination of movement from Medicaid to separate CHIP programs remains an issue and continued efforts to improve transitions between programs and the adoption of policies that simplify these transitions are needed. It remains to be seen whether the Affordable Care Act will reduce the gaps in coverage that result when children experience transitions in eligibility for different types of coverage.

There is some room for improvement in care provided to children.

While CHIP is providing dental and well-child checkups to four in five enrollees, there is room for improvement in care provided to some enrollees. In particular, one in four children enrolled in CHIP had some type of unmet need as reported by parents, with the most frequent unmet need being for dental services, reported for 12 percent. Although most CHIP enrollees received annual well-child checkups, many did not receive key preventive services such as immunizations and health screenings during those visits. And while 84 percent CHIP enrollees received annual dental checkups, a significant share was not getting recommended follow-up dental treatment and many had oral health problems, according to their parents. Gaps in care were also found among children with private coverage and were not unique to Medicaid and CHIP coverage.

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