CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. V. Medicaid and CHIP Enrollment Trends in the 10 Study States, 2007 - 2012

08/01/2014

KEY FINDINGS:

  • Enrollment in both Medicaid and CHIP grew steadily from 2007 to 2012, with the strongest growth in 2009, the second year of the recent recession.
  • While most CHIP enrollees (80 percent) in the 10 study states were enrolled in separate CHIP programs, that number is expected to decline in the future because of Affordable Care Act requirements.
  • Medicaid and CHIP worked as intended to provide an insurance safety net for low-income children, particularly during times of economic hardship.

In this chapter, we report findings on Medicaid and CHIP enrollment trends for the 10 study states during the five-year period from late 2007 to late 2012.39 We also show the relative influence of new enrollment and disenrollment on observed enrollment trends.

Enrollment in Medicaid and CHIP grew steadily from 2007 to 2012, with the strongest growth in 2009, the second year of the recent recession.

Across the 10 study states, the number of children enrolled in public coverage increased from 13.8 to 17.3 million over the five-year period, a 26 percent increase (Figure V.1). Growth was particularly strong during the first three years of the period, with growth rates above 5 percent in 2008, 2009, and 2010. In 2011, growth slowed to 3 percent, then to 1.7 percent in 2012 (data not shown). The growth in public coverage was driven by increases in Medicaid, which was the dominant program in each of the 10 states, covering approximately 80 percent of all publicly insured children over the period.

The majority of CHIP enrollees in the 10 states were enrolled in separate CHIP programs, but the proportion in separate programs is expected to decline over time as the Affordable Care Act is implemented.

Approximately 80 percent of CHIP enrollees across the 10 states were enrolled in separate CHIP programs. This ratio was consistent over the period until late 2011, when New York became the first state in our sample to implement the transition of children in families with income between 100 and 133 percent of the FPL from its separate CHIP program to its Medicaid program. As New York shifted these children during their annual renewal process, the percentage of CHIP enrollees in separate state programs dropped to 77 percent across the 10 states. We expect this trend to continue, as Affordable Care Act rules require states to cover children in these eligibility/age categories in Medicaid. California had begun doing so when this report was written, nearly eliminating its separate CHIP program for children in 2013.40

Figure V.1. Trends in Enrollment in Public Coverage among Children for 10 Study States, by Program Type, November 2007–October 2012a

Figure V.1. Trends in Enrollment in Public Coverage among Children for 10 Study States, by Program Type, November 2007–October 2012

Source: Mathematica analysis of enrollment data provided by states

Notes: S-CHIP = separate CHIP program; M-CHIP= Medicaid expansion CHIP program

a We used November 2007 as the starting point for all analyses because it is the earliest month for which we have consistent data for all the study states. We used October 2012 as the end point for many analyses, as many states exhibit dips in enrollment during the last quarter that are likely attributable to administrative data lags.


Medicaid and CHIP programs worked as intended to provide an insurance safety net for low-income children, particularly during times of economic hardship.

Over the five-year period, consistently more children were enrolling in rather than leaving public insurance, although this gap narrowed in 2011 and disappeared in 2012 (Figure V.2). New enrollment peaked during 2009 and largely remained above the period monthly average in new Medicaid enrollment (370,000) through 2010. The trend suggests that growth in public health insurance coverage helped counter the impact of the recession on children’s health insurance coverage. In addition to more children entering public coverage during the recession period, fewer children were exiting. We observe a corresponding dip in monthly disenrollment from public coverage in 2009, lasting through 2010.

Figure V.2. Trends in New Enrollment and Disenrollment in Public Coverage Among Children for 10 Study States, November 2007–October 2012

Figure V.2. Trends in New Enrollment and Disenrollment in Public Coverage Among Children for 10 Study States, November 2007–October 2012

Source: Mathematica analysis of state-provided administrative data
Note: Top 10 enrollment group months (shown with the grey bars) indicate the 10 months with the largest month-over-month increase (percent) in net enrollment.


Medicaid Enrollment. The monthly change in Medicaid enrollment is strikingly consistent with changes in the average unemployment across the 10 states over the five year period, as seen in Figure V.3. Medicaid enrollment in the 10 study states increased 27 percent, from 11.1 million to 14.2 million between November 2007 and October 2012.41 The largest increases occurred in early 2009, during the height of the recession, after which there was a gradual decline in the growth rate between 2010 and 2012.

CHIP Enrollment. Unlike Medicaid, in which enrollment growth was generally consistent with the trend in the unemployment rate, the monthly change in CHIP enrollment was more uneven. Between November 2007 and October 2012, CHIP enrollment in the 10 study states increased by 24 percent, with 582,129 more children enrolled in October 2012 than five years earlier. As we show in Figure V.4, the largest increase occurred during the first year of our data (a 9.5 percent yearly growth rate from November 2007 to October 2008), coinciding with the first year of the recession, after which yearly CHIP enrollment growth fluctuated between 2.4 and 3.3 percent.

Figure V.3. Monthly Change in Children’s Medicaid Enrollment Relative to the Unemployment Rate for 10 Study States, November 2007–October 2012

Figure V.3. Monthly Change in Children’s Medicaid Enrollment Relative to the Unemployment Rate for 10 Study States, November 2007–October 2012

Source: Mathematica analysis of state-provided administrative data


Figure V.4. Monthly Change in Children’s CHIP Enrollment Relative to the Unemployment Rate for 10 Study States, November 2007–October 2012

Figure V.4. Monthly Change in Children’s CHIP Enrollment Relative to the Unemployment Rate for 10 Study States, November 2007–October 2012

Source: Mathematica analysis of state-provided administrative data


Taken together, these findings suggest that state Medicaid and CHIP programs served as an insurance safety net during this time of economic hardship. We note a pattern where the first year of the recession coincided with the largest increases in CHIP enrollment in the period studied; as higher income families faced unemployment and cuts in employer sponsored coverage, families turned to CHIP programs for coverage. Then as the economy continued on its downward trend and family incomes continued to drop, new enrollment in Medicaid began to spike and disenrollment in these programs fell, with the greatest increases in Medicaid enrollment occurring in 2009 and 2010. These patterns highlight the essential role that both Medicaid and CHIP play in ensuring that low-income children have health insurance and show a counter-cyclical safety-net system working as intended.


39 Further details on findings reported in this chapter appear in a memorandum submitted to ASPE by Orzol et al. (2013).

40 California continues to cover the conception to birth population in its separate CHIP program.

41 Together, the 10 study states represent just under 50 percent (47.9) of all children enrolled in Medicaid as of 2012 (Statistical Enrollment Data System (SEDS); these data are available at: http://medicaid.gov/Federal-Policy-Guidance/Downloads/FY-2012-Childrens-....

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