The Children’s Health Insurance Program (CHIP), a landmark initiative to help close the health insurance coverage gap for low-income children, celebrated its 15th anniversary in August 2012. Together with Medicaid, CHIP has helped fuel a decline in the number of uninsured children, which has fallen from 11.4 million (15.1 percent of children) in 1997 when CHIP was enacted to 8.0 million (10.0 percent of children) in 2010 (Current Population Survey, Annual Social and Economic Supplement 2011). In February 2009, the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) reauthorized CHIP and funded it through 2013. Funding for CHIP was further extended to 2015 by the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act).
Congress provided states with new tools and new funds through CHIPRA to address shortfalls in enrollment, as well as in access to, and quality of, care (Harrington et al. 2011). One of these new options is a policy that implements CHIPRA section 203 called Express Lane Eligibility (ELE). With ELE, a state’s Medicaid and/or CHIP program can rely on another agency’s eligibility findings to qualify children for public health coverage, despite their different methods of assessing income or otherwise determining eligibility. ELE thus gives states another way to try to identify, enroll, and retain children who are eligible for Medicaid or CHIP but who remain uninsured. The concept of using data from existing government databases and other means-tested programs to expedite and simplify enrollment in CHIP and Medicaid has been promoted for more than a decade; before CHIPRA, however, Federal law limited state reliance on information from other agencies (Families USA 2010; The Children’s Partnership 2012). CHIPRA also gave states an incentive to implement ELE by making it one of the eight policies states could adopt to qualify for performance bonus payments (CHIPRA section 104).
The ELE option is intended to simplify the identification, enrollment, and retention of uninsured children eligible for CHIP or Medicaid. In turn, this simplification process may produce gains in coverage, as families who might otherwise not apply for (or renew) coverage for their eligible children, or might not complete this process successfully, are able to do so. Although prior research on ELE’s possible coverage effects is limited, the available evidence supports the potential of the policy to produce meaningful gains in coverage. For example, using ELE to qualify children for health coverage based on their participation in the Supplemental Nutrition Assistance Program (SNAP), Kenney et al. (2010) estimate that ELE could reach 15.4 percent of eligible, uninsured children. Using ELE to qualify children for health coverage based on state income tax records could reach even more children: an estimated 89 percent of uninsured children who qualify for Medicaid or CHIP live in families who file Federal income tax returns (Dorn 2009). Presumably, a large proportion of these families file state tax returns as well, particularly in states that supplement the Federal Earned Income Tax Credit. A recently published descriptive analysis of the ELE program in Louisiana reported that state officials attribute the decline in the percentage of uninsured children who qualified for Medicaid from 5.3 percent in 2009 to 2.9 percent in 2011 to the state’s ELE policy, implemented in February 2010 (Dorn et al. 2012).
CHIPRA requires an evaluation of ELE, with reports of evaluation findings to be submitted to Congress. In September 2011, a contract was awarded to Mathematica Policy Research and its subcontractors, the Urban Institute and Health Management Associates, to conduct the evaluation, which is being overseen by the Office of the Assistant Secretary for Planning and Evaluation (ASPE).
CHIPRA specifies that the ELE evaluation include four components:
- An evaluation of the administrative costs or savings related to identifying and enrolling children through ELE methods compared to the costs of identifying and enrolling eligible but unenrolled children through the state’s regular methods
- An assessment of whether ELE improves a state’s ability to identify and enroll eligible but unenrolled children
- Recommendations for legislative or administrative changes that would improve ELE’s effectiveness as a method for enrolling or retaining children in Medicaid or CHIP
- A report on the percentage of children erroneously enrolled in Medicaid or CHIP based on the Express Lane agency findings
This interim report is the first of two reports to Congress that will fulfill the statutory requirements; it addresses the first of the four CHIPRA-specified components, with the latter three components to be addressed in the second report to Congress, due in September 2013. This report has three purposes:
- To describe existing ELE programs, including the costs and new enrollment trends associated with ELE implementation
- To estimate the impact of ELE adoption on total enrollment
- To preview the issues that will be examined through future evaluation activities and presented in the final evaluation report, due to Congress in September 2013
This report describes the nine programs approved for ELE as of April 2012, providing a descriptive analysis of the costs associated with ELE implementation in six of these states (Alabama, Iowa, Louisiana, Maryland, New Jersey, and Oregon); it also provides a descriptive analysis of the new enrollment trends in Alabama, Iowa, Louisiana, and New Jersey; it estimates the impact of ELE adoption on total enrollment in eight ELE states (Alabama, Georgia, Iowa, Louisiana, Maryland, New Jersey, Oregon, and South Carolina); and it previews issues that will be examined through future evaluation activities and presented in the final evaluation Report to Congress to be submitted in September 2013. This report draws on primary and secondary data sources, including qualitative data collected through interviews with program administrators in six states, and quantitative (enrollment) data obtained both directly from selected ELE states and from the CHIP Statistical Enrollment Data System (SEDS), a reporting system maintained by the Centers for Medicare & Medicaid Services (CMS) since 2000 that collects new and total Medicaid and CHIP enrollment data from all states on a quarterly basis. The report also draws on other secondary data to support the qualitative analysis, including published and unpublished literature on CHIP, CHIPRA, and ELE, to supplement the main data sources and to provide motivation and context for the findings in each chapter. Sources include state plan amendments, ELE and standard application forms, and state budget and performance reports. And, likewise, to support the analysis of the SEDS data, the report draws on several sources, including data from the Bureau of Labor Statistics, U.S. Census Bureau, and Kaiser Family Foundation.