Examining Substitution: State Strategies to Limit "Crowd Out" in the Era of Children's Health Insurance Expansions. B. The September 9th roundtable discussion was designed to identify state experiences with and future concerns regarding substitution, especially as it impacts expansions under the provisions of Title XXI.


The purpose of the September 9th discussion entitled "A Roundtable Discussion on State Experiences Regarding Crowd Out and Children's Health Insurance" was to: (1) discuss concerns of states that have been considering and addressing the issues of real and/or potential substitution effects in their efforts to expand health insurance for children; (2) consider the implications of research in the context of such state experiences; and (3) examine and explore these state experiences in order to identify issues and implications for future changes under Title XXI of the Social Security Act.

The following set of questions represents the issues discussed on September 9th. These questions were designed to address the complexity of the issues including those factors that might mediate substitution. The questions were divided into the following four categories:

  • Defining Substitution

    · What are the real program concerns regarding substitution?

    · What are the political concerns?

    · What is the real problem? (e.g.,, "crowd out," "push out," or "opt out")

  • Financing and Market Issues

    · Is the problem grounded in the concern that programs will not be able to pay for all of the children who have decided to enroll?

    · Is the concern that employer-based coverage is going to erode in the market as other state options are becoming available to the public?

    · Is there really a different problem between employer-sponsored insurance and individual coverage?

  • Determining Demographics

    · Will programs have the ability to assist children already enrolled in private insurance programs in such a way that it does not replace existing coverage?

    · Is substitution really occurring among individuals who have appropriate access to employer-sponsored coverage? (e.g., individuals who have access to affordable family coverage)

  • Considering Other Concerns

    Will this be viewed as a transition program or as a permanent replacement of insurance for eligible children?

The information collected through initial interviews and the September 9th roundtable discussion are the basis for this qualitative analysis which focuses on accurately reporting both state experiences with substitution and presenting additional issues that will need further exploration. This analysis identifies issues states are facing as they plan and implement programs to cover uninsured children at higher income levels. Moreover, this study points out the lack of data surrounding substitution, which limits state and federal officials' ability to evaluate possible solutions. Researchers and federal representatives participating in the roundtable discussion provided the context in which these concerns might be addressed (e.g., the collection of appropriate data, enrollment processes, and market-based issues, etc.).