Interim Evaluation Report: Congressionally Mandated Evaluation of the State Children’s Health Insurance Program. 2. The National Picture

02/26/2003

a. Program Awareness

In early 2001, almost all (91 percent) low-income uninsured children had parents who had heard of either Medicaid or the separate SCHIP program in their state. Awareness of Medicaid, at 87 percent, is much more common than of SCHIP, at 55 percent (see Figure 1). 31 As SCHIP programs mature, however, awareness of them has been growing. For example, awareness of SCHIP programs in existence in 1999 was 10 to 15 percentage points higher by early 2001 than it was in 1999. 32 And SCHIP programs launched at least 18 months prior to the fielding of the SLAITS survey were recognized by twice as many of the relevant respondents as more recently launched programs were.

Figure 1: Awareness of Medical and Separate SCHIP Programs

Early 2001

Figure 1: Awareness of Medical and Separate SCHIP Programs

Sourse Urban Institute tabulations of SLAITS National Survey of CSHCN, Preliminary Data File.

Notes: 1. Defined for those in states with separate SCHIP programs with different names than Medicaid programs: Alabama, Arizona, California, Colorado, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Maine, Michigan, Mississippi, Montana, Nevada, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Oregon, Pennsylvania, Texas, Utah, Virginia, Washington, West Virginia, and Wyoming.


b. Interest in Enrolling in Medicaid/SCHIP

The vast majority of respondents say they would enroll their children if told they were eligible. For example, among low-income uninsured children whose parents know of at least one of the programs, more than four out of five have parents who say they would enroll their child if told that the child was eligible (see Figure 2). Twelve percent have parents who say they would not enroll their uninsured child, and 6 percent have parents who do not know whether or not they would enroll their child. The stated interest in enrolling children in both programs is high, at over 75 percent; but it appears to be somewhat higher for SCHIP than for Medicaid. Among the low-income uninsured children whose parents had heard only of Medicaid, 77 percent had parents who said they would enroll their child if told they were eligible; among those whose parents had heard of both programs, 85 percent had parents who said they would enroll their child; and among the small number whose parents had heard only of SCHIP, 89 percent had parents who said they would enroll their child.

Figure 2: Perceptions of Eligibility for and Attitudes Toward Enrolling in Medicaid/SCHIP Programs

Early 2001

Figure 2: Perceptions of Eligibility for and Attitudes Toward Enrolling in Medicaid/SCHIP Programs

Source: Urban Institute tabulations of SLAITS National Survey of CSHCN, Preliminary Data File.


Furthermore, almost all parents whose children have been enrolled in either Medicaid or SCHIP previously have positive views about enrolling their children again. Nearly 9 out of 10, for example, say they would enroll or reenroll their child if told the child was eligible. And interest in enrolling children is similar among families whose children have previously been enrolled in Medicaid and families whose children have previously been enrolled in SCHIP. Eighty-eight percent of low-income uninsured children previously enrolled in Medicaid have parents who say they would enroll their child in Medicaid/SCHIP if told they were eligible, compared with 89 percent for previous SCHIP enrollees. The interest in enrollment is consistent with high levels of satisfaction with Medicaid and SCHIP reported by parents in focus groups who had experiences with the programs, as discussed above. The challenge of converting this expressed interest into actual Medicaid and SCHIP enrollment remains, however.

c. Beliefs about Eligibility

In spite of widespread program awareness and expressed willingness to enroll, the majority of parents with low-income uninsured children still do not understand that their children are eligible for coverage. According to the most recent estimates (Dubay, Haley, and Kenney 2002), 84 percent of all low-income, uninsured children actually qualify for coverage under Medicaid or SCHIP. But the parents of just under half of the low-income uninsured children whose parents have heard of either Medicaid or SCHIP believe that their child is eligible (see Figure 2). The rest of the parents either believe their child is not eligible (22 percent of children) or do not know (29 percent).

Older children are more likely than younger children to have parents who do not believe they are eligible. Specifically, school-age children (ages 6 to 12, and 13 to 17) are considerably less likely to have parents who think their child is eligible for coverage, than are preschool children (under age 6)--even though all children below a state's income eligibility threshold are eligible for coverage regardless of age (Ullman et al. 1999). 33 These findings strongly suggest that many parents of uninsured children are confused about Medicaid and SCHIP eligibility policies, and are unaware that eligibility is not a function of age.

d. Perceptions of Medicaid and SCHIP Application Processes

Many low-income parents with uninsured children who have heard of Medicaid and SCHIP programs have fairly positive views overall about both the Medicaid and SCHIP application processes. Still, a substantial minority has negative views, and a sizable group has no view at all. In addition, beliefs about the Medicaid process seem to be both more negative, and more intensely negative, compared to beliefs about SCHIP. For example, more parents say that applying for Medicaid is difficult than do so for SCHIP; in addition, parents are more likely to say that applying for Medicaid is very difficult as opposed to somewhat difficult. Among low-income uninsured children whose parents have heard of Medicaid, half have parents who believe it is very or somewhat easy to apply for Medicaid, a third have parents who believe it is somewhat or very difficult, and 15 percent have parents who do not know. In comparison, among the low-income, uninsured children whose parents have heard of the SCHIP program in their state, half have parents who believe it is very or somewhat easy to apply for SCHIP, 22 percent have parents who believe it is very or somewhat difficult, and 24 percent have parents who do not know.

Combining perceptions about the Medicaid and SCHIP application processes into a single indicator clarifies overall perceptions of the application processes. As measured by this indicator, 45 percent of all low-income uninsured children whose parents have heard of at least one of the two programs have parents who see the application processes as easy. This, however, leaves more than half (55 percent) with parents who either think the process is difficult or have too little information to form a view--strongly suggesting that the application processes themselves still constitute a potential barrier to enrollment.

It is encouraging that families who are the most familiar with the processes (that is, those whose children have had prior experiences with Medicaid and SCHIP) have significantly more positive views about the application processes and are much less likely to say they do not know how difficult or easy the processes are, compared to those with no prior experience. For example, about 60 percent of low income uninsured children with prior Medicaid experience had parents who thought the Medicaid application process was easy, while just 37 percent of those with no prior Medicaid experience believed this. Five percent of those with prior Medicaid experience had parents who did not know how easy/difficult the process was, compared with 31 percent of those with no prior Medicaid experience. At the same time, however, those with prior experience are just as likely as those with no prior experience to have negative perceptions of the process--for example, about a third of each group believed the Medicaid application process was difficult.

e. Potential Barriers to Enrollment

The discussion so far has identified several potential barriers to enrollment. Table 7 pulls this information together and categorizes children into five groups based upon the type of barrier their parents reported: lack of knowledge about the programs; problems with the enrollment system; both lack of knowledge and problems with the enrollment system; lack of interest; and no barriers identified. Nearly two-thirds (65 percent) of low-income uninsured children have parents who indicate a knowledge barrier (25 percent), an enrollment system barrier (20 percent), or both (20 percent). Thus, a large group of children appear not to be enrolled because their families lack information about the existence of the programs, their eligibility rules, and/or their enrollment processes; or because they have negative perceptions of those processes.

TABLE 7: 
POTENTIAL BARRIERS TO MEDICAID/SCHIP ENROLLMENT
FOR LOW-INCOME UNINSURED CHILDREN, EARLY 2001
Type of Barrier Percentage of Children
Knowledge Barriers Only 25
Not heard of either program (9 percent)  
Heard of at least one program, would enroll child, see application process as easy, but confused about eligibility (16 percent)  
Enrollment System Barriers Only 20
Heard of at least one program, would enroll child, not confused about eligibility, but do not see application process as easy (20 percent)  
Both Knowledge and Enrollment System Barriers 20
Heard of at least one program, would enroll child, confused about eligibility, and do not see application process as easy (20 percent)  
Lack of Interest Barriers 16
Heard of at least one program, would not enroll child (10 percent)  
Heard of at least one program, do not know if would enroll child (6 percent)  
No Barriers Identified 19
Heard of at least one program, would enroll child, not confused about eligibility, see application process as easy (19 percent)  
Total 100
Source: Urban Institute tabulations of SLAITS National Survey of CSHCN, 2001 Preliminary Data File.  

Only 16 percent indicate a lack of interest in enrolling. Those who say they would not enroll their child give various reasons for their unwillingness. But the most common reasons are: unwillingness to accept welfare or not wanting to be in a public program; no need for insurance for their child; and time-consuming application processes. Other data indicate that the children of parents who report not needing or wanting insurance tend to be in better health and have fewer unmet needs than other low-income uninsured children (Kenney and Haley 2001).34

Parents of the remaining 19 percent of children indicate no identifiable barrier related to enrolling in Medicaid or SCHIP. These families may be in transition in or out of the workforce, they may have applied for the programs and be awaiting a determination, or they may simply have not applied even though they intend to. Understanding more about this significant group is a key to states' efforts to facilitate program enrollment.


31. Knowledge of SCHIP programs was analyzed for the states with separate SCHIP programs in 2000/2001, with different names than Medicaid programs.

32. According to the National Survey of America's Families (NSAF), 47 percent of low-income uninsured children had parents who had heard of the separate SCHIP program in the 25 states with separate SCHIP programs in 1999 (Kenney et al. 2001). When we reexamined awareness of separate SCHIP programs in those same states in 2001, using the SLAITS, we found that 62 percent of the low-income uninsured children had parents who had heard of these programs. In contrast, we found virtually no difference in the proportion of low-income uninsured children whose parents had heard of Medicaid in these two years, using the two surveys.

33. However, whether the child is eligible for Medicaid or SCHIP does vary by age in some states.

34. Analysis from the 1999 National Survey of America's Families (NSAF).

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