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

02/26/2003

As a result of the outreach and enrollment procedures discussed above, the six study states enrolled more than 1.5 million SCHIP enrollees by September 2001 (see Table 11). 41 Most of these enrollees were in California, New York, and Texas, which have the three largest programs in the nation, each with between 400,000 and 500,000 children enrolled. The states with smaller populations--Colorado, Louisiana, and Missouri--had enrolled fewer than 100,000 children. In every state, SCHIP enrollment is dwarfed by that of Medicaid (for children).

TABLE 11: 
SCHIP AND MEDICAID ENROLLMENT
State SCHIP Enrollment (2001)a Medicaid b Child Enrollment (FFY2000)
California 475,795 3,243,667
Colorado 36,536 196,695
Louisiana 63,046 450,806
Missouri 75,856 432,899
New York 479,973 1,510,433
Texas 432,745 1,612,401
Total 1,563,951 7,446,901

Notes: 
aPoint-in-time data for the most recent month available, which is September 2001 for all states. 
bChildren's programs under Title XIX. Children under age 19 ever enrolled during federal fiscal year 2000.

Source: SCHIP enrollment figures: State administrative data; Medicaid: Kaiser Family Foundation. State Health Facts Online. Medicaid enrollment figures: Rosenbach et al. 2002.


Enrollment in the study states grew significantly during the first three years of SCHIP, as seen in Figure 4, but trend lines vary across the states. Whereas California, Colorado, Louisiana, and Missouri experienced fairly steady growth, Texas' enrollment increased dramatically with the implementation of its Phase 2 TexCare program in April 2000; and New York's enrollment recently began to decline as a result of low renewal rates (see Chapter IX). Figure 5 illustrates the percentages of their goals that states have enrolled. 42 Target attainment varies widely from a high of 101 percent in Texas, to a low of 53 percent in Colorado; California, Louisiana, Missouri, and New York each enrolled 68 percent or more of their target populations of children, as of late 2001.

FIGURE 4: SCHIP ENROLLMENT TRENDS FOR THE STUDY STATES

FIGURE 4: SCHIP ENROLLMENT TRENDS FOR THE STUDY STATES

SOURCE: Centers for Medicare and Medicaid Services (CMS), “State Children’s Health Insurance Program (SCHIP) Aggregate Enrollment Statistics for the 50 States and the District of
Columbia for Federal Fiscal Years (FFY) 2000 and 1999.”
Web site [http://cms.hhs.gov/schip/fy99-00.pdf]
Vernon K. Smith, “CHIP Program Enrollment: December 2000,” Kaiser Commission on Medicaid and the Uninsured, September 2001.
Colorado Department of Health Care Policy and Financing (HCPF)
Louisiana Department of Health and Hospitals, Medicaid Division
Managed Risk Medical Insurance Board. Health Families Program Enrollment History. Web site [http://www.mrmib.ca.gov/MRMIB/HFP/HFPRptHG.html]
Missouri Department of Medical Services
Web site [http://www.dss.state.mo.us/mcplus/index.htm]
New York State Department of Health.
Web site [http://www.health.state.ny.us/nysdoh/chplus/index.htm]
Texas Department of Health Services. Cumulative DHS CHIP Status Report (Updated Weekly): CHIP Enrollment and Referrals, September 04, 2001. TexCare Partnership Web site: [http://www.hhsc.state.tx.us/chip/DHSrpt.pdf]


FIGURE 5: SCHIP ENROLLMENT TRENDS AS A PERCENTAGE OF THE TARGET FIGURE FOR EACH STATEFIGURE 5: SCHIP ENROLLMENT TRENDS AS A PERCENTAGE OF THE TARGET FIGURE FOR EACH STATESOURCE: See Sources Figure 4.


Most state officials were highly satisfied with their enrollment success. They were pleased with the simpler enrollment systems, as well as the success of outreach in building strong program recognition and persuading large numbers of families to enroll their children. Community-based application assistors, working in a variety of settings, appear to be an important ingredient in achieving high enrollment. Satisfaction varied among other case study respondents, both across the study states and within each state. Comments from case study respondents in the states that used application assistance the most (those with separate programs) include the following:

  • In California, state officials, advocates, and local-level enrollers consistently believed that the state had improved after a shaky start. The launch of Healthy Families was marred by the state's use of a 28-page form, which was universally criticized as unworkable. By early 1999, state officials, working closely with advocates and other interested groups, had developed a simpler, four-page form and designated its vendor, EDS, as the "single point of entry" for all applications. These improvements helped increase enrollment, beginning in late 1999. The case study respondents also pointed to steady expansion and growth in funding for application assistance as crucial to reaching hard-to-reach groups and improving the state's enrollment of Hispanic children, who now comprise roughly 70 percent of all enrollees, commensurate with the representation of low-income Hispanic children.
  • In New York, state officials believe that it takes time to increase enrollment. They had an advantage over most states in building SCHIP on a state-funded initiative that had been in place for six years before SCHIP enactment. Most case study respondents felt that health plans had been successful partners in outreach and enrollment. With careful oversight and monitoring by the state, these plans had aggressively identified and enrolled eligible children. With the addition of Facilitated Enrollment in mid-2000, New York appears to have improved its screen-and-enroll capability.
  • In Texas, enrollment grew rapidly beginning in April 2000, coincident with the launch of its separate program, TexCare. While some criticized the state's slow start, which left many thousands of children uninsured during its two-year planning phase, within 18 months of start-up, Texas' enrollment had reached nearly the level of enrollment in California and New York. State officials attribute this success to two years of careful planning of outreach and enrollment strategies that drew heavily on the input of consumers, advocates, and other groups interested in expanding insurance coverage for children, as well as on observations of strategies that had worked in other states.
  • In Colorado, case study respondents believed that enrollment growth could have been greater. While they viewed the SCHIP eligibility process as dramatically simplified, they also cited factors that had suppressed enrollment, including a complicated joint application form (recently revised and improved), inconsistencies in SCHIP and Medicaid rules, sometimes problematic relationships between SCHIP and county social services agencies, and a premium structure that may have induced consumer resistance to the program, especially in light of the state's existing low-cost Indigent Care Program (see Chapter XII which discusses cost sharing).

41. Table 11 presents the latest point-in-time enrollment estimates for Medicaid and SCHIP.

42. These targets do not represent the total number of low-income uninsured children eligible for SCHIP in each state; also, states employed different assumptions to set these targets. The targets do, however, reflect policymakers' program goals and are the benchmarks against which they judged whether they were achieving their goals.

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