Gaps in Outreach and Awareness.States beginning to implement their SCHIP programs faced the challenge of reaching out to a large and diverse population of low-income families with uninsured children, who may never have been enrolled in a public assistance program. Outreach has not been uniformly effective across states or across subpopulations, and more work is needed to increase program awareness and understanding of SCHIP and Medicaid program rules among families, regardless of race, ethnicity, or age of children.
Among low-income families with uninsured children, those least aware of SCHIP are Hispanic families interviewed in Spanish and the very poorest families (that is, those below 50 percent of the poverty level). Many low-income parents with uninsured children, though they are aware of Medicaid and SCHIP, do not believe that their children are eligible. Confusion about who is eligible is most common among parents of Hispanic children interviewed in Spanish, parents of white children, parents of older children, and parents of children in families with higher incomes.
Application Process Widely Perceived as Difficult.Fewer than half of all low-income uninsured children whose parents had, in 2001, heard of at least one of the two programs have parents who view the Medicaid and SCHIP application processes as easy. Negative perceptions are more widespread for the Medicaid program than for SCHIP (32 versus 22 percent). This result is consistent with focus group participants' comments comparing Medicaid and SCHIP application processes. (Focus group participants also reported negative experiences in the past with Medicaid applications.) Less-educated parents and those interviewed in Spanish more often reported difficulties with the application process. Thus, making the application process for the programs easier and more accessible to parents from diverse ethnic backgrounds and educational levels remains as a program challenge.
More Coordination Needed.SCHIP and Medicaid together offer the potential for seamless coverage so that children whose family's income changes can move between the programs without disruption, and families with children in both programs need not navigate two distinct systems. However, coordination has not yet been perfected in states that operate separate SCHIP programs. While separate programs appear to enjoy high levels of support, case study respondents in states with such programs reported that coordinating SCHIP and Medicaid poses significant challenges. These challenges stem from differences between the two programs' eligibility rules, administrative structures, and delivery systems. Even minor discrepancies in eligibility policy between the two programs can complicate the "screen-and-enroll" procedures, required by law to place children into the program for which they are eligible. Likewise, focus group participants found differences between the programs to be confusing.
Understanding Why Children Leave the Program. As state programs mature, an emerging challenge is tracking the retention and disenrollment of eligible children and understanding the reasons for disenrollment of eligible children. No one yet knows what "reasonable" rates of retention or disenrollment are, and the availability and quality of data on the reasons for disenrollment are limited. Although disenrollment might appropriately result from changes in employment, income, access to employer-sponsored insurance, or other factors, there is a concern among state officials interviewed in the case studies that administrative barriers (for example, redetermination procedures) and confusion among parents of enrolled children are significant causes of disenrollment. This concern was also found in the statements of some focus group participants who reported that they had not intended to disenroll their children, but did not realize what the renewal process entailed.
Lingering Resistance to Medicaid. Despite the positive views about Medicaid among many families whose children have been enrolled in the program, Medicaid is not always viewed so positively. Providers have often been reluctant to accept Medicaid patients, mostly because of low Medicaid payment rates in the past. Some families are reluctant to enroll in Medicaid; their reasons include past difficulties applying, the stigma arising from Medicaid's longstanding linkage to the welfare program, and the concern among immigrant families that receipt of Medicaid could jeopardize their immigration status or their efforts to obtain citizenship. These perceptions were reportedly one of the factors that led some states to choose separate SCHIP programs rather than Medicaid expansions.
Gaps in Access.Despite the broad benefits offered by Medicaid and SCHIP, early success enrolling health plans and providers into SCHIP networks, and reported good access to primary and preventive care, focus group participants and case study respondents indicate that families still have difficulty obtaining some covered benefits, particularly dental and certain specialists' services.
Access in rural areas is reported to be more limited than in urban areas. Some states have responded to the limited number of providers in rural areas and provider rejection of capitated managed care by introducing "exclusive provider organizations," which recruit and extend to families an identified network of primary care physicians for their children.
Maintaining Provider Payment Levels. Most states employ capitated managed care for the majority of their SCHIP enrollees. Lacking an alternative basis for setting capitation rates, state officials have typically paid health plans participating in SCHIP the same (or nearly the same) rates they pay under Medicaid. Likewise, health plans have most often elected to pay their providers according to the fee schedules they use in Medicaid. In states where providers view these rates as unfairly low, case study respondents were concerned about reduced provider participation and potential reductions in access to care.