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

02/26/2003

High Enrollee Satisfaction.State officials and advocates responding to case study interviews report that families are satisfied with SCHIP. Focus group participants with children enrolled in SCHIP and Medicaid bear out these reports. Families like the low price, the range of benefits, and the access to providers that the programs offer. While these findings must be considered preliminary, the survey of parents in ten states, whose findings will be reported in the final Report to Congress, will provide richer and more detailed information about enrollee satisfaction.

Millions of Low-Income Children Enrolled. The flexibility afforded by Title XXI allowed states to adopt the program designs that best met their needs. Some states elected Medicaid expansions both as a means of extending Medicaid's broad coverage to more children and because it was administratively efficient. Others chose separate programs in order to use features of private insurance, and sometimes to avoid saddling the new program with longstanding negative associations that many had with Medicaid. Regardless of their program choice, however, most states enjoyed strong support for implementing a SCHIP program.

States began implementing their SCHIP programs soon after the law was passed, and enrollment has grown continuously ever since. By the end of 1998, about 1 million children had been enrolled (CMS, 2002). Enrollment grew steadily so that by FY 2002, 5.3 million children were covered under the program at some time during the year--a 15 percent increase over the numbers enrolled in FY 2001. The growth from year to year was fueled both by increases in the number of states operating a program (all but two states had programs up and running by the second anniversary of SCHIP's enactment) and by aggressive outreach to and simpler enrollment processes for families with eligible children. While quantitative evidence is scant, state officials who were interviewed in the study states indicate that Medicaid enrollment has increased as a result of SCHIP outreach.

Streamlined Program Entry.Nearly all states developed simple application and enrollment processes for their separate SCHIP programs. Aspects of typical SCHIP application processes include short, joint applications for SCHIP and Medicaid, mail-in application options, and telephone-based or local hands-on application assistance. Few use an asset test (a common feature of Medicaid applications in the past for families and children on welfare), and many have 12-month continuous eligibility periods and require only minimal documentation to prove eligibility. State officials believe that these features have been crucial to their successful enrollment of children in SCHIP.

Some of the design features of SCHIP have spilled over to Medicaid. For example, due to reforms in California and Texas, children can now apply for Medicaid, too, by mail, and documentation requirements have been reduced. To the extent that such reforms make Medicaid and SCHIP more alike, coordination and family transitions between the two programs become smoother. The cumulative effect of the streamlining has been a "reinvention" of public health insurance--a replacement of the old welfare-style program with a more accessible, consumer-driven program.

Strategic Outreach.Based on their experience, states have continued to adopt new outreach strategies for SCHIP that they expect to be more effective. While the early emphasis in outreach was on statewide mass media campaigns to establish an identity for the new programs, community-based efforts have since played an increasingly important role. Community-based outreach, often conducted by local organizations and trusted community groups, is often used to target hard-to-reach families and subpopulations.

Broad and Affordable Benefits.Medicaid benefits are usually more comprehensive than benefits covered under separate state SCHIP programs. But SCHIP programs, too, offer broad benefits that were consistently described as much broader than benefits offered in private health insurance. Case study respondents and focus group participants said SCHIP benefits met the needs of the vast majority of children.

Many states require modest cost-sharing, including premiums, enrollment fees, and co-payments in their separate SCHIP programs. According to case study respondents interviewed for this study, as well as most focus group participants, families consider the cost-sharing reasonable and not overly burdensome, financially. Also, many of those interviewed support the cost-sharing requirements in SCHIP because they believe that they encourage "pride of ownership" and appropriate use of services. An additional reason that states have included cost-sharing is to discourage families with private insurance coverage from disenrolling from that coverage and substituting public coverage. However, the impacts of premiums on SCHIP participation will be rigorously assessed later in this study.

Apparent Good Access to Care. Overall, access to care under SCHIP was described by case study respondents as good, especially in urban areas. In large part, this was attributed to states' widespread use of managed care arrangements, which have reportedly helped increase both the supply of participating providers and the number of children with a "medical home." Where Medicaid programs use service delivery arrangements similar to those used by SCHIP--most often in urban areas--access to care for Medicaid enrollees was also described as good.

Positive Attitudes toward SCHIP and Medicaid.The steady growth in SCHIP enrollment confirms that the programs are successful in providing coverage for low-income children. Families want to and will enroll their children in affordable health insurance. Analyses of low-income families' knowledge and attitudes toward SCHIP and Medicaid showed that fully 82 percent of low-income uninsured children whose parents had heard of either Medicaid or SCHIP, or both, say they would enroll their children if told they were eligible. In addition, 88 percent of parents of low-income, uninsured children who have been enrolled in Medicaid in the past have positive views about enrolling their children again (Kenney et al. 2002).

Although awareness of SCHIP among low-income families still lags behind awareness of Medicaid (55 percent versus 87 percent in early 2001)--as might be expected given that SCHIP is relatively new--awareness of the program appears to be increasing over time among low-income families with uninsured children. Widespread interest in enrolling their children among parents who had heard of Medicaid and SCHIP, suggests that improving awareness of the programs and understanding of eligibility rules could lead to further increases in enrollment.

Ongoing SupportSupport for SCHIP has been strong and steady since the program's inception. The enhanced federal match for SCHIP made it popular with the states, and states have been using their tobacco settlement dollars and general appropriations to fund their portion of the program. Despite the softening economy, most state officials we interviewed pointed to broad-based support for the program and predicted a positive future.

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