By Anna S. Sommers, Lisa Dubay, Linda J. Blumberg, Fredric E. Blavin, and John L. Czajka
Health Affairs
August 7, 2007
In 2004 approximately six million children were eligible for public health insurance through Medicaid or the State Children’s Health Insurance Program (SCHIP) but remained uninsured at least part of the year. These numbers reflect one of the biggest challenges facing the public health insurance system for children today: how to reduce the number of uninsured eligible children and increase continuous coverage for children enrolled. These issues are a major policy concern because the uninsured are more severely ill when diagnosed and receive less therapeutic care than the insured, resulting in higher mortality. Parents of uninsured children report worrying all the time that their children will get hurt and need medical care. Children with discontinuous coverage are more than thirteen times as likely to delay care as are children who are continuously insured.
Only nine states and the District of Columbia administer SCHIP solely as a Medicaid expansion, relying on the same benefits and provider networks but applying different eligibility rules. In all other states, certain populations are enrolled in a separate SCHIP program, with more limited benefits and a different provider network, and some families are required to pay copayments and premiums.
Churning in and out of public coverage is a well-documented burden in Medicaid. In addition, about two million children move between Medicaid and SCHIP each year. Less well understood is the underlying eligibility dynamics of children, which could be of a much larger magnitude than is apparent from studying enrolled populations. In 2002, thirty-six million children were eligible for either program during the year. Because eligibility depends on a child’s age, family income, and assets, and, in SCHIP, access to private coverage, a change in any of these factors can trigger changes in eligibility.
In this study we analyze eligibility dynamics in Medicaid and SCHIP for children over the period 1996-2000. (Changes in the Census Bureau’s Survey of Income and Program Participation after 2000 made it impossible to continue tracking past that date.)
Study Results
Over the full course of the four-year panel, 66 percent of all children (fifty-nine million) were eligible for either Medicaid or SCHIP at some point during the panel. By comparison, point-in-time estimates are much lower and show that 33 percent of all children in the first wave of the panel and 46 percent in the last wave were eligible for either program.
More than one-third of all children who were ever eligible for Medicaid during the panel were also eligible for SCHIP in other waves, while nearly three-fourths of all children who were ever eligible for SCHIP during the panel were also eligible for Medicaid in other waves.
Overall, 32 percent of all eligible children were eligible for both Medicaid and SCHIP during the course of the panel, representing about one-fifth of all children, or almost nineteen million children. Another 57 percent were eligible only for Medicaid, and 12 percent were eligible only for SCHIP. About one in five children (18 percent) were always eligible for either Medicaid or SCHIP in every wave of the panel, while 48 percent of all children were eligible for only some waves, and the remaining third were never eligible.
The sometimes eligible children represent 73 percent of children who were eligible at any point, while the always eligible constitute 27 percent. About half of the sometimes eligible became SCHIP-eligible, compared with 29 percent of the always eligible. Eligibility for public coverage is often characterized by interruptions in eligibility. All of the sometimes eligible were ineligible for both programs in at least one wave, and 56 percent had two or more distinct spells of eligibility. Overall, 41 percent of all eligible children had multiple spells of eligibility.
Many eligible children–42 percent–faced at least some period of uninsurance while eligible, although only 7 percent remained uninsured for the entire period they were eligible. Forty-four percent of eligible children were covered by Medicaid or SCHIP during at least one eligible wave, while 66 percent were covered by private insurance.
Churning in and out of public coverage has historically been blamed on administrative barriers; however, fluidity in eligibility is an important contributor that affects a broader population of children.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.5.w598v1
Comment:
By Don McCanne, MD
Let’s see. What is it they keep telling us? We don’t want to disrupt what is working by throwing out our existing private insurance plans and public programs, but instead we to need to fix what isn’t working. And we should begin by getting all children insured.
As we consider using our current financing system to expand coverage to everyone, the children are the easy part of that problem. Children are a relatively healthy subset of our population with a low incidence of chronic disease and catastrophic medical events (though they do occur and that, plus preventive services, are why coverage for children is so important). But the fact remains that children are very inexpensive to insure.
So what is the debate taking place in Washington right now? The politicians agree that the State Children’s Health Insurance Program (SCHIP) should be renewed, but the debate is over whether only very poor children should be included, or should children from moderately-low income families who might be eligible for private, employer-sponsored coverage also be allowed to participate?
So why don’t we just use SCHIP and/or Medicaid to insure only low-income children, and then mandate parents or their employers to purchase private insurance for the rest of the children?
This study confirms once again that arbitrary standards of eligibility are not static, but are a dynamic. Though federal and state legislators can change the eligibility requirements, creating some instability in program enrollment, much greater instability results from the changing status of the participants. Eligibility related to personal circumstances continues to change not only for the Medicaid and SCHIP programs, but also for employer-sponsored plans and for compliance with underwriting standards in the individual market. Being above the threshold for public program qualification, ineligible for employer-sponsored coverage (if offered at all), and not having the income to pay premiums in the individual market inevitably results in the additional category of uninsurance.
Further, the dynamic of changing eligibility results in fragmentation of care because of variations in the networks of approved providers under the multiple public and private programs. This denies these children of the crucial benefit of having a stable medical home.
If the politicians are serious about initiating comprehensive reform by covering all children, they must come up with a proposal that enrolls all children automatically and permanently. Watching them stumble around with the SCHIP program proves that building on our public and private plans will never get us there, and unfortunately most seemed resigned to that fact that we can’t do it.
But what about Medicare? For that sector of our population isn’t that a program that covers essentially everyone, automatically and permanently? Why can’t we do that for children? For that matter, why can’t we do that for everyone?
Oh, that’s right. We can’t do that because we would have to throw out what is working for some, even though it means that we can never fix our system so that it works for everyone. It’s too bad that the way we frame our political rhetoric is much more important to us than adopting policies that actually would prevent suffering and death.