Many children still falling off Medicaid

About 2 million children became uninsured in 2008, despite their ongoing eligibility for the Children's Health Insurance Program (CHIP), according to a new report from the Harvard School of Public Health, Enrolling Eligible Children In Medicaid And CHIP: A Research Update.

"The results were a bit of a mixed story of good news and bad news," says Benjamin D. Sommers, MD, PhD, the study's author and an assistant professor at Harvard School of Public Health in Boston. "The bad news is that we still have a major problem with loss of insurance among millions of Medicaid and CHIP-eligible children."

Tricia Brooks, a senior fellow at Georgetown University's Center for Children and Families in Washington, DC, says the fact that 2 million uninsured children who are eligible for Medicaid or CHIP were enrolled in the prior year clearly indicates that retention should be a primary focus of these important programs.

Dr. Sommers says, "The good news is that over the past three years, the previous trend of worsening drop out has been reversed. Drop out is still a major issue, but at least we're moving in the right direction."

The retention of eligible children has improved. In a previous report, Dr. Sommers noted that one-third of uninsured children were enrolled in Medicaid or CHIP in the previous year, peaking in 2006. That drop-out rate declined to 25% in the latest study, with most of the improvement in Medicaid.

"During the same period, the rate at which uninsured eligible children enrolled has deteriorated," says Ms. Brooks. "Both of these trends suggest that enrollment and retention policies and procedures make a difference in assuring that kids get the coverage they need."

Good approaches

While retention remains a challenge, the study shows it is possible to make improvements. U.S. Department of Health and Human Services Secretary Kathleen Sebelius has set a goal to enroll the 5 million children who are uninsured, but eligible for Medicaid or CHIP.

"Streamlining the renewal application process, and making it less burdensome for parents, is the single most important approach to improving retention," according to Dr. Sommers.

Some approaches to make the renewal process easier are spacing out eligibility redeterminations to once a year instead of six months, eliminating the need for face-to-face interviews, and using a joint renewal form for Medicaid and CHIP.

Another approach is the "Express Lane" option, in which states can use information from other programs, like the free and reduced school lunch programs and food stamps, to reduce the amount of information families need to provide for Medicaid enrollment and renewal.

"Similarly, states can cross-reference names and Social Security numbers with the Social Security Administration to save families the hassle of providing citizenship documentation when applying," says Dr. Sommers.

Ms. Brooks says that most families are aware that their states have Medicaid and CHIP programs. "However, they often don't think their children are eligible or do not know how to apply for coverage," she says. "Tackling these issues through outreach and public education, along with addressing linguistic and cultural barriers, is important."

Ms. Brooks says that the ways to improve both enrollment and retention are similar. "Implementing streamlining policies, such as 12-month continuous eligibility, and aligning requirements between Medicaid and CHIP, is good place to start," she says.

Simplifying the application and renewal process is also important, with the use of technology to verify eligibility rather than requiring families to submit paperwork which eligibility workers then have to process.

Providing multiple ways to enroll or renew, including online applications, telephone renewals, and working through community partners, can help families overcome gaps in knowledge or linguistic and cultural barriers, adds Ms. Brooks.

Ms. Brooks notes that the implementation of the complex citizenship documentation requirement through the Deficit Reduction Act of 2005 had a "chilling effect" on enrollment of eligible, citizen children.

"Thankfully, CHIP reauthorization provides a new electronic means for states to verify citizenship," says Ms. Brooks. "This is proving extremely successful in simplifying the process for eligible families and reducing the state's administrative burden and costs."

Health care reform

Many of these same approaches would likely help with enrollment and retention among newly eligible adults. "In fact, we already have research that shows that adults have even higher drop-out rates from Medicaid than children. This is a major issue," says Dr. Sommers.

Even though the Medicaid expansion mainly affects adults, Dr. Sommers says that one promising part of health reform for children is that it will bring more families together under a single plan, with both parents and children enrolled together in Medicaid.

"We know that Medicaid retention for children is significantly enhanced when their parents are also in Medicaid," says Dr. Sommers. "This offers a great opportunity to further improve the stability of children's health insurance."

Ms. Brooks says that the lessons learned from more than a decade of concerted effort to advance children's coverage provide a lot of insight into how policies, procedures, and systems should be crafted to maximize enrollment in health reform.

"States can continue to implement the best practices, and align coverage between current parent and adult coverage and children, to ramp up their ability and capacity to serve more Americans," she says. Measures to improve outreach, enrollment, retention, and coordination between programs today will help reach the 5 million uninsured — but eligible — children. "It will help their families weather the current economic storm, while improving program efficiency and cost-effectiveness in preparation for 2014," says Ms. Brooks.

Contact Ms. Brooks at (202) 365-9148 or pab62@georgetown.edu and Dr. Sommers at (617) 432-3271 or bsommers@hsph.harvard.edu.