New research could help CHIP reach and enroll additional eligible families

Now that the Children’s Health Insurance Program (CHIP) has been operating for a few years, states are starting to turn their attention to steps that need to be taken to significantly increase the number of families enrolling and remaining in the program. And they are being aided in this effort by much of the research now being undertaken by public policy think tanks.

Among the newest studies are
two from the Urban Institute in Washington, DC, on how familiar low-income parents are with Medicaid and CHIP and why more children aren’t enrolled in the programs.

Using data from the 1999 National Survey of America’s Families, researchers found that although 88% of low-income children have parents who have heard of either the Medicaid or CHIP programs in their state, only 38% have parents who have heard of at least one of the programs and also know that children can participate even if the family is not on welfare. Also, while 86% of low-income uninsured children in states with separate CHIP programs had parents who had heard of the Medicaid program, by 1999 just 47% had parents who had heard of the separate CHIP program in their state. (For a graph showing awareness of Medicaid and separate CHIP programs among low-income families nationally, broken out by insurance status, see box, p. 6.)

Awareness of Medicaid and Separate SCHIP Programs among Low-Income Families, Nationally, by Insurance Status, 1999

Genevieve Kenney, researcher with the Urban League and the lead researcher on the two studies, tells State Health Watch that there should not be concern that many people still are not familiar with CHIP because "it takes several years for a new program to take root and grow. So it’s not surprising that not all the members of a targeted population are aware of the program despite the innovations in outreach. We’re impatient and want results now, but a good assessment will come two to three years from now. Don’t forget that the 1999 data we’re working with was just one year into the new program."

Ms. Kenney’s report says it is encouraging that the vast majority of low-income parents have heard of at least one public health insurance program in their state. But it is surprising how many people had heard of the CHIP program by 1999. Ms. Kenney says she takes that as evidence that the new program was quickly becoming an established part of the landscape.

A problem is that many low-income parents still were not aware of the existence of the non-Medicaid CHIP program in their state or were confused about whether participation in welfare programs was a prerequisite for health insurance coverage under CHIP. And the confusion wasn’t only among families who don’t participate in the programs. Almost one-third of all children enrolled in either Medicaid or CHIP had parents who were unsure whether they needed to be receiving welfare in order to participate.

Reducing barriers to Medicaid participation is critical to increasing coverage, given that 60% of all uninsured children are eligible for Medicaid under Title XIX, Ms. Kenney says. Her second study looked at some of the obstacles, finding that knowledge gaps were a primary barrier to enrolling one-third of low-income uninsured children and that administrative hassles were a primary barrier to enrolling another 10% of low-income uninsured children.

She calls for continued state investment in outreach efforts, especially in states where awareness and understanding of Medicaid and CHIP programs are low, and even in the face of potential budget reductions, if there is a continuing economic downturn.

But outreach efforts will not solve the problem by themselves because there are significant segments of the population not reporting knowledge gaps or administrative hassles. Ms. Kenney and her colleagues found that 22% of low-income uninsured children had parents who said that public health insurance coverage was not wanted or needed. Another 18% who were uninsured at the time of the survey had been enrolled in Medicaid or CHIP at some point during the previous year, but had not stayed in the program.

"Those who choose not to participate in the program are tough from a public policy standpoint," Ms. Kenney explains. "Their actions may be somewhat rational. If their kids are very healthy, they may feel they don’t need the coverage. They see insurance as dealing with acute episodes and don’t understand the importance of ongoing monitoring of their children’s health. But without coverage, they’re not getting well child care and dental coverage."

It’s difficult to know how to reach such families, she says. State officials need to consider whether it would be better to try to meet their needs through an expanded school health program or some other avenue. "Maybe states need to work more on promoting the benefit of continuous coverage and monitoring."

The other difficult population is the group that is enrolled in Medicaid or CHIP and then leaves. The researchers were surprised at the number of uninsured who had been covered and dropped their coverage, but cannot assess the reasons because there were no follow-up questions in the survey, Ms. Kenney says. The extent of the problem means that those questions will definitely be asked in the next survey, she adds.

"We don’t know if they moved into private coverage, were disenchanted with the program, had problems re-enrolling, or believed that they didn’t need the services, perhaps because they weren’t using them. We think they are a real good target audience if we can learn why they’ve gone from being covered to being uninsured. States should be able to turn this into a positive because there’s clearly not an information problem with this group," she says.

The Urban League findings complement those in a recent study by the Center for Studying Health System Change, which recommends targeting outreach efforts in communities that have high rates of uninsured children.

Peter Cunningham, an Urban League researcher, found that uninsured children tend to be concentrated more heavily in some areas of the nation. While only one-fourth of all children live in high uninsurance areas, about 40% of all uninsured children live in such areas. Conversely, while about 40% of all children live in low-uninsurance areas, only one-fourth of all uninsured children live there.

Mr. Cunningham’s surveys find that lower enrollment rates in Medicaid and CHIP in high-uninsurance communities reflect a combination of higher costs for employer-sponsored coverage, lower incomes among families with children, and noneconomic factors. Since it might be expected that enrollment in government programs would be higher when cost of private coverage is high, he says, it appears that the noneconomic factors are significantly affecting enrollment, including the perceived stigma of government programs and lower preferences for health coverage among the population.

Particularly troubling is the relatively high percentage of Hispanic children who are uninsured in high-uninsurance communities. Hispanics typically have lower enrollment rates in health insurance programs for which they are eligible, Mr. Cunningham says, possibly because of immigration concerns, language barriers, lack of awareness of public programs, or not understanding the role that insurance coverage plays in the United States in securing access to high-quality health care.

[Contact Ms. Kenney at (202) 833-7200, and Mr. Cunningham at (202) 484-5261.]