Publications by Amy Westpfahl Lutzky for Health Policy Center

Back to Browse by Author

This report synthesizes findings from case studies conducted in 2001 and 2002 in ten states selected for the Congressionally Mandated Evaluation of SCHIP: California, Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey, New York, North Carolina, and Texas (Hill et al. 2002). Discussion addresses such issues as program design, outreach and enrollment strategies, benefits, service delivery systems, cost sharing, crowd out prevention, parental coverage, financing, and coordination of SCHIP and Medicaid. Overarching conclusions identify lessons learned from effective implementation.

SCHIP lets states subsidize employer premiums for low-income children and, in some cases, their parents. Many states viewed the federal requirements for premium assistance programs to be administratively complex. Consequently, few states have implemented premium assistance programs under SCHIP. This study of Massachusetts, Mississippi, and Wisconsin examines the development and implementation of premium assistance programs under SCHIP. Findings suggest several limitations and challenges: States are faced with the new challenge of augmenting broader outreach campaigns with specific efforts to target employers and working families; the enrollment process is complex and time-consuming, particularly investigating employer benefit packages and comparing it to the SCHIP benchmark; and enrollment in these programs is relatively small, in part due to federal SCHIP eligibility criteria.

This analysis of the SCHIP and Medicaid eligibility redetermination processes in 8 states finds that redetermination processes have not been simplified to the same extent as initial enrollment processes. Less than 50 percent of children appeared to retain SCHIP eligibility at redetermination. Between 10 and 40 percent of children were "lost" at redetermination because their parents never responded to renewal notices or submitted renewal applications. Failure to pay premiums may reflect several possible outcomes besides affordability. State data systems are unable to report precisely on the outcomes of the eligibility redetermination process.

This analysis of the SCHIP and Medicaid application processes in 8 states finds that states have implemented similar strategies for simplifying SCHIP enrollment, but simplifications to Medicaid are less extensive. Inconsistencies between SCHIP and Medicaid eligibility requirements and procedures can make the enrollment process confusing for families. While less than 50 percent of applications were approved for SCHIP in many states, a large proportion appeared eligible for Medicaid and were referred to that program. Large proportions of SCHIP applications are denied for procedural reasons. SCHIP programs ask families about existing health insurance coverage, but only a small proportion already have insurance. State data systems cannot precisely report on the outcomes of the eligibility process.

Based on site visit interviews with state officials, consumers, providers, and reviews of public documents and web sites, this report summarizes what happened to health care policy over the last few years in each of the following states: Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin. Among some of the general patterns found: Medicaid rolls dropped between 1995 and 1998 because of the improved economy and welfare reform, but have increased in more recent years. Welfare reform also allowed states to expand Medicaid eligibility to families with much higher incomes than previously. States responded to the enactment of SCHIP in 1997 by expanding coverage for children in families with relatively high incomes.

During the late 1990s, New York began to address the state's large and growing uninsured population. The state expanded coverage to children through the Child Health Plus program and Medicaid expansions. More recently, New York expanded coverage to adults through the Family Health Plus and Healthy New York programs. New York has been phasing in enrollment of over two million Medicaid recipients into managed care on a mandatory basis. As of May 2001, approximately 34 percent of those eligible for Medicaid managed care were enrolled. Implementation of mandatory managed care has moved more slowly than anticipated for several reasons. These include: sensitivity around past marketing abuses in New York City, the exit of several Medicaid managed care plans, and lack of support from hospitals-related to plans' and hospitals' perception that the Medicaid capitation rates are too low. New York is faced with the important challenge of enrolling and retaining eligible populations in the new insurance coverage programs. Rising Medicaid expenditures, the current recessionary environment, and the impact of the September 11th attacks on the World Trade Center are likely to complicate this challenge.

Since 1997, California expanded public health insurance coverage and increased provider and health plan payments in a fiscally responsible way. The state enacted moderate Medi-Cal expansions for adults, significantly expanded children's coverage through the Healthy Families program, and is planning to expand Healthy Families further to include parents. California addressed consumer concerns about managed care through the creation of the Department of Managed Health Care, where consumers can go for assistance in dealing with their health plan. California decreased fragmentation in long-term care programs and improved quality of services through the establishment of the Long-Term Care Council. The state also achieved wage increases for nursing home staff and home health workers, and reduced patient-to-nurse staffing ratios in nursing homes.

Under the Medicaid Demonstration Project for Los Angeles, Los Angeles County agreed to fundamentally restructure its Department of Health Services (LACDHS) and its approach to delivering indigent care in return for federal funds. LACDHS attempted to reduce its traditional emphasis on emergency room and inpatient care by building an integrated system of communitybased primary, specialty, and preventive care. As part of the Centers for Medicare and Medicaid Services (CMS) evaluation of this waiver, the Urban Institute conducted site visits in 1997 and 2001. This report is based on findings from both of these site visits.

This analysis of Denver, Houston, and Los Angeles finds that the degree to which financial and organizational flexibility and managerial agility can be combined with a mission of public service under the constraints of public financing appears to be key to a successful ambulatory care safety net. An ability to strictly define the eligible population and to enforce eligibility standards also strongly influences success. The assets of the Denver system include strong leadership, the integration of ambulatory care with inpatient and specialty care, strong local financial and political support, and a geographically limited service area. Los Angeles has some of the assets of the Denver system, but is currently in a state of transition. Houston has fewer assets but has an opportunity for change under its new system leadership.

This report analyzes 18 states' experiences implementing policies to limit "crowd out" — the substitution of publicly-sponsored health insurance for private coverage. Interviews with governments officials, providers, and advocates reveal that 11 states adopted a relatively aggressive approach to limit crowd out such as waiting periods during which children must be uninsured before being permitted to enroll in SCHIP. Although waiting periods have been criticized as imposing an enrollment barrier, several states include waiting period exceptions that permit families with very expensive coverage or with children with special health care needs to immediately enroll in SCHIP. Monitoring and using application questions to inquire about health insurance status were also commonly used crowd out prevention policies.

Return to list of authors.