The Experiences of SCHIP Enrollees and Disenrollees in 10 States

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Abstract

Congress mandated in the Balanced Budget Refinement Act of 1999 (BBRA) that the Secretary of the U.S. Department of Health and Human Services conduct an independent comprehensive study of the State Children's Health Insurance Program (SCHIP). This report presents the findings from the mandated surveys of SCHIP enrollees and disenrollees in 10 states (conducted during 2002). SCHIP programs were found to provide health coverage to the population SCHIP was intended to serve, primarily children who would otherwise have been uninsured. The programs availed enrollees of needed primary and other health care services, and were found to have a positive impact on enrollees’ access to health care services, leaving enrollees with fewer unmet needs than they would have had in the absence of SCHIP. Families were satisfied with the ease of enrolling children, many of whom remained enrolled for 12 months, depending on the state.

Introduction

In 1997, Congress passed legislation creating the State Children’s Health Insurance Program (SCHIP), the first major federally funded health program to be established since Medicare and Medicaid were enacted in 1965. SCHIP, authorized by the new Title XXI in the Social Security Act, was designed to expand coverage among uninsured children whose family incomes were too high to qualify for Medicaid. Under Title XXI, states share in the program’s financing and have considerable flexibility in designing their programs. They can expand Medicaid, create a separate program, or do both. State SCHIP programs vary in their eligibility thresholds, cost sharing and benefit packages, and enrollment and outreach strategies (Hill et al. 2003; Wysen et al. 2003; Perry 2003; and Cohen-Ross and Hill 2003).

In the Balanced Budget Refinement Act of 1999, Congress mandated that the U.S. Department of Health and Human Services (DHHS) conduct an evaluation of 10 states’ SCHIP programs. Congress further directed that the evaluation address a wide range of issues, including (1) SCHIP enrollment and disenrollment dynamics, (2) the impact of SCHIP and Medicaid enrollment practices on enrollment of children, and (3) coordination between SCHIP and Medicaid. The mandate also required surveys of the target population—enrollees, disenrollees, and children who are eligible for but not enrolled in SCHIP.

This report draws on surveys of enrollees and disenrollees in 10 states. The 10 states were selected in accordance with the legislative requirements to include (1) a high proportion of low income uninsured children in the United States, (2) wide geographic (including both rural and urban) representation, and (3) diverse approaches to program design. The 10 states—California, Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey, New York, North Carolina, and Texas—represent all four Census regions and account for 56 percent of the nation’s uninsured children living in families with incomes below 200 percent of the federal poverty level.1 Moreover, 62 percent of the children who were enrolled in SCHIP in the last quarter of fiscal 2003 lived in these states (CMS 2005). Census data also show that low-income children in these 10 states are more likely than low-income children in the nation as a whole to be Hispanic and to live in Metropolitan Statistical Areas. For example, 42 percent of low-income children in these 10 states are Hispanic, and 89 percent live in metropolitan areas, compared, respectively, to 29 and 78 percent of low-income children nationally.

The 10 states vary in the design of their SCHIP programs (Table I.1). Six states rely on a separate SCHIP program, two rely on a Medicaid expansion, and two use a combination of both Medicaid and a separate program. Of the 10 states, 4 have an eligibility income threshold at or above 250 percent of the federal poverty level. The SCHIP programs in these 10 states also vary in their eligibility policies, the presence of waiting periods, covered benefits, and cost-sharing requirements.

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