Seven Million Children Uninsured in US, Large Majority from Three States
September 9, 2010 at 7:40 AM
General Health News
As many as 7.3 million children were uninsured on an average day in 2008. Thirty-nine percent of eligible uninsured children (1.8 million) live in just three states—California, Texas, and Florida— according to research published in Health Affairs.
"We found substantial variation in participation rates across states and among subgroups of children. We also found that the majority of uninsured children who are eligible for Medicaid/CHIP but not enrolled are concentrated in a small number of the most populous states," said researchers led by Genevieve M. Kenney, a senior fellow at the Health Policy Center, Urban Institute, in Washington, D.C,
The study was taken up in the backdrop of a call by Kathleen Sebelius, secretary of health and human services, to enroll the millions of uninsured children eligible for public insurance. Medicaid and the Children's Health Insurance Program (CHIP) are two key public insurance programmes, and the Obama administration is anxious to demonstrate its concern for the underprivileged.
The new study notes the coverage of children has indeed been rising since 1997 following the enactment of CHIP in 1997. Indeed a number of studies found declines in the number of low-income uninsured children. This occurred at a time when uninsurance was rising for adults. The increased coverage among children eligible for Medicaid and CHIP was likely to have been attributable to states' outreach and enrollment efforts. Despite this progress, when CHIP was reauthorized, close to two-thirds of all uninsured children appeared to be eligible for, but not enrolled in, Medicaid or CHIP. Moreover, there was much variation across states with respect to enrollment and retention policies.
The CHIP reauthorization act (CHIPRA) provides states with new tools to address shortfalls in participation in Medicaid and CHIP. These include outreach and enrollment grants and bonus payments to states that adopt five of eight enrollment and retention strategies and states that experience Medicaid enrollment increases that exceed target growth rates. States also were given "Express Lane" options, which allow them to use administrative data from other programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to facilitate enrollment.
The law also gave states new options to meet citizenship requirements for child enrollees. In addition, it allowed states to use federal dollars to cover legal immigrant children who had been in the United States fewer than five years, and it provided states with additional federal funds to cover more children.
By February 2010, one year after CHIPRA became law, a number of states had either expanded eligibility for coverage or introduced improvements to their enrollment and retention processes. By April 2010, the federal government had awarded $50 million in outreach grants, including $40 million to organizations in forty-two states and an additional $10 million for targeting Native American children. These policy changes are expected to change the composition of the population of children enrolled in public coverage and raise participation rates among children who are already eligible.
At the same time, however, the ongoing recession and state budget shortfalls could reduce state-level efforts to promote greater enrollment and retention among eligible children. Ultimately, policy changes to be implemented in 2014 under the Patient Protection and Affordable Care Act of 2010 will introduce major changes to Medicaid and CHIP coverage for children and parents.
To assess progress covering uninsured children under CHIPRA and, ultimately, through health reform, information on nationwide participation and coverage is needed, the researchers said.
Although 64 percent of uninsured children eligible for Medicaid/CHIP had family incomes below 133 percent of poverty, children in this income group participated in Medicaid/CHIP at higher rates relative to higher-income children). Most of the remaining 2.5 million uninsured children did not qualify for Medicaid/CHIP because their family incomes exceeded income eligibility thresholds in 2008.
The number of uninsured children who were eligible for Medicaid/CHIP but not enrolled was heavily concentrated in a relatively small number of populous states. Just three states combined—California, Texas, and Florida—contained 38.6 percent of all eligible uninsured children in the country. Moreover, an estimated 61 percent (about 2.9 million) of all eligible uninsured children lived in the ten states.
The main reason these states accounted for such a large share of the eligible uninsured children is that they also contained a disproportionate share of children: 52 percent of all children and 56 percent of eligible children in the nation. However, Florida, Texas, and Arizona also had participation rates that were well below the national average —69.8 percent, 74.7 percent, and 76.6 percent, respectively, the study noted.
"Overall, we estimated that the national rate of Medicaid/CHIP participation for children was 81.8 percent in 2008. The median rate across states was even higher, 83.3 percent. Although not exactly comparable, the Medicaid/CHIP participation rate we estimated for children was much higher than the participation rates typically found in other government programs. This is probably due to concerted efforts to improve Medicaid/CHIP eligibility, enrollment and retention processes, and outreach. We found higher participation rates for states in the Northeast (87.7 percent) and Midwest (85.3 percent) census regions and lower rates for states in the West (78.8 percent) and South (79.8 percent) regions."
Participation rates varied greatly across states, from lows of 55.4 percent in Nevada and 66.2 percent in Utah to highs of 95.4 percent and 95.2 percent in the District of Columbia and Massachusetts, respectively. Hawaii, Maine, Massachusetts, Vermont, and the District of Columbia had participation rates of 91 percent or higher, and Arkansas, Kentucky, Louisiana, Michigan, New York, and West Virginia had rates of 88-90 percent. A total of thirteen states had participation rates under 80 percent (Alaska, Arizona, Colorado, Idaho, Florida, Montana, Nevada, North Dakota, Oregon, South Carolina, Texas, Utah, and Wyoming).
The lower Medicaid/CHIP participation rates in some western states may be linked to the relatively larger shares of Native American children in those states. New higher federal matching rates are now available to states to cover these children, which may increase their enrollment in Medicaid and CHIP, the researchers hoped.
Despite their relatively high participation rate, the poorest children made up a sizable majority (63.4 percent) of all children who were eligible but uninsured. Children living in homes without phones had participation rates that were almost ten percentage points lower than those of children who had phones in their homes.
The remaining eligible uninsured children were heterogeneous along a number of different dimensions. For example, 39.1 percent were Hispanic; 36.9 percent were white; 15.8 percent were black; and the remaining 8.2 percent included Asian/Pacific Islanders, American Indian/Alaska Natives, and children in the "other/multiple race" category.
In addition, although the majority did not live in households that received food stamps, Express Lane strategies that connect families who receive food stamps to Medicaid and CHIP coverage could help reduce uninsurance among the 15.4 percent of uninsured children who were eligible for Medicaid/CHIP and whose families did receive food stamps.
These new estimates suggest that as of 2008, nearly five million uninsured children were eligible for but not enrolled in Medicaid/CHIP. To achieve the goal of reaching and enrolling all of these children, as set forth by the HHS secretary, progress is needed in all states.
These estimates indicate that outreach efforts and policy reforms aimed at improving eligibility, enrollment, and retention processes will need to reach children of different ages, incomes, races, ethnic groups, and primary language, given the diversity of the remaining eligible uninsured population. At the same time, however, targeted enrollment, retention, and outreach efforts may be needed for children in particular subgroups who constitute a disproportionate share of the eligible uninsured children nationally and in individual states.
The data raise questions about the underlying reasons for the observed state-level variation in participation rates as also variations within states.
The worsening economy should have its own impact, the picture could become clear when the results of the new Current Population Survey and American Community Survey are released in the fall of 2010.
Whether states can develop and maintain momentum around increasing Medicaid/CHIP participation among children in the coming years will be critical to determining the extent of progress. In the short term, a key issue relates to current state budget problems. Without strong economic growth, states may be reluctant to seek aggressively to increase enrollment among eligible children in the near term, or even to maintain recent coverage improvements. The recently enacted extension of enhanced federal Medicaid matching rates through the first half of 2011 may encourage states to implement new policies or maintain existing policies aimed at increasing Medicaid/CHIP participation among children.
Although questions remain about the future of CHIP and state capacity issues, the combination of policies to be implemented under the Affordable Care Act should increase participation in Medicaid and CHIP among children who are eligible but not enrolled. These policies include the increased funding for streamlined enrollment, renewal, and outreach; the Medicaid expansion to parents; and the individual mandate for both adults and children to obtain coverage, the researchers concluded.
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