New Surveys Raise Questions About Uninsured Children

Published October 1, 2004

A recent report on the State Children’s Health Insurance Program (SCHIP), issued by the Kaiser Commission on Medicaid and the Uninsured, has people wondering whether a reported enrollment decline in late 2003 is a harbinger or statistical blip.

The report, issued July 27, shows SCHIP enrollment declined during the second half of 2003, for the first time since enactment of the program in 1997. For the year, enrollment was up 4.2 percent, compared with a 9.7 percent increase in 2002.

SCHIP is a joint federal-state effort that provides health insurance coverage for children of working parents with low incomes.

“We simply reported the numbers. It remains to be seen what happens in the next year as far as where enrollment goes,” said Rakesh Singh, the Kaiser commission’s communications officer. “As the economy improves, we will have to see if that [enrollment decline] changes.”

The report shows SCHIP enrollment peaked at 3.96 million in June 2003 and was 3.93 million in December 2003. Three states–Maryland, New York, and Texas–accounted for nearly all the enrollment decline, according to the Kaiser report, which casts the decline as a problem and blames it on program changes designed to shrink enrollments for state budgetary reasons.

Second Survey Shows Decline in Low-Income Uninsurance Rate

Coming right on the heels of the Kaiser report, however, was one from the Center for Studying Health System Change (CSHSC), which found that between 2001 and 2003 there was a big increase nationally in the number of children covered by government insurance programs. The study showed only one quarter of decline in late 2003, and only a small decrease.

The CSHSC report, released August 3, shows more than five million children were added to Medicaid and SCHIP rolls between 2001 and 2003. The report was released in conjunction with the launch of the Robert Wood Johnson Foundation’s “Covering Kids and Families” fifth annual campaign to enroll kids in government health care.

“If we look at the Kaiser study, it shows enrollment (in SCHIP) actually increased 4.2 percent in 2003 with a small decline in the last quarter,” said CSHSC spokeswoman Alwyn Cassil. “Many of those children probably got picked up by Medicaid. We believe we saw a lot of shifting of coverage among groups. The 2001 to 2003 uninsured rate didn’t change in a statistically significant way.”

Cassil said that among children from low-income families (below 200 percent of the federal poverty level), there has been a decline in the uninsurance rate.

“They lost employer coverage, probably most because their parents lost a job,” Cassil said. “But there was a big increase in public coverage, which offset the loss. SCHIP and Medicaid not only protected kids from the economic fallout of the recession, it scooped up kids who were eligible and not enrolled. Uninsurance for them actually declined.”

Concerns Raised About Further Declines

However, Cassil said, the Kaiser study could be an indication of coming declines in enrollments.

“The reality is that the first thing that happens when states have budget problems is they stop doing outreach,” she said. “Research shows kids who are uninsured miss out on important preventive stuff. But if they get sick they would get enrolled in one of those programs. The other good thing is most kids are healthy. When people talk about how to get handle on the uninsured, … a lot of states have made progress in simplifying enrollment.”

Robert Kenney, spokesperson for the New York State Health Department, said enrollment in the state’s Child Health Plus program, which provides insurance for children who qualify based on family size and income level, peaked in 2001 at 533,000. This year about 486,000 children are enrolled. He said much of the change is accounted for by changes in Medicaid, which has taken about 70,000 children out of the Child Health Plus program.

“Child Health Plus has expanded from 93,000 in 1995 to 486,000” today, Kenney said. “Each year we provide $20 million to community-based programs to enroll kids in Child Health Plus or Medicaid. We believe we lead the nation in our efforts. Overall, the Medicaid program in New York is one of the largest in the country–$41 billion. It is an extensive commitment to health care.”

Policy Changes Cut Enrollment in Texas

In Texas, nearly 150,000 youngsters have been removed from the SCHIP program since the beginning of fiscal year 2004, according to the Kaiser study, which cites cuts in some health services, along with eligibility and administrative changes including:

  • elimination of income deductions such as child care costs in determining income eligibility;
  • establishment of an asset test, beginning in August 2004, for families above 150 percent of federal poverty level, about $23,500 for a family of three;
  • establishment of a 90-day waiting period to receive coverage after a child is deemed eligible; and
  • establishment of a six-month continuous coverage period, shortened from 12 months.

Dr. Roland Goertz, chief executive at Heart of Texas Community Health Center in Waco, Texas, said the dropoff in enrollment is noticeable.

“We have gone to about a 60 percent cut (in the number of SCHIP visits) since last September,” Goertz said. The health center sees about 100,000 patients a year, about one-third of them children.

“What’s driven the decline is changes in eligibility and how parents must pay for certain aspects of the program,” he said. “Texas went through a significant budget crisis. They changed eligibility and what benefits were provided. SCHIP suffered some of those cutbacks.”

Though most SCHIP cases are for typical childhood preventive care and illnesses, Goertz said some of those who have dropped out of the program have serious problems.

“In our situation we’ll see those kids anyway, whether they’re funded or not,” he said. “The demand for care is not going to go away.”

Steve Stanek ([email protected]) is an Illinois-based freelance writer and regular contributor to Health Care News.