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Christopher Fleming

Fluidity In Eligibility Underlies Churning Into And Out Of Medicaid And SCHIP

In Second Paper In Health Affairs Series On SCHIP, Researchers Call On Congress To Protect Children From Discontinuities In Coverage

Bethesda, MD -- Income volatility causes many children to cycle into and out of eligibility for Medicaid and the State Children’s Health Insurance Program (SCHIP), putting these children at risk for injurious gaps in coverage, researchers report in a Health Affairs Web Exclusive published today. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.5.w598

“Many researchers have documented the problem of ‘churning’ in Medicaid and SCHIP, in which children cycle into and out of these programs,” said lead author Anna Sommers, a research associate at the Urban Institute’s Health Policy Center. “However, this phenomenon has generally been attributed primarily to administrative barriers. Our work shows that changes in children’s eligibility status are a major cause of churning as well.”

The researchers found that eligibility changes and interruptions were common. Two-thirds of all surveyed children were eligible for Medicaid or SCHIP, or both, at some point during the four-year period from 1996 to 2000, in the early years of SCHIP. Almost half of the surveyed children (48 percent) experienced interruptions in eligibility, and 41 percent of these “sometimes eligible” children had multiple spells of eligibility.

In addition to gaining and losing eligibility for coverage through Medicaid or SCHIP, children also moved frequently from eligibility for one program to eligibility for the other during the survey period. Of the children ever eligible for SCHIP during the survey period, 72 percent became eligible for Medicaid at some other point during the period. And in the far larger population of children ever eligible for Medicaid, 36 percent also became eligible for SCHIP at some point.

Overall, one-fifth of all surveyed children, representing almost 19 million American children, became eligible for both Medicaid and SCHIP during the survey period. “Particularly relevant to the SCHIP reauthorization debate,” at the time each child first became eligible for SCHIP, 33 percent had previously been covered by Medicaid, report Sommers and her coauthors, Lisa Dubay of the Johns Hopkins Bloomberg School of Public Health Linda Blumberg of the Urban Institute, Fredric Blavin of the Wharton School, and John Czajka of Mathematica Policy Research.

Sommers and her colleagues used the Census Bureau’s Survey of Income and Program Participation (SIPP) to track a nationally representative sample of children over the 1996-2000 period. “The SIPP gave us the ability to track what happened to a constant group of children over time,” Sommers explained. “Unfortunately, changes in the survey after 2000 made it impossible to continue tracking past that date, but the doubling in SCHIP’s size since then means that this fluidity in eligibility we document is even more likely to affect children’s access to public coverage now.”

What Can Congress Do To Prevent Coverage Gaps
Stemming From Changing Eligibility Status?

The Sommers paper is the second in a series of articles Health Affairs is publishing this summer on the debate over SCHIP. “As Congress considers reauthorization of SCHIP, it should consider how policies, in addition to minimizing administrative barriers, will protect children from discontinuous coverage resulting from fluid eligibility,” Sommers and her coauthors write. During the survey period, “few children remained uninsured for the whole time they were eligible for public insurance programs, yet 42 percent experienced at least one bout of uninsurance while eligible.” The extent of the volatility in income and family structure that lead to eligibility changes among children present a challenge to policymakers interested in eliminating gaps in coverage, especially in states with separate SCHIP programs, where administrative coordination between the two programs is more challenging.

The researchers outline a number of steps Congress could take to protect children from gaps in coverage caused by their changing eligibility status. One example is “express-lane eligibility,” which several of the SCHIP reauthorization proposals would make feasible. “Under such eligibility, states would be allowed to use income and asset data from other federal means-tested programs to determine eligibility for Medicaid and SCHIP. Express-lane eligibility would facilitate the enrollment of eligible uninsured children who participate in other programs and facilitate transitions between Medicaid and SCHIP,” Sommers and her colleagues note.

“In general, any policies that simplify or automate the eligibility and renewal process and support continuous coverage will reduce barriers to coverage for eligible children and minimize headaches for state officials who administer these programs,” said Sommers.


Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.


©2007 Project HOPE–The People-to-People Health Foundation, Inc.