Embargoed Until:
June 23, 2009
12:01 a.m. Eastern Time



Christopher Fleming

Study Finds Higher Numbers Of Eligible But Uninsured Children In "Mixed Eligibility" Families

Researcher Provides The First Comprehensive Examination Of Families Where Children Have Differing Eligibility Statuses For Medicaid And CHIP

Bethesda, MD -- Families with two or more children of differing eligibility for public insurance programs are more likely to have an uninsured child, even when all children in the family are eligible for some form of public coverage, according to a study published today on the Health Affairs Web site. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w697

The article by Julie Hudson, a senior economist in the Center for Financing Access and Cost Trends at the Agency for Healthcare Research and Quality, is the first study to document the phenomenon of "mixed eligibility."

In some mixed-eligibility families, one or more children are eligible for Medicaid and other children are eligible for the Children’s Health Insurance Program (CHIP). This occurs because in most states, Medicaid income eligibility thresholds differ by age, leading to a "stairstep" profile where, at some income levels, younger children are eligible for Medicaid while older children in the same family are not.

In families with a mixture of Medicaid- and CHIP-eligible children, Hudson found that the probability that one or more children would be uninsured was 26 percent. That was significantly higher than the chance that a family where all children were eligible for Medicaid would have one or more uninsured children (21 percent) and the chance that a family where all children were eligible for CHIP would have one or more uninsured children (16 percent).

In other mixed-eligibility families, one or more children are eligible for some form of public insurance, either Medicaid or CHIP, while other children are ineligible for any form of public coverage. This primarily occurs in states that limit eligibility to legal immigrants who have lived in the United States for less than five years. These families often have a mixture of (1) older, noncitizen children who are ineligible for public insurance and (2) younger, U.S.-born, citizen children who are eligible for Medicaid or CHIP. Hudson found that 43 percent of families with a mixture of eligible and ineligible children had one or more uninsured children. The study further "highlights that even eligible children in such families remained uninsured."

Overall, in 2005 there were 1.43 million mixed-eligibility families in the United States. Children in these families accounted for more than 15 percent of the 5.5 million children who were eligible for Medicaid or CHIP but remained uninsured.

"The fact that eligible children in these families continue to have lower rates of insurance despite their full eligibility status is troubling," Hudson says. "It suggests that parents may be unaware of their children’s eligibility status or may face hurdles in either enrolling in or maintaining coverage."

One hurdle families might face is navigating two separate programs with different sets of rules and procedures. Families with mixed Medicaid/CHIP eligibility had a 27.6 percent chance of having one or more uninsured children if they lived in a state where CHIP and Medicaid were run as separate programs, versus only a 16.3 percent chance of having one or more uninsured children if they lived in a state where CHIP was run entirely as an expansion of Medicaid.

An additional hurdle may occur in states where children must transition from Medicaid to CHIP as they get older. Hudson found that families with mixed Medicaid/CHIP eligibility were more likely to have one or more uninsured children as the number of age-related Medicaid categories in a state increased. "Coverage gaps can occur even when parents are fully informed," Hudson writes. "Children might not have seamless transitions between Medicaid and CHIP when faced with administrative delays, waiting periods, or enrollment caps that are out of their control."

Policy Implications

Hudson says that her "results suggest that reaching out to mixed-eligibility families may prove fruitful in states’ efforts to enroll eligible but uninsured children." She further observes that "Improvements may result by either reducing the prevalence of mixed eligibility (reducing/removing age-related income categories in Medicaid, covering recent documented immigrants), or fine-tuning outreach to target mixed-eligibility families, especially in states running separate CHIP programs."

Hudson’s study uses 1996-2005 data from the Medical Expenditure Panel Survey, a nationally representative data set of individuals and families.

After the embargo lifts, you can read Hudson’s article at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w697


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.


©2009 Project HOPE–The People-to-People Health Foundation, Inc.