Medicaid enrollment increases as states work with welfare reform
Medicaid enrollment increases as states work with welfare reform
Children fare better than parents
An increase in Medicaid enrollment — seen in a recent survey of 21 states by the Kaiser Commission on Medicaid and the Uninsured in Menlo Park, CA — appears to be primarily the result of states getting used to the changes brought by welfare reform and an easing of the pressures of trying to run two new programs at once.
"The Kaiser numbers are quite credible," says Trish Riley, executive director of the National Academy of State Health Policy in Portland, ME. "Our experience has been more anecdotal, but it is in line with what the Kaiser survey found."
The Kaiser analysis looked at Medicaid enrollment for selected months from June 1997 to June 1999 in 21 states: Arkansas, California, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Massachusetts, Michigan, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Utah, and Wisconsin. Those states represent nearly 75% of national Medicaid enrollment.
From June 1997 to June 1998, overall Medicaid enrollment decreased 2.7% in the 21 states, a decline of some 620,000 individuals. But from June 1998 to June 1999, total enrollment increased by 1.4%, or 320,000 people, with more than half of the states showing an upturn in enrollment. Despite the progress, net total enrollment over the two-year period declined in the 21 states by 1.3%.
A study recently released by the Urban Institute, which used 1997 data, confirmed the downward trend that year. Those data suggested that some people leaving welfare were unintentionally and inappropriately dropped from Medicaid, says John Holahan, director of the Urban Institute Health Policy Center in Washington, DC. Federal law guarantees at least six months and up to 12 months of Medicaid coverage to those who leave welfare because of increased earnings. And state provisions allow even longer Medicaid eligibility for many.
But according to the Urban Institute’s National Survey of American Families, slightly more than half the women who left welfare were still on Medicaid or other state health insurance in the first six months after leaving, and one-third had no health insurance at all. By the time they had been off welfare for a year or more, less than one-quarter of the women were receiving Medicaid benefits and about one-half were without health insurance.
Children appear to fare better than their parents because they are more likely to be eligible for Medicaid coverage than their mothers, the report says. Of the children whose families left Medicare, almost 75% were still on Medicaid and only 20% lacked health insurance six months later. However, of the children whose families were off welfare for a year or more, less than half had Medicaid coverage and one-third were uninsured.
The 1997 decline was "partly due to the fact that people get Medicaid through the welfare offices, and with welfare reform, states tried to divert people," Mr. Holahan says. "It took states a while to understand what was happening. Now they’re starting to take steps [to restore people to the rolls]."
Major contributing factors
Previous Kaiser Commission studies have identified changes in immigration policy and high employment rates as the major factors contributing to the Medicaid enrollment decline along with welfare reform.
"I don’t think it was intentional that states missed transitional people [from welfare reform]," Ms. Riley says. "A lot of what happened was a real oops.’ New programs create chaos and confusion, and it takes some time for things to settle down."
While all states surveyed, except Arkansas, Massachusetts, and Oklahoma, experienced an enrollment decrease between June 1997 and June 1999, 12 states showed an increase between 1998 and 1999. Indiana led the states with nearly a 23% increase from June 1998 to June 1999. Despite that positive trend, enrollment continued to decline in nine of the states studied: Iowa, Michigan, New Jersey, New York, Ohio, Pennsylvania, Texas, Utah, and Wisconsin.
Vernon Smith, principal of Health Management Associates in Naples, FL, who conducted the survey for the Kaiser Commission, says the numbers give an early indication of the relationship between Medicaid and the Children’s Health Insurance Program (CHIP).
When Congress enacted CHIP in 1997, states were given the option to expand their Medicaid program, create a separate CHIP program, or do both. Of the 21 states included in this study, 14 had implemented a Medicaid expansion program by June 1999 (including five states that also created a separate CHIP program). The remaining six states only implemented separate CHIP programs.
The effects of CHIP
From December 1998 to June 1999, Medicaid enrollment increased by 216,900 people. Increases in Medicaid-expansion CHIP programs accounted for 28% of the total, while enrollment in the regular Medicaid program was 72%.
"The implementation of CHIP programs, often accompanied by substantial outreach, appears to be contributing to the identification and enrollment of children and families eligible for Medicaid," Mr. Smith says.
Ms. Riley says that while Medicaid enrollment may have reversed its downward trend, it’s hard to predict where it will go from here.
"There are problems with enrollment and retention," she says, "and we’re likely to see some dips and changes as the economy dips and changes. We’ll also see movement back and forth between Medicaid and CHIP."
[Contact Mr. Holahan at (202) 833-7200, Ms. Riley at (207) 874-6524, and Mr. Smith at (517) 482-9236.]
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