CHIP: Health Affairs Reviews Implementation
Three articles in the current issue of Health Affairs take a look at whether the Children's Health Insurance Program is meeting its goal of reducing the number of uninsured children. In the first article, researchers use data from the 1996 Medical Expenditure Panel Survey to estimate that 3.1 million uninsured children from families earning up to 200% of the federal poverty level will be eligible for CHIP in 1999. Under current state plans, some of which have lower eligibility thresholds, 2.6 million children will be eligible. Hispanic children account for 29.5% of those eligible, and black children for 19.9%. Teenagers represent 39.4% of the CHIP eligible population. "CHIP eligible children are projected to be disproportionately located in the South," according to the analysis. However, the study predicts that under the current 200% federal eligibility threshold actual CHIP enrollment will be 1.8 million children in the first half of 1999 and under current state plans it will be 1.5 million children. The study concludes that outreach is critical to reaching unenrolled, eligible children (Selden et al., March/April 1999 issue).
In a separate piece, Trish Riley, executive director of the National Academy for State Health Policy, says that in its rush to enact the program, Congress may not have given enough attention to its provisions for reports and evaluations. As it stands, Congress requires participating states to submit annual reports and a comprehensive evaluation to HHS by March 2000. However, Riley says that states "simply may not be able to provide the breadth and depth of information included in these mandates." Congress capped states' outlays for CHIP administrative costs at 10%, and Riley says that most of the administrative funds are diverted to outreach efforts rather than program evaluation. One of the most controversial congressional requests is deceptively simple, says Riley: a state-level analysis of progress in reducing the number of uninsured children. Without an accurate way to predict the number of uninsured children -- the Current Population Survey, state-level samples, the Medical Expenditure Panel Survey and the National Center for Health Statistics survey are all considered either inappropriate for a state-level analysis or prohibitively expensive -- states must provide an "imperfect" estimate. Nonetheless, the figures provide the "baseline for determining states' success or failure in meeting CHIP objectives." States recognize "the scale of the hurdles ahead," concludes Riley, and she warns that "stakeholders must accept the limits of program reporting and evaluation" rather than dwell on the limitations of the data collection process (Riley, March/April 1999 issue).
The Not-So-Easy Answer
In the final piece, Neal Halfon of the University of California- Los Angeles offers a model for tracking children's access to CHIP. Halfon develops a multistage approach to monitor access using a "pathway model" to track education and outreach, initial enrollment, retention and transition. Suggesting a comprehensive evaluation strategy for access that is coordinated on both the federal and state level, Halfon says that the "federal government is ultimately accountable for the implementation of CHIP and should be encouraged to take the lead." Calling for an expert working group to "build upon the access pathway framework," Halfon notes that the federal agencies responsible for CHIP implementation could work hand-in-hand with state agencies. Conceding that "a number of political issues still must be resolved" before the implementation of any national CHIP evaluation, Halfon concludes that states and the federal government must "collaborate in designing an evaluation strategy" that meets evaluation requirements and serves "ongoing improvement purposes" (Halfon et al., March/April 1999 issue).