Author(s): Genevieve M. Kenney, Jennifer M. Haley, Frank C. Ullman

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Posted to Web: December 01, 2000

Permanent Link: http://www.urban.org/url.cfm?ID=309302

Number B-4 in Series, "New Federalism: National Survey of America's Families"

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Many children remain uninsured despite being eligible for public insurance coverage (Dubay and Kenney 1996; Selden, Banthin, and Cohen 1998). Estimates from 1996, prior to the implementation of the Children's Health Insurance Program (CHIP), suggest that as many as 40 percent of all uninsured children were eligible for but not enrolled in Medicaid (Selden et al. 1998). With the advent of national welfare reform and CHIP, the share of uninsured children who are eligible for public programs has likely risen.

Using estimates drawn from the 1997 National Survey of America's Families (NSAF), this brief examines the potential of certain federal programs for reaching the families of uninsured children. We focus here on four particular programs: the National School Lunch Program; the Special Supplemental Program for Women, Infants, and Children (WIC); the Food Stamp program; and the Unemployment Compensation Program.¹ The first three of these are operated by the U.S. Department of Agriculture (USDA); the last is overseen by the U.S. Department of Labor. These programs rely on very different enrollment procedures and require different documentation as compared with Medicaid and CHIP. At the same time, they serve many families with children who should be eligible for Medicaid and CHIP.

Our findings suggest that almost three-quarters of all low-income uninsured children and about 60 percent of all uninsured children live in families that participate in the National School Lunch, WIC, Food Stamp, or Unemployment Compensation programs. The National School Lunch Program— serving families with about 4 million low-income uninsured children—appears to be a particularly efficient vehicle for identifying uninsured children who are eligible for Medicaid and CHIP.

Data and Methods

The NSAF is a national household survey that provides information on over 100,000 children and nonelderly adults representing the noninstitutionalized civilian population under age 65 (Brick et al. 1999). The NSAF oversamples the low-income population (those with incomes below 200 percent of the federal poverty level [FPL]) and the population in 13 states 2 and provides reliable estimates for the nation. Detailed information on health insurance coverage and other characteristics was collected on up to two sampled children in each household (one age 5 or under and one between ages 6 and 17). The adult who knew the most about each child's education and health care—the primary caregiver—was the respondent. Interviewers asked primary caregivers about children's current and past year's enrollment in private and public insurance and followed up with a confirmation question if respondents did not identify any coverage (Rajan, Zuckerman, and Brennan 1999).³ Overall, information was collected on 34,439 children.⁴

Participation in the National School Lunch ⁵ and WIC ⁶ programs was measured at the family level. If primary caregivers reported that at least one individual in the family received free or reduced-price lunches at school or participated in WIC in calendar year 1996, the family as a whole was considered a participant in the National School Lunch or WIC programs. Participation was measured by the enrollment of someone in the child's family, but not necessarily the sampled child whose insurance status was assessed. Therefore, our estimates of how many children can be reached through other programs assume that all children in the household are being reached, not just the child who participates. Participation in these two programs was only assessed for families with incomes that were estimated to be below 200 percent of the FPL based on information provided during the interview.⁷ A family's participation in the Food Stamp program was indicated by the reported receipt of benefits at the time the NSAF was administered in 1997; its participation in the Unemployment Compensation Program was demonstrated by the receipt of benefits in calendar year 1996. ^{8, 9}

We also assessed the demographic and socioeconomic characteristics of the uninsured children whose families participated in these programs. These characteristics include the child's age, race/ethnicity, and immigration status; the educational attainment of the primary caregiver; the family structure, income, and work status; and the region and state in which the family lived.

Extent of Program Participation

Table 1 shows the number of children in families that received benefits during 1996 or 1997 from any or all of the National School Lunch, WIC, Food Stamp, or Unemployment Compensation programs, along with the number of these children who were uninsured and who lived in families with incomes below 200 percent of the FPL. The proportions of low-income and all uninsured children covered by these programs are also presented. We find that an estimated 16.8 million low-income children resided in families in which at least one child received benefits from the National School Lunch Program during 1996. The NSAF indicates that almost 23 percent of low-income children residing in families that received benefits from this program in 1996 were uninsured at the time that the survey was administered in 1997 (3.9 million divided by 16.8 million). We estimate that about 3.9 million low-income uninsured children—60 percent of all low-income uninsured children and almost half of all uninsured children— resided in families that participated in the National School Lunch Program.

Approximately 9.2 million low-income children are estimated to reside in families that received benefits from the WIC Program during 1996. About 17 percent of the children living in these families—or 1.5 million children— were uninsured at the time of the survey. Altogether, about one in four low-income uninsured children live in families that received WIC benefits at some point during 1996. We estimate that the WIC Program could reach an additional 620,000 low-income uninsured children in families that do not participate in the National School Lunch Program.

According to the NSAF, approximately 8.6 million low-income children resided in families that received benefits from the Food Stamp program at the time of the survey. Only 8 percent of these children were uninsured, which means that about 651,000 low-income uninsured children live in families that received food stamps. We estimate that the Food Stamp program could reach an additional 68,000 low-income uninsured children who do not participate in the National School Lunch or WIC programs.

The NSAF also indicates that there were about 629,000 low-income uninsured children whose families received income from Unemployment Compensation programs in 1996. Among these uninsured children, about a quarter—or 158,000—lived in families that did not participate in the National School Lunch, WIC, or Food Stamp programs.

Altogether, 73 percent of all low-income uninsured children and 62 per-cent of all uninsured children lived in families that participated in the National School Lunch, WIC, Food Stamp, or Unemployment Compensation programs. Thus, outreach efforts directed through these programs could target nearly three-quarters of low-income uninsured children, the vast majority of whom are likely to be eligible for Medicaid or CHIP coverage.

Program Participation by Child and Family Characteristics

Table 2 presents the share of low-income uninsured children whose families participated in the School Lunch, WIC, Food Stamp, and Unemployment Compensation programs in 1996 or 1997, by various demographic and socioeconomic characteristics. Participation varies by program, by child and family characteristics, and by geographic location.

The School Lunch Program could reach a high proportion of low-income uninsured children who are school age; fully three-quarters of low-income uninsured children ages 6 to 11 and 65 percent of low-income uninsured children ages 12 to 17 live in families who participate. In contrast, only 38 percent of low-income uninsured children under age 6 live in families that participate in the National School Lunch Program. The WIC program offers greater potential for reaching low-income, uninsured preschool children. About half of all low-income uninsured children under age 6 live in families that participate in WIC.

The capacity to reach low-income uninsured children through the School Lunch, WIC, Food Stamp, and Unemployment Compensation Programs varies by race and birthplace. Overall, 81 percent of Hispanic and 78 percent of black low-income uninsured children could be reached through these programs, while a smaller percentage of other, primarily white, non-Hispanic low-income children could be targeted (66 percent). A slightly higher proportion of low-income uninsured children in foreign-born families relative to uninsured children born in the United States, 76 percent versus 73 percent, could be National Survey of America's Families identified through these programs, although the proportions are not statistically different from one another. Overall, Hispanic children represent over one-third of all the low-income uninsured children whose families participate in any of these programs, while foreign-born children represent a smaller proportion, 13 percent, of uninsured children participating in any of these programs (results not shown).

These programs could reach about 76 percent of all uninsured children in families below 150 percent of the FPL and about 62 percent of the uninsured children whose family incomes are between 150 percent and 200 percent of the FPL. Similarly, they could reach higher proportions of low-income uninsured children whose parents lack a high school diploma or general equivalency diploma (GED) relative to uninsured children whose parents have more education.

Table 2 also shows that the capacity to direct Medicaid and CHIP enrollment efforts to low-income uninsured children through these programs varies across regions and states. Specifically, smaller percentages of low-income uninsured children in the Northeast could be reached through these programs relative to other regions of the country. Among the 13 states oversampled in the NSAF, Alabama, California, and Mississippi exhibit the highest percentage of low-income uninsured children who could be reached through these programs, at about 80 percent, while Massachusetts, Colorado, and Washington exhibit the lowest proportion, at about 61 percent.

Policy Implications

Over the last several years, federal and state governments have been working to overcome barriers that prevent eligible children from gaining insurance coverage. Many resources are now being devoted to outreach efforts aimed at increasing Medicaid and CHIP enrollment among eligible uninsured children.¹⁰ Under CHIP, which was enacted in 1997, states are entitled to approximately $40 billion through the year 2007 to expand insurance coverage for children and are mandated to develop outreach strategies as part of their CHIP plans. The welfare reform legislation of 1996, which "delinked" Medicaid from welfare, provided states with additional funds to ensure that children continue to receive Medicaid coverage under the new Temporary Assistance for Needy Families (TANF) program.

One federal effort has involved bringing together federal departments that serve children in order to identify ways to enroll more children in Medicaid and CHIP (DHHS 1998, 1999). The Interagency Task Force on Children's Health Insurance Outreach led a number of government agencies to identify ways to use other government programs to reach uninsured children (DHHS 1998, 1999). One of the problems in designing outreach strategies is the absence of information on how best to target outreach efforts. The analysis presented here suggests that government programs, especially those operated by the USDA, are indeed already serving families with large numbers of uninsured children and thus represent a very promising outreach tool—especially for reaching uninsured Medicaid-eligible children. Because fewer uninsured children in families with incomes between 150 percent and 200 percent of the FPL participate in these programs as compared with families with even lower incomes, our findings suggest that these programs will reach proportionally more Medicaid-eligible than CHIP-eligible children.

The key question is how to effectively use these programs to enroll uninsured children who are eligible for public health insurance (The Children's Partnership 1999). Florida has been recognized as one of the first states to utilize schools to reach uninsured chil-dren, and in 1996 the Florida Healthy Kids program was the recipient of the 1996 Innovations in American Government Award. Several states have modeled their CHIP programs after Florida's approach, but new complexities have been introduced under CHIP because states are now required to screen children for Medicaid eligibility and enroll eligibles in Medicaid. President Clinton has asked the secretaries of education, health and human services, and agriculture to identify effective school-based strategies that can be replicated throughout the nation (DHHS 1999).

Some localities are building outreach efforts around the School Lunch Program, which, according to the NSAF, serves the families of an esti-mated 60 percent of all low-income uninsured children. The USDA added a health insurance information box to its prototype application forms, although no information is available on how widely used the new prototype forms are. Other efforts have included sending informational flyers to parents and positioning trained volunteers at schools to answer questions and help complete applications (Pulos and Lee 1999). States that have attempted to coordinate children's health insurance coverage with the National School Lunch Program have faced a number of barriers, including the need to protect the privacy of lunch program applicants and the fact that Medicaid and CHIP programs require more information (e.g., details on income, other sources of health insurance, and immigration status) than the National School Lunch Program (Pulos and Lee 1999). One suggestion has been to use participation in the National School Lunch Program as presumptive proof of eligibility for health insurance ("A Sensible Way to Improve Kid Care" 1999). It will be important to identify how programs can successfully overcome these hurdles, because these data suggest that removing such barriers could yield substantial reductions in the number of children who are uninsured.

To be successful, outreach and enrollment efforts must address other barriers as well. Focus groups conducted in California in 1998 suggest that there are many reasons that uninsured children do not obtain public coverage (Lake Snell Perry & Associates 1998). The issues included confusion about the eligibility criteria, frustration with the enrollment process, the negative image associated with enrolling in a program so closely linked to welfare, and concerns about the quality of health care services available through public programs. An additional issue for immigrant families in California was the concern that enrollment could threaten their immigration status. Informing the parents who participate in the National School Lunch Program that their uninsured children are eligible for public coverage may be only one part of the solution; it may also be necessary to address these other concerns.

While these data indicate that the majority of uninsured children live in families that participate in other government programs, a large number of uninsured children—over 1.5 million— live in low-income families that do not participate in these programs. Identifying these children and getting them health insurance coverage may pose even greater obstacles. Recent evidence also suggests that growing numbers of children and families are not participating in other programs, such as Food Stamps, for which they are eligible (Zedlewski and Brauner 1999). If the objective is to provide insurance and other benefits to low-income children, new strategies may be required in the era of federal welfare reform.

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Notes

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References

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About the Authors

Genevieve M. Kenney is a principal research associate in the Urban Institute's Health Policy Center. Her research focuses on the study of how public policies affect access to care and insurance coverage for pregnant women and children.

Jennifer M. Haley is a research associate in the Urban Institute's Health Policy Center whose focus has been on analyzing the NSAF.

Frank Ullman is a research associate with the Urban Institute's Health Policy Center, where he focuses on implementation of state children's health insurance programs.

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