Churning: Children

1
Churning Childrens Coverage Discontinuity and
Its Consequences in Kentucky

• Julia F. Costich and Svetla Slavova
• College of Public Health
• University of Kentucky

2
What we know about discontinuity in childrens
coverage

• NY half lost coverage in a year despite most
  remaining technically eligible (Lipson 2003)
• 12 states less than half timely renewed (Hill
  2003)
• 4 states half lapsed at renewal but one-fourth
  back in 2 months (Dick 2002)
• 7 states two-thirds of disenrolled ineligible
  for SCHIP (but Medicaid?) (Riley 2002)
• Kansas procedural and computer problems often at
  fault (Allison 2003)

3
Kentucky Childrens Health Insurance Program
(KCHIP)

• Medicaid expansion to 150 FPL
• Look-alike to 200 FPL
• Administered by Dept. for Medicaid Services
• Eligibility determination by same agency as cash
  assistance, food stamps, etc.
• Enrollment stable at 50,000 children
• Compare Medicaid at 321,000

4
KCHIP Policy Changes

• 1998 Mail-in application, in-person renewal
• 7/1/2000 Mail-in renewal with pre-populated form
  and self-declaration of income
• 6/1/2001 Return to in-person interview for
  renewal
• 7/1/2002 Mailed renewal reinstated return to
  in-person interview for initial application
• Confusion among caseworkers and families

5
Percentage of All Children Enrolled in KCHIP or
Medicaid, SFY 2003 Data source Kentucky Dept.
for Medicaid Services
Under 30
30-39
40-49
Campbell
Boone
Kenton
50-59
Gallatin
Bracken
Pendleton
Carrll
Over 60
Grant
Mason
Trimble
Owen
Greenup
Robertson
Lewis
Henry
Harrison
Oldham
Fleming
Nicholas
Boyd
Carter
Scott
Franklin
Jefferson
Rowan
Shelby
Bourbon
Bath
Elliott
Lawrence
Fayette
Woodford
Montgomery
Spencer
Anderson
Bullitt
Meade
Menifee
Clark
Jessamine
Morgan
Johnson
Powell
Mercer
Hancock
Nelson
Martin
Breckinridge
Henderson
Madison
Daviess
Estill
Magoffin
Wolfe
Washington
Hardin
Garrard
Boyle
Union
Lee
Larue
Webster
Mclean
Marion
Breathitt
Floyd
Lincoln
Jackson
Ohio
Pike
Grayson
Owsley
Rockcastle
Crittenden
Taylor
Knott
Casey
Hart
Hopkins
Perry
Edmonson
Green
Muhlenberg
Clay
Livingston
Caldwell
Laurel
Pulaski
Leslie
Letcher
Adair
Ballard
Mccracken
Metcalfe
Lyon
Russell
Barren
Warren
Carlisle
Marshall
Christian
Knox
Harlan
Logan
Cumberland
Todd
Trigg
Wayne
Simpson
Allen
Graves
Bell
Whitley
Clinton
Hickman
Mccreary
Monroe
Calloway
Fulton

Prepared by Julia F. Costich, College of Public
Health
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8
Problems with added eligibility office
workloadSource Family Resource Youth Service
Center Staff Survey

• Long waits in understaffed urban offices
• Refusal to provide scheduled appointments
• Overloaded phone system unanswered voice mails
• Unexpected requests for additional documentation
• Inappropriate denial based on confusion
• Staff reporting suspect immigration status
• Failure or inability to accommodate working
  families schedules

9
Churning effect

• 46 did not renew on time
• New applications were 52 of total enrollment
• Yet total enrollment grew by only 4
• Millions of wasted state dollars
• Risk of gaps in coverage
• Wide variation across the state
• Timely renewal highest in Medicaid expansion

10
Low enrollment
Low renewal rate
High reapplication rate
11
Data sources

• Open records request to Medicaid for data by
  county, month and program
• Requires staff to provide data
• Data limitations
• Not individual-level
• New applications may be internal to system when
  renewal deadline is missed by staff
• 3 categories
• Number of children up for renewal
• Number timely renewed
• Number of new applications approved

12
Methodology

• Percentage of all children (Census data) enrolled
  in KCHIP or Medicaid
• Critically important to include both because of
  frequent movement between programs
• Failure to account for movement overstates
  churning
• Percentage of children eligible for renewal in
  either program who renewed on time
• New applications approved as percentage of total
  enrollment

13
Percentage of Children Enrolled and Percentage of
Timely Renewals (R2 .44)
14
New Approvals as Percentage of Total and
Percentage of Timely Renewals (R2 .55)
15
Methodology and statistical findings

• SAS univariate regression analysis
• F test found p lt .0001 for relationships between
• renewal and enrollment
• new applications and non-renewal
• R2 .44 and .55 respectively

16
Discussion

• Low rate of timely renewal similar to other
  studies findings
• Identified need for pre-termination contact,
  follow-up
• Problem hiring freezes, state budget deficit
• Next steps
• Determine whether supportive environment of
  high-renewal counties can be replicated with
  outreach workers, volunteers
• Advocate for more realistic federal budget
  allocations

17
Limitations

• Inability to track individual children
• Considerable migration among programs
• Eligibility determination office practice giving
  rise to spurious new applications
• Possible delinking issues in information systems
• Antiquated eligibility determination system may
  introduce errors