Health & Human Services

Rolling Medicaid Rules

Several states made changes in their Medicaid and SCHIP programs that will, in effect, push children off the rolls.
by | September 2003

You could almost hear the sigh of relief coming from Medicaid and child-advocate circles when governors and state legislators finished their budget-balancing job for this fiscal year. Although health care benefits for poor and near-poor women and children didn't escape unscathed, the cuts to those programs weren't as deep or extensive as they could have been. Many of Medicaid's optional services were slashed and some co-payments were added, but only a few states touched eligibility requirements for either impoverished persons who qualify for Medicaid or the slightly better-off families who get their children's (and sometimes the parent's) health needs covered by SCHIP.

There was other good news: Children's health insurance programs that had been expanded in the 1990s were finally bearing fruit. Despite a weak economy during the past three years and an increase in the overall number of uninsured Americans, the number of uninsured children without coverage fell by 1.8 million, to 7.8 million, according to the Urban Institute's 2002 National Survey of America's Families.

And in a July report for the Kaiser Commission on Medicaid and the Uninsured, author Donna Cohen Ross, director of outreach at the Center on Budget and Policy Priorities, looked at eligibility, enrollment, renewal and cost-sharing practices in Medicaid and SCHIP. She found much to be positive about. Some states--Virginia and Louisiana, for instance--had made strong and effective efforts at making it simpler, and therefore easier, for families to enroll in either Medicaid or SCHIP.

Yet, the health-coverage outlook is far from rosy. There is, in fact, something of a dark secret lurking behind many states' approaches to these programs. In remarks Ross made after the report was published, she noted that "policies adopted during the most recent state legislative season after the survey period indicate an erosion of health coverage for low-income children and parents is occurring." All of which points up, she said, that "progress on expanding coverage is tenuous."

A number of states made changes in their Medicaid programs that don't appear, on the surface, to be targeted at pushing people off the rolls. That is likely to be the practical result, however. Some have rescinded simplifications for applying for Medicaid and SCHIP--reforms that many of them put in place only a year or two ago. Or, if they didn't have the streamlining concepts in place yet, they are scrapping changes they were about to implement.

One of those simplifications is the 12-month continuous eligibility timeline. Under the 12-month approach, once a child is enrolled in Medicaid or SCHIP, the parent does not have to report changes in family circumstances for one year. The child, in other words, is guaranteed health-care coverage for a year.

Three states dropped the 12-month rule in 2002: Connecticut, Indiana and Nebraska reverted to a six-month timeline. Connecticut made the switch in its Husky A Medicaid program. Before the change, enrollment had been climbing steadily and had reached nearly 210,000 children in March. But between May and July, after the new policy went into effect, enrollment plunged by nearly 8,000 children. No one suspects, given the economic climate, that all 8,000 were no longer eligible.

Several states are considering following suit or are rethinking another simplification rule: that enrollees no longer have to provide the paperwork that proves their incomes are low enough to make them eligible. At first glance, asking beneficiaries to prove they qualify would seem to fall under the rubric of "good government." If you insist people prove their incomes qualify them for Medicaid, doesn't that cut down on fraud and abuse? Not really. According to Ross, many states have databases to check on income; they no longer need to have beneficiaries gather receipts and scraps of paper to show what money they earned, how much cash they have in the bank and the like. By checking records they have available online, states have improved accuracy in accepting only those who are income-eligible and have also become more efficient--to say nothing of relieving much of the burden on those applying for the program.

Which is the implicit point of changing back to the old system. When poor people, many of whom have language or literacy problems or for whom gathering information and making copies of those papers seem the equivalent of a trek up Mount Everest, are faced with such requirements, they may not be able to complete their applications.

It's not hard to figure out why states are doing this. It's even understandable: This is a way of cutting costs without taking the political heat for compromising benefits that help keep vulnerable populations healthy. At the same time, it's an underhanded strategy that is difficult for the media or even advocates for the poor to get a handle on, much less make the case that something adverse has happened. It's simply too complicated a story to sell.

Such techniques may be politically savvy, but from a policy standpoint, they're just plain sneaky.

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