Churning: Children’s Coverage
Discontinuity and Its
Consequences in Kentucky
Julia F. Costich and Svetla Slavova
College of Public Health
University of Kentucky
What we know about discontinuity in
children’s 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)
Kentucky Children’s 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
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
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
Pendleton
Carrll
Over 60%
Bracken
Grant
Trimble
Mason
Owen
Robertson
Henry
Fleming
Nicholas
Shelby
Meade
Anderson
Elliott
Lawrence
Fayette
Woodford
Bath
Montgomery
Menifee
Clark
Jessamine
Henderson
Nelson
Breckinridge
Daviess
Washington
Webster
Larue
Mclean
Ohio
Hart
Livingston
Ballard
Clay
Laurel
Metcalfe
Lyon
Warren
Christian
Trigg
Hickman
Pulaski
Adair
Graves
Knott
Perry
Caldwell
Marshall
Pike
Green
Mccracken
Carlisle
Floyd
Owsley
Casey
Edmonson
Butler
Jackson
Rockcastle
Taylor
Muhlenberg
Breathitt
Lincoln
Grayson
Magoffin
Lee
Marion
Crittenden
Hopkins
Wolfe
Estill
Garrard
Boyle
Union
Johnson
Martin
Madison
Hardin
Morgan
Powell
Mercer
Hancock
Boyd
Rowan
Bourbon
Spencer
Bullitt
Carter
Scott
Franklin
Jefferson
Greenup
Lewis
Harrison
Oldham
Todd
Leslie
Knox
Logan
Cumberland
Simpson
Allen
Monroe
Letcher
Russell
Barren
Clinton
Harlan
Wayne
Mccreary
Whitley
Bell
Calloway
Fulton
Prepared by: Julia F. Costich, College of Public Health
Fig. 1: KCHIP Enrollment May 2001-March 2004
56000
55000
Recertification policy changes
54000
Premiums
53000
End of mail-in application
52000
51000
50000
49000
48000
47000
46000
45000
Mar-04
Feb-04
Jan-04
Dec-03
Nov-03
Oct-03
Sep-03
Aug-03
Jul-03
Jun-03
May-03
Apr-03
Mar-03
Feb-03
Jan-03
Dec-02
Nov-02
Oct-02
Sep-02
Aug-02
Jul-02
Jun-02
May-02
Apr-02
Mar-02
Feb-02
Jan-02
Dec-01
Nov-01
Oct-01
Sep-01
Aug-01
Jul-01
Jun-01
May-01
Fig. 2: Combined KCHIP and Children's Medicaid Enrollment, May 2001-March 2004
380000
370000
360000
350000
340000
330000
320000
310000
Mar-04
Feb-04
Jan-04
Dec-03
Nov-03
Oct-03
Sep-03
Aug-03
Jul-03
Jun-03
May-03
Apr-03
Mar-03
Feb-03
Jan-03
Dec-02
Nov-02
Oct-02
Sep-02
Aug-02
Jul-02
Jun-02
May-02
Apr-02
Mar-02
Feb-02
Jan-02
Dec-01
Nov-01
Oct-01
Sep-01
Aug-01
Jul-01
Jun-01
May-01
Problems with added eligibility office
workload
Source: 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
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
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
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
Percentage of Children Enrolled and
Percentage of Timely Renewals (R2 = .44)
New Approvals as Percentage of Total and
Percentage of Timely Renewals (R2 = .55)
Methodology and statistical findings
• SAS univariate regression analysis
• F test found p < .0001 for relationships
between
– renewal and enrollment
– new applications and non-renewal
• R2 = .44 and .55 respectively
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 highrenewal counties can be replicated with outreach
workers, volunteers
– Advocate for more realistic federal budget allocations
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