Public Release: 

Targeting communities with high rates of uninsured children

Health Affairs

WASHINGTON, D.C. - 25 July 2001 - If you build near-universal access to health insurance for low-income children, will they come? Evidently not without a lot more targeted outreach, especially in communities with the highest rates of uninsured children, according to a study by the Center for Studying Health System Change (HSC) published today in, as a Web-exclusive in the journal Health Affairs.

Despite near-universal eligibility through the State Children's Health Insurance Program (SCHIP), Medicaid and employer-sponsored coverage, millions of low-income children still lack health insurance, according to the study by Peter J. Cunningham, a senior health researcher at HSC, a nonpartisan policy research organization funded solely by the Robert Wood Johnson Foundation.

The percentage of low-income children--those living in families below 200 percent of the federal poverty level--eligible for public coverage soared from 63 percent in 1997 to 92 percent in 1999 after SCHIP became law in 1997, according to the study. Despite the dramatic increase in low-income children's eligibility, the proportion of low-income children enrolling--or the "take-up" rate-- in public programs remained under 50 percent.

"The road to insuring all low-income children is no longer expanding eligibility; it's getting states and communities to reach out and find these kids and encouraging parents to enroll them in existing public programs," Cunningham said. "Almost all low-income children are eligible for public coverage but less than half are enrolled."

The study, "Targeting Communities with High Rates of Uninsured Children," details changes in children's eligibility and enrollment in public and private insurance between 1997 and 1999. Based on HSC's Community Tracking Study Household Survey, the study included about 18,800 children in 60 randomly selected, nationally representative communities. Because of the timing of the 1999 survey, SCHIP enrollment increases after 1999 are not reflected in the results.

The study also examines differences in public coverage eligibility in high- uninsurance communities--more than 16 percent of children uninsured--and low-uninsurance communities--less than 8 percent uninsured. SCHIP "virtually eliminated" differences in children's coverage eligibility between the two types of communities. But persistently low take-up rates in high-uninsurance communities, primarily in southern and western states, have kept many low- income children from gaining coverage.

The percentage of low-income children eligible for public coverage in high- uninsurance communities jumped from 52 percent in 1997 to 91 percent in 1999. In low-insurance communities, the rate of low-income children eligible for public coverage increased from 76 percent to 96 percent during the same time.

Despite the dramatic increase in children's eligibility for public coverage in high- uninsurance communities, the rate of publicly insured children in these communities increased only 3 percentage points from 14 percent in 1997 to 17 percent in 1999 because of low take up. And the increase in publicly covered children in high- uninsurance communities was almost entirely offset by a decline in children covered through private insurance in these communities.

Lower take-up rates in high-uninsurance communities may reflect a combination of higher costs for employer-sponsored coverage, lower incomes for families with children and non-economic factors, including stigma associated with public programs and less desire for health coverage in these communities.

One striking characteristic of high-uninsurance communities is the relatively large percentage of Hispanic children--29 percent compared to 10 percent in low-uninsurance communities. Hispanics typically have lower take-up rates for health insurance and may face immigration concerns, language barriers, lack of awareness of public programs, and a lack of understanding about the important role insurance plays in securing health care in the United States.

"If we truly want to make sure all low-income children have coverage, policy- makers need to understand why take-up problems persist," Cunningham said. "There's no magic solution. It's going to take time and perseverance to reverse longstanding attitudes about health insurance coverage in some parts of the country."

While all states have conducted outreach activities and many have streamlined enrollment procedures, the study's results suggest there is more work to be done to increase SCHIP and Medicaid enrollment, especially in states with high- uninsurance communities. For example, states with high-uninsurance communities had a considerably higher percentage of unspent SCHIP funds in 1999 compared to states with low-uninsurance communities.

"Whether this reflects states' level of effort in getting eligible children enrolled is unclear, but it's troubling because these states have the farthest to go," Cunningham said.

The federal government earlier this month encouraged states to take full advantage of an opportunity to use up to 10 percent of nearly $2 billion in unspent SCHIP funding from fiscal year 1998 to boost outreach efforts to enroll more children in SCHIP and Medicaid.


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