Journal Issue: Health Insurance for Children Volume 13 Number 1 Spring 2003
Improving Access to Publicly Subsidized Health Insurance for Adolescents
Medicaid and SCHIP represent the two most significant sources of publicly funded health insurance for low-income children and adolescents. Several researchers and organizations have examined the unique challenges of and opportunities for serving adolescents in Medicaid and SCHIP.21–24 These studies have found that Medicaid and SCHIP offer the potential to provide comprehensive health insurance coverage to millions of adolescents, and that states have made progress toward covering adolescents in recent years. Nevertheless, the extent to which states implement these programs so that eligible adolescents fully benefit has yet to be determined, and several challenges to serving this population remain.
Historically, adolescents were less likely than younger children to be eligible for public coverage under Medicaid, but program expansions adopted in the late 1980s and early 1990s and the creation of SCHIP in 1997 significantly increased adolescents' eligibility for public coverage.25
Medicaid is jointly financed and administered by states and the federal government. States may vary program guidelines as long as they adhere to federal standards or receive federal permission (in the form of a waiver) to depart from those standards.26 Thus, adolescents' eligibility for Medicaid—along with benefits, provider reimbursement, and many other issues of critical importance to youth and their families—varies by state.
Federal Medicaid law specifies a number of groups that must be covered in every state (referred to as "mandatory eligibility categories") and groups that may be covered if the state chooses to do so (referred to as "optional eligibility categories").27,28 Before 1988, Medicaid eligibility for children and adolescents essentially was limited to those who qualified on a "categorical" basis, such as those whose parents received cash assistance, Supplemental Security Income for disabilities, or federal foster care or adoption assistance.
Between 1988 and 1990, Congress enacted several laws that required states to expand coverage to children and adolescents based on family income.29,30 Among these, the Omnibus Budget Reconciliation Act of 1990 was most important for adolescents. It required states to gradually phase in Medicaid coverage (one year at a time) for poor children and adolescents ages 6 through 18, so that by October 1, 2002, all poor adolescents under age 19 would be eligible.31
Beyond the mandatory phase-in of coverage for poor adolescents, two optional Medicaid expansions of the 1990s were of particular importance: an option that allows states to provide Medicaid eligibility to age 21 for young people who "age out" of the foster care system after their eighteenth birthdays;32 and an option that allows states to disregard certain income and assets and to provide coverage for children and adolescents beyond the age or income levels set as minimums under federal law.33
Despite these expansions, progress across the states has varied, and Medicaid still serves significantly more infants and younger children than adolescents. During Fiscal Year 1999, the latest year for which data are available, Medicaid served more than twice as many children under age 6 and children and adolescents ages 6 through 14 as it served older adolescents ages 15 through 20.34 (See Figure 1.)
The creation of SCHIP in 1997 expanded the potential for states to provide public health insurance coverage to adolescents in two significant ways. First, the population eligible for SCHIP (called "targeted low-income children") includes children and adolescents under age 19 in families with incomes less than or equal to 200% of the federal poverty level (FPL) in most states.35 In addition, the definition of "targeted low-income children" excludes children and adolescents who are eligible for Medicaid, based on eligibility standards in effect on March 31, 1997, and those who do not have access to other insurance.36 This definition particularly benefited adolescents because they were both less likely than younger children to have been eligible for Medicaid before SCHIP and less likely to have private insurance coverage. By September 30, 2001, only five states did not provide Medicaid coverage to all poor adolescents under age 19: Colorado, Montana, Nevada, Pennsylvania, and Utah did not accelerate the mandatory Medicaid phasein schedule to cover poor adolescents to a higher age than federal law requires.
Second, because the federal match for SCHIP is more generous than the match for Medicaid, Congress essentially provided states with a financial incentive to use SCHIP funds to accelerate the phase-in of Medicaid eligibility for poor adolescents.37 As a result, while only 14 states provided Medicaid coverage to all poor adolescents under age 19 as of March 31, 1997, by September 30, 2001, 46 states (including the District of Columbia) provided Medicaid or SCHIP coverage to all poor adolescents under age 19.38
When looking at the highest income level at which adolescents are eligible for public insurance (either SCHIP or Medicaid), states' progress is similarly impressive (see Figure 2). On March 31, 1997, only 6 states provided Medicaid coverage to all adolescents under age 19 in families with incomes above 100% of the FPL.39 By September 30, 2001, all but 12 states provided SCHIP or Medicaid eligibility to all children and adolescents under age 19 with family incomes up to at least 200% of the FPL.40
Progress in Expanding Coverage
During Fiscal Year 2001, nearly 4.5 million children and adolescents under age 19 were enrolled in SCHIP, and nearly one-third (32%) of these enrollees were between ages 13 and 18.41 An interesting picture emerges when SCHIP enrollment data are analyzed by both age group and program type. First, older adolescents were more likely than younger children to have been enrolled in Medicaid expansion SCHIP—36% of adolescents ages 13 to 18 were enrolled in Medicaid expansion SCHIP, compared with 22% of children and adolescents ages 6 through 12 and 16% of children under age 6.42 Second, although more children and adolescents of all ages were enrolled in state-designed SCHIP programs than in Medicaid expansion SCHIP, adolescents ages 13 through 18 represented nearly one-half (46%) of all Medicaid expansion SCHIP enrollees, but only 28% of enrollees in state-designed SCHIP programs during Fiscal Year 2001.43 (See Figure 3.)
The distinction of enrollment by program type is important because it has implications for the benefits that enrollees may receive, and for whether or not eligibility is an entitlement. For example, because Medicaid is an entitlement program, children and adolescents covered by Medicaid expansion SCHIP will remain eligible for Medicaid even if a state has used up its allotment of SCHIP funds.44,45 By contrast, there is no entitlement to eligibility in a separate (non-Medicaid) SCHIP program, which means that states can limit services to eligible children and youth by placing them on waiting lists or by capping enrollment.The proportion of SCHIP enrollees who are adolescents varies considerably by state. During Fiscal Year 2001, for example, adolescents ages 13 through 18 represented anywhere from less than 25% of total SCHIP enrollment (in four states) to 100% of total SCHIP enrollment (in two states). Among the five states that reported a majority of total SCHIP enrollees being ages 13 through 18, four were Medicaid-expansion-only states.46
Benefits Available to Adolescents
Once adolescents enroll in Medicaid or SCHIP, their access to particular benefits may vary, depending on the state in which they live and the type of program for which they are eligible. The Medicaid benefit package includes a broad range of mandatory and optional services.47 However, for children and adolescents under age 21, all mandatory and optional Medicaid services must be made available by a state if medically necessary.48 Nevertheless, states are allowed to impose initial limits on the amount, duration, and scope of a particular benefit—such as mental health services—and adolescents may have to overcome such limits to obtain all the services they need. Also, states may be less generous to adolescents than to younger children, such as in establishing the frequency of required comprehensive health assessments, or screenings, in Medicaid.
The scope of benefits available in a state's SCHIP program depends on the type of program that was created—that is, Medicaid expansion, combination, or separate SCHIP program (see the article by Wysen, Pernice, and Riley in this journal issue). Benefits for adolescents in Medicaid expansion SCHIP must meet the requirements for Medicaid. Benefits for adolescents in a state-designed SCHIP program must meet minimum criteria, but they can be more generous. Uniform data about the range of services offered to adolescents under state-designed SCHIP programs are not readily available, although some state-by-state data about specific benefits suggest that states vary with respect to preventive health services, reproductive health services, substance-abuse and mental health services, dental services, and the breadth and depth of the benefit package for adolescents with special health care needs.49