The graph above is the most telling figure from the study, “The Association Between Medicaid Coverage for Children and Parents Persists: 2002-2010,” which analyzes the relationship between parent and child enrollment in public coverage in Oregon from 2002 to 2010. In the graph, children’s coverage (represented by the dotted blue line) is higher than parent coverage (represented by the dashed gray line), but the two lines have the same trend, indicating a very strong association between parent and child enrollment and disenrollment.
In order to track how parent’s enrollment or disenrollment affects their children’s coverage, researchers from the Oregon Health & Science University used Medicaid and CHIP administrative data spanning 2002 to 2010. To assess the strength of the relationship between parent and child coverage, the researchers divided the nine years into five time periods, separated by three major policy changes in Oregon:
- In 2003, Oregon expanded CHIP eligibility from 133 percent FPL to 185 percent FPL. At the same time, the Oregon Health Plan, Oregon’s Medicaid and CHIP programs, split into two separate programs for adults. The state created OHP Plus for mandatory groups, and OHP Standard for non-disabled adults making less than 100 percent FPL. However, OHP Standard closed enrollment to new applicants from mid-2004 to 2008, and because of this, 50,000 adults lost coverage. Though adult coverage was cut, Oregon intended to strengthen children’s coverage by expanding their public coverage eligibility. Researchers used this policy change to assess what happened to children when their parents lost public coverage even when children’s eligibility is increased.
- In 2008, Oregon re-opened enrollment for adults into OHP Standard. This began the creation of the Oregon Health Insurance Experiment (OHIE). Oregon was granted permission to randomly select individuals who signed up on a ‘reservation list’ to enroll in OHP, creating a natural experiment. Eight random drawings were held and approximately 10,000 people received coverage. This policy change is used to investigate the likelihood of a child gaining coverage if their parent received coverage after a policy change intended to only affect adults.
- In 2010, Oregon repeated the random selection process, and expanded CHIP eligibility for children up to 200 percent FPL. The state also created the Healthy Kids Connect program, which provided premium subsidies for children between 200 and 300 percent FPL. An estimated 90,000 children gained coverage, but many eligible children did not enroll in coverage. Researchers used this policy change to gauge what happened to children when parents gained coverage.
The authors studied the time periods before and after each of these three changes, and as the graph indicated the results show a strong relationship between parent and child coverage over the entire nine-year span. Children whose parents were not covered by Medicaid in the same month had a probability range of 0.28 to 0.57 of being insured, while children who had at least one parent insured in the same month had a probability range from 0.89 to 0.95 of being insured. Study authors concluded:
“In other words, the historic association between coverage for children and their parents persisted, even when public coverage was expanded for children. Our results suggest that children whose parents were covered by public insurance had similar patterns of coverage to their parents, even though policies diverged for children and adults. Child-only expansions in public coverage were associated with increases in children’s health insurance coverage rates overall, yet children’s coverage remained strongly associated with parental coverage patterns.”
This is something our Say Ahhh! readers know well. Increased eligibility levels for children are important for coverage, but equally important is coverage for their parents. Parent coverage has a significant influence on children’s coverage, so policies that prevent parents from enrolling into coverage also hurt children. The authors acknowledge this by stating, “In this population of children and parents reliant on the OHP (Oregon’s Medicaid and CHIP programs) for health insurance, the overall patterns of coverage for children mirrored that of parents, suggesting that children’s public coverage was affected by policies intended for adults only.”
States may make decisions aimed at adults, such as not expanding Medicaid or cutting parent eligibility, but when implemented, or in the case of Medicaid expansion, not implemented, these policies could have serious unintended consequences on children. We’ve blogged extensively on the ‘welcome mat’ effect, how parent coverage is good for the family’s health and financial security, and how coverage for kids lead to long-term benefits. Not only does better parent coverage lead to more insured children, but contributes to the whole family’s well-being and creates a better environment for healthier growth.