EstimatingSCHIP/MedicaidEligiblebutNotEnrolled

attheCountyLevel
November2009

Introduction
Keytoincreasingaccesstohealthinsurancecoverageforuninsuredchildren,isknowingwhoisalready
eligiblebutnotenrolledinexistingprograms.Medicaidprovidescoverageforverylowincomechildren
whiletheChildrensHealthInsuranceProgram(CHIP)providescoverageforchildrenwithincomestoo
hightobeeligibleforMedicaidbutstilltoolowtoaffordprivatecoverage.Whiletheseprogramsare
operatinginall50statesandtheDistrictofColumbiaitisestimatedthatapproximately70%ofall
uninsuredchildrenareeligibleforeitherMedicaidorCHIP(Dubay,Holahan,andCook2007).

The2009Children'sHealthInsuranceProgramReauthorizationAct(CHIPRA)providedadditionalfunding
forenrollmentactivities,including$100millioninoutreachgrantfundingandanenhancedfederal
matchfortranslationandinterpretationservices.Theoutreachactivitiesincludenewgrantsto
eligibleentitiesduringtheperiodoffiscalyears2009through2013toconductoutreachand
enrollmenteffortsthataredesignedtoincreasetheenrollmentandparticipationofeligiblechildren
underCHIPandMedicaid,anda10percentstateasideoffundingforanationalenrollmentcampaign
(P.L.1113).

Manystatesanalystsareinterestedinunderstandingthenumberandcharacteristicsoftheeligiblebut
uninsuredchildrentobettertargetoutreachandenrollmentinitiatives.Estimatingthisnumberatthe
stateandsubstatelevel(i.e.,county)canbedifficult,especiallyforstatesandcountieswithlarge
geographicareasandsmallerpopulations.SHADAChasworkedwithColoradotodevelopapossible
modelbasedapproachfordevelopingestimatesofeligiblebutnotenrolledchildrenatthestateand
countylevelsusingMedicaid/SCHIPenrollmentandsurveydata.

OverviewoftheProcess
EstimatingthenumberofSCHIP/Medicaideligiblechildreninallofastatescountiesinvolvesestimating
boththenumberofchildrencurrentlyenrolledandthenumbereligiblebutnotenrolledineachofthe
countiesinastate.EstimatingthenumberofchildrencurrentlyenrolledinSCHIPandMedicaidrequires
aqueryofthestatelevelSCHIP/Medicaidenrollmentfiles.

Estimatingthenumberofeligiblebutnotenrolledchildrenissignificantlymoredifficult.Appropriately
developingtheestimaterequirescomprehensivedataonchildrenineverycountyinthestate.These
dataneedtodescribedetailedsourcesandamountsoffamilyincome,familyexpenses(suchaschild
care),familyrelationshipsbetweeneveryoneinthehousehold,citizenshipstatusofthechild,andthe
lengthoftimeanoncitizenhaslegallybeeninthecountry.Theanalystneedsinformationonallof
thesevariablesinadditiontoareasonablylargesampleofchildrenineachcounty(e.g.,300400)to
makereliablecountylevelestimates.Acomprehensivedatafilewiththisinformationdoesnotyet
exist;thereforeanalystsneedtocollectandcompileavailabledatatoestimatethenumberofuninsured
SCHIP/Medicaideligiblechildrenbycounty.

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SHADACEstimationApproachforEligiblebyNotEnrolledChildren
InthisapproachdeterminingthenumberofchildreneligibleforSCHIP/Medicaidinastatescountiesisa
twophaseprocesstoreflectthetwocomponentsoftheeligiblepopulation:(1)thosecurrently
enrolled,plus(2)thoseeligiblebutnotenrolled.Asdescribeabove,theanalystcanusecurrentstate
enrollmentfilestodetermineacountofthenumberofchildrenenrolledinSCHIP/Medicaid.The
analystcanthenuserecentsurveydatafromtheAmericanCommunitySurvey(ACS)toestimatethe
numberofeligiblebutnotenrolledchildrenforthestatesSCHIP/Medicaidprogram.Thesetwocounts
arethenaddedtogetherforanestimateofthetotalnumberofchildreneligibleforSCHIP/Medicaidin
allthecountiesinastateatapointintime.Bothphasesaredescribedindetailbelow.

ACSSurveydatabecomeavailableduringthefallofeachyear,makingthisagoodtimefortheanalystto
establishaprocessofupdatingthepreviousyearsestimate.Theestimatewillbederivedusingdata
thatrepresentstheprecedingcalendaryear.Forexample,infallof2009thedatafromcalendaryear
2008canbeusedtoestimatethenumberofeligiblechildrenforastatesSCHIP/Medicaid.However,
ACSestimatesarenotavailableforeverycountyinthestate.InPhase2,below,wedescribea
techniquetodevelopproxyestimatesforeachcounty.

Phase1:
UsingtheSCHIP/Medicaidenrollmentdata,determinetheaveragemonthlyenrollmentforthe
SCHIP/Medicaidprogrambycountywithinastateforthecalendaryearforwhichtheestimatesare
needed.

Phase2:
Step1:ObtainthemostrecentcountypopulationestimatesfromtheU.S.CensusBureau.The
estimatesareupdatedeachspringbytheCensusBureauandrepresentthepopulationbyage,sexand
raceasofJuly1duringtheprecedingcalendaryear.Obtainfromthesetablesthenumberofchildrenin
thecountyage018.Thestateandcountypopulationestimatescanbedownloadedfromthefollowing
website:http://www.census.gov/popest/estimates.php

Step2:DownloadtheAmericanCommunitySurvey(ACS)microdatafromtheIPUMSwebsite.These
dataarereleasedeachfall,representtheprecedingcalendaryear,andareavailableat:
http://usa.ipums.org/usa/

CountyleveldataarenotavailableinthesingleyearACS.Thecountyinformationneedstobe
approximatedusingthepublicusemicrodataarea(PUMA),whichisthelowestlevelofidentifiable
geographyinthesingleyearACSdata.Thesearepopulationareaswith100,000ormorepopulation,
andgenerallycorrespondwithoneormorecounties.Inareaswithhighpopulationdensitythe
boundariesmaynotcoincidewithcounties.1Theestimationtechniquedescribedhereassumesthatyou
willdevelopestimatesforeachPUMAinthestateandapplythoseasaproxyforthecountieswithin
thatPUMA.

AdescriptionofthePUMAguidelinesandassignmentprocessisat:
http://www.census.gov/geo/puma/puma2000.html.ForamapofPUMAsavailableinthestatessee:
http://usa.ipums.org/usa/volii/2000pumas.shtml

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ForeachPUMAinthestatedeterminetheproportionofchildrenwhoareincomeeligiblefor
SCHIP/Medicaid,whoareuninsured,andwhoareU.S.citizensorqualifiedaliens.Usetheseguidesto
developspecificparameters:

IncomeEligibility:FromtheACSmicrodataestimatethepercentofchildren018whohave
familyincomesbetween0%ofthefederalpovertylevel(FPL)andthemaximumpercentofthe
federalpovertylevelforeligibilityinSCHIP/Medicaidforthatstate.

CitizenshipandQualifiedAliens:Tobeaqualifiedalienachildmustbealegalresidentofthe
U.S.foratleastfiveyears.However,thesurveyonlyasksaboutlengthoftimeintheU.S.You
cannotdeterminewhetheranoncitizenhasresidedintheU.S.legallyduringthattime.One
simpleapproachfordealingwiththisdeficiencyinthedataistofollowthesesteps.
1. UsetheACSmicrodatatoestimatethepercentofkidsineachPUMAthatareinthe
eligibilityincomerangeandwhoarenotU.S.citizensandwhoarenotlikelyqualified
aliens.
2. Selectthesubsetofthesecasesthathaveresidedinthecountryforatleastfiveyears.
3. Selecttheseorasubsetofthesecasesandconsiderthemtobeeligible.2

Uninsured:Beginningwiththe2008ACS,releasedinSeptember2009,theACSpublicuse
microdatafilehasanindicatorforhealthinsurancestatus.

Oncethepercentofincomeeligible,uninsured,andU.S.citizensorqualifiedaliensisdetermined,
multiplythispercentforthePUMAinwhichthecountyisamemberbythenumberofchildrenobtained
instep1.3

Theresultsfromphase1(whichestimatesthenumberofeligiblechildrenenrolled)ineachcounty
shouldbeaddedtophase2(whichestimatesthenumberofeligiblewhoareuninsured).Thisgivesyou
thetotaleligibleandalsothetotaleligiblebutnotenrolled.Thesenumberscanthenbemonitoredby
countyovertime.Alsotheestimatesfromeachphasecanbetrackedseparatelytoevaluatehowwell
theprogramisperforming.

PotentialModelEnhancements
IncomeAdjustmentModels
Determiningincomeeligibilitycanbecomplexandmanystatesincludeincomedisregardsandexempt
certainexpenses(e.g.,childsupport,childcareexpenses,alimony)whencalculatingincomeinorderto
meeteligibilityincomelimits.Bynotmakingtheseadjustmentstoincometheanalystwilllikely
estimatefewerpeopletobeeligiblethanactuallyareeligible.However,childsupport,alimonyand
child/elderdaycareexpensesarenotincludedonsurveydataandthesetypesofadjustmentswould
needtobeappliedthroughstatisticalsimulationinordertodevelopamoresophisticatedeligibility

ForanexampleseeDubay,HaleyandKenney2002.
SomelargepopulationcountiesaredividedintomultiplePUMAs.Forexample,MultnohmahCounty,ORis
dividedbetweenthreePUMAs.Disaggregatedsubcountyestimatesarepossibleoryoucanjustruntheratefor
thewholecounty.AlsosomecountiesaredividedintotwoseparatePUMAs(partofacountyisinonePUMAand
partisinanotherPUMA).Inthiscasesometypeofweightedestimateofthepopulationshouldbeused.Thiswill
needtobedevelopedfromdecennialcensusdata(either2000or2010oncethatbecomesavailable).
3

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model.Tohavethisdoneappropriatelywouldcostsignificantlymorethanthemodeldiscussedabove.4
Foranexcellentexampleofaverycomplexandveryexpensivemodelpleaseseethedetailed
informationonTRIMmodeladjustmentscurrentlybeingmadebytheUrbanInstitute(UrbanInstitute
2008).

SmallAreaEstimation
Anotherapproachthatcouldbefruitfulanddiffersdramaticallyfromtheapproachsuggestedaboveis
touseasmallareamodelbasedestimationapproach.Smallareaestimationisanappealingtechnique
andithasmanyadvantagesandsomedisadvantagesforthepurposeofestimatingthenumberof
SCHIP/Medicaideligiblechildrenineachcountyinastate.

SmallareamodelbasedestimationusesexistingauxiliarydatafromtheU.S.CensusBureau,Bureauof
LaborStatistics,HealthResourcesandServicesAdministrationandothersources,todevelopamodelof
howmanychildrenineachcountyareeligibleforSCHIP/Medicaid.Examplesofsmallareamodelsof
thistypeincludetheSmallAreaIncomeandPovertyEstimates(SAIPE)fromtheCensusBureauorfrom
theBureauofLaborStatisticsLocalAreaUnemploymentStatistics(LAUS)estimates.5Thisapproachcan
alsobeverycostlyduetotheintensivestatisticalanalysisinvolvedinthistypeofsmallareaestimation
modeling.

Infallof2013theACSwillproducesummarytablesofhealthinsurancecoverageforeverycountyina
state,basedonfiveyearaverages.Itwouldbeworthinvestigatingthedevelopmentofsmallarea
estimationtechniquestoimprovethemodelusingthiscountyspecificinformation.Thisis
advantageousovertheapproachedoutlinedinthispaperbecauseitwilladdressbetweencounty
variationwithinPUMAs.Giventherapidchangesinthetypesofdatathatwillbecomeavailableover
thenextfiveyears,wewouldrecommendnotinvestingtimeandmoneyintothiseffortuntilthecounty
dataforallcountiesareavailablein2013.

AfinaloptionwouldbetoaccesstherestrictedACSdatafileataCensusBureauResearchDataCenter
(RDC).6TherestricteddatafileidentifiesallcountiesandcountyequivalentsintheU.S.Varioussmall
areaestimationtechniquescouldthenbeusedtoestimateeligiblebutunenrolledchildrenincounties
thathavelowobservationcounts(lessthan300400).Suchestimationmethodsincludethosedescribed
above,andBayesiantechniquesthathavebeenshowntoyieldequallyvalidestimateswithconsiderably
lesscomputationaleffort.Thismethodwouldalsobecostlytodevelopduetotheintensivestatistical
analysistimeandlogisticalrestrictionsofconductingresearchatanRDC.However,afterthefirst
attempttheapplicationprocesswouldbecomeroutineandrequirelesseffortinensuingyears.

FormorebackgroundonsmallareaanalysisasusedforpolicyspecificpurposespleaseseeSHADACs
issuebriefonthetopic,andourtechnicalbriefdescribingtheSAEprocedureusedforthe2008
OklahomaHealthCareInsuranceandAccessSurvey(StateHealthAccessDataAssistanceCenter2002,
2009).

AsimplerapproachcouldbetojustwidentheFPLbandstobeupto225inthemodeleventhoughtheyare
officiallysetat205%ofFPLtoadjustforearningsdisregardsandexpenses.
5
Forexamplesofsmallareaestimationthistypeofworksee:http://www.bls.gov/LAU/and
http://www.census.gov/hhes/www/saipe/
6
InformationonCensusBureauRDCsandlocationsisavailableat:
http://www.ces.census.gov/index.php/ces/researchprogram.

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GeneralDataLimitationsofEligibilityModels
IncomeMeasurement
Therearethreemajorproblemsthatshouldbenotedinusingincomedataforeligibilitymodeling,as
measuredinsurveyssuchastheACSandCurrentPopulationSurvey(CPS).First,thereferenceperiodof
theincomeitemsmaynotmatchtheactualreferenceperiodusedforprogrameligibilitydetermination.

TheCPSmeasuresincomefortheentirepastcalendaryear,whiletheACS(whichisfieldedeverymonth
oftheyear)asksaboutincomeforthepast12months.SCHIPeligibilityisnotbasedontheexactsame
referenceperiodandsomefamilieswillhavehadhighincomeslastyearbutduetoalayoffor
unemploymentspellmaybeeligibleatanygivenpointintime.Likewise,peoplewhowereeligible
basedonlastyearsincomemaynotbeeligibleatagivenpointintimeastheirincomemayhavegone
upsignificantlyortheymayhavefoundanewjob(ifpreviouslyunemployedorlaidoff).Thiswouldlead
somepeopleyoudeterminetobeeligibletoactuallybeineligibleatanygivenpointintime.Given
howeligibilitydeterminationworksatenrollment,morepeoplewillbeeligibleatsomepointintime
duringtheyearthanwewillestimate.

Thesecondproblemwithusingsurveyincomedataisthatsomerespondentsdonotprovideincome
dataonthesurvey.Anywherefrom1525%oftheincomedatawillbemissing,dependingonhowthe
dataarecollectedand/oredit.IncomedataareimputedonboththeACSandtheCPSsurveys,and
theremaybeproblemsusingthesedatatotheextentthattheimputationprocessesdoesordoesnot
reflecteligibility.

Thethirdproblemisthatthereisasubstantialamountofmeasurementerrorinselfreportedincome
data.Thiserrorusuallypresentsitselfasanunderestimationofincomerelativetoadministrativedata
sources(Moore,Stinson,andWelniak2000).

IssueswithMeasuringHealthInsuranceCoverage
Healthinsuranceisacomplexandtimevaryingconceptthatisdifficulttomeasure.Themostwell
knownproblemwithcoverageestimatesisknownastheMedicaidundercount.Thisphenomenon
describesthetendencyofsurveyresultstounderestimateenrollmentinMedicaidwhencomparedto
administrativerecords.ThisundercountnotonlyproducesbiasedMedicaidestimates,butartificially
biasesupwardstheestimatesofuninsuranceandprivatecoverage(Davernetal.2009;Calletal.2008).

TheMedicaidundercountiscausedbytwothings.Thefirstcauseisassociatedwitheliminating
duplicativecountsandotherwisealigningtheMedicaidadministrativedatacountstomatchthe
ACS/CPSsampleframe.Forexample,Medicaidadministrativedatawillincludethesamepersontwiceif
theylivedinmorethanonestateandwereenrolledinMedicaidinboth,buttheACS/CPSwillonlycount
theminonestate.

Thesecondcauseisreportingerroronthepartofrespondents.Forexample,matchingstudiessuggest
that43%oftheCPSsamplewhoappearedtohavebeenenrolledinMedicaidatsomepointoverthe
prioryearaccordingtotheadministrativedatafiles,donotindicatethattheyhavehadMedicaid
coverageoverthattimeframe(StateHealthAccessDataAssistanceCenter2008).Twentyfourpercent
respondthattheyhaveanothertypeofcoveragebut17%reportbeinguninsured.Itislikelythatthis
typeofmeasurementerrorwillbemuchlowerontheACSthanontheCPSsincetheACSreliesona
pointintimemeasurementasopposedtotheanytimeinthepastyearmeasurementontheCPS

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(Call,Davern,andBlewett2007).DuetotheMedicaidUndercountwewilllikelycountmanychildrenas
beingeligibleforSCHIPwhoareactuallyenrolledinMedicaidorSCHIPbutansweredthesurveyas
thoughtheywereuninsured(Calletal.2008).

OnefixforthiscouldbetohavetheCensusBureaumatchtheACSwiththeMedicaidadministrative
dataandtoproduceamodelthatcanbeusedtopartiallycorrecttheACSformisreportingofinsurance
statusasDavernetaldidfortheCurrentPopulationSurveyusingamodeldevelopedonlinkedCPSand
Medicaidenrollmentdata(Davern,Klerman,Ziegenfuss2007).However,thisiscurrentlynotavailable.

Geography
ThePUMAgeographymaynotbeareliableproxyforcounty.Conceivablytheremaybevariationinthe
proportionofuninsuredchildren,averagefamilyincome,andproportionofcitizens/qualifiedaliensfor
everycountyaPUMA.InthesecasesthePUMAestimatewillnotaccountforthedifferences.These
geographiclimitationsofthedatamaybeimpossibletoovercomewithoutaconsiderableinvestmentin
ongoingstatespecificsurveillance.

Conclusion
Thisbriefprovidesamethodologicaldescriptionforonepossibletechniquetoassessthenumberof
eligiblebutuninsuredchildrenincounties.Thesetechniquesareimprecise,butneverthelesshavebeen
usefulforanalysts.AnexampleofoneapplicationusedinColoradomaybeworthreview(Colorado
HealthInstitute2009).NotetheColoradoanalysisusedtheCPShealthinsuranceestimatesbecause,at
thetime,ACSestimateswerenotavailable.SHADACrecommendsusingACSdataforcalendaryear
2008andlater.

SuggestedCitation
StateHealthAccessDataAssistanceCenter.2009.EstimatingSCHIP/MedicaidEligiblebutNotEnrolled
attheCountyLevel.MinneapolisMN:UniversityofMinnesota.

References
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CurrentPopulationSurvey."HealthAffairs26(1):26978.

Call,K.T.,G.Davidson,M.Davern,L.A.Blewett,andR.Nyman.2008."TheMedicaidUndercountandBiasto
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ColoradoHealthInstitute.2009.Estimatesofuninsuredchildrenbyincomeandcounty,methodologymemo
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