Evolution of the children's health insurance program (CHIP): Findings from the second national program evaluation

Background: The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) called for a comprehensive evaluation of CHIP's evolution in recent years and its impact on children's coverage and access to care. The evaluation's case studies describe states' policy and program adaptations in response to CHIPRA, the Affordable Care Act, and the Great Recession. Methods: Key informant interviews and focus groups with parents of CHIP enrollees in ten states (Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, Virginia). Results: During the study period (2006-2012) states continued to adopt innovative eligibility and enrollment policies, citing CHIPRA performance bonuses as a direct incentive in many cases. State-funded marketing and outreach efforts were cut or eliminated in many states due to budget concerns and the perception that CHIP's “brand” was already well-established. States instead relied heavily on community-based outreach to enroll and retain children in coverage. Key informants and parents consistently described CHIP benefits as generous, and most also thought enrollees had good access to care. Quality improvement efforts have intensified since CHIPRA's passage. Voluntary reporting of child health quality measures has increased and states are complying with requirements for external quality review. Conclusions: CHIPRA's increased federal funding has stabilized the program for now, and also spurred innovation. Simplified enrollment processes, generous benefits, and positive perceptions of access to and quality of care have contributed to the continued widespread popularity of CHIP among stakeholders and beneficiaries. Lessons learned from CHIP may be particularly applicable to implementation of the Affordable Care Act.