As President Bush and the Congress continue to disagree about how many children should be enrolled in the State Children's Health Insurance Program (SCHIP) in the next five years, a major health organization says more than two-thirds of currently uninsured U.S. children are eligible for SCHIP or Medicaid but are not enrolled in those public programs.

The reason for the children's lack of coverage, according to an article published in the November 2007 issue of the journal Health Affairs, is not just "poor take-up" (meaning that eligible children were never identified and informed of their eligibility), but also "poor retention" (children were once enrolled in Medicaid or SCHIP but lost coverage temporarily and were never re-enrolled).

A growing body of evidence suggests, researchers say, that dropout from the public programs often happens if families do not complete the eligibility renewal process--which may involve re-applying once or twice a year, depending on the state—causing their children to be "dis-enrolled," a loss of coverage that was in most cases entirely unintentional.

To try to determine whether such dropping of eligible children by state and district Medicaid and SCHIP agencies is a major reason that so many children lack public insurance, researchers looked at data on insurance, demographics, and family incomes from 2000 to 2006. Each child's eligibility for public insurance was based on family income and a state’s rules for Medicaid or SCHIP eligibility.

The study found that poor retention in public programs plays a critical role in the ongoing presence of uninsured children in the United States. One-third of all uninsured children had lost Medicaid or SCHIP coverage in the previous year—two in five uninsured children had dropped out of Medicaid or SCHIP in the year. The number may actually be higher than that, the researchers speculated, but in any case, "The implication is clear. Policymakers do not need to find eligible children to get them enrolled. Rather, for many of these children, public insurance programs merely need to keep them enrolled."

Given the serious consequences when children lack health insurance—both chronically uninsured children and those with frequent lapses of coverage have lower rates of check-ups and vaccinations, experience more illness-related restrictions on activities, and are more likely to forego needed care—dis-enrollment of children is a major public health problem that needs attention, the researchers concluded.

Unfortunately, they also said, the problem is getting worse, not better, as the result of several developments in recent years. For one thing, states facing budget difficulties have often made the renewal process more cumbersome or have increased SCHIP premiums, both of which may accelerate dropout. A new federal requirement of citizenship documentation for Medicaid renewal considerably complicates the process. And states that established separate SCHIP programs instead of adding to their existing Medicaid programs are now running two separate administrative structures, which complicates all procedures, including renewal.

Among ways to help solve the retention problem, they suggest simply making renewal of eligibility easier—for example, requiring renewal only once a year and providing renewal forms in multiple languages. Something called "passive renewal" has worked well for premium-paying SCHIP parents—families are required to submit paperwork only if their circumstances have changed in the past year. A similar approach for Medicaid is to send preprinted forms with the prior year’s information, which parents can simply sign and return if their circumstances have not changed.

In any case, it's time to realize that poor retention in Medicaid and SCHIP is an important factor, the researchers say. "Dropout, not simply poor take-up, plays a large role in the presence of more than eight million American children without health insurance."

The article, "Why Millions of Children Eligible for Medicaid and SCHIP Are Uninsured: Poor Retention Versus Poor Take-Up," is published in the November issue of Health Affairs. Author Benjamin Sommers can be contacted at bsommers@post.harvard.edu.