Children's Health Insurance Plan Research Articles

Children and Youth with Special Health Care Needs: Progress Towards More Family-Centered Systems of Care.

Children and youth with special health care needs have increasingly been included in community and society over the past 50 years. Changing definitions and programs in the education, health, and public health/Title V sectors document this greater inclusion. The most profound change was in the education system, with the passage of legislative mandates for inclusion and parental rights. Although the health system has no similar universal mandate, the sequential passage of Medicaid, Children's Health Insurance Plan, and the Patient Protection and Affordable Care Act led to expanded health care coverage with no pre-existing conditions and lifetime caps. Title V of the Social Security Act, originally passed in 1935, evolved from a focus on individual medical services to a public health systems approach focusing on building family-centered, coordinated, comprehensive care in community settings. Most of the changes in all the sectors are the result of the advocacy and engagement of parents and families; the Maternal and Child Health Bureau was a supportive and innovative leader for family-professional partnerships. Much work on understanding disparities across the sectors has led to more recent focus on equity.

Association of Patient and Geographic Variables in Pediatric Patients With Prediabetes Becoming Lost to Follow-up.

Prediabetes (PD) is becoming more common, and management is complicated by high rates of loss to follow-up. We evaluated variables associated with lost to follow-up status for pediatric patients with PD referred to endocrinology for evaluation and management. We evaluated new patients referred to Children's of Alabama Endocrinology for PD from March 2017 through March 2021. Variables included patient medical and demographics as well as county-level metrics. Comparisons of patients who returned to clinic and those who were lost to follow-up were assessed by chi-square for categorical variables and Student's t-test/Wilcoxon rank sum test for continuous normal/skewed variables, respectively. Univariate logistic regression modeling identified risk factors for coming lost to follow-up and odds ratios with 95% confidence intervals were reported with a 2-sided P-value for significance of <.05. A total of 524 patients were included in the analysis. Almost one-fourth of patients were lost to follow-up (24.6%). The odds of returning to clinic were higher in patients with the Children's Health Insurance Plan, who were prescribed endocrine medications, who had a concurrent diagnosis of cholesterol disorder, who had referral to the endocrine clinic before COVID-19, and who were offered a telehealth visit. No other assessed variable was significantly associated with the likelihood of returning to clinic. Independent of obesity severity, age, sex, race, county-level health, and economic variables, the factor most strongly associated with returning to clinic was having a telemedicine visit scheduled. Our data suggest that offering telemedicine visits may reduce lost to follow-up rates in this patient population.

Rebounding with Medicare: Reform and Counterreform in American Health Policy

Abstract America's major health care programs were all enacted on the rebound from defeat of more expansive progressive ideas. Chastened reformers have typically adopted rebound strategies that accommodate some sources of opposition, incorporate elements of counterreforms, and reflect intervening institutional change. This dynamic has unfolded three times: from the Progressive Era to the enactment of Medicare and Medicaid in 1965, from the late 1960s to the expansion of Medicaid in the 1980s, and from defeat of the 1993 Clinton plan to the enactment of the Children's Health Insurance Plan in 1997 and the Affordable Care Act in 2010. Setbacks in the Trump era will require advocates of universal coverage to coalesce around a rebound strategy that similarly takes account of recent developments and recognizes the Affordable Care Act's limitations and political vulnerabilities. This article argues that Medicare provides a platform for such a strategy and that the next fiscally and politically feasible step is the creation of a new “Midlife Medicare” program that would extend protection to people fifty to sixty-four years of age.

Payment and Care for Hematopoietic Cell Transplantation Patients: Toward a Specialized Medical Home for Complex Care Patients

Patient-centered medical home models are fundamental to the advanced alternative payment models defined in the Medicare Access and Children's Health Insurance Plan Reauthorization Act (MACRA). The patient-centered medical home is a model of healthcare delivery supported by alternative payment mechanisms and designed to promote coordinated medical care that is simultaneously patient-centric and population-oriented. This transformative care model requires shifting reimbursement to include a per-patient payment intended to cover services not previously reimbursed such as disease management over time. Payment is linked to quality measures, including proportion of care delivered according to predefined pathways and demonstrated impact on outcomes. Some medical homes also include opportunities for shared savings by reducing overall costs of care. Recent proposals have suggested expanding the medical home model to specialized populations with complex needs because primary care teams may not have the facilities or the requisite expertise for their unique needs. An example of a successful care model that may provide valuable lessons for those creating specialty medical home models already exists in many hematopoietic cell transplantation (HCT) centers that deliver multidisciplinary, coordinated, and highly specialized care. The integration of care delivery in HCT centers has been driven by the specialty care their patients require and by the payment methodology preferred by the commercial payers, which has included bundling of both inpatient and outpatient care in the peritransplant interval. Commercial payers identify qualified HCT centers based on accreditation status and comparative performance, enabled in part by center-level comparative performance data available within a national outcomes database mandated by the Stem Cell Therapeutic and Research Act of 2005. Standardization across centers has been facilitated via voluntary accreditation implemented by Foundation for the Accreditation of Cell Therapy. Payers have built on these community-established programs and use public outcomes and program accreditation as standards necessary for inclusion in specialty care networks and contracts. Although HCT centers have not been described as medical homes, most HCT providers have already developed the structures that address critical requirements of MACRA for medical homes.

Feasibility of colocating dental hygienists into medical practices

To test the feasibility of colocating registered dental hygienists (RDHs) into medical practices and to evaluate parent/caregiver oral health characteristics. From December 2008 to April 2009, we colocated five RDHs into five medical practices identified for their service to low-income children. Dual-function exam rooms were built in each office. Caregiver-child dyads were recruited from the practices for program evaluation. We used both qualitative (key informant interviews) and quantitative (survey) methods to evaluate the project. Feasibility was measured by assessment of RDH and practice factors that facilitated and/or created barriers to colocation, sustainability of services 5 years after colocation, and caregiver satisfaction with services. Caregiver oral health knowledge, attitudes, beliefs, and behaviors were also measured. Over 27 months, five part-time RDHs provided care to 2,071 children. Children of caregiver-child dyads (n = 583) recruited for evaluation were young (mean age = 1.8 years), white (46 percent), non-Hispanic (56 percent), and publicly insured (68 percent Medicaid/11 percent State Children's Health Insurance Plan). Key informant interviews revealed various factors that facilitated and created barriers to program adoption, implementation, and sustainability. Most barriers were overcome. Five RDHs remained in the practices 2 years after program initiation and four remained after 5 years. At 1 year, 27 percent of caregiver-child dyads returned for evaluation and were highly satisfied with services. Caregivers reported favorable oral health characteristics and few barriers to receiving preventive dental care at baseline and 1-year follow-up. Colocating RDHs into medical practices is feasible and an innovative model to provide preventive oral health services to disadvantaged children.

Protecting Plastic Surgery under the Affordable Care Act

Sir:FigureThis past June, the Supreme Court upheld the Patient Protection and Affordable Care Act as constitutional, and by doing so sparked debate among many parties, including physicians.1 The bill, which broadens health insurance coverage, will certainly impact health care in the United States, including plastic and reconstructive surgery. This article serves to highlight certain policies in the current “Obamacare” bill with which plastic surgeons should be familiar, as the ramifications of the law may significantly affect the field of plastic surgery in the United States. The Patient Protection and Affordable Care Act attempts to increase health care access for Americans by broadening insurance coverage for health care.2 This includes extending coverage for many uninsured children through the expansion of the Children Health's Insurance Plan and Medicaid.3 In addition, with health care use expected to rise secondary to the expansion of insurance coverage, the bill proposes several incentive schemes to recruit physicians to underserved areas and specialties. Furthermore, by establishing the Patient-Center Outcomes Research Institute, it emphasizes comparative cost-effectiveness research, which many academic plastic surgeons already participate in. These programs require funding, and revenues will be derived from various sources ranging from collecting an excise tax on high-cost employer-sponsored health insurance to increasing the Medicare Hospital Insurance tax for those in the high-income category. Initially, it even included a 5 percent tax on cosmetic surgery (section 9017, Title IX). This piece of legislation, however, was felt to discriminate against the middle class and women, and was eventually nullified with the help of strong lobbying by the American Society of Plastic Surgeons.4 Another revenue provision that has not been eliminated, despite American Society of Plastic Surgeons efforts, relates to containing Medicare physician fees through the sustainable growth rate formula. Each year, this highly controversial approach undergoes an adjustment or repeal. The Patient Protection and Affordable Care Act omits addressing the sustainable growth rate formula that can fix the current myopic, short-term “solution” of adjusting the sustainable growth rate annually. Anything short of a full repeal of the sustainable growth rate may jeopardize medical care for the Medicare population, as costs for some physicians to treat these patients may be insurmountable. Lastly, the Patient Protection and Affordable Care Act's implementation of the Independent Payment Advisory Board is concerning. This 15-member board, elected by the president, can submit proposals to Congress that limit Medicare from exceeding target spending levels. These binding recommendations will go into effect unless Congress passes alternative cuts of the same size. Limited oversight over such a board that may not be adequately experienced with the intricacies of patient disease and its surgical management could be problematic. Plastic surgeons must remain politically active and continue to be leaders in organized medicine, and it is imperative that each surgeon understands the policies set forth in the Patient Protection and Affordable Care Act. Although the specialty remains small, the camaraderie and cohesiveness can be used to ensure that our voices are heard in Washington in an effort to deliver the best care to our patients. Anup Patel, M.D., M.B.A. Ajul Shah, M.D. Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Conn. Devinder Singh, M.D. Division of Plastic Surgery, University of Maryland School of Medicine, Baltimore, Md. Alexander Au, M.D. Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Conn. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

The Effects of Premium Changes on ALL Kids, Alabama’s CHIP Program

Describe the trends in enrollment and renewal in the Alabama Children's Health Insurance Plan (CHIP), ALL Kids, since its creation in 1998, and to estimate the effect that an annual premium increase, along with coincident increases in service copays, had on the decision to renew participation. Unlike many other CHIP programs, ALL Kids is a standalone program that provides year long enrollment and contracts with the state's Blue Cross and Blue Shield program for its network of providers and its provider fee structure. In October 2003 premiums for individual coverage were increased by $50 per year and copays by $1 to $3 per visit. This study is based upon a sample of 569,650 person-year observations of 230,255 children enrolled in the ALL Kids program between 1999 and 2009. The study models enrollment as a time series of cross section renewal decisions and specifies a series of linear probability regression models to estimate the effect of changes in the premium shift on the decision to renew. A second analysis includes interaction effects of the premiums shift with demographics, health status, income and previous enrollment to estimate differential response across subgroups. The increases in premiums and copays are estimated to have reduced program renewals by 6.1 to 8.3 percent depending upon how much time one allows for families to renew. Families with a child who has a chronic condition were more likely to renew coverage. However, those with chronic conditions, African-Americans and those with lower family incomes were more price-sensitive. An increase in annual premiums and visit copays had a modest impact on program reenrollment with effects comparable to those found in Florida, New Hampshire, Kansas and Arizona, but smaller than those in Kentucky and Georgia.

Rule Changes May Reduce Medicaid Services for Mental Illness

Rule Changes May Reduce Medicaid Services for Mental Illness

The painful face of poverty

The painful face of poverty

Healthcare utilization and expenditures for low income children with sickle cell disease

While multiple studies have examined the healthcare burden of sickle cell disease (SCD) in adults, few have specifically focused on healthcare utilization and expenditures in children. The objective of this study was to characterize the healthcare utilization and costs associated with the care of low-income children with SCD in comparison to other children of similar socioeconomic status. For the study period, 2004-2007, we conducted a retrospective, cross-sectional descriptive analysis of administrative claims data from a managed care plan exclusively serving low-income children with Medicaid and the State Children's Health Insurance Plan (SCHIP). Patient demographics, continuity of insurance coverage, healthcare utilization, and expenditures were collected for all children enrolled with SCD and the general population within the health plan for comparison. On average, 27% of members with SCD required inpatient hospitalization and 39% utilized emergency care in a given calendar year. Both values were significantly higher than those of the general health plan population (P < 0.0001). Across the study period, 63% of members with SCD averaged one well child check per year and 10% had a minimum of one outpatient visit per year to a hematologist for comprehensive specialty care. Low-income children with SCD demonstrate significantly higher healthcare utilization for inpatient care, emergency center care, and home health care compared to children with similar socio-demographic characteristics. A substantial proportion of children with SCD may fail to meet minimum guidelines for outpatient primary and hematology comprehensive care.

Healthcare Reform: Obama vs McCain

Healthcare Reform: Obama vs McCain

State Strategies to Reduce the Number of Uninsured Children

We present a local and state phased approach for expanding coverage and improving the health care system for children. During the first phase, state regulatory reforms can be instituted to enhance the ability of Medicaid and State Child Health Insurance Plan (SCHIP) programs to provide measurable, high-quality clinical care that is patient-centered, safe, effective, timely, and efficient. The second phase can implement regulatory and legislative reforms that build program awareness in the community and streamline the enrollment process to maximize the enrollment of eligible uninsured children into a state's Medicaid/SCHIP program. The third phase involves a legislative expansion of income eligibility for SCHIP together with state-financed programs for legal immigrant children and foreign national children. The fourth phase considers legislative reforms to make family coverage more affordable to slow the erosion of employer-sponsored family insurance coverage, especially in small businesses.

Health-Care Use Among Puerto Rican and African-American Children With Asthma

To compare the rates of emergency department (ED) visits, hospitalizations, hospital days, and outpatient clinic visits for asthma among children in two ethnic minority groups that are disproportionately affected by asthma (Puerto Ricans and African Americans).This cross-sectional study was part of an asthma intervention program in Hartford, CT, in which 6,554 children were screened for asthma by primary care providers using a parental survey. Medicaid and the supplementary State Children's Health Insurance Plan data about health-care utilization for asthma were obtained for each child for the 12 months preceding completion of the screening survey.Among 2,304 children in whom asthma had been diagnosed, Puerto Ricans had more severe asthma than African Americans. In analyses adjusted for asthma severity and other potential confounders, Puerto Rican children had more clinic visits for asthma (rate ratio [RR], 1.31; 95% confidence interval [CI], 1.12 to 1.53) but spent fewer days in the hospital for asthma (RR, 0.36; 95% CI, 0.24 to 0.53) than African-American children. There were no differences in the rates of ED visits or hospitalizations between the two groups.Puerto Rican children had more severe asthma but were less likely than African-American children to have prolonged hospitalizations for asthma. This finding may be due to the frequent clinic visits for asthma made by Puerto Rican children. Further research is needed to understand the cultural factors that contribute to different approaches to health-care utilization among ethnic minorities.

Changes in Access, Utilization, and Quality of Care After Enrollment Into a State Child Health Insurance Plan

There currently are few published data evaluating the effect of State Children's Health Insurance Programs on health care outcome measures in children. Colorado's Child Health Plan Plus (CHP+) is a non-Medicaid State Children's Health Insurance Program that began enrollment in April 1998. The objectives of this study were to compare reported (1) access to care, (2) utilization of health care, and (3) quality of care during the year before and the first year after enrollment into CHP+. We interviewed 480 randomly selected families by telephone 2 months after their first enrollment into CHP+ (September 1999 to January 2000) and, again, 1 year later. We used generalized linear models to examine the effect of enrollment on health care access, utilization, and quality while controlling for type of previous insurance, length of time uninsured before enrollment, race/ethnicity, and age. Regarding access to care, the percentage of families who reported a usual site of preventive care did not change significantly, but families reported more often being able to see providers as soon as desired for routine care (incidence ratio [IR]: 2.03; 95% confidence interval [CI]: 1.37-3.02]), for care when sick or injured (IR: 2.77; 95% CI: 1.85-4.16), for specialty care (IR: 1.96; 95% CI: 1.16-3.32), and for all health care (IR: 2.35; 95% CI: 1.81-3.07). Unmet medical needs decreased after versus before enrollment for prescription medications (IR: 0.38; 95% CI: 0.26-0.55), mental health care (IR: 0.63; 95% CI: 0.40-0.97), prescription glasses (IR: 0.44; 95% CI: 0.29-0.65), and dental care (IR: 0.59; 95% CI: 0.47-0.76). Regarding utilization, the proportion who saw a provider for routine care in the past year increased (IR: 1.39; 95% CI: 1.06-1.83), but reported visits for sick, specialty, and emergency department care and hospitalizations did not increase. Regarding quality of care, the proportion who rated their health care as "best" increased (RI: 1.31; 95% CI: 1.04-1.66) after versus before enrollment. Families who were newly enrolled into CHP+ perceived dramatic increases in access to all types of care and decreases in unmet medical needs, no increase in utilization of emergency department or hospitalization services, and improved overall quality of care in the year after enrollment into CHP+.

Disenrollment From a State Child Health Insurance Plan: Are Families Jumping S(c)HIP?

Colorado's Child Health Plan Plus (CHP+) is a non-Medicaid state child health plan that began enrollment in April 1998. Families are disenrolled 12 months after enrollment if they fail to re-enroll. To assess insurance coverage before and 1 year after initial enrollment in CHP+; reasons for disenrollment; and factors associated with re-enrollment. We interviewed 480 randomly selected families 2 months after initial enrollment into CHP+ (September 1999 through January 2000) and 1 year later. Prior to CHP+, 38% of families had Medicaid (MK), 35% were privately insured (PI), 6% were uninsured (UI), and 20% had other/unknown insurance. After the 12 months, 34% were re-enrolled, 16% got other insurance (6% MK, 10% PI/other), 4% had children older than 18 years, and 46% were UI (9% had intentionally and 37% had unintentionally disenrolled from CHP+). All unintentionally disenrolled families were planning to re-enroll and 90% still appeared eligible. In multivariate analysis, having a primary care provider prior to enrollment was associated with re-enrollment (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1 to 2.6), but having problems with the application process impeded re-enrollment (OR 0.7, 95% CI 0.6 to 0.9). Only about a third of families eligible for State Children's Health Insurance Program successfully re-enrolled before their termination date. Institution of a passive renewal process would decrease unnecessary disenrollment in eligible families.

Effective Health Coverage for America's Children: Reformation and the Pediatrician's Role

Although the State Children's Health Insurance Plan was enacted to provide health care to children who are uninsured or are not eligible for Medicaid, a number of factors are preventing the system from meeting the health care needs of all of the nation's children. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

US Child Health Insurance Plan improves resource use

US Child Health Insurance Plan improves resource use

Family income and the impact of a children's health insurance program on reported need for health services and unmet health need.

Family income and the impact of a children's health insurance program on reported need for health services and unmet health need.

Barriers to Enrollment in a State Child Health Insurance Program

To identify barriers to enrollment into Colorado's Child Health Insurance Plan (CHP+) for non-Hispanic (NH), Hispanic (H), and uninsured families. Telephone survey of 1) random samples of families who requested an application but did not complete it (N = 273 NH, N = 159 H) and 2) families with uninsured children identified by random-digit-dial statewide surveys (N = 165). Major reasons for not enrolling included 1) got other insurance (NH 16.5%; H 27.2% P <.01), 2) thought household income was too high to qualify (NH 21.0%; H 11.9% P =.01), and 3) paperwork (NH 13.4%; H 14.7%, P = NS). Of those who thought their income was too high (N = 76, 17.6%), 58.5% appeared eligible based on reported income. Of uninsured families, only 41.7% had heard of CHP+. Of those who had never applied, major remediable reasons included not knowing enough about the program (20.9%) and thinking household income was too high (9.3%). Effective marketing and education to increase awareness of CHP+ and ensure understanding of eligibility are critical to the success of the program.

Implications of welfare reform for child health: emerging challenges for clinical practice and policy.

* Abbreviations: PRWORA = : Personal Responsibility and Work Opportunity Reconciliation Act • AFDC = : Aid to Families With Dependent Children • TANF = : Temporary Assistance for Needy Families • SCHIP = : State Child Health Insurance Program • SSI = : Supplemental Security Income The passage of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in 1996 represented one of the most profound developments in American social policy since the Great Society programs of the mid- 1960s and has the potential to affect the health of millions of American children. The overall purpose of the legislation, commonly referred to as welfare reform, was to decrease reliance on welfare and increase the economic independence of poor families. Its impact has been far-reaching, affecting many determinants of child health and well-being, such as family resources, reproductive choices, maternal employment, parental supervision, childcare, and access to health insurance. The implementation of PRWORA has been associated with unprecedented declines in the number of children receiving public benefits. In the first 2 years after welfare reform, the number of children receiving welfare benefits fell by 28%.1,2 In addition, the number of children enrolled in Medicaid, the principal public health insurance program for poor children in the United States, also fell, despite provisions in the legislation to extend Medicaid coverage to all children who lose welfare benefits.3 Similarly, the number of children receiving food stamps has dropped by 20% between 1996 and 1998.4–6 Although there is consensus that both growth in the economy and welfare policies themselves have contributed to these declines, the exact proportion attributable to each factor remains unclear.7–9 This discussion considers how these major shifts in public support for poor children and their families are likely to affect patterns of child health and the provision of clinical services to children. It addresses these concerns by exploring 4 related issues: the elements of the welfare legislation most likely to affect child health, the impact of this legislation on enrollment in public programs for children, the potential health effects of welfare reform, and the …