Children's Health Insurance Program Reauthorization Act Research Articles

Disappearing Medicaid Enrollment Disparities for US Citizen Children in Immigrant Families: State-Level Trends from 2008 to 2015

ObjectiveMedicaid and the Children's Health Insurance Program (CHIP) provide health insurance to 38% of all children in the United States. Uninsured rates continued to fall over the past decade, and citizen children in immigrant families experienced the most dramatic gains. Our objective is to test whether states have managed to close Medicaid enrollment gaps between US citizen children in native and immigrant families. MethodsWe use the 2008 to 2015 American Community Surveys to compare uninsured rates for 2.4million Medicaid-eligible citizen children in immigrant and native families. State fixed-effects probit models estimate the probability of children remaining uninsured when eligible for public coverage, excluding children covered by private insurance. We compare the states with the largest enrollment gains across differences in policies relevant to CHIP/Medicaid participation for all children, including CHIP Reauthorization Act (CHIPRA) enrollment simplification, Immigrant Children's Health Improvement Act, and Affordable Care Act (ACA) Medicaid expansion. ResultsMost states reduced their enrollment disparities by one half or even completely eliminated their enrollment differentials. However, the states with the largest gains did not adopt ACA and CHIPRA policy options that would have improved CHIP/Medicaid participation for children in their states–or implemented the policies long before the observed gains. ConclusionsRather than policy anchoring the gains, the improvements may be rooted in operational changes and outreach efforts during CHIPRA and ACA implementation. Absent a policy anchor, the large enrollment differentials of a decade ago may reappear for children in immigrant families, affect the wellbeing of children and their communities.

Medicaid Politics and Policy

Medicaid Politics and Policy

What Factors Influence States' Capacity to Report Children's Health Care Quality Measures? A Multiple-Case Study.

Objectives The objective of this study was to describe factors that influence the ability of state Medicaid agencies to report the Centers for Medicare & Medicaid Services' (CMS) core set of children's health care quality measures (Child Core Set). Methods We conducted a multiple-case study of four high-performing states participating in the Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program: Illinois, Maine, Pennsylvania, and Oregon. Cases were purposively selected for their diverse measurement approaches and used data from 2010 to 2015, including 154 interviews, semiannual grant progress reports, and annual public reports on Child Core Set measures. We followed Yin's multiple-case study methodology to describe how and why each state increased the number of measures reported to CMS. Results All four states increased the number of Child Core Set measures reported to CMS during the grant period. Each took a different approach to reporting, depending on the available technical, organizational, and behavioral inputs in the state. Reporting capacity was influenced by a state's Medicaid data availability, ability to link to other state data systems, past experience with quality measurement, staff time and technical expertise, and demand for the measures. These factors were enhanced by CHIPRA Quality Demonstration grant funding and other federal capacity building activities, as hypothesized in our conceptual framework. These and other states have made progress reporting the Child Core Set since 2010. Conclusion With financial support and investment in state data systems and organizational factors, states can overcome challenges to reporting most of the Child Core Set measures.

The Children's Health Insurance Program Reauthorization Act Evaluation Findings on Children's Health Insurance Coverage in an Evolving Health Care Landscape

The Children's Health Insurance Program (CHIP) Reauthorization Act (CHIPRA) reauthorized CHIP through federal fiscal year 2019 and, together with provisions in the Affordable Care Act, federal funding for the program was extended through federal fiscal year 2015. Congressional action is required or federal funding for the program will end in September 2015. This supplement to Academic Pediatrics is intended to inform discussions about CHIP's future. Most of the new research presented comes from a large evaluation of CHIP mandated by Congress in the CHIPRA. Since CHIP started in 1997, millions of lower-income children have secured health insurance coverage and needed care, reducing the financial burdens and stress on their families. States made substantial progress in simplifying enrollment and retention. When implemented optimally, Express Lane Eligibility has the potential to help cover more of the millions of eligible children who remain uninsured. Children move frequently between Medicaid and CHIP, and many experienced a gap in coverage with this transition. CHIP enrollees had good access to care. For nearly every health care access, use, care, and cost measure examined, CHIP enrollees fared better than uninsured children. Access in CHIP was similar to private coverage for most measures, but financial burdens were substantially lower and access to weekend and nighttime care was not as good. The Affordable Care Act coverage options have the potential to reduce uninsured rates among children, but complex transition issues must first be resolved to ensure families have access to affordable coverage, leading many stakeholders to recommend funding for CHIP be continued.

Advancing the Science of Measurement in Pediatric Quality of Care

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 provides an opportunity to consider and enhance the measurement of children's health care quality as a means to improve child health.1 The legislation required the identification of an initial child core set of measures for voluntary use by Medicaid/Child Health Insurance (CHIP) programs. The initial child core set was published in 2009, and after its most current update in 2014, the list now includes 23 pediatric measures.

Coverage for low-income immigrant children increased 24.5 percent in states that expanded CHIPRA eligibility.

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 provided states with the option of expanding eligibility for federally funded public insurance to low-income immigrant children within their first five years of legal residence in the United States. By 2011 twenty states and the District of Columbia had adopted that option. Using cross-sectional data from the 2003, 2007, and 2011-12 National Survey of Children's Health, we compared trends in coverage and access to care among immigrant children in states that did expand eligibility to children in states that did not. Compared to immigrant children in states that did not expand eligibility, children in states expanding eligibility experienced a 24.5 percent increase in insurance coverage, largely due to greater enrollment in public insurance. Immigrant children in states that expanded eligibility also experienced significant reductions in unmet health care needs, compared to their counterparts in nonexpansion states. Disparities relative to children in nonimmigrant families were substantially reduced in states that expanded eligibility, compared to states that did not. Expanding eligibility for federally funded public insurance to immigrant children within their first five years of legal residence in other states could improve coverage for immigrant children and might also increase access to care.

Measuring Quality in Pediatrics: Florida’s Early Experiences with the CHIPRA Core Measure Set

Enacted in 2009, the Children's Health Insurance Program Reauthorization Act (CHIPRA) aims, among other things, to increase state's accountability for providing quality health care to all children in the United States. Although it is important for states to report on the measures, learning from their successes and failures is critical in producing the measures so that states will be prepared for future regulations. Florida covered roughly 2.59 million children in 2010. Administrative, medical record, registry, and survey data were used to report on 20 of the 24 CHIPRA core measures. Technical specifications from the Centers for Medicare and Medicaid Services were used. Approximately 10 months were needed to identify, collect, safeguard, and process the required data. Florida was able to build on its past experiences with performance measurement reporting and surveying. Conducting medical record reviews at the state level and producing measures that required registry data proved to be challenging. Although Florida was successful in its first year of reporting the CHIPRA core measures, certain populations were not included in some of the measures. The next phase of Florida's CHIPRA project will focus on developing and implementing a dissemination plan and creating opportunities to improve the measures. Florida has made significant progress in the early phases of reporting the CHIPRA measures. As Florida gains more experience in reporting the measures, and results from other states are released, it will be easier to put the statewide measure results into context. Once meaningful comparisons can be made, Florida will be able to better plan for the future of child health and health outcomes.

Measuring prevention more broadly: an empirical assessment of CHIPRA core measures.

To assess limitations of using select Children's Health Insurance Program Reauthorization Act (CHIPRA) core claims-based measures in capturing the preventive services that may occur in the clinical setting. We use claims data from ALL Kids, the Alabama Children's Health Insurance Program (CHIP), to calculate each of four quality measures under two alternative definitions: (1) the formal claims-based guidelines outlined in the CMS Technical Specifications, and (2) a broader definition of appropriate claims for identifying preventive service use. Additionally, we examine the extent to which these two claims-based approaches to measuring quality differ in assessments of disparities in quality of care across subgroups of children. Statistically significant differences in rates were identified when comparing the two definitions for calculating each quality measure. Measure differences ranged from a 1.9 percentage point change for measure #13 (receiving preventive dental services) to a 25.5 percentage point change for measure #12 (adolescent well-care visit). We were able to identify subgroups based upon family income, rural location, and chronic disease status with differences in quality within the core measures. However, some identified disparities were sensitive to the approach used to calculate the quality measure. Differences in CHIP design and structure, across states and over time, may limit the usefulness of select claims-based core measures for detecting disparities accurately. Additional guidance and research may be necessary before reporting of the measures becomes mandatory.

Monitoring Duration of Coverage in Medicaid and CHIP to Assess Program Performance and Quality

ObjectiveTo assess measures of Medicaid and Children's Health Insurance Program (CHIP) coverage duration for potential inclusion in a core set of children's health care quality measures as called for by the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009. MethodsWe reviewed published and unpublished reports and spoke to researchers, analysts, and program officials at the federal level and in selected states. Measures available in administrative data were assessed with regard to the feasibility of implementation and their validity in terms of their association with child health outcomes and state policy choices. ResultsAlthough many measures are feasible to construct using existing administrative data, prospective measures of duration that examine a cohort of new enrollees were found to be the most valid measures based on research linking their outcomes to program policies and their consistent interpretation across states with similar enrollment and renewal structures. However, the inability of some states to link together data from their Medicaid and CHIP enrollment files affects the interpretation of these and other measures across states. ConclusionsProspective and retrospective measures of duration were recommended for inclusion in the core set of quality measures. Although the prospective and retrospective measures were ranked high in terms of validity and importance by the Subcommittee on Quality Measures for Children's Health Care in Medicaid and CHIP, concerns were raised about feasibility given that no state currently uses these measures to monitor program performance. Additional technical and financial resources and enhancements to administrative data systems will be needed to support state efforts in this area of quality assessment, particularly in the areas of linking Medicaid and CHIP data files, improving reason for disenrollment codes, and improving race and ethnicity coding. Monitoring how well states are doing at enrolling and retaining children in Medicaid and CHIP is a critical component to assessing overall program performance and quality and for interpreting many of the other proposed quality measures.