State Children's Health Insurance Program Enrollment Research Articles

SCHIP premiums, enrollment, and expenditures: a two state, competing risk analysis

Faced with state budget troubles, policymakers may introduce or increase State Children's Health Insurance Program (SCHIP) premiums for children in the highest program income eligibility categories. In this paper we compare the responses of SCHIP recipients in a state (Kentucky) that introduced SCHIP premiums for the first time at the end of 2003 with the responses of recipients in a state (Georgia) that increased existing SCHIP premiums in mid-2004. We start with a theoretical examination of how these different policies create different changes to family budget constraints and produce somewhat different financial incentives for recipients. Next we empirically model the impact of these policies using a competing risk approach to differentiate exits due to transfers to other eligibility categories of public coverage from exiting the public health insurance system. In both states we find a short-run increase in the likelihood that children transfer to lower- income eligibility/lower-premium categories of SCHIP. We also find a short-run increase in the rate at which children transfer from SCHIP to Medicaid in Kentucky, which is consistent with our theoretical model. These findings have important financial implications for state budgets, as the matching rates and premium levels are different for different eligibility categories of public coverage.

Crowd‐Out in the State Children's Health Insurance Program (SCHIP): Incidence, Enrollee Characteristics and Experiences, and Potential Impact on New York's SCHIP

The extent to which the State Children's Health Insurance Program (SCHIP) crowds our private insurance is poorly understood. To assess the incidence of crowd-out and enrollee characteristics associated with crowd-out. Parent telephone survey for 2,644 children after enrollment in NY SCHIP. MEASURES AND ANALYSES: Crowd-out is measured based on enrollee reports of coverage (and loss of coverage) before SCHIP. Multivariate logistic regression is used to relate crowd-out to enrollee characteristics. Only 7.1 percent of SCHIP enrollees dropped private coverage < or =6 months before SCHIP, suggesting relatively modest crowd-out. Crowd-out was associated with some enrollee traits including income, but not with health status. Most movement from private to public insurance in NY was not crowd-out. Under current program structure in NY, crowd-out concerns should not dampen enthusiasm for SCHIP.

SCHIP Expansion Bedeviled by Cost Concerns

Back to table of contents Previous article Next article Government NewsFull AccessSCHIP Expansion Bedeviled by Cost ConcernsRich DalyRich DalySearch for more papers by this authorPublished Online:21 Sep 2007https://doi.org/10.1176/pn.42.18.0004Opponents and advocates of a massive expansion of the State Children's Health Insurance Program (SCHIP) agree that some privately insured children will switch to a publicly backed health program if they are made eligible, but the two sides differ on whether that “crowd out” is reason enough to not expand coverage.The argument has been a key issue in the ongoing legislative battle to reauthorize and expand SCHIP. Each chamber of Congress has passed a bill to expand the federal and state insurance program, but President Bush has argued the expansion is too large and would crowd out too many children already privately insured (Psychiatric News, September 7).The House and Senate are negotiating compromises on the two bills (HR 3162 and S 1893) passed before the August recess, which would insure an additional 5 million or 4 million uninsured, respectively, beyond the 6 million children already covered under SCHIP.These proposed SCHIP enrollees do not include new enrollees crowded out of private insurance. The Congressional Budget Office (CBO) estimates that the program expansions in the House bill would cover 2.4 million minors with private insurance and other health coverage, and the Senate bill would add 2.1 million such children.President Bush had proposed a smaller expansion of the program and has promised to veto the House and Senate versions.The impact of crowding out such children, who are overwhelmingly healthy, is that their participation and their families' participation in private employers' health plans help hold down their overall costs because children's expenses are well below their premium payments, according to Janet Trautwein, vice president of government affairs for the National Association of Health Underwriters, who joined other officials in an Alliance for Health Reform discussion of the issue in August.She and other critics of the larger expansions said the government could more efficiently achieve broader insurance coverage through a subsidy of private insurer plans, beyond existing tax breaks.“Our research found it would be less expensive for the government to subsidize those plans,” she said.However, CBO research indicates that the Senate and House approaches are among the most efficient plans offered to cover a larger number of uninsured children with the smallest amount of crowd out, said CBO Director Peter Orszag.Supporters of the SCHIP expansion bills said they each include measures to encourage states to focus the programs on children without insurance coverage.“Crowd out is an inevitable byproduct of any effort to increase government coverage,” said Lisa Dubay, Ph.D., an associate professor of health policy management at Johns Hopkins Bloomberg School of Public Health.However, Dubay said, no evidence has emerged to indicate that crowd out has led any employers to reduce coverage.The issue of crowd out was again raised during Congress's August recess when the Centers for Medicare and Medicaid Services (CMS) ordered new restrictions on the income thresholds of SCHIP-funded programs, which would limit states to covering children whose family incomes are up to 250 percent of the federal poverty level, or $42,925 a year for a family of three (see chart).The order directs any state that seeks to expand eligibility for SCHIP-funded children's health plans to those earning more than that 250 percent of the federal poverty level to adopt “crowd-out strategies,” designed to prevent those who might otherwise pay for coverage from private insurers from enrolling in government plans. They include a mandatory one-year waiting period during which individuals must be uninsured before they receive coverage.Ann Clemency Kohler, New Jersey's deputy commissioner of human services, said such crowd-out mandates would have a major impact in New Jersey and other high-cost states, where children from families with incomes up to 350 percent of the federal poverty level are eligible for SCHIP.“We have an incredibly high cost of living,” she said.“ Families with those incomes are actually doing poorly, and the state wants to help them.”She and other expansion advocates said the data indicate that many of the children had insurance earlier in the year they enrolled in SCHIP but lost that insurance through their parents' job loss or discontinuation of insurance coverage by a parent's employer.Another mandate from the August CMS order requires states to certify that at least 95 percent of children already eligible for health care coverage under SCHIP are receiving that coverage before expanding above 250 percent of the federal poverty level. Kohler said that level of SCHIP enrollment has never been achieved by any state.The administrative attempts to reduce crowd out may never go into effect, according to some critics, because congressional leaders are likely to override them legislatively before they go into effect.Further information on insurance crowd out is posted at<www.allhealth.org/event_reg.asp?bi=112>.▪ ISSUES NewArchived

The effect of premium changes on SCHIP enrollment duration.

To examine the impact of premium changes in Florida's State Children's Health Insurance Program (SCHIP) on enrollment duration. Administrative records, containing enrollment and demographic data, were used to identify 173,330 enrollment spells for 153,768 children in Florida's SCHIP from July 2002 through June 2004. Health care claims data were used to classify the children's health status. Accelerated failure time models were used to examine the immediate and longer term effects on enrollment length of a temporary premium increase of $15 to $20 per family per month (PFPM) for children in families with income between 101-150 percent of the federal poverty level (FPL) and a permanent premium increase of $15 to $20 PFPM for children in families with 151-200 percent FPL. Health status and sociodemographic variables were included as covariates. Transfers to other public health insurance programs were taken into account. Enrollment lengths decreased significantly immediately following the premium increases, with a greater percentage decrease among lower income children (61 percent) than higher income children (55 percent). Enrollment lengths partially recovered in the longer term for both the temporary and permanent changes. Those with significant acute or chronic health conditions had longer enrollment lengths and were less sensitive to premium changes than healthy children. An increase in the PFPM premium amount had differential effects across income categories and health status levels. Enrollment lengths remained shortened after the premium increase was rescinded for lower income families, suggesting that it may be difficult to reverse the impacts of even a short-term premium increase.

Lessons from SCHIP

Lessons from SCHIP

Substitution Of SCHIP For Private Coverage: Results From A 2002 Evaluation In Ten States

This paper examines the extent to which the State Children's Health Insurance Program (SCHIP) might be substituting for private health insurance coverage at the time of enrollment. Among children who were newly enrolled in SCHIP in 2002 in ten states, about 14 percent had private coverage that they could have retained as an alternative to SCHIP. Of this 14 percent, about half of parents reported that the private coverage was unaffordable compared with SCHIP. This suggests that relatively few SCHIP enrollees could have retained private coverage and that even fewer had parents who felt that the option was affordable.

The Impacts of the State Children's Health Insurance Program on Children Who Enroll: Findings from Ten States

Examine the extent to which enrollment in the State Children's Health Insurance Program (SCHIP) affects access to care and service use in 10 states that account for over 60 percent of all SCHIP enrollees. Surveys of 16,700 SCHIP enrollees were conducted in 2002 as part of a congressionally mandated study. Three domains of SCHIP enrollees were included: (1) children who were recently enrolled in SCHIP, (2) those who had been enrolled in SCHIP for 5 months or more, and (3) those who had recently disenrolled from SCHIP. Response rates varied across states and domains but were clustered between 75 and 80 percent. Five different types of indicators were examined: (1) service use; (2) unmet need; (3) parental perceptions about being able to meet their child's health care needs; (4) presence and type of a usual source of care; and (5) provider communication and accessibility. The experiences SCHIP enrollees have while on the program are compared with those a separate sample of children had before enrolling using a separate sample pretest and posttest design, controlling for observable characteristics of the children and their families. The sample was drawn based on a list frame of SCHIP enrollees. The survey was administered in English and Spanish, by Computer-Assisted Telephone Interviewing (CATI). Field follow-up was used to locate families who could not be reached by telephone and these interviews were conducted by cellular telephone. SCHIP enrollment was found to improve access to care along a number of different dimensions, other things equal, particularly relative to being uninsured. Established SCHIP enrollees were more likely to receive office visits, preventive health and dental care, and specialty care, more likely to have a usual source for medical and dental care and to report better provider communication and accessibility, and less likely to have unmet needs, financial burdens, and parental worry associated with meeting their child's health care needs. The findings are robust with respect to alternative specifications and hold up for individual states and subgroups. Enrollment in SCHIP appears to be improving children's access to primary health care services, which in turn is causing parents to have greater peace of mind about meeting their children's needs.

Prior Health Care Experiences of Adolescents who Enroll in SCHIP

The State Children's Health Insurance Program (SCHIP) was designed to provide health insurance to low-income children and adolescents. Little is known about prior access to care and health care experiences of new SCHIP enrollees. We surveyed Florida and New York new adolescent SCHIP enrollees about their health status, prior health care utilization, access, and unmet needs. Most enrollees were younger (ages 12-16 years), Black or Hispanic, lived in poverty, and were without health insurance the year before SCHIP. Most had a usual source of care (USC) prior to enrollment; Blacks and Hispanics were less likely than Whites to have had a USC. Although 69% of Florida and 80% of New York adolescents reported seeing a physician the year before enrollment, 24% and 40%, respectively, reported unmet health care needs. Only 32% of Florida and 40% of the New York adolescents who were surveyed reported ever having met privately with their clinicians. Many new SCHIP enrollees report unmet needs, disparities in access, and sub-optimal care prior to enrollment. Adolescents' needs should be considered in SCHIP program and quality assurance efforts.

Improved Asthma Care After Enrollment in the State Children's Health Insurance Program in New York

Uninsured children with asthma are known to face barriers to asthma care, but little is known about the impact of health insurance on asthma care. We sought to assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with asthma. Parents of a stratified random sample of new enrollees in New York's SCHIP were interviewed by telephone shortly after enrollment (baseline, n = 2644 [74% of eligible children]) and 1 year later (follow-up, n = 2310 [87%]). Asthma was defined by parent report using questions based on National Heart, Lung, and Blood Institute criteria. A comparison group (n = 401) who enrolled in SCHIP 1 year later was interviewed as a test for secular trends. Access (having a usual source of care [USC], unmet health needs, problems receiving acute asthma care), asthma-related medical visits, quality (continuity of care at the USC, problems receiving chronic asthma care, use of antiinflammatory medications), and asthma outcomes (change in asthma care or severity) were the main outcome measures used. Bivariate and multivariate analyses compared measures at baseline (year before SCHIP) versus follow-up (year during SCHIP). Three-hundred eighty-three children (14%) had asthma at baseline, and 364 had asthma at follow-up (16%). No secular trends were detected between the baseline study group and the comparison group. After enrollment in SCHIP, improvements were noted in access: lacking a USC (decrease from 5% to 1%), unmet health needs (48% to 21%), and problems getting to the USC for asthma (13 to 4%). Children had fewer asthma-related attacks and medical visits after SCHIP (mean number of attacks: 9.5 to 3.8: mean number of asthma visits: 3.0 to 1.5; hospitalizations: 11% to 3%). Quality of asthma care improved for general measures (most/all visits to USC: 53% to 94%; mean rating of provider: 7.9 to 8.8 of 10) and asthma-specific measures (problems getting to the USC for asthma care when child was well: 13% to 1%). More than two thirds of the parents at follow-up reported that both quality of asthma care and asthma severity were "better or much better" than at baseline, generally because of insurance coverage or lower costs of medications and medical care. Enrollment in New York's SCHIP was associated with improvements in access to asthma care, quality of asthma care, and asthma-specific outcomes. These findings suggest that health insurance improves the health of children with asthma.

How Medicaid and the State Children's Health Insurance Program Can Do a Better Job of Insuring Uninsured Children: The Perspectives of Parents of Uninsured Latino Children

Eight and a half million US children are uninsured, despite the 1997 enactment of the State Children's Health Insurance Program (SCHIP) with $39 billion in funding, and Latinos continue to be the most uninsured racial/ ethnic group, with 24% (3 million) uninsured. Why SCHIP and Medicaid have not been more successful insuring uninsured children is unclear. To identify reasons why parents are unable to insure uninsured Latino children in a state where all low-income children are eligible for insurance. Bilingual focus groups of parents of uninsured Latino children from Boston communities with the highest proportion of uninsured Latino children. The 30 parents interviewed in 6 focus groups had a mean age of 39 years; 63% never graduated high school and 33% were US citizens. The mean age of their children was 12 years, and the median annual family income was $9120. Parents reported 52 barriers to insuring children. Major obstacles included lack of knowledge about the application process and eligibility (especially misconceptions about work, welfare, and immigration), language barriers, immigration issues, income, hassles, pending decisions, family mobility, misinformation from insurance representatives (being told insurance is too expensive and parents must work), and system problems (including lost applications, discrimination, and excessive waits). Parents universally agreed case managers would be helpful in insuring uninsured children. Even in a state where all low-income children are eligible for health insurance, current SCHIP and Medicaid outreach and enrollment are not effectively reaching uninsured Latino children. Parents need better information about programs, eligibility, and the application process, and a more efficient, user-friendly system.

Barriers to SCHIP enrollment: A cross-county study of the State Children's Health Insurance Program in Pennsylvania

BACKGROUND. Enrollment in the State Children's Health Insurance Program (SCHIP), created under the federal Balanced Budget Act of 1997, had a distressingly slow start and varied substantially county-to-county in many states, including Pennsylvania.METHODS. We performed a quantitative county-level analysis of barriers to enrollment in Pennsylvania's Children's Health Insurance Program (CHIP) for the year 2000, seven years after it was implemented and three years after federal SCHIP legislation. Using multivariate regression analysis with a county as the unit of observation, we modeled enrollment in SCHIP as a function of accessibility to health care, availability of clinicians, and community economic health.RESULTS. High clinic density and Medicaid managed-care membership predicted SCHIP enrollment success, while female head-of-household predicted SCHIP enrollment failure. A principal-components factor analysis revealed four underlying barriers to enrollment: accessibility, availability, affordability, and effort.CONCLUSIONS. The most formidable barriers to SCHIP enrollment success in Pennsylvania were not programmatic; they were correlates of poverty itself.

Reduction in Racial and Ethnic Disparities After Enrollment in the State Children's Health Insurance Program

Racial/ethnic disparities are associated with lack of health insurance. Although the State Children's Health Insurance Program (SCHIP) provides health insurance to low-income children, many of whom are members of racial/ethnic minority groups, little is known about whether SCHIP affects racial/ethnic disparities among children who enroll. The objectives of this study were to (1) describe demographic characteristics and previous health insurance experiences of SCHIP enrollees by race, (2) compare racial/ethnic disparities in medical care access, continuity, and quality before and during SCHIP, and (3) determine whether disparities before or during SCHIP are explained by sociodemographic and health system factors. Pre/post-parent telephone survey was conducted just after SCHIP enrollment and 1 year after enrollment of 2290 children who had an enrollment start date in New York State's SCHIP between November 2000 and March 2001, stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The main outcome measures were usual source of care (USC), preventive care use, unmet needs, patterns of USC use, and parent-rated quality of care before versus during SCHIP. Children were white (25%), black (31%), or Hispanic (44%); 62% were uninsured > or =12 months before SCHIP. Before SCHIP, a greater proportion of white children had a USC compared with black or Hispanic children (95%, 86%, and 81%, respectively). Nearly all children had a USC during SCHIP (98%, 95%, and 98%, respectively). Before SCHIP, black children had significantly greater levels of unmet need relative to white children (38% vs 27%), whereas white and Hispanic children did not differ significantly (27% vs 29%). During SCHIP, racial/ethnic disparities in unmet need were eliminated, with unmet need at 19% for all 3 racial/ethnic groups. Before SCHIP, more white children made all/most visits to their USC relative to black or Hispanic children (61%, 54%, and 34%, respectively); all improved during SCHIP with no remaining disparities (87%, 86%, and 92%, respectively). Parent-rated visit quality improved for all groups, but preexisting racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. Sociodemographic and health system factors did not explain disparities in either period. Enrollment in SCHIP was associated with (1) improvement in access, continuity, and quality of care for all racial/ethnic groups and (2) reduction in preexisting racial/ethnic disparities in access, unmet need, and continuity of care. Racial/ethnic disparities in quality of care remained, despite improvements for all racial groups. Sociodemographic and health system factors did not add to the understanding of racial/ethnic disparities. SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care.

Barriers to SCHIP enrollment

BACKGROUND. Enrollment in the State Children's Health Insurance Program (SCHIP), created under the federal Balanced Budget Act of 1997, had a distressingly slow start and varied substantially county-to-county in many states, including Pennsylvania. METHODS. We performed a quantitative county-level analysis of barriers to enrollment in Pennsylvania's Children's Health Insurance Program (CHIP) for the year 2000, seven years after it was implemented and three years after federal SCHIP legislation. Using multivariate regression analysis with a county as the unit of observation, we modeled enrollment in SCHIP as a function of accessibility to health care, availability of clinicians, and community economic health. RESULTS. High clinic density and Medicaid managed-care membership predicted SCHIP enrollment success, while female head-of-household predicted SCHIP enrollment failure. A principal-components factor analysis revealed four underlying barriers to enrollment: accessibility, availability, affordability, and effort. CONCLUSIONS. The most formidable barriers to SCHIP enrollment success in Pennsylvania were not programmatic; they were correlates of poverty itself.

The Relationship Between SCHIP Enrollment and Hospitalizations for Ambulatory Care Sensitive Conditions in California

The State Children's Health Insurance Program (SCHIP) was implemented in 1998, providing new funds for states to cover uninsured children. This study examines the relationship between SCHIP implementation in California and hospitalizations for ambulatory care sensitive conditions (ACSCs), an indicator of primary care access and quality. We use administrative SCHIP enrollment records for urban California counties, linked with corresponding rates of hospitalization for seven ACSCs among children ages 1-18 for 1996-2000. Results from multivariate regression models indicate that increases of 1 percentage point in SCHIP enrollment are associated with reductions of 0.42 ACSC admissions per 100,000 children age 1-18 (p = 0.009). Models that use lagged effects of SCHIP enrollment indicate an even stronger relationship. These are population-level relationships, and translate to much larger effects on the specific population subset that enrolled in SCHIP. These results suggest a strong beneficial effect of SCHIP on primary care among the children covered.

Enrolling children in the State Children's Health Insurance Program (S-CHIP): Can we do more?

Enrolling children in the State Children's Health Insurance Program (S-CHIP): Can we do more?

States Have Second Thoughts About Health Benefit Cuts

Back to table of contents Previous article Next article Government NewsFull AccessStates Have Second Thoughts About Health Benefit CutsKate MulliganKate MulliganSearch for more papers by this authorPublished Online:1 Oct 2004https://doi.org/10.1176/pn.39.19.0390006Texas Gov. Rick Perry (R) gave children in the State Children's Health Insurance Program (SCHIP) a temporary reprieve in mid-August when he announced a delay in implementation of regulations that would have eliminated coverage for beneficiaries whose parents have overdue premiums.The new rules, which were scheduled to take effect on August 15, could have affected as many as 20,000 children, according to an August 13 report at<www.kaisernetwork.org>.Texas's Fiscal 2004 budget, which was implemented July 1, 2003, reduced funds for the SCHIP program by $299 million and increased participating families' copayments and premiums.Texas children accounted for more than half of this first-ever national decline in SCHIP enrollment. In that state, SCHIP enrollment has declined by more than 149,000 children (29 percent) since the beginning of Fiscal 2004. Most of the reduction in enrollment occurred among children in families with incomes below 150 percent of the federal poverty level (Psychiatric News, September 3).The Web site<www.startelegram.com> reported on September 2 that the SCHIP cuts had become a campaign issue in Texas's 17th congressional district. Rep. Chet Edwards (D) organized a press conference at which physicians spoke against the budget cuts that began July 1, 2003. Edwards lambasted his opponent, state Rep. Arlene Wohlgemuth (R), who“ was the author of the state's overhaul of the health system.. .that resulted in changes to SCHIP.”Cuts in Medicaid also have become a campaign issue in Mississippi. The new chair of the state Democratic Party, Wayne Dowdy, said, “The Democratic Party is going to concentrate on the issues that affect the real people of Mississippi like health care for the elderly [and] this Medicaid issue.”He asked for a special legislative session to rescind changes to and cuts in Medicaid.At the urging of Mississippi Gov. Haley Barbour (R), the state's legislature enacted budget cuts that could result in dropping 65,000 Medicaid beneficiaries from the rolls.Implementation of the cuts was delayed from July 1 to September 15. The Mississippi legislature passed a resolution in May requesting the governor's permission to “revisit” the legislation (Psychiatric News, August 6).Policy analyst Barbara Yondorf told attendees at the National Academy for State Health Policy's annual conference in August that a literature review found that the SCHIP and Medicaid programs had been the most effective strategies to address the problem of how those without health insurance can receive needed medical care (see Original article: page 5).A report released August 31 by the Center for Studying Health System Change (HSC) came to a similar conclusion.According to “Trends in Americans' Access to Needed Medical Care, 2001-2003,” the “most notable improvements in access to medical care occurred for low-income children, likely reflecting growth in public insurance coverage.”That report is posted online at<www.hschange.org/CONTENT/701>.▪ ISSUES NewArchived

Improved access and quality of care after enrollment in the New York State Children's Health Insurance Program (SCHIP).

Background. Although many studies have noted that uninsured children have poorer access and quality of health care than do insured children, few studies have been able to demonstrate the direct benefits of providing health insurance to previously uninsured children. The State Children9s Health Insurance Program (SCHIP), enacted as Title XXI of the Social Security Act, was intended to improve insurance coverage and access to health care for low-income, uninsured children. With limited state and federal resources for health care, continued funding of SCHIP requires demonstration of success of the program. As yet, little is known about the effectiveness of SCHIP on improving access and quality of care to enrollees. Objectives. To measure the impact of the New York State (NYS) SCHIP on access, utilization, and quality of health services for enrolled children. Design Setting. NYS, stratified into 4 regions. The NYS SCHIP is modeled on commercial insurance (32 managed care plans) and at the time of the study had 18% of SCHIP enrollees nationwide. Study Design. For the study group, the design used pre/poststudy telephone interviews of parents of children enrolling in the NYS SCHIP, with baseline interviews soon after enrollment and follow-up interviews 1 year after enrollment. Baseline interviews reflected the child9s experience during the 1-year period before enrollment in SCHIP. The follow-up interviews reflected the 1-year period after enrollment in SCHIP. For the comparison group, the design used baseline interviews of a comparison group enrolled 1 year after the study group to test for secular trends; these interviews reflected the 1-year period before enrollment in SCHIP. Subjects. Children ( n = 2644) 0 to 18 years of age who enrolled in the NYS SCHIP for the first time (November 2000 to March 2001), stratified by age (0-5, 6-11, and 12-18 years), race/ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic; others excluded), and region of NYS. The comparison group consisted of 400 children. Telephone interviews were conducted in English or Spanish throughout the day and evening, 7 days per week, to obtain measures. Main Outcome Measures. Demographic and health measures (child and family characteristics, health status, presence of a special health care need, and prior health insurance), access (usual source of care [USC] and unmet needs for health care), utilization (visits for specific health services), and quality (continuity with USC and measures of primary care interactions). Analyses included bivariate tests, comparing the pre-SCHIP period to the 1-year period after enrollment in SCHIP. Multivariate models were computed to generate standardized populations comprised of key characteristics of the sample to test for differences in measures (after SCHIP versus before SCHIP), controlling for demographic characteristics. Results. Of the 2644 study-group children who completed the initial interview, 2290 (87%) completed the follow-up interview. Key measures for the pre-SCHIP period and short-term “postenrollment” measures for the study group were not statistically different from measures for the comparison group, suggesting no major secular trends. Participants were non-Hispanic white (25%), non-Hispanic black (31%), and Hispanic (45%). Fifty-one percent of the parents were single, and 61% had a high school education or less; 81% of families had income The proportion of children who had a USC increased after enrollment in the NYS SCHIP (86% to 97%). Two measures of accessibility (difficulty getting a medical person by telephone and difficulty getting an appointment) improved after enrollment in SCHIP. The proportion of children with any unmet health care needs decreased (31% to 19%). Specific types of unmet need also were reduced after enrollment; for example, among SCHIP enrollees who had a need for specific type of care, unmet needs were significantly lower postenrollment versus pre-SCHIP for specialty care (−15.5% in unmet need), acute care (−10.1%), preventive care (−9.6%), dental care (−13.0%%), and vision care (−13.2%). Emergency and total ambulatory visits did not change, but the proportion of children with a preventive care visit increased (74% to 82%). The proportion of children who used their USC for most or all visits increased (47% to 89%), demonstrating increased continuity of care. Several indicators of health care quality improved, including an overall rating of quality, the 4 indicators of physician-patient interaction used by the Consumer Assessment of Health Plans Survey, and a measure of parental worry about their child9s health. Improvements were noted among major subgroups of children, with the greatest improvements for those with the lowest baseline levels. For example, at baseline, a lower percentage of children living at 160% of the federal poverty level, and these poorer children experienced the greatest gains in having a USC or having continuity with their USC after enrollment in SCHIP. Conclusions. Enrollment in the NYS SCHIP was associated with 1) improved access, continuity, and quality of care and 2) a change in the pattern of health care, with a greater proportion of care taking place within the usual source of primary care.

The role of race and ethnicity in the State Children's Health Insurance Program (SCHIP) in four states: are there baseline disparities, and what do they mean for SCHIP?

Elimination of racial and ethnic disparities in health has become a major national goal. The State Children's Health Insurance Program (SCHIP) has the potential to reduce disparities among the children who enroll if they exhibit the same disparities that have been documented in previous studies of low-income children. To determine the potential impact of SCHIP on racial and ethnic disparities, it is critical to assess baseline levels of health disparities among children enrolling in SCHIP. To use data from the Child Health Insurance Research Initiative (CHIRI) to 1) describe the sociodemographic profile of new enrollees in SCHIP in Alabama, Florida, Kansas, and New York; 2) determine if there were differences in health insurance and health care experiences among white, black, and Hispanic SCHIP enrollees before enrollment in SCHIP; and 3) explore whether race or ethnicity, controlled for other factors, affected pre-SCHIP access to health coverage and health care. SCHIP programs in Alabama, Florida, Kansas, and New York, which together include 26% of SCHIP enrollees nationwide. Telephone interview (mailed survey in Alabama) about the child's health, health insurance, and health care experiences conducted shortly after SCHIP enrollment to assess experience during the time period before SCHIP. New SCHIP enrollees (0-17.9 years old in Alabama, Kansas, and New York and 11.5-17.9 years old in Florida). Stratified sampling was performed in Kansas and New York, with results weighted to reflect statewide populations of new SCHIP enrollees. Sociodemographic characteristics including income, education, employment, and other characteristics of the child and the family, race and ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic [any race]), prior health insurance, health care access and utilization, and health status. Bivariate analyses were used to compare baseline measures upon enrollment for white, black, and Hispanic SCHIP enrollees. Multivariate analyses were performed to assess health status and health care access measures (prior insurance, presence of a usual source of care (USC), and use of preventive care), controlling for demographic factors described above. Weighted analyses (where appropriate) were performed by using SPSS, STATA, or SUDAAN. Racial and ethnic composition varied across the SCHIP cohorts studied, with black and Hispanic children comprising the following proportion of enrollees, respectively: Alabama, 33% and <1%; Florida, 16% and 26%; Kansas, 12% and 15%; and New York, 24% and 36%. Black and Hispanic children were more likely to reside in single-parent and lower-income families. With some variation by state, children from minority groups were more likely to report poorer health status than were white children. Relative to white children, children from minority groups in Florida and New York were more likely to have been uninsured for the entire year before SCHIP enrollment. In all states, children from minority groups who had prior coverage were more likely to have previously been enrolled in Medicaid than in private health insurance and were less likely to have had employer-sponsored coverage compared with white children. Except in Alabama, there was a difference in having a USC, with children from minority groups less likely to have had a USC before SCHIP enrollment compared with white children. No consistent pattern of health care utilization before SCHIP was noted across states with respect to race or ethnicity. Findings from multivariate analyses, controlling for sociodemographic factors, generally confirmed that black and Hispanic children were more likely to have lacked insurance or a USC before enrollment in SCHIP and to have poorer health status compared with white children. SCHIP is enrolling substantial numbers of racial and ethnic minority children. There are baseline racial and ethnic disparities among new enrollees in SCHIP, with black and Hispanic children faring worse than white children on many sociodemographic and health system measures, and there are differences among states in the prevalence and magnitude of these disparities. After controlling for sociodemographic factors, these disparities persisted. IMPLICATIONS FOR MONITORING AND IMPROVING SCHIP: SCHIP has the potential to play a critical role in efforts to eliminate racial and ethnic disparities in health among the children it serves. However, study findings indicate that programmatic efforts are necessary to ensure that disparities are not perpetuated. Program effectiveness and outcomes should be monitored by race and ethnicity to ensure equity in access, use, and outcomes across all racial and ethnic groups. Assessing the health characteristics and needs of new SCHIP enrollees can provide a benchmark for evaluating the program's impact on eliminating racial and ethnic disparities in health and inform service delivery enhancements.

Health of children in title XXI: should we worry?

Health of children in title XXI: should we worry?

OMB estimates indicate that 900,000 children will lose health insurance due to reductions in federal SCHIP funding.

Despite the success of the State Children's Health Insurance Program (SCHIP) in reducing the ranks of uninsured children, the program now faces significant financing challenges. Analysis based on a model developed by the Centers for Medicare and Medicaid Services indicates that by 2007, 20 states will have insufficient federal funding to sustain their current programs, with the first states affected in 2004. As a result, the Office of Management and Budget projected last year that SCHIP enrollment will fall by 900,000 children between 2003 and 2007. The funding shortfalls are the result of several factors. Federal SCHIP funding fell by 26 percent--by more than dollar 1 billion-in each of fiscal years 2002, 2003, and 2004; dollar 1.2 billion in SCHIP funds has already expired and reverted to the Treasury at the end of fiscal year 2002, and another dollar 1.5 billion will expire at the end of 2003. The SCHIP program also has a redistribution system with targeting and timing problems. However, proposed Congressional legislation restoring federal funding, extending the dollar 2.7 billion in expiring funds, and targeting the funds to the states that most need them could avert most, if not all, of the projected enrollment decline. On the other hand, the Bush administration proposed to extend the expiring funds but does not target them to needy states; the proposal will do little to reduce the magnitude of the decline.