State Children's Health Research Articles

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.

Planning the Next Wave of SCHIP Research

Was the State Children's Health Insurance Program (SCHIP) a flash in the pan or is it the future of children's health insurance? Your answer may depend on the news you read. As states have grappled with tight budgets in the recession economy and the long-ago planned “dip” in federal funding for SCHIP for fiscal years 2002–2004, several states made decisions to limit their SCHIPs through restricting enrollment, increasing premiums, limiting benefits, and decreasing outreach activities. As a consequence, July through December 2003 marked the first period since SCHIP was enacted in 1997 that program enrollment decreased nationally, attributable to marked declines in 11 states and the District of Columbia.1 On the other hand, during the latter half of 2003, a handful of states expanded SCHIP eligibility and enhanced program benefits, and the majority of states continued to report modest increases in SCHIP enrollment.1 Despite the national recession beginning in 2001 that led to increased unemployment and associated decreases in employer-sponsored insurance coverage for children, increased child enrollment in SCHIP and Medicaid more than offset the reduction in employer-sponsored coverage.2 As a result, the rate of uninsurance among US children declined from 15% in 19973 (at SCHIP inception) to 11.4% in 2003,4 a decline attributable in large part to SCHIP enrollment that was particularly robust among children living in households with annual incomes 2 to 3 times the poverty level, beyond the eligibility limits of most Medicaid programs. The findings of Kempe et al5 in this issue of Pediatrics regarding the Colorado version of SCHIP, Child Health Plan Plus, offer good news about SCHIP beyond enrollment statistics. Families reported higher rates of being able to see providers for a variety of routine and acute care needs and also reported a significant decline … Reprint requests to (M.M.D.) University of Michigan, 300 NIB, 6C23, Ann Arbor, MI 48109-0456. E-mail: mattdav{at}med.umich.edu

Effect of Medicaid Eligibility Category on Racial Disparities in the Use of Psychotropic Medications Among Youths

This study sought to determine the degree to which Medicaid eligibility categories modify disparities between black and white youths in the prevalence of psychotropic medication. Computerized claims for 189,486 youths aged two to 19 years who were continuously enrolled in a mid-Atlantic state Medicaid program for the year 2000 were analyzed to determine population-based annual prevalence of psychotropic medication by race or ethnicity and by whether the youths were eligible for Medicaid for reasons of family income, disability, or foster care placement. Logistic regression was used to assess the interaction of eligibility category and race. The mean annual prevalence of psychotropic medication for the population was 9.9 percent. The prevalence was 2.17 times higher for white youths than for black youths (16.5 percent compared with 7.6 percent). However, within eligibility categories, the white-to-black disparity was 3.8 among youths who were eligible for Medicaid because their family income was below the federal poverty level and 3.2 for youths enrolled in the State Children's Health Insurance Program. Medicaid eligibility categories had a profound impact on the racial disparity associated with the prevalence of psychotropic medications for youths. Eligibility category should be taken into account when ascertaining the role of access, undertreatment, and culture in disparities in mental health treatment.

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?

CMS Reflections: A Milestone For Medicare And Medicaid

Web Exclusives Health AffairsVol. 24, No. Suppl1: Web Exclusives CMS Reflections: A Milestone For Medicare And MedicaidPUBLISHED:2005No Accesshttps://doi.org/10.1377/hlthaff.W5.325AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions AbstractPROLOGUE:On 30 July 1965 President Lyndon B. Johnson signed laws establishing the Medicare and Medicaid programs (Titles 18 and 19 of the Social Security Act), the nation's first federally sponsored programs to finance health insurance with tax dollars. Medicare, the federally administered and financed health insurance program for the elderly and disabled, covers more than forty million people age sixty-five or older or with permanent disabilities; program expenditures were $283 billion in 2003. Medicaid, which offers health insurance to the disabled as well as to needy adults and children, is jointly funded by states and the federal government but is managed primarily by individual states. The program covers more than fifty million people, with combined state and federal expenditures now exceeding $300 billion.At the programs' inception, Medicare and Medicaid were administered separately—Medicare under the Social Security Administration and Medicaid under the Social and Rehabilitative Services Administration. In 1977 the Carter administration created the Health Care Financing Administration (HCFA), within the Department of Health, Education, andWelfare (HEW), to consolidate the administration of these two programs. HCFA is known today as the Centers for Medicare and Medicaid Services (CMS) and is part of the Department of Health and Human Services (HHS).Despite perennial fiscal pressures, both programs have expanded in the past decade, via the State Children's Health Insurance Program (SCHIP), which since 1997 has helped states expand health care coverage to the nation's uninsured children, and the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, which, among other things, will offer drug coverage to all Medicare beneficiaries for the first time in the program's history. To commemorate the forty-year anniversary of Medicare and Medicaid, Health Affairs invited former HCFA/CMS administrators to share their thoughts and reflections on the programs and the agency that administers them. We include here essays from HCFA's first administrator, Robert Derzon, followed by pieces from Leonard Schaeffer, Bill Roper, Gail Wilensky, Bruce Vladeck, Nancy-Ann DeParle, and Tom Scully. The publication of these papers coincides with a 26 July 2005 event in Washington, D.C., cosponsored by the Commonwealth Fund and the Henry J. Kaiser Family Foundation, also commemorating the anniversary. AWebcast of the event, titled “Medicare + Medicaid at 40,” is available at www.kaisernetwork.org/healthcast/kff/26jul05 . TOPICSMedicaidMedicare savings programsFederal health plansMedicareSocial SecurityDisabledChildren's healthChildren's Health Insurance Program Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 5 June 2018 InformationCopyright © by Project HOPE: The People-to-People Health Foundation, Inc.PDF download

Beyond Primary Care: Ensuring Access to Subspecialists, Special Services, and Health Care Systems for Medically Underserved Children

Access to medical care for children remains one of the more intractable challenges facing pediatric providers and policymakers. Numerous barriers, in spite of Medicaid and the State Children's Health Insurance Program (SCHIP), contribute to the absence of comprehensive medical insurance coverage for 8.5 million children.1 In addition to financial and insurance barriers, there are a host of other factors that limit access, irrespective of a family's insurance status. At least 3 million children have reduced access to needed medical care because of limited availability of affordable transportation.

Extending Health Care Coverage to the Low-Income Population: The Influence of the Wisconsin Badgercare Program on Labor Market Outcomes

The Wisconsin BadgerCare program, which became operational in July 1999, expanded public health insurance eligibility to families with incomes below 185 percent of the U.S poverty line (200 percent for those already enrolled). This eligibility expansion was part of a federal initiative known as the State Children's Health Initiative Program (SCHIP). In this paper, we investigate the effect of Wisconsin's BadgerCare on the labor market outcomes of low-income single mothers. Using a coordinated set of administrative databases, we track three cohorts of mother-only families: those who were receiving cash assistance under the Wisconsin AFDC and TANF programs in September 1995, 1997, and 1999, and who subsequently left welfare. We follow the 19,201 single mothers heading these welfare leaver families on a quarterly basis from two years before they left welfare through the end of 2001. We use information on the labor market and welfare history of these women and their household characteristics and macroeconomic environment to analyze the effect of the availability of additional public health coverage on their employment and earnings. We apply multiple methods to investigate these outcomes, comparing across- and within-individual differences. The core finding is that labor earnings increased with the introduction of BadgerCare. This increase was small in absolute dollar value but sizeable in percentage terms.

Health insurance coverage and the macroeconomy

This paper investigates the relationship between the macroeconomy and health insurance coverage for non-elderly Americans. We find that, for men, state unemployment rate is positively correlated with the probability of health insurance coverage in general and through an employer in particular, and that these correlations are only partly explained by changes in employment status. In contrast, the insurance coverage of women and children appears to be insulated from fluctuations in the unemployment rate by public health insurance programs like Medicaid and State Children's Health Insurance Program (SCHIP). We estimate that 984,000 Americans, nearly all of whom were adult men, lost health insurance due to macroeconomic conditions alone during the 2001 recession.

Evaluation of an Emergency Department–Based Enrollment Program for Uninsured Children

We evaluate the effectiveness of an emergency department (ED)-based outreach program in increasing the enrollment of uninsured children. The study involved placing a full-time worker trained to enroll uninsured children into Medicaid or the State Children's Health Insurance Program in an inner-city academic children's hospital ED. Analysis was carried out for outpatient ED visits by insurance status, average revenue per patient from uninsured and insured children, proportion of patients enrolled in Medicaid and State Children's Health Insurance Program through this program, estimated incremental revenue from new enrollees, and program-specific incremental costs. A cost-benefit analysis and breakeven analysis was conducted to determine the impact of this intervention on ED revenues. Five thousand ninety-four uninsured children were treated during the 10 consecutive months assessed, and 4,667 were treated during program hours. One thousand eight hundred and three applications were filed, giving a program penetration rate of 39%. Eighty-four percent of applications filed were resolved (67% of these were Medicaid). Average revenue from each outpatient ED visit for Medicaid was US135.68 dollars, other insurance was US210.43 dollars, and uninsured was US15.03 dollars. Estimated incremental revenue for each uninsured patient converted to Medicaid was US120.65 dollars. Total annualized incremental revenue was US224,474 dollars, and the net incremental revenue, after accounting for program costs, was US157,414 dollars per year. A program enrolling uninsured children at an inner-city pediatric ED into government insurance was effective and generated revenue that paid for program costs.

The Evolution of Fetal and Infant Mortality Review as a Public Health Strategy

Infant mortality review (IMR), the forerunner of fetal and infant mortality review (FIMR), emerged at the national level in the mid-1980s as a promising method to improve understanding of local factors contributing to infant mortality and to motivate community response. Building on federal efforts to enhance data capacity and early state and local infant mortality case review studies, the federal Maternal and Child Health Bureau (MCHB) initiated its IMR Program in 1988. Key actions taken to refine and diffuse the IMR/FIMR method include forging a public-private partnership between MCHB and the American College of Obstetricians and Gynecologists in 1990 to develop the National Fetal and Infant Mortality Review Program, recruiting prominent leaders to advocate for FIMR, seeding community projects in geographically dispersed states and localities, and routinely reporting best practices information to the field. In concert with the articulation of core public health functions and a growing emphasis on accountability, attention at the national level has turned to promoting and institutionalizing FIMR in state systems. Efforts are underway in states to build on the FIMR model and coordinate multiple maternal and child health-related review programs. Increasingly, FIMR is recognized as a strategy for contributing to implementation of the core public health functions of assessment, policy development, and quality assurance. The recent national evaluation of FIMR sheds new light on the role of FIMR in community and state maternal and child health systems and marks a new phase in the evolution of FIMR.

Funding Child, Elderly Health Care Gets Widespread Support

Back to table of contents Previous article Next article Health Care EconomicsFull AccessFunding Child, Elderly Health Care Gets Widespread SupportMark MoranMark MoranSearch for more papers by this authorPublished Online:15 Oct 2004https://doi.org/10.1176/pn.39.20.0390016A majority of Americans believe that the health care needs of children and the elderly are not being met, according to a survey published in the online edition of the journal Health Affairs last month.The survey also found that many Americans assume an equal distribution of health care resources among children and the elderly, when in fact there is a significant per capita and aggregate difference favoring the elderly.There is widespread support for a strong government role in providing health care to all children and the elderly, regardless of income level, and this support cut across age groups, gender, and political party affiliation, the results of the survey indicated.According to the survey, 59 percent of adults believe that the health care needs of children are not being met, while 67 percent believe that the health care needs of the elderly are not being met. When questioned about the role government should play in financing health care for these groups, 90 percent thought that government should fund health care for all low-income children and elderly, while almost the same percentage felt that this funding should be available to both age groups, regardless of income.“People want to take care of the poor and people who have needs,” said lead study author Marc Berk, vice president and senior fellow at the National Opinion Research Center (NORC) at the University of Chicago, which conducted the survey. “In an era of likely budget deficits where there is a lot of pressure to look for ways to cut programs, this survey shows that health care is not an area that the public wants to consider cutting.”The survey was funded by the Nemours Foundation and was conducted by telephone from June 4 to 18. Using random-digit dialing, 2,013 respondents from a nationwide sample were interviewed. They were asked a series of questions concerning their views on public funding of health care programs for children and for the elderly.In addition to the survey results, the September Health Affairs offers new data on generational differences in government spending, how children are affected by downturns in the economy, and an analysis of the challenges facing the State Children's Health Insurance Program (SCHIP).At least two-thirds of those surveyed indicated that they believed that children and the elderly were already receiving the same level of health care resources. In fact, however, current per capita public spending on health care for the elderly is far higher than that for children. In 2001, for example, per capita government spending on health care for the elderly was $4,360, compared with $258 for children, the authors of the survey article noted.In an interview with Psychiatric News, Berk explained that the survey question did not specify whether people assumed equal resource allocation in per capita or aggregate terms. Rather, he said, the question was a measure of how people viewed societal priorities; that is, the responses were an indication of a general assumption that the government would not favor one group over the other, he said.“Although governmental spending on the elderly vastly exceeds that for children, most Americans, including those with a college education, do not [believe] this to be the case,” Berk and colleagues stated in their report. “When asked about the relative priority that government should place on the health care needs of children versus those of the elderly, Americans clearly do not want government to choose, with a majority indicating that government should be spending about the same on children as it does on the elderly. In light of the apparent lack of understanding about current spending, the public sentiment that supports equal funding for health care for children and the elderly should probably be interpreted not as a call for an enormous shift of resources from one group to the other but as evidence that the public considers these needs to be of equal and high priority.”A study by researchers at the University of Pennsylvania School of Medicine, also published in the same issue of Health Affairs, shows that the gap in per capita social welfare spending between children and the elderly grew 20 percent in the past two decades. The study indicates that unlike spending on the elderly, spending for children suffers during economic recessions, as evidenced by recent cutbacks in many SCHIP programs stemming from overall state budget cutbacks (see Original article: page 6).The survey report, “Americans' Views About the Adequacy of Health Care for Children and the Elderly,” is posted online at<content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.446>.▪ ISSUES NewArchived

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

The State Children's Health Insurance Program: successes, shortcomings, and challenges.

This paper examines successes and shortcomings of the State Children's Health Insurance Program (SCHIP). SCHIP is a source of coverage for millions of children, improving their access to health care and sparking innovation in program design and improvements in Medicaid. However, SCHIP adds to the complexity of the insurance system and introduces new inequities in access to insurance; it is imperfectly targeting eligible children who are uninsured; and its financing is problematic because of the block-grant funding structure and use of SCHIP funds to cover adults. These issues need to be addressed during the SCHIP reauthorization process.

Chipping away at the uninsured.

Although the State Children's Health Insurance Program (SCHIP) has accomplished a great deal, more than nine million children-many of whom are eligible for public health insurance-remain uninsured. In this commentary I propose that coverage for children should be universal, with eligibility systems operating behind the scenes in a way that relieves individual families of the burden of enrollment. States, the federal government, employers, and families would have to reconsider their roles in providing coverage, but starting with the appropriate vision would put the focus on practical problems and overcome the inherently limited approach of layered, incremental programs.

Tracking changes in eligibility and coverage among children, 1996-2002.

Data from the 1996 Medical Expenditure Panel Survey (MEPS) reveal that 4.7 million children were eligible for Medicaid but were uninsured. Numerous changes have occurred in the landscape for children's health insurance since then, including welfare reform and implementation of the State Children's Health Insurance Program (SCHIP). We use data from the 1996-2002 MEPS to track changes in the eligibility and coverage of children. As of 2002, uninsurance among children remained as much a problem of participation as one of eligibility. Nevertheless, we find evidence of dramatic improvements in program participation, reflecting the success of efforts to improve outreach, simplify enrollment, and increase retention.

The National Survey of Children's Health: A New Data Resource

Federal and state maternal and child health programs are responsible for promoting and improving the health and well-being of children. To support achievement of this goal, the federal Maternal and Child Health Bureau (MCHB) in partnership with the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention has developed a new survey that will provide uniform national and state data on the health and well-being of children, as well as the characteristics of their families and neighborhoods. The National Survey of Children's Health was designed to produce reliable and representative state- and national-level estimates for Healthy People 2010 national prevention objectives, for each state's Title V needs assessment, and for Title V program planning and evaluation. In addition, it will provide a new data resource for researchers, advocacy groups, and other interested parties. It is anticipated that this survey will be repeated periodically, making trend analysis possible. This survey was conducted using the State and Local Area Integrated Telephone Survey (SLAITS) mechanism, which shares the random-digit-dial sampling frame of the National Immunization Survey (sponsored by the National Immunization Program and NCHS). Using the SLAITS platform, interviews on approximately 2000 children were conducted in each state and the District of Columbia. The parent or guardian most knowledgeable about the child completed a battery of questions on health and development, health insurance coverage, access to care, utilization of health care services, presence of a medical home, family functioning, parental health, and neighborhood characteristics. Data collection began in January 2003 and continued through April 2004. Summary reports and electronic data files will be available to the public by early 2005. This is the second state and national survey jointly completed by MCHB and NCHS. It is designed to complement the 2001 National Survey of Children with Special Health Care Needs by providing data on the health of the general child population.

Context or composition: what explains variation in SCHIP disenrollment?

To investigate (1) the relative contributions of family and contextual characteristics to observed variation in disenrollment rates from the State Children's Health Insurance Program (SCHIP), and (2) whether context explains observed family-level patterns. We use secondary data on 24,628 families enrolled in New Jersey's SCHIP program (NJ KidCare), and county-level data from the Area Resource File, the Census, and the NJ FamilyCare provider roster. Information on family characteristics, SCHIP plan, and dates of enrollment and disenrollment are taken from NJ KidCare administrative records, which provided surveillance data from January 1998 through April 2000. We estimate a multilevel discrete-time-hazards model of SCHIP disenrollment. Families enrolled in plans involving cost-sharing, blacks, and those with only one enrolled child have higher than average rates of disenrollment. Disenrollment rates for blacks are lower in counties with a high share of black physicians. These characteristics account for part of the intercounty variation in disenrollment rates; remaining intercounty variation is largely explained by physician density or population density. It may be worthwhile to pay special attention to black families and counties with high disenrollment rates to address the reasons for their lower retention. Addressing cultural differences between physician and client and the geographic distribution of medical providers might reduce disenrollment.

Activism in an Age of Restraint: The Resiliency of Administrative Structure in Implementing the State Children's Health Insurance Program

This article examines, state efforts to build administrative structures and outreach networks in the State Children's Health Insurance Program (CHIP) through a comparative review of 18 states that have been the subject of ongoing research by the Nelson A. Rockefeller Institute of Government. The article explores the role that institutional structures play at the state level in shaping the implementation and administration of federal policy choices. States have generally opted to rely largely on existing Medicaid bureaucracies in order to implement the new CHIP programs. As a result. CHIP programs have been tightly integrated into existing Medicaid structures. Rarely put forward as exemplars of responsiveness and. these bureaucracies have nonetheless played a crucial role in building and managing CHIP programs across the United States. As this analysis will show, this has even been the case in those few states that have opted to officially house CHIP administration outside of the Medicaid bureaucracy. Furthermore, existing Medicaid systems have often been active as partners and participants in efforts to publicize and promote the CHIP program through outreach and education efforts. As part of these initiatives, efforts have been made to portray CHIP as a form of health insurance rather than a welfare benefit. A slight paradox results where key actors, in the health and human services bureaucracy play an active role in program management while making efforts to dissassociate the program from the traditional welfare system. These efforts have been largely successful. And in doing so, not only have children been brought into the CHIP program but more families have been connected to the Medicaid program. In short, a review of state experiences reveals the resiliency and flexibility of existing state administiative systems in responding to and addressing substantive policy change.

The State Children's Health Insurance Program: Has it Reduced the Percentage of Uninsured Children?

Recent data indicate that the percentage of children in the United States who are uninsured is declining. Although many factors have contributed to that decline, this study assesses the role of public health insurance, specifically the State Children's Health Insurance Program (SCHIP),1 in reducing the percentage of uninsured children without health insurance from 1998–2000 and whether Medicaid and SCHIP crowd out exists. While this research confirms a significant decline in the percentage of uninsured children since SCHIP began enrolling children in 1998, other factors, including the poverty rate, the percentage of children on Medicaid, geographic region and race had a greater impact in explaining that result than SCHIP. Lastly, the data findings are consistent with research suggesting crowd out does exist.2

Enrolling children in public insurance: SCHIP, Medicaid, and state implementation.

The Balanced Budget Act of 1997 established federal grants to the states to create the State Children's Health Insurance Program (SCHIP). This presented the states with a number of implementation choices concerning administrative models for the new programs, as well as choices about eligibility standards, enrollment simplification, crowd-out, and cost sharing requirements. At the same time, the states were also implementing welfare reform. We describe the most important of these implementation choices, and using data from the Current Population Survey, we estimate the impacts of state policy on enrollment in this multiprogram environment. The results indicate that SCHIP programs that are administered as Medicaid expansions are more successful than either separate SCHIP plans or combination programs in enrolling children. States that remove asset tests and implement presumptive eligibility and self-declaration of income have higher enrollment levels. Continuous eligibility and adoption of mail-in applications have no effect on overall enrollment. Waiting periods and premiums reduce enrollment. Stringent welfare reform reduces children's enrollment, despite federal policy that was intended to protect children from the consequences of welfare reform. The negative impacts of a number of these policy reforms substantially reduce enrollment, potentially offsetting the more favorable impacts of other policy choices. We estimate that if all states adopted the policy options that facilitate program use, enrollment for children with family incomes less than 200 percent of the poverty line could be raised from the current rate of 42 percent to 58 percent.