State Children's Health Research Articles

Advair Prescribing Patterns in a State Medicaid and Child Health Insurance Program

Advair Prescribing Patterns in a State Medicaid and Child Health Insurance Program

Economic Grand Rounds: The Deficit Reduction Act: Should We Love It or Hate It?

Some new options created for state Medicaid programs under Title VI of the Deficit Reduction Act (DRA) could have grave consequences for people with mental illness. Some provisions allow states to limit coverage, increase copayments, impose new premiums, and cap benefits. More positive DRA provisions would make it easier for states to provide home- and community-based services. A ten-state demonstration program will expand coverage for children. The author concludes that a state's adoption of the DRA's mental health-friendly provisions may not offset the damage done by its other provisions.

Economic Grand Rounds: The Deficit Reduction Act: Should We Love It or Hate It?

Economic Grand Rounds: The Deficit Reduction Act: Should We Love It or Hate It?

The effects of state policy design features on take‐up and crowd‐out rates for the state children's health insurance program

We evaluate the effects of state policy design features on SCHIP take-up rates and on the degree to which SCHIP benefits crowd out private benefits. The results indicate overall program take-up rates of approximately 10 percent. However, there is considerable heterogeneity across states, suggesting a potential role of inter-state variation in policy design. We find that several design mechanisms have significant and substantial positive effects on take-up. For example, eliminating asset tests, offering continuous coverage, simplifying the application and renewal processes, and extending benefits to parents all have sizable and positive effects on take-up rates. Mandatory waiting periods, on the other hand, consistently reduce take-up rates. In all, inter-state differences in outreach and anti-crowd-out efforts explain roughly one-quarter of the cross-state variation in take-up rates. Concerning the crowding out of private health insurance benefits, we find that between one-quarter and one-third of the increase in public health insurance coverage for SCHIP-eligible children is offset by a decline in private health coverage. We find little evidence that the policy-induced variation in take-up is associated with a significant degree of crowd out, and no evidence that the negative effect on private coverage caused by state policy choices is any greater than the overall crowding-out effect. This suggests that states are not augmenting take-up rates by enrolling children that are relatively more likely to have private health insurance benefits.

Within-State Availability of Transition-to-Adulthood Services for Youths With Serious Mental Health Conditions

This study describes the existence and nature of services within state child and adult mental health systems that support the transition from adolescence to adulthood. State child and adult mental health administrators from all but one state were interviewed by telephone with a semistructured questionnaire regarding transition services in their state mental health system, such as supported housing, vocational support, preparation for independent living, and dual diagnosis treatment. Eight states were deemed sufficiently decentralized to render state-level administrator reports invalid. Specific service data from the remaining 41 states and the District of Columbia were analyzed with descriptive statistics. One-quarter of child state mental health systems and one-half of adult state mental health systems offered no transition services, and few provided any kind of transition service at more than one site. Most types of transition services were available at all in less than 20 percent of the states. Across the United States transition support services are lacking. The adult system in particular will require major transformation to provide the service capacity that is needed to meet the current standards of transition service accessibility for young Americans with serious mental health conditions.

Characteristics of U.S. Youths With Serious Emotional Disturbance: Data From the National Health Interview Survey

Although it is estimated that serious emotional disturbance affects 9 to 13 percent of children and adolescents in the United States, there are few national data on the characteristics of this group. This study used data for 13,579 youths from the 2001 National Health Interview Survey (NHIS) to describe the sociodemographic features and insurance coverage of youths with serious emotional disturbance living in the United States. Youths with serious emotional disturbance were identified through their scores on the Strengths and Difficulties Questionnaire, which was added to the NHIS in 2001. A large majority of youths with serious emotional disturbance were white and had income at 200 percent of the poverty level or higher. About 40 percent of youths with serious emotional disturbance had private insurance coverage, whereas Medicaid and the State Children's Health Insurance Program provided coverage for about a third of youths with serious emotional disturbance. Although Medicaid is an important payer of mental health services for youths with serious emotional disturbance, private insurance is still the primary source of health coverage for youths with serious emotional disturbance and for the overall population of youths.

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.

Within-State Availability of Transition-to-Adulthood Services for Youths With Serious Mental Health Conditions

This study describes the existence and nature of services within state child and adult mental health systems that support the transition from adolescence to adulthood.State child and adult mental health administrators from all but one state were interviewed by telephone with a semistructured questionnaire regarding transition services in their state mental health system, such as supported housing, vocational support, preparation for independent living, and dual diagnosis treatment. Eight states were deemed sufficiently decentralized to render state-level administrator reports invalid. Specific service data from the remaining 41 states and the District of Columbia were analyzed with descriptive statistics.One-quarter of child state mental health systems and one-half of adult state mental health systems offered no transition services, and few provided any kind of transition service at more than one site. Most types of transition services were available at all in less than 20 percent of the states.Across the United States transition support services are lacking. The adult system in particular will require major transformation to provide the service capacity that is needed to meet the current standards of transition service accessibility for young Americans with serious mental health conditions.

Do Access Experiences Affect Parents’ Decisions to Enroll Their Children in Medicaid and SCHIP? Findings from Focus Groups with Parents

The Covering Kids and Families (CKF) program seeks to expand health insurance coverage for children by supporting community-based outreach and enrollment. For the evaluation of CKF, researchers conducted focus groups to explore parents' experiences accessing health care for their children, and to assess whether these experiences affected decisions to enroll their children in Medicaid or the State Children's Health Insurance Program (SCHIP). In May and June 2003, 13 focus groups were conducted in 5 cities--Everett, MA; Denver, CO; Los Angeles, CA; Mena, AR; and San Antonio, TX. In each community, groups were conducted with parents of children insured under Medicaid or SCHIP and parents of uninsured children. Three groups were conducted with Spanish-speaking parents in two communities--Denver and Los Angeles. Access to primary care was considered good by most parents with children in Medicaid and SCHIP. Among parents of uninsured children, there was more variation in perceptions of access to care. For parents of both uninsured and insured children, access to dentists and specialists was more problematic. Spanish-speaking families reported numerous barriers to care due to language differences and perceived discrimination. All focus group participants said that they placed great value on health insurance. Even when parents encountered problems accessing care, very few indicated that this discouraged them from enrolling their children into Medicaid or SCHIP, or from renewing their children's public coverage.

Management Tools for Medicaid and State Childrenʼs Health Insurance Program (SCHIP)

Medicaid and the State Children's Health Insurance Program need analytic tools to manage their programs. Drawing upon extensive discussions with experts in states, this article describes the state of the art in tool use, making several observations: (1) Several states have linked Medicaid/State Children's Health Insurance Program administrative data to other data (eg, birth and death records) to measure access to care. (2) Several states use managed care encounter data to set payment rates. (3) The analysis of pharmacy claims data appears widespread. The article also describes "lessons learned" regarding building capacity and improving data to support the implementation of management tools.

Wisconsinʼs Recent BadgerCare Enrollment Decline

The State Children's Health Insurance Program (SCHIP) has been intended to provide healthcare coverage to that group of children previously caught between Medicaid eligibility and adequate access to employer insurance. However, SCHIP can be implemented quite differently across the states, potentially affecting actual enrollment. We review prior studies that have attempted to dissect how the administration of SCHIP impacts enrollment, including a multivariate study by the authors that indicates presumptive eligibility, expanded parent coverage, and 12-month continuous eligibility all contribute to a reduced likelihood of being uninsured. We then detail an administrative policy change in one state, Wisconsin, that yielded unanticipated and dramatic enrollment fluctuations in its SCHIP program, BadgerCare.

State Childrenʼs Health Insurance Program Financing and the Need for Significant Federal Funding Increases as Part of Reauthorization

In order to better inform the debate as federal policymakers prepare to reauthorize the State Children's Health Insurance Program (SCHIP) in 2007, this brief analyzes the key components of the financing structure of SCHIP including capped federal block-grant funding, the methodology for determining state's allotments of federal funding, the period of availability of allotments, and the redistribution of unspent funds. In addition, estimates presented in this brief indicate that under Congressional Budget Office baseline assumptions, SCHIP is reauthorized but annual SCHIP funding will be permanently frozen at 5.04 billion US dollars without any increases for population growth or healthcare inflation. As a result, states will suffer an aggregate federal SCHIP funding shortfall of 10.4 billion US dollars to 12.1 billion US dollars over the 5-year period from 2008 through 2012, thus placing SCHIP coverage of many low-income children at significant risk. As part of SCHIP reauthorization, federal policymakers should include substantial increases to SCHIP funding above baseline levels to avert these shortfalls.

What Happens to Children Who Lose Public Health Insurance Coverage?

Little is known about what happens to children who disenroll from public health-insurance programs. A telephone survey was conducted of children who recently had disenrolled from either Oregon's State Children's Health Insurance Program (SCHIP) or FHIAP (premium assistance) programs, both of which have identical eligibility requirements. Access for these disenrolled children was driven largely by health insurance coverage. Insured children were more likely to have a usual source of care and to have seen a physician when they needed one. While FHIAP-disenrolled children were more likely to have private health-insurance coverage than those leaving SCHIP, absolute levels were low (53 percent and 33 percent, respectively). Thus, these programs generally did not provide a bridge to nonsubsidized private health insurance. Despite higher incomes (the main reason for losing coverage), many families did not purchase private health insurance, presumably because they still could not afford to do so.

Why Parents Disenroll Children from Public Health Insurance: The Case of Southeastern North Carolina

Nationally, less than 50 percent of children reenroll in the State Children's Health Insurance Program (SCHIP), a program for children from families with incomes too high to qualify for Medicaid, but too low to afford private health insurance. To identify why, we surveyed parents who disenrolled children from a North Carolina program in 2004. Seventy-two percent of the respondents knew that their children were disenrolled and 28 percent did not know. The most common reasons parents reported for not reenrolling their children were that they never received the reenrollment forms, or they submitted their forms late. Most said they would pay out of pocket now to purchase health care services for their children. Most respondents took their children to see a provider while enrolled in SCHIP in the last year, and most were satisfied with the care received. We conclude that the goal of increasing children's reenrollment in public health insurance programs requires an improvement in health insurance information, an increase in trust in our social and health institutions, and a reorganization of the reenrollment process.

Why Are Latinos the Most Uninsured Racial/Ethnic Group of US Children? A Community-Based Study of Risk Factors for and Consequences of Being an Uninsured Latino Child

Latinos continue to be the most uninsured racial/ethnic group of US children, but not enough is known about the risk factors for and consequences of not being insured in Latino children. [corrected] The objective of this study was to identify the risk factors for and consequences of being uninsured in Latino children. A cross-sectional survey was conducted of parents at urban, predominantly Latino community sites, including supermarkets, beauty salons, and laundromats. Parents were asked 76 questions on access and health insurance. Interviews were conducted of 1100 parents, 900 of whom were Latino. Uninsured Latino children were significantly more likely than insured Latino children to be older (mean age: 9 vs 7 years) and poor (89% vs 72%) and to have parents who are limited in English proficiency (86% vs 65%), non-US citizens (87% vs 64%), and both employed (35% vs 27%). Uninsured Latinos were significantly less likely than their insured counterparts to have a regular physician (84% vs 99%) and significantly more likely not to be brought in for needed medical care because of expense, lack of insurance, difficulty making appointments, inconvenient office hours, and cultural issues. In multivariable analyses, parents who are undocumented or documented immigrants, both parents working, the child's age, and the $4000 to $9999 and $15000 to $19999 family income quintiles were the only factors that were significantly associated with a child's being uninsured; neither Latino ethnicity nor any other of 6 variables were associated with being uninsured. Compared with insured Latino children, uninsured Latino children had 23 times the odds of having no regular physician and were significantly more likely not to be brought in for needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. After adjustment, parental noncitizenship, having 2 parents work, low family income, and older child age are associated with being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino children's high risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and State Child Health Insurance Program outreach and enrollment efforts.

The impact of realized access to care on health-related quality of life: A two-year prospective cohort study of children in the California State Children’s Health Insurance Program

To examine the effect of realized access to care (problems getting care, access to needed care) on health-related quality of life (HRQOL) in the California State Children's Health Insurance Program. This was a prospective cohort study (n = 4,925; 70.5% [3438] had complete data). Surveys were taken at enrollment and after 1 and 2 years in the program. Parents and children reported HRQOL (PedsQL 4.0 Generic Core Scales). Repeated-measures analysis accounted for within-person correlation and adjusted for baseline PedsQL, baseline realized access, race/ethnicity, language, chronic health condition, and having a regular physician. Realized access to care during the prior year was related to HRQOL for each subsequent year. Foregone care and problems getting care were associated with decrements of 3.5 (P < .001) and 4.5 (P < .001) points for parent proxy-report PedsQL and with decrements of 3.2 (P < .001) and 4.4 (P < .001) points for child self-report PedsQL. Improved realized access resulted in higher PedsQL scores, continued realized access resulted in sustained PedsQL scores, and foregone care resulted in cumulative declines in PedsQL scores. Realized access to care is associated with statistically significant and clinically meaningful changes in HRQOL in children enrolled in the California State Children's Health Insurance Program.

Determinants of Children's Participation in California's Medicaid and SCHIP Programs

To develop a comprehensive predictive model of eligible children's enrollment in California's Medicaid (Medi-Cal [MC]) and State Children's Health Insurance Program (SCHIP; Healthy Families [HF]) programs. 2001 California Health Interview Survey data, data on outstationed eligibility workers (OEWs), and administrative data from state agencies and local health insurance expansion programs for fiscal year 2000-2001. The study examined the effects of multiple family-level factors and contextual county-level factors on children's enrollment in Medicaid and SCHIP. Simple logistical regression analyses were conducted with sampling weights. Hierarchical logistic regressions were run to control for clustering. Participation in MC and HF programs is determined by a combination of family-level predisposing, perceived need, and enabling/disabling factors, and county-level enabling/disabling factors. The strongest predictors of MC enrollment were family-level immigration status, ethnicity, and income, and the presence of a county-level "expansion program"; and the county-level ratio of OEWs to eligible children. Important HF enrollment predictors included family-level ethnicity, age, number of hours a parent worked, and urban residence; and county-level population size and outreach and media expenditure. MC and HF outreach/enrollment efforts should target poorer and immigrant families (especially Latinos), older children, and children living in larger and urban counties. To reach uninsured eligible children, it is important to further simplify the application process and fund selected outreach efforts. Local health insurance expansion programs increase children's enrollment in MC.

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.

ALL CHILDREN ARE NOT CREATED EQUAL: PRWORA'S UNCONSTITUTIONAL RESTRICTION ON IMMIGRANT CHILDREN'S ACCESS TO FEDERAL HEALTH CARE PROGRAMS

The lack of health insurance for children is a serious problem in the United States, especially for those children in families that earn too little to get private health insurance and too much to qualify for Medicare. Even within this subclass of children, immigrant children are particularly vulnerable to the problems faced by lack of health care. Nevertheless, with the passage of the Personal Responsibility and Work Reconciliation Act (PRWORA) by Congress, equality interests of low-income immigrant children are undermined when immigrant children are denied federal benefits for the first 5 years of residency in the United States. The first part of this Note examines the importance of child health care and the long-term problems with uninsured children, especially with uninsured immigrant children and pregnant women. The next part introduces Medicaid as well as State Children's Health Insurance Program, a supplemental federal program designed to increase health care coverage to all children, while contrasting these programs in light of the restrictive anti-immigrant PRWORA provisions. The third part explains the passage of PRWORA, its anti-immigrant provisions, and how these provisions prevent needy immigrant children from receiving federally funded health care. Then, the fourth part uses both the Equal Protection Clause of the Fourteenth Amendment and the Due Process Clause of the Fifth Amendment to argue the unconstitutionality of the anti-immigrant provisions. Finally, the last part lays out the recommendation to amend the Social Security Act so that the PRWORA barriers can be removed and recent immigrant children can receive federally funded health care.

Public finance policy strategies to increase access to preconception care.

Policy and finance barriers reduce access to preconception care and, reportedly, limit professional practice changes that would improve the availability of needed services. Millions of women of childbearing age (15–44) lack adequate health coverage (i.e., uninsured or underinsured), and others live in medically underserved areas. Service delivery fragmentation and lack of professional guidelines are additional barriers. This paper reviews barriers and opportunities for financing preconception care, based on a review and analysis of state and federal policies. We describe states’ experiences with and opportunities to improve health coverage, through public programs such as Medicaid, Medicaid waivers, and the State Children's Health Insurance Program (SCHIP). The potential role of Title V and of community health centers in providing primary and preventive care to women also is discussed. In these and other public health and health coverage programs, opportunities exist to finance preconception care for low-income women. Three major policy directions are discussed. To increase access to preconception care among women of childbearing age, the federal and state governments have opportunities to: (1) improve health care coverage, (2) increase the supply of publicly subsidized health clinics, and (3) direct delivery of preconception screening and interventions in the context of public health programs.