State Children's Health Research Articles

Insuring the Children: Obstacles and Opportunities

Passage of Title XXI of the Social Security Act, the State Children's Health Insurance Program (CHIP), offers new opportunities for helping children gain health insurance coverage. This article examines the current status of the problem of children without health insurance, describes the major provisions of Title XXI, and considers some of the implications of this new policy. Strategies human service professionals can use to help increase insurance among children are identified including: (1) helping families capitalize on opportunities for health care coverage through Medicaid and CHIP; (2) influencing key state policy decisions in the design and implementation of CHIP; and (3) continuing to engage in the research, policy analysis, and advocacy, which will help to improve the health insurance coverage available to children and families.

Outreach and enrollment challenges: increasing participation in Child Health Plus in Onondaga County, New York.

Title XXI of the Social Security Act, the State Children's Health Insurance Program (CHIP), was signed into law as part of the Balanced Budget Agreement in August 1997. The program provides $24 billion to states over a five-year period to provide health insurance to uninsured children in low-wage, working families with incomes too high to qualify for Medicaid and too low to afford private coverage. Based on interviews with participating insurers in Fall 1998, total enrollment of children in Child Health Plus in Onondaga County, New York is approximately 5,250. However, there are still approximately 10,000 uninsured and potentially eligible children in Onondaga County. In order to ensure the success of Child Health Plus and enroll these uninsured children, the State and County governments, communities, and plans participating in the program must be committed to effective outreach and ease of enrollment.

Crowd out: evidence from the Florida Healthy Kids Program.

To determine the percentage of children who had insurance coverage in the 12 months preceding enrollment in a state-subsidized program; the percentage of parents who had access to employer-based family coverage; and the cost of the families' share of the premium per month. We randomly selected 930 families whose children were enrolled in the Florida Healthy Kids Program for a period of between 1 and 3 months and conducted telephone interviews with them in 1998 about their children's insurance coverage before program entry and their access to employer-based family coverage. There were 653 families in the final sample. Only 5% of the children had employer-based coverage before program enrollment. However, 26% had access to family coverage through their employers with the family share of the premiums representing on average 13% of their incomes. Access to employer-based coverage varied significantly by family income. Throughout the development of the State Children's Health Insurance Program legislation, policy analysts expressed concern that families may crowd out or substitute a subsidized state plan for employer-based coverage. This substitution could result in fewer improvements in access to care and health status than were anticipated, because families are simply moving to a different form of health insurance. There is some degree of crowd out in the Healthy Kids Program. The economic burden to near-poor families to purchase employer-based coverage is significant. Some degree of substitution may need to be tolerated to ensure that children receive needed health insurance.

Adolescent health insurance coverage: recent changes and access to care.

To assess the health insurance status of adolescents, the trends in adolescent health care coverage, the demographic and socioeconomic correlates of insurance coverage, and the role that insurance coverage plays in influencing access to and use of health care. Together, the results provide a current and comprehensive profile of adolescent health insurance coverage. We analyzed data on 14 252 adolescents, ages 10 to 18 years, included in the 1995 National Health Interview Survey. The survey obtained information on insurance coverage and several measures of access and utilization, including usual source of care, site of the usual source of care, indications of missed or delayed care, and use of ambulatory physician services by adolescents. We conducted multivariate analyses to assess the independent association of age, sex, race, poverty status, family structure, family size, region of residence, metropolitan resident status, and health status on the likelihood of insurance coverage. We conducted bivariate and multivariate analyses to ascertain how insurance coverage was related to each of the access and utilization measures obtained in the survey. We also examined trends in health insurance coverage using the 1984, 1989, and 1995 editions of the National Health Interview Survey. An estimated 14.1% of adolescents were uninsured in 1995. Risk of being uninsured was higher for older adolescents, minorities, adolescents in low-income families, and adolescents in single parent households. Compared with their insured counterparts, uninsured adolescents were five times as likely to lack a usual source of care, four times as likely to have unmet health needs, and twice as likely to go without a physician contact during the course of a year. Between 1984 and 1995 the percentage of adolescents with some form of health insurance coverage remained essentially unchanged. During this period, the prevalence of private health insurance decreased, while the prevalence of public health insurance increased. This study demonstrates the critical importance of health insurance as a determinant of access to and use of health services among adolescents. It also shows that little progress has been made during the past 15 years in reducing the size of the uninsured adolescent population. The new State Children's Health Insurance Program could lead to substantial improvements in access to care for adolescents, but only if states implement effective outreach and enrollment strategies for uninsured adolescents.adolescents, health insurance, access, Medicaid, SCHIP.

Family Planning Funding Through Four Federal-State Programs, FY 1997

The maternal and child health (MCH) and the social services block grants have long played an important role in the provision of family planning services in the United States. The extent to which states have incorporated family planning services into the newer federally funded, but state-controlled, programs--Temporary Aid to Needy Families (TANF) and the State Children's Health Insurance Program (CHIP)--has yet to be identified. The health and social services agencies in all U.S. states, the District of Columbia and five federal jurisdictions were queried regarding their family planning expenditures and activities through the MCH and social services block grants and the TANF program in FY 1997. In addition, the states' CHIP plans were analyzed following their approval by the federal government. Because of differences in methodology, these findings cannot be compared with those of previous attempts to determine public expenditures for contraceptive services and supplies. In FY 1997, 42 states, the District of Columbia and two federal jurisdictions spent $41 million on family planning through the MCH program. Fifteen states reported spending $27 million through the social services block grant. Most of these jurisdictions indicated that they provide direct patient care services, most frequently contraceptive services and supplies. Indirect services--most often population-based efforts such as outreach and public education--were reported to have been provided more often through the MCH program than through the social services program. MCH block grant funds were more likely to go to local health departments, while social services block grant funds were more likely to be channeled through Planned Parenthood affiliates. Four states reported family planning activities funded under TANF in FY 1997, the first year of the program's operation. Virtually all state plans for the implementation of the CHIP program appear to include coverage of family planning services and supplies for the adolescents covered under the program, even when not specifically required to do so by federal law. Joining two existing--but frequently overlooked--block grants, two new, largely state-controlled programs are poised to become important sources of support for publicly funded family planning services. Now more than ever, supporters of family planning services need to look beyond the traditional sources of support--Title X and Medicaid--as well as beyond the federal level to the states, where important program decisions are increasingly being made.

The Children's Health Council: a community foundation/state government partnership.

The Children's Health Council: a community foundation/state government partnership.

Enrollment in the State Child Health Insurance Program: a conceptual framework for evaluation and continuous quality improvement.

Children's enrollment in the State Child Health Insurance Program (SCHIP) is a key indicator of program impact. Past studies demonstrate that many children eligible for Medicaid or for private employer-based insurance remain uninsured, indicating that eligibility does not guarantee either enrollment or access to medical care. Important features of SCHIP evaluation include not only eligibility thresholds and enrollment volume, but also program retention, transitions in coverage, and access to medical care. Focusing on SCHIP features that affect children's participation and continuity of coverage would allow states to continually improve procedures that affect enrollment. An exploration of federal and state policy options suggests several approaches for creating evaluation strategies that can stimulate ongoing improvement.

Factors Leading to Passage of the State Child Health Insurance Program of 1997: Legislators' and Advocates' Views

Factors Leading to Passage of the State Child Health Insurance Program of 1997: Legislators' and Advocates' Views

Challenges in securing access to care for children.

Congressional approval of Title XXI of the Social Security Act, which created the State Children's Health Insurance Program (CHIP), is a significant public effort to expand health insurance to children. Experience with the Medicaid program suggests that eligibility does not guarantee children's enrollment or their access to needed services. This paper develops an analytic framework and presents potential indicators to evaluate CHIP's performance and its impact on access, defined broadly to include access to health insurance and access to health services. It also presents options for moving beyond minimal monitoring to an evaluation strategy that would help to improve program outcomes. The policy considerations associated with such a strategy are also discussed.

Waiting in the wings: eligibility and enrollment in the State Children's Health Insurance Program.

Waiting in the wings: eligibility and enrollment in the State Children's Health Insurance Program.

The Use of Administrative Discretion in Implementing the State Children's Health Insurance Program

States have exercised administrative discretion in at least six different ways during the intergovernmental implementation of the State Children's Health Insurance Program (CHIP) provision of the Balanced Budget Act of 1997. States have used this flexibility to determine when to submit their plans and when to put the CHIP program into effect. After describing the problem of uninsured children in America and the politics of program adoption, multivariate analysis is used to attempt to answer the following question: Why have some states moved more quickly than others to get plans for introducing CHIP submitted, approved, and implemented? The nature and extent of a relationship between a state's economic, political, and health-need characteristics, on the one hand, and the timing of submission and implementation, on the other, are examined.

The Use of Administrative Discretion in Implementing the State Children's Health Insurance Program

The Use of Administrative Discretion in Implementing the State Children's Health Insurance Program

The new child health insurance expansions: how will school-based health centers fit in?

In June 1998, the Making the Grade National Program Office and the National Assembly on School-Based Health Care sponsored a workshop on the relationship between the State Child Health Insurance Program (SCHIP) and school-based health centers. Workshop participants used the health centers' experience with Medicaid managed care as a window for understanding their prospects for negotiating contracts with health plans under SCHIP. Speakers representing the federal perspective, state agencies, health plans, and local school-based health centers offered their views on the challenges of developing contracts, incentives, and disincentives that health plans have to contract with school-based health centers, and what has accounted for success where relationships are moving forward. Experiences in Colorado and Connecticut were presented as case studies on these evolving issues.

Access to care is the centerpiece in the elimination of socioeconomic disparities in health.

Many health care professionals have sustained an almost single-minded conviction that disparities in access to health care across socioeconomic groups are the key reason for the major discrepancies in health status between wealthy persons and poor persons. Others, however, have argued that a host of factors work to create major impediments and that reducing or eliminating financial barriers to health care in particular will do little to reduce discrepancies in health status. This paper, while acknowledging the spectrum of contributing factors, argues that the elimination of financially based differences in access is central to any effort to create equity in outcomes across socioeconomic groups. Through selected review of the many studies on health insurance, access, outcomes, and socioeconomic status, it establishes that a core links affected populations, their difficulty in financing health care, and the threat to their well-being. In so doing, it cites findings that strongly associate lack of insurance (especially for persons who live in poverty), inability to obtain services, and adverse health outcomes. It also uses the example of Medicaid and other coverage for HIV-infected persons in particular as an important positive instance in which leveling the discrepancies in health care across socioeconomic groups can move toward creating quality in access and outcomes. The competitive pressures in today's health care environment threaten to drive socioeconomic groups further apart, especially insured and uninsured persons. However, the recent enactment of state actions, especially the State Child Health Insurance Program, represent powerful examples of health insurance expansion that have lessons for policymakers at all levels for the monitoring and reduction of socioeconomic disparities.

The politics of EPSDT policy in the 1990s: policy entrepreneurs, political streams, and children's health benefits.

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, which was designed to ensure that Medicaid-eligible children receive comprehensive health services, is the only national attempt to provide a right to these services. The political factors that have shaped national EPSDT policy during the past decade are described, based on a conceptual framework developed by John W. Kingdon. The analysis focuses on the roles of two distinct sets of policy entrepreneurs: child health advocates and fiscally conservative governors. Their activities are described in relation to the larger political environment, or "political stream," from the period of the expansion of Medicaid eligibility for pregnant women and children in the late 1980s to the enactment of a new State Children's Health Insurance Program (SCHIP) in 1997. The relative saliency of eligibility and benefit issues in children's health policies had a major influence on the politics and outcomes.

Implementation principles and strategies for Title XXI (State Children's Health Insurance Program). Academy of Pediatrics. Committee on Child Health Financing.

A major provision of the Balanced Budget Act of 1997 established the State Children's Health Insurance Program (Title XXI of the Social Security Act). This program is a historic milestone in the financing of health care for children. Not since the enactment of Medicaid has there been a greater investment in children's health care. Title XXI does not create universal coverage for all children, but this program does offer an unprecedented opportunity to expand insurance ot a large portion of uninsured children. Title XXI of the Social Security Act makes >$40 billion in federal grants available to states over the next 10 years to provide health insurance coverage, including Medicaid. However, states mus contribute a defined share of funds to obtain federal matching funds. The legislation gives great flexibility to states in designing and implementing their programs, and it is critical that they do this in a timely manner. If states fail to use all State Children's Health Insurance Program funds available, it is possible that future federal funding will be reduced. If this happens, a major opportunity to improve health insurance coverage of America's children will be diminished.

Welfare and immigration reforms: unintended side effects for Medicaid.

Welfare reform and changes in immigrants' eligibility may lead to significant reductions in Medicaid caseloads, even though many states are expanding Medicaid eligibility rules to accommodate changes under the new welfare programs. In 1996, for the first time in almost a decade, Medicaid participation of adults and children fell about 2 percent, and further reductions seem likely in 1997. The gradual restrictions on new immigrants also will affect future caseloads. Although new initiatives such as the State Children's Health Insurance Program (CHIP) should expand health coverage for children, the welfare reform and immigration changes will disproportionately lead to loss of insurance among adults.

The children's hour: the State Children's Health Insurance Program.

The State Children's Health Insurance Program (CHIP) is the product of a series of policy and political compromises and generates numerous structural and policy issues for states. CHIP entitles states to federal financial aid to provide health assistance to targeted children, through Medicaid expansions, new program implementation, or a product of the two. States that elect to operate CHIP programs apart from Medicaid have enormous discretion under the law to determine how they will structure their programs, the services they will cover, the form that benefits will take, and the conditions of participation and consumer protections that will apply. Determining what approach to take, as well as how to respond to the choices posed by the statute, represents a major test of how states address the needs of children and families.

The State Children's Health Insurance Program (CHIP)

Between 7 million and 10 million children in the United States lack health insurance. Many of these uninsured children experience difficulty obtaining needed health care.1 To expand health insurance coverage for children, in August 1997, Congress enacted the State Children’s Health Insurance Program (CHIP) as part of the Balanced Budget Act of 1997.2 CHIP, also known as Title XXI of the Social Security Act, offers states new federal funding in the form of block grants to provide “child health assistance to uninsured children in low-income families in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children.” The program is authorized for 10 years and is expected to provide insurance coverage for millions of currently uninsured children. Federal expenditures on child health assistance under the law are estimated to total $40 billion to $50 billion over the life of the legislation.

Child health benefits packages: lessons from Minnesota for State Children's Health Insurance Programs.

The State Children's Health Insurance Program (SCHIP) provides state maternal and child health (MCH) programs an opportunity to assure comprehensive health services are available to children through the selection of an appropriate benefits package. Minnesota had this chance in 1994 when the state was considering development of a universal standard benefits set. While the Minnesota MCH program was not at the policy table, they worked through a process that increased their influence on decisions by responding to a legislative call for a definition of "appropriate and necessary" care. This definition was ultimately adopted by policymakers in creating the recommended Universal Standard Benefits Set. This experience may provide an important incentive to other state MCH programs seeking opportunities to participate in the development of state SCHIP plans.