State Children's Health Research Articles

Social Justice Considerations in Neonatal Care for Nurse Managers and Executives

This article presents the struggle between social justice and market justice within the current health care system, specifically issues affecting neonatal care. Community benefit is described and discussed as an aspect of social justice demonstrated by hospitals. The federal and state Children's Health Insurance Program also is discussed in relation to social justice and health care costs. Implications for managers and executives overseeing neonatal care are presented in relation to the economic and social issues.

Resident Finds Rewards Atop Capitol Hill

Back to table of contents Previous article Next article Association NewsFull AccessResident Finds Rewards Atop Capitol HillKen HausmanKen HausmanSearch for more papers by this authorPublished Online:2 Apr 2010https://doi.org/10.1176/pn.45.7.psychnews_45_7_022AbstractFew psychiatrists find themselves in a position to directly influence the development and progress of federal legislation that can benefit their profession and the people who need treatment for psychiatric illnesses. PGY-4 psychiatry resident Kahlil Johnson, M.D., however, was one of the fortunate ones who was able to do just that.Johnson, who was a resident at George Washington University, was APA's 2009 Jeanne Spurlock, M.D., Congressional Fellow, which gives one psychiatry resident each year the opportunity to work on Capitol Hill in the office of a member of the House or Senate or on the staff of a congressional committee that can make or influence mental health policies nationwide.Psychiatry resident Kahlil Johnson, M.D. (right), worked with Rep. Edolphus Towns (D-N.Y.) on health-related legislation during an APA congressional fellowship.Credit: Ashley Wilson, Office of Rep. TownsOnce he was chosen as last year's Spurlock Fellow, Johnson, with the help of APA, arranged a position in the office of Rep. Edolphus Towns, a Democrat representing a district in Brooklyn, N.Y., where he hoped he could apply his interest in public health and in treating underserved mentally ill populations. He said he was “especially interested in the connection between the environment people live in and its impact on their overall mental health,” areas in which Towns was also interested, having been a social worker and hospital administrator prior to his election to Congress.Johnson said that he had frequent opportunities to meet with Towns's constituents and “to weigh in on several key policy initiatives by providing the unique view of a psychiatrist. . . . I found that I had to draw on all of my medical knowledge during the course of the fellowship—psychiatric and otherwise.”Among the issues on which he advised was the American Investment and Recovery Act's health-related provisions and the reauthorization of the State Children's Health Insurance Program, he told Psychiatric News.Johnson spent the first few months of the fellowship working in Towns's personal office and on health issues under review by the House Oversight and Government Reform Committee, such as Medicare fraud, H1N1 vaccine production, and “the evaluation process of doctors fulfilling their commitments to the National Health Service Corps.” Later he attended meetings on health reform legislation with a variety of groups and then briefed Towns on the positions of these individuals and groups. He also appeared as a guest on Towns's cable-access television show, during which access to health care and the need to ensure that mental health was included in any health reform proposal were discussed.He said he is especially proud of the work he did “spearheading the addition of health-impact tracking language ... into the Urban, Revitalization and Livable Communities Act of 2009.” This bill makes grant funds available for building new parks and recreation spaces, repairing existing ones, and keeping youth off the streets. Grant applicants, he explained, will receive preference if they “track the impact of their recreational space or programs on chronic-disease outcomes” including depression outcomes.“One of the most valuable things about my fellowship,” Johnson said, “was the hands-on experience with the legislative process and meeting people who Americans chose to lead as our representatives in Washington, D.C. I will carry what I have learned with me and share the unique perspective, knowledge, and understanding I have gained with the local psychiatric community.”After completing the fellowship late last year, Johnson began working for Unity Health Care, providing treatment at the District of Columbia jail, fulfilling his goal of working with underserved populations. He said he is slated to become director of psychiatry at the jail later this year.The fellowship is administered by the American Psychiatric Foundation in conjunction with APA and is supported by an unrestricted education grant from Wyeth Pharmaceuticals. It comes with a $35,000 stipend, which may be supplemented by the fellow's institution. Fellows are also reimbursed up to $2,500 for moving expenses to Washington, D.C.An application and information about the Jeanne Spurlock Congressional Fellowship and APA's other minority fellowships are posted at <www.psych.org/Resources/OMNA/MFP.aspx>. ISSUES NewArchived

State Variation in Underinsurance Among Children With Special Health Care Needs in the United States

National attention has focused on providing health insurance coverage for children. Less awareness has been given to underinsurance, particularly for children with special health care needs (CSHCN). Defined as having inadequate benefits, underinsurance may be a particular problem for CSHCN because of their greater needs for medical care. We used the 2005-2006 National Survey of Children With Special Health Care Needs, a nationally representative study of >40,000 CSHCN, to address state variations in underinsurance. CSHCN with health insurance were considered underinsured when a parent reported that the child's insurance did not usually or always cover needed services and providers or reasonably cover costs. We calculated the unadjusted prevalence of underinsurance for each state. Using logistic regression, we estimated state-specific odds and prevalence for underinsurance after adjusting for poverty level, race/ethnicity, gender, family structure, language use, insurance type, and severity of child's health condition. We also conducted multilevel analyses incorporating state-level contextual data on Medicaid and the State Children's Health Insurance Program. Bivariate and multivariate analyses indicated that CSHCN's state of residence had a strong association with insurance adequacy. State-level unadjusted underinsurance rates ranged from 24% (Hawaii) to 38% (Illinois). After multivariate adjustments, the range was largely unchanged: 23% (Hawaii) to 38% (New Jersey). Multilevel analyses indicated that Medicaid income eligibility levels were inversely associated with the odds of being underinsured. The individual-level and macro-level factors examined only partly explain state variations in underinsurance. Furthermore, the macro-level factors explained only a small portion of the variance; however, other macro-level factors may be relevant for the observed patterns.

State-Level Child Health System Performance and the Likelihood of Readmission to Children's Hospitals

To assess the relationship between children's hospital readmission and the performance of child health systems in the states in which hospitals are located. We conducted a retrospective cohort study of 197,744 patients 2 to 18 years old from 39 children's hospitals located in 24 states in the United States in 2005. Subjects were observed for a year after discharge for readmission to the same hospital. The odds of readmission were modeled on the basis of patient-level characteristics and state child health system performance as ranked by the Commonwealth Fund. A total of 1.8% of patients were readmitted within a week, 4.8% within a month, and 16.3% within 365 days. After adjustment for patient-level characteristics, the probability of readmission varied significantly between states (P=.001), and the likelihood of readmission during the ensuing year increased as the states' health system performance ranking improved. States in the best ranking quartile had a 2.03% higher readmission rate than states in the lowest quartile (P=.02); the same directional relationship was observed for readmission intervals from 1 to 365 days after discharge. Hospital readmission rates are significantly related to the performance of the surrounding health care system.

Yes, Mr. President: A Free Market Can Fix Health Care

In March 2009, President Barack Obama said, If there is a way of getting this done where we're driving down costs and people are getting health insurance at an affordable rate, and have choice of doctor, have flexibility in terms of their plans, and we could do that entirely through the market, I'd be happy to do it that way. This paper explains how letting workers control their health care dollars and tearing down regulatory barriers to competition would control costs, expand choice, improve health care quality, and make health coverage more secure.First, Congress should give Medicare enrollees a voucher and the freedom to choose any health plan on the market. Vouchers would be means-tested, would contain Medicare spending, and are the only way to protect seniors from government rationing.Second, to give workers control over their health care dollars, Congress should reform the tax treatment of health care with large health savings accounts. Large HSAs would reduce the number of uninsured Americans, would free workers to purchase secure health coverage from any source, and would effectively give workers a $9.7 trillion tax cut without increasing the federal budget deficit.Third, Congress should break up state monopolies on insurance and clinician licensing. Allowing consumers to purchase health insurance licensed by other states could cover one-third of the uninsured without any new taxes or government subsidies.Finally, Congress should reform Medicaid and the State Children's Health Insurance Program the way it reformed welfare in 1996. Block-granting those programs would reduce the deficit and encourage states to target resources to the truly needy. The great advantage of a free market is that innovation and more prudent decision-making means that fewer patients will fall through the cracks.

SCHIP's Impact on Dependent Coverage in the Small‐Group Health Insurance Market

To estimate the impact of State Children's Health Insurance Program (SCHIP) expansions on public and private coverage of dependents at small firms compared with large firms. 1996-2007 Annual Demographic Survey of the Current Population Survey (CPS). This study estimates a two-stage least squares (2SLS) model for four insurance outcomes that instruments for SCHIP and Medicaid eligibility. Separate models are estimated for small group markets (firms with fewer than 25 employees), small businesses (firms under 500 employees), and large firms (firms 500 employees and above). We extracted data from the 1996-2007 CPS for children in households with at least one worker. The SCHIP expansions decreased the percentage of uninsured dependents in the small group market by 7.6 percentage points with negligible crowd-out in the small group and no significant effect on private coverage across the 11-year-period. The SCHIP expansions have increased coverage for households in the small group market with no significant crowd-out of private coverage. In contrast, the estimates for large firms are consistent with the substantial crowd-out observed in the literature.

The Status of States' Policies to Support Evidence-Based Practices in Children's Mental Health

This study examined the efforts of states' mental health authorities to promote the use of evidence-based practices through policy. Data were drawn from three components of a national study, including a survey of state children's mental health directors (N=53), which was developed using a three-step process that involved stakeholders. Data from the directors' survey revealed that over 90% of states are implementing strategies to support the use of evidence-based practices. The scope of these efforts varies, with 36% reporting statewide reach. Further, states' strategies for implementing evidence-based practices are often not accompanied by comparable efforts to enhance information systems, even though enhancing such systems can bolster opportunities for successful implementation. Variability in the adoption of evidence-based practices, poor attention to information systems, and inconsistent fiscal policies threaten states' efforts to improve the quality of children's mental health services.

Recent Trends in State Children's Health Insurance Program Eligibility and Coverage for CSHCN

Policy makers and physicians need to understand recent trends in State Children's Health Insurance Program (SCHIP) eligibility and coverage given the ongoing debate on SCHIP. Although many studies have examined these issues, few have focused on children with special health care needs (CSHCN). With this study we aimed to fill this gap in the literature. Data on state-specific SCHIP eligibility criteria were merged with the National Survey of Children With Special Health Care Needs to determine SCHIP eligibility and coverage in 2001 and 2005. In addition to descriptive analysis, a multilevel analysis was performed to identify personal and state-level factors that significantly affected uninsurance among the SCHIP-eligible CSHCN. Our analyses showed that there was a slight increase in SCHIP eligibility for CSHCN between 2001 and 2005 (8.44% vs 9.83%; P < .05, chi(2) test). Among the SCHIP-eligible CSHCN, we found a substantial decrease in the uninsurance rate from 21.15% in 2001 to 10.87% in 2005 (P < .05, chi(2) test). After controlling for covariates, our analyses indicated that CSHCN in 2005 were 57% less likely to be uninsured than those in 2001. Our multilevel analysis also identified state policies that significantly affected uninsurance among the SCHIP-eligible CSHCN, including asset tests (positive effects) and presumptive eligibility (negative effects). Our results show a dramatic decrease in the uninsurance rate among SCHIP-eligible CSHCN between 2001 and 2005.

Financial Burden of Raising CSHCN: Association With State Policy Choices

We examined the association between state Medicaid and State Children's Health Insurance Program (SCHIP) income eligibility and the financial burden reported by low-income families raising children with special health care needs (CSHCN). Data on low-income CSHCN and their families were from the National Survey of Children With Special Health Care Needs (N = 17039), with a representative sample from each state. State Medicaid and SCHIP income-eligibility thresholds were from publicly available sources. The 3 outcomes included whether families had any out-of-pocket health care expenditures during the previous 12 months for their CSHCN, amount of expenditure, and expenditures as a percentage of family income. We used multilevel logistic regression to model the association between Medicaid and SCHIP characteristics and families' financial burden, controlling state median income and child- and family-level characteristics. Overall, 61% of low-income families reported expenditures of >$0. Among these families, 30% had expenses between $250 and $500, and 34% had expenses of more than $500. Twenty-seven percent of the families reporting any expenses had expenditures that exceeded 3% of their total household income. The percentage of low-income families with out-of-pocket expenses that exceeded 3% of their income varied considerably according to state and ranged from 5.6% to 25.8%. Families living in states with higher Medicaid and SCHIP income-eligibility guidelines were less likely to have high absolute burden and high relative burden. Beyond child and family characteristics, there is considerable state-level variability in low-income families' out-of-pocket expenditures for their CSHCN. A portion of this variability is associated with states' Medicaid and SCHIP income-eligibility thresholds. Families living in states with more generous programs report less absolute and relative financial burden than families living in states with less generous benefits.

The Impact of Insurance on Satisfaction and Family-Centered Care for CSHCN

Children with special health care needs (CSHCN) have worse health outcomes and satisfaction compared with children with typical needs. Although individual characteristics influence satisfaction and family-centered care, additional effects of health insurance and state child health policies are unknown. To determine if satisfaction and family-centered care varied among CSHCN, after adjusting for individual characteristics, according to insurance type and state child health policies. We performed descriptive and multivariate analyses by using demographic, insurance, and satisfaction data from the 2006 National Survey of Children With Special Health Care Needs (N = 40723). Additional state data included Medicaid and State Children's Health Insurance Program (SCHIP) characteristics and the supply of pediatricians. We supplemented the national findings with survey data from Florida's SCHIP comprehensive care program (CMS-Duval ["Ped-I-Care"]) for CSHCN (N = 300). Nationally, 59.8% of parents were satisfied with their child's health services, and two thirds (65.7%) received family-centered care. Adjusting for individual predictors, those uninsured and those with public insurance were less satisfied (odds ratios [ORs]: 0.45 and 0.83, respectively) and received less family-centered care (ORs: 0.43 and 0.80, respectively) than privately insured children. Of note, satisfaction increased with state Medicaid spending. Survey data from Ped-I-Care yielded significantly higher satisfaction (91.7%) compared with national levels of satisfaction in the SCHIP (54.2%) and similar rates of family-centered care (65.6%). These results suggest that satisfaction is based more on experiences with health systems, whereas family-centered care reflects more on provider encounters. Insurance type affects both satisfaction and family-centered care for CSHCN, and certain state-level health care characteristics affect satisfaction. Future studies should focus on interventions in the health care system to improve satisfaction and patient encounters for family-centered care.

Household Language Use and Health Care Access, Unmet Need, and Family Impact Among CSHCN

We examined the association of household language use and access to care among children with special health care needs (CSHCN). From this study we describe the demographics of children and the prevalence of selected access characteristics according to their primary household language and examine the independent effects of household language on health care access, unmet needs, and family impact while controlling for confounding variables. Data from the 2005-2006 National Survey of Children With Special Health Care Needs, a nationally representative telephone survey of 40,723 CSHCN, were analyzed. Bivariate and multivariable analyses were used to examine disparities and estimate adjusted odds ratios of health care access, satisfaction, and family-impact measures for CSHCN from non-English-primary-language (NEPL) versus English-primary-language (EPL) households. Nearly 14% of all US children live in NEPL households. NEPL CSHCN were significantly more likely to be Hispanic or other race, be poor, have less educated parents, and reside in metropolitan areas and larger households and yet were less likely to be on cash assistance from welfare. Logistic regression showed that NEPL CSHCN were twice as likely to lack access to a medical home, a usual source of care, and family-centered care. They were 4 times as likely to lack health insurance, and their family members were also more likely to lack adequate insurance. Family members of NEPL children were almost twice as likely to have to stop employment as a result of their child's condition. Although limited by program eligibility contingent on immigrant status and state policies, increased referrals to programs such as the State Children's Health Insurance Program and Medicaid can improve access while utilization can be improved by the availability of interpreters, community health workers, linguistically concordant providers, and outreach education efforts of NEPL parents.

Update on Disparities in Oral Health and Access to Dental Care for America's Children

This contribution updates federal survey findings on children's oral health and dental care since release of Oral Health in America: A Report of the Surgeon General in 2000. Dental caries experience continued at high levels, impacting 40% of all children aged 2 to 11 years, with greater disease and untreated disease burden borne by poor and low-income children and racial/ethnic minorities. Caries rates increased for young children (to 28% of 2- to 5-year-olds in the period 1999-2004) and remained flat for most other ages. The total volume of caries and untreated caries increased as the numbers of children increased. The proportion of US children with a dental visit increased modestly (from 42% to 45% between 1996 and 2004), with the greatest increases occurring among children newly covered by the State Children's Health Insurance Program (SCHIP). Disparities in dental visits continued to be evidenced by age, family income, race/ethnicity, and caregiver education. Parental reports of children's oral health and dental care parallel these findings and also reveal higher unmet dental needs among children with special health care needs. Racial- and income-based disparities in both oral health and dental care continue into adolescence and young adulthood. These disparities can, as in the past, be expected to exacerbate under the forces of growing income disparities and demographic trends.

The Erosion of Employer-Sponsored Health Insurance: Declines Continue for the Seventh Year Running

Employer-sponsored health insurance (ESI) remains the most prominent form of health coverage in the United States, at 62.9 percent of the under-65 population; however, the rate of this coverage has fallen every year since 2000, when 68.3 percent had ESI. By 2007, this rate had fallen 5.4 percentage points, and 3 million fewer people under the age of 65 had ESI in 2007 than in 2000. Because of these large declines in ESI, workers and their families have become uninsured at alarming rates. Despite a small gain in overall coverage for workers from 2006 to 2007, there were over 4 million more uninsured workers in 2007 than in 2000. Uninsured workers are disproportionately young, nonwhite, less educated, and low wage; however, workers across the socioeconomic spectrum experienced losses in coverage over the 2000-2007 period. Even the most highly educated and highest-wage workers had lower rates of insurance coverage in 2007 than in 2000. As with workers, the downward trend in ESI coverage for children (through their parents' employers) continued into 2007: 3.4 million fewer children had ESI in 2007 than in 2000, cutting across all race and income groups. Even as employment-based coverage has declined, the share of Americans who receive coverage through private purchase (non-group market) has also declined. The safety net programs--Medicaid and the State Children's Health Insurance Program--have kept millions of families insured as employment-based coverage fell.

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Following efforts made in recent years to provide effective mental health treatments based on evidence-based guidelines, a working definition was developed in the literature detailing a minimum level of "adequate mental health care" for serious mental illness. However, little is known about racial or ethnic disparities in receipt of adequate mental health care for individuals affected with serious mental illness. The objective of this study was to examine disparities among Caucasian and Hispanic youths in receipt of adequate mental health care for past-year major depressive episodes. Data for this study were drawn from the 2005 National Survey on Drug Use and Health. The study sample was composed of 1,169 Caucasian youths and 316 Hispanic youths aged 12 to 17 with past-year major depressive episodes. The percentages of youths in the sample who received adequate mental health care for past-year major depressive episodes were estimated, and the correlates of receipt of adequate mental health care were examined. Thirty-four percent of the full sample received adequate mental health care for past-year major depressive episodes, but separate analyses indicated that adequate mental health care was received by a significantly higher proportion of Caucasian youths (36%) than Hispanic youths (27%). The odds of receiving adequate mental health care for past-year major depressive episodes for Caucasians were 1.55 times that of Hispanics (p=.01). Having Medicaid or coverage via the State Children's Health Insurance Program significantly increased the odds of receiving adequate mental care for past-year major depressive episodes for both Hispanics and Caucasians. As mental health problems of adolescents from diverse racial or ethnic backgrounds become more easily identified and a larger proportion of these groups is referred to mental health treatment services, it is important to examine the degree to which treatment should be tailored to engage and retain specific racial or ethnic groups so that they will receive the minimum of adequate mental health care.

Differential Effect of the State Children's Health Insurance Program Expansions by Children's Age

This paper tests for differences in the effect of State Children's Health Insurance Program (SCHIP) on children's insurance coverage and physician visits across three age groups: pre-elementary school-aged children (pre-ESA), ESA children, and post-ESA children. The study uses two cross sections of the Survey of Income and Program Participation (SIPP) from the 1996 and 2001 panels. A difference-in-differences approach is used to estimate the effect of SCHIP on coverage and physician visits of newly eligible children of different age groups. Demographic, insurance, and physician visit information for children in families with income below 300 percent of federal poverty line were extracted from the SIPP. Uninsurance rates for post-ESA children declined due to SCHIP while public coverage and the likelihood of visiting a physician increased. Estimates of cross-age differences show that post-ESA children experienced a larger decline in uninsurance rates compared with pre-ESA and ESA children and a larger increase in physician visits compared with ESA children. The higher rate of physician visits for post-ESA children due to SCHIP demonstrates the importance of extending insurance coverage to teens as well as young children.

Maternal Mental Health and Pediatric Health Care Use Among a National Sample of Medicaid- and SCHIP-Insured Children

While the literature has shown that health care use is associated with mental health status, little is known about the relationship between a mother's mental health status and her children's health care use. This study examined the association of maternal mental health status and pediatric health care for their children in a nationally representative sample of 17,830 women parenting children ages 0-17 insured through Medicaid or a State Children's Health Insurance Program (SCHIP). Mothers with a mental health problem were significantly more likely to be poorer, single parents, with lower levels of education, fewer parenting supports, and greater difficulty coping with parenting than mothers without a mental health problem; however, they reported comparable receipt of pediatric health care for their children, indicating their resilience as caretakers. The findings also suggest that all Medicaid- or SCHIP-eligible families could benefit from targeted engagement strategies linking them with consistent and appropriate sources of pediatric health care.

Number of Uninsured Appears Poised for Dramatic Surge

Back to table of contents Previous article Next article Professional NewsFull AccessNumber of Uninsured Appears Poised for Dramatic SurgeMark MoranMark MoranSearch for more papers by this authorPublished Online:17 Jul 2009https://doi.org/10.1176/pn.44.14.0012aRising health care costs and slow growth in personal income related to the current recession will add at least another 6.9 million nonelderly Americans to the rolls of the uninsured by 2010, according to a study published May 28 on the Web site of the journal Health Affairs.In the study report, researchers Todd Gilmer, Ph.D., and Richard Kronick, Ph.D., of the University of California, San Diego, predicted that 19.2 percent of all nonelderly Americans will be uninsured by 2010, an increase of 2 percentage points from 2007.The researchers used a complex method that involves several data sources to calculate an “affordability index,” defined as the ratio of per-capita health spending for insured adults to the median income among workers. Those data sources included the National Health Accounts developed by the Office of the Actuary at the Centers for Medicare and Medicaid Services, the 1977 National Medical Care Expenditure Survey, the 1987 National Medical Expenditure Survey, and the 1996 and 1999 Medical Expenditure Panel Surveys. Their analysis also takes into account employment characteristics such as firm size, industry, and self-employment and part-time status, as well as demographic and socioeconomic characteristics such as age, sex, marital status, race and ethnicity, education, and home ownership. After using their index to derive predictions for uninsurance rates among workers, Gilmer and Kronick used the historical relationship between coverage rates for workers and for all nonelderly adults to generate predicted uninsurance rates for all nonelderly adults.They estimate that the number of uninsured Americans will reach 52 million in 2010. Among workers not covered by a dependent's plan or by a public program, the fraction that is uninsured is expected to increase sharply, reaching 26.4 percent in 2010.Moreover, Gilmer and Kronick acknowledged that their model cannot completely account for uninsurance that will arise from job losses during the current recession.“Our model focuses on forecasting the rate of uninsurance among workers,” they write. “It does not directly take unemployment into account. During recessions we would expect the number of uninsured people to increase by more than projected by the model, because some of the newly unemployed will lose coverage when they lose their jobs.”They cited researchers at Kaiser Family Foundation who have estimated that each 1 percent increase in unemployment leads to a 0.59 percent increase in the percentage uninsured among nonelderly adults. If unemployment were to increase to 10 percent, the number of uninsured people would increase by close to 6 million in the absence of policy change.“Some of this projected increase would be in addition to our projected increase of 6.9 million, which will occur primarily as a result of the increasing unaffordability of health care for adults who continue working,” Gilmer and Kronick wrote.They noted that the American Recovery and Reinvestment Act of 2009 may somewhat attenuate the effects of increasing unemployment on the number of uninsured people and that extension and expansion of the State Children's Health Insurance Program is expected to reduce the number of uninsured children.“Given major uncertainties about the depth and length of the recession, about federal and state policy responses, and about the effect of any public policy response, it would be foolish to attempt to offer precise forecasts of the number of uninsured Americans,” the researchers observed. “These caveats notwithstanding, our work demonstrates that if personal income grows as slowly as projected... and health care costs grow at the rate projected by CMS, then the number of uninsured people is likely to grow by at least 6.9 million during 2008-10.”Gilmer is an associate professor in the Department of Family and Preventive Medicine at the University of California at San Diego, and Kronick is a professor in that department.“Hard Times and Health Insurance: How Many Americans Will be Uninsured in 2010” is posted at<http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w573>.▪ ISSUES NewArchived

Health Care Reform and Adolescents—An Agenda for the Lifespan: A Position Paper of the Society for Adolescent Medicine

Health Care Reform and Adolescents—An Agenda for the Lifespan: A Position Paper of the Society for Adolescent Medicine

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.