State Children's Health Research Articles

Ambitious Health Reform Plans Take Shape in Senate

Ambitious Health Reform Plans Take Shape in Senate

Mass. Workers Stick With Employer Health Coverage

Back to table of contents Previous article Next article Health Care EconomicsFull AccessMass. Workers Stick With Employer Health CoverageRich DalyRich DalySearch for more papers by this authorPublished Online:19 Dec 2008https://doi.org/10.1176/pn.43.24.0009aAn examination of the impact of Massachusetts' near-universal health care plan on employers found that a growing number added insurance coverage for employees since the state insurance reform program was launched in 2006.The finding appears to rebut concerns that residents would flee employer-sponsored plans for cheaper and higher-quality publicly assisted insurance programs.The research, based on a survey of 1,003 randomly selected Massachusetts companies last spring and compared with a separate survey of companies nationwide, was published online October 28 in Health Affairs. The authors found that the percentage of firms with three or more workers that offer health insurance coverage increased from 73 percent to 79 percent since their previous employer survey published in 2007. Those figures compared with national coverage rates of employers of all sizes of 60 percent in 2007 and 63 percent in 2008, according to a survey of employers nationwide by the Henry J. Kaiser Family Foundation and Health Research and Educational Trust.Critics of the Massachusetts plan had warned that the availability of a low-cost, high-benefit, publicly funded health insurance system would produce several unintended consequences, collectively known as “crowd out.” One crowd-out worry was that such public plans would drain participants from employer-sponsored plans and undermine them.President George W. Bush, for example, explaining his vetoes of the renewal of the State Children's Health Insurance Program (SCHIP), cited concerns that an expansion of public programs would lead people to substitute—or“ crowd out”—private health insurance plans.Additionally, critics worried that private employers would dissolve their plans, knowing that their employees could qualify for public health insurance benefits, while the company paid a nominal penalty for failing to offer insurance. (Households earning less than 300 percent of the federal poverty level can receive subsidized coverage under part of the state plan known as Commonwealth Care if no one in the household is offered employer-sponsored coverage.)The authors of the recent research said their findings indicate that concerns of widespread crowd out appear unfounded.“Last year we reported that there was little early evidence of crowd out, and this year the same conclusion applies,” wrote Jon Gabel, a senior fellow at National Opinion Research Center and lead author of the report, and colleagues.The survey reported fewer firms planned to reduce or eliminate coverage than in the previous year. The Massachusetts companies with three to 50 workers were no more likely in 2008 to plan to drop coverage or restrict eligibility than they were in 2007. Those findings contrasted with increases of 3 percent to 6 percent in the rate of firms nationally that indicate they are planning to drop coverage and the 5 percent to 15 percent increase in the percentage planning to restrict eligibility.The decision of Massachusetts employers to expand coverage when there are publicly funded alternatives available to their employees may stem from a growing belief that it is a duty of businesses to provide employer-sponsored health insurance, according to the authors of the new study. Their conclusion was based on other survey findings that solid majorities of firms believe that employers have such a responsibility and that employees have a responsibility to buy health insurance. An increasing percentage of companies also indicated in response to the recent Massachusetts study that they believe that health insurance requirements of the state should apply equally to firms with fewer than 11 workers, which now face fewer insurance requirements, than those with larger workforces.“After the Mandates: Massachusetts Employers Continue to Support Health Reform as More Firms Offer Coverage” is posted at<http://content.healthaffairs.org/cgi/reprint/27/6/w566>.▪ ISSUES NewArchived

The Impact of the Public Insurance Expansions on Children’s Use of Preventive Dental Care

To determine if children eligible for coverage by the State Children's Health Insurance Program (SCHIP) and Medicaid Programs were more likely to receive preventive dental visits after implementation of the SCHIP policy, retrospective cross-sectional analysis was done from the 1996-2000 Medical Expenditure Panel Surveys (MEPS) data. We linked the individual level data from the MEPS to state-level information on program eligibility. Using logistic regression models that adjust for the complex survey design, the association between SCHIP implementation and receipt of preventive dental care was examined for children aged 3-18 with family incomes < or =200% of the Federal Poverty Line (FPL). Children who were eligible for SCHIP/Medicaid coverage in their respective states were more likely to have received preventive care three years after SCHIP implementation than children with similar eligibility profiles prior to SCHIP implementation. SCHIP has successfully increased the proportion of eligible children receiving preventive dental care among children in families with incomes less than or equal to 200% FPL. Our findings indicate, however, that SCHIP needed time to mature before detecting significant effects on national level.

The painful face of poverty

The painful face of poverty

Healthcare utilization and expenditures for low income children with sickle cell disease

While multiple studies have examined the healthcare burden of sickle cell disease (SCD) in adults, few have specifically focused on healthcare utilization and expenditures in children. The objective of this study was to characterize the healthcare utilization and costs associated with the care of low-income children with SCD in comparison to other children of similar socioeconomic status. For the study period, 2004-2007, we conducted a retrospective, cross-sectional descriptive analysis of administrative claims data from a managed care plan exclusively serving low-income children with Medicaid and the State Children's Health Insurance Plan (SCHIP). Patient demographics, continuity of insurance coverage, healthcare utilization, and expenditures were collected for all children enrolled with SCD and the general population within the health plan for comparison. On average, 27% of members with SCD required inpatient hospitalization and 39% utilized emergency care in a given calendar year. Both values were significantly higher than those of the general health plan population (P < 0.0001). Across the study period, 63% of members with SCD averaged one well child check per year and 10% had a minimum of one outpatient visit per year to a hematologist for comprehensive specialty care. Low-income children with SCD demonstrate significantly higher healthcare utilization for inpatient care, emergency center care, and home health care compared to children with similar socio-demographic characteristics. A substantial proportion of children with SCD may fail to meet minimum guidelines for outpatient primary and hematology comprehensive care.

Time to First Dental Visit After Initially Enrolling in Medicaid and S-SCHIP

Accessing dental care is a significant problem for children in Medicaid and S-SCHIP (Separate State Children's Health Insurance Program). Previous studies have indicated that the design of the Medicaid or S-SCHIP dental program can have an impact on the ability to use services. To evaluate the factors related to how quickly children had any dental visit and had a preventive dental visit after first enrolling in the Iowa Medicaid and S-SCHIP programs. The primary question was whether the structure of the dental plan was related to improved access to care. Iowa Medicaid and S-SCHIP dental claims and enrollment files for FY 2001 through 2003 were used to identify children who were newly enrolled in the programs and their use of dental services. Factors related to the time to a child's first dental visit were analyzed using survival analytic techniques. After 6 months in the program, between 21% and 36% of children had received their first dental visit, depending on their dental plan. This increased from 39% to 56% after 1 year. Based on the survival analysis, earlier dental utilization was related to the type of plan in which the child was enrolled as well as the child's age, race, and urban/rural location. Children in the S-SCHIP 2 dental plan, which had an open provider network and paid dentists' full charges, were most likely to have had a dental visit sooner after enrollment. States looking for options to improve access to dental care in their Medicaid and S-SCHIP programs should consider contracting with dental plans with these features.

U.S. Youth More Apt Than Europeans to Be Prescribed Psychotropics

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessU.S. Youth More Apt Than Europeans to Be Prescribed PsychotropicsAaron LevinAaron LevinSearch for more papers by this authorPublished Online:21 Nov 2008https://doi.org/10.1176/pn.43.22.0018aPsychotropic medications were prescribed two to three times more often to American children and adolescents than to their peers in the Netherlands or Germany, according to a study by investigators from all three countries. The study was based on data from the year 2000.“The annual prevalence of any psychotropic medication in youth was significantly greater in the United States (6.7 percent) than in the Netherlands (2.9 percent) and in Germany (2.0 percent),” wrote Julie Zito, Ph.D., of the University of Maryland School of Pharmacy and seven colleagues who posted their findings September 25 in the open-access online journal Child and Adolescent Psychiatry and Mental Health.About 19.2 percent of U.S. youth taking these medications were prescribed more than one drug, twice the rate in the Netherlands and three times that in Germany, they said.The researchers used administrative claims data from 2000 to look at prescribing patterns. Data covered children up to age 19: 110,944 in the Netherlands, 356,520 in Germany, and 127,157 in the United States, the last drawn from enrollees in the State Children's Health Insurance Program. Classes of drugs included antidepressants, antipsychotics, alpha-agonists, anxiolytics, hypnotics, lithium, and antiparkinsonian agents. Prevalence was defined as dispensing one or more prescriptions for those classes of medications per 100 youth.Zito and colleagues suggested several reasons for the differences, starting with culture.“U.S. medical treatment is more interventionist and activist across the board,” said Zito in an interview. In the study, more than half (51.7 percent) of the patients prescribed these medications in the United States were under age 5, compared with 24.7 percent in the Netherlands and 21 percent in Germany. The authors used statistical methods to adjust the disparity caused by the U.S. data to the age distribution found in the 2000 census.Lithium, antiparkinsonian agents, anxiolytics, and antipsychotics were used by less than 1 percent of youth in all three countries. However, among patients prescribed antipsychotics, just 5 percent of German children were prescribed atypical antipsychotics, compared with 48 percent in the Netherlands and 66 percent in the United States.“Furthermore, among 0-4 year-olds, German youth had the highest antipsychotic prevalence (0.64 percent), followed by the Netherlands (0.10 percent), and the United States (0.07 percent), a stark reversal of the leading usage trends observed in other drug classes, [such as] antidepressants and stimulants,” wrote the authors.Prevalence of stimulant prescriptions across the entire age range was 4.3 percent in the United States, 1.2 percent in the Netherlands, and 0.7 percent in Germany.Overall antidepressant prevalence was 2.7 percent in the United States, 0.5 percent in the Netherlands, and 0.2 percent in Germany. Within this class, 15 percent of U.S. youth received tricyclic antidepressants, compared with 48 percent in the Netherlands and 73 percent in Germany.There may be a number of reasons for the differences in prescribing patterns among the three countries, said Zito. For one, in Europe, regulations limit or prohibit prescription of amphetamines, and cost restrictions limit use of many expensive, on-patent drugs.The use of the International Classification of Diseases-10 rather than DSM-IV as a standard in Europe may also affect diagnoses and treatment choices. Specialists such as pediatricians and psychiatrists prescribe these drugs more often in the United States, while in Europe general practitioners prescribe most psychotropics.Higher rates of prescribing more than one medication may represent more than a quick reach for the prescription pad in the United States, said Zito.“It may be because the response of children in the community to drugs is not as high as among the carefully selected clinical trials cohorts,” she said. In those cases, a second drug may be added.But children also need a comprehensive treatment plan, one involving the whole family and not focused on the child alone.“Sending a child home on five medications after four days in the hospital can only lead to bad outcomes and wasted treatment opportunities,” she said. “Maybe we could invest more in behavioral training of children.”Her study should be viewed as a starting point for further research that will follow cohorts of children over longer periods, not merely assess the efficacy of a drug over a few weeks, she added.“A Three-Country Comparison of Psychotropic Medication Prevalence in Youth” is posted at<www.capmh.com/content/pdf/1753-2000-2-26.pdf>.▪ ISSUES NewArchived

AMA Sets Agenda to Benefit Patients on Numerous Fronts

Back to table of contents Previous article Next article Professional NewsFull AccessAMA Sets Agenda to Benefit Patients on Numerous FrontsMark MoranMark MoranSearch for more papers by this authorPublished Online:21 Nov 2008https://doi.org/10.1176/pn.43.22.0006Access to care, revising the Medicare payment formula, encouraging healthy lifestyles, and medical education reform.Those are among the AMA's top priorities, according to Michael Maves, M.D., the AMA's executive vice president and chief executive officer. He was the keynote speaker at APA's Institute on Psychiatric Services last month in Chicago. Maves was standing in for Rep. Danny Davis (D-Ill.), who was unable to attend due to the financial crisis requiring Congress to be in Washington to deliberate bailout legislation.Michael Maves, M.D., the AMA's executive vice president and chief executive officer, tells attendees at last month's Institute on Psychiatric Services that the problem of the uninsured was the AMA's leading priority.Credit: Ellen DallagerMaves said the AMA has been striving to make its legislative and lobbying agenda more patient- and public-health friendly, reversing its public image as sometimes being primarily concerned with the financial interests of doctors. As part of this effort, Maves said, the AMA was focusing on encouraging healthy patient behaviors, with an emphasis on diet; physical activity; and tobacco, drug, and alcohol use. He added that the AMA is planning to provide primary care physicians with tools to address these subjects in every patient visit.“The AMA is trying to become engaged and to advance an agenda not only for the profession, but most importantly for the patients we serve,” Maves told psychiatrists and others at the APA institute.“ We are putting ourselves in a position that perhaps we should have been in for many, many years but haven't.”During a meeting at which APA President Nada Stotland, M.D., emphasized the need for health-system reform, Maves said the number-one priority for the AMA is the problem of under- and un-insurance. And he offered a broad outline of the AMA's proposal for health insurance reform and tax credits designed to give individuals power to buy their own insurance.“Do I think this will pass? No. Do I think it will help start a discussion? Yes.” He added, “Ours is a market-based proposal, but I don't think any one proposal is ever going to solve this problem.”Moving on to Medicare fee concerns, Maves said that for several years, the AMA has had to go back to Congress “as a supplicant” to reverse fee-schedule reductions that were projected to be as high as 10 percent this year. This year advocates were able to secure an adjustment resulting in approximately a 1.5 percent across-the-board increase, along with a phase down from 50 percent to 20 percent in the copay that Medicare requires beneficiaries to pay for mental health services.“The bad news is that in 2010 we are scheduled to have roughly a 21 percent cut [in physician Medicare fees], and by 2015 it will be 40 percent,” Maves said. “You don't need to have an M.B.A. to figure out what will happen to profits and losses in your practice. People will be running away from Medicare because they cannot afford to provide the services.”What's needed, he said, is a permanent fix that would replace the sustainable growth rate formula, which requires that increases in Medicare volume be paid for by decreases in physician payment and without compensation for increasing practice costs. “There is no doubt in my mind that if these cuts go through, we will have a medical-care crisis, just as we are having a financial crisis,” he said.Maves predicted that a Medicare reform bill would be packaged with reauthorization of the popular State Children's Health Insurance Program (SCHIP), which is expected to expire next March. “Reauthorization [of SCHIP] will be a top priority,” he said, adding that he believed that Congress will continue to authorize coverage within SCHIP for women who are pregnant—a source of some controversy among lawmakers.Finally, Maves cited reform of medical education as another priority for AMA in coming years. He noted that the current model of education—two years of preclinical book work followed by two years of clinical practice and bedside education—derived from a model developed nearly 100 years ago by Abraham Flexner in the 1910 “Flexner Report.”And he said that AMA would be looking at ways to update the model to meet modern realities.“Any of you involved in academic medical education know that things are not that simple anymore,” Maves said. “The way medical students are being educated today is sporadic, and they have to connect the dots themselves.”He said that in 2010, the 100th anniversary of the “Flexner Report,” the AMA will release a new report on medical education outlining the challenges and opportunities of medical education in the 21st century. ▪ ISSUES NewArchived

Sinking SCHIP: A First Step Toward Stopping the Growth of Government Health Programs

Federal lawmakers are considering legislation that could result in millions more middle-income families obtaining health insurance from government. Unfortunately, the debate over expansion of the State Children's Health Insurance Program is divorced from the reality of who truly needs assistance and the forces that are making health insurance increasingly unaffordable. SCHIP and its larger sibling Medicaid currently enroll many people who do not need government assistance, including some families of four earning up to $72,000 per year. That is a direct result of federal funding rules that reward states for making more Americans dependent on government for their health care. Rather than expand SCHIP, Congress should (1) make private health insurance more affordable by allowing consumers and employers to purchase less expensive policies from other states, and (2) fold federal Medicaid and SCHIP funding into block grants that no longer encourage states to open taxpayer-financed health care to non-needy families. With more Americans able to afford private insurance and no incentive for states to expand government programs beyond the truly needy, federal and state governments could reduce spending on those programs.

Current Status of State Policies That Support School-Based Health Centers

This study explored the current status of the role of state school-based health center (SBHC) initiatives, their evolution over the last two decades, and their expected impact on SBHCs' long-term sustainability. A national survey of states was conducted to determine (1) the amount and source of funding dedicated by the state directly for SBHCs, (2) criteria for funding distribution, (3) designation of staff/office to administer the program, (4) provision of technical assistance by the state program office, (5) types of performance data collected by the program office, (6) state perspective on future outlook for long-term sustainability, and (7) Medicaid and the State Children's Health Insurance Program (SCHIP) policies for reimbursement to SBHCs. Nineteen states reported allocating a total of $55.7 million to 612 SBHCs in school year 2004-2005. The two most common sources of state-directed funding for SBHCs were state general revenue ($27 million) and Title V of the Social Security Act ($7 million). All but one of the 19 states have a program office dedicated to administering and overseeing the grants, and all mandate data reporting by their SBHCs. Sixteen states have established operating standards for SBHCs. Eleven states define SBHCs as a unique provider type for Medicaid; only six do so for SCHIP. In 20 years, the number of state SBHC initiatives has increased from five to 19. Over time, these initiatives have played a significant role in the expansion of SBHCs by earmarking state and federal public health funding for SBHCS, setting program standards, collecting evaluation data to demonstrate impact, and advocating for long-term sustainable resources.

The State Child Health Insurance Program Debate: Background and Insights

Even though the State Child Health Insurance Program (SCHIP) has strong bipartisan support, the Bush Administration and the 110th Congress were unable to agree to a comprehensive reauthorization of the program. The Bush Administration disagreed with a bipartisan majority of the House of Representatives and a veto-proof majority in the U.S. Senate on a wide variety of SCHIP issues including: (1) the desired scope of coverage for children, (2) needed funding, (3) coverage of adults, (4) limitations on enrollment, (5) cost sharing, and (6) benefit packages. A review of legislative proposal reveals the compromise bill passed by Congress was substantially less ambitious than the bill sought by many Congressional Democrats. The most difficult economic problem associated with a successful SCHIP expansion involves control of crowding out, the tendency for an expansion of public health insurance to result in individuals switching from private to public insurance. In my view, the vetoed bill, while not perfect from any perspective, was a reasonable way to balance the goal of expanding coverage to the uninsured with the goal of limiting crowding out.

The State Children's Health Insurance Program (SCHIP) and Prepregnancy Coverage of Teenage Mothers

The 1997 State Children's Health Insurance Program (SCHIP) program allowed states to expand Medicaid to uninsured children through age 18 in families under 200% of the federal poverty level. Prepregnancy insurance coverage of adolescents may help reduce unintended pregnancies, address other medical issues, and allow for early and adequate prenatal care for those carrying to term. We tested the effects of SCHIP implementation on insurance coverage for teenage mothers and investigated whether these effects varied by type of state SCHIP program--Medicaid expansion, stand-alone program, or some combination of these. We used Pregnancy Risk Assessment Monitoring System data from 1996 through 2000 and difference-in-differences analysis to analyze coverage changes for teenage mothers (age <20) relative to those for mothers aged 20-24 years old, a group whose Medicaid eligibility was not affected by SCHIP policies. Our raw sample of teenage and older mothers in Alaska, Oklahoma, South Carolina, Florida, Maine, New York, and West Virginia equaled 23,171 (811,638 weighted). SCHIP implementation was associated with an almost 10 percentage point increase in prepregnancy coverage among teens under age 17. Although there were increases in both public and private coverage only the latter was statistically significant. The only statistically significant increase in Medicaid coverage, equal to almost 16 percentage points, was among 18-year-olds in states with Medicaid expansion programs. The temporary extension of SCHIP allows time to consider how to maintain the program's potentially positive effect on the reproductive health of adolescents.

Longitudinal factorial invariance of the PedsQL™ 4.0 Generic Core Scales Child Self-Report Version: One year prospective evidence from the California State Children’s Health Insurance Program (SCHIP)

The measurement of health-related quality of life (HRQOL) in pediatric medicine and health services research has grown significantly over the past decade. The paradigm shift toward patient-reported outcomes (PROs) has provided the opportunity to emphasize the value and critical need for pediatric patient self-report. In order for changes in HRQOL/PRO outcomes to be meaningful over time, it is essential to demonstrate longitudinal factorial invariance. This study examined the longitudinal factor structure of the PedsQL 4.0 Generic Core Scales over a one-year period for child self-report ages 5-17 in 2,887 children from a statewide evaluation of the California State Children's Health Insurance Program (SCHIP) utilizing a structural equation modeling framework. Specifying four- and five-factor measurement models, longitudinal structural equation modeling was used to compare factor structures over a one-year interval on the PedsQL 4.0 Generic Core Scales. While the four-factor conceptually-derived measurement model for the PedsQL 4.0 Generic Core Scales produced an acceptable fit, the five-factor empirically-derived measurement model from the initial field test of the PedsQL 4.0 Generic Core Scales produced a marginally superior fit in comparison to the four-factor model. For the five-factor measurement model, the best fitting model, strict factorial invariance of the PedsQL 4.0 Generic Core Scales across the two measurement occasions was supported by the stability of the comparative fit index between the unconstrained and constrained models, and several additional indices of practical fit including the root mean squared error of approximation, the non-normed fit index, and the parsimony normed fit index. The findings support an equivalent factor structure on the PedsQL 4.0 Generic Core Scales over time. Based on these data, it can be concluded that over a one-year period children in our study interpreted items on the PedsQL 4.0 Generic Core Scales in a similar manner.

Healthcare Reform: Obama vs McCain

Healthcare Reform: Obama vs McCain

How Does the SCHIP Exclusion Affect Health Insurance Coverage for Children of Low Income State Workers?

A provision of the law that created the State Children's Health Insurance Program (SCHIP) to provide low cost coverage for moderate income children whose parents do not have employment-based coverage excludes children whose families are eligible for participation in a state employee health benefit plan from enrollment in the state's SCHIP program. This exclusion applies even when a child is not covered and would otherwise be eligible for SCHIP based on his or her family's income. This article presents an analysis of the implication of this policy on coverage among state employee dependents and the potential effect on these children. We found no evidence that low income children of state workers were disproportionately lacking coverage from 2002 to 2004, but rapidly increasing premiums in state benefit plans may portend problems for these children.

Public Dental Expenditures and Dental Visits among Children in the U.S., 1996–2004

Congress created the State Children's Health Insurance Program (SCHIP) in 1997 as an expansion of the Medicaid program to provide health insurance to children whose family income is above the Medicaid eligibility standards-generally up to 200% of the federal poverty level (FPL). This article examines changes in the utilization of dental services during a period of increasing public funding of dental services. Public dental expenditure estimates came from the Centers for Medicare & Medicaid Services (CMS), and a breakdown of these expenditures by patient age and income level was based on the Medical Expenditure Panel Survey (MEPS). According to CMS, funding for dental SCHIP and dental SCHIP expansion grew from $0 prior to 1998 to $517 million in 2004. According to the MEPS, between 1996 and 2004 there was an increase in the number and percent of children 2 to 20 years of age who reported a dental visit during the past year. These increases were most notable among children in the 100% to 200% FPL category. Approximately 900,000 more children in this income group visited a dentist in 2003-2004 than in 1996-1997. Children in this income group reported an increase in the amount of mean dental charges paid for by Medicaid and a real increase in mean dental charges per patient from $217 to $310. Recent increases in the public funding of dental services targeted to children in the 100% to 200% FPL category were related to increased utilization of dental services among these children from 1996 to 2004.

The State Children's Health Insurance Program: Participation and Substitution

We examine the effects of SCHIP enactment by focusing on two policy concerns: take-up and crowd-out. The literature has examined how income eligibility expansions affect the type of children's insurance coverage. However, states jointly implemented various policy instruments. The results in previous works do not control for this variety. We analyze how changes in several SCHIP factors affected decisions regarding health insurance coverage. Our analysis indicates that the estimates in the literature may have combined the effects of various policy factors. In distinguishing individual policy factors, our results provide useful information for designing effective public health insurance programs.

Disclosure of Industry Payments to Physicians

Within the next several years, the manufacturers of drugs, medical devices, and medical supplies that are paid for by Medicare, Medicaid, or the State Children's Health Insurance Program may be required to report publicly many of these gifts and payments; the information would be made available on a searchable government Web site. Dr. Robert Steinbrook discusses the Physician Payments Sunshine Act, which is pending in Congress.

Barriers to Care Among US School-Aged Children With Disabilities

We examined financial barriers to care experienced by US school-aged children with disabilities. Data from the 2005 National Health Interview Survey were analyzed. Children aged 5 to 17 years were classified into 4 health condition groups: children with activity limitations, disabling conditions, chronic asthma, or no health conditions. Financial barriers to care were defined as being unable to afford prescriptions, delaying medical care, and/or having forgone medical care because of concern about cost. Our study included 8870 school-aged children; 338 children had an activity limitation, 1535 had a disabling condition, 594 children had chronic asthma, and 6288 children had no health conditions. Children with activity limitations were significantly more likely than children with no health conditions to experience all 3 financial barriers to care. Uninsured children with activity limitations, disabling conditions, or no health conditions had the highest prevalence of all financial barriers to care. Of children living greater than or equal to 200% Federal Poverty Level, children with activity limitations and disabling conditions were more likely than children with no health conditions to experience all 3 financial barriers to care. Multivariate analysis showed uninsured children (odds ratio, 7.40; 95% confidence interval, 5.28-10.37) and children with an activity limitation (odds ratio, 3.70; 95% CI, 2.37-5.76) were at highest risk for financial barriers to care. Uninsured and privately insured children with activity limitations were significantly more likely to experience financial barriers. The results show that many uninsured children still experience financial barriers to care despite the creation of the State Children's Health Insurance Program.

Federalism, Partisan Politics, and Shifting Support for State Flexibility: The Case of the U.S. State Children's Health Insurance Program

Federalism, Partisan Politics, and Shifting Support for State Flexibility: The Case of the U.S. State Children's Health Insurance Program