State Children's Health Insurance Program Eligibility Research Articles

Declining child mortality and continuing racial disparities in the era of the Medicaid and SCHIP insurance coverage expansions.

We investigated trends in national childhood mortality, racial disparities in child mortality, and the effect of Medicaid and State Children's Health Insurance Program (SCHIP) eligibility expansions on child mortality. We analyzed child mortality by state, race, and age using the National Center for Health Statistics' multiple cause of death files over 20 years, from 1985 to 2004. Child mortality continued to decline in the United States, but racial disparities in mortality remained. Declines in child mortality (ages 1-17 years) were substantial for both natural (disease-related) and external (injuries, homicide, and suicide) causes for children of all races/ethnicities, although Black-White mortality ratios remained unchanged during the study period. Expanded Medicaid and SCHIP eligibility was significantly related to the decline in external-cause mortality; the relationship between natural-cause mortality and Medicaid or SCHIP eligibility remains unclear. Eligibility expansions did not affect relative racial disparities in child mortality. Although the study provides some evidence that public insurance expansions reduce child mortality, future research is needed on the effect of new health insurance on child health and on factors causing relative racial disparities.

Coverage, Utilization, and Health Outcomes of the State Children's Health Insurance Program

This paper uses data from the National Survey of America's Families (1997-2002) to explore the links between eligibility for the State Children's Health Insurance Program (SCHIP), health insurance coverage, medical care utilization, and health outcomes. We find that SCHIP significantly increased health insurance coverage rates for American children between 1997 and 2002, with most of the gains in coverage for older children. Higher coverage rates translated into increased utilization of the types of medical care that would be expected to improve children's health, such as well-child doctor visits. The effects of SCHIP eligibility expansions on health outcomes, however, are relatively small.

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.

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.

The State Children's Health Insurance Program and Job Mobility: Identifying Job Lock among Working Parents in Near-Poor Households

To assess whether near-poor parents' job mobility is reduced due to the non-portability of employer-provided health insurance—an effect termed job lock—the authors examine data from the Survey of Income and Program Participation for 1996 and 2001, years bracketing the introduction of the State Children's Health Insurance Program (SCHIP). Among the working fathers whose children met the SCHIP eligibility criteria, those whose wives did not have their own employer-provided insurance were 5–6% more likely to separate from their current employer in the year of the later survey than in the year of the earlier survey, whereas those whose wives were insured exhibited no comparable change in mobility. These results confirm the presence of job lock: for men whose wives were uninsured, but not for those whose wives were insured, the authors argue, the SCHIP program presented a new opportunity to switch jobs without losing health insurance.

How Did SCHIP Affect the Insurance Coverage of Immigrant Children?

Abstract The State Children's Health Insurance Program (SCHIP) significantly expanded public insurance eligibility and coverage for children in ``working poor" families. Despite this success, it is estimated that over 6 million children who are eligible for public insurance remain uninsured. An important first step for designing strategies to increase enrollment of eligible but uninsured children is to determine how the take-up of public coverage varies within the population. Because of their low rates of insurance coverage and unique enrollment barriers, children of immigrants are an especially important group to consider. We compare the effect of SCHIP eligibility on the insurance coverage of children of foreign-born and native-born parents. In contrast to research on the earlier Medicaid expansions, we find similar take-up rates for the two groups. This suggests that state outreach strategies were not only effective at increasing take-up overall, but were successful in reducing disparities in access to coverage.

Why Does President Bush Oppose the Expansion of SCHIP?

Health reform has again emerged as a salient political issue (Gorin, 2007). In a March 2007 New York Times/CBS News poll, 64 percent of respondents supported a government guarantee of for everyone, and 47 percent said they would support a system administered by the government and financed by taxpayers (compared with 38 percent who supported the system) (Toner & Elder, 2007). In a June 2007 poll by the Kaiser Family Foundation (KFF, 2007), ranked second (behind Iraq) among issues the public wanted the presidential candidates to address; the most important issues were coverage and costs. More than half of the respondents, including a third of Republicans, would support A new plan that would make a major effort to provide insurance for all or nearly all of the uninsured BUT would involve a substantial increase in spending. In this light, it is not surprising that candidates from both parties have discussed reform (Toner, 2007). The expiration of the 10-year-old State Children's Health Insurance Program (SCHIP) on September 30, 2007, has given legislators an opportunity to address one segment of the uninsured problem. SCHIP grew out of the last major legislative battle for reform in the early 1990s. After the demise of the Clinton administration's 1993 Health Security Act, Congress passed the Balanced Budget Act of 1997 (P.L. 105-33), which significantly changed Medicaid by allowing coverage to in working families. The federal government provided matching funds to the states to cover in families with incomes up to 200 percent of the federal poverty level (FPL). However, states that had already raised their Medicaid eligibility levels above 150 percent could increase the eligibility level for uninsured an additional 50 percent above current levels and impose premiums, deductibles, or other cost-sharing measures (using a sliding scale up to 5 percent of the family's income). At a minimum, states initially received $2 million per year and were required to provide matching funds to receive their allocation. States also had the option of providing this coverage by either expanding Medicaid or establishing (or expanding) a state children's insurance program, or some combination of the two approaches. The primary targets of SCHIP were whose parents were temporarily unemployed, in transition between jobs, or employed in jobs that did not provide coverage, that is, families ineligible for Medicaid, but unable to afford private insurance. By 2006, 15 states had SCHIP eligibility levels above 200 percent of the FPL (Congressional Budget Office, 2007). Although SCHIP is a relatively small program, it, along with Medicaid, has made a difference (Dubay, Guyer, Mann, & Odeh, 2007; Kenney & Yee, 2007). Studies (Kaiser Commission on Medicaid and the Uninsured, 2007; Kenney & Yee) show that SCHIP has improved children's access to care, narrowed ethnic and racial disparities in access to care, increased preventive care, helped to improve the quality of care, made it more likely for to have a regular source of care, and resulted in improved outcomes and school performance. The most dramatic impacts of both Medicaid and SCHIP are found in early childhood. Access to reduces infant mortality, childhood deaths, and the rate of babies born with low birthweight. In a recent survey of health care leaders, a wide majority agreed that SCHIP has been successful in expanding access and increasing the rate of insurance among low-income children (Shea et al., 2007). Currently, SCHIP covers 6.6 million (Kaiser Commission on Medicaid and the Uninsured, 2006), and if expanded it could include more. Between 2007 and 2012, an additional $13 billion to $15 billion is needed to maintain SCHIP enrollments at their current levels (KFF, 2007). …

Federal Government Eases Medicaid Citizenship Rules

Back to table of contents Previous article Next article Government NewsFull AccessFederal Government Eases Medicaid Citizenship RulesRich DalyRich DalySearch for more papers by this authorPublished Online:7 Sep 2007https://doi.org/10.1176/pn.42.17.0004The final rule listing proof-of-citizenship requirements for Medicaid eligibility was released in July by the Centers for Medicare and Medicaid Services (CMS). The rule has loosened the much-maligned requirements in the interim rule that had been in effect since last July.The changes reflected in the final rule came in response to more than 1,400 public comments—including those from APA. It was published in the July 13 Federal Register and went into effect that same day.The rule stemmed from the Deficit Reduction Act of 2005 (DRA), which required states to verify the identity and prove citizenship of current or potential Medicaid beneficiaries. The restrictions aimed to prevent undocumented immigrants from falsely claiming to be citizens and receiving benefits. Until passage of the DRA, Medicaid applicants in most states needed only to “self-attest” to U.S. citizenship under penalty of perjury (Psychiatric News, September 15, 2006). Documentation was required only from those whose citizenship status was in doubt.The interim rule had exempted beneficiaries who received Medicare and Supplemental Security Income, because they had already met documentation requirements. The final rule expands this exemption to include people eligible for Social Security Disability Insurance.Also exempted are children receiving adoption assistance or foster-care payments. In making that change, CMS responded to concerns from many, including APA, that children in foster care may have a hard time documenting citizenship and thus may not be able to obtain needed health care coverage under Medicaid. Foster children, APA pointed out, may be even more likely to need mental health care than other beneficiaries.Also, as required by the Tax Relief and Health Care Act of 2006, the responsibility to verify the citizenship or immigration status of children in foster care who receive Medicaid benefits rests with the states instead of foster parents.The final rule includes a CMS policy change that extends Medicaid benefits for up to the first year of life to a newborn whose mother was receiving Medicaid on the date of the child's birth, regardless of the mother's immigration status.The final rule also expands the list of documents to prove citizenship status and identity beyond such documents as a U.S. passport, naturalization certificate, or certificate of U.S. citizenship. The newly approved documents include religious records filed in the United States within three months of a child's birth, as well as some school records. The Roll of Alaska Natives also was approved as evidence of citizenship.In recent months, two independent reports have found that Medicaid's citizenship documentation requirements under the interim rule led to citizens' losing Medicaid coverage without the government's achieving the savings sought.The Government Accountability Office (GAO) found that eligible citizens faced barriers to access when applying for Medicaid coverage under the interim rule documentation requirements. Data from 22 of 44 states studied by the GAO showed a decline in eligible citizens' Medicaid enrollment and delays in obtaining coverage.Another report, conducted by the majority staff of the House Committee on Oversight and Government Reform, investigated nine states and found that for every $100 spent to administer the documentation requirements, the federal government saved only 14 cents.“By way of comparison, for every $100 the Office of the Inspector General of the Department of Health and Human Services expends to investigate waste, fraud, and abuse, the federal government recovers nearly $1,300,” committee chair Rep. Henry Waxman (D-Calif.), wrote in the report.Acting CMS Administrator Leslie Norwalk said in a July 3 press release that the final rule ensures that Medicaid dollars are “spent effectively on those who are qualified for coverage.” Norwalk resigned on July 20.Further loosening of the citizenship requirements may come through reauthorization of the State Children's Health Insurance Program (SCHIP), which also is subject to the requirements. Legislation under consideration in the House (HR 3162) and Senate (S 1893) would extend SCHIP eligibility through Medicaid to all newborns within their first year of life, regardless of the mother's immigration status. Further, both SCHIP reauthorization bills would give states the option of returning to pre-DRA citizenship-documentation requirements—including parental testaments to their children's U.S. citizenship under penalty of perjury—for children, with the requirement that the state conduct audits to demonstrate compliance. Opponents said this option ultimately would allow states to set the criteria for citizenship determinations.The Senate SCHIP reauthorization bill would further reduce administrative barriers to enrollment by encouraging states to standardize their enrollment procedures and eliminate the requirement for face-to-face interviews to complete enrollment.CMS's final rule on Medicaid citizenship requirements is posted at<http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/pdf/07-3291.pdf>.▪ ISSUES NewArchived

State Children's Health Insurance Program Reauthorization: Will It Get Us Closer to Universal Coverage for America's Children?

The State Children's Health Insurance Program (SCHIP) was passed by Congress in the Balanced Budget Act of 1997 during the Clinton presidency. The legislation appropriated approximately $40 billion for 10 years, 1998–2007.1 By 2003, 4.4 million children were enrolled in separate SCHIPs, and an additional 1.6 million were enrolled in SCHIP-financed Medicaid expansions.1 As of 2006, 7 states (Vermont, New Jersey, Connecticut, Maryland, New Hampshire, West Virginia, and Massachusetts) had expanded their SCHIP eligibility to families who are earning at least 300% of the federal poverty level (FPL), which will make almost all uninsured children who are US citizens eligible for public programs. The governors of California, Pennsylvania, Oregon, and Wisconsin have also introduced initiatives that include SCHIP expansions to substantially reduce the number of uninsured children in their states. In 2007, SCHIP must be reauthorized by Congress with a new appropriation of funds to continue to function in 2008. Because SCHIP is a block grant or capped-grant program, a number of states that established programs having higher income-eligibility thresholds, better outreach and marketing, and more streamlined enrollment procedures are projected to have a shortfall in federal support in 2007. For fiscal years 1998 through 2001, the annual appropriation was slightly over $4.2 billion. The appropriation dropped to under $3.2 billion from 2002 through 2004 but then increased to $4.1 billion for 2005 and 2006 and $5.0 billion in 2007.2 Because of greater than anticipated enrollment and per capita expenditures, the states’ total spending of federal SCHIP funds has exceeded the annual appropriations since 2002. The shortfalls of federal SCHIP funds after 2002 were covered by redistributing … Address correspondence to Stephen Berman, MD, FAAP, Children's Hospital, 1056 E 19th Ave, B032, Denver, CO 80218. E-mail: berman.stephen{at}tchden.org

Effects of the State Children's Health Insurance Program on Access to Dental Care and Use of Dental Services

To provide national estimates of implementation effects of the State Children's Health Insurance Program (SCHIP) on dental care access and use for low-income children. The 1997-2002 National Health Interview Survey. The study design is based on variation in the timing of SCHIP implementation across states and among children observed before and after implementation. Two analyses were conducted. The first estimated the total effect of SCHIP implementation on unmet need for dental care due to cost in the past year and dental services use for low-income children (family income below state SCHIP eligibility thresholds) using county and time fixed effects models. The second analysis estimated differences in dental care access and use among low-income children with SCHIP or Medicaid coverage and their uninsured counterparts, using instrumental variables methods to control for selection bias. Both analyses controlled for child and family characteristics. When SCHIP had been implemented for more than 1 year, the probability of unmet dental care needs for low-income children was lowered by 4 percentage points. Compared with their uninsured counterparts, those who had SCHIP or Medicaid coverage were less likely to report unmet dental need by 8 percentage points (standard error: 2.3), and more likely to have visited a dentist within 6 or 12 months by 17 (standard error: 3.7) and 23 (standard error: 3.6) percentage points, respectively. SCHIP program type had no differential effects. Consistent results from two analytical approaches provide evidence that SCHIP implementation significantly reduced financial barriers for dental care for low-income children in the U.S. Low-income children enrolled in SCHIP or Medicaid had substantially increased use of dental care than the uninsured.

Dynamics In Medicaid And SCHIP Eligibility Among Children In SCHIP's Early Years: Implications For Reauthorization

Two-thirds of children in the United States were income-eligible for Medicaid or the State Children's Health Insurance Program (SCHIP) at some point from 1996 to 2000. One in five children were income-eligible for both programs, and 73 percent of children ever eligible for SCHIP were eligible at other times for Medicaid. As SCHIP is reauthorized, Congress will need to give states the tools and financial commitment to assure that uninsured children are enrolled in and retain the coverage for which they are eligible.

Eligibility under State Children's Health Insurance Programs.

This study analyzed associations between income eligibility criteria under the State Children's Health Insurance Program (SCHIP) and state characteristics. We used multivariate methods to explore relations between eligibility expansions under SCHIP and percentages of uninsured children from low-income families, per capita income, and political characteristics. Proportions of uninsured children, per capita income, and states' preexisting eligibility thresholds were statistically associated with changes in eligibility thresholds, whereas only per capita income was associated with overall SCHIP eligibility thresholds. Political dynamics were not statistically related to SCHIP expansions. State demographic characteristics were associated with changes in eligibility from preexisting levels but rarely were associated with SCHIP eligibility thresholds.