State Children's Health Insurance Program Research Articles

Fiscal structure and programme response over the business cycle: evidence from Medicaid and SCHIP

ABSTRACT In this paper, I show that fiscal structure can have large effects on the ability of safety net programmes to provide benefits. I examine the response of child enrolment in Medicaid, which is funded through a matching grant, and enrolment in the State Children’s Health Insurance Program (SCHIP), which is funded through a block grant, to business cycle fluctuations. I find that while child Medicaid enrolment is relatively acyclical, a one percentage point increase in the unemployment rate decreases SCHIP enrolment per child by 6.3%, and a 1% decrease in gross state product (GSP) or GSP growth decreases enrolment in SCHIP by approximately 1%, suggesting block grant funding reduces the ability of safety net programmes to respond to macroeconomic fluctuations.

Annual Report on Children's Health Care: Dental and Orthodontic Utilization and Expenditures for Children, 2010–2012

ObjectiveTo examine general dental and orthodontic utilization and expenditures by health insurance status, public health insurance eligibility, and sociodemographic characteristics among children aged 0 to 17 years using data from 2010–2012. MethodsNationally representative data from the Medical Expenditure Panel Survey (2010–2012) provided data on insurance status, public health insurance eligibility, and visits to dental providers for both general dental care and orthodontic care. ResultsOverall, 41.9% of US children reported an annual dental office–based visit for general (nonorthodontic) dental care. Fewer Hispanic (34.7%) and non-Latino black children (34.8%) received dental care compared to non-Hispanic whites (47.3%) and Asians (40.3%). Children living in families with the lowest income were also the least likely to have a visit (32.9%) compared to children in the highest-income families (54.7%). Among children eligible for public coverage, Medicaid-eligible children had the lowest percentage of preventive dental visits (29.2%). Socioeconomic and racial/ethnic disparities in use and expenditures for orthodontic care are much greater than those for general and preventive dental care. Average expenditures for orthodontic care were $1,823, of which 56% ($1,023) was paid out of pocket by families. ConclusionsOur findings provide a baseline assessment for examining trends in the future, especially as coverage patterns for children may change as the Affordable Care Act is implemented and the future of the State Child Health Insurance Program remains uncertain beyond 2017.

Insuring the Uninsured: Reducing the Barriers to Public Insurance

Health insurance is one of the essential enabling resources to gain access to medical care and ultimately increase health status. Over 11 million or one quarter of the nation’s uninsured individuals are eligible for Medicaid or the State Children’s Health Insurance Program (SCHIP), but are not enrolled. Interviews with 368 individuals from 1999 through 2003 identify eight primary barriers to enrollment in public insurance. These include: economic aspects of qualifying, lack of knowledge, benefit design of public programs, poor experiences and stigma, complexity and literacy, immigration status, poor customer service, and fear of fraud. These results suggest policy options alone are unlikely to result in reaching eligible uninsured individuals unless knowledge and instrumental support are offered to them about insurance.

The impact of the State Children's Health Insurance Program's unborn child ruling expansions on foreign-born Latina prenatal care and birth outcomes, 2000-2007.

The 2002 "unborn child ruling" resulted in State Children's Health Insurance Program (SCHIP) expansion for states to cover prenatal care for low-income women without health insurance. Foreign-born Latinas who do not qualify for Medicaid coverage theoretically should have benefited most from the policy ruling given their documented low rates of prenatal care utilization. This study compares prenatal care utilization and subsequent birth outcomes among foreign-born Latinas in six states that used the unborn child ruling to expand coverage to those in ten states that did not implement the expansion. This policy analysis examines cross-sectional pooled US natality data from the pre-enactment years (2000-2003) versus post-enactment years (2004-2007) to estimate the effect of the UCR on prenatal care utilization and birth outcome measures for foreign-born Latinas. Then using a difference-in-difference estimator, we assessed these differences across time for states that did or did not enact the unborn child ruling. Analyses were then replicated on a high-risk subset of the population (single foreign-born Latinas with lower levels of education). The SCHIP unborn child ruling policy expansion increased PNCU over time in the six enacting states. Foreign-born Latinas in expansion enacting states experienced increases in prenatal care utilization though only the high-risk subset were statistically significant. Birth outcomes did not change. The SCHIP unborn child ruling policy was associated with enhanced PNC for a subset of high-risk foreign-born Latinas.

How bipartisanship and incrementalism stitched the child health insurance safety net (1982-1997).

Today, 96.5 percent of children and adolescents either have health insurance or are uninsured but eligible for a public plan. This proportion far exceeds the most optimistic coverage projections for adults under the Patient Protection and Affordable Care Act. The child health insurance safety net was crafted from 1982 to 1997 through several incremental, bipartisan federal and state legislative actions. It began by offering and later mandating state Medicaid eligibility expansions and culminated with the enactment of the State Child Health Insurance Program. Two-thirds of the states leveraged these laws to expand coverage beyond federal requirements. As a senior executive with the American Academy of Pediatrics, the author was directly involved or closely monitored these federal and state child health insurance expansions. This case study is a participant-observer analysis of that period, an era that stands in stark contrast to today's highly partisan times. The successive expansions of publicly funded children's health insurance during this conservative period, when many other human services programs were slashed, are attributed to public sympathy for children, political acceptability by the right and the left, manageable costs, and the relative ease of state implementation as these changes came in incremental pieces over several years.

School-Located Influenza Vaccination With Third-Party Billing: Outcomes, Cost, and Reimbursement

ObjectiveTo assess rates of immunization; costs of conducting clinics; and reimbursements for a school-located influenza vaccination (SLIV) program that billed third-party payers. MethodsSLIV clinics were conducted in 19 elementary schools in the Denver Public School district (September 2010 to February 2011). School personnel obtained parental consent, and a community vaccinator conducted clinics and performed billing. Vaccines For Children vaccine was available for eligible students. Parents were not billed for any fees. Data were collected regarding implementation costs and vaccine cost was calculated using published private sector prices. Reimbursement amounts were compared to costs. ResultsOverall, 30% of students (2784 of 9295) received ≥1 influenza vaccine; 39% (1079 of 2784) needed 2 doses and 80% received both. Excluding vaccine costs, implementation costs were $24.69 per vaccination. The percentage of vaccine costs reimbursed was 62% overall (82% from State Child Health Insurance Program (SCHIP), 50% from private insurance). The percentage of implementation costs reimbursed was 19% overall (23% from private, 27% from Medicaid, 29% from SCHIP and 0% among uninsured). Overall, 25% of total costs (implementation plus vaccine) were reimbursed. ConclusionsA SLIV program resulted in vaccination of nearly one third of elementary students. Reimbursement rates were limited by 1) school restrictions on charging parents fees, 2) low payments for vaccine administration from public payers and 3) high rates of denials from private insurers. Some of these problems might be reduced by provisions in the Affordable Care Act.

Children’s Health Insurance Program (CHIP): Accomplishments, Challenges, and Policy Recommendations

Sixteen years ago, the 105th Congress, responding to the needs of 10 million children in the United States who lacked health insurance, created the State Children's Health Insurance Program (SCHIP) as part of the Balanced Budget Act of 1997. Enacted as Title XXI of the Social Security Act, the Children's Health Insurance Program (CHIP; or SCHIP as it has been known at some points) provided states with federal assistance to create programs specifically designed for children from families with incomes that exceeded Medicaid thresholds but that were insufficient to enable them to afford private health insurance. Congress provided $40 billion in block grants over 10 years for states to expand their existing Medicaid programs to cover the intended populations, to erect new stand-alone SCHIP programs for these children, or to effect some combination of both options. Congress reauthorized CHIP once in 2009 under the Children's Health Insurance Program Reauthorization Act and extended its life further within provisions of the Patient Protection and Affordable Care Act of 2010. The purpose of this statement is to review the features of CHIP as it has evolved over the 16 years of its existence; to summarize what is known about the effects that the program has had on coverage, access, health status, and disparities among participants; to identify challenges that remain with respect to insuring this group of vulnerable children, including the impact that provisions of the new Affordable Care Act will have on the issue of health insurance coverage for near-poor children after 2015; and to offer recommendations on how to expand and strengthen the national commitment to provide health insurance to all children regardless of means.

Children’s public health insurance and scholastic success

There are currently two public health insurance options available to United States children, Medicaid and the State Children’s Health Insurance Program (SCHIP). The programmes are similar in that they both target improvements in children’s health through increased access to medical care. A well-developed body of literature has examined the effect these programmes have on a child’s health and to a large extent has found that the programmes perform as desired. This article uses data from the Early Childhood Longitudinal Study–Kindergarten Cohort to determine whether access to public health insurance translates to an improvement in a child’s academic performance.

Digital Detection for Tobacco Control: Online Reactions to the 2009 U.S. Cigarette Excise Tax Increase

The Internet is revolutionizing tobacco control, but few have harnessed the Web for surveillance. We demonstrate for the first time an approach for analyzing aggregate Internet search queries that captures precise changes in population considerations about tobacco.We compared tobacco-related Google queries originating in the United States during the week of the State Children's Health Insurance Program (SCHIP) 2009 cigarette excise tax increase with a historic baseline. Specific queries were then ranked according to their relative increases while also considering approximations of changes in absolute search volume.Individual queries with the largest relative increases the week of the SCHIP tax were "cigarettes Indian reservations" 640% (95% CI, 472-918), "free cigarettes online" 557% (95% CI, 432-756), and "Indian reservations cigarettes" 542% (95% CI, 414-733), amounting to about 7,500 excess searches. By themes, the largest relative increases were tribal cigarettes 246% (95% CI, 228-265), "free" cigarettes 215% (95% CI, 191-242), and cigarette stores 176% (95% CI, 160-193), accounting for 21,000, 27,000, and 90,000 excess queries. All avoidance queries, including those aforementioned themes, relatively increased 150% (95% CI, 144-155) or 550,000 from their baseline. All cessation queries increased 46% (95% CI, 44-48), or 175,000, around SCHIP; including themes for "cold turkey" 19% (95% CI, 11-27) or 2,600, cessation products 47% (95% CI, 44-50) or 78,000, and dubious cessation approaches (e.g., hypnosis) 40% (95% CI, 33-47) or 2,300.The SCHIP tax motivated specific changes in population considerations. Our strategy can support evaluations that temporally link tobacco control measures with instantaneous population reactions, as well as serve as a springboard for traditional studies, for example, including survey questionnaire design.

Reforming Medicaid for Medically Complex Children

Children's hospitals play a central role in our child health care system. These hospitals face unique challenges under health care reform. They care for children with the most complex medical problems but often are not reimbursed for good preventive care, care coordination, or quality. We discuss a proposal by children's hospital leaders to create a network of Nationally Designated Children's Hospitals. These would be Centers of Excellence on which states and families could rely to care for a uniquely vulnerable and uniquely costly population of children. On a federal level, the proposal is focused on 3 provisions: (1) creating and delivering a national coordinated delivery model for children with chronic and complex conditions in Medicaid and the State Child Health Insurance Program; (2) developing pediatric-specific care coordination guidelines, quality metrics, and network adequacy standards to improve pediatric care delivery; and (3) producing cost savings by reducing fragmentation in care delivery, while providing a payment model that provides a significant measure of budget certainty for states and the federal government, either through a bundled payment or a shared savings payment method. We believe that this approach will ensure access to appropriate care without compromising the quality of care. It will also provide enhanced budget certainty for Medicaid and the State Child Health Insurance Program.

How Do Public Health Expansions Vary by Income Strata? Evidence from Illinois' All Kids Program

This paper examines how income levels affected the substitution of public health insurance for private health coverage under expansions of Illinois' State Children's Health Insurance Program (SCHIP). Building on a technique developed by Abadie and Gardeazabal (2003), I estimate that among children whose family incomes are between 200% and 300% of the federal poverty level (FPL), 35% of those covered by SCHIP would have retained private coverage in the absence of SCHIP. Significant substitution also appears between 300% and 400% FPL, but surprisingly I find evidence that the introduction of SCHIP caused an increase in private health insurance coverage for those with family incomes between 400% and 500% FPL.

The effect of the children's health insurance program on pediatricians' work hours.

Our study examines changes in physicians' work hours in response to a coverage expansion. We use as a natural experiment the Children's Health Insurance Program (CHIP), which was established in 1997 and significantly expanded children's eligibility for public health insurance coverage. The magnitude of the CHIP expansion varied across states and over time, allowing its effects to be identified using a state-year fixed effects model. We focus on pediatricians, and we measure their self-reported work hours using multiple waves (pre- and post-CHIP) of the physician survey component of the Community Tracking Study. To address endogeneity concerns, we instrument for CHIP enrollment using key program features (income eligibility cutoffs and waiting times). We find a large negative relationship between the magnitude of a state's CHIP expansion and trends in pediatricians' work hours. This relationship could be due to key supply-side features of CHIP, including relatively low provider reimbursements and heavy use of managed care tools.

The Doctor Might See You Now: The Supply Side Effects of Public Health Insurance Expansions

In the United States, public health insurance programs cover over 90 million individuals. Expansions of these programs, such as the recently passed Patient Protection and Affordable Care Act (PPACA), may have large effects on physician behavior. This study finds that following the implementation of the State Children's Health Insurance Program (SCHIP), physicians decreased the number of hours spent with patients, but increased their program participation. Suggestive evidence shows that this decrease resulted from shorter office visits. These findings are consistent with the predictions from a mixed-economy model of physician behavior and provide evidence of crowd out resulting from the creation of SCHIP. (JEL H75, I11, I13, I18)

Is Health Care a Right? Health Reforms in the USA and their Impact Upon the Concept of Care.

In 2008 United States President Barack Obama declared that health care “should be a right for every American”.1 This statement, although noble, does not reflect US healthcare statistics in recent times, with the number of uninsured reaching over 50 million in 2010.2 Such disparity has sparked a political drive towards change, and the introduction of the Patient Protection and Affordable Care Act (PPACA).3 These changes have been highly polemical, raising the fundamental question of whether health care is a right; a contract between the nation and its inhabitants granted at birth, or an entitlement; a privilege that must be earned as opposed to universally provided.Access to healthcare in the US is mediated by insurance coverage, either in the form of private or employer based cover, which may be government based for public sector employees or private for private sector employees. The majority of spending on healthcare however, comes from government expenditure on health programs such as Medicare, Medicaid, Tricare, and the State Children's Health Insurance Program (SCHIP).4 Medicare is a federal government funded social insurance program that provides health insurance to people aged 65 and older, younger people with disabilities, and those with end stage renal failure requiring dialysis. Medicaid is a means tested insurance coverage program for individuals with low incomes and their families, and is jointly funded by state and federal governments. Tricare is a healthcare program that provides healthcare insurance for military personnel, retirees, and their dependents. The SCHIP provides states with federal government funding to provide health insurance to children from families with modest incomes that do not qualify for Medicaid. As such, although the majority of the US population is insured by federal, state, employer, or private health insurance, the remainders go uninsured.

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis

Who Is Paying the Price? Loss of Health Insurance Coverage Early in Psychosis

Medicaid, Managed Care, and Kids

This policy brief talks about what managed care for Medicaid is, how it influences kids, and how it relates to the State Child Health Insurance Program (CHIP). It focuses on what we have learned over the last 20 years through research about cost, use, and quality. It also discusses some of the expectations we had for children covered by Medicaid managed care. Finally, it talks about the future of Medicaid managed care and the implications for CHIP.

The Effect of a Major Coverage Expansion on Physician Work Hours: Evidence from the Children’s Health Insurance Program

The passage of health reform has raised a number of questions, including the following: how will physicians respond to a major coverage expansion? In particular, will they work longer hours to accommodate an influx of demand? Our study addresses this question with a natural experiment - we use the introduction of the Children’s Health Insurance Program (CHIP) in 1997, which significantly expanded children’s eligibility for public health insurance coverage. The magnitude of the CHIP expansion varied across states and over time, allowing its effects to be identified using a state-year fixed effects model. We focus on pediatricians, and we measure their self-reported work hours using multiple waves of the physician survey component of the Community Tracking Study. We test whether pediatricians in states with larger CHIP expansions increased their annual work hours relative to pediatricians in states with smaller CHIP expansions. We find a large negative relationship between the magnitude of a state's CHIP expansion and trends in pediatricians' work hours. One possible explanation for this finding is that reimbursement rates in the CHIP program are well below that of private insurers. If CHIP expansions reduced average reimbursement rates, and if pediatricians exhibit a normal supply curve, then lower average reimbursement rates could account for the observed association with work hours.

Using search query surveillance to monitor tax avoidance and smoking cessation following the United States' 2009 "SCHIP" cigarette tax increase.

Smokers can use the web to continue or quit their habit. Online vendors sell reduced or tax-free cigarettes lowering smoking costs, while health advocates use the web to promote cessation. We examined how smokers' tax avoidance and smoking cessation Internet search queries were motivated by the United States' (US) 2009 State Children's Health Insurance Program (SCHIP) federal cigarette excise tax increase and two other state specific tax increases. Google keyword searches among residents in a taxed geography (US or US state) were compared to an untaxed geography (Canada) for two years around each tax increase. Search data were normalized to a relative search volume (RSV) scale, where the highest search proportion was labeled 100 with lesser proportions scaled by how they relatively compared to the highest proportion. Changes in RSV were estimated by comparing means during and after the tax increase to means before the tax increase, across taxed and untaxed geographies. The SCHIP tax was associated with an 11.8% (95% confidence interval [95%CI], 5.7 to 17.9; p<.001) immediate increase in cessation searches; however, searches quickly abated and approximated differences from pre-tax levels in Canada during the months after the tax. Tax avoidance searches increased 27.9% (95%CI, 15.9 to 39.9; p<.001) and 5.3% (95%CI, 3.6 to 7.1; p<.001) during and in the months after the tax compared to Canada, respectively, suggesting avoidance is the more pronounced and durable response. Trends were similar for state-specific tax increases but suggest strong interactive processes across taxes. When the SCHIP tax followed Florida's tax, versus not, it promoted more cessation and avoidance searches. Efforts to combat tax avoidance and increase cessation may be enhanced by using interventions targeted and tailored to smokers' searches. Search query surveillance is a valuable real-time, free and public method, that may be generalized to other behavioral, biological, informational or psychological outcomes manifested online.

Devolution's Policy Impact on Non-emergency Medical Transportation in State Children's Health Insurance Programs

Proponents of devolution often maintain that the transfer of power and authority of programs enables local officials to craft policy solutions that better align with the needs of their constituents. This article provides one of the first empirical evaluations of this assumption as it relates to non-emergency medical transportation (NEMT) in the State Children's Health Insurance Program (SCHIP). NEMT programs meet a critical need in the areas in which they serve, directly targeting this single key access barrier to care. Yet states have great latitude in making such services available. The authors utilize data from 32 states to provide a preliminary assessment of devolution's consequences and policy impact on transportation-related access to care. Their findings provide mixed evidence on devolution's impact on policy outcomes. Proponents of devolution can find solace in the fact that several states have gone beyond federally mandated minimum requirements to offer innovative programs to remove transportation barriers to care. Detractors of devolution will find continued pause on several key issues, as a number of states do not offer NEMT to their SCHIP populations while cutting services and leaving over $7 billion in federal matching funding unspent.

Policy Adoption of the Special Design (SD) Provision in the State Children's Health Insurance Program

AbstractIntroduction: Political partisanship and institutional arrangement can influence a state's decision to include special provisions (e.g., a premium assistance program, an enrollee buy‐in program, coverage expansion and health services initiatives) in the State Children's Health Insurance Program (SCHIP). Methods: Four published sources of data on SCHIP for 2005 were subjected to a logistic regression analysis to investigate the political and practical relationships. Results: The logistic regression analysis reveals that a Democratic governor and dominance in both the upper and lower legislative bodies combined with the existence of a SCHIP increase the likelihood that special design features will be adopted. Conclusion: Democratic political dominance in United States favors expanded SCHIP. States with more limited income eligibility are less likely to adopt special design provisions. The dominance of liberal ideology in politics, an increased organizational flexibility and the existing scope of beneficiaries provide the conditions for addressing a new children's health policy in international countries.