State Children's Health Insurance Program Research Articles

Crowd‐Out in the State Children's Health Insurance Program (SCHIP): Incidence, Enrollee Characteristics and Experiences, and Potential Impact on New York's SCHIP

The extent to which the State Children's Health Insurance Program (SCHIP) crowds our private insurance is poorly understood. To assess the incidence of crowd-out and enrollee characteristics associated with crowd-out. Parent telephone survey for 2,644 children after enrollment in NY SCHIP. MEASURES AND ANALYSES: Crowd-out is measured based on enrollee reports of coverage (and loss of coverage) before SCHIP. Multivariate logistic regression is used to relate crowd-out to enrollee characteristics. Only 7.1 percent of SCHIP enrollees dropped private coverage < or =6 months before SCHIP, suggesting relatively modest crowd-out. Crowd-out was associated with some enrollee traits including income, but not with health status. Most movement from private to public insurance in NY was not crowd-out. Under current program structure in NY, crowd-out concerns should not dampen enthusiasm for SCHIP.

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). …

The First Quarter-Century: Looking Back, Looking Ahead

From the Editor-In-Chief Health AffairsVol. 26, No. 6: 25 Years In The Health Sphere The First Quarter-Century: Looking Back, Looking AheadJames C. RobinsonPUBLISHED:November/December 2007Free Accesshttps://doi.org/10.1377/hlthaff.26.6.1523AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSHealth servicesQuality of careMedicare T his issue marks the twenty-fifth anniversary of the founding of Health Affairs and challenges us to reflect on where we have been and where we are going. It is also a moment to celebrate the contributions of John Iglehart, who as founding editor has led the journal’s evolution from a slim volume to a broad portfolio of interrelated activities, including the peer-reviewed print and Web-based journal and the interactive blog. For me, this issue creates the moment to start walking the walk as incoming editor-in-chief, with a fiduciary responsibility to maintain the journal’s scholarly integrity and brand reputation while extending into global health and biomedical innovation. To stimulate our collective reflections, we have solicited Perspectives from a selective list of policy analysts and activists, allowing them full freedom to choose their topics and comment on historical trends, contemporary politics, intellectual debates, the role of the journal, and the larger health services research enterprise. Many of these authors are veterans of battles past, of efforts to create universal health insurance or to promote coordinated care or to mainstream mental health. The tone of some contributions is circumspect with respect to what can be expected. One senses a fatigue from so many high hopes unfulfilled, projects not adopted, initiatives never given a fair chance to succeed. Instead of emphasizing what we have not achieved over the past quarter-century, however, I believe that it is important to note some of the deep and positive trends that have developed and from which there is no going back.We have forever left the domain of “third-party reimbursement” in favor of using public and private insurers as active purchasers of services on behalf of their enrollees. No longer do physicians enjoy unquestioned authority to define what is medically necessary and how it must be delivered, by whom, in which context, and for what price. We can dispute the virtue of contemporary initiatives in “pay-for-performance,” but no one suggests a return to “pay-for-nonperformance.” We have moved from the framework of professional dominance to one of measurement and accountability, with quality defined as processes done in accord with the best available evidence and with good risk-adjusted outcomes. We have moved from professional dominance toward a new ideal of shared decision making, after a short detour through consumer-driven health care. Americans can be counted on to do the right thing, after all, once they have tried every alternative. Conservative political objections notwithstanding, the populace continues to shift into governmental insurance programs, as private employers restrict coverage, Medicaid and State Children’s Health Insurance Program (SCHIP) programs expand, and the baby boomers age into Medicare. Liberal political objections notwithstanding, those public programs rely ever more extensively on private plans to contract with providers, structure benefits for individuals, manage care for chronic illnesses, and identify patterns of over- and underuse.We have made major advances against heart disease and other major scourges of modern epidemiology, greatly reduced tobacco use, and developed a breathtaking array of biopharmaceuticals and medical devices.Last but not least, we continue to develop the infrastructure of health services research, policy analysis, and management training. The universe of peer-reviewed journals, philanthropic foundations, university programs, and conferences has expanded these past decades beyond the imagination of anyone in 1982.We will continue to debate strategies for market and social change, torn between the desire for deep change and caution born of past defeats. Many of our authors suggest incremental changes to elide the three obstacles to change: vested interests, rival visions of the good, and the advantages of incumbency. The twin papers by Jack Wennberg and his colleagues take the contrary position, advocating that we use pay-for-performance principles as the thin edge of a wedge to shift Medicare toward supporting informed patient choice for high-cost surgical procedures and the channeling of services to providers that practice in an evidence-based and efficient manner.Lest we despair at what we have not achieved, let us measure our shortcomings against our ambitions. We want to expand insurance coverage, reduce administrative expenses, foster clinical innovation, improve quality and efficiency, reduce errors, encourage prevention, induce cost-conscious and informed consumer demand, limit fraud and excess profits, coordinate the continuum of clinical services, and, speaking for my fellow Californians, feel good, look good, and live forever. Not a bad list. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 November 2007 InformationCopyright 2007 by Project HOPE - The People-to-People Health Foundation, Inc.PDF download

Discontinuity of Coverage for Medicaid and S‐CHIP Children at a Transitional Birthday

To investigate disenrollment from public insurance at the 6-year transitional birthday when eligibility for many children moves from Medicaid to State Children's Health Insurance Program (S-CHIP). Data from Georgia's S-CHIP (PeachCare) and Medicaid programs from 2000 to 2002. The likelihood of dropping public coverage after the reference birthday is modeled for children turning age 6 compared with a control cohort of children turning age 9 controlling for demographic and geographic differences between enrollees. Over 17 percent of 6-year-olds versus only 7 percent of the control cohort dropped coverage. After controlling for other factors (e.g., race/ethnicity, prior enrollment, and geographic region) having lower historical expenditures is predictive of dropping coverage among all children, although the unadjusted effect is stronger among children enrolled in PeachCare before their sixth birthday. Only 1 percent of Medicaid children who remained covered transitioned to PeachCare. Turnover at transitional birthdays identifies a common pathway for children into the ranks of the uninsured. Facilitating continuous enrollment would retain in the programs children with lower than average expenditures. This may be one of the more cost effective ways of reducing the number of uninsured children in Georgia.

SCHIP Expansion Bedeviled by Cost Concerns

Back to table of contents Previous article Next article Government NewsFull AccessSCHIP Expansion Bedeviled by Cost ConcernsRich DalyRich DalySearch for more papers by this authorPublished Online:21 Sep 2007https://doi.org/10.1176/pn.42.18.0004Opponents and advocates of a massive expansion of the State Children's Health Insurance Program (SCHIP) agree that some privately insured children will switch to a publicly backed health program if they are made eligible, but the two sides differ on whether that “crowd out” is reason enough to not expand coverage.The argument has been a key issue in the ongoing legislative battle to reauthorize and expand SCHIP. Each chamber of Congress has passed a bill to expand the federal and state insurance program, but President Bush has argued the expansion is too large and would crowd out too many children already privately insured (Psychiatric News, September 7).The House and Senate are negotiating compromises on the two bills (HR 3162 and S 1893) passed before the August recess, which would insure an additional 5 million or 4 million uninsured, respectively, beyond the 6 million children already covered under SCHIP.These proposed SCHIP enrollees do not include new enrollees crowded out of private insurance. The Congressional Budget Office (CBO) estimates that the program expansions in the House bill would cover 2.4 million minors with private insurance and other health coverage, and the Senate bill would add 2.1 million such children.President Bush had proposed a smaller expansion of the program and has promised to veto the House and Senate versions.The impact of crowding out such children, who are overwhelmingly healthy, is that their participation and their families' participation in private employers' health plans help hold down their overall costs because children's expenses are well below their premium payments, according to Janet Trautwein, vice president of government affairs for the National Association of Health Underwriters, who joined other officials in an Alliance for Health Reform discussion of the issue in August.She and other critics of the larger expansions said the government could more efficiently achieve broader insurance coverage through a subsidy of private insurer plans, beyond existing tax breaks.“Our research found it would be less expensive for the government to subsidize those plans,” she said.However, CBO research indicates that the Senate and House approaches are among the most efficient plans offered to cover a larger number of uninsured children with the smallest amount of crowd out, said CBO Director Peter Orszag.Supporters of the SCHIP expansion bills said they each include measures to encourage states to focus the programs on children without insurance coverage.“Crowd out is an inevitable byproduct of any effort to increase government coverage,” said Lisa Dubay, Ph.D., an associate professor of health policy management at Johns Hopkins Bloomberg School of Public Health.However, Dubay said, no evidence has emerged to indicate that crowd out has led any employers to reduce coverage.The issue of crowd out was again raised during Congress's August recess when the Centers for Medicare and Medicaid Services (CMS) ordered new restrictions on the income thresholds of SCHIP-funded programs, which would limit states to covering children whose family incomes are up to 250 percent of the federal poverty level, or $42,925 a year for a family of three (see chart).The order directs any state that seeks to expand eligibility for SCHIP-funded children's health plans to those earning more than that 250 percent of the federal poverty level to adopt “crowd-out strategies,” designed to prevent those who might otherwise pay for coverage from private insurers from enrolling in government plans. They include a mandatory one-year waiting period during which individuals must be uninsured before they receive coverage.Ann Clemency Kohler, New Jersey's deputy commissioner of human services, said such crowd-out mandates would have a major impact in New Jersey and other high-cost states, where children from families with incomes up to 350 percent of the federal poverty level are eligible for SCHIP.“We have an incredibly high cost of living,” she said.“ Families with those incomes are actually doing poorly, and the state wants to help them.”She and other expansion advocates said the data indicate that many of the children had insurance earlier in the year they enrolled in SCHIP but lost that insurance through their parents' job loss or discontinuation of insurance coverage by a parent's employer.Another mandate from the August CMS order requires states to certify that at least 95 percent of children already eligible for health care coverage under SCHIP are receiving that coverage before expanding above 250 percent of the federal poverty level. Kohler said that level of SCHIP enrollment has never been achieved by any state.The administrative attempts to reduce crowd out may never go into effect, according to some critics, because congressional leaders are likely to override them legislatively before they go into effect.Further information on insurance crowd out is posted at<www.allhealth.org/event_reg.asp?bi=112>.▪ ISSUES NewArchived

AMA Campaigns for Tax Credits to Bring Coverage to the Uninsured

Back to table of contents Previous article Next article Professional NewsFull AccessAMA Campaigns for Tax Credits to Bring Coverage to the UninsuredRich DalyRich DalySearch for more papers by this authorPublished Online:21 Sep 2007https://doi.org/10.1176/pn.42.18.0001aThe AMA launched a multimillion-dollar media campaign in August to promote its proposals to provide health insurance to the record number of uninsured Americans.The AMA campaign, called “Voices for the Uninsured,” is spending $5 million initially to coincide with the 2008 U.S. presidential election. It involves newspaper, television, and radio ads that will run in early-primary states including Iowa, New Hampshire, and South Carolina. The campaign will go national next year and will include lobbying Congress to pass comprehensive insurance legislation.The campaign was announced the week before the latest census figures showed the number of uninsured Americans rose 2.2 million in 2006 to 47 million. The Current Population Survey found that 15.8 percent of Americans lacked coverage last year, up from 15.3 percent in 2005. The increase equaled 1998 as the year with the highest percentage of uninsured people over the last two decades.The impact on children was trouble-some as well, according to data from t U.S. Census Bureau, which found t 11.7 percent of U.S. citizens under age 18 had no health insurance in 2006, up from 10.9 percent in the previous year. The percentage of uninsured children has increased two years in a row after declining for at least five years, according to the census data.“It is unconscionable that the number of uninsured children has substantially increased over the past year,” said AMA Board member Joseph Heyman, M.D., in a written statement. “Children are our future, and for kids to get a good start in life, they need access to regular visits to the doctor.”The AMA's insurance campaign supports tax credits for the purchase of health insurance and for increasing federal funds to expand government health programs such as the State Children's Health Insurance Program (SCHIP) and Medicaid. Both houses of Congress have passed SCHIP expansions but President Bush has threatened to veto both versions because of their cost (Psychiatric News, September 7).The AMA insurance proposal was created with several other groups as part of an alliance called the Health Coverage Coalition for the Uninsured, which includes AARP and the U.S. Chamber of Commerce.However, AMA leaders said the 250,000-member organization could support other approaches.“If [elected officials] don't like our plan, then let's meet and come up with a common plan,” said Nancy Nielsen, M.D., AMA president-elect, during an August press conference.Nielsen said part of the campaign aims to educate the public and political candidates that people without insurance are not just among the ranks of those who are homeless or unemployed. As many as 82 percent of people without health insurance are in working families.The AMA doesn't endorse candidates for president but is urging presidential hopefuls to incorporate its proposals into their health care platforms.“We want candidates to make a commitment to reducing the number of uninsured,” Nielsen said.Although APA has not endorsed the AMA plan specifically, APA President Carolyn Robinowitz, M.D., said that the Association does support any effort that will increase Americans' access to health care, including treatment for mental illness. Many uninsured Americans end up using emergency rooms as their main source of medical care, Robinowitz told Psychiatric News, which means they are unlikely to receive preventive care and early interventions that avoid further suffering and save money that will have to be spent on acute care.“Even the business community has realized the long-term benefits from wide access to quality health care,” Robinowitz said, citing business groups' recent support for Senate mental health parity legislation that their earlier opposition had stalled.More information on the AMA's “Voice for the Uninsured” campaign is posted at<www.ama-assn.org/ama/pub/category/17712.html>.▪ ISSUES NewArchived

Early Signs From Massachusetts Give Hope to MH Advocates

Early Signs From Massachusetts Give Hope to MH Advocates

The effect of premium changes on SCHIP enrollment duration.

To examine the impact of premium changes in Florida's State Children's Health Insurance Program (SCHIP) on enrollment duration. Administrative records, containing enrollment and demographic data, were used to identify 173,330 enrollment spells for 153,768 children in Florida's SCHIP from July 2002 through June 2004. Health care claims data were used to classify the children's health status. Accelerated failure time models were used to examine the immediate and longer term effects on enrollment length of a temporary premium increase of $15 to $20 per family per month (PFPM) for children in families with income between 101-150 percent of the federal poverty level (FPL) and a permanent premium increase of $15 to $20 PFPM for children in families with 151-200 percent FPL. Health status and sociodemographic variables were included as covariates. Transfers to other public health insurance programs were taken into account. Enrollment lengths decreased significantly immediately following the premium increases, with a greater percentage decrease among lower income children (61 percent) than higher income children (55 percent). Enrollment lengths partially recovered in the longer term for both the temporary and permanent changes. Those with significant acute or chronic health conditions had longer enrollment lengths and were less sensitive to premium changes than healthy children. An increase in the PFPM premium amount had differential effects across income categories and health status levels. Enrollment lengths remained shortened after the premium increase was rescinded for lower income families, suggesting that it may be difficult to reverse the impacts of even a short-term premium increase.

Many With Mental Illness Could Benefit From Changes to SCHIP

Back to table of contents Previous article Next article Government NewsFull AccessMany With Mental Illness Could Benefit From Changes to SCHIPRich DalyRich DalySearch for more papers by this authorPublished Online:7 Sep 2007https://doi.org/10.1176/pn.42.17.0004aThe House and Senate have passed large expansions in the leading federal health care program for children, known as the State Children's Health Insurance Program (SCHIP).The measures vary in several ways, including differing provisions related to mental health care. At press time Congressional leaders planned to begin conference committee discussions to reconcile the differences this month.Without reauthorization, SCHIP will expire on September 30. Nonetheless, the legislation faces another serious obstacle: President Bush has threatened to veto it because of the high cost and large expansion of a government-run program.Among the provisions that have drawn cost-related criticism from opponents of the legislation is a House-passed component mandating an end to Medicare's discriminatory payment requirements for outpatient mental health services.The House narrowly approved SCHIP reauthorization legislation (HR 3162) over Republican opposition that was based largely on the cost of the $47-billion expansion over five years, which would be financed largely by a tobacco-tax increase and cuts for managed care companies in Medicare.The Senate, where the legislation (S 1893) has strong bipartisan support, approved a less-aggressive $35 billion expansion. Bush had proposed a $5 billion expansion of SCHIP over five years.The bills would insure 5 million more children, in addition to the 6 million children already covered. Under the expansion, children in the program would gain coverage for dental and mental health care.The House bill also includes $19 billion over five years to prevent scheduled cuts to physician reimbursements under Medicare. The Senate bill does not address this issue, thus it will be up to a joint conference committee to resolve the difference.Opponents of the House bill—mainly Republicans—criticized it as the first step toward nationalized health care and said it would reduce access to Medicare and imperil seniors. The Medicare criticism was based on a provision that would reduce insurance reimbursements under Medicare Advantage plans to the level provided under standard Medicare.Among several mental health gains in the bill was inclusion of APA's long-sought equalization of reimbursements for outpatient mental health services with those for other medical illnesses. The 50 percent coinsurance that Medicare beneficiaries have had to pay for outpatient mental health services would drop to the 20 percent coinsurance charged for all other Part B services beginning in 2008.“By any measure, the repeal of the 50 percent coinsurance would be a huge win for patients and for APA members, a testament to the emphasis on 'pro-patient' priorities of the Board of Trustees and vindication for 20 years for relentless lobbying by staff in that time period,” said Nicholas Meyers, director of APA's Department of Government Relations.The Medicare copayment change would affect a significant number of nonelderly Medicare beneficiaries who have a disability and qualify through the Social Security Disability Insurance (SSDI) program. As many as 40 percent of SSDI beneficiaries have a mental disorder and must pay the higher cost for outpatient mental health services, according to a 1999 report by the Consortium for Citizens With Disabilities Housing Task Force.The House-passed version, known as the Children's Health and Medicare Protection (CHAMP) Act, includes legislation APA helped develop to cover benzodiazepines under Medicare Part D and to establish new protections for access to critical psychiatric medications. The measure would lift the benzodiazepine exclusion in 2013, due to cost concerns; however, APA is lobbying to move that date closer.The CHAMP Act also includes a temporary 5 percent increase in Medicare payments for psychotherapy services. The increase aims to offset previous payment reductions that disproportionately affected psychotherapy due to the way federal officials assign value to different medical services.The Senate bill does not include any major Medicare provisions—such as parity—but it does provide mental health parity benefits for children enrolled in SCHIP plans. The parity provisions would prohibit discriminatory limits on mental health care in SCHIP plans by mandating that the same financial requirements and treatment limitations that apply to mental health or substance abuse services apply to other medical services.House and Senate supporters of the measures face a challenge to produce legislation that can be approved in both chambers and withstand a presidential veto.Negotiators must decide whether to keep the Medicare provisions and SCHIP expansion linked. APA and the AMA have lobbied for the physician-payment change, and a majority of Congress seems to agree that the cut must be averted. However, the expensive plan to reverse the physician payment cuts—estimated at $101 billion over 10 years, according to Congressional Budget Office—will require either steep cuts in other areas or additional taxes.The text of the SCHIP reauthorization bills can be accessed at<http://thomas.loc.gov> by searching on the bill numbers, HR 3162 and S 1893. ▪ ISSUES NewArchived

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

The Battle over SCHIP

Interview with Sara Rosenbaum on the battle over the State Children’s Health Insurance Program (SCHIP). (07:06)Download Reauthorization of the State Children's Health Insurance Program (SCHIP), which was considered a routine matter until recently because of the program's success in expanding coverage to children of the working poor, has become embroiled in a larger struggle over ideologies that divide the political parties. The immediate battle to reauthorize SCHIP, for which the legal mandate expires on September 30, will resume this fall as Democrats, who command the House and Senate by slender margins, seek to stand up to President Bush, who has said he would veto the SCHIP bills approved by the two chambers because they authorize too . . .

No Child Left Uncovered

Interview with Sara Rosenbaum on the battle over the State Children’s Health Insurance Program (SCHIP). (07:06)Download In the grand tradition of bare-knuckle American politics, the reauthorization of the State Children's Health Insurance Program (SCHIP), which provides health coverage for low-income children, has become part of a war of political philosophies between a bipartisan group of legislators in the House and Senate on the one hand and President Bush and his administration on the other. In a Perspective article in this issue of the Journal,1 Iglehart provides a summary of the current state of this political confrontation, and his article is amplified by an audio interview with Sara Rosenbaum, a professor at the George Washington University School . . .

Pay Relief Tied to Unrelated Funding Issue

Pay Relief Tied to Unrelated Funding Issue

A Health Plan to Reduce Poverty

Noting that the failures of the U.S. health care system are compounding the problems faced by low-income Americans, Alan Weil argues that any strategy to reduce poverty must provide access to health care for all low-income families. Although nearly all children in families with incomes under 200 percent of poverty are eligible for either Medicaid or the State Children's Health Insurance Program (SCHIP), the parents of poor children often lack health insurance. Parents who leave welfare normally get a year of coverage but then lose coverage unless their employer provides it, and many employers of low-wage workers do not offer health insurance. Similarly, parents who take low-paying jobs to avoid welfare usually have no coverage at all. This lack of coverage discourages adults from working and may also affect the health of children because adults without health insurance are less likely to take their children for preventive care. Weil proposes creating a federal earned income health credit (EIHC) and redefining the federal floor of coverage through Medicaid and SCHIP. His aim is to make health insurance affordable for low-income families and to make sure enough options are available that individuals and families can get coverage using a combination of their own, their employer's, and public resources. Weil would expand Medicaid eligibility to include all families whose income falls below the poverty line. The EIHC would be a refundable tax credit that would be available to parents during the year in advance of filing a tax return. The credit, which would be based on taxpayer earnings and family structure, would phase in as earnings increase, reach a plateau, and then phase out farther up the income scale. The credit would be larger for families with dependents. The EIHC would function seamlessly with the employee payroll withholding system. It would be available only to adults who demonstrate that they had health insurance coverage during the year and, for adults with children, only if their eligible dependent children were enrolled in either a private or public insurance program. Weil's proposal would cover individuals who receive coverage from their employer and those who do not. The proposal smooths transitions from public to private coverage, and it anticipates a substantial role for states. Weil estimates that his policy would cost about $45 billion a year.

Did State Children’s Health Insurance Program Affect Married Women’s Labor Supply?

While the relationships between health insurance and the labor supply of women have been explored in the literature, little is known about the effects of offering public health insurance on the labor supply decisions of married women. This paper examines how the enactment of the State Children’s Health Insurance Program (SCHIP) affected the labor supply decisions of married women. Our empirical analysis showed that certain groups of married women reduced their number of hours worked upon SCHIP implementation. The results imply it is possible that some wives decreased their labor supply in order to make their children eligible for public health insurance.

States Try Several Strategies to Expand Health Coverage

States Try Several Strategies to Expand Health Coverage

Lessons from SCHIP

Lessons from SCHIP

Healthcare Providers’ Satisfaction with a State Children’s Health Insurance Program (SCHIP)

This study's purpose was to understand how experiences with and perceptions of the health care plan characteristics influence provider satisfaction with a State Children's Health Insurance Program (SCHIP). Physicians and other health care providers participating in one program (ALL Kids) were mailed a survey (n = 500). Pediatricians were the most likely to return the survey. We used frequencies, chi-square and logistic regression analysis to explore relationships. The odds of being less satisfied with the program among providers who perceived that reimbursement in the ALL Kids program was less compared to private insurance were almost 7 times (OR = 6.81; 95% CI = (1.88-24.73)) greater than for those who perceived that reimbursement was more or the same in ALL Kids. Likewise, respondents who perceived that All Kids families were less likely than families with private insurance to return for follow-up visits were less satisfied with ALL Kids (OR = 17.42; 95% CI = (1.85-164.70)). The stigma of SCHIP may be less than that often associated with Medicaid; however, this investigation should be considered with others that have identified barriers for provider's participation. This study indicates that provider satisfaction is related to their perceptions of SCHIP policies and families, though it does not tell us what factors might contribute to this perception, such as, previous experience with public insurance (Medicaid) and publicly insured patients. Increasing reimbursement rates may not address perceptions that affect provider views of publicly-supported health plans and the participating families.

Distributing State Children's Health Insurance Program Funds: A Critical Review of the Design and Implementation of the Funding Formula

The development of formulas to distribute federal funds to states based on demographic data continues to challenge data and policy analysts. Analysts must forward the best objective statistical analysis and data inputs to formula specifications while acknowledging the politics of the legislative process that authorizes federal funding formulas. This article evaluates the federal funding formula for the State Children's Health Insurance Program (SCHIP) using key formula components of need, effort, capacity, and performance. We also examine the operationalization and measure of the target population in the SCHIP funding formula. Legislative decisions on formulas are, by nature, based on compromises that balance competing policy objectives. The analyst's role is to continually review current research standards, data quality, and relevant formula inputs and make recommendations to refine federal funding formulas to better target resources to their intended populations.

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