State Children's Health Insurance Program 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.

Julie Rovner’s Health Care Policy and Politics A to Z: a review

Drawing on her vast experience covering health care policy on Capitol Hill, Julie Rovner has written explanations for over 300 key concepts that demystify the world of United States Government health care policy. In the newest edition of Health Care Policy and Politics A to Z, readers will find updated information on long-term health care spending, abortion, Medicaid and Medicare, health insurance and the uninsured, and the State Children’s Health Insurance Program (SCHIP). New entries reflect important changes in recent years and include the Medicare Modernization Act, abstinence education, electronic health records, health savings accounts, and Project BioShield. The book does have its gaps, especially as it relates to mental health. However, this book should become a standard reference for all health care professionals.

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.

The Effects of the State Children’s Health Insurance Program on Insurance Status and Health Care Utilization of Children

The State Children’s Health Insurance Program (SCHIP) of 1997 aimed to increase public insurance eligibility to children in families that were above the Medicaid income cutoff line, but were too poor to afford private coverage. This paper shows that SCHIP helped as many as 1.3 million children leave the ranks of the uninsured. However, almost 400,000 of these children came from families with two privately insured parents, and added approximately $300 million in health care expenses to federal and state budgets. This paper also presents estimates of health care consumption of children who switched to public insurance as a result of SCHIP.

Can Health Insurance Reduce School Absenteeism?

Enacted in 1997, the State Children’s Health Insurance Program (SCHIP) represented the largest expansion of U.S. public health care coverage since the passage of Medicare and Medicaid 32 years earlier. Although the program has recently been reauthorized, there remains a considerable lack of thorough and well-designed evaluations of the program. In this study, we use school attendance as a measure of the program’s impact. Utilizing state-level data and the use of fixed-effects regression techniques, we conclude that SCHIP has had a positive and significant effect on state average daily attendance rates, as measured by both SCHIP participation and eligibility rates. The results support the renewal and expansion of the program.

Improving children's healthcare through state health insurance programs: An emerging need

State Children's Health Insurance Program (SCHIP) in the USA plays a critical role in healthcare service utilization. This study assesses children's needs for healthcare services among the variations of SCHIP. This study applies the PRECEDE-PROCEED behavioral model to analyze the behavior of children with healthcare needs and unmet healthcare needs by using the National Survey of Children with Special Healthcare Needs of the USA. Children who were previously under a Medicaid program are apt to enroll in SCHIP programs. SCHIP children with healthcare needs are more likely than comparable non-SCHIP children to use hospital outpatient departments instead of using doctors' offices and health centers. Children under the SCHIP single and SCHIP combination programs are more likely to use doctors' offices and health centers than those in the Medicaid expansion program. SCHIP combination or SCHIP Medicaid expansion states are significantly less likely to have unmet healthcare needs than children in SCHIP single states. Medicaid has a significant impact on the SCHIP program. There is a substitution of healthcare service facilities between hospital outpatient departments and either the doctors' offices or health centers.

Consequences of SCHIP Expansions for Household Well-Being

About 7.4 million children were covered by the State Children’s Health Insurance Program (SCHIP) at some point during fiscal year 2008. Many of these children would probably have had private coverage in the absence of SCHIP; recent estimates of the extent of “crowd-out” associated with SCHIP are about 60 percent (Gruber and Simon 2008). The high rate of crowd-out means that the program is not as effective as it could be at reducing the number of uninsured children and has been a political liability for the program. Both political concerns and policy research focusing on crowd-out in SCHIP build on more than a decade of similar attention to the crowd-out associated with the Medicaid expansions of the late 1980s and early 1990s. While there is little doubt that expanding eligibility for public insurance to children who are not poor will lead some to substitute public for private coverage, this substitution should increase total resources available to these households in two ways. First, those who drop private coverage in order to enroll their children in SCHIP can take whatever they had been spending on health insurance and spend it on something else. Second, public insurance requires less cost-sharing than a typical private insurance policy, providing first-dollar coverage with minimal co-payments. This means that switching from private to public coverage reduces a family’s out-of-pocket medical spending, freeing up even more of the family’s resources for other uses. From the perspective of a low-income family, then, crowd-out is a windfall. In this paper we ask: what do these families do with the additional resources? We address this question with an empirical analysis of consumption data from the Consumer Expenditure Survey. We find that eligibility for SCHIP is associated with an increase in overall expenditure, and most of this increase is allocated to consumption of transportation or saving for retirement. These results suggest that the SCHIP expansions substantially improved the material well-being of the low-income families it is intended to assist – including those who had previously been paying for their own coverage. This evidence should allow a better accounting of the benefits and not just the costs of recent expansions in public health insurance programs.

The Crowding Out of Private Health Insurance of State Children Health Insurance Program in US

Ⅰ. Introduction Ⅱ. Literature review Ⅲ. Data and method Ⅳ. Results Ⅴ. Conclusion References

School Nurses' Perceptions and Practices of Assisting Students in Obtaining Public Health Insurance

From January through June 2009, 6.1 million children were uninsured in the United States. On average, students with health insurance are healthier and as a result are more likely to be academically successful. Some schools help students obtain health insurance with the help of school nurses. This study assessed public school nurses' knowledge and beliefs of the impact of health insurance on students' health and academic success. The study also determined whether public school nurses or their schools were involved in helping students obtain public health insurance, and if so, how they did so. Additionally, the study assessed the public school nurses' perceived benefits of and barriers to helping students obtain public health insurance. A paper-and-pencil survey was sent to a national random sample of 750 public school nurses. The response rate was 56%. Nearly 60% of respondents had helped students enroll in public health insurance. The majority perceived that helping students obtain public health insurance would reduce school absenteeism (90%), improve attention during school (84%), reduce the number of students held back (80%), reduce school dropouts (72%), and increase academic test scores (69%). Although the majority (53%) of nurses thought schools should assist students' parents with filling out public health insurance enrollment forms, some expressed reservations about the process. School nurses indicated health insurance is important for the health and academic success of students. These beliefs are congruent with state Child Health Insurance Program (CHIP) directors' perceptions, yet few schools have taken on the role of facilitating student enrollment in public health insurance programs.

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.

Discrepancies in Health Care Funding for Individuals with Special Needs

Approximately 47 million Americans ‐ 16% of the total US population ‐ lack health insurance [10]. An additional 25 million have insurance plans that limit their access to services, or cover only a small percentage of expenses ‐ they, in fact, are underinsured. In 1997, the original State Children’s Health Insurance Program (SCHIP) established coverage for children who did not qualify for Medicaid but whose families could not afford private insurance. This legislation reduced the rate of uninsured low-income children by almost one third, from 23% (7.6 million children) to 14% (5.6 million children) and improved health care quality. The prevalence of uninsured children in 2007 ranged from 4.1% to 21.2% across various states [7]. In 2009, 7 million children were enrolled in SCHIP and 29 million children were enrolled in Medicaid. CHIP’s (Children’s Health Insurance Program) reauthorization in 2009 liberalized the means test criteria (> 300% of the federal poverty level) of the initial legislation, extended coverage to more recent immigrants (less than 5 years) and authorized the states to cover an increased number of services, including dental and mental health care. Children under the age of 18 years comprise 26% of the US population, yet they are responsible for only 10% of total healthcare expenditures and consume only 9% of public funds for healthcare [10]. However, the 14% of children and youth in the United States with special health care needs account for 42% of the medi

Financial Burden of Raising CSHCN: Association With State Policy Choices

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

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

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

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.

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

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

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

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

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

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

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

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

SCHIP premiums, enrollment, and expenditures: a two state, competing risk analysis

Faced with state budget troubles, policymakers may introduce or increase State Children's Health Insurance Program (SCHIP) premiums for children in the highest program income eligibility categories. In this paper we compare the responses of SCHIP recipients in a state (Kentucky) that introduced SCHIP premiums for the first time at the end of 2003 with the responses of recipients in a state (Georgia) that increased existing SCHIP premiums in mid-2004. We start with a theoretical examination of how these different policies create different changes to family budget constraints and produce somewhat different financial incentives for recipients. Next we empirically model the impact of these policies using a competing risk approach to differentiate exits due to transfers to other eligibility categories of public coverage from exiting the public health insurance system. In both states we find a short-run increase in the likelihood that children transfer to lower- income eligibility/lower-premium categories of SCHIP. We also find a short-run increase in the rate at which children transfer from SCHIP to Medicaid in Kentucky, which is consistent with our theoretical model. These findings have important financial implications for state budgets, as the matching rates and premium levels are different for different eligibility categories of public coverage.

SCHIP Directors’ Perception of Schools Assisting Students in Obtaining Public Health Insurance

Health insurance coverage increases access to health care. There has been an erosion of employer-based health insurance and a concomitant rise in children covered by public health insurance programs, yet more than 8 million children are still without health insurance coverage. This study was a national survey to assess the perceptions of State Child Health Insurance Program (SCHIP) directors (N = 51) regarding schools assisting students in obtaining public health insurance. This study examined the perceived benefits of and barriers to working with school systems and the perceived benefits to schools in assisting students to enroll in SCHIPs and what SCHIP activities were actually being conducted with school systems. The majority (78%) of SCHIPs had been working with school systems for more than a year. Perceived benefits of working with schools were greater access to SCHIP-eligible children (75%), assistance with meeting mandates to cover all SCHIP-eligible children (65%), and greater ability of state agencies to identify SCHIP-eligible children (58%). A majority of the directors did not identify any of the potential barrier items. The directors cited the following benefits to schools in helping enroll students in public health insurance programs: reduces the number of students with untreated health problems (80%), reduces student absenteeism rates (68%), improves student attention and concentration during school (58%), and reduces the number of students being held back in school because of health problems (53%). The perceived benefits derived from schools assisting in enrolling eligible students into SCHIPs are congruent with the mission of schools. Schools need to become proactive in helping to establish a healthy student body, which is more likely to be an academically successful body.