Waiting in the wings: eligibility and enrollment in the State Children's Health Insurance Program

Eligibility and Take-up of the Medicare Part D Low-Income Subsidy

There is concern about poor take-up of the Medicare Part D Low-Income Subsidy (LIS), but uncertainty in published estimates. The Medicare Current Beneficiary Survey (MCBS), which contains Medicare LIS enrollment records and extensive survey data on individual beneficiary characteristics, would appear an ideal resource for evaluating LIS take-up. However, use of the MCBS to identify eligible beneficiaries is limited due to underreporting of income and lack of asset information in the published MCBS releases. We evaluate LIS eligibility and participation by enhancing the reliability of MCBS financial information using unpublished survey data on income and assets together with an income imputation procedure.

An investment in health: anticipating the cost of a usual source of care for children

OBJECTIVES

Among adults, having a usual source of care has been associated with lower health care expenditures primarily through decreased emergency department and inpatient expenditures. The extent of this effect among children is unknown. We hypothesized that children with a usual source of care would have greater odds of having any outpatient expenditures, lower odds of emergency department and inpatient expenditures, and lower expenditures overall.

PATIENTS AND METHODS

Using a 2-part model, we studied expenditures among children < or =17 years of age in the 2004 Medical Expenditure Panel Survey (N = 8810). Logistic regression was used to assess the relationship between having a usual source of care and the odds of having any outpatient, emergency department, and inpatient expenditures, and ordinary least-squares regression was used to compare the amount of total, outpatient, emergency department, and inpatient expenditures among children with and without a usual source of care, controlling for confounders.

RESULTS

The odds of having any expenditures overall and any outpatient expenditures were 2.42 and 2.91 times higher among children with a usual source of care than among those without a usual source of care. The odds of having any emergency department or inpatient visits did not differ between groups. Having a usual source of care was associated with higher total expenditures and lower inpatient expenditures.

CONCLUSIONS

Having a usual source of care is associated with increased odds of having any expenditures overall and any outpatient expenditures, higher total expenditures, and lower inpatient expenditures. Because emergency department and inpatient visits are less common among children than among adults, reductions in receipt of such care do not offset the associated increase in total expenditures and may not be appropriate indicators of the benefit of having a usual source of care among children. Intermediate indicators such as receipt of age-appropriate preventive services should be assessed.

The impact of SCHIP on insurance coverage of children

In this paper we use the Medical Expenditure Panel Survey between 1996 and 2002 to investigate the impact of the State Children's Health Insurance Program (SCHIP) on insurance coverage for children. We explore a range of alternative estimation strategies, including instrumental variables and difference-in-trends models. We find that SCHIP had a significant impact in decreasing uninsurance and increasing public insurance for both children targeted by SCHIP and those eligible for Medicaid. With respect to changes in private coverage our results are less conclusive: some specifications resulted in no significant effect of SCHIP on private insurance coverage, while others showed significant decreases in private insurance. Associated estimates of SCHIP crowd-out had wide confidence intervals and were sensitive to estimation strategy.

The State Children's Health Insurance Program

PURPOSE OF REVIEW

The State Children's Health Insurance Program expanded public health insurance to children who are ineligible for Medicaid yet unable to afford private health insurance. The program was a natural experiment, offering the opportunity to study the effects of expanding health insurance to a large population of children who would otherwise be uninsured. The State Children's Health Insurance Program is reviewed in the context of program goals, evaluation dimensions, past and current findings, and future directions. The studies and findings fall into five dimensions: (1) outreach/enrollment/uptake and profile of enrollees, (2) impact on insurance coverage and uninsured rates, (3) coverage dynamics, (4) impact on outcomes, and (5) costs.

RECENT FINDINGS

Older studies focused on outreach, enrollment, characteristics of enrollees, disenrollment, and coverage dynamics. Current studies report the impact of the program on outcomes--including access to care, quality, satisfaction, unmet need, and health outcomes--for the overall population of children and for vulnerable subgroups, including racial and ethnic minorities and children with chronic illness. A smaller number of studies address costs.

SUMMARY

The State Children's Health Insurance Program is evolving with demonstrated successes and areas for improvement. This information can enhance practicing pediatricians' understanding of barriers that face low-income children and families in seeking care for their children, can offer insight into what health insurance can and cannot do in terms of ameliorating those barriers, can provide insight into the prior experiences and current medical needs that a new enrollee in the program might have at the first visit to a practitioner, and can illuminate the challenges that low-income children and families may face in obtaining and maintaining health insurance coverage.

Tracking Changes In Eligibility And Coverage Among Children, 1996–2002

Data from the 1996 Medical Expenditure Panel Survey (MEPS) reveal that 4.7 million children were eligible for Medicaid but were uninsured. Numerous changes have occurred in the landscape for children's health insurance since then, including welfare reform and implementation of the State Children's Health Insurance Program (SCHIP). We use data from the 1996-2002 MEPS to track changes in the eligibility and coverage of children. As of 2002, uninsurance among children remained as much a problem of participation as one of eligibility. Nevertheless, we find evidence of dramatic improvements in program participation, reflecting the success of efforts to improve outreach, simplify enrollment, and increase retention.

The ABCs of children's health care: how the Medicaid expansions affected access, burdens, and coverage between 1987 and 1996

The Medicaid poverty expansions were among the major health policy initiatives of the late 1980s. This paper examines changes over a nine-year period in access, burdens, and coverage among children eligible for Medicaid through the expansions. Among eligible children, the Medicaid expansions reduced rates of uninsurance, increased access to physicians, and reduced families' risk of bearing a heavy financial burden. Gaps remain, however, and expansion-eligible children are more likely than never-eligible children to have been uninsured, to have gone without a physician office visit, and to have lived in a family that spent at least 20% of family income on medical care.

The impact of the Iowa S-SCHIP program on access, health status, and the family environment

OBJECTIVES

To determine the effect of the Iowa Separate State Child Health Insurance Program (S-SCHIP) on need for services, utilization and access to care, child health status, and the family environment.

METHODOLOGY

A longitudinal pretest-posttest panel survey was used to evaluate differences in children's access to health care, health status, and family environment at the beginning of the program and after 1 year. Written surveys with telephone follow-up calls were used to collect the data. Pre- and postquestionnaire results for 463 children were matched and compared using the McNemar test for correlated proportions and the Wilcoxon signed rank test. Approximately 71% of families responded to both surveys.

PRINCIPAL FINDINGS

Similar rates of perceived need for each of 6 service areas were found after being in the program for a year as before. Unmet need was significantly reduced among those needing services: medical care (27% before, 6% after), specialty care (40% before, 13% after), dental care (30% before, 10% after), vision care (46% before, 12% after), behavioral and emotional care (42% before, 18% after), and prescription medications (21% before, 13% after). Overall health status was rated significantly better (ie, excellent: 37% before, 42% after). Ninety-five percent of families reported a reduction in family stress, and there was significantly less worry about the ability to pay for their child's health care (92% before, 57% after). The activities of fewer children were limited because of potential health care costs.

CONCLUSIONS

The Iowa S-SCHIP program improved access to care and the family environment for children enrolled during the first year without a change in perceived need for services.

SCHIP making progress: increased take-up contributes to coverage gains

Previous research based on the Community Tracking Study (CTS) showed that while coverage expansions through the State Children's Health Insurance Program (SCHIP) greatly increased children's eligibility for public or private health insurance coverage, uninsurance rates remained unchanged because of low take-up by eligible children. However, more recent data show that this is changing. Children's uninsurance rates decreased sharply between 1999 and 2001; these changes were greatest in communities where take-up rates have traditionally been the lowest and uninsurance rates the highest. Although uninsurance rates still can be decreased further, state budget pressures threaten the momentum toward higher participation in public programs.

Design strategies and innovations in the medical expenditure panel survey

BACKGROUND

Recent efforts to provide an annual profile of the health care quality of the nation's health care delivery system and to identify health care disparities in the population's access to and use of health care services have served to stimulate design innovations and content enhancements to the Medical Expenditure Panel Survey (MEPS).

OBJECTIVES

To present a summary of the analytical objectives, design, and core content of the MEPS, and to provide an overview of the new and innovative design features that add capacity for health status and quality of care measurement and improve data quality.

SUMMARY

The MEPS questionnaire has been expanded to include content taken from the Consumer Assessment of Health Plans Study (CAHPS) to facilitate assessments of patient experiences with health care at the national level. The survey now includes the series of questions from the SF-12 and the EuroQol 5D to improve the survey's capacity to measure health status. Additional condition-specific questions for diabetes, asthma, high blood pressure, and heart disease were added to identify the health care services received for treatment and to determine whether the care received was consistent with practice guidelines. Sample design modifications are presented, with particular emphasis given to a summary of the recent sample size increase and resultant improvements in the precision of resultant survey estimates. Attention is also given to changes in survey design, estimation, and data collection strategies that improve data quality.

Children of working poor families in California: the effects of insurance status on access and utilization of primary health care

We examined the effects of health insurance on access and utilization of health care among children of working poor families. These children experience strong access barriers yet have not been studied systematically. 1,492 children in California under 19 years old who had workforce participating parents and a subset of full-time year round working families earning below 200% of poverty were examined from the 1994 National Health Interview Survey. Thirty-two percent of children of working poor families were uninsured in California compared with 26% nationwide. Difficulties in accessing a regular care source and obtaining after-hour care were markedly higher in California. Full-time year round work did not increase insurance coverage and worsened access to a regular source of care. Uninsured children in California were far more likely than insured children to face access barriers and less likely to see a physician in the previous year. Between privately and publicly insured children, the gap in access and utilization narrowed markedly. Health insurance is critical for children in working poor families. Healthy Families, California's response to CHIP, could improve coverage for this population.

Language proficiency and the enrollment of Medicaid-eligible children in publicly funded health insurance programs

OBJECTIVES

The purpose of the study was to examine the effect of language proficiency on enrollment in a state-sponsored child health insurance program.

METHODS

1055 parents of Medicaid-eligible children, who were enrolled in a state-sponsored child health insurance program, were surveyed about how they learned about the state program, how they enrolled their children in the program, and perceived barriers to Medicaid enrollment. We performed weighted chi2 tests to identify statistically significant differences in outcomes based on language. We conducted multivariate analyses to evaluate the independent effect of language controlling for demographic characteristics.

RESULTS

Almost a third of families did not speak English in the home. These families, referred to as limited English proficiency families, were significantly more likely than English-proficient families to learn of the program from medical providers, to receive assistance with enrollment, and to receive this assistance from staff at medical sites as compared to the toll-free telephone information line. They were also more likely to identify barriers to Medicaid enrollment related to "know-how"--that is, knowing about the Medicaid program, if their child was eligible, and how to enroll. Differences based on language proficiency persisted after controlling for marital status, family composition, place of residence, length of enrollment, and employment status for almost all study outcomes.

CONCLUSIONS

This study demonstrates the significant impact of English language proficiency on enrollment of Medicaid-eligible children in publicly funded health insurance programs. Strong state-level leadership is needed to develop an approach to outreach and enrollment that specifically addresses the needs of those with less English proficiency.

Socioeconomic disparities in health: pathways and policies

Socioeconomic status (SES) underlies three major determinants of health: health care, environmental exposure, and health behavior. In addition, chronic stress associated with lower SES may also increase morbidity and mortality. Reducing SES disparities in health will require policy initiatives addressing the components of socioeconomic status (income, education, and occupation) as well as the pathways by which these affect health. Lessons for U.S. policy approaches are taken from the Acheson Commission in England, which was charged with reducing health disparities in that country.

Family income and the impact of a children's health insurance program on reported need for health services and unmet health need

OBJECTIVE

In an era when expanding publicly funded health insurance to children in higher income families has been the major strategy to increase access to health care for children, it is important to determine if the benefits to higher income children attributable to the receipt of health coverage are similar to those observed for lower income children. This study investigated how the likely impact of child health insurance expansions varies with family income.

METHODS

We surveyed parents or guardians of children who were enrolled in a state-sponsored health insurance program (Massachusetts Children's Medical Security Plan [CMSP]) that, before the implementation of the State Children's Health Insurance Plan (SCHIP), was open to all children regardless of income. A stratified sample of children was drawn from administrative files. We grouped children by income category (low-income [LI]: < or =133% of the federal poverty limit [FPL], middle-income [MI]: 134%-200% of the FPL, high-income [HI]: >200% of the FPL) that corresponded to eligibility for public health insurance programs in the state (Medicaid-eligible, SCHIP-eligible, and income that exceeded SCHIP eligibility). The majority of telephone interviews were conducted between November 1998 and March 1999. The overall response rate was 61.8%, yielding a sample of 996 children. The CSMP benefit package included comprehensive coverage for preventive and specialty care and limited coverage for ancillary services. Children enrolled in CMSP were not covered for inpatient hospital stays but those whose family income was <400% of the FPL were eligible to receive full or partial coverage for inpatient care through the state's free care pool. Although the CMSP benefit package did not meet the standards for a SCHIP, it is an approximate equivalent for children with incomes <200% of the FPL, who have full coverage for hospitalization through the state's free care pool. We used survey responses to develop 2 sets of indicators: the first for reported need for services and the second for unmet need or delays in care among children whose parents reported a need for the service. Within each set, we created indicators for 5 types of service (medical care, dental care, prescription drugs, vision services, and mental health care) and an additional composite indicator. The composite indicator aggregated all categories of services covered under CMSP in a single measure; it included all services except dental services, which, at the time of the study, were not covered by the program. The composite indicator served as the dependent variable in regression models. We used weighted chi2 tests to identify statistically significant differences in reported need and unmet need for the 5 types of medical services and the aggregate measure of all services covered by CMSP. We examined differences across income groups at 2 points in time: during the period children were uninsured before enrollment and while enrolled. We used weighted logistic regression to assess the independent association of family income with our dependent variables: reported need for health services and the presence of unmet need, controlling for other covariates. To evaluate the impact of participation in a child health insurance program, we examined unmet need before and after program enrollment, testing for statistical significance using McNemar's test for within-subject changes.

RESULTS

During the period of uninsurance before enrollment, prescription drugs (70%) was the health service needed most frequently, followed by medical (65%) and dental (57%) care. For the composite measure of services covered by CMSP, reported need for services was not significantly different by income. Need for medical care, dental care, and prescription drugs were significantly greater among children who had been uninsured for >6 months before enrollment. In addition, a significantly greater proportion of adolescent participants needed dental, vision, and mental health services than younger enrollees. While enrolled, among recently enrolled children, 77% need medical services, 68% prescription drugs, and 59% dental. In unadjusted models MI and HI children were more than 2 times as likely to report need for covered services as LI children. After adjusting for possible confounders, the effect of income was no longer significant. Instead, nonadolescents (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25-4.76) and children with white ethnicity (OR: 3.03; 95% CI: 1.43-6.67) were significantly more likely to report need for services. Before enrollment, unmet need among those who reported need for services was 5% for medical, 4% prescription drugs, 31% dental, 30% vision, and 33% mental health. For the composite measure of services covered by CMSP, LI children were significantly more likely to have had unmet need before enrollment than MI and HI children (20%, 10%, 7% by income). As compared with younger children, adolescents also had significantly greater unmet need for the composite measure (19% vs 10%). In multivariate models, not having a usual site of care was a highly significant predictor of unmet need or delayed care (OR: 3.41; 95% CI: 1.28-9.11). Ninety-eight percent of parents cited cost as the reason they had difficulty obtaining needed care. After enrollment, the proportion of children who needed care and had difficulty obtaining it decreased for all categories of care. Less than 1% of enrollees reported unmet need or delays in care for medical services and 3% for prescription drugs. Children who needed vision and mental health services continued to experience difficulty obtaining these services (17% for each category of care), although they were covered as part of the benefit package. Unmet need or delays in care for dental services, which at the time of the study were not covered under CMSP, remained high (27%). We found a significant reduction in unmet need among children in all income groups and no significant differences in unmet need by income. Controlling for other covariates, adolescents (OR: 3.11; 95% CI: 1.58-6.12) and children with compromised health (OR: 3.20; 95% CI: 1.35-7.58) were more likely to have had difficulty obtaining needed services while enrolled in the program. Children in larger families (OR: 0.40; 95% CI: 0.17-0.96) and who were previously uninsured for >6 months (OR: 0.45; 95% CI: 0.22-7.58) were less likely to have difficulty obtaining care.

CONCLUSION

Our findings demonstrate the positive impact of providing health insurance coverage to children regardless of income. The HI children who enrolled in the program looked similar to children with incomes that meet current SCHIP eligibility guidelines, suggesting that expansions of SCHIPs to HI children should not qualitatively change the program dynamics.

Inside the sausage factory: improving estimates of the effects of health insurance expansion proposals

The fate of a proposal to expand health insurance is influenced by predictions of the proposal's effects on the number of newly insured and the cost of new coverage. Estimates vary widely, for reasons that are often hard to discern and evaluate. This article describes and compares the frameworks and parameters used for insurance modeling. It examines conventions and controversies surrounding a series of modeling parameters: how individuals respond to a change in the price of coverage, the extent of participation in a new plan by those already privately insured, firms' behavior, and the value of public versus private coverage. The article also suggests ways of making models more transparent and proposes "reference case" guidelines for modelers so that consumers can compare modeling results.

How much did the Medicaid expansions for children cost? An analysis of state Medicaid spending, 1984-1994

The authors examine the relationship between the Medicaid eligibility expansions for children and state Medicaid spending during the period from 1984 to 1994. They find that the Medicaid expansions had relatively low incremental cost per enrollee--substantially below the average Medicaid expenditure for children. Expansion children tend to be older and have fewer disabilities. Moreover, many of the most expensive expansion children would have been covered by Medicaid-medically-needy provisions had the expansions not occurred. The authors examine the implications of our findings for intensified Medicaid outreach efforts and for the State Children's Health Insurance Program.

Determinants of public and private insurance enrollment among Medicaid-eligible children

BACKGROUND

Many Medicaid-eligible children are not enrolled in Medicaid and are not covered by private insurance. Reducing persistent lack of insurance for children requires a better understanding of why Medicaid-eligible children do not participate.

RESEARCH QUESTIONS

Does the availability of free or low-cost medical services substitute for Medicaid or private insurance enrollment among Medicaid-eligible children? Does the availability and affordability of insurance coverage, particularly the offer of employer-sponsored insurance (ESI) and the presence of managed care, affect child insurance coverage?

RESEARCH DESIGN

We use data from the National Health Interview Survey for 1994 and 1995, supplemented with county level measures of insurance and provider supply, to estimate a multinomial choice model of insurance coverage among children identified as Medicaid-eligible. We focus on county supply of public hospitals and community/migrant health centers (C/MHC); and the availability and cost of ESI. We control for child and parent characteristics.

RESULTS

A positive effect of C/MHC supply is found on Medicaid enrollment, but no evidence is found of substitution between low-cost providers and Medicaid or private coverage. Local availability of ESI and private HMO penetration increased private insurance enrollment.

CONCLUSIONS

Local community providers can play an important role in outreach and enrollment for Medicaid. Availability and cost of ESI constrain private coverage for Medicaid-eligible children. Policies that encourage offers of insurance coverage by employers, decrease premiums, and encourage adoption of managed care could have important positive effects on coverage for this population.

Barriers to enrollment in a state child health insurance program

OBJECTIVE

To identify barriers to enrollment into Colorado's Child Health Insurance Plan (CHP+) for non-Hispanic (NH), Hispanic (H), and uninsured families.

DESIGN

Telephone survey of 1) random samples of families who requested an application but did not complete it (N = 273 NH, N = 159 H) and 2) families with uninsured children identified by random-digit-dial statewide surveys (N = 165).

RESULTS

Major reasons for not enrolling included 1) got other insurance (NH 16.5%; H 27.2% P <.01), 2) thought household income was too high to qualify (NH 21.0%; H 11.9% P =.01), and 3) paperwork (NH 13.4%; H 14.7%, P = NS). Of those who thought their income was too high (N = 76, 17.6%), 58.5% appeared eligible based on reported income. Of uninsured families, only 41.7% had heard of CHP+. Of those who had never applied, major remediable reasons included not knowing enough about the program (20.9%) and thinking household income was too high (9.3%).

CONCLUSIONS

Effective marketing and education to increase awareness of CHP+ and ensure understanding of eligibility are critical to the success of the program.

A comparison of the socioeconomic and health status characteristics of uninsured, state Children's health insurance program-eligible children in the united states with those of other groups of insured children: implications for policy

OBJECTIVES

To describe the sociodemographic and health status characteristics of the national uninsured, State Children's Health Insurance Program (SCHIP)-eligible population, and to compare this population with Medicaid-enrolled children, privately insured children, and privately insured children who have family income in the SCHIP eligibility range.

PROCEDURES

Data were analyzed for 50 950 children 0 to 18 years of age included in the 1993 and 1994 National Health Interview Surveys. The survey obtained information on insurance coverage and sociodemographic and health status measures. Bivariate analyses were conducted to identify the relationships between SCHIP eligibility and sociodemographic and health status characteristics. Multivariate analyses were conducted to assess the independent association of the sociodemographic and health status variables with the likelihood of being uninsured, SCHIP-eligible.

PRIMARY FINDINGS

Results indicate that SCHIP children exhibit markedly different socioeconomic and health status characteristics than do both Medicaid- enrolled and privately insured children, although these differences are less significant in privately insured children. SCHIP children more often live with college- educated (39.4%) and employed adults (91.2%) than do Medicaid-enrolled children (23.0% and 53.9%, respectively). However, SCHIP children live with college-educated and employed adults less than do all privately insured children (66.7% and 96.9%, respectively) and privately insured/same-income children (57.8% and 97.0%, respectively). Parents of SCHIP-eligible children are also disproportionately self-employed or employed in industries (e.g., retail trade) and occupations in which health insurance coverage is less available or affordable. SCHIP-eligible children are also 2 times more likely to be adolescents and 11/2 times more likely to be in excellent health than Medicaid-eligible children. Compared with privately insured children, SCHIP-eligible children are nearly 3 times more likely to be Hispanic and nearly 2 times more likely to be rated in fair or poor health.

CONCLUSIONS

The results demonstrate that uninsured, SCHIP-eligible children are substantially different from children in these groups, particularly compared with Medicaid-enrolled children. These differences need to be taken into account when setting policies and implementing programs intended to increase health insurance coverage and access to health care.