CHIRI™ Issue Brief 3
Since 1997, States have used the State Children's Health Insurance Program (SCHIP) to provide health insurance coverage to uninsured low-income children who lack private health insurance but are ineligible for Medicaid due to family income. Demographic and health care information about SCHIP enrollees can help States understand enrollee needs, assess effects of program changes, and determine if SCHIP improves low-income child access to health care.
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By Karen VanLandeghen and Cindy Brach
Contents
Introduction
What Was Learned
Study Methodology
Sources and Related Studies of Interest
About CHIRI™
CHIRI™ Funders
Other Funders
For More Information
Introduction
This Issue Brief summarizes findings from Child Health Insurance Research Initiative
(CHIRI™) projects in five States with separate SCHIP programs that accounted for 30 percent of SCHIP enrollment in 2001. The families of new SCHIP enrollees were asked
about their demographic characteristics and health care experiences before enrolling in
SCHIP. These CHIRI™ findings reveal that new SCHIP enrollees resemble other low-income uninsured children in many respects, but they also depart from some
expectations about who would enroll in SCHIP.
- Nearly two-thirds to three-quarters of new enrollees, depending on the State
examined, lived in working families with incomes equal to or below 150
percent of the Federal Poverty Level.
- From one-quarter to nearly three-quarters of new enrollees were uninsured
the entire year prior to SCHIP enrollment.
- A solid majority of new enrollees had received health care services prior to
SCHIP enrollment, particularly preventive care, yet one-quarter to almost
one-half of them had unmet health care needs.
- A significant proportion of new enrollees were black or Hispanic. Compared
with white enrollees, minority enrollees had lower incomes, had poorer
health status, and were more likely to have been uninsured the entire year
prior to SCHIP enrollment.
- From 17 percent to 25 percent of new enrollees were children with special
health care needs (CSHCN), which is higher than the prevalence in the
general population.
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What Was Learned
Researchers conducted surveys of new enrollees in
separate SCHIP programs in five States—Alabama,
Florida (adolescents only), Indiana (CSHCN only in
both the separate and Medicaid expansion SCHIP
programs), Kansas, and New York. This CHIRI™ Issue
Brief describes enrollees' demographic characteristics
and health care experiences in the year prior to SCHIP
enrollment.
Many SCHIP Enrollees Were From Low-Income
Full-Time Working Families
The vast majority of children lived in households with a
working adult (ranging from 80 percent to 87 percent
in the study States) and most enrollees were from
families with adults who worked full-time (63 percent
to 74 percent). More than half of SCHIP enrollees
lived in two-parent households, and in a substantial
proportion of these families, both parents worked.
More SCHIP enrollees came from families with
incomes at the bottom of the SCHIP eligibility range
(100-150 percent of the Federal Poverty Level, or
FPL) than from the top of the range (151-200 or 250
percent of FPL). From 65 percent to 79 percent of
SCHIP enrollees lived in families with incomes equal
to or below 150 percent of FPL ($27,600 for a family
of four in 2003).
A Significant Proportion of Children Were
Uninsured Prior to SCHIP Enrollment
One-quarter to nearly three-quarters of SCHIP
enrollees were uninsured the entire year before
enrolling in SCHIP, depending on the State. Of
enrollees with prior health care coverage, most had
private health insurance (group or individual), but one-quarter
to one-half of them had been enrolled in
Medicaid. Families lost their prior insurance most often
because of a change in employment, the high cost of
insurance, or an income increase that resulted in the
loss of Medicaid.
Despite Significant Connection to the Health Care
System, Many Children Had Unmet Needs
The vast majority of children (75 percent to over 90
percent) had a regular source of health care before
SCHIP enrollment—primarily private doctor's offices,
community health centers, and hospital clinics. From
one-quarter to over one-third of children changed their
regular source of care upon SCHIP enrollment. In
addition, many children received health care services in
the year before SCHIP, including a solid majority (67
percent to 73 percent) who received preventive care.
Even though most new SCHIP enrollees had some
prior contact with the health care system, from one-quarter
to almost one-half of them had unmet health
care needs at the time of enrollment. Unmet needs
were most frequently noted for mental health, specialty,
dental, and vision care, and prescription medications.
Families most often cited financial barriers as the cause
of these unmet health care needs.
Black and Hispanic Children Constituted a
Significant Proportion of SCHIP Enrollees
In most States, a significant proportion of children
who enrolled in SCHIP were black or Hispanic (Figure 1). Black and Hispanic children were more
likely than white children to live in single-parent or
lower income families, to have lacked a regular source
of health care, and to have poorer health status. Of
children with prior health care coverage, minority
children were more likely than white children to have
had Medicaid coverage before SCHIP enrollment.
The Prevalence of CSHCN Was Higher Among
New SCHIP Enrollees Than the General
Population
From 17 percent to 25 percent of SCHIP enrollees in
the study States had special health care needs. These
were children who had physical, developmental,
behavioral, or emotional limitations; higher health
care use; or a dependency on prescription medications
for 12 months or longer. The prevalence of CSHCN
in the general population for the study States ranged
from 12 percent to 15 percent, according to a study
by the National Center for Health Statistics.
CSHCN were similar to other SCHIP enrollees in
income, race/ethnicity, and prior health insurance
status. They were more likely than other enrollees to
have used health care services prior to enrollment,
including the emergency department, mental health
care, and specialty and acute care. Nevertheless,
CSHCN were more likely to have unmet health
needs upon enrollment (Figure 2). Approximately
one-third of CSHCN in each State changed their
regular source of health care after enrolling in SCHIP.
Conclusion
When Congress enacted SCHIP in 1997, it sought to
establish a health insurance program for children in
low-income working families who lacked health
insurance coverage. These CHIRI™ findings indicate
that SCHIP is indeed insuring the population
intended by Congress. It is important to note,
however, that more children with special health care
needs and children from lower income families
enrolled in SCHIP than some policymakers might
have predicted when SCHIP was enacted.
SCHIP appears to narrow the gap between private
and public health insurance coverage for low-income
children. In addition to providing coverage to
children who were uninsured for a substantial period
of time, SCHIP covered children whose families lost
private insurance coverage, most often because of
high insurance costs or a job change. It also covered
children who became ineligible for Medicaid,
generally as a result of increases in family income or
becoming too old for age-based eligibility categories.
SCHIP enrollees do not appear to differ dramatically
from children enrolled in Medicaid. Many SCHIP
enrollees, particularly CSHCN, had wide-ranging
unmet health care needs. Black and Hispanic
children, who constituted a significant proportion of
SCHIP enrollees, suffered from worse health status
than white children and were more likely to lack a
regular source of care. SCHIP enrollees, however,
were not disconnected from the health care system
prior to enrollment. Most enrollees had received
health care services in the prior year.
Ensuring that children maintain continuity of care
with primary care providers is an important goal for
public health insurance programs. Thus, it is
noteworthy that many children changed their regular
source of health care once they enrolled in SCHIP.
The effect of these changes on children's access to
and quality of health care is not clear. These findings
underscore the importance of monitoring continuity
of care during the transitions that low-income
children make when their insurance coverage changes.
Monitoring the quality of health care and evaluating
SCHIP's effectiveness in serving low-income
children, particularly vulnerable populations, are also
critical. Policymakers will likely want to ensure that
SCHIP is meeting the needs of the many minority
children and CSHCN who are enrolled in the
program. Forthcoming CHIRI™ products will
address the impact of SCHIP on access to and quality
of health care for these groups.
Policy Implications
Even though SCHIP enrollees are a diverse group
and State SCHIP programs vary, these CHIRI™
findings point to strategies that States can use to
improve children's access to care and better inform
SCHIP design, monitoring, and evaluation.
- SCHIP program design, including benefit design,
should consider that many new SCHIP enrollees,
particularly CSHCN, have a wide range of
unmet health care needs.
- Most State SCHIP benefit packages
currently cover the most frequently
unmet needs (i.e., vision, dental, and
mental health care, and prescription
medications).
- Additional strategies to address unmet
needs include educating enrollees about
accessing benefits and ensuring that a
sufficient number of providers are
available.
- Steps can be taken to promote continuity of health
care for the many children who change their
regular source of care upon SCHIP enrollment.
- Procedures can be implemented that
facilitate smooth transitions between
health insurance programs, monitor the
reasons for changing providers, and
minimize unnecessary transitions.
- Comprehensive baseline data can help States
accurately assess SCHIP's effectiveness in
providing quality health care to diverse
populations.
- Analysis of race/ethnicity and CSHCN
data and use of the findings for program
improvement can help ensure equity in
access to health care.
- Information on the prevalence and prior
health care experiences of CSHCN can
help States tailor programs to meet the
needs of this population.
- Program evaluation that compares
baseline to post-enrollment data can be
accomplished through a variety of
strategies, including partnerships between
State SCHIP programs and research
organizations.
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Study Methodology
The findings highlighted in this CHIRI™ Issue Brief
are drawn from a group of articles published in a
supplement to the American Academy of Pediatrics'
journal Pediatrics, where individual study
methodologies are described in greater detail. CHIRI™
projects in five States (Alabama, Florida, Indiana,
Kansas, and New York) participated in the articles.
This CHIRI™ Issue Brief mainly highlights findings from
two of the articles, one on the race/ethnicity of new
SCHIP enrollees and one on CSHCN enrolled in
SCHIP. Four of the five States participated in each
article. Findings were produced for each State and then
compared across States. All projects studied children
aged 0-18 years who were enrolled in separate SCHIP
programs, with two exceptions. The Florida project
included only children aged 11.5-18 years, and the
Indiana project included only CSHCN enrolled in
either the separate or Medicaid expansion SCHIP
program.
To maximize the comparability of findings
across the study States, several CHIRI™ researchers
developed a set of survey questions, known as the
CHIRI™ Common Core, that were used by all
projects. These questions were mainly drawn from
validated survey instruments and assess children's
health care experiences prior to enrollment. They
include the Child and Adolescent Health Measurement
Initiative CSHCN screener—a five-question screener
used in national studies to identify CSHCN.
In Florida, Indiana, Kansas, and New York, telephone
interviews were performed 2 to 7 months following
enrollment in SCHIP in 2001. Interviewers spoke with
the adult in the household (a parent in 95 percent of
cases) who was the most knowledgeable about the
child's health insurance and medical care (one child per
family). In Alabama, surveys were mailed 9 to 11
months after enrollment. The number of new enrollees
who were surveyed in the study States ranged from
767 in Kansas to 3,740 in Alabama.
Bivariate and multivariate analyses were conducted to
determine whether there were differences among
children in different racial/ethnic groups and among
children with different health care needs.
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Sources and Related Studies of Interest
Allison RA, St. Peter RF, Cheng-Chung H, et al. Do
children enrolling in public health insurance have other
options? Topeka: Kansas Health Institute. 2003.
Betley CL, St. Peter RF, Cheng-Chung H, et al. Who
are the children enrolling in SCHIP and Medicaid?
Topeka: Kansas Health Institute. 2003.
Blumberg S, Olson L, Frankel M, et al. Design and
operation of the National Survey of Children with
Special Health Care Needs, 2001. National Center for
Health Statistics. Vital Health Stat 1(41). 2003.
Centers for Medicare & Medicaid Services, U.S.
Department of Health and Human Services. State
Children's Health Insurance Program Annual
Enrollment Report. Baltimore, MD. February 6, 2002.
http://www.cms.gov/schip/schip01.pdf.
Dubay L, Kenney G, Haley J. Children's participation
in Medicaid and SCHIP: early in the SCHIP era.
Washington, DC: The Urban Institute. 2002.
Office of the Assistant Secretary for Planning and
Evaluation, U.S. Department of Health and Human
Services. Annual Update of the HHS Poverty
Guidelines. February 7, 2003.
http://www.aspe.hhs.gov/poverty/03fedreg.htm.
Wooldridge J, Hill I, Harrington M, et al. Interim
evaluation report: congressionally mandated evaluation
of the State Children's Health Insurance Program.
Cambridge, MA: Mathematica Policy Research, Inc.
February 2003. http://aspe.hhs.gov/health/schip/interimrpt/index.htm.
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About CHIRI™
CHIRI™ is an effort to supply policymakers with
information to help them improve access to, and
the quality of, health care for low-income children.
Nine studies of public child health insurance
programs and health care delivery systems were
funded in the fall of 1999 by:
- The Agency for Healthcare Research and Quality (AHRQ).
- The David and Lucile Packard Foundation.
- The Health Resources and Services Administration (HRSA).
These studies seek to uncover which
health insurance and delivery features work best for
low-income children, particularly minority children
and those with special health care needs.
Five CHIRI™ projects contributed to this Issue
Brief:
- "Access and Quality of Care for Low-Income
Adolescents" (Principal Investigator:
Elizabeth Shenkman, University of Florida).
- "Evaluation of Kansas HealthWave" (Principal
Investigator: Robert St. Peter, Kansas Health
Institute).
- "Health Care Access, Quality and
Insurance for Children with Special Health Care
Needs" (Principal Investigator: Nancy Swigonski,
Indiana University School of Medicine).
- "New York's SCHIP: What Works for Vulnerable
Children" (Principal Investigator: Peter Szilagyi,
University of Rochester).
- "Provider Participation and Access to Care in Alabama and
Georgia" (Principal Investigator: Janet Bronstein,
University of Alabama).
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CHIRI™ Funders
AHRQ, part of the U.S. Department of Health and Human
Services, is the lead agency charged with supporting
research designed to improve the quality of health
care, reduce its costs, address patient safety and
medical errors, and broaden access to essential
services. AHRQ sponsors and conducts research
that provides evidence-based information on health
care outcomes; quality; and cost, use and access.
The David and Lucile Packard Foundation is a
private family foundation that provides grants in a
number of program areas, including children,
families and communities, population, and
conservation and science.
The Health Resources and Services Administration,
also part of the U.S. Department of Health and
Human Services, directs national health programs
that provide access to quality health care to
underserved and vulnerable populations. HRSA
also promotes appropriate health professions
workforce supply, training and education.
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Other Funders
Additional support for the Kansas project was
provided by the Kansas Health Foundation, the
United Methodist Health Ministry Fund, and the
Prime Health Foundation.
Additional support for the Alabama project was
provided by the Alabama Children's Health
Insurance Program.
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For More information
Select for more information on CHIRI™.
*This Issue Brief is based on articles in a 2003 supplement to the journal Pediatrics (Volume 112; Issue 6):
- Brach C, Lewit EM, VanLandeghem K, et al.
Who's enrolled in SCHIP? Findings from the
Child Health Insurance Research Initiative
(CHIRI™). Pediatrics; 112(6):499-507; 2003.
- Dick AW, Klein JD, Shone LP, et al. The
evolution of SCHIP in New York: changing
program features and enrollee characteristics.
Pediatrics; 112(6):542-50; 2003.
- Rosenbaum S, Budetti P. Low-income
children and health insurance: old news and new
realities. Pediatrics; 112(6):551-3; 2003.
- Shenkman E, Youngblade L, Nackashi J.
Adolescents' preventive care experiences before
entry into SCHIP. Pediatrics; 112(6):533-41;
2003.
- Shone LP, Dick AW, Brach C, et al. The role of
race and ethnicity in SCHIP in four states: are
there baseline disparities, and what do they mean
for SCHIP? Pediatrics; 112(6):521-32; 2003.
- Szilagyi PG, Shenkman E, Brach C, et al.
Children with special health care needs enrolled
in SCHIP: patient characteristics and health care
needs. Pediatrics; 112(6):508-20; 2003.
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AHRQ Publication No. 04-0015
Current as of December 2003
Internet Citation:
Who's Enrolled in SCHIP? CHIRI™ Issue Brief 3. AHRQ Publication No. 04-0015, December 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/chiri/chirischip.htm
540 Gaither Road Rockville, MD 20850