More Monitoring Needed to Evaluate How SCHIP Meets Children's Health Needs
From 1997 to 2000, researchers affiliated with the Maternal & Child Health Policy Research Center studied the role of insurance in determining children's access to primary care. The research team also examined employer-sponsored private health insurance for children, and analyzed the federal State Children's Health Insurance Program (SCHIP).
Research efforts included a survey of 450 employers and telephone interviews with 46 state health officials.
The center, based in Washington, is a nonprofit, nonpartisan organization specializing in health policy research and education.
Key Findings and Recommendations
- Insured children have better access to care, and those with private insurance have better access than those on Medicaid.
- Most employers believe covering their employees' children is "the right thing to do."
- One in five employees elects not to take employer coverage for their children, and half select a "minimum" basic benefits package.
- SCHIP grants states wide latitude in deciding which children to cover and how to structure benefits and cost-sharing arrangements.
- One in six children eligible for SCHIP coverage has special health care needs, and states generally have not structured their programs to meet these needs.
- The investigators recommended an integrated monitoring program to evaluate how SCHIP and Medicaid meet the health needs of children in low-income families.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $627,152.
Little information about the scope, quality, and effectiveness of health care insurance for children is available. This grant from RWJF provided partial funding to researchers affiliated with the Maternal & Child Health Policy Research Center in Washington, D.C., to develop a series of analyses on how children are faring under current coverage patterns. A grant from the federal Maternal and Child Health Bureau provided additional support for this project. Specifically, the project team:
- Studied the role of insurance in determining children's access to primary care.
- Examined employer-sponsored private health insurance for children.
- Analyzed SCHIP, a federal program under which states can extend health coverage to children in low-income families who are not eligible for Medicaid.
Researchers conducted literature reviews, reviewed SCHIP plans and contracts, and analyzed national survey data from the National Health Interview Survey and the National Medical Expenditure Survey. A subcontractor, Lake, Sosin, Snell, Perry and Associates (Washington, D.C.), conducted a telephone survey of 450 small, medium, and large employers on employer health insurance policies for children. Two other contractors, McManus Health Policy, Inc. (Washington, D.C.), and Fox Health Policy Consultants (Washington, D.C.), conducted telephone interviews with 46 state officials involved with SCHIP and Medicaid programs, and prepared reports on state activities and private health plans.
The Role of Insurance in Children's Access to Care
The following findings were published in peer-reviewed journals, as noted below:
- Health insurance coverage for children is strongly associated with access to primary care. An estimated 13 percent of US children did not have health insurance in 19931994. Uninsured children were less likely than insured children to have a usual source of care; more likely to have gone without needed medical, dental, or other health care; and less likely to have seen a physician during the previous year. (The New England Journal of Medicine, February 19, 1998.)
- Poor children covered by Medicaid had better access to health care than the uninsured, but lagged behind non-poor children with private health insurance. Medicaid beneficiaries were more likely to have a usual source of care than the uninsured. Children covered by Medicaid and private insurance used similar levels of physician services (defined by number of physician visits). But Medicaid recipients were more likely to have unmet health needs (medical care, dental care, medications, eyeglasses, or mental health care) and were less likely to have a usual source of care than children with private insurance. (Journal of the American Medical Association, November 25, 1998.)
- Health insurance is a critical determinant of access to and use of health services among adolescents. An estimated 14.1 percent of adolescents were uninsured in 1995; older adolescents, minorities, and adolescents in low-income families or single-parent households were the most likely to be uninsured. Compared to insured adolescents, uninsured adolescents were five times as likely to lack a usual source of care, four times as likely to have unmet health needs, and twice as likely to go without a physician contact during a year. (Pediatrics, August 1999.)
- Unmet health needs remain prevalent among US children and can harm their short- and long-term health. For example, untreated physical, psychological, and behavioral problems put children at risk for developing lifelong chronic conditions. Some 7.3 percent (4.7 million) of US children had at least one unmet health care need. The most common unmet health needs were dental care, medical care, eyeglasses, and prescription medications. Uninsured children were about five times as likely as privately insured children to have an unmet need, and publicly insured children were about 50 percent more likely than privately insured children to have an unmet need. Poor and near-poor children were three to four times as likely to have an unmet need as those in middle or higher income households. (Pediatrics, April 2000.)
Employer-Sponsored Private Health Insurance for Children
The report on the employer survey, Private Health Insurance Coverage for Children: A Survey of 450 Employers, included the following findings:
- The vast majority of employers believe that providing employees with health insurance for their children is "the right thing to do."
- One in five employees elects not to take employer coverage for their children.
- Most employees with dependent children participate in a health maintenance organization (HMO) or a preferred provider organization (PPO).
- Half of the employers characterize the package of services covered under the health insurance plans that families generally select as a "minimum" basic benefits package.
- One out of five employers characterize their health insurance plan's cost-sharing policies as similar to a "common" (typical of health insurance plans) cost-sharing arrangement.
- Employers contribute less toward the coverage for their employees' dependent children than they do for their employees.
- About one in four employers report that a year from now, employees will pay more for their children's coverage and one in five predicts more dependents will be enrolled in HMOs.
- A majority of employers expressed interest in possibly expanding health insurance to offer more parenting education programs, preventive visits, and mental health counseling and support for children and their families.
Analysis of SCHIP
The following findings were reported in four issue briefs:
- States have many choices for determining which low-income children to cover under SCHIP, and the flexibility to focus on children with the greatest health care needs and the least access to insurance.
- States have many plan and benefit options to choose from. States must weigh the financial tradeoffs of covering more uninsured children with a narrower benefit package versus covering fewer children with more comprehensive services. They must also evaluate the cost and efficiency of using Medicaid or other private or public-private arrangements to administer SCHIP.
- States have several cost-sharing arrangements to consider, each with implications for enrollment and utilization of services. States could eliminate premium charges for some groups of children or set them using a single or multiple rate according to income and family size; use deductibles for some or all services; and eliminate, selectively use, or cap co-payments. High premiums tend to reduce enrollment, while high co-insurance or co-payments tend to reduce the utilization of services.
- An estimated one in six children who are eligible for SCHIP has special health care needs (a chronic physical, developmental, behavioral, or emotional condition requiring health and related services of a type or amount beyond those required by children generally); states generally have not structured their programs to meet these needs. States can make children with disabilities eligible for SCHIP at higher family income levels than other children.
- An estimated 6.3 percent of low-income, uninsured children were somewhat disabled (limited in or unable to conduct age-appropriate school or play activities due to chronic conditions) in 1994. Without health insurance, these children experience substantial difficulties obtaining needed health care.
Researchers made the following recommendations in an article published in the April 2000 issue of Pediatrics:
- An effective monitoring strategy for SCHIP should include:
- a comprehensive approach to monitoring
- collection of comparable data across states
- making effective use of existing data sources
- sponsoring new data collection efforts where needed to provide reliable state estimates.
- An integrated monitoring program that combines population-based data with information from state evaluations could enhance the ability of SCHIP and Medicaid to meet the health needs of children in low-income families.
Project staff produced four issue briefs and four fact sheets on SCHIP, which were disseminated to 1,000 state and federal maternal and child health agencies, SCHIP and Medicaid agencies, and other interested organizations, and posted online. The report, Private Health Insurance Coverage for Children: A Survey of 450 Employers, covered results of the employer survey and is also available online. Findings were also published in five journal articles (one each in The New England Journal of Medicine and Journal of the American Medical Association, and three in Pediatrics). Results were also featured in The Washington Post and USA Today. (See the Bibliography for details.)
AFTER THE GRANT
From 2000 to 2003, the researchers received $600,000 in funding from the W.T. Grant Foundation to continue their work on child and adolescent health insurance issues.
During the grant period, the researchers examined the relationship between socioeconomic status and use of healthcare. The team categorized the participants according to family income, so that adolescents with family incomes below the 1999 Federal Poverty Line of $17,029 for a family of four were classified as 'poor,' while adolescents with family incomes of greater than three times the Federal Poverty Line were classified as 'high-income'.
In an October 2003 article published in Health Services Research, the investigators presented the following findings:
- Some 24.6 percent of poor adolescents lacked health insurance coverage, compared to 4.6 percent of high-income adolescents.
- Poor adolescents were almost five times as likely to be in fair or poor health as high-income adolescents.
- Some 6.7 percent of poor adolescents were unable to get medical care due to costs, compared to 0.9 percent of high-income adolescents.
Researchers also reported direct correlations between income level and:
- Healthcare satisfaction.
- Access to a personal doctor or nurse.
- Frequency of visits to a dentist in one year.
Investigators concluded that adolescents in low-income families remained at a disadvantage with regard to healthcare access and use despite expansions of the Medicaid program and of SCHIP, and suggested that further efforts be taken to increase eligible adolescent enrollment in these programs.
In a 2004 article published in the Journal of the American Medical Association, the team reported on findings related to the number of adolescents covered by private and public health insurance plans. Investigators noted that:
- The percentage of uninsured adolescents as a proportion of the general population decreased from 14.1 percent in 1984 to 12.1 percent in 2002.
- Some 65.1 percent of youth were covered by private health insurance plans, compared to 21.5 percent covered by public health insurance, and 1.3 percent by a combination of the two.
- Between 1984 and 2002, the proportion of adolescents with private insurance declined from 75.9 percent to 66.4 percent.
- Within that same time period, the proportion of adolescents with public coverage increased from 11.9 percent to 22.8 percent.
In the article, researchers stated that the overall decrease in the proportion of uninsured adolescents despite the decline in the proportion of adolescents with private coverage was due to the expansion of programs such as Medicaid and SCHIP. The investigators suggested that continued efforts to increase eligible enrollment would further decrease the proportion of uninsured adolescents within the general population.
GRANT DETAILS & CONTACT INFORMATION
Children's Health Insurance: Analysis of Trends and Initiatives
University of California, San Francisco, Institute for Health Policy Studies (San Francisco, CA)
Dates: July 1997 to June 2000
Paul W. Newacheck, Dr.P.H.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Books and Reports
Fox H, McManus, M, Almeida R, and Graham R. Issue Brief No. 1: Eligibility Options Under the State Children's Health Insurance Program. Washington, D.C.: Maternal and Child Health Policy Research Center, December 1997. Approximately 1,000 copies mailed. Also available online.
Fox H, McManus M, Graham R, and Almeida R. Issue Brief No. 2: Plan and Benefit Options Under the State Children's Health Insurance Program. Washington, D.C.: Maternal and Child Health Policy Research Center, January 1998. Approximately 1,000 copies mailed. Also available online.
Fox H, McManus M, Rodger J, and Hayden K. Issue Brief No. 3: Cost-Sharing Options Under the State Children's Health Insurance Program. Washington, D.C.: Maternal and Child Health Policy Research Center, March 1998. Approximately 1,000 copies mailed. Also available online.
Fox H, Graham R, and McManus M. Issue Brief No. 4: States' CHIP Policies and Children with Special Health Care Needs. Washington, D.C.: Maternal and Child Health Policy Research Center, October 1998. Approximately 1,000 copies mailed. Also available online.
McManus, M, Fox H, Perry M, Stark E, and Kennel S. Private Health Insurance Coverage for Children: A Survey of 450 Employers. Washington, D.C.: Maternal and Child Health Policy Research Center, April 1999. Approximately 100 copies mailed. Also available online.
Newacheck PW, Stoddard JJ, Hughes DC, and Pearl M. "Health Insurance and Access to Primary Care for Children." New England Journal of Medicine, 338(8): 513519, 1998. Abstract available online.
Newacheck PW, Pearl M, Hughes DC, and Halfon N. "The Role of Medicaid in Ensuring Children's Access to Care." Journal of the American Medical Association, 280(20): 17891793, 1998. Abstract available online.
Newacheck PW, Brindis CD, Cart CU, Marchi K, and Irwin CE. "Adolescent Health Insurance Coverage: Recent Changes and Access to Care." Pediatrics, 104(2 Pt. 1): 195202, 1999. Abstract available online.
Newacheck PW, Halfon N, and Inkelas M. "Commentary: Monitoring Expanded Health Insurance for Children: Challenges and Opportunities." Pediatrics, 105(4 Pt. 2): 10041007, 2000.
Newacheck PW, Hughes DC, Hung YY, Wong S, and Stoddard JJ. "The Unmet Health Needs of America's Children." Pediatrics, 105(4 Pt. 2): 989997, 2000.
Newacheck PW, Hung YY, Marchi KS, Hughes DC, Pitter C, and Stoddard JJ. "The Impact of Managed Care on Children's Access, Satisfaction, Use and Quality of Care." Health Services Research, 36(2): 315334, 2001. Abstract available online.
Newacheck PW, Hung YY, Park MJ, Brindis CD and Irwin CE. "Disparities in Adolescent Health and Health Care: Does Socioeconomic Status Matter?" Health Services Research, 38(5): 12351252, 2003. Available online.
Newacheck PW, Park MJ, Brindis CD, Biehl M and Irwin CE. "Trends in Private and Public Health Insurance for Adolescents." Journal of the American Medical Association, 291(10): 12311237, 2004. Abstract available online.
Brochures and Fact Sheets
"Fact Sheet No. 1: Children With Disabilities Under the State Children's Health Insurance Program." Maternal and Child Health Policy Research Center, December 1997. Also available online.
"Fact Sheet No. 2: An Analysis of the Scope of Covered Benefits in the Florida, New York and Pennsylvania Health Plans." Maternal and Child Health Policy Research Center, December 1997. Also available online.
"Fact Sheet No. 3: The Potential for Crowd Out Due to CHIP: Results from a Survey of 450 Employers." Maternal and Child Health Policy Research Center, March 1998. Also available online.
"Fact Sheet No. 4: New Estimates of Children with Special Health Care Needs and Implications for the State Children's Health Insurance Program." Maternal and Child Health Policy Research Center, March 1998. Also available online.
"Clinton announces moves to expand children's medical care," in The Washington Post, February 19, 1998.
"Children's health insurance," in USA Today, February 19, 1998.
Report prepared by: Lori De Milto
Reviewed by: Janet Heroux
Reviewed by: Robert Narus
Program Officer: Pamela S. Dickson