November 2007

Grant Results

SUMMARY

Assessing the New Federalism is an Urban Institute project that tracks the impact of state and federal policy changes on: (1) the health and social welfare of families and children; and (2) the structure of health and social welfare programs. As part of this project, the Robert Wood Johnson Foundation (RWJF):

Key Findings

  • Medicaid and SCHIP face considerable financial stress and would benefit from a broad restructuring, including higher levels of mandated coverage and greater federal financial contributions.
  • SCHIP, together with the Medicaid outreach and enrollment simplification efforts that accompanied it, led to reductions in the number of children who are uninsured.
  • The wide variation in employer-sponsored coverage across states is a major contributor to a corresponding variation in uninsurance rates.

Funding
RWJF provided $16,515,533 for this unsolicited project from 1998 to 2007.

 See Grant Detail & Contact Information
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THE PROBLEM

In the 1990s, federal and state policies toward work and low-income families changed substantially. These changes included:

  • A substantial transfer of responsibility for social programs (e.g., health care, income security, employment and training programs, and social services) from the federal government to the states.
  • The Personal Responsibility and Work Opportunity Reconciliation Act of 1996, which reduced the number of welfare recipients from 4 million in 1996 to 2 million in 2000, and reduced the number of children insured through Medicaid. A year after leaving welfare, 41 percent of mothers and children were uninsured, according to researchers at the Urban Institute, a nonpartisan economic and social policy research organization.

In 1996, an estimated 10.6 million children were uninsured, according to the Current Population Survey (the U.S. Census Bureau's monthly survey of about 50,000 households).

To expand coverage for children, the Balanced Budget Act of 1997 (Title XXI) created the State Children's Health Insurance Program (SCHIP). SCHIP gives states the authority to broaden Medicaid eligibility, develop new programs or both. (For information on the SCHIP legislation, see Appendix 1.)

Assessing the New Federalism

In 1996, the Urban Institute began Assessing the New Federalism, a research project that tracks how children and families are faring, and how program structure, financing and administration are changing as the federal government transfers authority for health and social welfare programs to states. Key components are:

  • The National Survey of America's Families. This survey of about 40,000 households measures child, adult and family well-being, with an emphasis on low-income families. It was first fielded in 1997. (For more information, see Appendix 2.)
  • In-depth case studies of policies in 13 states that are home to more than half the nation's population (Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington and Wisconsin). RWJF partially funded the study of New Jersey. (See Grant Results on ID# 030554.)
  • A database with information on all states and the District of Columbia.
  • Analyses of secondary data sources such as the Current Population Survey and National Health Interview Survey.

Before October 1998, the Annie E. Casey Foundation (the primary funder) and 10 other foundations provided $30.5 million for Assessing the New Federalism.

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RWJF STRATEGY

For more than 30 years, RWJF has been concerned about Americans' lack of access to affordable and stable health care coverage. RWJF has funded studies, demonstration projects and symposia about this problem.

For example, in 2000, RWJF provided grant support to researchers at the Nelson A. Rockefeller Institute of Government (the Rockefeller Institute), the public policy research arm of the State University of New York, who studied the effects of state implementation of welfare reform on Medicaid enrollment among low-income adults and children.

The study found that enrollment of low-income adults and children dropped after welfare reform, then began to increase in 1998. (See Grant Results on ID# 038230.)

In 1997, Congress funded SCHIP with the aim of providing health insurance coverage to children who were not eligible for private or other public insurance programs. That same year, RWJF created Covering Kids®. (See Grant Results on the program.)

In 2001, RWJF reshaped the program and renamed it Covering Kids and Families®, reflecting the Foundation's commitment to help states also cover parents and other adults who work in jobs that do not provide health coverage for them or their children.

Through a series of State Coverage Initiatives, RWJF assisted states in developing and implementing policies that made health care insurance more available and affordable to low-income residents.

RWJF also created State Solutions: An Initiative to Improve Enrollment in Medicare Savings Programs, to enroll in Medicaid those Medicare beneficiaries who are eligible for it.

Communities in Charge: Financing and Delivering Health Care to the Uninsured was a national program to help cities or counties improve access to care for low-income, uninsured individuals by changing the organization and financing of local care delivery. (See Grant Results on the program.)

The Access Project: National Access to Care Initiative began work to improve health and health care in 1998. (See Grant Results on the program.)

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THE PROJECT

The scope of Assessing the New Federalism broadened over time, with Urban Institute researchers examining changes to the social safety net in all 50 states by analyzing the major federal and state health, income security, social service and job training programs as they affect low-income families and children.

Researchers used RWJF support to evaluate SCHIP and to collect and analyze health data. Under the first grant (ID# 034267), they:

  • Conducted the health portion of the 1999 National Survey of America's Families.
  • Examined issues relating to federalism, Medicaid policy changes, role of the health care safety net, racial/ethnic disparities in health care, employer-sponsored insurance and uninsurance.
  • Analyzed the impact of SCHIP, studying these key issues:
    • Policy choices and implementation challenges at the state level.
    • Participation and nonparticipation in Medicaid and SCHIP when SCHIP programs were initiated, and as they matured.
    • Impacts of SCHIP and related policy changes on insurance coverage of children.

Under the second grant (ID# 040167), RWJF partially supported:

  • A second round of case studies in the 13 states in 1999 and 2000.
  • The 2002 National Survey of America's Families, and continued data analysis from the 1997 and 1999 surveys.

Other Funding

From October 1998 through January 2007, other foundations, the federal government and the Urban Institute contributed approximately $92.4 million to Assessing the New Federalism. (See Appendix 3 for details on other funding.)

Project Activities

Urban Institute researchers:

  • Conducted intensive case studies in 13 states that adopted different styles of programs. To develop the case studies, researchers conducted site visits with state officials, consumers and providers and reviewed public documents and Web sites.
  • Performed descriptive and impact analyses of changes in insurance coverage, access, use and other outcomes after SCHIP programs were implemented, primarily drawing on data from the National Survey of America's Families. Researchers also used data from the Current Population Survey (a joint effort between the Bureau of Labor Statistics and the Census Bureau) and the National Health Interview Survey (a continuous household survey of about 43,000 households conducted by the National Center for Health Statistics).
  • Prepared and fielded the 2002 National Survey of America's Families. Westat, a research corporation, fielded the survey from February to October 2002 and handled data collection under a subcontract with the Urban Institute.

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RESULTS

Assessing the New Federalism produced the following overall results:

  • Timely, relevant information for policy-makers and researchers. Urban Institute researchers wrote more than 450 publications, ranging from short "Snapshots" (straightforward presentations of key facts intended for a broad audience) to lengthier, more complex analyses that explore the connections between policies and results. Publications included journal articles (in the American Journal of Public Health, Health Affairs, Health Services Research and Pediatrics, among others), reports, papers and policy briefs.

    Most publications are available free on the Urban Institute's Web site. See the Partial Bibliography for details. Urban Institute researchers disseminated information through commentators, the media, a listserv, the Urban Institute's Web site, mail and presentations. For more information about dissemination, see Appendix 4.)

    Urban Institute researchers also conducted numerous briefings of Congressional staff related to Assessing the New Federalism research.

    Among the ways this information has affected policy, according to Nancy Barrand, RWJF program officer and special advisor for program development, and Urban Institute Project Director Genevieve Kenney:
    • The finding that people have poor recall of their health insurance status led the Census Bureau to develop a verification question. This led to a small reduction in the estimated number of uninsured people in the United States.
    • Findings on state spending of SCHIP monies led Congress to revise its allocation formula to give states more time to expand their SCHIP programs without losing federal funding.
    • The finding that most uninsured children are in families served by other public programs led the Clinton Administration to change confidentiality rules to promote information sharing. This has streamlined enrollment and administration and facilitated outreach activities.
    • The Congressional Budget Office (CBO) cited project findings on eligible but uninsured children and crowd-out in background memos on SCHIP that laid the groundwork for CBO's assessment of SCHIP reauthorization bills.
    • Findings about SCHIP related to its positive impacts on insurance coverage and access to care among low-income children influenced the development of proposed policies for the SCHIP reauthorization discussion in 2007.
  • Free public data. The data are comprised of the following and are available after registration:
    • National Survey of America's Families Public Use Data: Self-extracting files.
    • National Survey of America's Families Online Statistical Analysis: A set of programs that allows researchers to perform Web-based analysis.
    • Welfare Rules Database: A resource to compare the rules of cash assistance programs between states, or within one state.

Findings

The Urban Institute reported the following findings in Federalism and Health Policy (2003), Assessing the New Federalism: Eight Years Later (2005) and in journal articles, policy briefs and other reports.

Restructuring Health Coverage

(Source: Assessing the New Federalism: Eight Years Later, 2005)

  • Medicaid and SCHIP are facing considerable stress and would benefit from a broad restructuring, including higher levels of mandated coverage and greater federal financial contributions. According to the project director, this was the most important overall finding.

    Despite the system's many strengths, including providing coverage and access to care for many low-income children and their parents, there are major reasons to restructure:
    • Fiscal stress on state budgets. Pressures on state budgets make it difficult for states to fund rising health care costs. In tight economic times, such as the early 2000s, constrained state budgets may collide with increased enrollment in Medicaid and SCHIP as families lose jobs and coverage.
    • Access and equity. Although Medicaid has improved access to health services for large numbers of low-income Americans, beneficiaries in many states face persistent access problems. Coverage varies considerably across states, particularly for adults. While states face very disparate situations, most of them must deal with formidable barriers to improving equity.
    • Lack of innovation. The states have in general not taken the lead in increasing health coverage and access to care for adults.
    • Threats to trust and integrity from Medicaid maximization strategies. Some state practices aim to bring more federal money to states with little or no additional contribution of their own (often called "Medicaid maximization"). For example, the federal government believes that some states have used their federal allotments to help hospitals defray the costs of caring for the uninsured (a practice known as disproportionate share hospital payments). The effect of this is to decrease the state's fiscal responsibilities for Medicaid.

      This and other practices, common when states are facing budget shortfalls, disrupt the intended balance between federal and state payments for program costs. While legal, they are the subject of heated federal-state disputes and threaten federal-state trust and the integrity of the program.

SCHIP Coverage and Participation

(Primary Sources: Assessing the New Federalism: Eight Years Later, 2005; Federalism and Health Policy, 2003; Children's Insurance Coverage and Service Use Improve, July 2003 Snapshots 3 brief; Five Things Everyone Should Know About SCHIP, October 2002 issue brief).

  • States responded to SCHIP enthusiastically and most of them implemented the program rapidly:
    • SCHIP enrollment grew gradually, reaching 3.6 million by June 2002. Over time, states made major efforts to improve outreach and simplify enrollment procedures.
    • More than a dozen states extended coverage to children with family incomes of more than twice the federal poverty level. Other states have extended coverage to parents of SCHIP enrollees, arguing that this will increase the participation of their children.
    • Early in the program's history, few states imposed premiums and cost sharing, although SCHIP allowed them to do so in amounts up to five percent of family income. However, most states now impose modest premiums and cost sharing.
    • SCHIP programs covered a broad range of preventive, primary and acute-care services for children.
    • States and the federal government developed positive relationships with SCHIP, in contrast to the often contentious and adversarial relationships surrounding the Medicaid program.

    (For more information on how states designed and implemented their SCHIP programs, see Appendix 5.)
  • In 1999, 84 percent of low-income uninsured children and 77 percent of all uninsured children in the United States were eligible for either Medicaid or SCHIP. Actual participation varied across states and subgroups of children:
    • In 1999, between 59 to 93 percent of all eligible children participated in either Medicaid or SCHIP in the 13 states studied closely.
    • Participation was lower among children with fewer health care needs or with parents who held negative views about welfare.
  • Overall, the participation of uninsured children in the United States in both Medicaid and SCHIP increased between 1999 and 2002 as states streamlined the application process and invested heavily in publicizing SCHIP. Nationwide:
    • Participation in SCHIP by eligible children increased from 43 to 66 percent.
    • The share of low-income uninsured children whose parents had heard of their state's SCHIP program increased from 47 to 71 percent.
  • Between 1999 and 2002, following expansions in SCHIP coverage and related Medicaid outreach and enrollment simplification efforts, the rates of uninsured children fell and access to health care increased. Nationwide:
    • The number of uninsured children fell from 9.6 million to 7.8 million.
    • The rate at which low-income children were uninsured declined by nearly six percentage points.
    • The percentage of African-American and Hispanic children without insurance declined by more than four percentage points.
    • Low-income children received 3.5 percent more well-child care, 4.5 percent more office visits and 2.1 percent more dental care.
  • Between 1999 and 2002, SCHIP reduced unmet health needs and out-of-pocket spending for children and increased visits to dentists and eye doctors.
  • Four million children who appeared to be eligible for Medicaid or SCHIP remained uninsured as of 2002.

More Recent Findings About SCHIP Coverage and Participation

(Source: "Coverage Patterns among SCHIP-Eligible Children and Their Parents," Health Policy Online, February 2007)

  • SCHIP has signed up close to 70 percent of its target population, but 1.8 million eligible children nationwide were not enrolled, based upon the 2005 Current Population Survey. Among eligible children in fair to poor health, 80 percent were enrolled in SCHIP.
  • Since SCHIP began, the number of children without insurance has fallen, particularly in low-income families. Still, about 9 million children do not have health insurance, according to 2005 Current Population Survey estimates.
  • Federal funding, about $5 billion in 2007, will have to increase substantially if the 1.8 million eligible children not enrolled are to join the approximately 3.9 million children now with SCHIP coverage, according to estimates by Urban Institute researchers.
  • 25 percent of SCHIP enrollees live in families where both parents have employer-sponsored insurance coverage, indicating that most SCHIP enrollees lack access to affordable employer-sponsored insurance.

Impact of Tight State Budgets

(Source: Assessing the New Federalism: Eight Years Later, 2005)

  • States' ability to finance health care programs for low-income people deteriorated dramatically between the late 1990s and 2004:
    • In the late 1990s, states experienced strong economic growth, gained new revenues from tobacco settlements and Medicaid maximization strategies, and implemented the new SCHIP program. After 2001, the economy slowed and states began to contemplate Medicaid cuts; at the same time, Medicaid enrollment was increasing as employment fell and health care costs rose. By 2003, states were under serious budget pressure and faced difficult choices among spending reductions and tax increases.
    • In 2003, states generally protected Medicaid enrollment but made some cuts in SCHIP. Savings in Medicaid costs came primarily by reducing reimbursement rates and eliminating some optional benefits. Every state except New York made at least one cut in SCHIP, typically by limiting eligibility, increasing cost sharing or reducing funds for enrollment simplification and provider reimbursement. Most states also cut outreach activities.
    • In 2004, some states raised taxes and some enacted broader spending cuts, including deeper cuts in health care.
    • The state budget choices made in 2004 are likely to have long-term consequences for fiscal stability. For example, as state economies improve, general revenues will be needed to replenish reserves and trust funds. As well, states may face more people without insurance because of restrictions on Medicaid and SCHIP enrollment and outreach. Other challenges include reimbursement rate cuts that are likely to reduce provider participation and Medicaid spending that may increase faster than state revenue growth.

State Role in Reducing Uninsured Levels

(Source: Assessing the New Federalism: Eight Years Later, 2005)

  • With few exceptions, states have not taken the lead as innovators in reducing the numbers of adults without insurance. While Medicaid provides many mechanisms for states to expand coverage, only 11 states covered all adults to at least 100 percent of the federal poverty level, and another 10 states covered primarily parents to that level. The remaining states hovered at the minimum required coverage, which is below the poverty level.
  • In some states, expanding public programs has reduced the rates of uninsured adults. Of the 13 states studied in depth:
    • Coverage expansion in Massachusetts significantly reduced the rates of uninsured low-income adults.
    • Significant expansions in California, New Jersey and Wisconsin reduced the overall rates of the uninsured. However, in New Jersey, much of the expansion was apparently the result of a shift from private coverage.
  • Medicaid coverage among adults varies significantly across states. In the 13 states studied intensively:
    • The proportion of adults with incomes below 100 percent of the federal poverty level eligible for Medicaid varies from 84 percent in Washington to 15 percent in Colorado.
    • Participation rates among those eligible for Medicaid varied from 81 percent in Massachusetts to 36 percent in Mississippi.
  • Spending and usage of Medicaid and SCHIP vary substantially by state:
    • For children, spending per Medicaid enrollee is twice as high in Massachusetts and New York as in California and 50 percent higher than in Alabama, Mississippi and Texas.
    • For several measures of health care access and usage, children in Massachusetts and New York fare better than the national average; children in Alabama, California, Mississippi and Texas fare worse.

Trends in Employer-Sponsored Coverage

(Source: Assessing the New Federalism: Eight Years Later, 2005)

  • The wide variation in employer-sponsored insurance coverage rates across states mirrors a corresponding variation in the percentage of the population without insurance:
    • For example, among the 13 case-study states, rates of employer-sponsored coverage among low-income adults varied from 40 percent in California to 63 percent in Wisconsin.
    • The 1999 National Survey of American Families showed a corresponding effect on insurance levels among low-income workers. In California, more than 35 percent of service workers lacked health coverage, while in Wisconsin that figure was about 22 percent.
  • Differences in income distribution across states figure into differences in the extent of their health coverage problems:
    • Despite lower income cutoffs for eligibility, much higher percentages of children and adults were covered in public programs in Mississippi and Texas, where a greater percentage of low-income families reside, than in Minnesota and Massachusetts.
  • The rate of employer-sponsored insurance is declining over time. Nationwide, employer coverage of low-income adults fell from 41.6 percent in 1999 to 37 percent in 2002:
    • Two-thirds of the decline stemmed from the decision by employees not to take insurance.
    • The share of workers with access to employer coverage who enrolled fell from:
      • 73 to 67 percent for low-income workers.
      • 90 to 88 percent for all workers.

Impact of Welfare Reform

(Source: Assessing the New Federalism: Eight Years Later, 2005)

  • Medicaid coverage among eligible children dropped after their families left welfare. Even though most recipient families remained eligible for Medicaid after leaving welfare, many were confused about their continued eligibility, faced barriers created by complex state policies, were inadvertently dropped from the rolls or discontinued coverage for some other reason:
    • According to the 1997 National Survey of America's Families, a year after leaving welfare, 41 percent of mothers and children were uninsured, 36 percent were on Medicaid and 23 percent had private insurance coverage.
    • At the urging of the federal Centers for Medicare & Medicaid Services, many states worked to increase former welfare recipients' knowledge about their Medicaid eligibility and to simplify program enrollment. As a result, among families that left welfare between 2000 and 2002, compared to families that left between 1997 and 1999:
      • Medicaid use by children increased from 57 to 64 percent.
      • Participation in Medicaid and SCHIP by adults rose from 40 to 48 percent.

Affordability of Health Insurance Coverage

(Source: "The Uninsured and the Affordability of Health Insurance Coverage," Health Affairs, November 2006)

  • 25 percent of the 44.6 million uninsured Americans in 2004 were eligible for health insurance coverage through Medicaid or SCHIP but were not enrolled. The percentage varied by populations:
    • 74 percent of uninsured children are eligible for public programs.
    • 27.8 percent of uninsured parents are eligible for public programs.
    • 8 percent of childless adults are eligible for public programs.
  • 56 percent of uninsured Americans need financial assistance to purchase private nongroup health insurance and 20 percent live in families whose incomes make the purchase of such insurance affordable:
    • 57 percent of parents need financial assistance to purchase health insurance.
    • 69 percent of childless adults need financial assistance to purchase health insurance.

Racial and Ethnic Disparities in Coverage and Access

(Source: Racial and Ethnic Differences in Insurance Coverage and Health Care Access and Use: A Synthesis of Findings from the Assessing the New Federalism Project, 2006)

  • The gap in insurance coverage between low-income Hispanic and white adults increased from 1997 to 2002.
  • Low-income African-American and white children were equally likely to be uninsured. However, African-American children were 24 percent more likely to be covered under public programs and 19 percent less likely to have employer-sponsored coverage.
  • Coverage differences between Hispanic and white citizens were small for those who are proficient in English. Noncitizens and Hispanic citizens who primarily speak Spanish were much less likely to have employer-sponsored insurance coverage than white citizens.
  • African-American and Hispanic adults were less likely than white adults to have a usual source of health care or to have seen a physician in the past 12 months. This was so even after controlling for demographic and socioeconomic characteristics, health insurance coverage and other characteristics.
  • Some racial and ethnic differences in access and use of health care can be attributed to differences in health insurance coverage. However, this is at best a partial explanation. Differences in income, education and employment also matter and are even more important in some cases.

Other Findings

Other findings, including findings by state, are available on the Urban Institute's Web site.

Recommendations

In Federalism and Health Policy (2003), researchers from the Urban Institute offered two proposals to create a stronger federal role in setting higher minimum standards for health insurance coverage and in providing financing. They proposed:

  • Expanding the minimum levels of Medicaid and SCHIP coverage while giving the states incentives to extend coverage further.
  • Shifting responsibility for a substantial portion of the health care safety net to the federal government.

The intent of both proposals is to provide fiscal relief to states, cover more people at higher income levels, limit the extensive disparities that exist today and eliminate at least some of the financial problems in the current system. (For more information on these recommendations, see Appendix 6.)

In an article in Health Affairs, researchers from the Urban Institute offered four options to re-design Medicaid financially without sacrificing its protections for vulnerable Americans ("Toward Real Medicaid Reform," February 2007):

  • Reform option one: The first two options expand eligibility for coverage to 150 percent of the federal poverty level. The first option would end SCHIP, and children's coverage would be integrated with Medicaid, with no enrollment caps; premiums such as those in the present SCHIP would be allowed. Coverage of adults would be expanded to 150 percent of poverty with the federal government match to state expenditures increased by 30 percent. States could expand further for children and adults at the enhanced matching rates. Federal matching rates on all acute-care services for current beneficiaries would be increased by 30 percent; there would be no change in matching rates for long-term care. The federal government would be responsible for Medicare premium and cost sharing for Medicare acute-care services. The current "clawback" policy for prescription drugs would remain in place. Because of the broad coverage expansion, disproportionate share hospital (DSH) payments would be eliminated.
  • Reform option two: This option, similar to the first, equalizes matching-rate increases across services and programs. Federal matching rates for all services, including long-term care, would increase by 15 percent. SCHIP would also be retained in its current form but with the matching rate reduced to 15 percent above current Medicaid rates. Coverage of adults would be expanded to 150 percent of poverty with a 15 percent enhanced match. States could further expand for both adults and children at the 15 percent enhanced match. Acute care service for dual eligibles, including state clawback payments, would become the responsibility of the federal government, and DSH payments would be eliminated.
  • Reform option three: This option would expand coverage for adults only to the poverty line, allowing states to go further if they choose. The current Medicaid/SCHIP structure for children would be retained. The federal government would be responsible for acute care services for dual eligibles, including eliminating the drug clawback. Matching rates for acute care services would remain at current levels. To help states with the looming costs of long-term care, matching rates for these services would increase by 30 percent. Because the mandatory coverage expansion would be less, DSH would not be eliminated but rather restructured with a new formula that would be based on the number of low-income people and potentially the number of recent immigrants.
  • Reform option four: This option would federalize all care for dual eligibles, including long-term care; this would not include acute care services not now covered by Medicare. The prescription drug clawback payment would be eliminated. Long-term care services for non-dual eligibles would be wholly the responsibility of states. The current Medicaid/SCHIP structure for children would be retained. Coverage of parents and nonparents would be expanded to 100 percent of poverty; states could expand further with current federal matching payments. The current matching payments on all Medicaid services would be retained; states could expand at the current matching rates. DSH would be restructured, not eliminated.

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SIGNIFICANCE TO THE FIELD

According to project staff at the Urban Institute and RWJF program officers, Assessing the New Federalism advanced the field by:

  • Analyzing variations in state coverage and the reasons for these variations.
  • Providing a comprehensive picture of health insurance and other issues that affect low-income children, such as family income security, social services and job training programs.
  • Analyzing reasons that parents do not enroll their children in available programs.
  • Advancing measurement of the uninsured.

Variations Among States

This was the first research to collect and analyze detailed data about low-income families on a state-by-state basis. The findings helped policy-makers understand that no single solution to health insurance and other problems will work for all states.

"This project helped people understand why state data are important," said Alan Weil, project director of Assessing the New Federalism until 2004. "We got into a level of detail about state variation which is critical in thinking about state policy and national policy."

The project enhanced understanding of the tremendous variability among the states and their ability to expand insurance, according to Linda Bilheimer, a former RWJF senior program officer. She said that the researchers "were able to demonstrate the very different impact that coverage expansion had depending upon the level of poverty and the degree of employer-sponsored coverage in the state. This insight has been very helpful for the whole recent debate about coverage expansions."

"It was extremely relevant to anyone looking at state policy," added RWJF's Barrand.

Understanding the Lives of Low-Income Children

The cumulative effect of Assessing the New Federalism's findings was to help the field understand how children in poverty are living and how federal health and welfare programs implemented at the state level affect them. "It's hard to think of any project dealing with low-income children where you won't be able to find an analysis of data on the Urban Institute Web site," said Barrand.

Reasons Parents Do Not Enroll Children

Assessing the New Federalism also helped the field understand why low-income parents do not enroll their children in public health insurance programs. The primary reason is a lack of understanding about the programs. "The project drew attention to the importance of ongoing outreach," said Bilheimer. She noted that it was harder to enroll children once coverage is expanded beyond families receiving welfare because other families continually become eligible but are not aware of it.

Measuring the Uninsured

Assessing the New Federalism introduced a follow-up question designed to verify that people who said they had no health insurance actually did not. "This was the first survey that really began to understand the complexities of asking people about their insurance coverage," said Bilheimer. "People have very poor recall of their health insurance coverage."

In response to project findings, the U.S. Census Bureau added a similar verification question to its Current Population Survey. "This moved the field forward to accurately measure the uninsured," said Weil.

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LESSONS LEARNED

  1. Case studies can help inform quantitative analysis. Researchers used insights gained from the state case studies to plan the quantitative analysis. For example, after learning that most programs did not become fully operational until well after they received federal approval, researchers waited until programs were mature before measuring their impact. (Project Director)
  2. Disseminating short reports quickly increases a project's impact. Researchers used policy briefs and snapshot reports to disseminate information that reached their intended audience quickly. (Project Director)
  3. Conducting the same survey over time generates useful information about trends. Project staff conducted a survey in 1997 that provided a baseline about health insurance coverage for children; two more surveys followed in 1999 and 2002. This made it possible for the field to see the impact of expanded coverage in children's health insurance over time. (Former Program Officer/Bilheimer)

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AFTER THE GRANT

Building on Assessing the New Federalism, the Urban Institute began a new research project, Low-Income Working Families, in 2006. Low-Income Working Families spotlights the private and public sector contexts for families' success or failure. Researchers are tracking families over time to document and analyze the risks they face.

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GRANT DETAILS & CONTACT INFORMATION

Project

Assessing the New Federalism

Grantee

Urban Institute (Washington,  DC)

  • Monitoring and Evaluating the State Children's Health insurance Program (SCHIP)
    Amount: $ 5,380,399
    Dates: October 1998 to December 2002
    ID#:  034267

  • Assessing the New Federalism Project
    Amount: $ 11,135,134
    Dates: February 2001 to January 2007
    ID#:  040167

Contact

Genevieve Kenney, Ph.D.
(202) 261-5568
JKenney@ui.urban.org
John F. Holahan, Ph.D.
(202) 261-5666
JHolahan@ui.urban.org

Web Site

http://www.urban.org/center/anf

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APPENDICES


Appendix 1

The State Children's Health Insurance Program (SCHIP)

SCHIP benefits became available October 1, 1997. SCHIP provided $40 billion in federal matching funds over 10 years to help states expand health care coverage to an estimated 10.6 million uninsured children. SCHIP was designed primarily to cover children who are not eligible for Medicaid in families with incomes up to 200 percent of the federal poverty level.

SCHIP is jointly financed by the federal and state governments and administered by the states. The federal government establishes budget allocations for states, and it matches state expenditures at a considerably higher rate than it does for Medicaid.

SCHIP offers three options to expand health insurance coverage with federal support:

  • Extending Medicaid coverage: Under this option, children in families with incomes higher than current Medicaid eligibility levels qualify for benefits. Medicaid rules for other eligibility criteria and for benefits apply.
  • Creating a new state-defined program: Each state defines both its eligibility standards (including age, income and asset levels, residency, disability status and duration of eligibility), and, within broad federal guidelines, the benefits the new insurance program will provide.
  • Combining the two options: For example, a state could raise its income eligibility ceiling for Medicaid and create a new insurance program for children in families with incomes between that Medicaid ceiling and the limit it chooses for SCHIP eligibility.


Appendix 2

National Survey of America's Families

The Urban Institute's National Survey of America's Families provides a comprehensive look at the well-being of children and non-elderly adults, charting new territory by asking new questions, devising new methods of collecting data, and developing advanced estimating techniques. The household survey focuses on the economic, health and social characteristics of children, adults under the age of 65 and their families.

The Urban Institute conducted the survey in 1997, 1999 and 2002. Each round comprised telephone interviews with more than 40,000 families, providing information on more than 100,000 people (including those without telephones; researchers screened families without telephones in person, and then provided them with cell phones for the telephone interview).

The survey gives researchers the tools to track national trends during the survey period, drawing on unusually detailed and comprehensive information about low-income parents and their children. In addition, the survey provides significant samples in 13 states with a broad range of fiscal capacity, indicators of child well-being and approaches to government programs. For a discussion of the methodological contributions made by the survey, see "Lessons Learned from the National Survey of America's Families" by Timothy Triplett and Laura Wherry, available online.

In addition to demographic and household composition information, questions covered:

  • Child well-being.
  • Family environment.
  • Health and health care.
  • Economic security.
  • Attitudes on welfare, work and raising children.
  • Social services.

Health questions covered:

  • Coverage.
  • Usage and access.
  • Status and limitations.
  • Familiarity with and perceptions of Medicaid/SCHIP programs.


Appendix 3

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Other Funding for Assessing the New Federalism (1998 to 2007)

Major funders were:

  • Annie E. Casey Foundation, $40.1 million
  • W.K. Kellogg Foundation, $12 million
  • Ford Foundation, $6 million
  • Henry J. Kaiser Foundation, $5 million
  • John D. and Catherine T. MacArthur Foundation, $4.67 million
  • David and Lucile Packard Foundation, $4.6 million
  • Charles Stewart Mott Foundation, $1 million


Appendix 4

Dissemination of Information
Project staff disseminated publications produced as part of Assessing the New Federalism through:

  • A commentator network: Project staff developed a network of researchers, advocates and representatives from professional and trade associations and from government (elected officials and administrative agency staff). When research was nearly ready to be released, project staff e-mailed the appropriate commentators to invite their participation, described the major findings and provided a timeline for release. Project staff then sent media materials to the commentators, who made themselves available to reporters interested in understanding how the research related to a particular local or state environment.
  • Release to the media: Project staff released research directly to reporters, linked them with interested commentators and drafted articles about the findings for use by the media.
  • A listserv, the Urban Institute's Web site and mail. Researchers sent:
    • An e-mail brief describing each report and summarizing key findings, with a link to the full text of the report to more than 17,000 subscribers of the "Hot Off the Press from ANF" listserv.
    • Full copies of the reports through the mail to stakeholders interested in Medicaid, SCHIP and children's health.
  • Speaking engagements and the release of findings at conferences and events: For example, in 2002, researchers worked with 40 organizations, including the March of Dimes, Family Voices, American Public Human Services Association, Center for Policy Alternatives and National Conference of State Legislatures to release four reports that are part of the SCHIP evaluation.


Appendix 5

Design and Implementation of SCHIP Programs

(Source: Five Things Everyone Should Know About SCHIP, October 2002 issue brief)

Following passage of the federal Balanced Budget Act of 1997 (Title XXI), which created SCHIP:

  • All 50 states and the District of Columbia created some form of expanded health care coverage for children:
    • 26 states and the District of Columbia adopted strategies to expand coverage to children in families at 200 percent of the federal poverty level.
    • 13 states opted to cover children in families with even higher incomes.
    • 11 states set income eligibility limits below 200 percent of the federal poverty level.
  • Nearly one-third of states (15 states, as well as the District of Columbia) chose to expand coverage under SCHIP by building exclusively on existing Medicaid programs. Thirty-five states created separate programs, either alone or in combination with smaller Medicaid expansions.
  • States invested heavily in outreach to raise awareness of the availability of new coverage. Typically, states used statewide media campaigns to generate public awareness and community-based efforts to reach and enroll families.
  • Streamlined enrollment is now the norm across the nation. States are:
    • Using a single short application form to determine eligibility for both SCHIP and Medicaid.
    • Permitting families to submit applications by mail.
    • Dropping asset tests from the process.
    • Reducing the documentation parents must submit with their applications.

    Although efforts to simplify Medicaid enrollment procedures have not kept pace with those of SCHIP, there has been significant "spillover" of these strategies to Medicaid. The result is that applying for Medicaid has become much simpler than in past years.
  • States with SCHIP programs that are separate from Medicaid cover a broad range of preventive, primary and acute-care services:
    • One-third of all states with separate programs chose to provide the full Medicaid benefit package to SCHIP enrollees.
    • At least six other states designed policies to ensure that children with special health care needs received Medicaid-equivalent coverage.
    • In other states, the few services most often excluded from separate SCHIP programs are typically those most likely to be used by children with special health care needs (e.g., case management).
  • States with separate SCHIP programs attempted to make cost sharing for families "affordable":
    • Of the 33 states that initially had separate programs, 27 imposed monthly premiums or annual enrollment fees (22 states) and/or co-payments on selected services (20 states). (Two states created separate programs later and were not included in this analysis.)
    • Case studies and focus groups suggest that premiums and co-payments were "affordable" for many families.


Appendix 6

Proposals to Create a Stronger Federal Role in Health Care for Low-Income People

In Federalism and Health Policy (2003), researchers from the Urban Institute offered two proposals to create a stronger federal role in setting higher minimum standards for health insurance coverage and in providing financing:

Expand minimum coverage and give states incentives for further expansion
This proposal would redefine the base of Medicaid and SCHIP coverage while giving the states incentives to extend coverage further. For example, minimum eligibility standards would be set at twice the federal poverty level for children and at the federal poverty level for adults. The federal government would then define a set of benefits for those who are eligible.

Under this proposal:

  • The current federal entitlement to coverage would remain in place.
  • States could extend coverage beyond the federal base of eligibility as high up the income scale as they wished. They could also impose co-payments, premiums, limits on benefits and enrollment caps on groups with higher incomes.
  • Federal matching payments would be 15 percent higher than they are under Medicaid.
  • The federal government would take over all financial responsibility for Medicare-covered acute-care services and prescription drugs for people who are eligible for both Medicaid and Medicare (dual eligibles).
  • A new and expanded Medicaid home and community-based services program would be adopted, with the 15 percent higher federal matching rate.
  • There would be minimum standards for payments to providers, but the disproportionate share hospital program, under which Medicaid payments are used to help hospitals defray the costs of caring for the uninsured, would be eliminated. That system could be replaced with a program that would provide grants directly to designated providers.

Shift more responsibility to the federal government
This proposal would shift responsibility for a substantial portion of the health care safety net to the federal government. For example, the federal government could assume full responsibility for covering the acute care costs of the same groups described in the first proposal: children with family incomes up to twice the federal poverty level and adults up to the federal poverty level.

Under this proposal:

  • Alongside the current Medicare program, the federal government would finance and operate a program across states that included a defined, comprehensive package of benefits and a uniform national system of provide reimbursement.
  • The federal government would take over full responsibility for people eligible for both Medicare and Medicaid.
  • States could continue to cover populations and provider benefits beyond the federally defined minimum, using the savings from the new federal program.
  • Existing shared responsibility for long-term care would remain in place, but the new program for home and community-based services described above could be included as an option.
  • The disproportionate share hospital program would be eliminated.


Appendix 7

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Glossary

Clawback: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 has a provision requiring states to help finance the new Medicare drug benefit (Medicare Part D) by making monthly payments to the federal Medicare program that are roughly equal to the expenditures the states would make if they continued to pay for outpatient prescription drugs through Medicaid on behalf of dual eligibles (low-income seniors and people who are disabled who are eligible for both Medicare and Medicaid). This is known as the "clawback" (the statutory term is "phased-down State contribution").

Crowd-out: Expanded public health insurance coverage through Medicaid, SCHIP and state-initiated coverage expansions "crowds out" private health insurance. While low-income families benefit from substituting public for private health insurance, the cost of reducing the number of uninsured rises, as both people who were uninsured and those who had private insurance receive subsidies. Crowd-out has implications for the cost, equity, efficiency and efficacy of public coverage initiatives.

Disproportionate share hospital (DSH) payments: Medicare makes these special payments to hospitals that treat a disproportionately high share of low-income patients, as per Federal law.

Dual eligibles: People who are eligible both for Medicare because they are older or disabled and for Medicaid because of their low income. Dual eligibles tend to be sicker, and use more acute and long-term care services, than other Medicare beneficiaries.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

PARTIAL BIBLIOGRAPHY

The Urban Institute's Web site contains the complete set of more than 450 publications of Assessing the New Federalism.

Books

Holahan J, Weil A and Wiener JM (eds.). Federalism and Health Policy. Washington: Urban Institute, 2003.

Selected Articles

Cohen RD and Hill I. "Enrolling Eligible Children and Keeping them Enrolled." Future of Children, 13(1): 81–97, 2003.

Coughlin TA and Zuckerman S. "Three Years of State Fiscal Struggles: How Did Medicaid and SCHIP Fare?" Health Affairs Web Exclusive, W5: w385–w398, 2005.

Coughlin TA, Long SK and Shen Y. "Assessing Access Under Medicaid: Evidence for the Nation and Thirteen States." Health Affairs, 24(4): 1073–1083, 2005. Abstract available online.

Davidoff AJ, Lo Sasso AT, Bazzoli GJ and Zuckerman S. "The Effect of Changing State Health Policy on Hospital Uncompensated Care." Inquiry, 37(3): 253–267, 2000. Abstract available online.

Davidoff AJ, Garrett AB, Makue D and Schirmer M. "Medicaid Eligible Children Who Do Not Enroll: Health Status, Access to Care and Implications for Medicaid Enrollment." Inquiry, 37(2): 203–218, 2000. Abstract available online.

Davidoff AJ and Garrett B. "Determinants of Public and Private Insurance Enrollment Among Medicaid Eligible Children." Medical Care, 39(6): 523–535, 2001. Abstract available online.

Davidoff AJ, Dubay L, Kenney GM and Yemane A. "The Effects of Parents' Insurance Coverage on Access to Care for Low-Income Children." Inquiry, 40(3): 254–268, 2003.

Davidoff AJ, Kenney GM and Dubay LC. "Effects of the SCHIP Expansions on Children with Chronic Health Conditions." Pediatrics, 116(1): e34–e42, 2005.

Dubay L and Kenney G. "Assessing SCHIP Impacts Using Household Survey Data: Promises and Pitfalls." Health Services Research, 35(5 Pt. 3): 112–127, 2000. Abstract available online.

Dubay L and Kenney GM. "Health Care Access and Use Among Low-Income Children: Who Fares Best?" Health Affairs, 20(1): 112–121, 2001. Abstract available online.

Dubay L and Kenney G. "Expanding Public Health Insurance Coverage to Parents: Effects on Children's Coverage under Medicaid." Health Services Research, 38(5): 1283–1301, 2003. Abstract available online.

Dubay L and Kenney G. "Gains in Children's Health Insurance Coverage but Additional Progress Needed." Pediatrics, 114(5): 1338–1340, 2004.

Dubay L and Kenney G. "Addressing Coverage Gaps for Low-Income Parents." Health Affairs, 23(2): 225–234, 2004. Abstract available online.

Dubay L, Holahan J and Cook A. "The Uninsured and the Affordability of Health Insurance Coverage," Health Affairs Web Exclusive, 26(1): w22–w30, 2006. Abstract available online.

Fairbrother G, Kenney G, Hanson K and Dubay L. "How Do Stressful Environments Relate to Access and Use of Health Care by Low-Income Children?" Medical Care Research and Review, 62(2): 205–230, 2005. Abstract available online.

Garrett B and Holahan J. "Health Insurance Coverage After Welfare." Health Affairs, 19(1): 175–184, 2000. Abstract available online.

Garrett B and Zuckerman S. "National Estimates of the Effects of Mandatory Medicaid Managed Care Programs on Health Care Access and Use, 1997–1999." Medical Care, 43(7): 649–657, 2005. Abstract available online.

Haley J and Kenney G. "Coverage Gaps for Medicaid-Eligible Children in the Wake of Federal Welfare Reform." Inquiry, 40(2): 158–168, 2003. Abstract available online.

Hill I. "Charting New Courses for Children's Health Insurance." Policy and Practice, 58(4): 30–38, 2000.

Holahan J, Rangarajan S and Schirmer M. "Medicaid Managed Care Payment Rates in 1998." Health Affairs, 18(3): 217–227, 1999. Abstract available online.

Holahan J and Kim J. "Why Does the Number of Uninsured Americans Continue to Grow?" Health Affairs, 19(4): 188–196, 2000.

Holahan J, Dubay L and Kenney G. "Which Children are Still Uninsured and Why." Future of Children, 13(1): 55–79, 2003. Abstract available online.

Holahan J and Weil A. "Toward Real Medicaid Reform." Health Affairs Web Exclusive, 26(2): w254–270, 2007. Abstract available online.

Kenney GM and Chang DI. "The State Children's Health Insurance Program: Successes, Shortcomings, and Challenges." Health Affairs, 23(5): 51–62, 2004. Abstract available online.

Kenney GM, McFeeters JM and Yee JY. "Preventive Dental Care and Unmet Dental Needs Among Low-Income Children." American Journal of Public Health, 95(8): 1360–1366, 2005. Abstract available online.

Kenney GM and Yee J. "SCHIP at a Crossroads: Experiences to Date and Challenges Ahead." Health Affairs, 26(2): 356–369, 2007. Abstract available online.

Ku L and Matani S. "Left Out: Immigrants' Access to Health Care and Insurance." Health Affairs, 20(1): 247–256, 2001. Abstract available online.

Long SK, Graves JA and Zuckerman S. "Assessing the Value of the NHIS for Studying Changes in State Coverage Policies: The Case of New York." Health Services Research, 42(6 Pt. 2): 2332–2353, 2007. Abstract available online.

Long SK and Shen YC. "Low-Income Workers with Employer-Sponsored Insurance: Who's at Risk When Employer Coverage is No Longer an Option?" Medical Care Research and Review, 61(4): 474–494, 2004. Abstract available online.

Long SK and Zuckerman S. "MassHealth Succeeds in Expanding Coverage for Adults." Inquiry, 41(3): 268–279, 2004. Abstract available online.

Long SK, Coughlin T and King J. "How Well Does Medicaid Work in Improving Access to Care?" Health Services Research, 40(1): 39–58, 2005. Abstract available online.

Long SK, Zuckerman S and Graves J. "Are Adults Benefiting from State Coverage Expansions?" Health Affairs, 25(2): w1–w14, 2006. Abstract available online.

Perry CD and Kenney GM. "Differences in Pediatric Preventive Care Counseling by Provider Type." Ambulatory Pediatrics, 7(5): 390–395, 2007. Abstract available online.

Perry C and Kenney G. "Preventive Care for Children in Low-Income Families: How Well Do Medicaid and State Children's Health Insurance Programs Do?" Pediatrics, 120(6): 2007.

Rajan S, Zuckerman S and Brennan N. "Confirming Insurance Coverage in a Telephone Survey: Evidence from the National Survey of America's Families." Inquiry, 37(3): 317–327, 2000. Abstract available online.

Ross DC and Hill IT. "Enrolling Eligible Children and Keeping Them Enrolled." Future of Children, 13(1): 81–97, 2003. Abstract available online.

Shen YC and Long SK. "What's Driving the Downward Trend in Employer-Sponsored Health Insurance?" Health Services Research, 41(6): 2074–2096, 2006. Abstract available online.

Shen YC and McFeeters J. "Out-of-Pocket Health Spending Between Low- and Higher-Income Populations: Who is at Risk of Having High Expenses and High Burdens?" Medical Care, 44(3): 200–209, 2006. Abstract available online.

Shen YC and Zuckerman S, "Why Is There State Variation in Employer-Sponsored Insurance?" Health Affairs, 22(1): 241–251, 2003. Abstract available online.

Sommers AS. "Access to Health Insurance, Barriers to Care, and Service use Among Adults with Disabilities," Inquiry, 43(4): 393–405, 2006/2007. Abstract available online.

Ullman F and Hill I. "Eligibility Under State Children's Health Insurance Programs." American Journal of Public Health, 91(9): 1449–1451, 2001. Abstract available online.

Zuckerman S, Bazzoli G, Davidoff A and LoSasso A "How Did Safety-Net Hospitals Cope in the 1990s?" Health Affairs, 20(4): 159–168, 2001.

Zuckerman S, Brennan N and Yemane A, "Has Medicaid Managed Care Affected Beneficiary Access and Use?" Inquiry, 39(3): 221–242, 2002. Abstract available online.

Zuckerman S, Kenney GM, Dubay L, Haley J and Holahan J. "Shifting Health Insurance Coverage, 1997–1999." Health Affairs, 20(1): 169–177, 2001.

Zuckerman S and Shen YC. "Characteristics of Occasional and Frequent Emergency Department Users: Do Insurance Coverage and Access to Care Matter?" Medical Care, 42(2): 176–182, 2004. Abstract available online.

Zuckerman S, Haley J, Roubideaux Y and Lillie-Blanton M. "Health Service Access, Use and Insurance Coverage Among American Indians/Alaska Natives and Whites: What Role Does the Indian Health Service Play?" American Journal of Public Health, 94(1): 53–59, 2004. Abstract available online.

Selected Reports

Assessing the New Federalism: Eight Years Later. Washington: Urban Institute, 2005. Available online.

Almeida RA and Kenney GM. Gaps in Insurance Coverage for Children: A Pre-CHIP Baseline. Policy Brief No. B-19. Washington: Urban Institute, 2000. Available online.

Almeida RA, Hill I and Kenney GM. Does SCHIP Spell Better Dental Access for Children? An Early Look at New Initiatives. Occasional Paper No. 50. Washington: Urban Institute, 2001. Available online.

Bovbjerg RR, Cuellar AE and Holahan J. Market Competition and Uncompensated Care Pools. Occasional Paper No. 35. Washington: Urban Institute, 2002. Available online.

Bovbjerg RR, Marsteller JA and Ullman FC. Health Care for the Poor and Uninsured after a Public Hospital's Closure or Conversion. Occasional Paper No. 39. Washington: Urban Institute, 2000.

Bruen BK and Ullman FC. Children's Health Insurance Programs: Where States Are, Where They are Headed? Policy Brief No. A-20. Washington: Urban Institute, 2001. Available online.

Capps R, Kenney GM and Fix ME. Health Insurance Coverage of Children in Mixed-Status Immigrant Families. Snapshots of America's Families III, No. 12. Washington: Urban Institute, 2003. Available online.

Capps R, Fix ME and Reardon-Anderson J. Children of Immigrants Show Slight Reductions in Poverty, Hardship. Snapshots of America's Families III, No. 13. Washington: Urban Institute, 2003. Available online.

Coughlin TA and Zuckerman S. States' Use of Medicaid Maximization Strategies to Tap Federal Reserves: Program Implications and Consequences. Discussion Paper No. 02-09. Washington: Urban Institute, 2002. Available online.

Davidoff A, Garrett AB, Makuc DM and Schirmer M. Children Eligible for Medicaid but Not Enrolled: How Great a Policy Concern? Policy Brief No. A-41. Washington: Urban Institute, 2000. Available online.

Davidoff A, Kenney GM, Dubay LC and Yemane A. Patterns of Child-Parent Insurance Coverage: Implications for Coverage Expansions. Series No. B-39. Washington: Urban Institute, 2001. Available online.

Davidoff A, Garret B and Yemane A. Medicaid-Eligible Adults Who Are Not Enrolled: Who Are They and Do They Get the Care They Need? Series No. A-48. Washington: Urban Institute, 2001. Available online.

Dubay LC, Hill I and Kenney GM. Five Things Everyone Should Know about SCHIP. Policy Brief No. A-55. Washington: Urban Institute, 2002. Available online.

Dubay LC, Kenney GM and Haley J. Children's Eligibility for Medicaid and SCHIP: A View from 2000. Policy Brief No. B-41. Washington: Urban Institute, 2002. Available online.

Dubay LC, Kenney GM and Haley J. Children's Participation in Medicaid and SCHIP: Early in the SCHIP Era. Policy Brief No. B-40. Washington: Urban Institute, 2002. Available online.

Dubay LC, Kenney GM and Zuckerman S. Extending Medicaid to Parents: An Incremental Strategy for Reducing the Number of Uninsured. Policy Brief No. B-20. Washington: Urban Institute, 2000. Available online.

Finegold K and Wherry L. Race, Ethnicity, and Health. Snapshots III, No. 20. Washington: Urban Institute, 2004. Available online.

Garrett B and Yemane A. Racial and Ethnic Differences in Insurance Coverage and Health Care Access and Use: A Synthesis of Findings from the Assessing the New Federalism Project. Discussion Paper No. 06-01. Washington: Urban Institute, 2006. Available online.

Golden O. Assessing the New Federalism - Eight Years Later. Washington: Urban Institute, 2005. Available online.

Hill I, Lutzky A and Schwalbeg R. Are We Responding to Their Needs? States' Early Experiences Serving Children with Special Health Care Needs Under SCHIP. Occasional Paper No. 48. Washington: Urban Institute, 2001.

Hill I and Lutzky A. Getting In, Not Getting In, and Why: Understanding SCHIP Enrollment. Occasional Paper No. 66. Washington: Urban Institute, 2003. Available online.

Hill I and Lutzky A. Is There a Hole in the Bucket? Understanding SCHIP Retention. Occasional Paper No. 67. Washington: Urban Institute, 2003. Available online.

Hill I and Snow J. Are Children Covered for the Services They Need? An Assessment of Benefit Coverage Under SCHIP. Policy Brief No. A-65. Washington: Urban Institute, 2004.

Hill I, Stockdale H and Courtot B. Squeezing SCHIP: States Use Flexibility to Respond to the Ongoing Budget Crisis. Policy Brief No. A-65. Washington: Urban Institute, 2004. Available online.

Hill I, Courtot B and Sullivan J. Ebbing and Flowing: Some Gains, Some Losses as SCHIP Responds to Third Year of Budget Pressure. Policy Brief No. A-68. Washington: Urban Institute, 2005. Available online.

Holahan J and Pohl MB. States as Innovators in Low-Income Health Coverage. Research Report. Washington: Urban Institute, 2002. Available online.

Holahan J. Variations among States in Health Insurance Coverage and Medical Expenditures: How Much Is Too Much? Washington: Urban Institute, 2002. Available online.

Holahan J. Changes in Employer-Sponsored Health Insurance Coverage. Snapshots of America's Families III, No. 9. Washington: Urban Institute, 2004. Available online.

Holahan J, Coughlin T, Bovbjerg R, Hill I, Ormond B and Zuckerman S. State Responses to 2004 Budget Crises: A Look at Ten States. Research Report. Washington: Urban Institute, 2004. Available online.

Holahan J, Cook A and Dubay LC. Characteristics of the Uninsured: Who is Eligible for Public Coverage and Who Needs Help Affording Coverage? Washington: Henry J. Kaiser Family Foundation, February 2007. Available online.

Howell E, Almeida R, Dubay L and Kenney G. Early Experience with Covering Uninsured Parents under SCHIP. Policy Brief No. A-51. Washington: Urban Institute, 2002. Available online.

Howell E, Hill I and Kapustka H. SCHIP Dodges the First Budget Ax. Policy Brief No. A-56. Washington: Urban Institute, 2002. Available online.

Howell E. Access to Children's Mental Health Services Under Medicaid and SCHIP. Policy Brief No. B-60. Washington: Urban Institute, 2004.

Hurley R and Zuckerman S. Medicaid Managed Care: State Flexibility in Action. Discussion Paper No. 02-06. Washington: Urban Institute, 2002. Available online.

Kenney G and Cook A. Coverage Patterns among SCHIP-Eligible Children and Their Parents. Health Policy Online Brief 15. Washington, D.C.: Urban Institute, 2007. Available online.

Kenney GM, Haley LC and Ullman F. Most Uninsured Children are in Families Served by Government Programs. Policy Brief No. B-4. Washington: Urban Institute, 1999. Available online.

Kenney GM, Ullman F and Weil A. Three Years into SCHIP: What States Are and Are Not Spending. Policy Brief No. A-44. Washington: Urban Institute, 2000. Available online.

Kenney GM, Dubay LC and Haley LC. Health Insurance, Access and Health Status of Children. Snapshots of America's Families II: A View of the National and 13 States from the National Survey of America's Families. Washington: Urban Institute, 2000. Available online.

Kenney GM, Ormond BA and Ko G. Gaps in Prevention and Treatment: Dental Care for Low-Income Children. Policy Brief No. B-15. Washington: Urban Institute, 2000. Available online.

Kenney GM and Haley J. Why Aren't More Uninsured Children Enrolled in Medicaid or SCHIP? Policy Brief No. B-35. Washington: Urban Institute, 2001. Available online.

Kenney GM, Dubay LC and Haley LC. How Familiar are Low-Income Parents with Medicaid and SCHIP? Policy Brief No. B-34. Washington: Urban Institute, 2001. Available online.

Kenney GM, Haley J and Tebay AC. Children's Insurance Coverage and Service Use Improve. Snapshots of America's Families III, No. 1. Washington: Urban Institute, 2003. Available online.

Kenney GM, Haley J and Tebay AC. Familiarity with Medicaid and SCHIP Programs Grows and Interest in Enrolling Children is High. Snapshots of America's Families III, No. 2. Washington: Urban Institute, 2003. Available online.

Ku L, Ullman F and Almeida R. What Counts? Determining Medicaid and CHIP Eligibility for Children. Discussion Paper No. 99-05. Washington: Urban Institute, 1999. Available online.

Long SK. Hardship Among the Uninsured: Choosing Among Food, Housing, and Health Insurance. Series No. B-54. Washington: Urban Institute, 2003. Available online.

Lutzky AW and Hill I. Has the Jury Reached a Verdict? States' Early Experiences with Crowd Out Under SCHIP. Occasional Paper No. 47. Washington: Urban Institute, 2001. Available online.

Lutzky AW, Holahan J and Wiener J. Health Policy for Low-Income People: Profiles of 13 States. Occasional Paper No. 57. Washington: Urban Institute, 2002. Available online.

Lutzky A and Hill I. Premium Assistance Programs under SCHIP: Not for the Faint of Heart? Occasional Paper No. 65. Washington: Urban Institute, 2003. Available online.

Ormond BA and Lutzky AW. Ambulatory Care for the Urban Poor: Structure, Financing, and System Stability. Occasional Paper No. 49. Washington: Urban Institute, 2001. Available online.

Ormond BA, Wallin S and Goldenson SM. Supporting the Rural Health Care Safety Net. Occasional Paper No. 36. Washington: Urban Institute, 2000. Available online.

Spillman B, Zuckerman S and Garrett B. Does the Health Care Safety Net Narrow the Access Gap? Discussion Paper No. 03-02. Washington: Urban Institute, 2003. Available online.

Triplett T and Wherry L. Lessons Learned from the National Survey of America's Families. Washington: Urban Institute, 2006. Available online.

Ullman F, Hill I and Almeida R. CHIP: A Look at Emerging State Programs. Policy Brief No. A-35. Washington: Urban Institute, 1999. Available online.

Zuckerman S and Haley J. Variation and Trends in the Duration of Uninsurance. Discussion Paper No. 04-10. Washington: Urban Institute, 2004. Available online.

Zuckerman S. Gains in Public Health Insurance Offset Reductions in Employer Coverage Among Adults. Snapshots of America's Families II, No. 8. Washington: Urban Institute, 2003. Available online.

Survey Instruments

"1999 National Survey of American's Families," Westat, fielded February–October 1999.

"2002 National Survey of American's Families," Westat, fielded February–November 2002.

World Wide Web Sites

www.urban.org/center/anf. The section of the Urban Institute Web site contains background information on the Assessing the New Federalism project as well as free reports, information about journal articles and books, and related research.

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Report prepared by: Lori De Milto
Reviewed by: Karyn Feiden
Reviewed by: Marian Bass
Program Officer: David C. Colby
Program Officer: Nancy Barrand

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