Effects of the State Children’s Health Insurance Program on Children with

Chronic Health Conditions

Amy J. Davidoff, Ph.D.

Genevieve Kenney, Ph.D.

Lisa Dubay, Sc.M.The Urban Institute

Academy Health Meetings June 8, 2004

Funded by the Maternal and Child Health Bureau and the Robert Wood Johnson Foundation

The State Children’s Health Insurance Program

• Created with passage of BBA in 1997• Voluntary, but all states participating by 2000; states

vary in how implemented– 16 states only extend Medicaid eligibility– 16 states established separate programs– 19 states use both mechanisms

• Separate programs more like private insurance • Crowd-out provisions• Emphasis on outreach, enrollment simplification

SCHIP expansions provide important access to public insurance for children with chronic conditions

• Children have greater needs for care, greater unmet needs

• Private insurance alternatives limited, costly• Public coverage particularly desirable

– Shifts most financial burden from family– Offers broader spectrum of services

But SCHIP crowd-out provisions may inhibit enrollment

Expected effects of SCHIP expansions for children with chronic conditions:

• Increased public coverage, reduced uninsured

• Increased access to care, use of outpatient services– Reduced ER, inpatient use?

• Reduced family spending on care• Outreach & enrollment simplification =>

spillover effects on Medicaid eligible children

Evidence on effects of SCHIP expansions limited

• Take up among newly income eligible children relatively low – Crowd-out estimates range widely - 15% to 50%,

depending on methods, measurement

• Limited literature on access & use effects for SCHIP– state specific studies on effects for enrolled children– few studies examine effects for children with chronic

health conditions – No studies examine effects of SCHIP eligibility on

access & use

Research Objectives

• Examine effects of SCHIP expansions nationally for children with chronic health conditions on:– Public & private insurance, uninsured rates – Access, use of services, spending

• Estimate spillover effects on Medicaid eligible children

• Compare to healthy children

Analytic Approach: Difference in Difference (DD)

• Pre-post design with comparison group– Examine changes between 1997 and 2000/2001– Treatment group = newly SCHIP income eligible– Comparison = nearly SCHIP eligible – Examined spillover on Medicaid poverty expansion

eligible children

• Control for differences in characteristics across groups and over time using multivariate regression

Analytic Approach (cont.)

• Estimate OLS regression models

Outcome = a0 + a1 tx + a2 postper +

a3 tx*postper + a4 X + e

• Coefficient a3 = effect of being in treatment group during post period

• X controls for child, family, area characteristics, states

Data• National Health Interview Survey (NHIS), 1997,

2000 & 2001• Identifying Children with Chronic Health

Conditions– Condition checklist: chronic developmental, physical

& behavioral conditions– Limited in activity, caused by condition lasting >= 1

year– Reported sad or unhappy most of time, past 6

months– Very low birth weight, < 2 years

• 18% of children meet criteria

Identifying Treatment, Comparison Groups

Used detailed algorithm that replicates eligibility determination process

• Link federal, state rules on disregards, categorical requirements, income thresholds

• Create relevant measures using household survey data• Determine eligibility for Medicaid, SCHIP

• Compare relevant categorical & income requirements to measures from household survey data

Results

SCHIP Impacts on Insurance For Children With Chronic Conditions

-0.029

0.098*

-0.064*

Private Insurance Uninsured

Publicly Insured

* Signif icant at p<=.10Source: Urban Institute analysis of 1997, 2000, 2001 National Health Interview Survey

Effects of SCHIP Expansions on Use of Services

0.02

0.02

0.04

0.05

-0.04

-0.04

-0.01

0.03

Any Doctor Visit

Specialist Visit

General Physician Visit

Dental Visit

Mental Health Specialist Visit

Eye Care Visit

ER Visit

Any Hospital Stay

Source: Urban Institute analysis of NHIS 1997, 2000, 2001

Effects of SCHIP on Unmet Need

-0.02

0.00

-0.04

0.00

-0.07*

-0.09*

Delay Due to Cost

Any Unmet Need

Unmet Medical Need

Unmet Dental Care Need

Unmet Mental Health Need

Unmet Rx Need

Estimates significant at p<=.10Source: Urban Institute estimates from the 1997, 2000, 2001 NHIS

SCHIP Effects on Family Out-of-Pocket Spending

0.02

0.03

-0.04

-0.01> =$2000

$500 - $1,999

$1 - $499

Zero Dollars

Source: Urban Institute estimates from the 1997, 2000, 2001 NHIS

Spillover effects on Medicaid poverty expansion group similar

• Increased public coverage, reduced uninsured

• Similar effects on access, use

• Larger, significant downward shifts in out-of-pocket spending

Magnitude of effects depends on reference point

• Absolute effects small• Relative to target group mean at baseline

– 30 % reduction in % uninsured– 35 % reduction in any unmet need– 42 % reduction in unmet dental need

• Relative to % newly publicly insured– 88 % experienced reduction any unmet need– 76 % reduced unmet dental need

Comparison with healthy children suggests bigger effects on children with chronic conditions

Children with chronic conditions experienced:• Less loss of private coverage, more newly

insured• Larger increase in specialist visits• Larger decrease in mental health specialist

visits• Larger decrease in ER visits

In summary..

• SCHIP expansions successfully increased coverage, but 16 % of eligible remain uninsured

• Expansions had positive effects on some access measures, but problems remain– 17 % with unmet dental need– 10 % with unmet Rx need

• Positive effects were more pronounced for children with chronic health conditions

Study Limitations

• Eligibility, outcome measures based on self report • = > measurement error• Error in eligibility assignment => contamination of

treatment, comparison groups => downward bias• Comparison group may differ in unobserved ways • NHIS access & use measures limited; may miss

important impacts for special services used by children with chronic conditions

• Don’t capture reduced parent anxiety about accessing needed care for child

Policy implications

• Further progress in reducing uninsured may require targeted outreach – Specialty providers, educators

• Improvements in access may require restructured provider contracts

• State caps on SCHIP enrollment => no special protections for children with chronic conditions => risk of losing ground

• Reduced outreach efforts => reduce positive spillover benefits to Medicaid eligible children