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
Effects of SCHIP Expansions on Use of Services
Any Doctor Visit
0.02
General Physician Visit
0.02
Specialist Visit
0.04
Dental Visit
Mental Health
Specialist Visit
0.05
-0.04
0.03
Eye Care Visit
ER Visit
Any Hospital Stay
-0.04
-0.01
Source: Urban Institute analysis of NHIS 1997, 2000, 2001
Effects of SCHIP on Unmet Need
Delay Due to Cost
Any Unmet Need
-0.02
-0.09*
Unmet Medical Need
Unmet Dental Care Need
0.00
-0.07*
Unmet Mental Health
Need
Unmet Rx Need
Estimates significant at p<=.10
Source: Urban Institute estimates from the 1997, 2000, 2001 NHIS
0.00
-0.04
SCHIP Effects on Family Out-of-Pocket Spending
> =$2000
$500 - $1,999
-0.01
-0.04
$1 - $499
Zero Dollars
Source: Urban Institute estimates from the 1997, 2000, 2001
NHIS
0.03
0.02
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