What Role Does SCHIP Play in the Patchwork Insurance System for
Children?
Andrew W. Dick PhD1
R. Andrew Allison PhD2
Peter G. Szilagyi MD, MPH3,1
Betsy Shenkman PhD4
1Dept. of Pediatrics, University of Rochester2 Kansas Health Institute3Dept. Of Community & Preventive Medicine, University of Rochester4Institute for Child Health Policy and Dept of Pediatrics, University of Florida
Background - SCHIP State Children’s Health Insurance Program
BBA of 1997 established SCHIP, providing $40 billion for block grants to states (10 years)
Provides a mechanism for insuring children who fall in the gap between Medicaid and private insurance
Provides wide latitude for states in designing and changing enrollment and eligibility policies
Study Objectives
Determine how SCHIP fits into the patchwork system
Describe SCHIP-enrollment patterns Duration of enrollment, insurance prior to and following
enrollment, and their relationships.
Describe differences in these patterns by subgroups Race/ethnicity, special health care needs, poverty
Relationship between enrollment patterns and health systems access and use measures
SCHIP Policies in Three States
Kansas (HealthWave, 1999) 2001 enrollment = 34,241
Florida (Healthy Kids, 1990) 2001 enrollment = 298,705
New York (Child Health Plus, 1991) 2001 enrollment = 590,000 (18% of US)
SCHIP Policies in Three States
Policy Florida Kansas New York
Guaranteed Eligibility
No 12 months No
Re-certification Procedure
Passive Active Active
Frequency of Re-certification
6 months 12 months 12 months
Premiums All Enrollees Above 150% FPL Above 160% FPL Waiting Period No 6 months No Insurance Plan Participation
15 Capitated Managed Care
1 Capitated PCCM MCO
32 Capitated Managed Care
Study Design
Surveys: telephone interviews at T1 : pre-SCHIP access/use, baseline SES
3 to 6 months after enrollment about year before enrollment T2 : during-SCHIP access/use, post-SCHIP insurance
status 13 to 16 months after enrollment about year after
enrollment Administrative data: monthly SCHIP-enrollment
status and (KS and FL only) Medicaid enrollment status
Subjects: (New Enrollees 7/00-3/01)
New York: 2,290 completed T1 and T2 surveys
Florida: 944 completed T1 and T2 surveys
Kansas: 434 completed T1 and T2 surveys
Measures
Access: Usual Source of Care (USC), type of USC, Unmet needs
Use of care: Any, preventive, acute, specialty
Pre-SCHIP Insurance: Within the 12 months prior to SCHIP -- Medicaid, private Ever insured prior to the 12 months before SCHIP enrollment Never insured
Post-SCHIP Insurance: Insurance status in month 13 -- Public (SCHIP, Medicaid), private,
uninsured Insurance Status immediately following SCHIP-disenrollment -- Public,
private, uninsured
Analyses: Enrollment Duration
Kaplan-Meier survivor functions by prior insurance and by NY regions
(9/11) Multivariate logistic regressions
probability of surviving at least 10 months probability of surviving at least 13 months
given at least 10 months
Analyses: Insurance Disposition
Multivariate multinomial logistic regression Estimate insurance status immediately
following SCHIP-disenrollment Multivariate controls include:
SES prior insurance pre-SCHIP access and use during-SCHIP access and use (when appropriate)
KM Survivor FunctionsBy Prior Insurance
Kansas
0
0.25
0.5
0.75
1
0 6 12 18 24 30
Month
Pro
bab
ilit
y
Uninsured Non-Public Public
KM Survivor FunctionsBy Prior Insurance
Florida
0
0.25
0.5
0.75
1
0 6 12 18 24 30
Month
Pro
bab
ilit
y
Uninsured Non-Public Public
KM Survivor FunctionsBy Prior Insurance
New York
0
0.25
0.5
0.75
1
0 6 12 18 24 30
Month
Pro
bab
ilit
y
Uninsured Non-Public Public
KM Survivor FucntionsBy Region (New York)
0
0.25
0.5
0.75
1
0 6 12 18 24 30
Months
Pro
bab
ilit
y
NYC NYC Metro Upstate Urban Upstate Rural
Length of SCHIP Enrollment
By race By income By prior insurance By CSHCN status By use
Enrollment Duration Enrollment DurationProbability of remaining enrolled > 9 months Probability of remaining enrolled > 12 months | 10 months
Odds RatiosNew York Kansas Florida
Race/Ethnicity (vs White)Black 0.83 1.18 0.59 ***Hispanic 1.08 1.97 * 1.05
Probability of remaining enrolled > 12 months | 10 months
Black 0.76 1.23 0.54 *Hispanic 0.91 0.76 0.83
Enrollment Duration Probability of remaining enrolled > 12 months | 10 monthsProbability of remaining enrolled > 9 months
Odds RatiosNew York Kansas Florida
Income (vs >150% FPL)Income < 150% FPL 0.32 *** 0.94 0.63 ***Income Unknown 1.58 ** 0.59
Probability of remaining enrolled > 12 months | 10 months
Income < 150% FPL 0.82 1.26 0.67Income Unknown 1.02 0.72
Enrollment DurationBy Health Status and Use of Services
Odds of Odds of Surviving > 9 Surviving > 12 | 10
New York Kansas New York Kansas
CSHCN 0.89 0.70 0.47 ** 1.40
Acute Use Before SCHIP 1.66 ** 3.28 ** 0.93 4.06 *
Insurance Status Following Disenrollment from SCHIP
By duration and By prior insurance By CSHCN status By access and use during SCHIP
Insurance Status Following SCHIP DisenrollmentBy Length of Enrollment
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1-9 months 10-12 months 1-9 months 10-12 months 1-9 months 10-12 months
Pro
ba
bili
ty
Ever Insured Never Insured Public Private
Enter Public Enter Private Enter No Insurance
Insurance Status Following SCHIP DisenrollmentBy Speical Needs Status
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
1-9 monthsPublic
1-9 monthsPrivate
1-9 monthsNone
10-12 monthsPublic
10-12 monthsPrivate
10-12 monthsNone
Pro
ba
bili
ty
Not CSHCN CSHCN
Insurance Status Following SCHIP DisenrollmentBy Access During SCHIP
0
0.1
0.2
0.3
0.4
0.5
0.6
Public Private None
Pro
bab
ilit
y
No unmet need Unmet need No use Use
Conclusions - Recertification
Confirms and strengthens previous finding about recertification No difference in exit rates in Florida (quantity or
correlates) around recertification Large increases in disenrollment rates around
recertification in New York and Kansas Disenrollment process differed in months 1 - 9
and 10 - 12 by income, CSHCN status and prior use
Very large differences by NY regions, consistent with 9/11 change.
Conclusions – Length of Enrollment
No notable differences in length of enrollment by prior insurance status
No evidence of racial/ethnic differences except for blacks in Florida
Conclusions – Insurance Status Following SCHIP Disenrollment
Children who disenrolled around active recertification were much more likely to become uninsured.
Pre-SCHIP insurance is a predictor of post-SCHIP insurance
SCHIP is not serving as a pathway to private insurance
No evidence that during SCHIP use and unmet needs affect insurance status after disenrollment.
Conclusions - CSHCN
CSHCN could be at greater risk of losing insurance.
disenroll more quickly (esp. around recert.). more likely to become uninsured after SCHIP.
LimitationsLimitations:
Internal Validity Self-report
large conflicts between self-reported SCHIP-enrollment status and administrative data
Longitudinal survey response rates KS: 35 % (T1 = 60%, T2=58%) FL: 30 % (T1 = 60%, T2=50%) NY: 55% (T1 = 64%, T2=87%)
External Validity: Three states that may not be representative of many other
states.
CHIRITM Funders
Agency for Healthcare Research and Quality (AHRQ)
The David and Lucile Packard Foundation Health Resources and Services
Administration