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

Chronic Health ConditionsAmy J. Davidoff, Ph.D.

Genevieve Kenney, Ph.D.Lisa Dubay, Sc.M.The Urban Institute

June 5, 2004

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

SCHIP Coverage Particularly Important 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:

• 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

• Crowd-out estimates range widely - 15% to 50%, depending on methods, measurement

• Limited literature on access & use effects

• No studies examine effects on children with chronic conditions

Research Objectives

• Examine effects of SCHIP expansions 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– 1997 vs 2000/2001– Treatment group = newly SCHIP eligible– Comparison = slightly higher income

• Control for differences in characteristics across groups using multivariate regression

Analytic Approach: DD (cont.)

• Estimate OLS 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

Multivariate Controls

• Child characteristics– Chronic condition– Age – Gender– Race/ethnicity– Child immigrant status

• Family characteristics– Size – Single parent – Parent health problems – Earnings – Parent ed

• Predicted ESI Offer• Area characteristics

– Premiums– HMO penetration– Unemployment rate (+)

• State

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

Algorithm replicates eligibility determination process

• Link federal, state rules on deeming, disregards, categorical requirements

• Measure monthly countable income using earnings data, relevant disregards

• Determine eligibility for Medicaid, SCHIP• Determine categorical eligibility• Compare federal & state specific income thresholds

to countable income

SCHIP Impacts on Insurance For Children With Chronic Conditions

-0.029

0.098*

-0.064*

Private Insurance Uninsured

Publicly Insured

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

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

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

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

Summary Effects of SCHIP Expansions

• Increased coverage, but 16 % of eligible remain uninsured

• Improved access, but problems remain– 17 % with unmet dental need– 10 % with unmet Rx need

• Positive effects more pronounced for children with chronic health conditions

Policy Implications• Further progress requires targeted outreach

– Specialty providers, educators• Restructured provider contracts may be

needed to facilitate access• 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