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Lisa Dubay, Ph.D., Sc.M.
Johns Hopkins Bloomberg School of Public Health and
Center for Children and [email protected]
Getting to the Finish Line: Where We Have Been, Where We
Need to Go, and How to Get There!
2
A Brief History of Children’s Health Insurance Expansions
In 1965, Medicaid program enacted as part of the Social Security Act coverage of children initially limited to those in families
participating in welfare and those who were disabled In late 1980’s, Medicaid was expanded to “poverty
related” infants and children through a series of legislation with these expansions Medicaid was de-linked from welfare
In 1997, SCHIP authorized as part of the Balanced Budget Act allowed states to extend public health insurance coverage to
uninsured children not eligible for Medicaid as of June 1997
3
But SCHIP Sits on Top of the Medicaid Program
Eligible Children, 2004
35%
65%
Enrolled Children, 2003
82%
5%13%
SCHIP Eligible
Medicaid Eligible Medicaid
SCHIPSeparateProgram
SCHIPMedicaid Expansion
4
Coverage of Children Improves Access to Care
711
4
30
19
49*54*
22*27* 27*
37*
7*
0
10
20
30
40
50
60
LacksConfidence
No UsualSource of Care
No Well ChildVisit
No DentalVisit
Uninsured Private Medicaid/Public
Source: 1997 National Survey of America’s Families
*Statistically different from Medicaid at the 0.05 level using multivariate analyses.
4
5
The Good News and the Bad News:Uninsured Children in 1997 and 2005
1997 2005
Number of Uninsured Children
10.0 million 7.5 million
Percentage of All Children Uninsured
13.5% 9.7%
Percentage of Low Income Uninsured
22.3% 14.9%
Source: Authors tabulations of 1997 and 2005 National Health Interview Survey
6
Trends in the Percentage of Children Uninsured 1997 – 2005, All Children and Low-Income Children
0%
5%
10%
15%
20%
25%
1997 1998 1999 2000 2001 2002 2003 2004 2005
All Children Low-Income Children
Source: Authors tabulations of 1997-2005 National Health Interview Survey.
7
Eligibility for Public Health Insurance Coverage Expanded with SCHIP
35%
67%
47%
84%
50%
89%
0%
20%
40%
60%
80%
100%
All Children Low-Income Children
1997 1999 2002
Source: National Survey of America’s Families
8
Medicaid and SCHIP Participation:
1997, 1999, 2002
74% 73%
48%
82%
68%
0%
20%
40%
60%
80%
100%
Medicaid SCHIP
1997
1999
2002
Source: 1997,1999,2002 National Survey of America’s Families
Note: Excludes children with private coverage and defined for citizen children ages 0 to 17.
8
9
Who Are the Uninsured Children?
Race/Ethnicity of Child
37%
16%
40%
7%
Age of Child
39%27%
34%
Age 0-5
Age 6-12
Age 13-18White
Black
Hispanic
Other
Source: March 2005 Current Population Survey
10
Who Are The Uninsured Children?
Firm Size of Workers
10%
11%34%
23%
23%
Family Work Status
23%
52%
16%
9%
2 Full-Time
1 Full-Time
Only Part-Time
No Worker No Worker
Self-Employed
Less than 25
25-499 500 or More
Source: March 2005 Current Population Survey
11
Who Are the Uninsured Children?
Citizenship of Child
13%
87%
Region of Residence
28%16%
13%
44%
Midwest
West
South
Northeast
Citizen
Non-Citizen
Source: March 2005 Current Population Survey
12
Most Uninsured Children are Eligible for Public Health Insurance Coverage, 2004
21%
13%
66%
SCHIP Eligible
Not Eligible
19%
32%
49%
Medicaid Eligible
SCHIP Eligible
Not Eligible
Low-Income Uninsured Children
Uninsured Children
12
Medicaid Eligible
Source: March 2005 Current Population Survey using July 2004 eligibility rules.
6.5 million9.0 million
13
Knowledge Gaps Among Low-Income Parents with Uninsured Children, 2002
52%
8%40%
Heard of Programs and Aware Child Can Participate
Without Receiving Welfare
Haven't Heard of Medicaid or
SCHIP
Heard of Programs but Not Aware Child Can Participate Without Receiving Welfare
13
Source: Kenney, Haley and Tebay (2003)
14
Interest in Enrolling in Medicaid and SCHIP is High, 2002
81.7% 89.8%
74.8%
0%
20%
40%
60%
80%
100%
All Low-incomeuninsured
Poor uninsured Near-pooruninsured
Lo
w-I
nco
me
Un
insu
red
Ch
ild
ren
Source: Kenney, Haley and Tebay (2003)
15
But State Issues Exist as Well
When states enroll children they face higher costs Economic downturns Overall resource capacity
Many states face federal shortfalls under SCHIP currently or in the future
These issues make some states reluctant to implement and maintain effective enrollment strategies
16
Enrollment in SCHIP Increases Access to Care
3%
15%**
22%**
16%**
10%**
0%
5%
10%
15%
20%
25%
Confident CanGet Needed
Care
Has UsualSource of
Care
AnyDoctor/HealthProfessional
Visit
Any Well ChildVisit
Any DentalVisitP
erce
nta
ge
Po
int
Ch
ang
e
** Significant at the .01 level.
Source: Urban Institute Analysis of National Survey of America's Families (NSAF).
17
How Do We Get to the Finish Line?
Fully fund SCHIP to maintain success of program 24 states estimated to face shortfalls by 2008 36 states estimated to face shortfalls by 2012 Estimated that 1.6 million children would loose coverage
Increase funding under SCHIP to allow states to cover eligible but uninsured
Identify and implement strategies designed to enroll more children in Medicaid and SCHIP
Expand eligibility to ineligible populations
18
Uninsurance Gap Between Low-Income Children and Parents, 1994 to 2004
363436 36 37
343434323230.3
202021212324
2726252323.4
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Parents Children
Source: Tabulations of 1995-2005 Current Population Survey
19
Effects of Covering Parents on Children’s Participation in Medicaid
Medicaid Participation Among Poverty-Related Medicaid Eligible Children By Family Coverage Status, 1999
57.1
78.5* 80.8*
0%
20%
40%
60%
80%
100%
No FamilyCoverage
Family Coverage-Separate Program
Family Coverage-Medicaid
Expansion
Pe
rce
nt
En
rolle
d in
Me
dic
aid
* Different from rate in states with no family coverage at .05 level using multivariate analysis.
20
Covering Parents Leads to Small Increases in Use Among Insured Children
65.4%69.8%*
30%
40%
50%
60%
70%
80%
Received Well-Child Visit
Low-Income Insured Children with Uninsured Parent
Low-Income Insured Children with Insured Parent
20
Source: 1999 National Survey of America’s Families* Different from low-income insured children with uninsured parent at .05 level using multivariate analysis.
21
We are at a crossroads in children’s coverage !
SCHIP and, its partner, Medicaid, have together worked to significantly lower the number and percent of uninsured children.
We should fully fund the SCHIP program to continue this progress and move forward in finding ways to ensure that all uninsured children secure coverage that assures high quality access to care.
