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

Prob

abili

ty

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

Prob

abili

ty

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

Prob

abili

ty

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

Prob

abili

ty

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 SCHIPBy 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

Prob

abili

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

Prob

abili

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

Prob

abili

ty

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