The Urban Institute Declining Child Mortality & Continuing Racial Disparities in the Era of the Medicaid/SCHIP Insurance Coverage Expansions THE URBAN.

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The Urban Institute Declining Child Mortality & Continuing Racial Disparities in the Era of the Medicaid/SCHIP Insurance Coverage Expansions THE URBAN INSTITUTE shhe Embry Howell, Ph.D., Sandy Decker Ph.D., Sara Hogan, M.H.S., Alshadye Yemane, M.P.P. & Jonay Foster

The Urban Institute Presentation Outline Background Methods Analysis Discussion Conclusions

The Urban Institute Background 1900 – Present: Declines in child mortality in nearly all countries around the world Declines across many major causes of death Infectious disease Unintentional injuries Asthma Childhood Cancer Health disparities persist: racial/ethnic, SES, access

The Urban Institute Background, cont. US public insurance coverage expansions for children Medicaid (OBRA 86, 87, 89, 90) Decoupling of welfare + Medicaid (PRWOA 96) SCHIP (BBA 97) 2002: majority US states expanded coverage up to 200% FPL through SCHIP Dearth of knowledge on child mortality during Medicaid/SCHIP expansions + disparities Photo:

The Urban Institute Methods Mortality Multiple Cause-of-Death Files, National Center for Health Statistics Select all children under age 18 Calculate number of deaths from “natural” (disease-related) and “external” (injuries, homicide, suicide) causes by: - state - year - race categories (black, white, other) - age group (1-5, 6-11, 12-17) Calculate mortality rates per 100,000 children by state, year, race and age group by using three-year moving averages (for )

The Urban Institute Empirical Specification Test relationship between fraction of children simulated eligible for Medicaid/SCHIP and mortality by state (s), year (t), race (r), and age group (a)

The Urban Institute Fraction Medicaid/SCHIP Eligible Used fraction of children simulated eligible for Medicaid/SCHIP by state, year + age Currie J, Decker SL, Lin W “Has Public Health Insurance for Older Children Reduced Disparities in Access to Care and Health Outcomes?” Journal of Health Economics 27 (6): Fraction obtained by sampling children by age + calendar year from the Current Population Survey, then calculating fraction of this fixed group of children who would be eligible for Medicaid/SCHIP in each state.

The Urban Institute (1) Omnibus Budget Reconciliation Act of 1986 (2) Omnibus Budget Reconciliation Act of 1987 (3) Medicare Catastrophic Coverage Act of 1988 (4) Omnibus Budget Reconciliation Act 1989 (5) Omnibus Budget Reconciliation Act 1990 (6) Personal Responsibility and Work Opportunity Act of 1996 (7) Balanced Budget Act of 1997 US Child Mortality + Medicaid/SCHIP Child Eligibility

The Urban Institute Mortality Rate for U.S. Children: Year, Age + Race (Deaths per 100,000)

The Urban Institute Causes of Death: Children Aged in 2003

The Urban Institute Mortality for Natural Causes of Death: Age + Year

The Urban Institute Mortality for External Causes of Death: Age + Year

The Urban Institute Multivariate Analysis of U.S. Mortality Rate Among Children Ages 1-17, Dependent Variable: Log of Mortality Rate (N=8262) Note: Results are not shown for “other” race, or for state or year dummy variables. Selected Independent Variables Alternative Models: Coefficient on Medicaid Eligibility (Significance Level) Model 1: Natural Cause Mortality — Linear time trend Model 2: Natural Cause Mortality — Year Dummy Variables Model 3: External Cause Mortality — Linear Time Trend Model 4: External Cause Mortality — Year Dummy Variables Medicaid/SCHIP Eligibility Expansion Level (Linear) (p<.001)-.030 (Not significant) (p<.001)-.198 (p<.001) Race: Black (compared to white).168 (p<.001).167 (p<.001).451 (p<.001) Ages: 6-11 (compared to 1-5) (p<.001)-.842 (p<.001)-.605 (p<.001)-.600 (p<.001) Ages: (compared to 1-5) (p<.001)-.541 (p<.001).608 (p<.001).689 (p<.001) Year (linear) R-squared (p<.001).347 Not applicable (year dummies) (p<.001).845 Not applicable (year dummies).845

The Urban Institute Conclusions Child mortality (natural and external) declined on average of 3% per year during study period Decline in difference between black and white child mortality Relative racial disparity at end of study period remains unchanged

The Urban Institute Conclusions Medicaid/SCHIP eligibility expansions related to improved survival, especially for external causes of death Mandates and state-optional eligibility did not differentially affect black and white children Other targeted strategies needed to reduce racial disparities in child health

The Urban Institute Acknowledgements Title slide photo : Ford Foundation Timothy Waidmann - Urban Institute Robert Anderson, Jennifer Madans, Charles Rothwell, Jane Sisk – NCHS