What Role Does SCHIP Play in the Patchwork Insurance System for Children? Andrew W. Dick PhD 1 R. Andrew Allison PhD 2 Peter G. Szilagyi MD, MPH 3,1 Betsy Shenkman PhD 4 1 Dept. of Pediatrics, University of Rochester 2 Kansas Health Institute 3 Dept. Of Community & Preventive Medicine, University of Rochester 4 Institute 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

Study Design  Surveys: telephone interviews at  T 1 : pre-SCHIP access/use, baseline SES  3 to 6 months after enrollment about year before enrollment  T 2 : 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 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)

Length of SCHIP Enrollment By race By income By prior insurance By CSHCN status By use

Insurance Status Following Disenrollment from SCHIP By duration and By prior insurance By CSHCN status By access and use during SCHIP

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 and 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.

Limitations Limitations:  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.

CHIRI TM Funders Agency for Healthcare Research and Quality (AHRQ) The David and Lucile Packard Foundation Health Resources and Services Administration