How Well is SCHIP Meeting Children’s Primary Health Care

Needs?: Findings From A Congressionally Mandated Study

Genevieve KenneyThe Urban InstituteJamie RubensteinCornell University Anna Sommers

University Of Maryland Baltimore County Grace Ko

Gunderson Dettmer Stough Villeneuve Franklin and Hachigian, LLP

Academy Health Annual Research MeetingWashington, DCJune 10, 2008

Funding for this research was provided under a Congressionally-mandated evaluation for ASPE

Background on the State Children’s Health Insurance Program

• SCHIP was created in August 1997 to allow states to extend public health insurance coverage to uninsured children not eligible for Medicaid

• All states chose to expand eligibility for children under SCHIP: Eligibility thresholds vary from 140% in North Dakota to 350% in New Jersey, but most states set eligibility levels at 200% FPL

• States can expand Medicaid, create a separate SCHIP program, or use a combination approach

• Over two-thirds of states adopted separate programs, either alone or in combination with smaller Medicaid expansions

• Separate programs’ benefits approach breadth of Medicaid and are broader than most private insurance, covering:

– Preventive services in accordance with AAP guidelines

– Dental, hearing, and vision screening

Research Questions• How do access and use outcomes and parental

perceptions about being able to meet their child’s health care needs vary across groups of enrollees, including:– The Race/ethnicity of the child and primary language

spoken – Highest education level of the parents– Child’s health status

• How do these measures vary across the 10 states studied?

• Do these differences persist when controlling for other socioeconomic and demographic characteristics?

Data• Data analyzed comes from the “2002 congressionally mandated survey of

SCHIP enrollees and disenrollees in 10 states.”

• SCHIP enrollees surveyed in 10 states (CA, CO, FL, IL, LA, MO, NC, NJ, NY, TX) containing 60% of SCHIP enrollees nationally and representing all 3 program types.

• Analysis includes 5,394 SCHIP enrollees who had been in the program six months or longer.

• Outcomes examined include:– Service Use– Unmet Need– Attitudes and Worry– Presence/Type of Usual Source of Care– Provider Communication and Accessibility as Reported by Parent

• All measures refer to experiences over the past 6 months.

States Included in the Evaluation

Methods• I will talk primarily about raw/unadjusted means.

• Adjusted and unadjusted means almost always show substantively similar results. However, when results differ substantively between raw and regression adjusted means, I will highlight these differences.

• Regression adjusted means control for– Child’s age, sex, health status, race/ethnicity, and

interview language– Household income and size– Educational attainment/work status of parents– Parental attitudes toward efficacy of medical care– County of residence

Race, Ethnicity and LanguageWhite, Non-Hispanic, Primary Language if English 30.2Hispanic, Primary Language is English 20.1Hispanic, Primary Language is Spanish 27.7Black, Non-Hispanic, Primary Language is English 10.6Other, Non-Hispanic, Primary Language is English 4.0Other, Non-Hispanic, Primary Language is Not English 4.4Missing Race, Ethnicity or Language 2.9

Child Has Elevated Health Care Needs 24.1

Highest Education Level of ParentsLess than High School 24.5High School or GED 34.9Some College or Higher 40.6

N 5,394

SELECTED CHARACTERISTICS OF SCHIP ENROLLEES IN 10 STATES

Table 1

Service Use Based on Parents' ReportDoctor/Other Health Professional 66.7%Preventive Care or Check-up 45.4Dental for Checkup/Cleaning 57.3

Unmet NeedDoctor/Health Prof. Care 2.1Prescription Drugs 4.1Dental Care 11.9Hospital, Specialist, Doctor, Drug 9.2Hospital, Specialist, Doctor, Drug, Dentist 18.3

Parental PerceptionsVery or Somewhat Confident 81.2Never or Not Very Often Stressed 78.4Never or Rarely Worried 55.2Never or Rarely Cause Financial Difficulties 83.4Doctors and Nurses Look Down SCHIP Enrollees 18.6

N 5,394

Table 2

SELECTED MEASURES FOR ENROLLEES IN 10 STATES

FIGURE 1. PARENTS' ATTITUDES TOWARDS MEETING CHILD'S HEALTH CARE NEEDS BY RACE/ETHNICITY AND LANGUAGE

89.3% 88.2%

71.6%

83.1 %85.4 %

66.7 %

80.0 %75.4 %

48.1 %

74.7 %

67.1 %

36.6 %

0.0 %

10.0 %

20.0 %

30.0 %

40.0 %

50.0 %

60.0 %

70.0 %

80.0 %

90.0 %

100.0 %

Very Confident Child Could Get NeededHealthcare

Never or Not Very Often Stressed aboutMeeting Child's Health Needs

Never or Rarely Worried about MeetingChild's Healthcare Needs

White, Non-Hispanic

Black, Non-Hispanic

Hispanic, English Speaking

Hispanic, Spanish Speaking

Source: 2002 Congressionally-Mandated Survey of SCHIP Enrollees and Disenrollees in 10 States1 "White" (English speaking non-Hispanic) is the reference category for tests of signif icance

**p-value<0.01;*p-value<0.05

**

**

**

****

**

1

**

FIGURE 2. ACCESS AND SERVICE USE FOR SCHIP ENROLLEES BY HIGHEST EDUCATION LEVEL OF PARENT(S)

56.8 %

36.0 %

16.8 %

67.5 %

46.8 %

20.4 %

71.8 %

49.8 %

22.4 %

0.0 %

10.0 %

20.0 %

30.0 %

40.0 %

50.0 %

60.0 %

70.0 %

80.0 %

Any Doctor Vist Any Preventive Care or Check-up Any Specialist or Mental Health Visit

Less than High School

High School

Some College

**

**

**

**

Source: 2002 Congressionally-Mandated Survey of SCHIP Enrollees and Disenrollees in 10 States1"Less than High School" is the reference category for tests of signif icance

**p-value<0.01;*p-value<0.05

1

**

FIGURE 3. PARENTS' CONFIDENCE, STRESS, WORRY, AND FINANCIAL DIFFICULTIES BY HIGHEST EDUCATION LEVEL OF PARENT(S)

73.2 %

65.3 %

39.8 %

73.1 %

83.4 %80.1 %

56.1 %

85.3 %84.4 % 84.8 %

63.2 %

88.0 %

0.0 %

10.0 %

20.0 %

30.0 %

40.0 %

50.0 %

60.0 %

70.0 %

80.0 %

90.0 %

100.0 %

Very or Somew hat Confident Never or Not Very Often Stressed Never or Rarely Worried Never or Rarely Cause FinancialDiff iculties

Less than HighSchool

High School

Some College

**

**********

**

Source: 2002 Congressionally-Mandated Survey of SCHIP Enrollees and Disenrollees in 10 States1"Less than High School" is the reference category for tests of signif icance

**p-value<0.01;*p-value<0.05

1

**

FIGURE 4. SERVICE USE AND UNMET NEED FOR SCHIP ENROLLEES WITH AND WITHOUT ELEVATED HEALTH NEEDS

14.0 %

2.5 % 3.0 %

0.9 %

15.9 %

2.4 %

25.1 %

6.4 % 5.8 %

2.9 %

25.9 %

6.2 %

0.0 %

5.0 %

10.0 %

15.0 %

20.0 %

25.0 %

30.0 %

Any Specialist Visit Specialist UnmetNeed

Any Hospital Stays Unmet Need forHospital Stays

Any Unmet Need More than OneUnmet Need

Children Without Elevated HealthNeeds

Children with Elevated HealthNeeds

**

**

**

**

****

Source: 2002 Congressionally-Mandated Survey of SCHIP Enrollees and Disenrollees in 10 States**p-value<0.01;*p-value<0.05

1"Children w ith Special Health Care Needs" is the reference category for tests of signif icance

1

FIGURE 5. PARENTS' REPORTS OF DOCTORS AND NURSES LOOKING DOWN ON SCHIP ENROLLEES VARY BY STATE

18.5 %

16.1 %17.5 % 17.9 %

14.1 % 13.7 %

25.4 %

33.5 %

23.6 %25.4 %

0.0 %

5.0 %

10.0 %

15.0 %

20.0 %

25.0 %

30.0 %

35.0 %

40.0 %

CA CO FL NY NC TX IL NJ LA MOSeparate MedicaidCombination

Source: 2002 Congressionally-Mandated Survey of SCHIP Enrollees and Disenrollees in 10 States**p-value<0.01;*p-value<0.05

Signif icance tests indicate w hether a given state had an outcome that w as statistically signif icant from the nine other states collectively.

**

**

**

**

*

*

Conclusions• Overall, SCHIP programs provide high levels of access to

care. However, some groups of enrollees fared better than others.

• SCHIP enrollees whose parents have more education tend to receive more care, and their parents have fewer concerns about meeting their children’s health needs.

• SCHIP enrollees with elevated health care needs receive more care but have more unmet needs. In addition, their parents report greater levels of worry and financial difficulty associated with meeting their children’s health care needs.

• Hispanic enrollees, especially those whose primary language is Spanish, have parents who experience greater stress and worry, have lower confidence, and are more likely to experience financial difficulty.

Conclusions (2)

• There was little cross state variation in access and use measures studied, though some differences do exist, including for dental care and type of usual source of care.

• Another difference is that families in states with Medicaid expansion or combination programs were more likely to feel providers “look down on” SCHIP enrollees, though it is unclear whether this is can be generalized to all 50 states.

Policy Implications• Given that some groups of SCHIP enrollees experience

greater difficulty accessing health care, states may have to target more resources at children of parents with lower education levels, Hispanic children, and children with elevated health care needs to help them make better use of the services available to them.

• These findings also suggest a need to develop policies that improve how providers treat public clients, particularly in combination and Medicaid expansion programs.

• In light of the differences that are found across subgroups, as Congress debates changes in SCHIP for its reauthorization, it will be important to consider how the state and federal governments could strengthen the monitoring and reporting of quality and access to care for SCHIP and Medicaid enrollees, particularly for vulnerable subgroups.