Potential of Medicaid and SCHIP Expansions To Increase Insurance

Coverage for CSHCN

Amy Davidoff, Ph.D.

Alshadye Yemane, B.A.

The Urban Institute

American Public Health Association Annual MeetingSan Francisco, November 2003

Funding provided by a grant from the Maternal and Child Health Bureau

Background

Public insurance plays key role for CSHCN• Special eligibility mechanisms for disabled children,

medically needy• Broad scope of benefits highly desirable• Higher public coverage rates overall

SCHIP expansions - key for low income uninsured Little known about differential eligibility,

participation patterns for CSHCN• Unique characteristics may affect eligibility• Participation patterns may differ• Program features, e.g. crowd-out provisions expected to

be particularly strong deterrent

Background (cont)

Family Opportunity Act (S. 321)

Permits public insurance buy in for severely disabled children

Various program designs• Expansions to 250% vs. 300% FPL• Medicaid vs. SCHIP buy-in

Research Objectives

Describe patterns of Medicaid, SCHIP eligibility for CSHCN

Examine participation patterns for CSHCN Simulate eligibility & participation under FOA

proposals

Sources of Data

National Health Interview Survey (NHIS)• Household survey• Non-institutionalized civilian population in U.S.• Pooled data from 2000 and 2001

Federal and state Medicaid and SCHIP eligibility rules

Identifying CSHCN

MCHB Definition of CSHCN NHIS elements replicate CSHCN Screener (Bethell et al.

2002). Captures children who have: • Regular need/use for prescription drugs;• Elevated need/use of services• Need/use special therapies (RT, OT, PT)• Limitations in normal activities• Emotional, behavioral or developmental condition that requires

counseling or therapy

Consequences associated with health condition lasting or expected to last 12 months

12 % of children identified as CSHCN on NHIS

Identifying Medicaid & SCHIP eligibles

Algorithm replicates eligibility determination process

Determine monthly earnings, relevant expenses for disregards• Calculate “countable” income

Determine eligibility for Medicaid or SCHIP• Determine categorical eligibility• Compare federal & state specific income thresholds to

countable income

Simulate FOA eligibility assuming existing rules, new income thresholds

Methods Descriptive comparison of eligibility,

participation for CSHCN, other children Multivariate linear probability models

estimate effects of child, parent, program characteristics on participation • Separate models for CSHCN, other children• Regression coefficients used to simulate

participation under FOA expansions

Patterns of Public Insurance Eligibility

All Eligible 49.5 *** 43.1 73.5 67.8

Eligible according to 1997 rules

32.7 *** 25.0 44.3 38.6

SSI 5.7 *** 0.4 2.8 * 0.2

Non-SSI 27.0 ** 24.5 41.5 38.4

Any SCHIP Expansion 16.8 18.1 29.3 29.2(0.008) (0.003) (0.032) (0.010)Freestanding SCHIP 11.4 ** 13.1 17.3 21.7

Not Eligible 50.5 *** 56.9 26.5 32.2

Uninsured ChildrenAll Children

Eligibility Pathway

Source: Urban Institute estimates based on pooled 2000-2001 data from the National Health Interview Survey.

Estimates for CSHCN significantly different than other children: *** p<.01, ** .01<p<=.05, .05<*p<=.10

CSHCN (%)

No SCHN (%)

No SCHN (%)

CSHCN (%)

Waiting Periods, Premiums – Likely Barriers?

19 % all eligible, 72 % SCHIP eligible CSHCN face waiting periods

Among SCHIP eligible CSHCN with waiting period• 27 % publicly insured• 10 % uninsured > waiting period• 60 % with private insurance

Among uninsured SCHIP eligible CSHCN• 80 % faced waiting period• ¾ uninsured longer than waiting period

20 % eligible CSHCN have premium requirements

Public insurance participation rates higher for eligible

CSHCN

Other (%)

Other (%)

All Eligibles 55.0 *** 38.8 80.6 *** 65.6

Eligible according to 1997 rules 68.0 *** 53.0 84.9 *** 72.5

SSI 82.1 ** 63.7 94.9 92.5

Non-SSI 65.0 *** 52.8 82.7 *** 72.1

Any SCHIP Expansion 30.0 *** 19.3 65.4 *** 48.5Medicaid SCHIP 27.7 22.9 58.6 53.6Freestanding SCHIP 30.8 *** 17.9 69.1 *** 46.4

Waiting Periods

Subject to 26.2 *** 16.0 62.6 *** 42.4

Not subject to 61.7 *** 46.6 82.9 *** 70.3

PremiumsRequired 35.0 *** 17.5 69.5 *** 47.8Not required 59.9 *** 46.2 82.3 *** 69.0

Estimates for CSHCN significantly different than other children: *** p<.01, ** .01<p<=.05, .05<*p<=.10

All Eligible Children

Eligible Children without Private or

Other Public Insurance

CSHCN (%)

CSHCN (%)

Source: Urban Institute estimates based on pooled 2000-2001 data from the National Health Interview Survey.

Eligibility Pathways and Program Requirements

Participation in Family Opportunity Act expansions depends on program design

Design Options

250% FPL Expansion

300% FPL Expansion

Percent of CSHCN that are newly eligible

6.4 13.7

Percent of New CSHCN Eligibles that Participate

Medicaid Buy-In 41.3 38.9

SCHIP Buy-In 22.2 20.1

Source: Urban Institute estimates based on pooled 2000-2001 data from the National Health Interview Survey.

Discussion SCHIP expanded public insurance eligibility

to large group of CSHCN• SCHIP expansions affected fewer CSHCN,

allowed other children to catch up• Few uninsured remain ineligible• Policy focus on enrollment, retention

Participation generally higher among CSHCN but• few significant structural differences in

participation behavior• difference in participation due partly to different

characteristics of eligible CSHCN

Discussion (continued)

Participation rates generally lower for SCHIP programs. May be related to• Program characteristics: waiting periods, benefits,

managed care provisions• More recent implementation• Characteristics of eligible children• Need further research on role of program design &

implementation Family Opportunity Act could add additional

eligible CSHCN• Participation rates depend on program design