Genevieve Kenney, a principal research associate in the Urban Institute's Health Policy Center, co-directs the Urban Institute's foundation-supported evaluation of the State Children's Health Insurance Program (SCHIP)—which gave states the authority and funding to expand health insurance coverage to low-income children by broadening Medicaid eligibility, developing new programs, or both. She also is a lead author of a congressionally mandated evaluation of SCHIP.
Five Questions Archives
August 7, 2006
1. Why did Congress create the State Children's Health Insurance Program in 1997?
It fulfilled a commitment by both political parties, and the general public, to give more children access to health care—and the resources existed to do it. We had an incredibly strong budget situation in the late 1990s and a very strong economy. Children tend to be healthy, so covering them through health insurance is cheaper than covering adults or the elderly.
SCHIP represented the single largest expansion in coverage for children since Medicaid was created in 1965. And, it's really the only major coverage expansion that came out of the failed health care reform effort earlier in the 1990s.
Welfare reform played a role too. Enacted in 1996, the new welfare law emphasized work supports. SCHIP was seen as supporting work for low-income parents since it covered children in families with incomes up to, or exceeding, twice the federal poverty level. These families may have trouble affording private coverage.
2. Do evaluations find SCHIP succeeded?
Yes, they do. Study after study has shown that after public coverage under SCHIP was expanded, simplified, and publicized, the number of uninsured children did drop. Although SCHIP is optional, every state created a program. Outreach and simplification efforts occurred in Medicaid programs for children too. And, SCHIP has become an important source of coverage for children—the most recent statistics indicate that SCHIP is covering close to 4 million U.S. kids.
Our research shows that parents now have a greater awareness of these programs and a better understanding of eligibility rules. Understanding that SCHIP's success depended on wide participation, we added questions on program awareness to the National Survey of America's Families, that was part of our foundation sponsored-evaluation of SCHIP through the Assessing the New Federalism Project. That gave us a picture in 1999 that was really crucial. Following up in 2002, we saw real growth in awareness. Still, even in 2002, a lot of people didn't know about the SCHIP program or remained confused about whether only welfare families qualified for both Medicaid and SCHIP.
The other strong finding from that work was how many low-income families said that, had they known their children were eligible for Medicaid or SCHIP coverage, they would have enrolled them. Since then, findings from other studies have confirmed the willingness of most low-income families to enroll eligible children in Medicaid and SCHIP. This finding is important. It suggests that we could enroll many of the millions of uninsured children who are eligible for coverage.
Evidence suggests that, without SCHIP, most kids served by the program would otherwise be uninsured. One initial concern about SCHIP was that it would simply substitute for coverage that children already had. These are higher-income families than are normally targeted by public programs. But we consistently find that most SCHIP enrollees are in families that do not have access to affordable employer-sponsored coverage.
A number of state-specific studies also show that kids do better after they enroll in SCHIP. They're more likely to be getting preventive care, they have fewer unmet health and dental needs, and their parents worry less about being able to meet their children's health care needs.
But while all of these successes have been documented, we still have millions of uninsured kids in this country, many who are eligible for Medicaid or SCHIP. According to the most recent Current Population Survey, there are nine million uninsured children. And there is little research on the impacts of SCHIP on children's health status and functioning.
3. Who are the children being served — or not — by SCHIP?
Ninety percent of these kids live in a family with a working parent. That's not surprising given the income level that the program serves. This detailed information on the characteristics of SCHIP enrollees comes from the congressionally mandated 10-state study on larger states with higher Hispanic populations. That study indicates that SCHIP is serving kids with diverse ethnic and racial backgrounds, parental educational backgrounds, and degrees of health care problems.
Our foundation-sponsored evaluation had also shown that gains were largest for minority children and for low-income children. It showed coverage improvements for children with chronic health conditions -- a group in especially dire need of coverage. And coverage improvements occurred for both poor and near poor children. That means that the outreach and enrollment efforts led to more coverage for Medicaid and SCHIP-eligible children alike.
Some families struggle more with the application process, such as those with lower education and those whose first language isn't English. Despite steps taken to simplify enrollment, applying requires more facility with English than more of these families have. Such families need application assistance.
Bottom line: We have a lot of eligible poor and near poor children who are not participating. There are probably a million low-income kids with special health care needs that are not insured. Reaching them has to be the top priority. We need to really target outreach to them.
4. Does the program meet enrollees' health care needs?
From what we can tell, SCHIP is meeting the primary health care needs of most enrolled children. According to our 10-state study, about 90 percent of them have a usual source of care. Most reported getting a "well-child visit" and preventive dental care in the six months before their parents were interviewed.
We do find that kids who are healthier are less likely to participate. That might not sound worrisome, but other work we've done suggests that those kids may not be getting necessary monitoring.
Unmet needs are fairly low except for some groups, such as children with special health care needs. While kids with special needs are better off being in these programs than not, their unmet needs are still quite high. Some don't get all the needed prescription drugs, doctor care, dental care, and attention by specialists. Unmet dental needs are still pretty high, for instance, though much lower than what the uninsured experience.
Parents report fairly high levels of confidence that they will be able to meet their children's health care needs with little financial burden. So that's encouraging. Families report high levels of satisfaction with their children's health care providers.
The data we have suggest that in the households where English is not the spoken language, experiences don't seem to be as positive. Poor communication can really jeopardize quality of care for kids and that's a real concern.
Unfortunately, we do not have national statistics that allow us to track how different kinds of children are being served under SCHIP and whether different plans and programs are more effective than others. For example, there is no consistent reporting on quality of care across states. This is true in Medicaid programs that serve children as well.
5. What changes are being discussed to ensure that low-income children get the health care they need?
Congress is scheduled to reauthorize SCHIP in 2007. Because the program is largely considered a success, legislators may be reluctant to tamper with any of its main features. Funding levels for the program, however, will most likely be debated.
Unlike Medicaid, an entitlement program, SCHIP was funded as a block grant — with over $5 billion of new federal funds provided in 2005. An increasing number of states have been spending more than their annual allotments, but have used unspent funds from prior years to cover the difference. Still, many states expect federal funding shortfalls in coming years unless allotments increase. So the big questions will be on the size of the federal commitment to SCHIP and how those funds are allocated across states.
Up to now, no state has lacked the federal resources to provide services to SCHIP enrollees. But that is because SCHIP was fully funded from day one—Oct. 1, 1997—but enrollment levels remained under two million until 2000. So states accumulated large, unspent funds. For that reason, the block grant structure under SCHIP hasn't really been tested yet. That's a fundamental issue going forward.
Other important issues include current funding formulas and matching rates. Right now, covering a child in SCHIP requires fewer state dollars than covering a child in Medicaid. This edge was given to SCHIP to sweeten the deal and to encourage states to participate in it.
But the SCHIP advantage leads to perverse incentives. When budget times are tough, states may try to cut back on Medicaid enrollment or may make fewer efforts to enroll poor children in Medicaid. One solution might be to reward states that achieve low uninsured rates for both poor and near poor children by raising matching rates under both Medicaid and SCHIP.
We also should assess whether it makes sense to run two programs providing health care for kids. Some research suggests that having more seams — which is what happens with two programs — causes more kids to fall between the cracks and lose coverage. Sometimes siblings qualify for different programs, just based on their age. That complicates families' lives.
Government should be doing a better job monitoring both access to and quality of care being provided under Medicaid and SCHIP. Together, these programs serve millions of children, so it's critical that we have a better idea of how well they are meeting these children's needs. We should test ways of rewarding higher quality.
Expanding public coverage to parents gets more kids covered, we've found, which in turn may lead to better access for both parents and children. There's also evidence that the mental health status of parents affects whether children get the health care they need. So even if the ultimate goal is to improve the lives of children, what's going on with the parents needs to be taken into account too.