January 15, 2004

IMPROVING CHILDREN’S HEALTH:
A Chartbook About the Roles of Medicaid and SCHIP
by Leighton Ku and Sashi Nimalendran

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Summary

This chartbook summarizes numerous recent research findings about children who receive health insurance coverage from either Medicaid or the State Children’s Health Insurance Program (SCHIP), the two primary publicly-funded health insurance programs for low-income children.  The findings are drawn from a variety of recent sources, including the Centers for Disease Control and Prevention’s (CDC’s) 2001 National Health Interview Survey.

Key findings:

Taken together, these findings indicate that the federal and state policies that were initiated in the late 1990s to expand children’s health insurance coverage have been successful in lowering the number of uninsured children, in providing access to good quality medical and dental care services, and in improving children’s health.  As states have developed their SCHIP programs, they expanded eligibility and devised new approaches to simplify and streamline eligibility procedures and to provide outreach.  These new methods led to similar efforts to improve procedures for children in Medicaid as well.  More low-income children were thus able to gain coverage in the public programs, and fewer were uninsured.

The results on health care use and on improvements in health documented in this report  are consistent with other reviews of the research, which also have identified the beneficial effects of Medicaid and SCHIP for children (Bennett, Kenney and Dubay 2003; O’Brien and Mann 2003).

Unfortunately, there are signs that the progress in children’s health coverage is eroding.  A number of states have adopted policies that will reduce children’s enrollment in Medicaid or SCHIP because of state budget pressures.  A recent report found that states have adopted policies that are cutting about 1.2 to 1.6 million people off Medicaid, SCHIP or similar state-funded health insurance programs, of whom almost half — 490,000 to 650,000 — are low-income children (Ku and Nimalendran 2003).  Six states (Alabama, Colorado, Florida, Maryland, Montana, and Utah) have frozen or capped enrollment in their SCHIP programs, so that eligible, low-income children who apply are denied entry (Cohen Ross and Cox 2003). Governor Schwarzenegger has proposed freezing enrollment in SCHIP in California as well, which could preclude coverage of more than 100,000 children in that state alone.

As states begin to plan their budgets for the state fiscal years that (in most states) begin July 1, 2004, there is strong pressure for states to cut Medicaid and SCHIP programs further because of state budget shortfalls.  The pressure is heightened in many states because the federal fiscal relief measures enacted in May 2003 are scheduled to expire on June 30, 2004.  The fiscal relief legislation made health programs more affordable for states by temporarily increasing the federal matching rate for Medicaid.

In addition, in the next few years, an increasing number of states will begin to run out of federal funds for their SCHIP programs.  Unlike Medicaid, which is an entitlement program, states receive fixed federal grants for SCHIP, and many states will be unable to sustain their current SCHIP enrollment levels under the current federal funding arrangements.  A larger number of states have unspent federal funds in their SCHIP grants that could be used to help meet the needs of the states that are running short, but federal funding procedures for SCHIP would have to be modified for this to occur.

The expansions of children’s health insurance coverage under Medicaid and SCHIP have been major public policy successes.  They have helped lower the number of uninsured children, given these children better access to medical and dental care and helped improve their health.

Although evidence of the success of the children’s health insurance programs is accumulating, there are signs that the programs are being weakened.  Unless the federal government and the states take steps to shore up these vital programs, the progress that has been made in recent years could erode.

[Note:  A brief discussion about the data, notes about specific figures and references are located at the end of the report.]

Figure 1
Trends in Insurance Coverage of Low-income Children

Source: CDC 2003a, National Health Interview Survey, as analyzed by CBPP.  See note at end.

Figure 2
Low-Income Children

 Source: March 2003 Current Population Survey, as analyzed by CBPP.  See note at end.

Figure 3
Health Status

Source: CDC 2003b, analyses of 2001 National Health Interview Survey

Figure 4
Asthma

*Difference from Medicaid/SCHIP is significant with 90% or better confidence.
Source:  CDC 2003b, analyses of 2001 National Health Interview Survey

 Figure 5
Learning Disorders

*Difference from Medicaid/SCHIP is significant with 90% or better confidence.
 Source: CDC 2003b, analyses of 2001 National Health Interview Survey

Figure 6
Need for Medications

*Difference from Medicaid/SCHIP is significant with 90% or better confidence.
Source: CDC 2003b, analyses of 2001 National Health Interview Survey.

Figure 7
Usual Source of Health Care

*Difference from Medicaid/SCHIP is significant with 90% or better confidence.
Source: CDC 2003b, analyses of 2001 National Health Interview Survey.  See note at end.

Figure 8
Trends in Usual Source of Care

Source:  CDC 2003c, analysis of National Health Interview Survey data.  See note at end.

Figure 9
Preventive Care

*Difference from uninsured is significant with 90% or better confidence.
Source:  Kenney, et al. 2003, analyses of National Survey of America’s Families.

Figure 10
Access to Physician Services

*Difference from uninsured is significant with 90% or better confidence.
Source:  Kenney, et al. 2003, analyses of National Survey of America’s Families.

Figure 11
Access to Dental Care

*Difference from uninsured is significant with 90% or better confidence.
Source: Kenney, et al. 2003, analyses of National Survey of America’s Families.

Figure 12
Unmet Medical and Dental Needs

*Difference from Medicaid/SCHIP is significant with 90% or better confidence.
Source: CDC 2003b, analyses of 2001 National Health Interview Survey.

Figure 13
Improved
Health Status

*Difference from Medicaid/SCHIP is significant with 90% or better confidence.
 Source: CDC 2003b, analyses of 2001 National Health Interview Survey.  See note at end.

NOTES AND REFERENCES

Much of the data cited in this report is drawn from the 2001 National Health Interview Survey (NHIS), which is part of a long-running series of health surveys.  NHIS is a nationally representative survey of the civilian non-institutionalized population of the United States and includes data on about 100,000 people in almost 40,000 families.  NHIS is conducted by the National Center for Health Statistics, which is an agency of the Centers for Disease Control and Prevention (CDC).  The information about children is generally reported by their parents or caretakers.  As with any household survey, there may be errors or omissions in respondents’ answers.  For more detailed information, see CDC 2003b.  In NHIS, like many other surveys, responses for children in Medicaid and SCHIP are combined because SCHIP programs are often administered as part of Medicaid, so parents may not be able to distinguish the programs.

Note for Figure 1.  CDC presents data separately for children with incomes below the poverty line and children with incomes between 100 and 199 percent of the poverty line.  We pooled the data and computed a weighted average for children with incomes below 200 percent of the poverty line, using weights based on the relative number of children in these income strata, as reported by the Current Population Survey in each year.

Note for Figure 3.  The majority of states have income eligibility criteria for their SCHIP or Medicaid programs equal to 200 percent of the poverty line.  Nine states (California, Connecticut, Georgia, Maryland, New Hampshire, New Jersey, New York, Vermont and Washington) establish income limits higher than 200 percent of the poverty line.  The annual income reported in the Current Population Survey does not necessarily correspond with the period that a child participates in a health insurance program.  For example, a child may be in SCHIP or Medicaid in January 2002 when his or her parents are unemployed and have a low income but leave the insurance program after a parent finds work.  Although the family’s overall income for 2002 may exceed 200 percent of the poverty line, the child’s partial-year participation would still mean that the child counts as being on Medicaid or SCHIP during the year of the survey.

Note for Figures 7 and 8.  The percentages of children with no usual source of care differ slightly in these two figures.  This is because Figure 7 presents data from the 2001 NHIS, while Figure 8 pools data from both the 2000 and 2001 NHIS samples.

Note for Figure 13.  CDC presents the improved health status data for three groups: those currently in fair or poor health, those in good health and those in very good or excellent health.  We pooled data for all three categories by computing a weighted average and calculated the pooled standard errors to test for statistical significance.  The trends for each category were similar.

 References

Bandari, S. and Gifford, E., “Children with Health Insurance: 2001,” U.S. Census Bureau report P-60-224, Aug. 2003.

Bennett, C., Kenney, G. and Dubay, L., editors, “Health Insurance for Children,” The Future of Children, Vol. 13, Issue 1, Spring 2003.  (This special issue contains a number of articles that examine the research and discuss recent policies concerning health coverage of children.)

Billings, J. and Weinick, R. Monitoring the Health Care Safety Net.  Book I: A Data Book for Metropolitan Areas, Agency for Healthcare Research and Quality and Health Resources and Services Administration, Aug. 2003, Chapter 7.

CDC 2003a.  Early Release of Selected Estimates from the January to March 2003 National Health Interview Survey, National Center for Health Statistics, Sept. 30, 2003.

CDC 2003b.  Bloom, B., Cohen, R.A., Vickerie, J.L., Wondimu, E.A., Summary Health Statistics for U.S. Children: National Health Interview Survey.  2001 National Center for Health Statistics, November 2003.

CDC 2003c.  Health, United States, 2003.  National Center for Health Statistics, 2003.

California Healthy Families Program. “Health Status Assessment Project.  First Year Results,” Nov. 2002.

Center for Health Care Strategies, “Asthma Care for Children: Financing Strategies,” October 2001. 

Children’s Dental Health Project, “Preserving the Financial Safety Net by Protecting Medicaid and SCHIP Dental Benefits,” Sept. 2003. 

CHIRI (Child Health Insurance Research Initiative), “Children’s Dental Care Access in Medicaid: The Role of Medical Care Use and Dentist Participation,” June 2003.

Cohen Ross, D. and Cox, L.,  “Out in the Cold: Enrollment Freezes in Six States’ State Children’s Health Insurance Programs Withhold Coverage from Eligible Children,” Kaiser Commission on Medicaid and the Uninsured, Dec. 10, 2003.

Damiano. P., Willard. J., Momany. E., Chowdhury. J. “The Impact of the Iowa S-SCHIP Program on Access, Health Status, and the Family Environment.”  
Ambulatory Pediatrics, 3(5):263-9, Sept./Oct. 2003.

Dubay, L. and Kenney, J. “Health Care Access and Use Among Low-income Children: Who Fares Best?” Health Affairs, 20(1):112-21, Jan./Feb. 2001.

Fox, M., et al.  “Changes in Reported Health Status and Unmet Need for Children Enrolling in the Kansas Children’s Health Insurance Program,” American Journal of Public Health, 93(4): 579-82, April 2003.

Kenney, G., Haley, J., Tebay, A. “Children’s Insurance Coverage and Service Improve.” Snap Shots3 of America’s Families.  Urban Institute, September 2003.

Ku, L., “CDC Data Show Medicaid and SCHIP Played a Critical Counter-Cyclical Role in Strengthening Health Insurance Coverage During the Economic Downturn,” Center on Budget and Policy Priorities, revised Oct. 8, 2003.

Ku, L., and Nimalendran, S. “Losing Out: States Are Cutting 1.2 to 1.6 Million Low-Income People from Medicaid, SCHIP and Other State Health Insurance Programs,” Center on Budget and Policy Priorities, December 22, 2003.

National Conference of State Legislatures, “Access to Oral Services for Low-income People,” October 2002.  Report authored by Shelly Gehshan and Tara Straw under contract to the Robert Wood Johnson Foundation.

O’Brien, E. and Mann, C., “Maintaining the Gains: The Importance of Preserving Coverage in Medicaid and SCHIP,” Health Policy Institute, Georgetown Univ., prepared for Covering Kids and Families, July 2003.