IMPROVING CHILDREN'S HEALTH:
A Chartbook about the Roles of Medicaid and SCHIP
By Leighton Ku, Mark Lin, and Matthew Broaddus
This chartbook summarizes current knowledge about the health insurance coverage and health needs of low-income* children in the United States and the roles that Medicaid and the State Children’s Health Insurance Program (SCHIP) — the joint federal-state, publicly funded health insurance programs for children — play in improving children’s health care access and health status. Medicaid and SCHIP provide health coverage for over 30 million low-income children, opening doors to children and their families to affordable preventive, primary, and acute health care services.
This is a completely revised and updated version of a report originally issued three years ago (Ku and Nimalendran, 2004). Given current concerns about the pending reauthorization of SCHIP, it is relevant to provide clear and updated information about the important role these public insurance programs play in the lives of America’s low-income children.
This report complements other recent reports about public insurance programs for children, such as the Kaiser Commission on Medicaid and the Uninsured’s review of the evidence about health insurance for low-income people (2006) or its summary of SCHIP’s first ten years (2007), the Congressionally-mandated evaluation of SCHIP by Wooldridge et al. (2005), or the series of reports by the Children’s Health Insurance Research Initiative (which is sponsored by the Agency for Health Care Quality, the David and Lucile Packard Foundation, and the Health Resources and Services Administration).
Other new reports provide a wealth of useful information about SCHIP and children’s health insurance coverage. To avoid duplication with those reports, this chartbook provides relatively little discussion of certain topics. Readers interested in information about states’ eligibility and enrollment policies should refer to Cohen Ross et al. (2007), while those interested in SCHIP funding issues and shortfalls will find useful information in Park and Broaddus (2006), Broaddus and Park (2006), and Peterson (2006).
A substantial body of recent medical, health, and economic research, conducted by scholars across the nation, offers detailed information about the needs of low-income children and compelling evidence about the ways that public insurance programs help these children. Even so, it must be acknowledged that the research knowledge base about the effects of Medicaid and SCHIP remains incomplete. For example, it has not been possible to design and implement a random-assignment experiment of the effects of children’s health insurance coverage that would be considered the “gold standard” of research evidence. Such a randomized study would probably not be considered ethically acceptable in any case. In addition, while health insurance coverage is critical, it is just one of the many determinants of children’s health, including family environment and nutrition.
This report is organized into four sections, summarized below. You can click the title of each section to view a PDF document containing the charts in that section or you can download the full version of the chartbook.
Section 1 Health Insurance Coverage of Low-Income Children
- The percentage and number of low-income children who are uninsured has fallen by more than one-third since 1997, when SCHIP legislation was enacted. The growth in Medicaid and SCHIP enrollment of low-income children more than offset the reduction in employer-sponsored coverage that occurred between 1997 and 2005. (See Figures 1 and 2)
About 7 out of every 10 uninsured children are already eligible for Medicaid or SCHIP. To make substantial headway in further reducing the number of uninsured children, it will be necessary to increase participation in these programs by eligible children and to ensure that sufficient federal and state funds are available to cover their health needs. (See Figure 3)
Most children covered by Medicaid or SCHIP are in working families that are unable to get or afford private health insurance for their children. (See Figure 4)
White children, African American children, and Hispanic children have all experienced substantial reductions in rates of uninsurance in the past decade because of the expansion of the public programs. (See Figure 7)
Over the past decade, insurance coverage has eroded for immigrant children even as it has grown for children who live in native-born citizen families. Under a 1996 law, a large number of legal immigrant children are ineligible for federal coverage under Medicaid or SCHIP. (See Figure 8)
One of the most effective ways to bolster enrollment of eligible low-income children is to expand coverage for their parents. For parents, the typical income limit for publicly funded coverage is about one-third the typical income limit for children, but a number of studies show that when states expand parents’ coverage, children’s participation improves. (See Figures 10 and 11)
Section 2 Health Needs of Children in Medicaid and SCHIP
Children served by Medicaid and SCHIP often have serious health problems. They are more likely to be rated as having fair or poor health than privately insured children. While children covered by the public programs are somewhat more likely to be in fair or poor health than those without insurance, substantial numbers of uninsured children with fair or poor health remain uninsured. (See Figure 12)
Publicly insured children are more likely to have asthma, learning disabilities, and/or health conditions that require regular treatment with prescription medications. Medicaid and SCHIP provide access to the medical care that can treat these problems and help children grow, function, and learn more effectively. Like other American children, publicly-insured children are often overweight and Medicaid and SCHIP may be able to do more to address this problem. (See Figures 13-16)
Section 3 Effects on Medical Care Access and Utilization
One critical way to improve health access is to ensure that a child has a “medical home” or a usual place to receive medical care. Children covered by Medicaid or SCHIP are much more likely to have a medical home than children who are uninsured. Moreover, over the past decade the percentage of children who have access to a medical home has grown for children covered by public programs while declining for uninsured children. (See Figures 17 and 18)
Before joining SCHIP, African American and Hispanic children in New York were less likely than white children to have a usual source of care. One year after enrollment, these racial and ethnic disparities had largely been eliminated. (See Figure 19)
Children need preventive health care such as well-child visits, where doctors make sure that the child is immunized or check for health problems that might jeopardize the child’s development. Children covered by Medicaid or SCHIP are much more likely than uninsured children to have preventive health care and to keep up with recommended schedules of well-child visits. (See Figures 21 and 22)
Because children enrolled in Medicaid or SCHIP are typically in poorer health than other children, it is not surprising that they need to use emergency rooms more often than privately insured children. However, the use of emergency rooms by publicly insured children has declined by about one-quarter over the past decade. (See Figure 23)
Children enrolled in Medicaid or SCHIP have fewer unmet medical or dental needs than uninsured children. Moreover, a New York study found that although African American and Hispanic children were at greater risk than white children of having unmet needs before they entered SCHIP, these racial and ethnic disparities disappeared after one year of SCHIP coverage. (See Figures 25 and 26).
Although low-income children’s access to dental care is insufficient, those who are continuously covered by public insurance are more likely to receive dental care than those who are continuously covered by private insurance. In addition, low-income children who are continuously covered by public insurance are much more likely to get dental care than children who are uninsured for part or all of a year. (See Figure 27)
Section 4 Effects in Improving Child Health
In California, parents reported improvements in their children’s school performance after they had been enrolled in SCHIP for a year: the children were more likely to pay attention in class and were better able to keep up with school activities. Similarly, a Kansas study found that children missed fewer school days due to sickness after they were enrolled in SCHIP. (See Figure 30)
The Challenges Ahead
In sum, extensive evidence demonstrates that Medicaid and SCHIP have bolstered children’s health insurance coverage, strengthened access to medical and dental care, and improved children’s health. Other research indicates that improved child health may ultimately lead to better health when children grow up to become adults, so there could be more long lasting repercussions (Case et al., 2005).
Unfortunately, the progress in children’s health insurance coverage made over the past decade could slow or even slip backward. For example, new federal mandates that state agencies document the citizenship and identity of citizens applying for Medicaid, including children and even newborns, threaten to delay or deny coverage to tens of thousands of eligible low-income citizen children (Center on Budget and Policy Priorities, 2006; deLone, 2006; Cohen Ross 2007).
In addition, many states are facing shortfalls in their federal SCHIP funding levels that could begin as soon as mid-2007 (Park and Broaddus, 2006; Peterson, 2006). If these shortfalls are not filled, enrollment could fall substantially in the coming year. Furthermore, SCHIP is due for reauthorization in 2007, and if Congress freezes annual federal SCHIP funding in nominal terms for the next five years, funding shortages could lead 1.5 million or more children to lose coverage (Broaddus and Park, 2006).
Census data for 2005 indicate that about 9 million children 18 or younger are uninsured. In the coming year, Congress and the President have the opportunity to address these problems and to provide the additional resources that would strengthen the nation’s system of health insurance coverage for low-income children so the nation can continue to reduce the number of children who lack health insurance and to improve their health.
* In this document, “low-income” is defined as family income below 200 percent of the poverty line. In 2006, 200 percent of the poverty line was equal to an annual income of $33,200 for a family of three or $40,000 for a family of four (the poverty line is higher in Alaska and Hawaii).