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SCHIP programs have been successful in extending health coverage to uninsured children by a number of methods: enrolling children into separate SCHIP programs, creating Medicaid expansion SCHIP programs, and identifying and enrolling eligible children into traditional Medicaid. (This topic is explored at more length in the Outreach/Enrollment module.) As of September 2000, 36 States had expanded coverage to at least 200 percent of the Federal Poverty Level (FPL).¹ Federal regulation has permitted States to equalize eligibility for children of all ages under Medicaid and SCHIP, so that States now have the potential to provide insurance coverage for almost all low-income uninsured children ages 18 and under, not just the younger children.²

In fiscal year 2000, 3.3 million children nationwide received health insurance through SCHIP, with 995,121 in Medicaid expansion programs and 2,316,784 in separate SCHIP programs. In that same year, States anecdotally reported an increase in the number of children enrolled in traditional Medicaid as a result of SCHIP, however, the exact number of these children is unknown.1 These children represent nearly two-thirds of the 5 million children estimated to be eligible for SCHIP. Much recent research deals with the children not yet covered, focusing on specific hard-to-reach populations, especially adolescents, children in immigrant families, and children with special health care needs. These populations may have unique health care needs (such as the need for equipment, translation, or other special services), or they may be particularly difficult to reach and enroll in health insurance. The following sections summarize articles and issue briefs that focus on the needs of special, hard-to-reach populations of children.

Adolescents

For the first time in 20 years, adolescents are increasing as a percentage of the overall population. Approximately 3.7 million adolescents ages 13-18 are uninsured in the United States; nearly two-thirds of them are eligible but not enrolled in Medicaid or SCHIP.³ It is estimated that the number of young people ages 10-19 will increase by 13 percent between 1995 and 2005.⁴ These projections also point to an increase in the number of young people in racial/ethnic minorities, who are more likely than whites to live in poverty and to be uninsured.

Federal Medicaid eligibility rules required that coverage for children living in poverty be phased in beginning in 1989, starting with 6-year-olds and adding 1 year of age each year. Therefore, State Medicaid programs were not required to cover all children in poverty through age 18 until 2001, and adolescents were the last to be covered. When SCHIP was enacted in 1997, States were required to cover all children in poverty through age 13. The average eligibility threshold for children ages 14-18 was 84 percent of the FPL, compared with 148 percent for children ages 1-5.² Therefore, many adolescents remain uninsured.

According to a report released by the Association of Maternal and Child Health Programs, States' difficulties enrolling adolescents into SCHIP programs may be related to how they have targeted the adolescent population. The report's authors assert that efforts to address the needs of adolescents and at-risk youth are in the very early stages of development, and few States have included provisions to reduce barriers to care, such as confidentiality protections.⁴

Children in Immigrant Families

One in five children under age 18 is either an immigrant or a member of an immigrant family; since 1990, the number of children in immigrant families has risen seven times as fast as the number of children in non-immigrant families.⁵ Children in immigrant families are more likely than those with U.S.-born parents to live in poverty, and they are three times as likely to lack health insurance.⁵ According to data from the Medical Expenditure Panel Survey, a household survey conducted by the Agency for Healthcare Research and Quality:

• Less than half of all Hispanics and blacks had private health insurance, compared to three-fourths of whites.
• Over one-fifth of all Hispanics and over one-fourth of blacks had only public insurance, compared to one-tenth of whites.
• Hispanics and blacks were much more likely than whites to be uninsured.⁶

According to a study conducted by the National Conference of State Legislatures, many immigrant families have been reluctant to seek public health insurance for fear that use of public benefits will jeopardize their immigration status or lead to "public charge" determinations. An alien deemed to be a public charge is ineligible to become a legal immigrant of the United States. Data from this study further show that many immigrant children live in "mixed status" households, in which one parent is a noncitizen and one is a citizen. Nearly 1 in 10 U.S. families with children is of mixed status, comprising legal immigrants, refugees, undocumented immigrants, and/or naturalized citizens.⁷ That variation in eligibility within families may affect the parents' decision to seek benefits and may complicate the provision of health services from public programs.

In fact, the receipt of Medicaid or SCHIP benefits (with the one minor exception) cannot be considered in making a public charge determination, so a major perceived barrier to enrollment of immigrant children and families in Medicaid and SCHIP has been removed. State efforts to enroll these eligible children and families should be greatly facilitated.¹

Children With Special Health Care Needs

The Maternal and Child Health Bureau defines children with special health care needs (CSHCN) as children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. According to Newacheck and colleagues, based on this definition, 15-20 percent of children in the United States could be classified as CSHCN.⁸ In order to promote the development and maintenance of appropriate systems of care for CSHCN, they say, SCHIP programs should specifically address CSHCN as a special targeted population.

According to Fox, Graham, and McManus, many CSHCN require more than just preventive and acute health care services; they may need additional health services as part of their initial identification and evaluation, intermittent and ongoing treatment, and daily routine care.⁹ These services include:

• Monitoring by primary care physicians and pediatric subspecialists.
• Prescription medications.
• Ancillary therapies.
• Mental health services.
• Nursing services.
• Durable medical equipment or assistive technologies.
• Care coordination.

Because they need these services, the health care needs and expenses of CSHCN are higher than those are for other children.⁹

A study by Fox, McManus, and Limb found that difficulties in access to care were greater for children with chronic behavioral, emotional, or developmental conditions than for children with chronic physical conditions.¹⁰ Some difficulties for children with mental health conditions stemmed from service denials, but more stemmed from a lack of providers, particularly child and adolescent psychiatrists and inpatient and residential treatment facilities.¹⁰ In light of this evidence, States should consider ways to facilitate access to mental health and developmental services and to expand pediatric provider networks in order to provide comprehensive coverage to CSHCN.

As SCHIP programs mature and their focus shifts from outreach and enrollment to monitoring and evaluation, it is increasingly important for State officials to maintain current information on the target populations, including adolescents, children in immigrant families, and CSHCN. Their challenge will be to evaluate how well their programs have attracted members of their target populations and to determine the number and composition of the group of children who remain uninsured despite outreach efforts. This information may then be used to reassess how SCHIP can best reach and serve those populations.

1 HCFA (now CMS) SCHIP Web site: http://cms.hhs.gov/schip/.

2 Kenney, G.M., Dubay, L. and J. Haley. "Health Insurance, Access and Health Status of Children: Findings from the National Survey of America's Families." Washington, DC: The Urban Institute. October 2000.

3 English, A., Morreals, M. and A. Stinnett. "Adolescents in Public Health Insurance Programs: Medicaid and CHIP." Chapel Hill, NC: Center for Adolescent Health and the Law. December 1999.

4 Brindis, C.D., Kirkpatrick, R. and T. Macdonald. "Adolescents and the State Children's Health Insurance Program (CHIP): Healthy Options for Meeting the Needs of Adolescents." Washington, DC: Association of Maternal and Child Health Programs. September 1999.

5 Hernandez, D.J. and E. Charney, eds. From Generation to Generation: The Health and Well-Being of Children in Immigrant Families. Washington, DC: National Academy Press. 1998.

6 "Insurance Component Index to Tables." Rockville, MD: Agency for Healthcare Research and Quality. March 2001. Available at: http://www.meps.ahrq.gov/mepsweb/survey_comp/Insurance.jsp.

7 Morse, A. "SCHIP and Access for Children in Immigrant Families." Denver, CO; Washington, DC: National Conference of State Legislatures. February 2000.

8 Newacheck, P.W., Strickland, B., Shokoff, J.P. and J.M. Perrin, et al. "An Epidemiologic Profile of Children with Special Health Care Needs." Pediatrics. 102.1.1 (July 1998): 117-121.

9 Fox, H.B., Graham, R.R. and M.A. McManus. "States' CHIP Policies and Children with Special Health Care Needs." San Francisco, CA; Washington, DC: Maternal and Child Health Policy Research Center. October 1998.

10 Fox, H.B., McManus, M.A. and S.J. Limb. "Access to Care by S-CHIP Children with Special Needs." San Francisco, CA; Washington, DC: Maternal and Child Health Policy Research Center. October 2000.