Findings from the Child Health Insurance Research Initiative (CHIRI™)

Below are summaries of and links to findings from the Child Health Insurance Research Initiative (CHIRI™).

CHIRI™ research findings are now available on the following topics:

CHIRI™ Impact
CHIRI™ Summary
Access and Quality in CHIP (formerly SCHIP) and Medicaid
Enrollment and Disenrollment in CHIP and Medicaid
Provider Participation
Special Populations
     Adolescents
     Children with Special Health Care Needs
     Minority Children
State CHIP and Medicaid Design Choices

Links to CHIRI™ grantees' final reports will be added to the list of CHIRI™ Projects as they become available from the National Technical Information Service. The final report from the CHIRI™ project, "Responsiveness of SCHIP to Children With Special Health Care Needs," is already available at http://www.mchlibrary.info/MCHBfinalreports/docs/fr00165.doc.

Return to Contents

CHIRI™ Impact

One of the goals of CHIRI™ is to provide information useful to health care policymakers. Select to read about CHIRI™ research highlights and CHIRI™'s impact on policy in Kansas.

Return to Content

CHIRI™ Summary

CHIRI™ Issue Brief No. 10. What Has Been Learned About Expanding Children's Health Insurance? Highlights from CHIRI™ (2009). Karen VanLandeghem and Cindy Brach.

This Issue Brief highlights some of the CHIRI™ findings that were featured in the series of CHIRI™ Issue Briefs developed for policymakers. The findings focus on the State Children's Health Insurance Program (SCHIP), a Federal program implemented in 1997 and reauthorized in 2009 as the Children's Health Insurance Program (CHIP). This Issue Brief summarizes findings, including: (1) demographic characteristics of SCHIP enrollees, (2) impact of SCHIP on health care access and quality for low-income children, (3) impact of SCHIP design on enrollment, reenrollment, and access to care, and (4) insurance pathways of children after SCHIP enrollment.

CHIRI™ Issue Brief No. 10 is available online (PDF File, 270 KB; Plugin Software Help), or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 09-0034).

Access and Quality in CHIP (formerly SCHIP) and Medicaid

CHIRI™ Issue Brief No. 8. Impact of Primary Care Case Management (PCCM) Implementation in Medicaid and SCHIP (2009). Karen VanLandeghem and Cindy Brach.

PCCM systems are designed to increase patients' use of well-child and primary care in physician offices while decreasing use of specialty care and emergency department use. Researchers studied the impact of implementing PCCM systems in Alabama and Georgia. Children enrolled in the Alabama and Georgia Medicaid programs were less likely to use emergency departments, but were also less likely to use well-child and other primary care after PCCM implementation. Physician participation in Alabama and Georgia Medicaid also declined. The transition to PCCM can be disruptive to established patterns of provider participation and enrollees' use of health care. Efforts to ensure continuity of care and provider participation during PCCM transition might be addressed through public insurance program design and targeted education and outreach strategies to enrollees.

CHIRI™ Issue Brief No. 8 is available online (PDF File, 610 KB; Plugin Software Help), or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 09-0020

CHIRI™ Issue Brief No. 6. Who Enrolls in Oregon's Premium Assistance Program and How Do They Fare? (2007). Karen VanLandeghem, Cindy Brach, Jennie Bonney, and Lisa Kretz.

Little is known about the characteristics of families who enroll in premium assistance programs, their experiences in using these programs, and what happens when they disenroll. Researchers studied the factors that affect parental choice and compared the effects of enrollment in SCHIP and the Oregon Family Health Insurance Assistance Program (FHIAP) on health status, access to care, utilization of services, and parental satisfaction. In addition, researchers studied what happens to children who disenroll from either program. Low-income children benefited equally from enrollment in SCHIP and FHIAP. Yet, few families had access to employer-sponsored health insurance. As a result, 70 percent of FHIAP families purchased their coverage in the individual market. Increases in family income were cited as the main reason for disenrollment from FHIAP and from SCHIP. Two-thirds of SCHIP disenrollees and almost half of FHIAP disenrollees became uninsured.

CHIRI™ Issue Brief No. 6 is available online or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 07-0022).

What Happens to Children Who Lose Public Health Insurance Coverage? (2006). Janet B. Mitchell, Susan G. Haber, and Sonja Hoover

Little is known about what happens to children who disenroll from public health insurance programs. Researchers studied children who disenrolled from Oregon's State Children's Health Insurance Program (SCHIP) or Family Health Insurance Assistance Program (FHIAP), a premium assistance program. Both programs have identical eligibility requirements. Two-thirds of SCHIP disenrollees and almost half of FHIAP disenrollees became uninsured. Increases in family income were cited as the main reason for disenrollment from SCHIP and FHIAP. Even with increases in their income, many of these families were unable to afford the costs of private health insurance, which left their children uninsured. For more details, read "What Happens to Children Who Lose Public Health Insurance Coverage?" in the October 2006 issue of Medical Care Research & Review 63(5), pp. 623-635.

CHIRI™ Issue Brief No. 5. SCHIP Enrollees with Special Health Care Needs and Access to Care (2006). Karen VanLandeghem, Jennie Bonney, Cindy Brach, and Lisa Kretz.

Numerous factors—such as restrictions on health care coverage and insufficient provider participation—can limit access to care for children enrolled in public insurance programs, particularly children with special health care needs (CSHCN). This CHIRI™ Issue Brief summarizes findings regarding: health care access and satisfaction of CSHCN enrolled in SCHIP, services that were limited and/or excluded under SCHIP in some of the study States, and how SCHIP design decisions can limit coverage for CSHCN.

In general, CSHCN enrolled in SCHIP did not experience any problems in obtaining a primary health care provider or routine specialty services. However, certain specialty services were difficult to obtain in some study States that imposed limits and/or exclusions on certain services or were ambiguous in defining a standard of medical necessity. In addition, income restrictions and/or medical condition criteria made it difficult to access supplemental services from other Federal and State programs for CSHCN with severe chronic health conditions in some of the study States.

CHIRI™ Issue Brief No. 5 is available online or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 06-0051).

Improved Asthma Care after Enrollment in the State Children's Health Insurance Program (SCHIP) in New York (2006). Peter G. Szilagyi, Andrew W. Dick, Jonathan D. Klein, Laura P. Shone, Jack Zwanziger, Alina Bajorska, and H. Lorrie Yoos.

Asthma is the most prevalent chronic medical condition of childhood, with a disproportionate share of low-income and minority children affected by the condition and less likely to receive asthma care. Researchers found that enrollment in SCHIP was associated with improvements in access to and quality of asthma care, and reductions in asthma attacks and urgent care asthma-related visits. Improvements were greatest among children who had been previously uninsured. Researchers conclude that these findings suggest that health insurance improves the health of children with asthma. For more details, see "Improved Asthma Care after Enrollment in the State Children's Health Insurance Program (SCHIP) in New York" in the February 2006 issue of Pediatrics 117(2), pp. 486-96.

New York's SCHIP Program Improves Health Care Access, Continuity, and Quality (2006). Karen VanLandeghem, Jennie Bonney, Cindy Brach, Lisa Kretz, Peter Szilagyi, Laura Shone.

What is the impact of the State Children's Health Insurance Program (SCHIP) on the health care that children receive in one of the Nation's first and largest SCHIP programs? This four-page issue brief examines the impact of the New York SCHIP program on access, quality and utilization of health care services for SCHIP enrollees and suggests strategies that other States can use to improve access and quality for low-income children. For a copy of the issue brief, contact Bonnie_doran@urmc.rochester.edu

Premium Subsidy Programs: Who Enrolls and How do They Fare? (2005). Janet B. Mitchell, Susan G. Haber, and Sonja Hoover.

Given the choice of enrolling in SCHIP or a premium subsidy program, what program do parents choose and do their children experience better access to health care? Researchers found that parents of children enrolled in the Oregon premium subsidy program were more likely to be employed, English speaking, have prior experience with premiums and private health insurance, and perceive insurance as protection against future health care needs as compared to parents of Oregon SCHIP enrollees. There were few differences in access to care between children enrolled in the two programs. The authors conclude that several factors are likely to impact the success of premium subsidy programs in serving low-income families—families' knowledge of and experience in using the private health care system, access to employer sponsored health insurance, and cost-sharing requirements. "Premium Subsidy Programs: Who Enrolls and How do They Fare?" was published in the September/October 2005 issue of Health Affairs 24(5), pp. 1344 -1355.

Reduction in Racial and Ethnic Disparities After Enrollment in the State Children's Health Insurance Program (2005). Laura P. Shone, Andrew W. Dick, Jonathan D. Klein, Jack Zwanziger, and Peter G. Szilagyi.

How does SCHIP impact racial/ethnic disparities among enrollees? Researchers found that enrollment in the New York SCHIP program—Child Health Plus—improved access, continuity, and quality of care for enrollees from racial/ethnic groups and reduced preexisting racial/ethnic disparities in health care access, unmet need, and continuity of care. In spite of these improvements, racial/ethnic disparities in quality of care remained. The authors conclude that SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care. "Reduction in Racial and Ethnic Disparities After Enrollment in the State Children's Health Insurance Program" was published in the June 2005 issue of Pediatrics 115(6), pp. e697-e705.

SCHIP's Impact In Three States: How Do The Most Vulnerable Children Fare? (2004) Andrew W. Dick, Cindy Brach, R. Andrew Allison, Elizabeth Shenkman, Laura P. Shone, Peter G. Szilagyi, Jonathan D. Klein and Eugene M. Lewit.

At a time when States are implementing cost-saving measures and making the most of program resources, policymakers are interested in knowing how the State Children's Health Insurance Program (SCHIP) benefits low-income and vulnerable children and possible strategies for improvements. This study provides consistent evidence, from three diverse States with heterogeneous populations and distinct programs (Florida, Kansas, and New York), that SCHIP increased access to and satisfaction with health care among enrolled low-income children. The study shows that vulnerable children—minorities, children, and adolescents with special health care needs, and children uninsured for long periods of time—shared in these gains. It also highlights areas to target for future improvement. For details, see "SCHIP's Impact In Three States: How Do The Most Vulnerable Children Fare?" in the Sept/Oct 2004 issue of Health Affairs 23(5), pp. 63-75. Article reprints can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-R066).

CHIRI™ Issue Brief 4: Does SCHIP Benefit All Low-Income Children? summarizes the findings and can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 05-0010).

Improved Access and Quality of Care After Enrollment in the New York State Children's Health Insurance Program (SCHIP) (2004). Peter G. Szilagyi, Andrew W. Dick, Jonathan D. Klein, Laura P. Shone, Jack Zwanziger, Thomas McInerny.

Does SCHIP improve access to and the quality of health care for children who enroll in the program? This study examined the impact of New York State's SCHIP on access, utilization, and quality of health services for enrolled children. Among new enrollees, the authors found that the program: increased the proportion of enrollees with a usual source of care; improved access; and reduced unmet needs for specialty, acute, preventive, dental and vision care services. Continuity of care also increased, with a greater proportion of families seeking care for their SCHIP-enrolled children from their main source of primary care. Enrollment in SCHIP was associated with significant improvements in access, continuity, and quality of care. "Improved Access and Quality of Care After Enrollment in the New York State Children's Health Insurance Program (SCHIP)" was published in the May 3, 2004, electronic issue of Pediatrics.

Do Enrollees in "Look-Alike" Medicaid and SCHIP Programs Really Look Alike? (2002). Jennifer N. Edwards, Janet Bronstein, and David B. Rein.

The State Children's Health Insurance Program (SCHIP), passed by Congress in 1997, has been implemented by States in many different forms, thus creating a myriad of natural experiments about insurance coverage for low-income children. In Georgia, SCHIP children are enrolled in a Medicaid look-alike program, PeachCare for Kids, with nearly the same administrative rules and providers as the Medicaid program. Comparing the experiences of PeachCare and Medicaid children allowed the authors to examine the impact of population differences on utilization and satisfaction. The authors found Medicaid children, controlling for many demographic characteristics, reported both less use of services and lower satisfaction with services used. Evidence presented supports three possible explanations for these differences: Medicaid families are less familiar with and supportive of systems requiring use of an assigned primary care physician, the families face more nonprogram barriers to using care, and physicians' have different responses to the two programs. For more details see "Do Enrollees in 'Look-Alike' Medicaid and SCHIP Programs Really Look Alike?" in the May/June 2002 issue of Health Affairs 21(3), pp. 91-102. 

Dental Care

CHIRI™ Issue Brief No. 2. Children's Dental Care Access in Medicaid: The Role of Medical Care Use and Dentist Participation (2003). Karen VanLandeghem, Janet Bronstein, and Cindy Brach.

Many policymakers are examining State public insurance programs for ways to reduce costs and maximize the return on State and Federal investments. This CHIRI™ Issue Brief reports on children's dental care use in the Alabama and Georgia Medicaid programs and strategies for improving access to dental care, providing States with an additional resource as they make critical decisions about public insurance programs. Researchers found that less than 40 percent of Medicaid-enrolled children received dental care. Most of these children received preventive care and half used intensive dental services.

While dentists' participation in Medicaid had some effect on improving dental care access, researchers conclude that other factors also influence dental care use in public insurance programs. Strategies that capitalize on the fact that Medicaid-enrolled children are far more likely to receive medical care than dental care could boost access tremendously. If every child who had a medical visit also had a dental visit, many (61 percent in Alabama and 78 percent in Georgia) Medicaid-enrolled children would have received dental care. The CHIRI™ Issue Brief is available online or it can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 03-0032).

Return to Contents 

Enrollment and Disenrollment in CHIP and Medicaid

CHIRI™ Issue Brief No. 7. Do SCHIP Enrollees Stay Insured? (2008). Karen VanLandeghem and Cindy Brach.

SCHIP has helped increase insurance rates by providing coverage to low-income children whose families earn too much to qualify for Medicaid but lack private coverage, and by increasing Medicaid enrollment through SCHIP outreach and enrollment efforts. Achievements in reducing uninsurance rates can only be sustained, however, if low-income children retain public insurance or transition to private insurance coverage.

Researchers studied the impact of SCHIP enrollment on low-income children's public and private insurance coverage in the short-term. Over three-quarters of SCHIP enrollees were publicly insured (Medicaid or SCHIP) at least one year after enrollment, while some SCHIP enrollees (4 percent to 15 percent) obtained private insurance coverage after leaving SCHIP. SCHIP retention was increased by a simplified renewal policy that automatically reenrolled children in SCHIP unless their families submitted reenrollment forms indicating a change affecting their eligibility.

CHIRI™ Issue Brief No. 7 can be downloaded as a PDF File, 300 KB; (Plugin Software Help), or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 08-0057).

CHIRI™ Issue Brief No. 6. Who Enrolls in Oregon's Premium Assistance Program and How Do They Fare? (2007). Karen VanLandeghem, Cindy Brach, Jennie Bonney, and Lisa Kretz.

Little is known about the characteristics of families who enroll in premium assistance programs, their experiences in using these programs, and what happens when they disenroll. Researchers studied the factors that affect parental choice and compared the effects of enrollment in SCHIP and the Oregon Family Health Insurance Assistance Program (FHIAP) on health status, access to care, utilization of services, and parental satisfaction. In addition, researchers studied what happens to children who disenroll from either program. Low-income children benefited equally from enrollment in SCHIP and FHIAP. Yet, few families had access to employer-sponsored health insurance. As a result, 70 percent of FHIAP families purchased their coverage in the individual market. Increases in family income were cited as the main reason for disenrollment from FHIAP and from SCHIP. Two-thirds of SCHIP disenrollees and almost half of FHIAP disenrollees became uninsured.

CHIRI™ Issue Brief No. 6 is available online or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 07-0022).

What Happens to Children Who Lose Public Health Insurance Coverage? (2006). Janet B. Mitchell, Susan G. Haber, and Sonja Hoover

Little is known about what happens to children who disenroll from public health insurance programs. Researchers studied children who disenrolled from Oregon's State Children's Health Insurance Program (SCHIP) or Family Health Insurance Assistance Program (FHIAP), a premium assistance program. Both programs have identical eligibility requirements. Two-thirds of SCHIP disenrollees and almost half of FHIAP disenrollees became uninsured. Increases in family income were cited as the main reason for disenrollment from SCHIP and FHIAP. Even with increases in their income, many of these families were unable to afford the costs of private health insurance, which left their children uninsured. For more details, read "What Happens to Children Who Lose Public Health Insurance Coverage?" in the October 2006 issue of Medical Care Research & Review 63(5), pp. 623-635.

The Impact of SCHIP Enrollment on Physician Participation in Medicaid in Alabama and Georgia (2004). Janet M. Bronstein, E. Kathleen Adams, Curtis S. Florence.

Does an increase in SCHIP enrollment impact office physicians' participation in Medicaid? This study compared physician participation in Alabama's freestanding SCHIP program to Georgia's Medicaid look-alike SCHIP program. It found that increases in SCHIP enrollment had little effect on physician participation in Alabama, which uses an open health care provider panel. However, in Georgia, where the same provider network serves both Medicaid and SCHIP, increases in SCHIP enrollment were associated with a decline in office-based physician participation in Medicaid in urban areas. The authors conclude that an adequate provider system is critical to assuring improvements in access to care for children enrolled in public insurance programs. For more details, read "The Impact of SCHIP Enrollment on Physician Participation in Medicaid in Alabama and Georgia" in the April 2004 issue of Health Services Research 39(2), pp. 299-315.

CHIRI™ Issue Brief No. 3. Who's Enrolled in SCHIP? (2003). Karen VanLandeghem and Cindy Brach.

Policymakers are interested in learning more about SCHIP enrollees and knowing whether SCHIP is in fact serving the children it was intended to serve. This CHIRI™ Issue Brief, based on articles published in the December 2003 supplement to the journal Pediatrics, highlights findings on SCHIP enrollees and strategies that States can use to improve children's access to care. The CHIRI™ Issue Brief is available online (PDF file, 344 KB; Plugin Software Help) or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-0015).

Children Enrolled in the State Children's Health Insurance Program (SCHIP): Findings on Demographics and Prior Health Care Experiences from the Child Health Insurance Research Initiative (CHIRI™) (2003). Edited by Cindy Brach and Eugene M. Lewit.

This supplement to the December 2003 issue of the the American Academy of Pediatrics' journal Pediatrics presents the first collection of studies that report on the characteristics of children newly enrolled in the State Children's Health Insurance Program (SCHIP) in multiple States. The supplement consists of 5 articles and a commentary, each of which is summarized below.

Who's Enrolled in SCHIP? Findings from the Child Health Insurance Research Initiative (CHIRI™) (2003). Cindy Brach, Eugene M. Lewit, Karen VanLandeghem, Janet Bronstein, Andrew W. Dick, Kim S. Kimminau, Barbara J. LaClair, Elizabeth Shenkman, Laura P. Shone, Nancy Swigonski, and Peter G. Szilagyi.

This paper highlights key findings from a collection of papers on SCHIP enrollees published in the December 2003 supplement to Pediatrics. Most SCHIP enrollees lived in working families with incomes equal to or below 150 percent of the federal poverty level; a significant proportion of enrollees were black or Hispanic, with racial and ethnic disparities present; and 17 percent to 25 percent of enrollees were CSHCN, which is higher than the prevalence in the general population. It concludes that SCHIP enrollees are a diverse group and have substantial and wide-ranging health care needs, despite high levels of prior contact with the health care system. The quality of care adolescents received prior to enrollment in SCHIP was suboptimal, with many reporting unmet health care needs and not receiving recommended counseling. The characteristics of SCHIP enrollees can be expected to change as SCHIP programs evolve and mature. Seven policy implications are drawn from the data. Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO15).

Children with Special Health Care Needs Enrolled in SCHIP: Patient Characteristics and Health Care Needs (2003). Peter G. Szilagyi, Elizabeth Shenkman, Cindy Brach, Barbara J. LaClair, Nancy Swigonski, Andrew W. Dick, Laura P. Shone, Virginia A. Schaffer, Jana F. Col, George Eckert, Jonathan D. Klein, and Eugene M. Lewit.

The prevalence of children with special health care needs (CSHCN) was higher among SCHIP enrollees than the general population in the four CHIRI™ study States (Indiana, Kansas, Florida and New York). CSHCN were similar to children without special health care needs, but CSHCN had poorer health status, were more likely to have had unmet needs, and were more likely to use the emergency department, mental health care, specialty care, and acute care in the year prior to enrolling in SCHIP than children without special health care needs. The authors draw four implications for monitoring and improving SCHIP for CSHCN. Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO17).

The Role of Race and Ethnicity in SCHIP in Four States: Are There Baseline Disparities, and What Do They Mean for SCHIP? (2003). Laura P. Shone, Andrew W. Dick, Cindy Brach, Kim S. Kimminau, Barbara J. LaClair, Elizabeth A. Shenkman, Jana F. Col, Virginia A. Schaffer, Frank Mulvihill, Peter. G. Szilagyi, Jonathan D. Klein, Karen VanLandeghem, and Janet Bronstein.

This paper assesses baseline levels of health disparities in health status and health care experiences among children enrolling in SCHIP in Alabama, Florida, Kansas and New York. A significant proportion of SCHIP enrollees were black or Hispanic. Relative to white children, minority children lived in lower income families, and were in poorer health, and less likely to have had a regular source of health care or private insurance prior to enrolling in SCHIP. The authors conclude that SCHIP has the potential to reduce disparities among enrollees, and underscore the importance of monitoring program outcomes by race and ethnicity to ensure equity across groups. Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO16).

Adolescents' Preventive Care Experiences Before Entry into SCHIP (2003). Elizabeth Shenkman, Lise Youngblade, and John Nackashi.

Adolescents have unique health care needs that public insurance programs will want to consider in SCHIP design and implementation. About three-quarters of Florida adolescents who enrolled in SCHIP reported engaging in at least one risk behavior. Almost 70 percent of adolescents reported having had a preventive care visit the previous year, but a majority of these did not receive counseling in each of four counseling areas. Controlling for other factors, having a private, confidential visit with the physician was associated with an increased likelihood (2 to 3 times more likely) that the adolescent received counseling for 3 out of 4 counseling areas. Health plans and providers involved in SCHIP are likely to serve adolescents who have had limited opportunities for private preventive care visits and counseling during such visits.

The Evolution of SCHIP in New York: Changing Program Features and Enrollee Characteristics (2003). Andrew W. Dick, Jonathan D. Klein, Laura P. Shone, Jack Zwanziger, Hao Yu, and Peter. G. Szilagyi.

How do the characteristics of SCHIP enrollees change as a program evolves? New York State's SCHIP program evolved from a statewide health insurance program that was developed in 1991. Understanding how current SCHIP enrollees differ from early enrollees may shed light on how to best serve the SCHIP population. This study found that more black and Hispanic children, more New York City residents, and children from families with lower education, income, and employment levels enrolled in SCHIP in 2001 than were enrolled in 1994. Introduction of a single application form for SCHIP and Medicaid, expansions in the benefit package, and progressively increased marketing and outreach, particularly in New York City, may have in part, accounted for the large change in the characteristics of enrollees.

Low-income Children and Health Insurance: Old News and New Realities (2003). Sara Rosenbaum and Peter Budetti.

This article provides commentary to the collection of articles on SCHIP enrollees published in the December 2003 supplement to Pediatrics. The authors conclude that the findings regarding the depth of health care needs and the dependence on publicly funded insurance are crucial as States seek to preserve public insurance programs for children, and Congress debates the future of Medicaid and SCHIP.

Do Children Enrolling in Public Health Insurance Have Other Options? (2003). R. Andrew Allison, Robert F. St. Peter, Cheng-Chung Huang, and Barbara J. LaClair.

This four-page Issue Brief describes the prior health insurance coverage of children entering Kansas' SCHIP program, as well as current coverage within their families. Findings include: 70% of children entering SCHIP had health insurance for at least some portion of the previous year; 66% of enrollees had at least one uninsured parent; and half were eligible to enroll in job-based health insurance, although this option may not have been affordable. Go to the Kansas Health Institute's Web site: http://www.khi.org/documents/2003/sep/01/do-children-enrolling-public-health-insurance-have/

Who are the Children Enrolling in SCHIP and Medicaid? (2003). Charles L. Betley, Robert F. St. Peter, Cheng-Chung Huang, Barbara J. LaClair, and R. Andrew Allison.

This four-page Issue Brief describes characteristics of children entering Kansas' SCHIP and Medicaid programs, as well as characteristics of their families. Findings indicate that enrollment is consistent with the design of the programs, with SCHIP serving more older children and adolescents and Medicaid serving a younger, poorer population. SCHIP enrollees lived in households whose head attained higher educational levels and with parents who were more likely to be employed; nevertheless, two-thirds of Medicaid children had at least one working parent. Go to the Kansas Health Institute's Web site: http://www.khi.org/news/2003/sep/01/research-brief-who-are-the-children-enrolling-in/.

The Consequences of States' Policies for SCHIP Disenrollment (2002). Andrew W. Dick, R. Andrew Allison, Susan G. Haber, Cindy Brach, Elizabeth Shenkman.

Policymakers are concerned about disenrollment from SCHIP. This article describes disenrollment in Florida, Kansas, New York, and Oregon and assesses the links between disenrollment and States' SCHIP policies. It finds that SCHIP is used on a long-term basis by a significant subset of enrollees, and as temporary coverage for many other enrollees. Re-certification generates large disenrollments (about half of children still enrolled at the time), but as many as 25 percent return within 2 months. The increased disenrollment rate at re-certification is completely eliminated by a policy of passive re-enrollment. This article appeared in the Spring 2002 issue of Health Care Financing Review 23(3):65-88.

Print copies can ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 02-R070). The CHIRI™ Issue Brief "SCHIP Disenrollment and State Policies" (PDF File, 100 KB; Plugin Software Help), that summarizes the article's findings for policymakers can also be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 02-0017).

Children's Enrollment in HealthWave and Medicaid: Where Do We Stand? (2001). R. Andrew Allison, Robert F. St. Peter.

How successful has the State been in enrolling eligible children in public health insurance over the last 2 years? This four-page Issue Brief discusses the actual and potential enrollment of children in public health insurance, some of the challenges of assessing success, and implications for public health insurance in the future. This Brief is the third in a series of reports from the Kansas HealthWave Evaluation Project, a 3-year evaluation of HealthWave, Kansas' SCHIP program. Go to the Kansas Health Institute's Web site: http://www.khi.org/documents/2001/sep/01/childrens-enrollment-healthwave-and-medicaid-where/

Dynamics of HealthWave and Medicaid Enrollment: Into, Out of, and Between Two State Programs (2001). R. Andrew Allison, Barbara LaClair, Robert F. St. Peter.

The recent growth in the number of children enrolled in SCHIP and Medicaid is well-documented. This four-page Issue Brief examines the dynamics underlying this growth, focusing on the movement of children into, out of, and between the two Kansas programs that provide health insurance to eligible low-income children. Go to the Kansas Health Institute's Web site: http://www.khi.org/s/index.cfm?sid=7

Children's Enrollment in Kansas Public Health Insurance Programs Since the Introduction of HealthWave (2001). R. Andrew Allison, Barbara LaClair, Robert F. St. Peter.

This four-page Issue Brief examines enrollment patterns of children in Kansas' HealthWave and Medicaid during the first 18 months of the new HealthWave program. Go to the Kansas Health Institute's Web site: http://www.khi.org/documents/2001/mar/01/childrens-enrollment-kansas-public-health-insuranc/

Does SCHIP Provide Continuity of Coverage to Low-Income Children? Lessons from Oregon (2001). Susan Haber, Janet Mitchell.

During just over 2 years of operation, Oregon's SCHIP program covered more than 45,000 unique children. There has been considerable turnover in enrollment and nearly all children have a single spell of SCHIP enrollment. Most are covered for only 6 months and do not re-enroll at the end of their initial guaranteed enrollment period. Approximately one-third, more for Hispanic and Spanish-speaking SCHIP enrollees, moves into Medicaid when their SCHIP coverage ends. In addition, more than half transition into SCHIP from Medicaid. Taking into account contiguous periods of Medicaid enrollment, SCHIP children were covered for an average of 14 months during the 2-year study period, with SCHIP accounting for somewhat less than half of this coverage. Approximately 10 percent were continuously covered during the 2-year period. In sum, Oregon's SCHIP program has provided episodic coverage to most enrolled children. A high percentage of children transition between SCHIP and Medicaid because of fluctuations in family income. These results were presented at the Academy for Health Services Research and Health Policy annual meeting in June 2001. Select for the full abstract of that presentation.

Return to Contents 

Provider Participation

CHIRI™ Issue Brief No. 8. Impact of Primary Care Case Management (PCCM) Implementation in Medicaid and SCHIP (2009). Karen VanLandeghem and Cindy Brach.

PCCM systems are designed to increase patients' use of well-child and primary care in physician offices while decreasing use of specialty care and emergency department use. Researchers studied the impact of implementing PCCM systems in Alabama and Georgia. Children enrolled in the Alabama and Georgia Medicaid programs were less likely to use emergency departments, but were also less likely to use well-child and other primary care after PCCM implementation. Physician participation in Alabama and Georgia Medicaid also declined. The transition to PCCM can be disruptive to established patterns of provider participation and enrollees' use of health care. Efforts to ensure continuity of care and provider participation during PCCM transition might be addressed through public insurance program design and targeted education and outreach strategies to enrollees.

CHIRI™ Issue Brief No. 8 is available online (PDF File, 610 KB; Plugin Software Help), or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 09-0020).

The Impact of SCHIP Enrollment on Physician Participation in Medicaid in Alabama and Georgia (2004). Janet M. Bronstein, E. Kathleen Adams, Curtis S. Florence.

Does an increase in SCHIP enrollment impact office physicians' participation in Medicaid? This study compared physician participation in Alabama's freestanding SCHIP program to Georgia's Medicaid look-alike SCHIP program. It found that increases in SCHIP enrollment had little effect on physician participation in Alabama, which uses an open health care provider panel. However, in Georgia, where the same provider network serves both Medicaid and SCHIP, increases in SCHIP enrollment were associated with a decline in office-based physician participation in Medicaid in urban areas. The authors conclude that an adequate provider system is critical to assuring improvements in access to care for children enrolled in public insurance programs. For more details, see "The Impact of SCHIP Enrollment on Physician Participation in Medicaid in Alabama and Georgia" in the April 2004 issue of Health Services Research 39(2), pp. 299-315.

The Impact of Medicaid Primary Care Case Management (PCCM) on Office-Based Physician Supply in Alabama and Georgia (2003). E. Kathleen Adams, Janet M. Bronstein, Curtis S. Florence.

The success of Medicaid in assuring low-income children's access to health care is largely dependent on States' ability to enroll and retain primary care provider participation in the program. This study examined the early impact of Primary Care Case Management, a form of managed care, on office-based primary care physicians' participation in the Alabama and Georgia Medicaid programs. The implementation of the PCCM model, without increases in physician reimbursement, was associated with reduced physician participation in Medicaid and reduced visit volume among participants. For more details, see "The Impact of Medicaid Primary Care Case Management (PCCM) on Office-Based Physician Supply in Alabama and Georgia" in the fall 2003 issue of the journal Inquiry 40(3), pp. 269-282.

CHIRI™ Issue Brief No. 2. Children's Dental Care Access in Medicaid: The Role of Medical Care Use and Dentist Participation (2003). Karen VanLandeghem, Janet Bronstein, and Cindy Brach.

Many policymakers are examining State public insurance programs for ways to reduce costs and maximize the return on State and Federal investments. This CHIRI™ Issue Brief reports on children's dental care use in the Alabama and Georgia Medicaid programs and strategies for improving access to dental care, providing States with an additional resource as they make critical decisions about public insurance programs. Researchers found that less than 40 percent of Medicaid-enrolled children received dental care. Most of these children received preventive care and half used intensive dental services.

While dentists' participation in Medicaid had some effect on improving dental care access, researchers conclude that other factors also influence dental care use in public insurance programs. Strategies that capitalize on the fact that Medicaid-enrolled children are far more likely to receive medical care than dental care could boost access tremendously. If every child who had a medical visit also had a dental visit, many (61 percent in Alabama and 78 percent in Georgia) Medicaid-enrolled children would have received dental care. The CHIRI™ Issue Brief is available online (PDF file, 162 KB; Plugin Software Help) or it can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 03-0032).

Return to Contents 

Special Populations 

Adolescents

Prior Health Care Experiences of Adolescents who Enroll in SCHIP (2006). Jonathan D. Klein, Elizabeth Shenkman, Cindy Brach, Laura P. Shone, Virginia A. Schaffer, Andrew W. Dick, Karen VanLandeghem, and Peter G. Szilagyi

Little is known about prior access to care and health care experiences of adolescents who enroll in SCHIP. Researchers studied the characteristics (e.g., health status, prior health care utilization, access, and unmet needs) of adolescent SCHIP enrollees. Most enrollees were younger (ages 12-16 years), Black or Hispanic, lived in poverty, and were without health insurance the year before SCHIP. Most had a usual source of care (USC) prior to enrollment; Blacks and Hispanics were less likely than Whites to have had a USC. Although many adolescents reported seeing a physician the year prior to enrollment, a significant proportion reported unmet health care needs. The authors conclude that for state SCHIP programs to be effective, they must pay careful attention to the benefit structure, provider networks, coordination of care and services, and the quality of care delivered to youth. For more details, go to the 2006 issue of the Journal of Health Care for the Poor and Underserved 17, pp 789-807. Reprints can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 07-R032)

Adolescents' Preventive Care Experiences Before Entry into SCHIP (2003). Elizabeth Shenkman, Lise Youngblade, and John Nackashi.

Adolescents have unique health care needs that public insurance programs will want to consider in SCHIP design and implementation. About three-quarters of Florida adolescents who enrolled in SCHIP reported engaging in at least one risk behavior. Almost 70 percent of adolescents reported having had a preventive care visit the previous year, but a majority of these did not receive counseling in each of four counseling areas. Controlling for other factors, having a private, confidential visit with the physician was associated with an increased likelihood (2 to 3 times more likely) that the adolescent received counseling for 3 out of 4 counseling areas. Health plans and providers involved in SCHIP are likely to serve adolescents who have had limited opportunities for private preventive care visits and counseling during such visits. This article is one of a collection of papers on SCHIP enrollees published in the December 2003 supplement to Pediatrics.

Congruence Between Parents' and Adolescents' Reports of Special Health Care Needs in a Title XXI Program (2003). Lise M. Youngblade and Elizabeth A. Shenkman.

The purpose of this study was to examine agreement between adolescents enrolled in Florida's SCHIP program and their parents about whether or not the adolescent had a special health care need, using the Children with Special Health Care Needs (CSHCN) Screener. Adolescents and their parents frequently agreed as to whether or not the adolescent had a chronic condition, but a full 15 percent of pairs disagreed. The level of agreement is higher using the consequence-based CSHCN Screener than is typically reported for diagnosis-based approaches. Parents reported adolescents' chronic conditions more often than adolescents, most strikingly for mental health conditions. Pairs with older adolescents, female adolescents, and who were Hispanic were more likely to be congruent than their counterparts. These findings are relevant to work related to the use of tools such as the CSHCN Screener in profiling enrollees in healthcare programs that serve children and adolescents. For more details, see "Congruence between Parents' and Adolescents' Reports of Special Health Care Needs in a Title XXI Program," in the September 2003 issue of the Journal of Pediatric Psychology 28(6), pp. 393-401. 

Children with Special Health Care Needs

CHIRI™ Issue Brief No. 9. Mental Health Needs of Low-Income Children With Special Health Care Needs (2009). Karen VanLandeghem and Cindy Brach.

Low-income and minority children with special health care needs (CSHCN) have higher rates of mental health problems yet are less likely than their counterparts to receive mental health services. Families play a crucial role in obtaining and coordinating care for CSHCN, including mental health services. Researchers found that mental health issues were second only to asthma as the top health problems in CSHCN as reported by their families. More than one-third of CSHCN had a mental health problem, but only one-quarter of caregivers recognized the need for mental health services in their children.

CHIRI™ Issue Brief No. 9 is available online (PDF File, 270 KB; Plugin Software Help), or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 09-0033).

Improved Health Care Among Children With Special Health Care Needs After Enrollment Into the State Children's Health Insurance Program. (2007). Peter G. Szilagyi, Laura P. Shone, Jonathon D. Klein, Alina Bajorska, Andrew W. Dick

Little is known about the impact of SCHIP on children with special health care needs (CSHCN). In a study of CSHCN who were enrolled in the New York SCHIP program, enrollment was associated with improved access to health care, continuity of care, and quality of care, as reported by parents. Unmet needs for prescription medications declined 3-fold for all study sub-groups (e.g., from 36 percent to 9 percent among the previously uninsured). Unmet needs for specialty care declined more than 4-fold among CSHCN who were previously insured (48 percent to 10 percent) or had mental health or behavioral disorders (32 percent to 2 percent). The authors conclude that enrollment in the New York SCHIP program improves health care for CSHCN. For more details, go to "Improved Health Care Among Children With Special Health Care Needs After Enrollment Into the State Children's Health Insurance Program," in the January 2007 issue of Ambulatory Pediatrics, 7(1), pp. 10-17.

The Impact of Managed Care Enrollment on Emergency Department Use Among Children with Special Health Care Needs (2006). Harold A. Pollack, John R. Wheeler, Anne Cowan, and Gary L. Freed

This study examined the impact of managed care enrollment on emergency department use in children with special health care needs (CSHCN) who were dually enrolled in Michigan's Medicaid program and the State's Title V MCH Services Block Grant program for CSHCN. These enrollees were served by Special Health Plans (SHPs)-managed care plans designed specifically to serve CSHCN, including a strong care coordination component. Enrollment in the plan was associated with a 23 percent reduction in the rate of emergency department use among CSHCN. Study results suggest that key characteristics of this managed care model, particularly selection of a principal coordinating doctor and development of an Individualized Health Care Plan for enrollees, are associated with reductions in emergency department use among CSHCN. For more details, go to "The Impact of Managed Care Enrollment on Emergency Department Use Among Children with Special Health Care Needs," in the February 2007 issue of Medical Care 45(2), pp. 139-45.

Policy Brief No. 6: From SCHIP Benefit Design to Individual Coverage Decisions (2006). Anne Markus, Sara Rosenbaum, Ruth E.K. Stein, Jill Joseph.

This Policy Brief explores the coverage decisions of private insurers for children with special health care needs (CSHCN) in six States with separate State Children's Health Insurance Programs (SCHIP). Study States limited or excluded similar benefits for CSHCN enrolled in SCHIP, although the nature of the limitations or exclusions varied. When SCHIP insurers made coverage determinations in response to hypothetical case scenarios posed by the researchers, there was significant variation in coverage decisions. With one exception, insurers did not agree on the coverage of any specific service. The study also found that: (1) SCHIP insurers often provided coverage beyond State SCHIP limits and exclusions; (2) insurers were more likely to impose exclusions for less acute conditions; and (3) in the majority of study States some insurers excluded services that should have been covered according to State plan/contract language. Researchers concluded that external reviews of insurers' coverage decisions and coordination with other sources of care are important components of SCHIP program design.

CHIRI™ Issue Brief No. 5. SCHIP Enrollees with Special Health Care Needs and Access to Care (2006). Karen VanLandeghem, Jennie Bonney, Cindy Brach, and Lisa Kretz.

Numerous factors—such as restrictions on health care coverage and insufficient provider participation—can limit access to care for children enrolled in public insurance programs, particularly children with special health care needs (CSHCN). This CHIRI™ Issue Brief summarizes findings regarding: health care access and satisfaction of CSHCN enrolled in SCHIP, services that were limited and/or excluded under SCHIP in some of the study States, and how SCHIP design decisions can limit coverage for CSHCN.

In general, CSHCN enrolled in SCHIP did not experience any problems in obtaining a primary health care provider or routine specialty services. However, certain specialty services were difficult to obtain in some study States that imposed limits and/or exclusions on certain services or were ambiguous in defining a standard of medical necessity. In addition, income restrictions and/or medical condition criteria made it difficult to access supplemental services from other Federal and State programs for CSHCN with severe chronic health conditions in some of the study States.

CHIRI™ Issue Brief No. 5 is available online or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 06-0051).

Race, Urban Community Stressors, and Behavioral and Emotional Problems of Children with Special Health Care Needs (2005). Kim D. Jaffee, Gilbert C. Liu, Janie Canty-Mitchell, Rong Amy Qi, Joan Austin, and Nancy Swigonski

Do community-level stressors have an impact on behavioral and emotional problems among African-American and white children with special health care needs (CSHCN)? Researchers collected information about CSHCN sociodemographic characteristics as well as behavioral and emotional problems, health status, perceptions of urban community stress, and health care access and satisfaction to determine racial differences in the impact of urban stress on behavioral and emotional problems. Urban community stressors, race, and child's health status were significantly associated with behavioral and emotional problems among CSHCN. The authors conclude that when caring for CSHCN, especially those with emotional or behavioral problems, primary care providers may be better able to identify important aggravating factors if they also assess urban stress. They note that comprehensive systems of care are needed to assist in addressing urban community-level stressors. For more details, see "Race, Urban Community Stressors, and Behavioral and Emotional Problems of Children with Special Health Care Needs" in the January 2005 issue of Psychiatric Services 56(1), pp. 63-69.

Health-Related Quality of Life in Publicly Insured Children with Special Health Care Needs (2005). Janie Canty-Mitchell, Joan K. Austin, Susan M. Perkins, Rong Amy Qi, and Nancy Swigonski

Researchers examined the demographic characteristics and health-related quality of life (HRQOL) among CSHCN at an urban community health center to determine racial differences and examine child, parent, health care and environmental characteristics associated with HRQOL. Nearly one-third of the randomly selected publicly insured children who kept their routine clinic visit had a special health care need. Physical and psychosocial HRQOL were significantly lower than national benchmarks. Poorer psychosocial HRQOL was associated with more health problems and urban life stressors. The authors conclude that comprehensive and coordinated care is essential in order to meet the diverse physical and psychosocial needs of CSHCN. For more details, see "Health-Related Quality of Life in Publicly Insured Children with Special Health Care Needs " in the 2005 issue of Children's Health Care 34(1), pp. 1-18.

Behavioral and Mental Health Problems in Low-Income Children with Special Health Care Needs (2004). Janie Canty-Mitchell, Joan K. Austin, Kim Jaffee, Rong Amy Qi, and Nancy Swigonski.

What are the behavioral and mental health problems and needs of low-income children with special health care needs (CSHCN)? Researchers examined caregiver perceptions of mental health problems and counseling needs in low-income CSHCN, using the Child Behavior Checklist (CBCL) and an investigator-designed questionnaire. Findings indicate that 38 percent of CSHCN had a behavioral or mental health problem, but only 26 percent of caregivers perceived the need for treatment or counseling. The authors conclude that because caregivers do not always recognize behavior and mental health problems, CSHCN should be assessed for these problems during routine health care visits and referred to appropriate services. For more details, see "Behavioral and Mental Health Problems in Low-Income Children with Special Health Care Needs" in the June 2004 issue of the Archives of Psychiatric Nursing 18(3), pp. 79-87.

Children with Special Health Care Needs Enrolled in SCHIP: Patient Characteristics and Health Care Needs (2003). Peter G. Szilagyi, Elizabeth Shenkman, Cindy Brach, Barbara J. LaClair, Nancy Swigonski, Andrew W. Dick, Laura P. Shone, Virginia A. Schaffer, Jana F. Col, George Eckert, Jonathan D. Klein, and Eugene M. Lewit.

The prevalence of children with special health care needs (CSHCN) was higher among SCHIP enrollees than the general population in the four CHIRI™ study States (Indiana, Kansas, Florida and New York). CSHCN were similar to children without special health care needs, but CSHCN had poorer health status, were more likely to have had unmet needs, and were more likely to use the emergency department, mental health care, specialty care, and acute care in the year prior to enrolling in SCHIP than children without special health care needs. The authors draw four implications for monitoring and improving SCHIP for CSHCN. This article is one of a collection of papers on SCHIP enrollees published in the December 2003 supplement to Pediatrics. Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO17).

Congruence Between Parents' and Adolescents' Reports of Special Health Care Needs in a Title XXI Program (2003). Lise M. Youngblade and Elizabeth A. Shenkman.

The purpose of this study was to examine agreement between adolescents enrolled in Florida's SCHIP program and their parents about whether or not the adolescent had a special health care need, using the Children with Special Health Care Needs (CSHCN) Screener. Adolescents and their parents frequently agreed as to whether or not the adolescent had a chronic condition, but a full 15 percent of pairs disagreed. The level of agreement is higher using the consequence-based CSHCN Screener than is typically reported for diagnosis-based approaches. Parents reported adolescents' chronic conditions more often than adolescents, most strikingly for mental health conditions. Pairs with older adolescents, female adolescents, and who were Hispanic were more likely to be congruent than their counterparts. These findings are relevant to work related to the use of tools such as the CSHCN Screener in profiling enrollees in healthcare programs that serve children and adolescents. For more details, see "Congruence between Parents' and Adolescents' Reports of Special Health Care Needs in a Title XXI Program," in the September 2003 issue of the Journal of Pediatric Psychology 28(6), pp. 393-401.

Emergency Department Use Among Children with Special Health Care Needs: An Introductory Study (2002). Harold A. Pollack, Kevin J. Dombkowski, Janet B. Zimmerman, Matthew M. Davis, Anne E. Cowan, John R. Wheeler, A. Craig Hillemeier, and Gary L. Freed.

This article describes the patterns of emergency department (ED) use among Michigan children who are dual-enrolled in Medicaid and Michigan's Title V Children's Special Health Care Services (CSHCS) program. High rates of ED use were displayed among dual-enrolled children less than 1 year of age and those diagnosed with anemia, hemophilia, asthma, epilepsy, and juvenile diabetes. Although race, location, and other demographic variables have statistically significant effects, the complexity and severity of children's illnesses are the most important source of variation in ED use among children with special health care needs. The authors conclude that clinical and policy interventions designed to promote appropriate ED use must not only address important socio-demographic disparities and adverse incentives, but must also address the challenge of appropriately managing complex and persistent conditions over time. The need to understand sources of variations in children's health services use—and the related need to understand how such variation is influenced by health policy and service delivery—is particularly acute as States seek to enroll children with special needs into managed care arrangements. For more details, see "Emergency Department Use Among Children with Special Health Care Needs: An Introductory Study," in the June 2004 issue of Health Services Research 39(3), pp. 665-692.

Policy Brief No. 5: Behavioral Health and Managed Care Contracting Under SCHIP (2002). Sara Rosenbaum, Colleen Sonosky, Karen Shaw, D. Richard Mauery.

This Policy Brief examines behavioral health managed care contracting under separately administered SCHIP. Of the 27 separate SCHIP programs reporting any managed care services in 2000, 15 purchased services from managed care organizations using freestanding contract instruments, that is, contracts that are wholly independent of the Medicaid contract and stand on their own as legal instruments, while 12 used a modified Medicaid contract. Every State that covers any level of behavioral disorders as a contractual benefit applies limitations and exclusions that would not be permissible in the Medicaid program (e.g., limits on inpatient days and outpatient services).

Policy Brief No. 2: State Benefit Design Choices under SCHIP—Implications for Pediatric Health Care (2001). Sara Rosenbaum, Anne Markus, Colleen Sonosky, Lee Rapasch.

This Policy Brief examines the extent to which State agencies adopt conventional insurance norms or adhere to special principles of Medicaid coverage design for children in designing separately administered (or freelancing) SCHIP programs. The issue of coverage design is particularly relevant for children with low prevalence conditions and special health care needs. Increasingly, conventional insurance uses standardized coverage norms to limit coverage and treatment. These standardized norms take the form of across-the-board treatments and exclusions, limited definitions of medical necessity, and the use of irrebuttable, standardized treatment guidelines in determining when covered treatments will be available. All of these practices are impermissible under Medicaid, which uses exceptionally broad preventive standards to determine coverage of children; such standards favor coverage of children with low prevalence problems.

Return to Contents 

Minority Children

Effects of Primary Care Case Management (PCCM) on Medicaid Children in Alabama and Georgia: Provider Availability and Race/Ethnicity (2006). E. Kathleen Adams, Janet M. Bronstein, and Curtis S. Florence.

PCCM programs are designed to increase patients' use of primary and preventive care in doctors' offices while decreasing use of specialty and urgent care by assigning Medicaid enrollees to gatekeeper providers who make referrals for specialty, emergency, and inpatient care. Researchers examined the impact of PCCM implementation on children's use of primary and preventive care by race/ethnicity. Reductions in primary and preventive care use under Medicaid PCCM in Alabama and Georgia were more dramatic for minority children. The authors conclude that implementation of PCCM without fee increases may affect decisions of providers to participate in Medicaid which, in turn, may have unexpected negative effects that differentially impact minority children. More details are available in "Effects of Primary Care Case Management (PCCM) on Medicaid Children in Alabama and Georgia: Provider Availability and Race/ethnicity," in the February 2006 issue of Medical Care Research & Review 63(1), pp. 58-87.

Reduction in Racial and Ethnic Disparities After Enrollment in the State Children's Health Insurance Program (2005). Laura P. Shone, Andrew W. Dick, Jonathan D. Klein, Jack Zwanziger, and Peter G. Szilagyi.

How does SCHIP impact racial/ethnic disparities among enrollees? Researchers found that enrollment in the New York SCHIP program—Child Health Plus—improved access, continuity, and quality of care for enrollees from racial/ethnic groups and reduced preexisting racial/ethnic disparities in health care access, unmet need, and continuity of care. In spite of these improvements, racial/ethnic disparities in quality of care remained. The authors conclude that SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care. "Reduction in Racial and Ethnic Disparities After Enrollment in the State Children's Health Insurance Program" was published in the June 2005 issue of Pediatrics 115(6), pp. e697-e705.

The Role of Race and Ethnicity in SCHIP in Four States: Are There Baseline Disparities, and What Do They Mean for SCHIP? (2003). Laura P. Shone, Andrew W. Dick, Cindy Brach, Kim S. Kimminau, Barbara J. LaClair, Elizabeth A. Shenkman, Jana F. Col, Virginia A. Schaffer, Frank Mulvihill, Peter. G. Szilagyi, Jonathan D. Klein, Karen VanLandeghem, and Janet Bronstein.

This paper assesses baseline levels of health disparities in health status and health care experiences among children enrolling in SCHIP in Alabama, Florida, Kansas and New York. A significant proportion of SCHIP enrollees were black or Hispanic. Relative to white children, minority children had lower income families, and were in poorer health, and less likely to have had a regular source of health care or private insurance prior to enrolling in SCHIP. The authors conclude that SCHIP has the potential to reduce disparities among enrollees, and underscore the importance of monitoring program outcomes by race and ethnicity to ensure equity across groups. This article is one of a collection of papers on SCHIP enrollees published in the December 2003 supplement to Pediatrics. Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO16).

Return to Contents 

State CHIP and Medicaid Design Choices

CHIRI™ Issue Brief No. 8. Impact of Primary Care Case Management (PCCM) Implementation in Medicaid and SCHIP (2009). Karen VanLandeghem and Cindy Brach.

PCCM systems are designed to increase patients' use of well-child and primary care in physician offices while decreasing use of specialty care and emergency department use. Researchers studied the impact of implementing PCCM systems in Alabama and Georgia. Children enrolled in the Alabama and Georgia Medicaid programs were less likely to use emergency departments, but were also less likely to use well-child and other primary care after PCCM implementation. Physician participation in Alabama and Georgia Medicaid also declined. The transition to PCCM can be disruptive to established patterns of provider participation and enrollees' use of health care. Efforts to ensure continuity of care and provider participation during PCCM transition might be addressed through public insurance program design and targeted education and outreach strategies to enrollees.

CHIRI™ Issue Brief No. 8 is available online (PDF File, 610 KB; Plugin Software Help), or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 09-0020).

CHIRI™ Issue Brief No. 7. Do SCHIP Enrollees Stay Insured? (2008). Karen VanLandeghem and Cindy Brach.

SCHIP has helped increase insurance rates by providing coverage to low-income children whose families earn too much to qualify for Medicaid but lack private coverage, and by increasing Medicaid enrollment through SCHIP outreach and enrollment efforts. Achievements in reducing uninsurance rates can only be sustained, however, if low-income children retain public insurance or transition to private insurance coverage.

Researchers studied the impact of SCHIP enrollment on low-income children's public and private insurance coverage in the short-term. Over three-quarters of SCHIP enrollees were publicly insured (Medicaid or SCHIP) at least one year after enrollment, while some SCHIP enrollees (4 percent to 15 percent) obtained private insurance coverage after leaving SCHIP. SCHIP retention was increased by a simplified renewal policy that automatically reenrolled children in SCHIP unless their families submitted reenrollment forms indicating a change affecting their eligibility.

CHIRI™ Issue Brief No. 7 can be downloaded as a PDF file, 300 KB; (Plugin Software Help) or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 08-0057).

Crowd-Out in the State Children's Health Insurance Program (SCHIP): Incidence, Enrollee Characteristics and Experiences, and Potential Impact on New York's SCHIP (2008). Laura P. Shone, Paula M. Lantz, Andrew W. Dick, Michael E. Chernew, and Peter G. Szilagyi

The extent to which the State Children's Health Insurance Program (SCHIP) displaces or "crowds-out" private insurance whereby individuals drop private insurance coverage to obtain public insurance coverage remains a topic of interest for many policymakers. Researchers studied the incidence of crowd-out, and whether enrollee characteristics were associated with crowd-out, in the New York SCHIP program. Crowd-out was relatively modest in New York SCHIP: only 7 percent of SCHIP enrollees were deemed enrolled due to crowd-out. Crowd-out was associated with some enrollee characteristics including income but not health status. Researchers conclude that most movement from private insurance to enrollment in New York SCHIP was not the result of crowd-out. States are encouraged to implement ongoing, detailed monitoring methods to determine crowd-out in SCHIP. For more details, see the 2008 issue of the Health Services Research 2008 Feb;43(1 Pt 2):419-34.

The Impact of Managed Care Enrollment on Emergency Department Use Among Children with Special Health Care Needs (2006). Harold A. Pollack, John R. Wheeler, Anne Cowan, and Gary L. Freed

This study examined the impact of managed care enrollment on emergency department use in children with special health care needs (CSHCN) who were dually enrolled in Michigan's Medicaid program and the State's Title V MCH Services Block Grant program for CSHCN. These enrollees were served by Special Health Plans (SHPs)-managed care plans designed specifically to serve CSHCN, including a strong care coordination component. Enrollment in the plan was associated with a 23 percent reduction in the rate of emergency department use among CSHCN. Study results suggest that key characteristics of this managed care model, particularly selection of a principal coordinating doctor and development of an Individualized Health Care Plan for enrollees, are associated with reductions in emergency department use among CSHCN. For more details, see "The Impact of Managed Care Enrollment on Emergency Department Use Among Children with Special Health Care Needs," in the February 2007 issue of Medical Care 45(2), pp. 139-45.

Policy Brief No. 6: From SCHIP Benefit Design to Individual Coverage Decisions (2006). Anne Markus, Sara Rosenbaum, Ruth E.K. Stein, Jill Joseph.

This Policy Brief explores the coverage decisions of private insurers for children with special health care needs (CSHCN) in six States with separate State Children's Health Insurance Programs (SCHIP). Study States limited or excluded similar benefits for CSHCN enrolled in SCHIP, although the nature of the limitations or exclusions varied. When SCHIP insurers made coverage determinations in response to hypothetical case scenarios posed by the researchers, there was significant variation in coverage decisions. With one exception, insurers did not agree on the coverage of any specific service. The study also found that: (1) SCHIP insurers often provided coverage beyond State SCHIP limits and exclusions; (2) insurers were more likely to impose exclusions for less acute conditions; and (3) in the majority of study States some insurers excluded services that should have been covered according to State plan/contract language. Researchers concluded that external reviews of insurers' coverage decisions and coordination with other sources of care are important components of SCHIP program design.

SCHIP Structure and Children's Use of Care (2006). Janet Bronstein, Kathleen Adams, and Curtis Florence.

How does SCHIP design impact enrollee's use of health care? This study examined whether health care utilization differs between children enrolled in Medicaid and SCHIP in a state where both programs use the same provider network and primary care case management (PCCM) system, and between SCHIP enrollees in two states that use very different program structures. In the State where SCHIP and Medicaid share a PCCM system, researchers found Medicaid children were more likely to receive well-child care than SCHIP enrollees and that SCHIP enrollees were more likely to use office-based physicians.

Researchers also compared these SCHIP enrollees with children enrolled in a SCHIP program that used a private insurance fee-for-service (FFS) system. They found children in the FFS system used more primary, specialty, and non-urgent emergency department care than children in the PCCM-based system. Well-child care was more frequent under the FFS system for urban children and under the PCCM system for rural children.

"SCHIP Structure and Children's Use of Care" was published in the summer 2006 issue of Health Care Financing Review, 27(4), pp. 41-52. The article can be downloaded from http://www.cms.hhs.gov/HealthCareFinancingReview/downloads/2006Summer.zip. Unzip the file and open 06Summerpg41.pdf; Plugin Software Help.

CHIRI™ Issue Brief No. 5. SCHIP Enrollees with Special Health Care Needs and Access to Care (2006). Karen VanLandeghem, Jennie Bonney, Cindy Brach, and Lisa Kretz.

Numerous factors—such as restrictions on health care coverage and insufficient provider participation—can limit access to care for children enrolled in public insurance programs, particularly children with special health care needs (CSHCN). This CHIRI™ Issue Brief summarizes findings regarding: health care access and satisfaction of CSHCN enrolled in SCHIP, services that were limited and/or excluded under SCHIP in some of the study States, and how SCHIP design decisions can limit coverage for CSHCN.

In general, CSHCN enrolled in SCHIP did not experience any problems in obtaining a primary health care provider or routine specialty services. However, certain specialty services were difficult to obtain in some study States that imposed limits and/or exclusions on certain services or were ambiguous in defining a standard of medical necessity. In addition, income restrictions and/or medical condition criteria made it difficult to access supplemental services from other Federal and State programs for CSHCN with severe chronic health conditions in some of the study States.

CHIRI™ Issue Brief No. 5 is available online or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 06-0051).

Effects of Primary Care Case Management (PCCM) on Medicaid Children in Alabama and Georgia: Provider Availability and Race/Ethnicity (2006). E. Kathleen Adams, Janet M. Bronstein, and Curtis S. Florence.

PCCM programs are designed to increase patients' use of primary and preventive care in doctors' offices while decreasing use of specialty and urgent care by assigning Medicaid enrollees to gatekeeper providers who make referrals for specialty, emergency, and inpatient care. Researchers examined the impact of PCCM implementation on children's use of primary and preventive care by race/ethnicity. Reductions in primary and preventive care use under Medicaid PCCM in Alabama and Georgia were more dramatic for minority children. The authors conclude that implementation of PCCM without fee increases may affect decisions of providers to participate in Medicaid which, in turn, may have unexpected negative effects that differentially impact minority children. More details are available in "Effects of Primary Care Case Management (PCCM) on Medicaid Children in Alabama and Georgia: Provider Availability and Race/ethnicity," in the February 2006 issue of Medical Care Research & Review 63(1), pp. 58-87.

Public Health Insurance Design for Children: The Evolution from Medicaid to SCHIP (2005). Sara Rosenbaum, Anne R. Markus, and Colleen Sonosky.

The majority of States that have implemented SCHIP as a separately-administered program have opted for benefit and coverage design in the case of early childhood preventive and developmental services that are considerably less comprehensive than the standard of coverage furnished to infants and young children under Medicaid. Researchers found that all States with separate SCHIP programs cover basic well-baby and well-child care in their service agreements; however, wide variation was found among the study States in their use of coverage standards that explicitly require participating health plans to cover child development services required under Medicaid, such as anticipatory guidance (18%), lead screening (43%), and comprehensive developmental assessments (68%). In addition, only half of the study States require participating health plans to use a medical necessity standard comparable to the Medicaid standard. The authors conclude that when States are given the flexibility to do so, they tend to reduce the level of coverage to that found in standard health insurance products, rather than the level of coverage in the Medicaid Early and Periodic Screening Diagnosis and Treatment program. "Public Health Insurance Design for Children: The Evolution from Medicaid to SCHIP" was published in the 2004 issue of the Journal of Health & Biomedical Law 1(1).

Children's Service Use During the Transition to PCCM in Two States (2005). Janet M. Bronstein, E. Kathleen Adams, and Curtis S. Florence.

Primary care case management programs (PCCM) are a form of managed care that gained popularity in the 1980s as a way to improve access and quality of care for Medicaid enrollees and to reduce program costs. This study examined the impact of PCCM on use of primary, preventive or emergency care for children enrolled in the Alabama and Georgia Medicaid programs. Implementation of the PCCM program was associated with a decline in use of all three types of care in both States. Based on focus group findings, researchers conclude that family difficulties in understanding and adjusting to restrictions on providers authorized for routine care were likely the primary factor in the decline. "Children's Service Use During the Transition to PCCM in Two States" was published in the Summer 2005 issue of Health Care Financing Review, 26(4), pp. 95-108.

The Impact of SCHIP Enrollment on Physician Participation in Medicaid in Alabama and Georgia (2004). Janet M. Bronstein, E. Kathleen Adams, Curtis S. Florence.

Does an increase in SCHIP enrollment impact office physicians' participation in Medicaid? This study compared physician participation in Alabama's freestanding SCHIP program to Georgia's Medicaid look-alike SCHIP program. It found that increases in SCHIP enrollment had little effect on physician participation in Alabama, which uses an open health care provider panel. However, in Georgia, where the same provider network serves both Medicaid and SCHIP, increases in SCHIP enrollment were associated with a decline in office-based physician participation in Medicaid in urban areas. The authors conclude that an adequate provider system is critical to assuring improvements in access to care for children enrolled in public insurance programs. For more details, see "The Impact of SCHIP Enrollment on Physician Participation in Medicaid in Alabama and Georgia" in the April 2004 issue of Health Services Research 39(2), pp. 299-315.

The Impact of Medicaid Primary Care Case Management (PCCM) on Office-Based Physician Supply in Alabama and Georgia (2003) E. Kathleen Adams, Janet M. Bronstein, Curtis S. Florence.

The success of Medicaid in assuring low-income children's access to health care is largely dependent on States' ability to enroll and retain primary care provider participation in the program. This study examined the early impact of Primary Care Case Management, a form of managed care, on office-based primary care physicians' participation in the Alabama and Georgia Medicaid programs. The implementation of the PCCM model, without increases in physician reimbursement, was associated with reduced physician participation in Medicaid and reduced visit volume among participants. For more details, see "The Impact of Medicaid Primary Care Case Management (PCCM) on Office-Based Physician Supply in Alabama and Georgia" in the fall 2003 issue of the journal Inquiry 40(3), pp. 269-282.

CHIRI™ Issue Brief No. 2. Children's Dental Care Access in Medicaid: The Role of Medical Care Use and Dentist Participation (2003). Karen VanLandeghem, Janet Bronstein, and Cindy Brach.

Many policymakers are examining State public insurance programs for ways to reduce costs and maximize the return on State and Federal investments. This CHIRI™ Issue Brief reports on children's dental care use in the Alabama and Georgia Medicaid programs and strategies for improving access to dental care, providing States with an additional resource as they make critical decisions about public insurance programs. Researchers found that less than 40 percent of Medicaid-enrolled children received dental care. Most of these children received preventive care and half used intensive dental services. While dentists' participation in Medicaid had some effect on improving dental care access, researchers conclude that other factors also influence dental care use in public insurance programs. Strategies that capitalize on the fact that Medicaid-enrolled children are far more likely to receive medical care than dental care could boost access tremendously. If every child who had a medical visit also had a dental visit, many (61 percent in Alabama and 78 percent in Georgia) Medicaid-enrolled children would have received dental care. The CHIRI™ Issue Brief is available online (PDF file, 162 KB; Plugin Software Help) or it can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 03-0032).

Do Enrollees in "Look-Alike" Medicaid and SCHIP Programs Really Look Alike? (2002). Jennifer N. Edwards, Janet Bronstein, and David B. Rein.

The State Children's Health Insurance Program (SCHIP), passed by Congress in 1997, has been implemented by States in many different forms, thus creating a myriad of natural experiments about insurance coverage for low-income children. In Georgia, SCHIP children are enrolled in a Medicaid look-alike program, PeachCare for Kids, with nearly the same administrative rules and providers as the Medicaid program. Comparing the experiences of PeachCare and Medicaid children allowed the authors to examine the impact of population differences on utilization and satisfaction. The authors found Medicaid children, controlling for many demographic characteristics, reported both less use of services and lower satisfaction with services used. Evidence presented supports three possible explanations for these differences: Medicaid families are less familiar with and supportive of systems requiring use of an assigned primary care physician, the families face more nonprogram barriers to using care, and physicians' have different responses to the two programs. For more details see "Do Enrollees in 'Look-Alike' Medicaid and SCHIP Programs Really Look Alike?" in the May/June 2002 issue of Health Affairs 21(3), pp. 91-102.

Policy Brief No. 5: Behavioral Health and Managed Care Contracting Under SCHIP (2002). Sara Rosenbaum, Colleen Sonosky, Karen Shaw, D. Richard Mauery.

This Policy Brief examines behavioral health managed care contracting under separately administered SCHIP. Of the 27 separate SCHIP programs reporting any managed care services in 2000, 15 purchased services from managed care organizations using freestanding contract instruments, that is, contracts that are wholly independent of the Medicaid contract and stand on their own as legal instruments, while 12 used a modified Medicaid contract. Every State that covers any level of behavioral disorders as a contractual benefit applies limitations and exclusions that would not be permissible in the Medicaid program (e.g., limits on inpatient days and outpatient services).

Policy Brief No. 4: State Eligibility Rules under Separate State SCHIP Programs-Implications for Children's Access to Health Care (2002). Sara Rosenbaum, Anne Markus.

This Policy Brief focuses on formulas that States have developed to count children's family income for purposes of determining eligibility. This review found that only 20 of the 34 States with separate SCHIP programs use rules to count income that are sufficiently compatible with Medicaid rules that a determination of SCHIP eligibility could be reasonably interpreted as a finding of ineligibility for Medicaid. In 14 of the 20 States, the rules for counting income are either more restrictive than those used under Medicaid or else are so ambiguous that it is impossible to know without a detailed audit if more restrictive criteria in fact are in use. As a result, a SCHIP child's countable income in these States actually may be lower than it is for a Medicaid-enrolled child. This misallocation of SCHIP resources to Medicaid-eligible children means that other low-income children who truly do not meet Medicaid standards may find that no assistance is available.

Policy Brief No. 3: Managed Care Purchasing Under SCHIP: A Nationwide Analysis of Freestanding SCHIP Contract (2001). Sara Rosenbaum, Karen Shaw, Colleen Sonosky.

This Policy Brief provides the first nationwide overview of how separate SCHIP programs structure "freestanding" SCHIP managed care contracts, i.e., contracts that exist independently of a State's Medicaid managed care agreements. Fifteen such "freestanding" contracts existed as of Calendar Year 2000, and this Policy Brief reports on their general terms of coverage, access, and care coordination.

Policy Brief No. 2: State Benefit Design Choices under SCHIP-Implications for Pediatric Health Care (2001). Sara Rosenbaum, Anne Markus, Colleen Sonosky, Lee Rapasch.

This Policy Brief examines the extent to which State agencies adopt conventional insurance norms or adhere to special principles of Medicaid coverage design for children in designing separately administered (or freelancing) SCHIP programs. The issue of coverage design is particularly relevant for children with low prevalence conditions and special health care needs. Increasingly, conventional insurance uses standardized coverage norms to limit coverage and treatment. These standardized norms take the form of across-the-board treatments and exclusions, limited definitions of medical necessity, and the use of irrebuttable, standardized treatment guidelines in determining when covered treatments will be available. All of these practices are impermissible under Medicaid, which uses exceptionally broad preventive standards to determine coverage of children; such standards favor coverage of children with low prevalence problems.

Policy Brief No. 1: State SCHIP Design and The Right to Coverage (2001). Sara Rosenbaum, Barbara Smith.

This Policy Brief explores whether States in their enabling legislation establishing separate SCHIP programs confer upon eligible children an individual legal right to health insurance benefits (i.e., an individual entitlement) under State law, similar to the entitlement that Medicaid eligible children enjoy under Federal law. The question of whether States guarantee necessary health coverage for low-income children through the creation of an individual entitlement is fundamental to the study of State policymaking under SCHIP.

Devolution of Authority and Public Health Insurance Design: National SCHIP Study Reveals an Impact on Low-Income Children (2001). Sara Rosenbaum, Barbara Smith, Colleen Sonosky, Lee Repasch, Anne Markus.

How do States implement public health insurance programs for low-income children when given the choice to depart from the extensive Medicaid rules and principles? This article presents main findings in two key areas of insurance design as they relate to SCHIP: (1) whether States decide to design their SCHIP programs as individually enforceable, legal entitlements and (2) whether States, as a matter of benefit design, rely on comprehensive managed care arrangements to deliver services to children enrolled in the programs. It finds that most States choose not to entitle SCHIP-eligible children to public health insurance as a matter of either Federal or State law and that most States build comprehensive managed care into benefit design and tend to draft contracts that are legally distinct from the State's Medicaid managed care contracts. It discusses implications of these findings for pediatric access to care. This article appeared in the first symposium issue focusing on children's health of the Houston Journal of Health Law and Policy 1(1):33-61.

Return to Contents

More Information and Feedback

For more information, please contact: CHIRI@ahrq.gov. Feedback on how CHIRI™ research findings are being used is important to this initiative. If you are willing to provide feedback, please use this E-mail box to briefly describe how you are using the CHIRI™ findings.

Page last reviewed October 2012
Internet Citation: Findings from the Child Health Insurance Research Initiative (CHIRI™). October 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/cpi/initiatives/chiri/findings.html