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The Role of Race and Ethnicity in the State Children’s Health Insurance Program (SCHIP) in Four States: Are There Baseline Disparities, and What Do They Mean for SCHIP?

Laura P. Shone, MSW^*, Andrew W. Dick, PhD, Cindy Brach, MPP, Kim S. Kimminau, PhD^||, Barbara J. LaClair, MHA^||, Elizabeth A. Shenkman, PhD^¶, Jana F. Col, MS^¶, Virginia A. Schaffer, MA^¶, Frank Mulvihill, PhD^#, Peter G. Szilagyi, MD, MPH^*, Jonathan D. Klein, MD, MPH^*, Karen VanLandeghem, MPH^** and Janet Bronstein, PhD^#

^* Strong Children’s Research Center, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
Center for Delivery, Organization and Markets, Agency for Healthcare Research and Quality, Rockville, Maryland
^|| Kansas Health Institute, Topeka, Kansas
^¶ Institute for Child Health Policy, University of Florida, Gainesville, Florida
^# University of Alabama, Birmingham, Alabama
^** Independent Consultant, Chicago, Illinois

Background. Elimination of racial and ethnic disparities in health has become a major national goal. The State Children’s Health Insurance Program (SCHIP) has the potential to reduce disparities among the children who enroll if they exhibit the same disparities that have been documented in previous studies of low-income children. To determine the potential impact of SCHIP on racial and ethnic disparities, it is critical to assess baseline levels of health disparities among children enrolling in SCHIP.

Objective. To use data from the Child Health Insurance Research Initiative (CHIRI) to 1) describe the sociodemographic profile of new enrollees in SCHIP in Alabama, Florida, Kansas, and New York; 2) determine if there were differences in health insurance and health care experiences among white, black, and Hispanic SCHIP enrollees before enrollment in SCHIP; and 3) explore whether race or ethnicity, controlled for other factors, affected pre-SCHIP access to health coverage and health care.

Setting. SCHIP programs in Alabama, Florida, Kansas, and New York, which together include 26% of SCHIP enrollees nationwide.

Design. Telephone interview (mailed survey in Alabama) about the child’s health, health insurance, and health care experiences conducted shortly after SCHIP enrollment to assess experience during the time period before SCHIP.

Sample. New SCHIP enrollees (0–17.9 years old in Alabama, Kansas, and New York and 11.5–17.9 years old in Florida). Stratified sampling was performed in Kansas and New York, with results weighted to reflect statewide populations of new SCHIP enrollees.

Measures. Sociodemographic characteristics including income, education, employment, and other characteristics of the child and the family, race and ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic [any race]), prior health insurance, health care access and utilization, and health status.

Analyses. Bivariate analyses were used to compare baseline measures upon enrollment for white, black, and Hispanic SCHIP enrollees. Multivariate analyses were performed to assess health status and health care access measures (prior insurance, presence of a usual source of care (USC), and use of preventive care), controlling for demographic factors described above. Weighted analyses (where appropriate) were performed by using SPSS, STATA, or SUDAAN.

Results. Racial and ethnic composition varied across the SCHIP cohorts studied, with black and Hispanic children comprising the following proportion of enrollees, respectively: Alabama, 33% and <1%; Florida, 16% and 26%; Kansas, 12% and 15%; and New York, 24% and 36%. Black and Hispanic children were more likely to reside in single-parent and lower-income families. With some variation by state, children from minority groups were more likely to report poorer health status than were white children. Relative to white children, children from minority groups in Florida and New York were more likely to have been uninsured for the entire year before SCHIP enrollment. In all states, children from minority groups who had prior coverage were more likely to have previously been enrolled in Medicaid than in private health insurance and were less likely to have had employer-sponsored coverage compared with white children. Except in Alabama, there was a difference in having a USC, with children from minority groups less likely to have had a USC before SCHIP enrollment compared with white children. No consistent pattern of health care utilization before SCHIP was noted across states with respect to race or ethnicity. Findings from multivariate analyses, controlling for sociodemographic factors, generally confirmed that black and Hispanic children were more likely to have lacked insurance or a USC before enrollment in SCHIP and to have poorer health status compared with white children.

Conclusions. SCHIP is enrolling substantial numbers of racial and ethnic minority children. There are baseline racial and ethnic disparities among new enrollees in SCHIP, with black and Hispanic children faring worse than white children on many sociodemographic and health system measures, and there are differences among states in the prevalence and magnitude of these disparities. After controlling for sociodemographic factors, these disparities persisted.

Implications for Monitoring and Improving SCHIP. SCHIP has the potential to play a critical role in efforts to eliminate racial and ethnic disparities in health among the children it serves. However, study findings indicate that programmatic efforts are necessary to ensure that disparities are not perpetuated. Program effectiveness and outcomes should be monitored by race and ethnicity to ensure equity in access, use, and outcomes across all racial and ethnic groups. Assessing the health characteristics and needs of new SCHIP enrollees can provide a benchmark for evaluating the program’s impact on eliminating racial and ethnic disparities in health and inform service delivery enhancements.

Key Words: access to health care • health insurance • children • minorities • racial disparities • race • ethnicity • SCHIP • uninsured • State Children’s Health Insurance Program

Abbreviations: USC, usual source of care • SCHIP, State Children’s Health Insurance Program • CHIRI, Child Health Insurance Research Initiative • ED, emergency department • CSHCN, children with special health care needs • ESHI, employer-sponsored health insurance • FPL, federal poverty level

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