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COMMENTARY |
Child Health Evaluation and Research Unit, Division of General Pediatrics, Division of General Internal Medicine, and Gerald R. Ford School of Public Policy
University of Michigan
Ann Arbor, MI 48109-0456
Abbreviations: SCHIP, State Children's Health Insurance Program
Was the State Children's Health Insurance Program (SCHIP) a flash in the pan or is it the future of children's health insurance? Your answer may depend on the news you read. As states have grappled with tight budgets in the recession economy and the long-ago planned "dip" in federal funding for SCHIP for fiscal years 2002–2004, several states made decisions to limit their SCHIPs through restricting enrollment, increasing premiums, limiting benefits, and decreasing outreach activities. As a consequence, July through December 2003 marked the first period since SCHIP was enacted in 1997 that program enrollment decreased nationally, attributable to marked declines in 11 states and the District of Columbia.1
On the other hand, during the latter half of 2003, a handful of states expanded SCHIP eligibility and enhanced program benefits, and the majority of states continued to report modest increases in SCHIP enrollment.1 Despite the national recession beginning in 2001 that led to increased unemployment and associated decreases in employer-sponsored insurance coverage for children, increased child enrollment in SCHIP and Medicaid more than offset the reduction in employer-sponsored coverage.2 As a result, the rate of uninsurance among US children declined from 15% in 19973 (at SCHIP inception) to 11.4% in 2003,4 a decline attributable in large part to SCHIP enrollment that was particularly robust among children living in households with annual incomes 2 to 3 times the poverty level, beyond the eligibility limits of most Medicaid programs.
The findings of Kempe et al5 in this issue of Pediatrics regarding the Colorado version of SCHIP, Child Health Plan Plus, offer good news about SCHIP beyond enrollment statistics. Families reported higher rates of being able to see providers for a variety of routine and acute care needs and also reported a significant decline in unmet health needs. Notably, rates of routine primary care and subspecialty visits increased, whereas rates of acute care and emergency and inpatient visits did not, indicating a greater opportunity to emphasize preventive services and access subspecialist care with SCHIP coverage compared with children's prior circumstances. It is not surprising that, given these changes, parents rated the quality of their children's health care better when enrolled in SCHIP than before.
The Kempe et al Colorado report follows assessments of SCHIPs in Florida, Iowa, Kansas, New York, and North Carolina,6–10 conducted with similarly rigorous methods that found comparable program effects on measures of parent-reported access to care and quality of care. Although we should be cautious in generalizing findings from these state programs to all state versions of SCHIP, the consistency of program effects across several studies follows a pattern that we have come to expect: the presence of health insurance facilitates access to health care. Static comparisons of uninsured and insured children suggest marked differences in outpatient, emergency department, and inpatient utilization11 but, because of their cross-sectional design, leave open the question of whether the uninsured may use fewer services because of lower perceived need rather than inferior access to care. Analyses of SCHIP initiatives, in contrast, illustrate through prepost comparisons that previously uninsured children indeed have higher utilization and fewer unmet medical needs when they acquire coverage.
Nonetheless, to conclude solely on the basis of favorable programmatic analyses5–11 that SCHIP "works" would be to confuse efficacy with effectiveness. SCHIP is improving access to care but only for those who are enrolled; children who are eligible for their states' SCHIP but are not enrolled fail to benefit from the plans. Although the SCHIP uptake rate (enrollment among eligible children) has improved over time, national estimates of SCHIP uptake in 2002 (most recent data) were only 60%, substantially below rates of 75% to 80% for Medicaid programs, which are typically more stigmatized.12 The analogy in clinical research would be that we have a product that is safe and effective for children who use it, but 40% of patients eligible to use the medication either don't take it or stop taking it once they have started. Would we be satisfied clinically with such a drug? Should we be satisfied with SCHIPs used at this level?
At a time when SCHIP enrollment has declined because state budget constraints have reduced program availability for eligible children1 (clinically akin to a drug shortage), the answer to this question may be "yes." In the longer term, however, the approaching decision of Congress on whether to reauthorize SCHIP (and in what form) will likely rest not only on analyses of how many children have benefited from the programs and attributable effects on children's health and health care but also on how the different state programs have functioned and how federal dollars have been spent. SCHIP itself will benefit if the next wave of SCHIP research focuses on state-to-state comparisons in 3 arenas: overall program function and consequent fiscal status, eligibility for adults, and broad dynamics of child uninsurance.
One of the most appealing facets of SCHIP, from the public policy perspective, is the discretion left to states to tailor their programs to local needs and policy preferences. That discretion has led to substantial state-to-state variation in program function with regard to enrollment and retention of eligible children and the programs' fiscal health overall, to the point that, although some states are facing SCHIP funding shortfalls, other states have left more than $1 billion in federal SCHIP funds unspent.13 Explanations for such variation across states and ideas for possible reconfiguring of the federal SCHIP-funds allotment formula are integral to the success of future SCHIP efforts and deserve immediate research attention in preparation for congressional deliberations regarding SCHIP reauthorization.
As SCHIPs have evolved, some states have secured federal waivers to enroll adults, usually for uninsured parents or caregivers of children who were Medicaid- or SCHIP-eligible under the premise (and with some evidence14) that parents with coverage gain better access to care for their children. Covering adults is a worthy aim in general, but the political reality of SCHIP legislation is that its bipartisan intent was (and is likely to remain) to cover uninsured children. On the other hand, covering uninsured adults may be one of the most effective enrollment strategies available for SCHIP, especially as the national and many state economies continue to struggle to restore jobs and employer-sponsored health insurance for adults. Therefore, coverage for parents through SCHIP is most likely to continue if state-to-state comparisons indicate that such coverage initiatives increase enrollment among eligible children, improve children's appropriate utilization of health care, and do not threaten the fiscal viability of the programs because of adults' typically higher health care utilization. Of note, in some states SCHIP funds are being used to cover childless adults; understanding effects on children's coverage through these initiatives (where the connection to children's insurance status is more remote, conceptually) will be even more important to sustaining them under future SCHIP legislation.
Finally, one of the most positive aspects of SCHIP is how it has served as a major source of coverage for newly uninsured children in recent challenging economic times. However, our collective understanding of how families navigate transitions in children's insurance status remains relatively poor. Recent research has illustrated how frequently children undergo insurance transitions (from uninsured to insured and vice versa, or from privately insured to publicly insured), and that children who experience both uninsured and insured periods in a single year (regardless of order) more closely resemble the continuously uninsured than the continuously insured with respect to postponed medical care.15 Other investigators have examined the barriers to SCHIP across states and concluded that SCHIP-entry features such as waiting periods and premiums reduce enrollment,16 whereas passive reenrollment helps sustain program participation.17 These findings are all aggregate, which is generally indicative of trends but not necessarily helpful in sorting out how families might make decisions differently about program enrollment if SCHIP features were different in the future. Person-level longitudinal research that followed children over time through insurance transitions and tracked the near- and long-term implications of lacking or having coverage would shed bright light on these and other remaining questions about the American phenomenon of uninsurance. Such research would be expensive, however, and likely only to come from the federal government if the case can be made that information obtained from such intensive investigation would make programs work more effectively and use public dollars more efficiently.
Whether SCHIP will be a fading memory or remain status quo 10 years from now will depend on the growing body of evidence regarding its effectiveness. Those who support SCHIP and its accomplishments for children must be mindful of its critics' potential arguments regarding the failure to enroll eligible individuals and nonuniform program implementation across states and act now to enhance our collective understanding of how the second decade of SCHIP could build on the successes and minimize the struggles of the first decade.
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FOOTNOTES |
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Reprint requests to (M.M.D.) University of Michigan, 300 NIB, 6C23, Ann Arbor, MI 48109-0456. E-mail: mattdav{at}med.umich.edu
No conflict of interest declared.
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REFERENCES |
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