Recent Trends in State Children's Health Insurance Program Eligibility and Coverage for CSHCN

METHODS

RESULTS

Our analysis shows that there is a slight increase in SCHIP eligibility for CSHCN between 2001 and 2005 (8.44% vs 9.83%; P < .05, χ² test).

As Fig 1 shows, among the SCHIP-eligible CSHCN, we found a significant decrease in the uninsurance rate from 21.15% in 2001 to 10.87% in 2005 (P < .05, χ² test). After controlling for predisposing, need, enabling, and system factors, our analysis indicates that the CSHCN in 2005 were 57% less likely to be uninsured than those in 2001, as shown in Table 1.

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FIGURE 1

Uninsured rate among SCHIP-eligible CSHCN, 2001 and 2005 (P < .05, χ² test).

Table 1 also summarizes the logistic models, indicating factors that significantly affected uninsurance among the SCHIP-eligible CSHCN. Among predisposing factors, children between 6 and 12 years of age were less likely to be uninsured than children younger than 5 years, whereas teenagers had a higher probability of being uninsured. Children from households in which everyone's education level was below high school were less likely to be uninsured than those children from households with someone who had received a high school education. Compared with children from households in which English was the language used during the interview, children whose families used other languages were 91% more likely to be uninsured. For enabling factors, income was significantly associated with uninsurance, with individuals from households with lower income less likely to be uninsured than those with incomes higher than 200% of the FPL. Among need factors, CSHCN with disability or limitation were 62% more likely to be uninsured than those CSHCN who needed prescription medicine.

In terms of system factors, Table 1 shows that the uninsurance rate was significantly affected by 2 state policies: asset tests and presumptive eligibility. Those CSHCN who are from a state that required an asset test at SCHIP enrollment were more likely to be uninsured. Those CSHCN who are from a state that had presumptive eligibility were less likely to be uninsured.

DISCUSSION

Although there was a slight increase in the proportion of CSHCN who were eligible for SCHIP between 2001 and 2005, we found that the uninsurance rate among the SCHIP-eligible CSHCN dropped by nearly one half during the study period. In 2001, SCHIP was still a very young program in most states, whereas it had become relatively mature by 2005. Thus, the reduction in the uninsured rates among CSHCN between 2001 and 2005 closely corresponds to the maturing of SCHIP. The reduction in SCHIP-eligible uninsured CSHCN was confirmed by our multivariate analysis in which we controlled for a wide range of socioeconomic characteristics of CSHCN and their families.

Our study provides the first, to our knowledge, national estimate of trends in SCHIP eligibility and coverage for CSHCN. It is useful to compare our results with the trends reported by other researchers, although those published studies did not focus on CSHCN. Our finding of a reduced uninsurance rate is consistent with the study by Hudson and Selden,⁷ who analyzed the Medical Expenditure Panel Survey and reported that the number of children who were eligible for Medicaid or SCHIP but uninsured fell from 2001 to 2005. Authors of other studies have also reported a reduction in the number of SCHIP-eligible but uninsured children.⁸

This study relies on national survey data and has a number of notable limitations. As pointed out by Selden et al, “no survey or eligibility simulation is free from potential errors, and estimates from any one survey or eligibility simulation should be interpreted with caution.”⁸

First, when the second wave of the NS-CSHCN was conducted in 2005–2006, Tennessee dramatically changed its SCHIP program and did not cover any child. Consequently, our results did not reflect the SCHIP eligibility and coverage after Tennessee restored its SCHIP program in 2007. Second, as described above, the public-use files from the NS-CSHCN do not indicate in which year the child was surveyed, and as a result, the above-listed SCHIP eligibility criteria applied to the NS-CSHCN in this study approximately reflected SCHIP eligibility for CSHCN in the periods of 2000–2001 and 2005–2006. Finally, we applied the state-level eligibility criteria according to age, income, and year, which matched with most data of the NS-CSHCN. However, that was not a perfect match, because the income level of ∼3% of the CSHCN interviewed in each wave of the NS-CSHCN did not match precisely with the eligibility criteria. Finally, although we examined some important state SCHIP policies, other policies were not included in our analysis because of unavailable data for the study period, such as income disregards, which refers to the states’ policies regarding whether certain types or amounts of income will be counted or exempted in determining income eligibility. It remains an interesting topic for future studies to examine how state policies of income disregards affect enrollment of CSHCN in SCHIP.

Our results show the relatively stable SCHIP eligibility for CSHCN and the reduction in uninsurance among the SCHIP-eligible CSHCN and have important policy implications in “a time of great possibility in the realm of children's health insurance.”²⁵ In the wake of President Obama's inauguration and the Democrats’ increased majorities in both houses of Congress, legislative leaders moved quickly to break the political stalemate over SCHIP expansion, and on February 4, 2009, President Obama signed the Children's Health Insurance Reauthorization Act of 2009 to reauthorize and expand SCHIP. The empirical evidence found by our study supports renewal of SCHIP so that CSHCN can have continued eligibility and the reduction in their uninsurance rate can be sustained.

Despite our finding that ∼10% of the SCHIP-eligible CSHCN were uninsured in 2005, this group clearly includes some of the most disadvantaged children in the United States; numerous studies have reported that CSHCN require continuing care both at home and from the formal health care system and incur higher medical expenditures than other children.^26–29 In particular, we found that those CSHCN whose families speak languages other than English were more likely to remain uninsured. They should be targeted by specific outreach efforts to help them get enrolled.

Our analysis also indicates that the uninsurance status is strongly related to state policies. We found that an asset test at SCHIP enrollment is positively related to uninsurance, whereas presumptive eligibility is negatively related to uninsurance. These findings have important policy implications. States may want to review and revise their SCHIP policies to help enroll uninsured CSHCN. In particular, in 2005 there were only 3 states (Oregon, South Carolina, and Utah) that still required asset tests at the time of SCHIP enrollment and only 7 states that offered presumptive eligibility (California, Illinois, Massachusetts, Michigan, Missouri, New Jersey, and New York). Our results suggest that asset tests should be changed, because they may significantly impede enrollment in SCHIP for CSHCN. Conversely, on the basis of our results, presumptive eligibility may facilitate enrollment in SCHIP for CSHCN, and its adoption could help expand SCHIP participation substantially.

CONCLUSIONS

Our results show the dramatic decrease in the uninsurance rate among SCHIP-eligible CSHCN as the SCHIP program matured from 2001 to 2005. Our results also identify important state policies that significantly affect the uninsurance rate, including asset tests (positive effects) and presumptive eligibility (negative effects).