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The creation of the State Children's Health Insurance Program (SCHIP) in 1997 was a landmark event in American social history. The program substantially broadened the role of public health insurance for children living near poverty, illuminating wide popular support for ensuring coverage for the most vulnerable in American society. Not since Medicare and Medicaid were established in 1965 had the Congress enacted such a large, subsidized health insurance program. Designed to provide health insurance coverage for many of our nation's low-income uninsured children, the SCHIP legislation enjoyed enthusiastic support in all quarters. Universal concern for low-income children, the availability of federal surpluses, and successful compromises converged to make this historic achievement possible.
SCHIP was created as Title XXI of the Social Security Act by the Balanced Budget Act of 1997, which was signed into law in August 1997. Congress appropriated approximately $40 billion for the program's first ten years (fiscal years [FY]1998 through 2007). The funds were allotted to the states based on a formula that considers, primarily, the number of all low-income children and the number of low-income uninsured children residing in each state. It also includes a factor for each state's health care costs relative to the others'. To encourage states to implement this program, the federal match for SCHIP expenditures was enhanced relative to Medicaid: each state's share was set at 70 percent of its Medicaid (Title XIX) share. Under the law, states may cover uninsured children in families with income under 200 percent of the federal poverty level (FPL), and up to higher income levels in states that already provide extensive coverage under Medicaid.
The SCHIP legislation gave states three broad options for program design. A state could choose to expand its Medicaid program, develop a separate program, or implement a combination of both. By law, Medicaid expansion programs under SCHIP are subject to all the requirements of Title XIX, but raise the income eligibility thresholds. In particular, these programs establish an entitlement for all children who meet the eligibility criteria, and eligibility must comply with the Title XIX requirements for comparability and statewideness. In addition, states that expand Medicaid under SCHIP must cover the same broad benefits offered under Medicaid and use the Medicaid service delivery network, and may not impose cost-sharing. (Medicaid expansions established under a Section 1115 demonstration may require cost-sharing for children if a waiver of the prohibition against cost-sharing has been obtained.)
By contrast, the option for separate, non-Medicaid SCHIP programs permits states to adopt programs that more closely resemble private insurance. Separate child health programs do not establish an entitlement for children. Moreover, states electing this option have considerable flexibility in defining eligibility. Another important eligibility-related difference between Medicaid and separate child health programs concerns other insurance coverage. Whereas insurance status is irrelevant to eligibility for Medicaid (i.e., insured individuals can still qualify for Medicaid if they meet the eligibility criteria), SCHIP explicitly excludes insured children. Further, to discourage parents from substituting SCHIP for their children's existing private insurance, states with separate programs may impose waiting periods on children who have or who recently dropped their private health insurance. Except when using waiver authority, states with Medicaid expansion programs may not impose waiting periods.
Although subject to statutory standards for benefit packages, states with separate child health programs can provide benefits less broad than Medicaid's and more like coverage offered in the private sector. All the states with separate programs have adopted broad benefit packages, though usually not as comprehensive as Medicaid's. States with separate child health programs may also impose premiums and cost-sharing, and many do. Some have developed service delivery networks different from those serving Medicaid, and managed care is more widespread in SCHIP than in Medicaid.
By December 1999, all states, territories, and the District of Columbia had received federal approval to expand coverage under SCHIP (CMS 2002a). States launched their SCHIP programs at different times. Most states started enrolling children during 1998; however, a few began as early as October 1997, and a few did not start until 1999. By March 2002, 16 states were operating separate programs, 21 were operating Medicaid expansion programs, and 19 were operating combination programs (CMS 2002b). State programs have evolved steadily; one indication of this dynamism is that, by March 2002, 106 state plan amendments had been submitted to and approved by DHHS and seven more were under review.
The states have enrolled large numbers of children and enrollment has grown rapidly from year to year. During FY 2002, 5.3 million children were enrolled in SCHIP for at least part of the year, (CMS 2003). Before that, enrollment (i.e., number of children enrolled at some point in the year) grew from 1.0 million in calendar 1998, to 2.0 million in FY 1999, and, further, to 3.3 million in FY 2000. Enrollment has grown most rapidly in separate programs. The proportion of children in SCHIP who were enrolled in separate programs rose from 65 percent in FY 1999 to 74 percent in FY 2001. (1) In part, this growth reflects an increase in the number of states that operate separate programs, whether alone or in combination with a Medicaid expansion program.
Many of the states have chosen to deliver services to their SCHIP children through capitated managed care plans. Most states developed experience in managed care contracting after its rapid adoption in their Medicaid programs during the 1990's. However, in rural and other areas where managed care penetration is limited or non-existent, alternative delivery systems are used. In these cases, a mix of primary care case management and fee-for-service arrangements is common.
Based on steadily rising enrollment in SCHIP and the recently reported decline in the number of uninsured children, from 9.9 million (13.9 percent) in 1997 to 7.8 million (10.8 percent) in 2001, (2) we know SCHIP has succeeded in expanding health insurance coverage among children. However, three years after SCHIP was enacted, when this evaluation got underway, understanding of the mechanisms that produced this overall result was still limited. While the need for information and analysis to guide federal and state policy was great and growing, little systematic analysis of the implications of states' program choices had been conducted. Although a body of literature on the program is emerging, knowledge is still limited about a host of important issues across the states and at the national level. For example, the reasons why some parents enroll their children and others do not, and the factors associated with disenrollment are still unclear. Likewise, knowledge about children's access to care and use of SCHIP benefits is limited, as is information about their parent's satisfaction with the care they receive. The impact of cost-sharing on utilization and satisfaction has been little studied. Empirical evidence to inform the debate about "crowd-out"--the substitution of SCHIP for private coverage also remains limited and equivocal.
Recognizing the importance of improving our knowledge about these issues and others, Congress appropriated $10 million for a comprehensive evaluation of SCHIP. The scope and purpose of this congressionally mandated evaluation are described in the next chapter.
This report to Congress summarizes the findings to date stemming from the Congressionally mandated study of SCHIP. The study, to be completed in three years, had been underway for only one year when this report was prepared. Therefore, this first report presents interim findings from data collected and analyzed early in the study, and it focuses primarily on the implementation of SCHIP and its effects on state, contractor, health care provider, and family experiences.
The report has two parts. Part 1 provides background about SCHIP and the mandated evaluation, including the evaluation design. Part 2 presents interim findings from the study. Appendix A displays the legislation mandating the study. Appendix B includes tables displaying the composition of the 51 focus groups. Appendix C describes further analyses that will be conducted under this evaluation and the final report to Congress in which they will be presented.
This chapter begins by providing an overview of the congressional mandate to evaluate SCHIP. This is followed by a description of how the evaluation "blueprint," laid out in the statutory language, was translated into a concrete research strategy and evaluation design. In the process, the broad policy concerns and specific research questions this evaluation addresses are reviewed.
Congress mandated in the Balanced Budget Refinement Act of 1999 that the Secretary of the Department of Health and Human Services (DHHS) conduct an independent study of the State Children's Health Insurance Program. The legislation articulates the range of issues that the evaluation is to investigate, as well as some of the methods to be used. Congress specifically directed that the evaluation:
The mandate also stipulated the following study parameters:
The congressional mandate was broad in scope, and to fulfill it required that a complex set of activities be organized and implemented rapidly. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the Department of Health and Human Services (DHHS) was assigned responsibility for the evaluation. The task of translating Congress' comprehensive mandate into a responsive and manageable evaluation plan was challenging. To carry it out, ASPE consulted widely with policy experts and researchers, with the aim of producing a robust specification of the questions the evaluation should address and thorough consideration of methodological issues. This consultation also enabled ASPE to devise a strategy that: built on existing research efforts to the extent possible; avoided duplication of other work; and maximized the potential of the evaluation to add to our knowledge about SCHIP and Medicaid.
Federal and state policymakers and researchers both within and outside the government participated in these early planning efforts and discussions, which formed the basis for ASPE's decisions about the evaluation design and methods. A multi-faceted research strategy ultimately emerged that, while addressing the broad range of issues articulated in the mandate, also met the need for results in the near term. The three-year evaluation project has numerous research components that include both qualitative and quantitative approaches and that bring data and information from multiple sources--including states, health care providers, families, and other interested parties--to bear. While time, resource and legislative constraints necessitated this somewhat complex strategy, the design is expected to produce a uniquely rich assessment of the program.
The evaluation plan ASPE developed included three contractual components: (1) an overall study of the issues identified in the legislative mandate, but focused primarily in ten states; (2) a focus group study in nine states during 2001; and (3) special studies on issues of immediate policy interest, such as the experience of states providing family coverage under SCHIP. Although conducted under separate contracts, the findings from the three different components will be fully integrated by the investigators under the contract for the overall study. (4) , (5), (6), (7)
The central focus of the overall study is states' programmatic and policy choices and their implications. Data and information for this study will come from three sources: (1) in-depth case studies of ten states; (2) a nationally representative survey, in the same ten states, of parents of SCHIP enrollees and disenrollees, and, in two of the states, of parents of Medicaid enrollees and disenrollees; and (3) a survey of SCHIP administrators in all 50 states, the District of Columbia, and the five U.S. territories. The study will also draw on a national survey of awareness and perceptions of Medicaid and SCHIP among low-income families with uninsured children, using the State and Local Area Integrated Telephone Survey (SLAITS), as well as states' SCHIP and Medicaid administrative files. Finally, as indicated earlier, the overall study will incorporate the findings from the focus group study and the studies of special topics. These data sources are described in Chapter III as part of the discussion on the evaluation design.
ASPE identified eight distinct areas of inquiry contained in the evaluation mandate, as follows: (1) SCHIP program choices; (2) outreach and barriers to enrollment; (3) enrollment and retention in SCHIP; (4) enrollment trends; (5) SCHIP's relationship to Title XIX and private insurance; (6) impact of SCHIP on the uninsured; (7) premiums and cost-sharing; and (8) access to care, utilization, and satisfaction with care. These topics reflect key aspects of SCHIP programs and their impacts. Table 1 displays the data sources that are used to explore each of them, and the subsequent narrative identifies the primary questions associated with each topic.
| Evaluation Topics | Survey of Target Population | State Case Studies | Survey of Program Administrators | Program Data | Focus Groups | SLAITS Survey | Special Studies |
|---|---|---|---|---|---|---|---|
| 1. SCHIP Program Choices | P | P | S | ||||
| 2. Outreach and Barriers to Enrollment | P | S | S | S | P | ||
| 3. Enrollment and Retention in SCHIP | P | S | P | S | S | ||
| 4. Enrollment Trends | S | P | |||||
| 5. SCHIP's Relationship to Title XIX and Private Insurance | P | P | P | S | S | ||
| 6. Impact of SCHIP on the Uninsured | S | P | |||||
| 7. Premiums and Cost Sharing | P | S | S | S | S | ||
| 8. Access to Care, Utilization, and Satisfaction | P | S | S | ||||
| Note: P indicates primary source for addressing topic; S indicates a secondary source for addressing topic | |||||||
Topic: 1. SCHIP Program Choices. A detailed understanding of the context in which states designed and operate their SCHIP programs is essential to critically assess the SCHIP implementation experience. Knowledge about states' program design choices is necessary in order to explore how different choices bear on such key outcomes as enrollment trends, access, and enrollee satisfaction. Program design choices cover many matters, including (among others): outreach, enrollment and retention strategies, benefit design, delivery systems and payment arrangements, cost-sharing policies, anti-crowd-out measures, and state financing.
The key question to be addressed under this evaluation topic is:
Topics: 2. Outreach and Barriers to Enrollment; 3. Enrollment and Retention in SCHIP; and 4. Enrollment Trends. Perhaps because SCHIP enrollment has grown continuously from year to year, our understanding of the barriers to enrollment and retention and the turnover and churning behind the total enrollment numbers remains limited. For example, the reasons why families enroll and disenroll their children are not well understood. Furthermore, we know little about families' experience with the coordination (or lack thereof) between Medicaid and SCHIP, which is important because of the need for easy transitions between the two programs for low-income families.
Key questions to be addressed under these topics include:
Topics: 5. SCHIP's Relationship to Title XIX (Medicaid) and Private Insurance; and 6. Impact of SCHIP on the Uninsured. Little is known about the most recent insurance status of children before they enroll in SCHIP, or about their insurance status following disenrollment. Understanding the role SCHIP plays in the larger scheme of insurance dynamics among low-income children and families is an important evaluation issue, and may help federal and state policymakers guide the program's future effectively and strategically.
Key questions under these topics include:
Topic: 7. Premiums and Cost-Sharing. Many states have introduced premiums and cost sharing in their programs, and the effects of these program choices on beneficiaries is a subject of keen interest. The two key questions are:
Topic: 8. Access to Care, Utilization, and Satisfaction with Care. The purpose of SCHIP and Medicaid is to improve access to health care by providing health insurance. Policy makers and program officials need to know whether the programs are improving access to care, satisfaction, and appropriate utilization and what the chief determinants of these outcomes are.
Key questions to be addressed within this topic include:
This chapter describes the design of each of the evaluation components and explains how these components, together, will yield a rich and integrated evaluation of SCHIP. The study will provide both a profile of the program at the national level and state-specific analyses. Further, it will explore whether and how important program outcomes vary by subpopulation.
The time frame that Congress provided for a report on the evaluation could not be met, given the scope and requirements of the evaluation mandate. Indeed, significant aspects of the required work--in particular, the enrollee survey and related analyses--were infeasible in the time frame allowed. Consequently, following consultation with Congressional staff, ASPE developed a research strategy that would enable the Secretary to provide a preliminary report on the full range of issues specified in the mandate early on, and a final report on findings at the end of the three-year-long evaluation. To illustrate, this first report's description and analysis of states' program choices and their outcomes are based on the first six of the ten case studies completed for the evaluation. The analysis of program perceptions, attitudes and experiences among families whose children are eligible for Medicaid and SCHIP is based on: (1) a focus group study including 51 diverse focus groups across nine states and (2) preliminary data from a 50-state survey of parents of low-income, uninsured children. These efforts provide valuable new information for this first report. However, a richer and more rigorous quantitative analysis will be available for the final report, based on all ten of the state case studies, a nationally representative survey of enrollees and disenrollees in all ten of those states, and the final data files from the survey of parents of eligible-but-uninsured children.
Designing the evaluation required specifying the research questions in detail, selecting the ten evaluation states and gaining their cooperation, designing the primary data collection approaches, and defining the analytic approaches to be used to address the questions. A ten-member technical advisory group of researchers and policy experts convened by the contractor, along with a departmental advisory group convened by ASPE, reviewed the draft evaluation design. The input from these groups was incorporated in a final design report (Wooldridge et al. 2001).
The first year of the congressionally mandated study of SCHIP was devoted primarily to case study and focus group data collection and analysis, and to other study components that would provide usable information for this report. Also during the first year, the contractor designed the mandated survey of SCHIP enrollees and disenrollees and worked with the states to collect the enrollment records needed both to conduct the survey and to analyze enrollment and disenrollment patterns.
This chapter begins by describing the activities related to the study components whose findings are included in this report to Congress:
The chapter continues with a discussion of the design of the remaining study components, which will generate findings that will be reported in a final, comprehensive report to Congress. Those components are:
Ten states were selected for this study in accordance with the legislative requirements. These ten states capture: (1) a high proportion of low-income uninsured children in the United States; (2) wide geographic (including urban/rural) representation, and (3) diverse approaches to program design. The selection process began with a list of 25 states, prepared by ASPE based on a wide array of factors, including the size of the SCHIP and Medicaid populations, the number of low-income uninsured children, representation of important subpopulations, program design features, maturity of program, and state data capability. (8) In addition, priority was given to selecting states from among the nine states included in the focus group study that was also a part of ASPE's evaluation. Based on a nonprobability, replicable protocol, ten states were selected: California, Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey, New York, North Carolina, and Texas. (9) These ten states fulfill the legislatively specified selection criteria:
To capture additional diversity, other program design features were monitored and taken into consideration:
Finally, six of the ten states were among those included in the focus group study: California, Colorado, Florida, Missouri, New York, and Texas.
The states were keenly interested in the study. When approached about participating, all states agreed to cooperate with the evaluation contractor to provide access to state staff and to provide program enrollment data needed for the study, and all signed memoranda of understanding to do so. By the end of 2001, most of the states had supplied both test data and the enrollment data required for drawing the first sample wave of the survey of SCHIP enrollees and disenrollees. The two states selected for a survey of Medicaid enrollees and disenrollees--California and North Carolina--had by March 2002 signed memoranda of understanding to provide the necessary Medicaid enrollment data. (10)
Case studies of the ten selected states were designed and conducted in 2001 to develop an understanding of why states designed their children's health insurance programs as they did, the challenges and issues states faced during implementation, the perceived and measurable effects of states' efforts, and the continuing evolution of SCHIP programs. These case studies provide critical background for interpreting findings from other analyses conducted under this evaluation.
The first step was to collect and review information about the case study states. Protocols for semi-structured interviews with policymakers, advocates, providers and other key state and local staff were developed, and visits to each state were arranged. Between June 2001 and October 2001, the evaluation team visited six of the ten study states: California, Colorado, Louisiana, Missouri, New York, and Texas. The team spent a full week in each state. Team members conducted interviews with between 40 and 50 state and local officials, including SCHIP and Medicaid administrators and their staff, state legislators and their staff, officials from the governor's office, state public health officials, provider associations, health plan associations, and private sector vendors under contract with the states to perform various administrative functions. In selected localities in each state, the team interviewed providers, child and family advocates, health plan officials, local Medicaid eligibility workers, outreach workers, and community-based application assisters. These 40 to 50 individuals in each state are described throughout the report as "case study respondents." Based on the information gathered during the site visits, detailed state-specific, case study reports were developed.
The site visit protocols included questions on the following topics:
Each case study report synthesized the information collected. The case study reports from the first six states were the primary source for an interim cross-cutting report (Hill, Harrington and Hawkes 2002), from which Part 2 of this report (study findings) draws heavily.
As indicated earlier, the survey of enrollees and disenrollees, which will be the principal source of data and analysis on families' experience of SCHIP and Medicaid, could not be fielded in time to meet the due date for the report to Congress. To provide preliminary information on this subject for this report, ASPE contracted for a focus group study, which was conducted during the summer of 2001. Focus groups were held in nine states, of which the six marked with asterisks are also included in the overall ten-state study: California*, Colorado*, Florida*, Georgia, Maryland, Missouri*, New York*, Ohio, and Texas*. A total of 51 focus groups was convened with parents of SCHIP and Medicaid enrollees and disenrollees and with parents of low-income uninsured and privately insured children. Nineteen focus groups included parents of children enrolled in SCHIP and Medicaid; 14 groups included parents of children who had disenrolled from one of the two programs; 13 groups included the parents of eligible but not enrolled low-income children; and five focus groups were with the parents of privately insured children in low-income families. Ethnicity, race, and language spoken at home were also factors used to define the focus groups, so as to capture the experience of important subpopulations. In total, 367 parents participated. (11) These parents are described throughout the report as focus group participants. Appendix B shows the distribution of focus groups by the insurance status of the child and other selection criteria.
The focus groups addressed the following key topics: parents' perceptions of the SCHIP and Medicaid programs; barriers to enrolling children in SCHIP and Medicaid; family attitudes toward and experience of cost-sharing (premiums and copayments) in SCHIP; access to services, benefits used; parents' experiences with private insurance; the effect of outreach efforts and messages on parents' awareness and understanding of the programs; and parents' attitudes toward enrolling their children.
To organize and synthesize the information collected, transcripts from the focus groups were coded uniformly using software, designed for analyzing qualitative data, that allows all passages related to a specific theme to be retrieved for synthesis and comparison across groups. The study findings, reported in full in Bellamy et al. (2002), are incorporated in Part 2 of this report.
It should be noted that the findings from focus groups represent only the views of those individuals who participated in the focus groups and thus cannot be generalized to the broader population. While recognizing the limitations of this study methodology, ASPE believed it was important to include the beneficiary perspective in this first report on the evaluation. The quantitative analyses of the enrollee and disenrollee survey data and SLAITS data will explore in more detail and with greater rigor the issues raised by the focus groups.
The State and Local Integrated Telephone Survey (SLAITS) is a sampling and survey mechanism, developed by the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC). The Health and Resources Services Administration (HRSA) of the DHHS is currently using SLAITS to study the prevalence and experience of children with special health care needs. ASPE determined that the large number of households that had to be sampled to identify special needs children for the HRSA study made the survey an ideal source for identifying low-income households with uninsured children. By adding to the HRSA survey a Low-Income Uninsured Supplement, information could be gathered that was needed to address Congress' interest in the reasons many eligible children are not enrolled in Medicaid and SCHIP.
This survey is the largest to date that addresses barriers to enrollment in Medicaid and SCHIP. The survey, which was still in the field at the time this report was being prepared, will ultimately provide detailed data on an average of 200 low-income uninsured children in each state, for a total of nearly 10,000 nationwide. (12)
For this first evaluation report, the National Center for Health Statistics developed a preliminary data file and preliminary sample weights. An analysis of these preliminary data is included in Part 2 of this report, in Chapter VII (on families' awareness and perceptions of SCHIP and Medicaid). The analysis focuses on the awareness of SCHIP and Medicaid among parents of low-income uninsured children, their beliefs about their children's eligibility for these programs, their perceptions of SCHIP and Medicaid application processes, their experiences in these programs, and their attitudes toward enrolling their children. An analysis of the complete survey supplement will be conducted later in the study and included in the final report to Congress.
To gather information on specific policy or program topics that were not covered by the overall study, or that emerge in the course of the evaluation, ASPE plans to conduct several targeted studies. In this report to Congress, ASPE has included findings from a special study on family coverage. Other special studies will be conducted for the final report to Congress.
The family coverage study analyzed family coverage policies in three states--New Jersey, Rhode Island, and Wisconsin--that received demonstration authority to cover families, not just children, under Title XXI. The focus of the study was on program design, enrollment, the effect on the private health insurance market, and the impact on children's insurance coverage. The study was based on visits to the three states, during which interviews were conducted with state SCHIP staff, staff of managed care organizations, child health advocates and parents, employers, state insurance agency staff, legislators, and governors' health policy advisors. The information gathered through these interviews and a literature review is presented in full in a report to ASPE (Kaye, Wysen, and Pernice 2001). The findings are incorporated in Part 2 of this report in Chapter XIV (on family coverage).
State SCHIP and Medicaid enrollment data are key sources of data for this evaluation. First, they are being used to select the sample for the survey of enrollees and disenrollees. Second, these data are being analyzed to cast light on program enrollment, disenrollment, retention patterns and movement between the two programs. Enrollment data will be used to describe the SCHIP population--how many children are enrolled, the characteristics of these children, how many children are disenrolled and their characteristics, and net growth in program enrollment. A second focus of analysis is the redetermination process and its outcomes. Finally, the states' administrative data will be matched with data from the enrollee and disenrollee survey, providing a rich source for understanding the relationships and dynamics that underlie program entry and exit of members of the study sample.
In the course of the initial data acquisition for survey sampling, sufficient data were acquired from three of the states (Louisiana, New Jersey, and Texas) to permit preliminary analyses of both retention and reenrollment of children who were previously enrolled (Moreno and Black 2001). Findings from this analysis are described in Part 2 of the report, in Chapter IX (on eligibility redetermination and retention). Later in the study, the program data will be matched to the data from the survey of SCHIP enrollees and disenrollees to conduct an extensive analysis of enrollment patterns, duration of enrollment, reasons for exit, and reenrollment for members of the survey sample.
1. Survey of SCHIP and Medicaid Enrollees and Disenrollees
A unique feature of this evaluation is a telephone survey of SCHIP enrollees and recent disenrollees in ten states, and of Medicaid enrollees and recent disenrollees in two of the ten. This survey will permit the first systematic look across states of the characteristics of the SCHIP population, as well as an assessment of the effects of particular program features on the enrollment experience, experience in the SCHIP program, and reasons for disenrollment. The survey, which will be fielded during 2002 and early 2003 and analyzed during 2003, will collect information from approximately 21,000 children across the ten study states.
The survey instrument was designed to address the detailed evaluation questions spelled out in the design report. To the extent possible, it draws heavily on valid and reliable questions from existing surveys. (13)
The survey asks about:
The survey targets three distinct groups of children: (1) those who enrolled recently, (2)those who have been enrolled for five or more months, and (3) those who disenrolled recently. By targeting children in these distinct groups, the survey will gather data on questions that are salient for each group. (14) For example, the parents of recent enrollees--for whom the experience of enrollment is fresh--will be asked how easy it is to enroll, while the parents of disenrollees--for whom leaving is recent--will be asked why their child left the program.
The analysis of the survey of SCHIP enrollees and disenrollees will provide new descriptive information about program participation behavior and enrollment dynamics--why families enroll and disenroll from SCHIP and Medicaid; coverage transitions (that is, among SCHIP, Medicaid, private coverage and periods without insurance); SCHIP's role as a transitional versus longer-term source of insurance; whether public health insurance programs substitute for private coverage; and access to care, service use and satisfaction with SCHIP and Medicaid. The analysis will also estimate whether SCHIP leads to improvements in access to care, service use, and satisfaction.
To provide a national context for the intensive analysis of the ten study states, the evaluation also includes a survey of the SCHIP program administrators in all 50 states, the District of Columbia, and the five territories. This telephone survey, which will collect information about program design and evolution, will take place in 2003; the analysis, summarizing national trends, will be completed during 2003. In addition to providing basic descriptive information on program design features, the findings will be organized around three topics: (1) reasons why children's health insurance programs are designed as they are; (2) accomplishments and challenges to date, for example, with respect to outreach and enrollment, design of delivery systems and provider networks, and administration of premium and cost-sharing provisions; and (3) pressing new issues requiring attention in the near term.
1. In one third of the states operating both types of programs, the Medicaid portion of the SCHIP initiative represents less than 10 percent of the enrollment, whereas in just over one third, the Medicaid portion is more than half. CMS op. cit.
2. Table 1.1, Family Care Component of 1997-2001 NHIS.
[ www.cdc.gov/nchs/about/major/nhis/released200207/table01_1.htm]
3. As described in the section on evaluation design (see page 15), ASPE required substantial additional time to carry out the required study, and renegotiated the due date for the report with Congressional staff. After all the research components have been completed, a final report will be submitted to Congress in 2004.
4. The contract for the overall study was awarded to Mathematica Policy Research, Inc. (MPR), under contract number HHS-100-01-00002. MPR subcontracted with The Urban Institute and The MayaTech Corporation. The contract began on December 22, 2000, and will end in October 2004.
5. This is the second study of SCHIP to be mandated by Congress. In the legislation creating SCHIP (the Balanced Budget Act of 1997), Congress had already mandated that DHHS submit a report to Congress by December 31, 2001, based on mandated state evaluations. Recognizing this statutory requirement--as well as the need for a more detailed assessment of the performance of the SCHIP programs--the Centers for Medicare & Medicaid Services (CMS), which administers SCHIP, contracted for an evaluation.
The CMS evaluation also is being conducted by MPR (contract number 500-96-0016 [03]). That evaluation is reviewing the literature on the effects of SCHIP; drawing on state data to examine SCHIP enrollment, expenditures, and service use; synthesizing information on program performance from the state evaluations and annual reports; and examining outreach and enrollment processes in eight states using site visits and focus groups. In addition, the study will review trends in the number of uninsured children before and after SCHIP implementation, using data from the Current Population Survey (CPS).
6. Health Systems Research, Inc. (HSR) conducted the focus group study for ASPE (Bellamy et al. 2002).
7. George Washington University and the National Academy for State Health Policy conducted the family coverage study for ASPE (Kaye, Wysen, and Pernice 2001)
8. The 25 states from which the 10 were chosen were: Alabama, Arizona, California, Colorado, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Missouri, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Texas, Utah, and Virginia.
9. The statistical information used for state selection (and reported here) was the most recent available at the time of selection in early 2001. Note that Arizona was originally selected; but, because it was unable to participate, Colorado was selected as its replacement.
10. The states are being paid to provide the data for the evaluation. Therefore, the contractor has entered into subcontracts with each state or its contractor to supply the data.
11. The contractor worked with the states to identify enrolled and disenrolled families and with local groups to identify privately-insured and eligible but not enrolled families. Community agencies such as community health centers and women, infants, and children (WIC) programs also were a supplemental source of families.
12. SLAITS is a random digit dial survey of households that uses computer-assisted telephone interviewing methods.
13. Surveys from which the SCHIP survey drew are: SLAITS, the National Study of America's Families (NSAF), the Medical Expenditure Panel Study (MEPS), the National Health Insurance Study (NHIS), the Community Tracking Study (CTS), the Medicaid CAHPS, the Studies of Section 1115 Medicaid Demonstrations conducted in five states by MPR and in four states by the Urban Institute, and Kaiser Family Foundation Medicaid surveys on barriers to enrollment. In addition, we looked at the set of common questions developed by researchers participating in the Child Health Insurance Research Initiative (CHIRI) and questionnaires developed by Peter Szilagyi and his coworkers for a longitudinal study of SCHIP enrollees in four geographic regions of New York State.
14. Recent enrollees are defined as those who have been enrolled one month or less at the time the sample frame was constructed. Longer-term enrollees are those enrolled five or more months. Recent disenrollees were disenrolled at the time of sample frame construction but were enrolled in the preceding month (In all three cases, however, by the time the sample member is surveyed, additional time will have passed).