OCTOBER 2006 HOT TOPIC

Filling the Health Care Gap for Children: How Is SCHIP Faring?

Based on the most recent figures, more than 8 million children are without health insurance in the United States. Many of these children fall into a gap—they live in families that are too “rich” to qualify for Medicaid but too “poor” to have private insurance coverage.

When Congress created the State Children's Health Initiative Program, or SCHIP, in August 1997, the goal was to help fill this gap by providing states with funding to cover children from families with incomes 100 to 200 percent above the federal poverty level. Now, as Congress is poised to debate reauthorizing SCHIP in 2007, it is a good time to step back and assess the impact SCHIP has had.

A series of studies within the RAND Corporation's Health Program examines SCHIP in terms of such issues as access and quality of life, and can help policymakers better understand how SCHIP is doing nearly a decade out.

More Than Just Insurance

If children can get good primary care, their health improves, racial and ethnic disparities in health care decrease, and overall health care costs go down. One of the keys to ensuring good primary care is, of course, ensuring that more children have access to health insurance, which is what SCHIP aims to do. Three RAND studies address access issues.

The first study, which analyzed 2000 and 2001 survey data from the National Center for Health Statistics, found that about 35 percent of SCHIP-eligible children are not enrolled in SCHIP or any other insurance program, and identified three reasons for this. First, children in states that set up SCHIP as an expansion of Medicaid were four times more likely to be enrolled than children in states with freestanding programs for a number of reasons, including that Medicaid expansion generally offered more generous benefits and required less cost sharing than separate SCHIPs. Second, children are less likely to be enrolled if they live in a household in which English is a second language. And third, many parents believe SCHIP is too costly, even though it is free or very inexpensive.

But in a second study, RAND researchers found that ensuring financial access to health insurance is only part of the solution. Focusing on parents of elementary-school children in a large urban district in California, researchers found that potential access—ensuring that the child has a regular health care provider to take advantage of that financial access—and realized access—ensuring that the child actually receives care when it is needed from that regular health care provider—are just as important as having access to health insurance in the first place. Disparities in care across racial and ethnic lines virtually disappear when researchers account for the effects of having a regular provider, getting care when needed, and parents' primary language.

Finally, working with data from the 2001 California Health Interview Survey, researchers examined primary-care experiences of children with multiple risk factors, such as race/ethnicity and household poverty status. The results showed that children with multiple risk factors—the most vulnerable children—have poorer health and are less likely to have a regular provider.

Beyond Access—Improving Quality of Life

The ultimate goal of SCHIP is not merely to ensure that children have realized access to primary care: It is to improve health outcomes for children as a result of that access. Another RAND study examined this issue by following a sample of California families (with nearly 3,500 children ages 2 to 16) that had recently enrolled in the state's SCHIP.

In surveying families at three points in time—the beginning of enrollment, one year in, and two years in—researchers found that children enrolled in the state's SCHIP had less forgone care—defined as needed care that is not received—and fewer problems seeking care. SCHIP also reduced ethnic- and language-group disparities in access.

But more important, the study found that these access improvements translated into real gains in low-income children's health-related quality of life—as assessed on the Pediatric Quality of Life Inventory, which measures a range of outcomes—physical, social, emotional, and school-related—on a single 100-point scale.

More specifically, children who reported no forgone care and no problems getting care scored about 8 percentage points higher than those who reported some forgone care—a difference that is clinically important. To put this difference into clinical perspective, the scores for children with forgone care in both Year 1 and Year 2 are similar to those of newly diagnosed pediatric cancer patients receiving treatment. Parent-reported information on children's health-related quality of life showed similar results.

INTERVIEW

The Way Forward: Thoughts on the Future of SCHIP Michael Seid is a psychologist and RAND behavioral/social scientist who was formerly the Associate Director for Research, Center for Child Health Outcomes at Children's Hospital and Health Center, San Diego. His research focuses on measuring and improving pediatric health care quality and health-related quality of life for chronically ill children. He has served as a member of the Health Care Quality and Effectiveness Research Study Section at the Agency for Healthcare Quality and Research (AHRQ) and on several national and local expert panels. Nearly 10 years out now, what do we know about SCHIP's effectiveness? Our research shows that SCHIP improves access—financial, potential, and realized access—and that SCHIP and other programs (like Medicaid) can substantially reduce racial and ethnic disparities in health. But perhaps even more important, these improvements in access actually improve children's quality of life. All in all, this makes SCHIP a successful program, and policymakers should take this into account. Despite its success, more than a third of eligible families aren't enrolled in SCHIP? How can take-up rates be increased? Improving awareness about SCHIP would obviously help; many of those who are eligible don't realize that it's either free or very low cost. But beyond that, we found that not all programs are created equal. States were given a lot of latitude in implementing programs, and the research shows that programs that expand on Medicaid are a lot more effective than freestanding programs at increasing take-up rates. Given how important potential and realized access are, what can policymakers do to improve such access? When it comes to improving both potential and realized access, more gains are possible with policies and programs that both facilitate a regular source of care and ensure the receipt of necessary care. For the former, this could mean health plans that have open panels so that new enrollees would not have to change an existing provider—or, if no regular provider exists, having mechanisms in place to actively link new enrollees based on geographic accessibility and/or language. For the latter, this could mean having nurse help-lines or extended office or urgent care hours. How about ways to enhance SCHIP's effectiveness in reducing racial and ethnic disparities? The research shows that children with multiple risk factors are most vulnerable. Unfortunately, strategies to reduce disparities in primary care tend to take a fragmented approach of targeting single risk factors. To make substantial gains, strategies must be tailored to address co-occurring risks; this means, for example, simultaneously addressing financial barriers to pediatric care (such as insurance gaps) and such nonfinancial barriers as health literacy (reflected, in part, by education level) and language and cultural barriers (such as linguistic and cultural competence). Expanding the pool of qualified medical interpreters could make a big difference in addressing such nonfinancial barriers. Any final thoughts? The ultimate measure of any program like SCHIP is whether it actually improves health outcomes. We now know from our research that when it comes to at least one outcome—quality of life—SCHIP, which improves realized access to care, has a significant positive effect. If policymakers and the public value programs that improve children's quality of life, SCHIP's pending reauthorization gives them the opportunity to continue to fund a program proven to do just that.

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