Alabama’s Children’s Health Insurance Program (CHIP): Access to Care for Children With and Without Special Needs

1. Alabama’s Children’s Health Insurance Program (CHIP): Access to Care for Children With and Without Special Needs Prepared through a contract with the Children’s Health Insurance Program Alabama Dept of Public Health By UAB Department of Maternal and Child Health CHIP Evaluation Team Beverly A. Mulvihill, PhD, Principal Investigator Joseph Telfair, DrPH, Co-Principal Investigator Frank Mulvihill, PhD, Project Analyst Anita Jackson, BS, Project Coordinator Cathy Caldwell, MPH, Data Manager American Public Health Association Annual Meeting Atlanta 2001

2. State Children’s Health Insurance Program (SCHIP) • Created in 1997 with enactment of Title XXI of the Social Security Act • Generous federal fiscal participation; wide latitude to states for program design; evaluation mandated • Phase I – Medicaid Expansion (February 1998) • Phase II – ALL Kids: State-designed plan (Oct 1998) • Phase III – All Kids Plus: Expanded coverage for children with special needs

3. Program Objective • To reduce the number of uninsured low income children by decreasing financial and administrative barriers for low income families to obtain health insurance for their children

4. CHIP Time Line SEPTEMBER Plan Amendment approved - ALLKids Plus FEBRUARY Phase I - Medicaid expansion began MAY CHIP Commission meeting, Plan Amendment submitted - ALLKids OCTOBER CHIP Commission meeting, Plan submitted OCTOBER Phase II - ALLKids began AUGUST BBA Passed/President signed, Workgroup established. Agency budget hearing SEPTEMBER CHIP Resolution, Initial appropriation & Commission formed AUGUST Plan Amendment approved JANUARY Plan approved - First in nation OCTOBER ALL Kids Plus begins 1997 1998 1999

5. CHIP Coverage(1998) Phase II ALL Kids Medicaid Eligibles Phase I Medicaid Expansion Medicaid for Low Income Families

6. Estimate Of Uninsured Children Under 200 Percent Federal Poverty Level(Alabama-specific data from the National Survey of American Families, Urban Institute, 1997) 49,579 100-200% FPL 91,209 <100% FPL

7. Enrollment Phase Education Outreach Eligibility Enrollment Renewal Disenrollment Utilization Phase Access & Barriers Utilization of Services Quality of Services Consumer Satisfaction CHIP Program Phases

8. CHIP Enrollment Through September 2001(FY 200-2001 Goal = 39,000; Sept 30, 2001= 39,240)

9. ALL Kids Access to Care Survey • Conducted by University of Alabama at Birmingham, School of Public Health, Department of Maternal and Child Health • Survey Population: 26,242 Children enrolled in ALL Kids FY 99 • Data collected between November 1999 and February 2000 • Survey Sample: • Random Sample of 6,200 Parents of ALL Kids Children • 3,738 (60%) surveys returned

10. POPULATION (n=26,242) No Fee 75% (income <150% of FPL) Male - 51% White - 64% Black - 34% Other - 2% 0-12 months - <1% 1-5 years - 12% 6-12 years - 48% 13-18 years - 39% ALL Kids Characteristics • RETURNED (n=3,738) • No Fee • 63% (income <150% of FPL) • Male - 51% • White - 64% • Black - 33% • Other - 3% • 0-12 months - 1% • 1-5 years - 16% • 6-12 years - 49% • 13-18 years - 34%

11. Identifying Children With Special Health Care Needs • Five screening questions were used on the survey • 27% were identified as CSHCN by answering yes to at least one of the screening question • Our sample consisted of parents who sought health insurance for their child. • In 1998 Newacheck et al. examined a cross-section of the population in the NHIS-D survey and found a child disability prevalence rate of 18%. • Among those NHIS-D families who were at or below the federal poverty level, the rate of child disability was 24%.

12. Children with Special Health Care Needs Screener Questions • Does your child require extra or specialized medical care, therapies, diet supplies, medical equipment, nursing or home health care because of a special health need? • Does your child need more assistance than other children the same age with any of the following: eating, dressing, bathing, moving around, going to the bathroom, or playing? • Does your child need more assistance than other children the same age with understanding or using language or learning? • During the past 12 months, have your child’s activities been limited compared to other children the same age because of your child’s physical health? • During the past 12 months, have your child’s activities been limited compared to other children the same age because of your child’s behavioral or emotional health?

13. Income Level of Families Completing Survey

14. Education Level of Persons Completing Survey

15. Age of ALL Kids Child

16. Gender of ALL Kids Child

17. Race of ALL Kids Child

18. Has Health Insurance Ever Been Available

19. Why Child Did Not Have Health Insurance

20. Measuring Differences Between CSHCN and No Special Needs in Direction of Change Before and After CHIP • Diminished Care: had more problems accessing health care after CHIP than before • No Difference: no change in accessing health care after enrolling in CHIP • Improved Care: had fewer problems accessing health care after CHIP than before

21. One Person/Group Child Sees When Sick p = .02

22. One Person/Group Child Sees for Routine Care NS

23. Child Needed Care But Could Not Get It p <.001

24. Waited Longer Than Should Have For Medical Care p <.001

25. Child Needed Specialty Care But Could Not Get It p <.001

26. Dental Care p <.001

27. Vision Care p <.001

28. Prescription Medicine p <.001

29. Summary • Characteristics of CSHCN and their families compared to those without special needs • More below 150% of Federal Poverty Level • Fewer high school graduates • More CSHCN among older children, especially adolescents • More males • No differences between racial/ethnic groups

30. Summary (con.) • Children with and without special needs reported improved access to care on nearly all items measured • Compared to children without special needs, proportionately more CSHCN experienced improved access to care after enrolling in CHIP • When parents reported having a usual source of care for their sick child, there was a small difference between the groups, but no differences were reported for routine care. On all other measures (needing care, waiting too long for care, and services such as specialty care, dental, vision, and prescription medicine), parents of CSHCN reported significantly greater access after enrolling in CHIP than their counterparts without special needs.

31. Survey Conclusions and Implications • More children with and without special needs have health insurance in Alabama than before SCHIP • Access to health care has improved for all children in ALL Kids • More children have a regular health care provider • Fewer children are going without needed medical care • Medical care can be accessed in a more timely manner • Compared to those without a special needs child, families who perceive their child as having a special health care need experienced significantly more improved access to health care after enrolling in CHIP • In Alabama there is a large network of providers available (BC/BS has 85% of insurance market) and a rich benefit package • Families who need and know about affordable and accessible health insurance will respond to outreach efforts • Despite preliminary indications of improved access to care for CSHCN who enroll in CHIP, we do not know if substantial gaps in services for this population still exist. On-going investigation is needed regarding the effectiveness of ALL Kids and ALL Kids Plus to meet the needs of CSHCN. • Met FY 2001 goal of having 39,000 children enrolled in ALL Kids • Many families still have not been reached – continue efforts to decentralize outreach and marketing activities