The impacts of schip on insurance coverage for low income children
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The Impacts of SCHIP on Insurance Coverage for Low-Income Children. Lisa Dubay and Genevieve Kenney The Urban Institute Academy Health Meetings June 2004. Background. The State Children’s Health Insurance Program created in August 1997 All states have expanded coverage under SCHIP

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The Impacts of SCHIP on Insurance Coverage for Low-Income Children

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The impacts of schip on insurance coverage for low income children

The Impacts of SCHIP on Insurance Coverage for Low-Income Children

Lisa Dubay and Genevieve Kenney

The Urban Institute

Academy Health Meetings

June 2004


Background

Background

  • The State Children’s Health Insurance Program created in August 1997

  • All states have expanded coverage under SCHIP

  • States given latitude over structure of programs

  • States simplified enrollment process and engaged in unprecedented levels of outreach

  • Measuring impact of SCHIP is complicated by concurrent changes in the economy and health insurance market


Cross sectional studies

Cross-Sectional Studies

  • Buchmueller and LoSasso (2004)

  • Dubay, Kenney, Hill (2002)

  • Cunningham, Hadley, Reschovsky (2002)

  • Cunningham (2002)

  • Davidoff et al. (forthcoming)


Longitudinal studies

Longitudinal Studies

  • Shenkman et al. (2002)

  • Shenkman et al. (2002)

  • St. Peter et al. (2002)


Our objectives

Our Objectives

  • Develop estimates of impact of SCHIP and other policy changes on insurance coverage

    • SCHIP/Medicaid coverage

    • employer-sponsored coverage

    • private non-group coverage

    • uninsurance

  • Estimate the share of increase in Medicaid/ SCHIP coverage attributable to reductions in uninsurance and in employer-sponsored coverage


The impacts of schip on insurance coverage for low income children

Data

  • 1997, 1999, and 2002 National Survey of America’s Families (NSAF)

    • nationally representative household survey

    • over-samples low-income population

    • over-samples populations in 13 states

    • interviews conducted in English and Spanish

    • includes telephone and non-telephone households

  • Collects information on range of measures

    • health insurance coverage and socioeconomic characteristics of children, parents, and families


Medicaid and schip eligibility model

Medicaid and SCHIP Eligibility Model

  • Three eligibility groups

    • TANF-related Medicaid

    • Poverty-related Medicaid

    • SCHIP

  • Detailed eligibility model

    • creates eligibility units

    • uses state-specific TANF, Medicaid and SCHIP rules regarding income, disregards, assets, and income deeming


Methodological approach to assessing impacts of expansions in coverage

Methodological Approach to Assessing Impacts of Expansions in Coverage

  • Examine change over time for two treatment groups:

    • newly eligible under SCHIP

    • already eligible for Medicaid under poverty-related expansions

  • Examine change over time for a comparison population

  • Use the experience of the comparison population as a counterfactual for what would have happened in the absence of the policy changes

  • Use multivariate methods to control for:

    • differences in the composition of the treatment and comparison groups

    • changes in the composition of the treatment and/or comparison groups between the pre- and post-period


There is no perfect comparison group

There Is No Perfect Comparison Group

  • Similar to SCHIP-eligible group, but not affected by the policy change

  • Children with family incomes between 50 and 100 percentage points above the SCHIP eligibility threshold.


Control variables

Control Variables

  • Child and family characteristics including: age, race, health status of child, education, industry and firm size of working parent, income, marital status of parents, and state of residence.

  • Two different controls for insurance costs faced by families:

    • Weighted average ESI premium in the county

    • Weighted average ESI premium or ESI contribution in the county, depending on whether an offer in the household.


Insurance distribution of schip eligible group 1997 1999 and 2002

Insurance Distribution of SCHIP Eligible Group 1997, 1999, and 2002

Source: 1997, 1999, and 2002 National Survey of America’s Families

* Estimate is significantly different than estimate for 1997 at 0.05 level


Insurance distribution of medicaid poverty related eligible group 1997 1999 and 2002

Insurance Distribution of Medicaid Poverty-Related Eligible Group, 1997, 1999, and 2002

Source: 1997, 1999, and 2002 National Survey of America’s Families

* Estimate is significantly different than estimate for 1997 at 0.05 level


The impacts of schip on insurance coverage for low income children

Impacts on Insurance Coverage of Medicaid and SCHIP-Eligible Children: Difference-In-Difference Results Using Premiums as Control

SCHIP-Eligible

Medicaid/Poverty-Related

 Medicaid/SCHIP

Employer

Uninsured

Private

Source: 1997, 1999, and 2002 National Survey of America’s Families

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The impacts of schip on insurance coverage for low income children

Impacts on Insurance Coverage of Medicaid and SCHIP-Eligible Children: Difference-In-Difference Results Using Premiums, Contributions and Offers as a Control

SCHIP-Eligible

Medicaid/Poverty-Related

 Medicaid/SCHIP

Employer

Uninsured

Private

Source: 1997, 1999, and 2002 National Survey of America’s Families

14


What was expected under schip

What Was Expected Under SCHIP?

“On the basis of a review of the literature and analyses of participation in the Medicaid program, CBO estimates that 60 percent of the participants in S-CHIP would otherwise have been uninsured. The remaining 40 percent would have had some other form of coverage.” CBO February 1998


Crowd out estimates

Crowd-Out Estimates


Take up estimates

Take-Up Estimates


What is going on with take up

What is going on with take-up?

  • Preliminary estimates suggest that 80 percent of Medicaid eligible and 70 percent of SCHIP eligible children have parents who would enroll if told their children were eligible

  • Only about 50 percent of uninsured eligible children have parents who have heard of Medicaid or SCHIP and understand the rules

  • Among eligible children with employer-sponsored coverage, about 15 percent have parents who would drop their coverage and enroll if told their children were eligible


Future steps

Future Steps

  • Test for endogeneity of offer rates

  • Use HIS and NSAF to assess impacts on access and use using DD and instrumental variable techniques

  • Use SIPP to examine SCHIP impacts


Food for thought about crowd out and incremental reform

Food For Thought About Crowd-Out and Incremental Reform

  • Private coverage still mainstay for SCHIP- eligible children

  • Potential financial benefits to families and firms

  • Potential adverse effects of churning in insurance coverage on continuity of care for children who switch in and out of different types of coverage

  • Horizontal equity

  • In light of recent Medicare drug benefit to the elderly, how much should we be concerned about crowd-out among low-income children?

  • Increasing participation should be the current focus


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