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SCHIP: What's Happening? What's Next?
What Will We Know About SCHIP's Success?
Alan Weil, J.D., M.P.P., Director, Assessing the New Federalism Project, The Urban Institute, Washington, DC.
John Holahan, Ph.D., Director, Health Policy Research Center, The Urban Institute, Washington, DC.
Wendy J. Wolf, M.D., M.P.H., Senior Policy Fellow, Office of the Administrator, Agency for Health Care Policy and Research (AHCPR) and the Health Resources and Services Administration (HRSA), Rockville, MD.
Gregory A. Vadner, M.P.A., Missouri Department of Social Services, Jefferson City, MI.
David Parrella, Ph.D., Connecticut Department of Social Services, Hartford, CT.
Sandra Shewry, M.S.W., M.P.H., California Managed Risk Medical Insurance Board, Sacramento, CA.
Mr. Weil opened this session stating that success is judged by those who hold you accountable (the public and elected officials), who are influenced by communities of interest, who often amplify their voices through the media. The implicit State Children's Health Insurance Program (SCHIP) premise is that providing insurance to a child equals better health outcomes. The insurance card leads to access, utilization, medical home, and security.
To quantify the success of SCHIP, States can initially look at the number of enrolled and document their previous insurance status. Once the program has been implemented for some time, States can then look at utilization of services, continuity of coverage and source of care, consumer confidence in obtaining care, and quality of care. Qualitative success can be measured by administrative smoothness and simplicity and program design.
Dr. Holahan reported on findings from the Urban Institute's 1997 Assessing the New Federalism survey, which provides a baseline of information for 13 States prior to SCHIP implementation. The survey examined how access to and use of health services varied for children by insurance status and income.
Overall, uninsured children, from families both below and above 200 percent of the Federal poverty level (FPL) had no usual source of care and used the emergency room more often than children with private or public insurance. Uninsured children were less likely to have at least one well-child visit per year and less likely to have at least one visit to the doctor a year. A significant number of parents of uninsured children were not confident that they could obtain needed care for their children, compared with parents of children with private or public insurance.
The Urban Institute will continue to assess whether SCHIP:
- Reduces the rate of uninsurance among the eligible population.
- Leads to crowd-out of the private coverage.
- Improves parents' confidence that they can obtain needed health care for their family.
- Increases the use of preventive care.
- Decreases unmet health care needs for low-income children.
Dr. Wolf recognized the problems States face when trying to evaluate the quality and performance of SCHIP:
- Lack of good baseline data.
- Inadequate data information systems for baseline, tracking, and comparisons.
- Lack of measurement uniformity across States and across measurement systems.
- No mechanism for risk adjustment.
- The possible fluctuation of insurance status of SCHIP kids, thereby limiting enrollment duration.
This being said, Dr. Wolf gave examples of national/Federal data sources that may help assess SCHIP, which include:
- Behavioral Risk Factors Surveillance Systems (BRFSS).
- Youth Risk Behavior Survey (YRBS).
- National Health Interview Survey (NHIS).
- Medical Expenditure Panel Survey (MEPS)
- Early Childhood Longitudinal Survey.
However, each has limitations and may not actually be that helpful in measuring quality or performance in the short term on a State-by-State basis.
The three State respondents as well as workshop participants reiterated that the Federal tools do not address or meet the needs of States for evaluation (i.e., the Consumer Assessment of Health Plans Survey [CAHPS®] is only available in English). Also, with the 10 percent administrative cap, State expenditures are limited, and States often cannot afford to conduct surveys to the extent they would like. Concerns were also voiced about cost effectiveness:
- Where do we draw the line between the cost of evaluating and the cost of providing care?
- Will States be required to spend more money on processes rather than on services?
Riley T. How will we know if SCHIP is working? Health Aff 1999 Mar/Apr;18(2):64-6.
Selden SM, Banthin JS, Cohen JW. Waiting in the wings: eligibility and enrollment in the State Children's Health Insurance Program. Health Aff 1999 Mar/Apr;18(2):126-34.