Findings from the Child Health Insurance Research Initiative (CHIRI)™)

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Child Health Insurance Research Initiative (CHIRI™)

Children with Special Health Care Needs

CHIRI™ Issue Brief No. 9. Mental Health Needs of Low-Income Children With Special Health Care Needs (2009). Karen VanLandeghem and Cindy Brach.

Low-income and minority children with special health care needs (CSHCN) have higher rates of mental health problems yet are less likely than their counterparts to receive mental health services. Families play a crucial role in obtaining and coordinating care for CSHCN, including mental health services. Researchers found that mental health issues were second only to asthma as the top health problems in CSHCN as reported by their families. More than one-third of CSHCN had a mental health problem, but only one-quarter of caregivers recognized the need for mental health services in their children.

CHIRI™ Issue Brief No. 9 is available online (PDF File, 545 KB; Plugin Software Help), or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 09-0033).

Improved Health Care Among Children With Special Health Care Needs After Enrollment Into the State Children's Health Insurance Program. (2007). Peter G. Szilagyi, Laura P. Shone, Jonathon D. Klein, Alina Bajorska, Andrew W. Dick

Little is known about the impact of SCHIP on children with special health care needs (CSHCN). In a study of CSHCN who were enrolled in the New York SCHIP program, enrollment was associated with improved access to health care, continuity of care, and quality of care, as reported by parents. Unmet needs for prescription medications declined 3-fold for all study sub-groups (e.g., from 36 percent to 9 percent among the previously uninsured). Unmet needs for specialty care declined more than 4-fold among CSHCN who were previously insured (48 percent to 10 percent) or had mental health or behavioral disorders (32 percent to 2 percent). The authors conclude that enrollment in the New York SCHIP program improves health care for CSHCN. For more details, go to "Improved Health Care Among Children With Special Health Care Needs After Enrollment Into the State Children's Health Insurance Program," in the January 2007 issue of Ambulatory Pediatrics, 7(1), pp. 10-17.

The Impact of Managed Care Enrollment on Emergency Department Use Among Children with Special Health Care Needs (2006). Harold A. Pollack, John R. Wheeler, Anne Cowan, and Gary L. Freed

This study examined the impact of managed care enrollment on emergency department use in children with special health care needs (CSHCN) who were dually enrolled in Michigan's Medicaid program and the State's Title V MCH Services Block Grant program for CSHCN. These enrollees were served by Special Health Plans (SHPs)-managed care plans designed specifically to serve CSHCN, including a strong care coordination component. Enrollment in the plan was associated with a 23 percent reduction in the rate of emergency department use among CSHCN. Study results suggest that key characteristics of this managed care model, particularly selection of a principal coordinating doctor and development of an Individualized Health Care Plan for enrollees, are associated with reductions in emergency department use among CSHCN. For more details, go to "The Impact of Managed Care Enrollment on Emergency Department Use Among Children with Special Health Care Needs," in the February 2007 issue of Medical Care 45(2), pp. 139-45.

Policy Brief No. 6: From SCHIP Benefit Design to Individual Coverage Decisions (2006). Anne Markus, Sara Rosenbaum, Ruth E.K. Stein, Jill Joseph.

This Policy Brief explores the coverage decisions of private insurers for children with special health care needs (CSHCN) in six States with separate State Children's Health Insurance Programs (SCHIP). Study States limited or excluded similar benefits for CSHCN enrolled in SCHIP, although the nature of the limitations or exclusions varied. When SCHIP insurers made coverage determinations in response to hypothetical case scenarios posed by the researchers, there was significant variation in coverage decisions. With one exception, insurers did not agree on the coverage of any specific service. The study also found that: (1) SCHIP insurers often provided coverage beyond State SCHIP limits and exclusions; (2) insurers were more likely to impose exclusions for less acute conditions; and (3) in the majority of study States some insurers excluded services that should have been covered according to State plan/contract language. Researchers concluded that external reviews of insurers' coverage decisions and coordination with other sources of care are important components of SCHIP program design.

CHIRI™ Issue Brief No. 5. SCHIP Enrollees with Special Health Care Needs and Access to Care (2006). Karen VanLandeghem, Jennie Bonney, Cindy Brach, and Lisa Kretz.

Numerous factors—such as restrictions on health care coverage and insufficient provider participation—can limit access to care for children enrolled in public insurance programs, particularly children with special health care needs (CSHCN). This CHIRI™ Issue Brief summarizes findings regarding: health care access and satisfaction of CSHCN enrolled in SCHIP, services that were limited and/or excluded under SCHIP in some of the study States, and how SCHIP design decisions can limit coverage for CSHCN.

In general, CSHCN enrolled in SCHIP did not experience any problems in obtaining a primary health care provider or routine specialty services. However, certain specialty services were difficult to obtain in some study States that imposed limits and/or exclusions on certain services or were ambiguous in defining a standard of medical necessity. In addition, income restrictions and/or medical condition criteria made it difficult to access supplemental services from other Federal and State programs for CSHCN with severe chronic health conditions in some of the study States.

CHIRI™ Issue Brief No. 5 is available online or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 06-0051).

Race, Urban Community Stressors, and Behavioral and Emotional Problems of Children with Special Health Care Needs (2005). Kim D. Jaffee, Gilbert C. Liu, Janie Canty-Mitchell, Rong Amy Qi, Joan Austin, and Nancy Swigonski

Do community-level stressors have an impact on behavioral and emotional problems among African-American and white children with special health care needs (CSHCN)? Researchers collected information about CSHCN sociodemographic characteristics as well as behavioral and emotional problems, health status, perceptions of urban community stress, and health care access and satisfaction to determine racial differences in the impact of urban stress on behavioral and emotional problems. Urban community stressors, race, and child's health status were significantly associated with behavioral and emotional problems among CSHCN. The authors conclude that when caring for CSHCN, especially those with emotional or behavioral problems, primary care providers may be better able to identify important aggravating factors if they also assess urban stress. They note that comprehensive systems of care are needed to assist in addressing urban community-level stressors. For more details, see "Race, Urban Community Stressors, and Behavioral and Emotional Problems of Children with Special Health Care Needs" in the January 2005 issue of Psychiatric Services 56(1), pp. 63-69.

Health-Related Quality of Life in Publicly Insured Children with Special Health Care Needs (2005). Janie Canty-Mitchell, Joan K. Austin, Susan M. Perkins, Rong Amy Qi, and Nancy Swigonski

Researchers examined the demographic characteristics and health-related quality of life (HRQOL) among CSHCN at an urban community health center to determine racial differences and examine child, parent, health care and environmental characteristics associated with HRQOL. Nearly one-third of the randomly selected publicly insured children who kept their routine clinic visit had a special health care need. Physical and psychosocial HRQOL were significantly lower than national benchmarks. Poorer psychosocial HRQOL was associated with more health problems and urban life stressors. The authors conclude that comprehensive and coordinated care is essential in order to meet the diverse physical and psychosocial needs of CSHCN. For more details, see "Health-Related Quality of Life in Publicly Insured Children with Special Health Care Needs " in the 2005 issue of Children's Health Care 34(1), pp. 1-18.

Behavioral and Mental Health Problems in Low-Income Children with Special Health Care Needs (2004). Janie Canty-Mitchell, Joan K. Austin, Kim Jaffee, Rong Amy Qi, and Nancy Swigonski.

What are the behavioral and mental health problems and needs of low-income children with special health care needs (CSHCN)? Researchers examined caregiver perceptions of mental health problems and counseling needs in low-income CSHCN, using the Child Behavior Checklist (CBCL) and an investigator-designed questionnaire. Findings indicate that 38 percent of CSHCN had a behavioral or mental health problem, but only 26 percent of caregivers perceived the need for treatment or counseling. The authors conclude that because caregivers do not always recognize behavior and mental health problems, CSHCN should be assessed for these problems during routine health care visits and referred to appropriate services. For more details, see "Behavioral and Mental Health Problems in Low-Income Children with Special Health Care Needs" in the June 2004 issue of the Archives of Psychiatric Nursing 18(3), pp. 79-87.

Children with Special Health Care Needs Enrolled in SCHIP: Patient Characteristics and Health Care Needs (2003). Peter G. Szilagyi, Elizabeth Shenkman, Cindy Brach, Barbara J. LaClair, Nancy Swigonski, Andrew W. Dick, Laura P. Shone, Virginia A. Schaffer, Jana F. Col, George Eckert, Jonathan D. Klein, and Eugene M. Lewit.

The prevalence of children with special health care needs (CSHCN) was higher among SCHIP enrollees than the general population in the four CHIRI™ study States (Indiana, Kansas, Florida and New York). CSHCN were similar to children without special health care needs, but CSHCN had poorer health status, were more likely to have had unmet needs, and were more likely to use the emergency department, mental health care, specialty care, and acute care in the year prior to enrolling in SCHIP than children without special health care needs. The authors draw four implications for monitoring and improving SCHIP for CSHCN. This article is one of a collection of papers on SCHIP enrollees published in the December 2003 supplement to Pediatrics. Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO17).

Congruence Between Parents' and Adolescents' Reports of Special Health Care Needs in a Title XXI Program (2003). Lise M. Youngblade and Elizabeth A. Shenkman.

The purpose of this study was to examine agreement between adolescents enrolled in Florida's SCHIP program and their parents about whether or not the adolescent had a special health care need, using the Children with Special Health Care Needs (CSHCN) Screener. Adolescents and their parents frequently agreed as to whether or not the adolescent had a chronic condition, but a full 15 percent of pairs disagreed. The level of agreement is higher using the consequence-based CSHCN Screener than is typically reported for diagnosis-based approaches. Parents reported adolescents' chronic conditions more often than adolescents, most strikingly for mental health conditions. Pairs with older adolescents, female adolescents, and who were Hispanic were more likely to be congruent than their counterparts. These findings are relevant to work related to the use of tools such as the CSHCN Screener in profiling enrollees in healthcare programs that serve children and adolescents. For more details, see "Congruence between Parents' and Adolescents' Reports of Special Health Care Needs in a Title XXI Program," in the September 2003 issue of the Journal of Pediatric Psychology 28(6), pp. 393-401.

Emergency Department Use Among Children with Special Health Care Needs: An Introductory Study (2002). Harold A. Pollack, Kevin J. Dombkowski, Janet B. Zimmerman, Matthew M. Davis, Anne E. Cowan, John R. Wheeler, A. Craig Hillemeier, and Gary L. Freed.

This article describes the patterns of emergency department (ED) use among Michigan children who are dual-enrolled in Medicaid and Michigan's Title V Children's Special Health Care Services (CSHCS) program. High rates of ED use were displayed among dual-enrolled children less than 1 year of age and those diagnosed with anemia, hemophilia, asthma, epilepsy, and juvenile diabetes. Although race, location, and other demographic variables have statistically significant effects, the complexity and severity of children's illnesses are the most important source of variation in ED use among children with special health care needs. The authors conclude that clinical and policy interventions designed to promote appropriate ED use must not only address important socio-demographic disparities and adverse incentives, but must also address the challenge of appropriately managing complex and persistent conditions over time. The need to understand sources of variations in children's health services use—and the related need to understand how such variation is influenced by health policy and service delivery—is particularly acute as States seek to enroll children with special needs into managed care arrangements. For more details, see "Emergency Department Use Among Children with Special Health Care Needs: An Introductory Study," in the June 2004 issue of Health Services Research 39(3), pp. 665-692.

Policy Brief No. 5: Behavioral Health and Managed Care Contracting Under SCHIP (2002). Sara Rosenbaum, Colleen Sonosky, Karen Shaw, D. Richard Mauery.

This Policy Brief examines behavioral health managed care contracting under separately administered SCHIP. Of the 27 separate SCHIP programs reporting any managed care services in 2000, 15 purchased services from managed care organizations using freestanding contract instruments, that is, contracts that are wholly independent of the Medicaid contract and stand on their own as legal instruments, while 12 used a modified Medicaid contract. Every State that covers any level of behavioral disorders as a contractual benefit applies limitations and exclusions that would not be permissible in the Medicaid program (e.g., limits on inpatient days and outpatient services).

Policy Brief No. 2: State Benefit Design Choices under SCHIP—Implications for Pediatric Health Care (2001). Sara Rosenbaum, Anne Markus, Colleen Sonosky, Lee Rapasch.

This Policy Brief examines the extent to which State agencies adopt conventional insurance norms or adhere to special principles of Medicaid coverage design for children in designing separately administered (or freelancing) SCHIP programs. The issue of coverage design is particularly relevant for children with low prevalence conditions and special health care needs. Increasingly, conventional insurance uses standardized coverage norms to limit coverage and treatment. These standardized norms take the form of across-the-board treatments and exclusions, limited definitions of medical necessity, and the use of irrebuttable, standardized treatment guidelines in determining when covered treatments will be available. All of these practices are impermissible under Medicaid, which uses exceptionally broad preventive standards to determine coverage of children; such standards favor coverage of children with low prevalence problems.

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Minority Children

Effects of Primary Care Case Management (PCCM) on Medicaid Children in Alabama and Georgia: Provider Availability and Race/Ethnicity (2006). E. Kathleen Adams, Janet M. Bronstein, and Curtis S. Florence.

PCCM programs are designed to increase patients' use of primary and preventive care in doctors' offices while decreasing use of specialty and urgent care by assigning Medicaid enrollees to gatekeeper providers who make referrals for specialty, emergency, and inpatient care. Researchers examined the impact of PCCM implementation on children's use of primary and preventive care by race/ethnicity. Reductions in primary and preventive care use under Medicaid PCCM in Alabama and Georgia were more dramatic for minority children. The authors conclude that implementation of PCCM without fee increases may affect decisions of providers to participate in Medicaid which, in turn, may have unexpected negative effects that differentially impact minority children. More details are available in "Effects of Primary Care Case Management (PCCM) on Medicaid Children in Alabama and Georgia: Provider Availability and Race/ethnicity," in the February 2006 issue of Medical Care Research & Review 63(1), pp. 58-87.

Reduction in Racial and Ethnic Disparities After Enrollment in the State Children's Health Insurance Program (2005). Laura P. Shone, Andrew W. Dick, Jonathan D. Klein, Jack Zwanziger, and Peter G. Szilagyi.

How does SCHIP impact racial/ethnic disparities among enrollees? Researchers found that enrollment in the New York SCHIP program—Child Health Plus—improved access, continuity, and quality of care for enrollees from racial/ethnic groups and reduced preexisting racial/ethnic disparities in health care access, unmet need, and continuity of care. In spite of these improvements, racial/ethnic disparities in quality of care remained. The authors conclude that SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care. "Reduction in Racial and Ethnic Disparities After Enrollment in the State Children's Health Insurance Program" was published in the June 2005 issue of Pediatrics 115(6), pp. e697-e705.

The Role of Race and Ethnicity in SCHIP in Four States: Are There Baseline Disparities, and What Do They Mean for SCHIP? (2003). Laura P. Shone, Andrew W. Dick, Cindy Brach, Kim S. Kimminau, Barbara J. LaClair, Elizabeth A. Shenkman, Jana F. Col, Virginia A. Schaffer, Frank Mulvihill, Peter. G. Szilagyi, Jonathan D. Klein, Karen VanLandeghem, and Janet Bronstein.

This paper assesses baseline levels of health disparities in health status and health care experiences among children enrolling in SCHIP in Alabama, Florida, Kansas and New York. A significant proportion of SCHIP enrollees were black or Hispanic. Relative to white children, minority children had lower income families, and were in poorer health, and less likely to have had a regular source of health care or private insurance prior to enrolling in SCHIP. The authors conclude that SCHIP has the potential to reduce disparities among enrollees, and underscore the importance of monitoring program outcomes by race and ethnicity to ensure equity across groups. This article is one of a collection of papers on SCHIP enrollees published in the December 2003 supplement to Pediatrics. Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO16).

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State CHIP and Medicaid Design Choices

CHIRI™ Issue Brief No. 8. Impact of Primary Care Case Management (PCCM) Implementation in Medicaid and SCHIP (2009). Karen VanLandeghem and Cindy Brach.

PCCM systems are designed to increase patients' use of well-child and primary care in physician offices while decreasing use of specialty care and emergency department use. Researchers studied the impact of implementing PCCM systems in Alabama and Georgia. Children enrolled in the Alabama and Georgia Medicaid programs were less likely to use emergency departments, but were also less likely to use well-child and other primary care after PCCM implementation. Physician participation in Alabama and Georgia Medicaid also declined. The transition to PCCM can be disruptive to established patterns of provider participation and enrollees' use of health care. Efforts to ensure continuity of care and provider participation during PCCM transition might be addressed through public insurance program design and targeted education and outreach strategies to enrollees.

CHIRI™ Issue Brief No. 8 is available online (PDF File, 610 KB; Plugin Software Help), or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 09-0020).

CHIRI™ Issue Brief No. 7. Do SCHIP Enrollees Stay Insured? (2008). Karen VanLandeghem and Cindy Brach.

SCHIP has helped increase insurance rates by providing coverage to low-income children whose families earn too much to qualify for Medicaid but lack private coverage, and by increasing Medicaid enrollment through SCHIP outreach and enrollment efforts. Achievements in reducing uninsurance rates can only be sustained, however, if low-income children retain public insurance or transition to private insurance coverage.

Researchers studied the impact of SCHIP enrollment on low-income children's public and private insurance coverage in the short-term. Over three-quarters of SCHIP enrollees were publicly insured (Medicaid or SCHIP) at least one year after enrollment, while some SCHIP enrollees (4 percent to 15 percent) obtained private insurance coverage after leaving SCHIP. SCHIP retention was increased by a simplified renewal policy that automatically reenrolled children in SCHIP unless their families submitted reenrollment forms indicating a change affecting their eligibility.

CHIRI™ Issue Brief No. 7 can be downloaded as a PDF file, 300 KB; (Plugin Software Help) or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 08-0057).

Crowd-Out in the State Children's Health Insurance Program (SCHIP): Incidence, Enrollee Characteristics and Experiences, and Potential Impact on New York's SCHIP (2008). Laura P. Shone, Paula M. Lantz, Andrew W. Dick, Michael E. Chernew, and Peter G. Szilagyi

The extent to which the State Children's Health Insurance Program (SCHIP) displaces or "crowds-out" private insurance whereby individuals drop private insurance coverage to obtain public insurance coverage remains a topic of interest for many policymakers. Researchers studied the incidence of crowd-out, and whether enrollee characteristics were associated with crowd-out, in the New York SCHIP program. Crowd-out was relatively modest in New York SCHIP: only 7 percent of SCHIP enrollees were deemed enrolled due to crowd-out. Crowd-out was associated with some enrollee characteristics including income but not health status. Researchers conclude that most movement from private insurance to enrollment in New York SCHIP was not the result of crowd-out. States are encouraged to implement ongoing, detailed monitoring methods to determine crowd-out in SCHIP. For more details, see the 2008 issue of the Health Services Research 2008 Feb;43(1 Pt 2):419-34.

The Impact of Managed Care Enrollment on Emergency Department Use Among Children with Special Health Care Needs (2006). Harold A. Pollack, John R. Wheeler, Anne Cowan, and Gary L. Freed

This study examined the impact of managed care enrollment on emergency department use in children with special health care needs (CSHCN) who were dually enrolled in Michigan's Medicaid program and the State's Title V MCH Services Block Grant program for CSHCN. These enrollees were served by Special Health Plans (SHPs)-managed care plans designed specifically to serve CSHCN, including a strong care coordination component. Enrollment in the plan was associated with a 23 percent reduction in the rate of emergency department use among CSHCN. Study results suggest that key characteristics of this managed care model, particularly selection of a principal coordinating doctor and development of an Individualized Health Care Plan for enrollees, are associated with reductions in emergency department use among CSHCN. For more details, see "The Impact of Managed Care Enrollment on Emergency Department Use Among Children with Special Health Care Needs," in the February 2007 issue of Medical Care 45(2), pp. 139-45.

Policy Brief No. 6: From SCHIP Benefit Design to Individual Coverage Decisions (2006). Anne Markus, Sara Rosenbaum, Ruth E.K. Stein, Jill Joseph.

SCHIP Structure and Children's Use of Care (2006). Janet Bronstein, Kathleen Adams, and Curtis Florence.

How does SCHIP design impact enrollee's use of health care? This study examined whether health care utilization differs between children enrolled in Medicaid and SCHIP in a state where both programs use the same provider network and primary care case management (PCCM) system, and between SCHIP enrollees in two states that use very different program structures. In the State where SCHIP and Medicaid share a PCCM system, researchers found Medicaid children were more likely to receive well-child care than SCHIP enrollees and that SCHIP enrollees were more likely to use office-based physicians.

Researchers also compared these SCHIP enrollees with children enrolled in a SCHIP program that used a private insurance fee-for-service (FFS) system. They found children in the FFS system used more primary, specialty, and non-urgent emergency department care than children in the PCCM-based system. Well-child care was more frequent under the FFS system for urban children and under the PCCM system for rural children.

"SCHIP Structure and Children's Use of Care" was published in the summer 2006 issue of Health Care Financing Review, 27(4), pp. 41-52. The article can be downloaded from http://www.cms.hhs.gov/HealthCareFinancingReview/downloads/2006Summer.zip. Unzip the file and open 06Summerpg41.pdf; Plugin Software Help.

CHIRI™ Issue Brief No. 5. SCHIP Enrollees with Special Health Care Needs and Access to Care (2006). Karen VanLandeghem, Jennie Bonney, Cindy Brach, and Lisa Kretz.

CHIRI™ Issue Brief No. 5 is available online or can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 06-0051).

Public Health Insurance Design for Children: The Evolution from Medicaid to SCHIP (2005). Sara Rosenbaum, Anne R. Markus, and Colleen Sonosky.

The majority of States that have implemented SCHIP as a separately-administered program have opted for benefit and coverage design in the case of early childhood preventive and developmental services that are considerably less comprehensive than the standard of coverage furnished to infants and young children under Medicaid. Researchers found that all States with separate SCHIP programs cover basic well-baby and well-child care in their service agreements; however, wide variation was found among the study States in their use of coverage standards that explicitly require participating health plans to cover child development services required under Medicaid, such as anticipatory guidance (18%), lead screening (43%), and comprehensive developmental assessments (68%). In addition, only half of the study States require participating health plans to use a medical necessity standard comparable to the Medicaid standard. The authors conclude that when States are given the flexibility to do so, they tend to reduce the level of coverage to that found in standard health insurance products, rather than the level of coverage in the Medicaid Early and Periodic Screening Diagnosis and Treatment program. "Public Health Insurance Design for Children: The Evolution from Medicaid to SCHIP" was published in the 2004 issue of the Journal of Health & Biomedical Law 1(1).

Children's Service Use During the Transition to PCCM in Two States (2005). Janet M. Bronstein, E. Kathleen Adams, and Curtis S. Florence.

Primary care case management programs (PCCM) are a form of managed care that gained popularity in the 1980s as a way to improve access and quality of care for Medicaid enrollees and to reduce program costs. This study examined the impact of PCCM on use of primary, preventive or emergency care for children enrolled in the Alabama and Georgia Medicaid programs. Implementation of the PCCM program was associated with a decline in use of all three types of care in both States. Based on focus group findings, researchers conclude that family difficulties in understanding and adjusting to restrictions on providers authorized for routine care were likely the primary factor in the decline. "Children's Service Use During the Transition to PCCM in Two States" was published in the Summer 2005 issue of Health Care Financing Review, 26(4), pp. 95-108.

The Impact of SCHIP Enrollment on Physician Participation in Medicaid in Alabama and Georgia (2004). Janet M. Bronstein, E. Kathleen Adams, Curtis S. Florence.

Does an increase in SCHIP enrollment impact office physicians' participation in Medicaid? This study compared physician participation in Alabama's freestanding SCHIP program to Georgia's Medicaid look-alike SCHIP program. It found that increases in SCHIP enrollment had little effect on physician participation in Alabama, which uses an open health care provider panel. However, in Georgia, where the same provider network serves both Medicaid and SCHIP, increases in SCHIP enrollment were associated with a decline in office-based physician participation in Medicaid in urban areas. The authors conclude that an adequate provider system is critical to assuring improvements in access to care for children enrolled in public insurance programs. For more details, see "The Impact of SCHIP Enrollment on Physician Participation in Medicaid in Alabama and Georgia" in the April 2004 issue of Health Services Research 39(2), pp. 299-315.

The Impact of Medicaid Primary Care Case Management (PCCM) on Office-Based Physician Supply in Alabama and Georgia (2003) E. Kathleen Adams, Janet M. Bronstein, Curtis S. Florence.

The success of Medicaid in assuring low-income children's access to health care is largely dependent on States' ability to enroll and retain primary care provider participation in the program. This study examined the early impact of Primary Care Case Management, a form of managed care, on office-based primary care physicians' participation in the Alabama and Georgia Medicaid programs. The implementation of the PCCM model, without increases in physician reimbursement, was associated with reduced physician participation in Medicaid and reduced visit volume among participants. For more details, see "The Impact of Medicaid Primary Care Case Management (PCCM) on Office-Based Physician Supply in Alabama and Georgia" in the fall 2003 issue of the journal Inquiry 40(3), pp. 269-282.

CHIRI™ Issue Brief No. 2. Children's Dental Care Access in Medicaid: The Role of Medical Care Use and Dentist Participation (2003). Karen VanLandeghem, Janet Bronstein, and Cindy Brach.

Many policymakers are examining State public insurance programs for ways to reduce costs and maximize the return on State and Federal investments. This CHIRI™ Issue Brief reports on children's dental care use in the Alabama and Georgia Medicaid programs and strategies for improving access to dental care, providing States with an additional resource as they make critical decisions about public insurance programs. Researchers found that less than 40 percent of Medicaid-enrolled children received dental care. Most of these children received preventive care and half used intensive dental services. While dentists' participation in Medicaid had some effect on improving dental care access, researchers conclude that other factors also influence dental care use in public insurance programs. Strategies that capitalize on the fact that Medicaid-enrolled children are far more likely to receive medical care than dental care could boost access tremendously. If every child who had a medical visit also had a dental visit, many (61 percent in Alabama and 78 percent in Georgia) Medicaid-enrolled children would have received dental care. The CHIRI™ Issue Brief is available online (PDF file, 162 KB; Plugin Software Help) or it can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 03-0032).

Do Enrollees in "Look-Alike" Medicaid and SCHIP Programs Really Look Alike? (2002). Jennifer N. Edwards, Janet Bronstein, and David B. Rein.

The State Children's Health Insurance Program (SCHIP), passed by Congress in 1997, has been implemented by States in many different forms, thus creating a myriad of natural experiments about insurance coverage for low-income children. In Georgia, SCHIP children are enrolled in a Medicaid look-alike program, PeachCare for Kids, with nearly the same administrative rules and providers as the Medicaid program. Comparing the experiences of PeachCare and Medicaid children allowed the authors to examine the impact of population differences on utilization and satisfaction. The authors found Medicaid children, controlling for many demographic characteristics, reported both less use of services and lower satisfaction with services used. Evidence presented supports three possible explanations for these differences: Medicaid families are less familiar with and supportive of systems requiring use of an assigned primary care physician, the families face more nonprogram barriers to using care, and physicians' have different responses to the two programs. For more details see "Do Enrollees in 'Look-Alike' Medicaid and SCHIP Programs Really Look Alike?" in the May/June 2002 issue of Health Affairs 21(3), pp. 91-102.

Policy Brief No. 5: Behavioral Health and Managed Care Contracting Under SCHIP (2002). Sara Rosenbaum, Colleen Sonosky, Karen Shaw, D. Richard Mauery.

Policy Brief No. 4: State Eligibility Rules under Separate State SCHIP Programs-Implications for Children's Access to Health Care (2002). Sara Rosenbaum, Anne Markus.

This Policy Brief focuses on formulas that States have developed to count children's family income for purposes of determining eligibility. This review found that only 20 of the 34 States with separate SCHIP programs use rules to count income that are sufficiently compatible with Medicaid rules that a determination of SCHIP eligibility could be reasonably interpreted as a finding of ineligibility for Medicaid. In 14 of the 20 States, the rules for counting income are either more restrictive than those used under Medicaid or else are so ambiguous that it is impossible to know without a detailed audit if more restrictive criteria in fact are in use. As a result, a SCHIP child's countable income in these States actually may be lower than it is for a Medicaid-enrolled child. This misallocation of SCHIP resources to Medicaid-eligible children means that other low-income children who truly do not meet Medicaid standards may find that no assistance is available.

Policy Brief No. 3: Managed Care Purchasing Under SCHIP: A Nationwide Analysis of Freestanding SCHIP Contract (2001). Sara Rosenbaum, Karen Shaw, Colleen Sonosky.

This Policy Brief provides the first nationwide overview of how separate SCHIP programs structure "freestanding" SCHIP managed care contracts, i.e., contracts that exist independently of a State's Medicaid managed care agreements. Fifteen such "freestanding" contracts existed as of Calendar Year 2000, and this Policy Brief reports on their general terms of coverage, access, and care coordination.

Policy Brief No. 2: State Benefit Design Choices under SCHIP-Implications for Pediatric Health Care (2001). Sara Rosenbaum, Anne Markus, Colleen Sonosky, Lee Rapasch.

Policy Brief No. 1: State SCHIP Design and The Right to Coverage (2001). Sara Rosenbaum, Barbara Smith.

This Policy Brief explores whether States in their enabling legislation establishing separate SCHIP programs confer upon eligible children an individual legal right to health insurance benefits (i.e., an individual entitlement) under State law, similar to the entitlement that Medicaid eligible children enjoy under Federal law. The question of whether States guarantee necessary health coverage for low-income children through the creation of an individual entitlement is fundamental to the study of State policymaking under SCHIP.

Devolution of Authority and Public Health Insurance Design: National SCHIP Study Reveals an Impact on Low-Income Children (2001). Sara Rosenbaum, Barbara Smith, Colleen Sonosky, Lee Repasch, Anne Markus.

How do States implement public health insurance programs for low-income children when given the choice to depart from the extensive Medicaid rules and principles? This article presents main findings in two key areas of insurance design as they relate to SCHIP: (1) whether States decide to design their SCHIP programs as individually enforceable, legal entitlements and (2) whether States, as a matter of benefit design, rely on comprehensive managed care arrangements to deliver services to children enrolled in the programs. It finds that most States choose not to entitle SCHIP-eligible children to public health insurance as a matter of either Federal or State law and that most States build comprehensive managed care into benefit design and tend to draft contracts that are legally distinct from the State's Medicaid managed care contracts. It discusses implications of these findings for pediatric access to care. This article appeared in the first symposium issue focusing on children's health of the Houston Journal of Health Law and Policy 1(1):33-61.

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Current as of February 2012

Internet Citation:

Findings from CHIRI™. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/chiri/chirifind.htm