Evaluation of Children's Health Insurance: From New York State's Child Health Plus to SCHIP
Authors: Szilagyi Peter G. , Holl Jane L. , Rodewald Lance E. , Shone Laura Pollard , Zwanziger Jack , Mukamel Dana B. , Trafton Sarah , Dick Andrew W. , Raubertas Richard F. 
Published: December 2021

Background.
The legislation and funding of the State Children's Health Insurance Program (SCHIP) in 1997 resulted in the largest public investment in child health care in 30 years. The program was designed to provide health insurance for the estimated 11 million uninsured children in the United States. In 1991 New York State implemented a state-funded program—Child Health Plus (CHPlus)—intended to provide health insurance for uninsured children who were ineligible for Medicaid. The program became one of the prototypes for SCHIP. This study was designed to measure the association between CHPlus and access to care, utilization of care, quality of care, and health care costs to understand the potential impact of one type of prototype SCHIP program.

Methods.
The study took place in the 6-county region of upstate New York around and including the city of Rochester. A before-and-during design was used to compare children's health care for the year before they enrolled in CHPlus versus the first year during enrollment in CHPlus. The study included 1828 children (ages 0–6.99 years at enrollment) who enrolled between November 1, 1991 and August 1, 1993. A substudy involved 187 children 2 to 12.99 years old who had asthma. Data collection involved: 1) interviews of parents to obtain information about demographics, sources of health care, experience and satisfaction with CHPlus, and perceived impact of CHPlus; 2) medical chart reviews at all primary care offices, emergency departments, and health department clinics in the 6-county region to measure utilization of health services; 3) claims analysis to assess costs of care during CHPlus and to impute costs before CHPlus; and 4) analyses of existing datasets including the Current Population Survey, National Health Interview Survey, and statewide hospitalization datasets to anchor the study in relation to the statewide CHPlus population and to assess secular trends in child health care. Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus.

Results.
Enrollment: Only one third of CHPlus-eligible children throughout New York State had enrolled in the program by 1993. Lower enrollment rates occurred among Hispanic and black children than among white children, and among children from lowest income levels.
Profile of CHPlus Enrollees: Most enrollees were either previously uninsured, had Medicaid but were no longer eligible, or had parents who either lost a job and related private insurance coverage or could no longer afford commercial or private insurance. Most families heard about CHPlus from a friend, physician, or insurer. Television, radio, and newspaper advertisements were not major sources of information. Nearly all families had at least 1 employed parent. Two thirds of the children resided in 2-parent households. Parents reported that most children were in excellent or good health and only a few were in poor health. The enrolled population was thus a relatively low-risk, generally healthy group of children in low-income, working families.
Access and Utilization of Health Care: Utilization of primary care increased dramatically after enrollment in CHPlus, compared with before CHPlus. Visits to primary care medical homes for preventive, acute, and chronic care increased markedly. Visits to medical homes also increased for children with asthma. There was, however, no significant association between enrollment in CHPlus and changes in utilization of emergency departments, specialty services, or inpatient care.
Quality of Care: CHPlus was associated with improvements in many measures involving quality of primary care, including preventive visits, immunization rates, use of the medical home for health care, compliance with preventive guidelines, and parent-reported health status of the child. For children with asthma, CHPlus was associated with improvements in several indicators of quality of care such as asthma tune-up visits, parental perception of asthma severity, and parent-reported quality of asthma care.
Health Care Costs: Enrollment in CHPlus was associated with modest additional health care expenditures in the short term—$71.85 per child per year—primarily for preventive and acute care services delivered in primary care settings.

Conclusions.
Overall, children benefited substantially from enrollment in CHPlus. For a modest short-term cost, children experienced improved access to primary care, which translated into improved utilization of primary care and use of medical homes. Children also received higher quality of health care, and parents perceived these improvements to be very important. Nevertheless, CHPlus was not associated with ideal quality of care, as evidenced by suboptimal immunization rates and receipt of preventive or asthma care even during CHPlus coverage. Thus, interventions beyond health insurance are needed to achieve optimal quality of health care.
This study implemented methods to evaluate the association between enrollment in a health insurance program and children's health care. These methods may be useful for additional evaluations of SCHIP.

Implications:
Based on this study of the CHPlus experience, it appears that millions of uninsured children in the United States will benefit substantially from SCHIP programs.