The impacts of the State Children's Health Insurance Program on children who enroll: findings from ten states.

The State Children's Health Insurance Program (SCHIP) was created in 1997 primarily to expand insurance coverage to more low-income children. States had latitude over numerous aspects of their program design and ultimately all states expanded eligibility for public coverage under the new program (Kenney and Chang 2004). One of the yardsticks by which SCHIP is measured is the extent to which the program improves children's access to and receipt of care over and above what they would have experienced otherwise. SCHIP is expected to lower the costs and other barriers associated with obtaining care for the children who enroll, particularly relative to being uninsured, which should in turn, increase their access to care. Prior research has demonstrated that uninsured children experience more access problems and receive fewer services than children with public health insurance coverage (Rosenbach 1989; Monheit and Cunningham 1992; Stoddard, St. Peter, and Newacheck 1994; Currie and Thomas 1995; Newacheck, Hughes, and Stoddard 1996; Moreno and Hoag 2001; Dubay and Kenney 2001). However, the access and use gaps found between the uninsured and the insured may derive not only from differential access to health care, but may also reflect unmeasured differences between the two groups in health seeking behavior and attitudes toward health care. A number of studies have attempted to address the potential bias introduced when comparing the uninsured and insured, by examining changes in access and use following enrollment in a public health insurance program (Lave et al. 1998; Szilagyi et al. 2000, 2004, 2006; Slifkin et al. 2001; Damiano et al. 2002; Dick et al. 2004; Kempe et al. 2005; McBroome, Damiano, and Willard 2005; Shone et al. 2005). These studies have found improvements in access and use for children who enrolled in the program based on a longitudinal analysis of children's experiences before and after they have coverage. Two of these studies examined the impacts of non-Medicaid programs that predated the enactment of the SCHIP program: Szilagyi et al. (2000) reported on Child Health Plus in New York and Lave et al. (1998) reported on the Children's Health Insurance Program in Pennsylvania while the other studies focused on SCHIP programs. All of these studies found improvements in a number of different measures of health care access and use for children who enrolled in these programs. These findings suggest that differences in service use found between the uninsured and the insured are not all driven by unmeasured differences in characteristics of the two groups, but instead reflect greater access to care afforded to children with health insurance coverage. In this paper, the impacts of SCHIP on the children who are served by the program are examined using an approach that is a variant on that used by Lave et al. (1998), Szilagyi et al. (2000), Damiano and Williard (2002), and Dick et al. (2004). The 10 states examined—California, Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey, New York, North Carolina, and Texas—include a large proportion of all low-income uninsured children in the United States, wide geographic representation, and diverse approaches to program design. These states account for over 60 percent of all SCHIP enrollees nationwide and represent all four census regions (Smith and Rousseau 2005). They reflect the three different SCHIP program structures (California, Colorado, Florida, New York, North Carolina, and Texas have separate non-Medicaid expansions,1 Louisiana and Missouri have Medicaid expansions, and Illinois and New Jersey have a combination program with Medicaid and non-Medicaid components). They also vary in terms of their reliance on managed care, their cost sharing structures, and benefit packages (Hill et al. 2005). To estimate impacts, the experience of a sample of enrollees who have been on the program for at least 5 months is contrasted with the pre-SCHIP experience of a separate sample of recent enrollees, using data from 2002. The following section describes the data and methodological approach. Subsequent sections present results and discuss the implications.