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© 2003 American Public Health Association
RESEARCH AND PRACTICE |
Michael H. Fox and Raymond Davis are with the Department of Health Policy and Management, University of Kansas, Medical Center, Kansas City. Janice Moore is with the School of Nursing, University of Kansas Medical Center, Kansas City. Robert Heintzelman is with the Kansas Department of Social and Rehabilitation Services, Topeka.
Correspondence: Requests for reprints should be sent to Michael H. Fox, ScD, Department of Health Policy and Management, Research Director, Research and Training Center on Independent Living, 4089 Dole Center, University of Kansas, Lawrence, KS 66045-2093 (e-mail: mfox{at}ku.edu).
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INTRODUCTION |
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 TOP INTRODUCTION METHODSRESULTSDISCUSSIONReferences |
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To date, most work investigating the effect of the State Children’s Health Insurance Program on uninsured children has focused on eligibility or insurability.1–5 Few studies have analyzed its effect on children’s health status or access to health care. Current literature discusses the experience of children newly covered by state or privately funded children’s health insurance programs that existed before the Balanced Budged Act of 1997 that established the State Children’s Health Insurance Program.6–10 Recent work has summarized research studies that have showed the broader effect of having health insurance on health status and access to health care.11–14
In an effort to understand the effects of the Kansas State Children’s Health Insurance Program—HealthWave—on newly insured children and a small number moving into the State Children’s Health Insurance Program from Medicaid, researchers working with the state designed a survey to profile children’s health status, unmet medical needs, and access to services over the first year of the program. The questionnaire drew on standardized questions from national health surveys. Kansas HealthWave is a stand-alone State Children’s Health Insurance Program plan with benefits patterned after the state employees’ health insurance program. Most care is delivered through 1 statewide managed care organization under contract with the Kansas Department of Social and Rehabilitation Services.
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METHODS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Survey questionnaires were mailed to parents or guardians of all children who enrolled during the first 6 months of the program, January through June 1999. Of the continuously enrolled respondents, 60.9% returned surveys in 2000, allowing for a preenrollment and postenrollment comparison of the 1955 respondents who completed both surveys.
Because high attrition presented a potential bias, we used the binomial test statistic to compare aggregate administrative demographic data for nonrespondents with our final sample (Table 1
). When compared with the other groups, the children in our sample were more likely to be White, slightly older, of somewhat higher income, and living outside metropolitan statistical areas.
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Speculation exists on why the program experienced large attrition during its first year. Recent unpublished work by the Kansas Health Institute found that, despite legislative intent, many eligible children were not continuously enrolled.15,16 This issue is still poorly understood, although problems with the automated eligibility system linking health insurance to social services in Kansas appear to have contributed to inadvertent movement between HealthWave and Medicaid.
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RESULTS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Both at baseline and after 1 year, selfreported health status, as measured by the range of excellent to poor, was lower for HealthWave enrollees than for Kansas children at large; 71.2% of the HealthWave enrollees reported excellent to very good health at baseline and 75.7% a year later (P < .01) (Table 2
), compared with 91.8% of Kansas children younger than 18 years and 81% to 82% nationally.17–19 The most marked difference between HealthWave and all Kansas children was the lower proportion of HealthWave children in "excellent" health—27.2% at baseline and 29.2% at 1 year compared with 69.6% for Kansas and 52.0% nationally in 2000.
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The majority of HealthWave enrollees (51.1%) reported unmet health care need at baseline, compared with only 16.5% a year later (P < .001). During their preenrollment period, 40.1% of the children had an unmet need for dental services, 18.3% for medical care, 17.0% for eye care, and 14.1% for prescription medicine. After a year of coverage, unmet need had declined to 4% or less in all categories except dental care (11.5%).
The 91.9% of the children reporting a regular source of care at baseline compares favorably with the national average of 91.2%.18 After HealthWave, this number rose to 95.6% (P < .001), and 11.1% more were visiting a physician’s office or clinic instead of multiple or casual sources of care.
The mean number of reported visits to doctor’s offices rose from 1.62 to 3.26 for the 6 months preceding the survey period and to 2.40 for children reporting no recent use at baseline. Although well and sick visits were not tracked separately, the number receiving a physical examination during the year rose from 60.5% to 76.7%. The use of hospital emergency departments as a usual source of care, although low initially (1%), declined 60% during the year. Emergency department and inpatient use increased only for those reporting no recent use at baseline; for others, it decreased. Because there were fewer young children in the sample—only 15.3% were younger than 6 years and only 1% of those younger than 12 months—the primary beneficiaries of this increased use appear to have been preschool- and school-aged children.
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DISCUSSION |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Although the health status of continuously enrolled HealthWave enrollees still lagged behind the general population after 1 year, evidence suggests that improved access and increased use made possible by the program had a positive effect on the health of these children in Kansas. The shift toward use in primary care settings and the reduction in emergency department use, particularly by previous users, suggests a pattern of more appropriate use. Although enrolling and retaining State Children’s Health Insurance Program–eligible children is ultimately critical to reducing the number of uninsured children in states, our findings suggest that the State Children’s Health Insurance Program holds great promise in terms of improved health and access to care.
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Acknowledgments |
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The authors appreciate the help and guidance of members of the Kansas Health Care Data Governing Board who assisted the research team in the development of the survey instrument. Thanks also to Dr Narinder Singh, currently with the Centers for Medicare and Medicaid, who assisted in this project throughout his tenure with the Kansas Department of Social and Rehabilitation Services.
Human Participant Protection
This study complied with the requirements and policies established by the University of Kansas for protection of human subjects in research and was approved by the advisory committee on human experimentation.
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Footnotes |
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M. H. Fox was the principal investigator for this work and directed all analysis, conceptualization, and writing. J. Moore performed the data analysis, contributed to the writing, and assisted in the discussion of findings. R. Davis assisted in the conceptualization and writing. R. Heintzelman assisted in data management, including survey design and data acquisition, and contributed to policy discussion.
Accepted for publication May 20, 2002.
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References |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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1. Fender LM, Panagides-Busch M, Schulzinger R. The Child Health Insurance Program: Early Implementation in Six States. American Institutes for Research; July 1999. Available at: http://aspe.hhs.gov/health/reports/earlyCHIP/toc.htm. Accessed June 28, 2001.
2. Dunbar JL, Sloan HI, Mueller CD. Implementation of the State Children’s Health Insurance Program: Outreach, Enrollment, and Provider Participation in Rural Areas. Bethesda, Md: Project HOPE Walsh Center for Rural Health Analysis; November 1999. Available at: http://www.projecthope.org/CHA/pdf/schip99.pdf. Accessed June 28, 2001.
3. Rosenbach M, Ellwood M, Czajka J, Irvin C, Coupé W, Quinn B. Implementation of the State Children’s Health Insurance Program: Momentum Is Increasing After a Modest Start. Report submitted to the Health Care Financing Administration. Cambridge, Mass: Mathematica Policy Research Inc; January 2001. Available at: http://www.mathematica-mpr.com/PDFs/schip1.pdf. Accessed June 28, 2001.
4. Selden TM, Banthin JS, Cohen JW. Waiting in the wings: eligibility and enrollment in the State Children’s Health Insurance Program. Health Aff (Millwood).1999;18:126–133.[Medline]
5. Medicaid and SCHIP: Comparisons of Outreach, Enrollment Practices, and Benefits. Washington, DC: US General Accounting Office; April 2000. Publication GAO/HEHS-00–86. Available at: http://frwebgate.access.gpo.gov/cgi-bin/useftp.cgi?IPaddress=162.140.64.88&filename=he00086.pdf&directory=/diskb/wais/data/gao. Accessed July 16, 2001.
6. Shenkman E, Bucciarelli R, Wegener DH, Naff R, Freedman S. Crowd out: evidence from the Florida Healthy Kids Program. Pediatrics. 1999;104:507–513.
7. Tilford JM, Robbins JM, Shema SF, Farmer FL. Response to health insurance by previously uninsured rural children. Health Serv Res. 1999;34:761–775.[Web of Science][Medline]
8. Holl JL, Szilagyi PG, Rodewald LE, et al. Evaluation of New York State’s Child Health Plus: access, utilization, quality of health care, and health status. Pediatrics. 2000;105:711–718.
9. Keane CR, Lave JR, Ricci EM, LaVallee CP. The impact of a Children’s health insurance program by age. Pediatrics. 1999;104:1051–1058.
10. Lave JR, Keane CR, Lin CJ, Ricci EM, Amersbach G, LaVallee CP. Impact of a children’s health insurance program on newly enrolled children. JAMA. 1998;279:1820–1825.
11. Damiano PC, Willard JC, Momany ET. Impact on Access and Health Status: First Evaluation Report. Iowa City: The University of Iowa Public Policy Center; March 2001. Available at: http://ppc.uiowa.edu/. Accessed July 16, 2001.
12. Newacheck PW, Stoddard JJ, Hughes DC, Pearl M. Health insurance and access to primary care for children. N Engl J Med. 1998;338:513–519.
13. Rosenbach ML, Irvin C, Coulam RF. Access for low-income children: is health insurance enough? Pediatrics. 1999;103:1167–1174.
14. Weinick R, Weigers M, Cohen J. Children’s health insurance, access to care, and health status: new findings. Health Aff (Millwood). 1998;17:127–136.[Abstract]
15. Allison A, LaClair B, St. Peter R. Dynamics of HealthWave and Medicaid Enrollment. Topeka: Kansas Health Institute; March 2001. Issue brief, No. 11.
16. Allison A, LaClair B, St. Peter R. Children’s Enrollment in Kansas Public Health Insurance Programs Since the Introduction of HealthWave. Topeka: Kansas Health Institute; March 2001. Issue brief, No. 10.
17. Behavioral Risk Factor Surveillance Survey. Topeka: Kansas Department of Health and Environment; 1997.
18. Medical Expenditure Panel Survey Household Component 1996. Rockville, Md: Center for Cost and Financing Studies, Agency for Health Care Policy and Research; August 2001.
19. Health United States, 2000 With Adolescent Chartbook. Hyattsville, Md: National Center for Health Statistics; 2000.
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