American Public Health Association Annual Meeting Atlanta 2001

Alabama’s Children’s Health Insurance Program (CHIP): Access to Care for Children With and Without Special

NeedsPrepared through a contract with the Children’s Health

Insurance Program

Alabama Dept of Public Health

By

UAB Department of Maternal and Child Health CHIP Evaluation Team

Beverly A. Mulvihill, PhD, Principal Investigator

Joseph Telfair, DrPH, Co-Principal Investigator

Frank Mulvihill, PhD, Project Analyst

Anita Jackson, BS, Project Coordinator

Cathy Caldwell, MPH, Data Manager

State Children’s Health Insurance Program (SCHIP)

• Created in 1997 with enactment of Title XXI of the Social Security Act

• Generous federal fiscal participation; wide latitude to states for program design; evaluation mandated

• Phase I – Medicaid Expansion (February 1998)• Phase II – ALL Kids: State-designed plan (Oct

1998)• Phase III – All Kids Plus: Expanded coverage

for children with special needs

Program Objective

• To reduce the number of uninsured low income children by decreasing financial and administrative barriers for low income families to obtain health insurance for their children

CHIP Time LineA

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CHIP Coverage(1998)

0%20%40%60%80%

100%120%140%160%180%200%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age

Fed

eral

Po

vert

y L

evel Phase II ALL

Kids

MedicaidEligibles

Phase IMedicaidExpansion

Medicaid for Low Income Families

Estimate Of Uninsured Children Under 200 Percent Federal Poverty Level

(Alabama-specific data from the National Survey of American Families, Urban Institute, 1997)

49,579

100-200% FPL

91,209

<100% FPL

CHIP Program Phases

• Enrollment Phase– Education Outreach

– Eligibility

– Enrollment• Renewal

• Disenrollment

• Utilization Phase– Access & Barriers

– Utilization of Services

– Quality of Services

– Consumer Satisfaction

CHIP Enrollment Through September 2001(FY 200-2001 Goal = 39,000; Sept 30, 2001= 39,240)

0

5000

10000

15000

20000

25000

30000

35000

40000

Ap

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ALL Kids Medicaid

ALL Kids Access to Care Survey

• Conducted by University of Alabama at Birmingham, School of Public Health, Department of Maternal and Child Health

• Survey Population: 26,242 Children enrolled in ALL Kids FY 99

• Data collected between November 1999 and February 2000

• Survey Sample:– Random Sample of 6,200 Parents of ALL Kids Children – 3,738 (60%) surveys returned

ALL Kids Characteristics

POPULATION (n=26,242)• No Fee

75% (income <150% of FPL)

• Male - 51%

• White - 64%

Black - 34%

Other - 2%

• 0-12 months - <1%

1-5 years - 12%

6-12 years - 48%

13-18 years - 39%

RETURNED (n=3,738)• No Fee

63% (income <150% of FPL)

• Male - 51%

• White - 64%

Black - 33%

Other - 3%

• 0-12 months - 1%

1-5 years - 16%

6-12 years - 49%

13-18 years - 34%

Identifying Children With Special Health Care Needs

• Five screening questions were used on the survey• 27% were identified as CSHCN by answering yes to at least one of

the screening question– Our sample consisted of parents who sought health insurance for their child.– In 1998 Newacheck et al. examined a cross-section of the population in the

NHIS-D survey and found a child disability prevalence rate of 18%. – Among those NHIS-D families who were at or below the federal poverty

level, the rate of child disability was 24%.

Children with Special Health Care Needs Screener Questions

– Does your child require extra or specialized medical care, therapies, diet supplies, medical equipment, nursing or home health care because of a special health need?

– Does your child need more assistance than other children the same age with any of the following: eating, dressing, bathing, moving around, going to the bathroom, or playing?

– Does your child need more assistance than other children the same age with understanding or using language or learning?

– During the past 12 months, have your child’s activities been limited compared to other children the same age because of your child’s physical health?

– During the past 12 months, have your child’s activities been limited compared to other children the same age because of your child’s behavioral or emotional health?

Income Level of Families Completing Survey

60%67%

40%33%

0%

10%

20%

30%

40%

50%

60%

70%

< 150% FPL > 150% FPL

NotCSHCN

CSHCN

Education Level of Persons Completing Survey

16%

25%

45%

38%

32%31%

6%6%

0%5%

10%15%20%25%30%35%40%45%

Not HighSchoolGrad

HighSchoolGrad

SomeCollege

4 or MoreYears ofCollege

NotCSHCN

CSHCN

Age of ALL Kids Child

1%1%

18%

10%

49%51%

32%37%

0%

10%

20%

30%

40%

50%

60%

Birth - 12Months

1 - 5Years

6 - 12Years

13 andOlder

NotCSHCN

CSHCN

Gender of ALL Kids Child

49%

57%

51%

42%

0%

10%

20%

30%

40%

50%

60%

Male Female

NotCSHCN

CSHCN

Race of ALL Kids Child64% 64%

33% 33%

3% 3%0%

10%

20%

30%

40%

50%

60%

70%

White Black Other

NotCSHCN

CSHCN

Has Health Insurance Ever Been Available

72% 71%

28% 29%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Yes No

NotCSHCN

CSHCN

Why Child Did Not Have Health Insurance

0%

10%

20%

30%

40%

50%

60%

70%

NotCSHCN

CSHCN

Measuring Differences Between CSHCN and No Special Needs in Direction of Change

Before and After CHIP• Diminished Care: had more problems

accessing health care after CHIP than before

• No Difference: no change in accessing health care after enrolling in CHIP

• Improved Care: had fewer problems accessing health care after CHIP than before

p = .02

One Person/Group Child Sees When Sick

3%

72%

25%

4%

68%

29%

0%

10%

20%

30%

40%

50%

60%

70%

80%

DiminishedCare

No Difference Improved Care

NotCSHCN

CSHCN

NS

One Person/Group Child Sees for Routine Care

3%

71%

26%

4%

67%

29%

0%

10%

20%

30%

40%

50%

60%

70%

80%

DiminishedCare

No Difference Improved Care

NotCSHCN

CSHCN

p <.001

Child Needed Care But Could Not Get It

1%

70%

29%

2%

52%47%

0%

10%

20%

30%

40%

50%

60%

70%

80%

DiminishedCare

No Difference Improved Care

NotCSHCN

CSHCN

p <.001

Waited Longer Than Should Have For Medical Care

0.50%

55%

44%

1%

46%

53%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

DiminishedCare

No Difference Improved Care

NotCSHCN

CSHCN

p <.001

Child Needed Specialty Care But Could Not Get It

0.50%

87%

13%

2%

61%

37%

0.00%10.00%

20.00%30.00%

40.00%50.00%

60.00%70.00%

80.00%90.00%

100.00%

DiminishedCare

No Difference Improved Care

NotCSHCN

CSHCN

p <.001

Dental Care

1%

52%47%

1%

45%

54%

0%

10%

20%

30%

40%

50%

60%

DiminishedCare

No Difference Improved Care

NotCSHCN

CSHCN

p <.001

Vision Care

1%

75%

24%

2%

65%

33%

0%

10%

20%

30%

40%

50%

60%

70%

80%

DiminishedCare

No Difference Improved Care

NotCSHCN

CSHCN

p <.001

Prescription Medicine

1%

63%

36%

1%

48%51%

0%

10%

20%

30%

40%

50%

60%

70%

DiminishedCare

No Difference Improved Care

NotCSHCN

CSHCN

Summary

• Characteristics of CSHCN and their families compared to those without special needs– More below 150% of Federal Poverty Level

– Fewer high school graduates

– More CSHCN among older children, especially adolescents

– More males

– No differences between racial/ethnic groups

Summary (con.)• Children with and without special needs reported

improved access to care on nearly all items measured

• Compared to children without special needs, proportionately more CSHCN experienced improved access to care after enrolling in CHIP– When parents reported having a usual source of care for

their sick child, there was a small difference between the groups, but no differences were reported for routine care. On all other measures (needing care, waiting too long for care, and services such as specialty care, dental, vision, and prescription medicine), parents of CSHCN reported significantly greater access after enrolling in CHIP than their counterparts without special needs.

Survey Conclusions and Implications

• More children with and without special needs have health insurance in Alabama than before SCHIP

• Access to health care has improved for all children in ALL Kids– More children have a regular health care provider– Fewer children are going without needed medical care– Medical care can be accessed in a more timely manner

• Compared to those without a special needs child, families who perceive their child as having a special health care need experienced significantly more improved access to health care after enrolling in CHIP

– In Alabama there is a large network of providers available (BC/BS has 85% of insurance market) and a rich benefit package

– Families who need and know about affordable and accessible health insurance will respond to outreach efforts

– Despite preliminary indications of improved access to care for CSHCN who enroll in CHIP, we do not know if substantial gaps in services for this population still exist. On-going investigation is needed regarding the effectiveness of ALL Kids and ALL Kids Plus to meet the needs of CSHCN.

– Met FY 2001 goal of having 39,000 children enrolled in ALL Kids– Many families still have not been reached – continue efforts to decentralize

outreach and marketing activities