Expert Commentary

Impacts of the Children’s Health Insurance Program (CHIP)

The Children’s Health Insurance Program (CHIP) currently provides low-cost insurance coverage to 9 million children. In September 2017, Congress failed to pass legislation reauthorizing the program, which now faces an uncertain future. We’ve collected the latest scholarship on the program to highlight the stakes in this legislative battle.

listening to child with stethoscope

The Children’s Health Insurance Program (CHIP) currently provides coverage to 9 million children. The coverage is a low-cost option for families who cannot afford private insurance but make too much money to qualify for Medicaid. While the program is administered by individual states, the federal government contributes about 70 percent of the funding, on average. In fiscal year 2016, the federal government spent $14.4 billion on CHIP.

The program was created as a 10-year program in 1997 through bipartisan legislation co-sponsored by Sen. Ted Kennedy of Massachusetts and Sen. Orrin Hatch of Utah. In 2007 it received a two-year reauthorization that allocated the federal funds needed to continue the program. Subsequent reauthorizations shored up the program until September 30, 2017. To date, Congress has failed to pass legislation reauthorizing the program, which now faces an uncertain future.

States still provide CHIP coverage, but expect to run out of funds and discontinue the program without federal reauthorization. What would this mean for the millions of children who receive insurance through CHIP? We’ve collected the latest scholarship on the program to highlight the stakes in this legislative battle.


Funding renewal

Low-Income Children With Chronic Conditions Face Increased Costs If Shifted From CHIP To Marketplace Plans
Peltz, Alon; et al. Health Affairs, April 1, 2017, Vol. 36, No. 4. doi: 10.1377/hlthaff.2016.1280.
Abstract: “More than eight million children risk having their health insurance coverage disrupted if federal funding for the Children’s Health Insurance Program (CHIP) is not extended beyond 2017. In this study we explored two current policy alternatives: extending federal funding for CHIP or enrolling children in the existing health insurance Marketplace plans. We simulated annual out-of-pocket expenses using detailed health plan data from CHIP and federally facilitated Marketplace plans for a nationally representative cohort of children with chronic conditions, conducting comparisons at four different percentage categories of the federal poverty level. If CHIP funding is not renewed and children with chronic conditions shift to coverage under Marketplace plans, their families face increased annual out-of-pocket expenses ranging from $233 at the lowest income levels to $2,472 at the highest income level of 251–400 percent of poverty. Families with children who have epilepsy, diabetes, or mood disorders may face the highest costs. Cost sharing for prescription drugs (25 percent) and hospitalizations (23 percent) account for much of the difference. Absent enhancements to Marketplace cost-sharing protections, and given recent efforts to repeal the Affordable Care Act, renewing funding for CHIP will provide the greatest financial protections to families of income-eligible children with chronic conditions.”


CHIP’s impact

The Long-Term Health Impacts of Medicaid and CHIP
Thompson, Owen. Journal of Health Economics, January 2017, Vol. 51. doi: 10.1016/j.jhealeco.2016.12.003.
Summary: Using data from the National Longitudinal Survey of Youth, a researcher from the University of Wisconsin estimated the effect of Medicaid and CHIP on long-term health. The models indicate “that each additional year of childhood eligibility reduces the probability of a health limitation by 1.3 percentage points, and decreases the probability of poor self-rated health, of having any chronic health condition, and of having had an asthma attack in the past year by 1 percentage point.” These findings are statistically significant for health limitations and asthma. The author explains these findings by suggesting that Medicaid and CHIP increase access to and use of health care.

Children with Special Health Care Needs in CHIP: Access, Use, and Child and Family Outcomes
Zickafoose, Joseph S.; Smith, Kimberly V.; Dye, Claire. Academic Pediatrics, May 2015, Vol. 15, No. 3. doi: 10.1016/j.acap.2015.02.001.
Summary: A team of researchers at Mathematica Policy Research compared the survey responses of parents of CHIP enrollees to those of previously uninsured and privately insured recent CHIP enrollees regarding their health care experiences for children with special needs. They found that parents of established CHIP enrollees reported fewer unmet needs, greater ease meeting these needs, and increased access to and use of health care compared to parents of previously uninsured children. Responses were similar between parents of established CHIP enrollees and parents of privately insured children.

The Effect of Child Health Insurance Access on Schooling: Evidence from Public Insurance Expansions
Cohodes, S., Grossman, D., Kleiner, S., Lovenheim, M. Journal of Human Resources, Summer 2016, Vol. 51, No. 3. doi:10.3368/jhr.51.3.1014-6688R1.
Summary: The researchers use Medicaid eligibility data and American Community Survey data on educational attainment to model the relationship between public health insurance expansion and schooling. They estimate that increases in Medicaid eligibility “would have reduced high school noncompletion by 10.0 percent, increased college enrollment by 1.3 percent, and increased college completion by 6.0 percent.”

The Role of Public Health Insurance in Reducing Child Poverty
Wherry, Laura R.; Kenney, Genevieve M.; Sommers, Benjamin D. Academic Pediatrics, April 2016, Vol. 16, No. 3. doi: 10.1016/j.acap.2015.12.011.
Summary: This article reviews the research on the financial benefits of public health insurance. Findings indicate positive links between public health insurance participation and test scores and completion rates of high school and college, which the researchers tie to improved long-term health and economic outcomes. They also point to public health insurance’s role in the alleviation of financial burdens through lower health care costs and facilitation of participation in food assistance programs.

How Well Is CHIP Addressing Primary and Preventive Care Needs and Access for Children?
Smith, Kimberly V.; Dye, Claire. Academic Pediatrics, May 2015, Vol. 15, No. 3. doi: 10.1016/j.acap.2015.02.012.
Abstract: “Parents of 4,142 recent enrollees and 5,518 established enrollees responded to the survey (response rates were 46 percent for recent enrollees and 51 percent for established enrollees). Compared to being uninsured, CHIP enrollees were more likely to have a well-child visit, receive a range of preventive care services, and have patient-centered care experiences. They were also more likely than uninsured children to have a regular source of care or provider, an easy time making appointments, and shorter wait times for those appointments. Relative to privately insured children, CHIP enrollees received preventive care services at similar rates and to be more likely to receive effective care coordination services. However, CHIP enrollees were less likely than privately insured children to have a regular source of care or provider and nighttime and weekend access to a usual source of care.”

How Well is CHIP Addressing Health Care Access and Affordability for Children?
Clemans-Cope, Lisa; et al. Academic Pediatrics, May 2015, Vol. 15, No. 3. doi: 10.1016/j.acap.2015.02.007.
Summary: Researchers from the Health Policy Center at the Urban Institute compared the health care experiences of long-standing CHIP enrollees to recently enrolled, formerly uninsured or privately insured children. CHIP enrollees were more likely to receive specialty and mental health care as well as prescription drugs compared to the uninsured. Outcomes were similar between the privately insured and CHIP enrollees, though parents of the latter group reported health care to be less of a financial burden.

The Health and Healthcare Impact of Providing Insurance Coverage to Uninsured Children: A Prospective Observational Study
Flores, Glenn; et al. BMC Public Health, December 2017, Vol. 17, No. 1. doi: 10.1186/s12889-017-4363-z.
Abstract: “This prospective observational study of uninsured Medicaid/CHIP-eligible minority children compared children obtaining coverage vs. those remaining uninsured. Subjects were recruited at 97 community sites, and 11 outcomes monitored monthly for 1 year … In this sample of 237 children, those obtaining coverage were significantly (P < .05) less likely than the uninsured to have suboptimal health (27 percent vs. 46 percent); no PCP (7 percent vs. 40 percent); experienced never/sometimes getting immediate care from the PCP (7 percent vs. 40 percent); no usual source of preventive (1 percent vs. 20 percent) or sick (3 percent vs. 12 percent) care; and unmet medical (13 percent vs. 48 percent), preventive (6 percent vs. 50 percent), and dental (18 percent vs. 62 percent) care needs. The uninsured had higher out-of-pocket doctor-visit costs (mean = $70 vs. $29), and proportions of parents not recommending the child’s healthcare provider to friends (24 percent vs. 8 percent) and reporting the child’s health caused family financial problems (29 percent vs. 5 percent), and lower well-child-care-visit quality ratings. In bivariate analyses, older age, birth outside of the U.S., and lacking health insurance for >6 months at baseline were associated with remaining uninsured for the entire year. In multivariable analysis, children who had been uninsured for >6 months at baseline (odds ratio [OR], 3.8; 95 percent confidence interval [CI], 1.4–10.3) and African-American children (OR, 2.8; 95 percent CI, 1.1–7.3) had significantly higher odds of remaining uninsured for the entire year. Insurance saved $2,886/insured child/year, with mean healthcare costs = $5,155/uninsured vs. $2,269/insured child (P = .04).”

The Children’s Health Insurance Program Reauthorization Act Evaluation Findings on Children’s Health Insurance Coverage in an Evolving Health Care Landscape
Harrington, Mary E. Academic Pediatrics, May 2015, Vol. 15, No. 3. doi: 10.1016/j.acap.2015.03.007.
Summary: A researcher from Mathematica Policy Research reviews the literature on CHIP, highlighting improved outcomes for CHIP enrollees compared with uninsured children, and similar outcomes as compared with privately insured children. Harrington also discusses changes in coverage over time, noting decreases in uninsurance rates since CHIP was enacted in 1997.


Prenatal care

Expanding Prenatal Care to Unauthorized Immigrant Women and the Effects on Infant Health Swartz, Jonas J.; Hainmueller, Jens; Lawrence, Duncan; Rodriguez, Maria I. Obstetrics & Gynecology, November 2017, Vol. 130, No. 5. doi: 10.1097/AOG.0000000000002275.
Summary: CHIP granted an “unborn child” option in 2002, in which the federal government agreed to match state funds for prenatal care offered to all women regardless of immigration status. This study looks at Oregon’s pilot program under this initiative, called Citizen/Alien Waived Emergent Medical Care. It finds that the program resulted in increased use of health care and better outcomes for expectant mothers and children. Findings include an estimated reduction in infant mortality by 1 per 1,000. The expansion also increased prenatal visits by about 7 per pregnancy for unauthorized immigrants.

Women in the United States Experience High Rates of Coverage ‘Churn’ in Months Before and After Childbirth
Daw, Jamie R.; Hatfield, Laura A.; Swartz, Katherine; Sommers, Benjamin D. Health Affairs, April 1, 2017, Vol. 36, No. 4. doi: 10.1377/hlthaff.2016.1241.
Summary: This study looks at women’s transitions on and off insurance around the time of childbirth. Through analysis of survey data collected from 2005 to 2013, it finds that half of women uninsured during their pregnancy gained insurance in the month leading up to their deliveries. Shortly after giving birth, however, many lost their insurance — 55 percent had a gap in coverage within the following six months.


Access to public health insurance

Do Restrictive Omnibus Immigration Laws Reduce Enrollment in Public Health Insurance by Latino Citizen Children? A Comparative Interrupted Time Series Study
Allen, Chenoa D.; McNeely, Clea A. Social Science & Medicine, October 2017, Vol. 191. doi: 10.1016/j.socscimed.2017.08.039.
Summary: This study looks at National Health Interview Survey data to analyze whether newly enacted state immigration laws have an effect on Medicaid/CHIP enrollment for U.S. citizen Latino children of undocumented parents. They found that these laws were linked with no change in enrollment for children with two undocumented parents and temporary increases in enrollment for children with one citizen parent. To explain these results, they suggest that when immigration reform is on the table, there might be increased community-based outreach about immigrants’ rights and benefits.

Housing Instability and Children’s Health Insurance Gaps
Carroll, Anne; et al. Academic Pediatrics, September 2017, Vol. 17, No. 7. doi: 10.1016/j.acap.2017.02.007.
Abstract: “In a U.S. nationally representative birth cohort, children who were unstably housed at age 2 were at higher risk, compared to their stably housed counterparts, of experiencing health insurance gaps between ages 2 and 4 years. The findings from this study suggest that policy efforts to delink health insurance renewal processes from mailing addresses, and potentially routine screenings for housing instability as well as referrals to appropriate resources by pediatricians, would help unstably housed children maintain health insurance.”

Access to Private Coverage for Children Enrolled in CHIP
McMorrow, Stacey; Kenney, Genevieve M.; Waidmann, Timothy; Anderson, Nathaniel. Academic Pediatrics, May 2015, Vol. 15, No. 3. doi: 10.1016/j.acap.2015.02.005.
Abstract: “We conducted a major household telephone survey in 2012 of enrollees and disenrollees in CHIP in 10 states. We used the survey responses and Medicaid/CHIP administrative data to estimate the coverage distribution of all new enrollees in the 12 months before CHIP enrollment and to identify children who may have had access to employer coverage through one of their parents while enrolled in CHIP. … Access to private coverage among CHIP enrollees is relatively limited. Furthermore, even when there is potential access to employer-sponsored insurance (ESI), affordability is a serious concern for parents, making it possible that many children with access to ESI would remain uninsured in the absence of CHIP.”

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