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Children's Coverage

The State Children’s Health Insurance Program: Successes, Shortcomings, And Challenges

Abstract

 
This paper examines successes and shortcomings of the State Children’s Health Insurance Program (SCHIP). SCHIP is a source of coverage for millions of children, improving their access to health care and sparking innovation in program design and improvements in Medicaid. However, SCHIP adds to the complexity of the insurance system and introduces new inequities in access to insurance; it is imperfectly targeting eligible children who are uninsured; and its financing is problematic because of the block-grant funding structure and use of SCHIP funds to cover adults. These issues need to be addressed during the SCHIP reauthorization process.

SCHIP provides states with more flexibility in the design of their programs than is generally available under Medicaid. States could expand coverage under SCHIP with existing Medicaid program rules, with separate non-Medicaid programs, or with some combination of the two approaches. With a separate SCHIP program, states have more latitude over benefits and cost sharing than under Medicaid and can impose enrollment caps and waiting periods.

Although both Medicaid and SCHIP are funded jointly by the federal and state governments, federal matching rates are about 30 percent higher under SCHIP than under Medicaid. Also, unlike Medicaid, SCHIP is funded as a capped grant to the states rather than as an open-ended entitlement to individuals. Under SCHIP, each state is granted an allotment, which is determined by a formula established by Congress. Once a state has exhausted its federal allotment, additional federal SCHIP funds are available only if other states have unspent allotments.³

Certainly the ultimate goal of SCHIP was to provide coverage to as many uninsured children as possible. But since insurance was recognized as just a first step, SCHIP had the broader goal of providing access to high-quality, affordable health care. Because of the difficulties inherent in measuring both the number of uninsured children and the number of enrolled children who would otherwise be uninsured, many states developed enrollment targets. The focus on enrollment led to a secondary goal: simplifying the enrollment processes for public coverage. A third goal embodied in the statute was that SCHIP not supplant or "crowd out" existing employer-sponsored coverage. Underpinning all of these goals was the desire to encourage state participation by allowing more flexibility in program design, including the creation of SCHIP programs with benefits and cost sharing similar to those available in the private sector as an alternative to Medicaid. This paper critically assesses the extent to which SCHIP met its goals in the years since enactment and examines the effects that SCHIP has had.

Successes Of SCHIP

Top Successes Of SCHIP Shortcomings And Challenges... Conclusions Editor's Notes NOTES

 
SCHIP has made notable achievements in a number of different areas, including its broad-based support at the state and federal levels, innovations in program design and spillover effects on Medicaid, the growth of the program and accompanying reductions in uninsurance, and the positive effects on children who enroll.

States embraced SCHIP. Immediately following SCHIP’s enactment, the federal government and many states acted quickly to implement it, and the few states that did not expand coverage at the outset felt pressure to enact some type of SCHIP program. By the fall of 1999 programs had been adopted by all states; sixteen states (including the District of Columbia) rely exclusively on Medicaid expansions, and thirty-five states rely on separate programs, either alone or in combination with a Medicaid expansion. In all but twelve states, coverage was expanded to children with incomes up to 200 percent of poverty, or even higher. SCHIP reduced differences in eligibility for public programs across age groups and states.

Prior to SCHIP, states could expand coverage through Medicaid, but before 1997, only six states had Medicaid coverage for children at or above 200 percent of poverty.⁴ It is unlikely that states would have expanded coverage as much under SCHIP without state flexibility over program design (including the option to use a separate program without an entitlement), the enhanced federal matching rate, and the large budget surpluses that states enjoyed in the late 1990s.⁵

State and federal governments worked together. Both the federal and state governments wanted programs to be adopted and implemented quickly. To serve that end, the U.S. Department of Health and Human Services (HHS) set up a committee to oversee and assist the Centers for Medicare and Medicaid Services (CMS, then HCFA), which was the lead implementing agency. This committee’s goal was to incorporate the expertise of the rest of HHS—in areas such as outreach and quality—as the program was being implemented. The HHS Steering Committee facilitated and coordinated the process of approving state plans and the issuance of guidance to states. Private organizations and foundations also helped facilitate early and rapid implementation.

The federal and state governments worked to develop a productive partnership. Information sharing facilitated SCHIP implementation in its early stages. Because of short time frames, the federal government conducted conference calls with stakeholders, organized meetings in various states, and provided information through a question-and-answer process, instead of simply issuing regulations.

Flexibility led to innovations in enrollment, outreach, and program design. Under SCHIP, states have worked to improve enrollment and retention processes and have used many different outreach strategies.⁶ Efforts include establishing continuous eligibility; adopting short, joint applications for Medicaid and SCHIP; eliminating face-to-face interviews and resource tests; allowing self-declaration of income and electronic submissions; and using passive renewal systems. Outreach strategies include use of mass media campaigns and community-based efforts such as providing direct financial support for local application assistance.

States’ latitude over program design allowed state officials to tailor their programs to their specific circumstances and political realities. Some chose programs that had cost sharing and more limited benefits; this was particularly important for states that wanted to expand coverage to higher-income children. One area in which states had less flexibility than they would have liked was in the design of premium assistance programs: There were numerous federal restrictions on what could be implemented. Thus, very few states developed such programs under SCHIP, and those that did saw very low enrollment.⁷

SCHIP now covers millions of children. SCHIP has become an important source of insurance coverage for many children. As of June 2003 almost four million children were enrolled in SCHIP (Exhibit 1). Although the number of children enrolled in SCHIP remains much lower than the number enrolled in Medicaid, it appears that SCHIP is now providing insurance coverage to 4–5 percent of all children.⁸ From December 1998 to June 2003, enrollment in SCHIP grew by about three million children, from less than 900,000 to about 3.9 million. Enrollment growth was very high in the program’s early years, but the growth rate has declined more recently, which may reflect both program maturation and cutbacks because of fiscal pressures.

Coverage gains were most pronounced for children in low-income households, particularly those with incomes between 100 and 200 percent of poverty, who were targeted by the SCHIP expansions.¹¹ In addition, SCHIP likely prevented many children from becoming uninsured, as coverage has deteriorated for low-income parents since the late 1990s.¹² Despite the fact that various surveys agree on the direction and, to a certain extent, the magnitude of the change in children’s insurance coverage following the implementation of SCHIP, it is not known precisely how much of the improvement is attributable to SCHIP and how much to other factors that were changing during this time period.¹³ However, there is no doubt that uninsurance rates dropped for children at an unprecedented rate given historical standards and that the experience of children during this period contrasts sharply with that of adults. Thus, it is unlikely that reductions in uninsurance rates among children would have taken place if SCHIP did not exist.

SCHIP enrollees see improved access. Research on SCHIP programs in Iowa, Florida, Kansas, New York, and North Carolina indicates that children who enroll have improved access to care.¹⁴ Enrollment in SCHIP in these five states appears to lead to reductions in unmet need and increases in the receipt of preventive care, and, in all but Kansas, SCHIP enrollment increases the likelihood of having a usual source of care. Other benefits to enrollees are evident: Enrollment in Iowa’s program seems to reduce stress and financial burdens associated with meeting a child’s health care needs, and children’s access to dental care appeared to improve following SCHIP enrollment in New York, Iowa, and North Carolina. These findings are consistent with those from a congressionally mandated SCHIP evaluation, which examines the effects of SCHIP enrollment in ten states covering 60 percent of all SCHIP enrollees.¹⁵ The fact that improvements are found in different states and under different types of programs reinforces the conclusion that SCHIP is having positive effects on the lives of the children who enroll and their families.

SCHIP has had positive spillover effects on Medicaid. SCHIP conferred positive benefits on Medicaid (Title XIX) programs for children. It appears that takeup of Medicaid coverage increased among children following SCHIP implementation, which is critical to reducing uninsurance because so many uninsured children are eligible for Medicaid.¹⁶ Many states reported higher Medicaid enrollment growth following the adoption of their SCHIP expansions.¹⁷

SCHIP also triggered reforms in Medicaid programs for children, most notably in the procedures used for enrollment and re-enrollment of children.¹⁸ With the need for coordination between Medicaid and SCHIP, some of the simplification efforts pioneered in SCHIP were carried over to Medicaid. Also, many outreach efforts were aimed broadly at increasing participation in both programs.

Shortcomings And Challenges Facing SCHIP

Top Successes Of SCHIP Shortcomings And Challenges... Conclusions Editor's Notes NOTES

 
Here we turn from considering SCHIP’s successes to its shortcomings and challenges, which include inequities associated with SCHIP expansions, unsolved coverage issues related to uninsurance and crowding out, uncertainties and potential shortfalls in federal funds, and trade-offs associated with covering adults.

SCHIP time frame put pressures on states and the federal government. Under SCHIP, funds became available to states with federally approved SCHIP plans less than two months after the enabling legislation was signed, which did not allow adequate time for planning and implementation. For example, federal program guidelines need to be established, which normally takes between six months and a year, and states need time to consider options and go through their administrative and legislative processes.

Although there was a clear upside to the compressed time frame—namely, that many children gained coverage quickly—downsides also arose in the early stages of the program. The federal government was establishing its policies at the same time that states were submitting plans for approval. This meant that issues that arose for a particular state, such as how to prevent crowding out in Florida, would drive the policy development process and define priorities, instead of there being a clear, well-articulated set of policies on which states could base their plans from the start. Some states had plans approved with provisions that needed to be changed when the federal regulations were finally promulgated. In addition, because of rushed program design and implementation, some states did not have the time to put management information systems in place, which meant that they lacked a sound baseline measure from which to track progress.

Evidence is still lacking to guide programmatic choices. States are given latitude over fundamental design issues within fairly broad parameters laid out in the statute, including Medicaid expansion or separate programs, eligibility levels, cost-sharing requirements and waiting periods, what types of outreach to support at what funding levels, and enrollment and renewal procedures. However, there was almost no solid evidence to guide administrators as they designed their programs. Despite the variety of programs across the country, we still lack the information needed to assess the effects of different features. This lack of knowledge is partially a consequence of the fact that states were not required or encouraged to conduct research on the effects of different features. Moreover, states implemented a whole set of program features at the same time, making it difficult to disentangle the effects of individual components.

The incremental nature of SCHIP introduced inequities and complexities. Layering SCHIP on top of existing programs created coordination and equity issues. For example, states were required to first determine Medicaid (Title XIX) eligibility before determining SCHIP eligibility (under the so-called screen-and-enroll provisions), which added complexity to enrollment processes (and which meant that some families had to go through two separate eligibility determination processes) at a time when states were trying to simplify those processes. Moreover, states that expanded SCHIP coverage through separate non-Medicaid programs had to coordinate with Medicaid, which involved setting up additional administrative systems.

Provisions in the statute relating to crowding out introduced inequities across families.¹⁹ In separate programs, children who had employer-sponsored coverage were not eligible for SCHIP, even if they had family incomes below the eligibility thresholds. Some states developed policies to exempt certain children, such as those with very costly private coverage or elevated health needs, from waiting periods.²⁰ However, the crowd-out provisions penalized children whose parents had been paying out of pocket for coverage, especially those with high-cost catastrophic plans. When SCHIP coverage is substituted for private coverage, children and families may experience a number of advantages, related to more comprehensive benefits and lower financial burdens.²¹

Inequities were also introduced across states because those that had already expanded Medicaid coverage to children could not receive the higher SCHIP matching rate for these children. This maintenance-of-effort requirement had a strong rationale in maximizing the additional coverage that would be achieved with SCHIP funds, but it meant that states that had been ahead of the curve in expanding Medicaid eligibility for children were penalized financially relative to states that expanded coverage after SCHIP. Additional cross-state inequities were introduced because the legislation allowed Florida, New York, and Pennsylvania, which had existing programs funded exclusively with state funds, to receive SCHIP funds to cover children who had been eligible for these programs.

SCHIP has substituted for private coverage to a degree. As indicated above, the statute required that SCHIP not substitute for employer coverage. However, when SCHIP was enacted, the Congressional Budget Office (CBO) estimated that 40 percent of enrollment would result from the substitution of SCHIP for private coverage.²² Research based on national surveys has produced a broad range of estimates of substitution under SCHIP.²³ Evidence from state surveys of SCHIP enrollees suggests that relatively few such enrollees transfer directly from employer coverage to SCHIP and that most longer-term SCHIP enrollees cannot enroll in an employer plan that includes their parents.²⁴ The precise amount of substitution is uncertain, but different sources indicate that SCHIP is substituting for private coverage for some enrollees. However, this may lead to better coverage for some families and reduce inequities in access to SCHIP coverage.

Some SCHIP-eligible children remain uninsured. According to the most recent CPS estimates, 9.3 million children age eighteen and under (12 percent of all children) lack insurance coverage.²⁵ SCHIP cannot be expected to eradicate uninsurance among children, given that only about one in four children who are uninsured qualify for SCHIP, but take-up rates in SCHIP are below those in Medicaid.²⁶ Further increases in SCHIP take-up are unlikely, given that many states have reduced their outreach.²⁷

It is difficult to assess the effects of SCHIP at the state level. Very few states have had the data and technical resources to develop credible estimates of SCHIP’s impact on coverage in their state.²⁸ Support for such infrastructure continues to be a low federal priority. States were hampered by a lack of accurate baseline data, which limited their ability to assess progress under SCHIP and Medicaid, and little state-specific information is available on coverage impacts. Thus, it will be difficult for states to determine the effectiveness of their own programs.

SCHIP has not been immune from budget pressures. Despite the popularity of SCHIP and the high federal matching rates, many states have scaled programs back in response to tight state budgets over the past two years.²⁹ Cutbacks have included enrollment caps, reductions in eligibility thresholds and outreach spending, and increased cost sharing. To this point, the likely enrollment effects of these cutbacks remains small as a proportion of total enrollment, although that could change if states initiate deeper cuts in SCHIP in subsequent budget cycles. Moreover, SCHIP has fared relatively well compared with other sectors of state spending.³⁰

It could be argued that key features of SCHIP—namely, the nonentitlement nature of the program and the flexibility that states have over eligibility thresholds and cost sharing—have also allowed states to cut back the program at a time when the need for public insurance coverage among low-income children is increasing, given the economic downturn. At the same time, the very flexibility available under SCHIP could give states greater ability to minimize the adverse consequences of cutbacks. Also, this same flexibility likely induced larger expansions in coverage from the outset than would have occurred otherwise.

Funding issues lead to uncertainty and potential shortfalls. SCHIP was funded as a ten-year block grant. Exhibit 2 shows federal SCHIP spending and allotments from the beginning through fiscal year 2003, the last full year of spending data available. Not surprisingly, given the time required for program design and implementation, spending fell far short of allotments in the first several years following enactment but has grown over time. In fact, total spending under SCHIP in FY 2003 amounted to $4.3 billion, more than the federal allotment for that year.

View larger version (18K): [in this window] [in a new window]   EXHIBIT 2 Federal Spending For The State Children’s Health Insurance Program (SCHIP) Versus Federal Allotment, By Fiscal Year, 1998–2003

In addition, allocations to states do not necessarily correspond well to state spending on the program. In fact, in FY 2003, a point of relative maturity in SCHIP, ten states had spending more than twice as high as their federal allotment for that year, while five states spent less than half their allotment in that year.³³ This mismatch is attributable in part to the imprecision of state-based estimates available from the CPS, which are used to allocate federal funds across states, and to the allocation formula, which does not necessarily correlate closely with a state’s SCHIP caseload or program costs.³⁴ Another problem is that states do not know how much in federal funds will be available to them in a given year. Differences between a state’s allotment and its spending level have also arisen because of the maintenance-of-effort requirements built into the statute, which prevented states from using SCHIP funds to cover children who were eligible for Medicaid before 15 March 1997. Thus, states such as New Mexico, Tennessee, and Washington, which had already expanded their Medicaid programs (and are not using SCHIP funds to cover adults), are spending only a fraction of their SCHIP federal funds.³⁵ In addition, half of the ten states with spending more than double their allotment in FY 2003—Arizona, Minnesota, New Jersey, Rhode Island, and Wisconsin—are using SCHIP funds to cover adults, although the allotments were designed to cover only children.

SCHIP coverage of adults introduces trade-offs. As of June 2003, seven states were using SCHIP funds to cover adults.³⁶ At that time, 244,636 adults were covered, and in all but two states the funds were used to cover the parents or care-givers of children who were eligible for Medicaid or SCHIP under HHS waivers granted to states. Concerns have been raised that these waivers, particularly those that allow the use of SCHIP funds to cover adults who are not parents, are not consistent with the original legislative intent of SCHIP and that they reduce the funds available to cover children.³⁷

Although SCHIP was created to improve insurance coverage among low-income children, the statute did permit coverage of parents as long as it was cost-effective to do so; that is, the costs of covering the parents and children could not exceed the costs of covering the child, which could be achieved only through subsidizing employer coverage for the family. Moreover, research suggests that covering parents leads to greater coverage and better access to care for their children.³⁸ Thus, it could be argued that expanding coverage to parents without requiring that spending on the parents meet the cost-effectiveness test is faithful to the statute’s intent: to expand coverage of children.

The statute did not anticipate that SCHIP funds would be used to cover non-parents, and the link between covering these adults and improving children’s coverage is tenuous. Without additional federal funding, it is increasingly likely that coverage of adults will cause some states to have insufficient federal resources to cover children. Moreover, some have argued that if SCHIP is broadened to include coverage of both parents and nonparents, the bipartisan consensus that led to the commitment of federal funds to cover children may be diluted, and support for the program may be undermined.³⁹

Conclusions

Top Successes Of SCHIP Shortcomings And Challenges... Conclusions Editor's Notes NOTES

 
By many different measures, SCHIP has been a success. It has provided health insurance coverage to millions of children and improved their access to care. In addition, SCHIP sparked a number of improvements in Medicaid, particularly related to the application process, and stimulated greater participation in Medicaid. The reasons for SCHIP’s successes are likely the combination of generous federal matching rates, states’ latitude over their programs, the state budget surpluses occurring around the time that SCHIP was enacted, and the strong bipartisan support for providing health insurance to children.

SCHIP has also had shortcomings and challenges. As an incremental expansion in coverage, SCHIP added to the complexity of the insurance system and introduced new inequities in access both across and within states. Despite the fact that uninsurance rates for children have fallen since SCHIP was enacted, some children remain uninsured despite being eligible for SCHIP. Moreover, the SCHIP and Medicaid retrenchment occurring in a number of states raises doubts about further improvements among low-income children, at least in the short run.⁴⁰

SCHIP is also facing issues related to program structure and financing that will need to be addressed in the coming years. State and national policymakers will need more information about the effects of various program features, such as cost sharing and waiting periods. Investments in data, research, and randomized experiments are needed to address important design issues and to make cost-effective, equitable use of scarce public resources. Additional investments will likely require an expanded federal role, aimed at both financing and supporting the development of more state-level data collection and research.

More time is needed to understand the consequences of the optional nature of SCHIP coverage and the fact that so many SCHIP enrollees are in programs where coverage is not an individual entitlement.⁴¹ Ultimately, it will be important to assess the extent to which incremental coverage expansions that are optional and require state funds can address the coverage and broader health care needs of children. From this vantage point, it appears that additional policy changes will be needed if we are to reduce and ultimately eliminate uninsurance among children.

SCHIP financing issues will surely rise to greater prominence in the coming years. More states will likely face shortfalls in federal funding, at a time when other states carry large SCHIP balances and unspent funds from earlier allotments are returned to the federal Treasury. Moreover, the use of SCHIP funds to cover adults raises a fundamental question about the purpose of SCHIP—namely, whether it should move beyond the direct insurance needs of children to address broader needs related to the coverage of their parents and others. It is also likely that the way that SCHIP is financed will limit what it can ultimately accomplish, since the fixed amount of federal resources available through the block grant is not adequate to cover all children who are potentially eligible for coverage.

As the 2007 reauthorization of SCHIP nears, policymakers will need to grapple with a number of issues related to the financing of SCHIP, the relationship between Medicaid and SCHIP coverage for children, and the roles of federal and state governments in funding and shaping Medicaid and SCHIP for children and families. These issues will need to be considered in the context of how Medicaid programs are evolving in response to new options available under Health Insurance Flexibility and Accountability (HIFA) waiver authority and the potential introduction of block grants in Medicaid.

Editor's Notes

Top Successes Of SCHIP Shortcomings And Challenges... Conclusions Editor's Notes NOTES

 
Genevieve Kenney (jkenney{at}ui.urban.org) is a principal research associate at the Urban Institute in Washington, D.C. Debbie Chang is senior vice president and executive director of the Nemours Division of Health and Prevention Services in Newark, Delaware.

Support for this paper was provided by the Urban Institute and the Nemours Foundation. The opinions expressed are those of the authors and do not necessarily reflect those of the Urban Institute, its funders, or the Nemours Foundation. The authors are grateful for the insightful suggestions and comments of Cindy Brach, Lisa Dubay, Ian Hill, John Holahan, Leighton Ku, Eugene Lewit, Cynthia Pernice, Cynthia Shirk, Lisa Simpson, and Alan Weil. They also appreciate the careful research assistance of Jamie Rubenstein, Joshua McFeeters, and Justin Yee.

NOTES

Top Successes Of SCHIP Shortcomings And Challenges... Conclusions Editor's Notes NOTES

 

1. Congress enacted SCHIP as Title XXI of the Social Security Act.
2. The statute stipulated that SCHIP funds not be used to cover children who were already eligible for Medicaid or who had employer-sponsored coverage.
3. States have three years to use a given allotment, at which point unused funds can be redistributed to states that have exhausted their allotments, with remaining funds reverting to the federal Treasury.
4. D.C. Ross and L. Cox, Preserving Recent Progress on Health Coverage for Children and Families: New Tensions Emerge—A Fifty-State Update on Eligibility, Enrollment, Renewal, and Cost-Sharing Practices in Medicaid and SCHIP (Washington: Kaiser Commission on Medicaid and the Uninsured, 2003).
5. L. Dubay, I. Hill, and G. Kenney, "Five Things Everyone Should Know about SCHIP," Assessing the New Federalism Policy Brief A-55 (Washington: Urban Institute, 2002).
6. D.C. Ross and I.T. Hill, "Enrolling Eligible Children and Keeping Them Enrolled," Future of Children 13, no. 1 (2003): 81–97[Medline]; and A.W. Dick et al., "Consequences of States’ Policies for SCHIP Disenrollment," Health Care Financing Review 23, no. 3 (2002): 65–88.[Medline]
7. A.W. Lutzky and I.T. Hill. "Premium Assistance Programs Under SCHIP: Not for the Faint of Heart?" Occasional Paper no. 65 (Washington: Urban Institute, 2002); and R.E. Curtis and E. Neuschler, "Premium Assistance," Future of Children 13, no. 1 (2003): 214–223.[CrossRef][Medline]
8. This range is based on Urban Institute tabulations of the 2002 National Survey of America’s Families (NSAF) and SCHIP enrollment statistics in V.K. Smith and D.M. Rousseau, SCHIP Program Enrollment: June 2003 Update (Washington: Kaiser Commission on Medicaid and the Uninsured, 2003).
9. G. Kenney, J. Haley, and A. Tebay, "Children’s Insurance Coverage and Service Use Improve," Snapshots of America’s Families no. 1 (Washington: Urban Institute, 2003).
10. A.T. LoSasso and T.C. Buchmueller, "The Effect of the State Children’s Health Insurance Program on Health Insurance Coverage," NBER Working Paper no. 9405 (Cambridge, Mass.: National Bureau of Economic Research, 2004); P.J. Cunningham, J. Hadley, and J. Reschovsky, The Effects of SCHIP on Children’s Health Insurance Coverage: An Update Based on Three Rounds of the Community Tracking Study, 1996–97 to 2000–2001, Research Report no. 7 (Washington: Center for Studying Health System Change, 2002); Kenney et al., "Children’s Insurance Coverage and Service Use Improve"; R.A. Cohen and H. Ni, "Health Insurance Coverage: Estimates from the National Health Interview Survey, January–June 2003," January 2004, www.cdc.gov/nchs/data/nhis/earlyrelease/insur200401.pdf (2 July 2004); and L. Ku and S. Nimalendran, Improving Children’s Health: A Chartbook about the Roles of Medicaid and SCHIP (Washington: Center on Budget and Policy Priorities, 2004).
11. Kenney et al., "Children’s Insurance Coverage and Service Use Improve."
12. L. Dubay and G. Kenney, "Addressing Coverage Gaps for Low-Income Parents," Health Affairs 23, no. 2 (2004): 225–234.[Abstract/Free Full Text]
13. L.C. Dubay and G. Kenney, "Assessing SCHIP Effects Using Household Survey Data: Promises and Pitfalls," Health Services Research 35, no. 5, Part 3 (2000): 112–127.
14. Although these surveys differ in terms of their design, response rates, instruments, and approaches to estimating impacts, the overall pattern of the findings is consistent. P.C. Damiano et al., hawk-i Impact on Access and Health Status: Second Evaluation Report to the Board of Directors of the Healthy and Well Kids in Iowa Program (Iowa City: University of Iowa, Health Policy Research Program, Public Policy Center, January 2002); R.T. Slifkin et al., Assessing the Effects of the North Carolina Health Choice Program on Beneficiary Access to Care (Chapel Hill: University of North Carolina, Cecil G. Sheps Center for Health Services Research, 2001); A.W. Dick et al., "SCHIP’s Impact in Three States: How Do the Most Vulnerable Children Fare?" Health Affairs 23, no. 5 (2004): 63–75[Abstract/Free Full Text]; and P.G. Szilagyi et al., "Improved Access and Quality of Care after Enrollment in the New York State Children’s Health Insurance Program (SCHIP)," Pediatrics 113, no. 5 (2004): e395–e404.[Abstract/Free Full Text]
15. G. Kenney et al., "The Experiences of SCHIP Enrollees and Disenrollees in Ten States: Findings from the Congressionally-Mandated SCHIP Evaluation," report prepared for the Assistant Secretary of Planning and Evaluation, U.S. Department of Health and Human Services (Princeton, N.J.: Mathematica Policy Research, forthcoming).
16. T.M. Selden, J.L. Hudson, and J.S. Banthin, "Tracking Changes in Eligibility and Coverage among Children, 1996–2002," Health Affairs 23, no. 5 (2004): 39–50.[Abstract/Free Full Text]
17. M. Rosenbach et al., Implementation of the State Children’s Health Insurance Program: Synthesis of State Evaluations (Baltimore: Centers for Medicare and Medicaid Services, 2003).
18. D.C. Ross and L. Cox, Making It Simple: Medicaid for Children and CHIP Income Eligibility Guidelines and Enrollment Procedures (Washington: Kaiser Commission on Medicaid and the Uninsured, 2000).
19. L.J. Blumberg, "Balancing Efficiency and Equity in the Design of Coverage Expansions for Children," Future of Children 13, no. 1 (2003): 203–211.
20. A.W. Lutzky and I. Hill, "Has the Jury Reached a Verdict? States’ Early Experiences with Crowd-Out under SCHIP," Occasional Paper no. 47 (Washington: Urban Institute, 2001).
21. G. Kenney and J. Holahan, "Public Insurance Expansion and Crowd-Out of Private Coverage," Medical Care 41, no. 3 (2003): 337–340.[CrossRef][ISI][Medline]
22. L. Bilheimer, "Expanding Health Insurance Coverage for Children under Title XXI of the Social Security Act" (Washington: Congressional Budget Office, February 1998).
23. See LoSasso and Buchmueller, "The Effect of the State Children’s Health Insurance Program"; and Cunningham et al., The Effects of SCHIP.
24. D. Hughes, J. Angeles, and E. Stilling, Crowd-Out in the Healthy Families Program: Does It Exist? (San Francisco: University of California, San Francisco, Institute for Health Policy Studies, 2002); E. Shenkman, H. Steingraber, and C. Bono, Florida KidCare Program Evaluation Report, January 2002, www.ichp.edu/FloridaKidCare/2001-2002Reports/2001-2002FinalKC3rdYear.pdf (2 July 2004); and R.A. Allison et al., "Do Children Enrolling in Public Health Insurance Have Other Options?" Kansas Health Institute Research Brief (Topeka: KHI, September 2003).
25. Urban Institute tabulations of the 2003 Current Population Survey.
26. Selden et al., "Tracking Changes in Eligibility and Coverage among Children."
27. I. Hill, H. Stockdale, and B. Courtot, "Squeezing SCHIP: States Use Flexibility to Respond to the Ongoing Budget Crisis," Assessing the New Federalism Policy Brief B (Washington: Urban Institute, 2004).
28. Rosenbach et al., "Implementation of the State Children’s Health Insurance Program."
29. See Ross and Cox, "Making It Simple"; and Hill et al., "Squeezing SCHIP."
30. See Hill et al., "Squeezing SCHIP"; and J. Holahan et al., State Responses to 2004 Budget Crises: A Look at Ten States, Research Report (Washington: Urban Institute, 2004).
31. Urban Institute tabulations of CMS expenditure data on SCHIP.
32. E. Park, L. Ku, and M. Broaddus, "OMB Estimates Indicate That 900,000 Children Will Lose Health Insurance Due to Reductions in Federal SCHIP Funding" (Washington: Center on Budget and Policy Priorities, 2002); and Ku and Nimalendran, Improving Children’s Health.
33. Urban Institute tabulations of CMS expenditure data on SCHIP. With a block grant, the total pool of resources available to states is independent of changes in the demand for coverage, which can make it difficult to address changing program needs. Historically, federal funds available through block grants tend to erode in real terms over time. K. Finegold, L. Wherry, and S. Schardin, "Block Grants: Historical Overview and Lessons Learned," Assessing the New Federalism Policy Brief A-63 (Washington: Urban Institute, April 2004).
34. This is less of an issue now because of the increases made to the CPS sample, beginning in 2001, which have increased the precision of the estimates of the proportion of low-income children in a state who are uninsured based on three years of data, but estimates for many states remain imprecise.
35. Urban Institute tabulations of CMS expenditure data on SCHIP.
36. Smith and Rousseau, SCHIP Program Enrollment.
37. U.S. General Accounting Office, SCHIP and Medicaid: Recent HHS Approvals of Demonstration Waiver Projects Raise Concerns (Washington: GAO, 2002); and GAO, SCHIP: HHS Continues to Approve Waivers That Are Inconsistent with Program Goals (Washington: GAO, 2004).
38. L. Dubay and G. Kenney, "Expanding Public Health Insurance to Parents: Effects on Children’s Coverage under Medicaid," Health Services Research 38, no. 5 (2003): 1283–1302[CrossRef][ISI][Medline]; and A. Davidoff et al., "The Effect of Parents’ Insurance Coverage on Access to Care for Low-Income Children," Inquiry 40, no. 3 (2003): 254–268.[ISI][Medline]
39. A. Weil and I. Hill, "The State Children’s Health Insurance Program: A New Approach to Federalism," in Federalism and Health Policy, ed. J. Holahan et al. (Washington: Urban Institute, 2003), 293–323.
40. L. Dubay and G. Kenney, "Gains in Children’s Health Insurance Coverage, but Further Progress Needed," Pediatrics (forthcoming).
41. S. Rosenbaum and B. Smith, "State SCHIP Design and the Right to Coverage," Issue Brief no. 1 (Washington: George Washington University, Center for Health Services Research and Policy, March 2001).

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