The State Children’s Health Insurance Program (SCHIP) enacted by Congress 10 years ago was the largest single expansion of health coverage for children in the United States in more than 30 years. How the program is working out and to what extent children are benefiting will be important questions when the incoming 110^th Congress turns to reauthorizing SCHIP next year.

To try to answer one of the most significant questions—whether SCHIP is having an impact on children’s access to and use of healthcare--researchers at the University of California San Francisco got support from the Centers for Disease Control and Prevention to analyze the medical data of almost 26,000 children, using 1997, the year predating passage of SCHIP, as the baseline and year 2003 as the comparison.

For starters, the researchers noted some of the characteristics of SCHIP, including:

• The program was created to address the healthcare needs of children from birth to 18 years of age living in near-poor families whose incomes exceed Medicaid eligibility limits but fall below 200 percent of the federal poverty level;
• The SCHIP legislation allowed states to provide coverage by expanding their existing Medicaid programs, creating freestanding separate insurance programs more like employer-sponsored private insurance, or a combination of those approaches. States that created separate programs were allowed greater flexibility in program eligibility, benefits, and costsharing, and could design benefit packages less generous than required under Medicaid;
• Thirty-five states are currently operating either separate SCHIP programs or a combination of SCHIP and Medicaid, and the fact that federal matching funds are higher under SCHIP than under Medicaid, along with the autonomy allowed in program design and implementation, has generated considerable interest in SCHIP.

Congress was motivated to enact SCHIP by the belief that expanding health insurance coverage would increase access to healthcare services, raise the use of preventive medical services, and improve the health of children, since it was known that uninsured children have decreased access to healthcare and have more serious health problems than children in public or private insurance programs. But actually measuring the impact of health insurance on health has turned out to be challenging, though a number of state studies based on interviews with parents of SCHIP children have reported some improvements in access, changes in patterns of healthcare (a greater proportion provided within the usual source of primary care), and better continuity and quality of care.

In the current study, reported in the October issue of the journal Pediatrics, the researchers attempted to determine if those findings apply nationally, possibly providing the kind of information Congress will want when it decides whether to reauthorize SCHIP. To do that, they analyzed data from the National Health Interview Study, a federally administered survey of households, conducted by trained personnel from the U.S. Bureau of the Census, that includes a broad set of access and use measures.

Overall, they found "a significant reduction" from 1997 to 2003 in the proportion of U.S. children without health insurance, down from 8.4 percent in 1997 to 5.3 percent in 2003, with all the reductions attributable to public insurance coverage.

When asked about access to healthcare for children, however, respondents in the target income group reported only "small" effects from SCHIP, possibly in many cases because households turned to SCHIP after losing private insurance that offered equal or wider benefits.

The researchers’ conclusions:

• SCHIP has been highly successful in reducing the number of uninsured children in the United States;
• Implementation of SCHIP is associated with substantial gains in public coverage for children in the target income group;
• There is less evidence of improvements in healthcare access and use for children in the SCHIP target group and need for continued monitoring.

The article "The Impact of Public Insurance Expansions" appears in the October issue of the journal Pediatrics. Correspondence should be addressed to kare.duderstadt@nursing.ucsf.edu

See also:
Separate SCHIP Programs Meet Needs of Special Children, http://www.healthinschools.org/ejournal/2004/mar2.htm and Covering Kids: Health Insurance Matters, http://www.healthinschools.org/coveringkids.asp.