Consequences of SCHIP Expansions for Household Well-Being

About 7.4 million children were covered by the State Childrens Health Insurance Program (SCHIP) at some point during fiscal year 2008. Many of these children would probably have had private coverage in the absence of SCHIP; recent estimates of the extent of crowd-out associated with SCHIP are about 60 percent (Gruber and Simon 2008). The high rate of crowd-out means that the program is not as effective as it could be at reducing the number of uninsured children and has been a political liability for the program. Both political concerns and policy research focusing on crowd-out in SCHIP build on more than a decade of similar attention to the crowd-out associated with the Medicaid expansions of the late 1980s and early 1990s. While there is little doubt that expanding eligibility for public insurance to children who are not poor will lead some to substitute public for private coverage, this substitution should increase total resources available to these households in two ways. First, those who drop private coverage in order to enroll their children in SCHIP can take whatever they had been spending on health insurance and spend it on something else. Second, public insurance requires less cost-sharing than a typical private insurance policy, providing first-dollar coverage with minimal co-payments. This means that switching from private to public coverage reduces a familys out-of-pocket medical spending, freeing up even more of the familys resources for other uses. From the perspective of a low-income family, then, crowd-out is a windfall. In this paper we ask: what do these families do with the additional resources? We address this question with an empirical analysis of consumption data from the Consumer Expenditure Survey. We find that eligibility for SCHIP is associated with an increase in overall expenditure, and most of this increase is allocated to consumption of transportation or saving for retirement. These results suggest that the SCHIP expansions substantially improved the material well-being of the low-income families it is intended to assist including those who had previously been paying for their own coverage. This evidence should allow a better accounting of the benefits and not just the costs of recent expansions in public health insurance programs.

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The Evolution of Medical Spending Risk

The Journal of Economic Perspectives ◽

10.1257/jep.23.4.25 ◽

2009 ◽

Vol 23 (4) ◽

pp. 25-48 ◽

Cited By ~ 24

Author(s):

Jonathan Gruber ◽

Helen Levy

Keyword(s):

Health Insurance ◽

Medical Care ◽

Low Income ◽

Private Insurance ◽

Insurance Coverage ◽

Health Spending ◽

The United States ◽

Consumer Expenditure ◽

Out Of Pocket Payments ◽

Over Time

How has the economic risk of health spending changed over time for U.S. households? We describe trends in aggregate health spending in the United States and how private insurance markets and public insurance programs have changed over time. We then present evidence from Consumer Expenditure Survey microdata on how the distribution of household spending on health—that is, out-of-pocket payments for medical care plus the household's share of health insurance premiums—has changed over time. This distribution has shifted up over time—households spend more on medical care and insurance than they used to—but for the purposes of measuring change in risk, it is not the mean but the dispersion of this distribution that is of interest. We consider two measures of dispersion that serve as proxies for household risk: the standard deviation of the distribution of household health spending and the ratio of the 90th percentile of spending to the median (the so-called “90/50 gap”). We find, surprisingly, that neither has increased despite the rapid rise in aggregate health spending. This conclusion holds true for broad subgroups of the population (for example, the nonelderly as a group) but not for some narrowly-defined subgroups (for example, low-income families with children). We next consider how much risk households should face, from the perspective of economic efficiency. Household risk may not have changed much over the past several decades, but do we have any evidence that this level represents either too much or too little risk? Finally, we discuss implications for public policy—in particular, for current debates over expanding health insurance coverage to the uninsured.

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Abstract P076: Increased Burden Of Chronic Illness Among Insured Compared To Uninsured Sudden Death Victims

Circulation ◽

10.1161/circ.143.suppl_1.p076 ◽

2021 ◽

Vol 143 (Suppl_1) ◽

Author(s):

Reaves Houston ◽

Susan Keen ◽

Chelsea Deitelzweig ◽

Hannah Jones ◽

Sarah Laible ◽

...

Keyword(s):

Health Insurance ◽

Chronic Illness ◽

Sudden Death ◽

Private Insurance ◽

Chronic Illnesses ◽

Categorical Variables ◽

Insurance Status ◽

Public Insurance ◽

Status Data ◽

Lower Frequencies

Introduction: Lack of health insurance is associated with reduced access to medical care and increased mortality. Chronic illness is associated with sudden death, a major cause of natural death. Insurance status of sudden death victims has not been characterized. Hypothesis: Uninsured compared to insured sudden death victims will have more chronic illnesses. Methods: From 2013-2015, emergency medical services-attended out of hospital deaths among ages 18-64 in Wake County, NC were screened to adjudicate sudden deaths. Medical records were reviewed for demographic, clinical, and health insurance status data. Insurance status was characterized as private, public, or no insurance. Cases were excluded from the analysis if no information on insurance was available. Comparisons of demographic and clinical characteristics were made between the three insurance status groups using Student’s t-test and ANOVA for continuous and categorical variables, respectively. Results: Of 399 cases of sudden death, insurance status data was available for 130: 25 (19.2%) had no insurance, 62 (47.7%) had public insurance, 31 (23.8%) had private insurance, and 12 (9.2%) had insurance of unknown type. Uninsured victims had lower frequencies of hypertension, hyperlipidemia, and chronic respiratory disease than those with private or public insurance, and lower frequencies of diabetes mellitus, mental illness, and substance abuse than those publicly insured (Table 1). No significant differences were found in coronary artery disease, age, gender, race, marital status, or years of education. Conclusion: Uninsured sudden death victims have less chronic illnesses than those insured. This counterintuitive finding suggests that uninsured sudden death victims have undiagnosed chronic illnesses that are treatable and preventable and contribute to their death. Our results suggest that expanding health insurance among working age adults may reduce the incidence of sudden death.

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Differential Uptake of Telehealth for Prenatal Care in a Large New York City Academic Obstetrical Practice during the COVID-19 Pandemic

American Journal of Perinatology ◽

10.1055/s-0040-1721510 ◽

2020 ◽

Author(s):

Meghana A. Limaye ◽

Meralis Lantigua-Martinez ◽

Megan E. Trostle ◽

Christina A. Penfield ◽

Erin M. Conroy ◽

...

Keyword(s):

New York ◽

New York City ◽

Prenatal Care ◽

Low Income ◽

York City ◽

Private Insurance ◽

Public Insurance ◽

Public And Private ◽

Key Points ◽

Equity In Access

During the coronavirus disease 2019 (COVID-19) pandemic in New York City, telehealth was rapidly implemented for obstetric patients. Though telehealth for prenatal care is safe and effective, significant concerns exist regarding equity in access among low-income populations. We performed a retrospective cohort study evaluating utilization of telehealth for prenatal care in a large academic practice in New York City, comparing women with public and private insurance. We found that patients with public insurance were less likely to have at least one telehealth visit than women with private insurance (60.9 vs. 87.3%, p < 0.001). After stratifying by borough, this difference remained significant in Brooklyn, one of the boroughs hardest hit by the pandemic. As COVID-19 continues to spread around the country, obstetric providers must work to ensure that all patients, particularly those with public insurance, have equal access to telehealth. Key Points

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OMB Estimates Indicate That 900,000 Children Will Lose Health Insurance Due to Reductions in Federal Schip Funding

International Journal of Health Services ◽

10.2190/cpd3-pgvg-clqd-jca1 ◽

2003 ◽

Vol 33 (2) ◽

pp. 369-381 ◽

Cited By ~ 3

Author(s):

Edwin Park ◽

Leighton Ku ◽

Matthew Broaddus

Keyword(s):

Health Insurance ◽

Federal Funding ◽

Bush Administration ◽

The State ◽

The Other ◽

Fiscal Year ◽

Insurance Program ◽

Health Insurance Program ◽

Enrollment Decline ◽

Uninsured Children

Despite the success of the State Children's Health Insurance Program (SCHIP) in reducing the ranks of uninsured children, the program now faces significant financing challenges. Analysis based on a model developed by the Centers for Medicare and Medicaid Services indicates that by 2007, 20 states will have insufficient federal funding to sustain their current programs, with the first states affected in 2004. As a result, the Office of Management and Budget projected last year that SCHIP enrollment will fall by 900,000 children between 2003 and 2007. The funding shortfalls are the result of several factors. Federal SCHIP funding fell by 26 percent—by more than $1 billion—in each of fiscal years 2002, 2003, and 2004; $1.2 billion in SCHIP funds has already expired and reverted to the Treasury at the end of fiscal year 2002, and another $1.5 billion will expire at the end of 2003. The SCHIP program also has a redistribution system with targeting and timing problems. However, proposed Congressional legislation restoring federal funding, extending the $2.7 billion in expiring funds, and targeting the funds to the states that most need them could avert most, if not all, of the projected enrollment decline. On the other hand, the Bush administration proposed to extend the expiring funds but does not target them to needy states; the proposal will do little to reduce the magnitude of the decline.

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Worse Outcomes Associated with Public Insurance in AYAs with Leukemia and Lymphoma

Blood ◽

10.1182/blood-2018-99-115519 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 977-977

Author(s):

Elysia Alvarez ◽

Helen Parsons ◽

Frances Maguire ◽

Yi Chen ◽

Cyllene Morris ◽

...

Keyword(s):

Overall Survival ◽

Health Insurance ◽

Late Stage ◽

Private Insurance ◽

Stage At Diagnosis ◽

Public Insurance ◽

Medicaid Enrollment ◽

Stage Disease ◽

Late Stage Disease ◽

The Impact

Abstract Introduction: Adolescent and young adult (AYAs: 15-39) patients with cancer have not had the same relative improvement in survival as other age groups over the last decades. Studies have shown that having public insurance or being uninsured at diagnosis is associated with more advanced disease at presentation and worse overall survival. However, previous studies have not differentiated patients who joined Medicaid at diagnosis from those with continuous enrollment which may have different implications for access to care prior to diagnosis. Therefore, we examined the impact of insurance status, including Medicaid enrollment at diagnosis, on stage at diagnosis for AYAs with non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) only] and on survival for AYAs with NHL, HL, acute myeloblastic leukemia (AML), and acute lymphoblastic leukemia (ALL). Methods: Using Medicaid enrollment data linked to the California Cancer Registry, we identified AYAs with NHL, HL, ALL, and AML diagnosed from 2005 to 2014. Insurance type was classified as: continuous Medicaid, discontinuous Medicaid prior to diagnosis, Medicaid at diagnosis, other public (Medicare, Indian/Public Health Service, county), private/military, and uninsured. Multivariable logistic regression and Cox proportional hazards regression were used to determine the impact of insurance type on stage at diagnosis (for NHL and HL) and overall survival, respectively. Results are represented as adjusted odds ratios (OR) and hazard ratios (HR) with associated 95% confidence intervals (CI). Results: Of the 11,667 AYA patients in our study, 4,435 had NHL, 4,161 had HL, 1,522 had AML and 1,549 had ALL. Patients with HL had the highest proportion of private insurance (66%) followed by those with NHL (60%), AML (50%) and ALL (37%). Of the 4,059 patients enrolled in Medicaid, 41% had continuous Medicaid, 15% had discontinuous Medicaid and 43% received Medicaid at diagnosis. Only 2-4% of patients, depending on primary diagnosis, remained uninsured after cancer diagnosis. The majority of AYAs with HL and NHL were diagnosed with stage I/II disease (59% and 52% respectively). Compared to AYAs with private insurance, NHL and HL patients with discontinuous Medicaid and Medicaid at diagnosis had a higher likelihood of later stage disease (III-IV vs I/II) at diagnosis (NHL: discontinuous OR 1.45, CI 1.10-1.92; at diagnosis OR 1.69, CI 1.38-2.06; HL: discontinuous OR 1.63, CI 1.19-2.23; at diagnosis OR 1.68, CI 1.35-2.09) after adjusting for sociodemographic factors, baseline comorbidities and type of facility. In addition, NHL patients with continuous Medicaid (OR 1.23, CI 1.01, 1.51) and HL patients with other public insurance (OR 1.56, CI 1.05-2.32) had a higher odds of late stage disease. Type of health insurance was associated with overall survival in multivariable models (Table). NHL patients with Medicaid (continuous HR 1.74, CI 1.39-2.17; discontinuous HR 2.52, CI 1.94-3.27; at diagnosis HR 1.88, CI 1.53-2.31), other public (HR 1.83, CI 1.16-2.87) and no insurance (HR 1.87, CI 1.09-3.20) had worse survival than NHL patients with private insurance. Similarly, HL patients with Medicaid (continuous HR 2.10, CI 1.42-3.12; discontinuous HR 1.89, CI 1.08-3.29; at diagnosis HR 2.43, CI 1.699-3.48) and no insurance (HR 1.87, CI 1.09-3.20) experienced worse survival. For AML, health insurance was not significantly associated with survival. For ALL, only continuous Medicaid (HR 1.32, CI 1.05-1.67) and other public (HR 1.32, CI 1.05-1.67) insurance were associated with worse survival, though discontinuous Medicaid trended toward significance (p=0.06). Conclusion: Our study demonstrates that a significant proportion of patients previously thought to have public insurance were discontinuously insured with Medicaid or uninsured at time of diagnosis, only receiving Medicaid after diagnosis. While important, insurance enrollment at diagnosis does not provide the same pre-diagnosis access to services as those with continuous enrollment. Indeed, for NHL and HL, we observed the strongest associations between discontinuous Medicaid and Medicaid at diagnosis and late stage disease. However, Medicaid, regardless of type of enrollment, was associated with worse survival in AYAs with NHL, HL and ALL relative to private insurance. Therefore, future studies should focus on factors influencing worse outcomes for AYA patients with public insurance. Disclosures No relevant conflicts of interest to declare.

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Take-Up of Public Insurance and Crowd-out of Private Insurance Under Recent CHIP Expansions to Higher Income Children

10.3386/w17658 ◽

2011 ◽

Cited By ~ 1

Author(s):

Carole Roan Gresenz ◽

Sarah Edgington ◽

Miriam Laugesen ◽

José Escarce

Keyword(s):

Private Insurance ◽

Public Insurance ◽

Crowd Out

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Racial Disparities in Men’s Health and the Transition to Marriage Among Unmarried Fathers

Journal of Family Issues ◽

10.1177/0192513x10365830 ◽

2010 ◽

Vol 31 (9) ◽

pp. 1183-1210 ◽

Cited By ~ 2

Author(s):

Eva C. Haldane ◽

Ronald B. Mincy ◽

Daniel P. Miller

Keyword(s):

Health Insurance ◽

Health Status ◽

Low Income ◽

General Health ◽

Well Being ◽

Good Health ◽

Health Problems ◽

Unmarried Fathers ◽

The Relationship ◽

Transition To Marriage

This article uses data from the Fragile Families and Child Well-being Survey to examine the association between transitioning to marriage and general health status or serious health problems among low-income men. Beginning with a sample of 3,631 unmarried fathers, the study observes the relationship between their transitions to marriage within 3 years after the birth of their child and their health status 5 years postbirth. The authors also explore if unmarried fathers benefit from marrying mothers who have health insurance. Results indicate that transitions to marriage and transitions to marriage with mothers who have health insurance, are associated with fewer serious health problems. The authors did not observe a significant relationship between transitioning to marriage and general health, likely because the sample comprised men who were young (average age was 26 years) and in very good health.

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ACA Medicaid Expansion Associated With Increased Medicaid Participation and Improved Health Among Near-Elderly: Evidence From the Health and Retirement Study

INQUIRY The Journal of Health Care Organization Provision and Financing ◽

10.1177/0046958020935229 ◽

2020 ◽

Vol 57 ◽

pp. 004695802093522

Author(s):

Melissa McInerney ◽

Ruth Winecoff ◽

Padmaja Ayyagari ◽

Kosali Simon ◽

M. Kate Bundorf

Keyword(s):

Older Adults ◽

Metabolic Syndrome ◽

Health Insurance ◽

Low Income ◽

Well Being ◽

Health And Retirement Study ◽

Medicaid Expansion ◽

Poverty Level ◽

Care Needs ◽

Retirement Study

The Affordable Care Act (ACA) dramatically expanded health insurance, but questions remain regarding its effects on health. We focus on older adults for whom health insurance has greater potential to improve health and well-being because of their greater health care needs relative to younger adults. We further focus on low-income adults who were the target of the Medicaid expansion. We believe our study provides the first evidence of the health-related effects of ACA Medicaid expansion using the Health and Retirement Study (HRS). Using geo-coded data from 2010 to 2016, we estimate difference-in-differences models, comparing changes in outcomes before and after the Medicaid expansion in treatment and control states among a sample of over 3,000 unique adults aged 50 to 64 with income below 100% of the federal poverty level. The HRS allows us to examine morbidity outcomes not available in administrative data, providing evidence of the mechanisms underlying emerging evidence of mortality reductions due to expanded insurance coverage among the near-elderly. We find that the Medicaid expansion was associated with a 15 percentage point increase in Medicaid coverage which was largely offset by declines in other types of insurance. We find improvements in several measures of health including a 12% reduction in metabolic syndrome; a 32% reduction in complications from metabolic syndrome; an 18% reduction in the likelihood of gross motor skills difficulties; and a 34% reduction in compromised activities of daily living (ADLs). Our results thus suggest that the Medicaid expansion led to improved physical health for low-income, older adults.

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