CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. Access, Service Use and Care Experiences of CHIP and Medicaid Enrollees <sup>51</sup>

08/01/2014

CHIP provided high levels of access to care, but areas for program improvement remain.

Overall, CHIP programs were meeting the health care needs of most of the children who enroll. CHIP enrollees had high levels of access to providers; almost all children enrolled in CHIP had seen a medical and dental provider in the past year and the vast majority of parents of CHIP enrollees reported feeling very confident their child will be able to get needed health care. However, despite high rates of overall service use in outpatient settings, one in four CHIP enrollees had an unmet health care need and many children enrolled in CHIP were not receiving recommended preventive care (Table VIII.1).

  • Health care access and use. Most CHIP enrollees had access to a regular source of care or provider and had little trouble finding or obtaining appointments with providers.52 More than 85 percent of children enrolled in CHIP had seen a doctor or health care professional in the past 12 months, and 80 percent had received a well-child visit. However, only 28 percent of CHIP enrollees had a usual source of care (USC) that offered appointments at night or on the weekend, and only 37 percent had after-hours access to a provider at their usual source of care. This may contribute to greater use of the emergency department, and nearly one-quarter of CHIP enrollees had an emergency department (ED) visit in the past year.
  • Content of preventive care received. Although most enrollees received annual well-child checkups, including having their height and weight measured, many children covered by CHIP were not receiving recommended health screenings and anticipatory guidance on a regular basis. For example, 60 percent had their vision screened in the past year, but slightly less than half received a flu vaccination and only about one-third received anticipatory guidance on all four key health topics examined, or a developmental screening (among children under age 6).53
  • Oral health care access and use. The vast majority of CHIP enrollees’ parents accurately reported that their child’s insurance covers dental benefits, and most (89 percent) reported they did not have trouble finding a dentist who would see their child. Nine in 10 CHIP enrollees had a USC for dental care, but less than 40 percent of them had access to a dental provider at the USC on nights or weekends. More than 80 percent of CHIP enrollees received a dental cleaning or checkup in the past year, and 54 percent of children over age 6 had dental sealants placed on their back teeth—a rate exceeding targets established in “Healthy People 2020” (U.S. DHHS). A significant share (32 percent) of CHIP enrollees did not get dental treatment when follow-up dental treatment was recommended by a dentist, and parents of over half of children enrolled in CHIP reported that their child’s teeth were in less than excellent or very good condition (data not shown).
  • Patient-centeredness of care received. Parents of CHIP enrollees reported positive care experiences with their child’s providers at high rates on most aspects of patient-centered care. Most parents reported they had no problem getting referrals when needed (74 percent) and received effective care coordination across a number of care coordination elements (68 percent).54 A relatively high proportion of CHIP enrollees’ parents also reported having family-centered care interactions with their child’s provider across the six dimensions of this care component. Specifically, about 65 to 80 percent reported that the provider usually spends enough time with the child, always listens carefully, is sensitive to family values/customs, gives needed information, makes the family feel like a partner, and receives interpreter services when needed. However, only 47 percent of CHIP enrollees’ parents reported positive care experiences on all six of these dimensions of family-centered care.
  • Unmet need. Almost one in 4 CHIP enrollees had an unmet need for any type of care. Unmet need was highest for dental care (12 percent of enrollees). About one in 20 CHIP enrollees had an unmet need for physician services, prescription drugs, or specialty care. Unmet need was lowest for hospital care and mental health service (about 3 percent).
  • Parental perceptions of coverage and financial burden of child’s health care. Most parents of CHIP enrollees (96 percent) were confident that they could get health care to meet their child’s needs, with more than 8 in 10 parents reporting never or not often feeling stressed about meeting these needs. In addition, only 8 percent of parents reported that they had any problem paying their child’s medical care bills in the past year—3 percent reported having out-of-pocket costs between $0 and $250, 4 percent reported out-of-pocket costs between $250 and $2,000, and less than one percent reported out-of-pocket costs greater than $2,000.

Table VIII.1. Access, Use, and Care Experiences In the Past 12 Months Among Established CHIP Enrollees, Based on Parent ReportsTable VIII.1. Access, Use, and Care Experiences In the Past 12 Months Among Established CHIP Enrollees, Based on Parent Reports

Reports for the Past 12 Months Percent
Access to Care Based on Parent Reports
 Had USC or personal doctor or nurse during past 12 months 88
    USC Type: Private doctor's office or group practice/HMO 49
    USC has night or weekend office hours 28
    Could reach doctor at USC after hours 37
Provider Accessibility Based on Parent Reports
    No trouble finding a general doctor 97
    No trouble finding a specialist 94
    Usually/always easy to get appointments with medical provider 83
Service Use Based on Parent Reports
Any doctor/other health professional visit 86
Any preventive care or checkup visit 80
Any specialist visit 21
Any mental health visit 7
Any emergency department (ED) visit 23
Any hospital stays 4
Content of Preventive Care Received Based on Parent Reports
Height and weight measurement 92
Vision screening 60
Flu vaccination 48
Anticipatory guidance on four key health topics 30
Developmental screening (among children under age 6) 30
Access to and Use of Oral Health Care Based on Parent Reports
Has dental benefits or coverage for dental services 92
Had USC for dental care 87
    USC for dental care has night or weekend hours 38
No trouble finding a dentist 89
Usually/always easy to get appointments with dental provider 72
    Any dental visit for checkup or cleaning 84
        Dentist recommended additional or follow-up treatment 37
            Had dental procedure, such as having a cavity treated or tooth pulled 68
Dental sealants (if age > 6 years) 54
Patient Centeredness of Health Care Based on Parent Reports
Obtained referrals when needed 74
Received effective care coordination 68
Received family-centered care 47
Unmet Needs Based on Parent Reports
Doctor/health professional care 5
Prescription drugs 6
Specialists 5
Hospital care 3
Mental health care 3
Dental care 12
Any unmet need 24
Parental Perceptions of Coverage and Financial Burden of Child’s Health Care
Very or somewhat confident could get needed health care for child 96
Never or not very often stressed about meeting child’s health care needs 84
No problem paying child’s medical bills for care (or no out-of-pocket costs) 92
Out of pocket costs: Greater than $0 up to $250 3
Out of pocket costs: Between $250 and $2,000 4
Out of pocket costs: Greater than $2,000 1

Source: 2012 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees.

Notes: Anticipatory guidance topics examined include: (1) how to avoid injury, (2) child’s eating habits, (3) child’s exercise habits, and (4) risks of secondary smoke. Receipt of effective care coordination is a composite measure that incorporates assessments of (1) communication between doctors when needed, (2) communication between doctors and schools when needed, and (3) getting help coordinating care when needed. Receipt of family-centered care is a composite measure based on parent reports of whether (1) the child’s provider usually spends enough time with the child, (2) always listens carefully, (3) is sensitive to family values/customs, (4) gives needed information, (5) makes the family feel like a partner, and (6) getting non-family member to interpret conversations with doctors or other health care providers. "No out-of-pocket costs" includes those who indicated out-of-pocket costs but then said they had no problem paying, or later indicated they paid $0 in out-of-pocket costs.


Medicaid enrollees had similar access and use experiences as CHIP enrollees.

Levels of primary care access and use were generally similar among CHIP and Medicaid enrollees in three selected states (California, Florida, and Texas), and consistent with the 10-state CHIP results presented above (Medicaid findings are presented in Appendix Table B.4). Similar to CHIP enrollees, most Medicaid enrollees had a regular source of care or provider, received a preventive medical and a dental care visit in the past year, and generally had little trouble finding a provider or obtaining appointments when needed.

Medicaid enrollees were less likely than CHIP enrollees to have a private provider as their USC, and they had similarly low access to their USC at nighttime and on weekends. For most of the services examined, levels of service use were similar between CHIP and Medicaid enrollees. One notable exception was the rate of hospitalization, which was twice as high for Medicaid enrollees (8 percent versus 4 percent). Despite similar rates of service use between children enrolled in Medicaid and CHIP, parents of Medicaid enrollees reported higher rates of unmet need. Almost one in three children enrolled in Medicaid in the three states had some type of unmet need in the past year (versus one in four CHIP children).

Access to care under CHIP varied with respect to the child’s race/ethnicity and primary language, age, parents’ educational attainment, and health care needs.

While CHIP provided high levels of access to care for most children, some groups of children appear to be faring better than others in CHIP. Table VIII.2 shows differences in selected access and use measures across subgroups.

Table VIII.2. Variation in Selected Access and Use Measures Under CHIP, by Child and Parent Characteristics

  Percent of Parent’s Reporting for Past 12 Months
  Child Had A Regular Source of Care or Provider USC is a Private Doctor’s Office, Group Practice, or HMO Child Had Preventive Care or Check-up Visit Child Had Specialist Visit Child Received Patient- Centered Care (Composite) Child Had an Unmet Need for Care Parent Confident Could Get Needed Health Care Parent(s) Had No Problem Paying Child’s Medical Bills
All CHIP Enrollees 88 49 80 21 47 24 96 92
Race/Ethnicity and Primary Language (PL)
Hispanic                
    PL: English 88 49** 78 20** 49** 24 97 90
    PL: Spanish 88 40** 78 15** 37** 26 94 95**
Non-Hispanic
White 91 67 82 29 62 23 97 90
Black 86** 47** 83 22** 51** 21 96 94**
Age of Child                
    1 to 5 years 88 48 87** 16 49 21 96 96
    6 to 12 years 88 49 80 19 48 23 97 93**
    13 to 18 years 88 49 77** 25** 45 27* 94 90**
Highest Education Level of Parents
Less Than High School 86 32 74 15 30 26 67 94
High School 85 45** 78 21** 47** 23 73 92
More Than High School 91** 59** 83** 23** 55** 24 80 91**
Health Status of Child
Without Special Health Care Needs 86 46 78 37 45 20 96 94
With Special Health Care Needs 93** 56** 83** 15** 52** 38** 95 87**

Source: 2012 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees.

Notes: Tests of significance compare children with this characteristic to the reference category (in italics). Primary language is based on interview language. Receipt of family-centered care is a composite measure based on parent reports of whether (1) the child’s provider usually spends enough time with the child, (2) always listens carefully, (3) is sensitive to family values/customs, (4) gives needed information, (5) makes the family feel like a partner, and (6) getting non-family member to interpret conversations with doctors or other health care providers.

**p-value (of difference) < 0.01; * p-value (of difference) < 0.05 level.


  • Race/ethnicity and language. Relative to non-Hispanic white enrollees, Hispanic and non-Hispanic black enrollees were less likely to have a regular source of care or provider, a private doctor’s office for their USC, and access to a provider at their USC at nighttime and on weekends. They were also less likely to have seen a doctor or health professional or to have received care from a specialist in the past 12 months. There were no significant differences across racial and ethnic subgroups in the ease of finding and making appointments with providers or in receipt of most of the preventive care services examined. However, parents of Hispanic and Non-Hispanic black enrollees were less likely to report patient-centered care experiences than white enrollees. Where there were differences in access to care between Non-Hispanic white enrollees and Hispanics or non-Hispanic black enrollees, the differences tended to be largest for Hispanics whose primary language is Spanish.
  • Age. Service use patterns tended to vary with the age of the child in ways that reflect the changing types of care children need and receive as they grow and develop. For example, the recommended rate at which children should receive well-child checkups varies by age, with more frequent visits recommended for younger children than adolescents. Consistent with this, we find a higher rate of well-child checkups for younger children. No age differences were found in access to a regular source of care or provider, provider accessibility, or the patient centeredness of care received. However, unmet need was higher among adolescents than younger children—roughly one-third of children ages 13 to 18 had an unmet need for any care versus one-fifth of children ages 1 to 5.
  • Parent’s education. CHIP enrollees whose parents had more education tended to have higher rates of access to care and outpatient service use, and lower hospitalization rates. Parents with more education also tended to report higher levels of confidence in their ability to meet their child’s health care needs. Differences were more pronounced and more likely to be significant when comparing enrollees whose parents have less than a high school education to enrollees whose parents have some college education. For example, CHIP enrollees whose parents had some college education were 10 percentage points more likely to have a preventive care visit than enrollees whose parents had less than a high school education.
  • Health status. Not surprisingly, CHIP enrollees with at least one special health care need (SHCN) were more likely to have a regular source of care or provider, a private doctor’s office as a USC, and a USC with night or weekend hours. Children with an SHCN were also more likely to have seen a general doctor or specialist in the past year, to have received a well-child visit, and to have patient-centered interactions with providers. However, children with an SHCN had roughly two- to three-times greater rates of unmet need for every type of health service examined compared to children without an SHCN. Unmet needs for children with an SHCN were especially high for prescription drugs (25 percent) and specialist care (10 percent).

Access to care was high but variable across states, with no apparent pattern to the variability.

Although CHIP enrollees tended to experience high levels of access to primary care in each of the 10 study states, several key access and use measures varied considerably across states, with few consistent patterns indicating persistently high- or low-performing states. Cross-state variation for selected primary care measures is shown in Table VIII.3.

  • Health care access. CHIP enrollees’ access to general doctors and specialists did not vary extensively across states, with the exception of USC characteristics. For example, the percentage of CHIP enrollees who had access to a regular source of care or provider ranged narrowly from 87 percent in Texas to 94 percent in Utah. However, there was considerable variation across states in the type of provider as the USC, and in access to USC providers during nighttime and weekends. For example, CHIP enrollees in Michigan were 30 percentage points more likely than enrollees in California to have a private doctor’s office or group practice as their USC, and the share of enrollees with a USC that has night or weekend office hours ranged from 20 percent in Louisiana to 44 percent in Utah (data not shown).
  • Service Use. Overall service use was consistently high across the study states, but rates of receipt of different types of care varied considerably. For example, the share of enrollees who received a well-child check-up in the last 12 months ranged from 66 percent in Utah to 88 percent in New York. There was also a two-fold difference in service use rates for specialist visits, mental health care, and prescription medicine between the lowest state and the highest state. Despite this variation in service use across states, unmet need for care did not vary extensively across states.
  • Patient-centeredness of care received. There were considerable differences across states in the patient-centeredness of care received. For example, the percentage of parents reporting that their child received family-centered care ranged from 40 percent in California to 67 percent in Michigan. There was also a 20 percentage point difference between the highest and lowest states in the share of parents of CHIP enrollees reporting that their child received referrals when needed and effective care coordination (not shown). Finally, in all 10 states, most parents of CHIP enrollees felt very confident in their ability to meet their child’s health care needs (ranging from 94 percent in Virginia to 99 percent in Alabama) and never or rarely had problems paying for their child’s medical bills (ranging from 85 percent in Utah to 97 percent in Louisiana).

Table VIII.3. Variation in Selected Access, Use, and Financial Burden Measures Under CHIP, by State

  Percent ofParent’s Reporting for Past 12 Months
  Child Had A Regular Source of Care or Provider USC is a Private Doctor’s Office, Group Practice, or HMO Child Had Preventive Care or Check-up Visit Child Had Specialist Visit Child Received Family- Centered Care (Composite)a Child Had an Unmet Need for Care Parent Confident Could Get Needed Health Care Parent(s) Had No Problem Paying Child’s Medical Bills
Pooled 10-state 88 49 80 21 47 24 96 92
Alabama 92* 65** 73* 35** 62** 14** 99** 90
California 86* 39** 76** 14** 40** 26 95 94**
Florida 88 60** 85** 25** 50 27 95 89*
Louisiana 87 52 78 28* 52 19* 97 97**
Michigan 92* 69** 81 33** 67** 18* 98** 91
New York 91** 57** 88** 30** 52** 23 96 93*
Ohio 91 60** 82 28** 61** 20 96 93
Texas 87 48 80 22 45 26 96 88**
Utah 94** 56* 66** 19 61** 20 97 85**
Virginia 90 62** 80 20 47 25 94 92

Source: 2012 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees.

**Difference between the state outcome and the mean outcome of the nine other states collectively is statistically significant at p -value<0.01; * significant at p-value<.05.

a This is a composite measure of family-centered care based on parent reports of whether the child’s provider usually spends enough time with the child, always listens carefully, is sensitive to family values/customs, gives needed information, and makes the family feel like a partner.


51 For further details on findings reported in this section, see Smith and Dye (2013), contained in Harrington and Kenney et al. (2014).

52 Access to a regular source of care or provider is a composite measure that incorporates (1) presence of a usual source or care and (2) having a personal doctor or nurse, and we use it to assess whether a child had a continuous source of care during the previous 12 months. More information on the construction and individual components of this measure can be found in Smith and Dye (2013), contained in Harrington and Kenney et al. (2014).

53 Anticipatory guidance topics examined include: (1) how to avoid injury, (2) child’s eating habits, (3) child’s exercise habits, and (4) risks of secondary smoke.

54 Receipt of effective care coordination is a composite measure that incorporates assessments of (1) communication between doctors when needed, (2) communication between doctors and schools when needed, and (3) getting help coordinating care when needed.

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