CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. Impacts of CHIP and Medicaid on Access, Use, Content of Care and Family Well-Being 55

08/01/2014

Ultimately, the impact of CHIP and Medicaid on the lives of children and their families depends on the extent to which the program improves access to care, receipt of services, and satisfaction with care, and reduces the financial burden of care for the children who enroll. To measure the impact of CHIP on the health and well-being of children and their families, evaluation of these intermediate outcomes is critical. These factors may also influence whether parents want their children to remain in the program and the extent to which they are willing to pay premiums and cost sharing.

CHIP and Medicaid are expected to lower the financial and nonfinancial barriers associated with obtaining care for the children who enroll and increasing enrollees’ access to health care, particularly relative to being uninsured.56 The expected effects of CHIP and Medicaid coverage compared to private insurance are uncertain. On one hand, children enrolled in CHIP and Medicaid generally have a broader benefits package with lower cost sharing than those with private insurance, thereby reducing financial barriers to care relative to those with private insurance.57 On the other hand, physician payments tend to be lower in CHIP and Medicaid, and physicians are more likely to accept privately insured children as new patients compared to children enrolled in CHIP and Medicaid, increasing nonfinancial barriers to care relative to those with private insurance (Zuckerman et al. 2009; Government Accountability Office 2011).

This section presents an assessment of CHIP impacts in the 10 study states and Medicaid impacts in 3 of these states. The estimates contrast the experiences of established enrollees who had been in CHIP (“CHIP enrollees”) or Medicaid (“Medicaid enrollees”) for at least 12 months to the pre-CHIP or pre-Medicaid experiences of comparison samples of recent enrollees. For the CHIP and Medicaid samples, the comparison groups of recent enrollees were classified into two groups: those who were uninsured for at least 5 of the 12 months before they enrolled in the relevant program (“uninsured”), and those who had 12 months of private coverage in the 12 months before they enrolled in the relevant program (“privately insured”). Estimates were computed for each group, controlling for observed differences between the groups. Percentage point differences in mean outcomes for CHIP enrollees and Medicaid enrollees are shown relative to both the uninsured and privately insured comparison groups.58 Analogous analyses for Medicaid were conducted for 3 states, with a generally similar pattern of results.

Children enrolled in CHIP have substantially better access to care compared to uninsured children.

The parents of children enrolled in CHIP reported substantially more confidence in their ability to get needed health care for their children, their children were more likely to have received a range of health services, and they reported fewer financial burdens associated with the child’s health care compared to parental reports of children who lacked coverage (Table VIII.4).59 Estimates in the table show, for example, that the percent with a usual source of care or a private doctor or nurse in the past 12 months was 10 percentage points higher for CHIP enrollees than for children who were uninsured. A parallel study of the health care experiences of children enrolled in Medicaid relative to uninsured children found similar results to those found for CHIP (Appendix Table B.5).

  • Health Care Access. Compared to being uninsured, children enrolled in CHIP had significantly better access to primary care. A total of 88 percent of CHIP enrollees had a regular source of care or provider compared to an estimated 78 percent of uninsured children. Compared to the parents of children who lack coverage, the parents of CHIP enrollees had less trouble finding a variety of providers to see their child. They were between 9 and 11 percentage points less likely to have trouble finding a general doctor or specialist to see their child. Parents of CHIP enrollees were also more likely to report having an easy time making appointments with medical providers.
  • Service Use. Enrollment in CHIP was also associated with increased health care use. Compared to uninsured children, CHIP enrollees were 25 percentage points more likely to have an annual well-child checkup visit: 80 percent of CHIP enrollees received a well-child checkup in the past year versus an estimated 55 percent of uninsured children. Children enrolled in CHIP were also more likely to receive a range of health services, including mental health visits, specialty care, and prescription drugs. However, the rates of use for ED visits and hospitals stays were comparable among children enrolled in CHIP and uninsured children.
  • Content of preventive care received. CHIP enrollees were more likely than uninsured children to receive all of the preventive care measures examined except a developmental screening for children under age 6. CHIP enrollees were 12 percentage points more likely to have had a flu vaccination, 9 percentage points more likely to have had a vision screening, and 18 percentage points more likely to have had their height and weight measured during the year. Moreover, parents of CHIP enrollees were 12 percentage points more likely than parents of uninsured children to have received anticipatory guidance on key health topics.60
  • Oral health care access and use. Children covered by CHIP were much more likely to have had a usual source of dental care compared to uninsured children, an estimated difference of 38 percentage points. The parents of children covered by CHIP were also less likely to have had trouble finding a dentist to see their child compared to uninsured children. Children covered by CHIP were much more likely to have had a dental checkup in the past year and more likely to have received dental sealants, compared to uninsured children. However, among children whose dentist recommended dental follow-up care, children with CHIP were not more likely than uninsured children to have had a dental procedure.
  • Patient-centeredness of care received. Compared to uninsured children, CHIP enrollees were more likely to have had care experiences that meet criteria for having a patient-centered medical home, including receipt of needed referrals, care coordination, and family-centered care. For example, 74 percent of parents of established enrollees reported they were able to obtain referrals for their child when needed, versus an estimated 36 percent of parents of uninsured children, a 38 percentage point difference. Compared to uninsured children, established CHIP enrollees were also 23 percentage points more likely to have received effective care-coordination services and 12 percent more likely to have had care experiences that meet the criteria for being family-centered.
  • Unmet needs. Children with CHIP coverage were less likely than uninsured children to have any unmet health needs. Although nearly one in four (24 percent) CHIP enrollees had an unmet health care need, more than one in three (36 percent) uninsured children were estimated to have an unmet need, a difference of 12 percentage points. Children enrolled in CHIP were between 3 and 7 percentage points less likely to have an unmet need for care from a doctor or health professional, prescription drugs, specialist care, hospital care, and mental health care compared to uninsured children, and are 12 percentage points less likely to have an unmet need for dental care.
  • Parental perceptions of coverage and financial burden of child’s health care. Compared to parental reports for uninsured children, the parents of children enrolled in CHIP were 28 percentage points less likely to report having trouble paying their child’s medical bills and they reported substantially more confidence in their ability to get needed health care for their child. While nearly all (94 percent) parents of CHIP enrollees reported being confident that they can meet their child’s health care needs, two-thirds (67 percent) of the parents of uninsured children reported this level of confidence. In addition, the parents of children who lack coverage were 37 percentage points more likely than the parents of CHIP enrollees to report being stressed about meeting their child’s health care needs.

Table VIII.4. Access, Use, and Care Experiences of Children in CHIP Compared to the Uninsured and those with Private Insurance

  Percentage of CHIP Enrolleesin 10 Statesa Percentage Point Difference Between CHIP Enrollees and Children Who Were Uninsuredb Percentage Point Difference Between CHIP Enrollees and Children Who Were Privately Insuredc
Access to Care Based on Parent Reports
Had USC or private doctor or nurse during past 12 months 88 10** -7**
    USC type: private doctor's office or group practice/HMO 49 9** -22**
    USC has night or weekend office hours 28 2 -13**
    Could reach doctor at USC after hours 37 3 -23**
Provider Accessibility Based on Parent Reports
No trouble finding a general doctor 97 11** -1
No trouble finding a specialist 94 9** -1
Usually/always easy to get appointments with medical provider 83 18** 2
Service Use Based on Parent Reports
Any doctor/other health professional visit 86 19** 0
Any preventive care or checkup visit 80 25** 1
Any specialist visit 21 12** 3
Any mental health visit 7 6** 2
Any emergency department visit 23 -3 -5*
Any hospital stays 4 0 -6**
Content of Preventive Care Received Based on Parent Reports
Flu vaccination 48 12** -9**
Height and weight measurement 92 18** -2
Vision screening 60 9** 2
Developmental screening (combined measure) 30 2 4
Anticipatory guidance (combined measure) 30 12** -3
Patient-Centeredness of Health Care Based on Parent Reports
Obtained referrals when needed 74 38** 0
Received effective care coordination 69 23** 9**
Received family-centered care 47 12** -5
Access to and Use of Oral Health Care Based on Parent Reports
Had dental benefits or coverage for dental services 92 67** 15**
Had USC for dental care 87 38** 7**
    USC for dental care has night or weekend hours 38 3 8*
No trouble finding a dentist 86 8** -5**
Usually/always easy to get appointments with a dental provider 72 18** -3
    Any dental visit for checkup or cleaning 84 39** 5*
        Dentist recommended additional or follow-up treatment 37 2 5
            Had dental procedure, such as cavity treated or tooth pulled 68 -4 -1
Dental sealants (if age > 6 years) 54 13** 2
Unmet Needs Based on Parent Reports
Doctor/health professional care 5 -7** 2
Prescription drugs 6 -7** -2
Specialists 5 -6** -3
Hospital care 3 -7** 0
Mental health care 3 -3* -1
Dental care 12 -12** 0
Any unmet need 24 -12** 3
Parental Perceptions of Coverage and Financial Burden of Child’s Health Care
Very or somewhat confident could get needed health care for child 96 27** 5**
Never or not very often stressed about meeting child’s health care needs 84 37** 12**
No problem paying child's medical bills (or no out-of-pocket costs) 92 28** 23**
Out-of-pocket costs: greater than $0 up to $250 3 -4** -1
Out-of-pocket costs: between $250 and $2,000 4 -21** -14**
Out-of-pocket costs: greater than $2,000 1 -1* -6**

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

Notes: The regression-adjusted differences derived from multivariate regression models control for age, sex; race/ethnicity and language groups, more than three children in the household, highest education of any parent, parents’ employment status, parent citizenship, and local area or county. Sample sizes diff across outcome indicators due to differences in response rates and survey skip patterns. "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. USC = usual source of care

a CHIP enrollees are those enrolled in CHIP for at least 12 months at time of sampling.

b Uninsured children had 5 or more months without any coverage in the past 12 months.

c Privately insured children had 12 months of private coverage in the past 12 months.

*/** Indicates that the values are statistically different from CHIP enrollees at the 0.05/ 0.01 level.


Medicaid also improved access to care for children who enrolled.

A parallel study of Medicaid impacts on access to care in three states (California, Florida, and Texas) relative to uninsured children found similar results to those found for CHIP, with higher levels of access and use relative to the uninsured, and parents more confident that they can meet their child’s health care needs (Appendix Table B.5). However, compared to CHIP, Medicaid appears to have had less of an impact on reducing the unmet need for dental care. Parents of children enrolled in Medicaid reported financial burdens that are as low as or even lower than those in CHIP, with parents of Medicaid children 30 percentage points more likely to have reported no problems paying for children’s health care relative to uninsured children.

Compared with private coverage, access and service use for CHIP enrollees was comparable for many measures but not as good for some. Financial burdens were substantially lower and dental access was better in CHIP.

Findings from the impact analysis suggest that children enrolled in CHIP and those with private insurance had largely similar health care access and service use, dental service use, levels of unmet need, and patient-centeredness of care, but CHIP enrollees were somewhat less likely to have a regular source of care and nighttime and weekend access to that source of care, and they were somewhat more likely to have a regular source of dental care (Table VIII.4). The parents of children enrolled in CHIP reported having had substantially less trouble paying their child’s medical bills, and were more likely to report that their child had “adequate” health insurance coverage (described below)—as well as more confidence and less stress associated with getting health care for their children.61

  • Health care access and use. Relative to privately insured children, CHIP enrollees were less likely to have a regular source of care or provider and nighttime and weekend access to a USC. Both groups of children experienced a similar level of problem finding a general doctor or specialist, and a similar level of ease in getting appointments with medical providers. Children with CHIP coverage used a similar level of preventive care and other health care services compared to children with private insurance, except CHIP enrollees had higher usage of prescription medicines and lower levels of ED visits and hospital stays.
  • Content of preventive care received. Children enrolled in CHIP had generally similar experiences to children with private insurance in terms of the content of preventive care received. Both groups had similar rates of health and development screenings and anticipatory guidance. The only significant difference was for receipt of a flu vaccination—CHIP enrollees were 9 percentage points less likely than privately insured children to receive a flu vaccination, 48 percent versus 39 percent, respectively.
  • Oral health care access and use. Overall, children covered by CHIP appear to have somewhat greater access to dental care compared to children with private coverage. While the vast majority (92 percent) of the parents of CHIP enrollees reported that their children had dental benefits, only about three-quarters (77 percent) of the parents of privately insured children reported having access to these benefits, a difference of 15 percentage points. Children covered by CHIP were more likely to have a usual source of dental care, and to have access to this usual source of dental care at night or on weekends. Their parents were also more likely to report that it was easy to get an appointment with a dentist. Compared to children with private coverage, children covered by CHIP were more likely to have had a dental checkup or cleaning and equally likely to have received dental sealants. Parents of CHIP enrollees were more likely to report problems with the condition of their child’s teeth, although these problems could have pre-dated their CHIP enrollment (data not shown).
  • Patient-centeredness of care received. CHIP enrollees were 10 percentage points more likely to have received comprehensive and effective care coordination services than privately insured children, 69 percent versus 59 percent, respectively. Nevertheless, CHIP enrollees were less likely than privately insured children to have had care experiences that met the criteria for having a patient-centered medical home. Roughly one-quarter of CHIP enrollees meet the criteria for having a medical home compared to one-third of privately insured children. This result is driven largely by the higher likelihood of having a regular source of care or provider among privately insured children. There are no significant differences between privately insured and CHIP children on the other three medical home components examined.
  • Unmet needs. Children with CHIP coverage have similar levels of unmet health need compared to children with private insurance.
  • Parental perceptions of coverage and financial protection of child’s health insurance. The parents of children enrolled in CHIP reported substantially less trouble paying their child’s medical bills compared to those with private coverage and had much lower out-of-pocket spending levels. Compared to parental reports for privately insured children, the parents of children enrolled in CHIP were 23 percentage points less likely to report having trouble paying their child’s medical bills. Parents of CHIP enrollees were more likely to report feeling very confident in their ability to meet their child’s health care needs and more likely to report that meeting their child’s health care needs did not often cause stress.
  • Children enrolled in CHIP were also more likely to be considered “adequately” insured across three domains— adequacy of benefits, adequacy of access to providers, and financial protection —particularly when taking into account coverage for dental benefits (data not shown).62

Children enrolled in Medicaid generally had similar experiences to privately insured children who later enroll in Medicaid, but Medicaid enrollment was associated with much higher levels of affordability.

A parallel study of Medicaid impacts on access to care in three states (California, Florida, and Texas) relative to privately insured children who later enroll in Medicaid found similar results to those found for CHIP, indicating that experiences were generally similar between the two groups (Appendix Table B.5). One exception is that children enrolled in Medicaid were less likely to have a preventive care visit than privately insured children; this difference was not observed in the analysis of CHIP enrollees. Similar to CHIP, Medicaid enrollment was associated with much higher levels of affordability compared to the comparison group of privately insured children. Nearly all (95 percent) of parents of children enrolled in Medicaid did not have trouble paying their child’s medical bills, whereas that share was only 70 percent among children in private coverage.


55 For further details on findings reported in this section of the chapter, see Clemans-Cope et al. (2013a) and Clemans-Cope et al. (2013b), contained in Harrington and Kenney et al. (2014).
56However, a priori, the expected effects of CHIP and Medicaid enrollment on visits to the ED and hospital stays are not clear.
57 For a comparison of benefits and cost sharing in Medicaid and private plans, see Baumrucker and Fernandez (2013).
58 The main CHIP findings reported are from models that combined all 10 states, but separate models estimated for each state produced generally similar patterns, as did separate models for different subgroups of enrollees.

59 As described above, these findings control for observed differences between the two groups.
60 Parents of CHIP enrollees are between 15 and 19 percentage points more likely to report having discussions with the child’s provider about how to avoid child injuries, the child’s eating and exercise habits, and the risks of secondary smoke, than parents of uninsured children.

61 As described above, these findings control for observed differences between the two groups.

62 The composite measure of insurance adequacy used in this analysis combines parental responses to questions about the following: whether the child’s health insurance offered benefits or covered services that met the child’s needs; adequacy of access to various providers through child's health insurance, and whether the parent was told by a provider that they do not accept child’s health coverage; and whether the parent reported having trouble paying child’s medical bills, if any were reported.

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