Interim Evaluation Report: Congressionally Mandated Evaluation of the State Children’s Health Insurance Program. C. Evaluation Topics and Research Questions


ASPE identified eight distinct areas of inquiry contained in the evaluation mandate, as follows: (1) SCHIP program choices; (2) outreach and barriers to enrollment; (3) enrollment and retention in SCHIP; (4) enrollment trends; (5) SCHIP's relationship to Title XIX and private insurance; (6) impact of SCHIP on the uninsured; (7) premiums and cost-sharing; and (8) access to care, utilization, and satisfaction with care. These topics reflect key aspects of SCHIP programs and their impacts. Table 1 displays the data sources that are used to explore each of them, and the subsequent narrative identifies the primary questions associated with each topic.

Evaluation Topics Survey of Target Population State Case Studies Survey of Program Administrators Program Data Focus Groups SLAITS Survey Special Studies
1. SCHIP Program Choices   P P       S
2. Outreach and Barriers to Enrollment P S     S S P
3. Enrollment and Retention in SCHIP P S   P S   S
4. Enrollment Trends   S   P      
5. SCHIP's Relationship to Title XIX and Private Insurance P P   P S   S
6. Impact of SCHIP on the Uninsured   S     P    
7. Premiums and Cost Sharing P S   S S   S
8. Access to Care, Utilization, and Satisfaction P S     S    

Note: P indicates primary source for addressing topic; S indicates a secondary source for addressing topic.

Topic: 1. SCHIP Program Choices. A detailed understanding of the context in which states designed and operate their SCHIP programs is essential to critically assess the SCHIP implementation experience. Knowledge about states' program design choices is necessary in order to explore how different choices bear on such key outcomes as enrollment trends, access, and enrollee satisfaction. Program design choices cover many matters, including (among others): outreach, enrollment and retention strategies, benefit design, delivery systems and payment arrangements, cost-sharing policies, anti-crowd-out measures, and state financing.

The key question to be addressed under this evaluation topic is:

  • What are the state characteristics and/or other factors that most influence the design and implementation of SCHIP?

Topics: 2. Outreach and Barriers to Enrollment; 3. Enrollment and Retention in SCHIP; and 4. Enrollment Trends. Perhaps because SCHIP enrollment has grown continuously from year to year, our understanding of the barriers to enrollment and retention and the turnover and churning behind the total enrollment numbers remains limited. For example, the reasons why families enroll and disenroll their children are not well understood. Furthermore, we know little about families' experience with the coordination (or lack thereof) between Medicaid and SCHIP, which is important because of the need for easy transitions between the two programs for low-income families.

Key questions to be addressed under these topics include:

  • What are the trends in SCHIP and Medicaid enrollment? How do they relate to program design choices?
  • What are the barriers to enrollment in SCHIP and Medicaid?
  • Is there a relationship between utilization and enrollment and retention in the program?
  • How does the extent of coordination between Medicaid and SCHIP affect disenrollment of eligible children?
  • Why do some eligible families enroll in SCHIP while others do not?
  • What policies reduce disenrollment of eligible children?
  • Why do eligible children disenroll? How likely are they to reenroll?

Topics: 5. SCHIP's Relationship to Title XIX (Medicaid) and Private Insurance; and 6. Impact of SCHIP on the Uninsured. Little is known about the most recent insurance status of children before they enroll in SCHIP, or about their insurance status following disenrollment. Understanding the role SCHIP plays in the larger scheme of insurance dynamics among low-income children and families is an important evaluation issue, and may help federal and state policymakers guide the program's future effectively and strategically.

Key questions under these topics include:

  • What types of health insurance coverage, if any, do children have before they enroll in SCHIP and after they leave?
  • What is the transition between Medicaid and SCHIP like for children?
  • To what extent does SCHIP enroll children who would otherwise be uninsured, versus children who would otherwise have other coverage, especially private coverage?

Topic: 7. Premiums and Cost-Sharing. Many states have introduced premiums and cost sharing in their programs, and the effects of these program choices on beneficiaries is a subject of keen interest. The two key questions are:

  • Does cost-sharing affect enrollment in SCHIP?
  • What is the effect of cost-sharing on use of services?

Topic: 8. Access to Care, Utilization, and Satisfaction with Care. The purpose of SCHIP and Medicaid is to improve access to health care by providing health insurance. Policy makers and program officials need to know whether the programs are improving access to care, satisfaction, and appropriate utilization and what the chief determinants of these outcomes are.

Key questions to be addressed within this topic include:

  • Do parents of children enrolled in SCHIP and Medicaid report adequate access to care? What is the utilization profile of these children? Are there essential services their parents believe are not available? How satisfied are parents with SCHIP and Medicaid?
  • Does enrollment in SCHIP and Medicaid lead to increased access to care? What is the impact of enrollment in SCHIP and Medicaid on utilization and satisfaction with care?

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