The State Children's Health Insurance Program

PURPOSE OF REVIEW: The State Children's Health Insurance Program expanded public health insurance to children who are ineligible for Medicaid yet unable to afford private health insurance. The program was a natural experiment, offering the opportunity to study the effects of expanding health insurance to a large population of children who would otherwise be uninsured. The State Children's Health Insurance Program is reviewed in the context of program goals, evaluation dimensions, past and current findings, and future directions. The studies and findings fall into five dimensions: (1) outreach/enrollment/uptake and profile of enrollees, (2) impact on insurance coverage and uninsured rates, (3) coverage dynamics, (4) impact on outcomes, and (5) costs. RECENT FINDINGS: Older studies focused on outreach, enrollment, characteristics of enrollees, disenrollment, and coverage dynamics. Current studies report the impact of the program on outcomes--including access to care, quality, satisfaction, unmet need, and health outcomes--for the overall population of children and for vulnerable subgroups, including racial and ethnic minorities and children with chronic illness. A smaller number of studies address costs. SUMMARY: The State Children's Health Insurance Program is evolving with demonstrated successes and areas for improvement. This information can enhance practicing pediatricians' understanding of barriers that face low-income children and families in seeking care for their children, can offer insight into what health insurance can and cannot do in terms of ameliorating those barriers, can provide insight into the prior experiences and current medical needs that a new enrollee in the program might have at the first visit to a practitioner, and can illuminate the challenges that low-income children and families may face in obtaining and maintaining health insurance coverage.     

Managed care of children with special health care needs: the ABC Program.

Families of children voluntarily enrolled in a managed care program for children with special health care needs receiving SSI and Medicaid benefits and their case managers were surveyed regarding care satisfaction, quality, and access. Claims data were used to compare the cost and utilization of health care before and during program enrollment. Families rated health care quality improved in 43%, unchanged as "excellent" in 50% of cases. The care received was seen as more nearly complete and of higher quality when the provider was based in the hospital or the hospital's community clinics as compared with "private" community pediatricians. Hospitalization decreased, but no decrease in cost was demonstrated. A carefully planned and implemented managed care program can improve patient perception of quality among chronically ill children.     

Managed care and children with special health care needs.

Providing care to children with special health care needs within a managed care environment presents special challenges for providers and parents alike. The goal of managed care is to contain costs by encouraging or requiring members to obtain services through a designated network. In managed care programs, children and families may experience limited access to specialized care and services, along with decreased fragmentation inherent in fee-for-service care. For providers, managed care creates financial risk while offering opportunities for acquiring new skills and knowledge. The primary care provider assumes a central role in creating a medical home that links the child and family to a single provider who is an ongoing resource and partner in care. To provide comprehensive, coordinated, family-centered care, the medical home provider must learn about a variety of services available within the community and guide parents in learning how to access the services that meet their child's needs. Pediatric nurse practitioners can play a significant role in ensuring that children receive the most appropriate care.     

Insurance coverage and financial burden for families of children with special health care needs.

OBJECTIVE: To examine the role of insurance coverage in protecting families of children with special health care needs (CSHCN) from the financial burden associated with care. METHODS: Data from the 2001 National Survey of Children with Special Health Care Needs were analyzed. We built 2 multivariate regression models by using "work loss/cut back" and "experiencing financial problems" as the dependent variables, and insurance status as the primary independent variable of interest while adjusting for income, race/ethnicity, functional limitation/severity, and other sociodemographic predictors. RESULTS: Approximately 29.9% of CSHCN live in families where their condition led parents to report cutting back on work or stopping work completely. Families of 20.9% of CSHCN reported experiencing financial difficulties due to the child's condition. Insurance coverage significantly reduced the likelihood of financial problems for families at every income level. The proportion of families experiencing financial problems was reduced from 35.7% to 23.0% for the poor and 44.9% to 24.5% for low-income families with continuous insurance coverage (P < .01 for both comparisons). Similarly, the proportion of parents having to cut back or stop work was reduced from 42.8% to 35.9% for the poor (P < .05) and 43.5% to 33.9% for low-income families (P < .01). CONCLUSIONS: Continuous health insurance coverage provides protection from financial burden and hardship for families of CSHCN in all income groups. This evidence is supportive of policies designed to promote universal coverage for CSHCN. However, many poor and low-income families continue to experience work loss and financial problems despite insurance coverage. Hence, health insurance should not be viewed as a solution in itself, but instead as one element of a comprehensive strategy to provide financial safety for families with CSHCN.     

Managed care and children with special health care needs

The implementation of managed care for children with special health care needs is often associated with apprehension regarding new barriers to health care services. At times, these barriers may overshadow opportunities for improvement. This statement discusses such opportunities, identifies challenges, and proposes active roles for pediatricians and families to improve managed care for children with special health care needs.     

Health status of children with special health care needs: measurement issues and instruments.

The methods for measuring health care outcomes and monitoring the health status of the child with a chronic health condition must be available, accessible, and meaningful. This review was evoked by this need to identify reliable and valid instruments for measuring the health status of children with special health care needs. The objectives are as follows: (1) to review the methodologic and substantive issues related to the selection of instruments and (2) to identify those instruments available currently for collecting data regarding health status of children with special health care needs. A Medline search of the literature published since 1966 through 1998 and restricted to human subjects and the English language was conducted. Indexing terms included health status, quality of life, outcome assessment, functional status, and patient satisfaction. Multiple reviewers selected instruments based on their usefulness in clinical settings as generic, disease nonspecific, child health status instruments. Few instruments were identified that can be used by pediatricians for tracking and monitoring the health status of children with special health care needs. In conclusion, to progress in the field of outcomes measurement of children with special health care needs, it will be necessary to develop new measurement tools. These instruments must (1) provide valid and reliable information on health status; (2) be useful in guiding the management of patients; and (3) not be a burden for physicians, patients, or patient's families.     

Assessing family-provider partnerships and satisfaction with care among US children with special health care needs

ObjectivesFamily-provider partnerships and satisfaction with services together are one of the Health Resources and Services Administration's (HRSA) Maternal and Child Health Bureau's (MCHB) 6 core outcomes for children with special health care needs (CSHCN) and are tracked using the 2005–2006 National Survey of Children with Special Health Care Needs. Our objectives were to examine demographic, health, and other correlates/associations, with the perception of family-provider partnership and satisfaction with care; determine the associations between these perceptions and other child/family outcomes; and evaluate differences in the perception of partnership and satisfaction between the families of CSHCN and other children.MethodsWe analyzed data for 40 723 CSHCN from the 2005–2006 National Survey of CSHCN and assessed the prevalence of family-provider partnerships and satisfaction with care and their association with other family-child outcomes. The partnership/satisfaction core outcome results were compared with a referent group of children without special needs included in the 2005–2006 survey.ResultsThe proportion of CSHCN attaining the core outcome was 57.4% and was lower for households with no health insurance, minority ethnic status, non-English speakers, nontraditional family structure, lower income, and lower functioning CSHCN. Lower rates of satisfaction and partnership were associated with poorer child and family outcomes. Disparities in attainment rates were noted for CSHCN versus other children.ConclusionsAlthough parent perceptions of family-provider partnership were relatively high, satisfaction with care contributed to an overall lower attainment rate for the partnership/satisfaction core outcome. Providers, families, government, and advocates need to work together to increase attainment of family-provider partnerships and satisfactory care experiences.