Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER Expanded Insurance Coverage

Intervention Description: Objectives: To use Medical Expenditure Panel Survey data to determine (1) whether adolescent well visit rates increased from the pre-ACA period to post-ACA period, and (2) whether caregivers' reports of past-year preventive services delivery increased from the pre- to post-ACA period among adolescents with any past-year health care visit.

Intervention Results: Under objective 1, we found that well-visit rates increased from 41% to 48% post-ACA implementation (odds ratio, 1.3; 95% CI, 1.2-1.5); minority and low-income groups had the greatest increases. Under objective 2, we found that among those with any past-year visit, most preventive services rates (8 of 9) increased post-ACA implementation (range, 2%-9%, absolute), with little or no change when controlling for demographic variables. Time alone with clinicians increased 1%, significant only when covariates were controlled (adjusted odds ratio, 1.2; 95% CI, 1.0-1.3).

Conclusion: Despite modest to moderate increases, with greatest gains for underserved youth, adolescent preventive care rates remain low, highlighting the need for increased efforts to bring adolescents into well care and improve clinician delivery of preventive care within their practices.

Study Design: QE: pretest-posttest

Setting: U.S.

Population of Focus: Adolescents ages 10-17

Data Source: Medical Expenditure Panel Survey

Sample Size: Total (N=25,695)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Expanded Insurance Coverage PAYER

Intervention Description: This study looked at the impact of the State Children's Health Insurance Program (SCHIP) on access to care and satisfaction among vulnerable subgroups of children in three diverse states - Florida, Kansas, and New York. The vulnerable subgroups included minority children, children with special health care needs, and children who were uninsured for long periods before enrolling. The study used a pre-post design, surveying newly enrolled children and their families about the 12 months before enrollment and again about the 12 months after enrollment.

Intervention Results: This study provides consistent evidence, from three very diverse states with heterogeneous populations and distinct programs (Florida, Kansas, and New York), that the State Children's Health Insurance Program (SCHIP) increased access to and satisfaction with health care among enrolled low-income children and that vulnerable children-minorities, children and adolescents with special health care needs, and children who were uninsured for long periods of time-shared in these improvements.

Conclusion: The study provides evidence from three very different states that SCHIP conferred benefits in access and satisfaction to the most vulnerable low-income children, not just average enrollees. As states face budget pressures and consider SCHIP policy changes, policymakers should consider these findings that the program improved care for the subgroups that are most at risk for poor access and unmet health care needs. Some areas for further improvement include increasing preventive care for Hispanic children and reducing the still high level of unmet need among CSHCN.

Study Design: QE: pretest-posttest

Setting: Florida, New York, Kansas

Population of Focus: Children and adolescents ages 1-18 who had enrolled in CHIP between July 2000 and March 2001

Data Source: Interviews

Sample Size: Florida (n=918)4 N=adolescent ages 12-18 New York (n=2,290) N=all children ages 1-18 Kansas (n=434) N=all children ages 1-18

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Expanded Insurance Coverage PAYER

Intervention Description: The evaluation of the Children's Health Insurance Program (CHIP) mandated by the CHIP Reauthorization Act of 2009 was conducted by Mathematica Policy Research and the Urban Institute. The evaluation included case studies in 10 states selected to provide geographic and demographic diversity, a nationwide telephone survey of state CHIP administrators, analysis of state eligibility and enrollment data, and a survey of 12,000 CHIP enrollees and disenrollees in the 10 study states, as well as 3,400 Medicaid enrollees and disenrollees in 3 of the states. The surveys collected information on health status, service utilization, and families' experiences with application, enrollment, and renewal processes. Other components included analysis of data from national surveys to examine coverage trends and Medicaid/CHIP participation rates.

Intervention Results: The evaluation found that CHIP, together with Medicaid, has significantly reduced uninsurance among low-income children, from 25% in 1997 to 13% in 2012, with coverage disparities narrowing for Hispanic children. Medicaid/CHIP participation rates increased from 82% in 2008 to 88% in 2012, with 21 states achieving rates above 90%. Relatively few CHIP enrollees had private coverage prior to enrollment, and direct substitution of CHIP for private coverage was estimated to be as low as 4%. The vast majority of children remained enrolled in CHIP for at least 28 months, and most disenrollees exited due to ineligibility. Compared to uninsured children, CHIP enrollees experienced better access to care, fewer unmet needs, and greater financial protection. While comparable to private coverage on many measures, CHIP enrollees had better access to dental care and much lower financial burden. Despite high rates of preventive visits, nearly 25% of enrollees had unmet needs and many were not receiving key

Conclusion: The evaluation demonstrated CHIP's success in expanding health insurance coverage for low-income children, improving their access to health care, and reducing financial burden and stress for their families across states with diverse program designs. Despite progress, further efforts are needed to cover the remaining 3.7 million uninsured children who are eligible for Medicaid or CHIP and improve retention and continuity of coverage. With the uncertain future of CHIP funding beyond 2015 and the changing health care landscape under the Affordable Care Act, the evaluation's insights on the value of CHIP and children's unique health care needs are particularly relevant for policymakers. Continuing to build on CHIP's accomplishments in providing affordable, comprehensive coverage will be critical to ensure that all low-income children can obtain the health care they need.

Study Design: QE: non-equivalent control group

Setting: Ten states: Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia

Population of Focus: Youth ages 13 and older enrolled in CHIP for at least 12 consecutive months

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

Sample Size: Established enrollees (n≈2345) Uninsured children (n≈381) N=children >13 years

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER Expanded Insurance Coverage

Intervention Description: Examine the extent to which enrollment in the State Children's Health Insurance Program (SCHIP) affects access to care and service use in 10 states that account for over 60 percent of all SCHIP enrollees.

Intervention Results: Significantly higher percentage of adolescent well visits for CHIP enrollees vs children uninsured for at least 2 months in the prior year (p<.01)

Conclusion: Enrollment in SCHIP appears to be improving children's access to primary health care services, which in turn is causing parents to have greater peace of mind about meeting their children's needs.

Study Design: QE: non-equivalent control group

Setting: Ten states; California, Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey, New York, North Carolina, and Texas

Population of Focus: Children enrolled in SCHIP for at least 5 months

Data Source: Surveys of 16,700 SCHIP enrollees

Sample Size: Established enrollees (n≈1747)6 Uninsured children (n≈758) N= children >13 years

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER Expanded Insurance Coverage

Intervention Description: We assessed the impact of New York's State Children's Health Insurance Program on access, use, and quality of care for adolescents.

Intervention Results: Significantly higher number of preventive-care visits in the insured group (8.3% difference; p=.003)

Conclusion: Adolescents who enrolled in New York's State Children's Health Insurance Program experienced improved access, use, and quality of care. These findings suggest that the provision of health insurance can help to improve health care for adolescents.

Study Design: Time 1/time 2 (T1/T2) cohort design

Setting: New York City, the urban environs of New York City, upstate urban areas, and upstate rural regions

Population of Focus: Adolescents ages 12-18 in New York State

Data Source: Telephone interviews

Sample Size: N=1118 at baseline N=970 at follow-up

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER Expanded Insurance Coverage

Intervention Description: Data are from 64,565 youth (ages 0–17 years) participants in the 2011 to 2015 National Health Interview Survey. We conducted multivariate logistic regression analyses to determine how the period after national implementation of the ACA (years 2011–2013 vs years 2014–2015) was associated with health insurance coverage and utilization of health care services (well-child visits, having visited an emergency department, and having visited a physician, all in the past 12 months), and whether changes over the pre- and post-ACA periods varied according to race and Latino ethnicity.

Intervention Results: The post-ACA period was associated with improvements in insurance coverage and well-child visits for all youth. Latino youth had the largest absolute gain in insurance coverage; however, they continued to have the highest proportion of uninsurance post national ACA implementation. With regard to health care equity, non-Latino black youth were less likely to be uninsured and Latino youth had no significant improvements in insurance coverage relative to non-Latino white youth after national ACA implementation. Inequities in health care utilization for non-Latino black and Latino youth relative to non-Latino white youth did not improve.

Conclusion: Insurance coverage and well-child visits have significantly improved for all youth since passage of the ACA, but inequities persist, especially for Latino youth.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER Expanded Insurance Coverage

Intervention Description: No intervention

Intervention Results: In the January−February 2018 issue of Academic Pediatrics, we used 2011−2015 National Health Interview Survey (NHIS) data to assess changes in insurance coverage and well-child visits for youth and to study whether racial and ethnic inequities were affected by the ACA.1 We found that insurance coverage improved for all youth, and that black youth had the largest relative gain compared to white youth. On the other hand, Latino youth had the largest absolute gain but no improvement in health insurance inequities compared to white youth. For well-child visits, all youth improved post-ACA, but Latino youth had the lowest prevalence of well-child visits.

Conclusion: Of course, insurance coverage is just one piece of the access-to-care puzzle.4 Despite the increases in uninsurance, well-child visits continued to improve for all youth from 2011−2013-to-2016−2018. In 2011−2013, 81.2% of all youth had a well-child visit in the past year. This proportion increased to 83.9% in 2014−2015 and to 85.4% in 2016−2018. Black youth continue to have higher percentages of well-child visits than white and Latino youth, and Latino youth continue to have the lowest percentages. Since the publication of our study, a few other studies have been published showing the associations of the ACA with health care inequities for youth. Using 2011−2016 NHIS data, one study found that insurance coverage and utilization improved for Latino youth, but there were inequities according to youth’s Latino heritage.5 Among Latino youth, Mexican and Central/South American youth experienced the largest absolute increase in coverage, but they had the highest levels of uninsurance post-ACA, and inequities in well-child visits between Mexican heritage and white youth worsened.5 A study using 2014−2016 California Health Interview Survey data found that in the post-ACA period there were no racial/ethnic inequities in provider-related barriers to care (eg, trouble finding a doctor, child’s insurance not accepted by provider, child not being accepted as new patient) for children.6 However, another study using the same California data found that there were insurance-based inequities (eg, Medicaid, employer-based, and privately purchased) in provider availability, where parents of children with Medicaid or privately purchased coverage had over twice the odds of reporting at least one provider-related barrier.7 In 2019, the individual mandate penalty was changed to zero by the Internal Revenue Service due to the Tax Cuts and Jobs Act (2017) passed by Congress and signed by President Trump. Though the individual mandate still exists by law, there is no federal penalty for not having insurance coverage. We should pay close attention to future insurance enrollment decisions by parents in the absence of the federal mandate that could affect gains made in youth insurance coverage across all racial and ethnic groups of youth.

Setting: States

Population of Focus: Youth in the U.S.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER Expanded Insurance Coverage

Intervention Description: The evaluation of the Children's Health Insurance Program (CHIP) mandated by the CHIP Reauthorization Act of 2009 was conducted by Mathematica Policy Research and the Urban Institute. The evaluation included case studies in 10 states selected to provide geographic and demographic diversity, a nationwide telephone survey of state CHIP administrators, analysis of state eligibility and enrollment data, and a survey of 12,000 CHIP enrollees and disenrollees in the 10 study states, as well as 3,400 Medicaid enrollees and disenrollees in 3 of the states. The surveys collected information on health status, service utilization, and families' experiences with application, enrollment, and renewal processes. Other components included analysis of data from national surveys to examine coverage trends and Medicaid/CHIP participation rates.

Intervention Results: The evaluation found that CHIP, together with Medicaid, has significantly reduced uninsurance among low-income children, from 25% in 1997 to 13% in 2012, with coverage disparities narrowing for Hispanic children. Medicaid/CHIP participation rates increased from 82% in 2008 to 88% in 2012, with 21 states achieving rates above 90%. Relatively few CHIP enrollees had private coverage prior to enrollment, and direct substitution of CHIP for private coverage was estimated to be as low as 4%. The vast majority of children remained enrolled in CHIP for at least 28 months, and most disenrollees exited due to ineligibility. Compared to uninsured children, CHIP enrollees experienced better access to care, fewer unmet needs, and greater financial protection. While comparable to private coverage on many measures, CHIP enrollees had better access to dental care and much lower financial burden. Despite high rates of preventive visits, nearly 25% of enrollees had unmet needs and many were not receiving key

Conclusion: The evaluation demonstrated CHIP's success in expanding health insurance coverage for low-income children, improving their access to health care, and reducing financial burden and stress for their families across states with diverse program designs. Despite progress, further efforts are needed to cover the remaining 3.7 million uninsured children who are eligible for Medicaid or CHIP and improve retention and continuity of coverage. With the uncertain future of CHIP funding beyond 2015 and the changing health care landscape under the Affordable Care Act, the evaluation's insights on the value of CHIP and children's unique health care needs are particularly relevant for policymakers. Continuing to build on CHIP's accomplishments in providing affordable, comprehensive coverage will be critical to ensure that all low-income children can obtain the health care they need.

Study Design: QE: non-equivalent control group

Setting: Ten states: Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia

Population of Focus: Youth ages 13 and older enrolled in CHIP for at least 12 consecutive months

Data Source: 2013 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees

Sample Size: Established enrollees (n≈2345) Uninsured children (n≈381) N=children >13 years

Age Range: Not specified