Muskie School of Public Service

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1 Health Insurance Stability among Rural Children: Impact of the Children s Health Insurance Program Erika Ziller Muskie School of Public Service Funded by a cooperative agreement with the Office of Rural Health Policy, HRSA, DHHS Maine Rural Health Research Center

2 Background: Success of CHIP Since the enactment of CHIP the uninsured rate in children has declined about 50% Prior studies indicate that rural children have been positively affected by the Children s Health Insurance Program (CHIP) (Ziller & Coburn, 2009) Take up rates among rural children eligible for Medicaid are higher than urban rates (King et al, 2010)

3 Background: The Other Side of the Coin 5 million uninsured children (2/3) are eligible for CHIP or Medicaid (2008) Among Medicaid/CHIP enrollees, there is substantial churning or gaps in coverage. About 3 million children exit Medicaid or CHIP and become uninsured each year, despite eligibility for public coverage Any gaps affect access to health care services & increase administrative burden Policy?

4 Background: Preliminary Policy Studies Limited research on the effect of policy on Medicaid enrollment/stability; mixed results. Medicaid expansion programs correlated with higher enrollment; other study finds lower uninsured rate in states with separate CHIP Continuous eligibility also has mixed findings Premiums generally associated with gaps Covering parents has generally positive impact on children s coverage, and waiting periods are associated with higher rates of public coverage and uninsurance

5 Background: Gaps Research into impact of CHIP policy has been cross-sectional, based on single-state or administrative data, or combination. Little is know about whether states with high concentration of rural children have implemented CHIP differently than states with primarily urban populations. Policy studies have generally been silent about rural children

6 Purpose Compare uninsured rates for rural and urban children over time, nationally Explore the relationship between rural residence and CHIP policies Assess the whether CHIP has improved insurance coverage for rural children, and specific policies associated with coverage point-in-time and longitudinally

7 Methods: Data & Sample Data: Pooled longitudinal panels from the 1996 through 2008 MEPS. State data on CHIP policy, for each state, each year Area resource file Sample: Nationally representative, 55,272 children aged 0-18 with 24 months of data (CHIP eligibility extends to 19)

8 Methods: Dependent Variables Health Insurance Coverage Coverage status at a point in time: uninsured, private coverage, public coverage Ever uninsured during a year Always insured during a year Number and frequency of gaps in coverage Coverage shifts

9 Methods: Independent Variables Residence Urban: All MSA counties Rural: Non-MSA counties Policy State CHIP policy: program type, eligibility levels, premiums, continuous eligibility, waiting periods, parents

10 Methods: Variables Covariates Child/Family level: parent education, work status, region of residence, race/ethnicity, child s age, income County-level: provider supply, percent of children living in poverty, racial/ethnic composition of the county, % of workers in health/human services, FQHC or RHC in county

11 Methods: Analyses MEPS employs complex probability sampling; thus all analyses will be conducted with SUDAAN 10.0 to address clustering and yield valid standard errors Bivariate: chi-square; t-tests Multivariate: logistic regression for Point-in- Time odds of being uninsured, and survival models to examine factors associated with coverage stability

12 Findings: Change in Point-In-Time Insurance Coverage 40% 35% 37% 30% 25% 20% 15% 10% 23% 23% 19% 20% 19% 17% 16% 16% Pre-CHIP (1996-7) Early CHIP ( ) 27% 14% 12% Mature CHIP ( ) Rural Uninsured Urban Uninsured Rural Public Urban Public

13 Findings: Change in Annual Uninsured Rate 30% 28% 25% 20% 23% NS 19% 20% 15% 10% 5% 13% 10% 6% 8% Rural Urban 0% Ever Uninsured (Pre-CHIP) Ever Uninsured (2003-8) Always Uninsured (Pre-CHIP) Always Uninsured (2003-8)

14 Findings: CHIP Policy, Rural-Urban Differences ( ) Policy Rural Urban Program** Medicaid Expansion Separate/COMBO Income Limit** Below 200% 200% Above 200% 28% 72% 12% 63% 25% 15% 85% 8% 49% 43% Premiums*** 69% 88% Waiting Period* 61% 73% Continuous Eligibility NS 54% 58% Parents 100% FPL* 36% 52%

15 Findings: Policy Relationship to Ever Being Uninsured (<200% FPL) URBAN Separate/combo CHIP, 200% FPL or less, waiting period, premium requirement, parents not covered, continuous eligibility in CHIP only or not at all Rural Waiting period (32% ever uninsured vs. 25% with no waiting period).

16 Preliminary Conclusions & Next Steps Public insurance expansions, in the form of CHIP, appears to have reversed rural-urban trends in child uninsured rates Lower uninsured rates at a point-in-time appear to stem from equalization in the number of rural children that have ANY gap in coverage, and dramatic reversal of chronic uninsurance (all year)

17 Preliminary Conclusions & Next Steps Rural and urban children live in different state policy environments, with rural children more likely to live in states that have: 1) Medicaid expansions; 2) lower eligibility; 3) have no waiting periods or premiums; and 4) don t cover parents. At the bivariate level, policies appear to affect likelihood of an urban uninsured spell, but limited effect on rural spells

18 Preliminary Conclusions & Next Steps Limited policy effect among rural children may be related to unobserved state characteristics future models will include fixed state effects Rural-urban differences in coverage continuity will be assessed at a multivariate level using survival analyses, with interactions between the policy variables and residence

19 Preliminary Limitations Policy variables not as nuanced as originally anticipated, especially premiums Dichotomous measurement of rurality (MSA/non-MSA) is not ideal and greater nuance was intended; limited by sample size

20 Contact Information Erika Ziller, Senior Research Associate Maine Rural Health Research Center Muskie School of Public Service University of Southern Maine PO Box 9300 Portland, ME