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Upper Income Limit for SCHIP and Forgone Care Among Uninsured US Children
To the Editor: Congress created the State Children's Health Insurance Program (SCHIP) in 1997 to provide public health insurance for families who could not afford private coverage yet earned too much to qualify for Medicaid.1 Although general guidelines for SCHIP eligibility were 100% to 200% of the federal poverty level (FPL), SCHIP gave states flexibility to set income eligibility. Some states exceed 250% FPL while others have proposed limits up to 400%. The SCHIP reauthorization debate in 2007 raised questions about whether to set income limits at, below, or above existing thresholds and particularly whether SCHIP should expand to 400% FPL.2
Although SCHIP income limits encompassed most uninsured children at its inception in 1997, insurance problems and related sequelae have recently shifted up the income scale.3 Therefore, we examined forgone care among insured vs uninsured children, stratifying by income to approximate the potential eligibility thresholds under debate for SCHIP.
Methods
We analyzed national data from the household component and medical provider component of the 2004 Medical Expenditure Panel Survey (MEPS) for insurance status and health care use among 10 815 children ( 18 years). We used cross-sectional point estimates to analyze 2 dependent measures of forgone care: (1) no medical care and no prescriptions in the preceding 12 months and (2) no preventive care in the preceding 12 months (annual preventive visits are recommended for all children >2 to 18 years and more frequently before age 2 years4). Independent measures were full-year insurance (uninsured vs insured) and FPL category (0%-100%, 101%-200%, 201%-300%, 301%-400%, >400%). Respondents to the MEPS reported race/ethnicity using federally defined categories. We included race/ethnicity because of their role in poverty and health care coverage and use. We performed multivariate logistic regression to identify independent associations between forgone care and insurance status by income level. The model included variables that either have an evidence base for associations with the outcomes or were significant at P .10 on bivariate analysis with the dependent variable of "no care" (insurance status, chronic health problem, age group, race/ethnicity, sex, parent education). Statistical significance was defined as 2-sided P < .05. Stata 10 (Stata Corp, College Station, Texas) was used to adjust for the complex sampling design.
Results
Uninsured children were much more likely to have forgone care compared with insured children with similar income (Table 1). Among uninsured children in income categories below 400% FPL, 42% to 54% had no medical care in the preceding year, approximately twice the rate for insured children within the same income categories. Of uninsured children in each income category below 400% FPL, 72% to 81% had no preventive care in the preceding year.
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Table 1. Insurance Status and Forgone Care in the Preceding 12 Months According to Income as Percentage of Federal Poverty Level (N = 10815)
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In multivariate analyses, being uninsured was independently associated with having forgone all care in the preceding year if income was 400% FPL or below (adjusted odds ratio, 1.8-2.7) (Table 2). The adjusted odds of having no care in the preceding year were highest among uninsured children at 301% to 400% FPL (odds ratio, 2.7; 95% confidence interval, 1.4-5.3), although the sample in this category was small.
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Table 2. Multivariate Analysis of Likelihood of Having No Medical Care in the Preceding Year According to Income as Percentage of Federal Poverty Level
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Comment
Nearly half of the children who were uninsured all year in 2004 were without any medical care or prescription medicines during that year, and even more were without preventive care. Percentages with forgone care among the groups at 201% to 400% FPL were closer to percentages among lower income groups than to those in the highest income group (>400% FPL). Health insurance is a necessary first step in accessing the health care system.5 SCHIP has been shown to improve health care access, use, and quality of care and to reduce preexisting disparities.6 These findings show that expansion of SCHIP to cover 200% to 400% of FPL has the potential to help many children receive needed care.
Author Contributions: Mr Blumkin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Shone, Klein, Szilagyi.
Acquisition of data: Blumkin.
Analysis and interpretation of data: Shone, Klein, Blumkin, Szilagyi.
Drafting of the manuscript: Shone, Blumkin.
Critical revision of the manuscript for important intellectual content: Klein, Szilagyi.
Statistical analysis: Shone, Blumkin.
Administrative, technical, or material support: Szilagyi.
Study supervision: Szilagyi.
Financial Disclosures: None reported.
Previous Presentation: Presented in part at the annual meeting of the Pediatric Ambulatory Societies; May 3, 2008; Honolulu, Hawaii.
Disclaimer: The content is solely the responsibility of the authors and does not reflect official perspectives of the University of Rochester or the Agency for Healthcare Research and Quality.
Laura P. Shone, DrPH, MSW
laura_shone{at}urmc.rochester.edu
Jonathan D. Klein, MD, MPH;
Aaron K. Blumkin, MS;
Peter G. Szilagyi, MD, MPH
Department of Pediatrics
University of Rochester School of Medicine and Dentistry
Rochester, New York
1. Balanced Budget Act of 1997: State Children's Health Insurance Program: Title XXI of the Social Security Act, PL 105-33 and PL 150-34, 105th Congress, First Session. http://www.ssa.gov/OP_Home/comp2/F105-033.html. Accessed September 18, 2008.
2. Iglehart JK. The battle over SCHIP. N Engl J Med. 2007;357(10):957-960.
FREE FULL TEXT
3. Collins SR. Congressional testimony—widening gaps in health insurance coverage in the United States: the need for universal coverage (November 14, 2007). Commonwealth Fund Web site. http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=583404. Accessed September 18, 2008.4. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine and Bright Futures Steering Committee. Recommendations for preventive pediatric health care. Pediatrics. 2007;120(6):1376.
FREE FULL TEXT
5. Eisenberg JM, Power EJ. Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality. JAMA. 2000;284(16):2100-2107.
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6. Shone LP, Szilagyi PG. The State Children's Health Insurance Program. Curr Opin Pediatr. 2005;17(6):764-772.
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Letters Section Editor: Robert M. Golub, MD, Senior Editor.
JAMA. 2008;300(16):1882-1884.
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