THE EFFECT OF THE STATE CHILDREN’S HEALTH INSURANCE PROGRAM ON HEALTH INSURANCE TRANSITIONS AMONG LOW-INCOME U.S. CHILDREN: A MULTILEVEL APPROACH
Open Access
- Author:
- Oluwole, Adetokunbo Babatunde
- Graduate Program:
- Health Policy and Administration
- Degree:
- Doctor of Philosophy
- Document Type:
- Dissertation
- Date of Defense:
- June 20, 2006
- Committee Members:
- Dennis G Shea, Committee Chair/Co-Chair
Pamela Farley Short, Committee Member
Marianne Messersmith Hillemeier, Committee Member
John Casterline, Committee Member - Keywords:
- MULTILEVEL MODELING
SCHIP
MEDICAID
PRIVATE INSURANCE
UNINSURED
HEALTH INSURANCE TRANSITION
CROWD-OUT
LOW-INCOME CHILDREN
EVENT HISTORY
DIFFERENCE-IN-DIFFERENCES - Abstract:
- The recent history of the Medicaid program has been characterized by periodic expansions of coverage to new populations. The latest expansion was the establishment of the State Children’s Health Insurance Program (SCHIP) in 1997. SCHIP extends public coverage to older children from families with income previously too high to qualify for Medicaid. Studies of previous Medicaid expansions have estimated the crowd-out effect of such public program expansions on private coverage using mostly traditional regression methods and often accounting for limited variables in estimated models. This study uses a combination of event history analysis and multilevel modeling techniques to examine both crowd-out and the effect of individual, family, and contextual factors influencing health insurance transitions among low-income U.S. children. The objective of this study is to investigate the effect of the post-1996 Medicaid/SCHIP eligibility expansion and other factors on health insurance transitions among low-income children. The results provide some insight into how health insurance policies might be directed to have maximum positive impact on targeted children in low-income families. The sample for the study consists of unmarried children nineteen or younger living in families with incomes at or below 325 percent of the federal poverty level (FPL), using data from the 1996 panel of the Survey of Income and Program Participation (SIPP) spanning the period 1996 to 2000. The empirical approach uses discrete-time logistic regression methods to estimate six health insurance transition models in a competing risk framework. The results do not support the hypothesis that eligibility for the Medicaid/SCHIP expansion causes disenrollment from private insurance; that is, no clear evidence is found of crowd-out of private insurance by the post-1996 public insurance eligibility expansion for children. Instead, the results indicate that the implementation of the SCHIP program might have prevented some low income children in public coverage from becoming uninsured, that is, a small reduction in the rate of uninsurance for sampled low-income children. The results also indicate that state policy decisions and employment characteristics have important effects. Expanding the existing Medicaid program, relative to establishing new stand-alone new SCHIP programs, is significantly associated with decreased rate of transitions from public to private insurance. The use of income disregard rules by states is also associated with a decreased rate of transitions from public insurance to private coverage. Finally, the results indicate that children living in states with higher proportions of total employment in the retail service sector are more likely to disenroll from private insurance. Family characteristics are another important factor in insurance transitions. The findings suggest that a parent’s full-time employment status, higher educational attainment beyond high school, higher family income, and the presence of two parents in families reduce the likelihood of a transition by a child out of private health insurance coverage. In summary, results of the study do not suggest that expansion of public insurance coverage through SCHIP implementation led to a significant amount of crowd-out. The form of the SCHIP expansion and administrative policies did influence transitions between public and private coverage as did characteristics of the children and their families. Together, these results suggest that features of the public insurance program and its expansion and private insurance markets have important effects on transitions in insurance coverage. These effects have not been previously been well accounted for and deserve further study.