Care Reform and State Children’s Health Insurance


The State Children’s Health Insurance Program was established in 1997 following a balanced act of the same year to provide matching funds to various states for health cover for families with children. The enacted Title XXI of the Social Security Act set aside 20 million US dollars for ten years so that states would be able to cover children from poor families who met eligibility criteria for Medicaid but had lesser income to afford private medical insurance (Cunningham et al, 2002, p. 363).

States are allocated federal match for this medical cover and it’s slightly higher than the state’s Medicaid match (Cunningham et al, 2002, p. 363). The program was set to expire in 2007 but President Bush failed to agree with the congress on the details of reauthorization of the program and they consequently extended it to 2009. When President Obama came into power, he signed the SCHIP reauthorization act which was approved by the congress.

All states are allowed flexibility in developing their SCHIP eligibility requirements and policies as long as they operated within the limits of the broad federal guidelines. Some states have even been authorized to use the SCHIP money to insure parents children benefitting from the program after waiver of the statutory restrictions (Lisa & Genevieve, 2003, p. 1287).

Pregnant women and even other adults with critical healthcare needs have sometimes benefitted in the same manner. Before it was about to expire in 2006, the program had covered about 6.6 million children during that physical year and over 670,000 adults across all the states in the USA (Lisa & Genevieve, 2003, p. 1287).

All these states have approved plans except Arizona. Despite the program, uninsured children continue to increase especially in families that do not meet the threshold to qualify for SCHIP (Horner & Morrow, 2006, p. 104). After ten years of operation, the report of the program prepared by Vimo Research group showed that about 68.7% of the increasing number of uninsured children came from families who had income of about 200% higher than the federal minimum poverty level of eligibility.

After reauthorization of the program is 2009, the program expanded to cover 4 million more children, pregnant women and for the first time the program accepted inuring children of legal immigrant children (Cunningham et al, 2002, p. 368). This is because the august 17 2007 directive was also withdrawn as it has restricted the options of states to design their eligibility for covering uninsured children. About 26 states increased their eligibility threshold to 200% of the poverty level recognized by the federal government (Cunningham et al, 2002, p. 369).

The same year, the federal government poverty level was 17,170 US dollars income for a family of three. States took advantage of this with the lowest poverty level for eligibility being 140% while the highest was 350%. Some states even subtracted part of the families’ earnings and some particular expenses to compute their net income to be used to gauge eligibility for SCHIP.

Some states on the other hand provided SCHIP cover by expanding the Medicaid care to children (11 states expanded it in 2006) who failed to attain eligibility for the program (Cunningham et al, 2002, p. 363), or creating a separate program under SCHIP to cover such children (18 states had separate program in 2006) or made use of the two strategies (21 states employed a combination of both).

Disparities and Interest Group

SCHIP was designed to cover children below 19 years from poor families which could not afford private medical cover (Brach et al, 2003, p. 502). Accordingly, the cover can be expanded to those families that have income of 200% above the level set by the federal government (Brach et al, 2003, p. 502).

The benefits of the program were evident as many of the health disparities were minimized with children and adolescents getting better medical care. The other benefits were seen in racial and ethnic disparities in terms of being able to access medical services following enrollment in SCHIP (Hill et al, 2001, p. 78; Ross & Cox, 2005, p. 106).

These disparities were reported commonly in one state and specifically against one group, the Hispanics and not African Americans. SCHIP was not able to fully get rid of these disparities was because of inadequate improvements for the African American and Hispanic/Latino children in regions where the Caucasian children benefited (Hill et al, 2001, p. 78). In some instances, the medical service disparities remained because the amount of disparities that existed before the SCHIP program was developed was so great.

There were some few disparities between children who enrolled with special health care need and the rest of the children who did not require special care in terms of access to healthcare and satisfaction of their families following enrollment (Fox et al., 2003, p. 56). Nonetheless, SCHIP did not alleviate the pre-enrollment disparities in the unmet need and as a result, many of the enrollees with special medical service needs with unmet needs remained unmet compared to other beneficiaries (Ross & Cox, 2005, p. 106).

For instance about 1/3 of the children with special health care needs had these unmet needs after enrolling with the program compared to the 1/6 of those without special needs but with unmet needs after enrolling with SCHIP (Fox et al., 2003, p. 56). Disparities in the access to health care and patient satisfaction between the newly insured children and those who had been uninsured for long were fairly common before the establishment of SCHIP (Horner & Morrow, 2006, p. 104). One year after enrollment in the program, however, these disparities between the two groups are done away with (Hill et al, 2001, p. 82).

Evidence Based Practice

Despite the many benefits that have been brought about by the establishment of SCHIP, there is still room for improvement especially to take care of the disparities that are still being witnessed after enrollment (Ross & Cox, 2005, p. 106). Preventative visits can have significant gains to most of the enrolled children particularly the Hispanic children, besides, a significant percentage of the people enrolled especially the children with special medical needs still face the problems of unmet needs while enrolled (Fox et al., 2003, p. 59).

In these unmet health needs are a reflection of poorer health condition and the needs of greater medical care needs or benefit from SCHIP allotment (Brach et al, 2003, p. 502). The program was not designed to meet special needs.

Policy Solution: when states are implementing their programs and incorporating cost-saving measures and exploiting the program resources, the policy makers on the other hand should focus on making sure that the benefits from SCHIP reach the most poor and vulnerable children (Brach et al, 2003, p. 502).

This means there should be strategies of channeling resource with such preference. Investing in public health insurance for the poor children produced measurable benefits in terms of access to care and satisfaction with its quality (Szilagyi et al, 2004, p. 398). The states that have managed to sufficiently increase access to care for the SCHIP beneficiaries should focus more on improving the quality of care offered to these children at health facilities.

There is opportunity to enhance quality of preventative care for children as states can employ a range of means to enhance care like carrying out outreach program to target groups, providing educative program for parents on the benefits of preventative care and developing health plans and offering incentive for adhering to the guidelines (Szilagyi et al, 2004, p. 398).

SCHIP also offers opportunities to address unmet needs of the special needs children and some of the approaches that can be employed include; carrying out needs assessments and special health needs screening among the children (Fox et al., 2003, p. 61). In addition, the reimbursement policies can be restructured to highlight the expanded needs of children with special needs, increasing the package for SCHIP and doing proper coordination of other related services like case management (Fox et al., 2003, p. 62).

States can make use of other health resources to identify data relevant to vulnerable children who have been seen to lag in terms of health care services. These children can then be addressed under special needs to give them specialized care (Fox et al., 2003, p. 65).

Missing discourses: medical cover offered by SCHIP struggles to address all discourses which were preciously missing like the legal immigrants children. The policymakers are using data from a wider source to ensure that elimination of health disparities is attained (Vanlandeghem & Brach, 2004, p. 123).

Drawing from the civil rights experience, the policymakers are collecting data on language, ethnicity, race and other factors that are relevant to SCHIPs healthcare delivery. All these will enable in elimination of ethnic and racial disparities in health (Vanlandeghem & Brach, 2004, p. 128), but this will require a comprehensive strategy which takes into account the multi-faceted nature of the program.

Language can be a problem especially for immigrant in accessing medical care and this has been a major obstacle in this disparity. However, SCHIP implementers are working to eliminate barriers of language to accessing healthcare (Szilagyi et al, 2004, p. 398). Practitioners are encouraged to be culturally competent and tone down any iota of racial discrimination. Implementers do not condone any form of racial stereotyping in as far as the provision of medical services is concerned (Vanlandeghem & Brach, 2004, p. 132).

Affordable Care Act

This law was signed in 2010 purposively to increase the possibility of accessing SCHIP and Medicaid benefits by as many vulnerable people as possible (Williams et al, 2010, p. 1482). Under this law, states have been able to increase the federally matched financing for health programs Medicaid and SCHIP.

The statute allows states to gain assistance from federal government to meet their increased limits in Medicaid and SCHIP hence allowing more American to access medical cover (Szilagyi et al, 2004, p. 398). The law prohibits states from implementing eligibility thresholds, methods or processes that are very restrictive than those previously used before the signing of the law. This is a very important part of the health reform law (Scott, 2010, para. 3).

Together with the patient protection act, these two laws are the basis of health reforms in the US today (Scott, 2010, para. 3). After about 12 months of contestation and contentious deliberations and discussion, finally President Obama got to sign the two laws that are bringing comprehensive reforms in the health system of America (Scott, 2010, para. 3).

The law is successfully dealing with disparity of affordability of care since the eligibility has been extended to cover more individuals reaching those with income as below 133% the level of poverty recognized by the federal government (Brach et al, 2003, p. 504). This is about 29,400 US dollar per family of four individuals or one person earning 14,400 US dollars. All states are required to make this change to their eligibility standard by January 1, 2014 even though the statute allowed the changes to begin April 2010.

When the poverty level mark was reduced to 133%, many pregnant women, non-pregnant adults with no children and non-elderly qualified for eligibility criteria to benefit from Medicaid. Increased coverage of the Medicaid based on income alone has increased the number of beneficiaries of the program especially the mentally ill patients.

Gaps in the act: the affordability care act fixes the problem of inequality in a number of ways but still it has some gaps not covered. Close to 7.5 million individuals benefiting from Medicaid are dual eligible, meaning that they are people with disabilities and they are also elderly and poor or low-income earners (Brach et al, 2003, p. 505).

By virtue of this, they are eligible for Medicare part A or B and Medicaid benefits. Most of the Medicare beneficiaries are often faced with considerable challenges that are related to gaps in Medicare cover like cost sharing requirements, premiums and therefore depend on Medicaid to help them in meeting these expenses. The Affordable Care Act however has set an office to help coordinate dual eligibility to ensure that Medicare and Medicaid policies are aligned and well integrated (Williams et al, 2010, p. 1482).

Key Findings and Recommendations

Looking at the implementation of the Affordable Care Act since its signing, it’s reasonable to conclude that the stature is sufficiently funded, efficiently implemented and leveraged resourcefully via the partnerships of the private sector and the government (Williams et al, 2010, p. 1483). This is the turning point of the medical system of the US which used to be shoddy to a superior system. The main findings are;

  1. The government has greatly invested in public health to ensure that the US health system offers top quality care at affordable cost. Several strategies have been used including awarding contracts, developing infrastructure that would encourage national prevention, public health approach coordination of federal programs and health promotion (Williams et al, 2010, p. 1487).
  2. Education the general public – the policymakers and implementers of SCHIP and the signing of the Affordable Care Act have used education campaigns conducted across the country to make parents aware of the available funds for health cover (Lisa & Genevieve, 2003, p. 1287). As a result the number of enrollees is increasing gradually and as a result, healthcare access has improved
  3. Expansion of insurance – the eligibility criteria has been increased to allow many people to qualify for the services of SCHIP and those of Medicaid. As a result, the number of beneficiaries increased by 4 million people. This provision has also allowed inclusion of preventative benefits of healthcare
  4. There is better capacity for prevention of health problems and this has been achieved through research, demonstrations and assessments (Vanlandeghem & Brach, 2004, p. 123).
  5. The need to use evidence-based practice has been effective where the SCHIP struggles to produce quality care to all the beneficiaries without discrimination. There are a number of studies that show many of the disparities have been addressed including race and ethnicity.

The recommendation that has been made to ensure the attainment of better quality health for all and the 2020 objective are as below. The federal government should leverage health reform financing and other funds to ensure there is sufficient money for medical cover (Scott, 2010, para. 4). Never before has the US government invested such amount of money in healthcare system. In the next ten years about $15 billion will be channeled into the system for preventative medical care.

The governments both federal and state are increasing attention to the traditionally underserved communities like the Hispanics and isolated groups like children of the legal immigrants. Another important recommendation is that the insurance cover should be guided by scientific evidence, this means that the law supports evidence based practice which is reliable and valid service provision strategy.

Reference List

Brach, C., et al. (2003. Who’s Enrolled In SCHIP? Findings from the Child Health Insurance Research Initiative (CHIRI). Pediatrics; 112 (6), 499 – 507.

Cunningham, P., Hadley, J., & Reschovsky, J. (2002). The Effects of SCHIP on Children’s Health Insurance Coverage: Early Evidence from the Community Tracking Study. Medical Care Research and Review, 59(4), 359–383.

Fox, H.B., Limb, S.J., & Mcmanus, M.A. (2003). SCHIP Innovations for Children with Special Health Care Needs in Managed Care. Princeton, NJ: Center for Health Care Strategies.

Hill, I., Lutzky, A.W., Schwalberg, R. (2001). Are We Responding To Their Needs? States’ Early Experiences Serving Children with Special Health Care Needs. Washington, DC: Urban Institute.

Horner, D., & Harrow, B. (2006). Opening Doorways for Health Care for Children: Ten Steps To Ensure Eligible but Uninsured Children Get Health Insurance, Menlo Park, Calif.: Henry J. Kaiser Family Foundation.

Lisa, D., & Genevieve, K. (2003). Expanding Public Health Insurance to Parents: Effects on Children’s Coverage under Medicaid. Health Services Research 38(5), 1283–130.

Ross, D.C., & Cox, L. (2005). In A Time Of Growing Need: Health Coverage Access For Children And Families: A 50 State Update On Eligibility Rules, Enrollment And Renewal Procedures, And Cost-Sharing Practices In Medicaid And SCHIP For Children And Families. Menlo Park, Calif.: Henry J. Kaiser Family Foundation.

Scott, G. (2010). Health Care Reform: Patient Protection, Affordable Care Act and Implications for Health Plans. Web.

Szilagyi, P.Get al. (2004). Improved Access and Quality of Care after Enrollment in the New York State Children’s Health Insurance Program (SCHIP). Pediatrics, 113 (5), 395-404.

Vanlandeghem, K., & Brach, C. (2004). Does SCHIP Benefit All Low-Income Children? CHIRI Issue Brief No. 4. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ) Pub.

Williams, D.R., McClellan, M.B., & Rivlin, S.M., (2010). Beyond the Affordable Care Act: Achieving Real Improvements in American’s Health. Health Affairs, 29: 1481-1488.

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