Children\'s Health Insurance Plans Regardless

¶ … Children's Health Insurance Plans

Regardless of one's political affiliation, it is hard to deny the fact that America is currently experiencing a tremendous healthcare crisis. Many Americans simply cannot afford private health insurance even when they have access to reduced-cost benefits through employers, and a growing number of employers are choosing not to offer health insurance benefits, at all, because of the exorbitant costs. For those who can obtain insurance through their employers, the costs can be prohibitive and the insurance provided may not provide significant everyday healthcare savings, even if it can make a dramatic difference in cases of serious illness or medical emergencies. This health crisis impacts the working lower class and the true middle class disproportionately because they oftentimes make too much money to qualify for Medicaid, but cannot access other forms of health insurance or afford the costs associated with regular and emergency health care. One reason that the lower class and the working middle class cannot access health insurance is because many hourly employers do not offer benefits to part-time employees, and some employers even have policies limiting hours for the majority of their employees, to avoid paying insurance and providing other benefits. Even when policies are offered, they are frequently only partially-sponsored by the employer, and the employee can be responsible for hundreds of dollars each month in insurance payments, which can consume the majority of a working-class paycheck. The result is that many Americans do not have health insurance, and because of that, they may also be denied access to routine health care, treatment for chronic illnesses, and treatment for minor emergencies.

Even more alarming is the fact that many of those who are uninsured are children. The impact of not having health insurance can be devastating on any person. The correlation between being uninsured and having a poorer standard of health is clearly established. However, children are disproportionately impacted by not having health insurance. This is because children without health insurance are frequently children who do not receive adequate medical care. Some doctor's offices and lower-level emergency care centers refuse to see patients without insurance, or insist upon up-front payments, which can be prohibitively expensive for people in lower income brackets, especially if the medical attention sought is unplanned or if a child has a chronic health condition. In fact, health insurance is important for children, including teenagers, for several reasons:

Children who have health insurance generally have better health throughout their childhood and into their teens. They are more likely to: receive needed shots that prevent disease; get treatment for recurring illnesses such as ear infections and asthma; get preventative care to keep them well; get sick less often; and get the treatment they need when they are sick." (U.S. Department of Health and Human Services, 2008).

While children without health insurance do have some access to medical care, they do not have access to the same type of reliable health care as insured children. For example, parents whose children are insured can pick one doctor and take the child to visit the same doctor for sick visits and well checks, rather than relying on emergency clinics and emergency rooms for sick visits. In addition, a lack of insurance benefits can mean that children may not be able to obtain prescription drugs.

Furthermore, a lack of health insurance impacts far more than a child's physical health. Good physical health has an impact on quality of life that goes beyond issues of sickness and health. For example:

Having health insurance will allow you to give them the medical care necessary for them to stay healthy and focus on their studies. Children with health insurance are less likely to miss school because they are sick. By helping them go to school every day ready to learn, [one] can help boost [a] child's performance in school today and in the future." (U.S. Department of Health and Human Services, 2008).

Obviously, the fact that so many children lacked health insurance, and therefore lacked access to health care, was a tremendous health care crisis. To help ease this crises, in "1997 Congress passed legislation that allows states to provide health insurance to more children in working families." (U.S. Department of Health and Human Services, 2008). S-CHIP was "created as part of the Balanced Budget Act of 1997 (BBA-97; P.L. 105-33) and enacted as Title XXI of the Social Security Act. In the act, Congress allocated over $40 billion for SCHIP through 2007, making it the largest federal expansion of health insurance coverage since the passage of Medicaid in 1965." (National Conference of State Legislatures Forum for State Health Policy Leadership, 2007).

Though the program is not Medicaid, "these programs build on the Medicaid program that started covering children and adults in the mid-1960." (U.S. Department of Health and Human Services, 2008). Therefore, the programs are funded by a combination of state and federal tax dollars. Like Medicaid, the programs are operated individually by each state, but with federal oversight and according to federally-set rules and regulations. As a result, the individual details about each program vary from state to state. However, there are some constants in the state programs. First, there are no time limits to the S-CHIP programs. A "child can stay on the program as long as he or she qualifies." (U.S. Department of Health and Human Services, 2008). However, parents need to renew their coverage periodically; usually every six to twelve months. Eligibility rules vary from state to state, "but in most states, uninsured children 18 years old and younger whose families earn up to $34,100 a year (for a family of four) are eligible." (U.S. Department of Health and Human Services, 2008). Some states expand the qualification range, permitting families with higher incomes to access the services. The cost for the S-CHIP program varies from state to state, and possibly according to income, but they are generally low-cost or free, and co-payments, if any, are low. Some states make payments contingent upon income, and use a sliding-scale to determine the payments for each individual family. However, children who are eligible for Medicaid are not eligible for S-CHIP, because they already have access to total health coverage.

States are able to structure their S-CHIP programs in three main ways. First, states can opt to expand their current Medicaid coverage, by covering "older children or children from families with incomes too high for them to qualify for regular Medicaid. In Medicaid expansion plans, all Medicaid rules apply. Medicaid's restrictions on cost sharing apply, and the state may not cap enrollment (turn away applicants who are eligible) after a certain number of children have enrolled or after the state has exhausted its funds. The state receives federal reimbursement for expenses at its regular Medicaid 'match rate.'" (National Conference of State Legislatures Forum for State Health Policy Leadership, 2007).

Next, states can design their own plans by creating:

An entirely new program with a benefit package consistent with provisions of Title XXI...In state-designed SCHIP programs, service delivery, quality assurance mechanisms, enrollment procedures, benefits and even the name of the program may be different from those of Medicaid. State-designed programs must be approved by the secretary of the Department of Health and Human Services. States have several benefit package options. (National Conference of State Legislatures Forum for State Health Policy Leadership, 2007).

States can choose benchmark coverage, which is equivalent to federal or state employee coverage or the package offered by the states largest non-Medicaid HMO coverage.

They can create benchmark equivalent coverage, which means that benefits have to have the same actuarial value as one of the benchmark benefit packages. States can also choose to implement existing state-based comprehensive coverage, which means that their benefits have to equivalent to similar non-Medicaid programs that existed before S-CHIP.

Finally, states can choose combination plans, which expand Medicaid and create a private plan for different populations. These combination plans are not required to accept all of the enrollees, and the states are required to use their own funds to help people after spending their full S-CHIP allotment. The combination plans give states the greatest autonomy, but also require states to exercise more oversight and spend a greater percentage of state funds than federal funds.

Of course, states are not required to use S-CHIP. The program is opt-in and requires active state participation. Furthermore, states are required to use some of their own funds to run and fund individual S-CHIP programs. The overwhelming majority of states have chosen to do so. However, Tennessee does not have an S-CHIP program.

One of the interesting facets about S-CHIP is that it was created to fill the gap between Medicaid and those who can afford insurance, not to address health care in the impoverished population. Therefore, it should come as no surprise that different states have set different income levels for people to qualify, because different states have different costs of living. "Twenty-five states and the District of Columbia have income limits at 200% of the FPL [federal poverty level], 13 states exceeded 200% of the FPL, and the remaining 12 states set maximum income levels below 200% of the FPL." (National Conference of State Legislatures Forum for State Health Policy Leadership, 2007). However, regardless of state, the applicants have to meet certain qualifications. First, applicants have to be both uninsured and not eligible for Medicaid for other forms of state sponsored insurance. In addition, not all S-CHIP recipients have to be children; states can get waivers to use S-CHIP funds to cover adults. These other recipients are generally adults who are responsible for S-CHIP eligible children, and/or pregnant women. However, "at the end of 2005, four states had waivers to use SCHIP to cover childless adults, and nine states cover unborn children who will be eligible for SCHIP at birth as well as prenatal and childbirth services for the mother of the child." (National Conference of State Legislatures Forum for State Health Policy Leadership, 2007). The fact that states have chosen to do this reaffirms the concept that the public wants access to low-cost health insurance for low income families.

However, the federal government's position on S-CHIP has not been consistent. The federal government developed the S-CHIP program and provided significant funding for the first years of the program, which led to it being successfully implemented in a large number of states. However, the overall healthcare crisis has caused many to call for a government-sponsored universal healthcare plan, and S-CHIP and Medicaid have been caught up in this political dispute. While many are supportive of such an idea, others are vocally opposed to it. Unfortunately, this debate over universal healthcare has threatened to impact the S-CHIP program. Proponents of S-CHIP claim that it has been very successful:

By every measure, the ten-year-old program- passed during the Clinton administration as a bipartisan, incremental effort to expand health coverage to millions of poor kids - has been a success. Thanks to S-CHIP, the number of low-income uninsured kids dropped by one-third over the decade, even as the number of uninsured adults went up. Three out of four eligible kids participate, and studies show they receive preventive care and have improved health outcomes and school performance. (Lieberman, 2007).

Despite its apparent success and the support of state officials, S-CHIP has not garnered the type of support from the federal government that one might anticipate from a successful program aimed at helping needy children. House and Senate bills aimed at increasing S-CHIP coverage have been defeated or critically altered, and proponents of S-CHIP suggest that insurance lobbyists are responsible for that defeat. In addition, Bush threatened to veto bills that would expand S-CHIP because of concerns about government-run medicine. In fact, Bush only wanted to add an additional $5 billion to S-CHIP, would not have been "enough to maintain the 6 million kids who are currently covered." (Lieberman, 2007). In fact, the Bush administration:

short-circuited the legislative process, issuing a 'guidance' that makes it impossible for states to expand coverage to kids in families whose incomes are above 250% of the poverty level unless the state can show that 95% of children in families under 200% are enrolled, a standard that's unachievable for a voluntary program (participation in Medicare Part B is about 93%, and enrollment is automatic). The number of uninsured children has started to climb again, as employers continue to drop coverage for their parents. Loss of employer coverage has declined for families at all income levels targeted by S-CHIP expansions. (Lieberman, 2007).

The new guidelines immediately impacted S-CHIP, and states that had planned to expand their programs were unable to do so.

While the federal government may not have a consistent view about S-CHIP, state officials do not have the same mixed emotions about the programs. State officials overwhelmingly support the S-CHIP, probably because they can tailor the program to fit the needs of individual states:

It's flexibility allows states to tailor their own programs or build on existing Medicaid arrangements to target children typically in families with incomes of up to 200% of the federal poverty level (about $41,300 for a family of four this year). Last year 91% of kids on S-CHIP lived in families with incomes at or below that amount. States have stepped in to fill a gap the federal government has refused to address: Nineteen states target or plan to target kids from families whose income is greater than 250% of the poverty rate, and some cover pregnant women and parents of eligible kids, a strategy that has proved successful in reaching more children. (Lieberman, 2007).

S-CHIP opponents believe that families in the upper-ranges of S-CHIP eligibility can find service in the private insurance market. They suggest that "public programs like S-CHIP... 'crowd out' insurance sold by WellPoint and United Healthcare, depriving them of profits they earn selling coverage to S-CHIP families." (Lieberman, 2007). However, the reality is that, if forced to resort to private insurance, many of these families would simply be unable to afford medical coverage. "The price for family coverage now averages $12,000, or about 20% of income for a family of four with income at 300% of the poverty level." (Lieberman, 2007). While bare-bones policies are available at a reduced cost, they offer greatly reduced benefits as well. For example, a policy sold by Anthem Blue Cross and Blue Shield in Ohio offered deductibles ranging from $4,000 to $40,000, covers only two doctor visits per year, and requires a 30% copay of any doctor bill. (Lieberman, 2007). In addition, many of these reduced-cost policies specifically exclude the very children who need health insurance the most; children with pre-existing chronic health conditions.

In fact, failure to fund S-CHIP has a potential to have a tremendously negative impact on children. Failure to reauthorize S-CHIP and fully fund it can result in states enacting cost-saving measures like waiting lists, enrollment caps, or removing people from the lists. It could also result in delaying outreach to eligible, unenrolled children. Perhaps the worst potential problem is that it could erode the public's confidence in the program, which would make it more difficult to later reenroll people who are disenrolled because of the cuts. (McInerney, 2007).

The most likely result of drops in S-CHIP funding is that "states may need to stop enrollment, erect enrollment barriers or even disenroll children from the program." (McInerney, 2007). The fact is that, without continued support, states will run out of funds to support their programs. As a result, states will have to curtail their programs in some significant ways. That means that either states will have to help fewer children, or the children will receive reduced benefits. In California alone, approximately 66,000 children per month were facing disenrollment if the budget shortfall was not addressed. (McInerney, 2007).

Furthermore, though S-CHIP has been tremendously successful at enrolling kids in need, the fact is that there are eligible children who have not been enrolled. Fearing a lack of future funding, some states have become very hesitant about expanding their outreach efforts. "Without the assurance of a continued SCHIP funding stream, states worry that bringing more children into the program could jeopardize states' ability to cover already enrolled children. States are also wary about offering coverage to children they may have to disenroll if funds run out." (McInerney, 2007).

In fact, understanding the potential impact on an individual state's S-CHIP programs is perhaps best explained by looking at what happened to Louisiana's program when it faced a decline in funds. Louisiana:

has been extraordinarily successful at enrolling children in SCHIP and Medicaid over the past decade. Between 1999 and 2005, the percentage of all uninsured children in the state fell from 23.8% to 8.4%, largely as a result of increased enrollment in SCHIP and Medicaid. The percentage of uninsured low-income children below 200% of the federal poverty fell even more dramatically, from 31.6% in 1997-1999 to 10.9% in 2006, as Louisiana went from the fifth highest percentage of uninsured low-income children to the tenth lowest. The state simplified enrollment procedures through facilitated enrollment, as well as other outreach strategies such as sending applications home with students, provider education, and producing public service announcements to advertise the program. (McInerney, 2007).

Finally, when funding is threatened and states respond by making program changes, they can find those changes very difficult to undo. For example, if a family has previously been declined S-CHIP enrollment, or disenrolled, it may be difficult to get them to re-apply for benefits:

For example, Texas responded to a fiscal crisis in 2003 by approving administrative rules designed to lower enrollment. These rules included reducing continuous eligibility from twelve to six months (making families renew coverage twice in one year), implementing a $5,000 asset limit, and eliminating all deductions from income, such as child care costs. The changes reduced coverage significantly, as enrollment declined by over 200,000 children over the next four years. In 2007, Texas rolled back many of these enrollment barriers by returning to a 12-month continuous eligibility and increasing the asset limit to $10,000. Even with these new policies, the state is finding that it is challenging to gain back the lost enrollment. Texas is expected to add only 100,000 children to the program by the end of 2009, recovering only half the children dropped from enrollment. (McInerney, 2007).

These possible negative ramifications are very alarming, given that S-CHIP programs seem to have been very effective at helping kids obtain and retain health coverage. In fact, "even though the total number of Americans without health insurance is on the rise, a new study analyzing government data suggests good news for the nation's children. The percentage of uninsured kids in America has decreased by 20% since the government-funded State Children's Health Insurance Program (SCHIP) was approved by Congress in 1997." (McCabe & Watt Knight, 2006). Since S-CHIP was introduced, the number of uninsured children has decreased by 2 million, while the number of uninsured Americans has increased by almost 5 million people. (McCabe & Watt Knight, 2006). Moreover, fewer children are receiving private health insurance, usually through parental employee-sponsored health plans; in fact, 1.4 million fewer children had private health insurance in 2006 than in 1998. (McCabe & Watt Knight, 2006). The states with the largest declines in private health insurance rates include "New Mexico (-23%), Mississippi (-23%), Alaska (-23%), Oklahoma (-19%), and Wyoming (-17%)." (McCabe & Watt Knight, 2006).

To truly understand the importance of S-CHIP and continued funding, it is important to investigate the impact that S-CHIP has had on healthcare coverage for children. Therefore, this paper will investigate whether the S-CHIP program has achieved its goals in the years 2000-2005, by examining the results of the S-CHIP program during that time period. In addition, because S-CHIP opponents suggest that the target adult populations could supply private health insurance for their children, this paper examines whether the uninsured S-CHIP-eligible population differs from privately insured children, including those privately-insured children whose family income would make them S-CHIP eligible. If they do differ, then this paper will investigate how they differ. Finally, this paper investigates whether there is a correlation between a state's poverty level, its average income, and the percentage of its children utilizing S-CHIP insurance.

Methodology

This paper utilizes a review of the existing literature to determine S-CHIP's impact on health insurance and access to healthcare for children who would be otherwise uninsured. Furthermore, because state populations varied tremendously, the study did not compare raw data, but looked at S-CHIP utilization as a percentage of the overall population. However, the study did not investigate what percentage of each state's population was composed of children aged nineteen and younger, therefore, it is important to keep in mind that the S-CHIP figures merely represent a percentage of the overall population. First, the paper investigates the relative success of the S-CHIP program in the country, and also examines the relative success or failure of S-CHIP programs in the individual states. Next, the paper looks at the total number of children enrolled in S-CHIP in 2005 versus the population of each state, to determine the percentage of people in each state utilizing S-CHIP, rounded to the nearest hundredth (Table 1). Next, the paper compares the percentage of people utilizing S-CHIP to the percentage of people living below the poverty level. Then, the paper compares the percentage of people utilizing S-CHIP to the average income in the state. Next, the paper compares the percentage of people utilizing S-CHIP to the percentage of uninsured people in the state. Finally, the paper looks at the impact of other variables on S-CHIP usage and the degrees of those impacts, if available, to determine whether poverty prevalence, average income, or a third variable has a greater impact on S-CHIP usage.

Results

The vast majority of the literature suggests that the S-CHIP has been a qualified success. Its goals were to reduce the number of uninsured children and improve access to health care for children in marginal financial conditions, and the program has done so. "Since 1997, when SCHIP was first created, the number of uninsured low-income children in the U.S. has decreased by one-third. Today, SCHIP covers more than 6 million children." (Results.org, 2007). These numbers take on an even greater meaning when placed in the context of a generalized economic downturn, which has seen the reduction or elimination of healthcare benefits for many Americans. Furthermore, the S-CHIP programs are not simply a placebo; they provide comprehensive benefits to low-income children. "Children enrolled in SCHIP are entitled to regular checkups, immunizations, doctor's visits, and hospital care." (Results.org, 2007).

In order to understand the success of S-CHIP, one really has to understand the extent of America's health care crises. Millions of Americans are uninsured, and these uninsured fall into particular demographics. Therefore, to understand the problem of uninsurance, one must first understand who is uninsured:

While the number of uninsured Americans has been growing, who the uninsured are, and the social and economic factors that place a person at risk of being uninsured, have not changed substantially over time. Two-thirds of the uninsured are individuals and families who are poor (incomes less than the federal poverty level or $20,614 for a family of four in 2006) or near-poor (with incomes between one and two times the poverty level). Another 16% have incomes just above this level (between two and three times the poverty level).

Over eight in ten of the uninsured come from working families. More than 70% are from families with one or more full-time workers. Employer-sponsored insurance is not an option for the large majority of uninsured employees -- "70% work where health benefits are not offered either by their own employer or a spouse's or they are not eligible for them. Young adults, racial and ethnic minorities, and those who are not U.S. citizens are more likely to be uninsured. However, 45% of the uninsured are white, and the large majority of uninsured are adults over the age of 25 and American citizens. (Hoffman, et. al, 2007).

Furthermore, it is important to understand the characteristics of the adult non-elderly uninsured, because those people are the parents of children who are uninsured. Understanding which demographics groups are more likely to be uninsured as adults can help explain why people are uninsured as children. First, people lacking college educations are much more likely to be uninsured than people with college educations and to remain uninsured for greater time periods. This is significant, because 65% of nonelderly adults did not attend college. (Hoffman, et. al, 2007). To understand this disparity, one must understand that health insurance benefits are almost-always included in benefit packages for highly-skilled workers, but the frequency of health benefits being offered declines with skill level. In addition, these same workers are less likely to be able to avoid private insurance.

Next, minorities are much more likely to be uninsured that whites:

About one third of Hispanics and Native Americans are uninsured compared to 13% of whites. The uninsured rate among African-Americans (22%) is also much higher than that of whites. This disparity reflects the fact that minorities are much less likely to have health insurance offered through their jobs, to be eligible for the benefit, or be able to afford their share of the premiums. Because racial and ethnic minority groups are more likely to come from low-income families, Medicaid is an important source of health insurance for them. However, its limited reach leaves large numbers of minorities uninsured. (Hoffman, et. al, 2007).

In addition, it is important to understand that even legal, ethnic minorities may be ineligible for S-CHIP benefits, because many of those people are recent immigrants. "SCHIP is not available to legal immigrants who entered the country after 1996, except for those residing in states that use state funds to cover legal immigrants who qualify." (Results.org, 2007). S-CHIP is also not available to illegal immigrants. Given that recent immigrants, both legal and illegal, are likely to be among the economically disadvantaged, these restrictions constitute part of the reason that some poor children do not have health insurance benefits.

Finally, it is important to understand that health status can have a dramatic impact on whether or not one can obtain insurance. Private health care plans regularly exclude people with pre-existing conditions, even if those people are children. As a result, some children with chronic illnesses, such as Type 1 diabetes or asthma, are ineligible for health-care coverage, even if their parents are able and willing to pay the high premiums for such coverage. In addition, some health-care policies cap benefits or do not pay for particular illnesses, which means that even insured children may not be able to access adequate health care, if their families do not have the finances to privately pay for that health care. Therefore, it should come as no surprise that "The uninsured tend to be in worse health than the privately insured. Eleven percent of the uninsured are in fair or poor health, compared to 5% of those with private coverage." (Hoffman, et. al, 2007).

In addition, there appear to be a significant number of children who are eligible for Medicaid or S-CHIP, but who remain uninsured. The scope of that problem is the subject of significant debate, because numbers produced by private researchers reveal a shortfall that is five to six times greater than the shortfall reported by the Bush Administration. (Dubay, 2007).

Dubay credits the differences in these estimates to the Administration's reliance on data from the Current Population Survey (CPS). (Dubay, 2007). The problem is that the CPS is unclear about whether its insurance questions reflect the entire past year, or whether they are simply point-in-time questions. (Dubay, 2007). Moreover, for some reason there is consistent underreporting of Medicaid on the CPS, which has been well-documented and might spill over to S-CHIP reporting. (Dubay, 2007). Dubay concludes that the greater estimates are much more accurate, because they:

draw on the current consensus regarding what the CPS health insurance measures represent, evidence from the peer-reviewed literature on the extent and source of the Medicaid undercount, and expert judgment regarding the strengths and weaknesses of the administrative data. In contrast, the estimates of 1.1 million eligible children uninsured for the entire year produced for the Administration run counter to widely accepted evidence regarding what insurance measures of the CPS reflect, as well as, previously published evidence on the undercount. (Dubay, 2007).

Furthermore, full-year uninsurance estimates are not appropriate for determining S-CHIP needs, because children need consistent health insurance coverage, not simply coverage at some point in time during the year. (Dubay, 2007).

While all of the states, except for Tennessee, which phased out its S-CHIP program prior to 2005, demonstrated significant usage of the S-CHIP program, there were tremendous differences in the rates of use. The rates of usage ranged from the high of 2.52% of the total population in Georgia to the low of.04% in Minnesota. The order of S-CHIP percentage usage, from highest to lowest is as follows: 1) Georgia, 2)Louisiana, 3) Mississippi, 4) California, 5) New York, 6) Arkansas, 7) Alaska, 8) Maryland, 9) Missouri, 10) Oklahoma, 11) North Carolina, 12) Texas, 13) South Dakota, 14)West Virginia, 15) New Jersey, 16) Nebraska, 17) Kansas, 18) South Carolina, 19) Nevada, 20) Iowa and Kentucky, 22) Montana, 23) Florida, 24) Alabama and Utah, 26) Hawaii, 27) Indiana and Pennsylvania, 29) Rhode Island, 30) Illinois and Ohio, 32) Maine, 33) Massachusetts, 34) Virginia, 35) Idaho, 36) Colorado, 37) Arizona, 38) Washington, D.C., 39) Wyoming, 40) Oregon, 41) North Dakota, 42) Michigan, 43) New Mexico, 44) New Hampshire, 45) Delaware, 46) Wisconsin, 47) Vermont, 48) Connecticut, 49) Washington, and 50) Minnesota. Because S-CHIP usage rates varied so widely by state, it made sense to investigate factors that might be related to such usage. These factors included average income, a state's poverty rate, and the state's overall percentage of uninsured people, regardless of age.

One might assume that S-CHIP usage would be linked to the average income in a state, especially in states where the average income was only marginally higher than the income guidelines established for S-CHIP assistance. In fact, one would assume that S-CHIP usage would be inversely proportional to income, which would make Minnesota the state with the highest average income and Georgia the state with the lowest average income. However, those results did not occur. New Jersey demonstrated the highest average income, while Mississippi had the lowest average income. In fact, California, which exhibited the fourth-highest percentage of S-CHIP usage also had the twelfth-highest average income. The average income ranking of each state, from highest to lowest is as follows: 1) New Jersey, 2) Maryland, 3) Hawaii, 4) New Hampshire, 5) Connecticut, 6) Alaska, 7) Minnesota, 8) Massachusetts, 9) Utah, 10) Virginia, 11) Colorado, 12) California, 13) Washington, 14) Delaware, 15) Vermont, 16) Rhode Island, 17) Nevada, 18) Illinois, 19) New York, 20) Nebraska, 21) Wisconsin, 22) Pennsylvania, 23) Wyoming, 24) Iowa, 25) Arizona, 26) Idaho, 27) Washington, D.C., 28) Michigan, 29) Ohio, 30) Georgia, 31) South Dakota, 32) Maine, 33) Missouri, 34) Oregon, 35) Indiana, 36) Florida, 37) Kansas, 38) Texas, 39) North Carolina, 40) North Dakota, 41) South Carolina, 42) New Mexico, 43) Tennessee, 44) Oklahoma, 45) Alabama, 46) Louisiana, 47) Kentucky, 48) Arkansas, 49) Montana, 50) West Virginia, and Mississippi.

It would also be natural to assume that S-CHIP usage would be correlated to poverty rates, even though families can exceed poverty level incomes by at least 100% and still qualify for S-CHIP. However, the poverty-guidelines are outdated, and states that have the largest numbers of people living in poverty might also be expected to have the largest numbers of people living in near-poverty conditions. However, S-CHIP usage was not directly correlated to a state's poverty level. Of course, the most dramatic example was Tennessee, which had the eighth-highest poverty level, but offered no S-CHIP benefits. There were other examples, as well. For example, Alaska was ranked seventh in S-CHIP usage, but forty-third in poverty ranking. The poverty ranking for each state, from highest (the greatest percentage of impoverished people) to lowest (the lowest percentage of impoverished people) is as follows: 1) Mississippi, 2) Washington, D.C., 3) Louisiana, 4) New Mexico, 5) Alabama, 6) Kentucky and Texas, 8) Tennessee, 9) South Carolina, 10) Arizona, New York, and West Virginia, 13) Arkansas, 14) Montana, 15) North Carolina, 16) Georgia, 17) California and Oklahoma, 19) South Dakota, 20) Michigan, 21) Indiana and Maine, 23) Kansas, 24) Illinois, Missouri, Oregon, and Ohio, 28) Rhode Island, 29) Florida, 30) Pennsylvania and Wisconsin, 32) Iowa, 33) Washington and Nevada, 35) Colorado, 36) North Dakota, 37) Wyoming, 38) Idaho, 39)Maryland, 40) Connecticut and Massachusetts, 43) Alaska and Nebraska, 46) Delaware, 47) Hawaii, 48) Vermont, 49) Minnesota, 50) New Jersey, and 51) New Hampshire.

Finally, one would imagine some type of correlation between S-CHIP usage in children and the overall uninsured rate. The higher the overall uninsured rate, the more one would anticipate that parents would utilize S-CHIP. Of course, efficient usage of the S-CHIP might also drive down the overall uninsured rate, because that rate includes uninsured children and children utilizing S-CHIP are not uninsured. However, the uninsured rates do not appear to have a direct positive or negative relationship to S-CHIP utilization. Georgia has the greatest rate of S-CHIP utilization, but is ranked tenth in its overall percentage of uninsured people. However,

Washington's S-CHIP utilization is ranked forty-ninth, but it is closer to the middle in uninsured rankings at thirty-one. Texas, which has the greatest percentage of uninsured people, is ranked twelfth in S-CHIP percentage, but Arizona, which has the second greatest number of uninsured people, is forty-third in S-CHIP percentage. There are some states that exhibit a strong correlation between S-CHIP usage and the overall uninsured rate. For example, the state with the lowest uninsured rate is Minnesota, and Minnesota also has the lowest S-CHIP utilization rate in the nation.

However, this trend does not continue; Hawaii has the second-lowest overall uninsured rate in the nation, but it is in the middle of S-CHIP utilization. The uninsured rate, from the greatest percentage of uninsured people to the lowest percentage of uninsured people is as follows: 1) Texas, 2) New Mexico, 3) Florida, 4) Arizona, 5) Oklahoma, 6) California and Louisiana, 8) Nevada, 9) Mississippi, 10) Georgia, 11) Arkansas, 12) Montana, 13) Alaska, 14) Colorado and Oregon, 16) North Carolina and South Caroline, 18) Utah, 19) West Virginia, 20) Idaho, 21) New Jersey, 22) Alabama, 23)Wyoming, 24) Kentucky, 25) Illinois, 26) Tennessee and Maryland, 28) Virginia and New York, 30) Indiana, 31) Washington and Delaware, 33) Washington, D.C., 34) Missouri, 35) South Dakota, 36) Kansas, North Dakota, and Nebraska, 39) Vermont, 40) Ohio, 41) Michigan, 42) Connecticut and New Hampshire, 44) Massachusetts, 45) Pennsylvania and Rhode Island, 47) Maryland, 48) Wisconsin, 49) Iowa, 50) Hawaii, and 51) Minnesota.

State

Monthly SCHIP Enrollment *

Average Income**

Below Poverty *** w/o Insurance ****

Population

Enrolled in SCHIP

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Washington D.C. (National Conference of State Legislatures Forum for State Health Policy Leadership, 2007). 2005 figures (U.S. Census Bureau, 2006). 2004-2005 figures (U.S. Census Bureau, 2007). 2004-2005 figures. (Denavas-Walt, Proctor, & Smith, 2007). Three-year average 2004-2006. (Fact Monster, 2007).

State

SCHIP Rank *

Income Ranking *

Poverty Ranking*

Insurance-less Rank*

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Washington D.C.

Highest to lowest

S-CHIP Rank

State

Average Income Rank

Poverty Rank

Insurance-less Rank

Georgia

Louisiana

Mississippi

California

New York

Arkansas

Alaska

Maryland

Missouri

Oklahoma

North Carolina

Texas

South Dakota

West Virginia

New Jersey

Nebraska

Kansas

South Carolina

Nevada

Iowa

Kentucky

Montana

Florida

Alabama

Utah

Hawaii

Indiana

Pennsylvania

Rhode Island

Illinois

Ohio

Maine

Massachusetts

Virginia

Idaho

Colorado

Arizona

Washington, D.C.

Wyoming

Oregon

North Dakota

Michigan

New Mexico

New Hampshire

Delaware

Wisconsin

Vermont

Connecticut

Washington

Minnesota review of the available literature reveals one interesting aspect about S-CHIP usage, which may help explain some of the differences in S-CHIP usage by state, where the states have similarities in average income, poverty rates, and uninsured rates. Employers seem to have an impact on whether or not people use S-CHIP.

For example, Wal-Mart is the nation's largest private employer. (Furman, 2005). Like other major retailers, it offers health benefits to its employees, though 34% of its eligible employees choose not to enroll. (Furman, 2005). The may do so because they are eligible for Medicaid or S-CHIP. In fact, while Wal-Mart employees receive pay that it comparable to other areas of the retail sector, and which places the majority of those employees well-within S-CHIP guidelines, only 27% of the children of Wal-Mart employees are covered by Medicaid or S-CHIP, compared to a national average of 36% for all children of parents employed in the retail sector. (Furman, 2005). However, the 27% figure is higher than the 22% of children that are covered by Medicaid or S-CHIP nationwide. (Furman, 2005).

In addition, other characteristics can impact whether a child is covered by S-CHIP. For example, there are currently 9.4 million uninsured children in the U.S. (Kaiser Commission on Medicaid and the Uninsured, Health coverage of children: the role of Medicaid and SCHIP 2007).

More than two-thirds of the 9.4 million uninsured children in the U.S. live in families with household incomes below 200% of the federal poverty level ($41,228 for a family of four in 2006). The majority of uninsured children (72%) live in families with at least one full-time worker. These families often are not offered coverage or cannot afford the premiums. Since 2001, premiums for family coverage have increased 78%, while wages have gone up 19%. The average total premium in 2007 for a family of four with employer coverage is over $12,000 per year. Public coverage targets lower income children who are more likely to be uninsured. Almost all of the 6.5 million uninsured children below 200% of poverty are eligible for Medicaid or SCHIP, but are not enrolled.

Nearly one in 10 children from middle income families (200-399% of poverty) is uninsured. Those children are less likely to be eligible for public coverage. Hispanic and African-American children are more likely to be uninsured than white children. Adolescents are also more likely than younger children to be uninsured, due in part to lower Medicaid income eligibility levels for older children in some states. (Kaiser Commission on Medicaid and the Uninsured, Health coverage of children: the role of Medicaid and SCHIP 2007).

Discussion

Although results vary by state, it is clear that the S-CHIP program has significantly accomplished its goal of providing health insurance to low-income children. Though health insurance coverage is declining in America, low-income children have not been impacted by this trend in the same way as the rest of Americans. This is important, because the same characteristics that make children likely to be eligible for S-CHIP, correlate with other factors that make it less likely for them to succeed in educational environments: such as bad neighborhoods and bad schools. In fact, impoverished children and non-impoverished lower-income children are also more likely than higher-income children to live in health-threatening conditions, because lower-income people are more likely to live in substandard housing, near polluted areas, and to be exposed to greater levels of environmental toxins, such as lead. While no single program can fix all of these social problems, the reality is that S-CHIP has taken a major step towards fixing one aspect of these problems, by having a dramatic impact on the health and well-being of the nation's children.