- Ghada Alem
State Children’s Health Insurance Program (CHIP): Eligibility Expansion Impact
During an introductory course about health policy, namely Fundamentals for Health Policy, health insurance coverage in the U.S. was among the subjects presented. Under the public sector, there are two large insurance programs that are funded by the federal government: 1) Medicare, and 2) Medicaid. Fundamental aspects of the Medicaid program were discussed along with The Patient Protection and Affordable Care Act (ACA) expansion of the program’s eligibility. Moreover, CHIP or State Children’s Health Insurance Program was introduced. Hence, the purpose of this paper is to further detail the CHIP program and to explore the impact of expanding its eligibility.
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CHIP was created in 1997 when Congress acted to provide low-income children with health insurance. Prior to CHIP, a coverage gap occurred for this group of children in their states whose family income is above the eligibility level for Medicaid program. Initially, the program had a ten years block grant of $40 billion. Upon its expiry in 2007, Congress made an attempt to extend the program through passing of two versions of CHIP Reauthorization Act (CHIPRA). However, the U.S. then president GW Bush vetoed both versions and signed a temporary extension instead. When president Barack Obama took office back in 2009, Congress made its second attempt toward extending the program and the president signed it into law to be his first acts assuming his office. The Reauthorization Act of CHIP (CHIPRA) granted $33 billion in federal funds for children’s coverage and an extension until 2019. However, the funding was effective only through fiscal year 2015. 
CHIPRA gave states additional resources and options to help reduce the uninsured children rate . Such options include expanding the CHIP program eligibility to new populations, encouraging families to signup for coverage through simplifying enrollment and renewal procedures for Medicaid and CHIP program, and funding outreach grants to help enroll eligible children . Although these policy changes would have potential and hence, invoke more studies examining their impact, few efforts have actually examined the implication of the new policy changes . In this paper, two articles that have actually addressed the impact of CHIP eligibility expansion are covered in the following sections.
II. FIRST ARTICLE ASSESSMENT
In the first article titled “Coverage For Low-Income Immigrant Children Increased 24.5 Percent In States That Expanded CHIPRA Eligibility”, Saloner et al., stated the absence of any previous studies examining the effect of CHIPRA for immigrant children. Thus, authors compared changes post CHIPRA passage in terms of coverage and access. The said comparison was aimed at immigrant children who reside in states that expanded eligibility to them against the states that did not expand their eligibility. 
Goals and Methods
This article indicates that CHIPRA policy did not eliminate some barriers that could be a cause for missing health insurance coverage in immigrant children (e.g., language and cultural barriers). However, states were provided with federally funded health insurance as a new option by the policy toward expanding eligibility to immigrant children. Accordingly, authors hypothesized that a coverage and access increase would occur among immigrant children as a result of the policy. The study design was cross-sectional by using the National Survey of Children’s Health (NSCH). The main data sources were the 2003, 2007, and 2011–12 rounds of the National Survey of Children’s Health. Sample selection was based on CHIP eligibility income threshold that would most likely extract eligible children population in the previous year. Two groups were compared against a children and parent in the same income category who are US-born: 1) children and parents who are foreign-born, and 2) children who are US-born with foreign-born parents. During the study period, children in the comparison group (i.e., US-born child and parents) had higher healthcare coverage and access. Three outcomes related to health insurance coverage had been examined: 1) coverage status at the time of the survey, 2) coverage type (i.e., private plan or public), and 3) coverage gap during past year. Sample characteristics of all children living in states that implemented (or did not) the policy were compared using descriptive analysis. In order to ensure that the policy was the source of differences affecting immigrant children in states, authors controlled for state-level trends of children and parents who are US-born. Isolation between independent outcomes changes and confounding ones occurring during the same time period were possible through difference-in-difference-in-difference method (quasi-experimental). 
Findings and Conclusions
Insurance coverage increase among immigrant children in states that expanded the eligibility was 24.5 percent compared to the same group in states that did not expand the eligibility. This increase was contributed to the public insurance high enrollment. Moreover, decrease of unmet healthcare needs and disparities (among immigrant children and nonimmigrant families) were evident in states that adopted the eligibility expansion. Finally, healthcare coverage and access gaps between immigrant and nonimmigrant children was reduced due to CHIPRA eligibility expansion. 
Article Assessment & Policy Implications
This research effort is a contribution highlights the importance of healthcare insurance coverage and access for immigrant children. Usually, immigrant children (foreign-born or US-born with foreign-born parents) have poor preventive care compared to nonimmigrant children. This poor status at the children earlier stages in life would have consequences through adulthood. Additional research effort should examine the remaining financial and cultural care barriers. Moreover, variation in the new policy implementation among states and other groups should be investigated. Finally, a significant factor that needs to be examined is sustainability; the explored healthcare coverage and access improvement in this study was applicable to the two years following CHIPRA and hence, further studies are required to check for any further improvements after those two years. 
II. SECOND ARTICLE ASSESSMENT
In the second article titled “The Impact Of Recent CHIP Eligibility Expansions On Children’s Insurance Coverage, 2008–12”, Goldstein et al., stated the absence of any in-depth analysis about the impact CHIP expansions to higher-income children on insurance coverage. Hence, they intended to estimate the impact of CHIP eligibility expansion on changes in un-insurance, public insurance, and private insurance. 
Goals and Methods
The data source for this study was from the 2008-2012 American Community Survey (ACS). A difference-indifferences framework study design was used in this study. Authors have analyzed two groups of children: 1) newly eligible children for CHIP (i.e., the treatment group), and 2) similar children who were not eligible for CHIP (i.e., comparison group). The treatment group consisted of all children who were made newly eligible for CHIP by their state’s expansion. Sensitivity analysis was used with different comparison groups to test the consistency of results since difference-indifferences estimates can vary depending on the composition of the comparison group. Authors first analyzed unadjusted changes in the three types of insurance coverage (public, private, and uninsured) by calculating the raw change in each type for the treatment and comparison groups between 2008 and 2012. They then calculated difference-in-differences estimates for each type of insurance coverage. Next, they estimated the relative change in the un-insurance rate attributable to the expansions. Finally, they assessed the degree of crowd-out (i.e., the share of gains in public coverage from the expansions that was a result of decreases in private coverage). All estimates were weighted using survey weights that reflected the complex survey design of the ACS. 
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Findings and Conclusions
A decrease of 1.1 percentage point in the newly eligible uninsured group was estimated in this study due to the expansion (15% cut in un-insurance rate). An increase of 2.9 percentage points in public coverage was evident with variations in states adoption. Since higher-income children might not have access to affordable coverage, the study findings suggest providing coverage to them through CHIP toward lowering their risk of being uninsured. The study concluded that a significant reductions in un-insurance among newly eligible children was produced by the recent CHIP expansions. 
Article Assessment & Policy Implications
Analytical approach includes a couple of limitations. First, authors included the year of the expansion’s passage in their pre-expansion period, which could be a source of bias to their change estimates downward. Second, measurement error could arise from their use of the ACS (ACS does not provide state-specific program names for CHIP or include a verification question for un-insurance, and it may overestimate no group coverage) . Third, it is unknown whether the changes reported in the results of this study could be generalized to the remaining thirty-five states in the case these states chose to expand CHIP eligibility .
A policy implication could be realized if CHIP funding is not extended. Authors indicated that in the case of no extension, families with children enrolled in the program could turn instead to a health insurance Marketplace to purchase subsidized coverage. However, many of these families would not be eligible for such subsidized coverage. This is due to the fact that ACA definition for affordability is based on the cost of premiums for employee-only coverage that ignores the cost to the family of covering dependents. For instance, dependent family members for a worker would not be able to receive Marketplace subsidies, even if the cost for full family coverage were unaffordable, since the worker were offered affordable employee-only coverage. Accordingly, some children would end up without either CHIP coverage or access to affordable private insurance. Thus, many children in this study could also lose coverage in the case of not addressing barriers to employer-sponsored family coverage and
Marketplace subsidies. 
Generally, CHIP expansion has a positive impact on children insurance coverage. While the first study addressed benefits to immigrant children from the expansion, the second one addressed the reduction of uninsured children through the expansion. Expansion was supported as it would result in maintaining a good health and reducing disparities among this immigrant population , and would decrease the risk for having uninsured children .
 Teitelbaum JB. Essentials of Health Policy and Law. Jones & Bartlett Learning; 2012.
 Goldstein IM, Kostova D, Foltz JL, Kenney GM. The impact of recent CHIP eligibility expansions on children’s insurance coverage, 2008-12. Health Aff (Millwood). 2014;33(10):1861-7.
 Saloner B, Koyawala N, Kenney GM. Coverage for low-income immigrant children increased 24.5 percent in states that expanded CHIPRA eligibility. Health Aff (Millwood). 2014;33(5):832-9.
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