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The Children's Health Insurance Program Strengthens Children's Health Care

      The Children's Health Insurance Program (CHIP) has provided substantial coverage for critical groups of children and youth since its inception in the 1990s. Meant to cover children in households with incomes greater than financial eligibility for Medicaid but unable to obtain health insurance through a parent's workplace, CHIP has played a major role in achieving the lowest rate of uninsurance among America's children ever.

      Larson K, Cull WL, Olson LM. US children's access to health services: trends and disparities by race/ethnicity and income, 2002-2012. Available at: https://www.aap.org/en-us/professional-resources/Research/pages/U-S--Childrens-Access-to-Health-Services-Trends-and-Disparities-by-RaceEthnicity-and-Income2002-2012.aspx. Accessed March 2, 2015.

      With current funding through the Affordable Care Act (ACA) (and due to expire in September 2015), CHIP also serves, along with Medicaid's Early and Periodic Screening, Diagnosis, and Treatment program, as health insurance tailored specifically to the needs of children. CHIP benefits have generally addressed the specific health care needs of children and youth.
      • Forrest C.B.
      • Simpson L.
      • Clancy C.
      Child health services research: challenges and opportunities.
      • Stille C.
      • Turchi R.M.
      • Antonelli R.
      • et al.
      The family-centered medical home: specific considerations for child health research and policy.
      Senator Rockefeller's last Senate hearing addressed the reauthorization of the CHIP program—with strong bipartisan testimony supporting the importance of child-specific benefits.

      United States Senate Committee on Finance. The Children's Health Insurance Program: Protecting America's Children and Families. Available at: http://www.finance.senate.gov/hearings/hearing/?id=9b08df31-5056-a032-5244-10d120336181. Accessed March 2, 2015.

      One of the current debates is whether to phase out CHIP and integrate it (and currently covered children) with the new exchange plans under the ACA. This strategy carries much risk. A recent review of state-specific benefits for children in the exchange plans shows major gaps in key coverage, especially for children with chronic physical and mental health conditions.
      • Grace A.M.
      • Noonan K.G.
      • Cheng T.L.
      • et al.
      The ACA's pediatric essential health benefit has results in a state-by-state patchwork of coverage with exclusions.
      Without major improvements in benefit coverage in exchange plans, children and youth will not fare well in those plans.
      More than 8 million children currently have coverage financed by CHIP. One of the vagaries of the ACA and the new exchange plans has to do with affordability of plan coverage for employees—and when employees may receive subsidies. The law makes employees eligible for subsidies when the cost of personal (individual) coverage is greater than certain financial limits. For an employee with children, the same limits apply, without consideration of the increased cost of dependent coverage, potentially leaving many children without access to subsidies and insurance due to this “family glitch” in the ACA legislation. Without a legislative fix for this problem, a large number of children currently covered by CHIP would not be able to obtain affordable insurance through the exchanges. An article in this supplement of Academic Pediatrics found that, although some CHIP-enrolled children have parents with employer-based insurance, most do not have affordable access themselves for dependent coverage through employer-sponsored insurance.
      • McMorrow S.
      • Kenney G.M.
      • Waldmann T.
      • et al.
      Access to private coverage for children enrolled in CHIP.
      CHIP has had a major role in insuring high-risk children and bringing rates of child health insurance in this country to the highest in history. The 2009 CHIP reauthorization also added significant funding for quality improvement. With leadership from the Agency for Healthcare Research and Quality, 7 centers of excellence in pediatric measurement across the country have systematically developed child-specific health care measures in key domains, including prenatal care, specific conditions (eg, sickle cell anemia, asthma, attention-deficit hyperactivity disorder, adolescent depression), care coordination, and hospital readmission.

      Agency for Healthcare Research and Quality. Pediatric Quality Measures Program (PQMP) Centers of Excellence Grant Awards. Available at: http://www.ahrq.gov/policymakers/chipra/pubs/pqmpfact.html. Accessed March 2, 2015.

      The legislation also supported 10 state quality demonstration grants that blossomed into 18 states, designed to test new ways to provide care and improve quality. These 2 sizeable efforts represent the first coordinated nationwide activities to examine and improve quality in publicly-financed child and adolescent health care. Where Medicare has had decades of investment in measuring quality among elderly patients and providing vast amounts of information on which to improve care for older people, Medicaid and CHIP long suffered from lack of attention to issues of quality. These new investments offer promise to change practice and make care better for children and their families. They also strengthen the base for work to prevent chronic conditions, whose prevalence continues to expand among adolescents and young adults.
      • Perrin J.M.
      • Anderson L.E.
      • Van Cleave J.
      The rise of chronic conditions among infants, children, and youth can be met with continued health system innovations.
      The articles in this supplement find many positive effects of CHIP on access to and quality care for children, but they also show room for improvement. They provide much information about unmet needs and missed opportunities for immunizations and other preventive care. Thus, it is critical to continue the key quality improvement activities described above. Most innovation in payment reform for children has come in the past few years from Medicaid state experiments, many linked to the quality demonstrations. Continuing these efforts will enhance pediatric practice transformation and the harnessing of new technologies to strengthen pediatric care.
      What else does this supplement tell about the success and current status of CHIP? It documents the tremendous growth in CHIP and other public coverage over the past few years. One benefit of the implementation of the ACA has been the systematic assessment of eligibility of households for other insurance, including Medicaid and CHIP—and many families learned about this option through the ACA enrollment, resulting in the highest ever percentages of children eligible for Medicaid and CHIP actually enrolled. Nonetheless, approximately 3.7 million uninsured US children remain eligible and yet have not enrolled, signaling a clear opportunity to further children's health insurance coverage.
      • Kenney G.M.
      • Haley J.
      • Anderson N.
      • et al.
      Children eligible for Medicaid or CHIP: who remains uninsured and why?.
      There is strong bipartisan support for CHIP and its renewal. Governors very much like the program, in part because it is a block grant rather than an entitlement, thus having predictable federal support each year, but also because it covers a large number of otherwise-uninsured children in the state and decreases overall state expenditures. The House Energy and Commerce Committee and the Senate Finance Committee jointly questioned the governors on their views of CHIP and received overwhelming support from governors of both parties. It is likely that funding for the CHIP program will be extended in 2015—hopefully it will include some of the key innovations that can lead to the right care, in the right place, at the right time for children and youth.

      References

      1. Larson K, Cull WL, Olson LM. US children's access to health services: trends and disparities by race/ethnicity and income, 2002-2012. Available at: https://www.aap.org/en-us/professional-resources/Research/pages/U-S--Childrens-Access-to-Health-Services-Trends-and-Disparities-by-RaceEthnicity-and-Income2002-2012.aspx. Accessed March 2, 2015.

        • Forrest C.B.
        • Simpson L.
        • Clancy C.
        Child health services research: challenges and opportunities.
        JAMA. 1997; 277: 1787-1793
        • Stille C.
        • Turchi R.M.
        • Antonelli R.
        • et al.
        The family-centered medical home: specific considerations for child health research and policy.
        Acad Pediatr. 2010; 10: 211-217
      2. United States Senate Committee on Finance. The Children's Health Insurance Program: Protecting America's Children and Families. Available at: http://www.finance.senate.gov/hearings/hearing/?id=9b08df31-5056-a032-5244-10d120336181. Accessed March 2, 2015.

        • Grace A.M.
        • Noonan K.G.
        • Cheng T.L.
        • et al.
        The ACA's pediatric essential health benefit has results in a state-by-state patchwork of coverage with exclusions.
        Health Aff (Millwood). 2014; 33: 2136-2143
        • McMorrow S.
        • Kenney G.M.
        • Waldmann T.
        • et al.
        Access to private coverage for children enrolled in CHIP.
        Acad Pediatr. 2015; 15: 50-55
      3. Agency for Healthcare Research and Quality. Pediatric Quality Measures Program (PQMP) Centers of Excellence Grant Awards. Available at: http://www.ahrq.gov/policymakers/chipra/pubs/pqmpfact.html. Accessed March 2, 2015.

        • Perrin J.M.
        • Anderson L.E.
        • Van Cleave J.
        The rise of chronic conditions among infants, children, and youth can be met with continued health system innovations.
        Health Aff (Millwood). 2014; 33: 2106-2115
        • Kenney G.M.
        • Haley J.
        • Anderson N.
        • et al.
        Children eligible for Medicaid or CHIP: who remains uninsured and why?.
        Acad Pediatr. 2015; 15: 36-43