Children's mental health care: differences by race/ethnicity in urban/rural areas.

This study examines racial/ethnic disparities in children's mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.

Assessing potential enrollment and budgetary effects of SCHIP premiums: findings from Arizona and Kentucky.

OBJECTIVE: To assess whether new premiums in SCHIP affect rates of disenrollment and reenrollment in SCHIP and whether they have spillover enrollment effects on Medicaid. DATA SOURCE: We used SCHIP administrative enrollment data from Arizona and Kentucky. The enrollment data covered July 2001 to December 2005 in Arizona and November 2001 to August 2004 in Kentucky. STUDY DESIGN: We used administrative data from two states, Arizona and Kentucky, which introduced new premiums for certain income categories in their SCHIP programs in 2004 and 2003, respectively. We used multivariate hazard models to study rates of disenrollment and re-enrollment for the recipients who had been enrolled in the categories of SCHIP in which the new premiums were implemented. Competing hazard models were used to determine if recipients leaving SCHIP following the introduction of the premium were obtaining other public coverage or exiting public insurance entirely at higher rates. We also used time-series models to measure the effect of premiums on changes in caseloads in premium-paying SCHIP and other categories of public coverage and we assessed the budgetary implications of imposing premiums. PRINCIPAL FINDINGS: In both states, the new premiums increased the rate of disenrollment and decreased the rate of re-enrollment in premium-paying SCHIP among the children who were enrolled in those categories before the premiums were implemented. The competing hazard models indicated that almost all of the increased disenrollment is caused by recipients leaving public insurance entirely. The time-series models indicated that the new premium reduced caseloads in premium-paying SCHIP, but that it might have increased caseloads for other types of public coverage. The amount of premiums collected net of the costs associated with administering premiums is small in both states. Estimating the full budgetary effects with certainty was not possible given the imprecision of the key time-series estimates. CONCLUSION: These results suggest that the new premium reduced enrollment in the premium-paying group by 18 percent (over 3,000 children) in Kentucky and by 5 percent (over 1,000 children) in Arizona, with some of these children apparently leaving public coverage altogether. While most children enrolled in these categories did not appear to be directly affected by the imposition of $10-$20 monthly premiums, the premiums may have caused some children to go without health insurance coverage, which in turn could have adverse effects on their access to care. Imposing nominal premiums may reduce state spending, but projected savings appear to be small relative to total state SCHIP spending and resulting increases in enrollment in other public programs and in uninsurance rates could offset those savings.

Restoring fiscal integrity to medicaid financing?

Using survey data, we examined Medicaid supplemental payments (SPs), including disproportionate-share hospital (DSH) and upper payment limit (UPL) payments in 2005 and changes in these payments between 2001 and 2005. We found that states increased their use of general funds in financing of DSH payments while expanding the size and scope of other SPs considerably. Although the federal government has made some headway in reforming state Medicaid financing, our findings suggest that more work remains.

Out-of-pocket health spending between low-and higher-income populations: who is at risk of having high expenses and high burdens?

OBJECTIVE: We studied the effects of health insurance, health care needs, and demographic and area characteristics on out-of-pocket health care spending for low and higher income insured populations. MATERIALS AND METHODS: We used the 2002 National Survey of America's Families to analyze out-of-pocket health spending. People were classified into 3 levels of expenses based on their out-of-pocket health care spending and 3 levels of financial burden based on spending as a share of family income. We used a multinomial logit model to estimate the effect of insurance status and other factors on expense and burden levels. RESULTS: Public insurance appears to offer the best financial protection from high out-of-pocket expenses and financial burden for those who are eligible. Families with private nongroup coverage have the highest odds of being in the high-expense and high-burden categories for all incomes. For higher-income families, having a family member in fair or poor health is a significant risk factor for high out-of-pocket expenses and financial burden. Having higher penetration of health maintenance organizations in an area appears to lower the odds of being in the high-burden category for all families. CONCLUSIONS: Health insurance may not prevent people from having high health care spending. Low-income people with serious health needs appear to be financially constrained and spend less on health care relative to higher-income people, and the presence of health maintenance organizations may help reduce out-of-pocket health care spending.

Effects of premium increases on enrollment in SCHIP: findings from three states.

This study examines the effects of new and higher premiums on SCHIP enrollment in Kansas, Kentucky, and New Hampshire--three states that implemented premium changes in 2003. We used state administrative enrollment records from 2001 to 2004-2005 to track changes in total caseloads, new enrollments, and disenrollment timing in premium-paying categories of SCHIP before and after the premium changes were implemented. Premium hikes were associated with lower caseloads in all three states and with earlier disenrollment in Kentucky and New Hampshire. Premium increases appeared to have greater disenrollment effects for lower-income children in New Hampshire and for nonwhite children in Kentucky.

Preventive dental care and unmet dental needs among low-income children.

OBJECTIVES: We examined the ways in which levels of preventive dental care and unmet dental needs varied among subgroups of low-income children. METHODS: Data were drawn from the 2002 National Survey of America's Families. We conducted bivariate and multivariate analyses, including logistic regression analyses, to assess relationships between socioeconomic, demographic, and health factors and receipt of preventive dental care and unmet dental needs. RESULTS: More than half of low-income children without health insurance had no preventive dental care visits. Levels of unmet dental needs among low-income children who had private health insurance coverage but no dental benefits were similar to those among uninsured children. Children of parents whose mental health was rated as poor were twice as likely to have unmet dental needs as other children. CONCLUSIONS: Additional progress toward improving the dental health of low-income children depends on identifying and responding to factors limiting both the demand for and the supply of dental services. In particular, it appears that expanding access to dental benefits is key to improving the oral health of this population.

Changes in medicaid physician fees, 1998-2003: implications for physician participation.

After slow growth during much of the 1990s, Medicaid physician fees increased, on average, by 27.4 percent between 1998 and 2003. Primary care fees grew the most. States with the lowest relative fees in 1998 increased their fees the most, but almost no states changed their position relative to other states or Medicare. Physicians in states with the lowest Medicaid fees were less willing to accept most or all new Medicaid patients in both 1998 and 2003. However, large fee increases were associated with primary care physicians' greater willingness to accept new Medicaid patients.