The Children’s Health Insurance Program Reauthorization Act of 2009  (CHIPRA) included provisions aimed at improving the information  available from states on the quality of health care furnished to children in  both CHIP and Medicaid. In addition, CHIPRA  required HHS to identify quality measures, known as the Child Core Set  measures, to serve as a tool for states to use to monitor and improve the  quality of health care provided to children enrolled in CHIP and Medicaid. Assessments of National Data Largely Show Positive Effect of CHIP on Coverage and Access, and Identify Areas for Improvement

Available assessments of national data we reviewed identify positive  effects of CHIP, including a reduction in the rate of uninsured children and  children’s improved access to care, and these findings are often  consistent with our prior work. Mandated Evaluation Highlights Reduction in the Rate of Uninsured Children and Improved Access to Health Care

HHS’s mandated evaluation identified several positive effects of CHIP  across states, particularly with regard to children who are uninsured. In particular, when compared with uninsured children, we  found that CHIP enrollees fared better, and the differences we identified  were statistically significant in most cases. When the mandated evaluation compared CHIP enrollees with the  privately-insured group, it also found that CHIP enrollees experienced  comparable access and service use for many, but not all, measures, and  that parents of children enrolled in CHIP experienced less financial  burden in paying their children’s medical bills. For our assessment of the Medical Expenditure Panel Survey, we also  compared CHIP enrollees’ access and service use with children who  were privately-insured, and our findings were consistent with some of the  findings in the mandated evaluation. HHS Has Ongoing Efforts to Enhance State Reporting of Quality Measures and Identify Areas for Improvement to Care Provided in CHIP

HHS publishes data that states report on the Child Core Set measures in  its annual quality report. 2.) For example,  a mean of 96 percent of children aged 12 to 24 months enrolled in CHIP  or Medicaid had at least one primary care physician visit during fiscal year  2013. For example, a mean of 46 percent of children received at  least one preventive dental service, and a mean of 25 percent of children   (See table 2.) For the  most recent annual quality report, 40 of the 42 states that contract with  managed care plans to deliver services to CHIP and Medicaid enrollees   Based on its review of these  submitted external quality review reports.reports, HHS found that the most frequently reported performance  measures from states’ external quality reports—which included well-child  care, primary care access, childhood immunization rates, and  prenatal/postpartum care—mirrored states’ most frequently reported Child  Core Set measures in fiscal year 2013. Cost, Coverage, and Access to Care Are Key Considerations in Determining the Reauthorization of CHIP Funding

Our prior work has identified important considerations related to cost,  coverage, and access when determining the ongoing need for CHIP,  many of which were echoed by officials from the 10 states we reviewed. With regard to cost, our prior work comparing CHIP plans to states’  benchmark plans, which were the models for health plans available under  health insurance exchanges established under PPACA, found that  costs—defined as deductibles, copayments, coinsurance, and  premiums—were almost always less for CHIP plans. Officials from five selected states also expressed concerns about the  higher costs of QHP coverage and the implications this would have for  families. We also previously reported that coverage is a relevant consideration,  and that separate CHIP and benchmark plans were generally similar in  terms of their coverage of selected services and the services on which  they imposed limits, with some variation. Officials from several  selected states pointed out that CHIP coverage was more comprehensive  than QHPs for certain services, particularly for services needed by  children with special health care needs. With regard to access, our work found that CHIP enrollees generally  reported positive responses in their ability to obtain care that was  generally comparable to those with private insurance, with some  exceptions, including lower utilization of dental and orthodontia services. Some of the states we reviewed also raised concerns related to access to  care if CHIP funding is not reauthorized. Agency Comments

We provided a draft of this report to HHS for comment. The department  provided technical comments, which we incorporated as appropriate. At that time, we will send copies to the Secretary of Health and  Human Services. Children’s Health Insurance: Cost, Coverage, and Access Considerations  for Extending Federal Funding.
Why GAO Did This Study

CHIP is a joint federal-state program that finances health insurance for over 8 million children. Since the program's inception, the percentage of uninsured children nationwide has decreased by half, from 13.9 percent in 1997 to 6.6 percent in the first three months of 2014. This year, Congress will decide whether to extend CHIP funding beyond 2015.
GAO was asked to provide information on the effect of CHIP on children's coverage, and what key issues may be considered in determining the ongoing need for CHIP. In this report, GAO examines (1) what assessments of CHIP suggest about its effect on children's health care coverage and access; and (2) what key issues identified by GAO's work the Congress may wish to consider in determining whether to extend CHIP funding.
For the assessments of CHIP's effect, GAO reviewed reports on CHIP, including a mandated evaluation and annual HHS reports on quality, which publish data that states report on Child Core Set measures, which are quality measures identified by HHS that states can use to monitor health care provided to children in CHIP and Medicaid. GAO also reviewed relevant federal statutes and regulations. To identify key issues that the Congress may wish to consider, GAO reviewed its own relevant reports and testimony; reviewed letters from state governors regarding CHIP; and interviewed CHIP officials in 10 states, which were selected based on variation in location, program size, and design.
HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.

What GAO Found

Assessments of national data GAO reviewed identify positive effects of the State Children's Health Insurance Program (CHIP), and the quality measures reported by states help identify areas needing improvement.
A mandated evaluation of CHIP published in 2014 noted that CHIP enrollees (1) had substantially better access to care, service use, and preventive care when compared with uninsured children; and (2) experienced comparable access and service use when compared with privately insured children. These findings are generally consistent with prior GAO work, which used national survey data to compare CHIP enrollees' access and service use with children who were uninsured or privately insured. When comparing CHIP enrollees with privately insured children, the mandated evaluation and prior GAO work differed regarding the utilization of certain services, such as emergency room use and dental services, which may be due to differences in when the data were collected and the particular measures that were used.
The Department of Health and Human Services (HHS) also publishes data on quality measures that states voluntarily report annually. These Child Core Set measures show mixed results regarding service utilization among CHIP and Medicaid enrollees. For example, states reported that nearly all children aged 12 to 24 months enrolled in CHIP or Medicaid had at least one primary care physician visit during fiscal year 2013. However, states reported that far fewer children obtained dental prevention or treatment services, with a mean of 46 percent of children receiving a preventive dental service, and a mean of 25 percent receiving dental treatment services. HHS officials said that they use these data to help identify areas for improvement in the care provided in CHIP and Medicaid.
GAO's prior work has identified important issues related to cost, coverage, and access that Congress may wish to consider when determining the ongoing need for CHIP, many of which were similar to issues raised by officials from the 10 states GAO reviewed.
With regard to cost, GAO's prior work found that costs—defined as deductibles, copayments, coinsurance, and premiums—were almost always less for selected CHIP plans when compared with states' benchmark health plans, which were the models for health plans available in health insurance exchanges established under the Patient Protection and Affordable Care Act. Officials in five states expressed concerns about the higher cost of exchange plans compared with CHIP and the implications for families' finances.
With regard to coverage, GAO previously reported that selected CHIP and state benchmark plans were generally similar in terms of their coverage of selected services and the services on which they imposed limits. However, officials from several of the 10 states pointed out that for many services needed by children with special health care needs, CHIP coverage was more comprehensive than exchange plans.
With regard to access, several states raised concerns about negative implications for children's coverage if CHIP funding is not reauthorized, including concerns that their states would lose gains made in covering children, who would also lose access to providers and dental care.