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Objective To examine the effects of parental Medicaid eligibility on parental health, parenting practices, and child development in low-income families. Methods Longitudinal analysis using data from the Early Child Longitudinal Study-Kindergarten: 2011 to 2016. Outcomes included parental self-rated health, parental depressive symptoms, parents’ communication and warmth toward children, and children's social skills and externalizing and internalizing behaviors. We estimated 2-way (individual and year) fixed effects models using Medicaid eligibility as a continuous variable, controlling for changing economic conditions, changes in family structure, and state-specific trends. We then estimated triple difference models comparing lower income families to those with higher incomes. Finally, we estimated difference-in-difference models and used entropy weights in order to account for differences in trends prior to 2014 for some outcomes. Results In fixed effects models, expanding Medicaid eligibility by 100% of the federal poverty line is associated with a 12.7 percentage point reduction in parents’ report of having fair or poor health (95% confidence interval [CI], -23.9, -1.5) and a 1.15-point improvement on a 12-point scale of parental warmth towards children (95% CI, 0.15, 2.16). Results were substantively similar in entropy-balanced difference-in-differences models. In triple difference models, expanded Medicaid eligibility is associated with a 0.46 point improvement in warmth (95% CI, 0.10, 0.83) but not improved parental health. No significant effects for child behavior or other outcomes were detected. Conclusions Expanding Medicaid for parents may have implications for intergenerational family functioning that could lead to broader social benefits.

ImportanceCOVID-19 relief legislation created a temporary moratorium on Medicaid disenrollment, but when the public health emergency ends, states will begin to “unwind” Medicaid enrollment. Prepandemic data shed light on factors that can affect Medicaid coverage stability.ObjectiveTo assess factors associated with the duration and continuity of Medicaid enrollment.Design, Setting, and ParticipantsIn this cross-sectional analyses of a Medicaid data set for 2016 that was released by the Agency for Healthcare Research and Quality in June of 2022, we analyze a nationally representative data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016. We focus on 22 million nondisabled, nonelderly adults for this analysis. The data were analyzed between July and September of 2022.Main Outcomes and MeasuresThe main outcomes were the average months of Medicaid enrollment in 2016 and the probability of churning, defined as a break in coverage between 2 periods of enrollment during the calendar year. We compared these outcomes by eligibility category, state, demographic characteristics, and key Medicaid policies, including whether the state expanded Medicaid and whether it used ex parte reviews (automated reviews of other administrative data to reduce renewal paperwork burdens).ResultsIn this cross-sectional analysis, we analyze a nationally representative Medicaid data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016, released by the Agency for Healthcare Research and Quality in June of 2022. The analysis focused on nonelderly, nondisabled adults (aged 18-64 years) with a weighted population size of 22.7 million, of which 18.4% were Black, 19.2% were Latino, 39.5% were White, 7.3% were other/Asian/Native American, and 15.5% had unknown race. Multivariable regression analysis indicated that those living in states that expanded Medicaid but did not use ex parte reviews had longer average duration (0.31 months longer; 95% CI, 0.03-0.59) and lower risk of churning(odds ratio [OR], .40; 95% CI, 0.39-0.40), whereas those living in nonexpansion states that used ex parte reviews had lower odds of churning (OR, .68; 95% CI, 0.66-0.70) but also had shorter average duration (3.1 months shorter; 95% CI, −3.4 to −2.8). Those living in expansion states that used ex parte reviews also had reduced churning (OR, .83; 95% CI, 0.82-0.85). The average duration varied widely by state, even after adjustments for demographic and state policy factors.Conclusions and RelevanceIf state Medicaid programs revert to prepandemic policies after the temporary moratorium ends, Medicaid coverage, particularly for nondisabled, nonelderly adults, is likely to become less stable again. Medicaid expansions are associated with improved continuity, but ex parte review may have a more complex role.

Introduction Cigarette smoking prevalence is higher among adults enrolled in Medicaid than adults with private health insurance. State Medicaid coverage of cessation treatments has been gradually improving in recent years; however, the extent to which this has translated into increased use of these treatments by Medicaid enrollees remains unknown. Aims and Methods Using Medicaid Analytic eXtract (MAX) files, we estimated state-level receipt of smoking cessation treatments and associated spending among Medicaid fee-for service (FFS) enrollees who try to quit. MAX data are the only national person-level data set available for the Medicaid program. We used the most recent MAX data available for each state and the District of Columbia (ranging from 2010 to 2014) for this analysis. Results Among the 37 states with data, an average of 9.4% of FFS Medicaid smokers with a past-year quit attempt had claims for cessation medications, ranging from 0.2% (Arkansas) to 32.9% (Minnesota). Among the 20 states with data, an average of 2.7% of FFS Medicaid smokers with a past-year quit attempt received cessation counseling, ranging from 0.1% (Florida) to 5.6% (Missouri). Estimated Medicaid spending for cessation medications and counseling for these states totaled just over $13 million. If all Medicaid smokers who tried to quit were to have claims for cessation medications, projected annual Medicaid expenditures would total $0.8 billion, a small fraction of the amount ($45.9 billion) that Medicaid spends annually on treating smoking-related disease. Conclusions The receipt of cessation medications and counseling among FFS Medicaid enrollees was low and varied widely across states. Implications Few studies have examined use of cessation treatments among Medicaid enrollees. We found that many FFS Medicaid smokers made quit attempts, but few had claims for proven cessation treatments, especially counseling. The receipt of cessation treatments among FFS Medicaid enrollees varied widely across states, suggesting opportunities for additional promotion of the full range of Medicaid cessation benefits. Continued monitoring of Medicaid enrollees’ use of cessation treatments could inform state and national efforts to help more Medicaid enrollees quit smoking.

Fluctuating insurance coverage, or churning, is a recognized barrier to health care access. We assessed whether state policies that allow children to remain covered in Medicaid for a 12-month period, regardless of fluctuations in income, are associated with health and health care outcomes, after controlling for individual factors and other Medicaid policies. This cross-sectional study uses a large, nationally representative database of children ages 0 to 17. Continuous eligibility was associated with improved rates of insurance, reductions in gaps in insurance and gaps due to application problems, and lower probability of being in fair or poor health. For children with special health care needs, it was associated with increases in use of medical care and preventive and specialty care access. However, continuous eligibility was not associated with health care utilization outcomes for the full sample. Continuous eligibility may be an effective strategy to reduce gaps in coverage for children and reduce paperwork burden on Medicaid agencies.

Supplemental Digital Content is available in the text., Objective: Prior studies of community health centers (CHCs) have found that clinicians supported by the National Health Service Corps (NHSC) provide a comparable number of primary care visits per full-time clinician as non-NHSC clinicians and provide more behavioral health care visits per clinician than non-NHSC clinicians. This present study extends prior research by examining the contribution of NHSC and non-NHSC clinicians to medical and behavioral health costs per visit. Methods: Using 2013–2017 data from 1022 federally qualified health centers merged with the NHSC participant data, we constructed multivariate linear regression models with health center and year fixed effects to examine the marginal effect of each additional NHSC and non-NHSC staff full-time equivalent (FTE) on medical and behavioral health care costs per visit in CHCs. Results: On average, each additional NHSC behavioral health staff FTE was associated with a significant reduction of 3.55 dollars of behavioral health care costs per visit in CHCs and was associated with a larger reduction of 7.95 dollars in rural CHCs specifically. In contrast, each additional non-NHSC behavioral health staff FTE did not significantly affect changes in behavioral health care costs per visit. Each additional NHSC primary care staff FTE was not significantly associated with higher medical care costs per visit, while each additional non-NHSC clinician contributed to a slight increase of $0.66 in medical care costs per visit. Conclusions: Combined with previous findings on productivity, the present findings suggest that the use of NHSC clinicians is an effective approach to improving the capacity of CHCs by increasing medical and behavioral health care visits without increasing costs of services in CHCs, including rural health centers.

Immigrant children in the US have very limited health insurance coverage and health care access. Immigration status is not static: Census data show that the majority of census respondents who enter as noncitizen children eventually become citizens. Eligibility restrictions that prevent noncitizen children from being publicly insured can contribute to their experiencing poorer health and higher medical costs in their adult lives. We isolate the impact of lack of citizenship from socioeconomic factors by comparing citizen and noncitizen siblings living in mixed-status families, using fixed-effects models to net out socioeconomic factors shared within families. Lacking citizenship increased a child's risk of being uninsured and lowered by 26 percentage points the chances that they would have Medicaid or Children's Health Insurance Program coverage. Noncitizen children had significantly more delays in needed medical care because of cost, primarily mediated by the lack of insurance coverage. The US should reexamine policies that exclude noncitizen children from public health insurance programs.

PURPOSE This study examines whether characteristics of dental education, practice characteristics and state Medicaid policies are associated with dentists' pediatric Medicaid participation. METHODS Cross-sectional analysis of data about dentists' Medicaid participation in 2016, based on current practice characteristics and characteristics of dental schools they attended 5 to 10 years earlier. We analyze data about 22,500 general and pediatric dentists, drawn from the American Dental Association's Masterfile for 2016 and its dental school survey for 2009-10. The primary outcome is whether dentists participated in Medicaid-enrolled to accept Medicaid patients and payments-in at least 1 of their practice sites in 2016. RESULTS A majority (55%) of dentists accepted Medicaid in at least 1 practice site, while a quarter (24%) accepted Medicaid in all their sites. Dentists who attended schools with higher tuition rates were less likely to serve Medicaid patients at any site several years later (adjusted odds ratio [AOR] = .761). Dental schools' receipt of grants that encourage community-based training were associated with increased Medicaid participation at all sites (AOR = 1.22). Those practicing in rural areas also had higher Medicaid participation (AOR = 2.62). A 10% increase in Medicaid reimbursement rates was associated with increased Medicaid participation at any site (AOR = 1.24). CONCLUSIONS Dental school practices and state Medicaid policies are associated with whether dentists care for Medicaid patients. Changes in dental school or Medicaid policies, such as higher reimbursement rates, could help encourage more dentists to accept Medicaid patients, thereby increasing access to care.

Key Points Question What are the associations between work requirements and Supplemental Nutrition Assistance Program participation for the overall target population and subpopulations? Findings In this pooled cross-sectional study of 866 000 low-income US adults, work requirements were associated with a 4.0 percentage point decrease in participation for the target population of childless adults without disability, with reductions in participation of 7.2 percentage points for non-Hispanic black adults, 5.5 percentage points for Hispanic adults, and 2.6 percentage points for non-Hispanic white adults within this group. There was also a 4.0 percentage point decrease for childless adults with disability. Meaning These findings suggest that Supplemental Nutrition Assistance Program work requirements are associated with decreased participation for subpopulations who have greater rates of food insecurity., This cross-sectional study examines whether work requirements in the Supplemental Nutrition Assistance Program (SNAP) are associated with lower program participation rates and whether there are racial/ethnic disparities or spillover effects for people with disabilities., Importance Increased work requirements have been proposed throughout federal safety net programs, including the Supplemental Nutrition Assistance Program (SNAP). Participation in SNAP is associated with reduced food insecurity and improved health. Objectives To determine whether SNAP work requirements are associated with lower rates of program participation and to examine whether there are racial/ethnic disparities or spillover effects for people with disabilities, who are not intended to be affected by work requirements. Design, Setting, and Participants This nationally representative, pooled cross-sectional study examined how changes in SNAP work requirements at state and local levels in the US are associated with changes in food voucher program participation. The study combined information on state and local SNAP work requirements with repeated cross-sections from the 2012 through 2017 American Community Survey (with outcomes covering 2013 to 2017). The analytical approaches were based on difference-in-difference and triple-difference methods, after controlling for other economic and social factors. The sample included low-income adults without dependents, stratified by racial/ethnic group and disability status. The study also included parents who would otherwise meet work requirement criteria as a comparison group to estimate triple-difference models. This accounted for otherwise unobserved factors affecting trends in SNAP participation within local areas. Data were analyzed from January 2019 through March 2020. Exposure Residence in areas where SNAP work requirements apply. Main Outcomes and Measures The primary outcome is SNAP participation measured by whether anyone in the household received food vouchers at any point over the prior 12 months. Results The final analytical sample included 866 000 low-income adults (weighted mean [SE] age, 33.6 [0.01] years; 42.5% [SE, 0.07%] men). The racial/ethnic breakdown was 56.5% (SE, 0.07%) non-Hispanic white respondents, 19.4% (SE, 0.06%) non-Hispanic black respondents, 17.7% (SE, 0.06%) Hispanic respondents, 2.5% (SE, 0.02%) Asian respondents, and 3.9% (SE, 0.03%) respondents of other or multiple races. In final triple-difference models, work requirements were associated with a 4.0 percentage point decrease in participation (95% CI, –0.048 to –0.032; P

Introduction Smoking rates for Medicaid beneficiaries have remained flat in recent years. Medicaid may support smokers in quitting by covering a broad array of tobacco cessation services without barriers such as copays. This study examines the impact of increasing generosity in Medicaid tobacco cessation coverage policies on smoking and cessation behaviors. Methods We used 2010 and 2015 National Health Interview Survey data merged with information on state tobacco, Medicaid cessation, and Medicaid eligibility policies to estimate state fixed effects models of cessation medication use, counseling use, quit attempts, and current smoking. Results Smokers living in states that cover cessation medications but not counseling services were less likely to use counseling. Smokers were more likely to report having tried to quit in states with higher rates of use of cessation medications among Medicaid beneficiaries. We found no impact of Medicaid policies on use of cessation medications. States that impose copays had higher rates of smoking, while those that require counseling as a condition of receiving medication had lower rates of smoking. Additionally, we found that expanding Medicaid eligibility under the Affordable Care Act is associated with decreased smoking prevalence among Medicaid beneficiaries. Conclusion Covering cessation counseling may encourage smokers that want to quit to use this service. Promoting the use of cessation medications may improve the likelihood that smokers try to quit. Medicaid coverage of cessation services is an important but incomplete strategy in addressing smoking among low-income populations. Implications States may be able to improve utilization of cessation counseling by providing Medicaid reimbursement for this service. Encouraging utilization of tobacco cessation medications may help more smokers quit. States should consider how to promote effective cessation methods among clinicians and patients.

Objectives. To assess the effects of work requirements for able-bodied adults without dependents in the Supplemental Nutrition Assistance Program (SNAP). Methods. We used changes in waivers of work requirements to assess the impact of requiring work on the number of SNAP participants and benefit levels in 2410 US counties from 2013 to 2017 using 2-way fixed effects models. Results. Adoption of work requirements was followed by reductions of 3.0% in total SNAP participation, 4.5% in SNAP households, and 3.8% in SNAP benefit dollars, after controlling for the unemployment, poverty, and Medicaid expansions. Because able-bodied adults without dependents comprise 8% to 9% of all SNAP participants, our findings indicate that work requirements caused more than one third of able-bodied adults without dependents to lose benefits. Conclusions. Expansions of work requirements caused about 600 000 participants to lose SNAP benefits from 2013 to 2017 and caused a reduction of about $2.5 billion in federal SNAP benefits in 2017. The losses occurred rapidly, beginning a few months after work requirements were imposed. Public Health Implications. SNAP work requirements rapidly reduce caseloads and benefits, reducing food and health access. Effects on participation could be similar for work requirements in Medicaid or other programs.

Objectives: Previous state interagency collaborations have led to successful tobacco cessation initiatives. The objective of this study was to assess the roles and interaction of state Medicaid and public health agency efforts to support tobacco cessation for low-income Medicaid beneficiaries. Methods: We interviewed Medicaid and state public health agency officials in 8 states in September and October 2015 about collaborations in policy development and implementation for Medicaid tobacco cessation, including Medicaid coverage policies, quitlines, and monitoring. Results: Collaboration between Medicaid and public health agencies was limited. Smoking cessation quitlines were the most common area of collaboration cited. Public health officials were typically not involved in developing Medicaid coverage policies. States covered a range of US Food and Drug Administration–approved tobacco cessation medications, but 7 of the 8 states imposed limitations, such as charging copayments or requiring previous authorization. States generally lacked data to monitor implementation of tobacco cessation efforts and had little ability to determine the effectiveness of their policies. Conclusions: To strengthen efforts to reduce smoking and tobacco-related health burdens and to monitor the effectiveness of policies and programs, Medicaid and public health agencies should prioritize tobacco cessation and develop and analyze data about smoking and cessation efforts among Medicaid beneficiaries. Recent multistate initiatives from the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services seek to promote stronger collaborations in clinical prevention activities, including tobacco cessation.

Through the expansion of Medicaid eligibility and increases in core federal grant funding, the Affordable Care Act (ACA) sought to increase the capacity of community health centers to provide primary care to low-income populations. We examined the effects of the ACA Medicaid expansion and changes in federal grant levels on the centers' numbers of patients, percentages of patients by type of insurance, and numbers of visits from 2012 to 2015. In the period after expansion (2014-15), health centers in expansion states had a 5 percent higher total patient volume, larger shares of Medicaid patients, smaller shares of uninsured patients, and increases in overall visits and mental health visits, compared to centers in nonexpansion states. Increases in federal grant funding levels were associated with increases in numbers of patients and of overall, medical, and preventive service visits. If federal grant levels are not sustained after 2017, there could be marked reductions in health center capacity in both expansion and nonexpansion states.

Background In this study, the authors examined the prevalence and cost of care for children enrolled in Medicaid for potentially preventable dental conditions who receive surgical care in hospital operating rooms (ORs) or ambulatory surgery centers (ASCs). Methods The authors analyzed Medicaid data from 8 states to find cases in which children aged 1 to 20 years received surgical care in ORs or ASCs in 2010 and 2011 for potentially preventable diagnoses, as defined with diagnostic codes. Results For 6 states with complete data, there were 26,373 cases in 2011 in which children received OR or ASC surgical care for potentially preventable conditions. These cases represent approximately 0.5% of all children enrolled in Medicaid in these states and approximately 1% of children enrolled in Medicaid who received any dental care. There were $68 million in total Medicaid payments for these cases, with an average of $2,581 per case. Diagnostic codes indicated that 98% of cases were related to treatment of dental caries. More than two-thirds of the cases (71%) were children aged 1 to 5 years. Conclusions Extrapolation to the United States suggests that approximately $450 million in additional expenditures occurred in 2011 because of OR or ASC surgical care for potentially preventable pediatric dental conditions, primarily related to early childhood caries. Practical Implications Strategies to improve prevention of early childhood caries, including community- and family-based education, and to increase access to timely and early dental care for low-income children could reduce the burdens and costs of these dental problems.

This study examines whether community health center (CHC) patients have lower medical expenditures. Using 2011-2012 Medical Expenditure Panel Survey data, propensity score methods are used to compare annual expenditures for adults and children receiving at least half their ambulatory care at CHCs versus those who did not. For children, CHC use was associated with 35.3% lower total medical expenditures ($627), 40.0% lower ambulatory expenditures ($279), and 49.1% lower prescription drug expenditures ($157) (all Ps < .05). For adults, the reduction in hospital expenditures for CHC users ($529) was statistically significant at a P < .10 threshold. Estimated differences in total expenditures and other expenditure categories were not statistically significant for adults.

The Centers for Medicare and Medicaid Services approved Medicaid work requirement demonstration projects in four states, and other states also have applied. However, the future of these projects has been clouded by legal and policy challenges.To assess whether state Medicaid work requirement projects are designed for success in promoting employment among unemployed Medicaid beneficiaries.To examine the design of new work requirement projects, we reviewed the evidence, analyzed the overlap of Medicaid and Supplemental Nutrition Assistance Program (SNAP) work requirements, and convened a roundtable of seven experts who have research or implementation experience with work programs for Medicaid and public assistance recipients.Mandatory work programs would be less effective and efficient than well-administered voluntary programs. Far more people will be subject to Medicaid work requirements than are currently subject to them in SNAP. This surge could overwhelm the limited resources of existing employment training and support programs. Medicaid demonstration projects contribute almost no additional funding to train the unemployed or provide necessary social supports. Medicaid work requirement programs are not well designed to help people get jobs or improve health and are more likely to lead to a loss of health insurance coverage.

Objectives. We estimated the number of women of reproductive age in need who would gain coverage for contraceptive services after implementation of the Affordable Care Act, the extent to which there would remain a need for publicly funded programs that provide contraceptive services, and how that need would vary on the basis of state Medicaid expansion decisions. Methods. We used nationally representative American Community Survey data (2009), to estimate the insurance status for women in Massachusetts and derived the numbers of adult women at or below 250% of the federal poverty level and adolescents in need of confidential services. We extrapolated findings to simulate the impact of the Affordable Care Act nationally and by state, adjusting for current Medicaid expansion and state Medicaid Family Planning Expansion Programs. Results. The number of low-income women at risk for unintended pregnancy is expected to decrease from 5.2 million in 2009 to 2.5 million in 2016, based on states’ current Medicaid expansion plans. Conclusions. The Affordable Care Act increases women’s insurance coverage and improves access to contraceptive services. However, for women who remain uninsured, publicly funded family planning programs may still be needed.

Objectives. We investigated basic measures used to assess collaboration between colocated providers and to gauge the extent to which health centers practice integrated care. Methods. We used the Assessment of Behavioral Health Services survey and the 2010 Uniform Data System to explore the elements of integrated care for behavioral health conditions. We used multivariable regression models to examine the correlates of integrated care. Results. More than 85% of health centers provided mental health services in 2010, and almost half offered substance use treatment. Health centers commonly reported shared access to information among behavioral health and medical providers and joint care planning. A higher degree of integrated care involving joint case conferences was less common. Health centers without electronic health records and those with lower percentages of total staff composed of behavioral health workers were less likely to provide integrated care. Conclusions. A 2-pronged strategy involving financial incentives and technical assistance to spread best practices might increase integrated care, particularly among health centers that are not maximizing the potential of electronic health records and health centers with low behavioral health staffing levels.

Community health centers are at the forefront of ambulatory care practices in their use of nonphysician clinicians and team-based primary care. We examined medical staffing patterns, the contributions of different types of staff to productivity, and the factors associated with staffing at community health centers across the United States. We identified four different staffing patterns: typical, high advanced-practice staff, high nursing staff, and high other medical staff. Overall, productivity per staff person was similar across the four staffing patterns. We found that physicians make the greatest contributions to productivity, but advanced-practice staff, nurses, and other medical staff also contribute. Patterns of community health center staffing are driven by numerous factors, including the concentration of clinicians in communities, nurse practitioner scope-of-practice laws, and patient characteristics such as insurance status. Our findings suggest that other group medical practices could incorporate more nonphysician staff without sacrificing productivity and thus profitability. However, the new staffing patterns that evolve may be affected by characteristics of the practice location or the types of patients served.

Introduction Smoking is highly prevalent among low-income Medicaid beneficiaries and tobacco-cessation benefits are generally available. Nonetheless, use of cessation medications or counseling remains low, and many clinicians are hesitant to urge smokers to quit. This study examines the extent to which physicians provide advice to Medicaid patients about quitting. Methods Data from the 2014–2015 Nationwide Adult Medicaid Consumer Assessment of Health Plans survey were merged with state Medicaid policy variables and analyzed in 2017–2018. Multivariate regression models examined factors associated with smoking status, physician advice to quit smoking, and discussion of cessation medications or other strategies, as well as patients’ ratings of their personal physicians. Results Almost one third (29%) of adult Medicaid beneficiaries smoke. Almost four fifths of smokers with a personal doctor (77%) say their doctor at least sometimes advised quitting and almost half of smokers discussed cessation medications (48%), or another strategy, such as counseling (42%). Smokers’ ratings of satisfaction with their physicians and their health plans rose as the frequency of smoking recommendations increased. Those in Medicaid managed care plans smoked more, but received less advice about cessation medications than those in fee-for-service care. Conclusions Clinicians and Medicaid managed care plans can improve their efforts to motivate Medicaid patients to try to quit smoking. These findings indicate that patients value prevention-oriented advice and give better ratings to physicians and health plans that offer more support and advice about cessation.

ISSUE: The American Health Care Act (AHCA), passed by the U.S. House of Representatives, would repeal and replace the Affordable Care Act. The Congressional Budget Office indicates that the AHCA could increase the number of uninsured by 23 million by 2026. GOAL: To determine the consequences of the AHCA on employment and economic activity in every state. METHODS: We compute changes in federal spending and revenue from 2018 to 2026 for each state and use the PI+ model to project the effects on states’ employment and economies. FINDINGS AND CONCLUSIONS: The AHCA would raise employment and economic activity at first, but lower them in the long run. It initially raises the federal deficit when taxes are repealed, leading to 864,000 more jobs in 2018. In later years, reductions in support for health insurance cause negative economic effects. By 2026, 924,000 jobs would be lost, gross state products would be $93 billion lower, and business output would be $148 billion less. About three-quarters of jobs lost (725,000) would be in the health care sector. States which expanded Medicaid would experience faster and deeper economic losses.

A key method of stabilizing Medicaid coverage is to provide beneficiaries with twelve months of continuous eligibility. Following the passage of the Children's Health Insurance Program Reauthorization Act in 2009, seven states adopted the continuous-eligibility option for children. That policy change led to a 1.8-percentage-point increase in the average length of child enrollment during fiscal year 2010 and increased annual costs for children by about 2.2 percent. The Medicaid and CHIP Payment and Access Commission has recommended offering states the option of giving adults twelve-month continuous eligibility for Medicaid. Our findings suggest that continuous eligibility could promote more stable coverage for adults enrolled in Medicaid at a modest cost.

Issue: The incoming Trump administration and Republicans in Congress are seeking to repeal the Affordable Care Act (ACA), likely beginning with the law’s insurance premium tax credits and expansion of Medicaid eligibility. Research shows that the loss of these two provisions would lead to a doubling of the number of uninsured, higher uncompensated care costs for providers, and higher taxes for low-income Americans. Goal: To determine the state-by-state effect of repeal on employment and economic activity. Methods: A multistate economic forecasting model (PI+ from Regional Economic Models, Inc.) was used to quantify for each state the effects of the federal spending cuts. Findings and Conclusions: Repeal results in a $140 billion loss in federal funding for health care in 2019, leading to the loss of 2.6 million jobs (mostly in the private sector) that year across all states. A third of lost jobs are in health care, with the majority in other industries. If replacement policies are not in place, there will be a cumulative $1.5 trillion loss in gross state products and a $2.6 trillion reduction in business output from 2019 to 2023. States and health care providers will be particularly hard hit by the funding cuts.

This report analyzes the use of dental services by children enrolled in Medicaid from federal fiscal years (FFY) 2000 to 2010. The number and percent of children receiving dental services under Medicaid climbed continuously over the decade. In FFY 2000, 6.3 million children ages 1 to 20 were reported to receive some form of dental care (either preventive or treatment); the number more than doubled to 15.4 million by FFY 2010. Part of the increase was because the overall number of children covered by Medicaid rose by 12 million (50%), but the percentage of children who received dental care climbed appreciably from 29.3% in FFY 2000 to 46.4% in FFY 2010. In that same time period, the number of children ages 1 to 20 receiving preventive dental services climbed from a reported 5.0 million to 13.6 million, while the percentage of children receiving preventive dental services rose from 23.2% to 40.8%. For children ages 1 to 20 who received dental treatment services, the reported number rose from 3.3 million in FFY 2000 to 7.6 million in FFY 2010. The percentage of children who obtained dental treatment services increased from 15.3% to 22.9%. In FFY 2010, about one sixth of children covered by Medicaid (15.7%) ages 6-14 had a dental sealant placed on a permanent molar. While most states have made steady progress in improving children's access to dental care in Medicaid over the past decade, there is still substantial variation across states and more remains to be done.

Pay for success (PFS) is a type of social impact investing that uses private capital to finance proven prevention programs that help a government reduce public expenditures or achieve greater value. We conducted an analysis of the first eleven PFS projects in the United States to investigate the potential of PFS as a strategy for financing and disseminating interventions aimed at improving population health and health equity. The PFS approach has significant potential for bringing private-sector resources to interventions regarding social determinants of health. Nonetheless, a number of challenges remain, including structuring PFS initiatives so that optimal prevention benefits can be achieved and ensuring that PFS interventions and evaluation designs are based on rigorous research principles. In addition, increased policy attention regarding key PFS payout issues is needed, including the "wrong pockets" problem and legal barriers to using federal Medicaid funds as an investor payout source.

Introduction State Medicaid programs can cover tobacco cessation therapies for millions of low-income smokers in the United States, but use of this benefit is low and varies widely by state. This article assesses the effects of changes in Medicaid benefit policies, general tobacco policies, smoking norms, and public health programs on the use of cessation therapy among Medicaid smokers. Methods We used longitudinal panel analysis, using 2-way fixed effects models, to examine the effects of changes in state policies and characteristics on state-level use of Medicaid tobacco cessation medications from 2010 through 2014. Results Medicaid policies that require patients to obtain counseling to get medications reduced the use of cessation medications by approximately one-quarter to one-third; states that cover all types of cessation medications increased usage by approximately one-quarter to one-third. Non-Medicaid policies did not have significant effects on use levels. Conclusions States could increase efforts to quit by developing more comprehensive coverage and reducing barriers to coverage. Reductions in barriers could bolster smoking cessation rates, and the costs would be small compared with the costs of treating smoking-related diseases. Innovative initiatives to help smokers quit could improve health and reduce health care costs.

Background— American Heart Association (AHA) public policy advocacy strategies are based on its Strategic Impact Goals. The writing group appraised the evidence behind AHA’s policies to determine how well they address the association’s 2020 cardiovascular health (CVH) metrics and cardiovascular disease (CVD) management indicators and identified research needed to fill gaps in policy and support further policy development. Methods and Results— The AHA policy research department first identified current AHA policies specific to each CVH metric and CVD management indicator and the evidence underlying each policy. Writing group members then reviewed each policy and the related metrics and indicators. The results of each review were summarized, and topic-specific priorities and overarching themes for future policy research were proposed. There was generally close alignment between current AHA policies and the 2020 CVH metrics and CVD management indicators; however, certain specific policies still lack a robust evidence base. For CVH metrics, the distinction between policies for adults (age ≥20 years) and children ( Conclusions— AHA’s public policies are generally robust and well aligned with its 2020 CVH metrics and CVD indicators. Areas for further policy development to fill gaps, overarching research strategies, and topic-specific priority areas are proposed.

We measured the impact of the 2008-2010 economic recession on local health departments (LHDs) across the United States. Between 2008 and 2010, we conducted 3 Web-based, cross-sectional surveys of a nationally representative sample of LHDs to assess cuts to budgets, workforce, and programs. By early 2010, more than half of the LHDs (53%) were experiencing cuts to their core funding. In excess of 23 000 LHDs jobs were lost in 2008-2009. All programmatic areas were affected by cuts, and more than half of the LHDs had to reduce or eliminate at least 1 programmatic area. The capacity of LHDs to provide core public health services was undermined by the economic recession.

Our analyses of federal survey data show that more than four in five office-based physicians could qualify for new federal incentive payments to encourage the adoption and "meaningful use" of electronic health records, based on the numbers of Medicare or Medicaid patients they see. The incentives are thus likely to accelerate the spread of electronic health records. However, our analyses also indicate that eligibility for the incentives is likely to vary by specialty: 90.6 percent of physicians working in general or family practice or internal medicine could qualify for incentives, but fewer than two-thirds of pediatricians, obstetrician-gynecologists, and psychiatrists may qualify. Eligibility and use will also vary by factors such as size and type of practice; physicians in solo practice are much less likely to use electronic health records than physicians in other practice settings. We suggest actions that policy makers can take to lessen disparities and increase the adoption and meaningful use of electronic health records.

In 2006 Congress passed, and the Centers for Medicare and Medicaid Services (CMS) rapidly issued, regulations requiring states to obtain proof of citizenship from citizens who had applied for Medicaid. This policy was framed as reducing fraud by illegal aliens to preserve benefits for citizens. In fact, evidence indicates there was no significant problem of fraud by immigrants, and the major effect of the policy was to reduce coverage of eligible citizens. This article addresses the reasons why Congress developed this policy and why CMS acted with uncharacteristic haste to implement these counterproductive policies. We note the importance of the policy's symbolic framing—that is, as establishing sanctions against illegal immigration—in congressional passage during a period of rising nativism in Congress and the nation. The regulatory actions reflected the ideological preferences of political appointees and an increasingly adversarial relationship between CMS and state agencies during this period. These haphazard regulatory actions made the policies more convoluted and likely led more eligible citizens to lose coverage. In 2009, Congress amended the law to modify implementation. These issues have continued to persist in the recent debate on national health care reform.

Objectives. I examined insurance coverage and medical expenditures of both immigrant and US-born adults to determine the extent to which immigrants contribute to US medical expenditures. Methods. I used data from the 2003 Medical Expenditure Panel Survey to perform 2-part multivariate analyses of medical expenditures, controlling for health status, insurance coverage, race/ethnicity, and other sociodemographic factors. Results. Approximately 44% of recent immigrants and 63% of established immigrants were fully insured over the 12-month period analyzed. Immigrants' per-person unadjusted medical expenditures were approximately one half to two thirds as high as expenditures for the US born, even when immigrants were fully insured. Recent immigrants were responsible for only about 1% of public medical expenditures even though they constituted 5% of the population. After controlling for other factors, I found that immigrants' medical costs averaged about 14% to 20% less than those who were US born. Conclusions. Insured immigrants had much lower medical expenses than insured US-born citizens, even after the effects of insurance coverage were controlled. This suggests that immigrants' insurance premiums may be cross-subsidizing care for the US-born. If so, health care resources could be redirected back to immigrants to improve their care.

U nauthorized immigrants have become the modern day pariahs. They are barred from programs like Medicare, Medicaid, and even the newHealth InsuranceMarketplace, no matter how long they have lived in the U.S., how sick or how impoverished. Paradoxically, they make payments into Medicare, but are prohibited from eventually receiving Medicare benefits. Part A of Medicare (the hospital component) is f inanced by workers ’— including undocumented workers’—payroll taxes, reserved in the Medicare Trust Fund and paid out as Medicare benefits to elderly or disabled beneficiaries. The government has acknowledged that undocumented immigrants’ untapped contributions to the Social Security Trust Fund, the counterpart to the Medicare fund, prolong its solvency and sustain Social Security benefits for retired citizens. Leah Zallman and her associates have estimated that unauthorized immigrants contributed a net surplus of $35 billion to the Medicare Trust Fund, extending its solvency. They also find that proposals to offer a pathway to citizenship for a portion of the undocumented would continue to create a generous surplus. Even though the new citizens could eventually become eligible for Medicare, legalization would increase their earning power, thereby boosting their tax contributions to the Medicare Trust Fund. It has long been known that immigrants, including the unauthorized, use medical services sparingly and, contrary to popular misconceptions, even use emergency departments less than citizens, so tend to be less costly even when they are insured. But ideological barriers have made it almost impossible to overcome the political challenges needed to improve the conditions for the undocumented, whether through legislation or executive action. For now, unauthorized immigrants are likely to remain in the shadows and reliant on the health care safety net.

This study examined how state decisions not to expand Medicaid have affected behavioral health services utilization in health centers. Because health center revenues are adversely affected, the ability to provide on-site nonrequired services, such as specialty mental health and substance abuse treatment services, is compromised.Using 2012 Uniform Data System data and the projected health center insurance case mix in 2020, the authors estimated the amount of additional revenue that could accrue to health centers if all states were to expand Medicaid by 2020. Using the estimated percentage of total revenues supporting the provision of specialty behavioral treatment services, the authors also estimated the number of encounters with behavioral health specialists that might be possible in 2020 if all states expand Medicaid by then. State-specific estimates are provided.If all states expand Medicaid by 2020, it is estimated that nearly $230 million in additional revenue could accrue to health centers in states that opted out of expanding Medicaid in 2014. An estimated $11.3 million would likely be used for mental health services and $1.6 million might be used to provide substance use disorder services. This translates to over 70,500 additional encounters that could occur with behavioral health specialists if all states expand Medicaid by 2020.On-site behavioral health services are needed in health centers. However, financial constraints might limit the ability of health centers to provide on-site behavioral health services, particularly in states opting out of Medicaid expansion.

Background Health reform, including Medicaid expansion, is increasing insurance coverage and financial access to breast and cervical cancer screening for low-income women, although services for low-income uninsured women are still needed. Methods American Community Survey and administrative data about Medicaid and health insurance enrollment are used to estimate the number of low-income women who will be uninsured in 2017, focusing on the age ranges 21 to 64, 40 to 64, and 50 to 64. Results Assuming that 29 states expand Medicaid (as of June 2015), the national percentage of low-income women 21 to 64 who are uninsured will fall from 32.2% in 2013 to 14.6% by 2017. Among Medicaid-expanding states, the percentage of uninsured will decrease from 28.7% to 8.0%, whereas in non-expanding states, the level will decrease from 36.9% to 23.3%. About 5.7 million women 21 to 64 and 2.6 million women 40 to 64 will remain uninsured in 2017. The size of the uninsured low-income population will remain much larger than the 659,000 women who have previously received Pap tests and 548,000 obtaining mammograms under the National Breast and Cervical Cancer Early Detection Program in 2013. Discussion Even before 2014, women living in states that are not expanding Medicaid were less likely to get mammograms and Pap tests than women in expanding states. Affordable Care Act–related insurance expansions will lower financial barriers to screening and should boost overall screening rates. But disparities in insurance coverage and cancer screening across Medicaid-expanding and non-expanding states could widen. Conclusions Programs to support cancer screening for low-income uninsured women will still be needed.

Objectives. This study assessed factors related to chlamydial infection among young men in the United States. Methods. Data were from interviews of nationally representative samples of 470 men aged 18 to 19 years (teenagers) and 995 men aged 22 to 26 years (young adults) and from urine specimens tested by means of polymerase chain reaction. Results. Although a majority of the men reported occasional unprotected intercourse, only a minority perceived themselves to be at risk for contracting a sexually transmitted disease (STD). Chlamydial infection was detected in 3.1% of the teenagers and 4.5% of the young adults. A minority of those infected had symptoms or had been tested for STDs; very few had been diagnosed with STDs. Conclusions. Chlamydial infection is common but usually asymptomatic and undiagnosed. Primary and secondary prevention efforts should be increased, particularly among young adult men. (Am J Public Health. 2002;92:1140–1143)

Many of the U.S. states with the largest anticipated Medicaid expansions are also the ones that have less primary care capacity. These states could face surging demand from the newly insured population without having sufficient primary care resources available.

Purpose: To analyze the extent to which teenage males receive preventive reproductive health services and identify demographic and health factors associated with their receipt. Methods: Bivariate and multivariate analyses of nationally representative data from the 1995 National Survey of Adolescent Males were conducted using logistic regression to determine which factors predicted whether teenagers had a physical examination and whether they discussed reproductive health topics with a medical professional, had a human immunodeficiency virus (HIV) test, or had a sexually transmitted disease (STD) test. Results: Although 71% of males aged 15–19 years received a physical examination in the past year, only 39% of them received any of the three reproductive health services. Less than one-third of all young men discussed reproductive health with their doctor or nurse. Among sexually experienced males, one-sixth had an STD test and one-quarter an HIV test. In multivariate analysis, males who had a physical examination were more likely to have an STD or HIV test, but were no more likely to discuss reproductive health topics. Minority and low-income youth were more likely to receive these reproductive health services, as were young men with multiple sex partners and those with health problems. Conclusions: In general, the proportion of teenage men receiving reproductive health services is low, although levels are higher among minority youth and certain groups at risk. To reduce rates of teen pregnancy and STDs, physicians and nurses need to incorporate reproductive health care into routine health services for teenage males, as well as females.

OBJECTIVES: This study examines shifts in sexual experience and condom use among US teenaged males. METHODS: Results from the 1988 and 1995 National Surveys of Adolescent Males were compared. RESULTS: The proportion of never-married 15- to 19-year-old males who had had sex with a female declined from 60% to 55% (P = .06). The share of those sexually active using a condom at last intercourse rose from 57% to 67% (P < .01). Overall, the proportion of males who had sex without condoms last year declined from 37% to 27% (P < .001). CONCLUSIONS: Although protective behaviors among teenagers have increased, significant proportions of teenagers--especially Black and Hispanic males--remain unprotected.

This study describes on-site behavioral health treatment capacity in health centers in 2007 and examines whether capacity was associated with health center characteristics, county-level behavioral health workforce, and same-day billing restrictions. Cross-sectional data from the 2007 Area Resource File and Uniform Data System were linked with data on Medicaid same-day billing restrictions. Mental health treatment capacity was common; almost four in five health centers provided on-site mental health services. Additional services such as crisis counseling (20 %), treatment from a psychiatrist (29 %), and substance abuse treatment were offered by fewer health centers (51 % provide on-site services and only 20 % employ substance abuse specialists). In multivariate analysis, larger health centers, health centers located in counties with a larger behavioral health workforce per capita, and those located in the West and Northeast were more likely to have behavioral health capacity. Same-day billing restrictions were associated with lower odds of substance use treatment capacity and providing 24 hr crisis counseling services.

The Affordable Care Act increases US investment in Medicaid and community health centers, yet many people believe that care in such safety-net programs is substandard. Using data from more than 31,000 visits to primary care physicians in the period 2006-10, we examined whether the length or content of a visit was different for safety-net patients-those insured by Medicaid, those who are uninsured, and those seen in a community health center-compared to patients with private insurance. We found no significant differences in the average length of a primary care visit or in the likelihood of a patient's receiving preventive health counseling. Medicaid patients received more diagnostic and treatment services, and uninsured patients received fewer services, compared to privately insured patients, but the differences were small. This analysis indicates that length and content of primary care visits are comparable for safety-net and other patients. The main factors that contribute to differences in visit length and content are patients' health needs and the type of visit involved.

With the demise of health care reform at the national level, much of the attention has shifted to state-level efforts. Recently, several states have begun looking to the Medicaid program as a way to solve their health care problems. A principal way in which states are implementing health care reform is through the Section 1115 research and demonstration Medicaid waiver program. The 1115 waiver authority provides states considerable flexibility to restructure their Medicaid programs to offer health care to new populations and thus has great potential for covering large segments of the uninsured population. While it shows great promise, however, there are many obstacles states must overcome both in implementing and in maintaining an 1115 program.

Introduction The Patient Protection and Affordable Care Act of 2010 (ACA) will increase insurance coverage for US citizens and for breast and cervical cancer screening through insurance expansions and regulatory changes. The primary objective of this study was to estimate the number of low-income women who would gain health insurance after implementation of the ACA and thus be able to obtain cancer screening. A secondary objective was to estimate the size and characteristics of the uninsured low-income population and the number of women who would still need National Breast and Cervical Cancer Early Detection Program (NBCCEDP) services. Methods We used the nationally representative 2009 American Community Survey to estimate the determinants of insurance status for women in Massachusetts, assuming full implementation of the ACA. We extrapolated findings to simulate the effects of the ACA on each state. We used individual-level predicted probabilities of being uninsured to generate estimates of the number of women who would gain health insurance after implementation of the ACA and to predict demand for NBCCEDP services. Results Approximately 6.8 million low-income women would gain health insurance, potentially increasing the annual demand for NBCCEDP cancer screenings initially by about 500,000 mammograms and 1.3 million Papanicolaou tests. Despite a 60% decrease in the number of low-income uninsured women, the NBCCEDP would still serve fewer than one-third of the estimated number of women eligible for services. The NBCCEDP-eligible population would comprise a larger number of women with language and literacy-related barriers to care. Conclusion Implementation of the ACA would increase insurance coverage and access to cancer screening for millions of women, but the NBCCEDP will remain essential for the millions who will remain uninsured.

Background and Objective A high proportion of low-income people insured by the Medicaid program smoke. Earlier research concerning a comprehensive tobacco cessation program implemented by the state of Massachusetts indicated that it was successful in reducing smoking prevalence and those who received tobacco cessation benefits had lower rates of in-patient admissions for cardiovascular conditions, including acute myocardial infarction, coronary atherosclerosis and non-specific chest pain. This study estimates the costs of the tobacco cessation benefit and the short-term Medicaid savings attributable to the aversion of inpatient hospitalization for cardiovascular conditions. Methods A cost-benefit analysis approach was used to estimate the program's return on investment. Administrative data were used to compute annual cost per participant. Data from the 2002–2008 Medical Expenditure Panel Survey and from the Behavioral Risk Factor Surveillance Surveys were used to estimate the costs of hospital inpatient admissions by Medicaid smokers. These were combined with earlier estimates of the rate of reduction in cardiovascular hospital admissions attributable to the tobacco cessation program to calculate the return on investment. Findings Administrative data indicated that program costs including pharmacotherapy, counseling and outreach costs about $183 per program participant (2010 $). We estimated inpatient savings per participant of $571 (range $549 to $583). Every $1 in program costs was associated with $3.12 (range $3.00 to $3.25) in medical savings, for a $2.12 (range $2.00 to $2.25) return on investment to the Medicaid program for every dollar spent. Conclusions These results suggest that an investment in comprehensive tobacco cessation services may result in substantial savings for Medicaid programs. Further federal and state policy actions to promote and cover comprehensive tobacco cessation services in Medicaid may be a cost-effective approach to improve health outcomes for low-income populations.

Federal and state governments must soon begin planning and developing systems to implement the expansion of Medicaid for low-income adults, as prescribed in the Patient Protection and Affordable Care Act of 2010. States will have to establish enrollment and coordination procedures, determine benefit packages, and update arrangements with providers. Federal estimates indicate that states will bear relatively little of the new cost, but some states disagree. State planning efforts will be challenged by current budget shortfalls and, in many states, political opposition. Paradoxically, many of the states opposing expansions are those whose Medicaid-eligible patient populations have the most to gain from health reform.

Data from the 2005 Medical Expenditure Panel Survey were used to conduct a disaggregated comparison of utilization and expenditures under Medicaid and private health insurance for low-income adults and children. After adjustment for health status and other factors, Medicaid adults and children had greater use of prescription drugs than the privately insured, but there were no significant differences in prescription expenditures. Adults on Medicaid had lower utilization of office-based medical and dental care and much lower expenditures than the privately insured. Contrary to stereotypes, there were no significant differences between Medicaid adults and children and the privately insured in emergency, outpatient, or inpatient hospital use, and the former had significantly lower expenditures.

Some proposals to expand health insurance coverage for people with low incomes are based on expansions of public programs, such as Medicaid or the State Children's Health Insurance Program (SCHIP), while others rely on the use of tax subsidies for individuals to purchase private insurance. Analyses of data from the 2005 Medical Expenditure Panel Survey indicate that total medical spending is much lower when coverage is provided by Medicaid or SCHIP than it is when coverage is provided by private insurance. Public insurance is particularly advantageous from the consumer's perspective because associated out-of-pocket spending is far lower.

Children in immigrant families now comprise more than one-fifth of all children in the United States. Low-income children in immigrant families, particularly children who are themselves immigrants, are more likely to be uninsured and to have poor access to health care than low-income children from native-born families. Differences in insurance coverage are related to restricted eligibility for public insurance coverage and to limited access to employer-sponsored insurance. The combination of poor insurance coverage, language barriers, and other factors contributes to reduced access to medical care services for immigrant children. This article reviews the literature, examines some common misconceptions regarding immigrants and the nation's health care problems, and describes potential federal, state, and local policies that could improve or weaken children's access to insurance and health care.

One in every five American children is a member of an immigrant family. (1) Despite their substantial numbers, these children are much less likely to have health insurance and ready access to health care than children in native-born citizen families. Family immigration status is, in fact, one of the most important risk factors for the lack of health care coverage among children in the United States. About one-third of the nation's low-income. (2) uninsured children live in immigrant families (see Figure 1). Almost all of these children meet the income requirements for eligibility for Medicaid or the State Children's Health Insurance Program (SCHIP), but for various reasons they are not enrolled. For example, some of these children are ineligible for Medicaid and SCHIP because of immigrant eligibility restrictions. Many others are eligible but not enrolled because their families encounter language barriers to enrollment, are confused about program rules and eligibility status, or are worried about repercussions if they use public benefits. Not only are children of immigrants more likely to be uninsured and less likely to gain access to health care services than children in native families, but communication barriers can also result in immigrant children receiving lower-quality services. The linguistic, cultural, legal, and socioeconomic circumstances of immigrants pose special challenges and opportunities for policy officials and health care practitioners seeking to provide health care and health insurance coverage to children in immigrant families. And because children in immigrant families constitute such a large share of the nation's uninsured, successfully reducing the total number of uninsured children depends in large measure on how well the needs of immigrant families are addressed. Furthermore, immigrants are increasingly a concern for every state. Although immigrants traditionally have been concentrated in a handful of states--California, Florida, New Jersey, New York, and Texas--an increasing number are relocating throughout the country in pursuit of employment. Seventy percent of immigrants still reside in California, Florida, New Jersey, New York, and Texas, but the immigration growth rate during the 1990s was highest in southern and central states such as Iowa, Nevada, North Carolina, and Virginia. (3) Health care and social service providers across the country are learning how to adjust their services to accommodate the needs of immigrant families. Federal, state, and local policies and practices can either promote or undermine insurance coverage and access to care for this large but underserved population. This article discusses the barriers immigrant children face in securing health coverage and quality care and describes strategies that have been adopted to overcome these barriers. The article concludes with policy recommendations and suggestions for future steps to improve public health insurance programs for immigrant children. Children in Immigrant Families--A Diverse Population with Shared Concerns Speaking of "children in immigrant families" as a homogeneous group is misleading because these children are extremely diverse. Immigrant families come from every country in the world, speak a multitude of languages, and bring a host of cultural traditions to their new homeland. Most children in immigrant families are U.S.-born and therefore are native citizens whose parents are immigrants, but many other children are foreign-born noncitizens. Despite this diversity, immigrant families have shared challenges and concerns. This section details some of the most common barriers that impede immigrant families' access to health coverage, including federal eligibility rules and fear of jeopardizing immigration status. The section also describes communication barriers that can influence the quality and cost of health care that immigrant families receive, as well as their use of health services and satisfaction levels with their health care. …

Despite the success of the State Children's Health Insurance Program (SCHIP) in reducing the ranks of uninsured children, the program now faces significant financing challenges. Analysis based on a model developed by the Centers for Medicare and Medicaid Services indicates that by 2007, 20 states will have insufficient federal funding to sustain their current programs, with the first states affected in 2004. As a result, the Office of Management and Budget projected last year that SCHIP enrollment will fall by 900,000 children between 2003 and 2007. The funding shortfalls are the result of several factors. Federal SCHIP funding fell by 26 percent--by more than dollar 1 billion-in each of fiscal years 2002, 2003, and 2004; dollar 1.2 billion in SCHIP funds has already expired and reverted to the Treasury at the end of fiscal year 2002, and another dollar 1.5 billion will expire at the end of 2003. The SCHIP program also has a redistribution system with targeting and timing problems. However, proposed Congressional legislation restoring federal funding, extending the dollar 2.7 billion in expiring funds, and targeting the funds to the states that most need them could avert most, if not all, of the projected enrollment decline. On the other hand, the Bush administration proposed to extend the expiring funds but does not target them to needy states; the proposal will do little to reduce the magnitude of the decline.

Data from the Census Bureau and the Centers for Disease Control and Prevention indicate that the number of uninsured Americans rose in 2001 and in the first quarter of 2002. The main reason insurance coverage fell was a drop-off in employer-sponsored insurance for workers and their dependents. This reduction was triggered by rising unemployment levels and rising health insurance premiums, which made it more difficult for employers to offer insurance or for workers to afford it. The downturn in private coverage was partially offset by increased enrollment in Medicaid and the State Children's Health Insurance Program (SCHIP). About two million more children and one million more adults would have been uninsured had it not been for the growth in these programs. Funding for the public programs is, however, threatened by budget shortfalls affecting most states, which administer these programs. Many states have cut their Medicaid programs and are planning further cutbacks. Increasing federal assistance to states and their Medicaid programs could help protect insurance coverage for low-income people during the current economic slowdown. Future SCHIP enrollment could drop sharply because of a shortage of federal funds, and Congress could take steps to bolster SCHIP funding.