CHILDREN'S HEALTH INSURANCE COVERAGE IN MASSACHUSETTS

1997年8月5日，国会通过了自医疗补助计划（Medicaid）最初颁布以来最重要的儿童健康保险计划（State Children's Health Insurance Program，CHIP）。 随着各州决定如何使用CHIP资金，迫切需要获得有关未满足的健康需求、获得护理以及在立法所针对的儿童人口中被排挤的新数据。 马萨诸塞州是美国少数几个州之一，它在为CHIP扩展所涵盖的儿童人口提供卫生服务方面有着丰富的经验。 1994年7月开始实施的“儿童医疗保障计划”为8万多名从出生到18岁的儿童提供了初级保健服务的医疗保险，其中40%的儿童生活在收入为联邦贫困线133%至200%的家庭中。 本研究利用CMSP行政与理赔档案资料及电话调查资料，探讨CMSP参保者之保险状况、未满足健康需求与卫生服务利用之关系，以及CMSP参保对卫生服务可及性指标之影响。以及3）确定CMSP参与者中发生排挤的程度。 调查结果和调查数据与索赔数据的联系预计将有助于估计可能参加CHIP计划的儿童的健康需求和费用。 与未满足的保健需求和获得保健有关的调查问题是仿照国家卫生保健系统获得保健模块中的问题提出的。 与家庭人口统计和保险状况有关的问题，基于1998年对马萨诸塞州居民保险状况的随机家庭调查，以便与该州人口进行比较。 研究人群是目前入组的儿童，这些儿童已连续入组至少6个月。 按收入组（小于133，133-200，大于200% FPL）和年龄分层并按入学日期系统选择的900名计划参与者的样本将产生主要研究问题的估计值，抽样误差为+/-3%，95% CI。访谈将以西班牙语和葡萄牙语进行，受访者更熟悉自己的母语。 一个额外的超过100个讲西班牙语的受访者的样本，建议允许特定的讲西班牙语的报名者稳定的推论。 使用McNemar检验来评估与未满足的健康需求和项目入组前后的访问指标相关的受试者内变化，研究设计具有超过85%的能力来检测变化。将使用多项和多项逻辑回归模型预测主要结局（排挤和卫生服务利用）与主要问题变量（无保险时间长度、获取指标、未满足的健康需求和家庭人口统计学）之间的关系。

On August 5, 1997 Congress passed the most significant funding increase for children's health care coverage since the original enactment of Medicaid, the State Children's Health Insurance Program (CHIP). As states decide how to use CHIP funds, there is an urgent need for new data about unmet health need, access to care, and crowd out among the population of children who are targeted under the legislation. Massachusetts is one of the few states in the nation that has had extensive prior experience providing health services to the population of children that are covered under CHIP expansions. The state's Children's Medical Security Plan (CMSP), initiated in July, 1994, has provided health insurance coverage for primary health care services to over 80,000 children from birth to age 18, 40 percent of whom live in families with incomes 133 percent-200 percent of the federal poverty level (FPL), the income group targeted under the CHIP expansions. Using data from CMSP administrative and claims files and information obtained from a telephone survey of CMSP participants, the proposed research aims to: 1) to determine the relationship between insurance status, unmet health need, and health service utilization among CMSP enrollees; 2) to assess the impact of enrollment in CMSP on indicators of access to health care; and 3) to determine the extent to which crowd out is occurring among CMSP enrollees. Survey findings and the linkage of survey data with claims data are expected to assist in estimating health needs and costs of children likely to enroll in CHIP programs. Survey questions related to unmet health need and access to care are modeled after those from the NHIS Access to Care Module. Questions related to family demographics and insurance status based on the 1998 random household survey of Massachusetts' residents insurance status to enable comparison to the state's population. The study population is currently enrolled children who have been continuously enrolled for a minimum of 6 months. A sample of 900 program participants stratified by income group (less than 133, 133-200, greater than 200 percent FPL) and age and systematically selected by date of enrollment will yield estimates with sampling errors of +/-3 percent at a 95 percent CI for major research questions. Interviews will be conducted in Spanish and Portuguese among respondents more comfortable in their native language. An additional over sample of 100 Spanish speaking respondents is proposed to permit stable inferences specific to the Spanish speaking enrollees. Using the McNemar test to assess within subject changes related to unmet health need and access indicators pre and post program enrollment, the study design has greater than 85 percent power to detect changes. Multiple and multinomial logistic regression models will be used predict relationships between major outcomes (crowd out and health service utilization) and primary question variables (length of time without insurance, access indicators, unmet health need, and family demographics).