CHILDREN'S HEALTH INSURANCE COVERAGE IN MASSACHUSETTS

1997年8月5日，国会通过了自最初制定医疗补助计划（即国家儿童健康保险计划）以来最重要的增加儿童医疗保险资金的法案。随着各州决定如何使用CHIP资金，迫切需要关于未满足的卫生需求、获得保健的机会以及在立法所针对的儿童人群中被排挤的新数据。麻萨诸塞州是美国为数不多的拥有丰富经验的州之一，它在为儿童提供医疗服务方面拥有丰富的经验。1994年7月启动的该州儿童医疗保障计划（CMSP）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水平（FPL）的133% - 200%的家庭中，这是CHIP扩大的目标收入群体。本研究利用医疗保障计划管理档案、理赔档案资料及电话调查资料，探讨医疗保障计划参保人的保险状况、未满足的健康需求与医疗服务利用之间的关系；2)评估加入社区卫生服务计划对医疗服务可及性指标的影响；3)确定在CMSP参保人中发生挤占的程度。调查结果以及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根据国家卫生保健系统获得保健模块的问题编制的。与家庭人口统计和保险状况相关的问题基于1998年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。研究人群为目前已连续入组至少6个月的儿童。900名项目参与者的样本按收入组别（低于133,133 -200，高于200% FPL）和年龄分层，并按入组日期系统选择，对主要研究问题的抽样误差为+/- 3%，CI为95%。访谈将以西班牙语和葡萄牙语进行，受访者更愿意使用自己的母语。一个额外的超过100个说西班牙语的受访者的样本被提议允许稳定的推论具体到说西班牙语的登记者。使用McNemar测试来评估受试者内部与未满足的健康需求和项目登记前后获取指标相关的变化，研究设计具有大于85%的检测变化的能力。将使用多元和多项逻辑回归模型预测主要结果（排挤和卫生服务利用）与主要问题变量（无保险时间长短、获取指标、未满足的卫生需求和家庭人口统计）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).