The Commonwealth Fund/"Modern Healthcare" Health Care Opinion Leaders Survey: Assessing SCHIP

Country: United States

Survey Organization: Harris Interactive, Inc.

Field Date: March 12, 2007–April 6, 2007

Sample: Peer-nominated experts in health care policy, finance, and delivery; select members of the Modern Healthcare database

Sample Size: 170 (survey successfully e-mailed to 1,467 people)

Interview Method: Online/E-mail

Read an analysis of the findings in a Data Brief, as well as two related commentaries, Return SCHIP to Its Roots by Michael O. Leavitt, Secretary of the U.S. Department of Health and Human Services, and Let's Complete the Job: Expanding SCHIP by Eliot Spitzer, Governor of New York State.

Introduction
The Commonwealth Fund Health Care Opinion Leaders (HCOL) Survey was conducted by Harris Interactive on behalf of The Commonwealth Fund and Modern Healthcare, with responses from a broad group of 170 opinion leaders in health policy and innovators in health care delivery and finance. This was the 10th in a series of surveys designed to highlight leaders' perspectives on the most timely health policy issues facing the nation. This survey focused on the State Children's Health Insurance Program (SCHIP).

Health care opinion leaders were identified by The Commonwealth Fund, Modern Healthcare, and Harris Interactive as individuals who are experts and influential decision makers within their respective industries.

Summary
SCHIP is a joint federal–state program enacted in 1997 to cover children in families with too much income to qualify for Medicaid that could still not afford private insurance. The program is scheduled for reauthorization this year, presenting an opportunity to reflect on its successes and challenges. Our survey asked health care opinion leaders to rate the success of SCHIP both overall and with regard to specific objectives, such as improving coverage and health care for low-income children. Sixty-one percent of health care opinion leaders think that, overall, SCHIP has been successful in meeting its goals. Seventy-one percent think that SCHIP has been successful in increasing access to health care for low-income children and 65 percent view SCHIP as successful in reducing the rate of uninsured, low-income children. However, only 34 percent of health care leaders feel that SCHIP was successful in stimulating state innovation in designing delivery models for children. Also, 26 percent of the opinion leaders were unable to judge if SCHIP was improving health outcomes for children.

The survey also gauged health care leaders' opinions on expanding SCHIP coverage. Originally, the program targeted children younger than 19 years of age, in families with income between 100 and 200 percent of the federal poverty level. States that had already expanded their Medicaid eligibility to this level were allowed to cover children up to 50 percentage points higher than their Medicaid limit. When asked who should be covered by SCHIP moving forward, an overwhelming majority (91%) of health care opinion leaders were in favor of making SCHIP available to legal immigrant children if they are income-eligible, with the academic/research institute leaders more likely than the business/insurance/other health industry leaders to be in favor of this move (95% v. 83% respectively). Health care opinion leaders are also in favor of the following initiatives: (a) covering children up to 300 percent of the federal poverty level (88% of health care leaders favor this), (b) allowing families with higher incomes to buy into SCHIP (82%), (c) in the absence of comprehensive action on the uninsured, allowing states to extend coverage to include parents of children covered under SCHIP (80%), and (d) after covering low-income children, allowing states to extend SCHIP coverage to childless adults under 100 percent of poverty (73%). In all four situations, academic/research institute leaders were more likely than other health care opinion leaders to be in favor of extending SCHIP coverage.

Opinion leaders were asked their views on using SCHIP benefit design to improve quality of care and health in children. Currently, SCHIP gives the states the option of providing children's health insurance through their Medicaid program, in a standalone SCHIP program, or through a combination of the two. Under the Medicaid expansion option, the SCHIP benefit package mirrors the Medicaid benefit package. Under a standalone SCHIP program, states have more flexibility in designing the benefits package and establishing eligibility standards but must meet certain standards. States are not allowed under current law to use SCHIP benefits to "wrap around" or supplement less comprehensive benefit packages for children. Eighty-four percent of health care leaders are in favor of allowing states to design packages that wrap around other coverage (i.e., translation services and care coordination) and establishing federal performance standards and outcome measures for all children in SCHIP (81%). Health care delivery and business/insurance/other health industry leaders are more likely than academic/research institute leaders to be in favor of setting aside a percentage of SCHIP funds to encourage states to adopt benefit standards to make SCHIP more responsive to public health issues such as childhood obesity (79% and 74% v. 55%).

Health care opinion leaders were asked to assess the funding and costs of SCHIP. The original SCHIP legislation included a 10-year federal cap of $39 billion for FY 1998–FY 2007 for the program, and annual allotment levels ($5 billion in 2007) for the states. States' allocations take into account the ratio of uninsured to low-income children in the state and geographic variation in wages. When asked their opinion on SCHIP's funding structure, 84 percent of health care opinion leaders were in favor of changing the state allocation formula to reflect the better data available on uninsured children that were not available when the original formula was developed. Eighty percent approve of requiring states to adopt proven use best practices for outreach and enrollment. Academic/research institute leaders were more likely than the health care delivery and business/insurance/other health care industry sectors to be in favor of indexing allocation with health care costs (80% v. 65% and 64%), while health care delivery leaders were more likely than academic/research institute leaders to be in favor of requiring parents to provide proof of their children's insurance coverage status prior to enrollment in school (65% v. 44%).

Finally, health care opinion leaders were asked their views on the financing of SCHIP. It has been estimated that it would cost an additional $12 billion to $14.5 billion over five years to maintain the current level of services provided under SCHIP. Conversely, if the $5 billion cap per year is kept in place, the Administration estimates that enrollment in SCHIP would drop from 4.4 million in FY 2006 to 2.5 million in FY 2016. Given these estimates, health care opinion leaders were asked how SCHIP should be financed. In the proposed initiatives, raising federal taxes or fees was the initiative most endorsed by the leaders. More than one-third (37%) of health care opinion leaders think that SCHIP expenditures should be financed or supported by raising federal taxes or fees, and 27 percent of health care opinion leaders support redirecting funds from other programs and 25 percent favor making an exception to the "PAYGO" rule for coverage of children.

Methodology
This survey was conducted online by Harris Interactive on behalf of The Commonwealth Fund among 170 opinion leaders in health policy and innovators in health care delivery and finance within the United States between March 12, 2007 and April 6, 2007. No weighting was applied to these results.

The initial sample for this survey was developed using a two-step process. Initially, The Commonwealth Fund and Harris Interactive jointly identified a number of experts across different sectors and professional sectors with a range of perspectives, based on their affiliations and involvement in various organizations and institutions. Harris Interactive then conducted an online survey with these experts asking them to nominate others within and outside their own fields whom they consider to be leaders and innovators in health care. Based on the result of the survey and after careful review by Harris Interactive, The Commonwealth Fund, and a selected group of health care experts the sample for this poll was created. Then in 2006, The Commonwealth Fund and Harris Interactive joined forces with Modern Healthcare to add new members to the panel. The Fund and Harris were able to gain access to Modern Healthcare's database of readers. The Fund, Harris, and Modern Healthcare identified readers in the database considered opinion leaders and invited them to participate in the survey. The final list included 1,467 people.

Harris Interactive sent out individual e-mail invitations containing a password-protected link to the entire sample. Data collection took place between March 12, 2007 and April 6, 2007. A total of four reminder emails was sent to anyone who had not responded. A total of 170 respondents completed the survey.

With a pure probability sample of 170 adults one could say with a 95 percent probability that the overall results have a sampling error of +/- 7.5 percentage points. However, that does not take other sources of error into account. This online survey is not based on a probability sample and therefore no theoretical sampling error can be calculated.