The supply of dentists and access to care in rural Kansas.

CONTEXT: Rural deficits in dental care and oral health are well documented and are typically attributed to the low number of dentists practicing in rural areas, but the relationships between rural residence, dental supply, and access to care have not been firmly established, impeding the development of effective public policy. PURPOSE: The purpose of this study is to develop a conceptual framework for observed variations in dental supply, oral health, and access to dental care in rural versus nonrural areas, and to test key empirical implications of this framework (eg, whether lower levels of utilization are associated with the lack of dentists and/or other aspects of residence in a rural area). METHODS: This study employs descriptive statistics, bivariate analyses, and multiple logistic regression to describe the relationship between oral health, access to care, and the supply of dentists in rural versus nonrural populations. Data analyzed includes Kansas' dental licensure records and the 2002 Behavioral Risk Factor Surveillance System. FINDINGS: Bivariate results confirm that dental supply, access to care, and oral health are lower for populations living in rural areas. Multivariate models indicate that dentist supply has a positive and independent association with utilization, but that rurality is not associated with utilization and oral health after controlling for demographics and dentist supply. CONCLUSIONS: Findings are consistent with a conceptual framework linking the geography of rural residence, individual preferences for services such as dental care, and the financial disincentives for dentists to locate in rural areas.

Effects of premium increases on enrollment in SCHIP: findings from three states.

This study examines the effects of new and higher premiums on SCHIP enrollment in Kansas, Kentucky, and New Hampshire--three states that implemented premium changes in 2003. We used state administrative enrollment records from 2001 to 2004-2005 to track changes in total caseloads, new enrollments, and disenrollment timing in premium-paying categories of SCHIP before and after the premium changes were implemented. Premium hikes were associated with lower caseloads in all three states and with earlier disenrollment in Kentucky and New Hampshire. Premium increases appeared to have greater disenrollment effects for lower-income children in New Hampshire and for nonwhite children in Kentucky.

SCHIP's impact in three states: how do the most vulnerable children fare?

This study provides consistent evidence, from three very diverse states with heterogeneous populations and distinct programs (Florida, Kansas, and New York), that the State Children's Health Insurance Program (SCHIP) increased access to and satisfaction with health care among enrolled low-income children and that vulnerable children-minorities, children and adolescents with special health care needs, and children who were uninsured for long periods of time-shared in these improvements. We highlight some areas to target for future improvement, such as reducing the high levels of unmet needs among special-needs children and increasing preventive care, especially for Hispanic children.

Measuring health inequality using qualitative data.

Many questions in health policy require an understanding of the distribution of health status across a given population and how it changes as a result of policy interventions. Since objective data on individual health status are often unavailable or incomplete, especially for populations with very low mortality, increasing use has been made of self-reported health status (SRHS) data, which record people's own perceptions of their health status. SRHS has been shown to be a strong predictor of objective health outcomes and indications, including mortality. Nevertheless, the qualitative or categorical nature of SRHS data prevents the straightforward use of traditional tools of distributional analysis, such as the Lorenz curve, in evaluating inequality. This paper presents a methodology for evaluating inequality when the data are qualitative rather than quantitative in nature. A partial inequality ordering is defined to indicate when a distribution is more "spread out" than another; a second partial ordering (first order dominance) is used to indicate when the overall health level rises. Both are applicable to qualitative data, such as SRHS, in that results do not depend on the numerical scaling assigned to the categories. The approach is illustrated using SRHS data from the National Health Interview Survey (NHIS) State Data Files for 1994, focusing on the distribution of SRHS within states.

The impact of local welfare offices on children's enrollment in Medicaid and SCHIP.

Nearly 20% of children entering Kansas' State Children's Health Insurance Program (SCHIP) and more than 25% of children entering the state's Medicaid program leave public health insurance altogether before completing a full year of coverage, when the first redetermination of eligibility should occur. Analyses of administrative data indicate that high rates of premature disenrollment are strongly associated with case management practices at local social services offices. However, local offices enroll the vast majority of children into public health insurance. To avoid a potential trade-off between local offices' impact on enrollment and retention, the study suggests that states such as Kansas consider improvements in automation to support caseworkers' difficult jobs.

Consequences of states' policies for SCHIP disenrollment.

Policymakers are concerned about disenrollment from the State Children's Health Insurance Program (SCHIP). We describe disenrollment in Florida, Kansas, New York, and Oregon and assess the links between disenrollment and States' SCHIP policies. We found that SCHIP is used on a long-term basis (at least 2 years) for a significant group of new enrollees and as temporary coverage (fewer than 12 months) for many others. Recertification generates large disenrollments (about one-half of children still enrolled at the time), but as many as 25 percent return within 2 months. The increased disenrollment rate at recertification is completely eliminated by a policy of passive re-enrollment.