Context or composition: what explains variation in SCHIP disenrollment?

OBJECTIVE To investigate (1) the relative contributions of family and contextual characteristics to observed variation in disenrollment rates from the State Children's Health Insurance Program (SCHIP), and (2) whether context explains observed family-level patterns. DATA SOURCES We use secondary data on 24,628 families enrolled in New Jersey's SCHIP program (NJ KidCare), and county-level data from the Area Resource File, the Census, and the NJ FamilyCare provider roster. STUDY DESIGN Information on family characteristics, SCHIP plan, and dates of enrollment and disenrollment are taken from NJ KidCare administrative records, which provided surveillance data from January 1998 through April 2000. DATA COLLECTION/ANALYSIS We estimate a multilevel discrete-time-hazards model of SCHIP disenrollment. FINDINGS Families enrolled in plans involving cost-sharing, blacks, and those with only one enrolled child have higher than average rates of disenrollment. Disenrollment rates for blacks are lower in counties with a high share of black physicians. These characteristics account for part of the intercounty variation in disenrollment rates; remaining intercounty variation is largely explained by physician density or population density. POLICY IMPLICATIONS It may be worthwhile to pay special attention to black families and counties with high disenrollment rates to address the reasons for their lower retention. Addressing cultural differences between physician and client and the geographic distribution of medical providers might reduce disenrollment.