Children in the United States with discontinuous health insurance coverage

Discontinuity of coverage for Medicaid and S-CHIP children at a transitional birthday

RESEARCH OBJECTIVE

To investigate disenrollment from public insurance at the 6-year transitional birthday when eligibility for many children moves from Medicaid to State Children's Health Insurance Program (S-CHIP).

DATA SOURCES

Data from Georgia's S-CHIP (PeachCare) and Medicaid programs from 2000 to 2002.

STUDY DESIGN

The likelihood of dropping public coverage after the reference birthday is modeled for children turning age 6 compared with a control cohort of children turning age 9 controlling for demographic and geographic differences between enrollees.

PRINCIPAL FINDINGS

Over 17 percent of 6-year-olds versus only 7 percent of the control cohort dropped coverage. After controlling for other factors (e.g., race/ethnicity, prior enrollment, and geographic region) having lower historical expenditures is predictive of dropping coverage among all children, although the unadjusted effect is stronger among children enrolled in PeachCare before their sixth birthday. Only 1 percent of Medicaid children who remained covered transitioned to PeachCare.

CONCLUSIONS

Turnover at transitional birthdays identifies a common pathway for children into the ranks of the uninsured. Facilitating continuous enrollment would retain in the programs children with lower than average expenditures. This may be one of the more cost effective ways of reducing the number of uninsured children in Georgia.

The relationship of immigrant status with access, utilization, and health status for children with asthma

OBJECTIVE

Despite their high levels of poverty and less access to health care, children in immigrant families have better than expected health outcomes compared with children in nonimmigrant families. However, this observation has not been confirmed in children with chronic illness. The objective of this study was to determine whether children with asthma in immigrant families have better than expected health status than children with asthma in nonimmigrant families.

METHODS

Data from the 2001 and 2003 California Health Interview Survey (CHIS) were used to identify 2600 children, aged 1 to 11, with physician-diagnosed asthma. Bivariate analyses and logistic regression were performed to examine health care access, utilization, and health status measures by our primary independent variable, immigrant family status.

RESULTS

Compared with children with asthma in nonimmigrant families, children with asthma in immigrant families are more likely to lack a usual source of care (2.6% vs 1.0%; P < .05), report a delay in medical care (8.9% vs 5.2%; P < .01), and report no visit to the doctor in the past year (7.0% vs 3.8%; P < .05). They are less likely to report asthma symptoms (60.8% vs 74.4%; P < .01) and an emergency room visit in the past year (14.1% vs 21.1%; P < .01), yet more likely to report fair or poor perceived health status (25.0% vs 10.5%; P < .01). Multivariate models revealed that the relationship of immigrant status with health measures was complex. These models suggested that lack of insurance and poverty was associated with reduced access and utilization. Children in immigrant families were less likely to visit the emergency room for asthma in the past year (odds ratio 0.58, confidence interval, 0.36-0.93). Poverty was associated with having a limitation in function and fair or poor perceived health, whereas non-English interview language was associated with less limitation in function but greater levels of fair or poor perceived health.

CONCLUSIONS

Clinicians should be aware of important barriers to care that may exist for immigrant families who are poor, uninsured, and non-English speakers. Reduced health care access and utilization by children with asthma in immigrant families requires policy attention. Further research should examine barriers to care as well as parental perceptions of health for children with asthma in immigrant families.

Inadequate therapy and poor symptom control among children with asthma: findings from a multistate sample

OBJECTIVES

Asthma continues to cause significant morbidity in children. We hypothesized that many children still do not use recommended preventive medications, or they have ineffective symptom control despite preventive medication use. The aim of this study was 1) to describe the use of preventive medications among children with persistent asthma, 2) to determine whether children using preventive medications have adequate asthma control, and 3) to identify factors associated with poor control.

METHODS

The State and Local Area Integrated Telephone Survey (SLAITS) Asthma Survey provided parent-reported data for children aged <18 years with asthma from a random-digit dial survey implemented in Alabama, California, Illinois, and Texas. We focused this analysis on children with persistent symptoms and/or children using preventive asthma medications (N = 975). Children with inadequate therapy had persistent symptoms and no preventive medication use. Children with suboptimal control had persistent symptoms or > 1 attack in the previous 3 months despite preventive medication use; children in optimal control had intermittent symptoms, < or = 1 attack, and reported using preventive medication. Demographic and asthma-related variables were compared across groups.

RESULTS

Among children with persistent asthma, 37 per cent had inadequate therapy, 42.9 per cent had suboptimal control, and only 20.1 per cent had optimal control. In multivariate regression, black race (odds ratio [OR], 2.0; 95 percent confidence interval [CI] 1.1-3.5), Hispanic ethnicity (OR, 1.8; 95 per cent CI, 1.1-2.9), and discontinuous insurance status (OR, 2.4; 95 per cent CI, 1.4-4.3) were associated with inadequate therapy. Potential explanations for poor control included poor adherence, exposure to smoke and other triggers, and lack of written action plans.

CONCLUSIONS

Inadequate asthma therapy remains a significant problem. A newly highlighted concern is the substantial number of children experiencing poor symptom control despite reported use of preventive medications.

Insurance + access not equal to health care: typology of barriers to health care access for low-income families

PURPOSE

Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers.

METHODS

A mixed methods analysis was undertaken using 722 responses to an open-ended question on a health care access survey instrument that asked low-income Oregon families, "Is there anything else you would like to tell us?" Themes were identified using immersion/crystallization techniques. Pertinent demographic attributes were used to conduct matrix coded queries.

RESULTS

Families reported 3 major barriers: lack of insurance coverage, poor access to services, and unaffordable costs. Disproportionate reporting of these themes was most notable based on insurance status. A higher percentage of uninsured parents (87%) reported experiencing difficulties obtaining insurance coverage compared with 40% of those with insurance. Few of the uninsured expressed concerns about access to services or health care costs (19%). Access concerns were the most common among publicly insured families, and costs were more often mentioned by families with private insurance. Families made a clear distinction between insurance and access, and having one or both elements did not assure care. Our analyses uncovered a 3-part typology of barriers to health care for low-income families.

CONCLUSIONS

Barriers to health care can be insurmountable for low-income families, even those with insurance coverage. Patients who do not seek care in a family medicine clinic are not necessarily getting their care elsewhere.

Health insurance and access to health care in the United States

Health insurance, poverty, and health are all interconnected in the United States. This article synthesizes a large and compelling body of health services research, finding a strong association between health insurance coverage and access to primary and preventive care, the treatment of acute and traumatic conditions, and the medical management of chronic illness. Moreover, by improving access to care, health insurance coverage is also fundamentally important to better health care and health outcomes. Research connects being uninsured with adverse health outcomes, including declines in health and function, preventable health problems, severe disease at the time of diagnosis, and premature mortality.

Disruptions in insurance coverage: patterns and relationship to health care access, unmet need, and utilization before enrollment in the State Children's Health Insurance Program

BACKGROUND

The numbers and types of disruptions in insurance that children experience and the effects of these disruptions on health care measures have not been well characterized.

OBJECTIVES

Our goals were to (1) describe the number and patterns of insurance disruptions within a population of children newly enrolling into the State Children's Health Insurance Program and (2) assess the relationship among insurance disruptions and sociodemographic characteristics of these children and their families to specific measures of access to care, unmet need, and health care utilization during the year before enrollment.

METHODS

We conducted telephone interviews in families with children newly enrolling in the State Children's Health Insurance Program. Families reported on measures for each of the 12 months preceding enrollment. They were grouped by number of insurance disruptions in the year before enrollment: continuously uninsured, > or = 2 disruptions, 1 disruption, or continuously insured.

RESULTS

Of 920 families contacted, 739 (80%) completed the interview and 710 had useable data. Thirty-five percent reported being continuously uninsured, 42% were intermittently insured (> or = 2 disruptions: 28%; 1 disruption: 14%), and 23% were continuously insured during the previous year. The most common patterns of change were between privately insured and uninsured (49%) and Medicaid and uninsured (40%). The continuously uninsured were more likely to be Hispanic and older in age. Multivariate modeling confirmed a gradient between greater insurance disruption and less access to care, less utilization, and greater unmet medical need. Using the continuously uninsured as a reference group, the adjusted odds ratio for having a medical home varied from 2.5 for those with > or = 2 disruptions to 4.5 for the continuously insured and from 1.9 to 3.2, respectively, for using any regular/routine care. The odds ratio for unmet need for a prescription medication was 0.9 for > or = 2 disruptions and 0.5 for those with continuous insurance coverage.

CONCLUSIONS

There was significant disruption in insurance coverage in the year before State Children's Health Insurance Program enrollment. Most of these disruptions took the form of children previously enrolled in either Medicaid or private insurance becoming uninsured. Increasing numbers of disruptions were associated with less routine care and greater unmet medical need. These findings suggest that disruptions in insurance coverage for children should be minimized with the adoption of policies regarding continuous eligibility criteria for Medicaid and streamlining transitions between Medicaid, the State Children's Health Insurance Program, and private insurance.

Dynamics in Medicaid and SCHIP eligibility among children in SCHIP's early years: implications for reauthorization

Two-thirds of children in the United States were income-eligible for Medicaid or the State Children's Health Insurance Program (SCHIP) at some point from 1996 to 2000. One in five children were income-eligible for both programs, and 73 percent of children ever eligible for SCHIP were eligible at other times for Medicaid. As SCHIP is reauthorized, Congress will need to give states the tools and financial commitment to assure that uninsured children are enrolled in and retain the coverage for which they are eligible.

Health insurance across vulnerable ages: patterns and disparities from adolescence to the early 30s

OBJECTIVE

Young adults have the lowest rate of insurance coverage of any age group. Little is known about insurance patterns from adolescence through the early 30s. The objective of this study was to assess patterns and disparities in health insurance from adolescence through the early 30s.

DESIGN

We analyzed data from the 2002 and 2003 National Health Interview Survey (ages 13-32; N = 48,827). We examined public and private insurance coverage and conducted logistic regression to evaluate racial/ethnic and income disparities in coverage. Outcomes were insurance coverage at ages 13 to 32.

RESULTS

Insurance patterns follow a U-shaped curve across the age categories. Rates are highest at ages 13 to 14, lowest at ages 23 to 24, and then increase gradually. Private rate patterns are similar; however, public coverage decreases across ages. In bivariate analyses, black and Hispanic groups had lower coverage rates than the white group, and the low- and middle-income groups had lower rates than the high-income group. After adjustment for confounding variables, all disparities remained significant except for differences between the black and white groups.

CONCLUSIONS

After age 18, all groups are vulnerable to lack of insurance. Rate increases beyond age 25 to 26 years are attributable to increases in private coverage, whereas decreases in public coverage account for the lack of a full recovery to the higher rates seen in adolescence. The safety net of public programs that cover adolescents disappears in young adulthood, leaving young adults vulnerable, a problem that persists into the 30s for those who are in poverty and those who are of Hispanic origin.

Canada-trained pediatric surgeons: a cross-border survey of satisfaction and preferences

OBJECTIVES

The American and Canadian health care delivery systems impact pediatric surgical practice differently. We conducted a survey of Canada-trained pediatric surgeons practicing in the United States and Canada to compare their levels of satisfaction and to assess their health care system preferences.

METHODS

Pediatric surgeons who graduated from Canadian training programs between 1983 and 2002 were invited to complete a web-based questionnaire. They rated their satisfaction on a scale ranging from 1 (most) to 5 (least) with issues pertaining to quality of life, compensation, work environment, academics, and patient care. Surgeons who had experience in both the American and Canadian systems marked their preferences for each system as it impacted the same areas.

RESULTS

Sixty surgeons (65% practicing in the United States and 35% in Canada) of 94 eligible participants (64%) responded to the survey. Surgeons in the United States were more satisfied with their overall workload and patient care issues, whereas those in Canada were more satisfied with the system of health care reimbursement and the medicolegal environment. Among 38 surgeons who had experience in both systems, 26% had an overall preference for the Canadian system, 24% did for the American system, and half had no preference.

CONCLUSIONS

Canada-trained pediatric surgeons practicing in the United States are more satisfied with patient care issues, whereas those practicing in Canada are more satisfied with the medicolegal environment and the system of health care reimbursement. There is no overwhelming preference for either system among surgeons who had experience in both.

Existing population-based health databases: useful resources for nursing research

Important research questions, such as the prevalence of health conditions in specific groups and health disparities, can be addressed through population-based health databases. Government-funded, federal databases can provide nurse researchers with a representative sample for various levels of analyses. Population-based health databases easily accessed from federal government Web sites for analysis are identified and discussed. These databases, such as the National Health Interview Survey and the National Sample Survey of Registered Nurses, were collected through rigorous probability sampling and data collection methods and can be generalized to the population of the study. The benefits and limitations of analyzing the databases as a research approach are summarized, using examples from the recently released National Survey of Children's Health. Findings from population-based studies provide significant information on health-related indicators and contribute to the development of sound recommendations for health care practice and policy, thereby supporting evidence-based practice. Analyses of population-based databases provide additional opportunities for nurse researchers to contribute to health policy and evidence-based practice within a framework of nursing-health services research.

Health care for the poor—An exploration of primary-care physicians’ perceptions of poor patients and of their helping behaviors

This paper explores the ways in which primary-care physicians in Israel perceive and help poor patients. Our findings are based on a qualitative study that utilized a focus group and in-depth interviews with 16 primary-care physicians who qualified both in Israel and in the former Soviet Union, and who work in community clinics one Health Maintenance Organization serving poor populations of diverse cultural, ethnic and socioeconomic backgrounds (immigrants from the former Soviet Union and from Ethiopia, Bedouin, ultra-orthodox Jews, the chronic poor, and the 'new' poor). It was found that the physicians presume causality between poverty and health, identify and distinguish between different types of poverty, and make associations based on the type of poverty and type of patient problem. Their thinking on poverty is patient-oriented rather than socially oriented. An analysis of these findings resulted in a conceptualization of five types of physician helping behavior: emotional and personal instrumental, reinforcing socially desirable behavior, preferential help and bending the rules, rights realization and working the system, and minimal community involvement. The components of this conceptual model depict and chart issues affecting the helping behavior of the primary-care physician, i.e., type of poverty, type of problem, administrative context and, particularly, physician attributes, such as gender and country where notable. Our findings reveal little social consciousness on the part of the physicians, and we conclude with remarks on the potential for change in this area.

How stable is medicaid coverage for children?

We examined Medicaid coverage patterns in five states for children who were covered as of December 2003. Looking back three years, we found that Medicaid was a source of continuous coverage for sizable proportions of children (43-66 percent were covered for two or more years) but a revolving door for others (16-41 percent had gaps). In all states, gaps were short, from two to four months. Continuity implies that states can demand more of the health care system to improve the quality of care; short gaps imply that policies and procedures should be revisited to reduce gaps for eligible children.

Genetic Counseling, Insurance Status, and Elements of Medical Home: Analysis of the National Survey of Children with Special Health Care Needs

OBJECTIVE

To examine associations between receiving genetic counseling and the enabling factors of insurance and medical home.

METHODS

This study uses data from the National Survey of Children with Special Health Care Needs (CSHCN). We use descriptive statistics to characterize families of CSHCN who needed and received genetic counseling as well as families who needed but did not receive genetic counseling. We conduct logistic regression to calculate the association between receiving genetic counseling, insurance status, and medical home while adjusting for child's age, mother's education, race, ethnicity, and severity of condition.

RESULTS

Seven percent of families with CSHCN, representing 643,432 CSHCN nationwide, reported needing genetic counseling in 2001. Of those in need of genetic counseling, an estimated 123,117 CSHCN reported not receiving genetic counseling. Compared to CSHCN with continuous insurance coverage, CSHCN with interrupted insurance coverage and CSHCN without insurance are significantly less likely to receive genetic counseling. The odds of receiving genetic counseling by CSHCN with medical homes are 2.70 times higher compared to peers without medical homes (95% CI: 1.58, 4.61; p </= .001). Among the four elements comprising medical home in this study, family-centered care is the only element significantly associated with receiving genetic counseling.

CONCLUSIONS

Our analysis presents evidence that receiving genetic counseling is positively associated with having continuous insurance coverage and receiving family-centered care. We discuss how researchers and policy makers may use these finding to explore strategies for improving care systems for CSHCN.

Underinsurance and key health outcomes for children with special health care needs

OBJECTIVE

The objective was to examine the relationship between underinsurance and other core outcomes for children with special health care needs.

METHODS

This study analyzed data from the National Survey of Children With Special Health Care Needs. Two alternative definitions of underinsurance, designated attitudinal and economic, were investigated. Logistic regression models in which the response variables were the child's status for each of the target core outcomes and underinsurance status was a dichotomous predictor variable were created. In addition to underinsurance status, 10 other predictor variables were included in the model.

RESULTS

Underinsurance is associated with the Maternal and Child Health Bureau core outcomes for children with special health care needs related to satisfaction with care and partnering with families in decision-making, access to a medical home, community-based service delivery that is easy to use, and access to services to make transitions to adulthood. In each case, children with special health care needs who were underinsured had significantly poorer outcomes than did children who were adequately insured.

CONCLUSIONS

Although these results cannot clarify the cause of poorer outcomes, there are clear negative effects associated with the problem of underinsurance. Inadequate health care coverage for children with special health care needs may save dollars in the short-term but, if other outcomes are compromised, then children, their families, and society at large may pay a price in the longer term.

Factors associated with not having a personal health care provider for children in Florida

OBJECTIVE

National recommendations by the American Academy of Pediatrics and the National Association of Pediatric Nurse Practitioners promote that all children obtain quality primary care through a consistent medical provider who can better assess, diagnose, and monitor a child's health. The purpose of this article was to identify characteristics of children in Florida without a personal health care provider.

METHODS

Florida data (N = 2116) from the 2003 National Survey of Children's Health were analyzed by using bivariate and multivariate methods. The dependent, or outcome, variable was a personal health care provider, defined in the National Survey of Children's Health as a personal doctor or nurse.

RESULTS

In Florida, 20.1% of children (0-17 years of age) do not have a personal health care provider compared with 16.7% in the United States. Children at greatest risk are those without health insurance. Other significant risk factors include family poverty up to 100% of federal poverty level, poverty level 100% to 199%, poverty level unknown, poverty level 200% to 399%, children aged 5 to 12 years, children aged 13 to 17 years, and Hispanic ethnicity. All the factors in the Florida model were also significant in the national model.

CONCLUSIONS

Lack of a personal health care provider is driven by larger community issues of health insurance, socioeconomic status, and ethnicity, including race, on a national level. To achieve the goal of a personal health care provider for children, a multifaceted approach needs to be considered. Knowing which children are without a personal health care provider provides valuable information for state policy-makers, program planners, and evaluators.

Compliance with well-child visit recommendations: evidence from the Medical Expenditure Panel Survey, 2000-2002

OBJECTIVES

This study examines national compliance rates with well-child visit recommendations using the Medical Expenditure Panel Survey. The Medical Expenditure Panel Survey provides nationally representative information on preventative care for children, combining visit-level data over a 2-year period with a rich array of socioeconomic and health status measures.

METHODS

Visit-level data from 2000 to 2002 were used to construct a well-child visit "compliance" measure equal to well-child visits as a percentage of age-specific recommendations from the American Academy of Pediatrics. Compliance was examined across age, gender, race/ethnicity, health status, poverty, insurance coverage, eligibility for public coverage, family structure, parent education, insurance, citizenship and country of origin, language, urbanicity, and census division.

RESULTS

On average, 56.3% of all children aged 0 to 18 years had no well-child visits during a 12-month period, and 39.4% had no well-child visits over a 2-year period. The average compliance ratio was 61.4%. Large differences in compliance exist among children. High compliance rates were observed among infants (83.2%), children with special health care needs (86.6%), children with college-educated parents (74.3%), children with family incomes >4 times the poverty level (71.6%), and children in the New England (94.6%) and Middle Atlantic (83.2%) census divisions. Low levels of compliance were observed among uninsured children (35.3%) and especially uninsured children simulated to be eligible for public coverage (28.4%). Other groups with low compliance rates include teenagers (49.2%), noncitizen children (43.9%), and children in the West South Central (44.9%), East South Central (48.8%), and Mountain (49.7%) census divisions.

CONCLUSIONS

Well-child visit compliance in the Medical Expenditure Panel Survey is less than found in other household surveys, yet consistent with or above results based on data from provider and claims data. Although experts dispute the optimal frequency of well-child visits, the disparities observed in compliance rates among population subgroups raise important public health concerns.

How does lack of insurance affect use of intensive care? A population-based study

OBJECTIVE

One in six Americans aged <65 yrs are without health insurance. Although lack of insurance is associated with reduced access to many health services, the relationship between lack of insurance and use of intensive care services is unclear. We sought to compare the use of intensive care by insured and uninsured populations.

DESIGN

Retrospective population-based cross-sectional study of five U.S. states (Florida, Massachusetts, New Jersey, New York, and Virginia), analyzing use of hospital and intensive care unit (ICU) services by all residents of these states <65 yrs of age. Data sources included the five 1999 state hospital discharge databases and the 2000 U.S. Census Bureau Current Population Survey.

SETTING

Nonfederal hospitals in the five states (all hospitalizations in these during 1999).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 39.3 million and 7.8 million individuals aged 0-64 yrs with and without insurance, respectively, in the five-state sample. The uninsured population was far less likely to be hospitalized (odds ratio [OR], 0.458; 95% confidence interval [CI], 0.456-0.460; p < .001) and to be admitted to the ICU (OR, 0.581, 95% CI: 0.576-0.587, p < .001). Differences persisted irrespective of age, gender, ethnicity, or reason for admission. Among those hospitalized, the uninsured were more likely to receive intensive care (OR, 1.24; 95% CI, 1.22-1.25; p < .01). Hospital mortality rates for patients admitted to the ICU ranged by age from 4.0% to 6.9% for the uninsured and from 2.7% to 5.5% for the insured (OR, 1.12-1.54; p < .01).

CONCLUSIONS

Americans without insurance use ICU services less often than those with insurance, primarily because of decreased likelihood of hospital admission in the first place. Outcome is worse for those who are admitted to the ICU, possibly because they are sicker when they seek care.

Increased rates of morbidity, mortality, and charges for hospitalized children with public or no health insurance as compared with children with private insurance in Colorado and the United States

BACKGROUND

There has been a gradual decrease in the proportion of children covered by private health insurance in Colorado and the United States with a commensurate increase in those with public insurance or having no insurance which may impact access to care and outcomes.

OBJECTIVE

The purpose of this work was to determine whether children with public or no health insurance have differences in hospital admission rates, morbidity, mortality, and/or charges that might be improved if standards of primary care comparable to those of children with private insurance could be achieved.

METHODS

We conducted a retrospective comparison of hospitalization-related outcomes for children < 18 years of age in Colorado from 1995-2003 and in the United States in 2000. Population-based rates for hospital admission were determined stratified by age, race/ethnicity, disease grouping, and health insurance status.

RESULTS

Compared with those with private insurance, children in Colorado and the United States with public or no insurance have significantly higher rates of total hospital admission, as well as admission for chronic illness, asthma, diabetes, vaccine-preventable disease, psychiatric disease, and ruptured appendix. These children have higher mortality rates, higher severity of illness, are more likely to be admitted through the emergency department and have significantly higher hospital charges per insured child. Higher hospitalization rates occur in children who are nonwhite and/or Hispanic and those who are younger. If children with public or no health insurance in the United States in 2000 had the same hospitalization outcomes as children with private insurance, $5.3 billion in hospital charges could have been saved.

CONCLUSIONS

There is an opportunity to achieve improved health outcomes and decreased hospitalization costs for children with public or no health insurance if private insurance standards of health care could be achieved for all US children.

Protecting low-income children's access to care: are physician visits associated with reduced patient dropout from Medicaid and the Children's Health Insurance Program?

OBJECTIVE

Dropout among patients who are enrolled in Medicaid and the Children's Health Insurance Program contributes to a lack of health care access among millions of Americans. The purpose of this study was to determine which, if any, types of clinical contact with physicians are associated with reduced dropout among children who are enrolled in Medicaid and the Children's Health Insurance Program.

METHODS

The data are from the nationally representative Medical Expenditure Panel Survey, 1998-2002. The sample is composed of all children (n = 3043) who were reported to have Medicaid or Children's Health Insurance Program coverage throughout their first year in the survey and who did not acquire other insurance during the study period. The outcome measure is whether an individual remained enrolled in Medicaid or the Children's Health Insurance Program by the end of the following year. Exposure variables were clinical contact during an individual's first year in the survey: numbers of office visits, hospital outpatient department visits, emergency department visits, inpatient hospital stays, and dental visits. The analysis uses multivariate logistic regression to control for patient and family characteristics-most important, health status, functional status, and overall health care expenditures.

RESULTS

Eight percent of the children in the sample had left Medicaid/the Children's Health Insurance Program by the end of the second year in the survey. More frequent contact with clinicians in an office setting was associated with a significantly lower risk for dropping out of Medicaid/the Children's Health Insurance Program among children, even controlling for demographics, health and functional status, and overall health care expenditures. After multivariate adjustment, more frequent contact in hospital outpatient departments also was associated with reduced dropout, with a borderline statistically significant odds ratio. Notably, emergency visits and inpatient stays were not associated with any significant change in the risk of Medicaid/Children's Health Insurance Program dropout.

CONCLUSIONS

These results suggest that some but not all types of clinician visits are serving an important function in maintaining Medicaid and the Children's Health Insurance Program coverage among low-income patients. Two possible approaches to improve access to care among low-income children therefore would be (1) increased awareness among clinicians, especially in hospitals and emergency departments, regarding Medicaid/Children's Health Insurance Program retention as an issue in the ongoing care of their patients and (2) Medicaid/Children's Health Insurance Program reimbursement of clinicians and their staff for assisting patients with the public insurance renewal process.

Associations between childhood vaccination coverage, insurance type, and breaks in health insurance coverage

OBJECTIVES

This study explored how vaccination coverage is associated with not being insured and with insurance type among children who are insured and to show how these associations are modified by race/ethnicity.

METHODS

We determined whether 8324 children sampled in the National Immunization Survey in 2001 and 2002 were covered by private insurance only, Medicaid/State Children's Health Insurance Program, or another insurance type or were uninsured at the time of the National Immunization Survey interview or were uninsured at some time before the interview. Children were up to date if, by the date of the interview, their vaccination providers had administered > or =4 doses of diphtheria-tetanus toxoids-acellular pertussis vaccine, > or =3 doses of polio vaccine, > or =1 dose of measles-mumps-rubella vaccine, > or =3 doses of Haemophilus influenzae type b vaccine, and > or =3 doses of hepatitis B vaccine. To evaluate the association between insurance type and breaks in insurance with timely completion of the recommended vaccination schedule soon after 19 months of age, we restricted our analyses to children 19 to 24 months of age.

RESULTS

Nationally, 12.6 +/- 1.6% of all children 19 to 24 months of age were uninsured at some time. Children who were uninsured at the time of the National Immunization Survey interview had significantly lower vaccination coverage than did children with Medicaid/State Children's Health Insurance Program coverage or children with private insurance only (52.6% vs 70.0% and 75.6%). Children who had never been insured and children who were insured but had a break in insurance coverage in the 12 months immediately preceding the National Immunization Survey interview had significantly lower vaccination coverage than did children who had been insured continuously (47.4% and 64.8% vs 73.5%).

CONCLUSIONS

Approximately 1 of 8 children were uninsured at some time, and those children were at greater risk of not being vaccinated on time as recommended.

Over the rainbow: advancing child health in the new millennium

Research studies presented at the annual Pediatric Academic Societies meeting provide continued evidence of the impact of the environment on child health, the prevalence of mental health problems in children and adolescents, and the benefits of comprehensive health care coverage. Other studies report on the efficacy of new formats for delivering pediatric health care and the content of health supervision visits, and identify potential solutions for existing deficits and disparities in health care delivery. Despite this abundance of positive studies, the United States continues to lag behind many developed countries in its broader adoption of effective strategies such as universal health coverage. Child health care professionals must continue to speak out on behalf of the needs of infants, children, and adolescents and work for systemic change in health care delivery.

Health Insurance Coverage in Survivors of Childhood Cancer: The Childhood Cancer Survivor Study

Purpose

To examine the prevalence and predictors of health insurance coverage and the difficulties obtaining coverage in a large cohort of childhood cancer survivors.

Patients and Methods

This study included 12,358 5-year survivors of childhood cancer and 3,553 sibling controls participating in the Childhood Cancer Survivor Study. Data were collected by surveys distributed in 1994 (baseline) and 2000 (follow-up).

Results

At baseline, 83.9% of adult survivors, compared with 88.3% of siblings, had health insurance coverage (P < .01); 6 years later, small but significant survivor-sibling differences remained (88% v 91%; P < .01). Twenty-nine percent of survivors reported having had difficulties obtaining coverage, compared with only 3% of siblings (P < .01). In multivariate analysis of survivors 18 years of age or older, factors associated with being uninsured included younger age at diagnosis (diagnosis age of 0 to 4 years; odds ratio [OR] = 1.7; 95% CI, 1.3 to 2.2), male sex (OR = 1.3; 95% CI, 1.2 to 1.5), age at baseline survey (age 22 to 24 years; OR = 1.6; 95% CI, 1.2 to 2.1), lower level of attained education (less than high school, OR = 2.6, 95% CI, 2.1 to 3.3; high school graduate, OR = 2.1, 95% CI, 1.8 to 2.5), income less than $20,000 (OR = 5.6, 95% CI, 4.5 to 7.1), marital status (widowed/divorced/separated; OR = 1.3; 95% CI, 1.1 to 1.6), smoking status (current smoker, OR = 2.0, 95% CI, 1.7 to 2.3; former smoker, OR = 1.4, 95% CI, 1.2 to 1.8), and treatment that included cranial radiation (OR = 1.3, 95% CI, 1.0 to 1.6).

Conclusion

Compared with siblings, adult survivors of childhood cancer had significantly lower rates of health insurance coverage and more difficulties obtaining coverage. Since lack of coverage likely has serious health and financial implications for this at-risk population, any disparity in availability and quality of coverage is of great concern.

The impact of Medicaid on children's healthcare and health

PURPOSE OF REVIEW

This article reviews the impact of the Medicaid program, including the proportion of children in America insured by Medicaid; the extent to which Medicaid-enrolled children have access to care; the use of services and the quality of care received by Medicaid enrollees, including evidence for disease reduction; and family satisfaction with the program.

RECENT FINDINGS

More than a quarter of all children in the United States were insured through public programs, primarily Medicaid, in 2002. Public insurance programs are even more critical for low-income children: 69.5% of children in families with incomes below 100% of the federal poverty level are covered by public programs. The reach of Medicaid is extensive, although substantial numbers of eligible children remain uninsured. Although Medicaid-insured children still face access barriers, particularly for certain types of specialty care, parents of children with public insurance report high levels of satisfaction with their experience with well-child care. While the study findings are mixed, several recent studies show very favorable comparisons between the experience of privately insured children and that of publicly insured children.

SUMMARY

Medicaid plays a critical role in providing health insurance coverage for children, particularly for very low-income families. Additional efforts are needed to fully enroll all eligible families and to assure full access to high-quality care.

Being uninsured: impact on children's healthcare and health

PURPOSE OF REVIEW

There are 8.4 million uninsured children in the United States. Many are eligible for coverage. Current literature on how lack of health insurance affects the quality and outcome of children's healthcare in the United States is reviewed, and effective solutions are identified. Recent policy changes have produced restrictions on basic preventive and curative services, despite concurrent major efforts to increase insurance coverage rates for children.

RECENT FINDINGS

With more than 70% of currently uninsured children eligible for either Medicaid or the State Children's Health Insurance Program, these public programs have not yet produced expected levels of coverage. Health systems and provider accountability for the primary care of uninsured children is not optimal. Families of uninsured children face non-financial access barriers to care such as lack of continuity with a primary care provider and inadequate visit time. These barriers are compounded for uninsured children with special healthcare needs.

SUMMARY

Pediatric primary care effectiveness is significantly reduced by insurance shortfalls. Lack of coverage inhibits appropriate care seeking; diminishes provider availability; compromises care content, quality, and satisfaction; and ultimately harms the entire family unit. However, provision of insurance alone is not a panacea.

Insurance gaps among vulnerable children in the United States, 1999-2001

OBJECTIVE

To quantify the number of children who experience gaps in insurance coverage and to determine whether vulnerable subgroups of children experience noteworthy lapses in insurance coverage.

METHODS

We analyzed nationally representative data from 24,149 children sampled in the 1999-2001 Medical Expenditure Panel Survey linked to the 1997-1999 National Health Interview Survey. Vulnerable subgroups of children included children with chronic conditions, those from ethnic/racial minorities, and those living in poverty. On the basis of cumulative annual monthly insurance coverage status, each child fell into 1 of 3 groups: continuous coverage, uninsured, or gaps in coverage. Using SAS-callable SUDAAN, we conducted multivariate ordinal logistic regression model to quantify the likelihood of having gaps in coverage for vulnerable subgroups of children.

RESULTS

From 1999 to 2001, we found that >9 million American children annually had gaps in coverage and that 5 to 6 million children annually were uninsured for the entire year. Sixty percent of children experienced gaps of at least 4 months, and >40% of all publicly and privately insured children had coverage gaps. After accounting for relevant covariates, children with chronic conditions were just as likely as other children to have gaps in coverage or be uninsured; Hispanic children were most likely to have insurance gaps or be uninsured; and children from poor and near-poor families were 4 to 5 times more likely to have lapsed coverage than children from high-income families. Poverty and maternal education were the strongest factors associated with lapsed coverage.

CONCLUSIONS

Unstable health insurance is an underrecognized problem for children, including those with chronic conditions. Because unstable insurance coverage can lead to inadequate health care utilization and poor child health outcomes, strategies to promote stable insurance coverage merit serious consideration.