Does health insurance continuity among low-income adults impact their children's insurance coverage?

An observational study of health insured visits for children following Medicaid eligibility expansion for adults among a linked cohort of parents and children

Despite its focus on adults, the Affordable Care Act (ACA) Medicaid expansion led to increased health insurance enrollment for children in the United States. Previous studies looked at parent and child insurance changes separately, or used a single survey response item to understand changes in health insurance for parents and children. It is, however, important to understand the connection between parent and child insurance changes together (not individually) using data sources that account for insurance over time. Therefore, to understand the association of parental health insurance on their children's coverage, leveraging a cohort of linked families seen in community health centers (CHCs), we used electronic health records to link a cohort of parents and children with ≥1 visit to a CHC in a Medicaid expansion state pre- (1/1/2012-12/31/2013) and ≥1 visit post-ACA (1/1/2014-12/31/2018) and determined primary payer type for all visits. This observational, cohort study assessed the rate of insured visits for children pre- to post-ACA across four parental insurance groups (always insured, gained Medicaid, discontinuously insured, never insured) using Poisson mixed effects models. We included 335 CHCs across 7 United States. Insurance rates were highest (~95 insured visits/100 visits) for children of parents who were always insured; rates were lowest for children of parents who were never insured (~83 insured visits/100 visits). Children with a parent who gained Medicaid had 4.4% more insured visits post- compared to pre-ACA (adjusted relative rates  = 1.044, 95% confidence interval: 1.014, 1.074). When comparing changes from pre- to post-ACA between parent insurance groups, children's insured visit rates were significantly higher for children of parents who gained Medicaid (reference) compared to children of parents who were always insured (adjusted ratio of rate ratio: 0.963, confidence interval: 0.935-0.992). Despite differences in Medicaid eligibility for children and adults, health insurance patterns were similar for linked families seen in CHCs. Findings suggest consideration should be paid to parent health insurance options when trying to increase children's coverage.

Association of maternal characteristics with latino youth health insurance disparities in the United States: a generalized structural equation modeling approach

Background

Disparities in access to care persist for Latino youth born in the United States (US). The association of maternal characteristics, such as maternal citizenship status and insurance coverage, on youth health insurance coverage is unclear and is important to examine given the recent sociopolitical shifts occurring in the US.

Methods

We analyzed pooled cross-sectional data from the 2010–2018 National Health Interview Survey to examine the association of Latina maternal citizenship status on maternal insurance coverage status and youth uninsurance among US-born Latino youth. Our study sample consisted of 15,912 US-born Latino youth (ages < 18) with linked mothers. Our outcome measures were maternal insurance coverage type and youth uninsurance and primary predictor was maternal citizenship status. Generalized structural equation modeling was used to examine the relationships between maternal characteristics (maternal citizenship, maternal insurance coverage status) and youth uninsurance.

Results

Overall, 7% of US-born Latino youth were uninsured. Just 6% of youth with US-born mothers were uninsured compared to almost 10% of those with noncitizen mothers. Over 18% of youth with uninsured mothers were uninsured compared to 2.2% among youth with mothers who had private insurance coverage. Compared to both US-born and naturalized citizen Latina mothers, noncitizen Latina mothers had 4.75 times the odds of reporting being uninsured. Once adjusted for predisposing, enabling, and need factors, maternal uninsurance was strongly associated with youth uninsurance and maternal citizenship was weakly associated with youth uninsurance among US-born Latino youth.

Conclusion

Maternal citizenship was associated with both maternal uninsurance and youth uninsurance among US-born Latino youth. Federal- and state-level health policymaking should apply a two-generational approach to ensure that mothers of children are offered affordable health insurance coverage, regardless of their citizenship status, thus reducing uninsurance among US-born Latino youth.

Building Meaningful Patient Engagement in Research: Case Study From ADVANCE Clinical Data Research Network

BACKGROUND

Strategies to engage patients to improve and enhance research and clinical care are increasingly being implemented in the United States, yet little is known about best practices for or the impacts of meaningful patient engagement.

OBJECTIVE

We describe and reflect on our patient stakeholder groups, engagement framework, experiences, and lessons learned in engaging patients in research, from generating proposal ideas to disseminating findings.

SETTING

The ADVANCE (Accelerating Data Value Across a National Community Health Center Network) clinical data research network is the nation's largest clinical dataset on the safety net, with outpatient clinical data from 122 health systems (1109 clinics) in 23 states.

RESULTS

Patients stakeholders codeveloped the ADVANCE engagement framework and its implementation in partnership with network leaders. In phase I of ADVANCE, patients were involved with designing studies (input on primary outcome measures and methods) and usability testing (of the patient portal). In phase II, the network is prioritizing research training, dissemination opportunities, an "ambassador" program to pair more experienced patient stakeholders with those less experienced, and evaluation of engagement activities and impacts.

DISCUSSION

The ADVANCE framework for patient engagement has successfully involved a diverse group of patients in the design, implementation, and interpretation of comparative effectiveness research. Our experience and framework can be used by other organizations and research networks to support patient engagement activities.

Maternal and child patterns of Medicaid retention: a prospective cohort study

BACKGROUND

We sought to determine whether maternal Medicaid retention influences child Medicaid retention because caregivers play a critical role in assuring children's health access.

METHODS

We conducted a longitudinal prospective cohort study of a convenience sample of 604 Medicaid-eligible mother-child dyads followed from the infant's birth through 24 months of age with parent surveys. Individual enrollment status was abstracted from administrative Medicaid eligibility files. Generalized estimating equations quantified the effect of maternal Medicaid enrollment status on child Medicaid retention, adjusting for relevant covariates. Because varying lengths of gaps may have different effects on child health outcomes, Medicaid enrollment status was further categorized by length of gap: any gap, > 14-days, and > 60-days.

RESULTS

This cohort consists primarily of African-American (94%), unmarried mothers (88%), with a mean age of 23.2 years. In multivariable analysis, children whose mothers experienced any gaps in coverage had 12.6 times greater odds of experiencing gaps when compared to children whose mothers were continuously enrolled. Use of varying thresholds to define coverage gaps resulted in similar odds ratios (> 14-day gap = 11.8, > 60-day gap = 16.8). Cash assistance receipt and maternal knowledge of differences between Temporary Assistance to Needy Families and Medicaid eligibility criteria demonstrated strong protective effects against child Medicaid disenrollment.

CONCLUSIONS

Medicaid disenrollment remains a significant policy problem and maternal Medicaid retention patterns show strong effects on child Medicaid retention. Policymakers need to invest in effective outreach strategies, including family-friendly application processes, to reduce enrollment barriers so that all eligible families can take advantage of these coverage opportunities.

Racial Disparities in Children's Health: A Longitudinal Analysis of Mothers Based on the Multiple Disadvantage Model

This secondary data analysis of 4373 mothers and their children investigated racial disparities in children's health and its associations with social structural factors, social relationships/support, health/mental health, substance use, and access to health/mental health services. The study drew on longitudinal records for mother-child pairs created from data in the Fragile Families and Child Wellbeing Study. Generalized estimating equations yielded results showing children's good health to be associated positively with mother's health (current health and health during pregnancy), across three ethnic groups. For African-American children, good health was associated with mothers' education level, receipt of informal child care, receipt of public health insurance, uninsured status, and absence of depression. For Hispanic children, health was positively associated with mothers' education level, receipt of substance-use treatment, and non-receipt of public assistance. Implications for policy and intervention are discussed.

The Association Between Medicaid Coverage for Children and Parents Persists: 2002-2010

To assess the association between a child's and their parent's public health insurance status during a time when children had access to coverage independent of policies that impacted adults' access. Secondary data from the Oregon Health Plan (OHP) [Oregon's Medicaid and Children's Health Insurance Programs] for families with at least one parent and one child with OHP coverage at any time during the study period (2002-2010). We linked children to their parents in the OHP data set and examined longitudinal associations between the coverage patterns for children and their parents, controlling for several demographic and economic confounders. We tested for differences in the strength of associations in monthly coverage status in five time periods throughout the nine-year study period. The odds of a child being insured by the OHP in months in which at least one parent had OHP coverage were significantly higher than among children whose parents were not enrolled at that time. Children with at least one parent who maintained or gained OHP coverage in a given month had a much higher probability of being enrolled in the OHP in that month, compared to children who had no covered parents in the given month or the month prior. Despite implementation of policies that differentially affected eligibility requirements for children and adults, strong associations persisted between coverage continuity for parents and children enrolled in Oregon public health insurance programs.

Trends in Type of Health Insurance Coverage for US Children and Their Parents, 1998-2011

OBJECTIVE

To examine trends in health insurance type among US children and their parents.

METHODS

Using the Medical Expenditure Panel Survey (1998-2011), we linked each child (n = 120,521; weighted n ≈ 70 million) with his or her parent or parents and assessed patterns of full-year health insurance type, stratified by income. We examined longitudinal insurance trends using joinpoint regression and further explored these trends with adjusted regression models.

RESULTS

When comparing 1998 to 2011, the percentage of low-income families with both child and parent or parents privately insured decreased from 29.2% to 19.1%, with an estimated decline of -0.86 (95% confidence interval, -1.10, -0.63) unadjusted percentage points per year; middle-income families experienced a drop from 74.5% to 66.3%, a yearly unadjusted percentage point decrease of -0.73 (95% confidence interval, -0.98, -0.48). The discordant pattern of publicly insured children with uninsured parents increased from 10.4% to 27.2% among low-income families and from 1.4% to 6.7% among middle-income families. Results from adjusted models were similar to joinpoint regression findings.

CONCLUSIONS

During the past decade, low- and middle-income US families experienced a decrease in the percentage of child-parent pairs with private health insurance and pairs without insurance. Concurrently, there was a rise in discordant coverage patterns-mainly publicly insured children with uninsured parents.

What does Medicaid expansion mean for cancer screening and prevention? Results from a randomized trial on the impacts of acquiring Medicaid coverage

BACKGROUND

The Oregon Medicaid lottery provided a unique opportunity to assess the causal impacts of health insurance on cancer screening rates within the framework of a randomized controlled trial. Prior studies regarding the impacts of health insurance have almost always been limited to observational evidence, which cannot be used to make causal inferences.

METHODS

The authors prospectively followed a representative panel of 16,204 individuals from the Oregon Medicaid lottery reservation list, collecting data before and after the Medicaid lottery drawings. The study panel was divided into 2 groups: a treatment group of individuals who were selected in the Medicaid lottery (6254 individuals) and a control group who were not (9950 individuals). The authors also created an elevated risk subpanel based on family cancer histories. One year after the lottery drawings, differences in cancer screening rates, preventive behaviors, and health status were compared between the study groups.

RESULTS

Medicaid coverage resulted in significantly higher rates of several common cancer screenings, especially among women, as well as better primary care connections and self-reported health outcomes. There was little evidence found that acquiring Medicaid increased the adoption of preventive health behaviors that might reduce cancer risk.

CONCLUSIONS

Medicaid coverage did not appear to directly impact lifestyle choices that might reduce cancer risk, but it did provide access to important care and screenings that could help to detect cancers earlier. These findings could have long-term population health implications for states considering or pursuing Medicaid expansion. Cancer 2016;122:791-797. © 2015 American Cancer Society.

Predictors of children's health insurance coverage discontinuity in 1998 versus 2009: parental coverage continuity plays a major role

To identify predictors of coverage continuity for United States children and assess how they have changed in the first 12 years since implementation of the Children's Health Insurance Program in 1997. Using data from the nationally-representative Medical Expenditure Panel Survey, we used logistic regression to identify predictors of discontinuity in 1998 and 2009 and compared differences between the 2 years. Having parents without continuous coverage was the greatest predictor of a child's coverage gap in both 1998 and 2009. Compared to children with at least one parent continuously covered, children whose parents did not have continuous coverage had a significantly higher relative risk (RR) of a coverage gap [RR 17.96, 95 % confidence interval (CI) 14.48-22.29 in 1998; RR 12.88, 95 % CI 10.41-15.93 in 2009]. In adjusted models, parental continuous coverage was the only significant predictor of discontinuous coverage for children (with one exception in 2009). The magnitude of the pattern was higher for privately-insured children [adjusted relative risk (aRR) 29.17, 95 % CI 20.99-40.53 in 1998; aRR 25.54, 95 % CI 19.41-33.61 in 2009] than publicly-insured children (aRR 5.72, 95 % CI 4.06-8.06 in 1998; aRR 4.53, 95 % CI 3.40-6.04 in 2009). Parental coverage continuity has a major influence on children's coverage continuity; this association remained even after public health insurance expansions for children. The Affordable Care Act will increase coverage for many adults; however, 'churning' on and off programs due to income fluctuations could result in coverage discontinuities for parents. If parental coverage instability persists, these discontinuities may continue to have a negative impact on children's coverage stability as well.

Linkage methods for connecting children with parents in electronic health record and state public health insurance data

The objective of this study was to develop methodologies for creating child-parent 'links' in two healthcare-related data sources. We linked children and parents who were patients in a network of Oregon clinics with a shared electronic health record (EHR), using data that reported the child's emergency contact information or the 'guarantor' for the child's visits. We also linked children and parents enrolled in the Oregon Health Plan (OHP; Oregon's public health insurance programs), using administrative data; here, we defined a 'child' as aged <19 years and identified potential 'parents' from among adults sharing the same OHP household identification (ID) number. In both data sources, parents had to be 12-55 years older than the child. We used OHP individual client ID and EHR patient ID numbers to assess the quality of our linkages through cross-validation. Of the 249,079 children in the EHR dataset, we identified 62,967 who had a 'linkable' parent with patient information in the EHR. In the OHP data, 889,452 household IDs were assigned to at least one child; 525,578 with a household ID had a 'linkable' parent (272,578 households). Cross-validation of linkages revealed 99.8 % of EHR links validated in OHP data and 97.7 % of OHP links validated in EHR data. The ability to link children and their parents in healthcare-related datasets will be useful to inform efforts to improve children's health. Thus, we developed strategies for linking children with their parents in an EHR and a public health insurance administrative dataset.

Adding insult to injury: discontinuous insurance following spine trauma

BACKGROUND

Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.

METHODS

We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.

RESULTS

The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.

CONCLUSIONS

Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.

Trends in health insurance status of US children and their parents, 1998-2008

In the United States (US), a parent's health insurance status affects their children's access to health care making it critically important to examine trends in coverage for both children and parents. To gain a better understanding of these health insurance trends, we assessed the coverage status for both children and their parents over an 11-year time period (1998-2008). We conducted secondary analysis of data from the nationally-representative Medical Expenditure Panel Survey. We examined frequency distributions for full-year child/parent insurance coverage status by family income, conducted Chi-square tests of association to assess significant differences over time, and explored factors associated with full-year insurance coverage status in 1998 and in 2008 using logistic regression. When considering all income groups together, the group with both child and parent insured decreased from 72.4 % in 1998 to 67.2 % in 2008. When stratified by income, the percentage of families with an insured child, but an uninsured parent increased for low-income families from 12.4 to 25.1 % and from 3.8 to 7.1 % for middle-income families when comparing 1998-2008. In regression analyses, family income remained the strongest characteristic associated with a lack of full-year health insurance. As future policy reforms take shape, it will be important to look beyond children's coverage patterns to assess whether gains have been made in overall family coverage.

The ADVANCE network: accelerating data value across a national community health center network

The ADVANCE (Accelerating Data Value Across a National Community Health Center Network) clinical data research network (CDRN) is led by the OCHIN Community Health Information Network in partnership with Health Choice Network and Fenway Health. The ADVANCE CDRN will ‘horizontally’ integrate outpatient electronic health record data for over one million federally qualified health center patients, and ‘vertically’ integrate hospital, health plan, and community data for these patients, often under-represented in research studies. Patient investigators, community investigators, and academic investigators with diverse expertise will work together to meet project goals related to data integration, patient engagement and recruitment, and the development of streamlined regulatory policies. By enhancing the data and research infrastructure of participating organizations, the ADVANCE CDRN will serve as a ‘community laboratory’ for including disadvantaged and vulnerable patients in patient-centered outcomes research that is aligned with the priorities of patients, clinics, and communities in our network.

Recent health insurance trends for US families: children gain while parents lose

In the past decade, political and economic changes in the United States (US) have affected health insurance coverage for children and their parents. Most likely these policies have differentially affected coverage patterns for children (versus parents) and for low-income (versus high-income) families. We aimed to examine--qualitatively and quantitatively--the impact of changing health insurance coverage on US families. Primary data from interviews with Oregon families (2008-2010) were analyzed using an iterative process. Qualitative findings guided quantitative analyses of secondary data from the nationally-representative Medical Expenditure Panel Survey (MEPS) (1998-2009); we used Joinpoint Regression to assess average annual percent changes (AAPC) in health insurance trends, examining child and parent status and type of coverage stratified by income. Interviewees reported that although children gained coverage, parents lost coverage. MEPS analyses confirmed this trend; the percentage of children uninsured all year decreased from 9.6 % in 1998 to 6.1 % in 2009; AAPC = -3.1 % (95 % confidence interval [CI] from -5.1 to -1.0), while the percentage of parents uninsured all year rose from 13.6 % in 1998 to 17.1 % in 2009, AAPC = 2.7 % (95 % CI 1.8-3.7). Low-income families experienced the most significant changes in coverage. Between 1998 and 2009, as US children gained health insurance, their parents lost coverage. Children's health is adversely affected when parents are uninsured. Investigation beyond children's coverage rates is needed to understand how health insurance policies and changing health insurance coverage trends are impacting children's health.