The State Children's Health Insurance Program

Pediatric COVID-19 Health Disparities and Vaccine Equity

While most children with coronavirus 2019 (COVID-19) experience mild illness, some are vulnerable to severe disease and develop long-term complications. Children with disabilities, those from lower-income homes, and those from racial and ethnic minority groups are more likely to be hospitalized and to have poor outcomes following an infection. For many of these same children, a wide range of social, economic, and environmental disadvantages have made it more difficult for them to access COVID-19 vaccines. Ensuring vaccine equity in children and decreasing health disparities promotes the common good and serves society as a whole. In this article, we discuss how the pandemic has exposed long-standing injustices in historically marginalized groups and provide a summary of the research describing the disparities associated with COVID-19 infection, severity, and vaccine uptake. Last, we outline several strategies for addressing some of the issues that can give rise to vaccine inequity in the pediatric population.

An evaluation on the effect of the copayment waiver policy for Korean hospitalized children under the age of six

BACKGROUND

In January 2006, the Korean government implemented a copayment waiver policy for hospitalized children under the age of 6 years to reduce the economic burden on patients. This policy was implemented from 2006 to 2007 in Korea and involved hospitalized children under the age of 6 years. The goal of this study is to evaluate the effect of the copayment waiver policy on health insurance beneficiaries.

METHODS

The change in medical service utilization before and after the policy implementation was analyzed using data from the national health insurance corporation (NHIC) and compared with medical aid beneficiaries who were already exempt from copayment. The "difference in difference" method was applied to determine the net effect of the copayment waiver policy.

RESULTS

The net effect of policy implementation on NHIC beneficiaries was unclear by the "difference in difference" method because the number of inpatient days and hospital expenditure after policy implementation showed opposite results. The copayment waiver policy did not decrease the intensity of health care utilization when compared with the medical aid beneficiaries group. Among the NHIC beneficiaries, patients who utilized medical services for fatal disease and those with the low premiums group were more affected by the policy.

CONCLUSIONS

The net effect of copayment waiver policy remains unclear. Therefore, further studies are needed to determine the effects of policies implemented to reduce the economic burden on patients, such as the herein-described copayment waiver policy.

The impact of health insurance coverage on pediatric diabetes management

AIMS

To examine the association between health insurance coverage, insulin management plans, and their impact on diabetes control in a pediatric type 1 diabetes mellitus clinic population.

METHODS

Retrospective cohort design drawn from the medical records of the Pediatric Endocrinology Clinic at the University of Louisville, Kentucky.

RESULTS

Out of 701 patients, 223 had public insurance, and 478 had private insurance. 77% of publically insured used two or three injections per day vs. 40% private. Conversely, 58% of privately insured used a multiple daily injection (MDI) plan or insulin pump (vs. 21%). 84% of MDI patients had private insurance with 93% using insulin pens compared with 38% of publically insured. Mean HbA1c was 8.6% for privately insured vs. 9.8% public, p<0.0001. Privately insured MDI and pump patients had the lowest HbA1cs.

CONCLUSIONS

Insurance type had a significant effect on the insulin management plan used and was the most significant factor in overall diabetes control. Limitations on insulin pen use and number of glucose test strips may play a role in the decreased use of MDI/insulin pumps by publicly insured patients. Addressing factors related to insurance type, including availability of resources, could substantially improve diabetes control in those with public insurance.

Managed care quality of care and plan choice in New York SCHIP

OBJECTIVE

To examine whether low-income parents of children enrolled in the New York State Children's Health Insurance Program (SCHIP) choose managed care plans with better quality of care.

DATA SOURCES

2001 New York SCHIP evaluation data; 2001 New York State Managed Care Plan Performance Report; 2000 New York State Managed Care Enrollment Report.

STUDY DESIGN

Each market was defined as a county. A final sample of 2,325 new enrollees was analyzed after excluding those in markets with only one SCHIP plan. Plan quality was measured using seven Consumer Assessment of Health Plans Survey (CAHPS) and three Health Plan Employer Data and Information Set (HEDIS) scores. A conditional logit model was applied with plan and individual/family characteristics as covariates.

PRINCIPLE FINDINGS

There were 30 plans in the 45 defined markets. The choice probability increased 2.5 percentage points for each unit increase in the average CAHPS score, and the association was significantly larger in children with special health care needs. However, HEDIS did not show any statistically significant association with plan choice.

CONCLUSIONS

Low-income parents do choose managed care plans with higher CAHPS scores for their newly enrolled children, suggesting that overall quality could improve over time because of the dynamics of enrollment.

Awareness and use of California's Paid Family Leave Insurance among parents of chronically ill children

CONTEXT

In 2004, California's Paid Family Leave Insurance Program (PFLI) became the first state program to provide paid leave to care for an ill family member.

OBJECTIVE

To assess awareness and use of the program by employed parents of children with special health care needs, a population likely to need leave.

DESIGN, SETTING, AND PARTICIPANTS

Telephone interviews with successive cohorts of employed parents before (November 21, 2003-January 31, 2004; n = 754) and after (November 18, 2005-January 31, 2006; n = 766) PFLI began, randomly sampled from 2 children's hospitals, one in California (with PFLI) and the other in Illinois (without PFLI). Response rates were 82% before and 81% after (California), and 80% before and 74% after (Illinois).

MAIN OUTCOME MEASURES

Taking leave, length of leave, unmet need for leave, and awareness and use of PFLI.

RESULTS

Similar percentages of parents at the California site reported taking at least 1 day of leave to care for their ill child before (295 [81%]) and after (327 [79%]) PFLI, taking at least 4 weeks before (64 [21%]) and after (74 [19%]) PFLI, and at least once in the past year not missing work despite believing their child's illness necessitated it before (152 [41%]) and after (156 [41%]) PFLI. Relative to Illinois, parents at the California site reported no change from before to after PFLI in taking at least 1 day of leave (difference of differences, -3%; 95% confidence interval [CI], -13% to 7%); taking at least 4 weeks of leave (1%; 95% CI, -9% to 10%); or not missing work, despite believing their child's illness necessitated it (-1%; 95% CI, -13% to 10%). Only 77 parents (18%) had heard of PFLI approximately 18 months after the program began, and only 20 (5%) had used it. Even among parents without other access to paid leave, awareness and use of PFLI were minimal.

CONCLUSIONS

Parents of children with special health care needs receiving care at a California hospital were generally unaware of PFLI and rarely used it. Among parents of children with special health care needs, taking leave in California did not increase after PFLI implementation compared with Illinois.

The impact of health insurance gaps on access to care among children with asthma in the United States

BACKGROUND

Health insurance coverage is important to help assure children appropriate access to medical care and preventive services. Insurance gaps could be particularly problematic for children with asthma, since appropriate preventive care for these children depends on frequent, consistent contacts with health care providers.

OBJECTIVE

The aim of this study was to determine the association between insurance gaps and access to care among a nationally representative sample of children with asthma.

METHODS

The National Survey of Children's Health provided parent-report data for 8097 children with asthma. We identified children with continuous public or continuous private insurance and defined 3 groups with gaps in insurance coverage: those currently insured who had a lapse in coverage during the prior 12 months (gained insurance), those currently uninsured who had been insured at some time during the prior 12 months (lost insurance), and those with no health insurance at all during the prior 12 months (full-year uninsured).

RESULTS

Thirteen percent of children had coverage gaps (7% gained insurance, 4% lost insurance, and 2% were full-year uninsured). Many children with gaps in coverage had unmet needs for care (7.4%, 12.8%, and 15.1% among the gained insurance, lost insurance, and full-year uninsured groups, respectively). In multivariate models, we found significant associations between insurance gaps and every indicator of poor access to care among this population.

CONCLUSIONS

Many children with asthma have unmet health care needs and poor access to consistent primary care, and lack of continuous health insurance coverage may play an important role. Efforts are needed to ensure uninterrupted coverage for these children.

Uninsurance among children whose parents are losing Medicaid coverage: Results from a statewide survey of Oregon families

CONTEXT

Thousands of adults lost coverage after Oregon's Medicaid program implemented cost containment policies in March 2003. Despite the continuation of comprehensive public health coverage for children, the percentage of uninsured children in the state rose from 10.1 percent in 2002 to 12.3 percent in 2004 (over 110,000 uninsured children). Among the uninsured children, over half of them were likely eligible for public health insurance coverage.

RESEARCH OBJECTIVE

To examine barriers low-income families face when attempting to access children's health insurance. To examine possible links between Medicaid cutbacks in adult coverage and children's loss of coverage.

DATA SOURCE/STUDY SETTING

Statewide primary data from low-income households enrolled in Oregon's food stamp program.

STUDY DESIGN

Cross-sectional analysis. The primary predictor variable was whether or not any adults in the household recently lost Medicaid coverage. The main outcome variables were children's current insurance status and children's insurance coverage gaps.

DATA COLLECTION

A mail-return survey instrument was designed to collect information from a stratified, random sample of households with children presumed eligible for publicly funded health insurance programs.

PRINCIPAL FINDINGS

Over 10 percent of children in the study population eligible for publicly funded health insurance programs were uninsured, and over 25 percent of these children had gaps in insurance coverage during a 12-month period. Low-income children who were most likely to be uninsured or have coverage gaps were Hispanic; were teenagers older than 14; were in families at the higher end of the income threshold; had an employed parent; or had a parent who was uninsured. Fifty percent of the uninsured children lived in a household with at least one adult who had recently lost Medicaid coverage, compared with only 40 percent of insured children (p=.040). Similarly, over 51 percent of children with a recent gap in insurance coverage had an adult in the household who lost Medicaid, compared with only 38 percent of children without coverage gaps (p<.0001). After adjusting for ethnicity, age, household income, and parental employment, children living in a household with an adult who lost Medicaid coverage after recent cutbacks had a higher likelihood of having no current health insurance (OR 1.44, 95 percent CI 1.02, 2.04), and/or having an insurance gap (OR 1.79, 95 percent CI 1.36, 2.36).

CONCLUSIONS

Uninsured children and those with recent coverage gaps were more likely to have adults in their household who lost Medicaid coverage after recent cutbacks. Although current fiscal constraints prevent many states from expanding public health insurance coverage to more parents, states need to be aware of the impact on children when adults lose coverage. It is critical to develop strategies to keep parents informed regarding continued eligibility and benefits for their children and to reduce administrative barriers to children's enrollment and retention in public health insurance programs.

Crowd-out in the State Children's Health Insurance Program (SCHIP): incidence, enrollee characteristics and experiences, and potential impact on New York's SCHIP

BACKGROUND

The extent to which the State Children's Health Insurance Program (SCHIP) crowds our private insurance is poorly understood.

OBJECTIVE

To assess the incidence of crowd-out and enrollee characteristics associated with crowd-out.

DATA

Parent telephone survey for 2,644 children after enrollment in NY SCHIP. MEASURES AND ANALYSES: Crowd-out is measured based on enrollee reports of coverage (and loss of coverage) before SCHIP. Multivariate logistic regression is used to relate crowd-out to enrollee characteristics.

PRINCIPAL FINDINGS

Only 7.1 percent of SCHIP enrollees dropped private coverage < or =6 months before SCHIP, suggesting relatively modest crowd-out. Crowd-out was associated with some enrollee traits including income, but not with health status.

IMPLICATIONS

Most movement from private to public insurance in NY was not crowd-out. Under current program structure in NY, crowd-out concerns should not dampen enthusiasm for SCHIP.

Delivering adolescent vaccinations in the medical home: a new era?

BACKGROUND

Medical homes are health care settings that offer continuous, comprehensive, accessible primary care; these settings generally involve pediatric and family physician practices or community health centers but can also involve gynecologists or internists.

OBJECTIVES

In this article, we review available evidence on the role of the medical home in optimizing adolescent immunization delivery, particularly with respect to health care utilization patterns and barriers to vaccinations in medical homes, and solutions.

METHODS

We conducted a systematic review of the existing immunization and adolescent literature and used a Delphi process to solicit opinions from content experts across the United States.

RESULTS

Most adolescents across the United States do have a medical home, and many pay a health care visit to their medical home within any given year. Barriers exist in regards to the receipt of adolescent immunizations, and they are related to the adolescent/family, health care provider, and health care system. Although few studies have evaluated adolescent vaccination delivery, many strategies recommended for childhood or adult vaccinations should be effective for adolescent vaccination delivery as well. These strategies include education of health care providers and adolescents/parents; having appropriate health insurance coverage; tracking and reminder/recall of adolescents who need vaccination; practice-level interventions to ensure that needed vaccinations are provided to eligible adolescents at the time of any health care visit; practice-level audits to measure vaccination coverage; and linkages across health care sites to exchange information about needed vaccinations. Medical homes should perform a quality improvement project to improve their delivery of adolescent vaccinations. Because many adolescents use a variety of health care sites, it is critical to effectively transfer vaccination information across health care settings to identify adolescents who are eligible for vaccinations and to encourage receipt of comprehensive preventive.

CONCLUSIONS

Medical homes are integral to both the delivery of adolescent immunizations and comprehensive adolescent preventive health care. Many strategies recommended for childhood and adult vaccinations should work for adolescent vaccinations and should be evaluated and implemented if they are successful. By incorporating evidence-based strategies and coordinating effectively with other health care sites used by adolescents, medical homes will be the pivotal settings for the delivery of adolescent vaccinations.

Improved Health Care Among Children With Special Health Care Needs After Enrollment Into the State Children’s Health Insurance Program

OBJECTIVE

To assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with special health care needs (CSHCN).

METHODS

Little is known about the impact of health insurance on CSHCN. Parents of a stratified random sample of new enrollees onto New York's SCHIP were interviewed by telephone at enrollment (n = 2644) and 1 year later (n = 2290, 87% response). At baseline, the cohort of CSHCN was defined by means of the standardized CSHCN screener instrument. The impact of SCHIP was assessed for CSHCN and for subgroups of CSHCN stratified by prior insurance (uninsured or insured) or type of chronic condition (physical or mental/behavioral). Access (having a usual source of care [USC], unmet medical needs); and quality (continuity of care at the USC, parent rating of quality of care or worry about child) were measured. Bivariate and multivariate analyses compared measures 1 year before SCHIP versus the year during SCHIP.

RESULTS

A total of 398 (17%) of 2290 children had special health care needs identified at baseline. Enrollment onto SCHIP was generally associated with improved access: unmet needs for prescription medications declined 3-fold for all subgroups (eg, 36% to 9% among the previously uninsured) and unmet needs for specialty care declined >4-fold among CSHCN who were previously insured (48% to 10%) or had mental/behavioral conditions (32% to 2%; all P < .05). Enrollment was associated with improved continuity with the USC, parent-reported quality of care, and worry, irrespective of prior insurance or type of chronic condition (P < .05).

CONCLUSIONS

Enrollment onto New York's SCHIP improved medical care for CSHCN.