Obtaining health care services for low-income children: a hierarchy of needs

Special supplemental nutrition programme for women, infants and children participation and unmet health care needs among young children

BACKGROUND

Research shows that the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programme improves the nutrition and health of low-income families. Recent studies have also shown that WIC improves access to health care services and use. However, no studies have reported whether WIC reduces unmet health care needs in young children.

METHODS

This is a retrospective study of 2810 mostly low-income urban mothers and their five-year-old children in the Fragile Families and Child Wellbeing Study. Mothers reported whether they received any WIC benefits since the child turned three. Unmet health care needs were operationalized through three outcomes: not having a place for routine care, not having seen a doctor for a regular checkup in the past year, and never having had a dental checkup.

RESULTS

In adjusted logistic regressions, children in families receiving WIC benefits were less likely to not have a place for routine care (odds ratio = 0.54, 95% CI: 0.32, 0.93), and less likely to never have had a dental check-up (odds ratio = 0.75, 95% CI: 0.58-0.97). There was no association between receiving WIC benefits and the child not having a regular checkup in the past year.

CONCLUSIONS

In this study of urban children, receiving WIC benefits was associated with a lower risk of unmet health care needs. Given that only half of eligible families receive WIC benefits, the programme has the potential to reduce unmet health care needs for a large number of children of eligible families not enrolled in the programme.

Fluoride Prescribing Behaviors for Medicaid-Enrolled Children in Oregon

INTRODUCTION

This study aims to examine physician and dentist fluoride prescription patterns and identify the factors associated with fluoride prescriptions for Medicaid-enrolled children. The hypothesis is that dentists will be the primary prescribers of fluoride and that caries risk factors will be associated with fluoride prescriptions.

METHODS

Data were analyzed for Oregon children aged 0-17 years enrolled in Medicaid for ≥300 days in both 2016 and 2017. The outcome variable was receiving a fluoride prescription in 2017. A 2-tailed chi-square test was used to assess fluoride prescribing differences between physicians and dentists. Multivariable logistic regression models were used to examine the likelihood of receiving a fluoride prescription in 2017 and to generate ORs. Model covariates included child's age, sex, race, ethnicity, Medicaid plan type, previous fluoride prescription, previous restorative dental treatment, and water fluoridation status.

RESULTS

Of 200,169 Medicaid-enrolled children, 6.7% (n=13,337) received fluoride prescriptions. Physicians were >3 times as likely to prescribe fluoride as dentists (73.4% vs 23.0%, p<0.001). Children with a history of fluoride prescriptions (OR=14.30, p<0.001) and any restorative dental treatment (OR=1.58, p<0.001) were significantly more likely to receive a fluoride prescription, whereas children living in areas with water fluoridation were significantly less likely (OR=0.50, p=0.01).

CONCLUSIONS

Physicians play an important role in prescribing fluoride to Medicaid-enrolled children, especially those at increased dental caries risk. Additional research is needed on strategies to ensure that all high-risk children have an opportunity to benefit from prescription fluoride.

Disparities in Biomarkers for Patients With Diabetes After the Affordable Care Act

BACKGROUND

Racial and ethnic minorities are disproportionately affected by diabetes and at greater risk of experiencing poor diabetes-related outcomes compared with non-Hispanic whites. The Affordable Care Act (ACA) was implemented to increase health insurance coverage and reduce health disparities.

OBJECTIVE

Assess changes in diabetes-associated biomarkers [hemoglobin A1c (HbA1c) and low-density lipoprotein] 24 months pre-ACA to 24 months post-ACA Medicaid expansion by race/ethnicity and insurance group.

RESEARCH DESIGN

Retrospective cohort study of community health center (CHC) patients.

SUBJECTS

Patients aged 19-64 with diabetes living in 1 of 10 Medicaid expansion states with ≥1 CHC visit and ≥1 HbA1c measurement in both the pre-ACA and the post-ACA time periods (N=13,342).

METHODS

Linear mixed effects and Cox regression modeled outcome measures.

RESULTS

Overall, 33.5% of patients were non-Hispanic white, 51.2% Hispanic, and 15.3% non-Hispanic black. Newly insured Hispanics and non-Hispanic whites post-ACA exhibited modest reductions in HbA1c levels, similar benefit was not observed among non-Hispanic black patients. The largest reduction was among newly insured Hispanics versus newly insured non-Hispanic whites (P<0.05). For the subset of patients who had uncontrolled HbA1c (HbA1c≥9%) within 3 months of the ACA Medicaid expansion, non-Hispanic black patients who were newly insured gained the highest rate of controlled HbA1c (hazard ratio=2.27; 95% confidence interval, 1.10-4.66) relative to the continuously insured group.

CONCLUSIONS

The impact of the ACA Medicaid expansion on health disparities is multifaceted and may differ across racial/ethnic groups. This study highlights the importance of CHCs for the health of minority populations.

Current status of scoliosis school screening: targeted screening of underserved populations may be the solution

OBJECTIVES

The growing body of evidence documenting the effectiveness of brace treatment for scoliosis has renewed interest in potential benefits of early detection through school screening. We aimed to assess the prevalence and identify barriers of screening. We hypothesized that school screening is more frequent in schools that have a nurse on staff compared to schools without nurse on staff.

STUDY DESIGN

A questionnaire survey.

METHODS

All schools located in four counties in Louisiana, United States of America comprising the New Orleans metropolitan area between September 2015 and January 2016 were contacted by phone to assess rates of scoliosis screening, report the availability of a school nurse, and specify barriers if screening was not performed.

RESULTS

Two hundred and ninety-one schools responded to the survey including 152 public, 30 charter, and 109 private schools (101 had religious affiliation). A staff nurse was available in 180 schools (61.8%). Only 21 schools (7.2%) performed scoliosis screening. The majority were charter schools (11 schools), while six were private and four were public (P < 0.0001). Of these 21 schools, 16 (76.2%) had a nurse on staff while five schools did not (P = 0.16). Lack of a referral pathway in the event of a positive screen was the most common barrier to performing scoliosis screening.

CONCLUSION

Scoliosis screening is infrequent in the examined school districts. Efforts to support school screening can facilitate clear referral pathways for schools in the event of a positive screen. These findings suggest a potential need for different pathway of scoliosis screening. Pediatricians and family physicians can assist with scoliosis screening during the annual visit. While universal screening is overburdensome and likely unnecessary, targeted screening of underserved populations may prove to be beneficial. Further investigation should include assessment of the economic viability of targeted screening programs.

LEVEL OF EVIDENCE

IV.

The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers

OBJECTIVE

To (1) compare clinic-level uninsured, Medicaid-insured, and privately insured visit rates within and between expansion and nonexpansion states before and after the Affordable Care Act (ACA) Medicaid expansion among the 3 cohorts of patient populations; and (2) assess whether there was a change in clinic-level overall, primary care visits, preventive care visits, and diabetes screening rates in expansion versus nonexpansion states from pre-ACA to post-ACA Medicaid expansion.

METHODS

Electronic health record data on nonpregnant patients aged 19 to 64 years, with ≥1 ambulatory visit between 01/01/2012 and 12/31/2015 (n = 483,912 in expansion states; n = 388,466 in nonexpansion states) from 198 primary care community health centers were analyzed. Using a difference-in-difference methodology, we assessed changes in visit rates pre-ACA versus post-ACA among a cohort of patients with diabetes, prediabetes, and no diabetes.

RESULTS

Rates of uninsured visits decreased for all cohorts in expansion and nonexpansion states. For all cohorts, Medicaid-insured visit rates increased significantly more in expansion compared with nonexpansion states, especially among prediabetic patients (+71%). In nonexpansion states, privately insured visit rates more than tripled for the prediabetes cohort and doubled for the diabetes and no diabetes cohorts. Rates for glycosylated hemoglobin screenings increased in all groups, with the largest changes among no diabetes (rate ratio, 2.26; 95% CI, 1.97-2.56) and prediabetes cohorts (rate ratio, 2.00; 95% CI, 1.80-2.19) in expansion states.

CONCLUSION

The ACA reduced uninsurance and increased access to preventive care for vulnerable patients, especially those with prediabetes. These findings are important to consider when making decisions regarding altering the ACA.

The Impacts of Medicaid Expansion on Rural Low-Income Adults: Lessons From the Oregon Health Insurance Experiment

Medicaid expansions through the Affordable Care Act began in January 2014, but we have little information about what is happening in rural areas where provider access and patient resources might be more limited. In 2008, Oregon held a lottery for restricted access to its Medicaid program for uninsured low-income adults not otherwise eligible for public coverage. The Oregon Health Insurance Experiment used this opportunity to conduct the first randomized controlled study of a public insurance expansion. This analysis builds off of previous work by comparing rural and urban survey outcomes and adds qualitative interviews with 86 rural study participants for context. We examine health care access and use, personal finances, and self-reported health. While urban and rural populations have unique demographic profiles, rural populations appear to have benefited from Medicaid as much as urban. Qualitative interviews revealed the distinctive challenges still facing low-income uninsured and newly insured rural populations.

Healthcare Utilization After a Children's Health Insurance Program Expansion in Oregon

OBJECTIVE

The future of the Children's Health Insurance Program (CHIP) is uncertain after 2017. Survey-based research shows positive associations between CHIP expansions and children's healthcare utilization. To build on this prior work, we used electronic health record (EHR) data to assess temporal patterns of healthcare utilization after Oregon's 2009-2010 CHIP expansion. We hypothesized increased post-expansion utilization among children who gained public insurance.

METHODS

Using EHR data from 154 Oregon community health centers, we conducted a retrospective cohort study of pediatric patients (2-18 years old) who gained public insurance coverage during the Oregon expansion (n = 3054), compared to those who were continuously publicly insured (n = 10,946) or continuously uninsured (n = 10,307) during the 2-year study period. We compared pre-post rates of primary care visits, well-child visits, and dental visits within- and between-groups. We also conducted longitudinal analysis of monthly visit rates, comparing the three insurance groups.

RESULTS

After Oregon's 2009-2010 CHIP expansions, newly insured patients' utilization rates were more than double their pre-expansion rates [adjusted rate ratios (95 % confidence intervals); increases ranged from 2.10 (1.94-2.26) for primary care visits to 2.77 (2.56-2.99) for dental visits]. Utilization among the newly insured spiked shortly after coverage began, then leveled off, but remained higher than the uninsured group.

CONCLUSIONS

This study used EHR data to confirm that CHIP expansions are associated with increased utilization of essential pediatric primary and preventive care. These findings are timely to pending policy decisions that could impact children's access to public health insurance in the United States.

Using mixed methods effectively in prevention science: designs, procedures, and examples

There is growing interest in using a combination of quantitative and qualitative methods to generate evidence about the effectiveness of health prevention, services, and intervention programs. With the emerging importance of mixed methods research across the social and health sciences, there has been an increased recognition of the value of using mixed methods for addressing research questions in different disciplines. We illustrate the mixed methods approach in prevention research, showing design procedures used in several published research articles. In this paper, we focused on two commonly used mixed methods designs: concurrent and sequential mixed methods designs. We discuss the types of mixed methods designs, the reasons for, and advantages of using a particular type of design, and the procedures of qualitative and quantitative data collection and integration. The studies reviewed in this paper show that the essence of qualitative research is to explore complex dynamic phenomena in prevention science, and the advantage of using mixed methods is that quantitative data can yield generalizable results and qualitative data can provide extensive insights. However, the emphasis of methodological rigor in a mixed methods application also requires considerable expertise in both qualitative and quantitative methods. Besides the necessary skills and effective interdisciplinary collaboration, this combined approach also requires an open-mindedness and reflection from the involved researchers.

Receipt of diabetes preventive services differs by insurance status at visit

BACKGROUND

Lack of insurance is associated with suboptimal receipt of diabetes preventive care. One known reason for this is an access barrier to obtaining healthcare visits; however, little is known about whether insurance status is associated with differential rates of receipt of diabetes care during visits.

PURPOSE

To examine the association between health insurance and receipt of diabetes preventive care during an office visit.

METHODS

This retrospective cohort study used electronic health record and Medicaid data from 38 Oregon community health centers. Logistic regression was used to test the association between insurance and receipt of four diabetes services during an office visit among patients who were continuously uninsured (n=1,117); continuously insured (n=1,466); and discontinuously insured (n=336) in 2006-2007. Generalized estimating equations were used to account for within-patient correlation. Data were analyzed in 2013.

RESULTS

Overall, continuously uninsured patients had lower odds of receiving services at visits when due, compared to those who were continuously insured (AOR=0.73, 95% CI=0.66, 0.80). Among the discontinuously insured, being uninsured at a visit was associated with lower odds of receipt of services due at that visit (AOR=0.77, 95% CI=0.64, 0.92) than being insured at a visit.

CONCLUSIONS

Lack of insurance is associated with a lower probability of receiving recommended services that are due during a clinic visit. Thus, the association between being uninsured and receiving fewer preventive services may not be completely mediated by access to clinic visits.

Understanding how low-income families prioritize elements of health care access for their children via the optimal care model

Background

Insurance coverage alone does not guarantee access to needed health care. Few studies have explored what “access” means to low-income families, nor have they examined how elements of access are prioritized when availability, affordability, and acceptability are not all achievable. Therefore, we explored low-income parents’ perspectives on accessing health care.

Methods

In-depth interviews with a purposeful sample of 29 Oregon parents who responded to a previously administered statewide survey about health insurance. Transcribed interviews were analyzed by a multidisciplinary team using a standard iterative process.

Results

Parents highlighted affordability and limited availability as barriers to care; a continuous relationship with a health care provider helped them overcome these barriers. Parents also described the difficult decisions they made between affordability and acceptability in order to get the best care they could for their children. We present a new conceptual model to explain these experiences accessing care with health insurance: the Optimal Care Model. The model shows a transition from optimal care to a breaking point where affordability becomes the driving factor, but the care is perceived as unacceptable because it is with an unknown provider.

Conclusions

Even when covered by health insurance, low-income parents face barriers to accessing health care for their children. As the Affordable Care Act and other policies increase coverage options across the United States, many Americans may experience similar barriers and facilitators to health care access. The Optimal Care Model provides a useful construct for better understanding experiences that may be encountered when the newly insured attempt to access available, acceptable, and affordable health care services.

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

Parent's insurance coverage is associated with children's insurance status, but little is known about whether a parent's coverage continuity affects a child's coverage. This study assesses the association between an adult's insurance continuity and the coverage status of their children. We used data from a subgroup of participants in the Oregon Health Care Survey, a three-wave, 30-month prospective cohort study (n = 559). We examined the relationship between the length of time an adult had health insurance coverage and whether or not all children in the same household were insured at the end of the study. We used a series of univariate and multivariate logistic regression models to identify significant associations and the rho correlation coefficient to assess collinearity. A dose response relationship was observed between continuity of adult coverage and the odds that all children in the household were insured. Among adults with continuous coverage, 91.4% reported that all children were insured at the end of the study period, compared to 83.7% of adults insured for 19-27 months, 74.3% of adults insured for 10-18 months, and 70.8% of adults insured for fewer than 9 months. This stepwise pattern persisted in logistic regression models: adults with the fewest months of coverage, as compared to those continuously insured, reported the highest odds of having uninsured children (adjusted odds ratio 7.26, 95% confidence interval 2.75, 19.17). Parental health insurance continuity is integral to maintaining children's insurance coverage. Policies to promote continuous coverage for adults will indirectly benefit children.

Why do some eligible families forego public insurance for their children? A qualitative analysis

BACKGROUND AND OBJECTIVES

Central to health insurance reform discussions was the recurring question: why are eligible children not enrolled in public insurance programs? We interviewed families with children eligible for public insurance to (1) learn how they view available services and (2) understand their experiences accessing care.

METHODS

Semi-structured, in-depth interviews with 24 parents of children eligible for public coverage but not continuously enrolled were conducted. We used a standard iterative process to identify themes, followed by immersion/crystallization techniques to reflect on the findings.

RESULTS

Respondents identified four barriers: (1) confusion about insurance eligibility and enrollment, (2) difficulties obtaining public coverage and/or services, (3) limited provider availability, and (4) non-covered services and/or coverage gaps. Regardless of whether families had overcome these barriers, all had experienced stigma associated with needing and using public assistance. There was not just one point in the process where families felt stigmatized. It was, rather, a continual process of stigmatization. We present a theoretical framework that outlines how families continually experience stigma when navigating complex systems to obtain care: when they qualify for public assistance, apply for assistance, accept the assistance, and use the public benefit. This framework is accompanied by four illustrative archetypes.

CONCLUSIONS

This study provides further insight into why some families forego available public services. It suggests the need for a multi-pronged approach to improving access to health care for vulnerable children, which may require going beyond incremental changes within the current system.

Paid sick days and health care use: an analysis of the 2007 national health interview survey data

BACKGROUND

In identifying factors of health care use, past research has focused on individual-level characteristics or on the health care system itself. This study investigates whether access to paid sick days, an amenable environmental factor outside the health care system, is associated with primary and emergency care use.

METHODS

A nationally representative sample of 14,302 U.S. working adults extracted from the 2007 National Health Interview Survey data was used. Multiple logistic regressions were performed, controlling for demographic variables, health conditions and status, and access to health care.

RESULTS

Workers with lower socioeconomic status, poorer health status, or without health insurance or regular places for care were more likely to lack paid sick days than higher-status workers. For all U.S. working adults, access to paid sick days benefits was significantly associated with increased use of outpatient care but not with reduced use of ER. For U.S. working adults with health insurance coverage, access to paid sick days benefits was significantly associated with increased use of outpatient care and reduced use of emergency care.

CONCLUSIONS

A public policy mandating paid sick days may help facilitate timely access to primary care, reduce avoidable emergency care use, and reduce health disparities among workers.

Educaid: what if the US systems of education and health care were more alike?

What if access to an education in the United States required insurance, leaving millions of children without a school? Would public insurance for education--Educaid look like public insurance for medical care--Medicaid? This essay describes a fictional education system analogous to our current health care system as a means to highlight some of US health care's failings. It incorporates real comments from parents whom we have interviewed about their experiences gaining access to health care services for their children. My purpose is to challenge each reader to consider the future for both the US education and health care systems, the urgent need for reform, and how major reforms might affect our children.