Barriers to enrollment in a state child health insurance program

Association of uninsured status and rurality with risk of financial toxicity after pediatric trauma

BACKGROUND

Pediatric traumatic injury is associated with long-term morbidity as well as substantial economic burden. Prior work has labeled the catastrophic out-of-pocket medical expenses borne by patients as financial toxicity. We hypothesized uninsured rural patients to be vulnerable to exorbitant costs and thus at greatest risk of financial toxicity.

METHODS

Pediatric patients (<18 years) experiencing traumatic injury were identified in the 2016-2019 National Inpatient Sample. Patients were considered to be at risk of financial toxicity if their hospitalization cost exceeded 40% of post-subsistence income. Individual family income was computed using a gamma distribution probability density function with parameters derived from publicly available US Census Bureau data, in accordance with prior work. A multivariable logistic regression was developed to assess factors associated with risk of financial toxicity.

RESULTS

Of an estimated 225,265 children identified for study, 34,395 (15.3%) were Rural. Rural patients were more likely to experience risk of financial toxicity (29.1 vs 22.2%, P < .001) compared to Urban patients. After adjustment, rurality (reference: urban status; adjusted odds ratio 1.45, 95% confidence interval 1.36-1.55) and uninsured status (reference: private; adjusted odds ratio 1.85, 95% confidence interval 1.67-2.05) remained linked to increased odds of risk of financial toxicity. Specifically among those with private insurance, Rural patients experienced markedly higher predicted risk of financial toxicity, relative to Urban.

CONCLUSION

Our findings suggest a complex interplay between rural status and insurance type in the prediction of risk of financial toxicity after pediatric trauma. To target policy interventions, future studies should characterize the patients and communities at greatest risk of financial devastation among rural pediatric trauma patients.

Design, methods, and baseline characteristics of the Kids' Health Insurance by Educating Lots of Parents (Kids' HELP) trial: a randomized, controlled trial of the effectiveness of parent mentors in insuring uninsured minority children

BACKGROUND & OBJECTIVES

Six million US children have no health insurance, and substantial racial/ethnic disparities exist. The design, methods, and baseline characteristics are described for Kids' Health Insurance by Educating Lots of Parents (Kids' HELP), the first randomized, clinical trial of the effectiveness of Parent Mentors (PMs) in insuring uninsured minority children.

METHODS & RESEARCH DESIGN

Latino and African-American children eligible for but not enrolled in Medicaid/CHIP were randomized to PMs, or a control group receiving traditional Medicaid/CHIP outreach. PMs are experienced parents with ≥1 Medicaid/CHIP-covered children. PMs received two days of training, and provide intervention families with information on Medicaid/CHIP eligibility, assistance with application submission, and help maintaining coverage. Primary outcomes include obtaining health insurance, time interval to obtain coverage, and parental satisfaction. A blinded assessor contacts subjects monthly for one year to monitor outcomes.

RESULTS

Of 49,361 candidates screened, 329 fulfilled eligibility criteria and were randomized. The mean age is seven years for children and 32 years for caregivers; 2/3 are Latino, 1/3 are African-American, and the mean annual family income is $21,857. Half of caregivers were unaware that their uninsured child is Medicaid/CHIP eligible, and 95% of uninsured children had prior insurance. Fifteen PMs completed two-day training sessions. All PMs are female and minority, 60% are unemployed, and the mean annual family income is $20,913. Post-PM-training, overall knowledge/skills test scores significantly increased, and 100% reported being very satisfied/satisfied with the training.

CONCLUSIONS

Kids' HELP successfully reached target populations, met participant enrollment goals, and recruited and trained PMs.

Community health events for enrolling uninsured into public health insurance programs: implications for health reform

OBJECTIVES

To determine whether enrollment events may serve as a venue to identify eligible individuals, enroll them into health insurance programs, and educate them about the changes the Patient Protection and Affordable Care Act will bring about.

METHODS

More than 2900 surveys were administered to attendees of 7 public health insurance enrollment events in California. Surveys were used to identify whether participants had any change in understanding of health reform after participating in the event.

RESULTS

More than half of attendees at nearly all events had no knowledge about health reform before attending the event. On average, more than 80% of attendees knew more about health reform following the event and more than 80% believed that the law would benefit their families.

CONCLUSIONS

Enrollment events can serve as an effective method to educate the public on health reform. Further research is recommended to explore in greater detail the impact community enrollment events can have on expanding public understanding of health reform.

Assessing barriers to health insurance and threats to equity in comparative perspective: the Health Insurance Access Database

BACKGROUND

Typologies traditionally used for international comparisons of health systems often conflate many system characteristics. To capture policy changes over time and by service in health systems regulation of public and private insurance, we propose a database containing explicit, standardized indicators of policy instruments.

METHODS

The Health Insurance Access Database (HIAD) will collect policy information for ten OECD countries, over a range of eight health services, from 1990-2010. Policy indicators were selected through a comprehensive literature review which identified policy instruments most likely to constitute barriers to health insurance, thus potentially posing a threat to equity. As data collection is still underway, we present here the theoretical bases and methodology adopted, with a focus on the rationale underpinning the study instruments.

RESULTS

These harmonized data will allow the capture of policy changes in health systems regulation of public and private insurance over time and by service. The standardization process will permit international comparisons of systems' performance with regards to health insurance access and equity.

CONCLUSION

This research will inform and feed the current debate on the future of health care in developed countries and on the role of the private sector in these changes.

State strategies to reduce the number of uninsured children

We present a local and state phased approach for expanding coverage and improving the health care system for children. During the first phase, state regulatory reforms can be instituted to enhance the ability of Medicaid and State Child Health Insurance Plan (SCHIP) programs to provide measurable, high-quality clinical care that is patient-centered, safe, effective, timely, and efficient. The second phase can implement regulatory and legislative reforms that build program awareness in the community and streamline the enrollment process to maximize the enrollment of eligible uninsured children into a state's Medicaid/SCHIP program. The third phase involves a legislative expansion of income eligibility for SCHIP together with state-financed programs for legal immigrant children and foreign national children. The fourth phase considers legislative reforms to make family coverage more affordable to slow the erosion of employer-sponsored family insurance coverage, especially in small businesses.

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.

Universal coverage for children: alternatives, key issues, and political opportunities

This paper describes four alternatives for expanding childhood insurance coverage, discusses key health policy issues, and assesses the political possibilities for enacting universal coverage. Alternatives are (1) a single federal child health program for all children; (2) a hybrid federal child health program (replacing Medicaid and the State Children's Health Insurance Program [SCHIP]), combined with employer coverage; (3) a new federal wraparound program for the uninsured (that keeps the existing Medicaid program); and (4) expansion of SCHIP. Key policy issues include the type of universal coverage, use of competing commercial health plans, financing, employer and individual mandates, and the definition of benefits.

How Medicaid and the State Children's Health Insurance Program can do a better job of insuring uninsured children: the perspectives of parents of uninsured Latino children

BACKGROUND

Eight and a half million US children are uninsured, despite the 1997 enactment of the State Children's Health Insurance Program (SCHIP) with $39 billion in funding, and Latinos continue to be the most uninsured racial/ ethnic group, with 24% (3 million) uninsured. Why SCHIP and Medicaid have not been more successful insuring uninsured children is unclear.

OBJECTIVE

To identify reasons why parents are unable to insure uninsured Latino children in a state where all low-income children are eligible for insurance.

METHODS

Bilingual focus groups of parents of uninsured Latino children from Boston communities with the highest proportion of uninsured Latino children.

RESULTS

The 30 parents interviewed in 6 focus groups had a mean age of 39 years; 63% never graduated high school and 33% were US citizens. The mean age of their children was 12 years, and the median annual family income was $9120. Parents reported 52 barriers to insuring children. Major obstacles included lack of knowledge about the application process and eligibility (especially misconceptions about work, welfare, and immigration), language barriers, immigration issues, income, hassles, pending decisions, family mobility, misinformation from insurance representatives (being told insurance is too expensive and parents must work), and system problems (including lost applications, discrimination, and excessive waits). Parents universally agreed case managers would be helpful in insuring uninsured children.

CONCLUSIONS

Even in a state where all low-income children are eligible for health insurance, current SCHIP and Medicaid outreach and enrollment are not effectively reaching uninsured Latino children. Parents need better information about programs, eligibility, and the application process, and a more efficient, user-friendly system.

Unworried parents of well children: a look at uninsured children who reportedly do not need health insurance

OBJECTIVES

We examined the characteristics of uninsured children from low-income households whose parents reported that health insurance coverage was not needed.

METHODS

With data from the 2001 National Survey of Children With Special Health Care Needs, we used logistic-regression analyses to investigate the odds of reporting that uninsured children do not need insurance for various sociodemographic groups and children of varying health status. We also explored the odds of health care use, awareness of Medicaid and the State Children's Health Insurance Program (SCHIP), and desire to enroll according to the reported need for insurance.

RESULTS

Parents of 6.8% of uninsured children from low-income households reported that their children did not need insurance. Rates were highest for American Indian/Alaska Native children (15.2%) and children whose parents completed the interview in a non-English language (10.6%). Rates were lowest for children with special health care needs (2.8%) and children with > or =7 school absences attributable to illness or injury in the past year (2.6%). Relative to children with another reason for lacking insurance, children who reportedly did not need insurance were less likely to have needed (adjusted odds ratio: 0.49) or used (adjusted odds ratio: 0.45) health care services in the past year and their parents were less likely to have heard of Medicaid or SCHIP (adjusted odds ratio: 0.58) or to have a desire to enroll their children if their children were eligible for Medicaid or SCHIP (adjusted odds ratio: 0.25).

CONCLUSIONS

Increasing participation among uninsured children whose parents do not perceive a need for insurance coverage may require more than simply increasing knowledge about the availability of public insurance programs.

Changes in access, utilization, and quality of care after enrollment into a state child health insurance plan

BACKGROUND

There currently are few published data evaluating the effect of State Children's Health Insurance Programs on health care outcome measures in children. Colorado's Child Health Plan Plus (CHP+) is a non-Medicaid State Children's Health Insurance Program that began enrollment in April 1998. The objectives of this study were to compare reported (1) access to care, (2) utilization of health care, and (3) quality of care during the year before and the first year after enrollment into CHP+.

METHODS

We interviewed 480 randomly selected families by telephone 2 months after their first enrollment into CHP+ (September 1999 to January 2000) and, again, 1 year later. We used generalized linear models to examine the effect of enrollment on health care access, utilization, and quality while controlling for type of previous insurance, length of time uninsured before enrollment, race/ethnicity, and age.

RESULTS

Regarding access to care, the percentage of families who reported a usual site of preventive care did not change significantly, but families reported more often being able to see providers as soon as desired for routine care (incidence ratio [IR]: 2.03; 95% confidence interval [CI]: 1.37-3.02]), for care when sick or injured (IR: 2.77; 95% CI: 1.85-4.16), for specialty care (IR: 1.96; 95% CI: 1.16-3.32), and for all health care (IR: 2.35; 95% CI: 1.81-3.07). Unmet medical needs decreased after versus before enrollment for prescription medications (IR: 0.38; 95% CI: 0.26-0.55), mental health care (IR: 0.63; 95% CI: 0.40-0.97), prescription glasses (IR: 0.44; 95% CI: 0.29-0.65), and dental care (IR: 0.59; 95% CI: 0.47-0.76). Regarding utilization, the proportion who saw a provider for routine care in the past year increased (IR: 1.39; 95% CI: 1.06-1.83), but reported visits for sick, specialty, and emergency department care and hospitalizations did not increase. Regarding quality of care, the proportion who rated their health care as "best" increased (RI: 1.31; 95% CI: 1.04-1.66) after versus before enrollment.

CONCLUSIONS

Families who were newly enrolled into CHP+ perceived dramatic increases in access to all types of care and decreases in unmet medical needs, no increase in utilization of emergency department or hospitalization services, and improved overall quality of care in the year after enrollment into CHP+.

Private Dental and Prescription-Drug Coverage in Children: Data From the Medical Expenditure Panel Survey

OBJECTIVE

Most studies on health insurance have examined primarily basic medical insurance coverage; few have looked at supplemental insurance and/or dental-insurance coverage. Prescription-drug and dental-insurance coverage are becoming increasingly important due to continued increase in health care costs and changes in cost-sharing structure of health plans. This study examined prescription-drug coverage and dental-insurance coverage in the context of overall insurance coverage.

METHOD

This study utilized the Household Component File from the 2000 Medical Expenditure Panel Survey (MEPS), a national survey on medical care conducted by the Agency for Healthcare Research and Quality (AHRQ). Univariate and bivariate analyses were performed to provide estimates on children's prescription-drug and dental-insurance coverage. Multivariate logistic regression analyses were conducted to identify demographic and socioeconomic factors that influence coverage.

RESULTS

In 2000, 68.5% of US children had private insurance, 22.2% had public insurance, and 9.3% were uninsured. Among children with private insurance, only 56.9% had dental-insurance coverage and 76.3% had prescription-drug coverage. Family income level, maternal education, and race were significant predictors of dental insurance and prescription-drug coverage.

CONCLUSION

Although significant strides have been made to insure US children, a large percentage of children still do not have comprehensive coverage. Even among privately insured children, many are without dental or prescription-drug coverage. Those who were poor, minority, and with low maternal education had lower likelihood of dental and prescription-drug coverage.

An examination of enrollment of children in public health insurance in New York City through facilitated enrollment

A cohort of families was followed through the enrollment process for Medicaid and Child Health Plus in New York City to determine success in enrollment and the time it takes to enroll. Families were recruited into the study by enrollers in community-based organizations and managed-care organizations. In our sample, three of four families were successful in enrolling. On average, it took 60 days to attain insurance. Most applicants (76%) received some sort of assistance from enrollers, most frequently in determining which documents were needed (74%). In a multivariable analysis, some of the factors associated with success in enrollment included being assisted by a community-based facilitated enroller, knowledge of required documents, and having lost a child's other health insurance.

Disenrollment From a State Child Health Insurance Plan: Are Families Jumping S(c)HIP?

BACKGROUND

Colorado's Child Health Plan Plus (CHP+) is a non-Medicaid state child health plan that began enrollment in April 1998. Families are disenrolled 12 months after enrollment if they fail to re-enroll.

OBJECTIVE

To assess insurance coverage before and 1 year after initial enrollment in CHP+; reasons for disenrollment; and factors associated with re-enrollment.

DESIGN/METHODS

We interviewed 480 randomly selected families 2 months after initial enrollment into CHP+ (September 1999 through January 2000) and 1 year later.

RESULTS

Prior to CHP+, 38% of families had Medicaid (MK), 35% were privately insured (PI), 6% were uninsured (UI), and 20% had other/unknown insurance. After the 12 months, 34% were re-enrolled, 16% got other insurance (6% MK, 10% PI/other), 4% had children older than 18 years, and 46% were UI (9% had intentionally and 37% had unintentionally disenrolled from CHP+). All unintentionally disenrolled families were planning to re-enroll and 90% still appeared eligible. In multivariate analysis, having a primary care provider prior to enrollment was associated with re-enrollment (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1 to 2.6), but having problems with the application process impeded re-enrollment (OR 0.7, 95% CI 0.6 to 0.9).

CONCLUSIONS

Only about a third of families eligible for State Children's Health Insurance Program successfully re-enrolled before their termination date. Institution of a passive renewal process would decrease unnecessary disenrollment in eligible families.

The first 2 years of a state child health insurance plan: whom are we reaching?

OBJECTIVE

The Colorado Child Health Plan Plus is a non-Medicaid state Child Health Insurance Plan. The objective of this study was to compare early enrolling (EE) children with uninsured children in low-income families (ULI) with respect to 1) sociodemographic factors and previous insurance, 2) health status, and 3) previous health care access and utilization.

METHODS

Cross-sectional telephone surveys were conducted during 1999 of 1) randomly selected EE children (n = 711) and 2) ULI children identified by random-dial survey (n = 105).

RESULTS

Enrolling children were less likely to be Hispanic (32.7% vs 55.2%); 5.5% of EE versus 27.6% of ULI children had never been insured. Prevalence of chronic conditions was similar (16.2% of EE vs 13.5% of ULI children), but learning/behavioral difficulties (9.7% of EE vs 18.6% of ULI) and fair/poor health (5.4% of EE vs 17.2% of ULI) were higher for uninsured children. In the previous year, 88.2% of EE versus 66.1% of ULI children had a usual source of care. The mean number of preventive visits was similar (1.4 vs 1.2), but the EE group reported a higher mean number of sick visits (2.0 vs 1.1), emergency visits (0.48 vs 0.15), and hospitalizations (0.09 vs 0.02).

CONCLUSIONS

In the first 2 years of the program, Child Health Plan Plus is not yet reaching the "hard-to-reach" but, rather, disproportionately high numbers of non-Hispanic children who already have a usual source of care and recent insurance. EE children did not have higher rates of chronic conditions but did demonstrate higher utilization before enrollment, possibly reflecting patterns of enrollment into the program.

Why are some children still uninsured?

INTRODUCTION

Nationally, 24% of low-income children remain uninsured after the implementation of the State Children's Health Insurance Program (SCHIP).

METHOD

The purpose of this study was to understand why children remain uninsured by comparing children with insurance to those without it. Using a cross-sectional survey design, 392 low-income parents were interviewed.

RESULTS

There were distinct profiles for the privately insured, Medicaid-insured and uninsured groups. Statistically significant differences were found across the three groups in income, working status of the adults, education, health status of the adult and child, and in the utilization of health care. Parents of the uninsured children were less knowledgeable about the application process.

DISCUSSION

Parents of uninsured children face multiple life challenges that may interfere with the enrollment process. Health problems, work schedules, and lack of knowledge may all need to be addressed before we can decrease the number of uninsured children in our nation.