Addressing coverage gaps for low-income parents

Annual Economic Burden of Productivity Losses Among Adult Survivors of Childhood Cancers

BACKGROUND AND OBJECTIVES

Although adult survivors of childhood cancers have poorer health and greater health limitations than other adults, substantial gaps remain in understanding the economic consequences of surviving childhood cancer. Therefore, we estimated the economic burden of productivity losses among adult survivors of childhood cancers.

METHODS

We examined health status, functional limitations, and productivity loss among adult survivors of childhood cancers (n = 239) diagnosed at ≤14 years of age compared with adults without a history of cancer (n = 304 265) by using the 2004-2014 National Health Interview Survey. We estimated economic burden using the productivity loss from health-related unemployment, missed work days, missed household productivity, and multivariable regression models controlling for age, sex, race/ethnicity, education, comorbidities, and survey year.

RESULTS

Childhood cancer survivorship is associated with a substantial economic burden. Adult survivors of childhood cancers are more likely to be in poorer health, need assistance with personal care and routine needs, have work limitations, be unable to work because of health, miss more days of work, and have greater household productivity loss compared with adults without a history of cancer (all P < .05). The annual productivity loss for adult survivors of childhood cancer is $8169 per person compared with $3083 per person for individuals without a history of cancer.

CONCLUSIONS

These findings underscore the importance of efforts to reduce the health and economic burden among adult survivors of childhood cancer. In addition, this study highlights the potential productivity losses that could be avoided during adulthood from the prevention of childhood cancer in the United States.

Predictors of delayed or forgone needed health care for families with children

BACKGROUND

We sought to determine how health care-related financial burden, childhood activity limitations, health insurance, and other access-related factors predict delayed or forgone care for families with children, using a nationally representative, population-based sample.

METHODS

Our sample included families with children aged 0 to 17 years whose family was interviewed about their health care expenditures in 1 of 7 panels of the 2001 to 2008 Medial Expenditure Panel Survey (N = 14 138). Financial burden was defined as (1) the sum of out-of-pocket health service expenditures during the first survey year and (2) that sum divided by adjusted family income. Delayed or forgone care was defined as self-report of delayed or forgone medical care or prescription medications for the reference parent or child during the second survey year.

RESULTS

Financial burden, discordant insurance, and having a child with an activity limitation were some of the strongest predictors of delayed or forgone care. Additionally, significant health insurance and income-related disparities exist in the experience of delayed or forgone care.

CONCLUSIONS

Children and their families are delaying or forgoing needed care due to health care-related financial burden. Policies are needed to effectively reduce financial burden and improve the concordance of insurance between parents and children because this may reduce the frequency of unmet need among families. Moreover, reducing the occurrence of delayed or forgone care may improve health outcomes by increasing the opportunity to receive timely and preventive care.

The effect of adult HIFA waiver expansions on insurance coverage of children

This article evaluates the effect of the Health Insurance Flexibility and Accountability (HIFA) demonstrations on uninsurance rates among children. HIFA could increase the probability that children would have health insurance either by directly enrolling a child into a HIFA program or by creating a "spillover" effect from adults onto children by making parents of children already eligible for public programs eligible for HIFA. Data were drawn from the Current Population Survey from 2000 to 2007. The estimation approach was a probit model using a difference-in-differences approach. The authors find that the HIFA wavier demonstrations had no measureable effect on the uninsurance rate among children, either through direct eligibility or through a "spillover" effect from parental eligibility. This suggests that public programs that integrate family insurance coverage into a single structure are likely to be more effective at reducing the rate of uninsurance than different programs for different members of the same family.

Insurance coverage gaps among US children with insured parents: are middle income children more likely to have longer gaps?

Millions of US children have unstable health insurance coverage. Some of these uninsured children have parents with stable coverage. We examined whether household income was associated with longer coverage gaps among US children with at least one insured parent. A secondary data analysis of the nationally-representative 2004 Medical Expenditure Panel Survey, this study uses logistic regression models to examine the association between income and children's insurance gaps. We focused on children with at least one parent insured all year (n = 6,151; estimated weighted N = 53.5 million). In multivariate models, children from families earning between 125 and 400% of the federal poverty level (FPL) had twice the odds of experiencing coverage gaps >6 months, as compared to those from high income families. Children in the poorest income groups (<125% FPL) did not have significantly greater odds of a gap >6 months. However, the odds of a gap ≤6 months were significantly greater for all income groups below 400% FPL, when compared to the highest income group. Among children with continuously insured parents, those from lower middle income families were most vulnerable to experiencing coverage gaps >6 months, as compared to those from the lowest and highest income families. These findings are likely due to middle class earnings being too high to qualify for public insurance but not high enough to afford private coverage. This study highlights the need for new US health care financing models that give everyone in the family the best chance to obtain stable coverage. It also provides valuable information to other countries with employer-sponsored insurance models or those considering privatization of insurance payment systems and how this might disproportionately impact the middle class.

Uninsured children and adolescents with insured parents

CONTEXT

Millions of US children and adolescents lack health insurance coverage. Efforts to expand their insurance often focus on extending public coverage to uninsured parents. Less is known about the uninsured whose parents already have coverage.

OBJECTIVE

To identify predictors of uninsurance among US children and adolescents with insured parents.

DESIGN AND SETTING

Cross-sectional and full-year analyses of pooled 2002-2005 data from the nationally representative Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

Children and adolescents younger than 19 years in 4 yearly MEPS files with positive full-year weights who had at least 1 parent residing in the same household. There were 39,588 in the unweighted cross-sectional analysis and 39,710 in the unweighted full-year analysis.

MAIN OUTCOME MEASURE

Prevalence of uninsurance among children and adolescents with at least 1 insured parent; predictors of uninsurance among children with at least 1 insured parent.

RESULTS

In the cross-sectional study population, 1380 of 39,588 children and adolescents were uninsured with at least 1 insured parent (weighted prevalence, 3.3%; 95% confidence interval [CI], 3.0%-3.6%). In multivariate analyses of children and adolescents with at least 1 insured parent, those uninsured were more likely Hispanic (odds ratio [OR], 1.58; 95% CI, 1.23-2.03) than white, non-Hispanic; low income (OR, 2.02; 95% CI, 1.42-2.88) and middle income (OR, 1.48; 95% CI, 1.09-2.03) than high income; from single-parent homes (OR, 1.99; 95% CI, 1.59-2.49) than from homes with 2 married parents; and living with parents who had less than a high school education (OR, 1.44; 95% CI, 1.10-1.89) than those with at least 1 parent who had completed high school. Those whose parents had public coverage were less likely to be uninsured (OR, 0.64; 95% CI, 0.43-0.96) than were those whose parents reported private health insurance. These predictors remained significant in full-year analyses. Similar patterns of vulnerability were also found among a subset of uninsured children with privately covered parents.

CONCLUSIONS

Among all US children, more than 3% were uninsured with at least 1 insured parent. Predictors of such uninsurance included having low and middle income. Having a parent covered by only public insurance was associated with better children's coverage rates.

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.

Uninsured but eligible children: are their parents insured? Recent findings from Oregon

BACKGROUND

Despite expansions in public health insurance programs, millions of US children lack coverage. Nearly two-thirds of Oregon's uninsured children seem to be eligible for public insurance.

OBJECTIVES

We sought to identify uninsured but eligible children and to examine how parental coverage affects children's insurance status.

METHODS

We collected primary data from families enrolled in Oregon's food stamp program, which has similar eligibility requirements to public health insurance in Oregon. In this cross-sectional, multivariable analysis, results from 2861 surveys were weighted back to a population of 84,087 with nonresponse adjustment. Key predictor variables were parental insurance status and type of insurance; the outcome variable was children's insurance status.

RESULTS

Nearly 11% of children, presumed eligible for public insurance, were uninsured. Uninsurance among children was associated with being Hispanic, having an employed parent, and higher household earnings (133-185% of the federal poverty level). Children with an uninsured parent were more likely to be uninsured, compared with those who had insured parents (adjusted odds ratio 14.21, 95% confidence interval 9.23-20.34). More surprisingly, there was a higher rate of uninsured children among privately-insured parents, compared with parents covered by public insurance (adjusted odds ratio 4.39, 95% confidence interval 2.00-9.66).

CONCLUSIONS

Low-income Oregon parents at the higher end of the public insurance income threshold and those with private insurance were having the most difficulty keeping their children insured. These findings suggest that when parents succeed in pulling themselves out of poverty and gaining employment with private health insurance coverage, children may be getting left behind.

Trends in private insurance, Medicaid/State Children's Health Insurance Program, and the health-care safety net: implications for asthma disparities

Disparities in asthma prevalence, severity, quality of care, and outcomes have been widely documented across racial/ethnic communities, among privately insured vs publicly insured patients, and according to patients' socioeconomic status, among other patient characteristics. In order to effectively address asthma disparities, changes will need to be made across all systems of care in which these subpopulations receive health-care services. The majority of current trends in private insurance, Medicaid/State Children's Health Insurance Program, and the safety net are likely to further exacerbate asthma disparities rather than help to reduce these disparities. Asthma cannot be effectively managed unless individuals have affordable access to a full range of services and receive coordinated, quality health care. Multiple policy levers will need to be simultaneously employed to ensure access to the full range of services needed for effective asthma management, especially among low-income and minority persons with asthma in order to reduce the gap in disparities. The needs of these patients must be thoughtfully addressed and strategically advocated for within all systems of care in which these subpopulations receive health services. This overall strategy must necessarily include consideration of the capacity of safety-net providers to meet the needs of uninsured and underinsured persons with asthma. This article reviews trends in health-care financing, in clinical management, and the health-care safety net, and assesses their likely impact on asthma disparities. It concludes with a discussion of key policy arenas that will have significant influence on the eventual success of efforts to reduce asthma disparities.

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.

Low income parents' reports of communication problems with health care providers: effects of language and insurance

OBJECTIVES

This study examines how parental reports of communication problems with health providers vary over a wider range of characteristics of low income children than considered in previous studies.

METHODS

Data were drawn from the 1999 and 2002 National Survey of America's Families. Communication problems, insurance type, socioeconomic characteristics, health factors, and provider type were examined. Data were analyzed using bivariate and multivariate techniques.

RESULTS

Bivariate analysis identified that the parents of 24.4% of low income children and 36.4% of publicly covered low income children with a Spanish interview reported poor communication with health providers. Coefficients from regression analysis suggest that, controlling for covariates, foreign-born parents with a Spanish interview were 11.8 percentage points (p<0.01) more likely to report communication problems than U.S.-born parents with an English interview. Among low income publicly covered children with a Spanish interview, regression analysis suggests that parents of children who used clinics or hospital outpatient departments as their usual source of care were 9.5 percentage points (p<0.05) more likely to report communication problems compared with those whose usual source of care was a doctor's or HMO office.

CONCLUSIONS

Implementing policies to improve communication barriers for low income children, particularly those with foreign-born parents whose native language is not English, may be necessary to reduce health disparities relative to higher income children across a variety of health domains including utilization, satisfaction, and outcomes. Focusing attention on the availability of professional translation services in clinics or hospital outpatient departments may be a cost-effective strategy for reducing communication problems for publicly insured children.

SCHIP expansion and parental coverage: an evaluation of Wisconsin's BadgerCare

The Wisconsin BadgerCare program, which became operational in July 1999, expanded public health insurance eligibility to both parents and children in families with incomes below 185% of the U.S. poverty line (200% for those already enrolled). This eligibility expansion was part of a federal initiative known as the State Children's Health Insurance Program (SCHIP). Wisconsin was one of only four states that initially expanded coverage to parents of eligible children. In this paper, we attempt to answer the following question: To what extent does a public program with the characteristics of Wisconsin's BadgerCare program reduce the proportion of the low-income adult population without health care coverage? Using a coordinated set of administrative databases, we track three cohorts of mother-only families: those who were receiving cash assistance under the Wisconsin AFDC and TANF programs in September 1995, 1997, and 1999, and who subsequently left welfare. We follow these 19,201 "welfare leaver" families on a quarterly basis for up to 25 quarters, from 2 years before they left welfare through the end of 2001, making it possible to use the labor market information and welfare history of the women in analyzing outcomes. We apply multiple methods to address the policy evaluation question, including probit, random effects, and two difference-in-difference strategies, and compare the results across methods. All of our estimates indicate that BadgerCare substantially increased public health care coverage for mother-only families leaving welfare. Our best estimate is that BadgerCare increased the public health care coverage of all adult leavers by about 17-25% points.

The effects of child-only insurance coverage and family coverage on health care access and use: recent findings among low-income children in California

OBJECTIVE

To compare the extent with which child-only and family coverage (child and parent insured) ensure health care access and use for low income children in California and discuss the policy implications of extending the State Children's Health Insurance Program (California's Healthy Families) to uninsured parents of child enrollees.

DATA SOURCES/SETTING

We used secondary data from the 2001 California Health Interview Survey (CHIS), a representative telephone survey.

STUDY DESIGN

We conducted a cross-sectional study of 5,521 public health insurance-eligible children and adolescents and their parents to examine the effects of insurance (family coverage, child-only coverage, and no coverage) on measures of health care access and utilization including emergency room visits and hospitalizations.

DATA COLLECTION

We linked the CHIS adult, child, and adolescent datasets, including the adolescent insurance supplement.

FINDINGS

Among the sampled children, 13 percent were uninsured as were 22 percent of their parents. Children without insurance coverage were more likely than children with child-only coverage to lack a usual source of care and to have decreased use of health care. Children with child-only coverage fared worse than those with family coverage on almost every access indicator, but service utilization was comparable.

CONCLUSIONS

While extending public benefits to parents of children eligible for Healthy Families may not improve child health care utilization beyond the gains that would be obtained by exclusively insuring the children, family coverage would likely improve access to a regular source of care and private sector providers, and reduce perceived discrimination and breaks in coverage. These advantages should be considered by states that are weighing the benefits of expanding health insurance to parents.

Out-of-pocket financial burden for low-income families with children: socioeconomic disparities and effects of insurance

OBJECTIVE

To determine whether socioeconomic disparities exist in the financial burden of out-of-pocket (OOP) health care expenditures for families with children, and whether health insurance coverage decreases financial burden for low-income families.

DATA SOURCE

The Household Component of the 2001 Medical Expenditure Panel Survey.

STUDY DESIGN

Cross-sectional family-level analysis. We used bivariate statistics to examine whether financial burden varied by poverty level. Multivariate regression models were used to assess whether family insurance coverage was associated with level of financial burden for low-income families. The main outcome was financial burden, defined as the proportion of family income spent on OOP health care expenditures, including premiums, for all family members.

DATA COLLECTION/EXTRACTION

We aggregated annual OOP expenditures for all members of 4,531 families with a child <18 years old. Family insurance coverage was categorized as follows: (1) all members publicly insured all year, (2) all members privately insured all year, (3) all members uninsured all year, (4) partial coverage, or (5) mix of public and private with no uninsured periods.

PRINCIPAL FINDINGS

A regressive gradient was noted for financial burden across income groups, with families with incomes <100 percent of the Federal Poverty Level (FPL) spending a mean of 119.66 US dollars OOP per 1,000 US dollars of family income and families with incomes 100-199 percent FPL spending 66.30 US dollars OOP per 1,000 US dollars, compared with 37.75 US dollars for families with incomes >400 percent FPL. For low-income families (<200 percent FPL), there was a 785 percent decrease in financial burden for those with full-year public coverage compared with those with full-year private insurance (p < .001).

CONCLUSIONS

Socioeconomic disparities exist in the financial burden of OOP health care expenditures for families with children. For low-income families, full-year public coverage provides significantly greater protection from financial burden than full-year private coverage.

The State Children’s Health Insurance Program: Successes, Shortcomings, And Challenges

This paper examines successes and shortcomings of the State Children's Health Insurance Program (SCHIP). SCHIP is a source of coverage for millions of children, improving their access to health care and sparking innovation in program design and improvements in Medicaid. However, SCHIP adds to the complexity of the insurance system and introduces new inequities in access to insurance; it is imperfectly targeting eligible children who are uninsured; and its financing is problematic because of the block-grant funding structure and use of SCHIP funds to cover adults. These issues need to be addressed during the SCHIP reauthorization process.