How stable is medicaid coverage for children?

A conceptual model of health insurance stability in the United States health care system

In the U.S. health care system, people under age 65 are at risk of losing and regaining health insurance coverage over their lifetimes, which has important consequences for their physical and mental health. Despite the importance of insurance stability, we have an incomplete understanding about the complex factors influencing whether people lose and regain coverage. To advance our understanding of the dynamics of health insurance coverage and guide future research, our purpose is to present a new conceptual model of health insurance stability, where instability is defined as a person’s loss or change of coverage, which can occur more than once in a lifetime. Drawing from theory and evidence in the literature, we posit that personal and plan characteristics, the health system, and the environmental context – economic, social/cultural, political/judicial, and geographic – drive health insurance stability over the life course and are understudied. Studies are needed to identify the populations most at risk of experiencing insurance instability and vulnerability in health outcomes that results from such insecurity, which may suggest reforms and health policies at the individual, health system, or environment levels to reduce those risks.

Enrollment Brokers Did Not Increase Medicaid Enrollment, 2008-18

Between 2008 and 2018, six states and Washington, D.C., began contracting with enrollment brokers to facilitate enrollment into Medicaid, joining the eighteen states that already had such contracts in place as of 2008. Using newly collected data covering all contracts between state Medicaid agencies and independent enrollment brokers during this period, we compared changes in Medicaid participation following the initiation of contracts with enrollment brokers with contemporaneous changes in Medicaid participation in states that never contracted with brokers. We found that contract initiation had no statistically significant effects on state-level Medicaid participation. We further found no evidence of other enrollment-related benefits, such as improved application processing times.

Medicaid Instability and Mental Health of Teen Parent Families

This study examines the effect of inconsistent Medicaid coverage on parenting stress, maternal depression, and child behavior in a sample of teen mothers and their children. The majority (54%) of mothers experienced inconsistent coverage. After 24 months, mothers experiencing inconsistent coverage had significantly higher parenting stress and depressive symptoms, and their children had more internalizing behaviors than families with consistent Medicaid. These differences existed despite no initial differences and controlling for numerous covariates. Policies and practices that stabilize Medicaid coverage for teen parent families may reduce unnecessary stress, depressive symptoms, and early childhood behavior problems.

An investigation of social determinants of health and outcomes in pediatric nonaccidental trauma

OBJECTIVES

Nonaccidental trauma (NAT) is a leading cause of pediatric mortality and disability. We examined our institution's experience with NAT to determine if socioeconomic status is correlated with patient outcomes.

METHODS

NAT cases were reviewed retrospectively. Socioeconomic determinants included insurance status and race; outcomes included mortality, discharge disability and disposition. Correlations were identified using t test, Fisher's exact test, and logistic regression.

RESULTS

The cohort comprised of 337 patients, with an overall uninsured rate of 5.6%. This rate was achieved by insuring 64.7% of the cohort after admission. Non-survivors were more likely to have no insurance coverage (14.8% versus 4.8%, p = 0.041). Regression revealed that uninsured had 8 times (95% CI 1.7-38.7, p = 0.008) higher in-hospital mortality than those with insurance when controlling for injury severity. Additionally, injury severity score ≥ 15, transfer from outside hospital, need for ICU or operative treatment were predictive of mortality. Adjusted risk factors for severe disability at discharge did not include insurance status or race, while ISS ≥ 15 and ICU stay were predictive.

CONCLUSIONS

There are significant associations of insurance status with pediatric NAT outcomes, highlighting that determinants other than disease severity may influence mortality and morbidity. High-risk patients should be identified to develop strategies to improve outcomes.

Transition-Age Medicaid Coverage for Adolescents With Autism and Adolescents With Intellectual Disability

Although the majority of adolescents with autism spectrum disorder (ASD) rely on healthcare coverage through Medicaid during their transition into adulthood, little is known about their continuing eligibility. This study used Medicaid Analytic Extract (MAX) data to examine Medicaid coverage in a national sample using a cohort of adolescents with ASD ( n = 4,179) and a like-aged cohort with intellectual disability (ID, n = 21,844) over 5 years using survival analysis and Cox regression models. More than 1 in 4 adolescents with ASD lost coverage and fewer than half subsequently regained it. They were more likely to disenroll than adolescents with ID. Similarities in overall patterns among the 2 groups suggest that the experience of adolescents with ASD was characteristic of more general aspects of behavioral health coverage and indicate the need for programmatic reforms.

Does capitated managed care affect budget predictability? Evidence from Medicaid programs

As the second largest item in the budget of every US state, Medicaid budget stability and financial transparency have significance for every state. This study is the first to test whether managed care enrollment reduces the variance of Medicaid spending, in contrast to the focus of the existing literature on spending levels. This variance bears directly on whether budget constrained states whether budget constrained states benefit from managed care in the form of stabilized spending, leading to improved budget predictability. Capitated payments stabilize spending at the margin, but the effects may be unobservable in aggregate due to variation in enrollment, which is directly measured in the analysis, or selection bias, which is unobserved. Although the majority of Medicaid enrollees are in managed care, the study shows that managed care use has been concentrated among the enrollees with the most stable spending, resulting in only small gains to budget predictability. This finding is robust to the exclusion of the claims expenditures that exhibit the most variance.

Electronic health record tools to assist with children's insurance coverage: a mixed methods study

Background

Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children’s coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children’s insurance assistance.

Methods

We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784).

Results

Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14–1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68–0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64–2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53–0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used.

Conclusions

This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care.

Trial registration

ClinicalTrials.gov, NCT02298361; retrospectively registered on November 5, 2014.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3159-x) contains supplementary material, which is available to authorized users.

Providers' Behaviors and Beliefs on Prescribing Antipsychotic Medication to Children: A Qualitative Study

Fragmentation in behavioral and mental health care to children has resulted in suboptimal care and high rates of psychotropic medication use, especially antipsychotic medications (APM). A qualitative study, based on the Theory of Planned Behavior (TPB), aimed to better understand prescribing practices, barriers to optimal treatment, and potential interventions to safeguard the use of APM for children in Kentucky. The most common barrier to optimal care was access to mental health specialists. Social norms and pressure from families contribute to increased medication use. We identify promising interventions to safeguard the use of APM through the lens of the TPB.

Can Medicaid Claims Validly Ascertain Foster Care Status?

Medicaid claims have been used to identify populations of children in foster care in the current literature; however, the ability of such an approach to validly ascertain a foster care population is unknown. This study linked children in the National Survey of Child and Adolescent Well-Being-I to their Medicaid claims from 36 states using their Social Security numbers. Using this match, we examined discordance between caregiver report of foster care placement and the foster care eligibility code contained in the child's Medicaid claims. Only 73% of youth placed in foster care for at least a year displayed a Medicaid code for foster care eligibility. Half of all youth coming into contact with child welfare displayed discordance between caregiver report and Medicaid claims. Children with emergency department utilization, and those in primary care case management health insurance arrangements, had the highest odds of accurate ascertainment. The use of Medicaid claims to identify a cohort of children in foster care results in high rates of underascertainment. Supplementing administrative data with survey data is one way to enhance validity of ascertainment.

Medicaid Disenrollment Patterns Among Children Coming into Contact with Child Welfare Agencies

Objectives To examine retention of Medicaid coverage over time for children in the child welfare system. Methods We linked a national survey of children with histories of abuse and neglect to their Medicaid claims files from 36 states, and followed these children over a 4 year period. We estimated a Cox proportional hazards model on time to first disenrollment from Medicaid. Results Half of our sample (50 %) retained Medicaid coverage across 4 years of follow up. Most disenrollments occurred in year 4. Being 3-5 years of age and rural residence were associated with increased hazard of insurance loss. Fee-for-service Medicaid and other non-managed insurance arrangements were associated with a lower hazard of insurance loss. Conclusions for Practice A considerable number of children entering child environments seem to retain Medicaid coverage over multiple years. Finding ways to promote entry of child welfare-involved children into health insurance coverage will be critical to assure services for this highly vulnerable population.

Spotlight on Express Lane Eligibility (ELE): A Tool to Improve Enrollment and Renewal

OBJECTIVE

We examine a new simplification policy, Express Lane Eligibility (ELE), introduced by the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), to understand ELE's effects on enrollment, renewal, and administrative costs.

METHODS

Beginning in January 2012 and lasting through June 2013, we conducted 2 rounds of phone interviews with 38 state administrators and staff in 8 states that implemented ELE in Medicaid, Children's Health Insurance Program (CHIP), or both; we also conducted case studies in these same states, resulting in 136 in-person interviews. We collected administrative data on enrollments and renewals processed through ELE methods from the 8 states.

RESULTS

ELE was adopted in different ways; the method of adoption influenced how many children were served and administrative savings. Automatic ELE processes, which enable states to use eligibility findings from partner agencies to automatically enroll or renew children, serve the most children and generate, on average, $1 million annually in administrative savings. Given the size of renewal caseloads and the recurring nature of renewal, using ELE for renewals holds substantial promise for administrative savings and keeping children covered.

CONCLUSIONS

Automatic ELE processes are a best practice for using ELE. However, because Congress has not yet made ELE a permanent policy option, states are discouraged from adopting this more efficient method of eligibility determination and redeterminations. Making ELE permanent would support states that have already adopted the policy; in addition, ELE could support the transition of children to Medicaid or exchanges should CHIP not be funded after September 30, 2015.

Program Churning and Transfers Between Medicaid and CHIP

OBJECTIVE

In the 10 states that are the focus of the Children's Health Insurance Program Reauthorization Act of 2009 evaluation, we analyze in detail the states' recent progress in retaining children in public coverage and public coverage churning.

METHODS

We used administrative data spanning a five-and-a-half-year period collected from 10 study states-Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia-to analyze the extent to which children return to the same program a short time after disenrollment and the extent to which transfers between Medicaid and Children's Health Insurance Program (CHIP) lead to public coverage gaps.

RESULTS

Our analysis yielded 3 key findings. First, many children moved between Medicaid and CHIP; while most transitioned seamlessly, coverage gaps occurred for as many as 40%, depending on the type of transition. Second, churning continued to be a concern for public coverage programs, with approximately 21% of Medicaid disenrollees and 10% of separate CHIP disenrollees returning to the same program within 7 months. Third, we found sizable differences in rates of program churning and nonseamless program transfers across the 10 study states.

CONCLUSIONS

Notable variation existed across programs and states, which persisted over the period in public program churning. These results suggest the need for continued efforts to simplify renewal processes, particularly in state Medicaid programs, along with the adoption of processes that improve coordination across programs and policies that simplify these transfers.

Use of preventive dental care among medicaid-enrolled, school-aged US children in immigrant and nonimmigrant families: trends in Pennsylvania From 2005 through 2010

OBJECTIVES

We describe trends in receipt of preventive dental care among Medicaid-enrolled children in Pennsylvania between 2005 and 2010, comparing the US children of immigrants with their co-ethnic peers in nonimmigrant families.

METHODS

We analyzed Pennsylvania Medicaid claims, birth records, and census data for children born in Pennsylvania and enrolled in Medicaid for 10 or more months during any of the calendar years assessed.

RESULTS

Receipt of preventive dental care was more likely among Latino children in immigrant families than among their peers in nonimmigrant families; also, it was more likely among White children in immigrant families than among their peers in nonimmigrant families. Rates of preventive dental care use among African American and Asian children in immigrant and nonimmigrant families were comparable. From 2005 to 2010, the percentage of Latino children in nonimmigrant families who received preventive dental care increased from 33% to 61%. Changes in other groups were significant but less dramatic.

CONCLUSIONS

Receipt of preventive dental care has increased among Medicaid-enrolled children in Pennsylvania, with marked gains among Latino children. Within each racial/ethnic group, the children of immigrants were either more likely than or equally likely as children in nonimmigrant families to receive care.

Caregivers' health literacy and gaps in children's Medicaid enrollment: findings from the Carolina Oral Health Literacy Study

Background and Objectives

Recent evidence supports a link between caregivers’ health literacy and their children’s health and use of health services. Disruptions in children’s health insurance coverage have been linked to poor health care and outcomes. We examined young children’s Medicaid enrollment patterns in a well-characterized cohort of child/caregivers dyads and investigated the association of caregivers’ low health literacy with the incidence of enrollment gaps.

Methods

We relied upon Medicaid enrollment data for 1208 children (mean age = 19 months) enrolled in the Carolina Oral Health Literacy project during 2008–09. The median follow-up was 25 months. Health literacy was measured using the Newest Vital Sign (NVS). Analyses relied on descriptive, bivariate, and multivariate methods based on Poisson modeling.

Findings

One-third of children experienced one or more enrollment gaps; most were short in duration (median = 5 months). The risk of gaps was inversely associated with caregivers’ age, with a 2% relative risk decrease for each added year. Low health literacy was associated with a modestly elevated risk increase [Incidence Rate Ratio (IRR) = 1.17 (95% confidence interval (CI) 0.88–1.57)] for enrollment disruptions; however, this estimate was substantially elevated among caregivers with less than a high school education [IRR = 1.52 (95% CI 0.99–2.35); homogeneity p<0.2].

Conclusions

Our findings provide initial support for a possible role of caregivers’ health literacy as a determinant of children’s Medicaid enrollment gaps. Although the association between health literacy and enrollment gaps was not confirmed statistically, we found that it was markedly stronger among caregivers with low educational attainment. This population, as well as young caregivers, may be the most vulnerable to the negative effects of low health literacy.

Massachusetts health reform and access for children with special health care needs

BACKGROUND AND OBJECTIVES

Children with special health care needs (CSHCN) face unique challenges in accessing affordable health care. Massachusetts implemented major health reform in 2006; little is known about the impact of this state's health reform on uninsurance, access to care, and financial protection for privately and publicly insured CSHCN.

METHODS

We used a difference-in-differences (DD) approach to compare uninsurance, access to primary and specialty care, and financial protection in Massachusetts versus other states and Washington, DC before and after Massachusetts health reform. Parent-reported data were used from the 2005-2006 and 2009-2010 National Survey of Children with Special Health Care Needs and adjusted for age, gender, race/ethnicity, non-English language at home, and functional difficulties.

RESULTS

Postreform, living in Massachusetts was not associated with significant decreases in uninsurance or increases in access to primary care for CSHCN. For privately insured CSHCN, Massachusetts was associated with increased access to specialists (DD = 6.0%; P ≤ .001) postreform. For publicly insured CSHCN, however, there was a significant decrease in access to prescription medications (DD = -7.2%; P = .003) postreform. Living in Massachusetts postreform was not associated with significant changes in financial protection compared with privately or publicly insured CSHCN in other states.

CONCLUSIONS

Massachusetts health reform likely improved access to specialists for privately insured CSHCN but did not decrease instances of uninsurance, increase access to primary care, or improve financial protection for CSHCN in general. Comparable provisions within the Affordable Care Act may produce similarly modest outcomes for CSHCN.

Medicaid enrollment gap length and number of Medicaid enrollment periods among US children

OBJECTIVES

We examined gap length, characteristics associated with gap length, and number of enrollment periods among Medicaid-enrolled children in the United States.

METHODS

We linked the 2004 National Health Interview Survey to Medicaid Analytic eXtract files for 1999 through 2008. We examined linkage-eligible children aged 5 to 13 years in the 2004 National Health Interview Survey who disenrolled from Medicaid. We generated Kaplan-Meier curves of time to reenrollment. We used Cox proportional hazards models to assess the effect of sociodemographic variables on time to reenrollment. We compared the percentage of children enrolled 4 or more times across sociodemographic groups. RESULTS. Of children who disenrolled from Medicaid, 35.8%, 47.1%, 63.5%, 70.8%, and 79.1% of children had reenrolled in Medicaid by 6 months, 1, 3, 5, and 10 years, respectively. Children who were younger, poorer, or of minority race/ethnicity or had lower educated parents had shorter gaps in Medicaid and were more likely to have had 4 or more Medicaid enrollment periods.

CONCLUSIONS

Nearly half of US children who disenrolled from Medicaid reenrolled within 1 year. Children with traditionally high-risk demographic characteristics had shorter gaps in Medicaid enrollment and were more likely to have more periods of Medicaid enrollment.

Continuity of Public Insurance Coverage

Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.

A longitudinal view of child enrollment in Medicaid

BACKGROUND

Although national cross-sectional estimates of the percentage of children enrolled in Medicaid are available, the percentage of children enrolled in Medicaid over longer periods of time is unknown. Also, the percentage and characteristics of children who rely on Medicaid throughout childhood, rather than transiently, are unknown.

METHODS

We performed a longitudinal examination of Medicaid coverage among children across a 5-year period. Children 0 to 13 years of age in the 2004 National Health Interview Survey file were linked to Medicaid Analytic eXtract files from 2004 to 2008. The percentage of children enrolled in Medicaid at any time during the 5-year observation period and the number of years during which children were enrolled in Medicaid were calculated. Duration of Medicaid enrollment was compared across sociodemographic characteristics by using χ(2) tests.

RESULTS

Forty-one percent of all US children were enrolled in Medicaid at least some time during the 5-year period, compared with a single-year estimate of 32.8% in 2004 alone. Of enrolled children, 51.5% were enrolled during all 5 years. Children with lower parental education, with lower household income, of minority race or ethnicity, and in suboptimal health were more likely to be enrolled in Medicaid during all 5 years.

CONCLUSIONS

Longitudinal data reveal higher percentages of children with Medicaid insurance than shown by cross-sectional data. Half of children enrolled in Medicaid are enrolled during at least 5 consecutive years, and these children have higher risk sociodemographic profiles.

Which states enroll their Medicaid-eligible, citizen children with immigrant parents?

OBJECTIVE

To identify which states achieve comparable enrollment rates for Medicaid-eligible, citizen children with immigrant and nonimmigrant parents.

DATA SOURCE

A total of 810,345 Medicaid-eligible, citizen children drawn from the 2008-2010 American Community Survey.

STUDY DESIGN

This study estimates a state fixed-effects probit model of uninsured status for Medicaid-eligible, citizen children. State and immigrant family interaction variables test whether citizen children in immigrant families have a higher probability of remaining uninsured compared to children in nonimmigrant families. Simulations predict the uninsured rates for Medicaid eligible children in immigrant and nonimmigrant families and rank states by the differences between the two groups.

PRINCIPAL FINDINGS

While some states have insignificant and near zero differences in predicted uninsured rates, many states have enrollment disparities reaching 20 percent points between citizen children with immigrant and nonimmigrant parents.

CONCLUSIONS

Many states have large differences in enrollment rates between their Medicaid-eligible, citizen children with immigrant and nonimmigrant parents. Addressing these enrollment disparities could improve the health status of citizen children in immigrant families and earn Children's Health Insurance Program Reauthorization Act bonus payments for many states.

Are pediatric quality care measures too stringent?

INTRODUCTION

We aimed to demonstrate the application of national pediatric quality measures, derived from claims-based data, for use with electronic medical record data, and determine the extent to which rates differ if specifications were modified to allow for flexibility in measuring receipt of care.

METHODS

We reviewed electronic medical record data for all patients up to 15 years of age with ≥1 office visit to a safety net family medicine clinic in 2010 (n = 1544). We assessed rates of appropriate well-child visits, immunizations, and body mass index (BMI) documentation, defined strictly by national guidelines versus by guidelines with clinically relevant modifications.

RESULTS

Among children aged <3 years, 52.4% attended ≥6 well-child visits by the age of 15 months; 60.8% had ≥6 visits by age 2 years. Less than 10% completed 10 vaccination series before their second birthday; with modifications, 36% were up to date. Among children aged 3 to 15 years, 63% had a BMI percentile recorded; 91% had BMI recorded within 36 months of the measurement year.

CONCLUSIONS

Applying relevant modifications to national quality measure definitions captured a substantial number of additional services. Strict adherence to measure definitions might miss the true quality of care provided, especially among populations that may have sporadic patterns of care utilization.

Adaptation and application of the Agency for Healthcare Research and Quality's asthma admission rate pediatric quality indicator to Ohio Medicaid claims data

BACKGROUND

The U.S. Agency for Healthcare Research and Quality (AHRQ) developed, in the context of a national pediatric discharge database, 18 pediatric quality indicators (PDIs) for assessing pediatric care. These measures have not yet been adapted for and applied to claims databases.

OBJECTIVES

The objectives of this study were to (1) adapt the asthma admission rate (AAR) PDI methodology for claims data; (2) calculate AARs for Ohio Medicaid beneficiaries for 2007-2009, overall as well as by patient and regional characteristics; (3) determine the cost and length of stay associated with these hospitalizations; (4) describe medication use for 90 days before the hospitalizations; and (5) estimate the effect of asthma prevalence rates on AARs across Ohio counties.

METHODS

A retrospective study was performed using Ohio Medicaid claims data. After adapting the AHRQ methodology for a claims database, AARs were computed for the pediatric asthma population (aged 2-17 years). Total and mean costs and days spent in the hospital were calculated. A Poisson regression model was developed to estimate the effect of asthma prevalence on the AAR.

RESULTS

Between 2007 and 2009, the Ohio Medicaid AAR rose from 182 to 258 per 100,000 children. Costs (in 2009$) rose from $1,069,783 to $1,470,918, whereas hospital days increased from 672 to 815. Close to 70% of patients had no claims for a maintenance medication for 90 days before their hospitalization. The asthma prevalence rate was significantly associated with the AAR.

CONCLUSIONS

The remaining 17 PDIs could also be adapted for claims data to assess the quality of pediatric care.

The impact of parental job loss on children's health insurance coverage

Children with private health insurance are more than six and a half times as likely to lose coverage in the three months after one or both of their parents loses a job, compared to children whose parents remain employed. In the current economic environment, this finding is especially troubling. We estimate that for every 1,000 jobs lost, 311 privately insured children lose coverage and more than 45 percent of the poorest and most vulnerable of privately insured children became uninsured. Much more effort is needed to quickly enroll children in public health insurance programs when their parents suffer a job loss.

Covered today, sick tomorrow? Trends and correlates of children's health insurance instability

Many children with health insurance will experience gaps in coverage over time, potentially reducing their access to and use of preventive health care services. This article uses the Survey of Income and Program Participation to examine how the stability of children's health insurance changed between 1990 and 2005 and to identify dynamic aspects of family life associated with transitions in coverage. Children's health insurance instability has increased since the early 1990s, due to greater movement between insured and uninsured states and between private and public insurance coverage. Changes in the employment and marital status of the family head are highly associated with an increased risk of a child losing and gaining public and private coverage, largely in hypothesized directions. The exception is that marital dissolution and job loss are associated with an increased probability of a child losing public insurance, despite there being no clear policy explanation for such a relationship.

Reporting on continuity of coverage for children in Medicaid and CHIP: what states can learn from monitoring continuity and duration of coverage

OBJECTIVE

The Children's Health Insurance Program Reauthorization Act (CHIPRA) requires states to measure and report on coverage stability in Medicaid and the Children's Health Insurance Program (CHIP). States generally have not done this in the past. This study proposes strategies for both measuring stability and targeting policies to improve retention of Medicaid coverage, using Ohio as an example.

METHODS

A cohort of newly enrolled children was constructed for the 1-year time period between July 2007 and June 2008 and followed for 18 months. Hazard ratios were estimated after 18 months to predict the likelihood of maintaining continuous enrollment in Medicaid, adjusting for income eligibility group, age, race, gender, county type, and change in unemployment. Children dropping from the program at the renewal period (12-16 months) were followed for 12 months to determine their rate of return.

RESULTS

Approximately 26% of children aged <1 year and 35% of children aged 1 to 16 years dropped from Medicaid by 18 months, with the steepest drop occurring after 12 months, the point of renewal. Likelihood of dropping was associated with the higher income eligibility groups, older children, and Hispanic ethnicity. Approximately 40% of children who were dropped at renewal re-enrolled within 12 months. Children in the lowest income group returned sooner and in higher proportions than other children.

CONCLUSIONS

A substantial number of children lose Medicaid coverage only to re-enroll within a short time. Income eligibility group appears to be a strong indicator of stability. Effective monitoring of coverage stability is important for developing policies to increase retention of eligible children.

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.

Monitoring duration of coverage in Medicaid and CHIP to assess program performance and quality

OBJECTIVE

To assess measures of Medicaid and Children's Health Insurance Program (CHIP) coverage duration for potential inclusion in a core set of children's health care quality measures as called for by the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009.

METHODS

We reviewed published and unpublished reports and spoke to researchers, analysts, and program officials at the federal level and in selected states. Measures available in administrative data were assessed with regard to the feasibility of implementation and their validity in terms of their association with child health outcomes and state policy choices.

RESULTS

Although many measures are feasible to construct using existing administrative data, prospective measures of duration that examine a cohort of new enrollees were found to be the most valid measures based on research linking their outcomes to program policies and their consistent interpretation across states with similar enrollment and renewal structures. However, the inability of some states to link together data from their Medicaid and CHIP enrollment files affects the interpretation of these and other measures across states.

CONCLUSIONS

Prospective and retrospective measures of duration were recommended for inclusion in the core set of quality measures. Although the prospective and retrospective measures were ranked high in terms of validity and importance by the Subcommittee on Quality Measures for Children's Health Care in Medicaid and CHIP, concerns were raised about feasibility given that no state currently uses these measures to monitor program performance. Additional technical and financial resources and enhancements to administrative data systems will be needed to support state efforts in this area of quality assessment, particularly in the areas of linking Medicaid and CHIP data files, improving reason for dis-enrollment codes, and improving race and ethnicity coding. Monitoring how well states are doing at enrolling and retaining children in Medicaid and CHIP is a critical component to assessing overall program performance and quality and for interpreting many of the other proposed quality measures.

Measuring and reporting quality of health care for children: CHIPRA and beyond

BACKGROUND AND PURPOSE

The coming years could be a watershed period for children and health care as the nation implements the most significant federal health care legislation in 50 years: the Accountable Care Act (ACA). A year earlier, the American Recovery and Reinvestment Act (ARRA) set up a framework and road map for the eventual universal adoption of health information technology in its Health Information Technology for Economic and Clinical Health (HITECH) provisions, and the Children's Health Insurance Program Reauthorization Act (CHIPRA) legislation articulated a new and compelling vision for quality measurement in child health services. Each of these landmark advances in federal health policy contains relevant provisions for the measurement and improvement of the performance of the health system. Less clear is the extent to which the child specific framework articulated in CHIPRA will be preserved and built upon. Here, we set forth recommendations for ensuring that measurement and reporting efforts under CHIPRA, ARRA, and ACA are aligned for children.

POLICY THEMES AND RECOMMENDATIONS

Our findings around problems and recommendations are grouped into 2 broad areas: those that deal with helping states report and use current measures, and those that deal with expanding the current measures. Recommendations include 5 aimed at focusing efforts on measure reporting and use: 1) help states build a measurement infrastructure; 2) provide specific technical assistance and support to states on how to collect, report, and use measures; 3) establish a national office for quality monitoring; 4) make available nationally data from states; and 5) ensure specific focus on child health in HITECH initiatives. Recommendations also include 3 aimed at extending what is being measured: 1) continue emphasis on insurance stability; 2) ensure that disparities can be measured and monitored; and 3) build measures that focus on system accountability and outcomes.

CONCLUSIONS

National health care reform provides the opportunity to extend coverage and dramatically restructure systems of care. It will be important to ensure that focus on health care quality for children be maintained and that the advances made under CHIPRA reinforce and are not diluted or overtaken by broader reform efforts.

Public health insurance in Oregon: underenrollment of eligible children and parental confusion about children's enrollment status

OBJECTIVES

We identified characteristics of Oregon children who were eligible for the Oregon Health Plan (OHP), the state's combined Medicaid-Children's Health Insurance Program (CHIP), but were not enrolled in January 2005. We also assessed whether parents' confusion regarding their children's status affected nonenrollment.

METHODS

We conducted cross-sectional analyses of linked statewide Food Stamp Program and OHP administrative databases (n = 10 175) and primary data from a statewide survey (n = 2681).

RESULTS

More than 20% of parents with children not administratively enrolled in OHP reported that their children were enrolled. Parents of 11.3% of children who were administratively enrolled reported that they were not. Eligible but unenrolled children had higher odds of being older, having higher family incomes, and having employed and uninsured parents.

CONCLUSIONS

These findings reveal an important discrepancy between administrative data and parent-reported access to public health insurance. This discrepancy may stem from transient coverage or confusion among parents and may result in underutilization of health insurance for eligible children.

Assessment of Children's Public Health Insurance Program enrollment applications: a health literacy perspective

INTRODUCTION

More than half of uninsured children in the United States qualify for Medicaid or the Children's Health Insurance Program (CHIP). Application readability and other complex features may be barriers to enrollment for some of these families. The purpose of this study was to conduct a literary assessment of state-issued English- and Spanish-language Medicaid/CHIP Internet-based enrollment applications, including an evaluation of reading demands, layout characteristics, and document complexity.

METHOD

In May 2010, we downloaded all currently available English-language (n = 50) and Spanish-language (n = 39) Internet-based, state-issued Medicaid/CHIP enrollment applications. We estimated the reading demands of each CHIP enrollment application "Signature" page using the Lexile Analyzer. We assessed layout characteristics using the User-Friendliness Tool and we evaluated document complexity using the PMOSE/IKIRSCH scale.

RESULTS

On average, Medicaid/CHIP enrollment application "Signature" pages were written at a high school reading level (English language = 12th- to 13th-grade reading level; Spanish language = 10th- to 11th-grade reading level). Five Medicaid/CHIP enrollment applications (5.6%) consistently used a 12-point or larger font size throughout. Most Medicaid/CHIP enrollment applications (n = 83; 93.3%) needed "some" or "much" improvement in the amount of white space. Document complexity ranged from level 3 (moderate) to level 5 (very high), with the majority of Medicaid/CHIP enrollment applications ranked at level 4 (high).

DISCUSSION

Revisions are required in almost all state Medicaid/CHIP enrollment applications to achieve consistency and to meet standard low-literacy guidelines (e.g., written at a 6th grade or lower reading level and using a font of 12 points or larger). Additionally, to increase access to Medicaid/CHIP for eligible Hispanic children, all states should provide an online Spanish-language version of the Medicaid/CHIP enrollment application.

Patterns of medicaid disenrollment for youth with mental health problems

Young people who receive Medicaid-funded mental health services during the transition to adulthood often face disenrollment from Medicaid without continuity into publicly funded services. This article investigates the longitudinal predictors of these coverage gaps and disenrollment from age 16 to 23 years. Cox regression analyses estimated predictors of time until the first loss of coverage for 180 days or more, and time until final disenrollment with no subsequent reenrollment. Females were much more likely to regain and retain coverage after initial loss. Funding source and diagnoses predicted Medicaid retention differentially by gender. For both genders, funding through Social Security Income or a diagnosis of Mental Retardation/ Developmental Disabilities was related to Medicaid retention. Disenrollment especially affected males precisely at their 18th and 19th birthdays. Nearly one third of females qualified for Medicaid because of pregnancy. Eligibility guidelines relate to retention and loss during the transition to adulthood and may need reevaluation to ensure continuity of care.

Disparities in the prevalence of cognitive delay: how early do they appear?

Cognitively delayed children are at risk for poor mental and physical health throughout their lives. The economically disadvantaged and some race/ethnic groups are more likely to experience cognitive delay, but the age at which delays first emerge and the underlying mechanisms responsible for disparities are not well understood. The objective of this study was to determine when sociodemographic disparities in cognitive functioning emerge, and identify predictors of low cognitive functioning in early childhood. Data were from 7308 singleton and 1463 multiple births in the Early Childhood Longitudinal Study-Birth Cohort (ECLS-B), a nationally representative cohort of children born in the USA in 2001. Multiple logistic regression analyses examined associations between sociodemographic characteristics and low cognitive functioning at 9 and 24 months, and tested whether gestational and birth-related factors mediate these associations. Sociodemographic characteristics were statistically significant predictors of low cognitive functioning among singletons at 24 months, including the three lowest quintiles of socio-economic status [lowest quintile, odds ratio (OR) = 2.7, 95% confidence interval [CI][1.7, 4.1]], non-white race/ethnicity (African American OR = 1.8 [95% CI 1.3, 2.5], Hispanic OR = 2.3 [95% CI 1.6, 3.2]), and gender (male OR = 2.1, [95% CI 1.7, 2.5]). Gestational and birth characteristics associated with low cognitive function at 9 months included very low and moderately low birthweight (OR = 55.0 [95% CI 28.3, 107.9] and OR = 3.6 [95% CI 2.6, 5.1]), respectively, and very preterm and moderately preterm delivery (OR = 3.6 [95% CI 2.0, 6.7] and OR = 2.4 [95% CI 1.7, 3.5]), respectively, but they had weaker effects by 24 months (ORs for birthweight: 3.7 [95% CI 2.3, 5.9] and 1.8 [95% CI 1.4, 2.3]; ORs for preterm: 1.8 [95% CI 1.1, 2.9] and 0.9 [95% CI 0.7, 1.3]). Results for multiple births were similar. Sociodemographic disparities in poor cognitive functioning emerged by 24 months of age, but were not mediated by gestational or birth characteristics. Further investigation of processes whereby social disadvantage adversely affects development prior to 24 months is needed.

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

INTRODUCTION

Basic health care is beyond the reach of many families, partly due to lack of health insurance. Many of those with insurance also experience unmet need and limited access. In this study, low-income parents illuminate barriers to obtaining health care services for their children.

METHODS

We surveyed a random sample of families from Oregon's food stamp population with children eligible for public insurance, based on household income. Mixed-methods included: (1) multivariable analysis of data from 2,681 completed surveys, and (2) qualitative study of written narratives from 722 parents.

RESULTS

Lack of health insurance was the most consistent predictor of unmet health care needs in the quantitative analysis. Qualitatively, health insurance instability, lack of access to services despite having insurance, and unaffordable costs were major concerns.

CONCLUSIONS

Parents in this low-income population view insurance coverage as different from access to services, and reported a hierarchy of needs. Insurance was the primary concern; access and costs were secondary.

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.

"Mind the Gap" in children's health insurance coverage: does the length of a child's coverage gap matter?

OBJECTIVE

Gaps in health insurance coverage compromise access to health care services, but it is unclear whether the length of time without coverage is an important factor. This article examines how coverage gaps of different lengths affect access to health care among low-income children.

METHODS

We conducted a multivariable, cross-sectional analysis of statewide primary data from families in Oregon's food stamp population with children presumed eligible for publicly funded health insurance. The key independent variable was length of a child's insurance coverage gap; outcome variables were 6 measures of health care access.

RESULTS

More than 25% of children reported a coverage gap during the 12-month study period. Children most likely to have a gap were older, Hispanic, lived in households earning between 133% and 185% of the federal poverty level, and/or had an employed parent. After adjusting for these characteristics, in comparison with continuously insured children, a child with a gap of any length had a higher likelihood of unmet medical, prescription, and dental needs; no usual source of care; no doctor visits in the past year; and delayed urgent care. When comparing coverage gaps, children without coverage for longer than 6 months had a higher likelihood of unmet needs compared with children with a gap shorter than 6 months. In some cases, children with gaps longer than 6 months were similar to, or worse off than, children who had never been insured.

CONCLUSIONS

State policies should be designed to minimize gaps in public health insurance coverage in order to ensure children's continuous access to necessary services.

America's uninsured: the statistics and back story

This article provides an overview of why health insurance matters, a profile of the uninsured, and a discussion of the roles and limits of private and public health insurance as sources of coverage. It concludes with reflections on the current health insurance environment and prospects for reform.

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.

Why millions of children eligible for Medicaid and SCHIP are uninsured: poor retention versus poor take-up

More than two-thirds of uninsured U.S. children are eligible for public coverage, and most current policy debate assumes that this is largely attributable to poor take-up. This paper explores the contribution of poor retention in Medicaid and the State Children's Health Insurance Program (SCHIP) to this phenomenon. The results indicate that one-third of all uninsured children in 2006 had been enrolled in Medicaid or SCHIP the previous year. Among those uninsured but eligible for public coverage in 2006, at least 42 percent had been enrolled in Medicaid or SCHIP the previous year. Both of these measures of disenrollment have increased since 2000.