Mandated child health insurance: an approach whose time has come?

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.

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+.