Underinsurance and key health outcomes for children with special health care needs

Underinsurance Among Children With Special Health Care Needs in the United States

Importance

A rise in pediatric underinsurance during the last decade among households with children with special health care needs (CSHCN) requires a better understanding of which households, by health care burden or income level, have been most impacted.

Objective

To examine the prevalence of underinsurance across categories of child medical complexity and the variation in underinsurance within these categories across different levels of household income.

Design, Setting, and Participants

This cross-sectional study used data from the National Survey of Children's Health and included 218 621 US children from 2016 to 2021. All children included did not reside in any type of institution (eg, correctional institutions, juvenile facilities, orphanages, long-term care facilities). Data were analyzed from January 2016 to December 2021.

Exposures

The primary exposure is a categorization of child health care needs constructed using parent-reported child physical and behavioral health conditions, as well as the presence of functional limitations.

Main Outcomes and Measures

The primary outcome variable is underinsurance, defined as absence of consistent or adequate health insurance. Models were adjusted for demographic and socioeconomic characteristics and stratified by household income. Multivariate logistic regression analysis of pooled cross-sectional survey data across multiple years (2016 to 2021) adjusted for complex survey design (weights).

Results

In a total sample of 218 621 children who were not in institutions and were aged 0 to 17 years from 2016 to 2021 (105 478 [48.9%] female; 113 143 [51.1%] male; 13 571 [13.0%] non-Hispanic Black children; 149 706 [51.2%] non-Hispanic White children), underinsurance prevalence was higher among the children who had complex physical conditions (3316 [37.0%]), mental or behavioral conditions (5432 [38.1%]), or complex physical conditions and functional limitations (1407 [40.7%]) or mental or behavioral conditions with limitations (3442 [41.1%]), compared with healthy children (ie, children without special health care needs or limitations) (52 429 [31.2%]). The association between underinsurance and complexity of child health care needs varied by household income. In households earning 200% to 399% federal poverty level (FPL), underinsurance was associated with children having complex physical conditions and limitations (OR, 2.74; 95% CI, 2.13-3.51) and mental or behavioral conditions and limitations (OR, 2.21; 95% CI, 1.87-2.62), compared with healthy children. In households earning 400% or more above FPL, children's mental or behavioral conditions and limitations were associated with underinsurance (OR, 3.31; 95% CI, 2.82-3.88) compared with healthy children.

Conclusions and relevance

In this cross-sectional study, the odds of being underinsured were not uniform among CSHCN. Both medical complexity and daily functional limitations led to increased odds of being underinsured. The concentration of underinsurance among middle-income households underpinned the challenge of health care financing for families of CSHCN whose incomes surpassed eligibility thresholds for dependent Medicaid insurance.

Underinsurance Among Children in the United States

OBJECTIVES

We describe the change in the percentage of children lacking continuous and adequate health insurance (underinsurance) from 2016 to 2019. We also examine the relationships between child health complexity and insurance type with underinsurance.

METHODS

Secondary analysis of US children in the National Survey of Children's Health combined 2016-2019 dataset who had continuous and adequate health insurance. We calculated differences in point estimates, with 95% confidence intervals (CIs), to describe changes in our outcomes over the study period. We used multivariable logistic regression adjusted for sociodemographic characteristics and examined relationships between child health complexity and insurance type with underinsurance.

RESULTS

From 2016 to 2019, the proportion of US children experiencing underinsurance rose from 30.6% to 34.0% (+3.4%; 95% CI, +1.9% to +4.9%), an additional 2.4 million children. This trend was driven by rising insurance inadequacy (24.8% to 27.9% [+3.1%; 95% CI, +1.7% to +4.5%]), which was mainly experienced as unreasonable out-of-pocket medical expenses. Although the estimate of children lacking continuous insurance coverage rose from 8.1% to 8.7% (+0.6%), it was not significant at the 95% CI (-0.5% to +1.7%). We observed significant growth in underinsurance among White and multiracial children, children living in households with income ≥200% of the federal poverty limit, and those with private health insurance. Increased child health complexity and private insurance were significantly associated with experiencing underinsurance (adjusted odds ratio, 1.9 and 3.5, respectively).

CONCLUSIONS

Underinsurance is increasing among US children because of rising inadequacy. Reforms to the child health insurance system are necessary to curb this problem.

Out-of-Pocket Health Care Expenditures Among United States Children: Parental Perceptions and Past-Year Expenditures, 2016 to 2017

OBJECTIVE

To examine the association between parental perceptions of out-of-pocket (OOP) health care costs for their child and the total amount of OOP health care expenditures for that child during the past year.

METHODS

We used data from the 2016 and 2017 National Surveys of Children's Health, cross-sectional, parent-reported, and nationally representative surveys of noninstitutionalized US children, ages 0 to 17 years. We conducted bivariate analyses to assess characteristics associated with the amount of OOP expenditures and parental perceptions of these costs. We estimated adjusted prevalence ratios for parental perceptions of OOP costs using logistic regression.

RESULTS

Based on parent report, nearly two thirds (65.7%) of children incurred some amount of past-year OOP expenditures, with 13.3% of children incurring expenditures of ≥$1000. Parents reported that costs were unreasonable for 35.3% of children with past-year expenditures. The amount of OOP spending was associated with parents' perceptions that costs were unreasonable, with 16.5% of those with $1 to 249 in expenditures reporting unreasonable costs compared to 77.5% of those with >$5,000 in expenditures (P < .05). In adjusted analyses, high OOP expenditures, non-Hispanic white race/ethnicity, lack of health insurance, low household income, parental education levels less than a college degree, and foreign-born nativity status were associated with reports of unreasonable costs (P < .05).

CONCLUSIONS

This study demonstrates an association between attitudinal and economic measures of health care expenditures for children while demonstrating differences in the perception of costs by measures of family economic vulnerability. Results may inform efforts to assess adequacy of health insurance coverage.

Health care utilization and spending among privately insured children with medical complexity

Children with medical complexity have high health service utilization and health expenditures that can impose significant financial burdens. This study examined these issues for families with children enrolled in US private health plans. Using IBM Watson/Truven Analytics℠ MarketScan® commercial claims and encounters data (2012-2014), we analyzed through regression models, the differences in health care utilization and spending of disaggregated health care services by health plan types and children's medical complexity levels. Children in consumer-driven and high-deductible plans had much higher out-of-pocket spending and cost shares than those in health maintenance organizations and preferred provider organizations (PPOs). Children with complex chronic conditions had higher service utilization and out-of-pocket expenditures while having lower cost shares on various categories of services than those without any chronic condition. Compared to families covered by PPOs, those with high-deductible or consumer-driven plans were 2.7 and 1.7 times more likely to spend over US$1000 out of pocket on their children's medical care, respectively. Families with higher complexity levels were more likely to experience financial burdens from expenditures on children's medical services. In conclusion, policymakers and families with children need to be cognizant of the significant financial burdens that can arise from children's complex medical needs and health plan demand-side cost sharing.

Differences in continence rates in individuals with spina bifida based on ethnicity

BACKGROUND

Ethnic disparities in continence rates in spina bifida (SB) have been studied regionally but not nationally. National SB Patient Registry (NSBPR) data were analyzed to explore differences in prevalence of bowel and bladder continence and interventions between Hispanics/Latinos and others.

METHODS

Participants 5 to 21 years were categorized into Hispanic/Latino and non-Hispanic/non-Latino. Bladder/bowel continence was defined as dry/no involuntary stool leakage during the day or none/⩽ monthly incontinence. Chi-square test, Wilcoxon Two Sample Test, and generalized estimating equation (GEE) were used for statistical analysis.

RESULTS

Twenty-five percent of the 4,364 patients were Hispanic/Latino. At their most recent clinic visit, Hispanics/Latinos demonstrated lower rates of urinary continence (38.6% vs. 44.9%; p= 0.0003), bowel continence (43.9% vs. 55.8%, p< 0.0001), private insurance (p< 0.0001), bowel (p< 0.0001) or bladder surgeries (p= 0.0054), and more vesicostomies (p= 0.0427) compared to others. In multiple GEE models, Hispanic/Latino participants demonstrated lower odds of bowel continence as compared to non-Hispanic/non-Latino participants (estimated odds ratio, 0.82, 95% CI, 0.72-0.94, p= 0.0032).

CONCLUSIONS

After controlling for covariates, Hispanics/Latinos with SB are less likely to report bowel continence. Clinicians are encouraged to consider the risk of negative health disparities for Hispanic patients with SB and work to mitigate this risk.

Shared decision-making and parental experiences with health services to meet their child's special health care needs: Racial and ethnic disparities

OBJECTIVES

Test the relationship between shared decision-making (SDM) and parental report of frustration with efforts to get services for their child and to address unmet health needs; assess SDM's influence on minority parents' service experiences.

METHODS

Performed secondary analysis using the 2009-2010 National Survey of Children with Special Health Care Needs (n = 40,242). Used multivariate logistic regressions to test the association between SDM and parent-reported service experiences, and whether SDM influenced the association between minorities and negative service experiences. Propensity scores accounted for observed selection bias.

RESULTS

Families engaged in SDM had lower odds of reporting service dissatisfaction. Fewer minority parents reported SDM engagement compared with Whites (between 62% and 66% versus 74%). Blacks engaged in SDM had higher odds of reporting negative service experiences compared with SDM-engaged Whites. This disparity was no longer significant after adjusting for covariates.

CONCLUSION

SDM is associated with lower reports of parental service dissatisfaction. Stratified analyses showed that SDM seems to be experienced differently across minority groups.

PRACTICE IMPLICATIONS

SDM may be a promising engagement strategy to improve parental service experiences. The role of SDM on increasing Black parents' reports of service dissatisfaction, perhaps due to increased awareness of service challenges, should be investigated.

Refining Our Understanding of Value-Based Insurance Design and High Cost Sharing on Children

BACKGROUND

There is significant concern about the financial burdens of new insurance plan designs on families, particularly families with children and youth with special health care needs (CYSHCN). With value-based insurance design (VBID) plans growing in popularity, this study examined the implications of selected VBID cost-sharing features on children.

METHODS

We studied children's health care spending patterns in 2 data sets that include high deductible and narrow network plans among others. Medical Expenditure Panel Survey data from 2007 to 2013 on 22 392 children were used to study out-of-pocket (OOP) costs according to CYSHCN, family income, and spending. MarketScan large employer insurance claims data from 2007 to 2014 (N = 4 263 452) were used to test for differences in mean total payments and OOP costs across various health plans.

RESULTS

Across the data sets, we found that existing health plans place significant financial burdens on families, particularly lower income households and families with CYSHCN; individuals among the top 10% of OOP spending averaged more than $2000 per child. Although high deductible and consumer-driven plans impose substantial OOP costs on children, they do not significantly reduce spending, whereas health maintenance organizations that use network restrictions and tighter management do.

CONCLUSIONS

Our results do not support the conclusion that high cost-sharing features that are common in VBID plans will significantly reduce health care spending on children.

Strategies to identify and stratify children with special health care needs in outpatient general pediatrics settings

Developing improved systems of care for children with special health care needs (CSHCN) requires accurate identification and stratification of this population. This study was designed to assess the ability of a brief screener to identify and stratify CSHCN in a primary care clinic to focus future quality improvement initiatives and allocate resources. All families presenting for health maintenance visits or acute care appointments at an academic primary care clinic between September 5, 2012 and September 28, 2012 were asked to complete the CSHCN Screener(©). This panel of patients was compared to registries previously created by: (1) retrospective chart reviews using published lists of International Statistical Classification of Diseases and Related Health Problems (ICD9) codes for CSHCN and (2) direct physician referral to a clinic case manager providing care coordination services to CSHCN. Screeners identified 246 CSHCN (16.8 % of unique completed screeners). Scores ranged from 0 to 5; higher scores indicate higher levels of complexity. Patients with positive screens had a mean score of 2.4. Patients previously identified by retrospective ICD9 search who completed a screener had a mean score of 1.6 with nearly one-half having negative screens. Patients previously identified by physician referral who completed a screener had a mean score of 2.7 with nearly one-half having scores of 4 or 5. The CSHCN Screener(©) can be utilized in an academic primary care clinic to prospectively identify CSHCN and potentially offers a more clinically meaningful method of identification given its inherent ability to stratify this population based on complexity of medical needs.

The Louisiana Family Opportunity Act Medicaid Buy-in Program

OBJECTIVES

The Family Opportunity Act Medicaid Buy-In Program (FOA) allows states to expand Medicaid coverage to children who meet selected disability and income eligibility criteria. FOA programs may help address family financial hardship as a result of underinsurance. We provide specific information about the FOA program and report the first results of a survey of parents or guardians of children with disabilities who were enrolled in Louisiana's FOA program.

METHODS

A convenience sample of families enrolled in the program (N = 52) responded to questions derived from the National Survey of Children with Special Health Care Needs (CSHCN). These results were compared to two groups of Louisiana families of CSHCN that had responded to the 2009/10 national survey.

RESULTS

Data suggest that children enrolled in the Louisiana FOA are younger than those enrolled in Supplemental Security Income, are more likely to have functional losses, and, perhaps due to their age, are less likely to have difficulty with anxiety, depression, or behavior problems. FOA families are less likely than families in either group to report receiving help with care coordination, and more likely to report financial problems due to their child's health. Respondents were also more likely to report that they received all the therapy services and specialty care they needed.

CONCLUSIONS

The FOA program thus appears to be filling a niche in coverage needs among families of children with disabilities in Louisiana.

Patient Protection and Affordable Care Act of 2010 and children and youth with special health care needs

The Patient Protection and Affordable Care Act (ACA) was designed to (1) decrease the number of uninsured Americans, (2) make health insurance and health care affordable, and (3) improve health outcomes and performance of the health care system. During the design of ACA, children in general and children and youth with special health care needs and disabilities (CYSHCN) were not a priority because before ACA, a higher proportion of children than adults had insurance coverage through private family plans, Medicaid, or the State Children's Health Insurance Programs (CHIP). ACA benefits CYSHCN through provisions designed to make health insurance coverage universal and continuous, affordable, and adequate. Among the limitations of ACA for CYSHCN are the exemption of plans that had been in existence before ACA, lack of national standards for insurance benefits, possible elimination or reductions in funding for CHIP, and limited experience with new delivery models for improving care while reducing costs. Advocacy efforts on behalf of CYSHCN must track implementation of ACA at the federal and the state levels. Systems and payment reforms must emphasize access and quality improvements for CYSHCN over cost savings. Developmental-behavioral pediatrics must be represented at the policy level and in the design of new delivery models to assure high quality and cost-effective care for CYSHCN.

Finding medical care for colorectal cancer symptoms: experiences among those facing financial barriers

Financial barriers can substantially delay medical care seeking. Using patient narratives provided by 252 colorectal cancer patients, we explored the experience of financial barriers to care seeking. Of the 252 patients interviewed, 84 identified financial barriers as a significant hurdle to obtaining health care for their colorectal cancer symptoms. Using verbatim transcripts of the narratives collected from patients between 2008 and 2010, three themes were identified: insurance status as a barrier (discussed by n = 84; 100% of subsample), finding medical care (discussed by n = 30; 36% of subsample) and, insurance companies as barriers (discussed by n = 7; 8% of subsample). Our analysis revealed that insurance status is more nuanced than the categories insured/uninsured and differentially affects how patients attempt to secure health care. While barriers to medical care for the uninsured have been well documented, the experiences of those who are underinsured are less well understood. To improve outcomes in these patients it is critical to understand how financial barriers to medical care are manifested. Even with anticipated changes of the Affordable Care Act, it remains important to understand how perceived financial barriers may be influencing patient behaviors, particularly those who have limited health care options due to insufficient health insurance coverage.

Parents' perspectives on their children's health insurance: plight of the underinsured

OBJECTIVES

To determine the prevalence and correlates of children's underinsurance within a primary care, practice-based research network.

STUDY DESIGN

A survey of 13 practices within the Southwestern Ohio Ambulatory Research Network using the Medical Expenses for Children Survey in 2009 and 2010 yielded a sample of 2972 parents of children >6 months old with health insurance in the previous 12 months. Data were analyzed using bivariate and loglinear model analyses.

RESULTS

Of the study children, 17.2% were classified as underinsured because of their inability to pay for ≥ 1 of their pediatrician's recommendations for care in the past 12 months. In addition, 15.5% reported it was harder to get medical care for their child in the past 3 years, and 6.5% indicated that their child's health had suffered. Multivariate analysis reveals complex relationships among the 3 factors related to ability to obtain care and between these factors and sociodemographic and health status factors. Across education and income categories, the underinsured rate ranged from 57% to 93% for parents who reported their child's health had suffered.

CONCLUSIONS

One in 6 parents reported that their child was underinsured. A similar percentage reported that it had become more difficult to get needed medical care over the past 3 years. The relationship between the perception that an underinsured child's health has suffered is much stronger for the highest socioeconomic category in this sample than for the other categories; 93% of these families were underinsured in 2009. It is possible that high deductible features of insurance plans contribute to these circumstances.

Enrolling and retaining uninsured and underinsured populations in public health insurance through a service integration model in New York City

Innovative strategies to identify uninsured and underinsured populations are critical to successful enrollment and retention in public health insurance. The New York City Department of Health and Mental Hygiene's Office of Health Insurance Services has partnered with the department's Early Intervention Program to implement a Service Integration Model to enroll special needs children, aged 0 to 3 years, into public health insurance. This model uses data from program databases and staff from children's programs to proactively identify uninsured and underinsured children and facilitate their enrollment into public health insurance. The model overcomes enrollment barriers by using consumer-friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

The value of the medical home for children without special health care needs

OBJECTIVE

Although the medical home is promoted by the American Academy of Pediatrics and the Affordable Care Act, its impact on children without special health care needs is unknown. We examined whether the medical home is associated with beneficial health care utilization and health-promoting behaviors in this population.

METHODS

This study was a secondary data analysis of the 2003 National Survey of Children's Health. Data were available for 70 007 children without special health care needs. We operationalized the medical home according to the National Survey of Children's Health design. Logistic regression for complex sample surveys was used to model each outcome with the medical home, controlling for sociodemographic characteristics.

RESULTS

Overall, 58.1% of children without special health care needs had a medical home. The medical home was significantly associated with increased preventive care visits (adjusted odds ratio [aOR]: 1.32 [95% confidence interval (CI): 1.22-1.43]), decreased outpatient sick visits (aOR: 0.71 [95% CI: 0.66-0.76), and decreased emergency department sick visits (aOR: 0.70 [95% CI: 0.65-0.76]). It was associated with increased odds of "excellent/very good" child health according to parental assessment (aOR: 1.29 [95% CI: 1.15-1.45) and health-promoting behaviors such as being read to daily (aOR: 1.46 [95% CI: 1.13-1.89]), reported helmet use (aOR: 1.18 [95% CI: 1.03-1.34]), and decreased screen time (aOR: 1.12 [95% CI: 1.02-1.22]).

CONCLUSIONS

For children without special health care needs, the medical home is associated with improved health care utilization patterns, better parental assessment of child health, and increased adherence with health-promoting behaviors. These findings support the recommendations of the American Academy of Pediatrics and the Affordable Care Act to extend the medical home to all children.

Underinsurance among children in the United States

BACKGROUND

Recent interest in policy regarding children's health insurance has focused on expanding coverage. Less attention has been devoted to the question of whether insurance sufficiently meets children's needs.

METHODS

We estimated underinsurance among U.S. children on the basis of data from the 2007 National Survey of Children's Health (sample size, 91,642 children) regarding parents' or guardians' judgments of whether their children's insurance covered needed services and providers and reasonably covered costs. Data on adequacy were combined with data on continuity of insurance coverage to classify children as never insured during the past year, sometimes insured during the past year, continuously insured but inadequately covered (i.e., underinsured), and continuously insured and adequately covered. We examined the association between this classification and five overall indicators of health care access and quality: delayed or forgone care, difficulty obtaining needed care from a specialist, no preventive care, no developmental screening at a preventive visit, and care not meeting the criteria of a medical home.

RESULTS

We estimated that in 2007, 11 million children were without health insurance for all or part of the year, and 22.7% of children with continuous insurance coverage--14.1 million children--were underinsured. Older children, Hispanic children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. As compared with children who were continuously and adequately insured, uninsured and underinsured children were more likely to have problems with health care access and quality.

CONCLUSIONS

The number of underinsured children exceeded the number of children without insurance for all or part of the year studied. Access to health care and the quality of health care are suboptimal for uninsured and underinsured children. (Funded by the Health Resources and Services Administration.)

Access to genetic counseling for children with autism, Down syndrome, and intellectual disabilities

OBJECTIVE

We examined the need for genetic counseling services (GCS) for families of children with autism spectrum disorder (ASD), Down syndrome (DS), and/or mental retardation (MR) and factors that influence the receipt of needed GCS for those children relative to other children with special health care needs (CSHCN).

METHODS

Analysis was conducted on the 2005-2006 National Survey of Children With Special Health Care Needs, a nationally representative sample. Bivariate analyses were conducted by examining need for and receipt of GCS for children with ASD, DS, and/or MR and other CSHCN as well as differences by contextual variables using the health belief model (HBM). Logistic regression analyses were conducted to assess the relative impact of receipt of needed GCS by HBM constructs.

RESULTS

Families of children with diagnoses of ASD, DS, and/or MR perceive significantly higher need for GCS than other CSHCN. The presence of a medical home is the single most important factor in facilitating access to GCS, together with the presence of insurance, particularly private or a combination of private and public insurance. As income and education attainment decrease, barriers to GCS rise.

CONCLUSIONS

This analysis supports strategies for improving linkages between specialty providers and the medical home at which primary care is delivered. Increased effort should be made to attend to those who experience barriers that result from lack of insurance, poverty, low education, or racial or ethnic differences. Health professionals need to collaborate in developing solutions to underinsurance or lack of insurance for CSHCN.

The impact of insurance on satisfaction and family-centered care for CSHCN

BACKGROUND

Children with special health care needs (CSHCN) have worse health outcomes and satisfaction compared with children with typical needs. Although individual characteristics influence satisfaction and family-centered care, additional effects of health insurance and state child health policies are unknown.

OBJECTIVES

To determine if satisfaction and family-centered care varied among CSHCN, after adjusting for individual characteristics, according to insurance type and state child health policies.

METHODS

We performed descriptive and multivariate analyses by using demographic, insurance, and satisfaction data from the 2006 National Survey of Children With Special Health Care Needs (N = 40723). Additional state data included Medicaid and State Children's Health Insurance Program (SCHIP) characteristics and the supply of pediatricians. We supplemented the national findings with survey data from Florida's SCHIP comprehensive care program (CMS-Duval ["Ped-I-Care"]) for CSHCN (N = 300).

RESULTS

Nationally, 59.8% of parents were satisfied with their child's health services, and two thirds (65.7%) received family-centered care. Adjusting for individual predictors, those uninsured and those with public insurance were less satisfied (odds ratios [ORs]: 0.45 and 0.83, respectively) and received less family-centered care (ORs: 0.43 and 0.80, respectively) than privately insured children. Of note, satisfaction increased with state Medicaid spending. Survey data from Ped-I-Care yielded significantly higher satisfaction (91.7%) compared with national levels of satisfaction in the SCHIP (54.2%) and similar rates of family-centered care (65.6%). These results suggest that satisfaction is based more on experiences with health systems, whereas family-centered care reflects more on provider encounters.

CONCLUSIONS

Insurance type affects both satisfaction and family-centered care for CSHCN, and certain state-level health care characteristics affect satisfaction. Future studies should focus on interventions in the health care system to improve satisfaction and patient encounters for family-centered care.

The future of health insurance for children with special health care needs

CONTEXT

Because of their elevated need for services, health insurance is particularly important for children with special health care needs. In this article we assess how well the current system is meeting the insurance needs of children with special health care needs and how emerging trends in health insurance may affect their well-being.

METHODS

We begin with a review of the evidence on the impact of health insurance on the health care experiences of children with special health care needs based on the peer-reviewed literature. We then assess how well the current system meets the needs of these children by using data from 2 editions of the National Survey of Children With Special Health Care Needs. Finally, we present an analysis of recent developments and emerging trends in the health insurance marketplace that may affect this population.

RESULTS

Although a high proportion of children with special health care needs have insurance at any point in time, nearly 40% are either uninsured at least part of the year or have coverage that is inadequate. Recent expansions in public coverage, although offset in part by a contraction in employer-based coverage, have led to modest but significant reductions in the number of uninsured children with special health care needs. Emerging insurance products, including consumer-directed health plans, may expose children with special health care needs and their families to greater financial risks.

CONCLUSIONS

Health insurance coverage has the potential to secure access to needed care and improve the quality of life for these children while protecting their families from financially burdensome health care expenses. Continued vigilance and advocacy for children and youth with special health care needs are needed to ensure that these children have access to adequate coverage and that they fare well under health care reform.

Medicaid managed care and the unmet need for mental health care among children with special health care needs

OBJECTIVE

To determine the association between Medicaid managed care pediatric behavioral health programs and unmet need for mental health care among children with special health care needs (CSHCN).

DATA SOURCE

The National Survey of CSHCN (2000-2002), using subsets of 4,400 CSHCN with Medicaid and 1,856 CSHCN with Medicaid and emotional problems. Additional state-level sources were used.

STUDY DESIGN

Multilevel models investigated the association between managed care program type (carve-out, integrated) or fee-for-service (FFS) and reported unmet mental health care need.

DATA COLLECTION/EXTRACTION METHODS

The National Survey of CSHCN conducted telephone interviews with a sample representative at both the national and state levels.

PRINCIPAL FINDINGS

In multivariable models, among CSHCN with only Medicaid, living in states with Medicaid managed care (odds ratio [OR]=1.81; 95 percent confidence interval: 1.04-3.15) or carve-out programs (OR=1.93; 1.01-3.69) were associated with greater reported unmet mental health care need compared with FFS programs. Among CSHCN on Medicaid with emotional problems, the association between managed care and unmet need was stronger (OR=2.48; 1.38-4.45).

CONCLUSIONS

State Medicaid pediatric behavioral health managed care programs were associated with greater reported unmet mental health care need than FFS programs among CSHCN insured by Medicaid, particularly for those with emotional problems.

Children and youth with special healthcare needs: there is no place like (a medical) home

PURPOSE OF REVIEW

This review highlights the importance, components, and outcomes of the medical home for children and youth with special healthcare needs. Relevant work supporting the medical home concept for this vulnerable group is highlighted for healthcare providers.

RECENT FINDINGS

Developing a medical home model is garnering support from many national organizations and agencies. Having a medical home for children and youth with special healthcare needs is associated with favorable impacts on healthcare utilization and family-centered care. Achieving family-centered care is associated with increases in satisfaction and linkages to specialists, decreases in school absences and unmet medical needs. Consistent insurance coverage is important for children and youth with special healthcare needs to thrive. Further, lack of access to informational resources minimizes families' knowledge of available public programs.

SUMMARY

Children and youth with special healthcare needs constitute a vulnerable population in need of comprehensive and accessible care. Provision of care via a medical home can be efficient and effective in this population of children and their families. Due to the relatively high cost of providing fragmented care to these children and youth, advances in coordinating access to services will have a cost-effective outcome.