The effects of varying periods of uninsurance on children's access to health care

Age of autism diagnosis in Latin American and Caribbean countries

LAY ABSTRACT

An earlier diagnosis of autism spectrum disorder might lead to earlier intervention. However, people living in Latin American and Caribbean countries do not have much knowledge about autism spectrum disorder symptoms. It has been suggested that the older a child is when diagnosed, the fewer opportunities he or she will have to receive services. We asked 2520 caregivers of autistic children in six different Latin America and Caribbean Countries, the child's age when they noticed some developmental delays and their child's age when they received their first autism spectrum disorder diagnosis. Results indicate that, on average, caregivers were concerned about their child's development by 22 months of age; however, the diagnosis was received when the child was 46 months of age. In addition, older children with better language abilities and public health coverage (opposed to private health coverage) were diagnosed later. On the contrary, children with other medical problems and more severe behaviors received an earlier diagnosis. In our study, children were diagnosed around the time they entered formal schooling, delaying the access to early intervention programs. In summary, the characteristics of the autistic person and the type of health coverage influence the age of diagnosis in children living in Latin America and Caribbean Countries.

Medicaid Expansion Under the Affordable Care Act and Pediatric Trauma Patient Insurance Coverage

INTRODUCTION

Uninsured pediatric trauma patients are at increased risk of poor outcomes. The impact of the Patient Protection and Affordable Care Act (ACA) on pediatric trauma patients has not been studied. We hypothesized that the expansion of Medicaid coverage under the ACA was associated with increased insurance coverage and improved outcomes.

METHODS

Retrospective review of patients <18 y old presenting to a level 1 pediatric trauma center 2009-2019. An interrupted time series analysis was performed to assess the impact of Medicaid expansion under the ACA in January 2014. The primary outcome was rate of insurance coverage. Secondary outcomes included in-hospital mortality, disposition, 30-day readmission, length of stay (LOS), and intensive care unit (ICU) LOS.

RESULTS

A total of 5645 patients were evaluated, (pre-ACA n = 2,243, post-ACA n = 3402). Expansion of Medicaid was associated with minimal changes on insurance coverage. There a decrease in mortality (RR = 0.96, P = 0.0355) and a slight increase in disposition to a rehabilitation facility (RR = 1.02, P = 0.0341). There was no association with 30-day readmission (RR = 1.02, P = 0.3498). Similarly, expansion of Medicaid was not associated with change in LOS (estimate = -0.00, P = 0.8893). There was a slight decrease in ICU LOS (estimate = -0.03, P < 0.0001).

CONCLUSIONS

Medicaid expansion was associated with marginal changes in insurance coverage among pediatric trauma patients. We did not identify significant impacts on patient outcomes.

A space-time analysis of disparities in age at diagnosis of autism spectrum disorder: environmental and socioeconomic risk factors

INTRODUCTION

Early diagnosis of autism is a critical step for gaining early intervention. The earlier interventions begin, the greater chance to reduce symptoms of autism over the lifespan. Despite the improvement in early diagnosis, age at diagnosis varies by residential locations. In order to improve early screening services, this study aims to identify geographic clusters of early and late diagnosis of autism, in addition, it is aimed to compare cases inside the clusters with the rest of the province on characteristics and socioeconomic factors.

MATERIALS AND METHODS

Survey data were collected from 163 autistics born from 1996 to 2011 in Isfahan Province, Iran. As this study found diagnosis of autism occur at an earlier age among children, who on average every 2.5 months increased for each year of age, distance from regression line has been used to determine how early a case was diagnosed compared to other identified cases. After dividing cases into 5 classes based on their distances from the regression line, the ordinal based space-time scan statistic in SaTScan was used to identify geographic areas within specific time periods that have significantly elevated proportions of autistic children who received diagnosis at the earlier or later stages.

RESULTS

The space-time analysis identified two geographic areas that age of diagnosis was inconsistent with the overall study area, the first area has an early diagnosis in central part of Isfahan megacity between 1998 and 2006 (P = .001), the second area shows to have a late diagnosis centered by Najafabad from 2010 through 2015 (P = .007).

CONCLUSIONS

The result of our spatial analysis can be used to evaluate the performance of diagnosis services and additionally provide information to target specific at-risk population for further interventions.

Outpatient healthcare access and utilization for neonatal abstinence syndrome children: A systematic review

OBJECTIVE

The objective of this study was to systematically assess the literature regarding postnatal healthcare utilization and barriers/facilitators of healthcare in neonatal abstinence syndrome (NAS) children.

METHODS

A systematic search was performed in PubMed, Cochrane Database of Systematic Reviews, PsychINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science to identify peer-reviewed research. Eligible studies were peer-reviewed articles reporting on broad aspects of primary and specialty healthcare utilization and access in NAS children. Three investigators independently reviewed all articles and extracted data. Study bias was assessed using the Newcastle-Ottawa Assessment Scale and the National Institute of Health Study Quality Assessment Tool.

RESULTS

This review identified 14 articles that met criteria. NAS children have poorer outpatient appointment adherence and have a higher rate of being lost to follow-up. These children have overall poorer health indicated by a significantly higher risk of ER visits, hospital readmission, and early childhood mortality compared with non-NAS infants. Intensive multidisciplinary support provided through outpatient weaning programs facilitates healthcare utilization and could serve as a model that could be applied to other healthcare fields to improve the health among this population.

CONCLUSIONS

This review investigated the difficulties in accessing outpatient care as well as the utilization of such care for NAS infants. NAS infants tend to have decreased access to and utilization of outpatient healthcare following hospital birth discharge. Outpatient weaning programs have proven to be effective; however, these programs require intensive resources and care coordination that has yet to be implemented into other healthcare areas for NAS children.

Maternal and child patterns of Medicaid retention: a prospective cohort study

BACKGROUND

We sought to determine whether maternal Medicaid retention influences child Medicaid retention because caregivers play a critical role in assuring children's health access.

METHODS

We conducted a longitudinal prospective cohort study of a convenience sample of 604 Medicaid-eligible mother-child dyads followed from the infant's birth through 24 months of age with parent surveys. Individual enrollment status was abstracted from administrative Medicaid eligibility files. Generalized estimating equations quantified the effect of maternal Medicaid enrollment status on child Medicaid retention, adjusting for relevant covariates. Because varying lengths of gaps may have different effects on child health outcomes, Medicaid enrollment status was further categorized by length of gap: any gap, > 14-days, and > 60-days.

RESULTS

This cohort consists primarily of African-American (94%), unmarried mothers (88%), with a mean age of 23.2 years. In multivariable analysis, children whose mothers experienced any gaps in coverage had 12.6 times greater odds of experiencing gaps when compared to children whose mothers were continuously enrolled. Use of varying thresholds to define coverage gaps resulted in similar odds ratios (> 14-day gap = 11.8, > 60-day gap = 16.8). Cash assistance receipt and maternal knowledge of differences between Temporary Assistance to Needy Families and Medicaid eligibility criteria demonstrated strong protective effects against child Medicaid disenrollment.

CONCLUSIONS

Medicaid disenrollment remains a significant policy problem and maternal Medicaid retention patterns show strong effects on child Medicaid retention. Policymakers need to invest in effective outreach strategies, including family-friendly application processes, to reduce enrollment barriers so that all eligible families can take advantage of these coverage opportunities.

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.

Predictors of Age of Diagnosis for Children with Autism Spectrum Disorder: The Role of a Consistent Source of Medical Care, Race, and Condition Severity

Having a consistent source of medical care may facilitate diagnosis of autism spectrum disorders (ASD). This study examined predictors of age of ASD diagnosis using data from the 2011-2012 National Survey of Children's Health. Using multiple linear regression analysis, age of diagnosis was predicted by race, ASD severity, having a consistent source of care (CSC), and the interaction between these variables after controlling for birth cohort, birth order, poverty level, parental education, and health insurance. While African American children were diagnosed earlier than Caucasians, this effect was moderated by ASD severity and CSC. Having a CSC predicted earlier diagnosis for Caucasian but not African American children. Both physician and parent behaviors may contribute to diagnostic delays in minority children.

Use of qualitative methods and user-centered design to develop customized health information technology tools within federally qualified health centers to keep children insured

Lack of health insurance negatively impacts children's health. Despite federal initiatives to expand children's coverage and accelerate state outreach efforts, millions of US children remain uninsured or experience frequent gaps in coverage. Most current efforts to enroll and retain eligible children in public insurance programs take place outside of the health care system. This study is a partnership between patients' families, medical informaticists, federally qualified health center (FQHC) staff, and researchers to build and test information technology tools to help FQHCs reach uninsured children and those at risk for losing coverage.

Health insurance coverage and healthcare utilization among infants of mothers in the national methadone maintenance treatment program in Taiwan

BACKGROUND

Children of heroin-using women have a higher risk of unfavorable health and developmental outcomes. Although methadone maintenance treatment (MMT) has been widely used to treat heroin-using pregnant women, potential effects on accessibility and utilization of healthcare service for their offspring are less explored.

METHODS

We used four national registry and health insurance datasets in Taiwan from 2004 to 2009 to form a population-based matched retrospective cohort study. A total of 1056 neonates born to women in the MMT program (857 born before mother's enrollment in the MMT program [BM], 199 born after mother's enrollment in the MMT program [AM]) was established; 10547 matched non-drug [ND] exposed neonates were identified for comparison. Outcome variables included offspring's health insurance coverage and utilization of preventive, outpatient, and emergency room cares in the first year after birth.

RESULTS

Infants born to mothers on MMT were more likely to have no or incomplete insurance coverage (BM: adjusted odds ratio [aOR]=1.29, 95% CI: 1.10-1.53; AM: aOR=1.56, 95% CI: 1.14-2.13) as compared with the socioeconomic status-matched ND group. The BM infants appeared to have fewer preventive care visits (adjusted relative risk [aRR]=0.85, 95% CI: 0.80-0.90), whereas the AM infants utilized outpatient and emergency room services more frequently (outpatient: aRR=1.11, 95% CI: 1.01-1.23; emergency: aRR=1.46, 95% CI: 1.11-1.90).

CONCLUSIONS

Addiction treatment and harm reduction programs for women of childbearing ages should be delivered in the coordinated framework that ensures comprehensiveness and continuity in healthcare and social services.

The impact of insurance coverage during insurance reform on diagnostic resolution of cancer screening abnormalities

We examined the impact of Massachusetts insurance reform on the care of women at six community health centers with abnormal breast and cervical cancer screening to investigate whether stability of insurance coverage was associated with more timely diagnostic resolution. We conducted Cox proportional hazards models to predict time from cancer screening to diagnostic resolution, examining the impact of 1) insurance status at time of screening abnormality, 2) number of insurance switches over a three-year period, and 3) insurance history over a three-year period. We identified 1,165 women with breast and 781 with cervical cancer screening abnormalities. In the breast cohort, Medicaid insurance at baseline, continuous public insurance, and losing insurance predicted delayed resolution. We did not find these effects in the cervical cohort. These data provide evidence that stability of health insurance coverage with insurance reform nationally may improve timely care after abnormal cancer screening in historically underserved women.

Emergency department-based health insurance enrollment for children: does linkage lead to insurance retention and utilization?

OBJECTIVES

Although 40% of emergency departments (EDs) report having an insurance linkage program, no studies have evaluated the long-term success of these programs. This study aimed to examine insurance retention and utilization by children initially referred to insurance by our ED insurance linkage program.

METHODS

We retrospectively examined insurance records of all uninsured children successfully enrolled in public insurance by the insurance linkage program established in our suburban academic ED between 2004 and 2009. Emergency department-enrolled children were matched by age, sex, program, and year of enrollment to a control group of children from the same county who were enrolled in non-ED settings. Wilcoxon signed rank and χ tests were used to compare enrollment and claims variables.

RESULTS

Emergency department-enrolled children retained insurance for longer, had a higher reenrollment rate, and were higher users of insurance. The average length of enrollment for ED children was 734 days versus 597 days in the control group. Eighty percent of the ED cohort reenrolled in insurance after initial eligibility expiration versus 64% of the control group. Children enrolled via the ED averaged 26 claims (vs 12 claims) and $20,087 (vs $5216) in hospital charges per year of enrollment. This higher utilization was reflected in increased primary care, specialty care, ED visits, inpatient, and mental health claims in the ED group.

CONCLUSIONS

Emergency department-based insurance enrollment programs have the potential to improve access to health care for children. Policies aimed at expanding insurance enrollment among the uninsured population, including the Affordable Care Act, may consider the ED's potential as an effective enrollment site.

Using electronic health record data to evaluate preventive service utilization among uninsured safety net patients

OBJECTIVE

This study compared the preventive service utilization of uninsured patients receiving care at Oregon community health centers (CHCs) in 2008 through 2011 with that of continuously insured patients at the same CHCs in the same period, using electronic health record (EHR) data.

METHODS

We performed a retrospective cohort analysis, using logistic mixed effects regression modeling to calculate odds ratios and rates of preventive service utilization for patients without insurance, or with continuous insurance.

RESULTS

CHCs provided many preventive services to uninsured patients. Uninsured patients were less likely than continuously insured patients to receive 5 of 11 preventive services, ranging from OR 0.52 (95% CI: 0.35-0.77) for mammogram orders to 0.75 (95% CI: 0.66-0.86) for lipid panels. This disparity persisted even in patients who visited the clinic regularly.

CONCLUSION

Lack of insurance is a barrier to preventive service utilization, even in patients who can access care at a CHC. Policymakers in the United States should continue to address this significant prevention disparity.

Financial barriers to care among low-income children with asthma: health care reform implications

IMPORTANCE

The Patient Protection and Affordable Care Act (ACA) includes subsidies that reduce patient cost sharing for low-income families. Limited information on the effects of cost sharing among children is available to guide these efforts.

OBJECTIVE

To examine the associations between cost sharing, income, and care seeking and financial stress among children with asthma.

DESIGN, SETTING, AND PARTICIPANTS

A telephone survey in 2012 about experiences during the prior year within an integrated health care delivery system. Respondents included 769 parents of children aged 4 to 11 years with asthma. Of these, 25.9% of children received public subsidies; 21.7% were commercially insured with household incomes at or below 250% of the federal poverty level (FPL) and 18.2% had higher cost-sharing levels for all services (e.g., ≥$75 for emergency department visits). We classified children with asthma based on (1) current receipt of a subsidy (i.e., Medicaid or Children's Health Insurance Program) or potential eligibility for ACA low-income cost sharing or premium subsidies in 2014 (i.e., income ≤250%, 251%-400%, or >400% of the FPL) and (2) cost-sharing levels for prescription drugs, office visits, and emergency department visits. We examined the frequency of changes in care seeking and financial stress due to asthma care costs across these groups using logistic regression, adjusted for patient/family characteristics.

MAIN OUTCOMES AND MEASURES

Switching to cheaper asthma drugs, using less medication than prescribed, delaying/avoiding any office or emergency department visits, and financial stress (eg, cutting back on necessities) because of the costs of asthma care.

RESULTS

After adjustment, parents at or below 250% of the FPL with lower vs higher cost-sharing levels were less likely to delay or avoid taking their children to a physician's office visit (3.8% vs. 31.6%; odds ratio, 0.07 [95% CI, 0.01-0.39]) and the emergency department (1.2% vs. 19.4%; 0.05 [0.01-0.25]) because of cost; higher-income parents and those whose children were receiving public subsidies (eg, Medicaid) were also less likely to forego their children's care than parents at or below 250% of the FPL with higher cost-sharing levels. Overall, 15.6% of parents borrowed money or cut back on necessities to pay for their children's asthma care.

CONCLUSIONS AND RELEVANCE

Cost-related barriers to care among children with asthma were concentrated among low-income families with higher cost-sharing levels. The ACA's low-income subsidies could reduce these barriers for many families, but millions of dependents for whom employer-sponsored family coverage is unaffordable could remain at risk for cost-related problems because of ACA subsidy eligibility rules.

The impact of rural health system reform on hospitalization rates in the Islamic Republic of Iran: an interrupted time series

OBJECTIVE

To assess the effects on hospital utilization rates of a major health system reform - a family physician programme and a social protection scheme - undertaken in rural areas of the Islamic Republic of Iran in 2005.

METHODS

A "tracer" province that was not a patient referral hub was selected for the collection of monthly hospitalization data over a period of about 10 years, beginning two years before the rural health system reform (the "intervention") began. An interrupted time series analysis was conducted and segmented regression analysis was used to assess the immediate and gradual effects of the intervention on hospitalization rates in an intervention group composed of rural residents and a comparison group composed of urban residents primarily.

FINDINGS

Before the intervention, the hospitalization rate in the rural population was significantly lower than in the comparison group. Although there was no significant increase or decline in hospitalization rates in the intervention or comparison group before the intervention, after the intervention a significant increase in the hospitalization rate - of 4.6 hospitalizations per 100 000 insured persons per month on average - was noted in the intervention group (P < 0.001). The monthly increase in the hospitalization rate continued for over a year and stabilized thereafter. No increase in the hospitalization rate was observed in the comparison group.

CONCLUSION

The primary health-care programme instituted as part of the health system reform process has increased access to hospital care in a population that formerly underutilized hospital services. It has not reduced hospitalizations or hospitalization-related expenditure.

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.

Disparities in psychiatric emergency department visits among youth in Hawai'i, 2000-2010

OBJECTIVE

To describe the frequency and patient characteristics of emergency department encounters for mental health among youth, and to examine differences in utilization and treatment patterns.

STUDY DESIGN

Data were obtained from the Hawai'i Health Information Corporation database of emergency department records between January 1, 2000, and December 31, 2010. Analyses were limited to records of visits by patients aged <18 years with a diagnosis of mental disorder or a suicide attempt.

RESULTS

The annual average rate was 49.7 emergency department visits related to mental health issues per 10 000 youth, accounting for 2.1% of all emergency department visits among youth. Rates of mental health-related visits significantly and steadily increased, from a low of 25.8 in 2000 to a high of 67.4 in 2010. Rural areas consistently exhibited higher rates and acceleration at a steeper incline across time. Rural youth were more likely to be discharged or transferred for inpatient care or outpatient services compared with urban youth (6.3% vs 12.4%; χ(2) = 61.42; df = 3; P < .001).

CONCLUSION

The trend in emergency department utilization for mental health-related issues in adolescents is apparently increasing, with significantly higher rate and morbidity for youth in rural areas. Several recommendations are described for creating a responsive and integrated system of mental health care for youth, covering training, consultation, screening, and brief interventions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Timely access to quality health care among Georgia children ages 4 to 17 years

We examined factors associated with children's access to quality health care, a major concern in Georgia, identified through the 2010 Title V Needs Assessment. Data from the 2007 National Survey of Children's Health were merged with the 2008 Area Resource File and Health Resources and Services Administration medically underserved area variable, and restricted to Georgia children ages 4-17 years (N = 1,397). The study outcome, access to quality health care was derived from access to care (timely utilization of preventive medical care in the previous 12 months) and quality of care (compassionate/culturally effective/family-centered care). Andersen's behavioral model of health services utilization guided independent variable selection. Analyses included Chi-square tests and multinomial logit regressions. In our study population, 32.8 % reported access to higher quality care, 24.8 % reported access to moderate quality care, 22.8 % reported access to lower quality care, and 19.6 % reported having no access. Factors positively associated with having access to higher/moderate versus lower quality care include having a usual source of care (USC) (adjusted odds ratio, AOR:3.27; 95 % confidence interval, 95 % CI 1.15-9.26), and special health care needs (AOR:2.68; 95 % CI 1.42-5.05). Lower odds of access to higher/moderate versus lower quality care were observed for non-Hispanic Black (AOR:0.31; 95 % CI 0.18-0.53) and Hispanic (AOR:0.20; 95 % CI 0.08-0.50) children compared with non-Hispanic White children and for children with all other forms of insurance coverage compared with children with continuous-adequate-private insurance. Ensuring that children have continuous, adequate insurance coverage and a USC may positively affect their access to quality health care in Georgia.

The effects of health insurance and a usual source of care on a child's receipt of health care

INTRODUCTION

Although recent health care reforms will expand insurance coverage for U.S. children, disparities regarding access to pediatric care persist, even among the insured. We investigated the separate and combined effects of having health insurance and a usual source of care (USC) on children's receipt of health care services.

METHODS

We conducted secondary analysis of the nationally representative 2002-2007 Medical Expenditure Panel Survey data from children (≤ 18 years of age) who had at least one health care visit and needed any additional care, tests, or treatment in the preceding year (n = 20,817).

RESULTS

Approximately 88.1% of the study population had both a USC and insurance; 1.1% had neither one; 7.6% had a USC only, and 3.2% had insurance only. Children with both insurance and a USC had the fewest unmet needs. Among insured children, those with no USC had higher rates of unmet needs than did those with a USC.

DISCUSSION

Expansions in health insurance are essential; however, it is also important for every child to have a USC. New models of practice could help to concurrently achieve these goals.

Feasibility of evaluating the CHIPRA care quality measures in electronic health record data

The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) includes provisions for identifying standardized pediatric care quality measures. These 24 "CHIPRA measures" were designed to be evaluated by using claims data from health insurance plan populations. Such data have limited ability to evaluate population health, especially among uninsured people. The rapid expansion of data from electronic health records (EHRs) may help address this limitation by augmenting claims data in care quality assessments. We outline how to operationalize many of the CHIPRA measures for application in EHR data through a case study of a network of >40 outpatient community health centers in 2009-2010 with a single EHR. We assess the differences seen when applying the original claims-based versus adapted EHR-based specifications, using 2 CHIPRA measures (Chlamydia screening among sexually active female patients; BMI percentile documentation) as examples. Sixteen of the original CHIPRA measures could feasibly be evaluated in this dataset. Three main adaptations were necessary (specifying a visit-based population denominator, calculating some pregnancy-related factors by using EHR data, substituting for medication dispense data). Although it is feasible to adapt many of the CHIPRA measures for use in outpatient EHR data, information is gained and lost depending on how numerators and denominators are specified. We suggest first steps toward application of the CHIPRA measures in uninsured populations, and in EHR data. The results highlight the importance of considering the limitations of the original CHIPRA measures in care quality evaluations.

Is health insurance enough? A usual source of care may be more important to ensure a child receives preventive health counseling

Despite the promise of expanded health insurance coverage for children in the United States, a usual source of care (USC) may have a bigger impact on a child's receipt of preventive health counseling. We examined the effects of insurance versus USC on receipt of education and counseling regarding prevention of childhood injuries and disease. We conducted secondary analyses of 2002-2006 data from a nationally-representative sample of child participants (≤17 years) in the Medical Expenditure Panel Survey (n = 49,947). Children with both insurance and a USC had the lowest rates of missed counseling, and children with neither one had the highest rates. Children with only insurance were more likely than those with only a USC to have never received preventive health counseling from a health care provider regarding healthy eating (aRR 1.21, 95% CI 1.12-1.31); regular exercise (aRR 1.06, 95% CI 1.01-1.12), use of car safety devices (aRR 1.10, 95% CI 1.03-1.17), use of bicycle helmets (aRR 1.11, 95% CI 1.05-1.18), and risks of second hand smoke exposure (aRR 1.12, 95% CI 1.04-1.20). A USC may play an equally or more important role than insurance in improving access to health education and counseling for children. To better meet preventive counseling needs of children, a robust primary care workforce and improved delivery of care in medical homes must accompany expansions in insurance coverage.

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.

Comparing types of health insurance for children: a public option versus a private option

BACKGROUND

Many states have expanded public health insurance programs for children, and further expansions were proposed in recent national reform initiatives; yet the expansion of public insurance plans and the inclusion of a public option in state insurance exchange programs sparked controversies and raised new questions with regard to the quality and adequacy of various insurance types.

OBJECTIVES

We aimed to examine the comparative effectiveness of public versus private coverage on parental-reported children's access to health care in low-income and middle-income families. METHODS/PARTICIPANTS/MEASURES: We conducted secondary data analyses of the nationally representative Medical Expenditure Panel Survey, pooling years 2002 to 2006. We assessed univariate and multivariate associations between child's full-year insurance type and parental-reported unmet health care and preventive counseling needs among children in low-income (n=28,338) and middle-income families (n=13,160).

RESULTS

Among children in families earning <200% of the federal poverty level, those with public insurance were significantly less likely to have no usual source of care compared with privately insured children (adjusted relative risk, 0.79; 95% confidence interval, 0.63-0.99). This was the only significant difference in 50 logistic regression models comparing unmet health care and preventive counseling needs among low-income and middle-income children with public versus private coverage.

CONCLUSIONS

The striking similarities in reported rates of unmet needs among children with public versus private coverage in both low-income and middle-income groups suggest that a public children's insurance option may be equivalent to a private option in guaranteeing access to necessary health care services for all children.

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.

Health-related unmet needs of supplemental security income youth after the age-18 redetermination

OBJECTIVE

Young adults who exit Supplemental Security Income (SSI) after their age-18 eligibility redetermination may have greater health-related unmet needs than those who remain on SSI. The objective of this paper is to determine the magnitude and causes of this gap.

DATA SOURCES

Uses the 2001-2002 National Survey of SSI Children and Families, a nationally representative survey of SSI youth.

STUDY DESIGN

Self-reported unmet medical, dental, and prescription drug needs of 869 individuals ages 19-23 who have had their SSI eligibility redetermined are compared. In addition to raw differences in unmet needs, logistic regressions are used to determine the sources of these differences.

PRINCIPAL FINDINGS

Young adults who exit SSI are almost twice as likely to have health-related unmet needs subsequent to their exit as those who remain on SSI after the age-18 redetermination. Access to care, particularly insurance coverage (either Medicaid or non-Medicaid), accounts for much of the difference between these two groups; measures of health status do not explain much of the difference.

CONCLUSION

Policies addressing access to health care are likely to be more successful in addressing unmet needs than policies focused on disability-specific issues in health for youth who lose access to SSI after their age-18 redetermination.

Comparing type of health insurance among low-income children: a mixed-methods study from Oregon

We employed a mixed-methods study of primary data from a statewide household survey and in-person interviews with parents to examine-quantitatively and qualitatively-whether low-income children experienced differences between public and private insurance coverage types. We carried out 24 in-depth interviews with a subsample of respondents to Oregon's 2005 Children's Access to Healthcare Study (CAHS), analyzed using a standard iterative process and immersion/crystallization cycles. Qualitative findings guided quantitative analyses of CAHS data that assessed associations between insurance type and parental-reported unmet children's health care needs. Interviewees uniformly reported that stable health insurance was important, but there was no consensus regarding which type was superior. Quantitatively, there were only a few significant differences. Cross-sectionally, compared with private coverage, public coverage was associated with higher odds of unmet specialty care needs (odds ratio [OR] 3.54; 95% confidence interval [CI] 1.52-8.24). Comparing full-year coverage patterns, those with public coverage had lower odds of unmet prescription needs (OR 0.60, 95% CI 0.36-0.99) and unmet mental health counseling needs (OR 0.24, 95% CI 0.10-0.63), compared with privately covered children. Low-income Oregon parents reported few differences in their child's experience with private versus public coverage.

Measuring the impact of outreach and enrollment strategies for public health insurance in California

OBJECTIVE AND STUDY SETTING: To evaluate the effectiveness of different approaches to outreach on public health insurance enrollment in 25 California counties with a Children's Health Initiative.

DATA SOURCE

Administrative enrollment databases.

STUDY DESIGN

The use of eight enrollment strategies were identified in each quarter from 2001 to 2007 for each of 25 counties (county quarter). Strategies were categorized as either technology or nontechnology. New enrollments were obtained for Medi-Cal, Healthy Families, and Healthy Kids. Bivariate and multivariate analyses assessed the link between each strategy and new enrollments rates of children.

DATA COLLECTION

Methods Surveys of key informants determined whether a specific outreach strategy was used in each quarter. These were linked to new enrollments in each county quarter.

PRINCIPAL FINDINGS

Between 2001 and 2007, enrollment grew in all three children's health programs. We controlled for the effects of counties, seasons, and county-specific child poverty rates. There was an increase in enrollment rates of 11 percent in periods when technology-based systems were in use compared with when these approaches were inactive. Non-technology-based approaches, including school-linked approaches, yielded a 12 percent increase in new enrollments rates. Deploying seven to eight strategies yielded 54 percent more new enrollments per 10,000 children compared with periods with none of the specific strategies.

CONCLUSIONS AND IMPLICATIONS

National health care reform provides new opportunities to expand coverage to millions of Americans. An investment in technology-based enrollment systems will maximize new enrollments, particularly into Medicaid; nontechnological approaches may help identify harder-to-reach populations. Moreover, incorporating several strategies, whether phased in or implemented simultaneously, will enhance enrollments.

Policy statement--health equity and children's rights

Many children in the United States fail to reach their full health and developmental potential. Disparities in their health and well-being result from the complex interplay of multiple social and environmental determinants that are not adequately addressed by current standards of pediatric practice or public policy. Integrating the principles and practice of child health equity-children's rights, social justice, human capital investment, and health equity ethics-into pediatrics will address the root causes of child health disparities. Promoting the principles and practice of equity-based clinical care, child advocacy, and child- and family-centered public policy will help to ensure that social and environmental determinants contribute positively to the health and well-being of children. The American Academy of Pediatrics and pediatricians can move the national focus from documenting child health disparities to advancing the principles and practice of child health equity and, in so doing, influence the worldwide practice of pediatrics and child health. All pediatricians, including primary care practitioners and medical and surgical subspecialists, can incorporate these principles into their practice of pediatrics and child health. Integration of these principles into competency-based training and board certification will secure their assimilation into all levels of pediatric practice.