Coverage Gaps for Medicaid-Eligible Children in the Wake of Federal Welfare Reform

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.

How Do Public Health Expansions Vary by Income Strata? Evidence from Illinois' All Kids Program

This paper examines how income levels affected the substitution of public health insurance for private health coverage under expansions of Illinois' State Children's Health Insurance Program (SCHIP). Building on a technique developed by Abadie and Gardeazabal (2003), I estimate that among children whose family incomes are between 200% and 300% of the federal poverty level (FPL), 35% of those covered by SCHIP would have retained private coverage in the absence of SCHIP. Significant substitution also appears between 300% and 400% FPL, but surprisingly I find evidence that the introduction of SCHIP caused an increase in private health insurance coverage for those with family incomes between 400% and 500% FPL.

Being uninsured: impact on children's healthcare and health

PURPOSE OF REVIEW

There are 8.4 million uninsured children in the United States. Many are eligible for coverage. Current literature on how lack of health insurance affects the quality and outcome of children's healthcare in the United States is reviewed, and effective solutions are identified. Recent policy changes have produced restrictions on basic preventive and curative services, despite concurrent major efforts to increase insurance coverage rates for children.

RECENT FINDINGS

With more than 70% of currently uninsured children eligible for either Medicaid or the State Children's Health Insurance Program, these public programs have not yet produced expected levels of coverage. Health systems and provider accountability for the primary care of uninsured children is not optimal. Families of uninsured children face non-financial access barriers to care such as lack of continuity with a primary care provider and inadequate visit time. These barriers are compounded for uninsured children with special healthcare needs.

SUMMARY

Pediatric primary care effectiveness is significantly reduced by insurance shortfalls. Lack of coverage inhibits appropriate care seeking; diminishes provider availability; compromises care content, quality, and satisfaction; and ultimately harms the entire family unit. However, provision of insurance alone is not a panacea.

Continuity of Health Insurance Coverage for Children with Special Health Care Needs

OBJECTIVES

To assess the continuity of health insurance coverage and its associated factors for children with special health care needs (CSHCN).

METHODS

Logistic regression and proportional hazard models were estimated on monthly insurance enrollment for 5594 children in the 1996 Medical Expenditure Panel Survey. CSHCN were identified using a non-categorical approach. Stratified analyses were conducted to determine whether any characteristics differentiated the effects of CSHCN status on children's coverage.

RESULTS

In 1996, more than 8% of CSHCN were uninsured for the entire year. For those who were insured in January 1996, 14% lost their coverage by December 1996. CSHCN were more likely than other children to be insured (92% vs. 89%), mainly due to their better access to public insurance (35% vs. 23%). Conversely, CSHCN were less likely than other children to stay insured if they were school-aged, non-Hispanic White, from working, low-income families or the US Midwest region. Higher parental education improved health insurance enrollment for CSHCN, whereas higher family income or having activity limitations protected them from losing coverage. Regardless of CSHCN status, being publicly insured was associated with a higher risk of losing coverage for children.

CONCLUSIONS

Despite increased health care needs, a considerable proportion of CSHCN is unable to access or maintain coverage. Compared to other children, CSHCN are more likely to have coverage but no more likely to stay insured. Improving continuity of coverage for publicly insured children is needed, especially CSHCN who are more likely to obtain their coverage through public programs.

Gaps in enrollment from a Medicaid managed care program: effects on emergency department visits and hospitalizations for children with asthma

BACKGROUND

For high-risk children with asthma enrolled in Medicaid, loss of Medicaid coverage is a potential threat to access to quality asthma care.

OBJECTIVE

We sought to quantify the effect of gaps in enrollment on emergency department visits and hospitalizations for children with asthma in TennCare, Tennessee's managed care program for Medicaid-eligible and uninsured children.

METHODS

Children with asthma were identified from a research database of files maintained by the state. Gaps in enrollment in the state insurance program were measured between 1998 and 2002. Children with gaps were compared with children without gaps with respect to emergency department visits and hospitalizations for asthma, respiratory illnesses, croup, and other diagnoses.

RESULTS

Among children who met study definitions of asthma, 2373 experienced a gap in enrollment during the study period (10.4%). The rate of hospitalizations and emergency department visits for children with gaps (7402/10,000 person years) was significantly lower than the rate of study events for children with no gaps (9230/10,000 person years) (adjusted incidence rate ratio 0.88; 95% confidence interval 0.81-0.96). The rate of hospitalizations for asthma and other respiratory conditions was not different between the 2 groups; however, there was a significantly lower rate of hospitalizations for other reasons for children with gaps (adjusted incidence rate ratio 0.59; 95% confidence interval 0.41-0.86).

CONCLUSIONS

Children with asthma who had gaps in a Medicaid managed care insurance program had no increase in asthma related emergency department visits and hospitalizations. Children who had gaps did have fewer nonrespiratory emergency department visits and hospitalizations than their non-gap counterparts. Further study is needed to explore the reasons for this unexpected finding.

Health Care for Children and Youth in the United States: Annual Report on Patterns of Coverage, Utilization, Quality, and Expenditures by Income

OBJECTIVES

To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States.

METHODS

Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations.

RESULTS

Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children.

CONCLUSIONS

While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

When insurance status is not static: insurance transitions of low-income children and implications for health and health care

OBJECTIVES

Among low-income children, to characterize the frequency of transitions in health insurance coverage and examine associations of transitions with health status and health care access.

METHODS

Data from the 1999 National Survey of America's Families were used in weighted analyses to identify sociodemographic characteristics associated with health insurance transitions for children living in households with income <200% of the federal poverty level over the preceding 12 months. In logistic regression models, we examined associations of insurance transitions with children's health status (fair/poor health), postponement of children's medical care or prescription medications, and lack of physician visits.

RESULTS

Among 27.93 million low-income children in 1999, 5.7 million (20.4%) had experienced an insurance transition in the preceding year. Non-Hispanic black children (24.5%) and children whose parents did not have a partner or spouse (23.5%) were significantly more likely than other children to have experienced transitions. Hispanic children (16%) were least likely to have experienced transitions. Compared with children with continuous private coverage, children who had transitioned from public to private coverage were more likely to report fair or poor health, children who experienced transitions that included a period of no coverage were more likely to report postponed medical care and prescription drugs, and children who experienced a no-coverage-to-private-coverage transition were more likely to have foregone physician visits.

CONCLUSION

Transitions in insurance coverage affect many low-income children and may represent barriers to their health care. Considering insurance transitions may provide a more complete picture of children's health and health care utilization.