Low-income children's preventive services use: implications of parents' Medicaid status

This article examines the effect of parents' Medicaid status on the use of preventive health services by young children. Using data from the 1996 Medical Expenditure Panel Survey (MEPS), we analyzed a logit model for receipt of any well-child visits (WCVs) that compared three groups of low-income children. The three groups, defined by the joint insurance status of children and their parents, involved Medicaid pairs (both the child and the parent had Medicaid throughout the year), mixed pairs (the child had Medicaid and the parent was uninsured), and uninsured pairs (both child and parent were uninsured). Medicaid coverage for children was positively associated with receipt of any WCVs. However, the utilization effect of Medicaid coverage for children was significantly larger when the parent was also on Medicaid instead of being uninsured. Considering uninsured children with uninsured parents in 1996, enrolling only the children in Medicaid would have increased the percentage with WCVs from 29 to 43 percent according to simulations with the logit model. If the parents were enrolled in Medicaid as well, the percentage of children with any WCVs would have increased to 67 percent.     

Factors associated with Medicaid enrollment for low-income children in the United States

This study analyzes the 1996-1997 Community Tracking Study Household Survey to identify factors associated with Medicaid enrollment for low-income children and to examine the differences between those enrolled in the Medicaid program and those who were eligible but uninsured. We estimated that 17.4% of Medicaid-eligible children were uninsured. Medicaid eligible children who were younger, African American, with single parents, with AFDC eligible parents, with no parent employed full-time were more likely to be enrolled in the Medicaid program. Children with better health status were less likely to be enrolled in Medicaid. In addition, children whose parents were uninsured were more likely not to be enrolled in Medicaid.     

Patient Satisfaction with Care in Programs for Low Income Individuals

Although a variety of public and private programs provide care for low-income individuals, little is known about patient satisfaction across these programs. The objective of this study was to examine patient satisfaction across a variety of health insurance programs. A survey was conducted of randomly selected adults in Kentucky who had an outpatient visit in the past 12 months (616 with private insurance, 683 Medicaid recipients, 287 in private sector charity program for uninsured indigents). Patient satisfaction with multiple dimensions of their most recent outpatient visit was assessed. All insurance groups were generally satisfied with the care received in their most recent visit. For all 8 dimensions of patient satisfaction, the private insurance group was significantly higher than the other groups. In a model controlling for standard demographic and health status variables, higher overall satisfaction with the visit was positively related to higher income and higher mental health functional status. The insurance category variable had no significant relationship to overall satisfaction with the visit. Although patients receiving care through health insurance programs for low-income individuals are generally satisfied with the services, there is an indication that low-income individuals, regardless of insurance type, are less satisfied with the care they receive.     

Welfare reform and health insurance coverage of low-income families

We study whether welfare reform adversely affected the health insurance coverage of low-educated single mothers and their children. Specifically, we investigate whether changes in the welfare caseload during the 1990s were associated with changes in Medicaid participation, private insurance coverage, and the number of uninsured among single mothers and their children. Estimates suggest that between 1996 and 1999, the 42% decrease in the welfare caseload was associated with the following changes in insurance coverage among low-educated, single mothers: a 7-9% decrease in Medicaid coverage; an increase in employer-sponsored, private insurance coverage of 6%; and a 2-9% increase in the proportion uninsured. Among children of low-educated, single mothers, effects were somewhat smaller. Since welfare policy was responsible for only part (e.g. one-third) of the decline in the caseload, welfare reform per se had significantly smaller effects on the health insurance status of low-income families. However, we found limited evidence that changes in the caseload due to state and federal welfare policy had fewer adverse consequences on insurance status than changes in the caseload due to other factors. This implies even smaller effects of welfare reform.     

Insuring low-income adults: does public coverage crowd out private?

During the mid-1990s Minnesota, Washington State, Oregon, and Tennessee implemented programs to provide subsidized health insurance for low-income persons who were not previously eligible for Medicaid. We estimate the effects of these programs on the health insurance status of low-income adults in these states. We find that among persons with family incomes below 100 percent of the federal poverty level, subsidized public coverage reduced the number of uninsured persons with very little effect on private coverage rates. Among persons with income between 100 percent and 200 percent of FPL, public coverage reduced the number of uninsured persons and crowded out some private insurance. The partial successes achieved by these programs should be kept in perspective: Even after program implementation, approximately 30 percent of low-income adults in the four states were uninsured.     

Expanding Medicaid to cover the uninsured

A decade of unparalleled economic prosperity has done little to reduce the number of Americans without health insurance. Despite an expansion of government-funded health insurance for the nation's low-income children, the number of working parents without health insurance continues to rise. Many states are looking at how Medicaid, long the health insurance program for families on welfare, could provide a health insurance safety net for the working poor. This issue of States of Health summarizes the issue and explores the Medicaid expansion strategies some states are using to provide health coverage for the working uninsured.     

How Well Does Medicaid Work in Improving Access to Care?

OBJECTIVE: To provide an assessment of how well the Medicaid program is working at improving access to and use of health care for low-income mothers. DATA SOURCE/STUDY SETTING: The 1997 and 1999 National Survey of America's Families, with state and county information drawn from the Area Resource File and other sources. STUDY DESIGN: Estimate the effects of Medicaid on access and use relative to private coverage and being uninsured, using instrumental variables methods to control for selection into insurance status. DATA COLLECTION/EXTRACTION METHOD: This study combines data from 1997 and 1999 for mothers in families with incomes below 200 percent of the federal poverty level. PRINCIPAL FINDINGS: We find that Medicaid beneficiaries' access and use are significantly better than those obtained by the uninsured. Analysis that controls for insurance selection shows that the benefits of having Medicaid coverage versus being uninsured are substantially larger than what is estimated when selection is not accounted for. Our results also indicate that Medicaid beneficiaries' access and use are comparable to that of the low-income privately insured. Once insurance selection is controlled for, access and use under Medicaid is not significantly different from access and use under private insurance. Without controls for insurance selection, access and use for Medicaid beneficiaries is found to be significantly worse than for the low-income privately insured. CONCLUSIONS: Our results show that the Medicaid program improved access to care relative to uninsurance for low-income mothers, achieving access and use levels comparable to those of the privately insured. Our results also indicate that prior research, which generally has not controlled for selection into insurance coverage, has likely understated the gains of Medicaid relative to uninsurance and overstated the gains of private coverage relative to Medicaid.     

Transitions in insurance coverage from before pregnancy through delivery in nine states, 1996-1999

Efforts to extend coverage to pregnant women, along with an expanding economy, did not prevent increases in the uninsured in the latter 1990s. Welfare reform may have led to declining Medicaid enrollments and caseloads. Data representative of live births in nine states show that in some states more than one-third of all pregnant women and almost two-thirds of low-income pregnant women lacked insurance before their pregnancy in 1996 and 1999. More than one-third of all pregnant women made some change in coverage by the time they delivered their baby. Among low-income women, the largest change was from uninsured status before pregnancy to Medicaid at delivery.     

Medicaid expansion under health reform may increase service use and improve access for low-income adults with diabetes

Medicaid's key role in financing diabetes care will grow when many low-income uninsured people with diabetes gain eligibility to the program in 2014 under the Affordable Care Act. Using a national data set to describe current health care use and spending among the nonelderly, low-income adult population, we found that adult Medicaid beneficiaries with diabetes had total annual per capita health expenditures more than three times higher ($14,229 versus $4,568) than those of adult beneficiaries without diabetes. At the same time, Medicaid facilitates financial protection and care access among beneficiaries with diabetes. Low-income adults with diabetes who were uninsured used fewer services, spent more out of pocket, and reported worse access than did their peers who were covered by Medicaid. Uninsured adults with diabetes who gain Medicaid coverage under health reform are likely to enter the program with unmet needs, and coverage is likely to result in both improved access and increased use of health care.     

Access to care for low-income women: the impact of Medicaid

This study was undertaken to assess how low-income women with Medicaid, private insurance, or no insurance vary with regard to personal characteristics, health status, and health utilization. Data are from a telephone interview survey of a representative cross-sectional sample of 5,200 low-income women in Minnesota, Oregon, Tennessee, Florida, and Texas. On the whole, low-income women were found to experience considerable barriers to care; however, uninsured low-income women have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts. Women on Medicaid had access to care that was comparable with their low-income privately insured counterparts, but in general had significantly lower satisfaction with their providers and their plans. Future federal and state efforts should focus on expanding efforts to improve the scope and reach of health care coverage to low-income women through public or private means.     

The role of community health centers in delivering primary care to the underserved: experiences of the uninsured and Medicaid insured

Community health centers (CHCs) have long served an important safety-net healthcare delivery role for vulnerable populations. Federal efforts to expand CHCs, while potentially reducing the Federal budget for Medicaid, raise concern about how Medicaid and uninsured patients of CHCs will continue to fare. To examine the primary care experiences of uninsured and Medicaid CHC patients and compare their experiences with those of similar patients nationally, cross-sectional analyses of the 2002 CHC User Survey with comparison data from the 1998 and 2002 National Health Interview surveys were done. Self-reported measures of primary care access, longitudinality, and comprehensiveness of care among adults aged 18 to 64 years were used. Despite poorer health, CHCs were positively associated with better primary care experiences in comparison with similar patients nationally. Uninsured CHC patients were more likely than similar patients nationally to report a generalist physician visit in the past year (82% vs 68%, P < .001), having a regular source of care (96% vs 60%, P < .001), receiving a mammogram in the past 2 years (69% vs 49%, P < .001), and receiving counseling on exercise (68% vs 48%, P < .001). Similar results were found for CHC Medicaid patients versus Medicaid patients nationally. Even within CHCs, however, Medicaid patients tended to report better primary care experiences than the uninsured. Health centers appear to fill an important gap in primary care for Medicaid and uninsured patients. Nonetheless, this study suggests that Medicaid insurance remains fundamental to accessing high-quality primary care, even within CHCs.     

Low-income persons' access to health care: NMCUES Medicaid data

Data from the National Medical Care Utilization and Expenditure Survey (NMCUES) are presented on access to medical care for low-income people in 1980. NMCUES was a national probability household survey jointly sponsored by the National Center for Health Statistics and the Health Care Financing Administration. NMCUES also included four State Medicaid Household Surveys. Data from both the national sample, for all low-income people, and from the four State surveys, for Medicaid people, were included in this analysis. The NMCUES data provided several measures which were previously unavailable on Medicaid experience, in particular, detailed Medicaid eligibility information in combination with income, health status, and health care use. This information can provide a comparison between access to care for those covered by Medicaid, and other low-income persons. In 1980 Medicaid covered a minority of poor and low-income people, only 44 percent of the poor younger than 65 years of age and 38 percent of poor people 65 years of age and older. While almost all elderly had Medicare coverage, about 25 percent of younger low-income people had no form of health insurance, compared with only 9 percent of nonpoor persons who were uninsured. Another measure of access is a regular source of care, the "place where a person goes for health care when sick." In 1980, 15 percent of people younger than 65 who were covered by Medicaid had no regular source of care. This is similar to the rate for the privately insured. However, the types of providers that were cited as the regular source of care differed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Physician utilization and expenditures in a Medicaid population.

The determinants of physician visit utilization and expenditures for the full-year Medicaid enrollees in the State Medicaid household survey portion of the National Medical Care Utilization and Expenditure Survey are analyzed in this article. The regression analyses for the probability of a physician visit, for number of physician visits, and for physician visit expenditures underscore the importance of perceived health status as a determinant of both physician utilization and expenditures. Other important determinants of physician utilization and expenditures were regular source of care, State, enrollment group, sex, and family size.     

Health Insurance Status and Eligibility Among Patients who Seek Healthcare at a Free Clinic in the Affordable Care Act Era

Free clinics provide care to over 1.8 million people in the United States every year and are a valuable safety net for uninsured and underinsured patients. The Affordable Care Act has resulted in millions of newly insured Americans, yet there is continued demand for healthcare at free clinics. In this study, we assessed health insurance status and eligibility among 489 patients who visited a free clinic in 2016. Eighty-seven percent of patients seen were uninsured, 53.1% of whom were eligible for health insurance (Medicaid or subsidized insurance premiums). The majority of these patients completed health insurance applications at their visit with the help of a navigator. A majority of patients who were not eligible for health insurance lacked citizenship status. This study highlights that a significant number of patients who visit free clinics are eligible for health insurance, and that free clinics are important sites for health insurance navigation programs.     

Effects of the State Children's Health Insurance Program on access to dental care and use of dental services

OBJECTIVE: To provide national estimates of implementation effects of the State Children's Health Insurance Program (SCHIP) on dental care access and use for low-income children. DATA SOURCE: The 1997-2002 National Health Interview Survey. STUDY DESIGN: The study design is based on variation in the timing of SCHIP implementation across states and among children observed before and after implementation. Two analyses were conducted. The first estimated the total effect of SCHIP implementation on unmet need for dental care due to cost in the past year and dental services use for low-income children (family income below state SCHIP eligibility thresholds) using county and time fixed effects models. The second analysis estimated differences in dental care access and use among low-income children with SCHIP or Medicaid coverage and their uninsured counterparts, using instrumental variables methods to control for selection bias. Both analyses controlled for child and family characteristics. PRINCIPAL FINDINGS: When SCHIP had been implemented for more than 1 year, the probability of unmet dental care needs for low-income children was lowered by 4 percentage points. Compared with their uninsured counterparts, those who had SCHIP or Medicaid coverage were less likely to report unmet dental need by 8 percentage points (standard error: 2.3), and more likely to have visited a dentist within 6 or 12 months by 17 (standard error: 3.7) and 23 (standard error: 3.6) percentage points, respectively. SCHIP program type had no differential effects. CONCLUSIONS: Consistent results from two analytical approaches provide evidence that SCHIP implementation significantly reduced financial barriers for dental care for low-income children in the U.S. Low-income children enrolled in SCHIP or Medicaid had substantially increased use of dental care than the uninsured.     

Children''s Health Insurance Status, Access to and Utilization of Health Services, and Unmet Health Needs in a Rural Alabama School System

PURPOSE: This study examines the relationship between children's health insurance status and utilization of health services, establishment of a medical home, and unmet health needs over a 3-year period (1996-1998) in a rural Alabama K-12 school system. METHODS: As part of a children's health insurance outreach program, questionnaires were administered to parents of 754 children regarding health and health care access. In addition, noninvasive head-to-toe physical assessments of children were conducted on-site at 4 schools. FINDINGS: A relationship between health care utilization and insurance status was observed. Results found that insured children had 1.183 (P < .0115) times the number of medical visits as uninsured children. Among uninsured children, the time since last dental visit was 1.6 (P < .001) times longer than that of insured children. Also, insured children were 5.21 times more likely than uninsured (P < .0001) to report having a medical home. No significant differences between insured and uninsured children were found regarding unmet health needs as measured by referrals made after the children's physical assessments. CONCLUSIONS: Child health coverage is an important determining factor in the ability of families to access and utilize health care services. These findings have implications for populations in similar rural communities across the nation.     

Health care access and use among low-income children: who fares best?

In this paper we assess how access to care and use of services among low-income children vary by insurance status. Although 40 percent of low-income children rely on private health insurance, little is known about how this coverage compares with Medicaid coverage in meeting their health care needs. We find that Medicaid and privately insured low-income children appear to have fairly comparable access but that Medicaid-covered children are more likely to receive services and to have more visits when they receive care. Expanding public coverage may not be sufficient to ensure that all low-income children have access to comprehensive and high-quality care. It may require improvements in preventive and dental care for children with private coverage, an area in which states have limited influence.     

Personal care services provided to children with special health care needs (CSHCN) and their subsequent use of physician services

BackgroundMedicaid Personal Care Services (PCS) help families meet children's needs for assistance with functional tasks. However, PCS may have other effects on a child's well-being, but research has not yet established the existence of such effects.ObjectivesTo investigate the relationship between the number of PCS hours a child receives with subsequent visits to physicians for evaluation and management (E&M) services.MethodsAssessment data for 2058 CSHCN receiving PCS were collected in 2008 and 2009. Assessment data were matched with Medicaid claims data for the period of 1 year after the assessment. Zero-inflated negative binomial and generalized linear multivariate regression models were used in the analyses. These models included patient demographics, health status, household resources, and use of other medical services.ResultsFor every 10 additional PCS hours authorized for a child, the odds of having an E&M physician visit in the next year were reduced by 25%. However, the number of PCS hours did not have a significant effect on the number of visits by those children who did have a subsequent E&M visit. A variety of demographic and health status measures also affect physician use.ConclusionsMedicaid PCS for CSHCN may be associated with reduced physician usage because of benefits realized by continuity of care, the early identification of potential health threats, or family and patient education. PCS services may contribute to a child's well-being by providing continuous relationships with the care team that promote good chronic disease management, education, and support for the family.     

Increasing Health Insurance Coverage in the First Year of Life

Objectives: To determine the proportion of infants who are uninsured and the sociodemographic characteristics of their mothers, including prenatal and post-partum insurance coverage, in order to identify strategies to increase infant health coverage. Methods: Data from the 2001 California Maternal and Infant Health Assessment (MIHA) were analyzed. MIHA is a cross-sectional survey of a statewide representative sample of 3,475 postpartum women. We calculated the proportion of uninsured infants overall and by several maternal characteristics. Adjusted and unadjusted odds ratios for infant uninsurance are reported. Results: In the overall study sample, 8.7% of infants were uninsured. Low-income infants were significantly more likely to be uninsured than infants in households with incomes above 200% of the federal poverty level (13.7% vs. 2.5%). The mother's prenatal and post-partum health coverage, her age, and family income were associated with an increased risk of infant uninsurance after adjustment for other maternal characteristics. A large majority of the uninsured infants (88.1%) were living in low-income families. The mothers of 60% of the uninsured infants were enrolled in Medicaid during the pregnancy. Conclusions: Approximately 14% of California's low-income infants were uninsured at the time of the survey despite being income-eligible for Medicaid. The proportion of uninsured infants could potentially be reduced by more than one-half through strategies to provide 12 month continuous enrollment of infants with federally mandated Medicaid eligibility for the first year of life.     

Children of working low-income families in California: does parental work benefit children's insurance status,access, and utilization of primary health care?

OBJECTIVE: To examine financial and nonfinancial access to care and utilization of primary health care services among children of working low-income families earning below 200 percent of the federal poverty level in California, and to compare them to children in nonworking low-income families and in families earning over 200 percent of poverty. DATA SOURCES/STUDY SETTING: The 1994 National Health Interview survey weighted to reflect population estimates for California. STUDY DESIGN: This cross-sectional study of 3,831 children under age 19 focuses on financial access, that is, the prevalence and continuity of health insurance coverage; structural access, including the presence of a usual source of care, the predominant care source, its responsiveness to patient's needs, and any indications of delayed or missed care; and utilization of health care measured by the presence of an outpatient doctor's visit and the mean number of visits relative to child health status. DATA COLLECTION: The study uses secondary analysis. FINDINGS: Compared to children of nonworking low-income parents and to nonpoor children, children of working low-income parents were more likely to be uninsured (32.1 percent versus 15.6 percent and 10.3 percent, p = .0001) and to experience disruptions in insurance coverage (p = .0009). These differences persisted after controlling for other covariates in multivariate analyses. Children of working low-income parents did not differ significantly from children of nonworking low-income parents on measures of structural access or utilization, after adjusting for other covariates. However, they differed significantly from nonpoor children on structural access and utilization, and these differences mostly persisted after adjusting for other covariates (odds ratios from 1.5 to 2.9). Similar patterns were observed when children of full-time, year-round working parents with low earnings were compared with the two reference populations. CONCLUSION: Children in working low-income families in California have some of the worst access problems. Even full attachment to the workforce does not guarantee health insurance benefits, access to care, or improved health care use for children of low-income parents. These children are not better off than other low-income children of nonworking parents and are much worse off than nonpoor children. Expansion of health insurance coverage through Healthy Families and Medi-Cal, and attention to nonfinancial barriers to care for working low-income families may help to reduce these disparities.