Patterns of Health Insurance Discontinuity and Children’s Access to Health Care

Objectives This study classified patterns of discontinuous health insurance coverage, including change in coverage type and gaps in coverage, and described their associations with children’s access to health care. Methods Using the 2011–2013 National Health Interview Survey data, we determined children’s insurance coverage over the past year, and whether children had a usual source of care, had to delay getting care, or had unmet health care needs. Using multivariable logistic regression, we compared measures of access to care across insurance coverage patterns, classified as continuous private coverage; continuous public coverage; continuous lack of coverage; change in coverage type (public versus private) without gaps in coverage; and any gap in coverage. A subgroup analysis repeated this comparison for children with a caregiver-reported chronic physical illness. Results The analysis included 34,105 children, of whom 7% had a gap in coverage and 1% had a change in coverage type. On multivariable analysis, gaps in coverage were associated with increased likelihood of unmet health care needs, compared to continuous private (OR 6.9; 95% CI 5.9, 8.0) or continuous public coverage (OR 5.1; 95% CI 4.4, 6.0). Seamless changes in coverage were also associated with greater likelihood of unmet health care needs [OR vs. private: 3.8 (95% CI 2.3, 6.1); OR vs. public: 2.8 (95% CI 1.8, 4.6); all p < 0.001]. Results were similar for other study outcomes, and among children with chronic physical illness. Conclusions for Practice Both gaps in coverage and seamless changes between coverage types were associated with limited health care access for children.

     

Healthcare Utilization After a Children’s Health Insurance Program Expansion in Oregon

Objective The future of the Children’s Health Insurance Program (CHIP) is uncertain after 2017. Survey-based research shows positive associations between CHIP expansions and children’s healthcare utilization. To build on this prior work, we used electronic health record (EHR) data to assess temporal patterns of healthcare utilization after Oregon’s 2009–2010 CHIP expansion. We hypothesized increased post-expansion utilization among children who gained public insurance. Methods Using EHR data from 154 Oregon community health centers, we conducted a retrospective cohort study of pediatric patients (2–18 years old) who gained public insurance coverage during the Oregon expansion (n = 3054), compared to those who were continuously publicly insured (n = 10,946) or continuously uninsured (n = 10,307) during the 2-year study period. We compared pre-post rates of primary care visits, well-child visits, and dental visits within- and between-groups. We also conducted longitudinal analysis of monthly visit rates, comparing the three insurance groups. Results After Oregon’s 2009–2010 CHIP expansions, newly insured patients’ utilization rates were more than double their pre-expansion rates [adjusted rate ratios (95 % confidence intervals); increases ranged from 2.10 (1.94–2.26) for primary care visits to 2.77 (2.56–2.99) for dental visits]. Utilization among the newly insured spiked shortly after coverage began, then leveled off, but remained higher than the uninsured group. Conclusions This study used EHR data to confirm that CHIP expansions are associated with increased utilization of essential pediatric primary and preventive care. These findings are timely to pending policy decisions that could impact children’s access to public health insurance in the United States.     

Children’s Receipt of Health Care Services and Family Health Insurance Patterns

PURPOSE Insured children in the United States have better access to health care services; less is known about how parental coverage affects children’s access to care. We examined the association between parent-child health insurance coverage patterns and children’s access to health care and preventive counseling services.METHODS We conducted secondary analyses of nationally representative, cross-sectional, pooled 2002–2006 data from children (n = 43,509), aged 2 to 17 years, in households responding to the Medical Expenditure Panel Survey (MEPS). We assessed 9 outcome measures pertaining to children’s unmet health care and preventive counseling needs.RESULTS Cross-sectionally, among US children (aged 2 to 17 years) living with at least 1 parent, 73.6% were insured with insured parents, 8.0% were uninsured with uninsured parents, and the remaining 18.4% had discordant family insurance coverage patterns. In multivariable analyses, insured children with uninsured parents had higher odds of an insurance coverage gap (odds ratio [OR] = 2.45; 95% confidence interval [CI], 2.02–2.97), no usual source of care (OR = 1.31; 95% CI, 1.10–1.56), unmet health care needs (OR = 1.11; 95% CI, 1.01–1.22), and having never received at least 1 preventive counseling service (OR = 1.20; 95% CI, 1.04–1.39) when compared with insured children with insured parents. Insured children with mixed parental insurance coverage had similar vulnerabilities.CONCLUSIONS Uninsured children had the highest rates of unmet needs overall, with fewer differences based on parental insurance status. For insured children, having uninsured parents was associated with higher odds of going without necessary services when compared with having insured parents.     

Adult-Oriented Health Reform and Children’s Insurance and Access to Care: Evidence from Massachusetts Health Reform

Maternal and Child Health Journal - Objective A national debate is underway about the value of key provisions within the adult-oriented Affordable Care Act (ACA)—the individual mandate,...     

Children’s Insurance Coverage and Crowd-Out Through the Recession: Lessons From Ohio

Objectives. We estimated changes in children’s insurance status (publicly insured, privately insured, or uninsured) and crowd-out rates during the 2007 to 2009 US recession in Ohio.Methods. We conducted an estimate of insurance coverage from statewide, randomized telephone surveys in 2004, 2008, 2010, and 2012. We estimated crowd-out by using regression discontinuity.Results. From 2004 to 2012, private insurance rates dropped from 67% to 55% and public rates grew from 28% to 40%, with no change in the uninsured rate for children. Despite a 12.0% decline in private coverage and a corresponding 12.6% increase in public coverage, we found no evidence that crowd-out increased during this period.Conclusions. Children, particularly those with household incomes lower than 400% of the federal poverty level, were enrolled increasingly in public insurance rather than private coverage. Near the Medicaid eligibility threshold, this is not from an increase in crowd-out. An alternative explanation for the increase in public coverage would be the decline in incomes for households with children.During the economic recession of 2007 to 2009, 8 million Americans lost employer-sponsored health insurance.1 During this same period, the national rate of uninsurance among adults increased by 15% while the rate for children decreased by 7%, as children increasingly moved from private insurance to public programs including Medicaid and the Children’s Health Insurance Program (CHIP).1 With spending for Medicaid accounting for almost 20% of state budgets,2 increases in Medicaid enrollment raise concerns for many state governments. A key debate among state legislators is whether these changes represent Medicaid fulfilling its planned role as a safety net or whether these increases represent Medicaid replacing or crowding-out private insurance coverage.Crowd-out refers to individuals who are insured by a public program but who otherwise would have private insurance if the public program did not exist. The archetype of crowd-out is when privately insured individuals gain eligibility for Medicaid and drop their private coverage to enroll in the public plan. This scenario is often referred to as public–private “substitution” in the literature.3 It should be noted that individuals who can no longer afford private individual insurance or who lose access to, or cannot afford their employer-sponsored plan, are excluded from crowd-out estimates. For example, a child whose parent has private insurance but cannot afford to include the child on the plan4 would not be considered to be crowded out. The second type of crowd-out, which we refer to as continuation crowd-out, occurs when an individual on a public program becomes eligible to enroll in an employer-sponsored private plan, but chooses to remain on public coverage. This scenario could occur when an unemployed parent begins a new job that offers an affordable, employer-sponsored plan, but the parent decides to keep their child enrolled in Medicaid instead of the newly available private option.The published literature primarily focuses on estimates of crowd-out based on increased enrollment following the expansion of eligibility, such as a state increasing Medicaid income eligibility limits. These estimates vary widely, ranging from high estimates of 50% (i.e., half of individuals gaining Medicaid coverage through an expansion would otherwise have private insurance) to other authors finding near zero crowd-out.5–7 Some of this variability is driven by the sensitivity of the econometric models used8 and some may be attributable to the actual crowd-out that occurred with different expansions of eligibility in different states.5 A smaller literature directly measures substitution from survey data, finding low levels of this type of crowd-out.9,10 From a legislative perspective, these crowd-out estimates reveal the budgetary cost of Medicaid expansions. For the average state in 2012, insuring a child through Medicaid cost $2700 per year.11 At a 50% crowd-out rate, a state would need to budget $5400 to reduce the number of uninsured by 1 child. The $5400 would include coverage for the previously uninsured child and for a second child who previously had private insurance (1 uninsured child and 1 case of crowd-out).The existing crowd-out literature implicitly assumes that crowd-out estimates are stable over time. The econometric approaches used in most studies require a change in Medicaid eligibility to estimate crowd-out, producing a single, national estimate for the policy change.5,12 Absent a more recent change, policymakers assume that crowd-out rates do not change with time because those estimates are not time dependent. This implicit assumption, though, is likely invalid. Crowd-out indicates the use of public insurance while private coverage is still available; the reasons for that are likely dependent on the current cost and expected future cost of insurance, the suitability of access provided by the types of coverage, and noneconomic factors such as the stigma associated with public coverage.13Each of these factors can change over time. Concern about the future cost of insurance during the recession may have been particularly important, as parents may have had strong concerns about retaining their employment or concerns that their employer would stop offering employer-sponsored health insurance. Between January 2007 and January 2010, Ohio’s unemployment rate almost doubled from 5.4% to 10.6%.14 This increase in the unemployment rate may have raised parents’ concerns about future access to health care for their children. If these concerns led to increased enrollment in public insurance, then crowd-out would increase. Previous work has not estimated state-level crowd-out levels over time. We evaluated how many children in Ohio moved from private health insurance to public health insurance and the degree to which those children were crowded out between 2004 and 2012. We estimated total crowd-out (substitution plus continuation) over time to see whether crowd-out levels changed during the recession in Ohio.     

Characteristics of Children Eligible for Public Health Insurance but Uninsured: Data from the 2007 National Survey of Children’s Health

To describe the state variation, demographic and family characteristics of children eligible for public health insurance but uninsured. Using data from the National Survey of Children’s Health we selected a subset of children living in households with incomes <200 % of the federal poverty level, who are generally eligible for Medicaid or CHIP. We used multiple logistic regression to examine associations between insurance status among this group of eligible children and certain demographic factors, family characteristics, and state of residence. In adjusted models children aged 6–11 and 12–17 years were more likely to be eligible but uninsured compared to those aged 0–5 years (AOR 1.57; 95 % CI 1.15–2.16 and AOR 1.93; 95 % CI 1.41–2.64). Children who received school lunch (AOR 0.67; 95 % CI 0.52–0.86) and SNAP (AOR 0.33; 95 % CI 0.24–0.46) were less likely to be eligible but uninsured compared to those children not receiving those needs based services; however, a majority (58.7 %) of eligible uninsured children were enrolled in the school lunch program. Five states (Texas, California, Florida, Georgia, New York) accounted for 46 % of the eligible uninsured children. Vermont had the lowest adjusted estimate of eligible uninsured children (3.6 %) and Nevada had the highest adjusted estimate (35.5 %). Using nationally representative data we have identified specific state differences, demographic and household characteristics that could help guide federal and local initiatives to improve public health insurance enrollment for children who are eligible but uninsured.     

Healthcare Providers’ Satisfaction with a State Children’s Health Insurance Program (SCHIP)

Purpose This study’s purpose was to understand how experiences with and perceptions of the health care plan characteristics influence provider satisfaction with a State Children’s Health Insurance Program (SCHIP). Methods Physicians and other health care providers participating in one program (ALL Kids) were mailed a survey (n = 500). Pediatricians were the most likely to return the survey. We used frequencies, chi-square and logistic regression analysis to explore relationships. Results The odds of being less satisfied with the program among providers who perceived that reimbursement in the ALL Kids program was less compared to private insurance were almost 7 times (OR = 6.81; 95% CI = (1.88–24.73)) greater than for those who perceived that reimbursement was more or the same in ALL Kids. Likewise, respondents who perceived that All Kids families were less likely than families with private insurance to return for follow-up visits were less satisfied with ALL Kids (OR = 17.42; 95% CI = (1.85–164.70)). Conclusions The stigma of SCHIP may be less than that often associated with Medicaid; however, this investigation should be considered with others that have identified barriers for provider’s participation. This study indicates that provider satisfaction is related to their perceptions of SCHIP policies and families, though it does not tell us what factors might contribute to this perception, such as, previous experience with public insurance (Medicaid) and publicly insured patients. Increasing reimbursement rates may not address perceptions that affect provider views of publicly-supported health plans and the participating families.     

The Agency for Healthcare Research and Quality’s Children’s Health Research Portfolio

The objective of this work was to describe and assess the potential impact of the Agency for Healthcare Research and Quality’s, AHRQ’s, children’s health activities. Using AHRQ databases and publications lists and generic search engines, we developed a comprehensive list of AHRQ’s funded children’s health activities (1990–2005) and related publications (1996–2002). We conducted bibliometric analyses and used Stryer’s (2000) approach to categorize their potential impact. We found that AHRQ’s child health portfolio has changed over time with an increase in activities related to patient safety and health information technology, reflecting trends at AHRQ as a whole. Further, AHRQ has contributed a substantial body of new knowledge as a result of its funding for children’s health activities. The bibliometric analysis suggests that AHRQ’s children’s health activities have successfully disseminated research findings and new knowledge through the published literature. Most of the publications present research findings that can be building blocks early in the translation continuum rather than findings that directly inform policy or change clinical practice. Through its funding of children’s health activities, AHRQ has contributed new knowledge that has been disseminated effectively in the published literature. However, while AHRQ has successfully engaged the child health services research community, efforts to broaden into policy, practice and patient arenas have been less successful.     

Oral Health Need and Access to Dental Services: Evidence from the National Survey of Children’s Health, 2007

This study examines associations between parents’ report of their children’s oral health and receipt of a dental visit for preventive care. We conducted a cross-sectional analysis of oral health status and receipt of a preventive dental visit among US children and youth, ages 1–17 years, using data from the 2007 National Survey of Children’s Health (n = 86,764). Survey-weighted logistic regression was used to estimate associations between perceived oral health status and receipt of a preventive dental health visit in the prior 12 months. Overall, 78 % of children and youth received at least one preventive dental health visit in the prior year. Among the youngest children, lower oral health status was associated with higher odds of receiving a preventive dental visit; among older children, lower oral health status was associated with lower odds of receiving a dental visit for preventive care. Use of preventive dental health care is below national target goals. Younger children in worse oral health are more likely, and older youth less likely, to receive preventive dental care. Public health efforts to educate parents to seek early and ongoing preventive oral health care, rather than services in response to problems, may yield oral health benefits later in childhood and over the life course.     

Do Health Insurance Mandates Spillover to Education? Evidence from Michigan’s Autism Insurance Mandate

Social programs and mandates are usually studied in isolation, but unintended spillovers to other areas can impact individual behavior and social welfare. We examine the presence of spillovers from health care policy to the education sector by studying how health insurance coverage affects the education of students with Autism Spectrum Disorder (ASD). We leverage a state mandate that increased insurance coverage of ASD-related services, which often are provided by both the private sector and within public schools. The mandate primarily affected coverage for children with private health insurance, so we proxy for private insurance coverage with students’ economic disadvantage status and estimate effects via triple-differences. While we find little change in ASD identification, the mandate crowds-out special education supports for students with ASD. A lack of short-run impact on achievement supports our crowd-out interpretation and indicates that the mandate had little net effect on the academic achievement of ASD students.     

Prevalence and Associated Factors of Tinnitus: Data From the Korean National Health and Nutrition Examination Survey 2009–2011

Background

Tinnitus is a common condition and frequently can be annoying to affected individuals. We investigated the prevalence and associated factors for tinnitus in South Korea using the data from the Korea National Health and Nutrition Examination Surveys (KNHANES) during 2009–2011.

Methods

KNHANES is a cross-sectional survey of the civilian, non-institutionalized population of South Korea (n = 21 893). A field survey team that included an otolaryngologist moved with a mobile examination unit and performed interviews and physical examinations.

Results

Among the population over 12 years of age, the prevalence of any tinnitus was 19.7% (95% CI 18.8%–20.6%). Tinnitus was more prevalent in women, and the prevalence rate increased with age (P < 0.001). Among those with any tinnitus, 29.3% (95% CI 27.3%–31.3%) experienced annoying tinnitus that affected daily life. Annoying tinnitus also increased with age (P < 0.001), but no sex difference was demonstrated (P = 0.25). In participants aged 40 years or older, age, quality of life, depressive mood, hearing loss, feeling of dizziness, and rhinitis were associated with any tinnitus (P < 0.05). Age, hearing loss, history of cardiovascular disease, and stress were associated with annoying tinnitus (P < 0.05).

Conclusions

Tinnitus is a common condition, and a large population suffers from annoying tinnitus in South Korea. Public understanding of associated factors might contribute to better management of tinnitus.Key words: tinnitus, epidemiology, associated factor, South Korea     

Disparities in Health Insurance Coverage and Access to Care for Children By Mother’s Sexual Orientation

Maternal and Child Health Journal - Few population-based studies have examined the health care experiences of children with sexual minority parents. The purpose of this study was to compare health...     

Parental Nativity Affects Children’s Health and Access to Care

Objective To examine the effect of parental nativity on child health and access to health care. Data Source The 2002 National Survey of America’s Families. Results Among US children, 14% have foreign-born parents; 5% have one foreign- and one native-born parent (“mixed-nativity”). In multivariate logistic regression analyses, children with foreign-born parents were less likely than children with US-born parents to be perceived in “very good” or “excellent health” [OR = 0.68; 95% CI (0.56–0.82)] and to have a usual health care site [OR = 0.52 (0.38–0.69)]; having mixed-nativity parents is associated with better perceived child health. These effects persisted for minority, but not white, children. Regardless of race and ethnicity, non-citizen children have worse access to care. Conclusion Efforts to improve children of immigrants’ health and access to care should focus on families in which both parents are immigrants, particularly those who are ethnic or racial minorities. Efforts to increase use of health services should focus on non-citizen children.     

Contribution of Parenting Factors to the Developmental Attainment of 9-Month-Old Infants: Results From the Japan Children’s Study

Background

Child development integrates several interdependent domains, but few studies have attempted to identify the common factors that contribute to these different domains of development in infancy. The aim of the present study was to identify the factors that contribute to several domains of developmental attainment in 9-month-old infants.

Methods

We used data from the Japan Children’s Study, a prospective cohort study underway in Japan since 2005. Mothers completed questionnaires about their children’s temperament, coparenting behaviors, maternal parenting stress, and parenting behavior. The Kinder infant development scale was used to evaluate child development outcomes.

Results

A total of 270 children were included in this analysis. After adjusting for the children’s birth weight, gestational age, temperament, and other family environmental variables, multiple logistic regression analyses showed that greater maternal cognitive stimulation was associated with the development of receptive language, expressive language, social relationships, and feeding. Results also suggest that early supportive coparenting helped to promote development in manipulation, receptive language, and social relationships. Maternal parenting stress was stable between the infant ages of 4 and 9 months and was negatively correlated with scores for coparenting and maternal stimulation, which suggests an indirect effect of maternal parenting stress on child outcomes.

Conclusions

Supportive coparenting and maternal cognitive stimulation were the most important contributors to most domains of child development. Our findings suggest that educational interventions targeting young families would help parents establish and maintain an environment of successful coparenting and cognitive stimulation as their children grow.Key words: development, coparenting, maternal stimulation, parenting stress, prospective study     

Children’s Television Viewing and ADHD-related Behaviors: Evidence from the Netherlands

This study examined how ADHD-related behaviors are associated with children’s overall amount of television viewing, specific content viewing (i.e. violent/scary and educational), and attention and arousal responses when viewing television. Additionally, it explored the moderating role of children’s sex in these relationships. To address these aims, parents of 865 Dutch children (3–7 years) completed a survey measuring ADHD-related behaviors and kept four-day television diaries. We found that ADHD-related behaviors were not associated with overall viewing nor with violent/scary content viewing. These relationships, however, were moderated by sex. Further analyses of these moderations revealed a positive trend between ADHD-related behaviors and overall and violent/scary content viewing for boys only. ADHD-related behaviors were not related to educational content viewing. Furthermore, ADHD-related behaviors were related to more arousal when viewing television, regardless of content, and less attention to overall and educational television. We did not find sex differences in arousal and attention responses.     

Does Mental Health Parity Encourage Mental Health Utilization Among Children and Adolescents? Evidence from the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA)

The Journal of Behavioral Health Services & Research - This study examines the effects of mental health parity laws on mental health care utilization and mental health outcomes of children and...