To our knowledge, this is the first study examining recent trends in the proportions of publicly insured and uninsured children who do and do not identify a USC and where they report getting care in light of 2 major initiatives (SCHIP and the PHCI) with potentially major influence on access to care for children. During the study period, the number and proportion of children who were uninsured decreased, consistent with other national studies of children’s insurance coverage during the SCHIP era.13
However, broader coverage and the PHCI have not translated into more uninsured children reporting USCs. In fact, the proportion reporting no USC increased during the PHCI era. This concerning finding has not been reported previously.
Our findings are consistent with data regarding increasing volumes of care at clinics/health centers during the PHCI era.14
Although it is difficult to directly compare because health center data do not specify volumes of visits for children, we found that the proportion of uninsured children who reported clinics/health centers as a USC was the same (34%) in 1998 and 2006. Because the overall number of children (uninsured and insured) increased, this translated into a larger number of children over time seen at clinics and health centers.
The more salient pattern of change seems to relate to the privately insured and to private offices as a USC. Private offices continued to be a USC for the bulk of children, regardless of insurance status. Even so, it is important to note that, recently, the proportion of uninsured and SCHIP-enrolled children who reported a private office as their USC decreased, as did the proportion of privately insured children overall who were most likely to attend private offices. Concurrently, an increasing proportion of uninsured children reported no USC, although the overall proportion of uninsured children remained stable. Together, these patterns are producing a concerning shift away from private offices as a USC and toward reporting no USC.
There are several possible explanations for these phenomena. Although the proportion of children who are uninsured has remained stable, an increasing proportion reporting no USC may reflect churning of children on and off coverage,15
leading to intermittent lapses and dropped coverage for children enrolled previously in public programs and private plans.16
The mounting losses in employer-based coverage related to the worsening economy and to increasing premium costs may explain the significant drop in private coverage for children during the study period.17
The dropout of publicly insured children from private offices may reflect concerns with private provider reimbursement, administrative policies, or billing related to government programs and its potentially negative effects on providing accessible care to this population.16
It is also possible that the trends for older children and adolescents to be uninsured and have no USC could also be contributing factors to our findings.
The fact that clinics/health centers have remained stable as USCs over time was not consistent with our hypothesis that clinics/health centers would increase as USCs during the PHCI. Flat trends, similar to stable rates of uninsurance among children, may indicate that access to health center care is unlikely to increase unless coverage further increases.18
This connection between coverage and USC identification is highlighted by the increase in SCHIP-enrolled children who reported clinic/health centers as a USC across the study period, consistent with the federally qualified community health center literature reporting increasing numbers of community health center patients enrolled in SCHIP.19
Publicly insured and uninsured children had higher odds of reporting an unmet medical need compared with privately insured children. The uninsured had the highest odds overall, consistent with previous studies examining unmet need.12
What is notable is that the odds of reporting an unmet medical need were stable or increasing over time, despite efforts at state and national levels to improve access to care for the uninsured. Among the insured, Medicaid and SCHIP-enrolled children had ~2 times the odds of reporting an unmet medical need compared with privately insured children. This reveals a dichotomy within the insured that has persisted and warrants attention by legislators and policy-makers on how to address and diminish this continuing disparity.
In comparison with privately insured children with a USC, the uninsured without a USC had the highest odds of reporting an unmet medical need. Uninsured children had significantly higher odds of reporting an unmet need compared with publicly insured children, highlighting the importance of coverage for children in reducing unmet medical need. The publicly insured children without a USC had similar odds of reporting an unmet medical need, as did the uninsured with a USC, illustrating that having a USC somewhat safeguards against unmet need even if uninsured. The safety net exists to provide that care and reduce the unmet need that vulnerable populations experience. A particularly and increasingly vulnerable group is Hispanic children, who are the most likely not only to be uninsured but also to report no USC.20,21
Our results should be interpreted in light of some limitations. First, because of the nature of the data, we cannot determine reasons for changes in an individuals’ USC. Second, serial cross-sectional analyses cannot attribute causality for the trends that we observed.
Third, questions in the NHIS did not distinguish between a clinic or health center as separate answers for the respondents, and that could influence the proportions of children who reported a health center as a USC over the study period. Nevertheless, we believe that federally qualified community health centers are a large subset of the clinic/health center group, and stable proportions of clinic/health center patients do shed light on how major initiatives have influenced the use of health care over time.
Fourth, what is considered an unmet medical need as defined in the data set may be variable. However, we designated unmet medical need based on precedent.12
We also performed analyses that examined the odds of unmet need for prescription medicines and mental health counseling only and found no significant differences in the trends seen by insurance status or USC as compared with the composite variable. There may be other factors that affect the odds of reporting unmet need, such as differences in case mix among providers, and within payer type that could influence these trends. The unmet needs presented are not all encompassing of the potential unmet needs that can be encountered by patients, and this is an acknowledged limitation of these data.