Related Articles

Objective

To examine the role of insurance coverage in protecting families of children with special health care needs (CSHCN) from the financial burden associated with care.

Methods

Data from the 2001 National Survey of Children with Special Health Care Needs were analyzed. We built two multivariate regression models using “work loss/cut back” and “experiencing financial problems” as the dependent variables and insurance status as the primary independent variable of interest while adjusting for income, race/ethnicity, functional limitation/severity, and other sociodemographic predictors.

Results

Approximately 29.9 % of CSHCN live in families where their condition led parents to report cutting back on work or stopping work completely. Families of 20.9 % of CSHCN reported experiencing financial difficulties due to the child’s condition. Insurance coverage significantly reduced the likelihood of families experiencing financial problems at every income level. The proportion of families experiencing financial problems was reduced from 35.7 to 23.0 % for the poor and 44.9 to 24.5 % for low-income families with continuous insurance coverage (p<0.01 for both comparisons). Similarly, the proportion of parents having to cut back or stop work was reduced from 42.8 to 35.9 % for the poor (p<0.05) and 43.5 to 33.9 % for low-income families (p<0.01).

Conclusions

Continuous health insurance coverage provides protection from financial burden and hardship for families of CSHCN in all income groups. This evidence is supportive of policies designed to promote universal coverage for CSHCN. However, many poor and low-income families continue to experience work loss and financial problems despite insurance coverage. Hence, health insurance should not be viewed as a solution in itself, but instead as one element of a comprehensive strategy to provide financial safety for families with CSHCN.

Objective

To determine the association between Medicaid managed care pediatric behavioral health programs and unmet need for mental health care among children with special health care needs (CSHCN).

Data Source

The National Survey of CSHCN (2000–2002), using subsets of 4,400 CSHCN with Medicaid and 1,856 CSHCN with Medicaid and emotional problems. Additional state-level sources were used.

Study Design

Multilevel models investigated the association between managed care program type (carve-out, integrated) or fee-for-service (FFS) and reported unmet mental health care need.

Data Collection/Extraction Methods

The National Survey of CSHCN conducted telephone interviews with a sample representative at both the national and state levels.

Principal Findings

In multivariable models, among CSHCN with only Medicaid, living in states with Medicaid managed care (odds ratio [OR]=1.81; 95 percent confidence interval: 1.04–3.15) or carve-out programs (OR=1.93; 1.01–3.69) were associated with greater reported unmet mental health care need compared with FFS programs. Among CSHCN on Medicaid with emotional problems, the association between managed care and unmet need was stronger (OR=2.48; 1.38–4.45).

Conclusions

State Medicaid pediatric behavioral health managed care programs were associated with greater reported unmet mental health care need than FFS programs among CSHCN insured by Medicaid, particularly for those with emotional problems.

Objective

To study the financial impact of state parity laws on families of children in need of mental health services.

Data Source

Privately insured families in the 2000 State and Local Area Integrated Telephone Survey National Survey of Children with Special Health Care Needs (CSHCN) (N=38,856).

Study Design

We examine whether state parity laws reduce the financial burden on families of children with mental health conditions. We use instrumental variable estimation controlling for detailed information on a child's health and functional impairment. We compare those in parity and nonparity states and those needing mental health care with other CSHCN.

Principle Findings

Multivariate regression results indicate that living in a parity state significantly reduced the financial burden on families of children with mental health care needs. Specifically, the likelihood of a child's annual out-of-pocket (OOP) health care spending exceeding $1,000 was significantly lower among families of children needing mental health care living in parity states compared with those in nonparity states. Families with children needing mental health care in parity states were also more likely to view OOP spending as reasonable compared with those in nonparity states. Likewise, living in a parity state significantly lowered the likelihood of a family reporting that a child's health needs caused financial problems. The likelihood of reports that additional income was needed to finance a child's care was also lower among families with mentally ill children living in parity states. However, we detect no significant difference among residents of parity and nonparity states in receipt of needed mental health care.

Conclusion

These results indicate that state parity laws are providing important economic benefits to families of mentally ill children undetected in prior research.

Objective

Although private insurance typically covers many health care costs, the challenges faced by families caring for a sick child are substantial. These challenges may be more severe for CSHCN with mental illnesses than for other special needs children. Our objective is to determine whether families of privately insured children needing mental health care face different burdens than other families in caring for their children.

Patients and Methods

We use the 2005–2006 National Survey of Children with Special Health Care Needs (NS-CSHCN) to study privately insured children ages 6–17. We compare CSHCN with mental health care needs (N=4,918) to three groups: children with no SHCN (N=2,346), CSHCN with no mental health care needs (N=16,250), and CSHCN with no mental health care need but a need for other specialty services (N=7,902). The latter group is a subset of CSHCN with no mental health care need. We use weighted logistic regression and study outcomes across four domains: financial burden, health plan experiences, labor market and time effects, and parent experience with services.

Results

We find that families of children with mental health care needs face significantly greater financial barriers, have more negative health plan experiences, and are more likely to reduce their labor market participation to care for their child than other families.

Conclusions

Families of privately insured CSHCN needing mental health care face a higher burden than other families in caring for their children. Policies are needed to aid these families in obtaining affordable, high quality care for their children.

Objective

To test the feasibility of using the National Health Interview Survey (NHIS) to identify children with chronic illness through a noncategorical approach, as exemplified by the Children with Special Health Care Needs (CSHCN) screener. The ability to use the NHIS to identify CSHCN will permit analyses of the effects of welfare reform and public insurance eligibility expansions during the late 1990s on CSHCN.

Data Sources

The NHIS from 1997, 1999, and 2000. The NHIS is an ongoing household survey representative of the civilian, noninstitutionalized population of the United States.

Study Design

Survey items were selected from the NHIS and thresholds designated to replicate the content and logic of the CSHCN screener. The screener asks explicit questions concerning an elevated need for, or use of health care services, and about limitations in activity, both caused by a chronic health condition. The algorithm created was applied to the pooled 1999–2000 NHIS to generate national prevalence estimates. Multivariate logistic regression was estimated to determine the effect of having particular demographic characteristics on the likelihood of being identified as CSHCN. Log odds ratios were compared to those from earlier NHIS-based estimates and from a pretest of the CSHCN screener.

Principal Findings

An estimated 12 percent of noninstitutionalized children aged 0 through 17 have a chronic condition that results in elevated service use or limitations in normal activity. This estimate is sensitive to inclusion of children with a broader array of less serious or shorter-term conditions. The estimated effects of child characteristics on the likelihood of being identified as having special health needs are similar but not identical to other algorithms that have been used to identify CSHCN.

Conclusions

It is feasible to use existing questions in the NHIS to identify a population of CSHCN that is substantially similar to children identified through other algorithms or through use of a screening instrument imbedded in a household survey. The availability of this algorithm will permit use of the NHIS for important analyses of the effects of welfare reform and public insurance expansions on children with special health care needs.

This paper grew out of a project reviewing progress in children's oral health since the Surgeon General's Report (SGR) on Oral Health. It includes a summary of advances in national surveillance of children with special health care needs (CSHCN), and presents more recent data on unmet dental care need among CSHCN. To that end, we used the 2006-National Survey of CSHCN to determine the prevalence of unmet dental care need among CSHCN and to compare this within subgroups of CSHCN, as well as to children without special health care needs, and to results from the previous iteration of this survey.

We found that dental care remains the most frequently cited unmet health need for CSHCN. More CSHCN had unmet need for non-preventive than preventive dental care. CSHCN who are teens, poorer, uninsured, had insurance lapses, or more severely affected by their condition had higher adjusted odds of unmet dental care needs. CSHCN who were both low-income and severely affected had 13.4 times the adjusted odds of unmet dental care need.

In summary, CSHCN are more likely to be insured and to receive preventive dental care at equal or higher rates than children without SHCN. Nevertheless, CSHCN, particularly lower income and severely affected, are more likely to report unmet dental care need compared to unaffected children. Despite advances in knowledge about dental care among CSHCN, unanswered questions remain. We provide recommendations towards obtaining additional data and facilitating dental care access for this vulnerable population.

Background

The purpose of this study is to identify factors affecting CSHCN's receiving needed specialty care among different socioeconomic levels. Previous literature has shown that Socioeconomic Status (SES) is a significant factor in CHSHCN receiving access to healthcare. Other literature has shown that factors of insurance, family size, race/ethnicity and sex also have effects on these children's receipt of care. However, this literature does not address whether other factors such as maternal education, geographic location, age, insurance type, severity of condition, or race/ethnicity have different effects on receiving needed specialty care for children in each SES level.

Methods

Data were obtained from the National Survey of Children with Special Health Care Needs, 2000–2002. The study analyzed the survey which studies whether CHSCN who needed specialty care received it. The analysis included demographic characteristics, geographical location of household, severity of condition, and social factors. Multiple logistic regression models were constructed for SES levels defined by federal poverty level: < 199%; 200–299%; ≥ 300%.

Results

For the poorest children (,199% FPL) being uninsured had a strong negative effect on receiving all needed specialty care. Being Hispanic was a protective factor. Having more than one adult in the household had a positive impact on receipt of needed specialty care but a larger number of children in the family had a negative impact. For the middle income group of children (200–299% of FPL severity of condition had a strong negative association with receipt of needed specialty care.

Children in highest income group (> 300% FPL) were positively impacted by living in the Midwest and were negatively impacted by the mother having only some college compared to a four-year degree.

Conclusion

Factors affecting CSHCN receiving all needed specialty care differed among socioeconomic groups. These differences should be addressed in policy and practice. Future research should explore the CSHCN population by income groups to better serve this population

OBJECTIVES: To show how health insurance (privately and publicly insured, insured and uninsured) relates to vaccination coverage in children 19-35 months old, and how this can be used to better target public health interventions. METHODS: The National Health Interview Survey (NHIS) gathers information on the health and health care of the U.S. non-institutionalized population through household interviews. The authors combined immunization and health insurance supplements from the 1993 through 1996 NHIS, and classified children 19-35 months old by their immunization and insurance status. Results were compared using both bivariate and multivariate analyses, and the backwards stepwise selection method was used to build multivariate logistic regression models. RESULTS: Uninsured children tended to have lower vaccination coverage than those who had insurance, either private or public. Among those with insurance, publicly insured children had lower vaccination coverage than privately insured children. Backwards stepwise regression retained insurance status, metropolitan statistical area, and education of responsible adult family member as major predictors of immunization. Factors considered but not retained in the final model included child race/ethnicity, family poverty index, and region of country. CONCLUSIONS: Insurance status was a critical predictor of vaccination coverage for children ages 19-35 months. After controlling for confounders, the uninsured were about 24% less likely to receive all recommended shots than the insured and, among the insured, those with public insurance were about 24% less likely to receive all recommended vaccines than those with private insurance.

Objective

To profile and compare the health and health services characteristics for children with special health care needs (CSHCN) with and without disabilities, and to determine factors associated with unmet need.

Methods

Secondary data analysis of the 2005-06 National Survey of Children with Special Health Care Needs was conducted. The socio-demographics, health, and health services of CSHCN with and without disabilities were compared. Multivariable logistic regression was employed to examine factors associated with unmet need for health services.

Results

Children from minority racial and ethnic groups and children living in or near poverty were overrepresented among CSHCN with disabilities compared to other CSHCN. Statistically higher percentages of CSHCN with disabilities had behavioral problems (39.6% vs. 25.2%), anxiety/depressed mood (46.1% vs. 24.0%) and trouble making/keeping friends (38.1% vs. 15.6%) compared to other CSHCN. 32% of CSHCN with disabilities received care in a medical home compared to 51% of other CSHCN. CSHCN with disabilities had higher rates of need and unmet need than other CSHCN for specialty care, therapy services, mental health services, home health, assistive devices, medical supplies and durable medical equipment. The adjusted odds of unmet need for CSHCN with disabilities were 71% higher than for other CSHCN.

Conclusion

CSHCN with disabilities had more severe health conditions and more health services need, but they less commonly received care within a medical home and had more unmet need. These health care inequities should be amenable to policy and health service delivery interventions to improve outcomes for CSHCN with disabilities.

What’s New

CSHCN with disabilities are identified as a distinct group of CSHCN because of their sociodemographic, health and health services characteristics. CSHCN with disabilities had more psychosocial problems and health service needs than other CSHCN. We also document inequities in health services by highlighting the rates of unmet need and low percentages of care within a medical home for CSHCN with disabilities.

Objectives

Limited studies consider the effect of differential item functioning (DIF) on health-related quality of life (HRQOL) comparisons between ill and health children. The objective is to assess DIF and compare HRQOL between children with special health care needs (CSHCN) and children without needs.

Methods

Data were collected from 1195 families of children enrolled in Florida’s public insurance programs. HRQOL was measured using physical, emotional, social, and school functioning of the PedsQL. We identified CSHCN using the CSHCN Screener and assessed DIF related to CSHCN using a multiple group-multiple indicator-multiple cause (MG-MIMIC) method. We assessed the impact of DIF by examining expected item/test scores and item/test information function. We tested the discrepancy between underlying HRQOL scores of both groups before and after DIF calibration (allowing parameters of DIF items to be different and DIF-free items to be the same across both groups).

Results

Two (25%) and 3 items (60%) of physical and school functioning, respectively, were identified with non-uniform DIF, and two items (40%) of social functioning were identified with uniform DIF. Expected item/test scores and item/test information function suggest the impact of DIF is minimal. Before DIF calibration, HRQOL in CSHCN was more impaired than children without needs (effect size −1.04, − 0.74, −0.96, and −0.98 for physical, emotional, social and school functioning, respectively). After DIF calibration, the discrepancy was increased slightly.

Conclusions

Although 30% of items in the PedsQL were identified with DIF related to CSHCN and children without needs, the impact of DIF is minimal.

OBJECTIVE: This study assessed the timeliness of immunization for children in a Medicaid managed care primary care case management program controlling for patient and provider predictors of immunization status. METHODS: Using administrative data and patient medical records, up-to-date (UTD) and age appropriate immunization (AAI) status were reviewed for 5598 children. The 4:3:1 immunization series (four diphtheria, pertussis, tetanus vaccinations; three polio vaccinations; and one measles, mumps, rubella vaccination) was the standard. RESULTS: Childhood immunization rates were low when assessed using strict adherence to vaccination recommendations. At age 18 months, 28.3% were classified as UTD, and 6.3% were classified as AAI. Compared to children not up-to-date, UTD children were more likely to have public rather than private providers, to have had older mothers, and less likely to have been African American. Among UTD children, AAI children were more likely to reside in urban areas. CONCLUSIONS: Low-income children continue to be under-immunized, even under a managed care initiative. Health care providers and child health advocates need to continue pressure for programs that will increase adherence to nationally recommended guidelines.

BACKGROUND

In an era of rising health care costs, many Americans experience difficulty paying for needed health care services. With costs expected to continue rising, changes to private insurance plans and public programs aimed at containing costs may have a negative impact on Americans' ability to afford care.

OBJECTIVES

To provide estimates of the number of adults who avoid health care due to cost, and to assess the association of income, functional status, and type of insurance with the extent to which people with health insurance report financial barriers.

RESEARCH DESIGN

Cross-sectional observational study using data from the Commonwealth Fund 2001 Health Care Quality Survey, a nationally representative telephone survey.

PARTICIPANTS

U.S. adults age 18 and older (N=6,722).

MEASURES

Six measures of avoiding health care due to cost, including delaying or not seeking care; not filling prescription medicines; and not following recommended treatment plan.

RESULTS

The proportion of Americans with difficulty affording health care varies by income and health insurance coverage. Overall, 16.9% of Americans report at least 1 financial barrier. Among those with private insurance, the poor (28.4%), near poor (24.3%), and those with functional impairments (22.9%) were more likely to report avoiding care due to cost. In multivariate models, the uninsured are more likely (OR, 2.3; 95% CI, 1.7 to 3.0) to have trouble paying for care. Independent of insurance coverage and other demographic characteristics, the poor (OR, 3.6; 95% CI, 2.1 to 4.6), near poor (OR, 2.1; 95% CI, 1.9 to 3.7), and middle-income (OR, 1.8; 95% CI, 1.3 to 2.5) respondents as well as those with functional impairments (OR, 1.6; 95% CI, 1.3 to 2.0) are significantly more likely to avoid care due to cost.

CONCLUSIONS

Privately and publicly insured individuals who have low incomes or functional impairments encounter significant financial barriers to care despite having health insurance. Proposals to expand health insurance will need to address these barriers in order to be effective.

Background And Objectives

To understand the association between shared decision-making (SDM) and health care expenditures and use among children with special health care needs (CSHCN).

Methods

We identified CSHCN <18 years in the 2002–2006 Medical Expenditure Panel Survey by using the CSHCN Screener. Outcomes included health care expenditures (total, out-of-pocket, office-based, inpatient, emergency department [ED], and prescription) and utilization (hospitalization, ED and office visit, and prescription rates). The main exposure was the pattern of SDM over the 2 study years (increasing, decreasing, or unchanged high or low). We assessed the impact of these patterns on the change in expenditures and utilization over the 2 study years.

Results

Among 2858 subjects representing 12 million CSHCN, 15.9% had increasing, 15.2% decreasing, 51.9% unchanged high, and 17.0% unchanged low SDM. At baseline, mean per child total expenditures were $2131. Over the 2 study years, increasing SDM was associated with a decrease of $339 (95% confidence interval: $21, $660) in total health care costs. Rates of hospitalization and ED visits declined by 4.0 (0.1, 7.9) and 11.3 (4.3, 18.3) per 100 CSHCN, and office visits by 1.2 (0.3, 2.0) per child with increasing SDM. Relative to decreasing SDM, increasing SDM was associated with significantly lower total and out-of-pocket costs, and fewer office visits.

Conclusions

We found that increasing SDM was associated with decreased utilization and expenditures for CSHCN. Prospective study is warranted to confirm if fostering SDM reduces the costs of caring for CSHCN for the health system and families.

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.

Recent years have seen shifts in health insurance coverage associated with economic fluctuations and changes in health policy. The analysis presented here uses data from the National Survey of America's Families to examine changes in health insurance coverage and respondent-reported health status by race and ethnicity. The data indicate that public coverage increased for black, Hispanic and white children between 1997 and 2002. Uninsurance rates fell among children in low-income black, Hispanic and white families, remained constant among black and white children in higher-income families, and increased among higher-income Hispanic children. The health status of children was stable for blacks, Hispanics and whites except for a decline in health among higher-income Hispanic children. Black and white adults saw increases in public health insurance coverage but not in overall coverage. The uninsurance rate of Hispanic adults increased, despite expanded public coverage of higher-income Hispanic adults. None of these developments altered racial and ethnic disparities in health. Hispanics fared worse than blacks in both health status and insurance coverage, and blacks fared worse than whites. Given the anticipated growth of minority populations in the United States, the nation's health will deteriorate if policymakers allow current disparities to continue.

Objective

To compare the extent with which child-only and family coverage (child and parent insured) ensure health care access and use for low income children in California and discuss the policy implications of extending the State Children's Health Insurance Program (California's Healthy Families) to uninsured parents of child enrollees.

Data Sources/Setting

We used secondary data from the 2001 California Health Interview Survey (CHIS), a representative telephone survey.

Study Design

We conducted a cross-sectional study of 5,521 public health insurance–eligible children and adolescents and their parents to examine the effects of insurance (family coverage, child-only coverage, and no coverage) on measures of health care access and utilization including emergency room visits and hospitalizations.

Data Collection

We linked the CHIS adult, child, and adolescent datasets, including the adolescent insurance supplement.

Findings

Among the sampled children, 13 percent were uninsured as were 22 percent of their parents. Children without insurance coverage were more likely than children with child-only coverage to lack a usual source of care and to have decreased use of health care. Children with child-only coverage fared worse than those with family coverage on almost every access indicator, but service utilization was comparable.

Conclusions

While extending public benefits to parents of children eligible for Healthy Families may not improve child health care utilization beyond the gains that would be obtained by exclusively insuring the children, family coverage would likely improve access to a regular source of care and private sector providers, and reduce perceived discrimination and breaks in coverage. These advantages should be considered by states that are weighing the benefits of expanding health insurance to parents.

Context

Millions of US children lack health insurance coverage. Efforts to expand children’s insurance often focus on extending public coverage to uninsured parents. Less is known about the uninsured children whose parents already have coverage.

Objective

To identify predictors of uninsurance among US children with insured parents.

Design/Setting

Cross-sectional and full-year analyses of pooled 2002-2005 data from the nationally-representative Medical Expenditure Panel Survey (MEPS).

Participants

All children under age 19 in four yearly MEPS files with positive full-year weights who had at least one parent residing in the same household (unweighted total number = 39,710).

Main Outcome Measure

Cross-sectional and full-year uninsurance among children with at least one insured parent.

Results

Cross-sectionally, over 3.3 percent of US children were uninsured with at least one insured parent (unweighted total number = 1,380, weighted average yearly population of approximately 2.3 million children). In multivariable analyses, children experiencing this discordant pattern of family coverage were more likely Hispanic (odds ratio [OR] 1.58; 95% confidence interval [CI], 1.23 to 2.03) compared to white, non-Hispanic; low and middle income (OR 2.02; 95% CI, 1.42 to 2.88; and OR 1.48; 95% CI, 1.09 to 2.03, respectively) compared to high income; from single-parent homes (OR 1.99; 95% CI 1.59 to 2.49) compared to children living with two married parents; and living with parents who had less than a high school education (OR 1.44; 95% CI 1.10 to 1.89) compared to those with at least one parent who had completed high school. Children whose parents had public coverage were less likely to be uninsured (OR 0.64; 95% CI 0.43 to 0.96) compared to those whose parents reported private health insurance. These predictors remained significant in full-year analyses. Similar patterns of vulnerability were also found among a subset of uninsured children with privately-covered parents.

Conclusions

Predictors of uninsurance among children with at least one insured parent included: having low and middle household incomes, being of Hispanic origin, having parents who did not complete high school, and living in a single-parent household. Having a parent covered by only public insurance was associated with better children’s coverage rates.

Objective.

This study assessed the timeliness of immunization for children in a Medicaid managed care primary care case management program controlling for patient and provider predictors of immunization status.

Methods.

Using administrative data and patient medical records, up-to-date (UTD) and age appropriate immunization (AAI) status were reviewed for 5,598 children. The 4:3:1 immunization series (4 diphtheria, pertussis, tetanus vaccinations; 3 polio vaccinations; and one measles, mumps, rubella vaccination) was the standard.

Results.

Childhood immunization rates were low when assessed using strict adherence to vaccination recommendations. At age 18 months, 28.3% were classified as UTD, and 6.3% were classified as AAI. Compared to children not up-to-date, UTD children were more likely to have public rather than private providers, to have had older mothers, and less likely to have been African-American. Among UTD children, AAI children were more likely to reside in urban areas.

Conclusions.

Low-income children continue to be under-immunized, even under a managed care initiative. Health care providers and child health advocates need to continue pressure for programs that will increase adherence to nationally recommended guidelines.

Data are presented from a recent survey of the United States population comparing the characteristics and levels of access to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third-party coverage. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coverage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. Implications of these findings for national health insurance and other health policy initiatives are discussed.

Objective

To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage.

Data Sources

The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File.

Study Design

We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care).

Principal Findings

VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect.

Conclusions

Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services.

A challenge facing immunization registries is developing measures of childhood immunization coverage that contain more information for setting policy than present vaccine series up-to-date (UTD) rates. This study combined milestone analysis with provider encounter data to determine when children either do not receive indicated immunizations during medical encounters or fail to visit providers. Milestone analysis measures immunization status at key times between birth and age 2, when recommended immunizations first become late. The immunization status of a large population of children in the Oregon ALERT immunization registry and in the Oregon Health Plan was tracked across milestone ages. Findings indicate that the majority of children went back and forth with regard to having complete age-appropriate immunizations over time. We also found that immunization UTD rates when used alone are biased towards relating non-UTD status to a lack of visits to providers, instead of to provider visits on which recommended immunizations are not given.

Objective

To quantify the number of children who experience gaps in insurance coverage and to determine whether vulnerable subgroups of children experience noteworthy lapses in insurance coverage.

Methods

We analyzed nationally representative data from 24 149 children sampled in the 1999–2001 Medical Expenditure Panel Survey linked to the 1997–1999 National Health Interview Survey. Vulnerable subgroups of children included children with chronic conditions, those from ethnic/racial minorities, and those living in poverty. On the basis of cumulative annual monthly insurance coverage status, each child fell into 1 of 3 groups: continuous coverage, uninsured, or gaps in coverage. Using SAS-callable SUDAAN, we conducted multivariate ordinal logistic regression model to quantify the likelihood of having gaps in coverage for vulnerable subgroups of children.

Results

From 1999 to 2001, we found that > 9 million American children annually had gaps in coverage and that 5 to 6 million children annually were uninsured for the entire year. Sixty percent of children experienced gaps of at least 4 months, and > 40% of all publicly and privately insured children had coverage gaps. After accounting for relevant covariates, children with chronic conditions were just as likely as other children to have gaps in coverage or be uninsured; Hispanic children were most likely to have insurance gaps or be uninsured; and children from poor and near-poor families were 4 to 5 times more likely to have lapsed coverage than children from high-income families. Poverty and maternal education were the strongest factors associated with lapsed coverage.

Conclusions

Unstable health insurance is an underrecognized problem for children, including those with chronic conditions. Because unstable insurance coverage can lead to inadequate health care utilization and poor child health outcomes, strategies to promote stable insurance coverage merit serious consideration.

Objective

To assess the impacts of recent state mental health parity legislation on perceived quality of health insurance coverage, perceived access to needed health care, and use of mental health specialty services by individuals with likely need for mental health care.

Data Sources

The study sample came from two waves of a national household survey first fielded in 1997–1998 and then in 2000–2001. The analysis used a subset of the sample.

Study Design

The study took the Difference-in-Difference-in-Difference approach to investigate changes in self-perceived quality of health insurance coverage and access to needed health care, and use of mental health specialty care by the group with mental disorders (relative to those without) in states with parity legislation of different comprehensiveness (relative to the nonparity states) in the years after the law (relative to before the law).

Principal Findings

Overall, there were no significant or consistent effects of the parity legislation. Descriptive statistics showed significant changes in some (but not all) outcome variables, but these results disappeared in detailed statistical analyses by controlling for important covariates.

Conclusions

The null findings of the effects of state mental health parity mandates suggest that under ERISA (Employee Retirement Income Security Act), the scope of state parity legislation may have been restricted because of large proportion of self-insured employers. Furthermore, comprehensiveness of state legislation appears to be related to the traditional level of use of mental health specialty care, which becomes another confounder for the potential policy effects.

OBJECTIVE

The purpose of this work was to identify the proportions of publicly (Medicaid and State Child Health Insurance Program) insured and uninsured children who did not identify a usual source of care from 1998 to 2006, spanning the State Children’s Health Insurance Program (1997 to present) and the President’s Health Center Initiative (2002 to present), and to characterize unmet medical need as it relates to insurance and a usual source of care for publicly insured and uninsured children.

METHODS

We conducted a secondary data analysis of multiple years of the National Health Interview Survey. We identified the proportion of publicly insured and uninsured children aged 0 to 17 years who did not identify a usual source of care and stratified according to the site of care. We described the odds of reporting an unmet medical need according to insurance status and usual source of care, compared with privately insured children with a usual source of care. Sample weights were used to derive national estimates.

RESULTS

From 1998 through 2006, there were significant increases in the proportions of children enrolled in Medicaid (16.7%–24.5%) and the State Child Health Insurance Program (2.0%–5.3%). The proportion of uninsured children has remained stable from 2002 to 2006 at ~10%. However, the proportion of uninsured reporting no usual source of care increased from 17.8% to 23.3%. Hispanic children had significant increases in the proportions of the uninsured and reporting no usual source of care by 2006. Hispanics constituted the largest proportion in both groups. Uninsured children and children without a usual source of care reported the highest odds of unmet need. Among the insured, publicly insured children had twice the odds of reporting an unmet need compared with privately insured children.

CONCLUSIONS

During the State Child Health Insurance Program and the President’s Health Center Initiative, growing proportions of uninsured children reported no usual source of care. Unmet medical need was the highest for the uninsured and those without a usual source of care. These findings suggest that initiatives designed to improve access to care must combine broadened insurance coverage with enhanced access to usual sources of care.

AIMS—To analyse inequalities by social class in children's access to and utilisation of health services in Catalonia (Spain), private health insurance coverage, and certain aspects of the quality of care received.
DESIGN—Cross sectional study using data from the 1994 Catalan Health Interview Survey.
SETTING—Child population of Catalonia.
PARTICIPANTS—A representative sample of non-institutionalised children younger than 15 years (n = 2433).
MAIN OUTCOME MEASURES—Health services utilisation, perceived health, type of health insurance (only National Health System (NHS) or both NHS and private health insurance), and social class.
RESULTS—No inequalities by social class were found for the utilisation of health care services provided by the NHS among children in most need. Double health care coverage does not influence the social pattern of visits. Nevertheless, social inequalities still remain in the use of those health services provided only partially by the NHS (dentist) and when characteristics of the last consultation are taken into account. That is, subjects who paid for a private service waited an average of 14.8 minutes less than those whose visit was paid for by the NHS only.
CONCLUSION—Equitable access and use of medical care services in relation to need, regardless of the type of insurance and social class of their children and families, has been achieved in this region of Spain; differences by social class remain for those services incompletely covered by national health insurance and aspects of the quality of care provided.