“Mind the Gap” in Children's Health Insurance Coverage: Does the Length of a Child's Coverage Gap Matter?

doi:10.1016/j.ambp.2007.10.003

Ambulatory Pediatrics

Volume 8, Issue 2, 17 March 2008, Pages 129-134

https://doi.org/10.1016/j.ambp.2007.10.003 Get rights and content

Objective

Gaps in health insurance coverage compromise access to health care services, but it is unclear whether the length of time without coverage is an important factor. This article examines how coverage gaps of different lengths affect access to health care among low-income children.

Methods

We conducted a multivariable, cross-sectional analysis of statewide primary data from families in Oregon's food stamp population with children presumed eligible for publicly funded health insurance. The key independent variable was length of a child's insurance coverage gap; outcome variables were 6 measures of health care access.

Results

More than 25% of children reported a coverage gap during the 12-month study period. Children most likely to have a gap were older, Hispanic, lived in households earning between 133% and 185% of the federal poverty level, and/or had an employed parent. After adjusting for these characteristics, in comparison with continuously insured children, a child with a gap of any length had a higher likelihood of unmet medical, prescription, and dental needs; no usual source of care; no doctor visits in the past year; and delayed urgent care. When comparing coverage gaps, children without coverage for longer than 6 months had a higher likelihood of unmet needs compared with children with a gap shorter than 6 months. In some cases, children with gaps longer than 6 months were similar to, or worse off than, children who had never been insured.

Conclusions

State policies should be designed to minimize gaps in public health insurance coverage in order to ensure children's continuous access to necessary services.

Section snippets

Study Population

We identified all families enrolled in Oregon's food stamp program at the end of January 2005. At that time, eligibility criteria for food stamps in Oregon required a household income of less than 185% of the federal poverty level (FPL) and US citizenship. These income and citizenship requirements were essentially the same for children's Medicaid or SCHIP; therefore, for the purposes of this study, Oregon children receiving food stamps were presumed eligible for publicly funded health insurance.

Results

We received completed surveys from 2681 of the 8636 eligible households (31% response rate). This response rate is consistent with other similar surveys of Medicaid-eligible populations.19, 20, 21 Survey respondents had similar characteristics to the total population, as assessed by comparisons of race/ethnicity, gender, age, geographic region, household income, and current enrollment status in a public insurance program. We used administrative data from respondents and nonrespondents to weight

Discussion

Among this population of Oregon children presumed eligible for public health insurance, 1 of 4 had a gap in coverage during a 12-month period. Explanations for children's insurance instabilities are beyond the scope of this article; however, Fairbrother and colleagues⁴ observed that Oregon's requirement to renew coverage every 6 months, instead of every 12 months, may contribute to higher levels of churning.

Our study confirms previous findings about the importance of continuous health insurance

Acknowledgments

Supported in part by a grant obtained by the Office for Oregon Health Policy and Research from the US Health Resources and Services Administration (HRSA). Jennifer DeVoe's time on this project was supported by grant numbers 5-F32-HS014645 and 1-K08-HS16181 from the Agency for Health care Research and Quality (AHRQ).

We thank the Office for Oregon Health Policy and Research (OHPR), the Oregon Department of Children, Adults and Families (CAF—food stamp office), and the Oregon Department of Medical

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We found the intensity of insurance transitions to be positively associated with healthcare utilization, both in terms of ED visits and hospitalizations. Higher ED utilization in this patient population is especially alarming because it could be a signal for delayed treatment and suboptimal management of RE [14]. Prior studies showed children with insurance coverage for only a few months of the year were less likely to have an annual medical visit, such as regularly scheduled outpatient medical care, than those with full-year insurance coverage [12,13].
The objective of the study is to investigate the association between insurance transitions and healthcare utilization among children with refractory epilepsy.
We applied published algorithms to identify the study cohort of children with a diagnosis of refractory epilepsy who were treated between 10/1/2013 and 9/30/2014 at 36 children's hospitals in the United States. Insurance transition was defined as having any change in the type of primary payer from the first date of diagnosis to the date of the last visit at the same hospital. Univariate and multilevel multivariable analytical methods were used in the study.
Among 3488 children hospitalized with refractory epilepsy, rates of insurance transitions at 1, 2, and 5 years of refractory epilepsy diagnosis were 8.1%, 14%, and 29.9%, respectively. Patients whose primary payer at diagnosis was Private or Others were more likely to experience insurance transitions than patients whose primary payer was Medicaid. Younger children were associated with a higher risk of insurance transitions than older children. The high intensity of insurance transitions was associated with a higher number of emergency department and inpatient visits.
Insurance transitions interrupted the continuity of medical care for children with refractory epilepsy and were associated with more frequent hospitalizations and emergency department visits, which then translated to higher healthcare costs. Medicaid provided stable insurance coverage and is critically important for these patients and should be the main focus for policies aiming to minimize insurance transitions and optimize healthcare delivery.
Innovative methods for parents and clinics to create tools for kids' care (IMPACCT Kids' Care) study protocol
2015, Contemporary Clinical Trials
Despite expansions in public health insurance, many children remain uninsured or experience gaps in coverage. Community health centers (CHCs) provide primary care to many children at risk for uninsurance and are well-positioned to help families obtain and retain children's coverage. Recent advances in health information technology (HIT) capabilities provide the means to create tools that could enhance CHCs' insurance outreach efforts.
To present the study design, baseline patient characteristics, variables, and statistical methods for the Innovative Methods for Parents And Clinics to Create Tools for Kids' Care (IMPACCT Kids' Care) study.
In this mixed methods study, we will design, test and refine health insurance outreach HIT tools through a user-centered process. We will then implement the tools in four CHCs and evaluate their effectiveness and barriers and facilitators to their implementation. To measure effectiveness, we will quantitatively assess health insurance coverage continuity and utilization of healthcare services for pediatric patients in intervention CHCs compared to matched control sites using electronic health record (EHR) and Oregon Medicaid administrative data over 18 months pre- and 18 months post-implementation (n = 34,867 children). We will also qualitatively assess the implementation process to understand how the tools fit into the clinics' workflows and the CHC staff experiences with the tools.
This study creates, implements, and evaluates health insurance outreach HIT tools. The use of such tools will likely improve care delivery and health outcomes, reduce healthcare disparities for vulnerable populations, and enhance overall healthcare system performance.
ClinicalTrials.gov Identifier: NCT02298361.
Insurance coverage and anticipatory guidance: Are Hispanic children at a disadvantage?
2014, Journal of Pediatrics
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Most likely, children with gaps in insurance coverage receive recommended guidance about diet and exercise during well-child visits, which they are likely to schedule during times of insurance coverage. Although our results show no ill-effects of health insurance coverage gaps on receipt of anticipatory guidance, insurance coverage discontinuity has been linked to poor health outcomes in other work.13-16 Children who were overweight or obese were more likely to receive anticipatory guidance about diet and exercise, which suggests that providers may be selective in counseling patients who present with an unhealthy body mass index—findings that are consistent with other research.16
Health insurance coverage within sibships: Prevalence of mixed coverage and associations with health care utilization
2013, Social Science and Medicine
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Previous studies also provide reason to believe that family insurance coverage patterns have consequences for children's health care access and utilization, net of an individual child's own coverage. For example, DeVoe et al. (2008) find that among insured children, those with uninsured parents have higher rates of unmet health care needs than those with insured parents. Our analyses examine both the possibility that any mixed insurance coverage among siblings is associated with poorer outcomes and the possibility that particular forms of mixed insurance coverage are associated with different health care utilization patterns.
An increasing proportion of children in the United States lives in families with complicated family structures and a mix of immigrant and US-born family members. Eligibility rules for health insurance coverage, however, were not designed with these families in mind. The result can be complicated insurance patterns among siblings within families, with some “sibships” only being partially-insured, and other sibships having both private and public coverage. We hypothesize that mixed coverage among siblings causes confusion and logistical difficulties for parents and may lead to less access to appropriate health care for their children. In this article, we use data from the 2009–2011 National Health Interview Survey (n = 51,418 children in 20,478 sibships) to present estimates of the prevalence of mixed health insurance coverage among siblings and describe the predictors of such coverage. We also use linked data from the 2001–2005 National Health Interview Survey and 2002–2007 Medical Expenditure Panel Survey (n = 17,871) to show how mixed coverage is related to health care utilization. We find that although few sibships are characterized by different health insurance coverage types, mixed coverage among siblings is far more common among families with mixed nativity status, and blended families with step- and half-siblings. In terms of outcomes, children living in sibships with mixed coverage have significantly lower odds of having a usual source of health care. We also consider whether the association between mixed insurance coverage and health care outcomes differs across particular combinations of insurance coverage. We find that both publicly-insured children who have uninsured siblings and privately-insured children with publicly-insured siblings are less likely to have a usual source of care than similar children with uniformly-insured siblings. Because a usual source of care is associated with better health care outcomes, we argue that policymakers should consider ways to reduce mixed coverage among children and families.
The Effects of Health Insurance and a Usual Source of Care on a Child's Receipt of Health Care
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The MEPS-HC only captures cross-sectional USC status; therefore, we reported on cross-sectional measures for both insurance and a USC. The duration of not having insurance affects the likelihood of having unmet needs; thus the vulnerabilities of subgroups with long periods of being uninsured would likely be even higher (Cummings, Lavarreda, Rice, & Brown, 2009; DeVoe, Graham, Krois, Smith, & Fairbrother, 2008; Olson et al., 2005). We were also limited to measuring only outcomes available in the MEPS-HC.
Although recent health care reforms will expand insurance coverage for U.S. children, disparities regarding access to pediatric care persist, even among the insured. We investigated the separate and combined effects of having health insurance and a usual source of care (USC) on children’s receipt of health care services.
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Approximately 88.1% of the study population had both a USC and insurance; 1.1% had neither one; 7.6% had a USC only, and 3.2% had insurance only. Children with both insurance and a USC had the fewest unmet needs. Among insured children, those with no USC had higher rates of unmet needs than did those with a USC.
Expansions in health insurance are essential; however, it is also important for every child to have a USC. New models of practice could help to concurrently achieve these goals.
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Our method would be harder to replicate in states that lack the ability to link and integrate individual-level data across different agencies. We could not identify all social complexity risk factors associated with use patterns in prior studies.12,19,23–25,27,29–31 To be included in the initial cohort, children had to have an identifiable biologic parent and at least 1 month of Medicaid coverage during the study period, resulting in the exclusion of 13% of otherwise eligible children.
Screening for social determinants of health is challenging but critically important for optimizing child health outcomes. We aimed to test the feasibility of using an integrated state agency administrative database to identify social complexity risk factors and examined their relationship to emergency department (ED) use.
We conducted a retrospective cohort study among children younger than 18 years with Washington State Medicaid insurance coverage (N = 505,367). We linked child and parent administrative data for this cohort to identify a set of social complexity risk factors, such as poverty and parent mental illness, that have either a known or hypothesized association with suboptimal health care use. Using multivariate analyses, we examined associations of each risk factor and of number of risk factors with the rate of ED use.
Nine of 11 identifiable social complexity risk factors were associated with a higher rate of ED use. Additionally, the rate increased as the number of risk factors increased from 0 to 5 or more, reaching approximately twice the rate when 5 or more risk factors were present in children aged younger than 5 years (incidence rate ratio = 1.92; 95% CI, 1.85-2.00) and in children aged 5 to 17 years (incidence rate ratio = 2.06; 95% CI, 1.99-2.14).
State administrative data can be used to identify social complexity risk factors associated with higher rates of ED use among Medicaid-insured children. State agencies could give primary care medical homes a social risk flag or score to facilitate targeted screening and identification of needed resources, potentially preventing future unnecessary ED use in this vulnerable population of children.

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Brief Report“Mind the Gap” in Children's Health Insurance Coverage: Does the Length of a Child's Coverage Gap Matter?

Objective

Methods

Results

Conclusions

Section snippets

Study Population

Results

Discussion

Acknowledgments

Ambul Pediatr

Uninsured children: how we count matters

Pediatrics

Children's health insurance status and emergency department utilization in the United States

Pediatrics

Insurance gaps among vulnerable children in the United States, 1999–2001

Pediatrics

How stable is Medicaid coverage for children?

Health Aff

Dynamics in Medicaid and SCHIP eligibility among children in SCHIP's early years: implications for reauthorization

Health Aff

Children's eligibility and coverage: recent trends and a look ahead

Health Aff

Battery-powered health insurance? Stability in coverage of the uninsured

Health Aff

Children in the United States with discontinuous health insurance coverage

N Engl J Med

The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States

JAMA

Associations between childhood vaccination coverage, insurance type, and breaks in health insurance coverage

Pediatrics

Factors associated with health care access for Mississippi children with special health care needs

Matern Child Health J

Brief Report
“Mind the Gap” in Children's Health Insurance Coverage: Does the Length of a Child's Coverage Gap Matter?