-
[show abstract]
[hide abstract]
ABSTRACT: The State Children's Health Insurance Program (SCHIP) has improved insurance coverage rates. However, children's enrollment status in SCHIP frequently changes, which can leave families with uncertainty about their children's coverage status. We examined whether insurance uncertainty was associated with unmet health care needs.
We compared self-reported survey data from 2,681 low-income Oregon families to state administrative data and identified children with uncertain coverage. We conducted cross-sectional multivariate analyses using a series of logistic regression models to test the association between uncertain coverage and unmet health care needs.
The health insurance status for 13.2% of children was uncertain. After adjustments, children in this uncertain "gray zone" had higher odds of reporting unmet medical (odds ratio [OR] =1.73; 95% confidence interval [CI]=1.07, 2.79), dental (OR=2.41; 95% CI=1.63, 3.56), prescription (OR=1.64, 95% CI=1.08, 2,48), and counseling needs (OR=3.52; 95% CI=1.56, 7.98), when compared with publicly insured children whose parents were certain about their enrollment status.
Uncertain children's insurance coverage was associated with higher rates of unmet health care needs. Clinicians and educators can play a role in keeping patients out of insurance gray zones by (1) developing practice interventions to assist families in confirming enrollment and maintaining coverage and (2) advocating for policy changes that minimize insurance enrollment and retention barriers.
Family medicine 02/2010; 42(2):121-32. · 1.33 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Little is known about how the stability of a usual source of care (USC) affects access to care. We examined the prevalence of USC changes among low-income children and how these changes were associated with unmet health care need.
We conducted a cross-sectional survey of Oregon's food stamp program in 2005. We analyzed primary data from 2681 surveys and then weighted results to 84087 families, adjusting for oversampling and nonresponse. We then ascertained the percentage of children in the Oregon population who had ever changed a USC for insurance reasons, which characteristics were associated with USC change, and how USC change was associated with unmet need. We also conducted a posthoc analysis of data from the Medical Expenditure Panel Survey to confirm similarities between the Oregon sample and a comparable national sample.
Children without a USC in the Oregon population had greater odds of reporting an unmet health care need than those with a USC. This pattern was similar in national estimates. Among the Oregon sample, 23% had changed their USC because of insurance reasons, and 10% had no current USC. Compared with children with a stable USC, children who had changed their USC had greater odds of reporting unmet medical need, unmet prescription need, delayed care, unmet dental need, and unmet counseling need.
This study highlights the importance of ensuring stability with a USC. Moving low-income children into new medical homes could disturb existing USC relationships, thereby merely creating "temporary housing."
PEDIATRICS 10/2009; 124(5):1363-71. · 4.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine if rural residence is independently associated with different access to health care services for children eligible for public health insurance.
We conducted a mail-return survey of 10,175 families randomly selected from Oregon's food stamp population (46% rural and 54% urban). With a response rate of 31%, we used a raking ratio estimation process to weight results back to the overall food stamp population. We examined associations between rural residence and access to health care (adjusting for child's age, child's race/ethnicity, household income, parental employment, and parental and child's insurance type). A second logistic regression model controlled for child's special health care needs.
Compared with urban children (reference = 1.00), rural children were more likely to have unmet medical care needs (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.07-2.04), problems getting dental care (OR 1.36, 95% CI 1.03-1.79), and at least one emergency department visit in the past year (OR 1.42, 95% CI 1.10-1.81). After adjusting for special health care needs (more prevalent among rural children), there was no rural-urban difference in unmet medical needs, but physician visits were more likely among rural children. There were no statistically significant differences in unmet prescription needs, delayed urgent care, or having a usual source of care.
These findings suggest that access disparities between rural and urban low-income children persist, even after adjusting for health insurance. Coupled with continued expansions in children's health insurance coverage, targeted policy interventions are needed to ensure the availability of health care services for children in rural areas, especially those with special needs.
The Journal of Rural Health 02/2009; 25(1):1-7. · 1.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Basic health care is beyond the reach of many families, partly due to lack of health insurance. Many of those with insurance also experience unmet need and limited access. In this study, low-income parents illuminate barriers to obtaining health care services for their children.
We surveyed a random sample of families from Oregon's food stamp population with children eligible for public insurance, based on household income. Mixed-methods included: (1) multivariable analysis of data from 2,681 completed surveys, and (2) qualitative study of written narratives from 722 parents.
Lack of health insurance was the most consistent predictor of unmet health care needs in the quantitative analysis. Qualitatively, health insurance instability, lack of access to services despite having insurance, and unaffordable costs were major concerns.
Parents in this low-income population view insurance coverage as different from access to services, and reported a hierarchy of needs. Insurance was the primary concern; access and costs were secondary.
Journal of Health Care for the Poor and Underserved 12/2008; 19(4):1192-211. · 1.10 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To examine the separate and combined effects of having health insurance and a usual source of care (USC) on access to healthcare for low-income children and to determine if one or the other is superior in ensuring better access to necessary services.
We conducted cross-sectional, multivariable analyses of data from a mail-return survey of Oregon's food stamp program. Results from 2681 completed surveys were weighted back to a population of 84,087 families with adjustments for oversampling techniques and nonresponse.
Among low-income Oregon children, those with health insurance and a USC reported the best access to healthcare. In multivariable comparisons to this reference group, insured children without a USC had higher rates of unmet medical need [odds ratio (OR) = 2.18; 95% confidence interval (CI): 1.27-3.73]; no doctor visits in 12 months (OR = 6.77; 95% CI: 3.80-12.06); and problems obtaining specialty care (OR = 4.12; 95% CI: 1.59-10.68). Similarly, having a USC but not health insurance was associated with an even higher likelihood of unmet medical needs (OR = 4.33; 95% CI: 2.85-6.57); as well as unmet prescription needs (OR = 2.64, 95% CI: 1.77-3.94), and problems obtaining dental care (OR = 4.83; 95% CI: 3.31-7.06).
Incremental policy solutions are being proposed that focus on either health insurance coverage for children or expanded access to primary care. However, neither approach displaces the need for the other. The effects of a USC and health insurance, together, are additive predictors of the likelihood that children have optimal access to necessary healthcare services.
Medical care 11/2008; 46(10):1041-8. · 3.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Thousands of adults lost coverage after Oregon's Medicaid program implemented cost containment policies in March 2003. Despite the continuation of comprehensive public health coverage for children, the percentage of uninsured children in the state rose from 10.1 percent in 2002 to 12.3 percent in 2004 (over 110,000 uninsured children). Among the uninsured children, over half of them were likely eligible for public health insurance coverage.
To examine barriers low-income families face when attempting to access children's health insurance. To examine possible links between Medicaid cutbacks in adult coverage and children's loss of coverage.
Statewide primary data from low-income households enrolled in Oregon's food stamp program.
Cross-sectional analysis. The primary predictor variable was whether or not any adults in the household recently lost Medicaid coverage. The main outcome variables were children's current insurance status and children's insurance coverage gaps.
A mail-return survey instrument was designed to collect information from a stratified, random sample of households with children presumed eligible for publicly funded health insurance programs.
Over 10 percent of children in the study population eligible for publicly funded health insurance programs were uninsured, and over 25 percent of these children had gaps in insurance coverage during a 12-month period. Low-income children who were most likely to be uninsured or have coverage gaps were Hispanic; were teenagers older than 14; were in families at the higher end of the income threshold; had an employed parent; or had a parent who was uninsured. Fifty percent of the uninsured children lived in a household with at least one adult who had recently lost Medicaid coverage, compared with only 40 percent of insured children (p=.040). Similarly, over 51 percent of children with a recent gap in insurance coverage had an adult in the household who lost Medicaid, compared with only 38 percent of children without coverage gaps (p<.0001). After adjusting for ethnicity, age, household income, and parental employment, children living in a household with an adult who lost Medicaid coverage after recent cutbacks had a higher likelihood of having no current health insurance (OR 1.44, 95 percent CI 1.02, 2.04), and/or having an insurance gap (OR 1.79, 95 percent CI 1.36, 2.36).
Uninsured children and those with recent coverage gaps were more likely to have adults in their household who lost Medicaid coverage after recent cutbacks. Although current fiscal constraints prevent many states from expanding public health insurance coverage to more parents, states need to be aware of the impact on children when adults lose coverage. It is critical to develop strategies to keep parents informed regarding continued eligibility and benefits for their children and to reduce administrative barriers to children's enrollment and retention in public health insurance programs.
Health Services Research 02/2008; 43(1 Pt 2):401-18. · 2.16 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Despite expansions in public health insurance programs, millions of US children lack coverage. Nearly two-thirds of Oregon's uninsured children seem to be eligible for public insurance.
We sought to identify uninsured but eligible children and to examine how parental coverage affects children's insurance status.
We collected primary data from families enrolled in Oregon's food stamp program, which has similar eligibility requirements to public health insurance in Oregon. In this cross-sectional, multivariable analysis, results from 2861 surveys were weighted back to a population of 84,087 with nonresponse adjustment. Key predictor variables were parental insurance status and type of insurance; the outcome variable was children's insurance status.
Nearly 11% of children, presumed eligible for public insurance, were uninsured. Uninsurance among children was associated with being Hispanic, having an employed parent, and higher household earnings (133-185% of the federal poverty level). Children with an uninsured parent were more likely to be uninsured, compared with those who had insured parents (adjusted odds ratio 14.21, 95% confidence interval 9.23-20.34). More surprisingly, there was a higher rate of uninsured children among privately-insured parents, compared with parents covered by public insurance (adjusted odds ratio 4.39, 95% confidence interval 2.00-9.66).
Low-income Oregon parents at the higher end of the public insurance income threshold and those with private insurance were having the most difficulty keeping their children insured. These findings suggest that when parents succeed in pulling themselves out of poverty and gaining employment with private health insurance coverage, children may be getting left behind.
Medical Care 02/2008; 46(1):3-8. · 3.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In January 2003, people covered by Oregon's Medically Needy program lost benefits owing to state budget shortfalls. The Medically Needy program is a federally matched optional Medicaid program. In Oregon, this program mainly provided prescription drug benefits.
To describe the Medically Needy population and determine how benefit loss affected this population's health and prescription use.
A 49-question telephone survey instrument created by the research team and administered by a research contractor.
A random sample of 1,269 eligible enrollees in Oregon's Medically Needy Program. Response rate was 35% with 439 individuals, ages 21-91 and 64% women, completing the survey.
Demographics, health information, and medication use at the time of the survey obtained from the interview. Medication use during the program obtained from administrative data.
In the 6 months after the Medically Needy program ended, 75% had skipped or stopped medications. Sixty percent of the respondents had cut back on their food budget, 47% had borrowed money, and 49% had skipped paying other bills to pay for medications. By self-report, there was no significant difference in emergency department visits, but a significant decrease in hospitalizations comparing 6 months before and after losing the program. Two-thirds of respondents rated their current health as poor or fair.
The Medically Needy program provided coverage for a low-income, chronically ill population. Since its termination, enrollees have decreased prescription drug use and increased financial burden. As states make program changes and Medicare Part D evolves, effects on vulnerable populations must be considered.
Journal of General Internal Medicine 07/2007; 22(6):847-51. · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: 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.
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.
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.
State policies should be designed to minimize gaps in public health insurance coverage in order to ensure children's continuous access to necessary services.
Ambulatory Pediatrics 8(2):129-34. · 1.60 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers.
A mixed methods analysis was undertaken using 722 responses to an open-ended question on a health care access survey instrument that asked low-income Oregon families, "Is there anything else you would like to tell us?" Themes were identified using immersion/crystallization techniques. Pertinent demographic attributes were used to conduct matrix coded queries.
Families reported 3 major barriers: lack of insurance coverage, poor access to services, and unaffordable costs. Disproportionate reporting of these themes was most notable based on insurance status. A higher percentage of uninsured parents (87%) reported experiencing difficulties obtaining insurance coverage compared with 40% of those with insurance. Few of the uninsured expressed concerns about access to services or health care costs (19%). Access concerns were the most common among publicly insured families, and costs were more often mentioned by families with private insurance. Families made a clear distinction between insurance and access, and having one or both elements did not assure care. Our analyses uncovered a 3-part typology of barriers to health care for low-income families.
Barriers to health care can be insurmountable for low-income families, even those with insurance coverage. Patients who do not seek care in a family medicine clinic are not necessarily getting their care elsewhere.
The Annals of Family Medicine 5(6):511-8. · 5.36 Impact Factor
