More than 5.7 million low-income children may experience a transition in their health insurance sometime during each year, the University of Michigan study finds. They may shift to or from being uninsured, or may join or leave private insurance policies and public programs like Medicaid, as their family income or situation changes.
And, the study finds, low-income kids who experience these changes in their coverage each year are more likely to postpone doctor visits and prescriptions, to go a year without seeing a doctor, or to be in fair or poor health.
The study is the first to show a link between health insurance transitions and child health care trends. It's published in the May issue of Ambulatory Pediatrics by a team from the Child Health Evaluation and Research Unit of the U-M Medical School's Department of Pediatrics and the U-M Health System's C.S. Mott Children's Hospital.
"The uninsured in America are not a homogenous group, but a rather mixed group, with some children and families remaining uninsured for a long time and others becoming uninsured more recently, or finding a new source of insurance after being without coverage for some period of time," says senior author and assistant professor Matthew Davis, M.D., MAPP. "These data show a lot of coverage transitions for low-income children, affecting one in every five of them each year. And the data indicate that these transitions can disrupt children's access to health care."
The study is based on an analysis of the Urban Institute's National Survey of America's Families, using data from 1999, the most recent year for which survey results are available. The survey asked the parents of nearly 36,000 children in 13 states about their child's insurance status in the last year, health status and medical care, and demographic characteristics.
More than a third of the families had incomes that fell below twice the poverty level, the group most likely to be eligible for public insurance programs. The survey sample was weighted so that results could be extrapolated to the entire U.S. population.
"If the trends we see were true in 1999, when the economy was healthy and states had just developed new SCHIP public insurance programs for low-income children, we can only speculate what has happened in recent years since the economic downturn and state budget crises hit," says Davis, who hopes to analyze data from 2002 when they become public later this year.
In recent years, some states have scaled back enrollment in Medicaid and State Children's Health Insurance Programs (SCHIP), or implemented new requirements for renewal of benefits that can act as barriers to continuous coverage. Meanwhile, many families have lost private insurance coverage as employers lay off workers or pass more of their benefit costs on to employees.
The U-M authors say their findings point to a need to increase, and then maintain, enrollment in public insurance programs designed for low-income children whose families don't have employer-sponsored health insurance and can't afford to buy their own. Only consistent coverage and minimized barriers such as income recertification will give these children the best chance at getting needed care.
"We found that families are postponing care for their children, likely until they can make the transition from being uninsured to having some form of coverage," says Davis, who notes that some insurance programs have waiting periods before new enrollees can begin to use their benefits. Postponing needed care because of a lack of insurance may mean that a child doesn't get regular checkups for asthma, or doesn't get a refill for his or her medications.
"Intermittent periods of insurance coverage are not sufficient to meet children's medical needs, even when adjusted for health status," adds Davis. "Gaps in coverage, whether preceded or followed by coverage, are barriers to adequate health care."
The researchers did find some evidence that eligible children were being enrolled in public programs for which they qualified because of family income. For instance, 5.4 percent of the children under 5 years of age at the time of the survey were enrolled in public insurance programs but had been uninsured sometime in the last year. In all, the researchers estimate that 1.3 million low-income children went from being uninsured to being covered by public insurance programs during the year leading up to the survey.
But then again, 4.6 percent of the children under 5, and an estimated 1.2 million children nationwide, had gone from public insurance to being uninsured in the same time period.
Barriers to re-enrollment in Medicaid or SCHIP, or changes in family income that put children just over the income eligibility limit for coverage, might be the cause, Davis suggests. Whatever the reason for their dropping out of the public system, their lack of insurance meant they were more likely to have care postponed.
The barriers to enrollment in public programs were erected partly to fend off an effect called "crowd out," in which some low-income families were expected to drop their private insurance coverage for their children in order to enroll them in SCHIP public insurance programs.
Davis and his colleagues saw little evidence of crowd-out: three times more children moved from public to private insurance during the year before the survey than moved from private to public.
Some children transitioned from one public insurance program to another, for example from Medicaid to SCHIP as their family income increased. But even such a transition can affect health care, Davis notes. He recently had a young patient stop coming to him for care because the SCHIP plan his family chose after their income rose too high for Medicaid didn't have a contract with U-M.
When the researchers looked at health insurance transition trends among different demographic groups, they found that non-Hispanic black children, and children whose parents did not have a partner or spouse, were more likely than other children to have experienced a transition. But Hispanic children were far less likely to have had a transition - in fact, almost 27 percent of Hispanic children had been uninsured for the entire past year, echoing previous findings of high rates of uninsurance in this ethnic group.
In addition to Davis, the study's authors are Kimberly Aiken, M.D., Ph.D., a clinical instructor of pediatrics who led the analysis during her fellowship; and Gary Freed, M.D., M.P.H., chief of the Division of General Pediatrics and director of the CHEAR unit.