Patterns of Health Insurance Discontinuity and Children’s Access to Health Care

Objectives This study classified patterns of discontinuous health insurance coverage, including change in coverage type and gaps in coverage, and described their associations with children’s access to health care. Methods Using the 2011–2013 National Health Interview Survey data, we determined children’s insurance coverage over the past year, and whether children had a usual source of care, had to delay getting care, or had unmet health care needs. Using multivariable logistic regression, we compared measures of access to care across insurance coverage patterns, classified as continuous private coverage; continuous public coverage; continuous lack of coverage; change in coverage type (public versus private) without gaps in coverage; and any gap in coverage. A subgroup analysis repeated this comparison for children with a caregiver-reported chronic physical illness. Results The analysis included 34,105 children, of whom 7% had a gap in coverage and 1% had a change in coverage type. On multivariable analysis, gaps in coverage were associated with increased likelihood of unmet health care needs, compared to continuous private (OR 6.9; 95% CI 5.9, 8.0) or continuous public coverage (OR 5.1; 95% CI 4.4, 6.0). Seamless changes in coverage were also associated with greater likelihood of unmet health care needs [OR vs. private: 3.8 (95% CI 2.3, 6.1); OR vs. public: 2.8 (95% CI 1.8, 4.6); all p < 0.001]. Results were similar for other study outcomes, and among children with chronic physical illness. Conclusions for Practice Both gaps in coverage and seamless changes between coverage types were associated with limited health care access for children.

     

Adult-Oriented Health Reform and Children’s Insurance and Access to Care: Evidence from Massachusetts Health Reform

Maternal and Child Health Journal - Objective A national debate is underway about the value of key provisions within the adult-oriented Affordable Care Act (ACA)—the individual mandate,...     

The Influence of Health Insurance on Parent’s Reports of Children’s Unmet Mental Health Needs

Objective The purpose of this study was to examine the prevalence of unmet mental health needs in children identified by parents as having long-term emotional and behavioral problems, to identify the characteristics of these children, and to evaluate the influence of health insurance status and type on the odds of reporting unmet mental health needs. Methods We used the National Survey of Children with Special Health Care Needs (NSCSHCN) to estimate the prevalence of unmet mental health needs among children with long-term emotional/behavioral conditions. Using logistic regression models, we also assessed the independent impact of insurance status and type on unmet needs. Results Analyses indicated that of the nearly 67% of children who needed mental health care or counseling in the previous 12 months, 20% did not receive it. Moreover, parents of uninsured children were more likely to report unmet mental health needs than insured children. Parents of children covered by public health insurance programs (Medicaid, Children Health Insurance Program-CHIP, Title V, Military, Native American) were less likely to report unmet mental health needs than those with children covered by private health insurance plans. Conclusion Results from this study suggest a need for expansion of health insurance coverage to children especially those with long-term mental health conditions. It also suggests a need for parity between mental and physical health benefits in private health insurance.     

A Review of Family and Social Determinants of Children’s Eating Patterns and Diet Quality

With the growing problem of childhood obesity, recent research has begun to focus on family and social influences on children’s eating patterns. Research has demonstrated that children’s eating patterns are strongly influenced by characteristics of both the physical and social environment. With regard to the physical environment, children are more likely to eat foods that are available and easily accessible, and they tend to eat greater quantities when larger portions are provided. Additionally, characteristics of the social environment, including various socioeconomic and sociocultural factors such as parents’ education, time constraints, and ethnicity influence the types of foods children eat. Mealtime structure is also an important factor related to children’s eating patterns. Mealtime structure includes social and physical characteristics of mealtimes including whether families eat together, TV-viewing during meals, and the source of foods (e.g., restaurants, schools). Parents also play a direct role in children’s eating patterns through their behaviors, attitudes, and feeding styles. Interventions aimed at improving children’s nutrition need to address the variety of social and physical factors that influence children’s eating patterns.     

Disparities in Health Insurance Coverage and Access to Care for Children By Mother’s Sexual Orientation

Maternal and Child Health Journal - Few population-based studies have examined the health care experiences of children with sexual minority parents. The purpose of this study was to compare health...     

Parental Nativity Affects Children’s Health and Access to Care

Objective To examine the effect of parental nativity on child health and access to health care. Data Source The 2002 National Survey of America’s Families. Results Among US children, 14% have foreign-born parents; 5% have one foreign- and one native-born parent (“mixed-nativity”). In multivariate logistic regression analyses, children with foreign-born parents were less likely than children with US-born parents to be perceived in “very good” or “excellent health” [OR = 0.68; 95% CI (0.56–0.82)] and to have a usual health care site [OR = 0.52 (0.38–0.69)]; having mixed-nativity parents is associated with better perceived child health. These effects persisted for minority, but not white, children. Regardless of race and ethnicity, non-citizen children have worse access to care. Conclusion Efforts to improve children of immigrants’ health and access to care should focus on families in which both parents are immigrants, particularly those who are ethnic or racial minorities. Efforts to increase use of health services should focus on non-citizen children.     

Health Promotion and Psychosocial Services and Women’s Assessments of Interpersonal Prenatal Care in Medicaid Managed Care

Objectives: If prenatal health promotion and psychosocial support services are to remain accessible to Medicaid eligible women, evidence is needed as to whether the services improve care and benefit women in ways that matter to health plans. The aims of this study are to determine whether prenatal health promotion and psychosocial services are associated with better interpersonal care and greater satisfaction with care; and whether the effects on interpersonal care help explain satisfaction with care. Research Design: A telephone survey of 363 African American, Latina (US and nonUS-born) and White women receiving prenatal care in four Medicaid public health plans in California in 2001. Multivariate regression analyses were done with adjustments for potentially confounding variables. Measures: Independent variables included dichotomous variables for health promotion advice (five separate areas) and composite scales for psychosocial assessment (six areas combined). Dependent variables included satisfaction with care, and indices for interpersonal care (communication, decision-making, and interpersonal style). Results: Women who report receiving health promotion or psychosocial services also report receiving better interpersonal care and rate their satisfaction with care higher. Receiving either type of support service is associated with higher quality communication, decision-making and interpersonal style. The effects of the support services on satisfaction are, in turn, explained by the effects on interpersonal care. Conclusions: Prenatal health promotion and psychosocial services have associated benefits to enrollees that should matter to Medicaid health plans and their providers.     

Prevalence of Children’s Mental Health Problems and the Effectiveness of Population-Level Family Interventions

The prevalence of mental health problems among children and adolescents is of growing importance. Intervening in children’s mental health early in life has been shown to be more effective than trying to resolve these problems when children are older. With respect to prevention activities in community settings, the prevalence of problems should be estimated, and the required level of services should be delivered. The prevalence of children’s mental health disorders has been reported for many countries. Preventive intervention has emphasized optimizing the environment. Because parents are the primary influence on their children’s development, considerable attention has been placed on the development of parent training to strengthen parenting skills. However, a public-health approach is necessary to confirm that the benefits of parent-training interventions lead to an impact at the societal level. This literature review clarifies that the prevalence of mental health problems is measured at the national level in many countries and that population-level parenting interventions can lower the prevalence of mental health problems among children in the community.Key words: child, mental health, prevalence, family intervention, evaluation     

Family Organizations in Children’s Mental Health Systems of Care: the Challenge of Maintaining Financial Sustainability

The Journal of Behavioral Health Services & Research - Family-run organizations are an important source of support for families of children with serious emotional disturbance, yet little work...     

Primary Care and Public Health Services Integration in Brazil’s Unified Health System

Objectives. We examined associations between transdisciplinary collaboration, evidence-based practice, and primary care and public health services integration in Brazil’s Family Health Strategy. We aimed to identify practices that facilitate service integration and evidence-based practice.Methods. We collected cross-sectional data from community health workers, nurses, and physicians (n = 262). We used structural equation modeling to assess providers’ service integration and evidence-based practice engagement operationalized as latent factors. Predictors included endorsement of team meetings, access to and consultations with colleagues, familiarity with community, and previous research experience.Results. Providers’ familiarity with community and team meetings positively influenced evidence-based practice engagement and service integration. More experienced providers reported more integration and engagement. Physicians reported less integration than did community health workers. Black providers reported less evidence-based practice engagement than did Pardo (mixed races) providers. After accounting for all variables, evidence-based practice engagement and service integration were moderately correlated.Conclusions. Age and race of providers, transdisciplinary collaboration, and familiarity with the community are significant variables that should inform design and implementation of provider training. Promising practices that facilitate service integration in Brazil may be used in other countries.The integration of primary care and public health is a key strategy, recommended nationally and internationally, for assisting underserved populations; it encourages community-focused initiatives and transdisciplinary approaches to practice. Integration allows health providers (e.g., physicians, nurses, health workers) to use individual- and community-level interventions to influence, respectively, individual behavior and community health.1–3 Brazil’s Sistema Único de Saúde (Unified Health System) was created as a result of Brazil’s 1988 federal constitution and the 1990 Lei Orgânica da Saúde (Organic Health Law). This law aimed to establish a large, decentralized health system offering free, universal care from medical consultations to organ transplants, health campaigns, and sanitation.4 This system struggles with access, quality, and service coordination (e.g., scheduling, monitoring) mainly because it is incorporated under a single legal structure that contradicts decentralization and affects the integration of services that different sectors of the Sistema Único de Saúde, such as hospitals, provide.5To integrate primary care and public health, the Sistema Único de Saúde employs the Estratégia Saúde da Família (ESF; Family Health Strategy), a transdisciplinary approach used by health providers. ESF reflects “the new public health” paradigm, positing that integration best addresses health and environmental issues affecting communities.6–8 The World Health Organization recommends that diverse providers pursue community-level outcomes and medical cost reductions through service integration.9 Established in 1994 as the Programa de Saúde da Família, today the ESF consolidates a model of assistance operationalized by professional teams, including nurses, physicians, and community health workers (CHWs), that serve about 4000 individuals per team.10,11In Brazil, service integration is accomplished by transdisciplinary collaboration—providers delivering primary care alongside public health interventions (e.g., disease prevention campaigns).11–14 Providers strive to engage in evidence-based practice (EBP), which is characterized by providers assessing the impact of environmental issues (e.g., water supply) on health and by incorporating patient input and research findings into diagnosis and treatment. EBP is encouraged by training local providers in integration methods.15,16 ESF has improved adult patients’ awareness of their diagnoses and prognoses and their adherence to children’s immunization schedules and has decreased infant mortality, hospitalizations, and medication costs.10,11,17–19     

Impact of Medical Home on Health Care of Children With and Without Special Health Care Needs: Update from the 2016 National Survey of Children’s Health

Objective The medical home has been promoted as an optimal model of health care delivery for children. The purpose of this study was to examine the association between having access to a medical home and the health care experiences of children with and without special health care needs (SHCN) in the United States. Methods We analyzed data from the 2016 National Survey of Children’s Health. We modeled logistic regressions to assess associations of having access to a medical home with health care experiences for 11,392 CSHCN and 38,820 non-CSHCN. Results We found that not having access to a medical home was negatively associated with preventive medical and dental care visits, greater unmet medical and dental needs, and hospital emergency room visits. Additionally, not having access to a medical home was negatively associated with the physical and oral health among CSHCN and oral health among non-CSHCN. However, we found no significant association between improved physical health status and having access to a medical home among non-CSHCN. Conclusions Results from our analysis suggest that having access to a medical home remains key determinant of improved health care experiences by CSHCN and non-CSHCN in the United States. Our findings underscore the need to develop policies and implement a more concerted program to increase access to health care delivered under the medical home model for CSHCN and non-CSHCN. Policymakers, health care administrators and physician groups can use these findings to inform future policy decisions and service delivery reforms.

     

Change Trajectories: Children’s Patterns of Improvement in Acute-Stay Inpatient Care

This study estimated classes of children’s acute-stay psychiatric acuity trajectories in terms of shape (i.e., linear, quadratic, cubic) and rate of change (slope). A total of 788 children served on three child units (ages 4–12) were studied. The Children’s Acuity of Psychiatric Illness (CAPI) was completed each weekday by trained frontline staff on the milieu. Latent class growth analysis was applied to the data, and seven acuity trajectory classes provided the most parsimonious fit. Four classes evidenced a significant quadratic term, one class a significant linear term, and two classes did not evidence a significant change in acuity. The classes varied in survival time to rehospitalization, in pre-treatment community service use and rates of seclusion, restraint, and emergency medications during the episode. Overall, the results suggest that acute-stay patients may have distinct and identifiable psychiatric acuity change patterns during their episodes and that some may experience non-linear (i.e., quadratic) acuity trajectories.     

Racial and Ethnic Disparities in the Continuation of Community-Based Children’s Mental Health Services

This paper examines racial and ethnic disparities in continuation of mental health services for children and youth in California and how English language proficiency moderates the effect of race/ethnicity on the continuation of service. While previous research indicated racial/ethnic or geographic disparities in accessing mental health services among children and youth, few studies specifically focused on the continuation of mental health care. The authors used administrative data from California county mental health services users under age 25. Applying logistic regression, English language proficiency was found to be the major determinant of continuation of mental health services in this age group. With the exception of children of Asian descent, non-English speaking children and youth of diverse racial/ethnic background were significantly less likely to continue receiving mental health services compared with White English-speaking peers, even after controlling for sociodemographic, clinical and county characteristics.     

Primary Care Pediatrics and Public Health: Meeting the Needs of Today’s Children

The proportion of children suffering from chronic illnesses—such as asthma and obesity, which have significant environmental components—is increasing. Chronic disease states previously seen only in adulthood are emerging during childhood, and health inequalities by social class are increasing. Advocacy to ensure environmental health and to protect from the biological embedding of toxic stress has become a fundamental part of pediatrics. We have presented the rationale for addressing environmental and social determinants of children’s health, the epidemiology of issues facing children’s health, recent innovations in pediatric medical education that have incorporated public health principles, and policy opportunities that have arisen with the passage of the 2010 Patient Protection and Affordable Care Act.In pediatrics, the acknowledgment of child development as a transactional process and ultimate determinant of adult capacity has important implications for the development of systems, practice models, and training. If we are to ensure children’s health and, ultimately, overall population well-being, childhood service systems must become responsive and coordinated on many levels; practitioners must develop multiple skills outside the traditional medical model; and training strategies must become innovative. Promoting access to effective health and health-related services is essential for achieving Healthy People 2020 objectives (the US Department of Health and Human Services’ set of health-promotion and disease-prevention goals to be achieved nationwide by 2020). There are many examples of shortfalls in adequacy of available services, effectiveness of care provided, organization of services, and focus on primary prevention. Up to 50% of developmental problems in children are not identified until school entry,1 more than 8 million children remain without health care coverage in the United States, and a much larger number have no regular source of health care except in emergencies.2 In addition to inadequate funding for appropriate services, the network of programs serving children is increasingly fragmented, difficult to navigate, and unresponsive.A major challenge for children’s and youths’ services is to develop more effective and efficient service integration models. In the present system, pediatricians tend to avoid asking parents about matters for which they feel inadequately trained and for which they are not aware of patient resources, including child development, obesity, breastfeeding, family violence, environmental health, and mental health. The system will not respond without adequately prepared clinician–advocates who recognize and understand these issues and their relationship to ultimate outcomes.     

The Impact of Single Mothers’ Health Insurance Coverage on Behavioral Health Services Utilization by Their Adolescent Children

Adolescents living in single-mother households are more likely to have behavioral health conditions, but are less likely to utilize any behavioral health services. Using nationally representative mother-child pair data pooled over 6 years from the National Survey on Drug Use and Health, the study finds that when single mothers were uninsured, their adolescent children were less likely to utilize any behavioral health services, even when the children themselves were covered by insurance. The extension of health coverage under the Affordable Care Act (ACA) to uninsured single mothers could improve the behavioral health of the adolescent population.     

Factors Determining Children’s Private Health Insurance Enrolment and Healthcare Utilization Patterns: Evidence From the 2008 to 2011 Health Panel Data

Objectives:

Parental socioeconomic status (SES) exerts a substantial influence on children’s health. The purpose of this study was to examine factors determining children’s private health insurance (PHI) enrolment and children’s healthcare utilization according to PHI coverage.

Methods:

Korea Health Panel data from 2011 (n=3085) was used to explore the factors determining PHI enrolment in children younger than 15 years of age. A logit model contained health status and SES variables for both children and parents. A fixed effects model identified factors influencing healthcare utilization in children aged 10 years or younger, using 2008 to 2011 panel data (n=9084).

Results:

The factors determining children’s PHI enrolment included children’s age and sex and parents’ educational status, employment status, and household income quintile. PHI exerted a significant effect on outpatient cost, inpatient cost, and number of admissions. Number of outpatient visits and total length of stay were not affected by PHI status. The interaction between PHI and age group increased outpatient cost significantly.

Conclusions:

Children’s PHI enrolment was influenced by parents’ SES, while healthcare utilization was affected by health and disability status. Therefore, the results of this study suggest disparities in healthcare utilization according to PHI enrollment.     

Patterns of Older Americans’ Health Care Utilization Over Time

Objectives. We analyzed correlates of older Americans’ continuous and transitional health care utilization over 4 years.Methods. We analyzed data for civilian, noninstitutionalized US individuals older than 50 years from the 2006 and 2008 waves of the Health and Retirement Study. We estimated multinomial logistic models of persistent and intermittent use of physician, inpatient hospital, home health, and outpatient surgery over the 2004–2008 survey periods.Results. Individuals with worse or worsening health were more likely to persistently use medical care and transition into care and not transition out of care over time. Financial variables were less often significant and, when significant, were often in an unexpected direction.Conclusions. Older individuals’ health and changes in health are more strongly correlated with persistence of and changes in care-seeking behavior over time than are financial status and changes in financial status. The more pronounced sensitivity to health status and changes in health are important considerations in insurance and retirement policy reforms.In choosing to seek medical care, individuals weigh the financial cost of treatment against its perceived benefit to their health. Clearly physician input, in combination with the presence and generosity of health insurance coverage, weighs heavily in this decision. As individuals age they begin to experience the onset of new health conditions at the same time that their households often begin to deplete their savings to finance retirement.1–4 Because of these new experiences and potentially limited financial resources, older individuals may become more selective in which types of care they receive, perhaps focusing first on their most pressing medical needs or delaying or skipping procedures prescribed by their physician that they deem relatively costly or not immediately necessary.Studies have investigated the differences in health care expenses for the elderly by health status and changes in health status,5 the changes in health related to persistence or changes in health insurance coverage for the near elderly,6 correlation between health and health insurance coverage,7,8 and the relationship between functional change and hospital use and cost.9 None of these studies, however, has focused on the relative importance of financial versus health factors in determining an elderly population’s persistent or intermittent health care use over time.The motivation for our study comes from a related recent analysis we conducted showing that dental use was surprisingly resistant to changes in household net wealth and household income.1 We found that only when household net wealth falls by 50% or more were older adults less likely to seek dental care.1 This finding inspired our interest in pursuing related findings for medical care.In this study, we determined correlates of continuous and intermittent health care use for a population of civilian, noninstitutionalized Americans older than 50 years. This population is of particular concern because they consume an increasingly disproportionate share of health care as the baby boomer generation advances to the top of the national age distribution. We investigated the relative strengths of financial factors and health factors at 1 point in time and over time as correlates of this older population’s altering or continuing medical care use.Our analysis is particularly relevant at a time when the financial status of many US households has been affected adversely by economic conditions.10 We used longitudinal data from the 2006 and 2008 waves of the Health and Retirement Study (HRS) to explore health and financial factors associated with older adults’ changes in and persistence of health care use between these periods, including (1) physician visits, (2) overnight hospital stays, (3) outpatient surgery, and (4) home health care. We hypothesized for this population that health factors would outweigh financial factors in explaining continuous and intermittent health care use over this period.     

The Impact of the Public Insurance Expansions on Children’s Use of Preventive Dental Care

To determine if children eligible for coverage by the State Children’s Health Insurance Program (SCHIP) and Medicaid Programs were more likely to receive preventive dental visits after implementation of the SCHIP policy, retrospective cross-sectional analysis was done from the 1996–2000 Medical Expenditure Panel Surveys (MEPS) data. We linked the individual level data from the MEPS to state-level information on program eligibility. Using logistic regression models that adjust for the complex survey design, the association between SCHIP implementation and receipt of preventive dental care was examined for children aged 3–18 with family incomes ≤200% of the Federal Poverty Line (FPL). Children who were eligible for SCHIP/Medicaid coverage in their respective states were more likely to have received preventive care three years after SCHIP implementation than children with similar eligibility profiles prior to SCHIP implementation. SCHIP has successfully increased the proportion of eligible children receiving preventive dental care among children in families with incomes less than or equal to 200% FPL. Our findings indicate, however, that SCHIP needed time to mature before detecting significant effects on national level.     

Impact of Caring for Children with Special Health Care Needs on the Family: Rhode Island’s Experience

Objectives: The impact of caring for children with special health care needs (CSHCN) on their families’ finances and employment was studied. Methods: Data from the 2001 National Survey of Children with Special Health Care Needs were used to measure financial and employment problems. The level of impact was examined by child’s age, gender, ethnicity, race, mother’s education, poverty status, and severity of the child’s condition. The association between core outcome measures and the level of family impact was determined after adjusting for potential confounding factors. Results: Financial or employment problems were more likely to occur among families with young children, with incomes below 200% poverty and with children whose condition usually/always affected their activities. Compared to families without these problems, impacted families were less likely to partner in decision making, be satisfied with services, receive comprehensive care in a medical home, have adequate health insurance, and feel service systems are organized for easy use. Conclusions: Many families of CSHCN face financial and employment problems and are less likely to have a medical home, adequate insurance, and access to health care services.     

Siege and Response: Reception and Benefits of Residential Children’s Mental Health Services for Parents and Siblings

This paper presents the results of a qualitative study with 29 parents of children who have been in residential mental health care. It examines three main patterns identified by parents: (a) the importance of respite, (b) feeling welcomed and understood, and (c) improved personal and family functioning. It argues that benefits for parents and siblings of placed children deserve equal valuation with the needs of children in residential care and that the processes of achieving such gains are independent considerations from creating systems of care for troubled children or engaging family members in treatment plans for these children.