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OVERVIEW
Why Are We Concerned About Uninsured Children?
Measurement Issues
Who Are the Uninsured Children?
Eligibility for and Availability of Coverage
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WHY ARE WE CONCERNED ABOUT UNINSURED CHILDREN?
Equity and Efficiency
Impact on Access to Health Care
Impact on Use and Expenditures
Impact on Health Status and Health Outcomes
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EQUITY AND EFFICIENCY ISSUES
Equity Issues
- Fairness
- Equitable standard of access
Efficiency Issues
- Efficiency gains (e.g., risk pooling)
- Resource costs (e.g., delayed care)
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IMPACT ON ACCESS TO HEALTH CARE
Usual Source of Health Care
Level of Services
Quality, Continuity, and Satisfaction With Care
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HEALTH INSURANCE AND ACCESS TO CARE
Percent with No Usual Source of Care
20.2
10.0
5.6
0
5
10
15
20
25
Uninsured Public Private
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HEALTH INSURANCE AND USUAL SOURCE OF CARE SITE
Percent with Office-Based Usual Source of Care
68.574.8
86.7
0
25
50
75
100
Uninsured Public Private
Source: Weinick, Weigers, and Cohen, 1998 (1996 MEPS)
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HEALTH INSURANCE AND BARRIERS TO CARE
Percent of Families Experiencing Barriers to Care
23.4
12.2
7.0
0
5
10
15
20
25
30
One or more membersuninsured
All members publicinsurance
All members privateinsurance
Source: Weinick, Zuvekas, and Drilea 1997 (1996 MEPS)
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IMPACT ON ACCESS TO HEALTH CARE
Uninsured Children Are Less Likely to Have a Usual Source of Health Care Than Insured Children, and Are Less Likely to Have an Office-Based Usual Source of Care
Uninsured Families Report More Barriers to Obtaining Needed Care, and Are More Likely to Report That They Are Unable to Afford Needed Care Than Insured Families
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IMPACT ON USE AND EXPENDITURES
Use of Any Services
Use of Specific Services
Proportion of Expenditures Paid Out-of-Pocket
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HEALTH INSURANCE AND PHYSICIAN CONTACT
Percent of Children with Any Physician Contact
54.0
72.677.3
0
25
50
75
100
Uninsured Public Private
Source: Monheit and Cunningham, 1992 (1987 NMES)
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HEALTH INSURANCE AND WELL-CHILD VISITS
Percent of Children with Well-Child Visits
48.556.4
64.7
31.438.0
47.5
0
25
50
75
Uninsured Public Private
Any visits Recommended visits
Source: Short and Lefkowitz, 1992 (1987 NMES)
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IMPACT ON USE AND EXPENDITURES
Uninsured Children Use Fewer Health Care Services Than Insured Children
Uninsured People Spend a Greater Proportion of Their Income on Health Care Services Than the Privately Insured (Taylor and Banthin 1994)
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IMPACT ON HEALTH STATUS AND HEALTH OUTCOMES
Adverse Health Outcomes Appear to Be Related to Being Uninsured
Avoidable Hospitalizations for a Variety of Conditions Are More Common Among the Uninsured Than the Privately Insured
Uninsured Newborns Are More Likely to Have Adverse Outcomes Than the Privately Insured
Source: Office of Technology Assessment, 1992; Weissman, Gastonis, and Epstein, 1991
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IMPACT ON HEALTH STATUS AND HEALTH OUTCOMES
The Uninsured Are More Likely to
- Experience avoidable hospitalizations
- Be diagnosed at later stages of disease
- Be hospitalized on an emergency or urgent basis
- Be more seriously ill upon hospitalization
- Die upon hospitalization
Source: Office of Technology Assessment, 1992
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WHY DO WE CARE ABOUT MEASUREMENT ISSUES?
Different methods can yield very different estimates
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DEFINING HEALTH INSURANCE
Current Population Survey Counts As Insured:
- Department of Veterans Affairs health care
- Some children who are “categorically eligible” for Medicaid
- Children of adults covered by Medicaid as automatically covered themselves
- Some single service or supplemental coverage
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DEFINING HEALTH INSURANCE
Medical Expenditure Panel Survey
- Only counts comprehensive physician and hospital coverage as insurance
- not single-service or Medigap plans
- Counts insurance coverage by Medicaid
- not service provision through IHS, VA, etc.
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TIME PERIOD
At a Point in Time?
During a Particular Period?
- One month
- One quarter
- Six months
- One year
- Other
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DEFINING WHO IS UNINSURED
Uninsured for:
- The whole period
- Some minimum part of the period
- At any time during the period
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DATA COLLECTION
How Are Respondents Contacted?
- Phone or in-person?
- Prospective or retrospective?
How Often Are Respondents Contacted?
- What is the recall period?
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MEASUREMENT ISSUES
When Comparing Estimates Check
- Definitions
- what is health insurance?
- who is uninsured?
- Time period
- Data collection methods
Before Concluding That Estimates of Uninsured Children Are
The Same or Are Different
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WHO ARE THE UNINSURED CHILDREN?
How Many Children Are Uninsured?
What Are Their Characteristics?
- Age
- Race
- Family structure
- Parents’ education
- Parents’ employment status
- Where children live
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HOW MANY CHILDREN ARE UNINSURED?
Health Insurance Status ofChildren Under Age 18
63.8%
15.4%
20.8%
UninsuredPublicPrivate
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HEALTH INSURANCE AND AGE
Percent Uninsured by Age
13.215.5
17.9
0
5
10
15
20
25
Less than 6 6-12 13-17
Source: Weinick, Weigers, and Cohen 1998 (1996 MEPS)
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HEALTH INSURANCE AND RACE
Percent Uninsured
27.7
17.6
12.3
0
5
10
15
20
25
30
Hispanic Black White
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HEALTH INSURANCE AND FAMILY STRUCTURE
Single-Parent Families
38.7%
19.8%
41.5%
UninsuredPublicPrivate
Two-Parent Families
73.7%
13.6%
12.7%
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HEALTH INSURANCE AND PARENTS’ EDUCATION
Percent Uninsured by Parents' Education
28.5
17.9
10.1
0
5
10
15
20
25
30
35
<12 years 12 years >12 years
Source: Weinick, Weigers, and Cohen 1998 (1996 MEPS)
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HEALTH INSURANCE AND PARENTS’ EMPLOYMENT
Percent Uninsured by Parents' Employment
15.819.1
11.4
0
5
10
15
20
25
0 1 2Number of parents employed
Source: Weinick, Weigers, and Cohen 1998 (1996 MEPS)
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HEALTH INSURANCE AND WHERE CHILDREN LIVE
Percent Uninsured by Metropolitan Statistical Area Status
14.0
20.7
0
5
10
15
20
25
30
MSA Non-MSA
Source: Weinick, Weigers, and Cohen 1998 (1996 MEPS)
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WHO ARE THE UNINSURED CHILDREN?
Uninsured Children Are Disproportionately Likely to
- Be ages 13-17
- Be Hispanic
- Live in single-parent families
- Have parents with little education
- Live without employed parents
- Live outside of MSAs
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ELIGIBILITY FOR AND AVAILABILITY OF COVERAGE
Private Insurance
- Offers of insurance
- Take-up rates
Public Insurance
- Eligibility
- Coverage
- Take-up rates
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PRIVATE INSURANCE: OFFER RATES
Percent of All Workers Offered Employment-Related Coverage
72.475.4
50
55
60
65
70
75
80
1987 1996
Source: Cooper and Schone 1997 (1987 NMES and 1996 MEPS)
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PRIVATE INSURANCE: TAKE-UP RATES
Percent of Workers Offered Insurance who are Policyholders
88.3
80.1
75
80
85
90
95
1987 1996
Source: Cooper and Schone 1997 (1987 NMES and 1996 MEPS)
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PUBLIC INSURANCE: ELIGIBILITY
29.5% of All Children Are Estimated to Be Medicaid Eligible
- 33.7% of children ages 0-12 are estimated to be eligible
- 20.2% of children ages 13-18 are estimated to be eligible
Source: Selden, Banthin, and Cohen 1998 (1996 MEPS)
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INSURANCE COVERAGE OF CHILDREN ELIGIBLE FOR MEDICAID
Private25.9%
Medicaid51.9%
Uninsured22.2%
Source: Selden, Banthin, and Cohen 1998 (1996 MEPS)
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MEDICAID TAKE-UP RATES AMONG ELIGIBLE CHILDREN
Percent of Children Without Private Coverage who Enrolled in Medicaid
70.0 73.2
59.1
0
20
40
60
80
100
All children Ages 0-12 Ages 13-18
Source: Selden, Banthin, and Cohen 1998 (1996 MEPS)
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SUMMARY
Why Are We Concerned About Uninsured Children?
- Health insurance has a considerable impact on:
- equity and efficiency
- access to health care
- use and expenditures
- health status and health outcomes
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SUMMARY (CONT.)
Measurement Issues
- Use caution when interpreting estimates
- Definitions, time periods, and survey methods may differ
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SUMMARY (CONT.)
Who Are the Uninsured Children?
- Certain groups are at greater risk
- Usually those who are most vulnerable to a variety of adverse outcomes
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SUMMARY (CONT.)
Eligibility for and Availability of Coverage
- Many workers who have employer-sponsored coverage available to them do not take it
- Many children who are eligible for Medicaid remain uninsured
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REFERENCES
Cooper, P.F. and B.S. Schone. 1997. “More Offers, Fewer Takers for Employment-Based Health Insurance: 1987 and 1996.” Health Affairs 16(6): 142-149.
Monheit, A. and P. Cunningham. 1992. “Children Without Health Insurance.” The Future of Children 2(2): 154-170.
Office of Technology Assessment. 1992. Does Health Insurance Make a Difference? Background Paper. Washington, DC: Congress of the United States.
Selden, T.M., J.S. Banthin, and J.W. Cohen. 1998. “Medicaid’s Problem Children: Eligible But Not Enrolled.” Health Affairs 17(3): 192-200.
Short, P. and D. Lefkowitz. 1992. “Encouraging Preventive Services for Low-Income Children: The Effect of Expanding Medicaid.” Medical Care 30(9): 766-780.
Taylor, A. and J. Banthin. 1994. Changes in Out-of-Pocket Expenditures for Personal Health Services: 1977-1987. National Medical Expenditure Survey Research Findings 21. Rockville, MD: Agency for Health Care Policy and Research (AHCPR Pub. No. 94-0065).
Weigers, M.E., R.M. Weinick, and J.W. Cohen. 1998. Children’s Health 1996. MEPS Chartbook No. 1. Rockville, MD: Agency for Health Care Policy and Research (AHCPR Pub. No. 98-0008).
Weinick, R.M., M.E. Weigers, and J.W. Cohen. 1998. “Children’s Health Insurance, Access to Care, and Health Status: New Findings.” Health Affairs 17(2): 127-136.
Weinick, R.M., S.H. Zuvekas, and S.K. Drilea. 1997. Access to Health Care--Sources and Barriers, 1996. MEPS Research Findings No. 3. Rockville, MD: Agency for Health Care Policy and Research (AHCPR Pub. No. 98-0001).
Weissman, J.S., C. Gastonis, and A.M. Epstein. 1991. “Rates of Avoidable Hospitalizations by Insurance Status in Massachusetts and Maryland.” Paper presented at the annual meeting of the Association for Health Services Research, San Diego, CA, 1-3 July.