# Presentation: 684245

## OVERVIEW

**Why Are We Concerned About Uninsured Children?**
**Measurement Issues**
**Who Are the Uninsured Children?**
**Eligibility for and Availability of Coverage**

## 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**

## 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)**

## IMPACT ON ACCESS TO HEALTH CARE

**Usual Source of Health Care**
**Level of Services**
**Quality, Continuity, and Satisfaction With Care**

## HEALTH INSURANCE AND ACCESS TO CARE

## HEALTH INSURANCE AND USUAL SOURCE OF CARE SITE

- Source:  Weinick, Weigers, and Cohen, 1998 (1996 MEPS)

## HEALTH INSURANCE AND BARRIERS TO CARE

- Source:  Weinick, Zuvekas, and Drilea 1997 (1996 MEPS)

## 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**

## IMPACT ON USE AND EXPENDITURES

**Use of Any Services**
**Use of Specific Services**
**Proportion of Expenditures Paid Out-of-Pocket**

## HEALTH INSURANCE AND PHYSICIAN CONTACT

- Source:  Monheit and Cunningham, 1992 (1987 NMES)

## HEALTH INSURANCE AND WELL-CHILD VISITS

- Source:  Short and Lefkowitz, 1992 (1987 NMES)

## 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)**

## 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

## 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

## WHY DO WE CARE ABOUT MEASUREMENT ISSUES?

**Different methods can yield very different estimates**

## 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**

## 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.**

## TIME PERIOD

**At a Point in Time?**
**During a Particular Period?**
**One month**
**One quarter**
**Six months**
**One year**
**Other**

## DEFINING WHO IS UNINSURED

**Uninsured for:**
**The whole period **
**Some minimum part of the period **
**At any time during the period**

## DATA COLLECTION

**How Are Respondents Contacted?**
**Phone or in-person?**
**Prospective or retrospective?**
**How Often Are Respondents Contacted?**
**What is the recall period?**

## 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**

## 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**

## HOW MANY CHILDREN ARE UNINSURED?

## HEALTH INSURANCE AND AGE

- Source:  Weinick, Weigers, and Cohen 1998 (1996 MEPS)

## HEALTH INSURANCE AND RACE

## HEALTH INSURANCE AND FAMILY STRUCTURE

## HEALTH INSURANCE AND PARENTS’ EDUCATION

- Source:  Weinick, Weigers, and Cohen 1998 (1996 MEPS)

## HEALTH INSURANCE AND PARENTS’ EMPLOYMENT

- Source:  Weinick, Weigers, and Cohen 1998 (1996 MEPS)

## HEALTH INSURANCE AND WHERE CHILDREN LIVE

- Source:  Weinick, Weigers, and Cohen 1998 (1996 MEPS)

## 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**

## ELIGIBILITY FOR AND AVAILABILITY OF COVERAGE

**ELIGIBILITY FOR AND AVAILABILITY OF COVERAGE**

**Private Insurance**
**Offers of insurance**
**Take-up rates**
**Public Insurance**
**Eligibility**
**Coverage**
**Take-up rates**

## PRIVATE INSURANCE:  OFFER RATES

- Source:  Cooper and Schone 1997 (1987 NMES and 1996 MEPS)

## PRIVATE INSURANCE:  TAKE-UP RATES

- Source:  Cooper and Schone 1997 (1987 NMES and 1996 MEPS)

## 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)

## INSURANCE COVERAGE OF CHILDREN ELIGIBLE FOR MEDICAID

**Medicaid**

**51.9%**

- Source:  Selden, Banthin, and Cohen 1998 (1996 MEPS)

## MEDICAID TAKE-UP RATES AMONG ELIGIBLE CHILDREN

- Source:  Selden, Banthin, and Cohen 1998 (1996 MEPS)

## 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**

## SUMMARY (CONT.)

**Measurement Issues**
**Use caution when interpreting estimates**
**Definitions, time periods, and survey methods may differ**

## 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**

## 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**

## 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.**