Jeanene Smith

''Mind the Gap'' in Children's Health Insurance Coverage: Does the Length of a Child's Coverage Gap Matter?

OBJECTIVE 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. METHODS We conducted a multivariable, cross-sectional analysis of statewide primary data from families in Oregons food stamp population with children presumed eligible for publicly funded health insurance. The key independent variable was length of a childs insurance coverage gap; outcome variables were 6 measures of health care access. RESULTS 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. CONCLUSIONS State policies should be designed to minimize gaps in public health insurance coverage in order to ensure childrens continuous access to necessary services.

Uninsurance among children whose parents are losing Medicaid coverage: Results from a statewide survey of Oregon families.

CONTEXT Thousands of adults lost coverage after Oregons 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. RESEARCH OBJECTIVE To examine barriers low-income families face when attempting to access childrens health insurance. To examine possible links between Medicaid cutbacks in adult coverage and childrens loss of coverage. DATA SOURCE/STUDY SETTING Statewide primary data from low-income households enrolled in Oregons food stamp program. STUDY DESIGN 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 childrens current insurance status and childrens insurance coverage gaps. DATA COLLECTION 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. PRINCIPAL FINDINGS 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). CONCLUSIONS 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 childrens enrollment and retention in public health insurance programs.

Uninsured but eligible children: are their parents insured? Recent findings from Oregon.

Background: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. Objectives:We sought to identify uninsured but eligible children and to examine how parental coverage affects children’s insurance status. Methods: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. Results: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). Conclusions: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.

Impact of Medicaid cutbacks on emergency department use: the Oregon experience.

STUDY OBJECTIVE Federal policy changes and tightened state budgets may reduce Medicaid enrollment in many states. In March 2003, the Oregon Health Plan (Oregons Medicaid expansion program) made substantial changes in its benefit package that resulted in the disenrollment of more than 50,000 beneficiaries. We sought to study the impact of these Oregon Health Plan policy changes on statewide emergency department (ED) use. METHODS In this observational study, hospital billing data on 2,680,954 visits to 26 Oregon EDs were obtained, sampled up to 24 months before and 24 months after the cutbacks. These visits represent approximately 62% of all visits to Oregons 58 EDs. We ascertained counts of ED visits by payer group before and after the Oregon Health Plan cutback date, plus hospital admissions from the ED as a measure of acuity. RESULTS After the Oregon Health Plan policy changes, ED visits by the uninsured underwent an abrupt and sustained increase, from 6,682 per month in 2002 to 9,058 per month in 2004. Oregon Health Plan-sponsored and commercially insured visits decreased, resulting in a slight decrease in overall ED visits. Multivariable models adjusting for secular trends and seasonality showed a 20% (95% confidence interval 13% to 28%) increase in uninsured ED visits, whereas the adjusted number of Oregon Health Plan-sponsored visits decreased. The proportion of uninsured ED visits resulting in hospital admission increased (odds ratio 1.50; 95% confidence interval 1.39 to 1.62). CONCLUSION Oregons Medicaid cutbacks were followed by increases in ED use and hospitalizations by the uninsured. Recent federal legislation facilitating similar Medicaid changes in other states may lead to replication of these events elsewhere.

Medicaid programme changes and the chronically ill: early results from a prospective cohort study of the Oregon Health Plan

Objective: To describe the impacts of recent Oregon Health Plan (OHP) policy changes on individuals living with chronic illness in Oregon. Methods: A mail survey was conducted of 1374 OHP beneficiaries who were directly affected by the new policies. The analyses reported in this article represent baseline findings from the first of three survey waves in an ongoing prospective cohort study. Results: A significant association was found between Medicaid policy changes and high rates of disenrolment from the OHP. Compared to the non-chronically ill, the chronically ill were more likely to report inability to pay for medications, higher medical debt, more unmet health needs, and poorer health status. Among the chronically ill, those who lost insurance reported decreased access to and utilization of healthcare, more medical debt, and more restriction of medications. Discussion: As policy-makers restructure public programmes to accommodate tight budgets and rising healthcare costs, people with chronic illness can easily be overlooked. Chronically ill individuals face disproportionate financial and health burdens. Small cost-saving policy changes can lead to widespread disenrolment that cascades into reduced access to healthcare services, altered utilization patterns, and financial strain.

Effect of Eliminating Behavioral Health Benefits for Selected Medicaid Enrollees

OBJECTIVE To determine the extent to which the elimination of behavioral health benefits for selected beneficiaries of Oregons Medicaid program affected general medical expenditures among enrollees using outpatient mental health and substance abuse treatment services. DATA SOURCE/STUDY SETTING Twelve months of claims before and 12 months following a 2003 policy change, which included the elimination of the behavioral health benefit for selected Oregon Medicaid enrollees. STUDY DESIGN We use a difference-in-differences approach to estimate the change in general medical expenditures following the 2003 policy change. We compare two methodological approaches: regression with propensity score weighting; and one-to-one covariate matching. PRINCIPAL FINDINGS Enrollees who had accessed the substance abuse treatment benefit demonstrated substantial and statistically significant increases in expenditures. Individuals who accessed the outpatient mental health benefit demonstrated a decrease or no change in expenditures, depending on model specification. CONCLUSIONS Elimination of the substance abuse benefit led to increased medical expenditures, although this offset was still smaller than the total cost of the benefit. In contrast, individuals who accessed the outpatient mental health benefit did not exhibit a similar increase, although these individuals did not include a portion of the Medicaid population with severe mental illnesses.

A Comprehensive Assessment of Four Options for Financing Health Care Delivery in Oregon

This article describes four options for financing health care for residents of the state of Oregon and compares the projected impacts and feasibility of each option. The Single Payer option and the Health Care Ingenuity Plan would achieve universal coverage, while the Public Option would add a state-sponsored plan to the Affordable Care Act (ACA) Marketplace. Under the Status Quo option, Oregon would maintain its expansion of Medicaid and subsidies for nongroup coverage through the ACA Marketplace. The state could cover all residents under the Single Payer option with little change in overall health care costs, but doing so would require cuts to provider payment rates that could worsen access to care, and implementation hurdles may be insurmountable. The Health Care Ingenuity Plan, a state-managed plan featuring competition among private plans, would also achieve universal coverage and would sever the employer-health insurance link, but the provider payment rates would likely be set too high, so health care costs would increase. The Public Option would be the easiest of the three options to implement, but because it would not affect many people, it would be an incremental improvement to the Status Quo. Policymakers will need to weigh these options against their desire for change to balance the benefits with the trade-offs.

Oregon's Options to Overhaul Health Care Financing: Health Care Reform 2.0?

This analysis of three options to reform health care payment in Oregon (two state-based plans that would ensure coverage for all state residents and a state-sponsored plan offered in Oregons nongroup market) found benefits and trade-offs for each.