Julie L. Hudson

Access to care and utilization among children : Estimating the effects of public and private coverage

Objectives:We examine the relationship between health insurance coverage and childrens access to and utilization of medical care. Access measures we study are having a usual source of care (USC) and lacking a USC for financial or insurance reasons. We also examine indicators for ambulatory visits, well-child visits, dental visits, emergency room use, and inpatient hospital stays. Methods:We pool data from the first 7 years of the Medical Expenditure Panel Survey (MEPS), 1996 to 2002. Pooling yields a large sample of children, enabling us to analyze access and utilization using simple descriptive statistics, multivariate analysis, and instrumental variables estimation (IV). IV estimation is of particular interest given the possibility of bias caused by confounding factors (such as child health or parent attitudes) and measurement error in insurance coverage. We also compare estimates from IV linear probability models to estimates from IV probit with residual inclusion. Results:As previous studies have found, public and private coverage are both associated with large increases in access and utilization. Simple mean comparisons suggest that private coverage has a larger effect than does public coverage. Differences between public and private coverage are reduced (and often reversed) when we control for other characteristics of children and their families. IV coverage effect estimates from both linear probability and residual inclusion probit models are substantially greater than conventional estimates across a wide range of access and utilization measures. Conclusions:Despite concerns that conventional estimates overstate the impact of coverage on access and use, our results suggest that the reverse may be true. One explanation may be that conventional estimates are biased toward zero due to error in the reporting of insurance coverage. The magnitude of the coverage effects we find highlights the importance of reducing uninsurance among children.

The Impact of SCHIP on Insurance Coverage of Children

In this paper we use the Medical Expenditure Panel Survey between 1996 and 2002 to investigate the impact of the State Childrens Health Insurance Program (SCHIP) on insurance coverage for children. We explore a range of alternative estimation strategies, including instrumental variables and difference-in-trends models. We find that SCHIP had a significant impact in decreasing uninsurance and increasing public insurance for both children targeted by SCHIP and those eligible for Medicaid. With respect to changes in private coverage our results are less conclusive: some specifications resulted in no significant effect of SCHIP on private insurance coverage, while others showed significant decreases in private insurance. Associated estimates of SCHIP crowd-out had wide confidence intervals and were sensitive to estimation strategy.

Explaining racial and ethnic differences in children's use of stimulant medications.

Objectives:To document and explain racial/ethnic differences in the use of stimulant drugs among US children. Data and Methods:We use a nationally representative sample of children ages 5–17 years old from the Medical Expenditure Panel Survey (MEPS) for the years 2000–2002. We estimate race-specific means and regressions to highlight differences across groups in individual/family characteristics that may affect stimulant use and differences in responses to these characteristics. Then, we use Oaxaca-Blinder decomposition methods to quantify the portion of differential use explained by differences in individual/family characteristics. Finally, we use pooled regressions with race/ethnicity interactions to formally test the hypothesis that responses to perceived mental health and behavioral problems vary across groups. Results:White children are about twice as likely to use stimulants as either Hispanic or Black children. Differences in individual/family characteristics account for about 25% of the difference between whites and Hispanics, but for none of the difference between whites and blacks. Pooled regressions show that racial/ethnic gaps in stimulant use persist among children with otherwise similar reported mental health conditions. Conclusions:Our finding that the majority of racial/ethnic differences in childrens stimulant use is explained by differences in responses to individual/family characteristics highlights the importance of further research to examine the reasons for these differences. It is striking that children with otherwise similar reports of mental health problems have such different outcomes in terms of stimulant use. Potential explanations range from discrimination to cultural differences by race/ethnicity or community.

Adults in the income range for the Affordable Care Act's Medicaid expansion are healthier than pre-ACA enrollees.

The Affordable Care Act (ACA) has dramatically increased the number of low-income nonelderly adults eligible for Medicaid. Starting in 2014, states can elect to cover individuals and families with modified adjusted gross incomes below a threshold of 133 percent of federal poverty guidelines, with a 5 percent income disregard. We used simulation methods and data from the Medical Expenditure Panel Survey to compare nondisabled adults enrolled in Medicaid prior to the ACA with two other groups: adults who were eligible for Medicaid but not enrolled in it, and adults who were in the income range for the ACAs Medicaid expansion and thus newly eligible for coverage. Although differences in health across the groups were not large, both the newly eligible and those eligible before the ACA but not enrolled were healthier on several measures than pre-ACA enrollees. Twenty-five states have opted not to use the ACA to expand Medicaid eligibility. If these states reverse their decisions, their Medicaid programs might not enroll a population that is sicker than their pre-ACA enrollees. By expanding Medicaid eligibility, states could provide coverage to millions of healthier adults as well as to millions who have chronic conditions and who need care.

Families With Mixed Eligibility For Public Coverage: Navigating Medicaid, CHIP, And Uninsurance

In the midst of health care reform, eligible but uninsured children remain a cause for concern. Children in the same family often have differing eligibility status for public coverage. Mixed eligibility is associated with higher uninsurance rates, even when all children in a family are eligible. Medicaid policies play an important role in creating mixed-eligibility families via age-related eligibility thresholds and limited benefits for immigrants; states running separate Childrens Health Insurance Program (CHIP) programs have higher uninsurance rates among eligible children. Recent policies to simplify enrollment have not lowered uninsurance among these children. States may improve take-up rates by focusing on eligible children in mixed-eligibility families.

Explaining racial and ethnic differences in antidepressant use among adolescents.

We investigate the extent to which antidepressant use among adolescents varies across racial and ethnic subgroups. Using a representative sample of U.S. adolescents, we find that non-Hispanic White adolescents are over twice as likely as Hispanic adolescents, and over five times as likely as non-Hispanic Black adolescents to use antidepressants. Results from a decomposition analysis indicate that racial/ethnic differences in characteristics, including household income, parental education, health insurance, and having a usual source of care explain between one half and two thirds of the gap in antidepressant use between Hispanics and non-Hispanic Whites. In contrast, none of the gap between Whites and Blacks in antidepressant use is explained by differences in observed characteristics. Further analysis suggests that there are large racial/ethnic differences in the extent to which behavioral and mental health problems prompt antidepressant use and that this may, in part, account for the large differences across race/ethnicity observed in our study.

How Much Can Really Be Saved by Rolling Back SCHIP? The Net Cost of Public Health Insurance for Children:

A growing body of research demonstrates the many benefits of expanded public coverage for children. Expansions in Medicaid and the State Childrens Health Insurance Program (SCHIP) have helped to increase insurance coverage, increase access to care, and reduce the financial burdens facing low-income families. Less attention has been focused on the cost of expanding public coverage. We argue that budgetary data may exaggerate the net costs of these expansions because many of the highest-cost children would have received publicly funded care even if the expansions had not taken place. Using data from the 2000 Medical Expenditure Panel Survey, we simulate the net cost of SCHIP, finding that the true cost of this program–both to states and to the federal government–is substantially less than average spending per enrollee would suggest. Our results strengthen the benefit-cost argument against implementing rollbacks in SCHIP.

Association Between Marketplace Policy and Public Coverage Among Medicaid or Children’s Health Insurance Program–Eligible Children and Parents

Funding/Support: This study was supported by grants J3-6800 and P3-0343 from the Slovenian Research Agency. This project received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement 115797 (INNODIA). This Joint Undertaking receives support from the Union’s Horizon 2020 research and innovation programme and the European Federation of Pharmaceutical Industries and Associations, JDRF, and the Leona M. and Harry B. Helmsley Charitable Trust.