Impact of Children’s Health Initiatives on Access to Care for Latino Children in California
Elena Fuentes-Afflick, MD, MPH Nancy A. Hessol, MSPH Tamar A. Bauer, JD University of California, San Francisco
Disclosure
No conflicts of interest Funding support: David and Lucile Packard Foundation
Uninsurance
Uninsurance is a problem that has clinical and policy implications Uninsurance affects adults and children Reducing uninsurance among adults and children may require different policy solutions
Uninsurance - Adults
We expect adults to work and receive employer-based insurance There are very few publicly-funded insurance options for uninsured adults unless the adult qualifies for Medicaid or Medicare (eg, ESRD)
Access to Care, Children
Since the 1980’s, Medicaid has expanded to increase access to care for children
In 1997, S-CHIP was implemented to expand access to care for low-income children. In California, S-CHIP is known as “Healthy Families.” Currently, 36 million children in the US (nearly half of all children), are covered by Medicaid or S-CHIP
Pear R, New York Times, April 1, 2007
Uninsured children
11% of all children in the US, more than 8 million children, remain uninsured
Howell EM & Trenholm C, 2006
2 high-risk groups of children:
Moderately poor Undocumented, who cannot meet the citizenship requirements, regardless of income
Uninsured children - CA
In 2002, there were nearly 1 million uninsured children in California
66% were eligible for Medicaid or Healthy Families 16% exceeded the income threshold 18% ineligible because of immigration status
Trenholm C, June 2004
Children’s Health Initiatives
1992: Blue Cross developed California Kids 2001: Children’s Health Initiatives (CHI) were implemented in several California counties CHI components:
Outreach and education Healthy Kids insurance, modeled on S-CHIP program (comprehensive in/outpatient services)
Eligibility: Income above S-CHIP limit (to 300-400% FPL) Immigration status: Undocumented eligible!
Howell EM, Hughes D, 2006 Millbank Q
Access and Use of services
Complex set of factors influence access to care and use of services
Having insurance may be necessary but not sufficient!
Other factors
Individual
Health status Medical home Number of children Immigration status Barriers and fears
Family
System
Linguistic competence Cultural competence
Objective
To assess the effect of Children’s Health Initiatives on access to and use of health services among Latino children in California.
To assess the effect of immigration status on access to and use of health services among Latino children in California.
Methods
Prospective cohort study of Latina women recruited during the delivery hospitalization at three San Francisco/Bay Area hospitals in 1999-2001
Re-interviewed at 2 and 3 years postpartum, n=711
Interview
Structured questionnaire of family attributes, all reported by the mother
Immigration status Access to care Use of health services
Dependent variables
Access: Insurance status Use of Preventive Care in the last 12 months Use of Urgent Care in the last 12 months
Use of Emergency Care in the last 12 months
County CHI Status
County CHI status was coded based on the date of the interview and the date of implementation of CHI programs:
Yes, the child resided in a county that had a CHI program at the time of the interview
No CHI program in the county where the child resided at the time of the interview
Immigration status
We coded the children’s immigration status as:
Mixed: The children in the family did not have the same immigration status Not mixed: The children in the family had the same immigration status (documented) One child
Other variables
Maternal
Age Education Marital status
Distribution
CHI
Yes, family resides in a CHI county No CHI program in the county
89.7% 10.3%
Immigration status
Multiple children, mixed status Multiple children, not mixed One child
24.3% 40.6% 35.1%
Uninsurance
One child 4 3 Unadjusted 2 OR 1 0 2.00 3.61 1.91 >1 child, not mixed >1 child, mixed CHI Yes CHI No
Use of Preventive Care
>1 child, not mixed >1 child, mixed CHI No
4 3 Unadjusted 2 OR 1 0.51 0 0.40
Use of Urgent Care
>1 child, not mixed >1 child, mixed CHI No
4 3 Unadjusted 2 OR 1 0.70 0 0.70
Use of Emergency Care
>1 child, not mixed >1 child, mixed CHI No
4 3 Unadjusted 2 OR 1 0.56 0 0.62 2.09
Uninsurance - Multivariate
>1 child, not mixed >1 child, mixed CHI No
After adjusting for confounders, mixed status children were twice as likely to be uninsured as only children 4
3 Adjusted OR* 2 1 0
After adjusting for potential confounders, children residing in counties without a CHI program were twice as likely to be uninsured as children residing in counties with CHI programs
2.24 2.49
*Adjusted for maternal age, education, marital status
Use of Preventive Care
>1 child, not mixed >1 child, mixed CHI No Uninsured
4
Uninsured children were 34% less likely to use preventive 3 care in the previous year than insured children
Adjusted OR* 2 1 0.59 0 0.58 0.66
*Adjusted for maternal age, education, marital status
Use of Urgent Care
>1 child, not mixed >1 child, mixed CHI No Uninsured
4 3 Adjusted OR* 2 1 0.67 0 0.67
*Adjusted for maternal age, education, marital status
Use of Emergency Care
>1 child, not mixed >1 child, mixed CHI No Uninsured
Children residing in counties without a CHI program were twice as 4 likely to use emergency care as children residing in counties with a CHI program 3
Adjusted OR* 2 1 0.59 0
Adjusted for maternal age, education, marital status
2.16
Summary
Latino children living in counties with CHI programs have lower rates of uninsurance and lower utilization of emergency care.
Latino children of mixed immigration status have an elevated risk of uninsurance.
Summary
Consistent with other studies, uninsured Latino children were 34% less likely to use preventive care services than insured children.
Use of preventive, urgent, and emergency services is inversely associated with the number of children in Latino families.
Limitations
Our results may not be generalizable to Latinos in other areas of the US
Immigration status was reported by the mother and may not be accurate (bias toward the null?)
Access to care and use of services were reported rather than obtained through chart review
Implications
County-level CHI programs in California are associated with reductions in uninsurance among Latino children.
Lower utilization of emergency care among Latino children residing in counties with CHI programs may contribute to cost savings.
Implications
Efforts should be made to maintain or expand insurance options for all children as a means of promoting use of preventive care services.
Latino children of mixed status are a high-risk group that should be targeted in research studies and policy development.
Future research
Further study is needed to assess the role of insurance programs, such as CHI expansions, on children’s health status and health conditions.