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Caring for the Uninsured and Underinsured |

Impact of a Children's Health Insurance Program on Newly Enrolled Children FREE

Judith R. Lave, PhD; Christopher R. Keane, ScD, MPH; Chyongchiou J. Lin, PhD; Edmund M. Ricci, PhD; Gabriele Amersbach, MA; Charles P. LaVallee
[+] Author Affiliations

From the Department of Health Services Administration, Graduate School of Public Health, University of Pittsburgh (Drs Lave, Keane, Lin, and Ricci and Ms Amersbach), and the Western Pennsylvania Caring Foundation for Children (Mr LaVallee), Pittsburgh.


JAMA. 1998;279(22):1820-1825. doi:10.1001/jama.279.22.1820.
Text Size: A A A
Published online

Context.— Although there is considerable interest in decreasing the number of US children who do not have health insurance, there is little information on the effect that health insurance has on children and their families.

Objective.— To determine the impact of children's health insurance programs on access to health care and on other aspects of the lives of the children and their families.

Design.— A before-after design with a control group. The families of newly enrolled children were interviewed by telephone using an identical survey instrument at baseline, at 6 months, and at 12 months after enrollment into the program. A second group of families of newly enrolled children were interviewed 12 months after the initial interviews to form a comparison sample.

Setting.— The 29 counties of western Pennsylvania, an area with a population of 4.1 million people.

Subjects.— A total of 887 families of newly enrolled children were randomly selected to be interviewed; 88.3% agreed to participate. Of these, 659 (84%) responded to all 3 interviews. The study population consists of 1031 newly enrolled children. The children were further classified into those who were continuously enrolled in the programs. The 330 comparison families had 460 newly enrolled children.

Main Outcome Measures.— The following access measures were examined: whether the child had a usual source of medical or dental care; the number of physician visits, emergency department visits, and dentist visits; and whether the child had experienced unmet need, delayed care, or both for 6 types of care. Other indicators were restrictions on the child's usual activities and the impact of being insured or uninsured on the families.

Results.— Access to health care services after enrollment in the program improved: at 12 months after enrollment, 99% of the children had a regular source of medical care, and 85% had a regular dentist, up from 89% and 60%, respectively, at baseline. The proportion of children reporting any unmet need or delayed care in the past 6 months decreased from 57% at baseline to 16% at 12 months. The proportion of children seeing a physician increased from 59% to 64%, while the proportion visiting an emergency department decreased from 22% to 17%. Since the comparison children were similar to the newly enrolled children at enrollment into the insurance programs, these findings can be attributed to the program. Restrictions on childhood activities because of lack of health insurance were eliminated. Parents reported that having health insurance reduced the amount of family stress, enabled children to get the care they needed, and eased family burdens.

Conclusions.— Extending health insurance to uninsured children had a major positive impact on children and their families. In western Pennsylvania, health insurance did not lead to excessive utilization but to more appropriate utilization.

Figures in this Article

THE BALANCED BUDGET ACT of 1997 established the State Children's Health Insurance Program (SCHIP), one of the most significant health system reform initiatives for children since the enactment of the Medicaid program in 1965. Under this legislation, $24 billion will be allocated to the states over a 5-year period to provide health insurance to children who would otherwise be uninsured. The law also gives the states considerable flexibility in how to insure children. They could expand their current Medicaid programs, launch or expand a children's health insurance program, or engage in some combination of the 2 strategies. Thus, the opportunity exists for the states to take a dramatic step in reducing the number of uninsured children in this country of which there were 9.8 million in 1995.1

While many studies have looked at the difference in the use of services between insured and uninsured children25 or have looked at the effect of different levels of cost-sharing on the use of services,6,7 few published studies have looked at the effect of extending health care coverage to uninsured children per se.8 The studies of the effects of the Medicaid expansions that occurred during the late 1980s and early 1990s tended to focus more on the total costs of expansion, the number of children covered, and the effect of these expansions on prenatal care and birth outcomes.911 Some researchers have also investigated the extent to which public health insurance has supplanted or "crowded out" private health insurance.12,13

Our study, which examines various effects of insurance designed to cover uninsured children, bridges this information gap. This article, which examines the impact of health insurance programs on newly enrolled children and their families, generated information on the types of benefits that this increased funding could provide to children. Specifically, we look at 2 programs that have been implemented in western Pennsylvania: the Children's Health Insurance Program of Pennsylvania (called BlueCHIP in western Pennsylvania), which is administered by the Western Pennsylvania Caring Foundation and the Highmark Blue Cross Blue Shield Caring Program (Caring). We used the responses to telephone interviews given at enrollment, 6 months, and 12 months to examine the programs' effects on factors such as whether the children had a usual source of care, received health care services of different types, experienced unmet need or delay in receiving services, and had childhood activities limited. To control for any underlying trends, we compared the baseline answers of the study families with those of families who were newly enrolled into the program 12 months later.

The Health Insurance Programs

The BlueCHIP and Caring programs provide health insurance coverage to uninsured children. The 2 programs, which are complementary, cover children up to the age of 19 years in families with incomes less than 235% of the federal poverty level. The programs provide the same comprehensive package of inpatient, outpatient (including dental and vision services), and preventive health care services to children. With the exception of a small co-payment for prescription drugs, there is no cost sharing. Most children (about 97%) are enrolled in managed care plans in which they are asked to select a primary care physician. Figure 1, which presents the eligibility criteria during the study period for the 2 programs as well as for the Medicaid program, shows how the eligibility for each varies by age and family income. (The insurance programs are linked to the Medicaid program in the following way: expenditures paid for hospital care under these programs count toward determining whether a family will spend down their personal resources to a level that makes them eligible for Medicaid.) Neither program is an entitlement program. The programs cover children who live in the 29 counties that make up western Pennsylvania, an area that includes 4.1 million people.

Graphic Jump Location
Eligibility guidelines for Medicaid BlueCHIP and Caring programs by family income and child's age.
The Study Population

We received the names of 5864 children as they were being enrolled in these programs between August and December 1995. We aggregated children to the family level and randomly selected 887 families to be interviewed by telephone by specially trained interviewers. The sample size was chosen to provide statistical power exceeding 90% for detecting expected differences.14 The families were contacted within 2 weeks after being accepted into either BlueCHIP or Caring but before receiving the insurance cards for their children. Of the 887 families, 783 (88.3%) agreed to participate and were interviewed, 44 (5.0%) refused, and 60 (6.8%) could not be contacted. We then contacted the 783 families again after 6 months and 12 months; 659 families (84.2%) answered all 3 surveys. These 659 families and their 1031 newly enrolled children make up the study population. (These children may have siblings who were not enrolled either because they were young enough to be enrolled in Medicaid or too old to be eligible for the programs.)

The interviewers used an almost identical survey instrument, which used both fixed-response format and open-ended questions, for all 3 interviews. The respondents, usually mothers (87%), were asked about each child in the family. In addition to standard demographic information, respondents were asked how long a child had been without insurance. They were also asked several questions about access and use of health care services. These questions included whether the child had a usual source of medical care, dental care, or both, the number of visits the child made to different types of health care providers, and whether the child experienced unmet need, delayed care, or both for 6 types of services (ie, physician services, emergency services, care recommended by the primary physicians, prescriptions, dental and vision care) in the past 6 months. For all questions related to health services utilization, the parents were asked to focus on the 6-month period prior to the interview. The interviewers also asked about the effect health insurance status had on usual childhood activities. In the initial interview, respondents were asked about the impact of lack of health insurance on their families; in the 12-month interview, they were asked about the impact of having insurance. The majority of the questions used in the interview were taken from other nationally implemented surveys.1518

The Comparison Families

We received a list of children who were enrolled in BlueCHIP or Caring between August and December 1996. We aggregated the children to the family level and randomly selected 371 families to be interviewed using the same telephone survey: 330 families (89%) who had 460 newly enrolled children agreed to participate. Through the use of this comparison group, we were able to assess whether changes observed in the study group were attributable to the insurance programs rather than to other underlying trends in the environment. This design, a variation of a recurrent institutional cycle design, rules out a major threat to the internal validity of simple before-after evaluations, namely, the effects of a secular trend.1921

Analysis

We first examined the children's insurance status at 6 and 12 months and categorized those who were enrolled in the program at 12 months as being continuously enrolled. In this article, we focus primarily on those children. We then compared the children over time along the factors described above. Since research has found that the longer children go without health insurance, the more likely they are to be without a usual source of health care or to experience unmet need, delayed care, or both,22,23 we categorized the children by the time period that they were uninsured prior to enrollment. We define children who were uninsured less than 6 months as the children with a shorter period without health insurance (SWI children) and those who were uninsured at least 6 months as the children with a longer period without health insurance (LWI children). We used the Statistical Package for the Social Sciences version 7.5 for the analyses.24

We used the appropriate within-subject tests to assess statistical significance of changes from baseline to follow-up assessments for each of the measured variables. We used the McNemar test to assess within-subject changes in dichotomous variables, such as unmet need and delayed care, and matched-pair Wilcoxon rank sum tests (because of nonnormal distributions) to assess within-subject changes of continuous variables such as the number of visits. To limit the number of comparisons, we report the within-subject tests only for the full cohort of continuously enrolled children. We conducted between-subject tests for the 2 subsamples at each time period using χ2 for dichotomous variables and Mann-Whitney U tests for continuous variables. We also used the between-subject, χ2, and t tests to compare the baseline findings for the study children with those of the comparison group of new enrollees. (Within-subject tests look at the changes over time within each subject, whereas between-subject tests compare one group of children with another group.) The Bonferroni correction was used to adjust for multiple comparisons.25

Baseline Characteristics and Health Insurance Status at 12 Months

Information on the study and comparison children is presented in Table 1. In the study families, 40.7% of the newly enrolled children did not have health insurance for at least 6 months prior to enrollment into CHIPs. The vast majority of these families were white (94.4%) and lived in standard metropolitan areas (74.2%), which reflect the characteristics of the region in which they live. Both parents were typically involved in the labor force, with over 60% of the fathers working full time. However, few parents had health insurance coverage. In the comparison families, the children were slightly younger, the average number of newly enrolled children per family was smaller, and a larger proportion of the newly enrolled children were uninsured longer than 6 months, which may reflect the impact of enrollment limits. It is worth noting that these children, as most children, were relatively healthy.

Table Graphic Jump LocationTable 1.—Baseline Characteristics of Study and Comparison Group Families

As indicated in Table 1, a total of 750 children (73%) were continuously enrolled, ie, still covered by one of these programs at 12 months. At the end of the study year, 15% were covered by private health insurance, 7% were covered by Medicaid, and 6% were uninsured. We do not know whether the children who shifted to the Medicaid program did so because their family income decreased or because some family member had incurred large enough health care expenditures that the family spent down to Medicaid. We also do not know why some children lost their health insurance. We believe that the children who gained private insurance did so as a result of a change in their parents' income or work status.

Source of Usual Health Care

The proportion of children having a regular source of medical and dental care increased over the year, as shown in Table 2. At 12 months, 99% of the children had a regular provider, up from 89% at enrollment. As may be expected, the table also indicates that on entry into the programs, the SWI children were more likely to have regular sources for both medical and dental care than were the LWI children. There were no differences at either 6 or 12 months in the proportion of children who had a regular source of medical care, dental care, or both based on the period they had been without health insurance coverage prior to enrollment. At enrollment, a higher proportion of the comparison children (94%) had a regular source of medical care than did the continuously enrolled children (87%), while there were no differences with respect to the proportion having a regular source of dental care. After adjustment with Bonferroni corrections for multiple comparisons,25 all tests for changes in usual source of care remained statistically significant at the P<.05 level except for the change in percentage with a regular physician between 6 and 12 months of follow-up. However, as demonstrated elsewhere in this article, having a usual source of health care did not imply that the source was regularly or appropriately used.

Table Graphic Jump LocationTable 2.—Children With Reported Regular Source of Care "In Past 6 Months" at Various Time Periods by Duration Uninsured Before Enrollment*
Reported Unmet Need and Delayed Care

According to Table 3, during the baseline interview, respondents reported that a large proportion of the children had experienced some unmet need, delayed care, or both in the prior 6 months. The proportion of all children who experienced unmet need, delayed care, or both for any of the identified types of care decreased from nearly 60% in the 6-month period prior to enrollment to 16% in the second 6-month period after enrollment. A decrease in unmet need, delayed care, or both was reported for each category of care. With the exception of dental care, all areas of unmet need, delayed care, or both were less than 4% in the 6- and 12-month periods after enrollment. There was no difference between the proportion of continuously enrolled children and the proportion of comparison children who experienced any unmet need, delayed care, or both for these services in the 6 months prior to enrollment. After adjusting with the Bonferonni correction for multiple comparisons,25 all these outcomes continued to be statistically significant at P<.05.

Table Graphic Jump LocationTable 3.—Reported Unmet Need/Delayed Care for Types of Services "In Past 6 Months" at Different Time Periods by Duration of Uninsurance Before Enrollment*

On entry into the program, the extent to which the children had experienced unmet need, delayed care, or both in the prior 6 months varied with the period of time the children had been uninsured. With the exception of emergency care, a higher proportion of the LWI children than of the SWI children experienced some unmet need, delayed care, or both for each type of service. However, at 6 and 12 months after enrollment, there were no differences between these 2 groups of children.

Use of Services

There was a significant increase in the proportion of all continuously enrolled children who were reported having any physician visits, dentist visits, and preventive dental visits "in the past 6 months" at both 6 months and 12 months after enrollment into CHIPs, as shown in Table 4. At the same time, there was a significant decrease in the proportion of children visiting an emergency department. There were some differences in utilization rates of these services across time. With respect to medical care, a higher proportion of children saw a physician in the 6 months after enrollment than in the second 6 months after enrollment. With respect to dental care, the proportion of children seeing a dentist increased between the first and second 6-month periods. After adjustment with Bonferroni corrections for multiple comparisons,25 all but one of these outcomes (percentage with any physician visit from enrollment to 12 months after enrollment) remained statistically significant at the P<.05 level.

Table Graphic Jump LocationTable 4.—Proportion of Children With Any Visit "In Past 6 Months" by Type of Visit and Duration Uninsured*

Much of the increase is attributable to the increased utilization rates of the children who had been uninsured for a longer period of time. With the exception of emergency department visits (where there were no differences), a smaller proportion of the LWI children than the SWI children had made any of these types of visits in the 6-month period prior to entry into the program. However, there were no statistically significant differences in the utilization rates of these groups of children in either the first or second 6-month period after enrollment. In the 6-month period prior to their enrolling in the program, a smaller proportion of the comparison group children than of the continuously enrolled children received any of these services.

While there was a significant increase in the proportion of children who used various services after enrollment in the health insurance programs, there was little change in the number of visits by children who had at least 1 visit. Data on the use of services by children with at least 1 visit are presented in Table 5. After adjustment with the Bonferroni correction for multiple comparisons, the differences between the number of physician visits per child from enrollment to 6 months and from enrollment to 12 months were no longer statistically significant at P<.05.

Table Graphic Jump LocationTable 5.—Mean Number of Visits "In Past 6 Months" By Children With at Least 1 Visit to Provider Type by Type of Visit and Duration Insured*
Impact of Health Insurance Coverage on Usual Activities

There was a significant decrease in the percentage of children whose basic activities were limited because they did not have health insurance. During baseline interviews, participants were asked, "Has [child's name] health insurance status led you to limit [child's name] activities in any way?" Respondents reported that 12% of the children were so limited—9.8% of the SWI children and 15.4% of the LWI children. (In the open-ended questions, 3% of the parents brought up the issue of limiting a child's activities again in response to the question, "What has not having health care coverage for your kids meant to you and your family?") Some parents said they limited sports activities like biking or roller-skating because they worried about possible accidents and attendant medical care costs associated with treating their injuries. Other limitations were imposed by organizations or individuals outside the family. For example, children were often not allowed to participate in sports programs because of regulations concerning health insurance coverage imposed by the schools or other organizations. At the 6-month and the 12-month interviews, the respondents reported essentially no limitations related to health insurance coverage. The comparison group respondents indicated that 18% of the children—15.2% of the SWI children and 20.1% of the LWI children—were limited in their usual activities because they did not have health insurance.

Effect of Health Insurance Coverage for Children on the Families

In response to the open-ended question, "What has not having health insurance for your kids meant to you and your family?" parents most frequently answered that lack of insurance was a major stressor in the family: they reported being worried, scared, and stressed out (73.5%). A substantial proportion (36.2%) indicated that lack of insurance led to financial difficulties within the family. Some respondents indicated that they felt that not having had health insurance contributed to their children's not receiving care or delay in getting care with adverse health consequences (Table 6). The comparison families responded similarly to this question.

Table Graphic Jump LocationTable 6.—"What Has Not Having Health Care Coverage for Your Kids Meant to You and Your Family?" (From Enrollment Interview)*

Table 7 summarizes the answers to the open-ended question, "What has having health insurance for your kids meant to you and your family?" In general, the answers were the mirror image of those given in Table 6. After their children had health insurance, parents responded overwhelmingly (61%) that having insurance led to peace of mind, reduced worry, and lowered stress. The next most common response was one of appreciation for the program (46%). Many parents (38%) indicated that the children could now get the care they needed, care that they otherwise would not have received. A number of respondents (12%) observed that having health insurance eased the financial burden on their families.

Table Graphic Jump LocationTable 7.—"What Has Having Health Insurance for Your Kids Meant to You and Your Family?" (12-Month Interview)*

In this article we examined some of the effects that children's health insurance programs had on the children and their families. We found that enrollment in the programs increased access to care. The pattern of use suggests that there was some pent-up demand for care that varied with the time the children had been uninsured prior to enrollment. The main effect of insurance coverage was to increase the proportion of children who used services, rather than to increase the intensity of use by children who used any services. This finding is consistent with that of other studies that found that cost sharing had a larger effect on whether someone got any care rather than on the intensity of care received.26,27 Finally, we also found more appropriate use of services after enrollment: children were more likely to see a physician, were more likely to see a dentist, and were less likely to make a visit to the emergency department. (Given the data on access to care and the use of services by the comparison children, the findings can be ascribed to the programs rather than to some change in the health care environment.)

The continuously enrolled children averaged 3.5 physician visits during their first year of coverage, which is slightly lower than the average number of physician visits made by insured children in 1987.4 Thus, there is no evidence that these children used services more heavily than insured children generally do and, therefore, that the costs would be higher for these children. Martin and colleagues8 also reached a comparable conclusion in their study of use under the Washington Basic Health Plan, a plan designed to cover low-income families. They found that the cost of covering these families was not higher than the cost of covering traditionally insured families.

We cannot ascertain the effect of these programs on children's health because one would not expect to observe major changes over the course of a single year. However, as noted in Table 5, the parents reported that their children had experienced a significant amount of unmet need and delayed care in the 6 months prior to enrollment in CHIPs. In responses to open-ended questions, respondents indicated that unmet need, delayed care, or both sometimes led to poor health outcomes. For example, some parents indicated that their children were sicker longer than they would have been had they received the care in a timely fashion; a few even indicated that more timely care would have eliminated the need for hospitalization.

With respect to dental care, parents reported leaving cavities unfilled and extracting teeth themselves, events they indicated would not have taken place had the price of dental care not been a factor. With respect to vision care, many parents reported that their children had headaches and difficulties seeing in school, which had an impact on their grades. Since some respondents (4.7%) indicated that they felt guilty because they did not have health insurance for their children, it is possible that they underreported some negative outcomes. We found that, with the exception of dental care, only a very small proportion of children experienced any unmet need, delayed care, or both following enrollment in the health insurance programs.

Health insurance had other, less generally studied effects on the lives of children. For instance, it enabled some children to live more physically active lives and to engage in some of the activities of normal childhood like playing sports in school or just playing with other children in the playground. Furthermore, according to responses to open-ended questions, the fact that their children had health insurance eliminated for parents a major source of stress and discord in many of these families. Consequently, at the end of the interview, many parents expressed their strong appreciation of the program.

This study has some limitations. One major limitation is that it focuses on children who voluntarily enrolled in a health insurance program in a small section of the country. However, the study children and their families are similar to those of uninsured children and families elsewhere with respect to family size, family structure, and working status of the parents.28 Children in the study also come from families with incomes below 235% of the poverty line (with the majority being below 185%); thus, they are similar to the types of children who will be eligible for care under SCHIP. It is worth noting that enrollment into SCHIP will also be voluntary. A second limitation is that the data are based on self-reported information. However, the respondents were asked to provide information on access and use of services "in the prior 6 months" during each interview, and it is unlikely that there would be any differences in the validity of the recall at each interview.

Our findings show that expanding health insurance coverage for children can have a major positive impact on the children and the family. As one of the Caring parents stated, "The cost of health care has become the determining factor in how you live." As states develop their plans to provide coverage for children's health insurance under the new federal program, legislators should be aware of the critical importance of their deliberations to the lives of uninsured children and their families. Investment in children's health insurance appears to represent a sound and responsible expenditure of public funds.

Bennefield RL. Health insurance coverage: 1995. In: Current Population Reports: Household Economic Studies. Washington, DC: US Bureau of the Census; 1996:60-95.
Stoddard JJ, St. Peter RF, Newacheck PW. Health insurance status and ambulatory care for children.  N Engl J Med.1994;330:1421-1425.
Newacheck PW, Hughes DC, Stoddard JJ. Children's access to primary care: differences by race, income and insurance status.  Pediatrics.1996;97:26-32.
Monheit AC, Cunningham PJ. Children without health insurance.  Future Child.1992;2:54-70.
Cunningham PJ, Hahn BA. The changing American family: implications for children's health insurance coverage and use of ambulatory services.  Future Child.1995;4:24-42.
Leibowitz A, Manning Jr WG, Keeler EB. The effect of cost sharing on the use of medical services by children.  Pediatrics.1985;75:942-951.
Manning WG, Newhouse JP, Duan N.  et al.  Health insurance and the demand for medical care.  Am Econ Rev.1987;77:251-277.
Martin DP, Diehr P, Cheadle A.  et al.  Health care utilization for the "newly insured."  Inquiry.1997;34:129-142.
Hill IT. The role of Medicaid and other government programs in providing medical care for children and pregnant women.  Future Child.1992;2:134-153.
Currie J, Gruber J. Saving Babies: The Efficacy and Cost of Recent Expansions of Medicaid Eligibility for Pregnant Women.  Cambridge, Mass: National Bureau of Economic Research; 1994. Working paper 4644.
Piper J, Ray W, Griffin M. Effects of medical eligibility expansion on prenatal care and pregnancy outcome in Tennessee.  JAMA.1990;264:2219-2223.
Cutler D, Gruber J. Does public insurance crowd out private insurance?  Q J Econ.1996;111:391-430.
Dubay LC, Kenney GM. The effects of Medicaid expansions on insurance coverage of children.  Future Child.1996;1:152-161.
Ullrich S. Evaluation Study of an Innovative Program to Provide Primary Health Care Benefits to Children [dissertation]. Pittsburgh, Pa: University of Pittsburgh; 1991.
 Data from the National Health Interview Survey.  Vital Health Stat 10.DHHS publication PHS 89, 1501.
 Health of our nation's children.  Vital Health Stat 10.DHHS publication PHS 95-1519.
Aday LA. Designing and Conducting Health Surveys.  San Francisco, Calif: Jossey Bass; 1989.
Valdez R. The Effects of Cost Sharing on the Health of Children.  Santa Monica, Calif: Rand Health Insurance Experiment Series; March 1986. Publication R-3270-HHS.
Cook T, Campbell D. Quasi-Experimentation.  Chicago, Ill: Rand McNally College Publishing Co; 1979.
Campbell DT, Stanley J. Experimental and Quasi-Experimental Designs for Research.  Chicago, Ill: Rand McNally Publishing Co; 1966.
Fitz-Gibbon CT, Morris L. How to Design a Program Evaluation.  Newbury Park, Calif: Sage Publications; 1987.
Lave JR, Keane CR, Lin CJ, Ricci EM, Amersbach G, LaVallee CP. The impact of lack of health insurance on children.  J Health Soc Policy.In press.
Kogan MD, Alexander GR, Teitelbaum MA, Jack BW, Pappas G. The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States.  JAMA.1995;274:1429-1435.
 Statistical Package for the Social Sciences.  Version 7.5. Chicago, Ill: SPSS Inc; 1996.
Edwards AL. Experimental Design in Psychological Research.  5th ed. New York, NY: Harper and Row Publishers; 1985.
Newhouse JP. Free for All? Lessons From the Rand Health Insurance Experiment.  Cambridge, Mass: Harvard University Press; 1993.
Lohr KN, Brook RH, Kamberg CJ.  et al.  Use of medical care in the Rand Health Insurance Experiment. Diagnosis- and service-specific analyses in a randomized controlled trial.  Med Care.1986;24(9 Suppl):S1-S87.
Employee Benefit Research Institute.  Characteristics of uninsured children.  EBRI Notes.1997;18(1):1-4.

Figures

Graphic Jump Location
Eligibility guidelines for Medicaid BlueCHIP and Caring programs by family income and child's age.

Tables

Table Graphic Jump LocationTable 1.—Baseline Characteristics of Study and Comparison Group Families
Table Graphic Jump LocationTable 2.—Children With Reported Regular Source of Care "In Past 6 Months" at Various Time Periods by Duration Uninsured Before Enrollment*
Table Graphic Jump LocationTable 3.—Reported Unmet Need/Delayed Care for Types of Services "In Past 6 Months" at Different Time Periods by Duration of Uninsurance Before Enrollment*
Table Graphic Jump LocationTable 4.—Proportion of Children With Any Visit "In Past 6 Months" by Type of Visit and Duration Uninsured*
Table Graphic Jump LocationTable 5.—Mean Number of Visits "In Past 6 Months" By Children With at Least 1 Visit to Provider Type by Type of Visit and Duration Insured*
Table Graphic Jump LocationTable 6.—"What Has Not Having Health Care Coverage for Your Kids Meant to You and Your Family?" (From Enrollment Interview)*
Table Graphic Jump LocationTable 7.—"What Has Having Health Insurance for Your Kids Meant to You and Your Family?" (12-Month Interview)*

References

Bennefield RL. Health insurance coverage: 1995. In: Current Population Reports: Household Economic Studies. Washington, DC: US Bureau of the Census; 1996:60-95.
Stoddard JJ, St. Peter RF, Newacheck PW. Health insurance status and ambulatory care for children.  N Engl J Med.1994;330:1421-1425.
Newacheck PW, Hughes DC, Stoddard JJ. Children's access to primary care: differences by race, income and insurance status.  Pediatrics.1996;97:26-32.
Monheit AC, Cunningham PJ. Children without health insurance.  Future Child.1992;2:54-70.
Cunningham PJ, Hahn BA. The changing American family: implications for children's health insurance coverage and use of ambulatory services.  Future Child.1995;4:24-42.
Leibowitz A, Manning Jr WG, Keeler EB. The effect of cost sharing on the use of medical services by children.  Pediatrics.1985;75:942-951.
Manning WG, Newhouse JP, Duan N.  et al.  Health insurance and the demand for medical care.  Am Econ Rev.1987;77:251-277.
Martin DP, Diehr P, Cheadle A.  et al.  Health care utilization for the "newly insured."  Inquiry.1997;34:129-142.
Hill IT. The role of Medicaid and other government programs in providing medical care for children and pregnant women.  Future Child.1992;2:134-153.
Currie J, Gruber J. Saving Babies: The Efficacy and Cost of Recent Expansions of Medicaid Eligibility for Pregnant Women.  Cambridge, Mass: National Bureau of Economic Research; 1994. Working paper 4644.
Piper J, Ray W, Griffin M. Effects of medical eligibility expansion on prenatal care and pregnancy outcome in Tennessee.  JAMA.1990;264:2219-2223.
Cutler D, Gruber J. Does public insurance crowd out private insurance?  Q J Econ.1996;111:391-430.
Dubay LC, Kenney GM. The effects of Medicaid expansions on insurance coverage of children.  Future Child.1996;1:152-161.
Ullrich S. Evaluation Study of an Innovative Program to Provide Primary Health Care Benefits to Children [dissertation]. Pittsburgh, Pa: University of Pittsburgh; 1991.
 Data from the National Health Interview Survey.  Vital Health Stat 10.DHHS publication PHS 89, 1501.
 Health of our nation's children.  Vital Health Stat 10.DHHS publication PHS 95-1519.
Aday LA. Designing and Conducting Health Surveys.  San Francisco, Calif: Jossey Bass; 1989.
Valdez R. The Effects of Cost Sharing on the Health of Children.  Santa Monica, Calif: Rand Health Insurance Experiment Series; March 1986. Publication R-3270-HHS.
Cook T, Campbell D. Quasi-Experimentation.  Chicago, Ill: Rand McNally College Publishing Co; 1979.
Campbell DT, Stanley J. Experimental and Quasi-Experimental Designs for Research.  Chicago, Ill: Rand McNally Publishing Co; 1966.
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