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Appendix D Recent Studies of the Impacts of Health Insurance for Children: Summary Tables Five tables summarizing the evidence since 2002 on the impacts of health insurance for children are presented in this appendix. These tables were originally presented in a literature review commissioned by the In- stitute of Medicine Committee on Health Insurance Status and Its Conse- quences in 2008 titled Health and Access Consequences of Uninsurance Among Children in the United States: An Update, by Genevieve M. Kenney, Ph.D., and Embry Howell, Ph.D., The Urban Institute. • Table D-1: General Health Care: Impacts of Health Insurance on Children’s Access and Use of Care • able D-2: Dental Services: Impacts of Health Insurance on Chil- T dren’s Access and Use of Dental Services • able D-3: Immunizations: Impacts of Health Insurance on Chil- T dren’s Immunizations • able D-4: Impacts of Health Insurance on Special Populations of T Children • able D-5: Impacts of Health Insurance on Children’s Health Status T and Related Outcomes Several abbreviations are used frequently in the tables: • ACSC = ambulatory care sensitive condition • ADHD = Attention Deficit Hyperactivity Disorder • CHI = children’s health initiatives • CSHCN = children with special health care needs 

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 AMERICA’S UNINSURED CRISIS • D-D = difference-in-difference • IR = incidence ratio • MEPS = Medical Expenditure Panel Survey • NHANES = National Health and Nutrition Examination Survey • NHIS = National Health Interview Survey • NSAF = National Survey of America’s Families • NSCH = National Survey of Children’s Health • OLS = ordinary least squares • Rx = prescription • SCHIP = State Children’s Health Insurance Program Changes are statistically significant unless otherwise noted as “not sig- nificant” (“NS”). N/A indicates that the study in question did not examine the specified outcome.

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 AMERICA’S UNINSURED CRISIS TAbLE D-1 General Health Care: Impacts of Health Insurance on Children’s Access and Use of Care Location and Time Period of Citation Analysis Data Sources Methodology National Studies Banthin and United States, National Medical D-D approach: change between Selden (2003) 1987 and 1996 Expenditure Survey 1987 and 1996 for poverty-related The ABCs of (1987) and MEPS children less change over same children’s health (1996) time period for slightly higher- care: How income children: Children made the Medicaid eligible for Medicaid under the expansions poverty-related expansions in the affected access, 1980s are the treatment group burdens, and and children with slightly higher coverage income levels—defined as those in between 1987 the income groups ultimately made and 1996 eligible for SCHIP as of 2000—are the primary comparison group; controls included a variety of sociodemographic characteristics, as well as income and health status. Service use refers to previous 12 months. Currie et al. United States, NHIS (N = Examine impacts of Medicaid/ (2008) 1986 to 2005 548,789) SCHIP eligibility expansions on Has public probability of an ambulatory visit health insurance and reported health status using for older a simulated eligibility indicator children reduced to address potential endogenity disparities in of eligibility. Medicaid/SCHIP access to care generosity index generated by and health applying state eligibility rules to a outcomes? sample of children for each state and year. Control variables include interaction terms and age and year dummies. Look at concurrent and lagged effects. Still potentially biased and concerns about appropriateness of simulated eligibility measure in studies of all kids. Service use refers to previous 12 months.

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 APPENDIX D Findings Usual Any Any Any Specific Source of Ambulatory Preventive Unmet Unmet Care Visit Visit Need Needs 2.1 percentage 9.3 percentage N/A N/A N/A point increase point increase (NS) N/A Eligible children N/A N/A N/A 6.8 percentage points more likely to have ambulatory visit in past year; children ages 9-17 who were eligible as younger children are 3.9 to 8.9 percentage points more likely to have doctor’s visit; find positive lagged eligibility effects Continued

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 AMERICA’S UNINSURED CRISIS TAbLE D-1 Continued Location and Time Period of Citation Analysis Data Sources Methodology Davidoff et al. United States, NHIS core D-D approach: two treatment (2005) 1997, 2000, data source groups—children in the income Effects of the 2001 supplemented group made newly eligible under State Children’s with state data on SCHIP and children already Health Insurance policy changes, eligible for Medicaid under the Program local data on poverty-related expansions; expansions on private premiums comparison group: children with children with incomes slightly above the SCHIP chronic health eligibility thresholds; wide-ranging conditions control variables to address possible confounding changes occurring over the same period. Service use refers to previous 12 months. Sample is restricted to children with chronic health conditions. Selden and United States, MEPS Children uninsured for full year Hudson (2006) 1996-2002 supplemented compared to children with private Access to care with state-level coverage only and to children with and utilization Medicaid/SCHIP any public coverage. Two-stage among children: eligibility and least squares with instrumental Estimating the private premiums variables used to address selection effects of public information; N = bias (estimates reported here and private 49,003 are from the model using family coverage instruments). Found that OLS estimates understate positive effects of coverage. Service use refers to previous 12 months.

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 APPENDIX D Findings Usual Any Any Any Specific Source of Ambulatory Preventive Unmet Unmet Care Visit Visit Need Needs N/A 2.4 percentage N/A 8.6 percentage Rx: 3.7 point increase point decrease percentage point (NS) decrease 38.5 (public) 32.7 (public) 33.5 (public) and N/A N/A and 39.7 and 30.1 26.8 (private) (private) (private) percentage points percentage percentage more likely to points more points more comply with well- likely than likely than visit guidelines uninsured uninsured Continued

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0 AMERICA’S UNINSURED CRISIS TAbLE D-1 Continued Location and Time Period of Citation Analysis Data Sources Methodology State Studies Damiano et al. Iowa, Two-wave Pre-post cohort/longitudinal (2003) 1999-2000 mail survey design. Outcomes for new The impact of (with telephone enrollees compared to outcomes the Iowa followup) of for the same enrollees 1 year later; S-SCHIP parents of new no information provided on prior program enrollees in Hawk- coverage of new enrollees. Service on access, I (SCHIP) and 1 use refers to previous 12 months. health status, year later; (N = and family 463) response rate environment = 80% for baseline and 72% for followup Dick et al. Kansas, Surveys of enrollees Pre-post cohort/longitudinal (2004) Florida, and in State Children’s design. Included children who had SCHIP’s impact New York. Health Insurance disenrolled from SCHIP. Provide in three states: Baseline Programs; separate estimates for children How do the between June adolescents only who were previously uninsured. most vulnerable 2000 and in FL. children fare? March 2001; KS: N = 434, Followup response rate = interviews were 35% FL: N = 944, conducted 1 response rate = year later 30% NY: N = 2,290, response rate = 55% Feinberg et al. Massachusetts, One-wave telephone Compared experiences of children (2002) 1998-1999 survey of parents of before and after enrollment, which Family income children in enrolled parents were asked to recall. and the impact in Mass. Children’s of a children’s Medical Security health insurance Plan, a precursor program on to SCHIP, that reported need included children for health of all incomes. (N = services and 877 primary sample unmet health plus 119 Spanish need oversample); response rate = 62%

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 APPENDIX D Findings Usual Any Any Any Specific Source of Ambulatory Preventive Unmet Unmet Care Visit Visit Need Needs Increased from N/A N/A Decreased from Specialty: 81% to 89% 27% to 9% Decreased from (medical need) 40% to 13%; Vision: Decreased from 46% to 12%; Behavioral/ Emotional: Decreased from 42% to 18%; Rx: Decreased from 21% to 13% NY: Increased N/A KS: Increased KS: Decreased N/A from 78% to from 51% to from 53% 97% 66% (NS); NY: to 20%; NY: increased from decreased from 67% to 80% 32% to 21% N/A N/A N/A Excluding dental: Rx: Declined Declined from from 4% to 3%; 12% before Vision: Declined enrollment to from 30% to 7% after 17% (NS); Mental: Declined from 33% to 17% (NS) Continued

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 AMERICA’S UNINSURED CRISIS TAbLE D-1 Continued Location and Time Period of Citation Analysis Data Sources Methodology Fox et al. (2003) Kansas, Two-wave survey Pre-post cohort/longitudinal Changes in 1999-2000 of parents of design. Responses for children reported health children enrolled in just after enrollment compared to status and unmet the program in its responses for same children 1 year need for children first 6 months and later. Service use refers to previous enrolling in the of the same parents 12 months. Kansas children’s 1 year later; (N = health insurance 1,955), response program rate = 60% (Wave 2) Kempe et al. Colorado, Survey of enrollees Pre-post cohort/longitudinal (2005) 1999-2001 in Colorado’s design, controlling for race/ Changes Child Health Plus ethnicity, age, prior insurance in access, Program; Baseline status; no separate results reported utilization, and survey during 1999 for the kids who had been quality of care and 2000; follow uninsured prior to enrolling in after enrollment up survey 1 year SCHIP. Report IR for post- versus into a state child later. (N = 480). pre-enrollment. health insurance Response rate = plan 77% for baseline and 68% for followup Kenney (2007) 10 states (CA, One-wave survey Compare pre-SCHIP experiences The impacts CO, FL, IL, of parents of of uninsured children to SCHIP of the state LA, MO, NC, children newly experiences of SCHIP enrollees; children’s health NJ, NY, TX), enrolled in SCHIP regression adjustment for insurance 2002 or enrolled for demographic characteristics and program on 1 year; response income; sensitivity analyses to children who rate = 75-80% examine selection. Service use enroll: Findings depending on refers to previous 6 months. from 10 states state; N = 16,700; data pooled across states. Primary sample consists of 5,394 established enrollees and 3,106 recent enrollees

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 APPENDIX D Findings Usual Any Any Any Specific Source of Ambulatory Preventive Unmet Unmet Care Visit Visit Need Needs Increased from N/A Increased from Share who Mental health: 91.9% to 95.6% 60.5% to 76.7% received all care Decreased from needed increased 4.2% to 1.1%; from 48.9% to Vision: Decreased 83.5% from 17.0% to 4.0%; Rx: Decreased from 14.1% to 2.3% Usual source of N/A Routine visit: N/A Rx: IR = .38; preventive care IR = 1.39 Mental: IR = .63; IR = 1.02 (NS) Dental: IR = .59; Routine care: IR = .17; Sick care: IR = .27; Eyeglasses: IR = .44 21 percentage 7 percentage 11 percentage 13 percentage Rx: 6 percentage point increase points increase point increase point decrease point decrease; Specialist: 6 percentage point decrease; Hospital care: 6 percentage point decrease Continued

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 AMERICA’S UNINSURED CRISIS TAbLE D-4 Continued Place and Time Period of Citation Findings Data Sources Yu et al. (2006) United States, 2001 National Survey of Children Role of SCHIP in with Special Health Care Needs serving children (N = 38,866) with special health care needs NOTE: Changes are statistically significant unless otherwise noted as “not significant” (“NS”). N/A indicates the study did not examine that outcome. CHSCN = children with special health care needs; MEPS = Medical Expenditure Panel Survey; NHIS = National Health Interview Survey; NSAF = National Survey of America’s Families; NSCH = National Survey of Children’s Health; SCHIP = State Children’s Health Insurance Program.

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 APPENDIX D Methodology Findings CSHCN eligible for SCHIP but uninsured Uninsured children significantly more likely compared to CSHCN enrolled in SCHIP; to have unmet health care needs (odds ratio regression adjustment for demographic = 5.92). characteristics and income.

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 AMERICA’S UNINSURED CRISIS TAbLE D-5 Impacts of Health Insurance on Children’s Health Status and Related Outcomes Place and Time Period of Citation Analysis Data Sources Late Diagnosis Froehlich et United States, 2001-2004 Children ages 8-15 in the NHANES al. (2007) who were screened for and Prevalence, identified with ADHD (N = 222) recognition, and treatment of attention-deficit/ hyper-activity disorder in a national sample of U.S. children Maniatis et al. Barbara Davis Center Medical record review for all (2005) for Childhood Diabetes, children with Type 1 diabetes Increased University of Colorado Health (N = 383) incidence and Sciences Center, 2002-2003 severity of diabetic ketoacidosis among uninsured children with newly diagnosed type 1 diabetes mellitus Preventable Hospitalization Aizer (2007) California, 1996-2000 Zip code–level/race/ethnicity Public health level quarterly data on: Medicaid insurance, enrollment, ACSC hospitalizations, program take- and child population counts up, and child from Medicaid enrollment files, health state hospital discharge files from California’s Office of Statewide Planning and Human Development, and U.S. census Bermudez and California, 1996-2000 County-level monthly data Baker (2005) on: SCHIP enrollment, ACSC The relationship hospitalizations, and child between SCHIP population counts from SCHIP enrollment and enrollment files, state hospital hospitalizations for discharge files from California’s ambulatory care Office of Statewide Planning and sensitive conditions Human Development, and U.S. in California census

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 APPENDIX D Methodology Findings Uninsured children with ADHD compared Uninsured children less likely to have to insured children with ADHD; regression previously received a diagnosis of adjustment for differences in demographic ADHD at the time of the examination characteristics and income. (odds ratio = .1). Uninsured children compared to privately Uninsured children were significantly insured children; no regression adjustment more likely to present with diabetic differences in characteristics. ketoacidosis (odds ratio = 6.19) and severed diabetic ketoacidosis (odds ratio = 6.09). Two-stage instrumental variable regression Higher Medicaid enrollment rate analysis predicting first the rate of Medicaid is associated with a lower ACSC enrollment using placement and timing of admission rate. A 10 percent increase outreach investments (e.g., application assistors in Medicaid enrollment leads to a 2.3 and advertising campaigns), and then the rate to 3.4% decrease in Medicaid ACS of ACSC admissions, controlling for zip code hospitalizations. Similar range found characteristics including income and county under alternative specifications. The fixed effects. Uses alternative instruments and OLS estimates were smaller in absolute also explored possible effects on length of stay. value. A regression model predicted the rate of ACSC A 1 percentage point increase in SCHIP hospitalization per child ages 1-18, controlling enrollment was associated with a for the rate of SCHIP enrollment in the county reduction of .86 ACSC hospitalizations (lagged by 1 year), county-level demographics per 100,000 children, a significant (including income), pediatric provider supply, but small effect compared to a mean and county fixed effects. As a control, test of 28.9. There was no significant whether SCHIP enrollment affected ACSCs change for young adults. Appendicitis among adults ages 19 to 29 or admission for hospitalization rates also declined appendicitis, which is not an ACSC. significantly, but at a much lower level. Continued

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0 AMERICA’S UNINSURED CRISIS TAbLE D-5 Continued Place and Time Period of Citation Analysis Data Sources Cousineau et al. 9 counties in California Quarterly hospital discharge data (2008) that implemented CHIs to on ACSCs Preventable cover uninsured children, hospitalizations 2000-2005 among children in California counties after child health insurance expansion initiatives Szilagyi et al. New York State, 2001-2002 Two-wave telephone survey of (2006) parents of children with asthma Improved in Child Health Plus—SCHIP asthma care (N = 334 at baseline and 364 at after enrollment followup) in the state children’s health insurance program in New York Perceived Health Status/Missed School Days/Other Currie et al. United States, 1986 to 2005 NHIS (N = 548,789) (2008) Has public health insurance for older children reduced disparities in access to care and health outcomes?

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 APPENDIX D Methodology Findings ACSC rates are modeled as a function of CHI The rate of hospitalization for ACSCs implementation, time, county, and insurance. declines following CHI implementation Changes in ACSC rates for children who are for lower-income children, while there is either publicly insured or self-pay in each of the no change for higher-income children. nine CHIs are compared to changes occurring among other children. Responses for parents of newly enrolled After 1 year enrolled in SCHIP, the children compared to responses for the same percentage of children hospitalized parents 1 year later. for asthma in the past year declined significantly from 11.1 to 3.4%. There were also significant reductions in emergency room visits and other health care visits for asthma. Examine impacts of Medicaid/SCHIP eligibility No statistically significant concurrent expansions on probability of a physician visit effects on perceived health status. and reported health status using a simulated Statistically significant, positive effects eligibility indicator to address potential of eligibility for children ages 2, 3, and endogeneity of eligibility. Medicaid/SCHIP 4 on health status of children ages 9 generosity index generated by applying state to 17, suggesting that the effects of eligibility rules to a sample of children for insurance coverage on perceived health each state and year. Control variables include do not show up immediately. interaction terms and age and year dummies. Look at concurrent and lagged effects. Still potentially biased and concerns about appropriateness of simulated eligibility measure in studies of all kids. Service use refers to previous 12 months. Continued

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 AMERICA’S UNINSURED CRISIS TAbLE D-5 Continued Place and Time Period of Citation Analysis Data Sources Damiano et al. Iowa, 1999-2000 Two-wave mail survey (with (2003) telephone followup) of parents of The impact of the new enrollees in Hawk-I (SCHIP) Iowa S-SCHIP and 1 year later; (N = 463) response program on rate = 80% for baseline and 72% access, health for followup status, and family environment Fox et al. (2003) Kansas, 1999-2000 Two-wave survey of parents of Changes in children enrolled in the program in reported health its first six months and of the same status and parents 1 year later; N = 1,955, unmet need response rate = 60% (Wave 2) for children enrolling in the Kansas children’s health insurance program Howell and Santa Clara County, CA, Survey of parents of undocumented Trenholm 2003-2004 children enrolled in Healthy Kids (2007) insurance; (N = 1,235) response rate The effect of = 89% new insurance coverage on the health status of low-income children in Santa Clara County Howell et al. San Mateo County, CA, One-wave survey of parents of (2008a) 2006-2007 primarily undocumented children Final report of newly enrolled in Healthy Kids the evaluation insurance and enrolled for 1 year; of the San (N = 1,404), response rate = 77% Mateo County Children’s Health Initiative

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 APPENDIX D Methodology Findings Pre-post cohort/longitudinal design. Outcomes The proportion of children identified as for new enrollees compared to outcomes for being in excellent or very good health the same enrollees 1 year later; no information by their parents increases significantly provided on prior coverage of new enrollees. from 79% to 82%. The proportion of Service use refers to previous 12 months. children who missed 5 or more days of school due to illness or injury declined significantly from 35% to 25%. Pre-post cohort/longitudinal design. Responses The proportion of children identified as for children just after enrollment compared to being in excellent or very good health responses for same children 1 year later. Service by their parents increases significantly use refers to previous 12 months. from 71.2% to 75.7%. The proportion of parents who reported that their child’s health is better now than it was a year ago also increased significantly from 11.6% to 20.0%. Newly enrolled children compared to children Percent in fair/poor health reduced enrolled for 1 year (established); regression by 13.0 percentage points; significant adjustment for demographic characteristics, change for both those who enroll and income, and medical and dental need. do not enroll for medical reasons; percent with more than 3 school days missed in month is reduced by 5.8 percentage points among those not enrolling for a medical reason. Newly enrolled children compared to children No significant effect on perceived enrolled for 1 year; regression adjustment health status. Significant reduction in for demographic characteristics, income, and percentage of children with missed medical and dental need. Service use refers to school days in past 4 weeks, from previous 6 months. 47.5% to 40.8%. Continued

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 AMERICA’S UNINSURED CRISIS TAbLE D-5 Continued Place and Time Period of Citation Analysis Data Sources Howell et al. Los Angeles County, CA, Two-wave survey of parents of (2008b) 2005-2007 primarily undocumented children The impact of ages 1-5 enrolled in Healthy Kids the Los Angeles insurance (N = 975); response rate = Health Kids 86% (Wave 1) and 77% (Wave 2) Program on access to care, use of services, and health status Szilagyi et al. New York State, 2001-2002 Two-wave telephone survey of (2004) parents of children enrolled in Child Improved access Health Plus (SCHIP) for 4-6 months and quality and about 1 year after enrollment; of care after N = 2,290; response rate = 87% for enrollment in followup the New York state children’s health insurance program NOTE: Changes are statistically significant unless otherwise noted as “not significant” (“NS”). N/A indicates the study did not examine that outcome. ACSC = ambulatory care sensitive condition; CHI = children’s health initiatives; MEPS = Medical Expenditure Panel Survey; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health In- terview Survey; NSCH = National Survey of Children’s Health; OLS = ordinary least squares; SCHIP = State Children’s Health Insurance Program.

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 APPENDIX D Methodology Findings D-D; changes over a year for children who had D-D for percentage in excellent/very been enrolled for a year in Wave 1 compared to good health not significant; however changes for newly enrolled children; regression both new and established enrollees adjustment for demographic characteristics, improve significantly from Wave 1 to income, and medical and dental need. Service Wave 2. use refers to previous 6 months. Outcomes for newly enrolled children compared No significant effect on perceived health to outcomes for the same children 1 year later. status. Pre period includes insured and uninsured kids, but 80% uninsured for part of the year.

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