Published online October 1, 2007
PEDIATRICS Vol. 120 No. 4 October 2007, pp. e1009-e1016 (doi:10.1542/peds.2006-3094)
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ARTICLE

Disruptions in Insurance Coverage: Patterns and Relationship to Health Care Access, Unmet Need, and Utilization Before Enrollment in the State Children's Health Insurance Program

Steven G. Federico, MDa,b, John F. Steiner, MD, MPHc,d, Brenda Beaty, MSPHd, Lori Crane, PhD, MPHe and Allison Kempe, MD, MPHa,f

a Departments of Pediatrics
c General Internal Medicine
e Preventive Medicine and Biometrics
d Colorado Health Outcomes Program, University of Colorado Health Sciences Center, Denver, Colorado
b Department of Pediatrics, Denver Health Medical Center, Denver, Colorado
f Children's Outcomes Research Program, Children's Hospital, Denver, Colorado

BACKGROUND. The numbers and types of disruptions in insurance that children experience and the effects of these disruptions on health care measures have not been well characterized.

OBJECTIVES. Our goals were to (1) describe the number and patterns of insurance disruptions within a population of children newly enrolling into the State Children's Health Insurance Program and (2) assess the relationship among insurance disruptions and sociodemographic characteristics of these children and their families to specific measures of access to care, unmet need, and health care utilization during the year before enrollment.

METHODS. We conducted telephone interviews in families with children newly enrolling in the State Children's Health Insurance Program. Families reported on measures for each of the 12 months preceding enrollment. They were grouped by number of insurance disruptions in the year before enrollment: continuously uninsured, ≥2 disruptions, 1 disruption, or continuously insured.

RESULTS. Of 920 families contacted, 739 (80%) completed the interview and 710 had useable data. Thirty-five percent reported being continuously uninsured, 42% were intermittently insured (≥2 disruptions: 28%; 1 disruption: 14%), and 23% were continuously insured during the previous year. The most common patterns of change were between privately insured and uninsured (49%) and Medicaid and uninsured (40%). The continuously uninsured were more likely to be Hispanic and older in age. Multivariate modeling confirmed a gradient between greater insurance disruption and less access to care, less utilization, and greater unmet medical need. Using the continuously uninsured as a reference group, the adjusted odds ratio for having a medical home varied from 2.5 for those with ≥2 disruptions to 4.5 for the continuously insured and from 1.9 to 3.2, respectively, for using any regular/routine care. The odds ratio for unmet need for a prescription medication was 0.9 for ≥2 disruptions and 0.5 for those with continuous insurance coverage.

CONCLUSIONS. There was significant disruption in insurance coverage in the year before State Children's Health Insurance Program enrollment. Most of these disruptions took the form of children previously enrolled in either Medicaid or private insurance becoming uninsured. Increasing numbers of disruptions were associated with less routine care and greater unmet medical need. These findings suggest that disruptions in insurance coverage for children should be minimized with the adoption of policies regarding continuous eligibility criteria for Medicaid and streamlining transitions between Medicaid, the State Children's Health Insurance Program, and private insurance.

Key Words: disruptions • insurance gaps • churning • uninsured • SCHIP

Abbreviations: SCHIP—State Children's Health Insurance Program • CU—continuously uninsured • CI—continuously insured • CICP—Colorado Indigent Care Program • FPL—federal poverty level • OR—odds ratio

Accepted Mar 14, 2007.