Factors associated with type of insurance coverage

Several types of issues were evaluated relative to whether the child had private health insurance, public health insurance through Medicaid or were uninsured. These included demographic characteristics of the child and family, the child's health status, access to health care and their school and family environment.

Demographics of child and family

The children who were uninsured or covered by Medicaid tended to be younger with over a third (34-38%) being ages 0-4 compared to 23% of those with private insurance. Latino children were almost twice as likely to be uninsured as white children (11% vs 6%) and were more likely to be covered by Medicaid (24% vs 9%). Children covered by Medicaid were the lowest income group of the three with 75% having incomes at 133% or less of the federal poverty level (FPL) (all children have to be in families with incomes of 133% of FPL or less to qualify for Medicaid when income is calculated more accurately according to program guidelines).

Figure 3. Marital status by insurance coverage

Children with private insurance were much more likely to be in families where parents were married or in a married-like relationship. 90% of children with private insurance were living in a household with vs 69% of those covered by Medicaid and 78% of the uninsured children. The parents of children with private insurance also tended to have a higher level of education with over a third (35%) having a four year college degree or more compared to 14% of uninsured children and 7% of children with Medicaid insurance.

Children's health status

Uninsured children had the highest overall health status while Medicaid enrolled children were reported to be in the lowest health state. 71% of uninsured children were reported to be in excellent health compared to 68% of those with private insurance and 50% of those covered by Medicaid. Medicaid enrolled children were also more likely to have a special health care need as defined using a series of questions developed by the Foundation for Accountability (see www. facct.org). One third of the children covered by Medicaid were determined to have a special health care need compared to 16% covered by private insurance and 10% of the uninsured.

Access to medical care

Six different dimensions of access to medical care were evaluated in this study: having a regular source of care, need for medical care, unmet need for medical care, emergency room visits in the past year, receipt of preventive care and prescription drugs. In general, uninsured children were reported to have lower access to medical care than children covered by either   Medicaid or a private health insurance plan.

Regular source of medical care

Parents were asked if they had one person they considered their child's regular doctor of nurse to gauge whether the child had a regular source of medical care. Uninsured children were much less likely to have a regular source of medical care with about three quarters (75%) reporting they had a personal doctor or nurse compared to over 90% of children covered by Medicaid (92%) or private insurance (91%).

Need and unmet need for medical care

Uninsured children had the lowest percent needing medical care in the previous year but the highest percent with unmet need for care (Figure 3) (defined as having been stopped from receiving needed medical care in the previous year).

Figure 4. Need and unmet need for medical care in previous year

Emergency room visits

Children covered by Medicaid were most likely to have made an emergency room visit in the previous year (47% vs 35% of the uninsured children and 30% of those with private insurance).

Preventive care

Children in Medicaid were least likely to have had a preventive visit in the previous year (53% vs 65% of the uninsured children and 70% of those with private insurance) and were most likely to not have had a preventive visit in 2 years or more (17%). While the receipt of age specific anticipatory guidance (i.e., preventive counseling about things such as watching what your child eats and using a car seat or bike helmet), was low for all groups, the uninsured were least likely to report receiving this counseling (21% vs 28% for the other two groups).

Prescription medications

As with medical care, the uninsured had the lowest reported need for prescription drugs but the most difficult problem getting them when needed (Figure 4). 42% of uninsured

Figure 5. Need and problem getting prescription medications in previous year

School and family environment

Two concepts were evaluated regarding associations between health insurance coverage and the school and family environment: the level of the child's school engagement and substance use problems in the home.

School engagement

A series of four questions were used to evaluate the degree to which school-age children in Iowa were engaged in school. These questions included how much the child cared about doing well, needed to be forced to complete homework, did just enough homework to get by and completed homework on time. Children covered by Medicaid were most likely to be reported to have low engagement in school while the uninsured were most likely to have high school engagement.

Substance use in the home

Uninsured children were most likely to be in families were substance use was reported to be a problem. 22% of uninsured children were in a home where substance use was reported to be either a big problem (11%) or a small problem (11%) compared to 13% of children enrolled in Medicaid and 9% of those with private insurance.

Children who were uninsured in the past year

For the children who were uninsured at some point in the past year, 62% now had private insurance and 38% were covered by Medicaid insurance. There were significant differences between children who were uninsured at the time of the call and children had insurance but had been uninsured at some point in the previous year. The children who were uninsured during the past year were generally sicker and used more services than uninsured children. They were more less likely to be rated in excellent health (47% vs 70%), were more likely to have special health care needs (29% vs 10%), were more likely to need medical care in the previous year (51% vs 39%), had more with unmet need for medical care (18% vs 10%) , were more likely to have been to the emergency room in the previous year (47% vs 35%), and were more to have needed prescription drugs (56% vs 43%).

Dental insurance coverage

There were significantly more children in Iowa without dental insurance than without medical insurance. 25% of Iowa children did not have dental insurance at the time of the interview. 10% of children received dental insurance through the Medicaid program while the remainder (65%) received dental coverage through private insurance. All of the children who were dentally uninsured were either medically uninsured or had private medical insurance since Medicaid provides comprehensive dental coverage for all children.

The percentage of children reported to need dental care in the previous year was similar for the dentally uninsured, those covered by Medicaid and those with private dental insurance, unlike medical care and prescription drugs. Even though they had dental insurance coverage, Medicaid enrollees reported the highest percentage of unmet need or dental care (18%) (Figure 5). The unmet need for dental care was also higher than the unmet need for medical care for all three groups.

Figure 6. Need and unmet for dental care

How recently the child received their last dental check-up was related to the type of dental insurance coverage. 81% of the privately insured children had a dental check-up in the previous year compared to 63% of both the children without dental insurance and the children covered by Medicaid.