Although the rate of uninsured children in Iowa is lower than in most states, there were roughly 50,000 to 100,000 Iowa children who were either uninsured or were at significant risk of being uninsured. This does not include the unidentified number of children who were underinsured in the event of a catastrophic health event.

Public insurance programs (i.e., Medicaid and hawk-i) appear to be playing an important role of providing transitional insurance coverage for children in the state. Over half of uninsured children had been covered by Medicaid at some point in their life. In addition, one in six children with private insurance had also been enrolled in Medicaid at some point in the past. About 80% of uninsured children were eligible for either Medicaid or hawk-i. While the reasons these children remain uninsured varies, the importance of education and outreach is clear. For example, at the time of the survey only about half of the parents had heard of the hawk-i program.

There was also a strong relationship between the health insurance coverage of children and their parents. Almost nine out of 10 insured children had parents with the same insurance coverage. The greater likelihood of children being insured in families where the parents were married may be due to the additional chance of receiving employer-based health insurance coverage through two adults rather than one. Conversely, 25% of uninsured children had parents who were insured and 30% of children enrolled in Medicaid had parents who were uninsured. The vastly different Medicaid income eligibility criteria for adults and children would account for some of this difference for Medicaid. Thinking about how children and families seek services, providing insurance coverage to families, rather than to individual children or adults, would greatly improve both overall insurance coverage and utilization of services. Studies have indicated that children with uninsured parents are much less likely to utilize services than children with parents who have insurance.

Higher satisfaction ratings by Medicaid enrollees compared to those with private health insurance could be related to several factors. First, Medicaid insurance coverage may be less complex, from the insured’s perspective, than some private insurance plans. Second, Medicaid offers a comprehensive benefit package based on what is needed to keep a child healthy compared to an employer-based plan in which covered services are based on what an employer can afford. Third, there are no out-of-pocket expenses for Medicaid-covered services for children. And fourth, health care coverage expectations for Medicaid enrollees could be lower than people with private insurance. These results were similar to findings from a study conducted with Iowa Medicaid enrollees where Medicaid coverage for children was rated higher than private insurance on factors including ability to meet their child’s health care needs, and types of services covered.

The association between insurance coverage and the child’s health status were different from findings in some other national studies.9 Uninsured children in Iowa were rated in better overall health and less likely to be defined as having a special health care need than those with private insurance or with Medicaid coverage. Uninsured children were also less likely to have needed health care in the previous year. Access barriers associated with not having health insurance were apparent, however, with uninsured children being most likely to report unmet need for medical care and problems getting prescription drugs.

Although uninsured children and children who had been uninsured in the previous year are both at higher risk of having problems accessing care, these two groups appeared very different. The significantly lower health status (and associated higher health care costs) of the children who were uninsured during the year may have created a more urgent incentive for parents to seek out insurance coverage for their children. The higher unmet need for care among uninsured children may indicate that not all parents are able to seek out insurance during times of need. Children who obtained health insurance during the year were twice as likely to transition to private insurance than to Medicaid.

Oral health is often considered separately from medical health and thus dental insurance is often provided separately from medical insurance. Children were four times more likely to be without dental insurance than medical insurance. The Medicaid program includes comprehensive medical and dental benefits for children, however, Medicaid’s comprehensive list of covered services did not correlate with better access to care. Medicaid enrollees had the highest unmet need for dental services. Many studies have identified low dentist participation in Medicaid as one of the key reasons for the higher unmet need for care.