insurance coverage and access to care for …...insurance coverage and access to care for immigrant...

Insurance Coverage and Access to Care for Immigrant Children: The Impact of the Children’s Health Insurance Program Reauthorization Act

By Neel Koyawala August 15, 2013 Mentor: Brendan Saloner, PhD

Roadmap • Background

• Methods

• Results

• Conclusions and policy implications

• “SUMR” insights

Background Methods Results Conclusion “SUMR” Insights

Federal welfare reform law in 1996 restricted immigrants from public insurance during their first five years in the United States.

Immigrant children have lower access to health care than non-immigrant children.



“INSURANCE FOR IMMIGRANTS,

TOO!”

Along with immigration reform, advocates have pushed for elimination of the five-year wait period.


In 2009, gave states the option to eliminate the five-year minimum wait period.

CHIPRA

• National Survey of Children’s Health (NSCH), a nationally-representative household survey • 2003, 2007, and 2011/2012 data were used • Telephone-based survey by the CDC

• Sample: 240,110 children in households below 400% FPL • Categorized sample into six categories:


We examined health care coverage and access using cross-sectional data.

First Generation in a State that Eliminated Five-Year Wait Period

Second Generation in a State that

Eliminated Five-Year Wait Period

Third Generation in a State that Eliminated Five-Year Wait Period

First Generation in a State that Did Not Eliminate Five-Year

Wait Period

Second Generation in a State that Did Not Eliminate Five-Year

Wait Period

Third Generation in a State that Did Not Eliminate the Five-Year Wait Period

First Generation in a State that Eliminated Five-Year Wait Period

We looked at both insurance coverage and health care access measures.

Insurance Coverage Variables:

• Any insurance • Public or private Insurance • Coverage gap in the past twelve

months

Our final model adjust for: • Demographic variables: race, income, sex, age, family structure,

living in MSA, parental education, employment, number of kids in household, general health status

• State variables: minimum wage, unemployment rate

Access to Health Care Variables:

• Personal doctor or nurse • Usual source of care • Preventive medical / dental

visits • Specialist care • Unmet or delayed health care

needs



We compared trends over time for immigrant children in the two state categories using a “Difference-in-Differences” approach.

53 52

73

45 46

51

40

45

50

55

60

65

70

75

80

85

2003 2007 2011

% V

aria

ble

of In

tere

st

State implementedpolicyState did not implementpolicy

22%

6%

Difference-in-Differences:

16%

Policy

*P<.05, **P<.001, ***P<.0001


Insurance rates increased for immigrant children in states that eliminated the five-year wait period.

58 57

78

55 51

51

40

45

50

55

60

65

70

75

80

85

2003 2007 2011

% In

sure

d

Immigrants in statesthat eliminated five-year waitImmigrants in statesthat did not eliminatefive-year wait

27%

6%


21%

CHIPRA

*P<.05, **P<.001, ***P<.0001

***


Most of the increase in insurance rates was from an increase in public insurance.

30 30

51

20

13

19

0

10

20

30

40

50

60

2003 2007 2011

% C

HIP

/ M

edic

aid


32%

17%


15%

CHIPRA

*P<.05, **P<.001, ***P<.0001

**


There was no statistically significant change in private insurance rates.

26 26 26

34

37

30

0

5

10

15

20

25

30

35

40

2003 2007 2011

% P

rivat

e in

sura

nce


4% 11%


7%

CHIPRA

*P<.05, **P<.001, ***P<.0001


Gaps in insurance coverage in the past 12 months decreased significantly for immigrant children in states implementing the policy.

51 53

33

52 52 54

0

10

20

30

40

50

60

2003 2007 2011

% In

sura

nce

cove

rage

gap

s


-21%

1% Difference-in-Differences:

-22%

CHIPRA

*P<.05, **P<.001, ***P<.0001

***


Having a personal doctor or nurse in the past 12 months significantly increased for immigrant children in policy-implementing states.

51

69 77

50

65 61

0

10

20

30

40

50

60

70

80

90

2003 2007 2011

% P

erso

nal d

octo

r or n

urse


16% 4%


12%

CHIPRA

*P<.05, **P<.001, ***P<.0001

*


Preventive dental visits increased for immigrant children in policy-implementing states.

58

73

54

59

0

10

20

30

40

50

60

70

80

2003 2007 2011

% P

erso

nal d

octo

r or n

urse


13%

4%


10%

CHIPRA

*P<.05, **P<.001, ***P<.0001

*


Having any unmet or delayed health care need in the past 12 months decreased for immigrant children in policy-implementing states.

11

8

5

14

0

2

4

6

8

10

12

14

16

2003 2007 2011

% U

nmet

hea

lth ca

re n

eed


-6%

6%


-12%

CHIPRA

*P<.05, **P<.001, ***P<.0001

**


-30% -20% -10% 0% 10% 20% 30% 40%

InsuredMedicaid

PrivateCoverage Gap

Personal doctor or nurseUsual Source of Care

Preventive medical visitPreventive dental visit

Received specialist careProblems receiving specialist care

Taking prescription drugsAny unmet health need

Unmet medical needUnmet dental need

Change from 2003 Change from 2007

Impact Estimates for the Effect of Eliminating the Waiting Period on Coverage and Access Among Immigrant Children.

*P<.05, **P<.001, ***P<.0001

* ***

* **

** ***

*

* *


Predicted probabilities for an immigrant child in 2011.


Predicted probabilities for a child in each generation category in 2011.

• Health insurance can have impact in a short amount of time. • Future studies should look at other health care access and

quality measures for immigrant children over a longer period. • Limitations

• Survey bias • Unable to assess legal status or duration in the United States • Variation in state implementation


Main Conclusion: Immigrant children in the 24 states that eliminated the five-year wait period had a 20 percentage point increase in health insurance rates, and improvement on some health care access measures.

“INSURANCE FOR IMMIGRANTS,

TOO!”

Along with immigration reform, advocates have pushed for elimination of the five-year wait period.


“SUMR” Insights • The importance of good mentorship: Brendan is the best • The usefulness of collaboration in research • Mistakes happen: creating systems to catch human error is key • Public data, an undergrad’s best friend • SAS • Other Thank You’s:

• Joanne Levy • Shanae and Safa • Hoag and Megan

• SUMR scholars ‘13


Thank You. Questions?

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