文章基本信息

标题：Longitudinal Patterns of Health Insurance Coverage Among a National Sample of Children in the Child Welfare System
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作者：Ramesh Raghavan ; Gregory A. Aarons ; Scott C. Roesch 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2008
卷号：98
期号：3
页码：478-484
DOI：10.2105/AJPH.2007.117408
语种：English
出版社：American Public Health Association
摘要：Objectives. We sought to describe health insurance coverage over time among a national sample of children who came into contact with child welfare or child protective services agencies. Methods. We used data from 4 waves of the National Survey of Child and Adolescent Well-Being to examine insurance coverage among 2501 youths. Longitudinal insurance trajectories were identified using latent class analyses, a technique used to classify individuals into groupings of observed variables, and survey-weighted logistic regression was used to identify variables associated with class membership. Results. We identified 2 latent insurance classes—1 contained children who gained health insurance, and the other contained children who stably maintained coverage over time. History of sexual abuse, and race/ethnicity other than White, Black, and Hispanic, were associated with membership in the “gainer” class. Foster care placement and poorer health status were associated with membership in the “maintainer” class. Caregiver characteristics were not associated with class membership. Conclusions. The majority of children in child welfare had stable health insurance coverage over time. Given this vulnerable population’s dependence upon Medicaid, protection of existing entitlements to Medicaid is essential to preserve their stable insurance coverage. Coverage for children in the child welfare or child protective services system (hereafter termed child welfare ) under a health insurance umbrella has been a policy priority for several decades, 1 yet relatively little attention has been paid to the stability over time of this insurance coverage. Stable health insurance is critical for these children, who are a highly vulnerable population with considerable physical 2 ^– 5 and mental health needs. 5 ^– 8 Currently, there is no information on the extent to which children in child welfare experience stability of health insurance coverage over time. Children in the child welfare system are dependent upon Medicaid to finance their health needs 9 and possess an entitlement to Medicaid based largely upon their residential status or placement. Federal regulations ensure that children who are placed into foster care have categorical eligibility for Medicaid, 10 and reportedly 99% of all children in foster care are covered under the program. 11 Children maintained within their own homes (in-home) have a Medicaid coverage rate of around 84%. Because there is no categorical entitlement to Medicaid for these children, most of them are covered by income-eligibility rules, or by other local and state regulations. 12 But because entitlement to Medicaid is dependent upon the child’s placement status (in-home or in foster care), and because 95% of these children experience changes in placement even as they remain within child welfare, 13 it has been suggested that such placement instability can produce instability in Medicaid coverage. 14 Somewhat paradoxically for these children, certain types of service utilization can produce insurance loss. In all jurisdictions, youths open to services through child welfare agencies who are then detained or committed to juvenile justice settings face disenrollment from Medicaid because federal law prohibits use of Medicaid funds to serve incarcerated individuals. 15 ^, 16 The extent to which these youths are successful in re-establishing Medicaid coverage after their release from detention is presently unknown. Funding reductions in the Medicaid program 17 and several of the provisions of the Deficit Reduction Act of 2005 18 can also place children in child welfare at increased risk for disenrollment from Medicaid. Finally, children in child welfare who have families that receive cash assistance (through Temporary Assistance for Needy Families or food stamps) are at particular risk for Medicaid disenrollment when their families stop receiving these benefits. 19 ^, 20 Despite the fact that the link between receipt of welfare benefits and Medicaid eligibility was broken in 1997, the existence of administrative data systems that continue to link individuals who receive all forms of public assistance accounts for such insurance loss. The cumulative effect of these Medicaid and welfare policies is to place children in child welfare at particular risk for insurance instability, the magnitude of which is currently unknown among this population. Data on Medicaid-enrolled children suggest that 13% to 68% have discontinuous insurance coverage in any given year 21 ; approximately 23% of children aged younger than 17 years experience spells of being insured during a 2-year period. 22 Longitudinal surveys reveal that 42% of all children spend some time without insurance and 68% of children below 200% of the federal poverty level spend more than 1 year without insurance. 23 Insurance instability disproportionately affects children, those from low-income families, minorities, and women leaving welfare programs, 24 groups from which many children enter child welfare. Its consequences can be serious—children with discontinuous insurance have higher rates of delayed care, unmet medical needs, and unfilled prescriptions compared with children with uninterrupted private insurance. 25 Such consequences are particularly devastating for children in the child welfare system who have very high needs for physical and mental health services. In an attempt to understand trajectories of insurance coverage possessed by children in the child welfare system, we analyzed nationally representative data on children who came into contact with child welfare agencies and who were then followed for 3 years. We identified child-level (sociodemographic characteristics, maltreatment history, placement, and need) and caregiver-level (education and employment status) variables that may place children at greater risk of insurance instability, to provide child welfare and Medicaid policymakers with information directed toward safeguarding health insurance and, thereby, access to services for this high-need population.