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Trends in health insurance type have changed over the past decade for low- and middle-income US
families: private coverage and uninsurance have decreased, while discordance between parent and
child coverage has increased.
STABLE HEALTH INSURANCE leads to better access to health care services and improved
health outcomes.14
Over the past decades, political and economic changes have affected access to and affordability of
coverage for families in the United Statesnotably, private health insurance costs have seen steep
increases. Though some families obtained coverage for their children through expansions in the
Childrens Health Insurance Program (CHIP), few public coverage options existed for adults (aged
1964 years) before 2014.5,6
Parental coverage status has an independent effect on childrens health insurance and access to
care, regardless of the childs coverage status.79 Previous research
utilizing a natural experiment that randomized adults to coverage found a causal link between parent
and child health insurance status.10 Thus, it is important to consider trends in childrens health
insurance coverage in conjunc- tion with trends affecting parents. Most past studies of health
insurance have focused on adults or children sepa- rately; those that considered both children and
parents did not assess type of coverage.714 To address this gap in the literature, we examined
full-year patterns of family health insurance coverage type among US children and their parents for
1998 through 2011, stratified by income.
METHODS
DATA SOURCE AND STUDY POPULATION
We analyzed data from 1998 through 2011 of the Med- ical Expenditure Panel SurveyHousehold
Component (MEPS-HC).15 MEPS-HC respondents are interviewed 5 times over a 2-year period,
with an overlapping panel design; annual public use files contain data from a single year for 2
consecutive panels. Each year of data constitutes
ACADEMIC PEDIATRICS
2 DEVOE ET AL
ACADEMIC PEDIATRICS
a nationally representative sample. Details about the
MEPS-HC are available elsewhere.15,16
The study population included children aged 0 to 17 years, with responses to at least 1 full year of
the survey (n 126,093). We linked each child with a parent or parents in the same household to
construct childparent pairs. We excluded children for whom no identifiable parent records could be
linked (n 4048), and for whom insurance infor- mation for the child or parent was not available for
the full year (n 1524). Our final sample size was 120,521 children, weighted to represent a yearly
average of approximately 70 million children in the civilian, noninstitutionalized US pop- ulation.
ANALYSIS
All analyses were stratified by family income categories. We do not report results from high-income
families because the majority (88%) had private insurance for both child and parent, and all
categories had either no sta- tistically significant changes or too few subjects to assess changes (n <
30). We used sampling stratification vari- ables, design weights, and a robust variance estimator in
accordance with MEPS guidelines to account for the com- plex sample design of the survey. This
accounts for both the intracluster correlation of children within families and in- traperson correlation
across years.22
We examined the following demographic characteristics for the entire study period as one pooled
sample and report the weighted percentage of each characteristic: age (child categories 04, 59,
1013, 1417 years; parent categories #24, 2544, $45 years), child race/ethnicity (non-Hispanic
white, non-Hispanic nonwhite, Hispanic), region (North, Midwest, South, West), parental education
(<12 years or $12 years), family composition (1 parent or 2 parents), parental employment
(currently employed or unemployed), and childs perceived health status (excel- lent/very good or
good/fair/poor). We conducted descrip- tive analyses of the prevalence of all 9 possible patterns of
coverage type for children paired with a parent or parents, as well as concordant versus
discordant insurance coverage. We assessed differences in the distribution of childparent health
insurance type between 1998 and
2011 with chi-square tests of association using SUDAAN
11.0.1 (Research Triangle Institute, Research Triangle
Park, NC).
We used joinpoint regression (sometimes called piece- wise regression or segmented regression) to
determine if and when coverage patterns showed significant changes throughout the entire study
period (Joinpoint Regression Software 4.0.4, May 2013; Statistical Methodology and Applications
Branch, Surveillance Research Program, National Cancer Institute).23 Joinpoint regression is often
used for 2 simultaneous goals: to identify statistically sig- nificant changes in trend over time (in
direction or rate of decrease or increase) and to quantify that change through an annual percentage
of change statistic. This approach has been used to assess temporal trends in health insurance and
other health care outcomes.2426 The null hypothesis in this analysis was no change in trend, and the
alternative hypothesis was a significant increase or decrease in the prevalence of each health
insurance coverage pattern. The minimum number of joinpoints allowed was 0 (ie, a straight line
over time), indicating no change in child and parent health insurance coverage patterns over time.
The maximum number of joinpoints was set at 2 on the basis of an algorithm taking into account
the number of time points available,23 with one exception: the child
ACADEMIC PEDIATRICS FAMILY
HEALTH INSURANCE TRENDS, 19982011 3
public/parent private, middle-income group was limited to only 1 joinpoint as a result of small cell
sizes (n < 30) in the years 1998 to 2000 and thus had fewer time points avail- able. A Monte Carlo
permutation method was used to select the model with the best fit, and yearly percentage point
changes were calculated for each segment. Statisti- cally significant changes were those that
increased or decreased over time and were significantly different than an annual percentage change
of 0 (no change over time).
To account for potential differences between child and parent health insurance types in our analysis
of change patterns over time, we used trend segments identified in joinpoint regression analyses
with multinomial logistic regression to allow inclusion of potential confounders. In these models,
the child and parent combined health insur- ance type was the outcome variable (9 categories) and
year was the primary independent variable. For the low-income models, all 9 categories were included
in the outcome var- iable; however, for the middle-income models, the child private/parent public and
child uninsured/parent public cat- egories were excluded as a result of small and/or zero cells (n < 30).
We adjusted for all demographic characteristics examined, as they are known to influence health
insurance
coverage.7,2729 Marginal effects for year were calculated
for each model and are represented as an adjusted yearly percentage point change. Multinomial
logistic regression models were conducted and marginal effects were calculated using STATA 11.2
IC (StataCorp, College Station, Tex).
Throughout this article, we do not report estimates based on sample sizes of fewer than 30 because
estimates based on such sample sizes are not reliable. A P value of <.05 was considered statistically
significant. Our institutional review board deemed the study exempt.
RESULTS
Children from this sample of low- and middle-income families in the United States predominantly
lived in the South, had excellent or very good health status, were non-Hispanic white, had
parents with $12 years of educa- tion, had employed parents, and had 2 parents living in the
household. Children and parents from low-income families tended to be younger than those from
middle-income fam- ilies (Table 1).
Among children from low- and middle-income families, the prevalence of full-year childparent
health insurance type changed significantly between 1998 and 2011 for several groups including the
following (child type/parent type): private/private; public/private, public/public, pub- lic/uninsured,
uninsured/private, and uninsured/uninsured (Table 2).
TRENDS IN UNINSURANCE
The prevalence of low-income childparent pairs with both child and parent uninsured showed
a decrease overall from 26.3% in 1998 to 14.8% in 2011, the yearly unadjusted percentage point
decrease was 0.81 (95% CI, 1.05, 0.58). Middle-income uninsured pairs also saw a decrease
from 13.2% in 1998 to 8.7% in 2011; from 1998 to 2004, there was a yearly unadjusted
percentage point decrease of 0.58 (95% CI, 1.01,
0.15) and from 2007 to 2011, the yearly percentage point decrease was 1.36 (95% CI, 2.19,
0.54).
DISCUSSION
Type of health insurance coverage patterns changed significantly for low- and middle-income US
children and their parents from 1998 to 2011. Families saw significant decreases in the percentage of
childparent pairs with full- year, private health insurance and pairs without coverage. This coincided
with a significant increase in the percentage of families with discordant coverage. Specifically, we found
an increase in publicly insured children with uninsured par- ents, suggesting that when families lost
private coverage, they were able to obtain public health insurance for their children only. Decreases in
private coverage, concurrent with increases in public coverage could be due to what is termed crowd
outthe movement of privately insured indi- viduals to public insurance.30 Reports of crowd out have
been mixed. For example, one study found that for every
100 children who became eligible for public insurance,
4 DEVOE ET AL ACADEMIC PEDIATRICS
Table 2. Percentage of Child and Parent Full-Year Health Insurance Type by Family Income,
1998 Versus 2011
Low Income (n 65,496) Middle
Income (n 33,246)
Full-Year Health 1998 Weighted 2011 Weighted 1998 Weighted 2011
Insurance
Child Type type
type/parent % % % Weighted %
Private/private 29. 19. 74. 66.3*
Private/public 2*
. 1*
. 5*
. .
Private/uninsured
2.
2.
2.
1.
Public/private 0
3.4 4
8.2 4
2.9 9
4.
Public/public *
21. *
24.
3.0 3
6.2*
Public/uninsured 3
10. 0
27. *
1.4 6.7*
Uninsured/private 4*
4.7 2*
2.5 4.* 5.
Uninsured/public 2.* 1.* .3 4
.
Uninsured/uninsured 1
26. 3
14.
13.
8.7*
Child/parent insurance 3* 8* 2*
concordancek
Concordant 76. 57. 90. 81.2*
Discordant 23. 42. 9.3 18.8*
8*
2* 9*
1* 7**
*P value (P < .05) considered statistically significant, calculated by chi-square tests,
comparing rates in 1998 vs 2011.
Data source: Medical Expenditure Panel SurveyHousehold Component survey. Column
percentages are approximately 100% (rounded to nearest tenth of a percent). Low income,
<200% federal poverty level (FPL); middle income, 200% to <400% FPL. The FPL for a family
of four in 2011 was $22,350.
Estimates not reported due to small cell sizes (n < 30).
Cell sizes for years 1998 to 2000 were <30; this value is from the year 2001.
kConcordant indicates child private/parent private; child public/parent public; child
uninsured/parent uninsured; discordant, child private/ parent public; child private/parent
uninsured; child public/parent private; child public/parent uninsured; child uninsured/parent
private; child uninsured/parent public.
income families to help pay for marketplace premiums, cost is still reported to be a barrier to
coverage.41
The unknown future of CHIP is cause for concern for low- and middle- income families.42
Without CHIP, millions of children may become uninsured through the family glitch (ie, adults
would not quality for ACA sub- sidies because they have the income to afford coverage for
themselves, even if they cannot afford the cost of
ACADEMIC PEDIATRICS FAMILY HEALTH INSURANCE TRENDS, 19982011 5
the premium for the family).43,44 This study uncovered a disturbing historical trend in families
insurance coverage: as children gained coverage, parents lost coverage at an alarming rate. Thus, as
changes in health insurance options and eligibility continue to occur, it will remain important to
monitor the stability of family coverage. In addition to demonstrating novel methods for this
continued evaluation of family coverage patterns, we
Figure 1. Trends in child and parent full-year health insurance type, low income. Symbols
represent actual percentage, while lines represent the trend per joinpoint regression. Change
in trend is identified through joinpoint regression (P < .05). Low income, <200% federal
poverty level (FPL). FPL in 2011 was $22,350. Source: Medical Expenditure Panel Survey,
19982011.
6 DEVOE ET AL ACADEMIC PEDIATRICS
Figure 2. Trends in child and parent full-year health insurance type, middle income. Symbols
represent actual percentage, while lines repre- sent the trend per joinpoint regression.
Change in trend is identified through joinpoint regression (P < .05). Middle income, 200% to
400% federal poverty level (FPL). FPL in 2011 was $22,350. Source: Medical Expenditure
Panel Survey, 19982011.
Table 3. Unadjusted and Adjusted Yearly Percentage Point Change in Child and Parent
Health Insurance Type by Family Income,
19982011
also demonstrate how joinpoint analyses can be used in future analyses for researchers to track
longitudinal changes in the slope and direction of trends in health insurance coverage.
LIMITATIONS
Our analyses were limited by existing MEPS-HC vari- ables. As with all self-reported data,
response bias remains a possibility. However, the MEPS-HC asks several ques- tions about health
insurance status and type at various time points, and survey staff logically edit responses for
consistency across variables. The MEPS is a nationally representative data set that does not
account for state- level differences stemming from individual state policies, which differentially
expanded and contracted public health insurance programs during the study time period.
CONCLUSIONS
From 1998 to 2011, low- and middle-income US fam- ilies experienced a decrease in the
percentage of child parent pairs with private health insurance and pairs without insurance.
Concurrently, there was a rise in discordant coverage patterns, mainly publicly insured children with
uninsured parents.
ACKNOWLEDGMENTS
This study was financially supported by the Agency for Healthcare Research and Quality (AHRQ)
(grant 1 R01 HS018569), Patient-Centered Outcomes Research Institute (Health Systems Cycle I,
2012), the National Cancer Institute of the National Institutes of Health (grant 1 R01
CA181452 01), the Oregon Health & Science University Department of
Family Medicine, and the Ohio State University Department of Family Medicine. The funding
agencies had no involvement in the design and conduct of the study; analysis, and interpretation of the
data; and prepara- tion, review, or approval of the manuscript. AHRQ collects and manages the
MEPS.
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