Ability to obtain health care : does family coverage matter?

192 Pages·1999·7.2 MB·English

by  Giovannini, Terence Anthony

AbilitytoObtainHealthCare-DoesFamilyCoverageMatter?
by
TerenceAnthonyGiovannini
Dissertation
submittedtotheSchoolofHygieneandPubUcHeahh
oftheJohnsHopkinsUniversityinconformitywiththe
therequirementsforthedegreeof
DoctorofPhilosophy
Baltimore,Maryland
1999
ABSTRACT
Recentstateinitiativestoinsurelow-incomechildren,suchastheStateChildren's
HealthInsuranceProgram(S-CHIP),havedonelittletoassurecoverageforuninsured,
non-pregnantadultfamilymembers.Childandfamilyadvocateshavearguedwithlittle
empiricalevidencethatextendinginsurancecoveragetoallfamilymemberswouldnot
onlyimproveadults'abilitytoobtaintimelyhealthcarebuttheirchildren'saswell.The
mainpurposeofthisstudywastoexaminetherelationshipoffamilyhealthinsurance
coveragewithabilitytoobtainhealthcareforindividuals,particularlychildren.
ThisstudyuseddatafromthefirstthreeroundsofthelongitudinalKaiserSurvey
ofFamilyHealthExperiences(K-SOFHE)conductedfromOctober1995through
January1998.hi1995-96,nearlyone-quarterofinsuredpersonsinfamilieswith
uninsuredfamilymembershadmaintainedarelationshipwiththeirusualsourceofcare
forlessthanoneyearcomparedwithonly13percentofinsuredpersonsinentirely
insuredfamilies.Forallinsuredchildren,justoverthreepercentwithprivatelyinsured
mothers,7.6percentwithmothersinMedicaid,and12.2percentwithuninsuredmothers
experienceddelayingettingcareordidnotobtainneededhealthcareatall.Ofinsured
childrenwhosemothershadlosthealthinsurancecoverageinRounds2or3,justover
eightpercentexperienceddifficultyinobtainingneededhealthcarepriortothelossof
coverage.Afterthemotherlostinsurance,however,theproportionofthesechildrenwho
experienceddifficultyinobtaininghealthcareroseto14.7percent,despitethechildren
havingretainedinsurancecoveragethemselves.Amongchildrenwhosemothersretained
healthinsurance,theproportionthatexperienceddifficultyinobtainingcareactually
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declinedfrom3.9percentto2.7percentduringthesameperiod.Differencesbetween
childrenwhosemotherslostinsuranceandthosewhosemothersdidnothadgrownfrom
anon-significantdifferencebeforethemother'slossofinsuranceto12.0percentafterthe
loss(p<.001).
Policiesthatextendhealthinsurancetosomefamilymemberswhileleaving
othersuninsuredmighthavetheinadvertentconsequenceofdiminishingthepotential
effectonabiUtytoobtaintimelyhealthcarefortargetedindividuals.
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ACKNOWLEDGMENTS
Thisdissertationsimplywouldnothavebeenpossibleifwerenotforthe
generousfinancialsupportoftheU.S.HealthCareFinancingAdministrationandthe
unwaveringmoralsupportofmanyverygenerousandlovingpeople.Firstandforemost,
Imustrecognizethesacrificethatmywife,MonicaTeran,hasselflesslyendured
throughoutthisthree-yearprocess;shehasearnedherspotinheavenmanytimesover.
Yonosoypoeta,peroreconozcoelamorverdaderoyloveoenti.Enpocotiempolos
doshemosvistocasiunmundoenteroyenelcaminojvmtoshemoscrecidosiempre
respetandonosydejandoqueelotrosigasupropriosendero.Tedebotantomiamor,y
esperoconmuchasganasvivirelrestodemisdiasjuntoati.Simplementeteadoro.
Ialsogreatlyappreciatetheguidanceandsoundadvicefi-omdedicatedfacultyat
theJohnsHopkinsUniversity.Dr.BarbaraStarfield,myadvisor,believedinme.Her
confidenceinmyabilitytogetthejobdonegavemestrengthandherlatitudespurredmy
creativity.Igreatlyappreciateherconstantaccessibilityirrespectiveofwhereshemight
bephysicallyandhervelocityinprovidingconstructivecriticism.Iamalsoindebtedto
Dr.JudithKasperforthemanyopportunitiesshehasprovidedtomeoverthepastyear.I
canonlyhopeonedaytorepayherkindness,generosity,andsincereconcernformy
welfare.IthasalsobeenanabsolutepleasuretoworkwithDr.JonathanWeinerduring
mytenureatHopkins.Iamstilltryingtofigureouthowmy'biggeststrength'can
simultaneouslybemy'biggestweakness',buthiswordsofwisdomandknackfor
remindingmeofmyownlimitationshavehelpedmetosetrealistic,accomplishable
goals.ThisdocimientisproofThankyou.
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TABLEOFCONTENTS
ABSTRACT
ii
ACKNOWLEDGEMENTS iv
TABLEOFCONTENTS v
LISTOFFIGURESANDTABLES vii
CHAPTERLINTRODUCTION 1
SpecificAims 4
CHAPTER2.LITERATUREREVIEW 8
TheRoleofFamilyinChildren'sAccesstoCare 8
HealthInsuranceCoverageandAbilitytoObtainHealthServices 9
RegularSourceofCareandAbilitytoObtainHealthServices 14
SociodemographicFactorsAssociatedwithHealth-CareSeeking 19
CHAPTER3.CONCEPTUALMODEL 23
Illustration:LatinoFamilieswithChildren 28
CHAPTER4:METHODSANDBACKGROUNDANALYSES 37
SourceofDataandStudyPopulation 37
StudySample 41
Measurement 61
ApproachtoAnalysis 63
CrossSectionalAnalyses 63
LongitudinalAnalysis 82
V
CHAPTER5.MANUSCRIPT1 87
Abstract 88
Introduction 89
DataandMethods 90
Results 91
DiscussionandPolicyImplications 95
Notes 98
CHAPTER6.MANUSCRIPT2 104
Abstract 105
Introduction 106
DataandMethods 108
Results 115
Discussion 118
CHAPTER7.SUMMARYANDDISCUSSION 130
Overview 130
SummaryofSignificantFindings 131
PolicyImplications 134
StudyLimitations 135
DirectionsforFutureResearch 138
APPENDIXA:REVIEWOFSELECTEDSTUDIESON
LONGITUDINALITY 140
REFERENCES 149
CURRICULUMVITAE 172
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LISTOFFIGURESANDTABLES
FIGURE1: TrendsinHealthCoverageforChildren,1987-1996 11
FIGURE2: FamiliesExperiencingBarrierstoMedicalCareby
TypeofFamilyCoverage 14
FIGURE3: PercentofChildrenwithoutARegularSourceof
CarebyInsuranceStatus,1996 16
FIGURE4: ConceptualFrameworkofFamilyAccessto
HealthCare 27
FIGURE5: DecisionTreeforSelectingAdultCaretakers 45
FIGURE6: ChangeinCaretakerHealthInsuranceType
forAllChildren 84
FIGURE7: LongitudinalAnalysisofLossinCaretaker
HealthInsurance 86
FIGURE8: HealthInsuranceCoverageinAmerican
Families,1995 100
TABLE1: UnweightedSociodemographicProfileofK-SOFHE
BaselineSample,1995-96 39
TABLE2: UnweightedHealthCareProfdeofK-SOFHE
BaselineSample,1995-96 40
TABLE3: PanelRetentionbyInsuranceType 40
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TABLE4: RetentionandParticipationofChildreninthe
K-SOFHE,1995-98 41
TABLE5: PanelAttritionandParticipationfor
Children,1995-98 42
TABLE6: ExamplesofCaretakerIdentificationby
DecisionTree 49
TABLE7: UnweightedComparisonofChildrenwithMale
andFemaleCaretakersatBaseline,1995-96 51
TABLE8: UnweightedComparisonofChildrenwithMale
andFemaleCaretakersatBaseline,1995-96 53
TABLE9: UnweightedComparisonofIn-ScopeChildrenLostto
Follow-upwithChildrenWhoRemainedinRound2on
SociodemographicMeasuresatBaseline,1995-97 55
TABLE10: UnweightedComparisonofIn-ScopeChildrenLost
toFollow-upwithChildrenWhoRemainedinRound2
onAccessMeasuresatBaseline,1995-97 57
TABLE11: UnweightedComparisonofIn-ScopeChildrenLostto
Follow-upwithChildrenWhoRemainedinRound3on
SociodemographicMeasuresatBaseline,1995-98 59
TABLE12: UnweightedComparisonofIn-ScopeChildrenLostto
Follow-upwithChildrenWhoRemainedinRound3on
AccessMeasuresatBaseline,1995-98 60
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TABLE13: SociodemographicCharacteristicsoftheU.S.
Population,1995-96,N=l,331 65
TABLE14: AccessProfileofU.S.Population,1995-96,N=l,331 68
TABLE15: SociodemographicCharacteristicsofChild-Caretaker
DyadsbyInsuranceStatus,1995-96 71
TABLE16: AccessProfileofChild-CaretakerDyadsby
InsuranceStatus,1995-96 73
TABLE17: SpearmanrCorrelations,1995-96 77
TABLE18: AdjustedOddsRatioofExperiencingDifficultyin
ObtainingCareforInsuredChildrenbyCaretaker
InsuranceStatusandControlVariables,1995-96 78
TABLE19: AdjustedOddsRatioofExperiencingDifficultyin
ObtainingCareforInsuredChildrenbyCaretaker
InsuranceStatus,Model2,1995-96 79
TABLE20: CaretakerInsuranceStatusandDifficultyinObtaining
HealthCareforChildrenbyFamilyPovertyStatus
forInsuredandAllChildren,1995-96 80
TABLE21: WeightedPercentofFamilyPovertyStatusbyChild
HealthStatusforAllChildren,1995-96 80
TABLE22: CaretakerInsuranceStatusandDifficultyinObtaining
HealthCareforChildrenbyChildHealthStatusfor
InsuredandAllChildren,1995-96 81
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TABLE23: ChangeinChildren'sInsuranceStatusbyChangein
Caretakers'InsuranceStatusforChildrenRepresented
inRl,R2,andR3,1995-98 85
TABLE24: FamilyType,Income,andWorkStatusbyPatterns
ofFamilyHealthCoverage,1995 101
TABLE25: ViewsaboutHealthCarebyPatternsofFamily
HealthCoverage,1995 102
TABLE26: AccessProfileforInsuredandUninsuredIndividuals
byFamily-LevelCoverage 103
TABLE27: PanelAttritionandParticipationforChildren,
K-SOFHE,1995-96 124
TABLE28: HealthInsuranceCoverageofChildrenbyMaternal
InsuranceCoverageatRound1,1995-96 125
TABLE29: MaternalInsuranceCoverageforChildreninMedicaid
bySociodemographicCharacteristicsatRound1 126
TABLE30: MaternalInsuranceTypeforInsuredChildrenby
ChildAccessIndicatorsatRound1,1995-96 127
TABLE31: AdjustedOddsRatioofExperiencingDifficulty
ObtainingCareforInsuredChildrenbyMaternal
InsuranceStatus,N=1074,1995-96 128
TABLE32: Pre-PostTestComparisonofMaternalInsuranceon
AbilitytoObtainCareforChildren,1995-98 129
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