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PubMed2000

The relationship of HMOs, health insurance, and delivery systems to breast cancer outcomes.

BACKGROUND: The current climate of anger and frustration with managed care has heightened interest in the quality of health care provided by managed-care plans, particularly health maintenance organizations (HMOs). This breast cancer outcomes study, investigating relationships of health insurance and delivery systems to stage at diagnosis, treatment selected, and survival, is based in a heavily penetrated, highly competitive HMO market. METHODS: Data for 1,788 residents of northern California younger than 65 years of age at diagnosis (1987-1993) were provided by a population-based cancer registry. Patient insurance included fee-for-service (FFS), group-model HMO, nongroup HMO, publicly insured, and uninsured. Diagnosis and treatment occurred in 73 hospitals (large, medium/moderately small, or very small community, rural, teaching, or HMO-owned hospitals). Regression models examined relationships of insurance and hospital type to 3 outcomes (stage, treatment, and survival), controlling for age, ethnicity, education, neighborhood occupational class, and time period. RESULTS: Early diagnosis was as likely for group-model and nongroup-model HMO-insured patients as for the private FFS-insured patients. In 1987-1990, HMO-owned hospitals were leaders in treating 46% of early-stage breast cancers with breast-conserving surgery plus radiation (BCS+); by 1991-1993, the most significant increases in BCS+ use occurred at teaching and large community hospitals. Survival of group-model HMO, nongroup-model HMO, and FFS patients was not significantly different. Publicly insured/uninsured patients had more stage III/IV disease (OR=2.01, P = 0.006) and greater all-cause mortality (risk ratio 1.46, P = 0.015). CONCLUSIONS: Group-model and nongroup-model HMO patients are similar to FFS-insured patients in stage at diagnosis and survival outcomes. Treatment selection is related to hospital type rather than insurance coverage.

Breast Neoplasms↗
PubMed1997

Insurance type and satisfaction with medical care among HIV-infected men.

Patient satisfaction is a valuable indicator of the quality of medical care. We assessed the impact of type of health insurance on satisfaction with seven aspects of medical care among 593 HIV-infected men without AIDS, drawn from three sites in San Francisco, California and Denver, Colorado. After adjustment for site of medical care, patient age, race, income, education, and CD4 lymphocyte count, there were few differences in satisfaction between men with fee-for-service and those with managed care insurance. Men with fee-for-service insurance were significantly more satisfied with their interpersonal relations with their clinicians (p = 0.01) but less satisfied with their finances (p = 0.0001) than persons with managed care. Uninsured men were significantly less satisfied with several aspects of care than insured persons. There were no significant differences in satisfaction between men with managed care and those with public insurance. HIV-infected persons who have a choice of insurance should carefully weigh their options, recognizing the implicit trade-offs between types of insurance. Those who choose fee-for-service insurance can expect to be more satisfied with interpersonal relations with their medical providers but less satisfied with financial aspects of their plans. Efforts to address the low satisfaction of uninsured persons are needed.

Adult↗
PubMed2004

The insurance effect on prescription drug expenditures among the elderly: findings from the 1997 Medical Expenditure Panel Survey.

BACKGROUND: Despite continuing debate over a prescription drug benefit for the Medicare program, there has been relatively little research estimating the potential cost of providing such a benefit. OBJECTIVE: The objective of this study was to estimate the effect of prescription drug insurance on outpatient prescription drug expenditures among the elderly. RESEARCH DESIGN: We studied respondents aged > or =65 years to the 1997 Medical Expenditure Panel Survey, a representative survey of the U.S. noninstitutionalized population. Survey-weighted linear regression models were used to estimate the probability of any expenditures and total expenditures while controlling for sociodemographic characteristics, chronic conditions, and health status. MEASURES: We used prescription drug insurance status and outpatient prescription drug expenditures. RESULTS: An estimated 34 million elderly people filled 630 million prescriptions in 1997. Thirty-seven percent did not have prescription drug insurance. Total prescription drug expenditures exceeded $23 billion. Persons without prescription drug insurance spent slightly less than $7 billion; those with insurance spent more than $16 billion. After controlling for health status, comorbidity, and demographic characteristics, prescription drug insurance increased expenditures by $183 per person. The marginal increase in total expenditures of extending the average observed benefit to those currently uninsured is $2.3 billion (95% confidence interval, $1.2-3.5 billion). CONCLUSIONS: Proposals for a Medicare drug benefit provide high copayments to protect against insurance effects and to address uncertainty in cost estimates of the proposed benefit. By quantifying the insurance effect on expenditures among the elderly, the data reported here could reduce uncertainty in the budget estimation process.

Aged↗
PubMed2006

Workers who decline employment-related health insurance.

BACKGROUND: Families of workers who decline coverage represent a substantial share of the uninsured and publicly-insured population in the United States. OBJECTIVE: We examined health status, access to health care, utilization, and expenditures among families that declined health insurance coverage offered by employers using data from the Medical Expenditure Panel Survey for 2001 and 2002. RESULTS: We found differences in insurance status for adults and children among families with offers. We found that among low-income families with offers, children are less likely to have private insurance compared with adults. However, the majority of children who decline private insurance end up with public coverage, whereas most of adults who decline offers remain uninsured. Decliners are more likely to report poor health, yet they are also less likely to have high cost medical conditions. Families declining coverage have weaker preferences for insurance than families that take up. Although access to care is lower among the decliners who remain uninsured, decliners with public insurance have similar access to care as those with private insurance. Families turning down coverage are more likely to face high expenditure burdens as a percentage of income and more likely to have financial barriers to care. Families who decline coverage rely heavily on the safety net. Public sources and uncompensated care account for 72% of total expenditures among adults who decline coverage. CONCLUSIONS: Our results suggest that policy initiatives aimed at increasing take up among workers need to take into account the incentives workers face given the availability of care through public sources and uncompensated care.

Adult↗
PubMed2006

Variation in pediatric intensive care therapies and outcomes by race, gender, and insurance status.

CONTEXT: The differential allocation of medical resources to adult patients according to characteristics such as race, gender, and insurance status raises the serious concern that such issues apply to critically ill children as well. OBJECTIVE: This study examined whether medical resources and outcomes for children admitted to pediatric intensive care units differed according to race, gender, or insurance status. DESIGN: An observational analysis was conducted with use of prospectively collected data from a multicenter cohort. Data were collected on 5,749 consecutive admissions for children from three pediatric intensive care units located in large urban children's hospitals. PARTICIPANTS: Children aged </=18 years admitted over an 18-month period beginning in June 1996 formed the study sample. MAIN OUTCOME MEASURES: Hospital mortality, length of hospital stay, and overall resource use were examined in relation to severity of illness. Standardized ratios were formed with generalized regression analyses that included the Pediatric Index of Mortality for risk adjustment. RESULTS: After adjustment for differences in illness severity, standardized mortality ratios and overall resource use were similar with regard to race, gender, and insurance status, but uninsured children had significantly shorter lengths of stay in the pediatric intensive care unit. Uninsured children also had significantly greater physiologic derangement on admission (mortality probability, 8.1%; 95% confidence interval [CI], 6.2-10.0) than did publicly insured (3.6%; 95% CI, 3.2-4.0) and commercially insured patients (3.7%; 95% CI, 3.3-4.1). Consistent with greater physiologic derangement, hospital mortality was higher among uninsured children than insured children. CONCLUSIONS: Risk-adjusted mortality and resource use for critically ill children did not differ according to race, gender, or insurance status. Policies to expand health insurance to children appear more likely to affect physiologic derangement on admission rather than technical quality of care in the pediatric intensive care unit setting.

Adolescent↗
PubMed2006

The effects of child-only insurance coverage and family coverage on health care access and use: recent findings among low-income children in California.

OBJECTIVE: To compare the extent with which child-only and family coverage (child and parent insured) ensure health care access and use for low income children in California and discuss the policy implications of extending the State Children's Health Insurance Program (California's Healthy Families) to uninsured parents of child enrollees. DATA SOURCES/SETTING: We used secondary data from the 2001 California Health Interview Survey (CHIS), a representative telephone survey. STUDY DESIGN: We conducted a cross-sectional study of 5,521 public health insurance-eligible children and adolescents and their parents to examine the effects of insurance (family coverage, child-only coverage, and no coverage) on measures of health care access and utilization including emergency room visits and hospitalizations. DATA COLLECTION: We linked the CHIS adult, child, and adolescent datasets, including the adolescent insurance supplement. FINDINGS: Among the sampled children, 13 percent were uninsured as were 22 percent of their parents. Children without insurance coverage were more likely than children with child-only coverage to lack a usual source of care and to have decreased use of health care. Children with child-only coverage fared worse than those with family coverage on almost every access indicator, but service utilization was comparable. CONCLUSIONS: While extending public benefits to parents of children eligible for Healthy Families may not improve child health care utilization beyond the gains that would be obtained by exclusively insuring the children, family coverage would likely improve access to a regular source of care and private sector providers, and reduce perceived discrimination and breaks in coverage. These advantages should be considered by states that are weighing the benefits of expanding health insurance to parents.

Adolescent↗
PubMed2006

The effect of private insurance on the health of older, working age adults: evidence from the health and retirement study.

OBJECTIVE: Primarily, to determine if the presence of private insurance leads to improved health status, as measured by a survey-based health score. Secondarily, to explore sensitivity of estimates to adjustments for endogeneity. The study focuses on adults in late middle age who are nearing entry into Medicare. DATA SOURCES: The analysis file is drawn from the Health and Retirement Study, a national survey of relatively older adults in the labor force. The dependent variable, an index of 5 health outcome items, was obtained from the 1996 survey. Independent variables were obtained from the 1992 survey. State-level instrumental variables were obtained from the Area Resources File and the TAXSIM file. The final sample consists of 9,034 individuals of which 1,540 were uninsured. STUDY DESIGN: Estimation addresses endogeneity of the insurance participation decision in health score regressions. In addition to ordinary least squares (OLS), two models are tested: an instrumental variables (IV) model, and a model with endogenous treatment effects due to Heckman (1978). Insurance participation and health behaviors enter with a lag to allow their effects to dissipate over time. Separate regressions were run for groupings of chronic conditions. PRINCIPAL FINDINGS: The OLS model results in statistically significant albeit small effects of insurance on the computed health score, but the results may be downward biased. Adjusting for endogeneity using state-level instrumental variables yields up to a six-fold increase in the insurance effect. Results are consistent across IV and treatment effects models, and for major groupings of medical conditions. The insurance effect appears to be in the range of about 2-11 percent. There appear to be no significant differences in the insurance effect for subgroups with and without major chronic conditions. CONCLUSIONS: Extending insurance coverage to working age adults may result in improved health. By conjecture, policies aimed at expanding coverage to this population may lead to improved health at retirement and entry to Medicare, potentially leading to savings. However, further research is needed to determine whether similar results are found when alternative measures of overall health or health scores are used. Future research should also explore the use of alternative instrumental variables. Preliminary results provide no justification for targeting certain subgroups with susceptibility to certain chronic conditions rather than broad policy interventions.

Chronic Disease↗
PubMed1997

Insurance status and provision of dental services in Australian private general practice.

Annual expenditure on dental care in Australia amounts to AUD 1.9 billion. Approximately one-third of this expenditure involves private dental insurance, yet little is known about the impact of insurance on the provision of services. The aim of this analysis was to examine differences in dental service provision between insured and non-insured patients. Data collected from a random sample of dentists from a survey conducted in 1993-94 were used, providing 817 responses (response rate 74%). Logistic regression analysis controlling for patient age and sex and reason for visit indicated that in private general practice insured patients were more likely to receive preventive (OR = 1.37), crown and bridge (OR = 2.25), and endodontic services (OR = 1.27), but less likely to receive extraction services (OR = 0.52). However, no significant differences by insurance status were found for diagnostic, restorative, or prosthodontic services in the multivariate models. These differences in service provision by insurance status indicate a more favorable pattern of services for insured patients, and point to equity issues in the provision of services.

Adolescent↗
PubMed2005

Dental insurance and clinical dental outcomes in NHANES III.

OBJECTIVES: The National Health and Nutrition Examination Survey (NHANES III) 1988-1994 is one of the few nationally representative data sets with information on both private dental insurance and a clinical dental exam. The objective of this analysis was to examine the possible associations between private dental insurance and clinical exam outcomes, demographic variables, and dental visits. METHODS: Using NHANES III data, analysis was limited to persons aged 20 years or older who had a dental exam and reported on their private dental insurance status. Initial analyses were based on comparisons between those with and without private dental insurance. Propensity scoring method was used to examine the effects of dental insurance on clinical exam variables. RESULTS: The percentage of individuals with private dental insurance was significantly greater among non-Hispanic blacks, those with higher educational attainment, those living at/above the federal poverty level, and those with a dental visit in the past year compared to their respective counterparts. Those with untreated caries, those with a loss of attachment of greater than 4 mm, and those with 12-27 missing teeth were significantly less likely to have dental insurance (p < 0.05) than their respective counterparts. CONCLUSIONS: These results suggest that having private dental insurance is associated with better clinical oral health status.

Adult↗
PubMed2006

Possession of health insurance in Australia--how does it affect hospital use and outcomes?

OBJECTIVE: To assess the effect of possession of private health insurance on hospital use and outcomes in Western Australia. METHOD: Hospital morbidity records were extracted from the Western Australian (WA) Data Linkage System for all 22 major diagnostic categories (MDCs) for the period 1994-99, with follow-up to the end of 2000. Multivariate modelling techniques were used to estimate the effect of possession of private health insurance on hospital admission rates, average and total length of stay (LOS), cumulative incidence of admission at 30 days and one year, and case fatality at one year. RESULTS: Possession of private health insurance had significant effects on hospital use and outcomes, even after adjustments for age, sex, aboriginality, socioeconomic status, location and comorbidity. Non-insured patients tended to have a higher overall hospital admission rate but a lower admission rate for surgical episodes, and they generally had a longer LOS although this difference was only greater than a day in three MDCs. Case fatality was higher in non-insured patients, but there was no systematic trend with regard to readmission rates. CONCLUSIONS: The study found that for all MDCs, other than those where treatment was required on an emergency basis, patients with private health insurance had improved access to surgical procedures. Either non-insured patients were disadvantaged in their access to surgery or the higher intervention rate in privately insured patients represented supplier-/consumer-induced demand which may not always have been to the patient's advantage or both may have occurred.

Adolescent↗
PubMed2004

The importance of employer sponsorship in the long-term care insurance market.

Medicare and Medicaid are major sources of long-term care payments and thus will bear much of the burden from the growth in long-term care service use. The large future demand for long-term care services is of great concern among policymakers due to its expense and the use of public program dollars. It is argued that the individual purchase of long-term care insurance can help alleviate the increasing financial pressure on public programs responsible for the majority of longterm care financing. However, consumers have shown little interest in insuring against the high costs of long-term care. This analysis examines the effect of several factors on the decision to purchase a long-term care insurance policy: knowledge and attitudes of long-term care insurance and the long-term care financing system, the perceived risk for longterm care, financial planning behavior, and the availability of long-term care insurance. The interim results indicate the factor most likely to affect the decision to purchase long-term care insurance is access to employer-sponsored long-term care insurance. This suggests tht the availability of affordable and high quality coverage is more important than demand-side factors such as awareness of long-term care insurance and a perceived greater risk for long-term care.

Adult↗
PubMed2000

Losing and acquiring health insurance: consequences for health care.

Data from a sample of 5530 Nebraska adults under age 65 are used to analyze the independent correlates of four different insurance statuses: insured 12 consecutive months, uninsured 12 consecutive months, insured at the end of a 12 month period, but not throughout, and uninsured at the end of a 12 month period, but not throughout. The effects of insurance status on utilization of health care services when perceived to be needed are assessed, controlling for demographic explanations. The results show that uninsurance status, whether long-lasting or recent, indicates lower utilization than being insured. Policies designed to expand the number of persons with insurance, especially those linked to practices of insurers, are predicted to have little impact since the underlying causes of uninsurance are related to household income. Lower use of health care services among the uninsured is thought to present financial problems to providers, since the uninsured who do seek care are more likely to need more services (without paying). Problems of higher cost to treat these individuals also present problems for public policies that in effect create subsidies to expand the number of insured. Finally, this study indicates that incremental policy approaches may not deal adequately with the fundamental problems that result in increases in the number of uninsured Americans and caring for their health care needs.

Adolescent↗
PubMed2005

Insurance gaps among vulnerable children in the United States, 1999-2001.

OBJECTIVE: To quantify the number of children who experience gaps in insurance coverage and to determine whether vulnerable subgroups of children experience noteworthy lapses in insurance coverage. METHODS: We analyzed nationally representative data from 24,149 children sampled in the 1999-2001 Medical Expenditure Panel Survey linked to the 1997-1999 National Health Interview Survey. Vulnerable subgroups of children included children with chronic conditions, those from ethnic/racial minorities, and those living in poverty. On the basis of cumulative annual monthly insurance coverage status, each child fell into 1 of 3 groups: continuous coverage, uninsured, or gaps in coverage. Using SAS-callable SUDAAN, we conducted multivariate ordinal logistic regression model to quantify the likelihood of having gaps in coverage for vulnerable subgroups of children. RESULTS: From 1999 to 2001, we found that >9 million American children annually had gaps in coverage and that 5 to 6 million children annually were uninsured for the entire year. Sixty percent of children experienced gaps of at least 4 months, and >40% of all publicly and privately insured children had coverage gaps. After accounting for relevant covariates, children with chronic conditions were just as likely as other children to have gaps in coverage or be uninsured; Hispanic children were most likely to have insurance gaps or be uninsured; and children from poor and near-poor families were 4 to 5 times more likely to have lapsed coverage than children from high-income families. Poverty and maternal education were the strongest factors associated with lapsed coverage. CONCLUSIONS: Unstable health insurance is an underrecognized problem for children, including those with chronic conditions. Because unstable insurance coverage can lead to inadequate health care utilization and poor child health outcomes, strategies to promote stable insurance coverage merit serious consideration.

Child↗
PubMed2004

Government and private insurance medical programs as well as MDVIP, an update.

On November 19,1945, President Truman outlined a Prepaid Medical Insurance Plan for all people through the Social Security System. Because of its comprehensive nature, it was coined "National Health Insurance." On July 30,1965, President Johnson signed the Medicare and Medicaid bill (Title XVII and Title XIX of the Social Security Act). Today, many groups of people are covered by Medicaid. However, there are strict requirements that may vary from state to state. Medicare offers the following types of medical heath care plans to include the original Medicare plan that is a "fee for service" plan. The individual may stay in the original plan unless he/she chooses to join a Medicare+ Choice Plan or a Medigap Plan. Most individuals will receive Medicare Part A when they are 65 without paying a premium because it has been deducted annually through their tax payments before the age of 65. Medicare Part A helps pay for the following: inpatient hospital care, skilled nursing facility, hospice care, and some home health care. Medicare Part B, however, must be paid by the individual through premiums to the Federal government. Medicare Part B medical insurance pays for doctors' services, outpatient services, and some other services that Medicare Part A doesn't cover. In an effort to supplement one's health care coverage, the individual may select either a Medicare+ Choice Plan or a Medigap Policy. The Medicare+ Choice Plan has four different types: Medicare Managed Care Plans, Medicare Private Fee for Service Plan, Medicare Preferred Provider Plans, and Medicare Specialty Plans. If one selects a Medigap policy, one may choose either a Medigap SELECT Policy or the standard Medigap policy. The front of a Medigap Policy must clearly identify it as a "Medicare Supplement Insurance." One must be carefully advised of the selection of the Medigap Policy. The Medicare Part B has a wide range of preventative services, including tests for breast cancer, cervical cancer, vaginal cancer, and colorectal cancer; bone mass measurements; diabetes monitoring and diabetes self-management; flu, pneumonia, Hepatitis B shots, and prostate cancer screening tests. It is important to emphasize that Medicare and Medicare supplemental insurance policies do not pay for home health care, such as durable medical equipment. Because of the enormous complexity of the wide variety of health insurance plans and their billing strategies, many physicians are electing to charge their patients an additional fee for being part of their practice. In return for their annual fee, their patients receive immediate cell phone access to their doctor 24 hours a day, 7 days a week. In addition, they receive same-day appointments and on-time appointments. They also spend as much time with their doctors as they wish. It is not surprising that there is growing evidence that the privately insured patient with a life-threatening illness will live longer than those individuals who have the same disease but have public insurance only. Legislatures are well aware of this crisis in medical care that must be corrected immediately.

Aged↗
PubMed1997

Health insurance and the financial impact of IDDM in families with a child with IDDM.

OBJECTIVE: To examine the health insurance experience and out-of-pocket health care costs of families with a child with IDDM. RESEARCH DESIGN AND METHODS: A case-control study of 197 families with a child with IDDM and 142 control families with no diabetic children was conducted. IDDM-affected families were identified from the Allegheny County IDDM Registry. Brothers and sisters of the parents in the IDDM-affected families were asked to participate as control subjects. Health insurance coverage and the money that families spent on health care services and supplies not reimbursed by insurance (out-of-pocket costs) were assessed by questionnaire. RESULTS: No difference was found between the IDDM-affected and control families in the percentages with or without insurance. Families with low household incomes ($10,000-$19,999) were at the greatest risk for having no insurance. While coverage provided by private plans was similar between the IDDM-affected and control families, many families had no reimbursement for insulin (10%), syringes (10%), or blood testing strips (30%). Out-of-pocket expenses were 56% higher in the IDDM-affected families than in the control families. Seventeen percent of the IDDM-affected families had expenses over 10% of their household income. This particularly affected families with low household incomes. Pre-existing illness clauses and insurance denial affected only a small proportion of the case families. CONCLUSIONS: These data illustrate that most families with a child with IDDM have health insurance, yet still incur larger out-of-pocket health care costs than do families without the presence of diabetes. IDDM-affected families likely face a number of economic decisions regarding health insurance and the use of health care.

Adolescent↗
PubMedDate not supplied

Shedding light on the insurance crisis.

The insurance crisis has hopscotched through all areas of the field--from professional liability and general liability, to benefit programs and health plans. Is the crisis real or imagined? To help inform medical group administrators about the current state of insurance coverage, the Medical Group Management Association, through its insurance committee and the Center for Research in Ambulatory Health Care Administration, embarked on an insurance survey. In this survey report, the key areas covered are: insurance needs and how groups cover them; methods used to purchase insurance, including evaluation of agencies and carriers; the type of medical malpractice insurance groups have and specifics about professional liability insurance; employee protection coverage; and an overview of current problems. Specific advice, comments, and recommendations are also provided.

Data Collection↗
PubMed1999

[ENT expert assessment for federal health insurance in North Rhine. A contribution to the internal discussion of quantitative and qualitative optimization of the expert witness process].

Contribution to an Internal Discussion on Quantitative and Qualitative Optimisation of Expertising Procedures: The medical advisory and expertising Services of the German statutory sickness insurance are according to German social legislation authorised to request supporting documents direct from the treating physicians or hospitals. The consultant medical expertiser for ENT diseases at Cologne worked out the percentage of requests that resulted in "further investigations" and the amount of work involved. A document form was used to record all such requests for a given period. 154 expertising procedures concerning ENT diseases were counted within a period of 5 weeks. 47% of the patients concerned pertained to workers' sickness insurance funds and 29% to guilds sickness insurance funds. Two thirds of all requests were channelled through the statutory sociomedical preconsultant service and one-third were sent by post. 55% of all the requested documents were considered to be "complete" and 45% "incomplete". N = 100 requests were initial and N = 54 were follow-up requests. The answers received were considered satisfactory and final in 62% of the requests, whereas "further inquiries" were considered necessary in n = 58 (38%) of the cases. 80% of the cases in which the requests resulted in satisfactory information, were approved for sickness insurance payment and approximately 20% were rejected. The average period of time that elapsed between a request for more information and the reply and the final expertising given to and passed on to the patient by the statutory insurance body was 2 weeks. In cases where "further inquiries" are considered necessary, three additional working days are usually required in the Cologne ENT diseases area. If the statutory sociomedical preconsultant service procedure could be intensified, this would result in better channelling of requests by the ENT medical and advisory service of the stautory sickness insurance bodies. A more pronounced examination by the statutory sociomedical preconsultant service could minimise the need for additional requests, follow-ups and "further inquiries" and could increase the speed of completion of approved or rejected insurance cases from 14 days to at the most one day or even 0 days. This pilot study was conducted to encourage the local bodies to optimise their work. In the long run good quality of work, patient satifaction and patients' job security will result and will be the corner-stones of modern quality assurance and quality management in North-Rhine Westphalian medical expertising and consultant services in association with the relevant statutory sickness insurance bodies.

Disability Evaluation↗
PubMed2000

Evaluation of children's health insurance: from New York State's CHild Health Plus to SCHIP.

BACKGROUND: The legislation and funding of the State Children's Health Insurance Program (SCHIP) in 1997 resulted in the largest public investment in child health care in 30 years. The program was designed to provide health insurance for the estimated 11 million uninsured children in the United States. In 1991 New York State implemented a state-funded program-Child Health Plus (CHPlus)-intended to provide health insurance for uninsured children who were ineligible for Medicaid. The program became one of the prototypes for SCHIP: This study was designed to measure the association between CHPlus and access to care, utilization of care, quality of care, and health care costs to understand the potential impact of one type of prototype SCHIP program. METHODS: The study took place in the 6-county region of upstate New York around and including the city of Rochester. A before-and-during design was used to compare children's health care for the year before they enrolled in CHPlus versus the first year during enrollment in CHPlus. The study included 1828 children (ages 0-6.99 years at enrollment) who enrolled between November 1, 1991 and August 1, 1993. A substudy involved 187 children 2 to 12.99 years old who had asthma. Data collection involved: 1) interviews of parents to obtain information about demographics, sources of health care, experience and satisfaction with CHPlus, and perceived impact of CHPlus; 2) medical chart reviews at all primary care offices, emergency departments, and health department clinics in the 6-county region to measure utilization of health services; 3) claims analysis to assess costs of care during CHPlus and to impute costs before CHPlus; and 4) analyses of existing datasets including the Current Population Survey, National Health Interview Survey, and statewide hospitalization datasets to anchor the study in relation to the statewide CHPlus population and to assess secular trends in child health care. Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus. RESULTS ENROLLMENT: Only one third of CHPlus-eligible children throughout New York State had enrolled in the program by 1993. Lower enrollment rates occurred among Hispanic and black children than among white children, and among children from lowest income levels. PROFILE OF CHPlus ENROLLEES: Most enrollees were either previously uninsured, had Medicaid but were no longer eligible, or had parents who either lost a job and related private insurance coverage or could no longer afford commercial or private insurance. Most families heard about CHPlus from a friend, physician, or insurer. Television, radio, and newspaper advertisements were not major sources of information. Nearly all families had at least 1 employed parent. Two thirds of the children resided in 2-parent households. Parents reported that most children were in excellent or good health and only a few were in poor health. The enrolled population was thus a relatively low-risk, generally healthy group of children in low-income, working families. ACCESS AND UTILIZATION OF HEALTH CARE: Utilization of primary care increased dramatically after enrollment in CHPlus, compared with before CHPlus. Visits to primary care medical homes for preventive, acute, and chronic care increased markedly. Visits to medical homes also increased for children with asthma. There was, however, no significant association between enrollment in CHPlus and changes in utilization of emergency departments, specialty services, or inpatient care. QUALITY OF CARE: CHPlus was associated with improvements in many measures involving quality of primary care, including preventive visits, immunization rates, use of the medical home for health care, compliance with preventive guidelines, and parent-reported health status of the child. (ABSTRACT TRUNCATED)

Child↗