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Trends in Type of Health Insurance Coverage for US Children and

Their Parents, 1998–!11

"ennifer #$ %e&oe, '%, %Phil( Carrie "$ Tillotson, 'PH( 'iguel 'arino, Ph%(

"ean )*'alley, 'PH( Heather +ngier, 'PH( orraine S$ -allace, Ph%(

.achel /old, Ph%, 'PH

0ro the %epartent of 0aily 'edicine 2%r %e&oe, %r 'arino, and 's +ngier3, %ivision of4iostatistics, %epartent of Pu5lic Health and Preventive 'edicine 2's Tillotson, %r'arino, and 's )*'alley3, )regon Health 6 Science University, Center for Health.esearch, 7aiser Peranente orthest 2%r /old3, Portland, )re( and %epartent of0aily 'edicine, The )hio State University, Colu5us, )hio 2%r -allace3The authors declare that they have no conflict of interest$+ddress correspondence to Heather +ngier, 'PH, %epartent of 0aily 'edicine, )regonHealth 6 Science University, :181 Sa "ac;son.d, 'ailcode 0', Portland, ). 9<:9 2e=ail> angierh? ohsu$ed u3$ .eceived for pu5lication "anuary <, !1@( accepted "une1@, !1@$

+4ST.+CT

)4"#CTI&#> To eAaine trends in health insurance type aong

US children and their parents$'#TH)%S> Using the 'edical #Apenditure Panel Survey 21998–!113, e lin;ed each child 2nB 1!,@1( eighted nC <! illion3 ith his or her parent or parents and assessed patterns of full=year health insurance type, stratified 5y incoe$ -e eAained longitudinal

insurance trends using Doinpoint regression and further eAplored these trends ith adDusted

regression odels$.#SUTS> -hen coparing 1998 to !11, the percentage of lo=incoe failies ith 5oth child and parent or parents pri= vately insured decreased fro 9$E

to 19$1E, ith an esti= ated decline of !$8F 29@E confidence interval, 1$1!,

!$F:3 unadDusted percentage points per year( iddle=incoe failies eAperienced a drop fro

<G$@E to FF$:E, a yearly un= adDusted percentage point decrease of !$<: 29@E confidence

interval, !$98, !$G83$ The discordant pattern of pu5licly insured children ith uninsured parents increased fro 1!$GE to <$E aong lo=incoe failies and fro 1$GE to F$<E aong

iddle=incoe failies$ .esults fro adDusted odels ere siilar to Doinpoint regression findings$C)CUSI)S> %uring the past decade, lo= and iddle=incoe US failies eAperienced a decrease in the percentage of child–parent pairs ith private

health insurance and pairs ithout insurance$ Concurrently, there as a rise in discordant coverage

patternsainly pu5licly insured children ith unin= sured parents$

7#-).%S> access to care( faily health( health insurance(

uninsured

+C+%#'IC P#%I+T.ICS !1@(

=

>1–8

-H+T*S #-

Trends in health insurance type have changed over the past decade for lo= and iddle=incoe

US failies> private coverage and uninsurance have decreased, hile discordance 5eteen parent

and child coverage has increased$

ST+4# H#+TH ISU.+C# leads to 5etter access to health care services and iprovedhealth outcoes$1–G

)ver the past decades, political and econoic changes have affected access to and afforda5ility of

coverage for failies in the United Statesnota5ly, private health insurance costs have seen steepincreases$ Though soe failies o5tained coverage for their children through eApansions in the

mailto:[email protected]





Children*s Health Insurance Progra 2CHIP3, fe pu5lic coverage options eAisted for adults 2aged

19–FG years3 5efore !1G$@,F

Parental coverage status has an independent effect on children*s health insurance and access to

care, regardless of the child*s coverage status$<–9 Previous research

utiliing a natural eAperient that randoied adults to coverage found a causal lin; 5eteen parent

and child health insurance status$1! Thus, it is iportant to consider trends in children*s healthinsurance coverage in conDunc= tion ith trends affecting parents$ 'ost past studies of healthinsurance have focused on adults or children sepa= rately( those that considered 5oth children and

parents did not assess type of coverage$<–1G To address this gap in the literature, e eAainedfull=year patterns of faily health insurance coverage type aong US children and their parents for 1998 through !11, stratified 5y incoe$

'#TH)%S

%+T+ S)U.C# +% STU% P)PU+TI)

-e analyed data fro 1998 through !11 of the 'ed= ical #Apenditure Panel Survey–Household

Coponent 2'#PS=HC3$1@ '#PS=HC respondents are intervieed @ ties over a =year period,ith an overlapping panel design( annual pu5lic use files contain data fro a single year for

consecutive panels$ #ach year of data constitutes

+C+%#'IC P#%I+T.ICS



%#&)# #T ++C+%#'IC P#%I+T.ICS

a nationally representative saple$ %etails a5out the'#PS=HC are availa5le elsehere$1@,1F

The study population included children aged ! to 1< years, ith responses to at least 1 full year of

the survey 2n B 1F,!9:3$ -e lin;ed each child ith a parent or parents in the sae household to

construct child–parent pairs$ -e eAcluded children for ho no identifia5le parent records could 5e

lin;ed 2n B G!G83, and for ho insurance infor= ation for the child or parent as not availa5le for

the full year 2n B 1@G3$ )ur final saple sie as 1!,@1 children, eighted to represent a yearly

average of approAiately <! illion children in the civilian, noninstitutionalied US pop= ulation$

C)ST.UCTI/ H#+TH I SU.+C# TP# &+.I+4#S

The '#PS=HC contains varia5les for hether a person had health insurance for at least 1 day in

each calendar onth of each year, and hether it as pu5lic or private insurance$ Using these, e

constructed varia5les represent= ing full=year health insurance type, classified as> 13 having private

insurance if a person had insurance in 1 onths of the year of hich 1 or ore onths included

private insur= ance 2those ith a co5ination of pu5lic and private insur= ance ere included in this

category3( 3 having pu5lic insurance if a person as insured in 1 onths of the year and had

pu5lic insurance only( and :3 5eing unin= sured, in hich the person as reported as having no insur=

ance in 1 or ore onths of the year$ -e included those ith a co5ination of pu5lic and privateinsurance in the private category to atch '#PS=HC health insurance var= ia5le categoriation1@(

e considered those ho did not have insurance in 1 or ore onths of a given year as unin=

sured 5ecause previous research has shon that preventive service rates for patients ith partial

health insurance are different fro those ith full=year coverage1< and are siilar to those ith

no coverage$18,19

-e then created a co5ined varia5le that paired full= year health insurance type for a child ith

that of his or her parent$ -e grouped child and parent type of health in= surance into 9 utually

eAclusive categories 2child typeJ parent type3> privateJprivate( privateJpu5lic, privateJunin= sured(

pu5licJprivate( pu5licJpu5lic( pu5licJuninsured( uninsuredJprivate( uninsuredJpu5lic( and

uninsuredJunin= sured$ In cases here a child had parents lin;ed, parent insurance as considered private if at least 1 parent had any private insurance, regardless of the other parent*s in= surance

status or type( parental insurance as considered pu5lic if 5oth parents had pu5lic insurance only, or

1 parent had pu5lic only and the other parent as uninsured( parental insurance as considered

uninsured if 5oth par= ents ere uninsured$ If the parent and child had the sae type of health

insurance, their coverage as considered concordant, and if the insurance type as different 5eteen

parent and child, their coverage type as considered discordant$

-e 5ased household incoe stratifications on esta5= lished '#PS=HC categories$ -e defined

lo incoe as less than !!E of the federal poverty level 20P3,co5ining the '#PS=HC poor, near=poor, and lo cate= gories( iddle incoe as !!E to less than

G!!E 0P( and high incoe as KG!!E 0P$1@

The 0P for a faily of G as K1F,G@! in 1998 andK,:@! in !11$!,1

+ +SIS

+ll analyses ere stratified 5y faily incoe categories$ -e do not report results fro high=

incoe failies 5ecause the aDority 288E3 had private insurance for 5oth child and parent, andall categories had either no sta= tistically significant changes or too fe su5Dects to assess changes 2n

L :!3$ -e used sapling stratification vari= a5les, design eights, and a ro5ust variance estiator in accordance ith '#PS guidelines to account for the co= pleA saple design of the survey$ Thisaccounts for 5oth the intracluster correlation of children ithin failies and in= traperson correlation

across years$

-e eAained the folloing deographic characteristics for the entire study period as one pooled

saple and report the eighted percentage of each characteristic> age 2child categories !–G, @–9,



+C+%#'IC P#%I+T.ICS 0+'IH#+TH I SU.+C# T.#%S, 1998–!11 :

pu5licJparent private, iddle=incoe group as liited to only 1 Doinpoint as a result of sall cell

sies 2n L :!3 in the years 1998 to !!! and thus had feer tie points avail= a5le$ + 'onte Carlo

perutation ethod as used to select the odel ith the 5est fit, and yearly percentage point

changes ere calculated for each segent$ Statisti= cally significant changes ere those that

increased or decreased over tie and ere significantly different than an annual percentage change

of ! 2no change over tie3$

To account for potential differences 5eteen child and parent health insurance types in our

analysis of change patterns over tie, e used trend segents identified in Doinpoint regressionanalyses ith ultinoial logistic regression to allo inclusion of potential confounders$ In these

odels, the child and parent co5ined health insur= ance type as the outcoe varia5le 29

categories3 and year as the priary independent varia5le$ 0or the lo=incoe odels, all 9

categories ere included in the outcoe var= ia5le( hoever, for the iddle=incoe odels, the child

privateJparent pu5lic and child uninsuredJparent pu5lic cat= egories ere eAcluded as a result of sall

andJor ero cells 2n L :!3$ -e adDusted for all deographic characteristics eAained, as they are

;non to influence health insurancecoverage$<,<–9 'arginal effects for year ere calculatedfor each odel and are represented as an adDusted yearly percentage point change$ 'ultinoial

logistic regression odels ere conducted and arginal effects ere calculated using ST+T+ 11$IC 2StataCorp, College Station, TeA3$

Throughout this article, e do not report estiates 5ased on saple sies of feer than :! 5ecause

estiates 5ased on such saple sies are not relia5le$ + P value of L$!@ as considered statistically

significant$ )ur institutional revie 5oard deeed the study eAept$

. #SUTS

Children fro this saple of lo= and iddle=incoe failies in the United States predoinantly

lived in the South, had eAcellent or very good health status, ere non=Hispanic hite, had

parents ith K1 years of educa= tion, had eployed parents, and had parents living in the

household$ Children and parents fro lo=incoe failies tended to 5e younger than those froiddle=incoe fa= ilies 2Ta5le 13$

+ong children fro lo= and iddle=incoe failies, the prevalence of full=year child–parent

health insurance type changed significantly 5eteen 1998 and !11 for several groups including the

folloing 2child typeJparent type3> privateJprivate( pu5licJprivate, pu5licJpu5lic, pu5= licJuninsured,

uninsuredJprivate, and uninsuredJuninsured 2Ta5le 3$

T.#%S I P.I&+T# I SU.+C# C)&#.+/#

The percentage of child–parent pairs ith private insur= ance decreased steadily fro 9$E in

1998 to 19$1E in !11 for lo=incoe failies 2L!!E 0P3, the yearly unadDusted percentage

point decrease as !$8F per year 29@E confidence interval OCI 1$1!, !$F:3$ The prevalence of iddle=incoe pairs ith child and parent privately insured fell significantly fro

<G$@E in 1998 to

FF$:E in !11, the yearly unadDusted percentage point decrease as !$<: 29@E CI, !$98, !$G83$

T.#%S I U ISU.+ C#

The prevalence of lo=incoe child–parent pairs ith 5oth child and parent uninsured shoed

a decrease overall fro F$:E in 1998 to 1G$8E in !11, the yearly unadDusted percentage point

decrease as !$81 29@E CI, 1$!@, !$@83$ 'iddle=incoe uninsured pairs also sa a decrease

fro 1:$E in 1998 to 8$<E in !11( fro 1998 to !!G, there as a yearly unadDusted

percentage point decrease of !$@8 29@E CI, 1$!1,

!$1@3 and fro !!< to !11, the yearly percentage point decrease as 1$:F 29@E CI, $19,

!$@G3$



T.#%S I %ISC).%+T I SU.+C# C)&#.+/#

)verall, discordant coverage increased fro :$E to

G$1E for lo=incoe failies$ The prevalence of pu5licly insured children ith uninsured parents

increased fro

1!$GE in 1998 to <$E in !11, the yearly unadDusted per= centage point increase as 1$<G 29@E CI,

1$:F, $13 fro1998 to !!:, hich continued rising, though less draat=ically, 5y !$98 29@E CI, !$<@, 1$!3 percentage points per year 5eteen !!: and !11$ %iscordant

coverage increased fro 9$:E to 18$8E for iddle=incoe failies$ The prevalence of pu5licly

insured children ith uninsured parents increased fro 1$GE in 1998 to F$<E in !11, the yearlyunadDusted percentage point increase as !$G 29@E CI, !$:G, !$@13$

early percentage point changes fro all adDusted ulti=noial logistic regression odels ere consistent in agnitude and direction ith those found in

Doinpoint regression ith eAceptions> the trends ere siilar in direction 5ut ere no longer

statistically significant for iddle=incoe failies ith pu5licly insured children and privately

insured parents, and lo=incoe failies ith uninsured children and pu5licly insured parents

20igs$ 1 and ( Ta5le :3$

%ISCUSSI)

Type of health insurance coverage patterns changed significantly for lo= and iddle=incoe USchildren and their parents fro 1998 to !11$ 0ailies sa significant decreases in the percentage of

child–parent pairs ith full= year, private health insurance and pairs ithout coverage$ This coincided

ith a significant increase in the percentage of failies ith discordant coverage$ Specifically, e

found an increase in pu5licly insured children ith uninsured par= ents, suggesting that hen failies

lost private coverage, they ere a5le to o5tain pu5lic health insurance for their children only$

%ecreases in private coverage, concurrent ith increases in pu5lic coverage could 5e due to hat is

tered crod outthe oveent of privately insured indi= viduals to pu5lic insurance$:! .eports of

crod out have 5een iAed$ 0or eAaple, one study found that for every

1!! children ho 5ecae eligi5le for pu5lic insurance,



%#&)# #T + +C+%#'IC P#%I+T.ICSG

Ta5le 1$ %eographic Characteristics 5y 0aily Incoe, 1998–!11Q

o Incoe 2n B F@,G9F3 'iddleIncoe 2n B ::,GF3

Characteristic

Child*s age

Uneighted n -eighted E Uneighted n -eightedE

!–G y 18,89@ :!$G<,8:1 G$9

@–9 y 19,<8: 9$<9,:@ <$9

1!–1: y 1G,G8! 1$:<,91@ :$

1G–1< y 1,::8 18$F8,1G8 G$!

Parent*s age

MG y <,G< 11$<1,:9! G$!

G–GG y @1,8GF <8$@F,F: <9$8

KG@ y F,G!: 9$8@,G 1F$

.egion

ortheast 8,9G 1@$1G,8<8 1F$<

'idest 1!,<!< !$

<,:9< G$@South F,:< :8$911,<1@ :@$@

-est !,1F8 @$99,@F :$:

Child*s health statusR

#AcellentJvery good G<,8! <@$<,@!F 8G$:

/oodJfairJpoor 1<,F<< G$8@,<9 1@$<

Child*s raceJethnicity on=Hispanic hite 1F,:88 G!$G1<,!!@ FF$

on=Hispanic nonhite 18,@<< <$<<,<8 1<$9

Hispanic :!,@:1 :1$98,9F: 1@$9

Parent*s educationR

K1 y G1,!1 <1$!9,99 9:$<

L1 y G,!G@ 9$!:,G F$:

0aily coposition



%#&)# #T + +C+%#'IC P#%I+T.ICSG

)ne parent 8,!!: G$1<,!<8 !$<

To parents :<,G9: @<$9F,1F8 <9$G

Parent*s eployentR

#ployed G9,9!: <8$::,!F8 9<$1

Uneployed 1@,G9 1$<1,1F1 $9

Q%ata source> 'edical #Apenditure Panel Survey–Household Coponent survey$

-eighted percentages are reported for the entir e study period 21998–!113 as 1 pooled

saple$ Colun percentages are approAiately 1!!E 2rounded to nearest tenth of a

percent3$ o incoe, L!!E feder al poverty level 20P3( iddle incoe, !!E to

LG!!E 0P$ The 0P for a faily of four in !11 as

K,:@!$

RSaple sies do not add to total uneighted colun nu5er as a result of eAclusion ofsall nu5er of issing responses$

G gained pu5lic coverage, yet only of the ere uninsured 5efore gaining coverage( thus, crod out

eAplained half of the increase$:1 )ther studies, hoever, found little or no evidence of crod

out$:,:: In this study, e sa a uch larger increase in pu5licly insured children ith uninsured parents copared to pu5licly insured children ith privately insured parents$ Thus, the increasingcost of private health insurance, coupled ith reductions in eployer=sponsored insurance offeringsand the historical lac; of opportunities for adults to gain pu5lic coverage, li;ely account for thechanges reported here$

-hen faced ith unafforda5le coverage options andJor reductions in 5enefit pac;ages, lo= and

iddle=incoe failies ere forced to loo; 5eyond eployer=sponsored, private coverage$:G,:@

%uring the tie period studied, any states eApanded their children*s health insurance prograshile siultaneously liiting eligi5ility and pu5lic insurance enrollent opportunities for

adults$:F

The changes in health insurance type seen in this study ere not eAplained 5y differences in child or

parent charac= teristics, as evidenced 5y the consistent results 5eteen un= adDusted and adDusted

analyses$ 0urther research is needed

to assess the ipact of these increasing discordant faily coverage patterns$

I'PIC+TI)S

%espite iproveents in children*s coverage rates, this study suggests a trend of coverage loss for

parents that could negatively affect the hole faily$ Insured children ith uninsured parents havehigher odds of eAperiencing health insurance coverage gaps and unet health care needs copared to

insured children ith insured parents$8,:< The +fforda5le Care +ct 2+C+3 calls for state 'edicaid progra eApansions to cover adults earning M1:8E of the 0P and for health insurance ar;etplacesto allo individuals not offered health insurance through their eployer the a5ility to purchase

coverage on their on( illions have gained coverage through these ne opportunities$:8,:9 0ecoverage options are availa5le for lo=incoe adults living in states that chose not to eApand their

'edicaid progras$G! -ithout eApansions in 'edicaid, uninsured parents ill need to rely on private health insurance through health insurance ar;etplaces$ Though federal taA credits eAist

for lo= and iddle=



+C+%#'IC P#%I+T.ICS 0+'I H#+TH I SU.+C# T.#%S, 1998–!11 @

Ta5le $ Percentage of Child and Parent 0ull=ear Health Insurance Type 5y 0aily Incoe,1998 &ersus !11R

o Incoe 2n B F@,G9F3 'iddleIncoe 2n B ::,GF3

0ull=ear Health 1998 -ei hted !11 -ei hted 1998 -ei hted !11

PrivateJpr ivate $ $ $ FF$:QPrivateJpu5lic

$ $ $ $

PrivateJuninsured $ $ $ $Pu5licJprivate $ $ $ $Pu5licJpu 5lic $ $ $ F$QPu5licJuninsured $ $ $ F$<QUninsuredJ private G$< $@ G$ @$UninsuredJ pu5lic $ $ $ $

UninsuredJuninsured $ $ $ 8$<QChildJparent insurance

concordance; Concordant <F$ @<$ 9!$ 81$Q%iscordant $ $ $ 18$8Q

QP value 2P L $!@3 considered statistically significant, calculated 5y chi=sNuare tests,coparing rates in 1998 vs !11$

R%ata source> 'edical #Apenditure Panel Survey–Household Coponent survey$ Colun

percentages are approAiately 1!!E 2rounded to nearest tenth of a percent3$ o incoe,

L!!E federal poverty level 20P3( iddle incoe, !!E to LG!!E 0P$ The 0P for a faily

of four in !11 as K,:@!$

#stiates not reported due to sall cell siCes 2n L :!3$

Cell siCes for years 1998 to !!! ere L:!( this value is fro the year !!1$

;Concordant indicates child privateJparent private( child pu5licJparent pu5lic( child

uninsuredJparent uninsured( discordant, child privateJ parent pu5lic( child privateJparent

uninsured( child pu5licJparent private( child pu5licJparent uninsured( child uninsuredJparent

private( child uninsuredJparent pu5lic$

incoe failies to help pay for ar;etplace preius, cost is still reported to 5e a 5arrier tocoverage$G1

The un;non future of CHIP is cause for concern for lo= and iddle= incoe failies$G

-ithout CHIP, illions of children ay 5ecoe uninsured through the faily glitchV 2ie, adultsould not Nuality for +C+ su5= sidies 5ecause they have the incoe to afford coverage for theselves, even if they cannot afford the cost of

the preiu for the faily3$G:,GG This study uncovered a distur5ing historical trend in failies*

insurance coverage> as children gained coverage, parents lost coverage at an alaring rate$ Thus, as

changes in health insurance options and eligi5ility continue to occur, it ill reain iportant toonitor the sta5ility of faily coverage$ In addition to deonstrating novel ethods for this

continued evaluation of faily coverage patterns, e



+C+%#'IC P#%I+T.ICS 0+'I H#+TH I SU.+C# T.#%S, 1998–!11 @

0igure 1$ Trends in child and parent full=year health insurance type, lo incoe$ Sy5olsrepresent actual percentage, hile lines represent the trend per Doinpoint regression$ Change

in trend is identified through Doinpoint regression 2P L $!@3$ o incoe, L!!E federal

poverty level 20P3$ 0P in !11 as K,:@!$ Source> 'edical #Apenditure Panel Survey,

1998–!11$



%#&)# #T + +C+%#'IC P#%I+T.ICSF

0igure $ Trends in child and parent full=year health insurance type, iddle incoe$ Sy5ols

represent actual percentage, hile lines repre= sent the trend per Doinpoint regression$

Change in trend is identified through Doinpoint regression 2P L $!@3$ 'iddle incoe, !!E to

G!!E federal poverty level 20P3$ 0P in !11 as K,:@!$ Source> 'edical #Apenditure

Panel Survey, 1998–!11$

Ta5le :$ UnadDusted and +dDusted early Percentage Point Change in Child and Parent

Health Insurance Type 5y 0aily Incoe,

1998–!11R

0ull=ear Health Insurance Type,

Child TypeJParent Type "oinpoint Identified Trend

o incoe

early Percentage Point Change 29@E CI3 UnadDusted +dDusted

PrivateJpr iv

ate

1998– !11

$

!$8F 2 1$1!,!$F:3Q

$

!$9 2 1$1,!$<3Q

$

!!G–!!9 $ $ , $ $ ,

!!9–!111998–!11

!$9G 2 !$81,$F83

!$8F 2 !$!G,1$<@3 Pu5licJuninsured 1998–!!: 1$<G 21$:F, $13Q $ $ ,

!!:–!11 !$98 2!$<@, 1$!3Q $ $ ,UninsuredJ private

UninsuredJ pu5lic

UninsuredJuninsured

1998–!111998–!11

1998–!11

!$1@ 2 !$,!$!<3Q

!$!G 2 !$!8,

!$1< 2 !$@,!$!93Q

!$!: 2 !$!8,

PrivateJpr ivate 1998– !$<: 2 !$98,Q

!$F1 2 !$8:,Q – $

Pu5licJprivate !!1–!11 –

!$1G 2!$!:, !$G3Q Q

!$11 2 !$!:,!$@3

Pu5licJuninsured 1998–!11 !$G 2!$:G, !$@13Q !$:< !$8,



%#&)# #T + +C+%#'IC P#%I+T.ICSFUninsuredJ private

UninsuredJ pu5lic

UninsuredJuninsured

1998– !11$

;

!$! 2 !$!F,!$113

$

;

!$!1 2 !$1!,!$113

$

;

CI indicates confidence interval$

QP value 2P L $!@3 considered statistically significant$

R%ata source> 'edical #Apenditure Panel Survey–Household Coponent survey$ o

incoe, L!!E federal poverty level 20P3( iddle incoe, !!E to LG!!E 0P$ The 0P in!11 as K,:@!$

UnadDusted results fro Doinpoint regression$

+dDusted results fro ultinoial logistic regression, ith covariates including child*s age,

parent age, raceJethnicity of the child, region of residence, parental education, faily

coposition, parental eployent, and child*s perceived health status$

;Sall saple siCes 2n L :!3 for ost years( estiates are unrelia5le$



+C+%#'IC P#%I+T.ICS 0+'I H#+TH I SU.+C# T.#%S, 1998–!11 <

also deonstrate ho Doinpoint analyses can 5e used in future analyses for researchers to trac;

longitudinal changes in the slope and direction of trends in health insurance coverage$

I'IT+TI)S

)ur analyses ere liited 5y eAisting '#PS=HC vari= a5les$ +s ith all self=reported data,

response 5ias reains a possi5ility$ Hoever, the '#PS=HC as;s several Nues= tions a5out health

insurance status and type at various tie points, and survey staff logically edit responses for

consistency across varia5les$ The '#PS is a nationally representative data set that does notaccount for state= level differences steing fro individual state policies, hich differentially

eApanded and contracted pu5lic health insurance progras during the study tie period$

C)CUSI)S

0ro 1998 to !11, lo= and iddle=incoe US fa= ilies eAperienced a decrease in the

percentage of child– parent pairs ith private health insurance and pairs ithout insurance$

Concurrently, there as a rise in discordant coverage patterns, ainly pu5licly insured children ith

uninsured parents$

+C7)-#%/'#TS

This study as financially supported 5y the +gency for Healthcare .esearch and Wuality 2+H.W3

2grant 1 .!1 HS!18@F93, Patient=Centered )utcoes .esearch Institute 2Health Systes Cycle I,

!13, the ational Cancer Institute of the ational Institutes of Health 2grant 1 .!1C+181G@ !13, the )regon Health 6 Science University %epartent of 0aily 'edicine, and the )hio State University %epartent of 0aily 'edicine$ The funding

agencies had no involveent in the design and conduct of the study( analysis, and interpretation of

the data( and prepara= tion, revie, or approval of the anuscript$ +H.W collects and anages the

'#PS$

.#0#.#C#S

1$ Soers 4%, 4aic;er 7, #pstein +'$ 'ortality and access to care aong adults after state

'edicaid e A pansions$ #ngl " 'e d $ !1(

:F<>1!@– 1 !:G$

$ +splin 4., .hodes 7 & , e vy H, et al$ Insurance status and access to ur gent a 5 ulatory care

foll o =up appointent s $ " +' + $ !!@(9G>

1G8–1@ G$

:$ 4urstin H., ipsit S., 4rennan T +$ Socioecono ic status and ris; for su5stand a rd edical

care$ " +' + $ 199(F8>: 8 :–:8 <$G$ 4indan +4, /ru5ach 7, )sond %, et al$ Pr e v e nta5le hospit ali=

ations and access to health care$ " +' + $ 199@(<G>:! @ –:1 1$

@$ & istnes ", Schone 4$ Pa thays to c o ver a ge> the changing roles of pu5= lic and pr iv ate sources$

Health +f f $ !!8(<>GG– @ <$F$ 7aiser Coission on 'edicaid and the Uninsured$ The Uninsu r ed

+ Prier> 7 e y 0 acts +5out Health Insu r ance on the #ve of Health .e= for $ 'enlo P a r;, Calif>

Henry "$ 7aiser 0ai ly 0o u ndation( !1 :$

<$ %e & oe ", 7rois , #dlund C, et al$ Uninsurance aong children hose parents are losing

'edicaid co v erage> results fro a stat e ide surv ey of )re g on failies$ Health Serv .es$

!!8( G :21 Pt 3>G!1–G1 8$

8$ %e & oe "#, T illotson C", - allace S$ Children * s receipt of health care services and faily health

insurance patterns$ +nn 0 a 'ed$ !!9(<>

G!F–G1 :$

http://refhub.elsevier.com/S1876-2859(15)00217-X/sref1




























































































































+C+%#'IC P#%I+T.ICS 0+'I H#+TH I SU.+C# T.#%S, 1998–!11 <

9$ %e & oe "#, T illotson C", +ngier H, et al$ Predict o rs of children *s health insurance co v erage

discontin u ity in 1998 ve r sus !!9> parental cov erage continuity plays a aDor role$ 'atern Child

Health "$ !1@(

19>889–89 F$

1!$ %e & oe "#, 'arino ', +ngier H, et al$ # f fect of eApan d ing 'edicaid for parents on children * s

health insurance c o ver a ge> lessons fro the )re gon e A perient$ "+'+ P ediat r $

!1@(1F9>e1G: 1 G @$

11$ Cohen .+, 'a;uc %', 4ernstein +4, et al$ Health insurancec o v e rage trends, 19@9–!!<> estiates fro the ational Health

Intervi e Sur v ey $ atl Health Stat .epor t$ !!9(1<> 1 –@$

1$ %e & oe "#, Cr a ford C, +ngier H, et al$ The associat ion 5eteen pu5= lic c o ver a ge for children

and parents persists, !!– ! 1!$ 'atern Child Health "$ !1@( 1 9>1<FF–1<< G$1:$ Xi e genfuss " , % a vern '#$ T enty years of c o v e rage> an enhanced

current population sur v ey 1 989–!!8$ Health Serv .es$ !11(GF21

Pt 13>199– !9$

1G$ 4erdahl T +, 0riedan 4S, 'cCor ic; 'C, et al$ +nnual report on health care for children and

youth in the United States> trends in racialJeth nic, incoe, and insurance disparities o v er tie,

!!– !!9$ +cad P ediat r $ !1:(1:> 1 91–! :$

1@$ +gency for Healthcare .esearch and Wuality$ 'edical #Apenditure Panel Survey> household

coponent$ +vaila5le at> http>JJeps$ah r N$ g o vJepse5J s urv e yYcopJh o usehold$Ds p( !1!$

+ccessed 0e5ruary

<, !1G$

1F$ Cohen ", 'onheit +, 4eaur e gard 7, et al$ The 'edical #Apend iture

P a nel Sur v ey> a national health inforation resource$ InNuir y$

199F=199 < (::>:<:–:8 9$

1<$ au "S, +das SH, Pa r ; '", et al$ Ipr o ve ent in pr e ven tiv e care of young adults after the

+ f forda5le Care +ct> the + f forda5le Care +ct is helping$ "+'+ P ediat r $ !1G(1F8 >11!1–11! F$18$ /old ., %e & oe "#, 'cIntire P", et al$ .eceipt of dia5etes pr ev ent ive

care aong safety net patients associated ith di f fering le v e ls of insurance c o ve r age$ " +1

4oa r d 0 a 'ed$ !1(@>G– G 9$19$ )lson ', T ang S 0 , e achec; P - $ Children in the United States

ith discontin u ous health insurance c o ve r age$ #ngl " 'ed$ !!@(

:@:>: 8 –:9 1$

!$ US %epartent of Health and Huan Services$ +nnual update of the

HHS po v erty guidelines$ 0 ed . eg$ 1998(F:>9: @ –9:8$

1$ US %epartent of Health and Huan Services$ +nnual update of the

HHS po v erty guidelines$ 0 ed . eg$ !11(<F>:F: < –:F:8$$ - illias .$ + note on ro5ust v ariance estiat ion for cluste r = correlated data$ 4ioetric s $

!!!(@F>FG@ – FG F$:$ 7i H", 0ay ' P , 0euer #", et al$ Perutation tests for Doinpoint

re g ression ith applica tions to cancer rates> correct ion$ Stat 'e d$

!!!( 1 9>::@–:@ 1$

G$ - ong "., Harris "7, .odrigu e =/alindo C, et al$ Incidence of child= hood and adolescent

elanoa in the United States, 19<:– !!9$ P ediatric s $ !1:(1:1>8G F –8@ G$@$ Sion +#, Uddin S/$ ational trends in priary cesarean del iv e r y,

la5or attepts, and la5or success, 199!–!1!$ +1 " )5stet /yneco l$

!1:( !9>@@G$e@@1–@@ G $e@@ 8$

F$ 4arnes .0 - , 'oore ', /arfein .S, et al$ T rends in ortali ty of tu5erculo sis patients in the

United States> the long=ter perspect ive$ +nn #pideio l$ !11(1> < 91–<9 @$




































































http://meps.ahrq.gov/mepsweb/survey_comp/household.jsp





































































































































































+C+%#'IC P#%I+T.ICS 0+'I H#+TH I SU.+C# T.#%S, 1998–!11 <<$ Hill H%, Shaefer H$ C o v e red toda y , sic; toorr o Z T rends and co r =

relates of children * s health insurance insta5ility $ 'ed Ca r e .es . e v$

!11( F 8>@:–@: F$

8$ Soers 4%$ Insuring children or insuring failies> do parental and si5ling co v e rage lead to

ipr o v e d retention of children in 'edicaid and CHIPZ " Health #con$ !!F(@> 1 1@G–11F 9$9$ aauchi ', Carlson '", -right 4", et al$ %oes health insurance

continui ty aong lo =incoe adults ipact their children * s insu r = ance co v erageZ 'atern Child

Health "$ !1:(1<>G8 – @ @$

:!$ Cutler %', /ru5er "$ %oes pu5lic insurance cr o d out pr iv ate insu r =anceZ W " #con$ 199F(111 >:91–G: !$

:1$ /resen C., #dgington S#, augesen ', et al$ T a;e=up of pu5lic in= surance and cr o d=out of

pr iv ate insurance under recent CHIP e A pan= sions to higher incoe children$ Health Serv

.es$ !1(G<>

1999– ! 1 1$

:$ Haersa S, 7i '$ P a rticipation and cr o d out> assessing the ef= fects of parental 'edicaid

e A pansions$ " Health #co n $ !1:(:>

1F!–1< 1$













































































%#&)# #T + +C+%#'IC P#%I+T.ICS8

::$ 'c'orr o S, 7 enney /', - aidann T , et al$ +ccess to pr ivate cov erage for children enrolled

in CHI P $ +cad P ediat r $ !1@(1@2: suppl3>S@!–S @ @$

:G$ oung .+, %e & oe "#$ -ho ill ha v e health insurance in the futureZ

+n updated proDection$ +nn 0 a 'ed$ !1(1!>1@F – 1F $

:@$ /ould #$ #ploye r =sponsor e d health insurance erosion continues in

!!8 and is e A pected to orsen$ Int " Health Ser v $ !1!(G!><G: – << F$

:F$ 7aiser Coission on 'edicaid and the Uninsured$ States respond to fiscal pressure> state

'edicaid spending groth and cost containent in fiscal years !!: and !!G$ .esults fro a@!=state survey$ +vaila5le at> htt p >JJ $; f f $o r gJ edi c ai d Ju p loa d JS ta tes = .es p ond =to= 0iscal=

Pressure=State='edicaid=Spending=/roth=and=Cost=Contain ent$pdf ( !!:$ +ccessed +ugust :,

!11$

:<$ %e & oe "#, 7rois , #dlund C, et al$ Uninsured 5ut eligi5le children>

are their parents insuredZ .ecent findings fro )re g on$ 'ed Ca re$

!!8(GF>:– 8$

:8$ Henry ", 7aiser 0aily 0o u ndation$ .ecent T r ends in 'edicaid and CHIP #n r ollent as of

" anuary !1@> #arly 0 indings f r o the C'S P erforance Indicat o r P r oDect$ 'enlo P a r;,

Calif> Henry "$ 7aiser 0 aily 0o u ndation( !1 @$

:9$ Henry ", 7aiser 0a ily 0ounda tion$ %ata ote> Ho Has the Individ= ual Insur a nce 'ar;et/ r on Under the +ffo r da5le Ca r e +ctZ$ 'enlo Pa r;, Calif> Henry "$ 7aiser 0a ily 0o u ndation(

!1 @$

G!$ Henry ", 7aiser 0a ily 0ounda tion$ Iplee n ting the + C + *s 'edicaid =.elated Health

.efor P r ovisions +fter the Sup r ee Court* s %ecision$ 'enlo Par;, Calif> Henry "$ 7aiser

0ai ly 0o unda= tion( !1$

G1$ Henry ", 7aiser 0a ily 0o u ndation$ +dults -ho .eained Uninsu r ed at the #nd of !1 G $ 'enlo

Par;, Calif> Henry "$ 7aiser 0ai ly 0o un= dation( !1@$G$ 7aiser 0aily 0oundation$ Children*s health coverage> 'edicaid,

CHIP and the +C+$ +vaila5le at> http>JJ; f f$orgJ h ealth=refo r Jissue= 5riefJchildr ens=health=

c ov erage=edica id=chip=and= the=acaJ( !1G$ +ccessed 0e5ruary :, !1@$G:$ Health Policy 4rief> the faily glitch$ Health +ffairs, ove5er 1!,

!1G, +vaila5le at> http>JJ $healtha f fairs$o rgJhealthp o li cy5riefsJ

5rief$php Z 5riefYidB19$ +ccessed "une 18, !1@$

GG$ Selden T', %u5ay , 'iller /#, et al$ 'a n y failies ay face sharply higher costs if pu5lic

health insurance for their children is rolled 5ac;$ Health +f f $ !1@( : G>F9<–<! F$




















http://www.kff.org/medicaid/upload/States-Respond-to-Fiscal-Pressure-State-Medicaid-Spending-Growth-and-Cost-Containment.pdf



































































http://kff.org/health-reform/issue-brief/childrens-health-coverage-medicaid-chip-and-the-aca/





http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=129






























































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