Health Insurance Coverage of Children in Iowa: An Overview of the 2010 Iowa Child and Family Household Health Survey

Transcription

1 Health Policy Research Health Insurance Coverage of Children in Iowa: An Overview of the 2010 Iowa Child and Family Household Health Survey Peter C. Damiano University of Iowa Ki H. Park University of Iowa Jean C. Willard University of Iowa Copyright 2013 the authors Hosted by Iowa Research Online. For more information please contact:

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3 June 2013 Health Insurance Coverage of Children in Iowa: An Overview of the 2010 Iowa Child and Family Household Health Survey Peter C. Damiano* Director, Public Policy Center Professor, Preventive & Community Dentistry Ki H. Park* Assistant Research Scientist Jean C. Willard* Senior Research Associate *Public Policy Center Child Health Specialty Clinics The University of Iowa

4 Table of Contents Health'Insurance'Coverage'of'Children'in'Iowa Background'...'3 Methods'...'4 Identification'of'Insurance'Coverage'...'5 Health'Insurance'Coverage'...'6 Uninsured'Children'...'7 Parents 'Insurance'Coverage'...'9 Rating'Children s'insurance'coverage'...'10 Factors'Associated'with'Type'of'Insurance'Coverage'...'11 Children s'health'status'...'13 Access'and'Need'...'14 Medical'Home'...'15 Personal'Doctor'...'15 Main'Place'for'Care'...'15 Referrals'...'16 Preventive'Care'...'16 Emergency'Room'Visits'...'16 Ability'to'Pay'for'Care'...'16 Dental'Insurance'Coverage'...'17 Conclusions'...'19 Implications'for'Implementation'of'the'Affordable'Care'Act'...'20 Appendix:'Health''coverage'by'demographics'...'21 2

5 Background Health coverage has been shown to greatly affect financial access to health care services, and potentially, quality of health care. Data presented in this report is from the 2010 Iowa Child and Family Household Health Survey (IHHS), and explores the level of health coverage among children in the state of Iowa, the factors related to their type of coverage, and related health outcomes. The IHHS is a collaborative effort of the Iowa Department of Public Health, the University of Iowa Public Policy Center, and the Iowa Child Health Specialty Clinics, and is designed to measure health and wellbeing of children and families in the state. The data from the 2010 survey, the third IHHS since 2000, was collected using population-based telephone and Internet surveys with parents from fall 2010 through spring Iowa families were asked over 165 questions regarding a randomlyselected child in the household and about their own coverage as well as topics related to their child s health such as: Functional health status; Access to and/or need for care; Medical home site; Prescription medications; Behavioral and emotional health and health care; Early childhood issues; Oral health; Child care and school issues; Social determinants of health; Nutrition and physical activity; Parent health status and family health; Substance use and gambling; and Demographic characteristics of the child and family. The population-based survey results in this report represent information for the 820,000 children in Iowa (based on the 2010 Census) along with information about parents coverage. Children account for about 25% of Iowa s population. Iowa s proportion of children is similar to that of the US as a whole (26%). An overview of the 2010 survey results is presented in this report. Many other noteworthy statistics can be found in the tables accompanying this report. 3

6 Methods The survey utilized an address-based sampling design to select the families statewide that were invited to participate in the study. Data collection was completed using mixed-mode telephone and Internet survey methods. First, a packet was mailed to a statewide random sample of addresses drawn from the United States Postal Service (USPS) Delivery Sequence File (DSF). The packet included an information letter with instructions for completing a web-based questionnaire, and if the web mode were not accessed within the next week, a follow up phone call would be placed. The University of Northern Iowa Center for Social and Behavioral Research (CSBR) coordinated the data collection efforts and made phone follow-up calls to those who did not complete the web-based survey (a phone number was available for about 60% of the sample). During the core data collection period, 1,859 phone and 527 online interviews took place with the parent or guardian of one randomly selected child age under 18 living in the household. Respondents were primarily mothers (78%), although 16% were fathers. The data was weighted to account for family size and post-stratified to reflect the 2010 child population in Iowa. Included in this report are results for Iowa children and adolescents age 17 or younger and their parents (n = 2,386). There were almost equal numbers of boys (51%) and girls (49%) included in the sample. The age distribution of the children in the sample is shown in the Table 1. Table 1. Demographic Characteristics of Children and their Families from whom Data were Collected (Weighted Sample) Age of Child Sex Percentage 0-5 years 33.3% 6-12 years 38.6% years 28.1% Female 48.7% Male 51.3% Federal Poverty Level () status <134% 11.7% % 15.9% % 23.2% 300+% 49.2% Race of Child** African-American (non- 4.7% White (non- 92.2% Ethnicity Spanish/Hispanic 6.5% * Total is less than sample because of missing data. ** Racial groups collected in the questionnaire were: African-Americans, Whites, Asians or Pacific Islanders, American Indians or Native Americans, and Other. The question allowed respondents to choose multiple races. 4

7 Identification of Insurance Coverage In this study, health coverage was defined at two points in time: 1) at the time of the interview, and 2) at any point in the previous year. To determine coverage at the time of the interview, participants were asked the following: Question 1: Do you or someone else have any type of health care coverage for [CHILD] including health, prepaid plans such as HMOs, or government plans such as Medicaid or Title 19? o Options for Response: Yes, No, Don t Know/Refused Question 2: What type of health care coverage do you use to pay for most of [CHILD s] medical care? Is it coverage through o Options for Response: Employer, Someone Else s Employer, A Plan You Buy, hawk-i, Medicaid, Other Participants were asked the following to determine coverage during the previous year for those currently insured (i.e., periods of being uninsured in past year): Question 1: In the past 12 months, has there been any time when [CHILD] has not had any health? o Options for Response: Yes, No, Don t Know/Refused For this report, the primary comparisons are between those respondents who, at the time of the survey, either: Had private ; Had public (i.e., Medicaid or hawk-i, Iowa s Separate State Child Health Insurance Program [S-CHIP]); or Were uninsured. 5

8 Health Insurance Coverage Ninety-seven percent of all children in Iowa were covered with either private or public health coverage as is shown in Figure 1. Iowa Children's Insurance Coverage 3% 22% In , 3% of Iowa children were without medical. 75% Public Insurance Private Insurance No Insurance Figure 1. Health Insurance Coverage of Children in Iowa The majority of Iowa children (75%) had their primary health coverage through private. This statistic was a decrease from the 2000 statistic (84%) as the proportion of employer-based for children declined and those with public increased. The 2010 survey results were similar to the percentage of children enrolled in private in Among those with, 70% had employer-based health coverage, while the other 7% had coverage through an individual policy (similar to proportions as in the 2000 and 2005 surveys). The remainder of children with (23%) had public or another form of. Slightly more than one in five of Iowa children had public either through the Medicaid program (18%) or the hawk-i program (4%). Less than 1% had their primary coverage through military-related (e.g., Tricare, Veterans Affairs [VA]). Additional questions were asked about the two public program options for children in Iowa. Approximately one in six children (16%) in Iowa not currently enrolled in Medicaid had been in the program at some point in their lives, including 44% of the uninsured children and 13% of the children with private. Regarding the hawk-i program, 6% of children not currently in the program had been enrolled in hawk-i at some point in their lives, including 13% of the uninsured children and 4% of the children with private. 6

9 Uninsured Children Sixty percent of uninsured children were eligible for Medicaid or hawk-i. Approximately 3% of Iowa children were uninsured at the time of the survey, similar to the number in 2005, and a decrease from 6% in 2000, which is shown in Figure 2. This statistic matched national trends indicating a decline in uninsured children since the beginning of the Children s Health Insurance Program (CHIP) in The 2010 rate (3%) was similar to a Census Bureau report based on the American Community Survey that found that 4% of Iowa children were uninsured in % 45% 40% 35% 30% 25% 20% US Iowa 15% 10% 5% 12% 6% 11% 8% 3% 3% A total of 99% of children in Iowa could have health if children already eligible for Medicaid or hawk-i were enrolled into existing programs. 0% Figure 2. Uninsured Children in the US 1,2 and Iowa 3,4 The proportion of uninsured children varied by income; about six out of ten of the uninsured children were from families with incomes under 200% of the Federal Poverty Level (). These children could be eligible for either Medicaid, since 15% were from families with incomes <133%, or the State Children s Health Insurance Program (SCHIP), since 28% were from families with incomes between % and 16% were from families with incomes between % (when the parent s selfreported income is used to estimate ). Thus, a total of 99% of children in Iowa could be covered with health by enrolling those children already eligible for Medicaid and hawk-i into existing programs. Actual program eligibility is more complex than using self-reported income, so this is considered a rough estimate of eligibility. 1 U.S. Census Bureau, Health Insurance Coverage: 2011, Health Insurance Coverage Status, American Community Survey Year estimates. Downloaded from: 2 U.S. Census Bureau, Health Insurance Coverage: 2000, Current Population Report, September Damiano, Peter C, Willard, Jean C, Borst, Jane, Dhooge, Lucia, Hageman, Gretchen, Kane, Debra, and Penziner, Andrew J The 2005 Iowa Child and Family Household Health Survey: Statewide Results, First Report in a Series. Vol. 2005, 1st. 4 Willard, Jean C, Damiano, Peter C, and Park, Ki H The 2010 Iowa Child and Family Household Health Survey - Statewide Report. 7

10 100% 90% 4% 6% 2% 1% 80% 70% 60% 50% 40% 30% 20% 10% 0% 96% 94% 98% 99% <134% % % 300+% No Yes Figure 3. Children s Health Coverage in Iowa by Poverty Level Although proportionally lower income children were more likely to be uninsured, the largest number of uninsured children in Iowa was in the higher income group. Those in households with incomes over 200% represent about three-quarters of all children in the state. Thus, about one-third of uninsured children in Iowa have incomes over 200% (about one in six uninsured children were from families with incomes between % ). The proportion of all uninsured children that were from higher income families (200+% ) increased from 21% in 2000 to 31% in This change is likely a result of lower income children enrolling in Medicaid and hawk-i and higher income children with private losing their coverage. Three percent of currently insured Iowa children were uninsured at some point in the previous 12 months, a decrease from 6% in 2000 and 4% in 2005, and this group may be considered at higher risk of being uninsured in the future. However, Iowa s rate was significantly lower than the national average for uninsured children (8%), and fourth lowest nationwide. 8

11 Parents Insurance Coverage Thirty-one percent of uninsured children had parents with coverage. Eleven percent of Iowa s children had a parent who was uninsured at the time of the survey (it was primarily mothers who completed the interview), which was no change from 2000 and As might be expected, there was a relationship between the coverage of children and their parents. Eighty percent of children had parents with the same, a slight decrease from the 2000 and 2005 survey numbers (88% and 83%, respectively). Thirty-one percent of uninsured children had parents with coverage. Also, one-third of children with public had parents who were uninsured. Of those children with private, 2% had parents who were uninsured. Parent coverage varied significantly by the race/ethnicity of the child. Figure 4 shows that almost half of the parents of Hispanic/Latino children were uninsured at the time of the call. 100% 90% 13% 8% 80% 70% 45% 60% 50% 40% 87% 92% No Yes Eleven percent of Iowa children had parents without health coverage; 45% of parents of Hispanic / Latino children 30% 20% 10% 0% African-American (non- 55% Hispanic (all races) White (non- Figure 4. Parents Health Insurance by Children s Race/Ethnicity (Parent Report) were uninsured. 9

12 Rating Children s Insurance Coverage Medicaid and hawk-i public program coverage was rated significantly higher than private health for Iowa children as is shown in Figure 5, which was consistent with results from the 2000 and 2005 surveys. Public coverage was rated as excellent for 56% of children as compared to 37% of those with private. Approximately one in twenty rated both types of as fair or poor. Public was rated significantly higher than private for Iowa children. 100% 90% 80% 70% 60% 50% 40% 6% 4% 15% 22% 25% 36% Fair or Poor Good Very Good 30% 56% Excellent 20% 37% 10% 0% Private Insurance Public Insurance Figure 5. Rating of Health Insurance Coverage (Parent Report) 10

13 Factors Associated with Type of Insurance Coverage Younger children (under age 4) were more likely to be enrolled in public programs. Several factors were evaluated relative to whether the child had private, public or no coverage. These included: 1) demographic characteristics of the child and family, 2) the child s health status, 3) their reported access to health care, and 4) their school and family environment. The rate of uninsured children (3%) was relatively consistent by gender. However, the distribution of children with public or private varied by age, with younger children more likely to be covered by public. The proportion of children with private gradually increased from 71% to 79% of children with increasing age, as is shown in Figure % 2% 4% 3% 90% 80% 70% Uninsured 60% 50% 71% 77% 79% Private Insurance Latino children were 40% 30% 20% 10% 27% 20% 19% Public Insurance: Medicaid, hawk-i more than three times as likely to be uninsured as other children in the state. 0% 0-5 years 6-12 years years Figure 6. Health Insurance of Children in Iowa by Age Group (Parent Report) There was a statistically significant difference in the rate of uninsured children by race/ethnicity and the type of (public vs. private) among those that were insured. Latino children were more than three times as likely to be uninsured as other children in the state (10% vs. 3%), which was an increase from the 2005 survey numbers (7.5% vs. 3%). African-American children were most likely to be enrolled in public programs (62%). Children covered by public were the lowest income group of the three, with 74% of children from families with incomes less than 133%. Among the uninsured children, children from households with income between % were twice as likely to be uninsured as other children in the state (6% vs. 3%). 11

14 100% 90% 80% 70% 38% 10% 36% 2% 3% 56% Uninsured African-American children were most likely to be enrolled in public programs. 60% 50% 40% 30% 20% 10% 62% 54% 80% 17% 42% Private Insurance Public Insurance: Medicaid, hawk-i 0% African-American (non- Hispanic (all races) White (non- Multi-racial/other (non- Figure 7. Health Insurance of Children in Iowa by Race/Ethnicity (Parent Report) The parents of children with private had significantly higher levels of education; 54% had at least a four-year college degree as compared to 22% of the parents of uninsured children and 20% of the parents of children with public coverage who had at least a four-year college degree. Fifty-three percent of uninsured children s parents did not have a high school degree. Parents of insured children had higher educational levels, were more likely to be married, and had higher incomes. Marital status was also related to coverage. Nine out of ten children with private were from families where parents were married or in a marriage-like relationship, as compared to about seven out of ten uninsured children and six out of ten children with public whose parents were in a committed relationship. As expected, parents in the lower were more likely to be uninsured: 37% parents with incomes less than 133% ; 19% parents with incomes between % ; 7% parents with incomes between % ; and 2% parents with incomes above 300%. Parents of Hispanic/Latino children (45%) were also most likely to be uninsured, with parents of African-American children (13%) the second most likely to be uninsured as is shown in Figure 4. 12

15 Children s Health Status Children with private had the highest overall health status as rated by their parents. Sixty-seven percent of privately insured children were reported to be in excellent health as compared to 54% of children covered by public and 50% of uninsured children. This number was similar to that of the 2005 survey, but was a significant change from 2000, when uninsured children were most likely to be rated in excellent health (71%). Children with public (24%) were more likely to have a special health care need compared to uninsured children (16%) and children with private (18%). Uninsured children and children with public had lower health status than children with private. 100% 90% 80% 70% 60% 50% 8% 14% 29% 1% 6% 26% 3% 16% 28% Fair or Poor Good 40% 30% 20% 50% 67% 54% Very Good Excellent 10% 0% Uninsured Private Insurance Public Insurance Figure 8. Overall Health Status by Children s Insurance Coverage (Parent Report) 13

16 Access and Need Almost 25% of More than half of the children in the state (57%) needed medical care of any kind during the previous 12 months. Parents with uninsured children (38%) were less likely to report that the child needed medical care of any kind as compared to children with private (59%) and children with public (54%). Among those who needed medical care, parents of uninsured children (23%) were significantly more likely to report that they could not get the care they needed as compared to parents of children with private (2%) and parents of children with public (5%), which is depicted in Figure 9. uninsured children had an unmet need for care compared to 100% 90% 80% 23% 2% 5% about 5% of insured children. 70% 60% 50% 40% 30% 77% 98% 95% Unmet Need No Unmet Need 20% 10% 0% Uninsured Private Insurance Public Insurance Figure 9. Unmet Medical Care Need by Children s Insurance Coverage 14

17 Medical Home The patient centered medical home is defined by the American Academy of Pediatrics as providing care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. 4 A series of questions were added to the survey in the 2010 to capture the concepts of a medical home. About 80% of children received care that met the About eight in ten children in the state had care that met the definition of a medical home. However, uninsured children (58%) were less likely to have medical home compared to children with public (69%) or private (84%) as is shown in Figure 10. definition of a 100% medical home; however, this was much less likely for uninsured children. 90% 80% 70% 60% 50% 40% 30% 42% 58% 16% 84% 31% 69% No Medical Home Medical Home 20% 10% 0% Uninsured Private Insurance Public Insurance About 25% of uninsured children did not have a personal doctor or nurse; 16% of uninsured children did not have a main place for care. Figure 10. Medical Home by Children s Insurance Coverage (Parent Report) Personal Doctor A key component of whether or not a child has a medical home is the presence of a personal doctor. Ninety-four percent of children had a personal doctor or nurse; however, more than 10% of children with public and about 25% of uninsured children did not have personal doctor or nurse. Main Place for Care Another component of children having a medical home is whether they have one main place to go for the care. The vast majority of children (98%) were reported to have one main place to go when needing care. For uninsured children, however, about one in six did not have a main place for care. 4 American Academy of Pediatrics. The Medical Home: Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Pediatrics Vol. 110 No. 1 July 1, pp

18 About one-third of uninsured children had problems if they needed a referral for specialty care. Referrals Approximately one in six children needed referral services during the past 12 months. Among those who needed these services, 86% of children did not have problem getting a referral. However, one-quarter of publicly insured children and about onethird of uninsured children experienced problems getting referrals for specialty care. Preventive Care About nine in ten children with health in Iowa received preventive care in the past year, with no difference based on whether or not they had or the type of that covered them. Emergency Room Visits Almost 40% of uninsured and publicly insured children received care in an ER last year. Ten times as many uninsured children s parents worried a great deal about paying for their child s health care as those with privately insured children. Approximately one in four children who needed any health care during the past year received this care in an emergency room (ER). Uninsured children were as likely to have made an ER visit as were children with public during the previous year. Children with private were least likely to have made an ER visit, which is shown in Figure % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 39% 61% Uninsured Figure 11. Emergency Room Visits by Children s Insurance Coverage Ability to Pay for Care 22% 78% 37% 63% Private Insurance Public Insurance Yes ER Visit No ER Visit Almost one-third of uninsured children (31%) had parents who worried a great deal about paying for their child s health care as compared to 8% of publicly insured children and 3% of privately insured children whose parents worried about paying for their child s health care. Conversely, 72% of privately insured children and 73% of publicly insured children had parents who did not worry at all about paying for their child s care, compared to 19% of uninsured children s parents who had no worries. 16

19 Dental Insurance Coverage Six times as many children were without dental as without medical. There were significantly more children in Iowa without dental than without medical. Eighteen percent of Iowa children did not have dental at the time of the interview, an improvement from 25% of children in the 2000 survey and 20% of children in the 2005 survey, which is shown in Figure % 90% 80% 70% 60% 50% 40% 30% 20% 25% 20% 18% No Dental Insurance No Medical Insurance 10% 6% 3% 3% 0% Figure 12. Children without Dental and Health Insurance Coverage About 25% of Iowa children had dental through the Medicaid and hawk-i programs. Twenty-one percent of children received dental through the Medicaid program, an increase from 10% of children in the 2000 survey and 17% of children in the 2005 survey. Seventy-three percent of children received dental coverage through private, an increase from 65% of children in the 2000 survey and 61% of children in the 2005 survey. The other 4% of children received dental coverage through the hawk-i program, which was similar to that in Of those children without dental, 12% also did not have health. Thus, 88% of children did have health, with 84% of children covered by private and 4% of children covered by public. Figure 13 presents the need and unmet need of children for dental care. Uninsured children were least likely to report needing dental care in the previous year. Unmet need for dental care was highest among those children without dental, similar to the number in the 2005 survey. Unmet need for dental care was more frequent than unmet need for medical care among all groups. 17

20 100% 90% 80% Unmet need for 70% dental care was highest among uninsured children. 60% 50% 40% 30% 20% 66% 74% 75% 80% Need Unmet Need 10% 0% 20% 9% 6% 3% Uninsured Medicaid hawk-i Private Insurance Figure 13. Need and Unmet Need for Dental Care Among children that were reported to need dental care, most needed either a check-up or cleaning (95%). About one in four children (24%) needed other treatment, such as a filling, and only 3% needed emergency care. 18

21 Conclusions Iowa has one of the lowest rates of uninsured children in the United States, with only 3% of children uninsured, a rate that has not changed since The challenges faced by children and families without health coverage were readily apparent in these results. Uninsured children in Iowa had lower health status ratings, were less likely to have a regular source of care or receive care in a medical home-like environment, and were more likely to seek care in an emergency room. Hispanic/Latino children were most likely to be uninsured, with the gap widening over the last 10 years. A similar pattern is seen with Hispanic/Latino parents, which is the parental group most likely to be without health. More generally, the higher rate of uninsured parents has implications for children because parents care seeking behavior affects how they seek care for their children. Thus, inconsistent or inappropriate patterns of care seeking may result, even if the child has, due to uninsured parents. 5 The role of public programs was also evident in these data. More than onequarter of very young children (ages four and under) were covered through either the Medicaid or hawk-i programs; and the satisfaction ratings with their coverage were higher for public than with private. These programs also provided safety net coverage to large proportions of the racial/ethnic minority populations in the state. Publicly insured children had lower health status ratings, but had rates of unmet need similar to those with private. However, the proportion of publicly insured children with care that met the definition of a medical home was lower, and publicly insured children had higher rates of emergency room use. There is still a significant difference between the rates of medical and dental coverage, though the gap has declined some over the years. The increase in dental coverage could be attributed to the increased number of children covered by public. Public often provides more comprehensive coverage of dental care than private dental policies. The vast majority of children without dental do have private medical ; however, dental coverage is not offered in all employee-sponsored plans. From a methodology perspective, the address-based sampling approach used for the 2010 survey should help control for increased cell phone use. The 2010 survey is also the first survey that included multiple races as an option, and thus, one of the racial/ethnic groups to be compared. 5 Davidoff, A., L. Dubey, G. Kenney, A. Yemane The Effect of Parents Insurance Coverage on Access to Care for Low-Income Children. Inquiry 40, ( ). 19

22 Implications for Implementation of the Affordable Care Act There are some implications from these results for the implementation of the expansion of the Affordable Care Act (ACA) and individual mandate requirements on January 1, With changes happening in the healthcare system due to the ACA, there may be increased incentive for families to find coverage for their children. The individual mandate requires that everyone have coverage through a health care plan. The ACA mandates expanded coverage to provide families with increased opportunities to purchase affordable health or to enroll in Medicaid. Many of Iowa s uninsured children may already be eligible for public coverage through the Medicaid or hawk-i programs. The law s increased incentive for parents to enroll children in a health plan may result in as many eligible children as possible enrolling in these programs. However, continuation of outreach and education efforts will be necessary, at least initially, to reach these families. The increased opportunities for affordable health care should also help the 33% of uninsured children who had parents with health ; many of these parents have that does not provide coverage for dependents. Individual child policies are often too expensive for parents to purchase, especially if the child has a pre-existing condition. Overall costs for expansion to cover these children should be modest because there are a relatively low number of children who are uninsured in Iowa. Additionally, families who purchase private individual child policies have already been assisted by the elimination of pre-existing conditions and annual cost caps, which should also improve coverage received by privately insured children in the state. The ACA s Medicaid health home program for children with multiple chronic diseases that began in 2012 should also improve the proportion of children receiving care that meets the standards of a medical home. Iowa has a unique ability to close the dental gap: it is the only state that allows children under 300% with medical but not dental to receive dental only coverage through the hawk-i program. If this option can become more widely known through the health Exchanges/Marketplaces, it could further improve access to dental care. Dental coverage is required for children receiving policies through the new Insurance Exchanges/Marketplace but a recent interpretation indicates the policies in only have to offer dental but not pay for it. 20

23 Appendix: Health coverage by demographics 21

24 Child s Insurance Status IC1. Do you or someone else have any kind of health care coverage for your child (Sample n = 2,386). Total % Yes 97.2 No 2.8 IC2. Child s type (Sample n = 2,386). Total % Don t have 2.8 Private 75.3 Public : Medicaid, Hawk-I, VA 21.9 Child s type by gender (Sample n = 2,386). Boy Girl Total % Don t have Private Public : Medicaid, Hawk-I, VA

25 Child s type by age group 0-5 years 6-12 years years Total % Don t have Private Public : Medicaid, Hawk-I, VA Child s type by < 133% % % 300+% Total % Don t have Private Public : Medicaid, Hawk-I, VA Note: The total % is slightly different than the previous tables because of the missing income information Child s type by African- American (non- Latino/ Hispanic (all races) White (non- Multiracial (non- Total % Don t have Private Public : Medicaid, Hawk-I, VA

26 Child s type by parent s education High School or Less Some college 4 year college or more Total % Don t have Private Public : Medicaid, Hawk-I, VA

27 Key Questions by Child s Insurance Status Recoded: Dichotomous-HS1 - In general, how would you rate CHILD overall health now? (Sample n = 2,386). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Good-Fair-Poor Excellent-Very Good CSHCN - Children with special health care need (Sample n = 2,386). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % No-CSHCN Yes-CSHCN HS7 - Has your child been diagnosed with a chronic condition or disease that has lasted or is expected to last for at least 12 months? (Sample n = 486). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Yes No

28 AN2 - During the last 12 months, was there any time when CHILD needed medical care but could not get it for any reason? (Sample n = 1,408). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Yes No Personal doctor (n = 658) Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % No Yes Usual place for care: advise and preventive care (n = 388) Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % No Yes Family centered care (n = 377) Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % No Yes

29 Referral and care: Didn't have problem getting care (n = 112) Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % No Yes Care coordination (n = 30) Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % No Yes MEDICAL HOME COMPOSITE MEASURE: (n = 2,340) Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % No Yes AN8 - During the last 12 months, how many times did CHILD go to a hospital emergency room? (Sample n = 1,407). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % 1 time to 4 times to 9 times or more times NONE

30 AN9 - What was the main reason for this visit to the ER? [Thinking about last ER visit] (Sample n = 336). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Trauma/broken bones/stitches Cold/flu Ear infection High fever only Trouble breathing (asthma) Severe cough/croup only Rash Other [SPECIFY] AN10 - Did a doctor, nurse, or emergency personnel tell you to go to the ER for this care? [Thinking about last ER visit] (Sample n = 370). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Yes No AN11 - Do you think this care could have been provided by a doctor's office or clinic if one had been available? [Thinking about last ER visit] (Sample n = 364). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Yes No

31 AN12 - What was the main reason you did not go to a doctor's office or clinic for this care? [Thinking about last ER visit] (n = 248). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Insurance/HMO coverage was inadequate Trouble getting an appointment Distance or transportation problems Available providers did not have expertise child needed Inconvenient hours not open when care needed Did not know where to go at night or on weekend Doctor/Nurse sent me to the ER OTHER [SPECIFY] Recoded: AN8 - During the last 12 months, how many times did CHILD go to a hospital emergency room? (Sample n = 1,407). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % No Yes

32 IC6 - During the last 12 months, how much, if at all, have you worried about your ability to pay for Child s health care? (Sample n = 2,384). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % A great deal Somewhat A little Not at all Recoded: IC6 - During the last 12 months, how much, if at all, have you worried about your ability to pay for Child s health care? (Sample n = 2,384). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % No Yes AN14A - During the last 12 months, has CHILD health care professional encouraged you to take any type of preventive health steps for CHILD e.g. watching what eats or using car seats? [Age < 3] (n = 189). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Yes No

33 AN14B - In the last 12 months, has CHILD health care professional encouraged you to take any type of preventive health steps for CHILD e.g. watching what eats or using bicycle helmets or seat belts? [Age 3-9] (n = 454). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Yes No AN14C - In the last 12 months, has CHILD health care professional encouraged you to take any type of preventive health steps for CHILD e.g. watching what eats or keeping CHILD from smoking or using alcohol? [Age 10+] (n = 748). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Yes No DX1 - Does CHILD currently have that covers dental care? (Sample n = 2,365). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Yes No

34 DX9 - When was CHILD last check-up by a dentist? (Sample n = 2,130). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Less than 12 months ago Between 1 and 2 years ago More than 2 years ago Child has never been to the dentist DX7 - Is there one main place where you usually go for your child s dental care? (Sample n = 2,268). Don't have Private Public Insurance: Medicaid, Hawk-i, VA Total % Yes No CHILD HAS NEVER BEEN

35 Key Questions by Child s Age Group Recoded: Dichotomous-HS1 - In general, how would you rate CHILD overall health now? (Sample n = 2,386). 0 to 5 years 6 to 12 years 13 to 17 years Total % Good-Fair-Poor Excellent-Very Good CSHCN - Children with special health care need (Sample n = 2,386). 0 to 5 years 6 to 12 years 13 to 17 years Total % No-CSHCN Yes-CSHCN HS7 - Has your child been diagnosed with a chronic condition or disease that has lasted or is expected to last for at least 12 months? (Sample n = 486). 0 to 5 years 6 to 12 years 13 to 17 years Total % Yes No AN2 - During the last 12 months, was there any time when CHILD needed medical care but could not get it for any reason? (Sample n = 1,408). 0 to 5 years 6 to 12 years 13 to 17 years Total % Yes No Personal doctor (n = 658) 0 to 5 years 6 to 12 years 13 to 17 years Total % No Yes

36 Usual place for care: advise and preventive care (n = 388) 0 to 5 years 6 to 12 years 13 to 17 years Total % No Yes Family centered care (n = 377) 0 to 5 years 6 to 12 years 13 to 17 years Total % No Yes Referral and care: Didn't have problem getting care (n = 112) 0 to 5 years 6 to 12 years 13 to 17 years Total % No Yes Care coordination (n = 30) 0 to 5 years 6 to 12 years 13 to 17 years Total % No Yes MEDICAL HOME COMPOSITE MEASURE: (n = 2,340) 0 to 5 years 6 to 12 years 13 to 17 years Total % No Yes

37 AN8 - During the last 12 months, how many times did CHILD go to a hospital emergency room? (Sample n = 1,407). 0 to 5 years 6 to 12 years 13 to 17 years Total % 1 time to 4 times to 9 times or more times NONE AN9 - What was the main reason for this visit to the ER? [Thinking about last ER visit] (Sample n = 336). 0 to 5 years 6 to 12 years 13 to 17 years Total % Trauma/broken bones/stitches Cold/flu Ear infection High fever only Trouble breathing (asthma) Severe cough/croup only Rash Other [SPECIFY] AN10 - Did a doctor, nurse, or emergency personnel tell you to go to the ER for this care? [Thinking about last ER visit] (Sample n = 370). 0 to 5 years 6 to 12 years 13 to 17 years Total % Yes No

38 AN11 - Do you think this care could have been provided by a doctor's office or clinic if one had been available? [Thinking about last ER visit] (Sample n = 364). 0 to 5 years 6 to 12 years 13 to 17 years Total % Yes No AN12 - What was the main reason you did not go to a doctor's office or clinic for this care? [Thinking about last ER visit] (n = 248). 0 to 5 years 6 to 12 years 13 to 17 years Total % Insurance/HMO coverage was inadequate Trouble getting an appointment Distance or transportation problems Available providers did not have expertise child needed Inconvenient hours not open when care needed Did not know where to go at night or on weekend Doctor/Nurse sent me to the ER OTHER [SPECIFY] Recoded: AN8 - During the last 12 months, how many times did CHILD go to a hospital emergency room? (Sample n = 1,407). 0 to 5 years 6 to 12 years 13 to 17 years Total % No Yes

39 IC6 - During the last 12 months, how much, if at all, have you worried about your ability to pay for Child s health care? (Sample n = 2,384). 0 to 5 years 6 to 12 years 13 to 17 years Total % A great deal Somewhat A little Not at all Recoded: IC6 - During the last 12 months, how much, if at all, have you worried about your ability to pay for Child s health care? (Sample n = 2,384). 0 to 5 years 6 to 12 years 13 to 17 years Total % No Yes AN14A - During the last 12 months, has CHILD health care professional encouraged you to take any type of preventive health steps for CHILD e.g. watching what eats or using car seats? [Age < 3] (n = 189). 0 to 5 years 6 to 12 years 13 to 17 years Total % Yes No AN14B - In the last 12 months, has CHILD health care professional encouraged you to take any type of preventive health steps for CHILD e.g. watching what eats or using bicycle helmets or seat belts? [Age 3-9] (n = 454). 0 to 5 years 6 to 12 years 13 to 17 years Total % Yes No

40 AN14C - In the last 12 months, has CHILD health care professional encouraged you to take any type of preventive health steps for CHILD e.g. watching what eats or keeping CHILD from smoking or using alcohol? [Age 10+] (n = 748). 0 to 5 years 6 to 12 years 13 to 17 years Total % Yes No DX1 - Does CHILD currently have that covers dental care? (Sample n = 2,365). 0 to 5 years 6 to 12 years 13 to 17 years Total % Yes No DX9 - When was CHILD last check-up by a dentist? (Sample n = 2,130). 0 to 5 years 6 to 12 years 13 to 17 years Total % Less than 12 months ago Between 1 and 2 years ago More than 2 years ago Child has never been to the dentist DX7 - Is there one main place where you usually go for your child s dental care? (Sample n = 2,268). 0 to 5 years 6 to 12 years 13 to 17 years Total % Yes No CHILD HAS NEVER BEEN

41 Key Questions by Household s Recoded: Dichotomous-HS1 - In general, how would you rate CHILD overall health now? (Sample n = 2,386). <133% 133%-199% % 300%+ Total % Good-Fair-Poor Excellent-Very Good CSHCN - Children with special health care need (Sample n = 2,386). <133% 133%-199% % 300%+ Total % No-CSHCN Yes-CSHCN HS7 - Has your child been diagnosed with a chronic condition or disease that has lasted or is expected to last for at least 12 months? (Sample n = 486). <133% 133%-199% % 300%+ Total % Yes No AN2 - During the last 12 months, was there any time when CHILD needed medical care but could not get it for any reason? (Sample n = 1,408). <133% 133%-199% % 300%+ Total % Yes No Personal doctor (n = 658) <133% 133%-199% % 300%+ Total % No Yes

42 Usual place for care: advise and preventive care (n = 388) <133% 133%-199% % 300%+ Total % No Yes Family centered care (n = 377) <133% 133%-199% % 300%+ Total % No Yes Referral and care: Didn't have problem getting care (n = 112) <133% 133%-199% % 300%+ Total % No Yes Care coordination (n = 30) <133% 133%-199% % 300%+ Total % No Yes MEDICAL HOME COMPOSITE MEASURE: (n = 2,340) <133% 133%-199% % 300%+ Total % No Yes

43 AN8 - During the last 12 months, how many times did CHILD go to a hospital emergency room? (Sample n = 1,407). <133% 133%-199% % 300%+ Total % 1 time to 4 times to 9 times or more times NONE AN9 - What was the main reason for this visit to the ER? [Thinking about last ER visit] (Sample n = 336). <133% 133%-199% % 300%+ Total % Trauma/broken bones/stitches Cold/flu Ear infection High fever only Trouble breathing (asthma) Severe cough/croup only Rash Other [SPECIFY] AN10 - Did a doctor, nurse, or emergency personnel tell you to go to the ER for this care? [Thinking about last ER visit] (Sample n = 370). <133% 133%-199% % 300%+ Total % Yes No AN11 - Do you think this care could have been provided by a doctor's office or clinic if one had been available? [Thinking about last ER visit] (Sample n = 364). <133% 133%-199% % 300%+ Total % Yes No

44 AN12 - What was the main reason you did not go to a doctor's office or clinic for this care? [Thinking about last ER visit] (n = 248). <133% 133%-199% % 300%+ Total % Trouble getting an appointment Distance or transportation problems Available providers did not have expertise child needed Inconvenient hours not open when care needed Did not know where to go at night or on weekend Doctor/Nurse sent me to the ER OTHER [SPECIFY] Recoded: AN8 - During the last 12 months, how many times did CHILD go to a hospital emergency room? (Sample n = 1,407). <133% 133%-199% % 300%+ Total % No Yes IC6 - During the last 12 months, how much, if at all, have you worried about your ability to pay for Child s health care? (Sample n = 2,384). <133% 133%-199% % 300%+ Total % A great deal Somewhat A little Not at all

45 Recoded: IC6 - During the last 12 months, how much, if at all, have you worried about your ability to pay for Child s health care? (Sample n = 2,384). <133% 133%-199% % 300%+ Total % No Yes AN14A - During the last 12 months, has CHILD health care professional encouraged you to take any type of preventive health steps for CHILD e.g. watching what eats or using car seats? [Age < 3] (n = 189). <133% 133%-199% % 300%+ Total % Yes No AN14B - In the last 12 months, has CHILD health care professional encouraged you to take any type of preventive health steps for CHILD e.g. watching what eats or using bicycle helmets or seat belts? [Age 3-9] (n = 454). <133% 133%-199% % 300%+ Total % Yes No AN14C - In the last 12 months, has CHILD health care professional encouraged you to take any type of preventive health steps for CHILD e.g. watching what eats or keeping CHILD from smoking or using alcohol? [Age 10+] (n = 748). <133% 133%-199% % 300%+ Total % Yes No DX1 - Does CHILD currently have that covers dental care? (Sample n = 2,365). <133% 133%-199% % 300%+ Total % Yes No

46 DX9 - When was CHILD last check-up by a dentist? (Sample n = 2,130). <133% 133%-199% % 300%+ Total % Less than 12 months ago Between 1 and 2 years ago More than 2 years ago Child has never been to the dentist DX7 - Is there one main place where you usually go for your child s dental care? (Sample n = 2,268). <133% 133%-199% % 300%+ Total % Yes No CHILD HAS NEVER BEEN