Children with Special Health Care Needs in CHIP: Access, Use, and Child and Family Outcomes Joseph S. Zickafoose, MD, MS; Kimberly V. Smith, PhD, MPA; Claire Dye, MSPH From Mathematica Policy Research, Ann Arbor, Mich (Dr Zickafoose and Dr Smith); and Mathematica Policy Research, Princeton, NJ (Ms Dye) The authors declare that they have no conflict of interest. Address correspondence to Joseph S. Zickafoose, MD, MS, Mathematica Policy Research, 220 E Huron St, Suite 300, Ann Arbor, MI 48104 (e-mail: [email protected]). Received for publication November 2, 2014; accepted February 4, 2015.
ABSTRACT OBJECTIVE: To assess how the Children’s Health Insurance Program (CHIP) affects outcomes for children with special health care needs (CSHCN). METHODS: We used data from a survey of parents of recent and established CHIP enrollees conducted from January 2012 through March 2013 as part of a congressionally mandated evaluation of CHIP. We identified CSHCN in the sample using the Child and Adolescent Health Measurement Initiative’s CSHCN screener. We compared the health care experiences of established CHIP enrollees to the pre-enrollment experiences of previously uninsured and privately insured recent CHIP enrollees, controlling for observable characteristics. RESULTS: Parents of 4142 recent enrollees and 5518 established enrollees responded to the survey (response rates, 46% recent enrollees and 51% established enrollees). In the 10 survey states, about one-fourth of CHIP enrollees had a special health care need. Compared to being uninsured, parents of
CSHCN who were established CHIP enrollees reported greater access to and use of medical and dental care, less difficulty meeting their child’s health care needs, fewer unmet needs, and better dental health status for their child. Compared to having private insurance, parents of CSHCN who were established CHIP enrollees reported similar levels of access to and use of medical and dental care and unmet needs, and less difficulty meeting their child’s health care needs. CONCLUSIONS: CHIP has significant benefits for eligible CSHCN and their families compared to being uninsured and appears to have some benefits compared to private insurance.
KEYWORDS: children with special health care needs; Children’s Health Insurance Program; health care access; health care utilization; public health insurance ACADEMIC PEDIATRICS 2015;15:S85–S92
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enrollees have a special health care need, depending on the state.4 CSHCN are defined as children that require “health and related services of a type or amount beyond that required by children generally,”5,6 and the prevalence of CSHCN is higher among low-income families who are likely to be eligible for public insurance programs.7 Access to health care services carries increased importance for CSHCN compared to those without special health care needs, including primary and preventive care to detect problems and manage common conditions; specialty, emergency, and hospital care to manage more severe conditions; and dental care to monitor and maintain dental health, which contributes to overall health.5,8,9 Health insurance coverage has been shown to be strongly associated with increased access to health care services, fewer unmet needs, and decreased financial burdens for CSHCN and their families, but the evidence is mixed on the effects of the type of insurance (public vs private) for these outcomes in CSHCN.9–11 There has been ongoing concern about how well CHIP meets the unique needs of CSHCN because CHIP programs were often not designed with CSHCN specifically in mind and have benefits modeled from private insurance plans, which are typically more restrictive compared to Medicaid.12,13 Prior studies have
The outcomes of Children’s Health Insurance Program (CHIP) coverage for children with special health care needs (CSHCN) have not been assessed in the last decade. CHIP coverage has significant benefits for eligible CSHCN and their families compared to being uninsured and has some benefits compared to private insurance as well.
THE CHILDREN’S HEALTH Insurance Program (CHIP) targets children in low-income households who do not qualify for Medicaid but face significant financial barriers in purchasing private health insurance. Currently, CHIP is authorized through September 2019, but federal funding is approved only through September 2015.1 In considering the implications of the expiration of CHIP funding in the context of health care reforms,2,3 it is important for policy makers and child health advocates to understand the effects the program has on the children it covers and their families, particularly for the most vulnerable groups of children, such as children with special health care needs (CSHCN). Although CSHCN are not a specific target population for the program, 15% to 40% of CHIP ACADEMIC PEDIATRICS Copyright ª 2015 by Academic Pediatric Association
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found that CSHCN who are enrolled in CHIP have greater access to care, fewer unmet needs, and lower levels of caregiver financial burdens related to health care compared to CSHCN who are uninsured.13–17 However, most of these studies were performed relatively early in the evolution of the CHIP program, use data from a small number of states, and do not compare CHIP enrollees to similar privately insured children. In the last decade, CHIP has evolved at the federal and state levels in many ways that could have significant effects on CSHCN, such as required dental and mental health benefits and increased cost sharing.18 In this study, we sought to update the evidence on access to care, service use, and outcomes for CSHCN enrolled in CHIP compared to being uninsured or privately insured.
METHODS SURVEY DATA The data for this study were drawn from a telephonebased survey of parents of 12,197 CHIP enrollees and disenrollees in 10 states fielded by Mathematica Policy Research from January 2012 through March 2013, as part of the Children’s Health Insurance Program Reauthorization Act of 2009–mandated evaluation of CHIP. The states included were Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia. These states were selected because they utilize diverse approaches to providing health insurance coverage for children, represent various geographic areas (including a mix of more rural and more urban states and variation of races/ethnicities), and each contain a significant portion of uninsured children. In 2012, CHIP enrollees in these states represented approximately 57% of CHIP enrollees nationally.19 We used state eligibility and enrollment files to construct the sample frame for each state and randomly selected children (18 years or younger) in 3 strata in each state: 1) established enrollees (children who had been enrolled in CHIP for 12 or more consecutive months at the time of sampling), 2) recent enrollees (children who had been enrolled in CHIP for exactly 3 consecutive months, preceded by a gap in public coverage of at least 2 months, at the time of sampling), and 3) recent disenrollees (children who were disenrolled from the program for exactly 2 months at the time of sampling, and who were previously enrolled for at least 3 months before the month of disenrollment). Recent CHIP enrollees who transferred from Medicaid or who returned to CHIP after a short gap in public insurance coverage (3 months or less) were excluded from the sampling frame for 2 reasons. First, parents of such CHIP enrollees are often unaware of these coverage transitions and therefore are not able to reliably describe health care experiences before their (re)enrollment in CHIP. Second, because their coverage history reflects a period of public coverage, these children do not represent a useful comparison group for assessing how CHIP differs from private or no insurance coverage. The final survey data included responses from parents of 5518 established enrollees, 4142 recent enrollees, and
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2537 disenrollees. The overall survey response rate was 51% for established enrollees, 46% for recent enrollees, and 43% for recent disenrollees. The survey included a wide range of questions related to the sampled child’s current and prior health insurance, health status and needs, and health care use and experiences, many of which were adapted from other large surveys relevant to children’s health. Details on the survey questionnaire and a nonresponse bias analysis are available elsewhere.20,21 The study was reviewed and approved by the New England Institutional Review Board (NEIRB 12-200). STUDY DESIGN We compared the experiences of established enrollees who had been on the program for at least 1 year to the preenrollment experiences of recent CHIP enrollees. Established enrollees were asked about their experiences during the last 12 months of enrollment, while recent enrollees were asked about their experiences during the 12 months before their enrollment in CHIP. We focused our analyses on comparisons between established enrollees and 2 subgroups of recent enrollees: 1) recent enrollees who were uninsured for 5 to 12 months before enrollment, and 2) recent enrollees who were privately insured for 12 months before enrollment. We use the previously uninsured children to compare CHIP to being uninsured and the children previously insured by a private plan to consider how outcomes differ under CHIP versus private coverage. For this study, we limited our analyses to established and recent CHIP enrollees with a special health care need, as identified using the CSHCN screener developed by the Child and Adolescent Health Measurement Initiative.6 DEPENDENT VARIABLES In our analyses, we included dependent variables from 2 broad domains of importance to children, families, and policy makers. The first domain includes measures of health care access and use, including primary and preventive, specialist, hospital, emergency department (ED), and dental care. Responses to some questions are not directly comparable to those in other surveys because of the inclusion of a 12month reference period. This is most notable for questions about having a usual source of medical care and other components of a medical home, where other surveys ask about current access, not access during the previous 12 months.22 For this reason, we present a combination variable that reflects whether the child is reported to have a usual source of care or a personal doctor or nurse; estimates for this combination variable more closely resemble levels of access to these aspects of primary care seen in other large surveys.23,24 We also present the composite measure of a child having a medical home frequently used in other survey-based studies, but it is important to note that the absolute values are not comparable to other surveys as a result of the 12-month reference period added to all the questions.22 The second domain of dependent variables includes measures of outcomes related to parents’ ability to get needed care for their child and the child’s health status, which we refer to as “child and family outcomes.” These
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include parents’ confidence they could get needed care for their child, parents’ feelings of stress about meeting their child’s health care needs, parents’ problems paying for their child’s medical bills, unmet needs for health care for the child, parent-reported overall and dental health status, and missed days of school. INDEPENDENT VARIABLES Our key explanatory variable was the insurance status of enrollees during the 12-month recall period. We also included potentially confounding variables, including child’s gender, age, and race/ethnicity; primary language and number of children in the household; parents’ highest education level, employment status, and citizenship; and geographical location at the time of sampling (through a series of state-region dummies). STATISTICAL ANALYSES We used binary dependent variables and estimated linear probability models to generate regression-adjusted differences between established CHIP enrollees and recent enrollees who were 1) previously uninsured and 2) previously covered by private insurance. All analyses were performed by Stata 12 (StataCorp, College Station, Tex) and used survey weights generated to account for the complex multistage sampling design of the survey and nonresponse bias.18,20 Another potential source of bias is the possibility that enrollment in CHIP is correlated with the severity of special health care needs. For example, parents of CSHCN with more severe needs might be more motivated to ensure the child stays insured by not allowing existing coverage to lapse. To address this concern, we performed a sensitivity analysis in which we limited our analytic sample to children with 2 or more special health care needs. We did not have sufficient power to perform analyses on other subgroups of CSHCN, such as those with functional limitations. Enrollment of CHIP could lead to the detection of new and potentially less severe special health care needs through increased access to care compared to previously uninsured children. This would result in a larger population of CSHCN among established enrollees with potentially less severe special health care needs, compared to recent enrollees. To address this concern, we performed a second set of sensitivity analyses among CSHCN who had an identified usual source of care in the prior 12 months, suggesting they had reasonable access to care regardless of insurance status.
RESULTS CHARACTERISTICS OF CSHCN ENROLLED IN CHIP The final survey results included responses from parents of 1527 established CHIP, 247 previously uninsured, and 281 previously privately insured CSHCN. In the 10 states in the survey, one-fourth of CHIP enrollees had a parentreported special health care need (established enrollees: 26%; recent enrollees: 23%). One in 10 CHIP enrollees
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had 2 or more special health care needs (established enrollees: 12%; recent enrollees: 10%). Over half of CHIPenrolled CSHCN were from racial/ethnic minority groups, and about 1 in 5 had a caregiver who primarily spoke Spanish, reflective of the large Hispanic/Latino populations in several of the sample states (Table 1). Nearly all CHIPenrolled CSHCN lived in households with incomes less than 200% of the federal poverty level and had at least 1 parent who was employed outside the home. Compared to the overall populations of established CHIP enrollees, higher proportions of CSHCN were boys and nonHispanic white, lived in single-parent households, and had fair or poor parent-reported overall health. CSHCN recently enrolled in CHIP closely resembled established enrollees, with a few notable exceptions (Table 1). Compared to established enrollees, recent enrollees who were previously uninsured were more likely to be from younger age groups and to have parents with less education. Recent enrollees who were previously privately insured were more likely to be from younger age groups, to have parents with higher education, and to live in households with higher incomes, and they were less likely to be from a minority racial/ethnic group. CHIP COMPARED TO BEING UNINSURED Compared to previously uninsured CSHCN, parents of established CHIP-enrolled CSHCN reported greater access to and use of a variety of health care services (Table 2). In primary care, established enrollees were significantly more likely to have a usual source of care or personal doctor or nurse, receive needed referrals, receive family-centered care, meet the full medical home composite, and receive important preventive care services, such as influenza immunizations and vision screening. Established CHIP-enrolled CSHCN had less trouble finding specialists and were more likely to have a specialist visit, a mental health visit, and a prescription medicine. There were no differences in the proportions with 1 or more ED visits in the prior 12 months, or in the proportions with hospitalizations. There were large differences in access to and use of dental services. Established enrollees were much more likely to have dental coverage, a usual source of dental care, preventive dental visits, and dental sealants. Findings were consistent in direction but not always in significance in sensitivity analyses with CSHCN who had 2 or more special health care needs and those who had a usual source of care for the prior 12 months (Online Appendix Tables 1 and 2). CHIP enrollment appeared to improve multiple familycentered outcomes for CSHCN compared to being uninsured (Table 3). Parents of established CHIP-enrolled CSHCN were significantly more likely to report confidence in getting needed health care for their child, not feeling stressed about meeting their child’s health care needs, and never or rarely having problems paying for their child’s medical bills. Parents of established CHIP-enrolled CSHCN were less likely to report unmet health care needs for their child compared to those of previously uninsured CSHCN. There were no significant differences between the groups in parent-reported overall health status and
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Table 1. Sociodemographic and Health Characteristics of CHIP Enrollees in 10 States, 2012* Weighted % (SE) Children With Special Health Care Needs Characteristic Child’s characteristics Gender, female Age 0–5 y 6–12 y $13 y Race/ethnicity Hispanic Non-Hispanic white Non-Hispanic black Other Missing race/ethnicity Household and parent characteristics Languagek English Spanish Employment At least 1 parent in household employed Missing employment information Family structure Two parents One parent and one stepparent/guardian One parent Other Highest education level of parent/guardian Less than high school High school or equivalent Some college, trade school, or other higher education Missing educational information Household income by FPL 1 year. **Aged $5 years.
research showing the positive effects of enrollment in CHIP compared to being uninsured on health care access and outcomes in CSHCN13–16 and build on those studies by making comparisons to private insurance. It is important to view these findings in the context of the current uncertainty about the future of CHIP, the alternative coverage options available to families should the program be discontinued, and the unique challenges for CSHCN presented by these alternative coverage options. Although many CHIP-enrolled children may be eligible for enrollment in Medicaid or health insurance marketplace plans if the program is discontinued, a substantial proportion of CHIP-enrolled children are predicted to become uninsured as a result of state variation in Medicaid eligibility and the affordability of employer-sponsored and marketplace plans.1,26 This could have negative effects on CSHCN currently enrolled in CHIP. As seen in our findings, CHIP enrollment has been associated with increased access to and use of a wide variety of services vital to the well-being of CSHCN compared to being uninsured. CHIP-enrolled CSHCN were much more likely to have an identified primary care provider; to receive needed referrals; to receive preventive care services that are important to identifying and managing special health care needs,
such as vision and growth screening; and to have visits with mental health providers and other specialists. They were also more likely to receive needed care coordination, although this difference was not statistically significant. The magnitude of the difference for CHIP enrollment compared to being uninsured on CSHCN’s access to and use of dental services was particularly notable, likely reflecting a history of inclusion of dental benefits in many CHIP programs, further strengthened by mandatory requirements in the Children’s Health Insurance Program Reauthorization Act of 2009.18 These findings are particularly notable because the “uninsured” group included many children with at least a few months of insurance coverage in the 12 months before enrollment. If CSHCN currently enrolled in CHIP were to become uninsured, our findings suggest that they could face a significant decrease in access to important health services, an increase in unmet health care needs, and worsening of dental health. For CSHCN currently enrolled in CHIP who could transition to health insurance marketplace plans, our findings suggest they would be likely to have similar access to health care but increased feelings of stress and financial challenges for their parents in meeting their needs, if marketplace plans are similar to private insurance options available when the survey was conducted in 2012. Parents
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of CSHCN face significant personal and financial stresses in meeting the needs of their children, particularly families living near the poverty line, and this can adversely affect parental employment and family functioning.8,27– 29 Although the Affordable Care Act limits cost sharing for low-income families and requires states to establish essential benefits for plans offered on the health insurance marketplaces, early analyses suggest that families transitioning from CHIP to marketplace plans will face significant increases in out-of-pocket costs and fewer benefits.1,30,31 Taken together with our findings, this suggests that families of CSHCN eligible for CHIP could face significantly increased hardships in accessing and paying for care if they are transitioned to private health insurance marketplace plans as they are currently structured. The results from this study should be considered in the context of several strengths and limitations. One advantage of this study is that it explicitly distinguished CHIP enrollees from children enrolled in Medicaid, which is often not possible on national surveys. Moreover, the use of preenrollment experiences of recent CHIP enrollees as a comparison helps to control for unobserved factors like motivation or perceived value of the program that might otherwise differ between CHIP enrollees and those with private or no insurance coverage. Despite this advantage, our results should not be interpreted as causal impacts of CHIP on the outcomes of interest. Although we perform several sensitivity analysis and account for many observable differences between established and recent enrollees, unmeasured factors that affect both the outcomes of interest and a child’s insurance status are likely to remain. Unfortunately, as a result of their limited experience in the program, we could not compare the post-CHIP experience of recent enrollees to their own pre-CHIP experiences to more directly assess the impacts of the program. In addition to these limitations, our assessment of outcomes was dependent on parental report, making them subject to recall and other biases. Parent report is the only valid way to assess many experiences with care, such as familycenteredness, and has been shown to be reasonably accurate for reports of health care utilization.32 Finally, the survey only included children from 10 states, potentially limiting the generalizability of the findings to other states. However, the states were chosen to represent a variety of CHIP features, and CHIP enrollees in these states represent over half of CHIP enrollees in the United States.19 At a time when the future of CHIP is uncertain, our findings show that coverage in CHIP had significant benefits for eligible CSHCN and their families compared to being uninsured, and seemed to have some benefits compared to private insurance as well. Any future changes to CHIP should be considered in the context of the potential effects on this group of vulnerable children.
ACKNOWLEDGMENTS This research was supported by the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, under contract HHSP23320095642WC/HHSP23337021T. The
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views expressed in this report are those of the authors and do not necessarily represent those of the US Department of Health and Human Services, the Office of the Assistant Secretary for Planning and Evaluation, the Urban Institute, or Mathematica Policy Research. Special thanks are due to the many staff members at Mathematica who contributed to the survey, including Julie Ingels, Kirsten Barrett, Eric Grau, and Mark Brinkley, who led the conduct of the survey, and Christopher Trenholm for valuable guidance and feedback on the survey design and earlier versions of work reported in this article.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.acap.2015.02.001. REFERENCES 1. Medicaid and CHIP Payment and Access Commission. Report to the Congress on Medicaid and CHIP: June 2014. Washington, DC: Medicaid and CHIP Payment and Access Commission; 2014. 2. Rubin D, Noonan K. A new opportunity to define health care reform for children. JAMA Pediatr. 2014;168:503–504. 3. Fry-Bowers EK, Nicholas W, Halfon N. Children’s health care and the Patient Protection and Affordable Care Act: what’s at stake? JAMA Pediatr. 2014;168:505–506. 4. Szilagyi P, Shenkman E, Brach C. Children with special health care needs enrolled in the State Children’s Health Insurance Program (SCHIP): patient characteristics and health care needs. Pediatrics. 2003;112(6 pt 2):e508. 5. McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needs. Pediatrics. 1998;102:137–139. 6. Bethell CD, Read D, Stein RE, et al. Identifying children with special health care needs: development and evaluation of a short screening instrument. Ambul Pediatr. 2002;2:38–48. 7. van Dyck PC, Kogan MD, McPherson MG, et al. Prevalence and characteristics of children with special health care needs. Arch Pediatr Adolesc Med. 2004;158:884–890. 8. Mayer ML, Cockrell Skinner A, Slifkin RT. Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs. Pediatrics. 2004;113:e109–e115. 9. Jeffrey AE, Newacheck PW. Role of insurance for children with special health care needs: a synthesis of the evidence. Pediatrics. 2006; 118:e1027–e1038. 10. Honberg LE, Kogan MD, Allen D, et al. Progress in ensuring adequate health insurance for children with special health care needs. Pediatrics. 2009;124:1273–1280. 11. Newacheck PW, Houtrow AJ, Romm DL, et al. The future of health insurance for children with special health care needs. Pediatrics. 2009;123:e940–e947. 12. Hill I, Lutzky AW, Schwalberg R. Are We Responding to Their Needs? States’ Early Experiences Serving Children With Special Health Care Needs under SCHIP. Washington, DC: Urban Institute. Available at: http://www.urban.org/UploadedPDF/occa48.pdf; 2001. Accessed January 29, 2015. 13. Dick AW, Brach C, Allison RA, et al. SCHIP’s impact in three states: how do the most vulnerable children fare? Health Aff (Millwood). 2004;23:63–75. 14. Szilagyi P, Shone L, Klein J. Improved health care among children with special health care needs after enrollment into the State Children’s Health Insurance Program. Ambul Pediatr. 2007;7:10–17. 15. Szilagyi PG, Dick AW, Klein JD, et al. Improved asthma care after enrollment in the State Children’s Health Insurance Program in New York. Pediatrics. 2006;117:486–496. 16. Davidoff A, Kenney G, Dubay L. Effects of the State Children’s Health Insurance Program expansions on children with chronic health conditions. Pediatrics. 2005;116:e34–e42. 17. Kenney G, Trenholm C, Dubay L, et al. The Experiences of SCHIP Enrollees and Disenrollees in 10 States: Findings from the Congressionally Mandated SCHIP Evaluation. Princeton, NJ: Mathematica Policy Research. Washington, DC: Urban Institute. Available at:,
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http://www.urban.org/uploadedPDF/1001117_schip_experiences. pdf; 2005. Accessed January 29, 2015. Harrington M, Kenney GM, Smith K, et al. CHIPRA Mandated Evaluation of the Children’s Health Insurance Program: Final Findings. Report submitted to the Office of the Assistant Secretary for Planning and Evaluation. Ann Arbor, Mich: Mathematica Policy Research. Available at:, http://aspe.hhs.gov/health/reports/2014/ CHIPevaluation/rpt_CHIPevaluation.pdf; 2014. Accessed on January 28, 2015. Henry J. Kaiser Family Foundatation. Number of children ever enrolled in the Children’s Health Insurance Program (CHIP). Available at: http://kff.org/other/state-indicator/annual-chip-enrollment. Accessed June 3, 2014. Smith K, Ingels J, Barrett K, et al. Methods for the 2012 Survey of Medicaid and CHIP Enrollees and Disenrollees: Report submitted to the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Washington, DC: Mathematica Policy Research; 2014. Harrington M. The Children’s Health Insurance Program Reauthorization Act evaluation findings on children’s health insurance coverage in an evolving health care landscape. Acad Pediatr. 2015;15:S1–S6. Bethell CD, Read D, Brockwood K. Using existing population-based data sets to measure the American Academy of Pediatrics definition of medical home for all children and children with special health care needs. Pediatrics. 2004;113:1529–1537. National Center for Health Statistics. National Survey of Children’s Health. Available at: http://www.cdc.gov/nchs/slaits/nsch.htm. Accessed June 3, 2014.
ACADEMIC PEDIATRICS 24. National Center for Health Statistics. National Survey of Children with Special Health Care Needs. Available at: http://www.cdc.gov/ nchs/slaits/cshcn.htm. Accessed June 3, 2014. 25. Hill I, Benatar S. CHIP—evolving to meet the needs of children. Acad Pediatr. 2015;15:S19–S27. 26. Kenney GM, Buettgens M, Guyer J, et al. Improving coverage for children under health reform will require maintaining current eligibility standards for Medicaid and CHIP. Health Aff (Millwood). 2011;30:2371–2381. 27. Kuo DZ, Cohen E, Agrawal R, et al. A national profile of caregiver challenges among more medically complex children with special health care needs. Arch Pediatr Adolesc Med. 2011;165:1020–1026. 28. Ngui EM, Flores G. Satisfaction with care and ease of using health care services among parents of children with special health care needs: the roles of race/ethnicity, insurance, language, and adequacy of family-centered care. Pediatrics. 2006;117:1184–1196. 29. Okumura MJ, Van Cleave J, Gnanasekaran S, et al. Understanding factors associated with work loss for families caring for CSHCN. Pediatrics. 2009;124(suppl):S392–S398. 30. Bly A, Lerche J, Rustagi K. Comparison of Benefits and Cost Sharing in Children’s Health Insurance Programs to Qualified Health Plans. Englewood, Colo: Wakely Consulting Group; 2014. 31. McManus P. A Comparative Review of Essential Health Benefits Pertinent to Children in Large Federal, State, and Small Group Health Insurance Plans: Implications for Selecting State Benchmark Plans. Elk Grove Village, Ill: American Academy of Pediatrics; 2012. 32. D’Souza-Vazirani D, Minkovitz CS, Strobino DM. Validity of maternal report of acute health care use for children younger than 3 years. Arch Pediatr Adolesc Med. 2005;159:167–172.
ABSTRACT OBJECTIVE: To assess how the Children’s Health Insurance Program (CHIP) affects outcomes for children with special health care needs (CSHCN). METHODS: We used data from a survey of parents of recent and established CHIP enrollees conducted from January 2012 through March 2013 as part of a congressionally mandated evaluation of CHIP. We identified CSHCN in the sample using the Child and Adolescent Health Measurement Initiative’s CSHCN screener. We compared the health care experiences of established CHIP enrollees to the pre-enrollment experiences of previously uninsured and privately insured recent CHIP enrollees, controlling for observable characteristics. RESULTS: Parents of 4142 recent enrollees and 5518 established enrollees responded to the survey (response rates, 46% recent enrollees and 51% established enrollees). In the 10 survey states, about one-fourth of CHIP enrollees had a special health care need. Compared to being uninsured, parents of
CSHCN who were established CHIP enrollees reported greater access to and use of medical and dental care, less difficulty meeting their child’s health care needs, fewer unmet needs, and better dental health status for their child. Compared to having private insurance, parents of CSHCN who were established CHIP enrollees reported similar levels of access to and use of medical and dental care and unmet needs, and less difficulty meeting their child’s health care needs. CONCLUSIONS: CHIP has significant benefits for eligible CSHCN and their families compared to being uninsured and appears to have some benefits compared to private insurance.
KEYWORDS: children with special health care needs; Children’s Health Insurance Program; health care access; health care utilization; public health insurance ACADEMIC PEDIATRICS 2015;15:S85–S92
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enrollees have a special health care need, depending on the state.4 CSHCN are defined as children that require “health and related services of a type or amount beyond that required by children generally,”5,6 and the prevalence of CSHCN is higher among low-income families who are likely to be eligible for public insurance programs.7 Access to health care services carries increased importance for CSHCN compared to those without special health care needs, including primary and preventive care to detect problems and manage common conditions; specialty, emergency, and hospital care to manage more severe conditions; and dental care to monitor and maintain dental health, which contributes to overall health.5,8,9 Health insurance coverage has been shown to be strongly associated with increased access to health care services, fewer unmet needs, and decreased financial burdens for CSHCN and their families, but the evidence is mixed on the effects of the type of insurance (public vs private) for these outcomes in CSHCN.9–11 There has been ongoing concern about how well CHIP meets the unique needs of CSHCN because CHIP programs were often not designed with CSHCN specifically in mind and have benefits modeled from private insurance plans, which are typically more restrictive compared to Medicaid.12,13 Prior studies have
The outcomes of Children’s Health Insurance Program (CHIP) coverage for children with special health care needs (CSHCN) have not been assessed in the last decade. CHIP coverage has significant benefits for eligible CSHCN and their families compared to being uninsured and has some benefits compared to private insurance as well.
THE CHILDREN’S HEALTH Insurance Program (CHIP) targets children in low-income households who do not qualify for Medicaid but face significant financial barriers in purchasing private health insurance. Currently, CHIP is authorized through September 2019, but federal funding is approved only through September 2015.1 In considering the implications of the expiration of CHIP funding in the context of health care reforms,2,3 it is important for policy makers and child health advocates to understand the effects the program has on the children it covers and their families, particularly for the most vulnerable groups of children, such as children with special health care needs (CSHCN). Although CSHCN are not a specific target population for the program, 15% to 40% of CHIP ACADEMIC PEDIATRICS Copyright ª 2015 by Academic Pediatric Association
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found that CSHCN who are enrolled in CHIP have greater access to care, fewer unmet needs, and lower levels of caregiver financial burdens related to health care compared to CSHCN who are uninsured.13–17 However, most of these studies were performed relatively early in the evolution of the CHIP program, use data from a small number of states, and do not compare CHIP enrollees to similar privately insured children. In the last decade, CHIP has evolved at the federal and state levels in many ways that could have significant effects on CSHCN, such as required dental and mental health benefits and increased cost sharing.18 In this study, we sought to update the evidence on access to care, service use, and outcomes for CSHCN enrolled in CHIP compared to being uninsured or privately insured.
METHODS SURVEY DATA The data for this study were drawn from a telephonebased survey of parents of 12,197 CHIP enrollees and disenrollees in 10 states fielded by Mathematica Policy Research from January 2012 through March 2013, as part of the Children’s Health Insurance Program Reauthorization Act of 2009–mandated evaluation of CHIP. The states included were Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia. These states were selected because they utilize diverse approaches to providing health insurance coverage for children, represent various geographic areas (including a mix of more rural and more urban states and variation of races/ethnicities), and each contain a significant portion of uninsured children. In 2012, CHIP enrollees in these states represented approximately 57% of CHIP enrollees nationally.19 We used state eligibility and enrollment files to construct the sample frame for each state and randomly selected children (18 years or younger) in 3 strata in each state: 1) established enrollees (children who had been enrolled in CHIP for 12 or more consecutive months at the time of sampling), 2) recent enrollees (children who had been enrolled in CHIP for exactly 3 consecutive months, preceded by a gap in public coverage of at least 2 months, at the time of sampling), and 3) recent disenrollees (children who were disenrolled from the program for exactly 2 months at the time of sampling, and who were previously enrolled for at least 3 months before the month of disenrollment). Recent CHIP enrollees who transferred from Medicaid or who returned to CHIP after a short gap in public insurance coverage (3 months or less) were excluded from the sampling frame for 2 reasons. First, parents of such CHIP enrollees are often unaware of these coverage transitions and therefore are not able to reliably describe health care experiences before their (re)enrollment in CHIP. Second, because their coverage history reflects a period of public coverage, these children do not represent a useful comparison group for assessing how CHIP differs from private or no insurance coverage. The final survey data included responses from parents of 5518 established enrollees, 4142 recent enrollees, and
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2537 disenrollees. The overall survey response rate was 51% for established enrollees, 46% for recent enrollees, and 43% for recent disenrollees. The survey included a wide range of questions related to the sampled child’s current and prior health insurance, health status and needs, and health care use and experiences, many of which were adapted from other large surveys relevant to children’s health. Details on the survey questionnaire and a nonresponse bias analysis are available elsewhere.20,21 The study was reviewed and approved by the New England Institutional Review Board (NEIRB 12-200). STUDY DESIGN We compared the experiences of established enrollees who had been on the program for at least 1 year to the preenrollment experiences of recent CHIP enrollees. Established enrollees were asked about their experiences during the last 12 months of enrollment, while recent enrollees were asked about their experiences during the 12 months before their enrollment in CHIP. We focused our analyses on comparisons between established enrollees and 2 subgroups of recent enrollees: 1) recent enrollees who were uninsured for 5 to 12 months before enrollment, and 2) recent enrollees who were privately insured for 12 months before enrollment. We use the previously uninsured children to compare CHIP to being uninsured and the children previously insured by a private plan to consider how outcomes differ under CHIP versus private coverage. For this study, we limited our analyses to established and recent CHIP enrollees with a special health care need, as identified using the CSHCN screener developed by the Child and Adolescent Health Measurement Initiative.6 DEPENDENT VARIABLES In our analyses, we included dependent variables from 2 broad domains of importance to children, families, and policy makers. The first domain includes measures of health care access and use, including primary and preventive, specialist, hospital, emergency department (ED), and dental care. Responses to some questions are not directly comparable to those in other surveys because of the inclusion of a 12month reference period. This is most notable for questions about having a usual source of medical care and other components of a medical home, where other surveys ask about current access, not access during the previous 12 months.22 For this reason, we present a combination variable that reflects whether the child is reported to have a usual source of care or a personal doctor or nurse; estimates for this combination variable more closely resemble levels of access to these aspects of primary care seen in other large surveys.23,24 We also present the composite measure of a child having a medical home frequently used in other survey-based studies, but it is important to note that the absolute values are not comparable to other surveys as a result of the 12-month reference period added to all the questions.22 The second domain of dependent variables includes measures of outcomes related to parents’ ability to get needed care for their child and the child’s health status, which we refer to as “child and family outcomes.” These
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include parents’ confidence they could get needed care for their child, parents’ feelings of stress about meeting their child’s health care needs, parents’ problems paying for their child’s medical bills, unmet needs for health care for the child, parent-reported overall and dental health status, and missed days of school. INDEPENDENT VARIABLES Our key explanatory variable was the insurance status of enrollees during the 12-month recall period. We also included potentially confounding variables, including child’s gender, age, and race/ethnicity; primary language and number of children in the household; parents’ highest education level, employment status, and citizenship; and geographical location at the time of sampling (through a series of state-region dummies). STATISTICAL ANALYSES We used binary dependent variables and estimated linear probability models to generate regression-adjusted differences between established CHIP enrollees and recent enrollees who were 1) previously uninsured and 2) previously covered by private insurance. All analyses were performed by Stata 12 (StataCorp, College Station, Tex) and used survey weights generated to account for the complex multistage sampling design of the survey and nonresponse bias.18,20 Another potential source of bias is the possibility that enrollment in CHIP is correlated with the severity of special health care needs. For example, parents of CSHCN with more severe needs might be more motivated to ensure the child stays insured by not allowing existing coverage to lapse. To address this concern, we performed a sensitivity analysis in which we limited our analytic sample to children with 2 or more special health care needs. We did not have sufficient power to perform analyses on other subgroups of CSHCN, such as those with functional limitations. Enrollment of CHIP could lead to the detection of new and potentially less severe special health care needs through increased access to care compared to previously uninsured children. This would result in a larger population of CSHCN among established enrollees with potentially less severe special health care needs, compared to recent enrollees. To address this concern, we performed a second set of sensitivity analyses among CSHCN who had an identified usual source of care in the prior 12 months, suggesting they had reasonable access to care regardless of insurance status.
RESULTS CHARACTERISTICS OF CSHCN ENROLLED IN CHIP The final survey results included responses from parents of 1527 established CHIP, 247 previously uninsured, and 281 previously privately insured CSHCN. In the 10 states in the survey, one-fourth of CHIP enrollees had a parentreported special health care need (established enrollees: 26%; recent enrollees: 23%). One in 10 CHIP enrollees
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had 2 or more special health care needs (established enrollees: 12%; recent enrollees: 10%). Over half of CHIPenrolled CSHCN were from racial/ethnic minority groups, and about 1 in 5 had a caregiver who primarily spoke Spanish, reflective of the large Hispanic/Latino populations in several of the sample states (Table 1). Nearly all CHIPenrolled CSHCN lived in households with incomes less than 200% of the federal poverty level and had at least 1 parent who was employed outside the home. Compared to the overall populations of established CHIP enrollees, higher proportions of CSHCN were boys and nonHispanic white, lived in single-parent households, and had fair or poor parent-reported overall health. CSHCN recently enrolled in CHIP closely resembled established enrollees, with a few notable exceptions (Table 1). Compared to established enrollees, recent enrollees who were previously uninsured were more likely to be from younger age groups and to have parents with less education. Recent enrollees who were previously privately insured were more likely to be from younger age groups, to have parents with higher education, and to live in households with higher incomes, and they were less likely to be from a minority racial/ethnic group. CHIP COMPARED TO BEING UNINSURED Compared to previously uninsured CSHCN, parents of established CHIP-enrolled CSHCN reported greater access to and use of a variety of health care services (Table 2). In primary care, established enrollees were significantly more likely to have a usual source of care or personal doctor or nurse, receive needed referrals, receive family-centered care, meet the full medical home composite, and receive important preventive care services, such as influenza immunizations and vision screening. Established CHIP-enrolled CSHCN had less trouble finding specialists and were more likely to have a specialist visit, a mental health visit, and a prescription medicine. There were no differences in the proportions with 1 or more ED visits in the prior 12 months, or in the proportions with hospitalizations. There were large differences in access to and use of dental services. Established enrollees were much more likely to have dental coverage, a usual source of dental care, preventive dental visits, and dental sealants. Findings were consistent in direction but not always in significance in sensitivity analyses with CSHCN who had 2 or more special health care needs and those who had a usual source of care for the prior 12 months (Online Appendix Tables 1 and 2). CHIP enrollment appeared to improve multiple familycentered outcomes for CSHCN compared to being uninsured (Table 3). Parents of established CHIP-enrolled CSHCN were significantly more likely to report confidence in getting needed health care for their child, not feeling stressed about meeting their child’s health care needs, and never or rarely having problems paying for their child’s medical bills. Parents of established CHIP-enrolled CSHCN were less likely to report unmet health care needs for their child compared to those of previously uninsured CSHCN. There were no significant differences between the groups in parent-reported overall health status and
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Table 1. Sociodemographic and Health Characteristics of CHIP Enrollees in 10 States, 2012* Weighted % (SE) Children With Special Health Care Needs Characteristic Child’s characteristics Gender, female Age 0–5 y 6–12 y $13 y Race/ethnicity Hispanic Non-Hispanic white Non-Hispanic black Other Missing race/ethnicity Household and parent characteristics Languagek English Spanish Employment At least 1 parent in household employed Missing employment information Family structure Two parents One parent and one stepparent/guardian One parent Other Highest education level of parent/guardian Less than high school High school or equivalent Some college, trade school, or other higher education Missing educational information Household income by FPL 1 year. **Aged $5 years.
research showing the positive effects of enrollment in CHIP compared to being uninsured on health care access and outcomes in CSHCN13–16 and build on those studies by making comparisons to private insurance. It is important to view these findings in the context of the current uncertainty about the future of CHIP, the alternative coverage options available to families should the program be discontinued, and the unique challenges for CSHCN presented by these alternative coverage options. Although many CHIP-enrolled children may be eligible for enrollment in Medicaid or health insurance marketplace plans if the program is discontinued, a substantial proportion of CHIP-enrolled children are predicted to become uninsured as a result of state variation in Medicaid eligibility and the affordability of employer-sponsored and marketplace plans.1,26 This could have negative effects on CSHCN currently enrolled in CHIP. As seen in our findings, CHIP enrollment has been associated with increased access to and use of a wide variety of services vital to the well-being of CSHCN compared to being uninsured. CHIP-enrolled CSHCN were much more likely to have an identified primary care provider; to receive needed referrals; to receive preventive care services that are important to identifying and managing special health care needs,
such as vision and growth screening; and to have visits with mental health providers and other specialists. They were also more likely to receive needed care coordination, although this difference was not statistically significant. The magnitude of the difference for CHIP enrollment compared to being uninsured on CSHCN’s access to and use of dental services was particularly notable, likely reflecting a history of inclusion of dental benefits in many CHIP programs, further strengthened by mandatory requirements in the Children’s Health Insurance Program Reauthorization Act of 2009.18 These findings are particularly notable because the “uninsured” group included many children with at least a few months of insurance coverage in the 12 months before enrollment. If CSHCN currently enrolled in CHIP were to become uninsured, our findings suggest that they could face a significant decrease in access to important health services, an increase in unmet health care needs, and worsening of dental health. For CSHCN currently enrolled in CHIP who could transition to health insurance marketplace plans, our findings suggest they would be likely to have similar access to health care but increased feelings of stress and financial challenges for their parents in meeting their needs, if marketplace plans are similar to private insurance options available when the survey was conducted in 2012. Parents
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of CSHCN face significant personal and financial stresses in meeting the needs of their children, particularly families living near the poverty line, and this can adversely affect parental employment and family functioning.8,27– 29 Although the Affordable Care Act limits cost sharing for low-income families and requires states to establish essential benefits for plans offered on the health insurance marketplaces, early analyses suggest that families transitioning from CHIP to marketplace plans will face significant increases in out-of-pocket costs and fewer benefits.1,30,31 Taken together with our findings, this suggests that families of CSHCN eligible for CHIP could face significantly increased hardships in accessing and paying for care if they are transitioned to private health insurance marketplace plans as they are currently structured. The results from this study should be considered in the context of several strengths and limitations. One advantage of this study is that it explicitly distinguished CHIP enrollees from children enrolled in Medicaid, which is often not possible on national surveys. Moreover, the use of preenrollment experiences of recent CHIP enrollees as a comparison helps to control for unobserved factors like motivation or perceived value of the program that might otherwise differ between CHIP enrollees and those with private or no insurance coverage. Despite this advantage, our results should not be interpreted as causal impacts of CHIP on the outcomes of interest. Although we perform several sensitivity analysis and account for many observable differences between established and recent enrollees, unmeasured factors that affect both the outcomes of interest and a child’s insurance status are likely to remain. Unfortunately, as a result of their limited experience in the program, we could not compare the post-CHIP experience of recent enrollees to their own pre-CHIP experiences to more directly assess the impacts of the program. In addition to these limitations, our assessment of outcomes was dependent on parental report, making them subject to recall and other biases. Parent report is the only valid way to assess many experiences with care, such as familycenteredness, and has been shown to be reasonably accurate for reports of health care utilization.32 Finally, the survey only included children from 10 states, potentially limiting the generalizability of the findings to other states. However, the states were chosen to represent a variety of CHIP features, and CHIP enrollees in these states represent over half of CHIP enrollees in the United States.19 At a time when the future of CHIP is uncertain, our findings show that coverage in CHIP had significant benefits for eligible CSHCN and their families compared to being uninsured, and seemed to have some benefits compared to private insurance as well. Any future changes to CHIP should be considered in the context of the potential effects on this group of vulnerable children.
ACKNOWLEDGMENTS This research was supported by the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, under contract HHSP23320095642WC/HHSP23337021T. The
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views expressed in this report are those of the authors and do not necessarily represent those of the US Department of Health and Human Services, the Office of the Assistant Secretary for Planning and Evaluation, the Urban Institute, or Mathematica Policy Research. Special thanks are due to the many staff members at Mathematica who contributed to the survey, including Julie Ingels, Kirsten Barrett, Eric Grau, and Mark Brinkley, who led the conduct of the survey, and Christopher Trenholm for valuable guidance and feedback on the survey design and earlier versions of work reported in this article.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.acap.2015.02.001. REFERENCES 1. Medicaid and CHIP Payment and Access Commission. Report to the Congress on Medicaid and CHIP: June 2014. Washington, DC: Medicaid and CHIP Payment and Access Commission; 2014. 2. Rubin D, Noonan K. A new opportunity to define health care reform for children. JAMA Pediatr. 2014;168:503–504. 3. Fry-Bowers EK, Nicholas W, Halfon N. Children’s health care and the Patient Protection and Affordable Care Act: what’s at stake? JAMA Pediatr. 2014;168:505–506. 4. Szilagyi P, Shenkman E, Brach C. Children with special health care needs enrolled in the State Children’s Health Insurance Program (SCHIP): patient characteristics and health care needs. Pediatrics. 2003;112(6 pt 2):e508. 5. McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needs. Pediatrics. 1998;102:137–139. 6. Bethell CD, Read D, Stein RE, et al. Identifying children with special health care needs: development and evaluation of a short screening instrument. Ambul Pediatr. 2002;2:38–48. 7. van Dyck PC, Kogan MD, McPherson MG, et al. Prevalence and characteristics of children with special health care needs. Arch Pediatr Adolesc Med. 2004;158:884–890. 8. Mayer ML, Cockrell Skinner A, Slifkin RT. Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs. Pediatrics. 2004;113:e109–e115. 9. Jeffrey AE, Newacheck PW. Role of insurance for children with special health care needs: a synthesis of the evidence. Pediatrics. 2006; 118:e1027–e1038. 10. Honberg LE, Kogan MD, Allen D, et al. Progress in ensuring adequate health insurance for children with special health care needs. Pediatrics. 2009;124:1273–1280. 11. Newacheck PW, Houtrow AJ, Romm DL, et al. The future of health insurance for children with special health care needs. Pediatrics. 2009;123:e940–e947. 12. Hill I, Lutzky AW, Schwalberg R. Are We Responding to Their Needs? States’ Early Experiences Serving Children With Special Health Care Needs under SCHIP. Washington, DC: Urban Institute. Available at: http://www.urban.org/UploadedPDF/occa48.pdf; 2001. Accessed January 29, 2015. 13. Dick AW, Brach C, Allison RA, et al. SCHIP’s impact in three states: how do the most vulnerable children fare? Health Aff (Millwood). 2004;23:63–75. 14. Szilagyi P, Shone L, Klein J. Improved health care among children with special health care needs after enrollment into the State Children’s Health Insurance Program. Ambul Pediatr. 2007;7:10–17. 15. Szilagyi PG, Dick AW, Klein JD, et al. Improved asthma care after enrollment in the State Children’s Health Insurance Program in New York. Pediatrics. 2006;117:486–496. 16. Davidoff A, Kenney G, Dubay L. Effects of the State Children’s Health Insurance Program expansions on children with chronic health conditions. Pediatrics. 2005;116:e34–e42. 17. Kenney G, Trenholm C, Dubay L, et al. The Experiences of SCHIP Enrollees and Disenrollees in 10 States: Findings from the Congressionally Mandated SCHIP Evaluation. Princeton, NJ: Mathematica Policy Research. Washington, DC: Urban Institute. Available at:,
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http://www.urban.org/uploadedPDF/1001117_schip_experiences. pdf; 2005. Accessed January 29, 2015. Harrington M, Kenney GM, Smith K, et al. CHIPRA Mandated Evaluation of the Children’s Health Insurance Program: Final Findings. Report submitted to the Office of the Assistant Secretary for Planning and Evaluation. Ann Arbor, Mich: Mathematica Policy Research. Available at:, http://aspe.hhs.gov/health/reports/2014/ CHIPevaluation/rpt_CHIPevaluation.pdf; 2014. Accessed on January 28, 2015. Henry J. Kaiser Family Foundatation. Number of children ever enrolled in the Children’s Health Insurance Program (CHIP). Available at: http://kff.org/other/state-indicator/annual-chip-enrollment. Accessed June 3, 2014. Smith K, Ingels J, Barrett K, et al. Methods for the 2012 Survey of Medicaid and CHIP Enrollees and Disenrollees: Report submitted to the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Washington, DC: Mathematica Policy Research; 2014. Harrington M. The Children’s Health Insurance Program Reauthorization Act evaluation findings on children’s health insurance coverage in an evolving health care landscape. Acad Pediatr. 2015;15:S1–S6. Bethell CD, Read D, Brockwood K. Using existing population-based data sets to measure the American Academy of Pediatrics definition of medical home for all children and children with special health care needs. Pediatrics. 2004;113:1529–1537. National Center for Health Statistics. National Survey of Children’s Health. Available at: http://www.cdc.gov/nchs/slaits/nsch.htm. Accessed June 3, 2014.
ACADEMIC PEDIATRICS 24. National Center for Health Statistics. National Survey of Children with Special Health Care Needs. Available at: http://www.cdc.gov/ nchs/slaits/cshcn.htm. Accessed June 3, 2014. 25. Hill I, Benatar S. CHIP—evolving to meet the needs of children. Acad Pediatr. 2015;15:S19–S27. 26. Kenney GM, Buettgens M, Guyer J, et al. Improving coverage for children under health reform will require maintaining current eligibility standards for Medicaid and CHIP. Health Aff (Millwood). 2011;30:2371–2381. 27. Kuo DZ, Cohen E, Agrawal R, et al. A national profile of caregiver challenges among more medically complex children with special health care needs. Arch Pediatr Adolesc Med. 2011;165:1020–1026. 28. Ngui EM, Flores G. Satisfaction with care and ease of using health care services among parents of children with special health care needs: the roles of race/ethnicity, insurance, language, and adequacy of family-centered care. Pediatrics. 2006;117:1184–1196. 29. Okumura MJ, Van Cleave J, Gnanasekaran S, et al. Understanding factors associated with work loss for families caring for CSHCN. Pediatrics. 2009;124(suppl):S392–S398. 30. Bly A, Lerche J, Rustagi K. Comparison of Benefits and Cost Sharing in Children’s Health Insurance Programs to Qualified Health Plans. Englewood, Colo: Wakely Consulting Group; 2014. 31. McManus P. A Comparative Review of Essential Health Benefits Pertinent to Children in Large Federal, State, and Small Group Health Insurance Plans: Implications for Selecting State Benchmark Plans. Elk Grove Village, Ill: American Academy of Pediatrics; 2012. 32. D’Souza-Vazirani D, Minkovitz CS, Strobino DM. Validity of maternal report of acute health care use for children younger than 3 years. Arch Pediatr Adolesc Med. 2005;159:167–172.
