Quality of Health Insurance Coverage and Access to Care for Children in Low-Income Families

IMPORTANCE: An increasing diversity of children's health coverage options under the US Patient Protection and Affordable Care Act, together with uncertainty regarding reauthorization of the Children's Health Insurance Program (CHIP) beyond 2017, merits renewed attention on the quality of these options for children. OBJECTIVE: To compare health care access, quality, and cost outcomes by insurance type (Medicaid, CHIP, private, and uninsured) for children in households with low to moderate incomes. DESIGN, SETTING, AND PARTICIPANTS: A repeated cross-sectional analysis was conducted using data from the 2003, 2007, and 2011-2012 US National Surveys of Children's Health, comprising 80,655 children 17 years or younger, weighted to 67 million children nationally, with household incomes between 100% and 300% of the federal poverty level. Multivariable logistic regression models compared caregiver-reported outcomes across insurance types. Analysis was conducted between July 14, 2014, and May 6, 2015. EXPOSURES: Insurance type was ascertained using a caregiver-reported measure of insurance status and each household's poverty status (percentage of the federal poverty level). MAIN OUTCOMES AND MEASURES: Caregiver-reported outcomes related to access to primary and specialty care, unmet needs, out-of-pocket costs, care coordination, and satisfaction with care. RESULTS: Among the 80,655 children, 51,123 (57.3%) had private insurance, 11,853 (13.6%) had Medicaid, 9554 (18.4%) had CHIP, and 8125 (10.8%) were uninsured. In a multivariable logistic regression model (with results reported as adjusted probabilities 95% CIs), children insured by Medicaid and CHIP were significantly more likely to receive a preventive medical (Medicaid, 88% 86%-89%; P < .01; CHIP, 88% 87%-89%; P < .01) and dental (Medicaid, 80% 78%-81%; P < .01; CHIP, 77% 76%-79%; P < .01) visits than were privately insured children (medical, 83% 82%-84%; dental, 73% 72%-74%). Children with all insurance types experienced challenges in access to specialty care, with caregivers of children insured by CHIP reporting the highest rates of difficulty accessing specialty care (28% 24%-32%), problems obtaining a referral (23% 18%-29%), and frustration obtaining health care services (26% 23%-28%). These challenges were also magnified for privately insured children with special health care needs, whose caregivers reported significantly greater problems accessing specialty care (29% 26%-33%) and frustration obtaining health care services (36% 32%-41%) than did caregivers of children insured by Medicaid, and a lower likelihood of insurance always meeting the child's needs (63% 60%-67%) than children insured by Medicaid or CHIP. Caregivers of privately insured children were also significantly more likely to experience out-of-pocket costs (77% 75%-78%) than were caregivers of children insured by Medicaid (26% 23%-28%; P < .01) or CHIP (38% 35%-40%; P < .01). CONCLUSIONS AND RELEVANCE: This examination of caregiver experiences across insurance types revealed important differences that can help guide future policymaking regarding coverage for families with low to moderate incomes.