1 A Disturbing Portrait of Uninsured Minority Children: Reasons for Uninsurance, Parental Awareness of Children’s Uninsured Status, and Children’s Health, Access to Care, Use of Services, and Quality of Care Glenn Flores, Candy Walker, Hua Lin, Tony Fierro, Monica Henry, Ken Massey, Alberto Portillo Division of General Pediatrics UT Southwestern/Children’s Medical Center Dallas Funding: NICHD R01

2 Disclosure l No relevant financial relationships to disclose or COIs to resolve

3 Background l Among US children, Latinos at highest risk and African-Americans at 2 nd highest risk of any racial/ethnic group of being uninsured, at 14% and 9% uninsured, respectively, vs. 7% in whites l Number of uninsured Latino children (2.5 million) continues to exceed number of uninsured white children l Latino and African-American children account for 53% of all uninsured children, although comprising only 38% of total population of US children

4 Background l Not enough known, however, about u Reasons for Medicaid- and CHIP-eligible minority children being uninsured u Parental awareness of minority children’s uninsured status u Uninsured minority children’s health, access to care, use of services, and quality of care

5 Study Aim l For uninsured but Medicaid- and CHIP-eligible minority children, to examine: u Reasons for being uninsured u Parental awareness of child’s uninsured status, u Children’s health, access to care, use of services, and quality of care

6 Methods l Research design: cross-sectional survey, as part of randomized, controlled trial of an insurance intervention for uninsured children l Study sites u Five communities in Dallas metropolitan area with highest proportion of uninsured and poor minority children u Recruitment occurred at 91 community sites, including supermarkets, department stores, public libraries, Goodwill stores, food banks, health fairs, Boys and Girls clubs, churches, schools, Laundromats, and housing projects

7 Methods l Eligibility criteria u Latino or African-American race/ethnicity u Age: 0-17 years old u No health insurance coverage, and eligible for but not enrolled in Medicaid or CHIP u Residing in Dallas County l Recruitment performed from June 2011 to January 2014 by trained, bilingual Latino and African-American staff

8 Methods l Characteristics examined (using validated instruments) included: u Sociodemographic characteristics u Health status u Use of health services u Quality of pediatric care (scale of 0-10, where 0 = worst and 10 = best) u Quality of life u Parental satisfaction u Financial burden

9 Results: Sample Characteristics l 49,411 potential caregivers screened for eligibility l Final sample size consisted of 275 uninsured Latino and African-American (AA) children eligible for but not enrolled in Medicaid or CHIP l Race/ethnicity: Latinos, 64%; AAs, 36% l 96% of caregivers female, 39% married and living with their spouse, and 32% had limited English proficiency l Mean annual family income = $21,864 (range: $1,440- $64,000). l Mean age of uninsured children = 7.3 years (range: 1-18), 51% male, and 95% born in US

10 Health-Insurance Characteristics l Mean time without insurance = 14 months (range: 1-144) l For those ever insured (95%), most frequent reasons for loss of insurance: u Insurance expired and never reapplied (24%) u Parent told income too high (13%) u Missing paperwork (10%) u “Don’t know why” (10%) l Among those never insured (5%), reasons for never having insurance included language barriers, too much hassle, and “move to Texas,” each at 20% l Only 51% of parents aware of their uninsured child’s eligibility for Medicaid or CHIP

11 Results: Health Status l 40% of children were in suboptimal health (not excellent/very good) l About 2/3 had special healthcare needs l 82% of parents reported worrying about their child’s health more than other people l 73% of parents reported worry or concern about their child’s physical health

12 Results: Access to Care and Unmet Needs l Only 37% of children have primary-care provider (PCP) l 62% have usual source of preventive care l 72% have delayed or did not receive needed healthcare l 53% have not received all needed dental care l 90% have not received all needed acute care l 12% have not received all needed specialty care l 11% have not received all needed vision care

13 Results: Quality of Care l Parental ratings (scale of 0-10, where 10 = best) of quality of pediatric care low u Overall mean = 4.8 u Primary care = 3.6 u Specialty care = 2.1 u Acute care = 3.9

14 Results: Financial Burden l 45% of parents reported they needed additional income to cover child’s medical expenses l 35% reported child’s health caused financial problems for family l 23% cut down their work hours to provide healthcare for their child l 10% ceased working because of child’s health

15 Comparison of Latino vs. AA Children CharacteristicLatinosAAsP Worry about child’s health more than other people89%73%<.01 No usual source of preventive care51%23%<.01 Same source of sick care and preventive care40%55%.02 No PCP70%52%<.01 Usual source of care has night or weekend hours7%21%<.01 Has 24-hour phone coverage for sick care5%25%<.01

16 Comparison of Latino vs. AA Children CharacteristicLatinosAAsP Never/sometimes receives help or advice over phone3%11%.01 Didn’t receive all needed acute care5%18%.01 Didn’t receive all needed prescription medications7%15%.03 Didn’t receive all needed vision care30%48%<.01 Doctor never/sometimes understands how you prefer to raise child21%37%.01 Need additional income to cover child’s medical expenses39%55%<.01

17 Conclusions l About half of parents of uninsured minority children unaware of their children’s eligibility for Medicaid or CHIP l Uninsured minority children average 14 months without health insurance u Some have been uninsured as long as 12 years u 10% have never been insured in their lifetime l For uninsured children who have been previously insured, most common obstacle not reapplying after insurance expiration

18 Conclusions l Many uninsured minority children in poor health, most have special healthcare needs, and > ¾ of their parents worry about their children’s health more than other people l About 2/3 of uninsured minority children have no PCP, most have delayed or not received all needed health and dental care, many have unmet specialty and vision care needs, and quality-of- care ratings quite low

19 Conclusions l > 1/3 of parents of uninsured minority children report child’s health causes financial problems for family u 1 in 10 ceased working due to child’s health l Uninsured Latino children at significantly higher risk of u Parental worry about child’s health u Having no PCP u Lacking 24-hour phone coverage for sick care

20 Implications l Parents of uninsured minority children need better education and awareness regarding Medicaid/CHIP eligibility and application process l Improvements needed in Medicaid/CHIP outreach and enrollment, such as greater use of known effective interventions, including community health workers and promotoras l Medicaid and CHIP should be maintained or expanded, and efforts to defund CHIP—such as recent House amendment to Continuing Resolution—should be avoided

21 Implications l There’s urgent need to insure and provide PCPs to uninsured Latino children u Given especially high risk for inefficient, costly use of ED for care, due to vast majority lacking access to 24-hour phone coverage for sick care