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Low-income uninsured children with special health care needs: why aren't they enrolled in public health insurance programs?

OBJECTIVE: We examined potential barriers to enrollment in public programs among low-income children with special health care needs who are uninsured. Barriers considered include parents not knowing about the Medicaid and State Children's Health Insurance programs, not believing that their child is eligible for public coverage, not perceiving the enrollment processes as easy, and not wanting to enroll their child in a public program. METHODOLOGY: The source of data is the 2001 National Survey of Children With Special Health Care Needs. A series of 5 questions about the child's health needs, known as the Children With Special Health Care Needs Screener, was used to identify children with special health care needs. Uninsurance is defined as having no insurance coverage at the time of the survey. Low-income families are defined as those with household incomes below 200% of the federal poverty level. The analytic sample consists of 968 low-income uninsured children with special health care needs. We examined the socioeconomic and demographic characteristics of the sample, the reasons the children lack coverage, and the awareness and perception measures, both individually and combined as a summary measure. RESULTS: Many low-income parents with uninsured children with special health care needs do not have full information about Medicaid and State Children's Health Insurance programs or do not have positive perceptions of the application processes. Although 93.5% had heard of at least 1 of the 2 programs, only 54.6% believed that their child was eligible for public coverage, and just 48.1% believed that the application processes were easy. Almost all said that they would enroll their child if told he or she was eligible for public coverage. CONCLUSIONS: Understanding why uninsured children with special health care needs do not participate in public programs is important, because these programs have the potential to cover almost all of this population. Initiatives to increase enrollment should yield real dividends given that the vast majority of low-income uninsured children with special health care needs have parents who say they would enroll their children in public coverage.

Child↗

School-related expenses, living expenses, and income sources for graduate students in nurse anesthesia programs.

Nurse anesthesia programs (NAPs) are the highest priced programs for graduate students compared with 7 other nursing master's degree programs. Not only are nurse anesthesia programs expensive, but also most students are encouraged by the policies within their individual programs to terminate full-time employment before matriculation. The purpose of this study was to determine school-related and living expenses, as well as the income and sources of income for graduate students in the second year of their NAP. To obtain the information, a student cost survey was designed and administered to participants attending NAPs across the United States during the 2001 school year. In addition, total degree costs were analyzed using a cost model assessing 4 components: educational costs, living expenses, net income foregone, and loan costs. The results showed that total degree costs incurred by graduate students in NAPs to complete their nurse anesthesia education totals $173,007. The analysis of the sources of income showed the following sources were used by respondents: guaranteed student loans; a spouse's income; agreements with future employers; stipends from universities, hospitals, and/or the military; grants; family support; and self-income. Completing a nurse anesthesia education program is expensive, although the expected return on the investment is high. Nevertheless, the expense may keep qualified graduate students from entering NAPs.

Adult↗

Social support, drug use, and employment among low-income women.

This study examined social support and its association with employment, income, and drug use in a sample of 534 low-income women. Functional support was defined as the perceived quality of one's interactions with others. Structural support was defined as the number of individuals within five particular types of networks: social, employment, drug, close, and emergency. Over the two-year study period, significant increases were observed in hours worked, income from work, income from other sources, and total income. There was also a significant decrease in welfare income. Results suggest that the perceived quality of support received is an important factor in achieving positive employment outcomes.

Demography↗

Sources of income and principal employers of California physicians, August 1965. A report of the Bureau of Research and Planning, California Medical Association.

As of August 1965, 54.4 per cent of the 31,551 California physicians in active practice indicated that they receive all of their income from fees-for-service, with another 7.9 per cent receiving at least some of their income in this manner. A total of 8,025 M.D.'s, or 25.4 per cent, are on full-time salaries with no other source of professional income, and the remaining 12.2 per cent are members of group practices, whether on an income sharing or a salaried basis. Almost two-thirds of California physicians (66.6 per cent) consider themselves to be primarily self-employed. Of the 21,011 self-employed physicians, 76.3 per cent are in individual practice, 10.5 per cent in partnerships or groups (without income-sharing arrangements) and the remaining 13.2 per cent in group practice (income-sharing). Slightly over one-fifth of all salaried physicians are employed by some Federal agency, primarily in the armed forces. Among the other four-fifths, more than half are hospital employees, with most of the remainder working for other physicians, clinics or educational institutions. General Practice remains the most heavily populated specialty in California, accounting for 26.3 per cent of all physicians; among self-employed physicians only, G.P.'s number more than one out of every three physicians, or 34.6 per cent. Internists, General Surgeons, Psychiatrists and Obstetrician-Gynecologists rank next in order among all physicians; however, the positions of Psychiatrists and OB.'s is reversed among self-employed physicians.

California↗

Social inequality and general practitioner utilisation: assessing the effects of financial barriers on the use of care by low income groups.

AIMS: To evaluate the extent to which financial barriers are still important deterrents to the utilisation of primary care by low income groups and to examine whether the willingness of patients to switch doctors is associated with ability to pay. METHOD: A practice and a population survey was used to compare the importance of price barriers, patient satisfaction and utilisation rates in two low income areas of Christchurch. Comparisons are made on the basis of gender, age, perceived health status, housing tenure, benefit status, income and ethnicity. RESULTS: Despite the introduction of the Community Services Card, delays in using services because of the cost of care remain significant for many groups of patients, including cardholders themselves. The removal of price barriers at the free clinic raised utilisation rates for all groups. Patterns of use at the free clinic show a consistent inverse relationship between income and consultation rates. However, this was not evident among patients in the population sample who continued to use fee-for-service providers. Further, the results do not support arguments that patients are insensitive to price when changing their doctors. CONCLUSIONS: Despite the removal of part-charges for children, financial barriers remain significant for many low income adults. To a large extent these barriers reflect the nature of welfare reform, particularly the detrimental effects of pro-market housing policies in limiting the disposable incomes of poorer New Zealanders.

Adult↗

The contribution of neighborhood and family income to developmental test scores over the first three years of life.

The effects of neighborhood and family income and family risk factors on developmental test scores at ages 1 through 3 are examined using a subsample (N = 347) from the Infant Health and Development Program. Beneficial effects of low numbers of risks were found for scores at ages 1 through 3. Family poverty was associated with lower scores at ages 2 and 3. Neighborhood affluence was associated with higher scores at age 3. The family risks-test score association at ages 1 through 3 and family income-test score association at ages 2 and 3 were mediated by home environment. Mediated effects were stronger for family income-test score associations at age 3 than for neighborhood income. Moderating effects of family risk on family and neighborhood income effects revealed an interaction between family poverty and risks for scores at age 3. Explanations for the early links between family risks and test scores and the later links between income and test scores are discussed.

Child Development↗

A panel study of migration, self-selection and household real income.

"The impact of migration on income for Swedish multi-adult households is examined using panel data pertaining to a sample of stable household constellations during the period 1980-1990. In contrast to previous studies, data on household disposable income is employed in estimating the income function. The empirical results indicate no significant effect on real disposable income from migration. In addition, the hypothesis of no self-selection, or zero correlation between the errors in the decision function and the income function, cannot be rejected."

Demography↗

The impact of demographic changes on income distribution in a developing country.

"A common hypothesis regarding the distribution of income is that it tends to become more unequal in the initial and middle stages of economic development, in part because of demographic changes. However, previous studies of the effect of demographic changes on income distribution are not based on the underlying micro determinants of the income components." In the present paper, "the micro determinants of the probability of receipt and amount received conditional on receipt of four income components are estimated for three regions defined by the degree of urbanization. Five simulations of hypothetical demographic changes are conducted. The simulated effects on some of the regional income component distributions are fairly considerable in regard both to equalizing the distributions and increasing the shares of the poorest. However, the overall effects are regressive in both urban and rural regions."

Demography↗

Family size and social utility: income distribution dominance criteria.

"This paper generalizes previous results on income distribution dominance in the case where the population of income recipients is broken down into groups with distinct utility functions. The example taken here is that of income redistribution across families of different sizes. The paper first investigates the simplest assumptions that can be made about family utility functions. A simple dominance criterion is then derived under the only assumptions that family functions are increasing and concave with income and the marginal utility of income increases with family size."

Economics↗

Childhood Economic Mobility and Systemic Inflammation Among Men Who Experienced Low Income in Toddlerhood: The Moderating Role of Trait Hostility.

OBJECTIVE: Childhood economic upward mobility (ie, increases in family income across childhood) may attenuate links between childhood poverty and systemic inflammation in adulthood, the extent of which may vary depending on inter-individual differences in personality characteristics, including hostility. METHODS: Men who experienced low income in toddlerhood (N=171) were followed prospectively into adulthood. Annual family income was collected 12 times when men were 1.5 to 17 years old. Men completed the Cook-Medley Hostility Scale and had their fasting blood drawn to measure circulating levels of C-reactive protein (CRP) at age 32. Multiple linear regression analyses examined main and moderation effects of childhood economic upward mobility and adult hostility on CRP levels adjusting for income at 1.5 years, race, parent educational attainment, and adult income, education, waist circumference, and smoking status. RESULTS: Main effects were nonsignificant, but an interaction effect emerged. Counter to expectations, childhood economic upward mobility related to greater adult CRP as trait hostility decreased ( β =-0.203, P =.018). Simple slope analyses further revealed that childhood economic upward mobility was positively associated with CRP among men lower in hostility ( β =0.23, SE=0.09, P =.020) but was unrelated to CRP among men higher in hostility. Results of post hoc sensitivity analyses are also discussed. CONCLUSIONS: Counterintuitive findings suggest that for men who experience poverty in toddlerhood, the association between childhood economic upward mobility and adult CRP may be nuanced and even in the positive direction for men low in hostility, which aligns with work on unintended health consequences of upward mobility.

Humans↗

Macro-to-micro links in the relation between income inequality and mortality.

A growing literature points to links between income inequality and mortality. Any examination of the link should distinguish, both theoretically and empirically, between shifts in inequality that result from changes in the bottom and top of the income distribution. When state-level data from the U.S. censuses of 1980 and 1990 were used to measure differences in mortality, the results indicated that inequality measures reflecting depth of poverty show stronger correlations with mortality than do inequality measures reflecting heights of affluence. In addition, longitudinal data from the Panel Study of Income Dynamics were used to related state-level inequality measures to individual-level data on mortality. This comparison revealed significant associations between degree of income inequality in state of residence and individual risk of death only for nonelderly individuals with middle-class incomes in 1990.

Health Status Indicators↗

Demographic change and income inequality in the United States, 1976-1989.

"The U.S. economy experienced significant increases in the degree of income inequality over the past two decades.... In this paper we consider the effects of race, age, female headship, and college education on the distribution of family income by developing a multivariate methodology that allows us to gauge the influence of one factor while holding other determinants of family incomes constant. Over the period studied we find that race had only a minor effect on the overall size distribution of income. Age had a somewhat greater effect than race. In contrast, the impact of female heads and college education were quite substantial. The multivariate estimates reveal that the effects of female heads and college education both increase the Gini to a much greater extent than the progressivity of federal income taxes decreases it. The effects of college education and female headed families on inequality have grown larger across time, while the influence of age has declined. We find that the effects of race on inequality have changed little over the 1976 to 1989 period."

Age Factors↗

Associations between community income and cancer incidence in Canada and the United States.

BACKGROUND: Associations between socioeconomic status (SES) and the incidence of cancer have been reported previously in the U.S. Canada has more comprehensive health care and social programs than the U.S. The purpose of this study was to compare the strength of associations between SES and cancer incidence in Canada and the U.S. METHODS: The regions studied were the Canadian province of Ontario and the areas of the U.S. covered by the Surveillance, Epidemiology, and End Results (SEER) program. The populations at risk were defined using the 1991 Canadian Census and the 1990 U.S. Census. The populations of Ontario and of the SEER areas of the U.S. were each divided into deciles on the basis of median household income. Population-based cancer registries were used to identify incident cases. Age-standardized incidence rates for all major groups of malignant diseases were calculated for each SES decile in Ontario and in the U.S. Income-associated incidence gradients observed in Ontario and the U.S. were compared. RESULTS: The incidence of most types of cancer was similar in Ontario and the U.S. In both countries, there were moderately strong, inverse associations between income level and the incidence of carcinomas of the cervix, the head and neck region, the lung, and the gastrointestinal tract. In both Ontario and the U.S., several of these diseases were twice as common in the bottom income decile than they were in the top decile. In contrast, carcinoma of the female breast and carcinoma of the prostate were more common among higher income communities in both countries, but the observed associations were weaker in Ontario. CONCLUSIONS: Despite Canada's universal health insurance and more comprehensive social security system, the association between lower socioeconomic status and the incidence of many common cancers is just as strong in Ontario as it is in the U.S. The mechanisms responsible for these associations require further investigation.

Age Factors↗

Income-related reporting heterogeneity in self-assessed health: evidence from France.

This paper tests for income-related reporting heterogeneity in self-assessed health (SAH). It also constructs a synthetic measure of clinical health to decompose the effect of income on SAH into an effect on clinical health (which is called a health production effect) and a reporting heterogeneity effect. We find health production effects essentially for low-income individuals, and reporting heterogeneity for the choice between the medium labels, i.e. 'fair' vs 'good' and for high-income individuals. As such, SAH should be used cautiously for the assessment of income-related health inequalities in France. It is however possible to minimize the reporting heterogeneity bias by converting SAH into a binary variable for poor health vs other health statuses.

Adult↗

Shared 'features' in prices: income and price elasticities for health care expenditures.

The evidence found in most studies suggests a strong positive relationship between health care expenditure and gross domestic product. However, this evidence weakens with respect to the actual value of the income elasticity. There are two possible sources of these discrepancies, the use of arbitrary deflators and specification errors. We find that health PPP cannot be taken as a 'universal' price index. The problem is that its components do not move together. Nevertheless, we derive a 'universal' health price index from a dynamic system in which its components share both short and long run co-movements. The omission of relevant explanatory variables seems to be the main cause of the discrepancies. We confirm that there exists a strong positive relationship between per capita health care expenditure and per capita GDP. However we estimate a long run income elasticity at or around unity, although it is greater than unity for the countries with lower per capita income (Spain and Ireland). The results for income elasticity are the same regardless of whether health care expenditure is converted using the GDP PPP or the 'universal' health price index. The importance of non-income variables is also confirmed, in particular the relative price of health care. We find that relative price has a strong rationing effect on the quantity of health demanded and has no effect on the expenditures.

Data Interpretation, Statistical↗

Associations of income with self-reported ill-health and health resources in a rural community sample of Austria.

OBJECTIVES: Three levels of health indicators (1) self-reported ill-health, (2) internal health resources, and (3) external health resources were analysed in relation to a four-category house-hold income distribution in order to describe possible social gradients. The particular aim of this study was to obtain information on the association of income data with self-reported ill-health. METHODS: This cross-sectional study was based on a health survey. The sample represents around 10% of the rural population of some communities in Styria, randomly selected from the population registry. Interview data was collected from 3781 participants aged 15 years and older, 1559 males and 2222 females. RESULTS: The results show that individuals from lower house-hold income classes are disadvantaged with regard to indicators of ill-health, internal and external health resources. Overall, the link between low income and poor health is highly consistent within our data. CONCLUSIONS: Considering our results we conclude that internal and external health resources are as unequally distributed over income levels as health outcome indicators.

Adolescent↗

Genetic effects on physical health: lower at higher income levels.

Given the robust finding that people in higher income groups tend to experience better physical health, there is interest in identifying mechanisms underlying this gradient. Using a nationwide sample of 719 twin pairs from the National Survey of Midlife Development in the United States, we investigated the possibility that gene-environment interaction underlies the income-health gradient. We observed that genetic variance associated with 2 measures of physical health, number of chronic illnesses and body mass index, each declined significantly with increasing income. This interaction effect could not be removed by adjusting income for the presence of health insurance coverage and education, suggesting that the interaction is not simply a result of differences in levels of those characteristics with income.

Adult↗

Income and dietary adequacy in an agricultural community.

Although many studies as well as conventional wisdom suggest that increases in income result in improved diet and nutritional status in rural areas of developing countries, several recent studies have failed to demonstrate such a relationship. In this paper the relationships between material wealth and income and dietary strategies are examined for an agricultural community in rural Mexico. A superficial examination focusing on summary indices of dietary adequacy frequently cited in the literature and indices of wealth and income demonstrates a positive relationship between them in this community. However, an examination of the same data emphasizing alternative dietary strategies to achieve nutritional adequacy shows a more complex picture. Increasing income is associated with consumption of purchased foods especially foods of animal origin, and is not associated with the consumption of staple foods produced within the household. Diets dependent on purchased foods do not necessarily meet nutritional needs more adequately than diets which rely on agricultural products and gathered foods. Among the implications of this research are a need for a method of analysis which focuses on alternative nutritional strategies available in particular settings, and a need to reassess the relative importance of income generating activities and subsistence agriculture in areas undergoing agricultural change.

Agriculture↗