Insurance Coverage and Access to Care for Immigrant Children: The Impact of the Children’s Health Insurance Program Reauthorization Act
By Neel Koyawala August 15, 2013 Mentor: Brendan Saloner, PhD
Roadmap • Background
• Methods
• Results
• Conclusions and policy implications
• “SUMR” insights
Background Methods Results Conclusion “SUMR” Insights
Federal welfare reform law in 1996 restricted immigrants from public insurance during their first five years in the United States.
Immigrant children have lower access to health care than non-immigrant children.
Background Methods Results Conclusion “SUMR” Insights
Background Methods Results Conclusion “SUMR” Insights
“INSURANCE FOR IMMIGRANTS,
TOO!”
Along with immigration reform, advocates have pushed for elimination of the five-year wait period.
Background Methods Results Conclusion “SUMR” Insights
In 2009, gave states the option to eliminate the five-year minimum wait period.
CHIPRA
Background Methods Results Conclusion “SUMR” Insights
In 2009, gave states the option to eliminate the five-year minimum wait period.
CHIPRA
• National Survey of Children’s Health (NSCH), a nationally-representative household survey • 2003, 2007, and 2011/2012 data were used • Telephone-based survey by the CDC
• Sample: 240,110 children in households below 400% FPL • Categorized sample into six categories:
Background Methods Results Conclusion “SUMR” Insights
We examined health care coverage and access using cross-sectional data.
First Generation in a State that Eliminated Five-Year Wait Period
Second Generation in a State that
Eliminated Five-Year Wait Period
Third Generation in a State that Eliminated Five-Year Wait Period
First Generation in a State that Did Not Eliminate Five-Year
Wait Period
Second Generation in a State that Did Not Eliminate Five-Year
Wait Period
Third Generation in a State that Did Not Eliminate the Five-Year Wait Period
First Generation in a State that Eliminated Five-Year Wait Period
We looked at both insurance coverage and health care access measures.
Insurance Coverage Variables:
• Any insurance • Public or private Insurance • Coverage gap in the past twelve
months
Our final model adjust for: • Demographic variables: race, income, sex, age, family structure,
living in MSA, parental education, employment, number of kids in household, general health status
• State variables: minimum wage, unemployment rate
Access to Health Care Variables:
• Personal doctor or nurse • Usual source of care • Preventive medical / dental
visits • Specialist care • Unmet or delayed health care
needs
Background Methods Results Conclusion “SUMR” Insights
Background Methods Results Conclusion “SUMR” Insights
We compared trends over time for immigrant children in the two state categories using a “Difference-in-Differences” approach.
53 52
73
45 46
51
40
45
50
55
60
65
70
75
80
85
2003 2007 2011
% V
aria
ble
of In
tere
st
State implementedpolicyState did not implementpolicy
22%
6%
Difference-in-Differences:
16%
Policy
*P<.05, **P<.001, ***P<.0001
Background Methods Results Conclusion “SUMR” Insights
Insurance rates increased for immigrant children in states that eliminated the five-year wait period.
58 57
78
55 51
51
40
45
50
55
60
65
70
75
80
85
2003 2007 2011
% In
sure
d
Immigrants in statesthat eliminated five-year waitImmigrants in statesthat did not eliminatefive-year wait
27%
6%
Difference-in-Differences:
21%
CHIPRA
*P<.05, **P<.001, ***P<.0001
***
Background Methods Results Conclusion “SUMR” Insights
Most of the increase in insurance rates was from an increase in public insurance.
30 30
51
20
13
19
0
10
20
30
40
50
60
2003 2007 2011
% C
HIP
/ M
edic
aid
Immigrants in statesthat eliminated five-year waitImmigrants in statesthat did not eliminatefive-year wait
32%
17%
Difference-in-Differences:
15%
CHIPRA
*P<.05, **P<.001, ***P<.0001
**
Background Methods Results Conclusion “SUMR” Insights
There was no statistically significant change in private insurance rates.
26 26 26
34
37
30
0
5
10
15
20
25
30
35
40
2003 2007 2011
% P
rivat
e in
sura
nce
Immigrants in statesthat eliminated five-year waitImmigrants in statesthat did not eliminatefive-year wait
4% 11%
Difference-in-Differences:
7%
CHIPRA
*P<.05, **P<.001, ***P<.0001
Background Methods Results Conclusion “SUMR” Insights
Gaps in insurance coverage in the past 12 months decreased significantly for immigrant children in states implementing the policy.
51 53
33
52 52 54
0
10
20
30
40
50
60
2003 2007 2011
% In
sura
nce
cove
rage
gap
s
Immigrants in statesthat eliminated five-year waitImmigrants in statesthat did not eliminatefive-year wait
-21%
1% Difference-in-Differences:
-22%
CHIPRA
*P<.05, **P<.001, ***P<.0001
***
Background Methods Results Conclusion “SUMR” Insights
Having a personal doctor or nurse in the past 12 months significantly increased for immigrant children in policy-implementing states.
51
69 77
50
65 61
0
10
20
30
40
50
60
70
80
90
2003 2007 2011
% P
erso
nal d
octo
r or n
urse
Immigrants in statesthat eliminated five-year waitImmigrants in statesthat did not eliminatefive-year wait
16% 4%
Difference-in-Differences:
12%
CHIPRA
*P<.05, **P<.001, ***P<.0001
*
Background Methods Results Conclusion “SUMR” Insights
Preventive dental visits increased for immigrant children in policy-implementing states.
58
73
54
59
0
10
20
30
40
50
60
70
80
2003 2007 2011
% P
erso
nal d
octo
r or n
urse
Immigrants in statesthat eliminated five-year waitImmigrants in statesthat did not eliminatefive-year wait
13%
4%
Difference-in-Differences:
10%
CHIPRA
*P<.05, **P<.001, ***P<.0001
*
Background Methods Results Conclusion “SUMR” Insights
Having any unmet or delayed health care need in the past 12 months decreased for immigrant children in policy-implementing states.
11
8
5
14
0
2
4
6
8
10
12
14
16
2003 2007 2011
% U
nmet
hea
lth ca
re n
eed
Immigrants in statesthat eliminated five-year waitImmigrants in statesthat did not eliminatefive-year wait
-6%
6%
Difference-in-Differences:
-12%
CHIPRA
*P<.05, **P<.001, ***P<.0001
**
Background Methods Results Conclusion “SUMR” Insights
-30% -20% -10% 0% 10% 20% 30% 40%
InsuredMedicaid
PrivateCoverage Gap
Personal doctor or nurseUsual Source of Care
Preventive medical visitPreventive dental visit
Received specialist careProblems receiving specialist care
Taking prescription drugsAny unmet health need
Unmet medical needUnmet dental need
Change from 2003 Change from 2007
Impact Estimates for the Effect of Eliminating the Waiting Period on Coverage and Access Among Immigrant Children.
*P<.05, **P<.001, ***P<.0001
* ***
* **
** ***
*
* *
Background Methods Results Conclusion “SUMR” Insights
Predicted probabilities for an immigrant child in 2011.
Background Methods Results Conclusion “SUMR” Insights
Predicted probabilities for a child in each generation category in 2011.
• Health insurance can have impact in a short amount of time. • Future studies should look at other health care access and
quality measures for immigrant children over a longer period. • Limitations
• Survey bias • Unable to assess legal status or duration in the United States • Variation in state implementation
Background Methods Results Conclusion “SUMR” Insights
Main Conclusion: Immigrant children in the 24 states that eliminated the five-year wait period had a 20 percentage point increase in health insurance rates, and improvement on some health care access measures.
“INSURANCE FOR IMMIGRANTS,
TOO!”
Along with immigration reform, advocates have pushed for elimination of the five-year wait period.
Background Methods Results Conclusion “SUMR” Insights
“SUMR” Insights • The importance of good mentorship: Brendan is the best • The usefulness of collaboration in research • Mistakes happen: creating systems to catch human error is key • Public data, an undergrad’s best friend • SAS • Other Thank You’s:
• Joanne Levy • Shanae and Safa • Hoag and Megan
• SUMR scholars ‘13
Background Methods Results Conclusion “SUMR” Insights
Thank You. Questions?