Insurance Matters: Adolescents with Special Healthcare Needs

Abstract

See Related Article p. 343Adolescents with special healthcare needs (ASHCN) constitute a highly vulnerable subpopulation of the nation’s youth. By definition, they experience ongoing health issues that require continuing interaction with the healthcare system. Their underlying chronic conditions put them at added risk for health complications that may undermine their normal functioning at school, in the family, and in the community. ASHCN face added challenges over their healthier counterparts as they make the transition to adulthood. Families of ASHCN may also sustain adverse emotional and financial consequences as a result of their adolescent’s health difficulties and elevated care needs.Receipt of timely and effective healthcare services is vital to maintaining and improving the health of ASCHN and smoothing the transition to adulthood. Although some countries have created publicly financed direct service systems to meet the health needs of their youth, the United States continues to rely principally on a patchwork of private and publicly sponsored health insurance to finance healthcare. Despite the fragmented nature of our financing system, health insurance—whether public or private—has the potential to secure access to quality healthcare for adolescents. Indeed, within the general population of adolescents, having insurance coverage is associated with improved access and utilization patterns for children, including fewer unmet needs, increased likelihood of having a usual source of care, and higher rates of use of well child care [1Feinberg E. Swartz K. Zaslavsky A. et al.Family income and the impact of a children’s health insurance program on reported need for health services and unmet health need.Pediatrics. 2002; 109: E29Crossref PubMed Scopus (55) Google Scholar, 2Newacheck P.W. Hung Y.Y. Park M.J. et al.Disparities in adolescent health and healthcare: does socioeconomic status matter?.Health Serv Res. 2003; 38: 1235-1252Crossref PubMed Scopus (186) Google Scholar].Although much has been written about the insurance needs of Children with Special Health Care Needs (CSHCN), much less has appeared in the peer review literature on the insurance needs of ASHCN. The article by Okumura and colleagues in this issue fills a major gap by providing a fresh analysis of the insurance characteristics of AHSCN as well as new evidence on the impact of insurance on access to care [[3]Okumura M.J. McPheeters M.L. David M.M. State and national estimates of insurance coverage and healthcare utilization for adolescents with chronic conditions from the National Survey of Children’s Health; 2003.J Adolesc Health. 2007; 41: 343-349Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar]. Their results underscore the importance of insurance coverage for ASHCN and their families. The authors demonstrate that insurance matters for ASCHN; those with continuous insurance coverage are about 80% less likely than those with no coverage to have unmet healthcare needs. Yet, coverage rates for ASHCN, while higher than for adolescents without special healthcare needs, remain highly variable across the states. Hence, even though ASCHN are more likely to be insured than adolescents without special healthcare needs, disparities and inequities in coverage remain across the states. Indeed, Okumura et al show that the percentage of ASCHN without continuous insurance coverage ranges from as low as 1% in New Hampshire to as high as 20% in Arizona.The publication of the study by Okumura et al is particularly timely, given the major changes occurring in our healthcare financing system, including the continuing decline of employer-based health insurance coverage for adolescents and the reauthorization of the State Children’s Health Insurance Program (SCHIP). During the past 2 decades, significant progress has occurred at the federal and state levels to expand healthcare coverage for children and adolescents from low and moderate income families, including those with special healthcare needs [4Grogan C. Patashnik E. Between welfare medicine and mainstream entitlement: Medicaid at the political crossroads.J Health Polit Policy Law. 2003; 28: 821-858Crossref PubMed Scopus (64) Google Scholar, 5Lewit E.M. Bennett C. Behrman R.E. Health insurance for children: analysis and recommendations.Future Child. 2003; 13: 5-29Crossref PubMed Scopus (14) Google Scholar, 6Lykens K.A. Jargowsky P.A. Medicaid matters: children’s health and Medicaid eligibility expansions.J Policy Anal Manage. 2002; 21: 219-238Crossref PubMed Scopus (34) Google Scholar]. SCHIP, enacted in 1997, along with the final phase-in of the Medicaid eligibility expansions enacted in the late 1980s, has helped to ensure that many adolescents have access to the care they need. However, continuing declines in private insurance coverage offered through parental employment have muted these gains. Hence, although progress has been made, continued vigilance is needed to ensure that ASCHN are not left behind as employer-based coverage continues to erode. Much of the loss of employer-based insurance is the result of the large-scale shift to a service-based economy that has taken place over the past 25 years. This secular trend shows no signs of abating, placing added pressure on the public sector to shore up our healthcare financing system.Particularly critical now is the reauthorization of SCHIP. Several state programs are now limiting enrollment under this program due to a lack of federal funds. Congressional proposals to increase SCHIP appropriation levels over the next decade are a welcome development, especially given the evidence that SCHIP expansions are associated with improved access to care for adolescents [7Klein J.D. Shone L.P. Szilagyi P.G. et al.Impact of the State Children’s Health Insurance Program on adolescents in New York.Pediatrics. 2007; 119: e885-e892Crossref PubMed Scopus (12) Google Scholar, 8Szilagyi P.G. Dick A.W. Klein J.D. et al.Improved access and quality of care after enrollment in the New York State Children’s Health Insurance Program (SCHIP).Pediatrics. 2004; 113: e395-e404Crossref PubMed Scopus (113) Google Scholar, 9Szilagyi P.G. Dick A.W. Klein J.D. et al.Improved asthma care after enrollment in the State Children’s Health Insurance Program in New York.Pediatrics. 2006; 117: 486-496Crossref PubMed Scopus (57) Google Scholar, 10Szilagyi P.G. Shone L.P. Klein J.D. et al.Improved healthcare among children with special healthcare needs after enrollment into the State Children’s Health Insurance Program.Ambul Pediatr. 2007; 7: 10-17Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar].Finally, the article by Okumura and colleagues adds to the growing evidence base on the importance of insurance for CSHCN and AHSCN [[11]Jeffrey A.E. Newacheck P.W. Role of insurance for children with special healthcare needs: a synthesis of the evidence.Pediatrics. 2006; 118: e1027-e1038Crossref PubMed Scopus (56) Google Scholar]. Previous studies have demonstrated that insurance plays a key role in ensuring that AHSCN receive adequate services to prepare them for the transition to adulthood [12Lotstein D.S. McPherson M. Strickland B. et al.Transition planning for youth with special healthcare needs: results from the National Survey of Children with Special Health Care Needs.Pediatrics. 2005; 115: 1562-1568Crossref PubMed Scopus (206) Google Scholar, 13Scal P. Ireland M. Addressing transition to adult healthcare for adolescents with special healthcare needs.Pediatrics. 2005; 115: 1607-1612Crossref PubMed Scopus (159) Google Scholar]. Other studies have shown that adequate insurance coverage (based on whether the family views their insurance as covering the services needed by their child, covering a reasonable share of costs, and allowing families to see the providers they feel are best for their child) confers important benefits to CSHCN including fewer unmet needs, fewer problems obtaining referrals, and a higher likelihood of having a personal doctor or nurse [[14]Honberg L. McPherson M. Strickland B. et al.Assuring adequate health insurance: results of the National Survey of Children with Special Health Care Needs.Pediatrics. 2005; 115: 1233-1239Crossref PubMed Scopus (49) Google Scholar].Recent analyses have also demonstrated the importance of health insurance in protecting families of CSHCN (and presumably AHSCN) against adverse financial impacts [15Chen A.Y. Newacheck P.W. Insurance coverage and financial burden for families of children with special healthcare needs.Ambul Pediatr. 2006; 6: 204-209Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 16Newacheck P.W. Kim S.E. A national profile of healthcare utilization and expenditures for children with special healthcare needs.Arch Pediatr Adolesc Med. 2005; 159: 10-17Crossref PubMed Scopus (374) Google Scholar]. Yet, even when insurance status is statistically held constant, a substantial income gradient remains in financial impact, such that poor and near-poor families are significantly more likely to experience burdensome healthcare expenses and reductions in employment [[15]Chen A.Y. Newacheck P.W. Insurance coverage and financial burden for families of children with special healthcare needs.Ambul Pediatr. 2006; 6: 204-209Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar]. These findings suggest that efforts to address nonfinancial access barriers, such as child care, transportation, and the cultural competence of providers, may be helpful. Other more fundamental changes, including altering the way healthcare is delivered, may also necessary to ensure access to quality healthcare. Kuhlthau et al showed that the development of well-designed systems of care that incorporate new mechanisms of care delivery, such as in medical home settings, combined with efficient organization of services can provide a mechanism for alleviating access barriers and financial burdens for families of CSHCN [[17]Kuhlthau K. Hill K.S. Yucel R. Perrin J.M. Financial burden for families of children with special healthcare needs.Matern Child Health J. 2005; 9: 207-218Crossref PubMed Scopus (157) Google Scholar]. Hence, insurance should be viewed as only one element, albeit an important one, of a multifaceted strategy to provide financial protection and support for all families of ASHCN. See Related Article p. 343 See Related Article p. 343 See Related Article p. 343 Adolescents with special healthcare needs (ASHCN) constitute a highly vulnerable subpopulation of the nation’s youth. By definition, they experience ongoing health issues that require continuing interaction with the healthcare system. Their underlying chronic conditions put them at added risk for health complications that may undermine their normal functioning at school, in the family, and in the community. ASHCN face added challenges over their healthier counterparts as they make the transition to adulthood. Families of ASHCN may also sustain adverse emotional and financial consequences as a result of their adolescent’s health difficulties and elevated care needs. Receipt of timely and effective healthcare services is vital to maintaining and improving the health of ASCHN and smoothing the transition to adulthood. Although some countries have created publicly financed direct service systems to meet the health needs of their youth, the United States continues to rely principally on a patchwork of private and publicly sponsored health insurance to finance healthcare. Despite the fragmented nature of our financing system, health insurance—whether public or private—has the potential to secure access to quality healthcare for adolescents. Indeed, within the general population of adolescents, having insurance coverage is associated with improved access and utilization patterns for children, including fewer unmet needs, increased likelihood of having a usual source of care, and higher rates of use of well child care [1Feinberg E. Swartz K. Zaslavsky A. et al.Family income and the impact of a children’s health insurance program on reported need for health services and unmet health need.Pediatrics. 2002; 109: E29Crossref PubMed Scopus (55) Google Scholar, 2Newacheck P.W. Hung Y.Y. Park M.J. et al.Disparities in adolescent health and healthcare: does socioeconomic status matter?.Health Serv Res. 2003; 38: 1235-1252Crossref PubMed Scopus (186) Google Scholar]. Although much has been written about the insurance needs of Children with Special Health Care Needs (CSHCN), much less has appeared in the peer review literature on the insurance needs of ASHCN. The article by Okumura and colleagues in this issue fills a major gap by providing a fresh analysis of the insurance characteristics of AHSCN as well as new evidence on the impact of insurance on access to care [[3]Okumura M.J. McPheeters M.L. David M.M. State and national estimates of insurance coverage and healthcare utilization for adolescents with chronic conditions from the National Survey of Children’s Health; 2003.J Adolesc Health. 2007; 41: 343-349Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar]. Their results underscore the importance of insurance coverage for ASHCN and their families. The authors demonstrate that insurance matters for ASCHN; those with continuous insurance coverage are about 80% less likely than those with no coverage to have unmet healthcare needs. Yet, coverage rates for ASHCN, while higher than for adolescents without special healthcare needs, remain highly variable across the states. Hence, even though ASCHN are more likely to be insured than adolescents without special healthcare needs, disparities and inequities in coverage remain across the states. Indeed, Okumura et al show that the percentage of ASCHN without continuous insurance coverage ranges from as low as 1% in New Hampshire to as high as 20% in Arizona. The publication of the study by Okumura et al is particularly timely, given the major changes occurring in our healthcare financing system, including the continuing decline of employer-based health insurance coverage for adolescents and the reauthorization of the State Children’s Health Insurance Program (SCHIP). During the past 2 decades, significant progress has occurred at the federal and state levels to expand healthcare coverage for children and adolescents from low and moderate income families, including those with special healthcare needs [4Grogan C. Patashnik E. Between welfare medicine and mainstream entitlement: Medicaid at the political crossroads.J Health Polit Policy Law. 2003; 28: 821-858Crossref PubMed Scopus (64) Google Scholar, 5Lewit E.M. Bennett C. Behrman R.E. Health insurance for children: analysis and recommendations.Future Child. 2003; 13: 5-29Crossref PubMed Scopus (14) Google Scholar, 6Lykens K.A. Jargowsky P.A. Medicaid matters: children’s health and Medicaid eligibility expansions.J Policy Anal Manage. 2002; 21: 219-238Crossref PubMed Scopus (34) Google Scholar]. SCHIP, enacted in 1997, along with the final phase-in of the Medicaid eligibility expansions enacted in the late 1980s, has helped to ensure that many adolescents have access to the care they need. However, continuing declines in private insurance coverage offered through parental employment have muted these gains. Hence, although progress has been made, continued vigilance is needed to ensure that ASCHN are not left behind as employer-based coverage continues to erode. Much of the loss of employer-based insurance is the result of the large-scale shift to a service-based economy that has taken place over the past 25 years. This secular trend shows no signs of abating, placing added pressure on the public sector to shore up our healthcare financing system. Particularly critical now is the reauthorization of SCHIP. Several state programs are now limiting enrollment under this program due to a lack of federal funds. Congressional proposals to increase SCHIP appropriation levels over the next decade are a welcome development, especially given the evidence that SCHIP expansions are associated with improved access to care for adolescents [7Klein J.D. Shone L.P. Szilagyi P.G. et al.Impact of the State Children’s Health Insurance Program on adolescents in New York.Pediatrics. 2007; 119: e885-e892Crossref PubMed Scopus (12) Google Scholar, 8Szilagyi P.G. Dick A.W. Klein J.D. et al.Improved access and quality of care after enrollment in the New York State Children’s Health Insurance Program (SCHIP).Pediatrics. 2004; 113: e395-e404Crossref PubMed Scopus (113) Google Scholar, 9Szilagyi P.G. Dick A.W. Klein J.D. et al.Improved asthma care after enrollment in the State Children’s Health Insurance Program in New York.Pediatrics. 2006; 117: 486-496Crossref PubMed Scopus (57) Google Scholar, 10Szilagyi P.G. Shone L.P. Klein J.D. et al.Improved healthcare among children with special healthcare needs after enrollment into the State Children’s Health Insurance Program.Ambul Pediatr. 2007; 7: 10-17Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. Finally, the article by Okumura and colleagues adds to the growing evidence base on the importance of insurance for CSHCN and AHSCN [[11]Jeffrey A.E. Newacheck P.W. Role of insurance for children with special healthcare needs: a synthesis of the evidence.Pediatrics. 2006; 118: e1027-e1038Crossref PubMed Scopus (56) Google Scholar]. Previous studies have demonstrated that insurance plays a key role in ensuring that AHSCN receive adequate services to prepare them for the transition to adulthood [12Lotstein D.S. McPherson M. Strickland B. et al.Transition planning for youth with special healthcare needs: results from the National Survey of Children with Special Health Care Needs.Pediatrics. 2005; 115: 1562-1568Crossref PubMed Scopus (206) Google Scholar, 13Scal P. Ireland M. Addressing transition to adult healthcare for adolescents with special healthcare needs.Pediatrics. 2005; 115: 1607-1612Crossref PubMed Scopus (159) Google Scholar]. Other studies have shown that adequate insurance coverage (based on whether the family views their insurance as covering the services needed by their child, covering a reasonable share of costs, and allowing families to see the providers they feel are best for their child) confers important benefits to CSHCN including fewer unmet needs, fewer problems obtaining referrals, and a higher likelihood of having a personal doctor or nurse [[14]Honberg L. McPherson M. Strickland B. et al.Assuring adequate health insurance: results of the National Survey of Children with Special Health Care Needs.Pediatrics. 2005; 115: 1233-1239Crossref PubMed Scopus (49) Google Scholar]. Recent analyses have also demonstrated the importance of health insurance in protecting families of CSHCN (and presumably AHSCN) against adverse financial impacts [15Chen A.Y. Newacheck P.W. Insurance coverage and financial burden for families of children with special healthcare needs.Ambul Pediatr. 2006; 6: 204-209Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 16Newacheck P.W. Kim S.E. A national profile of healthcare utilization and expenditures for children with special healthcare needs.Arch Pediatr Adolesc Med. 2005; 159: 10-17Crossref PubMed Scopus (374) Google Scholar]. Yet, even when insurance status is statistically held constant, a substantial income gradient remains in financial impact, such that poor and near-poor families are significantly more likely to experience burdensome healthcare expenses and reductions in employment [[15]Chen A.Y. Newacheck P.W. Insurance coverage and financial burden for families of children with special healthcare needs.Ambul Pediatr. 2006; 6: 204-209Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar]. These findings suggest that efforts to address nonfinancial access barriers, such as child care, transportation, and the cultural competence of providers, may be helpful. Other more fundamental changes, including altering the way healthcare is delivered, may also necessary to ensure access to quality healthcare. Kuhlthau et al showed that the development of well-designed systems of care that incorporate new mechanisms of care delivery, such as in medical home settings, combined with efficient organization of services can provide a mechanism for alleviating access barriers and financial burdens for families of CSHCN [[17]Kuhlthau K. Hill K.S. Yucel R. Perrin J.M. Financial burden for families of children with special healthcare needs.Matern Child Health J. 2005; 9: 207-218Crossref PubMed Scopus (157) Google Scholar]. Hence, insurance should be viewed as only one element, albeit an important one, of a multifaceted strategy to provide financial protection and support for all families of ASHCN. State and National Estimates of Insurance Coverage and Health Care Utilization for Adolescents with Chronic Conditions from the National Survey of Children’s Health, 2003Journal of Adolescent HealthVol. 41Issue 4PreviewTo examine health and insurance characteristics of adolescents with special health care needs (ASHCN), at state and federal levels. Full-Text PDF