Evaluation of New York State's Child Health Plus: Children who have asthma

Background. Little is known about the impact of providing health insurance to uninsured children who have asthma or other chronic diseases. Objectives. To evaluate the association between health insurance and the ut ilization of health care and the quality of care among children who have as thma. Design. Before-and-during study of children for a 1-year period before and a 1-year period immediately after enrollment in a state-funded health insur ance plan. Intervention. In 1991 New York State implemented Child Health Plus (CHPlus) , a health insurance program providing ambulatory and ED (ED), but not hosp italization coverage for children 0 to 12.99 years old whose family incomes were below 222% of the federal poverty level and who were not enrolled in Medicaid. Subjects. A total of 187 children (2-12.99 years old) who had asthma and en rolled in CHPlus between November 1, 1991 and August 1, 1993. Main Outcome Measures. Rates of primary care visits (preventive, acute, ast hma-specific), ED visits, hospitalizations, number of specialists seen, and quality of care measures (parent reports of the effect of CHPlus on qualit y of asthma care, and rates of recommended asthma therapies). The effect of CHPlus was assessed by comparing outcome measures for each child for the y ear before versus the year after CHPlus enrollment, controlling for age, in surance coverage before CHPlus, and asthma severity. Data Ascertainment. Parent telephone interviews and medical chart reviews a t primary care offices, EDs, and public health clinics. Main Results. Visit rates to primary care providers were significantly high er during CHPlus compared with before CHPlus for chronic illness care (.995 visits before CHPlus vs 1.34 visits per year during CHPlus), follow-up vis its (.86 visits vs 1.32 visits per year), total visits (5.69 visits vs 7.11 visits per year), and for acute asthma exacerbations (.61 visits vs 0.84 v isits per year). There were no significant associations between CHPlus cove rage and ED visits or hospitalizations, although specialty utilization incr eased (30% vs 40%; P = .02). According to parents, CHPlus reduced asthma se verity for 55% of children (no change in severity for 44% and worsening sev erity for 1%). Similarly, CHPlus was reported to have improved overall heal th status for 45% of children (no change in 53% and worse in 1%), primarily attributable to coverage for office visits and asthma medications. CHPlus was associated with more asthma tune-up visits (48% before CHPlus vs 63% du ring CHPlus). There was no statistically significant effect of CHPlus on se veral other quality of care measures such as follow-up after acute exacerba tions, receipt of influenza vaccination, or use of bronchodilators or antii nflammatory medications. Conclusions. Health insurance for uninsured children who have asthma helped overcome financial barriers that prevented children from receiving care fo r acute asthma exacerbations and for chronic asthma care. Health insurance was associated with increased utilization of primary care for asthma and im proved parent perception of quality of care and asthma severity, but not wi th some quality indicators. Although more intensive interventions beyond he alth insurance are needed to optimize quality of asthma care, health insura nce coverage substantially improves the health care for children who have a sthma.