HEALTH-INSURANCE FOR LOW-INCOME WORKING FAMILIES - EFFECT ON THE PROVISION OF IMMUNIZATIONS TO PRESCHOOL-AGE CHILDREN

Background: The out-of-pocket cost for immunizations is a cause for re ferral to public health department clinics and is associated with dela yed immunization. In 1991, New York State started Child Health Plus (C HPlus), an insurance program that covers ambulatory care and immunizat ion services for children of families earning less than 222% of the po verty level. Objective: To determine the effect of CHPlus on the provi sion of immunizations. Design: A before-and-after design was used to c ompare the year immediately before enrollment in CHPlus with the first year after enrollment in CHPlus. A mixed-model analysis of variance w as used to control for the effects of age. Setting: All area primary c are practices (n=164) and public health department clinics (n=6). Subj ects: Children (n=1730) younger than 6) ears who were enrolled in CHPl us. Main Outcome Measures: Number of immunization visits; types of pro viders (public health department clinics or primary care providers [pe diatricians and family physicians]): and series-complete immunization coverage, including the diphtheria toroid, tetanus toroid, and pertuss is vaccine, the oral poliovirus vaccine, and the measles, mumps, and r ubella vaccine. Results: The average age of the children was 37.7 mont hs, 85% were white, 50% had been uninsured for immunizations before en rollment in CHPlus, and 16% previously received Medicaid. For infants, CHPlus decreased immunization visits to public health department clin ics by 37% (from 0.14 to 0.09 visits per child, P=.009), increased imm unization visits to primary care providers' offices by 15% (from 2.3 t o 2.7 visits per child, P=.001), and increased immunization coverage b y 7% (from 76% to 83%, P=.03), For children aged 1 to 5 years, CHPlus decreased visits to public health department clinics by 67% (from 0.06 to 0.02 visits per child, P<.001), increased visits to primary care p roviders offices by 27% (from 0.46 to 0.59 visits per child, P<.001), and increased immunization coverage by 5% (from 83% to 88%, P<.001). T he effects were greatest among previously uninsured children and among those with a gap in insurance coverage that was longer than 6 months. Conclusions: Insurance coverage for low-income working families resul ted in a shift in the provision of immunizations from the health depar tment to primary care providers and in increased immunization coverage .