1. Does Private Insurance Adequately Cover Childhood Immunizations? 1 University of Florida, Dept. of Pediatrics, Jacksonville 2 Health Research and Evaluation Trust, Chicago, IL; 3 Partnership for Prevention Washington DC David L Wood 1, Jon Gabel 2, Maris A Bondi 3 and Molly E French 3

2. Background Financial barriers can decrease utilization of child immunizations Private Insurance > Medicaid Thompson et al. JAMA. 2003 Mustin et al. JAMA 1995 Any insurance better than being uninsured Wood et al. Pediatrics 1995;96:295-301; Jama 1997 Rodewald LE, Arch Pediatr Adolesc Med. 1997. RAND HIE—Higher co-payments reduce utilization of Imms Lurie et al. Am J Pub Health 1987 Universal purchase increased Imm. rates for under- and un-insured in NC* Freed G, et al. Arch Pediatr Adoles Med 1999

3. Types of Financial Barriers 1) Uninsured 2) Underinsured---Medicaid Poor reimbursement for administration of vaccine, cost of denials 2) Underinsured---Private Insurance Childhood imm. not a covered benefit Large copayments for preventive care or large deductibles

4. Some Relief Financial barriers VFC program helped address financial barriers Distributed free--reduced financial risk to providers Many states increased Medicaid administration fees—increasing incentive for providers Private Insurance underinsured covered unevenly VFC only states VFC + states Universal purchase states

5. AIMS Little is known about the rate of under-insurance for childhood immunization by private insurance We sought to estimate nationally: lack of coverage of childhood immunizations Financial barriers due to co-payments and deductibles

6. Methods: Estimation Steps 1.Private insurance coverage for population of 0-5 age years of age group from 2000 CPS 2.Distribution of insurance type (HMO, PPO, POS, FFS) within private insurance 3.Immunization benefit coverage rate by insurance type 4.Weighted average coverage rate across privately insured children 5.Estimate proportion with financial barriers due to co-pays and deductibles

7. Estimating insurance coverage Different national or large-scale surveys Current Population Survey (CPS) National Health Interview Survey (NHIS) Survey of Income and Program Participation (SIPP) Medical Expenditure Panel Survey (MEPS) Community Tracking Study (CTS) National Survey of America’s Families (NSAF)

8. Types of Coverage Estimates From SIPP and MEPS Uninsured for entire year (6.3%) Ever uninsured during past year (21.7%) Uninsured current month (13.1%) CPS uses annual period prevalence Recall bias==closer to point estimate Annual turnover for insured population high—insurance estimates are snap shots

9. Insurance Coverage for 0-5 year old children

10. Number of Children by Insurance Type In Thousands

11. Estimating Benefit Coverage Partnerships for Prevention/Mercer National Benefit survey Percent of children in each insurance type (PPO, HMO, POS, FFS) Percent with immunizations as covered benefit within each insurance type

12. 2001 Partnership for Prevention Benefit Survey**

13. High Co-pays and Deductibles Estimated % children with barriers due to high co-pays or deductibles. 8% of the 79% with private insurance AND coverage for immunizations turned away due to financial barriers 79% x 8% = 6.3% Zimmerman R JAMA 1997;278:996-1000

15. Coverage for Immunizations, US Children 0-5

16. Conclusions Only approximately 73% of privately insured children have coverage for immunizations Only 46% of all children 0-5 have private insurance that covers immunizations. Almost 1/4 or of children < 5 years of age have either no insurance or no coverage Co-pays and deductibles are a financial barrier to immunizations for a significant minority of privately insured children

17. Trends in Private Insurance Employment-based premiums rising 2001—11%; 2002—13%; 2003-14% Worker’s earnings increased by only 3%/year Companies responding by: Passing increased premium costs on to employees Monthly contribution/family increasing 1988-$52; 1993--$124; 2002--$174 Increasing co-pays—visits, drugs Increasing deductibles—up 37% 2001-2002 (ppo) Offering plans with limited benefits, flex plan Gabel et al. Health Affairs 2003:117-126; KFF/HRET 2002 Summary of Findings– www.kaisernetwork.org/healthcast/kff/o5sep02

18. Policy Implications IOM report solutions Mandated benefit coverage—changing ERISA requires new federal legislation First dollar legislation Eliminates co-pay/deductible barrier VFC +/UP in all states Will allow privately insured with no Immunization coverage to receive vaccine in Medical Home Still have barrier of administration fees for privately underinsured Need annual national and state stats. insurance benefit coverage for children

19. Study Limitations Insurance coverage difficult to measure Reliant on parent report Insurance coverage is a moving target Used 2000 CPS data and insurance coverage has changed Decrease in private insurance Increase in Medicaid/SCHIP

20. Limitations Insurance benefit data are difficult to obtain Limited number of surveys—MERCER, Kaiser/HRET survey, MEPS Benefits report reliable? Weighting on benefits survey for total US Do not sample employers with <10 employees Estimates of high co-pays and deductibles Reliant on provider reports Population of providers sampled assumed to have nationally representative population