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August 1997, Vol 151, No. 8 >
Article | August 1997

Health Insurance for Low-Income Working Families:  Effect on the Provision of Immunizations to Preschool-Age Children FREE

Lance E. Rodewald, MD; Peter G. Szilagyi, MD, MPH; Jane Holl, MD; Laura R. Shone, MSW; Jack Zwanziger, PhD; Richard F. Raubertas, PhD
Arch Pediatr Adolesc Med. 1997;151(8):798-803. doi:10.1001/archpedi.1997.02170450048007.
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Background:  The out-of-pocket cost for immunizations is a cause for referral to public health department clinics and is associated with delayed immunization. In 1991, New York State started Child Health Plus (CHPlus), an insurance program that covers ambulatory care and immunization services for children of families earning less than 222% of the poverty level.

Objective:  To determine the effect of CHPlus on the provision of immunizations.

Design:  A before-and-after design was used to compare the year immediately before enrollment in CHPlus with the first year after enrollment in CHPlus. A mixed-model analysis of variance was used to control for the effects of age.

Setting:  All area primary care practices (n= 164) and public health department clinics (n=6).

Subjects:  Children (n= 1730) younger than 6 years who were enrolled in (CHPlus.

Main Outcome Measures:  Number of immunization visits; types of providers (public health department clinics or primary care providers [pediatricians and family physicians]); and series-complete immunization coverage, including the diphtheria toxoid, tetanus toxoid, and pertussis vaccine, the oral poliovirus vaccine, and the measles, mumps, and rubella vaccine.

Results:  The average age of the children was 37.7 months, 85% were white, 50% had been uninsured for immunizations before enrollment in CHPlus, and 16% previously received Medicaid. For infants, CHPlus decreased immunization visits to public health department clinics by 37% (from 0.14 to 0.09 visits per child, P=.009), increased immunization visits to primary care providers' offices by 15% (from 2.3 to 2.7 visits per child, P=.001), and increased immunization coverage by 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 providers' 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). The 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 resulted in a shift in the provision of immunizations from the health department to primary care providers and in increased immunization coverage.Arch Pediatr Adolesc Med. 1997;151:798-803.

REFERENCES

1 +
Lieu TA, Smith MD, Newacheck PW, Langthorn D, Venkatesh P, Herradora R.  Health insurance and preventive care sources of children at public immunization clinics . Pediatrics . 1994;;93:373-378.
2 +
Salsberry PJ, Nickel JT, Mitch R.  Why aren't preschoolers immunized? a comparison of parents' and providers' perceptions of the barriers to immunization . J Community Health Nurs . 1993;;10:213-224.
3 +
Hueston WJ, Mainous AG, Palmer C.  Delays in childhood immunizations in public and private settings . Arch Pediatr Adolesc Med . 1994;;148:470-473.
4 +
Bordley WC, Freed GL, Garrett JM, Byrd CA, Meriwether R.  Factors responsible for immunization referrals to health departments in North Carolina . Pediatrics . 1994;;94:376-380.
5 +
Zimmerman RK, Janosky JE.  Immunization barriers in Minnesota private practices: the influence of economics and training on vaccine timing . Fam Pract Res J . 1993;;13:213-224.
6 +
Szilagyi PG, Rodewald LE, Humiston SG, et al.  Immunization practices of pediatricians and family physicians in the United States . Pediatrics . 1994;;94:517-523.
7 +
Orenstein WA, Atkinson W, Mason D, Bernier RH.  Barriers to vaccinating preschool children . J Health Care Poor Underserved . 1990;;1:315-330.
8 +
Bordley WC, Freed GL, Garrett JM, Byrd CA, Meriwether R.  Factors responsible for immunization referrals to health departments in North Carolina . Pediatrics . 1994;;94:376-380.
9 +
Schulte JM, Bown GR, Zetzman MR, et al.  Changing immunization referral patterns among pediatricians and family practice physicians, Dallas County, Texas, 1988 . Pediatrics . 1991;;87:204-207.
10 +
Wright JA, Marcuse EK.  Immunization practices of Washington State pediatricians: 1989 . AJDC . 1992;;146:1033-1036.
11 +
Ruch-Ross HS, O'Connor KG.  Immunization referral practices of pediatricians in the United States . Pediatrics . 1994;;94:508-513.
12 +
Zimmerman RK, Giebink GS, Street HB, Janosky JE.  Knowledge and attitudes of Minnesota primary care physicians about barriers to measles and pertussis immunization . JAm Board Fam Pract . 1995;;8:270-277.
13 +
National Vaccine Advisory Committee.  The measles epidemic: the problems, barriers, and recommendations . JAMA . 1991;;266:1547-1552.
14 +
NY Public Health Law §2510 and §2511.
15 +
Committee on Infections Diseases, American Academy of Pediatrics. Report of the Committee on Infections Diseases . Elk Grove Village, III: American Academy of Pediatrics; 1994;.
16 +
SAS Institute Inc. SAS/STAT Software: Changes and Enhancements Through Release 6.11 . Cary, NC: SAS Institute Inc; 1996;.
17 +
Kogan MD, Alexander GR, Teitelbaum MA, Jack BW, Kotelchuck M, Pappas G.  The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States . JAMA . 1995;;274:1429-1435.
18 +
Lurie N, Manning WG, Peterson C, Goldberg GA, Phelps CA.  Preventive care: do we practice what we preach? Am J Public Health . 1987;;77:801-804.
19 +
Centers for Disease Control and Prevention.  Recommendations of the Advisory Committee on Immunization Practices: programmatic strategies to increase vaccination rates: assessment and feedback of provider-based vaccination coverage information . MMWR Morb Mortal Wkly Rep . 1996;;45:219-220.
20 +
Rodewald LE, Szilagyi PG, Shiuh T, et al.  Is underimmunization a marker for insufficient utilization of preventive and primary care? Arch Pediatr Adolesc Med . 1995;;149:393-397.
21 +
Bordley WC, Margolis PA, Lannon CM.  The delivery of immunizations and other preventive services in private practices . Pediatrics . 1996;;97:467-473.
22 +
Fairbrother G, Friedman S, DuMont KA, Lobach KS.  Markers for primary care: missed opportunities to immunize and screen for lead and tuberculosis by private physicians serving large numbers of inner-city Medicaid-eligible children . Pediatrics . 1996;;97:785-790.
23 +
Rodewald LE, Szilagyi PG, Humiston SG, et al.  The effect of two primary care–based interventions on immunization rates and primary care utilization: a randomized controlled trail . Arch Pediatr Adolesc Med . 1996;;150:P53-P54.
24 +
Centers for Disease Control and Prevention.  National, state, and urban area vaccination coverage levels among children aged 19-35 months: United States, April 1994-March 1995 . MMWR Morb Mortal Wkly Rep . 1996;;45:145-150.
25 +
LeBaron CW, Chaney M, Baughman AL, et al.  Impact of measurement and feedback on vaccination coverage in public clinics, 1988-1994. 994. JAMA . 1992;;277:631-635.
26 +
Centers for Disease Control and Prevention.  State and national vaccination coverage levels among children aged 19-35 months: United States, April-December 1994 . MMWR Morb Mortal Wkly Rep . 1995;;44:613-623.

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References

1 +
Lieu TA, Smith MD, Newacheck PW, Langthorn D, Venkatesh P, Herradora R.  Health insurance and preventive care sources of children at public immunization clinics . Pediatrics . 1994;;93:373-378.
2 +
Salsberry PJ, Nickel JT, Mitch R.  Why aren't preschoolers immunized? a comparison of parents' and providers' perceptions of the barriers to immunization . J Community Health Nurs . 1993;;10:213-224.
3 +
Hueston WJ, Mainous AG, Palmer C.  Delays in childhood immunizations in public and private settings . Arch Pediatr Adolesc Med . 1994;;148:470-473.
4 +
Bordley WC, Freed GL, Garrett JM, Byrd CA, Meriwether R.  Factors responsible for immunization referrals to health departments in North Carolina . Pediatrics . 1994;;94:376-380.
5 +
Zimmerman RK, Janosky JE.  Immunization barriers in Minnesota private practices: the influence of economics and training on vaccine timing . Fam Pract Res J . 1993;;13:213-224.
6 +
Szilagyi PG, Rodewald LE, Humiston SG, et al.  Immunization practices of pediatricians and family physicians in the United States . Pediatrics . 1994;;94:517-523.
7 +
Orenstein WA, Atkinson W, Mason D, Bernier RH.  Barriers to vaccinating preschool children . J Health Care Poor Underserved . 1990;;1:315-330.
8 +
Bordley WC, Freed GL, Garrett JM, Byrd CA, Meriwether R.  Factors responsible for immunization referrals to health departments in North Carolina . Pediatrics . 1994;;94:376-380.
9 +
Schulte JM, Bown GR, Zetzman MR, et al.  Changing immunization referral patterns among pediatricians and family practice physicians, Dallas County, Texas, 1988 . Pediatrics . 1991;;87:204-207.
10 +
Wright JA, Marcuse EK.  Immunization practices of Washington State pediatricians: 1989 . AJDC . 1992;;146:1033-1036.
11 +
Ruch-Ross HS, O'Connor KG.  Immunization referral practices of pediatricians in the United States . Pediatrics . 1994;;94:508-513.
12 +
Zimmerman RK, Giebink GS, Street HB, Janosky JE.  Knowledge and attitudes of Minnesota primary care physicians about barriers to measles and pertussis immunization . JAm Board Fam Pract . 1995;;8:270-277.
13 +
National Vaccine Advisory Committee.  The measles epidemic: the problems, barriers, and recommendations . JAMA . 1991;;266:1547-1552.
14 +
NY Public Health Law §2510 and §2511.
15 +
Committee on Infections Diseases, American Academy of Pediatrics. Report of the Committee on Infections Diseases . Elk Grove Village, III: American Academy of Pediatrics; 1994;.
16 +
SAS Institute Inc. SAS/STAT Software: Changes and Enhancements Through Release 6.11 . Cary, NC: SAS Institute Inc; 1996;.
17 +
Kogan MD, Alexander GR, Teitelbaum MA, Jack BW, Kotelchuck M, Pappas G.  The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States . JAMA . 1995;;274:1429-1435.
18 +
Lurie N, Manning WG, Peterson C, Goldberg GA, Phelps CA.  Preventive care: do we practice what we preach? Am J Public Health . 1987;;77:801-804.
19 +
Centers for Disease Control and Prevention.  Recommendations of the Advisory Committee on Immunization Practices: programmatic strategies to increase vaccination rates: assessment and feedback of provider-based vaccination coverage information . MMWR Morb Mortal Wkly Rep . 1996;;45:219-220.
20 +
Rodewald LE, Szilagyi PG, Shiuh T, et al.  Is underimmunization a marker for insufficient utilization of preventive and primary care? Arch Pediatr Adolesc Med . 1995;;149:393-397.
21 +
Bordley WC, Margolis PA, Lannon CM.  The delivery of immunizations and other preventive services in private practices . Pediatrics . 1996;;97:467-473.
22 +
Fairbrother G, Friedman S, DuMont KA, Lobach KS.  Markers for primary care: missed opportunities to immunize and screen for lead and tuberculosis by private physicians serving large numbers of inner-city Medicaid-eligible children . Pediatrics . 1996;;97:785-790.
23 +
Rodewald LE, Szilagyi PG, Humiston SG, et al.  The effect of two primary care–based interventions on immunization rates and primary care utilization: a randomized controlled trail . Arch Pediatr Adolesc Med . 1996;;150:P53-P54.
24 +
Centers for Disease Control and Prevention.  National, state, and urban area vaccination coverage levels among children aged 19-35 months: United States, April 1994-March 1995 . MMWR Morb Mortal Wkly Rep . 1996;;45:145-150.
25 +
LeBaron CW, Chaney M, Baughman AL, et al.  Impact of measurement and feedback on vaccination coverage in public clinics, 1988-1994. 994. JAMA . 1992;;277:631-635.
26 +
Centers for Disease Control and Prevention.  State and national vaccination coverage levels among children aged 19-35 months: United States, April-December 1994 . MMWR Morb Mortal Wkly Rep . 1995;;44:613-623.

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