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Introduction: Several clinical outcome assessment (COA) instruments assess Sjögren's disease (Sjögren's) symptoms, but do not provide comprehensive assessment of the health-related quality of life (HRQoL) impact of Sjögren's. This study aimed to develop a patient-reported outcome (PRO) instrument for the assessment of HRQoL, intended for use in clinical trials and clinical practice in the assessment of treatment benefit., Methods: Review of study sponsor proprietary data and qualitative interviews informed the development of a conceptual model, the Sjögren's Related Quality of Life (SRQoL) and patient global impression of severity (PGI-S) and change (PGI-C) items. Combined concept elicitation and cognitive debriefing interviews with patients with Sjögren's explored their HRQoL impact experience and content validity of the SRQoL and PGI items., Results: Twenty participants were interviewed about their Sjögren's experience. Following inductive analysis of interviews, concepts were categorized into eight domains: emotional well-being (e.g., worry and stress; n = 20/20; 100%), sleep (e.g., daytime sleepiness and waking up during the night; n = 20/20; 100%), activities of daily living (e.g., difficulty looking at screens and difficulty driving; n = 20/20; 100%), cognition (e.g., concentration difficulties and word finding difficulties; n = 19/20; 95.0%), physical functioning (e.g., difficulty walking and difficulty exercising; n = 19/20; 95.0%), social and family functioning (e.g., dependent on others and relationship difficulties; n = 17/20; 85.0%), work (n = 15/20; 75.0%), and sexual functioning (n = 12/20; 60.0%). SRQoL and PGI items, instructions, response options, and recall period were well understood and relevant to participants., Conclusions: The SRQoL is a new PRO instrument to assess Sjögren's impact on HRQoL, developed in accordance with regulatory guidance. This study provides considerable insight into the patient experience of Sjögren's and evidence to support the content validity of the SRQoL. Future research should evaluate the psychometric properties of the SRQoL to support its use in clinical trials and clinical practice and further validate its use as an assessment of treatment benefit., Competing Interests: Declarations Conflict of Interest Jessica Marvel is an employee of Novartis Services Inc. Monia Steenackers, Chiara Perella, and Pushpendra Goswami are employees and shareholders of Novartis AG. Gayle Kenney was an employee and shareholder of Novartis AG at the time of this research. Elizabeth Gargon, Chloe Howse, Aishwarya Chohan, and Megan Mayhew are employees of Adelphi Values Ltd, a health outcomes agency who were paid by Novartis to conduct the research described in this manuscript. Nicola Williamson was an employee of Adelphi Values at the time of research and is now an employee and shareholder of UCB. Linda Stone has been a patient advocate representing Sjögren’s for Novartis and Servier. Benjamin Fisher has undertaken consultancy for Novartis, BMS, Servier, Galapagos, Roche, UCB, Sanofi, Janssen, Otsuka, Amgen, and AstraZeneca, and has received research funding from Janssen, Servier, Galapagos, Celgene, Novartis, and AstraZeneca. Ethical Approval Ethical approval and oversight was provided by Salus Institutional Review Board in the USA and Reading Independent Ethics Committee in the UK. Approval notices (protocol number NO9433A) were received in December 2022. The study was performed and developed in accordance with the Declaration of Helsinki and its later amendments in line with Good Clinical Practice guidelines. All subjects provided informed consent to participate in the study. Data Availability The datasets generated during and/or analyzed during the current study are not publicly available to protect participant confidentiality., (© 2024. The Author(s).)

Objective: We examine how access to and use of oral and dental care under the Children's Health Insurance Program (CHIP) compared to private coverage and being uninsured in 10 states., Methods: We report on findings drawn from a 2012 survey of CHIP enrollees in 10 states. We examined a range of parent-reported dental care access and use measures among CHIP enrollees. Comparisons of the experiences of established CHIP enrollees to the experiences of newly enrolling children who had been uninsured or privately insured were used to estimate the impacts of CHIP on children's oral health and dental care., Results: Most children enrolled in CHIP had a usual source of dental care and had received a dental checkup or cleaning in the past year, and most over age 6 had had sealants placed on their molars. In addition, parents of most CHIP enrollees were aware that CHIP covered dental benefits, and most reported not having trouble finding a dentist to see their child. Even so, 12% of CHIP enrollees had unmet dental care needs. Compared to being uninsured, CHIP enrollees did better across nearly all oral health measures. Compared to being privately insured, CHIP enrollees were more likely to have dental benefits, to have a usual source of dental care, and to have had a dental checkup/cleaning, but they were more likely to have trouble finding a dentist and less likely to say that their child's teeth were in excellent/very good condition., Conclusions: Enrolling eligible uninsured children in CHIP led to improvements in their access to preventive dental care, as well as reductions in their unmet dental care needs, yet the CHIP program has more work to do to address the oral health problems of children., (Copyright © 2015 Academic Pediatric Association. All rights reserved.)

Objective: We examine how access to care and care experiences under the Children's Health Insurance Program (CHIP) compared to private coverage and being uninsured in 10 states., Methods: We report on findings from a 2012 survey of CHIP enrollees in 10 states. We examined a range of health care access and use measures among CHIP enrollees. Comparisons of the experiences of established CHIP enrollees to the experiences of uninsured and privately insured children were used to estimate differences in children's health care., Results: Children with CHIP coverage had substantially better access to care across a range of outcomes, other things being equal, particularly compared to those with no coverage. Compared to being uninsured, CHIP enrollees were more likely to have specialty and mental health visits and to receive prescription drugs; and their parents were much more likely to feel confident in meeting the child's health care needs and were less likely to have trouble finding providers. CHIP enrollees were less likely to have unmet needs, but 1 in 4 had at least 1 unmet need. Compared to being privately insured, CHIP enrollees had generally similar health care use and unmet needs. Additionally, CHIP enrollees had lower financial burden related to their health care needs. The findings were generally robust with respect to alternative specifications and subgroup analyses, and they corroborated findings of previous studies., Conclusions: Enrolling more of the uninsured children who are eligible for CHIP improved their access to a range of care, including specialty and mental health services, and reduced the financial burden of meeting their health care needs; however, we found room for improvement in CHIP enrollees' access to care., (Copyright © 2015 Academic Pediatric Association. All rights reserved.)

Male sexuality in older age is an important issue but is not fully understood. This review aims to clarify the normal ageing process, the sexual behaviour of ageing men and the prevalence of sexual dysfunction. It identifies conditions affecting male sexuality in older age and highlights areas where more extensive research is required.

Objective: To assess the impact of the Children's Health Insurance Program (CHIP) on the distribution of health insurance coverage for low-income children., Data Source: The primary data for the study were from the 1997, 1999, and 2002 National Survey of America's Families (NSAF), which includes a total sample of 62,497 children across all 3 years, supplemented with data from other data sources., Study Design: The study uses quasi-experimental designs and tests the sensitivity of the results to using instrumental variable and difference-in-difference approaches. A detailed Medicaid and CHIP eligibility model was developed for this study. Balanced repeated replicate weights were used to account for the complex sample of the NSAF. Descriptive and multivariate analyses were conducted., Principle Findings: The results varied depending on the approach utilized but indicated that the CHIP program led to significant increases in public coverage (14-20 percentage points); and declines in employer-sponsored coverage (6-7 percentage points) and in uninsurance (7-12 percentage points). The estimated share of CHIP enrollment attributable to crowd-out ranged from 33 to 44 percent. Smaller crowd-out effects were found for Medicaid-eligible children., Conclusions: Implementation of the CHIP program resulted in large increases in public coverage with estimates of crowd-out consistent with initial projections made by the Congressional Budget Office. This paper demonstrates that public health insurance expansions can lead to substantial reductions in uninsurance without causing a large-scale erosion of employer coverage.

The bleomycins (BLMs) are a family of natural glycopeptides used clinically as antitumor agents. In the presence of required cofactors (Fe(2+) and O(2)), BLM causes both single-stranded (ss) and double-stranded (ds) DNA damage with the latter thought to be the major source of cytotoxicity. Previous biochemical and structural studies have demonstrated that BLM can mediate ss cleavage through multiple binding modes. However, our studies have suggested that ds cleavage occurs by partial intercalation of BLM's bithiazole tail 3' to the first cleavage site that facilitates its re-activation and re-organization to the second strand without dissociation from the DNA where the second cleavage event occurs. To test this model, a BLM A5 analog (CD-BLM) with beta-cyclodextrin attached to its terminal amine was synthesized. This attachment presumably precludes binding via intercalation. Cleavage studies measuring ss:ds ratios by two independent methods were carried out. Studies using [(32)P]-hairpin technology harboring a single ds cleavage site reveal a ss:ds ratio of 6.7 +/- 1.2:1 for CD-BLM and 3.4:1 and 3.1 +/- 0.3:1 for BLM A2 and A5, respectively. In contrast with BLM A5 and A2, however, CD-BLM mediates ds-DNA cleavage through cooperative binding of a second CD-BLM molecule to effect cleavage on the second strand. Studies using the supercoiled plasmid relaxation assay revealed a ss:ds ratio of 2.8:1 for CD-BLM in comparison with 7.3:1 and 5.8:1, for BLM A2 and A5, respectively. This result in conjunction with the hairpin results suggest that multiple binding modes of a single BLM can lead to ds-DNA cleavage and that ds cleavage can occur using one or two BLM molecules. The significance of the current study to understanding BLM's action in vivo is discussed.

Objective: To assess whether new premiums in SCHIP affect rates of disenrollment and reenrollment in SCHIP and whether they have spillover enrollment effects on Medicaid., Data Source: We used SCHIP administrative enrollment data from Arizona and Kentucky. The enrollment data covered July 2001 to December 2005 in Arizona and November 2001 to August 2004 in Kentucky., Study Design: We used administrative data from two states, Arizona and Kentucky, which introduced new premiums for certain income categories in their SCHIP programs in 2004 and 2003, respectively. We used multivariate hazard models to study rates of disenrollment and re-enrollment for the recipients who had been enrolled in the categories of SCHIP in which the new premiums were implemented. Competing hazard models were used to determine if recipients leaving SCHIP following the introduction of the premium were obtaining other public coverage or exiting public insurance entirely at higher rates. We also used time-series models to measure the effect of premiums on changes in caseloads in premium-paying SCHIP and other categories of public coverage and we assessed the budgetary implications of imposing premiums., Principal Findings: In both states, the new premiums increased the rate of disenrollment and decreased the rate of re-enrollment in premium-paying SCHIP among the children who were enrolled in those categories before the premiums were implemented. The competing hazard models indicated that almost all of the increased disenrollment is caused by recipients leaving public insurance entirely. The time-series models indicated that the new premium reduced caseloads in premium-paying SCHIP, but that it might have increased caseloads for other types of public coverage. The amount of premiums collected net of the costs associated with administering premiums is small in both states. Estimating the full budgetary effects with certainty was not possible given the imprecision of the key time-series estimates., Conclusion: These results suggest that the new premium reduced enrollment in the premium-paying group by 18 percent (over 3,000 children) in Kentucky and by 5 percent (over 1,000 children) in Arizona, with some of these children apparently leaving public coverage altogether. While most children enrolled in these categories did not appear to be directly affected by the imposition of $10-$20 monthly premiums, the premiums may have caused some children to go without health insurance coverage, which in turn could have adverse effects on their access to care. Imposing nominal premiums may reduce state spending, but projected savings appear to be small relative to total state SCHIP spending and resulting increases in enrollment in other public programs and in uninsurance rates could offset those savings.

This article examines experiences under Medicaid and the State Children's Health Insurance Program (SCHIP), drawing on surveys of over 3,000 enrollees in California and North Carolina in 2002. In both States, Medicaid enrollees were less likely than SCHIP enrollees to have parents who were covered by employer-sponsored insurance (ESI). With the exception of dental care and provider perceptions, access experiences were fairly comparable across the two programs, despite differences in the characteristics of the children served by the two programs. Relative to being uninsured, Medicaid enrollment was found to improve access to care along a number of different dimensions, controlling for other factors. Furthermore, this study emphasizes the need for continued evaluation of access to care for both programs.

Objective: Examine the extent to which enrollment in the State Children's Health Insurance Program (SCHIP) affects access to care and service use in 10 states that account for over 60 percent of all SCHIP enrollees., Data Sources/study Setting: Surveys of 16,700 SCHIP enrollees were conducted in 2002 as part of a congressionally mandated study. Three domains of SCHIP enrollees were included: (1) children who were recently enrolled in SCHIP, (2) those who had been enrolled in SCHIP for 5 months or more, and (3) those who had recently disenrolled from SCHIP. Response rates varied across states and domains but were clustered between 75 and 80 percent. Five different types of indicators were examined: (1) service use; (2) unmet need; (3) parental perceptions about being able to meet their child's health care needs; (4) presence and type of a usual source of care; and (5) provider communication and accessibility., Study Design: The experiences SCHIP enrollees have while on the program are compared with those a separate sample of children had before enrolling using a separate sample pretest and posttest design, controlling for observable characteristics of the children and their families., Data Collection/extraction Methods: The sample was drawn based on a list frame of SCHIP enrollees. The survey was administered in English and Spanish, by Computer-Assisted Telephone Interviewing (CATI). Field follow-up was used to locate families who could not be reached by telephone and these interviews were conducted by cellular telephone., Principal Findings: SCHIP enrollment was found to improve access to care along a number of different dimensions, other things equal, particularly relative to being uninsured. Established SCHIP enrollees were more likely to receive office visits, preventive health and dental care, and specialty care, more likely to have a usual source for medical and dental care and to report better provider communication and accessibility, and less likely to have unmet needs, financial burdens, and parental worry associated with meeting their child's health care needs. The findings are robust with respect to alternative specifications and hold up for individual states and subgroups., Conclusions: Enrollment in SCHIP appears to be improving children's access to primary health care services, which in turn is causing parents to have greater peace of mind about meeting their children's needs.

As reauthorization of the State Children's Health Insurance Program (SCHIP) looms, we examine the program's first decade and identify changes needed so that SCHIP can better serve its target population. We conclude that by many objective standards, SCHIP has been a success, but the challenge will be to maintain and build upon that success. Critical issues include the level and structure of federal funding; the continued problem of uninsurance among low-income children; the lack of information on quality, access, and costs; and whether SCHIP can serve as the foundation for addressing broader health care needs among low-income families.

This paper examines the extent to which the State Children's Health Insurance Program (SCHIP) might be substituting for private health insurance coverage at the time of enrollment. Among children who were newly enrolled in SCHIP in 2002 in ten states, about 14 percent had private coverage that they could have retained as an alternative to SCHIP. Of this 14 percent, about half of parents reported that the private coverage was unaffordable compared with SCHIP. This suggests that relatively few SCHIP enrollees could have retained private coverage and that even fewer had parents who felt that the option was affordable.

Objectives: This study examines how parental reports of communication problems with health providers vary over a wider range of characteristics of low income children than considered in previous studies., Methods: Data were drawn from the 1999 and 2002 National Survey of America's Families. Communication problems, insurance type, socioeconomic characteristics, health factors, and provider type were examined. Data were analyzed using bivariate and multivariate techniques., Results: Bivariate analysis identified that the parents of 24.4% of low income children and 36.4% of publicly covered low income children with a Spanish interview reported poor communication with health providers. Coefficients from regression analysis suggest that, controlling for covariates, foreign-born parents with a Spanish interview were 11.8 percentage points (p<0.01) more likely to report communication problems than U.S.-born parents with an English interview. Among low income publicly covered children with a Spanish interview, regression analysis suggests that parents of children who used clinics or hospital outpatient departments as their usual source of care were 9.5 percentage points (p<0.05) more likely to report communication problems compared with those whose usual source of care was a doctor's or HMO office., Conclusions: Implementing policies to improve communication barriers for low income children, particularly those with foreign-born parents whose native language is not English, may be necessary to reduce health disparities relative to higher income children across a variety of health domains including utilization, satisfaction, and outcomes. Focusing attention on the availability of professional translation services in clinics or hospital outpatient departments may be a cost-effective strategy for reducing communication problems for publicly insured children.

Objective: To examine the effects of policy, health system, and sociodemographic characteristics on the likelihood that uninsured persons pay a lower price at their regular source of care, or that they are aware of lower priced providers in their community., Data Sources: The 2003 Community Tracking Study household survey, a nationally representative sample of the U.S. population and 60 randomly selected communities., Study Design: The survey asked uninsured persons if they paid full or reduced cost at their usual source of medical care, or if they were aware of providers in their community that charge less for uninsured people. We use binomial and multinomial logistic regression analysis to examine the effects of various policy, health system, and sociodemographic characteristics on use and awareness of lower priced providers. We focus especially on the effects of safety-net capacity, measured by safety-net hospitals, community health centers, physicians' charity care, and Community Access Program (CAP) grants., Principal Findings: Less than half of the uninsured (47.5 percent) reported that they used or were aware of a lower priced provider in their community. Multivariate regression analysis shows that greater safety-net capacity is associated with a higher likelihood of having a lower priced provider as the regular source of care and greater awareness of lower priced providers. Lower incomes and racial/ethnic minorities also had a higher likelihood of having a lower priced provider, although health status did not have statistically significant effects., Conclusion: Although increased safety-net capacity may lead to more uninsured having a lower priced provider, many uninsured who live near safety-net providers are not aware of their presence. Greater outreach designed to increase awareness may be needed in order to increase the effectiveness of safety-net providers in improving access to care for the uninsured.

Objective: We examined potential barriers to enrollment in public programs among low-income children with special health care needs who are uninsured. Barriers considered include parents not knowing about the Medicaid and State Children's Health Insurance programs, not believing that their child is eligible for public coverage, not perceiving the enrollment processes as easy, and not wanting to enroll their child in a public program., Methodology: The source of data is the 2001 National Survey of Children With Special Health Care Needs. A series of 5 questions about the child's health needs, known as the Children With Special Health Care Needs Screener, was used to identify children with special health care needs. Uninsurance is defined as having no insurance coverage at the time of the survey. Low-income families are defined as those with household incomes below 200% of the federal poverty level. The analytic sample consists of 968 low-income uninsured children with special health care needs. We examined the socioeconomic and demographic characteristics of the sample, the reasons the children lack coverage, and the awareness and perception measures, both individually and combined as a summary measure., Results: Many low-income parents with uninsured children with special health care needs do not have full information about Medicaid and State Children's Health Insurance programs or do not have positive perceptions of the application processes. Although 93.5% had heard of at least 1 of the 2 programs, only 54.6% believed that their child was eligible for public coverage, and just 48.1% believed that the application processes were easy. Almost all said that they would enroll their child if told he or she was eligible for public coverage., Conclusions: Understanding why uninsured children with special health care needs do not participate in public programs is important, because these programs have the potential to cover almost all of this population. Initiatives to increase enrollment should yield real dividends given that the vast majority of low-income uninsured children with special health care needs have parents who say they would enroll their children in public coverage.

Objective: Examination of the extent to which federal surveys provide the data needed to estimate the coverage/cost impacts of policy alternatives to address the problem of uninsurance., Data Sources/study Setting: Assessment of the major federal household surveys that regularly provide information on health insurance and access to care based on an examination of each survey instrument and related survey documentation and the methodological literature., Study Design: Identification of the data needed to address key policy questions on insurance coverage, assessment of how well existing surveys meet this need, definition of the critical elements of an ideal survey, and examination of the potential for building on existing surveys., Data Collection/extraction Methods: Collection and critical assessment of pertinent survey documentation and methodological studies., Principal Findings: While all the federal surveys examined provide valuable information, the information available to guide key policy decisions still has major gaps. Issues include measurement of insurance coverage and critical content gaps, inadequate sample sizes to support precise state and substate estimates, considerable delays between data collection and availability, and concerns about response rates and item nonresponse. Our assessment is that the Current Population Survey (CPS) and the National Health Interview Survey could be most readily modified to address these issues., Conclusions: The vast resources devoted to health care and the magnitude of the uninsurance problem make it critical that we have a reliable source for tracking health care and coverage at the national and state levels and for major local areas. It is plausible that this could be more cost effectively done by building on existing surveys than by designing and fielding a new one, but further research is needed to make a definitive judgment. At a minimum, the health insurance information collected on the CPS should be revised to address existing measurement problems.

This study examines the effects of new and higher premiums on SCHIP enrollment in Kansas, Kentucky, and New Hampshire--three states that implemented premium changes in 2003. We used state administrative enrollment records from 2001 to 2004-2005 to track changes in total caseloads, new enrollments, and disenrollment timing in premium-paying categories of SCHIP before and after the premium changes were implemented. Premium hikes were associated with lower caseloads in all three states and with earlier disenrollment in Kentucky and New Hampshire. Premium increases appeared to have greater disenrollment effects for lower-income children in New Hampshire and for nonwhite children in Kentucky.

States increasingly are using premiums for near-poor children in their public insurance programs (Medicaid/SCHIP) to limit private insurance crowd-out and constrain program costs. Using national data from four rounds of the Community Tracking Study Household Surveys spanning the seven years from 1996 to 2003, this study estimates a multinomial logistic regression model examining how public and private insurance premiums affect insurance coverage outcomes (Medicaid/SCHIP coverage, private coverage, and no coverage). Higher public premiums are significantly associated with a lower probability of public coverage and higher probabilities of private coverage and uninsurance; higher private premiums are significantly related to a lower probability of private coverage and higher probabilities of public coverage and uninsurance. The results imply that uninsurance rates will rise if both public and private premiums increase, and suggest that states that impose or increase public insurance premiums for near-poor children will succeed in discouraging crowd-out of private insurance, but at the expense of higher rates of uninsurance. Sustained increases in private insurance premiums will continue to create enrollment pressures on state insurance programs for children.

This study uses 2000 to 2004 Current Population Survey data to examine the effects of public premiums on the insurance coverage of children whose family incomes are between 100% and 300% of the federal poverty level. The analysis employs multinomial logistic models that control for factors other than premium costs. While the magnitude of the estimated effects varies across models, the results consistently indicate that raising public premiums reduces enrollment in public programs, with some children who forgo public coverage having private coverage instead and others being uninsured. The results indicate that public premiums have larger effects when applied to lower-income families.

Objectives: We examined the characteristics of uninsured children from low-income households whose parents reported that health insurance coverage was not needed., Methods: With data from the 2001 National Survey of Children With Special Health Care Needs, we used logistic-regression analyses to investigate the odds of reporting that uninsured children do not need insurance for various sociodemographic groups and children of varying health status. We also explored the odds of health care use, awareness of Medicaid and the State Children's Health Insurance Program (SCHIP), and desire to enroll according to the reported need for insurance., Results: Parents of 6.8% of uninsured children from low-income households reported that their children did not need insurance. Rates were highest for American Indian/Alaska Native children (15.2%) and children whose parents completed the interview in a non-English language (10.6%). Rates were lowest for children with special health care needs (2.8%) and children with > or =7 school absences attributable to illness or injury in the past year (2.6%). Relative to children with another reason for lacking insurance, children who reportedly did not need insurance were less likely to have needed (adjusted odds ratio: 0.49) or used (adjusted odds ratio: 0.45) health care services in the past year and their parents were less likely to have heard of Medicaid or SCHIP (adjusted odds ratio: 0.58) or to have a desire to enroll their children if their children were eligible for Medicaid or SCHIP (adjusted odds ratio: 0.25)., Conclusions: Increasing participation among uninsured children whose parents do not perceive a need for insurance coverage may require more than simply increasing knowledge about the availability of public insurance programs.

Background: Understanding the impacts of Medicaid managed care on pregnant women is critical because Medicaid covers more than a third of all births nationally, many under managed care arrangements., Objectives: We sought to examine the impacts of mandatory Health Maintenance Organization (HMO) enrollment on prenatal care use, smoking, and birth weight for Medicaid-covered pregnant women in Ohio., Research Design: Impact estimates are derived from a pre-post design with a comparison group, using Ohio birth certificate data linked to Medicaid enrollment files. Between April 1993 and April 1995 is the baseline period and October 1997 to June 1998 is the post-period. The treatment group consists of deliveries in 6 counties that implemented mandatory HMO enrollment in the mid 1990s; the comparison group consists of deliveries in 4 counties with voluntary HMO enrollment., Subjects: Medicaid-covered deliveries to 24,799 non-Hispanic white women with no college education living in Ohio., Measures: Seven outcomes are analyzed: first trimester care; last trimester or no care; adequate prenatal care; inadequate prenatal care; smoking during pregnancy; and birth weight., Results: Our findings indicate that mandatory HMO enrollment in Ohio's Medicaid program had positive effects on prenatal care and led to reductions in maternal smoking. No effects were found on birth weight., Conclusions: Even with the improvements related to Medicaid managed care, rates of inadequate prenatal care and maternal smoking remain relatively high. Addressing the underlying risk factors that are facing poor women and further expanding public programs may be critical to achieving further progress.

Objective: To estimate the effects of the State Children's Health Insurance Program (SCHIP) expansions on insurance coverage, use of health care services, and access to care for children with chronic health conditions., Methods: The primary source of data was the National Health Interview Survey. Children with chronic health conditions were identified primarily through reported diagnoses of common chronic conditions (eg, asthma, attention-deficit disorder, mental retardation, Down syndrome, cerebral palsy, muscular dystrophy, sickle cell disease, diabetes, arthritis, heart disease) and on the presence of activity limitations caused by a health problem lasting at least 12 months. We examined changes in a broad array of outcomes for children with chronic health conditions who gained eligibility under SCHIP or who were already eligible for coverage under Medicaid, comparing the periods before and after implementation of the program. Changes for these treatment groups were compared with children with slightly higher incomes, who should not have been affected by the eligibility expansions. Comparisons were made with adjustment for child, family, and other characteristics that might have independent effects on the outcomes of interest. Outcomes included health insurance coverage, use of general and specialty services, access to care, and out-of-pocket spending on health care. Selected analyses were conducted for children not identified as having chronic health conditions., Results: The SCHIP expansions resulted in a 9.8 percentage point increase in the proportion of children with chronic conditions reporting public insurance and a 6.4 percentage point decline in the proportion uninsured. Unmet need for health care decreased by 8 percentage points, with most of the decline found for dental care. Increases in specialist, eye care, and dental visits and decreases in out-of-pocket spending and emergency-department and mental health visits were observed but did not meet standards of statistical significance. Estimated reductions in unmet need were greater for children with chronic conditions than for other children., Conclusions: Recent expansions in public insurance eligibility under SCHIP have improved coverage for children with chronic conditions, with selected improvements in access to care. However, some eligible children with chronic conditions remain uninsured, and the impact on access to care and service use were limited. Additional progress may require targeted outreach to children with chronic conditions and improvements in Medicaid and SCHIP service-delivery systems. Given the current fiscal environment and the fact that children with chronic conditions have not generally been protected from cutbacks, the recent progress documented in this study may be reversed.

This study examines the effect of stressful family environments on children's access to and use of health care, using a sample of 9,854 low-income children from the 1999 National Survey of America's Families. Indicators of stress included aspects of family structure, economic hardship, family turbulence, and parental ill health; these were combined into a composite family stress indicator. Having health insurance was the strongest predictor of health care access and use, but stressful family environments were significantly and inversely associated with parents' having confidence in the ability of family members to obtain health care, children having health care needs met, and children having any dental care in the previous year. The authors concluded that while enrollment in health insurance may be necessary to access and use health care, it is not sufficient. Stressful family environments also appear to influence the ability of parents to obtain care for their children.

In this study, we examine the effects of Medicaid managed care (MMC) on prenatal care utilization, infant birth weight, pre-term birth, and use of cesarean section in the United States. We obtain separate estimates of the effect of primary care case management managed care programs and health maintenance organization managed care plans on these outcomes. The results suggest the following: among white, non-Hispanic women, MMC was associated with a 2 percent decrease in the number of prenatal care visits and a 3-5 percent increase the incidence of inadequate prenatal care; MMC was associated with a significant increase in the incidence pre-term birth for non-Hispanic white women, but that this association does not appear to be causal; and MMC had no association with the incidence of cesarean section.