AMBULATORY PEDIATRICS Volume 4, Number 3 237 Copyright  2004 by Ambulatory Pediatric Association May–June 2004 When Insurance Status Is Not Static: Insurance Transitions of Low-Income Children and Implications for Health and Health Care Kimberly D. Aiken, MD, PhD; Gary L. Freed, MD, MPH; Matthew M. Davis, MD, MAPP Objectives.—Among low-income children, to characterize the frequency of transitions in health insurance coverage and examine associations of transitions with health status and health care access. Methods.—Data from the 1999 National Survey of America’s Families were used in weighted analyses to identify sociodemographic characteristics associated with health insurance transitions for children living in households with income 200% of the federal poverty level over the preceding 12 months. In logistic regression models, we examined associations of insurance transitions with children’s health status (fair/poor health), postponement of children’s medical care or prescription medications, and lack of physician visits. Results.—Among 27.93 million low-income children in 1999, 5.7 million (20.4%) had experienced an insurance transition in the preceding year. Non-Hispanic black children (24.5%) and children whose parents did not have a partner or spouse (23.5%) were significantly more likely than other children to have experienced transitions. Hispanic children (16%) were least likely to have experienced transitions. Compared with children with continuous private coverage, children who had transitioned from public to private coverage were more likely to report fair or poor health, children who experienced transitions that included a period of no coverage were more likely to report postponed medical care and prescription drugs, and children who experienced a no-coverage-to-private-coverage transition were more likely to have foregone physician visits. Conclusion.—Transitions in insurance coverage affect many low-income children and may represent barriers to their health care. Considering insurance transitions may provide a more complete picture of children’s health and health care utilization. KEY WORDS: child; health care utilization; health insurance; health status; low income Ambulatory Pediatrics 2004;4:237 243 N umerous studies have illustrated that children without health insurance experience worse access to medical care compared with children with health insurance, which may in turn be associated with the development and progression of chronic conditions and worsened health status. 1–6 Publicly insured children have greater access to medical care than do uninsured children but less access than do privately insured chil- dren. 2,5,6 Expansion of Medicaid programs and the imple- mentation of the State Children’s Health Insurance Pro- gram (SCHIP) have made more low-income children eli- gible for public health insurance. 7,8 In addition, rapid eco- nomic growth in the late 1990s led to increases in employer-sponsored coverage for children. 9 On the other hand, welfare reform in the mid-1990s and the delinking of cash assistance and Medicaid led to decreases in Med- icaid coverage for children. 10 Such changes in the economy and the form and func- tion of public insurance programs lead to gaps in insur- ance coverage for children that correspond to transitions From the Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics (Drs Aiken, Freed, and Davis) and Division of General Internal Medicine (Dr Davis), University of Michigan, Ann Arbor, Mich. Address correspondence to: Matthew M. Davis, MD, MAPP, Uni- versity of Michigan, 300 NIB, 6D20, Ann Arbor, MI 48109-0456 (e-mail: mattdav@med.umich.edu). Received for publication July 10, 2003; accepted December 18, 2003. among periods of private coverage, public coverage, and no coverage. However, few studies have examined the general effects of such insurance transitions on children’s health status or access to care, 11,12 and none have done so since the advent of SCHIP in 1997. Rather, studies com- paring insured with uninsured children have typically ex- amined insurance status at a single point in time or for children with only 12 months of continuous insurance sta- tus. 1,2,4–6 Point-in-time measures of health insurance may not provide a comprehensive picture of the dynamic be- tween insurance coverage and health, depending on the number of children affected by insurance transitions and the degree to which patterns of health and health care are distinct for children with different insurance transition ex- periences. A recent analysis of monthly insurance cover- age data from the Medical Expenditure Panel Survey found that 14% of US children in 1999 experienced in- surance transitions that involved periods of uninsurance, but the analysis did not examine the relationships between such transitions and children’s health status and health care utilization. 13 Using the Urban Institute’s 1999 National Survey of America’s Families (NSAF), we analyzed health status and access to care measures for low-income children, based on their insurance history within the 12 months pre- ceding the survey. Data from this survey have been used in other studies of children’s health insurance but have not previously been used to examine health insurance transi- tions. 2,8,14–16 Our study questions were the following: 1)