Background: Over the past decade, the percentage of Americans with access to employer-sponsored insurance (ESI) has declined. Dependents, specifically children, are the most likely to bear the burden of lost coverage.

Objectives: The objectives of this study were to 1) describe trends in children’s health insurance taking into account the heterogeneity across different sub-populations and 2) assess the associations between individual, local (offers of ESI), and supply side (proximity to safety net hospitals) characteristics and children’s health insurance.

Methods: We analyzed locally collected survey data for children living in the 12 counties of greater Houston, Texas (years 2003, 2006, 2008, 2011). For each year, telephone interviews were conducted with caregivers through random digit dialing. Among households with at least one employed caregiver (N=2,508), we performed an adjusted multinomial logistic regression analysis to evaluate the odds of being publicly insured or uninsured, with the option for ESI and proximity to a public hospital as primary independent variables.

Results: Low-income and racial/ethnic minority children experienced the largest increases in coverage through public insurance. Children in households without the option for ESI had higher odds (Odds ratio 10.87, 95% confidence interval 7.31-16.17) of being publicly insured or uninsured (Odds ratio 9.50, 95% confidence interval 6.14-14.70) compared to those in households with the option for ESI. Proximity to a public hospital was not associated with being uninsured.

Conclusions: As the availability of ESI has declined, public insurance has acted as a safety net for low-income and minority children. While access to free care plays an important role, it may not substitute for insurance coverage.

Key Take Away Points

  • The option of employer sponsored insurance plays a critical role in the health care of children
  • Public insurance has increased its role as a safety net for children during the recent economic downturn, particularly for low-income and minority children
  • Proximity to public hospitals does not substitute for insurance coverage
  • Awareness of public insurance has increased among families with uninsured children

Author Biography

Jean L. Raphael M.D., M.P.H., is an Assistant Professor of Pediatrics at Baylor College of Medicine and a faculty investigator at the Center for Clinical Effectiveness at Texas Children’s Hospital. He is a pediatrician and health services researcher with expertise in minority health policy. Dr. Raphael’s work combines health services research and behavioral interventions to enhance care delivery for minority children with chronic conditions. He is currently principal investigator on NIH and Aetna Foundation funded studies.

Richard R. Batsell, Ph.D., is the Jesse H. Jones Distinguished Associate Professor of Management in the Jesse H. Jones Graduate School of Management, Rice University, Houston, Texas where he specializes in Data Analysis and Marketing Research. In addition to serving as a full-time faculty member at Rice, he has also consulted with such organizations as General Foods, AT&T, Exxon, Schlumberger, Brown & Root, Asea Brown Boveri (ABB), Baker Hughes, NYCE, the PULSE EFT Association, and the Texas Finance Commission.

Marc A. Kowalkowski, M.S., is a data analyst in the Department of Health Services Research at Baylor College of Medicine.

Aileen M. Beltran, M.P.H, is the Manger of Community Benefits at Texas Children's Hospital. She is a Fulbright Scholar with a background in child advocacy and an active member of the Association for Community Health Improvement.

Angelo P. Giardino, M.D., Ph.D., is the medical director of Texas Children’s Health Plan, a clinical professor of pediatrics at Baylor College of Medicine, the Associate Chief for Academic General Pediatrics, Research, Texas Children's Hospital, an Adjunct Associate Professor in the School of Public Health at The University of Texas Health Science Center at Houston, an attending physician on the Texas Children’s Hospital Child Protection Team and a member of the forensic pediatrics service at the Children’s Assessment Center in Houston, Texas.

Charles G. Macias, M.D., M.P.H., is an associate professor of Pediatrics and director of the Center for Clinical Effectiveness. Additionally, as director of the Evidence Based Outcomes Center at Texas Children’s Hospital, he has helped develop a number of evidence based guidelines and implementation strategies for clinical care delivery and tracking of outcomes. He is on the executive steering committee of the Child Health Corporation of America’s national library of evidence based guidelines.


This study was funded by a grant to Dr. Raphael, NIH Grant Number 1K23 HL105568.



Responses to this Article:

Claire Elizabeth Bocchini, Commentary on "Trends in Child Health Insurance Coverage: A Local Perspective" (December 2013)