Caregivers’ Health Literacy and Gaps in Children’s Medicaid Enrollment: Findings from the Carolina Oral Health Literacy Study

<div><p>Background and Objectives</p><p>Recent evidence supports a link between caregivers’ health literacy and their children’s health and use of health services. Disruptions in children’s health insurance coverage have been linked to poor health care and outcomes. We examined young children’s Medicaid enrollment patterns in a well-characterized cohort of child/caregivers dyads and investigated the association of caregivers’ low health literacy with the incidence of enrollment gaps.</p><p>Methods</p><p>We relied upon Medicaid enrollment data for 1208 children (mean age = 19 months) enrolled in the Carolina Oral Health Literacy project during 2008–09. The median follow-up was 25 months. Health literacy was measured using the Newest Vital Sign (NVS). Analyses relied on descriptive, bivariate, and multivariate methods based on Poisson modeling.</p><p>Findings</p><p>One-third of children experienced one or more enrollment gaps; most were short in duration (median = 5 months). The risk of gaps was inversely associated with caregivers’ age, with a 2% relative risk decrease for each added year. Low health literacy was associated with a modestly elevated risk increase [Incidence Rate Ratio (IRR) = 1.17 (95% confidence interval (CI) 0.88–1.57)] for enrollment disruptions; however, this estimate was substantially elevated among caregivers with less than a high school education [IRR = 1.52 (95% CI 0.99–2.35); homogeneity p<0.2].</p><p>Conclusions</p><p>Our findings provide initial support for a possible role of caregivers’ health literacy as a determinant of children’s Medicaid enrollment gaps. Although the association between health literacy and enrollment gaps was not confirmed statistically, we found that it was markedly stronger among caregivers with low educational attainment. This population, as well as young caregivers, may be the most vulnerable to the negative effects of low health literacy.</p></div

Medicaid Enrollment Estimates (Children with and without Gaps in Enrollment) by Caregiver Characteristics among the COHL Study Follow-up Cohort during the Follow-up Period (Median 25 Months), North Carolina, 2008–2010.

<p><i>Note</i>. COHL = Carolina Oral Health Literacy; CI = Confidence Interval; HS = High School; GED = General Educational Development; NVS = Newest Vital Sign. The sample size was n = 1208.</p>a<p> Enrollment gap was defined as any disruption in Medicaid enrollment within a period of eligibility, preceded and superseded by periods of enrollment.</p>b<p> Column figures may not add up to total because of missing values.</p>c<p> Corresponds to X² tests of the equality of distribution of participants with and without enrollment gap across categories of caregiver characteristics.</p>d<p> Enrollment proportion was calculated for children with enrollment gaps as the ratio of months enrolled over months eligible.</p>e<p> Defined as NVS score: 0–1.</p>f<p> Defined as NVS score: 2–3.</p>g<p> Defined as NVS score: 4–6.</p><p>Medicaid Enrollment Estimates (Children with and without Gaps in Enrollment) by Caregiver Characteristics among the COHL Study Follow-up Cohort during the Follow-up Period (Median 25 Months), North Carolina, 2008–2010.</p

Distribution of Health Literacy Estimates (NVS) across Levels of Caregivers’ Characteristics, in the COHL Study Follow-up Cohort, North Carolina, 2008–2010.

<p><i>Note</i>. NVS = Newest Vital Sign; COHL = Carolina Oral Health Literacy; CI = Confidence Interval; HS = High School; GED = General Educational Development. The sample size was n = 1208.</p>a<p>Column figures may not add up to total because of missing values.</p><p>Distribution of Health Literacy Estimates (NVS) across Levels of Caregivers’ Characteristics, in the COHL Study Follow-up Cohort, North Carolina, 2008–2010.</p

Results of Multivariate Poisson Regression Modeling of Medicaid Enrollment Gap Incidence on Caregiver and Child Characteristics, among the COHL Study Follow-up Cohort in North Carolina, during the Study Period (A) and Using all Available Medicaid History (B) between January 2004 and December 2010.

<p><i>Note</i>. NVS = Newest Vital Sign; COHL = Carolina Oral Health Literacy; IRR = Incidence Rate Ratio; CI = Confidence Interval. The sample size was n = 1208.</p>a<p>Variable selection was based on a backward hierarchical procedure starting from a full model and a <i>P</i><.2 criterion; caregivers’ race, age and general health were included a priori in the models; time at risk for a gap was considered time (months) of Medicaid enrollment.</p>b<p>Defined as NVS score: 0–1.</p>c<p>Defined as NVS score: 2–6.</p><p>Results of Multivariate Poisson Regression Modeling of Medicaid Enrollment Gap Incidence on Caregiver and Child Characteristics, among the COHL Study Follow-up Cohort in North Carolina, during the Study Period (A) and Using all Available Medicaid History (B) between January 2004 and December 2010.</p

Estimates of the Association between Caregivers’ Low Health Literacy (Defined as NVS Score of less than 2) and the Incidence of Children’s Medicaid Enrollment Gaps, Overall and Stratified by Educational Attainment, among the COHL Study Follow-up Cohort in North Carolina, during the Study Period (A) and Using all Available Medicaid History (B) between January 2004 and December 2010.

<p><i>Note</i>. NVS = Newest Vital Sign; COHL = Carolina Oral Health Literacy; IRR = Incidence Rate Ratio; CI = Confidence Interval; GED = General Educational Development. The sample size was n = 1208.</p>a<p>Variable selection was based on a backward hierarchical procedure starting from a full model and a <i>P</i><.2 criterion; caregivers’ race, age and general health were included a priori in the models; time at risk for a gap was considered time (months) of Medicaid enrollment.</p>b<p>Wald χ² test of a common IRR (across-strata homogeneity).</p><p>Estimates of the Association between Caregivers’ Low Health Literacy (Defined as NVS Score of less than 2) and the Incidence of Children’s Medicaid Enrollment Gaps, Overall and Stratified by Educational Attainment, among the COHL Study Follow-up Cohort in North Carolina, during the Study Period (A) and Using all Available Medicaid History (B) between January 2004 and December 2010.</p