Urban vs. rural differences in insurance coverage and impact on employment among families caring for a child with cerebral palsy

Figures & data

Figure 1. Survey design of NS-CSHCN.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, State and Local Area Integrated Telephone Survey (2011).

Table 1. Demographics

Variable	Level	N = 744	%
Urban/rural living status	Rural	118	22.3
	Urban	411	77.7
CSHCN age 0–17 years who have a little or a lot of difficulty with one or more activities or participation	No difficulties with activities	13	1.7
	A little or a lot of difficulty with one or more activities	731	98.3
CSHCN age 18 months–17 years who have a little or a lot of difficulty with one or more emotional or behavioral factors	No emotional or behavioral difficulties	211	29.1
	A little or a lot of difficulty with one or more emotional or behavioral factors	515	70.9
CSHCN age 0–17 years who have a little or a lot of difficulty with one or more body functions	No difficulties involving bodily functions	150	20.2
	A little or a lot of difficulty with one or more bodily functions	594	79.8
Gender	Male	431	57.9
	Female	313	42.1
Age group	0–5 years old	161	21.6
	6–11 years old	291	39.1
	12–17 years old	292	39.2
Race/ethnicity	Hispanic	86	11.6
	White, non-Hispanic	505	67.9
	Black, non-Hispanic	91	12.2
	Other, non-Hispanic	62	8.3
Poverty level (% of federal poverty level)	0–99% FPL	157	21.1
	100–199% FPL	155	20.8
	200–399% FPL	255	34.3
	400% FPL or greater	177	23.8
Family structure	Parent household biological or adopted	486	66.1
	2 parent stepfamily household	52	7.1
	Mother only household	132	18.0
	Other family structure household	65	8.8
Highest education level attained of any adult in the family	Less than high school	37	5.0
	High school grad	136	18.3
	More than high school	571	76.7

Table 2. Logistic regression model for the probability the child has adequate insurance coverage

Variable	Odds ratio	Odds ratio 95% confidence limits		p-value
Urban/rural variable (reference = urban)
Located in a rural area	1.21	0.96	1.54	0.1096
Education level of parents (reference = More than high school)
High school graduate	1.58*	1.09	2.28	0.0152
Less than high school	0.55*	0.33	0.92	0.0238
Missed school days (reference = 7 or more missed days)
0–6 missed days	0.74*	0.62	0.89	0.0013
Unmet needs for care (reference = at least 1 unmet need)
No unmet needs for services/equipment	1.23*	1.03	1.47	0.0235
Out-of-pocket expenses (reference = more than $1000)
Less than $1000	1.60*	1.34	1.91	<0.0001
Family financial burden (reference = having financial problems)
No financial problems due to child’s health	1.27*	1.06	1.52	0.0092
Family is partner in decision making for child’s optimal health (reference = MEETS criteria)
Does not meet criteria	0.79*	0.65	0.96	0.0168
Medical home composite measure (reference = MEETS criteria)
Care does not meet medical home criteria	0.82*	0.67	0.99	0.0364
Ease of access to community-based services (reference = MEETS criteria)
Does not meet criteria	0.75*	0.62	0.91	0.0027

* Statistically significant at p < 0.05

Table 3. Urban/rural-adjusted odds ratios for variables in “adequacy of insurance coverage” model

Variable	OR^*	Lower 95% CI	Upper 95% CI
Urban
Missed school days 0–6	0.73^*	0.59	0.91
No unmet needs for support services	1.33^*	1.08	1.64
<$1000 out-of-pocket expenses (reference=>$1000)	1.58^*	1.25	1.94
No family financial burden due to child’s health	1.29^*	1.05	1.59
No easy access to community based services	0.71^*	0.57	0.89
Rural
Family is NOT a partner in decision-making for child’s optimal health	0.57^*	0.36	0.90
<$1000 out-of-pocket expenses	1.80^*	1.18	2.74

* Statistically significant at p < 0.05.

Table 4. Logistic regression model for the probability that family member’s employment is not affected due to the child’s health

Variable		Odds ratio		Odds ratio 95% confidence limits	p-value
Urban/rural variable (reference = urban)
Located in a rural area		2.09*	1.35	3.23	0.0011
Family structure (reference = parent household, biological or adopted)
Family structure—2 parent stepfamily household		1.85	0.95	3.60	0.0722
Family structure—mother only household		1.30	0.80	2.11	0.295
Family structure—other family structure		2.72*	1.51	4.90	0.0009
Race (reference = other, non-Hispanic)
Race—black, non-Hispanic		0.86	0.40	1.83	0.6928
Race—Hispanic		0.33*	0.15	0.72	0.0057
Race—white, non-Hispanic		0.59	0.32	1.10	0.0974
Missed school days (reference = 7 or more missed days)
Missed school days—0–6 missed days		1.89*	1.24	2.88	0.0036
Unmet needs for family support services (reference = one or more unmet needs)
		2.24*	1.30	3.84	0.0035
Family financial burden (reference = financial problems due to child’s health)
No financial problems due to child’s health		2.41*	1.66	3.51	<.0001
Hours per week providing care (reference = less than 1 h)
1–4 h per week		0.76	0.44	1.33	0.3364
5–10 h per week		0.42*	0.21	0.85	0.0157
11+ h per week		0.35*	0.21	0.60	0.0001
Medical home composite measure (reference = care MEETS medical home criteria)
Care does not meet medical home criteria		0.60*	0.42	0.86	0.0047
Early and continuous screening for special health care needs (reference = MEETS criteria)
Does not meet criteria		1.99*	1.32	2.98	0.001

^* Statistically significant at p < 0.05.

Table 5. Urban/Rural-adjusted odds ratios for variables in “Adequacy of Insurance Coverage” model

Variable	Odds Ratio	Lower 95% CI	Upper 95% CI
Urban
Missed school days 0–6	1.42^*	1.13	1.79
No unmet needs for support services	1.79^*	1.26	2.54
No family financial burden due to child’s health	1.56^*	1.25	1.96
Hours/week providing care 5–10	0.62^*	0.44	0.87
Medical home environment	0.79^*	0.63	0.96
No early and continuous screening for special health care needs	1.41^*	1.11	1.80
Rural
No family financial burden due to child’s health	2.53^*	1.11	5.78
Hours/week providing care 5–10	0.17^*	0.04	0.75
Hours/week providing care 11+	0.21^*	0.05	0.95

^* Statistically significant at p < 0.05.

Table 6. Association of covariates with Urban/rural living status

Covariate	Level	Urban/rural living status		p-value^*
		Rural (N = 118)	Urban (N = 411)
Activity limitations	Daily activities never affected	5 (17.86)	23 (82.14)	0.279
	Daily activities moderately affected some of time	13 (16.25)	67 (83.75)
	Daily activities consistently affected, often a great deal	100 (23.81)	320 (76.19)
Missed school days	<7 missed school days	32 (23.36)	105 (76.64)	0.719
	≥7 missed school days	40 (25.16)	119 (74.84)
Inconsistently insured	Insured entire year	106 (21.37)	390 (78.63)	0.050
	NOT insured at some point during year	11 (36.67)	19 (63.33)
Currently uninsured	Currently insured	114 (22.18)	400 (77.82)	0.571
	Currently NOT insured	4 (28.57)	10 (71.43)
Adequacy of current insurance coverage	Current insurance is NOT adequate	36 (18.37)	160 (81.63)	0.109
	Current insurance IS adequate	76 (24.44)	235 (75.56)
Unmet needs for care	No unmet needs for 14 specific health care services	68 (21.73)	245 (78.27)	0.712
	At least 1 unmet need for services/equipment	46 (23.12)	153 (76.88)
Unmet needs for family support services	No unmet needs for specific family support services or did not need	97 (22.93)	326 (77.07)	0.490
	One or more unmet needs for family support services	21 (19.81)	85 (80.19)
Problems obtaining referral	Needed referral, no problems getting it	56 (25.23)	166 (74.77)	0.858
	Needed referral, YES problems getting it	14 (26.42)	39 (73.58)
Usual source for sick care	Docs office is usual source for sick care	79 (21.24)	293 (78.76)	0.169
	Clinic, health center or other regular source for sick care	30 (28.85)	74 (71.15)
	No usual source for sick care or ER, Mexico or no one place most often	9 (17.31)	43 (82.69)
Personal doctor or nurse	No, does not have a PDN	4 (19.05)	17 (80.95)	0.714
	Yes, has one or more PDNs	114 (22.44)	394 (77.56)
Family centered care	Does NOT have family centered care	43 (21.94)	153 (78.06)	0.832
	Yes, has family centered care	73 (22.74)	248 (77.26)
Out-of-pocket expenses	Less than $1000	84 (24.42)	260 (75.58)	0.113
	More than $1000	32 (18.29)	143 (81.71)
Family financial burden	No financial problems due to child’s health	72 (22.64)	246 (77.36)	0.934
	Yes, financial problems	46 (22.33)	160 (77.67)
Hours per week providing care	Less than 1 h	18 (27.69)	47 (72.31)	0.398
	1–4 h per week	23 (17.83)	106 (82.17)
	5–10 h per week	18 (25.35)	53 (74.65)
	11 or more hours per week	52 (22.32)	181 (77.68)
Impact on family work life	Employment not affected	58 (28.57)	145 (71.43)	0.007
	Family member cut back hours or stopped working or both	60 (18.58)	263 (81.42)
OUTCOME #1: How many children met Outcome #1 on shared decision-making, usually/always on all questions	Did not meet Outcome #1	33 (20.63)	127 (79.38)	0.535
	Met Outcome #1	84 (23.08)	280 (76.92)
OUTCOME #2: CSHCN receiving coordinated, ongoing, comprehensive care within a medical home	Care DOES NOT meet medical home criteria	71 (21.07)	266 (78.93)	0.196
	Care MEETS medical home criteria	44 (26.19)	124 (73.81)
OUTCOME #3: Families of CSHCN have adequate insurance to pay for the services they need	Did not meet outcome #3	44 (20.47)	171 (79.53)	0.446
	Met outcome #3	71 (23.28)	234 (76.72)
OUTCOME #4: Number of CSHCN with both preventive medical AND dental visits in the past 12 months	Did not meet outcome #4 criteria	24 (19.83)	97 (80.17)	0.514
	Met outcome #4 criteria	91 (22.64)	311 (77.36)
OUTCOME #5: How many children met outcome #5, ease of access to service use/experienced no barriers or difficulties in accessing care?	Did not meet outcome #5	62 (22.46)	214 (77.54)	0.937
	Met outcome #5	55 (22.18)	193 (77.82)
OUTCOME #6: Transition to adulthood—ages 12−17 only	Did not meet outcome #6	38 (24.05)	120 (75.95)	0.640
	Met outcome #6	10 (27.78)	26 (72.22)
CSHCN age 0–17 years who have a little or a lot of difficulty with one or more activities or participation	No difficulties with activities	0 (0)	11 (100)	0.073
	A little or a lot of difficulty with one or more activities	118 (22.78)	400 (77.22)
CSHCN age 18 months–17 years who have a little or a lot of difficulty with one or more emotional or behavioral factors	No emotional or behavioral difficulties	33 (21.02)	124 (78.98)	0.658
	A little or a lot of difficulty with one or more emotional or behavioral factors	82 (22.78)	278 (77.22)
CSHCN age 0–17 years who have a little or a lot of difficulty with one or more body functions	No difficulties involving bodily functions	19 (18.45)	84 (81.55)	0.294
	A little or a lot of difficulty with one or more bodily functions	99 (23.24)	327 (76.76)
Gender	Male	73 (24.09)	230 (75.91)	0.253
	Female	45 (19.91)	181 (80.09)
Age group	0–5 years old	25 (23.15)	83 (76.85)	0.497
	6–11 years old	41 (19.71)	167 (80.29)
	12–17 years old	52 (24.41)	161 (75.59)
Race/ethnicity	Hispanic	16 (23.19)	53 (76.81)	0.078
	White, non-Hispanic	86 (24.86)	260 (75.14)
	Black, non-Hispanic	13 (16.67)	65 (83.33)
	Other, non-Hispanic	3 (8.33)	33 (91.67)
Poverty level (% federal poverty level)	0–99% FPL	39 (31.71)	84 (68.29)	<0.001
	100–199% FPL	31 (28.97)	76 (71.03)
	200–399% FPL	38 (21.59)	138 (78.41)
	400% FPL or greater	10 (8.13)	113 (91.87)
Family structure	CSHCN in parent household biological or adopted	73 (21.53)	266 (78.47)	0.855
	CSHCN in 2 parent stepfamily household	11 (25.58)	32 (74.42)
	CSHCN in mother only household	25 (25)	75 (75)
	CSHCN in other family structure household	9 (21.95)	32 (78.05)
What is the highest education level attained of any adult in the family?	Less than high school	10 (29.41)	24 (70.59)	0.132
	High school grad	28 (28.28)	71 (71.72)
	More than high school	80 (20.2)	316 (79.8)

^* All p-values were calculated using a Chi-Square test.

^** Statistically significant at p < 0.05.

Table 7. Univariate logistic regression results

Covariate	Level	Impact on family work life		Adequacy of insurance coverage
		Odds ratio (95% CI)	OR p-value	Odds ratio (95% CI)	OR p-value
Urban/rural living status	Rural	1.75 (1.16–2.65)	0.008	1.44 (0.92–2.24)	0.110
	Urban	–	–	–	–
CSHCN age 0–17 years who have a little or a lot of difficulty with one or more activities or participation	No difficulties with activities	3.70 (1.13–12.12)	0.031	0.74 (0.22–2.44)	0.620
	A little or a lot of difficulty with one or more activities	–	–	–	–
CSHCN age 18 months–17 years who have a little or a lot of difficulty with one or more emotional or behavioral factors	No emotional or behavioral difficulties	1.54 (1.11–2.14)	0.009	0.90 (0.65–1.26)	0.546
	A little or a lot of difficulty with one or more emotional or behavioral factors	–	–	–	–
CSHCN age 0–17 years who have a little or a lot of difficulty with one or more body functions	No difficulties involving bodily functions	2.24 (1.56–3.22)	<0.001	1.16 (0.79–1.70)	0.440
	A little or a lot of difficulty with one or more bodily functions	–	–	–	–
Gender	Male	1.11 (0.82–1.50)	0.505	0.93 (0.69–1.27)	0.654
	Female	–	–	–	–
Ages group	0–5 years old	0.77 (0.52–1.15)	0.209	0.92 (0.61–1.38)	0.681
	6–11 years old	0.87 (0.62–1.21)	0.395	0.81 (0.58–1.14)	0.229
	12–17 years old	–	–	–	–
Race/ethnicity	Black, non-Hispanic	1.24 (0.65–2.38)	0.517	1.01 (0.51–2.00)	0.981
	Hispanic	0.47 (0.24–0.95)	0.034	1.23 (0.60–2.49)	0.571
	White, non-Hispanic	0.79 (0.46–1.35)	0.385	0.88 (0.51–1.53)	0.652
	Other, non-Hispanic	–	–	–	–
Poverty level (% federal poverty level)	0–99% FPL	1.03 (0.66–1.61)	0.899	1.49 (0.95–2.33)	0.080
	100–199% FPL	1.10 (0.70–1.71)	0.680	1.50 (0.96–2.36)	0.075
	200–399% FPL	1.08 (0.73–1.61)	0.701	1.38 (0.93–2.06)	0.106
	400% FPL or greater	–	–	–	–
Family structure	2 parent stepfamily household	1.99 (1.12–3.54)	0.209	1.07 (0.59–1.94)	0.673
	Mother only household	1.05 (0.71–1.57)	0.033	1.02 (0.68–1.53)	0.411
	Other family structure household	2.43 (1.44–4.12)	0.020	1.77 (0.98–3.18)	0.079
	Parent household biological or adopted	–	–	–	–
Highest education level attained of any adult in the family	High school grad	1.15 (0.79–1.69)	0.462	1.89 (1.23–2.90)	0.003
	Less than high school	1.43 (0.73–2.79)	0.297	0.89 (0.43–1.88)	0.767
	More than high school	–	–	–	–
Activity limitations	Daily activities moderately affected some of time	2.45 (1.65–3.64)	<0.001	1.33 (0.88–2.03)	0.179
	Daily activities never affected	2.78 (1.40–5.51)	0.003	2.17 (0.96–4.87)	0.061
	Daily activities consistently affected, often a great deal	–	–	–	–
Missed school days	<7 missed school days	1.52 (1.03–2.25)	0.035	1.29 (0.87–1.94)	0.208
	≥7 missed school days	–	–	–	–
Inconsistently insured	Insured entire year	1.18 (0.62–2.25)	0.613	2.12 (0.95–4.75)	0.067
	NOT insured at some point during year	–	–	–	–
Adequacy of current insurance coverage	Current insurance is NOT adequate	0.61 (0.44–0.84)	0.002	NA	NA
	Current insurance IS adequate	–	–	NA	NA
Unmet needs for care	No unmet needs for 14 specific health care services	1.75 (1.27–2.41)	<0.001	2.42 (1.76–3.33)	<0.001
	At least 1 unmet need for services/equipment	–	–	–	–
Unmet needs for family support services	No unmet needs for specific family support services or did not need	3.95 (2.44–6.42)	<0.001	2.56 (1.75–3.77)	<0.001
	One or more unmet needs for family support services	–	–	–	–
Problems obtaining referral	Needed referral, no problems getting it	1.09 (0.62–1.92)	0.756	1.53 (0.91–2.57)	0.108
	Needed referral, YES problems getting it	–	–	–	–
Usual source for sick care	Clinic, health center or other regular source for sick care	1.01 (0.56–1.84)	0.971	1.78 (0.96–3.29)	0.066
	Docs office is usual source for sick care	1.21 (0.72–2.04)	0.464	1.15 (0.68–1.93)	0.604
	No usual source for sick care or ER, Mexico or no one place most often	–	–	–	–
Personal doctor or nurse	No, does not have a PDN	0.80 (0.35–1.80)	0.584	1.33 (0.56–3.12)	0.516
	Yes, has one or more PDNs	–	–	–	–
Family centered care	Does NOT have family centered care	0.71 (0.52–0.97)	0.034	0.58 (0.42–0.79)	<0.001
	Yes, has family centered care	–	–	–	–
Out-of-pocket expenses	Less than $1000	2.24 (1.61–3.12)	<0.001	3.24 (2.35–4.48)	<0.001
	More than $1000	–	–	–	–
Family financial burden	No financial problems due to child’s health	3.45 (2.46–4.82)	<0.001	2.30 (1.68–3.14)	<0.001
	Yes, financial problems	–	–	–	–
Hours per week providing care	1–4 h per week	0.66 (0.39–1.10)	0.015	0.92 (0.53–1.56)	0.324
	5–10 h per week	0.33 (0.18–0.59)	0.037	0.62 (0.34–1.14)	0.142
	11 or more hours per week	0.23 (0.14–0.37)	<0.001	0.71 (0.43–1.18)	0.350
	Less than 1 h	–	–	–	–
Impact on family work life	Employment not affected	NA	NA	1.64 (1.20–2.26)	0.002
	Family member cut back hours or stopped working or both	NA	NA	–	–
OUTCOME #1: How many children met Outcome #1 on shared decision-making, usually/always on all questions	Did not meet Outcome #1	0.69 (0.50–0.97)	0.032	0.43 (0.31–0.60)	<0.001
	Met Outcome #1	–	–	–	–
OUTCOME #2: CSHCN receiving coordinated, ongoing, comprehensive care within a medical home	Care DOES NOT meet medical home criteria	0.49 (0.36–0.67)	<0.001	0.40 (0.28–0.57)	<0.001
	Care MEETS medical home criteria	–	–	–	–
OUTCOME #3: Families of CSHCN have adequate insurance to pay for the services they need	Did not meet outcome #3	0.63 (0.46–0.86)	0.003	0.00 (0.00–1.97E132)	0.906
	Met outcome #3	–	–	–	–
OUTCOME #4: Number of CSHCN with both preventive medical AND dental visits in the past 12 months	Did not meet outcome #4 criteria	1.63 (1.15–2.32)	0.007	0.97 (0.67–1.39)	0.858
	Met outcome #4 criteria	–	–	–	–
OUTCOME #5: How many children met outcome #5, ease of access to service use/experienced no barriers or difficulties in accessing care?	Did not meet outcome #5	0.47 (0.35–0.63)	<0.001	0.36 (0.26–0.49)	<0.001
	Met outcome #5	–	–	–	–
OUTCOME #6: Transition to adulthood—ages 12–17 only	Did not meet outcome #6	0.38 (0.20–0.70)	0.002	0.42 (0.20–0.86)	0.018
	Met outcome #6	–	–	–	–

Centers for Disease Control and Prevention, National Center for Health Statistics, State and Local Area Integrated Telephone Survey. (2011, December). 2009–2010 National survey of children with special health care needs frequently asked questions. Retrieved from http://www.cdc.gov/nchs/slaits/cshcn.htm

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