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Health Care Access and Use Among Children & Adolescents Exposed to Parental Incarceration—United States, 2019

  • Author Footnotes
    # Dr. Khazanchi's current affiliation is with the Departments of Internal Medicine and Pediatrics at Harvard Medical School and the Internal Medicine-Pediatrics Residency Program at Brigham & Women's Hospital, Boston Children's Hospital, and Boston Medical Center, Boston, MA.
    Rohan Khazanchi
    Correspondence
    Address correspondence to Rohan Khazanchi, MD, MPH, Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, 701 Park Ave, S2.309, Minneapolis, MN 55415.
    Footnotes
    # Dr. Khazanchi's current affiliation is with the Departments of Internal Medicine and Pediatrics at Harvard Medical School and the Internal Medicine-Pediatrics Residency Program at Brigham & Women's Hospital, Boston Children's Hospital, and Boston Medical Center, Boston, MA.
    Affiliations
    Health, Homelessness, and Criminal Justice Lab (R Khazanchi and TNA Winkelman), Hennepin Healthcare Research Institute, Minneapolis, Minn

    School of Public Health (R Khazanchi), University of Minnesota, Minneapolis, Minn

    College of Medicine (R Khazanchi), University of Nebraska Medical Center, Omaha, Nebr
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  • Nia J. Heard-Garris
    Affiliations
    Division of Advanced General Pediatrics, Department of Pediatrics and Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center (NJ Heard-Garris), Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Chicago, Ill

    Department of Pediatrics (NJ Heard-Garris), Northwestern University Feinberg School of Medicine, Chicago, Ill

    Institute for Policy Research (NJ Heard-Garris), Northwestern University, Chicago, Ill
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  • Tyler N.A. Winkelman
    Affiliations
    Health, Homelessness, and Criminal Justice Lab (R Khazanchi and TNA Winkelman), Hennepin Healthcare Research Institute, Minneapolis, Minn

    Division of General Internal Medicine (NA Winkelman), Department of Medicine, Hennepin Healthcare, Minneapolis, Minn
    Search for articles by this author
  • Author Footnotes
    # Dr. Khazanchi's current affiliation is with the Departments of Internal Medicine and Pediatrics at Harvard Medical School and the Internal Medicine-Pediatrics Residency Program at Brigham & Women's Hospital, Boston Children's Hospital, and Boston Medical Center, Boston, MA.
Open AccessPublished:October 07, 2022DOI:https://doi.org/10.1016/j.acap.2022.10.001

      Abstract

      Objective

      The United States has the highest incarceration rate in the world, with spillover impacts on 5 million children with an incarcerated parent. Children exposed to parental incarceration (PI) have suboptimal health care access, use, and outcomes in adulthood compared to their peers. However, little is known about their access and utilization during childhood. We evaluated relationships between PI and health care use and access throughout childhood and adolescence.

      Methods

      We analyzed the nationally representative 2019 National Health Interview Survey Child Sample to examine cross-sectional associations between exposure to incarceration of a residential caregiver, access to care, and health care use among children aged 2–17. Respondents were asked about measures of preventive care access, unmet needs due to cost, and acute care use over the last year. We estimated changes associated with PI exposure using multiple logistic regression models adjusted for age, sex, race, ethnicity, parental education, family structure, rurality, income, insurance status, and disability.

      Results

      Of 7405 sample individuals, 467 (weighted 6.2% [95% CI 5.5–6.9]) were exposed to PI. In adjusted analyses to produce national estimates, exposure to PI was associated with an additional 2.2 million children lacking a usual source of care, 2 million with forgone dental care needs, 1.2 million with delayed mental health care needs, and 865,000 with forgone mental health care needs.

      Conclusions

      Exposure to PI was associated with worse access to a usual source of care and unmet dental and mental health care needs. Our findings highlight the need for early intervention by demonstrating that these barriers emerge during childhood and adolescence.

      Keywords

      What's New
      Exposure to parental incarceration was associated with worse access to a usual source of care and unmet dental and mental health care needs. This nationally representative study extends existing literature on suboptimal access to care among young adults previously exposed to PI by demonstrating these trends start within childhood.
      Incarceration rates in the US have increased fivefold since 1970.
      • Wildeman C
      • Wang EA.
      Mass incarceration, public health, and widening inequality in the USA.
      With over 2.2 million people incarcerated on any given day, the United States maintains the highest incarceration rate (700 per 100,000) in the world.
      • Wildeman C
      • Wang EA.
      Mass incarceration, public health, and widening inequality in the USA.
      As a result, over 5 million kids—7% of all US children—have had a parent who lived with them go to jail or prison.
      • Murphey D
      • Cooper PM.
      Parents Behind Bars: What Happens to Their Children?.
      ,
      • Finkelhor D.
      Trends in adverse childhood experiences (ACEs) in the United States.
      Parental incarceration (PI) is disproportionately concentrated among Black, poor, and rural children, as well as among children of parents with low educational attainment.
      • Wildeman C.
      Parental imprisonment, the prison boom, and the concentration of childhood disadvantage.
      ,
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      Importantly, the inequitable and racialized distribution of PI can lead to other adverse exposures, including child poverty.
      • Heard-Garris N
      • Boyd R
      • Kan K
      • et al.
      Structuring poverty: how racism shapes child poverty and child and adolescent health.
      Exposure to PI has been identified as a key adverse childhood experience (ACE) with physical and mental health impacts across the life course.
      • Felitti VJ
      • Anda RF
      • Nordenberg D
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) Study.
      ,
      • Wildeman C
      • Goldman AW
      • Turney K.
      Parental incarceration and child health in the United States.
      Moreover, children with one or more incarcerated parent are exposed to nearly five times as many other ACEs as their counterparts without incarcerated parents.
      • Turney K.
      Adverse childhood experiences among children of incarcerated parents.
      This is especially concerning given the additive, dose-response impact of ACEs on health.
      • Felitti VJ
      • Anda RF
      • Nordenberg D
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) Study.
      ,
      • Flaherty EG
      • Thompson R
      • Dubowitz H
      • et al.
      Adverse childhood experiences and child health in early adolescence.
      PI exposure is independently associated with increased incidence of learning and developmental disabilities, physical health conditions, and mental health conditions in adulthood.
      • Wildeman C
      • Goldman AW
      • Turney K.
      Parental incarceration and child health in the United States.
      ,
      • Lee RD
      • Fang X
      • Luo F.
      The impact of parental incarceration on the physical and mental health of young adults.
      ,
      • Turney K.
      Stress proliferation across generations? examining the relationship between parental incarceration and childhood health.
      Exposure to PI is also associated with worse access to health care in young adulthood; a longitudinal study using National Longitudinal Study of Adolescent to Adult Health (Add Health) data from 1995 to 2008 found increased odds of forgone medical care among young adults (24–32 years old) exposed to paternal incarceration. In the same study, exposure to maternal incarceration was associated with increased odds of forgone medical care and lacking a usual source of primary care.
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      However, very little is known about the health care access and use of children and adolescents exposed to PI during childhood itself. This may be a missed opportunity for early intervention, given that access to care and unmet health care needs in childhood independently predict adult health behaviors and outcomes.
      • Goodman-Bacon A.
      The long-run effects of childhood insurance coverage: Medicaid implementation, adult health, and labor market outcomes.
      ,
      • Hargreaves DS
      • Elliott MN
      • Viner RM
      Unmet health care need in US adolescents and adult health outcomes.
      A cross-sectional study of the 2011–2012 National Survey of Children's Health (NSCH) data found substantial unmet mental health care needs among children exposed to PI.
      • Turney K.
      Unmet health care needs among children exposed to parental incarceration.
      Yet, given that health care coverage and access for children have improved significantly over the last decade across a number of relevant indicators,
      • Larson K
      • Cull WL
      • Racine AD
      • et al.
      Trends in access to health care services for US children: 2000–2014.
      older evaluations with limited measures of access and utilization may not necessarily reflect the current context. This is especially pertinent after implementation of the Affordable Care Act (ACA) in 2010 and Medicaid expansions in 2014, which substantially increased coverage for adults with criminal justice involvement and had broadly documented spillover impacts on key child health and access to care indicators.
      • Howell BA
      • Hawks L
      • Wang EA
      • et al.
      Evaluation of changes in US health insurance coverage for individuals with criminal legal involvement in Medicaid expansion and nonexpansion states, 2010 to 2017.
      • Hudson JL
      • Moriya AS.
      Medicaid expansion for adults had measurable “welcome mat” effects on their children.
      • Khouja T
      • Burgette JM
      • Donohue JM
      • et al.
      Association between Medicaid expansion, dental coverage policies for adults, and children's receipt of preventive dental services.
      • Venkataramani M
      • Pollack CE
      • Roberts ET.
      Spillover effects of adult Medicaid expansions on children’s use of preventive services.
      Thus, the current state of health care access and use during childhood and adolescence among those exposed to PI remains ill-defined.
      In this study, we leveraged a new biennial question about PI added to the 2019 National Health Interview Survey (NHIS), a gold standard evaluation of health care access and use.
      Survey Description, National Health Interview Survey, 2019.
      Among this nationally representative cohort, we assessed the association of PI with health care access and use to determine the scale and scope of barriers among children and adolescents exposed to PI. Our a priori hypothesis, based on existing literature,
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      ,
      • Turney K.
      Unmet health care needs among children exposed to parental incarceration.
      was that children and adolescents exposed to PI would have worse access to preventive care, higher rates of delayed or forgone care, and increased utilization in acute care settings compared to those who had not experienced PI.

      METHODS

      Study Design and Data Source

      We conducted a cross-sectional study of the 2019 NHIS Child Sample to examine the association of PI with measures of health care access and use. Institutional review board approval was not required for this secondary analysis of a publicly available and nonidentifiable dataset. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

      Study Sample

      The NHIS Child Sample is a nationally representative, cross-sectional survey of the noninstitutionalized, civilian population across all 50 US states and the District of Columbia.
      Survey Description, National Health Interview Survey, 2019.
      The NHIS uses geographically clustered sampling techniques to select a sample of dwelling units. Within each sample household, information was obtained from in-person interviews with a parent or adult knowledgeable about and responsible for the health care of one randomly selected child aged 0 to 17 years. The NHIS Child Sample response rate for 2019 was 59.1%. Details about the sampling methodology and the specific phrasing of the 2019 NHIS Child Sample questionnaire are available publicly online.
      Survey Description, National Health Interview Survey, 2019.
      We excluded children less than 2 years of age from our sample, as measures of health care access and use were not assessed for this subpopulation. Respondents who refused to answer, whose answers were not ascertained, or who did not know the answer to a given question were recorded as “missing” for that item.

      Measures

      Independent Variable: Parental Incarceration

      As part of the rotating core NHIS questions on Stressful Life Events initiated in 2019, adult respondents were asked whether the sample child “ever lived with a parent or guardian who served time in jail or prison after they were born.” This variable captures both current and previous parental incarceration, but only captures incarceration of a residential parent and thus may underestimate overall prevalence of PI.
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      ,
      • Turney K.
      Stress proliferation across generations? examining the relationship between parental incarceration and childhood health.
      Nevertheless, capturing residential parental incarceration may be especially important since these children experience worse outcomes than children with a nonresidential incarcerated parent.
      • Turney K
      • Wildeman C.
      Redefining relationships: explaining the countervailing consequences of paternal incarceration for parenting.
      This question may also capture exposure to incarceration of a nonparental guardian (eg, grandparent).

      Dependent Variables: Health Care Access and Use

      We selected key dependent variables from questions asked for all sample children aged 2–17 across four primary domains of interest: 1) preventive care access (including having a usual source of care, well visit, and routine dental cleaning in the last year), 2) delayed care due to cost (including dental, medical, and mental health care), 3) forgone care due to cost (including dental, medical, and mental health care), and 4) acute care use (hospitalization, urgent care clinic use, or hospital emergency room use in the last year).

      Covariates

      Using the Andersen Health Utilization Model and the Gelberg-Andersen Behavioral Model for Vulnerable Populations as grounding conceptual frameworks, we identified sociodemographic and clinical factors which might confound the relationships between PI exposure and health care access or health service use.
      • Andersen R
      • Newman JF.
      Societal and individual determinants of medical care utilization in the United States.
      ,
      • Gelberg L
      • Andersen RM
      • Leake BD.
      The behavioral model for vulnerable populations: application to medical care use and outcomes for homeless people.
      These applied conceptual models encompass characteristics which are predisposing, enabling, and need-based dynamics that lead to health utilization. Predisposing factors, in addition to history of PI, included age (early childhood: 2–5 years, middle childhood: 6–11 years, early adolescence: 12–17; based on National Institute of Child Health & Human Development standards), sex assigned at birth (male, female), self-reported race and ethnicity groups (non-Hispanic white, Hispanic, non-Hispanic Black, Other [including non-Hispanic Asian, non-Hispanic American Indian/Alaska Native, and non-Hispanic multirace, combined for regression analyses due to the small number of observations]) given the multilevel impacts of racism on access to care for minoritized groups,
      • Bailey ZD
      • Krieger N
      • Agénor M
      • et al.
      Structural racism and health inequities in the USA: evidence and interventions.
      maximum parental education (less than high school, high school diploma or equivalent, post-secondary) and family structure (2-parent household, 1-parent, no residential parents). Enabling factors included rurality (metropolitan, non-metropolitan, based on the 2013 National Center for Health Statistics Urban-Rural classification scheme,
      • Ingraham DD
      • Franco SJ.
      2013 NCHS urban–rural classification scheme for counties.
      included because of higher documented incarceration rates in rural settings
      • Wildeman C
      • Wang EA.
      Mass incarceration, public health, and widening inequality in the USA.
      ,
      • Wildeman C.
      Parental imprisonment, the prison boom, and the concentration of childhood disadvantage.
      ), household income (poor: <100% of the federal poverty level [FPL], near-poor: 100–199% FPL, not poor: ≥200% FPL, based on prior studies of child health care access using NHIS
      • Larson K
      • Cull WL
      • Racine AD
      • et al.
      Trends in access to health care services for US children: 2000–2014.
      ), and insurance status (private or military; Medicaid, CHIP, or other public; uninsured currently or anytime in the last 12 months). Lastly, the need-based factor included was a validated ecobiodevelopmental measure of disability ("Yes," “No” for the Washington Group Short Set Composite Disability Indicator, which defines presence of disability based both on the person's individual functional limitations and their experiences with environmental/societal barriers).

      Statistical Analysis

      First, we created our study sample of children aged 2–17 years by selecting respondents with non-missing data for all variables of interest. We summarized descriptive statistics for our study population to document the weighted prevalence of parental incarceration and outcomes of interest. We compared the weighted associations of each variable and PI with χ2 tests.
      Then, for each outcome measure of health care access and use, we constructed multiple logistic regression models to estimate associations with exposure to PI. Each regression included adjustment for all predisposing, enabling, and need-based characteristics measured. We used these models to identify the percentage-point (PP) difference in adjusted marginal effects of PI on each outcome of interest, with our results presented as predicted probabilities by PI exposure and predicted number of children experiencing each outcome.
      • Norton EC
      • Dowd BE
      • Maciejewski ML.
      Marginal effects—quantifying the effect of changes in risk factors in logistic regression models.
      We performed all analyses using Stata, version 17 (StataCorp, College Station, TX), accounted for the clustered, stratified complex survey design, and used poststratification survey weights to produce nationally representative estimates for the population of non-institutionalized, housed children aged 2 to 17 years in the United States. We considered two-tailed P < .05 to be statistically significant.

      RESULTS

      Descriptive Statistics and Univariate Analyses

      Of 7686 sample children aged 2–17 in the 2019 NHIS Child Sample, we excluded 303 (3.9%) with missing data for key variables. Of the 7383 remaining individuals, 469 (weighted 6.4% [95% CI 5.7–7.1]) had been exposed to incarceration of a residential caregiver. In Table 1, we describe the sociodemographic characteristics of our sample by PI exposure. Notably, exposure to PI was significantly associated with adolescent age, non-Hispanic Black race, lower parental educational attainment, zero or one parent in the household, nonmetropolitan residence, poverty or near-poverty, enrollment in Medicaid or other public insurance, and a positive disability screen. Sex and uninsurance were similar between the 2 groups.
      Table 1Weighted Descriptive Statistics for Characteristics of Respondents Exposed and Not Exposed to Parental Incarceration (PI)
      PINo PIχ2 Test
      Weighted N = 3,648,217 (469 Observations)Weighted N = 55,305,832 (6914 Observations)
      Proportion95% CIProportion95% CIP-value
      Age Category
       Early Childhood (2-5 y)13.8[10.0,18.7]19.8[18.6,21.0]<.001
       Middle Childhood (6-11 y)41.0[35.8,46.3]39.5[38.1,41.0]
       Adolescence (12-17 y)45.2[39.7,50.9]40.7[39.3,42.2]
      Sex
       Female50.6[45.0,56.2]49.1[47.7,50.4].609
       Male49.4[43.8,55.0]50.9[49.6,52.3]
      Race and Ethnicity
       NH White51.6[45.7,57.4]51.7[49.6,53.8].157
       Hispanic22.0[17.5,27.1]25.9[23.8,28.0]
       NH Black16.5[12.7,21.2]12.5[11.2,13.9]
       Other (NH Asian, NH AIAN, Other/Multiracial)9.9[6.7,14.4]9.9[8.9,11.1]
      Highest Level of Parental Educational Attainment
       Less than high school11.0[8.0,14.9]8.4[7.3,9.6]<.001
       High school, GED, or equivalent25.4[20.7,30.8]18.6[17.4,19.9]
       Post-secondary education51.7[46.3,57.1]71.9[70.1,73.5]
      Number of Parents in Household
       No parents in household11.8[8.6,16.0]1.1[0.9,1.4]<.001
       1 parent57.6[52.0,63.0]29.0[27.5,30.5]
       2+ parents30.6[25.5,36.2]69.8[68.3,71.3]
      Rurality
      Rurality is based on the 2013 NCHS Urban-Rural Classification Scheme for Counties.
       Nonmetropolitan21.6[17.1,26.9]13.3[11.8,15.0]<.001
       Metropolitan78.4[73.1,82.9]86.7[85.0,88.2]
      Family Income as % of Federal Poverty Level (FPL)
       Poor (<100% FPL)31.5[26.5,37.0]16[14.7,17.4]<.001
       Near-Poor (100% to 199% FPL)32.6[27.3,38.3]22.1[20.8,23.5]
       Not Poor (>=200% FPL)36.0[30.8,41.4]61.8[59.9,63.7]
      Primary Source of Health Insurance
       Private or military24.2[19.9,29.0]61.8[59.9,63.7]<.001
       Medicaid, CHIP, or other public70.9[65.8,75.5]33.2[31.5,34.9]
       Uninsured4.9[3.1,7.8]5.0[4.3,5.8]
      Washington Group Short Set Composite Disability Indicator
       No77.4[72.7,81.6]89.8[88.8,90.7]<.001
       Yes22.6[18.4,27.3]10.2[9.3,11.2]
      Proportion indicates weighted column percent; 95% CI = 95% Confidence Interval, based on Standard Errors computed using Taylor Series; NH = non-Hispanic; and AIAN = American Indian or Alaskan Native.
      P-values in bold reflect statistical significance at P < .05.
      low asterisk Rurality is based on the 2013 NCHS Urban-Rural Classification Scheme for Counties.
      In Table 2, we compare the weighted prevalence of each access and utilization outcome between children exposed and not exposed to PI. In these bivariate analyses, those exposed to PI were more likely to lack a usual place of care but were more likely to have had a routine dental cleaning within the last year (P < .05). There was no significant difference in the likelihood of having a well visit within the last year. Delayed and forgone medical, mental health, and dental care due to cost were all more common among those exposure to PI (P < .05). Lastly, emergency department use and overnight hospitalization were more common among those exposed to PI (P < .05), but there was no significant difference in urgent care use.
      Table 2Weighted Descriptive Statistics for Access to Care and Health Care Use among Respondents Exposed and Not Exposed to Parental Incarceration (PI)
      PINo PIχ2 Test
      Weighted N = 3,648,217 (469 Observations)Weighted N = 55,305,832 (6914 Observations)
      Proportion95% CIProportion95% CIP-value
      Usual place of care
       Has a usual place of care (doctor's office)87.4[83.4,90.6]93.1[92.3,93.8]<.001
       Does not have a usual place of care (urgent care, emergency room, other, or no usual place of care)12.6[9.4,16.6]6.9[6.2,7.7]
      Well visit, past 12 m
       Had a well visit92.4[89.2,94.7]92.9[92.2,93.6].669
       No well visit7.6[5.3,10.8]7.1[6.4,7.8]
      Routine dental cleaning, past 12m
       Had routine dental cleaning98.5[96.7,99.3]96.1[95.5,96.6].013
       No dental cleaning1.5[0.7,3.3]3.9[3.4,4.5]
      Delayed dental care d/t cost, past 12m
       Did not delay dental care91.1[87.2,93.9]94.5[93.8,95.2].017
       Delayed dental care8.9[6.1,12.8]5.5[4.8,6.2]
      Delayed medical care d/t cost, past 12 m
       Did not delay medical care96.7[93.7,98.3]98.6[98.3,98.9].012
       Delayed medical care3.3[1.7,6.3]1.4[1.1,1.7]
      Delayed mental health care d/t cost, past 12 m
       Did not delay mental health care95.5[92.6,97.3]99.1[98.9,99.3]<.001
       Delayed mental health care4.5[2.7,7.4]0.9[0.7,1.1]
      Needed dental care but did not get it d/t cost, past 12 m
       No forgone dental care needs91.2[87.3,93.9]96[95.4,96.6]<0.001
       Forgone dental care needs8.8[6.1,12.7]4[3.4,4.6]
      Needed medical care but did not get it d/t cost, past 12m
       No unmet medical care needs96.6[93.7,98.3]99[98.7,99.2].001
       Forgone medical care needs3.4[1.7,6.3]1[0.8,1.3]
      Needed mental health care but did not get it d/t cost, past 12m
       No unmet mental health care needs96.1[93.4,97.7]99[98.7,99.2]<.001
       Forgone mental health care needs3.9[2.3,6.6]1[0.8,1.3]
      Visited urgent care, past 12 m
       0 visits73.4[68.5,77.7]73.1[71.5,74.6].908
       1+ visit(s)26.6[22.3,31.5]26.9[25.4,28.5]
      Visited hospital ED, past 12m
       0 visits78.1[73.2,82.2]83.5[82.3,84.7].010
       1+ visit(s)21.9[17.8,26.8]16.5[15.3,17.7]
      Hospitalized overnight, past 12m
       Never hospitalized95.1[92.2,96.9]97.7[97.2,98.1].003
       Hospitalized4.9[3.1,7.8]2.3[1.9,2.8]
      Proportion indicates weighted column percent; and 95% CI = 95% Confidence Interval, based on Standard Errors computed using Taylor Series.
      P-values in bold reflect statistical significance at P < .05.

      Access to Care, Health Care Use, and Parental Incarceration

      We display our adjusted models in Table 3 with corresponding weighted population differences to highlight the predicted number of children and adolescents whose outcome would have differed without exposure to PI. Exposure to PI was associated with 2,158,608 children and adolescents lacking a usual source of care (PI: 10.6% vs No PI: 7.0%, adjusted difference 3.7 percentage-points [PP]; [95% confidence interval 0.3,7.0]), 1,215,550 delaying mental health care due to cost (3.0% vs 0.9%, adjusted difference 1.9 PP [0.5,3.7]), 1,954,256 forgoing needed dental care due to cost by (7.3% vs 4.0%, adjusted difference 3.3 PP [0.2,6.4]), and 863,871 forgoing needed mental health care due to cost (2.5% vs 1.0%, adjusted difference 1.5 PP [0.1,2.9]). In adjusted analyses, there were not statistically significant differences in the probability of having no well visit or routine dental visit, delaying dental or medical care due to cost, forgoing medical care needs due to cost, and being hospitalized or seen at an emergency department. Supplemental Appendices 1–12 contain bivariate and multiple logistic regression models for each outcome, including the exponentiated coefficients (odds ratios) and 95% CIs for all included covariates.
      Table 3Association of Exposure to Parental Incarceration with Access to Care and Health Care Use
      PINo PIAdjusted Difference
      Adjusted Difference reflects the difference in predictive margins.
      Predictive Margins
      Predictive margins and 95% CIs reflect the predicted percent probability of each outcome for individuals with or without exposure to PI. All predictive margins were obtained from logistic regression models adjusted for age category, sex, race/ethnicity, max parental education, family structure, rurality, poverty status, insurance status, and the Washington Group Short Set Composite Disability Indicator. Outputs for bivariate and multiple logistic regression models are displayed in Supplemental Appendices 1–12.
      95% CIPredictive Margins
      Predictive margins and 95% CIs reflect the predicted percent probability of each outcome for individuals with or without exposure to PI. All predictive margins were obtained from logistic regression models adjusted for age category, sex, race/ethnicity, max parental education, family structure, rurality, poverty status, insurance status, and the Washington Group Short Set Composite Disability Indicator. Outputs for bivariate and multiple logistic regression models are displayed in Supplemental Appendices 1–12.
      95% CIPercentage-Point Difference95% CIWeighted Population Difference
      Weighted population difference reflects the percentage-point difference multiplied by the weighted population size.
      P-Value
      P-values reflect a significance test for the null hypothesis that there is no difference between the predictive margins from the “PI” and “No PI” groups. P-values in bold reflect statistical significance at P < .05.
      Preventive Care Access
       No usual source of care10.6[7.3,14.0]7.0[6.2,7.7]3.7[0.3,7.0]2,158,608.033
       No well visit7.8[5.2,10.5]7.0[6.3,7.8]0.8[−1.9,3.4]463,968.559
       No dental visit2.3[0.5,4.0]3.8[3.3,4.4]−1.6[−3.4,0.2]−922,808.087
      Delayed Care due to Cost
       Delayed dental care8.8[5.4,12.2]5.5[4.8,6.2]3.3[−0.2,6.8]1,958,571.061
       Delayed medical care2.6[0.6,4.7]1.4[1.1,1.7]1.2[−0.9,3.3]719,823.252
       Delayed mental health care3.0[1.4,4.5]0.9[0.7,1.2]2.1[0.5,3.7]1,215,550.012
      Forgone Care due to Cost
       Forgone dental care needs7.3[4.3,10.3]4.0[3.4,4.6]3.3[0.2,6.4]1,954,256.037
       Forgone medical care needs2.4[0.4,4.5]1.0[0.8,1.3]1.4[−0.7,3.5]829,336.182
       Forgone mental health care needs2.5[1.1,3.9]1.0[0.8,1.3]1.5[0.1,2.9]863,871.040
      Acute Care Use
       Visited urgent care25.5[20.6,30.4]27.0[25.4,28.6]−1.5[−6.7,3.6]−911,1940.558
       Visited hospital ED17.1[13.3,21.0]16.8[15.6,18.0]0.3[−3.6,4.3]192,420.871
       Hospitalized overnight3.3[1.7,4.9]2.4[2.0,2.8]0.9[−0.8,2.6]548,391.283
      Footnotes: 95% CI = 95% Confidence Interval, based on unconditional Standard Errors. Total Weighted N = 59,163,934 (7405 Observations).
      low asterisk Predictive margins and 95% CIs reflect the predicted percent probability of each outcome for individuals with or without exposure to PI. All predictive margins were obtained from logistic regression models adjusted for age category, sex, race/ethnicity, max parental education, family structure, rurality, poverty status, insurance status, and the Washington Group Short Set Composite Disability Indicator. Outputs for bivariate and multiple logistic regression models are displayed in Supplemental Appendices 1–12.
      Adjusted Difference reflects the difference in predictive margins.
      Weighted population difference reflects the percentage-point difference multiplied by the weighted population size.
      § P-values reflect a significance test for the null hypothesis that there is no difference between the predictive margins from the “PI” and “No PI” groups. P-values in bold reflect statistical significance at P < .05.

      DISCUSSION

      In this contemporary, nationally representative study of children and adolescents ages 2–17, we performed an in-depth analysis of PI and health care access and use by analyzing responses to a novel question about PI on the 2019 NHIS. We found that suboptimal access to care associated with PI exposure begins within childhood itself, corroborating and extending prior work examining care utilization in adulthood.
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      We noted that children exposed to PI were more likely to use the emergency department or be hospitalized overnight in bivariate analyses, but this association was not robust after accounting for other explanatory factors. In covariate-adjusted analyses, we estimated that exposure to parental incarceration was associated with an additional 2.2 million children with no usual source of care, 2 million with forgone dental care needs, 1.2 million with delayed mental health care needs, and 865,000 with forgone mental health care needs. Even after large coverage expansions and striking improvements in children's health care access over the last two decades,
      • Larson K
      • Cull WL
      • Racine AD
      • et al.
      Trends in access to health care services for US children: 2000–2014.
      ,
      • Hudson JL
      • Moriya AS.
      Medicaid expansion for adults had measurable “welcome mat” effects on their children.
      • Khouja T
      • Burgette JM
      • Donohue JM
      • et al.
      Association between Medicaid expansion, dental coverage policies for adults, and children's receipt of preventive dental services.
      • Venkataramani M
      • Pollack CE
      • Roberts ET.
      Spillover effects of adult Medicaid expansions on children’s use of preventive services.
      access to preventive, mental health, and primary care remains challenging and inaccessible for many children and adolescents exposed to PI. As interest in the downstream implications of ACEs continues to grow, the opportunity to prevent PI exposure and sustainably support children exposed to PI cannot be overlooked.
      • Lopez MA
      • Wong SL
      • Raphael JL.
      Health policies to address adverse childhood experiences: taking a whole child approach.
      Prior work has highlighted poor access to a usual source of care
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      ; unmet dental care needs
      • Turney K.
      Unmet health care needs among children exposed to parental incarceration.
      ,
      • Testa A
      • Jackson DB.
      Parental incarceration and children’s oral health in the United States: findings from the 2016-2018 National Survey of Children’s Health.
      ; poor oral health
      • Testa A
      • Jackson DB.
      Parental incarceration and children’s oral health in the United States: findings from the 2016-2018 National Survey of Children’s Health.
      ; unmet mental health care needs
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      ,
      • Turney K.
      Unmet health care needs among children exposed to parental incarceration.
      ; and increased incidence of depression, anxiety, post-traumatic stress disorder, substance misuse, and suicidality in young adulthood among individuals exposed to childhood PI.
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      ,
      • Lee RD
      • Fang X
      • Luo F.
      The impact of parental incarceration on the physical and mental health of young adults.
      ,
      • Turney K.
      Stress proliferation across generations? examining the relationship between parental incarceration and childhood health.
      However, existing literature has relied upon outdated nationally representative data sources, limited health care access and use outcomes, limited adjustment for key confounding factors, and examination of downstream impacts on access to care and utilization during adulthood rather than impacts during childhood itself.
      • Wildeman C
      • Goldman AW
      • Turney K.
      Parental incarceration and child health in the United States.
      While studies have long identified that material hardship and insurance status may partially explain the association of PI exposure with health care access and outcomes, our study documents an independent association with PI and extends the literature with several novel secondary findings. First, although children who were uninsured in the last year are more likely to lack a usual source of care and forgo or delay needed care,
      • Tumin D
      • Miller R
      • Raman VT
      • et al.
      Patterns of health insurance discontinuity and children's access to health care.
      we found no significant difference in uninsurance between children exposed or unexposed to PI. Second, although children exposed to PI were more likely to be enrolled in Medicaid, CHIP, or other public insurance, insurance status did not fully mediate associations between PI exposure and worse access to a usual source of care, dental care, and mental health care, even in a sample timeframe which includes the documented spillover benefits of post-ACA Medicaid expansions.
      • Hudson JL
      • Moriya AS.
      Medicaid expansion for adults had measurable “welcome mat” effects on their children.
      • Khouja T
      • Burgette JM
      • Donohue JM
      • et al.
      Association between Medicaid expansion, dental coverage policies for adults, and children's receipt of preventive dental services.
      • Venkataramani M
      • Pollack CE
      • Roberts ET.
      Spillover effects of adult Medicaid expansions on children’s use of preventive services.
      Lastly, our findings complement a body of research highlighting unmet mental health care needs and increased prevalence of mental health conditions during adolescence and young adulthood
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      ,
      • Lee RD
      • Fang X
      • Luo F.
      The impact of parental incarceration on the physical and mental health of young adults.
      ,
      • Turney K.
      Stress proliferation across generations? examining the relationship between parental incarceration and childhood health.
      by showing that disparate rates of delayed and forgone mental health care begin during childhood itself for individuals exposed to PI.
      Overall, our findings support calls for continued evaluation and structural intervention to address care disruption spanning from childhood to early adulthood among individuals exposed to PI. Our findings reflect the most recently updated national estimates and demonstrate a striking persistence of poor access to a usual source of care and substantive unmet care needs, corroborating an overall lack of improvement in targeted support for children exposed to PI across the last several decades.
      • Wildeman C.
      Parental imprisonment, the prison boom, and the concentration of childhood disadvantage.
      Suboptimal access to care among children exposed to PI reflects a myriad of intertwined social and structural risk conditions, but our study highlights that differences in age, sex, race/ethnicity, educational attainment, family structure, rurality, poverty, insurance status, and disability do not fully explain worse access to care associated with PI. Thus, interventions to improve the health care access, use, and outcomes of children and adolescents exposed to PI will require multifaceted strategies to target both risk and protective factors across multiple levels.
      • Jackson DB
      • Testa A
      • Semenza DC
      • et al.
      Parental incarceration, child adversity, and child health: a strategic comparison approach.
      Screening for ACEs like PI cannot be viewed as a standalone approach.
      • Loveday S
      • Hall T
      • Constable L
      • et al.
      Screening for adverse childhood experiences in children: a systematic review.
      Policy interventions must complement clinical screening tools to consider the “whole child” in the context of their families, schools, communities, and environments.
      • Lopez MA
      • Wong SL
      • Raphael JL.
      Health policies to address adverse childhood experiences: taking a whole child approach.
      Clinicians can leverage this framework to interrupt intergenerational transmission of ACEs by integrating care for families through caregiver mental health screening.
      • Lopez MA
      • Wong SL
      • Raphael JL.
      Health policies to address adverse childhood experiences: taking a whole child approach.
      ,
      • Zuckerman B
      • Wong SL.
      Family history: an opportunity to disrupt transmission of behavioral health problems.
      Moreover, at institutional and policy levels, families are likely to need multiple fronts of support around periods of parental incarceration. Carceral facilities should train staff in family centered practices and on the impact of PI on children; ensure parental needs are assessed at intake and used for linkage to jail and community resources; support family friendly contact, noncontact, video, and phone visits between parents, their children, and systems that impact their children; implement evidence-based parent management training programs; involve caregivers in facility programming; and include caregivers and children in reentry planning.
      • Peterson B
      • Fontaine J
      • Cramer L
      • et al.
      Model Practices for Parents in Prisons and Jails: Reducing Barriers to Family Connections.
      • Eddy JM
      • Martinez Jr., CR
      • Burraston B.
      A Randomized controlled trial of a parent management training program for incarcerated parents: proximal impacts.
      • Eddy JM
      • Martinez CR
      • Burraston BO
      • et al.
      A randomized controlled trial of a parent management training program for incarcerated parents: post-release outcomes.
      • Lynn A
      • Shlafer RJ
      • Eshun J.
      Supporting Children of Incarcerated Parents.
      Policymakers should advocate for community investments which prevent ACE exposure as a means of improving health outcomes
      • Vasan A
      • Mitchell HK
      • Fein JA
      • et al.
      Association of neighborhood gun violence with mental health–related pediatric emergency department utilization.
      ,
      Centers for Disease Control and Prevention
      Preventing Adverse Childhood Experiences (ACEs) to improve U.S. health.
      and support upstream interventions for children exposed to PI to enhance school readiness, address food and economic insecurity, and meet basic unmet social needs.
      • Heard-Garris N
      • Boyd R
      • Kan K
      • et al.
      Structuring poverty: how racism shapes child poverty and child and adolescent health.
      ,
      • Testa A
      • Jackson DB.
      Parental incarceration and school readiness: findings from the 2016 to 2018 National Survey of Children’s Health.
      ,
      • Johnson T.
      Mapping the critical service needs of adolescent children of prisoners.
      In short, we must shift from solely identifying ACEs as an individual-level risk condition to recognizing ACEs as consequences and exacerbators of structural trauma.
      Strengths of this study include our use of a novel, nationally representative data source on PI. The prevalence of PI exposure in our 2019 NHIS sample (6.4% for children and adolescents 2–17 years) is comparable to point prevalence estimates from recent analyses of the 2016–2018 NSCH (6.4% for children 0–17 years) and 1994–2008 Add Health (9.1% for adolescents 12–19 years).
      • Jackson DB
      • Testa A
      • Semenza DC
      • et al.
      Parental incarceration, child adversity, and child health: a strategic comparison approach.
      ,
      • Heard-Garris N
      • Sacotte KA
      • Winkelman TNA
      • et al.
      Association of childhood history of parental incarceration and juvenile justice involvement with mental health in early adulthood.
      Thus, the NHIS may be a reliable data source to glean new information about PI exposure and evaluate interventions, especially given plans for biennial repeated measurement. Limitations of the study include, first, the use of parent-reported measures, which may contribute to underreporting because of social desirability bias and stigma, though proxy-report is a generally considered a reliable and valid approach for measuring child health care access and use since guardian perceptions strongly influence health services use.
      • Varni JW
      • Limbers CA
      • Burwinkle TM.
      Parent proxy-report of their children's health-related quality of life: an analysis of 13,878 parents’ reliability and validity across age subgroups using the PedsQLTM 4.0 Generic Core Scales.
      Second, the measurement of “parental incarceration” as a variable describing one or more parent/guardian must be interpreted reasonably, since other studies have documented possible differential impacts of paternal, maternal, and both-parent incarceration on health and health care use,
      • Heard-Garris N
      • Winkelman TNA
      • Choi H
      • et al.
      Health care use and health behaviors among young adults with history of parental incarceration.
      ,
      • Wildeman C
      • Goldman AW
      • Turney K.
      Parental incarceration and child health in the United States.
      ,
      • Lee RD
      • Fang X
      • Luo F.
      The impact of parental incarceration on the physical and mental health of young adults.
      though they were limited by small survey samples of individuals reporting maternal or both-parent incarceration. Third, as the NHIS measure of PI is a binary indicator, we were unable to capture the differential impacts of type (e.g., jail versus prison incarceration), duration, or timing of PI.

      CONCLUSIONS

      Exposure to PI is associated with worse access to a usual source of care and unmet dental and mental health care needs during childhood and adolescence, even after controlling for a number of predisposing, enabling, and need-based factors associated with health care utilization including insurance status. Poor access may contribute to poor health outcomes within childhood and across the life course for individuals exposed to PI. Trauma-informed, cross-sector care delivery innovations are needed to incentivize partnership between jails, prisons, policymakers, and clinicians which mitigate these immediate and life-course implications. Moreover, policymakers should consider how upstream interventions to ameliorate persistently high rates of incarceration in the United States could reduce childhood PI exposure, diminish downstream costs, and prevent adverse health consequences.

      Acknowledgments

      The authors would like to thank Donna McAlpine, PhD (University of Minnesota School of Public Health) for feedback on an early version of this study.
      Funding: Nia Heard-Garris's efforts were supported by the National Heart Lung and Blood Institute (grant number 5K01HL147995-02 ).
      Role of funder: The NHLBI had no role in the design and conduct of the study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agency.

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