HEALTH CARE AND CHILDREN

The United States has the most sophisticated and advanced medical care in the world, attracting people from around the globe for treatment of complex and difficult health conditions. The extent to which individuals living in this country benefit from this care, however, depends to a great degree on whether they have health insurance. Studies consistently show that persons without health insurance are far less likely to use health services than those with health insurance. In addition, the number of people without health insurance is on the rise, providing more cause for concern. More than 42 million Americans under the age of sixty-five were completely uninsured in 1999.

While children's access to care is a function of a wide range of factors, including family characteristics and the organization of the health system, financial barriers such as lack of health insurance play a significant role. Health insurance is by far the most important predictor of whether children will receive needed health care. Uninsured children receive fewer aggregate annual physician visits than their insured counterparts, and they are significantly less likely than publicly insured poor children to identify a usual source of routine care.

Despite the predominant role of health insurance in access to health care, sizable numbers of children in this country are uninsured. While no age group is immune from the threat of losing health insurance, children make up a significant proportion of the uninsured. In 1999, 10 million children, nearly 14 percent of all children in the United States, were uninsured.

The Importance of Access

Most children are healthy. Some may ask, therefore, why it is important for children to have access to health care. In fact, despite relatively good health, children do need access to regular health care, as well as access to special services when acute or chronic conditions occur. Moreover, children are distinct from other age groups in several important ways. For one thing, they are entirely dependent on their adult caregivers for health services. Children are incapable of making decisions about health care, purchasing services or insurance, or making judgments about the appropriateness of services. Children are also unable to voice preferences or to influence decisions made on their behalf. Thus, it is the responsibility of adults to represent their interests and to ensure that their needs are met.

Children's health needs are also significantly different from those of adults. By nature, children grow and develop at rapid rates, placing them at special risk of being affected by illness and injury. If health problems are not identified and treated, they can affect a child's cognitive, physical, behavioral, and emotional development. It is therefore essential to identify and treat health conditions early to prevent or minimize the impact on overall growth and development.

Finally, the type, severity, and frequency of health conditions that children experience also differ from adults. Children generally experience a wider variety of health problems, but of less severity. Conversely, adults are more likely to have chronic degenerative conditions than children. But certain childhood conditions, though relatively mild in single instances, have the capacity to lead to long-term disabilities in children. For example, chronic oti tis media (ear infections), if unchecked, can lead to hearing loss, and possibly learning disabilities. Other rare but severe conditions, such as spina bifida and sickle cell disease, manifest themselves early and require ongoing monitoring and expensive, tertiary care.

The Role of Insurance

The groups most at-risk of being uninsured are adolescents, minorities, children living with a single parent, and children in poor and near-poor families (especially working families living at the near-poverty level). Family income and ethnicity are the factors most associated with being uninsured. In 1990, Hispanic children were more than twice as likely to be uninsured as non-Hispanic white children. Similarly, children in poor and near-poor families were more than twice as likely to be uninsured as children in more advantaged families.

The percentage of children without health insurance grew sizably during the late 1970s and the 1980s. Between 1977 and 1987, the percentage of children without any form of health insurance rose by 40 percent. Since then, the overall percentage of uninsured children has remained relatively stable, though the distribution of children within various sources of insurance has dramatically shifted. Between 1987 and 1993, the proportion of children covered by private, employment-based insurance declined 12 percent, from 60.7 percent to 53.6 percent. Meanwhile, the proportion of children covered by Medicaid increased from 15.6 percent to 23.9 percent, and the number of children covered by Medicaid climbed from 10.0 million in 1988 to 20 million in 1999, reflecting a fundamental shift in the type of insurance children hold.

A number of factors account for this dramatic shift in the distribution of children's insurance coverage. A nationwide recession, in addition to the rising cost of medical care, affected the ability of insurance companies to provide increasingly expensive health insurance benefits. A rapid shift of jobs away from industries such as manufacturing, which typically have generous benefits, to service jobs industries, which typically offer few, if any, benefits, also contributed to changes in children's insurance status.

The large increase in the number of children covered by Medicaid is the result of legislative changes enacted by the Congress and the states in the middle and late 1980s, as well as the recession that pushed more families into poverty during the early 1990s. Following more than a decade of retrenchment in Medicaid eligibility at the state and federal levels, Congress enacted a series of Medicaid expansions between 1984 and 1990. These laws were designed to gradually cover additional low-income children and pregnant women, and to increase uniformity in income-eligibility levels across states. Virtually all poor children (with incomes below the federal poverty level) are eligible for Medicaid (with the exception of those who are undocumented).

These Medicaid expansions have produced important results. Numerous studies demonstrate that the availability of Medicaid has resulted in improved access to care among low-income children. Poor children with Medicaid were far more likely than poor uninsured children to have access to care, based on multiple dimensions of access, including the presence of a usual source of care, frequency of unmet health needs, and the use of medical services. Among adolescents, the impact of Medicaid has been even more dramatic. Although poor adolescents were 35 percent more likely than nonpoor adolescents to have waited two or more years between physician contacts, poor adolescents with Medicaid coverage used physician services at rates similar to nonpoor adolescents. The availability of Medicaid has also led to improvements among children in terms of the use of preventive services. A full year of Medicaid increases the chances that a child will have a well-child visit by 17 percent, and also increases compliance with national guidelines from the American Academy of Pediatrics by 13 percent.

The State Children's Insurance Program (SCHIP), established in 1997, provides additional assistance to low-income children. This program is designed for uninsured children who are not eligible for Medicaid because their families' incomes are too high, but for whom private insurance is unaffordable. Close to 90 percent of these uninsured children have at least one parent who works, but for many of these families affordable health coverage is not offered through their employer. As of 2000, nearly 2 million children were enrolled in the program nationwide.

Unfortunately, both Medicaid and SCHIP suffer from under-enrollment. Of the 10 million uninsured children in the United States, more than half are likely eligible for either program. Studies show a variety of reasons for under-enrollment, including negative views about public insurance programs, confusion about eligibility, and complex enrollment processes. In addition, studies show that potential enrollees associate Medicaid with burdensome eligibility requirements, difficult enrollment processes, demeaning attitudes of eligibility workers, and inadequate services by health care providers. Other research has found that some immigrants fail to enroll in public programs because of their fear of potential ramifications for their immigration status. There may also be problems associated with communicating clear information about the programs. Research indicates that many low-income parents have not heard of SCHIP or are confused about their children's eligibility. Whatever the reasons, improvements in access to health care cannot be reasonably expected as long as eligible children are not enrolled in available programs.

The Limitations of Insurance

Extending health insurance to low-income children has a beneficial impact on access. However, simply providing insurance does not mean that children will necessarily have full access to health care, especially among low-income children. Indeed, insured low-income children use fewer services than more affluent, insured children. Moreover, poor children with insurance are less likely to go to a private physician's office and more likely to utilize community health centers, compared to nonpoor children with insurance. There are a number of reasons for these differences. The families of poor children with insurance face nonfinancial barriers to health care that insurance cannot address, such as lack of transportation, lack of child care, inconvenient location of services, and service hours that conflict with work. Children of immigrant families may face additional barriers, such as an inability to communicate in their primary language, fear of deportation, and cultural conflicts with Western medicine. For these reasons, providing insurance without developing a delivery system to serve the needs of low-income children does not produce the desired outcome of improved access to quality health care.

Conclusion

All children need health care, whether for regular check-ups, for episodic health problems such as ear infections, or for chronic conditions. Because health services are relatively expensive, children's access to care is largely dependent on whether or not they have health insurance. Unfortunately, far too many children are not covered and therefore, do not receive needed care. One solution is to assist eligible children to enroll in public programs like Medicaid and SCHIP. As indicated, approximately half of all uninsured children are eligible for these programs. To achieve this goal, the process by which children enroll must be simplified, eligibility rules clarified, and any negative stigma about public programs removed.

Other efforts will also be required for uninsured children who are not eligible for these programs. Many of these children are undocumented, which means that rules preventing them from participating in Medicaid and SCHIP would need to be revised, or special programs must be created for them.

See also: Health and Education; Health Education, School; Health Services, subentry on School; Managed Care and Children.

bibliography

Bilheimer, Linda T., and Colby, David C. 2001. "Expanding Coverage: Reflections on Recent Efforts." Health Affairs 20 (1):83–95.

Ellwood, Marilyn. 1999. The Medicaid Eligibility Maze: Coverage Expands, but Enrollment Problems Persist: Findings from a Five-State Study. Cambridge, MA: Mathematical Policy Research.

Guendelman, Sylvia, and Pearl, Michelle. 2001. "Access to Care for Children of the Working Poor." Archives of Pediatric Adolescent Medicine 155:651–658.

Halfon, Neal; Inkelas, Moira; and Wood, David. 1995. "Non-Financial Barriers to Care for Children and Youth." Annual Review of Public Health 16:447–472.

Hughes, Dana; Cart, Courtney; Moreno, Melanie; and Ng, Sandy. 2000. Barriers to Enrollment in Healthy Families and Medi-Cal: Differences by Race and Ethnicity. San Francisco: Institute for Health Policy Studies, University of California.

Hughes, Dana; Cart, Courtney; Vogel, Sarah; Moreno, Melanie; and Ng, Sandy. 2000. Barriers to Enrollment in Healthy Families and Medi-Cal: Findings from Nine Focus Groups with Chinese, Korean, and Vietnamese Parents of Eligible Children. San Francisco: Institute for Health Policy Studies, University of California.

Kenney, Genevieve; Haley, Jack; and Dubay, Lisa. 2001. How Familiar Are Low-Income Parents with Medicaid and SCHIP? Washington DC: The Urban Institute.

Lave, Judith R. ; Keane Christopher R. ; Lin, Chyongchiou J.; et al. 1996. "Impact of a Children's Health Insurance Program on Newly Enrolled Children." Journal of the American Medical Association 279:1820–1825.

Newacheck, Paul W. 1988. "Access to Ambulatory Care for Poor Persons." Health Services Research 23 (3):401–419.

Newacheck, Paul W. 1989. "Improving Access to Health Services for Adolescents from Economically Disadvantaged Families." Pediatrics 84 (6):1056–1063.

Newacheck, Paul W. ; Hughes, Dana C. ; Hung, Yung-Yi; et al. 2000. "The Unmet Health Needs of America's Children." Pediatrics 105:989–997.

Newacheck, Paul W. ; Pearl, Michelle; Hughes, Dana C.; and Halfon, Neal. 1998. "The Role of Medicaid in Ensuring Children's Access to Care." Journal of the American Medical Association 280:1789–1793.

Newacheck, Paul W. ; Stoddard, Jeffrey J.; Hughes, Dana C.; and Pearl, Michelle.1998. "Health Insurance and Access to Primary Care for Children." New England Journal of Medicine 338:513–519.

Starfield, Barbara. 1997. "Social, Economic, and Medical Care Determinants of Children's Health." In Health Care for Children: What's Right, What's Wrong, What's Next, ed. Ruth Stein. New York: United Hospital Fund.

Stoddard, Jeffrey J. ; St. Peter, Robert F.; and Newacheck, Paul W. 1994. "Health Insurance Status and Ambulatory Care for Children." New England Journal of Medicine 330:1421–1425.

Wood, David L. ; Hayward, Rodney.; Corey, Christopher.; Freeman, Howard E.; and Shapiro, Martin F. 1990. "Access to Medical Care for Children and Adolescents in the United States." Pediatrics 86 (5):666–673.

Dana Hughes