Access to care for children of the working poor

Novel Methods of Identifying Individual and Neighborhood Risk Factors for Loss to Follow-Up After Ophthalmic Screening

PRCIS

Residence in a middle-class neighborhood correlated with lower follow-up compared with residence in more affluent neighborhoods. The most common explanations for not following up were the process of making an appointment and lack of symptoms.

PURPOSE

To explore which individual-level and neighborhood-level factors influence follow-up as recommended after positive ophthalmic and primary care screening in a vulnerable population using novel methodologies.

PARTICIPANTS AND METHODS

From 2017 to 2018, 957 participants were screened for ophthalmic disease and cardiovascular risk factors as part of the Real-Time Mobile Teleophthalmology study. Individuals who screened positive for either ophthalmic or cardiovascular risk factors were contacted to determine whether or not they followed up with a health care provider. Data from the Social Vulnerability Index, a novel virtual auditing system, and personal demographics were collected for each participant. A multivariate logistic regression was performed to determine which factors significantly differed between participants who followed up and those who did not.

RESULTS

As a whole, the study population was more socioeconomically vulnerable than the national average (mean summary Social Vulnerability Index score=0.81). Participants whose neighborhoods fell in the middle of the national per capita income distribution had a lower likelihood of follow-up compared with those who resided in the most affluent neighborhoods (relative risk ratio=0.21, P -value<0.01). Participants cited the complicated process of making an eye care appointment and lack of symptoms as the most common reasons for not following up as instructed within 4 months.

CONCLUSIONS

Residence in a middle-class neighborhood, difficulty accessing eye care appointments, and low health literacy may influence follow-up among vulnerable populations.

A Community Initiative to Help Children Who Are Homeless

Children experiencing homelessness (CEH) have several health-related needs. It is necessary to address barriers posed by homelessness to improve health outcomes. Our objectives were to (1) conduct a health-related needs assessment and (2) determine acceptability/feasibility of the community-based initiative designed to identify and address health-related needs for CEH. The initiative involved a mobile care center, a health-focused education series for CEH, and resource provision, which included establishing connections with a stable source of health care. The needs assessment included standardized screening questions assessing health-related needs. We surveyed guardians of CEH who attended Summer360 between June and July 2022. Guardians were invited to evaluate our intervention via survey. We used descriptive statistics to characterize health-related needs. A needs assessment was completed on 36 of 100 children (42% white persons, 64% male), with 94% reporting at least 1 health-related need, and 61% with ≥3 needs. The most common needs identified were dental health and food insecurity. Twenty-four (24%) campers participated in a mobile health clinic that included hearing and vision screening, fluoride application, and vaccinations. The education series included dental hygiene, nutrition, and mental health. All families who desired assistance (73%) were connected to resources, and 91% of guardians agreed that the initiative helped meet their children's health-related needs and provided helpful resources. Implementation required planning with contributors including dental partners, mobile clinic operators, and school leadership. A community-based health initiative may serve as a unique opportunity to identify and address health-related needs for CEH.

Identifying Health-Related Social and Unintentional Injury Risks Among Patients Presenting to a Pediatric Urgent Care

OBJECTIVE

Many families seek medical care at pediatric urgent care centers. The objective of this study was to determine social and unintentional injury risks reported by these families.

METHODS

This cross-sectional study surveyed a convenience sample of guardians of patients 1 to 5 years of age presenting to our pediatric urgent care, 9/10/21 to 2/25/22. Outcomes were the number of reported social and unintentional injury risks. Predictors and covariates included child and parent demographic characteristics and a neighborhood socioeconomic deprivation index. Chi-square, Student's t test, Pearson's correlation tests, and multinominal regression were used.

RESULTS

A total of 273 guardians (and children) were included; 245 of guardians (89.7%) were female; 137 (50.2%) of included children identified as Black. Approximately 60% reported ≥1 social risk; 31.5% reported ≥3. Approximately 90% reported ≥1 unintentional injury risk; 57.9% reported ≥3. There were significant associations between social risk presence and Black race, public/no insurance, and neighborhood deprivation (all P < .05). There were no significant associations between unintentional injury risks and assessed predictors. Black guardians were more likely than those of other races to report a greater number of social risks (adjusted odds ratio [AOR] 2.90, 95% confidence interval [CI] 1.50, 5.58 for ≥3 vs 0 risk). Children with public/no insurance compared to private insurance were more likely to experience a greater number of social risks (AOR 3.34, 95% CI 1.42, 7.84 for ≥3 vs 0 risks).

CONCLUSIONS

Many presenting to pediatric urgent cares experience social and unintentional injury risks. Risk identification may guide equitable responses.

Disparities in Incidence and Severity of Shigella Infections Among Children-Foodborne Diseases Active Surveillance Network (FoodNet), 2009-2018

BACKGROUND

Shigella infections are an important cause of diarrhea in young children and can result in severe complications. Disparities in Shigella infections are well documented among US adults. Our objective was to characterize disparities in incidence and severity of Shigella infections among US children.

METHODS

We analyzed laboratory-diagnosed Shigella infections reported to FoodNet, an active, population-based surveillance system in 10 US sites, among children during 2009-2018. We calculated the incidence rate stratified by sex, age, race/ethnicity, Shigella species, and disease severity. Criteria for severe classification were hospitalization, bacteremia, or death. The odds of severe infection were calculated using logistic regression.

RESULTS

During 2009-2018, 10 537 Shigella infections were reported in children and 1472 (14.0%) were severe. The incidence rate was 9.5 infections per 100 000 child-years and the incidence rate of severe infections was 1.3 per 100 000 child-years. Incidence was highest among children aged 1-4 years (19.5) and lowest among children aged 13-17 years (2.3); however, children aged 13-17 years had the greatest proportion of severe infections (21.2%). Incidence was highest among Black (16.2 total; 2.3 severe), Hispanic (13.1 total; 2.3 severe), and American Indian/Alaska Native (15.2 total; 2.5 severe) children. Infections caused by non-sonnei species had higher odds of severity than infections caused by Shigella sonnei (adjusted odds ratio 2.58; 95% confidence interval 2.12-3.14).

CONCLUSIONS

The incidence and severity of Shigella infections among US children vary by age, race/ethnicity, and Shigella species, warranting investigation of unique risk factors among pediatric subpopulations.

Increasing Immunization Compliance

School nurses often have the responsibility to ensure that students meet all immunization requirements for school entry and school attendance. In large inner-city school districts, many obstacles exist which make this task daunting and often result in lengthy absences and exclusions for students. It is critical that school nurses find creative and systematic ways to meet these challenges, which include working parents, lack of access to primary care, lack of transportation, cost of immunizations, poor compliance and follow-up, myths regarding immunizations, and the impact of the Health Insurance Portability and Accountability Act (HIPAA) legislation. This article describes an immunization project that removed most of those barriers for high-risk students and gave the school nurses tools to succeed in achieving higher levels of immunization compliance in inner-city schools. Since the immunization project’s conception, compliance in the district has risen from an overall level of 50–60% to 90–100%, along with better record-keeping and the prevention of exclusions.

Continuity of Public Insurance Coverage

Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.

Asthma and the achievement gap among urban minority youth

OBJECTIVES

To outline the prevalence and disparities of asthma among school-aged urban minority youth, causal pathways through which poorly controlled asthma adversely affects academic achievement, and proven or promising approaches for schools to address these problems.

METHODS

Literature review.

RESULTS

Asthma is the most common chronic disease affecting youth in the United States; almost 10 million youth under 18 (14%) have received a diagnosis and 6.8 million (9%) have active asthma. Average annual prevalence estimates were approximately 45% higher for Black versus White children (12.8% vs. 8.8%), as were average annual estimates of asthma attacks (8.4% vs. 5.8%). Urban minority youth have highly elevated prevalence of poorly controlled asthma as evidenced by overuse of emergency departments and under-use of efficacious medications. Poorly controlled asthma has functional consequences on cognition, connectedness with school, and absenteeism. Exemplary asthma programs include management and support systems, school health and mental health services, asthma education, healthy school environments, physical education and activity, and coordination of school, family, and community efforts.

CONCLUSIONS

Asthma and, more importantly, poorly controlled asthma are highly and disproportionately prevalent among school-aged urban minority youth, has a negative impact on academic achievement through its effects on cognition, school connectedness, and absenteeism, and effective practices are available for schools to address this problem. To reduce the adverse effects of poorly controlled asthma on learning, a multifaceted approach to asthma control and prevention in which schools can and must play a central role is essential.

Sorry doctor, I can't afford the root canal, I have a job: Canadian dental care policy and the working poor

BACKGROUND

In Canada, most dental care is privately financed through employment-based insurance, with only a small amount of care supported by governments for groups deemed in social need. Recently, this low level of public financing has been linked to problems in accessing dental care, and one group that has received major attention are the working poor (WP), or those who maintain regular employment but remain in relative poverty. The WP highlight a significant gap in Canadian dental care policy, as they are generally not eligible for either public or private insurance.

METHODS

This is a mixed methods study, comprised of an historical review of Canadian dental care policy and a telephone interview survey of WP Canadian adults.

RESULTS

By its very definitions, Canadian dental care policy recognizes the WP as persons with employment, yet incorrectly assumes that they will have ready access to employment-based insurance. In addition, through historically developed biases, it also fails to recognize them as persons in social need. Our telephone survey suggests that this policy approach has important impacts in that oral health and dental care outcomes are significantly mitigated by the presence of dental insurance.

DISCUSSION

Canadian dental care policy should be reassessed in terms of how it determines need in order to close a gap that holds negative consequences for many Canadian families.

Health insurance, access to prescription medicines and health outcomes in children

Ensuring optimal access to medications has received increasing attention as healthcare systems struggle with increasing costs. Although this has been studied extensively in adults, there has been little investigation in pediatric populations, which have different healthcare needs. A literature review was conducted to examine the evidence regarding the relationship between insurance-mediated access to prescription medicines and outcomes in children. In total, 12 studies were classified according to uninsured versus insured, type of insurance provider and impact of family income. The studies demonstrated that insurance coverage and low-cost sharing are both essential to facilitate access to medications. Increased access was consistently observed for insured compared with uninsured children. Access to prescription drugs frequently differed by type of health provider organization. Adequate family income was an important determinant of access to and receipt of prescriptions. Moreover, income-indexed insurance coverage may increase unmet need. Compared with the literature on access to prescription medicines and health outcomes in adults, there have been few studies in children. Further research relating pharmaceutical policies to pediatric health outcomes is needed to strengthen the quality of policy decision making regarding access to prescription medicines for children.

The impact of health insurance gaps on access to care among children with asthma in the United States

BACKGROUND

Health insurance coverage is important to help assure children appropriate access to medical care and preventive services. Insurance gaps could be particularly problematic for children with asthma, since appropriate preventive care for these children depends on frequent, consistent contacts with health care providers.

OBJECTIVE

The aim of this study was to determine the association between insurance gaps and access to care among a nationally representative sample of children with asthma.

METHODS

The National Survey of Children's Health provided parent-report data for 8097 children with asthma. We identified children with continuous public or continuous private insurance and defined 3 groups with gaps in insurance coverage: those currently insured who had a lapse in coverage during the prior 12 months (gained insurance), those currently uninsured who had been insured at some time during the prior 12 months (lost insurance), and those with no health insurance at all during the prior 12 months (full-year uninsured).

RESULTS

Thirteen percent of children had coverage gaps (7% gained insurance, 4% lost insurance, and 2% were full-year uninsured). Many children with gaps in coverage had unmet needs for care (7.4%, 12.8%, and 15.1% among the gained insurance, lost insurance, and full-year uninsured groups, respectively). In multivariate models, we found significant associations between insurance gaps and every indicator of poor access to care among this population.

CONCLUSIONS

Many children with asthma have unmet health care needs and poor access to consistent primary care, and lack of continuous health insurance coverage may play an important role. Efforts are needed to ensure uninterrupted coverage for these children.

Welfare, Work, and Health Care Access Predictors of Low-Income Children's Physical Health Outcomes

This analysis examines whether young children's (N= 494) general physical health is associated with parental employment, welfare receipt, and health care access within a low-income population transitioning from welfare to work. A latent physical health measure derived from survey and medical chart data is used to capture children's poor health, and parental ratings of child health are used to identify excellent health. Controlling for a host of factors associated with children's health outcomes, results show that children of caregivers who are unemployed and off welfare have better health than children of caregivers who are working and off welfare. Children whose caregivers are unemployed and on welfare, or combining work and welfare, have health outcomes similar to children of caregivers who are working and off welfare. Health care access characteristics, such as gaps in health insurance coverage, source of primary care setting, and type of health insurance are associated with children's general physical health. Implications of these results for state TANF programs are discussed.

Family perceptions of the usual source of care among children with asthma by race/ethnicity, language, and family income

A usual source of care (USC) can serve as the foundation for good primary health care and is critical for children living with a chronic health condition. This study applies national data to the following objectives: (1) describe family reports of the presence and characteristics of the USC for children with asthma; (2) examine evidence of systematic differences in the USC for these children with asthma by race/ethnicity, English language proficiency in Hispanic respondents, and family income; and (3) conduct multivariate analysis adjusting for possible confounding factors to examine independent effects of race/ethnicity, language, and income. Data from the 1996-2000 Medical Expenditure Panel Survey (MEPS) were analyzed. Overall, 95% of children with asthma had a USC, with Spanish-speaking Hispanics least likely to report a USC (89%). There were significant differences in USC attributes by race/ethnicity, language, and income, with the largest differences by type of provider and accessibility. Hispanics with poor English language proficiency had the greatest accessibility barriers.

Use of preventive care by the working poor in the United States

OBJECTIVE

Examine the association between poverty and preventive care use among older working adults.

METHOD

Cross-sectional analysis of the pooled 1996, 1998 and 2000 waves of the Health and Retirement Study, a nationally representative sample of older community-dwelling adults, studying self-reported use of cervical, breast, and prostate cancer screening, as well as serum cholesterol screening and influenza vaccination. Adults with incomes within 200% of the federal poverty level were defined as poor.

RESULTS

Among 10,088 older working adults, overall preventive care use ranged from 38% (influenza vaccination) to 76% (breast cancer screening). In unadjusted analyses, the working poor were significantly less likely to receive preventive care. After adjustment for insurance coverage, education, and other socio-demographic characteristics, the working poor remained significantly less likely to receive breast cancer (RR 0.92, 95% CI, 0.86-0.96), prostate cancer (RR 0.89, 95% CI, 0.81-0.97), and cholesterol screening (RR 0.91, 95% CI, 0.86-0.96) than the working non-poor, but were not significantly less likely to receive cervical cancer screening (RR 0.96, 95% CI, 0.90-1.01) or influenza vaccination (RR 0.92, 95% CI, 0.84-1.01).

CONCLUSION

The older working poor are at modestly increased risk for not receiving preventive care.

Continuity of Health Insurance Coverage for Children with Special Health Care Needs

OBJECTIVES

To assess the continuity of health insurance coverage and its associated factors for children with special health care needs (CSHCN).

METHODS

Logistic regression and proportional hazard models were estimated on monthly insurance enrollment for 5594 children in the 1996 Medical Expenditure Panel Survey. CSHCN were identified using a non-categorical approach. Stratified analyses were conducted to determine whether any characteristics differentiated the effects of CSHCN status on children's coverage.

RESULTS

In 1996, more than 8% of CSHCN were uninsured for the entire year. For those who were insured in January 1996, 14% lost their coverage by December 1996. CSHCN were more likely than other children to be insured (92% vs. 89%), mainly due to their better access to public insurance (35% vs. 23%). Conversely, CSHCN were less likely than other children to stay insured if they were school-aged, non-Hispanic White, from working, low-income families or the US Midwest region. Higher parental education improved health insurance enrollment for CSHCN, whereas higher family income or having activity limitations protected them from losing coverage. Regardless of CSHCN status, being publicly insured was associated with a higher risk of losing coverage for children.

CONCLUSIONS

Despite increased health care needs, a considerable proportion of CSHCN is unable to access or maintain coverage. Compared to other children, CSHCN are more likely to have coverage but no more likely to stay insured. Improving continuity of coverage for publicly insured children is needed, especially CSHCN who are more likely to obtain their coverage through public programs.

Reduction in racial and ethnic disparities after enrollment in the State Children's Health Insurance Program

BACKGROUND

Racial/ethnic disparities are associated with lack of health insurance. Although the State Children's Health Insurance Program (SCHIP) provides health insurance to low-income children, many of whom are members of racial/ethnic minority groups, little is known about whether SCHIP affects racial/ethnic disparities among children who enroll.

OBJECTIVES

The objectives of this study were to (1) describe demographic characteristics and previous health insurance experiences of SCHIP enrollees by race, (2) compare racial/ethnic disparities in medical care access, continuity, and quality before and during SCHIP, and (3) determine whether disparities before or during SCHIP are explained by sociodemographic and health system factors.

METHODS

Pre/post-parent telephone survey was conducted just after SCHIP enrollment and 1 year after enrollment of 2290 children who had an enrollment start date in New York State's SCHIP between November 2000 and March 2001, stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The main outcome measures were usual source of care (USC), preventive care use, unmet needs, patterns of USC use, and parent-rated quality of care before versus during SCHIP.

RESULTS

Children were white (25%), black (31%), or Hispanic (44%); 62% were uninsured > or =12 months before SCHIP. Before SCHIP, a greater proportion of white children had a USC compared with black or Hispanic children (95%, 86%, and 81%, respectively). Nearly all children had a USC during SCHIP (98%, 95%, and 98%, respectively). Before SCHIP, black children had significantly greater levels of unmet need relative to white children (38% vs 27%), whereas white and Hispanic children did not differ significantly (27% vs 29%). During SCHIP, racial/ethnic disparities in unmet need were eliminated, with unmet need at 19% for all 3 racial/ethnic groups. Before SCHIP, more white children made all/most visits to their USC relative to black or Hispanic children (61%, 54%, and 34%, respectively); all improved during SCHIP with no remaining disparities (87%, 86%, and 92%, respectively). Parent-rated visit quality improved for all groups, but preexisting racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. Sociodemographic and health system factors did not explain disparities in either period.

CONCLUSIONS

Enrollment in SCHIP was associated with (1) improvement in access, continuity, and quality of care for all racial/ethnic groups and (2) reduction in preexisting racial/ethnic disparities in access, unmet need, and continuity of care. Racial/ethnic disparities in quality of care remained, despite improvements for all racial groups. Sociodemographic and health system factors did not add to the understanding of racial/ethnic disparities. SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care.

Health Care for Children and Youth in the United States: Annual Report on Patterns of Coverage, Utilization, Quality, and Expenditures by Income

OBJECTIVES

To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States.

METHODS

Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations.

RESULTS

Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children.

CONCLUSIONS

While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

Risk Factors for Readmission After Neonatal Cardiac Surgery

BACKGROUND

Repeat hospitalizations place a significant burden on health care resources. Factors predisposing infants to unplanned hospital readmission after congenital heart surgery are unknown.

METHODS

This is a single-center, case-control study. Cases were rehospitalized or died within 30 days of discharge following an arterial switch operation (ASO) or Norwood procedure (NP) between 1992 and 2002. Controls underwent an ASO or NP between 1992 and 2002, and were neither readmitted nor died within 30 days of discharge. Patients and controls were matched by gender, year of birth, and procedure. Potential risk factors examined included indices of medical status at the time of discharge, determinants of access to health care, and provider characteristics.

RESULTS

Forty-eight patients were readmitted; 19 of 498 (3.8%) following an ASO and 29 of 254 (11.4%) after a NP (p < 0.001). Six infants died within 30 days of discharge; 1 after an ASO and 5 after a NP. In multivariate analysis, predictors of readmission or death were: residual hemodynamic problem(s) (odds ratio [OR] 4.10 [1.18, 14.3], p = 0.026); an intensive care unit stay greater than 7 days (OR 5.17 [1.12, 23.9] p = 0.035) (ASO); residual hemodynamic problem(s) (OR 5.84 [1.98, 17.2], p = 0.001); and establishment of full oral intake less than 2 days before discharge (OR 5.83 [1.83, 18.6], p = 0.003) (NP). Combining both groups, living in a low income Zip Code (< 30,000 dollars/annum) was associated with a lower likelihood of readmission (OR 0.25 [0.07, 0.85], p = 0.027).

CONCLUSIONS

Residual hemodynamic problem(s) predispose to hospital readmission after the ASO and NP. Low socioeconomic status may reduce the likelihood of readmission even when problems arise.

Person and place: the compounding effects of race/ethnicity and rurality on health

Rural racial/ethnic minorities constitute a forgotten population. The limited research addressing rural Black, Hispanic, and American Indian/Alaska Native populations suggests that disparities in health and in health care access found among rural racial/ethnic minority populations are generally more severe than those among urban racial/ethnic minorities. We suggest that disparities must be understood as both collective and contextual phenomena. Rural racial/ethnic minority disparities in part stem from the aggregation of disadvantaged individuals in rural areas. Disparities also emerge from a context of limited educational and economic opportunity. Linking public health planning to the education and economic development sectors will reduce racial/ethnic minority disparities while increasing overall well-being in rural communities.

Private Dental and Prescription-Drug Coverage in Children: Data From the Medical Expenditure Panel Survey

OBJECTIVE

Most studies on health insurance have examined primarily basic medical insurance coverage; few have looked at supplemental insurance and/or dental-insurance coverage. Prescription-drug and dental-insurance coverage are becoming increasingly important due to continued increase in health care costs and changes in cost-sharing structure of health plans. This study examined prescription-drug coverage and dental-insurance coverage in the context of overall insurance coverage.

METHOD

This study utilized the Household Component File from the 2000 Medical Expenditure Panel Survey (MEPS), a national survey on medical care conducted by the Agency for Healthcare Research and Quality (AHRQ). Univariate and bivariate analyses were performed to provide estimates on children's prescription-drug and dental-insurance coverage. Multivariate logistic regression analyses were conducted to identify demographic and socioeconomic factors that influence coverage.

RESULTS

In 2000, 68.5% of US children had private insurance, 22.2% had public insurance, and 9.3% were uninsured. Among children with private insurance, only 56.9% had dental-insurance coverage and 76.3% had prescription-drug coverage. Family income level, maternal education, and race were significant predictors of dental insurance and prescription-drug coverage.

CONCLUSION

Although significant strides have been made to insure US children, a large percentage of children still do not have comprehensive coverage. Even among privately insured children, many are without dental or prescription-drug coverage. Those who were poor, minority, and with low maternal education had lower likelihood of dental and prescription-drug coverage.

Children's ability to access and use health care

Under new regulations for Medicaid and the State Children's Health Insurance Program (SCHIP), states can extend health insurance to child enrollees' uninsured parents. We compared the extent to which child-only and family coverage (child and parent insured) ensure health care access and use for children in working-poor families. Among these children, 21 percent were uninsured, as were 30 percent of their parents. Children with no family coverage encountered more access barriers than insured children. Extending insurance to children markedly increases access and use. The additional benefits of family coverage over child-only coverage seem less pronounced, but family coverage expansions may narrow disparities in access.

Gender and uninsurance among young adults in the United States

OBJECTIVE

Although one third of young adults in the United States are uninsured, lack of insurance in this age group has been the subject of few published studies. Because opportunities to obtain public and private insurance are likely to differ for men and women, the objective of this study was to describe the gender-specific relationship of sociodemographic variables and lack of insurance among young adults.

METHODS

We examined data for 6884 young adults (aged 19-24 years) who completed the Sample Adult Questionnaire of the National Health Interview Survey for 1998, 1999, and 2000. Gender-stratified multiple logistic regression was used to estimate the odds of being uninsured associated with race/ethnicity, household income, major activity in the previous week, marital status, and pregnancy (women).

RESULTS

Overall, 32% of male participants and 27% of female participants reported being uninsured at the time of the survey. Uninsured men outnumbered insured men in several sociodemographic categories, including Hispanic men (58% uninsured), men not attending high school (85%), and men employed in a workplace that did not offer health insurance (51%). High rates of uninsurance were reported by women not attending high school (65%), Hispanic women (46%), those who were keeping house (41%), and women with a household income between 10 000 dollars and 20 000 dollars (41%). In multiple logistic regression models, many of the sociodemographic variables studied were similarly correlated with health insurance for both men and women. Employment in a workplace where the young adult was not offered health insurance coverage, low household income, low educational attainment, and Hispanic ethnicity were associated with increased odds of being uninsured for both genders. Having attended college, higher household income, and being a student or employed in a workplace that offers health insurance coverage were associated with lower odds of being uninsured for both genders.

CONCLUSION

This study suggests that additional opportunities for health insurance coverage are needed for young adults-particularly men, Hispanics, and those in low- and middle-income households. Increasing the availability of employment-based health insurance, discouraging attrition from primary and secondary education, and the creation of insurance opportunities for minorities and near-poor and middle-income households are potentially important target areas for programs that seek to reduce the number of uninsured young adults.

Effectiveness of school-based telehealth care in urban and rural elementary schools

OBJECTIVE

This study evaluated the quality and cost effectiveness of health care provided in urban and rural elementary school-based telehealth centers, using plain old telephone system (POTS) technology.

METHODS

A telehealth school-based model was developed that used a full-time school nurse, half-time mental-health consultant, linked pediatric practice, and linked child psychiatrist via POTS with an electronic stethoscope; ears, nose, and throat endoscope; and otoscope. One rural and 1 urban center were evaluated. Providers, nurses, children, and parents completed satisfaction questionnaires. Providers and nurses also evaluated how well telemedicine supported their clinical decision making. Parents were asked how use of the center affected them financially and at work.

RESULTS

Of the combined 3461 visits to school nurses at both centers, 4.3% resulted in 150 telehealth consultations referrals; 142 (95%) were completed during the 2-year project. The most common teleconsult diagnoses were otitis media, pharyngitis, dermatitis, and upper respiratory infections. Provider, nurse, child, and parent satisfaction all were high. Providers' and nurses' decision confidence scores ranged from a low of 4 to a high of 4.8 on a 5-point scale. Average family savings per encounter were 3.4 hours of work time (43 dollars) and 177 dollars in emergency department or 54 dollars in physician costs. Including travel, savings for families ranged from 101 dollars to 224 dollars per encounter. Thirteen children received telepsychiatric evaluations resulting in diagnoses of depression and attention-deficit/hyperactivity, anxiety, and conduct disorders.

CONCLUSIONS

Telehealth technology was effective in delivering pediatric acute care to children in these schools. Pediatric providers, nurses, parents, and children reported primary care school-based telehealth as an acceptable alternative to traditional health care delivery systems. The POTS-based technology helps to make this telehealth service a cost-effective alternative for improving access to primary and psychiatric health care for underserved children.