Children's health insurance, access to care, and health status: new findings

Effects of prenatal polycyclic aromatic hydrocarbons and childhood material hardship on reading achievement in school-age children: A preliminary study

Background

Children from socioeconomically disadvantaged backgrounds are at elevated risk for reading problems. They are also likely to live in neighborhoods with high levels of air pollution and to experience material hardship. Despite these risk factors, the links between prenatal chemical exposures, socioeconomic adversities, and reading problems in youth from disadvantaged backgrounds remain understudied. Here we examine associations between prenatal exposure to polycyclic aromatic hydrocarbons (PAH), a common air pollutant, and reading skills, and determine if this relationship is exacerbated by material hardship among Black and/or Latinx children who have been followed as part of a longitudinal urban birth cohort.

Methods

Mothers and their children, who were participants in a prospective birth cohort followed by the Columbia Center for Children's Environmental Health, were recruited for the current study. Personal prenatal PAH exposure was measured during the third-trimester of pregnancy using a personal air monitoring backpack. Mothers reported their level of material hardship when their child was age 5 and children completed measures of pseudoword and word reading [Woodcock Johnson III Tests of Achievement (WJ-III) Basic Reading Index] at age 7. We used multiple linear regression to examine the effects of the interaction between prenatal PAH and material hardship on Basic Reading Index, controlling for ethnicity/race, sex, birthweight, presence of a smoker in the home (prenatal), and maternal education (prenatal) (N = 53).

Results

A prenatal PAH × material hardship interaction significantly associated with WJ-III Basic Reading Index scores at age 7 (β = -0.347, t(44) = -2.197, p = 0.033). Exploratory analyses suggested that this effect was driven by untimed pseudoword decoding (WJ-III Word Attack: β = -0.391, t(44) = -2.550, p = 0.014).

Conclusion

Environmental chemical exposures can be particularly toxic during the prenatal period when the fetal brain undergoes rapid development, making it uniquely vulnerable to chemical perturbations. These data highlight the interactive effects of environmental neurotoxicants and unmet basic needs on children's acquisition of reading skill, specifically phonemic processing. Such findings identify potentially modifiable environmental risk factors implicated in reading problems in children from economically disadvantaged backgrounds.

Nativity, Duration of Residence, Citizenship, and Access to Health Care for Hispanic Children

This article examines differences in access to a regular source of health care for children of Hispanic subgroups within the United States. Particular attention is paid to the impact of the immigration status of the mother –including nativity, duration in the United States, and citizenship status – and its affect on access to health care for Hispanic children. Data are pooled from the National Health Interview Survey for 1999–2001 and logistic regression models are estimated to compare Mexican American, Puerto Rican, Cuban, and Other Hispanic children with non-Hispanic whites and blacks. While initial disparities are recorded among the race/ethnic groups, in the final model, only Mexican American children display significantly less access to health care than non-Hispanic whites. The combined influence of the mother's nativity, duration, and citizenship status explains much of the differentials in access to a regular source of care among children of Hispanic subgroups in comparison to non-Hispanic whites.

Information ranks highest: Expectations of female adolescents with a rare genital malformation towards health care services

Background

Access to highly specialized health care services and support to meet the patient’s specific needs is critical for health outcome, especially during age-related transitions within the health care system such as with adolescents entering adult medicine. Being affected by an orphan disease complicates the situation in several important respects. Long distances to dedicated institutions and scarcity of knowledge, even among medical doctors, may present major obstacles for proper access to health care services and health chances. This study is part of the BMBF funded TransCareO project examining in a mixed-method design health care provisional deficits, preferences, and barriers in health care access as perceived by female adolescents affected by the Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS), a rare (orphan) genital malformation.

Methods

Prior to a communicative validation workshop, critical elements of MRKHS related care and support (items) were identified in interviews with MRKHS patients. During the subsequent workshop, 87 persons involved in health care and support for MRKHS were asked to rate the items using a 7-point Likert scale (7, strongly agree; 1, strongly disagree) as to 1) the elements’ potential importance (i.e., health care expected to be “best practice”, or priority) and 2) the presently experienced care. A gap score between the two was computed highlighting fields of action. Items were arranged into ten separate questionnaires representing domains of care and support (e.g., online-portal, patient participation). Within each domain, several items addressed various aspects of “information” and “access”. Here, we present the outcome of items’ evaluation by patients (attended, N_PAT = 35; respondents, N_RESP = 19).

Results

Highest priority scores occurred for domains “Online-Portal”, “Patient participation”, and “Tailored informational offers”, characterizing them as extremely important for the perception as best practice. Highest gap scores yielded domains “Tailored informational offers”, reflecting perceived lack of disease-related information for affected persons, medical experts, and health insurance companies, “Online-Portal” (with limited information available on specialist clinics and specialized doctors), and regarding insufficient support offers (e.g., in school and occupational settings). Conversely, lowest gap scores were found with group offers for MRKHS patients (“Transition programs”) and MRKHS self-help days (“Patient participation”), suggesting satisfaction or good solutions in place.

Discussion

The importance assigned to disease-related information indicates that informational deficits are perceived by patients as barriers, hindering proper access to health care, especially in an orphan disease. Access to health-related information plays a role for all persons seeking help and care. However, the overwhelmingly high scores attributed to these elements in the context of an orphan disease reveal that here improved information policies are crucial, demanding for institutionalized solutions supported by the health care system.

Implications for practice

The disparity between experience of care and attribution as best practice detected describes areas of action in all domains involved, highlighting information related fields. New concepts and structures for health care in orphan diseases could draw upon these patient-oriented results a) regarding orphan-disease specific elements demanding institutionalized reimbursement, b) essential elements for center care and corresponding networks, and c) elements reflecting patients´ participation in the conception of centers for rare diseases.

Association Between Parental Barriers to Accessing a Usual Source of Care and Children's Receipt of Preventive Services

OBJECTIVES

Preventive health services are important for child development, and parents play a key role in facilitating access to services. This study examined how parents' reasons for not having a usual source of care were associated with their children's receipt of preventive services.

METHODS

We used pooled data from the 2011-2014 National Health Interview Survey (n = 34 843 participants). Parents' reasons for not having a usual source of care were framed within the Penchansky and Thomas model of access and measured through 3 dichotomous indicators: financial barriers (affordability), attitudes and beliefs about health care (acceptability), and all other nonfinancial barriers (accessibility, accommodation, and availability). We used multivariable logistic regression models to test associations between parental barriers and children's receipt of past-year well-child care visits and influenza vaccinations, controlling for other child, family, and contextual factors.

RESULTS

In 2014, 14.3% (weighted percentage) of children had at least 1 parent without a usual source of care. Children of parents without a usual source of care because they "don't need a doctor and/or haven't had any problems" or they "don't like, trust, or believe in doctors" had 35% lower odds of receiving well-child care (adjusted odds ratio = 0.65; 95% CI, 0.56-0.74) and 23% lower odds of receiving influenza vaccination (adjusted odds ratio = 0.77; 95% CI, 0.69-0.86) than children of parents without those attitudes and beliefs about health care. Financial and other nonfinancial parental barriers were not associated with children's receipt of preventive services. Results were independent of several factors relevant to children's access to preventive health care, including whether the child had a usual source of care.

CONCLUSIONS

Parents' attitudes and beliefs about having a usual source of care were strongly associated with their children's receipt of recommended preventive health services. Rates of receipt of child preventive services may be improved by addressing parents' attitudes and beliefs about having a usual source of care. Future studies should assess causes of these associations.

Children and Managed Care: What Research can, can’t, and Should Tell Us about Impact

The speed and ubiquity of the move from fee-for-service to managed care raises questions about how these changes affect children. This article examines (1) the pace and context of the move to managed care for children, (2) potential opportunities and challenges emerging from these changes, (3) research findings on how managed care affects children, and (4) next steps for learning more. The research review provides a consistent answer to whether managed care is good for children: it depends on what kind of managed care, which children, and under what circumstances. This finding suggests lessons for future research: (1) focus on particular features of managed care, (2) get inside the “black box” of managed care and examine providers, (3) expand the portfolio of research on children: research on adults cannot “trickle down” to children, (4) foster research partnerships and networks, and (5) focus on poor and chronically ill children.

Health care access disparities among children entering kindergarten in Nevada

The objective of this study was to advance our understanding and appreciation of the health status of young children in the state of Nevada in addition to their discrepancies in accessing health care. This study used the 2008-2009 Nevada Kindergarten Health Survey data of 11,073 children to assess both independent and combined effects of annual household income, race/ethnicity, primary language spoken in the family, rural/urban residence, and existing medical condition on access to health care. Annual household income was a significant predictor of access to health care, with middle and high income respondents having regular access to care compared to low income counterparts. Further, English proficiency was associated with access to health care, with English-speaking Hispanics over 2.5 times more likely to have regular access to care than Spanish-speaking Hispanics. Rural residents had decreased odds of access to preventive care and having a primary care provider, but unexpectedly, had increased odds of having access to dental care compared to urban residents. Finally, parents of children with no medical conditions were more likely to have access to care than those with a medical condition. The consequences for not addressing health care access issues include deteriorating health and well-being for vulnerable socio-demographic groups in the state. Altogether these findings suggest that programs and policies within the state must be sensitive to the specific needs of at risk groups, including minorities, those with low income, and regionally and linguistically isolated residents.

Duration of a well-child visit: association with content, family-centeredness, and satisfaction

BACKGROUND

Studies of pediatric primary care suggest that time is an important limitation to the delivery of recommended preventive services. Given the increasingly frenetic pace of pediatric practice, there is an increased need to monitor the length of pediatric visits and the association of visit length with content, family-centered care, and parent satisfaction with care.

OBJECTIVE

To examine the length of well-child visits and the associations of visit length with content, family-centered care, and parent satisfaction among a national sample of children.

METHODS

We conducted a cross-sectional telephone survey of parents of children aged 4 to 35 months from the 2000 National Survey of Early Childhood Health (n = 2068).

RESULTS

One-third (33.6%) of parents reported spending ≤ 10 minutes with the clinician at their last well-child visit, nearly half (47.1%) spent 11 to 20 minutes, and 20.3% spent >20 minutes. Longer visits were associated with more anticipatory guidance, more psychosocial risk assessment, and higher family-centered care ratings. A visit of >20 minutes was associated with 2.4 (confidence interval [CI]: 1.5-3.7) higher odds of receiving a developmental assessment, 3.2 (CI: 1.7-6.1) higher odds of recommending the clinician, and 9.7 (CI: 3.5-26.5) higher odds of having enough time to ask questions.

CONCLUSIONS

Many well-child visits are of short duration, and shorter visits are associated with reductions in content and quality of care and parent satisfaction with care. Efforts to improve preventive services will require strategies that address the time devoted to well-child care. The results of this study should be interpreted in light of changes in practice standards, reimbursement, and outcome measurement that have taken place since 2000 and the limitations of the measurement of utilization solely on the basis of parent report.

Continuity of insurance coverage and ambulatory care-sensitive hospitalizations/ED visits: evidence from the children's health insurance program

OBJECTIVE

To assess the effects of continuity of insurance coverage on treatment of ambulatory-care sensitive conditions (ACSC).

STUDY POPULATION

42,382 children enrolled in ALL Kids (Alabama Children's Health Insurance Program) for 3 or more years.

METHODS

We model annual hospitalizations and ED visits for six ACSCs identified by the AHRQ - bacterial pneumonia, dehydration, perforated appendix, urinary tract infection, gastroenteritis, and severe ear, nose and throat infection.

RESULTS

In unadjusted models, we find lower risk of ACSC hospitalizations and ED visits in the second and third years of continuous enrollment. Risk of hospitalization in year 3 was significantly lower for pneumonia (OR 0.608, 95% CI: 0.421-0.878) and gastroenteritis (OR 0.549, 95% CI: 0.404-0.746). These beneficial effects of duration of coverage disappear after controlling for age, year and other enrollee characteristics.

CONCLUSIONS

Hospitalizations and ED visits for ACSCs are rare and do not decrease with additional years of coverage.

Material hardship and the physical health of school-aged children in low-income households

OBJECTIVES

We examined the relationship between material hardship reported by low-income caregivers and caregivers' assessments of their children's overall health.

METHODS

We used logistic regression techniques to analyze data from 1073 children aged 5 through 11 years whose caregivers participated in multiple waves of the Illinois Families Study.

RESULTS

Caregivers' reports of food hardship were strongly associated with their assessments of their children's health. Other sources of self-reported material hardship were also associated with caregivers' assessments of their children's health, but the effects disappeared when we controlled for caregiver physical health status and mental health status. Proximal measures of material hardship better explained low-income children's health than traditional socioeconomic measures. There were no statistically significant cumulative effects of material hardships above and beyond individual hardship effects.

CONCLUSIONS

Our findings highlight the importance of developing and supporting programs and policies that ensure access to better-quality food, higher quantities of food, and better living conditions for low-income children, as well as health promotion and prevention efforts targeted toward their primary caregivers as ways to reduce health disparities for this population.

Received, understanding and satisfaction of National Health Insurance premium subsidy scheme by families of children with disabilities: a census study in Taipei City

The purposes of the present study are to provide the first data on utilization, understanding and satisfaction of the National Health Insurance (NHI) premium subsidy for families of children with disabilities in Taipei. Data from the 2001 Taipei Early Intervention Utilization and Evaluation Survey for Aged 0-6 Children with Disabilities were analyzed. In the study, a total of 1006 questionnaires were mailed, of which 340 valid questionnaires were returned, giving a response rate of 33.8%. More than one-third of families of children with disabilities did not receive any financial subsidy of National Health Insurance (NHI). Less than half of the respondents (43.8%) understood the NHI premium subsidy policy completely, while 28.7% partial understood and 27.5% still did not know this auxiliary policy. Approximately 38.5% of the respondents were specifically very satisfied or satisfied, with the NHI subsidy program. There were 18.9% respondents who felt dissatisfied or very dissatisfied with the NHI scheme for children with disabilities in Taiwan. Chi-square or t-test analyses were significant for the caregiver's age (p<0.05), children's disability onset and disability diagnosed age and disability level (p<0.01) on receiving the subsidy assistance. A multiple stepwise logistic regression revealed that the factor of 'onset age of disability' was slightly significant associated with the use of NHI premium subsidy (OR=0.966; 95% CI=0.947-0.986). Health policies should aim to reduce the inequity in NHI premium subsidy utilization and improve their understanding and satisfaction toward this subsidy scheme.

Immigrant children's reliance on public health insurance in the wake of immigration reform

OBJECTIVES

We sought to determine whether the reversal of the public charge rule of the Illegal Immigration Reform and Immigrant Responsibility Act, which may have required families to pay for benefits previously received at no cost, led to immigrant children becoming increasingly reliant on public health insurance programs.

METHODS

We conducted a secondary data analysis focusing on low-income children sampled in the 1997 through 2004 versions of the National Health Interview Survey.

RESULTS

Between 1997 and 2004, public health insurance enrollments and the numbers of uninsured foreign-born children in the United States increased by 3.1% and 2.7%, respectively. Using multinomial logistic regression models to account for the substantial differences in socioeconomic status between foreign-born and US-born children, we found that low-income US-born children were just as likely as foreign-born children to have public health insurance coverage (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.89, 1.52) and that, after 2000, foreign-born children were 1.59 times (95% CI = 1.24, 2.05) more likely than were US-born children to be uninsured (vs publicly insured).

CONCLUSIONS

In the wake of the reversal of the public charge rule, immigrant children are increasingly likely to be uninsured as opposed to relying on public health insurance.

Family structure differences in health care utilization among U.S. children

This study explores the relationship between family structure and children's access to health care using data from the 2001-2003 waves of the child sample files from the U.S. National Health Interview Survey. Specifically, we investigate the extent to which family structure types predict children's utilization of preventive health care, and barriers to care. We then explore whether observed differences across family structures can be attributed to differences in demographic characteristics, socioeconomic status (SES), and child health status. Using logistic regression models, we document substantial variation in health care usage and barriers to health care across a variety of family structures. Of note is the finding that the children of single mothers demonstrate extremely different patterns of health care access than do the children of single fathers, and the importance of SES as a risk factor for diminished levels of access to health care varies by family type. SES plays a major role in mediating the relationship between access to care for children in single mother and cohabiting families (when contrasted against children in two married parent families), but less of a role for children living with stepparents, a single father, or with parents and other relatives.

The effect of parental immigration authorization on health insurance coverage for migrant Latino children

OBJECTIVE

To examine if immigration authorization among parents is associated with health insurance coverage for migrant Latino children.

DATA SOURCE

A cross-sectional household survey of 300 migrant families for which one child, aged <13 years, was randomly selected.

RESULTS

Most children lacked insurance (73%) and had unauthorized parents (77%). Having an authorized parent or parental stay of more than 5 years in the US were each positively associated with children's health insurance coverage [OR: 4.9; 95% CI: (2.7-8.7) and [OR = 6.7; 95% CI: (3.8-12.0), respectively]. The effect of parental authorization did not persist in multivariable logistic regression analysis; however, more than 5 years of parental stay in the US remained associated with children's insurance coverage [OR = 4.8; 95% CI (1.8-12.2)], regardless of parental authorization.

CONCLUSION

Increased parental familiarity with US health and/or social services agencies, rather than parental authorization status, is important to obtaining health insurance for migrant children. Efforts to insure eligible migrant children should focus on recently arrived families.

Assessment of children's health-related quality of life in the United States with a multidimensional index

OBJECTIVE

Using nationally representative data, we examined biological, medical system, and sociodemographic factors that are associated with health-related quality of life as measured by a multidimensional index that accounts for a wide range of child health domains.

METHODS

Children aged > or = 6 years (N = 69,031) were drawn from the 2003/2004 National Survey of Children's Health. A random 25% sample was used to create a 12-item index of health-related quality of life with a range of 0 to 100, based on the conceptual framework of the Child Health and Illness Profile. Bivariate and multivariable regression analyses were conducted to identify the unadjusted and independent associations of key biological, medical system, and sociodemographic variables with health-related quality of life.

RESULTS

The index mean was 72.3 (SD: 14.5), median value was 73.7, and range was 11.1 to 99.9. Only 0.2% of children had a score at the ceiling. In multivariable regression analysis, the following variables were independently associated with lower health-related quality of life: biological factors (greater disease burden, severe asthma, and overweight status); medical system factors (unmet medical needs, lack of a regular health care provider, Medicaid insurance, or being uninsured previously during the year); and sociodemographic factors (older age groups, lower family education, single-mother family, having a smoker in the household, black race, and poverty).

CONCLUSIONS

Health-related quality of life in the United States is poorest for children and youth in lower socioeconomic status groups, those with access barriers, adolescents compared with children, and individuals with medical conditions. A multidimensional health-related quality-of-life index is an alternative to conventional measures (eg, mortality) for national monitoring of child health.

Usual source of health care among Hispanic children: the implications of immigration

Deep inequities continue to exist in the access to and sources of care across racial and ethnic groups in the United States. This research examines differences in the regular source of usual health care for children among Hispanic subgroups of the United States. The immigration status of the mother -- including nativity, duration in the United States, and citizenship status -- as well as sociodemographic factors are considered as significant influences on the type of regular sources of care. Using the National Health Interview Survey from 1999 to 2001, multinomial logistic regression models are estimated to compare Mexican American and other Hispanic children with non-Hispanic whites and blacks. Both Mexican Americans and other Hispanics were more likely to report the use of clinic or the emergency room over private doctor's office as their regular source of health care compared with non-Hispanic whites. Together, the impact of the mother's nativity, duration, and citizenship status explains much of the differentials in the sources of care among Mexican American and other Hispanic children compared with non-Hispanic whites.

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.

Access to care and utilization among children: estimating the effects of public and private coverage

OBJECTIVES

We examine the relationship between health insurance coverage and children's access to and utilization of medical care. Access measures we study are having a usual source of care (USC) and lacking a USC for financial or insurance reasons. We also examine indicators for ambulatory visits, well-child visits, dental visits, emergency room use, and inpatient hospital stays.

METHODS

We pool data from the first 7 years of the Medical Expenditure Panel Survey (MEPS), 1996 to 2002. Pooling yields a large sample of children, enabling us to analyze access and utilization using simple descriptive statistics, multivariate analysis, and instrumental variables estimation (IV). IV estimation is of particular interest given the possibility of bias caused by confounding factors (such as child health or parent attitudes) and measurement error in insurance coverage. We also compare estimates from IV linear probability models to estimates from IV probit with residual inclusion.

RESULTS

As previous studies have found, public and private coverage are both associated with large increases in access and utilization. Simple mean comparisons suggest that private coverage has a larger effect than does public coverage. Differences between public and private coverage are reduced (and often reversed) when we control for other characteristics of children and their families. IV coverage effect estimates from both linear probability and residual inclusion probit models are substantially greater than conventional estimates across a wide range of access and utilization measures.

CONCLUSIONS

Despite concerns that conventional estimates overstate the impact of coverage on access and use, our results suggest that the reverse may be true. One explanation may be that conventional estimates are biased toward zero due to error in the reporting of insurance coverage. The magnitude of the coverage effects we find highlights the importance of reducing uninsurance among children.

Mothers' views on hyperactivity: a cross-cultural perspective

To examine cultural variation in mothers' perceptions of hyperactive behaviors in school-age boys, we surveyed 135 mothers in 3 ethnic groups: Puerto Rican, Central and South American, and Anglo. Mothers read or heard 8 taped vignettes of boys with behaviors related to DSM-IV hyperactivity criteria. In 50% of the vignettes, Spanish-responding mothers were less likely to consider the boys' behaviors expected than were the English-responding mothers. In 62.5% of the vignettes, Latina mothers expressed more interest in discussing behaviors with their physicians than did the Anglo mothers, and in 62.5% of the vignettes, Spanish-responding mothers expressed more interest in discussing behaviors with their physicians than did the English-responding mothers. We found no association of the 2 scores by the bicultural scale. Mothers' perception of hyperactivity boys varies both with ethnicity and language of response. Latina mothers, especially Spanish-responding mothers, seem interested in discussing children's behavior with physicians.

Cumulative social disadvantage and child health

CONTEXT

Disparities in child health are a major public health concern. However, it is unclear whether these are predominantly the result of low income, race, or other social risk factors that may contribute to their health disadvantage. Although others have examined the effects of the accumulation of risk factors, this methodology has not been applied to child health.

OBJECTIVE

We tested 4 social risk factors (poverty, minority race/ethnicity, low parental education, and not living with both biological parents) to assess whether they have cumulative effects on child health and examined whether access to health care reduced health disparities.

DESIGN

We analyzed data on 57,553 children <18 years from the 1994 and 1995 National Health Interview Survey Disability Supplement. Of the 4 risk factors, 3 (poverty, low parental education, and single-parent household) were consistently associated with child health. These were summed, generating the Social Disadvantage Index (range: 0-3).

RESULTS

A total of 43.6% of children had no social disadvantages, 30.8% had 1, 15.6% had 2, and 10.0% had all 3. Compared with those with no social disadvantages, the odds ratios (ORs) of being in "good, fair, or poor health" (versus "excellent or very good") were 1.95 for 1 risk, 3.22 for 2 risks, and 4.06 for 3 risks. ORs of having a chronic condition increased from 1.25 (1 risk) to 1.60 (2 risks) to 2.11 (3 risks). ORs for activity limitation were 1.51 (1 risk) to 2.14 (2 risks) and 2.88 (3 risks). Controlling for health insurance did not affect these findings.

CONCLUSIONS

The accumulation of social disadvantage among children was strongly associated with poorer child health and having insurance did not reduce the observed health disparities.

Gradients in the Health Status and Developmental Risks of Young Children: The Combined Influences of Multiple Social Risk Factors

OBJECTIVES

To analyze child vulnerability as a profile of multiple risk factors for poorer health based on race/ethnicity, social class (maternal education and family poverty status), child health insurance coverage, and maternal mental health. Profiles are examined in relation to disparities in the health status and developmental risks of young children.

DATA SOURCES

Cross-sectional data on 2,068 children ages 4-35 months from the 2000 National Survey of Early Childhood Health.

STUDY DESIGN

Multiple logistic regression models are used to examine risk profiles in relation to child health status and developmental risk (based on parent concerns about development). The profiles are also examined in relation to three measures of basic access to health care: telephone contact with a physician, well-child visit in the past year, and missed or delayed needed care.

PRINCIPAL FINDINGS

About one-third of (or 3.1 million) young children in the United States have two or more risk factors (RF) for poor health. Controlling for other family factors, having more RFs is associated with poorer health status (i.e., percent reported "good/fair/poor" vs. "excellent/very good") and being higher risk for developmental delays. For example, the likelihood of having either poorer health or higher developmental risk increases with each RF (vs. zero): 1 RF (OR = 1.70, CI: 1.20-2.38), 2 RFs (OR = 3.28, CI: 2.27-4.73), 3 RFs (OR = 4.69, CI: 2.84-7.73), 4 RFs (OR = 14.58, CI: 4.98-42.64). Higher RFs were also associated with poorer health care access.

CONCLUSIONS

This study demonstrates a dose-response relationship of higher risk profiles with poorer child health status and higher developmental risk. Because children with higher profiles of risk are also more likely to lack access to care, this suggests that children who most need care have the greatest difficulty obtaining it. Addressing health gradients for vulnerable children will require explicit attention to these multiple, overlapping risk factors.

Dimensions of the local health care environment and use of care by uninsured children in rural and urban areas

OBJECTIVE

Despite concerted policy efforts, a sizeable percentage of children lack health insurance coverage. This article examines the impact of the health care safety net and health care market structure on the use of health care by uninsured children.

METHODS

We used the Medical Expenditure Panel Survey linked with data from multiple sources to analyze health care utilization among uninsured children. We ran analyses separately for children who lived in rural and urban areas and assessed the effects on utilization of the availability of safety net providers, safety net funding, supply of primary care physicians, health maintenance organization penetration, and the percentage of people who are uninsured, controlling for other factors that influence use.

RESULTS

Fewer than half of uninsured children had office-based visits to health care providers during the year, 8% of rural and 10% of urban children visited the emergency department at least once, and just over half of children had medical expenditures or charges during the year. Among uninsured children in rural areas, living closer to a safety net provider and living in an area with a higher supply of primary care physicians were positively associated with higher use and medical expenditures. In urban areas, the supply of primary care physicians and the level of safety net funding were positively associated with uninsured children's medical expenditures, whereas the percentage of the population that was uninsured was negatively associated with use of the emergency department.

CONCLUSIONS

Uninsured children had low levels of utilization over a range of different health care provider types and settings. The availability of safety net providers in the local area and the safety net's capacity to serve the uninsured influence access to care among children. Possible measures for ensuring access to health care among uninsured children include increasing the density of safety net providers in rural areas, enhancing funding for the safety net, and policies to increase primary care physician supply.

Health status and health service access and use among children in U.S. immigrant families

OBJECTIVES

We examined the health status and patterns of health care use of children in US immigrant families.

METHODS

Data from the 1999 National Survey of America's Families were used to create 3 subgroups of immigrant children: US-born children with noncitizen parents, foreign-born children who were naturalized US citizens, and foreign-born children with noncitizen parents. Chi-square and logistic regression analyses were used to examine relationships between immigrant status and health access variables. Subgroup analyses were conducted with low-income families.

RESULTS

Foreign-born noncitizen children were 4 times more likely than children from native families to lack health insurance coverage and to have not visited a mental health specialist in the preceding year. They were 40% and 80% more likely to have not visited a doctor or dentist in the previous year and twice as likely to lack a usual source of care. US-born children with noncitizen parents were also at a disadvantage in many of these aspects of care.

CONCLUSIONS

We found that, overall, children from immigrant families were in worse physical health than children from non-immigrant families and used health care services at a significantly lower frequency.

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.

Insurance gaps among vulnerable children in the United States, 1999-2001

OBJECTIVE

To quantify the number of children who experience gaps in insurance coverage and to determine whether vulnerable subgroups of children experience noteworthy lapses in insurance coverage.

METHODS

We analyzed nationally representative data from 24,149 children sampled in the 1999-2001 Medical Expenditure Panel Survey linked to the 1997-1999 National Health Interview Survey. Vulnerable subgroups of children included children with chronic conditions, those from ethnic/racial minorities, and those living in poverty. On the basis of cumulative annual monthly insurance coverage status, each child fell into 1 of 3 groups: continuous coverage, uninsured, or gaps in coverage. Using SAS-callable SUDAAN, we conducted multivariate ordinal logistic regression model to quantify the likelihood of having gaps in coverage for vulnerable subgroups of children.

RESULTS

From 1999 to 2001, we found that >9 million American children annually had gaps in coverage and that 5 to 6 million children annually were uninsured for the entire year. Sixty percent of children experienced gaps of at least 4 months, and >40% of all publicly and privately insured children had coverage gaps. After accounting for relevant covariates, children with chronic conditions were just as likely as other children to have gaps in coverage or be uninsured; Hispanic children were most likely to have insurance gaps or be uninsured; and children from poor and near-poor families were 4 to 5 times more likely to have lapsed coverage than children from high-income families. Poverty and maternal education were the strongest factors associated with lapsed coverage.

CONCLUSIONS

Unstable health insurance is an underrecognized problem for children, including those with chronic conditions. Because unstable insurance coverage can lead to inadequate health care utilization and poor child health outcomes, strategies to promote stable insurance coverage merit serious consideration.

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.

CSHCN in Texas: Meeting the Need for Specialist Care

OBJECTIVE

Assuring the sufficiency and suitability of systems of care and services for children with special health care needs (CSHCN) presents a challenge to Texas providers, agencies, and state Title V programs. To meet the need for specialist care, referrals from primary care doctors are often necessary. The objective of this study was to describe the factors associated with the need for specialist care and problems associated with obtaining referrals in Texas.

METHODS

Bivariate and multivariate analyses were performed using the National Survey of Children with Special Health Care Needs (NS-CSHCN) weighted sample for Texas (n = 719,014) to identify variables associated with the need for specialist care and problems obtaining referrals for specialist care.

RESULTS

Medical need of the CSHCN and sensitivity to family values/customs was associated with greater need for specialist care, and Hispanic ethnicity and lower maternal education were associated with less need. Medical need, amount of time spent with doctors and sensitivity to values/customs, living in a large metropolitan statistical area, and lack of medical information were associated with problems obtaining a specialist care referral.

CONCLUSIONS

Findings revealed some similarities and differences with meeting the need for specialist care when comparing Texas results to other studies. In Texas, aspects of customer satisfaction variables, especially doctors' sensitivity to family values/customs and parents' not receiving enough information on medical problems, were significantly associated with problems obtaining specialist referrals. Findings indicate a need to further research relationships and communication among doctors, CSHCN, and their families.

Are all children equal? An analysis of the predictive value of selected pediatric characteristics of the referral of children to pediatric home health services

ISSUES AND PURPOSE

To examine the predictive value of selected pediatric characteristics of the referral of children to pediatric home health services (PHHS). No empirical studies to date have evaluated the criteria used to determine the need for PHHS or if disparities in the referral of children to PHHS occur.

DESIGN AND METHODS

Randomly selected hospital records of 557 children discharged from one pediatric hospital between October 1999 and September 2000 were examined. Sequential logistic regression was used to calculate the odds of being referred to PHHS based on age, race or ethnicity, number of legal guardians in the household, and the number of technological devices at discharge. Insurance was excluded as a predictor because 97% of the study sample was insured.

RESULTS

Only the number of technological devices at discharge added predictive value (chi(2)[DF = 3, N= 557]= 42.023, P<0.001) to the SLR model. There was no evidence of disparities in referral.

IMPLICATIONS FOR PRACTICE

To ensure availability and equitable access to PHHS, nurses must actively participate in the discharge planning process for all children.

Delayed or forgone care among children with special health care needs: an analysis of the 2001 National Survey of Children with Special Health Care Needs

OBJECTIVE

To examine the associations of sociodemographic characteristics with both the prevalence and the causes of delayed or forgone care in a nationally representative sample of children with special health care needs.

METHODS

Data were abstracted from the 2001 National Survey of Children with Special Health Care Needs. The families of children with special health care needs (CSHCN) who reported delayed or forgone care were asked about the reasons. The 12 reasons in the questionnaire were grouped into 5 categories. Bivariate and multivariate logistic regression analyses were conducted in SUDAAN to examine the relationship between sociodemographic characteristics of CSHCN and the incidence of delayed or forgone care by its reasons.

RESULTS

Nearly 10% of CSHCN had experienced delayed or forgone health care in the past 12 months in 2001. Logistic regression showed that delayed or forgone care was more likely to be reported by the families of CSHCN who were adolescents, who had more severe limitations, lived in the South or West, lacked medical insurance, and who lived in families under or near the federal poverty line. Hispanics were more likely to report "lack of medical specialty" and "had language, communication, or cultural problems with provider." Both Hispanics and non-Hispanic others were twice as likely to report "provider not accessible" as reasons for the delayed or forgone care compared with non-Hispanic whites or blacks. conclusion: CSHCN with certain socioeconomic status and sociodemographic characteristics, as well as those with severe limitations in activity, were more likely to be affected by circumstances that result in delayed or forgone care.

Attendance for general practitioner asthma care by children with moderate to severe asthma in Auckland, New Zealand

Attendance for general practitioner (GP) care of childhood asthma varies widely in New Zealand (NZ). There is little current research to account for the variations, although groups such as Māori and Pacific peoples have traditionally faced barriers to accessing GP care. This paper aims to describe and account for attendance levels for GP asthma care among 6-9 year-olds with moderate to severe asthma in Auckland, NZ. During 2002, randomly selected schools identified all 6-9 year-olds with possible breathing problems. Completion of a questionnaire by each parent/guardian indicated which children had moderate to severe asthma, and what characteristics influenced their access to GP asthma care. A multilevel, negative binomial regression model (NBRM) was fitted to account for the number of reported GP visits for asthma, with adjustment for clustering within schools. Twenty-six schools (89.7 percent) identified 931 children with possible breathing problems. Useable questionnaires were returned to schools by 455 children (48.9 percent). Results indicated 209 children with moderate to severe asthma, almost one in every three reportedly making 5 or more GP visits for asthma in the previous year. Māori, Pacific and Asian children were disproportionately represented among these 'high attendees'. Low attendees (0-2 visits) were mainly NZ Europeans. The NBRM (n=155) showed that expected visits were increased by perceived need, ill-health, asthma severity and, in particular, Māori and Pacific child ethnicity. It may be that Māori and Pacific children no longer face significant barriers to accessing GP asthma care. However, more likely is that barriers apply only to accessing routine, preventative care, leading to poor asthma control, exacerbations requiring acute care, and paradoxically an increase in GP visits. That barriers may increase total numbers of visits challenges the assumption, for all health systems, that access can be defined in terms of barriers that must be overcome to obtain health care.

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.

Quality of health care: the views of homeless youth

OBJECTIVE

To develop homeless-youth-identified process and outcome measures of quality of health care.

DATA SOURCES/STUDY SETTING

Primary data collection with homeless youth from both street and clinic settings in Seattle, Washington, for calendar year 2002.

STUDY DESIGN

The research was a focused ethnography, using key informant and in-depth individual interviews as well as focus groups with a purposeful sample of 47 homeless youth aged 12-23 years.

DATA COLLECTION/EXTRACTION METHODS

All interviews and focus groups were tape-recorded, transcribed, and preliminarily coded, with final coding cross-checked and verified with a second researcher.

PRINCIPAL FINDINGS

Homeless youth most often stated that cultural and interpersonal aspects of quality of care were important to them. Physical aspects of quality of care reported by the youth were health care sites separate from those for homeless adults, and sites that offered a choice of allopathic and complementary medicine. Outcomes of health care included survival of homelessness, functional and disease-state improvement, and having increased trust and connections with adults and with the wider community.

CONCLUSIONS

Homeless youth identified components of quality of care as well as how quality of care should be measured. Their perspectives will be included in a larger follow-up study to develop quality of care indicators for homeless youth.

Mental health services use among school-aged children with disabilities: the role of sociodemographics, functional limitations, family burdens, and care coordination

OBJECTIVE

To examine the use of mental health services and correlates of receiving services among community-dwelling children with disabilities, ages 6 to 17 years.

STUDY DESIGN

Data are from the 1994 and 1995 National Health Interview Survey Disability Supplements (NHIS-D), conducted by the National Center for Health Statistics. The study sample is 4,939 children with disabilities, representing an estimated eight million children with disabilities nationwide. Parents of children under 16 years of age reported (17-year-olds self-reported) on health, emotional and behavioral problems, mental health services use, and who, if anyone, coordinated the child's health care.

PRINCIPAL FINDINGS

Among disabled children with poor psychosocial adjustment (11.5 percent), only 11.8 percent received mental health services in the past year. Multivariate logistic regression analysis showed service use was associated with poor psychosocial adjustment; communication, social, and learning-related functional impairments; public health insurance; and financial family burdens. Younger and black disabled children were less likely to receive mental health services. The odds of service use were greater with the involvement of a health professional in coordinating care, in contrast to no one or family only. Moreover, children with disabilities were more likely to use outpatient mental health services if their care was jointly coordinated by a family member and a health professional, compared to a health professional working alone. In contrast to inpatient and outpatient care, race and family burden were not associated with the likelihood of mental health counseling in special education school settings.

CONCLUSIONS

Findings indicate that only two in five disabled children with poor psychosocial adjustment receive mental health services. Differences by age, race, and insurance coverage suggest that inequalities to access exist. However, the school setting may be one in which some barriers to mental health services for disabled children are reduced. The study also shows that the involvement of health professionals in care coordination is associated with greater access to mental health care for disabled children. These findings underscore the importance of engaging both health care professionals and the family in the care process.

Substance use, dependence, and service utilization among the US uninsured nonelderly population

OBJECTIVES

We examined the prevalence and correlates of substance use, dependence, and service utilization among uninsured persons aged 12 to 64 years.

METHODS

We drew study data from the 1998 National Household Survey on Drug Abuse.

RESULTS

An estimated 80% of uninsured nonelderly persons reported being uninsured for more than 6 months in the prior year. Only 9% of these uninsured persons who were dependent on alcohol or drugs had received any substance abuse service in the past year. Non-Hispanic Whites were an estimated 3 times more likely than Blacks to receive substance abuse services.

CONCLUSIONS

Compared with the privately insured, uninsured persons had increased odds of having alcohol/drug dependence and appeared to face substantial barriers to health services for substance use problems.

Factors associated with Medicaid enrollment for low-income children in the United States

This study analyzes the 1996-1997 Community Tracking Study Household Survey to identify factors associated with Medicaid enrollment for low-income children and to examine the differences between those enrolled in the Medicaid program and those who were eligible but uninsured. We estimated that 17.4% of Medicaid-eligible children were uninsured. Medicaid eligible children who were younger, African American, with single parents, with AFDC eligible parents, with no parent employed full-time were more likely to be enrolled in the Medicaid program. Children with better health status were less likely to be enrolled in Medicaid. In addition, children whose parents were uninsured were more likely not to be enrolled in Medicaid.

Adolescent health care expenditures: a descriptive profile

PURPOSE

To examine health care spending patterns for U.S. adolescents aged 10 to 18 years using nationally representative household survey data.

METHODS

We analyzed data from the 1997 Medical Expenditure Panel Survey on total expenditures and out-of-pocket expenditures for health care based on a sample of 4882 adolescents.

RESULTS

Compared with that for adults, health care expenditures for adolescents were low, averaging $799 US dollars per adolescent in 1997. Disabled and functionally impaired adolescents had disproportionately high expenditures ($1960 US dollars per capita). Blacks and adolescents living in poor families had disproportionately low expenditures ($358 and $609 US dollars per capita, respectively). Professional services provided by physicians and dentists accounted for more than one-half of all health care spending for adolescents. Only 2% of adolescents were hospitalized in 1997, but they accounted for about one-fifth of all health care expenditures. The share of health expenditures paid out of pocket varied by type of service, ranging from 3% for inpatient hospital care to 51% for dental care. When covered, insurance provided substantial financial protection for families of adolescents: those with public coverage paid 8%, those with private coverage paid 32%, and those without coverage paid 61% of their health care bills out of pocket. The share of health care bills paid out of pocket would be much lower if dental care was excluded.

CONCLUSIONS

On the basis of our findings that health care expenditures for adolescents are low and that insurance coverage provides critically needed financial protection, we conclude that further expansions of public and private health insurance coverage for this population would provide significant benefits at modest additional cost. Additional efforts to improve coverage of services that are not now well-covered, such as dental care, would also be valuable.

Crossing the border for health care: access and primary care characteristics for young children of Latino farm workers along the US-Mexico border

OBJECTIVES

To examine prevalence and correlates of cross-border health care for children of Latino farm workers in counties near the US-Mexico border and to compare access and primary care in the United States and Mexico.

METHODS

Two hundred ninety-seven parents at Head Start centers in San Diego and Imperial counties were surveyed regarding percentage of health care received in Mexico and the United States, access, and primary care characteristics.

RESULTS

More than half of all health care was reported as received in Mexico. Reasons for Mexican use revolved around cost, accessibility, and perceptions of effectiveness. Parents of insured children reported slightly more US care, yet even this group reported approximately half of health care in Mexico. Insurance status was related to having a regular source of care, while uninsured children reporting most care in Mexico were less likely than uninsured children in the United States to have had a routine health care visit. Primary care characteristics were related to insurance status and source of care. Uninsured children reporting most care in Mexico fared better in some aspects of primary care than uninsured children reporting most care in the United States and as well as children with insurance receiving care in the United States or Mexico.

CONCLUSIONS

Children of farm workers living along the US-Mexico border, almost irrespective of insurance status, receive a large proportion of care in Mexico. Especially for uninsured children, parent reports of Mexican care characteristics compare favorably with that received in the United States. Mexican health care might be a buffer against vulnerability to poor health outcomes for these children.

Children in need of Pharmacare: medication funding requests at the Toronto Hospital for Sick Children

OBJECTIVES

Although a national Pharmacare program ensuring access to and affordability of needed medications has repeatedly been cited as a priority to policymakers, 20% of families remain either uninsured or under-insured. The Hospital for Sick Children's Patient Amenities Fund (PAF) covers out-of-pocket medication expenses for inpatient and outpatient children. The research objectives were to 1) examine family demographics and socio-economic status (SES), the types of medications requested and government program process issues of PAF applicants in 1998 and 1999, and 2) describe trends in PAF requests from 1998 to 2000.

METHODS

Data were extracted retrospectively from fund requests, charts and social work and discharge planning reports. Descriptive statistics were used to summarize the data and to examine time trends.

RESULTS

Eighty-six applicants submitted 112 requests from 1998-1999. Most were for children with cancer, neurological disorders and transplant patients. Medication expenditures were 22,408 dollars in 1999, a 39% increase over 1998. Most requests came from two-parent nuclear families where one or both parents were employed. High deductibles, waiting time, application form complexity and request denials were cited as problems encountered with government drug plans.

DISCUSSION

The findings suggest that for provinces that do not provide universal drug insurance programs, relying on a patchwork of government plans and community agencies may not be effective in ensuring easy and timely access to necessary medications for children.

Racial and ethnic disparities in the primary care experiences of children: a review of the literature

Substantial racial and ethnic disparities persist in children's health and use of health services in the United States. Although equitable access to primary care services is widely promoted as one of the most feasible remedies to reduce health disparities, there has only recently been an effort to assess its quality, particularly for children. Racial and socioeconomic differences in access to care have been previously well documented, but recent research has begun to elucidate differences in more qualitative experiences in the receipt of primary care. This article presents a synthesis and critique of the existing research according to the core attributes of primary care: first-contact care, longitudinality, comprehensiveness, and coordination. Finally, the article proposes an agenda for further research into the pathways by which racial and ethnic disparities in primary care exist.

America's adolescents: where have we been, where are we going?

PURPOSE

To determine historical trends and current status of the health of America's youth.

METHODS

A thorough literature review was conducted to establish the best sources for adolescent data across a wide range of health-related issues using major national data sources. Data were collected and synthesized to create a comprehensive overview of adolescent health and demographic trends.

RESULTS AND CONCLUSIONS

Adolescence is a distinct developmental stage posing unique challenges. Although generally considered a time of health and well-being, traditional health indicators often overlook areas specific to adolescence. Despite encouraging improvements in recent years, this population continues to have high rates of morbidity and mortality owing to violence, injury, and mental health disorders. Also, potentially health-damaging behaviors, such as premature and unprotected sexual behavior and substance use, pose significant threats. Fortunately, adolescence is a time of great behavioral plasticity. Because the vast majority of adolescent health risks are the result of behavioral causes, much of this morbidity and mortality is preventable. The adolescent population is projected to greatly increase over the next 2 decades. However, older age groups are increasing more rapidly, reducing the proportion of adolescents in the overall population. The aging population will likely demand increased access to scarce resources. The public needs to be educated about the need to support programs for youth. If resources are properly allocated, and health professionals trained to deal with adolescents' unique needs, America's youth have the potential to benefit greatly from successful implementation of new knowledge, developing healthy, positive, life-long behaviors.

Factors that influence receipt of recommended preventive pediatric health and dental care

OBJECTIVE

This study examined the factors that affect children's receipt of recommended well-child and dental visits using nationally representative data.

METHODS

We analyzed the Child Public Use File of the 1999 National Survey of America's Families, including 35 938 children who were younger than 18 years. Bivariate and multivariate analyses were conducted to examine the relationship between dependent variables, including receipt of well-child visits as recommended by the American Academy of Pediatrics' periodicity schedule and dental visits as recommended by the American Academy of Pediatric Dentistry and Bright Futures, and independent variables, including health status and sociodemographic and economic indicators.

RESULTS

Overall, 23.4% of children did not receive the recommended well-child visits, whereas 46.8% did not receive the recommended number of dental visits. The factors that predict nonreceipt of care differed for well-child and dental care and with child's age. Logistic regression reveals that children who were young (<10 years old), uninsured, non-Hispanic white, had a parent who was less than college educated, or in poor health were least likely to meet the recommendations for well-child care. Children who did not meet the dental recommendation were more likely to be black, uninsured, from families with low incomes, have a parent who was less than college educated, and have postponed dental care in the last year. These risk factors increased with children's age.

CONCLUSIONS

A substantial proportion of US children do not receive preventive care according to professionally recommended standards, particularly dental care. Publicly insured children experience higher rates of recommended well-child visits; however, much improvement is needed among public programs in providing recommended dental care, especially among adolescents and children in poor general health.

Who shall care for the children of the poor and uninsured? Pediatric dentistry in the United States

Although Medicaid was established at least in part to help alleviate dental problems for children of the indigent, the program has not been particularly successful. Some possible solutions to the problem of disparities in access to pediatric dental care are suggested, including access and workforce approaches. Whatever approaches are undertaken, cost-benefit analyses should be done to demonstrate economic value.

Patterns of health insurance coverage among rural and urban children

Despite the potential for the State Children's Health Insurance Program to improve the health care coverage of rural children, the expansion of public health insurance to children in rural areas may be hampered by a lack of understanding about the patterns of insurance coverage they experience. This study uses the Census Bureau's 1993-1996 panel of the Survey of Income and Program Participation to evaluate differences in the duration of, and in their entry into and exit from, uninsured spells. While the average duration of new spells was shorter for rural children and most regained coverage quickly, rural children were also more likely than urban children to experience protracted spells of uninsurance. Moreover, rural children were more likely than urban children to move between public and private coverage. These findings have important implications for designing insurance expansion programs and outreach strategies to effectively enroll and retain rural children.

Racial and ethnic disparities in access to care for children with special health care needs

OBJECTIVE

Numerous studies have examined racial and ethnic differences in access to and utilization of health services. However, few studies have addressed these issues with respect to children with special health care needs. This study examines whether disparities in access and utilization are present among black, white, and Hispanic children identified as having special health care needs.

METHODS

We analyzed data on 57 553 children younger than 18 years old included in the 1994-95 National Health Interview Survey on Disability. Of these, 10 169, or 17.7% of the sample, were identified as having an existing special health care need. Bivariate and multivariate analyses were used to assess how race and ethnicity are related to measures of access and utilization, such as usual source of care, missed care, and use of physician and hospital services.

RESULTS

Our analyses show that among children with special health care needs, minorities were more likely than white children to be without health insurance coverage (13.2% vs 10.3%; P <.01), to be without usual source of care (6.7% vs 4.3%; P <.01), and to report inability to get needed medical care (3.9% vs 2.8%; P <.05). Also, white children with special health care needs were more likely than their minority counterparts to have used physician services (88.6 vs 85.0; P <.01); however, minority children with special health care needs were more likely to have been hospitalized during the past year (7.6% vs 6.3%; P < 0.5). After adjustments for confounding variables (income, insurance coverage, health status, and other variables), racial and ethnic differences in access and utilization were attenuated but remained significant for several measures (without a usual source of care, receipt of care outside of a doctor's office or HMO, no regular clinician, no doctor contacts in past year, and volume of doctor contacts). Gaps in access were more frequent and generally larger for Hispanic children with special health care needs.

CONCLUSIONS

Our analysis indicates that access and utilization disparities remain between white and minority children with special health care needs, with Hispanic children experiencing especially disparate care.

Health insurance and family structure: the case of adolescents in skipped-generation families

Since 1970, both the number and proportion of children being parented by a grandparent without the help of a parent has increased substantially. The increase in skipped-generation households has generated much concern from policy makers because such households are, on average, disadvantaged compared with most other household types. One important challenge facing grandparents with parenting responsibilities is securing health insurance for their dependent grandchildren. In this study, the authors investigate the extent to which grandparents raising their grandchildren were able to secure health insurance for their dependent grandchildren. They find that adolescents living in skipped-generation families in 1995 were more often uninsured, more often publicly insured, and less often privately insured compared with adolescents in other family types. Even after controlling for income, work status, and education, adolescents in skipped-generation families were still more likely to have public insurance and less likely to have private insurance compared with other adolescents.

Children in the Oregon Health Plan: how have they fared?

This study examines the impact of the Oregon Health Plan (OHP) on children's access to care. A telephone survey was conducted in 1998 of two groups of children: OHP enrollees and food stamp recipients not enrolled in OHP. Much of OHP's impact has been realized by the simple extension of health insurance coverage to Oregon's low-income children. The availability of insurance significantly increased the use of physician visits and dental care. The priority list had little effect on children, affecting only 2 percent of OHP children surveyed, most of whom succeeded in getting the service anyway. Thus, despite the negative publicity prior to its implementation, there is no evidence that "rationing" under OHP has substantially restricted access to needed services for children.

Improving childhood asthma outcomes in the United States: a blueprint for policy action

BACKGROUND/OBJECTIVE

Asthma is increasingly being recognized as an important public health concern for children in the United States. Effective management of childhood asthma may require not only improving guideline-based therapeutic interventions, but also addressing social and physical environmental risk factors. The objective of this project was to create a blueprint for improvement of national policy in this area.

DESIGN/METHODS

A nominal group process with nationally recognized experts and leaders (referred to as "the committee") in childhood asthma.

RESULTS

The committee identified 11 policy recommendations (numbered in order below) in 2 broad categories: Improving Health Care Delivery and Financing, and Strengthening the Public Health Infrastructure. Recommendations regarding Improving Health Care Delivery and Financing include the development and implementation of quality-of-care standards in 1) primary care, 2) self-management education, and 3) case-management interventions, and the expansion of insurance coverage and benefit design by 4) extending continuous health insurance coverage for all children, 5) developing model insurance benefits packages for essential childhood asthma services, and 6) educating health care purchasers in how to use them. Recommendations for Strengthening the Public Health Infrastructure include public funding of asthma services that fall outside the insurance system through establishing 7) public health grants to foster asthma-friendly communities and 8) school-based asthma initiatives. 9) Launching a national asthma public education campaign, 10) developing a national asthma surveillance system, and 11) establishing a national agenda for asthma prevention research, with an emphasis on epidemiologic and behavioral sciences, are also recommended.

CONCLUSIONS

Implementing these recommendations will require coordination of activities at the national, state, and local community level, and within and outside the health care delivery system. With a further commitment of national and local resources, implementation of these recommendations will likely lead to improved child and family asthma outcomes in the United States. childhood asthma, health care policy, health care services.