The impact of realized access to care on health-related quality of life: a two-year prospective cohort study of children in the California State Children's Health Insurance Program

OBJECTIVE: To examine the effect of realized access to care (problems getting care, access to needed care) on health-related quality of life (HRQOL) in the California State Children's Health Insurance Program. STUDY DESIGN: This was a prospective cohort study (n = 4,925; 70.5% [3438] had complete data). Surveys were taken at enrollment and after 1 and 2 years in the program. Parents and children reported HRQOL (PedsQL 4.0 Generic Core Scales). Repeated-measures analysis accounted for within-person correlation and adjusted for baseline PedsQL, baseline realized access, race/ethnicity, language, chronic health condition, and having a regular physician. RESULTS: Realized access to care during the prior year was related to HRQOL for each subsequent year. Foregone care and problems getting care were associated with decrements of 3.5 (P < .001) and 4.5 (P < .001) points for parent proxy-report PedsQL and with decrements of 3.2 (P < .001) and 4.4 (P < .001) points for child self-report PedsQL. Improved realized access resulted in higher PedsQL scores, continued realized access resulted in sustained PedsQL scores, and foregone care resulted in cumulative declines in PedsQL scores. CONCLUSIONS: Realized access to care is associated with statistically significant and clinically meaningful changes in HRQOL in children enrolled in the California State Children's Health Insurance Program.     

Parent caregiver-related predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid.

INTRODUCTION: This study examined the associations between characteristics of the parent caregiver and health care service utilization by children with cerebral palsy enrolled in Medicaid. METHODS: A questionnaire was administered to the parents of children with cerebral palsy being treated in a North Carolina hospital, and the responses were linked with health services claims data from Medicaid. Data were available for 93 patients who maintained 1 year of continuous enrollment. The impact of selected demographic variables (race, years the child had the condition, employment, transportation) and behavioral variables (belief the child was receiving appropriate care, willingness to use home nursing and respite services, self-assessment of the severity of the child's condition, and use of orthopedic aids) on the frequency and costs of health care services was explored with use of multiple regression analysis. RESULTS: Parents who were willing to use home nursing and respite services were more likely to utilize these services, as well as inpatient facilities and orthopedic care, for their children (P <.05). However, parents who perceived that their child was receiving adequate care were less likely to utilize orthopedic care and home nursing for their children (P <.05). DISCUSSION: The belief of the parents in the adequacy of care received by their child, as well as their willingness to utilize supplemental health care services, were major predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid. Parents who believed that their children receive enough care may need to be targeted for care management and disease management programs to ensure the continuum of treatment and care for these children.     

The State Children's Health Insurance Program

PURPOSE OF REVIEW: The State Children's Health Insurance Program expanded public health insurance to children who are ineligible for Medicaid yet unable to afford private health insurance. The program was a natural experiment, offering the opportunity to study the effects of expanding health insurance to a large population of children who would otherwise be uninsured. The State Children's Health Insurance Program is reviewed in the context of program goals, evaluation dimensions, past and current findings, and future directions. The studies and findings fall into five dimensions: (1) outreach/enrollment/uptake and profile of enrollees, (2) impact on insurance coverage and uninsured rates, (3) coverage dynamics, (4) impact on outcomes, and (5) costs. RECENT FINDINGS: Older studies focused on outreach, enrollment, characteristics of enrollees, disenrollment, and coverage dynamics. Current studies report the impact of the program on outcomes--including access to care, quality, satisfaction, unmet need, and health outcomes--for the overall population of children and for vulnerable subgroups, including racial and ethnic minorities and children with chronic illness. A smaller number of studies address costs. SUMMARY: The State Children's Health Insurance Program is evolving with demonstrated successes and areas for improvement. This information can enhance practicing pediatricians' understanding of barriers that face low-income children and families in seeking care for their children, can offer insight into what health insurance can and cannot do in terms of ameliorating those barriers, can provide insight into the prior experiences and current medical needs that a new enrollee in the program might have at the first visit to a practitioner, and can illuminate the challenges that low-income children and families may face in obtaining and maintaining health insurance coverage.     

Parental satisfaction with early pediatric care and immunization of young children: the mediating role of age-appropriate well-child care utilization

OBJECTIVE: To prospectively evaluate the impact of parental satisfaction on childhood immunization and the mediating role of age-appropriate well-child care. DESIGN: Secondary analyses of cohort data from the National Evaluation of Healthy Steps for Young Children. Data sources included an enrollment questionnaire, parent interview at 2 to 4 months, and medical records. SETTING: Twenty-four pediatric practices across the United States. PARTICIPANTS: A total of 4896 (85%) of the initial 5565 enrolled families who were interviewed at 2 to 4 months and had abstracted medical records. MAIN EXPOSURE: Parental satisfaction with overall pediatric care assessed at 2 to 4 months as excellent, good, or fair/poor. MAIN OUTCOME MEASURES: Age-appropriate first dose of diphtheria-tetanus-pertussis; third dose of diphtheria-tetanus-pertussis; and measles, mumps, and rubella vaccinations; and up-to-date vaccinations at 24 months (4 diphtheria-tetanus-pertussis, 3 polio, and 1 measles, mumps, and rubella). RESULTS: The majority of parents were satisfied with their child's health care; only 4% rated overall care as fair or poor. Children whose parents reported fair/poor satisfaction with care had a reduced odds of receiving age-appropriate first dose of diphtheria-tetanus-pertussis vaccination (odds ratio, 0.43; 95% confidence interval, 0.28-0.67); third dose of diphtheria-tetanus-pertussis vaccination (odds ratio, 0.52; 95% confidence interval, 0.36-0.74); and measles, mumps, and rubella vaccination (odds ratio, 0.58; 95% confidence interval, 0.37-0.92); and of being up to date by 24 months (odds ratio, 0.65; 95% confidence interval, 0.43-0.99) compared with children whose parents reported excellent care, independent of sociodemographic and maternal health care utilization variables. The negative effect of fair/poor satisfaction on immunization was largely explained by reduced utilization of age-appropriate well-child care. CONCLUSION: Quality assurance activities that assess parental satisfaction with care may have added value in identifying children who are less likely to receive timely preventive services.     

Reporting on Continuity of Coverage for Children in Medicaid and CHIP: What States Can Learn from Monitoring Continuity and Duration of Coverage

ObjectiveThe Children’s Health Insurance Program Reauthorization Act (CHIPRA) requires states to measure and report on coverage stability in Medicaid and the Children’s Health Insurance Program (CHIP). States generally have not done this in the past. This study proposes strategies for both measuring stability and targeting policies to improve retention of Medicaid coverage, using Ohio as an example.MethodsA cohort of newly enrolled children was constructed for the 1-year time period between July 2007 and June 2008 and followed for 18 months. Hazard ratios were estimated after 18 months to predict the likelihood of maintaining continuous enrollment in Medicaid, adjusting for income eligibility group, age, race, gender, county type, and change in unemployment. Children dropping from the program at the renewal period (12–16 months) were followed for 12 months to determine their rate of return.ResultsApproximately 26% of children aged <1 year and 35% of children aged 1 to 16 years dropped from Medicaid by 18 months, with the steepest drop occurring after 12 months, the point of renewal. Likelihood of dropping was associated with the higher income eligibility groups, older children, and Hispanic ethnicity. Approximately 40% of children who were dropped at renewal re-enrolled within 12 months. Children in the lowest income group returned sooner and in higher proportions than other children.ConclusionsA substantial number of children lose Medicaid coverage only to re-enroll within a short time. Income eligibility group appears to be a strong indicator of stability. Effective monitoring of coverage stability is important for developing policies to increase retention of eligible children.     

Enrollment success in state children's health insurance program after free clinic referral.

INTRODUCTION: More than 11 million children remain uninsured and receive no primary health care despite the advent of the State Children's Health Insurance Program (S-CHIP). The purpose of this pilot study was to evaluate whether each child in a northeast Ohio county free pediatric clinic is referred to S-CHIP and whether the enrollment process is successful. METHOD: A record review was done to evaluate documentation indicating that such a referral was made. A phone call was made to each family for whom there was no evidence of application to S-CHIP. RESULTS: Twenty-eight referrals to Ohio's S-CHIP were documented (60%). Only 12% of families submitted an application to S-CHIP. Ten parents agreed to share their reasons for nonsubmission, the most common reason being that they thought their household income too high, followed by they did not think the program was needed. DISCUSSION: The mere existence of or referral to such a program is not adequate to ensure utilization of health care resources. Recommendations are made to increase enrollment and access to health care for low-income children.     

Access to care for children of the working poor

CONTEXT: Recent evidence suggests that children in working poor families lack health resources, placing them at risk for inadequate access to care. OBJECTIVES: To examine financial and nonfinancial access and utilization of health services among children in working poor families, and to compare these data with those of children from both nonworking poor and moderate to affluent families. DESIGN: A cross-sectional study of 13 785 children younger than 18 years. PARTICIPANTS: Subjects from the 1997 National Health Interview Survey. MAIN OUTCOME MEASURES: Prevalence and continuity of health insurance coverage, of delayed or missed care, and of unmet care needs; presence and type of usual source of care; and the amount of visits to physicians, emergency departments, and hospitals. RESULTS: Compared with children of nonworking poor parents and moderate to affluent children, more working poor children were uninsured (22% vs 12% and 5%, respectively; P<.01) and experienced disruptions in insurance coverage (P<.01). After adjusting for other covariates, disparities in insurance coverage and continuity persisted, as did delays in care and unmet care needs; these delays were far higher for the working poor. Although these children had access to a regular source of care and had utilization rates comparable with those of other poor children, they differed markedly from moderate to affluent children on structural access and utilization (adjusted odds ratios, 1.5-3.4). CONCLUSIONS: Children in working poor families experience far more barriers to care than other children. Health insurance expansions through the Children's Health Insurance Program and Medicaid, which reduce financial and nonfinancial barriers to care, may help correct these disparities.     

Impact of North Carolina's universal vaccine purchase program by children's insurance status.

OBJECTIVE: To examine the impact of a new universal purchase vaccine program on immunization rates of children with different types of insurance. DESIGN: Ecologic study using parent telephone interviews, medical chart abstraction in sites of outpatient care, and insurance verification with Medicaid and private insurers. SETTING: State of North Carolina. PARTICIPANTS: Of a random birth certificate sample of 4385 children born in North Carolina during 1994 and 1995, 507 were excluded. A total of 2767 children had completed parent interviews; 95% of those had medical chart abstraction and insurance data. MAIN OUTCOME MEASURES: Immunization rates at each month during the first 2 years of age, site of delivery for immunizations and well-child visits, and insurance status. RESULTS: In month-by-month comparisons, children born in 1995 had immunization rates 4% to 10% higher than their 1994 counterparts. By 24 months of age, 84% of the 1995 cohort had completed the primary immunization series, compared with 79% of the 1994 cohort (P<.001). In all insurance subgroups, 1995 immunization rates were higher than 1994 rates. The largest increases occurred among privately insured children with no well-child coverage, children who had periods of being uninsured, and children enrolled in Medicaid exclusively or with private insurance. More children in the 1995 cohort received immunizations in the private sector. CONCLUSIONS: Implementation of North Carolina's universal purchase program was associated with improved immunization rates, especially for children with inadequate insurance for well-child care. However, insurance status still influences the ability of children to receive immunizations on schedule.     

Historical overview of children's health care coverage

America's public health insurance programs reflect a deeply rooted commitment to caring for low-income families and children. This article chronicles the evolution of Medicaid and the State Children's Health Insurance Program (SCHIP), two public programs designed to provide free or low-cost health coverage to low-income children who do not have access to private health insurance. Such a historical overview is key to understanding where the programs come from and the challenges that policymakers must grapple with in order to effectively provide health coverage to children. Depression-era maternal and child health programs created the foundation for Medicaid. Expansions of the program during the 1980s and 1990s made Medicaid the largest single insurance provider for children in the United States. In 1997, SCHIP boosted these efforts by filling the gap between Medicaid and employment-based coverage. In addition to expanding coverage, SCHIP also motivated efforts to address obstacles to coverage such as application and enrollment procedures. Together, SCHIP and Medicaid have made significant progress in providing health coverage to children in low-income families. They are the primary sources of coverage for children in low-income families. In a discussion of major challenges to providing public health coverage to children, the authors highlight some important issues that threaten current progress, such as rising health care costs and falling state revenues, gaps in coverage, and remaining barriers to enrollment and retention.     

Why are some children still uninsured?

INTRODUCTION: Nationally, 24% of low-income children remain uninsured after the implementation of the State Children's Health Insurance Program (SCHIP). METHOD: The purpose of this study was to understand why children remain uninsured by comparing children with insurance to those without it. Using a cross-sectional survey design, 392 low-income parents were interviewed. RESULTS: There were distinct profiles for the privately insured, Medicaid-insured and uninsured groups. Statistically significant differences were found across the three groups in income, working status of the adults, education, health status of the adult and child, and in the utilization of health care. Parents of the uninsured children were less knowledgeable about the application process. DISCUSSION: Parents of uninsured children face multiple life challenges that may interfere with the enrollment process. Health problems, work schedules, and lack of knowledge may all need to be addressed before we can decrease the number of uninsured children in our nation.     

New federal policy for children with special health care needs: implications for pediatricians.

Title V of the Social Security Act of 1935 established the nation's first categorical health care program for children: the Crippled Children's Service. In 1985, federal legislation changed the name of the Crippled Children's Service to the Program for Children With Special Health Care Needs. Four years later, new amendments to Title V dramatically altered the Program's mission. States are now required to spend 30% of the funds from the Maternal and Child Health Services block grant on children with special health care needs and to take specific steps toward improving the service system for these children and their families. The new mandate is the only current foundation of a national health policy for children with special health care needs. The 1989 law substantially broadens the mission of the state programs and explicitly recognizes that all children with a special health care need should have access to an appropriate, community-based system of care monitored by state Children with Special Health Care Needs agencies. In addition, states are now required to conduct needs assessments pertaining to these children, to foster local systems of care, and to ensure a high quality of community-based services. Understanding the implications of the new amendments is essential because pediatricians and other child health care professionals have key roles to play in implementing these new policies.     

Which children are still uninsured and why

A strong economy and increased enrollment in employer-sponsored health insurance coverage, together with expansions in Medicaid and State Children's Health Insurance Program (SCHIP) led to reductions in uninsurance among low-income American children between 1998 and 2000 (from 15.6% to 13.3%). Nonetheless, 12% (about 9 million) of children remained uninsured. Identifying these children and understanding the factors that contribute to their continued lack of health coverage is key to providing them access to health care. Using 1994, 1998, and 2000 census data, this article analyzes recent trends in children's health coverage, as well as the groups that make up the population of uninsured children. The picture that emerges from these analyses is one of tremendous variation in coverage for different groups of children, with some groups having a higher risk for lacking health insurance. For example, poor children, Hispanics, adolescents, and children with foreign-born parents (particularly those whose parents are not U.S. citizens) are overrepresented among the uninsured. The authors conclude that the strong economy and concomitant increase in employer-based coverage played a bigger part in reducing uninsurance rates than did expansions in public programs. They also argue that lack of participation by eligible children rather than inadequate eligibility levels is the key policy issue, and conclude with several recommendations to increase program participation.     

Parents with low literacy report higher quality of parent-provider relationships in a residency clinic.

OBJECTIVE: Quality of care in pediatrics is suboptimal for many children from families of low socioeconomic status. Literacy is one aspect of socioeconomic status. We hypothesized that low parental literacy would be associated with low-quality well-child care. METHODS: We performed a cross-sectional study of caregivers of 1- to 4- year-old children in a pediatric resident clinic. To assess parental literacy, we used the Rapid Estimate of Adult Literacy in Medicine. To assess the quality of well-child care, we used 5 subscales from the Promoting Healthy Development Survey relevant to either provider-parent relationships or content of discussions in the well-child visit. RESULTS: We enrolled 157 caregivers. The mean age of the respondents was 30 years, 55% were African American, 69% received Medicaid, and 85% had graduated high school. A total of 34% of the respondents scored below a ninth-grade reading level (low literacy). Parents with low literacy were more likely than those with higher literacy to report Family-centered care (79% vs 61%, P = .03), and Helpfulness and Confidence building (79% vs 57%, P = .01). There was no difference, by literacy level, in the percentage of parents who reported reaching established threshold levels for discussion of Psychosocial issues, Safety issues, or Anticipatory guidance topics. CONCLUSIONS: The lower-literacy respondents reported higher-quality parent-provider relationships; there was no difference in quality of content of discussions by literacy level. Parents with low literacy may have lower expectations regarding relationships with their health care provider or may be less likely to be critical. Alternatively, pediatric residents may be more effective at relationship building with low-literacy families.     

Changes in continuity of enrollment among high-risk children following implementation of TennCare.

BACKGROUND: TennCare, Tennessee's Medicaid managed care program, was introduced in 1994 with the goals of controlling spending and of improving access to health care. OBJECTIVE: To assess changes in the continuity of enrollment following the implementation of TennCare for 2 groups: infants in the first year of life (defined as persons aged 0-12 months in this study) and children hospitalized with a chronic health condition (defined as persons aged 0-18 years in this study). DESIGN: Retrospective cohort analysis. SETTING AND POPULATION: Infants born during 1992 or 1995 to women enrolled in Medicaid or TennCare and 0- to 18-year-old children enrolled in Medicaid or TennCare who were discharged from a hospital during 1992 or 1995 with a chronic health condition. MAIN OUTCOME MEASURES: For infants, failure to enroll an infant in the first 30 days of life or subsequent gaps in enrollment for 7 days or longer during the first year of life. For children hospitalized with a chronic health condition, any gap in enrollment lasting 7 days or longer by 1 year after discharge from a hospital. RESULTS: There was a reduction in the proportion of infants without continuous enrollment in the first year of life following TennCare (19.4% after vs 25.1% before TennCare; odds ratio, 0.69; 95% confidence interval, 0.67-0.72). Improvements in continuity of enrollment for infants occurred despite an increase in the proportion of infants who were not enrolled in TennCare in the first 30 days of life, even though their mother was enrolled at delivery (14.0% after vs 8.0% before TennCare; odds ratio, 1.86; 95% confidence interval, 1.78-1.96). There was a decrease in the proportion of children hospitalized with a chronic health condition who had subsequent gaps in enrollment by 1 year following discharge from a hospital (14.3% after vs 23.3% before TennCare; odds ratio, 0.52; 95% confidence interval, 0.46-0.59). CONCLUSION: For infants in the first year of life and for children hospitalized with a chronic health condition, implementation of TennCare improved continuity of coverage.     

Unmet mental health need and access to services for children with special health care needs and their families.

OBJECTIVES: Studies suggest that children with disabilities or serious health conditions are vulnerable to mental health problems due to adjustment and limitation problems. The aim of this study was to examine rates and predictors of unmet mental health need among children with special health care needs (CSHCN) and their family members and to determine if race/ethnicity and language are associated with unmet need for the child and family members who have a mental health need attributed to the child's special needs. METHODS: Data are from the 2001 National Survey of Children with Special Health Care Needs, a nationally representative sample of CSHCN. RESULTS: Rates of unmet need were higher for CSHCN and family members of CSHCN with a chronic emotional, behavioral, or developmental problem (EBDP) compared to CSHCN with a mental health need but not a chronic EBDP. In multivariate analysis controlling for condition impact and demographics, among CSHCN with a chronic EBDP, African-American children had greater odds of unmet need (OR 1.60, 95% CI, 1.12-2.28), and family members of Hispanic children with a Spanish language parent interview had greater odds of unmet need compared to others (OR 4.48, 95% CI, 1.72-11.63). Lacking a personal doctor or nurse was associated with higher odds of unmet need for CSHCN with and without a chronic EBDP. CONCLUSION: Parents reported prevalent mental health needs of CSHCN as well as family members. Given the importance of family members to the care of CSHCN, research on racial/ethnic disparities in access to perceived needs should focus on children and their family members.     

Well-child care: effectiveness of current recommendations

Well-child care is the main source of preventive health care for children in the United States. Repeated examinations of healthy children during health supervision visits are used to assess biomedical health, development, behavior, and family functioning. In addition, well-child care serves to provide parent education through age appropriate counseling referred to as anticipatory guidance. Recommendations for well-child care are found in the Health Supervision Guidelines III, published by American Academy of Pediatrics, last revised in 1993, and a publication from the National Center for Education in Maternal and Child Health, The Bright Futures, Guidelines for Health Supervision of Infants, Children and Adolescents, revised in 2000. This article reviews the evidence for the effectiveness of the current recommendation for well-child care including the recommendations for the number of visits, history and physical examination as a screening technique, observation of parent-child interaction, and the recommendation for provision of anticipatory guidance. This article also summarizes the recent advances in well-child care and identifies an agenda for future research.     

A health plan to reduce poverty

Noting that the failures of the U.S. health care system are compounding the problems faced by low-income Americans, Alan Weil argues that any strategy to reduce poverty must provide access to health care for all low-income families. Although nearly all children in families with incomes under 200 percent of poverty are eligible for either Medicaid or the State Children's Health Insurance Program (SCHIP), the parents of poor children often lack health insurance. Parents who leave welfare normally get a year of coverage but then lose coverage unless their employer provides it, and many employers of low-wage workers do not offer health insurance. Similarly, parents who take low-paying jobs to avoid welfare usually have no coverage at all. This lack of coverage discourages adults from working and may also affect the health of children because adults without health insurance are less likely to take their children for preventive care. Weil proposes creating a federal earned income health credit (EIHC) and redefining the federal floor of coverage through Medicaid and SCHIP. His aim is to make health insurance affordable for low-income families and to make sure enough options are available that individuals and families can get coverage using a combination of their own, their employer's, and public resources. Weil would expand Medicaid eligibility to include all families whose income falls below the poverty line. The EIHC would be a refundable tax credit that would be available to parents during the year in advance of filing a tax return. The credit, which would be based on taxpayer earnings and family structure, would phase in as earnings increase, reach a plateau, and then phase out farther up the income scale. The credit would be larger for families with dependents. The EIHC would function seamlessly with the employee payroll withholding system. It would be available only to adults who demonstrate that they had health insurance coverage during the year and, for adults with children, only if their eligible dependent children were enrolled in either a private or public insurance program. Weil's proposal would cover individuals who receive coverage from their employer and those who do not. The proposal smooths transitions from public to private coverage, and it anticipates a substantial role for states. Weil estimates that his policy would cost about $45 billion a year.