Improving health insurance and access to care for children in immigrant families.

Children in immigrant families now comprise more than one-fifth of all children in the United States. Low-income children in immigrant families, particularly children who are themselves immigrants, are more likely to be uninsured and to have poor access to health care than low-income children from native-born families. Differences in insurance coverage are related to restricted eligibility for public insurance coverage and to limited access to employer-sponsored insurance. The combination of poor insurance coverage, language barriers, and other factors contributes to reduced access to medical care services for immigrant children. This article reviews the literature, examines some common misconceptions regarding immigrants and the nation's health care problems, and describes potential federal, state, and local policies that could improve or weaken children's access to insurance and health care.     

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.     

Comparison of health status of children using a school-based health center for comprehensive care.

OBJECTIVE: Our objective was to compare health problems and medical coverage of homeless and housed children who used a school-based health center (SBHC) for comprehensive care. METHODS: Medical charts of homeless children (n = 76) and housed children (n = 232) seen for comprehensive care at an SBHC in New York City during the 1998-99 school year were systematically reviewed and compared. RESULTS: Controlled for ethnicity and medical coverage, homeless children were 2.5 times as likely (P <.001) to have health problems and 3 times as likely (P <.001) to have severe health problems as housed children. The most common health problems identified in the homeless population were asthma (33%), vision (13%), mental health (9%), and acute problems (8%). Lack of medical coverage was evident in 58% of homeless children, compared with 15% of housed children (P <.001). CONCLUSION: Study findings identify homeless children as being at increased risk for health problems and lack of medical coverage. These findings support use of an SBHC for comprehensive care by underserved segments of the population and a need for increased vigilance on the part of health care providers caring for homeless children.     

Associations between housing instability and food insecurity with health care access in low-income children.

OBJECTIVE: Homelessness and hunger are associated with poor health care access among children. Housing instability and food insecurity represent milder and more prevalent forms of homelessness and hunger. The aim of this study was to determine the association between housing instability and food insecurity with children's health care access and acute health care utilization. METHODS: We conducted a cross-sectional analysis of 12,746 children from low-income households included in the 2002 National Survey of America's Families (NSAF). In multivariate models controlling for important covariates, we measured the association between housing instability and food insecurity with 3 health care access measures: 1) no usual source of care, 2) postponed medical care, and 3) postponed medications. We also measured 3 health care utilization measures: 1) not receiving the recommended number of well-child care visits, 2) increased emergency department visits, and 3) hospitalizations. RESULTS: Our analysis showed that 29.5% of low-income children lived in households with housing instability and 39.0% with food insecurity. In multivariate logistic regression models, housing instability was independently associated with postponed medical care, postponed medications, and increased emergency department visits. Food insecurity was independently associated with no usual source of care, postponed medical care, postponed medications, and not receiving the recommended well-child care visits. CONCLUSION: Families that experience housing instability and food insecurity, without necessarily experiencing homelessness or hunger, have compromised ability to receive adequate health care for their children. Policy makers should consider improving programs that decrease housing instability and food insecurity, and clinicians should consider screening for housing instability and food insecurity so as to provide comprehensive care.     

Health status of children with special health care needs: measurement issues and instruments.

The methods for measuring health care outcomes and monitoring the health status of the child with a chronic health condition must be available, accessible, and meaningful. This review was evoked by this need to identify reliable and valid instruments for measuring the health status of children with special health care needs. The objectives are as follows: (1) to review the methodologic and substantive issues related to the selection of instruments and (2) to identify those instruments available currently for collecting data regarding health status of children with special health care needs. A Medline search of the literature published since 1966 through 1998 and restricted to human subjects and the English language was conducted. Indexing terms included health status, quality of life, outcome assessment, functional status, and patient satisfaction. Multiple reviewers selected instruments based on their usefulness in clinical settings as generic, disease nonspecific, child health status instruments. Few instruments were identified that can be used by pediatricians for tracking and monitoring the health status of children with special health care needs. In conclusion, to progress in the field of outcomes measurement of children with special health care needs, it will be necessary to develop new measurement tools. These instruments must (1) provide valid and reliable information on health status; (2) be useful in guiding the management of patients; and (3) not be a burden for physicians, patients, or patient's families.     

Planning for health promotion in low-income preschool child care settings: focus groups of parents and child care providers.

OBJECTIVE: To identify potentially successful strategies, barriers, and facilitators for health promotion in preschool child care settings. METHODS: We conducted 6 focus groups including each of the following: parents of children attending child care centers and home-based family child care (2 in English, 1 in Spanish) and directors of child care centers and family child care providers (2 in English, 1 in Spanish). Systematic thematic analysis was conducted to generate themes to address study questions. RESULTS: A total of 24 parents and 45 child care providers, serving predominantly urban, low-income children in Boston, participated. Parents and child care providers agreed that in-person group discussions would be the most effective strategy for providing health education information to parents. Several barriers that could affect implementation emerged. First, some providers expressed frustration toward parents' attitudes about child safety and health. Second, there was diversity of opinion among providers on whether conducting health promotion activities was consistent with their training and role. In addition, literacy, language, and cultural barriers were identified as potential barriers to health promotion in child care. CONCLUSIONS: In order to be successful, health promotion strategies in child care settings will need to overcome tensions between providers and parents, allow professional growth of child care providers to serve in a health promotion role, and better integrate external health resources and personnel. Group sessions and peer learning opportunities that are culturally and linguistically sensitive are potentially successful strategies for implementation of health promotion interventions for many parents.     

Well-child care practice redesign for low-income children: the perspectives of health plans, medical groups, and state agencies

ObjectiveThe aim of this study was to examine the views of key stakeholders in health care payer organizations on the use of practice redesign strategies to improve the delivery of well-child care (WCC) to low-income children aged 0 to 3 years.MethodsWe conducted semistructured interviews with 18 key stakeholders (eg, chief medical officers, medical directors) in 11 California health plans and 2 medical group organizations serving low-income children, as well as the 2 state agencies that administer the 2 largest low-income insurance programs for California children. Discussions were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis.ResultsParticipants reported that nonphysicians were underutilized as WCC providers, and group visits and Internet services were likely a more effective way to provide anticipatory guidance and behavioral/developmental services. Participants described barriers to redesign, including the start-up costs required to implement redesign as well as a lack of financial incentives to support innovation in WCC delivery. Participants suggested solutions to these barriers, including using pay-for-performance programs to reward practices that expanded WCC services, and providing practices with start-up grants to implement pilot redesign projects that would eventually become self-sustaining. State-level barriers included poor Medicaid reimbursement rates and disincentives to innovation created by current Healthcare Effectiveness Data and Information Set measures.ConclusionsAll stakeholders will ultimately be needed to support WCC redesign; however, California payers may need to provide logistic, design, and financial support to practices, whereas state agencies may need to reshape the incentives to reward innovation around child preventive health and developmental services.     

Challenges in long-term health care for children.

More children with chronic conditions are surviving than in previous times, and many have serious and significant ongoing health care needs. This paper reviews 1) the population characteristics of children with chronic health conditions in terms of the epidemiology and their sociodemographic profiles; 2) the implications of children's development on their needs, on caretaker roles and responsibilities, on the concept of medical necessity, and on service systems; 3) financing issues and service options for long-term care; and 4) strengths and limitations of existing mechanisms for monitoring the quality of services provided. The following discussion highlights the need for 1) improved data on the numbers of children who need and receive different types of long-term care; 2) better coordination of services and creation of a workable system; 3) a child-specific standard of medical necessity in defining service eligibility; 4) better support systems for families caring for children with long-term needs in non institutional settings; and 5) improved consistency in the mechanisms for financing of care for these children. More attention also should be focused on developing ways of monitoring the quality of long-term care provided. Addressing these needs would go a long way toward improving the quality of long-term care for infants, children, and adolescents.