oversight

Health Insurance: Coverage Leads to Increased Health Care Access for Children

Published by the Government Accountability Office on 1997-11-24.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Honorable
                 John F. Kerry, U.S. Senate



November 1997
                 HEALTH INSURANCE
                 Coverage Leads to
                 Increased Health Care
                 Access for Children




GAO/HEHS-98-14
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division

      B-278038

      November 24, 1997

      The Honorable John F. Kerry
      United States Senate

      Dear Senator Kerry:

      The number of children who lack health insurance has increased since the
      late 1980s, so that, in 1996, nearly 10.6 million children were uninsured.
      Many experts believe that the lack of health insurance discourages
      families from seeking preventive and other needed care for their children.
      However, some question the extent to which children need coverage and
      whether an expansion of coverage would appreciably affect children’s
      access to health care. In response to concerns about the millions of
      uninsured children, the Congress has allotted, through the Balanced
      Budget Act (P.L. 105-33), almost $40 billion over the next 10 years to help
      states expand insurance coverage to more children, through either
      Medicaid or other health plans.1 Now states are considering how much of
      their funding they will contribute to match this federal investment in
      children’s health care and how they can best implement an expansion of
      coverage.

      In light of these events, you asked us to determine what effect health
      insurance has on children’s access to health care, whether expanding
      publicly funded insurance improves their access, and what barriers
      besides lack of insurance might deter children from getting health care. As
      we agreed with your office, we analyzed evaluations published during the
      past 10 years on the relationship between health insurance and health care
      access.

      The evaluations and our analysis of them have several limitations. Access
      is the ability to obtain preventive or acute care and cannot be measured
      directly. Therefore, most studies measure access in one of several
      ways—by how families adhere to a recommended schedule for preventive
      care, whether they can identify a source of care, their use of health care,
      or their self-reported access problems. Looking at use cannot by itself
      distinguish appropriate from inappropriate use. Therefore, some
      researchers have analyzed specific types of use by recommended


      1
       The Congressional Budget Office (CBO) estimates that other changes in the law, such as the new
      programs attracting currently eligible children to enroll in Medicaid and allowing states the option of
      considering children presumptively eligible for Medicaid, will result in additional federal Medicaid
      spending on children of $6.5 billion in the same decade.



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                   schedules, such as children’s making at least one visit to a physician every
                   year.

                   In addition, while insurance may influence children’s access to care, a
                   number of other factors, such as their family income or their ethnicity,
                   also influence their health care use. We focused on studies that attempted
                   to control for such factors. Because we reviewed articles published over
                   the past 10 years, generally based on analyses of large national surveys,
                   most of the studies analyzed data collected in the late 1980s. However, the
                   similarity of findings from analyses of surveys done at different times
                   suggests that findings from earlier surveys still apply. Finally, we did not
                   validate the results from any of the studies that we cite. We did our work
                   between June and October 1997 in accordance with generally accepted
                   government auditing standards.


                   Health insurance increased children’s access to health care services in
Results in Brief   almost all the studies we analyzed.2 Most of the evaluations showed that
                   insured children were more likely to have preventive and primary care
                   than uninsured children. Insured children were also more likely to have a
                   relationship with a primary care physician and to receive required
                   preventive services, like well-child checkups, than uninsured children.
                   Differences in access between insured and uninsured children held true
                   even for children who had chronic conditions and special health care
                   needs. When ill, insured children were more likely to receive a physician’s
                   care for their health problems, such as asthma or acute earache.

                   In contrast, lack of insurance can inhibit parents from trying to get health
                   care for their children and can lead providers to offer less-intensive
                   services when families seek care. Several studies found evidence that
                   low-income and uninsured children were more likely to be hospitalized for
                   conditions that could have been managed with appropriate outpatient
                   care. Two studies found that uninsured children sometimes received
                   less-intensive hospital care than insured children. While health insurance
                   benefits differed and some excluded coverage for some basic health care
                   needs, increasing the number of insured children increased the likelihood
                   that more children would receive care.

                   Although health insurance can considerably increase access, it does not
                   guarantee entry into the health care system. Low family income and

                   2
                    Health insurance includes both private and publicly funded health insurance. Much of the research
                   reported here compared uninsured children to those who had health insurance (public and private
                   combined). Where researchers made other comparisons, we have noted this in the text.



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             education levels, limited availability of neighborhood primary health care
             facilities, lack of transportation, and language differences are among the
             barriers to obtaining and appropriately using health care services. Both
             children who have no health insurance and those who have Medicaid
             coverage are more likely than privately insured children to face such
             barriers. To ensure access to high-quality care, public health and clinical
             experts recommend that children have a stable source of health insurance
             benefits that cover their health care needs, a relationship with a primary
             care provider that helps them obtain more complex care as needed,
             primary care facilities that are conveniently situated, and outreach and
             education for their families.


             In 1996, only 66 percent of U.S. children younger than 18—47 million—
Background   were covered by private health insurance.3 Most private insurance for
             children is acquired through a parent’s employer. However, in 1993, almost
             one-fourth of the workforce worked for an employer that did not cover
             dependents.4 In addition, even if employers offer coverage, the amount
             that employees have to pay toward it for their families may make health
             insurance unaffordable. Since the late 1980s, workers’ costs for family
             coverage have risen sharply.5 Increases in insurance costs may affect
             children disproportionately, since the 71 million children younger than 18
             represent 27 percent of the U.S. population but 42 percent of the poor.
             Even if children have insurance, their coverage—and their relationship
             with their providers—may be disrupted if their parents lose their jobs or
             change jobs frequently.

             Public health insurance for children is generally provided through the
             Medicaid program. Currently about 15.5 million (22 percent) of children
             younger than 18 are covered through Medicaid. The majority of
             low-income children (65 percent) in Medicaid have a working parent and,
             of those that do, about half have a parent working full time. To remain in
             Medicaid, families generally have their eligibility redetermined at least
             every 6 months. If family income or other circumstances change, children

             3
              Children’s Health Insurance, 1995 (GAO/HEHS-97-68R, Feb. 19, 1997.)
             4
              This includes both employees who work for employers that offer no coverage at all and those who
             offer employee-only coverage. A Census survey asked employees if their employers had a health
             insurance plan, so that among those who answered yes, there are probably employees who either were
             not eligible to enroll in their employer’s plan or chose not to participate. See Employee Benefit
             Research Institute, Employment-Based Health Benefits: Analysis of the April 1993 Current Population
             Survey, Special Report SR-24 and Issue Brief 152 (Washington, D.C.: 1994).
             5
              Employment-Based Health Insurance: Costs Increase and Family Coverage Decreases
             (GAO/HEHS-97-35, Feb. 24, 1997.)



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                             may go in and out of the Medicaid program during a year, disrupting their
                             coverage. This can delay needed care, which can have long-term health
                             consequences.

                             Children are uninsured when they have neither public nor private
                             coverage. In 1996, 10.6 million children (14.8 percent) were uninsured,
                             living generally in lower-income working families. Compared with
                             privately insured children, a higher proportion of their parents worked for
                             small employers—the group least likely to offer health insurance. In 1993,
                             only a quarter of employees in firms with fewer than 10 employees and
                             about half in firms with 10 to 24 employees reported that their employer
                             offered a health insurance plan for workers and their dependents,
                             compared with 89 percent in firms with 1,000 or more employees.


                             Health insurance does not always cover the preventive care, such as
Health Insurance             immunizations, that children need to develop optimally. Nevertheless,
Increases Children’s         most of the studies we analyzed used many different measures of access
Access to Preventive,        and found that insured children were more likely to have access to both
                             preventive and acute or chronic health care. Children who were insured
Primary, Acute, and          were more likely to be connected to the health care system through a
Hospital Care                physician. Having a primary care connection made it easier for children to
                             get regular preventive care, acute care when ill, and more complex care as
                             needed. Uninsured and lower-income children were more likely to be
                             hospitalized for conditions that could have been treated through primary
                             care.


Health Insurance Increases   Most of the studies we reviewed showed that children who had health
Children’s Access to         insurance had better access to preventive and primary health care than
Preventive and Primary       uninsured children. (See table 1.) They were more likely to have a primary
                             care provider, which increased their access to both routine and more
Care                         complex care. Children who had private health insurance were also more
                             likely than children who had no insurance to get medical care from one
                             source, and that source was more likely to be in a physician’s office. In
                             addition, they were more likely to have seen a doctor recently and to have
                             been up to date with their well-child care.




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Table 1: Primary Care Access for
Uninsured Children: Statistically    Compared with insured children,
Significant Measures Identified in   uninsured children were less likely                Study
Recent Studies                       In access to and continuity of care
                                     To have continuity between well or routine         Halfon and others, 1997a
                                     and sick care                                      Holl and others, 1995
                                     To have a usual source of care                     Newacheck, Hughes, and Stoddard, 1996b
                                                                                        Smith and others, 1996c
                                                                                        Holl and others, 1995
                                                                                        Lieu, Newacheck, and McManus, 1993d,e
                                     To see a specific physician                        Newacheck, Hughes, and Stoddard, 1996b
                                     To have a source of after-hours emergency          Newacheck, Hughes, and Stoddard, 1996b
                                     care
                                     To travel less than 30 minutes to receive care Newacheck, Hughes, and Stoddard, 1996b
                                     To wait less than 1 hour to see a provider         Newacheck, Hughes, and Stoddard, 1996b
                                     To see a physician for selected symptoms           Newacheck, Hughes, and Stoddard, 1996b
                                     To have the usual source of care in a              Holl and others, 1995
                                     physician’s office (and not in a clinic or
                                     health center)
                                     To receive care from a single site                 Kogan and others, 1995f
                                     In receipt of care
                                     To have made a visit to a physician in the         Halfon and others, 1997a
                                     past year, avoiding physician care for
                                     financial reasonsg
                                     To have had a visit to a physician in the past Holl and others, 1995
                                     year                                           Lieu, Newacheck, and McManus, 1993d
                                                                                    Newacheck and others, 1992
                                     To have had a routine checkup in the past          Ettner, 1996
                                     year
                                     To have had dental care in the past year           Smith and others, 1996g
                                     To ever have had routine care                      Holl and others, 1995
                                     To be up to date with well-child care              Holl and others, 1995
                                                                                        Lieu, Newacheck, and McManus, 1993d,h
                                     To have a nonemergency ambulatory care             Spillman, 1992i
                                     visit

                                                                                                          (Table notes on next page)




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Notes: Full study citations are in the bibliography. All differences reported in this table between
uninsured and insured children were statistically significant at the 0.05 level. Some were
significant at the .01 or .001 level.
a
 Limited to Los Angeles inner-city Latino children aged 12 to 36 months in 1992. Regression
compared privately insured children with uninsured children, children with continuous Medicaid
enrollment, and children with intermittent Medicaid enrollment.
b
 Compared uninsured poor and minority children with children from white, nonpoor, and insured
families.
c
 Limited to children aged 1 to 12 years in McFarland County, California. Regression compared
privately insured with uninsured children and publicly insured children separately.
d
    Study on adolescents.
e
 Differences significant for white and Hispanic adolescents but not significant for black
adolescents at the 0.05 level, although the differences were significant at the 0.10 level.
f
 Study on children aged 3 years, comparing children with gaps in insurance covered with the
continuously insured.
g
 Study subpopulation limited to children aged 5 to 12 years in McFarland County, California.
Regression compared privately insured with uninsured children and publicly insured children
separately.
h
 Minority uninsured adolescents were significantly less likely to be up to date with well-child care
than minority insured adolescents, but the differences were not statistically significant for white
adolescents.
i
Compared children continuously insured with private insurance for both hospital and outpatient
services with children continuously uninsured over the course of a year.



A child’s having a usual source of care increases the likelihood he or she
will receive preventive or acute health care. One research study based on
nationally representative data found that 20 percent of all uninsured
children lacked a usual source of care, compared with 7 percent of
insured, white, nonpoor children.6 Using regression analysis to isolate the
effect of insurance from race, income, and ethnicity, this study found that
uninsured children were twice as likely to lack a usual source of care as
insured children.7 Uninsured children were also more likely to lack
after-hours care and to spend more time traveling and more time waiting
to receive care. Similarly, another study found that 33 percent of
uninsured children did not go to a physician’s office for their routine care,
compared with 14 percent of insured children (insured privately or
through Medicaid). Controlling for factors other than insurance, the study


6
 Having a usual source of care can mean using the emergency room or a public clinic where children
do not consistently see the same provider.
7
 P. W. Newacheck, D. C. Hughes, and J. J. Stoddard, “Children’s Access to Primary Care: Differences
by Race, Income, and Insurance Status,” Pediatrics, Vol. 97, No. 1 (1996), pp. 26-32.



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found that uninsured children were more than twice as likely as insured
children to get care in places other than a physician’s office.8

Generally, lower-income children (whether uninsured or receiving public
insurance) are less likely to go to a physician’s office for their care. The
National Center for Health Statistics (NCHS) found that 94 percent of U.S.
children—more than 65 million—had a usual source of care in 1993. Of
these, 94 percent of privately insured children, 62 percent of publicly
insured children, and 74 percent of uninsured children used a doctor’s
office as their usual source of care. Conversely, 5 percent of privately
insured children, 30 percent of publicly insured children, and 20 percent of
uninsured children used a clinic as their regular source of care.9

Most experts believe that preschool children need regular visits to
physicians to stay current in their immunizations and to be screened for
health problems, but researchers found access problems for preschool
children. About one-quarter of U.S. 3-year-olds born in 1988 had a gap in
their health insurance coverage of at least 1 month, and almost 15 percent
had a gap of 7 months or more or had never been covered. Preschool
children who had gaps in coverage were more likely to have gone to
multiple sites for care than children who had continuous insurance
coverage, suggesting that the care they received was more likely to be
sporadic and fragmented. Just over 40 percent of preschool children went
to two or more sites of care (not counting emergency care). However,
controlling for other factors affecting access, preschool children who had
a gap in coverage of more than 6 months were 74 percent more likely to
have gone to more than one site for care.10 Disruption of insurance
coverage seems to be the salient factor because children who had no
insurance were no more likely than insured children to have gone to
multiple sites of care.

Experts have stated that adolescents can benefit from the guidance of a
trusted health provider to help them through a period when their bodies
are changing and they may be tempted to take risks, such as having

8
J. L. Holl and others, “Profile of Uninsured Children in the United States,” Archives of Pediatric and
Adolescent Medicine, Vol. 149 (Apr. 1995), pp. 398-406.
9
 “Clinic” includes a company or school health clinic or center; community, migrant, or rural clinic or
center; county, city, or public county hospital outpatient clinic; and private or other hospital outpatient
clinic. These are percentage estimates that are not adjusted for multiple factors that influence choice
of care site. See Gloria Simpson and others, “Access to Health Care Part 1: Children,” Vital and Health
Statistics, Series 10, No. 196 (Hyattsville, Md.: U.S. Department of Health and Human Services, 1997).
10
 Michael D. Kogan and others, “The Effect of Gaps in Health Insurance on Continuity of a Regular
Source of Care Among Preschool-aged Children in the United States,” Journal of the American Medical
Association, Vol. 274, No. 18 (1995), pp. 1429-35.



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                                      unprotected sex or using drugs, alcohol, or tobacco products. Yet
                                      uninsured adolescents also have access problems. Researchers found that
                                      adolescents who were not insured were less likely to have a usual source
                                      of care and regular provider.11 (See fig. 1.)


Figure 1: Percentage of Adolescents
Who Had a Usual Source of Care by
Insurance Status and Race or          Percentage
Ethnicity, 1988                       100
                                                                  91                                92
                                                                                                                                       87
                                                     82                               84
                                       80

                                                                                                                       66

                                       60



                                       40



                                       20



                                           0
                                                          White                            Black                            Hispanic

                                                                                  Uninsured        Insured

                                      Source: T. A. Lieu, P. W. Newacheck, and M. A. McManus, “Race, Ethnicity, and Access to
                                      Ambulatory Care among U.S. Adolescents,” American Journal of Public Health, Vol. 83, No. 7
                                      (1993), pp. 960-65.




Better Access to Primary              Better access to primary care is important, because primary care is a
Care Leads to Better                  gateway to better preventive care and needed specialized services. A
Linkage to Complex Care               number of studies found that uninsured children had fewer health care
                                      and dental visits and fewer preventive visits. Compared with the parents of
and More Adequate                     low-income children who had public insurance like Medicaid, parents of
Preventive Care                       uninsured children of all income levels were more likely to defer bringing
                                      them into care for financial reasons.

                                      Having a primary care provider has been shown to improve care by
                                      facilitating the timely receipt of complex care. One study showed that

                                      11
                                       T. A. Lieu, P. W. Newacheck, and M. A. McManus, “Race, Ethnicity, and Access to Ambulatory Care
                                      Among U.S. Adolescents,” American Journal of Public Health, Vol. 83, No. 7 (1993), pp. 960-65.



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children in Medicaid or who had no insurance were much less likely to
have contacted a primary care physician before they came to the hospital
with appendicitis. Children whose families did not contact a primary care
physician before hospital admission were operated on less quickly if they
were admitted on weekends and were more likely to have a perforated
appendix. Contact with a primary care provider, not insurance status, was
the key to differing rates of this complication, but having private insurance
did increase the likelihood that a child would have a relationship with a
primary care physician.12

Six studies that controlled for other factors affecting access found that
uninsured children were less likely to receive routine checkups, dental
care, or any kind of doctor’s visit. Some of them compared routine visits
made with the number of visits recommended by the American Academy
of Pediatrics (AAP) (see table 2) and found that uninsured children were
less likely to meet such standards.




12
  V. T. Chande and J. M. Kinnane, “Role of the Primary Care Provider in Expediting Care of Children
With Acute Appendicitis,” Archives of Pediatric and Adolescent Medicine, Vol. 150, No. 7 (1996), pp.
703-6. Having a usual source of care may have been more important for some kinds of care than
others. It increased routine checkups and well care for women in one study but did not significantly
increase well child care for children—see Susan Louise Ettner, “The Timing of Preventive Services for
Women and Children: The Effect of Having a Usual Source of Care,” American Journal of Public
Health, Vol. 86, No. 12 (1996), pp. 1748-54.



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Table 2: AAP’s Recommended
Schedule of Preventive Well-Child   Age                                  Type of care
Visits, 1995                        In hospital after birth              Basic well-child visit (newborn assessment),a immunization
                                    Within first week of life            Basic well-child visita
                                    By 1 month                           Basic well-child visita and heredity and metabolic
                                                                         screening tests (if not done before)
                                    2 months                             Basic well-child visit,a immunization
                                    4 months                             Basic well-child visit,a immunization
                                    6 months                             Basic well-child visit,a immunization
                                    9 months                             Basic well-child visit,a hematocrit or hemoglobin (if not
                                                                         done before), lead screening
                                    12 months                            Basic well-child visita
                                    15 months                            Basic well-child visit,a immunization
                                    18 months                            Basic well-child visita
                                    Yearly visits between 2 and 6 Basic well-child visit,a immunization (at 4, 5, or 6), initial
                                    years                         dental referral (by 3), lead screening (2), urinalysis (5)
                                    8 years                              Basic well-child visita
                                    10 years                             Basic well-child visita
                                    Yearly visits between 11 and         Basic well-child visit,a immunization (as needed, 11
                                    21 years                             through 16), hematocrit or hemoglobin (as needed),
                                                                         urinalysis (as needed)
                                    a
                                     Basic well-child visits include health history, weight and height measurement, developmental
                                    and behavioral assessment, physical exam, and anticipatory guidance that includes counseling
                                    and discussion of topics for the developing child, with specific discussion of injury prevention.
                                    Through 24 months of age, all visits should include measurement of head circumference. Starting
                                    at age 3, all visits should also include a blood pressure check.

                                    Source: American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine,
                                    “Recommendations for Preventive Pediatric Health Care,” Pediatrics, Vol. 96 (1995), pp. 373-74.



                                    For example, one study found that 30 percent of uninsured children were
                                    not up to date with well-child care visits, as AAP recommends, compared
                                    with 22 percent of insured children. Compared with insured children, and
                                    controlling for other factors that affect access, uninsured children were
                                    50-percent more likely not to have made any visits to a physician in the
                                    past year and almost twice as likely never to have had routine care.13 In a
                                    local California study, lack of insurance was the strongest predictor that
                                    children older than 5 had not seen a dentist in the past year, compared
                                    with privately insured children.14



                                    13
                                      Holl and others, “Profile of Uninsured Children in the United States.”
                                    14
                                     M. W. Smith and others, “How Economic Demand Influences Access to Medical Care for Rural
                                    Hispanic Children,” Medical Care, Vol. 34, No. 11 (1996), pp. 1135-48.



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                                      Uninsured children were less likely to have received care when it was not
                                      an emergency. An analysis of the 1980 National Medical Care Utilization
                                      and Expenditure Survey, after adjusting for other factors affecting access,
                                      found that uninsured children had a 69-percent likelihood that they would
                                      use nonemergency ambulatory care during the year, compared with
                                      81 percent for privately insured children. The uninsured children who had
                                      used health services had made fewer nonemergency ambulatory visits,
                                      compared with privately insured children.15 (See fig. 2.) Similarly, an
                                      analysis of a more recent survey also showed that being uninsured was a
                                      significant predictor of not using a physician’s services.16


Figure 2: Average Number of Annual
Nonemergency Ambulatory Care Visits   Average Number
Among Insured and Uninsured
                                      5
Children Who Used Services, 1980
                                                                4.5


                                      4                                                        3.8



                                      3




                                      2




                                      1




                                      0
                                                              Insured                       Uninsured



                                      Source: Brenda C. Spillman, “The Impact of Being Uninsured on Utilization of Basic Health Care
                                      Services,” Inquiry, Vol. 29 (winter 1992), pp. 457-66.




                                      15
                                        Brenda C. Spillman, “The Impact of Being Uninsured on Utilization of Basic Health Care Services,”
                                      Inquiry, Vol. 29 (winter 1992), pp. 457-66.
                                      16
                                       P. W. Newacheck, “Characteristics of Children with High and Low Usage of Physician Services,”
                                      Medical Care, Vol. 30, No. 1 (1992), pp. 30-42.



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Uninsured Children       Several studies found that uninsured children were not getting care for
Receive Less Care When   conditions that could be serious. Children who had no insurance had
Injured or Ill           lower rates of treatment for injuries, including serious injuries such as
                         broken bones or cuts requiring stitches, compared with children who had
                         private insurance, and were less likely to get care when sick. Sometimes
                         they received care later, after they had become sicker.

                         Childhood injuries were fairly common, but insurance status affected a
                         child’s chances of being medically treated for an injury. In 1988, children
                         younger than 18 had total injury rates of 16.3 per 100. Serious injuries that
                         resulted in restricted activity, bed days, surgery, hospitalization, or
                         substantial pain represented about half of total injuries. A study that
                         compared injury treatment for insured children (private insurance and
                         Medicaid combined) and uninsured children found that the uninsured
                         were less likely to be brought in for the treatment of injuries. The study’s
                         researchers estimated that for children who had no coverage in 1988, the
                         year of the study, between 20 and 30 percent of total injuries may not have
                         been examined and treated by a health professional. At least 40 percent of
                         serious injuries to uninsured children younger than 11 might not have been
                         examined and treated.

                         These researchers also found that Medicaid-insured children had
                         treatment rates similar to privately insured children, suggesting that public
                         insurance helped ensure that children would receive treatment for
                         injuries.17 Their finding that families that had Medicaid coverage for their
                         children would seek health care for them, while families of uninsured
                         children would not, is consistent with the findings from the Rand Health
                         Insurance Experiment that families of poor children in cost-sharing plans
                         were less likely to seek care for diagnoses related to trauma or accidents
                         than families of poor children with free care.

                         Uninsured children were less likely to receive treatment for some of the
                         common illnesses of childhood. Uninsured children were about twice as
                         likely to have received no care from a physician for pharyngitis, acute




                         17
                           Mary D. Overpeck and Jonathan B. Kotch, “The Effect of U. S. Children’s Access to Care on Medical
                         Attention for Injuries,” American Journal of Public Health, Vol. 85, No. 3 (1995), pp. 402-4. Serious
                         injuries were defined as those for which the child (1) had to stay in bed for more than half a day;
                         (2) had any limitations or was prevented from usual childhood activities; (3) spent 1 or more nights in
                         the hospital; (4) had surgery, including setting bones or sewing stitches; (5) had pain often or all the
                         time; or (6) was bothered more than a little.



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                                                   earache, recurrent ear infections, and asthma.18 (See fig. 3.) These are
                                                   common conditions—with an incidence rate of 8 to 10 per 100
                                                   children—for which medical care is considered necessary.19 They can also
                                                   have serious consequences for some children if they are left untreated. For
                                                   example, pharyngitis, if caused by untreated group A streptococci, can
                                                   lead to rheumatic fever. Untreated middle-ear infections can lead to
                                                   long-term hearing loss and sometimes to related speech and language
                                                   difficulties. Severe asthma can cause respiratory failure and death.



Figure 3: The Likelihood That Uninsured and Insured Children Received Medical Care When Ill, 1987


Relative Likelihood (Odds Ratio)
3




2




1




0
          Pharyngitis              Acute Earache        Recurring Ear Infection           Asthma


                                           Insured     Uninsured
                                                  Source: Jeffrey J. Stoddard, Robert F. St. Peter, and Paul W. Newacheck, “Health Insurance
                                                  Status and Ambulatory Care for Children,” New England Journal of Medicine, Vol. 330, No. 20
                                                  (1994), pp. 1421-25.




                                                   18
                                                     Overpeck and Kotch’s definitions for these conditions were pharyngitis, or sore throat with high
                                                   fever or tonsillitis for at least 2 days during the past 30 days; acute earache, or ear infection or earache
                                                   for at least 2 of the past 30 days; recurrent ear infections, or more than 2 ear infections within the past
                                                   12 months; and asthma, or asthma or wheezing within the past 12 months.
                                                   19
                                                    Jeffrey J. Stoddard, Robert F. St. Peter, and Paul W. Newacheck, “Health Insurance Status and
                                                   Ambulatory Care for Children,” New England Journal of Medicine, Vol. 330, No. 20 (1994), pp. 1421-25.


                                                   Page 13                                         GAO/HEHS-98-14 Insurance and Health Care Access
                         B-278038




                         Looking at more rare conditions, one study examined severity of illness
                         when privately insured and underinsured children were diagnosed with
                         inflammatory bowel diseases.20 Inflammatory bowel diseases (Crohn’s
                         disease and ulcerative colitis) can result in absence from school,
                         progressive malnutrition, weight loss, anemia, depression, and fatigue.
                         Early diagnosis can catch these diseases before they have progressed so
                         that they can be treated with less-aggressive therapies. The study’s
                         authors, comparing a limited number of cases of underinsured children
                         who had these rare illnesses with insured children who had the same
                         illnesses, found that children who were underinsured had 2-1/2 times the
                         weight loss of insured children and had waited 8 months longer before
                         diagnosis. The children’s laboratory results also indicated that they were
                         sicker before diagnosis and were more likely to be anemic. The authors
                         suggested that delay in diagnosis could have occurred for several reasons,
                         such as seeing different physicians at the same clinic or emergency room
                         or not being able to get timely appointments with subspecialists.21


Uninsured Children Are   A lack of appropriate ambulatory care can cause children to be
Hospitalized More        inappropriately hospitalized when they could have been treated as
Frequently for Lack of   outpatients. Several researchers have studied hospital admissions among
                         adults and children for conditions that can be managed with good
Primary Care             ambulatory care. In general, they found that U.S. communities with poor
                         access to ambulatory care—that is, low-income communities with many
                         residents uninsured or enrolled in Medicaid—had higher rates of this kind
                         of hospitalization. In contrast, hospital admissions in Spain for conditions
                         sensitive to ambulatory care did not vary for children living in lower- and
                         higher-income neighborhoods.

                         Lower-income U.S. neighborhoods had higher avoidable hospitalization
                         rates compared with higher-income neighborhoods for both children and
                         adults. Income differences in avoidable hospitalizations dropped for
                         persons 65 years old or older, probably because of their Medicare
                         coverage. Compared with privately insured patients in the same age
                         category, uninsured patients had higher rates of avoidable hospitalization.


                         20
                           The authors combined uninsured children and children in Medicaid to come up with their category
                         “underinsured.” They considered children in Medicaid as having insufficient insurance because of the
                         difficulty Medicaid children had in getting primary and specialty care at that time (1983-93) in that
                         locality.
                         21
                          W. Spivak, R. Sockolow, and A. Rigas, “The Relationship Between Insurance Class and Severity of
                         Presentation of Inflammatory Bowel Disease in Children,” American Journal of Gastroenterology, Vol.
                         90, No. 6 (1995), pp. 982-87.



                         Page 14                                      GAO/HEHS-98-14 Insurance and Health Care Access
                       B-278038




                       Medicaid patients had even higher rates.22 Most of the potentially
                       avoidable hospitalizations for children younger than 15 were for
                       pneumonia or asthma. Communities where people perceived that they had
                       poorer access to medical care had higher rates of hospitalization for
                       chronic diseases. Self-rated access to care was lower in communities that
                       had greater proportions of uninsured residents, Medicaid beneficiaries,
                       and persons without a usual source of care.23

                       Analysis of crossnational data also suggests that broader access to primary
                       care reduces the number of hospitalizations for conditions sensitive to
                       ambulatory care. Several researchers compared such admissions for
                       children in Spain and several U.S. cities. Although rates of hospital
                       admission were higher in general for children in Spain, rates of
                       hospitalization for conditions sensitive to ambulatory care were lower. In
                       addition, lower-income communities in Spain, unlike the United States, did
                       not have higher rates of children’s hospital admissions sensitive to
                       ambulatory care. The authors attributed this difference to Spanish
                       children’s access to universal health care, each child being covered by a
                       responsible primary care provider.24


Uninsured Children     Two studies indicated that when children were hospitalized, providers did
Receive Unequal Care   not give the same type of care to uninsured and privately insured children.
When Hospitalized      Providers may have been unwilling to provide the same intensity of care if
                       the payment source was uncertain or likely to be less than actual charges.25

                       One group of researchers found that sick uninsured newborns in
                       California had shorter hospital stays and received less-intensive care while
                       in the hospital than privately insured sick newborns, even though the
                       uninsured newborns and those in Medicaid were sicker. Newborns in
                       Medicaid had lengths of stay and levels of service between those of
                       uninsured and privately insured newborns. Adjusted mean length of stay
                       was 15.2 days for privately insured newborns, 14.2 for Medicaid-covered
                       newborns, and 12.7 for uninsured newborns. Total mean charges were
                       $15,899 for privately insured newborns, $13,858 for Medicaid-covered
                       newborns, and $11,414 for uninsured newborns. Charges per day were also

                       22
                        G. Pappas and others, “Potentially Avoidable Hospitalizations: Inequities in Rates Between U.S.
                       Socioeconomic Groups,” American Journal of Public Health, Vol. 87, No. 5 (1997), pp. 811-22.
                       23
                         Andrew B. Bindman and others, “Preventable Hospitalizations and Access to Health Care,” Journal of
                       the American Medical Association, Vol. 274, No. 4 (1995), pp. 305-11.
                       24
                        Carmen Casanova and Barbara Starfield, “Hospitalizations of Children and Access to Primary Care: A
                       Cross-National Comparison,” International Journal of Health Services, Vol. 25, No. 2 (1995), pp. 283-94.
                       25
                         Of course, privately insured children may have been getting more care than they needed.


                       Page 15                                       GAO/HEHS-98-14 Insurance and Health Care Access
                          B-278038




                          significantly different depending on insurance status. In all, length of stay,
                          total charges, and charges per day were 16-percent, 28-percent, and
                          10-percent less for uninsured than privately insured newborns.26

                          Another group of researchers found that uninsured children and adults
                          were generally sicker when admitted to the hospital, received less care
                          given their condition on admission, and had higher mortality than privately
                          insured children and adults. For children between ages 1 and 17,
                          uninsured black males and white females rated significantly higher on a
                          risk-adjusted mortality index, indicating that they were sicker on
                          admission. The differences for uninsured black females and white males
                          were not significant. Another measure of children’s being sicker on
                          admission is admission on weekends, which was more likely for all
                          uninsured children except black males. For the entire sample of all ages,
                          uninsured people had shorter lengths of stay for conditions for which
                          physicians had more discretion over the length of stay, and they had a
                          lower probability of getting selected procedures that were either costly or
                          more likely to be done at the physician’s discretion. The researchers
                          cautioned that their adjustment for health risk might be imperfect.
                          Nevertheless, they concluded that insurance coverage affects resource use
                          for a broad spectrum of clinical problems, particularly elective and
                          discretionary services.27


Uninsured Children Who    Many children have a chronic condition—one study estimated that
Have Chronic Conditions   31 percent of children younger than 18 in 1988 had one or more chronic
or Special Health Needs   conditions.28 NCHS estimated that about 15 percent of children who had
                          chronic conditions had special health care conditions that were disabling
Receive Less Care Than    because they missed school, stayed in bed, limited their activities, or
Insured Children          experienced pain or discomfort often.29 Many children who have chronic
                          conditions are uninsured. In 1988, 21.1 percent of poor children and
                          9.7 percent of nonpoor children who had chronic conditions were


                          26
                            P. Braveman and others, “Differences in Hospital Resource Allocation Among Sick Newborns
                          According to Insurance Coverage,” Journal of the American Medical Association, Vol. 266, No. 23
                          (1991), pp. 3300-8.
                          27
                           Jack Hadley, Earl Steinberg, and Judith Feder, “Comparison of Uninsured and Privately Insured
                          Hospital Patients: Condition on Admission, Resource Use, and Outcome,” Journal of the American
                          Medical Association, Vol. 265, No. 3 (1991), pp. 374-79.
                          28
                           P. W. Newacheck, “Poverty and Childhood Chronic Illness,” Archives of Pediatric and Adolescent
                          Medicine, Vol. 148, No. 11 (1994), pp. 1143-49.
                          29
                           L. A. Aday, “Health Insurance and Utilization of Medical Care for Chronically Ill Children With Special
                          Needs,” Advance Data, No. 215 (Hyattsville, Md.: National Center for Health Statistics, 1992).



                          Page 16                                      GAO/HEHS-98-14 Insurance and Health Care Access
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                                        uninsured.30 About 13 percent of children who had chronic conditions and
                                        special health care needs were uninsured—with low-income, Hispanic,
                                        and nonsuburban children more likely to be uninsured.31

                                        Having a regular source of care ensures continuity of care and
                                        professional monitoring of disease symptoms. Only a few studies looked at
                                        children who had chronic conditions and those who had special health
                                        care needs, and fewer controlled for factors that influence access other
                                        than insurance.32 However, these few studies found differences in access
                                        to care by insurance status. (See table 3.) For example, poor children who
                                        had chronic conditions but no insurance were more than twice as likely as
                                        similar, insured children, to lack a usual source of routine care or sick
                                        care.33 (See fig. 4.) Adjusting for severity of illness and other factors, they
                                        had only 2.3 physician contacts per year, compared with 3.7 for similar but
                                        insured children.

Table 3: Statistically Significant
Differences in Access to Care for       Compared with insured children, uninsured children                             Study
Chronically Ill Children and Children   Poor children with chronic conditions
Who Had Special Health Care Needs,
                                        Were more likely to lack a usual source of routine care                        Newacheck, 1994
by Insurance Status
                                        Were more likely to lack a usual source of sick care
                                        Had fewer annual physician visits
                                        Children with chronic conditions and special health care needs
                                        Were less likely to have been hospitalized in the past year                    Aday and others,
                                                                                                                       1993
                                        Children reported in fair or poor health
                                        Were more likely not to have used a physician’s services during a              Newacheck, 1992
                                        year
                                        Notes: Full study citations are in the bibliography. All differences reported in this table between
                                        uninsured and insured children were statistically significant at the .05 level. Some were significant
                                        at the .01 or .001 level.




                                        30
                                          Newacheck, “Poverty and Childhood Chronic Illness.”
                                        31
                                          Aday, “Health Insurance and Utilization of Medical Care.”
                                        32
                                         For a study that compared access of asthmatic children by insurance status, without controlling for
                                        other factors that influence access, see Holl and others, “Profile of Uninsured Children in the United
                                        States.”
                                        33
                                          Newacheck, “Poverty and Childhood Chronic Illness.”


                                        Page 17                                       GAO/HEHS-98-14 Insurance and Health Care Access
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Figure 4: Insured and Uninsured Poor Children Who Had Chronic Conditions and Lacked a Usual Source of Routine or Sick
Health Care by Insurance Status, 1988

Percentage
20



                               16
15



                                                                         11
10
                 8


                                                           5
 5




 0
                     Routine                                     Sick

                                    Insured       Uninsured
                                              Source: P. W. Newacheck, “Poverty and Childhood Chronic Illness,” Archives of Pediatric and
                                              Adolescent Medicine, Vol. 148, No. 11 (1994), pp. 1143-49.




                                              An analysis that went even further to separate insurance status from other
                                              factors that could affect children’s access to care found that children who
                                              had chronic conditions and special health care needs were more than
                                              twice as likely to be hospitalized if they had public or private insurance




                                              Page 18                                    GAO/HEHS-98-14 Insurance and Health Care Access
                              B-278038




                              than if they were uninsured, adjusting for differences in need for
                              hospitalization based on their conditions.34


Health Insurance Differs in   Many health plans do not cover a number of preventive, primary, and
Coverage of Children’s        developmental health services needed by some or all children. Private
Common Health Care            policies differ in whether they cover well-child, dental, and vision care. In
                              1996, KMPG Peat Marwick reported that 57 percent of the indemnity
Needs                         health plans used by firms with 200 to more than 5,000 workers covered
                              well-child care, compared with 96 percent of health maintenance
                              organizations (HMO) and 73 percent of preferred provider organization
                              (PPO) plans.35 Dental caries are a common problem for children, while poor
                              vision can lead to problems in learning. Nevertheless, only about half or
                              less of the private plans surveyed covered dental or vision care. Medicaid’s
                              child health benefit package, the Early and Periodic, Screening, Diagnosis,
                              and Treatment (EPSDT) program requires coverage of well-child care,
                              including dental, hearing, and vision care. Other publicly funded programs,
                              such as the Florida HealthyKids Program and New York’s Child Health
                              Plus Program, have not covered dental care; HealthyKids covered vision
                              and hearing care, but Child Health Plus did not.36

                              Children who have chronic conditions and special health care needs may
                              have particular difficulties because the services and supplies they need
                              may not be covered by their insurance. For example, coverage for speech
                              or physical therapy to help with developmental delays is often limited or
                              explicitly excluded from private health insurance policies. In contrast,
                              Medicaid’s EPSDT program covers a wide variety of developmental services.

                              Some children are insured but with “bare-bones” policies that provide
                              minimal coverage except for catastrophic costs. Such children, if eligible
                              for Medicaid, could get coverage for services not covered by their private

                              34
                                Defined as children who had one or more selected chronic conditions that caused them to
                              experience pain or discomfort or to be upset often or all the time in the past year or who were limited
                              in their major childhood activities as a result of these or other impairments or health problems. Their
                              conditions included frequent or repeated ear infections, digestive allergies, frequent diarrhea or bowel
                              trouble, diabetes, sickle cell anemia, anemia, asthma, hay fever or respiratory allergies, epilepsy or
                              seizures, frequent or severe headaches, musculoskeletal impairments including arthritis, cerebral
                              palsy, heart disease, and other conditions requiring surgery and lasting longer than 3 months. L. A.
                              Aday and others, “Health Insurance and Utilization of Medical Care for Children With Special Health
                              Care Needs,” Medical Care, Vol. 31 (1993), pp. 1013-26. Another study looking at similar issues for
                              adults and children combined is C. Hafner-Eaton, “Physician Utilization Disparities Between the
                              Uninsured and the Insured: Comparisons of the Chronically Ill, Acutely Ill, and Well Nonelderly
                              Populations,” Journal of the American Medical Association, Vol. 269, No. 6 (1993), pp. 787-92.
                              35
                                KPMG Peat Marwick, Health Benefits in 1996 (n.p.: 1996).
                              36
                                Children’s Health Insurance Programs, 1996 (GAO/HEHS-97-40R, Dec. 3, 1996).



                              Page 19                                       GAO/HEHS-98-14 Insurance and Health Care Access
                     B-278038




                     insurance. However, Title XXI—the new child health insurance
                     program—was designed to be restricted to uninsured children, so that
                     low-income children with coverage, even if it were only catastrophic
                     coverage, would not be considered eligible. Florida HealthyKids and New
                     York’s Child Health Plus, two state-based plans whose benefits have been
                     grandfathered into Title XXI, have in the past covered insured children if
                     their health insurance was not comparable in scope to the state-based
                     coverage.37

                     Some experts have argued that special pediatric standards should be
                     developed that recognize children’s specific needs, such as their need for
                     health services to ensure optimal development. They have argued that
                     such services should be considered medically necessary and should be
                     covered by private health insurance.38 Medicaid’s standard of medical
                     necessity is more global than that of private plans. However, families in
                     Medicaid have sometimes had difficulty finding mainstream providers
                     willing to accept them as patients, which limits their ability to secure
                     covered benefits for their children.


                     Since providing uninsured children with publicly funded insurance
Expanding Public     improves their access to preventive and acute health services, families are
Insurance Improves   more likely to report that their children’s health needs are being met.
Access               Children are more likely to be up to date with recommended preventive
                     care and are more likely to see a physician. Two different researchers
                     estimated that the expansion of publicly funded insurance in the United
                     States and Canada decreased child mortality, in association with either
                     more physicians’ visits or more prenatal care.

                     NCHS reported that uninsured children were about three times as likely to
                     have an unmet health need as children with publicly funded insurance
                     (generally Medicaid). (See fig. 5.) Dental care was the most common
                     unmet need for all children—but uninsured children were more than three
                     times as likely not to receive needed dental care as children who had




                     37
                      Health Insurance for Children: State and Private Programs Create New Strategies to Insure Children
                     (GAO/HEHS-96-35, Jan. 18, 1996).
                     38
                       E. Wehr and E. J. Jameson, “Beyond Benefits: The Importance of a Pediatric Standard in Private
                     Insurance Contracts to Ensuring Health Care Access for Children,” The Future of Children: Critical
                     Health Issues for Children and Youth, Vol. 4, No. 3 (1994), pp. 115-33.



                     Page 20                                      GAO/HEHS-98-14 Insurance and Health Care Access
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                                           publicly funded insurance. Almost 16 percent of uninsured children were
                                           reported as needing but not receiving dental care.39



Figure 5: Percentage of U.S. Children Who Had Publicly Funded Insurance or No Insurance and Unmet Health Needs, 1993

 Percentage

30

                         26
25


20

                                                                                       16
15
                                                     13


10             9


 5                                                                        4
                                       2

 0
              Any Unmet Need       Delay Because of Cost               Dental Care Needed


                                  Public
                                                      Uninsured
                                  Insurance

                                           Source: Gloria Simpson and others, “Access to Health Care Part 1: Children,” Vital and Health
                                           Statistics, Series 10, No. 196 (Hyattsville, Md.: U.S. Department of Health and Human Services,
                                           1997).




                                           Parents of uninsured children reported delaying getting care for their
                                           children because of its cost almost five times as often as children who had
                                           publicly funded insurance. One local study in Los Angeles found that
                                           inner-city Latino parents were also most likely to report that they deferred



                                           39
                                             The NCHS study simply compared privately insured, Medicaid, and uninsured children without
                                           controlling for other factors that could affect access. However, since children in Medicaid have lower
                                           average family income than uninsured children and are more likely to be more socially disadvantaged,
                                           regression analysis might well increase the comparative effect of insurance, so we are including these
                                           results for a simple comparison. See Simpson and others, “Access to Health Care Part 1.”



                                           Page 21                                      GAO/HEHS-98-14 Insurance and Health Care Access
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health care for their toddlers for financial reasons when they were
uninsured, compared with others who had Medicaid or private coverage.40

A number of studies estimated the effect that providing publicly funded
insurance, such as Medicaid, had on lessening the gap between uninsured
and insured children. One research team examined the effect of expanding
Medicaid coverage to children and found decreases over time in the
probability that children would go without at least one ambulatory care
visit in a year. Making a child eligible for Medicaid lowered the child’s
estimated probability of going without a visit by 13 percent.
Hospitalizations also rose by an estimated 14 percent—but the estimated
probability of making visits to physicians’ offices increased even more
than making visits to other sites, suggesting to the authors that expanding
Medicaid coverage increased ambulatory care. These authors also looked
at the effects of Medicaid expansion on child health as measured by
decreases in child mortality. They estimated that the 15-percent rise in the
number of children eligible for Medicaid between 1984 and 1992 decreased
child mortality by 5 percent.41 A similar study that looked at the effect of
providing national health insurance in Canada found a statistically
significant increase in early prenatal care and a significant decrease in
infant mortality.42

Another study of children’s rates of preventive and illness-related primary
care visits found that, adjusting for other factors such as race and
perceived health status, the predicted probability of making either a
preventive or illness-related visit increased if children were covered by
public or private insurance, compared with being uninsured. For example,
for uninsured children younger than 6 in single-parent families headed by
mothers, the predicted probability of making a preventive visit was more
than 40-percent greater if the children were covered by public or private
insurance, and it was almost 100-percent greater for children aged 6 to 17.43


40
  N. Halfon and others, “Medicaid Enrollment and Health Services Access by Latino Children in
Inner-city Los Angeles,” Journal of the American Medical Association, Vol. 277, No. 8 (1997), pp.
636-72.
41
 J. Currie and Jonathan Gruber, “Health Insurance Eligibility, Utilization of Medical Care, and Child
Health,” Quarterly Journal of Economics, Vol. 111, No. 2 (1996), pp. 431-66.
42
 Maria J. Hanratty, “Canadian National Health Insurance and Infant Health,” American Economic
Review, Vol. 86, No. 1 (1996), pp. 276-84.
43
 Peter J. Cunningham and Beth A. Hahn, “The Changing American Family: Implications for Children’s
Health Insurance Coverage and the Use of Ambulatory Care Services,” The Future of Children: Critical
Health Issues of Children and Youth, Vol. 4, No. 3 (1994), pp. 24-42. See also Mary L. Rosenbach, “The
Impact of Medicaid on Physician Use by Low-Income Children,” American Journal of Pediatric Health,
Vol. 79, No. 9 (1989), pp. 1220-26.



Page 22                                       GAO/HEHS-98-14 Insurance and Health Care Access
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                         Many children miss recommended preventive visits, but uninsured
                        children fare worse than insured children. Short and Lefkowitz found that
                        in 1987, only 49 percent of uninsured preschool children had made any
                        well-child visits, compared with 65 percent of insured children, and only
                        32 percent of uninsured preschool children had made the recommended
                        number of visits, compared with 48 percent of insured children.44 They
                        found that when adjusting for other factors, private insurance status was
                        only marginally significant in predicting well-child visits, which they
                        explained by the degree to which private insurance varies in its coverage
                        of well-child care. However, they estimated that for low-income children
                        who would otherwise be uninsured, a full year of Medicaid coverage
                        increased the probability of making any well-child visits by 17 percentage
                        points, and compliance with AAP’s guidelines for well-child visits would
                        increase by 13 percentage points. (See table 2 for AAP guidelines.)


                        Getting appropriate health care when it is needed can be difficult for
Lack of Health          children. Parents and guardians usually make the decision to seek care for
Insurance Is Only One   them. Having health insurance and having a regular source of health care
Barrier to Care         facilitate a family’s use of health services, but some families experience
                        systemic, financial, and personal barriers to care. Systemic barriers can
                        include a lack of primary care providers readily available in the
                        neighborhood, physicians’ missing opportunities to provide vaccinations
                        during health care visits, and physicians’ refusing to accept certain
                        patients. Financial barriers, apart from lack of insurance, can include lack
                        of funds to make copayments or pay for uncovered services. Personal
                        barriers can include parents’ lack of knowledge that care is needed and
                        language differences between parents and providers. Similarly,
                        discrimination and poor treatment by health care workers can discourage
                        the use of health care services.45

                        Uninsured children and children in Medicaid may also be likely to face
                        systemic, financial, or personal barriers that limit their access to care,
                        beyond their lack of insurance. Compared with privately insured children,
                        uninsured children and those in Medicaid are more likely to have less
                        family income, to be members of a minority group, to have parents who
                        have lower educational attainment, or to live with only one
                        parent—characteristics associated with lower use of health services.

                        44
                         Pamela Farley Short and Doris C. Lefkowitz, “Encouraging Preventive Services for Low-Income
                        Children: The Effect of Expanding Medicaid,” Medical Care, Vol. 30, No. 9 (1992), pp. 766-80.
                        45
                         Paul W. Newacheck and others, “Children’s Access to Health Care: The Role of Social and Economic
                        Factors,” in Health Care for Children: What’s Right, What’s Wrong, What’s Next, ed. by Ann R. E. Stein
                        (New York: United Hospital Fund of New York, 1997).



                        Page 23                                      GAO/HEHS-98-14 Insurance and Health Care Access
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             As a result, experts in health issues have concluded that while insurance
             plays a critical role in getting children access to health care, encouraging
             their appropriate use of health care encompasses multiple strategies.
             These include making insurance coverage more continuous in order to
             foster children’s relationships with providers, maintaining a better
             organized system of primary care in settings that ease access for parents
             and that have good links to more complex care, enhancing systems in
             which primary care providers can track and prompt preventive visits and
             immunizations, and aiming outreach and educational programs at
             parents.46


             Research has clearly demonstrated that having health insurance makes a
Conclusion   difference for children. Children who have no insurance—even those who
             are sick or chronically ill or have special health care needs—get less
             health care than children who have insurance. Many studies have shown
             that increasing children’s coverage increases their access to care,
             particularly primary care. Without appropriate access to primary care,
             children are more likely to suffer unnecessarily from illness.

             But having health insurance is no guarantee that children will get
             appropriate, high-quality care. Some children live in families that do not
             understand the need for preventive care or do not know how to seek
             high-quality care. Some live in neighborhoods that have few health care
             providers, where they have to travel further and wait longer to get care.
             Some live in families in which most of the members do not speak English
             or defer getting care because they have had difficulty getting care
             previously. Some children have health insurance that does not cover some
             of the services that they need most—such as dental care or physical
             therapy for the developmentally disabled. Some children have health
             insurance whose deductibles and cost-sharing are unaffordable. Such
             barriers can reduce the likelihood that even insured children will get the
             care they need.

             Overcoming these kinds of barriers would require that children be more
             continuously covered by health insurance so that they could develop
             long-term relationships with primary care providers. Having a stable


             46
               Institute of Medicine, Paying Attention to Children in a Changing Health Care System (Washington,
             D.C.: National Academy Press, 1996); James Perrin, Bernard Guyer, and Jean M. Lawrence, “Health
             Care Services for Children and Adolescents,” The Future of Children: U.S. Health Care for Children,
             Vol. 2, No. 2 (1992), pp. 58-77; J. Currie, “Socio-Economic Status and Child Health: Does Public Health
             Insurance Narrow the Gap?” Scandinavian Journal of Economics, Vol. 97, No. 4 (1995), pp. 603-20;
             Short and Lefkowitz, “Encouraging Preventive Services for Low-Income Children.”



             Page 24                                       GAO/HEHS-98-14 Insurance and Health Care Access
                    B-278038




                    source of insurance can help families use the health system for their
                    children optimally over time. Beyond that, children have needs for specific
                    developmental and preventive care that differ in some ways from those of
                    adults. For insurance to work for children, the services they need must be
                    both covered and affordable.

                    Overcoming nonfinancial barriers might require outreach and education
                    for families so that they can learn how better to use preventive and
                    primary health care for their children. In addition, making high-quality
                    primary health services convenient for families in local communities might
                    facilitate children’s access to appropriate care.


                    We asked experts on access to health insurance and children’s health care
Experts’ Comments   to review a draft of this report, and we incorporated their comments and
and Our Response    suggestions where appropriate.


                    We will make copies of this report available on request. Please contact me
                    at (202) 512-7114 if you or your staff have any questions. This report was
                    prepared by Michael Gutowski, Jonathan Ratner, Sheila Avruch, and Sarah
                    Lamb.

                    Sincerely yours,




                    William J. Scanlon
                    Director, Health Financing
                      and Systems Issues




                    Page 25                          GAO/HEHS-98-14 Insurance and Health Care Access
Contents



Letter                                                                                                1


Bibliography                                                                                         28


Related GAO Products                                                                                 40


Tables                 Table 1: Primary Care Access for Uninsured Children:                           5
                         Statistically Significant Measures Identified in Recent Studies
                       Table 2: AAP’s Recommended Schedule of Preventive Well-Child                  10
                         Visits, 1995
                       Table 3: Statistically Significant Differences in Access to Care for          17
                         Chronically Ill Children and Children Who Had Special Health
                         Care Needs, by Insurance Status

Figures                Figure 1: Percentage of Adolescents Who Had a Usual Source of                  8
                         Care by Insurance Status and Race or Ethnicity, 1988
                       Figure 2: Average Number of Annual Nonemergency Ambulatory                    11
                         Care Visits Among Insured and Uninsured Children Who Used
                         Services, 1980
                       Figure 3: The Likelihood That Uninsured and Insured Children                  13
                         Received Medical Care When Ill, 1987
                       Figure 4: Insured and Uninsured Poor Children Who Had Chronic                 18
                         Conditions and Lacked a Usual Source of Routine or Sick Health
                         Care by Insurance Status, 1988
                       Figure 5: Percentage of U.S. Children Who Had Publicly Funded                 21
                         Insurance or No Insurance and Unmet Health Needs, 1993




                       Abbreviations

                       AAP        American Academy of Pediatrics
                       CBO        Congressional Budget Office
                       EPSDT      Early and Periodic, Screening, Diagnosis, and Treatment
                       HMO        health maintenance organization
                       NCHS       National Center for Health Statistics
                       PPO        preferred provider organization


                       Page 26                           GAO/HEHS-98-14 Insurance and Health Care Access
Page 27   GAO/HEHS-98-14 Insurance and Health Care Access
Bibliography


               Aday, LuAnn. “Health Insurance and Utilization of Medical Care for
               Chronically Ill Children With Special Health Care Needs.” Advance Data,
               No. 215. Hyattsville, Md.: National Center for Health Statistics, 1992.

               Aday, LuAnn, and others. “Health Insurance and Utilization of Medical
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Page 39   GAO/HEHS-98-14 Insurance and Health Care Access
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              Uninsured Children and Immigration, 1995 (GAO/HEHS-97-126R, May 27, 1997).

              Health Insurance for Children: Declines in Employment-Based Coverage
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              Medicaid and Children’s Insurance (GAO/HEHS-96-50R, Oct. 20, 1995).

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(101568)      Page 40                           GAO/HEHS-98-14 Insurance and Health Care Access
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