BOX 6.1 Summary of Findings

  • Uninsured children have less access to health care, are less likely to have a regular source of primary care, and use medical and dental care less often compared with children who have insurance. Children with gaps in health insurance coverage have worse access than do those with continuous coverage.

  • Previously uninsured children experience significant increases in both access to and more appropriate use of health care services following their enrollment in public health insurance programs.

  • Lower-income, minority, non-citizen, or uninsured children consistently have worse access and utilization than do children with none of these characteristics. These factors overlap to a large extent. However, each exerts its own independent effect on access and utilization.

  • Uninsured adolescents are more likely to lack a regular source of care and have unmet health needs than are insured adolescents.

  • Uninsured children with special health care needs are more likely than those who have insurance coverage to be without a usual source of health care, to have gone without seeing a doctor in the last 12 months, and to be unable to get needed medical, dental, vision, and mental health care and prescriptions.

  • Uninsured children often receive care late in the development of a health problem or do not receive any care. As a result, they are at higher risk for hospitalization for conditions amenable to timely outpatient care and for missed diagnoses of serious and even life-threatening conditions.

  • Undiagnosed and untreated conditions that are amenable to control, cure, or prevention can affect children’s functioning and opportunities over the course of their lives. Such conditions include iron deficiency anemia, otitis media, asthma, and attention deficit–hyperactivity disorder.

  • Uninsured women receive fewer prenatal care services than their insured counterparts and report greater difficulty in obtaining the care that they believe they need. Studies find large differences in use between privately insured and uninsured women and smaller differences between uninsured and publicly insured women.

  • Health insurance status affects the care received by women giving birth and their newborns. Uninsured women and their newborns receive, on average, less prenatal care and fewer expensive perinatal services.

  • Uninsured newborns are more likely to have adverse outcomes, including low birth weight and death, than are insured newborns. Evidence of improvements in outcomes for newborns as a result of increased population health insurance rates is inconclusive, however.

  • Uninsured women are more likely to have poor outcomes during pregnancy and delivery than are women with insurance. Studies have not demonstrated an improvement in maternal outcomes related to health insurance alone.



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Health Insurance is a Family Matter BOX 6.1 Summary of Findings Uninsured children have less access to health care, are less likely to have a regular source of primary care, and use medical and dental care less often compared with children who have insurance. Children with gaps in health insurance coverage have worse access than do those with continuous coverage. Previously uninsured children experience significant increases in both access to and more appropriate use of health care services following their enrollment in public health insurance programs. Lower-income, minority, non-citizen, or uninsured children consistently have worse access and utilization than do children with none of these characteristics. These factors overlap to a large extent. However, each exerts its own independent effect on access and utilization. Uninsured adolescents are more likely to lack a regular source of care and have unmet health needs than are insured adolescents. Uninsured children with special health care needs are more likely than those who have insurance coverage to be without a usual source of health care, to have gone without seeing a doctor in the last 12 months, and to be unable to get needed medical, dental, vision, and mental health care and prescriptions. Uninsured children often receive care late in the development of a health problem or do not receive any care. As a result, they are at higher risk for hospitalization for conditions amenable to timely outpatient care and for missed diagnoses of serious and even life-threatening conditions. Undiagnosed and untreated conditions that are amenable to control, cure, or prevention can affect children’s functioning and opportunities over the course of their lives. Such conditions include iron deficiency anemia, otitis media, asthma, and attention deficit–hyperactivity disorder. Uninsured women receive fewer prenatal care services than their insured counterparts and report greater difficulty in obtaining the care that they believe they need. Studies find large differences in use between privately insured and uninsured women and smaller differences between uninsured and publicly insured women. Health insurance status affects the care received by women giving birth and their newborns. Uninsured women and their newborns receive, on average, less prenatal care and fewer expensive perinatal services. Uninsured newborns are more likely to have adverse outcomes, including low birth weight and death, than are insured newborns. Evidence of improvements in outcomes for newborns as a result of increased population health insurance rates is inconclusive, however. Uninsured women are more likely to have poor outcomes during pregnancy and delivery than are women with insurance. Studies have not demonstrated an improvement in maternal outcomes related to health insurance alone.

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Health Insurance is a Family Matter 6 Health-Related Outcomes for Children, Pregnant Women, and Newborns This chapter examines clinical and epidemiological evidence about the effects of health insurance status on the health of children, pregnant women, and newborns.1 It extends the assessment of health outcomes that the Committee presented in Care Without Coverage to pediatric and pregnancy-related care and outcomes. It places this analysis within the broader context of family interests, behavior, and constraints of this report because, as demonstrated in the previous chapter, children’s access to and use of health care is highly dependent on their parents’ opportunities and actions. The financially constrained patterns of use by uninsured families, as documented in Chapter 4, can affect the overall health and development of their members, particularly of children. Table 6.1 summarizes the health insurance status of American children by age, race and ethnicity, and family income. The Committee reviewed studies that compare the access to and use of health care services by insured and uninsured children, pregnant women, and newborns as well as research that relates their insurance status to health outcomes.2 Only 1   Many studies classify people age 18 and under as children, conforming to the federal Medicaid eligibility standard definition of children; others, however, are based on national surveys that classify people age 17 and under as children. The American Academy of Pediatrics considers people up to age 21 children. 2   The review draws on studies identified in a MEDLINE search of the English language literature published between 1985 and September 2001. The search terms included “insurance status,” “insurance, longitudinal,” “insurance, cohort,” “uninsured, longitudinal,” “uninsured, cohort,” “payer status,” “payer source,” “medically indigent,” and “uncompensated care.” Studies with fewer than 250 participants, those with unadjusted results, and those from a single institution were excluded, unless broader studies of a particular outcome were unavailable or limited. In addition, more recent

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Health Insurance is a Family Matter TABLE 6.1 Number of Uninsured Children by Age, Race or Ethnicity, and Family Income, 2000, United States   Total Number (millions) Total Uninsureda (millions) Percent Uninsured All children 72.6 8.4 11.6 Age Under 3 years 11.9 1.3 11.3 3–5 years 11.8 1.3 10.8 6–11 years 24.8 2.8 11.5 12–17 years 24.1 2.9 12.2 Race or ethnicity Non-Hispanic white 45.4 3.3 7.3 Black 11.6 1.6 13.5 Asian and Pacific Islander 3.1 0.4 14.3 Hispanic origin 12.0 3.0 24.9 Family income 0–99% FPL 12.2 2.7 22.1 100–149% FPL 7.7 1.5 19.5 150–199% FPL 7.6 1.1 14.5 200% FPL and over 45.0 3.1 6.9 NOTE: FPL = federal poverty level. aThe Current Population Survey (CPS) defines uninsured as having no form of health insurance during an entire calendar year. SOURCES: Census Bureau, CPS Annual Demographic Survey, March Supplement, 2001, Table HI08. Available at: http://ferret.bls.census.gov/macro/032001/health/h08_000.htm. Accessed April 21, 2002; and Fronstin, 2001. studies that the Committee judged methodologically sound are presented in this chapter. Additional studies reviewed by the Committee and the Subcommittee are included in Appendix C. Opportunities for low and lower-income children and pregnant women to obtain coverage through public health insurance programs have increased substantially over the past one and a half decades. Many of the studies reviewed in this chapter are evaluations of these program expansions. Others of the studies of access, use and health outcomes pre-date most of these expansions. The Committee believes that the general patterns of utilization and outcomes that are reported for insured and uninsured children, pregnant women and infants remain valid even as     journal articles and unpublished studies brought to the Committee’s attention by experts were included if they met the other criteria mentioned above. Appendix C provides brief descriptions of all the studies that met the review criteria.

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Health Insurance is a Family Matter the relative proportions of insured and uninsured populations have shifted over time. Appropriate health care interventions for children and pregnant women have been related to educational achievement, exit from welfare or social services, and ultimate employment—all outcomes that extend well beyond traditional health. For children, using health care services routinely and appropriately is considered a positive health outcome in its own right because well-child care is a practice grounded in evidence of its effectiveness in enhancing longer-term health and development. Early intervention, even in the face of severe physical or mental problems, often can minimize long-term health and developmental problems and thus can benefit society overall. Without opportunities for health and developmental assessments, particularly with an ongoing source of care, problems go undetected and children may suffer consequences that limit their life chances in both obvious and less evident ways. Before birth, good prenatal care also provides opportunities to ensure the best possible health for both mother and child. To the extent that having health insurance can remove access barriers and foster timely assessments of development and health, the health of children measured on a population-wide basis will improve. Of course, health insurance is not the only factor influencing use of health care, and use of health care is but one of many factors that influence health outcomes. For example, poverty, presence of chronic disease, socioeconomic status, educational attainment (and, for children, their parents’ educational attainment), and health-related behaviors such as diet, exercise, drug use, and smoking may affect utilization and outcomes as much as health insurance status (Szilagyi and Schor, 1998). Figure 1.1 in Chapter 1 depicts the multiple factors and characteristics that relate health insurance to access, use, and outcomes. A full discussion of the conceptual framework that depicts the relationships among personal characteristics, health care, and outcomes is presented in Appendix A. Ideally, to answer the question, Does health insurance enhance health status?, one would perform a true experiment, in which some individuals would be randomly assigned to receive insurance and others not. Because of the ethical and practical obstacles to conducting a health insurance experiment that leaves some participants uninsured, none have been conducted.3 Instead, most of the evidence for the effect of insurance on health outcomes is based on observational studies of insured and uninsured individuals. A few studies with quasi-experimental designs 3   The notable exception to this generalization is the RAND Health Insurance Experiment, conducted between 1974 and 1982, which randomly assigned roughly 2,000 families in six different sites to one of 14 experimental health insurance plans that varied in their cost-sharing arrangements. Cost sharing ranged from none in the free care plan to 95 percent for all health services, limited to a maximum of $1,000 per family per year (in then-current dollars) with reduced amounts for low-income families (Keeler et al., 1985; Newhouse et al., 1993). The study was designed so that no participating family could be made worse off as a result of its participation than if it had not participated. This social experiment did not, however, include a study group without any health insurance at all.

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Health Insurance is a Family Matter have been conducted within the past decade and a half. These so-called natural experiments are ones in which a population of children or pregnant women gains coverage because of policy changes (e.g., as a result of increases in the Medicaid income eligibility standard or the introduction of the State Children’s Health Insurance Program [SCHIP]) allowing comparisons of access, use, and outcomes before and after coverage policy changes; or differences in income eligibility levels among state Medicaid programs provide an opportunity to evaluate the impact of the different levels. These quasi-experimental studies allow for greater confidence in the validity of their results than do cross-sectional studies that rely on analytic controls for characteristics that co-vary with health insurance status.4 Other factors that can influence health outcomes, such as income, educational attainment, race and ethnicity, or immigrant status, often coincide with lack of insurance. This report relies on studies that account for these factors with analytic adjustments that isolate the effects of health insurance status. Studies report adjusted statistics (e.g., odds ratios [ORs]5) that account for such characteristics as family income, race or ethnicity, age, gender, and sometimes health status. Quantified study results are presented only if they are statistically significant at the conventional p = 0.05 level or at higher significance levels, unless otherwise noted. The first section of this chapter reviews the link between children’s health insurance status and their access to and appropriate use of services. The second section presents empirical studies that examine specific health outcomes for children and youth as related to coverage status. The third section reviews longer-term adverse outcomes for children’s health and development for specific conditions that have not been studied in terms of their relationship to health insurance status that merit further investigation. The fourth and last section assesses the evidence regarding the relationship between pre- and perinatal care and birth outcomes for mothers and infants. 4   See Chapter 2 of Care Without Coverage (IOM, 2002a) for a fuller discussion of methodological issues. 5   The odds ratio is the relative odds of having an outcome in the uninsured and insured groups. For example, if the odds of receiving an immunization are 2:1 in a group of uninsured children (i.e., two out of every three children, or 67 percent, receive the immunization) and the odds are 4:1 in a group of children with insurance (i.e., four out of every five children, or 80 percent, receive the immunization), the odds ratio for uninsured compared to insured children is 0.5 (2:1/4:1). The OR is not a good estimate of the relative risk (the probability of being immunized in the uninsured group divided by the probability of being immunized in the insured group) because immunization is not a rare event.

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Health Insurance is a Family Matter ACCESS TO AND USE OF HEALTH CARE BY CHILDREN Access is most simply understood as the ability to see a physician or other health care provider when one wants to do so. Access and use of health care services are closely connected. A child without good access is expected to have a harder time using care and thus expected to have fewer visits and more unmet needs than one with good access to care. Research examining the impact of insurance on access employs a variety of measures, such as whether a child or pregnant woman has a regular source of care or a “medical home,” a usual physician within a regular place of care (i.e., a medical home), ability to obtain care outside of normal business hours, a regular dentist (for children), and unmet health needs or delays in care due to cost.6 Measurement of utilization has two aspects, the number of visits and the appropriate use of health care services (e.g., receipt of indicated services on a timely basis or inappropriate use of emergency departments as the site of primary care). Empirical studies support the link between access to care, use, and improved health outcomes (Bindman et al., 1995; Starfield, 1995; Hadley, 2002; IOM, 2002a). Finding: Uninsured children have less access to health care, are less likely to have a regular source of primary care, and use medical and dental care less often compared to children who have insurance. Children with gaps in health insurance coverage have worse access than do those with continuous coverage. Studies using databases with national probability samples, such as the National Health Insurance Survey (NHIS), the Medical Expenditure Panel Survey (MEPS), and the National Survey of America’s Families (NSAF), consistently report that uninsured children have poorer access to health care and use health services less frequently than their insured counterparts. Insurance status remains a significant factor even after studies control for income, race and ethnicity, and health status. Children with health insurance are more likely to have a usual source of health care than uninsured children. A study based on the 1993–1994 NHIS reported an odds ratio of 6.1 between insured and uninsured children’s likelihood of having a usual source of care (Newacheck et al., 1998b).7 Among those 6   The American Academy of Pediatrics (AAP) characterizes a “medical home” for infants, children, and adolescents as one that provides continuous, comprehensive, family-centered, coordinated, and compassionate care delivered by well-trained physicians known to the child and family who are able to develop a relationship of mutual responsibility and trust with them (AAP, Medical Home Statement. Available at: http:www/aap.org. Accessed December 28, 2001). 7   Health insurance is not the only factor in parental decision-making on whether to develop a relationship with a health care provider for their children. An analysis of the 1996 MEPS reports that parents of children who did not have a regular source of care give as the main reasons, that the child is seldom or never sick (66 percent) and, that they cannot afford one (10 percent) (Weinick et al., 1998). Financial reasons do, however, constitute the main barriers to receiving care perceived as needed.

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Health Insurance is a Family Matter children whose parents reported having a usual site of care, uninsured children were more likely to lack a regular physician and to be unable to obtain medical care after normal business hours. Uninsured children were also more likely than those with insurance to go without care that parents reported they needed (OR = 5.8), to go without any dental care (OR = 4.3), and more likely to have had no contact with a physician during the previous year (OR = 2.1) (Newacheck et al., 1998b). Not surprisingly, the parents of uninsured children were more likely to be dissatisfied with at least some aspect of their child’s care. This comprehensive survey analysis adjusted for age, sex, race, family income, family structure and size, region of the country, population density, and health status. These results confirmed those of an earlier study using 1988 NHIS data. Holl and colleagues (1995) reported that uninsured children were more likely than those with insurance never to have had a regular source of care (OR = 1.8) and more likely not to meet standards of timeliness for well-child visits (OR = 1.3). Furthermore, uninsured children were more likely to obtain routine and sick care from different sources than were insured children (Holl et al., 1995). Uninsured children are less likely to have received medical care for common childhood illnesses than are children with health insurance. In a study based on the 1987 National Medical Expenditure Survey (NMES), uninsured children were significantly less likely to visit a physician for pharyngitis, acute earache, recurrent ear infection or asthma, conditions for which medical attention is usually considered necessary (ORs = 1.7, 1.85, 2.1, 1.7, respectively) (Stoddard et al., 1994). The uninsured child’s worse odds remained despite extensive sociodemographic and health status adjustments. Most studies combine both children with private and children with public insurance into a single “insured” category. The impact of insurance on access and utilization differs depending on whether it is private or public insurance, with better access and higher use rates among those with private insurance.8 However, children with no insurance still have the worst measures of access and utilization, below those of publicly insured poor children. Although not all of the differences in access and use among children of differing health insurance status are due to their coverage status, these differences are pronounced. Children with private insurance have considerably more medical office visits, dental visits, and filled prescriptions than do both children who have public insurance and those who are uninsured. An analysis of 1996 MEPS data shows the following differences in the use of any service within a year for     Among families who reported difficulty in obtaining care or a delay in getting care, 60 percent cited their inability to afford the care as the main reason (Weinick et al., 1998). 8   See pp. 34 and 100–101 of the Committee’s report Care Without Coverage for discussions of the factors contributing to systematic differences in use and outcome findings for adults insured by Medicaid and private coverage (IOM, 2002a).

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Health Insurance is a Family Matter physician office visits (76, 67, and 51 percent for privately insured, publicly insured, and uninsured children, respectively); dental visits (50, 29, and 21 percent, respectively); and prescriptions filled (61, 56, and 43 percent, respectively) (McCormick et al., 2001). Despite being the least likely to have a regular source of care, uninsured children on average receive less care from emergency departments than do children with any kind of coverage (McCormick et al., 2001). Hospitalizations and emergency department visits are highest for children with public insurance, possibly reflecting inadequate access to other ambulatory care providers. Publicly insured children are hospitalized at more than twice the rate of the privately insured and uninsured (5.4, versus 2.4 and 1.9 percent with any hospital stay for publicly insured, privately insured, and uninsured, respectively). Emergency department visits are also highest for the publicly insured (15.5, versus 12.5 and 10.8 percent with a visit for publicly insured, privately insured, and uninsured, respectively) (McCormick et al., 2001). Finding: Previously uninsured children experience significant increases in both access to and more appropriate use of health care services following their enrollment in public health insurance programs. Studies that have evaluated Medicaid program expansions since the mid-1980s and, more recently, children’s health insurance demonstrations that preceded SCHIP conclude that increased eligibility for and enrollment in public programs results in greater and more appropriate use of health services among children. Between 1984 and 1992, the first period of expansions in Medicaid eligibility and enrollment, Currie and Gruber (1996b) analyzed National Health Interview Survey (NHIS) data as a function of state Medicaid eligibility standards and found that eligibility for Medicaid was associated across the child population with reducing the likelihood that a child would go without any physician visit within a year by half. They also found an association between increases in Medicaid eligibility at the state level and reductions in child mortality after the first year of life. A second study by Currie (2000) that used NHIS data from 1989 to 1992 (prior to the enactment of Medicaid restrictions on eligibility for immigrants) to compare the effects of Medicaid eligibility on insurance coverage and use of services between children of U.S.-born and immigrant parents found that the effects of increased Medicaid eligibility on utilization of ambulatory care were twice as great for the children of immigrants, whose average use of physician services was lower, as for children of U.S.-born parents. As discussed later in this chapter, a national study of Medicaid eligibility expansions between 1983 and 1996 concluded that these expansions reduced potentially avoidable hospitalizations among children (Dafny and Gruber, 2000). Enactment of SCHIP in 1997, with implementation beginning the next year, provided the opportunity for states to insure children at higher family income

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Health Insurance is a Family Matter levels than those established for Medicaid. States vary in how much they raised the income eligibility threshold for public health insurance, but expansion to 200 percent FPL was most common. Studies of the earliest state demonstration programs in two states, New York and Pennsylvania, report a significant increase in both access and utilization for previously uninsured children after receipt of health insurance. The New York program evaluation involved an examination of the state as a whole (Szilagyi et al., 2000c) as well as a focused study on six upstate counties (Rodewald et al., 1997; Holl et al., 2000; Szilagyi et al., 2000a, 2000b). In both cases, the researchers compared children’s health care use and health outcomes for the year before they entered the New York program to those for the first year after enrollment. A study of a similar program in 29 counties in western Pennsylvania also used a before-and-after design (and also had a comparison group of later enrollees) and surveyed newly enrolled children at 6 and 12 months following enrollment (Lave et al., 1998a). The findings of these three evaluations consistently show that the newly insured children had increased access to a medical home, paving the way for more timely and appropriate care and greater satisfaction with services. In Pennsylvania, 12 months after enrollment, 99 percent of the children had a regular source of medical care and 85 percent had a regular dentist, up from 89 and 60 percent, respectively, at baseline. Further, the proportion of children reporting any unmet need or delayed medical care in the previous six months decreased from 57 percent at baseline to 16 percent at 12 months (Lave et al., 1998a). The proportion of children with any physician visit increased from 59 to 64 percent, accompanied by a 5 percentage point decrease in the proportion with an emergency room visit, from 22 percent to 17 percent (Lave et al., 1998a). The proportion of children seeing a dentist increased from 40 percent at enrollment to 65 percent after 12 months (Lave et al., 1998a). Because the separate comparison group of later-enrolling children were similar to those initially enrolling, these changes over time in the insured group can be attributed to the coverage with greater confidence. In New York State, enrollment in the state insurance program also reduced the number of children without a medical home (from 5 percent before the expansion to 1 percent after enrollment), and one in three parents of newly insured children reported improved quality of care for their children (Szilagyi et al., 2000c). Visits to primary care physicians for preventive, acute, and total care increased markedly (up by 25, 52, and 42 percent, respectively). Visits to specialists following enrollment more than doubled from before enrollment. Emergency department (ED) use did not change significantly, but hospitalization declined by 36 percent statewide (Szilagyi et al., 2000c). In the upstate program, the parents of one-quarter of the enrolled children reported that their children’s health had improved as a result of the coverage (Holl et al., 2000). Tracking specific services and childhood conditions also reveals changes in access and use. For example, throughout New York, use of public health depart-

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Health Insurance is a Family Matter ments for immunizations decreased by 67 percent after implementation of the program, with more immunizations delivered in the medical home during the period of expanded coverage (Rodewald et al., 1997). The upstate evaluation reported that visits to medical homes increased for children with chronic conditions (from 5.7 to 7.1 visits annually), a sign of better care (Szilagyi et al., 2000b). The impact of insurance status on one chronic condition, asthma, was also documented. Following enrollment in the insurance program, parents perceived that their child’s severity level and quality of care for asthma had improved, and about half of these parents reported that their asthmatic child’s overall health had improved as a result of the program services (Szilagyi et al., 2000a). Primary care visits increased following enrollment; with no significant changes in ED or hospital use for asthma care, suggesting increased access to ambulatory services for these children. The authors hypothesize that uninsured children with asthma who gained health insurance coverage were more likely to receive care both for acute exacerbations of their conditions and for routine services because of reduced financial barriers (Szilagyi et al., 2000a). The results of these program evaluations suggest that the nation’s near-poor children will likely benefit from the recently implemented SCHIP program. The Pennsylvania study did not focus on the urban population, and although the New York statewide study did include New York City and both urban and rural regions throughout the state, low-income urban populations were still under-represented. Because the problems of poverty and lack of insurance may be distinctive for residents of large cities, the effects of insurance program expansion within major metropolitan areas may be even greater than those noted in the early demonstration programs. For example, the portion of children lacking a medical home in New York City was more than twice that of the state as a whole (11 percent versus 5 percent prior to expansion), and many of the access measures improved most in New York City, where baseline levels of access had been the poorest (Szilagyi et al., 2000c). In examining children’s health insurance expansions and anticipating the impact of SCHIP, it is important to keep in mind that children enrolled in SCHIP are from families with higher income than children enrolled in Medicaid and may have different characteristics and respond to insurance and health care differently. One study based on 1993–1994 NHIS data suggests that SCHIP-eligible children have markedly different socioeconomic and health status characteristics than either Medicaid or privately insured children (Byck, 2000). SCHIP-eligible children more often live with college-educated and employed adults than do Medicaid-eligible children, but less often than privately insured children. SCHIP-eligible children are more likely to be in excellent health than Medicaid children but also are twice as likely to be in fair or poor health than privately insured children (Byck, 2000).

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Health Insurance is a Family Matter Interactions and Covariance of Race and Ethnicity, Income, Immigrant Status, and Health Insurance Finding: Lower-income, minority, non-citizen, or uninsured children consistently have worse access and utilization than do children with none of these characteristics. These factors overlap to a large extent. However, each exerts its own independent effect on access and utilization. The finding that lower-income, minority, and uninsured children have worse access to and lower use of health care services than other children is well established (Newacheck et al., 2000a; Weinick et al., 2000; McCormick et al, 2001). Further, there is high overlap between poverty, minority status, and lack of insurance. Among children in one of these at-risk groups, 40 percent also belong to other at-risk groups (Newacheck et al., 1996). This high degree of overlap among risk groups means that results from studies on the impact of gaining insurance must be interpreted with caution. For example, when it is found that poor children have fewer physician visits, this result could be attributable partly to lack of insurance but also to the interplay of other characteristics (e.g., a parent’s inability to take time off from work or a different conception of the value of medical attention for certain kinds of health problems). The results presented in the preceding sections examine the effect of insurance on access and use that are isolated analytically from the effects of income and race or ethnicity. These adjustments help to measure the impact of health insurance status alone. However, more information would be helpful about the effect on utilization for a child who is both uninsured and a member of a minority group or who is uninsured and poor. Because these risk factors exert independent effects on access and utilization, children who are members of more than one at-risk group (e.g., African American and uninsured; poor and uninsured) tend to have even more difficulty using medical services than do children who are members of only one at-risk group. Using 1987 NMES data, researchers report that with few exceptions, being low income (below 100 percent FPL), a member of a minority racial or ethnic group, or uninsured is each independently and significantly related to six different measures of access to or use of primary care (Newacheck et al., 1996). When compared with the reference group of children who are white, not low income, and insured, children in each of these at-risk groups are less likely to have a usual source of care and more likely to not see a specific physician even if they have a usual source of care. They are also more likely to wait 60 minutes or more at their sites of care and more likely to go without after-hours emergency care. Uninsured children are least likely to have a usual source of care than the reference group (OR = 0.47), while low-income and minority children are least likely to see a consistent physician within their care site and are most likely to wait a long time for care at their care site (Newacheck et al., 1996).

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Health Insurance is a Family Matter BOX 6.2 Prenatal Care Professional and public health guidelines for prenatal care recommend a first visit for pregnancy-related care in the first trimester and regular visits at increasing frequency throughout the course of the pregnancy (DHHS, 2000; ACOG, 1989). The recommended number of visits over the course of pregnancy varies, depending on the source of the recommendation, and ranges from 13 to 14 prenatal visits to as few as 9 visits for low-risk pregnancies (ACOG, 1989; Public Health Service, 1989; McDuffie et al., 1996). Fully a quarter of pregnant women receive less than adequate prenatal care as measured by an index that takes both initiation of prenatal care and the number of visits into account (Kogan et al., 1998b; Minino et al., 2002). Women who belong to racial and ethnic minority groups on average receive less prenatal care than do non-Hispanic white women. In 1999, 74 percent of African-American and Hispanic women and 88 percent of non-Hispanic white women began prenatal care in the first trimester of pregnancy. 7, 6, and 2 percent of African-American, Hispanic, and non-Hispanic white women, respectively, had their first prenatal visit very late, in the third trimester of their pregnancy, or no prenatal care at all (NCHS, 2001). prenatal care late (OR = 2.54) and to have too few prenatal visits (Braveman et al. 1993). A number of studies examine changes in care patterns across entire populations when insurance coverage changes. These studies have taken advantage of the large-scale expansions of Medicaid coverage for previously uninsured women that began in 1986. Prior to these expansions, pregnant women were eligible for Medicaid only if they were single and received income support benefits or if they met very low income thresholds. By 1990, Medicaid eligibility was universal for all pregnant women and newborns in families with incomes below 133 percent of FPL, although states were allowed to raise the income ceiling to 185 percent FPL. Enrollment grew rapidly and the number of pregnant women with health insurance grew substantially (Howell, 2001).14 By 1991, 43 percent of women of childbearing age were eligible for Medicaid coverage and about a third of deliveries 14   Howell (2001) reviewed 14 studies examining the impact of these expansions and added a further study of her own. Five (5) of the 14 studies were national in scope, whereas the remaining 9 were conducted in individual states and generally involved linking data from Medicaid files to birth certificates. The methodologies varied. The early studies often used aggregate state or county data, which did not permit analyses by subgroup. Studies using this methodology were not able to examine impact for specific socioeconomic groups or birthweight categories. Nor were they able to examine impact on infant mortality since they did not include death certificates. Later studies linked individual birth and death certificate information to files that contained Medicaid enrollment information.

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Health Insurance is a Family Matter in that year were covered by Medicaid (Singh et al., 1994; Currie and Gruber, 1996a). However, a significant percentage of pregnant women remained uninsured. In California, for example, 11 percent of births in 1990 were to women who remained uninsured for prenatal care (Braveman et al., 1993). Some of the studies of the impact of the Medicaid program expansions examine changes in utilization across entire populations, rather than by comparing insured and uninsured groups. In general, these studies have found that among low-income women within a particular state, the timeliness with which prenatal care is initiated and the total number of visits are improved (Cole, 1995; Kenney and Dubay, 1995; Ray et al., 1997; Long and Marquis, 1998; Currie and Grogger, 2002). For example, a study in Florida in 1991 after its Medicaid expansion, found that the percentage of low-income women (including both uninsured and publicly insured women) who received no prenatal care dropped from 2.3 to 1.6, their total number of visits increased on average, and fewer women entered care late than had done so prior to the expansion in 1989 (Long and Marquis, 1998). Three nationwide studies comparing prenatal care indicators in counties that had expanded coverage to those without expansions report that the rate of timely initiation of prenatal care in counties with expanded programs is slightly higher (Cole, 1995; Kenney and Dubay, 1995; Dubay et al., 2001). Other studies have shown that improvements in prenatal use are limited to certain geographic areas (i.e., South and Midwest) and to some groups of women (e.g., white women, teenagers) (Cole, 1995; Coulam et al., 1995; Howell, 2001). State-level studies in four states (Tennessee, California, Massachusetts, and Wisconsin) show no difference in prenatal care use before and after expansion (Piper et al., 1990; Braveman et al, 1993; Haas et al. 1993b) whereas studies in three states (a later study in Tennessee, Missouri, and Florida) do find better prenatal care use following expansion (Coulam et al., 1995; Ray et al., 1997; Long and Marquis, 1998). The states with improvements in prenatal care use were those that had the most restrictive eligibility standards for Medicaid prior to the expansions (Howell, 2001). Several studies have examined the quality of prenatal care used by a cross section of privately insured, publicly insured, and uninsured women at a point in time, controlling for variables such as maternal education, marital status, race and ethnicity.15 The investigators find large differences in utilization between privately insured and uninsured women and smaller differences or no differences between uninsured and publicly insured women (Braveman et al., 1993; Amini et al., 1996; Bernstein, 1999). The researchers evaluating the California experience with a Medicaid expansion reported that uninsured and Medicaid-enrolled women as a single group are much more likely than those with private insurance to receive no prenatal care (OR = 6.7) (Braveman et al., 1993). 15   Even with these analytic adjustments for characteristics other than health insurance status that affect use and outcomes, cross-sectional studies are not as strong a research design as are longitudinal studies.

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Health Insurance is a Family Matter Hospital-Based Perinatal Care Finding: Health insurance status affects the care received by women giving birth and their newborns. Uninsured women and their newborns receive, on average, less prenatal care and fewer expensive perinatal services. At the time of delivery, the care received by uninsured women and their newborns differs from the care received by women and newborns that are covered by health insurance. Studies that have examined providers’ and pregnant women’s decision making find that uninsured pregnant women and their newborns are less likely to have certain more expensive maternity and neonatal services. Procedures and services such as cesarean sections and neonatal intensive care can have a substantial financial impact on providers. Researchers have also looked at whether patients of lower socioeconomic status have lower expectations for the care that they receive. Obstetric Services Insurance coverage affects the services women receive at childbirth. A study based on hospital data over the period 1987–1992 of rates of use of four obstetric procedures: cesarean section, use of fetal monitor, ultrasound, and induction of labor among women covered by Medicaid found that, among those most likely to have been without Medicaid prior to coverage expansions, use of each of these procedures increased. However, among those women who were most likely to have been covered by private health insurance before expanded Medicaid coverage, increased Medicaid coverage resulted in lesser use of these technologies at birth (Currie and Gruber, 2001). There is a strong relationship between insurance status and cesarean section rates, with uninsured women less likely to receive cesarean sections (Keeler and Brodie, 1993). It is difficult to determine the extent to which the differences in cesarean section rates between insured and uninsured women are due to overuse of the procedure among women with coverage and to underuse of the procedure among uninsured women. Overuse of cesarean section is well documented (ACOG, 2000; DHHS, 2000). Nonetheless, it is apparent that economic incentives are at work in the case of both insured women’s rates of cesarean section and uninsured women’s rates, incentives that act in opposite directions. At the time data were collected by Keeler and Brodie (1993), cesarean section charges, including both hospital and physician fees, were 66 percent higher than those for vaginal deliveries. Hospitals are unlikely to recoup fully the costs of care provided to uninsured women, and hospitals lose more money when deliveries are by cesarean section than when they are vaginal. Financial incentives also exist for the women themselves who are giving birth. Whereas out-of-pocket costs for mothers with fee-for-service insurance may be

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Health Insurance is a Family Matter low, uninsured mothers may face substantial out-of-pocket costs. Because of limited resources to pay for the deliveries of uninsured women, these women, their physicians, and hospitals all have incentives to opt for less expensive alternatives when clinical considerations allow for choice. Studies of cesarean section rates have the same methodological problem as other outcomes studies; health insurance status is associated with other factors such as age, race and ethnicity, income, and education that also affect these rates. Analyses adjust for at least some of these factors to isolate and measure the contribution of health insurance status to the likelihood of being delivered by cesarean section. Studies in California (Stafford, 1990; Stafford et al., 1993), Ohio, and Maine, New Hampshire, and Vermont (Aron et al., 2000) found substantial differences in adjusted cesarean section rates by payment source, with uninsured women having the lowest rates. The rates for women with public insurance tend to fall between those for uninsured and privately insured women. Haas et al. (1993a) reported an increase in cesarean section rates after expansion of Medicaid in Massachusetts. Some studies that have examined the relationship between health insurance status and rates of cesarean section have also taken clinical appropriateness into account. One study reported that in cases where cesarean section was more clearly indicated, such as with breech presentation, fetal distress, or failure of labor to progress, uninsured women were still significantly less likely than those with any form of insurance to receive a cesarean section (Stafford, 1990). Aron and colleagues (2000) found that after adjusting for a wide variety of maternal and neonatal risk factors, uninsured women were less likely to receive a cesarean section (OR = 0.65, p = .067). While not statistically significant at the conventional .05 level, this finding was consistent across all levels of clinical risk. Of particular concern is the lower rate of cesarean section among the very high-risk women who were uninsured. Site of Care Differences in the care received by low-birthweight babies with differing health insurance status may stem from differences in the resources available to the hospitals that predominantly treat patients with either private, public, or no coverage. A study conducted among maternity patients in San Francisco revealed that privately insured women at high risk for complications were much more likely to deliver at a hospital with neonatal intensive care facilities than were similar women with Medicaid or without insurance (Phibbs et al., 1993). Hospitals with more privately insured patients, especially those with more privately insured low-birthweight newborns, have more neonatal intensive care beds than do those with fewer such patients (Glied and Gnanasekaran, 1996). The result persists within hospital categories (public, private nonprofit, and proprietary) and after adjusting for low birthweight and other measures of patient need. Uninsured pregnant women and newborns may be more likely to be trans-

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Health Insurance is a Family Matter ferred between hospitals than are those with private insurance. A study conducted in southeastern Pennsylvania found that uninsured newborns were twice as likely (RR = 1.96) to be transferred to another general or specialty acute care hospital than were similar infants with private insurance, after controlling for prematurity, severity of illness, and expertise of neonatal care in the referring hospital (Durbin et al., 1997). Health Outcomes for Mother and Infant As depicted in Figure 6.1, health insurance status is hypothesized to affect the extent of premature deliveries and pregnancy complications in mothers and of low birthweight, mortality, and prolonged hospital stays for infants. The benefits of appropriate prenatal care accrue to both the newborn and the mother, resulting in improved birth outcomes, particularly in reduced rates of low birthweight and a subsequent reduction in infant mortality. For the mother, good prenatal care is expected to translate into reduced complications of pregnancy. Birth Outcomes Finding: Uninsured newborns are more likely to have adverse outcomes, including low birthweight and death than are insured newborns. Evidence of improvement in outcomes for newborns as a result of increased population health insurance rates is mixed, however. Box 6.3 presents national statistics on birth outcomes. Investigators have examined the effect of insurance on birth outcomes using measures such as low birthweight, prematurity, prolonged hospital stays, in-hospital services, and infant mortality. Low Birth Weight and Prematurity. Evaluations of Medicaid expansions to previously uninsured women have yielded mixed results for improvements in birthweight and rates of prematurity. Two of five national studies found no effect of increased insurance coverage of the population overall on these factors (Kenney and Dubay, 1995; Currie and Gruber, 1996a) while the remaining three found improvements only for select subgroups (white women and black teenagers [Cole, 1995]; white women without a high school diploma [Dubay et al., 2001]; white women had a lower incidence of very low birthweight babies [Currie and Grogger, 2002]). State-level studies also show mixed effects after widening Medicaid eligibility and expanding benefits. In Florida, Long and Marquis (1998) report a reduction in low birthweight for the expansion group relative to low-income women with private insurance. An expansion in Washington that includes supportive services and counseling was associated with a reduction in the ratio of low birthweight infants. Reduction was greatest among high-risk women with preexisting condi-

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Health Insurance is a Family Matter BOX 6.3 Neonatal Outcomes More than 4 million babies were born in the United States in 2000 (Martin et al., 2002). Low birthweight babies (less than 2,500 grams or 5.5 pounds) comprise 7.6 percent of all births, and very low birthweights (less than 1,500 grams or 3.25 pounds) account for 1.4 percent of all births (Martin et al., 2002). Preterm births account for 11.6 percent of the total number, with preterm births among non-Hispanic black women significantly higher at 17.4 percent of the total (Martin et al., 2002). The U.S. infant mortality rate for 2000 was 6.9 deaths per 1,000 live births; the second leading cause (after congenital abnormalities) was disorders related to short gestation and low birthweight: 15.4 percent of all infant deaths (Martin et al., 2002). Infant death rates among non-Hispanic whites and Hispanics were roughly the same at 5.6–7 deaths per 1,000 live births and were much higher among African Americans at 14.0 deaths per 1,000 live births (Martin et al., 2002). tions such as diabetes or hypertension (Baldwin et al., 1998). In Colorado, a state without additional supportive services, the rate of low-birthweight infants among medically high-risk women increased slightly during the same period. Infant Mortality. Infants of uninsured women are more likely to die than are those of insured women. In one region of West Virginia, the fetal death rate dropped from 35.4 to 7.0 per 1,000 live births after introduction of a prenatal care program for the uninsured (Foster et al., 1992). Despite this decline, the fetal death rate among uninsured women was still twice that among privately insured women, and the rate for the uninsured climbed again to 10.3 after the program was discontinued (Foster et al., 1992). A nationwide analysis of insurance coverage and Women, Infants, and Children (WIC) program participation based on the 1988 National Maternal and Infant Health Survey (NMIHS) found that despite the more adverse risk profile of infants born to mothers with Medicaid coverage compared to those born to uninsured mothers, uninsured infants had a significantly higher risk of death due to endogenous causes (i.e., those that are closely related to pregnancy and delivery) (OR = 1.42) than did either Medicaid (OR = 1.04) or privately insured infants (the comparison group) (Moss and Carver, 1998). Two studies of Medicaid expansions examined their impact on infant mortality (Currie and Gruber, 1996a; Howell, 2001). Currie and Gruber calculated an overall population reduction in infant mortality of 8.5 percent associated with a 30

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Health Insurance is a Family Matter percentage point increase in Medicaid coverage among women 15–44 between 1979 and 1992. The authors acknowledge that they are unable to determine whether the mortality decrease should be credited to better prenatal care or to more intensive hospital care after birth. Howell’s original analysis finds no significant differences in the rates of change in infant mortality for unmarried women as a function of the extent of Medicaid expansions between 1985 and 1991. She concludes that the decline in infant mortality found by some investigators after Medicaid expansions is in part a consequence of improvements in the care of fragile infants during the same time period and suggests that the Medicaid expansions provided additional resources to hospitals that allowed them to add, improve, or expand neonatal intensive care services (Howell, 2001). In Tennessee, no decrease was observed in infant mortality but there was also no increase in the use of prenatal care in the first trimester (Piper et al., 1990). In Missouri, Coulam and colleagues (1995) likewise found no impact on mortality but also report improvements in prenatal care among enrolled low-income teens. Prolonged Hospital Stays and In-Hospital Services. In the several years before Medicaid expansion (1982 to 1986), the percentage of newborns without health insurance in California increased by 45 percent (from 5.5 to 8.0 percent). Hospital discharge data on births to residents of selected counties show the consequences of this decline in coverage (Braveman et al., 1989). Researchers found that the increasing uninsured rate over time was associated with an elevated and increasing risk of adverse outcomes in newborns (defined as prolonged hospital stay, transfer of the newborn to another institution, or death), after adjusting for race or ethnicity. These results are most marked in African-American (OR = 2.24) and Hispanic populations (OR = 1.56). The authors suggest that inadequate and diminishing access to care accounts for the increased rates of adverse outcomes and that this disproportionately affects minority populations. Looking at length of hospital stay alone, on average, uninsured infants do not stay as long in the hospital or receive the same scope of services while in the hospital as do privately or publicly insured infants. A retrospective analysis of discharge data from all California acute care hospitals demonstrated a link between newborns’ insurance coverage and the allocation of hospital services as measured by total hospital charges and charges per day (Braveman et al., 1991). After controlling for race and ethnicity, diagnoses, hospital characteristics, and disposition, sick newborns without insurance received fewer inpatient services than did comparable privately insured newborns. The mean stay was 15.7 days for privately insured newborns, 14.8 days for Medicaid-covered newborns, and 13.2 days for uninsured newborns. Resources for newborns covered by Medicaid were generally greater than for uninsured and less than for privately insured newborns, despite the fact that both uninsured and Medicaid-covered newborns had more severe medical problems than did those with private coverage.

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Health Insurance is a Family Matter Maternal Outcomes Finding: Uninsured women are more likely to have poor outcomes during pregnancy and delivery than are women with insurance. Studies have not demonstrated an improvement in maternal outcomes related to health insurance alone. Studies find that uninsured women have higher rates of adverse maternal outcomes, such as pregnancy-related hypertension, placental abruption, and extended hospital stays, than do privately insured women (Weis, 1992; Haas et al., 1993a). Despite the greater likelihood of maternal complications, uninsured women have shorter hospital stays than either publicly or privately insured women (Weis, 1992). Although better prenatal care may be associated with better obstetrical outcomes, insurance coverage alone may not be enough to improve infant or maternal outcomes detectable at the population level (Weis, 1992; Haas et al., 1993b). Smoking, substance use, poor diet, and other health-related behaviors affect birth outcomes and providing health insurance coverage alone is unlikely to change these behaviors (Joyce, 1987). With respect to the use of prenatal care, other factors beyond insurance, such as the mother’s level of education, the availability of providers in general and a regular source of care in particular, may also be important determinants (Braveman et al., 2000). The point at which health insurance becomes available to women of childbearing age also affects the adequacy and timeliness of prenatal care, which become important when examining the effect of coverage on birth outcomes. Ellwood and Kenney (1995) note that depending on the state, 39 to 54 percent of women enrolled in Medicaid after the first trimester of pregnancy. When the State of Washington, in addition to providing insurance coverage, also provided assessment, education intervention, and nutritional and psychosocial counseling to pregnant women and targeted case management to women needing further services, substantial improvements in birthweight were achieved for high-risk mothers (Baldwin et al., 1998). Another study in California reports that provision of at least one nutrition, psychosocial, and health education service session each trimester of care is significantly associated with better birth outcomes, compared to provision of fewer sessions (Homan and Korenbrot, 1998). Nonetheless, insurance remains an important determinant of access to and utilization of health care by low-income women, who have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts (Salganicoff and Wyn, 1999). SUMMARY Having health insurance increases the chances that infants, children, and pregnant women will receive preventive services when well and timely medical

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Health Insurance is a Family Matter care when sick or at high risk of poor outcomes. These, in turn, help avoid unnecessary hospitalizations, premature births, extended morbidity, or even death. Less Access and Use Uninsured children have poorer access to health care, use fewer services, and delay seeking care. This scenario repeats itself for uninsured pregnant women and newborns. Having a medical home is a hallmark of quality pediatric care, and uninsured children are less likely to have a medical home than are children with health insurance of any kind. The deficits in health services for the uninsured extend to preventive medical, dental, and mental health care for children and youth; care when a child is sick or has special health care needs; access to prescription medications; prenatal care, more expensive obstetrical procedures, and length of maternal stay; and specialized care such as interventions for children with injuries or coarctation of aorta. Too often uninsured parents do not seek care that insured parents and their providers would consider necessary. Disparities stem from their financial constraints and from providers’ decisions to provide less intensive services to uninsured patients or the failure to develop health facilities that are geographically accessible to uninsured populations. Interplay of Insurance with Race, Poverty, and Immigrant Status Low-income, minority, non-citizen, and uninsured children and pregnant women fare worse than those with health insurance in access to care. Uninsured children and pregnant women usually have one or more of these additional risk factors. Each characteristic exerts its own independent effect on access and utilization, but insurance remains a significant factor even after controlling in research studies for poverty, race, and ethnicity (Haas and Adler, 2001). Those who are members of more than one risk group have greater difficulty obtaining care and worse health outcomes. Type of Insurance Children and pregnant women with private health insurance are most likely to receive adequate health care. Generally, those with no health insurance have the least adequate care, and those with Medicaid coverage have access and utilization experiences intermediate between the privately insured and the uninsured.

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Health Insurance is a Family Matter Lack of private insurance is a strong risk factor for receiving inadequate medical care for children or inadequate prenatal care. On measures of access and use, generally the uninsured have the least access to and use of health care services, with persons with Medicaid coverage being intermediate between those who are uninsured and those with private insurance. Sometimes, however, there is little difference between having Medicaid coverage and being uninsured. Children insured through public programs are at greater risk than privately insured children of experiencing periods without coverage because of the frequent need to reestablish eligibility. These gaps may interrupt relationships with a usual source of care, resulting in access problems comparable to those faced by the uninsured. Studies of Expanded Insurance Coverage Natural experiments that compare the experiences of a population before and after expansion of public insurance coverage demonstrate improvements in access to and use of care for uninsured children and frequently for pregnant women as well. These natural experiments allow assessment of population-wide changes in care patterns when insurance coverage is made available. In the public program expansions and demonstrations reviewed earlier in this chapter, newly insured children experienced increased access to a medical home and were more likely to visit primary care practitioners, specialists, and dentists. In one state, this increased access was accompanied by a 5 percent decrease in emergency department use and, in the other, by a 36 percent decline in hospitalizations. Investigators generally, but not always, find that timeliness of initiating prenatal care and the total number of prenatal visits for low-income women are better after the Medicaid expansions. The states with the greatest improvements tended to be those that had the most restrictive eligibility prior to expansion. Health Impact of Delayed or No Care When needed care is delayed or nonexistent, health can deteriorate. We have the ability to prevent or control many of the health problems associated with common childhood conditions that can have a long-term detrimental impact on children’s development and opportunities in life. This argues for access to well-child care for all children to identify problems early and manage chronic conditions effectively. Delays in receipt of care when acutely ill are also more common for uninsured children than for those with coverage. Uninsured children are more likely to be hospitalized than privately insured children for conditions such as pneumonia or asthma because they are less likely to receive appropriate care early in the course of their illness. Similarly, women with less prenatal care, particularly those at high risk of complications, may have worse obstetrical outcomes. The newborns of uninsured mothers have longer hospital stays and have a higher mortality rate. Uninsured mothers themselves have higher rates of complications

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Health Insurance is a Family Matter of delivery than do privately insured women but have shorter hospital stays despite more maternal complications. Improving Health Outcomes Through Expanded Insurance Coverage Evaluations of expansions in health insurance coverage for children and pregnant women indicate that health outcomes improve with coverage. Children’s access to and utilization of appropriate health care, a positive outcome in itself, improves with higher rates of insurance coverage. In examining population-wide improvements in birthweight and prematurity due to public insurance expansions, some states found no improvement while others identified progress for selected groups (e.g., white women and black teenagers). Attributing improvements in infant mortality to insurance expansions is complicated by co-occurring improvements in neonatalogy. The population effect of public insurance eligibility expansions on utilization and health outcomes is less than some experts would predict based on the substantial number of pregnant women who are eligible. However, a significant number of eligible women do not enter prenatal care in the first trimester or enroll at all. This chapter has reviewed the research addressing the impact of insurance status on access to health care, its use, and ultimately, health outcomes for children, pregnant women, and newborns. Although having insurance makes a difference, simply making insurance available may not be enough to improve health care and health outcomes for all of the uninsured. Some high-risk groups may require additional services (e.g., educational interventions, targeted case management) if they are to obtain good preventive and routine care.