Health Insurance is a Family Matter (2002) / Chapter Skim
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6 Health-Related Outcomes for Children, Pregnant Women, and Newborns
6 Health-Related Outcomes for Children, Pregnant Women, and Newborns
Pages 106-139
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From page 106... ...
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From page 107... ...
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.
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From page 108... ...
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are reported for insured and uninsured children, pregnant women and infants remain valid even as journal articles and unpublished studies brought to the Committee s attention by experts were included if they met the other criteria mentioned above.
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From page 109... ...
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~.
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From page 110... ...
5The 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)
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From page 111... ...
, 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 ethn~city, and health status.
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From page 112... ...
, 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.
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From page 113... ...
(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.
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From page 114... ...
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)
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From page 115... ...
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 (S~ilagy~ et al., 2000a)
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From page 116... ...
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~.
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From page 117... ...
experience at least one unmet health care need, but both children below 100 percent FPL and those with family incomes between 100 and 200 percent FPL were more likely to have an unmet need (medical, dental, medication, or vision) than were higher income children, after controlling for health insurance status.
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From page 118... ...
The Institute of Medicine National Research Council Committee on the Health and Adjustment of Immigrant Children and Families concluded that health care for children in immigrant families benefits both from insurance coverage and from families efforts to establish an ongoing connection with the health care system, as is the case for all children (Hernandez and Charney, 1998~. Only 66 percent of foreign-born children of lower-income working families have access to a regular source of care compared with 92 percent of lower-income U.S.-born children (Guendel~nan et al., 2001~.
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From page 119... ...
Children with Special Health Care Needs Finding: Uninsured children with special health care needs are more likely than are 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 prescnptions. Approximately 18 percent of U.S.
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From page 120... ...
. As is true for uninsured children generally, uninsured children with special needs are more likely than insured children to · be without a usual source of health care (OR = 5.8 )
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From page 121... ...
When no care is sought, this introduces a methodological limitation to studies of health outcomes dependent on insurance status: rates of"no shows" can be quantified only indirectly and the attendant health consequence may be difficult to quantify. Pent-up demand for care clearly exists for uninsured children, as illustrated by the evaluation of the Pennsylvania insurance expansion described earlier: the portion of children reporting unmet need dropped from 57 percent to 16 percent 12 months following the program expansion (Lave et al., 1998a)
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From page 122... ...
In the worst cases of delayed care seeking on the part of families and the failure of the health care system to provide the same intensity of services to uninsured children, the uninsured child has a greater risk of dying. Uninsured children with certain diagnoses have been found to be more likely to die than insured children, due to failure to reach a hospital or receive appropriate specialized care until late in the course of the illness and to the greater severity of illness at presentation resulting from delayed care.
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From page 123... ...
Lack of insurance is one barrier to timely and appropriate primary care, and several studies have explored ACSCs for child populations and their relationship to insurance status. As in cross-sectional studies of ACSCs for adults, cross-sectional studies of children find that those enrolled in Medicaid have higher population rates of hospitalizations for ACSCs than do either privately insured or uninsured children (Pappas et al., 1997; Parker and Schoendorf, 2000; Shi and Lu, 2000~.
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From page 124... ...
The increase was greatest among previously uninsured children and among those who had had a gap in insurance coverage longer than six months. As noted previously, visits to health department immunization clinics decreased by 67 percent and visits to primary care providers offices increased by 27 percent (Rodewald et al., 1997~.
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From page 125... ...
Importantly, the long-term health risks of iron deficiency are frequently interrelated with other detrimental environmental exposures and social and economic depnvations, which may intensify the likelihood of poorer outcomes (Lozoff et al., 1998; Shonkoff and Phillips, 2000~. Dental Disease Dental care is incorporated into employment-based health insurance plans less often than it is excluded (KPMG, 1998~.
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From page 126... ...
One multicenter study of children with asthma assessed the quality of asthma care received by uninsured children as significantly worse than that received by insured children (Ferris et al., 2001~. As discussed earlier in this chapter, a beforeand-after comparison study of an SCHIP prototype program in New York found that asthma care and parent-evaluated health outcomes for children with asthma improved after enrollment in the program (S~ilagyi et al., 2000a)
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From page 127... ...
Although evidence of the importance of ADHD as a health and developmental problem is plentiful, the impact of health insurance coverage on receipt of appropriate care for this condition is lacking, as it is for child mental health services in general. 127 PRENAT~ AND PERINAT~ ARE AND OUTCOMES This section examines how health insurance status affects the receipt of health care by uninsured pregnant women and outcomes for both mother and child.
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From page 128... ...
A recent study based on the national Community Tracking Study Household Survey conducted in 1996 and 1997 reports that, on average, uninsured women have fewer prenatal care visits that women with health insurance and 15 percent had no prenatal visits, compared to 4 percent of women with private or public coverage (Bernstein, 1999~. This same study found that 29 percent of uninsured pregnant women did not have a usual source of care, compared to 14 percent of women with Medicaid and 9 percent of those with private health insurance.
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From page 129... ...
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.
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From page 130... ...
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.~5 The investigator 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)
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From page 131... ...
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~.
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From page 132... ...
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~.
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From page 133... ...
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.
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From page 134... ...
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)
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From page 135... ...
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.
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From page 136... ...
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)
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From page 137... ...
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.
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From page 138... ...
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.
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From page 139... ...
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.
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