New Findings on Poverty and Child Health and Nutrition Summary of a Research Briefing (1998) / Chapter Skim
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chose this issue as the subject of its third annual research briefing on welfare anc3 chilciren's development. The briefing, held in May 1997, was cosponsorec3 by the Family anc3 Child WellBeing Research Network (of the National Institute of Child Health anc3 Human Development, U.S.
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Research on children's insurance coverage, as a major determinant of their access to care, is relatively new and has received focused attention in today's policy context. The research on this issue presented at the briefing comes from the new Community Tracking Study, new analyses of the National Health Interview Survey, and a new survey of state Medicaid officials.
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Appenclix B contains a list of projects monitoring the effects of welfare reform. The presenters were selected through a lengthy process of peer nominations, starting with calls to major experts on child poverty, health, anc3 nutrition.
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Researchers studying the relation between income and poverty and the health of children and youth have found that child health varies by family income, with the percentage of children and adolescents in very good or excellent health rising as family income increases2 (Federal Interagency Forum on Child and Family Statistics, 1997~. Researchers have also shown that health problems affecting children in the United States, including iron deficiency anemia, underweight and obesity, and asthma, are more prevalent among the poor (Newacheck et al., 1994; Wise and Meyers, 1988~.
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poverty thresholds, based on family income and size at the 12-month assessment (conducted in 1996~. Regarding neighborhood income, families living in neighborhoods in which fewer than 10 percent of neighbors earned more than $30,000 were designated as poor; families in neighborhoods in which 10 to 29 percent or more of neighbors earned $30,000 or more were designated as middle income; and families in neighborhoods in which 30 percent or more of the neighbors earned more than $30,000 were designated as affluent.
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and 29 percent lived within 150 percent of poverty ($24,000~; 19 percent lived in families that had received some form of social welfare within the previous month. The study found that the effects of poverty and welfare receipt on health and risk be 4Subsequent to the research briefing, the first data from the Add Health study were released (in September 1997~.
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for , , , each neattn outcome, adolescents who live below poverty experience poorer health than nonpoor adolescents; in most cases, the welfare poor those receiving either Aid to Families with Dependent Children (AFDC) or food stamps have the poorest 1 1 1 1 .
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c Welfare poor adolescents live in families with income below the poverty line and receipt of either AFDC or food stamps. SOURCE: Data from Harris ~ 1 997]
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Wickrama of Iowa State University, explored adolescent health in a rural economy, specifically the effect of family economic pressure on adolescent physical health status. The study (Conger and Wickrama, 1997)
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What is the role of the family alone anc3 jointly with health providers in promoting health among adolescents living in high-risk communities? How will recent changes in health care delivery affect this age group, anc3 will the effects cliffer by family income anc3 economic composition of the neighborhooc3?
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Under the proposed Performance Partnership Grants Program, each state must negotiate a maternal and child health action plan with the U.S. Department of Health and Human Services in 1998; the plan will include perfor' mance objectives that are specific in terms of outcomes, processes, and capacity, and that can be achieved over 3 to 5 years.
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Studies have shown, for example, that poverty affects pregnant women's nutritional status by reducing in' come available for food and failing to ensure that fetuses receive the nutrition essential to normal brain development. Malnutrition in young children can leac3 to iron deficiency and growth failure.
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American children living in families that no longer receive food benefits and whose incomes under welfare reform do not compensate for overall benefit losses. And studies overseas of iron deficiency anemia, which affects an estimated 25 percent of infants worldwide (Florentino and ~ ~u~rr~ec, 1984)
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A separate study in Chile found slower nerve conduction in the auclitory pathway among 6-month-oic3 infants with iron clefi ciency anemia, according to Lozoff. Differences were not corrected after a year of iron therapy (Roncagliolo et al., 1996~.~2 This is the first direct eviclence that iron deficiency alters brain development in human infants.
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However, she noted, toddlers and preschoolers still suffer from anemia (Yip et al., 1992~; adolescents are also at risk due to rapid growth and poor diet (Looker et al., 1997~. Because of the changes resulting from welfare reform, researchers may need to monitor populations such as the children of immigrants and the near-poor who may no longer be enrolled in entitlement programs that provide food benefits.
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The aim of the studies was to assess the differential effect of two dietary supplements, Atole (a highly nutritious supplement containing 163 kcal/682 kI and ~ ~ .5 g protein per cup) and Fresco (a less nutritious supplement containing 59 kcal/247 kI and O g protein per cup)
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Figure 3 Effect of Supplementation on Vocabulary Scores, by Degree of Poverty {Guatemala, ~ 988-89} 30 Lo .a: ~ 25 Q ~ 20 o a: o ~ 10 supplement ~ Fresco supplement 26 5 27 28 o 26 2S 19 Severe Moderate Degree of Poverty SOURCE: Adapted from Brown and Pollitt t1996~. to Guatemalan mothers, infants, anc3 young children up to age 3.
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More than 25 million Americans used food stamps in 1996. The study, the 18 first to measure monthly cycles nationally, used two nationally representative surveysthe Bureau of Labor Statistics' Diary Consumer Expenditure Survey (CEX)
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Aclults absorbec3 almost the full cirop in food intake, eating significantly less in the fourth week than in the first. Food intake for children and aclo' lescents remained fairly constant over the food stamp month, inclicating that parents may be protecting their children from the cirop in food at month's end (or may be reluctant to report that their children are going hungry)
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Or other household differences between AFDC recipients and nonrecipients could be responsible, according to the study. Wilde and his colleagues called for further research to assess the nutritional implications of the cycle of food intake, as well as for the addition to current national surveys of questions related to the time of month when households receive cash income; surveys currently ask only when households receive food stamps.
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with medical reports on nutritional status of the children. in a separate study, Frank anc3 her colleagues tested the hypothesis that poor families' receipt of housing subsidies is associated with improved nutritional status in their children (Meyers et al., 1992/93~.
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1 7For existing research on the ejects of school nutrition programs, WIC, and food stamps on children and youth, see Fraker, 1990a and l990b; Fraker et al. 1995; Gordon et al., 1995; and Devaney et al., 1989 and 1990.
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, using data from the 1987 National Medical Expenditure Survey, found that uninsured children anc3 youth received 70 percent of the outpatient visits received by similar children anc3 youth with insurance, anc3 about 75 to 85 percent of the inpatient clays. Furthermore, children anc3 adolescents who lack health insurance are less likely to have a usual source of care, are less likely to be immunized anc3 receive well~baby care or well~chilc3 care, anc3 are more likely to be hospitalized for conditions that could be avoiclec3 (Kasper, 1987; Rosenbach, 1985; Short anc3 Leftkowitz, 1992; Leftkowitz anc3 Short, 1989~.
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, compared to children and youth covered by private insurance. Low-income children with Meclicaic3 have improved access to care compared to uninsured poor children; however, compared to children living above the poverty level, they are less likely to receive routine care in physicians' offices and more likely to lack continuity of i8For further discussion of problems in access to health care and related services by adolescents, see Office of Technology Assessment, 1991.
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are more likely to have a well~child visit; but even if all chil' dren under 200 percent of the poverty line had Medicaid, low income children would lag behind other children in their use of preventive services (Short and I-eftkowitz, 1 992~.l9 Despite the expansion of Medicaid and increases in coverage over time, many chil' dren and youth lack health insurance. Kogan and colleagues (Kogan et al., 1995)
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Fourteen percent of uninsurec3 children are African-American. 2iThis figure is lower than the 9.8 million uninsured children that is most commonly used in the policy debate on uninsured children, and which comes from the March 1996 Current Population Survey, which asked about insurance coverage during 1995.
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"Our data needs reflect the agency's change from having a primary focus on regulating the health care market to simply understanding it." James Welsh, New York State Department of Health If parents lack access to employer-sponsorec3 insurance coverage for their chilciren anc3 are unable or unwilling to purchase policies incliviclually, they can either go uninsurec3 or seek public assistance. The CTS study estimated that about 20.3 million children are eligible for benefits through Meclicaic3, the primary public insurance program for chilciren.22 Slightly over half of these are enrolled in Meclicaic3, anc3 another 6 percent have other types of public insurance.
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[ 1 997~. Parents ~unemployed 1 49% Figure 6 Reasons Why Working Parents of Uninsured Children Are Ineligible for Employer-Offered Health Benefits Other reasons 10% Do not work enough hours/on-call 32% SOURCE: Data from Reschovsky et al.
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Even with Medicaid coverage. lowincome children and adolescents can have reduced access to after-hours care, reduced access to a regular provider, and higher rates of dissatisfaction with the quality of their care, compared with nonpoor children and ~, 1 1 1 1 .
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To find out more about current trends in Medicaid enrollments, specifically how Medicaid managed care policies affect children and adolescents, Fox Health Policy Consultants conducted telephone surveys of state Medicaid officials in the fall of 1996, and reviewed 1996 managed care contracts, referenced documents, and contract language revisions (Fox et al., 1997~. According to preliminary results of the survey, presented at the research briefing by Harriette Fox of Fox Health Policy Consultants, all states but one have enrolled or will enroll Medicaid-eligible children and youth in some form of Medicaid managed care.
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definition of poverty, which classifies as poor those families and unrelated individuals with pretax money income below the applicable poverty threshold for the family size; the poverty threshold for a two-adult, two-child family in 1993 was $14, 654 {U.S. Bureau of the Census, 1995]
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Nor a full list of strategies to enhance preventive and primary care services for high-risk children in HMOs based on a review of the literature, a survey of HMOs, a review of Medicaid-HMO contracts, and site visits see McManus Health Policy, Inc., and Fox Health Policy Consultants, 1995. For more information on how the identi fied strategies are carried out in specific programs, see Fox Health Policy Consultants, 1996, and McManus Health Policy, Inc., 1996.
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Another study found that managed care plans selectec3 anc3 served healthier children (Scholle et al., 1997~; if this phenomenon is wiclespreac3, fee-for-service Meclicaic3 may experience increased problems as it serves a population with poorer baseline health. The research presented on changing patterns of health insurance coverage raises a number of questions, including: How can accurate counts of the number of uninsured children anc3 youth be obtained ?
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· State officials lack a reliable estimate of the number of uninsured children anc3 youth, making it difficult to identify anc3 provide coverage to those children anc3 aclolescents. · States often have difficulty collecting data across states anc3 tracking children anc3 adolescents as they move.
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· Communities and states do not always work together on issues of access to health care and use of data, identifying the effective elements of community coalitions so that community members' concerns and suggestions are incorporated into policy. In the context of these challenges, state officials highlighted the need for research that: · is longitudinal, with a focus on how a wide array of factors affect child health, starting in the prenatal period or even prior to conception; · assesses the differential effect of health care for families with different levels of income (by studying families in poverty as well as those newly out of poverty)
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Healthy Start Healthy Start is a five-year, 15-site, community-based demonstration program to reduce infant mortality rates by 50 percent (Mathematica Policy Research, Inc., and Harvard School of Public Health, 1997~. The project was launched in 1992; the evaluation started in 1 993 and a final report is expected in 1998.
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Healthy Steps expands traditional medical boundaries beyond monitoring physical health, to include the promotion of child development and family nurturing. The program has eight components: Enhanced strategies in well-child care, periodic home visits, a child health ant!
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Start Healthy, Stay Healthy Millions of young children and adolescents ~ . trom tow-1ncome working families lack health insurance and are missing out on benefits available to them through Meuic aiu.
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By facilitating the enrollment of these children in Medicaid and similar state-funded programs, Start Healthy, Stay Healthy seeks to reduce the number of children who are uninsured or underinsured. The problem of uninsurance or underinsurance becomes increasingly significant under welfare reform, as fewer children are expected to qualify for cash assistance programs.
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Researchers made a number of recommenuations, including training health educators and advocates from the community to re auce misunderstandings. Healthy Communities In more than 1,200 locations States, communities are addressing issues of how to get well and stay healthy through a movement called Healthy Communities (also known as Healthy Cities)
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The Asset-Based Community Development Institute Established in 1995, the Asset-Basec3 Community Development Institute (ABCD) seeks to disseminate two clecacles of research on capacity-builcling community clevelopment (Asset-Basec3 Community Development Institute, 1997~.
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A number of projects are monitoring the effects of TANF on low-income children and youth and their families (few monitor or measure child health and nutrition outcomes related to welfare reform1.
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In addition, the National Institute of Child Health and Human Development (NICHD) Family
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. State Documerltatiorl Project, Center for Law arid Social Policy arid Center ort Bud' get arid Policy Priorities: Using "reporters" at the state level, this project will monitor, document, anc3 analyze how the 50 states restructure their welfare policies, cash assis' tance programs for poor families, anc3 food stamp anc3 Meclicaic3 programs, anc3 assess policy trencis around the country.
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The project is supported in part by the I-ynde and Harry Bradley and Charles Stewart Mott Foundations. · Welfare reform analysis, Center for Child arid Family Policy Research, School of Public Policy arid Social Research, University of California at I-os Ar~geles: This center, which conducts and promotes research, .
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Conger, Rand D., and K.A.S. Wickrama 1997 Family Economic Pressure and Adolescent Physical Health Status.
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Almeida 1997 Current Policies arid Future Directions ire State Medicaid Managed Care Arrar~gemer~ts for Children. Washington, D.C.: Fox Health Policy Consultants, March.
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Kohrman, Claire H 1997 Sociocultural Influence on Child Health.
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Washington, D.C.: McManus Health Policy, Inc., and Fox Health Policy Consultants. McManus Health Policy, Inc., and Fox Health Policy Consultants 1995 Strategies to Enhance Preventive and Primary Care Services for High-Risk Children in Health Maintenance Organizations.
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from the Community Tracking Study. Paper presented at research briefing, Board on Children, Youth, and Families, May 1920, 1997.
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Department of Health and Human Services, July. Spillman, Brenda 1992 The impact of being uninsured on the use of basic health care services.
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Arlington,Va.: NationalCenter for Education in Matemal and Child Health. Holahan, John 1997 Expanding Insurance Coverage for Children.
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Maynard 1995 EEects of welfare reform on teenage parents and their children. The Future of Childrer 5 ~ 2 Summer/fall 1995:53 - 71.
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Phillips, Deborah, and Anne Bridgman, eds. 1995 New Fir~dir~gs ore Children, Families, arid Economic Self-Sufficier~cy: Summary of a Research Briefing.
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GUERRA, San Antonio Metropolitan Health District, Texas BERNARD GUYER, Department of Maternal and Child Health, Johns Hopkins University AI-ETHA C HUSTON, Department of Human Ecology, University of Texas, Austin RENEE JENKINS, Department of Pediatrics and Child Health, Howard University Hospital SARA McI-ANAHAN, Office of Population Research, Princeton University ROBERT MICHAEI-, Harris Graduate School of Public Policy Studies, University of Chicago PANIC NEWACHECK, Institute of Health Policy Studies and Department of Pediatrics, University of California, San Francisco MARTHA PHII-I-IPS, The Concord Coalition, Washington, D.C.
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Department of Health anc3 Human Services AMY FINE, Association of Maternal anc3 Chilc3 Health Programs HARRIETTE FOX, Fox Health Policy Consultants DEBORAH FRANK, Growth anc3 Development Program, Boston Medical Center RUTH T GROSS, Department of Pediatrics (Emerita)
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SUSAN NALDER, Maternal Child Health Epidemiology, Public Health Division, New Mexico Department of Health PAUL NEWACHECK, Institute of Health Policy Studies and Department of Pediatrics, University of California at San Francisco ERNESTO POLLITT, Department of Pediatrics, University of California at Davis, and Visiting Scholar, The World Bank JAMES RESCHOVSKY, Center for Studying Health System Change MARYBETH SHINN, Department of Psychology, New York University MARIAN SIGMAN, Department of Psychiatry, University of California at Los Angeles THEODORE WACHS, Department of Psychological Sciences, Purdue University JAMES WELSH, Division of Planning and Policy and Resource Development, New York State Department of Health KATHY WIBBERLY, Office of Health Policy, Virginia Department of Health K.A.S. WICKRAMA, Center for Family Research, Iowa State University PARKE WILDE, Department of Agricultural Resource and Managerial Economics, Cornell University PAUL H
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New Firrdir~gs or Chit~rerr, Families, Arid Economic Self-Sufficier~cy: Summary of a Research Briefing (1995) The Impact of War or Child Health ire the Countries of the Former Yugoslavia: A Workshop Summary (with the Institute of Medicine and the Office of International Affairs of the National Research Council)
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(1994) Protecting and Improving the Quality of Care for Children Under Health Care Reform: Workshop Highlights (with the Board on Health Promotion and Disease Prevention of the Institute of Meclicine)
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The National Academy of Sciences is a private, nonprofit, self~perpetuating society of distin' guished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters.
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