Geography matters: state-level variation in children's oral health care access and oral health status.

OBJECTIVES: To ascertain differences across states in children's oral health care access and oral health status and the factors that contribute to those differences. STUDY DESIGN: Observational study using cross-sectional surveys. METHODS: Using the 2007 National Survey of Children's Health, we examined state variation in parents' report of children's oral health care access (absence of a preventive dental visit) and oral health status. We assessed the unadjusted prevalences of these outcomes, then adjusted with child-, family-, and neighbourhood-level variables using logistic regression; these results are presented directly and graphically. Using multilevel analysis, we then calculated the degree to which child-, family-, and community-level variables explained state variation. Finally, we quantified the influence of state-level variables on state variation. RESULTS: Unadjusted rates of no preventive dental care ranged 9.0-26.8% (mean 17.5%), with little impact of adjusting (10.3-26.7%). Almost 9% of the population had fair/poor oral health; unadjusted range 4.1-14.5%. Adjusting analyses affected fair/poor oral health more than access (5.7-10.7%). Child, family and community factors explained ∼» of the state variation in no preventive visit and ∼½ of fair/poor oral health. State-level factors further contributed to explaining up to a third of residual state variation. CONCLUSION: Geography matters: where a child lives has a large impact on his or her access to oral health care and oral health status, even after adjusting for child, family, community, and state variables. As state-level variation persists, other factors and richer data are needed to clarify the variation and drive changes for more egalitarian and overall improved oral health.

The impact of managed care on children's access, satisfaction, use, and quality of care.

OBJECTIVE: To examine the impact of managed care on children's access, satisfaction, use, and quality of care using nationally representative household survey data. DATA SOURCE: The 1996 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: Bivariate and multivariate analyses are used to detect independent effects of managed care on access, satisfaction, utilization, and quality of pediatric health services. DATA COLLECTION/EXTRACTION METHODS: Data were obtained from rounds 1, 2, and 3 of the 1996 MEPS. MEPS collects data on health care use, insurance, access, and satisfaction, along with basic demographic and health status information for a representative sample of the U. S. civilian, noninstitutionalized population. Our sample consists of 5,995 children between the ages of 0 and 17. FINDINGS: Among the 18 outcome indicators examined, the bivariate analysis revealed only three statistically significant differences between children enrolled in managed care and children in traditional health plans: children enrolled in managed care were more likely to receive physician services, more likely to have access to office-based care during evening or weekend hours, and less likely to report being very satisfied with overall quality of care. However, after controlling for confounding factors, none of these differences remained statistically significant. CONCLUSIONS: Our findings suggest that there are no statistically significant differences in self-reported outcomes for children enrolled in managed care and traditional health plans. This conclusion is provisional, however, because of limitations in the data set.

A comparison of health care experiences for medicaid and commercially enrolled children in a large, nonprofit health maintenance organization.

BACKGROUND: Proponents of Medicaid managed care have argued that this type of care offers the potential to provide mainstream health care for poor children and the elimination of the 2-tier system of care that has long existed for poor and nonpoor children. However, few studies have attempted to assess whether differences in access, utilization, and satisfaction exist between Medicaid and commercially sponsored children who are enrolled in the same managed care plan. OBJECTIVE: To systematically answer the following research question: Within the same large, nonprofit, group-model health maintenance organization (HMO), how do children enrolled in Medicaid compare with children enrolled commercially across the domains of access, utilization, and satisfaction with care? METHODS: We compared access, satisfaction, and utilization of services between Medicaid and commercially sponsored children enrolled in Kaiser Permanente of Northern California during 1998 through use of a telephone survey and administrative data. Kaiser Permanente is a nonprofit, integrated, group HMO that serves 2.8 million members in more than 15 counties in northern California. The sample for this survey included 510 Medicaid-enrolled children and 512 commercially enrolled children. An overall response rate of 82% was achieved. Bivariate and multivariate analyses were used to compare Medicaid and commercially enrolled children. RESULTS: We found few differences between commercial and Medicaid enrollees across the domains of access, utilization, and satisfaction. Where access differences were present (problems in finding a personal care provider, problems getting care overall, and experiencing 1 or more barriers to care), the differences favored Medicaid-enrolled children. That is, Medicaid enrollees were reported to experience significantly fewer access problems and barriers than commercial enrollees, even after adjustment for confounding factors. Only one difference was found between Medicaid and commercial enrollees across the 6 utilization variables examined (volume of emergency department visits), and no differences were found among the 4 satisfaction and 2 global assessments of care received. Taken together, our results suggest that Medicaid-enrolled children experience as good as or better care than their commercially enrolled counterparts. However, there are other possible explanations for our findings. It may be that families of Medicaid-enrolled children hold their care providers to a lower standard than families of commercially enrolled children, given historic inequities in care between poor and nonpoor families. In addition, some degree of selection bias may be present in our sample, although that is true for both the Medicaid and commercial populations. CONCLUSIONS: Our findings suggest that large commercial HMOs are capable of eliminating the access barriers and stigma traditionally associated with the Medicaid program. However, this conclusion must be tempered with the knowledge that other explanations for our findings may also be at play.

Access to health care for children with special health care needs.

OBJECTIVE: To assess the role health insurance plays in influencing access to care and use of services by children with special health care needs. METHODS: We analyzed data on 57 553 children younger than 18 years old included in the 1994-1995 National Health Interview Survey on Disability. The survey obtained information on special health care needs, insurance status, and access to and use of health services. Bivariate and multivariate analyses were used to assess the association of insurance with several measures of access and utilization, including usual source of care, site of usual care, missed or delayed care, and use of ambulatory physician services. RESULTS: Using the federal Maternal and Child Health Bureau definition of children with special health care needs, we estimate that 18% of US children under 18 years old had an existing special health care need in 1994-1995. An estimated 89% of these children had some form of health insurance coverage, most often private health insurance. Insured children were more likely than uninsured children to have a usual source of care (96.9% vs 79.2%). Among those with a usual source of care, insured children were more likely than uninsured children to have an identified regular clinician (87. 6% vs 80.7%). Insured children were less likely to report unmet health needs, including medical care (2.2% vs 10.5%), dental care (6. 1% vs 23.9%), prescriptions, and/or eyeglasses (3.1% vs 12.3%), and mental health care (.9% vs 3.4%). Insured children were also more likely to have a physician contact in the past year (89.3% vs 73.6%) and have more physician contacts on an annual basis (8.5 vs 4.1 contacts). Unexpectedly, no differences were found between insured and uninsured children in availability of after hours medical care (evenings and weekends) or satisfaction with care. We also found some modest differences in access between publicly and privately insured children. Privately insured children were more likely to have a usual source of care (97.6% vs 95.3%) and a regular clinician (91.0% vs 81.1%). Privately insured children were also less likely to report dissatisfaction with care at their usual site of care (14. 9% vs 21.0%) and have access to care on evenings and weekends (6.8% vs 13.4%). No substantial differences were found between privately and publicly insured children in prevalence of unmet health needs or delays in obtaining care due to cost. CONCLUSIONS: This study illustrates the importance of health insurance for children with special health care needs. Continued efforts are needed to ensure that all children with special health care needs have insurance and that remaining access and utilization barriers for currently insured children with special health care needs are also addressed.

The unmet health needs of America's children.

OBJECTIVE: Unmet need for health care is a critical indicator of access problems. Among children, unmet need for care has special significance inasmuch as the failure to obtain treatment can affect health status and functioning in the near- and long-term. The purpose of this study was to present current prevalence estimates and descriptive characteristics of children with unmet health needs using nationally representative household survey data. METHODS: We analyzed 4 years of National Health Interview Survey data spanning 1993 through 1996. Our analysis included 97 206 children <18 years old. Measures of unmet need for medical care, dental care, prescription medications, and vision care were obtained from an adult household member (usually the mother) responding for the child. Bivariate and multivariate analyses were used to assess the degree to which unmet need was related to the demographic and socioeconomic characteristics of the child and family. RESULTS: Overall, 7.3% (4.7 million) of US children experienced at least 1 unmet health care need. Dental care was the most prevalent unmet need. After adjustment for confounding factors, near-poor and poor children were both about 3 times more likely to have an unmet need as nonpoor children (adjusted odds ratio [95% confidence interval] = 2.89 [2.52, 3.32], 3.0 [2.53, 3.56], respectively). Uninsured children were also about 3 times more likely to have an unmet need as privately insured children (adjusted odds ratio [95% confidence interval] = 2. 92 [2.58, 3.32]). CONCLUSIONS: Despite the nation's great wealth, unmet health needs remain prevalent among US children. A combined public policy that addresses financial and nonfinancial barriers to care is required to reduce the prevalence of unmet need for health care.

Prevalence, impact, and trends in childhood disability due to asthma.

BACKGROUND: Although not widely recognized as such, asthma is the single most prevalent cause of childhood disability and has contributed to a substantial rise in the overall prevalence of disability among children during the past 25 years. OBJECTIVE: To provide a national profile of the prevalence, impact, and trends in childhood disability due to asthma. (Disability is a long-term reduction in the ability to participate in children's usual activities, such as attending school or engaging in play, due to a chronic condition.) METHODS: We derived our primary findings from a cross-sectional, descriptive analysis of 62171 children younger than 18 years who were included in the 1994-1995 National Health Interview Survey. MAIN OUTCOME MEASURES: Outcome measures include the presence of disability, degree of disability, restricted activity days, school absence days, and use of hospital and physician services. We also used data from the 1969-1970, 1979-1981, and 1994-1995 National Health Interview Surveys to assess trends in the prevalence of disability due to asthma. RESULTS: A small, but significant, proportion of children, estimated at 1.4% of all US children, experienced some degree of disability due to asthma in 1994-1995. Prevalence of disability due to asthma was higher for adolescents (odds ratio [OR], 1.64), black children (OR, 1.66), males (OR, 1.23), and children from low income (OR, 1.46) and single-parent families (OR, 1.37). Disabling asthma resulted in an annual average of 20 restricted activity days, including 10 days lost from school-almost twice the level of illness burden as experienced by children with disabilities due to other types of chronic conditions. Finally, prevalence of disabling asthma, as reported in the National Health Interview Survey, has increased 232% since 1969, the first year that electronic data are available from the survey. In contrast, prevalence of disability due to all other childhood chronic conditions increased by 113% over the same period. CONCLUSIONS: Disabling asthma has profound effects on children. The social costs of asthma are likely to rise in the future if current trends in the prevalence of disabling asthma continue.

Adolescent health insurance coverage: recent changes and access to care.

OBJECTIVE: To assess the health insurance status of adolescents, the trends in adolescent health care coverage, the demographic and socioeconomic correlates of insurance coverage, and the role that insurance coverage plays in influencing access to and use of health care. Together, the results provide a current and comprehensive profile of adolescent health insurance coverage. METHODS: We analyzed data on 14 252 adolescents, ages 10 to 18 years, included in the 1995 National Health Interview Survey. The survey obtained information on insurance coverage and several measures of access and utilization, including usual source of care, site of the usual source of care, indications of missed or delayed care, and use of ambulatory physician services by adolescents. We conducted multivariate analyses to assess the independent association of age, sex, race, poverty status, family structure, family size, region of residence, metropolitan resident status, and health status on the likelihood of insurance coverage. We conducted bivariate and multivariate analyses to ascertain how insurance coverage was related to each of the access and utilization measures obtained in the survey. We also examined trends in health insurance coverage using the 1984, 1989, and 1995 editions of the National Health Interview Survey. RESULTS: An estimated 14.1% of adolescents were uninsured in 1995. Risk of being uninsured was higher for older adolescents, minorities, adolescents in low-income families, and adolescents in single parent households. Compared with their insured counterparts, uninsured adolescents were five times as likely to lack a usual source of care, four times as likely to have unmet health needs, and twice as likely to go without a physician contact during the course of a year. Between 1984 and 1995 the percentage of adolescents with some form of health insurance coverage remained essentially unchanged. During this period, the prevalence of private health insurance decreased, while the prevalence of public health insurance increased. CONCLUSIONS: This study demonstrates the critical importance of health insurance as a determinant of access to and use of health services among adolescents. It also shows that little progress has been made during the past 15 years in reducing the size of the uninsured adolescent population. The new State Children's Health Insurance Program could lead to substantial improvements in access to care for adolescents, but only if states implement effective outreach and enrollment strategies for uninsured adolescents.adolescents, health insurance, access, Medicaid, SCHIP.

Enrollment in the State Child Health Insurance Program: a conceptual framework for evaluation and continuous quality improvement.

Children's enrollment in the State Child Health Insurance Program (SCHIP) is a key indicator of program impact. Past studies demonstrate that many children eligible for Medicaid or for private employer-based insurance remain uninsured, indicating that eligibility does not guarantee either enrollment or access to medical care. Important features of SCHIP evaluation include not only eligibility thresholds and enrollment volume, but also program retention, transitions in coverage, and access to medical care. Focusing on SCHIP features that affect children's participation and continuity of coverage would allow states to continually improve procedures that affect enrollment. An exploration of federal and state policy options suggests several approaches for creating evaluation strategies that can stimulate ongoing improvement.

Prevalence and impact of parent-reported disabling mental health conditions among U.S. children.

OBJECTIVE: To provide a current national profile of the prevalence and impact of parent-reported disabling mental health conditions in U.S. children. METHOD: A cross-sectional descriptive analysis of 99,513 children younger than 18 years old included in the 1992-1994 National Health Interview Survey (NHIS). The response rate exceeded 94% in each year. Disability is defined as the long-term reduction in a child's ability to perform social role activities, such as school or play, as a result of his/her mental health condition. RESULTS: On average, 2.1% of U.S. children were reported to suffer from a disabling mental health condition in 1992-1994. The most common reported causes of disability include mental retardation, attention-deficit hyperactivity disorder, and learning disabilities. While national prevalence estimates were produced for some low-prevalence conditions such as autism (38/100,000), for many specific diagnoses the reported prevalence rates were too low for accurate national population estimates using this data set. Logistic regression analysis demonstrates that prevalence of a disabling mental health condition was higher for older children; males; children from low-income, single-parent families; and those with less education. These conditions are also associated with high rates of special education participation (approximately 80%) and health system use. CONCLUSIONS: The NHIS provides a useful and untapped resource for estimating the prevalence of disabling mental health conditions. These conditions are increasingly prevalent and have a profound impact on children and the educational and health care systems.

Challenges in securing access to care for children.

Congressional approval of Title XXI of the Social Security Act, which created the State Children's Health Insurance Program (CHIP), is a significant public effort to expand health insurance to children. Experience with the Medicaid program suggests that eligibility does not guarantee children's enrollment or their access to needed services. This paper develops an analytic framework and presents potential indicators to evaluate CHIP's performance and its impact on access, defined broadly to include access to health insurance and access to health services. It also presents options for moving beyond minimal monitoring to an evaluation strategy that would help to improve program outcomes. The policy considerations associated with such a strategy are also discussed.

The role of Medicaid in ensuring children's access to care.

CONTEXT: Congress enacted a series of laws beginning in the mid 1980s to expand Medicaid eligibility for children, especially those in poor families. As a result, Medicaid enrollment of children has nearly doubled over the past decade. OBJECTIVE: To assess the effectiveness of Medicaid in improving access to and use of health services by poor children. DESIGN: Analysis of cross-sectional survey data from the 1995 National Health Interview Survey. Poor children with Medicaid were compared to poor children without insurance and nonpoor children with private insurance. SETTING AND PARTICIPANTS: A total of 29711 children younger than 18 years (3716 poor children with Medicaid, 1329 poor children without insurance, 14609 nonpoor children with private insurance, and 10057 children with other combinations of poverty and insurance status) included in a nationally representative stratified probability sample of the US noninstitutionalized population. MAIN OUTCOME MEASURES: Usual source of care, access to a regular clinician, unmet health needs, and use of physician services. RESULTS: Poor children with Medicaid compared to poor children without health insurance experienced superior access across all measured dimensions of health care, including presence of a usual source of care (95.6% vs 73.8%), frequency of unmet health needs (2.1 % vs 5.9%), and use of medical services (eg, > or =1 physician contact in past year) (83.9% vs 60.7%). Poor children with Medicaid compared to nonpoor children with private insurance used similar levels of physician services (83.9% vs 84%), but were more likely to have unmet health needs (2.1 % vs 0.6%) and were less likely to have a usual source of care (95.6% vs 97.4%). CONCLUSION: Medicaid is associated with improvements in access to care and use of services. However, there remains room for improvement when Medicaid is judged against private health insurance. The Balanced Budget Act of 1997 contains several Medicaid provisions that could stimulate further improvements in access for poor children.

Assessing managed care for children with chronic conditions.

This paper reviews opportunities to monitor managed care for children and adolescents with chronic conditions and considers how well the Health Plan Employer Data and Information Set, version 3.0 (HEDIS 3.0), assesses care for these children. We propose four steps to strengthen the applicability of HEDIS to children with chronic conditions: (1) develop methods of identifying and monitoring groups of children with chronic conditions; (2) report HEDIS indicators for these children separately from those for other children; (3) develop and implement consumer and provider surveys that elicit information specific to these populations; and (4) develop specific structure, process, and outcomes indicators for children with chronic conditions.

An epidemiologic profile of children with special health care needs.

OBJECTIVE: To present an epidemiologic profile of children with special health care needs using a new definition of the population developed by the federal Maternal and Child Health Bureau. METHODS: We operationalized the new definition using the recently released 1994 National Health Interview Survey on Disability. Estimates are based on 30 032 completed interviews for children <18 years old. The overall response rate was 87%. RESULTS: Eighteen percent of US children <18 years old in 1994, or 12.6 million children nationally, had a chronic physical, developmental, behavioral, or emotional condition and required health and related services of a type or amount beyond that required by children generally. This estimate includes children with existing special health care needs but excludes the at-risk population. Prevalence was higher for older children, boys, African-Americans, and children from low-income and single-parent households. Children with existing special health care needs had three times as many bed days and school absence days as other children. An estimated 11% of children with existing special health care needs were uninsured, 6% were without a usual source of health care, 18% were reported as dissatisfied with one or more aspects of care received at their usual source of care, and 13% had one or more unmet health needs in the past year. CONCLUSIONS: A substantial minority of US children were identified as having an existing special health care need using national survey data. Children with existing special health care needs are disproportionately poor and socially disadvantaged. Moreover, many of these children face significant barriers to health care.

Evaluating community efforts to decategorize and integrate financing of children's health services.

Publicly funded categorical programs for children often differ in eligibility rules, allowable services, and criteria for provider participation, making it necessary for families to navigate through several programs to piece together care for their children. Recognizing these problems, the Robert Wood Johnson Foundation launched a national demonstration project in 1991 with the goal of decategorizing children's health services in nine communities. It was hoped that by releasing funds from categorical restrictions on their use, scarce public resources could be directed where they might have the greatest impact. However, the demonstration sites confronted a number of challenges in designing and implementing decategorization strategies: an absence of existing models and effective technical assistance; political hurdles in gaining cooperation from the multiple local agencies engaged in service provision; and difficulties in carrying out major programmatic changes when the health care system itself was rapidly being transformed. The proposition that decategorization holds promise as a tool for improving access to health care deserves further investigation.

Prevalence and impact of disabling chronic conditions in childhood.

OBJECTIVES: This study provides a current national profile of the prevalence and impact of chronic conditions causing childhood disability. Disability is defined as a long-term reduction in ability to conduct social role activities, such as school or play, because of a chronic physical or mental condition. METHODS: A cross-sectional descriptive analysis was performed on data from 99513 children younger than 18 years who were included in the 1992-1994 National Health Interview Survey. The response rate exceeded 93% during each year. RESULTS: A significant proportion of children, estimated at 6.5% of all US children, experienced some degree of disability. The most common causes of childhood disability were respiratory diseases and mental impairments. Prevalence of disability was higher for older children, boys, and children from low-income and single-parent families. Childhood disability is estimated to result in 66 million restricted activity days annually, including 24 million days lost from school. Furthermore, disability in childhood results in an added 26 million physician contacts and 5 million hospital days annually. CONCLUSIONS: Childhood disability has profound impacts on children, the education system, and the health care system.

The use of formative evaluation to assess integrated services for children. The Robert Wood Johnson Foundation Child Health Initiative.

This article describes the use of formative evaluation in assessing the feasibility of implementing a new service integration effort. The Child Health Initiative, a nine-site, national demonstration project funded in 1991 by the Robert Wood Johnson Foundation, sought to implement systemic change through the creation of new mechanisms for spending service dollars more flexibly at the local site. The Child Health Initiative called for developing local child health-monitoring systems, a care coordination mechanism, and a program for decategorizing the myriad of restrictive categorical public programs serving children. Most demonstration communities experienced some degree of success in achieving the first two components, but none was able to implement decategorization during the 3- to 5-year funding period. Key lessons for evaluators include the need for (a) a flexible evaluation design that can sequentially adapt to changes in program implementation, (b) repeated longitudinal data collection measures to document changes over time, (c) avoidance of a premature focus on program outcomes, and (d) methods to establish attribution of outcomes.

Health insurance and access to primary care for children.

BACKGROUND: Numerous studies have demonstrated that insurance status influences the amount of ambulatory care received by children, but few have assessed the role of insurance as a determinant of children's access to primary care. We studied the effect of health insurance on children's access to primary care. METHODS: We analyzed a sample of 49,367 children under 18 years of age from the 1993-1994 National Health Interview Survey, a nationwide household survey. The overall rate of response was 86.5 percent. The survey included questions on insurance coverage and access to primary care. RESULTS: An estimated 13 percent of U.S. children did not have health insurance in 1993-1994. Uninsured children were less likely than insured children to have a usual source of care (75.9 percent vs. 96.2 percent, P<0.001). Among those with a usual source of care, uninsured children were more likely than insured children to have no regular physician (24.3 percent vs. 13.8 percent, P<0.001), to be without access to medical care after normal business hours (11.8 percent vs. 7.1 percent, P<0.001), and to have families that were dissatisfied with at least one aspect of their care (19.6 percent vs. 14.0 percent, P=0.01). Uninsured children were more likely than insured children to have gone without needed medical, dental, or other health care (22.2 percent vs. 6.1 percent, P<0.001). Uninsured children were also less likely than insured children to have had contact with a physician during the previous year (67.4 percent vs. 83.8 percent, P<0.001). All differences remained significant after we controlled for potential confounders using linear and logistic regression. CONCLUSIONS: Among children, having health insurance is strongly associated with access to primary care. The new children's health insurance program enacted as part of the Balanced Budget Act of 1997 may substantially improve access to and use of primary care by children.

Community health monitoring: taking the pulse of America's children.

OBJECTIVE: To describe the development, content, enablers/barriers, and impact of child health reports in nine communities participating in the Robert Wood Johnson Foundation funded Child Health Initiative (1991-1996). METHODS: A qualitative, prospective, multiyear, longitudinal evaluation using a multiple case-study methodology. Three waves of structured in-person and telephone interviews of the project staff, community leaders, and key participants tracked the development of child health reports in all nine communities. A mailed survey of project directors was administered to assess accomplishments at the completion of the project. Content analysis of each community health report was conducted using different conceptual frameworks for health measurement and reporting. RESULTS: All communities succeeded in creating a report that contained a broad set of outcome indicators reflecting children's health and well-being. The process of creating these reports, their content, level of analysis, presentation formats, and dissemination varied across sites based on available resources, data and analysis capacity, and other political considerations. While commonly accepted outcome measures were used in most reports (e.g., infant mortality, teen births, immunization rates), process indicators, important for quality monitoring and community health improvement, were notably lacking. In each community the reports were credited with providing a more comprehensive and integrated view of the health needs of children. CONCLUSIONS: Additional conceptual and technical work is needed to improve the ability of community health reports to capture key indicators of interest. Community reports can serve an important role in building the consensus needed to create program and policy changes. Community reports may have additional utility in monitoring the impact of health systems change on population health. Community reports can also facilitate a shared learning process for the participants and the community, and can be a useful tool to advance a children's health policy agenda.