Persistent spatial structuring of coastal ocean acidification in the California Current System.

The near-term progression of ocean acidification (OA) is projected to bring about sharp changes in the chemistry of coastal upwelling ecosystems. The distribution of OA exposure across these early-impact systems, however, is highly uncertain and limits our understanding of whether and how spatial management actions can be deployed to ameliorate future impacts. Through a novel coastal OA observing network, we have uncovered a remarkably persistent spatial mosaic in the penetration of acidified waters into ecologically-important nearshore habitats across 1,000 km of the California Current Large Marine Ecosystem. In the most severe exposure hotspots, suboptimal conditions for calcifying organisms encompassed up to 56% of the summer season, and were accompanied by some of the lowest and most variable pH environments known for the surface ocean. Persistent refuge areas were also found, highlighting new opportunities for local adaptation to address the global challenge of OA in productive coastal systems.

Financing health care for disabled children.

Information about health care use, charges, and out-of-pocket expenses is critical to the development of an equitable and efficient treatment system for disabled children. Data from the 1980 National Medical Care Utilization and Expenditure Survey were used, and differences in use, charges, and out-of-pocket expenses for children with and without limitations in their activities due to chronic health problems are described. The results indicate that children limited in their activities used more medical services than other children, especially hospital-based services and services provided by health professionals other than physicians. Charges and out-of-pocket expenses were two to three times higher on average for disabled children, compared with other children. Charges and out-of-pocket expenses were also skewed; 10% of the sample children accounted for more than 60% of total charges and out-of-pocket expenses for the disabled population. The skewed distribution of out-of-pocket expenses suggests that financial burdens are unevenly shared by families of disabled children. Several public policy options designed to result in a more equitable distribution of financial risks are discussed.

Health insurance status of adolescents in the United States.

This analysis of a sample of 15,181 adolescents aged 10 to 18 years from the National Health Interview Survey indicates that 86% of adolescents had some form of private or public health care coverage during 1984. Nevertheless, one in every seven adolescents, or nearly 4.5 million nationwide, were without any form of health insurance coverage. Adolescents without insurance coverage were concentrated in poor and near-poor households, families with little formal education, and were more likely to live in the South or West. Minorities, especially Hispanic adolescents, were less likely than white adolescents to have some form of health insurance coverage, but much of this difference was attributable to the smaller incomes of minorities. Similarly, although adolescents living in single-parent households were less likely to be insured, the reduced likelihood of coverage appears to be primarily attributable to smaller family income in single-parent households. That family economics plays a central role in determining whether an adolescent had some form of coverage was confirmed by interview results concerning the major reasons for absence of coverage; 8 of 10 uninsured families cited economic reasons for absence of coverage. Together, these results indicate the principal barriers to obtaining health insurance are economic in nature. Public and private sector initiatives for reducing the size of the uninsured adolescent population are discussed.

Health insurance coverage of adolescents: a current profile and assessment of trends.

Data from the National Health Interview Survey reveal that 4.7 million or 15% of US adolescents aged 10 through 18 were uninsured in 1989. Among adolescents, 73% were privately insured, 10% were publicly insured, and 2% were both privately and publicly insured. Poor, near-poor, and minority adolescents were at the greatest risk for lack of health insurance coverage. Among adolescents without insurance, cost continued to be cited as the leading barrier to obtaining coverage. A comparison of 1989 National Health Interview Survey data with a previous analysis, in which 1984 data were used, revealed a 10% increase in the proportion of adolescents without insurance coverage. The increase in the proportion of uninsured adolescents was entirely attributable to an erosion of private health insurance coverage. No significant change occurred in the proportion of adolescents with coverage under public programs. Planned expansions of the federally and state-financed Medicaid programs will help to stem further increases in the size of the uninsured adolescent population. However, unless marked improvements occur in the private health insurance sector, progress will be limited.

Young adults with special health care needs: prevalence, severity, and access to health services.

Health care needs of disabled young adults and access to care are analyzed using the 1984 National Health Interview Survey, a nationally representative sample of 10,394 randomly selected noninstitutionalized young adults aged 19 to 24. In 1984, 1.4 million young adults (almost 6%) suffered from disabilities. The leading cause of disability was diseases of the musculoskeletal system and connective tissue. Young adults living in poverty, in households where the family reference person had less than a high school education, and who were male were at elevated risk of disability. Disabled young adults made almost three times as many physician contacts and were hospitalized for close to six times as many days as nondisabled young adults. One of every 5 disabled young adults was uninsured in 1984. Forty-one percent of disabled Hispanic 19- to 24-year-olds and 51% of disabled young adults of other races were uninsured compared with 19% of whites and blacks. Research and financing policy implications are discussed.

Health insurance status of young adults in the United States.

Sociodemographic and health characteristics of young adults who are uninsured, publicly insured, and privately insured were examined using the 1984 National Health Interview Survey. The results indicated that 26% of 19 to 24-year-old persons had no health insurance protection, 65% were privately insured, 7% were publicly insured, and 1% had both private and public coverage. Young adults at greatest risk for being uninsured were male, Hispanic and black, poor and near-poor, unemployed, high school dropouts, living with others, and residing in the South and West. All young adults predictably lose or change health insurance as they move from dependence to independence. It was concluded that greater use of new and existing transitional insurance options should be offered as well as targeted educational and communication strategies to assure that all young persons enter adulthood with some basic insurance protection.

A decade of Medicaid in perspective: what have been the effects on children?

This study of the Medicaid program analyzes changes in child recipients, costs, and service use during the 1980s to assess the effects of recent federal policy shifts and to project future costs for children. Data presented in this study are from the Health Care Financing Administration's Medicaid Statistical Report for the years 1979, 1985, and 1990, three time-points that demarcate major federal policy shifts. About half of all recipients added to the Medicaid program during the last decade were children; they comprised 14% of the total cost growth experienced by the program. In addition, the eligibility distribution of children receiving Medicaid shifted markedly over the last decade. In 1979, children receiving cash assistance comprised 90% of total child recipients; by 1990, this figure dropped to 72%. Future expansions to the Medicaid program are projected to cost less than the initial expansions. This is because the early expansions disproportionately served infants, who require more hospital services than older children. Despite the major changes in Medicaid eligibility for children during the 1980s, only limited cost shifts occurred in expenditures for children. Children continue to consume a small portion of the Medicaid budget. Congress should explore options for guaranteeing that their share of funding for services will be adequate. Moreover, since future expansions will be far less expensive than those already implemented, accelerating the phase-in process for all poor children may be a more financially feasible policy option than many policymakers anticipate, despite the fiscal hardships facing many states.

How far have state Medicaid agencies advanced in performance measurement for children?

BACKGROUND: While children represent the largest population group enrolled in Medicaid managed care, little is known about the pediatric performance measures used by state Medicaid agencies. OBJECTIVE: To identify Medicaid managed care requirements for using Health Plan Employer Data and Information Set and other performance measures for children (defined as those aged 0-21 years in this study). DESIGN: A structured telephone survey of pediatric performance measures. PARTICIPANTS: Survey respondents were state Medicaid officials responsible for managed care quality oversight in 39 states. MAIN OUTCOME MEASURES: Percentage of states in 1998 with effectiveness-of-care measures on health promotion and disease prevention, early detection and screening, and acute and chronic illness; with use measures on preventive care, ambulatory care, pharmacy, inpatient hospital care, and mental health and chemical dependency services; and with access measures on primary care, low-birth-weight neonates delivered at appropriate facilities, and dental care. RESULTS: In 1998, state Medicaid agencies placed most of their emphasis on monitoring preventive care for children, with immunization rates being the primary focus. Far less attention was directed at assessing the treatment of acute illness. Although more than half of states monitored the treatment of chronic childhood conditions, they focused exclusively on asthma and selected mental health diagnoses. CONCLUSIONS: States are still in the initial phases of designing and implementing quality oversight systems for Medicaid-insured children. Additional quality reporting requirements are clearly needed to assess the treatment of acute and chronic illness among children along with more age-specific reporting requirements.

Rural maternal, child, and adolescent health.

Authors cite recommendations for research in light of a general lack of current literature on health status, health services utilization, organization and delivery of health services, and health care financing in this field.

PIP: This article summarizes the most current US national information on rural maternal, child, and adolescent health. Its purpose is to present a state-of-the-art overview of rural demographics and fertility, health status, health services utilization, and health care financing from which future research recommendations can be developed. The research reviewed is extremely limited. Most of the literature uses 1970s data, with few exceptions (rural perinatal care). Published information from the surveys of the National Center for Health Statistics (NCHS) is usually not organized into useful groupings by metro/nonmetro status, such as 3-year child age intervals. Not even micro-data from the NCHS data bases can be considered very useful for rural analysis, because metro/nonmetro status does not adequately take into account variation in population density within and outside of metropolitan statistical areas. Children in nonmetro areas, as compared to children in metro areas, are more likely to be 1) white, living in 2-parent families, residing in the South, and poor; 2) as healthy or slightly healthier, as measured by mortality, acute and chronic conditions, bed days, and drug use; 3) similar or slightly lower users of physician services; 4) served by family or general practitioners rather than pediatricians; and 5) uninsured or underinsured, residing in the least generous Medicaid states, and liable for greater out-of-pocket medical costs relative to their family income.

Background tables on demographic characteristics, health status, and health services utilization.

PIP: These background tables include data on demographic characteristics, health status, and health services utilization for the US metro and nonmetro area populations. Demographic data were obtained from the National Center for Health Statistics and the US Bureau of the Census. Health status and health services utilization information was provided by the National Center for Health Statistics. Some highlights from these background tables follow. 1) A greater proportion of persons over 65 resided in nonmetro areas compared to metro areas in every region of the US in 1980. 2) Fewer than 1/4 of all US residents lived in nonmetro areas. 3) Overall, persons in metro and nonmetro areas sought medical attention for acute conditions at the same rate. However, there was a wide disparity in the frequency with which medical attention was sought for specific acute conditions. 4) Among all physicians, 80% practiced in metro areas and only 20% in nonmetro areas in 1985. This varied tremendously by specialty, with 65% of general and family practitioners located in metro areas and 35% in nonmetro areas. 5) 15% of all nonmetro residents were uninsured in 1984 compared to 12% in metro areas.^ieng

Managed care's impact on Medicaid financing for early intervention services.

Medicaid has been a major source of financing for early intervention services since the inception of the Infants and Toddlers with Disabilities Program in 1986. In this article, the authors analyze Medicaid financing of early intervention services in 39 States before and after the introduction of managed care. The association between level of Medicaid financing and program characteristics, provider arrangements, managed care carve-out policies, and managed care contract requirements is assessed. The authors discuss the reduction of Medicaid financing after managed care and its implications for State Infants and Toddlers with Disabilities Programs, State Medicaid agencies, and managed care organizations.

Medicaid managed care policies affecting children with disabilities: 1995 and 1996.

The authors present findings from a study of State Medicaid managed care enrollment and benefit policies in 1995 and 1996 for children with disabilities. During this time the number of States serving children through fully capitated plans grew by more than one-third, and enrollment of children receiving Supplemental Security Income (SSI) payments and children in subsidized foster care increased. Most States required plans to provide all mandatory and most optional Medicaid services. Although States have begun to make noticeable improvements in their contract language concerning medical necessity and the early and periodic screening, diagnosis, and treatment (EPSDT) benefit, overall State guidance in these areas remains weak.

Financing health services in school-based clinics. Do nontraditional programs tap traditional funding sources?

This telephone survey of directors of 50 school-based clinics (SBCs) examined the influence of organizational factors on use of traditional funding sources, such as Medicaid and private insurance. These factors included: initial funding source (Robert Wood Johnson Foundation's School-Based Adolescent Health Care Program vs. comparison), administrative structure, age of clinic, and state Medicaid policy. Results indicated that over half (51%) of the clinics used Medicaid as a funding source to some extent, while fewer (32%) used private insurance. Use of Medicaid and private insurance, however, varied with the initial funding source, administrative structure, and age of the clinic. Initial funding source and age of the clinic were the strongest predictors of Medicaid usage. Barriers to traditional funding sources, as well as methods used to overcome constraints, are discussed. The importance of the link between a nontraditional health care delivery system, the school-based clinic, and the traditional funding sources of Medicaid and private insurance is examined in light of the organizational factors which facilitate this link.

A national study of commercial health insurance and medicaid definitions of medical necessity: what do they mean for children?

OBJECTIVE: To analyze medical necessity standards used by state Medicaid agencies and the largest commercial insurers in the United States on the basis of criteria related to scope of health problems covered and requirements for effectiveness and cost. METHODS: Information was obtained from managed care contract documents used by the 45 state Medicaid agencies enrolling children into managed care organizations and from certificates of coverage used by the largest health maintenance and preferred provider organization insurers in each state. RESULTS: Commercial insurers are more likely than Medicaid agencies to articulate medical necessity standards that limit coverage to treatment for illnesses and injuries and to include stringent requirements for cost and evidence of effectiveness. CONCLUSION: To reduce the discretion retained by insurers in determining medical necessity, particularly around the scope of health problems covered, much greater clarity and uniformity in medical necessity language will be required in the future.

Metropolitan and nonmetropolitan adolescents: differences in demographic and health characteristics.

The demographic and health characteristics of metropolitan and nonmetropolitan adolescents are examined based on a nationally representative sample of 15,181 randomly selected adolescents from the 1984 National Health Interview Survey. One third of all adolescents reside in nonmetropolitan areas of the United States. Nonmetropolitan youth differed from their metropolitan counterparts in race, population concentration in the South, poverty status, family composition, education of household head, and marital status. While the health status of metropolitan and nonmetropolitan youth were similar, their patterns of health services utilization and health insurance coverage were not. Nonmetropolitan adolescents made fewer physician visits and were more apt to delay seeking physician care than metropolitan youth. Adolescents in nonmetropolitan areas were also 39 percent more likely to be hospitalized and 30 percent more likely than metropolitan youth to be without any form of health insurance protection. Despite higher rates of poverty among nonmetropolitan adolescents, they were 20 percent less likely to be publicly insured. The delivery and financing implications of these distinct metropolitan and nonmetropolitan demographic and health characteristics are discussed.

Genetic counseling in Catholic hospitals. Facilities must provide guidance to keep pace with new knowledge and techniques.

As advances in the knowledge of human genetics change the practice of medicine, Catholic healthcare facilities will, according to ethicists, be increasingly obliged to provide genetic counseling services to their patients. Facilities should ensure that counselors make genetic information available in a context in which no pressure, overt or subtle, is exerted to use that information in a way that may violate an individual's value system. Some hospitals may, for example, set up a separate genetic counseling department, which does not diagnose or treat genetic disorders but does facilitate access to these treatments when patients need them. Effective counseling requires accurate, current knowledge about tests and treatments, as well as about theological discussions and Church decisions on the subject. Counselors also need to be aware of some typical misconceptions people have about genetic disease. Catholic hospitals should also work with other Catholic organizations to influence legislation addressing human genetic issues, especially when such legislation addresses reproductive rights.