Health care access and use among low-income children: Who fares best?

Health Affairs

Volumn 20, Issue 1, 2001, Pages 112-121

  Dubay, Lisa ^a   Kenney, Genevieve M ^a  

^a URBAN INSTITUTE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AMBULATORY CARE; ARTICLE; CHILD; CHILD HEALTH CARE; CLASSIFICATION; COMPARATIVE STUDY; ECONOMICS; EPIDEMIOLOGY; HEALTH CARE DELIVERY; HEALTH INSURANCE; HUMAN; MEDICAID; MULTIVARIATE ANALYSIS; POVERTY; STATISTICS; UNITED STATES; UTILIZATION REVIEW;

CHILD; CHILD HEALTH SERVICES; HEALTH CARE SURVEYS; HEALTH SERVICES ACCESSIBILITY; HUMANS; INSURANCE, HEALTH; MEDICAID; MULTIVARIATE ANALYSIS; OFFICE VISITS; POVERTY; UNITED STATES;

EID: 0003624079     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.20.1.112     Document Type: Article

References (32)

1. F. Sloan, R. Mitchell, and J. Cromwell, "Physician Participation in State Medicaid Programs," Journal of Human Resources (Supplement 1978): 211-245; J. Mitchell, "Participation in Medicaid Revisited," Medical Care (July 1991): 645-653; J.W. Fossett et al., "Medicaid and Access to Child Health Care in Chicago," Journal of Health Politics, Policy and Law 17, no. 2 (1992): 273-298; and P. Newacheck et al., "The Role of Medicaid in Ensuring Children's Access to Care," Journal of the American Medical Association 280, no. 20 (1998): 1789-1793.
2. F. Sloan, R. Mitchell, and J. Cromwell, "Physician Participation in State Medicaid Programs," Journal of Human Resources (Supplement 1978): 211-245; J. Mitchell, "Participation in Medicaid Revisited," Medical Care (July 1991): 645-653; J.W. Fossett et al., "Medicaid and Access to Child Health Care in Chicago," Journal of Health Politics, Policy and Law 17, no. 2 (1992): 273-298; and P. Newacheck et al., "The Role of Medicaid in Ensuring Children's Access to Care," Journal of the American Medical Association 280, no. 20 (1998): 1789-1793.
3. F. Sloan, R. Mitchell, and J. Cromwell, "Physician Participation in State Medicaid Programs," Journal of Human Resources (Supplement 1978): 211-245; J. Mitchell, "Participation in Medicaid Revisited," Medical Care (July 1991): 645-653; J.W. Fossett et al., "Medicaid and Access to Child Health Care in Chicago," Journal of Health Politics, Policy and Law 17, no. 2 (1992): 273-298; and P. Newacheck et al., "The Role of Medicaid in Ensuring Children's Access to Care," Journal of the American Medical Association 280, no. 20 (1998): 1789-1793.
4. F. Sloan, R. Mitchell, and J. Cromwell, "Physician Participation in State Medicaid Programs," Journal of Human Resources (Supplement 1978): 211-245; J. Mitchell, "Participation in Medicaid Revisited," Medical Care (July 1991): 645-653; J.W. Fossett et al., "Medicaid and Access to Child Health Care in Chicago," Journal of Health Politics, Policy and Law 17, no. 2 (1992): 273-298; and P. Newacheck et al., "The Role of Medicaid in Ensuring Children's Access to Care," Journal of the American Medical Association 280, no. 20 (1998): 1789-1793.
5. J.P. Newhouse and the Insurance Experiment Group, Free for All? Lessons from the RAND Health Insurance Experiment (Cambridge: Harvard University Press, 1994); and H.E. Freeman and C.R. Corey, "Insurance Status and Access to Health Services among Poor Persons," Health Services Research 28, no. 5 (1993): 531-542.
6. J.P. Newhouse and the Insurance Experiment Group, Free for All? Lessons from the RAND Health Insurance Experiment (Cambridge: Harvard University Press, 1994); and H.E. Freeman and C.R. Corey, "Insurance Status and Access to Health Services among Poor Persons," Health Services Research 28, no. 5 (1993): 531-542.
7. N. Brennan, J. Holahan, and G. Kenney, "Health Insurance Coverage of Children," Snapshots of America's Families, Snapshot B-1 (Washington: Urban Institute, 1999).
8. U.S. General Accounting Office, Children's Health Insurance Program: State Implementation Approaches Are Evolving, Pub. no. GAO/HEHS-99-65 (Washington: GAO, May 1999).
9. M.L Rosenbach, "The Impact of Medicaid on Physician Use by Low-Income Children," American Journal of Public Health 79, no. 9 (1989): 1220-1226; P.F. Short and D.C. Lefkowitz, "Encouraging Preventive Services for Low-Income Children: The Effect of Expanding Medicaid," Medical Care 30, no. 9 (1992): 766-780; and Freeman and Corey, "Insurance Status and Access."
10. M.L Rosenbach, "The Impact of Medicaid on Physician Use by Low-Income Children," American Journal of Public Health 79, no. 9 (1989): 1220-1226; P.F. Short and D.C. Lefkowitz, "Encouraging Preventive Services for Low-Income Children: The Effect of Expanding Medicaid," Medical Care 30, no. 9 (1992): 766-780; and Freeman and Corey, "Insurance Status and Access."
11. M.L Rosenbach, "The Impact of Medicaid on Physician Use by Low-Income Children," American Journal of Public Health 79, no. 9 (1989): 1220-1226; P.F. Short and D.C. Lefkowitz, "Encouraging Preventive Services for Low-Income Children: The Effect of Expanding Medicaid," Medical Care 30, no. 9 (1992): 766-780; and Freeman and Corey, "Insurance Status and Access."
12. Newacheck et al., "The Role of Medicaid."
13. R. Kaestner, "Medicaid and Children's Access to Care," Journal of the American Medical Association 281, no. 14 (1999): 1273.
14. For details on NSAF, see P. Brick et al., National Survey of America's Families:Survey Methods and Data Reliability, NSAF 1997 Methodology Series, no. 1, July 1999, .
15. We use imputed data on the health insurance, access, and utilization variables with missing values. Imputed values account for 1.3 percent or less of all observations for these measures.
16. In this case, there may be a tendency to report more care than was received so that caregivers do not appear negligent. Because these data are self-reported, they may understate the extent to which children fail to receive physician, well-child, or dental care. While reported levels of care may be overstated, it is unlikely that the regression-adjusted differences in utilization that are reported by insurance status will be biased.
17. Medicaid coverage includes a small proportion (5.4 percent) who indicated that they were covered by state-sponsored insurance programs. Measurement of insurance coverage on NSAF is defined in S. Rajan, S. Zuckerman, and N. Brennan, "Confirming Insurance Coverage in a Telephone Survey: Evidence from the National Survey of America's Families," Inquiry (Fall 2000): 317-327.
18. We omitted children with mixed types of coverage in the past year (21 percent of all low-income children) but found, with few exceptions, that their inclusion did not alter our main results in any meaningful way. We excluded from our analysis children who receive Supplemental Security Income (SSI), have Medicare coverage, receive special education, or are in foster care (together, 8.1 percent of low-income children) because previous research indicates that their patterns of care are much different from those of other children. See I. Flores-Cervantes, M.J. Brick, and R. DiGaetano, 1997 NSAF Variance Estimation, Report No. 4, NSAF Methodology Series (Washington: Urban Institute, 1999).
19. R. Anderson, A Behavioral Model of Families' Use of Health Services (Chicago: Center for Health Administration Studies, University of Chicago, 1968); and M. Grossman, "The Demand for Health: A Theoretical and Empirical Investigation," National Bureau of Economic Research Occasional Paper no. 119 (New York: Columbia University Press, 1972). Control variables include perceived health status; presence of activity limitations; age, sex, race, and ethnicity of the child's family income as a percentage of poverty; urban/rural location; and state. We also control for the education, work status, and birthplace of the most knowledgeable adult. We undertook a number of supplemental analyses because of concern that the access and use differences found across different types of insurance coverage were due to unobserved differences in the children in the three different coverage categories that are not accounted for by the control variables included in the regression analyses. Because we thought that unmeasured differences in health status posed the most serious possible threat to the validity of our findings, we reestimated our multivariate models on subgroups that were likely to be more homogeneous with respect to health status. On the whole, the pattern of our findings (available on request from the authors) did not change when we narrowed the analysis to focus on these smaller subgroups, although the differences tended to have weaker statistical significance. We also found that our results on the effects of insurance coverage were not sensitive to the control variables that were included in the multivariate models.
20. R. Anderson, A Behavioral Model of Families' Use of Health Services (Chicago: Center for Health Administration Studies, University of Chicago, 1968); and M. Grossman, "The Demand for Health: A Theoretical and Empirical Investigation," National Bureau of Economic Research Occasional Paper no. 119 (New York: Columbia University Press, 1972). Control variables include perceived health status; presence of activity limitations; age, sex, race, and ethnicity of the child's family income as a percentage of poverty; urban/rural location; and state. We also control for the education, work status, and birthplace of the most knowledgeable adult. We undertook a number of supplemental analyses because of concern that the access and use differences found across different types of insurance coverage were due to unobserved differences in the children in the three different coverage categories that are not accounted for by the control variables included in the regression analyses. Because we thought that unmeasured differences in health status posed the most serious possible threat to the validity of our findings, we reestimated our multivariate models on subgroups that were likely to be more homogeneous with respect to health status. On the whole, the pattern of our findings (available on request from the authors) did not change when we narrowed the analysis to focus on these smaller subgroups, although the differences tended to have weaker statistical significance. We also found that our results on the effects of insurance coverage were not sensitive to the control variables that were included in the multivariate models.
21. A.S. Johanses, B. Starfield, and J. Harlow, Analysis of the Concept of Primary Care for Children and Adolescents (Baltimore: Child and Adolescent Health Policy Center, Johns Hopkins University, 1994); and B. Starfield, Primary Care: Concept, Evaluation, and Policy (New York: Oxford University Press, 1992).
22. A.S. Johanses, B. Starfield, and J. Harlow, Analysis of the Concept of Primary Care for Children and Adolescents (Baltimore: Child and Adolescent Health Policy Center, Johns Hopkins University, 1994); and B. Starfield, Primary Care: Concept, Evaluation, and Policy (New York: Oxford University Press, 1992).
23. AFDC was replaced in 1996 welfare reform legislation by Temporary Assistance for Needy Families (TANF).
24. Rosenbach, "The Impact of Medicaid"; Short and Lefkowitf, "Encouraging Preventive Services"; and J. Currie and D. Thomas, "Medical Care for Children: Public Insurance, Private Insurance, and Racial Differences in Utilization," Journal of Human Resources 30, no. 1 (1995): 135-162.
25. Rosenbach, "The Impact of Medicaid"; Short and Lefkowitf, "Encouraging Preventive Services"; and J. Currie and D. Thomas, "Medical Care for Children: Public Insurance, Private Insurance, and Racial Differences in Utilization," Journal of Human Resources 30, no. 1 (1995): 135-162.
26. Rosenbach, "The Impact of Medicaid"; Short and Lefkowitf, "Encouraging Preventive Services"; and J. Currie and D. Thomas, "Medical Care for Children: Public Insurance, Private Insurance, and Racial Differences in Utilization," Journal of Human Resources 30, no. 1 (1995): 135-162.
27. M.S. Marquis and S.H. Long, "Reconsidering the Effect of Medicaid on Health Care Services Use," Health Services Research 30, no. 6 (1996): 791-808.
28. J.R. Lave et al., "Impact of a Children's Health Insurance Program on Newly Enrolled Children," Journal of the American Medical Association 279, no. 22 (1998): 1820-1825.
29. F. Ullman, I. Hill, and R. Almeida, CHIP: A Look at Emerging State Programs, Assessing the New Federalism Policy Brief no. A-35 (Washington: Urban Institute, September 1999).
30. L. Dubay and G. Kenney, "Lessons from the Medicaid Expansions for Children and Pregnant Women: Implications for Current Policy," Statement before the House Ways and Means Subcommittee on Health, Hearing on Children's Access to Health Coverage, Serial 105-68 (Washington: U.S. Government Printing Office, 1999); and J. Gruber, Statement before the House Ways and Means Subcommittee on Health, Hearing on Children's Access to Health Coverage, Serial 105-68 (Washington: U.S. GPO, 1999).
31. L. Dubay and G. Kenney, "Lessons from the Medicaid Expansions for Children and Pregnant Women: Implications for Current Policy," Statement before the House Ways and Means Subcommittee on Health, Hearing on Children's Access to Health Coverage, Serial 105-68 (Washington: U.S. Government Printing Office, 1999); and J. Gruber, Statement before the House Ways and Means Subcommittee on Health, Hearing on Children's Access to Health Coverage, Serial 105-68 (Washington: U.S. GPO, 1999).
32. GAO, Children's Health Insurance Program.