Health Insurance: Coverage Leads to Increased Health Care Access for
Children (Letter Report, 11/24/97, GAO/HEHS-98-14).

Pursuant to a congressional request, GAO reported on the relationship
between health insurance and health care access, focusing on: (1) what
effect health insurance has on children's access to health care; (2)
whether expanding publicly funded insurance improves their access; and
(3) barriers besides lack of insurance that might deter children from
getting health care.

GAO noted that: (1) health insurance increased children's access to
health care services in almost all the studies GAO analyzed; (2) most of
the evaluations showed that insured children were more likely to have
preventive and primary care than uninsured children; (3) insured
children were also more likely to have a relationship with a primary
care physician and to receive required preventive services, like
well-child checkups, than uninsured children; (4) differences in access
between insured and uninsured children held true even for children who
had chronic conditions and special health care needs; (5) when ill,
insured children were more likely to receive a physician's care for
their health problems, such as asthma or acute earache; (6) in contrast,
lack of insurance can inhibit parents from trying to get health care for
their children and can lead providers to offer less-intensive services
when families seek care; (7) several studies found evidence that
low-income and uninsured children were more likely to be hospitalized
for conditions that could have been managed with appropriate outpatient
care; (8) two studies found that uninsured children sometimes received
less-intensive hospital care than insured children; (9) while health
insurance benefits differed and some excluded coverage for some basic
health care needs, increasing the number of insured children increased
the likelihood that more children would receive care; (10) although
health insurance can considerably increase access, it does not guarantee
entry into the health care system; (11) low family income and education
levels, limited availability of neighborhood primary health care
facilities, lack of transportation, and language differences are among
the barriers to obtaining and appropriately using health care services;
(12) both children who have no health insurance and those who have
Medicaid coverage are more likely than privately insured children to
face such barriers; and (13) to ensure access to high-quality care,
public health and clinical experts recommend that children have a stable
source of health insurance benefits that cover their health care needs,
a relationship with a primary care provider that helps them obtain more
complex care as needed, primary care facilities that are conveniently
situated, and outreach and education for their families.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-98-14
     TITLE:  Health Insurance: Coverage Leads to Increased Health Care 
             Access for Children
      DATE:  11/24/97
   SUBJECT:  Health insurance
             Children
             Medical examinations
             Disadvantaged persons
             Health care programs
             Health care services
             Public health research
             Child care programs
             Health statistics
IDENTIFIER:  Medicaid Program
             
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Cover
================================================================ COVER


Report to the Honorable
John F.  Kerry, U.S.  Senate

November 1997

HEALTH INSURANCE - COVERAGE LEADS
TO INCREASED HEALTH CARE ACCESS
FOR CHILDREN

GAO/HEHS-98-14

Insurance and Health Care Access

(101568)


Abbreviations
=============================================================== ABBREV

  AAP - American Academy of Pediatrics
  CBO - Congressional Budget Office
  EPSDT - Early and Periodic, Screening, Diagnosis, and Treatment
  HMO - health maintenance organization
  NCHS - National Center for Health Statistics
  PPO - preferred provider organization

Letter
=============================================================== LETTER


B-278038

November 24, 1997

The Honorable John F.  Kerry
United States Senate

Dear Senator Kerry: 

The number of children who lack health insurance has increased since
the late 1980s, so that, in 1996, nearly 10.6 million children were
uninsured.  Many experts believe that the lack of health insurance
discourages families from seeking preventive and other needed care
for their children.  However, some question the extent to which
children need coverage and whether an expansion of coverage would
appreciably affect children's access to health care.  In response to
concerns about the millions of uninsured children, the Congress has
allotted, through the Balanced Budget Act (P.L.  105-33), almost $40
billion over the next 10 years to help states expand insurance
coverage to more children, through either Medicaid or other health
plans.\1 Now states are considering how much of their funding they
will contribute to match this federal investment in children's health
care and how they can best implement an expansion of coverage. 

In light of these events, you asked us to determine what effect
health insurance has on children's access to health care, whether
expanding publicly funded insurance improves their access, and what
barriers besides lack of insurance might deter children from getting
health care.  As we agreed with your office, we analyzed evaluations
published during the past 10 years on the relationship between health
insurance and health care access. 

The evaluations and our analysis of them have several limitations. 
Access is the ability to obtain preventive or acute care and cannot
be measured directly.  Therefore, most studies measure access in one
of several ways--by how families adhere to a recommended schedule for
preventive care, whether they can identify a source of care, their
use of health care, or their self-reported access problems.  Looking
at use cannot by itself distinguish appropriate from inappropriate
use.  Therefore, some researchers have analyzed specific types of use
by recommended schedules, such as children's making at least one
visit to a physician every year. 

In addition, while insurance may influence children's access to care,
a number of other factors, such as their family income or their
ethnicity, also influence their health care use.  We focused on
studies that attempted to control for such factors.  Because we
reviewed articles published over the past 10 years, generally based
on analyses of large national surveys, most of the studies analyzed
data collected in the late 1980s.  However, the similarity of
findings from analyses of surveys done at different times suggests
that findings from earlier surveys still apply.  Finally, we did not
validate the results from any of the studies that we cite.  We did
our work between June and October 1997 in accordance with generally
accepted government auditing standards. 


--------------------
\1 The Congressional Budget Office (CBO) estimates that other changes
in the law, such as the new programs attracting currently eligible
children to enroll in Medicaid and allowing states the option of
considering children presumptively eligible for Medicaid, will result
in additional federal Medicaid spending on children of $6.5 billion
in the same decade. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Health insurance increased children's access to health care services
in almost all the studies we analyzed.\2 Most of the evaluations
showed that insured children were more likely to have preventive and
primary care than uninsured children.  Insured children were also
more likely to have a relationship with a primary care physician and
to receive required preventive services, like well-child checkups,
than uninsured children.  Differences in access between insured and
uninsured children held true even for children who had chronic
conditions and special health care needs.  When ill, insured children
were more likely to receive a physician's care for their health
problems, such as asthma or acute earache. 

In contrast, lack of insurance can inhibit parents from trying to get
health care for their children and can lead providers to offer
less-intensive services when families seek care.  Several studies
found evidence that low-income and uninsured children were more
likely to be hospitalized for conditions that could have been managed
with appropriate outpatient care.  Two studies found that uninsured
children sometimes received less-intensive hospital care than insured
children.  While health insurance benefits differed and some excluded
coverage for some basic health care needs, increasing the number of
insured children increased the likelihood that more children would
receive care. 

Although health insurance can considerably increase access, it does
not guarantee entry into the health care system.  Low family income
and education levels, limited availability of neighborhood primary
health care facilities, lack of transportation, and language
differences are among the barriers to obtaining and appropriately
using health care services.  Both children who have no health
insurance and those who have Medicaid coverage are more likely than
privately insured children to face such barriers.  To ensure access
to high-quality care, public health and clinical experts recommend
that children have a stable source of health insurance benefits that
cover their health care needs, a relationship with a primary care
provider that helps them obtain more complex care as needed, primary
care facilities that are conveniently situated, and outreach and
education for their families. 


--------------------
\2 Health insurance includes both private and publicly funded health
insurance.  Much of the research reported here compared uninsured
children to those who had health insurance (public and private
combined).  Where researchers made other comparisons, we have noted
this in the text. 


   BACKGROUND
------------------------------------------------------------ Letter :2

In 1996, only 66 percent of U.S.  children younger than 18--47
million--
were covered by private health insurance.\3 Most private insurance
for children is acquired through a parent's employer.  However, in
1993, almost one-fourth of the workforce worked for an employer that
did not cover dependents.\4 In addition, even if employers offer
coverage, the amount that employees have to pay toward it for their
families may make health insurance unaffordable.  Since the late
1980s, workers' costs for family coverage have risen sharply.\5

Increases in insurance costs may affect children disproportionately,
since the 71 million children younger than 18 represent 27 percent of
the U.S.  population but 42 percent of the poor.  Even if children
have insurance, their coverage--and their relationship with their
providers--may be disrupted if their parents lose their jobs or
change jobs frequently. 

Public health insurance for children is generally provided through
the Medicaid program.  Currently about 15.5 million (22 percent) of
children younger than 18 are covered through Medicaid.  The majority
of low-income children (65 percent) in Medicaid have a working parent
and, of those that do, about half have a parent working full time. 
To remain in Medicaid, families generally have their eligibility
redetermined at least every 6 months.  If family income or other
circumstances change, children may go in and out of the Medicaid
program during a year, disrupting their coverage.  This can delay
needed care, which can have long-term health consequences. 

Children are uninsured when they have neither public nor private
coverage.  In 1996, 10.6 million children (14.8 percent) were
uninsured, living generally in lower-income working families. 
Compared with privately insured children, a higher proportion of
their parents worked for small employers--the group least likely to
offer health insurance.  In 1993, only a quarter of employees in
firms with fewer than 10 employees and about half in firms with 10 to
24 employees reported that their employer offered a health insurance
plan for workers and their dependents, compared with 89 percent in
firms with 1,000 or more employees. 


--------------------
\3 Children's Health Insurance, 1995 (GAO/HEHS-97-68R, Feb.  19,
1997.)

\4 This includes both employees who work for employers that offer no
coverage at all and those who offer employee-only coverage.  A Census
survey asked employees if their employers had a health insurance
plan, so that among those who answered yes, there are probably
employees who either were not eligible to enroll in their employer's
plan or chose not to participate.  See Employee Benefit Research
Institute, Employment-Based Health Benefits:  Analysis of the April
1993 Current Population Survey, Special Report SR-24 and Issue Brief
152 (Washington, D.C.:  1994). 

\5 Employment-Based Health Insurance:  Costs Increase and Family
Coverage Decreases (GAO/HEHS-97-35, Feb.  24, 1997.)


   HEALTH INSURANCE INCREASES
   CHILDREN'S ACCESS TO
   PREVENTIVE, PRIMARY, ACUTE, AND
   HOSPITAL CARE
------------------------------------------------------------ Letter :3

Health insurance does not always cover the preventive care, such as
immunizations, that children need to develop optimally. 
Nevertheless, most of the studies we analyzed used many different
measures of access and found that insured children were more likely
to have access to both preventive and acute or chronic health care. 
Children who were insured were more likely to be connected to the
health care system through a physician.  Having a primary care
connection made it easier for children to get regular preventive
care, acute care when ill, and more complex care as needed. 
Uninsured and lower-income children were more likely to be
hospitalized for conditions that could have been treated through
primary care. 


      HEALTH INSURANCE INCREASES
      CHILDREN'S ACCESS TO
      PREVENTIVE AND PRIMARY CARE
---------------------------------------------------------- Letter :3.1

Most of the studies we reviewed showed that children who had health
insurance had better access to preventive and primary health care
than uninsured children.  (See table 1.) They were more likely to
have a primary care provider, which increased their access to both
routine and more complex care.  Children who had private health
insurance were also more likely than children who had no insurance to
get medical care from one source, and that source was more likely to
be in a physician's office.  In addition, they were more likely to
have seen a doctor recently and to have been up to date with their
well-child care. 



                          Table 1
          
             Primary Care Access for Uninsured
            Children: Statistically Significant
           Measures Identified in Recent Studies

Compared with insured
children, uninsured children
were less likely              Study
----------------------------  ----------------------------
In access to and continuity of care
----------------------------------------------------------
To have continuity between    Halfon and others, 1997\a
well or routine and sick      Holl and others, 1995
care

To have a usual source of     Newacheck, Hughes, and
care                          Stoddard, 1996\b
                              Smith and others, 1996\c
                              Holl and others, 1995
                              Lieu, Newacheck, and
                              McManus, 1993\d\,\e

To see a specific physician   Newacheck, Hughes, and
                              Stoddard, 1996\b

To have a source of after-    Newacheck, Hughes, and
hours emergency care          Stoddard, 1996\b

To travel less than 30        Newacheck, Hughes, and
minutes to receive care       Stoddard, 1996\b

To wait less than 1 hour to   Newacheck, Hughes, and
see a provider                Stoddard, 1996\b

To see a physician for        Newacheck, Hughes, and
selected symptoms             Stoddard, 1996\b

To have the usual source of   Holl and others, 1995
care in a physician's office
(and not in a clinic or
health center)

To receive care from a        Kogan and others, 1995\f
single site


In receipt of care
----------------------------------------------------------
To have made a visit to a     Halfon and others, 1997\a
physician in the past year,
avoiding physician care for
financial reasons\g

To have had a visit to a      Holl and others, 1995
physician in the past year    Lieu, Newacheck, and
                              McManus, 1993\d Newacheck
                              and others, 1992

To have had a routine         Ettner, 1996
checkup in the past year

To have had dental care in    Smith and others, 1996\g
the past year

To ever have had routine      Holl and others, 1995
care

To be up to date with well-   Holl and others, 1995
child care                    Lieu, Newacheck, and
                              McManus, 1993\d\,\h

To have a nonemergency        Spillman, 1992\i
ambulatory care visit
----------------------------------------------------------
Notes:  Full study citations are in the bibliography.  All
differences reported in this table between uninsured and insured
children were statistically significant at the 0.05 level.  Some were
significant at the .01 or .001 level. 

\a Limited to Los Angeles inner-city Latino children aged 12 to 36
months in 1992.  Regression compared privately insured children with
uninsured children, children with continuous Medicaid enrollment, and
children with intermittent Medicaid enrollment. 

\b Compared uninsured poor and minority children with children from
white, nonpoor, and insured families. 

\c Limited to children aged 1 to 12 years in McFarland County,
California.  Regression compared privately insured with uninsured
children and publicly insured children separately. 

\d Study on adolescents. 

\e Differences significant for white and Hispanic adolescents but not
significant for black adolescents at the 0.05 level, although the
differences were significant at the 0.10 level. 

\f Study on children aged 3 years, comparing children with gaps in
insurance covered with the continuously insured. 

\g Study subpopulation limited to children aged 5 to 12 years in
McFarland County, California.  Regression compared privately insured
with uninsured children and publicly insured children separately. 

\h Minority uninsured adolescents were significantly less likely to
be up to date with well-child care than minority insured adolescents,
but the differences were not statistically significant for white
adolescents. 

\i Compared children continuously insured with private insurance for
both hospital and outpatient services with children continuously
uninsured over the course of a year. 

A child's having a usual source of care increases the likelihood he
or she will receive preventive or acute health care.  One research
study based on nationally representative data found that 20 percent
of all uninsured children lacked a usual source of care, compared
with 7 percent of insured, white, nonpoor children.\6 Using
regression analysis to isolate the effect of insurance from race,
income, and ethnicity, this study found that uninsured children were
twice as likely to lack a usual source of care as insured children.\7
Uninsured children were also more likely to lack after-hours care and
to spend more time traveling and more time waiting to receive care. 
Similarly, another study found that 33 percent of uninsured children
did not go to a physician's office for their routine care, compared
with 14 percent of insured children (insured privately or through
Medicaid).  Controlling for factors other than insurance, the study
found that uninsured children were more than twice as likely as
insured children to get care in places other than a physician's
office.\8

Generally, lower-income children (whether uninsured or receiving
public insurance) are less likely to go to a physician's office for
their care.  The National Center for Health Statistics (NCHS) found
that 94 percent of U.S.  children--more than 65 million--had a usual
source of care in 1993.  Of these, 94 percent of privately insured
children, 62 percent of publicly insured children, and 74 percent of
uninsured children used a doctor's office as their usual source of
care.  Conversely, 5 percent of privately insured children, 30
percent of publicly insured children, and 20 percent of uninsured
children used a clinic as their regular source of care.\9

Most experts believe that preschool children need regular visits to
physicians to stay current in their immunizations and to be screened
for health problems, but researchers found access problems for
preschool children.  About one-quarter of U.S.  3-year-olds born in
1988 had a gap in their health insurance coverage of at least 1
month, and almost 15 percent had a gap of 7 months or more or had
never been covered.  Preschool children who had gaps in coverage were
more likely to have gone to multiple sites for care than children who
had continuous insurance coverage, suggesting that the care they
received was more likely to be sporadic and fragmented.  Just over 40
percent of preschool children went to two or more sites of care (not
counting emergency care).  However, controlling for other factors
affecting access, preschool children who had a gap in coverage of
more than 6 months were 74 percent more likely to have gone to more
than one site for care.\10 Disruption of insurance coverage seems to
be the salient factor because children who had no insurance were no
more likely than insured children to have gone to multiple sites of
care. 

Experts have stated that adolescents can benefit from the guidance of
a trusted health provider to help them through a period when their
bodies are changing and they may be tempted to take risks, such as
having unprotected sex or using drugs, alcohol, or tobacco products. 
Yet uninsured adolescents also have access problems.  Researchers
found that adolescents who were not insured were less likely to have
a usual source of care and regular provider.\11 (See fig.  1.)

   Figure 1:  Percentage of
   Adolescents Who Had a Usual
   Source of Care by Insurance
   Status and Race or Ethnicity,
   1988

   (See figure in printed
   edition.)

Source:  T.  A.  Lieu, P.  W.  Newacheck, and M.  A.  McManus, "Race,
Ethnicity, and Access to Ambulatory Care among U.S.  Adolescents,"
American Journal of Public Health, Vol.  83, No.  7 (1993), pp. 
960-65. 


--------------------
\6 Having a usual source of care can mean using the emergency room or
a public clinic where children do not consistently see the same
provider. 

\7 P.  W.  Newacheck, D.  C.  Hughes, and J.  J.  Stoddard,
"Children's Access to Primary Care:  Differences by Race, Income, and
Insurance Status," Pediatrics, Vol.  97, No.  1 (1996), pp.  26-32. 

\8 J.  L.  Holl and others, "Profile of Uninsured Children in the
United States," Archives of Pediatric and Adolescent Medicine, Vol. 
149 (Apr.  1995), pp.  398-406. 

\9 "Clinic" includes a company or school health clinic or center;
community, migrant, or rural clinic or center; county, city, or
public county hospital outpatient clinic; and private or other
hospital outpatient clinic.  These are percentage estimates that are
not adjusted for multiple factors that influence choice of care site. 
See Gloria Simpson and others, "Access to Health Care Part 1: 
Children," Vital and Health Statistics, Series 10, No.  196
(Hyattsville, Md.:  U.S.  Department of Health and Human Services,
1997). 

\10 Michael D.  Kogan and others, "The Effect of Gaps in Health
Insurance on Continuity of a Regular Source of Care Among
Preschool-aged Children in the United States," Journal of the
American Medical Association, Vol.  274, No.  18 (1995), pp. 
1429-35. 

\11 T.  A.  Lieu, P.  W.  Newacheck, and M.  A.  McManus, "Race,
Ethnicity, and Access to Ambulatory Care Among U.S.  Adolescents,"
American Journal of Public Health, Vol.  83, No.  7 (1993), pp. 
960-65. 


      BETTER ACCESS TO PRIMARY
      CARE LEADS TO BETTER LINKAGE
      TO COMPLEX CARE AND MORE
      ADEQUATE PREVENTIVE CARE
---------------------------------------------------------- Letter :3.2

Better access to primary care is important, because primary care is a
gateway to better preventive care and needed specialized services.  A
number of studies found that uninsured children had fewer health care
and dental visits and fewer preventive visits.  Compared with the
parents of low-income children who had public insurance like
Medicaid, parents of uninsured children of all income levels were
more likely to defer bringing them into care for financial reasons. 

Having a primary care provider has been shown to improve care by
facilitating the timely receipt of complex care.  One study showed
that children in Medicaid or who had no insurance were much less
likely to have contacted a primary care physician before they came to
the hospital with appendicitis.  Children whose families did not
contact a primary care physician before hospital admission were
operated on less quickly if they were admitted on weekends and were
more likely to have a perforated appendix.  Contact with a primary
care provider, not insurance status, was the key to differing rates
of this complication, but having private insurance did increase the
likelihood that a child would have a relationship with a primary care
physician.\12

Six studies that controlled for other factors affecting access found
that uninsured children were less likely to receive routine checkups,
dental care, or any kind of doctor's visit.  Some of them compared
routine visits made with the number of visits recommended by the
American Academy of Pediatrics (AAP) (see table 2) and found that
uninsured children were less likely to meet such standards. 



                                Table 2
                
                AAP's Recommended Schedule of Preventive
                        Well-Child Visits, 1995

Age                 Type of care
------------------  --------------------------------------------------
In hospital after   Basic well-child visit (newborn assessment),\a
birth               immunization

Within first week   Basic well-child visit\a
of life

By 1 month          Basic well-child visit\a and heredity and
                    metabolic screening tests (if not done before)

2 months            Basic well-child visit,\a immunization

4 months            Basic well-child visit,\a immunization

6 months            Basic well-child visit,\a immunization

9 months            Basic well-child visit,\a hematocrit or hemoglobin
                    (if not done before), lead screening

12 months           Basic well-child visit\a

15 months           Basic well-child visit,\a immunization

18 months           Basic well-child visit\a

Yearly visits       Basic well-child visit,\a immunization (at 4, 5,
between 2 and 6     or 6), initial dental referral (by 3), lead
years               screening (2), urinalysis (5)

8 years             Basic well-child visit\a

10 years            Basic well-child visit\a

Yearly visits       Basic well-child visit,\a immunization (as needed,
between 11 and 21   11 through 16), hematocrit or hemoglobin (as
years               needed), urinalysis (as needed)
----------------------------------------------------------------------
\a Basic well-child visits include health history, weight and height
measurement, developmental and behavioral assessment, physical exam,
and anticipatory guidance that includes counseling and discussion of
topics for the developing child, with specific discussion of injury
prevention.  Through 24 months of age, all visits should include
measurement of head circumference.  Starting at age 3, all visits
should also include a blood pressure check. 

Source:  American Academy of Pediatrics, Committee on Practice and
Ambulatory Medicine, "Recommendations for Preventive Pediatric Health
Care," Pediatrics, Vol.  96 (1995), pp.  373-74. 

For example, one study found that 30 percent of uninsured children
were not up to date with well-child care visits, as AAP recommends,
compared with 22 percent of insured children.  Compared with insured
children, and controlling for other factors that affect access,
uninsured children were 50-percent more likely not to have made any
visits to a physician in the past year and almost twice as likely
never to have had routine care.\13 In a local California study, lack
of insurance was the strongest predictor that children older than 5
had not seen a dentist in the past year, compared with privately
insured children.\14

Uninsured children were less likely to have received care when it was
not an emergency.  An analysis of the 1980 National Medical Care
Utilization and Expenditure Survey, after adjusting for other factors
affecting access, found that uninsured children had a 69-percent
likelihood that they would use nonemergency ambulatory care during
the year, compared with 81 percent for privately insured children. 
The uninsured children who had used health services had made fewer
nonemergency ambulatory visits, compared with privately insured
children.\15 (See fig.  2.) Similarly, an analysis of a more recent
survey also showed that being uninsured was a significant predictor
of not using a physician's services.\16

   Figure 2:  Average Number of
   Annual Nonemergency Ambulatory
   Care Visits Among Insured and
   Uninsured Children Who Used
   Services, 1980

   (See figure in printed
   edition.)

Source:  Brenda C.  Spillman, "The Impact of Being Uninsured on
Utilization of Basic Health Care Services," Inquiry, Vol.  29 (winter
1992), pp.  457-66. 


--------------------
\12 V.  T.  Chande and J.  M.  Kinnane, "Role of the Primary Care
Provider in Expediting Care of Children With Acute Appendicitis,"
Archives of Pediatric and Adolescent Medicine, Vol.  150, No.  7
(1996), pp.  703-6.  Having a usual source of care may have been more
important for some kinds of care than others.  It increased routine
checkups and well care for women in one study but did not
significantly increase well child care for children--see Susan Louise
Ettner, "The Timing of Preventive Services for Women and Children: 
The Effect of Having a Usual Source of Care," American Journal of
Public Health, Vol.  86, No.  12 (1996), pp.  1748-54. 

\13 Holl and others, "Profile of Uninsured Children in the United
States."

\14 M.  W.  Smith and others, "How Economic Demand Influences Access
to Medical Care for Rural Hispanic Children," Medical Care, Vol.  34,
No.  11 (1996), pp.  1135-48. 

\15 Brenda C.  Spillman, "The Impact of Being Uninsured on
Utilization of Basic Health Care Services," Inquiry, Vol.  29 (winter
1992), pp.  457-66. 

\16 P.  W.  Newacheck, "Characteristics of Children with High and Low
Usage of Physician Services," Medical Care, Vol.  30, No.  1 (1992),
pp.  30-42. 


      UNINSURED CHILDREN RECEIVE
      LESS CARE WHEN INJURED OR
      ILL
---------------------------------------------------------- Letter :3.3

Several studies found that uninsured children were not getting care
for conditions that could be serious.  Children who had no insurance
had lower rates of treatment for injuries, including serious injuries
such as broken bones or cuts requiring stitches, compared with
children who had private insurance, and were less likely to get care
when sick.  Sometimes they received care later, after they had become
sicker. 

Childhood injuries were fairly common, but insurance status affected
a child's chances of being medically treated for an injury.  In 1988,
children younger than 18 had total injury rates of 16.3 per 100. 
Serious injuries that resulted in restricted activity, bed days,
surgery, hospitalization, or substantial pain represented about half
of total injuries.  A study that compared injury treatment for
insured children (private insurance and Medicaid combined) and
uninsured children found that the uninsured were less likely to be
brought in for the treatment of injuries.  The study's researchers
estimated that for children who had no coverage in 1988, the year of
the study, between 20 and 30 percent of total injuries may not have
been examined and treated by a health professional.  At least 40
percent of serious injuries to uninsured children younger than 11
might not have been examined and treated. 

These researchers also found that Medicaid-insured children had
treatment rates similar to privately insured children, suggesting
that public insurance helped ensure that children would receive
treatment for injuries.\17 Their finding that families that had
Medicaid coverage for their children would seek health care for them,
while families of uninsured children would not, is consistent with
the findings from the Rand Health Insurance Experiment that families
of poor children in cost-sharing plans were less likely to seek care
for diagnoses related to trauma or accidents than families of poor
children with free care. 

Uninsured children were less likely to receive treatment for some of
the common illnesses of childhood.  Uninsured children were about
twice as likely to have received no care from a physician for
pharyngitis, acute earache, recurrent ear infections, and asthma.\18
(See fig.  3.) These are common conditions--with an incidence rate of
8 to 10 per 100 children--for which medical care is considered
necessary.\19 They can also have serious consequences for some
children if they are left untreated.  For example, pharyngitis, if
caused by untreated group A streptococci, can lead to rheumatic
fever.  Untreated middle-ear infections can lead to long-term hearing
loss and sometimes to related speech and language difficulties. 
Severe asthma can cause respiratory failure and death. 

   Figure 3:  The Likelihood That
   Uninsured and Insured Children
   Received Medical Care When Ill,
   1987

   (See figure in printed
   edition.)

Source:  Jeffrey J.  Stoddard, Robert F.  St.  Peter, and Paul W. 
Newacheck, "Health Insurance Status and Ambulatory Care for
Children," New England Journal of Medicine, Vol.  330, No.  20
(1994), pp.  1421-25. 

Looking at more rare conditions, one study examined severity of
illness when privately insured and underinsured children were
diagnosed with inflammatory bowel diseases.\20 Inflammatory bowel
diseases (Crohn's disease and ulcerative colitis) can result in
absence from school, progressive malnutrition, weight loss, anemia,
depression, and fatigue.  Early diagnosis can catch these diseases
before they have progressed so that they can be treated with
less-aggressive therapies.  The study's authors, comparing a limited
number of cases of underinsured children who had these rare illnesses
with insured children who had the same illnesses, found that children
who were underinsured had 2-1/2 times the weight loss of insured
children and had waited 8 months longer before diagnosis.  The
children's laboratory results also indicated that they were sicker
before diagnosis and were more likely to be anemic.  The authors
suggested that delay in diagnosis could have occurred for several
reasons, such as seeing different physicians at the same clinic or
emergency room or not being able to get timely appointments with
subspecialists.\21


--------------------
\17 Mary D.  Overpeck and Jonathan B.  Kotch, "The Effect of U.  S. 
Children's Access to Care on Medical Attention for Injuries,"
American Journal of Public Health, Vol.  85, No.  3 (1995), pp. 
402-4.  Serious injuries were defined as those for which the child
(1) had to stay in bed for more than half a day; (2) had any
limitations or was prevented from usual childhood activities; (3)
spent 1 or more nights in the hospital; (4) had surgery, including
setting bones or sewing stitches; (5) had pain often or all the time;
or (6) was bothered more than a little. 

\18 Overpeck and Kotch's definitions for these conditions were
pharyngitis, or sore throat with high fever or tonsillitis for at
least 2 days during the past 30 days; acute earache, or ear infection
or earache for at least 2 of the past 30 days; recurrent ear
infections, or more than 2 ear infections within the past 12 months;
and asthma, or asthma or wheezing within the past 12 months. 

\19 Jeffrey J.  Stoddard, Robert F.  St.  Peter, and Paul W. 
Newacheck, "Health Insurance Status and Ambulatory Care for
Children," New England Journal of Medicine, Vol.  330, No.  20
(1994), pp.  1421-25. 

\20 The authors combined uninsured children and children in Medicaid
to come up with their category "underinsured." They considered
children in Medicaid as having insufficient insurance because of the
difficulty Medicaid children had in getting primary and specialty
care at that time (1983-93) in that locality. 

\21 W.  Spivak, R.  Sockolow, and A.  Rigas, "The Relationship
Between Insurance Class and Severity of Presentation of Inflammatory
Bowel Disease in Children," American Journal of Gastroenterology,
Vol.  90, No.  6 (1995), pp.  982-87. 


      UNINSURED CHILDREN ARE
      HOSPITALIZED MORE FREQUENTLY
      FOR LACK OF PRIMARY CARE
---------------------------------------------------------- Letter :3.4

A lack of appropriate ambulatory care can cause children to be
inappropriately hospitalized when they could have been treated as
outpatients.  Several researchers have studied hospital admissions
among adults and children for conditions that can be managed with
good ambulatory care.  In general, they found that U.S.  communities
with poor access to ambulatory care--that is, low-income communities
with many residents uninsured or enrolled in Medicaid--had higher
rates of this kind of hospitalization.  In contrast, hospital
admissions in Spain for conditions sensitive to ambulatory care did
not vary for children living in lower- and higher-income
neighborhoods. 

Lower-income U.S.  neighborhoods had higher avoidable hospitalization
rates compared with higher-income neighborhoods for both children and
adults.  Income differences in avoidable hospitalizations dropped for
persons 65 years old or older, probably because of their Medicare
coverage.  Compared with privately insured patients in the same age
category, uninsured patients had higher rates of avoidable
hospitalization.  Medicaid patients had even higher rates.\22 Most of
the potentially avoidable hospitalizations for children younger than
15 were for pneumonia or asthma.  Communities where people perceived
that they had poorer access to medical care had higher rates of
hospitalization for chronic diseases.  Self-rated access to care was
lower in communities that had greater proportions of uninsured
residents, Medicaid beneficiaries, and persons without a usual source
of care.\23

Analysis of crossnational data also suggests that broader access to
primary care reduces the number of hospitalizations for conditions
sensitive to ambulatory care.  Several researchers compared such
admissions for children in Spain and several U.S.  cities.  Although
rates of hospital admission were higher in general for children in
Spain, rates of hospitalization for conditions sensitive to
ambulatory care were lower.  In addition, lower-income communities in
Spain, unlike the United States, did not have higher rates of
children's hospital admissions sensitive to ambulatory care.  The
authors attributed this difference to Spanish children's access to
universal health care, each child being covered by a responsible
primary care provider.\24


--------------------
\22 G.  Pappas and others, "Potentially Avoidable Hospitalizations: 
Inequities in Rates Between U.S.  Socioeconomic Groups," American
Journal of Public Health, Vol.  87, No.  5 (1997), pp.  811-22. 

\23 Andrew B.  Bindman and others, "Preventable Hospitalizations and
Access to Health Care," Journal of the American Medical Association,
Vol.  274, No.  4 (1995), pp.  305-11. 

\24 Carmen Casanova and Barbara Starfield, "Hospitalizations of
Children and Access to Primary Care:  A Cross-National Comparison,"
International Journal of Health Services, Vol.  25, No.  2 (1995),
pp.  283-94. 


      UNINSURED CHILDREN RECEIVE
      UNEQUAL CARE WHEN
      HOSPITALIZED
---------------------------------------------------------- Letter :3.5

Two studies indicated that when children were hospitalized, providers
did not give the same type of care to uninsured and privately insured
children.  Providers may have been unwilling to provide the same
intensity of care if the payment source was uncertain or likely to be
less than actual charges.\25


One group of researchers found that sick uninsured newborns in
California had shorter hospital stays and received less-intensive
care while in the hospital than privately insured sick newborns, even
though the uninsured newborns and those in Medicaid were sicker. 
Newborns in Medicaid had lengths of stay and levels of service
between those of uninsured and privately insured newborns.  Adjusted
mean length of stay was 15.2 days for privately insured newborns,
14.2 for Medicaid-covered newborns, and 12.7 for uninsured newborns. 
Total mean charges were $15,899 for privately insured newborns,
$13,858 for Medicaid-covered newborns, and $11,414 for uninsured
newborns.  Charges per day were also significantly different
depending on insurance status.  In all, length of stay, total
charges, and charges per day were 16-percent, 28-percent, and
10-percent less for uninsured than privately insured newborns.\26

Another group of researchers found that uninsured children and adults
were generally sicker when admitted to the hospital, received less
care given their condition on admission, and had higher mortality
than privately insured children and adults.  For children between
ages 1 and 17, uninsured black males and white females rated
significantly higher on a risk-adjusted mortality index, indicating
that they were sicker on admission.  The differences for uninsured
black females and white males were not significant.  Another measure
of children's being sicker on admission is admission on weekends,
which was more likely for all uninsured children except black males. 
For the entire sample of all ages, uninsured people had shorter
lengths of stay for conditions for which physicians had more
discretion over the length of stay, and they had a lower probability
of getting selected procedures that were either costly or more likely
to be done at the physician's discretion.  The researchers cautioned
that their adjustment for health risk might be imperfect. 
Nevertheless, they concluded that insurance coverage affects resource
use for a broad spectrum of clinical problems, particularly elective
and discretionary services.\27


--------------------
\25 Of course, privately insured children may have been getting more
care than they needed. 

\26 P.  Braveman and others, "Differences in Hospital Resource
Allocation Among Sick Newborns According to Insurance Coverage,"
Journal of the American Medical Association, Vol.  266, No.  23
(1991), pp.  3300-8. 

\27 Jack Hadley, Earl Steinberg, and Judith Feder, "Comparison of
Uninsured and Privately Insured Hospital Patients:  Condition on
Admission, Resource Use, and Outcome," Journal of the American
Medical Association, Vol.  265, No.  3 (1991), pp.  374-79. 


      UNINSURED CHILDREN WHO HAVE
      CHRONIC CONDITIONS OR
      SPECIAL HEALTH NEEDS RECEIVE
      LESS CARE THAN INSURED
      CHILDREN
---------------------------------------------------------- Letter :3.6

Many children have a chronic condition--one study estimated that 31
percent of children younger than 18 in 1988 had one or more chronic
conditions.\28 NCHS estimated that about 15 percent of children who
had chronic conditions had special health care conditions that were
disabling because they missed school, stayed in bed, limited their
activities, or experienced pain or discomfort often.\29

Many children who have chronic conditions are uninsured.  In 1988,
21.1 percent of poor children and 9.7 percent of nonpoor children who
had chronic conditions were uninsured.\30 About 13 percent of
children who had chronic conditions and special health care needs
were uninsured--with low-income, Hispanic, and nonsuburban children
more likely to be uninsured.\31

Having a regular source of care ensures continuity of care and
professional monitoring of disease symptoms.  Only a few studies
looked at children who had chronic conditions and those who had
special health care needs, and fewer controlled for factors that
influence access other than insurance.\32 However, these few studies
found differences in access to care by insurance status.  (See table
3.) For example, poor children who had chronic conditions but no
insurance were more than twice as likely as similar, insured
children, to lack a usual source of routine care or sick care.\33
(See fig.  4.) Adjusting for severity of illness and other factors,
they had only 2.3 physician contacts per year, compared with 3.7 for
similar but insured children. 



                                Table 3
                
                Statistically Significant Differences in
                   Access to Care for Chronically Ill
                 Children and Children Who Had Special
                 Health Care Needs, by Insurance Status

Compared with insured children, uninsured children    Study
----------------------------------------------------  ----------------
Poor children with chronic conditions
----------------------------------------------------------------------
Were more likely to lack a usual source of routine    Newacheck, 1994
care

Were more likely to lack a usual source of sick care

Had fewer annual physician visits


Children with chronic conditions and special health needs
----------------------------------------------------------------------
Were less likely to have been hospitalized in the     Aday and others,
past year                                             1993


Children reported in fair or poor health
----------------------------------------------------------------------
Were more likely not to have used a physician's       Newacheck, 1992
services during a year
----------------------------------------------------------------------
Notes:  Full study citations are in the bibliography.  All
differences reported in this table between uninsured and insured
children were statistically significant at the .05 level.  Some were
significant at the .01 or .001 level. 

   Figure 4:  Insured and
   Uninsured Poor Children Who Had
   Chronic Conditions and Lacked a
   Usual Source of Routine or Sick
   Health Care by Insurance
   Status, 1988

   (See figure in printed
   edition.)

Source:  P.  W.  Newacheck, "Poverty and Childhood Chronic Illness,"
Archives of Pediatric and Adolescent Medicine, Vol.  148, No.  11
(1994), pp.  1143-49. 

An analysis that went even further to separate insurance status from
other factors that could affect children's access to care found that
children who had chronic conditions and special health care needs
were more than twice as likely to be hospitalized if they had public
or private insurance than if they were uninsured, adjusting for
differences in need for hospitalization based on their conditions.\34


--------------------
\28 P.  W.  Newacheck, "Poverty and Childhood Chronic Illness,"
Archives of Pediatric and Adolescent Medicine, Vol.  148, No.  11
(1994), pp.  1143-49. 

\29 L.  A.  Aday, "Health Insurance and Utilization of Medical Care
for Chronically Ill Children With Special Needs," Advance Data, No. 
215 (Hyattsville, Md.:  National Center for Health Statistics, 1992). 

\30 Newacheck, "Poverty and Childhood Chronic Illness."

\31 Aday, "Health Insurance and Utilization of Medical Care."

\32 For a study that compared access of asthmatic children by
insurance status, without controlling for other factors that
influence access, see Holl and others, "Profile of Uninsured Children
in the United States."

\33 Newacheck, "Poverty and Childhood Chronic Illness."

\34 Defined as children who had one or more selected chronic
conditions that caused them to experience pain or discomfort or to be
upset often or all the time in the past year or who were limited in
their major childhood activities as a result of these or other
impairments or health problems.  Their conditions included frequent
or repeated ear infections, digestive allergies, frequent diarrhea or
bowel trouble, diabetes, sickle cell anemia, anemia, asthma, hay
fever or respiratory allergies, epilepsy or seizures, frequent or
severe headaches, musculoskeletal impairments including arthritis,
cerebral palsy, heart disease, and other conditions requiring surgery
and lasting longer than 3 months.  L.  A.  Aday and others, "Health
Insurance and Utilization of Medical Care for Children With Special
Health Care Needs," Medical Care, Vol.  31 (1993), pp.  1013-26. 
Another study looking at similar issues for adults and children
combined is C.  Hafner-Eaton, "Physician Utilization Disparities
Between the Uninsured and the Insured:  Comparisons of the
Chronically Ill, Acutely Ill, and Well Nonelderly Populations,"
Journal of the American Medical Association, Vol.  269, No.  6
(1993), pp.  787-92. 


      HEALTH INSURANCE DIFFERS IN
      COVERAGE OF CHILDREN'S
      COMMON HEALTH CARE NEEDS
---------------------------------------------------------- Letter :3.7

Many health plans do not cover a number of preventive, primary, and
developmental health services needed by some or all children. 
Private policies differ in whether they cover well-child, dental, and
vision care.  In 1996, KMPG Peat Marwick reported that 57 percent of
the indemnity health plans used by firms with 200 to more than 5,000
workers covered well-child care, compared with 96 percent of health
maintenance organizations (HMO) and 73 percent of preferred provider
organization (PPO) plans.\35

Dental caries are a common problem for children, while poor vision
can lead to problems in learning.  Nevertheless, only about half or
less of the private plans surveyed covered dental or vision care. 
Medicaid's child health benefit package, the Early and Periodic,
Screening, Diagnosis, and Treatment (EPSDT) program requires coverage
of well-child care, including dental, hearing, and vision care. 
Other publicly funded programs, such as the Florida HealthyKids
Program and New York's Child Health Plus Program, have not covered
dental care; HealthyKids covered vision and hearing care, but Child
Health Plus did not.\36

Children who have chronic conditions and special health care needs
may have particular difficulties because the services and supplies
they need may not be covered by their insurance.  For example,
coverage for speech or physical therapy to help with developmental
delays is often limited or explicitly excluded from private health
insurance policies.  In contrast, Medicaid's EPSDT program covers a
wide variety of developmental services. 

Some children are insured but with "bare-bones" policies that provide
minimal coverage except for catastrophic costs.  Such children, if
eligible for Medicaid, could get coverage for services not covered by
their private insurance.  However, Title XXI--the new child health
insurance program--was designed to be restricted to uninsured
children, so that low-income children with coverage, even if it were
only catastrophic coverage, would not be considered eligible. 
Florida HealthyKids and New York's Child Health Plus, two state-based
plans whose benefits have been grandfathered into Title XXI, have in
the past covered insured children if their health insurance was not
comparable in scope to the state-based coverage.\37

Some experts have argued that special pediatric standards should be
developed that recognize children's specific needs, such as their
need for health services to ensure optimal development.  They have
argued that such services should be considered medically necessary
and should be covered by private health insurance.\38 Medicaid's
standard of medical necessity is more global than that of private
plans.  However, families in Medicaid have sometimes had difficulty
finding mainstream providers willing to accept them as patients,
which limits their ability to secure covered benefits for their
children. 


--------------------
\35 KPMG Peat Marwick, Health Benefits in 1996 (n.p.:  1996). 

\36 Children's Health Insurance Programs, 1996 (GAO/HEHS-97-40R, Dec. 
3, 1996). 

\37 Health Insurance for Children:  State and Private Programs Create
New Strategies to Insure Children (GAO/HEHS-96-35, Jan.  18, 1996). 

\38 E.  Wehr and E.  J.  Jameson, "Beyond Benefits:  The Importance
of a Pediatric Standard in Private Insurance Contracts to Ensuring
Health Care Access for Children," The Future of Children:  Critical
Health Issues for Children and Youth, Vol.  4, No.  3 (1994), pp. 
115-33. 


   EXPANDING PUBLIC INSURANCE
   IMPROVES ACCESS
------------------------------------------------------------ Letter :4

Since providing uninsured children with publicly funded insurance
improves their access to preventive and acute health services,
families are more likely to report that their children's health needs
are being met.  Children are more likely to be up to date with
recommended preventive care and are more likely to see a physician. 
Two different researchers estimated that the expansion of publicly
funded insurance in the United States and Canada decreased child
mortality, in association with either more physicians' visits or more
prenatal care. 

NCHS reported that uninsured children were about three times as
likely to have an unmet health need as children with publicly funded
insurance (generally Medicaid).  (See fig.  5.) Dental care was the
most common unmet need for all children--but uninsured children were
more than three times as likely not to receive needed dental care as
children who had publicly funded insurance.  Almost 16 percent of
uninsured children were reported as needing but not receiving dental
care.\39

   Figure 5:  Percentage of U.S. 
   Children Who Had Publicly
   Funded Insurance or No
   Insurance and Unmet Health
   Needs, 1993

   (See figure in printed
   edition.)

Source:  Gloria Simpson and others, "Access to Health Care Part 1: 
Children," Vital and Health Statistics, Series 10, No.  196
(Hyattsville, Md.:  U.S.  Department of Health and Human Services,
1997). 

Parents of uninsured children reported delaying getting care for
their children because of its cost almost five times as often as
children who had publicly funded insurance.  One local study in Los
Angeles found that inner-city Latino parents were also most likely to
report that they deferred health care for their toddlers for
financial reasons when they were uninsured, compared with others who
had Medicaid or private coverage.\40

A number of studies estimated the effect that providing publicly
funded insurance, such as Medicaid, had on lessening the gap between
uninsured and insured children.  One research team examined the
effect of expanding Medicaid coverage to children and found decreases
over time in the probability that children would go without at least
one ambulatory care visit in a year.  Making a child eligible for
Medicaid lowered the child's estimated probability of going without a
visit by 13 percent.  Hospitalizations also rose by an estimated 14
percent--but the estimated probability of making visits to
physicians' offices increased even more than making visits to other
sites, suggesting to the authors that expanding Medicaid coverage
increased ambulatory care.  These authors also looked at the effects
of Medicaid expansion on child health as measured by decreases in
child mortality.  They estimated that the 15-percent rise in the
number of children eligible for Medicaid between 1984 and 1992
decreased child mortality by 5 percent.\41 A similar study that
looked at the effect of providing national health insurance in Canada
found a statistically significant increase in early prenatal care and
a significant decrease in infant mortality.\42

Another study of children's rates of preventive and illness-related
primary care visits found that, adjusting for other factors such as
race and perceived health status, the predicted probability of making
either a preventive or illness-related visit increased if children
were covered by public or private insurance, compared with being
uninsured.  For example, for uninsured children younger than 6 in
single-parent families headed by mothers, the predicted probability
of making a preventive visit was more than 40-percent greater if the
children were covered by public or private insurance, and it was
almost 100-percent greater for children aged 6 to 17.\43

Many children miss recommended preventive visits, but uninsured
children fare worse than insured children.  Short and Lefkowitz found
that in 1987, only 49 percent of uninsured preschool children had
made any well-child visits, compared with 65 percent of insured
children, and only 32 percent of uninsured preschool children had
made the recommended number of visits, compared with 48 percent of
insured children.\44 They found that when adjusting for other
factors, private insurance status was only marginally significant in
predicting well-child visits, which they explained by the degree to
which private insurance varies in its coverage of well-child care. 
However, they estimated that for low-income children who would
otherwise be uninsured, a full year of Medicaid coverage increased
the probability of making any well-child visits by 17 percentage
points, and compliance with AAP's guidelines for well-child visits
would increase by 13 percentage points.  (See table 2 for AAP
guidelines.)


--------------------
\39 The NCHS study simply compared privately insured, Medicaid, and
uninsured children without controlling for other factors that could
affect access.  However, since children in Medicaid have lower
average family income than uninsured children and are more likely to
be more socially disadvantaged, regression analysis might well
increase the comparative effect of insurance, so we are including
these results for a simple comparison.  See Simpson and others,
"Access to Health Care Part 1."

\40 N.  Halfon and others, "Medicaid Enrollment and Health Services
Access by Latino Children in Inner-city Los Angeles," Journal of the
American Medical Association, Vol.  277, No.  8 (1997), pp.  636-72. 

\41 J.  Currie and Jonathan Gruber, "Health Insurance Eligibility,
Utilization of Medical Care, and Child Health," Quarterly Journal of
Economics, Vol.  111, No.  2 (1996), pp.  431-66. 

\42 Maria J.  Hanratty, "Canadian National Health Insurance and
Infant Health," American Economic Review, Vol.  86, No.  1 (1996),
pp.  276-84. 

\43 Peter J.  Cunningham and Beth A.  Hahn, "The Changing American
Family:  Implications for Children's Health Insurance Coverage and
the Use of Ambulatory Care Services," The Future of Children: 
Critical Health Issues of Children and Youth, Vol.  4, No.  3 (1994),
pp.  24-42.  See also Mary L.  Rosenbach, "The Impact of Medicaid on
Physician Use by Low-Income Children," American Journal of Pediatric
Health, Vol.  79, No.  9 (1989), pp.  1220-26. 

\44 Pamela Farley Short and Doris C.  Lefkowitz, "Encouraging
Preventive Services for Low-Income Children:  The Effect of Expanding
Medicaid," Medical Care, Vol.  30, No.  9 (1992), pp.  766-80. 


   LACK OF HEALTH INSURANCE IS
   ONLY ONE BARRIER TO CARE
------------------------------------------------------------ Letter :5

Getting appropriate health care when it is needed can be difficult
for children.  Parents and guardians usually make the decision to
seek care for them.  Having health insurance and having a regular
source of health care facilitate a family's use of health services,
but some families experience systemic, financial, and personal
barriers to care.  Systemic barriers can include a lack of primary
care providers readily available in the neighborhood, physicians'
missing opportunities to provide vaccinations during health care
visits, and physicians' refusing to accept certain patients. 
Financial barriers, apart from lack of insurance, can include lack of
funds to make copayments or pay for uncovered services.  Personal
barriers can include parents' lack of knowledge that care is needed
and language differences between parents and providers.  Similarly,
discrimination and poor treatment by health care workers can
discourage the use of health care services.\45

Uninsured children and children in Medicaid may also be likely to
face systemic, financial, or personal barriers that limit their
access to care, beyond their lack of insurance.  Compared with
privately insured children, uninsured children and those in Medicaid
are more likely to have less family income, to be members of a
minority group, to have parents who have lower educational
attainment, or to live with only one parent--characteristics
associated with lower use of health services. 

As a result, experts in health issues have concluded that while
insurance plays a critical role in getting children access to health
care, encouraging their appropriate use of health care encompasses
multiple strategies.  These include making insurance coverage more
continuous in order to foster children's relationships with
providers, maintaining a better organized system of primary care in
settings that ease access for parents and that have good links to
more complex care, enhancing systems in which primary care providers
can track and prompt preventive visits and immunizations, and aiming
outreach and educational programs at parents.\46


--------------------
\45 Paul W.  Newacheck and others, "Children's Access to Health Care: 
The Role of Social and Economic Factors," in Health Care for
Children:  What's Right, What's Wrong, What's Next, ed.  by Ann R. 
E.  Stein (New York:  United Hospital Fund of New York, 1997). 

\46 Institute of Medicine, Paying Attention to Children in a Changing
Health Care System (Washington, D.C.:  National Academy Press, 1996);
James Perrin, Bernard Guyer, and Jean M.  Lawrence, "Health Care
Services for Children and Adolescents," The Future of Children:  U.S. 
Health Care for Children, Vol.  2, No.  2 (1992), pp.  58-77; J. 
Currie, "Socio-Economic Status and Child Health:  Does Public Health
Insurance Narrow the Gap?" Scandinavian Journal of Economics, Vol. 
97, No.  4 (1995), pp.  603-20; Short and Lefkowitz, "Encouraging
Preventive Services for Low-Income Children."


   CONCLUSION
------------------------------------------------------------ Letter :6

Research has clearly demonstrated that having health insurance makes
a difference for children.  Children who have no insurance--even
those who are sick or chronically ill or have special health care
needs--get less health care than children who have insurance.  Many
studies have shown that increasing children's coverage increases
their access to care, particularly primary care.  Without appropriate
access to primary care, children are more likely to suffer
unnecessarily from illness. 

But having health insurance is no guarantee that children will get
appropriate, high-quality care.  Some children live in families that
do not understand the need for preventive care or do not know how to
seek high-quality care.  Some live in neighborhoods that have few
health care providers, where they have to travel further and wait
longer to get care.  Some live in families in which most of the
members do not speak English or defer getting care because they have
had difficulty getting care previously.  Some children have health
insurance that does not cover some of the services that they need
most--such as dental care or physical therapy for the developmentally
disabled.  Some children have health insurance whose deductibles and
cost-sharing are unaffordable.  Such barriers can reduce the
likelihood that even insured children will get the care they need. 

Overcoming these kinds of barriers would require that children be
more continuously covered by health insurance so that they could
develop long-term relationships with primary care providers.  Having
a stable source of insurance can help families use the health system
for their children optimally over time.  Beyond that, children have
needs for specific developmental and preventive care that differ in
some ways from those of adults.  For insurance to work for children,
the services they need must be both covered and affordable. 

Overcoming nonfinancial barriers might require outreach and education
for families so that they can learn how better to use preventive and
primary health care for their children.  In addition, making
high-quality primary health services convenient for families in local
communities might facilitate children's access to appropriate care. 


   EXPERTS' COMMENTS AND OUR
   RESPONSE
------------------------------------------------------------ Letter :7

We asked experts on access to health insurance and children's health
care to review a draft of this report, and we incorporated their
comments and suggestions where appropriate. 


---------------------------------------------------------- Letter :7.1

We will make copies of this report available on request.  Please
contact me at (202) 512-7114 if you or your staff have any questions. 
This report was prepared by Michael Gutowski, Jonathan Ratner, Sheila
Avruch, and Sarah Lamb. 

Sincerely yours,

William J.  Scanlon
Director, Health Financing
 and Systems Issues


BIBLIOGRAPHY
=========================================================== Appendix 0

Aday, LuAnn.  "Health Insurance and Utilization of Medical Care for
Chronically Ill Children With Special Health Care Needs." Advance
Data, No.  215.  Hyattsville, Md.:  National Center for Health
Statistics, 1992. 

Aday, LuAnn, and others.  "Health Insurance and Utilization of
Medical Care for Children with Special Health Care Needs." Medical
Care, Vol.  31, No.  11 (1993), pp.  1013-26. 

"American Academy of Pediatrics Committee on Child Health Financing: 
Principles of Child Health Care Financing." Pediatrics, Vol.  91, No. 
2 (1993), pp.  506-7. 

Bashshur, R.L., R.K.  Homan, and D.G.  Smith.  "Beyond the Uninsured: 
Problems in Access to Care." Medical Care, Vol.  32, No.  5 (1994),
pp.  409-19. 

Behrman, R.E., and C.S.  Larson.  "Health Care for Pregnant Women and
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RELATED GAO PRODUCTS

Uninsured Children and Immigration, 1995 (GAO/HEHS-97-126R, May 27,
1997). 

Health Insurance for Children:  Declines in Employment-Based Coverage
Leave Millions Uninsured; State and Private Programs Offer New
Approaches (GAO/T-HEHS-97-105, Apr.  8, 1997). 

Employment-Based Health Insurance:  Costs Increase and Family
Coverage Decreases (GAO/HEHS-97-35, Feb.  24, 1997). 

Children's Health Insurance, 1995 (GAO/HEHS-97-68R, Feb.  19, 1997). 

Children's Health Insurance Programs, 1996 (GAO/HEHS-97-40R, Dec.  3,
1996). 

Private Health Insurance:  Millions Relying on Individual Market Face
Cost and Coverage Trade-Offs (GAO/HEHS-97-8, Nov.  25, 1996). 

Medicaid and Uninsured Children, 1994 (GAO/HEHS-96-174R, July 9,
1996). 

Health Insurance for Children:  Private Insurance Coverage Continues
to Deteriorate (GAO/HEHS-96-129, June 17, 1996). 

Health Insurance for Children:  State and Private Programs Create New
Strategies to Insure Children (GAO/HEHS-96-35, Jan.  18, 1996). 

Medicaid and Children's Insurance (GAO/HEHS-96-50R, Oct.  20, 1995). 

Health Insurance for Children:  Many Remain Uninsured Despite
Medicaid Expansion (GAO/HEHS-95-175, July 19, 1995). 

Medicaid:  Experience With State Waivers to Promote Cost Control and
Access Care (GAO/HEHS-95-115, Mar.  23, 1995). 

Uninsured and Children on Medicaid (GAO/HEHS-95-83R, Feb.  14, 1995). 

Employer-Based Health Insurance:  High Costs, Wide Variation Threaten
System (GAO/HRD-92-125, Sept.  22, 1992). 


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