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America's Children Health Insurance and Access to Care Margaret Edmunds and Molly Joel Coye, Editors Committee on Children, Health Insurance, and Access to Care Division of Health Care Services, Institute of Medicine, and Board on Children, Youth, and Families, National Research Council and Institute of Medicine NATIONAL ACADEMY PRESS Washington, DC 1998
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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported by the Robert Wood Johnson Foundation. The views presented in this report are those of the Institute of Medicine's Committee on Children, Health Insurance, and Access to Care and are not necessarily those of the funding organization. Additional copies of this report are available for sale from the National Academy Press, Box 285, 2101 Constitution Avenue, N.W., Washington, D.C. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line bookstore at http://www.nap.edu. Library of Congress Cataloging-in-Publication Data America's children : health insurance and access to care / Margaret Edmunds and Molly Joel Coye, Editors. p. cm. "Committee on Children, Health Insurance, and Access to Care Division of Health Care Services, Institute of Medicine, and Board on Children, Youth, and Families, National Research Council and Institute of Medicine." Includes bibliographical references and index. ISBN 0-309-06560-7 (pbk.) 1. Child health services—United States—Finance. 2. Health services accessibility—United States. 3. Insurance, Health—United States. 4. Medically uninsured persons—United States. I. Edmunds, Margaret. II. Coye, Molly Joel. III. Institute of Medicine. Committee on Children, Health Insurance, and Access to Care. IV. Board on Children, Youth, and Families (U.S.) RJ102 .A387 1998 362.1'9892'000973—ddc21 98-25491 Copyright 1998 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
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COMMITTEE ON CHILDREN, HEALTH INSURANCE, AND ACCESS TO CARE MOLLY JOEL COYE (Chair),* Director, West Coast Office, The Lewin Group, San Francisco IRENE AGUILAR, Primary Care Physician, Westside Family Health Center, Denver BRIAN K. ATCHINSON, Second Vice President, Government Relations, UNUM, Portland, ME STEPHEN M. BOROWITZ, Associate Professor of Pediatrics, University of Virginia Health Sciences Center RICHARD BUCCIARELLI, Professor, Institute for Child Health Policy, and Associate Chair, Department of Pediatrics, University of Florida College of Medicine PETER BUDETTI, Professor of Health Services Management, Preventive Medicine and Law, and Director, Institute for Health Services Research and Policy Studies, Northwestern University THOMAS W. CHAPMAN, Senior Vice President for Network Development and Professor of Health Services Management and Policy, The George Washington University Medical Center MARGARET C. HEAGARTY,* Director of Pediatrics, Harlem Hospital Center, and Professor of Pediatrics, College of Physicians and Surgeons, Columbia University ROBERT B. HELMS, Resident Scholar, Director of Health Policy Studies, American Enterprise Institute, Washington, DC VELVET MILLER, Deputy Commissioner, New Jersey Department of Human Services, Trenton ARNOLD MILSTEIN, Managing Director, William M. Mercer, Inc., and Medical Director, Pacific Business Group on Health, San Francisco PAUL NEWACHECK, Professor of Health Policy and Pediatrics, Institute for Health Policy Studies and Department of Pediatrics, University of California at San Francisco DAVID S. WEINER, President and CEO, Children's Hospital, Boston STEVEN H. WOOLF, Fairfax Family Practice Center, and Clinical Professor, Department of Family Practice, Medical College of Virginia Institute of Medicine Staff MARGARET EDMUNDS, Study Director ELISE LIPOFF, Research Associate (March 1997 through June 1997) ANNICE HIRT, Research Assistant (March 1997 through September 1997) KATHLEEN NOLAN, Research Assistant (November 1997 through May 1998) TRACY MCKAY, Project Assistant JOHN BROTHERS, Graphics Consultant CARINA WEI-YEE FUNG, Student Intern MICHAEL DOMBECK, Student Intern * Member, Institute of Medicine.
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BOARD ON HEALTH CARE SERVICES INSTITUTE OF MEDICINE DON E. DETMER (Chair),* Senior Vice President, The University of Virginia STUART H. ALTMAN,* Sol C. Chaikin Professor of National Health Policy, The Florence Heller Graduate School for Social Policy, Brandeis University NANCY W. DICKEY, Private Practice, College Station, TX B. KEN GRAY, Corporate Medical Director, Metroplex Emergency Physician Associates, P.A., Dallas PAUL F. GRINER,* Vice President and Director, Center for the Assessment and Management of Change in Academic Medicine, Association of American Medical Colleges, Washington, DC BRENT C. JAMES, Executive Director, Institute for Health Care Delivery Research, and Vice President, Medical Research and Continuing Medical Education, Intermountain Health Care, Salt Lake City JACQUELINE KOSECOFF, President and Co-Chief Executive Officer, Value Health Sciences, Inc., Santa Monica SHEILA T. LEATHERMAN, Executive Vice President, Center for Health Care Policy and Evaluation, United Health Care Corporation, Minneapolis JOHN LUDDEN, Senior Vice President for Medical Affairs, Harvard Pilgrim Health Care, Brookline BARBARA J. McNEIL,* Ridley Watts Professor, Department of Health Care Policy, Harvard Medical School RUSSELL L. MILLER, Health Science Center, State University of New York at Brooklyn MILDRED MITCHELL-BATEMAN,* Clinical Director, Huntington Hospital, Huntington, WV MARY MUNDINGER,* Dean and Centennial Professor in Health Policy, Columbia University UWE E. REINHARDT,* James Madison Professor of Political Economy and Professor of Economics and Public Affairs, Princeton University MARY LEE SEIBERT, Acting Provost, Ithaca College GAIL L. WARDEN,* President and Chief Executive Officer, Henry Ford Health System, Detroit Institute of Medicine Staff CLYDE J. BEHNEY, Deputy Executive Officer and Director, Board on Health Care Services * Member, Institute of Medicine.
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BOARD ON CHILDREN, YOUTH, AND FAMILIES NATIONAL RESEARCH COUNCIL AND INSTITUTE OF MEDICINE JACK P. SHONKOFF (Chair), Professor and Dean, Heller Graduate School, Brandeis University DAVID V. B. BRITT, President-Chief Executive Officer, Children's Television Workshop, New York City LARRY BUMPASS, Professor of Sociology, Center for Demography and Ecology, University of Wisconsin-Madison FERNANDO A. GUERRA, Director of Health, San Antonio Metropolitan Health District BERNARD GUYER,* Professor and Chairman, Department of Maternal and Child Health, Johns Hopkins School of Hygiene and Public Health ALETHA C. HUSTON, Professor, Department of Human Ecology, University of Texas at Austin RENEE R. JENKINS, Professor and Chairman, Department of Pediatrics and Child Health, Howard University SARA McLANAHAN, Office of Population Research, Princeton University ROBERT MICHAEL, Professor, Harris Graduate School of Public Policy Studies, University of Chicago PAUL NEWACHECK, Professor of Health Policy, Institute for Health Policy Studies, and Department of Pediatrics, University of California at San Francisco MARTHA PHILLIPS, Executive Director, The Concord Coalition, Washington, DC JULIUS B. RICHMOND,* Professor of Health Policy, Emeritus, Department of Social Medicine, Harvard Medical School TIMOTHY M. SANDOS, Vice President, Education Division, ETC, Inc., Littleton, CO DEBORAH STIPEK, Professor of Education, Graduate School of Education, University of California at Los Angeles DIANA TAYLOR, Director, Women's Health Program, Department of Family Health Nursing, University of California at San Francisco GAIL WILENSKY,* Senior Fellow, Project Hope, Bethesda, MD National Research Council and Institute of Medicine Staff DEBORAH PHILLIPS, Executive Director, Board on Children, Youth, and Families * Member, Institute of Medicine.
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PREFACE The Committee on Children, Health Insurance, and Access to Care was asked by the Robert Wood Johnson Foundation to address a series of questions about health insurance for children. In addition to evaluating empirical evidence about the relationship between health insurance and access to care, the committee was asked to identify key trends in insurance coverage and in the delivery of care for uninsured children. The committee was asked to pay particular attention to changes in the provider community that might have an impact on access to care for uninsured and underserved children. The committee approached the study as an opportunity to evaluate the strengths and limitations of insurance as a means of improving children's health. From the beginning of their deliberations, the committee members took the position that several strategies potentially could increase the number of insured children and that their task was not to recommend one particular option. Rather, they decided to evaluate the advantages and disadvantages of a wide variety of approaches and to provide the best possible analysis of the various policies that might be considered, including some that have not yet been fully implemented or evaluated. The timing of the study brought special challenges. The committee held four meetings and a public workshop between March 1997 and January 1998. From the beginning of 1997, President Clinton and members of Congress debated a variety of proposals about insurance coverage for children, including Medicaid expansions, block grants, vouchers, tax credits, and several other strategies. In August 1997, Congress passed the Balanced Budget Act of 1997, enacting a new State Children's Health Insurance Program (SCHIP) with provisions for Medicaid expansions as well as market-based approaches to reducing the number of uninsured children. Because of the rapid rate of ongoing change in the health care system, particularly the increasing emphasis on Medicaid managed care, the committee intended for this report to present a general framework that would apply to several programs and strategies over time. The committee prepared a separate report entitled Systems of Accountability: Implementing Children's Health Insurance Programs, to focus on the evaluation of SCHIP and its impact. The committee included clinicians, researchers, policy analysts, and administrators. This consensus report reflects compromises made by committee members with differing views in order to reach language that each member of the committee could accept. For example, some committee members were willing to recommend universal, comprehensive coverage for all American children, while others were reluctant to do so because they felt it was beyond the scope of the study, or because they questioned the availability of resources, political will, or feasibility of comprehensive approaches. In the end, the
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committee recommended that all children should have health insurance, but did not recommend a single set of benefits or a single source of financing. This report, then, is intended as an overview of key issues in the organization, delivery, and financing of health care for children. The audience for the report is intentionally quite broad. It includes the study's sponsor, the Robert Wood Johnson Foundation, as well as other philanthropic organizations; members of Congress, congressional staff, and federal agencies; governors, state legislatures, and state agencies; the public health community; providers and the many provider associations representing them; employers; health insurers; parents; and children's advocates. The committee hopes that this report will help a variety of policy makers and other decision makers to make more informed decisions about how to achieve their multiple—and often competing—objectives as the SCHIP program is implemented across the country. The committee hopes that over time its contribution will be useful in shedding light on the impact and possible consequences of choosing various policy options to expand health insurance coverage for children. MOLLY JOEL COYE CHAIR
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ACKNOWLEDGMENTS The members of the Committee on Children, Health Insurance, and Access to Care and the study staff appreciate the assistance and contributions from many individuals and organizations during the course of the study. We express deep appreciation to all of the individuals and groups who contributed to the public workshop on June 2, 1997. Presentations were made by the following invited speakers: Maureen Ceidro, Julius Goepp, John Goodman, Jane Horvath, Dennis Johnson, Kay Johnson, Karen LaPlante, Charles LaVallee, John McDonough, Kim Monk, Diane Rowland, and Eugene Steuerle. Public statements were made by James Bentley, Stan Dorn, Steve Edwards, Samuel Flint, Shelly Gehshan, Catherine Hess, Ross Marine, and Kathleen Means. The committee and staff are particularly grateful to Patrick Chaulk and Carl J. Schramm, who served as moderators, and J. Michael McGinnis, who aptly summarized the day's proceedings. We also would like to thank the speakers who made invited presentations at the committee's first meeting in March 1997. They are Pamela Dickson, Burton Edelstein, Paul Fronstin, Dan Hawkins, Lawrence McAndrews, and Jacqueline Noyes. We particularly appreciate the contributions made by Paul Fronstin of the Employee Benefits Research Institute, who analyzed and provided data especially for this study and was responsive to numerous requests for additional information. We also thank Mark Hall of Wake Forest University's School of Law and Bowman Gray School of Medicine for providing a background paper and glossary on private insurance. Jane Koppelman's insightful and helpful comments on an earlier draft of the report are gratefully acknowledged. Michael Hayes, copy editor, also made many useful contributions and suggestions to improve the report. Thanks also go to Jane Andrews, Ellen Bayer, James Crall, Shelly Gehshan, Shirley Girouard, Suzanne Hansen, Dan Hawkins, Joan Henneberry, Robert Isman, Barbara Lamb, Marjorie Shofer, Marina Weiss, and Pete Wilson for providing technical comments on draft sections of the report. We are especially grateful to the members of the liaison panel for providing materials and public statements for the committee's consideration. The complete list of liaison panel members is included in Appendix D. Among those who were particularly active and helpful at various stages of the study are Sheila Avruch, Laura Camisa, Patrick Chaulk, Burton Edelstein, Donna Grossman, Elizabeth Hadley, Catherine Hess, Ed Howard, Ron Manderscheid, John McDonough, Kathleen Means, Ed Neuschler, and Eugene Steuerle. The committee could not have accomplished its tasks without the steadfast and creative efforts of
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the Institute of Medicine staff, led by Margo Edmunds, the study director. Her thoughtfulness, foresight, and ingenuity in planning and managing the study were exemplary. Her efforts were supported by Elise Lipoff, research associate; Annice Hirt, research assistant; Kathleen Nolan, research assistant; Tracy McKay, project assistant; two summer interns, Carina Wei-Yee Fung and Michael Dombeck; and John Brothers, graphics consultant. Several members of the staff of the Institute of Medicine and National Research Council made contributions to this report. Clyde Behney developed the idea for the study with the sponsor and provided guidance throughout the project. Kenneth Shine, Karen Hein, and Deborah Phillips also made several helpful comments at several stages of the project. Others who made contributions are Drusilla Barnes, Sue Barron, Mona Brinegar, Claudia Carl, Margo Cullen, Molla Donaldson, Jane Durch, Mike Edington, Robert Epstein, Marilyn Field, Kay Harris, Roger Herdman, Carrie Ingalls, Jeff Isenhour, Jim Jensen, Patricia Kaiser, Linda Kilroy, Michele Kipke, Jeffrey Koshel, Karen Kreiger, Marion Ein Lewin, Cathy Liverman, Luis Nunez, Constance Pechura, Deborah Phillips, Barbara Kline Pope, Dan Quinn, Barbara Rice, Kristen Robinson, Evelyn Simeon, Mary Lee Schneiders, Sally Stanfield, Michael Stoto, Kathleen Stratton, and Gooloo Wunderlich. This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the IOM in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review process: John Bartkowski, Sixteenth Street Community Health Centers, Inc., Milwaukee, WI; Judith Feder, Georgetown University Institute for Health Care, Public Policy, and Research, Washington, DC; Julius Goepp, Division of Pediatric Emergency Medicine, University of Rochester School of Medicine, Rochester, NY; Bernard Guyer, Department of Maternal and Child Health, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD; Mark Hall, Wake Forest University School of Law and Bowman Gray School of Medicine, Winston-Salem, NC; and Melvin Worth, IOM Scholar in Residence. While the individuals listed above have provided many constructive comments and suggestions, responsibility for the final content of this report rests solely with the authoring committee and the IOM. The study was undertaken with the support of the Robert Wood Johnson Foundation. The contributions of Foundation staff members Pamela Dickson, senior program officer, Robert Hughes, vice president, and Judith Whang, program officer, are gratefully acknowledged.
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CONTENTS Summary 1 Part I: Does Insurance Equal Access To Care? 1 Introduction And Overview 11 Purpose of This Study 13 The Policy Context 14 Conclusions 19 Organization of This Report 21 References 22 2 Health Insurance And Children In America 23 Background 23 Profile of Health Insurance Coverage 25 Demographics of Coverage for Children 27 Duration of Lack of Coverage 34 Regional Variations in Lack of Coverage 38 Summary and Discussion 41 References 42 3 Health Insurance And Access To Care 44 Why Access Matters 44 Financial Barriers to Access 44 Nonfinancial Barriers to Access 52 Access to What? Defining Necessary Health Services 55 Implications 56 References 62
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Part II: Financing Health Care For Children 4 Safety Net Providers 67 Definition of Safety Net 67 Sources of Funding for Safety Net Providers 68 Disproportionate Share Hospital Payments 70 Community Health Centers 70 Children's Hospitals 72 Public Health Departments 75 School-Based Health Centers 79 Implications 79 References 80 5 Medicaid 81 History and Overview of the Medicaid Program 81 Eligibility 83 Access to Care 86 Scope of Services 90 Medicaid Managed Care 94 Impact of Recent Federal Legislation 96 Implications 99 References 100 6 State And Private Insurance Initiatives 102 Background 102 Designing Children's Insurance Programs 104 Profiles of State-Sponsored Programs 110 Private Programs 115 Summary and Implications 118 References 118 7 Children's Health Care Needs 120 Epidemiology of Illnesses in Children 121 Public Coverage for Special Health Care Needs 127 Financial Barriers Associated with Special Needs 129 Nonfinancial Barriers for Special Needs Children 129 Information Technology 133 Access Under Managed Care 133 Implications for Children's Insurance Expansions 136 References 137 Appendixes A Market-Based Approaches to Insurance Reform, by Robert B. Helms 143 B Information for Accountability 155 C Public Workshop Agenda and Participants 170 D Members of Liaison Panel 177 E Committee and Staff Biographies 185 Index 189
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Boxes, Tables, and Figures Boxes 1.1 Highlights of the State Children's Health Insurance Program 13 1.2 Headlines in The New York Times: Children's Health Care Coverage, 1996-1997 15 1.3 Data and Information Reviewed for This Report 17 3.1 Benefits Recommended by the National Forum on the Future of Children and Families 58 3.2 U.S. Preventive Services Task Force Recommended Routine Preventive Services for Children (0-10 years) 59 3.3 American Academy of Pediatrics Recommended Health Care Services for Children and Adolescents 60 3.4 Services Allowed Under SCHIP 61 5.1 A Brief History of Medicaid Legislation Concerning Children 84 5.2 Medicaid Services 91 5.3 EPSDT Health Services Requirements 93 7.1 Supplemental Security Income Program 130 7.2 Caregivers' Time Costs 132 7.3 Scenarios Demonstrating Increased Access to Care via Information Technology 134 Tables 2.1 Trends in Health Insurance Coverage Among Children, Ages 0-17, United States, 1987-1995 (percent) 24 2.2 Trends in Health Insurance Coverage Among Adults, 1987-1995 (percent), Ages 18-64, United States, 1987-1998 (percent) 24 2.3 Trends in Health Insurance Coverage by Actual Numbers Among Children, Ages 0-17, United States, 1987-1995 26 2.4 Trends in Health Insurance Coverage Among Adults, Ages 18-64, United States, 1987-1995 (millions) 26 2.5 Federal Poverty Thresholds, by Size of Family, United States, 1995 38 2.6 Number and Percentage of Children Without Health Insurance Coverage, Ages 0-17 by Number of Consecutive Months Without Coverage, United States, 1992-1994 39 3.1 Hospitalizations for Ambulatory Care-Sensitive Conditions per 1,000 Children Under Age 5, by Area of Residence, United States, 1989 48 3.2 Urgent and Nonurgent Emergency Room Visits for Children Under Age 15, United States, 1995 51 3.3 Drivers of Health Care Dollars, United States, 1993 57 4.1 Sources and Amounts of Funding for Selected Safety Net Programs in Health Services, United States, 1992-1995 69 4.2 National Cost of Uncompensated Care for Registered Community Hospitals, United States, 1987-1995 71 4.3 Insurance Status of CHC Patients, United States, Selected Years, 1980-1995 73
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4.4 CHC Federal Grant Funds and Number of Patients, United States, Selected Years, 1980-1995 74 4.5 Trends in Hospital Admissions, Length of Stay, and Percentage of Care Devoted to Low-Income Patients, Freestanding Children's Hospitals, United States, Selected Fiscal Years, 1990-1995 77 4.6 Percentage of City and County Health Departments Offering Selected Health Care Programs, United States, 1992-1993 78 5.1 Trends in Managed Care and Fee-for-Service Enrollment under Medicaid, United States, 1991-1996 95 5.2 Comparison of Prior Welfare Laws and the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193), United States 97 6.1 State Initiatives to Expand Coverage to Children (as of May 1997) 103 6.2 Eligibility Criteria for Programs Providing Health Care Coverage for Children (as of May 1996) 106 6.3 Scope of Benefits of Programs Providing Health Care for Children 109 6.4 Premium Subsidy Structure for State-Subsidized Insurance Programs 111 7.1 Children's Needs for Health Care, United States, 1992 121 7.2 Number of Acute Conditions Per 100 Persons Per Year, for Children and All Ages, United States, 1994 122 Figures 2.1 Trends in health insurance coverage among children, ages 0-17, United States, 1987-1995 28 2.2 Trends in health insurance coverage among adults, ages 18-64, United States, 1987-1995 28 2.3 Comparison of trends in health insurance coverage for adults, ages 18-64, and children, ages 0-17, United States, 1987-1995 29 2.4 Patterns of children's health insurance coverage by age, for employer-based insurance, Medicaid, and children without coverage, United States, 1995 30 2.5 Children's health insurance coverage within age groups, for employer-based insurance, Medicaid, and uninsured children, United States, 1995 31 2.6 Health insurance coverage among children by race and ethnicity, United States, 1995 32 2.7 Patterns of health insurance coverage among children by race and ethnicity, United States, 1995 33 2.8 Characteristics of families of children with employer-based insurance,ages 0-17, United States, 1995 35 2.9 Characteristics of families of children with Medicaid coverage, ages 0-17, United States, 1995 36 2.10 Characteristics of families of uninsured children, ages 0-17, United States, 1995 37 2.11 Percentage of children without health insurance coverage, ages 0-17, by number of consecutive months without coverage, United States, 1992-1994 39 2.12 Distribution of uninsured children by state, 1995 40 3.1 A framework for approaching financial and nonfinancial influences on access 45 3.2 Hospitalizations for ambulatory care-sensitive conditions per 1,000 children under age 5, United States, 1989 48
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3.3 Vaccinations against selected diseases for children ages 19-35 months by poverty status, United States, 1994 49 3.4 Vaccinations of children ages 19-35 months for selected diseases, by race, United States, 1994 49 3.5 Urgent and nonurgent emergency room visits for children under age 15, United States, 1995 51 3.6 Drivers of health care dollars, United States, 1993 57 4.1 National cost of uncompensated care in registered community hospitals, United States, 1987-1995 71 4.2 CHC patients by payer source, United States, selected years, 1980-1995 73 4.3 CHC federal grant funds and number of patients, United States, selected years, 1980-1995 74 4.4 Percentage of revenues from public and private sources for children'shospitals, United States, 1995 76 4.5 Average gross revenue per freestanding acute-care children's hospital, United States, 1991-1995 76 4.6 Sources and percentages of funding for local health departments, United States, 1992-1993 78 5.1 Medicaid beneficiaries and expenditures, by enrollment group, United States, 1995 82 5.2 Trends in the number of Medicaid recipients, by enrollment group, United States, 1987-1995 82 5.3 State Medicaid expenditures as a percentage of total state expenditures, by fiscal year, United States, 1987-1996 86 5.4 Trends in the number of dependent children ages 0-21 years receiving Medicaid, United States, 1980-1995 87 5.5 Trends in the average annual cost per dependent child receiving Medicaid, United States, 1980-1995 87 5.6 Percentage of Medicaid recipients enrolled in fee-for-service and managed care plans, United States, 1991-1996 95 7.1 Number of children ages 0-17 with selected chronic conditions, United States 124
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