hospital death rate that was almost one and one-half (1.46) times higher for uninsured children than for those who were insured (Carr et al., 1992). The uninsured children were more likely to be admitted to the hospital in a critical condition, and their needs for care were more urgent on admission. The study also found that hospitalization and mortality rates were highest in the poorest neighborhoods included in the study and in neighborhoods with the highest percentage of black and Hispanic residents. While each of these factors independently predicted the hospitalization rates, they were also significantly interrelated.

A California study found that newborns who were uninsured were more likely to be sick but received fewer services in the hospital than newborns who had insurance coverage (Braveman et al., 1989). The increased levels of risk for newborns were thought likely to be due in part to the lack of access to prenatal care for the uninsured mothers, who were also more likely to be black and Hispanic.

Figure 3.2 and Table 3.1 present the rates of hospitalizations for children whose conditions could have been treated on an outpatient basis (also known as "ambulatory care-sensitive conditions" or "preventable hospitalizations"). The rates are based on data from 10 states with a total population of 95 million analyzed by the Ambulatory Care Access Project of the United Hospital Fund of New York (Center for Health Economics Research, 1993, p. 57).

Children living in low-income areas have two to four times as many preventable hospitalizations as children living in high-income areas. These rates are likely to be due to poorer general health status, poorer access to preventive and routine care when needed, as well as to lack of insurance among low-income families (Newacheck and Halfon, 1988; Newacheck et al., 1996).

If you don't think coverage is important not only to remove barriers, but to restore dignity, go watch a family walk a child into an emergency room and have to ask for services that they can't pay for. They don't enjoy it, and you wouldn't enjoy it either.

James Bentley

American Hospital Association, Washington, DC

Public Workshop, June 2, 1997

Preventive Care

Insured children are much more likely to have a usual provider for routine preventive services and to receive recommended and age-appropriate services (Holl et al., 1995; Kogan et al., 1995). Preschoolers who lack insurance are less likely to be fully immunized than insured preschoolers (Wood et al., 1990), and so are children in families with incomes below poverty level (see Figure 3.3). During the course of a year, fewer than half (44.8 percent) of uninsured preschool-age children have any well-child visits, and fewer than one-third receive the recommended schedule of visits for their age (Short and Lefkowitz, 1992).

Racial comparisons of immunization rates show that white children are more likely to be immunized than are black children (see Figure 3.4). These rates are consistent with findings from other studies that have found poverty, minority status, and absence of insurance to be significant predictors of access to adequate primary care (Newacheck et al., 1996). Members of racial and ethnic minorities are disproportionately more likely to be uninsured and poor. While each of these characteristics independently is related to poor health status and lower health care utilization, these characteristics can not be viewed separately when outreach and community-based interventions are designed to increase the use of preventive services.

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