Other Financial Barriers to Access

Even when they have insurance coverage, children from low-income families have fewer contacts with physicians than other insured children (Rosenbach, 1989). Low-income, privately insured families bear a greater burden of the direct costs of health care for their children than families who have higher incomes or coverage through Medicaid, because out-of-pocket expenses such as copayments and deductibles represent a higher relative proportion of family income (Newacheck, 1989; Newacheck et al., 1996). Studies have shown that when cost-sharing increases (i.e., when out-of-pocket expenses are higher), the use of outpatient services for a variety of illnesses decreases (Rosenbach, 1989; Valdez et al., 1985).

Out-of-pocket expenses can be particularly burdensome for children with chronic conditions. A recent study sponsored by the Agency for Health Care Policy and Research found that more than 60 percent of insured families with a child with insulin-dependent diabetes mellitus had to pay a deductible for either insulin, syringes, or blood testing strips and that more than 85 percent had a copayment for these items. The annual out-of-pocket expenses were 56 percent higher than those for families with comparable coverage without an insulin-dependent diabetic child ($1,125 compared to $625) (Songer et al., 1997).

Faced with additional expenses from either seeing a provider or paying for medical supplies, many insured families choose to treat a condition at home or to wait and see whether the health condition resolves on its own. According to testimony from several presenters in the committee's public workshop (Appendix C), insured families with large medical expenses may be forced to choose between paying medical bills and other bills and eventually may end up in poverty.

Nonfinancial Barriers To Access

As summarized in Figure 3.1, several other factors have been found to influence utilization, including educational background and other characteristics of parents and families; racial, ethnic, and cultural factors; and the presence of special health care needs. Public health risks as well as structural and organizational characteristics of the health care system also can reduce access to care.

If you step back and take an overview of this issue of worrying about coverage, the debate over Medicaid versus tax credits and incentives for people to buy their own insurance is curious. For thirty or forty years, we have known that if you really want to change health status, the surefire way to do it is to increase personal disposable income, improve education, improve nutrition, and make sure people have safe and affordable housing. From a public health perspective, direct access to health care services would come in fifth.

Carl Schramm

Greenspring Advisors, Inc., Towson, MD

Public Workshop, June 2, 1997

Parental and Family Characteristics

Children depend on their parents, family members, and other caretakers to determine when they need care and to seek care on their behalf. Studies have shown that several characteristics of parents and families can reduce children's access to care. These include low levels of parental education (Newacheck,



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