PART I
DOES INSURANCE EQUAL ACCESS TO CARE?



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PART I DOES INSURANCE EQUAL ACCESS TO CARE?

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1 Introduction and Overview Since 1987, the number of American children covered by employer-based health insurance coverage has decreased. By 1996, more than 11 million children lacked insurance (Weigers et al., 1998). According to a recent national survey sponsored by the Robert Wood Johnson Foundation, 1 of every 10 American children were unable to obtain health care in 1994, and lack of insurance was the primary reason (Berk et al., 1995). Data from a 1996 federal survey showed that 1 of every 4 Hispanic children, 1 of every 6 black children, and 1 of every 10 white children were uninsured (Employee Benefits Research Institute, 1997). Most uninsured children live with parents who are low-income workers (EBRI, 1997). In general, their parents tend to work for employers that do not offer health insurance. These working parents earn too little to be able to afford to buy health insurance on their own, and they earn too much to be eligible for public health insurance such as Medicaid. Among employers who do offer some form of health insurance coverage for full-time employees, a larger share of the costs of dependent coverage is being shifted to employees (GAO, 1996; Weigers et al., 1998). Traditionally, uninsured children have received ''charity care" from hospital emergency rooms, outpatient departments in public and teaching hospitals, state and local health departments, community health centers, and individual practitioners, all of which are known as "safety net providers." The availability of safety net services varies from community to community. Local economic and social environments are different, as are the mix of providers, the concentration of responsibility for uninsured children, and the availability of financing for unpaid care (Baxter and Mechanic, 1997). One common element among safety net providers has been their reliance on funding from the Medicaid program, which is the largest single source of insurance coverage for American children. In recent years, state Medicaid agencies have been evolving into large-scale buyers of managed health care coverage. With the rapid expansion of Medicaid into managed care in the 1990s, states increasingly are using private-sector bargaining strategies to negotiate reasonable rates, while protecting Medicaid enrollees (Rosenbaum et al., 1997). At the same time that public subsidies for free and low-cost care have been reduced, the number of uninsured Americans has been increasing, and so has the demand for uncompensated care (Center for Health Economics Research, 1993). Together, these changes have challenged safety net providers to adapt their strategies to the competitive health care marketplace. Safety net providers are taking a variety of steps to continue

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serving uninsured and low-income Americans, but this is a period of major transition (Baxter and Mechanic, 1997; Fishman and Bentley, 1997; Lipson and Naierman, 1996). About a year ago we made a decision to close down five church-based immunization clinics because of funding cuts. Consequently, we had people come to the health department for immunizations for their children. We have subsequently seen a sharp decline in the immunization rates because transportation is a major problem, and we are unable to provide that service at this point in time. Ross Marine Jackson County Health Department, Kansas City, MO Public Workshop, June 2, 1997 In addition to market forces, recent national legislation also can be expected to have a significant impact on the delivery and financing of health care for low-income Americans, and children may be particularly affected. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 ("welfare reform"), which was required to be in effect in all states by July 1, 1998, eliminates the automatic connection between welfare and Medicaid eligibility. In combination with other changes in Medicaid, this could dramatically change the flow of funding for safety net providers over the coming years. In August of 1997, the Balanced Budget Act of 1997 (BBA) authorized $20.3 billion for a new State Children's Health Insurance Program (SCHIP) and $3.6 billion for Medicaid improvements (see Box 1. 1). The SCHIP program was designed to help states cover uninsured children with family incomes that are too high for Medicaid but too low to afford private coverage. As of October 1, 1997, the SCHIP program will provide federal matching funds to states for new children's health care initiatives based on private insurance coverage, Medicaid expansions, and combinations of approaches. In New York, we have had a long process of moving an entire AFDC [Aid to Families with Dependent Children] population into managed care programs. We are already experiencing a great deal of anxiety at the community level as the community health centers and a number of the essential community providers see themselves getting caught in a squeeze in terms of dollars. They are looking at their survivability, and unfortunately, if these folks can't be viable in the new health care landscape, then we're going to see a deficit of providers in poor communities. We are going to see a real loss for the residents of those communities as there will be no one rushing in to fill the vacuum. We have to be careful that in a rush to allow the market to work its magic, that as a by-product we don't end up losing some of the best providers we have for medically needy populations. Dennis Johnson Children's Health Fund, New York City Public Workshop, June 2, 1997 Medicaid managed care in combination with new SCHIP programs could help to bolster the safety net, or could begin to replace it. Unless states specifically require safety net providers to be included in

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BOX 1.1 Highlights of the State Children's Health Insurance Program The Balanced Budget Act of 1997 provides approximately $24 billion in funding over five years to help states develop children's health care initiatives. Most of this funding will support the new State Children's Health Insurance Program (SCHIP), which was established as Title XXI of the Social Security Act. This is the largest allocation of funds for children's health since the Medicaid program was enacted in 1965. As of October 1, 1997, the SCHIP program entitles states to block grants to expand or initiate health insurance programs for low-income uninsured children, with higher federal matching payments than under Medicaid. States may choose to expand Medicaid, support existing state or private programs, design new programs, or use a combination of these approaches. Each state's allocation of SCHIP funds s based on the number of uninsured children in the state who live in families with incomes below 200 percent of the federal poverty level (FPL). States may cover currently uninsured children in families with incomes up to 200 percent of FPL, and states which already have programs for families at that level may increase eligibility to 250 percent of FPL. States must submit a program plan for approval by the Secretary of the Department of Health and Human Services no later than June 30, 1998 for participation in the first funding cycle. By April 1, 1998, the Department of Health and Human Services (DHHS) had approved plans for 8 states that will cover more than 1 million children, and another 15 states had submitted plans for review and approval by DHHS. Under SCHIP, states must screen all applicants for Medicaid eligibility and must enroll any eligible children in the Medicaid program. The law gives participating states the option of "presumptive" Medicaid eligibility to facilitate enrollment. It restores Medicaid coverage for disabled children who would lose their eligibility because of changes in the 1996 welfare law. It also gives states the option of guaranteeing Medicaid coverage for children for 12 months regardless of changes in their financial circumstances. SOURCES: Title XXI Summary from The Balanced Budget Act of 1997, Children's Health Insurance Program by the Health Care Financing Administration at http://www.hcfa.gov/init/kidssum.htm and Expanding Health Insurance Coverage for Children Under Title XXI of the Social Security Act by the Congressional Budget Office at http://www.cbo.gov/showdoc.cfm?index=353&sequence=0&from=5 Medicaid and SCHIP managed care contracts, these providers—with the most experience in serving low-income populations—may not be included in the delivery of care. Under those circumstances, the quality of care and the scope of services for uninsured children could be adversely affected. If, however, states actively support the inclusion of safety net providers in SCHIP and enhance their efforts to coordinate enrollment and services across different programs and sources of financing, a seamless system of children's coverage could begin to emerge. Purpose Of This Study In the summer of 1996, the Robert Wood Johnson Foundation asked the National Academy of Sciences to conduct a study of the relationship between health insurance and access to care for children. In response to this request, the Institute of Medicine (IOM) Division of Health Care Services and the Board on Children, Youth, and Families of the National Research Council and the IOM, formed an expert committee to do the following:

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examine the extent of health insurance coverage of children, analyze evidence on the relationship between health insurance coverage and children's access to health care, identify safety net programs (e.g., community health centers, children's hospitals, and public health departments) that affect the degree of access children have to health care; examine available evidence on trends in the magnitude or availability of safety net programs, and consider the effects of changes in those programs on children's access to health care. The Committee on Children, Health Insurance, and Access to Care included 14 individuals with expertise in health care financing and delivery. Collectively, these individuals had expertise in private insurance, managed care, Medicaid, and other public programs; health care delivery, including primary and specialty care in pediatrics and adult populations; health care policy, including legislative policy, regulation, health law, and health economics; epidemiology; and health services research. The committee met three times between March and June 1997 and convened a public workshop in June 1997. Appendix C presents the workshop's agenda and participants. The committee met again in January 1998 to discuss the new SCHIP program. The committee's recommendations about the SCHIP program are presented in a separate report, Systems of Accountability: Implementing Children's Health Insurance Programs (IOM, 1998). To increase the input from a variety of stakeholders, the committee formed a liaison panel with nearly 200 representatives of national associations, provider groups, children's advocacy organizations, health policy organizations, and state and federal government agencies (see Appendix D). Members of the liaison panel were invited to make presentations at the public workshop and to provide written testimony and other materials for the committee's consideration. Given the budget agreement, the challenge now is how to find political consensus on solutions, principally involving federal and state governments. So the challenge has shifted from where it was earlier this year, which was whether or not to take action, to how to take action. Kathleen Means Health Care Leadership Council, Washington, DC Public Workshop, June 2, 1997 The Policy Context The timing of this study presented an unusual set of challenges. The committee's deliberations took place over several months when children's health insurance and access were being debated by the U.S. Congress, the states, and the American public (see Box 1.2). At the beginning of the study, there seemed to be widespread support for incremental steps to reduce the number of uninsured children, building on activities that were already under way in several states. During the course of the study, both political parties and the Clinton Administration presented a variety of proposals, including Medicaid expansions, block grants, vouchers, refundable tax credits for families, a tax credit for all children, family Medical Savings Accounts, and a new Children's Health Trust Fund. It was unclear what, if any, national legislative approach would be taken until Congress passed the Balanced Budget Act of 1997 in August, with its provisions for a flexible new program for states to expand children's health insurance (SCHIP) (see Box 1.1).

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BOX 1.2 Headlines in The New York Times: Children's Health Care Coverage, 1996-1997 November 1, 1996 New Approach to Overhauling Health Insurance: Step by Step January 15, 1997 Health Insurance for Children Is Latest Hot Idea as Both Democrats and GOP Prepare Proposals February 7, 1997 President Moves to Protect Half of Uninsured Children February 7, 1997 135,000 Children to Be Struck from Disability Benefit Rolls March 12, 1997 President's Plan to Rein in Medicaid Costs Draws Bipartisan Fire March 14, 1997 Hatch Joins Kennedy to Back a Health Program March 17, 1997 Children's Health Insurance: Sorting Through the Options April 8, 1997 Insuring Children Sensibly (editorial) April 12. 1997 GOP Fights Bill to Offer a Health Plan for Children May 21, 1997 Citing Lost Cigarette Revenue, GOP Fights Child Insurance May 22, 1997 Clinton Helps Kill Proposal to Raise Tax on Cigarettes May 22, 1997 Child Health Plan Defeated in Senate June 9, 1997 GOP Lawmakers Want $16 Billion for Health Plan June 17, 1997 Capitol in Discord Over Plan to Aid Uninsured Youths June 18, 1997 Senate Panel Rebuffs Clinton on Child Health Plan July 2, 1997 Health Care Bills Don't Meet Goals, Budget Aides Say July 20, 1997 Item in Tax Bill Poses Threat to Job Benefits July 24, 1997 GOP Leadership Agrees on a Plan to Insure Youths July 29, 1997 White House and the GOP Announce Deal to Balance Budget and Trim Taxes: Passage Is Likely—Plan Includes Tax Credit for Children and Cuts on Capital Gains July 30, 1997 $24 Billion Would Be Set Aside for Medical Care for Children August 3, 1997 Bills on Spending Are Moving Easily Through Congress: Few Partisan Disputes August 15, 1997 Disability Checks of 95,000 Children Are to Be Cut Off August 17, 1997 Workers Getting Greater Freedom in Health Plans: Flexibility for a Price August 31, 1997 Welfare Mothers Prepare for Jobs, and Wait September 3, 1997 Hospitals Serving the Poor Struggle to Retain Patients: Health-Care Changes Help Private Centers Lure Awa Recipients of Medicaid September 13, 1997 Disabled Children Get a Needed Review (editorial) December 29, 1997 Clinton Ordering Effort to Sign Up Medicaid Children: About 3 Million Eligible March 30, 1998 Health Insurance is G.O.P. Initiative for Election Year. Drafting Tax-Break Bill. Plan to Use Tobacco Revenue to Aid Uncovered Workers and Small Businesses

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This issue concerns not just children without adequate access to health care, but also parents who get up every morning and go to work, pay their bills, pay their taxes, and still can't provide health insurance for their children. That is an important piece of the political dynamics here. This issue speaks more broadly than the question of uninsured children. It speaks to what it is like to be a working person in America today. How can you take care of your family's needs? Stan Dorn Children's Defense Fund, Washington, DC Public Workshop, June 2, 1997 In the United States the primary way that we encourage people to get health insurance is tax subsidies. The problem with this system is that the greatest encouragement goes to the people who need it the least. We are giving six times as much help to families in the top fifth of the income distribution as we give to families in the bottom fifth of the income distribution. John Goodman National Center for Policy Analysis, Dallas, TX Public Workshop, June 2, 1997 The tax subsidy is open-ended. It encourages excessive consumption of health insurance, which in turn encourages excessive consumption of health care, which in turn raises costs, which makes it more difficult to expand coverage and cover more people. The budget question is not one of whether we have enough money being spent in total, but rather to what extent can we reallocate that money to buy what we really think is best. Eugene Steuerle Urban Institute, Washington, DC Public Workshop, June 2, 1997 In response to the charge from the Robert Wood Johnson Foundation, the committee's intention was to conduct a thorough review of the existing scientific evidence on insurance and access and to present and summarize the best available information as clearly and objectively as possible. With the rapid rate of ongoing change in the health care delivery system, the committee supplemented its review of scientific evidence with an analysis of other published information on health care trends that are likely to affect the implementation of new children's insurance programs (see Box 1.3).

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BOX 1.3 Data and Information Reviewed for This Report Large national. federally supported databases primarily the Current Population Survey (U.S. Department of Commerce), the National Health Interview Survey (Centers for Disease Control and Prevention, U.S. Department of Health and Human Services [DHHS]), and the National Medical Expenditure Survey (Agency for Health Care Policy and Research, DHHS). Additional analyses of the Current Population Survey conducted by the Employee Benefits Research Institute especially for this study: Published health services research findings from national databases: state, local, and private information sources (e.g.. medical records); national surveys: and original data collection. Publicly available descriptions of federal and state programs, health policy research, health services research, and public statements by government agencies, including the Agency for Health Care Policy and Research, DHHS: Bureau of Labor Statistics of the U.S. Department of Labor; the California State Senate Insurance Committee; Congressional Budget Office; the U.S. General Accounting Office; the Health Care Financing Administration of DHHS; the State of Florida Agency for Health Care Administration; and the Social Security Administration: Published materials and public statements submitted to the committee by national organizations, including the American Academy of Pediatrics, American Association of Asian and Pacific Islander Community Health Organizations, American Association of Health Plans, American College of Preventive Medicine, American Association of Maternal and Child Health Programs, American Hospital Association, Children's Defense Fund, Children Now. Children's Health Fund, Employee Benefits Research Institute, Families USA, Hewitt Associates LLC, Health Insurance Association of America. National Academy of Social Insurance. National Association of Children's Hospitals and Related Institutions. National Association of City and County Health Officials. National Association of Community Health Centers, National Association of Insurance Commissioners, National Association of Public Hospitals. National Conference of State Legislatures, National Governors Association, and the Washington Business Group on Health; Published reports sponsored by philanthropic organizations, including the Annie E. Casey Foundation, the Kaiser Commission on the Future of Medicaid, the David and Lucile Packard Foundation, and the Robert Wood Johnson Foundation; and Policy analyses, reports, newsletters, and news analyses by private organizations including the Alliance for Health Reform, Alpha Center, American Enterprise Institute. Bureau of National Affairs, Center for Budget and Policy Priorities. Center for Health Policy Research of George Washington University, Center for Studying Health System Change. Health care Leadership Council, The Heritage Foundation, National Bureau for Economic Research, National Academy for State Health Policy. National Center for Policy Analysis, National Center for Youth Law. National Health Policy Forum, and the Urban Institute; and Reports published by the Institute of Medicine, including The Future of Public Health (IOM. 1988). Access to Health Care in America (IOM, 1993a). Emergency Medical Services for Children (IOM, 1993b), Employment and Health Benefits: A Connection at Risk (IOM, 1993c). Telemedicine: A Guide to Assessing Telecommunications in Health Care (IOM, 1996), Managing Managed Care: Quality Improvement in Behavioral Health (IOM, 1997a), Primary Care: America's Health in a New Era (IOM. 1997b). Improving Health in the Community: A Role for Performance Monitoring (IOM, 1997c). The Computer-Based Patient Record: An Essential Technology for Health Care (revised edition) (IOM, 1997d). and reports by the National Research Council, including Paying Attention to Children in a Changing Health Care System (NRC. 1996). Including Children and Pregnant Women in Health Care Reform (NRC. 1992), and Assessment of Performance Measures for Public Health, Substance Abuse, and Mental Health (NRC, 1997).

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There is a real difficulty in building a consensus for a particular approach. An analyst in one state basically told me "We need a break from Medicaid." It is really hard to figure out what vehicle to choose. There is support for a number of different approaches. It is a zero sum game in states. You almost always have to take something away from somebody who has got it in order to get something new, and that is very hard. Shelly Gehshan National Conference of State Legislatures, Washington, DC Public Workshop, June 2, 1997 From the perspective of employers, health care coverage was never considered an entitlement. It was always a way of paying additional compensation, and employers have had to address equity issues between employees. Say you have two employees who are performing the same job and one is single and one has a family. The one with the family would be earning more in compensation because of their family, not because they are taking on any additional responsibilities and functions. With spiraling health care costs, many employers have asked employees to contribute more towards their share of health coverage, especially toward family coverage, to address the equity issue. Kim Monk Washington Business Group on Health, Washington, DC Public Workshop, June 2, 1997 It's very important to worry about safety net providers because they are doing very critical work in our communities. But I would hope that we come to some lessons about the value of insuring individuals and creating financial resources which follow the individual, as opposed to trying to set those resources into the institutions. That, it seems to me, is a policy that has failed. Kay Johnson George Washington University, Washington, DC Public Workshop, June 2, 1997 The committee's goal for this report, therefore, was to draw a general set of conclusions about ways to help improve children's access to care that would apply to a variety of public and private insurance programs. The committee hopes this report will help to improve the evidence base for children's health insurance efforts and for efforts to improve the quality of children's health care. The committee's specific concerns about the need for data to evaluate the SCHIP program and its recommendations for designing a system of accountability for SCHIP are presented separately (IOM, 1998).

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Conclusions 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 policy option. The committee members agreed throughout their deliberations that the ultimate goal of these strategies is to provide access to coordinated, efficient, and effective health care for all American children, including children who have preventable illnesses and injuries, chronic conditions, or other special health care needs. Based on a review of scientific evidence and analysis of current trends, the committee drew the following conclusions. 1. All children should have health insurance. Children's access to health care depends on several financial and nonfinancial factors. Financial factors include insurance status (insured or uninsured); the nature and extent of insurance coverage, including cost-sharing requirements such as copayments and deductibles; family income; and the costs of care. Among many nonfinancial factors, the availability and proximity of providers; types of coverage accepted by providers; logistical difficulties in scheduling and transportation; racial, ethnic, and cultural backgrounds of providers and families; and parental health beliefs have been shown to influence access to care. When compared with insured children, uninsured children are more likely to be sick as newborns, less likely to be immunized at appropriate ages, less likely to receive medical treatment when they are injured, and less likely to receive treatment for illnesses such as acute or recurrent earaches and asthma. Having analyzed the available evidence on financial and nonfinancial barriers to care, the committee concludes that children's health insurance status is the single most important influence in determining whether health care is accessible to children when they need it. 2. Public and private insurers should be encouraged to develop affordable products that address the specific needs of children, including children with chronic conditions and special health care needs. As a matter of principle, the committee believes that all children should have appropriate access to coordinated, efficient, child-appropriate, and effective care, including generally accepted preventive services; acute care for short-term illnesses and injuries; ongoing care for children with chronic medical conditions; rehabilitative care, including allied health services, for children with disabilities; and care for children with special needs, such as speech disorders. The committee recognizes that financial resources are not unlimited and that accountable purchasers and policymakers must set priorities in order to make reasoned and equitable decisions about spending. However, costs of treatment and coverage for children vary according to their health status and can be difficult to determine from the information available in the public domain. There are many areas of disagreement and uncertainty about the specific services to which children should have access. Providers, parents, and insurers often have different attitudes and positions about which services are "essential" and what expenditures and sources of payment are reasonable. The limited scientific evidence and professional consensus do not clearly indicate which specific diagnostic tests, treatments, procedures, drugs, specialists, and other services should be available to children, any more than is the case for adults. There is tremendous variability in the structure and scope of health care benefits for children according to the source and the type of insurance coverage. In the current health care system, employers, states, parents, and others who purchase coverage on behalf of children bear the responsibility for

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ensuring that their purchasing decisions reflect the specific needs of children as much as possible within the existing resources. In the committee's view, purchasers should take the initiative to request new child-appropriate products. 3. Nonfinancial barriers to care should be reduced through the provision of assistance with child care and transportation, through the provision of culturally appropriate services, and through the use of information technology. Health insurance alone does not guarantee utilization of appropriate care. Studies have shown that logistical difficulties for parents, such as transportation and child care, differences in the racial, ethnic and cultural backgrounds of providers and parents, and parental health beliefs can affect children's access to care. For children who live in medically underserved urban and rural areas, the availability and proximity of providers can present barriers to access. Even with insurance, it can be difficult to obtain health care. The committee believes that information technology holds extraordinary promise to improve access for children in underserved areas, as well as to improve clinical quality and efficiency of care and to increase the availability of clinical information for research. Although it has not been systematically studied, the application of information technology continues to increase in patient care, professional education, patient education, research, and administration. Based on the available scientific evidence and current trends in the delivery of care, the committee believes that programmatic design and delivery system issues have a vital impact on access for children. In sum, three particular areas need to be addressed: logistical barriers, cultural barriers, and advances in the use of information technology. 4. Outreach and enrollment procedures and coordination efforts should be designed so that all programs achieve the highest enrollment possible, particularly when states offer multiple programs with different eligibility requirements. Years of experience with Medicaid indicate that there are many reasons why children who are eligible for the program may not be enrolled. For example, parents or other caretakers may not be aware of the program, may not know they or their dependents are eligible, or may not want to accept public aid. Other parents have experienced difficulties in trying to enroll in the program, including denials of applications for procedural errors or incomplete information, or because of cultural factors such as the need for translation. States designing and implementing new SCHIP programs have learned from these experiences and are improving their procedures. With the new children's health insurance programs and other initiatives, more efforts are being made to help parents learn about the different programs and make enrollment easier, including having common application forms and streamlining the application and enrollment process. States also will need to improve their efforts to coordinate administration and data collection among Medicaid, SCHIP, Title V maternal and child health agencies, and other state and private programs involving children and families, especially low-income working families. More specifically, states should coordinate health insurance efforts with initiatives in maternal and child health, mental health and substance abuse treatment and prevention, education, disabilities, and other areas. 5. Information generated from children's health care and insurance programs should be designed to be useful in evaluating short-term trends and making program adjustments, and should be made widely available.

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For cost-conscious purchasers and public policymakers, accountability rests on a foundation of good information. There are technical problems, gaps, and inconsistencies in analyzing health insurance and health status information from Medicaid, national surveys, and other sources. These include differences in capacity to report current information; differences in definitions and data collection methods; lack of statistical breakdowns for children, or breakdowns at different ages; lag time in collecting and reporting information; and many other technical challenges. These technical problems make it difficult to measure performance, to protect children as health care consumers, and to improve the quality of care. In the area of clinical information, relatively few performance measures have been developed for children, and their scope and quality need to be improved. Additional research is needed to develop new measures of child health status and outcomes that can be used to assess performance of health plans in meeting children's health needs, especially for children with special health care needs. With the design and implementation of new SCHIP programs, many new opportunities will be available to study the impact of changing mechanisms for financing and providing insurance. For example, changes in sources of care (types of providers and settings) after enrollment in SCHIP would be a useful measure of the program's impact. Comparisons of utilization rates for preventive care, basic services, and visits to specialists would be extremely useful to compare the program's impact for different subgroups, such as racial and ethnic minorities, or children with disabilities. Commercial managed care plans measure access to care in terms of utilization and penetration rates, such as the number of visits per 1,000 enrollees; length of time to follow-up appointments; provider to enrollee ratios; and other information that is readily available from most managed care information systems. For the new SCHIP programs and Medicaid managed care, additional access measures may need to be developed to reflect the array of child-specific services such as subsidized child care or transportation assistance, or expanded services such as telephone advice nurses, translators, or health education. Monitoring and evaluation strategies require commitments of time and resources on the part of government, private foundations, health plans, providers, and others to provide timely and useful information for a variety of audiences and purposes. The committee believes that future data and information systems can be designed and implemented in ways that are efficient and easy to use and in ways that provide timely feedback for midcourse corrections as well as for longer-term applications. Incentives should be developed to encourage the use of data sources that have rapid turnaround times, are inexpensive, and that can be used to evaluate short-term trends and make program adjustments. Organization Of This Report The first three chapters of this report address the contextual issues that describe the relationship between insurance status and access to care. Chapter 1, Introduction and Overview, has described the rationale for the study, the committee's approach to the study, and its conclusions. Chapter 2, Health Insurance and Children in America, reviews evidence related to the patterns of health insurance coverage for children. including trends in employer-based coverage and Medicaid enrollment. Chapter 3, Health Insurance and Access to Care, reviews the evidence about the effects of health insurance status on the care that children receive and describes different ways of defining the scope of health care services that should be accessible to children. The second section of the report describes a variety of means for financing health care for children. Chapter 4, Safety Net Providers, describes the current safety net providers and the ways in which they are meeting the demands for expansion of health insurance coverage for children during a period of rapid change in the health care delivery system. Chapter 5, Medicaid, describes the Medicaid program in its current form as a major source of public financing for health care and how its role is changing because of market forces, welfare reform, children's health insurance legislation, and other factors. Chapter 6, State and Private Insurance Initiatives, describes a variety of programs that have been implemented to provide

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children's health insurance coverage. Some of these programs are likely to be expanded by states under the terms of the new legislation on children's health insurance. Chapter 7, Children's Health Care Needs, addresses the need for health care among healthy children and among those with chronic medical conditions and special health care needs. Based on the distribution of acute and chronic medical conditions among children, the chapter discusses the importance of designing children's insurance to better address children's needs. Two Appendixes provide a supplement to the committee's analysis of the evidence presented throughout the report. Appendix A, ''A Review of Tax-Based Approaches to Insurance Reform," was written by Robert B. Helms at the request of the other committee members. It describes some of the main federal tax policy options which have been proposed but have not yet been widely implemented, including tax credits and vouchers. Appendix B, "Information for Accountability," describes the technical aspects of the existing data and information systems that are used to monitor insurance, access, utilization, and health status over time. Appendix C includes the agenda and list of participants who attended the committee's public workshop in Washington, D.C. on June 2, 1997. Appendix D lists the members of the liaison panel, including those who submitted written statements for the committee's consideration, and Appendix E includes short biographies for the committee and IOM staff. References Baxter RJ, Mechanic RE. 1997. The Status of Local Health Care Safety Nets. Health Affairs 16(4):7-23. Berk ML, Schur C, Cantor JC. 1995. Ability to Obtain Health Care: Recent Estimates from the Robert Wood Johnson Foundation National Access to Care Survey. Health Affairs 14(3):139-146. Center for Health Economics Research. 1993. Access to Health Care: Key Indicators for Policy. Princeton, NJ: Robert Wood Johnson Foundation. Employee Benefits Research Institute. 1997. Analysis of data provided for this study, based on estimates from the March 1996 Current Population Survey, Bureau of the Census, U.S. Department of Commerce. Fishman LE, Bentley JD. 1997. The Evolution of Support for Safety-Net Hospitals. Health Affairs 16(4):30-47. GAO (U.S. General Accounting Office). 1996. Health Insurance for Children: Private Coverage Continues to Deteriorate. GAO/ HEHS-96-129, June 17, 1996. Washington, D.C. IOM (Institute of Medicine). 1988. The Future of Public Health. Washington, D.C.: National Academy Press. IOM. 1993a. Access to Health Care in America. Washington, D.C.: National Academy Press. IOM. 1993b. Emergency Medical Services for Children. Washington, D.C.: National Academy Press. IOM. 1993c. Employment and Health Benefits: A Connection at Risk. Washington, D.C.: National Academy Press. IOM. 1996. Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, D.C.: National Academy Press. IOM. 1997a. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, D.C.: National Academy Press. IOM. 1997b. Primary Care: America's Health in a New Era. Washington, D.C.: National Academy Press. IOM. 1997c. Improving Health in the Community: A Role for Performance Monitoring. Washington, D.C.: National Academy Press. IOM. 1997d. The Computer-Based Patient Record: An Essential Technology for Health Care. Rev. ed. Washington, D.C.: National Academy Press. IOM. 1998. Systems of Accountability: Implementing Children's Health Insurance Programs. Washington, D.C.: National Academy Press. Lipson DJ, Naierman N. 1996. Effects of Health System Changes on Safety Net Providers. Health Affairs 15(2):33-48. NRC (National Research Council). 1992. Including Children and Pregnant Women in Health Care Reform. Washington, D.C.: National Academy Press. NRC. 1996. Paying Attention to Children in a Changing Health Care System. Washington, D.C.: National Academy Press. NRC. 1997. Assessment of Performance Measures for Public Health, Substance Abuse, and Mental Health. Washington, D.C.: National Academy Press. Rosenbaum S, Shin P, Smith BM, Wehr E, Borzi, PC, Zakheim MH, Shaw, K, Silver K, Johnson KA. 1997. Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts. Washington, D.C.: George Washington University Center for Health Policy Research. Weigers ME, Weinick RM, Cohen JW. 1998. Children's Health 1996. MEPS Chartbook No. 1. Rockville, MD: Agency for Health Care Policy and Research, AHCPR Pub. No. 98-0008.