National Academies Press: OpenBook

Health Insurance is a Family Matter (2002)

Chapter: Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants

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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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C
Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants1

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This appendix provides brief synopses of the studies that were reviewed for and presented in Chapter 6. The table is organized according to the four major sections in Chapter 6: “Access to and Use of Health Care by Children,” “Health Outcomes for Children and Youth,” “Effect of Health on Children’s Life Chances,” and “Prenatal and Perinatal Care and Outcomes,” Studies are listed alphabetically within each section.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Sample Size/ Data Source

Outcome Measures

Access to and Use of Health Care by Children

Aday (1992)

Health Insurance and Utilization of Medical Care for Chronically Ill Children with Special Needs. Advance Data

Data from the NHIS Child Health (CH) Supplement, 1998

Chronic illness and special needs children

Aday et al. (1993)

Health Insurance and Utilization of Medical Care for Children with Special Health Care Needs. Medical Care

Data from 1988 NHIS, Child Health Supplement; 9.6 million U.S. children with special health care needs

Utilization of physicians, hospitals, and prescribed medicine

Bindman et al. (1995)

Preventable Hospitalizations and Access to Health Care. JAMA

Data from California hospital discharge records; 6,674 English- and Spanish-speaking adults aged 18–64

Reports of access to medical care

Brown et al. (1999)

Access to Health Insurance and Health Care for Children in Immigrant Families. In Children of Immigrants: Health, Adjustment, and Public Assistance

March 1996 CPS survey and 1994 NHIS (n = 35,600 children 0–17 and n = 32,000 children 0–17, respectively)

Access to health care services; health insurance coverage; and citizenship status

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Findings

The highest-prevalence conditions included in the 1988 NHIS-CH included hay fever and respiratory allergies, frequent or repeated ear infections, and asthma. About 9.6 million children under 18 years of age were estimated to have special needs: 76% of the children had insurance coverage, 11% had Medicaid, and 13% had neither. Black and Hispanic children were two times as likely to be uninsured. The proportion of uninsured children who had seen a physician was lower than the proportion of those with private insurance.

There is substantial variation in access to routine medical care among these children. In general, poor minority children living with their mothers or someone other than their parents, or those without insurance or a regular medical provider, were more likely to experience financial barriers to access or less apt to seek care than other children with comparable needs. Children with Medicaid coverage were more than three times as likely to see a doctor than those who were uninsured. Those who were insured as well as those who had coverage that was not known were more likely to be hospitalized than the uninsured.

Access to care was inversely associated with hospitalization rates for the five chronic medical conditions (asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes). Self-rated access to care and the prevalence of the condition remained independent predictors of cumulative hospitalization rates for chronic medical conditions. Communities where people perceive they have poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely to reduce hospitalization rates for chronic conditions than changing patients’ propensity to seek care or eliminating variations in physician practice style.

The immigration status of both the child and the primary breadwinning parent has an independent effect on the child’s risk of uninsurance, even controlling for the parent’s educational attainment and residency of 10 years or more. Non-citizen children have the greatest risk of being uninsured. Non-citizen Latino and Asian children have a higher risk of being uninsured than their U.S.-born counterparts or white children with U.S.-born parents. U.S. citizen children with immigrant parents have a greater risk of uninsurance than those with U.S.-born parents. These children have an even greater risk if their families immigrated on or after 1984. Uninsured rates are higher among children in immigrant families from Korea and Central America than those from other regions. Immigrant children and U.S.-born children with immigrant parents are more likely to have difficulty accessing health care services than nonimmigrant children. Immigrant children are less likely to have had a physician visit in the past year than nonimmigrant children. For those who have insurance (immigrant children and citizen children), the disparities are not large: 43% of uninsured immigrant children report having no physician visit in the last 12 months, compared to 28% of immigrant children with private coverage and 16% with Medicaid.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Byck (2000)

A Comparison of the Socioeconomic and Health Status Characteristics of Uninsured, State Children’s Health Insurance Program-Eligible Children in the United States with Those of Other Groups of Insured Children: Implications for Policy. Pediatrics

Data for 50,950 children 0–8 years of age included in the 1993 and 1994 NHIS

Socioeconomic and demographic characteristics of children

Currie and Duncan (1995)

Medical Care for Children: Public Insurance, Private Insurance, and Racial Differences in Utilization. J Hum Resources

Child–mother module of National Longitudinal Survey of Youth; longitudinal data from 1986 and 1988 waves for children born between 1979 and 1985, repeated observations for same child

Physician checkups; physician illness visits

Currie and Gruber (1996b)

Health Insurance Eligibility, Utilization of Medical Care, and Child Health. Quarterly Journal of Economics

NHIS sample of children <15; 30,000 each year between 1984 and 1992; CPS for Medicaid coverage rates and eligibility

Any ambulatory visits in year; recent visit; hospitalizations in year; site of care; mortality

Currie (2000)

Do Children of Immigrants Make Differential Use of Public Health Insurance? In Issues in the Economics of Immigration

NHIS sample of children <15; 1989–1992

Insurance coverage; probability of no visits in past year; number of physician visits annually; hospitalizations annually

Dubay and Kenney (2001)

Health Care Access and Use Among Low-Income Children: Who Fares Best? Health Affairs

Data from the 1997 NSAF; sample: 12,680 low-income (<200% FPL) children

Access to care and use of services based on insurance coverage

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Children in SCHIP differ socioeconomically and by health status from those on Medicaid and those that are privately insured (however, they differ to a lesser extent from those that are privately insured). SCHIP children live with college-educated individuals (39.4%) and employed adults (91.2%) versus 23% and 53.9%, respectively, for Medicaid children and 66.7% and 96.9% for those privately insured. Parents of SCHIP children are disproportionately self-employed or in industries and occupations in which health insurance coverage is less available or affordable. Compared to privately insured children, SCHIP-eligible children are three times more likely to be Hispanic and nearly two times more likely to be rated in fair or poor health.

White children with Medicaid have more checkups than black children with Medicaid. Black children with Medicaid have more checkups than uninsured black children. White children with Medicaid or private insurance have more illness visits than uninsured white children. Black children with Medicaid or private insurance do not have more illness visits than uninsured black children. Over time, the same child receives more services when insured than when uninsured.

Eligibility for Medicaid lowers the probability of no visits within a year by 10–13% (1/2 of baseline probability) and increases the probability of hospitalization by 14%. It also substantially increases the chances of being seen in a physician’s office relative to other sites. Between 1984 and 1992, increases in the proportion of children eligible for Medicaid reduced child mortality by an estimated 5%.

Children of immigrants are less likely to take up Medicaid than are children of U.S.-born parents. Becoming eligible for Medicaid increased immigrant children’s use of physician visits more than it did for nonimmigrant children. Only children of U.S.-born parents had increased hospital use with greater Medicaid eligibility.

Uninsured children, other things equal, were 8.8 percentage points (p <.01) more likely to rely on the ED or to have no usual source of care than those covered by Medicaid. They were also 2.8 percentage points (p <.01) more likely to have an unmet need for medical or surgical care and 7.4 percentage points (p <.01) more likely to have an unmet need for dental care. The families of uninsured children were 9.2 percentage points (p <.01) more likely to not feel confident that they could get the care they needed and 4.4 percentage points (p <.01) more likely to not feel satisfied with care than those in private and public insurance programs. Uninsured children were less likely than Medicaid-covered children to have at least one physician visit (regression adj. difference = 25.6; p <.01), one visit for well-child care (regression adj. difference = 25.6; p <.01), and at least one visit to a dentist of dental hygienist (regression adj. difference = 29.4; p <.01).

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Guendelman et al. (2001)

Unfriendly Shores: How Immigrant Children Fare in the U.S. Health System. Health Affairs

Data from 1997 NHIS (n = 14,290)

Access and use of care

Hernandez and Charney (1998)

Health Status and Adjustment. In From Generation to Generation: The Health and Well-Being of Children in Immigrant Families

1994 NHIS; 1996 NHANES III

General health status; chronic and acute health conditions

Holl et al. (1995)

Profile of Uninsured Children in the United States. Arch Pediatr Adolesc Med

1988 Child Health Supplement of the NHIS (n = 17,110)

Utilization of medical services and health status; also an assessment of factors associated with lack of health insurance among children

Kogan et al. (1995)

The Effect of Gaps in Health Insurance on Continuity of a Regular Source of Care Among Preschool-Aged Children in the United States. JAMA

Sample—8,129 children whose mothers were interviewed in the 1991 Longitudinal Follow-up to the National Maternal and Infant Health Survey

Gap in health insurance, length of the gap, and continuity of care

Ku and Freilach (2001)

Caring for Immigrants: Health Care Safety Nets in Los Angeles, New York, Miami, and Houston

Case study site visits with clinic and hospital administrators, doctors and nurses, local Medicaid and health officials, community-based organizations, and immigration and health experts and advocates: Los Angeles, New York, Houston, and Miami.

The response of local providers and agencies to changes in state and local policies and practices affecting the access to insurance and health care services for immigrants in these areas

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Of the children not born in the United States, 52% were uninsured and 66% had a usual source of care compared to 20 and 92%, respectively of those that were native born. Of foreign-born children, 51% had their usual source of care at a doctor’s office or HMO, compared to 68% of U.S.-born children. Of those who were in less than excellent health, 39% of foreign-born children had not seen a doctor in the past year compared to 17% of U.S.-born children. Health insurance and immigrant policies should act to increase health care access for this population.

Children in immigrant families tend to be healthier than children in U.S.-born families. Immigrant children have fewer acute and chronic health problems than U.S.-born children, including acute infectious and parasitic diseases; ear infections; acute accidents; chronic respiratory conditions; and chronic hearing, speech, and deformity impairments. However, over time, immigrant children lose this health advantage concordant with the length of residence in the United States. Children in immigrant families also have a high risk of certain health problems. Mexican immigrant children are more likely to be reported by their parents as being in fair or poor health and having teeth in only fair to poor condition. The report theorizes that these paradoxical findings suggest that strong family bonds among immigrants may act to sustain cultural orientations leading to healthful behavior or that there are other unknown factors at work serving as protection. The subsequent deterioration in the health of children from immigrant families the longer they reside in the United States suggests that with assimilation into American culture the protective aspects of immigrant culture diminish, allowing the harmful effects of low socioeconomic status, high poverty, and racial or ethnic stratification to emerge.

Residence in the South (OR = 2.3) and West (OR = 1.9) and being poor, <100% FPL (OR = 2.2), or nearly poor, 100–200% FPL (OR = 2.1), are independently associated with being uninsured. Being uninsured was independently associated with having different sources for routine and sick care (adj. OR = 1.7; 95% CI = 1.5–2.0). There was also an independent association between never having routine care (adj. OR = 1.8; 95% CI = 1.2–2.7) and being uninsured, as well as an association between not having had a physician visit in the last 12 months and being uninsured (adj. OR = 1.5; 95% CI = 1.3–1.8).

About ¼ of children were without health insurance for at least one month during their first three years of life. More than half of these children had a gap of more than six months. Less than half had only one site for care during the first three years of life. Those with a gap longer than six months had an increased chance of having more than one site for care (OR = 1.52; 95% CI = 1.19–1.96). This chance increased when emergency treatment was discounted as a multiple site of care.

All cities reported a sharp decline in enrollment, but these could not be documented because most systems did not indicate if enrollees were immigrants. Data from Los Angeles indicated that the number of non-citizen immigrants and their children on Medicaid fell more than 50% between 1996 and 1998, but some believe that it has begun to climb again. More than half of low-income immigrants are uninsured and are particularly reliant on safety-net providers. Immigrants also tend to use alternative sources of care and delay or go without care. In every city, language barriers were viewed as the most serious threat to medical care quality. The access problem seemed to be the most severe for undocumented aliens who held an additional fear of being reported to the Immigration and Naturalization Service.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Ku and Matani (2001)

Left Out: Immigrants’ Access to Health Care and Insurance. Health Affairs

Data from the NSAF; n = 109,992

Access to care

Lave et al. (1998a)

Impact of a Children’s Health Insurance Program on Newly Enrolled Children. JAMA

Data for 887 families of newly enrolled children in 29 counties of western Pennsylvania

Access to care and use of care

Lieu et al. (1993)

Race, Ethnicity, and Access to Ambulatory Care Among US Adolescents. Am. J Pub Health

Data on 7,465 10–17-year-olds included in the Child Health Supplement to the 1998 NHIS

Health care access and use

McCormick et al. (2001)

Annual Report on Access to and Utilization of Health Care for Children and Youth in the United States—2000. Ambulatory Pediatrics

Data on insurance coverage, utilization, and expenditures from MEPS. (1996, n = 6,735; 1997, n = 11,278; and 1998 n = 7,839); data on hospitalization from the Database for Pediatric Studies

Use of health care services and health expenditures for children and youth in the United States

Newacheck et al. (1998b)

Health Insurance and Access to Primary Care for Children. N Engl J Med

Sample of 49,367 children under 18 from the 1993–1994 NHIS

Access to care, use of care, satisfaction with care, and unmet needs

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Recent policy changes have limited immigrants’ access to insurance and health care. Fewer non-citizen immigrants and their children have Medicaid or job-based insurance, and many more are uninsured than native citizens or children of citizens. Of the non-citizen adults with incomes under 200% FPL, 58% were uninsured, and of the non-citizen children with non-citizen parents, 54% were uninsured. Overall, 41% of non-citizen adults, 38% of non-citizen children, and 21% of citizen children with non-citizen parents had no doctor, nurse, or ED visits in a year, while 21% of native adults and 13% of children of citizens had no doctor, nurse, or ED visits in a year. Even though insured noncitizens had less access to care than citizens, they had better access than uninsured noncitizens. The disparity in access to care has two components. First, noncitizens and their children are much more likely to be uninsured, which reduces the ability to access care. Secondly, even insured noncitizens and their children have less access to medical care than insured native-born citizens. There are nonfinancial barriers that they face such as language difficulties and lack of translations.

Access to services improved after enrollment in the program. At 12 months of enrollment, 99% of the children had a regular source of care (vs. 89% prior to SCHIP) and 85% had a regular dentist (vs. 60% prior to SCHIP). The number of children reporting unmet needs or delayed care in the past six months decreased from 57% to 16%. The proportion of children seeing a physician increased from 59% to 64%, and the proportion visiting an ED decreased from 22% to 17%.

Higher proportions of blacks and Hispanics than whites are uninsured (16% blacks, 28% Hispanics, 11% whites). Blacks and Hispanics reported poorer health status, made fewer doctor visits in the past year, and were more likely to lack a usual source of care than whites. Health insurance was associated with a greater increase in access to and use of care for minority youth than for white youth. After adjustment for health insurance, family income, need and other factors, racial differences persisted.

About 2/3 of Americans are covered by private insurance, 19% by public, and 15% uninsured. Children with any private insurance were found more likely to have office visits than those on public insurance only or those that were uninsured (76% for those with private insurance vs. 67% for those with public insurance only and 51% for the uninsured). Dental visits and prescriptions filled showed the same pattern. Of those with some private insurance, 51% had dental visits, while 29% of those with only public insurance and 21% of those who were uninsured had dental visits. Of those with some private insurance, 61% had their prescriptions filled, while 56% of those with only public insurance and 43% of those that were uninsured had theirs filled. Publicly insured children were more likely to be hospitalized than those who had some private insurance or were uninsured. Of publicly insured children, 5.4% had hospital stays and 15.5% visited the ED. Of those with any private insurance, 2.4% had hospital stays and 12.5% of them visited the ED. For those that were uninsured, 1.9% had hospital stays and 10.8% visited the ED.

An estimated 13% of U.S. children did not have health insurance in 1993–1994. Uninsured children were less likely to have a usual source of care (adj. OR = 6.1; 95% CI = 5.2–7.2). The uninsured were also more likely to have no regular physician (adj. OR = 1.7; 95% CI = 1.4–1.9), to be without access to care after hours (adj. OR= 1.6; 95% CI = 1.3–2.0), and to have families that were dissatisfied with at least one aspect of care (adj. OR = 1.4; 95% CI = 1.1–1.9). Uninsured children were more likely to have gone without needed medical (adj. OR = 5.8; 95% CI = 4.6–7.5), dental (adj. OR = 4.3; 95% CI = 3.7–4.9), or other health care. The uninsured were also less likely to have contact with a physician during the previous year (adj. OR = 2.1; 95% CI = 1.9–2.3).

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Newacheck et al. (1996)

Children’s Access to Primary Care: Differences by Race, Income, and Insurance Status. Pediatrics

Data from 7,578 1–17-year-old children of families responding to the 1987 NMES

Measures of access to and use of care

Newacheck et al. (2000a)

The Unmet Health Needs of America’s Children. Pediatrics

NHIS data from 1993 to 1996, 97,206 children <18 years old

Used measures of unmet need for medical care, dental care, prescription medications, and vision care

Newacheck et al. (1999)

Adolescent Health Insurance Coverage: Recent Changes and Access to Care. Pediatrics

Data on 14,252 adolescents, ages 10–18, from the 1995 NHIS

Assess health insurance status, trends in health care coverage, demographic and socioeconomic correlates of coverage, and role of insurance in influencing use of and access to care

Newacheck et al. (1998a)

An Epidemiologic Profile of Children with Special Health Care Needs. Pediatrics

Data from 1994 NHIS Disability. Sample based on 30,032 completed interviews for children <18 years old

Characteristics of special needs children such as health status, access to care, satisfaction, and demographics

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Results are presented in four subgroups compared to children generally: poor children, minority children, uninsured children, and white non-poor insured children (reference group). Poor, minority, and uninsured children fared consistently worse on all indicators than children in the reference group, and of the children in at least one risk group, 40% are in another risk group as well. Children in all of these risk groups were less likely to have a usual source of care (OR = 0.76; 95% CI = 0.57–1.02 for poor children; OR = 0.56; 95% CI = 0.43–0.73 for minorities; and OR = 0.47; 95% CI 0.35–0.64 for the uninsured). These groups were more likely not to see a specific physician (OR = 1.88; 95% CI = 1.46–2.41 for the poor; OR = 2.44; 95% CI = 1.86–3.19 for minorities; and OR = 1.30; 95% CI = 1.01–1.67 for the uninsured) and were more likely to go without after-hours emergency care (OR = 1.30; 95% CI = 0.99–1.70 for the poor; OR = 1.77; 95% CI = 1.38–2.27 for minorities; and OR = 1.35; 95% CI = 1.03–1.77 for the uninsured). These groups were also more likely to have to wait 60 minutes or more at their site of care (OR = 2.03; 95% CI = 1.52–2.72 for the poor; OR = 2.12; 95% CI = 1.52–2.94 for minorities; and OR = 1.52; 95% CI = 1.14–2.03 for the uninsured). These individuals were more likely to be inadequately vaccinated for measles (OR = 1.40, 95% CI = 1.11–1.79 for the poor; OR = 2.66; 95% CI = 2.18–3.25 for minorities; OR = 1.09; 95% CI = 0.86–1.39 for the uninsured) and more likely to not have seen a physician for selected symptoms (OR = 1.25; 95% CI = 0.90–1.73 for the poor; OR = 1.54; 95% CI = 1.21–1.95 for minorities; OR = 1.65; 95% CI = 1.26–2.16 for the uninsured).

Of children overall, 7.3% experience at least one unmet need. After adjusting for confounders, children who were near poor or poor were both about three times more likely to have an unmet need as non-poor children (adj. OR = 2.89; 95% CI = 2.52–3.32 for near poor adj. OR = 3.0; 95% C I = 2.53–3.56 for poor). Uninsured children were three times as likely to have an unmet need as an insured child (adj. OR = 2.92; 95% CI = 2.58–3.32). The unmet need for dental care was the most prevalent form of unmet need; 5.3% of children reported an unmet need for dental care in the last year during 1993–1996. An unmet need for medical care in the past year during 1993–1996 was experienced by 1.6% of children.

In 1995, 14% of adolescents were estimated to be uninsured. Risk of being uninsured was higher for older adolescents, minorities, those in low-income families, and those in single-parent households. The uninsured were less likely to have a usual source of care (71% vs. 95.6%), more likely to have unmet needs (23.1% vs. 6.2%), and less likely to see a physician during the course of a year (74.9% vs. 89.8%). Between 1984 and 1995 the percentage of adolescents with some sort of insurance remained unchanged; however those with private insurance decreased and those with public insurance increased.

Among U.S. children under 18 years, 18% were classified as a special needs. Of these children, 11% were uninsured, 6% were without a usual source of care, 18% were reported as dissatisfied with one or more aspect of care received at their usual source, and 13% had one or more unmet needs in the past year. Children with existing special needs are disproportionately poor and socially disadvantaged, and many of these children face significant barriers to health care.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Newacheck et al. (2000b)

Access to Health Care for Children with Special Health Care Needs. Pediatrics

Data on 57,553 children, <18 years old in the 1994–1995 NHIS Disability Survey

Access to and use of care

Newacheck (1992)

Characteristics of Children with High and Low Usage of Physician Services. Med Care

Data from the Child Health Supplement of the 1998 NHIS (n = 17,110).

Use of care (physician services)

Starfield (1995)

Chapter 3 in Health Care for Children: What’s Right, What’s Wrong, What’s Next

Literature review

Environmental factors, social and economic factors, and medical and health system factors

Stoddard et al. (1994)

Health Insurance Status and Ambulatory Care for Children. N Engl J Med

Data from a subsample of 7,578 children and adolescents 1–17 years of age included in the 1987 NMES

Medical attention by a physician for pharyngitis, acute earache, recurrent ear infection, or asthma

Szilagyi et al. (2000a)

Evaluation of New York State’s Child Health Plus: Children Who Have Asthma. Pediatrics

187 children (2–12) who had asthma and enrolled in CHPlus between Nov. 1, 1991 and, Aug. 1, 1993

Rates of primary care visits, ED visits, hospitalizations, number of specialists seen, and quality-of-care measures

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Of U.S. children, 18% were defined as having special health care needs (based on the Maternal and Child Health Bureau definition) and 89% of these had health insurance. Socioeconomic characteristics were related to insurance coverage: 16.7% of those <100% FPL were uninsured, while 18.1% of those 100–199% FPL were uninsured, and 4.1% of those ≥200% FPL were uninsured. Uninsured children were less likely to have a usual source of care (adj. OR = 5.8; 95% CI = 4.4–7.6) and more likely to have gone without seeing a doctor in the last 12 months (adj. OR = 2.5; 95% CI = 2.0–3.1). The uninsured were more likely to go without or delay care due to cost (OR = 11.4; 95% CI = 6.9–18.9) than the insured. Uninsured children were more likely to report unmet needs in medical care (adj. OR = 5.8; 95% CI = 4.4–7.6) in dental care (adj. OR = 4.0; 95% CI= 3.2–5.0), in prescriptions, and/or eyeglasses (adj. OR = 3.2; 95% CI = 2.4–4.3), and in mental health care (adj. OR = 3.4; 95% CI = 1.7–6.9). Data showed that cost was the primary barrier to obtaining health insurance (74.1% said it was too expensive and they could not afford health insurance).

Children averaged three contacts with doctors; however 21% of children did not use physician services, and 7% had 10 or more contacts (accounting for 37% of the total number of contacts in 1998). Age and ethnicity of the child; family income, health insurance status, size and area of residence, and mother’s educational attainment were important sociodemographic correlates of low usage.

Social, environmental, and medical or health system factors promote and inhibit children’s health. Social conditions such as poor living conditions and inadequate income are factors that predispose individuals to disease (poverty is an important correlate of disease). On the other hand, good nutrition and good housing counteract disease. Physical factors in the environment have effects on health that are specific to developmental stages for children. Medical care and health system factors can improve health, prevent disease, and reduce the impact of disease. Children in the United States are at a disadvantage compared to those in other industrialized countries due to the lack of guaranteed access to health services.

Uninsured children were more likely to not receive care for all four conditions than those with insurance (unadjusted ORs, 2.83 for pharyngitis; 2.04 for acute earache; 2.84 for recurrent ear infections; and 1.87 for asthma). After adjustment, significant differences remained (for pharyngitis, adj. OR = 1.7; 95% CI = 1.1– 2.7; for earache, adj. OR = 1.85; 95% CI = 1.2– 3.0; for recurrent ear infections, adj. OR= 2.1; 95% CI = 1.28–3.51; and for asthma, adj. OR = 1.7; 95% CI = 1.1–2.8).

Visit rates to primary care providers were significantly higher during CHPlus than before for chronic illness (0.995 visit before and 1.34 visits per year during). The increase was seen in follow-up visits (0.86 vs. 1.32), total visits (5.69 vs. 7.11), and visits for acute asthma exacerbations (0.61 vs. .84) as well. There was no significant association between CHPlus coverage and ED visits or hospitalizations, however specialty utilization increased (30% vs. 40%; p = .02). Parents felt that CHPlus reduced asthma severity for 55% of children. CHPlus was also reported to have improved overall health status for 45% of children, attributed primarily to coverage for office visits and asthma medication. There was no statistically significant effect of CHPlus on several other quality-of-care measures such as follow-up after acute exacerbations, receipt of influenza vaccination, or use of bronchodilators or antiinflammatory medications.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Szilagyi et al. (2000b)

Evaluation of Children’s Health Insurance: From New York State’s Child Health Plus to SCHIP. Pediatrics

1,828 children who enrolled in CHP between Nov. 1, 1991, and Aug. 1, 1993, in a six-county region of upstate NY

To measure the association between CHP and access to care, utilization of care, quality of care, and health care costs

Szilagyi et al. (2000c)

Evaluation of a State Health Insurance Program for Low-Income Children: Implications for State Child Health Insurance Programs. Pediatrics

2,126 children (0–12 years of age) enrolled in Child Health Plus (CHP) in 1992–1993 within New York State. (response rate in New York City was particularly low [33%] due to various barriers, including language)

Access to care, utilization of care, and quality measures

Weinick et al. (1998)

Children’s Health Insurance, Access to Care, and Health Status: New Findings. Health Affairs

MEPS data from 1996

Access to care, use of care, and perceived health status

Weinick and Krauss (2000)

Racial/Ethnic Differences in Children’s Access to Care. Am J Pub Health

Data from the 1996 MEPS

Usual source of care

Weinick et al. (2000)

Racial and Ethnic Differences in Access to and Use of Health Care Services, 1977 to 1996. Med Care Res Rev

Data from three surveys: the 1977 NMCES (n = 38,336), the 1987 NMES (n = 33,536), and the 1996 MEPS (n = 20,793)

Usual source of care; the probability of having at least one ambulatory care visit; and the average number of visits for those who have used any ambulatory care services

Health Outcomes for Children and Youth

Dafny and Gruber (2000)

Does Public Insurance Increase the Efficiency of Medical Care? Medicaid Expansions and Child Hospitalizations

NHDS data for four age groups: <1, 1–5, 6–10, and 11–15, 1983–1996

Avoidable hospitalizations for children <16

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Utilization of primary care increased after enrollment in SCHIP. However, there was no association between SCHIP and changes in utilization of ED specialty services or inpatient care. SCHIP was associated with improvements in many measures involving quality of primary care, including preventive care and immunization rates. Enrollment was associated with a modest increase in expenditures, $71.85 per child per year.

Enrollment in CHP resulted in fewer children lacking a medical home (5% before vs. 1% during enrollment), with the largest change in New York City (11% vs. 1%). There was also an increase of 42% in total visits for care: 25% of an increase for preventive visits and 52% for acute visits. The number of specialists seen during CHP was more than twice as high as before. CHP was not associated with changes in ED utilization, but hospitalization was lower by 36% (even though this was not covered by CHP). Use of public health departments for immunizations decreased by 64%, and more immunizations were delivered in the medical home. One-third of parents also reported improved quality of health care for their children because of CHP.

Hispanic children are more likely to be uninsured (27.7%), to lack a usual source of care (17.2%), and to be in fair or poor health (7.8%), compared to all other racial and ethnic groups. The main reasons reported by parents for children being without a usual source of care were that the child was seldom or never sick (65.9%), they could not afford it (10.0%), they recently moved or did not know where to go (7.8%), and various other reasons (16.3%). About 11.6% of families had difficulty or delays in obtaining care or did not receive needed care. Of these families, 59.9% stated that they were unable to afford care, 19.5% gave insurance reasons, and 20.7% said there were other problems.

Black and Hispanic children were substantially less likely than white children to have a usual source of care. Differences persisted after controlling for health insurance and socioeconomic status. Controlling for language ability eliminated differences between Hispanic and white children.

The proportion of Americans without a usual source of care had not changed much from 1977 to 1996; however, the proportion of Hispanics without a usual source of care increased from 19.9 in 1977 to 29.5 in 1996, while the proportion for whites and blacks remained fairly stable. Blacks and Hispanics were more likely to lack a usual source of care than whites. Overall, the probability of Americans using ambulatory care increased over the years, but there are differences in this probability based on racial and ethnic groups. Black and Hispanics were less likely to use ambulatory care services over all three years, and the average number of visits for both groups was less than that for whites in all three years.

Over 1983–1996, child hospitalizations increased by 10% due to Medicaid expansions. Avoidable hospitalizations fell 22% due to Medicaid eligibility expansions. Treatment intensity per day increased with an increasing proportion of Medicaid hospital stays, but there were fewer days per stay.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Kaestner et al. (2001)

Medicaid Eligibility and the Incidence of Ambulatory Care Sensitive Hospitalizations for Children. Social Science Medicine

Nationwide inpatient sample of the Healthcare Cost and Utilization Project (HCUP-3) for 1988 and 1992 (before and after Medicaid expansions)

Difference in ACSC hospitalizations between low-income and high-income groups

Kuehl et al. (2000)

Insurance and Education Determine Survival in Infant Coarctation of the Aorta. J Health Care Poor Underserved

Data from 1981 to 1989 for 103 cases of infant coarctation of the aorta diagnosed before 1 year of age

Coarctation of the aorta

Li and Davis (2001)

Insurance Status and Survival Outcome in Pediatric Trauma Patients. Academic Emergency Medicine

National Pediatric Trauma Registry (23,135 patients)

Survival status at discharge in relation to insurance status, demographic characteristics, injury circumstances, and injury severity

Lykens and Jargowsky Forthcoming (2002)

Medicaid Matters: Children’s Health and Medicaid Eligibility Expansions. J Policy Analysis Manage

NHIS Child Health Supplement, 1988 and 1991 combined; children <15 years in families ≤185% FPL

Number of acute illness episodes; bed days; school loss days; restricted activity days reported for two-week period before interview

McInerny et al. (2000)

Uninsured Children with Psychosocial Problems: Primary Care Management. Pediatrics

235 pediatric and family practice clinicians from 90 practices in 38 states and the Commonwealth of Puerto Rico; each clinician enrolled an average sample of 55 consecutive children (4–15 years old)

Clinician-reported items: insurance status, clinician identification of a psychosocial problem, visit characteristics; parent- or guardian-reported items: psychosocial problems, family functioning

O’Toole et al. (1996)

Insurance-Related Differences in the Presentation of Pediatric Appendicitis. J Ped Surgery

Retrospective chart review of all cases of confirmed acute appendicitis (n = 288) presenting to Children’s Hospital of Buffalo, Jan. 1990–Dec. 1993

Rate of appendiceal perforation

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Results of the analyses were mixed. There was “relatively robust” evidence that Medicaid expansions decreased the incidence of ACSC hospitalizations among children aged 2–6 from very low income areas. For other groups of children, results were less consistent. There was some evidence that Medicaid expansion reduced ACSCs in children age 2–6 from near-poor areas (areas with a family income between $25,000 and $30,000). Among older children (from 7 to 9), there was little evidence that Medicaid expansion reduced rates of ACSCs.

Coarctation of the aorta is associated with greater maternal education and having any health insurance but not with measures of severity. Infants without health insurance are 12.8 times more likely to die than infants with any health insurance. Of the infants with coarctation whose mothers were uninsured, 33% died compared to 3.8% of infants with mothers who had health insurance. Of all deaths in infant coarctation, 55% occur prior to surgical treatment. One-third of deaths occur without diagnosis.

The case fatality rate for patients with commercial insurance was 2.06%, increasing to 2.86% for patients with government-assisted insurance (RR: 1.48, 95% CI 1.22, 1.76), and to 4.17% for the uninsured (RR: 2.02, CI 1.69, 2.42). Uninsured and underinsured pediatric trauma patients were at significantly elevated risk of in-hospital mortality. Association with insurance status and likelihood of survival are independent of injury severity and demographic characteristics.

In aggregated analysis, for non-Hispanic whites, both Medicaid eligibility and private insurance reduces the number of acute illness episodes. A 10-percentage point increase in the level of Medicaid eligibility reduced acute episodes 12% from the overall mean for 1991. Although significant, the confidence interval was large. Results for Hispanic and non-Hispanic black children were in the same direction but not statistically significant. Results for bed days, restricted activity days, and school absences as a function of area Medicaid eligibility level did not reach statistical significance for any ethnic group, but the direction of the effect went toward fewer functional limitations at higher Medicaid eligibility levels.

Of the 13,401 visits to clinicians, 93.4% were insured and 6.6% were uninsured. A higher percentage of adolescents, Hispanic children, those with unmarried parents, and those with less educated parents were uninsured. According to clinicians, uninsured children and insured children had similar rates of psychosocial problems (19%) and severe psychosocial problems (2%). No difference was found in clinician reported counseling, medication use, or referral to mental health professionals for children with identified psychosocial problems. A greater percentage of uninsured children are rated as having behavioral problems by their parents; however there is no difference in the rates of clinicians’ identifying psychosocial problems for uninsured versus insured children. This implies that clinicians are not recognizing behavioral problems as much in the uninsured. This discrepancy may be explained by the fact that uninsured children have fewer clinician visits than insured children, especially for well-child care. Of these children, 50% had been uninsured before enrollment in CHP and 16% previously had received Medicaid.

All children (≤16) were categorized as Medicaid or uninsured, HMO, or private FFS insurance. Rate of appendiceal perforation was significantly higher among Medicaid or uninsured vs. HMO and private FFS (44%, 27%, 23%; p <.05); duration of symptoms before presentation was longer (47.3, 29.3, and 23.1 hours, respectively p <.01); and their hospital stay was longer (7.9, 4.8, and 4.6 days, respectively; p <.01).

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Overpeck and Kotch (1995)

The Effect of US Children’s Access to Care on Medical Attention for Injuries. Am J Pub Health

Data from the NHIS 1988 Child Health Supplement (n = 17,110)

Injury rates, severity of injuries, and medical attention

Overpeck et al. (1997)

Socioeconomic and Racial/Ethnic Factors Affecting Non-fatal Medically Attended Injury Rates in US Children. Injury Prevention

1988 Child Health Supplement to the NHIS (n = 17,110)

Injury rates, severity of injury, and medical attention for injury

Pappas et al. (1997)

Potentially Avoidable Hospitalizations: Inequalities in Rates Between US Socioeconomic Groups. Am J Pub Health

1990 NHDS, NHIS, census (474 hospitals submitted records of which 192,734 were used for study)

Hospital discharge rates (by age, race, median income of zip code, and insurance status)

Parker and Schoendorf (2000)

Variation in Hospital Discharges for Ambulatory Care-Sensitive Conditions Among Children. Pediatrics

1990–1995 NHDS, U.S. census, NHIS (survey collected 15,000 medical records for children per year)

Hospital discharge rates

Rodewald et al. (1997)

Health Insurance for Low-Income Working Families: Effect on the Provision of Immunizations to Preschool-Age Children. Arch Pediatr Adolesc Med

1,730 children younger than 6 years who were enrolled in CHP. (for all of the upstate NY area served by CHP)

Number of immunization visits; types of providers (public health department clinics or primary care providers [pediatricians and family physicians]); and series-complete immunization coverage

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Of the serious medically attended injuries, 17% of children had no medical care coverage, 6.5% had no place for sick or injured care, and 2.5% had neither coverage nor a place for care. Adjusted relative rates (uninsured to insured) of total medically attended injuries ranged from 0.70 at ages 12 through 17 years to 0.80 at ages younger than 6 without coverage. Serious injury relative rates for those with no coverage ranged from 0.57 at ages younger than 6 to 0.84 at ages 12 through 17. All relative rates showed that children without medical care coverage were significantly less likely to have injuries attended (except for serious injuries at ages 12–17 (RR: 0.84, 95% CI = 0.061-1.16). The relative rates show that for those without coverage, between 20 and 30% of total injuries in 1988 may not have been attended, and at least 40% of serious injuries occurring to children aged 11 years and younger without coverage may not have been attended.

Lack of coverage was consistently associated with lower medically attended injury rates in non-Hispanic blacks or whites and Mexican Americans. The total rates of medically attended injuries for each group reflected that population’s uninsured rate. Injuries occur about 40% more frequently to children and adolescents living in singe-adult households for all injury categories except those occurring in schools.

Children under 15 had 439,000 avoidable hospitalizations, which represented 19% of all discharges (adjusted) for this age group. Avoidable conditions accounted for 27% of all adjusted discharges for children 1–4 years of age compared to 11% for children under 1 year and 19% for those age 5–14. Most of the potentially avoidable hospitalizations for this group were for two conditions: pneumonia (43%) and asthma (39%). A smaller proportion of patients with private insurance (10%) experienced a potentially avoidable hospitalization than patients who are uninsured (13%) or on Medicaid (15%).

Hospitalization rates were significantly higher among children who were younger, were black, had Medicaid insurance, and lived in poorer areas. Hospital discharge rates for ACSCs (per 1,000 children) were 10.5 for uninsured, 25.8 for Medicaid, and 13.3 for private or other insured children. The proportion of discharges attributed to ACSCs was similar for those who were uninsured and those with private or other insurance but higher for those on Medicaid. The authors state that if the assumption is made that uninsured children are disadvantaged within the health care system and may have a higher percentage of discharges for ACSCs, it is likely that some of the findings for the uninsured could be attributed to misclassification of insurance status.

There was a decrease in immunization visits to public health department clinics by 37% for infants and an increase in immunization visits to primary care providers’ offices by 15% due to CHP. There was an increase in immunization coverage by 7%. For children aged 1–5 there was a decrease in visits to public health department clinics by 67% and an increase in visits to primary care providers’ offices by 27%, with an increase in immunization coverage by 5%. The greatest effect was seen among those who were uninsured and those who had a gap in coverage longer than six months.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Shi and Lu (2000)

Individual Sociodemographic Characteristics Associated with Hospitalization for Pediatric Ambulatory Care Sensitive Conditions. J Health Care Poor Underserved

Data from 1994 NHDS (478 out of 512 hospitals responded to the survey)

Hospital discharge rates for ACSCs

Spivak et al. (1995)

The Relationship Between Insurance Class and Severity of Presentation of Inflammatory Bowel Disease. Am J Gastroenterology

20 underinsured (uninsured + Medicaid) children matched with 20 children with private insurance from a pool of 63 with inflammatory bowel disease at a pediatric GI service

Delayed presentation; disease severity at presentation

Effect of Health on Children’s Life Chances

Acs et al. (1999)

The Effect of Dental Rehabilitation on the Body Weight of Children with Early Childhood Caries. Pediatr Dent

Percentile weight categories of children with noncontributory medical histories

Weight percentile

Brunelle (1989)

Oral Health of United States Children: The National Survey of Dental Caries in U.S. Schoolchildren, 1986–1987

National Survey of Oral Health by the National Institute of Dental Research (NIDR) of children ages 5–17 in 1986–1987; survey was the second in a series (the first was in 1979–1980)

Dental caries

Carr et al. (1992)

Variations in Asthma Hospitalizations and Deaths in New York City. Am J Pub Health

Data on asthma hospitalizations (1982 to 1986) and deaths (1982 to 1987) among persons aged 0–34

Hospitalization for asthma, death from asthma

Casby (2001)

Otitis Media and Language Development: A Meta-Analysis. Am J Speech-Language Pathology

Literature review and meta-analysis of existing research

Language development outcomes

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

In a logistic regression, children with Medicaid were more likely than privately insured children to be hospitalized for an ACSC (adj. OR = 1.1; CI = 1.04–1.20). Younger children were more likely than older ones to have an ACSC hospitalization (adj. OR = 0.95; CI = 0.95–0.96), and black children were more likely to have an ACSC hospitalization than white children (adj. OR = 1.7; CI = 1.0–1.7).

Underinsured children had more weight loss (20.9 vs. 8.6l; p <.005) and longer delay in months (10.3 vs. 2.7; p <.005) before diagnosis was made. Laboratory data indicated that underinsured children were more ill at presentation than insured (hemoglobin: 10.5 vs. 12.5; erythrocyte sedimentation rate: 59 vs. 21; p <.05) and had higher platelet count and depressed alkaline phosphatase levels.

Before the dental rehabilitation test the percentile weight categories were significantly lower than those of the comparison counterparts. Of the early childhood caries patients, 13.7% weighed less than 80% of their ideal weight. After intervention, these children showed significant weight increases through the course of follow-up. At the end of the follow-up period (1.58–1.36 years) there were no significant differences noted in percentile weight categories.

For the 41.3 million school children aged 5–17 in the United States who have at least one permanent tooth, the mean number of decayed, missing, and filled permanent teeth was estimated at 3.07 per child (CI 2.93–3.21). The caries level in permanent teeth increased with age, and females had slightly higher levels than males.

The average annual hospitalization rate was 39.2 per 10,000, and the mortality rate was 1.2 per 100,000. Death rates and hospitalizations were higher among blacks and Hispanics than among whites (3–5.5 times higher). There were geographic variations in hospitalization and mortality. Hospitalization and mortality rates were highly correlated (r = .67), with the highest rates in the city’s poorest neighborhoods. Household income and percentage of blacks and Hispanics in the population were predictors of the areas’ hospitalization rates.

The magnitude of the statistical population effect of otitis media with effusion on language development is low. However, it should be acknowledged that the findings of low population effects might be related to vicissitudes of the primary research. Among these are failure to determine research participants’ hearing levels, other intrinsic and/or extrinsic individual differences among research participants, and sensitivity of language measures.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Celano, and Geller (1993)

Learning, School Performance, and Children with Asthma: How Much at Risk? J Learn Disabil

Research review

School functioning

CDC (1996a)

Asthma Surveillance Programs in Public Health Departments—United States

Data from survey conducted by Council of State and Territorial Epidemiologists and the CDC during March and April 1996 (n = 48 states and 3 territories)

Existence of asthma surveillance program

Dallman et al. (1984)

Prevalence and Cause of Anemia in the United States, 1976 to 1980. Am J Clin Nutr

Data from the second NHANES (n = 15,093)

Anemia

DuPaul et al. (2001)

Preschool Children with Attention-Deficit/ Hyperactivity Disorder: Impairments in Behavioral, Social, and School Functioning. J Am Acad Child Adolesc Psychiatry

Data from children between age 3 and 5 years (n = 58 with ADHD and n = 36 normal controls)

Parent or teacher ratings of problem behavior and social skills, parent ratings of stress and family functioning, medical functioning, observations of parent–child interactions, classroom behavior, and test of preacademic skills

Edelstein and Douglass (1995)

Dispelling the Myth That 50 Percent of U.S. Schoolchildren Have Never Had a Cavity. Pub Health Rep

Literature review

Dental caries

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

There is not sufficient evidence to suggest that children with asthma are at significantly higher risk for poor school performance than children without asthma. Factors that may contribute to poor school performance include iatrogenic effects of oral steroids, poor medical management of disease, and psychological problems.

Asthma affects more than 14 million persons in the United States. Asthma is the most common chronic disease of childhood, affecting approximately 5 million children aged less than 18 in the United States. Of the respondents, 43 reported no state or territorial-level asthma control programs. When asked why states may not have asthma programs, the most important reasons included lack of funds and shortage of staff. Ten states reported that asthma was not a public health priority, but 86% of the states or territories showed an interest in starting an asthma control program.

Anemia is often defined in terms of individuals with Hb values below 95% of the reference range. Anemia can also be considered in terms of the depression of Hb concentration. The highest prevalence of anemia for all races was in infants 1–2 years of age (5.7%), girls 15–17 years of age (5.9%), young women (4.5%), and elderly men (4.8%). The lowest prevalence of anemia was in children 6–8 years old (2.3%) and in males 12–44 years old (2.6%–2.9%). The prevalence of depression in Hb concentration due to anemia and inflammatory disease was highest in infants between the age of 1 and 2 (6.8%) and declined in children between 3 and 5 years (5.3%), 6 and 8 years (5.5%), and 9 and 11 years of age (4.6%).

Young children with ADHD exhibited more problem behavior and were less socially skilled than their normal counterparts. Parents of children with ADHD experienced greater stress and were coping less adaptively than parents of non-ADHD children. These children show more noncompliant and inappropriate behavior than normal controls particularly during task situations. Parents of ADHD children were more likely to show negative behavior toward their children. Children with ADHD exhibited more negative social behavior in preschool settings and scored lower on tests for preacademic skills. Preschool-age children are at risk for behavioral, social, familial, and academic difficulties relative to normal preschool-age children.

The article reviews the underreporting of children’s caries in policy documents and dental literature. The article also review epidemiological studies of caries reported in U.S. dental literature since 1985. Dental caries remain the single most common disease of childhood that is not self-limiting or amenable to a course of antibiotics. The belief that many children do not suffer from this has resulted in inappropriate policy and funding decisions.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Edmunds and Coye (1998)

America’s Children: Health Insurance and Access to Care

CPS, literature review, publicly available information on state and federal programs, other published reports, and papers presented to the committee by various organizations

Multiple measures of access, use, and health status.

Fischer et al. (1990)

The Adolescent Outcome of Hyperactive Children Diagnosed by Research Criteria: II. Academic, Attentional, and Neuropsychological Status. J Consult Clin Psychol

100 hyperactive children and 60 control children followed prospectively over an eight-year period into adolescence

Academic skills, attention and impulse control, and select frontal lobe functions

Frick et al. (1991)

Academic Underachievement and the Disruptive Behavior Disorders. J Consult Clin Psycol

177 clinic-referred boys diagnosed as having ADHD or conduct disorder (CD)

Academic underachievement

Gergen and Weiss (1990)

Changing Patterns of Asthma Hospitalization Among Children: 1979 to 1987. JAMA

NHDS for 1979–1987 (a randomized sample of 181,000 to 227,000 discharges collected per year)

Asthma hospitalization

Gordon et al. (1994)

Sustained Attention and Grade Retention. Percept Mot Skills

Data from children involved in a project designed to standardize the Gordon Diagnostic System (n = 83 students who failed a grade; n = 93 normal)

Scores on the Continuous Performance Test, the Peabody Picture Vocabulary Test, the Child Behavior Checklist, and the Child Behavior Checklist Teacher Report Form

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

The Committee concluded that health insurance coverage was a major determinant of whether children have access to health care. Access to care can influence children’s physical and emotional growth, development, and overall health and well-being. Uninsured children are the least likely population group to have routine access to a physician. Among American children, 20% have chronic problems that could impose on their ability to function effectively in school and at home; 10% of children have one or more severe chronic conditions and account for 70–80% of all medical expenditures for children. The most prevalent chronic conditions are dental conditions, mental health and substance abuse problems, and developmental disabilities. Tooth decay is the single most common chronic disease of children. Access to coordinated, efficient, effective, and cost-effective health care for all American children should be a national goal.

At follow-up, hyperactive children demonstrated impaired academic achievement, impaired attention and impulse control, and greater off-task, restless, and vocal behavior during an academic task. Frontal lobe measures did not differentiate between those who were hyperactive and the control group. Several measures showed age-related declines in both groups, and it was concluded that hyperactive children may remain chronically impaired in academic achievement, inattention, and behavioral disinhibition into late adolescence.

Academic underachievement was associated with both ADHD and CD when the disorders were examined individually. The percentage of children underachieving who had ADHD, was higher in both reading and mathematics than for the control group. However, when examined together, the relationship between CD and academic underachievement was found to be due to its comorbidity with ADHD. When boys with ADHD were divided into those with attention deficit only and those with co-occurring hyperactivity, findings did not support the hypothesis that academic underachievement has a stronger association with attention deficit without co-occurring hyperactivity.

From 1979 to 1987, asthma hospitalizations among children aged 0–17 increased 4.5% per year. The increase was the greatest among 0–4-year-olds, 5.0% per year, vs. 2.9% per year for 5–17-year-olds. For children aged 0–4, blacks had about 1.8 times the increase of whites. Total hospitalizations decreased –4.6% during this time, while admissions for lower respiratory tract infections had a statistically insignificant decrease, –1.3%. Acute and chronic or unspecified bronchitis hospitalizations decreased –6.1%, but this decrease did not begin until 1983.

89 children, who had been retained at some point in school, had a higher frequency of abnormal scores on a sustained attention index than 93 children who had never repeated a grade. Those who had a history of grade retention in a sample of children that had been referred for an evaluation for ADHD had lower scores on the same measures of sustained attention.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Grantham-McGregor and Ani (2001)

A Review of Studies on the Effect of Iron Deficiency on Cognitive Development in Children. J Nutr

Seven studies in which Hb levels in early childhood were linked to cognitive development or school achievement

Studies were reviewed looking for causal relationship between iron deficiency and children’s cognition and behavior

Gutstadt et al. (1989)

Determinants of School Performance in Children with Chronic Asthma. Am J Dis Child

99 children with moderately severe to severe chronic asthma

Performance on standardized achievement tests

Halterman et al. (2000)

Health and Health Care for High-Risk Children and Adolescents. Pediatrics

Data from the NHANES III 1988–1994 for children 2 months to 16 years old. (n = 40,000)

Adequate treatment for asthma

Halterman et al. (2001)

Iron Deficiency and Cognitive Achievement Among School-Aged Children and Adolescents in the United States. Pediatrics

Data from NHANES III 1988–1994. (sample: 5,398 children ages 6–16)

Iron deficiency and cognitive test scores

Hurtado et al. (1999)

Early Childhood Anemia and Mild or Moderate Mental Retardation. Am J of Clin Nutr

Data from Special Supplemental Program for Women, Infants, and Children (WIC) (1979 to 1980) and school records (from 1990 to 1991) in Dade County, FL (n = 5411)

Special education placement and mild or moderate retardation

Lang and Polansky (1994)

Patterns of Asthma Mortality in Philadelphia from 1969 to 1991. N Engl J Med

Data from Philadelphia Department of Public Health on deaths from asthma between 1969 and 1991

Death from asthma

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Most correlation studies found associations between iron deficiency anemia and poor cognitive and motor development and behavioral problems. Longitudinal studies showed that children anemic in infancy continue to have poorer cognition and school achievement and more behavior problems in middle childhood. Possible confounding of poor socioeconomic status prevents a causal relationship from being determined. In children that are anemic and less than 2 years of age, short-term trials of iron treatment have generally failed to benefit development. Only one trial has shown benefit, and it remains unclear whether poor development of iron-deficient infants is due to poor social background, represents irreversible damage, or is remediable with iron treatment.

Test scores and intelligence tests showed that overall academic capabilities of children with asthma are average to above average. Factors associated with low performance scores were low socioeconomic status, older age, history of continuous oral steroids, and presence of emotional and behavioral problems. Investigation of poor classroom performance of a child with chronic asthma should include investigation of the roles of socioeconomic status, oral steroid therapy, and emotional and behavioral problems.

9.4% of the children had physician-diagnosed asthma. Overall, 74% of the children with moderate to severe asthma had inadequate therapy. Of those with moderate asthma, 26% had taken maintenance medication during the past month. Among children who had two or more hospitalizations in the last year, only 32% had taken maintenance medications. Factors found to be associated with inadequate therapy include ≤5 years old, Medicaid insurance, and Spanish speaking.

Children with iron deficiency had greater than two times the risk of scoring below average in math than did children with normal iron status (OR: 2.3; 95% CI = 1.1–4.4). This elevated risk was present even for iron-deficient children without anemia (OR: 2.4; 95% CI = 1.1–5.2).

There was an increase in the likelihood of mild or moderate mental retardation associated with anemia, independent of birthweight, maternal education, sex, race or ethnicity, the mother’s age, or the child’s age at entry into the WIC program. In addition, for each decrease in quantity of hemoglobin, the risk of mild or moderate mental retardation increased by 1.28 (adj. OR = 1.28; 95% CI: 1.05–1.60).

Death rates from asthma decreased from 1.68 per 100,000 people in 1969 to 0.68 per 100,000 in 1977. However, there was an increase to 0.92 per 100,000 in 1978 and to 2.41 per 100,000 in 1991. From 1965 to 1990, the concentration of major air pollutants decreased. Between 1985 and 1991, 258 people were identified with asthma as the primary cause of death. These death rates were significantly higher where there was a higher percentage of blacks, Hispanics, females, and people with incomes in the poverty range.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Lanphear et al. (1997)

Increasing Prevalence of Recurrent Otitis Media Among Children in the United States. Pediatrics

Data from Child Health Supplement to 1981 and 1988 NHIS (n = 5,189 [1981] and n = 6,209 [1988])

Changes in the prevalence of otitis media and associated risk factors for recurrent otitis media

Lindgren et al. (1992)

Does Asthma or Treatment with Theophylline Limit Children’s Academic Performance? N Engl J Med

In Iowa, 255 children with asthma who had taken nationally standardized scholastic achievement tests; matched sibling controls were used for 100 of them

Performance on scholastic achievement test

Litt et al. (1995)

Multidimensional Causal Model of Dental Caries Development in Low-Income Preschool Children. Pub Health Rep

Data from assessment of 184 low-income preschool children

Dental caries and mutans Streptococcus

Looker et al. (1997)

Prevalence of Iron Deficiency in the United States. JAMA

Data from NHANES 1988–1994 (n = 24,894 aged 1 year or older)

Iron deficiency and iron deficiency anemia

Lous (1995)

Otitis Media and Reading Achievement: A Review. Int J Pediatr Otorhinolaryngol

Literature review of 19 studies

Reading achievement

Lozoff et al. (1991)

Long-Term Developmental Outcome of Infants with Iron Deficiency. N Engl J Med

191 participants in San Jose, Costa Rica, follow-up to original study (age 5)

Cognitive, socioemotional, and motor tests, and measures of school functioning

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

The number of visits for otitis media, the most common diagnosis among preschool children, increased in the past decade. Recurrent otitis media among preschool children increased from 18.7% in 1981 to 26% in 1988 (OR: 1.6; 95% CI 1.4–1.7). The greatest increase occurred in infants (OR: 0.9; CI 1.3– 2.9). Factors associated with otitis media were allergic conditions (OR: 1.9; CI 1.7– 2.2), survey year (OR: 1.7; CI 1.5–1.9), black race (OR: 0.6; CI 0.5–0.7), Hispanic ethnicity (OR: 0.8; CI 0.6–0.9), day care (OR: 1.5; CI 1.3–1.7), out-of-home care by an unrelated sitter (OR: 1.3; CI 1.1–1.6), and male gender (OR: 1.2; CI 1.1–1.3).

Academic achievement among the children with asthma was similar to normative standards for Iowa and higher than national standards. For the 101 children with control siblings, the composite test score for children with asthma was 58.3 and for siblings 57.5. None of the differences between the children with asthma and their siblings were statistically significant. Achievement among children with asthma, at least for those whose status is closely monitored in structured treatment programs, appears to be unaffected.

Results confirmed that caries development at a one-year follow-up was strongly dependent on earlier caries development. Early caries in this sample was determined in part by mutans levels and by dental health behavior. Historically, blacks had a lower percentage of dental caries than whites. Recently, Hispanics and blacks have been found to have a higher percentage of caries. This has been attributed to socioeconomic status in terms of risk of caries. It is likely that socioeconomic status has more of an indirect effect in that it affects social norms (i.e., tooth brushing, dental services, consumption of sugar).

In the United States, 9% of toddlers aged 1–2 years old and 9–11% of adolescent girls and women of childbearing age were iron deficient. In these individuals, iron deficiency anemia was found in 3% of toddlers and in 2–5% of adolescents and women. Iron deficiency occurred in no more than 7% of older children or those older than age 50 and in any more than 1% of teenage boys and young men. Iron deficiency is more likely to occur in minority, low-income, and multiparous women of childbearing age. Iron deficiency and anemia are still common in toddlers, adolescent girls, and women of childbearing age.

Children catch up in their cognitive development when their ears and hearing become normal. A correlation has been found between secretory otitis media (SOM) and reading, but the correlation is small. Reading achievement was more closely correlated with cognitive, language, and linguistic factors as well as socioenvironmental classroom factors. The high frequency of hearing loss resulting from SOM and the rate of OM in those who are prone to otitis underlie the need for more research.

All children had excellent hematologic status and growth at 5 years. Children who had had moderately severe iron deficiency anemia as infants had lower scores on tests of mental and motor functioning at school entry than the rest of the children. Statistically significant differences were found on all tests except verbal IQ. This difference remained significant after controlling for socioeconomic status. Children who have iron deficiency anemia in infancy are at risk for long-lasting developmental disadvantages compared to their peers.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Lozoff et al. (1998)

Behavior of Infants with Iron-Deficiency Anemia. Child Dev

191 participants in San Jose, Costa Rica (n = 52 iron deficient infants, n = 139 comparison infants)

Increased proximity to caregivers, increased wariness or hesitance, and decreased activity (mental and motor testing)

Lozoff et al. (2000)

Poor Behavioral and Developmental Outcomes More Than 10 Years After Treatment for Iron Deficiency in Infancy. Pediatrics

191 participants in San Jose, Costa Rica, follow-up to original study (age 11–14)

Cognitive, socioemotional, and motor tests, and measures of school functioning

Lubker et al. (1999)

Chronic Illnesses of Childhood and the Changing Epidemiology of Language-Learning Disorders. Topics in Language Disorders

Reviews evidence on chronic childhood illness and psycho-educational and language-learning disorders

Language-learning disorders

Mannuzza et al. (1997)

Educational and Occupational Outcomes of Hyperactive Boys Grown Up. J Am Acad Child Adolesc Psychiatry

Prospective follow-up of white boys who were diagnosed, at approximately age 7 with ADHD (n = 104 of the 207 original boys were evaluated)

Long-term educational achievement and occupational rank

Mannuzza and Klein (2000)

Long-Term Prognosis in Attention-Deficit/ Hyperactivity Disorder. Child Adolesc Psychiatr Clin N Am

Review of three studies

School achievement, social skills, and self-esteem

Marshall et al. (1999)

Arithmetic Disabilities and ADD Subtypes: Implications for DSM-IV. J Learn Disabil

20 students aged 8–12 with attention deficit disorder with hyperactivity and 20 students with attention deficit disorder without hyperactivity

Academic deficit

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Infants with iron deficiency and anemia remained in closer contact with caregivers; showed less pleasure and delight; and were more wary, hesitant, and easily tired. They were less playful, made fewer attempts at test items, and were less attentive to instructions or demonstrations. These results indicated that iron deficiency anemia in infancy was associated with alterations in affect and activity.

Children with severe chronic iron deficiency in infancy scored lower on measures of mental and motor functioning even after controlling for background factors. More of the formerly iron-deficient children had repeated a grade and/or been referred for special services or tutoring. Parents and teachers rated their behavior as more problematic in several areas and had increased concerns about anxiety or depression, social problems, and attention problems.

Children with a number of chronic illnesses are at increased risk for language-learning disorders as a result of the conditions themselves and iatrogenesis.

Those with ADHD completed significantly less schooling (about two years less on average) than controls. These individuals also had lower-ranking occupational positions than controls. This study suggested that childhood ADHD predisposes individuals to disadvantages that continue to affect functional domains unrelated to current psychiatric diagnosis.

Among children in early and middle adolescence with lower levels of academic and social functioning, 2/3–3/4 have ADHD symptoms. Many of the same behaviors continue through late teen years, and deficits continue to be present in academic and social areas, compared to control groups (lower grades, more courses failed, worse performance on standardized tests, few friends, and rated less adequate in psychosocial adjustment). About 2/5 continue to experience symptoms to a clinically significant degree; 1/4–1/3 have a diagnosed antisocial disorder, and 2/3 of these individuals are arrested. When individuals were evaluated in their twenties, dysfunctions are apparent in the same areas. Compared to controls, these individuals complete less schooling, hold lower-ranking occupations, and continue to suffer from poor self-esteem and social skill deficits.

Students did not differ in age or grade; however there were significant differences in Full Scale IQ and Performance IQ. Students in the ADD/H group had higher scores than the ADD/noH groups on both tests. No significant difference was found between groups on the achievement measures. Significant differences did appear in within-group comparisons, involving lower performance on the math calculation subtest. Students with ADD/noH had significantly lower scores on the calculation subtest compared to all other achievement

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

McCowan et al. (1996)

School Absence— A Valid Morbidity Marker for Asthma. Health Bull

773 children with asthma or related symptoms and 773 controls from school registers in the Tayside, Scotland region

School absences and days absent per term

Merrell and Tymms (2001)

Inattention, Hyperactivity, and Impulsiveness: Their Impact on Academic Achievement and Progress. Br J Educ Psychol

Data from 4,148 children from a nationally representative sample of schools in England

Behavior and reading and mathematics achievement

Mody et al. (1999)

Speech Perception and Verbal Memory in Children With and Without Histories of Otitis Media. J Speech, Language, Hearing Res

Data from the participants in the Longitudinal Infant Follow-up and Evaluation program (n = 14)

Speech perception and verbal short-term memory tasks

NIH (2000)

Consensus Development Conference Statement: Diagnosis and Treatment of Attention-Deficit/ Hyperactivity Disorder (ADHD). J Amer Acad Child Adolesc Psychiatry

Literature review

Diagnosis of ADHD

Otero et al. (1999)

Psychological and Electroncephalographic Study in School Children with Iron Deficiency. Int J Neurosci

Two groups selected randomly from a group of 100 6–12-year-old primary school children

Test outcomes for WISC-R, a computerized test of learning (DEL), and a qEEG

Rana et al. (2000)

Asthma Prevalence Among High Absentees of Two Philadelphia Middle Schools. Chest

Data from 5th and 6th graders who were absent 25 or more days in two Philadelphia middle schools during spring 2000 (n = 176)

Diagnosis of asthma

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

subtests. These results provided support for the hypothesis that inattention exerts a specific and deleterious effect on the acquisition of arithmetic computation skills.

When the control group and the children taking asthma medication were compared, there were significant differences in the days absent and episodes of absence. The increase in absences was about one school day each term. Severity of asthma was not related to increase in absence. Those who were not receiving asthma medication but had related symptoms were absent more than their matched controls.

The reading and mathematics attainment and value-added for children with high scores on the behavior rating scale were found to be educationally and statistically significantly lower than for children with scores of zero on the rating scale.

The otitis media group performed less accurately than the otitis-free group. However the pattern of errors was the same for each group. The children with and without positive histories of otitis media were negatively affected by an increase in phonetic similarity of the stimulus item. The two groups did not differ on identification or on temporal order recall when multiple features differentiated speech sounds. Findings suggested that long-term effects of early episodes of otitis media on phonological representations and on working memory do exist.

ADHD is the most commonly diagnosed behavioral disorder of childhood estimated to affect 3–5% of school-age children. Symptoms include developmentally inappropriate levels of attention, concentration, activity, distractibility, and impulsivity. Children with ADHD usually have functional impairment in a number of settings including home, school, and peer relationships. This disorder has also been shown to have long-term adverse effects on academic performance, vocational success, and social–emotional development. The lack of insurance coverage and disconnect between medical and educational services are substantial barriers for assessment and follow-up.

The WISC-R showed that iron-deficient children had lower values in WISC item of information, comprehension, and verbal, performance, and full-scale IQ than control children. The EEG power spectrum showed more theta energy in all leads using Laplacian montage and more delta energy in frontal areas using referential montage in iron-deficient children than in the control group. Aside from the well-known effect of iron deficiency on intellectual performance during childhood, the EEG power spectrum of iron-deficient children had a slower activity than that of control children suggesting a developmental lag and/or CNS dysfunction.

High-absentee children were compared to low-absentee children from the same grades. The prevalence of self-reported asthma was 34.9% for high-absentee children and 25.2% for low-absentee children. Diagnosis of asthma through the ISAAC (International Study of Asthma and Allergies in Children) survey showed that 48.3% of high-absentee children and 36.7% of low-absentee children had asthma. Among high-absentee children with asthma, 43% were not aware of the diagnosis, and among low-absentee children, 51.9% were unaware.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Rietveld and Colland (1999)

The Impact of Severe Asthma on School Children. J Asthma

25 children with severe asthma, aged 10–13 years, compared to 25 matched controls

Normal daily functioning

Roberts et al. (2000)

Otitis Media in Early Childhood in Relation to Preschool Language and School Readiness Skills Among Black Children. Pediatrics

Data from a prospective study of 85 black children examined from 6 months to 5 years of age

Language skills, school readiness

Shelton et al. (1998)

Psychiatric and Psychological Morbidity as a Function of Adaptive Disability in Preschool Children with Aggressive and Hyperactive Impulsive Inattentive Behavior. J Abnorm Child Psych

Data from 154 children with aggressive-hyperactive-impulsive-inattentive behavior (AHII); of these, 38 had adaptive disability and 116 did not; 47 control children were also used

ADHD, oppositional defiant disorder, conduct disorder, symptoms of general psychopathology, social skills deficit, parental problems, lower levels of academic achievement

Silverstein et al. (2001)

School Attendance and School Performance: A Population-Based Study of Children with Asthma. J Pediatr

A cohort of children with asthma and a matched group without asthma in Rochester, MN (n = 92 children with asthma)

School attendance and performance

Silverstein et al. (2001)

School Attendance and School Performance: A Population-Based Study of Children with Asthma. Pediatrics

Data from a cohort of children in Rochester, MN, with asthma and age- and sex-matched children without asthma (n = 92 with asthma)

Days absent, achievement test scores, grade point average, grade promotion, and class rank or graduating students

Taragonski et al. (1994)

Trends in Asthma Mortality Among African Americans and Whites in Chicago 1968 Through 1991. Am J Pub Health

Death certificates among African Americans and whites aged 5–34 in Chicago from 1968 through 1991 (n = 340 deaths)

Asthma mortality rates

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Children with asthma did not vary significantly from controls. They reported more dyspnea after physical exercise, which could not be attributed to lung function. Differences in school performance were not significant. It was concluded that children may generally adapt well to living with asthma.

Otitis media and associated hearing loss were significantly positively correlated with measures of expressive language at 3 and 4 years of age. However, this relationship did not remain significant when the child’s gender, socioeconomic status, maternal educational level, and the responsiveness and support of the home and child care environments were accounted for. Both otitis media and hearing loss were moderately correlated with school readiness skills at entry. Children with more otitis media scored lower in verbal math problems. Children with more hearing loss scored lower in math and recognizing incomplete words. These associations remained after accounting for background factors.

Children with AHII have greater risk for a variety of psychological, academic, emotional, and social difficulties than children with either behavior pattern alone. Both AHII groups were more likely to have ADHD, oppositional defiant disorder, and conduct disorder than the control group. These children also had more symptoms of general psychopathology, greater social skill deficits, more parental problems, and lower levels of academic achievement.

Children with asthma had 2.21 (95% CI = 1.41–3.01) more days absent than children without asthma. There was no significant difference in standardized achievement scores: reading percentile difference 1.22%; 95% CI = -3.68–6.12; mathematics percentile difference 2.36%; 95% CI = -2.89–7.60, and language percentile difference 2.96%; 95% CI = -4.03–7.15. There was also no significant difference in grade point average, grade promotion, or class rank for graduation.

Children with asthma had 2.21 (95% CI = 1.41–3.01) more days absent than those without asthma. There was no significant difference in the achievement test scores. There was also no significant difference in grade point average, grade promotion, or class rank between the two groups.

African Americans had consistently higher asthma mortality throughout the period. Asthma mortality remained stable for whites, but increased by 337% among African Americans from 1976 through 1991. The increase was greatest among 20–34-year-olds. Outpatient and ED deaths increased during this period, while the proportion of dead-on-arrival cases remained stable. This shift to non-inpatient deaths suggests that lack of access to health care may play a role in asthma mortality.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Teele et al. (1990)

Otitis Media in Infancy and Intellectual Ability, School Achievement, Speech, and Language at Age 7 Years. J Infect Dis

Data from a randomly selected group (n = 207) of 7-year-old children from a larger cohort (n = 498) were followed prospectively since birth

Assessment of hearing, cognitive, speech, and linguistic data

Vargas et al. (1998)

Sociodemographic Distribution of Pediatric Dental Caries: NHANES III 1988–1994. J Am Dent Assoc

Data from the third NHANES 1988–1994 (n = 10,332)

Dental caries

Wolfe (1985)

The Influence of Health on School Outcomes. Med Care

Data used is part of the child health survey conducted over a period of years in the early 1970s in Rochester, NY; sample of chronically ill school-age children and a matched sample of well children (n = 248)

School outcomes (achievement and attendance)

Zargi and Boltezar (1992)

Effects of Recurrent Media in Infancy on Auditory Perception and Speech. Am J Otolaryngol

33 children with a history of at least three episodes of acute otitis media before age 2; a control group of 29 children with fewer episodes of otitis media. All children from 8 to 10 years old

Speech ability

Prenatal and Perinatal Care and Outcomes

Amini et al. (1996)

Effect of Prenatal Care on Obstetrical Outcome. J Matern Fetal Med

A seven-year computerized perinatal database with 29,225 consecutive deliveries from a single inner city tertiary medical center; data from 23,181 women who had documented prenatal visits

Access and use of services and outcomes from prenatal testing as well as scores at birth

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

The time spent with a middle-ear effusion during the first three years of life was significantly associated with lower scores on tests of cognitive ability, speech and language, and school performance at 7 years of age (after controlling for confounding variables). The adjusted mean full-scale WISC-R scores were 113.1 for those with least time with middle ear effusion, 107.5 for those with moderate time, and 105.4 for those with the most time. Significant differences were also seen for verbal and performance IQ scores. It was found that for the Metropolitan Achievement Test, middle-ear disease in the first three years of life was associated with lower scores in mathematics and reading. Similar differences were found for articulation and use of morphologic markers.

Lower-income children and Mexican-American and African-American children are likely to have a higher prevalence of caries and more unmet treatment needs than their higher-income and non-Hispanic white counterparts.

Children with certain health problems, such as those creating problems with strenuous activities and difficulties with physical activities and peer communication, have lower school outcomes compared to children with other health problems. Health problems that are likely to interfere with school interactions such as communication in the classroom or physical activities significantly increase days absent. Severe psychological discomfort has the largest direct negative impact on achievement. On the other hand, health problems that interfere with ordinary activities do not affect attendance, and children with these problems seem to be able to compensate for their health.

Of the children who had a history of at least three episodes of otitis media, 88% had auditory perception disorders. Decreased auditory stimulation during the time of auditory maturation could have prevented the development of these functions completely. Statistically significant differences were not observed in the development of articulation.

Overall, 90.6% of the mothers had at least three prenatal visits (C), while 9.4% had two or fewer visits (NC). The NC group was 2.3 times more likely to be unmarried (80% vs. 59%; p <.001), 6.3 times more likely to be staff patients (no private insurance), and 1.5 times more likely to be black. NC mothers delivered at an earlier gestational age (37.3 ± 3.3 vs. 39.0 ± 2.6 weeks; p <.001), had lower birthweights (BWs) (2810 ± 743 vs. 3,203 ± 607 g for singleton births; p <0.001), and their infants had longer neonatal hospital stays (8.4 ± 17.3 vs. 4.8 ± 10.4 days; p <.001) compared with C mothers. After adjustment, C mothers delivered infants who were on the average 550 g heavier than those of NC mothers. The neonates of NC mothers had consistently lower Apgar scores and were more likely to be breech (5.7% vs. 3.1%) and to be transferred to the ICU (11.6% vs. 5.2%; p <.001). The NC group had fewer cesareans (94% vs. 14.2%; p <.001), but thicker meconium fluid (12.4% vs. 8.9%; p <0.001). Neonatal outcomes were all uniformly worse in the NC group. Incidences of low birthweight, low Apgar scores, and admissions to the neonatal ICU were all higher compared to the C group.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Aron et al. (2000)

Variations in Risk-Adjusted Cesarean Delivery Rates According to Race and Health Insurance. Med Care

Data from 25,697 women without prior cesarean deliveries admitted for labor and delivery Jan. 1993– June 1995 (Cleveland, OH)

Cesarean sections

Baldwin et al. (1998)

The Effect of Expanding Medicaid Prenatal Services on Birth Outcomes. Am J Pub Health

Vital records data linked with Medicaid files and AFDC-enrolled women in Colorado and Washington State

Use of prenatal care and low birthweight

Bernstein (1999)

Insurance Status and Use of Health Services by Pregnant Women

Data from Community Tracking Study Household Survey, 1996–1997 (n = 60,000 individuals)

Access to and use of pregnancy or birth services and subsequent maternal and pediatric outcomes

Braveman et al., (1989)

Adverse Outcomes of Health Insurance Among Newborns in an Eight-County Area of California, 1982 to 1986. N Engl J Med

Hospital discharge data on births to residents of an eight-county region of California from the Office of Statewide Health Planning and Development for the last half of 1982, all of 1984, and 1986

Adverse outcomes among newborns; transfer to another acute care hospital or to a long-term care facility; death

Braveman et al. (1991)

Differences in Hospital Resource Allocation Among Sick Newborns According to Insurance Coverage. JAMA

In California civilian acute care hospitals, a population-based sample, including all newborns discharged in 1987 with evidence of serious problems (n = 29,751)

Length of stay, total charges, and charges per day

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Overall rates for cesarean deliveries were similar among whites and nonwhites (15.8% and 16.1%, respectively). The rates based on insurance status varied according to insurance, with 17.0% for those with commercial insurance, 14.2% for those with government insurance, and 10.7% for those without insurance. After adjusting for clinical factors the adjusted OR for nonwhites was higher (adj. OR = 1.34; 95% CI = 1.14–1.57; p <.001), similar for those on government insurance (adj. OR = 1.01; 95% CI = 0.90–1.14; p = 0.84) and lower for uninsured patients (adj. OR = 0.65; 95% CI = 0.41-1.03; p = 0.067) although not statistically significant. After stratification for predicted risk of cesarean delivery, racial differences were limited to patients who had lower risks. Differences in the odds ratios were seen in all risk categories (odds ratios were not statistically significant).

There was a clinically significant reduction in the overall low-birthweight rate, from 7.1% in 1989 to 6.4% in 1992 in Washington, which provided enhanced prenatal services. This change was greatest among high-risk women, 90% of whom had diabetes or chronic hypertension. The low-birthweight rate for Colorado’s population (the control group) increased slightly from 10.4 to 10.6%

Among pregnant women, 17% of the uninsured reported fair or poor health status compared to 6.8% of privately insured patients. In addition, 29% of the uninsured pregnant women reported not having a usual source of care compared to 14% of Medicaid-enrolled patients and 9% of privately insured women. This group also made fewer visits to the doctor (7.9% for the uninsured, 10.3% for Medicaid enrolled, 10.1% for the privately insured). Lastly, uninsured women had greater perceived unmet medical needs (18% of uninsured pregnant women reported they did not receive some needed medical care vs. 7.6% of privately insured and 8.1% of Medicaid-enrolled pregnant women).

Between 1982 and 1986 the percentage of newborns without health insurance increased by 45% (from 5.5 to 8.0%; p <.001); the increases were larger among Asians (54%, from 7.8 to 12.0%; p <.001) and Latinos (140%, from 8.2 to 19.7%; p <.001). By 1986 the adj. OR for an adverse hospital outcome (prolonged hospital stay, transfer, or death) was 1.31 (95% CI 1.17–1.46) in uninsured compared with privately insured controlled for race. The comparable adj. ORs in 1982 and 1984 were 1.11 (95% CI = 0.93–1.33) and 1.19 (95% CI = 1.05– 1.35). In 1986 the adj. ORs for uninsured vs. insured among blacks and Latinos were 2.24 (95% CI = 1.60–3-13) and 1.56 (95% CI = 1.26-1.94). The elevated and increasing risk for uninsured newborns may be partly explained by inadequate and diminishing access to care, and this burden was disproportionately borne by blacks and Latinos.

Sick newborns without insurance received fewer inpatient services than comparable privately insured newborns with either indemnity or prepaid coverage. The pattern was observed across all hospital ownership types. Mean stay was 15.7 days for all privately insured newborns (15.6 for those with indemnity and 15.7 for those with prepaid coverage), 14.8 days for Medicaid, and 13.2 for uninsured (p <.001). Length of stay, total charges, and charges per day were 16, 28, and 10% less, respectively for the uninsured than for all privately insured newborns (p <.001). Resources for newborns covered by Medicaid were generally greater than for the uninsured and less than for the privately insured. Both uninsured and Medicaid-covered newborns were found to have more severe medical problems than the privately insured.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Braveman al. (1993)

Access to Prenatal Care Following Major Medicaid Eligibility Expansion. JAMA

Single live births to California residents occurring in state in 1990 (n = 593,510)

Untimely initiation of care, too few visits, and no prenatal care

Braveman et al. (2000)

Barriers to Timely Prenatal Care Among Women with Insurance: The Importance of Prepregnancy Factors. Obstet Gynecol

Postpartum survey conducted in California during 1994–1995, focusing on 3,071 low-income women with Medi-Cal or private coverage throughout pregnancy

Timely prenatal care

Bronstein et al. (1995)

Access to Neonatal Intensive Care for Low-Birthweight Infants: The Role of Maternal Characteristics. Am J Pub Health

Alabama vital statistics records between 1988 and 1990 for infants weighing 500–1,499 g

Transfer to hospitals with neonatal ICUs

Cole (1995)

Increasing Access to Health Care: The Effects of Medicaid Expansions for Pregnant Women

Census data, state-level aggregate birth certificates for all states (1983–1990)

Prenatal care use and low birthweight and/or prematurity

Coulam et al. (1995)

Final Report of the Evaluation of the Medicare Catastrophic Coverage Act: Impacts on Material and Child Health Programs and Beneficiaries

Birth certificates linked to Medicaid enrollment files for Missouri

Pregnant women eligible for Medicaid or deliveries covered by Medicaid; prenatal care use; low birthweight or prematurity; infant mortality

Currie and Gruber (1996a)

Saving Babies: The Efficacy and Cost of Recent Changes in the Medicaid Eligibility of Pregnant Women. J Political Econ

CPS state-level aggregate birth and death statistics, United States

Pregnant women eligible for Medicaid, deliveries covered by Medicaid, and infant mortality

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Despite Medicaid expansion, nearly 11% of live births were uninsured for prenatal care. Compared to women with private FFS coverage, uninsured women had a higher risk of untimely initiation (adj. OR = 2.54; 95% CI = 2.47–2.60) and too few visits (adj. OR = 2.49; 95% CI = 2.44–2.55). Those on Medi-Cal also had a high risk of untimely care (adj. OR = 3.33; 95% CI = 3.26–3.40) and too few visits to the doctor (adj. OR = 1.63; 95% CI = 1.60–1.66). Lack of private insurance was also a strong risk factor for no care (adj. OR = 6.70; 95% CI = 6.0–7.47).

Factors associated with untimely initiation of prenatal care among low-income women with continuous prenatal coverage included the following: unwanted or unplanned pregnancy (affecting 43 and 66% of women, respectively), no regular provider before pregnancy (affecting 22% of women), and no schooling beyond high school (affecting 76% of women). Assistance with transportation could contribute to more timely care for some low-income women, but programs focusing primarily on other noninsurance barriers during pregnancy might not substantially improve the timeliness of care, at least among low-income women with third-party coverage.

Non-white mothers with early prenatal care were more likely than white mothers to deliver low-birthweight infants in hospitals with neonatal ICUs without transfers (after adjusting for other factors). In hospitals without such facilities, those with late prenatal care were less likely to be transferred to hospitals with neonatal ICUs before delivery. Medicaid coverage increased the likelihood of antenatal transfer for white women.

An increase in the Medicaid-eligible population was associated with a reduced percentage with late prenatal care; results were more pronounced for white women (those with late prenatal care declined from 22.3% to 21.8%). An increase in the Medicaid-eligible population was associated with reduced rates of low birthweight and prematurity for white women and black teenagers; changes were slight (from 5.5% premature to 5.4% premature) among white women, after controlling for other characteristics.

Medicaid enrollment grew in the AFDC and expansion groups; Medicaid covered 13% of all live births in 1987 and 23% in 1989. Expansion group teenagers had lower rates of inadequate care (27.4%) than non-Medicaid low-income teenagers (32.0%). Significant results were not found for low birthweight, prematurity, or infant mortality.

There was a dramatic increase in the eligibility of pregnant women for Medicaid, but there were different rates of increase across states. The percentage of pregnant women eligible for Medicaid rose from 12% in 1979 to 43% in 1991. A 30% rise in the percentage of pregnant women eligible for Medicaid was associated with an 8.5% decline in state-level infant mortality. In addition, it was found that targeted changes in Medicaid eligibility, restricted to low-income groups, had much greater effects on birth outcomes than broader expansions of eligibility to women of higher income levels.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Currie and Gruber (2001)

Public Health Insurance and Medical Treatment: The Equalizing Impact of the Medicaid Expansions. J Pub Econ

U.S. birth certificate data 1987–1992

Use of four obstetrical procedures: cesarean delivery, fetal monitor, induced labor, and ultrasound

Currie and Grogger (2002)

Medicaid Expansions and Welfare Contractions: Off-setting Effects on Prenatal Care and Infant Health. J Health Econ

U.S. birth certificate data 1990–1996

Use and timeliness of prenatal care; low and very low birthweight

Dubay et al. (2001)

Changes in Prenatal Care Timing and Low Birth Weight by Race and Socioeconomic Status: Implications for the Medicaid Expansion for Pregnant Women. Health Serv Res

Data on 8.1 million births from the National Natality Files, 1980, 1986, and 1993. Births in all areas of the United States except CA, TX, WA, and upstate NY

The rate of late initiation of prenatal care and the rate of low birthweight

Durbin et al. (1997)

The Effect of Insurance Status on Likelihood of Neonatal Interhospital Transfer. Pediatrics

Southeastern Pennsylvania, five-county general acute care nonpediatric hospitals, 56,789 infants (0–28 days of age) admitted or born in a study hospital between Jan. and Dec. 1991

Transfer to another general or specialty acute hospital

Ellwood and Kenney (1995)

Medicaid and Pregnant Women: Who Is Being Enrolled and When. Health Care Financ Rev

Medicaid enrollment and claims files for CA, GA, MI, and TN

Women covered by Medicaid and/or deliveries covered by Medicaid

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Among younger and less educated women, Medicaid eligibility expansions were associated with increased use of each of the procedures. Among college-educated women for whom higher Medicaid eligibility may have resulted in higher rates of Medicaid coverage relative to private health insurance, higher Medicaid eligibility levels were associated with decreased use of these procedures.

Increases in Medicaid eligibility had statistically significant effects on use of prenatal care: reducing the probability of inadequate care for both white and black women; increasing the proportion of each group getting care in the first trimester; and reducing late initiation of care by both groups of women. Increases in Medicaid eligibility slightly reduced the probability of very low birthweight babies to white mothers. No comparable effect was found for black women.

From 1986 to 1993, rates of late initiation of prenatal care decreased by 6.0 to 7.8 percentage points beyond the estimated changes for the 1980–1986 period for white and African-American women of low socioeconomic status. The rate of low birthweight was reduced by 0.26 to 0.37 percentage point between 1986 and 1993 for white women of low socioeconomic status. Other white women and all African-American women of low socioeconomic status showed no relative improvement in the rate of low birthweight during 1986–1993. For white women with less than 12 years of schooling, improvements were found in the rate of low birthweight; the same was not found in other groups.

Uninsured infants were almost twice as likely to be transferred as privately insured infants even with adjustments for prematurity, severity of illness, and level of the neonatal intensive care unit in the referring hospital (adj. RR = 1.96; 95% CI = 1.67–2.31). Infants with Medicaid were more likely to be transferred than similar privately insured neonates (adj. RR = 1.20; 95% CI = 1.01–1.43). Uninsured and publicly insured infants were more likely to be born prematurely (adj. RR = 1.49; 95% CI = 1.39–1.60) and to have both moderate (adj. RR = 1.11; 95% CI = 1.04–1.23) and high (adj. RR = 1.21; 95% CI= 1.11–1.32) illness severity compared to privately insured infants. Neonates with no insurance or those on Medicaid were more likely to be transferred than those with private insurance.

Medicaid eligibility expansions and improved enrollment procedures for pregnant women during the late 1980s were examined, and it was found that more women enrolled in Medicaid and they enrolled earlier in pregnancy. The percentage of deliveries covered by Medicaid grew from 48 to 116% (depending on the state). However, there are still substantial numbers of women who are enrolling too late, and therefore the expansion may not promote significantly earlier use of prenatal care (39 to 54% joined Medicaid after the first trimester of pregnancy).

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Foster et al. (1992)

The Impact of Prenatal Care on Fetal and Neonatal Death Rates for Uninsured Patients: A “Natural Experiment” in West Virginia. Obstet Gynecol

4,534 patients delivered in one Level 2 hospital between Jan. 1984 and Dec. 1986 in three counties of West Virginia

Fetal death ratio

Glied and Gnanasekaran (1996)

Hospital Financing and Neonatal Intensive Care. Health Serv Res

1991 data from Greater New York Hospital Association and New York State Department of Health (45 hospitals, n = 139,076 births)

Number of neonatal intensive care beds in a hospital

Haas et al. (1993b)

The Effect of Providing Health Coverage to Poor Uninsured Pregnant Women in Massachusetts. JAMA

Massachusetts in-hospital, single-gestation live births in 1984 (n = 57,257) and 1987 (n = 64,346)

Satisfaction rates, care initiated before the third trimester, and adverse infant outcomes

Haas et al. (1993)

The Effect of Health Coverage for Uninsured Pregnant Women on Maternal Health and the Use of Cesarean Section. JAMA

All in-hospital, single-gestation births in 1984 (n = 57,257) and 1987 (n = 64,346)

Rates of adverse maternal outcome and cesarean section for uninsured women and for two concurrent control groups: women with Medicaid and women with private insurance

Homan and Korenbrot (1998)

Explaining Variation in Birth Outcomes of Medicaid-Eligible Women with Variation in the Adequacy of Prenatal Support Services. Medi Care

Medical record data on maternal risks and use of prenatal visits for more than 3,485 women receiving care at 27 ambulatory sites in four regions of California

Birth outcomes

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

A program was developed to give prenatal care to a population of uninsured patients. The overall fetal death ratio declined from 11.8 to 7.2 per 1,000 live births (p = .02) during the years of clinic operation. Uninsured patients experienced a reduction in fetal deaths during the program, from 35.4 to 7.0 per 1,000 live births (p = .02), whereas those covered by medical assistance did not experience a reduction. Privately insured patients also had a significant decrease, from 10.0 to 3.1 per 1,000 live births (p < .001). After suspension of the program the death ratio returned to 10.3 deaths per 1,000 live births in 1987. Over the same time period and for the same population, overall neonatal deaths declined.

After adjusting for low birthweight and other measures of patient need and for hospital affiliation, the study found that hospitals with more privately insured patients—especially those with more privately insured, low-birthweight newborns—have statistically significantly more neonatal intensive care beds than those with fewer such patients. These findings remain within hospital affiliation categories as well.

Between 1984 and 1987, the satisfaction rate for prenatal care declined from 96.4% to 93.8% for all women in the state. There was no statewide change in overall incidence of adverse birth outcomes. In 1984, uninsured women were less likely to receive satisfactory prenatal care and to initiate care before the third trimester. They were also more likely to suffer an adverse outcome. There was no statistically significant change between 1984 and 1987.

In 1984, uninsured women had higher rates of adverse maternal health outcome than privately insured women (5.5% and 5.1%, respectively) and received fewer cesarean sections (17.2% and 23.0%, respectively). Between 1984 and 1987, there was no statistically significant change in the interpayer difference in adverse outcome relative to women with private insurance. Theinterpayer difference in cesarean sections between the uninsured and the privately insured was reduced by 2.3% (95% CI = 0.4%–4.2%), although the uninsured continued to undergo fewer cesarean section (22.4% vs. 25.9%); similar results were observed when the uninsured women were compared to women with Medicaid. The provision of health insurance alone to low-income pregnant women may not be associated with . improvement in maternal health An expansion of coverage was associated with an increase in the rate of cesarean sections.

Providing at least one nutrition, psychosocial, and health education service session each trimester of care contributes significantly to explaining better birth outcomes when compared with providing fewer sessions. However, even with these services, outcomes differ among sites and types of settings. Although repeated support service sessions during prenatal care improve the chances of avoiding poor birth outcomes in low-income women, variations in outcomes at different sites and practice settings remain to be explained by other factors.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Howell (2001)

The Impact of Medicaid Expansions for Pregnant Women: A Synthesis of the Evidence. Med Care Res Rev

Review of published literature and data from the NCHS for 1985–1991 (n = 3.8 million births in 1985 and 4.1 million in 1991)

Prenatal care and birth outcomes

Keeler and Brodie (1993)

Economic Incentives in the Choice Between Vaginal Delivery and Cesarean Section. Milbank Q

Literature review (225 journal articles, 3 dissertations, and 9 books between 1970 and 1992)

Obstetric decisions

Kenney and Dubay (1995)

A National Study of the Impacts of Medicaid Expansions for Pregnant Women

County-level aggregate birth certificates for all states (1986–1990)

Prenatal care use

Long and Marquis (1998)

Effects of Florida’s Medicaid Eligibility Expansion for Pregnant Women. Am J Pub Health

Birth and death certificates, linked to hospital discharge abstracts, Medicaid enrollment and claims files, and county health department records from July 1988 to June 1989 (to 100% of poverty), (n = 56,101) and in calendar year 1991 (to 150% of poverty), (n = 78,421)

Use (amount and timing) of prenatal care, low-birthweight rates, and infant death rates

Oberg et al. (1991)

Prenatal Care Use and Health Insurance Status. J Health Care Poor Underserved

149 women at six hospitals in Minneapolis, MN

Source, use, and quality of prenatal care

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

14 studies were used to look at the impact of Medicaid expansion. There was evidence that new groups of pregnant women were receiving coverage and that some women received improved prenatal care services. The improvements in prenatal care vary among states, and patterns were found in national studies showing a greater impact in the South and Midwest. The evidence stating that the expansion led to an improvement in birth outcomes is much weaker. When looking at the data from the NCHS, the results were similar to previous studies. However, an alternative explanation was offered for the decrease that did occur in infant mortality after the expansion. About half of the decline in infant mortality for unmarried women (those with the highest rates of very low birthweight) is due to declines in very low birthweight infant mortality from 1985 to 1991. Medicaid expansion did not result in a reduction in the rate of low birthweight; however, other factors were affected. Due to the expansion and additional resources, hospitals may have been able to expand or improve their neonatal ICUs, providing better care for these infants.

There has been a dramatic increase in cesarean section rates; the cost is high, and there is wide variation in its use. The economic incentives for physicians, hospitals, payers, and mothers all come into play. Providers who encounter higher opportunity costs while attending to mothers in prolonged labor can reduce these costs by operating or restricting their practices. When physician and hospital charges for C-sections ($7,186) and for vaginal births ($4,334) were compared, the C-section cost was 66% more. Private insurance pays more, and there are higher rates of C-sections in populations with private coverage. Not only are physicians, hospitals, and payers influenced by financial incentives, so are the mothers. The mainly indirect evidence on financial incentives shows that insured mothers have low marginal cost sharing when they undergo C-sections. Mothers who have private FFS insurance have higher rates of C-sections than mothers who are covered by staff-model HMOs, are uninsured, or are on public insurance.

Medicaid expansions were associated with a reduced percentage (from 20.8% to 19.2%) of white women receiving late or no prenatal care in the South and Midwest.

The number of deliveries covered by Medicaid increased by 47% after expansion. Access to prenatal care for the target population (low-income women without private insurance) improved: prior to the expansion, 2.3% had no prenatal care, and after the expansion, 1.6% had no prenatal care. Among those receiving care, fewer delayed care after the expansion (4.8% vs. 6.8%), and they had more prenatal visits (11.1 vs. 10.5). The rate of low birthweights declined after the expansion (61.8 vs. 67.9 per 1,000). The number of infant deaths also declined from 7.3 per 1,000 to 5.9 per 1,000.

In this study, insurance status was significantly related to the source of prenatal care (p <.0001). Private physicians cared for 52% of privately insured, 23% of those insured by Medicaid, and 2% of uninsured women. Medicaid and uninsured women, when compared to privately insured women, used public clinics as their primary source of care, experienced longer waiting times, and were more likely to lack continuity of care with a provider.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Phibbs et al. (1993)

Choice of Hospital for Delivery: A Comparison of High-Risk and Low-Risk Women. Health Serv Res

Data from 1985 California Office of Statewide Health Planning and Development discharge abstracts and hospital financial data

Delivery where there was a newborn intensive care unit

Piper et al. (1990)

Effects of Medicaid Eligibility Expansion on Prenatal Care and Pregnancy Outcome in Tennessee. JAMA

Linked birth, death certificate, and Medicaid enrollment files

Pregnant women eligible for Medicaid or deliveries covered by Medicaid

Ray et al. (1997)

Effect of Medicaid Expansion on Pre-term Births. Am J Prev Med

610,056 singleton births to African-American or Caucasian women

Pregnant women eligible for Medicaid or deliveries covered by Medicaid and prenatal care use

Salganicoff and Wyn (1999)

Access to Care for Low-Income Women: The Impact of Medicaid. J Health Care Poor Underserved

Telephone interview survey of a representative cross-sectional sample of 5,200 low-income women in MN, OR, TN, FL, and TX

Health insurance coverage, health status, access to care, use of care, and satisfaction

Singh et al. (1994)

Impact of the Medicaid Eligibility Expansions on Coverage of Deliveries. Fam Plan Perspect

Alan Gutmacher Institute Survey of States (national study comparison of states [50 states and District of Columbia, 5 states did not respond ]), 1991

Women covered by Medicaid and/or deliveries covered by Medicaid

Stafford (1990)

Cesarean Section Use and Sources of Payment: An Analysis of California Hospital Discharge Abstracts. Am J Pub Health

California data on hospital deliveries (461,066 deliveries) in 1986

Cesarean section

Stafford et al. (1993)

Trends in Cesarean Section Use in California, 1983–1990. Am J Obstet Gynecol

Data from CA discharge abstracts on hospital deliveries in 1983–1990 (379,759–587,508 annual deliveries)

Cesarean section

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Results show that high-risk and low-risk women do not have the same choice process. Hospital quality was more important for high-risk women. Results also show that factors influencing choice of hospital are different for those who are privately insured and those who are on Medicaid. High-risk women who were covered by Medicaid were less likely to deliver in a hospital with a newborn intensive care unit than high-risk women who were privately insured.

An expansion to all married women meeting income requirements increased the percentage of births covered by Medicaid from 22 to 29%. The year before Medicaid was compared to the year after; there were no improvements in the use of prenatal care in the first trimester, no changes in the rates of very low and moderately low birthweight and neonatal mortality. There were no improvements in these outcomes for the groups where coverage change was the greatest.

The percentage of deliveries covered by Medicaid increased from 21 to 51%; however Medicaid coverage increased only from 10 to 37% in the first trimester. The rate of inadequate prenatal care went down for all low-income groups and low-education groups (18.5% to 13.7% for unmarried women). Medicaid expansion increased enrollment and use of prenatal care in high-risk women; however it did not decrease the likelihood of preterm birth.

Low-income women were found to experience considerable barriers to care. Uninsured low-income women have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts. Women on Medicaid had access to care that was comparable to their low-income privately insured counterparts but, in general, had significantly lower satisfaction with their providers and their plans.

The number of deliveries covered by Medicaid rose from 0.5 million (14.5% of deliveries) in 1985 to 1.2 million (32.0% of deliveries) in 1991. The rise in Medicaid-covered births was due in part to greater coverage among women who previously had received uncompensated care, but about half of the increase was from new coverage of women who in the mid-1980s were covered by private insurance.

Cesarean sections were performed for 24.4% of deliveries; women with private insurance had the highest rates of cesarean section (29.1%). Lower rates were seen for women covered by non-Kaiser HMOs (26.8%), Medi-Cal (22.9%), Kaiser (19.7%), self-pay (19.3%), and indigent services (15.6%). Vaginal birth after cesarean occurred more often in women covered by Kaiser (19.9%) and indigent services (24.8%) compared to those with private coverage (8.1%). There was a sizable, although less pronounced, association between payment source and cesarean sections for breech presentation, dystocia, and fetal distress. Accounting for maternal age and race or ethnicity did not alter the findings.

California C-section rates increased from 21.8% in 1983 to 25% in 1987 and then decreased to 22.7% in 1990. Patterns were similar for all ages, races, and/or ethnicities. Differences in C-section use among patients with different insurance status increased from 1983 to 1990. Privately insured women consistently had higher rates of C-sections.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

 

Sample Size/ Data Source

Outcome Measures

Weis (1992)

Uninsured Maternity Clients: A Concern for Quality. Appl Nursing Res

Chart review of inpatient maternity client medical records; 500 cases: half uninsured and half insured (public and private)

Length of stay, maternal complications

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×

Findings

Compared with the privately insured, the uninsured had more life-style risks. Uninsured women had a shorter hospital stay with more maternal complications. Insurance coverage and prenatal care were positive predictors of birthweight, while life-style risk factors detracted. Length of stay was not influenced by insurance coverage but rather by health problems before delivery.

Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
×
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Suggested Citation:"Appendix C: Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants." Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: The National Academies Press. doi: 10.17226/10503.
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Next: Appendix D: Data Tables »
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Health Insurance is a Family Matter is the third of a series of six reports on the problems of uninsurance in the United Sates and addresses the impact on the family of not having health insurance. The book demonstrates that having one or more uninsured members in a family can have adverse consequences for everyone in the household and that the financial, physical, and emotional well--being of all members of a family may be adversely affected if any family member lacks coverage. It concludes with the finding that uninsured children have worse access to and use fewer health care services than children with insurance, including important preventive services that can have beneficial long-term effects.

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