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a Division of Community Health, Department of Family Medicine, University of Southern California Keck School of Medicine, Alhambra, California
b RAND Corporation, Santa Monica, California
c Center for Healthier Children, Families, and Communities, UCLA Schools of Medicine, Public Health, and Public Policy, Los Angeles, California
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONADDENDUMREFERENCES |
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METHODS. Using data on 19485 children from the 2001 California Health Interview Survey, this study examined differences in primary care access and health status for UBE children versus those who were enrolled in public coverage. Results are stratified by profiles of other risk factors (RF) for poor access: nonwhite, low income, low parent education, and non–English speaking.
RESULTS. UBE children were less likely than publicly enrolled children to have a physician visit in the past year, dental visit in the past year, and a regular source of care. On the basis of differences between the UBE children and enrollees in the prevalence of each dependent measure, UBE children with multiple RFs experienced greater disparities than UBE children with fewer RFs. For example, enrollees were more likely than UBE children to have a regular source of care among children with 2, 3, or 4 RFs (differences of 26, 26, and 25 percentage points, respectively) compared with 1 RF (19 percentage points) and 0 RFs (12 percentage points). A similar pattern was found for dental visits but not physician visits. Although there was no difference in health status between UBE children and enrollees overall, enrollees were more likely than UBE children to have excellent/very good health status among children with 2 RFs (difference of 9 percentage points), 3 RFs (12 percentage points), and 4 RFs (11 percentage points).
CONCLUSIONS. This study demonstrates that UBE children in California have poorer access to care compared with enrollees, and those with the highest levels of risk have poorer health status. This suggests that providing insurance to these children (and particularly those with multiple RFs) may lead to improved access and health for these vulnerable children.
Key Words: children • uninsured • Medicaid • State Children’s Health Insurance Program • primary care • access to care
Abbreviations: SES—socioeconomic status • RF—risk factor • CHI—children’s health initiative • UBE—uninsured but eligible • CHIS—California Health Interview Survey • FPL—federal poverty level • PR—prevalence ratio • CI—confidence interval
Primary care is a cornerstone of the US child health system.1 The receipt of high-quality primary care has been associated with improved health status, lower morbidity and mortality in adults, and reduced illness complications in children.2–9 As a health care delivery strategy, primary care has been also associated with lower health care costs, which has been attributed, in part, to reductions in hospitalizations and emergency department use as a result of improved ability to address and manage problems in primary care.10–15 Evidence of the benefits of a strong primary care system has been so consistent that primary care has become a major focus of national efforts to reduce child health disparities.16
Despite its value, many children do not receive adequate primary care. Children in lower socioeconomic status (SES) families, racial/ethnic minorities, recent immigrants and the undocumented, and children in underserved areas (eg, rural areas) report poorer access to primary care.17–24 Unfortunately, these children are also more likely to be in poor health, which suggests that children who are most in need of health care are least able to obtain it.25–34 The greatest risk factor (RF) for inadequate primary care access, however, is lack of health insurance coverage. Uninsured children are much more likely to lack a regular source of health care, have fewer physician and dental visits, and receive less preventive care.35–41
In California, extensive new efforts are being made to cover the estimated 900000 uninsured children who are aged 0 to 19 in the state (or 8.5% of children in 2003). Since 2001, public program expansions have helped to reduce the number of uninsured children by 11700042 and have fueled the momentum of additional state and local efforts. An increasing number of California counties and regions, for example, have designed local child health insurance programs, called children’s health initiatives (CHIs), to cover those who are ineligible for other public programs. A statewide plan that unites these local CHIs into a single state program has just been introduced into the legislature.
Although these initiatives and legislative proposals face many obstacles, covering all of the state’s uninsured children may be closer than expected. An estimated two thirds of the uninsured are eligible for but not enrolled in Medi-Cal or Healthy Families (California Medicaid and State Children’s Health Insurance Programs).42 Of the remaining one third of children who are ineligible for these programs as a result of family income or noncitizenship, many may be eligible for existing county CHIs that have broader eligibility criteria.
With recent attention on uninsured but eligible (UBE) children, understanding their health status and primary care access and estimating the potential benefit of enrollment are timely and important for researchers, policy makers, and clinicians, yet enrollment would not likely affect all UBE children equally. UBE children vary with regard to the presence of other RFs for poor primary care (eg, living in a low-income family, not speaking English). These other RFs may attenuate or accentuate the effect of coverage on UBE children’s health status and primary care access. The experiences of UBE children with multiple RFs therefore are a research priority.
A method for examining the influence of multiple RFs on health and health care outcomes was developed by Shi and Stevens.43 Using the same data set as in this study, Stevens et al (under review) examined both the individual and the combined influences of RFs on primary care access for vulnerable children using this method.44 This approach takes into account that RFs rarely exist in isolation, examines RF combinations, and summarizes them in risk profiles. Other studies by Sameroff and Furstenberg have shown that poor child health is defined, in part, by the multiplicity of RFs that a child has.45,46 Our study builds on these previous studies and foundational work by examining the impact of insurance coverage for children of varying risk profiles.
The purpose of this study is to examine the health status and primary care access of UBE children. Data from the state representative 2001 California Health Interview Survey (CHIS) are analyzed first to identify the prevalence and correlates of UBE children for Medi-Cal, Healthy Families, and CHIs. Second, to understand how differences in health status and primary care access vary between UBE children and enrollees at various levels of vulnerability, we examined the outcomes by risk profiles on the basis of race/ethnicity, family income, education, and language.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONADDENDUMREFERENCES |
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55000 randomly selected households drawn from every county. For each household, 1 adult was randomly selected for interview. In households with children, 1 adolescent who was aged 12 to 17 years was interviewed, and information was obtained for 1 child who was younger than 12 years by interviewing the most knowledgeable adult. Telephone interviews were conducted between November 2000 and October 2001 in English, Spanish, Chinese (Mandarin and Cantonese), Vietnamese, Korean, and Khmer (Cambodian). Response rates are reported for adults (37.7%), children (33.0%), and adolescents (23.9%) and are based on the product of the screener completion rate (59.2%), adult interview completion rate (63.7%), and child/adolescent interview completion rates (87.6% and 63.5%). More information on CHIS is available online (www.chis.ucla.edu).
Public Health Insurance Program Eligibility in California
Eligibility for public health insurance programs in California is a patchwork of age and family poverty status criteria. Figure 1 shows the eligibility criteria for the 3 main public programs: Medi-Cal, Healthy Families, and CHIs. Although a range of criteria may qualify a child for Medi-Cal (including disabilities, foster care, etc), most children qualify on the basis of poverty status, calculated from countable family income and size. Eligibility for the Healthy Families program is less complex, with eligibility extending up to 250% of the federal poverty level (FPL) for children who are not eligible for Medi-Cal.
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Measures
Child Health Insurance Coverage and Eligibility
The main study independent variables are child health insurance coverage and, if uninsured, eligibility for public health insurance. Health insurance coverage was coded as private coverage, Medi-Cal, Healthy Families, other, or uninsured. Most CHIs had not yet enrolled children by 2001, so CHI enrollment was not assessed in CHIS. Eligibility for the programs was determined from child age, family income as a percentage of FPL (derived from countable family income and family size), and citizenship.
There are 2 caveats in the eligibility estimates that we use. First, whereas other criteria qualify children for Medi-Cal, this analysis focuses only on full-scope Medi-Cal eligibility through age and poverty status as provided in CHIS data sets. Because of this approach, there may be minor differences in eligibility estimates in CHIS compared with the actual eligibility complexities of the Medi-Cal program. Second, with the rapid growth of CHIs to 20 other counties and proposed creation of a statewide CHI program to cover children through age 19 or higher, this analysis assumes a "best-case scenario" that eligibility for CHIs through age 19 will soon be available in most California counties.
Primary Care Access and Health Status
The study dependent variables are 3 measures of access to primary care services and a single measure of child health status. Reported physician and dental visits in the past year are dichotomized (any visit versus none). Access is also measured by having a regular source of care, defined as a "health care source usually visited if sick or if advice is needed about the child’s health." Emergency departments were not considered a regular source. Health status is reported by the "most knowledgeable adult" for children aged 0 to 11 and self-reported by those aged 12 to 19. It is assessed with a standard 5-category Likert-type response scale dichotomized for this analysis as "excellent/very good" versus "good, fair, or poor." This was done to reflect children in the top 2 tiers of health status versus others.
Child Vulnerability RFs and Profiles
In some analyses, results are stratified by 4 key RFs for poor access to primary care, summarized as risk profiles to capture the experiences of children with multiple RFs. RFs include nonwhite or Hispanic child race/ethnicity, family income <200% of the FPL, parent education less than high school, and non-English language spoken at home. Selection of the RFs was informed by a heuristic model of demographic, SES, and health system correlates of inadequate pediatric primary care.48 The individual risks are combined into a risk profile that counts the number of RFs. For example, a child with family income <200% of the FPL and has a parent who did not graduate from high school would have a risk profile of 2 risks.
The individual RFs that were included in the risk profile were measured as follows. Child race/ethnicity was self-reported and coded as white (non-Hispanic), black (non-Hispanic), Asian/Pacific Islander (non-Hispanic), Latino, or other. Family poverty status was determined from countable family income and family size and coded as <100% of the FPL, 100% to 199% of the FPL, 200% to 299% of the FPL, and 300%+ of the FPL. Education of the adult respondent was coded as less than high school, high school graduate, some college, or college graduate or higher. Language was dichotomized as English versus non-English on the basis of whether English is a language spoken at home. Study covariates include child age (0–11 and 12–19 years), gender, and single-parent household.
Analysis
Analyses were performed using survey procedures in Stata 8.0 to account for the complex sample design of the 2001 CHIS and to produce estimates that are representative of children who are aged 0 to 19 in California. Because odds ratios tend to overestimate the relative risk for an outcome when the outcome is common in a population (as are most dependent measures in this study), prevalence ratios (PRs), a form of relative risks for cross-sectional studies, with 95% confidence intervals (CIs) are presented for all logistic regressions.49
First, the prevalence of child insurance coverage and, for the uninsured, eligibility for public health insurance coverage is presented for children in California. Distribution of insurance coverage and eligibility for coverage across the 4 RFs for poor primary care is examined. The statistical significance of insurance coverage rates and eligibility for coverage is assessed across these RFs using Pearson 
2 to account for the multiple comparisons. Population counts (N) are presented.
Second, multiple logistic regression is used to examine differences in primary care access and health status between UBE children and enrolled children. Children who were UBE for Medi-Cal are compared with Medi-Cal enrollees, and children who were UBE for Healthy Families are compared with Healthy Families enrollees. CHIs’ UBE children are compared with enrollees in Medi-Cal or Healthy Families because CHI benefits are frequently based on these programs.
Third, 4 graphs present the prevalence of the primary care and health status outcomes for UBE children versus enrollees. These prevalence estimates are stratified by risk profile to examine whether the benefits of enrolling UBE children differ according to risk profile. Pearson 2 is used to assess the statistical significance of differences in prevalence of the outcome measures between UBE children and enrollees within a given risk profile.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONADDENDUMREFERENCES |
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5.0% are covered by Healthy Families. Among uninsured children, nearly 90% are eligible for some form of public insurance program: 32.8% are eligible for Medi-Cal, 27.2% are eligible for Healthy Families, and 29.5% are eligible for CHIs. Nonwhite children (with the exception of Asian/Pacific Islanders) are more likely than white children to be UBE, as are those with lower education levels and those who do not speak English at home.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONADDENDUMREFERENCES |
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This finding expands on the widely known "inverse care law," whereby children with the greatest health care needs also have the poorest access to medical care, by showing that lack of insurance coverage may have an impact on primary care access and health status more for those who are most vulnerable.50 With the exception of physician visits that show an opposite trend, the findings suggest that families with fewer RFs may be overcoming lack of health insurance in gaining access to care (perhaps by using public clinics or paying out of pocket for care), whereas those with more RFs may be less able to negotiate ways to obtain care without coverage. That the smallest difference in physician visits between UBE children and enrollees occurs for those with 4 RFs may indicate that regardless of insurance, the sickest children are gaining access to at least some services.
One of the most striking findings is that having public health insurance coverage seems to ensure that children have a regular source of health care regardless of other RFs. Ninety-percent or more of children with each risk profile reported having a regular source of care in 2001, whereas the proportion of UBE children with a regular source of health care decreased as risk profiles increased. This nearly wholly protective effect was not apparent for the other measures of primary care access or health status, suggesting that coverage may help to ensure that families can confidently identify a regular source from which they could seek care, even if children with more RFs experience greater barriers in ultimately accessing care.
Success in enrolling UBE children depends, to a great extent, on effectiveness of outreach and enrollment strategies. Families report several reasons for not enrolling children in public programs, including not knowing about the program, complex eligibility criteria, and onerous application forms and processes. In California, several initiatives are being piloted to improve enrollment of UBE children. These include Express Lane Eligibility that links school lunch applications with screening for Medi-Cal eligibility and One-E-App, a Web-based system to enroll families in multiple public programs via a single application.
Enrolling eligible children in public coverage, however, is not without substantial additional costs to the state and counties. These costs are incurred from health premiums, expanded outreach and enrollment activities, and increased health care utilization. Although the costs for covering children are small relative to adults, they may be a difficult hurdle to overcome given pending budget cuts to the Medi-Cal program as a result of major ongoing state and national budget deficits. Over the long term, however, some costs may be offset by a lesser reliance on emergency departments and better identification and/or management of child health problems in primary care. Estimates of these short- and long-term costs are an important policy issue but could not be assessed using the CHIS.
Despite these potential financial barriers, counties and local regions in California are making consistent progress in covering uninsured children. The Los Angeles CHI, for example, has enrolled >40000 children in just 2 years, nearly 10000 more children than initially projected.51 The growth of these CHIs is increasing, and by late 2006, more than half of counties in the state are expected to have operational CHIs. There are several limitations to the successes of CHIs. Many face sustainability issues, some CHIs have had to cap enrollments because of large demand and limited finances, and others are addressing portability limitations for migrant populations across counties.47 Although CHIs are only just beginning to encounter these issues, preliminary data suggest that CHIs can be successful and improve access to care.52 Although this study could not assess this directly, the results suggest that enrolling UBE children in the health insurance programs for which they are eligible (including Medi-Cal, Healthy Families, and CHIs) may lead to substantial increases in primary care access and potentially health status for children with multiple RFs. Because these vulnerable children are more likely to be in poorer health and to have difficulty gaining access primary care,44 efforts to cover them may lead to greater gains in health status, as these sicker children now potentially may obtain needed health services. Although this finding should be interpreted cautiously, previous research has linked health insurance to gains in child health status.53,54
Making 2 assumptions, it is possible to speculate how many children in California might experience improved primary care access and potentially better health status if enrolled in the coverage for which they are eligible. If we assume that the estimates for the number of UBE children in the state are accurate and that UBE children are otherwise similar to enrollees after accounting for risk profiles (see below for limitations of this assumption), then it is possible to multiply the difference (
) in prevalence of the access measures between UBE children and enrollees with the number of UBE children to estimate the approximate gains in access and health status associated with gaining coverage.
If this is done by risk profile, then it is possible to understand how the gains may vary by the level of child vulnerability. Using a regular source of care as an example, for children who have 1 RF, we multiply the number of UBE children who have 1 RF (n = 173632) with the corresponding prevalence difference in a regular source (from Fig 2D) for children who have 1 RF ( = 19%). This results in 32990 UBE children who may gain a regular source if enrolled. The gains in regular source of care are higher for UBE children who have 2 RFs (n = 103122) or 3 RFs (n = 73590) but are slightly lower for UBE children who have 4 RFs (n = 28413). Summing these estimates, enrollment may result in an estimated 238100 children gaining a regular source of care. Repeated for the other measures, enrolling UBE children may result in 164550 children gaining a dental visit and 64660 gaining a physician visit, and although there remains a tenuous link between health insurance and child health, especially over a short period, 82163 may gain excellent/very good health status if enrolled. The complete methods for these speculative calculations are not shown in this article but are available from the authors on request.
There are some important limitations to this study. First, the data are cross-sectional and do not allow for the demonstration of a causal relationship between insurance coverage and improved primary care access and health status. The consistency of previous research that examined Medi-Cal and State Children’s Health Insurance Program coverage and its relationship to primary care, including a few longitudinal analyses, however, lends some validity to the findings of this study.35–41 A relatively low response rate for the 2001 CHIS may also be a limitation, raising concerns about generalizing the results to all children in California.
Second, UBE children are assumed to be similar to enrolled children when inferring gains. There may be something unique, however, about the families of UBE children that is not captured in this study (eg, motivation level) and that may lead them to be less likely to gain access to care, regardless of coverage, than enrollees. It is possible, for example, that parents who have the motivation and both knowledge and skills to obtain insurance are also more likely to seek care for their children, leading to a selection bias in both enrollment and utilization. If this bias indeed is present, then the estimates of improved primary care access may be overestimations of the gains that could be achieved.
Third, both family and health system factors may reduce the gains associated with enrolling UBE children. Although this study assumes that all eligible children would gain coverage, participation rates may remain less than complete. Families with children who have a higher risk profile also have been shown to use health services differently from children with few RFs (eg, relying on emergency departments for care), potentially limiting the gains in primary care access achieved regardless of insurance.39,55 Furthermore, although this analysis controls for health status, there may be unmeasured health differences that confound the relationship between insurance coverage and utilization of care.
On the health system end, even if all children were enrolled and using health services optimally, it is possible that existing provider capacity may not be sufficient to meet the increased demand for primary care.56–58 Although this is a concern, the 238115 UBE children who may gain a regular source of care reflect <3% of all children in the state, suggesting that although local shortages may exist, the current health system likely would be able to handle the relatively small increase in demand.
Fourth, although previous research has demonstrated a linkage between insurance and health, the association of gaining insurance with child health remains tenuous. Although the ability to obtain primary care may lead to better health for some specific health conditions (eg, asthma), most uninsured children are healthy and may not show any gains in health as a result of insurance, especially over the short term. This caveat is supported by the finding of no differences in health status between UBE children and enrollees with lower risk profiles. However, the potential gains in child health status in this study might still be plausible because the estimated gains were found only among the children who had a higher risk profile, who have poorer health status overall and may benefit the most from access to primary care.
Fifth, the primary care access measures in CHIS are limited and do not capture the complete range of pediatric primary care experiences that are essential for high-quality care. The physician visit measure, for example, does not specifically exclude specialists, but 1 national study showed that >85% of all child physician visits are to primary care providers (eg, pediatricians, family practitioners).59 More detailed measures of primary care that assess continuity of care, comprehensiveness of services, family-centered care, and coordination of care are now available but have not yet been incorporated into statewide or national surveys.60,61
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ADDENDUM |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONADDENDUMREFERENCES |
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Address correspondence to Gregory D. Stevens, PhD, MHS, Division of Community Health, University of Southern California, Keck School of Medicine, 1000 South Fremont Ave, Building A7, Room 7411, Alhambra, CA 91803. E-mail: gstevens{at}usc.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
The views in this article are those of the authors and do not necessarily represent the views of the regents of the University of California, the California Program on Access to Care, its advisory board, or any state or county executive agency represented thereon.
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 G. D. Stevens, K. Rice, and M. R. Cousineau Children's Health Initiatives in California: The Experiences of Local Coalitions Pursuing Universal Coverage for Children Am J Public Health, April 1, 2007; 97(4): 738 - 743. [Abstract] [Full Text] [PDF]
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