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ONCE a year most employed families must choose which health insurance benefit plan best meets their health and financial needs. Most often these decisions are made on the basis of […]

A large minority of children in the United States have a special health care need, and these children or disproportionately poor and socially disadvantaged. Because of their poverty, many of them have limited access to health care. Some 18% of children in the United States (12.6 million in 1994) have a chronic physical, behavioral, developmental, or emotional condition which requires special health care. The predominant demographics are African-American, boys, low income, single parent homes., Objective. To present an epidemiologic profile of children with special health care needs using a new definition of the population developed by the federal Maternal and Child Health Bureau. Methods. We operationalized the new definition using the recently released 1994 National Health Interview Survey on Disability. Estimates are based on 30 032 completed interviews for children [is less than] 18 years old. The overall response rate was 87%. Results. Eighteen percent of US children [is less than] 18 years old in 1994, or 12.6 million children nationally, had a chronic physical, developmental, behavioral, or emotional condition and required health and related services of a type or amount beyond that required by children generally. This estimate includes children with existing special health care needs but excludes the at-risk population. Prevalence was higher for older children, boys, African-Americans, and children from low-income and single-parent households. Children with existing special health care needs had three times as many bed days and school absence days as other children. An estimated 11% of children with existing special health care needs were uninsured, 6% were without a usual source of health care, 18% were reported as dissatisfied with one or more aspects of care received at their usual source of care, and 13% had one or more unmet health needs in the past year. Conclusions. A substantial minority of US children were identified as having an existing special health care need using national survey data. Children with existing special health care needs are disproportionately poor and socially disadvantaged. Moreover, many of these children face significant barriers to health care. Pediatrics 1998;102:117-123; children with special health care needs, chronic illness, children, National Health Interview Survey. ABBREVIATIONS. NHIS, National Health Interview Survey; NHIS-D, National Health Interview Survey on Disability., A number of conceptual approaches can be used to classify and characterize children with chronic conditions and ongoing health problems.[1] In particular, three approaches have been commonly used. Condition lists [...]

A new coherent definition for children with special health care needs is needed in order to overcome the hodge-podge of services which have grown up without direction in order to serve needs as they have arisen. Because the current system is an assemblage which grew from older services, there is duplication, missing areas of service, and fragmentation. Re-defining children with special needs should include those with chronic conditions, and to include those at high risk for purposes of planning and anticipation., ABBREVIATIONS. MCH, Maternal and Child Health (program); CSHCN, Children With Special Health Care Needs (program); DSCSHCN, (Maternal and Child Health Bureau's) Division of Services for Children With Special Health Care [...]

Minority children with a chronic physical or mental condition may be less likely to have private health insurance than non-minority children with a chronic condition. Different federal agencies or private foundations may help provide health care insurance to uninsured children. A 1988 research study examined the health insurance status of 17,110 white, Hispanic and black children under 18 years old. Eighty-eight percent of the children with a chronic condition had some type of health insurance. Private medical insurance was the most common type of coverage among chronically ill children who were insured. Hispanic children with a chronic illness were less likely to have health insurance than the white or Black children. An insured Hispanic or black child with a chronic condition was more likely to have Medicaid rather than private health insurance.

The incidence of chronic physical or mental conditions may vary among children from different ethnic and racial groups. Socioeconomic factors may affect the prevalence of certain conditions in different communities. A study examined the incidence of chronic physical or mental conditions among white, Hispanic and black children under 18 years old. An estimated 31% of the children had at least one chronic condition. The incidence of chronic conditions was significantly higher among white children than among Hispanic or black children. Parents of white children may report chronic conditions in their children more often than those of Hispanic or black children. Other factors that may have contributed to this difference include variations in income or access to health care.

Children may only receive a small portion of the Medicaid benefits available. The Medicaid program was expanded in the 1980s to provide more health care benefits to poor and disabled children. A study examined the number of children receiving Medicaid benefits and associated Medicaid expenditures in 1979, 1985 and 1990. Half of the individuals added to the Medicaid program during the 1980s were children and half were adults. Children were responsible for only 14% of the increase in Medicaid expenditures that occurred during this time period. Ninety percent of the children receiving Medicaid benefits in 1979 were also receiving cash assistance, compared with 72% in 1990. Further expansion of the Medicaid program may be less costly than the expansions that occurred during the 1980s. The initial expansions focused on providing more health care services to infants. Infants usually require more medical care than other children., This study of the Medicaid program analyzes changes in child recipients, costs, and service use during the 1980s to assess the effects of recent federal policy shifts and to project future costs for children. Data presented in this study are from the Health Care Financing Administration's Medicaid Statistical Report for the years 1979, 1985, and 1990, three time-points that demarcate major federal policy shifts. About half of all recipients added to the Medicaid program during the last decade were children, they comprised 14% of the total cost growth experienced by the program. In addition, the eligibility distribution of children receiving Medicaid shifted markedly over the last decade. In 1979, children receiving cash assistance comprised 90% of total child recipients; by 1990, this figure dropped to 72%. Future expansions to the Medicaid program are projected to cost less than the initial expansions. This is because the early expansions disproportionately served infants, who require more hospital services than older children. Despite the major changes in Medicaid eligibility for children during the 1980s, only limited cost shifts occurred in expenditures for children. Children continue to consume a small portion of the Medicaid budget. Congress should explore options for guaranteeing that their share of funding for services will be adequate. Moreover, since future expansions will be far less expensive than those already implemented, accelerating the phase-in process for all poor children may be a more financially feasible policy option than many policymakers anticipate, despite the fiscal hardships facing many states. Pediatrics 1993; 91:287-295; Medicaid, expenditures, eligibility.

The health of poor children and pregnant women has improved since the mid 1980s, when they became eligible for Medicaid. However, because the reimbursement levels are low and administrative procedures are complex, the number of physicians willing to participate in the program is decreasing. The Medicaid reimbursement fees for pediatric care in 47 states and the District of Columbia were analyzed in 1989. Reimbursement policies from several states were also assessed. Most of the states used fixed fee schedules to reimburse physicians. Fees had not been updated since 1986 in approximately one-half the states. The reimbursement rates for five commonly used pediatric services varied significantly among the states and different regions within a given state. Reimbursement for office visits was greatest in Western states and the least in Northeastern states. The Medicaid reimbursement rates averaged less than two-thirds of the fees received from private patients. They were also less than four-fifths of Medicare reimbursement. These findings show that the Medicaid rates should be increased to be closer to private fees and Medicare reimbursement, especially in the Northeast, so that more pediatricians will offer care to children eligible for Medicaid. (Consumer Summary produced by Reliance Medical Information, Inc.)

The development from adolescence into adulthood is associated with major changes in the delivery and financing of health care for disabled persons. Young adults must transfer from pediatric health care providers to new adult health care providers, and may no longer be classified as dependents under their families' health insurance plans. There is limited information about the prevalence and severity of disabilities, health care use, and insurance coverage of disabled young adults. The health care needs and access to medical services for disabled young adults were assessed using the 1984 National Health Interview Survey. This study included 10,394 young adults aged 19 to 24 years who were not living in institutions; the group consisted of a nationally representative sample. The survey showed that 1.4 million young adults suffered from disabilities in 1984. Diseases of the bones, muscles, and connective tissues were the most common causes of disability. Poverty, male gender, and an education level of less than high school were associated with an increased risk of disability. Disabled young adults had visited a doctor three times more often and had been hospitalized for six times as many days as non-disabled young adults. In addition, one out of five disabled young adults did not have health insurance in 1984. Medical services for disabled youths are discussed. (Consumer Summary produced by Reliance Medical Information, Inc.)

Objective. To assess the role health insurance plays in influencing access to care and use of services by children with special health care needs. Methods. We analyzed data on 57553 children younger than 18 years old included in the 1994-1995 National Health Interview Survey on Disability. The survey obtained information on special health care needs, insurance status, and access to and use of health services. Bivariate and multivariate analyses were used to assess the association of insurance with several measures of access and utilization, including usual source of care, site of usual care, missed or delayed care, and use of ambulatory physician services. Results. Using the federal Maternal and Child Health Bureau definition of children with special health care needs, we estimate that 18% of US children under 18 years old had an existing special health care need in 1994-1995. An estimated 89% of these children had some form of health insurance coverage, most often private health insurance. Insured children were more likely than uninsured children to have a usual source of care (96.9% vs 79.2%). Among those with a usual source of care, insured children were more likely than uninsured children to have an identified regular clinician (87.6% vs 80.7%). Insured children were less likely to report unmet health needs, including medical care (2.2% vs 10.5%), dental care (6.1% vs 23.9%), prescriptions, and/or eyeglasses (3.1% vs 12.3%), and mental health care (.9% vs 3.4%). Insured children were also more likely to have a physician contact in the past year (89.3% vs 73.6%) and have more physician contacts on an annual basis (8.5 vs 4.1 contacts). Unexpectedly, no differences were found between insured and uninsured children in availability of after hours medical care (evenings and weekends) or satisfaction with care. We also found some modest differences in access between publicly and privately insured children. Privately insured children were more likely to have a usual source of care (97.6% vs 95.3%) and a regular clinician (91.0% vs 81.1%). Privately insured children were also less likely to report dissatisfaction with care at their usual site of care (14.9% vs 21.0%) and have access to care on evenings and weekends (6.8% vs 13.4%). No substantial differences were found between privately and publicly insured children in prevalence of unmet health needs or delays in obtaining care due to cost. Conclusions. This study illustrates the importance of health insurance for children with special health care needs. Continued efforts are needed to ensure that all children with special health care needs have insurance and that remaining access and utilization barriers for currently insured children with special health care needs are also addressed. Pediatrics 2000;105:760-766; access, utilization, insurance, chronic conditions, special health, care needs., ABBREVIATIONS. NHIS, National Health Interview Survey; FPL, federal poverty level; SCHIP, State Children's Health Insurance Program. An extensive body of literature has demonstrated that health care access and use by [...]

To the Editor.-- I read with interest the commentary "Weighing the Risks of Consumer-Driven Health Plans for Families" by McManus et al. (1) The authors correctly point out that high-deductible [...]

The lack of adequate health insurance is known to have a negative impact upon adult populations. In general, people who do not have health insurance coverage use medical services less often and have increased rates of illness and death. Until now, no studies of health insurance coverage of adolescents in the United States have been done. This study provides an overview of the insurance status of adolescents aged 10 to 18. The number of uninsured individuals was determined, and the effect on the utilization of health care services was assessed. The data were gathered in 1984 and included 15,181 adolescents. Although 86 percent of the adolescents surveyed had some type of insurance coverage, one in every seven, or almost 4.5 million individuals, had no health insurance. Characteristics that were associated with the likelihood of not having insurance included: poor economic conditions, little formal education, and being a member of a minority group. Also, individuals living in the southern or western United States and in single-parent households were less likely to be insured. Adolescents from families with low incomes and single-parent homes were the most likely to be uninsured. Economic factors were found to be the most influential; in 8 of 10 families that had no insurance coverage, economic obstacles were most frequently cited as the reason. Measures that could undertaken by the public and private sectors to improve the insurance coverage of adolescents are also discussed. (Consumer Summary produced by Reliance Medical Information, Inc.)

Recent surveys have indicated that, in the United States, the population group at the greatest risk for being without health insurance coverage is young adults. This is attributed in part to the loss of coverage from parents' insurance plans due to the child's age or loss of dependent status. The medical insurance coverage of 10,394 young adults aged 19 to 24 was assessed, with a focus on the number of uninsured persons and the factors linked to uninsured status. Data were derived from the 1984 National Health Interview Survey. The results indicated that a total of six million of these individuals (26 percent) were uninsured. Of those who were insured, 65 percent had private insurance, 7 percent had public insurance, and 1 percent had both types of coverage. The following factors were associated with the highest risk for not having health insurance: low economic status, being male, being from a minority group (black or Hispanic), having dropped out of high school, living with others, and living in the South and West. Based on the results of this survey, it was recommended that young adults be targeted for educational programs regarding the importance of insurance. Also, full utilization of existing insurance programs and exploration of new insurance options for young adults should be emphasized. (Consumer Summary produced by Reliance Medical Information, Inc.)

Information about health care use, charges, and out-of-pocket expenses is critical to the development of an equitable and efficient treatment system for disabled children. Data from the 1980 National Medical Care Utilization and Expenditure Survey were used, and differences in use, charges, and out-of-pocket expenses for children with and without limitations in their activities due to chronic health problems are described. The results indicate that children limited in their activities used more medical services than other children, especially hospital-based services and services provided by health professionals other than physicians. Charges and out-of-pocket expenses were two to three times higher on average for disabled children, compared with other children. Charges and out-of-pocket expenses were also skewed; 10% of the sample children accounted for more than 60% of total charges and out-of-pocket expenses for the disabled population. The skewed distribution of out-of-pocket expenses suggests that financial burdens are unevenly shared by families of disabled children. Several public policy options designed to result in a more equitable distribution of financial risks are discussed. [ABSTRACT FROM AUTHOR]

This policy statement reviews the impressive progress of the State Children's Health Insurance Program since its enactment in 1997 and identifies outstanding challenges and state and federal policy recommendations. The American Academy of Pediatrics urges Congress to reauthorize SCHIP to strengthen its historic gains. The following set of recommended strategies for reauthorization pertain to funding, eligibility and enrollment, coverage, cost sharing, payment and provider-network capacity, and quality performance.