Missing Link

Connection Found Between Government Health Insurance and Better Child Health

By Michael Seid

Michael Seid, formerly a RAND behavioral and social scientist, is now a professor of pediatrics in the Divisions of Pulmonary Medicine and Clinical Effectiveness and the director of health outcomes and quality of care research in the Division of Pulmonary Medicine at Cincinnati Children’s Hospital and Medical Center.

Created in 1997 and slated for reauthorization this summer, the State Children’s Health Insurance Program (SCHIP) is the largest expansion of spending for children’s health care in the United States since the creation of Medicaid in 1965. Funded jointly by the states and the federal government and managed by all 50 state governments, SCHIP is designed for families who earn too much money to qualify for Medicaid but cannot afford private insurance.

Federal policymakers should consider the proven salutary effect of realized access to care.

Studies have shown that SCHIP has increased children’s realized access to care (or receipt of needed care). Until now, though, little evidence has existed to link the increase in realized access to care with improved health outcomes. Our study, funded by a grant from The David and Lucille Packard Foundation, bridges the gap, finding a statistically significant correlation between realized access to care and clinically meaningful improvements in the health-related quality of life among children enrolled in a large version of SCHIP, specifically California’s program, known as Healthy Families.

Our study confirms that children in the Healthy Families program had less forgone care and fewer problems obtaining care than they had experienced prior to enrollment in this government-sponsored health insurance program. Moreover, the improvements in receiving care translated into significantly better health-related quality of life for the children. Enrollment in the program also reduced preenrollment disparities among racial, ethnic, and linguistic groups in the use of needed health care services.

Norma Arroyo walks with her children near their home in Vallejo, California.
AP IMAGES/RICH PEDRONCELLI
Norma Arroyo walks with her children near their home in Vallejo, California. Although her husband’s job provides health insurance for the couple, it does not cover their children. Like many working Californians, they depend on the state’s Healthy Families program to cover the children.

The U.S. Congress will soon decide whether to reauthorize or to expand SCHIP. Given the evidence from California, which we believe is applicable nationwide, federal policymakers should consider the proven salutary effect of realized access to care. The solid evidence linking realized access to care with better health outcomes among children should propel federal policymakers to expand such access to more children.

Better Bills of Health

The term health-related quality of life refers to those aspects of life directly related to physical, mental, and social well-being. Given the subjective nature of health-related quality of life, it is best measured from the perspective of an individual. When assessing the health of children, though, it is equally important to incorporate the perspective of parents, because both parent and child report vital information about overall health.

To assess the children’s health-related quality of life, we used the Pediatric Quality of Life Inventory™ (PedsQL™), a widely used 23-item survey encompassing physical, social, emotional, and school factors and using a 100-point scale. Higher scores indicate higher qualify of life. Typical questions on the survey ask, “how much of a problem” is it for the child to “walk more than one block” or “keep up with schoolwork?” Answers range from “never” to “sometimes” to “almost always.”

From 2001 to 2003, the State of California surveyed the families enrolled in the Healthy Families program at three separate times: upon enrollment and then at one and two years afterward. Almost 5,000 families were enrolled at all three points in time, and more than 70 percent of them — nearly 3,500 families — responded to the survey all three years. Sicker children were not more likely to drop out of the program, nor was child health related to survey participation. The survey was conducted in English, Spanish, Vietnamese, Korean, and Chinese.

The state survey measured trends in realized access by asking parents to report, from year to year, if they faced any problems obtaining needed care for the children or if there were times when needed care could not be obtained at all. We hypothesized that both experiences, either problems obtaining care or forgone care, would be related to lower health-related quality of life among children, after controlling for factors such as race, ethnicity, parental language, chronic health conditions, baseline receipt of needed care, baseline health-related quality of life, and whether the children had regular physicians.

We first verified the higher realized access to care. For the sample overall, the proportion of families reporting forgone care decreased from enrollment to year one and then again from year one to year two. At enrollment, 16 percent of families reported forgone care; by year two, just 7 percent did so (see the Centerpiece). Likewise, the proportion of families reporting problems obtaining care decreased from the baseline to year one. (The proportion of families reporting problems obtaining care held steady from year one to year two.)

By year two, the baseline disparities of forgone care among racial, ethnic, and linguistic groups were substantially reduced.

By year two, the baseline disparities of forgone care among racial, ethnic, and linguistic groups were also substantially reduced. At enrollment, 17 percent of African American parents, 16 percent of Latino and Asian parents, and 13 percent of white parents said their children had forgone needed care during the previous year. By the end of year two, just 8 percent of Latino parents, 7 percent of African American and Asian parents, and 6 percent of white parents reported forgone care. Among the linguistic groups, the initial variation of 9 percentage points had shrunk to 4 points. By year two, Spanish speakers reported the most forgone care (8 percent) and Chinese speakers the least (4 percent).

With respect to problems obtaining care, the rates decreased for African Americans and Latinos and for English speakers and Spanish speakers. With the exceptions of Asians and Pacific Islanders and Asian-language speakers, there was a substantial elimination over time of the disparities across groups in having problems obtaining care.

Craig and Timothy Bedford, of Baltimore, Maryland, testify before a Senate Finance Committee.
AP IMAGES/EVAN VUCCI
Craig Bedford, of Baltimore, Maryland, left, accompanied by his son Timothy, testifies before a Senate Finance Committee hearing on the future of the State Children’s Health Insurance Program in Washington, D.C., on February 1, 2007.

Our statistical analysis then confirmed the hypothesized link between higher realized access to care and better health outcomes. Children who received needed health care services reported quality-of-life improvements, such as doing better in school, feeling better physically, and getting along better with peers.

The statistical analysis allowed us to derive the number of points that each detrimental factor would independently “deduct from” a child’s quality of life, as scored on the 100-point scale. We found statistically significant evidence that forgone care in the previous 12 months would reduce a child’s health-related quality of life by 3.5 points according to the parent surveys and 3.2 points according to the child surveys. Problems obtaining care in the previous 12 months would reduce a child’s quality of life by an additional 4.5 points according to the parent surveys and 4.4 points according to the child surveys.

These numbers are clinically meaningful. Judging by the parent reports, experiencing both forgone care and problems obtaining care correspond with an 8-point drop in the quality-of-life scores. (Previous research on the PedsQL™ has shown that a change of 4.5 points is a clinically important difference.) Moreover, this 8-point drop was greater than the change in scores associated with having a chronic health condition (a 6.2-point reduction). To put the numbers in further clinical perspective, the parent-reported scores for children with forgone care at both year one and year two were similar to scores for newly diagnosed pediatric cancer patients undergoing treatment.

For children whose parents had reported forgone care before enrollment, obtaining needed care led to significant increases in the average quality-of-life scores: from 75 at baseline to 79 after the first year and 78 after the second. By contrast, children who had forgone care at baseline and continued to do so during both successive years saw ever-declining scores: from 75 at baseline to 72 after the first year and 67 after the second.

Based on both parent proxy-report and child self-report, families who had reported forgone care before enrolling in the Healthy Families program scored higher with improved access. Families with access to needed care prior to enrollment maintained their scores with realized access to care after enrollment. Persistently poor access was associated, in a cumulative manner, with a declining quality of life.

Continued access to care is associated with continued health. Forgone care over time is associated with declining health.

Better Bills in Congress

The key contribution of our study is demonstrating the link between realized access to care and children’s health-related quality of life, even after adjusting for child and family characteristics, the care of a regular doctor, and baseline health-related quality of life. Continued access to care is associated with continued health. Forgone care over time is associated with declining health.

Our study has three major implications for health policy. First, SCHIP and similar programs could help reduce health disparities, given the much greater likelihood that poor and minority children will experience unmet needs for care in the absence of such programs. In California, a consortium of child health experts, advocacy groups, and legislators has launched a campaign, called Californians for Healthy Kids, to promote legislation that would ensure health insurance for all children across the state. The campaign builds on existing county health insurance programs modeled on SCHIP but aims to broaden the eligibility criteria to expand access statewide. Our study provides empirical support for this policy direction, suggesting that enrollees in comparable programs experience fewer instances of unmet need, with concomitant health improvements.

Texas Representative Abel Herrero (D-Robstown).
AP IMAGES/HARRY CABLUCK
Texas Representative Abel Herrero (D-Robstown), right, speaks in Austin, Texas, on January 24, 2007. A group of Texas House Democrats, including Representative Borris Miles (D-Houston), left, and Representative Joe Heflin (D-Crosbyton), center, filed legislation to restore health coverage through the state’s Children’s Health Insurance Program.

Second, despite the heartening decrease in forgone care, our data show that 7 percent of the Healthy Families enrollees still experienced forgone care in their second year of enrollment. Other factors besides lack of health insurance might be at play here: parents having to take time off work, transportation barriers, negative expectations of the health care system, or poor knowledge of health care. Because forgone care is associated with such large decrements in health-related quality of life, more attention should be paid to policies and interventions aimed at overcoming the obstacles to needed care, even among the insured.

Third, although our study concerned SCHIP in California, we believe that the lessons are generally applicable to other states. The improvements in health-related quality of life among children in California came about by raising the rates of realized access to care, and that is the common, underlying purpose of SCHIP in all states. To the extent that the variations of SCHIP succeed in improving realized access to care, the relation to health-related quality of life should hold constant.

These programs reduce forgone care. They reduce problems in obtaining care. They reduce disparities in care. And, as we now know, they increase health-related quality of life. Policymakers faced with deciding whether to reauthorize or to expand SCHIP should consider the proven effects of their decisions on the lives of children. square

Related Reading

“Access to Care and Children’s Primary Care Experiences: Results from a Prospective Cohort Study,” Health Services Research, Vol. 40, No. 6, Part 1, December 2005, pp. 1758-1780, Michael Seid, Gregory D. Stevens.
“Disparities in Primary Care for Vulnerable Children: The Influence of Multiple Risk Factors,” Health Services Research, Vol. 41, No. 2, April 2006, pp. 507-531, Gregory D. Stevens, Michael Seid, Ritesh Mistry, Neal Halfon.
“Enrolling Vulnerable, Uninsured but Eligible Children in Public Health Insurance: Association with Health Status and Primary Care Access,” Pediatrics, Vol. 117, No. 4, April 2006, pp. e751-e759, Gregory D. Stevens, Michael Seid, Neal Halfon.
“The Impact of Realized Access to Care on Health-Related Quality of Life: A Two-Year Prospective Cohort Study of Children in the California State Children’s Health Insurance Program,” The Journal of Pediatrics, Vol. 149, No. 3, September 2006, pp. 354-361, Michael Seid, James W. Varni, Lesley Cummings, Matthias Schonlau.
“Parents’ Perceptions of Pediatric Primary Care Quality: Effects of Race/Ethnicity, Language, and Access,” Health Services Research, Vol. 38, No. 4, August 2003, pp. 1009-1031, Michael Seid, Gregory D. Stevens, James W. Varni.
“Uninsurance Among Children Eligible for the State Children’s Health Insurance Program: Results from a National Survey,” Managed Care Interface, Vol. 19, No. 5, May 2006, pp. 31-39, Hao Yu, Michael Seid.