RAND Study Finds Medical Safety Net Plays Key Role in Providing Care to Uninsured Children

How public “safety net” medical services are structured and funded plays a key role in determining whether uninsured children receive health care, according to a new study from the RAND Corporation.

Examples of safety net providers include community health centers, primary care programs in public housing, migrant worker health centers, and public hospitals.

Researchers found that uninsured rural children are more likely to receive some type of medical services if they live closer to safety net providers or if there are more primary care physicians nearby. Longer distances to safety net providers were associated with fewer doctor visits and fewer health services overall in rural areas.

“Whether it is the time a parent has to take away from work or the cost of transportation, it's clear that in rural areas distance between home and a health care provider is an obstacle to care for uninsured children,” said Carole Roane Gresenz, a RAND economist and lead author of the study.

The RAND Health study, published online by the journal Pediatrics, found that proximity to safety net providers is not a key factor for uninsured urban children, although the researchers caution that other factors influencing the accessibility of providers (such as availability of local public transit) were not measured and may influence the services children receive. However, researchers said that urban children are more likely to receive medical care if they live in areas where safety net providers are better funded and where there are more primary care physicians.

“The medical safety net really matters to uninsured children,” Gresenz said. “No matter how much we try to improve the availability of insurance for children, some will inevitably remain uninsured. How we fund and how we structure the safety net influences whether these uninsured kids have access to health care.”

The RAND study is the first to examine how the local health care safety net and the structure of the local health care market influence the use of medical services by uninsured children.

Researchers studied a nationally representative group of more than 2,600 children ages 2 to 17 who were uninsured for at least one full calendar year from 1996 to 2000. The study found that 60 percent of the children had no physician visits during the preceding year and slightly less than half received no health care services of any kind. Patterns of care did not differ significantly between uninsured children from rural and urban areas.

By comparison, other research has shown that nearly three quarters of privately insured children and more than two thirds of publicly insured children (such as those insured by Medicaid) had at least one physician visit, and more than 80 percent of privately and publicly insured children had at least some medical expenditures.

Researchers say their findings show that whether uninsured children receive medical care is not exclusively determined by personal and familial characteristics — such as health status, education and family income. Rather, aspects of the area where the children live bear importantly on whether children without insurance receive care.

In urban areas, children who lived in regions where local governments spent more on health and hospitals (such as for outpatient health clinics, public hospitals, and immunization programs) were more likely to receive medical care, the study found.

Researchers suggested that greater funding in urban areas may allow for additional staffing at safety net providers, the introduction of more convenient hours of operation, or more steeply discounted prices for care.

A greater number of primary care physicians also increased the chance of care for uninsured children in urban areas, possibly because a larger supply of physicians made it easier to find a doctor willing to provide free or discounted care, researchers said.

Despite efforts to expand government programs that provide health insurance to children, recent estimates suggest that 12 to 13 percent of the nation's children — 9 to 10 million — remain without health coverage. Experts estimate that as many as two-thirds of the uninsured children may quality for government coverage, yet remain unenrolled.

Prior studies have shown that compared to children who have health insurance, uninsured children are less likely to have contact with a physician, receive prescription drugs or have regular preventive check-ups and immunizations.

Information about children's use of the health care system was taken from the federal Medical Expenditure Panel Survey. Information about health system use was combined with details from a number of other surveys that provided information about local health care market characteristics.

The article is titled “Dimensions of the Local Health Care Environment and Use of Care By Uninsured Children in Rural and Urban Areas.” Other authors of the report are Jeannette Rogowski of the University of Medicine and Dentistry of New Jersey School of Public Health, and Dr. José J. Escarce of RAND and UCLA's David Geffen School of Medicine.

RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care quality, costs and delivery, among other topics.