Children's Health in Washington, D.C.

In Washington, D.C., the vast majority of children have health insurance. Yet District children often lack sufficient access to medical care and face significant health threats from chronic conditions and risk factors such as exposure to violence in schools and neighborhoods. These findings emerged from an assessment of children's health in Washington, D.C., conducted by RAND Health and sponsored by the Children's National Medical Center. The study provides the first comprehensive profile of health and health care issues among District children and of both the health service delivery system and the communities in which the District's more than 100,000 children live. Researchers synthesized an unprecedented combination of data to inform analyses and recommendations. Key findings included the following:

• Insurance coverage. The percentage of children who lack health insurance coverage in the District is far lower than the national percentage. As of 2007, according to the National Survey of Children's Health data, only 3.5 percent of children were uninsured, compared with 9.1 percent of children nationwide.
• Access to care. Despite the high rate of health insurance coverage, many D.C. children experience problems obtaining medical care, particularly from specialists. More than 12 percent of parents reported difficulty accessing specialty care, compared with 8 percent nationwide, and in some areas of the city nearly one-third of parents reported problems accessing specialty care. In an alarming trend, the rate of "ambulatory care sensitive" hospitalizations—that is, hospital admissions that may be preventable with timely access to high-quality primary care—increased among D.C. youth by almost 40 percent between 2004 and 2007. Access problems appeared especially acute for children with publicly funded insurance. Rates of office-based care among this group were substantially below national levels. In addition, this group had high rates of emergency department use. More than one in four had an emergency department visit at least once a year.
• Barriers to care. Numerous barriers hindered D.C. youth from receiving health care in nonhospital settings. One factor was the uneven distribution of primary and specialty care providers across the District relative to health need. Other barriers cited by parents and adolescents included a perceived lack of provider understanding of cultural and neighborhood issues as well as a limited availability of health care providers who speak languages other than English. Barriers were most pronounced in areas of the city with lower-income populations.
• High-priority diseases and medical conditions. Particular health conditions and health behaviors deserve priority attention because of their high rate of prevalence or the patterns of health care use associated with them. These include asthma, sickle cell anemia, HIV/AIDS, and obesity. In addition, a substantial fraction of children in the District experience mental health problems or developmental delays, and many youth with a mental health diagnosis do not appear to be receiving nonhospital-based care for their condition.
• Violence. Experiencing violence and being exposed to it, particularly in school, continue to be major problems in the District. Fourteen percent of youth reported fears about school safety, more than double the national average of 6 percent, and violence-related mortality was very high. Dating violence was also high, increasing from 11 to 17 percent from 2005 and 2007, above the U.S. rate of 10 percent. Moreover, rates of child abuse and neglect were twice the national average.
• Environmental conditions. The characteristics of the neighborhoods in which children live carry important implications for health. Socioeconomic conditions, such as poverty, income, education, and family structure, are known to affect health. Also important are the physical conditions of neighborhoods. These include the availability of parks and recreational facilities, vacant or overcrowded housing, tree cover, and air pollution. The analysis showed substantial variation across the District in physical environments and highlighted areas that may benefit most from interventions to improve environmental conditions that affect children's health (see the figure).

Shaded areas indicate neighborhoods with high environmental health risk. Darkest shaded areas have both high environmental risk and poor socioeconomic conditions. Unshaded areas have low-to-moderate environmental risk across all socioeconomic levels. Data are from 2000–2009.

Researchers suggest that health promotion efforts to address these problems must focus on a partnership involving private- and public-sector organizations that serve children, including schools, community-based organizations, and the business community. The researchers' recommendations include the following:

• Pursue strategies to increase children's access to primary and specialty care, including increasing the network of providers, especially those who treat publicly insured or uninsured children. Stronger incentives for treating these children could include improving Medicaid reimbursement and supporting electronic health record implementation.
• Focus on children with high-priority conditions: asthma, sickle cell anemia, HIV/AIDS, obesity, and mental health conditions such as episodic mood disorders. Early disease management will help parents and children address these conditions and reduce the need for emergency room visits.
• Devote greater resources to prevention and wellness programs across sectors. Efforts could include violence prevention programs that address school safety issues, emotional wellness programs to address mental health issues early, and sexual health interventions that combine discussions of risky sexual activity with life skills training.
• Increase efforts to monitor children's health continuously and more comprehensively. More data on health care capacity and environmental health risks, annual or biennial assessment of child health, and routine analysis of administrative data are needed.

Topics

• Child Health
• Children's Access to Health Care
• District of Columbia
• Health Care Access
• Health Care Quality
• Health Equity
• Health Insurance
• Neighborhood Influences on Health
• Populations