Pediatric Annals

CME 

Access to Care for Children: Recent Progress, Remaining Challenges

Lindsey Jeanne Leininger, PhD; John Meurer, MD, MBA

Abstract

CME Educational Objectives

1. Provide a definition of access to care and its correlates in the pediatric population.

2. Discuss recent policy initiatives that have targeted improving access to quality health care for children.

3. Recommend policy changes that improve pediatric access to care and promote the health of children.

Research consistently demonstrates the centrality of having access to medical care in the production of good health. Illustratively, the important role that access to care plays in promoting pediatric health is echoed throughout the articles in this issue. Whether fighting communicable disease, providing behavioral health services to at-risk adolescents, or managing chronic physical conditions (such as asthma), achieving key pediatric health goals is crucially dependent upon the presence and accessibility of high-quality health care services.


Abstract

CME Educational Objectives

1. Provide a definition of access to care and its correlates in the pediatric population.

2. Discuss recent policy initiatives that have targeted improving access to quality health care for children.

3. Recommend policy changes that improve pediatric access to care and promote the health of children.

Research consistently demonstrates the centrality of having access to medical care in the production of good health. Illustratively, the important role that access to care plays in promoting pediatric health is echoed throughout the articles in this issue. Whether fighting communicable disease, providing behavioral health services to at-risk adolescents, or managing chronic physical conditions (such as asthma), achieving key pediatric health goals is crucially dependent upon the presence and accessibility of high-quality health care services.


Research consistently demonstrates the centrality of having access to medical care in the production of good health.1–4 Illustratively, the important role that access to care plays in promoting pediatric health is echoed throughout the articles in this issue. Whether fighting communicable disease, providing behavioral health services to at-risk adolescents, or managing chronic physical conditions (such as asthma), achieving key pediatric health goals is crucially dependent upon the presence and accessibility of high-quality health care services.

In this overview article, we define access to care, provide a statistical portrait of its levels and correlates in the pediatric population, and discuss recent policy initiatives that have targeted its achievement. The article concludes with a series of policy recommendations that we believe would improve pediatric access to care and, in so doing, promote the health of our nation’s children.

The Institute of Medicine (IOM), guided in large part by the seminal work of Lu Ann Aday and Ronald Andersen, defines access to care as “the timely use of personal health services to achieve the best possible outcomes.”5–7 Variables measuring access to care are conceptualized as reflecting either “potential” access or “realized” access.5,6 Insurance coverage, parental knowledge surrounding appropriate care-seeking behavior, and close geographical proximity to a pediatrician may all be characterized as “potential” access measures because each of these facilitates, but does not necessarily guarantee, optimal care receipt.

Variables reflecting health care utilization — for example, having received a recent preventive services visit — are considered “realized” access measures. Their fulfillment indicates that barriers to care receipt were either absent or surmountable.

Figure 1, Figure 2, and Figure 3 (see above) display estimates of the following set of commonly employed pediatric access to care measures: having a usual source of care that is not an emergency department (ED); having any in-person medical provider visit in the past year; and having any dental visit in the past year. The data were drawn from the 2007 round of the Medical Expenditure Panel Survey, a nationally representative survey sponsored by the Agency for Healthcare Research and Quality, and include children 1 through 17 years.

Pediatric access to care: all children. (N = 8,007). Source: Agency for Healthcare Research and Quality.

Figure 1. Pediatric access to care: all children. (N = 8,007). Source: Agency for Healthcare Research and Quality.

Pediatric access to care by income level. (N = 8,007 Note: “Low-income” defined as family income of less than 200% of the Federal Poverty Level, which in 2007 translated into a yearly income of $34,340 for a family of three.) Source: Agency for Healthcare Research and Quality.

Figure 2. Pediatric access to care by income level. (N = 8,007 Note: “Low-income” defined as family income of less than 200% of the Federal Poverty Level, which in 2007 translated into a yearly income of $34,340 for a family of three.) Source: Agency for Healthcare Research and Quality.

Pediatric access to care by insurance status. (N=8,007). Source: Agency for Healthcare Research and Quality.

Figure 3. Pediatric access to care by insurance status. (N=8,007). Source: Agency for Healthcare Research and Quality.

As demonstrated in Figure 1 (at left), approximately 90% (89.6%) of children have a non-ED usual source of medical care, a reassuring indicator. Slightly greater than 70% (71.3%) of all children had at least one medical provider visit in the past year. Given that the American Academy of Pediatrics (AAP) recommends that all children have a routine physical exam at least once a year, it is concerning that almost 30% of children received no medical care within this timeframe.8

Rates of pediatric dental care receipt are markedly lower than the analogous rates of medical care receipt. The American Academy of Pediatric Dentistry recommends that children older than 1 years receive two dental check-ups per year. The fact that only half (49.4%) of children received any dental visit over a year is a legitimate cause for concern.9

Figure 2 and Figure 3 (at left) demonstrate the socioeconomic disparities that characterize children’s access to care. Children living in low-income families, defined as having income below 200% of the Federal Poverty Level (FPL), have worse access to care than children in higher-income families. Unsurprisingly, uninsured children also experience considerable access disadvantages.

As will be developed in subsequent sections, recent decades have witnessed significant victories in expanding access to care for low-income children; however, as the estimates in Figure 2 and Figure 3 (at left) underscore, providing optimal access to quality care for all children remains an unrealized goal.

Two Decades of Public Health Insurance Expansions

The expansion of public insurance eligibility has been the single largest child health policy effort implemented over the past two decades. In this section, we provide a brief overview of these expansions, highlighting their successes and documenting remaining challenges in the pursuit of universal coverage for children.

Medicaid is the largest public program covering health care services for low-income families. It is jointly financed by the federal and state governments, with the federal government’s contribution ranging from 50% to 76%, determined by per capita state income levels.10 The federal government imposes a series of minimum requirements regarding eligible populations and mandated services covered, but beyond this basic structure, states benefit from considerable latitude in the administration of the program.

Consequently, Medicaid programs across states vary greatly with respect to provider payment levels, eligibility of optional populations, services covered, and administrative requirements expected of beneficiaries.

Up through the mid-1980s, Medicaid eligibility was tied to the receipt of Aid to Families with Dependent Children, the cash welfare program for the poor. Enrollment was largely restricted to very poor (generally less than 50% of the FPL in most states) preschool-age children living in families headed by single mothers. In the 1980s and 1990s, there was a vast loosening of Medicaid eligibility thresholds. Congress first extended eligibility to children living in two-parent families with comparable income and age profiles as existing recipients before gradually increasing the income thresholds to include poor older children and teenagers and near-poor younger children.

A new era of public insurance expansions for children began in 1997. The State Children’s Health Insurance Program (recently expanded and renamed the Children’s Health Insurance Program, or CHIP) was created to increase the insurance coverage of near-poor children of all ages. CHIP is a joint federal/state program that offers a higher federal match than Medicaid. States were given the option to either create a stand-alone CHIP program or expand their existing Medicaid program, and approximately three-quarters of states opted for the former structure.11 Unlike Medicaid, CHIP is not an entitlement program, meaning that states can, and do, limit enrollment when weighing budget resource decisions. Outreach and enrollment simplification efforts were a major part of CHIP implementation and these efforts have had important beneficial spillover effects for the Medicaid-eligible population. Indeed, over two-thirds of the increase in insurance coverage among low-income children in the decade after CHIP’s passage came from increases in Medicaid enrollment.12

With the expansions to Medicaid and the implementation of CHIP, the average eligibility threshold for all children up through the age of 18 rose to 200% FPL.11 As of 2008, the most recent year for which data are available, 31% of children were enrolled in Medicaid or CHIP, 55% were enrolled in employer-sponsored plans, and 4% were enrolled in private non-group plans.13 Approximately 10% of children were uninsured, and although this figure is considerably lower than the 1990 rate of 15%, its magnitude calls attention to the fact that the expansions have not led to the universal coverage of children.13,14

More than two-thirds of all uninsured children are eligible for Medicaid or CHIP; accordingly, it is of critical importance that policy efforts focus on facilitating the enrollment of these eligible children and on finding ways to cover children ineligible for either program.15

A key point of contention among critics of the public insurance expansions has been that the presence of public insurance eligibility will encourage families to drop private coverage, a phenomenon termed “crowd-out.” The magnitude of crowd-out is hotly debated in the research literature and receives a great deal of attention in policy discourse.16

From an access-to-care perspective, the attention devoted to crowd-out is misplaced. Existing research indicates that publicly and privately insured low-income children experience roughly comparable levels of access to care, with publicly insured children doing slightly better on some prevention-related access measures and private insurance providing higher payments for services to hospitals and physicians.17

As will be discussed in the next section, private and public plans suffer from different liabilities in their ability to confer optimal access to care, and a more appropriate framing of the debate would focus on overcoming their respective weaknesses.

Beyond Insurance Eligibility: Other Barriers to Access to Care

As noted above, the granting of public insurance eligibility has not translated into universal coverage gains. The incomplete take-up of Medicaid and CHIP has long been a serious policy challenge. Researchers at the Urban Institute find that parental lack of awareness regarding children’s eligibility status is a major reason why eligible children remain uninsured. The researchers also find that the majority of these parents would enroll their children in Medicaid and/or CHIP if told that the children were eligible.18

An additional driver of incomplete take-up is the presence of considerable administrative requirements in navigating enrollment and recertification under public insurance programs. Examples of enrollment and recertification barriers include the requirement of a face-to-face interview, the presence of an asset test, and detailed income verification requests. Research documenting the effects of administrative simplification efforts establishes that enrollment increases when administrative barriers are lowered.19,20

It is extremely important to acknowledge that the achievement of universal coverage for children, although critically important, will not guarantee universal access to care. The additional sequence of barriers precluding universal access to quality care has been usefully conceptualized as a series of “voltage drops” similar to those present in an electrical system.21,22

Families face several points of “resistance,” each of which deters access for a group of children. One such obstacle is the presence of deficiencies in the benefits or services covered under various insurance plans. Private insurance plans generally require cost-sharing, in the form of premium payments and copayments for services received. Such expenses are prohibitive for many low-income families and serve as deterrents to using needed care. Moreover, private insurance plans are less generous in their coverage of preventive services than public programs.23 Preventive care comprises the bedrock of pediatric health care and its coverage is of vital importance.

Medicaid confers a comprehensive benefit package in the form of the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program. EPSDT services cover preventive services, including immunizations; vision and hearing services; dental services; and a variety of medical care, physical therapy, and personal care services. States are not mandated to provide the EPSDT benefit to children enrolled in standalone CHIP programs, underscoring a vulnerability in CHIP’s ability to provide quality access to its recipients.

Public insurance recipients frequently experience difficulties in finding providers who will accept their coverage. Medicaid reimbursement rates are much lower than those of private policies and for many services they are also lower than the comparable Medicare rates.24 Low reimbursement rates coupled with onerous paperwork requirements deter physicians from caring for publicly insured patients; as a consequence, approximately 15% of pediatricians are not accepting any new Medicaid patients.25,26

The following quote, provided by the mother of a Medicaid recipient in Oregon, powerfully illustrates the dire situation that some beneficiaries face when attempting to seek care: “My daughter got a severe sore throat, and absolutely no doctors in Bend would accept OHP [Oregon Health Plan, Oregon’s Medicaid program]. We were referred to the local free clinic but weren’t accepted there because we had OHP. The nearest medical service was in Prineville (40 miles away). And I had no means of transportation.”27

Also of note is that near-poor beneficiaries in many states are required to pay premiums and/or copayments under their public insurance plans. Cost-sharing requirements in Medicaid and CHIP, even those of minimal dollar amounts, have been shown to deter enrollment and care use among eligible children.28

A variety of additional obstacles also jeopardize children’s access to care. Family deprivations, such as economic hardship, residential instability, low health literacy, and clinical depression restrict parents’ ability to pursue and obtain quality health care on behalf of their children.29,30 A lack of reliable transportation, mentioned in the quote above, is a salient difficulty that many families must overcome to utilize medical services. Finally, many families do not have access to linguistically and culturally appropriate care, leaving them vulnerable to provider-patient communication problems that preclude desired outcomes.30 Social policies to enhance educational and employment opportunities and to reduce discrimination, and specific policies to address the above barriers would ultimately improve the health of children and families.

Community Health Centers

Although the challenges hindering access to care for at-risk children are numerous and complicated, they are not insurmountable, as evidenced by the many successes of Community Health Centers (CHCs) in improving population health for the low-income children and families that they serve. CHCs, also known as Federally Qualified Health Centers, play a crucial role in the health care safety net. These non-profit organizations receive special federal funding tied to their mandate to serve all persons regardless of insurance status or ability to pay.

Created under the Economic Opportunity Act of 1964 and vastly expanded in recent years during the tenure of President George W. Bush, the network of CHCs is comprised of approximately 1,200 organizations that serve approximately 18 million patients in roughly 7,000 delivery sites.31 The passage of the Health Care Safety Net Act of 2008 reauthorized CHC funding for an additional 4 years, anticipating program growth of 50% over this time horizon.

CHCs are located in geographical areas determined to be “high-need,” as defined by high poverty status, high infant mortality rates, and a low physician-population ratio.31 Consequently, patients with family incomes under 200% FPL constitute more than 90% of the CHC patient population. More than two-thirds of patients are from racial and ethnic minority groups, and almost 1 in 3 patients are best served in a language other than English. Thirty-eight percent of CHC patients are uninsured and an additional third of patients are covered by Medicaid.

Recognizing that they serve a population that confronts a constellation of access barriers, CHCs provide a variety of support services to facilitate appropriate care receipt. Examples of these support services include translation, transportation, case management, health and nutrition education, and home visits. The provision of these enabling services is the hallmark of CHCs that differentiates them from other providers.

Moreover, many CHCs provide dental and mental health services onsite. CHCs are operated under a unique governance structure that requires a consumer-dominated board of directors and includes active involvement and input from the patient community, allowing centers to tailor service offerings to the needs of their specific patient populations.

Research confirms that CHCs effectively meet the health needs of the vulnerable populations that they serve. A review of the evidence on the health impact of CHCs finds that they are appreciably reducing racial/ethnic disparities in access to care and are improving a variety of health outcomes for many at-risk populations.32

For example, pregnant women who receive prenatal care at CHCs have lower infant mortality rates than comparable women who receive their care elsewhere.33 Additionally, Medicaid patients with a CHC as their usual source of care have lower expenses and fewer potentially avoidable hospitalizations than Medicaid patients who seek care from alternate providers.34

These successes establish that the effective provision of health care in a high-needs context is possible when supports targeting the social and economic determinants of care-seeking are included as key parts of service delivery. As Sara Rosenbaum and colleagues have argued, the organization and delivery systems inherent in the design of CHCs serve as exemplars of the “medical home” concept currently promoted in health care policy discussions.35

The medical home model of care delivery is grounded in a strong primary care orientation, focusing on the provision of coordinated and comprehensive management of patients’ multiple health care needs over time. A systematic review of the literature on the efficacy of the medical home model in improving pediatric health outcomes demonstrates that this model is linked to better and earlier diagnoses, better patient compliance, fewer hospitalizations, better prevention, and fewer unmet needs relative to alternate-care arrangements.36 These findings suggest that children of all income levels would benefit from changes in the delivery system that embody a primary care-centered emphasis.

Recommendations

In late 2009, the House of Representatives and the Senate passed landmark pieces of legislation designed to profoundly change the American health care system. Signed into law by President Obama in March 2010, the historic reform effort is characterized by a primary goal of increasing insurance coverage, an aim also embodied in recent state-level reforms. Coverage gains will come from a variety of measures, including the provision of subsidies to purchase private coverage, the expansion of public insurance eligibility, and a near-universal mandate that individuals have coverage.

We applaud policy efforts to increase insurance coverage; however, as argued above and in keeping with the American Academy of Pediatrics (AAP) Principles on Access to Health Care, we believe that increasing coverage comprises only one of several needed system improvements. The following six AAP principles constitute the framework for our policy recommendations, and are detailed below.37

Every Child must have quality health insurance

Universal health insurance coverage is necessary to ensure affordable access to quality health services for all children, especially the poor and sick. Although the implementation of national health care reform will greatly increase coverage among the pediatric population, several vulnerable populations—most notably undocumented immigrants—will continue to be denied eligibility for public coverage and subsidies for the purchase of private coverage.

Moreover, the very poorest families are exempt from the coverage mandate and its accompanying surveillance mechanisms; vigilance must be exerted in helping these families enroll in and remain covered by Medicaid.

Quality health insurance should be a right, regardless of income

Health and health care are social goods. Society benefits when economic vitality is widely shared and when generosity and respect are provided for the poor and sick. Income tax subsidies are needed to provide affordable, equitable health care for people in poverty or with special health care needs. During the past 45 years, public health insurance expansions in Medicaid and then CHIP have reduced health-related disparities, and the recent national reform holds the potential to build substantially upon this progress.

Although patients have a right to health insurance coverage, they also collectively share a responsibility to pursue healthy lifestyle choices. Policymakers should continue to develop individual incentives and environmental supports encouraging nutritious diets, physical activity, and smoke-free worksites as well as penalties for driving under the influence of alcohol and other risky behaviors.

Comprehensive, age-appropriate benefits

Health insurance benefit plans must include comprehensive coverage and payment for services, such as pediatric obesity assessment, evaluation, and treatment and mental health services.

Moreover, health insurance plans for vulnerable pediatric populations should include coverage for enabling services, such as transportation and language interpreters. We recommend that Congress establish a national commission to ensure the provision of appropriate health plan benefits across all types of providers, private and public.

Every child should receive care

Health plans and payment systems must support the family-centered medical home model through adequate benefits coverage, appropriate payment, and infrastructure support for implementation.38 Primary care medical homes offer family-professional partnerships, early and continuous screening, diagnosis, treatment, and referrals, and coordinated chronic illness management.

In serving as medical homes for vulnerable patients, Community Health Centers not only provide primary and preventive services but also provide much needed oral health care and behavioral health services. Although effective at delivering primary care, CHCs often lack the capability to secure access to referral and specialty services on behalf of their uninsured patients.39

In addition, although required by federal statute to provide evening and weekend availability, many lack robust arrangements for round-the-clock coverage for patients. Providing resources targeted at eliminating these deficiencies would further improve access to care among vulnerable populations. Health care reform legislation expands funding for CHCs, on the order of doubling the current budget. Given the success of CHCs in providing quality access to care for underserved populations, we strongly support such large-scale expansion efforts.

Limits should be affordable and emphasize quality, not quantity

Payers should set affordable cost-sharing limits for patients. They should provide first-dollar coverage (ie, without copays) for preventive services, immunizations, and medications to control chronic conditions.

In early 2009, the Commonwealth Fund Commission on a High Performance Health System provided the following recommendations, grounded in the belief that payment systems should reward value and not volume:

  • Strengthen primary care by enhancing public health insurance payment for services;
  • Encourage the adoption of the medical home model and promote accessible, coordinated, patient-centered care with a focus on health and disease prevention;
  • Promote more integrated care delivery through bundled payment approaches for the duration of an illness and rewards for quality, outcomes and efficiency; and
  • Correct prices to align payments with value.40

We further recommend that physician tiering or profiling and pay-for-performance programs must emphasize quality, be based on valid, accurate and transparent outcome measures, and provide positive incentives for performance improvement and serving higher-risk populations.

In general, IOM dimensions of quality care (effective, efficient, equitable, safe, timely, and patient-centered) and specific scientific evidence and best practices should guide the financing of health services.41 Clinical practice networks and business integration should be fostered with minimal financial risk for such innovations. Moreover, payment reform should allow insurers and health care providers to share in any resulting savings.

Concept of Quality Health Insurance

Medicaid and SCHIP must invest in outreach, enrollment and continued enrollment, including innovations, such as automatically enrolling those who already participate in free and reduced-price lunch.

Communities need integrated systems for health care, social services, education, and environmental programs. Health information technology and electronic health records can be useful in performance measurement in hospitals and physician practices for quality assessment and transparent reporting. With proper privacy protections, individual citizens/patients/clients would benefit from the development of population-based registries integrating medical, social service and public health programs.

The AAP supports the Patient Protection Affordable Care Act and is working to ensure the law is appropriated and implemented to provide the best possible outcomes for children.42

We conclude by encouraging pediatricians and other child health advocates to use this and other outlets to influence the policy discourse regarding children’s access to health care.

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Sidebar.

Recommended Sources

Authors

Lindsey Jeanne Leininger, PhD, is Researcher, Chapin Hall at the University of Chicago. John Meurer, MD, MBA, Professor and Chief of General Pediatrics, Medical College of Wisconsin and Children’s Research Institute.

Dr. Leininger has disclosed the following relevant financial relationship: Robert Wood Johnson Foundation’s Health and Society Scholars Program: Grant recipient. Dr. Meurer has disclosed no relevant financial relationships.

Dr. Leininger and Dr. Meurer appreciate the research assistance of Michelle Yang. They are also especially grateful for the input of Donna Friedsam, who provided extensive comments on the manuscript sections describing Community Health Centers. The opinions expressed in this paper are the authors’ alone and do not necessarily represent the views of the Medical College of Wisconsin, Children’s Research Institute, the Robert Wood Johnson Foundation, or the University of Wisconsin-Madison.

Address correspondence to: Lindsey Jeanne Leininger, PhD, Chapin Hall at the University of Chicago, 1313 E. 60th Street, Chicago, IL 60637, 773-750-7706; or e-mail: lleininger@chapinhall.org.

10.3928/00904481-20110217-10

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