print ed365415.tif (196 pages) · lucile packard foundation, 300 second street, suite 102, los...

ED 365 415

AUTHORTITLEINSTITUTIONREPORT NOPUB DATENOTE

AVAILABLE FROM

PUB TYPE

JOURNAL CIT

EDRS PRICEDESCRIPTORS

IDENTIFIERS

ABSTRACT

DOCUMENT RESUME

PS 021 646

Behrman, Richard E., Ed.; Lewit, Eugene M., Ed.U.S. Health Care for Children.Center for the Future of Children, Los Altos, CA.ISSN-1054-8289Dec 92196p.; Individual articles appearing in this journalare indexed in CIJE.Center for the Future of Children, The David andLucile Packard Foundation, 300 Second Street, Suite102, Los Altos, CA 94022.Information Analyses (070) Collected WorksSerials (022)Future of Children; v2 n2 Win 1992

MF01/PC08 Plus Postage.Adolescents; *Child Health; Children; FederalPrograms; *Health Care Costs; Health Insurance;*Health Needs; Health Programs; *Health Services;Mothers; Pregnancy; State Programs*Health Delivery Systems; Health ResourcesUtilization; *Maternal and Child Health Services;Maternal Health

The articles in this journal issue provide anoverview of ways in which health services are presently delivered tochildren, youth, and pregnant women; the means by which theseservices are financed; and some of the major deficiencies in meetingthe health needs of these groups. In the first article, the Centerfor the Future of Children presents several recommendations forpolicies to make the United States health care :.,-,stem more responsiveto the needs of children and pregnant women. The ,cond articleoffers an analysis of the health care system that focuses on therelationship between health care and children's health, and examinesthe issues of efficiency, access, and affordability. The succeedingarticles are: (1) "Child and Adolescent Health Status Measures"(Barbara Starfield); (2) "Effectiveness of Health Care Services forPregnant Women and Infants" (Andrew D. Racine, Theodore J. Joyce,Michael Grossman); (3) "Health Care Services for Children andAdolescents" (James Perrin, Bernard Guyer, Jean M. Lawrence); (4)

"Health Care Resources for Children and Pregnant Women" (Janet D.Perloff); (5) "Expenditures on Health Care for Children and PregnantWomen" (Eugene M. Lewit, Alan C. Monheit); (6) "The Role of PrivateHealth Insurance in Children's Health Care" (John F. Sheils, PatriceR. Wolfe); (7) "The Role of Medicaid and Other Government Programs inProviding Medical Care for Children and Pregnant Women" (Ian T.Hill); (8) "Children without Health Insurance" (Alan C. Monheit,Peter J. Cunningham); (9) "Nonfinancial Barriers to the Receipt ofMedical Care" (Lorraine V. Klerman); and (10) "Child Indicators:Teenage Childbearing" (Eugene M. Lewit). References are included atthe end of each article, and a selected bibliography concluded thecollection. (TJQ)

U S DEPARTMENT Of EDUCATIONOntce of Educattonat Research and Onproverneni

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

Itre sy,ThtS document has been reproduced asrepetved from the person or otgndat.ononpmal.nij

C Mtn°, changes nave been made to improvereproduction Owen`,

Pants 01 at!. Or OfernOnS staled m this dOCumen! do not necessertly represent otrtmatOERI p05.1.00 Or PO,.CY

CENTER FOR THE FUTURE OF CHILDREN THE DAVID and LUCILE PACKARD FOUNDATION

The Futureof ChildrenVOLUME 2 NUMBER 2 WINTER 1992

"PERMISSION TO REPRODUCE THISMATERIAL HAS BEEN GRANTED BY

4,-vLcc.

TO THE EDUCATIONAL RESOURCESINFORMATIC" CENTER (ERIC)"

BEST COPY MARE 2

U.S. HEALTH CARE

FOR

CHILDREN

Statement of PurposeThe primary purpose of The Future of Children is to disseminate timely infor-mation on major issues related to children's well-being, with special empha-

sis on providing objective analysis and evaluation, translating existing knowledgeinto effective programs and policies, and promoting constructive institutionalchange. In attempting to achieve these objectives. we are targeting a multidiscipli-nary audience of national leaders, including policmakers, practitioners, legislators,executives, and professionals in the public and private sectors. This publication isintended to complement, not duplicate, the kind of technical analysis found inacademic journals and the general coverage of children's issues by the popular pressand special interest groups.

In this issue of The Future q-C1, Wren, we provide an overview of the ways in which health servicesare presently delivered to children, youth, and pregnant women: the means by which these servicesare finan(ed; and some of the major deficiencies in meeting the health needs of these groups. Wehave attempted to do so objectively from multiple perspectives in a format that is accessible to abroad readership.

As the nation addresses the problems of health care reform for the entire population, it isimportant to appreciate the special nature and needs Of children, y(tuth, and pregnant womenbecause of the long-term. amplified effect that their health status has on the well-being of society.The articles presented her summarize the knowledge and experience that has been accumulatedabout the health care of children. youth, and pregnant women. It is hoped that the individualperspectives, descriptions, and analyses they contain will provide the hasis for a better under-standing of the issues and will suggest reasonable policies and program strategies to pursue. TheAnabsis, authored by the staff of the Center for the Future of Children, draws front these articlesand from our own research and deliberations.

We invite your continents and suggestions as von read this issue of The haw of Children. Ourintention is to encourage informed debate about health reform proposals tnd their potentialeffects on the health of children, youth, and pregnant women. To this end we invite correspon-dence to the Editor. We would also appreciate your comments about the approach we have takenin presenting the focus topic and welcome your suggestions for future topics.

Richard E. Behrman. M.D.Editor

The Future of ChildrenPublished by the Center for the Future of Children, The David and Lucile Packard Foundation

Volume 2 Number 2 Winter 1992

EditorRichard E. Behrman, M.D.

Managing EditorDona M. LesA'a

Staff Issue EditorEugene NI. leivit. Ph.D.

Staff EditorsDeanna S. Gomby, Ph.D.Carol S. Larson. J. D.Patricia I I. Shiono, Ph.D.

Production EditorsJulie KovanoBobbie Sorensen

Copy EditorSherri NI. Butterfield

Publications AssistantI.ori Corry

Graphics and DesignFog Press

Editorial Advisory Board

Byron Wm. Brown, Jr., Ph.D.Professor and Chair, Department

of Health Research and PolityStanford University School of

Medicine

Peter P. Budetti,Hirsh Professor and Director.Center for I icalth ResearchThe George Washington

University

David M. Eddy, M.D., Ph.D.Professor of Health Policy

and NlanagementDuke University

Leon Eisenberg, M.D.Presley Professor of

Social MedicineHarvard University Medical School

Victor R. Fuchs, Ph.D.Henry j. Kaiser, r. Professor

Department of Economicsand Department of HealthResearch and Policy

Stanford University

Shirley M. Hufstedler, LLB.Partner. Hufstedler, Kaus FC

Ettinger

Eleanor E. Maccoby, Ph.D.Professor (Emerital of

Developmental PsychologyStanford University

Paul W. Newacheck, Dr. P.H.Professor of Health PolicyInstitute for Health PolicesUniversity of California,

San Francisco

Judith S. Palfrey, M.D.Chief. Division of Geneml PediatricsThe Children's I lospitalHarvard Universitv

Nigel Paneth, M.D., M.P.H.Director, Program in

EpidemiologyProfessor of PediatricsCollege of Human MedicineMichigan State University

Nancy Scheper-Hughes, Ph.D.Professor of Medical AnthropologyDirector. Medical Anthropology

Ph.D. ProgramUniversity of California. Berkeley

Alvin L. Schorr, MS.W.,Leonard W. Mayo Professor

(Emerituslof Family andChild Welfare

Case Western Reserve University

Marshall S. Smith, Ph.D.Dean, School of EducationStanford Universin.

Barbara Starfield, M.D., M.P.H.Professor of Health PolicyThe Johns Hopkins Medical

InstitutionsMichael S. Wald, J.D.

Jackson Eli ReynoldsProfessor of l.aiv

Stanford l'niversity

Heather B. Veiss, Ed.D.Director, Harvard Family

Research ProjectIlarsurd University

Daniel Wilder, Ph.D.Professor of Medical EthicsUniversitv of Wisconsin Medical

School

The David and Lucile Packard FoundationBoard of Trustees

David Packard, ChairmanNancy Packard BurnettRobin Chandler DukeRoberti. Glaser, M.D.

Dean 0. Morton

Susan Packard OrrDavid W. PackardJulie E. Packard

Frank RobertsEdwin E. Van Bronkhorst

The Future of Children (ISSN 1054-8289) © copyright 1992 by theCenter for the Future of Children, The David and Lucile PackardFoundation, all rights reserved. Printed in the United States ofAmerica. Cover photo © Nita Winter Photography 1992. ® Printedon recycled paper.

The Future of Children ispublished quarterly bythe Center for the Futureof Children. The Davidand Lucile PackardFoundation, 300 SecondStreet. Suite 102. Los Al-tos, California 94022.Fourth class postage paidat Los Altos. Californiaand at additional mailingoffices. The Future ofChildren is a controlled-circulation publicationdistributed free ofcharge. Opinions ex-pressed in The Future ofChildren by the editors orthe writers are their ownand are not to he con-sidered those of ThePackard Foundation.Authorization to photo-copy articles for personaluse is granted by The Fu-ture of Children. Reprint-ing is encouraged, withthe following attribu-tion: from 7'he Future ofClildren, a publication ofthe Center for the Futureof Children, The Davidand Lucile PackardFoundation. Correspon-dence should be ad-dressed to Dr. Richard E.Behrman, Editor. TheFuture of Children, Centerfor the Future of Chil-dren, 300 Second Street,Suite 102, Los Altos, Cali-fo rn i a 94022. To headded to the mailing list,write to CirculationDenartment at the sameaduress.

"SP

U.S. Health Carefor Children

ContentsStatement of Purpose Inside front cover

Introduction 4Richard E. Behrman, M.D.

Recommendations 6Center for the Future of Children staff

Recommendations for policies to make the U.S. health care systemmore responsive to the needs of children and pregnant women.

Analysis 7

Center for the Future of Children staff

An analysis of the U.S. health care system that locusts on the refe-tionship between health care and children's health and examines thissues of efficiency, access, and affordability.

Child and Adolescent Health Status Measures 25

Barbara Starlield, M.D., M.P.H.A review of the evidence concerning the state of health niche nation'schildren and youth.

Effectiveness of Health Care Services for Pregnant Womenand Infants 40

nthrls, Racine, 11.1)., Ph.D.Theodore' Joyce, Ph.D.Abrhael Grossman, Ph.D.

An examination of the health care services received by pregnantwomen and infants, and the ways in which these services affect childhealth outcomes.

Health Care Services for Children and Adolescents 58

James Perrin, MD,Bernard Gavel; M.D., M.P.H.Jean Al. Lawrence, M.S.S.A., Al.P.H.

An analysis identifying risks to health and other Factors that deter-mine the need for health are services among children andadolescents.

Health Care Resources for Children and Pregnant Women 78

Janet 1). Perloff, Ph.D.A review of the state of the health care resources currently availableto childten and pregnant vomen in the United States.

)

Expenditures on Health Care for Childrenand Pregnant Women 95

Eugene M. Lewit, Ph.D.Alan C. Monheit, Ph.D.

An analysis of annual expenditures on medical care services forchildren covering the period from conception through age 18 years,including expenditures on pregnancy and delivery.

The Role of Private Health Insurance in Children'sHealth Care 115

John F. Sheds, M.P.PPatrice R. Wolfe, ALP.P. M.

An overview of the private health insurance market with a focus onrecent trends.

The Role of Medicaid and Other Government Programsin Providing Medical Care for Children and Pregnant Women . . . 134

Ian 11 Hill, ALA., M.S.W

An overview of the major federal and state health care programsserving children and pregnant women with a focus on recent expan-sions of the Medicaid program.

Children Without Health Insurance 154Alan C. Monheit, Ph.D.Peterj. Cunningham, Ph.D.

An examination of changes in children's health insurance status andutilisation of health services during the past decade.

Nonfinancial Barriers to the Receipt of Medical Care 171Lorraine V. Klerman, Dr.

A description of the nonfinancial harriers that make it difficult forchildren and pregnant women to receive adequate medical care.

CHILD INDICATORS: Teenage Childbearing 186Eugene M. Lewit, Ph.D.

An analysis of the implications and limitations of kes statisticalindicators related to the birthrate fur teenage mothers.

Call for Papers 192

A Selected Bibliography Inside back cover

The next issue ofThe Future of Children will focus

On Adoption.

IntroductionAlthough there is considerable disagreement about what shouldhe done and by whom, virtually no one disputes the need for

health care reform in this country. As various specific changes in healthcare arc considered, it is critical to assure that these changes result inimprovements in the health of children, youth, and pregnant women.IIt is equally important that, in our zeal fOr reform, we do not make thekinds of changes that would have adverse consequences !Or these groups.

Out- ability to accomplish these objec-tives depends on an understanding Ofwhat good health means for children,Youth, and pregnant wmuen, an accuratitStietitillletlt of what services are now pro-vided to theta and the costs of these SI'V-ices. and a 1ecogttition of the significantdifferences in many dimensions of healthcare for these groups compared with carefOr the rest of the population. Because toknow where we are going, we need toknow where we are, this issue of The Fla ureof Children deals primarily- with the ways inWhich exiAti lig programs are working inregard 10 preventive, chronicmedical and surgical services for chil-dren. youth, and preg»a»t women.

A subsequent issue of the journal willhe devoted entirely to the system for pro-viding speciali/ed mental health servicesto children: therelOre. this important andcomplex issue is not separately dealt withhere. (It has been estimated in a rept wtprepared by the Institute of Medicine thatat least 12e; of children have a diagnos-able mental illness. -) The oral lw..tith ofchildren is encompassed in a limited fash-ion within discussions of Medicaid. theEarly Periodic Screening, Diagnosis, andTreatment (EPSDI) program, the Title VNlaternal and Child Health Care Block(rant, and the article on expenditures forchildren's health care.

1)r. Barbara Starfield, It pediatricianwho heacls the 1)i% ision of I Icalth Policyand Nlanagenwnt at .johns 1 lopkins

describes the health status of chil-clren from several points of N. iew. Shenotes important distinctions from Inas-

"(Mt 11"1111 311(kugg''stslicw wa

of viewing child health.

1)rs. IZacine..lovce. and Gtossman Ofthe National Bureau of Et (wont iResearch focus attention on the eflectie-

ness of prenatal, obstetrical. and neonatalcare in terms of infant nit trbidit% and nu>r-taliu related to pregnancy. discussrecent trends. the cost-effectiveness ofneonatal intensive cat-e. and neNVIIC011111111technologies.

The current spc-ctrum of health careservices delivered in the private andpublic sectors is reviewed in articles IAPerrin, Glutei., and Limn-nee. and 1)vJanet l'erloff. Perrin. Guyer. andLawrence discuss the need for communityintegration of certain programs such asimmunivation, injury prevention. andservices for adolescents. In addition, Per-loff reviews the supply, distribution, andaccessibility of medical and obstetricalservices and providers for children andpregnant wonun.

1)rs. Fatgene hewn of the Center stall.and Alan Nhmlicit of the ;Ng-click forI lealth Care Policy and Research providesignificant new data and analyses on NvItichto base estimates of the .innual medicalexpenditures for (-hitch-en from concep-tion through 18 Years of age. includingexpenditures on pregnancy and cleliven.This information is critical to making ef-fective health polio because financial in-161111:Mon al)out the health care skstem ingeneral mac mask important considera-tions that are applicable to children inparticular.

The next three articles address the im-portant issue of insutance cos entge forchildren and pregnant women. JohnShells of 1.(Aviti-ICF mid Patrice Wolfe ofMEI)STM Systems provide a review of thecurrent tole of prikate health insurance.which is the pritnar source of coveragefor most children and pregnant women.11tH Hill of 1 lealth Systems Research. Inc..descril)es and analvfes the existing cover-age of children and pregnant Nvonten

U.S. Health Care for Children 5

under Nledicaid and other governmentprograms. Drs. Alan \lonheit and PeterCunningham of the Agency for HealthCare Policy and Research present newinfOrmation about children who do nothave private or public insurance and theimplications of various strategies thatmight he implemented to deal with thisproblem.

Finally, Dr. Lorraine Klerman of theUniversity of Alabama discusses the nonfi-nancial barriers that may prevent familiesof children and pregnant women from

obtaining medical care. This issue needsto be addressed if reform of the healthcare system is to achieve its goals.

In addition to the foregoing articles,the Center staff provides an analysis of themajor -ssues involval in health care fOrchildren, youth, and pregnant women inthe United States. This summary and thestalls recommendations are based 011 aconsideration of the views discussed by thepreceding authors, a reexamination of theliterature, and conversations with leadersin variotty

Richard E. Behrman, M.D.Editor

I. National Research Council, Institute of \l dicine. Including thilthrn and pregnant women inhealth care reform. \Vashington. DC: National Academy Press. 19112.

2. Institute of NItdi ne.search on ehildtrn filladolevents with mental. behavioral. 7nel developmen-tal &smilers: Mobilizing a national initiative. \Vashington, DC: National Academy Press, 1989.

Recommendations

The following are the Center for the Future of Children staffrecommendations for policy in response to inadequacies of thehealth care system for children and pregnant women in the United

States. An Analysis discussing these recommendations follows.

1. Develop and implement a system of financing for all effectivehealth care services for children and pregnant women so that access willbe assured regardless of income level, employment status of parent orguardian, or geographic location of child or pregnant woman. Coveredservices should include care for acute and chronic illnesses and prevention.

2. Develop procedures to evaluate the effectiveness of health careservices for children and pregnant women. Assessments should includepatients' and parents' perceptions of health status as well as clinicaloutcomes. The evaluation process should be continuous and ongoing sothat new services are assessed as they become available. Evaluation resultsshould be used as a basis for reimbursement under any health carefinancing system.

3. Replace incentives for technology-intensive, high-cost carewith incentives to identify high-risk children and pregnant women andto provide risk-reducing interventions for them. Rechannel resourcesfrom wasteful, duplicative, and ineffective health services to providecare for underserved populations.

4. Establish incentives to redress the imbalance between primarycare providers and specialists. In addition, incentives should be establishedto redress the geographic maldistribution of pediatricians and obstetri-cians by altering relative rates of reimbursement to encourage migrationof providers to underserved areas and to discourage their continuedconcentration in overserved areas.

5. Develop and implement community-based programs for impor-tant health problems, such as environmental hazards, accident prevention,and safety, wl'ich can be best addressed by public action.

6. Maintain and expand data collection effOrts designed to monitorthe health status and health care needs of children on a regular basis.Develop and apply new tools to measure children's health status. Shift

9

health status measures and objectives from mortality statistics, whichprovide ;ttle information about the health of most children, to reliablemeastires of morbidity, satisfaction, functional status, and quality of lift.

7. Develop active outreach 1,rid support programs to increaseaccess to medical care for pregnant women who do not actively pursueit and for children whose parents do not otherwise seek care for them.Enhance the ability of pregnant women to seek care for themselvesand the ability of parents to seek care for their children.

8. Develop the capability of providers to deal effectively with aculturally diverse and multilingual patient population. Provide fortranslators and other intermediaries where possible or channel pa-tients to appropriate providers to assure that patient-parent-Voviderinteractions arc maximally effective.

9. Reduce the fragmentation in the system and increase collabo-ration and coordination among providers and between the i .-sonalhealth care system and the public health system. Decrease dri3endenceon categorical funding, and finance most special services through thesame system used for routine care to assure greater stability anduniformity of service delivery in different communities and improvedaccess as family situations change.

10. Develop, maintain, and enhance provider arrangementswhich effectively meet the needs of underserved, high-risk, or specialpopulations. Such entities should, however, be integrated into themainstream health care system to allow for coordination of patientcare, access to specialized services without duplication, adequate fund-ing, and flexibility to be responsive to changing circumstances.

Analysis

Americans are increasingly dissatisfied with their health caresystem and feel that it is in need of change. A summer 1991 LosAngeles TimesGallup Poll indicated that 91 % of respondents

thought there was a health care crisis in the United States and 85%thought Ow health care system needed reform) Of respondents inanother 1991 poll, 55% identified the high cost of care as the most

u

8 THE FUTURE OF CHILDREN WINTER 1992

important health care issue facing the country, and 32% chose theproblem of the uninsured as most important.2 Recently, other polls have,for the first time, documented rising levels of dissatisfaction expressedby individuals with the health care received by their families andthemselves.3

But what is happening to children as health care costs continueto escalate and access problems multiply? The evidence suggests thattheir health care is being adversely affected by the very same forcesthat are buffeting the entire U.S. health care system. For many,health care is excellent and health status is high; for many others,health care appears deficient and health status wanting. For all,health care is expensive, perhaps ne.-cllessly so, causing a shift ofresources from other worthwhil.c pursuits, and health care is at timesuncertain as dynamics in the private health insurance market makecontinued insurance coverage unpredictable.

Because health plays such a pivotal role in the development andwell-being of children, we believe that children and pregnant womencannot afford to wait while the health care crisis deepens to the pointwhere reforms are unavoidable. Accordingly, this journal issue fo-cuses on the health care system for children and pregnant women inthe United S ates because of the need to advance health care policyfor children now. Each article in this issue addresses a specificcomponent of the complex U.S. health care system for children. Inthis article, we synthesize the individual analyses and our own re-search to highlight the system's strengths and weaknesses and theinterconnections among the various components of the system, andto assess the impact of forces at work in the system on the well-beingof children.

Assessing the role of the U.S. health care system in assuring andimproving children's health is difficult because children's health re-sults from a complex interaction of health care, genetics, parentalbehavior, family and community environment, and individual behav-ior. Evaluation is further complicated because the resources devotedto health care for children and pregnant women are obtained at theexpense of other desirable activities for this group or at the expenseof other population groups. Nonetheless, we feel a health care systemwhich is efficient and ensures access for all who need care at a pricesociety can afford is a reasonable minimum goal for the nation.4 Thisgoal provides both criteria with which to review the current health caresystem for children and pregnant women and guidelines for poten-tial reforms. We begin by examining the relationship betweenhealth care and children's health. We then turn our attention to theissues of efficiency, access, and affordability. Throughout, our ob-jective is to help build a consensus for actions which will make thesystem more responsive to the needs of children and pregnant women.

4

1

Analysis 9

Medical Care andChildren's Health

The primary purpose of medical care isto preserve and improve health.Health, when perceived as "state ofcomplete physical, mental, and socialwell-being and not merely the absenceof disease or infirmity,"' is clearly desir-able in its own right. In addit::m, espe-cially for children, good health isessential for the multidimensionalprocesses of growth and development.Indeed, children's health status is inpart manifested in the process of theirdevelopment.

Children's health depends on a com-plex array of factors. Medical care is butone element of the matrix. Family,home, and community environmentsplay major roles in determining chil-dren's health. Because adequate nutri-tion, safe environments, and healthylife-styles may 1w as important to chil-dren's health as timely access to appro-priate medical care, we begin thisanalysis with an overview of how thesefactors impact health through the devel-opmental stages of pregnancy and in-fancy, childhood, and adolescence. Wethen turn our attention to assessing howwell the U.S. health care system is servingthe needs of children and preg-nant women.

Pregnancy and Infancy

Children's health status begins with theconditions from which children emerge.A child's genetic endowment and intrau-terine and neonatal environments arecrucial determinants of health. Maternalhealth status, diet, and use of unhealth-ful substances such as tobacco, alcohol,and illegal drugs during pregnancy canall influence the health of the infant atbirth and throughout childhood. Nega-tive influences in the prenatal environ-ment are expressed most dramatically inneonatal mortality and serious congeni-tal abnormalities and, less dramaticallybut more frequently, in infants born pre-term or with low or very low birthweights. Low birth weight babies aremuch more likely than heavier babies to(lie during infancy. to experiencechronic health conditions, and to en-counter problems in school.

Childhood

Even during childhood, health statusmay depend more on parental and com-munity factors than on health care.Parents' responsibilities include encour-aging healthy life-styles, assuring a safehome environment, and seeking neces-sary medical services. Parental behaviorhas an important impact not only on themental and emotional health and devel-opment of children, but as in the case ofparental cigarette smoking for example,on their physical health as well.

Injuries are today the major cause ofmortality, morbidity, and disability inchildren. In addition to accidental inju-ries, child deaths from homicide are in-creasing, and intentional violence is animportant threat to health in many com-munities. Medical care has an importantrole to play in treating the trauma causedby accidents and violence, but injury pre-vention remains primarily in the purviewof the family and the community. Pro-tecting children from exposure to leadand other environmental toxins anddangerous physical environments, pro-viding safe toys, using car seats andsmoke detectors, and not leaving chil-dren unattended are all importanthealth promoting and sustaining activi-ties which rest largely within the family.Cotnmunity activities which create safeenvironments and protect children fromviolence inside and outside their homesalso contribute to children's health.

Adolescence

Behavioral and environmental factorssimilar to those that affect the health ofchildren also play a major role in deter-mining the health of adolescents. In ado-lescence, however, responsibility forbehavior and health increasingly shiftsfrom parents to the teenager. In partbecause of high-risk behaviors engaged inby some adolescents and the hazardousenvironments they may inhabit, the 10- toI9- year -old age group is the only segmentof the U.S. population in which mortalityrates have not declined substantially overthe past 2(1 Vearti. l'nsafc driving, smok-ing, alcohol and drug a' )use, prematureand unprotected sexual activity, and vio-lent, delinquent behavior all take theirtoll. These behaviors cannot be addressedsolely or sufficiently by the healthcare system.


others. rely on objective measures ofRECOMMENDATION: Implement health status in performing our analysis.community programs to addressimportant health problems that can be Efficiencymost effectively addressed by publicaction. Given Americans' concern over the high

cost of health core, it is reasonable to askif the system is efficient. Efficiency is adesirable characteristic of a health care

Our Frame of Reference system because, in a world where resourcesare scare, and wants are not, an efficient,stcri, will produce a desired level of

To those who view health compRhensivelv ,neattn with a minimum of waste. expense,as a state "complete well-being. mak- or unnecessary effort. As compared withing distinction, among the health-enhanc- an inefficient health care system, an Oft-ing roles played by the health care system. (Tient system will release resources to satisfythe family, and the community may strike other wants or to produce a higher level ofa false 'rd. Indeed, we would agree that health fOr a given expenditure.the public Uealth communit has playedand should continue to phr: important Determining the efficiency of the U.S.roles in educating parents in N-aVS to pro- health care sYstm for pregnant woolenmote the health of children. in cii:;tourag- and children requires accurate measure-ing unhealthy behaviors. and in mem of-both the value of resources enter-promoting safe communities. These ef- ing the system and the value of outcomesForts are to he encouraged and supported. attributable to the system. ExpendituresSome societal problems such as poverty on inputsdoctors' time and expertise,may be too substantial and intractable (Or hospital care, drugs, tests and x-rayscanthe public health community to address be used as a measure of the value of n'-effectively and will require nune broad- mmrces going into our health care system.based action. Rs this measure, the U.S. health care

system is the most expensive in the world.Ultimately, however, Any analysis ,

is est imated t hat we will spend $3.057 perthe health care system reflects explicit person on health care in 1992,6 one thirddecisions regarding what behaviors and more than Canada, the country with theenvironmental conditions are the respon-

, ratere of expenditure onsibilitv of the system and what are bevono health care in the world.? Although datathe system's borders. In this analysis wefocus on the traditional medical care do not exist from other countries to cony

pre with U.S. data about expenditures onsystem. M'e believe that what most peoplebra lth care fin- pregnant women and chill-want first from a health care system is dren, there is reason u) believe that ourprompt and effective treatment of illness expenditures hit- these population groupsand trauma. Specific services that are may also be the highest in the world. U.S.touched on in this context include diag- expenditures on health care for children

nos's and treatment of illness: ameliora- and pregnant women totaled Sh7.1lion of symptoms to improve the qualitybillion

in I 987. (See the article by Lewit and :Mon-of life: prognostic services to facilitate licit in Clis journal issue.)planning and coordination of medicaland nonmedical services: and prevention Moreover, expenditures on childr(of certain illnesses through early inlet- and pregnant women have been growingvention and immuniiations. We recog- rapidly. I.ewit and Monheit find that, evennife that even when narrowly defined. after adjustments for inflation, aggregatehealth care can provide main other sere- expenditures on health care 1.01. Childrenices such as comfort, reassurance, and neark doubled between 1977 and 1987.guidance that are tight allied In parents Their analysis suggests that expendituresand children. We recognize, too, that on obstetrical care for pregnant womenUnlatch- any answer to questions about v:ere also increasing rapidly during thishow well a health care sxstem is serving period. If we are concerned :ilium effi-the needs of children reflects indhidnal cicncv, it is not unreasonable to askpreferences. In the absence of agree- whether the ire lease in resources devotedme m, on how to measure preferences to health came has resulted in a (miniu-and to distinguish the preferences of par- situate improvement in the health of preg-ems fi urn those of:children we, like most nant women and children.

1 3

Analysis 11

Measuring Outcomes

The measurement of outcomes is vital toassessing the efficiency of the health caresystem. However, 1112asuring children'shealth status is a complex undertaking.The complexity drives in part froai thefacts that children are generally per-ceived as healthy and that they experi-ence low mortality rates. When deathsoccur at the rate of less than 5 per10,000, as they do for children 1 to 14years old, it is unreasonable to view deathrates as useful measures of the healthstatus of the 99.95% of children whosurvive.8 Even among infants, death isalso an in frecisient event, so the infantmortality rate may not be a reliable guideto the health of the overwhelming ma-jorit of infants who survive.

Starlield's review in this issue of thevarious measures of health status con-firms that it is easier to catalog and countspecific diseases than it is to measure"health." In fact, the key to adequatelyaccessing the health care system may beto develop a set of fairly comprehensivemeasures which capture the severity, va-riety. co-occurrence, and recurrence orpersistence over time of children'shealth problems. Such health statusmeasures are crucial for identifyingprohlem areas that need attention andsuccesses that may provide models forsubsequent remedial activities.

Outcome measures also need tocapture the distribution of health prob-lems in the population and the severity ofillness. Health problems are not evenlydistributed in the population. Childrenliving in extreme poverty and childrenwith severe chronic illness have a rela-tively high likelihood of experiencing avariety of health problems which call fira medical care response. (See the articlesby Starfield and by Perrin, Guyer, andLawrence in this journal issue.) Identifi-cation of these children is necessary iftheir needs are to be addressed. Recogni-tion of the multiplicity of their needs isnecessary if treatment is to he successful.Severity of illness is an important charac-teristic of health status that may be diffi-cult to reflect in overall health statusmeasures. Fortunately, serious healthproblems among children are relativelyrare: but when they do occur, they have asignificant impact on the child and hisfamily, and they offer a challenge to thehealth care system.

RECOMMENDATION: Developnew tools to measure children's healthstatus and expand data collection toregularly monitor the health status andhealth care needs of children.

Although it may be difficult to reachconsensus on a single set of indicators tomeasure children's health status.American children are on averagehealthy.`-1 Nonetheless, on some keyhealth indices, children's health statusdoes not appear in line with expenditurelevels and may actually be declining de-spite rising expenditures.

Infant Mortality

Although infant mortality continues todecline, the rate of decline in infant mor-tality in the United States has slowed overthe past decade. hi 1991, the U.S. infantmortality rate of 8.9 deaths per 1,000 birthswas higher than infant mortality rates in 22other industrialized nations. 1° In addition.infant mortality rates for blacks and certainother minority population groups are con-sistently considerably higher than the ratefor the population as a whole. (See thearticle by Racine, Joyce, and Grossman inthis journal issue.)

Low Birth Weight

Birth weight is a key indicator of thehealth of newborn infants. Low birthweight babies (those weighing less than51/2 pounds) are much more likely thanother babies to die during their first yearof life and to suffer from long- and short-term disabilities. Approximately 7% ofbabies in the United States are born at lowbirth weight. This rate, which has notchanged in the past decade, is higher thanthe rate in 30 other countries. The rate forblack infants, which is almost twice therate for white infants. has actually in-creased in recent vears.10

Preventable DiseasesMany of childhood's communicable dis-eases can be prevented with routine im-munizations. Yet immunization rates forpreschool children in the United Statesare low, and the country has experiencedmeasles outbreaks in many cities in recentyears. Although these diseases are fre-quently not serious, deaths and signifi-cant neurologic morbidity have resultedfrom these outbreaks. Moreover, failureto protect children from the risk of mor-

1 4

12

biditv and possibly serious illness at rea-sonable cost is further evidence of ineffi-ciency in the health care system forchildren."Chronic and Disabling Conditions

At least 1 5% of children are affected bychronic and disabling conditions includ-ing mental and nervous disorders whichlimit normal childhood activities)`' Someof these conditions may have been easilyprevented or substantially ameliorated bytimely health care and reductions in envi-ronmental risks. For other conditions.prevention mav he extremely difficult orimpossible given the current state ofknowledge. All of these children couldbenefit from effective health care. As Per-rin. Guyer, and Lawrence note, providingcare efficiently for these children has be-come a major challenge to the healthcare system.

Improving Efficiency

The evidence suggests that the health caresystem is not functioning efficiently Forchildren: costs are high and rising, andhealth indices are disappointing. Improv-ing the system's efficiency begins with theidentification of health care services thathave been reasonably well demonstratedprovide significant net benefits fOr patientswith specific clinical conditions. Thenchoices have to he made benveen alterna-tive approaches to clinical problems andincentives established to assure that waste-ful practices are avoided while effectivecare is encouraged. There is reason to be-lieve that efficiency could he substantiallyincreased if these three steps were f011owedin the delivery of acute and preventive carefin- children, and of prenatal care.

Acute Care

Because of fin uncial and nonfinancial bar-riers, many children do not receive timelyacute care. Although most childhood ill-nesses will improve whether they aretreated or not, delays in obtaining effectivecare can sometimes lead to extended peri-ods of morbidity and discomfOrt ilnd tomore serious illnesses or disabilitv.13 Limi-tations on access to appropriate acute careare more likely to occur among low-incomechildren who may be at increased risk foranumber of health problems. These are the\IT\ children fix whom timely care mightbe most effective. Ultimately, most chil-dren will receive care fOr serious illness. Bythen. theirovemll health and developmentmay have been compromised and the care

THE FUTURE OF CHILDREN WINTER 1992

HMV he more (05th than it would have beenif the disease had been treated earlier.

Although much attention has been fo-cused on the health problems resultingfrom under-treatment of illness in chil-dren with limited access to health care,12less attention has been focused on over- orinappropriate treatment. Yet, there is evi-dence to suggest that the unnecessal v andinappropriate treatment, which is a seri-ous source of inefficiency in the U.S.health care system as a whole, affects chil-dren also. For example. until recently ton-sillectomy on children was the mostfrequently performed surgical procedurein the United States, although it is nowagreed that these operations are rarely ofvalue. 1 -1 Similarly, the use of antibiotics totreat common upper respiratory infec-tions of viral etiolor and decongestants totreat otitis media are common practices,but of doubtful efficacv.17)

RECOMMENDATION: Evaluate theeffectiveness of health care servicesand use the assessments as the basisfor reimbursement.

Preventive Care

In Ow area of preventive care, the Officeof Technology Assessment (() I A) hasquestioner' whether the protocol for well-child care recommended bv- timeAmerican Academy of Pediatrics (AAP)and practiced by natty physicians has apositive effect on health.9 lnt-ntunitations For a number of childhoodillnesses, however, are not only efk-ctivebut appear to he cost-saving as well. Ac-cordingly. it has been recommended thatin otherwise healthy children, well-childisits be limited to those IlerCtitiarl 10 carry

out the required number of immuni/a-firms and timed to coincide with the im-munization schedule. The resourcesfreed up by reducing the visit schedulecould be reallocated to increase the like-lihood that children receive inuntiniia-lions and other effective health' services,and to offer a more intensive, nonn trli-tiottal set of services for high-risk chil-dren.' 11 Curren tIV. ISO experts I rumvarious disciplines are developing Na-tional Guidelines for I lealtli-Sfipery isionfor Infants, Children and Adolescents aspart of the Bright Futures project. Theywill address the issue of the appropriate

Analysis 13

'WI-10(1161N bV first look-ing- at content and tli need to fashioncare to the circumstances ofdifferent chil-dren. Efficiency misty be improved if

;i150 d.CVC10pCd 10 targetservices to appropriate populations.

Exposure to ineffective acute or pre-ventive care can cause discomfort, andplaces children at risk of treatmen t-induced illness. It also wastes resources.Nloreover, the financial incentives thatreward Mei fliN e medical care divert re-sources from the provision of necessarycare to needs children. The nation can-not afford 10 waste medical care re-sources when manv children are notreceiving basic effective services such astimely acute care and immunizations. Ef-forts should be directed at evaluating thecontent of health care for children withthe objective of identifying effectivehealth care services. Incentives shouldhe established to encourage a shill inresources from the pit vision of ineffec-tive care to the provision of effectivesrvices to children in need.

RECOMMENDATION: Replaceincentives for high-cost andineffective care with incentives torechannel resources to high-risk,underserved populations.

Nor should efforts to increase effi-ciency be limited to an attack on ineffec-tiyeintt.ryentions. Attention should also focus(III alternative Wass to produce and delivercare. Increased utilization of par:prolsionitIN and ;Ilicrnaiivr wags of organizingservice delivery, ,fs in communitv healthecuiers, ma\ efficiently enhance very ice de-livery and health levels. (See the article bsPerloff in this journal issue.) Similarly, or-ganizing networks of providers capable ofdelivering health cart. at different levels oftet hnological sophistic:Moil, its in peri-natal referral networks and chronic carehierarchies. holds out the profilist of c ott-st the duplication of the %CIy costivhigh technology services which are tileliallmalk of the l.S. health cart s\while facilitating access to_these cutting:-edge technologies for those children vylioneed them. (See the articles by Perloff;12acine, Jov«.. and (;1(tssinair. and 1'crrin.(:tner, and I .invreticc in this journal issue.)

Prenatal Care

Early and comprehensive prenatal carefor pregnant women has been identifiedas an effective intervention to improveboth maternal and infant health. Vet.despite the recent :mention focused onprenatal care by policvmakers and thematernal and child health community,iu 19)10, I in -I American infants was bornto a mother who did not receive earlsprenatal care. and since the mid-I 980s.the proportion of expectant motherswho receive early prenatal care has de-clined somewhat.")

While the United States was makinglittle progress expanding utilization ofprenatal care services in the late Igtins.the number of high-risk pregnancies wasincreasing. The number of childrenborn to families with incomes below155'( of the federal poc rtv levelwhich is $11,57( for a family of threeincreased to almost 2 million infants peryear, 501 of all births. In addition, thepercentage of births to unwed and teen-age mothers has !wn increasing (seethe Child Indicators section). Rothgroups tend to receive less prenatal careand are at increased risk of deliveringlow birth weight infants.

RECOMMENDATION:outreach and support forunderserved pregnantparents, and children.

Provideotherwisewomen,

II Mil\ for a serious reevalu-ation of U.S. policy on pregnancy andbirth outcomes. Slow but steady progressin reducing the U.S. infant mortalitv ratein the face of constant or slighth increas-ing rates of lots birth weight births hasbeen achieved by apph ing increasinglysophisticated and technologicallv ad-vanced therapies to high-risk infants. Asa result, U.S. mortality rates for low birthweight babies are the lowest in the world.We pas, however, a high cost for thistechnologically intensive approach to in-fant health. I .ow weight babies who ac-count for 7e; of all births consume

tin'; of the health care costs of allnwi,C,-n,4.10 fn addifit,, many. will re-quire costh medical, educational, andother spec ial suppol t SCrViCls fin. man\%ears after their initial hospitalization.

G

14

Since the incidence of low birthweight may be reduced by comprehen-sive prenatal care and other supportservices, the failure of the U.S. healthcare system to deliver this care to a sub-stantial segment of the population ofpregnant women is a significant sourceof inefficiency in the system. Because offinancial and other barriers, many high-risk mothers have little or no prenatalcare. Their babies, however, receive ex-pensive and very technologically sophis-ticated care once they are achnitted to aneonatal intensive care unit (NICE').There is also reason to believe that theprenatal care received by many low-riskwomen, who primarily just need watch-ing and guidance, can be unnecessarilyinvasive and expensive.17 The high fre-quency of use of expensive proceduressuch as ultrasound, electronic fetalmonitoring, and cesarean delivery inlow-risk women may he a waste of re-sources, particularly when evidence sug-gests that use of these interventions mayhe as much a function of financial incen-tives as clinical necessity. IS

It may he time to rethink the deliveryof pre- and perinatal care. Population-based clinical protocols could he devel-oped to provide for a reasonable,cost-effective standard of care for all preg-nant women.17 The content of prenatalcare should be examined to identify thespecific components that work and thepopulations for which they are effective.Research emphasis should be shifted awayfrom advancing the frontiers of survivabil-ity in the NICU to developing innovativeprograms, such as active case manage-ment, to reach and effectively care forhigh-risk women. Because whether or nota baby is wanted is an important factor inpregnancy outcomes and child health,family planning and preconception careshould also be encouraged.

AccessThe problems caused by restrictions onthe access of children and pregnantwomen to needed medical care servicesare growing and attracting more atten-tion. For many, the problem of access isdefined by a growing pool of individualswithout health insurance or with inade-quate coverage in an environment of ris-ing health care costs. It appears that thedeclining rate of health insurance cover-age is itself a product of the rapid increase


in health care costs. In addition, howeventhere are a number of important nonfi-nancial barriers which seriously limit theaccess of children and pregnant womento health care. Efforts will need to bemade to reduce these nonfinancial barri-ers if the health care system is to success-fully address the needs of children.

The Lack of Health !nsurance

Because it reduces the out-of-pocket costsof health care at the time when servicesare received, health insurance, both pri-vate and public, plays a crucial role infacilitating access to health care services.Depending on the breadth of services cov-ered, health insurance may enhance useof prenatal care, may improve pregnancyoutcomes and infant health and, as a re-sult, have a beneficial impact on the entirerange of child health and development.Consequently, concern over children'shealth engenders a focus on disparities inhealth insurance coverage for childrenand pregnant women.

Because health insurance can playsuch an important role in children'shealth, it is disheartening to rate thatover 8 million children under the age of18 years and 9% of pregnant women(433.000) were without health insurancein 1991.12 These numbers reflect a morethan decade-long falling trend in the per-cent of children covered by private,largely employment-related coverage.Moreover, these numbers understate thetotal number of children uninsured atsome time during a Year. Almost 1 in 1children (23%) were without health in-surance at some time in 1987. (See thearticle by Monheit and Cunningham inthis journal issue.)

Monheit and Cunningham documentthat compared to children with either pri-vate or public insurance, uninsured chil-dren are less likely to have a usual sourceof care and have fewer physician visits forparticular acute illnesses. Uninsured chil-dren are also less likely to be adequatelyimmunited than children with health in-surance. Others have documented the re-lationship between inadequate insurancecoverage and inadequate prenatal ci,re.19Moreover, the increased use of expensiveinpatient hospital care by uninsured chil-dren appears to be, in part. a consequenceof delays in obtaining effectiveacute eare."

Overall, the impact of a large popula-tion of children and pregnant women

Analysis 15

without health insurance is multifaceted.Children suffer increased incidence of ill-ness, morbidity, and perhaps deathbecause access to care is constrained.Families suffer because of uncertaintyabout their abilitv to obtain timely care fortheir children and because of the substan-tial burden of paying for care for a seri-ously ill child represents. Moreover, theburden on society is substantial; ulti-mately, society absorbs the costs of medi-cal care for uninsured pregnant womenand children who cannot pay for theirown care. This burden is greater than itneed be if the uninsured are more costlyto care for because of reduced access totimely care. Added to the financial bur-den of providing care for the uninsuredare the costs of increased morbidity andreduced potential among those in poorhealth. The facts argue strongly for actionto expand financial access to basic effec-tive health care services for all childrenand pregnant women.

RECOMMENDATION: Implement asystem of financing to pay for alleffective health care services forpregnant women and children,regardless of income, employmentstatus, or location.

41111111111111111111111111111NII

MedicaidRecognition of the vulnerable healthatus of children and pregnant women

and of the importance of prenatal careand children's health care were (as dis-cusxd by Hill in this journal issue) impor-tant elements in the decisions to expandMedicaid coverage fir pregnant womenand children in the 1980s. Several stateshave also extended health insurance cov-erage to uninsured children who do notqualify for Medicaid.

Enacted in 1965 by the federal govern-ment but administered by the individualstates with some federal funding, Medicaidhas been called this nation's health caresafety net. Unfortunately. Medicaid's com-plexity and variability from state to state incoverage options and eligibility criteriahave resulted in many inequities and in-consistencies regarding who is served andthe services to which they are entitled. As aresult of a series of federally mandatedMedicaid expansions, states are now re-

quired to cover all pregnant women andchildren 0 to 6 years old in families withincomes up to 133% of the federal povertylevel. In addition, states may expand cover-age for this group to include those withhicomes up to 185% of the poverty level.States are also required to phase in cover-age for children 6 to 19 years old in familieswith incomes tip to 100% of the povertylevel so that all children in this category arecovered by 2002. Although these expandedeligibility criteria may add millions of chil-dren to the Medicaid program nationwide,many children will remain uninsured, andpoor children 10 years of age and oldertoday will never be insured under the 10-year phase-in because they will always beolder than the advancing age cutoff point.Clearly, although the recent expansions ofMedicaid eligibility criteria are to be ap-plauded, they still fall far short of assuringaccess to health care for all children.

Because so many children remain un-insured despite recent Medicaid expan-sions, at least six states have developedprograms using their own funds to providehealth care coverage for children ineligiblefor Medicaid.2° Minnesota, through itsChildren's Health Plan, created an insur-ance program for children up to age IS infamilies with incomes at or below 185% ofpoverty. For a nominal annual premium of$25 per child, the plan covers primary andoutpatient medical services, dental serv-ices, prescription drugs, and limited men-tal health services. Inpatient hospital care,however, is not covered, an important limi-tation. In January 1992, almost 25,000 chil-dren were covered by the plan which isfinanced by general state revenues in addi-tion to the premiums.21

Although there have been no formalevaluations of the Minnesota program, thestate has expanded the concept into a gen-eral health plan, Health Right, which willhe phased in over se :eral years. It will offercoverage for inpatient hospital care andexpand eligibility criteria to include chil-dren and adults in families with incomesup to 275% of the poverty level. The ex-panded plan will be financed in part bypremiutns graduated according to incomelevel and tailored to the benefit package.

We have previously suggested an incre-mental approach to universal health insur-ance coverage fir children and pregnantwomen.22 Minnesota's incremental ap-proach of expanding the breadth of serv-ices covered, extending coverage to larger

16

groups of uninsured populations, and re-lying on a mix of financing mechanisms isan example of how such a strategy mightoperate. Minnesota's experience is cer-tainly worthy of further study to evaluatehow well the plan is serving the needs ofits targeted population and to identif fea-tures of the plan which facilitated its im-plementation and function. Ultimately,the approach may serve as a model toother states and even the federal govern-ment for tackling the problems of unin-sured children.

Programmatic Barriers to Access

Lack of private health insurance and ineli-gibility for Medicaid coverage are not theonly financial barriers pregnant womenand children face in gaining access tomedical care. Particularly with regard toMedicaid, utilization of health care hasbeen limited by programmatic and admin-istrative complexities and low provider re-imbursement rates. Recently, privateinsurers have increasingly invoked admin-istrative controls to limit utilization andcosts. (See the article by Sheils and Wolfein this journal issue.)

I Jill, in this issue, provides a catalog ofMedicaid policies and procedures that ef-fectively reduce access to care fen- childrenand pregnant women, and a description ofthe actions many states have taken recentlyto reduce these administrative harriers.Although the jury is still out regarding howeffective these reforms will he and whetheror not all states will participate in the in .ive-mem to expand access, these changes arca long time in coming and should he en-couraged. Facilitating enrollment in Medi-caid is particularly important for pregnantwomen because delay in establishing eligi-bility can thwart and discourage pregnantwomen who are attempting to receive careearly in pregnancy.

Sonic state Medicaid programs arcalso engaging in active outreach, case-finding, and public education activities.Although these initiatives are also largelyunevaluated, available in limited areas,and even experimental. they hold outpromise not only for enhancing access toprenatal care but also for facilitatingutilization of the health rare system andimproving the health-related practicesof targeted populations. The potentialfavorable fallout from these efforts forthe long-term health of the children ofmothers exposed to these programs war-rants further investigation.


UnfOrtunatelv, as Ilill notes, the lawsthat expanded coverage for poor moth-ers and their children have not stimu-lated activities to enroll childrencommensurate with the activities di-rected toward pregnant women. For ex-ample, the Early Periodic- Screening,Diagnostic, and Treatment (EPSDT)program, a part of Medicaid for morethan 20 years, could have a substantialimpact on the health of poor children.Yet, EPSDT services are used by only aminority of eligible children. Effectiveuse of these and other services requiresoutreach, marketing, and public in/in--Illation campaigns designed to makefamilies aware of' the availability and util-ity of these services and of eligibility cri-teria so that children are enrolled in asimple and timely manner. Most stateshave vet to make programmatic adjust-ments to enhance access for childreneligible for Medicaid benefits.

Lack of Providers

Perhaps the most pervasive obstacle tohealth care access for both pregnantworn( n and children on Medicaid is inade-quate provider participation in Medicaidand inadequate supply of providers inneighborhoods where poor families live.Low reimbursement rates and administra-tive and programmatic complexities whichmake obtaining reimbursement costly andproblematic have resulted in low and de-clining rates of participation in Medicaidprograms by obstetrical care providers andpediatricians. Rising concerns about mal-practice suas are also cited as discouragingobstetricians from treating low-incomewomen at risk for poor pregnancy out-comes. Apparently, physicians feel the lowMedicaid fees are not commensurate withthe increased intensity of care necessary totreat at-risk women or with the risk of alawsuit because ola had outcome.23Effnrtsto increase access for children and preg-nant women by expanding Medicaid andother insurance programs may be compro-mised if the pool of providers available toaccept enrollees in these programs isshrinking as enrollment is expanding.

Janet Perlofl . in this journal issue, ana-lyzes the dilemma wrought I of more than 25years of health manpower policy in thiscountr: a generous supply of physicianshas developed. but the resulting geo-graphic distribution of pediatricians doesnot match that of U.S. children. As a result,although excellent access to health rare is

Analysis 17

experienced h' Main' Children, the in-crease in the supply of pediatricians has notimproved access for the underscryed Medi-caid population. the poor in inner cities,and children in rural areas.

hospital emerg,encv rooms, outpatientdepartments, and health centers play animportant rol in providing Nit!) primaryacme care and preventive care for manychildren. and help offset sonic of' the dis-parities in the distribution of physicians.However, dependence on some of thesefacilities for care by the uninsured, minori-ties, and those who live in underservedcommunities has long been regarded asone of the shortcomings of the U.S. healthcare s\stem serving children. Care in sonicof these settings is frequently unnecessarilyexpensive and does not provide the conti-nuity and comprehensiveness of care thatdeveloping children require.2 t Facilitatingaccess of currently underserved childrento more effective modes of primary carecould improve their health status, perhapsat little or no increase in cost.

Perloff provides several suggestions toimprove access: ( 1 ) bolster the supply offamilv ph\ sicians: (2) lessen medical pro-fessional liability problems for maternitycare providers: (3) support the NationalI health Service Corps to provide physiciansh) ttndersersed rural and urban areas: and( 1) continue efforts to increase physicianparticipation in serving Medicaid-eligiblewomen and children. These recommenda-tions could have a salutary ef feci on thebarriers to access faced b\ some. They donot, however, address the issue of risinghealth care costs or pros ide a lasting solu-tion to the failure of health manpowerpolicy to improve access for traditionallvunderserved populations.

Manpower Policy

U.S. manpower policy has lot used on in-creasing the supply of provitlers with thegoal that eventually access for the under-served would improve. However, many ofthe additional pro\ iders wind up practic-ing in areas that were already well-servedb\ the existing pit wider pool. This leads toa rapid escalation of costs, little improve-ment in access for the underserved, and awidening gulf between the level of servicesecei \ rd by those with access to cane and

those without. For example, Monheit andCunningham report that die gap betweenthe amount of ambulatory care servicesreceived by insured and uninsured chil-dren widened between 1 977 and 1987. Per-

haps more telling is the tact that pediatri-cians' and obstetricians' income rose stead-ily during the past decade despite anincrease in the proportion of the popula-tion without health insurance, a decreasein physician participation in the Medicaidprogram, and a substantial increase in thephysician-to-population ratio.25 Thesedata suggest that the increase in the num-ber of practicing physicians during the pastdecade was largely absorbed in providingmore services at higher fees to that substan-tial segment of the population that enjoysexcellent access to health care.

RECOMMENDATION: Establishincentives to redress the geographicmaldistribution of physicians and theimbalance between primary careproviders and specialists.

It is time to establish incentives to re-dress the geographic maldistribution ofproviders. especially in urban areas. Rela-tive rates of reimbursement should be al-tered to encourage providers to locate inunderserved areas and to discourage theircontinued concentration in oserserved ar-eas. In addition, the use of reimbursementincentives to redress the imbalancebetween the number of primary careproviders and the number of specialistsshould also be explored. Current attemptsto re\ ise the physician fre schedule underMedicare and the efforts of some states toincrease participation in !Medicaid by rais-ing fees may provide some guidance fin- arevised manpower policy. Ultimately, poli-cies that effectively address the persistentproblems unite maldistribution of medicalmanpower may not only increase access.but also improve health status, increaseefficiency, and moderate the increase incosts by shifting expensive resources intoincwe pngluctive employment.

Special Providers for SpecialPopulations

In the absence of an effective, uniformpolicy to assure access for all to neededhealth care services. programs have beendeveloped to meet the identified needs ofspecial populations. These include localhealth department clinics and out,. r am-bulatory care facilities receiving a combi-nation of federal. state, and sometimeslocal hinds to deliver principally preven-tive care (inimuni/ations, well-child and

r)

18

prenatal care) in a limited number of com-munities. Unfortunately, these clinics arefrequently overburdened and in short sup-ply, effectively limiting access for the popu-lations they are intended to serve.

Community health centers and mi-grant health centers, supported by gov-ernment and other sources of funds, alsoprovide comprehensive primary andpreventive care to people in medicallyunderserved areas. Their focus has beenOn reducing infant mortality and child-hood disease and disability. it has beenestimated..howey"r, that the number ofcenters does no, begin to match theneed for their services, and many havecalled for a substantial increase in fund-ing to support the expansion of existingcenters and to build may new ones.I2

Few doubt that existing centers playan important role in providing care tootherwise underserved populations."[here has been, however, some reluc-tance to expand them because of con-cern that a major expansion will create a"two-tiered system" of health care, that itIllaV be difficult to sustain adequate po-litical support for health care ins'Atu-lions that cater exclusively to the poor.and that creation of special programs forspecial populations may frustrate at-tempts to solve the larger problems ofthe entire health care system. Recentchanges in federal Medicaid laws mayprovide a reasonable compromisetoward preserving the special service fea-tures of community health centers andother "look-alike" federally qualifiedhealth centers. New regulations requirethat state Medicaid programs reimbursethese providers on the basis of 100% oftheir costs of providing care. Health cen-ters have historically relied heavily ongrants for their funding; however, if theycan successfully switch to Medicaid andother third-party payers for financing,they may be able to tap a reliable sourceof funds for operating costs and to laythe groundwork for potential expansion.

Ultimately. given adequate financialsupport. centers may emerge as acceptedmainstream providers of health care intheir communities. From a funding per-spective, they may become indistinguish-able f-rom other providers; and becatise offull cost reimbursement, they should beable to offer an enhanced package of serv-ices tailored to the needs of the communi-ties they serve.


RECOMMENDATION: Develop andsupport provider arrangements whichmeet the needs of special populationsbut integrate them into themainstream health care system.

Children with Special Health CareNeeds

Although most children are basicallyhealthy, approximately 2 million havesevere conditions that require extensivehealth services. Perrin, Guyer, andLawrence note that, largely as a result ofthe dramatic shift in medical technologyduring the past quarter ceatury, at least90% of children with severe long-term ill-ness survive to early adulthood. These re-markable survival rates, themselvesevidence of some of the important techno-logical successes of U.S. health care, createimperatives for improving the quality oflife of these children and preparing themto become productive adults.

Vet, not only is the care that keeps thesechildren alive expensive, it is also fre-quently difficult to coordinate and man-age effectively. These children mayrequire highly specialized care which isnow available in many urban areasthrough children's hospitals and majorteaching hospitals. Access to these special-ized services, however, may be problem-atic for many children in rural areas.where the demand is insufficient to sup-port a variety of specialized providers. Inaddition, because chronically ill childrenhave multiple health care needs, they tendto utilize multiple providers. Collabora-tion and coordination among providers isoften lacking; and because of the disease-oriented approach of many specialists, theprimary and preventive care needs ofthese children may be overlooked.

RECOMMENDATION: Reduce frag-mentation and increase collaborationand coordination among providers,the public health system, and thefinancing system.

Federal and state Title V Maternal andChild I health programs fOr children withspecial health care needs typically provide

2 4.

Analysis 19

services for low income children withchronic illness. Nonetheless, services varygreatly from state to state. Although pri-vate insurance plans mar provide for manyor the medical care needs of these chil-dren, social and other important supportservices may 1101 be covered. Parents ofchildren with significant chronic illnessincreasingly find that some private insur-ers will not provide coverage over the en-tire period of illness. Limiting insurancecoverage may compromise the care re-ceived by a child and place a substantialfinancial burden on a family. Even if chil-dren formerly covered bs private insur-ance are eligible for public programs,parents may not know about these pro-grams or mar face procedural impedi-ments to enrollment.26

To help families take advantage of thefull range of specialty and comprehensiveservices (publicly and privately financed)fOr children with chronic illness, Perrin,Guyer. and Lawrence recommend closercollaboration between the public healthsystem and personal health service provid-ers. 'Ibis activity could be facilitated bypatient- and/or family- centered casemanagement. Such case managementwould he responsive to the needs of thechild and would provide liaison svidi andcoordinate multiple providers. Case man-agers should also be able to link familieswith sources of funding for necessary serv-ices which mav he available through spe-cial programs.

Adolescents

For mans' adolescnts, the traditionalhealth care system works well, and rates ofserious illness are low. However. becauseoiany adolescent health problems arc re-lated to high-risk behavior and becauseadolescents are in a transition statebetween dependency and adult status.they mar have problems accessing thehealth care they need.

The 1991 Office of Technology Assessnu t Report on Adolescent Ilealth identi-fied a number of barriers to health careamong adolescents which are also dis-cussed in this issue by Merman and hsPerrin, (:aver, and Lawrence. These barri-ers include low income and lack of healthinsurance coverage, Nit]) private and pub-lic: requirements tin' parental f011tielll Or!MI ifirallOO; teens' lack of knowledgeabout the need fOr and availability of serv-ices; scarcity of pros-Hers who want to dealwith the health problems of teetiagers; and

geographic and cultural factors which alsocan be important barriers for other popu-lation groups. In addition, access may heparticularly difficult for adolescents (run-aways, dropouts) who may have no regularcontact with the health care system.

The health problems of at-risk ado-.

.escents are complex and largely beyondthe scope of this issue. Alternative mod-els of health care delivers' such as school-based clinics (discussed in the Spring1992 issue of the journal) and street-front or shopping-center-based clinicsare being developed to meet the healthcare needs of adolescents. These effOrtsare to he encouraged, but they will needto be thoroughly evaluated before theycan he touted as solutions to the healthcare needs of adolescents. It is unlikelythat any one improvement in access topersonal health services will be success-ful in addressing adolescent health prob-lems caused by violence, substanceabuse, and other high-risk behavior.These will require broader, community-based interventions.

Other Nonfinancial Barriers to Care

As Klerman points out. "at sonic timealmost everyone encounters one ormore legal. geographic, institutional, orpersonal harriers to health care." Cer-tain populationsincluding the eco-nomically deprived, racial and ethnicminorities, those in isolated rural areas.migrants, undocumented aliens, home-less families, children in foster carehomes or institutions, and runawaysexperience these obstacles more often.To reduce these barriers requires therecognition that each patient may face adifferent set of impediments. Accord-ingly, facilitating access starts with iden-tifying specific impediments,implementing policies to reduce them,and evaluating the changes to gaugetheir effects. At all stages, the processshould involve those experiencing thebarriers. When resources are limited, itwill be necessary to implement these ac-tivities in the order of their actual costsand expected effects.

RECOMMENDATION: Develop thecapacity of providers to deal with adiverse patient population.

20

AffordabilityAlthough expenditures on health care foradults are many times greater than expen-ditures on health care for children, healthcare for children is still costly. The Lewitand Monheit analysis presented in thisissue indicates that average expenditureson all children 0 to 18 tears old were S737in 1987. Extrapolation based on the trendin growth of aggregate expenditures sug-gests that expenditures per childS1.130 in 1992.27 Expenditures are lowestfor 3- to 12-year-olds and highest for in-fants. In 1989, the cost of meclical care fora normal pregnancy and delivery ex-ceeded $4.500, cesarean deliveries costabout S3,000 more, and the cost of:inten-sive care given a very low birth weightinfant can exceed 3100,000.25

Families faced with the need to makedecisions on expenditures for health carefor their children know very well thathealth care purchases result in foregoneconsumption of other goods. Similarly,families who purchase health insurancelOr themselves and their children eitherindependently or through employergroups know that health insurance is not"free- and that insurance benefits receivedreflect premiums paid. Ultimately,although health instuance can reduce theburden of paving kw medical care at thetime of utilization, health care nmst bepaid for, and increasing access to medicalcare, particularly in a highly inflationaryenvironment, can be obtained only by in-creasing efficiency or reducing expendi-tures on other goods and services.

Private Health Insurance

Tile demand for health insurance,whether purchased individually orthrough employers, depends on a con-sumer's ability and willingness to pay forit. As a benefit of employment. employerpet Aided health insurance is part of a total«nnpensation package. received as an al-ternative to higher wages or other bene-fits. "Fhe NIonhit and Cunninghamanalysis indicates that the largest gonip ofuninsured children are in poor or low-income families. Although many of thesefamilies have at least one employed par-cm. their low incomes may make it unfea-sible for them to acquire insurance eitherprivatlY Or as a condition of employment.Because children in the poorest single pat -ent households are likely to be insuredthrough the Medicaid program. the hulk


of children without insurance are found infamilies with incomes too high to qualifyfor Medicaid but too low to affOrd privatecoverage.

Sheils and Wolfe chronicle how dra-matically rising costs are eroding the pri-vat t. insurance market that providesprotection fin- most Americans. As costshave risen, employers have increased costsharing and employee premiums fin' de-pendent coverage. In this environment, itis not surprising to find that as employeesare asked to pay a larger part of the costsof dependent coverage. more (particu-larly low-wage) employees are choosing todrop it. This trend has been exacerbatedkw children because they are more highlyconcentrated in families where earningsare low.29

Countervailing trends within the em-ployment-based insurance market have dif-feting impacts on children. Technicallyspeaking, the term "health insurance- is amisnomer. Most private health care cover-age is a combination of insurance againstthe large expenditures associated with in-frequent serious illness and prepaymentfor common predictable services (such astreatment fOr otitis media or prenatalcare). One response of employers to risinghealth care costs has been to increase thefirst-dollar cost sharing (co-payment anddeductihles) features of traditional healthinsurance plans while expanding coveragefor costly illness. Because much health carefor children is characterized bv presenteeand primary care, such changes in insur-ance plans may make this care less affOrd-able. Some families mav even dropdependent coverage if they believe the pre-mium contribution is not justified by thereduced benefits received under the plan.

Running counter to the trend to in-crease first-dollar cost sharing is the in-creasing popularity of various managedcare plans which attempt to control costsby limiting access to expensive health careservices. Typically, these plans offer accessto priman and preventive care with littleor no cost sharing with the idea that, 1wkeeping enrollees healthy, they can reducethe total cost of care. Although managedcare plaits have been able to market theirservices at premiums typically 10'; belowthose charged by traditional health insur-ance plans. the impact of manage(lcare onchildren's health status and utilization ofservices has cet to be bilk dew! mined.Some observers are concerned that the

Analysis 21

incentives in managed care plans are aslikely to lead to restricted access to neededservices as to improvement in health. AsennAlinent in managed care plans grows,it will he necessary to monitor the effectsof these plans on children's healthstatus particularly the health of childrenwith infrequent, costly illnessto see howtheir care compares with care received inthe traditional health care system and withreasonable, oljectiv standards of care tin'children \vith these serious illnesses.

Uncompensated Care and CostShifting

llecause of i"creases in the number ofuninsured persons and increasingly ag-gressive cost-containment efforts in mainpublic and some private programs. therehas been an increase in the level Of tinc.oin-pen sated and undercompensatd care,partic ularlY at hospitals and other organ-ized prcnicici. settings. 3() This has led toincreased cost shifting as providers raisecharges to insured paying patients in or-der to cover losses caused lw caring For theuninsurcl. !ronially, this practice may ac-tually increase the level of unconyensatedcare as it reduces the at fordabilit \- of pri-vate insurance. Moroker, as some parentsrealize that. by presenting theinscl\ es athospital emergency moms, they can ob-min expensi\ e care fiir their children re-gardless or their ability 10 pm. they ma\reassess the unlit\ of the risk protectionfeature of private health insurance andreduce their co\ erage as premiums rise.

As a result of these various cross-subsidies, the current system of financinghealth c are for children aml pregnantwonicii is so complex that it is difficult toidentify where the burden of pa\ ing forhealth care actuall \ tally. l'or example. itappears that health care for the uninsuredis Largely paid for 1w Cl 1st shifting to thosew ho are insured. This suggests that as<aeni which provided health insurance toall children and pregnant women mightnot be nun h more costly in the aggregateif pros icier cost shifting were eliminatedand charg-es to all insured patients werereduced to reflect the absence of cross-subsidies. 31 :1n anal\ sis performed 1)v I.e-

1CI: for the National Commission onChildien and the Le\vit and MonhitAnalysis in this issue both suggest thathealth insurance c nest(' could be ex-tended to main calrretitl\ uninsured chil-dren at atilt a iiii)(14.a int ras in mciall

Npvildipli es.

Whether currentl \ uninsured childrenand their families come out ahead underau expanded health insurance program.however, depends critically on how thatprogram is financed. Under the presentsystem, because of provider cost shifting.resources are shifted front well-insurdhigher income families to uninsured lowerincome families. :\ more unifOrni manda-tory insurance program, financed, for ex-ample by a payroll tax, might shift theburden of paving for expensive healthcare hack to lower income families. Care-ful attention will need to be paid to thefinancing of any expanded insurance pro-gram to make sure that it is equitable.

Health Care and Other Programs forChildren

Government expenditures for health carefor children ancl pregnant women facebudget constraints similar to those whichexist within families and businesses. El-forts to expand health care services fOrthese vulnerabl populations competewith other programs which serve thesegroups, as well as with programs whichserve other constituencies.

Evidence of the realities of publicbudget constraints is common. The recentproposal by the state of Oregon to institutea public rationing scheme in order to pro-\ ide health insurance for more uninsuredadults and children by reducing feclei all\mandated benefits for poor children andpregnant \cornett but not tile elderly is ahighih publicized example of c-ompelitionamong vulnerable populations for limitedpublic fluids, e! Similarly, in 1989. the Na-tional Governors .1ssociation asked Con-gress for a moral ol him on furtherexpansions in the Medicaid programbecause of difficulties with paving rm. PRvionslt enacted xpansions.33 yen moreto the point alt administrati\ e and otherobstacles to health care under tech( aidand other public programs which rc.flect.in part, efforts to control costs.

The trade-offs among different pro-grams heneliting children are e\ ident inthe current recessionary envinaiment asexpenditures on health care compete forpublic binds with income suppoi t pro-grams, aid to urban areas. and support I cmsc !tools. The reality is that health care forchildren and pregnant 550111ell is but 011Cpart of a larger bundle of lie -essat set \ices. \Viten making de( isions"Paudiug healthmake' s must catelttlly balanc e. the hem-

9

22

fits to lx' gained from program expan-sions against the costs of alternative serv-ices foregone.

Ultimately. the issues of efficiency,access, and affOrdabilitY are linked. If'health care can be made more efficient, itwill be more affOrdable. We will be able toafford healthier children and possibly byredistributing the savings, greater equity.In the absence of gains in efficiency,growth in health care for children will faceincreasingly stiff competition front otherchildren's programs and from the claimsof other groups. Some knowledgeable ob-servers believe that growth in health carecosts will not be controlled without explicitrationing.3-4 Should that eventuality pre-sent itself. children's interests will he bestserved if the problems of inefficiency andlack of access are already under control.

Conclusion..\s health care costs continue to escalateand access problems multiply, a consensushas emerged that the U.S. health caresystem will not change radically until amajor crisis makes it impossible for thecurrent system to continue. t' I lowever, in-cremental change appears inevitable giventhe pressures building up in the SN'Sielll. Webelieve there are several important reasonsfOr focusing any impetus be incrementalchange on the health care system fir chil-dren and pregnant w(mien. First, childrenand pregnant women are being seriouslyaffected by the same fin-ces that plague thelarger health care system, but they cannotwait until the system implodes tow theirhealth care needs to he addressed. Becausehealth and development are so interre-lated in children, failure to address theirhealth care needs adequately may result inlifelong deficiencies. Moreover. children,more than other population groups. areincreasingly lising in povertY and in high-risk environments, which mav compromisetheir health and increase their need forhealth care services.

Second, although the health caresystem for children is in many \Vass amicrocosm of the entire health care


system. children's health care problemsmay be more manageable. Expenditureson health care for children are high. butthey represent less than 14% of totalhealth care expenditures. Moreover,because of the projected growth in theelderly population, this percentageshould decline in coming Years. In addi-tion, it IllaN he easier politically to buildreform of the health care system fir chil-dren and pregnant women on the baseof the many existing public programsthat s...rve this population and on thepro-child sentiment that led to the sub-stantial expansions of the Medicaid pro-gram only a few rears ago.

Last, two major provider groups, theAmerican Academy of Pediatrics and theNational Association of Children's I lospi-tals and Related Institutions, have pro-posed major reforms of the health caresystem for children. 36 Because oppositionof providers to reforms is regarded as amajor impediment to refitrm of the healthcare system. having the support of theseinfluential groups should expedite actionon children's health care refOrms.

Concern about the well -being of chil-dren and families has become a staple ofthe political debate in this very politicalyear. But as the debate has made clear, ageneral concern fin. children, no matterhow sincerely felt or eloquently expressed,does not provide the guidance. where-withal, or accountability for sound childhealth policies. We believe that a minimumgoal fir the nation is an efficient healthcare system for children and pregnantwomen that ensures access fOr all who needcare at a price the nation can affind. Thisgoal is reasonable but will require someeffort if it is to be realized. Many concretesuggestions for improvement in the systemare provided in this analysis. the accompa-nying list of rec(rnunendations, and theindividual articles in this issue. Moving toimplement these suggestions, either as afirst step in a more global overhaul of theentire U.S. health care system or becauseof the special needs of children, is goodpublic policy.

Eugene M. LewisCarol S. LarsonDeanna S. GombyPatricia I I. Shi4n.Richard E. Behrman

7J

Analysis 23

1. Blendott, RJ., and Edwards, J.N., eds. The future of .41nericau health rare, system in crisis: The'am, for health raw reform. Vol. 1. Washington, DC: Faulkner & Gray, 1991.

2. Blendon, R.I. Edwards, J.N., and Hymns, Al.. Making the critical choices. Journal 1,1 theAredieat Awn-lotion (1992) 267,18:2509-20.

3. In 1987. 81 of Americans reported themselves as very or somt.".s.hat satisfied with thehealth care services used 1w themselves or their families; In were very or somewhat dis-satisfied with their own care. In 1992, only 71...'; were satisfied with their own care and26`.; were dissatisfied with the care received by themselves and their I.-amines. Smith.M.D.. Altman, D.E., Leitntan, R., et al. Taking the public's pulse on health system reform.//canh Affairs (Summer 1992) 11,2:125-33.

I. This goal is a modification of one attributed to third-party pavers and the public by . \TimidReiman, editor of the A'ew England Journal 01.1bylirine. Reiman, A.S. Edi, n's reply. NewE ng *Intel journal 01.111,1Th-int% 32-113:922.

5. VsAirld Health Organization. Primary health caw: Report of the htternational Corr erenee on Pri-may Health Care. Alma Ala. I'SSR. Geneva: WHO, 1978.

fi. Sonnefeld. ST, Wald. D.R., Lemieux, J.A., and Mckusick, D.R. Projections of nationalhealth expenditures through the year 2000. Health Care Finaucing Review (Fall 1991113,1:1-15.

7. Schiehr. GJ.. and Ptiullier, J. International health care expenditure trends: 1987. Health.l% /airs (Fall 1989) 8,3:169-77.

8. Bureau of the Census. Ntatistical .Ahstratt o f the foiled Stales. II I th ed. Washington, IX::U.S. Government Printing Office. 1991, table 109.

9. Office of Technology Assessment. Congress. healthy e/ii/dren: /fliviiing in the 'Wore.Washington, DC: U.S. Government Printing Office (m-A-11-345). 1988.

If). National (:outtnission to Prevent Infant Mortalitt. Troubling trend.s Short-doing tog Amer -ica's next gynoution. Washington, DC: March 1992.

I. Virtually all studies of childhood immunization hake found that immunitations not oil r-duce disease Inn also Wet substantial health care cost sayings. On this basis, failure to im-num ire a large port'on of the population of young children is a source of inefficiency.See note no. 9. above.

12. National Commission on Children. Beyond rhetoric: A 11(70 A meth a n agenda Ito fhildu andlamilies.Vas.hinghns. DC: 1991.

13. Mans acute illnesses in ch,ldren (fin- example, ear infections, asthma. and lead poisoning)can he successfully treated in (Itch early- stages. hut IlliR lead to serious chronic disahilittor death if untreated. However, establishing a relationship on a population basis betweenlack of access to timely health care for acute illness and increased severity of illness orhigher health care costs has been difficult. Recentlt, several researchers have examinedthis relationship by looking at variations in rates of hospitalitation of children for condi-tions that are respnisive to eftective primary care. I.*sing this approach, Valdc/ and Dallekhate documented substantialh increased rates of hospitalization in Los. Angeles for poorblack and Latino children for conditions which Valdez and Dallek judged were unlikels tolead to hospitalitation with adequate ambulatory care. Other factors which may contrib-ute to higher rates of hospitalitation among poor children with limited access to primarycase include: increased frequency or seterin of disease among Imo: children. parents' in-ability to pay out-f-pocket for treatment on an ambulators basis, and physician concernsthat Lindh,. c ommunio and other factors might undermine outpatient therapt..lt cord-high, while suggestive. the results from Los Angeles cannot he regarded as definitiveproof that lack of act ess to adequate ambulatort care is the printart cause of high rates ofhospitalitation among poor children in Los Angeles. Valdez, R.R.. and Dallck. G. Ow\ thehealth system hue Nark and Latino communities in l.ns ?weirs County? Il'ronuis RiveraCenter, Claremont. C.A. February 1991.

I I. Institute of Medicine, Panel of I lealth Services Research. .1ssesotieni of medical «Ile 101 (1111-(1101. Washington, DC: National Academy Press, 197.1.

15. Sink :, I... et al..Hu misuse of antibiotics For ovattnent of upper respirafin s (rat t inlet bonsin children. Pediarnic (19751 55:552: Woolhett, I.. F. Do antihistamines and decongestants

es.enf otitis Inedia.i. Adialni Nursing I\ lav-Inue 19901 16,3.265-67: Randall, I.. andde«mgestant antihistamine mixture in the pletention of otitis media in chil-

di tsith c olds. Pediaten s ( 19711) 63:183.

16. Wagnet, J.1... I lerdman. R.C., and .thwit,t, DAV Welk hild (are: I loss mut It is enough%//euilh .1 /fans (Fall 1989) 8.3:117-57.

2 7)

24 THE FUTURE OF CHI _DREN WINTER 1992

17. Rosenblatt, R.A. The perinatal paradox: Doing more and accomplishing less. Health Affairs(Fall 1989) 8.3:158-68.

18. Hillman, 11,1., Joseph, C.A., Mabry, M.R., et al. Frequency and costs of diagnostic imaging inoffice practice: A comparison of self-referring and radiologist-referring physicians. NewEnglandlournal of Afedicine (December 1990) 523,23:1604-1608.

19. institute of Medicine. Prenatal care: Reaching mothers, reaching infants. S.S. Brown, ed.Wash-ington, DC: National Academy Press, 1988.

20. Minnesota. Maine, New York, sermont, Washington, Wisconsin. and Horida are among thestates with health insurance programs that target children. Hawaii has expanded healthinsurance coverage for all age groups.

21. Nlinnesota Department of Human Services. The children's health plan, a profile of /991. Pre-pared for the Minnesota State Legislature by the Minnesota Department of Human Serv-ices.

22. Barman, R.E.. and I arson, C.S. Health care for pregnant women and young children, pur-r/al of Diseases of Children (Mar 1991) 145:572-74.

23. Studies. however, suggest poor women are no more likely to sue for malpractice thancalthicr women.

24. St. Peter, R.E. Newacheck, PAP.. and Halfon, N. Access to care for poor children.purnaiqfthe American Mediral Association (May 27, 1992) 267,20:2760-04: Adav, I..A., Fleming, GX.,and Anderson, R. Aerisss to medical rare in the I1..5.: 111w has it, who doesn't. Chicago: PluribusPress for the University of Chicago, 1984.

25. Pope. G.C., and Schneider. J.E. Trends in physician income. Health Affairs (Spring 1992)I.1:181-93.

26. Kolata. S. New insurance practice: Dividing sick from well. New liffk pares. March 4. 1992.at Al.

27. See note no. 6, Sonnefeld, et al.

28. Minor. Al:. The cost of maternity care and childbirth in the United States, 1089. Health insuranceAssociation olAmrica research bulletin. Washington. DC: I 11AA, 1989.

29. More than of children live in families with income below 125% of the poverty level.See note no. 8. U.S. Bureau of the Census. table 750.

30. Fraser. 1.. Narcross, J., and Kralovic. I'. Medicaid shortfalls and total unreimbursed hospitalcare Ow the poor, 1980-89. futpury (Winter 1991) 28,4:385-92.

31. This result depends, however, on rates of reimbursement being adjusted downward in re-sponse to a reduction in the level of (Armlet-compensated care. Based on past experience.such a scenario appears unlikely. Previously, increases in the proportion of the populationcovered by third-party pavers hale been very inflationary because providers continued tobe reimbursed at established rates for both the newly insured and previously insuredpopulations.

32. Behrman, R.E.. and Lt-rson. GS. The Oregon Medicaid Priority-Setting Project: The impacton poor children. Her.lth Mairiv (Summer 1991) 1,2:235-49.

Sardell. A. Child health policy in the U.S.: The paradox of consensus. journal of Health Poli-tas. Polley and Law (Summer 19901 15.2:271-301.

3 I. Aaron, Ili.. and Schwart/. W.B. The painful presoiption: l?ationing hoqiital rare. Washington.DC: The Brookings Institution. 1981.

35. See, lea' example. Fuchs. V.R. National health insurance revisited. Health Affairs (Winter1991) I 0.4:7-17: Giniberg, L. Letter. Neie England Journal of Medicine (March 28. 19911324,13:920: Reinhardt. U.1.1. Breaking American health policy gridlock. Health Affairs(Summei 1991) 102:90-103.

30. Hai yes. B. A proposal to provide health insurance to all children and all pregnant women.Nrw kngland Journal of .1Iedn In( (19901 323:1216-20: also, National Association of Chil-dren's I lospitals and Related Institutions. wring children's nary, to &with rare: Fixing theMedu aid safety net, .11exandria. VA: NACIIRI. October 1989.

2 7

Child and AdolescentHealth Status MeasuresBarbara Starfield

Abstract

This paper reviews evidence concerning the state of health of the nation's childrenand youth. Although the major causes of death in this population are related toinjuries, the most common abnormalities on physical examination involve the ear,the teeth, and the skin. Findings from household interview surveys and from visitsto physicians indicate that upper respiratory infections and influenza, ear infections.and allergies are the most common health problems among children and youth.Chronic physical illness and mental health problems are present in 10% to 20% ofthis population, although these types of conditions are not readily apparent inroutinely collected data. Neu er conceptualizations of health suggest that, rather thanbeing distributed independently, multiple health problems coexist in individualchildren and that characteristics of ill health tend to persist over time in thesechildren. These findings indicate the need for health policies that place priority onprimary care which provides a source of continuous, comprehensive. and coordi-nated services over time, and for health status measures that reflect not only theincidence and prevalence of specific health problems but also their interrelation-ships and the variety of functional impairments associated with them.

lthough much is known about the health problems of childrenand adolescents, little is known about their health. It is far easierto catalog and count specific diseases than it is to define and

measure health. Yet it is the measurement of health that is the appropriateconcern of a health services system. The mere presence of a medicallyidentifiable disorder signifies little if the disorder does not compromiselife expectancy, interfere with normal functioning, or cause undue discom-fort. Conversely, the absence of a medically defined disorder does notprevent individuals from feeling ill or from being at risk of an abnormallyshort life span. Biological entities as vet unnamed and social entities notin medical lexicons can and do affect the way people feel and behave.

These generalizations, of course, apply to adults as \veil as to childrenand youth, but their implications are greater for young people than forolder people. Young people arc healthy by adult standards because, onaverage, they have fewer medically definable illnesses and particularlybecause, on average, they have fewer chronic disabling or life threateningdisorders. In fact, a recent report on the state of health of children in theUnited Stales concluded that "the vast majority of children arc healthy."1

0 nC,

Barham Stu rfield,M.D.,M.P.H., is a professorand head of the Divi-sion n f Health Pofiev,Departments of HealthPolicy and Manage-ment, and Pediatrics at

johns Hopkins University School of Hygieneand Public fliwIth.


Other characteristics of children distinguish their health problemsfrom those of adults. There is more biologic variability in health amongyounger people as compared to adults because the biologic deteriora-tion that comes with aging narrows the range of healthy functioning.Even where there are existing illnesses in children, they arc often in anearlier stage of development and hence may be harder to identify.

In addition, the concept of health in children and youth is differentfrom the concept in adults. Children are in a developmental phase; illhealth may he manifested by decelerations in the normal rate ofdevelopment as well as by reversals in the process of development. Thatis, abnormalities may not be manifested by pathology but only byinadequate or delayed attainment of physiological and behavioral mile-stones. Furthermore, a health indicator that is relevant at one age isoften not relevant at another, since the process of development changesboth the exposure to various threats to health and the vulnerability ofindividuals to those threats.

The concept of health in childhood and adolescence and that inadults differs in yet another way. We know, more or less, what a healthyadult should he like; self-sufficiency and economic productivity areprime concerns at least until retirement age. Other than attendance atschool and educational achievement for children over the age of 5,society's expectations of children are limited; self-sufficiencv is notexpected. From a utilitarian point of view, future economic productivityis a desirable goal, but it may be difficult to measure. Even if expecta-tions were broadened to encompass characteristics other than eco-nomic productivity, We still would not know what the importantcharacteristics are from the viewpoint of children.

Furthermore, the implications of labeling are greater for childrenthan for adults. Any health status measure that emphasizes handicapmakes children appear to be more dysfunctional than they may hebecause children have inherently greater developmental potential andhence greater capacity to adapt to or compensate for their infirmitiesthan do adults.

Lastly, the concept of positive health, as embodied in the defi-nition set forth by the World Health Organization as "a state ofcomplete physical, mental, and social well-being and not merely theabsence of disease or infirmity,"2 is most meaningful for childrenbecause the greatest danger may result from interference with theattainment of characteristics that make individuals resistant to fu-ture threats to their health.

The way in which society views and measures child health deter-mines its judgments about children's health care needs. The followingsections of this paper discuss (1) how health is measured and what weknow about the existence of important health problems and threats tohealth in different age groups of childhood and adolescence; (2) thehealth problems of children from low-income families and others at

29


special risk: and (3) new w of viewing health and how they may helpsociety to plan more appropriate and adequate services.

Health Status Measures

Vital Statistics

The most conventional method of meas-uring the health of populations is bymeans of vital statistics. including birthstatistics and death statistics. Birth statis-tics provide infOrmation on birth weight.a very important correlate of health ininfancy and childhood. and death statis-tics provide information on the majorcauses of mortality at different ages. Bothlow birth weight and infant mortality aremore frequent in the United States thanin other economically developed coun-tries. The proportion of infants horn atlow birth weight (defined as less than2,500 grams, or about 5142 pounds) ishigher than that in at least 16 other coun-tries. Because low birth weight is associ-ated with a greater likelihood ofsubsequent death or health problems,:the low standing of the United States is ofconsiderable concern. Infants of very lowbirth weight ( under 1.500 grams. or about31/3 pounds) are at especially high risk ofhealth problems. .\ decade or so ago. mostof these infants would have died. but it isnow not uncommon for infants weighingless than 1.000 grams Oust over 2 pounds)to survise. About 1 in h has() persistentproblems consisting of congenitallies or developmental delas: babies whoweigh under 751) grains at birth (aboutI I/2 pounds) have a 25ci to chanceof being so affected. (See the article byRacine. Joyce. and Grossman in this jour-nal issue.) The lower the birth weight. thegreater the likelihood of persistent prob-lems. An overall increase in the numberof children with disability in the country[nay be. in part. a result of the success ofmedical technology in keeping mans lowbirth weight newborns alive.1

Infant mortality in the United Statesis twice as high as in some countries andhigher than in at least 20 countries. Thisis a result, in part. of the greater Ire-quencs of low birth weight. (See thearticle hs Racine, Joyce, and Grossmanin this journal issue.) In fact, mortalityin the first month of life within each lowbirth weight group is lower in the UnitedStates than in other countries. suggest-ing the successes of technology-intensiveneonatal care in salsaging infants born

immature or with 11(.111111 problems thatotherwise would be fatal. The relativelyhigh mortality in the remainder of thefirst year of life is not primarily a resultof the greater frequency of low birthweight.

The five major causes of death in in-fancy are congenital anomalies, suddeninfant death svndrome, disorders relat-ing to short gestation or low birth weight.respiratory distress syndrome. and con-ditions that result from maternal compli-cations. These causes differ greatly fromthe major causes of death later on inchildhood, which are shown in figure 1.11w major cause in preschoolers is in-jury. which far surpasses congenitalanomalies. infections, cancer. and homi-

Figure 1. Major Causes of Death forU.S. Children, 1988

"uses

:angendainornahes

- -n"c!ae

S ode

Neoolasrns

^tections

::,sease

10 27 25 10 35 40 45 53

es Ger ICC SIOC DOGular!On

0 I 4 ,g_CS IN S 14 ,,e,ems 111 1574 years

Source. Nationot Center for :lealth Statistics (NICHS). Advance Reportof Final Mortality Statistics. 1988 Monthly Vital Statistics Report, 39 (7)supplement Hyattsville. MD Public Health Service, 1990.

28

cide. In the school-age Nears Ci to 1.1

wars old). the most common causes areinjuries and cancer. with other causestrailing far behind. In adolescence andyoung adulthood t 15 to 21 Years old),the most common cause of death is inju-ries, with suicide and homicide less thanone- fourth as common. Cancer is thefourth most common. with cardiovascu-hir problems emerging for the first timein this age of transition to adulthood.Rates of death are much hover in child-hood than in adulthood. 'Fond mortalityin childhood (excluding the first Year oflife) does not approach the -loath rateassociated with the most common causeof death (heart disease) in adults..-'

Population Surveys ParentalReports

Inf,wination on the frequency of acute ill-nesses in the child population can be ob-tained each Year Friuli the National 1 lealth

Figure 2. The Prevalence of Children's HealthProblems in the United States, 1981

A lerges

:1:ecotv

C et'

-:nstlittiS

ores .; ; of cue

For exornole. jaundice. skin rashes. headaches. or anemia

Source zz.tartield. B and Newacheck, P Children's Health Status.Health 'isks and Use of Health Services. In Children in a Changing"eat" S%slem 4.ssessment ana Proposals for Reform M Schlesingerana L E senberg °cis Baltimore Johns Hopkins University Press, 1990,DP 3 -2t


Interview Survey (NH'S). The most com-mon acute conditions in childhood t under1 8 years) are upper respiratory problems.Injuries are the second noist common typeof condition: the frequencies of all types ofinjuries is 22.7 and 2S.9 per 1(1(1 childrenper year for ages under 5 and between 5and 1 7. respectively. Among preschoolers.the frequencies of these acute conditionsare greater for males than females:between the ages of 5 and 17, the frequen-cies are equal except fin- higher ratesamong males tbr injuries t 3-1.7 per 100 chil-dren per Year (br males, compared with 22.8per 100 children per year for leinales).6

Supplements to the NI-I IS provide in-fOrmation about other specific conditionscommon in childhood. Figure 2 shows thatthe most commonly rportycl physical con-dition in childhood tau:es U to 17) is aller g-v.

which is reported as present in I 2`."i of

hildren in a single Year. :hronic specialtyconditions. including- CUrVattlre of thespine. hearing imxthlents, and vision prob-lems as well as hone or muscle problems.are experienced byalmost 1 Oq of childrenin a given Year..kbout 8'7 of children haverepeated ear infections. and an equal pr-cnt lime ill- defined conditions consistingof symptoms or signs such as jaundice. skinrashes. headaches. or anemia. Chronicmedical conditions such tr: al thritis. epi-lepsy. or diabetes are rpoted lb, about7'7 of children. and almost 6'7 hate oneor more episodes of 1()I1Sillifiti. VoUr per-«111 have an acute self-limitd conditionsuch as a urinary- tract intection. and morethan :1' have asthma. specific drma-tologic conditions. such zts. acne. :ut re-ported file almost 3' .7

Information on the restriction and limi-tation of normal activity caused by illnessis another aspect of health) stains measuredin household surveys. Children experi-(ice. on average, about three acute ill-

nesses a Veal' With about " days of restrictedactivity per war. including clays lost fromplay or school. <lats spent in bed. and dayswhen activity is otherwise restricted (seetable 1 ). Children reported by parents asbeing in pion- health are much more likelythan children in good health to have alimitation of their abilitY to perform activi-ties associated with their specific age gt nipas a result of One or more chronicconditions.

Until Icccntly. teliable national dataon the f requencY of in c tirrence devl-opmntal and bellaY ioral 1)roblentsin


children have been hard to come bv. Vetthese problems can interfere with achild's schooling and peer relationships,severely strain family functioning, and re-sult in costly interventions, typically eitherin the schools or the medical care system.Information collected from adult familymembers, however, as part of the 1988National Health Interview Survey ofChildHealth shows that developmental, learn-ing, and behavioral disorders are amongthe most prevalent chronic conditions ofchildhood and adolescence.8 Nearly 20%of 3- to 17-Year-olds were reported to havehad at least one mental health problemat some time during their lives. The fre-quency of reported problems was highest(29%) among males 12 to 17 %ears old andlowest for girls 3 to 5 years old. In general.the reported rates of illness rose with agebecause learning disabilities and emo-tional and behavioral problems fre-quently go unrecognized until childrenreach the ages of 6 to 8 v,ars. Evaluationof survey results suggests that black andHispanic parents may have underre-ported the incidence of developmental,learning, and behavioral problems intheir children for a number of reasons

and that the frequency of occurrence ofthese problems among children maytherefore be higher than reported.

Developmental, learning, and behavioraldisorders are among the most prevalentchronic conditions of childhood andadolescence.

Information from surveys is limited tothe types of things that mothers knowabout the health problems of their chil-dren. They would not know, for example,about problems that are undiagnosedbecause they are in a very early stage ofdevelopment. They also cannot reportconditions that would he identified onlyby a doctor's examination when the childhas not seen a doctor. Health surveys alsocannot provide accurate information onuncommon but important problemsbecause they either would not be encoun-tered in a sample survey, even one as largeas the National Health Interview Survey.or would be encountered too infrequently

Table 1. Restricted Activity Resulting from Acute Conditions and Limitation ofActivity Because of Chronic Conditions, U.S. Children and Youth

Number of acute conditions per 100 persons per year

Number of restricted activity days resulting fromacute conditions per 100 persons per year

Age Group (years)

Under 5 5 to 17

395.5 252.5

955.9 793.7

Percent of children limited in activity because ofchronic conditions

Age Group (years)

Under 5 5 to 17

of all children in fair or poor health'

of all children in good to excellent health'

22.5 37.3

1.7 5.5

of all children 2.3 6.2

'Parental report of activity limitations and as to whether child's health is excellent, very good. good, fair, or poor. In thesetabulations, good health means reports of excellent, very good, or good, and poor health means reports of fair or poorhealth.

Data from 1989 except restricted activity days by limitation of activity and parent assessed health (1984-88).

Source: Adapted from Adams. P.. and Benson. V. Current Estimates from the National Health Interview Survey. 1989. Vitaland Health Statistics 10(176). National Center for Health Statistics. 1990. Calculations and special tabulations from Ries. P.,and Brown, S. Disability and Health: Characteristics of Persons by Limitations of Activity and Assessed Health Status. U.S.1984-88. Advance data from Vital and Health Statistics. no 197. Hyattsville. MD: Notional Center for Health Statistics. 1991,

30

to yield stable estimates of their trueprevalence in the population. For this rea-son, other sources of information areneeded to round out the picture of childhealth problems.

Health Examination Surveys

Health examination surveys conducted bythe National Center for Health Statisticsin the 19705 provide information on thosehealth problems that can he detected byan examination and by a select number oflaboratory tests. Table 2 lists the fre-quency of these conditions in three differ-ent child age groups. The most commonconditions found on examination arethose related to the teeth, the skin, and tothe ear or the eve. Cardiovascular orneuromuscular abnormalities arc alsofound in about 1 in 20 children, but sus-picious conditions that are discoveredduring- a screening- examination mayprove- on 1 urther testing to be non-pathological.

One important problem not detect-able bY examination but detectable bylaboratory testing as part of a health ex-amination survey is lead poisoning.Between 1(('; and 13e; of newborns andyoung- children have blood lead leY els that


put them at high risk of later developmen-tal abnormalities. I"

Surveys of Health Care Providers

Because conditions that are less commonor are not discoverable by physical exami-nation mav not he detected by health ex-amination surveys, diagnoses made whenchildren seek care in medical facilitiesserve as an additional source of informa-tion about the frequency of child healthproblems in this country.

The National Hospital DischargeSurvey obtains information each year onthe discharge diagnoses of individuals ina representative sample of U.S. acutegeneral hospitals. 'Fable 3 shows the dis-tribution of problems leading to hospitali-zation among children in 1984. In infancybut excluding- lieu br nits). the live major

( arses of hospitalizations are acuterespiratory- infections. pneumonia,systemic infections, nonintectious enteri-tis or colitis. and diseases of the centralnervous system. The main causes ofhospitalization in preschoolers are dis-eases of the central nervous system. pneu-monia, acute respiratory infection.dsthina. and noninfectious enteritis:coli-tis. Chronic tonsil and adenoid disease is

Table 2. Percent of Children with Abnormalities on PhysicalExamination

Condition Percent of Children in Each Age Group(years)

1 to 5 6 t o l l 12 to 17

Abnormalities of the ear or ear canal NA* 20% 15%

Hearing difficulty NA 1 1

Dental problems 17 64 54

Significant skin problems 14 17 36

Poor vision NA 5 5

Cardiovascular findings** NA 3 5

Neuromuscular or joint findings NA. .

4 8

*NA indicates that the examination either did not include the condition or that it was toouncommon to provide stable estimates. Only problems with a frequency of at least I per 100are listed

"Includes findings such as innocent murmursthat may prove nonpathoioaical onsubsequent testing.

Source: Adapted from Kozak. L.. Norton, C . McManus. M.. McCarthy E. Hospital Use Patternsfor Children in the U.S., 1983 and 1984 Pediatrics 1987, 80.481-90 Starfield. B.. and Newocheck0 Children s Health Status. Health Risks. and Use of Health Services In Children in o Changing-ealth System: Assessment and Proposals for Reform M Schlesinger and L Eisenberg. eds.Baltimore: Johns Hopkins University Press, 1990. pp. 3-26.


the top cause of hospitalization in the 5-to1-1-Avar-old age group, followed bv frac-tures. asthma, appendicitis. and systemicinfections. The main causes of hospitali-zation are quite different front the maincauses of death t see figure I) in each agegroup. It is worth noting that hospitaliza-tion rates among both children andadults have been steadily falling, since1983: between 1984 and 1990. hospitali-zation rates for children under age 15 fellabout 29%, both overall and tOr most Ofthe major causes. (See the article by Per-rin and Guyer in this journal issue.)

Information obtained from medicalfacilities has drawbacks. It fails to reflectthe health problems of children who donot use services. and it nuclei-representsthe problems pit people who seek rareinfrequently. It also reflects health prob-lems only to the extent that practitioners

recognize them. Problems tbund in popu-lations that use services less, problems for

hich people are less likely to seek care.and problems that are poorly diagnosedare underrepresented in informationtom medical facilities. A related draw-

back is that the data reflect problems at amore serious stage than their distributionin the population because more seriousproblems are more likely to receive medi-cal attention.

'the National Ambulatory Medical( :are Sut-vev provides additional nationaland regional estimates of the frequency ofdiagnoses among children. Because, how-ever, this information is collected from asample of office-based physicians, the find-ings are limited to the population of chil-dren cared for in office-based physicianpractices. Acute medical problems such as«Ms (acute upper respiratot- infections ).

Table 3. Rates of Hospital Discharge' by Main Diagnosis and Age,U.S. Children, 1984

Diagnosis

Less than 1

Age Group1 to 4

(years)

5 to 14 All less than 15 '

All conditions 224.5 70.1 41.2 62.0

Infections 18.2 41 1.8 3.6

Diseases of the nervous system 16.7 7.6 2.6 5.0

Otitis meal° ' 0.3 4.5 10 2.7

Diseases of the respiratory system 24.0 '0.1 17.0

4cute respiratory infection 22.7 5.4 12 3.9

Chronic tonsil and adenoid disease 4.5 4.5 4.2

Pneun Ionia 19.6 6.5 13 4.0

Asthma 3.9 4.6 2.1 2.9

Diseases of the digestive system 32.0 8.5 5.1 7.9

Appenaicitis 19 1.3

ingutnal hernia 6.7 1.3 5 1.1

Noninfectious enteritis/colitis 7.1 4.6 1.3 3.3

Congenital anomalies 1.9 3.8 1.3 3.2

Perinatal conditions 45.5 3.2

Injury and poisoning 7 8 9.0 8.3 8.5

Fractures 2.6- 1.5 3.4 2.8

Per 1000 children: total and most common main diagnoses only

"Estimate is unstable because numoers are small

Source. Adapted from Kozak. L Norton C.. McManus M . ana McCarthy. EJ S 1983 ana 1C84 Pediatrics (1987) 80 481-90.

Hospital Use Patterns for Children in the

32

sore throats. viral infections. and contactdermatitis are common at all ages and arethe most common diagnoses made forchildren and adolescents seen in office-based practice. Chronic sinusitis and bron-chitis account for at least 1% of visits at allages. Conditions of substantial frequencyonly in preschoolers include croup (larm-gitisltracheitis). thrush (candidiasis). andneed for a vaccination. Diagnoses seenprimarily in the middle years (ages 5 to 17)include forearm fractures and hyperactiv-ity; other fractures and sprains are particu-larly common in late childhood and earlyadolescence. Allergic rhinitis occurs with

Table 4. Estimated Prevalence of the MajorUncommon* Diseases and Conditions in_Children

Disease/Condition Estimated Prevalenceper 1,000 Children

Congenital heart disease 7.0

Seizure disorders 3.5

Cerebral palsy 2.5

Arthritis 2.2

Paralysis from injury 2.1

Diabetes mellitus 1.8

Cleft lip/palate 1.5

Down's Syndrome 1.1

Blindness 0.6

Mental retardation due to fragilex chromosome

0.5

Sickle cell disease 0.5

Neural tube defect 0.5

Autism 0.4

Cystic fibrosis 0.3

Neurofibromatosis 0.3

Hemophilia 0.2

Duchenne muscular dystrophy 0.1

Acute leukemia 0.1

Deafness 0.1

Other hereditary metabolicdisorders**

0.1

'Conditions with frequency in the child population of less than 1%.

Source: Adapted from GortmaKer. and Sappenfield. W. ChronicChildhood Disorders: Prevalence and Impact. Pediatric Clinics ofNorth America (1984) 31.3-18. 'Personal communication with Dr. N.A.Holtzman


relatively high frequency at ages 5 andabove. On the other hand, internal earproblems (otitis media) almost disappearin late adolescence. Asthma appears topeak in middle childhood and then wanein late adolescence. Normal pregnancy ac-counts for almost 8% of visits among 15-to 21 -year -olds: diseases of the sebaceousglands are the second most frequentlycited cause for a visit by members of thisage group. It is important to note that theproblems of children and adolescents whoreceive their care in hospital clinics, emer-gency rooms, and facilities other than of-lice practices are not included in thesedata. Because lower-income children dis-proportionately seek care from facilities ofthis type, this listing of problems may notadequately represent the relative magni-tudes or types of problems found amongthese children.

Despite the variety of informationsources described above. many importantproblems are not apparent from these rou--tinely collected sources. Special studies arerequired to learn about these problems.

Special Surveys of ChildhoodDiseases

Information about selected childhooddisorders may be obtained from epide-mologic surveys designed to detect specificconditions. Table 4 shows the percent ofchildren with those conditions that havebeen identified by means of these specialsurveys. All of these conditions are presentin fewer than 1 `c of children. Diabetes. forexample. is present in fewer than 2 chil-dren per 1.000: many other diseases areeven less common, as the table shows.

Special surveys also document the ex-tent of other types of problems amongchildren, such as mental health problemsand problems associated with health-com-promising behaviors which are commonin the teenage population. For example.almost 1 in 5 high school seniors reportsusing marijuana in the past month. and:3%. report using cocaine at least once inthat period. Alcohol use is much morecommon: 1 in 25 seniors drink an alco-holic beverage at least once daily, and35c7 have five or more drinks in a rowwithin any 2-week period) I Despite thehigh frequency of these types of prob-lems. they are poorly recognized by mosthealth practitioners so that special studiesarc required to document their frequencyin the population.I2

U.S. Hearn Care for Children 33

)ther important problems arc missedin routinely collected data. Many child-hood illnesses are relatively uncommonbut completely preventable. These in-clude measles, mumps. German measles.polio, and whooping cough. Becauseimmunizations can prevent all of them.rates of immunization are an importantaspect of child health. Special surveys arerequired to document rates of immuniza-tion in the population: these indicate thatonly about tirlq of preschool children inthis country receive all the immunizationsthat they should receive.13 In 1990. morethan 26,000 cases of measles were reportedin the United States. Another growingproblem not reflected in routinely col-lected data is AIDS. By 1991 approximately3.385 cases of pediatric AIDS had beenreported and many more are expected inthe coming decade.; 1 Inadequate 11 UM-tionai intake is another problem that maybe -invisible- in many conventional datasources.

These special problems are relativelyuncommon. They do, however, occur dis-proportionately in low-income segmentsof the population. The next section of thispaper deals with the special problem's oflow-income children and youth.

Health Problems ofLow-income Children andOthers at Special Risk

\bout t child in 5 and l Nen. young- childut lire in families with incomes be'.ow t hefederal poverty level. and many more licin families marginally above the povertylevel. Because health problems in child-1100d compromise future health. thehealth problems of low-income childrenshould he of considerable concern in acountry dedicated to equality of opportu-nity. Low income is responsible for muchit not most of the disadvantages toundamong children in other high -risk ,groupssuch as racial minorities.15

The summary in table a indicates thatpoor children are more likely to becomeill and have more serious illnesses. Amongthe reasons for this are increased environ-mental exposures resulting from poorhousing and hazardous neighborhoods.poor nutrition. and inadequate preventive( However. the higher rates of themore serious problems and the increased(Leath rates from diseases at all childhood

ages also reflect poor access to medicalcare.17

The 15 million children who live inrural areas of the country are anothergroup at high risk. 'These children com-prise one third of all children in the na-tion, and almost one half of them residein the South. Rural and urban children donot differ much in their overall deathrates, and the frequency of the majorhronic conditions and limitation of activ-

ily associated with them are very similar.Rural children have slightly lower rates ofacute conditions, however.ls The majordisadvantage of rural children is a resultof their greater likelihood of death frominjuries. particularly those caused by expo-sure to farm machinery, firearms, and fall-ing objects: and drowning and injuries towe-imams of motor vehicles ( especially:tick-no trucks).19.'=° (See the articles by

Table 5. Relative Frequency of HealthProblems in Low-income Children Comparedwith Other Children

Health Problem Relative Frequency inLow-income Children

Low birth weight double

:relayed immunization triple

Asthma higher

Bacterial meningitis aouble

Theumatic fever doubleMole

Lead poisoning f; iple

Neonatal mortality 1.5 times

Postneonatal mortality doubletriple

Child deaths due to accidents doubletriple

Child deaths due to disease triplequadruple

Complications of appendicitis doubletriple

Diabetic ketoacidosis double

Complications of bacterial doubletriplemeningitis

Percent with conditions limiting doubletripleschool activity

Lost school days 40% more

Severely impaired vision double-triple

Severe iron-deficiency anemia double

Starfield, B Effectiveness of Medical Core. validating uintcat.1.risdom. Baltimore. Johns Hopkins university Press. 1985.

34

Perrin, Guyer, and Lawrence, and by Kler-man, in this journal issue.)

New Ways of ViewingChild HealthThe previous sections provided detailabout the conditions afflicting children.interfering with their activities, and leadingto premature death. Such catalogs are ven-useful in pointing directions to neededresearch about their cause and treatment.For example. the relatively high injury rateamong rural children serves as a stimulusto directing research on how injuries mighthe prevented. They are also useful in indi-cating where resources need to be directedto deal with localized clusters of problemsor apparent epidemics. For example. in-creased rates of aCIlle but preventable com-municable diseases may signify thatadditional resources are required to Iwo-vide immunizations. Similarly, the observa-tion that p or children have increasedrates of serious illness provides a rationalefor expanding access to health servicesthrough programs such as Medicaid.

Statistics on the frequency and distribu-tion of individual conditions or types ofproblems are less useful, however. for theoverall planning of health services. Healthservices should he organized so that theyare best suited to meeting the health needsof individuals. The health needs of indi-

A substantial proportion of children have arelatively high likelihood of experiencingseveral different types of health problemssimultaneously.

yiduals are less well represented by sepa-rately. counting the frequency of specificdiagnoses than by characterizing individu-als according to their burdens of morbidityand functional derangement. In otherwords. a person-oriented view of healthrather than a disease- or condition-ori-ented approac It is preferable for designingand operating a health services system.

Three characteristics of health prob-lems deserve consideration in developingpolicy concerning health services. Theyare variety and variability. co-occurrence.and recurrence or persistence over time.The following section reinterprets the


data provided earlier in the context ofthese characteristics when related to indi-viduals in the population.

Variety and Variability

Concepts of illness, as expressed by chil-dren and youth themselves, have severalcomponents. "Illness" can be reflected bysomatic (bodily) feelings, objective signsof abnormality, specific diseases or condi-tions, states of mood or behavior, limita-tions of activity and role deviations, or byactivities that jeopardize health.tn Chil-dren of all ages report somatic feelingswithin their concept of health: but theolder the children, the more likely they areto include mental feelings and functionallimitations as well. There is no stand-ardized measurement instrument whichincludes all of these various concepts ofl tealth. As a result. their distribution in thepopulation is unknown. However. we havesome knowledge of the distribution ofsome of them.

Table 6 contains information from theNational Health Interview Surev. In thisanalysis, each child in the survey was cate-gorized according to the number of fivemain apes of conditions that a parentreported a child to have in the sear pre-ceding the interview. The five types in-cluded acute self-limited conditions,acute but recurring conditions. chronicmedical or chronic surgical conditions.and psychosocial and psychosomatic con-ditions. Almost 3 in 5 children had noconditions in the survey year: this categonyof children includes those without anyconditions on the checklist as well as chil-dren with only minor acute illnesses, in-juries, or mental health problems. Ofchildren with one or more apes of condi-tions on the checklist, however. 25% hadtwo types and 11% had three or moretypes. The table also shows that childrenwith increased burdens of morbidity haveincreased disability as reflected by daysspent in bed. clays on which activity wasotherwise restricted, number of physicianvisits, and number of days spent in thehospital).

In addition. other data from it varietyof sources. which include diagnostic infor-mation from health maintenance organi-iations in different parts of the country,and similar information from a state Medi-caid program all attest to the wide varietyof types of problems encountered by

children:2


Co-occurrence

The second characteristic of morbidity isco-occurrence. The information presentedabove on variety of illness also demon-strates the extent to which illnesses co-occur. The concept of co-occurrence canbe viewed in another way: as the numberand frequency of minor conditions experi-enced by a child over a 6-year period in-crease, the likelihood of other types ofconditions such as injuries, chronic ill-nesses. and psychosocial conditions alsoincreases over the same period.23 Otherinformation sources suggest that healthproblems are not evenly distributed in thepopulation and that a substantial propor-tion of children have a relatively high like-lihood of experiencing several differenttypes of health problems simultaneouslv.24

Recurrence and Persistence

The third characteristic of health prob-lems is their recurrence or persistenceover time. Children with psychosomaticconditions, "specialty" problems (involv-ing vision, hearing, or orthopedic prob-lems) , or allergies in a given year are abouttwice as likely as other children to experi-ence the same problems in a subsequentyear.23 Persistence is, ofcourse, a featureof chronic conditions. For example.asthma in a child is about seven timesmore likely to be diagnosed in a given yearif the child had the diagnosis in a previousyear than if the child did not. More gener-ally, year-to-year persistence has beenfound to be a feature of the morbiditypatterns of a number of children, includ-

ing some not afflicted with what have tra-ditionally been regarded as chronic condi-tions.23 Furthermore, children with highburdens of morbidity (as reflected in thenumber of different types of health prob-lems) are much more likely than otherchildren to have similarly high burdens insubsequent years.22

Conclusions andImplications for HealthPolicyThis overview of child health status dem-onstrates that "health" may be charac-terized in many different ways and byseveral different methods. The proportionof children who are considered healthy orill depends on the measure used to char-acterize them and on the way in which thecharacteristics are measured. From theviewpoint of health policy, what is the mostappropriate conceptualization of health?

Conventionally, the health of popula-tions of children has been measured by agroup of indicators that are obtainablefrom data collected as part of vital statisticsor as part of ongoing surveillance systems.Infant mortality rates, childhood mortalityrates, proportion of infants born at low orvery low birth weight, and adolescent fer-tility rates are indicators that are availablefrom vital statistics. Rates of various com-municable diseases are indicators avail-able through ongoing surveillancesystems.25 There are some indicators thatare known as "sentinel events- because

Table 6. The Burden of Physical Illness for Children Under 18 Years of Age,as Reported by a ParentUnited States, 1981

Percent ofChildren

Avg. AnnualBed Days"

Avg. AnnualRestricted

Activity Days"

Avg. AnnualPhysician

Visits-

Hospital Daysper 1,000Children

No conditions' 58.1 3.4 7.3 2.8 132

One type of condition 27.1 6.0 13.7 4.7 443

Two types of conditions 10.3 8.9 18.8 7.4 625

Three or more types ofconditions

4.6 9.6 27.7 10.8 1,476

All children 100.0 5.1 11.1 4.2 329

'As ascertained by administering a checklist of 100 conditions but excluding most acute conditions, injuries, andmental health problems.

"Per child per year

Source Starfield. B.. and Newacheck. P. Children's Health Status. Health Risks, and Use of Health Services. In Children ina Changing Health System: Assessment and Proposofs for Reform. M. Schlesinger and L. Eisenberg, eds. Baltimore: JohnsHopkins University Press, 1990, pp. 3-26.

3 3

36

their occurrence in a population signals aneed for special attention. These includethe occurrence of a case of measles. teta-nus. diphtheria. poliomyelitis. congenitalsyphilis. mental retardation caused byphenviketonuria or hypothyroidism.vitamin D-deficient rickets, and deathassociated with diarrheal disease.26 Otherindicators that are believed to be useful inassessing children's health status includefailure to thrive. elevated blood lead levels.inadequate immunization status. growthstunting, suicides, iron deficiency anemia.and child abuse or neglect.27 Some addi-tional indicators thought to be useful inresearch or evaluations of specific inter-ventions include multiple foster homeplacements. days missed from school, dis-abling conditions, perceptual disorders.learning disability, school failures or drop -outs. inappropriate school placements. be-havioral disturbances, involvement inviolent crime, and substance abuse.

Most of the routinely or easily availableindicators are useful for monitoring ofmajor changes in large populations.Because they are relatively rare events.however, random fluctuations in their oc-currence would produce unstable and.therefore. uninterpretable rates in smallcommunities (for example. in populationsof fewer than 500.000 people).

It is apparent. however, that individualcharacteristics of health cannot capturethe range of characteristics that arc rele-vant to the health of children. At the veryleas:. measures that reflect rates and causesof death have to he separated from thosereflecting characteristics of living children.The higher the rates of death of childrenwith health problems. the lower will be thefrequency of illness in the population.other things being equal. That is. if illnessrates are stable in the population. a highercase-fatalit rate will leave fewer individualscharacterized as ill. Because mortality ratesthus "compete.' with morbidity rates. theycannot be combined in an index. at leastnot without a differential weighting:because there is no accepted method forassigning appropriate weights to death ver-sus life short of personal judgments.weighting is not likely to be achievable.

Health among the living also has sev-eral components. The most conventionalof these is morbidity as characterized byconditions diagnosed by physicians. Thesecharacterizations do net reflect the varietyof other types of manifestations of health.


Table 6 characterizes children accordingto one of these other manifestations ofhealth: restriction or limitation of activity.But even in this instance. the charac-terization depends upon the concomitantpresence of an associated health condi-

Discontinuities in the normalprocess of development cannotbe recognized without a healthsystem that provides for conti-nuity of care.

Lion. Particularly absent in any existingsource of data is health as characterized byphysical or mental feelings tssmptomatol-,,gyl, by srlf-perceptions of well-being, byachievement of normal developmentalexpectations (including the development(,f social relationships). or by the presenceor absence of characteristics that increaseor decrease the likelihood of subsequentgood or poor health.

When health problems are viewed asisolated events, which are generally self -limited in nature and expressed as medicaldiagnoses, it makes little difference howhealth services are organized as long asthey are readily available. Care from indi-vidual specialists, each focusing on thetype of health problem within their areaof expertise. might he all that is needed.Newer concepts of viewing healthwhichemphasize the varier of manifestations ofproblems. the interrelationships amongproblems. and their persistence overtimeindicate the need for deepercommitments to reorganizing services sothat they are better able to deal effectivelywith challenges CO the health of children.The developmental process that charac-terizes children and youth assures that themanifestations of health and illnesschange with time. Discontinuities in thenormal process of development cannot berecognized without a health system thatprovides for continuity of care regardlessof the presence or absence of parti,:ulartypes of medically defined conditions.

Variety of morbidity within individu-als, coexistence of different types of mor-bidity, and the likelihood of recurrenceor persistence are characteristics that de-mand primary care. Such care is readilyaccessible and recognizes the interrela-tionships of problems within people. It is

30


broad in scope and encompasses all of thei.rious aspects of health, including health

promotion, disease prevention, earlyrecognition of problems and deviationsfrom nor.nality, as well as management ofthe wide variety of manifestations of prob-lems. Primary care is care that is longitu-dinal in time and person-focused ratherthan disease-focused. It is care that is com-prehensive rather than piecemeal. It iscare that involves coordination of servicesrather than fragmentation of services. Pri-man care entails a relationship over timebetween a practitioner and a patient who,therefore. come to know each other. Thisknowledge facilitates recognition of pa-tients' problems and their management:it is especially important in the recogni-tion and management :if developmental,behavioral, and other pv.chosocial prob-lems that may otherwise be poorly recog-nized by health practitioners. Care that isconsistent over time leads to a betterappreciation of the relationships amongdifferent types of morbidity, thus makingpossible the design of better preventiveand management strategies. It also makesrecognition of discontinuities in normaldevelopment easier. Coordinated servicesprovide a better basis for efficient careand effective care than do fragmentedserYL-es, in which each problem orproblem type is managed by a differentspecialist.

Primary health care services in theUnited States are far from adequate, par-ticularly as compared with the healthsystems of many comparable industrial-ized nations. in contrast to many of thesenations, the United States lacks a well-de-veloped primary health services sector tocomplerwm its highly developed spe-cialty. services.28

Countries with well-developed pri-Marl care systems have clear lines ofdemarcation between primary care andspecialty services. Patients are either notpermitted to visit specialists on their owninitiative or are discouraged from doingso. -nu: rewards for primary (tire practiceare relat ivel greater than they are in theUnited States. As a result. te proportionof physicians practicing pi lmary care is111(1d1 greater in those countries than itis in the United States. This emphasis onpriman care tilm explain yliN, the levelof the health of children in these coun-tries is superior to tltat in the UnitedStates regardless of the measure oflicalth.29

Better ways of characterizing healthshould facilitate the recognition of thevariety of types of problems, their interre-lationships, their change over time, andtheir response to health services interven-tions. A profile of health, which includesthe several most important domains en-compassed by the concept of health,would facilitate the recognition of the va-riety of health problems in the popula-tion; the documentation of systematicdifferences across population subgroupscharacterized by social class, race, andethnicity; and changes over time that mayoccur as a result of changes in healthpolicies or health services. Such a profileis under deyelopment.30 It has five prin-cipal domains (and several subdomainswithiri each of the domains) which ad-dt Ps activity and physical fitness,physical and emotional symptoms, self-

The United States lacks a well-developed primary healthservices sector to complementits highly developed specialtyservices.

perceptions of health and satisfactionwith health, achievement of developmen-tal milestones including social interrela-tionships, and "resilteuce" (the degree towhich there arc characteristics that influ-ence subsequent health). In addition, theprofile includes an index of diagnosedmorbidity based upon the number oftypes of conditions as described earlier inthis article. Such a profile will make iteasier to determine what types of prob-lems are most common, which are distrib-uted most unevenly in the population,and which need more attention in ahealth services system striving towardgreater accountability.

\o standard of health is possible. Anstandard will change over time, as recentknowledge and social ad;ances replaceold types of problems with newer ones. Auappropriate goal would be the elimina-tion of systematic differences in healththat now exist across subgroups of thepopulation. Where these differences can-not be equalize el as. fin- example, wherethere is handicap restcltittg from birth de-fect or genetic cause, the goal should be

38

continuous improvement over time in atleast those aspects of health that are ame-nable to improvement,

Descriptions of health status a v usefulonly to the extent that they lead to the


adoption of policies directed at makinghealth services more responsive to healthneeds. This paper suggests areas for newlydirected attention and societal commit-ment toward improving child health.

1. U.S. Congress, Office of Technology Assessment. Healthy children: Investing in the future,Washington. DC: U.S. Government Printing Officc (OTA-H-345), 1988.

2. World Health Organif.ation (WHO). Primary health care. Report of the International Confer-ence on Primary Health Care, Alma Ata, USSR. Geneva: World Health Organization, 1978.

3. McCormick, M. The contribution of low birth weight to infant mortality and childhoodmorbidity. New England Journal of Medicirre (1985) 312:82-90.

4. Shapiro, S., McCormick, M., Starfield, B., and Crawley, B. Changes in infant morbidity asso-ciated with decreases in neonatal mortality. Pediatrics (1983) 72:408-15.

5. National Center for Health Statistics (NCHS). Advance report of final mortality statistics.1988. Monthly Vital Statistics Report 39(7) supplement. Hyattsville, MD: Public HealthService, 1990.

6. Adams, R. and Benson, V. Current estimates from the National Health Interview Survey,1989. Vital and Health Statistics 10(176). National Center for Health Statistics, 1990.

7. Starfield, B., and Newacheck, P. Children's health status, health risks, and use of healthservices. In Children in a changing health system: Assessment and proposals for reform. M. Schlesin-ger and I.. Eisenberg, eds. Baltimore: The Johns Ilopkins University Press. 1990, pp.3-26.

8. till, N.. and Schoenborn, C.A. Developmental. learning, and emotional problems: Health of ournation's children, United States. 1988. Advance Data, no. 190. Hyattsville. MD: U.S. Depart-ment , . Health and Human Services, Public Health Service. Centers for Disease Control,National Center for Health Statistics. 1988.

9. Dam from a more recent examination survey conducted in the late 1980s are not yetavailable.

10. Agency for Toxic Substances and Disease Registry. The nature and extent of lead poisoning inchildren in the (*.S.: A report to Congress. Atlanta: DHEIS, 1988.

1 I. Johnston, I.., O'Malley. P., and Bachman, J. Drug Itse, drinking and smoking: National surveyresults from high school, college and young adult polnilations 1975-1988. Pub. No. (ADM)89-1638. Washington, DC: DHHS, 1989.

12. Rankin, J., and Starfield, B. Epidemiologic perspectives on psychosocial problems in chil-dren. In Child health behavior N. Krasnegor. J. Arasteh, M. Cataldo, eds. New York: JohnWiley & Sons, 1986,

13. Merman. 1.. -1/ivr and well? A research and polio. wpiew health programs for poor young children.New Niirk: National Center for Children in Poverty, 1991, p. 69.

14. Centers for Disease Control. The second 100.000 cases of acquired immunodeficiency svn-dronic-U.S., June 1981-December 1991. .1 forbidiiy and Mortality lteekly Report (1992)41:28-99.

15. Starfield, B., Shapiro. S., Weiss.", et al. Race. family income, and low birth weight. A tiloicanJournal of Epidemiology (1991) 134:1167-74.

16. Siarfield, B. Effects of poverty on health status. Bulletin of the New lot* Academy of Medicine(19921 68:17-24.

17. Starfield, B. The effectiveness of nzedn al care: litigating clinical wisdom, Baltimore: Johns Hop-kins University Press, 1985.

18. McManus. M.. and Newacheck. P. Rural maternal, child and adolescent health. Health Serv-ices Research (1989) 23:807-18.

19. Waller, A., Baker. S., and Stocka. A. Childhood injury deaths: National analysis and geo-graphic variations. A nirnow journal of Public Health (1989) 79:310-15.

20. Raker. S., and Waller. A. Childhood injury: Mate by state mortality facts. Baltimore: The JohnsHopkins Injury Prevention Center, 1989.

21. Campbell. J. Illness is a point of viers: The development of children's concepts of illness.Child Development (1975) 46:92-100.


22. Star field. B. Weiner, J., Mumford. L., and Steinwachs, D. Ambulatory care groups: A catego-rization of diagnoses tot- research and management. Health Services Research (1991) 26,1:53 -74.

23. Starfield, B., Kati, H., Gabriel, A., et al. Morbidit in childhood: A longitudinal view. NewEngland journal of Medicine (19311 310:821-29.

24. Diaz, C., Starfield, B., Holtzman. N.. et al. 111 health and the use of medical care: Commu-nity-based assessment of morbidity in children. Medical Cate (1986) 24:848-56.

25. Peoples-Sheps, M., Siegel. E., Guild. P.. and Cohen, S. The management and use of data onmaternal and child 'wait:, and crippled children: A survey. Public Health Reports (1986)1(1:320-29.

26. Rutstein, D., Berenberg, W., Chalmers, T.. et al. Measuring the quality of medical care. NewEngland journal of (197(1) 29-1:582-88.

27. Miller. Fine, A., Adams-Tavlor, S., and Schorr, L. Almilioring childnm's health: Key indica-tors. Washington, DC: American Public Health Association, 1936.

28. Starfield, B. Primars care and health: A cross-national comparison. Journal of the .4 mericanMedical AASoriation (19911 266:2269-71.

29. Starfield. B. Primary rate: Concept, evaluation and policy. New Fork: Oxford l'aiversity Press, 1992.

30. Project Child, supported by the Bureau of-Maternal and Child Health, the Kaiser FamilyFoundation, the Agency for Health Care Policy and Research, and the National Instituteof Child Health and Human Development. B. Starfield, principal investigator.

Andrew D. Racine,M.D., Ph.D., is assis-tant professor of pedi-atrics at ColumbiaUniversity College ofPhysicians and Sur-geons and a facultyresearch fellow at theNational Bureau ofEconomic Research.

Theodore J. Joyce,Ph.D., is associate pro-lessor ofeconomics andof finance at City Uni-versity of New York,Baruch College, and aresearch associate atthe National Bureauof Economic Research.

Michael Grossman,Ph.D., is distin-guished professor ofeconomics at the Citytrniversi4 of New YorkGraduate School and aresearch associate althe National Bureauof Economic Research.

Effectiveness of HealthCare Services forPregnant Women andInfantsAndrew D. RacineTheodore J. JoyceMichael Grossman

Abstract

The authors of this paper focus on the health care services received by pregnantwomen and infants, and consider the ways in which these services affect child healthoutcomes. They examine the impact of prenatal. obstetrical, and neonatal care ontwo measures of infant health: the rate of low birth weight births and the rate ofinfant mortality. There is strong evidence that these two outcomes respond favorablyto the application of appropriate health services, particularly prenatal care andneonatal intensive care. The delivery of prenatal care in the United States needsimprovement: slightly more than 76% of women received early care in 1989, anddiscrepancies in prompt receipt of care among different ethnic and economic groupsarc large and persistent. Improved distribution of prenatal care services could havea significant impact on the rate of low birth weight births and infant deaths. Inaddition, expanded regionalization of prenatal, obstetric, and neonatal care in acoordinated approach to the entire continuum of gestation, labor, delivery, and earlydevelopment holds out the promise of continued improvement in infant health.Health care initiatives need to focus more on the needs of poor families and ofmothers and infants with special problems, especially high-risk pregnancies resultingfrom maternal substance abuse and pregnancies complicated 1)7 HIV infection. Theauthors describe advances in obstetrical technology and neonatology, and concludethat efforts to identify programs and activities which offer the greatest potential forimproving newborn survival with the least investment should have high priority.

Children are developing organisms. They continually grow anddifferentiate from one physical and psychological state to the next.An understanding of childhood health status, therefore, begins

with an understanding of the conditions out of which children emerge.Intrauterine and neonatal environments are crucial determinants of achild's well-being. A mother's health throughout pregnancy, the processof labor and delivery, and a child's experiences during the first criticalhours and days of life will influence health status for months and years

A')

afterward. Moreover, poor birth outcomes have been associated withimpeded cognitive development, reductions in years of formal schoolingcompleted, and lower levels of lifetime earnings and other measures ofeconomic well-being.1

Recognition of these principles has led policy analysts to give increas-ing attention to prenatal and neonatal health care services. In this paperwe focus on health care services received by pregnant women and infants,and consider the ways in which these services affect child health out-comes. For our purposes, these services include prenatal medical carereceived by women during the course of their pregnancies, obstetricalcare received at the time of delivery, and medical care received bynewborn infants during the first 28 days of life (the neonatal period). Weconsider trends in these services over time, differentials in the receipt ofthese services among various groups in the population, and the impactutilization of these services has on child health outcomes.

Two population outcome measures to which we devote particularattention are rates of low birth weight (LBW) and infant mortality. A lowbirth weight baby is one born weighing less than 2,500 grams (about51/2 pounds). The LBW rate is the number of such births per 1,000 livebirths in the population in a given year. The infant mortality rate ismeasured by the annual number of deaths among children in the firstyear of life per 1,000 live births. Because LBW babies have a higher riskof death than normal weight babies, these two rates are closely related.Though birth weight and infant mortality each have a genetic compo-nent, birth weight depends very much upon the length and quality of thefetal experience during pregnancy while infant mortality depends alsoupon the type of care, medical and otherwise, that a child receives afterbirth. Therefore, these two measures may tell us much about the effec-tiveness of prenatal and neonatal care.

We begin with a discussion of prenatal care and its relationship tolow birth weight and then proceed to a consideration of obstetrical andneonatal care and how they affect infant mortality. We shall also mentionsome promising new technologies being applied in the field ofneonatology.

Prenatal CareMuch of what influences the health of anewborn baby is beyond the control ofpolicymakers. Factors such as maternalweight and height at the beginning of

pregnancy, heritable genetic conditions, amother's previous obstetric history, eth-nicity, and marital status are conditionsthat are, to a large extent, fixed with

42

respect to most policy options. Other fac-tors, however, are amenable to change. Awoman's nutritional condition duringpregnancy, and her exposure to sub-stances known to be harmful to develop-ing fetuses, her blood pressure, bloodsugar levels, and her exposure to sexuallytransmitted diseases are some of the envi-ronmental factors that can influence thehealth of her newborn baby. These andother conditions, especially if identifiedearly in pregnancy. can be treated so as toimprove neonatal outcome. In general.the earlier in the course of fetal develop-ment that interventions are initiated, themore favorable the result. For this reasonattention to maternal health during thecourse of pregnancy is central to improv-ing newborn health.

Prenatal care has been shown to be acrucial avenue by which interventions inmaternal and thus newborn health statuscan he delivered. What services are in-cluded under this rubric. how receipt ofthese services has changed over time. andwhat the evidence is for their effectivenessare considered below.

Figure 1. Percentage of Births with Early*Prenatal Care, 1970-1989

A A A arA--rA

Vapor

W,110 jr A qc es -4-

CO

2

'First prenatal care visit within 3 months of conception (first trimester).

Source National Center for Health Statistics. U S. Department ofHealth and Human Services. Advance Report of Final Natality Statis-tics, 1989. Monthly Vital Statistics Report, vol. 40. no. 8. supplement.Hyattsville. MD: Public Health Service, 1991.

45


The Content of Prenatal Care

Access, utilization, and the efficacy of pre-natal care have dominated the infanthealth policy and research agenda for thepast 20 Years. Until recently, the actualcontent of prenatal care received relativelylittle attention. One reason for this omis-sion may have been the repeatedly ob-served association between the initiationof early prenatal care and healthy infantoutcomes. Whatever the content of prena-tal care, it seemed to work. The policyimplications appeared straightforward: ex-pand prenatal care utilization, and infanthealth will improve.

Unfortunately, though increasing utili-zation seems to be a necessary conditionfor improvements in infant health, it maynot be sufficient. As we shall see, for exam-ple, when we consider low birth weightrates in more detail. white/ black differ-ences in rates of low birth weight and in-fant mortality have persisted over timedespite significant relative gains in the per-centage of black women receiving earlyprenatal care (see figure 1). And althoughresearchers and policvmakers can cite awealth of studies that appear to demon-strate the effectiveness of prenatal care,specific explanations of how the interven-tion operates remain conspicuously ab-sent from most discussions.

The standard guidelines for prenatalcare as recommended by the AmericanCollege of Obstetricians and Gynecolo-gists (AGOG) call for care to begin as earlyas possible in the first trimester of preg-nancv.2 Additional visits are recom-mended every 4 weeks until the 28th week.followed by visits every 2 to 3 weeks untilthe 36th week. Beyond the 36th week, visitsshould occur weekly until delivery fbr atotal of 13 to 15 visits over the course of anormal pregnancy. By contrast, the Pul.:.Health Service Expert Panel on the Con-tent of Prenatal Care recommends only 7visits for healthy women who have hadprevious, uncomplicated deliveries and 9visits for first-time mothers.1

Both the AGOG and the Panel empha-size that prenatal care should have threebasic components: early and continuousrisk assessment, health promotion. andwhen necessary, medical and/or psycho-logical intervention. Although the Panelrecommends fewer visits for a healthywoman than does the AGOG, the Panel'smost novel contribution is its emphasis onenriching the content of care and on ex-


panding the time frame for prenatal care.3Panel members urge, for example, that apreconception visit occur as one of the 7or 9 recommended visits. Such a consult-ation permits the identification of medicalor behavioral problems before conceptionand offers the mother and clinician thegreatest range of options, from delayingthe pregnancy to providing immuniza-tions that would be contraindicated oncethe woman becomes pregnant. Prenatalcare, according to Panel members, shouldalso be viewed as a means of promotingthe health and well-being of the entirefamily. Thus, they highlight attention toparenting skills and family counseling asways to enhance the care and nurturing ofthe fetus beyond delivery.

The Panel's report focuses on the iden-tification and management of high-riskpregnancies. This includes the possibleuse of specialized tests such as amniocen-tesis and ultrasound imaging to screen thegenetic and structural development of thefetus; the use of routine blood pressureand blood sugar monitoring, and otherblood tests to detect exposure to certainviruses and to verify the mother's bloodtype; and the occasional use of more spe-cialized tests to evaluate fetal well-being.

Yet the advantages of the more highlyspecialized of these strategies may be lim-ited. As an example, consider amniocen-tesis, a procedure in which fluid isremoved from the sac containing the fetusto detect the presence of genetic abnor-malities. Because congenital abnormali-ties are a leading cause of neonatalmortality and about 25% of birth defectsare primarily of genetic origin,4 early rec-ognition of these conditions in time topermit termination of unwanted pregnan-cies could have a considerable impact onneonatal mortality.

But who should be screened using thisprocedure? At one time it was thought thatamniocentesis should target women over35 years of age who are at increased riskfor having babies with Down's syndrome,one of the more common identifiablechromosomal disorders, which affectabout 5,000 newborns a year. Yet, the ma-jority of Down's syndrome births are toyounger women,5 so a policy of targetingwomen over 35 years of age for testingcannot by itself substantially reduce theincidence of the syndrome. Furthermore,it is now appreciated that approximately5% of chromosomal defects which result

in Down's syndrome originate with thefather,6 making identification of appropri-ate candidates for screening even moredifficult. Therefore, without knowingwhom to target, even effective screeningprocedures such as amniocentesis mayhave limited impact on overall outcomes.

The recent expansion of Medicaid eligibility forpregnant women may improve the utilization ofprenatal care, but that may not be sufficient toimprove birth outcomes substantially.

The content of prenatal care recom-mended by the Panel, including home vis-its, case management, substance abusetreatment programs, and three categoriesof psychological risk assessment, is com-prehensive and ambitious. Despite thelack of cost-effectiveness evaluations ofmany of its recommendations, the Panelhas outlined a broad agenda that focusesmuch more sharply on the policy-relevantquestions that need to he addressed. Therecent expansion of Medicaid eligibilityfor pregnant women may improve theutilization of prenatal care, but that maynot be sufficient to improve birth out-comes substantially.? (See also the Hill ar-ticle in this journal issue.) By focusing onthe content of prenatal care, the Panel hasdeveloped a more general framework forunderstanding why nonspecific interven-tions may yield disappointing results.

Trends and Differentials in PrenatalCare

As we have seen, standard medical proto-col calls for the initiation of prenatal carewithin the first 3 months of pregnancy. Fora time the United States appeared to bemaking significant progress in the num-bers of women receiving early care. Trendsin the percentage of live births for whichcare began in the first trimester by race forthe years 1970 through 1989 are shown infigure 1. For white women, the percentreceiving early care rose by 9.7% between1970 and 1980 and then remained thesame. For black women, it increased dra-matically by 40.5% in the decade of the1910s and then declined by 2.1% in thedecade of the 1980s. The percentage oflive births in which there was either noprenatal care or in which prenatal carebegan in the third trimester conversely

A 7,

44

decreased in the 1970s and then eitherleveled off or increased (not shown).

Figure 1 documents the discrepant-1.-in the prompt initiation of prenatal carebetween blacks and whites. The rapid in-crease in the number of black women whoreceived early care in the 1970s reducedbut did not eliminate this discrepancy. In1988. 79.4% of white women and 61.1%

Women whose births are financed by Medicaidhave been found to delay longer before initiatingprenatal care than women whose births arefinanced by private health insurance.

of black women began care in the firsttrimester.8 In the same Year, the percent-age of black women who received thirdtrimester or no care was more than dou-ble the percentage of white women whoreceived third trimester or no care (10.9%versus 5.0%) .8 Teenagers and unmarriedwomen are also at substantially increasedrisk of obtaining late or no prenatal care.`'Overall, just over 7357. of pregnant womenreceived prenatal care in 1989. En- belowthe Public Health Service 1990 goal of


early prenatal care for 90% of all pregnantwomen regardless of race or ethnicity.I9

In 1988 the Institute of Medicine con-ducted a detailed review of the literaturedealing with a variety of determinants ofthe inadequate receipt of prenatal care.iIn addition to age. race, and marital status.the institute identified poverty. lack ofeducation, lack of health insurance, highbirth order, and residence in inner citiesand isolated rural areas as key determi-nants of this outcome (see the Klermanarticle in this journal issue). The impor-tance of almost all of these factors persist-ed in analyses that assessed theindependent effect of a given factor withother factors held constant.12 The impli-cation is that an effective strategy to ad-dress the problem of inadequate prenatalcare may need to operate on several frontssimultaneously.

Lowering financial barriers to the re-ceipt of prenatal care has been a populartactic of public policvmakers because itappears feasible given the traditionaltools at their disposal (see the Hill articlein this journal issue. but conventionalapproaches to these problems have theirlimitations. Medicaid. for example, isoften chosen as a convenient vehicle toalleviate financial barriers for poor preg-nant women. Yet women whose births are

Figure 2. Interval Between Date of Last Menstrual Period and First Prenatal Visitby Insurance Status, New York City, 1984

Adolescents (less than 20 years Of age)

NMI? e "ROOrliC

I 1.a 1. r_ c

Adults (20 veors or oae and older)

c

Source. Joyce. T.,1 . o ^a Grossman. M Pregnancy Wontedness and the Early Initiation of Prenatal Care. Demogropny(February 1990) 27.1 1-17


financed by Medicaid have been found todelay longer before initiating prenatalcare than women whose births arefinanced by private health in sur-ance.".13-I5 Figure 2 depicts the magni-tudes of these differentials among New

wk City women of various age, race, andethnic groups in 1984. Black adults onMedicaid can be seen to delay the initia-tion of prenatal care approximately 1

month longer than black adults with pri-vate health insurance. Similar differen-tials are observed for white Medicaidversus white private insurance patients re-gardless of age. Somewhat smaller differ-entials are also found between theMedicaid and self-pav categories fOr ado-lescents and I Iispanic adults. These differ-ences are all statistically significant in amultivariate analysis which controlled fora number of confounding factors in addi-tion to age, ethnicity, and insurancestatus."

MIy do pregnant women with Medi-caid receive less prenatal care than womenwith private health insurance? The Insti-tute of Medicine lists factors such as thetime-consuming nature of the ledicaidenrollment process, the failure of somephysicians to accept Medicaid patients,long travel times and clinic waits, and lackof information and unfavorable attitudesconcerning prenatal care. These factorsunderscore the potential value of out-reach programs and programs that aim todeliver, as Opposed to finance, prenatalcare fO the poor."

Beyond the financial barriers to prena-tal care, certain demographic factors havebegun to receive increasing attention.Marital status has been of particular rele-vance in this regard because changes inthis factor have been dramatic over thedecade of the 1980s. The number of birthsto unmarried mothers rose 6-i< over thisperiod. And while the birth rate (that isthe number of births per 1,(100 women ina given category) !Or married women ac-tually declined W; between 1980 and1989, the birth rate for unmarried womenincreased 42`; . As a result of these trends.more than 1 baby in 4 was bolo to anunmarried mother by 1989.16 The in-n-case ill the birth rate for unmarriedwomen has alarming implications for in-fant health because unmarried mothersarc moil. than three times as likely as mar-ried mothers to obtain late or no prenatalcare and because the ass( iciat &maritalstatus and receipt of prenatal care remains

largely unelucidated. It will be importantto determine whether unmarried womenreceive less prenatal care because of finan-cial barriers, educational differentials,general lack of social support, or otherfactors which may he difficult to measure.Each of these explanations implies differ-ent policy approaches.Efficacy of Prenatal CareThe consensus of an extensive literatureon the efficacy of prenatal care is that careworks. In particular, women who initiatecare earlier in their pregnancies give birthto healthier infants, are less likely to givebirth to an infant weighing less than 2,500grams, and are less likely to give birth toan infant who dies in the neonatal period.Following a detailed review of the litera-ture, the Office of Technology Assess-ment concluded: "The weight of theevidence on the efiectiveness of prenatalcare ... supports the contention that birthoutcomes can be improved with earlier ormo: comprehensive prenatal care. . . .

The evidence appears to support thevalue of both early and frequent prenatal

The evidence appears to support the value ofboth early and frequent prenatal care and theprovision of enhanced services to adolescents andhigh-risk women.

care and the provision of enhanced serv-ices to adolescents and high-riskwomen."' 7 Several years earlier, the Insti-tute of Medicine reached a similar conclu-sion: 'The overwhelming weight of thees idence is that prenatal care reduces lowbirth weight. This finding is strongenough to support a broad. national com-mitment to ensuring that all pregnantwomen, especially those at medical orsocioeconomic risk, receive high-qualitvcare.- I 8

While this consensus is impressive, cer-tain considerations suggest that caution isrequired in interpreting and applying it.Despite the agreement, for example, ofmost researchers and policy analysts thatprenatal care impros es newborn health.there is no consensus on the quantitativerelationship between the intensity of caredelivered and the improvement in birthoutcomes. Yet this mas be the critical issuein deciding how to allocate scarce re-

4


sources among different programs de-signed to achieve better newborn healthoutcomes.

No agreement exists on the relativemagnitude of the effect of prenatal carebecause studies on this subject do not use

<>data from prospective, randomized con-trolled trials. This raises the possibility thatthe results which emerge are biased andeither over- or underestimate the true ef-fect of prenatal care on newborn healthoutcomes.19

For example, the true effect of prena-tal care is underestimated in studies wherewomen who anticipate a problematic birthoutcome based on conditions unknown tothe researcher seek out more care whilewomen with positive expectations seek outless. The opposite occurs when the earlycare group is dominated by women whoeat more nutritiously, suffer less stress,smoke less, and receive more emotionalsupport from their families. Omission ofthese hard-to-measure factors overstatesthe impact of care.

The importance of correctly measuringthe efficacy of prenatal care is illustratedby consideration of the Public Health Serv-ice goal of care within the first trimester ofpregnancy for 90% of all pregnant women.To achieve this goal, the number of whitewomen receiving earl care must rise byapproximately 12%, and the number ofblack women receiving such care must riseby almost 50%. Achieving this goal may bea costly undertaking, and even if care isefficacious, birth outcomes may not im-prove substantially if there are marked dif-ferences in the content of care or in othercharacteristics between new and currentrecipients. Moreover, it is not clear that

limited resources would be better spentincreasing the proportion of women whoreceive early care rather than increasingthe number of women who get intermedi-ate care (second trimester care) by reduc-ing the number who get late or no care.Recent research by Joyce suggests that mostof the gains to prenatal care in New YorkCity accrued from moving women from theinadequate care to the intermediate carecategory and that the gains from movingwomen from the intermediate care cate-gor to the early/adequate care categoryare much smaller.2° The Joyce study doesnot address the issues of how care works orof whether resources are better spent onincreasing the rates of earlier initiation ofcare or on enhancing the content of carefor women at particular risk for an unfavor-able birth outcome. These are all impor-tant questions for those with limitedresources looking to implement programsto improve birth outcomes.

In considering what we know about thereceipt of prenatal care services and itseffect on infant health outcomes, we areleft in a situation in which we have goodtheoretical reasons to believe that prenatalcare is important to produce healthy new -horns; we have evidence, imperfectthough it is, that groups who receive moreprenatal care have better neonatal out-comes than groups who receive less,though how much better those outcomesare remains a subject of dispute; and wecan see that over time, for differentgroups, as the receipt of prenatal care in-creases, so does the percentage of goodoutcomes.

Yet our knowledge is far from com-plete, chiefly because we do not know howprenatal care works or, for that matter,how well. And though these questions be-come relevant only once the issue ofwhether prenatal care works has been de-finitivel addressed, they are still of greatimportance in and of themselves. If, forexample, prenatal care serves principallyto identify high-risk women early and ittervenes to minimize the effect of pre-existing risk factors in these women, thenfrom the standpoint of policy alternatives.populations in which known risk factorsare particulark prevalent should he prof.-eren daily recruited into prenatal care.This might involve extensive outreach andcase management efforts including reduc-ing financial barriers. relocating Facilitiesinto undersexed areas, and providingchild care for women using these services.

4",)


lf, on the other hand, improved neo-natal outcomes derive from the elimina-tion of risk factors either before or veryearly on in the pregnancy, then one couldargue that strategies such as reducing ex-posure to tobacco, to illicit substances, orto other environmental stresses should re-ceive priority. Settings other than prenatalservice centers may more efficiently pro-duce these policy objectives. Future re-search on these critical questions will beof enormous utility to policvmakers.

Obstetric and NeonatalCareIf birth weight is a valid indicator of theintrauterine experience and thus, indi-rectly, of the effectiveness of prenatal careservices, infant mortality (death within thefirst year of life) is an indicator of thequality and impact of obstetric and neona-tal care services. Because, in countries likethe United States, most children who diein the first year of life do so in the firstmonth, those factors that influence thebirth process and the immediate postnatalcondition of the baby may be expected tohave a discernible impact on the infantmortality rate. To appreciate what the re-ceipt of obstetric and neonatal care meansfor the health status of children, we beginwith a look at infant mortality.

Infant Mortality

Much progress has been made in reducingthe U.S. infant mortality rate during thetwentieth century. It fell from 100 deathsper 1,000 live births in 1915 to 9.1 deathsper 1.000 live births in 1990.21 Improve-ments in medical care and advances inmedical technology played an importantrole in this process, particularly the intro-duction of sulfonamide and other an ti-mi-crohial drugs in the period from 1935 to195022 and advances in neonatology sincethe late I 960s.23.2 1 Until recently, the onlyinterruption in the downward trend ininiant mortality occurred in the late 1950sand early 1960s.25

There are two components of infantmortality: neonatal mortality and postneo-natal mortality. The former refers todeaths of infants before the first 28 days oflife, while the latter refers to deaths ofinfants between the ages of 28 and 365(lays. Neonatal deaths are usually causedby congenital abnormalities, conditionsassociated with prematurity, and compli-cations of delivery; while postneonatal

mortality results primarily from suddeninfant death syndrome (SIDS), infectiousdiseases, and accidents. In the early 1900s,approximately 70% of all infant deathsoccurred in the postneonatal period. By1989, only 36% of infant deaths occurredin the postneonatal period. Unlike earlierin this century, recent trends in the infantmortality rate have been dominated bydeclines in the neonatal mortality rate.Today, the mortality rate (that is, thechance of dying) for a baby's first monthof life is more than twice as high as themortality rate during the remainder of thefirst year.

Neonatal mortality, in turn, is highlynegatively correlated with birth weight sothat the birth weight distribution of apopulation is a major determinant of itsneonatal mortality rate. Those popula-tions with higher proportions of low (lessthan 2,500 grams) and very low (less than1,500 grams) birth weight babies havehigher rates of neonatal mortality. Oncethe distribution of birth weights in a popu-lation is taken into account, the mortalityrates specific to each b'rth weight categorYare determinants of overall neonatal mor-tality. By multiplying the proportion ofbirths in each birth weight group by thebirth weight specific mortality rate for thatgroup, one arrives at the overall neonatalmortality rate for a population.

Despite the rapid decline in infantmortality, substantial differences in thisoutcome and in its most proximate de-terminantlow birth weighthave per-sisted between different groups overtime.26.27 The most notable of these isthe excess mortality of black babies whopresently experience an infant mortality

Black babies presently experience an infantmortality rate twice that of their whitecounterparts.

rate twice that of th,.ir white counter-parts. In addition, the black low birthweight rate has typically been more thantwice as large as the white rate. Amongthe Hispanic population, Puerto Ricanwomen give birth to LBW infants at approximately three-fourths the rate ofblacks, while the low birth weight ratesof other 11 ispanics are similar to those ofwhite non-Hispanics.28

5 )

48

In addition, the U.S. infant mortalityrate remains higher than those of a num-ber of other developed countries evenwhen the rate is limited to whites.17 Fi-nally, Marks and others report that in1980 "differences between the States ofthe U.S. in infant ... mortality are greaterthan those between the U.S. and thecountries of Scandinavia [with the lowestinfant mortality] ."29

These facts have led some observers toconclude that U.S. infant mortality policyhas reached a crossroad.3° Two decades ofdramatic declines in infant mortality havefailed to improve the survival prospects ofblack infants relative to white infants or ofwhite infants born in the United Statesrelative to those born in other developedcountries. Moreover, during the decade ofthe 1980s, tentative evidence emerged thatthe period of rapid decline may haveended. The fall in mortality slowed to anaverage year - to-year reduction of 2.5 %,31and the incidence of low birth weightstopped declining. In 1984 the fraction ofLBW births reached an all-time low forboth races: 5.59% for whites and 12.36%for blacks. The corresponding figures in1989 were 5.7% for whites and 13.5% forblacks.1632

The U.S. infant mortality rate remainshigher than those of a number of otherdeveloped countries even when the rate islimited to whites.

The infant mortality rate in 1990 was67( less than the rate in 1989.33 Theintroduction of treatment with artificialsurfactant, which helps prevent deaths ofpremature infants from respiratory dis-tress syndrome, and the expansions inMedicaid coverage for prenatal care mayhave contributed to this decline.31 Obvi-ously it is too early to determine whetherthis change represents a reversal of thedeceleration in the downward trend dur-ing the 1980s. It is clear, however, thatthree important 1990 infant health goalsof the Public Health Service as set forthin The 1990 health Objectives for the Nation:A Midcourse Review have not been met.10These are an infant mortality rate nohigher than 12 per 1,000 live births forany minority group (the black rate was17.6 per 1,000 live births in 1988), a low


birth weight rate of 5% of all infants, anda low birth weight rate of 9% for anminority group.

Trends in Obstetric Services

Where a child is horn, how that child isdelivered, and who attends the deliverymay all be important determinants of neo-natal outcome under certain circum-stances. The volume of obstetricalprocedures in the hospital where birthoccurs, for example, has been shown to berelated to survivorship in low birth weightbabies though not in term, normal birthweight babies.34 Recent trends indicatethat increasing numbers of infants in theUnited States are being born in the hospi-tal. For white infants the percentage ofbabies born in a hospital rose from 96.6%in 1975 to 98.7% in 1989, while for non-white infants the comparable percentageswere 94.6% in 1975 and 99% in 1989.35

In addition to in-hospital deliveries,cesarean section rates have also been onthe rise since the middle of the 1960s. In1965 the chances of being born via ce-sarean section were about 1 in 20. By 1989the likelihood had increased to I in 4.Most authors attribute this rise to the in-crease in electronic fetal monitoring,changes in the legal atmosphere sur-rounding obstetrical care, and the policyof discouraging spontaneous vaginal deliv-eries in women who have undergone pre-vious cesarean sections.36 The increase inthese procedures has not been shown tohave any positive contribution to neonataloutcome.37

Trends in Neonatal Intensive Care

As we noted earlier, the most importantcomponent of infant mortality in theUnited States today is the death rate ofbabies less than 28 days old. This rate, inturn, depends upon the distribution ofbirth weights in a population and thespecific death rate associated with eachbirth weight categor.

In the first part of this raper we dis-cussed some of the factors that influencethe birth weight distribution of a popu-lation, particularly the provision of ade-quate prenatal care for pregnantwomen. We now turn our attention todevelopments that have influenced birthweight specific mortality rates. The mostimportant of these has been the expan-sion in the availability of neonatal inten-sive care services.

U.S. Health Care for Children

Over the past 2 decades in the UnitedStates, the single most significant trend inthe delivery of neonatal health services hasbeen the emergence of regionalization asa guiding principle in the provision of carefor high-risk mothers and newbornbabies.38 Many hospitals began to intro-duce intensive care units for newbornsduring the decade of the 1960s, but it wasnot until the earls. 1970s that a compre-hensive set of guidelines was developed toorganize the distribution of these serviceswithin given geographic areas by incre-mental levels of intensity.

The 1977 National Foundation-Marchof Dimes recommendations.39 sub-sequently refined by the American Acad-emy of Pediatrics and the AmericanCollege of Obstetricians and Gvnecolo-gists,40 include three levels of infant care:(1) Level I nurseries to provide routinenewborn care; (2) Level Ii nurseries,manned by board certified pediatricians,to provide care to seriously ill infants withlife-threatening conditions for finite peri-ods and to maintain ongoing liaisons with(3) Level III nurseries which serve as re-gional referral centers offering the mostsophisticated neonatal care including spe-cialized respirators support systems, pedi-atric surgery services, and infant transportteams capable of delivering seriously illneonates to and from the hospital.

In practice there has been some blur-ring of the distinction between Level fIand Level III nurseries as the competitionfor patients has intensified in recentyears.41 Nevertheless, specific standardshave arisen for adequate staffing, physicaldesign, ancillary services, and transportfacilities appropriate to the most advancedlevels of neonatal care.40.42

During the decade of the 1980s, thenumber of Neonatal Intensive Care Units(NICUs)combined Level II and LevelIII unitsin U.S. hospitals has risen dra-matically (see figure 3). While the totalnumber of hospitals. as surveyed by theAmerican Hospital Association in their an-nual survey. rose 14.33% from 1979 to1988, the number of NICUs climbed44.33% from 485 to 700 and the numberof NICU beds increased 66.97% from6,591 to 11,005 during this period.43

Although no national data bases existwhich provide information on the utili-sation rates of these Ni( Us, the Officeof Technolog-v Assessment (1987) esti-mated that there were between 150,000

49

and 200,000 admissions to NICUs annu-ally in the mid-1980s.44 In recent Years,anecdotal evidence suggests that agreater and greater proportion of NICUadmissions have gone to infants weigh-ing less than 1.500 grams while the pro-portion of admissions of moderately lowbirth weight infants has declined.44 Onestudy from Cleveland reported increasesin the numbers of extremely low birthweight admissions (babies born weigh-ing less than 751 grams) from the earlyto the late 1980s of 30%.43 Whetherthese trends result from recent tenden-cies to focus more aggressive resuscita-tive efforts on smaller and smallern-onates remains to he fulls. elucidated.WI atever the origin of this trend tolower birth weight NICU admissions, thisdevelopment inevitably forces policy-makers to confront the question of howmuch improvement in health outcomescan reasonably be anticipated from suchhigh tech attention to smaller andsmaller babies.Efficacy of Neonatal Intensive Care

In view of the rapid growth in the numberof NICUs during the past 15 years, thesubstantial expense attendant upon caringfor newborns in such environments, and

Figure 3. Trends in Number of NICUs, NICUBeds, and Births

1981 1083 1,4'5

Year1488.

r.4., a Be1f. 11cN:151 (11110^s1

'Note 2-year time an except from 1987 to 1988

Source: American Hospital Association. Hospital Statistics. Chicago:American Hospital Association, 1980, 1989.


the trend to lower birth weight NICU ad-missions, it was inevitable that questionswould arise as to whether the expenditureof such prodigious resources was worth-while. (See the Lewit and Monheit articlein this journal issue.) Clinicians, epidemi-ologists, and economists have all ad-dressed this issue, with each groupapproaching it from the vantage point ofits own particular discipline.

As practitioners, neonatologistshave been anxious to demon-strate that the specific contentof care provided by NICUsmakes a difference in the out-come of patients treated there.

As practitioners, neonatologists havebeen. anxious to demonstrate that thespecific content ofcare provided by NICUsmakes a difference in the outcome of pa-tients treated there. To make this case,investigators have applied two differentmethods. One approach compares the ex-periences of successive cohorts of infantstreated at the same institution during twotime periods to show how the develop-ment of new technologies has improvedbirth weight specific survival rates for allbut the very smallest babies:15,4r' Increas-ing willingness to refer high-risk pregnan-cies to centers with neonatal intensive careunits, the antenatal use of steroids to has-ten fetal lung development, improve-ments in techniques to assist breathingartificially, and the ability to provide ade-quate intravenous nutrition to extremelyimmature infimts have all been implicatedin the trend toward increased birth weightspecific survival over time.

A second type of study makes use ofcross-sectional comparisons among sel.-eral NI(1.'s to demonstrate that differentapplications of similar technologies mayalso affect out comes:17,v Alter control-ling for the potential) confounding influ-ences of race, birth weight, and gender,these investigations were still able to dem-onstrate significant intercenter differ-ences in various outcome measures. Theresults of these studies imph that appro-priate application of assisted mechanicalventilation in NICUs can signilicanth re-duce morbidity and mortality an inrmature newborns.

Epidemiologists have looked at the im-pact of neonatal intensive care on the mor-tality rates of entire populations and havecome to the conclusion that new neonataltechnologies, properly distributed, pro-vide significant improvements in thismeasure of health status. For example, anearly Canadian study covering the period1967 to 1974 documented a 43% decreasein the neonatal mortality rate for the prov-ince of Quebec coincident with severalImportant institutional developments in-cluding (1) an increase in the proportionof sick and premature newborns cared forin referral centers; (2) the establishmentof perinatal intensive care units in twouniversity hospitals; and (3) the regionali-zation of the high-risk obstetric service as-sociated with McGill University, wherefully 14% of the province's births oc-curred.50 The authors of this study wereable to show that the improvement re-sulted from decreases in mortality rateswithin birth weight categories, not fromany dramatic shift in the birth weight dis-tribution itself, and that the diffusion ofspecialized care both to high-risk mothersand their newborn infants played a sig-nificant role in the observed decline inQuebec's neonatal mortality rates. Sub-sequently, Lee and his colleagues arrivedat similar conclusions using data from theUnited States for the period between 1950and 1975.51

Vhen considering the effectiveness ofneonatal intensive care, economists haveused their particular skills to accomplishtwo functions: (1) to estimate the magni-tude of' improvement in outcome associ-ated with neonatal intensive care and (2)to construct cost-benefit or cost-effective-ness analyses of these services.

As an example of the first type of con-tribution, I larris reported that an increasein the annual ohmic of deliveries in thehospital of birth lowered the probabilityof neonatal death (including late fetaldeath) among black babies in Massachu-setts in 1975-1976.:)2 A 10% increase inthe annual volume of deliveries was foundto lower the death rate by approximateh5%." A similar approach using data forwhite infants born in Michigan in 198.4found that birth in a hospital with a neo-natal intensive care unit lowered the prob-ability of a late fetal or neonatal death byapproximately 30%.

This type of analysis has been general-ized to examine the impact of the use of

Si


neonatal intensive care services on neona-tal mortality using data that cover almostthe entire C.S. population. These studiesshow that a 10% increase in neonatal in-tensive care use was found to lower themortality rate of white low birth weightinfants by 2%. For black infants, a 10%increase in use lowered the death rate by3%. These findings indicate how muchimprovement in mortality can be ex-pected from increases in the availabilityof neonatal intensive care to low birthweight babies.5-I

Cost-effectiveness of NeonatalIntensive Care

Faced with limited resources and the needto make decisions about the implementa-tion of costly but effective programs toimprove infant health, policvmakers haveincreasingly relied on the tools of cost-benefit and cost-effectiveness analysis tohelp determine whether the observed im-provements in health are worth the costsexpended to achieve them. Yet these tech-niques are not easy to apply.5 First,because traditional accounting practiceswithin hospitals use revenue from onesource to offset shortfalls elsewhere (apractice known as cost shifting), dollarcosts of neonatal intensive care are oftendifficult to determine accurately. Further-more, costs of the long-term care requiredby some severely disabled NICU survivorsare also difficult to estimate. On the bene-fits side, the probabilities of various out-comes are not easily determined and varysubstantially among institutions. More-over, to perform a full cost-benefit analy-sis. it is necessary to assign a monetaryvalue to survival with and without differ-ent degrees of disability. Th is often provesan intractable problem. Asa result ofthese difficulties, the conclusions drawnfrom cost-benefit studies must be re-garded with caution.

Despite these and other obstacles.however. attempts have been made tocompare the costs and benefits of neonatalintensive are in monetary terms. Budettiand his colleagues concluded that, whileNIC1* care for babies weighing less than1,500 grams was marginally cost-effectivegiven the data available to them at the timeof their analysis, such care for infantsweighing less than 1,000 grams was no1.76Because of the potentially large expendi-

es required to care for severely disabledNICU survivors, as the numbers of suchsun kors Met eased in lower birth weight

groups, Budetti and his colleagues foundthat the costs of providing this type of carebegan to substantially outweigh the bene-fits. Other investigators have reachedsimilar conclusions.56

To perform a full cost-benefit analysis, itis necessary to assign a monetary value tosurvival with and without different degreesof disability.

In a very careful analysis conducted inHamilton-Wentworth County in Ontario,Boyle and others used cost-benefit, cost-ef-fectiveness, and cost-utility analysis toevaluate NICU care.57 In the last of theseapproaches, an attempt is made to adjustlife -years gained by a factor which takesinto account the quality of life for individu-als who survive with disabilities. As in pre-vious studies, the findings were birthweight dependent. For infants in the1,000- to 1,499-gram range, the cost ofneonatal intensive care was found to he$59,500 (1978 Canadian dollars) per sur-vivor, $2,900 per life-year gained, or $3,200per quality-adjusted life-year gained. Thecorresponding figures for infants in the500- to 999-gram category were $102,500,S9,300, and $22,400. The authors con-cluded that "by every economic measureneonatal intensive care for infants weigh-ing 1.000 grams to 1,499 grams is superiorto neonatal intensive care for infantsweighing 500 grams to 999 grams." Neo-natal intensive care for the lower birthweight group appeared to generate a neteconomic loss in all scenarios analyzed.Yet, when the analysis focused on clinicaloutcomes, it yielded a different conclu-sion. Here it was found that neonatal in-tensive care for infants weighing 750grams to 999 grams at birth resulted in thelargest survival gain For any subgroup. Theapparent inconsistency introduced byevaluating neonatal intensive care fromthese alternative perspectives highlightsthe difficulties attendant to decision mak-ing regarding high-cost, high technologymedical services.

As authors of these and other studiesare quick to point out, cost-benefit analy-ses can help identify those programs thatnot only provide a health benefit to par-ticipants but also pat for themselves in aneconomic sense. Programs that are e()tisid-eyed cost-beneficial produce not onh

5

52

survivor for the cost outlay, but also thefuture economic productivity of that sur-vivor. Because this situation is akin to aman's going into a store to buy a loaf ofbread wit', coming out with not only thebread b,it also more money than when heWeill in, ;t is a very restrictive criterion bywhich to judge a medical intervention.Mon pertinent questions to pose, espe-ciall if costs outweigh the benefits in dol-lars generated by a program, are (1)whether society deems the net costs worthundertaking in view of the health benefitsproduced by the program under consid-eration and/or (2) whether alternative,less costly strategies exist to achieve similarhealth outcomes.

knowing that the economic costs ofcaring for very low birth weight infants(those weighing less than 1,000 grams)outweigh the economic benefits forcespolicvmakers to decide either that theseexpenditures arc worthwhile despite thecosts or that alternative strategies for sav-ing infants' lives need to be entertained.

A recent study In' Joyce, Gorman. andGrossman speaks directiv to this di-lemma.8 They found that expansion ofprenatal care is a more cost-effectivemethod of saving additional infant livesthan expansion of neonatal intensive care.For whites, the cost Of saying an additionallife by expanding the number of womenwho receive prenatal care in the first ti-mester is S31 per additional life saved in1981 dollars. The cost of saying an addi-tional lift 1w expanding the number of lowbirth weight babies who receive neonatalintensive care is S'2.83-I per additional lifesaved. "Ily comparable figures for blackwomen and infants are S39 in the case of

THE FUTURE OF CH:.1-)V.N WINTER 1992

prenatal care and $2,150 in the case ofneonatal intensive care.59 These cost-ef--fectiveness ratios although suggestive arcfar from definitive because they do notconsider improvements in neonatal inten-sive care technology. As with many policyalternatives, changes in technology, par-ticularly in rapidly developing fields of in-quiry, may be expected to shift theadvantage of one or another approach toa given problem over time.

New Neonatal TechnologiesFaced with the desire to improve thehealth of newborns and rapidly rising costsfor the care of sick infants, the policymak-ers' dilemma is that not all technologicalinnovations with potential clinical applica-tion may be cost saving. Two examples ofrecent improvements in NICU respiratorycare, artificial surfactant and extracor-poreal membrane oxygenation (ECM0),illustrate this point.

During the first week of life, many pre-mature infants are laced with the problemof breathing effectively with immaturelungs. When clinically significant, thisproblem is called respiratory distress syn-drome (RDS). RDS results from the fitilureof the premature infants' lungs to producesurfactant, a substance that allows thesmall air sacs in the lungs of prematureinfants to remain inflated during allphases of respiration. Providing prema-ture newborns with exogenous surfactantameliorates RDS. Since the efficacy of ex-ogenous surfactant was demonstrated in1980, it has been synthesized commer-cially and is now instilled in the windpipesof newly born premature infants in anattempt either to prevent or to treat RDSand thereby decrease the accompanyingmorbidityy and mortality.

The early experience with artificial sur-factant has been favorable.60 -68 At awholesale cost of approximately $900 pertreatment for a neonate, it is relativelyinexpensive and can be administered atvirtually any Level II or Level Ill nurserywithout special equipment or monitoring.A recent analysis from England suggestedthat the use of surfactant was cost-effectivein very low birth weight infants) andthere has been speculation that the dis-semination of the use of this material wasresponsible for the decline in infant mor-tality witnessed in 1991.70

The second technology mentioned,EGNIO, is a technique for bypassing thenewborns' lungs altogether by placing the

1


child on a machine similar to one usedduring open heart surgery. Not indicatedfor routine use in premature babies withRDS, ECM° is reserved for desperately ill,full-term babies whose condition is unre-sponsive to the conventional treatment ofrespiratory assistance. Very few newbornsare candidates for ECNIO so the potentialeffect of ECM() on neonatal mortality islimited. Nonetheless there appear to bemore centers in the United States with thecapability to perform ECNIO than are war-ranted by the number of infants whowould benefit from the therapv.71 Accord-ingly, there is concern that the therapymay be used inappropriately and that costsassociated with this technique may be dif-ficult to contain. As Southgate, who stud-ied the use of ECM() in Georgiaconcluded, :Short - sighted proliferation ofECM() units will almost certainly result inan increased consumption of shrinkinghealth care dollars, as well as the unneces-sary duplication of services. .. ."72

Careful analysis of both the cost andthe clinical efficacy of new technologieswould be helpful in guiding the alloca-tion of resources so as to optimize bothinfant survival and the ultimate health ofsurvivors.

Conclusion\'e have considered the impact of prena-tal. obstetrical. and neonatal care on themost important and easily measured out-comes of infant health, namely the rate oflow birth weight births and the rate ofinfant mortality. Though not all the stud-ies published to date have been well con-ti oiled, abundant evidence hasaccumulated demonstrating that thesetwo outcome measitres do respond to theapplication of appropriate health services.

Despite the recent slowing in the rateof decline of infant mortality and the lev-eling off in the decline of the low birthweight rate, there are continued reasonsfor optimism. The discrepancies that per-sist between white and nonwhite low birthweight rates imph that an improved distri-bution of prenatal care set-% ices could havea significant impact on the rate of low birthweight births. The development of newagents to aid in the treatment of respira-

tors distress syndrome raises hope thatmore widespread application of such treat-ments will significantly improve neonatalsurvival as well. Finally, expanded region-alization of prenatal, obstetric, and neona-tal -are in a coordinated approach to theentire continuum of gestation, labor. de-liver, and early development holds outthe promise of greater progress on bothfronts. Though there is reason to be opti-mistic, recent experience has highlightedthe needs of mothers and infants withemerging special problems. These includethe increase in high-risk pregnanciescaused by maternal substance abuse (seethe Spring 1991 issue of The Future of Chit-dim which deals with this problem) andpregnancies complicated by DR' infectionwhich, although few in number, presentthe problems of severe chronic illness inboth the mother and the infant (see thearticle by Perrin and Guyer in this [Winter1992] journal issue for a more completediscussion of HIV infection in children 1.Perhaps the greatest challenge, however,because of the sheer number of individu-als affected, is to improve birth outcomesin the face of increasing rates of povertyand an increase in the number of birthsto poor families.l8

The advance of obstetrical technologyinto more advanced genetic and fetalscreening,73 fetal therapies to amelioratepotentially serious infant conditions be-fore birth,7-I75 and other technologiessuch as home uterine monitoring to detectpossible premature labor76 as well as con-tinued advances in neonatology may pre-sent both problems and benefits. Thoughthere is clearly progress to he made, thepolitics cif competing claims on limitedresources dictates that those programsand activities which can (Mixer the great-est potential impriivement in newborn

val for the least investment are likhto prove the most attractive to decisionmakers. The effort to identify such pro-grams and activities deserves a prominentplace on the research agenda in the im-mediate ft iture.

We air indebted to Victor Is'. Eut Its andEugene 1,1. pr helpful comments on anearlier draft. 11.e wish to thank Patrma Del.17PAfor iciwarch (mishit/ie.

Fclk%ards. and (;rossinan. M. Flie relationship hen%cen (hitch cn's health and intelle(-inal cle.elopment. In /ifyrith: 1170(11 o it zowth:. Nltishkin. and DAV. l)unlop, eds.Elmsford, NY: Pet gamon Press, 1979, pp. 273-31.1.


American College of Obstetricians and Gynecologists. Standards for obstetric-gsnerologic serv-ices. 7th ed. Washington. DC: AGOG, 1989.

3. U.S. Department of Health and Human Services. Caring for our Mum: Tlw content of prenatalcare. Washington, DC: U.S. DIIHS, 1989.

4. Wilson, J.G. Environment and birth defects. New Thrk: Academic Press, 1973.

5. Based on estimated rates of Down's syndrome among women of different ages (20 to 49years) as reported by Hirschhorn, K. Prenatal disturbances. In Nelson textbook of pediatrics,14th ed. R.E. Barman, R.M. Kliegman, W.E. Nelson, and V.C. Vaughan, eds. Philadel-phia: W.B. Saunders Company. 1992. p. 284. And 1989 distribution of live births by age ofmother as reported in National Center for Health Statistics. U.S. Department of Healthand Human Services. Advance report of final natality statistics, 1989. Monthly Vital StatisticsReport, vol. 40, no. 8, supplement. Hyattsville, MD: Public Health Service, 1991.

6. Antonarakis, S.E., Lewis, J.G., Adelsberger, RA., et al. Parental origin of the extra chromo-some in Trisomy 21 revisited: DNA polymorphism analysis suggests that in 95% of casesthe origin is maternal. .4merican Journal of Human l.enetirs (1990) 47:A 97.

7. Schlesinger, NI., and Kronehusch, K. The failure of prenatal care policy for the poor. HealthAffairs (Winter 1990) 9,4:91-111.

8. National Center for Health Statistics, U.S. Department of Health and Human Services. Ad-vance report of final natality statistics. 1988. Monthly Vital Statistics Report, vol. 39, no. 4, sup-plement. Hyattsville, MD: Public Health Service, 1990.

9. Singh, S., Torres, A., and Forrest. J.D. The need for prenatal care in the L.'.S.: Evidence fromthe 1980 National Natality. Survey. Family Manning Perspectives (MaY-Jtme 1985) 17,3:1 18-124.

10. Public Health Service, U.S. Department of Health and Human Services. The 1990 health ob-jectives for the nation: A midcourse review. Washington, DC: Office of Disease Prevention andHealth Promotion, 1986.

11. Institute of Medicine. Prenatal care: Reaching mothers, leaching infants. S.S. Brown, ed. Wash-ington, DC: National Academy Press. 1988.

12. The one exception was race. But this conclusion must be interpreted with caution becausealmost all of the studies reviewed were conducted on a race-specific basis or specified afairly complex set of interactions among race, ethnicity, and poverty.

13. Grossman, M., and Joyce, Unobservables, pregnancy resolutions, and birth weight pro-ditction functions in New York City. journal of Political Economy (October 19140) 98,5:983-1007.

14. Joyce, T.", and Grossman, NI. Pregnancy wantedness and the early initiation of prenatalcare. Demography (February 1990) 27,1:1-17.

15. Howell, E.M., et al. A comparison of Medicaid and non-Medicaid obstetrical care in Califor-nia. Health Gore Financing Review (Summer 1991) 12.4:1-15.

16. National Center for Health Statistics, U.S. Department of Health and Human Services. Ad-vance report of final natality statistics, 1989. Monthly Vital Statistics Report, vol. 40, no. 8, sup-plement. Hyattsville, MD: Public Health Service, 1991.

17. Office of Technology Assessment, L'.S. Congress. Healthy children: Investing in the future.Washington. DC: U.S. Government Printing Office (OTA-H-345), 1988.

18. Institute of Medicine. Presenting low birthweight. Washington, DC: National Academy Press,1985, p. 146.

19. To estimate the magnitude of the true effect of prenatal care on infant health, one must con-trol for the impact of other determinants of newborn health outcomes which are them-selves correlated with prenatal care. Otherwise one ends up attributing to prenatal careinfluences originating from some other source. The most effective way to isolate the prena-tal care effect would he to perform a clinical trial in which a set of pregnant women wouldbe divided at random into two groups: one that receives prenatal care in the first trimesterand one that does not. Such an approach would ensure that the two groups of womenwould he as similar as possible in all respects other than their receipt of care.Thereafter, any observed differences in birth weight or infant survival between the twogroups of women would he most likely clue to differences in the receipt of early prenatalcare.

20. Joyce, TJ. Self selection, prenatal c are, and birthweight among blacks. whites, and Hispan-ics in New York City. National Bureau of Economic Researc It Working Paper No. 3549, re-vised April 1991.


21. The rate of decline was 3.1% per year annually compounded. Fuchs, Victor R. lime we live:An economic perspective on Americans from birth to death. Cambridge, MA: Harvard UniversityPress, 1983. National Center for Health Statistics, U.S. Department of Health and HumanServices. Annual summary of births, marriages, divorces, and deaths, United States, 1990.Monthly Vital Statistics Report, vol. 39, no. 13. Hyattsville, MD: Public Health Service,1991.

22. Fuchs, V.R. 113w shall live? Health, economics, and social choke. New York: Basic Books, 1974.

23. McCormick, M.C. The contribution of low birth weight to infant mortality and childhoodmorbidity. New England Journal of Medicine (January 10, 1985) 312,2:82-90.

24. Paneth, N. Technology at birth. American Journal of Public Health (July 1990) 80,7:791-92.

25. Between 1955 and 1964, the rate of decline eased to less than 1% per year but then acceler-ated to 4.1% per year between 1964 and 1984. Conran, H., Joyce, TJ., and Grossman, NI.Birth outcome production functions in the U.S. journal of Human Resources (Summer1987) 22,3:339-60.

26. Wegman, M.E. Annual summary of vital statistics-1990. Pediatrics (December1991)88,6:1081-92.

27. Given the importance of neonatal mortality in total infant mortality, differences in the lat-ter rate among groups in the population at a moment in time mirror differences in theformer.

28. U.S. Department of Health and Human Services. Report of the .Secretary's Task Force on Blackand Minority Health. Volume VI: Infant mortality and low birthweight. Washington, DC:U.S. Department of Health and Human Services, 1986.

29. Marks, IS_ et al. Variations in state-specific infant mortality risks. Public Health Reports(March-April 1987) 102,2:146-50.

30. National Commission to Prevent Infant Mortality. Troubling trends persist: Shortchanging Amer-ica's next generation. Washington, DC: National Commission to Prevent Infant Mortality,1992.

31. Hilts, P.J. U.S. reports drop in infant deaths. New York Times, April 7. 1991, pp. 1, 8.

32. National Center for Health Statistics, U.S. Department of Health and Human Services.Health U.S. 1990. DHHS Pub. No. (PHS) 90-1232. Hyattsville, MD: Public Health Service,1991.

33. National Center for Health Statistics, U.S. Department of Health and Human Services. An-nual summary of births, marriages, divorces, and deaths, United States, 1990. Monthly Vital Sta-tistics Report, vol. 39, no. 13. Hyattsville, MD: Public Health Service, 1991.

34. Mayfield, J.A., et al. The relation of obstetrical volume and nursery level to perinatal mortal-ity. A mencan journal of Public Health (July 1990) 80,7:819-23.

35. The percent of nonwhite babies born in hospital exceed the percentage for white babiesbecause fewer nonwhite infants underwent scheduled deliveries at home or in freestand-ing birthing centers. Birthing centers have recently been shown to be a safe, low-cost alter-native to hospital delivery for suitably screened low-risk mothers. Rooks, J.P., Weatherby,

Ernst, E.K.M., et al. Outcomes of care in birth centers: The national birth centerstudy. New England Puma/ of.liedicine (December 28, 1989) 321,26:1804-11.

36. Goyert, Bottoms, S.F., Treadwell, M.C.. and Nehra. P.C. The physician factor in ce-sarean birth rates. New England Journal al Medicine (1989) 320:706-709.

37. Haynes de Regt, R., Minkoff, H.1.., Feldman, J., and Schwartz. R.H. Relation of private orclinic care to the cesarean birth rate. New England Journal of Afetlirine (1986) 315:619-2-1.

38. Rudolph, C.S., and Borker, S.R. Regionalization: Issues in intensive rare for high risk newbornsand their families. New York: Praeger, 1987.

39. National Committee on Perinatal Health. 'inward improving the outcome of pregnancy: Recom-mendations for the regional development of maternal and perinatal health services. White Plains,NY: The National Foundation-March of Dimes, 1977.

40. American Academy of Pediatrics/American College of Obstetricians and Gynecologists.Guidelines for perinatal cam 2d ed. Washington, DC, 1988.

41. Gagnon, D.. Allison-Cooke, S., and Schwartz, R.M. Perinatal care: The threat of &regionali-zation. Pediatric Annals (July 1988) 17,7:447-52.

42. Ross Planning Associates. 1982 guide to centers pi-twit-Iry pmnatal and neonatal special rare. (*sr-Itnbus. OH: Ross I.aboratories. 1982.


-13. American Hospital Association. Hospital statistics. Chicago: American Hospital Association,1980, 1989.

-14. Office of Technology Assessment, U.S. Congress. Neonatal intensive our for low birthweight in-fants; Costs and effectiveness. Washington, DC: U.S. Government Printing Office (OTA-HCS-38), 1987.

45. Hack, NI., and Fanaroff, A.A. Outcomes of extremely-low-birth-weight infants between 1982and 1988. Nal, England Journal of Medicine (December 14, 1989) 321:1642-47.

46. Cohen, R.S., Stevenson, D.K., Malahoski, N., et al. Favorable results of neonatal intensivecare for very low-birth-weight infants. Pediatrics (Ma' 1982) 69,5:621-25.

-17. Avery, NI.E., Tooley, W.H., Keller. J.B.. et al. Is chronic lung disease in low birth weight in-fants preventable? A survey of eight centers. Pediatrics (January 1987) 79,1:26-30.

48. Horbar, NicAuliffe, TI.., Adler, S.M., et al. Variability in 28-day outcomes for very lowbirth weight infants: An analysis of 11 neonatal intensive care units. Pediatrics (October1988) 82,4:354-39.

49. Hack, M.. Horbar.J.D.. Nlalloy, M.H., et al. Very low birth weight outcomes of the NationalInstitute of Child Health and Human Development Neonatal Network. Pediatrics (M-)1991) 87.5:587-97.

50. Usher, R. Changing mortality rates with perinatal intensive care and regionalization. Semi-nars in Perinatology (July 1977) 1,3:309-19.

51. I.ce and others concluded that the major factor responsible for declining birth weightspecific mortality over that period was improvement in perinatal medical care because thebirth weight specific mortality rates did not change appreciably in the first 10 years of thatperiod and from 1967-1975, a time when the birth weight distribution actually worsenedsomewhat and other important factors were unchanged, neonatal mortality declined35%. Lee, K., et al. Neonatal mortality: An analysis of the recent improvement in the U.S.4merican Journal of Public Health (January 1980) 70,1:15-21.

52. Harris, J.E. Prenatal medical care and infant mortality. In Economic Aspects of Health. N'.R.Fuchs, ed. Chicago: University of Chicago Press, 1982, pp. 15-52.

53. Harris controlled for gestational age, birth weight, prenatal care, mother's age, mother'seducation, marital status, and parity in arriving at the estimated effect.

54. Joyce, TJ., Corman. H., and Grossman, NI. A cost-effectiveness analysis of strategies to re-duce infant mortality. Medical Care (April 1988) 26,4:348-60.

55. Budeui, P.. Barrand, N., NU :Manus. P., et al. The costs and effectiveness of neonatal inten-sive care. Case study 10. In Background paper 2: Case studies of medical technologies. Theimplications of cost-effectiveness analysi.s of medical technology. \Vashington, DC: Office of Tech-nology Assessment, August 1981.

56. Walker,[).B., Feldman, A., Vohr, B., and Oh. W. Cost-benefit analysis of neonatal intensivecare for infants weighing less than 1.00(1 grams at birth. Pediatrics (July 1984) 74,1:20-25.

57. Boyle, 4.H., Torrance, G. \V., Sinclair, J.C., and Harwood, S.P. Economic evaluation of neo-natal intensive care of very-low-birth-weight infants. New England Journal of Medicine (June2, 1983) 308,22:1330-37.

58. Sec note no. 54, Joyce. et al.. pp. 354-59,

59. These figures are averages of the high and low estimates presented by Joyce, Corman, andGrossman (see mite no. 54).

60. Hallman. NI.. Nlerritt, T.A., Jarvenpaa, A. et al. Exogenous ht11111111 surfactant for treat-ment of severe respirators- distress syndrome: A randomited prospective clinical trial. lour-nal of Pediatric, (1985) 106:963-69.

61. Kwong, NI.S., Egan. E.l., Notter, and Shapiro. D.1.. Double-blind clinical trial of calflung surfactant extract for the prevention of h)aline membrane disease in extremely pre-mature infUnts. PrilialM'l (1985) 76:585-92.

62. Enhorning, G.. Shennan, A.. Possmayer, R.. et al. Prevention of neonatal respiratory dis-tress syndrome by tracheal ii.st illation of surfactant: A randomised clinical trial. Pediatrics

(August 1985) 76.2:145-53.

113. Merritt, T.A.. Hallman, M., Bloom, B,T, et al. Prophyku tic treatment of very premature in-fants with human surfactant. New England Journal of :Iledicine (1986) 313:785-90.

61. GI j.D., farad, R.B.. et al. Randomised controlled tiial of exogenous surfac-tant for the neatment of hyaline membrane disease. Pediatrics (January 1987) 79,1:31-37.

53


65. Fujiwara, T., Konishi, M., Chida. S.. et al. Surfactant replacement therapy with a singlepostventilatory dose of a reconstituted bovine surfactant in preternt neonates with respira-tory distress syndrome: Final analysis of a multicenter, double-blind, randomized trial andcomparison with similar trials. Pediatrics (November 1990) 86,5:753-64.

66. Hennes, H.M., Lee, N1.13., Rimm, A.A., and Shapiro. D.1.. Surfactant replacement therapyin respiratory. distress syndrome.American Journal of Diseases of Children (I anuary 1991)145:102-104.

67. Phibbs, R.H., Ballard, R.A., Clements, J.A.. et al. Initial clinical trial of EXOSURF, a protein-free synthetic surfactant, for the prophylaxis and early treatment of hyaline membranedisease. Pediatrics (July 1991) 88,1:1-18.

68. Liechty, E.A., Donovan. E., Purohit, D., et al. Reduction of neonatal mortality after multipledoses of bovine surfactant in low birth weight neonates with respiratory distress syn-drome. /Wiwi-icy (July 1991) 88.1:19-28.

69. Nlugford, M., Mercy, J.. and Chalmers, 1. Cost implications of different approaches to pre-vention of respiratory distress syndrome. A rrhim of Diseases of Clrildhood (1991) 66:757-64.

70. F-D-C Reports, Inc. Lung surfactants responsible for 8% drop in U.S. infant mortality:Smoking linked to low birth weight. The Blue Sheet, April 29, 1992. pp. 4-5.

71. Cole, C.H.Jilson, E.. and Kessler. D. ECNIO: Regional evaluation of need and applicabilityof selection criteria. A merimn journal of Diseases of Children (December 1988) 142:1320-24.

72. Southgate. W. NI.. Howell, C.G.. and Kanto, W.P. Need for and impact on neonatal mortal-ity of extracorporeal membrane oxygenation in infants greater than 2.500-grant birthweight. Pediatrics (July 199(1) 86,1:71-74.

73. Dickerman, LH.. and Park. V.M. Cytogenic and molecular aspects of genetic disease andprenatal diagnosis. In .Neonatal-Perinatal Medicine, Fanaroff, A.A., and Martin, RJ., MosbyNear Book: St. Louis, MO. 1992.

74. Harrison, M.R., Adzick, N.S., Longaker, M.T., et al. Successful repair in mem of a fetal dia-phragmatic hernia after removal of herniated viscera from the left thorax. New England,Journal of Medicine (May 31, 1990) 33,22:1582-84.

75. Harrison, M.R., Filly, R.A., Parer, J.R.T., et al. Management of the fetus with it urinary trackmalformation. Journal of the American Medical Association (1981) 246:633-39.

76. Nlou, S.M., Sunderji, S.C., Gall, S., et al. Multicenter randomized clinical trial of home uter-ine activity monitoring for detection of preterm labor. American journal of Obstetrics and Cy-necology (1992 ) 165:858-66.

James 1'rnnu, ALI I.,is as.saciateproles.sorolhediatiirs at HarvardMedical School, Mas-sachusetts GeneralHospital. Wang A m-bulatorr Care Center.

Bernard Gina. M.D.,'11.13. I L. L5 PrQles-snrand chairman of theDepartment n/ Mater-nal and Child Health,at _Johns Hopkins("niversity. School ofHygiene and PublicI lea lth.

jean .1 I. 'x71'1'010',M.S.S.A.11.P.Il., isa doctoral candidate0 nd research assis-tant, Department ofMaternal and (lildHealth, at johns Hop-hiti.s 'Hiversi ts Schoolol Hygiene and Public

halth .

Health Care Servicesfor Children andAdolescentsJames PerrinBernard GuyerJean M. Lawrence

Abstract

The authors of this paper identify risks to health and other factors that determinethe need for health care services among children and adolescents. Theydocumentservice utilization patterns in the areas of well-child care and immunizations, acuteambulatory care and hospital services, and injury prevention. They also acknowledgethe special health care needs of adolescents and of children with chronic illnesses.

It appears that neither the traditional personal health service delivery system nor thepublic health system alone can effectively provide all of the health services childrenneed. Collaboration between public health and personal health service providers isessential to future effbits to improve the health of children and adolescents. Recom-mendations include development of community-based preventive care programs in

all parts of the country, extension of current traditional primary care capabilities,assurance of access to primary care services, enhancement of public health activities,expansion of specialized adolescent health programs, and coordination of a com-prehensive set of medical and other services for children with chronic illness andtheir families. The authors conclude that, to he effective, future health systemreforms most he implemented through a coordinated program of care rather thanthrough competing wstems of services.

The control of infectious diseases and the recognition of the valueof preventive care have dramatically changed the health careneeds of children. Infectious diseases such as pneumonia and

influenza accounted for about 25% of deaths of children from 1 through5 Years of age in 1950; by 1976, they accounted for less than 10%) Infantmortality rates in the United States dropped from 47 per 1,000 live birthsin 1940 to less than 10 in 1990. Postneonatal mortality rates (deaths toinfants 28 days to 1 year old) dropped during the same period from 18.3to 3.7 per 1,000 live births.2 (See the article by Racine, Joyce, andGrossman in this journal issue.)

6

New problemsincluding injuries, the effects of environmentaltoxins, family violence, homelessness, and disorders of develop-mentincreasingly define health care issues for children today. Injurieshave emerged as the major cause of childhood mortality, morbidity, anddisability.3,4 Changing patterns of illness among adolescents have fo-cused attention on tasks of healthy development, including the promo-tion of physical fitness and healthy sexual behaviors, and the preventionof injury, substance abuse, unwanted prt..gnancy, sexually transmitteddisease, and violence, as reflected in homicide, suicide, and majortrauma. (See the article by Starfield in this journal issue.)

Changing health care needs have led to changes in patterns ofoutpatient and inpatient hospital utilization. Physician and nursing serv-ices delivered in physicians' private offices, hospital outpatient depart-ments, and clinics are increasingly preventive. In addition to routineimmunizations, these services in-clude behavioral counseling, par-ent education, and health promo- Changing health care needstion guidance to families. Rates of have led to changes in patternsinpatient hospital care have de- of outpatient and inpatientdined, as have lengths of stay, indi- hospital utilization.eating both the changing patternsof illness and also greater use ofambulatory settings for the treatment of many acute and chronic healthcondition s.",6 New technologies frequentl) pia) an important role whena child is hospitalized and when sophisticated care in the home and othernonhospital settings is needed.7

Other important trends in the past 2 decades include the growth ofconsumerism, increased survival of children with severe long-term ill-nesses, greater use of legislation and regulatory mechanisms to improvechild health, and higher rates of childhood poverty. Consumerism hasled to greater interest in self-care and care by parents. Parents and familymembers provide significant amounts of care for minor illnesses withoutdirect contact with health providers. Children provide more of their owncare as they mature, and the few data available suggest extensive treat-ment with over-the-counter medication. The family also has a majorrole in prevention, especially in promoting home safety, seat belt andbicycle helmet use, a healthy diet, and exercise.

Government programs and specific legislation to protect childrenhave major impacts on the health of American children and on theservice delivery system. Since the mid-1960s, Medicaid has become the


major source of health insurance for poor children. (Sec the article byHill in this journal issue.) Other federal and state programs, includingmaternal and child health programs and community health centers,provide acc,ss to primary health care serices.ln,II Further efforts toprotect children's health include legislation that requires packagingdesigned to prevent poi son ing,12 flame retardant sleepwear," and auto-mobile passenger restraints for children." Other health promotionefforts for children include the fluoridation of water and the federalvaccine program. Media campaigns linked to housing codes have led tolower water heater temperatures and decreased risks of childhood hotwater scalds.I5

The long-term survival of children with chronic illnesses and physicaldisabilities, some of whom have associated developmental disabilities, hasgreatly improved,I6 and these changing rates affect the organization andprovision of health services for children. Poverty among children maroffset many of the advances in child health care, however. Poverty isassociated with increasing rates of poor health and childhood disability17(see the article by Starfield in this journal issue) as well as greater use ofmore expensive health care services, especially inpatient hospital andemergency room care.18

In this paper, we have three objectives: (1) to identify risks to healthand other factors that define the need for health care services amongchildren and adolescents; (2) to document service utilization patterns inrelation to these needs and barriers to services; and (3) to argue that futureeffOrts to improve the health of children and adolescents must focus oncommunity-level outcomes and include multidisciplinary models of care.

Risks to Health and theNeed for Services

t'se of health services among childrenand adolescents is determined br a com-plex interaction among patterns of ill-ness. pot orols for preventive health care,features of third-party reimbursementplans. and factors that facilitate or createbarriers to care.

Infants, Preschool, and Sch,-,ol-ageChildren

.fast childhood illnesses are self-limited.that is. dick t5 picalh improxe whether ornot they are treated. The purposes Ofsurveillance and 11'e:11111CW Of these«unlitions are (11 to decrease pain anddisc-01111On: (2) to decrease the impact ofwino, illnesses on dad,. life (such asschool or child c are itttendance andinterruption of parental routine. includ-ing kork) It decreasing the sew! it) ofsymptoms or the length of illness: (3) toniinimiic consequences Or complicit-

Lions of illness (such as the treatment ofstreptococcal infections to prevent rheu-matic- fever); and (1) to identify the rela-tively rare serious condition among theinuch larger number of minor illnesses.

The health care needs olchildren arcnot defined by the patients of injury anddisease conditions alone. New morbiditkconditionsincluding behavior disor-ders. disorders of development, adjust-men t problems in adolescence.psvhosocial issues related to chronic- ill-ness, family violence. and abuse. andexposure to environmental haiards1such as leadmay also respond to medi-cal care." " Figure I pro\ ides estimates ofthe relative prevalence of several of theseconditions.

To some degree. changing mill/anonpattern. of personal health services tv-fled this changing numbiditN, althoughthese changes may be pooch describedin studies of c hill health services tuili/a-lion. (See the article lA Starr-H1d in this.journal issue.) \laity physicians have had

6


little training in these new areas, such asin responding to the more than 1 millionchildren nationwide who experienceabuse or neglect.21 The current limitedreimbursement for care of some of theseconditions also discourages practitionersfrom using these labels to define the rea-sons for visits with the result that theirtrue prevalence is underestimated.Current efforts to expand codingmechanisms for childhood behavioraland developmental conditions may posi-tively affect identification andreimbursement.22.23

Routine programs of screening havebecome an integral part of the delivery ofchild health services. Since 1961, whenscreening for phenylketonuria (PKC)began, the availability of simple screeningprocedures for the detection of inbornerrors of metabolism in the neonatal pe-riod has resulted in a decrease in the num-ber of infants suffering the adverse effectsof preventable conditions. Screening forPKC and congenital hypothyroidism is rou-tinely conducted in all 50 states and theDistrict of Columbia. Approximately 4.500cases of diseases that can lead to death ormental retardation are detected each yearthrough the use of newborn screening.`_[

Routine preventive health care can bescheduled at intervals corresponding tothe recommended immunizations againstdiphtheria, pertussis, and tetanus (DPT):poliomyelitis; hemophilus influenza; andmeasles, mumps, and rubella (NIMR). Im-munization against hepatitis B has re-cently been added to recommendations.Beyond immunizations, children may alsobe screened for specific illnesses or healthconditions, including lead intoxication,hearing and visual problems, scoliosis, tu-berculosis, and iron deficiency anetnia.nAlso recommended are targeted screen-ing for sickle cell disease and for hyper-cholesterolemia. In addition, pediatricpractice is an appropriate setting for as-sessing risks of developmen tal, behavioral.and educational problems, and for search-ing for problems in the family, such asparental depression, substance abuse.physical and sexual abuse, or smoking.

Content of Well-child Care

The content of well-child care can be as-sessed in two broad areas: reducing childmortality and morbidity, and promotingoptimum growth and deyelopmen t.21i Thegoal of reducing child mortality and mor-bidity includes disease detection throughthe physical examination and other

Figure 1. New Morbidities of Childhood

Behavior Disorders

Moderate Chronic Illness

Lead Poisoning

Severe Chronic Illness

Child Abuse*

Developmental Delay

Sexual Abuse

0 20 40 60 80 100

Rates per 1.000 children

'Does not include sexual abuse

120 140

Source: U S. Department of Health and Human Services. Healthy People 2000 National HealthPromotion and Disease Prevention Objectives. Washington. DC: U.S Government PrintingOffice (DHHS PHS 91-50212), 1991; Newacheck. P.W.. and Starfield. B Morbidity and Use ofAmbulatory Care Services Among Poor and Non-poor Children. American Journal of PublicHealth (1988) 78.927-33.

62

screening mechanisms and disease pre-vention through immunization. Despite asubstantial literature which shows that fewphysical abnormalities are discovered dur-ing the routine well-child physical exami-nation,2426.27 this aspect of well-child carecontinues to occupy the bulk of time inphysician visits.28

The Committee on Practice and Am-bulatory Medicine of the American Acad-emy of Pediatrics (AAP) currentlyrecommends six well-child visits duringthe first rear of life, six visits over the next4 years, and visits every other year to age20. In addition, the AAP recommends onematernal prenatal visit to a pediatricianfor anticipatory guidance (for example,what to expect regarding sleep and cryingpatterns and how to cope with them) andto collect the pertinent medical andfamily history.29 (See the article by Rac-ine. Joyce, and Grossman in this journalissue.) The guidelines recommend takinga history and measurements (height,weight, head circumference through thefirst year of life, and blood pressure afterage 3), as well as developmental andbehavioral assessments, physical examina-tion, and anticipatory guidance (includ-ing counseling on feeding and sleepinghabits, accident prevention and safety_ , be-havior, and sex education). A typical well-child visit lasts 10 to l2 minutes and mayinclude laboratory work and other healthscreening measures.28

Observation of physician-patient inter-actions in private pediatric practices hasfound that anticipatory guidance ac-


counted for 8.4% of the total time spentduring well-child care visits. The timespent on anticipatory guidance variedfrom 1 minutes per visit with parents ofchildren under 5 months of age to 7 sec-onds with adolescent patients.28 Increasedutilization of pediatric nurse practitionersmay he a cost-effective way to increase theeducational component of well-child care.Research suggests that nurse practitionersprovide parent education that is compara-ble to that provided by pediatricians, buttheir visits are longer because they tend todiscuss developmental and behavioral is-sues in greater depth and to give parentsmore opportunity to talk.30

Immunization and promotion of pre-ventive health behaviors are the majorrationales for well-child care. Immuniza-tion against childhood infectious diseasesis the single most effective and cost-effec-tive intervention available to reducemorbidity and mortalitv.21 Other preven-tive interventions, however, are less welladdressed in well-child care. Only 4 sec-onds of the well-child visit, on average, arcdevoted to injury prevention, even thoughinjuries are the leading cause of death anddisability in childhood.28

The second broad area of well-childcarepromoting optimum growth anddevelopment encompasses counselingabout mother-child interaction, develop-mental advice, and parenting advice. Thegoals of this cc rnponen t of pediatricpractice are poorly defined. De facto,pediatricians find themselves giving pm.-chosocial guidance, offering advice onemotional disorders, and counseling forproblems in family relationships andchild behavior:" Although the effective-ness of such clinical interventions has notbeen adequately studied, there is asubstantial professional and parental con-sensus about their importance.

In general, counseling and advice inpediatric practice is based upon the clini-cal guidelines developed through expertcommittees. These guidelines representstate-of-the-art advice from the best avail-able clinical experience and the sharedcumulative experience of clinicians andacademicians. They lack a strong empiri-cal base because no randomized clinicaltrials have been carried out to evaluate theefficacy of pediatric counseling interven-tions in improving the health status ofchildren. We believe, however, that theabsence of a strong empirical research

6 5


base in this area of child health care doesnot necessarily lead to the conclusion thatthese activities are not worthwhile, as wasprematurely concluded by the Office ofTechnology Assessment in 1989. Furtherresearch is needed to evaluate both therecommended guidelines and the carethat is actually being provided.

All the benefits of well-child care havenot been clearly articulated. In addition tohelping prevent premature death or seri-ous illness, well-child care may offer sup-port and reassurance for families andprovide a "medical home" for parents iftheir child develops an acute illness. Themedical home promotes continuity of careand provides the physician with baselinemeasures of the child's health status be-fore the onset of illness.32 Identifying se-rious conditions is sometimes complex:fever and irritability in a very young childusually indicate a minor viral illness, butthey may indicate a far more severe andlife-threatening disease, such as meningi-tis or sepsis. As with much else in medicalcare, demonstrated efficacy of treatmentfor many common childhood illnesses iseither limited or lacking.33

Sources and Utilization of Health Care forChildren

Health services for children are availablefrom several sources. For most children, acommunity-based physician (usually a pe-diatrician or family practitioner) providesmost care, including preventive services(immunizations and anticipatory guid-ance) and care for most common illnesses.Although the majority of community-based pediatric care is supported throughsome form of fee-for-service payment, in-creasing numbers of children receive carethrough prepaid programs, mainly healthmaintenance organizations (HMOs). (Seethe article by Sheils and Wolfe in thisjournal issue.)

Other important sources of general pe-diatric care are community health centersand public health departments. Commu-nity health centers may integrate generalhealth services with different combinationsof community preventive services, linking,for example, Women, Infants, and Chil-dren (WIC) nutrition programs, socialservices, and mental health programs,among others. Community health centersusually serve high-risk communities withhigh rates of poverty and environmentaland social risks affecting child health.Medical services provided in health centers

are supported by third-party payers (mostlypublic, through Medicaid), by fees col-lected from patients (frequently on a slid-ing scale pegged to income), and by directservice grants (especially through the fed-eral community health centers program).

Coordination among preventiveand treatment services maybe substantial in some places,absent in others.

In some communities, a full range ofpreventive and treatment services is read-ily available. Other communities may lackmajor components or have major accessbarriers to immunizations or other serv-ices. Coordination among preventive andtreatment services may be substantial insome places, absent in others. In mostEuropean countries some form of commu-nity-based preventive or general healthcare is available to all residents, regardlessof social or economic status.34 Many U.S.communities lack similar services, andchildren thereby either go without servicesor receive them in settings designed forother purposes, such as hospital emer-gency rooms.

Most private health insurance pro-grams cover illness care for children, butmany do not cover the costs of preventiveservices such as immunizations. HMOs,which incorporate both insurance and or-ganizational functions, typically do coverthe costs of preventive care for children.Medicaid, the main public insurance pro-gram for low-income children, also pays forpreventive care, including immunizations.Variations in public financing also affectchildren's access to preventive health care.To receive immunizations in traditionalfee-for-service practice settings, parentsusually pay directly for the service. In somecommunities, public health departmentsoffer free immunization clinics.35 Othercommunities lack the budgets to providesuch services to many children who needthem. In some parts of the country, espe-cially the rural South, health departmentsprovide a broader range of general childhealth services, including both preventiveand treatment services, either free ofcharge or on a sliding-fee scale.35 Nonfi-nancial barriers such as culture or geogra-phy may, however, also limit access,

6 3

64

especially in community health centers.(See the articles by Sheils and Wolfe. Hill.and Klerman in this journal issue.)

The data on utilization of preventiveservices by young children are disturbing.Using data from the 1987 National MedicalExpenditure Survey (LAMES), Lefkowitzand Short found that a significant propor-tion of 2-year-old children did not receivepreventive health care.36 Twenty-five per-cent of Medicaid children, 30% of unin-sured children, and 20% of insuredchildren had not had a preventive healthcare visit during the previous year. Whenexamining the rate of preventive visits byracial and/or ethnic groups. Lefkowitz andShort found that 20% of white childrenhad received no preventive health care vis-its. whereas 33.4% of black Children and33.0% of Hispanic children nad made nopreventive visits to a f alts care provider.

Data from the 1989 National HealthInterview Survey (NHIS) indicate that, onaverage, children 0 to 5 years of age haveabout 4.1 physician visits annually, and chil-dren 5 to 17 years of age have 2.2 visits per-ear. When telephone and hospital physi-cian contacts are included in the number


of physician contacts, these figures in-crease to 5.8 and 3.1 contacts per year,respectively.37

Visits vary by family income, race, andinsurance status. Children under 18 Yearsof age whose family yearly income is under$10,000 have 2.3 °ince visits per year (or3.6 total contacts), whereas children whoseannual family income is between $10,000and $19,999 have 2.1 office visits per year(or 3.3 total contacts).37 This differenceserves as an illustration that the near-poor(the most likely to be uninsured) havefewer health care visits than do the poor,who have Medicaid to pay for their healthcare. Monheit and Cunningham in thisjournal issue provide a detailed analysisthat confirms the relationship betweeninsurance status and the utilization ofmedical services by children. White chil-dren under age 18 make 3.0 office visits( 4.2 total contacts), whereas black childrenin the same age category make 1.6 officevisits (2.5 total contacts).37

Hospital Services

Rates of hospitalization and lengths ofhospital stay have declined for both chil-dren and adults over the past decade.

Figure 2. Major Causes of Adolescent (10-19 Years Old)Mortality, 1985

Motbr Vehicle Accidents

Natural Causes

Suicide

Other Violence/Injury

Homicide

Drowning

Fires

1 I I I I i

5 10 15 20 25 30 35 40

Percent of total deaths

'Including neoplasms. congenital anomalies. and a number of relatively rare conditions.

Source: Fingerhut. L . and Kleinman, J. Trends and Current Status in Ct,(Idhood Mortality. U.S..1900-1985. Vital ona Health Statistics. Series 3. No. 26 (DHHS Pub No. 89-1410). Hyattsville, MD:National Center for Health Statistics, 1989

S. Health Care for Children 65

Approximately 2.4 million children underage 15 tears were hospitalized in 1990.representing a decline of about 29(.i. from198-1.5 (:Iiikiren utility a relatively smallproportion of total acute hospital careless than 8% of total hospital discharges).

Data from the 1990 National Hospital Dis-charge Survey indicate an overall averageof 0.21 hospital days per child per Year.

The number of children in hospitalswith chronic health conditions rather thanacute ones has been increasing. Recentestimates at specialty hospitals suggest thatabout 70% of all childhood admissionscurrently are for chronic condilions.38Major advances in medical and surgicaltechnology have led to the survival of agreater number of severely ill children.Technological advances. especially min-iaturization of complex equipment. havealso increasingly allowed tee >logy-dependent children to receive care inhome and community settings.

Recent studies have demonstrated size-able variations in rates of hospitalizationfor children.' 8 Children residing in Bos-ton. Massachusetts, for example. haveabout three times the risk of hospitaliza-

butt for medical problems as do childrenin Rochester. New York. These communi-ties have similar medical resources, as in-dicated by per capita physician andhospital bed rates. but the Boston popula-tion is poorer than that of Rochester.Because poverty increases children's risksof hospitalization. variations in poverty lev-els among communities may explain somebut not all of the variations in rates ofhospitalization. Other causes likely in-clude the availability and types of C0111111U-n itv-based general health services fornotipoor children and physician practicestyle. Children who lack regular commu-nity-based physician care are more likelyto use emergency 10011109 and are morelikely to be admitted to the hospital whenthey do.

Adolescents

Ad, tit-scents. 10 timing h 19 Years old. rep-resent the ()Illy segment of the popu-lation in which mortality rates have notdeclined rapidly during the past 2 dec-ades.:'. The major causes of mortality dur-ing adolescence are motor vehicleaccidents (38"i.). natural causes 127eisuicide (10(.';,). other violence and injuries

Figure 3. Estimated Prevalence of Adolescent (10 -19 YearsOld) Health Problems**

Alcohol Use. Major'

Smoong. Arc.3ng High School Seniors

Marijuana Use

Overweight. Age 12-19

Pregnancy. Age 15-17

Cocaine Use

Gonorrhea. Age 15-19

50 IOC 150 200 250 300 350

Rates per 1,000 adolescents

'High scnool seniors having five or more drinks in the past 2 weeks"Composite of dates, but basically 1976-1989

Source U S. Department of Health and Human Services_ Healthy People 2000 National Hec,IthPromotion and Disease Prevention Objectives. Washington. DC. U S Government PrintingOffice (DHHS PHS 91-50212). 1991

6 '2)

66

11111111,


(10%), homicide (9%), drowning (4%),and fires (2%)3 (see figure 2). Half of themotor vehicle accidents that result in thedeath of an adolescent involve alcohol.4°Thus, 73% of the deaths that occurbetween t he ages of 10 and 19 years can beattributed to intentional and uninten-tional injuries and violence. Many of thebehaviors that lead to these deaths can betargets of prevention and intervention ac-tivities by the health care system, the com-munity, and individual health careproviders.

Seventy-three percent of the deaths thatoccur between the ages of 10 and 19years can be attributed to intentionaland unintentional injuries and violence.

Goals for adolescent health go well be-yond the prevention of violence and injuryto include developing healthy behaviorsrelated to sexuality, physical fitness, anddietary habits, and preventing substanceabuse. Issues related to sexuality includeprevention of unwanted teenage preg-nancy (and the subsequent choices regard-ing parenting, adoption, or abortion ifpregnancy does occur) and sexually trans-mitted diseases, including HIV infection(see figure 3). To have an impact, educa-tion regarding these issues should startprior to adolescence, when children arcbeginning to think about these behaviors.

Addressing the health care needs ofadolescents may necessitate modificationof some sectors of the health care systemto accommodate their special cirim-stances. (See the article by Klerman in thisjournal issue.) Barriers to the effective useof traditional health care services by ado-lescents include discomfort with tradi-tional health care settings, lack ofinsurance coverage or money to cover thecost of care,41 parental consent require-ments for some services, lack of officehours that do not conflict with schoolhours, and the inability or refusal of someadolescents to comply with the recom-mended medical treatment or follow-up.42Many adolescents either do not use medi-cal services or, when they do, receive littleht p for their special problems. Physiciansmay represent parent-surrogate authorityfigures for many adolescents, affectingadolescents' comfort in medical settings.In addition, a greater need for privacya

normal part of adolescent developmentmakes issues of sexuality, drug and alcoholuse, cigarette smoking, and other behav-iors that expose them to health risks diffi-cult to disclose to health care providers,Finally, many physicians remain uncom-fortable or unskilled in addressing theseissues with their adolescent patients.43 Asa result, adolescents between the ages of10 and 18 make only 1.6 visits to an office-based physician cad' year. White adoles-cents make 1.7 visits, compared with 0.9visits made by black adolescents.44 Withthis limited number of contacts, tradi-tional health care providers may have littleimpact on many problems experienced byadolescents.

Moreover, adolescents are not a ho-mogeneous population. Among the ado-lescents at highest risk for poor healthoutcomes are homeless and runawayyouths. Up to one million Youths run awayfrom home each year.45 Among homelessand runaway Youths, 48% are depressed,46% have substance abuse problems, 31%have been victims of physical abuse, 21%sexual abuse, 58% have school-relatedproblems, and 9% have engaged in sexualactivity (prostitution) to survive on thestreets.46 Yet, despite the high-risk emo-tional and behavioral profile of this popu-lation, access to and utilization of healthservices are low because many of the samebarriers that limit effective use of healthservices by adolescents living in intactfamilies present even more formidableobstacles to homeless and runawayyouth.47

Integrating Services in theCommunity

Even where an effective intervention suchas immunization exists to protect thehealth of children, the traditional organi-zation of health care services has failed toassure the availability of the interventionto all children. In addition, traditionalpractice patterns may be inadequate toprotect children and adolescents frombroader risks, such as exposure to injuries.These observations lead us to support anexpanded approach to child health carethat integrates the roles of the office- andclinic-based pediatric practitioners withcommunity-based child health practitio-ners. Similarly, responsive preven:ive carefor adolescents may require a departurefrom traditional models.

69


Infants, Preschool, and School-ageChildren

Multidisciplinary models of (-are May heneeded to intim ive the health status of allchildren. Such models already exist inmost Vestern European countries.34sThis concept can be demonstrated by ex-amining the coordinated responses ofpublic and private health providers at theccanmunity level which are necessary toachieve recommended levels of immuni-zation by 2 years of age and to protectschool-age children from the risk of injury.

Immunizations

The United States has an enviable recordof achiek ing very high levels of immuniza-tion of school-age children. .111 states re-quire that a child receive a basic set ofimmunizations as a condition of schoolentry, and, as a result, U.S. immunizationrates for school-age children are generallyhigher than those of most other industri-alized countries. 19 Nonetheless, data fromthe 1985 national immunization survey(the most recent source of national dataon immunization status) showed that.among children I to 4 years old, 21.' ;NCR' not immunized against measles.2 4.3ui were inadequately protectedagainst polio, and 13c'; were inadequatelyj>rotected against diphtheria, pertussis,and tetanus.'" By 1990. the proportion oflow-income. inner cis children fulls im-muniied against all the vaccine-prevent-able diseases by age 2 years was estimatedto have fallen to less than 50'4 .51 As aresult of low and declining levels of immu-nizations during the 1980s. epidemics ofmeasles occurred in 1989 and 1990, with18,193 and 2 7.672 cases reported in thoseears.51 Nearly half of these cases (48.1 (..;occurred in children less than 5 Years ofage. Ni()rc than one (bird of the childrenin the age group who contracted measlesin 1991) were eligible lOr vaccinations buthad not been

Moremer, the United States failed tomeet a ke immunization ()hie( tine lot theyear 1990: that by 2 Years of age, 90'7 ofchildren would be immunived against themajor childhood diseases, particularlymeitsles.19 Thus, for the single most:lc( tined and cost-effec live component of

hill careroutine immunizationt he health care syslem has failed toachieve national objectives, failed tomaintain the professionally recom-mended immunization schedule, and

failed to protect Young children front thethreat of disease.

immunization coverage of a popula-tion is a function of three interlockingdomains: (1) health-seeking behavior onthe part of parents of atng children. (2)harriers to care, and (3) provider practicesthat inhibit appropriate immunization.-'2Each of these domains appears to contrib-ute to the failure to assttre adequate im-munization levels, although their relativecontributions are not known.

Poor children are less likely to be im-munized because they receive less preven-tive health Can. overall. stemming, in part,From negative family attitudes towardhealth care, disbelief in susceptibility todisease, or a feeling of powerlessness toprevent disease::; Marks and colleaguesfound that low maternal education was arisk factor, implying that a clear under-standing of immunization as an effectiveprotection against disease was lacking inthese tnothers.1

The U.S. health care sstem is notequally accessible to all children. Duttonhas linked low utilization among the poorto access barriers.53 (See the article hisklerman in this journal issue.) In the laceof financial barriers to appropt late immu-nization, many families now seek carefrom publicly subsidized maternal andchild health centers. communit% healthcenters, or county health departments.Unfortunately, users of these facilitiesoften face inadequate supplies of vaccine,inconvenient hours and locations, andlong waiting times.55

68

Overall, however, variation in officeand clinic practices among pintail- andpreventive health care providers may hethe most important component of the fail-ure of the health care system to assureadequate immunization coverage. Studies

Variation in office and clinic practices amongprimary and preventive health care providersmay be the most important component of the fail-ure of the health care system to assure adequateimmunization coverage.

by the Centers fOr Disease Control ofrecent measles outbreaks in Puerto Rico.Miami. and los Angeles fOund that onethird of children who had failed to receivea measles, mumps. and rubella (MMR)vaccination had actually presented theni-selves fir- preventive care at the appropri-ate time, but their providers had missedopportunities to immuniie then(.: r' theseobservations are consistent with earlier re-search.5657 In addition, the use ol multi-ple providers. which reduces thecontinuity of care. decreases the likeli-hood of adequate immunization.'` Fi-nally, lack of knowledge among sonicphysicians about scheduling, contraindi-cations, proper vaccine storage. and po-tential complications IllaN be aS:;OCiatedwith lower rates of immuni/ation amongchildren. 59

.\ successful communit\ -based immu-ni/ation program must in hide an accessi-ble system of comprehensive primaryhealth care, coordination between pediat-ric and public health practitioners, coin-in unit \ surveillance or immuni/ationstatus, an interactive information systemcontaining the immuni/ation status ofeach child that is accessible to all provid-ers, and incentives to families to seek pre-\ entive health services for immuniiationbeginning by the second month of life.Efforts to link adequate inummiiation tochild Care ellt IN Or to participation inbenefit programs like \IC or .\id to Fami-lies with Dependent Children (.\1:D(:)lime also been I ecommended.5

Injury Prevention

The inaj(qr threats to the health of chil-dren 5 to I I scars of age are pedestrian.motor (chicle occupant. bicycle- (elated.and lee 1(6;10°11,11 and sports-related inju-ries. In 1988, 1,990 children 5 to years


old died of injuries, 837 as pedestrians,and 940 as motor Chide OCCUpalliti."1Sports related injuries were estimated toaccount for more than 90,000 inpatientadmissions and 2.5 million emrgencsroom visits in 1985.-1.61

Although child health care providershave often been in the forefront of com-munity efforts to protect children (wit-ness the role of Dr. Robert San:niers ofMurfreesboro, Tennessee, in advocatingfor the nation's first child passenger safelylegislation in 19781. they have general! \relied upon office-based anticipatoryguidance as their method fin- influencingchild safety, with mixecfresults.62 Despiteefforts by the .1..1P to promote a compre-hensive program of office-based injurycounseling, The Injury Prevention Pro-gram (TIPP), relatively few pediatriciansactively use the program. and few alterna-tives are available. Studies are currentlyunder way to explain the failure Of pedia-tricians to use TIPP.63

Ricsrk safer is an area in which childhealth care providers must join ellOrts withpublic health and other communitY-basedagencies to address childhood Minn suc-cessfully. There is now good evidence thatsafety helmets reduce the risk of braininjuries in falls 11.0111 bicycles by as muchas than 1()(.(4)i((1id all ages wear e111 s.65)1::

recent study found convincing e5 alert«.that a low-cost classroom intenention suc-ceeded in promoting helmet use amongelementary school pupils.66 Unfortu-nately, several controlled studies of bicyclehelmet promotion in pInsicians officesand emergency rooms have not demon-strated successes.67-e.s.\sRUI1Vall and Run-yan concluded, physicians must notabandon their efforts to educate familiesabout these risks, but must, in addition,join community-wide efforts to promotesafe! y through legislation. regulations,

h001-baSd dt Cil Oils. and itn-ruined environmental flbrts.69 I le althcare professionals at all levels must findopportunities to build community coali-tions involving medical care providrs.school officials, parents, and public nalthagencies.

Adolescents

Feu man\ adolese mit., the invents stem that deli\ers cane through privatephysician practices, «mummify health«.ntel s, and aeloles«.tit health programssvorksssell. Rates of serious illness among


adolescents are low, and the tasks of ado-lescent health care typically focus oil pre-vention and encouragement of healthylife styles. Effective programs for adokes-cents help them to develop self-careskills, encourage exercise and appropri-ate diet, and decrease major risks tohealth such as :smoking, alcohol use, andother substance abuse. Further preven-tive care typically includes preparingadolescents tier healthy sexual activityand teaching them methods of earlyidentification of disease. such as throughbreast or testicular self-examination.

Alternative programs have been devel-oped in response to the difficulties someadolescents have in accessing health care.These programs include specific clinics fbradolescents in areas where they often con-gregate (such as shopping malls) andschool-based clinics that are available dur-ing and after school hours. (An analysis ofschool-based clinics appeaml in the Spring1992 issue of Me Futurt, of Children.) Fur-ther. health services are needed fOr hard-to-reach adolescents, such as homeless.runaway, and incarcerated youth. 7° UnfOr-innately, few adolescents have access toservices that are especially designed tomeet their health care needs. School-basedclinics exist in fewer than 200 oldie 16.000school districts nationwide.71

An evaluation Of the impact of 23school-based clinics on access to healthcare for adolescents from low- incomehouseholds found that many of those en-rolled in the clinics were previously medi-cally underserved.7l Twenty -( me percenthad no regular source of medical care.58% were self-pay (likely to be uninsured ),and 21% had made no health care visits inthe past 2 Years. These clinics providedcomprehensive services. Of the primaryreasons fi visits to these clinics. 26% were(or acute injury and illness. 21% for men-tal health, and In fiw other categoriesincluding reproductive health care. physi-cal exams. immunizations. and hearingand vision screening. Alcohol and drugabuse services constituted only 1 °r of theprimal, reasons for a visit.

Community and public support hasbeen highly variable for these services, inpart reflecting the controversy over pro-viding contraceptive devicesincludingcondoms and prescriptionsin school set-tings. The emphasis on the family plan-ning role of school -based ( linics concealsthe fact that 8(Y of the main reasons for

visits to these clinics concerned issuesother than family planning.7 Europeancountries provide universally availablecommunity-based preventive services.which provide many preventive services toadolescents.72 Similar forms of preventivecare are not available in most communitiesin the United States.

The high-risk behaviors engaged in bysome adolescents cannot he addressedsolely or sufficiently by the health caresystem. A multifaceted intervention ap-proach that is available. accessible, andaffordable is needed to address the needsof adolescents. Increasing numbers of spe-cialists in adolescent medicine may alsohelp to focus attention on the develop-ment of new interventions to improve ado-lescent health.

Children with SpecialNeeds: The Case ofChronic IllnessSome children's health problems makespecial demands upon children's healthservices. These conditions include chronicor catastrophic illness, major trauma. de-velopmental disabilities, and children atenvironmental and social risk. NN'e fbcushere on the example of childhood chronicillness as it illustrates the implications ofthese categories cif special need.

Between 10% and 30% of all U.S. chil-dren have some kind of chronic healthimpairment. although the large majorityuf these conditions are mild and have littleimpact on children's daily activities or

70

utilization of health seryices.737 t .About10% of children with chronic illnesses, orperhaps 2 million children nationwide.have severe conditions that require exten-sive health services. (See the article byStarfield in this journal issue.) Of thisgroup, only asthma and common andusually less severe) forms of congenitalheart disease occur with any great fre-queno . As figure 4 indicates. other indi-vidual conditionssuch as leukemia.arthritis, diabetes. cystic fibrosis. epilepsy.and kidney failureare rare. Estimates ofthe utilization of services by this popula-tion vary, but they generally suggest thatthe approximately 2c« of children withsevere illnesses use at least 25% of the childhealth dollar.7:1 This figure represents, inpart. the higher-than-average utilization ofinpatient hospital rare by this group ofchildren. (Se the at tide lw Lewit andMonheit in this journal issue.)

Although a common view is that manschildren with severe chronic illnesses diein childhood. current estimates of survivalsuggest that at least 9f) of children, evenwith very severe long-term illnesses, surviveto voting adulthood.I6 These rates reflect

Figure 4. Estimated Prevalence of ChildhoodChronic Illnesses*

.e: me severe)

.200 ,,seose

. :ore 0,50rder

ArtrudIS

JoVes Mellitus

loiPalote

s Svnerome

'1,00 8thaa

7,:k:e Cell Anemo

vst,c Fnrosm

err,00f11140

QGna: ,SPCISO

M.,SCUP,71:V.."00rW

',Wes per

'Composite of dotes, but basically 1979-1981

Source Gortmaker. S L . and Sappenfield. VI Chronic ChildhoodDisorders Prevalence and Impact Pediatric C.'inics or North America,1984) 31 3-18


a dramatic change in the past quartercentury. brought about by major improve-ments in medical and surgical technolo-gies and in the distribution and availabilityof sophisticated medical care. Indeed.these remarkable survival rates reflectsome of the important successes of U.S.health care. Thus, where until relativelyrecently the emphasis was on improvingsurvival rates. the emphasis now is on im-proving the quality of life for the largemajority of chronically ill children whosurvive to become Young adults, most ofwhom can participate as active membersin most aspects of adult life.

AIDS creates challenges for house-holds and health services similar to thosefrom other chronic illnesses, with someimportant distinctions. First, AIDS in chil-dren is highly concentrated in poor andminority tamilies.711 The disease had by1988 become the first and second leadingcause of death among Hispanic and Afri-can-American children, respectively, agesI through 4 in New York State.77 Second.it carries a very high fatality rate, with fewinfected children currently expected tosurvive to adulthood. Third. its i nain modeof acquisition (congenitally from inflictedinotlic..rs) means that other family mem-bers (especially mothers) Mai; also be illand therefOre unable to care for their chil-dren. By late 1991 it was estimated that10% 01 all pediatric hospital beds wereoccupied by children with Al DS.78 Cur-rently affecting fewer than 1 in 20.000 chil-cl re n AIDS will likely increase inprevalence. and treatment advances willlikely inipnwe survival rates among in-fected children. These trends, if realized.will probably increase the demands placedon the health care system for services forchildren with AIDS and for those infectedwith HIV.

Families provide substantial care fiirchildren with special health needs. Studiesby Breslau and colleagues indicate thatmothers spent significantly increased time.0 home caring for children with chronicillness and were less likely to be employedoutside the home.79 The children in thesestudies were mainly ones with moderatelysevere illnesses. In recent Years. many chil-dren with much more severe illnesses, in-cluding many dependent on majortechnologies, such as respirators or intra-venous or tube feedings. have receivedcare at home. Many of these children re-quire extensive nursing cart'. monitoring,and the use of complicated equipment.

7"1


oftenten around-the-clock. This move towardincreased home care is the result of severalfactors: the desire of most families to takemore responsibility for the care of theirown severely ill children and to have thesechildren at home with the family, thegrowth of technologies allowing moreminiaturization, and efforts at cost con-tainment that encourage home care as aless expensive alternative to continuingin-hospital care.?

Technological advances, especially ingenetics, are changing the preventive is-sues related to chronic health condi-tions.80 Two main genetic interventionsexist: the ability to predict before concep-tion the risk of conceiving a fetus with agiven genetic disorder and the identifica-tion of an affected fetus earl in preg-nancy. Most recent advances in genetictechnologies provide increasingly sensi-tive :was of defining the specific geneticdefect, allowing earlier and much moreexact determination of risk or disease. Inaddition. the detection of a fetal anomalymay now lead to termination of pregnancyor to other options. including a change inthe timing or in the mode of delivery, orin prenatal treatment. Prenatal treatmentsinclude intrauterine surger,8182 transfu-sions," and delivers. of medications to in-crease fetal survival rates and enhanceperi- and postnatal development. Detec-tion of a fetal anomaly may also allow theparents to be better prepared to deal withthe special medical and other needs of anafflicted infant after birth.

Other recently developed technolo-gies improve the lives of these childrenafter they are born. There have been dra-matic improvements in surgical tech-niques for the management of congenitalheart disease. greatly improved medica-tions for the treatment of leukemia andother childhood cancers. and therapeuticadvances in the management of childrenwith cystic fibrosis to lengthen their lifespans. Children who are dependent onventilators or who receive long-termintravenous feedings at home ate exam-ples of beneficiaries of other technologicaladvances. Office of Technolo,t,ry Assess-ment estimates (figure 5) are that 20.000to 30,000 U.S. children may require homecare with significant technology depett-ilence.s.1 Recent research suggests that thecost of home care can be exceptionallyhigh, for some children well over SI00,000per Year. However, such costs are stilllower than those tpicalls associated with

hospital care. Although some of these costdifferences reflect true savings, many pri-marily reflect cost shifting from hospitalsor insurers to parents.'

Children who survive with long-termchronic illness face risks of secondary dis-ability, as well as higher risks of mentalhealth problems and educational dvsfunc-tion.85-86 Multiple studies document thatcompared with apparently healthy chil-dren. children with long-term illnessescarry about twice the risk of haYing signifi-cant behavioral or psychiatric prob-ieMS.74K7 Most studies find that, with theexception of conditions that affect thecentral nervous system, all chronic ill-nesses whether severe or not seem to pro-duce approximately the same increase inthis risk. Children with chronic centralnervous system conditions appear to haveup to five times the risk of having signifi-cant behavioral or psychiatric problems aschildren without apparent illness."

Chronic illness also significantly affectsa child's ability to participate in regulareducation activities.39 Many developmen-tal disabilities create the need for specialeducation services that take into accountthe effect of the developmental problemon the child's a nilit to learn. Most chron isillnesses, however. create no direct impacton the child's ability to learn. althoughexcessive fatigue and the effects of medi-

Rgure 5. Chicken Dependent on Technology,Population Estimates

Patenterat Nutnton

ientitotot Dependent

Penal Dolvus

Rescgatory,Nonhon

'V ineropw.5

-ItDiner*

0 5 10 '5 20Poles per I CO3 etvidren

25 10

'Includes children assisted with devices such as urinary catheters orcolostomy bags.

Source: Multiple data sources (mainly 1985-86), documented in U.S.Congress, Office of Technology Assessment, Technology-dependentChildren: Hospital vs. Home Care. Washington DC: U.S. GovernmentPrinting Office(OTA-TM-H38). May 1987.

72

cation mac affect the child's cognitiveabilities.90 More commonly, the childfaces frequent absences because of medi-cal or surgical care or because of exacer-bations of conditions such as asthma orarthritis. Many years ago, when the issuefor these children was planning for prema-ture death, schooling was considered rela-tively unimportant; today, with mostchildren surviving to adulthood, there is agreat need to improve educational oppor-tunities and to diminish the effects of ill-ness or its treatment on the child'sparticipation in school:in

Federal and state Title V Maternal and ChildHealth programs for children with special healthcare needs typically provide services for lower-income children with chronic illness, thoughservices vary greatly from state to state.

Most children with chronic illness havesome public or private insurance for usualmedical, surgical. and hospital care, butthey often lack coverage for needed com-prehensive and long-term care services. :\recent Supreme Court ruling has led toexpanded childhood eligibility fir Supple-mental Security Income and its associatedMedicaid coverage, and poor childrenwith disability- may now find access to pub-lic insurance easier.`-t2 Even htr the largenumber of children insured through tra-ditional emplover-based family health in-surance programs. many needed serviceshave been unavailable or are not covered.Preexisting conditions clauses in insur-ance contracts may exclude chronic con-ditions, and specialized long-term caremay not be included in the benefit pack-age. (See the article b' Shells and Wolfein this journal issue.)

Federal and state Title V Maternal andChild Health programs for children withspecial health care needs typically provideservices fbr lower-income children withchronic illness. though services varygreatly from state to state. Some pro-grams support hospitalization for childrenwithout other insurance, others fund spe-cialized clinics for specific conditions, andothers apply resources to coordination ofservices or to regionalized programs ofcare involving several medical and non-medical disciplines. (See the article by Hillin this journal issue.)


Chronically ill children and their fami-lies need attention from a wide variety ofhealth and related providers. They needspecialized medical and surgical services.high-quality general health services(which they mac lack more than do able-bodied children 1, specialized nursing serv-ices, social services, preventive mentalhealth services, and specialized educa-tional planning. Further. many need cer-tain specific therapies. such as nutrition,respiratory therapy, and occupational andphysical therapy. Given the variety of serv-ices many of these families use, they wouldprobably find that care-coordination serv-ices, although often unavailable, would bevery beneficial.

Optimal care for these children andtheir fatnilies would provide most servicesin or near their home communities whileless frequently required specialized andtechnically advanced care of the child'smedical problems could be providedthrough centralized specialty medicalcenters.; 3

Regionalized service networks may henecessary to forge the links between com-munity-based services and centralized spe-cialty services which are necessary toimprove the delivery of comprc tensivecare to children with chronic illnesses.Traditional health insurance programswhich pay primarily for medical care serv-ices may not pay for the other services thatfamilies with chronically ill children need.Already financially strapped families mayhave to pay for these services out-of-pocketor do without them. In addition, trad.-tional health insurance plans may not sup-port the organization and maintenance ofregional multidisciplinary programs. Thedevelopment and maintenance of theseprograms mar require significant expen-ditures and responsibility front other, usu-ally public health, sources. In some states,the Title V programs have taken primaryresponsibility for developing and imple-menting a multidisciplinary approach tohealth care."

Conclusions andRecommendationsThe evidence suggests that neither the tra-ditional personal health service deliverysystem nor the public health system alonecan effectively provide all the health serv-ices children need. Collaboration betweenpublic health and personal health serviceproviders is essential to assure adequate


immunizations, prevent childhood inju-ries, ensure adolescents access to respon-sive preventive care, and provide a fullrange of specialty and comprehensive serv-ices to children with chronic illnesses andtheir fiunilies.

Nlost other industrialized countries em-ploy a community-based system available toall residents regardless of income to linktheir personal health services and publichealth systems. The structures of such pro-grams vary widely, from health visitors inGreat 13ritain9b to commullin health cn-ters in Norway97 to well-child conferencesin France.`[' Nevertheless, all of these coun-tries provide a mechanism to address issuessuch as assuring and r!onitoring

levels, providing community educa-tion about injury prevention or aspects ofadolescent sexuality. and helping to idn-tif-v children with special health needs andto coot dinate multidisciplinary care fOthem and their families. A similar systemof community-based health care monitor-ing and coordination %%mild greatly helpthe United States meet the health careneeds of children.

. ccordinglv, we make the following fiverecommendations:

I. Develop community-based preventivecare programs in all parts of the counhy. Thelimns and structures of preventive. careprOgrallIS Mal, vary among communities.depending on ivsourcs auul C011111111111iNneeds, but all communities should haveaccess to preventive services that screenand identifY children and adolescents withhealth risks, help families gain access toneeded health services, provide ccuntim-nin health education, and assure high lev-els of illness pivy en don, especially throughimmunizations.

2. Extend current traditional primary carecapabilities to provide satisfactory care for thehealth problems that children face, such asthreats to development, chronic illness, andsexual and physical abuse. Tliese changes willrequite impro%ed prolcssimEll school andin se tx is C training kir health providers andsystems of reimbursement that assure eq-nits between merle pi.occdurally orientedsickness care and the services needed toaddress nev.. moi bidity concerns.

3. Assure access to priman, care servicesthrough such mechanisms as expansion of com-munity health centers, both in number and inbreadth of services. For many communities.especially those with large numbers ofpoor and disenf ranchised households.

multidisciplinary communin health cen-ters are the preferred mechanism for pro-viding child and adolescent healthservices. Yet, main communities lackneeded health centers. Furthermore,funding limitations in recent years havecurtailed many multidisciplinary outreachprograms and limited malI programs toproviding only office-based medical andnursing services. Community health cen-ters need the resources to provide therange of services and outreach activities tomeet community health needs effectively.Maternal and child health agencies needto assure that the systems of communityhealth centers, county health depart-ments. .itnd private practitioners providehill coverage to all children and youth.

4. Enhance public health activities. Theodes and responsibilities of public healthagencies need clarification and support..1ta minimum they should include identif-ing and monitoring child and adolescenthealth needs and services: setting and en-forcing standards of care: implementingand maintaining systems of care, such asperinatal service programs and regionalin.<)grams few children with special healthcare needs: developing community healtheducation programs: preventing or elimi-nating environmental hazards such as lead:and providing certain direct ices, SUCIIas immunization programs.

5. Expand specialized adolescent healthprograms. Although many adolescents re-ceive adequate services through currentcommunity-based primary care programs,many °du rs do not. Services should hedeveloped in nontraditional settings fOradolescents who lack services or fOr whomservices are inappropriate for their needs.Programs should emphasize preventivecare and provide comprehensive servicesrather than locus narrowly on issues suchas sexuality or substance use. Two mainefforts should be the expansion of school-based health programs and of programs inalternative settings where adolescents con-gregate. Altlu nigh what works well for ado-lscents has not been clearly documented,it nervy most important to provide 1111111i-Lac etcl services in multiple. varied sites.

These five recommendations shouid beimplemented throng]) a coordinated pm-gram of care rather than through fist. (*o-nion.) competing systems of srvii es. 'foac hieve child and adolescent health goals,public health eflorts must link with com-munity-based preventive and primal-% (Ale


programs. The need is to link public andprivate systems or care to meet the healthcare needs of children and adolescents.

The authors acknowledge the helpful com-ments of Drs. Bid Harvey and Moses Grossmanon an earlier version of this paper.

I. i larkey, J. Epidemicilogv of childhood chronic illness: An in-depth analysis. Unpublishedstaff paper. Vanderbilt Institute for Public Policy Studies, Nashville, TN, 1981,

2. Wegman. N1.1.1. Annual summary of vital statistics, 1990. Pediairic., (1991) 88:1081-92.

3. Fingerhut, I.., and Kleininan,.1. Trends and current status in childhood motality.1900-1985. Vital and Health Statistics. Series 3, No. 26 (1)IIIIS Publication No. 89-1-1101.hattsille, N1D: National Center for Health Statistics, 1989.

-I. Guyer. B., and Filers. B. Childhood injuries in the U.S. A meci( an journal of Llivea+e8 of chil-dren (1990) I 1-1:619-52.

5. National Center fin- Health h Statistics. U.S. Department of Health and Human Services. .\'atinned Hospital Discharge Sarin.: Annual Summary, 1090. Vital and health statistics. Series 13:Data front the National Health Survey No. 112 June 1902, p. S. Hyattsville. Nil): Centersfor Disease Control. 1992.

6. Perrin, "NE, Valvona, J., and Sloan, F.A. Changing patterns of hospitali7ation for childrenrequiring surgery. Pediatrics (1986) 77:587-92.

7. Shayne, and Bloom, S.R. Home and community-based caw far ill lona-ally illchildren. New York: Oxford University Press. In press.

S. N tannin), 1...1., Becker, NUE, and Kaltic NAV. Correlates of mothers' use of medications fintheir children. Social Science and Medicine (1986) 22:11 -51.

1). Ames, Ilayden. G.F.. Campbell, R.E., and I.ohr, J.A. Parents' conception of thehr use ofover-the-counter medications. Clnaud Pediatrics. Philadelphia, PA: (19821 21:298-301.

10. Guyer, B. Fit le \': An overview of its evolution and future role. In Clahhen in a changingloalth sys/rm: Assessments and p-oposals for reform. NI. Schlesinger alid L. Eisenberg, uds.Baltimore: Johns I lOpkillS University Press. 1990.

Graiier, KA- and Thomas, RA:. The role of the public sector in providingchildren's health care. In Children in a changing health cam system: A sw+sntfin1( and proposalsfor Om m. NI. Schlesinger and I.. Eisenberg. eds. Baltimore: Joints I lopkins UniversityPress, 1990. /

12. ClarkeA.Ind Walton. W.W. El feet of safety packaging on aspirin ingestion in children.&attics (19 79) (13:687 -1)3.

13. NIcl.oughlin. E., Clarke, N.. and Stahl. K. ct al. One pediatric burn unit's experience withslecliw ear related injuries. Pediatrics (1977) 60:405-109.

I -I. Kahane, C.J. An evaluation o/ child passenger safely: II,, effethvoless and benlits al safely +eat)Isuuunary ). Washington, DC: National Highway Traffic Safety Administration (DOT I IS806-889 ), 198fi.

17). Ratchet. NI.I.. Scald burns front hot tap water. journal of the American Medial( A %sm./town(19811 216:1219-22.

16. Got ttnaker, ST., and Sappenfield, W. Chronic c hildhood disorders: Prealenc impac 1.prdwath ohm, u/ Nmth merino (1984) 31:3_ i 8.

17. ghtunut, I.., and Starfild. B. Child health and social status. Preiiatrn% (19821 611:550-57.

IS. Pert Homer, Berwick, D.NI., el al. Variations in rates of imspitaliiation of c hil-dlen in three urban communities. .Vrce Eng/and/nano/ Aledirine (11189) 32(1:1183 -87.

19. Haggerty. Roglunann. KJ.. and Pless.1,11. Child health and the communitt. New \ k:

Wil, 11)75.

20. NI flier. ( Fine. .1.. and .1(lains.-1-al. S. Monitoring Audi-, ti's heidth: key ;lithe aims. Wisai-inglon. DC: .1tnel is an Public He,rlth Iv.ot ittion, 1989.

21. '.S. Department of health and Human Sul ices. °III«. of !Tuition Dyclopment Set sit es..N(11111'11,11 ation for Children, Youth, and Families. Childten's Bureau National Center en(.hild . \ bust mid Neglect. Studs Findings. Sind of National Incidence and PUTalelil r a/ ChildIbu se awl .Vird : 19 SS.

22. ,Nmel 111 Atle1111 tit lie(11.111 it S. New task lot « 011 coding of mental health disorders inhildt en. Ancenenn thlonv of Peduitrus News, December 11191.


23. Society for Behavioral Pediatrics. 11w breadth of developmental and behavioral services.Journal of Developmental Behavioral Pithatries (19921 13:7-10.

24. l'.S. Congress, ()Bice of Technology Assessment. Ilealthy rhildlen: Investing in the future.Washington. DC: U.S. Government Printing Office (OA-H-3-I5). February 1188.

25. .\inerican Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Familylealth. 11)85-1988. Gllichifineyfir health supervision 11. Elk (iron: Village. IL: American Acad-

emy of Pediatrics, 1988.

26. Case, P., Sharp. !).1.. and Loda, F. Child health supervision for children under 2 years ofage: A resits of its content and effectiveness. purnai of Poliairics (1979) 95:1-9.

27. Yankauer, A. Child health supervision-Is it worth it? Pediatrics (1973) 52:272-77.

28. Reisinger, K.S., and Bires,.I.A. Anticipatory guidance in pediatric practice. Pediatrits (1980166:889-1011.

29. .\inerican ademy of Pediatrics. Recommendations fin pre\ (mike pediatric health care.American A( adem) of myi a In. es New, July 1991.

30. Fine, I I., Chamberlin, R., and Chantey, E. Content and emphasis of well-child visits..I mrthan Journal of Diseases of Chihlren (1977) 131: 791-97.

:11. Borst 11,11.:11. Issues in eNaluating child health supervision. Journal "ediatrics (1986)108:933-31

32. ),Vagner, 1,11m-cilium, R., and , \lberts, D. Well-child care: I low much is enough: Heath .1/-pars (Fall 1989) 8,3:117-57.

33. Stanfield, B. Thee /furtiveness of ?medial! rare: Validating (-finial, wisdom. Baltimore: Johns I lop-kins 'nivel shy Press, 1985.

3-1. Child health in 1990: The U.S. compared to Canada, England and Wales. France. '[lie Neth-erlnds. and Norway. Pediatrics (1990) 86: supplement.

35. National . \sscicial ion of Count% Health Of ficers. National profile of loud health departments:Oil' Italian's public health .systm. Washington. DC: National Asiaa la on o:.(:(ninty

Health 01 ficers. 1990.

l.efkowit/.1).. and Short, P. Medi( aid eligibility and Me use of piewntive smiiiie by Imo Mlle I hi I-d trn . National Center fin Health Set %ices Research and Health Care Teclmolo,g-v Assess-Weill (1989). Cited In pee mission of author, November 21,1991.

37. .tdams, RE.. and Benson, V. Current estimates from the National Health Interview Sin cs.19811 Nati(mal Center for i lealth Statistics. Vital Health Statistics (1990) 10:176.

38. I I( otte Peri in, ,]. \f., Bloom, S.R., and Evans, A. I lospital use by children with chronicillne .1bitrwits. Washington. DC: Ambulatory Pediatric AssociisMin (19891:28.

39. Orr. S., Chun ns, E.. Straus. 1.. et al. Emergency room use by low income children with aregular source of health care...kW/cal Cara (1991) 29:283-86.

10. National ionunission Against 1)t link Driving. }bulb &wing without impabment: A «mt (nannychallenge. Report on the youth impaired driving public hearings. December 1988. Washing-ton, DC: National Highway Traffic Administ rtion.

11. Newm heck. PAC.. and NIc Manus. lialth in arance status of adolescents in the U.S. Pr-dirmi s i 1989) 81:699-708.

12. ican Medical Assoc iat ion Council of Scientific fairs. Providing medical Sel'N'itt`sthrough sc Ion )1-based health programs. Journal /fir A merit an Medial' Assorialion (11181')261:1939-12.

13. Task Force on Pediatric Education, Tile Inture pedialrie Forceon P diatii Education. 11)78.

11. ( :4 nig' CY, ( )Ili( e of 'let Inn 'logy Nssesstilent. .1dolesi en 1 hettlib-twl it me 1; Su inmaty and/),,/,(1 Vashingt( in. I)(:: U.S. (;0 (.1 Innen( hinting Office (( HA-11-168), Api il 1991.

15. I...S. Dpat intent of Health mid I 111111i111 Sec sires. °flit e of the Inspec tot General. lilt newe;and homeless youth: National Inngrant inVire(ton, Region N. ()ctober 1983.

16. National Nemotk of Runaway andYinith Servi«is. leunaway and homeless youth: *lo whim, dolin l'rlung 1 V111iligiull .1)C: \ Nl)%)111s 01 Rullimily and Vu11111 Set ))) s 1111.

17. .\ inei all MeC:i( al . NMI( COUMil of Si ientific Health c are needs of homelessand t lour nal of the .1nicrtian ,11rd It al Awn halm, 9891 262:1358-til.

18. 11illiains. and Millet, ( ..A. I 'reventive health rate for you ng tlublrra. 1:11ahtig% finial a 1(1 wail1 shut, ant! /411 ( polrn..Si lino, VA: National ( for Chid,: I(.,tIttm tans lttcr-grants, 1991.


19. .\.R. niniuni,,ith, in the l*.S. i'tyhairit (1990) 86,6. supplement: 1061-66.

50. Centers for Diseas Control. Tables from the L.S. Immuniiation SLIrsec, 1985.1.'npublisheddata. .Ntlanta, Dep:.trtment of I health and Human Services. 1986.

51. Centers Ior Disease Cont11,1. .11whality and Alm tality Ihrk/r Reims! (19911 10:22.

52. Clots. F.T., Urenstein, \\',. \., and Bernier. R.11. :ans, al law la echaal Finrn11P1, atiun rut'rrage inthe 1".S. Atlanta, (:A: Centers for Disease Control, 1990.

53. 1)titton, D.B. Explaining the low use of health set \ 1CCS In t he poor: Cost. attitudes. or delis-r. syst CMS. :1 tner1( ti Saciologie al Rerieu. (19781 13:318-68.

Nlarks. _1...Alpin. T., Irvin. 1., et al. Risk factors associated with failure to receive tae cinations.Pediatric% (19791 6-1:301-309.

55. National Vaccine .1(1%isot y Commide ttiaNics epidt-1111( : I he pr ()Win., bat tier., andccot timcndat ions. journal al the. .11nerican sweint (1(.011 266:1517-52.

56. (henstein, \., and \ tkinson. \\. Oerxiet% and keynote address. Paper presented at I loos-tons Leadership 0)111(.1(11(v on himotni/ations. Houston. IN. 1990.

57. (:!Neer, ti.. Bill'1(1. S.A., 11u1( 11(11+011, I, (11 al. Failure hitch en against measlesdoting the second year of tile. /'n /di, I loth h Refines (19761 91:133 -37.

58. N1cDaniel, I).. Patton, E., and \lather. Inummitation actiities of prisate ptac tics.A record audit. l'ethatrics (19751 56:501.

Ptckhatn- lic(1101A, I I., Senntria- V. et A. Nat/mini inwinnizalirm with: Nu/uminan nal:alum plakc in rhilrlhand. London: Action Research Ica. the ( :rippled (111ildrert, 1989.

CIO. I:log(111in. L.A. Personal «mmittnic anon %pith author. October 21,1991.

61. Nlalek. \l.. Chang. B.. S.S.. and Caner, li. The cost of medic al care for input les tohildren. tails al Lit ci:Eyncy .11rd ( 19911 20:997-1005.

62. NatinTill (:otninit icc lot Prc\ cti t ion and (:exnttot. briroy ptreeirtimr: .1Irding the tuall-

fe"gr. Publish"' in (him (I I. iii`".`ii` 1.1 ess as a mein n nml u/ Prr-ernli:'e aw (1989)

1;3. 1,1eming, G. Pet soual communication with author, 1992.

61. Thompson. 12.S.. 12ivat a, El'.. and Thompson, D.C. A case-contiol stuck of the elle( tilenessof bit\ 4 1r Sit1(11 \ Ill11111(1), i'..tigiatialMit pird of .1Icd i ta. (19891 320:1361-67.

(6. \1,a(.1nl, R.. \valici..).. m.. al. Ricycli,, hein,,, and head iilics.. A Fidel_based st tids of helmt use and e1 7e( th. cites,. Ameri( Inu owl ol Piddle I I lath h (191(8)

78:1220-21.

66. \\*cis.... B.1). Ti cods in hicAtic helmet use by children: 1985 to 1990. Pet/ill/ries (1992189:78-80.

67. Cushman. P. Doun.1., Nhic \litho. \.. et al. Ilelmet protec lion in the cutlet grit( moor Iol-lotcing a hi( se he 'Mtn v. A tandotniied 11 ill. I'rdiethie (1991) titi:13-17.

68. and \Vacia`vik I 1. P"'"'"Ii'll4 bicycic helmets fm (61ch en: .\ tandontiiecl it ill. inwrioln pro tin/ l'n Ida 1 Irulth (1991) :31:1011-16.

69. 12ttnao, (:.\V., and Roman, 1).11. I low c an physicians gel kids to wear hies( he hcliztet,fpt oloiN pi( (11,111clige in milli 1, el. emit )11. .1mrtv ail lam nal al Health (1991)81:97'4-73.

70. lilth, D., Elstel..1.. et al. .1 oteriois tulalcs( cnt %: How 'width% me the%

et it an Medi( .11 \ssoctation. 1990.

71. ( ;lei< hei. I I., (4.1 manic...V. et .11.12eotganiiing health cal e lot adolescents: the (A-pe' memo e of sc knot -hosed ;Ades( cot health c at e ogiams.loto rue/ al .1dalt.scent I lentil, Car,

(1991) 12:150-58.

72. B.C.. and Nlille1. \. l'hyratipe hridth :1111 Jul You lig dal& n. pant aI(1 remold %hall and dm, tam% fin I fln/us..\rling(on, VA: N.1114 ( II

1111.1111 Ih 11110, 1991.

llobbs. N., Pert in..11.N1.. soul Ness, Clnnnrurllt dl,/ 1'1(11c,, ruin the,' la natal. Sad 11)111-

( is( 1104.% 'KIS', 1 (.1811,

71. ( :,t(1111,111. Il., liole, NI., ',imolai-1. P., et al. ( .1110ilic illness, disabilit . and mental and sot 1.11w11-heing. Pedmio,% t 1957) 79: 805-1:1.

75. Rude!. 1.A.. linden'. P., Nli Manus. \I.. \., et .11. I health l at c espenditto es lot c hildrrn Nilhontc illnesses. In 1,04(5 ur tier 1(11,. 11/ htiddler, loth 1141100, dlnrsprt. N. 11,116,..111(1.1.\1. Pet-

!iti. ed.. Salt 1.1.Int ist 11)87).


76. I Icilgc":' Pc(141111c a( (Wired ilmiumodulicicuc) sYlldrome. Puvelly and nationalAmerican [atonal of Diseases of Chilihrn (1991) 1-15:527-28.

77. Chu, SA:. OKtoby, et al. Impact of the human immunodeficiency vi'-usepidemic on mortality in children. U.S. Pediatrics (1991) 87:806.-810.

78. Van 1).ke, R.B. Pediatric human immunodeficiency virus infection and the acquir:.:4. Munn-itodliciencv syndrome. American Journal of Diseases of (lildren (19911 145:529-.'2.

79. Breslau, N.. Salkever, 0.. and Startu h. K.S. Winnen's labor force activity and n sponsibilityfor disabled dependents.janrnal r f Health and Social Behavior (1982) 23:169-83.

80. 1-loluman. N.A.. and Richmond, J. Genetic strategies lot- pre-:cluing chronic illness. It !s-

sues in the care of children with (hmnic illness:. ware/book on problems, services. and policirs.:'s1Iohhc and J.M. Perrin, eds. San Francisco: Josses -Bass, 1985.

81. I larrison, NI.R., Ad/ick. N.S., Longaker. NUE, et al. Successful repair in utero of a fetal dia-phragmatic hernia after Rhino\ al of herniated viscera From the left thorax. New EnglandJournal o (Nlav 31. 1991)) 3322:1582-8-1.

82. Harrison, NI.R., Fills, RA., Parer. J.R. F., et al. Management of the fetus with a urinary trackmalfortnation.lourna/ofthe American Medical ..lsodation (1981) 2.16:636-39.

83. Berkouiti. R.L. Intrauterine transfusion. 1980: An update. Clinics in Pecinatology (September198(1) 7.2:285-97.

8.1. .S. Congress, Office of Technology Assessment. lichnology-dependent children: Hospital vs.home caw. Washington. DC: Gmernment Printing Office (OTA-TNI-I I-38), May 1987.

Newacheck, PAV. Adolescents with special health needs: Prevalence, secritv. and access tohealth services. Pediatrics (1989) 84:872-81.

86. Mc NI anus. NI.A., Newacheck, P.W., and Grean%. A.N1. Young adults with special health areneeds. Pediators(199(1) 86:67.1-82.

87. frimaker SA. Walker, D.K., \Veit/man, NI., et al. Chronic conditions. socioeconomicrisks, and behavioral problems in children and adolescents. Pediatrics (I 99(1) 85:267-7(1.

88. Pies!, LB., and Roginnann, KJ. Chronic illness and its consecittnces: Observations based91[111111v epidennologic surves s Jounced of Prrhatrio (1971) 79:351-59.

89. Walker, 1).K.. and Jacobs, El 1. Public school programs for chronically ill children. In Acne%Hi the caw of rhddren with chronic illness. N. Hobbs andINI. Perrin. eds. San Francisco:Jossev-Bass. 1985. pp. 615-55.

90. Weeks, K.11. Private health inst trance and chronically ill child] en. /vows in The care of childrenwith chronic illness. N. Hobbs and J.N1. Perrin. eds San Francisco: Josses' -Bass. 1985:880-911.

91. American Acadnn. of Pediatrics, Committees on Children with Disabilities and SchoolIlcalth. Child' en with health impairments in sclu)ols. Pediatrics (199(1) 86:636-38.

92. Pet and Stein. R.E.K. Reinterpreting disability: Changes in SSI for children. Pediat-rics (19911 88 :11(17 -51.

93. !revs. 11.T.. 1 lauck, RJ.P., and Perrin. J.M. Variability among state Crippled Children's Sers-id programs: Pluralism dirk es. A menean Journal of Public Health (1985) 75:375-81.

9-1. Stein. R.E.K.. ed. caring-for children with chronic illness. Ness. Y(wk: Springer Publishing (:ont-pam. 1989.

95. Bilotti. (f.E. The Illinois model: A statewide initiative. In Cathlg for children with chronicR.F.X. Stein. ed. Neu York: Springer Publishing (:ompam. 1989.

96. Goodwin. S. I'mcsentise cats for children: Immuniiation in England and Wales. PrdiairicA1990) 86:1056-60,

97. 1.ie, S.) ). :hildt en in the Not wegian health care ,,stem. Pcdiatrhc 119901 86:10.18-52.

98. Man( lain. NI..Itaim C.. Frit,. NI.. and Bertrand. I). Child health care policy anti deli\ erN inFrance. Petiuttrirs t 1990) 86:11)37-13.

Pedioll. PhD.,is ail assemitlic 1,11111'5-

1m ((1 thy s( huttis 0/

Welfare midsir lbw lift al the .\/ate

rrnvrvh ,/}M). at Alba UV

Health Care Resourcesfor Children andPregnant WomenJanet D. Perloff

Abstract

lite audio' of this impel rey1(.1s. cidenc about the health caw ISMIII C111 I ClIlly

ail.1111 to t 1111(111'11 .111(1 pit-gnaw %%omen in the United States. The data reseal thatthe ()serail supply of phYsit ians has grown steadily in retell years. 1 lo%veyer, as aresult of fact(us sue h .is physicians' preferences for metropolitan prac lice locations.ising nialpra( iic . pf einituns, and physic rein( tame 10 a( «pt Medic aid patients.

the in( tease' in suppls has not improved act ess 101 many ttmlerserv(1 women :milchildren. .1t the same time. there has been a significant decline in the number ofniganiied settings hospital c links, public health e links, and !Mgt ant :1.11(1 «Immu-nity health (enterson %%hick) many of the undersend rely. Furthel . the capaeiIsof remaining facilities has been greatly diminished In reductions in support forpublic programs. Ben if the supply of health care resources is adequate to meet theneeds (Cl most %%omen and c hilthen, the persistent maldistribution mate] nal andbill health ( are 1)1-m1(1(1s:will continue 10 pose a serious threat to health arc at cess

lor the Nvomen and ( Itildren at greatest risk for adverse pregnancy outcomes andmot !hits and mortalits (luring childhood.

IMlics strategies suggested to maintain and improve the availability of maternal and( hild health resources in( hide: holstering the supply of famils physicians: recha ingthe Pruhicill` rchid In medical Pll'Ic"i"flal mf1)1)01 (ug the Nationalilealth Service Corps I N1 1S(:) scholarship and loan repayment programs: increasingpath( ipation of pInsicians in seeing Medicaid-eligible women and children: de el-(ping systematic data to eYaluate the supply of maternal and child health (-areas ailable in organised settings: and enham ing the (apaits Of orgatli/Cd settings tomeet the needs (Cl undersell. ed ( hilciren :111f1 pregnant women.

tiring the past decade, strides have been taken toward loweringfinancial barriers to the health care needed by children andpregnant women. Private third-part payers have begun to

cover more of the costs of" children's preventive and primary care. andNledicaid financing is available lint only for the care olpoor children andpregnant but also liar many women and children living in familieswith incomes above the federal poverty level. As financial barriers to careare lowered. problems in the supply and distribution of health careresources become more important than ever before.

Si

This paper reviews evidence about health care resources currentlyavailable to children and pregnant women in the United States andconcludes that, while the supply and distribution of these resources maybe adequate to meet the needs of most women and children, those whoare black, poor, and/or residents of rural and inner city communitiesremain underserved. The problem of maldistribution of maternal andchild health care resources is not new; however, data reviewed heredemonstrate that the dimensions of this problem have changed in recentyears. The overall supply of physicians (and the supply of medical andsurgical subspecialists, in particular) has grown; but as a result of factorssuch as physicians' preferences for metropolitan practice locations, ris-ing malpractice premiums, and physicians' reluctance to accept Medi-caid patients, this increase in supply has not necessarily meant improvedaccess for underseryed women and children. At the same time, datareviewed here document that there have been significant declines in thesupply of the organized settings on which many of the underservedrelyhospital clinics, public health clinics, and migrant and communityhealth centersand that the capacity of remaining facilities has beengreatly diminished by reductions in support for various public programs.The available evidence suggests that, to the extent that maldistributionof maternal and child health care persists, it will pose a serious threat tothe usefulness of third-party coverage in enabling access to health carefor the very women and children who are at greatest risk fOr adversepregnancy outcomes and morbidity and mortality during childhood.

Health Care Resources forPregnant WomenThe Supply, Distribution, andAccessibility of Maternity Care

Physicians and Certified Nurse MidwivesMost maternity care in the United States isprovided by obstetrician-gynecologists,family physicians and general practitio-ners, and certified nurse midwives. Factorsinfluencing die supply, distribution, andaccessibility of these health professionalsfigure prominently in women's access tomaternity care. These factors include (11Ilse tendency for these professionals tolocate in metropolitan areas. (2) the highcost of medical insurance for thesept ()vide' s and physicians' perceptionsabritit the risks of being stied by obstetric

patients, and (3) the reluctance of theseprofessionals to serve Medicaid patients.

According to theAmerican Medical Association Masterfilc.the most complete source of informationabout the supply of physicians, there were31.361 obstetrician-gynecologists in the'lined States in 1986. The supp\ of obste-

trician-gvnecologists is growing, and thefuture is likely to bring increasing compe-tition for patients. Projections indicatethat the population of obsttriian-gyne-cologists trill grow to a total of 10,000 to-1-1,600 fn the Year 2.1.2 I. anadjusted needs-based model developedin 198 In the Graduate Medical Edu-cation National Advisory Committee(GMENA(:)a quasi-governmental hod\charged with making recommendatirnis

80

7PL

3

47"

for the Iulurc organ/anon :111(1 finam-ingof graduate medical educationAl)! Asso-ciates estimated that there was anationwid surplus of nearly 0,000obstetricianirynecologists in 19t0 ;111(1 pre(ii( 1(s(1 that this still-this would grow tonearly 16,00(1 by the year 2000.2

1)cspite their generous to ob-stetrician-gynecologists are significantlymaldisti gutted I dative to the population.l'irst they are oxetlylichningly located inmetropolitan meas. Nonmettopolitancounties hake approximately one-fifth asman\ obstetricianl,ynec(1logisIs per capitaas metropolitan countis,:' and a substan-tial number of n(mnietropolitan countieshave no ol)stetrician-t,rvilecologist at all. tlie( more obstetrician - gynecologistslocate in metropolitan :ua:. and becausefewer familN physicians pi actice obstetrics,la( k of accessible obstetrical services inrural areas has become a inattel of greatconcern.

Second, within metropolitan areas pri-Sat of li( (-based obstetrician-gry necolo-gists lend to local- in central businessdistricts ot ill higher-income and subm-it:in residential communities. In 1986.:Mom tyo thirds Of the obstetri( Ian-gym-( ologists practicing in (:hicago's I esiden-t ial :11 eats practiced ill the most prosperous«untimilities vhile onh 2(7. ptacti«.(1 inthe most severely distressed inner CitVC0111-11111161.k, Tile ratio Or ObS1e1rician-t,nnccologists 10 the 1/01/111:111011 teas nearly10111 tittles greaten in the most prosperousmminunities than in inner (it\ areas.' Dil-1 er(ntials such as these are compensatedlilt. in pal t, In the maternit care providedby hospital outpatient clinics and odicrclinic settings. but access to obstetrical


care for inner city residents «minutes tohe problematic 11,8

The geographic ilial(listribution of ob-stetriciatti,rvilecologi.sts is compounded bstwo additional factors. First, the high costof medical malpractice insurance and per-ceptions about the risksolbeingsued havecaused a substantial proportion of obste-trician-gynecologists to drop the obstetri-cal portion of their practices and to curtailthe deliver% of matputy care to high-riskwouu 11.1`1 -1a Second, many obstetrician-.,rynecologists decline to accept patientsYliose care is paid for through NIe(li-caid.6.8.12.1.1 Asa result of these factors,although oftstetriciani,rynecologists are inrelatively generous supply, their servicesoften are inaccessible, particularly to low-income women and those at high risk foradverse pregnancy outcomes.

1, 01-10 1 he 11:I-

lion's roughly (18,000 general and familyphysicians, 28,000 ()Futon) are board-cer-tified in family practice, are. an importantsource of obstetrical care. When om-pared with obstetrician- gynecologists,general practitioners and family practicphysicians are moretre evenly distributedacross counties of all types and si/es.3lecittise (tf the malpractice crisis, how-ever, many of th(bse physicians discontin-ued the practice of obstetrics in the lateI 980s. 1 -9-13 Thus, \\gill( general pra(-tit lo-ners and family physicians currentlyprovide an estimated two thirds of all pri-vate obstetrical care in rural areas. it hasbeen estimated that only 35r; of ruralgeneral practitioners :111(1 familyphysicians curt-end offer obstetrical S1V-ices.5 A number of sources indicate thatgeneral practitioners and family physi-cians are somewhat more likely thanobstetrician-gynecologists to participatein Nledicai(I and, as a result, !heti( physi-cians 111:11' be M/111e101a1 11101 c aCSibl 10loy-income pregnant %vonieti.1:-'.1()

111115 InliRViVeS((:NMs) are registered nurses who havereceived special training in midwileIN and

ho have been certified 1w the American( Nurse Midwives. At the presenttime only about 2,600 (:NNIs pro.aice inthe United States, but they we slowlyRI ()lying ill number. It is estimate(I that200 to 250 news (:NN1s alt' certified eachyear,16 and from 1975 to 1988 the propm-non of births attended by ( :N Nis increasedfrom 0.9'; to 3..1 (1;..17 Eighty-sevenpercent of midwife-anturi(' births

'11.1 L.)


occurred in a hospital in 1988, and theW0111C11 served by IllidWilVti practicing illhospitals are increasingly poor and minor-it mothers.I7

Despite numerous studies document-ing the high quality of care provided byCNN1s) 7 economic, interprofessional,and medical liability factors have ham-pered prarli,e of the full range of CNNIservices and the growth of the profession.1.-ntil recently, only limited third-party ew-erage was available for CNN' services.Some improvements ill reimbursementfor CNN1 services provided under publicprograms resulted from federal legislationpassed during the I 980s.19 In addition,111111IV states have statutes and regulationsrestricting the scope of nursing practice.Even where third-party payment is avail-able and the scope of permissible nursingpractice is broad. resistance from themedical profession sometimes results itthe inability of CNN's to obtain admittingprivileges at local hospitals.ICNNIs have experienced problems obtain-ing malpractice insurance. have had to paymalpractice premiums representing a S17-able and growing proportionion of their sala-ries, and, as a result of liability problems.have sermetimes lost hospital privilegesand opportunities fii collaborative prac-tice with physicians.I

Office-based and Organized Prenatal CareSettings

Although a great many women receivetheir prenatal care in private physicians'offices, leiw-income wennen and \vemlenwithout any third-party coverage fre-quntiv obtain prenatal care in "organisedsettings- such as hospital outpatient de-partments, community and migranthealth centers, public health departmentchili( 5, and other c linic settings. It is esti-mated that approximateh 20(X of-omenreceive 11161 obstetrical care from theseorganized settings:, and national surveysconfirm that these sources are particularlyimportant to poor women and for voting.unmarried, black, or I lispanic women.20

There is evidence that the demand fOrmaiernits care from organized settings isgrowing but that the supply of care in thesesettings is becoming increasingly inad-quate. An Institute of Medicine (I0M)review of evidence about capacit \ in localheali'r departments and hospitals con-ducted during the mid-I980s found execs-MIVCIN long waiting times to obtain prenatalcare appoinum.nts and other indicators of

inadequate capacity. Comprehensive na-tional and state data about capacity in or-ganized settings are not available, but the1011 report concluded that "in some com-munities the capacity of the clinic systemsrelied on by low-income women is so lim-ited that prompt care is 1101 always avail-able and that in some additional areas caveis unavailable altogether ''N

There is evidence that the demand for maternitycare from organized settings is growing but thatthe supply of care in these settings is becomingincreasingly inadequate.

c- The nation's 5,871nonfederal, short-term general hospitalspanicularlv its 1,784 public hospitals and16,0 academic medical centersare animportant Mall-C of prenatal care for hiw-inconle and minority. women and for thoseresiding in underseryed communities.Demand for these services is thought to beincreasing, although national data on thesupply and distribution of outpatient pre-natal care services and on inlids in patientload are not available .2°

One important factor affecting thesupply of hospital-based maternity carehas been recent hospit, 1 closures.Between 1980 and 1989 a total of 508hospitals closed;21 many of these WIT(' inrural areas and most ,.ere small and un-derutil ized.22

The impact of hospital closures onaccess to care in general and to prenatalcare in particular remains unclear. Scum.appraisals conclude that closures do notseem to have hampered access to (nel--0-encl. and acute care while others dis-agree. Such generalizations Min obscurethe actual impact of int ividual hospitalclosures.. however, because this dependson characteristic's and circumstances ofthe hospital and the community itserved."2 For example, a significant pro-portionion of hospital closures since 1980have included public sector facilities vitalto the prenatal care of women who arepoor, nonwhite, lack health insurance,and/or live in undrserved areas." :t Publichospital closings signifie :Indy reduceaccess to care fOr the uninsured popula-tion residing in the communities served bythese facilities.''' large proportion of this

82

population is comprised of women seek-ing prenatal care.ub,,c iipaqh Cfirvcs State and local health de-partments play an important role in pro-vision of prenatal care. A 1986 survey of-16 state health agencies indicated that,while states vary considerably in theirhealth assurance activities, prenatal carewas among the few personal health serv-ices provided by all 46 agencies.25 Thebroad reach of these public health activi-ties and their positive impact on accessto prenatal care in some localities aresuggested by a recent survey which iden-tified 2,306 local prenatal care sitesfunded by state health agencies: 2,017were operated directly by health depart-ments, and 289 were operated by otheragencies.26

Because of low salaries, undesirable location,and unfavorable working conditions, communityhealth centers often have considerable difficultyattracting and retaining physician personnel.

Although a large number of prenatalcare clinics are operated by local healthdepartments, significant gaps exist in thisdelivery system. A 1986 survey of stateagencies receiving funds from the federalTitle V Maternal and Child Health BlockGrant indicated that 48 of the 51 agenciesoffered at least some prenatal care. How-ever, only 13 agencies indicated that pre-natal care was available on a statewidebasis: most states imposed income and riskstatus eligibility criteria, and only one statereported that funding levels were ade-quate to meet the needs of its target popu-lation.27 (For further discussion ofg wern men t-fu tided direct care providers,see the article by I fill in this journal issue.)

o-le; Communityand migrant health centers are also im-portant sources of prenatal care. Com-munity health centers provide basicpreventive and primary care in federallydesignated medically underserved areas,and migrant health centers provide simlar services to migrant and seasonal agri-cultural workers and their families. in1987 there were 567 community healthcenters providing prenatal care to

iween 150,00(1 and 225,000 women;28an additional 118 migrant health centers


also provide prenatal care. It has beenestimated that 28.6% of all communityand migrant health center users arewomen of age.29

Capacity in community and migranthealth centers was greatly reduced in theearly 1980s. Like other maternity careproviders, many health centers had to de-vote an increasing proportion of theirbudgets to medical liability insurance pre-miums and, in some instances, cuts in serv-ices resulted. id' Capacity was also reducedwhen a significant number of centers losttheir funding and others experienced sub-stantial reductions in their core operatinggrants. I5

Because of low salaries, undesirablelocation, and unfavorable working condi-tions, community health centers oftenhave considerable difficulty attracting andretaining physician personnel. During the1970s and 1980s, the National Health Sez--ice Corps (NHSC)a program offeringscholarships and loans for the educationalexpenses of health professionals in ex-change for a period of service in an un-derseryed communityhad been a veryimportant source of primary care physi-cians for community health centers. In1989, for example, the NHSC suppliednearly one half of the physicians workingin community and migrant health centers.However, field strength of the NHSC di-minished rapidly over the 1980s. Asa re-sult, the General Accounting Officereported that there were 800 vacancies incommunity and migrant health centerswhich had to he filled in order to reachfull staffing of about 2,700 physicians in1990.30

The Supply and Distribution of Laborand Delivery Services

Hospitals

Ninety-nine percent of U.S. births takeplace in hospitals.I 6 and general trends inthe hospital sector have therefore had animportant impact on the supply and distri-bution of labor and deliver!: services. Dur-ing the 1980s, in part as a result of theclosure of a significant number of small.rural, and public hospitals, labor and de-livery services were somewhat redistrib-uted across hospitals. The total number ofhospital obstetric bedsmost of which arein private, not-for-profit hospitalsin-creased, while the number of obstetricbeds in public hospitals decreased.Although the full impact of this redistribu-tion of obstetric beds on access to labor

85


and delivery services is not known, Kier-man and Schulte note that the decrease inpublic obstetric beds will have its biggestimpact on access to labor and deliveryservices for the poor who rely dispropor-tionately on these facilities.16

.11though most short-term general hos-pitals offer labfir and delivery services, tilescope of he services ()tiered Varies consid-erably. For example, only.65(;; of hospitalsresponding to the American Hospital.1ssociation's 1989 Annual Survey- of 1 fos-pitals reported having birthing rooms,only 39. reported offering rproduc-tive health services, and onl 9.-1(!c" r-ported offering genetic counseling andscrcning.21

Neonatal Intensive Care

Neonatal intensive can. units (Ni( Us)provide the high technology equipmentand services and the highly trained staffneeded to care for the seriously ill infant.One important influence on the supplyiind distribution of neonatal intensive carehas been the attempt On the part of themedical profession to regionalize peri-natal services. Regionalization differenti-ats levels of perinatal services andattll)plti to aVOI(1 costly duplication andinefficient use of the most technol(gicallysophisticated professionals and services.(See discussion of regionalization in theRacine, Joyce, and Grossman article in thisjournal issue.) Routine care fOr normalinfants (Level I call.) and Level II care formoderately to seriously ill infants can hefound in hospitals throughout the coun-try, but the most technologically sophisti-catd Level III or Level IV care is primarilylocated in children's hospitals and in ur-ban teaching hospitals with large high-riskdelivery services, .11though Level III ruir-ries typically treat sicker infants providing

a high intensity of care and a great diversityof specialists, the distinction betweenLen.] II and Level III facilities min becomeblurred because their equipment inulstaffing tend to he similar. 31

.1s reported by Racine, }ne. andGrossman in this journal issue, the num-bet of NI( A' beds has increased rapidly inrecent years while the cost of NI(1. care(as reported 1)5. 1 .('wit and Monhit in thisjournal issue) has exploded. Explicit (Til-I is havc 11(11 bucn (lewl()Pc(1 "1 itidgc this'adequacy of the nation's supply of NICL.beds so it is not possible to delennittewhether the ( urrnt supply of NIcl::; isappropriate On Whether their

laid organization into regional nem(Irks isadequate to provide for the needs of thepopulation.

Health Care Resources forChildren

The Supply and Distribution of ChildHealth Care Providers

Physicians and Pediatric Nurse Practitioners

In 1987, physicians' offices were the usualsource of care for 862; of children under19.32 Private office-base) pediatriciansand family physicians are the majorproviders of children's preventive and pri-mary care, and they aCC011111 [Or almost90(.4. oldie physicians treating children. '3There are significant differences in thecurrent and predicted supply and distribu-tion of pediatricians and family physicians,however, and these patterns an described111011' fully below.

Exc'elle'nt access to !Wahl] care,especially primary care, is experiencedby many child! enespecially childrenunder 6 years of ageand is due in partto a generous supply of pediatricians,

.1/11Itto..

Cc(

C

S

84

which has been growing at a tale muchfaster than the U.S. population of chil-dren. Between 1970 and 1985 the popula-tion of pediatricians grew be. 89`.:;. to a total(4.35,1117 pediatricians, while the numberof. children under 10 years olage increasedby only

i he clucstion of whether the nation is,in Fact, producing too main pediatricianshas been the subject of considerable de-bate. ht 1980, GNIENIC predicted a sur-plus of 3,000 pediatricians in the UnitedStates b\ 1990, although this reportultintateh concluded that supph and de-mand !Or pediatric services would benearly in balance by 1990.3:' ; \bt Associ-ates' recently published revision of

F.NA( hwcasts predicts a sur-plus of 7,000 pediatricians in 1990 and asurplus of. nearly 13,000 pediatricians bythe Year 2(00). The American Academy ofPediatrics (AAP) takes exception withmany otAbt's assumptions. arguing in partthat . \bt has substantially overestimatedthe role of pediatric nurse practitioners incaring for children and substantially un-drstimated the birth rate. Asa result, the, \cadeniv -thoroughly disagrees with thoseprojections.36.37

The apparently generoussupply of pediatricians masksthe equally apparentgeographic maldistribution ofpediatricians.

Vcliether or not there is a surplus ofpediatricians, and evlictlier the outcomesof such a surplus shotild 1) consideredeither positiNe or negative, it seems appar-ent that the child-to-pediatrician ratio will«aniline to decline in coming VeatS. 1)11,11[1'11111 the' Ittralt of Health Professionsindicate that nationally the number ofchildren per pediati ician declined from;098 in 197(1 to 2,082 in 1983 and is pro-jectel to drop to 1,251 in 2000, a ratio ofless than hall as IllitIlV C1111(11V11 per

alt as in 1970.31 The fact that familyphsicians also provide ;t significant por-tion of c hildren's health care compoundsthis tit lid. Defining the number of childhealth phYsiciims to include all pediatri-( ians plus one - fourth the. number ofgruel:it practitioners/family physii ians


(its has been recommended by the AAP),the ratio of children to child health physi-cian declined from 1,590 in 1970 to 1,11.1in 1983 and is projected to decline to 91:3in 2000.31 It is worth noting that the AAP'srule of thumb is that an area is under-served if thereare more than 2,500 chil-dren per child health physician.38

The apparently generous supply of pe-diatricians masks the equally apparentgeographic maldistribution of pediatri-cians. \\ink pediatrics is It primary carespecialty dedicated to the care of children,there is considerable agreement evenwithin the medical professionthat thegeographic distribution of pediatriciansdoes not match that of U.S. hilclren.31.37Vhile 291X. of all children lived innonmeto pun tan areas in 1981. 01115 11(';of pediatricians practiced in these areas;in the same N'earonly:17ei ofchildre ti livedin metropolitan art-as, IvItile 57e oI j.t.ditt-triciatis practiced 011131

Within metropolitan areas pediatri-cians also are nialdistrthutecl. favoring lo-cations close to major pediatric hospitalcenters or in relatively prosperous residen-tial communities. In (:Ilicago in 1987. forexample. there were '4.111110Si twice ashildn'll per office-based pediatrician in

inner city residential itreas as in the mostprosperous areas an<I 6)'; more childrenper child health provider in the poorestareas than in the best served residentialareas. Vhile care available from inner citehospitals and clinics offsets some of thesedisparities. the average- children-to-pedia-trician ratios in Chicago's inner city com-munities (5,887) tvt-re more than twice theAAP's unelersr% ice standard of-2,500 chil-dren per pediatrician. Significant levels ofmulct-service are observed even alter theinclusion in the ratio of one quarter of thefamily physicians practicing in Chicago'sinner cite comintinities.r;

Access problems caused bs illc geo-graphic- inaldistrihution of pediatriciansarc exacerbated by the unwillingness ofsome pediatricians to sent' childrenvliose care is paid lot hs Nleclicaid.Medicaid payments are reginntly cif, ci asa prime factor in lots: pediatricianparticipation in Medic aid, although thisparticipation is higher than in am otherspe ialt except Nil Lund\ 'nit( tic e. Recent[(Arial and state initial; es hire begun toI :Use these pite ment 1709-11 lice MIS('of (in' fundamntal geographic maldis-tribution of pediatricians, however, in-

8"6


creases in Nledicaid reimbursement areunlikely to improve access fiw all Medi-caid-eligible children. Higher reimburse-ment levels are likely to improve access fornear-poor children living in areas richlysupplied with physicians, but they will havelittle effect on the availability of office-based care file poorer and sicker childrenresiding in inner cities.1

More important, perhaps, thegeographic distribution offamily physicians closelymirrors that of children.

. The supply and distribution offamily physicians also contrilmttes signifi-can tl \ to the excellent access to health careexperienced by most children. Followinga decline in the supply of general practitit-ners/family ph\ sicialis b(iwt.en I 9 6 3 and1975, GNIENA( predicted in 1980 that thesupply of this type of physician would in-crease between 1978 and 1990. I IICIVilSCSwere indeed 01)SCIAVII 511C11 that ill( supplyof larnilv physicians is currently fudged tohe roughly in balance with the needs of the

population and is predicted to con-tinue to be so through the year 2000.2(niters have projected, however, that overthe next 1:1 \ ears the supph, family phy-sicians \yill grow much more slowly thanboth the overall physician population andthe t .S. population ancl, as a result, thedemand for the services of fatuily physi-cians may well exceed the suppl\-.".12

Family physicians are an extrentlx im-portant source of medical care for chil-dren living in nonmetropolitan areas.Family physicians receive training in abroad range of medical care and are there-1()": "v11-suitcd II) set-v patients dra`v11from all age groups. This flexibility in pa-tient base makes it more feasible file familyphysicians to maintain economically vi-able medical practices in less denshpopulated communities. Indeed. \dualcompared with other primary one physi-cians. f:unily phssiciansare by far the mostevenly distributed across comm. typesand sides, although few van be found inthe nation's most sparsel\ pop dated rut al«mimics:1

\lute important, pet haps, the geo-gt aphi«listtibution of famil \ physiciansClosely mirrors that of children. As a result,

In 1981, 60ei of children in nonmetro-politan areas had a general/family practi-tioner as their regular physician,compared with only 18e;. of children inthose areas who had a regular rlatimishipwith a pediatrician2.31

Even within metropolitan areas, familyphysicians tend to be broadly dispersedacross residential communities \\lin c( nn-pared with pediatricians. In addition, theMedicaid participation of family physi-cians tends to lx- higher than that of jw-diatricians. ibis fact. combined with theirgreater willingness to prat Lice in inner cityand rural communities, makes family phy-sicians an extremely important resourcefin low-income and minority. children.13

Pediatric nurse practi-tioners (PNPs) provide care for bothhealthy and chronically ill infants and chil-dren, and have particular expertise ingrowth, development. and physical assess-ment. Currently there are approximately6000 PNPs in the L'nited States, a numberthat has been relatively constant for thepast decade. Prior to 1992, certification ofPNI's was limited to licensed registerednurses with additional special training fiwthis expanded tole; beginning in 1992,certification of PNI's will require a mas-ter's degree in nursing. 13

Ilistoricalh, most pediatric nurse prac-titioners have worked in hospital-basedand community-based clinics in inner cit.communities, and only a small proportifof nurse practitioners has practiced in ru-ral areas.1115 Because of their limitednumbers, pediatric nurse practitioners arccurrenth estimated to 51111)1: no morethan 5(.7i to 15(4 of pediatric care.36

There is considerable evidence aboutthe efficacy and cost-effectiveness of thenurse practitioner n tie in a wide variety ulsettingsfrom hospital outpatient depart-ments and public health clinics to healthmaintenance organifationsand in con-junction with the cal e of many differentspecial populations and problems.16-I lowever. historically. complex economicand legal facu COW:train ed growth in thesupply of nurse practitioners, inhibitedtheir diffusion into mulct-servd ;1!Vils,and limited the SUOI Of their practice.These fa( tots included the inability to ob-tain direct reimbursement for services, thecostliness of medical liahilitt insurance,and interstate variation in the pet missiblescope of practice (including, particularhthe authority to prescriho. Some of these

8n

86

barriers to PNP practice were lowered inthe late 198(k and the early 1990s, includ-ing a new provision for direct reimburse-ment of PNI's by Medicaid,49 and thesechanges may result in an increased supplyand a broadened distribution of PNPs inthe coming Years.

Office-based and Organized Primary CareSettings

There is widespread agreement that themajority Of children in this country haveexcellent access to primary care. Substan-tial numbers olchildren are underservd.however, including children who reside ininner cities ancl rural arras and childrenwho ) are poor or black. In 1988, for exam-ple, !to% of I...S. children had a usualsource of routine care, but 15% of poorchildren had no usual source of carer'()

Data from the 1987 National MedicalExpenditure Survey (NN1ES) indicate that,overall, children's access to health carecontinues to be excellent. PreliminaryNM ES data indicate that 92% of childrenunder 6 \ Carti Of age and 87% of childrenbetween the ages of 6 and 18 years have ausual source of care. Eighty-four percent

'3


of children under 6 and 87% of childrenages 6 to 18 are reported to travel less than30 minutes to their usual source of care.Eighty-six percent of children with a usualsource of care rely on physicians' offices.while 5(li rely on hospital outpatient de-partments and emergency rooms and 8%relv on other nonhospital facilities such ashealth centers, company clinics, schoolclinics, and walk-in clinics.32

:ross-tahul a t ions of NMES data by age,ethnic and racial background, family in-come, and place of residence haw not vetbeen published, but these data can beexpected to highlight children who con-tinue to he among the structurally under-servedthat is, low-income and minoritychildren, iclolescnts, and inner city andrural children. Monheit and Cunning-hamin this journal issue use data from theNMES to examine the effect of health in-surance coverage on the presence of ausual source of medical care. They reportthat children lacking health insurancewere less likely to have a usual source ofcare than were children with either privateor public insurance coverage (Monheitand Cunningham table 2). Earlier datasuggest that many low-income childrenhave little access to office-based care andare among those relying on organized set-tings, including hospital emergencymoms, as their regular source of care 5t-:,is

dependence of some children on hospitaloutpatient clinics and emergency momsfor preventive and primary care has longbeen cited as one of the greatest shortcomings of the health care system servingchildren. Care in these settings is thoughtto lack the continuity and comprehensive-ness which should characterize children'shealth care, and it also is regarded as un-necessarily expensive. Reliance on thesesettings is more common among minoritychildren, those %vim are poor, those wholack health insurance, and those living inunderseryed communities. Preliminarydata from the 1987 NN1ESalthoughnot incrusted specificalh on childrenin-dicate that blacks and Hispanics with ausual source of care were more thantwice as likeh as shites to go to hospitaloutpatient departments and emergentrooms or health «liters :111d other 11011-huspital facilities as their usual sow«. ofcare. For 171.8% of blacks, a hospitaloutpatient department or emergencyoom was the site ()Illicit usual source of

(11V, «Hlipated with 9.9% of Hispanics

ri


and -1_4(.'; of whites_ t'-' Poor children alsoare more likely to be taken to emergencyrooms. Data from the 1987 NationalI lea1111 Interview Survey indicate thatof visits made by poor children were toemergency rooms as compared with only-1(;.; of visits by nonpoor children.54

'['here are few data with which to de-scribe the supply and distribution of hos-pital wtt patient department andemergency room facilities serving chil-dren or with which to judge the adequacyof the capacity in these settings. Much asis true tO pregnant women, while em-piric-al evidence is lacking, hospital clo-suresparticularly tl e closure of publichospitalsIt-aye had au important im-pact on access to preventive and primarycare fOr the children relying on thesesettings.

health department clip ics and other facili-ties receiving Title \' Maternal and ChildI lealth Block Grant funds are an impor-tant resource for children, but their tutusis primarily limited to preventive care andfuss states are able to offer services on astatewide basis. (For more infbrmationabout these providers, see the article by11111 in this journal issue.) A 1986 surveyof Th \' maternal and child health agen-cies lc Rind that, while -16 of 51 state agen-cis have pediatric outpatient programs,only 13 states offer these services on astatewide basis and no state provideseither comprehensive sell ices or servicesfor at least sonic acute care needs on astatewide basis. All of the agencies offer-ing pediatric outpatient services offeredwell-child care, but only 11 states reportedfurnishing any acute care services to chil-dren. Nineteen agencies relied exclu-sively on the local health departments forthe provision of pediatric outpatient care,but 32 states made use Of private

community health centers, and otherclinics.27

It has been estimated that 36(,; of allmigrant and community health centerpatients are children under the age of1.1;29 however, little sVSlMillic VidellCeis available with which to judge the ade-quacy of the capacity in these settings.\Inc Ii as is ti tie for pregnant women, themoll of funds to many centers in the

cal IN 980, left sct. c in many ( 0,111-

:nullities, and the difficulties that theremaining centers experience in attract-ing physicians limit their capacity.

At the present time, school-basedhealth services are a limited but poten-tially important preventive and priancare resource fO children. Compellingarguments have been made with regard tothe efficiency, effectiveness, and equity of'school-based health services, and most ofthe disagreement about school-basedservices seems to center on exactly howmuch primary care should be provided inthe schools.55 (See the Spring 1992 issueof The Future of Children for an in-depthanalysis of school-linked services.)

Comprehensive school-based clinics, althoughlimited in number, are thought to be a promisingstrategy for reaching adolescents.. .

Roth funding sources and levels ofinvestment in school health services varygreatly from state to state. Little informa-tion is available on the supply of schoolhealth services, although great variationin the supplyy is evident in pupil-to-nursratios: in 1985-86 the average pupil-to-nurse ratio was 2,473 to 1 for all districts,but this immix.: varied across districtsfrom 1,156 to 1 to 1,903 to .7)5

Comprehensive school-based clinics,although limited in nuher, are thoughtto he a promising strategy for reachingadolescents and, in particular, for im-proving opportunities for adolescents toavoid unintended pregnancies. In 1987there were 85 clinics affiliated with jun-ior high or high schools throughout thec mntrv. Such clinics are usually staffedby nurse practitioners, clinic aides, part-time physicians, social workers, nutri-tionists, and other prolessionals.50

The Supply and Distribution ofPhysicians Providing SpecializedCare to Children

Although the predominant health careneed among children is for primal-. I re.the services of various specialists and sub-specialists are also of great importance tothe health of children. It is therefore im-portant to consider the supply and distri-bution of specialty and subspecialtyphysicians serving children and to con-sider the adequacy ()Ellie supply of highlyspeciali/ed care relative to the supply ofprimary care.

88

1)ata from the l'.S. Itireatt of I lealthProfessions indicate that in 1986 there\Yew 60,700 medical specialists serving allage groups in die (..S. and that the. num-bers are rapidly increasing: the overallnumber of medical specialists is projectedto increase la 113('; between 19.861 and 2000and In SI I e; bulwen 1986 ;11)(1 2020,56

aggregate treticl masks differencesamong the pediatric medical subspecial-ties. however. For example. the supply ofpediati is allergists is expected to declinelw 21 e; between I 081i and 2(100. while. the,,upplv of pediatric. cardiologists is pro--jet ted to increase Iry 1 1 (,; ()they pediatricsubspcialists (a categon tvbich includesadolescent medicine, genetics. neonatalmedicine, pediatric neurolop, pediatricencloc riliologl. child ps ch lair:, pediatricptilmonolog, pcdiatric lientatolog-on-colog-., pediatric hunititiolo) \, pediatricinfectious diseases, pediatric gammen-terolot.,n, and pdiati it nephrolog0 areprojected to increase by 1)etween1086 and 2000 ancl by 86(i hewyeen 1986and 2020.:.'" The trends also do not takeinto at «atm the amount of time pediatricsubspecialists. tyro are 111(1111N bull-tittle

fit( \ (ill OM( IASI (0 manyadult subspecialists), spend in researchand ethic:Mon:1) activities.

Data with which 10 eVilitlate the ;Iti-(VIM t of the c lit -tent SIII)1/1\ and dish Hitt-


tion of specific pediatric specialists and sub-specialists are not available. flowevcr, datafrom the U.S. Bureau of I lealth Professionsshed some light on overall trends. -'t' Thesedata indicate that, while the overall supplyof physicians is increasing rapidh and thetotal number of physicians required in2000 will exceed requirements by 50.101physicians, the excess of supply over re-quirements is far greater for specialists(32,020) than for generalist physicians(general/ family medicine, general inter-nal medicine and general pediatrics)( 17,990). As noted elsewhere in this paper.the abundant supply of specialists and sub-specialists serving children has greatly im-povd access to specialized care for act ttelyand chronically ill children. However, theimbalance in the projected excess ofpro\ idersofgeneral and specialty care Sen.-ices raises important questions about whatdirections future policy should take withregard to the training of different types ofphysicians.

The Supply and Distribution ofHospital Care for Acutely andChronically Ill Children

Most children never require hospitaliza-tion: but some children, especially thosewith chronic and disabling conditions, re-quir multiple am! sometimes prolongedhospital stays. The access of children re-quiring inpatient and/or specialized hos-pital outpatient Care has undoubtedlybeen affected by the sanw broad !relicts inthe health care system clescrifwc1 else-where in this paper that is. hospital Ho-SUITS, mergers. and acquisitions whichhave reduced the stipply of care. pat-tic-Il-iad\ hom small, rural anc1 public hospi-talsalthough research is lacking on theimpact of these trends on children. Inurban areas children often have many in-patient and specialirecl outpatient re-sources available to them. including thehighlN specialized services of children'shospitals. although recent public hospitalclosures have undoubtedly limned choicesmail:11)1e to lute income Choi«.savail:11)1e to most rural children are un-chmhteclls much more limited and masentail travel over considerable distances.

)Because: great many of the childrenrequiring at liter carein hospitals havebeen injured. trends in the supply anddistribution of erne' gencv and traumacareespeciallv care tailored to meetthe spec ial chat :tete] istic s and needs ofchilch enhave particularly important

9i


implications for this group. TheAmerican Hospital Association notesthat during the 1980s, the number ofhospitals equipped to handle emergen-cies on a 24-hour basis increased, butdespite this encouraging trend, the avail-ability of specialized trauma care dimin-ished.2 I This unfortunate trend isattributed to the high costs of operatingtrauma centers which, together with theburden of the uninsured and low pa-ments rum \ledicaid, have fOrced manyhospitals to close their trauma centers.Even among the I5.1 children's hospitals

:crib-d in a recent report, only 11 fa-cilities have a certified pediatric traumacenter

Services for Children with Chronicand Disabling Conditions

When compared with other children. thenation's 3.3 million children with chronicand disabling conditions require a greatmane medical and nonmedical servicesThey make more physician visits. requiremore hospitalizations, and are more likelyto have multiple sources of health carc.58According to Perrin and Irevs, the past 2decades have seen great improvements inthe supply and distribution Of the highlyspecialized medical care needed by chil-dren with chronic and disabling condi-tionsparticularly. in urban areasand itis now primarily chronically ill childrenliving in rural areas for whom access toservices is the most problematic.0

.\s noted above, the number of highlyspecialized physicians has been increas-ing rapidly in recent years. While in-creases in the numbers of specialists andsubspecialists in ubal areas remediedmany of the supply problems that for-med\ impeded access to care li chroni-cally ill children. the medical care ofchronically ill children continues to liecharacterized ly% a great deal of confusionand fragmentation. Chronically ill chil-dren tend to have multiple providers. collaboration and «lordination aiming theseproviders is of ten lacking, and the prxli-lice and primary care needs of these chil-dren are of ten (IS erlooked:°-10 111

WIWIl'a", access to specializedmedical care front office-based phi sic sansand hospital outpatient clinic's teas be ex-cellent in mam urban areas. the availahil-its of 1 he wide arras of tiontnedir alservices needed by <hronicalb ill childrentends to be much more variable in bothurban and rural communities:0

ConclusionsThe foregoing resiew real firms a long-standing paradox in the health care systemserving the nation's children and preWant women: some communities andpopulations (alio\ an embarrassment ofriches of health care resources, while oth-ers remain mult-served. And the yetiwomen and children who are most woe-fully underseryed also are among those atgreatest risk fin- low birth weight births.infant deaths, and morbidity and mortalityduring childhood.

While the maldistribution of Mall\ ma-ternal and Child !Wahl' care resources is1101 new, the hwegoing review suggeststhat some of the dimensions of the prob-lem of maldistribution have changed inrecent years. In the private office-basedsector, the supply of family physicians hasgrown, bringing greatly improved accessto primary care particularly hn. children innonmtopolitan areas. The supply of pe-diatricians and pediatric subspecialistsalso has grown, although because of their

Physicians' reluctance to participate inMedicaid has also contributed to the difficultiesthat many women and children experience inobtaining needed care.NIP

continuing- malclistribution telatiye chil-(lien, these increases hate not bencfit Ledmany children who remain unclerserveclespeciallY c aronicalle ill children residingin rural areas. The rising costs of medicalliability insurance mach. what was a seriousproblemthe geographic maldistribtr-tion of obst et rician-gv tecol( )gist ssignili-candy \corme by impairing the ability oflatnih physicians, certified nurse mid-wives, and even soul obstetricians andgynecologists to provide maternity sell icesto pregnant women who are otherwisedersrvd. And the continuing problem ofphysicians' reluctance to participate inNleclicaid has also contributed to the diffi-culties that mans women and c !niche!' vis-perience in obtaining needed care. Someof the most chamatic changes haw oc-curred ill the sitppl% and dist ilmtion ofhealth cats resources in the institutionalsector, including closuits of mans lx)spi-tals and comntttnit5 health c (met 5, t (Auc-tions in core funding of manv c 0111111tIllitl


health centers and lc kcal public health clin-ics, and budget reductions in many of thecategorical and block grant health serviceprograms which have traditionally beenoffered to women and children in thesesettings.

fOregoing review suggests somepolicy strategics that seem particularly im-portant to efforts to maintain and improveupon the present conliguration of mater-nal and child health care resources in thecoming years:

I. Continue efforts to bolster the supply offamily physicians. Because fantilv physiciansare able to maintain viable practices innonmettopolitan and other tuiderservedareas and are apparently willing to practicein these communities and to participate inMedicaid, the maintenance of a generoussupply of these physicians represents anespecially important resource fin. childrenand pregnant wiimen. The foregoing re-view suggests some disagreement aboutwhether the future supply of familyphssicians will he adequate to meet thedemand for their services. The vital impor-lance of family physicians 10 UnderiserVedpopulations suggests that the Council onGrachtate Medical Education would dowell to conclude its deliberations with rec-ommendations for future health profes-sional supply which err on the side ofproducing too many family physiciansrather than too few.

2. Adopt strategies to lessen the problemsthat medical professional liability issues posefor maternity care providers. A number ofpromising strategies fire addressing thisproblem have been proposed by the Insti-tute of Medicine:' While a review of thesestrategies is beS (mid the scope of this pa-per, the evidence presented here makesclear the distortions in the supph of ma-ternity L arc pnwiders which have resultedfrom the medical professional liabilityproblem. Resolution of this problemwould free up considerable cap:wit\ forthe pro\ ision of maternity care services byfamilx physicians and certified nurse mid-wises a% well as nIOVide needed relief 11-0111die (INS of Itlaipra( lice insurance fire or-ganiied settings.

3. Continue support for the National!habit Service Corps WINO scholarship andloan repayment programs. ti( mu. rural andinner tits communities will always have(Win ultv anrac:ing and retaining phvsi-ians. 11oacvt F. the NI ISC has had de-

monstrable elle( tiseness ia filling sonic of

these gaps. Although this program wasvery nearly eliminated in the early 1980s.in the lace of the negative effects cutbackswere having in underserved areas, it wasreinstituted 1w Congress in 1990.22 Thisaction has slowed the rate of decline in thenumbers of physicians in the NI ISC pipe-line. Because of its important role in plac-ing primary care physicians inunderserved communities, continued andexpanded support vin' this program will hean important factor in future access tomaternal and child health care.

Members of the NI !SC are particularlyimportant in the staffing of migrant andcommunity health centers. Because thesecenters are supported by public resourcesand are targeted for unde-served commu-nities, it is especially important that theybe able to function at their maximum ca-pacity. Because in the short run, federalbudget constraints may mitigate againstsignificant expansions of the NI ISC, it mayhe worthwhile I() create special incentivesfor physicians and other health profession-als to fulfill NI ISC service obligationsthrough work in migrant and communityhealth center s.

4. Continue efforts to ensure the fullestpossible participation of physicians in servingMedicaid-eligible women and children. Themost universally accepted strategy for ac-complishing this is to ensure adequateMedicaid reimbursement levels. The fed-eral Omnibus Budget Reconciliation Act(()BRA) of 1989 required that states docu-ment and ensure the adequacy of theirMedicaid pc ill:ric and obstetric lees, andit number of-states have recently institutedfee increases. At the same time, the limi-tations of Medicaid reimbursement in-creases for improving access to maternaland child health services sly be ir(.044-niied: empirical evidence suggests it is un-likely that reimbursement increases will beof sufficient magnitude to encourage phy-sicians to locate in underserved areas ,8and in these communitieswhere mater-nal and child health care needs il-e alsogreatestother policy strategies to ex-pand the supply of services \Nil! be neededif access is to he Myr( wed (see recommen-dation below).

5. Develop systematic data with which todescribe and evaluate the adequacy of the sup -lily of maternal and child health care availablem organized settings. Utiliiation data fromnational snrvevs make it evident that agreat mans women and children (let 511(1

9 ;


On the resources of hospital clinics, publichealth clinics, migrant and communityhealth centers, and school-based healthservices. Vet, with the exception of theoccasional special-purpose survey,' -'% rela-tively little infbrmation is available to assistplanners and policymakers in makingjudgments about whether the supply isadequate to meet the growing demand forcare in various organized settings and toevaluate the impact of capacity shortfallson utilization and health status. Availableinformation suggests that in many com-munities the capacity in these settings isinadequate. but systematic informationdescribing the magnitude of these prob-lems, collected on a periodic basis, wouldimprove both our understanding of thissituation and the likelihood that the fed-

governments scarce discretionary re-sources will be comtnitted to addressingthis problem.

6. Enhance the capacity of organized set-tings to meet the needs of undeserved childrenand pregnant women. Ever in the absenceof systematic data, the fbregoing reviewsuggests the need for capacity-building inorganized settings. The clinics of publichospitals and academic medical centers,public health clinics, community and mi-grant health centers, and schools repre-sent a considerable foundation ofinstitutions upon which to expand the pre-ventive and primat-y care capacity in un-clerseryed communities. Some haveargued against expanding organized set-tings on the basis that it will displace pri-vate office-based care, but care fromorganized settings has been Ibund to ex-pand the overall availability of care ratherthan displacing care from private physi-cians.ti2.63 Others have argued against ex-panding organized settings because it willcrelne a "two-tiered system" of health care,but Williams and Miller make a compel-ling case that this stance oversimplifies andultimately dodges the VCI complex ques-tion of how best and most feasibly to nicerthe needs of the underserved."

lit recent years the financial pressuresexperienced by many organized settingshave made capacity-building very &Ili-cult: many of the public health programsfinancing care in these settings were re-duced or eliminated during the 1980s.and increases in others failed to Ice .1) pacewith medical care price inflation;r0:1Medicaid reimbursements frequentlyfailed to cover costs: malpractice premi-ums and other practice costs rose and the

numbers of medically indigent patientsseeking service increased.

There are a number of vehicles forproviding organized settings with the re-sources they need to expand their capac-,it'. The most direct approach to building`;capacity in community and migranthealth centers is to expand the core op-erating grants which currently comprisenearly half of their funding.22 Alterna-tively, grant programs can be developedspecifically for capacity-building pur-poses. For example, in 1989, the federalDepartment of Health and Human Serv-ices awarded S22 million to help commu-nity and migrant health centers recruitnew personnel and retain NIISC physi-cians past their period of obli gat ion .22Other similar in itiat ives would he helpfulto efforts to better meet the preventiveand primary care needs of the under-served.

A more indirect but nonethelesshelpful approach would be to enhancethe Medicaid reimbursement levels paidfor care provided in organized settings.While Medicaid reimbursement can onlyhe used to pay fOr services, increasedpayment levels would relieve some of thefiscal pressures faced by these institu-tions and help them maintain viability.The OBRAs of 1989 and 1990 tookimportant steps in this direction by re-quiring that state Medicaid programs re-imburse community health centers andother look-alike federally qualifiedhealth centers on the basis of 100(5;. ofthe costs of providing caret' Whilecommunity health centers will benefitfrom this new policy direction, the fullimpact of this policy change on the insti-tutions serving children and pregnantwomen will depen.i on whether federalregulations (not vet published) enablehospital outpatient and local publichealth clinics to obtain the look-alikedesignation and its associated cost-basedreimbursement.

The preceding list of policy strategiesconfirms what one might have sus-pectedthat is. that it will not be possi-ble to improve the supply anddistribution of preventive and primarycare for children and pregnant wanneryvithout additional resources. Nloreover,unless the health sen ice delivery pro-grams presently serving women and chil-dren at e funded at the level of medicalcare price inflation, additional erosion

92

in the capacity of organiied settings islikely to occur in the future.

In all era of tight federal and statebudget constraints, prospects lin. redress-ing persistent imbalances in maternal andchild health care resources arc limited, andthere is even some degree or likelihoodthat these imbalances will be allowed to

)I'Sll. 'alike health and \elfare entitle-ment progmins (such as Nledicai(1) forwhich appropriations are open-ended.mans of the programs that fund healthcare in ()I-gain/cc' settings are discretionat-vprograms fOr which budget allocations aremade each Year. As a result. these programs


are very vulnerable to limited growth, re-duction, Or elimination during periods oftight budget constraints. The budget rulesestablished bv the Budget EnfOrcementAct of 1990 will make it very difficult toincrease funding lin- the National HealthService Corps, the Maternal and ChildHealth Block Grant. or community andmigrant health centers because these in-creases will !teed to he offset hl cats inmilitary, international, or domestic clkere-tionan- spending-cuts which a number ofonlookers agree mav be politically difficultto achi,A.,..i.1.67,

.\ met ican Medical Assoc iat ion. The /slum r4 ob%letrir and gyueroloy. (A-tic-ago: ANI.X. 1987.

2. Abt . \ssI inns. l?ervoiri +ration of the adequary rd physieia sup /)h' male in I Cat r try Ha Coal u a hi

.1Iedieal &lurid irm :cat/rural Advisory Com miller, (G,li ,.\'.1( to, nut led Vier rallies. Final Report( IRS :\ 2 III-89-00 II. (:ambritigt. M.\: Alt Associates, 1991.

:t. Riclet s.. T.C. liar ruir s lo a«rss In serrates provided by plosicia its ire ~antral //r mill' e"nalmnhrnal met( i eine. general tiviiithu s. gneral %urger 1, ohstel rir sigy ulogt. a rut .grnera I rued hilt!p,),haan. Paper prpatl.(1 for the cowl( il on Graduate Medical 11t-Itication.,fitls 1991.

I. President's Commission tot the Stuck of Ethical Problems in Nledic ine and Biomedical andLIchasittral Rcss.art Ii..Sanetring (rotss to health twit Vol. I. lashing-tott, DC: (;c)s.crti-

min Priming (Mit t.,

5. Institute of Nledit itic..1h ival'no/rssrnn/al lialahtl ral the delivery of obstetrical rare. Vol. I.lVashington. IlC: National .1( adems Press. 1989.

6. F('``eu.1-I1'..1".1"11-.i."-, P-R-. and \. Nirdicaid It( ce5, I" 0111<I ilistetricialls./tturnat tti //eatiit Care /or the NM mid I 'frulerserrwrl (Spring 1991) 1:1115-

21.

7. Stale of Illinois. ()f li«. of the Audit". (icilral. "/"b`friri( in I/bunts. SPring-field: Of lice of the .\ minor General, 1991.

y. Fossett,.1.\\... Perlof f Peterson. J.. tut(' kletke. P.R. Nledit aid in die inner < its: The t assnl inaternits cart.. ni Chicago. lhe Alillmak Qua. ler ly (1990) 68,1:111-.11.

9. .1inet it an kill< .11 .V.sot iatiot). (:outicil on t.utt(1 Range Nanning and Development. flitmin e of taunts practice. lou rna I of the .1 uteri r Alerlii al :Iwo( ia I hal (September 1988)

2)(1,9:172-79.

10. \ \( mitim of Faillifs ph\ icialis. 1'ro/essmrralliability study. K city, mo:

\ royait all atlell1V of Ian., 198(i.

11. .1inerit an :ollegt. of (11)stetrit lass and (*Any( ologists. I'mlessamal halably ruul as elicits: liepa,/ a/ a stir ries tit .1C JC's membership. (1.`? awl .Vmortilier /9Si.\(:( ;, 1985.

12. Less is-Idcnia, 1). Ira wrist ug provider fra rtterfral Washington. IX:: National ( }seniors' Asso-

c 'anon. 1988.

13. I elsis-Idem.t. I). Nledical professional liability And ess to oh...it:Ili{ c al c: Is tittle asis: In Ilrefit (11 plutettwittil !ha/ably a ral the delivery of obstetrical arr. \'o l. 2. an int erdisc litre

um 5 t NIVS\ V.P. ROSIOW and R.f . Bulget. eds. kVasItinguin. IX:: National .Nt :Wenn Pi Cs,.1989.

I I. Min .1101,1,titil 8(11'11111,ot, es, to ',risme obsten-it s ),one( clogs sot slit's mule' \ kill-( aid. Ilttbot/ Cllie (198 '22:102(i-37.

15. Fossetl..1.1%. Rletke. P.R., and l'etersot J. \ !edit aid and at «... to c Itild healthue in ( :hit ago. Imo nal of I ',with Pada s. fulls! amid /are. hit111«)111111g.

1:lermaii, I.. \ ant! 1.4,11es the iamkictti of 111.1111 nits die. In .1 /nisei! a/ /min

1'i-triton: 1 he rase lor tr niversal mato nal r air It the f I.V.1.11. Rot( It, Galva Blake's. S.S.and F.1111Ong. eds. V1'ashington.1)(:: .Autertcart Pull( I lealth Assot imion, 1992.


17. Ile( ler(i.E.R. Hie tran,lorimition ()I .)alirican midwifery: 1975-1988. .1 mezira n Journal alI Health (1 992) 82,5:68(1 -8 I.

18. Office of Its 1'm )1()I.,n .\ssessuunl.. \'unr practitioners, physician as.srsta ni% and (el inurse midwiirs: .1 hallo analysis. IVasliingtf in, IX :: l..S. (4)(riimnt Penning Office, 1986.

19. I Iandlcr, A.. Pei-loll. J.. and 1:ennells.J. Ensitt ing the quality of prenatal care. In .1 lam )1(1 offlea err /run: Th rase for litensal maternity ran lhe 101(11. (:.11. Blakel. S.S.Ilto(sn. and Frank Y. 1,Votig, eds. 'Washington., 1)1:: American Public- Ilealth Association.1992.

Insiit 'tn. of Nleili( lit. i'totrad (me: Itwi hi. 11; mot het «v« hi rig in tains. S.S, Irot% II. ell. Wash-ington, DC: National Academy Press, 1988.

21. Amt' it an lit \ssociation. I ',Attila! statist , 1 1.1. 1990.

29. l'Insician Pasmnt ids Cominksion. 1c191 (wooed ?pima lo (..ongoss. lVashiligion, 1)C: Pin-sk ian l'as silent Reties 1991.

23. Kleman. ( (rarid. K.1., and Thomas, K.C. The role of the public sector in pi ()% iclingchildren s health rare. lit ( .hildren in a deer ((in health systrill. \I Schlesinger and I.. Eisen-berg, ( .1,. Johns 1 lopkins University Pecs,. 199(1.

2-1. "rilm pt, K., and lit eche), C. Impi ()Ned access to care hie the uninsured poet in hugeDo public hospitals make a sill let dice:Jur/rug/ .4 I lral h l'ulity and Late (1987112:313-21.

25. Institute of Medi( int.. The pilule ul publit health. \1ashingtoti.1)<:: National .Ncadcmy Press.1988.

2(1. Sing-11, S., Fort e.t..1.1)., and If trees.. \ ate in the I slate a nd to arty nal hay.V(4. I. New York: .klan Guinn:1(1'd Institute. 1989.

12osenbantn. S.. !bight... D.(:.. andiolmson. K. Maternal and child health sort it es (t)) medi-c all( indigent t hitch en and in egnant hornet'. Merl real Care (April 19881 26,1:315-32.

98. National .1) ssociat ion of Conintimit) I lealth ( :enters. .11()thers, {refills, and «manu ally arid it«gums( health «mien: .1 rtinni of the fin! rear of the Cominehensive l'erinenal I'mArt et m.11.; sltington.11C: National .1),so( iation of (:ommunitv I (catch Centers, 1989.

29. Rosenbaum. S. ( :amnia nil) and inigion I hen//h (enters: ((nodes of achievement 51.ashington,11C: 1987.

;1(). t .S. General .1( «milting ( )I li«.. PhySt( lel 11 ,11111111' Pant thi :VII umril /bull((! f" ('mps Vasil-ington, 1)1:: Gene] )11.1ccounting Office (GA( )11121)-9(1-128), 1990.

31. t '.5. ( col ilchtmlogl .\ssessment. Vconatai inten are fir low hit !inveigh( ilifarrfk: Cosh

()7.

anal rfillin's'orts 5Vio/lingl"11. DC. 1987.32. Contelitt..1.., Ileauregaed. K.. and Cohen, J. Usual sottrws of medic al care and then h.n,c(-

Iel istics..%gen( v lot Health Care Polk( and Rsean It Pub. No. 91-00.12. Roc Laille, M1):Center for Genetal Health Set sic es Intramural Research. September. 1991.

\ air "Irdic"Ifif"vidcl." and am its i" (h""gtrg- &Wilt %islem. Sehlesingei and 1,. Eisenberg. di.. Raltimore: John. llopki 11. 1 Ilikel

lies, 1990.

An" icall Medi( al NSM" The //awe 0/Prdial'7". Chicago: 5\1.5.1987.:15. GI admite Nldical Fully :Mon National . \dvisnrs Committee. Th, /ippot fy/ \

ington I)( 1'.S. intent of I leahli and I II1111/111 Smites, 1980.Li" Ay. stinion, of the Amt., i(

. \c .,(lent 01 Pediatrics to the \idninmer sub( winktee of the (:otun it on Graduate \ Educ atio:). Washington 1)(:. 1991.

:(7. Eaton. .1'.. and Hint. S. NV1Iitt happened to the predicted glut of pediatrician.: l'eduarits(C), Jobe' 19111) 88.1:870-72.

38. lituln, kletke, P.R., and Connell, Cm rem (list' ilmiion and stuns in the lo( anonpatty+ ti of pediati ie ian.. Limit( psit ions and general practitioners between 197(1 and1979. l'ithairn (NoNettilier 19821 70:750-89.

:19. l'er100,.1. 1,.111(.1 IV. Re( slit (.11(b, pal tic {tusk cu inlvdj( .11 reli Ow (19861 21.8:719-60.

i(1. proof( ,.1 Kidse, Ne( ke, K. phsi, {.msdec \t Dena minants and polio w impli( anon.. bur nal of I 'with Polio, l'ohta s and I .aw (1987112:221-35.

11. 111(11,amsks, li., Cat timid," and Hint. S. Prdiatt i( ion paint ipation itt Medicaid: 11178 to1989, i'edtatrul (19901 85.1:567-77.

9


12. Marder. Kletke, P.R.. Si lberger, A.B.. and Wilkie. R.J. Phssayan supp/y and nithzahan byspecialty: Trends and projection v. Chicago: American Medical Association, 1988.

3. Brotherton, S.. research associate. Dhision of Research on Child and Adolescent Health,American Academy of Pediatrics. Correspondence with author, March, 1992.

44. Rith%, G. Ness health professionals in child and maternal health. In vol. 4 of Baiter health forour children: .A national strati, --. The Report of the Select Panel for the Promotion of (lildHealth. Washinguni, DC: Department cif Health and human Services, 1981.

15. Weston.]: I.. NPs and Pis: Changes-where, whether, and why. Paper presented at theAnnual Meeting of the American Public Health Association. 1984.

46. Williams. C.A. Priman care and the cost dilemma: A case for nurse practitioners. In Childhealth /,alias in an age of:livid anility. R. Haskins. ed. Norwood, NJ: Ablex Publishing, 1983.

17. WeMer.J.P. Nurse prat titiciner and physician assistant practices in three HMOs: Inlplic.t-tions for future 1*.S. health manpower needs. American journal of Public Health (198(i)76.5:507-11.

8. Crnikshank. IAN. Pediatric nitrite practitioner functions in the outpatient clinics of a terti-an' care center. Medical Care (1986) 24,4:340-49.

49. Morris, B.K. FNPs. PNPs win direct payment from Medicaid. Name Practitioner (1090) 15.1:6.

5(1. U.S. Office of Technology Assessment. Healthy children: Investing in the future. Washing-ton, DC: U.S. Government Printing Office, 1987.

51. St. Peter, R.F., Ncwachcck, P.\\'., and HallOn, N. Access to care for poor children: Separateand unequal? journal of the American Aledhal Association (Islay 27, 1992) 267,20:2760-61.

52. Rosenbach. M.L. Insurance coverage and ambulatory medical care of low income e hildren:U.S.. 1980. In National medical rare utilization and expenditure survel. Series C, Analytic Re-port No. 1. Washington, DC: U.S. Government Printing Office IUHHS Puhlication No. 85-2(1.401). September 1985.

53. Kasper, .D. The importance of a usual source of cure for children's physician access atud ex-penditures. Medical Care (10871 25,5:386-98.

51. National ('.enter for Children in Poverty. izie million children: .1 statistical profile 01 our pooresttoting citizens. New York City: National Center fin- Children in Poverty. 1990.

55. Walker, D.K.. Butler. J.A., and Bender. A. C:hildre. heaith care in the schools. In Childrenin a changing health s)idon. N1J. Schlesinger and I.. Eisenberg, eds. Baltimore: Johns Hop-kins I. 11 Press, 1990.

56. 1..S. Bureau of I lealth Professions. .Neeputh riport to th President and Congress on the stains ofhealth pin Win nel in the 1 Wtshington.DC: Bureau of Health Professions (D111-1S Publica-tion No. I IRS-P-OD-90-31. October 1990.

57, National Association of Children's Hospitals and Related Institutions. Listing of selectedhis for I".S. children's hospitals. Ilexandria.VA: National Association of Children's Hospitalsand Related Institutions, 1991.

58. Newacheck, P.W. Financing the health care of children with chronic illnesses. PediatricAnnals (ianual 5 1990) 19.1:60-63.

59. Perrin. J.\1.. and keys. 1I.T. The organi/ation of services fin chronically ill children andtheir families. l'erhalm Clinics ()I .Vorth Amerim (February 1981) 31.1:235-57.

(;orimaker. S.I.., and Sappenlield, W. Chronic childhood disorders: Prevalence and impact.Prdialric (finds 0/ .v.-th America (rebruarN 1981) 31,1:3-17.

61. Pless.I.B. Current controversies and technical advances. Pediatric ci/,'N'orth . -1 nrrriru

(1. ebruar5 1981) 31.1:259-73.

62. Fossett, J.W.. Choi, C., and Peterson,.). Hospital outpatient services and Nledicaid patients'ac «ss 0> c e. Aledira/ Cure (October 1991) 29,10:961-76.

Fossett.i.W.. Peterson. J.. and Ring. NI. Public NCI tin primal s r are and Medicaid: Tradingfour 1113ilisn raming.lournal of Health Politics, Polley and Laze (1989) 14:3(19-25.

ti l. winiams. and Miller. c.A. berm aria, nmag,hildu.. Findings /101,1

/0-ccmnicY %Ind% and (Meda's /or I Arlington. VA: National Center for ClinicalInfant Programs. 1991.

65. and imP""'"-I ""i's 10 heililh "7'es/to duld"'"""dPrign""/ "'"/"eb-Washington. DC: The Brookings Institution. 1991.

Q "

Expenditures on HealthCare for Children andPregnant WomenEugene M. LewitAlan C. Monheit

Abstract

The chronic health care crisis in the United States is primarily the result of risinghealth care costs and ola system that leaves millions of children and pregnant womenwithout health insurance. with restricted access to health care, and at risk kw poolhealth. better understanding of the current system is key to any reform effort. Theauthors analyse estimates of annual expenditures on medical care services fnrchildren covering the period front conceptionion Mk High age IS years. includingexpenditures on pregnancy and delivery..I-hey focus their attention on the distribu-tion of health care expenditures by type of set-6( e and source of payment. on hotsexpenditures differ Inr children of different ages and hum adults, and on the rate ofgrowth in expenditures on health care fi children.

The authors suggest that. because there has been a decline in the RIM% e share ofexpenditures accounted for by children. eflorts to expand third-park financing oftheir health care will be less likely to overwhelm the system than would efforts toexpand cocci-age to other groups. Families who are especially in need of extendedhealth care coverage are duke of children with major illnesses who are exposed tocatastrophic costs. Effiwts at cost containment should be focused on the costs ofpregnancy and newborn care, areas in which expenditures have grows extremehrapidly in recent years. Finally, the authors conclude that, if expansion of healthinsurance coverage fiw children in the near term should be incremental. expandedcoverage for children 3 to 12 years old IN 0 dd probably have the smallest budgetaryimpact of am expansion in access to care.

Rising health care costs, which have thwarted both public andprivate efforts to slow their growth, arc at the heart of the chroniccrisis of the U.S. health care sstem.I These rising costs consume

ever greater portions of the budgets of governments, businesses, andhouseholds, leaving fewer resources for other activities. Attempts to dealwith the burden of rising health care costs have left millions of Americanswithout health insurance or with insurance that is seriously inadequate.

Children and pregnant women have not escaped the fallout from therapid increase in health care costs. Despite recent expansion of govern-ment programs (see the I Jill article in this journal issue), more than 1 in

!.:ngene .11. Lewd,('it.!)., is director ofresearch and gnintsfir economics at theCenter for Ilse En ticof Children.

Alan C. .11onheit,l'h.D.. is .seniorresearch manager. forthe Division of Medi-cal ExpenditureStudies. Center forGeneral Health Sem-ites Intramural Re-ta re', Vt.)? a forealth Care Policy

and Reseanh.

The views of this paperme those of the authors,and no Vidal endorse-ment by the :Agency forHealth Care Policy andResearrh or the Depad-Wilt of Health and Ilu-ma» Servir,.. is intendedrip should be inferred.


5 children were without health insurance at some time during 1991. Asdocumented by Monheit and Cunningham in this issue, children withouthealth insurance use less preventive care and less care fbr acute illness.Presumably their health suffers as a consequence of this reduced utiliza-tion. Legislation has been introduced at the federal level and in severalstates to extend health insurance coverage to more children, and publicopinion polls indicate that the public is sympathetic to the health careneeds of children. Yet there appears to be a reluctance to commit resourcesto new health care programs in an era ofgeneral fiscal austerity. Given theinexorable rise in health care costs, concerns about the wisdom of expand-ing health care financing without either bringing costs under control oraddressing what many feel are the inefficiencies of the current systemappear justified.

A better understanding of the current system, however, is key to anyeffort to reform health care financing for children and pregnant women.Generalizations drawn from the observations of the health care system asa whole may not be totally applicable to children, especially' at the level ofdetail necessary. fix r effective policvmaking.2 accordingly, this article pre-sents estimates of annual expenditures on medical care services for chil-

dren covering the period fromconception through age 18 years in-

In this era of heightened cost-consciousness,knowledge about the nature of U.S. expenditureson health care for children is vital for those whowould improve children's health.

chiding expenditures on pregnancyand deliverv. Among the questionsaddressed are: I low are these healthcare expenditures distributedamong cliff (-rent types of health serv-ices and different sources of payment? Is the level and mix of

medical care expenditures different for children of different ages anddifferent fO children as compared to adults? Are these differences greatenough so that an incremental approach to health care financing reformwhich focuser initially on children makes sense? What about the rate ofgrowth in expenditures on health care for children? Is it as rapid as therate of growth in aggregate health care expenditures? Is it driven by similarIbrces. so that developing effective cost control strategies will have to bean integral feature of any effort to expand children's access to health careservices?

To be sure, a description of where we are today and some of the trendsthat got its here will not be sufficient to point the wary to effective reforms,atid some of the information presented may raise as manyquestions as arcanswered. Still, it appears that, in this era of heightened cost-consciousness,knowledge about the nature of U.S. expenditures On health care fOr

children is vital fbr those who would improve children's health.

Sources of Data

lite 1987 National Nledical F. pendittuSitryt (NNIES) I lousehold Survey is the

1)1-11111N source of the penditurc esti-mates pro\ id(-(1 in this eport.: NVith a totalsample of about 35,(Hlt) ir .1i: idtmls in1 1.000 honscholds, this survey is designed


to provide estimates of the health status.use of health services, expenditures,sources of payment, and insurance cover-age of the U.S. civilian population for thecalendar year 1987. Each family in thesurvey sample was interviewed five timesduring 1987 and 1988 to obtain detailed.accurate information about each familymember's health and health care utiliza-tion during 1987. To verify and supple-ment the information provided by thehousehold respondents, separate surveyswere performed on the medical care andhealth insurance providers of the house-holds in the sample.4 Special tabulationsof individual NMES data on the utilization,cost, and source of payment for healthcare aggregated by age groups are the basisof the estimates reported in this article.5

Baseline data for explorations oftrends in health care costs over the I0 -yearperiod 1977-1987 are obtained from the1977 Natioa Medical Care ExpenditureSurvey (NMCES). Simi lat in design to the1987 NMES, the 1977 NMCES also supple-mented multiple interviews of individualsin 14.000 households with informationfrom health care providers, employers.and insurance companies to provide acomprehensive statistical picture of howhealth care services were used and paid forby the U.S. noninstitutionalized popula-tion in 1977.6

Both the NMCES and the WES tabu-lations used in this analysis follow theNN10ES procedure of not treating thestays of newborns delivered in hospitals asseparate admissions unless the infant re-mained in the hospital beyond the day onwhich the mother was discharged. 7 Thus,in the NMES data, the costs associated withuncomplicated births (typically those inwhich the infant is discharged at the sametime as the mother) are attributed to themother. and the costs of complicatedbirths ( those where the infant remains inthe hospital after the mother is dis-charged) are attributed to the infant andtabulated in the cost of medical care forchildren less than 2 ...ears old. Because wecould not obtain specific data on expendi-tures for all pregnancies in both theNMCES and NMES, our estimates of thecosts of pregnancy are constructed from avariety of data sources and reported in aseparate section .8

In the analysis that follows, we use the1987 NMES to analyze health care expen-ditures for children by type of service, age

of child, and sources of payment. We alsocompare expenditures on children'shealth care with expenditures on healthcare for adults and examine the source ofgrowth in expenditures on children'shealth between 1977 and 1987. We thenturn to a separate analysis of expendituresfor pregnancy and infant health care.

Personal Health CareExpendituresModified personal health care expendi-tures (MPHCE) as used in this report in-clude expenditures on hospital care,services of physicians, dentists, and otherhealth professionals; prescription drugs;and other personal health care services andproducts (eyeglasses, hearing aids, andother medical equipment). For childrenages 0 to 18 Years, MPHC expenditurestotaled 5-19.8 billion in 1987 (see table 1).(Detailed tabulations of expenditure pat-terns by age, type of service, and source ofpayment are presented in appendix tablesAt A4.) Per capita expenditures (mean ex-penditures per child) were 5737 and variedconsiderably by the age of the child.

As shown in table I. !Or each age group.aggregate expenditures are the product ofthe population of the group, the propor-tion of the population with expenditureson medical care, and the mean expendi-ture for those with expenses. Althoughthere are more than three times as manychildren in the 3- to 12- year -old age groupas in the 0- to 2- year -old age group, aggre-gate expenditures for the 0- to 2- year -oldswere 12% greater. ['his difference primar-ily reflects the fact that mean expendituresamong 0- to 2- year -olds were more thanthree tittles as large as mean expendituresamong 3- to 12-Year-olds. Mean expendi-tures for adolescents (ages 13 to 18) werealmost twice as large as mean expendituresfor 3- to 12-year-olds but about two-thirdsthe level of mean expenditures on 0- to2- year -olds. We explore some of the sourcesof these age-specific differences below.

In the aggregate, children ((to 18 'earsof age constituted 28.2% of the noninsti-tutionalized population in .987 but ac-counted for Only 13.7f2 ( f modifiedpersonal health care expen Inures. Percapita MPFICE for children was only 59%as large as adult per capita expenditures.Per capita expenditures of adults 19 to 64ve:Irs of age were slightly less than those ofyoung children (ages 0 to 21 but substan-tially greater than per capita expenditures

)

28

ofchildren age 3 to 18. Per capita expen-ditures among the elderly (those at least65 years of age) were, at S4.276. almost sixtimes those of children. The elderly, as agroup. consumed a disproportionateshare of health care: although they ac-counted lirr 11.8% of the noninstitution-alized population in 1987, theirexpenditures accounted for 33.2' of theexpenditures on personal health care bythe noninstitutionalized population.lu

Expenditures by Type of Service

For children U to 18 years of age, hospitalservices. both in- and outpatient, ac-counted for the largest share of modifiedpersonal health spendingS24.3 billionin 1987. representing 48.7% of is.11 expert-dinireS I figure l 1. Expenditures on physi-cian services fur children. bothambulator% and inpatient care. amountedto S11 billion in 19$7 while dental careexpenditures totaled 58.2 billion. Lesseramounts 152.4 billions were spent on non-physician ambulatory care (including seryices rendered by home health agencies.optometrists, chiropractors, and podia-1 ists. alining others), 52.1 billion on pre-scription drugs, and S1.3 billion on amiscellany of other personal health serv-ices including eyeglasses, hearing aids.other medical supplies and equipment,and similar items.


MPHCE by Age of Child

The distribution of expenditures amongthe different types of services varied con-siderably according to the age of the child(figure 2). Among children 0 to 2 yearsold. inpatient hospital care accounted fixalmost 60% of all expenditures. and inpa-tient care by physicians accounted fOr an-other 17%. The high concentration ofexpenditures on inpatient services in thisage group represents principally the careof sick newborns. Ambulatory care in play-sicians offices and in hospital clinics andemergency rooms accounts for most of therest of expenditures (18%) in this group.

In contrast. expenditures on ambula-tor care account for a high proportionof MPHCE for those 3 to 12 Years old.Expenditures ftir inpatient hospital care121r; 1 and ph\ sician services 14`; 1 ac-count l'or only 25% of expenditures inthis age group. while ambulatory care.about equally divided between care inphysicians' offices and hospital outpa-tient departments. accounts for almost36% of all expenditures. For this agegroup. dental care at 22% ()I' MPHCE isthe largest single category of expense ofthose detailed in figure 2. Prescriptiondrugs and nonphysician ambulatory careare also important sources of expendi-tures. The relatively small proportion of

Table 1. Modified Personal Health Care Expenditures by Age, NMES 1987

Age Group(years)

Total MPHCE(billions)

Total Population(millions)

Percent ofPopulation with

Expenditures

Per CapitaExpenditures

Expendituresper Individual

withExpenditures

All children (0 to 18) S49.8 68 83 $737 $893

0 to 2 16.8- 11 92 1,524- 1,660-

3 to 12 14.9 35 81 426 525

13 to 18 18.2 22 80 843 1.053

Adults

19 to 64 193.2 144 83 1,347 1,616

65+ 121.0 28 94 4,276 4,566

Modified personal health care expenditures (MPHCE) equal expenditures on hospital care. servicesof physicians.

dentists and other health care professionals, prescription drugs, and other personal health care services and productsncluding eyeglasses. rearing aids, and other medical equipment

Excludes expenditures associated with the initial newborn hospitalization of infantsdischarged at the same time as theirmothers These expenaitures are attributed to the mother in the NMES. When estimates of these expenditures from table 2are included in total MPHCE estimates for the 0- to 2-year-old group, total expenditures for this age group increase to:19.0 billion and per capita expenditures increase to S1.727

Source. Agency for Health Care Policy and Research. 1987 National Medical Expenditure Survey - Child Health Questionnaire

ono Housenold Survey


expenditures fir hospital care in this agegroup is probably responsible for the lowper capita expenditures reported for 3-to 12 -year -olds (table 1).

As per capita costs increase amongthose 13 to 18 Years of age relative to those3 to 12 years old, so does the proportionof expenditures which goes to inpatienthospital care (29%) and inpatient physi-cian care (7`' ). The higher per capitaexpenditures for inpatient. care tor 13- toI8-year-olds is in part attri'outable to preg-nancy-related costs. In 1987, there wereapproximately 320,000 live births to girlsless than 19 Years old." Based on theestimates of the mean cost A pregnancy-related health care services, we estimatethat these births accounted tOr almost51.24 billion in hospital-related obstetri-cal charges and almost 5190 million inexpenditures for inpatient care of healthynewborns.12 Together these expendi-tures amounted to S70 per 13- to 18-Year-old. Although a considerable amount.expenditures on pregnancy account foronly about 30% of the difference between13- to 18-year-olds and 3- to 12 -year -oldsin per capita expenditures for care in thehospital.

A hypothesis which requires furtherinvestigation is that the relatively high in-cidence of trauma associated with acciden-tal injuries and violence in the 13- toI8 -year -old group accounts for much ofthe increase in expenditures on their hos-pitalization. (See the article by Perrin.Guyer, and Lawrence in this journalissue.) In addition, as is true kir 3- to 12-year -olds. 13- to 18-Year-olds incur largeexpenditures tOr dental care. On average,13- to 18- Veal' -olds spend one and a halftimes as much on dental care as they doon ambulatory physician and ambulators:hospital care combined.

Comparison of Children's MPHCEwith Adult Health Care Expenditures

The distribution of MP 11(E by type ofservice for adults ( 19 years and older) isalso presented in figure I. A somewhatlarger proportion of adult than childhealth care expenditures go to hospitalcare (54% versus 49%), while a somewhathigher proportion of children's expenditures go to physicians as compared withadults (22% versus 2(1 %). These small dif-ferences between children and adults inthe proportion of modified personalhealth expenditures that go to physiciansand hospitals are almost entirely a result of

99

Figure 1. Health Care Expenditures by Type ofService and Age, NMES 1987

tOstadOISOIN.es4,71.

:Z4 Otte.

atescreThan Dwas

32 WWI

:)tner _metes

:I betee$50 billion'

Children (0-18 years of age)

Alytat Se,n5

ta40.

thescr,tan CNVOSti

jzo pipe Dental Sennces

$21 tAon

tetnorn-acton Arncetorort tenetael

Ste.

nnvettan Jen, es5

SerewteS

LN711.X1

$314 billion'Adults (19 years and over)

'Items in figures may not sum to totals for each age group because ofrounding.

Source: Agency for Health Care Policy and Research, 1987 NationalMedical Expenditure Survey - Household Survey

Figure 2. Distribution of Health Care Expendituresfor Children of Different Ages by Type of Service,NMES 1987

0 0 7 4,ln 1:11 3 ,3r5 13 l brS

Source. Agency for Health Care Policy and Research. 1987 NationalMedical Expenditure Survey - Household Survey

100

the increase in inpatient hospital care bythose 65 Years of age and over. The sharesof health expenditures going to physicians(22%) and hospitals (50%1 among adults19 to (54 years (not shown) are almostidentical to the relative shares of expendi-tures on these types of services in thehealth care expenditures of children. Per-haps the most striking difference in thehealth care expenditure patterns of adultsas compared to those of children is themuch larger share of dental care expendi-tures in the health care budget of children.The most extreme difference existsbetween children ages 6 to 18, for whomdental care represents almost 3(Y of- ex-penditures. and those 65 years of age andolder (not shown), for whom dental carerepresents less than 3%. of expenditures.

Sources of Payment forChildren's Health CareIn 1987. approximately two thirds of totalmodified personal health care expendi-tures for children were paid for by third-party payers, private health insurance andgovernment programs ( figure 31. Directpatient payments ( typically by adult familymembers fOr children ) including insur-ance co-payments and deductibles. as wellas out-of-pocket payments fOr uninsuredservices. financed 27% of expenditures onchildren's health care. Other privatesources, including philanthropy and serv-ices provided free horn provider (uncom-pensatd care I. accounted For theremaining 6%.

Hospital CareThe share of health care expendituresfunded by third parties ailed consider-ably by type of service. For hospital care.which accounted for almost 49e; (524.3billion ) of expenditures fOr children,third-party payments accounted fOr 81%of all expenditures in 1987 (table A I ).Out-of-pocket expenditures financedabout 11%. of hospital care lor this group.As compared with inpatient care, a some-what higher percent of outpatient hospitalcare was paid for out-of-pocket (15% ver-sus 10% ). The proportionion of hospital carepaid for by government programs (about33%1 differed little by type of service.

Physician Services

On a per capita basis. out-of-pocket expen-ditures for physician services totaled alunit553 ( table AI). Altogether, more than32% of the SI 1 billinn expended on phy-


sician services for children 0 to 18 Years oldwas paid for direct'v out-of-pocket. Thiswas three times the proportion of hospitalservices paid for out-of-pocket. Moreover.the proportion of physician charges paiddirectly by families for their children var-ied considerably with the kind of service:almost 43% of charges for ambulatory phy-sician services were paid out-of-pocket ascompared with 19%. of charges fOr hipa-tient care.

Private insurance paid for approxi-mately 41%. of physician services regard-less of where the service was delivered, butthere was considerable difference in theproportion of these services financed bypublic programs. Public programs paid for37% of inpatient physician expenditures:9% of these expenditures were financedby Medicaid and 28% by other public pro-grams( including state and local programsand hospitals which provide services di-rectly and the Civilian Health and MedicalProgram of the Uniformed Services((:I1ANIPUSthe health insurance pro-gram for dependents of military person-nel). In contrast, public programs paid foronly 15% of expenditures fOr ambulatoryphysician visits: 1 1 % was !midi)). Medicaid.and more than 3% was paid by other pub-lic. programs.

Nonphysician Ambulatory CareFamilies spent 5788 million out-of-pocketfor nonphYsiian ambulatory care (homehealth care, optometric care. and the like)for children in 1987. This amount repre-sentd almost of all expenditures onthese services. Out-of-pocket pa% men ts fi-nanced a smaller proportion of nonphysi-clan ambulatory services (33%) ascompared with ambulatory physician serv-ices (43%) because a larger proportion of

on nonphYsiian serviceswere paid for by Medicaid and other gov-ernment programs (16% and 10 %, respec-tivel, of expenditures on nonphysicianservices sersus 11% and 3" of expendi-tures on ambulatory physician services).

Prescription Drugs and Dental Care

Out-of-pocket payments accounted formore than 50% of all expenditures onprescription) drugs and dental care forchildren in 1987. However. there wereconsiderable differences in the distribu-tion of sources of payment for these serv-ices among the other pavers. Privatehealth insurance paid more than 3,7,7, ofexpenditures on dental care but only 28of expenditures On prescription medica-


tions. Public programs paid more than14% of prescription dl ag Costs but lessthan 5% of dental expenditures. On a percapita basis, annual expenditures on den-tal care fOr children are large. 5129 or17.5% of all modified personal health careexpenditures. Because almost 53% of den-tal care expenditures are paid out-of-pocket. out-of-pocket expenditures ondental care ($68 per child per Year) are thelargest service-specific component of di-rect family expenditures on health for chil-dren, accounting for more than one thirdof all out-of:pocket expenditures for chil-dren's health care. Out-of-pocket expendi-tures on dental care were 28% larger thanout-of-pocket expenditures for physiciancare and 71% greater than out-of-pocketexpenditures on hospital care.

Variation in Source of PaymentAmong Children of Different Ages

1-here is considerable variation in the dis-tribution of sources of payment 101 chil-dren's health care according to the age ofthe child (figure 4 and tables A2 A4). Theproportion of health care expendituresfinanced out-of-pocket is twice as large forchildren 13 to 18 years old (3-1`) as it isIt tr 0- to 2-Year-olds (17; ). Conversels,\ledicaid ait(1 other public programs paidfor 42e; of health care costs in the 0- to2-vear-old age group, but tOr only 1'; ofthe expenses of those 13 to 18 sears old.The distribution of expenditures fit 3- to12-year-old children an long the variouspasers generalls falls between the distribu-tions for older and younger groups withthe exception that Nledicaid accounts fora slightly higher proportion of expendi-tues in this group than it does in the 0- to2-vrar-old age group.

Variation in the sources of payment fOrhealth care in age reflect ( 1 I variation inthe sources of payment fi)r differenthealth care services and (2) age-specificditlerences in the utilization of differenthealth care services. For example. for allchildren 0 to 18 Years old, gosernmentprograms pas tOr more than 33"; of ex-penditures on hospital care. but less than5'; of expenditures on dental care. Expen-ditures for hospital cart- account tOr al-most 68e; of all expenditures fOr 0- to2- Year -olds but only :19c; of expendituresfor 13- to 18-Year-olds. while dental careaccounts for 30r; of expenditures for 13-to 18-vear-olds but is not a factor in expen-ditures for 0- to 2-sear-olds. Thus. govern-ment programs pay for a larger proportion

Figure 3. Expenditures on Health Care forChildren and Adults by Source of Payment,NMES 1987

crs.rote Insurance43%

siechcord12`11,

Over Sources

Frrsate Sources{Inclucinq Free awn ProsscerI

3%

)s-Pocxer Par,rer,,s27%

Children (0-18 years of age)

N.ledcosi8%

..orPncrrelPos,e^.s.

Adults (19 years and over)

'Out-of-pocket payments include copayments and deductiblesfor services partially covered by insurance as well as other directexpenditures.

Source: Agency for Health Care Policy and Research. 1987 NationalMedical Expenditure Survey Household Survey

Figure 4. Distribution of Payment for Children'sHealth Care by Age, NMES 1987

.15

r:J

- 35 -"."

30-

25-'3

1 20-15 _

10 -

5-

:',.:ru,CeS at Govment

0-2 ,.vs 3 ,2 cc1rs 13 18 Year;

Source: Agee cy for Health Care Policy and Research. 1987 NationalMedical Expenditure Survey Household Survey

102

of the total health care expenditures for0- to 2-year-olds than for 13- to 18-year-olds. Similarly, government programs thattarget particular age groups, such as the1989 expansion of Medicaid eligibility firchildren under 6 years old (see the Hillarticle in this journal issue) will affecthealth care providers differently depend-ing on the utilization of different healthcare services by children of different ages.

Differences in Sources of PaymentBetween Children and AdultsThe distribution of sources of payment forhealth care services for adults (19 yearsand older) differs from the distribution Ofsources of pm went for children in severalwas (figure 3). .Npproximately 37% ofadult modified personal health care ex-penditures are paid for 1w governmentprograms including the 21'7 of txpndi-tures financed bs Medicare.; $ The balanceof public expenditures is divided almostequally between Medicaid and other pub-lic programs. Including Medicare. publicprograms paid fbr 62'; 01 expendituresfor those (i5 and over (not shown). Forthose 19 to 64 years old. the 22% share ofMPHCE paid for by public programs isshared approximately equally by Medicaidand other public programs with almost 4'of funding coining from Medicare. While

Five percent of the populationof children (0 to 18 years old)accounted for more than 59%of all MPHCE in 1987.

the proportion of MPHCE fO 19- to 64-vear-olds financed through public pro-grams was quite similar to the proportionof children's health care financed pub-licly. the S42 billion public expenditure onadults 19 to 64 vears old was almost 3.5times the site of aggregate public expendi-tues on children in 1987. In the aggre-gate. expenditures on modified personalhealth care for adults are more than fivetimes as great as expenditures on children.Because the share of adult health carefinanced by public programs is muchgreater than the share of children's healthcare financed by public programs. publicexpenditures on adult health care (S116.7billion) were almost 10 times as great asthe public expenditures on children'shealth care (S12.2 billion I.


Within the population aged 0 to 18'ears, the proportion of health care expen-ditures financed by public programs tendsto fall and the proportion financed pri-vately, both out-of-pocket and through pri-vate insurance, tends to rise withadvancing age (figure 4). This tendency isreversed after early adulthood with theresult that the proportion of health careexpenditures paid directly out-of-pocket ishighest for school-age children, teenagers.and young adults (not shown). It is notunreasonable to speculate that policies de-signed to increase access by expandinghealth insurance coverage could substan-tially increase the utilization and cost ofhealth care in these age groups.

Burden of Children'sHealth Care ExpendituresAnalysis of the distribution of medical careexpendin a es among the various sources ofpayment for services can conceal the mag-!thud': of the financial burden some Luni-lies face in trying to pay for their children'smedical care. Each year a small proportionof the population accounts few the majorityof health care costs. Five percent of thepopulation of children (0 to 18 years old)accounted for more than 59% of allMPI ICE in 1987. One percent of the childpopulation accounts fen' 37'7 of MPHCE.These statistics also suggest that little isspent on health care few the majority of thepopulation of children. l'hese pats -..ens ofhealth care expenditures being concen-trated among a small percent of the popu-lation hold also among the elderly in theUnited States and in other countries.1.1.1Given per capita MPHCE of S737 for chil-dren in 1987. these ratios imply that percapita expenditures few the most costly 1%of the child population averaged S27,502in 1982. MPH(I as eraged S8,641 fir themost costly 5% of the population and only5316 for the least costly 95'7 . (For a discus-sion of the uneven distribution of morbid-ity among the child population from adifferent perspective. see the articles 1wStarfild and by Perrin. Guyer. andLawrence in this journal issue.)

The concentration of health care out-lays can have an enormous financial im-pact on a family. even on those with fairlytypical health insurance haying variouscost-sharing features. For example, amongchildren who were hospitalized in 1987.Inn-of-pocket e xpenditues for inpatientphysician services averaged $349. In addi-

I


Lion. mean out-of:pocket expenditures forinpatient hospital care were 5502 fbr chil-dren who incurred hospital expenses in1987. Oyerall. for children hospitalized in1987. out-of-pocket expenditures for hos-pital and physician care while in the hos-pital exceeded S85() on average comparedwith a mean expenditure of only 539 whenout-of-pocket expenditures on inpatientcare averaged over all children. Li

The concentration of medical oudaysalso provides an incentive fbr private in-surance companies and employers to iden-tify children likely to be heavy users ofmedical care. If they can identify poten-tially expensive patients or medical condi-tions in advance, payers may he able toreduce their exposure to the financial riskof paving for health care for these expert-,ive patients. I n See the article by Sheils and\Voile in this journal issue.)

Growth in Expenditures

Rapidly rising health care costs have pre-cipitated a health care financing crisis fbrthe nation. In this section, we comparebaseline data from the 1977 NNICES withexpenditure data from the 1987 N \IES toexplore changes in medical care spendingfin. children and adults between 1977 and1987. During this l0 -year period. aggre-gate modified personal health care expen-ditures for children (unadjusted forinflation, increased by 23-1 %, from 514.9billion in 1977 to 549.8 billion in 1987. Per

capita expenditures on children increasedby a slightly more rapid 240%, from 5217in 1977 to 5737 in 1987. The rate of in-crease in aggregate expenditures wasslightly less than the rate of increase in percapita expenditures because the popula-tion of children declined by 1.2 million(1.7%) over the decade.

In contrast, per capita expendituresfOr adults ages 19 to 64 increased by only158% during the same period. but thepopulation aged 19 to 64 Years grew by22.5 million or 18.5%. Accordingly, aggre-gate expenditures on the noninstitution-alized population 19 to 64 Years old grewby 207% front 1977 to 1987.

Aggregate NIPHCE of the noninstitu-tionalized population 65 years of age andolder grew even more rapidly. be 383(';.Iron S25 billion in 1977 no 5121 billion in1987. The high rate of growth in this agegroup resulted from the combination ofrapid growth (281c.; ) in per capita expen-ditures, from S1,124 in 1977 to 54,277 in1987, and an increase in population of 6million, or 27%.

Overall. per capit, expenditures onchildren increased 20% more rapidlythan per capita expenditures on adults:however. hecause the number of chil-dren declined slightly while the numberof adults increased by 28.5 million. chil-dren's N1PIICE declined to 13.7r; ()I

total expenditures in 1987 front 14.5e;in 1977.

Figure 5. Factors Accounting for Growth in Per CapitaExpenditures for Health Care for Children, 1977 to 1987

737

.Source Agency for Health Core Policy and Research. 1977 National Medical Care ExpenditureSurvey Hcusenold Survey: Agency for Health Core Policy and Research. 1987 NationalMedico: Expenditure Survey - Household Survey.

104

Sources of Growth in Children'sHealth Care Expenditures

It is useful to examine separately factorsthat contribute to growth in health carecosts. Although such analyses may not ex-plain why costs increase, they can help inassessing the relative contributions of thevarious factors which fuel growth. A fre-quently performed analysis allocates thechange in health care expenditures amongfour factors: general price inflation. indus-try-specific price inflation, populationgrowth. and all other factors.16

The results of decomposing the growthin per capita MPHCE for children between1977 and 11)87 arc presented in figure 5.General and medical price inflation havebeen tirund to account for a substantialpart of the growth in personal health careexpenditures for the general population.1They appear to account for almost half ofthe overall increase in per capita expendi-tures for children between 1977 and 9X7.In addition, an increase of almost 4 per-centage points m the proportion of chil-dren in the 0- to 2-Year-old age groupt hegroup %vita the highest per capita expen-dituresresulted in a 37( increase in percapita expenditures fro- children 0 to I8years old.

Once price and population changesare explicitly represented. the "all otherfactors" in this analysis is a measure of theincrease in the average Intensity" ofhealth care sry ices delivered on a perchild basis (more health services perchild). This residual term. which also in-cludes measurement error, accounted for48% of the increase in MPHCE for chil-dren during the 1977-1987 period.

Further analyses indicate that in-creased expenditures on both inpatientand outpatient hospital services ac-counted for more titan 75(7 of the in-crease in the resource intensity ofchildren's MPI ICE. Per capita expendi-tures On hospital care for children in-creased by 379'; between 1977 and 1987.While per capita expenditures on allother personal health care services forchile increased by 167'7 . !hospital ex-penditures increased most rapidly Cmthose 0 to 2 ears old, by more than 650f;between 1977 and 1987, As a result ofthis rapid growth, the proportion of hos-pital expenditures accounted for by thisage group grew to 47"'i- of all expendi-tures on hospital care for children in1987 from 29'; in 1977. Overall, close to


40% of the increase in intensity of allmedical care frw children of all ages overthe period was the result of an increasein the intensity of hospital care for chil-dren in the 0- to 2-year-old age group.

It is tempting to speculate that in-creased expenditures for this age groupreflected the rapid rate of technologicaladvance in the care of high-risk. very lowbirth weight babies in neonatal intensivecare units anti the proliferation of theseunits throughout the hospital system.(See the Racine. Joyce. and Grossmanarticle in this journal issue.) The in-crease in the level of real medical careservices received by these infants andvoting children may also reflect the in-creased health care needs of high-riskinfants who survive the neonatal period..kt this point in time. however. we do nothave access to N NIES data at a level ofdetail which would allow investigation ulthis conjecture.

Expenditures forPregnancy and InfantMedical Care

Medical care during pregnancy, child-birth, and infancy (the first year of life)not only has a significant impact on thehealth and survival of Young children.bin also is a major source of health careexpenditures. However. despite severalsurveys that examine pregnancy andchildbirth specifical107 anti others thatdetail health care expenditures gener-ally. an overall expenditures data setfrom which a comprehensive estimate ofthe costs of pregnancy and infant carecan he calculated is not ay ailable. Ac-cordingly, we follow the lead of severalprevious investigators in drawing ondata from a satiety elf SOUICCScomic'large national surveys. some smaller spe-cialized studieso) obtain estimates ofboth the volume of services provided topregnant woolen and infants in 1987 andthe prices of these various services. Allprices and quantities presented are for1987 unless otherwise stated. The esti-mates are detailed in tables 2 amid 3. Thesources, methods, and assumptions tin-deriving these estimates are pi esentedeither in the text or in notes to the tablesto enable the reader to assess the qualityof the estimates and place them withinthe context of the other anabss pre-sented in this article.


Table 2. Estimated Expenditures on Health Care for Infants, 1987

Type of Expenditure Number of Infants(thousands)

Average Cost Total Cost (millions)

Normal newborn carea

Hospitals

Physicians*

Other infant care (including NICUand rehospitalizations)b

3,007

3,007

S609

134

$1,831

401

Hospitalizations

Hospitals 939 7,107 6,671

Physicians 740 3,421 2,531

Ambulatory care

Hospital clinics and ERs 747 544 407

Physicians 3.068 179 551

Nonphysician ambulatory care 683 162 111

Drugs, denial. other- 3,865 36 138

Total expenditures on infant care 3,865 S3,271 S12,641

Includes a pediatrician's visit for all infants and circumcision charge for 50% of all infants.

Total population in less than 1-year-old age group and per capita charges for indicated services.

Sources()Minor. A.F. the cost of maternity care and childbirth in the United States. 1989. Health Insurance Association of America,

research bulletin. HIAA. December 1989.bAgency for Health Care Policy and Research. 1987 National Medical Expenditure Survey Child Health Questionnaire andHousehold Survey.

Medical Care for Infants

ENtimaitli health are expenditures fori hildren in their first Year of life totaledS12.6 billion, or 53.271 per infant in 1987(table 2)..kpproximate1v 18% of the totalwas spent on care in the hospital for nor-mat newborns. Another 72%. was spent forthe initial hospitalization and inpatientphysician care of newborns suffering somecomplication of birds and for the care ofinfants requiring rehospitalization during(heir first Year of life. Only 10(,: of thetotal. or S3I2 per child. was spent onhealth care not requiring hospitalization.including well-child and preventive care.

Approximately 81n to 8:5(.'; of new-horns are discharged from the hosritalwith their mothers after a routine nurserystay and normal well-infant care.111Because information on (Ise cost of Carefor these -normal" infants was not tabu-lated separately in the 1987 NNIES dataused elsehele in this report. we use esti-mates of the mean cost of care for theseinfants developed by the Health Insurance

Association of America.20.'2.1 In 1987. themean hospital charge for these infants was5609. and well-infant pediatric care costSi 3.1 on average.

Information on expenditures for in-fants horn with some complication whichresulted in their being discharged at a timeother than that at which their motherswere discharged is available in the 1987\NIES. Information on expenditures forall infants after their initial hospitalizationis also available in the 1987 NMES.although for this analysis it is not possibleto distinguish between expenditures onthe initial hospitalizations for infants withcomplications and expenditures on rehos-pitalizations. Details of' these costs are pre-sented in table 2 as are estimates of totalcosts which are the suns of total expendi-ture estimates Iron. NN1ES and the extra-neous estimates of expenditures onnormal newborns.

When estimated expenditures on nor-mal infant careS2.2 billion from table2are added to the estimate of total

1 e,

106 THE FUTURE OF CHILDREN - WINTER 1992

Table 3. Estimated Expenditures on Obstetrical Care, 1987

Type of Expenditure Nvimber(thousands)

AverageCost

Total Costs(millions)

LIVE BIRTHS

Hospital charges

Normal delivery 2,821 S1.766 S4.982

Cesarean delivery 953 3.460 3297

Professional charges

Normal delivery 2,723 1,313 3.575

Cesarean delivery 953 1,806 1.721

Midwife 98 874 86

Out of hospital delivery _.mcges 19 1,840 35

(Including practitioners' fees)

Prenatal Tests°

Electronic fetal monitoring 2,842 57 162

Amniocentesis 198 148 29

Ultrasound 3,001 287 861

ALL LIVE BIRTHS 3,809b 3,872 14,748

MISCARRIAGES AND STILLBIRTHSc 802 527 424

ALL OBSTETRICAL CARE 4,611 53.290 SI5,172

0 Estimates of the frequency of performance electronic monitoring and ultrasound ore based on data reported inMoore. Jr.. M.. Jeng. Kaczmarek. R.G., and Placek P J. Use of diagnostic imaging procedures and fetal monitoringdevices in the care of pregnant women. Public Health Reports (September-October 1990) 105.5:471-75. Estimates of thefreauency of amniocentesis are from preliminary tabulations of the 1987-1988 National Maternal ana Infant HealthSurvey providea by Stella Yu. ScD of the National Center for Health Statistics.

Estimates or the costs of electronic fetal monitonng and amniocentesis are from A.F. Minor. Estimates of the costs of...trasound are based on acta reported in Hillman. 8.1. Joseph. C.A.. Mabry, MR.. et al. Frequency and costsofIliagncstic imaging in office practice: A comparison or self - referring and radiologist-referring physicians. New Englandournai or Meactne (December 1990) 32323:1604-1608. The cost per pregnancy reported in the table is the weighted

averaae of charges per pregnancy for patients tested by either self-referring obstetricians and family practitioners oracitoiogists in 1986 to 1988 where the weights are the share or proceaures pertormea by each specialty.

o !ncivaes 16.000 births where place of birth is unknown. National Center for Health Statistics. Advance Report of FinalNatality Siatistics (June 29. 1989) 38,3:24.

c See text and note 23 for discussion of procedures followed and data used to estimate cost of miscarriages andstillbirths

Sources: Minor, A.F. The cost of maternity care and childbirth in the United States, 1989. Health InsuranceAssociation of America, research bulletin. HIAA, December 1989, except as noted.

N1PHCE fOr all children and for those 0 to2 Years old (table I1, total MPFICE forchildren is increased to 552.0 billion and\IPHCE kw those to 2 tears old is in-creased to S19.0 billion. Despite the factthat infants accounted for less than fig; ofthe population of children, expenditureson health care for infants accounted foralmost 25% of aggregate health care ex-penditures on all children U to ;8 years old

in On a per capita ba.sis. health careexpenditures on infants (less than 1 tear()Id) were greater than those of any otherage group except those 65 years of age ass('older,

Obstetrical CareUsing data from several sources (table 31.we estimate that total charges fdr obstetri-cal care in 1987 sv-..re S13.2 billion or

199


S3,983 per live birth. Obstetrical care in-cludes prenatal. delivery, and postnatalcare for pregnant women including thosewhose pregnancies terminate spontane-ousl in a miscarriage or stillbirth but notcontraception, abortion, or infertility serv-ices. Hospital charges f6 delivery accountfur 54% of expenditures on obstetricalcare: professional fees (including those ofmidwives), about 35(.10 of costs, and thebalance is largely expenditures for sepa-rately billed tests and diagnostic services.

Almost 99% of births in 1987 occurredin hospitals with a small number occurringin free-standing birthing centers. Meanhospital charge's were S1.7(i6 for a normaldelivery. Total charges includingpractitioners' fees at free-standing birth-ing centers for a normal delivery with a1-dav stay were about 33% less than hospi-tal charges for the same service, but only19,047 births occurred in such centers in1987. Hospital charges averaged S3,460for a cesarean delivery. The number ofcesarean deliveries has increased steadilyin the United States since 1980, and theyaccounted for more than 25% ofdeliveriesin 1987.20A cesarean delivery adds abouttwo thirds to the cost of obstetrical carebecause of longer hospital stays fin- bothmother .caid baby. nit reased physicians'fees, and higher hospital charges for laborand delivery rooms. anesthesia, and vari-ous ancillary services, including laboratoryand supplies.21

Roth the hospital and the physician'scharges used in the estimates are based ondata collected by the 1 HAA.22 The meancharge for a (.4)1111110c package of obstet-rical care including prenatal visits, the phy-sician's services at a normal delim, andone postpartum visit was SI ,313. A com-plte package of care front a midwife costsS874 on as eragel6r a normal delivery. andphysicians. fees for complete care includ-ing a cesarean delivery are about (me-thirdhigher than the charge 16r cc mtplete carewith it normal delivery.

A variety Of relatiyh new but nonethe-less frequently prfiirmed diagnostic pro-cedures add to the cost of pregnancy.These tests include amniocentesis to de-tect chromosomal abnormalities, elec-tronic monitoring of the fetal heart rate(luring labor, ultrasound imaging to moni-tor the developing fetus, and fetal oxytocinstress testing to e Altaic fetal response touterine contractions. As reported in table3. information on the costs and frequency

of performance of a number of these ex-pensive diagnostic procedures is availablefrom several sources. We have not, how-ever, been able to obtain an estimate ofthe frequency of perf6rmance of oxytocinstress tests which we estimate to have costS71 each in 1987.2" Accordingly, we havenot included the cost of that test in ourestimates.

Expenditures on Miscarriages and Stillbirths

Data from the National Survey of Famil(:rowth17 indicate that approximately17.3% of pregnancies terminate spontane-ously in stillbirths and miscarriages whichcan sometimes be as costly as live births.Applying this proportion to the 3,809,391live births fin' 1987 suggests that there were802,000 miscarriages and stillbirths in thatyear. Following Fuchs and Perreault.18 weassume that stillbirths occurring after 28weeks of pregnancy are as costly on aver-age as live births, that stillbirths occurringbetween 20 and 28 weeks cost 75% asmuch as live births, and that miscarriagesprior to 21) weeks result in a physiciancharge equal to one-third the fee ha- anormal delivery. Our estimate of the rela-tive proportion of miscarriages and still-births which occurred at different stages ofpregnancy are reflected in the average costestimate reported in table 3. Accordinglv,the total cost of spontaneous pregnancytermination in 1987 is estimated to havebeen $527 million.23

Comparison with Previous Estimatesof Expenditures on Obstetrical Care

Our estimate of total obstetrical care ex-penditures$15.2 billion in 1987is ap-proximately 85% higher than the estimateof $8.2 billion reported by Fuchs and Pet--math for 1982.18.2.) The increase in thenumber of live births (128,000) can ac-count lbr only 49i or the increase in totalcosts cm er the ii-veitr period. In addition,the increase in the frequency of cesareandeliveries to 25% (Alive births in 1987 fromalmost 18% in 1982 appears to have in-creased to ital obstetrical costs by mote thanone-half billion dollars or 3.% in 1987.

it appears, thercfme. that the differ-ences in average cost figures we used for1987 as compared to the Fuchs and Per-rault estimates for 1982 account for mostof the difference in the estimates of totalobstetrical costs. One reason fin' it dine'(ice in the average cost figures tray be itchange in the procedure the 1 Icalth Insur-ance Association of America (I IIAA) fol-lowed in estimating mean hospital costs

i

107

108

from responses to its survey of the cost ofhospital care for Maternity and new-borns.25 We estimate. however, that thischange in reporting only increased re-ported hospital costs by 2% for normaldeliveries and 3% for cesarean deliveriesover what would have been reported un-der the previous methodology.

Compared to other age groups, children's healthcare will in the aggregate be more affordable.Therefore, efforts to expand access to health carefor children by expanding third-party financingwill be less likely to overwhelm the system thanwill similar efforts targeted to other groups.

Another reason for the substantial in-crease in the cost of obstetric servicesbetween 1982 and 1987 is the increase inphysician fees. Physician fees in generalincreased rapidly between 1982 and1987by over -10% as measured by thephysician component of the ConsumerPrice Index.26 increases in the cost ofmedical malpractice insuram appear tohave been a factor in the general increasein physician fees between 1982 and 1987and an important factor in the escalationin obstetrical fees. In 1987, mean malprac-tice insurance premiums for obstetricianswere over $37,000, an increase of 238%over Ii o 5 -year period .20

The substantial increase in malpracticeinsurance costs does not appear, by itself,to account for the near doubling of physi-cian lees for obstetrical services. Even un-der the extreme assumptions that thepmnit nn cost increase was incurred by allpracticing obstetrician- gynecologists andthat these specialists accounted for all ob-stetrial care. the increased cost of mal-practice insurance of slightly under $170per pregnancy would account for less than

quarter increase ill physician let'sover the 5-year period.7

Summary andConclusionsOur estimates show that expenditures onmodified personal health care for chil-du en amounted to $19.8 billion in 1987,only 13.7% of expenditures on personalhealth care for the entire noninstitution-


allied population in that year. Moreover,the data show that, although per capitaexpenditures on health care fO childrenincreased 20ci more rapidly than per cap-ita expenditures for adults, the share ofMI'l ICE that went to children declined byalmost one percentage point between1977 and 1987 because of a fairly substan-tial increase in the adult population and aslight decline in the number of children.The proportion of health care expndi-tures going to children's health care islikely to continue to decline as the dynam-ics of demographic change cause chil-dren's share of total population to declinefrom 26% in 1989 to a projected 22% in2010, while the share of the populationaccounted fin- by those at least 65 years old(the group with the highest per capitaMPI10E) is projected to increase flow12.5% to 13.9% over the saute period."" -6For those concerned about the problemsof financing health care f(w children, thedecline in the relative share of expendi-tures accounted fOr by children n,,-ansthat, compared to other age groups.dren's health care will in the aggregate hemore affOrdable. ThrefOre, efforts to ex-pand access to health care for children byexpanding third -party financing will heless likely to overwhelm the system thanwill similar efforts targeted to othergroups.

Knowledge that expenditures onhealth care for children are relativeh mod-est average should not engender a falsesense olcomplacencv regarding the finan-cial burden children's health care pre-sents for some families. The data indicatethat a small number of families face veryhigh levels of expenditure fix health carefor their children each year. It is likely, betnot documented in the data anal ledhere . that for many, high levels of expn-diture are the result of chronic conditionswhich may persist over many years cleatinga severe financial burden on families. (Seethe article by Perrin. (.4.( and 1.,in this journal issue.)

The very skewed nature of the distribu-tion of children's health care expendi-tures means that efforts to expand healthinsurance coverage for children by offer-ing limited coverage for low intensity, ant-bulatot y rare fill. prevention and limitedacute illness will, In itself, leave most fami-lies exposed to the catastrophic costs ofserious illness. Moreover. the high concen-tration of expenditures creates incentiesfor traditional insurance companies and

111


employers who self-insure to identify chil-dren who are likely to be heavy users ofcare in order to invoke procedures whichmay reduce the insurer's responsibility fortheir high health care expenditures.Although special government programsexist to underwrite the extraordinarymedical care expenditures of some chil-dren with major illnesses, coverage is farfrom comprehensive and costs may mountrapidly for a family with a moderately illchild who is not enrolled in these specialprograms.28 Effective reform of healthcare financing will require that true healthinsurance benefits be available for chil-dren when needed to help underwrite thecosts of infrequent but expensive illnesses.

For those concerned with cost contain-ment, special attention needs to he paidto the costs of pregnancy and newborncare. In 1987, expenditures on infants(less than 1 'ear old) accounted for morethan 24% of children's MPHCE despitethe fact that infants make up less than 6ciof the population of children. Equally so-bering is our estimate that obstetrical care,a crucial factor in the health of infants andyoung children, cost an additional $15.2billion in 1987. Altogether, expenditureson pregnant women and infants con-sumed more than 40% of combined ex-penditures on obstetrical and child healthcare for the noninstitutionalized popula-tion in 1987. Moreover, expenditures inthis area have grown extremely rapidly inrecent years.

A comparison of our 1987 estimateswith estimates for 1982 suggests that thecosts of obstetrical care increased by 88%and of infant care by 95% over the 5-yearperiod as the result of a combination offactors including a very substantial in-crease in physician charges for obstetricalservices and a substantial increase in theresource intensity of hospital care for new-borns with complications.29 Additional re-search is needed to better understand thefactors behind the dynamic increase in

expenditures on both obstetric and infantcare. Even before these inquiries are ,..;m-pleted, however, aggressive implementa-tion of known cost-effective strategies todeliver care to pregnant women and in-fants appears warranted.

Because of its budgetary implications,any expansion of health insurance cover-age for children in the near term may beincremental. Our analysis suggests that ex-panded coverage for children 3 to 12 yearsold, whose per capita MPHCE ($426) isthe lowest among all population groups,would probably have the smallest budget-ary impact of any expansion in access tocare. Even if a universal health insurancesystem had been made mandatory in 1987,health care expenditures would have ex-panded only modestly for the 8 millionchildren 3 to 12 Years of age who wereuninsured at some time during that year.We estimate that health care expendituresfor this age group would have totaled only$16.4 billion, or $1.1 billion more thanactual expenditures.30 Consequently, ex-panded insurance coverage for this agegroup has the potential to improve theiraccess to health care with minimal bud-getary impact. At the same time, it wouldrelieve the families of such children fromthe uncertain financial burden and stressassociated with expenditures for chil-dren's health care.

We wish to thank Victor Fuchs, MichaelGrossman, Daniel Walden, Doris Lefkowitz,Richard Behrman, Deanna Gomb, CarolLarson, and Patricia Shiono for their helpfulcomments during various stages aphis anall-sis. Comments received during a seminar atStanford University School of Medicine arealso gratefully acknowledged. Unpublisheddata necessary to estimate the costs ofpregnancy and childbirth were provided byA.F. Minor of HIAA and S. l'u of NCHS.Don Hoban and Mikyung Park providedskillful statistical support. Holly Ernst helpedwith manuscript preparation. The usualcaveats apply.

Appendix Tables begin on page 110.

109

110 Appencix Tables

Table Al. Modified Persona! Health Care Expenditures for 0- to 18-year-olds: Aggregate and Per CapitaExpenditures and Percent Distribution, by Type of Expenditure and Source of Funds for Calendar Year 1987.(Total population 67.7 m8Kon 0- to 18-year-olds.)

Mate Government

AN PrivateFunds

Out-of-Pocket

Private Other AN PublicInsurance Funds

Medicaid Other

Type or Expenditure Total EAwditures percent **mutton(8l S)

Total S49.8 75.5 26.9 42.6 5.9 24.5 12.3 42.2Hospital 24.3 66.7 10.9 47.7 8.1 33.3 16.2 17.1

Inpatient 18.4 67.3 9.5 49.3 8.5 32.7 16.1 16.6

Ambulatory 5.9 64.8 15.3 43.0 6.6 35.2 16.5 18.7

Physicians 11.0 75.7 32.3 40.6 2.1 24.3 10.2 14.1

Inpatient 4.7 62.6 18.7 40.5 3.4 37.4 9.0 28.4Ambulatory 6.2 85.5 42.7 40.7 2.1 14.5 11.1 3.3

Nonphysiclan Ambulatory 2.4 74.7 32.7 37.5 4.6 25.3 15.7 9.5

Prescription Drugs 2.1 85.7 57.5 27.5 0.7 14.3 11.3 3.0

Dental Services 8.7 95.4 52.9 36.5 6.0 4.6 3.5 1.1

COM( 1.3 88.9 45.3 39.2 4.4 11.1 10.1 1.0

Told Per Capita per capita expenditures (1987 S)Expenditure s

Total $737 5557 $199 $314 $44 $181 $90 $90

Hospital 359 240 39 171 29 120 58 61

Inpatient 272 183 26 134 23 89 44 45

Ambulatory 87 56 13 37 6 31 14 16

Physicians 163 123 53 66 4 40 17 23

Ir.patient 70 44 13 28 2 26 6 20

Ambulatory 92 79 39 38 2 13 10 3

Nonahysician Ambulatory 36 27 12 13 2 9 6 3

Prescription plugs 32 27 18 9 0 5 4 1

j Dental Services 129 123 68 47 8 6 4 1

OINK 19 17 9 8 1 2 2 0

Note: Items In tables may not sum to totals because of rounding.

Source: Agency for Health Care Policy and Research, 1987 National Medical Expenditure Survey - Household Survey.

1 Table A2. Modified Personal Health Care Expenditures for 0- to 2-year-olds: Aggregate and Per Capitai

Expenditures and Percent Distribution, by Type of Expenditure and Source of Funds for Calendar Year 1987.(total population 11.0 million 0- to 2-year-olds.)

Source of Funds

Private Government

All Private Out-or- Private Other All Pubilc Medicaid OtherFunds Pocket Insurance Funds

Type of Expenditure Total Exwidltures$)(84

percent clishilsolion

Total $16.8 58.4 16.8 36.5 5.1 41.6 13.7 27.9

, Hospital 11.4 56.3 10.1 39.5 6.8 43.7 15.3 28.4

Inpatient 10.0 57.4 9.4 41.2 6.8 42.6 14 8 27.8

Ambulatory 1.4 48.6 14.7 27.1 6.8 51.4 19.1 32.3

Physicians 4.5 61.7 30.3 30.0 1.4 38.3 9.3 29.1

Inpatient 2.9 49.6 23.1 25.1 1.4 50.4 7 9 42.5

Ambulatory 1.7 82.3 42.5 38.2 1.5 17 7 11.5 6.2

Nonphysiclan Ambulatory 0.3 53.5 20.3 29.1 4.1 46.5 16.8 29.7

Prescription Drugs 0 3 80.8 54.9 25.6 0.3 19.2 13.7 5.5

Dental Services 0 0 80.7 36 0 33.5 11.2 19.3 6 8 12.6

Other 0 2 73.2 25.7 44.6 2.9 26.8 23.7 3.1

Trial Per Capitaexpenditures

per capita expenriNures (1987 S)

Total S1.521 S888 S255 $555 $78 $632 $209 $424

Hospital 1.037 584 105 409 70 453 159 294

Inpatient 910 522 86 375 61 387 134 253

Ambulatory 127 62 19 34 9 65 2,, 41

Physicians 411 253 124 123 6 158 38 120

inpatient 259 129 60 65 4 131 21 110

Ambulatory 152 125 64 58 2 27 17 9

Nonphysiclan Ambulatory 26 14 5 8 1 12 4 8

Prescription Drugs 30 24 17 8 0 6 4 2

Dental Services 2 2 1 1 0 0 0 0

Other 15 11 4 7 0 4 3 0

Note: Items in tables may not sum to totals because of rounding.

Source. Agency for Health Care Policy and Research, 1987 National Medical Expenditure Survey - Household Survey.

113


I Table A3: Modified Personal Health Cars Expenditures for 3- to 12-year-olds: Aggregate and Per CapitaExpenditures and Percent Distribution, by Type of Expenditure and Source of Funds for Ca lender Year 1987.(Total population 35.0 million 3- to 12-year-olds.)

Lsource OE runs

I--

1 AN PrivateFunds

Type at Expenditure Total Bcpenclitures(5iNon

Private Government

Out-of-Pocket

Private OtherInsurance

All PublicFunds

Medicaid Other

percent distribution

TotalHasp**

InpatientAmbulatory

PhysiciansInpatientAmbulatory

Nonphysician AmbulatoryPrescription DrugsDental ServicesOther

TotalHospital

inpatientAmbulatory

PhysiciansinpatientAmbulatory

Nonphysician AmbulatoryPrescription DrugsDental ServicesOther

S14.8 79.4 29.7 43.3 6.4 20.6 15.1 5.55.8 70.9 10.8 50.3 9.7 29.1 20.3 8.83.1 76.1 7.7 56.1 12.2 23.9 21.6 2.42.7 64.9 14.4 43.6 6.9 35.1 18.9 16.2

3.2 82.4 35.9 43.1 3.4 17.6 14.0 3.60.6 73.6 11.1 49.1 13.4 26.4 19 6 6.82.6 84.3 41.1 41.9 1.3 15.7 12.8 2.91.1 67.2 30.9 31.7 4.5 32.8 24.0 8.81.0 84.9 55.8 28.8 0.3 15.1 12.5 2.7

3.2 91.7 47.9 38.9 5.9 7.3 5.1 2.20.6 88.6 37 5 45.6 5.5 11.4 10.5 0.9

Total Per Capita per capita expenditures (1987 S)Expenditures

3424 S337 3126 $184 S27 $87 $64 323

165 117 18 83 16 48 34 14

89 67 7 50 11 21 19 276 49 11 33 5 27 15 12

91 75 33 39 3 16 13 3

16 12 2 8 2 4 3 1

75 63 31 31 I 12 10 2

32 22 10 10 1 11 8 3

28 24 16 8 0 4 4 1

92 85 44 36 5 7 5 217 15 6 8 1 2 2 0


Source: Agency for Health Care Policy and Research. 1987 National Medical Expenditure Survey Household Survey.

Table A4. Modified Personal Health Care Expenditures for 13- to 18-year-olds: Aggregate and Per CapitaExpenditures and Percent Distribution, by Type of Expenditure and Source of Funds forCalender Year 1987.

I (Total population 21.6 millon 13- to 18-year-olds.)

Source of Funds

Private Government

All PrivateFunds

Out-of-Pocket

Private OtherInsurance

; All PublicFunds

Medicaid Other

Type of Expenditure Total Expenditures(Sifto

percent distribution

Total 318.2 88 0 34 0 47.7 6.3 12.0 8.6 3.4

Hospital 7.1 80.1 12.3 59.0 8.8 19 9 14.3 5.7

Inpatient 5.3 81 0 10.7 60.6 9 7 19.0 15.4 3.6

Ambulatory 1.8 77 3 16 9 54.3 6.1 22 7 10.9 11.8

Physicians 3.3 88.4 31.8 53.0 3 7 11.6 7.9 3.7

inpatient 1 3 86.2 12,3 70.2 3 7 13.8 6.8 7.0

Ambulatory 2.0 90 0 45.0 41.3 3 7 10.0 8.6 1 4

Nonphysician Ambulatory 1.0 89.4 38.3 46.4 4 7 10.6 6.1 4.5

Prescription Drugs 0.8 88.7 60.6 26.8 1.3 11.3 8.9 2.4

Dental Services 5.5 97 1 55.9 35.1 6.1 2.9 2.5 0.4

Other 0.6 93.9 59.5 30.8 3.6 6.1 5 6 0 5

Total Per Capita per capita expend:tures (1987 5)Expenditures

Total S844 $743 5287 $403 S54 $101 S73 328

Hospital 328 263 40 193 29 65 47 19

Inpatient 244 197 26 148 24 46 38 9

Ambulatory 84 65 14 46 5 19 9 10

Physicians 152 134 48 81 6 18 12 6

Inpatient 61 53 8 43 2 9 4 4

Ambulatory 9! 81 41 37 3 9 0 i

Nonphysiclan Ambulatory 46 41 18 21 2 5 3 2

Prescription Drugs 37 33 23 10 0 4 3 1

Dental Services 255 248 143 89 16 7 6 1

Other 26 24 15 8 1 2 1 0


Source: Agency for Health Core Policy and Research, 1987 National Medical Expenditure Survey - Household Survey.

11_


I. Aaron, H.J. Serious and unstable condition: Financing America's health care.Washington, DC:The Brookings Institution, 1991.

2. Waldo. D.R., Sonnefeld, S.T., McKusick, D.R., and Arnett Ill, R.A. Health expenditures byage group. 1977 and 1987. Health Care Financing Review (Summer 1989) 10.4:111 -20; also,Fisher. C.R. Differences by age group in health care spending. Health Care Financing Re-

view (Spring 1980) 1.4:65-90.

3. The usual source of data for the published annual estimates of the cost of health care inthe United States is the National Health Accounts (NHA). Maintained by the Office ofthe Actuary of the Health Care Financing Administration, the NHA constitutes a frame-work in which data from a number of different sources are combined to construct esti-

mates of aggregate U.S. health care spending. Because NHA data are based largely onprovider reports of total revenue, the NHA is not ordinarily used to make estimates ofhealth care expenditures for children or other demographic subgroups of the popula-tion. The NHA has been used however to analyze expenditure levels and trends for the 65-years- and -older population and by Waldo and others (see note no. 2, above) for crudeestimates of expenditures for three age groups. Office of National Cost Estimates. Na-tional health expenditures. 1988. Health Care Financing Review (Summer 1990):1-41; Of-fice of National Cost Estimates. Revisions to the National Health Accounts andmethodology. Health Care Financing Review (Summer 1990) 7,4:42-54.

-1. A detailed description of the NMES Household Survey is contained in Edwards, W., andBerlin, M. Questionnaires and data collectton methods for the Household Survey and the Survey of

American Indians and Alaska Natives (DHHS Publication No. PHS-89-3450), National Medi-cal Expenditure Survey Methods 2. National Center for Health Services ResearchandHealth Care Technology Assessment. Rockville, MD: Public Health Service, September1989.

5. National health care expenditures were estimated to total $492.5 billion in 1987. This totalincludes cost items not measured in the NMES, such as research and construction, gov-ernment public health activities and private administrative expenses, nursing home care,and nonprescription drugs. Expenditures on these items exceeded S115 billion in 1987.Lazenby, H.C., and Letsch, S.W. National Health Expenditures, 1989. Health Care Financ-ing Review (Winter 1990) 12,2:1-26.

6. Detailed information on the design and data collection instruments of the 1977 NationalMedical Care Expenditure Survey is contained in Bonham. G.S. and Corder, E.S. NMCEShousehold interview instruments: Instruments and procedures I (DHHS Publication No. PHS-81-3280). National Health Care Expenditure Study. National Center for Health Services Re-search and Health Care Technology Assessment. Rockville, MD: Public Health Service,

April 1981.

7. At the time of this analysis, NMES data files, which reported on the hospital costs of new-

borns who were discharged with their mothers, were not available to us. In addition. fol-lowing the NMCES coding procedures in the NMES facilitated the analysis of the growthin expenditures between 1977 and 1987.

8. Because the NMCES and NMES Household Surveys do not include nursing home andother institutionalized populations, they provide representative estimates rf aggregate per-sonal health care expenditures for the civilian, noninstitutionalized population. This isnot a significant problem for estimates developed for children as expenditures for nurs-ing home care are less than 2% of total expenditures for those under 19 years of age. Incontrast, nursing home care accounted for more than 20% of personal health care expen-ditures among those over 65 years of age. (See Waldo and others in note no. 2, above.)

9. The NMES is designed to measure both service utilization and expenditures. Hence, servicesprovided through many special programs such as maternal and child health and crippledchildren's programs are included. WIC and other programs which provide services not tra-ditionally defined as health care are not included. Also, because information about utiliza-tion is obtained from parents, services such as routine screenings in schools, which parentsmay not be aware of, are probably underreported. Also excluded are nursing home care,nonprescription drugs, and expenditures on newborn care when the specific costs of thecare of the infant could not he disaggregated from the total cost of the delivery.

10. The elderly are the primary users of nursing home care, the largest category of health careexpenditures not included in MPHCE. Accordingly. the share of personal health care ex-penditures, including nursing home care, attributable to the elderly probably exceeds40% of all personal health care expenditures in the United States. See references in note

no. 3. above.

15


11. National Centel (Or I lealth Statistics. Advance Report al Final Ss:111(1111y StatiAtics, I9S7. NIonthlyvital statistics report. Washington, DC: U.S. Government Printing Office, supplement(June 29, 1989) 38,3:117.

12. Itt the NMES data used in the analysis. expenditures on hospital caw for "healthy" new-borns discharged with their mothers are attributed to health care expenditures (Or themother. Calculations based on our estimates Of the cost of care for normal newborns (ta-ble 2) suggest that his increased estimates olexpenditures in the 13- to I8- year -old groupby at most S190 million or 1 .

13. The Medicare program was the most significant factor in differentiating the distribution ofsources of payment fOr adult health services limn the distribution for children. An entitle-ment en]lived by most of the population 65 Wan; of age and older, Medicare accountedfor more than -18(.; of MPH CE fin- this age group. Even for those 19 to 61 years of age,Medicare accounted for of expenditures, principally through special Medicare pro-grams directed uiward the permanently disabled and those with end stage renal disease.

1 . Berk, N1.I... Nhinheit, A.C.. and Hagan, NI.M. How the U.S. spent its health care dollar:1929-1980. /Pall!, :Vain (Fall 1988) :17-60.

15. Information on expenditures for spec ilk health care services by children who used thoseservices is available from the authors.

16. The following procedures are used to identify varions components oldie growth in per cap-ita NIP11(11.1 for children over the 1977-1987 period: (I) the medical care price inflationcomponent of growth is measured by a fixed-weight price index where the weights are therelative proportions of 1977 children's NiPHC1. expenditures attributable to hospitalcare, plusician (-ale. dental care, nonphsician ambulant y care, prescription drugs, andother personal health care services. Price changes fin- each service category are measured

service- specific components of the Consumer Price Index for all services except hospi-tal care and by the I ICFA hospital input price index fOr hospital cart- (sec Oflice of Na-tional Gust Estimates, Summer 1990, in note no. 3. above); (2) general price inflation ismeasured by the GNP fixed-weight price index. Using this GNP deflator, it is possible toremove die elk( is of general inflation limn the \11'H CF. price index. leaving a measureof -ex( ess" medical care price inflation; (3) information from the 1977 NMCES on age -group -spec ific expenditures per capita and population si/e are used to measure the in-rease in expenditures that may hal resulted from a change in the age dish t ihution wihin

the child population.

17. Public I !edit h Seryice. Centers for Disease Control, National Center for I lealth Statistics.l 'dal and health stalisth,: Health aspects of pregnancy and childbirth, 19x5'3. Data froin theNational Stu of Family Growth. Series 23, No. 16. Hyattsville. Nil): U.S. Department ofHealth and I finnan Services (DI II IS: PI IS-89). 1989. keppel, K.G.. 1 leuser.12.1, Placek,P.G., et al. National Center (Or I lealth Statistics. Afilhods and liespanse (liaracteriqic%. a-tional .Vatality anti Mal Mortality Survey. Vital and Health St.,11stics. Series 2, No. 10(1. Wash-ington, DC: 1..S. (4A-et-Innen( Printing Office (1)14115/P1 IS-gri137-1), September 198(3.Placa, PA:. 1980 National Natality and Fetal Mortality Stnwev: Survey Methods 17sed andPublic I lealth Service Agency Participation. Public Fleshit Reports (198.0 99:111-16.

18. Fuchs. V.R., and Perreault, 1.. Expenditures fOr reproduction-related health care. journal ofthe American Altylical .ilswiantm (1986) 255.1;76-81; also, .Alan (1t1t tmacher Institute. TheFtnant lug of ,Maternity Care in the I...N. New York, 1989.

19. 55e asstime in our analvsis that 80`; of infants iwe disc 'large(' with their mothers based onOW data Irons sever al maim national snrvevs reported in Gold, 12.13., Kenney, A.N1.. andSingh. S. Financing maternity rare in the New lOk: ,flan Gut tinacher Institute, 1987. In-'urination on the precise number of infants discharged with their mothers is not readilyavailable because separate billing- records are not typically maintained for infants. More-over. even the condition of an infant at birth may not he a totally reliable indicator of itsstatus as matelnal hospital stays may in practice he lengthened to correspond ()citet tothe stay of a sicker infant. and healthy infants delivered 1w cesarean section may- havelonger than average In ispital stays while waiting for their mothers to be disc harged.

2(1. eels! of maternity care and childbi,lle in the 10S9. Health Insurance Associa-tion of Anni lea, reseal( It bulletin. Washington, DC; I !IAA, December 1989.

21. Prryions estimates of the cost of obstetric al care by Fuchs and Perreault (see note no. 18,tboyrl atol by the .11an (1uttmacher Institute (Blessed n,ents and the bottom 1 c: Ewan> ingmateinity cnre in the New link: Alan (:uinn:It her Institute. 1987) include a Separateline it111 in their (S11111ille% to relict t e hatges Ins anesthesia. These ( harges ate now in-hided in the hospital c barges repot ted hs 111.1.-N (pet sonal cot responden( e. %Null A..

Minor).

1 G


22. The HIAA estimated costs for 1989. To obtain estimates for 1987 we have deflated these1989 estimates by appropriate components of the Medical Care Price Index from HealthCare Financing Review (Winter 1990) 2.2:157.

23. Because most states do not require the reporting of miscarriages which occur prior to 20weeks gestation, miscarriages are substantially underreported. To obtain the average costof a miscarriage.'stillbirth, we use information on the number of spontaneous pregnancyterminations between 20 and 28 weeks, and after 28 weeks gestation as reported in PublicHealth Service, Centers for Disease Control, National Center for Health Statistics. VitalStatiqic, of the U.S.. 1987: Volume 11Morality, Part A. Hyattsville, MD: U.S. Department ofHealth and Human Services, 1990. We assume that miscarriages not accounted for in theVital Statistics occurred prior to 21) weeks gestation. 'We do not count. however, miscar-riages which occur very soon after conception. They are not likely to be recognized andtherefore require no treatment. Wilcox, AJ., Weinberg. C.R., O'Connor, J.F., et al. Inci-dence of early loss of pregnancy. New England journal of Medicine (1988) 319:189-94.

24. Researchers at the Alan Guttmacher Institute (see note no. 22, above) estimated that tl-most SIC billion was spent for maternity care of mothers and newborns in 1985. This in-cluded S 1.7 billion on physician care and laboratory procedures for both mothers andinfants, S6.3 billion on hospital care for mothers, and S5 billion on hospital care for new-borns. These estimates are appropriately mid-range between those of Fuchs and Perreaultand those presented in the text. Comparing the estimates for 1982 and 1985 with eachother and with those for 1989 does suggest an acceleration in the rate of increase in costsbetween 1985 and 1987.

25. In reporting estimates of mean hospital costs, data from hospitals in the 1989 HIAA surveywere weighted by the number of births in each hospital, Thus in determining averagecosts each birth counts equally, but charges reported by large institutions carry moreweight than those reported by small institutions. In calculating mean costs from previoussurveys, each hospital's charges received the same weight regardless of the number ofhit ths. Because births in larger hospitals tend to he more expensive than births in smallerhospitals, this change in the method of calculating average costs will increase reported1989 costs as compared with reported costs in 1982 and 1985. This inethodologic changeshould, however, have little impact on reported physician fres, which are obtained from adifferent data base.

26. U.S. Bureau of the Census. Statistical Abstract of the 1991. Washington, DC: U.S. Goy ern-ment Printing Office, 1991.

27. It is likely. limey cr. that concern for malpractice litigation has increased the costs of mater-nity care indirectly by encouraging the practice of "defensive- medicine resulting in an in-crease in the frequency of prenatal testing and imaging procedures and cesareandeli cries. There is also evidence to suggest that concerns regarding malpractice litigationand increases in the cost of mall» actice insurance led to a reduction in the number ofphysicians delivering obstetrical services. This reduction in the supply of physicians couldhave led to an increase in fees for maternity services.

28. Kolata S New insurance practice: Dividing sick from well. .Vein Yin* Times., March 4, 1992,at Al.

29. Of course, the primary reason expenditures on obstetrical care, childbirth, and infancy areso high is because infants, on average. are more vulnerable (less healthy ) than older chil-dren and adolesc ents. Therefor-, one would expect that per capita health care expendi-tures on infants would exceed expenditures on older children. Net it appears that inrecent years growth in expenditures on health care for infants and pregnant women hasfar outstripped improvements in their health status (see the article by Racine. Joyce, andGrossman in this journal issue).

30. We assume that expenditures on health care will increase by about 671 for those unin-sured all year and by 33e; lOr those insured for part of the year. These estimates are basedon data presented Ionize» and Cunningham in this journal issue which suggest that,compared with children insured all year, those insured part of the year have 25ci feweramhulatot y health care contacts per yea and those uninsured all year have 40% fewercontacts. They are also consistent with the observation that on average the uninsured con-sume about 60'; as much medical care as the insured. Pauly, N1.V.. Danzon, P., Feldstein.P., and I loft]. A plan for "responsible national health insurance." Health Affairs (Spring19911:5-25.

The Role of PrivateHealth Insurancein Children's Health CareJohn F. ShellsPatrice R. Wolfe

Abstract

Private health insurance is the primary means of financing health care for America'schildren and pregnant women. Most coverage is provided under employer plans.Access to private health care coverage, however, is threatened by the increasing costof health care, cost shifting by providers, and insurance marketing practices that tendto deny coverage to high-risk individuals. These pressures have already led to anincrease in the number of uninsured children and pregnant women.

This paper provides an overview of the private health insurance market with a focuson recent trends. The effects of self-funding arrangements 1w employers and ofvarious cost-control arrangementsincluding managed care plans, patient cost-shar-ing provisions, and employee premium contributionsare examined for theirpotential impact on children and pregnant mullets. Policies that might expandhealth insurance coverage for children, including a universal health insurance plan,and health insurance market refOrms, are explored. Alternathe strategies for en-hancing universal health insurance coverage for children include mandatoryemployer-based insurance programs, a program of tax credits to underwrite individ-ual insurance plans, and a single -paver government program financed through thetax system. The authors conclude that efforts should be made to preserve the currentpriN-ate health insurance system by reducing cost shifting from public programs,guaranteeing the availability of coverage to all groups, and controlling costs by meansof competition, managed care. and perhaps global spending limits. Such compre-hensive reforms might he necessary merely to preserve private insurance coveragefor a majority of America's children and pregnant women.

private insurance is the primary source of funding for health carefor children and pregnant women in the United States. TheMarch 1990 Currt.it Population Survey (CPS) reports that about

63% of all children are covered as dependents under employer healthinsurance plans and another 10% are covered under individually pur-chased non-group insurance. About 60% of pregnant women are coveredunder employer plans, either as employees or as dependent spouses, andabout 6% have non-group coverage. I

The extent of private insurance coverage for children declinedduring the 1980s largely because of an increase in health care costs, a

I S'

John F.is vire president ofLewin-ICF, a researchand consulting firmwhich specializes inhealth and environ-mental matters.

Patrice R. Wolfe,AL P. P. A I., is man-ager in the SysteMet-ries division of MID-

.Systems, Inc. Atthe time this paper :furswritten, she was seniorassociate at Lewin-K


de( .ine in employment associated with the 1982 recession, and a shift inemployment to the services sector Where health coverage is less extensivethan in most other industries.2 The percent of children with employer-based insurance declined from 66% in 1980 to 63(X, in 1990. Moreover,cost sharing for dependent coveragein the form of deductibles, pre-mium contributions, and the like- -has increased. There has also been atrend toward reduced coverage for benefits of particular importance tochildren such as dental care and treatment kw mental health andsubstance abuse problems. Although Main' employers have expandedcoverage kw certain cost-effe,-tive services such as prenatal care and haveintroduced case management programs for chronically ill children, thegeneral trend has been in the direction of reduced coverage for children.Moreover, many families with chronically ill children are finding itincreasingly difficult to obtain private health insurance because of in-surer enrollment practic,s intended to reduce tile insurer's exposure topayments kw high-cost illnesses.

Despite these disturbing trends, there arc many opportunities forexpanding coverage for children through private insurance. About 80%of the 8.5 million children without health insurance are dependents ofemployed persons. This statistic suggests that expansion of employer-based coverage could greatly reduce the number of uninsured children.in Fact. the American Academy of Pediatrics (AAP) has proposed requir-ing all employers to cover dependent children of employees even if theydo not now provide health insurance for employees:3

In this paper we review the principles of private health insurance. Weexamine evidence of trends in private health insurance coverage forchildren including the number of children with coverage, types ofbenefits provided. and cost-sharing requirements. We discuss subtlefeatures of the market for private insurance that have restricted theavailability of coverage for some chronically ill children. We also discussinitiatives that would expand health insurance coverage for' children andestablish a minimum standard of (-overage for all children.

An Overview of PrivateHealth InsuranceThe %at it of pri ate health insuranc .

product, available :ctcla is mrxvlilin-ing. The options ',Inge from naditionalinclemnit plans that provide only cashpa% mem for a limited menu of medicalsericc.s to lurch( al care service plansthat ()Ht a wide IaIie of set ices foren! olives. Ir this VII \ 11011 Illent, hilt'111,1i111 I hallenge is to determine which',Induct hest addi esses both the pun-( hasei 's Iinanc ial «mstraints theconsume! 's health carc needs. Thec holt e i, Ins Ihet «Iniplif :liC11 his the lace

that die 1)1111 (h1)1(;111V I:11 gl. C111-PIOlerS) and h COnSninIN tVintalhM1)101CCS and their dependents) mavhave different criteria fin- judging theadequac of an insurance plait.

This section presents and defines someof the fundamental concepts of health in-suranc that affect an employer's or indi-vidual's choice of health benefits plan. Italso pro. ides an met-view of the l) f WS ofprivate insurance products available topregnant women and children. 11'c focuson won!) tallier than individual instil:1mproducts. The inch\ ideal insurance mar-ket accounts for applo\iitiatel 10e; oftotal pi einitims sold in the 'tilted States.'


The purpose of health insurance is tominimize the risk of financial catastrophethat often results from unexpectedly largelosses or expenditures by pooling theexperiences of a large number of people.In general, large employer groups canpredict with reasonable accuracy whattheir health care expenses trill he (luringa particular sear. Although it nia\ be chili-cult to predict precisely how nr<un peoplwill incur large expenses and how mucheach person's illness will cost, a group canspread the resulting expenses among alarge number of people, thereby creatingan average expense that varies far less thanan individual's expense. This concept,known as risk pooling, allows a largeemployer to estimate fairly accurately thecost of offering health care insurance toits employees.5 Similarly, insurance com-panies pool the risk of numerous smallgroups and individuals to predict theiroverall expenses.

Fully Insured Arrangements

Traditional private health insurance isbased on a contractual arrangementbenVr.11 a purchaser (either an employeror an in-UN-41mill and an insurer where thepurchaser agrees to pay the insurer a pre-determined amount (the premium) perOn (Ted meinlwr per time period (typi-cally a month) in return for full assurancethat all approked expenditures will be paid1)5 the insurerfi In other \\mils, the pur-chaser is not at risk if expenses exceed thetotal premium amount. In 1989. Americanemployers and employees spent S36.9 bil-lion on fully insured group health insur-ance premiums.%

Under plans of this type, the insurer isruns responsible for all covered healthcare expenditures. The insurer's goal.therefore, is to set premiums so that the\«tver the expected claims pa\ (mt for thecovered population pills a margin forprofit, overhead expenses. and rCSIVS la"All" Illx1wct(liv iargr ( taints.

Self-funding Arrangements

Although insurance companies tradition-ails perf0rined the risk pooling I unctionfor employers and individuals, employershave in recent Years increasingly pursuedself-limding as an alternath method forfinancing their health care plans. The per-cent of medium and large employers whoself- funded grew from 19'; in 1979 to fiti`;in 198S.4 In self-funded plans. die cm-plo\ er assumes all risk for health espendi-

117

tures and contracts \\ilt a third-pareministrator or insurer to handle claimsprocessing ;Ind other aelministrati\ func-tions related to the pin.

Sell-funding has man\ advantages fortlw empleiver. Hrst, the Empl(wee Retire-ment Income See twits .\ct (ERIS.1.) of1974 preempts states from regulating sll-insure(' plans. Thus, cmploycrs who 01)1for plaits cant choid pining 1(11.those state-mandatecl benefits that the\do no: want IC) COV(T. Second, (1111)101XF \( an aVc)1(1 111sIlralICC 1)1V111111111 taws.Third. loll. all (1111)10\1A' that perceives itsemployees fu he healthier. cm a erage,than other comparable e'mploye'rs, sell-funding provides the. opportimin to panfor health care based on the groups ovenexperience. rather than paving an insur-ance pentium that reflects the experi-ence of a larger and sicken einplo\ etcommunity. hc ptimars drimhitcl, tosell-funding is the increased risk of largelosses as a result of unexpectedly highmedical claims.

Employers can reduce their xpostitto this haiaid bt pin chasing instil anspecifically to cover exit aordinai it\ Logeexpenditures. For example. in a mini-mum premium plan, the put chase' as-sums hill responsibility for health ccape ndiurres ill) II) .1 ceI I.tin Ihrsimiti.Rescind that threshold. an instuanc e c ourpans- lakes over of slimes in the paymentof all ;u1(litional pe-ntium plans arc often good options 101emplo\ ers that find it cc on()Inic di to ..1(-1.1111(1 hut do not ha\ e the financial Ic.sources to pan lor unexpe( fed high - dollarcaws such as low bit th x eight infants withmultiple complications,

118

Managed Care Arrangements.\Ithough the primary purpose of healthinsurance is to minimize the individualrisk of financial catastrophe as a result ofunexpected large expenditures fin- healthcare, increased attention is being fOcusedon using health care financing systems tocontrol costs and to improve the quality ofcare. This approach has led to the devel-opment of a variety of managed careorganizations which combine features ofhealth insurance with a variety of incentiveand regulatory devices in an attempt tomaximize the value of health benefits fora limited expenditure.

Ilcalth maintenance organizations(I I NI0s) are a form or managed care or-ganization which uses financial incentivesto limit excessive or inappropriate utiliza-tion of health care services. I INIOs arereimbursed on a capitate(' bask: they re-ceive a set payment antount per r111.011111111111bel. per month, reLtrdless of the

Increased attention is being focused onusing health care financing systems tocontrol costs and to improve the qualityof care.

member's level of sell ice utilization. As aresult. an I1\1() (or in certain models, theI (NI() member pin sician) is at risk fOhealth care expenditures above a specificthreshold. This transfer of a portion of thefinancial risk from the insurer to theprovider of health care services is kmiwitas risk sharing and creates incentics forI ) physicians to limit utilization of ex-pensive health care services. Today, thereare a number of alternative I I M() organ-izational structures. The prototype IN1()is the closed-panel prepaid group practiceplan (0r staff model) in which a largemultispecially group practice contracts toprovide all or the care for I IN1()-enrollet1patients using the I INI(Ys hospital exclu-six el . The pin sicians arc ivpicalIN salariedbut shale in the profit of the 1)1:111 at theend ()I the veal . 14:111011et'S urc 1.111111(41 tally

10 se1111('S Of 1)1101 physic inns 1111(1 1111111

hospitals.

.1110111(T 101111 of the Inde-pendent Pia( tic .1sso( iation f IPA), R.1)-tesents a melding of I1 \1( ) le:miles withttaditional Ice for setyi«.. I vpicall. IPAp11\ ians ate not all part of the same


group. and IPA physicians may serve non-{ INIO patients or patients enrolled in avariety of different I I NIOs and otherhealth plans. IPA physicians and IPA hos-pitals are commonly paid on a fee-for-serv-ice basis with in of the physicians' feesheld back as a reserve against high costs.Because the IPA is a collection of inde-pendent practitioners rather than a cen-tralized group, control over physicianbehaviors is weaker in an IPA than in astaff model I IMO.

Although II\ lOs have traditionallylimited enrollees to the services of planproviders, several plans have recentlyadded point-of:service options to their ba-sic package. Under a point-of:service plan,enrollees may choose to obtain indemnityreimbursement for out-of-plan medicalcare; however, such out-of-plan care is sub-ject to cost sharing which results in itsbeing more expensive than care from planproviders.

In another type of managed care ar-rangement. the preferred provider organi-zation (PPO), or its more restrictivecounterpart. the exclusive providerorganization (EPO), utilization reviewcontrols are used to manage costs. In ad-dition, PPOs and EPOS use their groupboring power to negotiate fee discountsfrom participating physicians and hospi-tals, and then pass these discounts on totheir enrollees in the f(trm of reducedpremiums Or reduced cost sharing. In aPPO, enrollees mav be charged a penaltyFor using nonparticipating providers. Inan FPO, enrollees have no coverage at allfOr services provided by a nonparticipatingprovider. 111 HMOs, benefits are alsorestricted to services obtained from par-ticipating providers except in limitedemergency situations. Among the controlstoed by these managed care organizationsto regulate costs are prior authorizationfor inpatient admissions and other high-cost services and retrospective claimsProfiling to determine whether a physi-cian's practice pattern is dramaticalh dif-ferent from that of his or her peers. "these'utilization controls provide managed careorganizations with the abilin; to (1(115 pa\mem for services considered inappropri-ate or to femme providers front thePP() /EN) network.

An increasingly popular feature ofmanaged care SA stems is case manage-ment. Case management can beimplemented in both I I M() and PP( ) or-

12i


ganizations and ven with traditional ill-delimits insurance plans. 1. cam. man-agement. a case manager coordinateshealth care from a variety 4-f providers fOrindividuals wit l) complex 111111 length); or(111'0111C illnesses. Case management canhe used to Facilitate cost-effective carewhich integrates health care with the totalneeds (developmental, educational. andenvironmental) of a child or a pregnantwoman. It can facilitatc. home 1Am-inemand reduce ox (Tall costs. As advocates Foran insurer, lioweser, case managers canat :o 1)c used to deter utilization 1)1 expen-sive services.

The effectiveness (inn:waged care i)ro-grams in reducing costs varies with thetype of managed care plan. .\ Rand Cor-poration stud of prepaid healthdicatc-s that expenditures in an 1 IM() can1w as much as 25`.; lower than in conven-tional health plans.'' The more loosely ar-ranged plans such as 1)1)()s show little. ifany , overall sayings because of their organ-izational structure. : \n A. Foster Higginssurvey indicates that some utilization re-

.1(yi on total mcdi_

cal plan costs.'" Sonic studies of selectedPmgrallIN fcl(al(' that even (101101 spenton utilization management results in a re-duction in claims of 5-1 to Sf); however,other studies indicate that these programsare 1111(15 cosi_,rti[ise.1

\\*He empirical evidence is limited, itis \videl( believed th it managed care ismost (ffec Use in m)difSing medical prac-tice when network providers serve exclu-sively those covered under the plan (ashappens in the I I NI() stall model) andwhen patients obtain their care exclusive'sthrough the network. There is some ex-pectation that the potential for cost say-ings tinclr managed care will grimy asmedical ell eciieness and outcomes r-search lire further developed to ield cosi.ef lective practice guidelines winch can hedisseminated through managed carenenycnis.

Cost Sharing Arrangements

Insurance products also vitil greatly in111)AV 111C) 1'1.'91111-c C1111)10% CCS and 111C11"

f,111111ics share 11C:11111 Car(' costs with 111clili di 15 c1 litiploy «ist ing takesmans fottlis.itu hiding piemium conttilm-tions, ddtu an(I coinsurance. \\*hiltemployee cost sharing naditionallv hasnot been .1 central [canto. in most eni-pin\ el in:111(yd insurance plans lespc-cialh those that arc union-negotiated), it

is becoming more populai in pal t becauseof increasing prcsstire to control healthexpenditures.

.-kl)out -15e; of emplmees contribute tothe cost of their health insurance prmi-unis.12 For health insurance plans that re-(wire : premium contribution. emplo,cestypically pay, on it pretax basis, it percent-age of the monthly premium amount. Theaverage employee contil)ution is 2 1 (:; ofthe mo1111115 premium.13 Under someplans the contril)ittion rate varies 1.y tviwof police Z111(1 HMV 1:e less fOr an inch; idealthan for a famils. Premium contributions11112 1110re 201111 nn tilr 1 1 \ 1( )s, in which5.1'i of pay a contril)tition, thanthey are Lou non-1 1 N1( ) plans, in which .1 1';of enrollees pay a ontribution.l

1)eductibles are common features innon-I INK) 111tilll'ill1('C II)11111 S. 1)111 Vail' C110r-

111OUSIV 111 110V1' they are structure(1. In (.17';of lulls insured plans. the insured individ-ual must satisfy an aggregate annual de-ductible amount for medical expenses.Common clecluctil)les for individual cov-erage are S1(10 and S200; for family cm-erage typical cle(litctil)les are S300 or 540(1per familt per vcar.li )11C the insuree.person or family has incurred :111(1 paidfor health care expenses equal to the de-ductible amount. the insurer assumes re-sponsibility for the majority of healthexpenditures.

Case management can be used to facilitatecost-effective care which integrates healthcare with the total (weds (developmental,educational, and environmental) of achild or a pregnant woman.

Some managed ( are plans attempt touse the deductible to dire( t co (1(01 inch-\ icluals to hospitals 1111(1 physicians withychont the managed care plan has a finan-cial arrangement I:or example. mans1)1)()s, .1'()s. ',Ind point-of-service planslime two sets of deductil>le rates. one fOrin-network providers with whom the planhas It c ac !nal lig? cement and one kn-out-of-network pro\ icier.. "I vpical15, theseplans use out-of-network deductibles thatale much higher than the in- network cle-

tibles in fn t to perstimle benefi-ciaries to use pros s \silo are pal t of thenetwork.

1 ?2

119

120

In many min-I IMO insurance plans.the beneficiary and the plan share the cov-ered expenses according to a predeter-mined ratio. Ordinarily, the plan pays for80(.: of covered expenses (once the bene-fiiary has exceeded the deductibleamount, if there is one), and the benefici-all. pays for the remainin 20e: . the 20(.:is the beneficiary's coinsurance rate. Aswith the deductible, the coinsurance rateis often lowered to provide an incentive tochange beneficiary behavior. For example,

of employers waive the coinsurancerate on outpatient surgery to persuadetheir employees to avoid costly hospitalsitu s.15 Many managed care plans raise thecoinst trance rate fOr ma-of-network serviceuse to induce beneficiaries to usework providers. In some instances the ',,r-rangement may be 10e; coinsurance ft rin-network use versus 30(( coinsurance forout-of-network use.

Factors influencing the choiceof insurance plan include thebencfits offered, the cost of theplan, and the freedom to chooseproviders.

Some fairly omnprehensive plans im-pose a nominal charge (fi example, SIto S5) each time a service is used. Althougha form of cost sharing, these co-paymentsare p-imarilv intended to discourage ex-cessive and frivolous utilization of healthcare services.

Factors Influencing the Choice ofInsurance PlanIn employer -based health insurance. theemploiee maN Ipically he presented withnumerous health insurance ofkrings andmust choose from among them. In indi-vidually purchased insurance, the choicesare usually more limited, for reasons dis-cussed below. Regardless of the type ofinsurance, the consumer must somehowrank each choice relative tot he others andpick the best one for him or her. Factorsinfluencing the choice of insurance planinclude the benefits nifred, the cost ofthe plan and the freedom to chooseP"'ider',Covered Benefits

Maternio, and wet'- child care benefits arepal tit ularli important to «insitmers of


childbearing age. Maternity benefits atemandated by state law in 48 states and arcincluded in more than 95% of employer-sponsored group policies underwritten bycommercial insurance companies.Ili Cov-ered services for a normal pregnancy usu-ally include a specified !lumber of prenatalVisits, diagnostic tests such as ultrasound,delivery. postpartum care, and an initialinpatient well-bab visit.

Sonic employers concerned about thecost of high-risk pregnancies provide addi-tional benefits to encourage prenatal care.For example, Florida Steel Corporation,through its medical plan carrier, AetnaI lealth Plans, oilers a Healthy Beginningsprogram. Free diaper service for 90 days isprovided after the baby is delivered to en-courage pregnant employees and preg-nant spouses of employees to register forprenatal care. Women enrolled in the pro-gram are monitored on a regular basis lwthe insurance company's nurse consultantwho records each woman's vital statistics(including weight gain and blood pres-sure), answers questions. and providesneeded assistance. The nurse coordinatesall efforts with the patients' obstetricians.the program also includes an educationalcomponent that provides the women withmaternity-related information, includingdiet and exercise suggestions.17

Well-child care consists of monitoringa child's physical and mental develop-ment and of providing routine preventiveservices. Covered benefits usually includea specified number of' physician visits be-fore a child reaches a certain age. routinelaboratory services, and immunizations.Some insurers consider immunizations tobe a separate benefit. As shown in table I.coverage for well-child care is far morecommon in HMOs than in traditional in-surance plans and PPOs, making I INIOsa popular choice for parents with smallchildren.

(;overage of. preventive diagnostic serv-ices is also an increasingly important bene-fit as employers become aware of thesignificant role played by preventive carein containing costs. The growing popular-ity of wellness programs has likely addedto this trend. Nlost corporate wellness pro-grams focus on weight reduction. smokingcessation. -tress management, and fitnessmaintenance.

Cost

.1 consumer's choice of insurance productis also greatly influenced by cost. Many

19 '3


Table 1. Percentage of Health Insurance Plans Covering Well-childCare and Preventive Diagnostic Services in 1989

Services TraditionalIndemnity

Plans

PreferredProvider

Organizations

IPA ModelHealth

MaintenanceOrganizations

Staff ModelHealth

MaintenanceOrganizations

Well-child care

Preventive diagnostics

50

67

62

71

98

94

99

100

Source: Health Insurance Association of America. Source Book of Health Insurance Data, 1990.Washington. DC: HIAA, 1990, p. 33.

factors influence the cost of a privatehealth insurance plan. including the com-prehensiveness of the benefits packageand the degree to which cost containmentprograms are used. From the insurer's per-spective, a major factor influencing thecost of insurance is the -riskiness" of thegroup or individual to be covered. Manyinsurers attempt to exclude high-costgroups and individuals from coverage ordesign policies to protect the insurer fromthe consequences of high-cost illness.

Preexisting condition limitations arefrequently used to protect the insurerfrom high-cost illnesses by excluding fromcoverage for a specified period (often 6 to12 months) medical care required to treata condition that was diagnosed and/ortreated prior to the commencement ofcoverage. By covering only new condi-tions, the insurer can reduce costs andoffer a lower premium. These limitationshave serious implications for pregnantwomen and infants. Because pregnancy istypically considered to be a preexistingcondition, women who become insuredafter they have become pregnant or dur-ing a waiting period before their insurancebecomes effective may find it difficult toobtain reimbursement for the costs of thepregnancy.

Trends in PrivateInsurance Coverage forChildren

Although private health insuranceremains the primary source of health in-surance for children and pregnantwomen in the United States, the percent-age of children with private coverage de-clined throughout the 1980s. The erosionin coverage can be traced to the rising costof health insurance and the growth ininsurer risk selection practices that

severely restrict the availability of insur-ance to persons with a history of medicalconditions. Moreover, the rising cost ofhealth care has caused many employers toreduce the range of benefits provided andto require additional employee cost shar-ing in the form of increased deductiblesand premium contributions. Thesetrends in private insurance coverage arediscussed below.

Trends in Coverage

The March 1990 Current Population Sur-vey (CPS) data indicate that about 74% ofall children have private insurance cover-age. Nearly two thirds of all children(63%) are covered as dependents under aworking parent's employer health plan(table 2). Another 11% of all children arecovered tinder individually purchasednon-group insurance plans. In addition.about 27% of all pregnant women are cov-ered as employees under an employerhealth plan. About 33% are covered asdependents under their spouses' em-ployer health plans, and another 6% arecovered under individually purchasednon-group insurance plans. Overall, about60% of pregnant women have employer-sponsored coverage.

The percentage of children with em-ployer health insurance declined from66% in 1980 to 62% in 1986; however, thepercentage with employer insurance in-creased to 63% by 1990. Although thereare differences in the way insurance cov-erage is measured across surveys, thesetrends are generally consistent with othersurvey data.I8 For example, in this journalissue NIonheit and Cunningham reportthat the percentage of children with pri-vate health insurance coverage through-out the year declined from 71% in 1977 to63% in 1987.

The decline in the percentage ofchildren covered under employer plans

124


during the early 1980s coincided with the1982-1983 recession. The unemploymentrate rose from 7% in 1980 to 9.5% by 1983,resultir -, in a widespread loss of employercoverage. The percent covered did not in-crease. however, as the economy recoveredbecause many of the jobs created after 1983were in service industries where many em-ployers do not offer insurance and/or con-tribute little to the cost of dependentcoverage.' It is likely that the, proportionof children without health insurance cov-erage increased recently because of therecession of 1990-1992.

Employer Health Care Costs

U.S. business health spending as a per-cent of total employee compensation in-creased from 2.0% in 1965 to 7.1% by1990 (table 3). The increase in employercosts in the past decade has been accel-

erated by cost shifting. Uninsured per-sons often cannot pay for the care theyreceive, which creates an uncompen-sated care burden for providers, typicallyhospitals that provide charity care.These providers attempt to shift the costsof uncompensated care onto other pay-ers in the form of higher providercharges. Also, in recent years, govern-ment programs such as Medicare andMedicaid have reduced their reimburse-ment rates below the cost of providingcare.19 This reduction creates reim-bursement shortfalls which providers at-tempt to recover by shifting costs toprivate payers. Cost shifting for uncom-pensated and undercompensated carehas increased in recent years as a resultof increases in the number of uninsuredpersons and increasingly aggressive costcontainment efforts in public pro-grams.19 Ironically, the practice of cost

Table 2. Sources of Insurance Coverage for Children andPregnant Women in 1989

Sources of Insurance' children(percent)

rregnant women(percent)

Employer coverage

On own job 0.1 26.5

As a dependent 63.0 33.1

I Non-group coverage 10.5 5.7

Public programs 19.6 25.4

Uninsured 13.2 14.4

Percentages do not add to 100% because individuals may have coverage from morethan one source.

*The CPS does not report pregnancy status. This survey identifies pregnant women asfemale parents of a child born in the prior year: therefore. it excludes females whosepregnancy does not go full term.

Source: Lewin-ICF analysis of the March 1990 Current Population Survey (CPS) Data.

Table 3. Business Faces Increasing Health Insurance Costs

U.S. Business Health Spending as a Percent of

Year Gross Private Domestic Product Total Employee Compensation

i1965 1.0 2.0

1980 2.7 4.9

1990 3.9 7.1

Source: Heatth Care Financing Review (Winter 1991) vol. 3. no. 2. Baltimore. MD: U.S.Department of Health and Human Services. 1991, p. 88

125


shifting may be causing increases in un-compensated and undercompensatedcare by further reducing the affordabil-ity of private insurance.

In response to rising health care costs,many employers have attempted to con-uol spending through a variety of man-aged care strategies. Industry data showthat HMO enrollment has grown steadilyduring the past decade.2° In 1988, about19% of persons insured b' benefit plansof firms with 100 or more employees wereenrolled in HMOs and approximately 7%were enrolled in selective contractingplans (PPOs and EPOs.21 In addition,91% of employer plans surveyed by A. Fos-ter I I iggins have some fOrm of utilizationreview program.22 For example, 73% ofinsurers require precertification fOr selec-tive hospital admissions, and about halfrequire concurrent review of hospital ad-missions. Despite these efforts to containcosts, however, many employers havefound it necessark to reassess the level ofcoverage provided.

Covered Services

The traditional role of private insurancewas to cover costs associated with acuteillnesses, not costs associated with servicesdesigned to prevent illness. Rapidly risinghealth care costs have led many employersto broaden that focus. Pregnant womenhave been a popular target of managedcare programs because expenses relatedto childbirth are the largest single compo-nent of a typical employee group's healthcare costs and may range from 10% to -19%of total expenditures.23 Employers and in-surers now offer services that were rarelycovered under traditional insuranceplans, including free obstetrical visits, be-havior modification classes for smokingcessation and weight loss, preconceptionhealth risk appraisals, and extensive pre-natal and postpartum educational materi-als and classes,'' -'-t One employer estimatesthat its pregnancy health benefits manage-ment program saved almost $500,000 in itsfirst vear by reducing the frequency of lowbirth weight babies.23

\inn-1g children arc also a popular tar-get for specialized programs such as casemanagement. For example, a midwstrnI IMO is implementing a case manage-ment program designed to help childrenwith chronic asthma. the program wasdesigned in response to the fact thatasthma was the number one reason forschool absenteeism in the area and a

123

major source of LIMO expenditures. Inconcert with the school nurse, primarycare physician, a social worker, the par-ents, and it combination of other profes-sionals, the pediatric asthma case managerworks with the child to help him or heraccept the responsibilities associated withasthma treatment. The goal is to keep thechild in school and out of the emergencyroom or hospital inpatient setting-2:'

Another increasingly popular programinvolves using so-called Centers of Excel-lnce. Centers of Excellence are Facilitiesidentified by insurers as high qualin , cost-effective providers of specialty care. Forexample, children's hospitals are oftendesignated as (:enters of Excellence tOrthe prcwision of specialized pediatric care.All cases for specific apes of care are thensent to the Center of Excellence for treat-ment. Currently, the most popular typesof Centers of Excellence are those special-izing in organ transplants and rehabilita-tion services.

While many of the trends in chil-dren's coverage are positive, coveragefor certain services of particular impor-tance to children has declined in recentyears. An annual survey of medium andlarge firms conducted by the Bureau ofLabor Statistics (BLS) indicates that thepercentage of persons with dental cm-erage declined from 77ri iii 1981 to Iifir;in 1989.26 The BLS data also indicatethat the percentage of participants inplans with limitations on the number 4)1days of inpatient coverage increasedfront 43''; in 198:2 to 77('; in 1989. In

1 ?

124

although 97(; of <tll partici-pants acre covered I or inpatientsubstance abuse detoxification (detoxifi-cation is generally consi(len.(1 medicallynecessar, is ustiallx covered), only68'; k%l-C covered for inpatient sub-stance ...ibuse rehabilitation and (mix01`; Mere covered for outpatienttreatment.

Thirty-two percent of workers were requiredto pay 40% or more of family premium costs.According to a Wyatt Company survey, theaverage employee contribution for family coverageincreased from $435 in 1986 to $605 in 1989.

:11rr11 trends in substance abuse cov-erage for dependent, raise importantquestions fur the lian'c ollialth in Amer-ica..\ recent survey of 1)usinss executivesI)% No1-111lCCMCCII NM:1011:11 Lift Insurance(.M111E111\ indicates that -15`i of those sur-

xec! 1)1:111 10 restrict or (minim cover-age fOr substance abuse treatment in thenext decade." 7 The suvx reveals thatbusiness executives consider substanceabuse to he the fastest growing component()I their health Cate hill. Suhstanee :11)1ISUV:11111CM costs hat (* proven I() be cliff idyl(111 111111( I. resulting in serious budg,etingproblems for mploxers. Nloreoxer, sub-stance abuse is wick+ perceived to be aself-inflict(d problem whos treatment isless worth\ of than other healthcaw srx ices. lh e omeern ON erad((1(((tiisubstance abuse treatment costs is so greatdrat 28'; of the Northwestern respondentsIvan' to tie (1111)1(15(v health insurance pre-miums to their dependents. age and SX.The stir\ Cl also indicates that 27(.7 of thetespl indents are ( onsidering prescreeninglamilx members betore extending cover-age (Or substance abuse ti:mm.111.27

Patient Cost SharingmpImets 1105e also responded to risinghealth can. «NI. ht inc reasing patient

titles and «Mist:lance lOr (-mendlicalth sC11 4CS. III 0 1986 sun ex, niplox-crs Indic and that increases in patient (1(-

tibles %%etc the most elle( live methodlot ( (mtaining (osts.2` The Foster I ligginsstint e' of C111111(0.C1 p1:111S111(11( aleS111,11 Ill(Ic(111( 111)Is 1( )1 79; of these plans wereraised between 1985 and 1988. The per-


centage of plans with a deductible of $150or more increased from -10% in 1986 to-17(7 in 1988.29

\Vhile deductibles have increased,many plans have implemented limits ontotal annual patient cost sharing rangingfrom S1,000 to 510,000 per family. In aRI.S survey of medium and large firmssponsoring health insurance, the percent-age of. employees covered by plans withmaximum cost-sharing limits increasedfrom about 20( %i in 1979 to about 82(...7 in1 988.3()Approx imatelv 7 of 10 participantsin health plans had an average maximmncost-sharing limit of less than 51,500, andonly 10(;; of participants bad a cost-shar-ing limit givater than S1,500. Only 3 yearsearlier, 916 of participants had cost-shar-ing limits greater than S2,000.

Employee Premium Contributions

\ lank employers require 1115.1 cm1)1("v"pay a portion of the premium for familycoverage. 111.S data indicate that the por-tion of employees whose health carepremiums were 1.1011V }mid by their em-ployer declined flow 72C; in 1980 to 61(!;-in 1989.3u 1986 survey of emphAersindicates that the average employee con-tribution for fitfully coverage was equal to`29(..; of the total premium compared withan average contribution of 1-1(.;. of thepremium for single coverage. In fact. :12'iof workers were required to pax- -10(,.. ormore of family premium costs.28 Acord-ing to a Wyatt 01111paIIV SIII-Vey, 111C aver-age employee contribution for familycoverage increased from S-135 in 1986 toS605 in 1989.27

The trend Iowan' increased contribu-tions for employee coverage may causemany workers Ic) decline dependent c(iy-rape which could result in an inct ease inthe number of uninsured children. Forexample, about 13.9'.f" (1.2 million) of alluninsured children have it parent with em-ploser health insurance on his or her jol)xn though nearly all employer healthplans have a dependent covet age(iption.31 .N.Ithough little is known aboutthis group, these max be children of work-ers who %yen. unable to afford the depend-ent oye. age premium. The affordabilityof dependent coverage is an importantconcur in view Of a Congressional1Zeseat (1) Sell ice ((:RS) analysis whichsuggests that the most dramatic trend illsources of health insurance between 1979and 1986 has been the decline in thepet cent of persons under 65 ,,tAerd as a

I'? "


dependent by another family member(34.3% in 1979 to 31.4% in 1986).32

Insurance Rating and AvailabilityPerhaps the most disconcerting trend inour health care financing system has beenthe erosion of insurance as a means ofpooling risk. In effect, we are rapidly mov-ing to an insurance system that is willing toinsure only health:. individuals. In theCadVdars of the health insurance industiv.all individuals paid a unifOrm community-rated premium. Community rating poolsthe cost of all health services provided in agiven region across all community mem-bers and sets a single uniform premium forall insured individuals. L'ilder a commu-nity-rated system, people who use lesseramounts of health care effecti;el subsi-dize the cost of care provided to sickerindividuals who use more services.Iowever, if one takes the long view, com-

munity rating assures that when healthyindividuals become ill they will receiveneeded health services while paving nogreater premium than other members ofthe community.

Community rating was brought to anend by competition among insurancecompanies. The apical marketing strategyfor an insurer is to attract business byoffering competitive premiums to only thehealthiest groups and limiting the in-surer's exposure by refusing to coverhealth conditions that were present befOrethe policy was issued. Renewal premiumsare adjusted based upon experience sothat premiums increase if the health statusof the group declines. lit today's system,most individuals pay a premium thatreflects their health status and typicalexpenditure patterns rather than theoverall average cost of health care in theircommunity.

Furthermore, insurers often engage ina practice known as medical underwritingwhich analyzes health characteristics of in-dividual group niembe.s to iclentin poten-tially high-risk individuals. Underwritingoccurs primarily in the small gomp andindividual insurance markets with the re-sult that slc ted people are denied cover-age through this process. To date, medicaluntlerwriting has been used infrequentlybs larger employers who are I:pie:illy sell=funded and or can effectively pool risk toreduce their exposure to large losses.

The demise of communin rating hasworked to the benefit of some and to thedetriment of others. I healthier indhiduals

benefit from this change because they pa:a premium that is often substantially lowerthan what they would have paid under acommunity-rated system. However, medi-cal underwriting has greatly increased pre-miums For sicker individuals and, in manyinstances, has left uninsured those most inneed of health coverage. Nloreoser, ashealthier people become sick, they oftenface dramatic increases in premiums andmay ultimately find themselves uninsured.

Insurer risk selection practices canhave a dramatic impact on fiunilies withchronically ill children. Many parents findthat they cannot change jobs without los-ing coverage for these children because ofpreexisting condition limitations. III somesmall groups, the presence of a singlechronicalh ill child can so increase premi-ums that the employer may terminate cov-erage. Moreover. as these chronically illchildren reach adulthood. they are Itolonger eligible for coverage as dependentsunder their parents' employer plans andmay not be able to obtain insurance ontheir own.

The Impact of BenefitPackages on Costs andon Children's Health Status

Using deductibles and coinsurance to in-crease patient cost sharing is an effctnemeans of reducing employer health plancosts. Cost sharing reduces health benefitscosts to the employer in two ways. First, itreduces the share or an individual's totalhealth spending which is paid for by theplan. Second, cost sharing creates an in-

126

centive for individuals to moderate theiruse of health services, resulting in an over-all reduction in utilization.

Many observers are concerned that re-duced utilization of certain services by chil-dren and pregnant women could result ina general decline in health status fOr manyof America's children. In response to thisconcern, many of the health reform pro-posals now before Congress would elimi-nate cost sharing for well-child andprenatal care to encourage use of theseservices. 3=3.34 Fortunately for policvmak-ers, there is a body of research document-ing the impact of cost sharing on thehealth status of children.

Research Design

The most authoritative research clone oncost sharing is based upon data from theHealth Insurance Experiment (HIE).The IIIE was a federally funded study ofthe effect of different levels of patient costsharing on health care use and healthstatus conducted during the 1970s. Fami-lies were randomly selected from six siteschosen to represent the four census re-gions and urban and rural areas.

Approximately 2,000 families werethen randomly enrolled for 3 to 5 yearsin one of l i different insurance planswith differing levels of cost sharing, andinformation about their health servicesutilization, costs, and health status wascollected. Approximately one third ofenrollees were assigned to a plan with nodeductibles or coinsurance. The remain-der were assigned to plans with varyingdegrees of cost sharing. While cost-shar-ing requirements differed across plans,all individuals were covered for an iden-tical package of services including ambu-latory and hospital care. preventiveservices. prescription drugs, and all den-tal services.

A critical feature of the IIIE is that itwas a randomised controlled 07.0 in whichfamilies were randomly assigned tohealth plans rather than permitted toselect their health coverage. This featureis important for evaluation purposeshecause individuals often select healthplans that suit their expected or desiredpattern of utilization. By randomly as-signing individuals to plans, the oh-served difference's in utilization thatresult from plan design can 1w distin-guished from the effects of health statusor individual preference-.

1 9


Cost Sharing and Service UtilizationThe HIE demonstrated that patient costsharing results in an overall reduction inutilization of health services few children.In general, hospital expenditures variedlittle among children insured with varyinglevels of cost sharing. I lowever, for office-based care, both annual costs and thenumber of episodes of care provided forchildren with cost sharing wet e about 30%below those with no cost sharing.35 Thefact that office-based utilization andcharges decreased by nearly equalamounts suggests that cost sharing did notcause families to seek care from lowerpriced physicians. Thus, the major impactof cost sharing appears to be on the num-ber of episodes of care received ratherthan on the price of that care oncereceived.

The HIE provides importantinsights into the cost ofeliminating cost sharing forchildren's preventive services.

The HIE data also indicate that utiliza-tion of preventive services was not dispro-portionately affected by cost sharing. Infact, these data indicated that cost sharingreduced utilization of preventive servicesamong children less than it reduced utili-zation for acute and chronic care epi-sodes.36 Thus, the I HE does not supportthe widely held notion that preventive careis more discretionary than other care andis therefore more sensitive to cost sharing.

The HIE provides important insightsinto the cost of eliminating cost sharingfor children's preventive services. Thesedata indicate that eliminating cost sharingfor these services would result in a 30C;increase in preventive services utilization:however. this overall increase in privatehealth insurance costs few children is likelyto be less than 5t7 because preventive serv-ices represent less than I51 .- of children'shealth expenditures.

While the HIE provides the most de-finitive data on the impact of cost sharing,these data are not strictly applicable to allof the polio initiatives under considera-tion today. For example. these data aremore than a decade old and do not re-flee tthe dramatic changes in medical practicepatterns that have occurred since that


time. Specifically, the data do not reflectthe general trend toward reduced inpa-tient utilization and increased use of out-patient treatments. Moreover, the HIEreflects the impact of overall family de-ductibles as well as individual deductibles.Thus, the utilization response under ch ild-only health policies could differ from theHIE experience.

Impact on Health Status

Analysis of the IIIE data indicates thatthe lower utilization associated with cost-sharing plans had no measurable impacton health status.37 The health status ofchildren in the various cost-sharingplans was compared on the basis of rwomeasures: objective physical examina-tions administered under the IIIE andsubjective health status reports providedby the individual. Little difference inhealth status was observed across thevarious types of cost-sharing plans undereither health status measure.

The results of the HIE study must betreated with caution because the data donot include a sufficiently large sample tomeasure the impact of cost sharing onat-risk children For example. thestudy indicated that poor children withcost sharing were more than twice aslikely to suffer front anemia than poorchildren with free care. This suggeststhat cost sharing may have a detrimentalimpact on health status for children inlow-income Ermines.

These results are generally consistentwith the results obtained in other studiesof service utilization and health status.'these studies provide little evidence thatadditional medical services result in im-proved health status fin children, exceptfor the poor. However, a study by Duttonanal Silber of alternative ambulatory caresettings with different cost-sharing require-ments indicated that small improvementsin health status were observed among chil-dren that do not face cost sharing. ;`-t

Policy Issues ConcerningPrivate Health Coveragefor ChildrenMore than 3(1 health care refinan hills havebeen introduced in Congress. Severalother proposals have been developed byinsurers. prat filer groups, and business as-sociations. While some of these proposals

private insurance and

cover all persons under a single govern-ment program, most of these proposalswould build upon the existing private in-surance system. Nearly all of the proposalsthat build upon the existing private insur-ance system would regulate insurancemarketing practices so that coverage isavailable to all regardless of health status.Some plans would provide incentives foremplovers and/or individuals to purchaseprivate insurance while others would re-quire that all individuals obtain insurance.These proposals typically emphasizeaccess to insurance for children and preg-nant women and often stress prenatal andwell-child care.

Universal Coverage for Children

The American Academy of Pediatrics(AAP) has proposed to require insurancecoverage finall pregnant women and chil-dren through the age of 21. The AAP planwould provide a comprehensive benefitspackage covering preventive services, in-patient care, prescription drugs, develop-mental disabilities, substance abusetreatment, nutritional supplements, andcounseling services related to parentaleducation and child abuse.-10 The planalso would require physician-directed case

4:4

13.)

4.

128

management programs for chronically illchildren to assure coordination of spe-cialty care, compatibility of drug therapies,and identification of families in need ofcounseling or health education services.The plan would eliminate cost sharing forpreventive care to encourage use ofperiodic health monitoring and screeningservices.

The AAP plan would require employ-ers to provide insurance to pregnantworkers, pregnant spouses of workers,and dependent children of workers. Allother children would be covered under astate-administered public program thatwould supplant theexisting Medicaid pro-gram fin- children and pregnant women.The AAP plan also would require thatpayment rates in the public plan be com-parable to those for privately insured in-dividuals to assure that provider paymentdifferentials do not create a second-classsystem of care for the economicallydisadvan taged.

The principle that a single tier of careshould be available to all regardless ofincome is reflected in many other healthreform plans also. Moreover, the AAP planreflects a growing sentiment that pfegnantwomen and children should be targetedtot au immediate expansion in access tohealth care.Health Insurance Market Reform

There is a growing C(»ISCIISIlti that ompe-finial in the insurance market should beregulated to make coverage available to allindividuals regardless of health status. Thelealth Insurance Association of America

(MIA) has proposed a program of mar-ket refOrms, as has the National Associa-

Although plans vary in significant ways, theycan be classified into three basic approaches: (1)mandated employer responsibility; (2) tax incen-tive programs; and (3) single payer approaches.

lion of insurance Commissions. [1w Presi-dent's I lealth Reform Initiative calls kminsurance market relOrin as do set endhealth care bills now before C.ongress.11The state of Connecticut recently imple-mented a program of market refiirms, andsimilar legislation is now pending beforseveral state legislatures including Mats -kind, Califiirnia, and Oregon.


While individual proposals differ, theyare all designed to restore insurance as ameans of pooling risk across society. Ingeneral, these reforms would require in-surers to cover all applicants and guaran-tee annual renewals of coverage.Exclusions of coverage for preexistingconditions would be severely restricted.Only minimal variations in premiumswould be permitted for differences inhealth status. For example, most proposalswould limit the variation in premiumscharged 1w an insurer to within 25u4, of theaverage premiums charged by the insurerfor all individuals in similar age and sexgroups. In most proposals, annual in-creases in premiums at time of renewalwould also he limited to Ito more than aspecified percentage (usually 159) in ex-cess of the average increase in health carecosts for all individuals covered by the in-surer. Most proposals also include a rein-surance mechanism that permits insurersto spread the (list of covering high-riskindividuals across all insured individuals.

Insurance market reforms would affectchildren's coverage in several ways. First,children with chronic health conditionswould he able to obtain insurance at agroup rate. This would be particularly rele-vant in the sale of child-only policies, butwould also affect the availability of de-pendent coverage for workers in smallfirms. Chronicall ill children also wouldbe able to obtain group-rated insurance asthey grow older and are no longer eligiblefOr dependent coverage under a parent'splan. Morei)Ver, Mans' healthy childrenmight obtain insurance if the overall costof family coverage were reduced for fami-lies with high-risk adult members.

\Utile these proposals would restoreinsurance as a risk-pooling mechanism,they typically stop short of reestablishinga community rating system. Most propos-als would permit variations in premiumsby age, sex, and geographic. region. Pre-mium variations by health status are alsopermitted subject to premium variationlimitations. The purpose (4' these propos-als is to impose a pooling of risk for insuredindividuals while permitting price compe-tition among insurers.

.1Ithough insurance market refOrmswould reduce health insurance costs fiircertain individuals, these refOrms woulddo little to change the overall average costof health cart- except to the extent that the

of underwriting practices re-

13 ^,


duces administrative costs. In fact, averagecosts could actually increase as high-riskindividuals who do not now have insur-ance obtain coverage and enter thebroader private insurance risk pool.Although the pooling of risk implied bythese refOrms can he expected to reducepremiums for high-risk individuals whonow purchase insurance, risk pooling willinevitably result in premium increases forlower-risk individuals who nosy enjoy favor-able premium rates. Thus, a restoration ofrisk pooling in our insurance SVSIC111 will1110VC us hack toward a SVSICIII where lower-risk individuals subsidize health costs ftn.high-risk cases and stay aCtlIalh; increasethe overall average cost of health insur-ance and health care.

Toward Universal Coverage

Most health reform plans are intended toextend coverage to all uninsured personsregardless of age. Although plans vary insignificant ways, they can be classified intothree basic approaches: (1) mandated em-ployer responsibility: (2) tax incentive pro-grams: and (3) single payer approaches.Although these plans would extend cover-age to all children, the benefits providedunder these proposals are typically lesswell tailored to the special needs of chil-dren than are child-only plans such as theone proposed by AAP.

Employer Responsibility

In 1988, Sen. Edward Kennedy (I) -MA)and Rep. Ilenry Waxman WA ) jointlyintroduced a bill that would require allemployers to cover their workers and theirdependents. 42 Since that time. the authorsof the bill have shifted their support to thepay-or-play approach. which gives employ-ers the option of paying a tax and hayingtheir workers covered under a public planin lien of providing employees with privateinsurance. however, both the employermandate and the pay-or-play approachestablish that employers are responsiblefor covering their workers. The pay-(if-playapproach is now embodied in the HealthAmerica Act currently under considera-tion by Congress.

The Health America Act (S. 1227)specifies a minimum standard benefitspackage to be provided I4) all individualswhich includes well-child care, prenatalcare, and substance abuse treatment. Thebill also includes insurance market reformsthat are designed to extend coverage to allindividuals while substantially restrictingvariations in pi etniums resulting from

changes in health status. Indeed, an em-ployer mandate could not be effective un-less accompanied by regulations makinginsurance available to all individuals.

Tax Credit Program

The I leritage Foundation has developed aprogram that would replace our existingsystem of employer-based coverage with arequirement that all individuals purchaseinsurance.-ti Employers would be requiredto convert their current contributions towages, which would then become taxableto the employee. The increase in tax reve-nues would be used to finance a tax creditto individuals, which would vary withincome and the cost of insurance. Thisproposal also includes insurance marketrefOrms designed to assure the availabilityof. insurance coverage and limit the vari-ation in premiums by health status.

The purpose of the I leritage Founda-tion proposal is to make individuals moreconscious of the cost of care they consumeby requiring that they purchase insuranceout of their income. The plan does notspeciti a minimum benefits package sothat individuals would be permitted to de-lete coverage for selected benefits. Thismay result in reductions in coverage Un-important child health services such aspreventive care.

Single Payer

Several bills have been introduced whichwould eliminate private insurance andcover all Americans under }Medicare." orcover all Americans under a single govern-ment program modeled on the Canadiansystem..15 I however, a publicly financed na-tional !width insurance plan does not nec-essarily mean the end of private insurance.For example, the !health USA Act intro-duced 1 »-Sen, 1. Robert kerrey of Nebraskawould establish a publicly financed na-tional health insurance program in whichindividuals choose among insurers com-peting on the basis of price and quality)} I

Cost Containment

The share of our gross national 1)1.0(111(.1devoted to health care increased from9.1 <!; in 1980 to 12.2% by 1990. Yet, despitethis dramatic increase in the share of ournational wealth devoted to the health sec-tor, the number of persons without healthinsurance increased by 9 million dimingthis same 1),-60(1.16 As costs have t isen,fewer and fewer employers ',Ind familieshave been able to afford insurance cover-age. Indeed, controlling costs is widely

131.

130

seen as essential to maintaining even theexisting level of insurance coverage.

Cost containment is a central theme ofnearly all of the health reform plans nowbefore Congress. However, the proposedmethods for controlling costs vary acrossproposals. The most frequently suggestedcost containment strategies are competi-tion in the health care market, managedcare, and global budgeting. The first twohave been tried in the United States withvarying degrees of success. The third, acommon feature in countries with nationalhealth insurance, is virtually nonexistent inthe United States.47

CompetitionCompetition as a means of controllingcosts is emphasized in several reformproposals, including the Heritage Foun-dation plan and the Health USA Act. Ina competitive market, there are enoughproducers of a particular product to al-low consumers to shop around andchoose the one with the optimal combi-nation of price and quality. The argu-ment is that if one creates anenvironment in which the consumer (forexample, an employer group) chooses to

Though typically thought of as a means ofexpanding insurance coverage, extensive reformsof the health care system may be needed just topreserve the existing level of private insurancecoverage.11111=11111416.

use only those producers (for example,hospitals) that sell high-quality. cost-ef-fective products (in this instance, healthcare), the other producers will eitherexit the market, reduce their prices, orincrease their quality to remain competi-tive. PPOs employ a competitive marketstrategy. The PPO contracts with se-lected hospitals and physicians, often ne-gotiating discounts off current charges,and provides financial incentives for theinsured population to use PPO networkproviders.

One of the problems with the com-petitive model, however, is that individu-als may not find the PPO's financialincentives persuasive if the network doesnot include their personal physicians orthe hospitals to which they refer. A more


fundamental problem with the competi-tive model may be that consumers ofhealth care services may not knowenough about their condition and ap-propriate therapy to shop around forcost-effective, high-quality care.

Managed Care

Many proposals would place greater em-phasis on expanded use of managed careand medical practice outcomes research.While there is some evidence that cer-tain managed care programs such as casemanagement do control costs, few com-prehensive evaluations of managed careprograms have been completed. Accord-ing to some industry observers, managedcare would successfully control costs onlyif the entire population were enrolled inclosed provider networks with a highdegree of care management.48 Many ofthe health reform proposals now beforeCongress would seek to expand man-aged care. For example, the HealthAmerica Act would preempt state lawsthat restrict the use of HMOs or selectivecontracting. This bill would also requirethat HMOs be available to small groupsand that managed care plans he availableto persons covered under publiclyfinanced health programs. Several billsalso propose to organize small employ-ers to negotiate provider discounts.

The effectiveness of managed carecould also improve as research on medicaloutcomes and on medical practiceparameters is further expanded. There isa growing body of research on the effec-tiveness of medical procedures. Thisresearch is being used to develop medicalpractice guidelines for managed care set-tings to eliminate unnecessary proce-dures and improve quality. Medicalpractice guidelines could also help ration-alize malpractice awards and reduce thepractice of defensive medicine by provid-ing empirically based standards of appro-priate care. While there are significantpotential benefits to medical outcomesresearch, it is unclear whether the devel-opment of medical practice guidelineswill reduce health care costs. For exam-ple, for some conditions these guidelinesare likely to recommend procedures thatcould result in net increases in health carecosts. Moreover, the potential impact ofoutcomes research on children's health isdifficult to assess because much of theresearch done to date has focused on theMedicare population.


Global Budgeting

Global budgeting is the process wherebysome portion of total health expendituresis paid according to a prospectively deter-mined (typically negotiated) annualbudget. Global budgets are commonlyimplemented in countries with nationalhealth insurance, particularly in the hospi-tal sector, where operating budgets areused also for planning purposes. It isharder to impose budget ceilings on physi-cian services, although West Germany hassuccessfully done so for many years. Arecent study by the General AccountingOffice ((:AO) estimated that globalbudgets reduced health care spending inreal terms by 9% in the hospital sector inFrance and by 17% in the physician sectorin West Germany.-19

While global budgets appear to be ef-fective in controlling health care costs,there is some evidence that they may leadto nun-price rationing of services and shift-ing of costs from the pavers (for example,the federal and regional governments) tothe citizens, primarily in the form of thelong waits associated with access to manyservices. Queuing is most common fornonemergency services such as diagnostictests and elective surgeries. There is littleevidence, however, that children are ad-versely affected by queuing. In fact, infantmortality rates in other developed coun-tries using global budgeting tend to be farIOWC1 than those in the United States.5(e

ConclusionsPrivate health insurance is the primarysource of coverage for America's chil-

dren and pregnant women. Access toprivate health coverage is threatened bythe spiraling cost of health care, costshifting, and insurance marketing prac-tices which tend to deny coverage tohigh-risk individuals. These pressuresthreaten to increase the number ofuninsured pet-sons and reduce the levelof coverage for persons who remain in-sured. These changes will ultimatelyresult in increased pressure On govern-ment programs to care for our nation'suninsured children.

Efforts should be taken to preservethe stability of our private insurancesystem. Reimbursement under publicprograms should be sufficient to reducethe cost shifting that is compounding thegrowth in private insurance costs. Insur-ance marketing practices should be re-formed to guarantee the availability ofcoverage to all groups by restoring insur-ance as a means of pooling risk. Aggres-sive cost containment efforts should alsohe initiated involving competition, man-aged care, and possibly global spendinglimits.

The rising cost of health servicesthreatens to transform health care intoa luxury good affordable only by higher-inome Americans. This will represent aparticular hardship fot America's chil-dren, a disproportionate share of whomare living below the poverty line. Thoughtypically thought of as a means of ex-panding insurance coverage, extensivereforms of the health care system may beneeded just to preserve the existing levelof private insurance coverage.

1. 1.ewin-1CF analysis of the March 1990 Current Population Sursev ;CPS) Data.

2. Kronick, R. Health insurance. 1978-1989: The frayed connection between employmentand insurance. inquiry (Winter 1991) 28:318-32.

3. American A.cadems of Pediatric s. Chilebn fink A Itgichtiive propmal. Washington, 1)C, 1990.

1. liealth ln,tir nu c . \ssuc iation Of America. Source Borth of Health I walmute Data, 1990. Wash-Mom. DC: 111,1A, 1990, pp. 29-30.

5. Although tisk pooling minimi/s a large group's need to insure against large unatmt ipatedexpenditures, most employers liciose to pass on some or all of the risk associated with un-xpectd «ists to an insurer that c an reduce risk even further by pooling the experiences

of malts large groups.

Apprisd SCI'N ices are those that are (I) considered coveted by the policy guidelines (torexanilile, most polit ies do notnotcoyes experimental procedures) and (2) determined to hemedic alh IICC eSS:CV (11 appl opi late (lot example. «ismetic stirger is considered mechcalls nec tsar (ink in spec ith situations). ht some managed (are arumgctnents, servicesmust he peril)! med IA a select group of providers to he approved for payment.

7. Sri' note no. 1, Ill.\ p. 29.

1?:


8. Congressional Research Snice. insurame and the uninsured: Background data andanalysis. Washington, DC: Congressional Research Service. Mat 1988.

9. \fanning. W.G., et al. A controlled trial on the ef feels of a prepaid group practice on use ofset's ices. New England Inertial ol Millie-Me (lune 1984) 310.23:1505-1510.

10. Higgins. AT. lien//h mre benefits %ann. 19S9: Indemnity Nuns. Ness' A. Foster I ligginsCompany, lnc., 1990. p. 13.

I I. Feldstein, et al. Pri5ate cost containment. The effects of mili/ation reties: programs on

131(1'8a1,2tif1:7:11r1(f 11.1-1 sic it't:81(81)e xpc n (1 i-

tures. Medical Cate Review(Fall 1990):327-03; In silt tite of Med:rine. Cmilrellingew, andnb.ring patient entr?: The role of lath:talon management. October 18. 1989. AVashington,

National Academy Press. 1989.

12. See note no. 10, I liggins. p. 32.

13. See note no. 10, I liggins, p. 11.

14. Bureau of Labor Statistics. Employer benefits in small prewar establishments. 199Q Washington.DC: l'.5. Government Printing Office. September 1991. Table 5 -I.

15. See note no. 10. Higgins. p. 12.

I (I. See note mt. 4, 111.N.N, p. 53.

17. Personal (411111Millica11011, Gretchen f 'anis. Florida Steel Corp.. October 11192.

18. For a discussion of issues related to CPS estimates regarding the uninsured population. seekronick. R. Adolescent health insuraner status: Analysis of bends in owerage and preliminary esti-mates on the ellee Is of an employer mandate and a Alediraid rxpancion nn therurrin Sa d-Back-ground paper. Vashington. DC; U.S. Congress Office of Technolop .Assessment.Jith 1989.

19. Moran. D., and Shik. Employer cost-shifting expenditures. Unpublished research paperprepated for the National Association of Nlanufactuvers. September 12, 1991.

20. Group Health Ass( )(I:Ilion of America. National direr/my of HMOs. AVashinguni. DC: GI IAA.1990.

21. tint! Ccrino. Td. I lealth benef its---t he employer role. In 1.30'i/1)nm/took on

Employee Benefits. Washington. D(:: Em plot cc Benefit Resear( It Instil ute, 1990, p.

22. Iliggins Health tare In:wlts suite-v. 1989: Indemnity plans-Cost, design and faulting.Princeton. NJ: A. Foster Higgins K Company, Inc., 1990.

23. \Valker. (:. Ilalthy babies For health% companies. Business & I ImIth (\En 1991 1:29-35.

2-1. iitker. A. An ounce of pre5ention. linsinns & !midi (1)(:(inbet. 19911 :17.

25. Meters, I..(:. A center of estcelleme for asthma: Case management at its best. //1/(1 /PPOTrends (February March 19921 5.1.

21. lim :tit 0) .1.abor Statistics. Etitpfever hemjits ice nte'ditott a)/(1 huge firms. 11)811. IVasliing1( III, l)(::

l'.S.1)epartinent of 1.abor,Itme 1990.

27. I lam. The [inur of dependent health benefits. Business & Health (Sptembet19891:19-21.

28. 1(1: Incorporate( I. I fetal!, talc tort:mgt. and easts en small and !awe lite shrew's. Final report pr -Nred for the 011i( e .1(15o( an. 1.S. Small Business .Adininistration..April 15. 1987.

29. Higgins. A.F. //ti/i/t wit /true/its %win I98;. Prin«.toli. Foster Higgins S.: Compass.

Inc.. 11)88.

30. Bute:tit ()I Itilior Statistics. Etttp/5):(. Benefits in Medium and Large Firms, PISS. \Vashington,DC: 1..5. 1)epaitinent of Laboi, June 1989.

Ncedlinati,.J., 1101(1..f.. Sheils..I.. et al. 1/,, hea/th (ale linteming %Oen, and the nianstin el. Re-

poi I 10 the Orli( e of Reseal (11. Health Cale Financing .Administration. April 1. 1990.

32. Congressional Research Set 50 es. Libi ai 5 of ( :(ingress. I 'Mill! alld the' 1(11111sIlled:

Barktvenual theta and analysis. Mats 1988, pp. 1111-111 . Table 48.

:13. Ss the I R.altli .Aitiet it a .\( t. S. 1227 119911, introduced by Sen. George]. Nlit( hell(1)-\11).

ti. See the 1 icalth 'ti . 5. 1 116 1 1991 I. inn witt«.(1 he tic.11..i. 12obei (. (1)-NF.I.

And" s". GAL. lic")k. R.. and Villimns. A. A 0191a11 imill of «(51"!1Iiing torsos h et "ITVElle( is on the demand for obi( e-based medical ( .11ethta/ Cate (Septeln-

bt 1991129,9:890-98.


36. Leibowitz. A., et al. Effect of cost-sharing on the use of medical services 1-: children: In-terim results from a randomized controlled trial. Pediatrics (Ma) 1985)75.5:942-50.

37. Burciaga Valdez, R.O. The effects of cast sharing 00 the health of children. RAND Corporation.March 1986. Prepared for the U.S. Department of Health and Human Services.

38. V miller reason the HIE may not be useful in assessing the impact of cost sharing on poorchildren is that the experimental insurance package had annual expenditure ceilings thatwere fixed as a proportion of family income. This diluted the effects of cost sharing onpoor families, who reached the expenditure ceilings more quickly than higher incomefamilies and then were eligible for free care the rest of the year. Most real-world insuranceplans have expenditure ceilings nondnally fixed for all beneficiaries regardless of familyincome. As a result poor families could face substantial cost-sharing requirements formost of a scar which might serve as a more substantial deterrent to utilization than mod-eled in the HIE. Starfield, B., and Dutton, D. Care, costs, and health: Reactions to and re-interpretation of the Rand findings. Pediatrirs (October 1983)76,4:614-21.

39. Dutton, D.M., and R.S. Sillier. Children's health outcomes in six different ambulatory caredelivers systems. Medied Care (1980118.7:693-713.

40. American Academy of l'ediatrics. Children first: A legislative proposal. Washington, DC: AAP,1990.

41. Exectithe Office of the President. The Presidentis rompwhensive health reform prof.,rram. Washing-ton, DC., Februar) 6, 1992.

12. The Basic Health Benefits for All Americans Act, S. 768 (1988) introduced bs Sen. EdwardKennedy (D-MA) and Rep. Henry A. Waxman (1) -CA).

-13. Butler. S.M. Assuring affordable health rinepr Antenrans. Washington, DC: The HeritageFoundation, 1991.

14. The Medplan Act of 1991, H.R. 650 (1991) introduced by Rep. Pete (Fortner) Stark(D-CA).

45. The Universal Health Care Act, H.R. 1300 (1991) introduced by Rep. Mart.- Russo (D-11.1.

-16. Sheik,,). The impact of the Health America Act on health spending. Testimony before theSenate Finance Subcommittee on Health for Families and the Uninsured, September 23,1991.

47. The health care delivery system of the Department of Veterans' Affairs is probably the onlyexception to this rule. Its sole source of revenue is the federal government, which deter-mines a global budget for the VA system prospectively.

-18. Moran, D. W.. and Wolfe, P.R. Can managed care really control costs:. Health Affairs (Winter19911 pp. 120-28.

49. General accounting Office. firath rare spending control: The experience of hymn', Germany, andJapan. Gaithersburg: GAO, November 1991, pp. 46-47.

50. Aaron, I I. Srrious and unstable condition. Washington, DC: The Brookings Institution,1991, p. 79.

Ian T. Hill, M.A.,director of

Maternal and ChildHealth Projects atHealth Systems Re-search, Inc_ inWashington, D.C.

The Role of Medicaidand Other GovernmentPrograms in ProvidingMedical Care forChildren and PregnantWomenIan T. Hill

Abstract

This article provides an overview of the major federal and state health care programsserving children and pregnant women. including Medicaid, the Maternal and ChildHealth Block Grant Program, the Community and Migrant Ilealth Center Program,and the Special Supplemental Food Program fin- Women, Infants, and Children. Adetailed description of key amendments to the federal Medicaid statute whichsubstantially expanded the number of pregnant women and children eligible /w-het-let-its is presented along with a discussion of the creative refinms of eligibility andservice delivery systems some states implemented to expand utilization of prenatalcare. Early evaluation results indicate that these perinatal reforms appear to he

having a positive impact on both infants and pregnant women. An assessment of thepossible impact of recent Medicaid expansions on children's access to medical carereveals that progress has been slow. States have not yet undertaken substantialinitiatives to improve the accessibility and efficacy of child health programs. Theauthor ccmcludes, however, that creative efforts by a growing number of states givereason to be cautiously optimistic about the prospect of progress in the future.

The latter half of the I 9S0s witnessed dramatic expansion in theroles that state and federal governments play in providing andfinancing perinatal and well-child care in America. Sweeping

initiatives were begun that have the potential to commit vastly larger sumsof public monies to the support of maternal and child health. Expandingthe delivery of prenatal care became a cause that attracted support acrossthe political spectrum, on the grounds that expanded coverage was botha humane course to take and an efficient. investment in our nation'sfuture)

Yet the manner in which change was achieved by expanding eligi-bility for pregnant women and young children under the Medicaidprogramhas raised a number of questions regarding the appropriateand potential roles of government in serving these populations. Ques-tions that have arisen include the following:

Is an insurance program like Medicaid the best vehicle to improve thehealth status of mothers and children?

Can a program that has such a strong historical link to the publicwelfare system escape that system's stigma and be fully embraced as apositive public health care program by mothers and families?

Can families' access to care be improved if the vehicle chosen toaccomplish this goal is a financing program that is held in such negativeregard by much of the private physician community?

Would government funds be better spent by increasing support forprograms other than Medicaid that directly provide, rather than justfinance, prenatal and well-child care?

Would real access he achieved more expeditiously by targeting dollarsto expand the capacity of such public providers as state and local healthdepartment clinics and community and migrant health centers?

"Ibis article describes the rapid evolution of this country's publiclysubsidized systems of health care for pregnant women and children whichhas taken place during the past a years. First, an overview of the variousmajor federal and state programs is provided. Second, a detailed descrip-tion of the key amendments in the federal Medicaid statute that enabledits expansion is presented along with a discussion of the flexibility utilizedby states to implement creative reforms of eligibility and service deliverysystems. Also included arc early evaluation results which indicate thepositive impact that perinatal refOrms appear to be haying on both theinsurance and health status of mothers and infants. Finally, an assessmentof the possible impact of recent Nledicaid expansions on children's accessto medical care is presented.

An Overview ofGovernment ProgramsServing Pregnant Womenand ChildrenMain government programs sent. disad-\ antaged pregnant mothei s and theit chit-(it en. Some Ill >Id these populations astheir sole target. while ()the; sere a much

broader population. Some progiams aidesigned to Iniance care by reimbursingfn ol icier, for rendering care. %\ bile odic;programs subsiclire the direct provision ofservices. Some programs are hilly mini in is-tel ed In federal agencies and operate un-dr I edcral vhile others shareresponsibility lor management and rulemaking bencen ledet at and stair level, Of

gmrnment. .11)praring brink% are brief

1 33

1

136

descriptions Of these programstheir ob-jectives, organ i/ation, administration, andfinancing.

MedicaidCreated in 1965 as Title NIX of the SocialSecurity Act. the Medicaid program haslong been the primary public prognimsupporting the pros ision of health careservices to love income Americans. Today.the program insures an estimated 26 mil-lion persons at an annual cost olapproxi-mauls- S90 billion.:

State Medicaid programs are requiredto extend to program recipients a rich setof health care benefits. including inpa-tient and outpatient hospital services, phy-sician services, rural health clinic services.laboratory and x-ray services. skilled nurs-ing facility and home health services forpersons over age 21, family planning sell"-ices and supplies, and nurs-midwile serv-ices. States provide for well-child caredining-1i their basic Nledicaid programs. Inaddition, under the Earls- and Periodic-Screening, Diagnosis, and treatment(F.PSDT1 Program, the federal gosern-IIIIII IllatIdatC.: that all states provide earlszinc' periodic screening. diagnosis. andtreatment services to eligible childrenunder age 2 1.3

Several characteristics set theMedicaid program apart frommost public health programsand contribute to its oftendaunting complexity.

States have the option of adding to thispackage a broad range of es. includ-ing but not limited to prescription drugs;physical, occupational, and speech thera-pies: case management: hospice. dental.and respirator. care: and services renderedin intermediate care facilities lot the men-tails retarded. States also !lase the flexibil-ity to define limits on the coverage of theseservices: therefor, considerable variationexists among the states in both the rangeof services covered and dle allIdttlit of ( areprovided tinder each categors.

Several chin acterist is s set the Medic aidpt ()giant apart from most public healthprograms and «ffitribute to its oftendaunting complexity. 1 hese chat a(-wrist ics are its I011ows:


Nledicaid is jointls administered In thefederal and slate governments. At the fed-eral level, under the direction of theHealth Care Financing Administration,broad regulations dictate the overall struc-ture of the program and its covered serv-ices. States. however. retain significantflexibility to establish income eligibility cri-teria, determine which among a long listof optional services to Myer, and set paV-mem rates for providers. This flexibilityhas resulted in wide variability among stateprograms with s1 nue programs beingmuch nu we gene-on:. than others.

Medicaid operates as a financing pro-gram rather than as a service delivers.system. .\s third-parts payers, state pro-grams directls reimburse providers of careupon the submission of a bill fin- servicesrendered to an eligible individual. Thefederal government then pays a percent-age of each state's expenditures with thepercentage based on the state's per capitaincome. In no state does the federal goy-eminent pm less than 50`.:?" of programcosts. In the poorest states, the federalshare can rise to more than SW:r"

Medicaid is II wort-tic-alb an open-endedentitlement program. Rather than operat-ing within a specified mutual budget, it isrequired to extend all medically necessarysers ic es to ail persons who quaffs.. Medi-caid administrators can exercise sonic con-trol over spending by selecting whichoptional benefits to cover, choosing- whereto set provider reimbursement rates. insti-tuting medical necessity and mill/adult 11.-views. and placing upper limits on theamount. duration, and scup. of cos (Tedservices. The open-ended nature of Medi-caid, howeser, has contributed signifi-can tb to its extremels rapid rate of growthin recent years. For example, after adjust-ing fin- general inflation, real Medicaidexpenditures grew by 34'; between I(141and 1988. Between 1 988 and 1 990, expen-ditures grew hs 23'; and then by 22(7( in1991 alone.'

The roots of Medicaid's eligibility rulesare linked to those of various public wel-fare programs. Medicaid was originallycreated as an additional benefit that per-sons eligible for welfare would receivealong \snit their cash assistance payment.Specificalls. Medicaid Wits prOVICICd, to1%0111(11 and children eligible fen the Aid toFamilies with Dependent Children(AFD(:) program, and to aged, blind, ordisabled individuals rrucising Supplemn-

13D


tal Security Income (SSI) cash benefits.These categorical links created a programthat is not available to even poor person.Rather, it is available to very divergentsubsets of the poor. Additionally, thislinkage creates a situation whereby astate's political outlook toward welfareassistlaice has a direct impact on its poli-cies fOr health care coverage. For exam-ple. in Alabama, Medicaid coverage hasbeen limited by Yen strict eligibility cri-teria for .AFDC. AFDC eligibility criterialimit cash assistance to families withincomes below I 5(;; of the federal pov-ell.. level.

Medicaid's specific intent has newt-been to improve pregnanc\ outcomes orredUee infant mortality: however, womenand children have always been the hugestportion of Nledicaid recipients (curl-club.approximately 75'; ). The coverage of pre-ventive, primary. and acute care servicesincluding prenatal, &liven, postpartum.and well-child carehave also ahvays beenmandatory components of each state'sNledicaid benefit package. Ironically,because of the relatively low costs associ-ated with such care, spending on theseNCIIICCS has typically consumed only 25'iof total Medicaid expenditures. Long-term care services. required by aged anddisabled populations, are responsible forroughh 75(.; of Nledicaid spending. 1

The Maternal and Child Health BlockGrant Program

Title V of the Social Securit \ Act, passedin 1<9 °S5, authorised federal monies to bespent to identify, assess, and wive thehealth care needs of women and chil-dren, particularly those wit h lowincomes or with limited access to care.Grant monies generalh were allocated tothe states on a formula basis, with statesmatching- the federal allotments withtheir own funds.

The most important change in theprogram occulted in 198 1 when the Ma-ternal and Child Health (N1(1 I ) RlockGrant Program was created. Sevenseparate categorical programs were con-solidated to create a single block grant.In return for an overall decrease in fed-eral monies. stales were given greaterflexibilit \ to determine how .o targetgrant rsom «.s and develop sonicdeliver 55

States hate af ted unique ,nisi inch id-ual I pt ()grains and. the! clove. it is

difficult to describe the typical program.

(:otinon traits that zir shared across statepr()grants are described below.

Rather than fallowing a specific fOrmulalike Medicaid. state MCI I programs con-tribute roughly S3 in matching funds fOrevery SI in federal funds they receive. Inaddition, because the program is not anentitlement, state NICI I programs must op-erate within each vein's appropriatedbudget.

NICI I programs tt pi( all support the di-rect deliver of services in public healthcare settings, either state or locally :Amin-isterd health department clinics. Dollarsare used to hire clinical and administrativestaff, contract with prhatc ph\ sicians tostall public clinics. and purchase medicalsupplies and equipment, among otherthings. In nearly all states, the program isdivided into two separate components: an\1(:I1 program that provides pre\ entiveand primary care to families and a childrenwith special health care needs componentthat provides chronic and long-term caresee ices to disabled children.

The programs generall\ adliet to in-mine eligibilm limits set at 1876 of thefederal poverty level.

NVItil state flNibilitv is the hallinal k oIthe bloc k gram philosoph \ recent amend-

If 1

0

138

moms to Title V have begun to restrictstates' autonomy. The Omnibus BudgetReconciliation Act of 1989 (OBRA-89), forexample. contained new requirementsthat states must spend no more than 10'of program funds on administrative costs,at least 30ci for preventive and pi imarkcare for children. and at least 30e; forservices kw children with special healthcare needs. This laes up to 30c; of pro-gram dollars fO prenatal and maternitycare provision.''

For federal fiscal vcar 1992. the N1C11Muck Gra" appropriation was S65() mil-lion.' In sheer site, the program is dwarfedb. the Nledicaid prc>gr;n in every state.I lower, in ter:ns of power. these pro-grams often assume a cry prominent rolein state health departments and exert in-creasing- influence over the shape and di-rection of states' perinatal and well-childcare deliver.. systems.

The Community and Migrant HealthCenter Program

Fccterally Raided communitY and migranthealth centers (1. ' receive directgrants from the federal government andoperate largeh outside the 'MIA iW of til:M',111(1 local goyernmnts. Thev were estab-lished in 1965 as a system through whichcomprehensive primary care services

mld be delivered to individuals and fami-lies W110 lack itetiti to health servicesbecause of geographic isolation, providershortages, or financial barriers. To it'll-illtheir mandate, specified in Sc'( dons 329and ',130 of the Public Health Service Act.centers must serve areas designated asmedicallv timid-served: provide basic pri-mary medical care services plus support

FI LA CLINICA DE LA RAZA

0


and facilitating services appropriate forthe target population; have a governingboard the majority of whose members areusers of their services; and adjust the costof services to the patient's ability to pay.8

Community health centers havebeen found to reduce infantdeaths by up to 40% is thecommunities they serve.

Centers have always placed high prior-ity on reducing in butt mortality and im-proving the health of mothers am.'children. Community health centers havebeen found to reduce infant deaths bv upto -10'.; in the communities they serve; andin 1987, 1 in 10 low-income infants bornin the United States had a mother whoreceived maternity care at a ommunitY Ormigrant health rimier.''

In the late 1980s Congress targetedC HCs as one of the vehicles to improvematernal and child health. In 1987. specialfunds were appropriated to the C ,NIIprogram to conduct a 1-s ear demonstra-tion project to enhance its capacity to re-spond to the needs of disadvantagedpregnant women and their infants. TheComprehensive Perinatal Care Program((:PCP) received just user S20 million,which was targeted to centers located incommunities experiencing high rates ofinfant mortality and inadequate access toprenatal care. Under this initiative, ap-proximately half of the nearly 600 centersacross the cotnitry received funding dur-ing calendar Year 1988, which supportedthe provision of enhanced care to morethan 100.000 pregnant women and .11,000infants.'' lit I9x8, because Of success ofthe CPCP, Congress made it a permai tetpart of the C MI1C program and in-creased funding fin- the initialise in thatand subsequent years.

Fot federal fiscal year 1991. the appro-priation for community and !Mgt anthealth centers totaled S;t:i0 million. Incomparison to \ludic-aid, the program is asmall on. Its impact. however, as a key[niblick subsidiled primatT care deliverysystem is significant. In 1989, C ICssend! nearh 6 million individuals. Ap-proximately 1.3 million of those patientswere women of childbearing age. and 2.1million wet e children under age 15.9.11)

14i


The Special Supplemental FoodProgram for Women, Infants, andChildren

The Special Supplemental Food Programfor Women, Infants, and Children (WIC)was created in 1972 as an amendment tothe Child Nutrition Act of 1966. Adminis-tered by the Department of Agriculture'sFood and Nutrition Service. WIC distrib-utes funds to the states to provide supple-mental food to low-income pregnantwomen, nursing mothers, and children di-agnosed as being at, nutritional risk. WICalso provides nutrition education and en-hances access to health care services forthose who are eligible for the program.

Although strictly speaking WIC is nota health care program, evaluation:: havefound WIC to he effective in reducing in-fant mortality, low birth weight. anemia,and other health problems.' "3 Becauseparticipation in WIC significantly reducesthe chances of prematurity and low birthweight and the extraordinary costs of neo-natal intensive care, the savings can besubstantial.14 A recent study concludedthat every dollar spent on WIC for preg-nant women saves between $1.77 and$3.13 in Medicaid costs for new mothersand their infants during the first 60 daysafter birth.t5

State Programs

In addition to the programs describedabove, state and local governments sup-port a plethora of additional health careprograms for mothers and children. Suchprograms are often designed to dovetailwith state Medicaid programs. Examplesof these programs are the following:

In Minnesota, the Children's HealthPlan provides health insurance for chil-dren up to age 18 in families with incomesbelow 185% of the federal poverty level.

The Maine Health Program covers chil-dren up to age 19 in families with incomesbelow 125% of poverty (with no restric-tions on assets).

New York's Child Health Plus Programpurchases private healtn insurance for alluninsured children up to age 13 living infamilies with incomes below 185% of thefederal poverty level.

In Vermont. the Dr. Dynasatir Programcovers children under age 7 to 225% ofpoverty and pregnant women up to 200%of povern.

Washington covers children up to age 18in families with incomes below 100% ofpoverty.

Wisconsin covers children between theages of 2 and 6 in families with incomesbetween 133% and 155% of poverty.

By covering the same or similar bene-fits for families that possess too much in-come to qualify for Medicaid, or forchildren who are older than an individualstate's upper age limit for Medicaid, theseprograms attempt to broaden the safetynet of coverage using entirely state and/orlocal monies.

Medicaid and Its NewRole as the PrimaryVehicle for ExpandingCare for Pregnant Women

By 1985, the research literature had dem-onstrated that lack of health insurance wasan important barrier to prenatal care forlow-income women.16 Yet the Medicaidprogram no longer held the capacity toprovide appropriately for these popula-tions because of a steady erosion in eligi-bility limits, which were tied to incomeeligibility thresholds for AFDC pro-grams.17 In response to this problem, theOmnibus Budget Reconciliation Act of1986 (OBRA-86) allowed states the flexi-bility to sever the traditional links betweenMedicaid and AFDC and to establish spe-cial income eligibility thresholds abovethose established for their AFDC pro-grams that could be as high as the federalpoverty level for pregnant women, infants,and children up to the age of 5.

In subsequent years, eligibility ruleswere liberalized further. The OmnibusBudget Reconciliation Act of 1987(OBRA-87) gave states the additional op-tion of raising income thresholds for preg-nant women and infants up to 185% of thepoverty level, and to raise poverty-level cov-erage of older children up to the age of 8.The Medicare Catastrophic Care Amend-ments (MCCA) of 1988 transformed whathad been optional authority into a man-date by requiring states that had not al-ready expanded coverage of pregnantwomen and infants to the poverty level todo so over a 2-year phase-in period. TheOmnibus Budget Reconciliation Act of1989 (OBRA-89) superseded MCCA'smandate schedule by requiring all statesto cover, at minimum. pregnant women

1 4 2

139

140

and children tip to b Years of age at 133';-.of poverty, beginning in April 1990. Fi-nally, OBRA-90 called !Or states to phasein by the rear 2001 coverage tin- all chil-dren up to age 19 in fitmilies with incomesbelow 100% of the poverty level.

States Respond Aggressively to NewFlexibility

States responded quickly to the passage ofthe various Medicaid expansion measures.Within 2 years of the initial effective dateof OBRA-86. -14 states and the District ofColumbia had established coverage at100% of poverty or higher: eighteen hadelected to raise eligibility up to I85(1 ofpoverty using OKRA -87 flexibility."' Theimpact of OBRA-89 and OKRA 90 were feltmore broadly. As a result. all states aretoday covering children up to the age of 9in families with poverty-level incomes orheir Av."' Combined. (BRA -S9 and OBRA-90 have established a uniform. minimumfloor of coverage tits pregnant women andchildren across all states at income levelstwo to three times higher than those thatexisted in the average state a mere 4 Yearsearlier. Figure I illustrates the status ofstates' income eligibility thresholds for


pregnant women mid children as of Janu-ary 1992.

Legislative provisions in the variousOBRAs opened new doors for statesthrough which financial access to healthcare could he extended to hundreds ofthousands of families. However, by them-selves. these actions did nothing to addressthe broad range of issues and problemsconfronting publicly funded perinatalprograms which more directly preventwomen front giving birth to healthierbabies. The much more complex and dif-ficult challenges included:

Making eligibility systems more -userfriendly,- so that large proportions of eli-gible women and children could he suc-cessfull enrolled in Medicaid:

I hercoming the general public's nega-tiv impression of the Medicaid program.informing %yomen and families of the int-pot lance of early and continuous prenatalr are. and persuading them to conic for-ward and apply for the new coverage;

Confronting the severe shortage of ob-stetrical providers and working to recruitmore providers into the system. so that

Figure 1. State Medicaid Income Eligibility Levels for Pregnant Women andInfants, January 1992

.'ate Mec. co Incomcfh.l.bs.tveven cs cvcent of

i ometot eves

;-.% 7 -A%

Source Notional G:iernor s Association. MCH Update State Coverage of Pregnant Women ana ChildrenJanuary992. Washington L.0 National Governor's Association. January 1992.


women seeking prenatal care could be as-sured of finding a caregiver: and

Addressing the quality of care coveredunder Medicaid and developing strategiesto hnlmwe set aPPr°Priatcile",comprehensiveness, and continuity of per-inatal services and service delivery systems.

Fortunate) . a majority of states havenot only expanded eligibility for pregnantwomen and children. but also used OBRA-86 as a catalyst for more comprehensiverfC)rms aimed at resolving many of theproblems outlined above. 'These efforts re-quired cooperation and collaborationamong Medicaid. MCI I. \VIC. public assis-tance and other programs working to itm-1>ro\e the accessibility and effectiveness ofpublic perinatal !migrants.

Streamlining Eligibility for Medicaid

The Medicaid cligihilin m stem, itself, canpresent a significant barrier to access forpregnant wonn in the following way....:1

The traditional welfare stigma attach -1to applying for public aid can discouragemans- women who might need or wantprenatal care:

Nledicaid eligibility workers are ivpicalllocated in county welfare offices, ratherthan at prenatal care provider sites, whichcreates an access harrier because applyingfor the coverage inv()Iyes a second, sepa-'ate trip to the welfare office:

Nledicaid application forms. which areoften used to determine eligibility for,N,FIX: and Mall other public programs.are frequenth complex and require exten-sive verification of income and resources:and

States generally use up to 15 days tofinalise their determinations of eligibility,causing a critical 6-week delay in coveragefor pregnant nutlet attempting to recciNe( are earl\ in pregnant c.

These factors combine to create a situ-ation whereby Minn" women who app) for:assistance are denied het ause they do not"«)mpl with pro«Aural requirements.Federal AFDC data hite consistenthshown that approximatek 611`; of allADC, application denials result Ironswomen not keeping an appointment with

eligihilin worker or not providing stir-fi( ient documentation of earnings, citi/en-ship. resources, and the like)

Since 1986, many states Ime begot toaddress these system barriers, Each of thestrategies described bek ny required that

state Nlediaid and AFIX: agencies coop-erate closely in designing refOrms thatmeet the dual objectives of facilitating andstreamlining access to care while preserv-ing the integrity of the screening process.

The Medicaid eligibility system, itself, canpresent a significant barrier to access forpregnant women.

Dropping Assets Restrictions

Nearly every state has elected to removeassets restrictions front its eligibility test fin'pregnant wimen and children as origi-nally allowed in O13RA-86. Bylttl I 991. -18states had determined that eliminatingsuch limits would greatly simplify their ap-plication processes:21'

Allowing Continuous Eligibility

State policies traditionally require AFDC(and thus Medicaid) recipients to recon-firm their eligibility status on a regularbasis. Now, however, following a periodof experimentation by a number ofstates, all states are required to guaran-tee pregnant women continuous eligibil-ity throughout their pregnancies and a60 -day postpartum period. regardless offluctuations in income.2 1

Granting Presumptive Eligibility

third option contained in ()IRA-86 per-mittd states to extend temporary, -15-daceligibility to pregnant women typo appearto be eligible for Medicaid benefits. Thispresumptive eligibility provision permitscertain pro widers of prenatal care to per-fOrm a simplified income test and. basedon its results. grant short-term coverage onthe same day. Rv cluing so, these providersalso guarantee for themselves Medicaidreimbursement for the services then ren-der. 1)espite numerous complexities. 26states had, by January 1992, elected toadopt the option.22

One drawback or presumptive eligibil-ity, however, is that it still requires womento make a second official contact with thewelfare agent to gain full Medicaid eligi-hle status. This has stimulated many statesto develop alternative eligibility system re-forms that ace mplish the same i esultswith fewer complexities.

OutstationIng Eligibility Workers

Rather than permitting providers to grantshort-term eligibility, many states have

[4:

142

opted to post their own eligibility workersat provider sites that render a high volumeof prenatal care services.20 This strategyallows women to access the state's eligibil-ity system directly at a provider site ratherthan at a COMM' welfare office. OBRA-90mandated that all states outstation eligibil-ity workers in two particular provider set-tings: federally qualified health centers(essentially, C/MI ICs) and hospitals thatserve an especially high volume of Medi-caid recipients.

Shortening Application Forms

As of January 1992, 33 states had adoptedshortened application forms for pregnantwomen.22 the ability to exclude as-sets restrictions from eligibility considera-tions, many states now require only thosepieces of information needed to deter-mine maternity-related eligibility. Shorterapplication forms possess several advan-tages: they are more easily completed byapplicants; they can be processed moreswiftly by state agencies, thereby reducingwaiting periods; and with less infOrmationto verify, they reduce the chance that ap-plicants will he rejected for proceduralreasons. In many states, short forms are sosimple that state wenre agencies leaveblank forms in providers' offices. This al-lows women either to take the form homeand complete the process by mail, or toreceive assistance from a provider's ad-ministrative staff and complete the appli-cation in the caregiver's office.

Vermont's initiative merits special at-tention. The state elected to expand eligi-bility for Medicaid to 185% of poverty anddeveloped a one-page form that is used todetermine income eligibility for bothMedicaid and WIG coverage, This modelis being studied closely by many states andduring 1991, Ohio had plans to impl-ment a similar form.20

Expediting Maternity-related Applications

Recognizing that the typically long delaysinherent in existing eligibility systemsjeopardize the timely initiation ofprenatalcare, 14 states had. by January. 1992, devel-oped policies that require agen-cies to process maternity-relatedapplications more quickly than applica-tions made by other populations.22 As aresult, turnaround times iri these statesrange from 5 to 10 days.

Table 1 illustrates which states hawadopted the strategies described above.Most states have combined several straw-gies for greater impact. For example, a


state that outstations eligibility workersmay equip those- workers with a shortenedform so that the intake of larger numbersof clients can take place during a healthdepartment's prenatal clinic hours.

Designing More Effective Outreachand Public Education Campaigns

In addition to revamping I\ ledicaid eligi-bility procedures for pregnant women,many states have also implemented newoutreach initiatives aimed at informingthese women of the availability of the newcoverage and of the importance of earland continuous prenatal care. These cam-paigns, coupled with eligibility streamlin-ing strategies, are intended to maximizeclient enrollment among the thousands ofpotentially eligible women who have beenextended financial access to Medicaid. Bycombining the financing know-how ofMedicaid agencies with the clinical exper-tise of Maternal and Child I lealth (NR 111programs, states have taken significantstrides in developing more creative andeffective outreach campaigns.

Two major challenges inhibitingstates' effOrts to develop effective outreachprograms have 'wen identifying an ongo-ing source of funding few the campaignsand selecting a strategy that is broadenough to spread its messages to all preg-nant vomen Yet targeted enough to reachthat subset of the population which is mostin need of assistance. In a developmentthat addressed the first of these chal-lenges, the Health Care Financing Ad-ministration stated in 1989 that outreachactivities could be eligible for federalmatching payments at the rate of 50%.23And while the second question may neverbe fully resolved, the multifaceted natureof state perinatal outreach elf( trts in recentwars has attracted a high number ofwomen into care.

Making Effective Use of Mass Media

Realizing that the traditional stigma at-tached to the receipt of welfare could elk-( outrage women front seeking Medicaid,'natty states have consciously de 'elopedprogram materials with the intention ofcreating a PeW image for the program.Utilizing softer, more positive images,bright colors, creative photogt aphygraphic arts, and video, and employingfriendlier themes like "Bala Love" (NorthCarolina). "First Steps" (Washington),"Baby Thur. Baby" (Utah). and "BeautilulBabies Right front the Stare' (District 44Columbia), state programs are attempting

14


Table 1. State Strategies to Streamline the Medicaid Eligibility Process for Pregnant Women,January 1992

Dropped PresumptiveAssets Test Eligibility

StatesAlabama

XAlaska X

ShortenedApplication

x

Expedited Mail-inEligibility Eligibility

NewbornReferral Form

X xX XX

Arizona X X X xArkansasCalifornia

Colorado X X X X

Connecticut x X X XX X

Delaware X x xDC X X X

Florida

GeorgiaHawaiiIdahoIllinois

t Indiana

xxxx.

xxx

x xx

IowaKansasKentuckyLouisianaMaine

MarylandMassacnusettsMichiganMinnesotaMississippi

MissouriMontanaNebraskaNevadaNew Hampshire

X'

XX

K

X

XK

X

New JerseyNew MexicoNew YorkNorth CarolinaNorth Dakota

xX

X

x

XX

OhioOklahomaOregonPennsylvaniaRhode Island

XKX

X X X

X X

South CarolinaSouth DakotaTennesseeTexasUtah

X

X

VermontVirginiaWashingtonWest VirginiaWisconsinWyoming

x

xxK.

x

Number of states 48 26adopting strategy

33

xxXXX

14

K

K

23 14

'Future impiementotion date

Source: National Governors' Association. MCH Update: State Coverage of Pregnant Women and ChildrenJanuary 1992. Washington, DC: National Governors' Association, January 1992.

to disassociate themselves from their wel-fare histon and alter the public's percep-tion of them. By doing so. they hope toattract many new clients.

More states have taken steps to tap thebroadcast media's creative and persuasivetalents. Understanding the media's neednot only to make a profit and get highaudience ratings, but also to earn the pub-lic's favor by demonstrating concernabout social issues. Utah's MCH and Medi-caid programs initiated this trend by en-

listing the involvement of an NBC affiliatestation in Salt Lake City in the design andimplementation of a multimedia outreachcampaign. That station, seeing value inestablishing its identity as the one that"cares about moms and kids." donated in-kind support in the form of free air time.art work, materials design, and targetedmarketing in return for a relatively smallfinancial fee. In the 3 years since the "BabyYour Baby- campaign was begun. the pro-gram achieved a 90% recognition rate

144

among the state's population. and stateevaluation studies have documented itssuccess in drawing women into care.1 7

Low provider fees, administrative and program-matic complexity, and problems with. Medicaidrecipients have been the principal explanationsoffered for poor provider participation.

Providing Toll-free Hotlines

As a component of their outreach efforts,nearly all states have incorporated toll-freehotlines. Displayed prominently onprinted materials as well as in video andradio spots, hotlines provide women withan immediate source for informationabout where to apply for assistance. whereto find prenatal care providers, and gen-eral advice and counsel in response to amquestions they might have a:/out preg-nancy. I lotlines have also played a key rolein helping states assess the relative effec-tiveness of various outreach effortstele-phone operators can ask clients "Wheredid von hear of this program:;--and inpinpointing which areas of the state seemto be exhibiting the most interest or great-est need. OBRA-89 mandated that all stateMCII programs provide or support suchtelephone access for maternal and childpopulations because of its demonstratedeffectiveness. BY December 1990,40 stateshad complied with this mandate:2-1

Supporting Case-finding Programs

Many believe that mass media campaignsdo not succeed well in reaching thosewomen most in needwomen in remote.rural areas, those living in extreme povertyin inner city ghettos, or women sufferingfrom serious problems such as drug oralcohol dependence. For such groups.more targeted. door-to-door case -fl ridingprojects have been employed in a limitednumber of states and communities. Usingeither time-limited foundation support orstate program administrative dollars. theseefforts have tpicalh utilized indigenouscommunity members and/or formerwelfare recipients to seek out peers inneed of prenatal care. Data demonstratingthese programs' successes or failures areextremels hard to come by: therefore.mans. observers question the cost-effective-ness of this extreme'y staff- and labor-intensive strategY.I%


Building Statewide Community Networks

Building statewide community efforts isan intermediate strategy that may com-bine the best of both mass media cam-paigns and door-to-door efforts. Manystates have worked to develop a statewidenetwork of community organizations todisseminate information on state serviceswhile also serving as a referral linkbetween needy women in the communityand Medicaid and MCH programs. NorthCarolina and Florida have conductedhundreds of orientations with organiza-tions such as churches, United Way agen-cies, community action programs,Healthy Mothers/Healthy Babies coali-tions, women's support groups. minorityand youth groups, Head Start programs.legal services groups. victims assistanceprograms and shelters, migrant councils.child care centers. and food hanks thathave contact with low-income families.' 7States have distributed program informa-tion and materials widely and enlisted thecooperative assistance of these groups toact as referral points.

Increasing Provider Participation

.Assuring adequate provider participationhas been a general concern for Medicaidprograms. As states have begun extendingMedicaid coverage to thousands of newlyeligible women. they have also confronteda severe shortage of obstetrical careproviders. Given the confluence of thesetwo trends, one may question what accesshas actually been provided to low-incomepregnant women if they are unable to finda provider willing to serve them.

Over the Years, low provider fees, ad-ministrative and programmatic complex-ity, and problems with Medicaid recipientshave been the principal explanations of-fered for poor provider participation. To-day, the rising cost of malpracticeinsurance and the fear of malpractice suitsare additionally cited as factors influenc-ing an obstetrician's decision aboutwhether to accept Medicaid clients. A 1988survey revealed that 89% of MCH pro-grams and 63% of Medicaid programswere experiencing significant problems inretaining adequate numbers of obstetricalproviders in their systems and, as a result.program administrators believed thataccess for pregnant women was being com-promised.25 In response to this trend,states have increasingly implementedmultiphe strategies both to recruit new

147


doctors and to retain existing physiciansin the system.

Raising Reimbursement

Public programs like Medicaid have a longhistory of paving providers at rates belowthose prevailing in the COMMUllit for pri-vate-par patients. Data from the NationalGovernors' Association for 36 states indi-cated that. in 1986, the median state Medi-caid program paid providers about 44% of'the approximate community charge fortotal obstetrical care. To help offset thisproblem, nearly one half of the statesraised obstetrical fees between 1987 and1989. some to levels comparable to or evenhigher than existing private insurancerates.` 5 In addition, OBRA-89 requiredstates to demonstrate that obstetrical andpediatric fees were sufficient to guaranteethat services were available to Medicaidclients to the same extent that they wereavailable to the general population. A pro-vision that defies operationalization, thismove has nonetheless succeeded in stimu-lating more states to raise obstetricalprovider fees. Unfortunately, most ana-lysts and state program managers believethat fee increases. by themselves, will notsignificantly raise the rate cif obstetricianparticipation in Medicaid. Therefore.states are also pursuing additional strate-gies, such as those described below.26

Simplifying Billing Procedures

An ongoing complaint among physiciansis that the complexity and inefficiency ofMedicaid claims submission and paymentprocedures frequently create a real disin-centive to participate. To counter thesecomplaints. nearly one fifth of the stateshave attempted to improve billing proce-dures. For example. California has insti-tuted a more efficient and logical claimsediting system that provides for moreprompt payment, special training semi-nars for providers' staffs on how to fill outMedicaid claims properly, and a toll-freehotline for physicians to call when theyhave billing questions.'25

Using Alternative Providers

Given a shrinking pool of participatingphysicians. many states are attempting toexpand their use of alternative providerssuch as certified nurse-midwives and nursepractitioners in maternity care programs.More than one half of the states have al-ready implemented such endeavors.either in Medicaid payment policies or instaffing MCI1

Recruitment and Retention Strategies

Many states have attempted to buildstronger links with medical societies toimprove recruitment and retention of ob-stetrical providers. Some states have beenmore aggressive. In Minnesota, Title Vgrant monies have been used to hirenurses who travel around the state to in-form private obstetrical providers of thechanges made to the Medicaid and MCHprograms and to attempt to persuadethem to participate. Arkansas has desig-nated personnel within the state Medicaidagency to act as provider liaisons who willrespond to specific problems and situ-ations. Washington has developed a com-puter alert program that notifies theMedicaid agency when a provider dropsout of the program, thereby giving thestate an opportunity to contact the physi-cian and attempt to resolve whatever prob-lems caused him or her to quit. The samestate is currently devising a system that willnotify Medicaid when physicians becomelicensed to practice, permitting the stateto contact these providers and attempt topersuade them to enroll. Ohio and NorthCarolina have developed systems of peerrecruitment whereby participating physi-cians approach their nonparticipating col-leagues and attempt to recruit them intoMedicaid:2u

Today, the rising cost of malpractice insuranceand the fear of malpractice suits are additionallycited as factors influencing an obstetrician'sdecision about whether to accept Medicaid clients.

Addressing Malpractice Concerns

A few states have attempted to addressdirectly the problems associated withmalpractice liability and cost. In Floridaand Virginia. no-fault liability coveragefor newborn birth-related injuries pro-vides payments through a workers' com-pensation-type system. Participation isvoluntary for both physicians and hospi-tals. who pay fees to support the compen-sation fund. Missouri adopted a programthat uses the state's general liability ftindfor malpractice claims made against phy-sicians who contract with local healthdepartments to serve indigent women.25A program in Louisiana will pay up to$1 00.00(, for any _judgment made againsta provider whose practice is made up ofat least We(' indigent women. North

11.


Figure 2. Status of Medicaid Enhanced Prenatal Benefit Programs by State,January 1992

4471CIEW

Eierneres Or Ennonced RenatoCore Senecas

Enncned settee PacKode

Cole Ccacknonon OnN

Enncneo 13Etnetas

'Combines care coordination/case management services with elements of risk assessment, nutritional counseling,health education, counseling, home visiting, and subsidized transportation. Precise elements of packages varyslightly from state to state.

Source: National Governors Association. MCH Update: State Coverage of Pregnant Women and ChildrenJanuary1992. Washington, DC: National Governors' Association, January 1992.

Carolina is using public funds to subsi-dize directly a portion of the costs ofmalpractice insurance premiums for ob-stetrical providers serving in rural areasunder the Rural Obstetrical AccessProgram.20

Unfortunately, yet few data are avail-able to evaluate the ability of any of theseefforts to increase provider participationin Medicaid.27 Until further evidenceemerges demonstrating the relative ef-fectiveness of these strategies, the lack ofprovider participation will persist as per-haps the most complex and insolubleproblem facing government perinatalprograms.

Enhancing the Scope, Quality, andCoordination of Prenatal CareImproving the health status of mothersand children by reducing rates of infantmortality and loss' birth weight also re-quires that attention be paid and re-forms be made to the content and qualityof medical care. (See the Racine. Joyce,and Grossman paper in this journalissue.) An impressive body of literature(most recently the report produced bythe U.S. Public Health Se"vice's Expert

Panel on the Content of Prenatal Care,1989)28 has suggested that prenatal careshould combine nutritional, psychoso-cial, and educational services with rou-tine and specialized medical care. Moststates have recognized the need to de-velop broader coverage of nonmedicalpsychosocial support services within thepackage of prenatal benefits.

As illustrated in figure 2. the after-math of OBRA-86 has seen 38 states de-velop progressive programs (3,1'

comprehensive prenatal care services. "2

With Medicaid contributing financingstrategies and MCI-1 providing clinicalguidance and protocols, these benefitpackages represent the cutting edge ofprenatal care and are already demon-strating their ability to have a positiveimpact on the birth outcomes of high-risk women.

Relying predominantly on optionalauthority contained in the ConsolidatedBudget Reconciliation Act of 1985 (CO-BRA), states typically have added a coreof new services including care coordina-tion/case management. risk assessment.nutritional counseling, psYchosocial

14D


counseling, health education, hot e vis-iting, and transportation.

Care Coordination

Care coordination (or case management )is considered by many states as the mostcritical component of their enhancedpackages. In 38 states, it is the glue thatholds the delivery system together.22These services typically consist of deter-mining the various needs of a client bassessing the risk factors she is experienc-ing; developing- a plan of care to addressthose needs: coordinating referrals of theclient to appropriate service providersidentified by the plan of care: and moni-toring to ensure that those services arereceived. Care coordinators also assist cli-ents with establishing Medicaid eligibility,pertOrm outreach and community educa-tion, and assist families with arrangingtransportation.2

Risk Assessment

In 38 states, risk assessments are used tohelp identify the various problems beingexperienced by a client and to enableproviders to plan Piz- and organize thevarious services she needs.22 Risk assess-ment can also he used to identify thosewomen with the most pressing need forenhanced care. Most states consider mul-tiple medical and psvchosocial risk factorsin their assessment instruments and willreimburse providers for the pet-fix-maw eof several risk assessments over the courseof a pregnancy.30

Nutritional Counseling

Thirty states have added coverage of nutri-tional counseling and education to theirlist of Medicaid-reimbursable seryic es.22State protocols generally highlight the re-lationship between proper nutrition andgood health, special dietary needs during-pregnancy, instructions for infant feeding(both breast and bottle), and guidance onweight gain and exercise. .\ few states spec-if\ interventions for W011111 at special nu-tritional risk, such as those with gest:zt;,,naldiabetes mellitus, gastrointestinal or renaldisease. or metabolic. problems. Most ofthe states that have added this benera havealso had to specify how best to coordinateenhanced nutritional services with thosealready being offered and financed underthe WIC program:10

Psychosocial CounselingPsychosocial counscling scrvicts, offeredin 21 states. anctit pi to assist women withthe numerous stresses that families face

and that can adversely affect birth out-comes, such as inadequate income andlorhousing, insufficient food, and unreliabletransportation.22 Alcohol and/or druguse, physical abuse, depression, and othersocial and psychological problems are alsotreated in most of the 24 states throughone-on-one counseling.30

Health Education

Childbearing women need to understandan enormous amount of information re-garding the physiology of pregnancy,healthy behaviors during pregnancy, theprocess of labor and delivery, and the fun-damentals of infant care and parentingskills. To provide such infOrmation, 31)states have added health education serv-ices While theices to their service list.` -"specific educational curricula vary, manystates supplement teachings on these top-ics with additional guidance on otherpregnancy - related issues. States employboth classroom and one-on-one teachingniodels.30

Home Visiting

I tome visiting, it traditional component ofAmerican public health models in yearspast and an integral part of perinatal deliv-ery sYstems in many western Europeancountries today, has been incorporatedinto 31 states. prenatal initiatiyes.22 Theservice, it is believed, allows providers(typically nurses or social workers) to as-sess patient needs better and to teachhealth behaviors more effectively by meet-ing with women in their own environment.Some states use visiting programs to assistwomen during the prenatal period, while

4 **

le:'

1 5 `)

f

148

others also emphasize postpartum supportof both mother and child.3()

TransportationA few states have tried to meet the trans-portation needs of pregnant women byhaving perinatal care coordinators ar-range transportation for women to andfrom their prenatal visits. A few states pro-vide direct financial assistance to clients tohelp them defray the costs of buses, taxis,and gasoline.30

Results of Early Evaluations ofPerinatal Care ReformsAt this time. politicians, policymakers, pro-gram managers. and advocates :,r alleager to know %. 'tether federal and stateperinatal medical care refbrms have im-proved the health status of mothers, in-fo n ts, and children and increasedpregnant womens use of prenatal care.Unfortunately. it is still too early to deter-mine the impact of the vast majority ofirdtiatives that are under way.

Main reasons exist for the ct wrent pau-city of both program data and evaluations.For example. complex program changestake time to implement properly at theslate and local levels and experience sig-nificant delays before accurate and mean-ingful descriptive data can be produced.Even after bugs are worked out of newprograms, the collection of sufficient datameasuring changes in utilization or birthoutcomes can take SCVeal VealS. The useOr certain indicators, such as infant mor-tality, is inherently problematic bothbecause infant deaths are statistically rareevents and because of the lags that occurwhile annual statistics are compiled. Fi-nally. the fact that data collection practicesin the 50 states vary greatly. in both ap-proach and (main\ makes it difficult todevelop national indicators of impact:1132

Policymakers are eager to know whetherfederal and state perinatal medical carereforms have improved the health statusof mothers, infants, and children.

These factors «ttnbine to frustratepolicNnittket s who need to decide whetherlo expand or redirct efforts to imprint.maternal ancl c hill health. These

are understandahlv looking for c<in-

THE FUTURE C- C.,HILDREN WINTER 1992

crete evidence that particular programstrategies are either producing desired re-sults or failing to do so.

Fortunately, this situation should im-prove in the ver near future. Nearly 5years have passed since the implementa-tion of the first Niedicaid expansions forpregnant women and children. Both fed-eral and state agencies have begun eithersponsoring or conducting program evalu-ations, and results from these effortsshould emerge ever the next several years.Two important evaluations have recentlycome to light that provide critical earlyinsight into the effects of particular pro-gram initiatives, These evaluations arebriefly summarized below.

In the spring of 1991, the U.S. GeneralAccounting Office (GAO) reported thatstates were experiencing early success inenrolling pregnant women into expandedMedicaid programs. Based on case studiesin I() states, the GA() study monitoredchanges in Medicaid enrollment after im-plementation of eligibility expansions andmeasured rates of increase against a pro-jected target estimate of potentially eligi-ble pregnant women in each state. Resultsindicate that 1)(1.n-cell two thirds and threequarters of potentially eligible women en-rolled within 2 years of these states' pro-gram expansionsan encouraging rategiven the past dismal perfOrmanc ofMedicaid programs in attracting newly eli-gible populations. While a direct correla-tion between positive enrollment ratesand individual eligibility streamlining ef-forts was not measured, it was observedthat states which had simultaneously im-plemented presumptive eligibility anddropped assets tests experienced the mostrapid growth in enrollment.;{

North Carolina has released a study illus-trating the positive impacts of its BabyLove maternity care coordination pro-grant. The program's effect on prenatalcare utilization and birth outcomes wasassessed by comparing pregnant Medicaidrecipients who clid and did not receivecare coordination services. The statefOund that women on Medicaid who re-ceived maternity care coordinationobtained more prenatal care. participatedin WIC at higher rates. and recencdgreater amounts of both postpartum careand well-child care for their infants.

not receiving care coordinationwere found to deliver low birth weightinfants at a rate 21(7( higher than those


that did. Simi lark, rates of very low birthweight infants were 62c; higher, and ratesof infant numalitv were 23c' higher forwomen not receiving care coordination.The stitch also estimated that, for each51.00 the state spent on care coordination,S2.02 was saved in Medicaid newbornmedical costs:3 1

The GAO and North Carolina studiesprovide polio makers with valuable insightinto the positive fli.cts that can be derivedfrom perinatal system refOrms. One canonly hope that similar evaluations willsoon emerge to give polivmakers furtherguidance fin- future action.

Shifting the Focus toChildrenSince 19,86. virtually all states have investedsignificant energy. and resources in design-ing and implementing more effective pre-natal care programs. However, laws thatexpanded Medicaid coverage for poormot hers crud their children have not stimu-lated a commensurate level of activity onbehalf of children. By 1990, few states hadaddressed (lie question of how health areprograms for children could be mademore effective.

Bt expanding children's eligibility fitsMedicaid to l33'; of poverty fin- childrentinder age 6 and to 100'.; of in wetly fitschildren between the ages of 6 and 19,respectively, ()BR.1-89 and ()BRA-90helped refocus attention on illyroyingaccess for kids. OIRA-89 also asked statesto make sweeping changes to their N 1 edi-caid EPSlif In ()grams. Theoretically,EPSDT programs provide comprehensivehealth care fOr eligible children by com-I(ining screening fin- health problms withoutreach. fidlov-tip care, and case man-agemnt to ensure that problems identi-fied in screening visits are addressed. Inpractice. EPS1)T programs have been af-fected by many of the same problems thathave reduced Nledicakf s effectiveness. Asa result. E1'S1)T services are used by onlya minority of eligible children.15 Therecent changes attempt to address sonic'of these problems by liberalizing policiesrelating to the provision of preventivehealth examinations, the participation ofpediatric providers, and the coverage' ofac ut and specialty services.

To determine the extent to whitstates \yen undertaking initiatives to) inn-pro\ e the act essibility and efficacv of child

health pflgrams, the National Governors'Association (NGA) surveyed state Nledi-caid and \1(:I1 programs in the summerof 1990. Study findings revealed it numberof disturbing trends which indicate thatprogress in this area may come Anna moreslowly than did reliirms in perinatal sys-(ems." These findings are summarizedbelow.

Improving Children's Access to CareImproving low-income children's access tocare involves more than expanding theireligibility fO Medicaid. Families must bemade aware of the availability of' coy erageand of the importance of well-child care:eligibility systems 1111151 SII11(1111(1 sothat children can be enrolled in a simpleand timely manner; and adequate num-bers of pediatric providers need to partici-pate in Medicaid so that children will beable to obtain needed care. (hi each ofthese scores, however, the NGA SUIAVrfound that .states were struggling with thefollowing persistent problems:

EPSDT programs have been affected by many ofthe same problems that have reduced Medicaid'seffectiveness. As a result, EPSDT services areused by only a minority of eligible children.

States reported experiencing significantdifficulty in enrolling many of the (-Illicit enwho had been made eligible under 011RA-89 and ()1112A-90. Establishing eligibilityfor netyl)orns, guaranteeing continuouscoverage fin- infants during their first yearof life, and particular requirements thatmake children's eligibility determinationsmore complex than those of t hei r motherswere just some of the issues hinderingenrollment.

Outreach, marketing, and public inloiillation campaigns specifically targetingchildren's health issues yvr not form( tobe a common component of most states'

edicai(1 and \ICI 1 programs. instead,the majority of states were still involvedwith developing and 'or managing cam-paigns aimed at increasing women's use ofprenatal care.

Nearly half the states indicated that theywere beginning to experience a«.ess prole!ems related to pediatricians' increasingunwillingness to serve MC(IICill(I C1111(11111.1.0W FCC's. (ICI:INV(I and cumber-

152

150

some administrative /claims processeswere identified as the leading reasons fornonparticipation,

Cause for optimism could also befound in the NGA survey results, however.For example, more states were found to beeither implementing or planning effortsto streamline eligibility systems for chil-dren. The strategies mentioned above thathad proven effective for pregnant womenwere being tried in an effort to boost chil-dren's enrollment rates. Similarly, a hand-ful of states had begun to build uponsuccessful prenatal care outreach cam-paigns by incorporating a new set of ma-terials and messages encouraging parentsto seek out and obtain preventive care fortheir children. Finally, efforts to recruitpediatric providers were beginning to rakeshape in a small number of states. Whilenot as significant a crisis as the shortage ofobstetrical providers, declining pediatricparticipation has spurred states to beginraising fees, restructuring payment sys-tems and incentives, and attempting toimprove relations with pediatric medicalsocieties. (See the Per loff article in thisjournal issue for a discussion of the supplyof pediatric providers.)

Restructuring Service DeliverySystems for Children

Devising a comprehensive system formeeting the health care needs of chil-drenone that is broad enough to pro-vide every child with preventive well-childservices, responsive enough to treat any.acute illnesses suffered by a child, andtargeted enough to provide special serv-ices to those children with chronic healthand/or developmental problemsis anincredibly complex task. Accordingly, theNGA survey found that states were strug-gling to enhance the quality and scope ofchildren's services.19 Some of the difficul-ties they encountered were as follows:

States' approaches to administeringtheir EPSDT programs were found to varygreatly, and this variation seemed to affecttheir success in providing Medicaid- eligi-ble children with EPSDT comprehensivescreening examinations, While federaldata show that only 39% of eligible chil-dren participate in EPSDT in the averagestate, participation rates range from as lowas liv4 in Delaware and Oklahoma to ashigh as 96(.%; in Arizona.33

Hate states reported that large numbersof pediatricians continue to provide well-child care to Medicaid-eligible children


outside the EPSDT system. This situationleaves states in a tenuous predicament:they have no way of knowing specificallywhat types and amounts of care are beingprovided, nor do they have any way ofensuring that child patients of theseproviders receive the comprehensive carerequired by the EPSDT program. Rulechanges contained in OBRA-89 intendedto broaden the number and types ofproviders eligible to participate in EPSDThave done little but confuse an alreadydifficult situation.

Children's access under Medicaid toacute, therapeutic, and chronic care serv-ices was judged to he inadequate by mans:states. To improve EPSDT's performanceas a treatment program, OBRA-89 re-quired states to cover any and all servicesneeded to treat conditions identified dur-ing an EPSDT screen, whether or notthose services are covered by their stateplans. While this move demanded thatstates broaden the scope of their programsto include many new services for mentallyill and/or developmentally disabledchildren (such as inpatient psychiatriccare and physical, occupational. andspeech therapies), many states are stillstruggling with how to implement this pro-vision and arc concerned about its impacton program costs.

Most states reported a serious lack ofcoordination between preventive, acute,and chronic care systems of care for chil-dren. These states had neither created For-mal administrative mechanisms nordesignated particular providers of care toensure that their systems operate in anintegrated, coordinated manner.

The NGA survey did identify manystates that were creatively designing pro-grams and strategies to resolve thesesystem problems. Slightly less than half ofthe states reported that their MCIL pro-grams had contracted with the state Medi-caid agency to manage the EPSDTprogram, thereby removing most EPSDT-related administrative responsibilitiesfrom the state and/or local welfare agen-cies. These states expressed a much higherlevel of satisfaction with the ability of theirEPSDT programs to effectively informfamilies of program benefits, identify chil-dren's health care needs, locate participat-ing providers, make appointments withproviders, and follow up with each familyto ensure that needed care was received.A growing number of states were also de-


signing reimbursement incentives to en-courage pediatricians to participate inEPSDT rather than continue to rendercare outside that system. In addition, asmall group of states have begun designingand implementing expanded packages ofbenefits for children, including the cover-age of far more comprehensive acute andchronic cart services. Finally, nearly halfthe states have adopted formal systems ofcase management under Medicaid. Inmost, children with special health careneeds are targeted fbr this benefit.

While state initiatives to improve theaccessibility and effectiveness of children'shealth care systems are lagging consider-ably behind those involving prenatal care,creative efforts by a growing number ofstates give reason to he cautiously optimis-tic about the prospect of progress in thefuture. Given states' consistent assignmentof priority to initiatives for pregnantwomen and children, this optimism existseven in spite of the growing fiscal pressuresfacing many state Medicaid programs.

ConclusionsAt the outset of this article, several ques-tions were posed regarding the appropri-ate and potential roles of Medicaid andother government programs in servingmothers and children. While definitive an-swers to these questions may never he ob-tained, certain indications have emergedfrom the past 5 years of activity.

First, the issue of whether Medicaid wasthe appropriate program to expand hasbecome almost irrelevant. While this pro-gram is not everyone's cup of tea, Medi-caid constitutes the only entitlementprogram currently available throughwhich federal dollars can he funneled intostate programs at such generous matchingrates. Medicaid offered in 1986, and con-tinues to offer today, the most efficientavailable means of supporting expansionsof coverage for poor and near-poor preg-nant women and children.

just as important is the fact that theseMedicaid resources are available to directservice programs. In nearly every state,local health departnient clinics and ccini-munitv health centers provide services loMedicaid- eligible pregnant women andchildren and, therelbre, can bill that pro-gram for reimbursement. Since the Medi-caid expansions, many of these publicproviders have experienced significant clic-Flunky capturing Medicaid revenues given

151

their unfamiliarity with establishing andoperating third-party billing systems. Yet,as these programs adjust their way of doingbusiness, the potential exists fbr tappinginto increased financial support for thedelivery of perinatal care and, in turn, forexpanding the capacity of public healthdelivery SVStems.

The fact that so many states have suc-cessfully built ongoing, collaborative rela-tionships between their Medicaid andMCI-I programs lends further support tothe notion that Medicaid expansions in:_vvery well work. 13v assisting Medicaid agen-cies with the design of enhanced prenatalcare benefit packages and with the imple-mentation of these services largelythrough public delivery systems, MCH pro-grams have had a significant impact on thescope and operations of their counterpartagencies and have helped assure them-selves of a source of ongoing financialsupport. In North Carolina, where effiwtson the part of Medicaid and MCII pro-gram officials to collaborate on system re-form have resulted in the implementationof a true model case management pro-gram, benefits are being experienced bymothers in the firm of' healthier infants.

Perhaps the most insoluble problem still facingpublic systems of care remains the crisis in accessthat families confront when private obstetricalproviders refuse to serve families covered byMedicaid.

Efforts to streamline and simplify theMedicaid eligibility process have helped tosever the traditional links between Medi-caid and the public welfare system. Fur-ther, bright, colorful, and positive publicoutreach campaigns have also lessened timeprogram's welfare image in many states. Itappears that these efforts, taken together,are helping Medicaid become a more at-tractive program. Results from the GAOstudy provide at least preliminary evidencethat potentially eligible mothers-to-be at ecoming fbrward to receive assistance.

Perhaps the most insoluble problemstill facing public systems of care remainsthe crisis in access that families confrontwhen private obstetrical providers ref useto serve families covered bx Medicaid.Throughout the county, the value of a

15;

152

Medicaid card is clearly brought intoquestion \Olen so many physicians refuseto accept it as a form of payment. Fearof malpractice liability, dissatisfactionwith levels of reiMborsement and theinconvenience of claims payment proce-dures. the belief that Medicaid patientsare noncompliant and difficult to serve,and the undying perception that Medi-caid is an unresponsive. inflexible systemwith which to do business continue todissuade many obstetricians from par-ticipating in the program. Until tangibleprogress can be made in addressing thiscritical provider shortage, the potentialsuccess of the Medicaid expansions willcontinue to be undermined.


At this time, reasons abound for be-ing optimistic about the ability of fed-eral and state governments to financeand deliver high-quality prenatal andchild health care services. Despitesevere budget crises, infant mortalityreduction remains a high public policypriority, and states continue to moveforward with designing and implement-ing more effective systems of care. Andwhile the health care access problemsfaced by mothers, children, and fami-lies are far from being solved, one canat least take heart in the progress thathas occurred in recent years.

I. Sardell. A. Child health policy in the U.S.: The paradox of consensus. j.fornal °Meath Pali-and Law (Summer 1990) 15,2:271 -30 -1.

2. llealt 0 Care Financing Administration, Department of I leatth and Human Services.Personal communication with John Klemm, October 1991.

a. the EPSDT program is designed to assure the availability and accessibility of preventiveand primary care services to covered children. Each state must provide, at a minimum,assessments of health, developmental, and nutritional status: unclothed physical examina-tions: immunifittions appropriate for age and health historv: appropriate vision, hearing.and lab( traton tests; dental screenings; and treatment for vision, hearing. and dentalproblems.

I. Factors contributing to the growth of the Medicaid program. Congressional Budget Officestaff memorandum. Washington, DC: CBO, lay 1992.

a. The federal government has established annual income levels fur families of different sluesto demark poverty status. (In 1992, the poverty level for a family of 3 is S11.570.) Thesepoverty levels. which are revised periodically to reflect changes in the cost of living, are'Ned to establish eligibility for government programs targeted to low-income groups. Eligi-bility guidelines are established as a certain percentage of the poverty level. meaning that6tmilies with incomes below the guidelines are eligible for benefits.

6. General oversight and administration of Title V (teems at the lieral level within theficalth Resources and Services Administration of the U.S. Public Ilealth Service.

7. .1ssociation of !Maternal and Child Health Programs. Personal communic ation with (lather-ine Hess, October P,191.

8. National Claringlnitise fine Primary Clare Infirrination. Community health coders: .1 quatity%1 stem Jo' the (hanging health caw mathet. Washington. DC. 1986.

9. National Association of Community }kiln centers, Comprehensive perinatal raw prop-an.:Diwaors of (7.11/10. Washington.. DC. 1990.

19. At the federal level. the program is administered by the Bureau of Health Care Deliverand ,1ssistitm e in the Public Ilealth Service.

11. Nlathernal kit Policy Research, lot . The saving% in .11edwaid rosh for newborn% and their mother%truer prenatal par tiripation in the WIC pmgram. Vol, I. Princeton. NJ. 1990.

12. Mathematic a Polk-% Research, Inc . Du, caving% in Mt (lima lints for newborn% and then 'anther%front Prenatal ImuticlPation in the WIC Pror-am. Addendum. Princeton, NI 1991.

13. Food Researr It and Action Center. MC: A cfli,ey ktorl. Vashington, DC, januart 1991.

11. The National Commission on C:hildrett. Beyond rhetoric .3 new apprenah lar rhildren and limn-kVashington. DC. 1991.

15. U.S. Delta) Intent of Agi ureFind and Nutrition Set e. A study of the sayings inMedicaid and indigent 1 at e lot newborns limn enatal pat ticipation in the WIC pro-

gram. NVashington. DC, 1990.

155


16. Institute of Medicine. Preventing low birth weight. Washington, DC: National Academy Press,1985.

17. Hill, 1. Reaching women who need prenatal care: Strategies Jim improving .state perinatal programs.Washington. DC: National Governors' Association, 1988.

18. National Governors' Association. !UCH update: Slate coverage of pregnant women and children-July 1989. Washington, DC: National Governors' Association, July 1989.

19. Hill, 1_, and Breyel, J. Caring for kids: Strategies for improving state child health programs. Wash-ington, DC: National Governors' Association, 1991.

20. National Governors' Association. MCH update: Slate coverage of pregnant women and children-fuly. 1991. Washington, DC: National Governors' Association, July 1991.

21. National Governors' Association. Arm update: State coverage of pregnant women and children-July. 1990. Washington, DC: National Governors' .Association, _July 1990.

22. National Governors Association. .1ICH update: Stale coverage of pregnant women and children-January 1992. Washington, DC: National Governors' Association, January 1992.

23. Breyl, J. Improving. tate programs for panant women and children: A conference proceedings.National Governors' Association. Washington, DC, 1990.

24. Association of Maternal and Child Health Programs. Building on the basics: lour approaches toenhancing .1ICH service delivers. Washington, DC, December 1990.

25. Lewis-Idema, D. Increasing provider participation: Strategies for improving state perinatal programs.Washington, D(:: National Governors' Association, 1988.

26. Hill. I. Improving state Medicaid programs for pregnant women and children. Health CareFinancing Review-1990 Annual Supplement. Health Care Financing Administration, U.S.Department of Health and Human Services. Baltimore, MD: DFIFIS, 1990.

27. Malpractice insurers in Missouri recently reduced premiums for those physicians who con-tract with local health departments. recognizing that their malpractice exposure has beenreduced because of the state-supported supplementary coverage.

28. U.S. Public Health Service. Curing fiir our future: The content of prenatal care. Washington, 1)C:DIMS. 1989.

29. Hill, I., and RI-eye'. J. Coordinating prenatal care: Strategies for improving state prenatal programs.Washington. DC: National Governors' Association, 1989.

30, Hill, 1., and Bennet, Ti Enhancing the scope of pirnatal services: Strategies fin- improving stateperinatal programs. Washington. DC: National Governors' Association, 1990.

31. Bilheimer, I.. Designing program evaluations: Strategies for improving. late perinatal programs.Washington, DC: National Governors' Association, 1989.

32. Problems such as these have plagued most evaluation efforts to date. In one example, astate-based evaluation focused on measuring the impact of a relatively minor regulatorychange to eligibility rules that occurred ncarl 2 years before implementation of the Medi-caid expansions. Piper, J.M., Ray, W., and Griffin. M. Effects of Medicaid eligibility expan-sions on prenatal care and pregnancy outcome in Tennessee. journal of the AmericanMedical Association (November 7, 1990) 264,17:2219-23. In another. lack of data reportingon the actual impact of Medicaid expansions required evaluators to simulate effects statis-tically based on a national survey database that was con piled during a period predatingthe expansions. Schlesinger, NI.. and Kronebusch. K. The Failure of prenatal care policyfor the poor. Health Affairs (Winter 1990) 9,4:9 i-111.

33. U.S. General Accounting Office. Prenatal 1-air: Early success in enrolling women made eligible byMedicaid expansions. Washington, DC: U.S. Government Printing Office (GAO/PEN1D-91-10), February 1991.

3. Buescher, P.. Roth, NI., kVilliarns. D., and Goforth, (;. An evaluation of the impact of mater-nits care coordination on Medicaid hirth outcomes in North Carolina. A withal/ Journal o/Public I lealth (December 19')1) 81,12:1625-29.

35. State Medicaid Manual (Transmittal No. I), Health (:;11-C Financing Administration.Department of Health and H11111:ill SerVICVS, JIIIV 19110.

5 ,1

.1 (an C. .110 01,41,

PhD., is 1 en ior re-trareb manager forDivision of llediralExhendiline Sindies,Om ter op Genera!iienith Semi tv, Jo(ra-nrurrrl lie sea )( h,Agent y fo, HealthCare Pairs andWW1( h.

Pierl. Cunningham,I 'h.l J., is senior re-searrher for Divisionof Medical Expendi-

n' Studies, letfor General I !cal fltSrivires Intro m arcaReseal( h1/..relay forI leallh Caw Pair yand liesta)( h.

IV 11111 Pallet

ail' HIM(' (11 air walteirs.and 11(1 official endorsemen t hr' the Agenr1 10?Health Carr l'olicy andHormel, in the Ih />art-rttrnl of health awl I In-111(111 1'1 /5 11111'10rd

o, should hr in Itro.d.

Children WithoutHealth InsuranceAlan C. MonheitPeter J. Cunningham

Abstract

Data from two nationally representative household surveysOw 1977 NationalMedical Care Expenditure Survey (NM( ;ES) and the 1987 National Medical Ex' wit-(Inure Sunes (NMES)are used um examine changes in t hildren's health insurancestatus over the past decade. '1'he consequences of disparities in children's healthinsurance status for their use of health services in each of these seats and Over timeis explored. The data demonstrate that children were more likely to lack healthinsurance in 1987 than in 1977, that in both ears children without insurance wileat a disadvantage in their use of health ;.!-ices relative to their insured counterparts.and that over nine, health service use by uninsured children declined relative to thatbe children with private or public coverage.

Because of the vulnerable health status of children and the importance of children'shealth d are, the authors assess how the number of uninsured c hildren might be

affected b two frequently discussed policy alternatives: mandated employment-re-hued e overage' and incremental Medicaid expansions. They conclude that combin-ing an employer mandate with a Medicaid expansion for some children whose

pat ems are ineligible for an emplmer Mandate appears 10 have the greatest potentialfor t educing the number of uninsured children.

n a 1991 report describing the welfare of children in the UnitedStates, members of the National Commission on Children observedthat "perhaps no set of issues moved members of the National

Commission more than the wrenching consequences of poor health andlimited access to care."1 As has been well documented, the consequencesof limited access to health care manifest themselves through a variety ofchild health problems at all stages of child development.2 Limitedprenatal care increases the risk of low birth weight, premature births, andother adverse outcomes, all of which are associated with infant mortalityor contribute to developmental disabilities. Because of poor access topreventive health services, fewer than 70% of white children and less thanhalf of black children 1 to 4 years of age received immunizations againstcommon childhood diseases (DPT, polio, measles, mumps, and rubella)in I 985. Tlw proportion of 2-Year-olds immunized has declined from

1980 levels and falls short of the goal established by the Surgeon Generalof the United States of immunizing 90% of all 2-year-old children by1990.3 Finally, limited access to health care services by school-age andadolescent children may reduce the frequency of periodic health ass . -s-

ments and, therefore, the ability ofparents and physicians to monitorthe physical growth, weight, andnutrition of children; to screen forpossible child abuse and neglect: todetect learning disabilities and po-tentially debilitating mental healthproblems; and to provide childrenwith sex education and with education regarding drug and alcohol abuse.(See the article by Perrin, Guyer, and Lawrence in this journal issue.)

By reducing the out-of-pocket costs of health care, private andpublic health insurance coverage play a critical role in improvingchildren's access to health care services. Depending on the breadth andgenerosity of coverage, health insurance may enhance access both topreventive care and to services that address acute and chronic healthproblems. Consequently, concern over disparities in children's use ofhealth services must necessarily focus on their health insurance status.

In this paper, we use data from two nationally representative house-hold surveys, the 1977 National Medical Care Expenditure Survey(NMCES) and the 1987 National Medical Expenditure Survey (NMES),to examine changes in children's health insurance status over the pastdecade. We also explore the consequences of disparities in children'shealth insurance status for their use of health services in each of theseyears and examine how their use of health services has changed overtime. NMCES and NMES are particularly well suited for this purposebecause each survey contains detailed information about the healthcare use, expenditures, health insurance coverage, and demographiccharacteristics of the civilian noninstitutionalized population andbecause each survey has been designed to produce national estimatesof health care use and expenditures.'1These data demonstrate that overthis period children were more likely to lack health insurance in 1987than in 1977, that in both years children without insurance were at adisadvantage in their use of health services relative to their insuredcounterparts, and that over time, health service use by uninsuredchildren declined relative to that of children with private or publiccoverage.

By reducing the out -of pocket costs of health care,private and public health insurance coverageplay a critical role in improving children's accessto health care services.

153


Children's HealthInsurance Status: 1977and 1987In the ot.^ade between 1977 and 1987, thelikelihood that a child less than 18 yearsof age wai(' be covered by private orpublic health insurance declined sharply.Estimates for the first quarter of 1977 and1987 indicate that the percent of unin-sured children increased by some 40 %from 12.7% to 17.8%or by 3.1 millionchildren. This increase in the number ofuninsured children reflects the decline inthe percentage covered by private, largelyemployment-related coverage, and thefact that fewer children in single-parenthouseholds were eligible for public insur-ance programs such as Medicaid.

As we have discussed elsewhere? thesechanges in children's health insurancestatus reflect a number of social, legislative.and economic influences over the past 2decades. In 1987, 25% of all children livedin single-parent households compared to17% in 1977. Their parents were far lesslikely to receive an offer of employment-re-lated health insurance than were the par-ents of children in two-parent households.

Figure 1. Annual Health Insurance Status ofChildren, 1977 and 1987

insurance3 1%

1977

1987

Source. Agency for Health Care Policy and Research, 1977 NationalMedical Core Expenditure Survey Household Survey: Agency forHealth Core Policy and Research, 1987 National Medical ExpenditureSurvey Household Survey

In fact, 79.1% of children in two-parenthouseholds had parents who were offeredemployment-related coverage comparedto 61.8% of those in single-parent house-holcis.5 During the early 1980s, publichealth insurance became far less accessibleto children whose parents earned smallamounts of income for at least two reasons:first, states failed to increase their incomeeligibility standards for Aid to Families withDependent Children (AFDC) with the rateof inflation; second, the Omnibus BudgetReconciliation Act of 1981 (OBRA-1981)restricted Medicaid eligibility for childrenof working parents by limiting the grossincome of such families applying forAFDC.6 Subsequent expansions of Medi-caid, beginning with the Deficit ReductionAct (DEFRA) of 1984 and culminating withOBRA-1990, have either mandated or al-lowed states to restore or expand coverageto various groups of pregnant women andyoung children. 7 (See the article by Hill inthis journal issue.)

The decline in the private health in-surance coverage of children between1977 and 1987 reflects the combined im-pact of increased out-of-pocket premium,osts for family coverage, employee earn-ings and family incomes that have notkept pace with the rate of inflation, andchanges in household composition andemployment. During the early 1980s, Bu-reau of Labor Statistics data indicate thatmonthly employee contributions forfamily coverage (adjusted for inflation)rose by 31% (from $25 in 1981 to S37 permonth in 1985) and that the proportionof covered employees required to contrib-ute to their family coverage increasedfrom 51% in 1982 to 65% in 1986.8 Dur-ing this period. employee earnings (alsoadjusted for inflation) showed little or nogrowth. For example, between 1977 and1987 (the decade covered by our study),average weekly earnings (in 1977 dollars)for workers in private, nonagricultural in-dustries declined from $189 to $169.Although median family income On 1989dollars) increased modestly from S32,758in 1977 to $33,805 in 1987, income fluc-tuated considerably during this period asthe economy entered and emerged fromthe 1981-1982 recession. These factorshave made it more difficult for families toafford health insurance coverage for allfamily members. The increasing likeli-hood that a child would reside in a single-parent household between 1977 and 1987also reduced the likelihood that a child

15


would be covered by private, employ-ment-related health insurance.")

Annual Estimates of Children'sHealth Insurance StatusTo further examine changes in children'shealth insurance status over this periodand to relate this experience to changes inhealth care utilization, we present annualestimates of children's health insurancestatus in 1977 and 1987 (see figure 1).11Overall, the percentage of children in-sured throughout each year declined from82.5% in 1977 to 76.9% in 1987, onceagain reflecting the sharp decrease in all-year private coverage (from 71% to 63%).As a result, the likelihood that a childwould lack health insurance at some timeduring the year increased from 17.5% in1977 to 23% in 1987.

The decline in private coverage af-fected children in all age groups and wasmodestly offset by a small increase in thepercent of children covered by Medicaidand other public insurance throughouteach year. Among the uninsured, the pro-portion covered only part of the year grewrelative to the proportion uninsured allyear so that in 1987 children were some-what more likely to have their health in-surance coverage interrupted ordiscontinued than in 1977. The decline inall-year private coverage and the increasein the likelihood that a child would heuninsured part of the 'ear affected chil-dren 6 to 12 years old somewhat more thanother children.

Health Insurance Status of Childrenby Selected CharacteristicsThe health care coverage of children de-scribed in table 1 and in appendix table Alis directly related to the characteristics ofthe families in which they live. Familystructure, income, and the employmentstatus of parents are all critical factors indetermining the type of coverage childrenwill obtain as well as their risk of beinguninsured.

Data for 1987 presented in table 1 in-dicate that children in two-parent families,especially those families in which both par-ents are employed all year (45 weeks ormore), have the highest rate of privatecoverage and are less likely to be unin-sured than children in other families. Al-most 90% of these children have privatecoverage, and fewer than 5% are unin-sured all Year. These findings reflect thefact that, in households with two working

parents, the likelihood that at least oneparent will be offered employment-relatedhealth insurance coverage is increased asis the level of family income necessary topay for the rising out-of-pocket costs ofthat coverage. By contrast, children in two-parent families with only one full-yearworking parent are less likely to have pri-vate health insurance and are twice aslikely as those with two full-year workingparents to be uninsured all or part year.Children in families in which both parentsfail to work all year or to obtain employ-ment at all are even less likely to haveprivate insurance and are more likely tobe uninsured. More than 50% of childrenin families where parents worked only partof the year and 40% of children in familieswhere neither parent worked lackedhealth insurance for all or part of 1987.

The employment circumstances of singleparents play a critical role in determiningtheir children's health insurance status.

A growing number of children areraised in single-parent families where thesocial and economic circumstances arequite different from those of two-parentfamilies. Children in single-parent familieshave disproportionately higher rates ofpoverty because of the lower rates of laborforce participation among single mothers.the lower wages for those who do work,and the unlikelihood of the presence ofanother working adult. However, it is im-portant to note that, as was true in two-par-e n t households, the employmentcircumstances of single parents play a criti-cal role in determining their children'shealth insurance status. Children in sin-gle-parent households in which the parentis employed all Year (see table 1) have ratesof private coverage (70.8%) which matchthose of two-parent households with onefull-year working parent (73.4%). More-over. the percentage of children unin-sured all or part of the year insingle-parent households in which the par-ent is employed all year is not statisticallydifferent from that of two-parent house-holds with one full-year working parent.Children with single parents who fail towork all year or who are not employedhave considerably lower rates of private

1 6

157

158

health insurance coverage. While Medi-caid provided an important buffer forthese children who might otherwise beuninsured, the likelihood is still high thatthey will spend some time without healthinsurance coverage. This is especially truefor children of single parents who workonly part of the year. Forty percent ofchildren in these families are uninsuredall or part of the year.

Family structure and parent's employ-ment are also strongly associated withfamily income, which itself is a critical fac-tor in the types of health care coverageavailable to children. For children in fami-lies with income below the poverty level,nearly 45% were without coverage for atleast part of 1987, including nearly 25%

THE FUTURE OF CHILDREN - WINTER 1992

who did not have coverage all year. Inaddition, less than one third of poor chil-dren had public coverage all year in 1987.By contrast, the vast majority of childrenfrom middle- and upper-income familieshad private insurance and were much lesslikely to spend any part of 1987 withoutcoverage.

Poverty is strongly correlated withmany factors, including education andfamily size. (See appendix table Al.) Ingeneral, the higher the educational at-tainment of the household head, themore likely the children were to haveprivate insurance coverage and the lesslikely they were to he uninsured. In fact,rates of children's private coverageranged from 25% where the head of

Table 1. Health Insurance Status of Children by Selected Characteristics, 1987

I

Insured All Year Uninsured

Population1 (thousands)

Private Public Part Year All Yeor

__All 63,749 63.0% 13.9% 12.4% 10.6%

Age of child1 0 to 5 years 22,133 59.3 17.3 14.1 9.3

1 6 to 12 years 23,863 63.8 13.4 12.3 10.5

1 13 to 17 years

i Family structure/parents' employment

17,753 66.7 10.3 10.5 12.5

Two- parent householdsBoth employed all year 16,469 89.3 1.6 4.7 4.4

One employed all year 20,591 73.4 4.5 11.1 11.1

One employed part year 3,859 30.1 15.4 33.7 20.8

Neither parent employed 738 19.0 41.2 22.2 17.6

Single-parent householdsParent employed all year 6,605 70.8 5.1 11.3 12.8

Parent employed part year 3,799 26.1 33.3 23.6 17.0

Parent not employed 5,374 8.7 69.0 14.3 8.0

Other families 4,577 56.4 19.6 13.7 10.3

Missing 1,737 19.8 33.4 20.3 26.5

Family income in relationship topoverty.

Poor 13,805 22.9 31.9 21.8 23.3

Other low income 12,983 45.3 21.5 17.9 15.3

Middle income 23,199 80.4 5.4 8.9 5.3

High income 13,762 90.7 3.0 3.7 2.6

.'Private insurance category includes persons covered only by private insurance all year: public insurance categoryincludes persons covered all year by public insurance or by a combination of public and private insurance.

**Poor refers to families with income below the federal poverty line: other low income, between the poverty line and199% of poverty; middle income, between 200% and 399% of poverty: high income, 400% of poverty or more.

Source: Agency for Health Care Policy and Research, 1987 National Medical Expenditure Survey, Child Health

Questionnaire and Household Survey.

I6


household had less than 7 years ofeducation to over 90% in householdswhere the head had 16 or more years ofeducation. Higher educational attain-ment enhances employment prospectsand leads to jobs with higher wages andmore generous fringe benefits such ashealth insurance.

Children in large families (six ormore children) have a greater likelihoodof being poor and uninsured (see appen-dix table Al). More than 42% of childrenfrom large families were without healthinsurance for all or part of 1987 as com-pared with around 20% of children fromsmall families (not more than two chil-dren). Lower rates of health insurancecoverage for children in large familiesare associated with higher rates ofpoverty and, therefore, with greater dif-ficulty in paving the additional out-of-pocket costs of private family coverage.

Access to and the Use ofHealth ServicesIn this section, we explore how the dif-ferences in children's health insurancecoverage described above are related todisparities in their access to and use ofhealth care services. We begin by exam-ining the relationship between chil-dren's health insurance status and thepresence of a usual source of medicalcare, one frequently used indicator ofaccess to care. For those children with ausual source of care. we also examine thespecific type of provider according to thechild's insurance status. Next, we exam-ine the relationship between health in-surance status and children's use ofambulatory medical care, prescriptiondrugs, and dental care in both 1977 and1987. Changes in the use of these serv-ices over this period are also discussed.Unless otherwise indicated, all differ-ences discussed in the text are statisti-cally significant at the .05 level(two-tailed t-tests.

Usual Source of Care

The presence of a usual source of medi-cal care is strongly correlated with abilityto obtain access to health care services,level of service use, and satisfaction withcare received.12 It is also an importantindicator of contin oily of care, which canaffect the quality of care through peri-odic review of the patient's adherence toa specific treatment regimen and the

progress of such treatment.12 In 1987,children lacking health insurance, espe-cially those uninsured throughout theyear, were less likely to have a usualsource of care than were those with pri-vate or public coverage (see table 2).Slightly more than 75% of children un-insured all year had a usual source ofcare compared to 90% of those with pri-vate or public coverage. Children withpart-year insurance coverage were alsomore likely to have a usual source of carethan the all-Year uninsured.I3

Regardless of insurance status. thepercentage of children with a usualsource of care declines with age, anddisparities between insured and unin-sured children increase. In the criticalearly years, however, differences in thepercent of children with a usual sourceof care are the smallest. Close to 90% ofall-year and part-year uninsured chil-dren ages 0 to 5 have a usual sourcecompared to 94% of privately insuredchildren and 92% of those publicly in-sured. Thus, along this dimension of po-tential access to care,I2 inequities byinsurance status are minimal. In con-trast, among the all-year uninsured,older children (especially adolescents)are far less likely than their insured coun-terparts to have a usual source of care.

Although having a usual source ofcare is one indicator of access to healthservices, differences in the site of carecan also affect access through the qualityand continuity of care received. For ex-ample. care obtained in a physician's of-lice is generally perceived as yieldinggreater continuity and satisfaction thancare obtained in a hospital outpatientsetting.12 Among children with a usualsource of care, site of care is related toinsurance status. More than 90% of pri-vately insured children with a usualsource of care have a physician's officeas the source of care. In contrast, ap-proximately 75% of uninsured childrenand only 65% of publicly insured chil-dren have a physician's office as theirusual source. The latter finding may re-flect the unwillingness of some physi-cians to lccept patients covered byMedicaid and other public programs,given low reimbursement levels relativeto other insurers. more extensive paper-work, processing delays, and arbitraryclaims denia1.14 As a result, publicly in-sured children are far more likely thanthose with private coverage to use hospi-

16


tal outpatient departments, emergencyrooms, or other nonhospital facilities(such as health centers) regularly as sitesof care. Finally, note that nearly 20% ofchildren uninsured all year obtain careregularly from other nonhospitalsources. For some of these children, thisresult may he a consequence of the un-willingness of hospitals to treat personsperceived as potential bad debts oneither an inpatient or an outpatient basis.

Use of Health Services

Differences in children's health insurancestatus also have important consequencesfor their use of health services, both interms of the likelihood that certain chil-dren will obtain particular medical servicesand also with regard to the actual level ofcare received. The re ationship betweeninsurance status and u;e of health services

is examined in table 3 for all ambulatorymedical care. Data tbr physician contacts.nonphysician contacts, prescription druguse, and dental care are presented in ap-pendix tables A2-A5. These tabulations de-scribe children's use of health services in

1987 by insurance status and age and com-pare their use to that of a decade earlier.The data in these tables demonstrate thatuninsured children are less likely to usethese health care services, that these chil-dren frequently have lower levels of usewhen they do obtain care, and that the gapbetween the u.,e of some of these servicesaccording to insurance status widenedbetween 1977 and 1987.15

Ambulatory Health Care Services

Data for both 1977 and 1987 (table 3)reveal that children with private healthinsurance throughout 1987 were farmore likely to obtain ambulatory healthcare services16 than children uninsuredall year. More than 80% of privately in-sured children in 1987 and 75% of thesechildren in 1977 had at least one ambu-latory contact, compared to only 60% ofthe all-year uninsured in each of theseyears. Particularly striking disparities arealso observed for children of specific agegroups. More than 90% of children 5years of age or younger with private in-surance obtained ambulatory care corn-

Table 2. Children's Health Insurance Status and the Presence of a Usual Source

of Care, 1987

With Usual Source of CarePercent Distribution

Insurance Status and Age Percent with UsualSource of Care

Physician's Office Hospital OutpatientDepartment/

Emergency Room

Other NonhospitalFacilities*

Total 88.8 85.3 5.7 8.9

Private insurance 91.5 93.0 2.8 4.2

0 to 5 years 94.0 I 95.1 2.4 2.5

6 to 12 years 92.5 93.2 2.5 4.2

13 to 17 years 88.1 90.8 3.5 5.7

Public insurance 89.7 64.5 14.4 21.1

0 to 5 years 92.0 64.1 12.2 23.6

6 to 12 years 90.0 67.7 13.8 18.5

13 to 17 years 86.3 59.7 18.4 21.9

Uninsured, part year 84.7 75.3 11.0 13.7

0 to 5 years 89.8 81.6 7.3 11.1

6 to 12 years 82.5 70.8 13.0 16.2

13 to 17 years 81.7 73.3 13.1 13.6

Uninsured, all year 76,7 74.3 7.5 18.3

0 to 5 years 88,7 73.0 7.9 19.1

6 to 12 years 75.8 73.2 9.2 17.6

13 to 17 years 69.8 76.6 4.9 18.4

'Other nonhospital facilities include health centers, company industrial clinics, school clinics, walk-in urgent core centers,

and patient's home.

Source: Agency for Health Care Policy and Research. 1987 National Medical Expenditure Survey.

163


pared to only 75% of children uninsuredall year. While 75% of children 6 years ofage or older with private insurance ob-tained ambulatory care, a little morethan half of those uninsured all year ob-tained such care.

In 1987, privately insured childrenwere also more likely to use ambulatoryhealth services than were children withpublic insurance or those uninsured partyear. Because in 1977 the differencesamong these groups were not statisticallysignificant, the increase in the likelihoodof ambulatory care use by privately in-sured children in 1987 represents a gainin access to such care relative to thatobtained by publicly insured and part-year uninsured children. It also repre-sents an expansion of their advantage inaccess to ambulatory care over childrenuninsured all year.

Privately insured children who usedambulatory care also had more ambula-tory contacts than the all -year uninsured:almost two more contacts in 1987 (5.7contacts to 4.0) and one more contact in

1977 (5.0 to 3.8). These differences werealso present when specific age groups werecompared. The number of ambulatorycontacts by children with public insurancein 1987 and 1977 was comparable to thatof children with private insurance (onlythe oldest children among the formergroup lost ground to children with privateinsurance), while the number of ambula-tory contacts by children uninsured partyear remained relatively constant in bothyears. Consequently, uninsured childrenalso lost ground to privately and publiclyinsured children with regard to the num-ber of ambulatory contacts obtained.

Physician and Nonphysician Contacts

Similar patterns are revealed when ambu-latory care is disaggregated into physicianand nonphysician contacts.17 Privately in-sured children were far more likely thanthose uninsured all or part of the year toobtain a physician contact in both 1977and 1987 (see appendix table A2), withwide disparities observed for all agegroups. Privately insured children werealso more likely to obtain physician serv-

Table 3. Children's Health Insurance Status and Use of Ambulatory HealthServices, 1987 and 1977

Percent with Ambulatory Care

Insurance Status and Age 1987 1977

Average Number ofI Ambulatory Care Contacts for

Those with Any Contacts

1987 1977

Total 76.5 74.7

Privately insured 80.4 76.6

0 to 5 years S:1.2 87.0

6 to 12 years 74.9 74.5

13 to 17 years 75.5 71.2

Publicly insured 75.9 73.3

0 to 5 years 84.3 83.7

6 to 12 years 69.3 67.9

13 to 17 years 69.8 67.1

Uninsured part year 71.9 74.9

0 to 5 years 79.0 86.2

6 to 12 years 65.0 70.0

13 to 17 years 51.3 55.3

Uninsured all year 59.4 60.9

0 to 5 years 76.7 74.1

6 to 12 years 52.2 56.2

13 to 17 years 51.3 55,3

5.45.7

6.1

5.55.4

5.8

6.26.04.64.7

5.53.3

3.54.04.83.0

3.5

4.95.05.9

4.54.74.95.7

4.1

4.94.7

5.63.9

3.83.85.0

3.2

3.8

Ambulatory health services include any physician or nonphysician contacts in any medical setting (except as aninpatient) including office visits, telephone contacts. outpatient departments. emergency rooms, and home care visits.

Source: Agency for Health Care Policy and Research, 1987 National Medical Expenditure Survey and 1977 NationalMedical Care Expenditure Survey.

164

162

ices in 1987 than in 1977, while the likeli-hood of a physician contact over this dec-ade remained the same for publiclyinsured children and those uninsured allyear. While the number of physician con-tacts was roughly equivalent for privatelyinsured children in both 1977 and 1987,the average number of contacts obtainedby publicly insured and children unin-sured all or part year actually declined.This decline was concentrated amongyoung children and was especially sharpfor the part-year uninsured between 6 and12 years of age (from 3.5 contacts in 1977to 2.2 in 1987).

Uninsured children were not able tocompensate for their lower levels of ambu-latory physician care through an increasein the use of nonphysician services relativeto that of insured children. Compared tochildren uninsured all year, those with pri-vate and public coverage were also morelikely to use ambulatory nonphysician serv-ices in 1987 (see appendix table A3).These groups also experienced a statisti-cally significant increase in this likelihoodfrom their 1977 levels, and increased theaverage number of nonphysician contactsbetween 1977 and 1987. In contrast, unin-sured children did not increase their prob-ability of using nonphysician care between1977 and 1987, and the average numberof contacts by uninsured children in 1987was not statistically different from that ob-tained in 1977.

Prescription Drugs

Prescription drugs are a particularly im-portant aspect of children's access tohealth services because they are com-monly used to treat a variety of both acutechildhood illnesses and chronic childhealth problems such as asthma and aller-gies. Therefore, it is particularly disturbingto find (see appendix table A4) that, com-pared to privately insured children in1987, children uninsured all or part of theyear and those covered by public insur-ance use significantly fewer prescriptiondrugs. Only 34% of children uninsured allyear and 45% of those uninsured part yearused prescription drugs in 1987 comparedto 55% of all privately insured children.Children uninsured all year were also lesslikely to use prescription drugs than thoseuninsured part of the year or those withpublic coverage. Children with public in-surance were also less likely than thosewith private insurance to use prescriptiondrugs, but their likelihood of use was no

THE FUTURE OF CHILDREN - WINTER 1992

different from that of children uninsuredpart year.

Among children who used prescrip-tion drugs in 1987, those with private orpublic health insurance averaged aboutone more prescription or refill than thoseuninsured all year (3.7 prescriptions com-pared to 2.7). Among the uninsured, av-erage drug use actually declined between1977 and 1987 (from 3.5 to 2.7 prescrip-tions per year), with the largest declineoccurring for children less than 6 years ofage (4.0 prescriptions in 1977 comparedto 2.9 in 1987). Because prescriptiondrugs are generally obtained throughconsultation with a physician, the reduc-tion in prescription drug use by the unin-sured may be a reflection of the declinein their access to physician care over thistime period.

Dental Care

Dental care has increasingly been recog-nized as an important aspect of children'sgeneral health care. As with the other serv-ices reviewed in this section, disparities inthe use of dental care appear correlatedwith children's health insurance status,particularly with regard to the likelihoodof use. However, as we have noted ear -lier,15 this correlation may reflect dispari-ties in family income between insured anduninsured children since dental benefitsare not uniformly held in private healthinsurance plans.I8 In 1987, children cov-ered by private insurance were 21/2 timesas likely as those uninsured all year toobtain dental care (57.6% of the formercompared to 21.6% of the latter).Although children with public coverageand those uninsured part year were morelikely than the all-year uninsured to obtaindental services, the likelihood of use by theformer groups also fell considerably belowthat of the privately insured. Moreover,while the percent offrivately insured chil-dren using dental care increased between1977 and 1987 (from 51.7% to 57.6%),that of the all-year uninsured actually de-clined from 30.1% to just over 20%. Thedecline for children uninsured part yearwas not statistically significant. The per-centage of publicly insured and part-yearuninsured children obtaining care stayedrelatively constant. Among those usingdental services, the average number ofdental visits by privately insured childrenexceeded that of children with public in-surance or those uninsur "d part year. Dif-ferences in the number of dental visitsmade by privately insured children and

163


those who were uninsured all year werenot statistically significant.

Use of Health Services for ParticularMedical Events

The tabulations presented above reveal ageneral pattern of limited access to anduse of health care services by uninsuredchildren compared to their insured coun-terparts. However, because insured anduninsured children may differ with regardto health status or health care needs, thedifferences reported above could over-state or understate the actual degree ofdisparity. Therefore, we examine chil-dren's use of health services for particularmedical conditions including asthma, earinfections, well-child visits, and immuniza-tions. Although limited in scope, theseanalyses provide additional evidence thatuninsured children are at a disadvantagecompared to those with private and publichealth insurance.

Children's use of physician services forasthma and ear infections (more than twoin the past 12 months) are reported infigure 2 for children ages 17 and youngeraccording to their insurance status.19 Un-insured children with asthma and thosewith more than two ear infections were farless likely to obtain treatment from a phy-sician than were children with private orpublic coverage. Less than half of all unin-sured children with asthma (49%) saw aphysician compared to 65% of those withprivate insurance and 70% with public cov-erage. Only two thirds of uninsured chil-dren whose parents' reported their havingmore than two ear infections in a 12-monthperiod saw a physician for care comparedto almost 90% of insured children.

Well-child visits and immunizations foryoung children are basic components ofpreventive health care.2 Thus it is also trou-blesome to note that, when these compo-n en ts of children's health care areconsidered according to their insurancestatus, service use differences similar tothose generally observed appear. Using1987 NMES data, Lefkowitz and Short20find that 0- to 2-year-olds uninsured all yearare far more likely than those privatelyinsured (all year or part of the year) to lacka well-child visit (35.8% of the former com-pared to only 20% of the latter). Lefkowitzand Short also compare rates of immuni-zation for young children (those turning 1or 2 years old in 1987) with the rates rec-ommended by the American Academy ofPediatrics. Although more than 90% of all

such children receive diphtheria, pertussis,and tetanus (DPT) immunizations and88% receive oral polio vaccinations, immu-nization rates for uninsured children stillfall below those of the privately insured:95.1% of privately insured children receiveDPT injections, and 90.1% receive oral po-lio immunizations compared to 84.9% and81.6% of the uninsured, respectively.While less than half of all these young chil-dren are immunized for measles, mumps,and rubella, rates of immunization for un-insured children are still below rates forprivately insured children.

Efforts to ExpandChildren's HealthInsurance CoverageOur tabulations document a rise in theproportion of uninsured childrenbetween 1977 and 1987. We also find thatuninsured children are far less likely toobtain ambulatory medical and otherhealth care services than are children cov-ered by private or public insurance. More-over, our findings suggest that thedisparities between insured and unin-sured children in the use of ambulatory

Figure 2. Children's Health, Health InsuranceStatus, and Use of Physician Services forSpecific Conditions, 1987*

Unrased AA a Pal Via

Public Inultac*

Pnvae klsonxIce

Children with Asnima

10 20 30 40Away* Soon by Physic on

Children with Two or MOM Ear Infections

Unnounpo AA of Pat Year

Public insurance

Prryoto Irauranai

10 20 30 40 50 60 70Percent Soon by Physkton

'Children ages 17 or younger

NI 90

Source: Agency for Health Care Policy and Research. 1987 NationalMedical Core Expenditure Survey: Child Health Questionnaire andHousehold Survey

16G

164

health services (including physician andnonphysician ambulatory care), numberof prescription drugs obtained, and theprobability of obtaining dental serviceshave widened over the past decade.

Recognition of the vulnerable healthstatus of children and the importance andcost-effectiveness of children's health carehas been an important factor in buildingthe political consensus necessary to expandaccess to health services for low-incomechildren and pregnant women during the1980s." (See the Hill article in this journalissue.) More recently, the OBRA-1990 hasmandated that, by the year 2002. statesprovide Medicaid coverage to all childrenand pregnant women in families with in-come below poverty. With regard to privatehealth insurance, numerous proposalshave sought to expand such coverage. es-pecially through expanded employment -related coverage or tax credits topopulation groups that are unlikely tomeet Medicaid eligibility standards. Inwhat follows, we provide a brief assessmentof how the two most frequently discussedpolicy alternativesmandated employ-ment-related coverage and incrementalMedicaid expansionsmight affect thenumber of uninsured children.

Mandated Employment-relatedCoverage

Health insurance obtained through anemployment arrangement remains theprimary source of insurance for the major-ity of Americans. Some 75.4% of personsless than age 65 bad such coverage in1987.21 Because the working uninsuredand their dependents comprise more thanthree quarters of all uninsured persons,proposals to mandate employment-basedcoverage are a natural response to theproblems associated with lack of coverage.Such a requirement, together with ex-panded public coverage for those withoutemployment-related insurance, has beenendorsed by a majority of members of theNational Commission on Children and isan integral part of their proposal for auniversal system of health insurance for alluninsured children through age 18 and alluninsured pregnant women.22 How effec-tive might an employer mandate be inreducing the number of uninsured chil-dren:. Assuming that the mandate wouldcover employees who work at least 20hours per week, Monheit and Short23 esti-mate that roughly two thirds of the 37million persons uninsured in the first


quarter of 1987 would obtain coverage. Ofthese 24.3 million newly insured persons,30%, or about 7.1 million, would be chil-dren less than 18 years of age and wouldrepresent almost two thirds of all unin-sured children (63.6%).

Such estimates are, however, very sen-sitive to whether the mandate includessmall firms. (Estimates will also vary accord-ing to the data sets used and the time framecovered.) For example. if establishments offewer than 10 employees are exempt fromthe mandate, Monheit and Short estimatethat only 35% of all persons uninsured inthe first quarter of 1987 (about 13 millionpersons) would be affected. Using datafrom the March 1990 Current PopulationSurvey (CPS), Rodgers estimates that anemployer mandate restricted to employeesworking at least 25 hours per week in firmsof more than I 0 workers would affect some17 million persons, or 52.6% of uninsuredpersons.24 Some 5 million children wouldbe affected, representing 59% of the 8.5million uninsured children estimated forMarch 1990.

Expanding MedicaidThe remaining one third of uninsured chil-dren not affected by an employer mandatewould include those whose parents are notemployed, work fewer hours than would berequired by the mandate, or work for smallfirms that might be exempt from an em-plover mandate. To the extent that suchchildren are in families with income belowthe federal poverty line, many would haveobtained Medicaid coverage under expan-sions of the program since 1987 or be eligi-ble for Medicaid under OBRA-1990 (whichwas effective as of July 1991 with full imple-mentation by the year 2002).

Several analysts have estimated the im-pact of Medicaid expansions on uninsuredchildren. Holahan and Zedlewski estimatethat in 1989 expansions in Medicaid re-sulted in coverage of 72.5% of the 4.9 mil-lion poor children under age 5 and 64.7%of 9.6 million poor children between theages of 6 and 17,25 leaving 15.2% of theformer and 20% of the latter uninsured.2(tWere Medicaid further expanded to coverall poor children (as in OBRA-1990), anadditional 4.9 million children (lackingemployer-provided insurance) would becovered. If eligibility were extended up to200% of poverty, 8.1 million childrenwould be included.27

Rodgers has also simulated the effect ofa Medicaid expansion which would include

167


all persons in families with incomes of lessthan 100% of poverty and would allow per-sons in families with incomes between100% and 200% of poverty to "buy in" toMedicaid on the basis of a sliding scale ofcontributions. This strategy would greatlyexpand the size of the Medicaid program(an estimated 39.9 million persons coveredunder the expanded program comparedto 14.6 million without such an expansion)and would result in a dramatic decline inthe number of uninsured persons (from33.4 million to 13.1 million). An expandedMedicaid program would also cover 74%of uninsured children, reducing the num-ber of uninsured children from 8.5 millionto 2.3 million.24

Both Holahan and Zedlewski, andRodgers caution that expanded Medicaidcoverage will add greatly to federal andstate spending burdens. Holahan andZedlewski estimate that an additional $15billion in financing would be required toenroll persons lacking employment-related insurance in a Medicaid expansion.Were Medicaid extended to such personswith incomes up to 200% of poverty, $28billion in additional financing would berequired. Rodgers provides similar esti-mates with federal spending increasing by$16 billion and state expenditures by $12billion.

In sum, either approach taken inde-pendently will fail to cover all uninsuredchildren. Estimates of the impact of an

Appendix Tables

employer mandate suggest that, at best,upwards of 60% of uninsured childrenwould be covered, while a Medicaid ex-pansion requiring coverage of all childrenbelow poverty and allowing a "buy in" forthose in families with incomes between100% and 200% of poverty would coversome 73% of uninsured children. Impos-ing an employer mandate together with aMedicaid expansion that would includesome children whose parents are ineligi-ble for the employer mandate would befar more successful. Rodgers estimatesthat such an approach would extend cov-erage to as many as 93% of uninsuredchildren. Such a private-public partner-ship, as has been advocated by the Na-tional Commission on Children, wouldtherefore appear to have much potentialto reduce the number of uninsured chil-dren. Given the trends we have docu-mented above, the failure to take boldinitiatives through the private and publicsectors may cause uninsured children tocontinue losing ground to insured chil-dren, both in terms of their access to careand in terms of their use of essential andcost-effective health services.

We with to thank Doris C. Lefizowitz andDaniel C. Walden for their helpful commentsduring various stages of this analysis. EugeneLentil and Ted Joyce provided useful commentson an earlier draft. Yimin Nagan of Social andScientific &stems, Bethesda, Maryland, pro-vided skillful computer programming support.

Table Al. Health Insurance Status of Children by Selected Family Characteristics, '1987

insured All INICIf" Uninsured

Population(thousands)

Private Public Pad Year All Year

Education of household Mod

6 years or less 2.096 25.4% 25.8% 23.0% 25.8%

7 to 9 years 4.190 36.5 22.7 17 1 23.8

10 to 12 years 27.126 59 7 16.0 13.0 11.2

13 to 15 years 12,156 744 99 11.2 4.6

16 or more years 11,904 90.8 2.0 5.0 2.3

Number of chNckon in family

2 or fewer 37.844 67 5 10.8 11.8 9.8

3 to 5 22.482 602 173 127 9.7

6 or more 3A23 31 7 26.0 16.8 25.5

'Private insurance category includes persons covered only by private insurance all year; public insurance category includes. persons covered all year by public insurance or by a combination of public and private Insurance.

Source: Agency for Health Care Policy and Research. 198' Notional Medical Expenditure Survey, Child Health Questionnaire and HouseholdSurvey

1.63

166 Appendix Tables

Table A2. Children's Health Insurance Status and Use cf Ambulatory Physicians' Services, 1987 and 1977

Insurance Status and Age Percent with Physician Contact Average Number of Physician Contactsper User

1987 1977 1987 1977

Told 73.1 71.1 4.0 4.3

Privately insured 77.3 72.9 4.3 4.4

0 to 5 years 88.9 64.6 5.2 5.3

6 to 12 years 71.3 70.8 3.7 3.9

13 to 17 years 72.3 66.5 3.8 4.0

Pubic:iv kuured 72.6 70.3 4.1 4.5

0 to 5 years 80.2 81.8 4.5 5.2

6 to 12 years 67.3 64.1 3.7 3 8

13 to 17 years 66.1 63.6 3.6 4.2


0 to 5 years 76.4 84.3 4.2 4.9

6 to 12 years 61.3 65.9 2.2 3.5

13 to 17 years 66.6 60.9 3.6 3.6

Uninsured, all year 54.0 57.0 3.0 3.6

0 to 5 years 71.8 71.6 3.7 4.6

6 to 12 years 46.7 50.3 2.4 2.9

13 to 17 years 45.5 52.3 2.8 3.3

Ambulatory physician services include any physician contacts in any medical setting (except as an inpatient) including officeContacts, Outpatient departments. emergency rooms. and home care visits.

Source: Agency for Health Care Policy and Research. 1987 National Medical Expenditure Survey and 1977 National Medical Core

Expenditure Survey.

Table A3. Children's Health Insurance Status and Uso of Ambulatory Nonphysician Services, 1987 and 1977

Insurance Status and Age Percent with Nonphysician Contact Average Number of NonphysicianContacts per User

1967 1977 /1987 1977

rota 23.2 19.3 5.1 3.0

Prtyalety insured 24.4 20.0 5.1 3.1

0 to 5 years 27.1 21.7 3.2 2.7

6 to 12 years 21.9 18.8 6.8 3.1

13 to 17 years 24.5 19.9 5.5 3.4

Pudic* Insured 23.5 17.9 6.2 2.6

0 to 5 years 30.4 19.4 5.3 2.5

6 to 12 years 19.2 16.7 8.9 2.2

13 to 17 years 16 7 - -17.6 -.-


0 to 5 years 25.8 23.8 -.-

6 to 12 years 16.1 17.3 -.-

13 to 17 years 20.2 - -17.3 -.-

Uninsured, all year 18.4 14.9 3.5 2.5

0 to 5 years 28.3 18.7 -.- -.-

6 to 12 years 13 4 14.1 -.

13 to 17 years 14.9 -.-12.6

Ambulatory nonphysician services inc ude contacts with nonphysiclan providers in an office or clinic. hospital outpatientdepartment (but not In an emergency room or as an inpatient), by telephOne, or at home.

-.- means that the cell size was too small to produce reliable estimates.

Source: Agency for Health Core Policy and Research. 1987 National Medical Expenditure Survey and 1977 Notional Medical Core

Expenditure Survey.

16J


Table A4. Children's Health Insurance Status and Use of Prescription Drugs, 1987 and 1977

Insurance Status and Age rerceru usury riusk.uprivi - - - -.

1987 1977 I 1987 1977

Total 50.9 50.7 3.6 3.8


0 to 5 years 67.6 68.0 3.9 4.5

6 to 12 yea:s 51.6 51.7 3.5 3.7

13 to 17 years 45.7 42.1 3.8 3.5

Publicly insured 49.6 48.7 3.5 3.5

0 to 5 years 55.6 60.8 3.7 2.7

6 to 12 years 46.3 43.5 3.3 3.3

13 to 17 years 42.9 40.0 3.5 3.1

Uninsured. part year 452 49.8 3.2 3.6

0 to 5 years 56.9 65.8 3.4 4.0

6 to 12 years 36.3 44.7 2.5 3.2

13 to 17 years 39.8 34.5 3.9 3.2

Uninsured. all year 3.4.4 38.6 2 7 3.5

0 to 5 years 48.4 53.2 2.9 4.0

6 to 12 years 28.1 34.8 2.3 3.3

13 to 17 years 28.4 31.0 2.9 3.0

Source: Agency for Health Care Policy and Research, 1987 National Medical Expenditure Survey and 1977 National Medical CareExpenditure Survey.

Table A5. Children's Health Insurance Status and Use of Dental Services, 1987 and 1977

Insurance Status and Age Percent Using Dental Care I Average Number of Visits per User----i

1987 1977 II

1987 1977

Total 47.1 46.7 3.0 3.41


3 to 5 years 43.0 27.7 1 7 2.1

6 to 12 years 62.8 56.1 2.8 2.8

13 to 17 years 59-1 56.6 4 3 4 6

Publicly insured 36.9 34.8 2.3 3.0

3 to 5 years 34.3 21.5 2.1 -.-

6 to 12 years 39.7 39.4 2.4 2.8

13 to 17 years 34.6 36.5 2.3 3.5

Uninsured, pad year 31.1 36.3 2.4 2.9

3 to 5 years 18.0 17 5

6 to 12 years 38.4 40.3 2.3 2.7

13 to 17 years 31.9 43.4 3.3

Uninsured. all year 21.6 30 1 2.6 3.2

3 to 5 years 18.5 15.7

6 to 12 years 25.4 36.1 2.3 2.9

13 to 17 years 18,8 29.6 3.6

-.- means that the cell size was too small to produce reliable estima. s.

Source: Agency for Health Care Policy and Research, 1987 National Medical Expenditure Survey and 1977 National Medical CareExpenditure Survey

17tl


1. U.S. National Commission on Children. Beyond rhetoric. A new American agenda for children andfamilies: Final report of the National Commission on Children. Washington, DC: U.S. GovernmentPrinting Office, 1991, p.118.

2. For a review and discussion see U.S. Congress, Office of Technology Assessment. Healthychildren: Investing in the future. Washington, DC: U.S. Government Printing Office (OTA-H-345), February 1988.

3. U.S. Bureau of the Census. Statistical abstract of the United States: 1988. 108th ed. Washington,DC: U.S. Government Printing Office, 1987, table 168, p. 106. The percentage of children 5to 14 years of age immunized exceeded 70% for whites and 60% for nonwhites (with the ex-ception of polio) in 1987. The only significant growth in immunization rates for these chil-dren between 1980 and 1985 was for mumps. The Health of America's Children. Washington,DC: Children's Defense Fund, 1989, table 2.7, pp. 63, xii.

4. Estimates of children's health insurance status and use of health services in 1987 and 1977 arefrom the household components of the 1987 NMES and 1977 NMCES, respectively. Esti-mates are for the noninstitutionalized civilian population and exclude residents of nursingand personal care homes, facilities for the mentally retarded, and prisons. The householdcomponents of each survey are year-long panel surveys of the medical care use, expendi-tures, health insurance coverage, employment, and demographic characteristics of the U.S.civilian noninstitutionalized population. Respondents in each survey were asked about theirhealth insurance status at each interview. Responses to questions regarding health insur-ance, types of plans held, and sources of coverage were used to classify respondents. The fol-lowing classification of insurance status was used for this paper: Children (for all categorieschildren are 17 years of age or younger) with private insurance were covered by individualor group insurance for medical or related expenditures, including prepaid health planssuch as health maintenance organizations (HMOs), but excluding extra cash coverage(small supplemental payments in the event of hospitalization), medical benefits linked tospecific diseases (such as cancer), and casualty benefits. Children with public health insur-ance were covered by Medicaid, other state and local medical assistance programs, CivilianHealth and Medical Program of the Uniformed Services (CHAMPUS), Civilian Health andMedical Program of the Veterans Administration (CHAMPVA), and/or Medicare. Unin-sured children had neither private nor public coverage. In each survey, children insured allyear were children with private or public insurance at all interviews. Children with privateinsurance all year wet e covered only by private insurance in all interviews' tnose with publicinsurance all year were covered only by public insurance in all interviews. Children unin-sured part of the year had private or public coverage at some but not all household inter-views. Children uninsured all year were children with neither private nor public coverage atall household interviews. Children were considered to have used the health care services re-ported in the text if their parents reported at least one instance of use for the specific serv-ices tabulated regardless of whether charges for the services were rendered. A detaileddescription of the 1987 NMES survey is contained in Edwards, W and Berlin, M. Question-naires and data collection methods for the Household Survey and the Survey of American Ind:.ns andAlaska Natives and the National Medical Expenditure Survey methods 2. National Cent .tr forHealth Services Research and Health Care Technology Assessment. Rockville, MD: PublicHealth Service (DHHS/PHS-89-3450), September 1989. Detailed information on the designand data collection instruments for the 1977 NMCES are contained in Bonham, G.S. andCorder, L.S. NMCES household interview instruments: Instruments and procedures 1. NationalHealth Care Expenditure Study. National Center for Health Services Research, Rockville,MD: Public Health Service (DHHS/PHS-81-3280), April 1981.

5. Cunningham, RI, and Monheit, A.C. Insuring the children: A decade of change. Health Af-fairs (Winter 1990): 76-90.

6. OBRA-1981 affected Medicaid enrollment by limiting the gross income of enrollees to 150%of each state's standard of need for AFDC eligibility and limiting various exempted incomecategories such as child care, work-related expenses, and specified amounts of earned in-come. See Holahan, J.F., and Cohen, J.W. Medicaid: The trade-off between cost containment andaccess to care. Washington, DC: The Urban Institute Press, 1986. OBRA-1981 has been esti-mated to have reduced Medicaid enrollment by more than 2 million persons. See Crom-well, J., Hurdle, S., and Wedig, G. Impacts of economic and programmatic changes onMedicaid enrollments. Review of Economics and Statistics (May 1986) 68,2:232-40.

7. Beginning with the Deficit Reduction Act (DEFRA) of 1984, Congress has sought to expandMedicaid by allowing or mandating states to expand coverage of pregnant women andyoung children. DEFRA-1984 mandated Medicaid coverage of all children up to age 5 inhouseholds with incomes below AFDC standards and also included pregnant women whowould qualify for AFDC once their children were born. The Consolidated Omnibus BudgetReconciliation Act (COBRA) of 1985 eliminated categorical eligibility restrictions for poor

17 AL


pregnant women by mandating cover age for all pregnant women with incomes of less thanthe state's AFDC standard even if they were not receiving AFDC benefits. The OmnibusBudget Reconciliation Act (OBRA) of 1986 permitted states to extend coverage to pregnantwomen and children under 5 years old in families with incomes up to the federal povertyline. OBRA-1987 continued this trend by allowing states to extend Medicaid coverage topregnant women and infants up to 1 year of age with family incomes up to 185% of the pov-ert line. States could also cover children less than age 5 with incomes up to the povertyline, and children less than age 8 were to be phased in. Among the provisions retainedfrom the Medicare Catastrophic Coverage Act was the mandated Medicaid coverage of preg-nant women and children up to age I in families with incomes of less than 100% of poverty.OBRA-1989 mandated Medicaid coverage fO pregnant women and children up to age 6with incomes of less than 133% of poverty, and most recently. OBRA-1990 requires states by2002 to cover children under age 18 in families earning less than 100% of the poverty line.For a more detailed description of these provisions, see the Hill article in this journal issue.

8. Seeensen, G.A., Morrisey, M.A., and Marcus, J.W. Cost-sharing and the changing pattern ofemployer-sponsored health benefits. The Milbank Quarterly(1987) 65,4:521-50; also, Short,.F. Trends in employee health benefits. Health Affairs (Summer 1988) 7,3:186-98.

9. Data 1M. weekly earnings are from U.S. President, Economic report of the hrsident 1990. Washing-ton DC: U.S. Government Printing Office. 1990, table C-44. Data on median family incomeare from U.S. Bureau of the Census. Statistical Abstract of the United Stales: 1991. 111th ed.Washington, DC: U.S. Government Printing Office, 1990, table 730.

10. The Congressional Research Service has argued that the most dramatic trend in sources ofhealth insurance between 1979 and 1986 has been the decline in the percent of thenonelderly population covered by the employment-related plan of another family member(from 34.3% in 1979 to 31.1% in 1986). See Congressional Research Service. Library ofCongress. Health insuranie and the uninsured: Backt,rinund data and analysis. May 1988, pp. 1101 I. table 4.8.

11. In both the NMES and the NMCES, questions regarding the presence and type of coveragewere asked of each person in the household. including children, so that children coveredby persons outside the household (for example, by a divorced parent) were considered in-sured. Each survey also has the capacity to produce alternative estimates of insurance (-over-age, such as insurance status at a point in time or insurance status during the calendar year.In contrast, frequently quoted estimates of insurance status from the Current PopulationSurvey ((:PS) between 1980 and 1987 were derived from questions that did not directly askabout the health insurance status of each individual in the household and did not recog-nize that persons could obtain coverage From policyholders residing outside the household.TherefOre. (TS estimates of the unit:sured prior to 1988 may have seriously overstated thenumber of uninsured children. Comparisons between NMES and CPS estimates of the unin-sured population for 1987 are ,ilso made difficult because CPS estimates are probably alsooverstated. These issues make NMES and NMCES estimates more reliable indicators of thehealth insurance status of children in 1987 and 1977. For a discussion of issues related toCPS estimates of the uninsured population, see Kronick, R. Adolescent health insurance stains:Analyses of trnd.s in coverage and preliminary es/inn, s of the effects of au employer mandate and a,11edicaid expansion on the uninsured. Background paper. Washington, DC: U.S. Congress,Office of 'rechnol(14-y Assessment, July1989. appendices A and B, pp. 49-60; Swartz. K., andPurcell, P.J. Counting uninsured Americans. Health Affairs (Winter 1989) 8,4:193-97. NMESestimates of persons uninsured in the first quarter of1987 and persons uninsured all yeararc From Short, Pi:. lislinrates Ul the uninsured population, calendar year 1987. National A WirdExpenditure Survey data summary 2. Agency for Health Care Policy and Research. Rockvill,MD: Public Health Service (1)1111S;PHS-90-3169). September 1990. CPS estimates are fromthe Congressional Research Service , Library of Congress. Health insurance and the nninsumd:Background data and analysis. Washington, DC: I '.S. Government Printing Office, 1988.

12, Aday, Fleming, GA'., and Andersen, R. Access to medical care in the Who has it. whodoesn't. Chicago: Pluribus Press for the University of Chicago, 1984.

13. Data on usual source of care were obtained fr()in the NMES Access to Care Supplement,which was administered in round 3 of the NMES household survey. Compared to the all-year uninstn ed. children with part-year coserage 1110.V have been more likely to have had ausual source of care if they were insured at round 3 or continued to use the usual source ofcare established when insured in prior periods.

Sardell, A. (lild health policy in the U.S.: :OM it «msensus./ourna/ 'V Health Polities.Miry and Lou' (Summer 1990) 15.2:271-301.

IS. In interpreting the results of tables 3 and A2 through AS. it is important to remembel thatthe measures of illM111111«' in NMES and NN10ES data Only indi( ate the presence of privateor public cove' age. NMES and NW:ES household data do not indicate whether specific

17'1

7


types of services are covered or the generosity of coverage for those services. In addition,some of the observed differences in health services used in these tables are likely to he at-tributable both to health insurance status and to income because persons with privatehealth insurance are likely to have higher family income than the uninsured (see table 1).The role of income may he more important for services such as dental care which are notuniformly available in private health insurance plans.

16. Ambulatory health care services include any physician or nonphysician contacts in any medi-cal setting (except as an inpatient) including office visits, telephone contacts, outpatient de-partments. emergency: rooms, clinics, and home care visits.

17. Ambulatory physician services are physician contacts in any medical setting (except as an in-patient), including office visits, telephone contacts, outpatient departments, clinics, emer-gency rooms, and home care visits. Ambulatory nonphysician services arc contacts withnonphysician providers in the above settings except as an inpatient or in an emergen,r0011).

18. For example, in 1988, 72% of full-time participants in health insurance plans in ined;.am andlarge establishments had dental benefits. In contrast, 99% of such participants had cover-age for physician office visits. See table 7.3 in LBW databook on employee benefits. WashingtonDC: Employee Benefits Research Institute, 1990. These tabulations are from U.S. Depart-ment of Labor, Bureau of labor Statistics. Employee benefits in medium and large firms 1988.Washington, DC: U.S. Government Printing Office, 1988.

19. The Child Health Questionnaire also asked about other child health conditions, includinghay fever and all allergies, frequent headaches, anemia, stammering/stuttering, heart prob-lems, and long-lasting digestive problems. Most of the conditions had insufficient responsefrequencies to make estimates according to children's health insurance status.

20. Lefkowit7, D.C., and Short, P.F. Medicaid eligibility and the use of preventive services by low incomechildren. Unpublished manuscript presented at the Annual Meeting of the American PublicHealth Association. Chicago, October 1989.

21. Sec Short, P.F., Monheit,VC., and Beattregard, K. A invfile of uninsured Americans. NationalMedical Expenditure Survey research findings I. National Center for Health Services Researchand Health Care Technology Assessment. Rockville, MD: Public Health Service(DHHS /PHS -89- 3443). 1989.

22. See note no. I. U.S. National Commission on Children, pp, 118 and 138-17, for a detailed dis-cussion of this proposal. The universal plan proposed by the Commission is of the "play orpay:- variety and would require all large employers to provide coverage to pregnant employ-ees, to nonworking spouses of employees, and to their dependent children. Small employ-ers would be phased in as insurance market reforms make coverage more affordable forthese employers. Employers not providing coverage directly would purchase insurancethrough a newly established public health plan, with costs set as a percentage of payroll. It isestimated that this plan-which would cover all 8.3 million uninsured children and 33,000uninsured pregnant womenwould cost the federal government S7.4 billion with employ-ers paying 58.9 billion in additional benefits, payroll taxes, or both. The net cost of the pro-posal is estimated to be $2.7 billion as state and local governments reduce the costs of carefor the uninsured and medically indigent by S2.5 billion, as employers who no longer bearcost shifting because of uncompensated care and low Medicaid reimbursements reducetheir costs by S1.3 billion, and as S6.8 billion in cost savings are gained by families from in-creased employer and government contributions to their health care coverage.

23. Monheit. A.C., and Short, P.F. Mandating health coverage For working Americans. HealthAffairs (Winter 1989) 8,2:22-38.

24. Rodgers, J. Selected optionc for expanding health insurance coverage. Congress of the United States.Congressional Budget Office. July 1991.

25. Helahan. J., and Zedlewski. S. Expanding Medicaid to cover 1111111S'.1 I ed Americans. healthAffe.!irs (Spring 19911:45-61.

26. The remaining I 2.3% of poor children mulct age 5 and 15.3% of poor children ti to 17 vearsof age are covered by other insurance (presumably private insurance and CHAMPUS).

27. See note no. 25. l lolahan and Zedlewski, in which the authors provide a range of estimates ac-cording ui children's poverty status and insurance status. Their estimates ex/flit illy recog-Mve that expanded Medicaid coverage Illa include children previously covered Inemployment-related or other private insurance. The estimate presented in the text includessome children who may have been covered by privately purchased nonemployment-relatedcoverage. See exhibit 3 of their :wile le for the full range of their estimates.

1 7 3

Nonfinancial Barriersto the Receiptof Medical CareLorraine V. Kierman

Abstract

Much has been written about financial barriers to health care, but nonfinancialharriers also increase the risk of inadequate health care. Nonfinancial harriersincluding legal restrictions, geographic isolation and provider shortages, providerpractices and policies, and personal attributes and circumstancescan preventindividuals from obtaining care. Children, adolescents, and women needing familyplanning or obstetric services arc especially vulnerable to these barriers regardlessof their ability to purchase care at prevailing market prices. Where individuals facea combination of financial and nonfinancial harriers, access can he severely limited.

The author discusses ways to reduce nonfinancial barriers, including modifying lawsand regulations, encouraging providers to locate in underserved areas, makingproviders more user-friendly, offering specialized services for specified populations,increasing patients' information regarding health care services and health mainte-nance, changing beliefs and attitudes, and establishing special approaches to carefor adolescents. Most nonfinancial harriers can and should be addressed immedi-ately without waiting for total reform of the national health care financing systembecause they will contribute to the likelihood of inadequate health care even iffinancial harriers are reduced.

Recent discussions of the problems Americans face in obtainingmedical care have focused c n financial barriers, particularly theabsence of health insurance . But studies of medical care utiliza-

tion suggest that nonfinancial barriers also make it difficult for individu-alsespecially children, adolescents, and women needing familyplanning or obstetric servicesto obtain care. Therefore, failure to makeprovisions for lowering these nonfinancial barriers will lessen the impactof health programs on these very vulnerable populations.)

MeasurementThis review will define nonfinancial barri-ers as legal, geographic, institutional, orpersonal factors that make it difficult forchildren and for women with reproductivehealth needs to receive medical care

regardless of their ability to purchase suchcare at prevailing market prices. Nonfi-nancial barriers may hinder car,..-seekingamong populations that have adequate re-sources to purchase care, as well as amongthose that face financial barriers. For theuninsured and inadequately insured par-

1 7

Lorraine V. Klerman,Dr. P.H., is a professorand director of theMaternal and ChildHealth Program in theSchool of PublicHealth, University ofAtacama at Birming-ham. At the time thispaper was written, Pro-fessor Kiernan was aScholar -in- Residenceat Carnegie Corpora-tion of New I'm* inWashington, D.C. Theviews expressed in thispaper, however, aresolely the responsibilityof the author.

172

ticularly, nonfinancial barriers increasethe risk of inadequate health care. As onestudy of prenatal care noted. "multiplenoneconomic barriers remain after CO-nomic barriers are reduced. In otherwords, removal of financial barriers is nec-essar, but not sufficient to ensure ade-quate prenatal care participation amongk-income women.".,Direct Measurement of NonfinancialBarriers

Researchers measu these nonfinancialbarriers both directly at id indiretl. Thedirect method is to ask individuals whatthey perceive as barriers or. alternatively.why they do not seek care for themselvesor fOr their children. Researchers can askopen-ended questions or the can providea list and ask respondents to choose all ofthe barriers that seem relevant to them or

rank the listed barriers by their impor-tance. Those who seek care appropriatelyshould be questioned as well as those whodo not, in order to better identif- factorswhich are barriers only fOr those who donot obtain adequate care.

Removal of financial barriersis necessary, but not sufficientto ensure adequate prenatalcare participation among low-income women.1111111MP

An example of this approach is the 1988Institute of Medicine (IOM) report On pre-natal care which concluded that financialbarriers, includit .g iniulequale or nonex-istent insurance and limited personalfunds. were the most important obstaclesfaced by who received insufficientcare.3 Other problems reported by largepercentages of this gnat!) of women weretransportation problems. widel:dilationof prenatal care, lack of awareness of preg-nancy, and institutional impediments. Forwomen who obtained no prenatal care,financial barriers were again the most citedfactor h)llowed b low \ aluation of prenatalcare. Three studies of adolescents" views 411prenatal cane 11Cild Si11111:11' ObUldC.Nit adolescents were 1114 Itc likely to men-tion fear. shame, anibi\ alence, and denialas barriers :t

.mothr wa\ of obtaining informa-tion iers to care is throughfocus groups. These are small groups as-


sembld to discuss issues under the guid-ance of a trained leader. Focus groupsare an excellent method for obtaininginsights into possible problems and cangenerate questions for large-scale, hv-pothesis-testing studies.

UnfOrtunatel, these direct approachesmav not elicit a complete list of barriersto care. Respondents 'nay be unwilling tomention the most important barriers, thelist offered nay not include the most im-portant barriers. or respondents mat con-sider only a limited range of possibilities.

Indirect Measurement ofNonfinancial Barriers

In addition to asking directiv about barri-ers, researciwrs can measure barriers indi-rectly b making inferences based onobservation of helm\ ior. One indirectapproach is to compare the characteristicsof those who use a service with the charac-teristics of those who do not, or to comparethe characteristics of those who use a serv-ice more or less adequately. ..end deducethat the differences between the groupsrepresent barriers. For example, if pregmutt women in a comm with a practicingobstetrician are more likely to receive pre-natal care early than women in COUllikswithout one, then the absence of a practic-ing obstetrician is presumed to be a barrierto prenatal care. A similar method is toexamine utilization of services befOre andafter changes in financial or nonfinancialpolicies. If not done carclitlI\ such inter-group comparison may rely on invalid as-sumptions, kw example, that the users andnonusers are similar in respect to all otherrelevant to riables or that 110 other itnpor-taut factors have changed.

Institutional studies are another indi-rect method used to measure nonfinancialbarriers to the access of health care. "rheNestudies Of the geo-graphic distribution of prodders to deter-mine the availability of health care servicesin specific geographic areas. There are alsosurveys of provider prat tices and or poli-cies. Studies that actualk observe institu-tional practises and procedures or theact Nil ies of individual practitioners can re-veal areas in an institution that create non-financial barriers to care. Rut to use thefindings of these institutional studies. itnay he necessar1/4 m make sew' al assump-tions about the relationship between whatis ohscrecl and the ( are-seeking brim\ orof potential patients.

l'? cJ


I

to,:

et

r

rI

Examples of studies that questionedproviders to assess barriers to medical careinclude the 1987 survey by the AmericanCollege ofObstetricians and G\necologists(AC0( A( X)(: asked its members to rank1 1 possibl reasons that might presentwomen in their communities front rceiv-ing ,adequate prenatal care. The reasonslisted as most important by over a third ofthe respondents were: pregnant womencannot pay for prenatal care {no insuranceor Ntedicaid); pregnant women do notthink prenatal care is necessary; and preg-nant women have difficulties with transpor-tation) in contrast, in the early 1980s. localphysicians in one New Mexico county in-k wmally suggested that lack of motivationor education, miller than financial proth-lems, were the barriers to care in theircommunity. Wiwi) women who receivedlittle or no care were survel ed, they men-tioned financial harriers most often. Actualchanges in prodder policies. developmentof prenatal clinics, and supplementaryfunding improved prenatal care us.-' TheNew slexico experience highlights the im-portance of addressing access problemstrout the perspective of the patients as well..ts from the perspective of the pmidrs.

A Description ofNon'tinancial Barriers

Four types of nonfinancial barbers t4medical (are lot children and hit womensrilit rept I Kluctis e needs will be reviewed:

legal, geographic, institutional, and per-sonal. Some of these barrk rs a, e probablymote important than others; and some,although formidable, ma he overcome bythose with sufficient financial. educa-tional, or psychological resources.

Legal Restrictions

Malty federal and state laws and regulationscreate harriers to medical care. Perhaps themost public-lied are the legal restrictionsrelated to abortion'. Although abortionmnains legal under the Supreme loures110 v. Wade decision, the Rat! V. Sullivandecision prohibits clinicians in federallyfinanced facilities from discussing-the abor-tion option. Failure to discuss this optioncan create an obstacle to care. Similar ob-stacles are created by state laws requiringparental consent or a judicial bypass beforea minor can secure an abortion.6 States alsomake obtaining abortions more difficult byimposing waiting periods and requiringcounseling sessions.

Some laws ntay deter women fromseeking prenatal care. Examples are lawsthat require substance-abusing pregnantwomen to be reported to child prottectiyeagencies or that pressure unmarriedwomen to reveal the identity of their in-fants' fathers to) meet child support(1161-cement guidelines.' Fear of deporta-tion etas cause undocumented aliens toforgo their own c are or that of their chil-dren. Regulations requiring Iroquent re-certification for programs such as

17,

174

Medicaid and the Special SupplementalFood Program for Women, Infants, andChildren (WIC) impose impediments toobtaining these benefits.

Geographic Problems

Geographic harriers include those that arecaused by inadequate numbers of provid-ers relative to the population in a specificarea and those that result from large dis-tances between patients and providers inrural or nonmetropolitan areas. In addi-tion, certain residential situations, such ashomelessness, might be considered to cre-ate geographic harriers.

Provider Shortages

Despite the absolute numbers of obstetri-cians, pediatricians, and family/generalpractitioners in this country, many chil-dren and pregnant women are faced witha shortage of providers in the areas inwhich they live because these health careproviders are not distributed evenly in re-lation to the population needing theirservices. This maldistribution is charac-terized by a high concentration of physi-cians in metropolitan counties and ascarcity or absence of practitioners inmany rural areas. In addition, within met-ropolitan areas, providers in private prac-tice tend to concentrate in higher-incomeneighborhoods. This may impose a travelburden on substantial populations ofwomen and children in rural areas and inpoorer neighborhoods. (See the article byPerlofi in this journal issue.)

Nonmetropolitan Areas

In 1990, approximately 23% of the popu-lation, or 56 million people, lived in non-metropolitan counties. In these areas,specialty care such as high-risk obstetricsand care for the handicapped child may

i'st, require traveling long distances. More-s..

Alyer_oecialists may not he accessible bypublic transportation, so that automobileownership or the ability to borrow a vehi-cle is essential. Vhile those who live incities stay also find inadequate publictransportation a barrier, travel-relatedproblems are most frequently associatedwith rural areas. According to federal sur-veys, children in nonmetropolitan areasare less likely to see a physician, and preg-nant women in such areas are less likely toinitiate care in the first trimester thanchase in metropolitan areas.8

Between 1980 and 1988, 200 rural hos-pitals closed, a higher rate of closure thanamong nonrural hospitals. Tlw closing of


rural hospitals and of obstetric unitswithin rural hospitals may have had anadverse effect not only on access, but alsoon pregnancy outcomes. For example,one study found that women who lived incommunities with relatively few obstetricproviders in relation to the number ofbirths were less likely to deliver in a localcommunity hospital than were those who

Children in nonmetropolitan areas areless likely to see a physician, and preg-nant women in such areas are less likelyto initiate care in the first trimester thanthose in metropolitan areas.

lived in communities with a higher ratio.In addition, women from "high-outflow"communities had a higher proportion ofcomplicated and premature births andremained in the hospital longer. l() Sonicanalysts, however. believe that rural hos-pital closings do not invariably affectaccess because other hospitals are withineasy traveling distance,l and women'suse of the closed units Min" have alreadydeclined before they closed.I2

In recent years there has been amarked reduction in the number offamilyplanning clinics and abortion providers innonmetropolitan areas. In 1988. 93% ofnonmetropolitan counties had no abor-tion provider." The Alan Guttmacher In-stitute also estimated that in 1988, 27% ofnonhospital abortion patients traveled atleast 50 miles from their homes to reach aclinic; 18%, 50 to 100 miles; and 9`.7( , morethan 100

It is difficult to attribute the higherrates of mortality and morbidity amongrural as compared to urban children inareas such as postneonatal mortality, inju-ries, and acute conditions entirely to geo-graphic harriers and the related delays insecuring medical care quickly. Rural areasalso stiffer front higher rates of pmertxand lower percentages of families withhealth insurance. Rural states have nuirerestrictive Aid to Families with DependentChildren (AFD(;) programs and are lesslikely to adopt Medicaid eligibility andservice options.I5

177

U.S. HeG'th Care for Children

Homeless Families

Few pregnant women or families with chil-dren are literally without housing. Home-lessness for this group usually is defined asno permanent home and means living ina welfare hotel, in a shelter, or doubled upwith another family. The number of chil-dren who are homeless on any given nightis estimated to be between 60,000 and500,000)6 Studies have found that home-less pregnant women receive less prenatalcare than other poor women)7 Similarly,homeless children have lower rates of im-munization and increased rates of hospitaladmission, both suggesting problems withobtaining primary health care)8 Home-less families are also less likely to receivebenefits under the WIG program.19

Being without a permanent home isassociated with several specific access bar-riers. Welfare hotels and shelters are oftennot located in residential neighborhoodsand frequently are in areas characterizedby violence and drugs. Fear may makeparents and children reluctant to leavetheir apartments or shelters even to seekmedical care. The depression and despaircharacteristic of homeless families com-pounds these problems. Also, homelessfamilies may have been relocated from theareas in which they normally sought medi-cal care and have little information aboutsources of care in their new areas.

Runaway Children

Adolescents who have run away fromhome or been "thrown out" often developmedical problems including abuse of alco-hol and drugs, sexually transmitted dis-eases, pregnancy, and malnutrition.20 Yetthey are unlikely to seek care from tradi-tional medical care providers. In additionto not having funds to pay for care, theyarc often fearful of being returned to theirhomes and reluctant to interact with clini-cians who may he unsympathetic with theirlifestyles. The may not know where toseek care even if they want it.21 (See thearticle by Perrin, Guyer, and Lawrence inthis journal issue.)

Institutional Barriers

Included among institutional barrier. aretile policies, practices, and attitudes of in-stitutions, such as hospitals and healthcenters, as well as those of clinicians intraditional private practice or in managedcare organizations. Unf.ortunatcly, the im-portance of these "softer" barriers is oftenoverlooked. Policymakers must be carefulnot to confuse institutional with personal

175

barriers. Some providers complain thatwomen do not .seek prenatal care, when thereality is that they are unable to obtain it.Such providers are "blaming the victim"when the culprit may be the institutionitself or sonic other factor which theproviders may control but not recognize.

Provider Policies

Explicit provider policies may create obsta-cies to the receipt of care. Many such poli-cies are based on the financial status of thepatient, such as refusal to accept Medicaidor to use a sliding fee schedule. But thepolicies of health maintenance organiza-tions (HMOs), preferred provider organi-zations, and other programs of managedcare can reduce access to care despite theabsence of financial disincentives. Studieshave found that these programs may limitor even deny pediatricians' referrals tosubspecialists or inpatient care;22 that incomparison to indemnity insurance plans,they may cover, without deductibles andco-payments, fewer services needed bychildren with chronic illnesses, such asprescriptions, durable medical equip-ment, and mental health services ;23 andthat they may ignore the benefits to whichenrolled Medicaid children are entitled,especially the Early and Periodic Screen-ing, Diagnosis, and Treatment (EPSDT)program.24 Women who have an estab-lished relationship with a family planningclinic, perhaps with a family planningnurse within the clinic, when switched toan HMO may be told to seek this type ofhelp from a busy obstetrician. An adoles-cent may feel more comfortable at aschool-based clinic but, if enrolled in a

173

illy

176

managed care program, may not be cov-ered for school-based care. These barriersmay result in receipt of substandard care,in delays in obtaining needed medicalcare, or in no care at all.

Provider policies affect adolescentsparticularly. Teenagers may not use aprovider who will treat them only afterinforming their parents. State laws usuallyallow the treatment ofsexually transmitteddiseases and prenatal care without paren-tal consent, bu, provider policies about theprescription of contraceptives van even inthe absence of state laws.25

Provider PracticesMany provider barriers, however, are notbased on explicit policies. Instead, they arethe result of patterns of practice that havebeen adopted over the years, frequentlywith little attention to the impact they haveon access. Providers seldom recognizehow difficult it may he for patients or theirparents even to make an appointment.Telephone numbers are often not listed inthe words the prospective patient or par-ent might expect. Under what categoryshould a mother look fOr health care forher child: pediatrics, primary care, well-child conferences? And under what category should a pregnant woman look forcare: prenatal care, maternity, obstetrics,women's clinic? When the correct numberis located, the provider may have insuffi-cient phone lines or staff to answer incom-ing Lillis. Patients and parents reporthearing a continual busy signal or havingphones ring for se oral minutes befbrebeing answered. Even if the phone is an-swered promptly, the caller may be put onhold while a desk clerk takes care of morepressing business. For the individual call-ing from home, these may he minor an-noyances, but they may be major harriersfor someone trying to make a private callfrom work or using a public phone.

A long delay between making an ap-pointment and being seen may discouragecare-seeking behavior. Such delays in ob-taining care may cause health problems,as for example when teenagers needfaraily planning advice or pregnantwomen need prenatal care. A long wait atthe time of the appointment may makewomen who must take time from work orwho a7 accompanied by small childrenless likely to return for care.

The "inappropriate" use of emergencyrooms (ERs) is often due to the restrictedhours and lack of back-up telephone and


referral systems at community clinics.From the patient's or parents' perspective,ER use may be logical. At many sites it isavailable 24 hours a day and 7 days a week,the clinicians are well trained, all necessarydiagnostic and therapeutic equipment isimmediately available, and Medicaid willoften pay for transportation costs.26 Medi-cal care experts, however, know the disad-vantages of ER use for routine care: lackof continuity of care, neglect of preventivemeasures, high cost to the institution andto the pay( r, and possible conflict withtrue emergencies. Many experts fault thepatient or the parent for inappropriate ER

A long delay between makingan appointment and being seenmay discourage care-seekingbehavior

use, but the real culprit may be the systemof primary care. Patients and parents willtend to limit their use of primary careproviders as long as little or no attempt ismade to explain the disadvantages of theER and the advantages of having a regularsource of primary care and consulting itbefore using the ER. One study fOund thatchildren enrolled in a primary care centerreceived a smaller percentage of theirhealth care in an ER than those without aregular source of care.27

The lack of important, nonmedicalservices also may discourage utilization,while their presence may improve access.Such services include on-site child care.bilingual staff, and assistance with trans-portation.3

Provider AttitudesThe attitudes of clinicians and their staffs,technicians, receptionists, and others mayhave a profOund effect on willingness toseek care. Negative attitudes toward indi-vidual patients or groups of patients de-fined by condition, race/ethnicity., oreconomic status can he detected not onlyin verbal statements but also in the waypatients and parents are treated. Clini-cians who believe that teenage pregnancyor pregnancy among the unmarried ismorally wrong may convey theso judg-mental attitudes by word and deed. Disre-spect for economically deprived patientsor for those from racial or ethnic minoritygroups can he shown by calling them by

I" '1


their first names without asking if that istheir preference or by keeping them wait-ing for long periods. Leaving inadequatetime to answer patients' or parents' ques-tions and a general hurried and hassledatmosphere also convey negative providerattitudes.

Personal Barriers

Pet sonal harriers include factors related toage and race or ethnicity, lack of sufficientcorrect infOrmation, and psychologicalproblems.

Age-related Factors

Infants and childrenwhether in paren-tal homes, foster care, or institutionsaredependent upon adults for medical care.School clinics arc probably the only placeswhere young children can initiate theirown care.

While adolescents are capable of in-itiating care, they arc often preventedfrom taking such action by legal restric-tions and transportation difficulties. Theproblems caused by these factors may hecompounded by fear of parental discov-ery of sexual activity. pregnancy, or sexu-ally transmitted diseases. When thefederal government promulgated regu-lations requiring family planning clinicsthat received federal funds to informparents that their children had re-quested contraceptives, advocates wereable to have the rule overturned by citingstudies showing that a large proportionof female adolescents would not seekfamily planning advice if this rule wereput into effect. Fear of discovery by par-ents remains a significant reason whyadolescent females postpone obtainingcon traceptiyes.28

An additional problem faced by adoles-cents is their in-between status. Few feelcomfOrtable in the offices of internists, vetmany pediatricians' offices are equallyunsuitable because most patients arc in-fants or young children. Ont. survey of sub-urban general pediatricians found thatmany were ambivalent about treatingadolescents and cited problems withpayment, time, lack of knowledge aboutadolescent health, and adolescents' per-ception of them as "baby doctors' as rea-sons for their ambivalence. Few providedanticipatory guidance about sexuality;questioned adolescents about depression,incest, or child abuse; or had the equip-ment necessary for a gynecological exami-itation.29

Children in Foster Care

In 1989 an estimated 360,000 childrenwere served by state 'Oster care pro-grams.30 Almost all children in (Oster careare eligible for Medicaid. Yet several stud-ies of foster children have shown that theirhealth status is poor and that their healthcare is fragmented and inadequate.31 Fos-ter children face several barriers to healthcare in addition to the usual problems withMedicaid coverage. Many were in poorhealth when they were placed., for exam-ple, infants of substance-abusing mothersor physically abused or neglected chil-dren. Foster parents mav not be 111f01-111dabout the child's right to medical care,may be uninformed about the health careneeds of the child in their care, or IllaV bet(M) busy to secure needed health care.Also, children who mow frequent's. fromOne foster care placement to another usu-ally experience fragmented medical careat best.

Female adolescents in fi)ster care lacespecial problems in obtaining family plan-ning services. Most states do not offertraining in adolescent sexuality to foster

it

al111111ha..

V

I

178

4

parents or caseworkers.32 Agencies thatarrange foster care placements may, forreligious or other reasons, not provide in-formation about access to birth controland abortion services.33 One study foundthat among 13- to 18-year-old sexually ex-perienced adolescents in the child welfaresystem, a smaller proportion in foster carethan in their own homes had used a con-traceptive during their most recent inter-course or had obtained contraceptivesfrom a family planning clinic.34

Juveniles in Custody

A 1987 census found 91,646 juveniles inpublic and private juvenile detention, cor-rectional, and shelter facilities.35 Becausethey usually have been placed there bycourt order, the state is responsible fortheir care. Family finances or motiva-tional issues cannot explain why many ofthese children receive inadequate medi-cal care, but several studies have shownthat they do.36

Racial and Ethnic Barriers

A variety of health statistics indicate thatwomen and children in certain minoritygroups including African- Americans,I ispan ics, and American Indianshavemore frequent and moo- severe healthproblems than the white majority orother minority groups. Some of thesedifferences in health status are due tothe larger percentage of these familieswho have inadequate financial resourcesand some are due to limited access tocare caused by the reluctance of manyclinicians to settle in low-income areas.Prejudices against members of minoritygroups may also contribute.37


Lack of Sufficient and Appropriate Information

Another personal barrier is inadequateinformation about the need for care. Thislack of information may be the result of aninability to speak or read English, func-tional illiteracy, marginal mental retarda-tion, and not being reached by healtheducation programs. Hispanics havefound their access to Medicaid blocked byforms that have not been translated intoSpanish38 or the absence of staff to assistSpanish-speaking clients.39 Other non-English-speaking groups, such as recentAsian immigrants, also face this harrier.

Patients with strong ties to other cul-turesincluding some American Indi-ans, Hispanics, and recent Asianimmigrantsmay find the Americanmedical care system alien to them. Thismay be a particular problem with regardto preventive care, that is, care unrelatedto an episode of illness or an injury. Thosefrom different cultures may not realizethe importance of early prenatal care orof the full immunization schedule. Theymay feel that a pregnant woman need notbe seen until after "quickening" or thatinfants are fully immunized after the in-itial shots in the first year of life. They mayprefer to use the types of healers typicalof their culture. Women may be unwillingto seek reproductive health services frommale clinicians.3

Psychological Problems

Although most barriers to care are prob-ably beyond the control of the patient orthe parent, patients and their families maycontribute directly to inadequate or inap-propriate use of health services. The cur-rent epidemic of drug use appears to haveincreased the number of pregnant womenwho are receiving inadequate prenatalcare and the number of young childrenwho are not receiving primary health care.including immunizations. The time re-quired to obtain the drugs, diminishedcontrol while under the influence ofdrugs, and fear of discovery may cause adelay in seeking care or an inadequatenumber of visits for the women and theiryoung children.40

Other psychological harriers includelack of motivation or competition withother activities that appear more impor-tant, depression, and fear of medical pro-cedures such as pelvic examinations andshots. One study of prenatal care foundthat "feeling depressed and not up togoing for care" and "needing time and

1'Y


energy to deal with other problems" werecommon reasons for seeking prenatal carelate or not at all, as was being a substanceabuser or holding negative attitudestoward prenatal care.41 Personal andfamily problems, depression and not feel-ing well, unhappiness with the pi :gnancy,and negative feelings about seeing doctorswere associated with poorer prenatal carein another stud.2

Combinations of Barriers

Certain population groups and certainservices illustrate how these nonfinancial

may combine to create significanthealth problems.

American Indian Families

Health status indicators suggest that thehealth of American Indian women andchildren is worse than that of otherAmericans. The women generally have lessadequate prenatal care,I2,43 and t headolescents use fewer preventive healthservices:" Health problems and under-utilization of health services are probablyattributable to main factors including poy-ertv, racism, long travel times to medicalcare facilities in sonic of the areas in whichAmerican Indians live, inadequate inftirillation about the need for medical care.reliance on native healers, and abuse ofcertain substances, especially alcohol.

Migrant Families

NVomen and children in migrant workerfamilies also have higher rates of healthproblems and face significant obstacles tocare.}' These obstacles include financialbarriers (their Medicaid status varies fromstate to state, and their incomes are usuallytoo low to purchase care out-of-pocket),discrimination, a work schedule that pre-cludes seeking care during the clay or onweekdays, lack of familiarity with the medi-cal care facilities in the different column-') i ties through which they travel,occasional language problems, and insome areas long distances to Facilities andan absence of public transportation.

Immunization

Recent outbreaks of measles and 0111C1-VaCC111-preventable diseases among pre-school children have drawn attention tothe inability of the American health caresystem to immunize many Nailing children.(See the Perrin, Guyer , and Lawrencearticle in this journal issue.) 'The NationalVaccine .1disor Ccmunitie iistod

itir key harriers to immuniz.:tion:

179

missed opportunities for administeringvaccinesa child is not immunized duringa health care visit because of inappropriatecontraindications, failure to assess immu-nization status, or other provider-relatedreasons;

shortfalls in the delivery systemimnm-nizations being availablt. by appointmentonly, requiring a physical examinationprior to immunization, need for a physi-cian referral, inconvenient clinic hours,inappropriate health educational materi-als, and inefficient immunization record-keeping systems;

inadequate access to careabsence ofroutine health care visits; and

inadequate public awareness and lack ofdemand for immunizations.46

Recent outbreaks of measles and othervaccinepreventable diseases among preschoolchildren have drawn attention to the inability ofthe Am,?rican health care system to immunizemany young children.

While most children receive initial dos-ages of' vaccine during their first Year oflife, returning for booster shots or forthose vaccines started later is less routine.This pattern suggests a lack of under-standing of the need fbr a full series ofshots to protect the child and the absenceof a follow-up system to bring into carechildren who miss shots. Such systems areroutine in many western European coun-tries.17

Reducing the Barriers

Reducing the nonfinancial barriers tomedical care fOr children and women withreproductive health needs will be difficult.particularly when federal and state interestin health care is focused 011 health insur-ance. Nevertheless, it is incumbent onhealth services researchers, policy analysts,planners, advocates. and clinicians to real-ize that a broader spectrum of problemsmust be addressed. A recent publicationnoted, 'lids is not to say that financingoptions are wrong or unimportant, butrather that the basic approach needs to gobeyond just giving people an insurance orMedicaid card."48

180

Ways to Reduce BarriersResearch and clinical experience suggestmany ways to reduce barriers to the receiptof medical care. (Many of the ideas thatfollow are described in greater detail in thepublications of advocacy and othergroups1)Modify Laws and Regulations

Lawmakers should he helped to under-stand the effect of laws and regulations onpatient behavicw. For example, rules thatseek to reduce fraud and abuse b increas-ing the frequency with which forms inustbe completed and the number of itemsneeded on the firms often make obtain-ing care more difficult and time-consum-ing. A balance should 1w struck betweenthe costs of some abuse and the costs ofcare avoided or delayed. Laws that appearto be promulgated with the intent ofreducing access, such as some of thefamily-planning-related ones, also need tobe rethought in terms of the cost-benefitbalance.

Reduce Geographic ProblemsGeographic problems can be reduced byencouraging clinicians to locate in under-served areas and by establishing clinics insuch areas. The federal government at-tempts to overcome manpower shortages1w funding the National Health Servicetarps. as well as conintunitl* and migrant

health centers and special programs forthe homeless. Sometimes, however, an iso-lated area arty 1101 have enough individn-

Offering several services in oneplace at one time (co-location)can also reduce travel-relatedbarriers.

111M1111M

als to support a clinician in prhate practiceor a clinic. In these instances, travelingto of primal-% care clinicians or special-ists, sometimes with specially equippedmobile vans, max. reduce obstacles_ Whenthe absence of public transportation is themain barrier, agency vans or taxi vouchers;MIN' he the answer. Vans are also bringused to provide health are to families in,,yellare hotels in New York City. tut

Publicly supported medical care pro-grams should determine whether all serv-ices are best provided in a centralized site.


\\Omen and children in need of routinecare might be seen at storefront facilitiesthat have minimum equipment or even becared fOr in their homes by nurses. Thecentralized and better-equipped facilitiescould be reserved fir those in need ofspecialists or laboratory and other services.

Offering several services in one placeat one time (co-location) can also reducetravel-related harriers. Studies have shownthat having WIC pi grams available wherewomen obtain prenatal care or pediatriccare increases the use of those services.Outposting welfare workers to the facilitieswhere women are seeking prenatal or pe-diatric care reduces the number of tripsand the amount of time needed to obtainMedicaid certification. This one-stopshopping concept was incorporated into.the 1989 amendments to the Maternal andChild Health Services Block Cwant.51 (Seethe Hill article in this journal issue.)

Make Providers More User-friendly

Changing provider policies, practices, andattitudes is Veil' difficult, but it can bedone. First, someone or some group mustbecome aware that patient behavior is notdetermined exclushel be psychologicalfactors, but that the institution or the indi-vidual provider mav also have an effect.With such an awareness tray come an in-terest in determining what or who is mak-ing patients less eager to see the provideror to comply with clinician recommenda-tions. A systematic review of policies andprocedures may be needed. Interviewswith patients or the use of anonymousquestionnaires can supply additional in-fiwmation. Accompanying a patient, par-tiularl a First-time patient, through a visitalso may yield fresh insights. With suchinfOrmation available, staff meetings be-come a whiche for devising new policiesand procedures, and for organizing in-service training programs. Patient advo-cates should, however, expect strongresistance to change.

Soni providers of prenatal care hit cgone through this process. In the early1970s, a maternity and infant care projectrequired all personnel on their first day ofemployment to register its new obstetricpatients and "to go through the clinic."The clink directors believed that this ex-perience increased staff awareness of-chat a patient's average day Inv dyes andunderlines the importance of treating pa-dents with respect and courtem.":"2 'FlueDepartment ofObstetrics and Gynecolcif.,ry

1$J


rt

at a state medical school, seeking ways toincrease the percentage of pregnantstamen Who initiated care carh, recog-nized that -deteriorating latitudes" towardpatients among clinic personnel was a pos-sible problem. Mentlrs of the obstetricfaculty were alerted to the problem andtold to improve clinicians' attitudes andbehavior, and Iratning pro)grams were de-veloped fin. norms.53

Offer Specialized Services for SpecifiedPopulations

Certain populations cannot he expectedto seek care from traditional providers intraditional settings. Runaways and streetchildren are examples. Communities withlarge populationsofstreet children shouldconsider providing vans or other outreachservices to serve them. Adolescents. par-ticulark those in medically underservedareas, ina\ respond well to school-based orschool-affiliated clinics. In some schoolswith these clinics, as man\ as i.) of theenrolled students use the clinic eachtear.'' \ligrant workers need facilities thatare accessible and accommodate theirworking conditions and lifestyles. Somestates are experimenting with specialisedhealth progt anis lire firmer

Increase Patients' Imormation and ChangeBeliefs and Altitudes

Pro% idcrs luny found sc\ cual founts of out-Iva( 1> to be successful in increasing infor-mation or changing lid iris and attitudes.111 111111 C01111111111111CS, W0111C11 ru> 11(1%.

Ca1111(111111CS 101C:1111 where 111(fy tall 0111,1111

75t02COCC

0

EE

80CO

O

es;

O

family planning, maternity, or pediatricservices. Home visitors not onl conveyinformation, but also nam modifY beliefSand provide the social support essential tousing health care effectively. 5

Sometimes it is more effectiveto serve patients within theframework of their culturalbeliefs than to try to changethem or to ignore them.

Education in provider settings by clini-cians or by their staffs is important to pa-tients' understtunlingolthe need in followhealth care instructions, including theneed for follow-up visits. 1,Vhile mass mediacampaigns 111115 provirle infOrmation andmodify beliefs and attitudes. their messageis more effective NvIten integrated with di-rected educational elf-owls in the home,provider facilities, schools, and commu-nity organisations.'' Involvement of com-munity members can contribute I0 the(1111111"111 sensitivity :111(1 :1(1(.11:111(T 01(110-C:111011:11 111:1111-1:11S.57

fIllr11111CS it 1S 1111)1C elli(11\ C IU servepatients 11'1111111 Ill(' ki11111111.1s of 11161 cul-un al 1/ClierS than to try to change them or

ignore them. If women arc reluctant tohe seen 1111( bodied In men, female phNsi-( ians of nurses (an serve as then primary

1Q;

181

182

clinicians. Clinicians can discuss culturalbeliefs with native healers and, unless theirpractices would have adverse impacts.work with them in providing care.

Special Approaches for AdolescentsThe special access problems faced byadolescents have been described in thispaper and in greater detail in the Officeof Technology. Assessment's report onadolescent health. 'x The report recom-mended that Congress take steps toimprove adolescents' access to appropri-ate health and related services throughfive general strategies:

supporting .the development of centersthat provide comprehensive and accessi-ble health and related services specificallyfor adolescents in schools and/or commu-nities;

improving adolescents' financial accessto health services:

improving adolescents' legal access tohealth services;

increasing support for training of healthcare providers who work with adolescents:and

empowering adolescents to gain accessto health serices.58

The Society for Adolescent Medicinehas published a position paper on accessto health care for adolescents suggestingthat proposals fi improving access beevaluated using the fbllowing criteria: avail-ability, visibility. quality, confidentiality. af-fordability, flexibility, and coordination. 5`t

Responsibility for AddressingProblemsThe federal government has responsibil-ity for reducing some of these harriers. Ithas the financial base necessary to im-prt e provider reimbursement and in-crease the number of public andquasi-public providers. The broad-basedmass media educational programs thatwould raise the level of health educationin this minim could he initiated by thefederal bureaucracy. And changes in fed-eral policies regarding reproductiverights will have an impact on the availabil-ity of reproductive health services.

States have a number of ways of reduc-ing barriers. They also can improveprovider reimbursement and increase thenumber of public and quasi-public provid-ers. They regulate Medicaid and privatehealth insurance within broad federalmandates, and with federal assistance,


most fund or operate family planning clin-ics and other public and quasi-public fa-cilities. Thus, states can establish standardsfor what set-vices will he provided, wherethey will he provided, and by whom. Statelaws regulate abortion and parental con-sent. again within the framework of fed-eral laws. States operate the foster careprograms and institutions for variousgroups of children. In several states, courtorders have been needed to assure thatthese children receive the care to whichthey are entitled. Sonic states mandate thecontent of health services and/or healtheducation within public schools.

City and county governments also canreduce obstacles. Many operate healthcare facilities and can modify their policiesand practices. Community' health educa-tion can he targeted very effectively at thelocal level. Local education authoritiesoften decide what health services will beprovided within the schools and whathealth subjects will be taught.

Professional organizations need toeducate their members about the barriersthat they, or the facilities in which they areemployed, may impose and about theirroles in helping to educate patients andpotential patients. Professional organiza-tions also can lobby fbr changes in federal,state, and local policies and practices. Ad-vocacy groups should keep the need firbroad-based approaches to barrier reduc-tion before legislators, professionals, andthe general public.

ConclusionsAt some time almost everyone encountersone or more legal, geographic, institu-tional, or personal barriers to health care.lowever, certain populationsfor exam-

ple, the economically deprived, racial andethnic minorities, those in isolated ruralareas, migrants, illegal aliens, homelessfamilies, children in fiister care homes orinstitutions, and runawaysexperiencethese obstacles more often. Certain serv-ices also appear to be more affected bybarriers to access.

While financial barriers remain themost important obstacles to health carefor children and for women with repro-ductive health needs, other factors playa significant role. It is unlikely that anational health insurance plan will servoall who need care opt imally. Obstacles tocare created by laws and regulations, theabsence of easily available providers, in-

1b5


stitutional policies, practices, and thepsychosocial problems of those whoneed care may be reduced but will re-main significant. Most of these barrierscan and should be addressed immedi-

atel, without waiting for a nationalhealth insurance proposal. Moreover.any national health plan should includeprovisions for lowering or eliminatingthese barriers.

1. Institute of Medicine. Including children and pregnant u'mnen in health rare reform. S.S. Brown,ed. Washington, DC: National Academy Press, 1992.

Lia-Hoagberg, B., Rode, P, Skovholt, (4, et al. Barriers and motivators to prenatal careamong low-income women. Social Science and Medicine (1990) 30:487-95.

3. Institute of Medicine. Prenatal care: Reaching mothers. reaching infants. S.S. Brown, ed. Wash-ington, DC: National Academy Press, 1988.

4. Committee on Health Care for Underserved Women. Ob/Gyn services for indigent women: Is-sues raised lay an AGOG survey. Washington, DC: American College of Obstetricians andGynecologists, 1988.

5. See note no. 3, IOM. pp. 171-74.

6. A recent review noted that, by requiring parental consent, many states treat decisions by mi-nors regarding abortion differently front other medical decisions (care for sexi:allv trans-mitted diseases, drug and alcohol abuse, pregnancy and birth control) and differentlyfrom other significant decisions such as dropping out of school or placing a child foradoption. Donovan, P. Our daughters' decisions. New York: The Alan Guttmacher Institute.1992.

9

7. Larson, C.S. Overview of state legislative and judicial responses. In The Future of Children(Spring 1991) 1:72-84.

S. Hughes, D., and Rosenbaum, S. An overview of maternal and infant health services in ruralAmerica. Journal ofRural Health (1989) 5:299-319.

9. McManus, M.. and Newacheck, P. Rural maternal, child, and adolescent health. HealthServices Research (1989) 23:807-48.

1(1. Nesbitt, T.S., Connell, F.A., Hart, and Rosenblatt, R.A. Access to obstetrical can inrural areas: Effect on birth outcomes. American Journal of Public Health (1990) 80:814-18.

11. Nadel, M.V. Rural hospitals: Closures and issues of access. Testimony of U.S. General Account-ing Office before U.S. House of Representatives Task Force on Rural Elderly, Select Com-mittee on Aging. September 4,1991.

12. Bronstein, J.M., and Morrisey, M.A. Bypassing rural hospitals for obstetrics care. Journal ofHealth Politics, Polity and Law (1991) 16:87 -1 18.

13. Henshaw, S.K., and VanVort. J. Abortion services in the United States. 1987 and 1988.Family Planning Perspectives (1990) 22:102-108.

14. Henshaw, S.K. The accessibility of abortion services in the United States. Family PlanningPerspectives (1991) 23:246-52.263.

15. Children's Defense Fund. Falling by. the wayside: Children in rural America. Washington. DC:1991.

16. Mihaly, 1..K. Homeless families: Failed policies and young vidims. Washington. DC: Children'sDefense Fund, 1991.

17. Chakin, W.. Kristal. A., Seabron, C., and Guigli, P. The reproductive experience of womenliving in hotels for the homeless in New York City. New Fork State Journal of Medicine (1987)87:10-13.

18. Miller, D.S., and I.in, F.H.B. Children in sheltered homeless families: Reported healthstatus and use of health services. Pediatrics (1988) 81:668-73: also, Wood, D.E., Valdei,R.B.. Hayashi, T., and Shen, A. Health of homeless children and housed. po children.Pediatrics (199(1) 86:858-66.

19. Bassuk, E.L., and Rubin, L. Why does family homelessness occur: A erase -tout (t1 studs.A mertcan journal of Public Health (1988) 78:783-88.

20. Yaws, GT., MacKenzie, R., Pennhridge, J., and Cu hen, E. A risk profile «imparison of run-away and non-runaway youth. American Journal of Public Health (1988) 78:82(1 -21.

21. Farrow, J.A. Homeless pregnant and parenting adolescents. Service delivery strategies. Maternal andChild Health Technical Informatioz. Bulletin. Washington, DC: National Center for Edu-cation in Maternal and Child Health. November 1991.

tS3


22. Cartland, J.D.C., and Yudkowsky, B.K. Barriers to pediatric referral in managed care sys-tems. Pediatrics (1992) 89:18'3-92.

23. Horwitz., S.NI., and Stein, R.E.K. Health maintenance organizations vs. indemnity insurancefor children with chronic illness: Trading gaps in coverage. American Journal of Diseases ofChildren (1990) 144:581-86.

24. Rosenbaum, S., Hughes, 1).C., Butler, E., and Howard, D. Incantations in the dark: Medi-caid, managed care and maternity care. The Milbank Quarterly (1988) 66:661-93.

25. Holder. A.R. Legal issues in adolescent sexual health. Adolescent Medicine: State of the ArtReviews (1992) 3:257-67.

26. Bonanno, R.A., Loy-,J.C., and Kinard, E.M, Neighborhood health centers: Parents' perspec-tives on pediatric primary care. Mas.sachusetts Journal of Community Health (1981) 1:1 -8.

27. Orr. S.T.. Charney, E., Straus, J., and Bloom. B. Emergency room use by low income chil-dren with a regular source of health care. Medical Care (1991) 29:283-86.

28. Zabin, 1..S., Stark. H.A.. and Emerson, M.R. Reasons for delay in contraceptive clinic utiliza-tion: Adolescent clinic and nonclinic populations compared. Journal of Adolescent Health(1991) 12:225-32.

20. Marks, A., Fisher. M.. and Lasker. S. Adolescent medicine in pediatric practice. journal ofAdolescent Health Care (1990) 11:149-53.

30. C.S. General Accounting Office. Foster Care. Children's experiences linked to various factors; betterdata needed. Washington, DC: U.S. Government Printing Office (GAO/HRD-91-64), Sep-tember 1991.

31. Halfon, N., and Klee, L. Health services for fitster children in California: Current practicesand policy recommendations. Pediatrics (1987) 80:183-91.

32. Pont. D.F., White, GM., and Morton, T.D. Sex education and family planning services foradolescents in foster care. Family Planning Perspectives (1987) 19:18-23.

33. The Catholic agencies that arrange fbster care for many of New York's children only re-centb reached an agreement vith the city that allowed foster children ages 12 and olderin Catholic-run group homes to he infbrmed about birth control and abortion serviceswithout the active participation of the agencies. The adolescents will receive letters statingthat they can receive counseling in one of three city-financed centers. The city will ar-range transportation. Duhger. C.W. Family planning in foster homes. The New York Times,December 22,1991.

34. Polit, D.F., Morton, T.D., and White, C.M. Sex, contraception and pregnancy among adoles-cents in foster care. Family Planning Perspectives (1989) 21:203-208.

35. Thornberry, TR, Tolnay, S.F.., Flanagan, and Glynn, P. Children in custody 1987. A com-parison of public and private juvenile custody facilities. Washington, DC: Office of Juvenile Jus-tice and Delinquency Prevention, US Dept-intent of Justice, March 1991.

36. Johnson, L.D. Health status of Juvenile delinquents: A review of literature. Journal of PrisonJail Health (1989) 8:41-61.

37. Haan, M., and Kaplan, G. Socioeconomic position and minority health: A summary of theevidence. In Report of the .iecretary's "ask Farce on Black and Minority Health. U.S. Departmentof Health and }Inman Services, Task Force on Black and Minority Health. Washington,DC: U.S. Grin-rum-I,: Printing Office, 1985.

38. Jones, I.E. Overcoming barriers to Medicaid eligibility. American journal of Public Health(1986) 76 :12 -17.

39. National Coalition of Hispanic Health and Human Services Organizations. And access finall: Medicaid and Hispanics. Washington, DC: National Coalition of Hispanic Health and11 umau Services Organizations, 1990.

40. Center for the Future of Children. Recommendations. 1 he Future if Children (Spring 1991)1:8-16.

41. Kalmuss, D., and Fennell. K. Barriers to prenatal care among low-income women in NewNOrk City. Family Planning Perspectives (1990) 22:215-31.

12. 'Valid, S.M. Characteristics of American Indian and Alaskan Native births, United States,1984. Monthly Vital Statistics Report (1987) 36,3: supplement.

43. Singh. 3., Forrest. J.D.. and Torres, A. Prenatal care in the United States: A state and countyinventory, volume 1. New Yr rk: The Alan Guttmacher Institute. 1989.

44. Blum, RAY., Ilarmon. II.. Harris, I.., et al. American Indian-Alaska Native youth health.Journal of the American Medical Association (1992) 267:1637-44.

IS?


45. Rust, G.S. Health status of migrant farmworkers: A literature review and commentary.A mericanfournal of Public Health (1990) 80:1213-17; also, Meister, J.S. The health of mi-grant farm workers. Occupational Medicine (1991) 6:503-18.

46. National Vaccine Advisory Committee. The measles epidemic: The problems. barriers, andrecommendations. journal of the Alm-titan Medical Association (1991) 266:1547-52.

47. Williams, B.C., and Miller, C.A. Preventive health care for young children: Findings from et 10-coun-try study and directions for I'nited Slates policy. Arlington, VA: National Center for Clinical In-fant Programs, 1991.

48. Wiener, J.NI., and Engel, J. Improving access to health services for children and pregnant women.Washington, DC: The Brookings Institution, 1991.

49. For example, see the publications of the Association of Nlaternal and Child Health Pro-grams. the Center on Budget and Policy Priorities, the National Commission to PreventInfant Mortality, and the National Governors' Association. The Institute of Medicine's re-port on prenatal care contains many ideas on improving access to prenatal care. See noteno. 3. IOM.

50. Redlener, I., and Burke, K. Children's health project update. Pediatrics (1992) 89:801 (letterto the editor).

51. National Commission to Prevent Infant Mortality. One-slop shopping: The mad to healthy moth-ers and children. Washington, DC: National Commission to Prevent Infant Mortality, April1991.

52. Health Services Administration, Bureau ofConununity Health Services. The Maternity andInfant Care Projects: Reducing risks for mother and babies. Rockville, MD: DHEW (HSA-75-5012), 1975.

53. See note no. 3,10M, pp. 184-85.54. Lear, J.G., Gleicher, H.R., St. Germaine, A., and Porter, P.j. Reorganizing health care for

adolescents: The experience of the school-based adolescent health care program. Journalof Adolescent Health (1991) 12:450-58.

55. Halfon, N., and Klee, I.. Health and deselopment ser% a-es for children with multiple needs:The child in foster care. Yale Law and Polity Review (1991) 9:71-95.

56. National Commission to Prevent Infant Mortality. Home visiting: Opening doors jiff America'spregnant women and children. Washington, DC: U.S. Government Printing Office, Jul) 1989.

57. Clahots, R.B., and Dolphin, D. The multilingual videotape project: Community invohc-ment in a unig.t health education program. Public Health Reports (1992) 107:75-80.

58. L'.S. Congress, Office of Technology Assessment. Adolescent health. vot¶nre 1: Summary and pot-icy options. Washington, DC: U.S. Government Printing Office (OTC-H-I68), 1991.

Society for Adolescent Medicine. Access to health care (Or adolescents. A position paper ofthe Society for Adolescent Medicine.fourna/ of Adolescent Health (1992) 13:162-70.

3

CHILDINDICATORS

Eugene .11. !Awl!,Ph.D., is director ofresearch and grantsfar economics at theCenter fi». the Futureof Children.

Teenage ChildbearingEugene M. Lewit

his article examines a frequently discussed indicator related to the U.S.health care system for children and pregnant women: the birthrate forteenage mothers. Pregnancy among teenagers represents a particular

challenge to the system. The pregnant teenager, often in many respects a childherself, requires a full complement of prenatal care services to maintain herhealth during pregnancy and the postpartum period. Adequate prenatal ,areis also important for the health of her newborn child, who will also have needfor medical care following birth.

Assuring adequate medical care for adolescents, pregnant or not, may heproblematic for a number of reasons, including adolescents' discomfort withtraditional health care settings and inadequate resources to pay for care, parentalconsent requirements for some services, and physicians who are uncomfortableor unskilled in dealing with adolescent patients. (See the article by Perrin, Guyer,and Lawrence in this journal issue.) Moreover, because 80% of teenagers reportthat their pregnancies were unintended, the difficulties many teenagers haveobtaining family planning services would appear to be a factor in many teenagepregnancies. As a consequence of the difficulty some teens have accessing healthcare, as well as ambivalent feelings about being pregnant, pregnant teenagets aremuch less likely than older women to begin prenatal care during the first trimesterand to receive an adequate amount of prenatal care. (See the article by Racine,Joyce, and Grossman in this journal issue.)

In part because of inade-quate prenatal care, teenagechildbearing is associatedwith a number of undesirableoutcomes for both the teen-age mothers and their babies.Among the poor Outcomesfor the infants are increasedrates of preterrn birth, lowbirth weight. and deathwithin the first year of life.)Alter infancy. children ofteenage mothers are alsomole likeh to hme problemsin school, score low on IQtests, and have emotionalproblems.' When theyom e teenagers. these chil-

dren are also at increased riskof pregnancy.

Teenage mothers arethemselves at increased risk ofseveral deleterious health con-ditions, but these events appearin most instances to be a con-sequence of the economic andpsychosocial factors associatedwith teenage pregnancy ratherthan of the biologic factorsassociated with maternal ageper se.1 Because teenage child-bearing tends to interrupt theusual transitional processwhich prepares teenagers forthe responsibilities of adult-hood, the adverse economic

1D

and psychosocial conse-quences of teenage childbear-ing can be significant. Womenwho give birth as teenagers aremuch less likely to finish eitherhigh school or college thanwomen who do not. They arealso more likely to be unem-ployed and to earn less thanwomen who were not teenagemothers when they areworking, 1

A 1987 National ResearchCouncil report estimated theannual costs for public pro-grams for all families begunwhen parents were adolescental SI6.65 billion (1985 costs).-

Figure 1. Births to 15- to 19-Year-Olds by Race of Child, U.S. 1970 to 1989

National birth statistics have been tabulatedand reported by the National Center forHealth Services Research (NCI IS) i,y a num-ber of characteristics includ'og age. educa-tion level, and marital stat:ts of mother.Natality statistics ,ire' also tabulated by race ofchild, which is determine° by an algorithmbased on information reported fur both themother and the lather. Beginning with the1989 data, births are also being tabulatedaccording to race of the mother; but to avoidintroducing a bias into intertemporal com-parisons, a1I statistics relented in this noteare tabulated the basis of the race of childalgorithm.

Births to both white and black teen-agers declined between 1970 and1985. remained steady for severalyears. and began to increase slowly inthe late 1980s.One reason for the decline in birthsto teenagr!, btween 1970 and 1985was a 4% decline in the number ofteenage girls between 1970 and 1985.Births rose between 1985 and 1989despite a continuing decline in thepopulation of teenage girls because ofan upturn in the birthrate lot' teenag-ers (see figure 2).

Note. 1 -year time spanexcept from 1970-1985

700'

0 white al black

970 -1985

070-c 300

200

100

0 ,.. -,--' _,--` ../I _.,-- ..,--" ..7i I 1 3 1 I 1

1970 1975 1980 1985 1986 1987 1988 1989

Year

Source. National Center for Health Statistics. see note no. 12.

This estimate includes the costof Aid to Families with De-pendent Children (AFDC),Medicaid, and food stamps forthese families. It does not,however, include many othercosts associated with teenagepregnancy such as the costs ofincreased morbidity amongteenage mothers, increasedmorbidity and mortalityamong their children. and thecosts of all the other services(social services, special!lousing and educational serv-ices. child protethe servicesand foster Cl a e) consumeddisproportionately In thisgroup. Ott one level. this esti-

mate of the additional publiccosts associated with teenagechildbearing can he viewed asa measure of the burden thisactivity places on the rest ofsociety; but on another level,it is a measure of the negativeimpact of teenage childbear-ing on families begun by ado-lescents and evidence thatihese effects are sustained formany years.

MeasuringChildbearingAmong TeenagersDifferent statistics are used tomeasure the. level of changesin teenage childbearing.

These statistics are tabulatedby age. race/edmicity, andmarital status of the mother .3Figure 1 presents births towomen under age 20 wars forthe period of 197(1 to 1989.Births to teenage mothers de-clined substantially between1970 and 1985-86 for bothblack and white mothers..ISince the mid-1980s, however,births to teenage mothers haveincreased in the aggregate byalmost 10%. These statisticsprovide a measure of the po-tential burden on the healthcare and social service systemswhich results (tom the specialneeds cif teenage mothers and

188

their infants, but offer no in-sights into reasons for therecent increase in births toteens.

Age-specific Birthrates

The actual number of births toteenage mothers will fluctuateas the teenage population fluc-tuates, perhaps independentlyor the actual rate of teenagechildbearing. Accordingly. an-nual age-specific birthrates(births lwr 1,000 women ofspecified age by year), an easilymeasured and fairly sensitiveindicator of fertility amongwomen of different ages, is auseful measure of teenagechildbearing. Birthrates forwomen of different ages arepresented in figure 2 for theperiod from 1970 to 1989, thelatest year for which data arcavailable.' Birthrates for bothwhite and black 15-10 19 -year-olds declined substzntiallyduring the 1970s, remained es-sentially unchanged dining!)the mid-1980s, and began toincrease in the late 1980s. Pro-visional data for the state ofCalirnia suggest that this ris-ing trend continued through1990.6 As can be seen in the


figure, birthrates fin- women20 to 44 years of age followeda similar pattern of decline,stabilit. and increase duringthe 1970 to 1989 period. Inter-estingly, the birthrate for bla(teens was more than twice therate kw white teens during theentire period, although birth-rates fOr older women in eachracial group were similar.

Births to Unmarried Teenagers

Perhaps even more troublingthan the recent upturn in the1-ate of birth to teenage moth-ers is the marked increase inthe rate of birth to unmarriedteenage mothers. As shown infigure 3, the birthrate for un-married black teenagers de-clined front 1970 to 1983 buthas since exceeded 1970 levels.Black teenagers are at higherrisk of both pregnancy andout-of-wedlock births than arewhite teens. but between 1970and 1989, the birthrate for un-married white teenagers in-creased by 152% while the ratefor unmarried black teens in-creased by only 10%.7 The in-crease in the rate of birth tounmarried teens is consistentwith the increase in the rate of

birth to unmarried women 20years of age and older. As aresult of this increase in ratesof birth for unmarried women,more than two thirds of birthsto teenagers were to unmar-ried mothers in 1989 as were21% of births to olderwomen:' The increase in theproportion Of births to unmar-ried women is cause for con-cern because out- of- Wedlockchildbearing is strongly associ-ated with increased risk of lowbirth weight and infant mortal-ity.. (See the article by Racine,Joyce, and Grossman in thisjournal issue.) In addition,children in single-parent fami-lies are much more likely tolive in poverty than are chil-dren in two-parent families.8

Proximal Causes

Many facto's, societal and per-sonal, influence the rate ofbirth to teenagers, married ornot. Most proximally the rateis the result of the interactionof the level of sexual activityand the use ()reflective contra-ception among teens and theirsexual partners, many ofwhom arc males 20 years of ageand older, as well as rates of

Figure 2. Birthrates by. Age of Mother and Race of Child, U.S 1570 to 1989

Annual ag -spec ifit his t!,i ate.(births pct tliou+atni iminen of a,pet Hied ago in .t given 4..11.1 are an

rasih nicasiti 111 indit atm of thecAkihilit% nl <Itddieuring a1111,ngmien Id Billet ent age,.

For both teeliagvi s am,adult. 211 to 11 teats ofawl. age-kiwi flit bit thl:ue,HI in the vailt mid-1970,and ti inleci to temain 1:1111%(11111(.111( 111111110 the 11m4

98111,.. Itutln.tlt appaientlibegan In III( 11.',11. rn 111,- 'Me

11/X(K.

1.111' I/111111(11C 1111 I plat I. toes,bats been inuti than nsn, Iler

Its %dim will,. hitIhel t odes inut It le, Id .I chiIelenc c bytm.evit bn iteratesIt ti .111(1 lilat k %%011111

'11 1,1 I I of agt In nu1970

Note. 1-year time spanexcept from 1970-1980

0 0 0,8 0.,82 l053 108/1 1981, 1988 198/ ivSS 1985

1/c,or

1`, 19 0,31, 1",1/8-.8 --A-- 11, 14 verbs 0/1,10 211 AA yr.lr, 1-.140Ck 4 70 44 wars ,y1,10

Source- National Center for Health Stotistics. see note no 12. U S_ Bureau of the Census. see notes nos. 14-16

CHILD INDICATORS: Teenage Childbearing 189

abortion and miscarriage andthe propensity to marry eitherprior to or subsequent to con-ception. Examination oftrends in these proximal fac-tors can aid our understandingof trends in teenage childbear-ing. For example, data frontthe National Survey of' FamilyGrowth indicate that, espe-cially- during the early' teenyears, black teens are morelikely to have had sex befOrean given birthday than whiteteens.9-Fhese statistics are Cl 01-sistent with the higher rate ofchildbearing among blackteenagers as compared towhite teenagers. Moreover.these same data indicate that,between 197(1 and 1988, theproportion of females 15 to 19years of age who had ever hadpremarital sexual intercourse

increased front 29% to 52%.1'The increase in the birthratefOr unmarried teens is consis-tent with this increase in therate of sexual activity amongteenagers and the decline inthe rate of marriage amongteenagers from 30.4% of thepopulation under 20 years oldin 1980 to only 18.1% in 1987.8

Alt1.ough suggestive, thechanges in these proximal fac-tors do not by themselves ex-plain the recent trends inteenage childbearing. For ex-ample, between 1970 and1985, the proportion of fe-males 15 to 19 years (Wage whohad ever had premarital sexualintercourse increased by morethan 50%, yet the teenagebirthrate fell by 35%.wBetween 1985 and 1988, how-ever, as the proportion or le-

males

e-

a 112 S I5 to 19 years of age whohad ever had pmnarital sexcontinued to increase. theteenage birthrate grew by fi%.The effects on teenage child-bearing of the contentious de-bate over abortion and recentpolicy changes which restrictteenage access to abortion andfamily planning services havevet to be fully analyzed. Theseevents, however, do notappear, at least through 1988,to have been important factorsin the upswing in the rate ofteenage childbearing) I

Conclusions

The evidence suggests that therate of childbearing amongteens in the United States limybe increasing after a decade ofstability; moreover, the actualnumber of births to teenage

Figure 3. Birthrates for Unmarried Women by Race of Child, U.S. 1970 to 1969

120

100C5)

S

80

a.),

0

60

6 400

20

01970 1075 1980 1981 198? 1983 1984 1985 1986 1987 1988 1989

Year

Note- 1 -year timespan except from1970-1980

V 15 -Iv VOCUS block A 15 19 years white IN 20 44 years black 41 20 44 years wrule

11111111.11es inimaitied women ale the iesull of Ila' invert 11"11 of 1111111,1" "I Im1"1` lilt 11161114 111t 1,1"bahilil, "I a "(11..1.` i'""nungplegmini It a I ei lain age and cal rung he I iln to term and the iitopewat to main m int to deliver% fire !eke! .11111 t 11.ingc in bit Mime. ofunman lied wells. horlililac 1. and shire, wflect the birthrate., of women '211 to 1.1 tear `to! the 5a0 ne an tad

"Pic 1)11011.We lin ninninTid unmen n 11 %ear, of age r ise ialrh slcadil% !HAM cell 1975 and 0119,1nu easing Ig I /I 1.12'7 diningthat petted. -111e tate to, minim [led white teen, I', Ill 19 tem. 11.1...AC.01k Indncen 197T, and 1989, its leasing In 1129';dw rig Ito. ref 10(1.111C 1/111111latc lot unmarried Hack women and teenagers du 1111(1 hensern 1970 and tire Cal 19511,. Immune(' mad% for ultra of thePINK. and int leased again in the law 19811,.. her black teem. Ow 111111,11-111.11 111011( 1 s %.1, Inglice in 1411 than in 1970.Pnl unman led Nat k adults, it %%a% HY; Inset in 1101 than in to 11.I litotighoin ilic put int! hemeen 01741and 1989.1th dilates lin 'unlimited bin Is 'annum. term. arid athils.55411. thi ye in 11 (111 timeshigher Man hit !knife,. Irn 11111111.1114,d shite teens anal adult., 'esp.,. meh.

Source Notional Center for Health Statistics. see note no 13, U S Bureau of the Census. see notes nos 14-28

1qCl

190

mothers also increased in 1988and 1989 after declining stead-ily for more than 2 decades.The rate of childbearingamong unmarried teens is alsosteadily increasing. It is notsurprising, therefore, thatpolicymakers are paying moreattention to teenage preg-nancy. To some extent, inter-est in teenage pregnancy,which predates the recent up-swing in birthrates, reflectsconcern about the substantialincrease in out-of-wedlockbirths in this age group. It alsoreflects concern that recent


attempts to limit teens' accessto family planning servicesmay lead to increases in birthsin this vulnerable population,although available evidencedoes not show a decline in con-traceptive use among teens.

Ultimately, those con-cerned with the problemsposed by teen age pregnancywill need to address two facts.The first is that the rising trendin childbearing among unmar-ried teens seems to be mimick-ing a similar trend amongolderwomen and, as such, maybe indicative of changes in

society as a whole which maybe difficult to address throughprograms targeted to teenag-ers alone. The second is that,for many teenagers, pregnancymay be as much a symptom asa cause of both personal andsocietal problems. Accord-ingly, it may be necessary toenhance the life options ofteenagers to deal effectivelywith this issue.

Linda Sandharn Quinn andDon Hoban aSS iS led in the prepa-ration of article.

1. Miller, A.C., Fine, A., and Adams-Taylor, S. Monitoring children's health: Key indicators. 2d ed.Washington, DC: American Public Health Association, 1989.

2. U.S. Congress, Office of Technology Assessment. Adolescent health, volume 1: Summary and pol-ic options. Washington, DC: U.S. Government Printing Office (OTA-H-468). April 1991,

S. One statistic that is frequently cited is the percent of births to teens or the percent of birthsto single teens defined as births to teenage mothers (both married and unmanied Or justthose unmarried) as a percentage of live births to either all women or all unmarriedwomen, respectively. (See, for example: National Center for Health Statistics. Consensusset of health status indicators for the general assessment of community health statusUnited States. Morbidity and Mon'ality Weekly Report (July 12, 1991) 4:27: also. Kids countdata book: Stale profiles of child well-being. Washington. DC: The Center for the Study of So-cial Policy, 1992.) This statistic is difficult to interpret because it is dependent not only onteenage childbearing, but also on the number of births to women over 20 years of age.Since there are many more women in the over-20-year-old group, even small fluctuationsin their fertility may dominate percent-births-to-teens measures and render them insensi-tive to actual changes in teenage childbearing.

4. Prior to 1989, natality statistics were tabulated by race of child .s determined by an algo-rithm based on information reported for both the Whet- and the mother. Beginning with1989 data, births are being tabulated by race of mother. In general, this change results inmore white births and fewer births to blacks and mothers of other races. In this note, weuse only data tabulated on the basis of the race of child algorithms to avoid introducing abias into the intertemporal comparisons of race-specific birthrates.

5. There wet e between 10,200 and 11,800 births to girls less than lb years old in each yearbetween 1970 and 1989. Although these births undoubtedly present major problems formany of the youngsters involved, they represent only about 2% of all births to teenagers.Because of the small numbers and special problems which may he attendant to thesebirths, we do not discuss them in this brief article. National Center for Health Statistics(NCHS). Advance report of final natality statistics, 1989. Monthly vital statistics report, vol. 40no. 8, supplement. Hyattsville, MD: Public Health Service, December 1991.

6. Personal communication from Greg Schiller, California State Department of HealthServices.

7. See note no. 5 above, NCI-IS. 1991. Birth data for the hispanic population first became'available in 1978 and are limited to reports from those stales with significant Hispanicpopulations. Accordingly, statistics for I lispanics are not available at the same level of de-tail as are statistics for other groups. Available data indicate that in 1989 about I in 6births to Hispanic mothers was to a teenage mother, compared with I in 10 births towhite mothers and 1 in 4 births to black mothers. Similarly, at 40 per 1,000 births, in1980, the out-of-wedlock birthrate for Hispanic teens was midway between the rates forblack and white teenagers in that year (NCHS, 1901).

8. U.S. Bureau of the Census. Staiisthal abstract the l'nited States: 1991. 111th ed. Washington.DC: U.S. Government Printing Office, 1991.

9. Mosher, W.D. Use of funny planning scmices in the United States: 1982 and 1088. ,4(17,ancedata from vital and health statistics, no. 184. Hyattsville, MD: National Center (Or HealthStatistics, 1990.

CHILD INDICATORS: Teenage Childbearing 191

10. National Survey of Family Growth, Division of Vital Statistics, National Center for HealthStatistics. Premarital sexual experience among adolescent women-United States, 1970-1988. Morbidity and Mortality Week/' Report (January 4, 1991) 39,51 & 52:929-32.

11. For women aged 15 to 19 years, the proportion of births which terminated in abortion(approximately 41%) was unchanged between 1980 and 1988, the latest year for whichdata are available. Pregnancy rates for women in this age group who have ever had inter-course actually declined by about 9% between 198'2 and 1988. However, pregnancy ratesfor sexually active minority teenagers increased by about 9% between 1982 and 1988.Renshaw. S.K. Abortion trends in 1987 and 1988: Age and race. Family Planning Perspec-tives (March /April 1992) 24,2:85-86, 96.

Sources for Figures 1-3:

12. National Center for Health Statistics. Advance report of final natality statistics, 1989. Monthlyvital statistics report, vol. 40, no. 8, supplement. Hyattsville, MD: Public Health Service,1991, table 4. pp. 20-21.

13. Sec note no. 12. NCHS, table 17, pp. 32-33.

14. U.S. Bureau of the Census. Preliminary estimates of the population of the l'nited States by age. .sex,and rare: 1970 to 1981. Current Population Reports, series P-25, no. 917. Washington, DC:I.'.S. Government Printing Office, 1982.

15. U.S. Bureau of the Census. 'nifty/ States population estimates by age. sex, and race: 1980 to 1988.Current Population Reports, series P-25, no. 1045. Washington, DC: U.S. GovernmentPrinting Office, 1990.

16. U.S. Bureau of the Census. Statistical abstract of the United States: /991. 111th cd. Washington,DC: U.S. Government Printing Office, 1991, tables 12 and 22.

17. U.S. Bureau of the Census. Marital status and family status: March 1970. Current PopulationReports, series P-20, no. 212. Washington, DC: U.S. Government Printing Office, 1971.table 1.

18. U.S. Bureau of the Census. Marital status and family status: March 1975. Current PopulationReports, series P-20, no. '287. Washington, DC: U.S. Government Printing Mice, 1975,table I.

19. U.S. Bureau of the Census. Marital status and living arrangements: March 1980. CurrentPopulation Reports, series P-20, no. 365. Washington, 1)C: U.S. Government PrintingOffice, 1981, table 1.

20. U.S. Bureau of the Census. Marital status and living arrangements: March 1981. CurrentPopulation Reports, series P-20, no. 372. Washington, DC: U.S. Government PrintingOffice, 1982, table I.

21. U.S. Bureau of the Census. Marital status and living arrangements: March 1982. CurrentPopulation Reports, series P-20. no. 380. Washington, DC: U.S. Government PrintingOffice, 1983, table I.

22. Bureau of the Census. Marital status and living arrangements: March 1983. CurrentPopulation Reports, series P-20, no. 389. Washington, DC: 1'.S. Government PrintingOffice, 1984, table I.

23. 1'.S. Bureau of the Census. Marital status and living arrangements: Afarch 1984. (ittrrentPopulation Reports, series P-20, no. 399. Washington, DC: U.S. Government PrintingOffice, 1985, table 1.

24. U.S. Bureau of the Census. Marital status and living arrangements: March 1985. CurrentPopulation Reports, series P-20, no. 410. Washington, DC: U.S. Government PrintingOffice. 1986, table I.

25. 1!.S. Bureau of the Census. Marital status and living arrangements: March 1986. CurrentPopulation Reports, series P-20, no. 18. Washington, DC: U.S. Government PrintingOffice. 1987, table 1.

26. L.'.S. Bureau of the Census. Marital status and living arrangements: March 1987. CurrentPopulation Repons, series P-20, no. 423. Washington, DC: U.S. Government PrintingOffice, 1988, table I.

27. .S. Bureau of the Census. Miiml status and living arrangements: ,llarch 1988. (:urrentPopulation Reports, series P-20, no. 433. Washington, DC: U.S. Government PrintingOffice, 1989, table I.

28. U.S. Bineatt of the Census. Manta/ status nod living arrangemen;i: March 1989. CurrentPopulation Reports, series no. 445. Washington, DC: U.S. Government PrintingOffice, 1990, table 1.

1 q fr

CALL FOR PAPERSNote from the Editor:

The Future of Children announces the publication of an annual multi -topic journal issue, beginning inFall 1993. This multi-topic format will provide a forum for individual papers addressing topics of spe-cial importance for policy affecting children and families. We invite policmakers, clinicians, practitio-ners, and researchers to submit their commentary, research, and analysis for publication in thesemulti-topic issues. Manuscript deadline for articles to he considered for publication in the Fall 1993issue is Februarx 1.1993. Manuscripts submitted alter this date will be considered for publication inthe Fall 1994. or a subsequent, multi-topic issue.

Advice to Authors:ORIGINAL ARTICLES ONLY. Manuscripts are accepted on the understanding that they are original worksfor publication solely in The Future al Children and that neither this manuscript nor a version of it has beenpublished elsewhere nor is being considered for publication elsewhere. If a paper has ben prepared forpresentation at a meeting, this information should be noted on the manuscript. Accepted manuscripts aresubject to editorial modification necessary to bring them into conformity with The Future of Children style.

TITLE PAGE. On the title page, include the full name(s) of author(s), academic degrees, institutional af-liliatioits. and in rent status. Provide the complete mailing address and business and home telephone andFAX numbers of the author to whom correspondence should he directed. For anonymous refereeing pur-poses, please omit author's name on all other pages.

ARTICLE LENGTH. Manuscripts should be approximately 30-35 double-spaced typewritten pages. includ-ing references. chibits (tables. graphs. charts), and an abstract of no more than 200 words. Lengthier ar-ticles ntas be considered at the discretion of the Editor when the subject matter warrants more extensivetreatment.

REFERENCES. References in the text should be numbered in order of citation and referred to by num-ber in superscript. I.ist references at the end of the paper in the order in which they appear in the text.

STYLE. FIR' primal-% sty le guides being used are: The Chicago Manual of Style (13th ed., University of(:hicago Press). and 11;)rd, into Ty I re (3rd ed., Prentice Hall). The primary dictionary source is Webster'sNinth New Colkgiate Dirtionarv. (A set of authors' guidelines is available from the Managing Editor upon re-quest. Prospective contributors are urged to review these guidelines before final preparation of theirmanuscripts.)

COPYRIGHT. For all accepted manuscripts copyright ownership must be transferred officially to theCenter for the Future of Children. Publicatioo agreements will include full information regarding this pol-icy and must be signed by all authors and returned to the Center.

REVIEW PROCESS. Manuscripts are ae knowledged upon receipt and submitted promptly for evaluation.Articles are reviewed by at least Iwo members of the in-house editorial hoard and by expert consultants forpeel- review: every attempt is made to complete prelimittai y reviews within six to eight weeks. The editorsof The Flame Cluldten will edit all accepted manuscripts for content, style, usage, and length its accord-ance with their usual practice and will, at their option, include additional material that is in the editors'sole judgment appropriate.

Please submit papers to the Editor:

Richard E. Behrman, M.D.The David and Lucile Packard Foundation

Center for the Future of Children300 Second Street, Suite 102Los Altos, California 94022

(415) 948-3696

A Selecled Bibliography

1. Aaron, H.J. Serious and unstable condition: Financing America's health care. Washington, DC: The BrookingsInstitution, 1991.

2. American Academy of Pediatrics. Children first: A legislative proposal. Washington, DC, 1990.

3. Boyle, M.H., Torrance, G.W., Sinclair. J.C., and Horwood, S.P. Economic evaluation of neonatal inten-sive care of very-low-birth-weight infants. New England Journal of Medicine (June 2, 1983) 308,22:1330-37.

4. Burciaga Valdez. R.O. The effects of cost sharing on the health of children. RAND Corporation, March 1986.Prepared for the U.S. Department of Health and Human Services.

5. Child health in 1990: The U.S. compared to Canada, England and Wales, France, The Netherlands, andNorway. Pediatrics (1990) 86: supplement.

6. Institute of Medicine. Prenatal care: Reaching mothers. reaching infants. S.S. Brown, ed. Washington, DC:National Academy Press, 1988.

7. Joyce. T.J., Corman, H., and Grossman, M. A cost-effectiveness analysis of strategies to reduce infantmortality. Medical Care (April 1988) 26.4:348-60.

8. Klerman, L. Alive and well? A research and policy review of health programs for poor young children. New York:National Center for Children in Poverty, 1991.

9. Kotch, J.B., Blakely, C.H.. Brown, S.S., and Wong, F.Y. eds. A pound of prevention: The case for universalmaternity care in the U.S. Washington. DC: American Public Health Association. 1992.

10. Miller, CA.. Fine. and Adams-Tavlor. S. Monitoring children's health: Key indicators. 2d. ed. Washington,DC: American Public Health Association. 1989.

11. National Commission to Prevent Infant Mortality-. Troubling trends persist: Shortchanging America's nextgeneration. Washington. DC: National Commission to Prevent Infant Mortality. 1992.

12. National Committee for Injury Prevention and Control. Injury prevention: Meeting the challenge. Publishedby Oxford University Press as a supplement to the A meriran Journal of Preventive Medicine (1989) 5,3.

13. National Research Council. Institute of Medicine. Including children and pregnant women in health carereform. Washington, DC: National Academy Press, 1992.

14. National Vaccine Advisory Committee. The measles epidemic: The problems. barriers, and recommen-dations.Journal of the American Medical Association (1991) 266:1547-52.

15. Rice. D.P. Cost of injury in the United States. A report to Congress, 1989. Atlanta, GA: Centers for DiseaseControl. 1989.

16. Rosenblatt, R.A. The perinatal paradox: Doing more and accomplishing less. Health Affairs (Fall 1989)8,3:158-68.

17. Sardell, A. Child health policy in the U.S.: The paradox of consensus. Journal of Health Politics, Policy andLaw (Summer 1990) 15,2:271-304.

18. Schlesinger, M., and Eisenberg, L., eds. Children in a changing health system: Assessment and proposals forreform. Baltimore: Johns Hopkins University Press, 1990, pp. 3-26.

19. Stein, R.E.K.. ed. Caring for children with chronic illness. New York: Springer Publishing Company, 1989.

20. U.S. Congress, Office of Technology Assessment. Healthy children: Investing in the future. Washington, DC:U.S. Government Printing Office (OTA-H-345), 1988.

U.S. Congress, Office of Technology Assessment. Adolescent Health-thluny 1: Summary and policy options.Washington, DC: U.S. Government Printing Office (OTA-H-468), April 1991.

22. U.S. Department of Health and Human Services. Caring for our future: The content of prenatal care.Washington, DC: U.S. DHHS, 1989.

23. U.S. National Commission on Children. Beyond rhetoric. A new American agenda for children and families:Final report of the National Commission on Children. Washington, DC: L'.S. Government "tinting Office,1991.

24. Wagner. J., Herdman. R., and Alberts, D. Well-child care: How much is enough? Heal.) Affairs (Fall1989) 8,3:147-57.

25. Weiner. J.M., and Engel. J. Improving access to health services for children and pregnant women. Washington.DC: The Brookings Institution. 1991.

1 6

print ed365415.tif (196 pages) · lucile packard foundation, 300 second street, suite 102, los...

Documents