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Health Services Financing and Utilization
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Health Services Financing and Utilization
The availability of, and access to, quality health care directly affects the health of mothers and children, especially those at high risk due to chronic medical conditions or low socio-economic status.
Every State has implemented a Children's Health Insurance Program (CHIP), expanding coverage to many uninsured children. Outreach and consumer education are key components of the expansion in health insurance for children. Despite the progress achieved through public programs such as Medicaid and CHIP, approximately 8.5 million children remain uninsured in the United States.
The following section presents data on the utilization of health services within the maternal and child population. The most recent data are summarized by source of payment, type of care, and place of service delivery. Data are presented by age, race/ethnicity, and income.
Health Care Financing
Nearly 12 percent (8.5 million) of children younger than 18 years of age had no insurance coverage in 2001, an increase from the previous year. Although the late 1990’s saw a reduction in the percentage of uninsured children, current economic conditions, coupled with the rising cost of health benefits, have contributed to the recent increase in the population of uninsured children.
In 2001, just over one quarter of all children (26.8 percent) were publicly insured, primarily through Medicaid, and two-thirds were covered by private insurance. By comparison, children living in families with incomes below the Federal poverty level were more likely to have public insurance (62.1 percent) or be uninsured (22 percent). Only 22 percent of low-income children had private coverage.
In 2001, most uninsured children (65.6 percent) lived in families whose head was employed year-round, on a full-time basis. Even when parents are employed, coverage may not be offered or may be prohibitively expensive. Most privately insured children (60.8 percent) received insurance through a parent’s employer.
Created in response to the growing number of uninsured children in low-income working families, the Children’s Health Insurance Program (CHIP) has enrolled 5.3 million children through the end of Federal Fiscal Year 2002. As of 2002, children with family incomes up to 200 percent of the Federal poverty level were eligible for coverage through CHIP in twenty states. Nine states implemented eligibility levels exceeding 235 percent of the Federal poverty level.
Health Care Financing: Children with Special Health Care Needs
The 2001 National Survey of Children with Special Health Care Needs (CSHCN) collected information about insurance coverage for CSHCN. Nearly two-thirds of CSHCN (64.7 percent) were reported to have private or employment-based health coverage, 21.7 percent had public coverage, 8.1 percent had both, and 5.2 percent reported having no coverage at the time of the interview.
The type of coverage varied across income groups. Among families in poverty, more than two-thirds of CSHCN were covered through public programs such as Medicaid and CHIP. In contrast, for CSHCN in families with incomes above 200 percent of the poverty level, more than 80 percent had private coverage.
Vaccination Coverage Levels
The Year 2010 objective for the complete series of routinely recommended childhood vaccinations is immunization of at least 90 percent of 19- to 35-month-olds with the full series of vaccines. Data released from CDC’s 2002 National Immunization Survey revealed that 74.8 percent of children ages 19-35 months received the recommended vaccines (4 DTaP, 3 polio, 1 MMR, 3 Hib, 3 hepatitis B) in 2002. In the past 5 years, the greatest increases in vaccination rates have occurred with the hepatitis B vaccine and the varicella (chicken pox) vaccine, which was added to the schedule in 1996. Since 1997, the vaccination rate for hepatitis B has increased by 6.3 percent to 89.9 percent in 2002. The varicella vaccination rate rose to 80.6 percent, which represents a 3-fold increase since 1997. Despite this progress, approximately 900,000 children under two years of age have not received the recommended immunization series to be fully protected.1 Black children are particularly vulnerable. With the exception of the varicella vaccine, Black children aged 19-35 months have the lowest immunization rates and are consistently below the national average.
In January 2003, the CDC published an updated immunization schedule (see next section). No major changes have been made since publication of the schedule in 2002. The 2003 schedule continues to encourage the routine use of hepatitis B vaccine for all infants before hospital discharge and also begins to focus on the expansion of routine influenza immunization to include all children between 6-to 23-months of age.
Recommended Childhood Immunization Schedule
Recommended Childhood Immunization Schedule United States
According to the Centers for Disease Control and Prevention (CDC), dental decay is the second most common chronic disease among U.S. children. This is a preventable health problem which can significantly affect children’s health, ability to concentrate in school, and quality of life. With half of children already experiencing tooth decay by the age of 8, beginning dental checkups early in life is essential. Some professional associations recommend that a child have his or her first dental visit by age 1.
Problems related to oral health are more common among particular populations, including Black and Hispanic children, as well as low-income children. Analysis of the 2001 National Health Interview Survey found that 79.3 percent of children living at or above 200 percent of the Federal poverty level had seen a dentist in the past year, compared to only 62 percent of low-income children (below 200 percent of the Federal poverty level). Among low-income children, 38.1 percent had not received dental care in the last year, compared to 20.7 percent of higher-income children.
Preventive services such as regular dental health screenings may not always be available to those children who need them most. In Federal Fiscal Year 2000, only 20 percent of children eligible for dental services under the Medicaid Early and Preventive Screening, Diagnosis, and Treatment (EPSDT) program received preventive dental services.
Based on data from the 2001 National Health Interview Survey, approximately 10.5 percent of children under age 18 had not seen a physician in the past year. Older children were more likely than younger children to go without a physician visit. Nearly 16 percent of children ages 15-17 years had not had a physician visit in the past year, compared to only 3.8 percent of children under age 5.
Across all age groups, Hispanic children were the least likely to have seen a physician in the past year, compared to White and Black children. Hispanic children were up to three times more likely than White children to have had no physician visits.
The American Academy of Pediatrics recommends that children have eight health care visits in their first year, three in their second year, and one a year, generally, from middle childhood throughout adolescence.
Place of Physician Contact
Most children with a usual source of care, regardless of age or racial and ethnic group, received their health care at either a physician’s office or an HMO in 2001. On average, 36.4 percent of low-income children used a clinic or health center as their usual source of acute care, compared to only 16.8 percent of higher-income children. Children with family incomes above poverty were approximately five times more likely to seek care through a physician’s office or HMO rather than a clinic or health center. Very few families reported that the hospital emergency department was the usual source of their children’s care.
Place of Physician Contact for Children with Special Health Care Needs
Access to health care is particularly important for children with special health care needs (CSHCN). One measure of access, and an important element of primary care, is whether children have an identified place to go when they are sick. Analysis of the 2001 National Survey of Children with Special Health Care Needs found that 92 percent of CSHCN had a usual source of acute care. For the majority of these children (73 percent), this was a physician’s office, although this varied based on income. Over 80 percent (82.5 percent) of CSHCN with family incomes above poverty identified a physician’s office as their usual source of acute care, compared to 62.0 percent of CSHCN with family incomes at or below the poverty level. Overall, health centers and hospitals were most commonly cited as a primary source of acute care by CSHCN with family incomes at or below the poverty level.
In 2001, Black and Hispanic children in low-income families (those with an annual income of less than $20,000) averaged more nights in the hospital (including deliveries) than children in higher-income families. Among children who were admitted to a hospital, low-income Black and Hispanic children averaged 6.1 days and 4.1 days respectively, compared to 5.8 days and 2.9 days among higher-income Black and Hispanic children. This difference was not observed for White children, as both income groups averaged 4.5 days of hospitalization a year. Across both income groups, Hispanic children averaged the least days of hospitalization and Black children averaged the most.
Early Prenatal Care
Receiving early and continuous prenatal care throughout pregnancy has been linked to improved pregnancy and health outcomes for mother and child. The proportion of mothers beginning prenatal care in the first trimester was 83.4 percent in 2001, a slight increase from 2000.
In the last decade, there have been substantial increases in the percentage of women receiving early prenatal care, especially among racial and ethnic minorities. The proportion of Black, Hispanic, and American Indian women receiving early prenatal care increased by 20 percent or more between 1990 and 2000. Although gains have occurred across all racial groups, racial disparities persist. On average, 85.2 percent of White women, compared to 74.5 percent of Black women and 75.7 percent of Hispanic women, began prenatal care in the first trimester in 2001.
The age of the mother was also related to prenatal care initiation. Women younger than 20 years of age were much less likely than older women to begin prenatal care in the first trimester.
Late or No Prenatal Care
The percentage of pregnant women beginning prenatal care in the third trimester or going without prenatal care decreased slightly from 3.9 percent in 2000 to 3.7 percent in 2001. Regardless of age, Black and Hispanic women were about twice as likely as White women to receive late or no prenatal care.
Risk factors for not using prenatal care included being younger than 20 years old, being unmarried, having low educational attainment, and being a member of a racial or ethnic minority group.
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