General Issues
1. There are over 47 MILLION Americans with NO health insurance.
2. One in four Americans say their family has had a problem paying for medical care during the past year.
3. Businesses, squeezed by soaring health insurance costs, are passing an increasing share of the price tag to their
workers. That's forcing employees to dig ever deeper into their pockets, prompting millions to forgo coverage altogether and gamble that their families will stay healthy.
4. The public health care system is overwhelmed by the country's 47 million uninsured that turn to hospital emergency rooms for even routine care.
5. Medicare is projected to run out of funds by 2019 at the current rate of expenditure growth.
6. 18,000 people per year die because they don't have health insurance.
7. Although nearly 47 million Americans are uninsured, the United States spends more on health care than other industrialized nations, and those countries provide health insurance to all their citizens.
What's driving medical costs?
1. Medical technology: New medical devices and the latest pharmaceuticals are pushing prices up fast.
2. Litigation: The rising cost of malpractice insurance is also increasing the practice of defensive medicine.
3. Uninsured: The growing number of uninsured is an increasing burden on the medical establishment.
4. Administrative costs: Health bureaucracy consumes money that does not go directly to patient care.
Why it’s a problem for the individual’s mental health?
1. Nearly one-quarter (23 percent) of the uninsured reported changing their way of life significantly in order to pay medical bills causing due stress.
2. Nearly 30 percent say someone in their family has delayed medical care in the past year. Most say the medical condition was at least somewhat serious.
3. Lack of health and insufficient health care may cause acute and/ or chronic stress an individual or an entire family.
4. Many individuals have housing problems resulted from medical debt, including the inability to make rent or mortgage payments and the development of bad credit ratings. This may cause stress, depression, and suicidal thoughts.
5. A survey of Iowa consumers found that in order to cope with rising health insurance costs, 86 percent said they had cut back on how much they could save, and 44 percent said that they have cut back on food and heating expenses.
6. Lack of health care may lead to self-medication such as using alcohol to dull pain or obtaining illegal prescriptions or taking illegal drugs to avoid pain and/ or feelings.
Why it’s a problem for the community’s mental health?
1. If people are not insured, they use the ER as their doctor. This creates long hours of waiting sometimes up to 18 to 20 hours of waiting to see a doctor.
2. When people are uninsured, they end up using government services, which use taxpayer money.
3. If people are ill and not able to work they will not be benefiting their community and will need further services from the government like disability and food stamps. If they were just given sufficient health care in the first place, all of that could be avoided.
4. When people are uninsured and use American hospitals, the hospitals “eat” the bills. This makes the price of everyone’s health care rise.
Ways to Get Involved
1. Research! Go to http://americanhealthcarereform.org/html/take-action.html
2. Contact your officials. Go to http://www.ffhs.org
3. Be concerned about your health and the health of your families.
Research Found From (All Articles Listed for viewing within Blog):
1. Americanhealthcarereform.org
2. www.nchc.org
3. Pediatrics; Feb 2002, Vol. 109 Issue 2, pE29-E29, 1p
4. Maternal and Child Health Journal; 29 Mar 2006, Vol. 10 Issue 2, p187-199, 13p
5. American Journal of Public Health; 29 Aug 2006, Vol. 96 Issue 8, p1449-1455, 7p
6. American Journal of Public Health; 28 Feb 2007, Vol. 97 Issue 2, p323-329, 7p
7. www.aflcio.org
8. San Francisco Chronicle
9. YouTube
10. Sicko, a feature film by Michael Moore
11. http://www.hhs.gov/- The United States Department of Health and Human Services
Monday, July 30, 2007
Saturday, July 28, 2007
Family income and the impact of a children's health insurance program on reported need for health services and unmet health need
Feinberg, Emily, Swartz, Kathy, Zaslavsky, Alan, Gardner, Jane Walker, & Deborah Klein
Source: Pediatrics; Feb 2002, Vol. 109 Issue 2, pE29-E29, 1p
ABSTRACT
OBJECTIVE: In an era when expanding publicly funded health insurance to children in higher income families has been the major strategy to increase access to health care for children, it is important to determine if the benefits to higher income children attributable to the receipt of health coverage are similar to those observed for lower income children. This study investigated how the likely impact of child health insurance expansions varies with family income. METHODS: We surveyed parents or guardians of children who were enrolled in a state-sponsored health insurance program (Massachusetts Children's Medical Security Plan [CMSP]) that, before the implementation of the State Children's Health Insurance Plan (SCHIP), was open to all children regardless of income. A stratified sample of children was drawn from administrative files. We grouped children by income category (low-income [LI]: < or =133% of the federal poverty limit [FPL], middle-income [MI]: 134%-200% of the FPL, high-income [HI]: >200% of the FPL) that corresponded to eligibility for public health insurance programs in the state (Medicaid-eligible, SCHIP-eligible, and income that exceeded SCHIP eligibility). The majority of telephone interviews were conducted between November 1998 and March 1999. The overall response rate was 61.8%, yielding a sample of 996 children. The CSMP benefit package included comprehensive coverage for preventive and specialty care and limited coverage for ancillary services. Children enrolled in CMSP were not covered for inpatient hospital stays but those whose family income was <400% of the FPL were eligible to receive full or partial coverage for inpatient care through the state's free care pool. Although the CMSP benefit package did not meet the standards for a SCHIP, it is an approximate equivalent for children with incomes <200% of the FPL, who have full coverage for hospitalization through the state's free care pool. We used survey responses to develop 2 sets of indicators: the first for reported need for services and the second for unmet need or delays in care among children whose parents reported a need for the service. Within each set, we created indicators for 5 types of service (medical care, dental care, prescription drugs, vision services, and mental health care) and an additional composite indicator. The composite indicator aggregated all categories of services covered under CMSP in a single measure; it included all services except dental services, which, at the time of the study, were not covered by the program. The composite indicator served as the dependent variable in regression models. We used weighted chi2 tests to identify statistically significant differences in reported need and unmet need for the 5 types of medical services and the aggregate measure of all services covered by CMSP. We examined differences across income groups at 2 points in time: during the period children were uninsured before enrollment and while enrolled. We used weighted logistic regression to assess the independent association of family income with our dependent variables: reported need for health services and the presence of unmet need, controlling for other covariates. To evaluate the impact of participation in a child health insurance program, we examined unmet need before and after program enrollment, testing for statistical significance using McNemar's test for within-subject changes. RESULTS: During the period of uninsurance before enrollment, prescription drugs (70%) was the health service needed most frequently, followed by medical (65%) and dental (57%) care. For the composite measure of services covered by CMSP, reported need for services was not significantly different by income. Need for medical care, dental care, and prescription drugs were significantly greater among children who had been uninsured for >6 months before enrollment. In addition, a significantly greater proportion of adolescent participants needed dental, vision, and mental health services than younger enrollees. While enrolled, among recently enrolled children, 77% need medical services, 68% prescription drugs, and 59% dental. In unadjusted models MI and HI children were more than 2 times as likely to report need for covered services as LI children. After adjusting for possible confounders, the effect of income was no longer significant. Instead, nonadolescents (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25-4.76) and children with white ethnicity (OR: 3.03; 95% CI: 1.43-6.67) were significantly more likely to report need for services. Before enrollment, unmet need among those who reported need for services was 5% for medical, 4% prescription drugs, 31% dental, 30% vision, and 33% mental health. For the composite measure of services covered by CMSP, LI children were significantly more likely to have had unmet need before enrollment than MI and HI children (20%, 10%, 7% by income). As compared with younger children, adolescents also had significantly greater unmet need for the composite measure (19% vs 10%). In multivariate models, not having a usual site of care was a highly significant predictor of unmet need or delayed care (OR: 3.41; 95% CI: 1.28-9.11). Ninety-eight percent of parents cited cost as the reason they had difficulty obtaining needed care. After enrollment, the proportion of children who needed care and had difficulty obtaining it decreased for all categories of care. Less than 1% of enrollees reported unmet need or delays in care for medical services and 3% for prescription drugs. Children who needed vision and mental health services continued to experience difficulty obtaining these services (17% for each category of care), although they were covered as part of the benefit package. Unmet need or delays in care for dental services, which at the time of the study were not covered under CMSP, remained high (27%). We found a significant reduction in unmet need among children in all income groups and no significant differences in unmet need by income. Controlling for other covariates, adolescents (OR: 3.11; 95% CI: 1.58-6.12) and children with compromised health (OR: 3.20; 95% CI: 1.35-7.58) were more likely to have had difficulty obtaining needed services while enrolled in the program. Children in larger families (OR: 0.40; 95% CI: 0.17-0.96) and who were previously uninsured for >6 months (OR: 0.45; 95% CI: 0.22-7.58) were less likely to have difficulty obtaining care. CONCLUSION: Our findings demonstrate the positive impact of providing health insurance coverage to children regardless of income. The HI children who enrolled in the program looked similar to children with incomes that meet current SCHIP eligibility guidelines, suggesting that expansions of SCHIPs to HI children should not qualitatively change the program dynamics
Author Affiliations: 1Department of Maternal and Child Health, Harvard School of Public Health, Boston, USA
Accession Number: 11826239
Persistent link to this record: http://search.ebscohost.com/login.aspx?direct=true&db=flh&AN=11826239&site=ehost-live
Database: Family & Society Studies Worldwide
Full Text Database: Biomedical Reference Collection: Comprehensive
FAMILY INCOME AND THE IMPACT OF A CHILDREN'S HEALTH INSURANCE PROGRAM ON REPORTED NEED OF HEALTH SERVICES AND UNMET HEALTH NEED
e29 ABSTRACT. Family Income and the Impact of a Children's Health Insurance Program on Reported Need for Health Services and Unmet Health Need. Emily Feinberg, ScD; Kathy Swartz, PhD; Alan Zaslavsky, PhD; Jane Gardner, ScD; and Deborah Klein Walker, EdD. Objective. In an era when expanding publicly funded health insurance to children in higher income families has been the major strategy to increase access to health care for children, it is important to determine if the benefits to higher income children attributable to the receipt of health coverage are similar to those observed for lower income children. This study investigated how the likely impact of child health insurance expansions varies with family income.
Methods. We surveyed parents or guardians of children who were enrolled in a state-sponsored health insurance program (Massachusetts Children's Medical Security Plan [CMSP]) that, before the implementation of the State Children's Health Insurance Plan (SCHIP), was open to all children regardless of income. A stratified sample of children was drawn from administrative files. We grouped children by income category (low-income [LI]: ≤ 133% of the federal poverty limit [FPL], middle-income [MI]: 134%-200% of the FPL, high-income [HI]: > 200% of the FPL) that corresponded to eligibility for public health insurance programs in the state (Medicaid-eligible, SCHIP-eligible, and income that exceeded SCHIP eligibility). The majority of telephone interviews were conducted between November 1998 and March 1999. The overall response rate was 61.8%, yielding a sample of 996 children.
The CSMP benefit package included comprehensive coverage for preventive and specialty care and limited coverage for ancillary services. Children enrolled in CMSP were not covered for inpatient hospital stays but those whose family income was < 400% of the FPL were eligible to receive full or partial coverage for inpatient care through the state's free care pool. Although the CMSP benefit package did not meet the standards for a SCHIP, it is an approximate equivalent for children with incomes < 200% of the FPL, who have full coverage for hospitalization through the state's free care pool.
We used survey responses to develop 2 sets of indicators: the first for reported need for services and the second for unmet need or delays in care among children whose parents reported a need for the service. Within each set, we created indicators for 5 types of service (medical care, dental care, prescription drugs, vision services, and mental health care) and an additional composite indicator. The composite indicator aggregated all categories of services covered under CMSP in a single measure; it included all services except dental services, which, at the time of the study, were not covered by the program. The composite indicator served as the dependent variable in regression models.
We used weighted χ² tests to identify statistically significant differences in reported need and unmet need for the 5 types of medical services and the aggregate measure of all services covered by CMSP. We examined differences across income groups at 2 points in time: during the period children were uninsured before enrollment and while enrolled. We used weighted logistic regression to assess the independent association of family income with our dependent variables: reported need for health services and the presence of unmet need, controlling for other covariates. To evaluate the impact of participation in a child health insurance program, we examined unmet need before and after program enrollment, testing for statistical significance using McNemar's test for within-subject changes.
Results. During the period of uninsurance before enrollment, prescription drugs (70%) was the health service needed most frequently, followed by medical (65%) and dental (57%) care. For the composite measure of services covered by CMSP, reported need for services was not significantly different by income. Need for medical care, dental care, and prescription drugs were significantly greater among children who had been uninsured for > 6 months before enrollment. In addition, a significantly greater proportion of adolescent participants needed dental, vision, and mental health services than younger enrollees.
While enrolled, among recently enrolled children, 77% need medical services, 68% prescription drugs, and 59% dental. In unadjusted models MI and HI children were more than 2 times as likely to report need for covered services as LI children. After adjusting for possible confounders, the effect of income was no longer significant. Instead, nonadolescents (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25-4.76) and children with white ethnicity (OR: 3.03; 95% CI: 1.43-6.67) were significantly more likely to report need for services.
Before enrollment, unmet need among those who reported need for services was 5% for medical, 4% prescription drugs, 31% dental, 30% vision, and 33% mental health. For the composite measure of services covered by CMSP, LI children were significantly more likely to have had unmet need before enrollment than MI and HI children (20%, 10%, 7% by income). As compared with younger children, adolescents also had significantly greater unmet need for the composite measure (19% vs 10%). In multivariate models, not having a usual site of care was a highly significant predictor of unmet need or delayed care (OR: 3.41; 95% CI: 1.28-9.11). Ninety-eight percent of parents cited cost as the reason they had difficulty obtaining needed care.
After enrollment, the proportion of children who needed care and had difficulty obtaining it decreased for all categories of care. Less than 1% of enrollees reported unmet need or delays in care for medical services and 3% for prescription drugs. Children who needed vision and mental health services continued to experience difficulty obtaining these services (17% for each category of care), although they were covered as part of the benefit package. Unmet need or delays in care for dental services, which at the time of the study were not covered under CMSP, remained high (27%). We found a significant reduction in unmet need among children in all income groups and no significant differences in unmet need by income. Controlling for other covariates, adolescents (OR: 3.11; 95% CI: 1.58-6.12) and children with compromised health (OR: 3.20; 95% CI: 1.35-7.58) were more likely to have had difficulty obtaining needed services while enrolled in the program. Children in larger families (OR: 0.40; 95% CI: 0.17-0.96) and who were previously uninsured for > 6 months (OR: 0.45; 95% CI: 0.22-7.58) were less likely to have difficulty obtaining care.
Conclusion. Our findings demonstrate the positive impact of providing health insurance coverage to children regardless of income. The HI children who enrolled in the program looked similar to children with incomes that meet current SCHIP eligibility guidelines, suggesting that expansions of SCHIPs to HI children should not qualitatively change the program dynamics. Pediatrics 2002;109(2). URL: http://www.pediatrics.org/cgi/content/full/109/2/e29; unmet health need, SCHIP, Medicaid, children's health services.
Source: Pediatrics; Feb 2002, Vol. 109 Issue 2, pE29-E29, 1p
ABSTRACT
OBJECTIVE: In an era when expanding publicly funded health insurance to children in higher income families has been the major strategy to increase access to health care for children, it is important to determine if the benefits to higher income children attributable to the receipt of health coverage are similar to those observed for lower income children. This study investigated how the likely impact of child health insurance expansions varies with family income. METHODS: We surveyed parents or guardians of children who were enrolled in a state-sponsored health insurance program (Massachusetts Children's Medical Security Plan [CMSP]) that, before the implementation of the State Children's Health Insurance Plan (SCHIP), was open to all children regardless of income. A stratified sample of children was drawn from administrative files. We grouped children by income category (low-income [LI]: < or =133% of the federal poverty limit [FPL], middle-income [MI]: 134%-200% of the FPL, high-income [HI]: >200% of the FPL) that corresponded to eligibility for public health insurance programs in the state (Medicaid-eligible, SCHIP-eligible, and income that exceeded SCHIP eligibility). The majority of telephone interviews were conducted between November 1998 and March 1999. The overall response rate was 61.8%, yielding a sample of 996 children. The CSMP benefit package included comprehensive coverage for preventive and specialty care and limited coverage for ancillary services. Children enrolled in CMSP were not covered for inpatient hospital stays but those whose family income was <400% of the FPL were eligible to receive full or partial coverage for inpatient care through the state's free care pool. Although the CMSP benefit package did not meet the standards for a SCHIP, it is an approximate equivalent for children with incomes <200% of the FPL, who have full coverage for hospitalization through the state's free care pool. We used survey responses to develop 2 sets of indicators: the first for reported need for services and the second for unmet need or delays in care among children whose parents reported a need for the service. Within each set, we created indicators for 5 types of service (medical care, dental care, prescription drugs, vision services, and mental health care) and an additional composite indicator. The composite indicator aggregated all categories of services covered under CMSP in a single measure; it included all services except dental services, which, at the time of the study, were not covered by the program. The composite indicator served as the dependent variable in regression models. We used weighted chi2 tests to identify statistically significant differences in reported need and unmet need for the 5 types of medical services and the aggregate measure of all services covered by CMSP. We examined differences across income groups at 2 points in time: during the period children were uninsured before enrollment and while enrolled. We used weighted logistic regression to assess the independent association of family income with our dependent variables: reported need for health services and the presence of unmet need, controlling for other covariates. To evaluate the impact of participation in a child health insurance program, we examined unmet need before and after program enrollment, testing for statistical significance using McNemar's test for within-subject changes. RESULTS: During the period of uninsurance before enrollment, prescription drugs (70%) was the health service needed most frequently, followed by medical (65%) and dental (57%) care. For the composite measure of services covered by CMSP, reported need for services was not significantly different by income. Need for medical care, dental care, and prescription drugs were significantly greater among children who had been uninsured for >6 months before enrollment. In addition, a significantly greater proportion of adolescent participants needed dental, vision, and mental health services than younger enrollees. While enrolled, among recently enrolled children, 77% need medical services, 68% prescription drugs, and 59% dental. In unadjusted models MI and HI children were more than 2 times as likely to report need for covered services as LI children. After adjusting for possible confounders, the effect of income was no longer significant. Instead, nonadolescents (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25-4.76) and children with white ethnicity (OR: 3.03; 95% CI: 1.43-6.67) were significantly more likely to report need for services. Before enrollment, unmet need among those who reported need for services was 5% for medical, 4% prescription drugs, 31% dental, 30% vision, and 33% mental health. For the composite measure of services covered by CMSP, LI children were significantly more likely to have had unmet need before enrollment than MI and HI children (20%, 10%, 7% by income). As compared with younger children, adolescents also had significantly greater unmet need for the composite measure (19% vs 10%). In multivariate models, not having a usual site of care was a highly significant predictor of unmet need or delayed care (OR: 3.41; 95% CI: 1.28-9.11). Ninety-eight percent of parents cited cost as the reason they had difficulty obtaining needed care. After enrollment, the proportion of children who needed care and had difficulty obtaining it decreased for all categories of care. Less than 1% of enrollees reported unmet need or delays in care for medical services and 3% for prescription drugs. Children who needed vision and mental health services continued to experience difficulty obtaining these services (17% for each category of care), although they were covered as part of the benefit package. Unmet need or delays in care for dental services, which at the time of the study were not covered under CMSP, remained high (27%). We found a significant reduction in unmet need among children in all income groups and no significant differences in unmet need by income. Controlling for other covariates, adolescents (OR: 3.11; 95% CI: 1.58-6.12) and children with compromised health (OR: 3.20; 95% CI: 1.35-7.58) were more likely to have had difficulty obtaining needed services while enrolled in the program. Children in larger families (OR: 0.40; 95% CI: 0.17-0.96) and who were previously uninsured for >6 months (OR: 0.45; 95% CI: 0.22-7.58) were less likely to have difficulty obtaining care. CONCLUSION: Our findings demonstrate the positive impact of providing health insurance coverage to children regardless of income. The HI children who enrolled in the program looked similar to children with incomes that meet current SCHIP eligibility guidelines, suggesting that expansions of SCHIPs to HI children should not qualitatively change the program dynamics
Author Affiliations: 1Department of Maternal and Child Health, Harvard School of Public Health, Boston, USA
Accession Number: 11826239
Persistent link to this record: http://search.ebscohost.com/login.aspx?direct=true&db=flh&AN=11826239&site=ehost-live
Database: Family & Society Studies Worldwide
Full Text Database: Biomedical Reference Collection: Comprehensive
FAMILY INCOME AND THE IMPACT OF A CHILDREN'S HEALTH INSURANCE PROGRAM ON REPORTED NEED OF HEALTH SERVICES AND UNMET HEALTH NEED
e29 ABSTRACT. Family Income and the Impact of a Children's Health Insurance Program on Reported Need for Health Services and Unmet Health Need. Emily Feinberg, ScD; Kathy Swartz, PhD; Alan Zaslavsky, PhD; Jane Gardner, ScD; and Deborah Klein Walker, EdD. Objective. In an era when expanding publicly funded health insurance to children in higher income families has been the major strategy to increase access to health care for children, it is important to determine if the benefits to higher income children attributable to the receipt of health coverage are similar to those observed for lower income children. This study investigated how the likely impact of child health insurance expansions varies with family income.
Methods. We surveyed parents or guardians of children who were enrolled in a state-sponsored health insurance program (Massachusetts Children's Medical Security Plan [CMSP]) that, before the implementation of the State Children's Health Insurance Plan (SCHIP), was open to all children regardless of income. A stratified sample of children was drawn from administrative files. We grouped children by income category (low-income [LI]: ≤ 133% of the federal poverty limit [FPL], middle-income [MI]: 134%-200% of the FPL, high-income [HI]: > 200% of the FPL) that corresponded to eligibility for public health insurance programs in the state (Medicaid-eligible, SCHIP-eligible, and income that exceeded SCHIP eligibility). The majority of telephone interviews were conducted between November 1998 and March 1999. The overall response rate was 61.8%, yielding a sample of 996 children.
The CSMP benefit package included comprehensive coverage for preventive and specialty care and limited coverage for ancillary services. Children enrolled in CMSP were not covered for inpatient hospital stays but those whose family income was < 400% of the FPL were eligible to receive full or partial coverage for inpatient care through the state's free care pool. Although the CMSP benefit package did not meet the standards for a SCHIP, it is an approximate equivalent for children with incomes < 200% of the FPL, who have full coverage for hospitalization through the state's free care pool.
We used survey responses to develop 2 sets of indicators: the first for reported need for services and the second for unmet need or delays in care among children whose parents reported a need for the service. Within each set, we created indicators for 5 types of service (medical care, dental care, prescription drugs, vision services, and mental health care) and an additional composite indicator. The composite indicator aggregated all categories of services covered under CMSP in a single measure; it included all services except dental services, which, at the time of the study, were not covered by the program. The composite indicator served as the dependent variable in regression models.
We used weighted χ² tests to identify statistically significant differences in reported need and unmet need for the 5 types of medical services and the aggregate measure of all services covered by CMSP. We examined differences across income groups at 2 points in time: during the period children were uninsured before enrollment and while enrolled. We used weighted logistic regression to assess the independent association of family income with our dependent variables: reported need for health services and the presence of unmet need, controlling for other covariates. To evaluate the impact of participation in a child health insurance program, we examined unmet need before and after program enrollment, testing for statistical significance using McNemar's test for within-subject changes.
Results. During the period of uninsurance before enrollment, prescription drugs (70%) was the health service needed most frequently, followed by medical (65%) and dental (57%) care. For the composite measure of services covered by CMSP, reported need for services was not significantly different by income. Need for medical care, dental care, and prescription drugs were significantly greater among children who had been uninsured for > 6 months before enrollment. In addition, a significantly greater proportion of adolescent participants needed dental, vision, and mental health services than younger enrollees.
While enrolled, among recently enrolled children, 77% need medical services, 68% prescription drugs, and 59% dental. In unadjusted models MI and HI children were more than 2 times as likely to report need for covered services as LI children. After adjusting for possible confounders, the effect of income was no longer significant. Instead, nonadolescents (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25-4.76) and children with white ethnicity (OR: 3.03; 95% CI: 1.43-6.67) were significantly more likely to report need for services.
Before enrollment, unmet need among those who reported need for services was 5% for medical, 4% prescription drugs, 31% dental, 30% vision, and 33% mental health. For the composite measure of services covered by CMSP, LI children were significantly more likely to have had unmet need before enrollment than MI and HI children (20%, 10%, 7% by income). As compared with younger children, adolescents also had significantly greater unmet need for the composite measure (19% vs 10%). In multivariate models, not having a usual site of care was a highly significant predictor of unmet need or delayed care (OR: 3.41; 95% CI: 1.28-9.11). Ninety-eight percent of parents cited cost as the reason they had difficulty obtaining needed care.
After enrollment, the proportion of children who needed care and had difficulty obtaining it decreased for all categories of care. Less than 1% of enrollees reported unmet need or delays in care for medical services and 3% for prescription drugs. Children who needed vision and mental health services continued to experience difficulty obtaining these services (17% for each category of care), although they were covered as part of the benefit package. Unmet need or delays in care for dental services, which at the time of the study were not covered under CMSP, remained high (27%). We found a significant reduction in unmet need among children in all income groups and no significant differences in unmet need by income. Controlling for other covariates, adolescents (OR: 3.11; 95% CI: 1.58-6.12) and children with compromised health (OR: 3.20; 95% CI: 1.35-7.58) were more likely to have had difficulty obtaining needed services while enrolled in the program. Children in larger families (OR: 0.40; 95% CI: 0.17-0.96) and who were previously uninsured for > 6 months (OR: 0.45; 95% CI: 0.22-7.58) were less likely to have difficulty obtaining care.
Conclusion. Our findings demonstrate the positive impact of providing health insurance coverage to children regardless of income. The HI children who enrolled in the program looked similar to children with incomes that meet current SCHIP eligibility guidelines, suggesting that expansions of SCHIPs to HI children should not qualitatively change the program dynamics. Pediatrics 2002;109(2). URL: http://www.pediatrics.org/cgi/content/full/109/2/e29; unmet health need, SCHIP, Medicaid, children's health services.
Gradients in the health status and developmental risks of young children: the combined influences of multiple social risk factors
By Gregory D. Stevens
Source: Maternal and Child Health Journal; 29 Mar 2006, Vol. 10 Issue 2, p187-199, 13p
ABSTRACT
OBJECTIVES: To analyze child vulnerability as a profile of multiple risk factors for poorer health based on race/ethnicity, social class (maternal education and family poverty status), child health insurance coverage, and maternal mental health. Profiles are examined in relation to disparities in the health status and developmental risks of young children. DATA SOURCES: Cross-sectional data on 2,068 children ages 4-35 months from the 2000 National Survey of Early Childhood Health. STUDY DESIGN: Multiple logistic regression models are used to examine risk profiles in relation to child health status and developmental risk (based on parent concerns about development). The profiles are also examined in relation to three measures of basic access to health care: telephone contact with a physician, well-child visit in the past year, and missed or delayed needed care. PRINCIPAL FINDINGS: About one-third of (or 3.1 million) young children in the United States have two or more risk factors (RF) for poor health. Controlling for other family factors, having more RFs is associated with poorer health status (i.e., percent reported 'good/fair/poor' vs. 'excellent/very good') and being higher risk for developmental delays. For example, the likelihood of having either poorer health or higher developmental risk increases with each RF (vs. zero): 1 RF (OR = 1.70, CI: 1.20-2.38), 2 RFs (OR = 3.28, CI: 2.27-4.73), 3 RFs (OR = 4.69, CI: 2.84-7.73), 4 RFs (OR = 14.58, CI: 4.98-42.64). Higher RFs were also associated with poorer health care access. CONCLUSIONS: This study demonstrates a dose-response relationship of higher risk profiles with poorer child health status and higher developmental risk. Because children with higher profiles of risk are also more likely to lack access to care, this suggests that children who most need care have the greatest difficulty obtaining it. Addressing health gradients for vulnerable children will require explicit attention to these multiple, overlapping risk factors
Source: Maternal and Child Health Journal; 29 Mar 2006, Vol. 10 Issue 2, p187-199, 13p
ABSTRACT
OBJECTIVES: To analyze child vulnerability as a profile of multiple risk factors for poorer health based on race/ethnicity, social class (maternal education and family poverty status), child health insurance coverage, and maternal mental health. Profiles are examined in relation to disparities in the health status and developmental risks of young children. DATA SOURCES: Cross-sectional data on 2,068 children ages 4-35 months from the 2000 National Survey of Early Childhood Health. STUDY DESIGN: Multiple logistic regression models are used to examine risk profiles in relation to child health status and developmental risk (based on parent concerns about development). The profiles are also examined in relation to three measures of basic access to health care: telephone contact with a physician, well-child visit in the past year, and missed or delayed needed care. PRINCIPAL FINDINGS: About one-third of (or 3.1 million) young children in the United States have two or more risk factors (RF) for poor health. Controlling for other family factors, having more RFs is associated with poorer health status (i.e., percent reported 'good/fair/poor' vs. 'excellent/very good') and being higher risk for developmental delays. For example, the likelihood of having either poorer health or higher developmental risk increases with each RF (vs. zero): 1 RF (OR = 1.70, CI: 1.20-2.38), 2 RFs (OR = 3.28, CI: 2.27-4.73), 3 RFs (OR = 4.69, CI: 2.84-7.73), 4 RFs (OR = 14.58, CI: 4.98-42.64). Higher RFs were also associated with poorer health care access. CONCLUSIONS: This study demonstrates a dose-response relationship of higher risk profiles with poorer child health status and higher developmental risk. Because children with higher profiles of risk are also more likely to lack access to care, this suggests that children who most need care have the greatest difficulty obtaining it. Addressing health gradients for vulnerable children will require explicit attention to these multiple, overlapping risk factors
Parental English proficiency and children's health services access
By Yu, Stella, Huang, Z Jennifer, Schwalberg, Renee H, & Nyman, Rebecca M
Source: American Journal of Public Health; 29 Aug 2006, Vol. 96 Issue 8, p1449-1455, 7p
OBJECTIVES: We examined the relation between parents' level of English proficiency and their children's access to health care. METHODS: Using the 2001 California Health Interview Survey, we conducted bivariate and multivariate analyses of several measures of children's access to health care (current health insurance status, usual source of care, emergency room visits, delayed or forgone care, traveling to another country for health care, and perceived discrimination in health care) and their association with parents' English proficiency. RESULTS: Compared with English-speaking households, children in non-English-speaking households were more likely to lack health insurance, to not have doctor contact, and to go to other countries for health care and were less likely to use emergency rooms. Their parents were less likely to report their children's experiencing delayed or forgone care or discrimination in health care. CONCLUSION: English proficiency is a strong predictor of access to health insurance for children, and children in non-English-speaking families are especially likely to rely on other countries for their health care. English proficiency may mitigate the effects of race/ethnicity commonly observed in health care access and utilization studies
Section: RESEARCH AND PRACTICE
Objectives. We examined the relation between parents' level of English proficiency and their children's access to health care.
Methods. Using the 2001 California Health Interview Survey, we conducted bivariate and multivariate analyses of several measures of children's access to health care (current health insurance status, usual source of care, emergency room visits, delayed or forgone care, traveling to another country for health care, and perceived discrimination in health care) and their association with parents' English proficiency.
Results. Compared with English-speaking households, children in non-English-speaking households were more likely to lack health insurance, to not have doctor contact, and to go to other countries for health care and were less likely to use emergency rooms. Their parents were less likely to report their children's experiencing delayed or forgone care or discrimination in health care.
Conclusion. English proficiency is a strong predictor of access to health insurance for children, and children in non-English-speaking families are especially likely to rely on other countries for their health care. English proficiency may mitigate the effects of race/ethnicity commonly observed in health care access and utilization studies. (Am J Public Health. 2006;96:1449-1455. doi:10.2105/AJPH. 2005.069500)
The US Census Bureau estimated that 18% of the population aged 5 years and older spoke a language other than English at home, and more than 8% of people living in the United States speak English "less than 'very well.'"[ 1] Being non-English speaking has been recognized as an obstacle to receiving health care and can affect the health of specific minority populations, as well as the general population.[ 2-4] Those with limited English proficiency report "lack of knowledge" as an access barrier to health services more frequently than do those who speak English well, and they are less likely to understand their diagnosis, medications, treatment, and follow-up instructions than more proficient English speakers:[ 5-10] Studies have shown that in various circumstances. non-English speakers are less likely to have a usual source of care; to receive preventive services, follow-up appointments, sufficient information, and adequate therapy; and to participate in medical decisionmaking.[ 11-15]
Studies of emergency room use have shown that patients with language barriers also may experience higher admission rates and more diagnostic studies, leading to higher costs for emergency services.[ 16-19] In addition, language barriers have been associated with lacking components consistent with family-centered care, fewer physician visits, lower rates of patient satisfaction, and increased reports of quality of care being adversely affected.[ 20-27] Language barriers have more deleterious effects in vulnerable populations, such as children with special health care needs, partly because of the complexity of some children's needs and the heightened importance of clear communication between parents and health care providers.[ 28] Recent studies on adolescents revealed significant psychosocial deficits in the school environment among those whose primary language at home is not English.[ 29][ 30]
To our knowledge, no previous study has examined levels of parental English proficiency and children's access to health care. The 2001 California Health Interview Survey (CHIS) collected the information necessary to accomplish this analysis.[ 31] With the assumption that the parent or guardian is the most knowledgeable person about the health and health care of the child and was also the person responsible for helping the child to access health care services, we examined the association between the parent respondent's level of English proficiency and the child's access to health care.
Considering the barriers faced by those who speak limited English in the general population in accessing and receiving health care, it was hypothesized that children whose parents have limited English proficiency would report lower rates of health care access than would children with English-speaking parents. Our goal was to describe the demographics of children and the prevalence of selected access characteristics by the English proficiency of the responding parent and to examine the independent effects of English proficiency on health care access while controlling for confounding variables.
METHODS Data
The data used in this study were derived from the 2001 CHIS, with revised sample weights released in February 2005. The CHIS, the largest statewide health survey in the United States, collects data on multiple public health issues, including health status, behaviors, and access to care. CHIS 2001 is a random-digit-dialed telephone survey of adults, adolescents, and children. Detailed methodological information is available elsewhere.[ 31]
The sampling frame consisted of all California households with a telephone. Each computer-generated telephone number was screened to determine eligibility (e.g., language fluency); 1 adult per household was randomly selected to be interviewed. If the interviewed adult was the parent or guardian of a child or an adolescent residing in the household, the adult was asked to complete the child interview and to give verbal consent for the adolescent to be interviewed. Data were collected from 55428 households; 12 592 parent proxies for child interviews were completed between November 2000 and October 2001. An additional 800 interviews from supplemental oversamples of ethnic subgroups were added to the most current version of the public use files, yielding a total of 12797 children with complete data for our analysis. Approximately 12% of the adult interviews were completed in a language other than English, as were 21% of all child (parent proxy) interviews:[ 32] One criterion for the adolescent and child to be selected for the survey was that they had to be "associated" with the selected adult. This meant that, in most cases, the interviewed adult had to be either the parent or guardian. Interviews were conducted in English, Spanish, Chinese (Mandarin and Cantonese dialects). Vietnamese, Korean, and Khmer.[ 33] These languages were selected to include the largest possible number of non-English-speaking California residents.
Measures
If a respondent selected English as the language spoken at home, the person was classified as an English speaker at home. Those not speaking English at home were asked whether they spoke English very well, fairly well, or not well. If the interview was conducted in a language other than English, respondents were asked if they spoke English very well, well, not well, or not at all. The parent's English proficiency was measured as a 4-level variable consisting of English speaker at home, speaks English very well, speaks English well, and speaks English not well or not at all.
We examined 7 measures of health care access. Insurance status was a dichotomous variable (uninsured vs some type of insurance) based on responses to the question on "type of current health coverage source — under 65 years old." The types of insurance included Medicaid, CHIP, Medicare, employment-based, privately purchased, and other public insurance. Usual source of care was assessed from the following question: "Is there a place that the child would go when he/she is sick or you need advice about his/her health?" Contact with the doctor was derived from the following question: "During the past 12 months, how many times has your child seen a medical doctor?" An assessment of emergency room visits was based on the following question: "During the past 12 months, did (the child) visit a hospital emergency room?" Delaying or forgoing care was based on the following question: "During the past 12 months, did you delay or not get a test or treatment that a doctor ordered?" Traveling to another country for health care or prescription drugs was derived from 2 questions: Respondents were classified as "Going to other country for medical, dental care, or prescription medicine" if they answered positively to either "During the past 12 months, did you take (the child) to another country, such as Mexico or any other country, for either medical or dental care?" or "During the past 12 months, did you or anyone else go to another country, such as Mexico or any other country, to buy any prescription medicine for (him or her)?" Discrimination in health care was determined by the following question: "Thinking of your experiences with receiving health care in the past 12 months for (the child); have you felt that you were discriminated against for any reason?" All access measures were coded into dichotomized outcomes.
The covariates included child's age, gender, citizenship status, area of residence, medical insurance, parent education, and family poverty level (FPL). The FPL variable was created from family income and family size using the US Census Bureau's poverty thresholds.[ 34]
Statistical Analyses
Sample weights, person-level weights, and population weights were used. These weights accounted for, among other variables, nonresponse, multiple telephone lines, and within-household probability of selection and adjusted for gender, age, race, ethnicity, urbanization, number of children, and number of adolescents in the household. The data were weighted based on the 2000 census data. Thus, our findings can be considered generalizable to children in California.
Chi-square statistics were used to test for differences in the proportion of negative health status indicators and health access and utilization factors among ethnic groups. Logistic regression analyses were used to examine the independent effects of English proficiency on various outcomes. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were computed by using the regression (β) coefficients and standard errors obtained from the logistic regression models.
To account for the complex sample design involving stratification, clustering, and multistage sampling of the CHIS, SUDAAN (Research Triangle Institute. Research Triangle Park, NC) was used to conduct the statistical analyses:[ 35] Taylor series linearization methods were applied for variance estimation as recommended.
RESULTS
Table 1 shows the demographic distributions of the sample population by English proficiency. Among the respondents, there were 7233 (48.9%) English speakers at home, 1954 (16.3%) who spoke English very well, 1312 (12.2%) who spoke English well, and 2184 (22.6%) who spoke English not well or not at all. Significant associations were found for English proficiency and all sociodemographic characteristics examined (P<.05), with the exception of child gender. The children of those who reported speaking English at home tended to be older than the children of the other English proficiency groups. A higher level of English proficiency was related to higher parental education attainment and family income. Nearly 70% of respondents who reported not speaking English well or not speaking English at all had less than a high-school education. More than half of these individuals were poor (< 100% FPL). Nearly one fifth reported fair or poor health status for the child, compared with 3% of children from English-speaking households. This group also indicated a high proportion of Hispanic (91%) and noncitizen children (13.6%) compared with fewer than 0.5% from English-speaking households. More than one fifth reported that their children were uninsured, compared with 4% among English-speaking households. Nearly 80% of children from English-speaking households had private insurance, whereas only about one fifth of the "not well or not at all" group had private insurance. A higher proportion of English-speaking households resided in rural areas.
Table 2 shows the children's insurance status and health care access and utilization patterns by parental English proficiency and other sociodemographic variables. Parental English proficiency was associated with children having insurance, contact with a doctor in the past 12 months, emergency room visits, going to another country for health care or prescription drugs, and experiencing delayed or forgone care. Less English proficiency was associated with higher level of uninsurance, lacking a doctor's contact in the past 12 months, and a higher proportion of children seeking health care or prescription drugs. Parents who spoke less English reported less delayed or forgone care. Perception of discrimination in health care was associated only with race/ethnicity, parental education attainment, and insurance status.
Table 3 shows the adjusted odds ratios from logistic regressions for both health insurance status and health services indicators, controlling for parents' English proficiency; children's age, health status, citizenship status, insurance status, area of residence, and parental education; and FPL. Compared with English-speaking households, children of parents with limited English proficiency were significantly more likely to lack health insurance (not well or not at all: OR = 2.05, 95% CI= 1.44, 2.93). Children of non-English-speaking households were less likely to visit the emergency room within the past 12 months (well: OR = 0.68, 95% CI = 0.49, 0.93; not well or not at all: OR=0.5, 95% CI=0.35, 0.72) and less likely to report having delayed or forgone care (well: OR = 0.54, 95% CI=0.35, 0.84; not well or not at all: OR = 0.49, 95% CI=0.34, 0.71). However, children of non-English-speaking households were more likely to have gone to other countries for health care and medications (very well: OR=6.39, 95% CI=2.75, 14.88; well: OR=15.32, 95% CI=6.11, 38.42; not well or not at all: OR= 10.68, 95% CI=3.89, 28.29). Parents who did not speak English well or did not speak English at all were less likely to report being discriminated against in health care (OR=0.48, 95% CI=0.26, 0.9).
Compared with non-Hispanic Whites, non-Hispanic Blacks and non-Hispanic Asians were less likely to lack health insurance. Asians were more likely to not have contact with a doctor in the past 12 months and were less likely to visit the emergency room and report delayed or forgone care. Hispanics were more likely to have gone to another country for health care and prescriptions. Non-Hispanic Blacks were less likely to report experiencing discrimination in health care. Compared with older children, children aged 0 to 4 years were less likely to lack health insurance, less likely to go without contact with a doctor in the past 12 months, and more likely to have had an emergency room visit in the past 12 months. Compared with children in fair or poor health, children in excellent, very good, or good health were less likely to have had emergency room visits, to lack insurance, to report delayed or forgone care, to go to another country for health care or prescriptions, and to report being discriminated against in health care.
Noncitizens were much more likely to lack health insurance, a usual source of care, and contact with a doctor and to report being discriminated against in health care, compared with US-born children. Urban children were more likely to report being discriminated against in health care and less likely to use health care outside of the United States.
Family poverty had a strong impact on insurance coverage. Children in the poorest families (<100 % FPL) were least likely to seek care outside or the United States. Children whose families earned from 200 to 299% of the FPL were more likely to experience discrimination in health care. Compared with college graduates, every level of parental education conferred higher risk of children lacking health insurance and not having contact with a doctor in the past 12 months. Children whose parents had some college education had a higher risk of visiting the emergency room in the past 12 months compared with those whose parents were college graduates. Compared with children with private insurance, publicly insured children were more likely to lack a usual source of care, more likely to have visited the emergency room in the past 12 months, more likely to report having delayed or forgone care, and more likely to report being discriminated against in health care. Children without insurance were 15 times more likely to lack a usual source of care and 2 times more likely to be without doctor contact in the past 12 months and reporting having delayed or forgone care. They were 4 times as likely to have gone to other countries for health care or prescription and 4 times more likely to report being discriminated against in health care.
DISCUSSION
Language barriers can present a significant problem in health care delivery. These problems are particularly significant for children, who depend on their parents to navigate the health care system on their behalf. In our study, 23% of children had a respondent parent who spoke English less than very well and would be considered linguistically isolated according to the census definition. Nonetheless, we found that in California, children of parents who do not speak English very well are no more likely than other children to lack a usual source of care or to not have seen a doctor within the past 12 months and are less likely to visit the emergency room or to delay or forgo needed care. However, they were significantly more likely to lack health insurance and more likely to go to other countries for health care.
Poverty, of course, is significantly related to health insurance as well, as are parental education and the citizenship status of the child. Race/ethnicity continues to play an important role in health care access. Similar to earlier findings from another study. Asians were less likely to have contact with the health care system and reported less forgone and delayed care.[ 37] Blacks in this sample were less likely to lack insurance and to report being discriminated against in care. Hispanic children were more likely to have gone to another country for health care or prescriptions. Lacking medical insurance was a potent factor in predicting health care access in our study, demonstrating the effects of legal and employment circumstances that prevent children of immigrant families from having health insurance. The fact that people with limited English proficiency have a lower likelihood of emergency room visits suggests that lacking English proficiency may be a deterrent to necessary emergency visits and may highlight the need for translation services in emergency care.[ 11][ 16] Interestingly, parents with limited English proficiency were less likely to report forgone or delayed care or to report experiencing discrimination in health care. This finding is consistent with other studies and could be partly attributable to lower health care expectations or sensitivities toward discrimination often expressed by more recent immigrants.[ 28][ 36][ 37]
We also demonstrated that English proficiency plays a stronger role in realized access (e.g., emergency room utilization and seeking care outside the United States) and a lesser role in potential access (e.g., insurance and usual source of care). An important finding of this study is the large percentage of children relying on health care outside of the United States within the limited English proficiency — speaking population. However. we were not able to differentiate between the use of health care, dental care, and prescription medicine outside of the United States because they were all asked within the same question. Of special concern are those people who do not have the economic resources to do so, as well as those undocumented immigrants who cannot leave the country to seek care because of visa concerns.
Our study has a number of potential limitations. The results of this survey are unlikely to be generalizable to the United States as a whole. Because California has the nation's highest proportion of foreign-born residents, people in California with low levels of English proficiency may have access to a health care system that is more adapted to a linguistically diverse population. (The 2000 census reported that 20% of Californians speak English less than very well, compared with 8.1% in the United States overall.) Health care providers in other states may be less accustomed to serving these individuals, and our findings in California may underestimate the risks experienced by those with limited English proficiency nationally. We are also not sure how adequately the survey represents the needs of undocumented children, who are likely to have more severe needs, ft has been estimated that approximately 10% of Californian children younger than 18 were undocumented or had at least 1 undocumented parent in 2000.[ 38] In this community, limited English proficiency is likely to compound issues of health care access in addition to existing systemic factors of lacking health insurance and financial resources. People who have limited English proficiency have proven to be a challenge to the US health care system. It is a strong predictor of not having insurance and multiple health care access indicators. Language barriers may be the main cause of the lack of knowledge of health and community resources seen in immigrant populations.[ 39]
We also did not have access to provider characteristics, which could allow us to assess the effects of provider — patient language concordance. Our study highlights the importance of speaking English well in ensuring access to public benefits such as health insurance. Access to services can be facilitated by translating written notices and communications, providing professional interpreters, and allowing enrollment in settings other than welfare offices. Research shows that bilingual staff members are more likely to be available at community health centers and that immigrant families are more apt to apply for benefits at community clinics or other health-based settings.[ 38] In addition, because a substantial amount of health and educational information is now communicated over the Internet, people with limited English proficiency are further disadvantaged from acquiring the same information as their English-speaking counterparts.
Further research on access to care among immigrant families[ 40] and the role of health services received outside the United States is needed as well. The effects of cultures and health care experiences in the native countries of those with limited English proficiency on their utilization of health care in the United States should be explored. Studies on the relation of health status, health insurance, and utilization in the limited English proficiency — speaking population should be encouraged. We also should examine the public health implications of an untreated limited English proficiency — speaking population who can seek care neither in the United States nor outside of the country.
Request for reprints should be send to Stella Yu. Maternal and Child Health Bureau, 5600 Fishers Lane, 18A-55, Rockville, MD 20857 (e-mail: syu@hrsa.gov).
This article was accepted October 16, 2005.
Note. The opinions expressed in this paper are the authors' and do not necessarily reflect the views or policies of the institutions with which the authors are affiliated.
Source: American Journal of Public Health; 29 Aug 2006, Vol. 96 Issue 8, p1449-1455, 7p
OBJECTIVES: We examined the relation between parents' level of English proficiency and their children's access to health care. METHODS: Using the 2001 California Health Interview Survey, we conducted bivariate and multivariate analyses of several measures of children's access to health care (current health insurance status, usual source of care, emergency room visits, delayed or forgone care, traveling to another country for health care, and perceived discrimination in health care) and their association with parents' English proficiency. RESULTS: Compared with English-speaking households, children in non-English-speaking households were more likely to lack health insurance, to not have doctor contact, and to go to other countries for health care and were less likely to use emergency rooms. Their parents were less likely to report their children's experiencing delayed or forgone care or discrimination in health care. CONCLUSION: English proficiency is a strong predictor of access to health insurance for children, and children in non-English-speaking families are especially likely to rely on other countries for their health care. English proficiency may mitigate the effects of race/ethnicity commonly observed in health care access and utilization studies
Section: RESEARCH AND PRACTICE
Objectives. We examined the relation between parents' level of English proficiency and their children's access to health care.
Methods. Using the 2001 California Health Interview Survey, we conducted bivariate and multivariate analyses of several measures of children's access to health care (current health insurance status, usual source of care, emergency room visits, delayed or forgone care, traveling to another country for health care, and perceived discrimination in health care) and their association with parents' English proficiency.
Results. Compared with English-speaking households, children in non-English-speaking households were more likely to lack health insurance, to not have doctor contact, and to go to other countries for health care and were less likely to use emergency rooms. Their parents were less likely to report their children's experiencing delayed or forgone care or discrimination in health care.
Conclusion. English proficiency is a strong predictor of access to health insurance for children, and children in non-English-speaking families are especially likely to rely on other countries for their health care. English proficiency may mitigate the effects of race/ethnicity commonly observed in health care access and utilization studies. (Am J Public Health. 2006;96:1449-1455. doi:10.2105/AJPH. 2005.069500)
The US Census Bureau estimated that 18% of the population aged 5 years and older spoke a language other than English at home, and more than 8% of people living in the United States speak English "less than 'very well.'"[ 1] Being non-English speaking has been recognized as an obstacle to receiving health care and can affect the health of specific minority populations, as well as the general population.[ 2-4] Those with limited English proficiency report "lack of knowledge" as an access barrier to health services more frequently than do those who speak English well, and they are less likely to understand their diagnosis, medications, treatment, and follow-up instructions than more proficient English speakers:[ 5-10] Studies have shown that in various circumstances. non-English speakers are less likely to have a usual source of care; to receive preventive services, follow-up appointments, sufficient information, and adequate therapy; and to participate in medical decisionmaking.[ 11-15]
Studies of emergency room use have shown that patients with language barriers also may experience higher admission rates and more diagnostic studies, leading to higher costs for emergency services.[ 16-19] In addition, language barriers have been associated with lacking components consistent with family-centered care, fewer physician visits, lower rates of patient satisfaction, and increased reports of quality of care being adversely affected.[ 20-27] Language barriers have more deleterious effects in vulnerable populations, such as children with special health care needs, partly because of the complexity of some children's needs and the heightened importance of clear communication between parents and health care providers.[ 28] Recent studies on adolescents revealed significant psychosocial deficits in the school environment among those whose primary language at home is not English.[ 29][ 30]
To our knowledge, no previous study has examined levels of parental English proficiency and children's access to health care. The 2001 California Health Interview Survey (CHIS) collected the information necessary to accomplish this analysis.[ 31] With the assumption that the parent or guardian is the most knowledgeable person about the health and health care of the child and was also the person responsible for helping the child to access health care services, we examined the association between the parent respondent's level of English proficiency and the child's access to health care.
Considering the barriers faced by those who speak limited English in the general population in accessing and receiving health care, it was hypothesized that children whose parents have limited English proficiency would report lower rates of health care access than would children with English-speaking parents. Our goal was to describe the demographics of children and the prevalence of selected access characteristics by the English proficiency of the responding parent and to examine the independent effects of English proficiency on health care access while controlling for confounding variables.
METHODS Data
The data used in this study were derived from the 2001 CHIS, with revised sample weights released in February 2005. The CHIS, the largest statewide health survey in the United States, collects data on multiple public health issues, including health status, behaviors, and access to care. CHIS 2001 is a random-digit-dialed telephone survey of adults, adolescents, and children. Detailed methodological information is available elsewhere.[ 31]
The sampling frame consisted of all California households with a telephone. Each computer-generated telephone number was screened to determine eligibility (e.g., language fluency); 1 adult per household was randomly selected to be interviewed. If the interviewed adult was the parent or guardian of a child or an adolescent residing in the household, the adult was asked to complete the child interview and to give verbal consent for the adolescent to be interviewed. Data were collected from 55428 households; 12 592 parent proxies for child interviews were completed between November 2000 and October 2001. An additional 800 interviews from supplemental oversamples of ethnic subgroups were added to the most current version of the public use files, yielding a total of 12797 children with complete data for our analysis. Approximately 12% of the adult interviews were completed in a language other than English, as were 21% of all child (parent proxy) interviews:[ 32] One criterion for the adolescent and child to be selected for the survey was that they had to be "associated" with the selected adult. This meant that, in most cases, the interviewed adult had to be either the parent or guardian. Interviews were conducted in English, Spanish, Chinese (Mandarin and Cantonese dialects). Vietnamese, Korean, and Khmer.[ 33] These languages were selected to include the largest possible number of non-English-speaking California residents.
Measures
If a respondent selected English as the language spoken at home, the person was classified as an English speaker at home. Those not speaking English at home were asked whether they spoke English very well, fairly well, or not well. If the interview was conducted in a language other than English, respondents were asked if they spoke English very well, well, not well, or not at all. The parent's English proficiency was measured as a 4-level variable consisting of English speaker at home, speaks English very well, speaks English well, and speaks English not well or not at all.
We examined 7 measures of health care access. Insurance status was a dichotomous variable (uninsured vs some type of insurance) based on responses to the question on "type of current health coverage source — under 65 years old." The types of insurance included Medicaid, CHIP, Medicare, employment-based, privately purchased, and other public insurance. Usual source of care was assessed from the following question: "Is there a place that the child would go when he/she is sick or you need advice about his/her health?" Contact with the doctor was derived from the following question: "During the past 12 months, how many times has your child seen a medical doctor?" An assessment of emergency room visits was based on the following question: "During the past 12 months, did (the child) visit a hospital emergency room?" Delaying or forgoing care was based on the following question: "During the past 12 months, did you delay or not get a test or treatment that a doctor ordered?" Traveling to another country for health care or prescription drugs was derived from 2 questions: Respondents were classified as "Going to other country for medical, dental care, or prescription medicine" if they answered positively to either "During the past 12 months, did you take (the child) to another country, such as Mexico or any other country, for either medical or dental care?" or "During the past 12 months, did you or anyone else go to another country, such as Mexico or any other country, to buy any prescription medicine for (him or her)?" Discrimination in health care was determined by the following question: "Thinking of your experiences with receiving health care in the past 12 months for (the child); have you felt that you were discriminated against for any reason?" All access measures were coded into dichotomized outcomes.
The covariates included child's age, gender, citizenship status, area of residence, medical insurance, parent education, and family poverty level (FPL). The FPL variable was created from family income and family size using the US Census Bureau's poverty thresholds.[ 34]
Statistical Analyses
Sample weights, person-level weights, and population weights were used. These weights accounted for, among other variables, nonresponse, multiple telephone lines, and within-household probability of selection and adjusted for gender, age, race, ethnicity, urbanization, number of children, and number of adolescents in the household. The data were weighted based on the 2000 census data. Thus, our findings can be considered generalizable to children in California.
Chi-square statistics were used to test for differences in the proportion of negative health status indicators and health access and utilization factors among ethnic groups. Logistic regression analyses were used to examine the independent effects of English proficiency on various outcomes. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were computed by using the regression (β) coefficients and standard errors obtained from the logistic regression models.
To account for the complex sample design involving stratification, clustering, and multistage sampling of the CHIS, SUDAAN (Research Triangle Institute. Research Triangle Park, NC) was used to conduct the statistical analyses:[ 35] Taylor series linearization methods were applied for variance estimation as recommended.
RESULTS
Table 1 shows the demographic distributions of the sample population by English proficiency. Among the respondents, there were 7233 (48.9%) English speakers at home, 1954 (16.3%) who spoke English very well, 1312 (12.2%) who spoke English well, and 2184 (22.6%) who spoke English not well or not at all. Significant associations were found for English proficiency and all sociodemographic characteristics examined (P<.05), with the exception of child gender. The children of those who reported speaking English at home tended to be older than the children of the other English proficiency groups. A higher level of English proficiency was related to higher parental education attainment and family income. Nearly 70% of respondents who reported not speaking English well or not speaking English at all had less than a high-school education. More than half of these individuals were poor (< 100% FPL). Nearly one fifth reported fair or poor health status for the child, compared with 3% of children from English-speaking households. This group also indicated a high proportion of Hispanic (91%) and noncitizen children (13.6%) compared with fewer than 0.5% from English-speaking households. More than one fifth reported that their children were uninsured, compared with 4% among English-speaking households. Nearly 80% of children from English-speaking households had private insurance, whereas only about one fifth of the "not well or not at all" group had private insurance. A higher proportion of English-speaking households resided in rural areas.
Table 2 shows the children's insurance status and health care access and utilization patterns by parental English proficiency and other sociodemographic variables. Parental English proficiency was associated with children having insurance, contact with a doctor in the past 12 months, emergency room visits, going to another country for health care or prescription drugs, and experiencing delayed or forgone care. Less English proficiency was associated with higher level of uninsurance, lacking a doctor's contact in the past 12 months, and a higher proportion of children seeking health care or prescription drugs. Parents who spoke less English reported less delayed or forgone care. Perception of discrimination in health care was associated only with race/ethnicity, parental education attainment, and insurance status.
Table 3 shows the adjusted odds ratios from logistic regressions for both health insurance status and health services indicators, controlling for parents' English proficiency; children's age, health status, citizenship status, insurance status, area of residence, and parental education; and FPL. Compared with English-speaking households, children of parents with limited English proficiency were significantly more likely to lack health insurance (not well or not at all: OR = 2.05, 95% CI= 1.44, 2.93). Children of non-English-speaking households were less likely to visit the emergency room within the past 12 months (well: OR = 0.68, 95% CI = 0.49, 0.93; not well or not at all: OR=0.5, 95% CI=0.35, 0.72) and less likely to report having delayed or forgone care (well: OR = 0.54, 95% CI=0.35, 0.84; not well or not at all: OR = 0.49, 95% CI=0.34, 0.71). However, children of non-English-speaking households were more likely to have gone to other countries for health care and medications (very well: OR=6.39, 95% CI=2.75, 14.88; well: OR=15.32, 95% CI=6.11, 38.42; not well or not at all: OR= 10.68, 95% CI=3.89, 28.29). Parents who did not speak English well or did not speak English at all were less likely to report being discriminated against in health care (OR=0.48, 95% CI=0.26, 0.9).
Compared with non-Hispanic Whites, non-Hispanic Blacks and non-Hispanic Asians were less likely to lack health insurance. Asians were more likely to not have contact with a doctor in the past 12 months and were less likely to visit the emergency room and report delayed or forgone care. Hispanics were more likely to have gone to another country for health care and prescriptions. Non-Hispanic Blacks were less likely to report experiencing discrimination in health care. Compared with older children, children aged 0 to 4 years were less likely to lack health insurance, less likely to go without contact with a doctor in the past 12 months, and more likely to have had an emergency room visit in the past 12 months. Compared with children in fair or poor health, children in excellent, very good, or good health were less likely to have had emergency room visits, to lack insurance, to report delayed or forgone care, to go to another country for health care or prescriptions, and to report being discriminated against in health care.
Noncitizens were much more likely to lack health insurance, a usual source of care, and contact with a doctor and to report being discriminated against in health care, compared with US-born children. Urban children were more likely to report being discriminated against in health care and less likely to use health care outside of the United States.
Family poverty had a strong impact on insurance coverage. Children in the poorest families (<100 % FPL) were least likely to seek care outside or the United States. Children whose families earned from 200 to 299% of the FPL were more likely to experience discrimination in health care. Compared with college graduates, every level of parental education conferred higher risk of children lacking health insurance and not having contact with a doctor in the past 12 months. Children whose parents had some college education had a higher risk of visiting the emergency room in the past 12 months compared with those whose parents were college graduates. Compared with children with private insurance, publicly insured children were more likely to lack a usual source of care, more likely to have visited the emergency room in the past 12 months, more likely to report having delayed or forgone care, and more likely to report being discriminated against in health care. Children without insurance were 15 times more likely to lack a usual source of care and 2 times more likely to be without doctor contact in the past 12 months and reporting having delayed or forgone care. They were 4 times as likely to have gone to other countries for health care or prescription and 4 times more likely to report being discriminated against in health care.
DISCUSSION
Language barriers can present a significant problem in health care delivery. These problems are particularly significant for children, who depend on their parents to navigate the health care system on their behalf. In our study, 23% of children had a respondent parent who spoke English less than very well and would be considered linguistically isolated according to the census definition. Nonetheless, we found that in California, children of parents who do not speak English very well are no more likely than other children to lack a usual source of care or to not have seen a doctor within the past 12 months and are less likely to visit the emergency room or to delay or forgo needed care. However, they were significantly more likely to lack health insurance and more likely to go to other countries for health care.
Poverty, of course, is significantly related to health insurance as well, as are parental education and the citizenship status of the child. Race/ethnicity continues to play an important role in health care access. Similar to earlier findings from another study. Asians were less likely to have contact with the health care system and reported less forgone and delayed care.[ 37] Blacks in this sample were less likely to lack insurance and to report being discriminated against in care. Hispanic children were more likely to have gone to another country for health care or prescriptions. Lacking medical insurance was a potent factor in predicting health care access in our study, demonstrating the effects of legal and employment circumstances that prevent children of immigrant families from having health insurance. The fact that people with limited English proficiency have a lower likelihood of emergency room visits suggests that lacking English proficiency may be a deterrent to necessary emergency visits and may highlight the need for translation services in emergency care.[ 11][ 16] Interestingly, parents with limited English proficiency were less likely to report forgone or delayed care or to report experiencing discrimination in health care. This finding is consistent with other studies and could be partly attributable to lower health care expectations or sensitivities toward discrimination often expressed by more recent immigrants.[ 28][ 36][ 37]
We also demonstrated that English proficiency plays a stronger role in realized access (e.g., emergency room utilization and seeking care outside the United States) and a lesser role in potential access (e.g., insurance and usual source of care). An important finding of this study is the large percentage of children relying on health care outside of the United States within the limited English proficiency — speaking population. However. we were not able to differentiate between the use of health care, dental care, and prescription medicine outside of the United States because they were all asked within the same question. Of special concern are those people who do not have the economic resources to do so, as well as those undocumented immigrants who cannot leave the country to seek care because of visa concerns.
Our study has a number of potential limitations. The results of this survey are unlikely to be generalizable to the United States as a whole. Because California has the nation's highest proportion of foreign-born residents, people in California with low levels of English proficiency may have access to a health care system that is more adapted to a linguistically diverse population. (The 2000 census reported that 20% of Californians speak English less than very well, compared with 8.1% in the United States overall.) Health care providers in other states may be less accustomed to serving these individuals, and our findings in California may underestimate the risks experienced by those with limited English proficiency nationally. We are also not sure how adequately the survey represents the needs of undocumented children, who are likely to have more severe needs, ft has been estimated that approximately 10% of Californian children younger than 18 were undocumented or had at least 1 undocumented parent in 2000.[ 38] In this community, limited English proficiency is likely to compound issues of health care access in addition to existing systemic factors of lacking health insurance and financial resources. People who have limited English proficiency have proven to be a challenge to the US health care system. It is a strong predictor of not having insurance and multiple health care access indicators. Language barriers may be the main cause of the lack of knowledge of health and community resources seen in immigrant populations.[ 39]
We also did not have access to provider characteristics, which could allow us to assess the effects of provider — patient language concordance. Our study highlights the importance of speaking English well in ensuring access to public benefits such as health insurance. Access to services can be facilitated by translating written notices and communications, providing professional interpreters, and allowing enrollment in settings other than welfare offices. Research shows that bilingual staff members are more likely to be available at community health centers and that immigrant families are more apt to apply for benefits at community clinics or other health-based settings.[ 38] In addition, because a substantial amount of health and educational information is now communicated over the Internet, people with limited English proficiency are further disadvantaged from acquiring the same information as their English-speaking counterparts.
Further research on access to care among immigrant families[ 40] and the role of health services received outside the United States is needed as well. The effects of cultures and health care experiences in the native countries of those with limited English proficiency on their utilization of health care in the United States should be explored. Studies on the relation of health status, health insurance, and utilization in the limited English proficiency — speaking population should be encouraged. We also should examine the public health implications of an untreated limited English proficiency — speaking population who can seek care neither in the United States nor outside of the country.
Request for reprints should be send to Stella Yu. Maternal and Child Health Bureau, 5600 Fishers Lane, 18A-55, Rockville, MD 20857 (e-mail: syu@hrsa.gov).
This article was accepted October 16, 2005.
Note. The opinions expressed in this paper are the authors' and do not necessarily reflect the views or policies of the institutions with which the authors are affiliated.
The Effect of Poverty and Caregiver Education on Perceived Need and Access to Health Services Among Children With Special Health Care Needs
By Shirley Porterfield & Timothy McBride
Source: American Journal of Public Health; 28 Feb 2007, Vol. 97 Issue 2, p323-329, 7p
RESEARCH AND PRACTICE
Objectives. We examined the association between several variables and the use of specialist physician services, developmental therapies, and prescription medications among children with special health care needs (N = 38 866).
Methods. We used a bivariate probit model to estimate whether a given child needed specialized services and whether that child accessed those services; we controlled for activity limitations and severity of special needs. Variables included family income, mother's (or other caregiver's) educational level, health insurance coverage, and perceived need for specialized services. We used data from the 2001 National Survey of Children with Special Health Care Needs.
Results. Lower-income and less-educated parents were less likely than higher-income and more-educated parents to say their special needs children needed specialized health services. The probability of accessing specialized health services-when needed--increased with both higher family income and insurance coverage.
Conclusions. Children with special health care needs have less access to health services because their parents do not recognize the need for those services. An intervention in the form of information at the family level may be an appropriate policy response. (Am J Public Health. 2007;97:323-329.)
Nearly 1 in 5 families in the United States have a child with special health care needs.( n1) Children with special health care needs, both physical and mental, are significantly more likely to live with poor families compared with children in general.( n2-n5) Although poverty is a risk factor for poor health among children, low parental education adds to this risk.( n6-n10) Lack of education is highly associated with low family income, and many families may not realize that children who "take their time" to gain particular skills have a disability or a delay that may be helped by a medical or therapeutic intervention. A survey of adults who accompanied special needs children during appointments with specialist physicians found that only half these caretakers (82.5% were parents) were able to provide even a lay description of their child's diagnosis.( n11) Information, including available intervention strategies, was the greatest expressed need in a recent survey of parents of children with disabilities.( n12) This suggests that support services should be tailored to meet the needs of intended recipients-both children and their caregivers.( n13)
Although children with special health care needs are as likely as other children to have health insurance coverage,( n14, n15) previous research has found lower use of specialty care among children whose parents were low income or less educated.( n8-n10) We hypothesized that information about special needs plays a key role in seeking specialty care--i.e., if parents do not think that their child needs a particular health care service, they will not seek access to that service. Therefore, even though a child with special health care needs may have insurance coverage for specialty care, service use will only occur if the parent seeks treatment.
We examined the association between several variables-family poverty, caregiver education level, health insurance coverage, perceived need for specialized health care--and the use of 3 types of specialty health care services--specialist physicians, developmental therapies, and prescription drugs--among children with special health care needs. We also examined caregiver-reported reasons for why some children's service requests were not met. The perceived need for specialty health care services was assumed to be based on information provided to the parents.
Information has typically been characterized as an asymmetry problem in health services research--i.e., the physician has more medical knowledge than the patient does.( n16) We hypothesized that asymmetry also occurs when physicians (and possibly insurers) lack information about the efficacy of possible interventions( n7) and when physicians perceive immigrant, minority, less-educated, and lower-income patients to be less able to act on medical information.( n17-n19) In either case, physicians may not pass critical information on to the parents of their patients. Furthermore, higher-income and more-educated parents may have access to additional sources of information that less-educated and lower-income families generally do not have access to.( n20) As a result, poverty and lack of education may reduce a parent's access to information about interventions for their child. Poverty also may contribute to a lack of health insurance, or underinsurance, and thus reduce access to needed services.
We therefore hypothesized that use of health services would be influenced by both perceived need (information) and access to care. We predicted that higher-income and more-educated parents would be more likely to report that their special needs child needed a specialized health service and that this child would also be more likely to access this service compared with a similar child with lower-income and less-educated parents.
We included additional variables in our study: ( 1) race/ethnicity, because discrimination may affect perceived need for specialized health care services; ( 2) number of adults in the household, because it may influence income status, and it may have some influence on levels of information; ( 3) native language, because parents who speak English as a second language may have difficulty gaining information and using the health care system; ( 4) child's age, because health care needs change as children age; and ( 5) health insurance, because it affects access to health services.
METHODS
The 2001 National Survey of Children with Special Health Care Needs (NSCSHCN) was primarily funded by the Maternal and Child Health Bureau and was conducted by the National Center for Health Statistics. The survey was designed to provide state and national estimates of both prevalence and health services use of children aged 0 to 17 years with special health care needs.( n21) In the survey, children with special health care needs were defined as those who had "a chronic physical, developmental, behavioral, or emotional condition and who also required health and related services of a type or amount beyond that required by children generally."(n22(p41)) Subjects were screened into the survey through a random digit-dialing sampling procedure that was stratified by state. There were 38 866 special needs interviews, 96% of which were completed by a parent of the child in question. The large sample size allowed for the identification of rural and urban residence in 34 states.( n10)
Dependent Variables
We examined the perceived need for and access to specialist physician services, therapy services, and prescription medications. The NSCSHCN asked the following questions: "During the past 12 months, was there any time when CHILD needed care from a specialty doctor?" If the answer was yes, the follow-up question was, "Did CHILD receive all the care from a specialty doctor that he/she needed?" If the answer was no, the next question was, "Why did CHILD not get the care from a specialty doctor he/she needed?" The first 2 questions in this sequence were used to determine the values of the dependent variables in the estimated models.
Independent Variables
Health status. The NSCSHCN did not ask parents to identify their child by diagnosis; therefore, for the purposes of our study, children were divided into groups on the basis of a severity-of-special-needs scale. Parents were asked, "Overall how would you rank the severity of CHILD'S condition(s) or problem(s)? Please pick a number between zero and ten where zero is the mildest and ten is the most severe." Similar to previous research, we collapsed this scale into 4 categories: very low, low, medium, and high severity of the special needs condition.( n10) We also used a yes-or-no screener question to indicate whether the child was "limited or prevented in any way in (his or her/their) ability to do the things most children of the same age can do."
Demographics. Parents' levels of information about their children's condition and needs were not directly available. We used 2 variables--family income and caregiver's educational level--as proxy measures for information. Family income, which has been shown to have an effect on access to health services and perceived need, was included as an independent variable when we estimated both dependent variables. We divided family income into 3 categories: incomes below the federal poverty level (calculated by dividing respondent's household income by the Department of Health and Human Services' guidelines for poverty by household size), incomes between 100% and 200% of the federal poverty level, and incomes above 200% of the federal poverty level. We controlled for the educational level of the mother (or the respondent if the mother's information was not available), which was categorized as having less than a high-school education, having completed a high-school education, or having at least some post--high-school education or training.
Several control variables were included. Race and ethnicity were examined separately, with categories for White, Black, other (including multiracial), and Hispanic. Because respondents were not asked their marital status, children were categorized as having only 1 adult in the household or having 2 or more adults in the household. Categorical variables indicated whether there was more than 1 child with special health care needs in the household.( n7) Dichotomous variables included whether the interview was conducted in a language other than English and whether the residence was in a metropolitan statistical area.
To capture the change in health care needs as children age, we created an age spline with kinks in the spline that corresponded roughly to the ages at which public interventions change. The first segment of the spline included children aged 0 to 2 years--i.e., those who conceivably might be eligible for and participating in a public birth-to-3 program, such as those funded through Title V (Maternal and Child Health). The second segment included children aged 3 to 5 years, which are the preschool years during which children become the responsibility of their local school district under the Individuals with Disabilities Education Act.( n23) The third segment included children aged 6 through 13 years (traditional elementary-school years), and the fourth segment included children aged 14 through 17 years (high-school years).
Health insurance. We asked questions about health insurance coverage during the past 12 months. Nonexclusive categorical variables indicated whether the child was uninsured at all during the past year and what types of insurance the child had during the months of coverage. Insurance categories included private coverage, Medicaid, the State Children's Health Insurance Program (SCHIP), Title V coverage, and other public insurance (Medicare, military, and Indian Health Service).
Analyses
When modeling the use of health care services, a widely used technique is a 2-stage model: a dummy variable is the dependent variable in the first equation, which indicates whether or not the person accessed health services, and a continuous variable in the second equation measures the amount of health services accessed (measured through total cost of services).( n24) In this study, however, we did not have a continuous measure of service use among those who accessed services. Therefore, we used a 2-stage model with dummy variables as the dependent variables for both equations (1 = needed/accessed services, 0 = did not). Nevertheless, the disturbance (error) terms were correlated between the equations. The bivariate probit model handles this type of estimation,( n25) where each equation is a probit estimation equation with the error terms distributed with the normal distribution. Maximum likelihood estimation is used for the 2 equations. To estimate the bivariate probit model, different variables must be included in the different equations; therefore, some variables are indicated as 'hot included" in the tables.
The estimation of the second stage of the model--whether or not the child accessed the needed service--was modeled as conditional on the child's need for service. Therefore, the model corrects for any selection bias that might be present, because those who indicated they needed services would access the services.( n25)
RESULTS
Study Population
Characteristics of the sample are shown in Table 1. The most common special health care need identified was prescription medications (87.9%). More than half the families reported that their child needed specialist physician services (51%), and 23.5% reported that their child needed therapy services.
Most children were described as having low to medium special health care needs (37.9% and 31.7%, respectively), and only 13.4% were described as having high needs. A little more than one third of the parents of children included in the sample had annual incomes below 200% of the federal poverty level (37%), which was similar to the proportion of mothers whose formal education had not extended beyond high school (43.5%). More than 70% of the children in the sample had been insured through a private policy sometime during the past year, and 11% had been uninsured for at least 1 month during the past year.
Information and Access to Specialty Health Care Services
The results of the multivariate analysis that was estimated with a bivariate probit model were somewhat difficult to interpret because of their nonlinearity; thus, they were converted into probabilities for more direct interpretation (full regression results are available from the authors). Table 2 shows the probability that a base case, or typical child with special health care needs, would both need services and then access services if the child needed the services. A typical child was defined as a child with the mean characteristics of all children in the data set; therefore, to compute the probabilities in Table 2, we used the mean of the variables in the regression models.
Table 2 shows, for example, that the statistical probability was .536 that a base case child would need specialist physician services and was similar to the percentage who were identified during screening as having accessed more health care than their peers. However, a child with these characteristics would be very likely to get the services if their parents identified the child as needing the services, because the probability was .925 that this base case child would get specialist physician services. Similarly, the parents of the base case child would be very likely to indicate that the child needed prescription medications (P=.896) and to get medications if the parents indicated a need (P=.993). However, the parents of the base case child would be much less likely to indicate a need for therapy services (P=.202) and less likely to obtain these services even if the parents indicated that therapy was needed (P=.730). The finding that fewer than three quarters of children with special health care needs who needed therapy services actually obtained these services suggests a potential problem of access to care.
The power of the multivariate procedures is to isolate the effects of individual child characteristics on the probability of needing and accessing services while holding all other characteristics equal. Table 2 shows the probability of needing and getting services for a base case child with all the characteristics set equal to the base characteristics, except for the characteristic isolated and shown in the table. For instance, parents whose family income was below the federal poverty level would be less likely to indicate that their child needed specialist physician services (P=.465) and also less likely to get the needed services (P=.875) compared with a base case child (P=.536 and .925, respectively).
We tested whether access to information affects parents' ability to know whether their child needs services and possibly their ability to access needed services, with both the education and the income variables. We found support for the hypothesis that education influences awareness of need for services, but education had less impact on access to services. For example, mothers who did not complete high school were about 13 percentage points less likely to indicate that their child needed specialist physician services (P=.439) compared with mothers who had college degrees (P=.566). The less-educated mothers also were about 5 percentage points less likely to report a need for prescription medications. There were mixed results with respect to the impact of mother's education on actual use of services, with children of less-educated mothers more likely to access specialist physician services and therapy services.
Consistent with our hypothesis about the role of family income, Table 2 shows that a child whose family was poor was significantly less likely to use specialist physician services and prescription medications compared with a child whose family income was above 200% of the federal poverty level. However, lower-income parents also were less likely to report that their child needed specialized health services.
Parents of children with activity limitations were significantly more likely to report that their children needed specialist physician services and therapy services, although the actual use of specialist physician services was significantly lower among these children, and use of therapy services was significantly higher. As expected, access to health insurance played a key role in gaining access to health services, although our analysis suggests that type of health insurance makes little difference, particularly for use of therapy services (Table 2).
Why Children Did Not Receive Services
Parents of children who did not access all services needed were asked why services were not accessed. The 2 most common responses were that the services "cost too much" or that there was a "health plan problem" (Table 3). However, the patterns of responses differed quite a bit across the services. For example, although 60.5% of respondents reported that prescription medications cost too much and 29% reported a health plan problem, the responses were reversed for therapy services, with 19.1% reporting the services costs too much and 22.6% reporting a health plan problem. Therefore, adequate coverage for therapy services was a significant barrier to accessing care for children with special health care needs. In addition to cost and health plan problems, "lack of resources at school" was often cited as a reason for not accessing all necessary therapy services.
DISCUSSION
Our study documents the impact of information (measured by proxy through poverty status and mother's education) on the perceived need for and access to 3 specialized health services for children with special health care needs. Access appears to be driven by the income and educational status of the parents and the severity and nature of the special needs. Both income and education affect access indirectly, because less-educated and lower-income parents have a lower perceived need for specialized health care services. Lower-income parents were more likely than higher-income parents to report that their child with special health care needs had severe functional limitations, but they were less likely than higher-income parents to say that their children needed specialized health care services. Some of these findings may be the result of parents who believed services were not affordable, because "high cost" was the reason most often reported for not accessing services (Table 3). However, the empirical results presented here point to another explanation: because income levels of parents affected their perceived need for specialized health care services--which should be there regardless of income--lower-income parents may lack the information or the resources to navigate the difficult terrain of accessing health care for their children. We saw a similar pattern when comparing families by mother's education. The probability of accessing specialized health care services increased with family income.
Many parents who did not access services cited the cost of services as the reason. It is not surprising that respondents cited out-of-pocket costs of services as a barrier, because in 2004, 97% of families with private insurance coverage were responsible for office visit copays or coinsurance, and nearly 80% of families in preferred provider organizations who saw in-network providers were responsible for annual deductibles that averaged $287.( n26) A separate 2003 survey reported that 42% (up from 28% in 2001) of working-age Americans with chronic illnesses spent more than 5% of their income on out-of-pocket medical costs (excluding health insurance premiums), despite being covered by private health insurance.( n27)
Insurance increases the probability of accessing health services, although insurance type did not appear to matter in our analysis. With the exception of therapy services, nearly everyone who reported a service need did indeed access the needed service. Interestingly, public insurance and private insurance appeared equally effective at providing access to specialist physician services and prescription medications, but they were equally ineffective at providing access to therapy services. However, we also found that parents of children with special health care needs were less likely to access health services if they had been uninsured for at least 1 month during the past year, which suggests that a broader policy response may be appropriate. Title V programs are available to only a small proportion of this population, but these programs appear to be particularly effective at providing access to specialized care.
Our results clearly point to the importance of targeted outreach to low-income and less-educated parents who have children with special health care needs. We found these children were less likely to access health services because their parents did not recognize the need for those services or did not know what services were available. Intervention in the form of information at the family level may be an appropriate policy response, particularly among harder-to-reach subpopulations, such as those with lower incomes or lower literacy.
The way parents obtain access to therapy services needs to be revised. Anecdotal evidence suggests that insurance plans often limit or restrict access to therapy services, although no systematic research appears to have been done in this area. Our results show that parents cited health plan problems more often than costs of care as a barrier to accessing therapy services. Although anecdotal evidence suggests that children with special health care needs benefit greatly from therapy services, the research evidence is mixed.( n28) Among school-aged children, therapy services are often accessed through the public schools (as mandated under the Individuals with Disabilities Education Act), yet many of the parents in our study reported that their child's school-based therapy was "inadequate."
Although children with special health care needs are disproportionately covered by Medicaid,( n29) the role of SCHIP in providing access to health care services for these children is being examined. In a 3-state study, 16% to 25% of new enrollees in SCHIP were children with special health care needs, and fewer than half of these children were covered by any insurance before SCHIP enrollment.( n30) Because of recent state proposals to cut SCHIP plans,( n31) it is imperative to know what impact the type of public health insurance has on the population of children with special health care needs.
This article was accepted November 6, 2005.
S. L Porterfield originated the study and completed most of the analysis and the writing of the article. T.D. McBride assisted with both the analysis and the writing. Both authors interpreted findings, drew conclusions, and reviewed drafts of the article.
Source: American Journal of Public Health; 28 Feb 2007, Vol. 97 Issue 2, p323-329, 7p
RESEARCH AND PRACTICE
Objectives. We examined the association between several variables and the use of specialist physician services, developmental therapies, and prescription medications among children with special health care needs (N = 38 866).
Methods. We used a bivariate probit model to estimate whether a given child needed specialized services and whether that child accessed those services; we controlled for activity limitations and severity of special needs. Variables included family income, mother's (or other caregiver's) educational level, health insurance coverage, and perceived need for specialized services. We used data from the 2001 National Survey of Children with Special Health Care Needs.
Results. Lower-income and less-educated parents were less likely than higher-income and more-educated parents to say their special needs children needed specialized health services. The probability of accessing specialized health services-when needed--increased with both higher family income and insurance coverage.
Conclusions. Children with special health care needs have less access to health services because their parents do not recognize the need for those services. An intervention in the form of information at the family level may be an appropriate policy response. (Am J Public Health. 2007;97:323-329.)
Nearly 1 in 5 families in the United States have a child with special health care needs.( n1) Children with special health care needs, both physical and mental, are significantly more likely to live with poor families compared with children in general.( n2-n5) Although poverty is a risk factor for poor health among children, low parental education adds to this risk.( n6-n10) Lack of education is highly associated with low family income, and many families may not realize that children who "take their time" to gain particular skills have a disability or a delay that may be helped by a medical or therapeutic intervention. A survey of adults who accompanied special needs children during appointments with specialist physicians found that only half these caretakers (82.5% were parents) were able to provide even a lay description of their child's diagnosis.( n11) Information, including available intervention strategies, was the greatest expressed need in a recent survey of parents of children with disabilities.( n12) This suggests that support services should be tailored to meet the needs of intended recipients-both children and their caregivers.( n13)
Although children with special health care needs are as likely as other children to have health insurance coverage,( n14, n15) previous research has found lower use of specialty care among children whose parents were low income or less educated.( n8-n10) We hypothesized that information about special needs plays a key role in seeking specialty care--i.e., if parents do not think that their child needs a particular health care service, they will not seek access to that service. Therefore, even though a child with special health care needs may have insurance coverage for specialty care, service use will only occur if the parent seeks treatment.
We examined the association between several variables-family poverty, caregiver education level, health insurance coverage, perceived need for specialized health care--and the use of 3 types of specialty health care services--specialist physicians, developmental therapies, and prescription drugs--among children with special health care needs. We also examined caregiver-reported reasons for why some children's service requests were not met. The perceived need for specialty health care services was assumed to be based on information provided to the parents.
Information has typically been characterized as an asymmetry problem in health services research--i.e., the physician has more medical knowledge than the patient does.( n16) We hypothesized that asymmetry also occurs when physicians (and possibly insurers) lack information about the efficacy of possible interventions( n7) and when physicians perceive immigrant, minority, less-educated, and lower-income patients to be less able to act on medical information.( n17-n19) In either case, physicians may not pass critical information on to the parents of their patients. Furthermore, higher-income and more-educated parents may have access to additional sources of information that less-educated and lower-income families generally do not have access to.( n20) As a result, poverty and lack of education may reduce a parent's access to information about interventions for their child. Poverty also may contribute to a lack of health insurance, or underinsurance, and thus reduce access to needed services.
We therefore hypothesized that use of health services would be influenced by both perceived need (information) and access to care. We predicted that higher-income and more-educated parents would be more likely to report that their special needs child needed a specialized health service and that this child would also be more likely to access this service compared with a similar child with lower-income and less-educated parents.
We included additional variables in our study: ( 1) race/ethnicity, because discrimination may affect perceived need for specialized health care services; ( 2) number of adults in the household, because it may influence income status, and it may have some influence on levels of information; ( 3) native language, because parents who speak English as a second language may have difficulty gaining information and using the health care system; ( 4) child's age, because health care needs change as children age; and ( 5) health insurance, because it affects access to health services.
METHODS
The 2001 National Survey of Children with Special Health Care Needs (NSCSHCN) was primarily funded by the Maternal and Child Health Bureau and was conducted by the National Center for Health Statistics. The survey was designed to provide state and national estimates of both prevalence and health services use of children aged 0 to 17 years with special health care needs.( n21) In the survey, children with special health care needs were defined as those who had "a chronic physical, developmental, behavioral, or emotional condition and who also required health and related services of a type or amount beyond that required by children generally."(n22(p41)) Subjects were screened into the survey through a random digit-dialing sampling procedure that was stratified by state. There were 38 866 special needs interviews, 96% of which were completed by a parent of the child in question. The large sample size allowed for the identification of rural and urban residence in 34 states.( n10)
Dependent Variables
We examined the perceived need for and access to specialist physician services, therapy services, and prescription medications. The NSCSHCN asked the following questions: "During the past 12 months, was there any time when CHILD needed care from a specialty doctor?" If the answer was yes, the follow-up question was, "Did CHILD receive all the care from a specialty doctor that he/she needed?" If the answer was no, the next question was, "Why did CHILD not get the care from a specialty doctor he/she needed?" The first 2 questions in this sequence were used to determine the values of the dependent variables in the estimated models.
Independent Variables
Health status. The NSCSHCN did not ask parents to identify their child by diagnosis; therefore, for the purposes of our study, children were divided into groups on the basis of a severity-of-special-needs scale. Parents were asked, "Overall how would you rank the severity of CHILD'S condition(s) or problem(s)? Please pick a number between zero and ten where zero is the mildest and ten is the most severe." Similar to previous research, we collapsed this scale into 4 categories: very low, low, medium, and high severity of the special needs condition.( n10) We also used a yes-or-no screener question to indicate whether the child was "limited or prevented in any way in (his or her/their) ability to do the things most children of the same age can do."
Demographics. Parents' levels of information about their children's condition and needs were not directly available. We used 2 variables--family income and caregiver's educational level--as proxy measures for information. Family income, which has been shown to have an effect on access to health services and perceived need, was included as an independent variable when we estimated both dependent variables. We divided family income into 3 categories: incomes below the federal poverty level (calculated by dividing respondent's household income by the Department of Health and Human Services' guidelines for poverty by household size), incomes between 100% and 200% of the federal poverty level, and incomes above 200% of the federal poverty level. We controlled for the educational level of the mother (or the respondent if the mother's information was not available), which was categorized as having less than a high-school education, having completed a high-school education, or having at least some post--high-school education or training.
Several control variables were included. Race and ethnicity were examined separately, with categories for White, Black, other (including multiracial), and Hispanic. Because respondents were not asked their marital status, children were categorized as having only 1 adult in the household or having 2 or more adults in the household. Categorical variables indicated whether there was more than 1 child with special health care needs in the household.( n7) Dichotomous variables included whether the interview was conducted in a language other than English and whether the residence was in a metropolitan statistical area.
To capture the change in health care needs as children age, we created an age spline with kinks in the spline that corresponded roughly to the ages at which public interventions change. The first segment of the spline included children aged 0 to 2 years--i.e., those who conceivably might be eligible for and participating in a public birth-to-3 program, such as those funded through Title V (Maternal and Child Health). The second segment included children aged 3 to 5 years, which are the preschool years during which children become the responsibility of their local school district under the Individuals with Disabilities Education Act.( n23) The third segment included children aged 6 through 13 years (traditional elementary-school years), and the fourth segment included children aged 14 through 17 years (high-school years).
Health insurance. We asked questions about health insurance coverage during the past 12 months. Nonexclusive categorical variables indicated whether the child was uninsured at all during the past year and what types of insurance the child had during the months of coverage. Insurance categories included private coverage, Medicaid, the State Children's Health Insurance Program (SCHIP), Title V coverage, and other public insurance (Medicare, military, and Indian Health Service).
Analyses
When modeling the use of health care services, a widely used technique is a 2-stage model: a dummy variable is the dependent variable in the first equation, which indicates whether or not the person accessed health services, and a continuous variable in the second equation measures the amount of health services accessed (measured through total cost of services).( n24) In this study, however, we did not have a continuous measure of service use among those who accessed services. Therefore, we used a 2-stage model with dummy variables as the dependent variables for both equations (1 = needed/accessed services, 0 = did not). Nevertheless, the disturbance (error) terms were correlated between the equations. The bivariate probit model handles this type of estimation,( n25) where each equation is a probit estimation equation with the error terms distributed with the normal distribution. Maximum likelihood estimation is used for the 2 equations. To estimate the bivariate probit model, different variables must be included in the different equations; therefore, some variables are indicated as 'hot included" in the tables.
The estimation of the second stage of the model--whether or not the child accessed the needed service--was modeled as conditional on the child's need for service. Therefore, the model corrects for any selection bias that might be present, because those who indicated they needed services would access the services.( n25)
RESULTS
Study Population
Characteristics of the sample are shown in Table 1. The most common special health care need identified was prescription medications (87.9%). More than half the families reported that their child needed specialist physician services (51%), and 23.5% reported that their child needed therapy services.
Most children were described as having low to medium special health care needs (37.9% and 31.7%, respectively), and only 13.4% were described as having high needs. A little more than one third of the parents of children included in the sample had annual incomes below 200% of the federal poverty level (37%), which was similar to the proportion of mothers whose formal education had not extended beyond high school (43.5%). More than 70% of the children in the sample had been insured through a private policy sometime during the past year, and 11% had been uninsured for at least 1 month during the past year.
Information and Access to Specialty Health Care Services
The results of the multivariate analysis that was estimated with a bivariate probit model were somewhat difficult to interpret because of their nonlinearity; thus, they were converted into probabilities for more direct interpretation (full regression results are available from the authors). Table 2 shows the probability that a base case, or typical child with special health care needs, would both need services and then access services if the child needed the services. A typical child was defined as a child with the mean characteristics of all children in the data set; therefore, to compute the probabilities in Table 2, we used the mean of the variables in the regression models.
Table 2 shows, for example, that the statistical probability was .536 that a base case child would need specialist physician services and was similar to the percentage who were identified during screening as having accessed more health care than their peers. However, a child with these characteristics would be very likely to get the services if their parents identified the child as needing the services, because the probability was .925 that this base case child would get specialist physician services. Similarly, the parents of the base case child would be very likely to indicate that the child needed prescription medications (P=.896) and to get medications if the parents indicated a need (P=.993). However, the parents of the base case child would be much less likely to indicate a need for therapy services (P=.202) and less likely to obtain these services even if the parents indicated that therapy was needed (P=.730). The finding that fewer than three quarters of children with special health care needs who needed therapy services actually obtained these services suggests a potential problem of access to care.
The power of the multivariate procedures is to isolate the effects of individual child characteristics on the probability of needing and accessing services while holding all other characteristics equal. Table 2 shows the probability of needing and getting services for a base case child with all the characteristics set equal to the base characteristics, except for the characteristic isolated and shown in the table. For instance, parents whose family income was below the federal poverty level would be less likely to indicate that their child needed specialist physician services (P=.465) and also less likely to get the needed services (P=.875) compared with a base case child (P=.536 and .925, respectively).
We tested whether access to information affects parents' ability to know whether their child needs services and possibly their ability to access needed services, with both the education and the income variables. We found support for the hypothesis that education influences awareness of need for services, but education had less impact on access to services. For example, mothers who did not complete high school were about 13 percentage points less likely to indicate that their child needed specialist physician services (P=.439) compared with mothers who had college degrees (P=.566). The less-educated mothers also were about 5 percentage points less likely to report a need for prescription medications. There were mixed results with respect to the impact of mother's education on actual use of services, with children of less-educated mothers more likely to access specialist physician services and therapy services.
Consistent with our hypothesis about the role of family income, Table 2 shows that a child whose family was poor was significantly less likely to use specialist physician services and prescription medications compared with a child whose family income was above 200% of the federal poverty level. However, lower-income parents also were less likely to report that their child needed specialized health services.
Parents of children with activity limitations were significantly more likely to report that their children needed specialist physician services and therapy services, although the actual use of specialist physician services was significantly lower among these children, and use of therapy services was significantly higher. As expected, access to health insurance played a key role in gaining access to health services, although our analysis suggests that type of health insurance makes little difference, particularly for use of therapy services (Table 2).
Why Children Did Not Receive Services
Parents of children who did not access all services needed were asked why services were not accessed. The 2 most common responses were that the services "cost too much" or that there was a "health plan problem" (Table 3). However, the patterns of responses differed quite a bit across the services. For example, although 60.5% of respondents reported that prescription medications cost too much and 29% reported a health plan problem, the responses were reversed for therapy services, with 19.1% reporting the services costs too much and 22.6% reporting a health plan problem. Therefore, adequate coverage for therapy services was a significant barrier to accessing care for children with special health care needs. In addition to cost and health plan problems, "lack of resources at school" was often cited as a reason for not accessing all necessary therapy services.
DISCUSSION
Our study documents the impact of information (measured by proxy through poverty status and mother's education) on the perceived need for and access to 3 specialized health services for children with special health care needs. Access appears to be driven by the income and educational status of the parents and the severity and nature of the special needs. Both income and education affect access indirectly, because less-educated and lower-income parents have a lower perceived need for specialized health care services. Lower-income parents were more likely than higher-income parents to report that their child with special health care needs had severe functional limitations, but they were less likely than higher-income parents to say that their children needed specialized health care services. Some of these findings may be the result of parents who believed services were not affordable, because "high cost" was the reason most often reported for not accessing services (Table 3). However, the empirical results presented here point to another explanation: because income levels of parents affected their perceived need for specialized health care services--which should be there regardless of income--lower-income parents may lack the information or the resources to navigate the difficult terrain of accessing health care for their children. We saw a similar pattern when comparing families by mother's education. The probability of accessing specialized health care services increased with family income.
Many parents who did not access services cited the cost of services as the reason. It is not surprising that respondents cited out-of-pocket costs of services as a barrier, because in 2004, 97% of families with private insurance coverage were responsible for office visit copays or coinsurance, and nearly 80% of families in preferred provider organizations who saw in-network providers were responsible for annual deductibles that averaged $287.( n26) A separate 2003 survey reported that 42% (up from 28% in 2001) of working-age Americans with chronic illnesses spent more than 5% of their income on out-of-pocket medical costs (excluding health insurance premiums), despite being covered by private health insurance.( n27)
Insurance increases the probability of accessing health services, although insurance type did not appear to matter in our analysis. With the exception of therapy services, nearly everyone who reported a service need did indeed access the needed service. Interestingly, public insurance and private insurance appeared equally effective at providing access to specialist physician services and prescription medications, but they were equally ineffective at providing access to therapy services. However, we also found that parents of children with special health care needs were less likely to access health services if they had been uninsured for at least 1 month during the past year, which suggests that a broader policy response may be appropriate. Title V programs are available to only a small proportion of this population, but these programs appear to be particularly effective at providing access to specialized care.
Our results clearly point to the importance of targeted outreach to low-income and less-educated parents who have children with special health care needs. We found these children were less likely to access health services because their parents did not recognize the need for those services or did not know what services were available. Intervention in the form of information at the family level may be an appropriate policy response, particularly among harder-to-reach subpopulations, such as those with lower incomes or lower literacy.
The way parents obtain access to therapy services needs to be revised. Anecdotal evidence suggests that insurance plans often limit or restrict access to therapy services, although no systematic research appears to have been done in this area. Our results show that parents cited health plan problems more often than costs of care as a barrier to accessing therapy services. Although anecdotal evidence suggests that children with special health care needs benefit greatly from therapy services, the research evidence is mixed.( n28) Among school-aged children, therapy services are often accessed through the public schools (as mandated under the Individuals with Disabilities Education Act), yet many of the parents in our study reported that their child's school-based therapy was "inadequate."
Although children with special health care needs are disproportionately covered by Medicaid,( n29) the role of SCHIP in providing access to health care services for these children is being examined. In a 3-state study, 16% to 25% of new enrollees in SCHIP were children with special health care needs, and fewer than half of these children were covered by any insurance before SCHIP enrollment.( n30) Because of recent state proposals to cut SCHIP plans,( n31) it is imperative to know what impact the type of public health insurance has on the population of children with special health care needs.
This article was accepted November 6, 2005.
S. L Porterfield originated the study and completed most of the analysis and the writing of the article. T.D. McBride assisted with both the analysis and the writing. Both authors interpreted findings, drew conclusions, and reviewed drafts of the article.
What's Wrong with America's Health Care
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In 2005, more than 46 million U.S. residents had no health insurance, and the numbers keep growing. Between 2000 and 2006, the number of uninsured under age 65 increased by six million, according to the Henry J. Kaiser Family Foundation (PDF). Eight of 10 uninsured Americans hold jobs or share households with someone who is employed.
Because employers increasingly are moving in the direction of providing Wal-Mart-style health coverage by shifting health care costs to employees, America’s workers struggle to pay higher premiums, deductibles and co-payments—if they can afford such coverage at all.
Of the more than 46 million Americans without health insurance, nearly one-quarter or more than 10 million are children. Read the AFL-CIO Executive Council's call for a universal health care system based on Medicare.
Working families are experiencing double-digit increases in the costs of health insurance, more out-of-pocket costs for doctor visits and skyrocketing prices for prescriptions, forcing many to delay getting needed medical care or worse—to decline coverage for themselves or their families because of cost. Health care costs are rising at five times the rate of inflation. According to the Center for Studying Health System Change, health care spending rose 10 percent in 2002 and that followed a slightly more than 10 percent increase in 2001—the largest jump in more than a decade. In the first six months of 2003, health spending rose another 8.5 percent. Premiums for employer-sponsored coverage increased nearly 13 percent in 2002. As employers refuse to pay their fair share, this trend may result in millions of workers losing their employer-based coverage (PDF).
Employers are responding to growing cost pressures by shifting more and more health care costs onto workers, especially through larger co-pays and deductibles that must be paid at the time treatment is sought.
Employer’s demands to slash health care coverage for workers was the major issue in the recent southern California grocery workers' strike and lockout in which nearly 60,000 workers saved affordable health care benefits and beat back employer demands to freeze pension funds after holding strong on the picket line for five months. Under grocery management’s original proposals, a worker making slightly less than $20,000 a year would have had to pay nearly $5,000 to maintain the same level of benefits they had in the previous contract.
Other cost increases hitting workers include larger hikes in the cost of family coverage, less access to needed prescription drugs through stricter HMO formularies and higher prices for more comprehensive coverage. See the Consumers Unions’ Health Care Plans and Managed Care (PDF).
Consumers are using more prescriptions, at younger ages and for more conditions, and substituting newer, more expensive medications for established products. As a result, pharmaceutical spending increased by 17.4 percent annually between 1999 and 2000 and another 16 percent from 2000 to 2001 (PDF). Read how the drug industry keeps prices high in “What the Drug Industry Doesn’t Want You to Know” in America@work.
The lack of quality health care in the United States also stems from our system’s lack of comprehensive quality measure and assurance programs,which unions now are establishing with community partners.
Our most successful public health insurance program, Medicare, is increasingly under attack at a time when the lack of access to health care is already a crisis in America. Most Americans ages 65 and older rely on Medicare, which serves more than 40 million beneficiaries in the United States. Instead of strengthening and modernizing Medicare to include a comprehensive, affordable prescription drug benefit for all seniors, the Bush administration in late 2003 strong-armed through Congress a Medicare prescription drug bill that moves Medicare toward privatization. The new Medicare bill also:
Forces 32.5 million seniors and people with disabilities to pay higher premiums and other Medicare costs.
Drops coverage for out-of-pocket expenses between $2,250 and $5,100.
Prevents the federal government from negotiating lower drug costs and does nothing to rein in soaring prescription drug prices.
Threatens the employer-provided drug benefits of millions of retirees.
Our health care system lacks safety controls that endanger front-line workers and patients. Staffing levels are dangerously low in hospitals, nursing homes and other health care facilities. As a result, medical errors are rising—and account for an estimated 44,000 to 98,000 needless death each year. See Medical Errors and Patient Safety and 20 Steps to Prevent Medical Errors from the Agency for Healthcare Research and Quality.
How can we fix our health care system?
Require employers to pay their fair share. The U.S. system of providing health care coverage is employer-based. Unfortunately, this system leaves too many working families uninsured or underinsured. Fifty-six percent of uninsured workers worked full-time in 2002. New incentives and rules can change this. Sen. Edward Kennedy (D-Mass.) has proposed legislation to require employers of more than 50 workers to provide employees with health insurance, and in 2003, California passed a state law (PDF) that requires employers to provide insurance for workers or pay into a state fund to insureworkers. With little federal action on health care, more states are addressing health care issues.
Beware of new “defined contribution” health care coverage. Shifting health care costs onto working families already is creating hardship at the doctor's office and the bargaining table. Now, many employers are talking about passing most or all of the risk of rising health care costs onto employees by adopting "defined contribution" plans (also described with terms including "vouchers,” “consumer driven health care,” “tiered benefits” and “fixed premiums”).
These defined contribution plans can come in many shapes and forms, but they share one feature that makes them different and more harmful to working families than the traditional "defined benefit" plans, which guarantee a certain amount of coverage. In a defined benefit plan, employees are guaranteed a fixed package of health insurance benefits. But in a defined contribution plan, the employer pays a fixed amount toward the premium, regardless of how much it costs, leaving it to the employee to pick up the rest. So under a defined contribution plan, a worker in poor health or someone who has a family member with medical problems would have to shoulder a much larger financial burden than a healthier person. Learn more about these plans through health care research group websites.
Provide coverage for all children. To expand health coverage to the more than 10 million children in America who today lack health insurance, Congress in 1997 passed the State Children’s Health Insurance Program (SCHIP) to work with the Medicaid program to cover low- and moderate-income families. Bringing eligible families into the program requires extensive education and outreach, and unions are playing a key role. But states are facing their biggest budget crisis since World War II. Confronted with three-plus years economic downturn, and the Bush administration’s cuts in state aid, coupled with larger financial burdens imposed by new and under-funded federal mandates, states are cutting back on health care programs such as Medicaid and SCHIP.
Help curb runaway prescription drug prices by supporting state legislation that gives lawmakers the power to negotiate drug discounts with pharmaceutical companies just as HMOs and insurers do. States then can pass savings to seniors covered by Medicare and to working families who lack drug coverage and make less than 300 percent of the poverty level.
Everyone loses when health care workers are forced to work overtime and are exposed to life-threatening diseases because of unsafe equipment. After years of struggle, health care workers won federal legislation to require safer needlesticks in 2000 and 24 states now have safer needlestick laws on the books. States can pass their own legislation mandating safety devices for needles.
In 2005, more than 46 million U.S. residents had no health insurance, and the numbers keep growing. Between 2000 and 2006, the number of uninsured under age 65 increased by six million, according to the Henry J. Kaiser Family Foundation (PDF). Eight of 10 uninsured Americans hold jobs or share households with someone who is employed.
Because employers increasingly are moving in the direction of providing Wal-Mart-style health coverage by shifting health care costs to employees, America’s workers struggle to pay higher premiums, deductibles and co-payments—if they can afford such coverage at all.
Of the more than 46 million Americans without health insurance, nearly one-quarter or more than 10 million are children. Read the AFL-CIO Executive Council's call for a universal health care system based on Medicare.
Working families are experiencing double-digit increases in the costs of health insurance, more out-of-pocket costs for doctor visits and skyrocketing prices for prescriptions, forcing many to delay getting needed medical care or worse—to decline coverage for themselves or their families because of cost. Health care costs are rising at five times the rate of inflation. According to the Center for Studying Health System Change, health care spending rose 10 percent in 2002 and that followed a slightly more than 10 percent increase in 2001—the largest jump in more than a decade. In the first six months of 2003, health spending rose another 8.5 percent. Premiums for employer-sponsored coverage increased nearly 13 percent in 2002. As employers refuse to pay their fair share, this trend may result in millions of workers losing their employer-based coverage (PDF).
Employers are responding to growing cost pressures by shifting more and more health care costs onto workers, especially through larger co-pays and deductibles that must be paid at the time treatment is sought.
Employer’s demands to slash health care coverage for workers was the major issue in the recent southern California grocery workers' strike and lockout in which nearly 60,000 workers saved affordable health care benefits and beat back employer demands to freeze pension funds after holding strong on the picket line for five months. Under grocery management’s original proposals, a worker making slightly less than $20,000 a year would have had to pay nearly $5,000 to maintain the same level of benefits they had in the previous contract.
Other cost increases hitting workers include larger hikes in the cost of family coverage, less access to needed prescription drugs through stricter HMO formularies and higher prices for more comprehensive coverage. See the Consumers Unions’ Health Care Plans and Managed Care (PDF).
Consumers are using more prescriptions, at younger ages and for more conditions, and substituting newer, more expensive medications for established products. As a result, pharmaceutical spending increased by 17.4 percent annually between 1999 and 2000 and another 16 percent from 2000 to 2001 (PDF). Read how the drug industry keeps prices high in “What the Drug Industry Doesn’t Want You to Know” in America@work.
The lack of quality health care in the United States also stems from our system’s lack of comprehensive quality measure and assurance programs,which unions now are establishing with community partners.
Our most successful public health insurance program, Medicare, is increasingly under attack at a time when the lack of access to health care is already a crisis in America. Most Americans ages 65 and older rely on Medicare, which serves more than 40 million beneficiaries in the United States. Instead of strengthening and modernizing Medicare to include a comprehensive, affordable prescription drug benefit for all seniors, the Bush administration in late 2003 strong-armed through Congress a Medicare prescription drug bill that moves Medicare toward privatization. The new Medicare bill also:
Forces 32.5 million seniors and people with disabilities to pay higher premiums and other Medicare costs.
Drops coverage for out-of-pocket expenses between $2,250 and $5,100.
Prevents the federal government from negotiating lower drug costs and does nothing to rein in soaring prescription drug prices.
Threatens the employer-provided drug benefits of millions of retirees.
Our health care system lacks safety controls that endanger front-line workers and patients. Staffing levels are dangerously low in hospitals, nursing homes and other health care facilities. As a result, medical errors are rising—and account for an estimated 44,000 to 98,000 needless death each year. See Medical Errors and Patient Safety and 20 Steps to Prevent Medical Errors from the Agency for Healthcare Research and Quality.
How can we fix our health care system?
Require employers to pay their fair share. The U.S. system of providing health care coverage is employer-based. Unfortunately, this system leaves too many working families uninsured or underinsured. Fifty-six percent of uninsured workers worked full-time in 2002. New incentives and rules can change this. Sen. Edward Kennedy (D-Mass.) has proposed legislation to require employers of more than 50 workers to provide employees with health insurance, and in 2003, California passed a state law (PDF) that requires employers to provide insurance for workers or pay into a state fund to insureworkers. With little federal action on health care, more states are addressing health care issues.
Beware of new “defined contribution” health care coverage. Shifting health care costs onto working families already is creating hardship at the doctor's office and the bargaining table. Now, many employers are talking about passing most or all of the risk of rising health care costs onto employees by adopting "defined contribution" plans (also described with terms including "vouchers,” “consumer driven health care,” “tiered benefits” and “fixed premiums”).
These defined contribution plans can come in many shapes and forms, but they share one feature that makes them different and more harmful to working families than the traditional "defined benefit" plans, which guarantee a certain amount of coverage. In a defined benefit plan, employees are guaranteed a fixed package of health insurance benefits. But in a defined contribution plan, the employer pays a fixed amount toward the premium, regardless of how much it costs, leaving it to the employee to pick up the rest. So under a defined contribution plan, a worker in poor health or someone who has a family member with medical problems would have to shoulder a much larger financial burden than a healthier person. Learn more about these plans through health care research group websites.
Provide coverage for all children. To expand health coverage to the more than 10 million children in America who today lack health insurance, Congress in 1997 passed the State Children’s Health Insurance Program (SCHIP) to work with the Medicaid program to cover low- and moderate-income families. Bringing eligible families into the program requires extensive education and outreach, and unions are playing a key role. But states are facing their biggest budget crisis since World War II. Confronted with three-plus years economic downturn, and the Bush administration’s cuts in state aid, coupled with larger financial burdens imposed by new and under-funded federal mandates, states are cutting back on health care programs such as Medicaid and SCHIP.
Help curb runaway prescription drug prices by supporting state legislation that gives lawmakers the power to negotiate drug discounts with pharmaceutical companies just as HMOs and insurers do. States then can pass savings to seniors covered by Medicare and to working families who lack drug coverage and make less than 300 percent of the poverty level.
Everyone loses when health care workers are forced to work overtime and are exposed to life-threatening diseases because of unsafe equipment. After years of struggle, health care workers won federal legislation to require safer needlesticks in 2000 and 24 states now have safer needlestick laws on the books. States can pass their own legislation mandating safety devices for needles.
Friday, July 27, 2007
Facts on the Cost of Health Care
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Introduction
By several measures, health care spending continues to rise at the fastest rate in our history.
In 2005 (the latest year data are available), total national health expenditures rose 6.9 percent -- two times the rate of inflation (1). Total spending was $2 TRILLION in 2005, or $6,700 per person (1). Total health care spending represented 16 percent of the gross domestic product (GDP).
U.S. health care spending is expected to increase at similar levels for the next decade reaching $4 TRILLION in 2015, or 20 percent of GDP (2).
In 2006, employer health insurance premiums increased by 7.7 percent – two times the rate of inflation. The annual premium for an employer health plan covering a family of four averaged nearly $11,500. The annual premium for single coverage averaged over $4,200 (3).
Experts agree that our health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.
National Health Care Spending
In 2005, health care spending in the United States reached $2 trillion, and was projected to reach $2.9 trillion in 2009 (2). Health care spending is projected to reach $4 trillion by 2015 (2).
Health care spending is 4.3 times the amount spent on national defense (4).
In 2005, the United States spent 16 percent of its gross domestic product (GDP) on health care. It is projected that the percentage will reach 20 percent in the next decade (2).
Although nearly 47 million Americans are uninsured, the United States spends more on health care than other industrialized nations, and those countries provide health insurance to all their citizens (4).
Health care spending accounted for 10.9 percent of the GDP in Switzerland, 10.7 percent in Germany, 9.7 percent in Canada and 9.5 percent in France, according to the Organization for Economic Cooperation and Development (5).
Employer and Employee Health Insurance Costs
Premiums for employer-based health insurance rose by 7.7 percent in 2006. Small employers saw their premiums, on average, increase 8.8 percent. Firms with less than 24 workers, experienced an increase of 10.5 percent (3)
The annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $11,500 in 2006. Workers contributed nearly $3,000, or 10 percent more than they did in 2005 (3).The annual premiums for family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker ($10,712).
Workers are now paying $1,094 more in premiums annually for family coverage than they did in 2000 (3).
Since 2000, employment-based health insurance premiums have increased 87 percent, compared to cumulative inflation of 18 percent and cumulative wage growth of 20 percent during the same period (3).
Health insurance expenses are the fastest growing cost component for employers. Unless something changes dramatically, health insurance costs will overtake profits by 2008 (6).
According to the Kaiser Family Foundation and the Health Research and Educational Trust, premiums for employer-sponsored health insurance in the United States have been rising four times faster on average than workers' earnings since 2000 (3).
The average employee contribution to company-provided health insurance has increased more than 143 percent since 2000. Average out-of-pocket costs for deductibles, co-payments for medications, and co-insurance for physician and hospital visits rose 115 percent during the same period (7).
The percentage of Americans under age 65 whose family-level, out-of-pocket spending for health care, including health insurance, that exceeds $2,000 a year, rose from 37.3 percent in 1996 to 43.1 percent in 2003 – a 16 percent increase (8).
The Impact of Rising Health Care Costs
National surveys show that the primary reason people are uninsured is the high cost of health insurance coverage (9).
Economists have found that rising health care costs correlate to drops in health insurance coverage (10).
Nearly one-quarter (23 percent) of the uninsured reported changing their way of life significantly in order to pay medical bills (10).
Almost 50 percent of the American public say they are very worried about having to pay more for their health care or health insurance, while 42 percent report they are very worried about not being able to afford health care services (11).
In a poll conducted by the Harvard School of Public Health, 43 percent of respondents named high costs as one of the two most important health care issues for government to address (12).
In a USA Today/ABC News survey, 80 percent of Americans said that they were dissatisfied (60 percent were very dissatisfied) with high national health care spending (13).
One in four Americans say their family has had a problem paying for medical care during the past year, up 7 percentage points over the past nine years. Nearly 30 percent say someone in their family has delayed medical care in the past year, a new high based on recent polling. Most say the medical condition was at least somewhat serious (13).
A recent study by Harvard University researchers found that the average out-of-pocket medical debt for those who filed for bankruptcy was $12,000. The study noted that 68 percent of those who filed for bankruptcy had health insurance. In addition, the study found that 50 percent of all bankruptcy filings were partly the result of medical expenses (14).
Every 30 seconds in the United States someone files for bankruptcy in the aftermath of a serious health problem.
One half of workers in the lowest-compensation jobs and one-half of workers in mid-range-compensation jobs either had problems with medical bills in a 12-month period or were paying off accrued debt. One-quarter of workers in higher-compensated positions also reported problems with medical bills or were paying off accrued debt (15).
If one member of a family is uninsured and has an accident, a hospital stay, or a costly medical treatment, the resulting medical bills can affect the economic stability of the whole family (16).
A new survey shows that more than 25 percent said that housing problems resulted from medical debt, including the inability to make rent or mortgage payments and the development of bad credit ratings (17).
A survey of Iowa consumers found that in order to cope with rising health insurance costs, 86 percent said they had cut back on how much they could save, and 44 percent said that they have cut back on food and heating expenses (18).
Retiring elderly couples will need $200,000 in savings just to pay for the most basic medical coverage (19).
Many experts believe that this figure is conservative and that $300,000 may be a more realistic number.
Time for Action on Reining in Health Care Costs
Policymakers and government officials agree that health care costs must be controlled. But they disagree on the best ways to address rapidly escalating health spending and health insurance premiums. Some favor price controls and imposing strict budgets on health care spending. Others believe free market competition is the best way to solve the problems. Public health advocates believe that if all Americans adopted healthy lifestyles, health care costs would decrease as people required less medical care.
There appears to be no agreement on a single solution to health care's high price tag. Many approaches may be used to control costs. What we do know is if the rate of escalation in health care spending and health insurance premiums continues at current trends, the cost of inaction will severely affect employer's bottom lines and consumer's pocketbooks.
Introduction
By several measures, health care spending continues to rise at the fastest rate in our history.
In 2005 (the latest year data are available), total national health expenditures rose 6.9 percent -- two times the rate of inflation (1). Total spending was $2 TRILLION in 2005, or $6,700 per person (1). Total health care spending represented 16 percent of the gross domestic product (GDP).
U.S. health care spending is expected to increase at similar levels for the next decade reaching $4 TRILLION in 2015, or 20 percent of GDP (2).
In 2006, employer health insurance premiums increased by 7.7 percent – two times the rate of inflation. The annual premium for an employer health plan covering a family of four averaged nearly $11,500. The annual premium for single coverage averaged over $4,200 (3).
Experts agree that our health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.
National Health Care Spending
In 2005, health care spending in the United States reached $2 trillion, and was projected to reach $2.9 trillion in 2009 (2). Health care spending is projected to reach $4 trillion by 2015 (2).
Health care spending is 4.3 times the amount spent on national defense (4).
In 2005, the United States spent 16 percent of its gross domestic product (GDP) on health care. It is projected that the percentage will reach 20 percent in the next decade (2).
Although nearly 47 million Americans are uninsured, the United States spends more on health care than other industrialized nations, and those countries provide health insurance to all their citizens (4).
Health care spending accounted for 10.9 percent of the GDP in Switzerland, 10.7 percent in Germany, 9.7 percent in Canada and 9.5 percent in France, according to the Organization for Economic Cooperation and Development (5).
Employer and Employee Health Insurance Costs
Premiums for employer-based health insurance rose by 7.7 percent in 2006. Small employers saw their premiums, on average, increase 8.8 percent. Firms with less than 24 workers, experienced an increase of 10.5 percent (3)
The annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $11,500 in 2006. Workers contributed nearly $3,000, or 10 percent more than they did in 2005 (3).The annual premiums for family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker ($10,712).
Workers are now paying $1,094 more in premiums annually for family coverage than they did in 2000 (3).
Since 2000, employment-based health insurance premiums have increased 87 percent, compared to cumulative inflation of 18 percent and cumulative wage growth of 20 percent during the same period (3).
Health insurance expenses are the fastest growing cost component for employers. Unless something changes dramatically, health insurance costs will overtake profits by 2008 (6).
According to the Kaiser Family Foundation and the Health Research and Educational Trust, premiums for employer-sponsored health insurance in the United States have been rising four times faster on average than workers' earnings since 2000 (3).
The average employee contribution to company-provided health insurance has increased more than 143 percent since 2000. Average out-of-pocket costs for deductibles, co-payments for medications, and co-insurance for physician and hospital visits rose 115 percent during the same period (7).
The percentage of Americans under age 65 whose family-level, out-of-pocket spending for health care, including health insurance, that exceeds $2,000 a year, rose from 37.3 percent in 1996 to 43.1 percent in 2003 – a 16 percent increase (8).
The Impact of Rising Health Care Costs
National surveys show that the primary reason people are uninsured is the high cost of health insurance coverage (9).
Economists have found that rising health care costs correlate to drops in health insurance coverage (10).
Nearly one-quarter (23 percent) of the uninsured reported changing their way of life significantly in order to pay medical bills (10).
Almost 50 percent of the American public say they are very worried about having to pay more for their health care or health insurance, while 42 percent report they are very worried about not being able to afford health care services (11).
In a poll conducted by the Harvard School of Public Health, 43 percent of respondents named high costs as one of the two most important health care issues for government to address (12).
In a USA Today/ABC News survey, 80 percent of Americans said that they were dissatisfied (60 percent were very dissatisfied) with high national health care spending (13).
One in four Americans say their family has had a problem paying for medical care during the past year, up 7 percentage points over the past nine years. Nearly 30 percent say someone in their family has delayed medical care in the past year, a new high based on recent polling. Most say the medical condition was at least somewhat serious (13).
A recent study by Harvard University researchers found that the average out-of-pocket medical debt for those who filed for bankruptcy was $12,000. The study noted that 68 percent of those who filed for bankruptcy had health insurance. In addition, the study found that 50 percent of all bankruptcy filings were partly the result of medical expenses (14).
Every 30 seconds in the United States someone files for bankruptcy in the aftermath of a serious health problem.
One half of workers in the lowest-compensation jobs and one-half of workers in mid-range-compensation jobs either had problems with medical bills in a 12-month period or were paying off accrued debt. One-quarter of workers in higher-compensated positions also reported problems with medical bills or were paying off accrued debt (15).
If one member of a family is uninsured and has an accident, a hospital stay, or a costly medical treatment, the resulting medical bills can affect the economic stability of the whole family (16).
A new survey shows that more than 25 percent said that housing problems resulted from medical debt, including the inability to make rent or mortgage payments and the development of bad credit ratings (17).
A survey of Iowa consumers found that in order to cope with rising health insurance costs, 86 percent said they had cut back on how much they could save, and 44 percent said that they have cut back on food and heating expenses (18).
Retiring elderly couples will need $200,000 in savings just to pay for the most basic medical coverage (19).
Many experts believe that this figure is conservative and that $300,000 may be a more realistic number.
Time for Action on Reining in Health Care Costs
Policymakers and government officials agree that health care costs must be controlled. But they disagree on the best ways to address rapidly escalating health spending and health insurance premiums. Some favor price controls and imposing strict budgets on health care spending. Others believe free market competition is the best way to solve the problems. Public health advocates believe that if all Americans adopted healthy lifestyles, health care costs would decrease as people required less medical care.
There appears to be no agreement on a single solution to health care's high price tag. Many approaches may be used to control costs. What we do know is if the rate of escalation in health care spending and health insurance premiums continues at current trends, the cost of inaction will severely affect employer's bottom lines and consumer's pocketbooks.
Wednesday, July 11, 2007
Health Care in America, Canada's Way
By Barry Brown, Chronicle Foreign Service
Click for Link
Discovering he had colon cancer came as a shock to John Kioussis, but after 10 days in the hospital, attended by a battery of medical specialists, technicians, nurses and other staff, his bill came to less than $85 in American dollars -- and that was only for his phone and cable TV.
Under Canada's government-funded health insurance system, Kioussis' care, from the first visit to a family doctor, through visits to two specialists of his choice and his hospital stay, was free, paid for by Ontario's publicly funded universal health coverage.
"When you're sick like that and off work, the last thing you want to worry about is how to pay the bill," said Kioussis, 55. "I had excellent care and one of the top specialists in the country, the same doctor who would treat the prime minister."
That's the side of Canadian health care familiar to many Americans -- a system that provides free cradle-to-grave treatment to all, regardless of income or employment status.
The fact is, though, that Canada's system is riddled with problems, many stemming from inadequate funding. As a result, delays of several months are common before seeing a specialist or getting nonemergency surgery.
For his part, Kioussis said the month he waited between seeing his family doctor and his surgery did not seem unreasonable. He admitted, though, that because of a personal connection between his brother and the surgeon, the doctor operated on him just before he left for vacation.
Although delays and other problems have caused support to dip slightly, Canadians still overwhelmingly back their universal health program. They think of their health care system as a mark of their national identity, something that separates them from Americans.
Meanwhile, a recent ABC News poll showed that while Americans value the quality of U.S. health care, 62 percent think the nation should shift to a universal health insurance program like Canada's.
As a result of the sharply differing approaches Canada and the United States have taken toward financing health care, their medical systems have developed in contrasting ways.
The United States has more hospital beds per person than Canada because most American hospitals are private, while almost all Canadian hospitals are publicly funded. As a result, American hospitals compete for patients, while Canadian hospitals "don't fund excess capacity," said Sharon Sholzberg-Gray, chief executive of the Canadian Healthcare Association.
By many measures, Canadians are healthier than Americans, with a longer lifespan and lower infant mortality, even though they spend much less on medical care. Canadians devote about 10 percent of their gross domestic product, the total of a nation's goods and services, to provide full health coverage for all citizens. American health costs account for about 14 percent of GDP, yet 45 million Americans have no health insurance and many more have limited coverage.
One of the main culprits pushing up the cost of care in the United States is the expense of administering a plethora of complicated health plans. It has been estimated that any large health insurer in a midsize U.S. state spends more on administration than is spent on health administration in all Canada.
Dr. Catherine Kurosu is a gynecologist at two San Diego hospitals. A Canadian, she said the biggest differences between the two systems are that poorer Americans won't seek medical care until their problems have become serious. In addition, she said, American insurers often play games to avoid paying bills.
In San Diego, a lot of pregnant women -- especially illegal immigrants -- show up with problems that could have been avoided with prenatal care, she said. The idea that they can't get this kind of care "still seems foreign to me," she said.
"My patients are always interested in finding out about the health care system when they find out I'm Canadian," she continued.
When it comes to billing, the Canadian system is a simple matter of sending an invoice to the Ministry of Health, which pays on a fee-for-service basis, she explained. In the United States, there are so many insurance companies, each with its own rules covering not only the patient but also the doctor -- as Kurosu learned when she had to wait months for an insurance company to approve her.
U.S. health insurers nickel and dime doctors by always sending bills back and questioning everything, she said. "It's like a game to see how long they can forestall payment."
Eleven years ago, Colleen Burns started a medical imaging business in Buffalo, N.Y., right across the border from Ontario. She expected 20 percent of her business would come from Canadians willing to pay $300 to $600 in U.S. for quicker access to high-tech diagnostics. Instead, the proportion is only about 8 to 10 percent, she said.
Canadians need to feel a sense of urgency and have the money before coming to the United States, "because they can get an MRI for free in Canada," she said.
The health system is now itself in need of emergency care in order to continue offering the benefits Canadians have come to think of as their birthright, according to many experts.
Dr. Albert Schumacher, president of the Canadian Medical Association, warns that shortfalls of cash and medical staff have left the system unsustainable without major reform.
Twenty years ago, Canada's federal government unified the various health insurance programs run by the provinces.
Ottawa offered to pay 50 percent of the programs' operating budgets, provided the provincial plans accepted five basic principles, including nationwide acceptance of each provincial plan, comprehensive coverage and no out-of-pocket costs (co-payments or deductibles) for insured services.
"But since then, the federal share has dropped to as low as 14 percent," said Schumacher, a family physician from the border city of Windsor, Ontario.
In the 1990s, Canadian governments at all levels began attacking their budget deficits with single-minded intensity. With health care accounting for about 40 percent of public sector spending, hospitals were closed, physician fees were frozen or cut, nurses were laid off, and spaces for medical students and medical technicians at government-funded universities and colleges were cut back.
Along with a money crunch, Canada "has a terrible shortage of physicians, " particularly specialists and surgeons, a high proportion of whom are over 55 and ready to retire, Schumacher said.
Fixing the health care system has become a high priority for Canada's political leaders.
Last month, Prime Minister Paul Martin made good on his main election promise to inject more cash into provincial health programs and move to shorten waiting lists.
At a national health care summit, Martin told provincial leaders Ottawa would ante up the equivalent of an additional $34 billion in U.S. funds over 10 years to provincial and territorial health programs, as well as an additional $3 billion to ease wait times for hip replacement surgeries, cardiac and cancer treatments. He also agreed to a plan for monitoring waiting lists to determine the best method of reducing them.
As in the United States, the main problems bedeviling Canada are the soaring cost of prescription drugs and an aging population. Canada's provinces had called on Ottawa to use its hefty budgetary surplus to launch a national drug plan and leave to them the remaining health care costs, including home care and services like psychiatry and chiropractics.
But during the summit, provincial leaders abandoned that effort in exchange for more overall funding from Ottawa.
Sholzberg-Gray of the Canadian Healthcare Association said another challenge plaguing the Canadian system is the drain of doctors and nurses lured by higher pay and lower taxes in the United States.
"There is also a circular effect, because some doctors come back so they don't have to collect bills," she added.
On the issue of waiting lists for nonemergency surgery, Sholzberg-Gray believes the federal government should establish time limits for treatment.
One feature of Canada's health care system is that if someone wants to bypass the public program and, for example, pay a doctor to perform hip replacement surgery after hours, he cannot. Because of fears that slipping the doctor a little something extra could lead to the breakdown of the equal- access-for-all principle, paying for insured services is illegal.
Those who believe that more private care clinics would solve the problem of funding and shortages have taken their case to Canada's Supreme Court in an effort to open the system.
--------------------------------------------------------------------------------
ODD MAN OUT
The United States is the only developed nation without universal health care. Although health insurance systems worldwide are straining as populations age, safety nets have largely remained in place. Here are brief descriptions of insurance systems of several nations..
France
Health care as percentage of GDP: 9.6
Health expenditure per person: $2,567
Universal care funded through mandatory health insurance provided by Social Security, with private supplemental coverage filling gaps..
Germany
Health care as percentage of GDP: 10.8
Health expenditure per person: $2,820
All individuals are enrolled in government-approved health insurance plans partly financed by employer and employee contributions, although high- income workers may buy private insurance instead..
Japan
Health care as percentage of GDP: 8
Health expenditure per person: $2,131
A dual system in which workers enroll in insurance programs through their jobs, while all others join Japan's national health insurance plan..
United Kingdom
Health care as percentage of GDP: 7.6
Health expenditure per person: $1,989
A publicly funded National Health Service provides free care, with the option of private insurance for those wanting treatment outside the state system..
United States
Health care as percentage of GDP: 13.9
Health expenditure per person: $4,887
Federal and state governments pay most of the cost of care for seniors and the poor, with employer or individually financed insurance available for others. About 45 million people lack coverage.
*2001 figures
Source: World Health Organization, Chronicle research
Click for Link
Discovering he had colon cancer came as a shock to John Kioussis, but after 10 days in the hospital, attended by a battery of medical specialists, technicians, nurses and other staff, his bill came to less than $85 in American dollars -- and that was only for his phone and cable TV.
Under Canada's government-funded health insurance system, Kioussis' care, from the first visit to a family doctor, through visits to two specialists of his choice and his hospital stay, was free, paid for by Ontario's publicly funded universal health coverage.
"When you're sick like that and off work, the last thing you want to worry about is how to pay the bill," said Kioussis, 55. "I had excellent care and one of the top specialists in the country, the same doctor who would treat the prime minister."
That's the side of Canadian health care familiar to many Americans -- a system that provides free cradle-to-grave treatment to all, regardless of income or employment status.
The fact is, though, that Canada's system is riddled with problems, many stemming from inadequate funding. As a result, delays of several months are common before seeing a specialist or getting nonemergency surgery.
For his part, Kioussis said the month he waited between seeing his family doctor and his surgery did not seem unreasonable. He admitted, though, that because of a personal connection between his brother and the surgeon, the doctor operated on him just before he left for vacation.
Although delays and other problems have caused support to dip slightly, Canadians still overwhelmingly back their universal health program. They think of their health care system as a mark of their national identity, something that separates them from Americans.
Meanwhile, a recent ABC News poll showed that while Americans value the quality of U.S. health care, 62 percent think the nation should shift to a universal health insurance program like Canada's.
As a result of the sharply differing approaches Canada and the United States have taken toward financing health care, their medical systems have developed in contrasting ways.
The United States has more hospital beds per person than Canada because most American hospitals are private, while almost all Canadian hospitals are publicly funded. As a result, American hospitals compete for patients, while Canadian hospitals "don't fund excess capacity," said Sharon Sholzberg-Gray, chief executive of the Canadian Healthcare Association.
By many measures, Canadians are healthier than Americans, with a longer lifespan and lower infant mortality, even though they spend much less on medical care. Canadians devote about 10 percent of their gross domestic product, the total of a nation's goods and services, to provide full health coverage for all citizens. American health costs account for about 14 percent of GDP, yet 45 million Americans have no health insurance and many more have limited coverage.
One of the main culprits pushing up the cost of care in the United States is the expense of administering a plethora of complicated health plans. It has been estimated that any large health insurer in a midsize U.S. state spends more on administration than is spent on health administration in all Canada.
Dr. Catherine Kurosu is a gynecologist at two San Diego hospitals. A Canadian, she said the biggest differences between the two systems are that poorer Americans won't seek medical care until their problems have become serious. In addition, she said, American insurers often play games to avoid paying bills.
In San Diego, a lot of pregnant women -- especially illegal immigrants -- show up with problems that could have been avoided with prenatal care, she said. The idea that they can't get this kind of care "still seems foreign to me," she said.
"My patients are always interested in finding out about the health care system when they find out I'm Canadian," she continued.
When it comes to billing, the Canadian system is a simple matter of sending an invoice to the Ministry of Health, which pays on a fee-for-service basis, she explained. In the United States, there are so many insurance companies, each with its own rules covering not only the patient but also the doctor -- as Kurosu learned when she had to wait months for an insurance company to approve her.
U.S. health insurers nickel and dime doctors by always sending bills back and questioning everything, she said. "It's like a game to see how long they can forestall payment."
Eleven years ago, Colleen Burns started a medical imaging business in Buffalo, N.Y., right across the border from Ontario. She expected 20 percent of her business would come from Canadians willing to pay $300 to $600 in U.S. for quicker access to high-tech diagnostics. Instead, the proportion is only about 8 to 10 percent, she said.
Canadians need to feel a sense of urgency and have the money before coming to the United States, "because they can get an MRI for free in Canada," she said.
The health system is now itself in need of emergency care in order to continue offering the benefits Canadians have come to think of as their birthright, according to many experts.
Dr. Albert Schumacher, president of the Canadian Medical Association, warns that shortfalls of cash and medical staff have left the system unsustainable without major reform.
Twenty years ago, Canada's federal government unified the various health insurance programs run by the provinces.
Ottawa offered to pay 50 percent of the programs' operating budgets, provided the provincial plans accepted five basic principles, including nationwide acceptance of each provincial plan, comprehensive coverage and no out-of-pocket costs (co-payments or deductibles) for insured services.
"But since then, the federal share has dropped to as low as 14 percent," said Schumacher, a family physician from the border city of Windsor, Ontario.
In the 1990s, Canadian governments at all levels began attacking their budget deficits with single-minded intensity. With health care accounting for about 40 percent of public sector spending, hospitals were closed, physician fees were frozen or cut, nurses were laid off, and spaces for medical students and medical technicians at government-funded universities and colleges were cut back.
Along with a money crunch, Canada "has a terrible shortage of physicians, " particularly specialists and surgeons, a high proportion of whom are over 55 and ready to retire, Schumacher said.
Fixing the health care system has become a high priority for Canada's political leaders.
Last month, Prime Minister Paul Martin made good on his main election promise to inject more cash into provincial health programs and move to shorten waiting lists.
At a national health care summit, Martin told provincial leaders Ottawa would ante up the equivalent of an additional $34 billion in U.S. funds over 10 years to provincial and territorial health programs, as well as an additional $3 billion to ease wait times for hip replacement surgeries, cardiac and cancer treatments. He also agreed to a plan for monitoring waiting lists to determine the best method of reducing them.
As in the United States, the main problems bedeviling Canada are the soaring cost of prescription drugs and an aging population. Canada's provinces had called on Ottawa to use its hefty budgetary surplus to launch a national drug plan and leave to them the remaining health care costs, including home care and services like psychiatry and chiropractics.
But during the summit, provincial leaders abandoned that effort in exchange for more overall funding from Ottawa.
Sholzberg-Gray of the Canadian Healthcare Association said another challenge plaguing the Canadian system is the drain of doctors and nurses lured by higher pay and lower taxes in the United States.
"There is also a circular effect, because some doctors come back so they don't have to collect bills," she added.
On the issue of waiting lists for nonemergency surgery, Sholzberg-Gray believes the federal government should establish time limits for treatment.
One feature of Canada's health care system is that if someone wants to bypass the public program and, for example, pay a doctor to perform hip replacement surgery after hours, he cannot. Because of fears that slipping the doctor a little something extra could lead to the breakdown of the equal- access-for-all principle, paying for insured services is illegal.
Those who believe that more private care clinics would solve the problem of funding and shortages have taken their case to Canada's Supreme Court in an effort to open the system.
--------------------------------------------------------------------------------
ODD MAN OUT
The United States is the only developed nation without universal health care. Although health insurance systems worldwide are straining as populations age, safety nets have largely remained in place. Here are brief descriptions of insurance systems of several nations..
France
Health care as percentage of GDP: 9.6
Health expenditure per person: $2,567
Universal care funded through mandatory health insurance provided by Social Security, with private supplemental coverage filling gaps..
Germany
Health care as percentage of GDP: 10.8
Health expenditure per person: $2,820
All individuals are enrolled in government-approved health insurance plans partly financed by employer and employee contributions, although high- income workers may buy private insurance instead..
Japan
Health care as percentage of GDP: 8
Health expenditure per person: $2,131
A dual system in which workers enroll in insurance programs through their jobs, while all others join Japan's national health insurance plan..
United Kingdom
Health care as percentage of GDP: 7.6
Health expenditure per person: $1,989
A publicly funded National Health Service provides free care, with the option of private insurance for those wanting treatment outside the state system..
United States
Health care as percentage of GDP: 13.9
Health expenditure per person: $4,887
Federal and state governments pay most of the cost of care for seniors and the poor, with employer or individually financed insurance available for others. About 45 million people lack coverage.
*2001 figures
Source: World Health Organization, Chronicle research
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