Correspondence

Insurance Status and Ambulatory Care for Children

N Engl J Med 1994; 331:878-879September 29, 1994

Article

To the Editor:

Stoddard et al. (May 19 issue)1 suggested that children who lack health insurance are less likely to receive medically indicated care than children with health insurance, and they conclude that uninsured children are therefore at risk for substantial avoidable morbidity. Unfortunately, the key question asked in the 1987 National Medical Expenditures Survey was “Did he or she see a doctor about it?” (i.e., the health problem). The wording of the question may have precluded a positive response if a nurse practitioner, physician's assistant, or nurse was consulted rather than a physician. In some settings, a parent may not assume that “see a doctor” means receive medical attention, particularly if medical care is routinely delivered by nonphysicians. Indeed, for some populations, physician visits may be less common by design and may be reserved for more serious illness. The authors acknowledge that they do not have information about visits to other health care practitioners or about the severity and outcomes of the health problems. Their conclusions, however, are stated in terms of deficiencies in medical care and ambulatory care, not just in terms of care provided by physicians.

Stephen Blattner, M.D.
University of Vermont College of Medicine, Burlington, VT 05405

1 References

1. 1

   Stoddard JJ, St Peter RF, Newacheck PW. Health insurance status and ambulatory care for children. N Engl J Med 1994;330:1421-1425
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: After controlling for other influences, we found that children without health insurance were significantly more likely than those with insurance to forgo care provided by physicians, for all the conditions we examined. Blattner points out that our data do not include information about visits to health care providers other than physicians. This limitation was acknowledged in our report. We view care provided by a physician as the traditional standard of medical care, but we acknowledge that other health care practitioners in some communities provide ambulatory care to ill children. Notwithstanding the issues of the quality and outcomes of care provided by various types of providers, we believe that an examination of differential access to care provided by physicians is worthwhile. It was beyond the scope of our study to determine whether care provided by nonphysicians is as available to children without health insurance as it is to those with insurance. We doubt that accounting for visits to nonphysician providers would have altered our findings, given the modest numbers of such practitioners.

Jeffrey J. Stoddard, M.D.
Robert F. St. Peter, M.D.
Paul Newacheck, Dr.P.H.
University of Wisconsin-Madison Medical School, Madison, WI 53792-4108