Correspondence
Health Insurance and Access to Primary Care for Children
N Engl J Med 1998; 339:50-52July 2, 1998
- Article
To the Editor:
Newacheck et al. (Feb. 19 issue)1 conclude that recent legislative efforts to expand health insurance coverage for children may substantially improve access to and use of primary care for children. A previous study analyzing the characteristics of mothers and their effects on children's visits to physicians also found that insurance was an important determinant of children's visits to the doctor.2 However, “convenience” factors also determined the amount of physicians' services children receive. For example, if the child's usual source of care offered weekend or evening office hours, children's sick-child visits increased by 16 percent per year. The children of mothers working 40 hours per week had 29 percent fewer visits than the children of nonworking mothers. In addition, the mothers who could walk, drive, or take a taxi to the doctor's office reported more than 75 percent more visits for their children than the mothers who used public transportation.
These results imply that expanding insurance coverage alone will not guarantee access to sufficient primary care for U.S. children. Inconvenient office hours and locations serve as barriers for many mothers seeking care for their children. In addition, working mothers need more flexibility from their employers if they are to attend to sick-child visits. Thus, increasing access to primary care for children will require a concerted effort by physicians, public health officials, and employers — not just the contribution of extra dollars through additional health insurance coverage.
2 ReferencesVivian Ho, Ph.D.
Washington University, St. Louis, MO 63130-48991
Newacheck PW ,Stoddard JJ ,Hughes DC ,Pearl M . Health insurance and access to primary care for children. N Engl J Med 1998;338:513-519
Full Text | Web of Science | Medline2
Vistnes J ,Hamilton V . The time and monetary costs of outpatient care for children. Am Econ Rev 1995;85:117-120
Web of Science | Medline
To the Editor:
Removing the financial barriers to pediatric care for all children is the top priority of the American Academy of Pediatrics. Thus, we were pleased to see the article by Newacheck et al. and the accompanying editorial by Budetti.1 Newacheck et al.'s documentation of the independent influence that the presence of health insurance has on the use of pediatric primary care should buttress outreach efforts by the states that are designed to maximize enrollment in Title XXI. We also feel compelled to add our voices to that of Dr. Budetti. We share his concern that this recent legislative victory for children could contribute to a false notion that the problem of uninsured children will become a historical artifact of 20th-century America.
With full state participation in Title XXI, three fourths of uninsured children in the United States under the age of 19 years would be eligible for either Medicaid or Title XXI. However, this program's longevity is not ensured. Unspent state allocations, fears that the public program would “crowd out” private coverage, or a dozen other risks to this non-entitlement program could erode its political support at the federal level. At the state level, local economies could sputter, pressuring some states to back off tentative expansion plans or simply not to muster the energy needed to enroll potentially eligible children. An analysis by the American Academy of Pediatrics concurs with the projection by the Congressional Budget Office that, in the absence of special outreach efforts by the states, little more than half the children eligible for Title XXI coverage will participate in the program.
1 ReferencesJoseph R. Zanga, M.D.
American Academy of Pediatrics, Elk Grove Village, IL 60007-10981
Budetti PP . Health insurance for children -- a model for incremental health reform? N Engl J Med 1998;338:541-542
Full Text | Web of Science | Medline
To the Editor:
Like the rest of American society, medicine is being redefined with business as the paradigm. Thankfully, the Journal has taken the lead in addressing the moral complexity of this simplistic approach. The editorial by Dr. Budetti points out the degree to which economists and other spokespersons for America's business interests shape the moral and social framework of medicine.
Budetti's editorial confronts us with the fact that business, rather than civic or humanitarian interests, defines medicine. He characterizes the probusiness nature of the “nation's policymaking elite.” This was done simply and effectively by elucidating the political realities that ensure the lack of primary care for our nation's children. This elite includes private health care insurers who are, along with the banking industry, by far the largest campaign donors in our nation.1 It also includes a probusiness Congress, which prefers “private-sector options over government-run programs.”2 Not mentioned, but also influential, are the policy analysts of such like-minded groups as the Heritage Foundation, the American Enterprise Institute, and the Cato Institute, among others. In short, our nation's policymaking elite are America's business interests and their representatives.
Budetti should be commended for illustrating the fact that America's business interests define the moral and social framework of medicine. They are this nation's policymaking elite, and they are represented by a working majority of Congress. Unfortunately, children cannot pay for their own health care, donate money to election campaigns, or even vote. Should we leave our children's health care up to employers and other business interests? Given that “employment-related coverage of dependents has been declining for many years, for reasons that are not fully understood,”2 the answer is an unequivocal no.
2 ReferencesKevin Hoover
University of California at Irvine, Irvine, CA 92717-22751
Makinson L. The big picture: money follows power shift on Capitol Hill. Washington, D.C.: Center for Responsive Politics, 1997.
2
Budetti PP . Health insurance for children -- a model for incremental health reform. N Engl J Med 1998;338:541-542
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Drs. Ho and Zanga both raise important points concerning the relation between insurance and access to care. We concur with Dr. Ho's view that nonfinancial factors can seriously affect children's receipt of care. Although our study focused on the role of the financial determinants of access, there is a growing body of evidence indicating the importance of nonfinancial determinants (e.g., availability of after-hours care, cultural and language barriers, and transportation barriers, among others).1 Thus, insurance is necessary but not sufficient to ensure that children obtain needed care.
We also share Dr. Zanga's concern that the new Title XXI program could lead the United States into a false sense of complacency. In fact, even when the program is fully implemented, substantial numbers of needy children will continue to be uninsured. Given the documented importance of insurance in our study and many others, these children will continue to receive substandard care. Together, these conclusions point to the need for concerted public and private efforts to remove the remaining financial and nonfinancial barriers to health care for children.
1 ReferencesPaul W. Newacheck, Dr.P.H.
University of California, San Francisco, San Francisco, CA 94109Jeffrey J. Stoddard, M.D.
University of Wisconsin–Madison, Madison, WI 53792-4108Dana C. Hughes, Dr.P.H.
University of California, San Francisco, San Francisco, CA 941091
Halfon N ,Inkelas M ,Wood D . Nonfinancial barriers to care for children and youth. Annu Rev Public Health 1995;16:447-472
CrossRef | Web of Science | Medline
