Distance to Hospital and Children's Use of Preventive Care: Is Being Closer Better, and for Whom?

I. INTRODUCTION This article examines the effect of distance to hospital on the utilization of preventive care among children. Many poor children, lacking alternative providers, rely on hospitals and clinics for preventive care. Moreover, in many poor neighborhoods, the majority of private doctors' offices are located in buildings adjacent to a hospital. Thus, hospitals indirectly serve to attract physician services that would otherwise be lacking in the neighborhood. This pattern of service provision raises several concerns. First, it is inefficient for children to be receiving preventive care directly from hospitals because preventive care can be delivered more cheaply in doctors' offices, and doctors' offices also provide greater continuity of care (an index of quality). Second, even when children are receiving care in a doctor's office adjacent to a hospital, continuation of that service may be jeopardized if the hospital were to close. In this study, we use distance to hospital as a proxy for access to medical services to examine the effect of distance to hospital on the use of preventive care services. If the use of these services falls with distance, other things being equal, then we interpret this as evidence of lack of access to alternative providers. Most previous studies of the effects of distance have concentrated on specific geographical areas and/or hospitalizations for specific procedures. We are therefore unaware of any previous studies that have focused on the effects of distance on the utilization of preventive care among children. (1) We use a national sample of children created by matching records from the National Longitudinal Survey of Youth's Child-Mother (NLSCM) file with the American Hospital Association's 1990 Hospital Survey. We allow the effects of distance to vary with race, ethnicity, insurance status, and degree of urbanicity. We control for other factors that might affect utilization of preventive care by including a rich set of control variables and by estimating models that include either city dummy variables or mother fixed effects. In particular, city dummies control for unobserved differences across cities in public transportation services and population density. Mother fixed effects control for unobserved differences in preferences for preventive health care. Robust estimates across models allow us to rule out these alternative explanations for why distance to hospital might affect different groups differentially. These innovations address the important question of whether children who rely on hospitals for preventive ca re do so because they lack access to other providers. We find that distance to hospital has significant effects on access to preventive care only among central-city black children. For these children, each additional mile from the hospital is associated with a 3% decline in the probability of having had a checkup (from a mean baseline of 74%). This effect is comparable to the 3% increase in the probability of having a checkup, which is associated with having private health insurance coverage rather than being uninsured. A striking result is that among these children, the size of the distance effect is similar for both the privately insured and those with Medicaid, suggesting that even black urban children with private health insurance have difficulty obtaining access to preventive care outside the area around hospitals. Thus, for this group questions of access to providers may be as important as insurance coverage in predicting use of preventive care. II. CHILDREN WHO RELY ON HOSPITALS FOR PRIMARY CARE Prior research suggests that children who are members of minorities, uninsured, covered by Medicaid, or residing in rural areas are all more likely to rely on hospitals for preventive care. This section discusses each of these groups in turn. Bloom (1990) demonstrates that, nationally, black children are twice as likely as white children to receive care in an institutional setting, such as a clinic or emergency room, and that they are more likely to be attended by residents than by staff physicians. …