In 1996, only 66 percent of U.S. children younger than 18—47 million— were covered by private health insurance. Most private insurance for children is acquired through a parent’s employer. However, in 1993, almost one-fourth of the workforce worked for an employer that did not cover dependents. In addition, even if employers offer coverage, the amount that employees have to pay toward it for their families may make health insurance unaffordable. Since the late 1980s, workers’ costs for family coverage have risen sharply. Increases in insurance costs may affect children disproportionately, since the 71 million children younger than 18 represent 27 percent of the U.S. population but 42 percent of the poor. Even if children have insurance, their coverage—and their relationship with their providers—may be disrupted if their parents lose their jobs or change jobs frequently. Public health insurance for children is generally provided through the Medicaid program. Currently about 15.5 million (22 percent) of children younger than 18 are covered through Medicaid. The majority of low-income children (65 percent) in Medicaid have a working parent and, of those that do, about half have a parent working full time. To remain in Medicaid, families generally have their eligibility redetermined at least every 6 months. If family income or other circumstances change, children may go in and out of the Medicaid program during a year, disrupting their coverage. This can delay needed care, which can have long-term health consequences. Children are uninsured when they have neither public nor private coverage. In 1996, 10.6 million children (14.8 percent) were uninsured, living generally in lower-income working families. Compared with privately insured children, a higher proportion of their parents worked for small employers—the group least likely to offer health insurance. In 1993, only a quarter of employees in firms with fewer than 10 employees and about half in firms with 10 to 24 employees reported that their employer offered a health insurance plan for workers and their dependents, compared with 89 percent in firms with 1,000 or more employees. Health insurance does not always cover the preventive care, such as immunizations, that children need to develop optimally. Nevertheless, most of the studies we analyzed used many different measures of access and found that insured children were more likely to have access to both preventive and acute or chronic health care. Children who were insured were more likely to be connected to the health care system through a physician. Having a primary care connection made it easier for children to get regular preventive care, acute care when ill, and more complex care as needed. Uninsured and lower-income children were more likely to be hospitalized for conditions that could have been treated through primary care. Most of the studies we reviewed showed that children who had health insurance had better access to preventive and primary health care than uninsured children. (See table 1.) They were more likely to have a primary care provider, which increased their access to both routine and more complex care. Children who had private health insurance were also more likely than children who had no insurance to get medical care from one source, and that source was more likely to be in a physician’s office. In addition, they were more likely to have seen a doctor recently and to have been up to date with their well-child care. A child’s having a usual source of care increases the likelihood he or she will receive preventive or acute health care. One research study based on nationally representative data found that 20 percent of all uninsured children lacked a usual source of care, compared with 7 percent of insured, white, nonpoor children. Using regression analysis to isolate the effect of insurance from race, income, and ethnicity, this study found that uninsured children were twice as likely to lack a usual source of care as insured children. Uninsured children were also more likely to lack after-hours care and to spend more time traveling and more time waiting to receive care. Similarly, another study found that 33 percent of uninsured children did not go to a physician’s office for their routine care, compared with 14 percent of insured children (insured privately or through Medicaid). Controlling for factors other than insurance, the study found that uninsured children were more than twice as likely as insured children to get care in places other than a physician’s office. Generally, lower-income children (whether uninsured or receiving public insurance) are less likely to go to a physician’s office for their care. The National Center for Health Statistics (NCHS) found that 94 percent of U.S. children—more than 65 million—had a usual source of care in 1993. Of these, 94 percent of privately insured children, 62 percent of publicly insured children, and 74 percent of uninsured children used a doctor’s office as their usual source of care. Conversely, 5 percent of privately insured children, 30 percent of publicly insured children, and 20 percent of uninsured children used a clinic as their regular source of care. Most experts believe that preschool children need regular visits to physicians to stay current in their immunizations and to be screened for health problems, but researchers found access problems for preschool children. About one-quarter of U.S. 3-year-olds born in 1988 had a gap in their health insurance coverage of at least 1 month, and almost 15 percent had a gap of 7 months or more or had never been covered. Preschool children who had gaps in coverage were more likely to have gone to multiple sites for care than children who had continuous insurance coverage, suggesting that the care they received was more likely to be sporadic and fragmented. Just over 40 percent of preschool children went to two or more sites of care (not counting emergency care). However, controlling for other factors affecting access, preschool children who had a gap in coverage of more than 6 months were 74 percent more likely to have gone to more than one site for care. Disruption of insurance coverage seems to be the salient factor because children who had no insurance were no more likely than insured children to have gone to multiple sites of care. Experts have stated that adolescents can benefit from the guidance of a trusted health provider to help them through a period when their bodies are changing and they may be tempted to take risks, such as having unprotected sex or using drugs, alcohol, or tobacco products. Yet uninsured adolescents also have access problems. Researchers found that adolescents who were not insured were less likely to have a usual source of care and regular provider. (See fig. 1.) Better access to primary care is important, because primary care is a gateway to better preventive care and needed specialized services. A number of studies found that uninsured children had fewer health care and dental visits and fewer preventive visits. Compared with the parents of low-income children who had public insurance like Medicaid, parents of uninsured children of all income levels were more likely to defer bringing them into care for financial reasons. Having a primary care provider has been shown to improve care by facilitating the timely receipt of complex care. One study showed that children in Medicaid or who had no insurance were much less likely to have contacted a primary care physician before they came to the hospital with appendicitis. Children whose families did not contact a primary care physician before hospital admission were operated on less quickly if they were admitted on weekends and were more likely to have a perforated appendix. Contact with a primary care provider, not insurance status, was the key to differing rates of this complication, but having private insurance did increase the likelihood that a child would have a relationship with a primary care physician. Six studies that controlled for other factors affecting access found that uninsured children were less likely to receive routine checkups, dental care, or any kind of doctor’s visit. Some of them compared routine visits made with the number of visits recommended by the American Academy of Pediatrics (AAP) (see table 2) and found that uninsured children were less likely to meet such standards. For example, one study found that 30 percent of uninsured children were not up to date with well-child care visits, as AAP recommends, compared with 22 percent of insured children. Compared with insured children, and controlling for other factors that affect access, uninsured children were 50-percent more likely not to have made any visits to a physician in the past year and almost twice as likely never to have had routine care. In a local California study, lack of insurance was the strongest predictor that children older than 5 had not seen a dentist in the past year, compared with privately insured children. Uninsured children were less likely to have received care when it was not an emergency. An analysis of the 1980 National Medical Care Utilization and Expenditure Survey, after adjusting for other factors affecting access, found that uninsured children had a 69-percent likelihood that they would use nonemergency ambulatory care during the year, compared with 81 percent for privately insured children. The uninsured children who had used health services had made fewer nonemergency ambulatory visits, compared with privately insured children. (See fig. 2.) Similarly, an analysis of a more recent survey also showed that being uninsured was a significant predictor of not using a physician’s services. Several studies found that uninsured children were not getting care for conditions that could be serious. Children who had no insurance had lower rates of treatment for injuries, including serious injuries such as broken bones or cuts requiring stitches, compared with children who had private insurance, and were less likely to get care when sick. Sometimes they received care later, after they had become sicker. Childhood injuries were fairly common, but insurance status affected a child’s chances of being medically treated for an injury. In 1988, children younger than 18 had total injury rates of 16.3 per 100. Serious injuries that resulted in restricted activity, bed days, surgery, hospitalization, or substantial pain represented about half of total injuries. A study that compared injury treatment for insured children (private insurance and Medicaid combined) and uninsured children found that the uninsured were less likely to be brought in for the treatment of injuries. The study’s researchers estimated that for children who had no coverage in 1988, the year of the study, between 20 and 30 percent of total injuries may not have been examined and treated by a health professional. At least 40 percent of serious injuries to uninsured children younger than 11 might not have been examined and treated. These researchers also found that Medicaid-insured children had treatment rates similar to privately insured children, suggesting that public insurance helped ensure that children would receive treatment for injuries. Their finding that families that had Medicaid coverage for their children would seek health care for them, while families of uninsured children would not, is consistent with the findings from the Rand Health Insurance Experiment that families of poor children in cost-sharing plans were less likely to seek care for diagnoses related to trauma or accidents than families of poor children with free care. Uninsured children were less likely to receive treatment for some of the common illnesses of childhood. Uninsured children were about twice as likely to have received no care from a physician for pharyngitis, acute earache, recurrent ear infections, and asthma. (See fig. 3.) These are common conditions—with an incidence rate of 8 to 10 per 100 children—for which medical care is considered necessary. They can also have serious consequences for some children if they are left untreated. For example, pharyngitis, if caused by untreated group A streptococci, can lead to rheumatic fever. Untreated middle-ear infections can lead to long-term hearing loss and sometimes to related speech and language difficulties. Severe asthma can cause respiratory failure and death. Looking at more rare conditions, one study examined severity of illness when privately insured and underinsured children were diagnosed with inflammatory bowel diseases. Inflammatory bowel diseases (Crohn’s disease and ulcerative colitis) can result in absence from school, progressive malnutrition, weight loss, anemia, depression, and fatigue. Early diagnosis can catch these diseases before they have progressed so that they can be treated with less-aggressive therapies. The study’s authors, comparing a limited number of cases of underinsured children who had these rare illnesses with insured children who had the same illnesses, found that children who were underinsured had 2-1/2 times the weight loss of insured children and had waited 8 months longer before diagnosis. The children’s laboratory results also indicated that they were sicker before diagnosis and were more likely to be anemic. The authors suggested that delay in diagnosis could have occurred for several reasons, such as seeing different physicians at the same clinic or emergency room or not being able to get timely appointments with subspecialists. A lack of appropriate ambulatory care can cause children to be inappropriately hospitalized when they could have been treated as outpatients. Several researchers have studied hospital admissions among adults and children for conditions that can be managed with good ambulatory care. In general, they found that U.S. communities with poor access to ambulatory care—that is, low-income communities with many residents uninsured or enrolled in Medicaid—had higher rates of this kind of hospitalization. In contrast, hospital admissions in Spain for conditions sensitive to ambulatory care did not vary for children living in lower- and higher-income neighborhoods. Lower-income U.S. neighborhoods had higher avoidable hospitalization rates compared with higher-income neighborhoods for both children and adults. Income differences in avoidable hospitalizations dropped for persons 65 years old or older, probably because of their Medicare coverage. Compared with privately insured patients in the same age category, uninsured patients had higher rates of avoidable hospitalization. Medicaid patients had even higher rates. Most of the potentially avoidable hospitalizations for children younger than 15 were for pneumonia or asthma. Communities where people perceived that they had poorer access to medical care had higher rates of hospitalization for chronic diseases. Self-rated access to care was lower in communities that had greater proportions of uninsured residents, Medicaid beneficiaries, and persons without a usual source of care. Analysis of crossnational data also suggests that broader access to primary care reduces the number of hospitalizations for conditions sensitive to ambulatory care. Several researchers compared such admissions for children in Spain and several U.S. cities. Although rates of hospital admission were higher in general for children in Spain, rates of hospitalization for conditions sensitive to ambulatory care were lower. In addition, lower-income communities in Spain, unlike the United States, did not have higher rates of children’s hospital admissions sensitive to ambulatory care. The authors attributed this difference to Spanish children’s access to universal health care, each child being covered by a responsible primary care provider. Two studies indicated that when children were hospitalized, providers did not give the same type of care to uninsured and privately insured children. Providers may have been unwilling to provide the same intensity of care if the payment source was uncertain or likely to be less than actual charges. One group of researchers found that sick uninsured newborns in California had shorter hospital stays and received less-intensive care while in the hospital than privately insured sick newborns, even though the uninsured newborns and those in Medicaid were sicker. Newborns in Medicaid had lengths of stay and levels of service between those of uninsured and privately insured newborns. Adjusted mean length of stay was 15.2 days for privately insured newborns, 14.2 for Medicaid-covered newborns, and 12.7 for uninsured newborns. Total mean charges were $15,899 for privately insured newborns, $13,858 for Medicaid-covered newborns, and $11,414 for uninsured newborns. Charges per day were also significantly different depending on insurance status. In all, length of stay, total charges, and charges per day were 16-percent, 28-percent, and 10-percent less for uninsured than privately insured newborns. Another group of researchers found that uninsured children and adults were generally sicker when admitted to the hospital, received less care given their condition on admission, and had higher mortality than privately insured children and adults. For children between ages 1 and 17, uninsured black males and white females rated significantly higher on a risk-adjusted mortality index, indicating that they were sicker on admission. The differences for uninsured black females and white males were not significant. Another measure of children’s being sicker on admission is admission on weekends, which was more likely for all uninsured children except black males. For the entire sample of all ages, uninsured people had shorter lengths of stay for conditions for which physicians had more discretion over the length of stay, and they had a lower probability of getting selected procedures that were either costly or more likely to be done at the physician’s discretion. The researchers cautioned that their adjustment for health risk might be imperfect. Nevertheless, they concluded that insurance coverage affects resource use for a broad spectrum of clinical problems, particularly elective and discretionary services. Many children have a chronic condition—one study estimated that 31 percent of children younger than 18 in 1988 had one or more chronic conditions. NCHS estimated that about 15 percent of children who had chronic conditions had special health care conditions that were disabling because they missed school, stayed in bed, limited their activities, or experienced pain or discomfort often. Many children who have chronic conditions are uninsured. In 1988, 21.1 percent of poor children and 9.7 percent of nonpoor children who had chronic conditions were uninsured. About 13 percent of children who had chronic conditions and special health care needs were uninsured—with low-income, Hispanic, and nonsuburban children more likely to be uninsured. Having a regular source of care ensures continuity of care and professional monitoring of disease symptoms. Only a few studies looked at children who had chronic conditions and those who had special health care needs, and fewer controlled for factors that influence access other than insurance. However, these few studies found differences in access to care by insurance status. (See table 3.) For example, poor children who had chronic conditions but no insurance were more than twice as likely as similar, insured children, to lack a usual source of routine care or sick care. (See fig. 4.) Adjusting for severity of illness and other factors, they had only 2.3 physician contacts per year, compared with 3.7 for similar but insured children. An analysis that went even further to separate insurance status from other factors that could affect children’s access to care found that children who had chronic conditions and special health care needs were more than twice as likely to be hospitalized if they had public or private insurance than if they were uninsured, adjusting for differences in need for hospitalization based on their conditions. Many health plans do not cover a number of preventive, primary, and developmental health services needed by some or all children. Private policies differ in whether they cover well-child, dental, and vision care. In 1996, KMPG Peat Marwick reported that 57 percent of the indemnity health plans used by firms with 200 to more than 5,000 workers covered well-child care, compared with 96 percent of health maintenance organizations (HMO) and 73 percent of preferred provider organization (PPO) plans. Dental caries are a common problem for children, while poor vision can lead to problems in learning. Nevertheless, only about half or less of the private plans surveyed covered dental or vision care. Medicaid’s child health benefit package, the Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT) program requires coverage of well-child care, including dental, hearing, and vision care. Other publicly funded programs, such as the Florida HealthyKids Program and New York’s Child Health Plus Program, have not covered dental care; HealthyKids covered vision and hearing care, but Child Health Plus did not. Children who have chronic conditions and special health care needs may have particular difficulties because the services and supplies they need may not be covered by their insurance. For example, coverage for speech or physical therapy to help with developmental delays is often limited or explicitly excluded from private health insurance policies. In contrast, Medicaid’s EPSDT program covers a wide variety of developmental services. Some children are insured but with “bare-bones” policies that provide minimal coverage except for catastrophic costs. Such children, if eligible for Medicaid, could get coverage for services not covered by their private insurance. However, Title XXI—the new child health insurance program—was designed to be restricted to uninsured children, so that low-income children with coverage, even if it were only catastrophic coverage, would not be considered eligible. Florida HealthyKids and New York’s Child Health Plus, two state-based plans whose benefits have been grandfathered into Title XXI, have in the past covered insured children if their health insurance was not comparable in scope to the state-based coverage. Some experts have argued that special pediatric standards should be developed that recognize children’s specific needs, such as their need for health services to ensure optimal development. They have argued that such services should be considered medically necessary and should be covered by private health insurance. Medicaid’s standard of medical necessity is more global than that of private plans. However, families in Medicaid have sometimes had difficulty finding mainstream providers willing to accept them as patients, which limits their ability to secure covered benefits for their children. Since providing uninsured children with publicly funded insurance improves their access to preventive and acute health services, families are more likely to report that their children’s health needs are being met. Children are more likely to be up to date with recommended preventive care and are more likely to see a physician. Two different researchers estimated that the expansion of publicly funded insurance in the United States and Canada decreased child mortality, in association with either more physicians’ visits or more prenatal care. NCHS reported that uninsured children were about three times as likely to have an unmet health need as children with publicly funded insurance (generally Medicaid). (See fig. 5.) Dental care was the most common unmet need for all children—but uninsured children were more than three times as likely not to receive needed dental care as children who had publicly funded insurance. Almost 16 percent of uninsured children were reported as needing but not receiving dental care. Parents of uninsured children reported delaying getting care for their children because of its cost almost five times as often as children who had publicly funded insurance. One local study in Los Angeles found that inner-city Latino parents were also most likely to report that they deferred health care for their toddlers for financial reasons when they were uninsured, compared with others who had Medicaid or private coverage. A number of studies estimated the effect that providing publicly funded insurance, such as Medicaid, had on lessening the gap between uninsured and insured children. One research team examined the effect of expanding Medicaid coverage to children and found decreases over time in the probability that children would go without at least one ambulatory care visit in a year. Making a child eligible for Medicaid lowered the child’s estimated probability of going without a visit by 13 percent. Hospitalizations also rose by an estimated 14 percent—but the estimated probability of making visits to physicians’ offices increased even more than making visits to other sites, suggesting to the authors that expanding Medicaid coverage increased ambulatory care. These authors also looked at the effects of Medicaid expansion on child health as measured by decreases in child mortality. They estimated that the 15-percent rise in the number of children eligible for Medicaid between 1984 and 1992 decreased child mortality by 5 percent. A similar study that looked at the effect of providing national health insurance in Canada found a statistically significant increase in early prenatal care and a significant decrease in infant mortality. Another study of children’s rates of preventive and illness-related primary care visits found that, adjusting for other factors such as race and perceived health status, the predicted probability of making either a preventive or illness-related visit increased if children were covered by public or private insurance, compared with being uninsured. For example, for uninsured children younger than 6 in single-parent families headed by mothers, the predicted probability of making a preventive visit was more than 40-percent greater if the children were covered by public or private insurance, and it was almost 100-percent greater for children aged 6 to 17. Many children miss recommended preventive visits, but uninsured children fare worse than insured children. Short and Lefkowitz found that in 1987, only 49 percent of uninsured preschool children had made any well-child visits, compared with 65 percent of insured children, and only 32 percent of uninsured preschool children had made the recommended number of visits, compared with 48 percent of insured children. They found that when adjusting for other factors, private insurance status was only marginally significant in predicting well-child visits, which they explained by the degree to which private insurance varies in its coverage of well-child care. However, they estimated that for low-income children who would otherwise be uninsured, a full year of Medicaid coverage increased the probability of making any well-child visits by 17 percentage points, and compliance with AAP’s guidelines for well-child visits would increase by 13 percentage points. (See table 2 for AAP guidelines.) Getting appropriate health care when it is needed can be difficult for children. Parents and guardians usually make the decision to seek care for them. Having health insurance and having a regular source of health care facilitate a family’s use of health services, but some families experience systemic, financial, and personal barriers to care. Systemic barriers can include a lack of primary care providers readily available in the neighborhood, physicians’ missing opportunities to provide vaccinations during health care visits, and physicians’ refusing to accept certain patients. Financial barriers, apart from lack of insurance, can include lack of funds to make copayments or pay for uncovered services. Personal barriers can include parents’ lack of knowledge that care is needed and language differences between parents and providers. Similarly, discrimination and poor treatment by health care workers can discourage the use of health care services. Uninsured children and children in Medicaid may also be likely to face systemic, financial, or personal barriers that limit their access to care, beyond their lack of insurance. Compared with privately insured children, uninsured children and those in Medicaid are more likely to have less family income, to be members of a minority group, to have parents who have lower educational attainment, or to live with only one parent—characteristics associated with lower use of health services. As a result, experts in health issues have concluded that while insurance plays a critical role in getting children access to health care, encouraging their appropriate use of health care encompasses multiple strategies. These include making insurance coverage more continuous in order to foster children’s relationships with providers, maintaining a better organized system of primary care in settings that ease access for parents and that have good links to more complex care, enhancing systems in which primary care providers can track and prompt preventive visits and immunizations, and aiming outreach and educational programs at parents. Research has clearly demonstrated that having health insurance makes a difference for children. Children who have no insurance—even those who are sick or chronically ill or have special health care needs—get less health care than children who have insurance. Many studies have shown that increasing children’s coverage increases their access to care, particularly primary care. Without appropriate access to primary care, children are more likely to suffer unnecessarily from illness. But having health insurance is no guarantee that children will get appropriate, high-quality care. Some children live in families that do not understand the need for preventive care or do not know how to seek high-quality care. Some live in neighborhoods that have few health care providers, where they have to travel further and wait longer to get care. Some live in families in which most of the members do not speak English or defer getting care because they have had difficulty getting care previously. Some children have health insurance that does not cover some of the services that they need most—such as dental care or physical therapy for the developmentally disabled. Some children have health insurance whose deductibles and cost-sharing are unaffordable. Such barriers can reduce the likelihood that even insured children will get the care they need. Overcoming these kinds of barriers would require that children be more continuously covered by health insurance so that they could develop long-term relationships with primary care providers. Having a stable source of insurance can help families use the health system for their children optimally over time. Beyond that, children have needs for specific developmental and preventive care that differ in some ways from those of adults. For insurance to work for children, the services they need must be both covered and affordable. Overcoming nonfinancial barriers might require outreach and education for families so that they can learn how better to use preventive and primary health care for their children. In addition, making high-quality primary health services convenient for families in local communities might facilitate children’s access to appropriate care. 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Summary: Pursuant to a congressional request, GAO reported on the relationship between health insurance and health care access, focusing on: (1) what effect health insurance has on children's access to health care; (2) whether expanding publicly funded insurance improves their access; and (3) barriers besides lack of insurance that might deter children from getting health care. GAO noted that: (1) health insurance increased children's access to health care services in almost all the studies GAO analyzed; (2) most of the evaluations showed that insured children were more likely to have preventive and primary care than uninsured children; (3) insured children were also more likely to have a relationship with a primary care physician and to receive required preventive services, like well-child checkups, than uninsured children; (4) differences in access between insured and uninsured children held true even for children who had chronic conditions and special health care needs; (5) when ill, insured children were more likely to receive a physician's care for their health problems, such as asthma or acute earache; (6) in contrast, lack of insurance can inhibit parents from trying to get health care for their children and can lead providers to offer less-intensive services when families seek care; (7) several studies found evidence that low-income and uninsured children were more likely to be hospitalized for conditions that could have been managed with appropriate outpatient care; (8) two studies found that uninsured children sometimes received less-intensive hospital care than insured children; (9) while health insurance benefits differed and some excluded coverage for some basic health care needs, increasing the number of insured children increased the likelihood that more children would receive care; (10) although health insurance can considerably increase access, it does not guarantee entry into the health care system; (11) low family income and education levels, limited availability of neighborhood primary health care facilities, lack of transportation, and language differences are among the barriers to obtaining and appropriately using health care services; (12) both children who have no health insurance and those who have Medicaid coverage are more likely than privately insured children to face such barriers; and (13) to ensure access to high-quality care, public health and clinical experts recommend that children have a stable source of health insurance benefits that cover their health care needs, a relationship with a primary care provider that helps them obtain more complex care as needed, primary care facilities that are conveniently situated, and outreach and education for their families.