Health care for children covered by government programs like Medicaid and the State Child Health Insurance Program (SCHIP) appears to be improving, but the gap in care is widening between these publicly insured children and poor children without insurance, a new national report by the University of South Florida and federal Agency for Healthcare Research and Quality (AHRQ) indicates.

"Publicly insured children still do not receive the same type or amount of health services as privately insured children, but they are better off than uninsured children," said lead author Lisa Simpson, MB, BCh, MPH, professor of pediatrics at the USF College of Medicine who holds the All Children's Hospital Endowed Guild Chair in Child Health Policy. "In fact, the proportion of uninsured children who made at least one office visit (to a physician or other health care practitioner) dropped from 52 percent in 1987 to 43 percent in 1999."

The report was published today in the March-April issue of the journal Ambulatory Pediatrics. It draws on two national databases to detail trends in insurance coverage, use of health care services, perceived quality of care and health care expenses for U.S. children, ages 17 and younger, from 1987 through 2001. The time periods reported vary depending upon which database was used.

Overall, the researchers found, access to health care appears to be better and children are receiving care in more appropriate and less expensive settings. For instance, emergency room visits and hospitalizations are down while office-based visits are up.

The study confirms a decrease in the rate of uninsurance among children, spurred over the last 15 years by state and federal initiatives to expand health insurance coverage for low-income children and a strong economy. But, the researchers write, "children who remained without coverage in the late 1990s appeared to experience worsening access to care."

"We already have evidence of states needing to cut eligibility, limit enrollment and eliminate outreach programs," Dr. Simpson said. "The challenge for the years ahead will be to prevent deterioration in coverage as the gains that have been made are threatened by economic downturns and state fiscal crises."

Based on information from the AHRQ's Medical Expenditure Panel Survey and Healthcare Cost and Utilization Project, the report's findings include:

  • The percentage of children uninsured for an entire year declined from 10.4 percent in 1996 to 7.7 percent in 1999 (from 7 million to 5.3 million).

  • The percentage of children hospitalized dropped 45 percent between 1987 and 1999.

  • The gap between publicly and privately insured children who did notreport a problem getting needed care narrowed from 2000 (a 9.9 percent difference) to 2001 (a 3.7 percent difference).

  • Parents of publicly insured and uninsured children were more than twice as likely as parents of privately-insured children to report that health care providers never or sometimes listened carefully to them, explained things carefully, or showed them respect.
  • The percent of total expenditures on children's health care decreased significantly from 14 percent in 1987 to 10 percent in 1999. Costs associated with hospital outpatient and emergency room visits declined, while those associated with office visits increased.

    "Despite our gains in insuring more children," Dr. Simpson said, "we're spending less of our overall health care dollars on children."

    The question remains whether this is due to more emphasis on primary and preventive care and less use of inpatient services, or if other factors, like barriers to care, might contribute to reduced spending for children's health, Dr. Simpson said.

    Other authors of the report were Marc Zodet, MS; France Chevarley, PhD; Pamela Owens, PhD; and Denise Dougherty, PhD, all of the AHRQ; and Marie McCormick, MD, ScD, of the Department of Maternal and Child Health, Harvard School of Public Health.

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    Ambulatory Pediatrics (Mar/Apr-2004)