Impact of a children's health insurance program on newly enrolled children

CONTEXT: Although there is considerable interest in decreasing the number of US children who do not have health insurance, there is little information on the effect that health insurance has on children and their families. OBJECTIVE: To determine the impact of children's health insurance programs on access to health care and on other aspects of the lives of the children and their families. DESIGN: A before-after design with a control group. The families of newly enrolled children were interviewed by telephone using an identical survey instrument at baseline, at 6 months, and at 12 months after enrollment into the program. A second group of families of newly enrolled children were interviewed 12 months after the initial interviews to form a comparison sample. SETTING: The 29 counties of western Pennsylvania, an area with a population of 4.1 million people. SUBJECTS: A total of 887 families of newly enrolled children were randomly selected to be interviewed; 88.3% agreed to participate. Of these, 659 (84%) responded to all 3 interviews. The study population consists of 1031 newly enrolled children. The children were further classified into those who were continuously enrolled in the programs. The 330 comparison families had 460 newly enrolled children. MAIN OUTCOME MEASURES: The following access measures were examined: whether the child had a usual source of medical or dental care; the number of physician visits, emergency department visits, and dentist visits; and whether the child had experienced unmet need, delayed care, or both for 6 types of care. Other indicators were restrictions on the child's usual activities and the impact of being insured or uninsured on the families. RESULTS: Access to health care services after enrollment in the program improved: at 12 months after enrollment, 99% of the children had a regular source of medical care, and 85% had a regular dentist, up from 89% and 60%, respectively, at baseline. The proportion of children reporting any unmet need or delayed care in the past 6 months decreased from 57% at baseline to 16% at 12 months. The proportion of children seeing a physician increased from 59% to 64%, while the proportion visiting an emergency department decreased from 22% to 17%. Since the comparison children were similar to the newly enrolled children at enrollment into the insurance programs, these findings can be attributed to the program. Restrictions on childhood activities because of lack of health insurance were eliminated. Parents reported that having health insurance reduced the amount of family stress, enabled children to get the care they needed, and eased family burdens. CONCLUSIONS: Extending health insurance to uninsured children had a major positive impact on children and their families. In western Pennsylvania, health insurance did not lead to excessive utilization but to more appropriate utilization.     

Availability of school health services for young children

A survey to assess availability of school health services was distributed to 221 directors of Schools of the 21st Century, an educational model that provides integrated services to children and families. Of this distribution, 126 (57%) surveys were returned; 88% of respondents reported they provided some type of school health services for their students; 75% of schools had access to school nursing services, yet only 33% had a school nurse on-site; 50% had less than daily access to a school nurse. Despite a high reported prevalence of physical and mental health problems, other services such as acute care, nutrition counseling, dental screenings, or mental health services were provided less frequently. Barriers perceived as problematic for schools providing health services included inadequate funding, limited parental awareness, and opposition by school or community members. Respondents believed transportation, limited financial resources, and inadequate health insurance were barriers to care for children and families. Among this sample of schools, school health services varied in availability and comprehensiveness. Educators, health providers, and parents must work together to provide improved school health services for children.     

Interpreting the Fort Bragg Children's Mental Health Demonstration Project: The cup is half full.

The Fort Bragg study is a significant contribution to understanding mental health services. The study"s finding of no differences between treatment and comparison sites raises difficult questions about the benefits of providing a continuum of care approach. The authors note a number of limitations of the study and suggest a more cautious set of conclusions. The findings must be interpreted in light of the knowledge base of children"s mental health services and the unequivocal lesson learned that a continuum of care is feasible and that children with a variety of mental disorders improve when they are provided with comprehensive care. Also, the results may speak more to the unique population of military families and the broad range of services available to those in the comparison sites rather than to a failure of the underlying construct. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diagnosis and management of lead-poisoned children: the pediatric nurse practitioner in a specialty program

Lead poisoning, the leading environmental illness in this country, is a challenge to our health care and social systems. Because they provide routine health care in a variety of settings, including care to children from poor inner city families, who are most at risk for plumbism, nurse practitioners should be knowledgeable about this illness and prepared to care for children who have it. This article describes the role of a pediatric nurse practitioner in a specialty program who cares for children with lead poisoning and informs the general practitioner about prevention, education, treatment, coordination of care, and long-term follow-up for these children and their families.     

Delivering health and mental health care services to children in family foster care after welfare and health care reform

As the 20th century draws to a close, fundamental changes in the organization, financing, and delivery of health care and welfare services, principally directed at poor families, are likely to result in an increased number of children entering out-of-home care. These children typically have significant physical, mental health, and developmental problems. Whether the quality of health care services they receive will improve as a result of health care reform efforts and new approaches to service delivery remains to be seen. This article addresses some of the major changes wrought by welfare and health care reform and describes the essential features of a health care system that can meet the special needs of children in care.     

Children with chronic conditions in the 21st century

The care of children who have chronic conditions should focus on improving the lives of the children and their families. This is accomplished most effectively through community-based, family-centered care. Critical issues for these children and families in entering the next century include the level of insurance, content of benefits package, level of evidence required for health insurance reimbursement, preparation of and incentives for health care professionals, roles being demanded of families. As the richest country in the world, we should be able to (1) provide universal coverage, (2) guarantee a comprehensive benefits package that applies a child-specific standard of medical necessity, (3) establish criteria for requiring insurers to reimburse for new effective therapies, (4) develop strategies for overcoming professional barriers, and (5) create mechanisms for compensating family caretakers for their care.     

Mental health services for children: The state of the art.

Throughout this century, people in the United States have been concerned about the serious deficiencies in the mental health care of our children. Despite eloquent needs assessment and recommendations for remediation, most of the unserved needs and deficiencies of our mental-health-care-delivery system remain the same. This article reviews the current status of mental health services to children, youth, and families to highlight the necessity of an integrated system of mental health care. The development of a continuum of care that is coordinated across the mental health and non-mental-health systems that naturally occur in all children's lives has the potential to vastly improve mental health services to children, youth, and families. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Who is for children?

Discusses some of the unmet needs of children in the areas of mental health care, day care, and foster and institutional care. It is argued that children with serious emotional problems do not get the treatment they need because adequate funds have not been set aside for children's mental health and because few incentives exist to serve children in community settings or in the most familylike settings possible. Specific functions that can be served by psychologists are presented, and strategies for creating public and private sector policies more responsive to the needs of children and their families are outlined. (2 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental health problems of homeless children and families: longitudinal study

OBJECTIVE: To establish the mental health needs of homeless children and families before and after rehousing. DESIGN: Cross sectional, longitudinal study. SETTING: City of Birmingham. SUBJECTS: 58 rehoused families with 103 children aged 2-16 years and 21 comparison families of low socioeconomic status in stable housing, with 54 children. MAIN OUTCOME MEASURES: Children's mental health problems and level of communication; mothers' mental health problems and social support one year after rehousing. RESULTS: Mental health problems remained significantly higher in rehoused mothers and their children than in the comparison group (mothers 26% v 5%, P = 0.04; children 39% v 11%, P = 0.0003). Homeless mothers continued to have significantly less social support at follow up. Mothers with a history of abuse and poor social integration were more likely to have children with persistent mental health problems. CONCLUSIONS: Homeless families have a high level of complex needs that cannot be met by conventional health services and arrangements. Local strategies for rapid rehousing into permanent accommodation, effective social support and health care for parents and children, and protection from violence and intimidation should be developed and implemented.     

Families and children's chronic conditions: knowledge development and methodological considerations

The complexity of studying families has been a deterrent in the development of knowledge about families as the unit of care. When chronicity in childhood is combined with family study, research and theory development is particularly challenging. Although publication in the field of chronic illness in childhood has been quite prolific, there are few comprehensive, recognizably organized ways to think about providing care for the family as a whole. This is profoundly important as increasing responsibility of day-to-day care for children with long-term health conditions shifts to the family and to community-based care. This paper presents a synthesis of what is known about families in health care when one member is a child with a long-term health concern, identifies gaps in knowledge that potentially compromise optimal health care delivery, and suggests methods for expanding and deepening our understanding so that we might improve the quality of our efforts to assist families that live with a child with a chronic condition.     

Home health care

Home health care is the fastest-growing expense in the Medicare program because of the aging population, the increasing prevalence of chronic disease and increasing hospital costs. Patients and families are choosing the option of home care more frequently. Medicare's regulations are often considered the standard of care for all home health agency interactions, even when a patient does not have Medicare insurance. These regulations require patients who receive home health care services to be under the care of a physician and to be homebound. The patient must have a documented need for skilled nursing care or physical, occupational or speech therapy. The care must be part time (28 hours or less per week, eight hours or less per day) and occur at least every 60 days except in special cases. A detailed referral and specific care plan maximize the care to the patient and the reimbursement received by the physician.     

Respite care for families of children with disabilities

The number of children with chronic health problems and resultant disabilities is increasing. Most of the care received by these children is provided by family members, often at severe economic and psychologic cost. One service that has appeared in the past two decades to assist family caregivers is respite services. This article describes the needs for respite identified by family members, the types of respite services available, the benefits of respite care to families, and the essential roles nurses can assume in assuring this essential service is available to families.     

Strengthening mental health services in Head Start: A challenge for the 1990s.

Steps must be taken to strengthen mental health services by building on Head Start's philosophy and by translating innovations in mental health services for older children and adolescents into improved services for young children and their families. Recommendations for strengthening Head Start's mental health program include creating a unified vision that reaffirms a holistic, family-focused, and comprehensive services approach; ensuring that mental health services are responsive to the diversity in families served; increasing coordination of mental health services and linkages with new initiatives; increasing resources and providing assistance in gaining access to new sources of funding; supporting innovation; and integrating the new paradigm for children's mental health services into more traditional approaches to intervention within Head Start. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Building Systems of Care for Children With Chronic Health Conditions.

Objective: To describe the leadership role that rehabilitation psychologists can play in improving the health care delivery system for children with special health care needs (CSHCN). Setting: Midwest academic health center and surrounding communities. Participants: Children with chronic health conditions and disabilities and their families. Intervention: A model research demonstration project designed to promote family-centered, comprehensive, coordinated, and community-based care for CSHCN. The project aims to enhance environmental supports for CSHCN and their families in 2 ways: (a) by improving the ability of primary care providers to deliver effective chronic care management and (b) by integrating this improved clinical practice into an enhanced Medicaid managed care service delivery system for persons with chronic illness and disabilities. Conclusions: Psychologists have the potential to improve the quality of life of CSHCN and their families by intervening not only through direct services but also by promoting positive changes in the larger health care environment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chemodectoma secreting carotid glomus: characteristics and contribution of magnetic resonance imaging. Apropos of 2 cases

Nurses must become aware of the high number of women affected by substance abuse during the childbearing years and the related health consequences. Health care providers also need to develop and maintain a positive attitude toward mothers who use cocaine, assess the needs of each individual mother and her infant, and become familiar with a wide range of available resources to address the identified needs of these multirisk families. Finally, nurses can assist families with a history of maternal cocaine use by supporting the development of appropriate parenting skills. Part 2 will describe strategies for nurses to work with mothers and children in the next issue of Pediatric Nursing.     

A call for integrating a mental health perspective into systems of care for abused and neglected infants and young children.

A system of care for abused and neglected infants and young children should adopt a comprehensive perspective, with mental health considerations systematically incorporated into policies and decisions affecting children and their families. Children age birth to 5 years have disproportionately high rates of maltreatment, with long-term consequences for their mental and physical health. Research on normal development and developmental psychopathology has shown that early development unfolds in an ecology of transactional influences among biological, interpersonal, and environmental domains. Psychologists should collaborate with other early intervention disciplines to create systems of care based on an ecological–transactional model of development that includes early mental health principles in order to serve the needs of these young children. Didactic courses, practicums, and internships in infant and early childhood mental health should become integral components of undergraduate and graduate curricula in psychology in order to build capacity to achieve this goal. Recommendations are offered for systemic change by integrating infant and early childhood mental health principles into existing systems of care for young children and their families. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Developmental sex differences in verbal learning

OBJECTIVE: To examine the health insurance experience and out-of-pocket health care costs of families with a child with IDDM. RESEARCH DESIGN AND METHODS: A case-control study of 197 families with a child with IDDM and 142 control families with no diabetic children was conducted. IDDM-affected families were identified from the Allegheny County IDDM Registry. Brothers and sisters of the parents in the IDDM-affected families were asked to participate as control subjects. Health insurance coverage and the money that families spent on health care services and supplies not reimbursed by insurance (out-of-pocket costs) were assessed by questionnaire. RESULTS: No difference was found between the IDDM-affected and control families in the percentages with or without insurance. Families with low household incomes ($10,000-$19,999) were at the greatest risk for having no insurance. While coverage provided by private plans was similar between the IDDM-affected and control families, many families had no reimbursement for insulin (10%), syringes (10%), or blood testing strips (30%). Out-of-pocket expenses were 56% higher in the IDDM-affected families than in the control families. Seventeen percent of the IDDM-affected families had expenses over 10% of their household income. This particularly affected families with low household incomes. Pre-existing illness clauses and insurance denial affected only a small proportion of the case families. CONCLUSIONS: These data illustrate that most families with a child with IDDM have health insurance, yet still incur larger out-of-pocket health care costs than do families without the presence of diabetes. IDDM-affected families likely face a number of economic decisions regarding health insurance and the use of health care.     

Randomised, prospective study comparing cemented and cementless total knee replacement: results of press-fit condylar total knee replacement at five years

OBJECTIVE: The objective of this study was to examine the effect of family and neighborhood income on health care use of young children born prematurely and of low birth weight (N = 619). DESIGN: A birth cohort was enrolled in a clinical randomized trial of early childhood educational and family services. SETTINGS/PARTICIPANTS: Infant Health and Development Program provided a sample of low birth weight premature infants stratified by clinical site, birth weight, and treatment group. Maternal reports of health care use, family income, and heath insurance were obtained at 12, 24, and 36 months of corrected age. Neighborhood income was based on census tract residence at birth. MAIN OUTCOME MEASURES: Maternal reports of hospitalizations, doctor visits, and emergency department visits were used; data were averaged over the child's first 3 years of life. RESULTS: Children from poorer families were more likely to be hospitalized and to have more emergency department visits than were children from more affluent families. Residence in poor and middle-income neighborhoods was associated with more emergency department visits than residence in affluent neighborhoods. Families in middle-income neighborhoods reported more doctor visits than families in poor or affluent neighborhoods. CONCLUSION: Neighborhood residence influences health care use by poor and nonpoor families and by insured and uninsured families. The use of the emergency department for low birth weight premature children in middle-income and poor neighborhoods is discussed.     

Probability of particle and salbutamol deposition in the respiratory tract: comparison between MDI and Autohaler

QOL for children with chronic neurological diseases (CND) depends mainly on the supporting system of children's development and respite measurements of their families. For supporting children's development with CND and for alleviating the burden on the family members, various staffs are needed such as pediatricians, nurses, psychologists, OT, PT, home helpers, etc. Especially children with CND are living at home needs in-home services supplied by these supporting staffs. An in-home care service center is desirable to be established in their living area. According to the maternal and child health law and child welfare law, several measures have been adopted, but these services are not available for children with CND and their family, without registration as handicapped children. All these children should be treated because they have the same problems as physically or mentally handicapped children. The capability of the medical and social service supply has been influenced by recent decrease of the birth rate and improvement of the level in the maternal and child health. The number of facilities, such as pediatric clinics or nursing homes for physically handicapped children, is decreasing because of poor profit. These trends will be continued if appropriate measurements are not introduced. The final estimation of need and supply must be made at the local community level.     

Community-based systems of care for children's mental health services

Community-based mental health systems of care for children, adolescents, and their families involve innovative approaches to improve access, utilization, financing, clinical efficacy, and cost-effectiveness of mental health services provided to children and adolescents within the context of their home communities. This model offers numerous advantages as rising needs for mental health services in an increasingly diverse population of children and families are recognized, while public and private resources are increasingly stressed. This report reviews the history of the development of this model, its basic principles, its emerging research literature, and its application within a managed care context.