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Ambul Pediatr. 2005 Jan-Feb;5(1):6-44.

Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by income.

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Department of Pediatrics, University of South Florida, St. Petersburg, FL 33712, USA.



To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States.


Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations.


Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children.


While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

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