Introduction

Access to basic health care is an important determinant of children’s physical health.  Many health problems that might otherwise threaten a child’s overall well-being can be either prevented—through parent and child education or preventive medicine—or treated by health care professionals. 

Unfortunately, thousands of children at risk do not have regular access to basic health care.  Access to health care is limited for children who live in poverty because health care is not available, because quality health care and health insurance are too expensive, or because health care services are not easily accessible (Eaton, 1997).  As a result, the incidence of health-related problems such as poor nutrition, lack of proper immunization, and delayed physical growth is higher among low-income children than middle-income children (Brown, 1987).

One of the most common reasons why many children at risk lack access to health care is that their families do not have health insurance and therefore have no regular health care provider (Wood et. al, 1990; Berk, 1996).  As of 1998, more than 9 million children under age 18 were not insured.  Of those 9 million, nearly a third are 5 years old or younger.  The lack of health insurance is even more prevalent among low-income children.  Twenty-two percent of children living in poverty and 25% of children in low-income working families did not have health insurance in 1998 (Kids Count, 1998).

In 1997, the federal government earmarked approximately $24 billion in funds for state block grants to provide health insurance for low-income children who do not qualify for Medicaid.  This new Children’s Health Insurance Program (CHIP) has the potential to remove a major barrier to health care access for millions of uninsured children.  However, many states are not currently taking full advantage of the funds to expand health coverage for children in poverty (Ullman, Bruen, & Holahan, 1998).

Availability and accessibility of health care are also barriers to health care access for many children at risk.  Community-based health care facilities and school health programs play an integral role in providing health care for many children and families at risk.  In some communities, local physicians and health organizations provide regular health screenings, physical check-ups, and childhood immunizations in locations convenient to community residents.  In other communities, coordinated community-based programs work with health care providers, schools, and families to plan and implement programs that provide children with basic health care.

For many school-aged children at risk, school-based or school-linked health clinics are an important provider of basic health care (Small et. al, 1995).  Many schools provide basic health care for their students because educators recognize that good health is related to good school performance (Kann et. al, 1995).  School clinics keep health records, screen vision and hearing, and treat many health-related problems in school-aged children (Small, et al, 1995).  Children who are eligible for Medicaid receive screening, diagnosis and treatment of health problems at clinics through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program. This program is conducted by the Health Care Financing Administration (Small, et al, 1995).  School health services are an important link in community efforts to ensure all children access to basic health care. 
 

Suggested Indicators

The following are some appropriate indicators of positive program outcomes for children in the area of access to basic health care, based on the NCEO model (Ysseldyke & Thurlow, 1993), as adapted for community-based programs by the Children’s Outcome Work Group.  The appropriateness of any given indicator for your program evaluation depends on the age of the children you serve, the setting, and the goals and activities of your particular program.
 

• Percent of children who receive childhood immunizations at recommended ages
• Percent of children who visit a health care provider for preventive check-ups at recommended intervals
• Percent of children who receive regular dental care
• Percent of children who receive regular vision and hearing screenings
• Percent of children who have adequate health insurance to cover basic medical care
• Percent of children who attend a school with a school-based health clinic that provides basic health care

Summary

Access to basic health care is an important step in ensuring children’s physical health.  In order to successfully access health care, children at risk need adequate health insurance, and easily accessible health care providers or clinics.  For many communities at risk, providing basic health care for children requires the cooperation of parents, health care providers, schools, and community-based programs.  State Strengthening programs can improve children’s physical health by helping plan and implement health care services in communities at risk. 

References

Berk, L. E.   (1996).  Infants, Children, and Adolescents. (2nd Ed.).  Boston:  Allyn & Bacon.

Brown, J. L.  (1987).  Hunger in the U. S.  Scientific American, 256(2), 37-41.

Kann, L., Collins, J. L., Pateman, B. C., Small, M. L., Ross, J. G., & Koble, L. J.  (1995).  The school health policies and programs study (SHPPS): Rationale for a nationwide status report on school health programs.  Journal of School Health, 65, 291 - 294.

Kids Count (1998).  Kids Count Data Book 1998.  Baltimore, MD: Annie E. Casey Foundation.

Small, M. L., Majer, L. S., Allensworth, D. D., Farquhar, B. K., Kann, L, & Pateman, B. C.  (1995).  School health services.  Journal of School Health, 65, 319-326.

Ullman, F., Bruen, B., & Holahan, J.  (1998).  The State Children’s Health Insurance Program: A Look at the Numbers.  Washington, DC: Urban Institute.

Wood, D. L., Hayward, R. A., Corey, C. R., Freeman, H. E., & Shapiro, M. F. (1990).  Access to medical care for children and adolescents in the United States.  Pediatrics, 86, 666-673.

Ysseldyke, J. E., & Thurlow, M. (1993, October). Developing a model of educational outcomes (NCEO Report No. 1). Minneapolis, MN: University of Minnesota, College of Education, National Center on Educational Outcomes.
 

MEASURES: Has Access to Basic Health Care 

Few formal, standardized measures of access to basic health care are available and practical for most community-based projects to use.  However, most projects can use existing data to provide general indices of children’s access to health care.

One measure that may provide an index of access to basic health care is whether the child is fully covered by health and dental insurance.  Parents can be asked to explain their child’s health insurance company, policy number, and extent of coverage through a series of questions on a program registration form or questionnaire.  When collecting such information, it is important to ask separate questions about dental coverage.  Many insurance plans provide generous coverage for most medical needs but do not cover dental care or require expensive additional premiums for dental coverage.   With parental permission, records from health care professionals, community clinics, school-based clinics or insurance companies may provide more in-depth information about the type and extent of insurance available to children in the program.

An important caution in using level of insurance coverage as a measure of access to basic health care is that it is an indirect measure.  Lack of insurance coverage may be a barrier to receiving health care for many children and families, but having health insurance does not necessarily insure that a child will receive the necessary care.  Other barriers such as lack of transportation may make accessing health care difficult for some families, even with full health insurance.  Thus, other measures of actual use of health care services are needed in combination with insurance records to insure accurate measurement.

Counting the number of visits to health care providers, community clinics, or school-based clinics within a certain period of time can provide a simple record of health care access.  Again, this number needs to be used with some caution.  The total number of health care visits may vary widely between children, depending on the specific health-care needs of individual children.  The number of visits for routine physical examinations or immunization may be a better indicator of access to basic preventive care.

Records of childhood immunizations are perhaps one of the most readily available measures of basic health care.  Doctors and clinics keep accurate records of immunizations on file.  Schools or child care centers may be a good source of immunization records for many children.  In most states, written proof of immunization is required for entry into kindergarten or pre-kindergarten programs.  Many child care centers also require parents or their health care providers to provide this information before a child can be enrolled.

Physical Health Outcomes

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