BACKGROUND. Latinos continue to be the most uninsured racial/ethnic group of US children, but not enough is known about the risk factors for and consequences of not being insured in Latino children. OBJECTIVE. The objective of this study was to identify the risk factors for and consequences of being uninsured in Latino children. METHODS. A cross-sectional survey was conducted of parents at urban, predominantly Latino community sites, including supermarkets, beauty salons, and laundromats. Parents were asked 76 questions on access and health insurance. RESULTS. Interviews were conducted of 1100 parents, 900 of whom were Latino. Uninsured Latino children were significantly more likely than insured Latino children to be older (mean age: 9 vs 7 years) and poor (89% vs 72%) and to have parents who are limited in English proficiency (86% vs 65%), non-US citizens (87% vs 64%), and both employed (35% vs 27%). Uninsured Latinos were significantly less likely than their insured counterparts to have a regular physician (84% vs 99%) and significantly more likely not to be brought in for needed medical care because of expense, lack of insurance, difficulty making appointments, inconvenient office hours, and cultural issues. In multivariable analyses, parents who are undocumented or documented immigrants, both parents working, the child's age, and the $4000 to $9999 and $15000 to $19999 family income quintiles were the only factors that were significantly associated with a child's being uninsured; neither Latino ethnicity nor any other of 6 variables were associated with being uninsured. Compared with insured Latino children, uninsured Latino children had 23 times the odds of having no regular physician and were significantly more likely not to be brought in for needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. CONCLUSIONS. After adjustment, parental noncitizenship, having 2 parents work, low family income, and older child age are associated with being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino children's high risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and State Child Health Insurance Program outreach and enrollment efforts.
Thirteen percent of Latinos in Massachusetts lack health insurance, the highest rate of any ethnic or racial group. Families without health insurance are more likely to be in poor or fair health, to lack a regular medical provider, and to not have visited a medical provider in the past year.
Latinos will soon be the largest minority group in the United States, but too little is known about major access barriers to health care for this group and whether these barriers result in adverse consequences.
Objective
To identify important access barriers to health care for Latino children, as cited by parents.
Design
Cross-sectional survey of parents of all 203 children coming to the pediatric Latino clinic at an inner-city hospital. Questions focused on barriers to health care experienced prior to receiving care at the Latino clinic.
Results
Parental ethnicity included Dominican (36%), Puerto Rican (34%), Central American (13%), and South American (11%). Only 42% of parents were American citizens, whereas 36% had green cards, and 13% had no documentation. Eight percent of parents and 65% of the children were born in the United States. Parents rated their ability to speak English as follows: very well/well, 27%; not very well, 46%; and not at all, 26%. The median annual household income was $11000; 40% of parents never graduated from high school, and 49% headed single-parent households. Forty-three percent of the children were uninsured. A sick child was routinely brought to hospital clinics by 56% of parents, to the emergency department by 21%, and to neighborhood health centers by 21%. When asked to name the single greatest barrier to health care for their children, parents cited language problems (26%), long waiting time at the physician's office (15%), no medical insurance (13%), and difficulty paying medical bills (7%). When parents were asked if a particular barrier had ever caused them not to bring their children in, transportation was cited by 21%; not being able to afford health care, 18%; excessive waiting time in the clinic, 17%; no health insurance, 16%; and lack of cultural understanding by staff, 11%. Some parents who spoke little or no English reported that medical staff not speaking Spanish had led to adverse health consequences for their children, including poor medical care (8%), misdiagnosis (6%), and prescription of inappropriate medications (5%). Multivariate analyses of selected health outcomes using 7 independent variables showed that low family income was significantly associated with greater odds of a child's having suboptimal health status (odds ratio, 1.5; 95% confidence interval, 1.04-2.2) and an increased number of physician visits in the past year (P<.04), but reduced odds (odds ratio, 0.6; 95% confidence interval, 0.4-0.9) of the child's being brought to the emergency department for a routine sick visit. Children whose parents had resided in the United States for fewer than 8 years were at reduced odds (odds ratio, 0.5; 95% confidence interval, 0.2-0.9) for having spent a day or more in bed for illness in the past year.
Conclusions
Parents identified language problems, cultural differences, poverty, lack of health insurance, transportation difficulties, and long waiting times as the major access barriers to health care for Latino children. Language problems can result in adverse health consequences for some children, including poor medical care, misdiagnosis, and inappropriate medication and hospitalization. Low family income is an important independent risk factor among Latino children for suboptimal health and high utilization of health services.
Lack of health insurance adversely affects children's health. Eight million US children are uninsured, with Latinos being the racial/ethnic group at greatest risk for being uninsured. A randomized, controlled trial comparing the effectiveness of various public insurance strategies for insuring uninsured children has never been conducted.To evaluate whether case managers are more effective than traditional methods in insuring uninsured Latino children.Randomized, controlled trial conducted from May 2002 to August 2004.A total of 275 uninsured Latino children and their parents were recruited from urban community sites in Boston.Uninsured children were assigned randomly to an intervention group with trained case managers or a control group that received traditional Medicaid and State Children's Health Insurance Program (SCHIP) outreach and enrollment. Case managers provided information on program eligibility, helped families complete insurance applications, acted as a family liaison with Medicaid/SCHIP, and assisted in maintaining coverage.Obtaining health insurance, coverage continuity, the time to obtain coverage, and parental satisfaction with the process of obtaining insurance for children were assessed. Subjects were contacted monthly for 1 year to monitor outcomes by a researcher blinded with respect to group assignment.One hundred thirty-nine subjects were assigned randomly to the intervention group and 136 to the control group. Intervention group children were significantly more likely to obtain health insurance (96% vs 57%) and had approximately 8 times the adjusted odds (odds ratio: 7.78; 95% confidence interval: 5.20-11.64) of obtaining insurance. Seventy-eight percent of intervention group children were insured continuously, compared with 30% of control group children. Intervention group children obtained insurance significantly faster (mean: 87.5 vs 134.8 days), and their parents were significantly more satisfied with the process of obtaining insurance.Community-based case managers are more effective than traditional Medicaid/SCHIP outreach and enrollment in insuring uninsured Latino children. Case management may be a useful mechanism to reduce the number of uninsured children, especially among high-risk populations.
We thank Ms Garvin for her letter regarding our article1 and commend her early interest as a medical student in advocating for immigrant children and their families.
We agree wholeheartedly that pediatricians can and should play an important role in shaping immigration policy. We take issue, however, with the statement that pediatricians have not traditionally engaged in shaping immigration policy. Indeed, there is clear and abundant evidence to the contrary. For example, several pediatricians recently testified on behalf of the American Academy …
Background. Avoidable hospitalization conditions (AHCs) are hospitalizations that potentially can be avoided with timely, appropriate outpatient care. The specific reasons for avoidability, and parents and physicians’ perspectives on the proportion of actually avoidable pediatric AHCs, have not been examined adequately. Objectives. To identify how pediatric hospitalizations might be avoided, and to determine the proportion of avoidable AHCs according to parents and physicians of hospitalized children. Methods. Cross-sectional survey of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of children who were admitted with AHCs to an urban hospital in a 14-month period. Results. The 554 hospitalized children had a median age of 4 years; most were poor (median annual family income: $12 000), nonwhite (91%), and had public (73%) or no (16%) health insurance. The most frequent AHC diagnoses were asthma (43%), dehydration/gastroenteritis (16%), pneumonia (11%), seizure disorder (8%), and skin infections (8%). Only 25% of parents said that their child’s admission was avoidable, compared with 29% of PCPs and 32% of IAPs. The proportion of AHC hospitalizations assessed as avoidable varied according to the source or combination of sources, from 13% for agreement among all 3 sources to 46% as identified by any 1 of the 3 sources. PCPs (71%) and IAPs (48%) significantly more often than parents (35%) cited parent/patient-related reasons for how hospitalizations could have been avoided, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (48%) significantly more often than PCPs (18%) and IAPs (37%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child’s condition, and better quality of care. Multivariate analyses revealed that an age ≥11 years, an asthma diagnosis, working poor family income, and having no health insurance were associated with approximately double to triple the odds of an avoidable hospitalization. Conclusions. The proportion of AHCs assessed as avoidable varies from 13% to 46%, depending on the source. Adolescents, children with asthma, children from working-poor families, and uninsured children are at greatest risk for avoidable hospitalizations. Many pediatric hospitalizations might be avoided if parents and children were better educated about the child’s condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers. Direct assessment by parents and physicians of hospitalized children can be an informative way to examine the proportion of avoidable pediatric hospitalizations and how they can be prevented.
