Reducing Health Disparities among Children

SUMMARY The ultimate goal of providing public health insurance is to improve the health of low-income children. Yet, acknowledging the limitations of health insurance is important because children's health is shaped by a variety of factors, many of which cannot be influenced by increased access to health care. Health status is also affected by race, language, culture, geography, and socioeconomic class. This article summarizes current research about what health insurance can and cannot do in three areas: providing access to health care, reducing stress and worry for parents, and improving children's health status. This review reveals several important themes, including: * A strong link between health insurance and access to care. * Evidence that health insurance reduces parental stress--both financial and emotional. * Mixed and inconclusive evidence about the link between health insurance and improved health status. The authors discuss some of the barriers to improving the health status of low-income children beyond increasing access to health care. They emphasize that ultimately, the underlying social inequities that lead to disparities in health status based on race, income, and education should be addressed. Over the past 15 years, federal and state initiatives have significantly expanded health insurance for low-income children, with the goal of increasing their access to care and, ultimately, improving their health status. Yet, low-income children still lag behind their more affluent peers in health and well-being. Socioeconomic level, which is typically expressed in terms of parental income, education, and occupation, is a strong and consistent predictor of health status. Children lower in the socioeconomic hierarchy suffer disproportionately from almost every disease and show higher rates of mortality compared with those in families that are better off. (1-3) During the 1980s and early 1990s, Congress greatly expanded the Medicaid program so that today, virtually all poor children are eligible for Medicaid coverage. (See the article by Mann, Rowland, and Garfield in this journal issue.) Complementing Medicaid, in 1997 Congress created the State Children's Health Insurance Program (SCHIP) for children in families with incomes too high to qualify for Medicaid, but who still cannot afford private insurance. SCHIP serves fewer children, but is an important source of coverage for those who would otherwise lack it. In addition, a small number of private-sector insurance efforts over the past two decades have sought to extend subsidized coverage to otherwise uninsured children. (4) The expansion of health insurance eligibility is an important and necessary step in the effort to improve the health status of low-income children--but it is only one of many needed steps. As a result, despite expanded insurance coverage, achieving measurable improvements in the health status of low-income children has proven elusive. To explain the complex social and policy environment that shapes children's health, this article discusses key factors besides health insurance that influence children's health. This article examines how health insurance can and cannot affect these factors--and, consequently, what insurance can do to improve children's health status--and why health insurance expansions are necessary, but not sufficient, to reduce health disparities between high- and low income children. Major Influences on Children's Health Children's health status, like that of adults, is influenced by many factors in addition to health care, including socioeconomic, biological and genetic, environmental, sociocultural, and behavioral factors. (5) Together, these influences protect children or contribute to poor health or disease. The primary role of health care (and by extension, health insurance as a means of gaining access to needed care) in influencing children's health status is to prevent and mitigate health problems. …