Journal Issue: Health Insurance for Children Volume 13 Number 1 Spring 2003
Richard E. Behrman
A challenge for any health insurance program, public or private, is reaching and serving the most vulnerable groups of children. Difficult-to-serve children tend to fall through the cracks of systems that provide adequate coverage for most other children. The "Special Populations" section focuses on the particular challenges of providing health coverage to three groups of children: immigrant children, adolescents, and children with special health care needs. Both immigrant children and adolescents tend to be overrepresented among the 9 million children who remain uninsured. For example, high rates of uninsurance persist among immigrant children despite the fact that most are eligible for public programs. Adolescents, who were initially excluded from public coverage, are also less likely to have coverage than younger children. Although children with special health care needs tend to have insurance coverage, their frequent use of health care services provides an important test of the programs' effectiveness in meeting children's health needs. The articles in this section describe the unique characteristics of these three groups of children, the gaps in their coverage, and efforts to improve their access to appropriate care.
The first article, by Lessard and Ku, notes that one of the most important risk factors for lack of health coverage is a child's family immigration status: About one-third of the nation's low-income, uninsured children live in immigrant families. Furthermore, because children of immigrants constitute a growing share of all American children and are increasingly dispersed across the United States, their health has become an issue of national concern. The article describes the barriers to health care that these children face, such as limited federal eligibility, and language and cultural barriers. Several solutions are explored, including restoring and expanding federal eligibility rules for Medicaid and the State Children's Health Insurance Program (SCHIP) without regard to a child's immigration status, providing language assistance, and developing culturally appropriate outreach efforts.
The second article, by Brindis, Morreale, and English, explores why adolescents (defined as young people ages 10 to 19) are less likely than younger children to have health coverage. As the authors note, about one in every seven adolescents has no health insurance. Lack of insurance coverage among adolescents is a concern because, as the authors explain, access to care during this critical developmental period helps prevent the onset of unhealthy, risky behaviors that can lead to chronic health problems. During adolescence, children experience a number of changes—physical, emotional, and cognitive—and their health needs differ from those of younger children. For example, adolescents may need services for health issues such as pregnancy or substance abuse. The article describes several strategies for improving access to health care for adolescents by developing specialized outreach materials and providing specific information about confidentiality protections.
In the third article, Szilagyi examines how well public health programs meet the needs of children requiring special care (broadly defined as children with chronic physical, mental, developmental, or behavioral needs who may require special services). With their consistent patterns of high need and use of services, children with special health care needs are expensive to serve. A recent survey indicates that although children with special needs represent a relatively small proportion of the total population of American children (12% to 14%), they account for almost 50% of all health care expenditures. While most children with special needs have good access to care and good relationships with health care providers, a significant portion do not. For example, nearly one in ten lacks a usual source of care, and about one in five has difficulties with referrals. Strategies for strengthening public programs for children with special needs include broadening benefits, ensuring adequate provider networks, increasing collaboration and coordination across programs that serve these children, and eliminating the mandatory waiting period under SCHIP.
By providing some insight into the challenges involved with providing health coverage for these uniquely vulnerable groups of children, these articles underscore the necessity of designing public programs that provide health coverage for children who sometimes encounter greater obstacles to receiving needed health services.