News Release

One in seven adolescents still doesn't have health insurance

Peer-Reviewed Publication

University of California - San Francisco

One in seven U.S. children aged 10 to 18 is not covered by health insurance. That figure has not changed in more than a decade, even though government-funded health plans now cover more children and teens.

"Little progress has been made over the past fifteen years in reducing the numbers of uninsured adolescents," said Paul Newacheck, DrPH, professor of health policy and pediatrics at the University of California, San Francisco (UCSF). He is the principal author of a study published in the August issue of the journal Pediatrics -- the first comprehensive, nationwide look, using data from the 1990s, at adolescent health insurance and health care.

"Approximately 4.2 million adolescents had no health insurance coverage in 1995, based on data from the National Health Interview Survey conducted that year by the Bureau of the Census," Newacheck said. "As a result, these children had significant obstacles to getting adequate health care. The new, federally-supported State Children's Health Insurance Program (SCHIP) may provide an opportunity to improve access to care - but only if states will implement effective outreach strategies to enroll families with adolescents."

The difference between insured and uninsured adolescents: Those without insurance are five times more likely to have no doctor or clinic where they and their parents know they can go for care; and four times more likely to have unmet health needs.

Study co-author Charles Irwin, MD, chief of the Division of Adolescent Medicine at UCSF, said one checkup by a doctor per year is the standard recommendation for children aged 10 to 18. Uninsured teens are twice as likely not to have seen a doctor in more than a year. That means they miss out on preventive screening for problems with vision, hearing and chronic diseases such as diabetes. They also miss what pediatricians call "anticipatory guidance" - they have no doctor to talk with them about sexual choices and other risky behaviors such as drugs or violence. Physicians who work with teens often can head off problems by offering appropriate screening, intervention or counseling.

There is little data to show a direct link between absence of health insurance and an increase in illness for this age group, Irwin said, but that may be because the majority of adolescents are healthy. However uninsured adolescents are three times as likely as those with insurance show up in the emergency room when they need a doctor.

"To me that's the red flag that tells us this group is not getting the care they need," Irwin said. Uninsured adolescents with unmet health needs missed out on dental care, prescription drugs, eyeglasses and sometimes basic medical care.

A Shift From Private to Public Insurance
The UCSF study is based on data on 14,252 adolescents aged 10 to 18 years included in the 1995 National Health Interview Study, an annual survey based on interviews with an adult member in more than 40,000 households.

The study documents a shift in the payors for adolescent health insurance. In 1984, more than three-quarters (75.9 percent) of adolescents were covered by private insurance; 11.9 percent had public coverage and about two percent had a combination of both. By 1995, public insurance had increased to cover 16.9 percent of children aged 10 to 18, thanks in part to a federal policy opening up Medicaid to additional children when it previously had been available only to the very poor in most states. In the same period, however, private coverage of adolescents slipped to 71.2 percent.

That leaves 14.1 percent, or one in seven adolescents, without coverage in 1995 -- the exact same percentage as in 1984. "You would expect some improvement, but there has been no change in ten years -- a net no gain," Irwin said. Newacheck said experts have offered several explanations why private insurance covers fewer adolescents, including higher premiums and a shift of jobs to the service sector of the economy where employers are less likely to offer health insurance as a benefit.

When parents were asked why their adolescent children were not covered by health insurance, most cited the high cost of coverage, or a job layoff or job loss.

"Despite the clear importance of health insurance, our study also shows that coverage is not evenly distributed within the adolescent population," Newacheck said. Four out of every five uninsured adolescents come from poor and "near poor" families -- those with incomes below 200 percent of the poverty level. Such families are six times more likely than more affluent families to have no health coverage for their teens.

Hispanics were the least likely to be covered, followed by blacks. The South and the West had the largest proportions of uninsured adolescents.

A new federal program to improve children's health insurance coverage offers an opportunity to reduce inequities, the authors say. The Balanced Budget Act of 1997 created the State Children's Health Insurance Program (SCHIP), which provides matching federal funds for states to expand health insurance coverage of children and adolescents up to age 19 from low income families with incomes below 200 percent of the poverty level.

"However, states will require aggressive outreach and enrollment efforts to take full advantage of the potential of SCHIP," Newacheck said. "Each state will design its own program, and Congress allocated no funds to evaluate programs or to compare program effectiveness across states. Adolescents are particularly challenging to enroll because traditionally they have fewer contacts with health care providers than younger children. The burden is on health care providers, especially pediatricians, and on all children's advocates to encourage the development of effective strategies so more American children and adolescents have adequate health insurance coverage."

Co-authors of the study were Paul W. Newacheck, DrPH and Claire D. Brindis, DrPH of the Institute for Health Policy Studies and the UCSF department of pediatrics; Charles E. Irwin, Jr., MD, chief of the division of adolescent medicine, UCSF department of pediatrics; and Kristen Marchi, MPH and Courtney Uhler Cart, MSW, MPH, of the UCSF Institute for Health Policy Studies. The research was funded by grants from the federal Maternal and Child Health Bureau, the Robert Wood Johnson Foundation and the Center for Studying Health System Change.

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REPORTERS' NOTE: A copy of the study may be obtained by calling the authors or UCSF News Service at 415-476-2557. For more information about State Children's Health Insurance Programs in individual states, call the public information office of the American Academy of Pediatrics at 847-228-7877.


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