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Judith R. Lave, PhD; Christopher R. Keane, ScD, MPH; Chyongchiou J. Lin, PhD; Edmund M. Ricci, PhD; Gabriele Amersbach, MA; Charles P. LaVallee

JAMA. 1998;279:1820-1825.

Context.— Although there is considerable interest in decreasing the number of US children who do not have health insurance, there is little information on the effect that health insurance has on children and their families.

Objective.— To determine the impact of children's health insurance programs on access to health care and on other aspects of the lives of the children and their families.

Design.— A before-after design with a control group. The families of newly enrolled children were interviewed by telephone using an identical survey instrument at baseline, at 6 months, and at 12 months after enrollment into the program. A second group of families of newly enrolled children were interviewed 12 months after the initial interviews to form a comparison sample.

Setting.— The 29 counties of western Pennsylvania, an area with a population of 4.1 million people.

Subjects.— A total of 887 families of newly enrolled children were randomly selected to be interviewed; 88.3% agreed to participate. Of these, 659 (84%) responded to all 3 interviews. The study population consists of 1031 newly enrolled children. The children were further classified into those who were continuously enrolled in the programs. The 330 comparison families had 460 newly enrolled children.

Main Outcome Measures.— The following access measures were examined: whether the child had a usual source of medical or dental care; the number of physician visits, emergency department visits, and dentist visits; and whether the child had experienced unmet need, delayed care, or both for 6 types of care. Other indicators were restrictions on the child's usual activities and the impact of being insured or uninsured on the families.

Results.— Access to health care services after enrollment in the program improved: at 12 months after enrollment, 99% of the children had a regular source of medical care, and 85% had a regular dentist, up from 89% and 60%, respectively, at baseline. The proportion of children reporting any unmet need or delayed care in the past 6 months decreased from 57% at baseline to 16% at 12 months. The proportion of children seeing a physician increased from 59% to 64%, while the proportion visiting an emergency department decreased from 22% to 17%. Since the comparison children were similar to the newly enrolled children at enrollment into the insurance programs, these findings can be attributed to the program. Restrictions on childhood activities because of lack of health insurance were eliminated. Parents reported that having health insurance reduced the amount of family stress, enabled children to get the care they needed, and eased family burdens.

Conclusions.— Extending health insurance to uninsured children had a major positive impact on children and their families. In western Pennsylvania, health insurance did not lead to excessive utilization but to more appropriate utilization.

From the Department of Health Services Administration, Graduate School of Public Health, University of Pittsburgh (Drs Lave, Keane, Lin, and Ricci and Ms Amersbach), and the Western Pennsylvania Caring Foundation for Children (Mr LaVallee), Pittsburgh.

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