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Child Health Information Project
Children's Defense Fund
August 4, 2000
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In this issue:

* NEW REPORT DOCUMENTS RACIAL DISPARITIES IN COVERAGE AND ACCESS TO CARE

* HCFA OUTLINES STATE CHIP PROGRAMS' PROGRESS IN INCREASING ENROLLMENT

* ETHICAL CONCERNS AND MIXED RESULTS FROM USING PUNITIVE MEASURES AND PENALTIES WITH WELFARE RECIPIENTS

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NEW REPORT DOCUMENTS RACIAL DISPARITIES IN COVERAGE AND ACCESS TO CARE

July 2000 - Working minority Americans are less likely than Whites to have job-based health coverage, according to research by the Kaiser Family Foundation and the UCLA Center for Health Policy Research. The report, entitled "Racial and Ethnic Disparities in Access to Health Insurance and Health Care," analyzes the relationship of ethnicity and other factors to health insurance coverage and access to health services for Latino, African American, Asian American/Pacific Islander and Native American/Alaska Native populations. It also provides information, for the first time, on health coverage and access to care for subgroups of Asian American/Pacific Islanders and Latinos.

Estimates from the March 1998 Current Population Survey show that 73% of Non-Latino Whites, 64% of Asian American/Pacific Islanders, 53% of African Americans, 51% of American Indian/Alaska Natives, and 43% of Latinos have job-based health coverage.

"The majority of the nation's 44 million uninsured are White, but minority groups are disproportionately affected by the lack of health insurance. Elected officials who represent [minority groups], advocates and minority communities themselves need to recognize the tremendous stake minority Americans have in this problem," said Drew Altman, PhD, President of the Kaiser Family Foundation. For example, Latinos represent 12% of the U.S. population but comprise nearly 25% of the nation's uninsured.

Although a similar percentage of African American and White children lack a usual source of care (4-5%), Latino, Asian American/Pacific Islander, and Native American children are nearly two to three times more likely than White children to lack a usual source of health care. These minority groups are also less likely to have recently seen a physician. While 7% of school-age White children have not visited a doctor in two years, 18% of Native American, 16% of Latino, 12% of Asian American/Pacific Islander, and 8% of African American school-age children have not visited a doctor in the two years prior to the survey.

Minority populations already experience major disparities in health status and therefore it is important to ensure coverage and access to health services and preventive health services in particular, for these groups. For instance, the infant mortality rate for African Americans is more than double that of Whites and for American Indians/Alaska Natives is nearly one and half times that of Whites.

Copies of the report and individual two-page fact sheets for each of the minority groups studied can be accessed at: www.kff.org/kcmu or www.healthpolicy.ucla.edu .

Sources:
1) Kaiser Family Foundation Press Release, August 1, 2000:
http://www.kff.org/content/2000/1525/UCLARelease.PDF
2) Brown ER, Ojeda VD, Wyn R, Levan R. April 2000, "Racial and Ethnic Disparities in Access to Health Insurance and Health Care." Kaiser Family Foundation and the UCLA Center for Health Policy Research.
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HCFA OUTLINES STATE CHIP PROGRAMS' PROGRESS IN INCREASING ENROLLMENT

July 2000 - The Health Care Financing Administration (HCFA) has released an evaluation report entitled "Preliminary Highlights of Implementation and Expansion" of the State Children's Health Insurance Programs (CHIP).

Based on each state's self-evaluation of its CHIP program, (in accordance with an "evaluation framework" from the Department of Health and Human Services (HHS)), HCFA assessed overall progress of the program, outlining which strategies to increase CHIP and Medicaid enrollment have been successful and what more needs to be done. The evaluations demonstrate that the numbers of children enrolled in CHIP have increased nationally and continue to do so. States have taken comprehensive steps to eliminate barriers to getting publicly-funded health insurance.

The state evaluations show that many states have amended their programs to expand eligibility beyond their original proposal; streamlined their applications to make them more user-friendly; and conducted innovative ways of outreach to enroll children in CHIP and Medicaid and keep them enrolled.

To read HCFA's evaluation of the State CHIP programs, go to www.hcfa.gov/init/children.htm Individual State's evaluations can also be accessed at HCFA's web site.

Source: "The State Children's Health Insurance Program: Preliminary Highlights of Implementation and Expansion," HCFA, July 2000, www.hcfa.gov
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ETHICAL CONCERNS AND MIXED RESULTS FROM USING PUNITIVE MEASURES AND PENALTIES WITH WELFARE RECIPIENTS

States are experimenting with financial incentives and penalties in an effort to improve health-related behavior among low- income populations. For example, Georgia's Preschool Immunization Project (PIP) removed families from AFDC if they were not able to prove that their children under 6 years of age were up-to-date with their immunizations. And Maryland's Primary Prevention Initiative (PPI) penalized families $25 per month per child if their preschool-aged children were not receiving preventive health care. These policies raise ethical concerns because of their punitive nature and the potential consequences to families of removing the benefits.

Two recently published studies reviewed such punitive approaches and found mixed results. The authors in a study on Georgia's PIP reported that immunization rates were significantly higher for those welfare recipients who were being threatened with loss of benefits, compared to those not being threatened. However, a study on Maryland's PPI reported little difference in immunization rates between families who were subject to the sanction and families who were not.

Other studies have shown an increase in immunization rates and the use of other preventive services without the threat of benefit reduction. For instance, immunization rates increased when Chicago's WIC program required women with children who were not up-to-date on immunizations to return to receive their benefits at one-month, rather than three-month, intervals. Enrollment in WIC remained the same, even with the additional requirements.

Of additional concern is that welfare recipients in these policy studies were not protected in the same way that participants in medical research are routinely protected. For example, the PIP study, unlike clinical studies, did not require any informed consent of participants nor did it require an independent assessment of risks and benefits.

Before states proceed with implementation of such punitive measures, more evaluations need to be carried out in an ethical manner to determine the consequences of such policies on the families that they target. States should also determine if incentives work as well, if not better than penalties, in attempting to improve immunization rates and the use of other preventive health services.

Summary by the Health Division, Children's Defense Fund.

Sources:
1) Davis M, Lantos J. "Ethical Considerations in the Public Policy Laboratory," JAMA. 2000; 284:85-87.
2) Hoekstra et al. "Impact of a Large-Scale Immunization Initiative in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)," JAMA. 1998; 280:1143-1147.
3) Kerpelman L, Connell D, Gunn W. "Effect of a monetary sanction on immunization rates of recipients of Aid to Families with Dependent Children," JAMA. 2000; 284:53-59.
4) Minkovitz C. et al. "The effect of parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland," Archives of Pediatrics and Adolescent Medicine. 1999; 153:1242-1247.
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