Studies of Welfare Populations: Data Collection and Research Issues. hild Health

06/01/2002

Access to health care services is a central consideration in the assessment of welfare reform, as these reforms change existing relationships among income, employment, and insurance of health care services for poor families and children (Child Trends, 2000a; Darnell and Rosenbaum, 1997; Moffitt and Slade, 1997; Schorr, 1997). Measures of child health typically emphasize access to care as an important measure, recognizing that health care is necessary but not sufficient for positive child health outcomes (Gortmaker and Walker, 1984; Margolis et al., 1997; Andrulis, 1998).

Parents access health care for their children through several paths. Many children receive health insurance provided by their parent's employer. However, some children of working parents may not have employer-sponsored health plans, and children of nonworking parents certainly do not have this benefit. These children of low-income or nonworking parents are eligible for services paid by publicly funded programs such as Medicaid or the new CHIP. The PRWORA legislation did not significantly alter Medicaid eligibility, and CHIP is designed to reach more of these uninsured children. Yet in July 1999 an estimated 4.7 million uninsured children were eligible for Medicaid but not enrolled (Families USA, 1999). Many states are beginning to track children's enrollment in Medicaid and CHIP, implement outreach efforts to increase CHIP enrollment, and expand Medicaid and CHIP income-level guidelines (Families USA, 1999; Children's Defense Fund, 1998).

The actual health services the child receives are also major determining factors in child health status. Examples of services may include (1) preventive care such as immunizations or dental care; (2) diagnostic screening such as vision and hearing screening, or weight for height measures; and (3) treatment for chronic conditions and disability, with corresponding risk of secondary disability. State policies about welfare reform have the potential to change, positively or negatively, the family environment where health behaviors and health decisions are carried out (Willis and Kleigman, 1997; O'Campo and Rojas-Smith, 1998; Brauner and Loprest, 1999). For example, even if a child is enrolled in Medicaid or CHIP, PRWORA work requirements may constrain a parent's ability to access health care. When access to health care services is limited, either through limited availability or limited utilization of services, children's health could suffer. Alternatively, the work requirements could encourage the parent to secure a job that includes health insurance (gaining access to health care), which may mean the family is able to utilize more services.

Access and utilization of services are interesting for evaluation purposes because they are believed to contribute to the actual health of the child. However, direct measures of child health outcomes are also needed to measure the effects of welfare reform on children. Direct measures of child health outcomes are scarce, however. Often researchers have to rely on indicators of health status. Recent discussions about welfare reform and health suggest some indicators to measure child health status. Children in poverty are more likely to be undernourished, iron deficient, or lead exposed (Geltman et al., 1996). Several measures such as infant mortality, injury, and the use of preventive medical services can be good indicators of child health status (Pappas, 1998). Starfield's Child Health and Illness Profile (Starfield et al., 1993) combines several of these indicators into a bio psycho social developmental assessment but is not found in administrative data sets. Even in survey research, questions about child health status may be limited to asking parents to rate their child's health from excellent to poor (Child Trends, 2000b). Thus, when using administrative data about child health status, it is often necessary to use measures of health services as markers for positive outcomes such as immunizations, enrollment in health plans, or preventive screening, along with indicators of actual outcomes such as infant mortality, low birthweight, blood lead levels, or adolescent substance abuse.

Our purpose here is to identify a reasonably comprehensive set of child health indicators available in at least some administrative data that are relevant to changes in welfare policy because they address health access or status of children. Healthy People 2000, an initiative begun in 1990 by the U.S. Department of Health and Human Services, set health objectives for the nation, including child health status objectives (National Center for Health Statistics, 1996). Over the years, the initiative has prompted state and local communities to develop their own similar objectives and indicators of progress toward achieving them. As a result, the Healthy People 2000 effort has created a set of fairly common measurements of child health across a range of public and private health programs. For example, one of the Healthy People objectives is to reduce infant mortality. This supports the inclusion of infant mortality reduction as part of most state health objectives, and as part of many state and local programs targeted toward women and children. At the federal level, the Maternal and Child Health Bureau (MCHB) identified 18 of the Healthy People 2000 objectives that specifically relate to women and children. Of these, 15 are child health status indicators that can be used to measure impact of welfare reform (Maternal and Child Health Bureau, 1996). Table 10-1 presents these indicators, along with several others, as recommendations for measuring utilization of health services as well as child health status. For each indicator, we describe whether data generally are available at the individual level or aggregated to some larger population. We also identify suggested data sources for these indicators. Many of these data sources are being used in current research about child health (Vermont Agency of Human Services, 2000; Child Trends, 1999).

Of the data sources identified in Table 10-1, the core indicators come from Medicaid and vital statistics. The following two sections discuss these two sources of data, how they can be used in studies of welfare reform outcomes on children, and some methodological issues in their use.

TABLE 10-1
Suggested Child Health Indicators
Indicator Level Data Sources
Medicaid eligibility/enrollment/services Individual Medicaid data files
CHIP eligibility/enrollment/services Individual CHIP data files
Number/percent uninsured Population State dept. of insurance
SSI benefits Individual SSA data
Infant mortality Individual Vital statistics
Low birth weight Individual Vital statistics
HIV infection among women with live births Individual Vital statistics
Prenatal care Individual Vital statistics
Newborn screening Individual Vital statistics
Birth defects registry
State data system for newborn screening
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Population Medicaid services/payment data
Identification of hearing impairments Individual
Population
State data system for newborn screening
Program evaluation data
Immunizations Individual
Population
Medicaid, state immunization registry
Program evaluation data
Blood lead levels Individual
Population
EPSDT, clinic record
Program evaluation data
Dental caries Individual Medicaid
Public health dept.
Unintentional injuries Individual Vital statistics, hospital discharge

School-Based health centers

Child homicide Individual Vital statistics
Adolescent suicides Individual Vital statistics
Adolescent substance use rates Individual
Population
Vital statistics
Hospital discharge/health deptartment
School-based health centers
Program evaluation data
STD rates among youth Population Hospital discharge
Program evaluation data
School-based health centers
Adolescent pregnancy rates Individual Vital statistics

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