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‹ Parents of over a quarter of all children (28%) in Los Angeles County have difficulty paying for their children’s health care.
‹ Fifteen percent of children in Los Angeles County do not have a regular health care provider.
‹ Parents of nearly 25% of all children living in the South and Metro Service Planning Areas have transportation difficulty to and from their health care provider.
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‹ Parents of an estimated 9% of all children in Los Angeles County are not able to get the health care they feel their child needs.
‹ The percentage of children not receiving needed medical care is highest among uninsured children who have family incomes less than twice the poverty level (18%) and those without a regular medical care provider (20%).
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The need for health care should be the most important determinant of who receives services. Access to primary care is particularly important for children because of the known benefits of receiving developmental screening, immunizations, and other preventive measures, particularly in the early years. Previous studies demonstrate that many children face obstacles in obtaining health care.1 Access to needed services is often difficult to obtain if a child is not covered by health insurance, if parents are unable to pay for services, or if a child has no regular provider.2 Other barriers include long waiting times to see a doctor, a lack of culturally sensitive and linguistically acceptable clinicians, transportation problems to and from clinicians, attitudes and beliefs about health care services, and characteristics of the delivery system itself. All of these may affect a parent’s decision or ability to obtain medical care for their children.3
Previously reported data from the Los Angeles County Health Survey showed that 25% of children in Los Angeles County are uninsured, that uninsured children are less likely to receive health care their parents feel they need, and that these children are less likely to have had contact with a physician in the past year.4 This report describes barriers families in Los Angeles County face in obtaining health care for their children. The report only includes data on parents’ decisions to seek care for their children. It does not include information about adolescents who decide on their own to seek certain types of health services.
Barriers that are examined include difficulty paying for services, not having a regular provider, and transportation problems. Also examined are how these barriers affect the use of needed medical services. Differences among groups by race and ethnicity, family income relative to poverty, and area of residence are described. Future reports will describe the health status of children.
Many Families Report Difficulty Paying For Health Services.
Overall, parents of an estimated 28% of the children in Los Angeles County, representing over three quarters of a million children, have difficulty paying for their children’s health services including medical, dental and vision care. Latino parents have greater difficulty than do other ethnic/racial groups. For example, among families with uninsured children, close to two-thirds of Latino parents have difficulty paying for health care for their children compared to 58% of whites, 42% of African Americans, and 35% of Asians. Overall, parents of nearly two thirds of uninsured children (over 400,000 children) have difficulty paying for health services. Problems paying for health care are not found exclusively in families with uninsured children: parents of over 200,000 children covered by Medi-Cal and over 100,000 privately insured5 children also have difficulty paying for care (Figure 1).
1. Newacheck PW; Hughes D.C: Stoddard JJ; Children’s access to primary care: differences by race, income and insurance status. Pediatrics 1996 (1), 1997.
2. Halfon N; Inkelas M; Wood D; Non-financial barriers to care for children and youth. Annual Review of Public Health; 16, 1995.
3. Hughes, DC, Halfon N, Brindis, CD; Newacheck PW; Improving Children’s Access to Health Care: The Role of Decategorization. Bulletin of the New York Academy of Medicine; 73(2), Winter 1996.
4. L.A. Health, Volume 1, Issue 2, July 1998.
5. Private coverage includes job-based insurance and plans that families purchase independently.
Many Children Do Not Have A Regular Doctor; Uninsured Children And Those On Medi-Cal Rely On Safety Net Clinics.
Having a regular provider is an important determinant of access to needed health care for adults and children. An estimated 15% of children in Los Angeles County have no regular health care provider (Figure 2). The percentage without a regular provider is highest among uninsured children (37%), followed by children covered by Medi-Cal (13%) and children with private coverage (6%) (Figure 3). Fourteen percent of children in Los Angeles County, representing nearly 400,000 children under 18 years of age, rely on a County DHS or private community clinic as their regular provider. This percentage rises to 23% for those children covered by Medi-Cal and 22% for uninsured children. Overall, nine of every ten children who rely on these safety net clinics for their regular care are either uninsured or covered by Medi-Cal.
Many Parents In Los Angeles County Have Difficulty With Transportation To And From Health Care Providers
Arranging transportation is another obstacle many families face in their efforts to obtain health care for their children. An estimated 17% of parents have difficulty with transportation to and from health care providers. Transportation problems are most common among families with incomes less than twice the poverty level6 (23%), Latino families (23%), and families living in the South (27%) and Metro (22%) Service Planning Areas (SPAs) (Figure 4).
Medi-Cal Has Reduced Financial Barriers For Low-Income Families, But Many Children Are Still Not Getting The Care Their Parents Feel They Need.
Throughout Los Angeles County, parents of over a third of all children have difficulty meeting day to day expenses such as food, clothing and other necessities. The proportion rises to about half among parents of uninsured children and children covered by Medi-Cal. In families with difficulty meeting day to day expenses, 28% of uninsured children do not get needed care compared to 12% of children covered by Medi-Cal and 8% of children with private insurance. Thus, for families that have trouble meeting day to day expenses, the Medi-Cal program helps to ensure that children get the health care their parents feel they need. Still, one in ten children covered by Medi-Cal is not getting needed care suggesting that the program has not reduced all barriers to health care in Los Angeles County.
Discussion
The survey indicates that many families in Los Angeles County face significant barriers in obtaining health care services for their children. Nearly one in ten children is not getting the medical care their parents feel they need. Many families face financial barriers, have no regular provider, or have difficulty in arranging transportation to and from health care providers. Financial barriers are particularly prevalent among uninsured children.
Many parents of uninsured children have difficulty paying for medical expenses which often results in these children not getting needed medical, dental or vision care.
Nearly one million children in Los Angeles County live in households with incomes less than twice the federal poverty level. Many of these families have difficulty meeting day to day expenses. Among these families, however, uninsured children are much more likely not to receive needed health services compared to children covered by Medi-Cal. This finding is consistent with other studies and demonstrates that Medi-Cal has provided an important buffer against these financial barriers to health care.8 Thus, expanding coverage provides an important way to increase access to health services and reduce the risk that parents will divert family resources away from purchasing food and other necessities in order to pay for health care.
Having Medi-Cal or private insurance coverage is associated with fewer barriers than being uninsured. Nonetheless, half of children whose parents report problems paying for health care have insurance coverage. Some insured families, particularly those with private coverage, may be under-insured or enrolled in health plans with coverage that does not meet their health care needs. Some plans may require co-payments or deductibles at levels that constitute financial hardship. Some families may be eligible for Medi-Cal only after first spending a portion of their income towards their medical bills.
8. Weigers, ME, Weinick, RM, and Cohen, JW., Children’s Health, 1996, Medical Expenditure Panel Survey, MEPS Chartbook No.1, Agency for Health Care Policy and Research, 1997.
9. Guendelman S; English P: Chavez G, Infants of Mexican Immigrants: health status of an emerging population. Medical Care, 33 (1), 1995.
Authors
This report was written by Cynthia Harding, Janet Blair, Michael R. Cousineau, and Brian Shimabukuro. Also contributing were Daniel Gera, Janice Gilden, Alicia Kokkinis and Micheal Shiffman.
Acknowledgment is given to Jonathan Fielding, Anna Long, Larry Portigal, Paul Simon, Marc Strassburg, and Toni Saenz Yaffe who reviewed earlier versions of this report.
In response to the immediate need for coordinated action to address the unmet healthcare needs of uninsured children in Los Angeles County, the Department of Health Services (DHS) created the Office of the Children’s Health Outreach Initiative (CHOI). On August 5, 1997, the Board of Supervisors adopted the Children’s Planning Council’s recommendation that concerted efforts be undertaken to enroll an additional 100,000 children in the Medi-Cal program and that participation in the Child Health & Disability Prevention (CHDP) program be increased 35% by September 1999.
The Office of CHOI has developed a plan to guide DHS’ actions in working toward meeting the Board of Supervisors adopted goals, as well as to increase the number of children enrolled in other government sponsored programs. The Office of CHOI, in collaboration with the Department of Public Social Services (DPSS) is implementing the Child Medi-Cal Enrollment Project (CMEP). Related activities include: identifying barriers to participant enrollment in these programs; working with the state to advocate for program enhancements and a simplified application process; increasing the number of application assistors; out-stationing eligibility workers at community-based sites to take applications; conducting informal presentations about these programs to promote them throughout the county; and encouraging collaboration among agencies and organizations with outreach responsibilities.
We are pleased with the progress we have made with our collaborative outreach efforts and look forward to significantly increased enroll-ment numbers in the future.
Los Angeles County
Department of Health Services
A Quarter Of A Million Children Do Not Always Receive The Medical Care Their Parents Feel They Need.
Parents participating in the survey were asked: “At any time in the past three months was there a time when your child didn’t get needed care?” Based on parents’ responses to this question, 9% of children in Los Angeles County (nearly a quarter of a million children) are not getting needed care7 (Figure 5). The true percentage is
likely to be higher given that the question only asked about needed care in the last three
months. The percentage of children not receiving needed care is highest among children
who are uninsured and whose family income is less than 200% of the federal poverty
level (18%). Among uninsured children ages 0-4, 16% did not receive needed medical
care in the past three months compared to 10% of children covered by Medi-Cal and
3% of children with private insurance. In addition, the following groups were more
likely not to receive needed care in the past three months.
‹ Latino children (12%),
‹ Children in families with incomes below the federal poverty level (14%),
‹ Children without a regular medical provider (20%),
‹ Children whose parents report transportation problems (19%).
Other obstacles to receiving needed health care services include not having a regular provider and being unsure when and where to seek care. For example, in the absence of a regular provider, many parents may not be as aware of the necessity of obtaining regular preventive care such as well child examinations, or how and when to seek care when their child has a health problem. Some families covered by Medi-Cal or by private insurance may not understand their benefits package or how to best use the health care system for their children. Some, particularly adolescents, may need confidential services and may not want to seek care from the family’s regular provider. For these children, access to alternatives such as schoolbased and other community clinics is very important.
The survey data also indicate that transportation in Los Angeles County is an important barrier to health care services, particularly in certain areas. Efforts to reduce transportation barriers will be an important part of any comprehensive effort to improve access to primary health care services. Such efforts might include expanding the frequency of bus service, adding new lines, and re-routing existing lines to make it easier for people to get to and from community providers.
Of particular importance for planners and policy makers is the higher frequency of access
barriers faced by Latino children and their families. Latino children comprise 62% of all
children in the county but 81% of children who are not getting needed medical care.
These findings are consistent with those of studies done in other parts of the country.9
Although not addressed in this survey, children’s access to health care services may be
affected by immigration status, lack of knowledge about how the health care system
works, racial discrimination, difficulty communicating with clinicians, and cultural
attitudes about when to seek health care and from whom.
In summary, the results of the survey suggest that many health care access barriers
remain for hundreds of thousands of children in Los Angeles County. These
barriers are more common among those who are poor, uninsured, Latino, and
among those with transportation problems to and from providers.
