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Access to Care for Children of the Working Poor
Sylvia Guendelman, PhD;
Michelle Pearl, PhD
Arch Pediatr Adolesc Med. 2001;155:651-658.
ABSTRACT
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Context Recent evidence suggests that children in working poor families lack
health resources, placing them at risk for inadequate access to care.
Objectives To examine financial and nonfinancial access and utilization of health
services among children in working poor families, and to compare these data
with those of children from both nonworking poor and moderate to affluent
families.
Design A cross-sectional study of 13 785 children younger than 18 years.
Participants Subjects from the 1997 National Health Interview Survey.
Main Outcome Measures Prevalence and continuity of health insurance coverage, of delayed or
missed care, and of unmet care needs; presence and type of usual source of
care; and the amount of visits to physicians, emergency departments, and hospitals.
Results Compared with children of nonworking poor parents and moderate to affluent
children, more working poor children were uninsured (22% vs 12% and 5%, respectively; P<.01) and experienced disruptions in insurance coverage
(P<.01). After adjusting for other covariates,
disparities in insurance coverage and continuity persisted, as did delays
in care and unmet care needs; these delays were far higher for the working
poor. Although these children had access to a regular source of care and had
utilization rates comparable with those of other poor children, they differed
markedly from moderate to affluent children on structural access and utilization
(adjusted odds ratios, 1.5-3.4).
Conclusions Children in working poor families experience far more barriers to care
than other children. Health insurance expansions through the Children's Health
Insurance Program and Medicaid, which reduce financial and nonfinancial barriers
to care, may help correct these disparities.
INTRODUCTION
ALTHOUGH access-to-care barriers have been amply documented for poor
children in general, it is not clear to what extent children in low-income
working families—the working poor—experience similar barriers
to care. In 1997, approximately 25 million children in the United States lived
in working families that earned less than 200% of the poverty level. In these
families, approximately 2 of 3 parents were fully attached to the workforce.
These children are usually grouped with other impoverished children, with
the uninsured, or with children who experience unmet health care needs, rendering
the working poor a virtually invisible population.1, 2, 3, 4
The sheer size of this population underscores the need to examine whether
work, especially full-time year-round (FTYR) parental work, pays off in terms
of improved access to care for their children. An examination of this issue
is timely and compelling given recent welfare and immigration policies that
place a strong emphasis on personal responsibility and work.5
New expansions in health insurance coverage through the Children's Health
Insurance Program (CHIP) are making insurance more available to the working
poor. To assess the effects of CHIP on access to care for children of the
working poor requires baseline information.
In California, children of the working poor are less likely to have
insurance coverage and more likely to experience disruptions in coverage than
children of welfare families or nonworking poor families, even after controlling
for other covariates.6 Having an FTYR working
parent does not improve insurance coverage or use of health care. These children's
access and utilization are much worse than those of children from moderate
to affluent families. A recent national study indirectly points to the unmet
needs of children of the working poor by demonstrating that uninsured children
eligible for CHIP are far more likely to have 2 employed parents than children
enrolled in Medicaid.2 However, scant information
exists nationally on the joint effects of work and income on access to care
for children.
Poor and near-poor children are at increased risk of having unmet health
care needs, yet these cannot be addressed through health insurance alone.1 In addition to gaps in insurance coverage, which increase
the chances that a child will receive health care from multiple sites,7 nonfinancial barriers to care exist for these children.
These barriers are partly due to a high reliance on community clinics and
county and city hospitals.8 Many of these facilities
have not been funded to keep pace with the growth in the uninsured population
and have longer waiting times for available appointments, excessive waiting
room times, and provider shortages. Having a regular source of care can increase
continuity; regular providers are more likely to know the child's medical
history and are better able to monitor treatment through follow-up visits.9 The lack of a regular care source and of health insurance
has been associated with an increase in emergency department use.10, 11 Low levels of education among low-income
working parents may lead to different health investments in their children
compared with children from more affluent families with more education and
disposable income.12, 13
The purpose of this article is to examine the joint effect of parental
work and income on children's health care access and utilization. We focus
on low-income children of parents in the labor force who earn less than 200%
of the poverty level (the working poor) and compare them with 2 other groups
of children: those in low-income families who do not participate in the labor
force (nonworking poor) and those from families in the labor force who earn
more than 200% of the poverty level (moderate to affluent). We explore the
extent to which work pays off by addressing 3 questions: Do children of working
poor families differ from the 2 reference groups with respect to financial
and structural dimensions of access to care? Are there differences in utilization
of health services among the groups? Does insurance coverage improve access
and utilization among children of the working poor? This analysis also provides
a baseline for evaluating the effects of CHIP and the 1996 welfare reform
act. Given the lack of consensus among policymakers regarding who constitutes
the working poor, we offer 2 profiles of children of the working poor: (1)
those who had at least 1 parent who was currently working or was employed
for at least 6 months in the past year; and (2) those who had at least 1 parent
working FTYR for at least 1 year at a main job 35 hours or more per week and
earning 200% of the poverty level or less (ie, an annual income of $31 822
for a family of 4 using 1996 poverty thresholds).
SUBJECTS AND METHODS
SAMPLE AND DATA SOURCES
Data were obtained from the National Health Interview Survey (NHIS),
a continuing cross-sectional survey of the civilian, noninstitutionalized
US population. Different households are sampled each year, and interviews
are administered face-to-face by trained Census Bureau staff using computer-assisted
technology.14 We used 1997 NHIS data to create
the baseline against which to evaluate the future effects of CHIP, which was
implemented in 1998.
In 1997, the NHIS randomly selected 1 child per family for a more in-depth
interview on access and utilization. Of the 15 350 families with eligible
children younger than 18 years, 14 290 had interview data on a selected
child. Mothers or other adult family members provided information about their
children; however, 17-year-olds could respond for themselves. Compared with
children of respondents, children of nonrespondents were more likely to be
African American and in good rather than excellent health. They did not differ
with respect to disability status, nativity status, receipt of public assistance,
or insurance coverage.
Sampled children's records were linked to their parents' records to
determine parental work status. Children who did not live with a parent (n
= 487) were excluded. After excluding records with missing work status, our
sample size was 13 785. We imputed poverty level for 1640 children who
had missing information on income and could not otherwise be classified into
a study population. Imputation randomly assigned a poverty level category
(in 25% increments) to individuals with similar geographic region, parental
education, race/ethnicity, and broad income level if available.5
Recipients of Temporary Assistance to Needy Families (TANF) were assumed to
have incomes less than 200% of the poverty level. The analytic sample consisted
of 5342 children in working poor families (including a subsample of 3394 children
[63.5%] living in FTYR working families), 1021 children in nonworking poor
families, and 7422 moderate to affluent children living with parents earning
200% of the poverty level or more, 99% of whom were working.
MEASURES OF ACCESS AND UTILIZATION OF CARE
Access to care was measured by financial and structural characteristics.
Financial access included current coverage and disruptions in coverage during
the past year. Several questions were used to classify children into the categories
of private coverage, public coverage, or uninsured. Among the privately insured,
children were classified into those insured through the parent's employer
or "self-pay." Continuous insurance coverage was determined by asking respondents,
"In the past 12 months, was there any time when [child] did not have any health
insurance or coverage?"
Structural measures of access included the presence or absence of a
regular source of care: a particular person or place to which a child usually
goes for treatment when sick, for health advice, or for routine or preventive
medical care. Parents of children with a usual source of care were asked about
the kind of place they go. Parents were also queried about any experience
in which their child's care was delayed or missed in the last 12 months because
of financial constraints, and about any experiences in which their child needed
medical or dental care, prescriptions, eyeglasses, or mental health care but
was unable to get it.
Utilization variables included entry into care, measured by a visit
to a physician or other health care professional in the last 12 months and
stratified by perceived health status into children with excellent and less
than excellent health. Among those with at least 1 visit in the past year,
we assessed whether children had 1 visit, 2 to 3, or 4 or more; whether they
had 2 or more emergency department visits; and the mean number of hospital
admissions, all stratified by perceived health status.
INDEPENDENT VARIABLES
Independent variables included demographic characteristics of the child
such as age, sex, and race/ethnicity, as well as child health measures including
perceived health status and the presence of disability, defined as a reduction
in capacity to perform the average type or amount of daily living activities.
Additional characteristics consisted of family structure and size, and receipt
of public assistance. Socioeconomic status was measured by highest level of
parental education, federal poverty level, and parental employment. Geographical
characteristics included region of the United States and whether the child
lived in a metropolitan statistical area (MSA).
DATA ANALYSIS
We first compared the 3 study populations by demographic and health
characteristics, family and geographic characteristics, access barriers, and
utilization measures. We then did similar bivariate comparisons of the children
of FTYR working parents and the 2 reference populations. We compared each
of the working poor groups to each of the 2 reference groups, and we indicate
statistically significant (P .05) differences
in the tables. Further bivariate analyses allowed us to examine differences
between the insured and uninsured among low-income children of working parents.
We conducted multivariate logistic regression analyses to determine whether
the differences in dichotomous outcomes between the 3 study populations (and
between the FTYR working group and the 2 reference populations) persisted
after adjusting for other variables. Linear regression was used to analyze
the mean number of hospital admissions, adjusting for other factors. We adjusted
for child's age, race/ethnicity, parental education, family structure, region,
MSA, child's disability, and health status except where already stratified.
These variables have been shown to affect health care access and utilization.3, 4, 8, 11, 15
We then added health insurance to the model.
Because the design of the NHIS is a complex, multistage sample, the
SEs and significance tests are weighted to reflect population totals and corrected
for stratification and sampling clustering. The analyses were conducted using
SAS version 6.12 (SAS Institute Inc, Cary, NC) and SUDAAN version 7.5.3 (Research
Triangle Institute, Research Triangle Park, NC) statistical software.
RESULTS
Compared with moderate to affluent families with predominantly 2 incomes
and college-educated parents, children in working poor families were more
likely to have an unemployed parent or only 1 parent employed (P<.01), with less than a completed high school education (P<.01) (Table 1).
Consequently, their income levels were lower (P<.01).
Forty-six percent were living below the federal poverty level, whereas 54%
had incomes falling between 100% and 200% of the poverty level. However, children
in working poor families were not as poor as those from nonworking low-income
families, 81% of whom lived in poverty (P<.01).
The differences are similar when comparing FTYR working poor families with
the 2 reference groups.
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Table 1. Demographic and Health Characteristics of Children in Working
Poor, Nonworking Poor, and Moderate to Affluent Families in the United States,
1997*
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Only 13% of working poor families received public assistance (TANF)
compared with 54% of nonworking poor families (P<.01).
The differential between working poor and nonworking poor families in public
assistance use was even larger among FTYR earners (P<.01).
Working poor families were almost 4 times more likely to have 2 parents in
the home compared with nonworking poor families (P<.01),
but less likely than moderate to affluent families (P<.01).
A large family size was also more common among the working poor (including
the FTYR group) than the reference groups (P<.01).
Compared with moderate to affluent children, those in working poor families
were younger (P<.01), 3 times more likely to be
Hispanic (P<.01), twice as likely to be African
American (P<.01), and less likely to be Asian
American (P<.06). They were less likely to be
perceived to have excellent health status (P<.01)
and more likely to be disabled (P<.03). Comparable
differences were found between children in the FTYR working poor group and
moderate to affluent children, except for a similar prevalence of disability.
Compared with children in nonworking poor families, those in working poor
families (including those in FTYR working families) were less likely to be
African American (P<.01) and more likely to be
white non-Hispanic (P<.01), and to enjoy better
perceived health status (P<.01) and less disability
(P<.01). Additionally, fewer working poor children
were concentrated in MSAs compared with the other 2 groups (P<.01). Children of the working poor were more likely than moderate
to affluent children to live in the West (P<.01)
and South (P<.01), and were more likely than nonworking
poor children to live in the South (P<.01).
FINANCIAL ACCESS TO CARE
Children in working poor families were far more likely to be uninsured
(22%) than children in nonworking poor families (12%; P <.01) or moderate to affluent families (5%; P<.01) (Table 2). In
addition, compared with children of nonworking poor families, the working
poor were less likely to be covered by Medicaid (31% vs 78%; P<.01). Medicaid income eligibility levels vary by state, but eligibility
is mandatory for children aged 1 to 5 years in families that earn 133% of
the poverty level or less and for older children from families with incomes
of 100% of the poverty level or less. Compared with moderate to affluent children,
children of the working poor were less likely to be privately insured (47%
vs 90%; P<.01). Only 44% had employment-based
coverage in comparison with 86% among moderate to affluent children (P<.01); self-paid coverage was also lower (P<.03). Furthermore, disruptions in insurance coverage were almost
twice as high among children of the working poor compared with the nonworking
poor (P<.01), and more than 3 times higher than
among moderate to affluent children (P<.01). Although
parental FTYR work did not improve the prevalence of insurance coverage among
working poor children, it improved the proportion of private coverage (P<.01).
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Table 2. Financial and Structural Access to Health Care for Children
in Working Poor, Nonworking Poor, and Moderate to Affluent Families in the
United States, 1997*
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STRUCTURAL ACCESS TO CARE
Far more children in working poor than nonworking poor families (7%
vs 4%; P<.04) or moderate to affluent families
(7% vs 3%; P<.01) experienced delayed or missed
care in the previous year because of financial constraints (Table 2). Although children of working poor families were as likely
as children of nonworking poor families to get needed medical care, mental
health care, or prescriptions, access to dental care was more of a problem
for the working poor (P<.01). Access to all dimensions
of care was much more difficult for children of the working poor (P<.01), including those of FTYR working parents (P<.01), than for moderate to affluent children.
The prevalence of a regular source of care was similar for children
of working and nonworking low-income families (90% vs 91%), but this percentage
was significantly lower than for moderate to affluent children (97%; P<.01). These differentials were also significant for
children of FTYR working poor families compared with moderate to affluent
children (P<.01). Among those having a regular
source of care, children of working poor families were far more likely than
children of nonworking poor families to seek care in a physician's office
or health maintenance organization (P<.01) and
less likely to seek care in a clinic or health center (P<.01) or hospital ambulatory setting (P<.03).
Compared with working poor children who sought care in clinics or hospitals,
those who sought care in the private sector were less likely to forgo needed
medical care (P<.05) and prescription medications
(P<.02) and more likely to have visited a physician
in the past year (P<.02). Compared with moderate
to affluent children, children of working poor families (including children
in FTYR working families) were less likely to seek care in the private sector
(P<.01) and more likely to seek care in health
clinics (P<.01), hospitals (P<.01), or emergency departments (P<.01).
Among children with no regular source of care, those in working and nonworking
poor families sought care predominantly in community clinics or health centers,
whereas moderate to affluent children sought care in physicians' offices (data
not shown).
HEALTH CARE UTILIZATION
Children in working poor families who were in excellent health were
as likely as children in nonworking poor families to have entered the health
care system in the past year, but far less likely than moderate to affluent
children (P<.01) (Table 2). However, among working poor children in less than excellent
health (including FTYR working poor families), 16% had not visited a physician
in the past year, a rate significantly worse than for the other 2 reference
groups (12%; P<.05 and 9%; P<.01).
Among children who had visited a physician in the past year, fewer children
in the FTYR working group had 4 or more visits compared with the moderate
to affluent children, whether in excellent health (P<.01)
or in less than excellent health (P<.04). Furthermore,
children in working poor families (including those in FTYR working families)
were far less likely than those of nonworking poor families to have 2 or more
emergency department visits in the past year (P<.05)
but were far more likely than moderate to affluent children (P<.01), irrespective of health status. A similar mean number of
hospital admissions was found among the 3 study populations, irrespective
of health status.
Structural access and utilization were further stratified by insurance
coverage for children of the working poor, which is the population targeted
for CHIP. As expected, insured children were far more likely than uninsured
children to have a regular source of care (P<.01),
to enter the health care system (P<.01), and to
have a higher number of physician visits (P<.01)
(data not shown). In contrast, uninsured children were far more likely than
insured children to delay or miss care because of financial constraints (P<.01) and to forgo needed medical care (P<.01), dental care (P<.01), mental
health treatment (P<.02), and prescription medications
(P<.01) (data not shown). Similar differentials
by insurance status were found among the FTYR subgroup.
MULTIVARIATE ANALYSIS
Compared with children of nonworking poor parents, children of working
poor parents were more likely to lack insurance coverage. These differences
persisted after controlling for child's age, race/ethnicity, health and disability
status, family structure, parental education, region, and MSA (odds ratio
[OR] = 1.8; 95% confidence interval [CI], 1.4-2.4) (Table 3). Among insured children, disruptions in insurance coverage
were more frequent for children of the working poor than the nonworking poor,
even after adjusting for other covariates (OR = 2.0; 95% CI, 1.3-3.1). Although
children of the working poor were as likely as children from nonworking poor
families to lack a regular source of care, the working poor were somewhat
more likely to seek care in a physician's office or health maintenance organization,
after adjusting for other covariates (OR = 1.2; 95% CI, 0.9-1.4). The working
poor were also more likely than the nonworking poor to delay or miss care
because of financial constraints and to express unmet needs for care, after
adjusting for other covariates (OR = 1.8; 95% CI, 1.2-2.8 vs OR = 1.5; 95%
CI, 1.1-2.1, respectively). After adjusting for other demographic and health
status covariates, poor children of working parents did not differ significantly
from poor children of nonworking parents on measures of health care utilization,
except for a lower likelihood of entering the health care system among the
working poor (OR = 1.2; 95% CI, 0.9-1.6). These results did not differ according
to health status and were not altered by adjusting further for insurance status.
Similar patterns were observed when comparing low-income children in FTYR
working and nonworking families.
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Table 3. Effects on Children's Insurance Status, Access to Care, and
Use of Care: Working Poor vs Nonworking Poor Parents*
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The disparities in access and utilization were far greater for children
of the working poor compared with moderate to affluent families, with the
exception of a high number of physician visits ( 4, conditional on entry
into the health care system) and the number of hospitalizations, which were
both similar. The differentials narrowed, then persisted after adjusting for
demographic factors and health status, and continued to narrow (particularly
for structural access) after controlling further for insurance status (Table 4). Similar but narrower discrepancies
were found when comparing children of FTYR working poor families with those
from moderate to affluent families.
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Table 4. Effects on Children's Insurance Status, Access to Care, and
Use of Care: Working Poor vs Moderate to Affluent Parents*
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COMMENT
This article portrays the sociodemographic characteristics, patterns
of health care access, and utilization rates among children of the working
poor. It shows that compared with poor children from nonworking families and
moderate to affluent children, children of the working poor experience far
more difficulties in accessing health care. In addition, utilization of health
services is markedly lower than for moderate to affluent children. Collected
the same year CHIP was established, these data from 1997 can be a useful baseline
from which to evaluate improvements in access to care for working poor children
through health insurance expansions.
Specifically, the findings show that 22% of children in working poor
families are uninsured compared with 12% of children in nonworking poor families
and 5% in moderate to affluent families. Even after adjusting for demographic
factors and health status, children of the working poor are less likely to
have health insurance compared with children in the other 2 reference groups.
For these children, parental employment does not provide adequate access to
employment-based coverage, yet it reduces the likelihood of eligibility for
Medicaid.
Full parental commitment to the labor force marginally increases employer-based
coverage. Only 50% of the children of FTYR working poor parents have this
type of private coverage, whereas 22% remain uninsured. Disruptions in coverage
among those insured children are 2 to 3 times more prevalent among children
of the working poor compared with children in nonworking poor and moderate
to affluent families. Even children of FTYR working poor parents have odds
of coverage disruptions that are 1.7 times higher than those of children from
nonworking poor families and 2.1 times higher than those of moderate to affluent
children, after adjusting for other factors. Welfare-to-work policies that
seek to increase work incentives for poor parents must address insurance barriers
by not only making insurance available to these families, but also making
it more continuous. Recent evidence suggests that because many people now
view public assistance as a temporary benefit, fewer recipients of TANF are
applying for Medicaid or maintaining enrollment.16
Lack of insurance and continuity in coverage among children of the working
poor contributed to a larger proportion of these children having to delay
or miss care because of financial constraints compared with the reference
child populations. These differentials are not reduced by adjusting for demographic
and health factors but are somewhat offset by health insurance coverage. Recent
expansions in health insurance coverage through CHIP may help to reduce the
disparities in timely access to care.
Despite these disparities, children of the working poor were as likely
as those from nonworking poor families to have a regular source of care, and
they had similar utilization of health services after adjusting for confounders.
As the results indicate, one reason for this favorable outcome may be related
to a significantly higher use of physician offices or health maintenance organizations
by children of the working poor compared with children of the nonworking poor,
who tend to seek care in the public sector. Children who seek care in the
private sector tend to have better structural access and utilization. As different
states implement and expand CHIP insurance programs, they should attempt to
facilitate enrollment with private providers or delivery systems.
Our findings also indicate that children in working poor families have
much less structural access to care and use of health services than children
in moderate to affluent families, even after adjusting for other factors.
Being fully attached to the labor force reduces the discrepancy but does not
equalize children's access to care or utilization of health services. If health
insurance were available, disparities in structural access and entry into
care could narrow. Nevertheless, the results of the regression models using
moderate to affluent children as the reference group suggest that health insurance
provision may not suffice to remove the barriers to adequate care for children
of working poor families. An additional challenge for health insurance programs
like CHIP will be to ensure that subscribing health plans offer providers
and delivery systems incentives to provide adequate care.
The Children's Health Insurance Program was designed to provide health
insurance to approximately 5 million eligible uninsured children in families
with incomes falling below 200% of the poverty level. By providing funds to
expand Medicaid or to establish new programs, Congress has given states flexibility
in designing and implementing their programs. Although CHIP plans are progressing
in most states, enrollment has fallen short of expectations because of multiple
barriers. These include the complexity of administrative and eligibility structures,
cost-sharing provisions that may discourage enrollment, poorly designed outreach
programs, insufficient efforts to ensure that children maintain coverage once
they are enrolled in CHIP or Medicaid, and poor coordination among CHIP, Medicaid,
and TANF programs.17 These access barriers,
in addition to cultural and linguistic barriers, need to be addressed if CHIP
is to cover the target population. Because states with high uninsurance rates
also have lower levels of average health status and more access problems,
they may require more resources to achieve success in health care reform.18 Future studies should continue to monitor statewide
differences in access to care for children of the working poor.
The baseline NHIS data have some shortcomings. The measure of health
insurance is complex and subject to parental reporting error. In addition,
the insurance measure reflects coverage at the time of the interview, whereas
health care use is measured in the last 12 months. Health care utilization
recall over a 12-month period may also be subject to error.19
The type of health plan, which may affect access and utilization, was not
examined because of concerns about inaccurate reporting.20
In cross-sectional studies, the causal direction of the relationship between
variables cannot be ascertained. Moreover, adjusting for demographics and
other factors does not preclude the possibility that unmeasured factors could
account for the observed differentials for the working poor. Although income
was imputed for 12% of the sample, pairwise relationships between access-to-care
variables and the study groups were similar for those with imputed and nonimputed
income.
Despite these limitations, this study demonstrates that compared with
other child populations that have been studied much more extensively, children
in working poor families face serious barriers to care. Access and utilization
of health services for the working poor need to be carefully monitored as
welfare and health insurance reforms provide new challenges and opportunities
for working poor families in the United States.
AUTHOR INFORMATION
Accepted for publication February 4, 2001.
This study was funded by the Henry J. Kaiser Family Foundation, Washington,
DC, to support the ongoing work of the Kaiser Commission on Medicaid and the
Uninsured.
We thank Connie Gee for clerical support and Steven Samuels, PhD, for
statistical consultation.
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