SCHIP reduces some, but not all, racial disparities in health care
Enrollment in an SCHIP program can improve access to health care services, continuity of care, and quality of care for all racial and ethnic groups. It also can reduce preexisting racial and ethnic disparities in access, unmet health care needs, and continuity of care. But racial and ethnic disparities in quality of care remain, despite improvements for all racial groups, according to a study by researchers at the University of Rochester (NY) medical school.
It has been shown that racial and ethnic disparities are associated with a lack of health insurance. And although the SCHIP program provides insurance to low-income children, many of whom are members of racial and ethnic minority groups, little is known about whether SCHIP affects racial and ethnic disparities among children who enroll.
Using parent telephone surveys just after SCHIP enrollment in the New York State program and then after one year, the researchers looked at usual source of care, preventive care use, unmet needs, patterns of usual source of care use, and parent-related quality of care before versus during SCHIP.
The researchers reported that before SCHIP, a greater proportion of white children had a usual source of care (95%), compared with black children (86%) and Hispanic children (81%). Nearly all children had a usual source of care during SCHIP (98% white, 95% black, and 98% Hispanic).
Before SCHIP, black children had significantly greater levels of unmet needs relative to white children (38% vs. 27%), whereas white and Hispanic children did not differ significantly. Also during SCHIP, racial and ethnic disparities in unmet need were eliminated, with unmet need at 19% for all three racial/ethnic groups.
Before SCHIP, more white children made all or most visits to their usual source of care, relative to black or Hispanic children. All improved during SCHIP with no remaining disparities.
Parent-rated visit quality improved for all groups, but pre-existing racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. The researchers concluded that sociodemographic and health system factors did not explain disparities in either period.
The researchers said despite evidence that lack of insurance contributes to racial/ethnic disparities, evidence has been scant that provision of health insurance to vulnerable children reduces pre-existing disparities.
National-level analyses have suggested that health disparities have not been reduced in children over the last 20 years despite Medicaid expansion and other efforts to provide health insurance to children, and that racial and ethnic disparities exist even without populations that have similar insurance coverage.
"Two of our findings demonstrate important successes of SCHIP in addressing racial/ethnic disparities," the researchers wrote. "First, all racial/ethnic groups showed marked improvement after enrollment in SCHIP for all measures. Second, statistically significant preexisting disparities in measures of access, unmet need, and continuity of care were virtually eliminated during SCHIP, and these effects remained even after controlling for sociodemographic factors such as income and family factors and health system factors such as changing the usual source of care."
Despite provision of health insurance, racial and ethnic disparities remained in use of preventive care and in ratings of visit quality. Although all racial and ethnic groups experienced an increase in use of preventive care and improved quality, Hispanic children continued to have the lowest levels during SCHIP. The researchers said the findings support results from other studies that health insurance is an essential first step toward improving care but may not result in optimal care by itself. They said their work demonstrates SCHIP's success in ensuring access to a usual source of care and markedly improved continuity of care there.
Quality disparities logical
They said it is logical that disparities remain in quality and suggested that consideration of differences in language, acculturation, or perception and reporting of health care experiences between and within different racial groups can lead to additional understanding of the barriers that remain within health care settings and even within established patient-provider relationships and may suggest strategies beyond health insurance alone that are necessary to eliminate remaining disparities.
"The results of this study have implications for the pursuit of national goals to eliminate racial and ethnic disparities in health," the authors said. "First, the shift toward a usual source of care for all or most care may reduce fragmentation of services and provide increased opportunities for primary care providers to establish and maintain relationships with children and families over time, potentially contributing to improved measures of quality over longer periods of observation. Second, the relatively smaller scale of improvement among Hispanic children raises questions about the nature of these disparities and alternative strategies to combat them. Additional work beyond the provision of health insurance should strive to understand better the causes of continued disparity and should test creative strategies that are designed to address and eliminate disparities in Hispanic children.
"Third, although disparities in access to care were nearly eliminated, disparities in quality of care remained. This study highlights the importance of ongoing initiatives to improve quality of care for all racial and ethnic groups."
Keep optimistic expectations
The researchers said policy-makers should maintain optimistic yet reasonable expectations for SCHIP. They said their finding of reduced disparities in key child health care measures after SCHIP enrollment represents an important achievement in providing health insurance to low-income families.
Future expansion of SCHIP or of other health insurance programs for children and additional research on mechanisms of disparities may both improve care and reduce disparities among vulnerable children, they said.
Enrollment in an SCHIP program can improve access to health care services, continuity of care, and quality of care for all racial and ethnic groups.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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