Parent and Child Usual Source of Care and Children’s Receipt of Health Care Services

Dependent Variables

Asking parents (or caregivers) about their perceptions of a child’s unmet need for care is one of the most common ways to assess unmet need.³¹ Accordingly, we used MEPS-HC items that pertained to parent-reported unmet health care needs to construct the following 6 unmet need variables: (1) insurance coverage gaps during the year, (2) no doctor visits in the past year, (3) less than yearly dental visits, (4) unmet medical and prescription needs, (5) delayed care, and (6) problems getting care. Yearly doctor visits were chosen because the American Academy of Pediatrics recommends yearly health care visits up to 21 years.³² For child dental care, the American Academy of Pediatric Dentistry recommends that yearly dental visits begin at the time of the first tooth and no later than 12 months of age.³³ The delayed care variable combined MEPS-HC parental reports that a child did not always get care as soon as was wanted for an illness, injury, or condition that needed care right away and that a child did not always get an appointment for routine health care as soon as was wanted. The variable pertaining to problems getting care combined 3 MEPS-HC questions regarding a child having problems obtaining needed medical care, tests, prescriptions, referrals, or other treatments.

Because receipt of age-appropriate preventive services has an important impact on long-term health,³⁴ we also constructed 4 composite outcomes pertaining to whether a child had not received anticipatory guidance regarding the importance of healthy eating, regular exercise, use of car safety devices (ie, seat belts, safety car seats, booster seats), and use of helmets while riding a bicycle or tricycle. We then assessed whether the child or parent had missed receiving guidance regarding at least 1 of the preventive counseling items in the past 2 years and during the child’s lifetime. Lastly, we assessed whether the child had not received guidance regarding any of the 4 preventive counseling items (missing all 4) in the past 2 years and during the child’s lifetime. Our analyses of the preventive counseling items excluded the 5,700 children in the MEPS-HC population that was younger than 2 years, because these questions were asked only of children aged 2 to 17 years.

Independent Variables

Among the MEPS-HC child sample (n = 56,302), we assessed the cross-sectional USC status of the child and parent(s) as the primary independent variable. We then created 6 mutually exclusive child-parent USC patterns (Table 1). These 6 groups were collapsed into 4 groups for univariate and multivariate analyses: (1) the child and 1 or both parent(s) have a USC (USC: yes child/yes parent[s]), (2) the child has a USC and 1 or both parents do not have a USC (USC: yes child/no parent), (3) the child does not have a USC and 1 or both parents have a USC (USC: no child/yes parent[s]), and (4) neither child nor parent has a USC (USC: no child/no parent).

Identification of the covariates that might influence children’s access to health care was guided by the conceptual model designed by Aday and Andersen^35,36 and by MEPS-HC variables shown to be associated with children’s unmet health care needs.²² We used 2-tailed χ² analyses to test univariate associations between these variables and each of the outcome variables. Ten independent variables were associated with at least 1 outcome (P <.10): household income, child’s age, child’s race/ethnicity, family composition, parental education, parental employment, region of residence, child’s insurance status, parent’s insurance status, and child’s health status. Thus, all covariates were included in logistic regression models with the exception of parental employment, which was found to have significant collinearity with parental education and household income variables.

Specifically, the household income groups were based on the MEPS-HC–constructed variable that divides families into 5 income groups based on earnings as a percentage of the federal poverty level, and in 2007 the federal poverty level for a family of 4 was $20,650.³⁷ We created 1 child race/ethnicity variable that was based on self-reported responses to standard options provided by MEPS interviewers. Family composition refers to whether the child could be linked to 1 parent or 2 parents residing in the same household (it does not account for biological relationship between parent and child or the marriage status between the 2 parents).

Analyses

We determined the prevalence of different child-parent USC patterns. We then used 2-tailed χ² tests to ascertain univariate associations between covariates and each of the 4 child-parent USC subgroups, and univariate associations between each of the child-parent subgroups and unmet need and preventive counseling outcomes. Finally, we used a series of logistic regression models to assess the adjusted associations between the 4 child-parent USC subgroups and the outcomes. Models were first built for the outcome of having no doctor visits in the past 12 months using forward selection modeling techniques. Covariates selected in this model were used for all remaining outcomes to achieve consistency in our examination and to facilitate comparisons of results across models, with 1 exception—child’s and parent’s insurance status were excluded from the model that assessed insurance coverage gap as the outcome. We reported measures of association as adjusted risk ratios (aRRs).³⁸

We used SUDAAN 10.0.1 (Research Triangle Institute, Research Triangle Park, North Carolina) for all statistical analyses to account for the complex sampling design of the MEPS; α level was set at .05 for all multivariable analyses a priori. This study protocol was reviewed by the Oregon Health & Science University Institutional Review Board, which deemed the study exempt because the MEPS-HC is publicly available.

Policy Implications

The results of this study—showing that a child’s receipt of recommended health care services is associated not only with their own access to a USC but also their parents’ access to a USC—highlight the need to broaden the focus beyond expansions in the child health care workforce and quality improvements in child health care to consider the role that parental access to a USC plays in ensuring access to health care services for children. There is a clear need to advocate for policy changes that improve access to a USC for all family members. The Patient Protection and Affordable Care Act (PPACA) has a provision to increase the number of primary care clinicians,⁴² which is a step in the right direction. Specifically, the PPACA will provide resources for increasing training through additional primary care residency programs and numbers of nurse practitioners, as well as training more physician assistants to work in primary care settings. Scholarship and loan repayment programs will also be implemented for primary care clinicians who choose to work in underserved areas.⁴³ Another possible policy change that could affect USC continuity is ensuring that a change in health insurance plans does not mean a change in one’s primary care clinician or site.

Furthermore, as more children and parents have discordant insurance coverage patterns (eg, child covered by public insurance, parents covered by employer-based private insurance),⁴⁴ the need for both child and parents to have a USC will become even more important. Further studies are needed to determine which aspects of care are most likely to improve when everyone in the family has a USC, and whether child-parent USC concordance might mitigate the impact of fragmented family insurance coverage.

Practice Implications

In addition to advocating for the important policy changes outlined above, clinicians can develop practice-based interventions to assist parents in finding a stable USC for their children and for themselves. Some clinicians, such as family physicians and general practitioners, are in the unique position of providing primary care to all members of the same family. The patient-centered medical home holds promise as a model that can focus on coordinating care for entire families.¹⁰

Even clinicians who see only children or only adults could perform similar interventions if they are part of larger centers that can provide coordinated care for all family members. Interventions could also involve methods to track USC status for all family members. With widespread and expanding implementation of electronic health record systems, such processes and potential interventions could be computerized, and family records could be linked across USC sites.

Limitations

Although the MEPS-HC is representative of the civilian, noninstitutionalized population in the United States, the observational nature of the survey, as well as the cross-sectional analysis of the data, limits causal inferences. In addition, secondary analyses are limited by existing data. For example, we could obtain only the USC status and other items (ie, education, employment, insurance status) from parents residing in the respondent household. As with all studies that rely on self-report (or parental report), response bias is also a possibility. For example, a parent’s report regarding his or her child’s health care patterns may be biased because of the belief that a child’s unmet needs reflect poorly on the parents. We did not measure type of USC or assess the comprehensive nature of the USC to determine whether the USC met the criteria needed to be considered a medical home. We did not investigate the type of health insurance or the effect that a specific type of plan may have had on receipt of health care services. Lastly, it is possible that parents do not have a USC because they do not believe that access to the health care system ensures health for their children or themselves and not because they cannot obtain one.

When parents lack a USC, their child typically receives fewer recommended health care services and experiences more unmet needs regardless of the child’s USC and insurance status. Ensuring better access to necessary health care services will require comprehensive policy reforms that make it easier for all individuals to find and maintain a USC. Keeping the entire family in mind when crafting any new reforms will be essential to achieving a sustainable health care system and the best possible health outcomes for our children.