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Show Ambulatory Care Sensitive Hospitalizations in Utah Children and Evaluation of Access to Primary Care by Marlene J. Egger, Ph.D.; Chun Lu, M.P.H.; Han Kim, M.S.P.H. Abstract The State Children's Health Insurance Program (CHIP) is one incremental approach to mending the American health care safety net for children. Intended to improve access to health care services for Utah children by offering insurance coverage to children up to age 19 in families up to 200% of the federal poverty level. Extensive annual program evaluations of the Utah CHIP are proposed. The rate of Ambulatory Care Sensitive (ACS) hospitalizations is considered an index of access of a population to primary care. These are hospitalizations for selected diagnoses some of which might reasonably have been prevented if primary care had been received in time. ACS hospitalizations are elevated in low-income areas and in rural/frontier areas. The ACS hospitalization rate appears sensitive to the presence or absence of economic barriers to access. It has been reported to be lower and/or less correlated with socioeconomic status in countries with national health insurance. In addition, in at least one American population, fewer hospitalizations are for ACS conditions for the Medicaid population than for the uninsured. Therefore, the ACS hospitalization rate may represent one viable, readily available tool among others in evaluation of the outcomes of the Children's Health Insurance Program. Child Uninsurance and the CHIP Americans paid nearly 10 billion dollars to purchase health care in 1995, 40% of which was for hospitalization (Levit et al., 1996). Yet, 10 million children under age 18 were uninsured in the same year (Weil, 1997). Access to basic health care continues to be problematic for economically challenged populations, uninsured children, rural populations, inner city residents, the elderly, culturally diverse people, and other vulnerable groups. The 20th century United States has not taken comprehensive approaches to health insurance coverage comparable to the national health insurance of other industrialized nations, except for Medicaid and Medicare. Instead, incremental mending of the medical safety net continues through statutes such as the Kassebaum-Kennedy Portability Act of 1996 and the Children's Health Insurance Program (CHIP) of 1997. At the national level, the CHIP program was created by the Balanced Budget Act of 1997 "to provide funds for States to enable them to initiate and expand the provision of child health assistance to uninsured, low income children" (U.S.Congress, 1997). CHIP was appropriated for ten years, at $4.2 billion for each of the first three years, and $3.15 billion in years 05-07. Uninsured children up to age 19 in families up to 200% of the federal poverty level are covered. Funds are available to states on a matching basis, with a match rate somewhat more favorable than that of Medicaid (Weil, 1997). Some view CHIP as a partial response to census data indicating that almost 14% of children were uninsured in 1995 (Weil, 1997). Whereas most American children are covered by a parent's employer-sponsored health insurance, there are several recurring reasons for not being insured. Some working families lack access to such a plan or cannot afford the copayments. Some families fall victim to gaps in eligibility requirements for public insurance due to income levels marginally above the federal poverty level, required waiting periods, etc. Some families are eligible for public insurance but do not enroll due to administrative or language barriers, or simple unawareness of available programs (Reschovsky & Cunningham, 1998). The CHIP program attempts to close the gap in eligibility requirements, both directly, by increasing the target population, and also indirectly, by requiring states to plan and evaluate outreach, coordination, and other performance efforts. CHIP was enacted in the context of national pressure to balance the budget, with a considerable resultant shifting to states of responsibility for major social programs (Anton, 1997). This is also a time in American history when health care cost-containment measures have emphasized managed care and rate regulation (Thorpe, 1992), and declining reimbursements have taken the slack out of the budgets of safety net providers (Fraser, 1997). This makes it difficult for providers to subsidize charity care or discounted fees for the poor. These circumstances are relevant to the necessity to monitor access to 50 |