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Health and Health Care Among District of Columbia Youth Anita Chandra, Carole Roan Gresenz, Janice C. Blanchard, Alison Evans Cuellar, Teague Ruder, Alex Y. Chen, Emily Meredith Gillen Supported by the Children’s National Medical Center HEALTH The research described in this report was supported by the Children’s National Medical Center and conducted within RAND Health. Library of Congress Cataloging-in-Publication Data is available for this publication. 978-0-8330-4805-9 The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R® is a registered trademark. © Copyright 2009 RAND Corporation Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes. Unauthorized posting of RAND documents to a non-RAND Web site is prohibited. RAND documents are protected under copyright law. For information on reprint and linking permissions, please visit the RAND permissions page (http://www.rand.org/publications/ permissions.html). Published 2009 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665 RAND URL: http://www.rand.org To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: [email protected] Summary S.1 Overview This study provides an assessment of health and health care among the more than 100,000 youth residing in Washington, D.C. It is designed to lay a factual foundation for advocacy and policy decisions related to children’s health in the District, as well as to help inform the allocation of community benefit resources by Children’s National Medical Center (Children’s National), a children’s hospital in the District. The three goals of the study are as follows: 1. Describe the health status of District children and their use of health services, with particular attention to changes over time in health status and health care use, as well as differences by age, insurance status, and location within the city. 2. Assess environmental characteristics that may contribute to or buffer against poor health outcomes among children. 3. Consider implications for improving children’s health in the District based on the evi- dence developed in (1) and (2). Our analyses are based on a synthesis of information from prior research (such as vital statistic reports and studies of the school nursing and school mental health programs), original data analysis of existing survey and administrative data, and information gathered through focus groups with parents, adolescents, and health providers. S.2 Key Findings In what follows, we summarize key findings related to particular domains, including health insurance, access to health care, and specific health conditions. Health Insurance Most children in the District have health insurance. The rate of uninsurance in the District (an estimated 3.5 percent of children in 2007) is lower than the national rate of uninsurance among children (an estimated 9.1 percent, based on data from the National Survey of Chil- dren’s Health). However, District parents and providers raised concerns about gaps in insur- ance coverage for children related to re-enrollment or recertification. xvii xviii Health and Health Care Among District of Columbia Youth Access to Health Care Despite the encouraging finding that most District children have health insurance and have a medical home (as reported by their parents), access to care among the pediatric population nonetheless appears to be limited in several problematic ways. t First, parents in the District are more likely than parents nationwide to report having dif- ficulty seeing a specialist (12 percent in D.C. versus 8 percent nationally). t District parents, teens, and providers noted particular difficulty accessing dental and mental health care as well as developmental assessments. t Ambulatory care–sensitive inpatient hospitalization (ACS-IP) rates, which are related to the availability and efficacy of primary care, increased among the youth population in the District between 2004 and 2007, suggesting a worsening trend in access to or quality of ambulatory care. The most notable increase was among children ages 0–4. t Among publicly insured children specifically, rates of office-based health care use in the District appear to be well below national rates. t Rates of hospital use among publicly insured children were substantial. For example, among nondisabled children in managed care, about 27 percent use the emergency department (ED) during a year and among disabled children in managed care, that figure was 42 percent. Further, a segment of the publicly insured youth population appears to use the ED heavily (more than 3–5 times per year), possibly as a primary source of care. Finally, inpatient readmission rates among publicly insured children show room for sig- nificant improvement. Barriers to Health Care Barriers to access to primary and specialty care in nonhospital settings are multiple and complex. t At least some of the access problem lies in the availability of primary and specialty care providers. – In focus groups, District parents indicated that availability of appointments for pri- mary care was a key factor limiting access. – Both parents and providers pointed to limited availability of off-hours (evening, week- end, early morning) ambulatory care. – With regard to specialty care, available data suggest that the distribution of pediatric specialists is uneven across locations throughout the city and is not correlated with children’s health care needs. A particular dearth appears to exist for pediatric mental health specialists east of the Anacostia River. t Capacity is not the only factor limiting the accessibility of ambulatory care, however. In focus groups, District parents, teens, and providers noted several issues, including – a perceived lack of understanding among providers of cultural and neighborhood issues important to their health care – the developmental appropriateness of health services for adolescents – health care providers’ general approach to and communication style with adolescents Summary xix – limited availability of providers who speak languages other than English and/or of interpreters – the inaccessibility of providers and challenges with existing services for transportation assistance – the limited amount of health education and health promotion available in schools and community settings – lack of a standard, uniform, and facile process for the authorization of specialty care referrals. Priority Health Conditions and Health Behaviors Particular health conditions and health behaviors warrant special attention because of their prevalence, importance to health, and/or the patterns of health care use associated with them. t Asthma – Among children in Medicaid/Alliance managed care and fee for service (FFS) Med- icaid, 8 and 5 percent of enrollees who use services, respectively, had asthma. Asthma was one of the top ten most prevalent qualifying conditions among children enrolled in Health Services for Children with Special Needs (HSCSN). – Children with asthma use substantial hospital-based services. For example, asthma contributed to between 11 and 16 percent of inpatient hospitalizations in 2007 among all District