Katherine Sawczuk
Spring, 2011
Honors Project: How Income and Insurance Affect Key Aspects of Children’s Healthcare
ABSTRACT
The objective of this study was to investigate how income and insurance affect key aspects of
children’s healthcare. To accomplish this, surveys were conducted with a sample of 101 parents with
children between two and eight years of age. The survey was developed for this research. It focused on
the number of times children in the sample saw a doctor within a year, the number of reasons for which
each child was taken to the doctor, whether the child had check-ups, whether the child had a family
doctor, how the child enjoyed visiting the doctor and whether the parents feel they could afford to take
their child to the doctor. The survey also recorded basic information about parents’ socioeconomic
status and insurance. Participants were recruited in person in public areas including churches and
daycare centers, and participants also were recruited using a snowball sampling plan to complete the
survey online.
This study found that increased income correlated with decreased reporting of difficulty paying
for visits to the doctor. Insurance, public or private, is a huge benefit for children and makes them much
more likely to get adequate healthcare. In this research, it was found that simply having or not having
insurance can mask the discrepancies in health care that are related to low income. Children with some
sort of insurance are shown to visit the doctor more times within a year, be taken to the doctor for a
wider variety of reasons. Children with some sort of insurance are more likely to have a family doctor
and are also more likely to enjoy their visits to the doctor, in part because they have a family doctor.
Overall, the study confirmed most of the expected results and offers support for continued assistance
providing health insurance to low income families who have children.
INTRODUCTION
Healthcare reform has been a central issue and concern in American life and a widely used
catchphrase in many recent elections. In the current economic recession, healthcare costs are steadily
rising and healthcare is becoming less affordable for many families. Before radically changing the
How Income and Insurance Affect Key Aspects of Children’s Healthcare
current system, it is important to determine the functional versus non-functional aspects of current
healthcare systems.
Medical insurance can defray the cost of medical care and help families maintain adequate
healthcare despite rising costs. Many families in the United States have access to private insurance of
some sort through their employers. Newacheck et al found that insurance status has a strong
correlation with children’s access to primary care. Uninsured children saw healthcare practitioners
much less often than children with insurance, and were much less likely to have a regular source of care.
Uninsured children were also more likely than insured children to go without needed medical, dental, or
other health care. This study also examined the reasons that not all children are insured by their parents
and the highest reported factor was affordability.1
Many attempts have already been made to promote equal access to healthcare for all children,
such as Medicaid and more recently State Children’s Health Insurance Program (SCHIP). Medicaid,
enacted in 1965, provides medical care to families who receive welfare, people with disabilities and
senior citizens. In 1996, when Congress enacted the Personal Responsibility Work and Opportunity
Reconciliation Act, Medicaid was completely severed from welfare. SCHIP, enacted in 1997, sought to
broaden health care coverage for children. Currently, these two programs function jointly to ensure
that both low-income families can obtain health insurance (Medicaid) and children of low-income
families who do not qualify for Medicaid can obtain health coverage (SCHIP). 2
Both Medicaid and SCHIP have been demonstrated to be helpful in closing the gap between
income levels access to insurance. In a study by Eishert and Gabow, a sample of children were followed
before and after enrollment in SCHIP. They found children enrolled in SCHIP had more well-child visits
to their health care provider than uninsured children, and children enrolled in SCHIP were more likely to
be up-to-date on their recommended shots and immunizations. Also, children enrolled in SCHIP were
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
less likely to have urgent care visits and more likely to have specialty care visits. 3 Similarly, Feinberg et
al. compared the unmet medical needs of children with Medicaid to those of children of similar income
but without Medicaid. Across all incomes, those without Medicaid were more likely to have unmet
needs for medical services, prescription drugs and dental care. 4
PURPOSE
The study presented here investigated how income and insurance affect key aspects of
children’s healthcare. Specifically, it looks at the number of times children in the sample saw a doctor
within a year, the number of reasons for which each child was taken to the doctor, whether the child
had check-ups, whether the child had a family doctor, how the child enjoyed visiting the doctor and
whether the parents feel they could afford to take their child to the doctor.
HYPOTHESES
I hypothesized that income level is related to doctor visits, and based on this, I predicted that:
low income participants would report fewer visits to the doctor, and low income participants would
report fewer reasons for visits to the doctor. I predicted that income level is related to ability to pay for
services both in children and adults – specifically, low income respondents would report more difficulty
paying for doctors visits (both for themselves and for their children).
I hypothesized that insurance type is also related to doctor visits. I predicted that respondents
lacking insurance would report the least doctor visits within a year, as well as the least number of
reasons for doctors visits. I predicted that respondents with public insurance would report fewer doctor
visits than those with private insurance, and also respondents with public insurance would report fewer
reasons for doctor visits than those with private insurance.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
Lastly, I hypothesized that having a family doctor is related to how well children enjoy visiting
the doctor. Based on this, I expected to find that having a family doctor would trend with children
having a higher level of comfort during doctor visits and positive attitude regarding doctor visits.
MATERIALS AND METHODS
I developed and piloted a survey in order to determine how parental income and insurance
affected the healthcare of their children and their children’s perception of their physician. (See
Appendix A) Before undertaking data collection, potential participants were restricted to parents with at
least one child between the ages of two and eight years of age.
The survey obtained socioeconomic status of parents, information about parents’ insurance,
and information about the health insurance of their child, if different from their own. Information about
the child’s healthcare was obtained next: how often the child is taken to the doctor, reasons for which
the child is taken to the doctor, whether the child has a family doctor and how the child enjoys visiting
the doctor.
Information about payment for the child’s healthcare was obtained last. Participants were
asked what factors were involved in their decision-making process when determining if their child
needed to visit a doctor. Participants were asked whether or not they had ever had any trouble paying
for their own or their child’s doctor visits, and also if they had ever had any trouble getting their
insurance company to cover their own or their child’s doctor visits.
Participants were recruited in person in public areas including churches and daycare centers, and
participants also were recruited using a snowball sampling plan to complete the survey online. A total
of 101 separate participants responded. Data was analyzed using T-tests, with a p-value of 0.05 set as
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
significant. Differences were not significant unless otherwise mentioned. Where data were not
significant, trends and patterns in the data were analyzed.
FINDINGS
PARTICIPANTS
Table 1 shows the breakdown of participants into income ranges and insurance categories. Of
the 101 participants, two chose not to answer income range or insurance and were thus removed from
all comparisons relating to insurance and income. In many cases, the child’s insurance status or source
differed from that of their parents, so data analysis was based on the Child Insurance Coverage, seen on
the right side of the table.
Table 1. Income and Insurance Breakdown of Participants
Parent Insurance type
Yearly
Income
Under
$15,000
$15,000$40,000
$40,000$60,000
$60,000$80,000
Above
$80,000
Child Insurance Coverage
Covered
Covered
Total
Self
Employer
Not
by
Medicare Medicaid None
by Public
Provided Provided
Covered Parent's
Insurance
Insurance
-
2
-
3
1
2
0
4
18
1
8
1
4
4
2
9*
11*
18
1
17
-
-
-
2
15*
2*
19
1
18
-
-
-
-
19
-
38
1
37
-
-
-
-
37
1
6
80
18
*= overlap
6
99
The age of children involved was restricted to children over two in order to disregard the many
doctor visits in the first two years of life. After two years, it was assumed, doctors visits decrease in
frequency both as the schedule of check-ups becomes less rigid and because the child’s immune system
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
has begun to develop, making most illnesses less serious. The age of children involved was restricted to
children under eight for several reasons: they are less likely to be involved in sports that can cause
serious injury or require more than annual physicals, and they are young enough that judgment as to the
necessity of a physician is a decision made entirely by the parents.
As seen in Table 1, the total sample size is 99. In some categories, the n is much smaller. The
lowest income category had only 6 respondents and breaking that down into categories based on
insurance, means there are only 2 respondents within that income range whose children were
uninsured, and 4 respondents whose children are covered by public health insurance. Despite the small
sample size, trends are still seen in the data, but further research would be necessary in order to solidify
the conclusions.
NUMBER OF DOCTOR VISITS PER YEAR
Table 2. shows the averages for number of doctor visits per year reported. More doctors visits in
a year was considered to be an indicator of good healthcare because it indicates that children are taken
to the doctor whenever necessary.
Table 2.
Average Doctor Visits per year
Yearly Income
Average for
income
Uninsured
Children
Parent
Insured
Public
Insured
Under $15,000
$15,000 - $40,000
$40,000 - $60,000
$60,000 - $80,000
Above $80,000
4.08
3.25
3.16
2.36
3.99
1.25
4
2.5
-
5.13
3.14
2.36
4.04
5.5
5.81
4
2
2.58
3.42
3.56
Average for Insurance
INCOME EFFECTS
As mentioned previously, it was hypothesized that children from lower income households
would see the doctor less often than children in higher income households. However, this hypothesis
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
was not supported by the data. As shown in Table 2, for the lowest four income categories, as parental
income increases, the number of doctor visits per year decreases, indicating that children of parents
with the lowest income go to the doctor more often than children of parents with higher income. This
trend is consistent for the lowest four income ranges, but not for the highest income range. Participants
in the highest income range report taking their child to the doctor an average of 3.99 times per year,
higher than the three income ranges preceding it, but still lower than the lowest income category.
A possible explanation for this trend could be that children of lower income parents are more
likely to get sick, due to poor diets, and increased exposure to illnesses in their environments. Also,
Middle-income parents may have spare capital to spend on over-the-counter medications even when
the child would heal without them, while lower income parents may take their children to the doctor
more often to confirm that the medications that they purchase to treat their children are necessary.
Essentially, disposable income makes a difference in children’s healthcare.
It is interesting that the lowest average of doctor visits per year occurs for children of parents
within the $60,000 - $80,000 income range. Parents in this group also have the lowest average
deductible compared to all other income groups. ($421, compared to $902, $1003, and $576
respectively to increasing income ranges and disregarding the lowest income range, where no
deductibles were reported). Conclusions as to the cause of this low are beyond the scope of these data.
It seems that something unrelated to income and insurance is causing the lower average number of
doctor visits for participants in this range.
INSURANCE EFFECTS
I hypothesized that averages for reported number of visits to the doctor within a year would be
lowest for uninsured children, slightly higher for children with public insurance, and highest of all for
children who are covered under their parents’ insurance. These data do not support these hypotheses.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
Overall, children who were insured in some way (n=98) had a higher average number of doctor visits per
year than children who were uninsured (n=6) (See Table 2). Children with public insurance (n=18) had
the highest average number of doctor visits per year with an average of 3.56, and they were followed by
children covered by parental insurance (n=80) and uninsured children with 3.42 and 2.58 visits per year,
respectively.
Public insurance provides a great help to families who struggle to pay for healthcare. Looking at
the data from the lowest income level only, the public insurance appears to have made a huge
difference in the number of doctor visits within a year. While uninsured children had an average of 1.5
doctor visits per year (n=2), children with public insurance had around four times that many visits with
an average of 5.5 doctor visits per year (n=4).
Looking specifically at the data from the participants with an income of more than $80,000, the
impact of being insured appears to subside. Of participants in the above $80,000 income range, 37
reported that their child was covered under their own insurance plan and 1 reported that their child was
covered under a public insurance plan. The children covered in their parents’ insurance plan saw the
doctor an average of 4.04 times in a year, while the child covered by public insurance only saw the
doctor 2 times in that year.
At the lowest income level, where public insurance is the alternative to no insurance at all, it
vastly increases the number of times they see the doctor within a year. The average number of visits
for children on public insurance in other income categories is comparable to the average number of
visits for children covered by their parents insurance within the highest income range. Thus, public
insurance confers a huge advantage to low income children over uninsured children of the same
income; it allows their parents to obtain medical attention on their behalf whenever they deem
necessary and not only when they can afford it.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
One would expect to see that public insurance would confer the same advantage to children of
all income levels. On the contrary, at the highest income level, where children with public insurance
(n=1) can be compared other children who are covered by their parent’s insurance (n=37), it appears
that coverage under parental insurance confers the greatest benefit and promotes the most doctor
visits within a year. However, it is important to note that only one participant in the above $80,000
income range had a child who was covered under public health insurance, therefore the two visits per
year could be (and probably is) much lower than the average number of visits for children on their
parents insurance for reasons beyond the insurance type. Public insurance may be best for lower
income families who may not be able to cover increased insurance costs for their children, but less
beneficial at upper incomes where employer provided insurance may be more economical and allow the
child to see the doctor more often. However, whatever the source, insurance increases the likelihood
that a child will see the doctor when they need to.
NUMBER OF REASONS CHILDREN WERE TAKEN TO VISIT A DOCTOR
In the survey, participants were asked to select from a list of items, which represented reasons
for which they would take their child to the doctor. The list consisted of: High Fever, Low Fever, Rash,
Stomachache, Persistent Cough, Vomiting, Check – Up, Sore Throat, Injury, Well – Child Care, and Shots
/ Immunizations. This list was adapted from a list of the top ten reasons children go to the doctor.5 The
number of reasons that each participant selected was tallied for analysis. The averages for each
category are shown in Table 3.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
Table 3.
Yearly Income
Average Number of Reasons to visit Doctor
Average for
Uninsured
Parent
Public
income
Children
Insured
Insured
Under $15,000
4.33
$15,000 - $40,000
4.94
$40,000 - $60,000
6.39
$60,000 - $80,000
5.47
Above $80,000
5.11
Average for Insurance
1.5
3.5
6.5
3.29
3.6
6.42
5.47
5.16
5.37
5.75
5.81
6
3
5.67
INCOME EFFECTS
As shown in Table 3, no pattern was observed in the data for the average selected number of
reasons to visit the doctor by income. I hypothesized that lower income participants would report fewer
reasons requiring a doctor’s visit. No relationship was seen between income and reported number
reasons requiring doctor’s visits.
INSURANCE EFFECTS
Although income had little effect on the number of reasons that participants reported for taking
their children to the doctor, insurance had a noticeable effect. The hypothesis that uninsured
participants would claim fewer reasons than insured counterparts was supported, but the expectation
that participants with public insurance would report fewer reasons than those with private insurance
was not. Parents of children who were covered under insurance of any sort reported, on average, more
reasons from the list that would prompt them to take their child to the doctor. Similar to the number of
doctor visits per year, the difference was most pronounced at the lower income levels (shown in Table
3), where uninsured children can be compared to insured children.
More specifically, within the lowest income range, the difference in reported reasons is very
pronounced between uninsured and publically insured children. For uninsured children (n=2), the
average number of reported reasons is 1.25, while for publically insured children (n=4) the average
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
number of reported reasons is 5.5. Averages for reported number of reasons for participants within the
$15,000 - $40,000 were 3.5, 3.6 and 5.81 for uninsured children (n=2), children covered on their parent’s
insurance (n=9) and publically insured children (n=11), respectively. Averages for reported number of
reasons for participants within the $40,000 - $60,000 were 6.5, 6.42 and 6 for uninsured children (n=2),
children covered on their parent’s insurance (n=15) and publically insured children (n=2), respectively.
The average for reported number of reasons for participants within the $60,000 - $80,000 income range
was 5.47 for children covered on their parent’s insurance (n=19). The averages for reported number of
reasons for participants within the above $80,000 was 5.16 for children covered on their parent’s
insurance (n=37), and 3 for children covered by public insurance (n=1).
For the lowest two income ranges, the publically insured children have much higher average
number of reasons than both their uninsured and parent-insured counterparts. The averages for the
publically insured children at these levels are comparable to parent-insured children at higher incomes.
Public insurance provides parents with such low cost access to health care that they can afford to take
their child to the doctor for a larger variety of reasons including reasons that may not be urgent.
SELECTED REASON TO VISIT THE DOCTOR: CHECK-UPS
Well visits or check-ups are an important part of children’s healthcare. During check-ups,
children are screened for diseases, and doctors monitor the growth and development of the child.
Regular check-ups help doctors to catch problems early when treatment is most effective. In the
survey’s list of reasons for taking children to the doctor, check-ups was one of the options, and below
the frequency of parents reporting check-ups is analyzed.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
Table 4.
Check – ups
Average
for
Uninsured Parent
Public
income
Under $15,000
5 83% 1
50%
4 100%
$15,000 - $40,000
9 50% 1
50% 3 33% 5
45%
$40,000 - $60,000
15 83% 2 100% 11 73% 2 100%
$60,000 - $80,000
12 63% 12 63% Above $80,000
31 82% 31 82% 0
0
Average for Insurance 72 73% 4
67% 57 71% 11
61%
Yearly Income
INCOME EFFECTS
As seen in Table 4, for all income ranges, fewer than 100% of participants selected “Check-Ups”
as a reason to take their child to the doctor. The percentage of respondents who reported taking their
child to the doctor for check-ups did not show any direct relationship to income. The group with the
lowest percentage of total respondents claiming to take their children to the doctor for check-ups, was
the $15,000-$40,000 income range with only 50% of respondents. The hypothesis that low income
respondents would not take their children to the doctor as often as high income respondents was not
supported. A possible explanation for this phenomenon is that parents within this category work jobs
that are not friendly to taking time off to take children to the doctor, as reported by some respondents.
Parents may have difficulty finding a physician’s office with hours compatible with their work schedule,
which could seriously disincline these parents to take their child to the doctor in non-illness situations.
Another low percentage of 63% was reported for the $60,000-$80,000 income range, but in the other
three income groups above 80% of participants reported taking their child to the doctor for check-ups.
INSURANCE EFFECTS
The hypothesis for the effects of insurance on check-ups was that the lowest number of checkups would be reported for children without insurance, and that no difference in reporting of check-ups
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
would be seen between children with public insurance and children covered in their parents’ insurance
plan. Neither hypothesis was supported by these data. The highest number of respondents by insurance
indicating that they take their children for check-ups was shown for children on their parent’s insurance
plan, with 71% reporting that they take their children for check-ups. (See Table 4) Of participants with
uninsured children, 67% reported that they take their children for check-ups. This number was higher
than expected, but it indicates how the importance of regular check-ups has been emphasized in this
society. This high level of reporting could also be attributed to schools and daycares, which may require
check-ups prior to enrolling children. The lowest reported percentage of participants taking their
children in for check-ups was for children with public insurance, with 61%. None of these categories had
a percentage of children who are taken for check-ups that was extremely different, and it appears that
insurance type does not affect the number of parents who take their children to the doctor for check
ups.
FAMILY DOCTOR
Family doctors are important for children’s healthcare, as having a regular source of primary
care can amplify the benefits received. 6 Also, there is evidence that forming a long-term relationship
with their healthcare provider will promote more accurate diagnoses and result in fewer hospitalizations
over time.7 Long-term relationships with healthcare providers can ultimately result in lower costs
related to healthcare costs. 7 Table 5 shows the breakdown of participants in each category that report
having a family doctor.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
Table 5.
Under $15,000
Participants reporting family doctor
Average for Uninsured
Parent
Public
income
Children
Insured
Insured
4
67%
0
0%
4
100%
$15,000 - $40,000
$40,000 - $60,000
20
19
Yearly Income
$60,000 - $80,000
Above $80,000
91%
100%
2
2
19
95%
37
97%
Average for Insurance 4
100%
100%
-
9
15
18
36
67% 78
100%
100%
9
2
95%
97%
1
98% 16
82%
100%
100%
89%
INCOME EFFECTS
I hypothesized that lower income children would be less likely to have a family doctor. The
lowest two income categories did have the lowest percentage of participants reporting a family doctor,
but this hypothesis was not supported, as shown in Table 5, there was no pattern for percentage of
participants reporting family doctor with income.
INSURANCE EFFECTS
I hypothesized that uninsured children would be less likely to have a family doctor than children
with insurance. Also, I hypothesized that children with public insurance would be less likely to have a
family doctor than children covered under their parents insurance. Both hypotheses were supported.
Participants whose children are insured under their own plan have the highest percentage reporting
that they have a family doctor with 98%. (See Table 5) Of participants with children covered by public
insurance (n=18), 89% reported having a family doctor. The lowest percentage of participants reporting
a family doctor was participants with uninsured children (n=6) at 67%.
REPORTED CHILD EXPERIENCE
In the survey, participants were asked to report, on a scale of 1 to 10, how their children feel
about visiting the doctor. The high end of the scale was 10, and it was designated as children “enjoy
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
visiting the doctor a lot- may even look forward to visits”. The middle of the scale was for children who
were “indifferent” to doctor visits. The low end of the scale, 1, was labeled “very poor reaction to
doctor, may cry or attempt to get out of visits”.
I hypothesized that lower income children would be more likely to report a low number on this
scale, for a couple of reasons. First, based on a previous hypothesis that lower income children visit the
doctor less often than higher income children; because these children are not accustomed to the
situation and it is not something that they would see regularly, they would be less comfortable in it.
Also, I hypothesized that lower income children were less likely to have check-ups and other well-child
care. This would mean that most of the times these children visited a doctor, there was already some
sort of uncomfortable symptoms, which could possibly become associated with the doctor’s office. Last,
I hypothesized that lower income children would be less likely to have a family doctor. Family doctors
facilitate trust, build relationships and can more accurately diagnose their patients. Without a family
doctor, each visit the child encounters a new stranger who performs seemingly invasive tests.
Obviously, this could contribute to discomfort during doctor’s visits.
These data are important because several private practice physicians limit their clientele to
those with private insurance because they stand to make more money from those patients. 8 Public
insurance beneficiates are then left to the clinics who will take their insurance, or the emergency room.
Neither of these options necessarily has a standard staff of physicians so that a child might see the same
person every time. Unless public health programs can increase payback to recruit more private practice
physicians or facilitate the child-family doctor relationship in some other way, the children are at a
disadvantage.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
Table 6.
How children enjoy Doctor visits
Average
for
income
Under $15,000
5.5
$15,000 - $40,000
7.06
$40,000 - $60,000
6.8
$60,000 - $80,000
7.36
Above $80,000
6.87
Average for Insurance
Yearly Income
Uninsured
Children
6.5
6
4
5.5
Parent
Insured
7.4
7.3
7.36
6.86
7.14
Public
Insured
5
7.09
6.5
7
6.38
INCOME EFFECTS
The hypothesis that lower income children would have a lower reported experience of doctor’s
visits was supported, as the lowest income group had the lowest score of all of the income groups.
However, reported experience did not show any relationship with income. Respondents in the lowest
income category report the lowest enjoyment for their children (n=6), but with the small sample size it
cannot really be compared to the higher numbers reported by other income categories.
INSURANCE EFFECTS ON CHILD REPORTED ENJOYMENT
The hypothesis that uninsured children would have the lowest reported experience at the
doctor of any of the groups was supported. Parents of uninsured children reported their children
enjoyed (n=6) doctor’s visits on average, 5.5. Both categories of insured children had a higher reported
enjoyment than their uninsured counterparts. However, the expectation that no difference would be
found between reported enjoyment for respondents whose children had public insurance and reported
enjoyment for respondents whose children had private insurance was not confirmed by the data. The
highest reported enjoyment was for children on their parents insurance (n=80), at 7.14. Children with
public insurance (n=18) reported experiences averaged 6.38.
FAMILY DOCTOR EFFECTS ON CHILD ENJOYMENT
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
Children on their parent’s insurance had the highest reported enjoyment of doctor’s visits and
also had the highest percentage of participants reporting that they had a family doctor for any category.
To determine how having a family doctor affects a child’s reported experience of doctor visits, average
reported experience for children of participants who reported having a family doctor was compared to
average reported experience for children of participants who reported that they did not have a family
doctor. Average enjoyment for children with a family doctor was 6.98 and average enjoyment for
children without a family doctor was 5.71. This difference was very close to statistically significant
(p=0.051).
The increase seen in parental reporting of enjoyment for children who have a family doctor is
likely for reasons mentioned above, familiarity with the environment and the doctor, a relationship with
the doctor and trust for the doctor.
REPORTED TROUBLE PAYING FOR DOCTOR
In the survey, participants were asked whether they had difficulty paying for their own or their
child’s doctor visits. This question digs deeper than the actual statistics of how often parents take their
child to the doctor and illustrates their actual situations. These data help clarify whether parents who
report taking their child to visit the doctor less often simply have healthy children, or money plays a part
their decision making process. Also, by asking about financial difficulty for child’s visits as well as their
own visits, I hoped to see if there was any difference in priority of healthcare for different members of
the household. The reported difficulty paying by participants paying for their own doctors visits is shown
in Table 7, and reported difficulty paying for doctor visits for their children is found in Table 8.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
Table 7.
Participants Reporting Trouble Paying for Their Own Doctor Visits
Yearly Income
Average
for
income
Uninsured
Children
Under $15,000
3
50%
2
100%
$15,000 - $40,000
9
50%
0
0%
$40,000 - $60,000
4
22%
0
$60,000 - $80,000
2
Above $80,000
4
Parent
Insured
Public
Insured
-
1
25%
2
22%
7
64%
0%
3
20%
1
50%
11%
-
2
11%
11%
-
3
8%
1
100%
33%
10
13%
10
56%
Average for Insurance 2
-
Table 8.
Participants Reporting Trouble Paying for Child's Doctor Visits
Yearly Income
Average
for
income
Uninsured
Children
Under $15,000
0
0%
0
0%
$15,000 - $40,000
4
22%
1
50%
$40,000 - $60,000
3
17%
0
$60,000 - $80,000
Above $80,000
Average for Insurance
2
2
11%
5%
11%
1
Parent
Insured
Public
Insured
-
0
0%
1
11%
2
18%
0%
2
13%
1
50%
17%
2
2
7
11%
5%
9%
0
3
0%
17%
INCOME EFFECTS
I hypothesized that lower income participants would report having trouble paying for their own
and their child’s doctor visits more often than higher income participants would, and this holds true
when talking about their own doctor visits. In Table 7, it shows that in the lowest two income ranges,
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
50% of participants report trouble paying for their own doctor visits, followed by 17% of participants in
the middle income range, and only 11% of participants in the highest two income ranges. Clearly, higher
income participants have less difficulty paying for their own visits to the doctor.
The relationship between low income and reported trouble paying for doctor visits observed for
parent’s own care does not hold entirely when discussing paying for their child’s doctor visits (See Table
8). In the lowest income category, no participants reported any difficulty paying. However, for the
subsequent four income categories difficulty is reported and, as income increases, reported difficulty
paying for child’s visits decreases. N’s are low, but still 11% of the sample (11/99) did report difficulty
paying for child’s visits. It is unexpected that the participants with the lowest income would report no
trouble paying for their child to visit the doctor while higher income participants had trouble. To clarify
this data, more study would be needed, with a larger low-income sample population. Without this, it is
hard to say what is causing children’s doctor visits to be so affordable for low income parents, but one
possibility is the high enrollment in public health insurance seen in this group. Public health programs
are directed at children in the lowest income families, and generally, families have to make very little
contribution to their healthcare costs under these plans, making visiting the doctor extremely
affordable.
It is interesting that in every income category, there are either an equivalent number or fewer
parents who report trouble paying for their child’s doctor visits as compared to those who report
trouble paying for their own doctor visits. Parents were asked in the survey, “What factors affect how
you decide if your child needs to see a doctor?”. I expected to see that money would be a reported
factor in determining if a doctor was necessary, but money was very rarely reported as a factor: only 2
out of 101 participants mentioned it. In fact, one parent reported exactly the opposite and said that if
their daughter is sick, they will do whatever it takes to get her feeling better, cost is not a factor. The
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
trend that parents are willing to do whatever it takes to best take care of their children was also
illustrated when they answered the question if they had trouble paying for their own doctor visits. As
mentioned before, fewer parents reported had trouble paying for their own visits than had trouble
paying for their child’s visits. This discrepancy was explained by participants on the survey. Many
participants, after reporting that they had no trouble paying for their own visits went on to say that
despite their possible need for medical attention, if they cannot afford to visit a doctor, they simply
don’t. However, when their child needs to see a doctor, they will do whatever it takes, even if it means
going into debt to cover the medical expenses.
INSURANCE EFFECTS ON REPORTING TROUBLE PAYING FOR DOCTOR VISITS
The breakdown of participants reporting trouble paying for their own doctor’s visits is shown in
Table 7. My hypothesis was that the uninsured would have the most difficulty paying for their own and
their child’s doctor visits. This appears not to be the case as only 33% of parents whose children are
uninsured report trouble paying for their own doctor visits (compared to 56% of parents whose children
are covered by public health insurance). Uninsured children in this study were mostly from families
where the parent had employer - provided insurance, but the child was not covered. This explains why
parents whose children are uninsured may have less difficulty paying for their own doctor visits, because
they have coverage. On the other hand, children with public health insurance are from either uninsured
parents or parents who have low paying jobs and employer- provided income. For uninsured parents, it
is obvious that paying for their own doctor visits would be much less affordable than their child’s (which
would be paid for by the public health insurance). For the parents who work low-paying jobs, employerprovided insurance is probably limited to few benefits and involves co-pay, which would make their own
doctor visits more expensive. The lowest percentage of participants reporting trouble paying for their
own doctor visits was found in participants whose children are covered on their own insurance. In
general, these tended to be higher income parents with employer-provided insurance. Obviously, the
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
insurance is reasonable enough that parents can afford to put their children on it as well, so it must
make parent’s doctor visits more affordable as well.
Similar to the effects of income on paying for their own versus their child’s doctor visits, the
percentage reporting difficulty decreases in all categories when talking about paying for their child’s
visits(See Table 8). Only 17% of participants with uninsured children report difficulty paying, compared
to 33% reporting difficulty covering their own visits. Only 9% of parents with children covered on their
own insurance report difficulty paying, compared to 13% reporting trouble paying for their own visits.
The most drastic difference is seen in the category of public insurance where only 17% of participants
report difficulty paying for their child’s visits while 56% of participants report trouble paying for their
own visits. In this section of the survey, space was provided to elaborate on their answers. Many
parents explained that if their child needs to be taken to the doctor, somehow they make it happen,
even if it involves going into debt. However, for their own visits, rather than make a visit they cannot
afford, they simply do not go – they prioritize their child’s healthcare over their own. This large
difference indicates how necessary public health insurance is and how beneficial it is to the children who
are covered under it. Not only does it allow families to take their children to the doctor who otherwise
might not be able to afford it, but it reduces the strain on the family and allows them to prioritize the
child’s healthcare over the balance of their bank account.
TROUBLE GETTING INSURANCE TO PAY FOR DOCTORS VISITS
Throughout this paper, it has been clearly demonstrated that insurance, whether public or
private has a clear benefit for children by providing them with greater access to healthcare. Insurance
also provides a benefit for parents by making their child’s healthcare more affordable. However, many
complaints arise about insurance as well.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
Just as parents were asked about difficulty paying for their own or their child’s doctor visits, the
same question was posed as to whether they had difficulty getting their insurance company to cover
their own or their child’s doctor visits. (See Table 9.)
Table 9.
Participants Reporting Trouble Getting the Insurance Company to cover visits
Parent Insured Children
Public Insured Children
Participants' visits
14
18%
4
22%
Children's visits
15
19%
2
11%
The data for reported trouble getting insurance coverage for doctor visits was limited to
participants who reported having insurance, and compared only across two insurance types instead of
broken down into income levels. (See Table 9) The percentage of participants was pretty constant for all
categories except for participants with children on public insurance concerning their child’s doctor visits.
It is expected that this category would be the lowest because public health insurance programs are
designed to increase access to healthcare and to make the process easier and more affordable. As
discussed previously, parents of children on public health insurance are not necessarily covered by the
same plan themselves, explaining the difference between the percentages of difficulty obtaining
payment for child’s claims as opposed to parent’s claims.
It is expected that parents whose children on their own plans would have more difficulty getting
the insurance company to cover either their own or their child’s doctor visits compared to those on
public insurance because private insurance companies are designed to make a profit. Paying off every
claim without question can significantly reduce the profits of a private insurance company. It is
reassuring to see that the percentages for both children and parents covered on these private plans are
similar because it indicates that neither party is more targeted as a profitable population, and it also
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
shows that the insurance companies does not discourage parents from taking their children to the
doctor when it is necessary.
LIMITATIONS
This study was performed on a limited timeline. Data collection was cut short in order to meet a
deadline and this resulted in an uneven sample. More participants were found for the upper income
ranges. Also, I was unable to find participants in each insurance category for each income level. The
lack of an evenly stratified sample decreased the validity of the conclusions made from the data, as
there were as few as two participants falling into some subcategories. The survey included mostly
closed ended questions and therefore the data was incomplete and lacked, for example an overall
assessment of health status of the children.
CONCLUSIONS
Of the three hypotheses and predictions proposed initially, two were supported. The findings of
this study support previous findings that children with insurance, whether public or private, are more
likely to have a family doctor, see the physician when they need to, and in general, visit the doctor’s
office more often.9 The effects of income on children’s healthcare are hard to see because of the uneven
proportions of uninsured, publically insured and privately insured for each income level. However, it is
clear that increased income correlates with decreased reporting of difficulty paying for visits to the
doctor. Insurance, public or private, is a huge benefit for children and makes them much more likely to
get adequate healthcare. Insurance can mask the discrepancies in health care that are seen with low
income. Children with some sort of insurance are shown to visit the doctor more times within a year,
be taken to the doctor for a wider variety of reasons. Children with some sort of insurance are more
likely to have a family doctor and are also more likely to enjoy their visits to the doctor, in part because
they have a family doctor. Parents whose children are insured are less likely to report trouble paying for
the doctor and thus less likely to have to prioritize their child’s healthcare over their own.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
As the idea of healthcare reform continues to be a politicized issue, this study demonstrates that
insurance is important in children’s healthcare. It is also vital that further research be performed
regarding aspects of healthcare that are affected by low income and lack of insurance, for example,
check-ups, frequency of visits to the doctor, and whether children have a regular source of care. How
the presence of a family doctor affects children’s experience with the doctor and their healthcare over
all would also be an interesting area of future research.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
1. Newacheck P, Stoddard J, Hughes D, Pearl M. Health insurance and access to primary care for
children. The New England Journal Of Medicine [serial online]. February 19, 1998;338(8):513519. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed March 29, 2011.
2. Lewit, E., Bennett, C., and Behrman, R., Health Insurance for Children: Analysis and
Recommendations. The Future of Children, Vol 13. No.1, Health Insurance for Children. (Spring,
2003) pp.4-29
3. Eisert S, Gabow P. Effect of Child Health Insurance Plan enrollment on the utilization of health
care services by children using a public safety net system. Pediatrics [serial online]. November
2002;110(5):940-945. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed April 2,
2011.
4. Feinberg E, Swartz K, Zaslavsky A, Gardner J, Walker D. Family income and the impact of a
children's health insurance program on reported need for health services and unmet health
need. Pediatrics [serial online]. February 2002;109(2):E29. Available from: MEDLINE with Full
Text, Ipswich, MA. Accessed April 1, 2011.
5. O’Keeffe, G. Top 10 Reasons Kids Go to the Doctor. Dr. Gwenn is In.
http://www.momlogic.com/2008/01/top_10_pediatrician_visits.php. Published January, 13,
2008. Accessed January 6, 2011.
6. Starfield, B. Evaluating the State Children's Health Insurance Program: Critical considerations.
Annual Review of Public Health. (2000) 21:569-85
7. Starfield, B . Primary care: Balancing health needs, services, and technology. New York: Oxford
University Press, 1998.
8. Grayson, A. Docs Bailing out of Medicare, Medicaid: Plummeting Reimbursement Rates Have
Some Doctors Looking for a way Out. ABC News. 2008. Available at:
http://abcnews.go.com/Health/story?id=5326078&page=1. Accessed April 20, 2011.
9. Newacheck P, Pearl M, Hughes D, Halfon N. The role of Medicaid in ensuring children's access to
care. JAMA: The Journal Of The American Medical Association [serial online]. November 25,
1998;280(20):1789-1793. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed April 6,
2011. See also, note 1, Newachek.
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
APPENDIX A:
Study: How Income and Insurance Affect Key Aspects of Children’s Healthcare
What is the yearly income of your household? (circle one)
Under $15,000
$15,000-$40,000
$40,000-$60,000
$60,000-$80,000
Above $80,000
How many people are supported by that income? ______
What type of health insurance do you have? (circle one)
None
Self – Provided
Employer Provided
Medicare
Medicaid
How much is your deductable? _____________________
Is your child covered under your health insurance plan? YES or NO (circle one)
IF no… Is your child covered by any sort of public health insurance (eg. Medicaid or SCHIP)? YES or NO
If your child is covered by Public Health Insurance, what is the name of the program they benefit from?
(If this does not apply, leave it blank) ________________________
How often, on average, do you take your child to the doctor? (circle one)
More than twice in a month
Twice in a year
Once a month
Once in a year
Once every 2 months
Less than once in a year
Once every 4 months
Which of the following are reasons that you take your child to the doctor?
__ High Fever
__ Rash
__Stomachache
__ Low Fever
__ Persistent Cough
__Vomiting
__ Check – up
__ Sore Throat
__ Injury
__Well – child care (eg. Visits for preventative care)
__ Shots / immunizations
Do you have a family doctor (a preferred doctor that you return to by name)?
Yes
No
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How Income and Insurance Affect Key Aspects of Children’s Healthcare
APPENDIX A
How do your children enjoy visiting the doctor?
10 ----- 9 ----- 8 ----- 7 ----Enjoy visiting doctor a
lot – may even look
forward to visits
6
-----
5
-----
4
-----
3
-----
2
Indifferent
-----
1
Very poor reaction to doctormay cry or attempt to get out
of visits
What factors affect how you decide if your child is needs to see a doctor?
Have you ever had troubles paying for visits to the doctor for yourself? YES
OR
NO
Explain YES answers:
Have you ever had troubles paying for visits to the doctor for your child? YES
OR
NO
Explain YES answers:
Have you ever encountered problems getting your insurance company to cover your doctor visits?
YES OR
NO
Explain YES answers:
Have you ever encountered problems getting your insurance company to cover your child’s doctor
visits?
YES OR
NO
Explain YES answers:
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