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The Role of the Safety Net

Stephen H. Long, PhD; M. Susan Marquis, PhD

JAMA. 1999;281:2035-2040.

Context  Although an extensive literature exists comparing national access to health care for uninsured vs insured children, few data exist regarding differences in access across states.

Objective  To examine variation in access to physician services for uninsured children in 10 states, the safety net's role in explaining this variation, and the potential effects of the State Children's Health Insurance Program (CHIP) on insurance coverage and access.

Design and Setting  The population-based Robert Wood Johnson Foundation Family Health Insurance Survey, conducted between summer 1993 and spring 1994 in 10 states (Colorado, Florida, Minnesota, New Mexico, New York, North Dakota, Oklahoma, Oregon, Vermont, and Washington), with a response rate of families by state ranging from 61% to 83%.

Participants  A total of 8565 children who were uninsured (1586), covered by Medicaid (2723), or covered by employer-sponsored private insurance (4256) for 1 full year prior to the survey.

Main Outcome Measures  Percentage of low-income children who are uninsured and predicted annual physician visits by state if insurance was provided to uninsured children in families with incomes of less than 200% of poverty level.

Results  In the 10 study states, low-income children ranged from 61% to 86% of all uninsured children and the uninsured rate for low-income children varied from 9% to 31%. On average, providing public coverage would increase annual physician visits from 2.3 to 4.6 (a 105% increase), but the increase would range from 41% to 189% across states. The annual physician visit rate in the 3 states with the highest access for the uninsured was 160% of that in the 3 lowest-access states. Safety net capacity in the high-access states ranged from 120% to 220% of that in the low-access states.

Conclusions  Our data suggest that the potential effects of CHIP vary substantially across states. Notably, improvements in access to health care by uninsured low-income children should be greater in states with the fewest safety net resources.

Author Affiliations: The authors are Senior Economists, RAND, Washington, DC.

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