The impact of health insurance status on adolescents' utilization of school-based clinic services: Implications for health care reform

JOURNAL OF ADOLESCENT HEALTH 1995;16:18-25

ORIGINAL ARTICLE

The Impact of Health Insurance Status on Adolescents' Utilization of School-Based Clinic Services: Implications for Health Care Reform CLAIRE BRINDIS, DR. P.H., C Y N T H I A K A P P H A H N , M.D., M.P.H., V I R G I N I A M C C A R T E R , Ph.D., A N D A M Y L. WOLFE, M.P.H.

Purpose: 1) To examine variations a m o n g students with different health insurance coverage in their use of school-based clinics (SBCs), reasons for not receiving health care w h e n needed, and reasons for u s i n g or not u s i n g SBCs, and 2) to determine if insurance status is a significant factor i n predicting SBC use, after controlling for demographic variables and health status. Methods: Confidential questionnaires were administered to 2,860 adolescents attending 3 u r b a n high schools with on-site SBCs. Chi-square a n d m u l t i p l e logistic regression analyses were used to assess differences a m o n g insurance groups in patterns of SBC use and reasons for clinic use/nonuse. Results: Students with private insurance or H M O coverage had the highest rates of SBC utilization (67% & 66%) and students w i t h o u t health insurance and with Medicaid had the lowest (57% & 59%) (p < 0.01). While there was no difference among adolescents according to insurance group m e m b e r s h i p in their use of SBC medical services, a significantly higher proportion of students with Medicaid coverage used SBC mental health services. Students w i t h o u t health insurance were less likely to receive health care from any source w h e n it was needed. After controlling for demographic variables and health status, no insurance factors remained significant.

From the Center for Reproductive Health Policy Research, Institute for Health Policy Studies, University of California at San Francisco and the Adolescent Medicine Division, Department of Pediatrics, Stanford University School of Medicine. For reprints please contact: Claire Brindis, Center for Reproductive Health Policy Studies, University of California, 1388 Sutter Street, llth Floor, San Francisco, CA 94109 Manuscript accepted July 20, 1994. 18

1054-1393(/95/$9.50 S S D I 1054-139X(94)0095-V

Conclusions: SBC users represent a variety of insurance groups. Health care reform efforts need to take into account the special needs of adolescents and the challenges they face i n accessing care that go b e y o n d financial barriers to care. SBC have been s h o w n to provide a c o n v e n i e n t a n d acceptable source of care, as well as offering the o p p o r t u n i t y to provide preventive and primary care services to at-risk youth. As the country moves to a m a n a g e d care e n v i r o n m e n t potential partnerships with SBCs represent a u n i q u e opportunity to improve the delivery of care to adolescents, assuring increased access to a package of health services that they need. KEY WORDS:

Adolescent health Health insurance School-based clinic

Background and Significance Health care delivery in the United States has undergone a major transformation in recent years, moving towards managed care and away from fee-for-service systems. Even without the enactment of President Clinton's health care reform proposal which emphasized universal health coverage through managed care, significant shifts are occurring. While universal insurance coverage through managed care could significantly decrease financial obstacles to care, it is unclear how this will alter the multiple other barriers adolescents face in obtaining health services.

© Societyfor AdolescentMedicine,1995 Publishedby ElsevierScienceInc., 655 Avenueof the Americas,New York, NY 10010

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ADOLESCENT INSURANCE STATUS AND SBC UTILIZATION

When financial obstacles exist, adolescents are less likely to seek care. In a s t u d y b y Resnick et al., y o u t h unequivocally stated that the high cost of medical care and their o w n lack of financial resources were barriers to service utilization (1). Newacheck and McManus f o u n d that one out of seven adolescents was without health care insurance, and that these individuals were twice as likely as insured adolescents to go for 2 or more years without seeing a physician (2). Even adolescents with health insurance were often inadequately covered for services such as mental health and substance abuse treatment, reproductive care, and preventive health visits (2,3). W o o d f o u n d that uninsured, poor, or nonwhite children and adolescents (-<17 years) were less likely to have seen a physician in the past year than those from insured, affluent or white families (4). The impact of a shift towards m a n a g e d care and away from fee-for service and public health systems on health care delivery to adolescents has not been studied. For adults and children, the n u m b e r of out-patient visits m a y increase in a prepaid health care setting (5--7). The Rand study also f o u n d that cost-sharing decreased a m b u l a t o r y health care utilization (8-11). H o w e v e r , w h e n factors other than visit frequency are explored, the data are less conclusive. Physicians in prepaid g r o u p practices tend to spend less time per out-patient visit w h e n compared to physicians in fee-for-service g r o u p practices (12). Studies of adults also suggest that physicians in prepaid systems are less likely to identify and treat certain health issues of particular importance to adolescents, such as depression (13). Adolescents m a y use different health care settings to address different needs. For example, McHarney-Brown, et al. (1991) f o u n d that adolescents used school-based clinics (SBCs) more for counseling and health care maintenance, and pediatric offices for acute and chronic illness (14). H o w ever, m a n y adolescents without health insurance do not have a choice of health care settings. For those adolescents w h o have no regular source of care, but w h o attend schools where SBCs have been established, SBCs have evolved as their "medical homes". A p p r o x i m a t e l y half of all students receiving care at SBCs do not have access to other sources of care. Less than 20% of SBC users are covered by conventional private insurance and H M O s and nearly 40% are completely u n i n s u r e d (15). Although m u c h of the initial impetus for SBCs was the increasing n u m b e r of adolescent pregnancies, their role has since e x p a n d e d and evolved.

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Students n o w use SBCs most often for p r i m a r y health care and mental health care (16). In a national s u r v e y of SBCs, approximately 70% of services prov i d e d were for medical care, 20% were for mental health, and 10% were for reproductive care (17). The school setting has been s h o w n to be effective in providing p r i m a r y health care, as well as mental health services to in-school y o u t h (18). School-based clinics are able to bring services to adolescents w h o traditionally are medically u n d e r s e r v e d b y responding to their multiplicity of needs and removing m a n y of the existing barriers. Because SBCs are located at or near the school, the services p r o v i d e d are free or low cost, and parental consent for care is obtained prior to the visit and maintained in the students' medical records, access to health care is enhanced (19). Allowing students to use SBCs in a confidential m a n n e r further facilitates adolescent access (20). I m p r o v i n g access b y providing comprehensive health services to adolescents through SBCs is expected to lead to increased utilization of n e e d e d services, with resulting changes in health status and health-related behavior (21). In an effort to better u n d e r s t a n d the impact of health insurance status on access to care for adolescents, this s t u d y focuses on the relationship between students' health insurance status and SBC use patterns. It was expected that use of the clinic, the type of services used, the students' reasons for and for not seeking care at SBCs, and reasons for not receiving care w h e n n e e d e d w o u l d vary b y health insurance status. It was anticipated that students with no health insurance w o u l d be more likely to use SBC medical services. Students with private health insurance, whether conventional or HMO, were expected to use the SBC m o r e c o m m o n l y for those services such as mental health and reproductive health services that are often not covered by private insurance or are of a sensitive nature. It was also expected that students' reasons for seeking or not seeking care at SBCs w o u l d reflect access to alternative sources of care, and that students not receiving n e e d e d care w o u l d most likely report financial reasons as a prim a r y obstacle. It was anticipated that differences in SBC utilization rates a m o n g students of varying insurance categories w o u l d be partially explained by differences in d e m o g r a p h i c variables and health status.

Methodology In the Fall of 1988 and in the Spring of 1989 a confidential Teen Health Risk Survey (THRS) (22)

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BRINDIS ET AL

was administered to students attending three urban high schools with SBCs in northern California. During the period of data collection, the combined school population of the three schools was 4338 students. Of these, 2860 (66%) completed the survey. The primary reason for not participating was absenteeism. At each site there was a full-time nurse practitioner who provided acute medical care, preventive health services, and reproductive health care including pelvic examinations and prescriptions for contraceptives. Medical back-up was available from a part-time physician. A part-time social worker provided mental health counseling. The survey was part of an evaluation of SBCs conducted by the Center for Reproductive Health Policy Research to determine clinic characteristics associated with achievement of optimum health for the student populations. It was given as a follow-up to a pre-clinic baseline survey administered two years previously. Both surveys included questions on health care status, health insurance status, health care utilization patterns, and risk-taking behaviors. Evaluation and approval of the questionnaires and oversight to ensure that all survey procedures complied with ethical research standards was carried out by a committee consisting of members of the school board, parents, and the principals of each participating school, and the study was approved by the Human Subjects Committee at The University of California, San Francisco. The baseline THRS was adapted from a risk survey originally developed for adults by the Center for Disease Control (CDC) (23) and modified for use with adolescents. Further modifications were incorporated by researchers at the Division of Adolescent Medicine at University of California, San Francisco (UCSF) (24) and then by the Center for Reproductive Health Policy Research (also at UCSF). Two of the high schools used a 9-page Teen Health Risk Appraisal (THRA), which offered the option of personalized feedback on their health status and lifestyle. In order to maintain confidentiality, a code number on the cover sheet was matched with one on the survey. Once the code sheet was removed by the student, the survey had no specific name identitier, and could thus be completed anonymously. Time constraints at the third school prompted the use of a condensed four-page version of the THRA called the Teen Health Needs Assessment (THNA), which included a subset of the questions on the THRA. At this school the surveys were completed anonymously. The sections relevant to this study were included in their intact form in both the THRA

JOURNAL OF ADOLESCENT HEALTH Vol. 16, No. 1

and THNA, to minimize potential framing differences between questionnaires. The process for conducting the follow-up survey was identical in all three schools. Students were asked to take home a letter informing their parents about the school survey and its use in evaluating the school-based clinic. Because each school required only parental notification, the available pool of students who completed the survey was greatly increased. Parents were given the option of withholding permission if they objected to the survey. A very small number, approximately 10 at each school, chose this option and these students were given another classroom assignment while the survey was being conducted. After students completed the survey they placed it in an envelope which was removed at the end of each class period by a member of the research team. DESCRIPTION OF VARIABLES. Students' health insurance status was self-defined as one of five categories: having conventional private health insurance, being enrolled in an HMO, receiving Medicaid, having no health insurance, or unknown. General health status was determined by a self-rating scale, with possible answers ranging from poor to excellent. Students were also asked to self-rate how often they felt depressed. The mother's highest level of educational attainment was used as a proxy measure for socioeconomic status. Eight potential reasons for not receiving needed care from any source included: "I just did not want to go"; "My parent(s) did not think I needed care"; and "It cost too much money". Students who reported ever using the SBC were asked to select from among 10 reasons for use, such as: "I feel I can trust the clinic"; "It's easy to get to"; and "I feel the care I get there is helpful". Students who had never been to the SBC could select from 18 possible reasons for non-use, ranging from "I was healthy and did not need the clinic" to "I already had a place to go". DATA ANALYSIS. T o examine variations among groups of students with different health insurance coverage, the following variables from the THRS were analyzed: use of the SBC, types of services used, reasons for not seeking health care when needed, and reasons for using or not using SBCs. Chi-square analysis was used to assess differences among insurance groups for types of health services used at SBCs, reasons for not receiving health care when needed, and reasons for using or not using SBCs. Multiple logistic regression analysis was used to assess the influence of age, ethnicity, mother's educational level, health status, and insurance cov-

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ADOLESCENT INSURANCE STATUS AND SBC UTILIZATION

erage o n overall SBC use a n d use of specific SBC services.

Results

DESCRIPTION OF SAMPLE. Of the 2860 s t u d e n t s w h o c o m p l e t e d the s u r v e y , the d i s t r i b u t i o n of fem a l e s a n d m a l e s w a s n e a r l y equal. As i n d i c a t e d in Table 1, m o s t r e s p o n d e n t s w e r e in the 15 to 17 y e a r old age range. The largest ethnic g r o u p w a s Hisp a n i c / L a t i n o ; h o w e v e r , there w e r e also m a n y African A m e r i c a n a n d A s i a n students. F o r t y - t w o percent of s t u d e n t s r e s p o n d i n g to the section on i n s u r a n c e status r e p o r t e d that their families h a d n o insurance, 25% b e l o n g e d to H M O s , 19% w e r e re-

Table 1. Survey Respondents by Gender, Age, Ethnicity, Health Insurance Status, Overall Health Status, Depression, and Mother's Educational Level Demographics Gender* Female Male Age* (yrs.) 14 15 16 17 18 Ethnicity* Hispanic/Latino African American, non-Hispanic Asian/Pacific Islander White, non-Hispanic Other Health Insurance Status* None HMO Medicaid Conventional Private Insurance Overall Health Status* Excellent/Very Good Good Fair/Poor Feels depressed* Sometimes, rarely, or never Almost always or often Mother's educational level* Less than high school High school At least some college

1432 (51) 1389 (49) 319 (11) 683 (24) 82O (29) 692 (25) 283 (10) 1332 (48) 572 (21) 452 (16) 236 (8) 205 (7) 1108 (42) 677 (25) 495 (19) 370 (14) 344 (13) 879 (33) 1408 (54) 1906 (72) 735 (28) 981 (44) 575 (26) 698 (31)

Note: Percentages in parentheses

*Missing/unknown data varied for each category: gender (39); age (63); ethnicity (63); health insurance status (210); overall health status (229); depression (219); mother's educational level (606).

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Table 2. Use of School-Based Clinics by Health Insurance Status

Clinic User* Clinic Non-User*

Private (n=370)

HMO (n=677)

Medicaid (n=495)

None (n=1108)

249 (67) 121 (33)

447 (66) 230 (34)

293 (59) 202 (41)

627 (57) 481 (43)

p <0.01 Note: Percentages in parentheses.

ceiving Medicaid, a n d 14% h a d c o n v e n t i o n a l p r i v a t e insurance. M o s t s t u d e n t s rated their overall health as fair or p o o r a n d felt t h e y w e r e s e l d o m , if ever, depressed. Most students had mothers who had not g r a d u a t e d f r o m h i g h school. T h e r e w e r e n o significant differences in g e n d e r a n d ethnicity b e t w e e n s t u d y r e s p o n d e n t s a n d the s t u d e n t p o p u l a t i o n enrolled at the schools d u r i n g the s t u d y period. INSURANCE STATUS AND SBC UTILIZATION. As ind i c a t e d in Table 2, there w e r e significant differences (p < 0.01) in the p r o p o r t i o n of s t u d e n t s u s i n g SBCs in each i n s u r a n c e g r o u p . The t w o g r o u p s w i t h the largest p e r c e n t utilization w e r e s t u d e n t s w h o h a d c o n v e n t i o n a l p r i v a t e i n s u r a n c e a n d those w i t h H M O c o v e r a g e , a n d the l o w e s t utilization rates occ u r r e d a m o n g s t u d e n t s w i t h o u t i n s u r a n c e or w i t h M e d i c a i d coverage. T h e r e w a s n o significant difference (p > 0.05) in use of m e d i c a l services at the SBCs a m o n g s t u d e n t s a c c o r d i n g to i n s u r a n c e status. H o w e v e r a signific a n t l y g r e a t e r p r o p o r t i o n of s t u d e n t s o n M e d i c a i d u s e d SBC m e n t a l health services (p < 0.05), as indicated in Table 3. Similar p r o p o r t i o n s of s t u d e n t s in each i n s u r a n c e c a t e g o r y u s e d SBC r e p r o d u c t i v e health services (9-11%). The n u m b e r of s t u d e n t s u s i n g r e p r o d u c t i v e health services w a s n o t sufficient to w a r r a n t f u r t h e r analysis a m o n g g r o u p s . CHARACTERISTICS OF SBC USERS. A s indicated in Table 4, SBC users w e r e m o r e likely to be white, female, a b o v e 16 y e a r s of age, d e p r e s s e d , a n d to h a v e a m o t h e r w h o c o m p l e t e d college. T h e y w e r e less likely to be A s i a n / P a c i f i c Islanders. A s o u t l i n e d in Table 5, s t u d e n t s u s i n g m e d i c a l services w e r e m o r e likely to be in g o o d , fair or p o o r Table 3. Type of School-Based Services Used by Health Insurance Status Services Used

Private (n = 249)

HMO (n = 447)

Medicaid (n = 293)

None (n = 627)

Medical Mental Health*

218 (88) 55 (22)

389 (87) 99 (22)

254 (87) 89 (30)

523 (83) 140 (22)

*p < 0.05 Note: Percentages in parentheses, can add to more than 100%

because students could use multiple services,

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JOURNAL OF ADOLESCENT HEALTH Vol. 16, No. 1

Table 4. Multiple Logistic Regression Model Predicting Use of School-Based Health Services Variable Over 16 years old Under 16 years old Female Male Hispanic/Latino Asian/Pacific Islander African American Other Ethnicity White Excellent Health Good Health F a i r / P o o r Health HMO Medicaid Private Insurance N o Insurance Not Depressed Depressed Mother Did Not Complete H i g h School Mother Completed H i g h School Mother Had College Education or Above

O d d s Ratio

95% CI

1.00 **0.69 1.00 **0.75 1.00 *0.76 0.85 1.11 **2.05 1.00 0.89 0.88 1.00 0.96 1.23 0.83 1.00 "1.27 1.00

-0.58, 0.81 -0.64, 0.88 -0.61, 0.96 0.68, 1.07 0.81, 1.52 1.48, 2.84 -0.68, 1.15 0.68, 1.13 -0.76, 1.22 0.95, 1.60 0.68, 1.00 -1.05, 1.52 --

1.05

0.86, 1.29

*'1.41

1.15, 1.74

*p < 0.05 **p < 0.01 CI: confidence interval

health (as o p p o s e d to v e r y good or excellent) and have a m o t h e r w h o completed high school, and were less likely to be Asian/Pacific Islanders. Students using SBC mental health services were more likely to report being depressed and have a m o t h e r w h o attended college. REASONS FOR N O T RECEIVING H E A L T H CARE W H E N

Students without any health insurance were significantly more likely (p < 0.01) than other students to not receive care from any source w h e n it was needed. Twenty-seven percent of students without health care had not received care w h e n needed, versus 18-19% for all other insurance groups. There were also significant differences a m o n g insurance categories for the top 3 reasons students gave for not receiving care from any source w h e n they felt it was n e e d e d (Table 6). While the most likely reason for students not to seek n e e d e d care was that they "just did not want to go", this was less likely a m o n g students without insurance coverage (p < 0.01). Moreover, those students were significantly more likely (p < 0.01) than other students to indicate that they did not seek care because it cost too much. Students with convenNEEDED FROM A N Y SOURCE.

Table 5. Multiple Logistic Regression Model Predicting Use of Medical and Mental Health Services by SchoolBased Clinic Clients Medical Services

Variable Over 16 years old U n d e r 16 years old Female Male Hispanic/Latino Asian/Pacific Islander African American Other Ethnicity White Excellent Health Good Health F a i r / P o o r Health HMO Medicaid Private Insurance N o Insurance Not Depressed Depressed Mother Did Not Complete High School Mother Completed High School Mother Had College Education or Above

Mental Health Services

Odds Ratio

95% CI

Odds Ratio

95% CI

1.00 0.95 1.00 0.91 1.00 "0.61 0.68 0.70 1.56 1.00 "1.59 *'1.76 1.00 1.43 1.23 0.99 1.00 0.93 1.00

-0.71, 1.27 -0.68, 1.20 -0.41, 0.92 0.46, 1.01 0.42, 1.16 0.87, 2.79 -1.07, 2.37 1.18, 2.61 -0.93, 2.21 0.79, 1.93 0.71, 1.37 -0.69, 1.26 --

1.00 0.85 1.00 0.97 1.00 1.23 1.12 1.43 0.66 1.00 0.86 0.80 1.00 1.34 0.99 0.94 1.00 **2.07 1.00

-0.66, 1.09 -0.77, 1.23 -0.87, 1.74 0.80, 1.57 0.93, 2.20 0.41, 1.05 -0.60, 1.22 0.56, 1.13 -0.96, 1.89 0.68, 1.43 0.70, 1.25 -1.62, 2.64 --

"1.50

1.02, 2.20

0.86

0.64, 1.17

1.35

0.94, 1.92

**0.67 0.49, 0.91

*p < 0.05 **p < 0.01 CI: confidence interval

tional private insurance were m o r e likely (p < 0.05) than other students not to go because their parents did not think care was needed. REASONS FOR USING A N D N O T U S I N G SBCS. There were no significant differences a m o n g insurance groups in reasons for using SBCs, of which the most frequent were that students could trust the clinic (37%), it was easy to get to (36%), and they f o u n d the care helpful (31%). Only 9% of students w e n t to SBCs "because it was cheap", and only 7% said it was because they had no other place to go. The most c o m m o n reason for not using the SBC (Table 7), given by all students regardless of insurance classification, was that they were healthy and did not need care. Students with conventional private insurance or H M O coverage were significantly (p < 0.01) more likely to indicate that they did not use the SBC because they already had a place to go for health care or because their parents had not signed the necessary permission form.

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ADOLESCENT INSURANCE STATUS AND SBC UTILIZATION

Table 6. Reasons Students Did Not Get Health Care From A n y Source When They Felt They N e e d e d It, by Health Insurance Status Reasons

Private None HMO Medicaid (n = 71) (n = 296) (n = 120) (n = 87)

I just did not 24 (34) want to go** My parent(s) did not 18 (25) think I needed care* It cost too much money** 6 (8) I did not want to 8 (11) miss school I did not think they 3 (4) would help me I did not know 1 (1) where to go My parent(s) could not 2 (3) take off from work

65 (22)

41 (34)

30 (34)

41 (14)

24 (20)

8 (9)

50 (17) 30 (10)

6 (5) 15 (12)

7 (8) 14 (16)

29 (10)

10 (8)

6 (7)

20 (7)

4 (3)

6 (7)

14 (5)

6 (5)

4 (5)

*p K 0.05 **p K 0.01 Note: Percentages in parentheses, may not add to 100% because students could check multiple reasons.

Discussion A c c e s s to a n d a c c e p t a b i l i t y of h e a l t h care for a d o l e s cents reflect a s p e c i a l set of c h a r a c t e r i s t i c s t h a t g o b e y o n d t r a d i t i o n a l f i n a n c i a l b a r r i e r s to care. T h e m a j o r i t y of a d o l e s c e n t s e n r o l l e d in t h e s c h o o l s s t u d i e d u s e d s c h o o l - b a s e d clinics r e g a r d l e s s of w h e t h e r o r n o t t h e y h a d i n s u r a n c e to c o v e r m e d i c a l c a r e p r o v i d e d e l s e w h e r e . F i n a n c i a l access is a critical factor, as i n d i c a t e d b y o u r f i n d i n g t h a t s t u d e n t s w i t h o u t i n s u r a n c e c o v e r a g e w e r e m o r e l i k e l y to h a v e h a d times when they did not receive necessary medical c a r e a n d to cite c o s t as a m a j o r r e a s o n for n o t s e e k i n g care from other sources. However, our finding that all SBC u s e r s r e p o r t s i m i l a r r e a s o n s for u s i n g t h e clinic, r e g a r d l e s s of i n s u r a n c e status, s u g g e s t s t h a t factors o t h e r t h a n f i n a n c i n g a r e i m p o r t a n t in t h e a d o l e s c e n t s ' d e c i s i o n to u s e a v a i l a b l e SBC services. A d o lescents s p e c i f i c a l l y v a l u e h a v i n g c a r e p r o v i d e d in a n e a s i l y a c c e s s i b l e l o c a t i o n , p r o v i d e d b y staff t h e y could trust and who they found helpful. W e f o u n d t h e t y p i c a l SBC u s e r to b e a n o l d e r white, depressed adolescent, with a mother with m o r e a d v a n c e d e d u c a t i o n . O u r f i n d i n g of h i g h e r u t i l i z a t i o n r a t e s b y f e m a l e s is c o n s i s t e n t w i t h o t h e r s t u d i e s of SBCs (20,25,26), a n d l i k e l y reflects t h e g r e a t e r o v e r a l l h e a l t h c a r e u t i l i z a t i o n b y g i r l s in this a g e g r o u p (27). F e w p r e v i o u s s t u d i e s h a v e cont r o l l e d for t h e i n f l u e n c e of o t h e r d e m o g r a p h i c a n d h e a l t h s t a t u s v a r i a b l e s o n e t h n i c u t i l i z a t i o n rates. L e v e l s of u t i l i z a t i o n b y m e m b e r s of e t h n i c g r o u p s c a n a l s o b e i n f l u e n c e d b y l e v e l of a c c u l t u r a t i o n .

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B a l a s s o n e d e m o n s t r a t e d , as w e d i d , t h a t A s i a n s t u d e n t s h a d p a r t i c u l a r l y l o w u t i l i z a t i o n r a t e s , alt h o u g h in c o n t r a s t to o u r s t u d y , f o u n d t h a t w h i t e s t u d e n t s u s e d t h e SBC less t h a n H i s p a n i c / L a t i n o a n d A f r i c a n - A m e r i c a n s t u d e n t s (20). K i s k e r f o u n d n o s i g n i f i c a n t d i f f e r e n c e s in SBC u t i l i z a t i o n a m o n g i n s u r a n c e g r o u p s in t h e R o b e r t W o o d J o h n s o n SBC s t u d y (26). N a d e r ' s f i n d i n g s w e r e m o r e c o n s i s t e n t w i t h o u r s , w i t h h i g h e r SBC u t i l i z a t i o n r a t e s a m o n g white students than among Hispanic/Latino or Afr i c a n - A m e r i c a n a d o l e s c e n t s (28). A d d i t i o n a l r e s e a r c h is n e e d e d to b e t t e r u n d e r s t a n d t h e c o m p l e x c u l t u r a l a n d s o c i a l f a c t o r s cont r i b u t i n g to SBC u t i l i z a t i o n . A s d i d W o o d ' s f i n d i n g t h a t n o n w h i t e a n d l o w i n c o m e a d o l e s c e n t s w e r e less l i k e l y to r e c e i v e c a r e r e g a r d l e s s of i n s u r a n c e s t a t u s (4), o u r f i n d i n g s s u g g e s t t h a t r e l a t i v e l y d i s e n f r a n c h i s e d g r o u p s s u c h as t h e p o o r o r e t h n i c m i n o r i t i e s m a y h a v e a m o r e d i f f i c u l t t i m e a c c e s s i n g SBC serv i c e s o r f e e l i n g t h a t SBCs w i l l m e e t t h e i r n e e d s . T h e s e i s s u e s reflect t h e n e e d for s p e c i a l o u t r e a c h s t r a t e g i e s to e n s u r e e q u a l a c c e s s for all s t u d e n t s a n d p a r t i c u l a r l y t h o s e m o s t in n e e d . W h i l e i n s u r a n c e s t a t u s d i d n o t affect t h e p e r c e n t of SBCs u s e r s s e e k i n g m e d i c a l s e r v i c e s , a signific a n t l y g r e a t e r p r o p o r t i o n of s t u d e n t s w i t h M e d i c a i d u s e d t h e a v a i l a b l e m e n t a l h e a l t h services. T h e r e l u c t a n c e o f m e n t a l h e a l t h p r o v i d e r s in t h e c o m m u n i t y to t a k e p a t i e n t s w i t h M e d i c a i d , o w i n g to t h e ext r e m e l y l o w r e i m b u r s a l r a t e for s e r v i c e s (29), r a i s e s

Table 7. Reasons Students Did Not Use the School-Based Clinic, b y Health Insurance Status Reasons I was healthy and did not need ~he clinic I already had a place to go for health care** My parent(s) didn't sign the permission form** I just didn't get around to it I didn't know about the clinic 1 didn't know where the clinic was I didn't want to miss class The clinic didn't have the services I wanted The hours were not convenient

Private None HMO Medicaid (n = 121) (n = 481) (n = 230) (n = 202) 54 (45) 199 (41) 117 (51) 91 (45) 42 (35)

92 (19)

78 (34)

51 (25)

20 (16)

35 (7)

30 (13)

17 (8)

11 (9)

46 (10)

26 (11) 23 (11)

4 (3)

26 (5)

1l (5)

12 (6)

2 (2)

31 (6)

8 (3)

9 (4)

2 (2) 3 (2)

15 (3) 11 (2)

8 (3) 7 (3)

10 (5) 4 (2)

4 (3)

7 (1)

1 (<1)

9 (4)

**p < 0.01 Note: Percentages in parentheses, may not add to 100% be-

cause students could check multiple reasons.

24

BRINDISET AL

concern that these students may rely on the SBC because they are unable to find mental health services elsewhere. However, the finding that increased utilization rates among students with Medicaid failed to persist when factors such as socioeconomic status and self-report of depression were taken into account, suggests that there may be increased need a n d / o r higher rates of identification of need in this population during medical visits to the SBC. These high utilization patterns suggest a need to ensure that mental health services are easily accessible to Medicaid enrollees, both at school sites and in the community. Students with conventional private insurance or HMO coverage were more likely than others to say they did not use the SBC because they already had a medical home. However, a higher proportion of students with coverage through private insurance or HMOs used the SBCs. This has important implications for health care reform, as it implies that even when a designated health care site is established there may still be compelling reasons for adolescents to seek care elsewhere. Further research that examines patterns of adolescent service utilization through SBCs, HMOs and community sites is needed to better understand the reasons adolescents access care from a particular source of care. Currently, there is a dearth of information regarding patterns of clinic utilization for adolescents enrolled in HMOs, as well as their level of satisfaction with services received. Studies of how adolescents use services at the multiple sites available to them will help establish whether the high SBC utilization rates seen in adolescents with private and HMO insurance are because they are preferentially choosing to receive their care at SBCs instead of their designated provider, or because they have simply learned how to use health services more effectively at all sites available to them. Policies are needed to ensure that in cases where a single care delivery site is designated, it does not discourage utilization by preventing access to care at alternative sites that may be more comfortable and acceptable to adolescents. The implication of frequent utilization of SBC services by adolescents who have alternative medical providers or funding mechanisms is important to consider. Up to now, SBCs have been primarily funded by federal and state funds and private foundations (30,31). If managed care systems are to be the primary model of service delivery, it will be important to assure that the system adequately incorporates service delivery ingredients found to be

JOURNALOF ADOLESCENTHEALTHVol. 16, No. 1

important in serving adolescents. In the past, HMOs have been reticent in providing financial support to SBCs and in part, SBCs have helped to subsidize health services to this already covered population. Given the widespread utilization of SBC services when available and the leading role SBCs can play in the provision of preventive health care and in health promotion to in-school youth (32,33), managed care providers should be encouraged to develop partnerships with SBCs. As health reform policy is formulated it is important to include non-traditional service delivery systems as essential community providers. Further refinements in the study of insurance status for SBC users might include requests that parents, rather than adolescents, provide up-to-date information about insurance status. It would also be informative to examine the depth and extent of insurance coverage for adolescents within different plans, the existence of co-payment requirements, and existing patterns of use before the availability of SBCs. These analyses would provide more information regarding the utilization of clinics and whether or not SBCs duplicate, supplant or supplement existing health care resources, Information from other studies of variations in SBC utilization by insurance status is quite limited. The Robert Wood Johnson Foundation's SBC evaluation project studied 19 sites throughout the nation and in contrast to our results found increased SBC utilization among students without insurance than among students who had conventional private insurance or HMO coverage (26). The proportion of students in the population they studied who had various types of insurance coverage differed significantly from our population, with a much larger proportion of students covered by conventional private insurance and fewer students enrolled in HMOs. This difference makes comparison between the two studies difficult. While the limited geographical area covered in our study limits its current generalizability to a national population, it may be an advantage when using it to predict the influence of potential health care reforms on SBC utilization by adolescents, as California has a higher proportion of residents who belong to an HMO than other regions. In addition, a higher proportion of California residents are ethnic minorities (34). A trend towards greater ethnic diversity is being seen throughout the nation, so studies based in California may help predict what might be expected in other regions in the years ahead. As health care reform unfolds, it is important that

January 1995

ADOLESCENT INSURANCE STATUS AND SBC UTILIZATION

policy makers recognize the special health care needs of adolescents. Even with universal coverage, issues of access to appropriate care persist, maintaining the critical need for access to non-centralized health care settings such as school-based, schoollinked, and community-based health centers. We gratefully acknowledge the support of the Stuart Foundations and the Carnegie Corporation in conducting this research. We would also like to thank the directors and coordinators of the school-based clinics, Dr. Georgiana Coray, Ms. Nancy Shardell, Ms. Glenda O'Donnell, Ms. Rochelle Preston, and Dr. Barbara Staggers, the dinic staff, the schools, and the students who participated in this study.

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