Access to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls

JOURNAL OF ADOLESCENT HEALTH 1999;25:120–130

ORIGINAL ARTICLE

Access to Medical Care for Adolescents: Results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls JONATHAN D. KLEIN, M.D., M.P.H., KAREN M. WILSON, M.P.H., MOLLY MCNULTY, J.D., CYNTHIA KAPPHAHN, M.D., M.P.H., AND KAREN SCOTT COLLINS, M.D., M.P.H.

Purpose: This study examined the factors associated with access to care among adolescents, including gender, insurance coverage, and having a regular source of health care. Methods: Analyses were done on the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls, a nationally representative sample of in-school adolescents in 5th through 12th grade. Access to health care, missing needed care, and whether the adolescent had private time with their provider were assessed. Cochran-MantelHaenszel chi-square statistics were computed using SUDAAN. Results: Nearly a third of the 6748 adolescents surveyed had missed needed care. The most common reason for missing care was not wanting a parent to know (35%). Girls were more likely than boys to miss care (29% vs. 24%). Most adolescents reported using a source of primary health care (92%); girls were more likely than boys to use a physician’s office rather than another site (65% vs. 60%). Eleven percent of adolescents reported having no health insurance. Uninsured adolescents were more likely to have missed needed care (40% vs. 23%). Conclusions: Certain groups of adolescents have less access to health care. Girls have more emotional barriers, such as not wanting parents to know about care, and embarrassment. Adolescents without health insurance are at high risk for missing care because of financial From the Division of Adolescent Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York (J.D.K., K.M.W., M.M.); the Stanford University School of Medicine, Division of Adolescent Medicine, Palo Alto, California (C.K.); and The Commonwealth Fund, New York, New York (K.S.C.). Address reprint requests to Dr. Jonathan D. Klein, Division of Adolescent Medicine, School of Medicine and Dentistry, University of Rochester, Box 690, 601 Elmwood Avenue, Rochester, NY 14642. Manuscript accepted August 30, 1998. 1054-139X/99/$–see front matter PII S1054-139X(98)00146-3

strain. States, insurers, and advocates can influence policies around confidentiality and insurance coverage to address these issues. © Society for Adolescent Medicine, 1999 KEY WORDS:

Adolescents Access Health insurance Gender differences Health care Confidentiality

Access to health care is an important indicator of the effectiveness and equity of health care systems. Access to care has been associated with reduction in risky behaviors, increase in healthy habits, and general improvement of health in adolescents (1–3). There are several ways in which access to appropriate medical care can be measured. Financial access and health insurance status affect adolescents’ ability to use care. Other indicators of access include the availability of health professionals, an individual’s ability to identify a regular source of health care (RSHC), and actual use of care (4). Missing needed care may indicate that an adolescent does not have access to medical care, or that the available care did not meet her needs. In general, adolescents are less likely to have access to health care than all other age groups, except for young adults (5). Among adults and children, race (5,6 –9), insurance, and socioeconomic status all affect access to care (6,10 –12). Adolescents who are

© Society for Adolescent Medicine, 1999 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010

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members of minority groups or who do not have the economic resources to access care effectively are at even higher risk of poor health outcomes and risky behaviors. Adolescents are especially underserved with regard to preventive care; few received recommended checkups, and many of those who do have preventive visits do not receive recommended preventive counseling or screening services (13). Several models have been proposed to describe the interactions among the various factors which influence access to care (14,15). For example, Aday and Anderson developed a model based on the premise that research into health care access is done with the goal of changing public policy, and so should reflect issues for which policy changes can be made (15). They proposed that for both the predisposing and enabling characteristics that influence whether an individual is at risk for reduced access to care, there are either mutable (changeable by public policy) or immutable characteristics. Mutable factors include income, health insurance status, having a regular source of care, and knowledge and sources of health care information, while immutable factors include age, gender, and race/ethnicity. In addition, system factors interact with the characteristics of the population at risk. Despite the necessity of analyzing both system and individual factors affecting teens’ access to care, and the unique perspectives which adolescents can offer on their care and developmental needs (i.e., their need for confidentiality), few studies have asked adolescents about their own access to care. Most surveys of adolescents’ access to care have relied upon parental report of access (5–7,9,11,12,16). Parents may be unaware of all of their children’s health care use, and they may have different perceptions of their health than the adolescents themselves would have reported. National surveillance efforts that directly ask teens about their health typically do not address service use and those surveys that do examine adolescents’ access are often limited to single regions or age groups (17–19). It is important to understand adolescents’ access both from the perspective of whether the system has the capacity to provide needed care and from the perspective of utilization data, which reflects services as they are actually used. In addition, as the State Child Health Insurance Program expands insurance coverage to a greater proportion of adolescents, understanding the nonfinancial factors that affect access to care becomes increasingly important. However, there are no nationally representative data on the extent to which adolescents themselves report having access to

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health care. In this study, we examined adolescents’ access to health services, regular sources of health care, and reasons that teens often miss care they felt was needed, using a nationally representative school-based survey of 5th- through 12th-grade adolescents.

Methods Subjects Our analyses are based on the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls, a nationally representative stratified sample of students in 297 public, private, and parochial schools in the United States, which was conducted by Louis Harris and Associates. The schools were sampled from the database of approximately 80,000 schools maintained as a national survey resource by the National Center for Educational Statistics. A total of 265 schools were selected randomly in proportion to their students representation in the population, and an additional 32 urban schools were selected to oversample minority youth. Schools refusing to participate in the study were replaced by randomly choosing one of five schools whose demographics and geography were most closely matched to the refusing school. Classrooms were then selected by randomly choosing a grade, and randomly choosing an English classroom from that grade. Surveys took about 45 min to complete and were administered in the classroom setting. In total, 6748 adolescents completed the survey: 1665 girls in Grades 5– 8, 1921 girls in Grades 9 –12, 1551 boys in Grades 5– 8, and 1611 boys in Grades 9 –12. Twenty adolescents were excluded based on inconsistent answers to survey questions. Response rates for eligible sampled youth could not be determined. Responses were weighted to allow the results to reflect the U.S. population of in school adolescents in terms of grade enrollment, region, race, and gender.

Variables Demographics. Gender, ethnicity, and parental education were assessed. The highest educational level achieved by either parent was used in these analyses as one proxy measure for socioeconomic statuses. A second variable was used to assess socioeconomic status, based on this question: “For most of the time in your family, which of the following statements best describes your family situation: . . . hard time getting enough money for food, clothes . . . just

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enough money for food, clothes . . . few problems buying what it needs, or . . . no problems buying what your family needs/have money for special things?” Adolescents were grouped by grade, with 5th to 8th grade the younger group and 9th to 12th grade the older group. In initial analyses, all racial/ethnic categories were analyzed separately; however, for some of the analyses, ethnic groups are collapsed into two categories: ethnic minority (all non-white and Hispanic white adolescents) and white. Health services measures. Adolescents were asked to rate their health as excellent, good, fair, or poor; whether they had a “Doctor or other health professional that you usually go to when you are sick”; and where they usually got their medical care, using items based on the National Health Interview Survey (6). Participants were also asked whether they went to the same doctor or health professional as their parents, whether they would prefer a male or female health professional, whether they would prefer to go to the same or different doctor as their parents, and whether they would rather be examined by themselves or with their parent present. The adolescents’ usual sources of care were close-ended choices of the following: doctor’s office, clinic or health care center, school nurse, school clinic, hospital emergency room, hospital [other than emergency room (ER)], some other place, or “do not know.” Answers given for the “other” category were: home, military medical center, parent, and pharmacy. Adolescents were considered to have a source of primary care if they indicated that they used a physician’s office, health clinic, or other hospital site (besides the ER) for care. All participants were also asked when they had had their last medical checkup or physical examination (only those who remembered when their checkup was were compared in the analyses) and whether they had seen a psychiatrist, psychologist, or other mental health professional in the previous 12 months. The adolescents were also asked whether they had health insurance. Adolescents were considered to have received confidential care if they answered “yes” to the question: “Do you get a chance to speak with the a doctor or health care professional privately, without your parents?” Adolescents were also asked whether there had ever been a time in their life when they were too embarrassed, afraid, or uncomfortable to discuss a problem with their doctor or health professional. Missing needed care was determined by the question: “Has there been a time when you needed

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medical care but didn’t get it?” Answers given were “yes,” “no,” and “don’t know.” Those who answered “yes” to the question were asked to choose a reason and indicate the severity of missing care (“very serious,” “somewhat serious,” “not very serious,” or “don’t know”). A total of 134 respondents who either did not answer the question on missed care or answered “don’t know,” but who provided a specific answer as to why they missed care were coded as “yes” for whether they had ever needed care but had not received it.

Statistical Analysis Data were initially analyzed using SAS (20) to determine preliminary estimates of significance and correlation coefficients. SUDAAN (21) was then used to generate proportions and Cochran-Mantel-Haenszel ␹2 values, as this allowed adjustment of the variance for the complex, multistage sample design. Sample stratification variables were the type of school (public and private or parochial), age (5th through 8th grade and 9th through 12th grade), and individual school classroom.

Results Demographics Of the 6728 adolescents who returned valid surveys, 49% were female and 51% were male. Sixty-four percent were white, 14% were black, 9% were Hispanic white, 2% were Hispanic black, 4% were Asian, 2% were Native American, and 6% were other or “don’t know.” The average age was 14 years. Approximately equal groups were from urban, suburban, and rural areas (35%, 36%, and 29%, respectively). Slightly more than half were in 5th to 8th grade, and 47% were in 9th to 12th grade (Table 1). When asked to describe their family’s financial situation, 49% reported no problems, 26% reported a few problems, 20% reported just enough money to get necessities, and 5% reported having hard times. Almost one in three adolescents reported that one of their parents was a college graduate (31%). For 6% of the teens, neither parent was a high school graduate; 21% reported that either parent had attended college, 15% reported that at least one parent had postcollege education, and 11% reported not knowing their parents’ education level. Parental education and financial status were modestly correlated (R ⫽ .217, p ⬍ .001), and 60% of those who reported parental education as less than high

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Table 1. Demographic Characteristics of the Adolescents in the Commonwealth Fund Survey of Adolescent Health

Gender Male Female Grade 5th– 8th 9th–12th Race/ethnicity White non-Hispanic Black non-Hispanic Hispanic Asian Native American Other/don’t know Income level Hard times Just enough Few problems No problems Parental education Less than high school High school graduate Some college College graduate Post-college education Don’t know Health insurance Yes No

Total N

Weighted %

Population Estimate*

3153 3575

51.3 48.7

15,812,232 15,010,833

3195 3533

53.0 47.0

16,336,224 14,486,841

52.9 46.8

53.2 47.1

3615 949 622 279 92 307

64.0 14.0 10.9 3.9 1.5 5.9

19,726,762 4,315,229 3,359,714 1,202,100 462,346 1,818,561

63.8 14.9 10.6 4.0 1.7 4.6

63.9 13.1 11.1 3.9 1.3 7.1

239 1150 1546 2837

4.5 19.7 26.3 49.4

1,387,038 6,072,144 8,106,466 15,226,595

4.1 22.2 24.9 48.8

4.9 17.3 27.8 50.0

345 1242 1035 1772 852 580

5.8 20.6 17.2 31.0 14.5 10.9

1,787,738 6,349,552 5,301,567 9,555,151 4,469,345 3,359,914

6.4 21.7 18.0 29.3 14.9 9.7

5.3 19.6 16.4 32.6 14.1 12.1

4100 477

89.4 10.6

27,555,821 3,267,245

89.8 10.2

89.0 11.0

Girls (%) 0 100

Boys (%) 100 0

* Based on 1990 Census data for adolescents aged 10 –18 years.

school had some degree of financial problems. Ethnicity and financial status were also related (R ⫽ ⫺.131, p ⬍ .001). Having parents with higher education levels did not necessarily mean adolescents did not feel financial stress in their families. Of the adolescents who reported that at least one parent had finished college, 7.8% indicated that their families had “hard times” or “just enough” resources. Health Status, Insurance, and Use of Health Services Eighty-five percent reported being in good or excellent health. Younger adolescents were more likely to report good or excellent heath status (87% vs. 82%; p ⬍ .01) (Table 2). Boys and girls were equally likely to report being in good health, as were white and non-white adolescents. However when stratified by age, older girls were less likely to report having good or excellent health (80% vs. 85%; ␹2 ⫽ 10.96; p ⫽ .001). Overall, 92% of the adolescents reported having a regular source of primary care (a physician’s office, health care center, or hospital-based clinic). The most

common sources of care for the adolescents were a physician’s office (62%), clinic or health center (24%), other hospital setting (7%), and hospital ER (5%). Most (85%) also reported having a health professional they visit when they are sick, and 74% remembered having a routine preventive visit within the past 2 years. There was relatively little reported use of multiple sources of care. Although adolescents could indicate multiple care sources, 2.5% checked two, and only 0.5% checked three or more sources of care. Adolescents who reported the ER, health clinics, and hospital-based care as their usual source of care were slightly more likely to report using multiple sources of care. A total of 294 adolescents (5%) reported that the ER was their only source of care. While only 70% of the adolescents answering the question about health insurance reported having insurance, 22% of those answering reported that they did not know their insurance status. The question was also skipped by 21% of the adolescents surveyed. The adolescents who answered “don’t know” were more likely to be male and young, to have reported harder financial times in the family, and

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Table 2. Gender, Age, and Ethnicity by Health Care Access (% of Adolescents in Each Group Reporting) Responses Excellent/good health status Have a usual source of primary care Usual source of care Physician’s office Clinic Hospital other ER Have a regular sick care provider Have had a recent well-visit In past year 1–2 years ago More than 2 years ago Spoke to MD privately Missed needed care Reasons for missing care: Cost too much No insurance Hide from parents Not that bad No time to go No way to get there

Total (%)

Girls (%)

Boys (%)

p

5th– 8th grade

9th–12th grade

p

White

Non-White

p

85 92

84 94

85 91

.112 .000

87 92

82 92

.001 .940

86 94

84 90

.043 .000

62 24 7 5 81

65 24 6 4 83

60 24 7 6 78

.001 .846 .051 .010 .000 .003

60 25 8 5 84

65

5 77

.095 .619 .003 .640 .000 .000

72 20 4 4 84

51 30 11 7 76

.000 .000 .000 .000 .000 .950

85 9 6 58 27

86 8 6 53 29

83 10 6 62 24

.000 .000

89 7 4 45 24

82 11 8 71 29

.000 .004

86 9 6 60 23

86 9 5 53 31

.000 .000

24 10 35 15 22 12

23 10 38 17 23 13

24 10 31 14 20 10

.759 .937 .012 .159 .107 .165

23 8 33 15 19 15

24 12 37 15 24 10

.528 .063 .164 .889 .019 .017

22 7 39 17 22 10

26 14 34 12 22 14

.144 .001 .076 .039 .873 .051

much more likely to have answered “don’t know” to the question on parental education. Their responses were intermediate between those with and without insurance on other access measures such as having a primary care source, having a regular provider, and health status. Since this group seemed to include both those with and without insurance, all statistics on health insurance and access were done for only those adolescents who knew their insurance coverage. This is similar to the way that the National Center for Health Statistics addresses missing data for self-reported insurance status in the Medical Expenditure Panel Survey (5). With “don’t knows” excluded, 89% of the adolescents reported having health insurance and 11% reported not having insurance. Girls and boys were equally likely to visit the same health professional as their parents, although girls were somewhat more likely to prefer a different one (19% vs. 15%; ␹2 ⫽ 15.44; p ⬍ .001). Girls were much more likely than boys to report being too embarrassed to discuss a problem with a health professional (39% vs. 24%; ␹2 ⫽ 135.53; p ⬍ .001). Boys were significantly less likely to have a regular source of care than girls (83% vs. 78%; ␹2 ⫽ 23.02; p ⬍ .001) and were less likely to have had a checkup or physical in the previous year (83% vs. 86%; ’632 ⫽ 13.3174; p ⬍ .004). There were no differences between the percentages of boys and girls who had visited a mental health professional (even though girls were

more likely to have higher scores on the depression index). The proportion of girls who reported using a physician’s office as their usual source of care was significantly higher than that for boys (65% vs. 60%; ␹2 ⫽ 10.89; p ⬍ .001). Both genders were equally likely to use health centers or clinics (24% each). Hospitals’ ERs were used more frequently by boys. Girls were slightly more likely overall to identify a true source of primary care as their usual source of care (94% vs. 91%; ␹2 ⫽ 19.5457; p ⬍ .001). In general, both boys and girls reported that they were most comfortable getting care at the places they usually visited. Younger adolescents were more likely than older ones to report having a doctor or health professional whom they usually visit when they are sick (84% vs. 77%; ␹2 ⫽ 25.3337; p ⬍ .001) and were more likely to have had a checkup in the past 2 years rather than 3 or more years ago (96% vs. 92%; p ⬍ .001). In addition, older and younger adolescents were equally likely to report having a primary care provider as their usual source of care (92%). Access to care was also related to ethnicity. White adolescents had better access to care overall than youth in other ethnic or racial categories and were somewhat more likely to report having a primary care source than were non-white youth (94% vs. 90%; ␹2 ⫽ 15.2385; p ⬍ .001). Race also had a significant impact on the source of that care. White adolescents

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were far more likely than any other group to identify a physician’s office as their usual source of care (70% vs. 51%; ␹2 ⫽ 75.5969; p ⬍ .001). Non-white adolescents were more likely to report using clinics, health centers, or hospital-based care (40% vs. 25%; ␹2 ⫽ 55.9013; p ⬍ .001), or hospital ER (7% vs. 4%; ␹2 ⫽ 13.0943; p ⬍ .001). Hispanic adolescents were most likely to use clinics as their usual source of care (45%). Asian adolescents were least likely to report having a regular MD (70%) or speaking with their health professional privately (49%); however, they were also the least likely to report missing needed care (21%). As might be expected, suburban adolescents fared the best when it came to access to appropriate care. Urban and rural adolescents had very similar patterns of health care usage when analyzed by both financial status and insurance status. The only major difference was in usual source of care; urban adolescents were more likely to report using clinics and rural adolescents were more likely to visit physicians’ offices. Similarly, health insurance affected the adolescents’ reported usual sources of care. Those who reported not having insurance were more likely to report using clinics (30% vs. 22%; ␹2 ⫽ 4.93; p ⫽ .03) and the ER (9% vs. 5%; ␹2 ⫽ 4.916; p ⫽ .03) and were less likely to use physicians’ offices (51% vs. 68%; ␹2 ⫽ 16.78; p ⬍ .001) than those with insurance. Confidentiality Overall, 58% of adolescents had the opportunity to talk privately with their health professional, and 30% stated they preferred to have their examinations without their parents. Boys were much less likely to prefer to have their examination without a parent present (19% vs. 41%; ␹2 ⫽ 151.37; p ⬍ .001). Nonetheless, they were more likely to have spoken with the doctor privately (62% vs. 53%; ␹2 ⫽ 39.56; p ⬍ .001). Older adolescents were also more likely to have spoken with their health professional privately (71% vs. 45%; ␹2 ⫽ 179.0698; p ⬍ .001). There were no differences in the rates of private time during visits by usual source of care, health insurance status, or financial status. Confidential visits varied by ethnicity: white adolescents (60%) and black adolescents (56%) had higher rates of private time, while Asians had the lowest rate (49%) (overall p ⬍ .005). Missing Needed Care Twenty-seven percent of the adolescents surveyed reported that they had missed care that they felt they

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needed. Most (60%) felt that missing care was not very serious; however, 27% reported that their missing care was somewhat serious, and 14% felt that it was very serious. Girls were more likely than boys to have missed needed care (29% vs. 24%; ␹2 ⫽ 16.1782; p ⬍ .001). Native American adolescents had the highest rates of missed care of all of the ethnic groups (41%), and black adolescents had the next highest rate (32%). Age was also significantly related to missing needed care; 29% of older adolescents versus 24% of younger adolescents reported missing needed care (␹2 ⫽ 8.5359; p ⬍ .005). Forty-two percent of adolescents who reported that the ER was their usual source of care reported missing needed care, whereas 26% of those reporting other sources of care reported missing needed care (␹2 ⫽ 23.333; p ⬍ .001). Adolescents who reported having a physician’s office as their regular source of care were less likely to report missing needed care than those who reported using clinics or health centers (25% vs. 29%; ␹2 ⫽ 9.4997; p ⬍ .003). Adolescents who reported not having a source of primary care also were more likely to report missing needed care (39% vs. 26%; ␹2 ⫽ 24.4312; p ⬍ .001). The most common reason given for missing care was not wanting to tell parents (35%). Other reasons included cost (24%), not having time (22%), not thinking the condition was that serious (15%), no transportation (12%), and not having insurance (10%). Older adolescents were more likely to report not having time to go (24% vs. 19%; ␹2 ⫽ 5.5218; p ⬍ .02), and younger adolescents were more likely to report not having transportation (15% vs. 10%; ␹2 ⫽ 5.7915; p ⬍ .02). Twice as many non-white (14%) as white adolescents (7%) reported missing care because of not having health insurance. Girls were much more likely than boys to report missing care because they did not want their parents to find out (38% vs. 31%; ␹2 ⫽ 6.3827; p ⬎ .02). Adolescents who reported that they missed care because it cost too much were more likely to report that missing care was “serious” or “very serious” (28% vs. 20%; ␹2 ⫽ 7.3705; p ⬍ .01), as were those who reported that they had no way to get to a provider (15% vs. 10%; ␹2 ⫽ 7.7609; p ⬍ .01). Health Insurance, SES, and Use of Care One of the major barriers to access to care was not having health insurance. Only 64% of adolescents without health insurance reported having a regular source of care, compared with 85% of those with insurance (␹2 ⫽ 44.6846; p ⬍ .001) (Table 3). Adoles-

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Table 3. Effect of Insurance and Household Financial Status on Access to Health Care: % of Adolescents in Each Group Reporting Insurance Status Responses Excellent/good health status Have a usual source of primary care Usual source of care Physician’s office Clinic Hospital other ER Have a regular sick care provider Have had a recent well-visit In past year 1–2 years ago More than 2 years ago Spoke to MD privately Missed needed care Barriers to receiving needed care Cost too much No Insurance Hide from parents Not that bad No time to go No way to get there

Family Financial Situation

Have Insurance

No Insurance

p

Hard Times

Just Enough

Few Problems

No Problems

p

86 94

79 97

.018 .001

74 84

81 91

84 94

89 94

.000 .002

68 22 5 5 85

52 29 8 9 64

.000 .000 .000 .017 .000 .000

46 32 7 8 68

56 27 9 7 77

65 25 5 5 80

68 21 6 4 84

.000 .001 .035 .006 .000 .015

87 8 5 61 25

76 12 12 57 46

.000 .000

82 8 10 52 54

83 11 6 54 32

85 9 6 59 28

88 8 5 59 20

.051 .000

18 5 38 17 23 11

44 37 31 8 18 11

.000 .000 .142 .001 .126 .909

49 23 31 8 17 20

32 16 29 12 23 12

21 7 39 15 22 12

13 6 40 20 23 10

.000 .000 .028 .003 .632 .346

cents without insurance more often identified the ER as their usual source of care (5% vs. 9%; ␹2 ⫽ 8.2516; p ⬍ .005). In addition, almost twice as many (24%) adolescents without health insurance had not had a checkup within a year, compared to 13% of those with insurance (␹2 ⫽ 17.5569; p ⬍ .001). Adolescents who reported not having health insurance were also more likely than those with insurance to report having missed needed care (40% vs. 23%; ␹2 ⫽ 23.0036; p ⬍ .001). The most frequent reason cited for missing care for those without insurance was high cost (44% vs. 18% for those with insurance; ␹2 ⫽ 35.2581; p ⬍ .001). In contrast, adolescents with insurance were more likely to report that they missed care because they “didn’t think it [their problem] was that bad” (17% vs. 8%; ␹2 ⫽ 11.3216; p ⬍ .001). Level of parental education and self-report of family financial status both were associated with adolescents’ access to appropriate care. Across all parental education levels, the adolescents who reported that their families had few or no financial problems reported better access. However, those without health insurance had less access than those who reported hard times but had insurance. Fiftyfour percent of the adolescents who reported “hard times” also reported missing needed care. This is

much higher than the percent reported by those in other financial categories, and higher than the rate reported by adolescents whose parents had not completed high school (34%, the highest rate for any of the parental education categories). Whether adolescents had received a checkup in the previous year depended upon parental educational level, family financial status, and insurance. Adolescents with fewer financial problems were equally likely to have a primary care provider, whether or not they had insurance. However, the sources of primary care they used were very different. Those without insurance were more likely than those with insurance to report that their usual source of care was a clinic (33% vs. 19%; ␹2 ⫽ 4.9316; p ⬍ .03). Adolescents without insurance who reported “hard times” were less likely to have a primary care provider (74% vs. 85%; ␹2 ⫽ 6.7589; p ⬍ .01) than those with insurance who also reported “hard times.”

Discussion This survey is the first nationally representative study of self-reported access to health care of adolescents who are in school. Among this sample of the 35 million 10-19-year-olds in the United States, 92% of

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those responding to a school-based survey reported having a regular source of primary care, 85% reported having a checkup in the past year, and 94% reported having a checkup in the past 2 years. In contrast, based on parental report from the National Health Interview Survey (NHIS), 84% of adolescents with regular care and 77% of all adolescents reported having had a preventive visit within 2 years (16). Overall, the adolescents in the Commonwealth Fund Survey were somewhat more likely than parents in the NHIS to respond with “don’t know” for questions (i.e., with regard to their health insurance status). However, based on the proportions of the responses of those with the information, adolescents who indicate that they know their insurance status appear to report it as reliably as do their parents. There were significant differences in the use of health services by gender, age, and ethnicity. Girls were much more likely than boys to report missing needed care, were more likely to report missing care because they did not want their parents to know, and were less likely to report speaking privately with their health professional. Boys, on the other hand, were less likely than girls to have had a checkup in the previous year, less likely to have a usual primary care source, and were more likely to report using the ER as their usual source of care. Younger adolescents were more likely than older ones to have had a recent checkup, rated their health as better, and were less likely to have missed needed care than older adolescents. They were also less likely to have received confidential care. White adolescents were more likely than non-white adolescents to indicate that their usual source of care is a primary care provider and that source of care was more frequently a physician’s office rather than a clinic, hospital, or ER. Overall, 27% of the adolescents reported ever missing needed care (approximately 10 million young adults). This is higher than the 11% of all children 0 –17 years of age reported by parents to have missed needed care in the NHIS (6). This rate is also higher than the rate of missed care reported for children (9.6%), adult men (15.3%), and adult women (21.4%) in the Robert Wood Johnson Foundation 1994 National Access to Care Survey (9). However, both of these studies relied on parental report of adolescents’ access. Another recent school-based study of adolescents in Oregon found that 15–19% of adolescents reported missing care within the previous year (17). However, because many schools in the Oregon study had school-based health clinics, it is less likely to be representative of adolescents nationally.

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Studies that have depended on parental report for identification of adolescents’ sources of care may be substantially biased relative to the care actually used by youth. In the National Health Interview Survey, 8% of parents reported that their adolescents’ care sources were community health centers or hospital outpatient clinics (16). In contrast, one in four adolescents in our survey reported using clinics or health centers. These discrepancies in identification of sources may reflect parents’ inaccurate perceptions of their child’s care use. Alternatively, adolescents may label or perceive sources of care differently than do their parents. Our finding that 35% of those adolescents who missed care reported that they did so because they did not want their parents to find out is evidence of the potential gaps between parental perceptions and adolescents’ actual health care use. These data illustrate the necessity of asking adolescents about their own experiences with care if we truly hope to understand whether the health care system is meeting their needs. The high rate of missed care reported by girls in this study highlights some important differences between adolescent boys and girls. Girls were far more likely to have missed care because they did not want their parents to know about their problems, and they were also much more likely to report being too embarrassed to tell their health professional about a problem. However, they were less likely to receive confidential care from their provider. Even though they were more likely to miss needed care, girls were more likely to report having a usual source of primary care and to have had a recent well visit. Previous studies have found that girls are more likely than boys to have forgone care because their parents might find out (22) and are more likely to have sought out confidential care (23). Non-white adolescents were more likely to miss needed care than white adolescents, and also were more likely to not have been able to talk privately with their provider. Previous studies based on parental report have shown that minority adolescents are particularly vulnerable to inadequate access to health care (8). These findings highlight persistent inequities in the delivery of care for both women and ethnic minorities. While these predisposing factors are both immutable characteristics (15), a greater understanding of the reasons behind these inequities can help providers and insurers address the specific needs of these groups. The results of our study strongly emphasize the importance of health insurance in providing access to care. Adolescents who report having health insur-

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ance had increased access to care. They were much more likely to have a primary care source and to have a physician’s office as their usual source of care. These findings are similar to those, also of adolescents, identified by the U.S. General Accounting Office (GAO) in 1996 (24), and to recent reports based on NHIS data (12). The GAO found that children with health insurance were more likely to have access to preventive, acute, and chronic care, and were more likely to have access to a physician. The NHIS data showed that children without health insurance had less access to primary care services and were far more likely to have missed needed medical care (12)]. In our study, adolescents without insurance were nearly twice as likely to report missing needed care, and their reasons for missing care were far more likely to be financial or because of no insurance coverage. In addition, adolescents with no insurance were less likely to report having had private time with their provider. A relatively high percentage (21%) of the adolescents skipped the question about health insurance, and some adolescents were not aware if they had coverage; however, among those who responded to this question, the percentage of those reporting having health insurance was similar to that reported by parents in other studies (7,12,24). Merely knowing they have health insurance is no guarantee of access to care. Given the high rate of missing care because of privacy issues, teens may be reluctant to use their health insurance if the reason for the visit will show up on billing statements that are sent to their parents. A survey of adolescents in Monroe County, New York, found that 9% of adolescents had used a confidential care source without their parents’ knowledge (23). Fewer adolescents (3.0%) reported using multiple sources of care in this study; however, specific questions about multiple sources of care were not asked. Understanding how adolescents depend on multiple sources remains an important future question with implications for access in managed care systems. Adolescent’s report of their family’s financial status had substantial effects on access to care independent of whether the adolescent had health insurance. Many adolescents (57%) who reported not having insurance and that their family had financial hard times reported missing needed care; 46% of those with insurance who reported hard times also reported missing needed care. For the adolescent whose family is experiencing financial difficulties, having insurance is no guarantee of access to health care. Nevertheless, those adolescents who reported

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having hard times who had insurance had better access that those without insurance. Parental education, also used as a proxy measure for income, had an impact on access, although its effect was less strong. However, there were a significant number of highly educated families who were experiencing hard times, and these adolescents on the margin (i.e., those whose parents may have lost their jobs or become disabled) are at a high risk for not having access to care. While these adolescents may be able to benefit from preventive interventions, they may be least familiar with public assistance or how to access free or low-cost clinics. Thus, many adolescents need outreach and information about available services, not merely those who are impoverished or uninsured. This study shows that adolescents face barriers to access which include lack of insurance, financial difficulty, and lack of confidentiality. These are mutable, and thus should be able to be changed by public policy (15). The implementation of State Child Health Insurance Programs (25) and the subsequent coverage of many more poor adolescents (up to age 18 years) provide an opportunity to improve the care system. However, they also raise the question of whether insurers and policy makers will establish systems that will meet the needs of adolescents. To be effective, these programs must also address the additional reasons that adolescents report missing needed care, such as concern about parents finding out, confidentiality, and the ability to chose a provider who is accessible both geographically and interpersonally. Advocacy at the state level will be necessary to ensure that adolescents are fully included in either Medicaid expansions or alternative coverage plans. States can also influence managed care organizations’ development of confidential systems through contracting requirements regarding alternatives to billing system disclosure of clinical information. State contract language can similarly stipulate that managed care organizations’ quality assurance activities include ensuring that providers’ delivery of care includes confidential counseling opportunities. Similarly, managed care organizations could be encouraged to monitor satisfaction and the content of care received by directly surveying adolescents, rather than by relying on parental report. Collaboration among the various agencies serving adolescents has been advocated before (26), and it is clear that the barriers faced by adolescents cannot be addressed by any one agency or policy change. This study is limited in several ways. The sample

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surveyed only youth in class on the day of administration; those who were not in attendance, either because of absence or dropout, are not represented. Such youth are at greater risk for poor health status and risky behaviors, and are more likely to be uninsured. Thus, their exclusion likely overestimates adolescents’ financial access to care. The sampling of schools may also have resulted in a bias toward communities and districts that were better or worse in some systemic way. In addition, the validity of adolescents’ reports of their care use is not known. In adults, more recent experiences and distorted time recall affect the accuracy of these reports (18). Thus, self-report of service use may be substantially skewed. The study is also limited by the potential ethnic and geographical variability in the interpretation of the questions on the survey. While we did not find any specific bias here, we cannot know for sure that all respondents interpreted the meaning of the questions (i.e., “missing needed care”) in the same way. In addition, the question used to ascertain confidential care, whether they had “private time” with their doctor, may not accurately reflect whether confidential care was actually given. In contrast, a strength of this study is that these data are based on adolescents’ own report of their experience with care. The data from this survey identify significant problems with the quality of care available to many youth. Among adolescents who had used care, only 58% had the opportunity to talk privately with their clinician. Thus, although many youth report having had preventive visits, the content of a substantive portion of these visits could not possibly have provided confidential counseling and screening for preventable risky behaviors. Many adolescents report that they would avoid or delay care unless it was available confidentially (22). Since a large proportion of adolescents did not have the opportunity for confidential discussion, their care is unlikely to have included effective delivery of recommended preventive services. During adolescence, teenagers form attitudes and habits that will be with them for the rest of their lives, and this is no less true for their use of health care. The GAO report on access to care and insurance coverage identified the need for insurance coverage that allows children and youth to develop relationships with their providers, and for systems to be developed which enable providers to track preventive visits and immunizations, and provide information and support to parents (24). However, unless the care provided to adolescents includes confidential

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screening and counseling, many opportunities to provide effective prevention will continue to be missed. Greater access to confidential care for adolescents can lead to better health, presents more opportunities for providers to intervene with adolescents involved in risky behaviors, and increases the likelihood that positive, healthy behaviors will continue into adulthood. Gender differences in access to care need to be addressed as well. Since girls will be not only the users of their own health care, but also the decisionmakers for their families’ health care, it is vital that their needs for confidentiality and their concerns about embarrassing topics are addressed. Otherwise, they may develop a distrust of the medical system that will influence their care-seeking behavior as adults. For all adolescents, outreach regarding available services, changes in clinician practices and systems that promote access to recommended services are needed if we hope to expand adolescents’ access to care. Finding ways to fully integrate these teenagers into the health care system may lead to benefits that will last far into the future. This study was supported by a grant from the Commonwealth Fund of New York. Dr. Klein is also supported by a Generalist Faculty Scholars Award from the Robert Wood Johnson Foundation.

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10. Saver BG, Peterfreund, N. Insurance, income and access to ambulatory care in King County, Washington. Am J Public Health 1993;83:1583– 8. 11. Weitzman M, Byrd RS, Auinger P. Children in big cities in the United States: Health and related needs and services. Ambulatory Child Health 1996;1:347–59. 12. Newacheck PW, Stoddard JJ, Hughes DC, et al. Health insurance and access to primary care for children. N Engl J Med 1998;338:513–9. 13. Igra V, Millstein, SG. Current status and approaches to improving preventive services for adolescents. JAMA 1993;269: 1408 –12. 14. Starfield B. Health services research: A working model. N Engl J Med 1973;289:132– 6. 15. Aday LA, Anderson R. A Framework for the study of access to medical care. Health Services Res 1974;9:208 –20. 16. Hedberg VA, Byrd RS, Klein JD, et al. The role of community health centers in providing preventive care to adolescents. Arch Pediatr Adolesc Med 1996;150:603– 8. 17. Zimmer-Gembeck MJ, Alexander T, Nystrom RJ. Adolescent report their need for and use of health care services. J Adolesc Health 1997;21:388 –99. 18. Klein JD, Graff CG, Santelli JS. Developing quality measures for adolescent care: validity of adolescent self-reported receipt of preventive services. Health Services Research. (In Press).

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19. Lowry R, Kann L, Collins J, et al. The effect of socioeconomic status on chronic disease risk behaviors among U.S. adolescents. JAMA 1996;276:792–7. 20. SAS Institute Inc. SAS/STAT User’s Guide, V. 6, 4th Ed., Cary, NC: SAS Institute, Inc., 1989. 21. Shah BV, Barnwell BG, Bieler GS. SUDAAN User’s Manual, Rel. 7.0, 1996. Research Triangle Park, NC: Research Triangle Institute. 22. Cheng TL, Savageau JA, Sattler AL, DeWitt TG. Confidentiality in health care: A survey of knowledge, perceptions, and attitutdes among high school students. JAMA 1993;269: 1404 –7. 23. Klein JD, McNulty M, Flatau CN. Adolescents’ access to care: Teens’ self-reported service use and perceived access to confidential care. Arch Pediatr Adolesc Med 1998;152: 676 – 82. 24. General Accounting Office. Health Insurance: Coverage Leads to Increased Health Care Access for Children (Letter Report, 11/24/97, GAO/HEHS-98-14). 25. The Balanced Budget Act of 1997, Pub L. No 105-33, 111 Stat. 251 (1997), Title IV, Subtitle J, State Children’s Health Insurance Program. 26. Brindis CD. What will it take: Placing adolescents on the American national agenda for the 1990s. J Adolesc Health 1993;14:527-30.