One in seven U.S. children aged 10 to 18 is not covered by health insurance.
That figure has not changed in more than a decade, even though
government-funded health plans now cover more children and teens.

“Little progress has been made over the past fifteen years in reducing the
numbers of uninsured adolescents,” said Paul Newacheck, DrPH, professor of
health policy and pediatrics at the University of California, San Francisco
(UCSF). He is the principal author of a study published in the August issue of
the journal Pediatrics—the first comprehensive, nationwide look, using data
from the 1990s, at adolescent health insurance and health care.

“Approximately 4.2 million adolescents had no health insurance coverage in
1995, based on data from the National Health Interview Survey conducted that
year by the Bureau of the Census,” Newacheck said. “As a result, these children
had significant obstacles to getting adequate health care. The new,
federally-supported State Children’s Health Insurance Program (SCHIP) may
provide an opportunity to improve access to care ” but only if states will
implement effective outreach strategies to enroll families with adolescents.”

The difference between insured and uninsured adolescents: Those without
insurance are five times more likely to have no doctor or clinic where they and
their parents know they can go for care; and four times more likely to have
unmet health needs.

Study co-author Charles Irwin, MD, chief of the Division of Adolescent Medicine
at UCSF, said one checkup by a doctor per year is the standard recommendation
for children aged 10 to 18.  Uninsured teens are twice as likely not to have
seen a doctor in more than a year. That means they miss out on preventive
screening for problems with vision, hearing and chronic diseases such as
diabetes. They also miss what pediatricians call “anticipatory guidance” -
they have no doctor to talk with them about sexual choices and other risky
behaviors such as drugs or violence. Physicians who work with teens often can
head off problems by offering appropriate screening, intervention or

There is little data to show a direct link between absence of health insurance
and an increase in illness for this age group, Irwin said, but that may be
because the majority of adolescents are healthy. However uninsured adolescents
are three times as likely as those with insurance show up in the emergency
room when they need a doctor.

“To me that’s the red flag that tells us this group is not getting the care
they need,” Irwin said.

Uninsured adolescents with unmet health needs missed out on dental care,
prescription drugs, eyeglasses and sometimes basic medical care.

A Shift From Private to Public Insurance

The UCSF study is based on data on 14,252 adolescents aged 10 to 18 years
included in the 1995 National Health Interview Study, an annual survey based on
interviews with an adult member in more than 40,000 households.

The study documents a shift in the payors for adolescent health insurance. In
1984, more than three-quarters (75.9 percent) of adolescents were covered by
private insurance; 11.9 percent had public coverage and about two percent had a
combination of both. By 1995, public insurance had increased to cover 16.9
percent of children aged 10 to 18, thanks in part to a federal policy opening
up Medicaid to additional children when it previously had been available only
to the very poor in most states. In the same period, however, private coverage
of adolescents slipped to 71.2 percent.

That leaves 14.1 percent, or one in seven adolescents, without coverage in 1995
—the exact same percentage as in 1984. “You would expect some improvement,
but there has been no change in ten years—a net no gain,” Irwin said.

Newacheck said experts have offered several explanations why private insurance
covers fewer adolescents, including higher premiums and a shift of jobs to the
service sector of the economy where employers are less likely to offer health
insurance as a benefit.

When parents were asked why their adolescent children were not covered by
health insurance, most cited the high cost of coverage, or a job layoff or job

“Despite the clear importance of health insurance, our study also shows that
coverage is not evenly distributed within the adolescent population,” Newacheck
said. Four out of every five uninsured adolescents come from poor and “near
poor” families—those with incomes below 200 percent of the poverty level.
Such families are six times more likely than more affluent families to have no
health coverage for their teens.

Hispanics were the least likely to be covered, followed by blacks. The South
and the West had the largest proportions of uninsured adolescents.

A new federal program to improve children’s health insurance coverage offers an
opportunity to reduce inequities, the authors say. The Balanced Budget Act of
1997 created the State Children’s Health Insurance Program (SCHIP), which
provides matching federal funds for states to expand health insurance coverage
of children and adolescents up to age 19 from low income families with incomes
below 200 percent of the poverty level.

“However, states will require aggressive outreach and enrollment efforts to
take full advantage of the potential of SCHIP,” Newacheck said. “Each state
will design its own program, and Congress allocated no funds to evaluate
programs or to compare program effectiveness across states. Adolescents are
particularly challenging to enroll because traditionally they have fewer
contacts with health care providers than younger children. The burden is on
health care providers, especially pediatricians, and on all children’s
advocates to encourage the development of effective strategies so more American
children and adolescents have adequate health insurance coverage.”

Co-authors of the study were Paul W. Newacheck, DrPH and Claire D. Brindis,
DrPH of the Institute for Health Policy Studies and the UCSF department of
pediatrics; Charles E. Irwin, Jr., MD, chief of the division of adolescent
medicine, UCSF department of pediatrics; and Kristen Marchi, MPH and Courtney
Uhler Cart, MSW, MPH, of the UCSF Institute for Health Policy Studies. The
research was funded by grants from the federal Maternal and Child Health
Bureau, the Robert Wood Johnson Foundation and the Center for Studying Health
System Change.