National Center for Education in Maternal and Child Health

MCH Alert Home Page

April 7, 2000

1. Study Finds Gun Safety Counseling Needed

2. Depression, Anxiety Associated with Increased Risk for Preeclampsia

3. Access to Care Limited for Children with Special Health Care Needs

4. Institute of Medicine Finds Health Care Safety Net "Intact but Endangered"

5. Report Looks at Medicaid Managed Care and Children with Special Needs

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1. STUDY FINDS GUN SAFETY COUNSELING NEEDED

More than 2 million US children live in homes where loaded guns are readily accessible, according to a study in the American Journal of Public Health.

Using data from the 1994 National Health Interview Survey and Year 2000 objectives supplement, the authors determined that in 1.4 million US homes, firearms are kept loaded and unlocked (i.e., are stored in an unlocked area and do not have trigger locks or other locking devices). Frequent media reports of children who kill or hurt themselves or others with firearms, paired with gun-safety recommendations issued by organizations ranging from the American Academy of Pediatrics to the National Rifle Association, indicate the need to prevent children from accessing firearms, according to the article.

Older children are more likely to live in homes with guns, as is indicated by this study's finding that 28% of children younger than 1 year and 38% of children between 13 and 17 years live with someone who owns a gun. According to the analysis

• 35% of US homes with children have firearms;
• 9% of families that own guns and that have children store the guns loaded and unlocked; and
• 39% of families who own guns keep them unloaded, locked, and stored separately from ammunition, which is regarded as making firearms least accessible to children.

The authors observed that these data indicate that in many homes firearms are stored in ways that are consistent with recommendations designed to reduce children's access to them. At the same time, the authors "believe that people with firearms … may overreport storing them locked, unloaded, and separate from ammunition because that is generally the socially desirable response."

Many professional associations call for counseling families with children about the accessibility of firearms in the home, and the authors cite studies that find that "parents are receptive to clinical provision of advice about firearm safety and storage." Nonetheless, the authors note that clinicians cannot address every possible topic upon which patients can be counseled, and they "do not control what goes on in the homes of children." The authors recommend that health professionals "make sure that when families make … decisions, they are informed about the risks associated with firearms and how to reduce those risks."

Schuster MA et al. 2000. Firearm storage patterns in US homes with children. American Journal of Public Health 90(4):588-594.

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2. DEPRESSION, ANXIETY ASSOCIATED WITH INCREASED RISK FOR PREECLAMPSIA

Depression or anxiety in early pregnancy is associated with risk for subsequent preeclampsia, a risk further increased by bacterial vaginosis, according to a study in the April issue of Obstetrics and Gynecology. Preeclampsia is a major pregnancy complication and is defined as elevated blood pressure and proteinuria (an excess of serum proteins in the urine). The authors conducted the population-based study at outpatient maternity clinics in Helsinki, Finland, and adjusted for the potential confounding factors of age, smoking, alcohol consumption, marital status, socioeconomic status, and bacterial vaginosis. Six hundred and twenty-three women who had not previously given birth were studied at 10 to 17 weeks gestation and at delivery.

Findings include the following:

• Twenty-eight (4.5%) of the women developed preeclampsia;
• Depression was observed in 185 (30%) of the women in early pregnancy, and anxiety was observed in 99 (16%) in early pregnancy;
• Either depression or anxiety, or both, were associated with increased risk for preeclampsia; and
• Bacterial vaginosis with depression was associated with additional risk for preeclampsia.

Study limitations include the following: (1) mood was evaluated only once in early pregnancy, (2) there was no information on family history, and (3) the series was too small to allow the authors to assess whether the degree of depression was associated with the magnitude of the risk for preeclampsia. The authors indicate that the study's strengths include its prospective nature, its enrollment of only women who had not previously given birth, and its early assessment of depression and anxiety before preeclampsia had begun. "Our results indicate that women showing depression are at increased risk for subsequent preeclampsia and need extra social and psychological support and close follow-up for symptoms of preeclampsia."

Kurki T et al. 2000. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstetrics & Gynecology 95(4):487-490.

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3. ACCESS TO CARE LIMITED FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS

Insured children with special health care needs (CSHCN) were much more likely than CSHCN without insurance to have the primary elements of a medical home, including a usual source of care and a regular clinician, states an article in Pediatrics. The authors analyzed data on 57,553 children younger than 18 included in the 1994-95 National Health Interview Survey on Disability. They found that an estimated 1.3 million CSHCN were uninsured during 1994-95.

The authors found that insurance coverage was strongly associated with the ability to obtain needed medical care, dental care, mental health services, prescription medications, and ambulatory care services. Furthermore, uninsured CSHCN were four times more likely than insured CSHCN to have unmet needs for these services. Insured CSHCN used approximately twice as many physician services as uninsured CSHCN, even after adjusting for health status. More than one in four uninsured CSHCN went without a physician contact in the year before the interview date.

In their analysis, the authors used the federal Maternal and Child Health Bureau's (MCHB) definition of CSHCN, which states that CSHCN "have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally."

Findings include the following:

• An estimated 18% of US children younger than 18 had an existing special health care need in 1994-95.
• An estimated 89% of these children had some form of health insurance coverage, most often private health insurance.
• Insured CSHCN were more likely than uninsured CSHCN to have a usual source of care (96.9% vs. 79.2%); among those with a usual source of care, insured CSHCN were more likely than uninsured CSHCN to have an identified regular clinician (87.6% vs. 80.7%).
• Insured CSHCN were less likely to report unmet health care needs, including medical care (2.2% vs. 10.5%), dental care (6.1% vs. 23.9%), prescriptions, and/or eyeglasses (3.1% vs. 12.3%), and mental health care (.9% vs. 3.4%).
• Insured CSHCN were also more likely to have a physician contact in the past year (89.3% vs. 73.6%) and have more physician contacts on an annual basis (8.5 vs. 4.1 contacts).
• Contrary to the authors' expectations, no differences were found between insured and uninsured CSHCN's access to after-hours medical care (evenings and weekends) or satisfaction of care.
• Modest differences were found between publicly and privately insured CSHCN. Privately insured CSHCN were more likely to have a usual source of care (97.6% vs. 95.3%) and a regular clinician (91.0% vs. 81.1%). Privately insured CSHCN were also less likely to report dissatisfaction with care at their usual site of care (14.9% vs. 21.0%) and to have access to care on evenings and weekends (6.8% vs 13.4%).

The authors conclude that "efforts to expand eligibility and enrollment in private and public insurance programs are of critical importance for this population, as are efforts to ensure that children with special health care needs, even when insured, have access to needed services."

Newacheck PW et al. 2000. Access to health care for children with special health care needs. Pediatrics 1-5(4):760-766.

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4. INSTITUTE OF MEDICINE FINDS HEALTH CARE SAFETY NET "INTACT BUT ENDANGERED"

"Rising numbers of uninsured patients, coupled with changes in Medicaid policies and cutbacks in public and other subsidies, are beginning to place America's health care safety net in a serious state of jeopardy," states a committee report from the Institute of Medicine. Commissioned by the Health Resources and Services Administration, the report examines "the current challenges facing historical providers of care to the poor and uninsured in terms of their future financial viability and survival" and "finds a compelling need for a stronger ongoing capacity to monitor the changing status of the safety net."

In particular, the report focuses on core safety net providers, defined as institutions that offer care regardless of patients' ability to pay for services and that see a substantial number of uninsured, Medicaid, and other "vulnerable populations." Trends of concern to core safety net providers include the rising number of uninsured people in the US, the erosion of direct and indirect subsidies that finance uncompensated care, and the adverse effects of the rapid growth of Medicaid managed care.

The committee's findings include the following:

• The shift to Medicaid managed care can have adverse effects on core safety net providers and the populations they serve;
• Implementation problems are undermining managed care's potential to provide improved health care for its primary constituents;
• The financial viability of core safety net providers is in greater jeopardy than in the past;
• There are wide variances in the availability of care for the uninsured and other vulnerable populations, with the greatest deficits often occurring where need is most urgent; and
• Core providers are adapting to changes, but many have not yet felt the full impact of market forces.

In light of these findings, the committee recommends that policy makers assess the full impact of policy changes on vulnerable populations; review the effectiveness of federal programs and policies; monitor the safety net (especially its funding programs and the health of those it serves); fund a new initiative to support the safety net; and coordinate technical assistance programs supporting the safety net.

Lewin ME, Altman S, eds. 2000. American's Health Care Safety Net: Intact but Endangered. Washington, DC: National Academy Press. Available at <http://books.nap.edu/catalog/9612.html >; click on icons at the left.

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5. REPORT LOOKS AT MEDICAID MANAGED CARE AND CHILDREN WITH SPECIAL NEEDS

Both the Health Care Financing Administration (HCFA) and the states face significant challenges in implementing safeguards for children with special health care needs (CSHCN) mandatorily enrolled in capitated Medicaid managed care, states a new report by the US General Accounting Office (GAO). "Managed care's emphasis on primary care and control of service use raises concerns for Medicaid's approximately 7 million disabled beneficiaries--many of whom have chronic conditions that require frequent access to specialized providers." The report (1) examines the implications of the Balanced Budget Act of 1997 (BBA) provisions defining this population; (2) provides an update on the number of states enrolling CSHCN in capitated health plans; and (3) assesses the steps HCFA has taken to establish appropriate safeguards for this population.

The BBA essentially defines a child with special health care needs as a child who participates in one of the following five programs:

(1) Supplemental Security Income (SSI) under the Social Security Act (SSA);

(2) The Katie Beckett state plan option (a discretionary Medicaid eligibility category that covers children living at home who would be eligible for Medicaid if they were institutionalized);

(3) Maternal and Child Health Services block grants for CSHCN under Title V of the SSA;

(4) Federal foster care or adoption assistance under Title IV-E of the SSA; or

(5) Foster care or out-of-home placements funded through other sources.

The authors state that although the BBA definition of CSHCN encompasses a great deal, it still may not cover some children in Medicaid with significant health conditions who may not qualify for one of the above-mentioned programs.

Concerning data on states, the report notes that nationwide data on the number of states with CSHCN in capitated managed care plans are available for only two of the five BBA categories: SSI and foster care. Between 1996 and July 1999 the number of states enrolling SSI children in capitated plans nearly doubled, rising from 17 to 32. Because HCFA has not traditionally required separate tracking for each of the BBA categories, it is unable to determine the number of BBA-defined CSHCNs who are enrolled in capitated Medicaid plans. HCFA is working to address these data limitations, according to the report.

HCFA has begun applying mandatory "interim criteria" to waiver requests by states requiring enrollment of CSHCN in capitated managed care plans. The report notes that many safeguards HCFA had identified in earlier recommendations--such as educating health plans and providers about issues of particular concern to this population--were not included in these criteria. Also, the interim criteria do not address the need to collect individual-level data to monitor delivery of services or the need to adopt criteria for the approval of medical services that maintain rather than improve a person's function (services HCFA previously recommended for approval). The report notes, however, that HCFA has indicated that the interim criteria will be revised as the agency learns more about states' best practices.

US General Accounting Office. 2000, March. Medicaid Managed Care: Challenges in Implementing Safeguards for Children with Special Needs. (GAO Publications No. HEHS-00-37.) This report can be downloaded from <http://www.gao.gov/daybook/000403.htm>.

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