Access to Care During Childhood: A Social Determinant of Health

Author:Michaela Lewis, DNP, ARNP, CPNP-AC/PC, CPN, CPEN, CNE, CNE-cl, PMHS, CCRN, VA-BC

Child health is defined as the extent to which an individual child is able or enabled to (1) develop and realize their potential, (2) satisfy their needs, and (3) develop the capacities that allow them to interact successfully with their biological, physical, and social environments (National Research Council & Institute of Medicine [IOM], 2004, p. 16). Child health is determined by the interaction of a multitude of complex biological, behavioral, and environmental influences.

SPN Access to Care Position Statement

SPN believes that all children deserve access to lifelong, affordable, comprehensive, compassionate, sensitive, timely, coordinated, ethical, equitable, holistic, quality, and evidence-based health care across all care delivery settings. Additional details pertaining to SPN’s stance on access to care can be found at: SPN Position Statement: Access to Care.

Biological influences include genetic expressions; prenatal, perinatal, and postnatal influences and events; and prior states of health. Behavioral influences include the child’s emotions, beliefs, attitudes, behaviors, and cognitive abilities that affect health outcomes. Environmental influences include exposure to infectious agents or toxins; relationships with caregivers and peers; socioeconomic resources in the family and community; culture; racism and discrimination; availability and quality of services; and policies that directly or indirectly affect these other interactive influences. (National Research Council & IOM, 2004)

Child health is the foundation of health and well-being for societies. Health during childhood sets the stage for health during adulthood; healthy children are likely to become healthy adults that contribute positively to the structure, function, and sustenance of current and future societies. Social determinants of health (the conditions and the environments where children and their families are born, live, learn, work, and age) affect a wide range of health, functioning, and quality-of-life outcomes and risks (U.S. Department of Health and Human Services, n.d.). Health care access and quality, or lack thereof, has been identified as a social determinant of health whose effects are wide reaching and long-lasting.

Access to health care is defined as “the timely use of personal health services to achieve the best health outcomes” which includes access to health care coverage and timely services provided by a qualified and capable workforce (Agency for Healthcare Research and Quality [AHRQ], n.d.). This article reviews common barriers to health care access during childhood and introduces the Society of Pediatric Nurses’ (SPN’s) position regarding this issue.

Health Insurance Coverage

Health insurance coverage facilitates entry into the health care system by ensuring financial viability. Cost prohibitive factors associated with health care delivery commonly result in delays in individuals seeking care once a need is identified. Without health insurance, caregivers of children are less likely to have a regular health care provider and more likely to skip routine health care, placing children at increased risk for poor health outcomes, less educational attainment, and less financial security in adulthood when compared to their insured counterparts (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, & Office of the Secretary, U.S. Department of Health and Human Services, n.d.). Uninsured children are almost four times more likely than children obtaining insurance to have no primary care provider (PCP) and 40 times more likely to have no usual preventive care or sick care source (Flores et al., 2017). Additionally, uninsured children are over three times more likely than the insured to either delay or not seek needed health care and three times more likely to have unmet dental care needs (Flores et al., 2017).

State and federally funded health insurance for children, via Medicaid and the Children’s Health Insurance Program (CHIP), remains the primary mechanism by which children gain and retain health care coverage. As of January 2023, over half of all children in the US (42 million) were covered by Medicaid (35 million) or CHIP (7 million) (Centers for Medicaid and Medicaid Services, 2023). Since the enactment of the Patient Protection and Affordable Care Act, the uninsured rate among adults and children decreased substantially; recent national data show that the uninsured rate among children (ages 0-17 years) fell from 6.4% in late 2020 to 4.5% in the third quarter of 2022 (Conmy et al., 2023).

Ensuring health care coverage for children can have a powerful impact on child and population health. Providing health insurance to Medicaid/CHIP-eligible, uninsured, children improves health, health care access and quality, and parental satisfaction; reduces unmet needs and out-of-pocket costs; and saves $2886/insured child/year (Flores et al., 2017). Provision of health insurance has also been associated with higher immunization rates; higher screening rates for anemia, lead, vision, and hearing; and reduced asthma related emergency department visits and hospitalizations (Flores et al., 2017). Despite these impacts, millions of children eligible for Medicaid and CHIP remain uncovered due to enrollment barriers and eligibility related restrictions.

Resource Limitations

Children who are unable to access physical health care locations, such as those living in resource limited or rural communities, experience impactful delays. Significant workforce and bed shortages, delays in insurer authorizations, and inadequate payment structures pose barriers to the provision of timely, comprehensive, health care and contribute to longer lengths of emergency department and inpatient stays, greater resource utilization within a taxed system, and poorer health outcomes for children and their families.

Individuals who cannot access the quality care they need may have more preventable complications, hospitalizations, and emotional stress, and experience increased costs of care (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, & Office of the Secretary, U.S. Department of Health and Human Services, n.d.).Delays in the provision of child health services can lead to missed opportunities for early screening and detection of health problems, increased risks for outbreaks of vaccine-preventable diseases, and chronic disease (Nguyen et al., 2022; Trent et al., 2019).

Health Care Policy and Practices

Mere access to care neither ensures quality nor eliminates health disparities that originate from discriminatory practices aimed at excluding health care participation upon the basis of protected characteristics. Discrimination in health care settings and legal restriction of evidence-based practices endangers lives through delays or denials of medically necessary care. 

Although progress has been made toward racial equality and equity, racial biases continue to permeate the US health care system and influence patient-clinician relationships and clinical decision making, negatively affecting members of minority populations in the form of poorer physical and mental health outcomes and inferior health care services. Racial trauma, the emotional impact of stress related to directly experiencing or witnessing racism; racial discrimination; and race-related stressors have been linked to birth disparities, mental health problems, and a predisposition for chronic disease among children and adolescents (U.S. Department of Veteran Affairs, 2023; Trent et al., 2019). Feelings of receiving irresponsible, inadequate, or incompetent treatment; poor patient-provider communication; and documentation of unconscionable abuses perpetuated by members of research and health care professions breed skepticism and hesitancy in seeking health care services among minority communities (Ayalon & Alvidrez, 2007).

“Now more than ever, young people are expressing gender identities that differ from the genders they were assigned at birth, and gender-affirming care is critical to their mental, physical, and social well-being” (Schaefer et al., 2022). Gender-affirming care is a series of evidence-based, developmentally appropriate, services that may include mental health counseling, social transition support, hormone therapy, surgical, and non-medical support for individuals who are transgender or non-binary (Hembree, 2017). Legislation seeking to limit or ban gender-affirming care for minors disrupts access to vital resources and supports; disruptions have been associated with poor mental health outcomes, including increases in rates of anxiety, depression, and suicide amongst those impacted.

SPN Access to Care Position Statement

SPN believes that all children deserve access to lifelong, affordable, comprehensive, compassionate, sensitive, timely, coordinated, ethical, equitable, holistic, quality, and evidence-based health care across all care delivery settings. Additional details pertaining to SPN’s stance on access to care can be found at: SPN Position Statement: Access to Care.

References

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Conmy, A.B., Peters, C., De Lew, N., Sommers, B.D. (2023). Children’s health coverage trends: Gains in 2020-2022 reverse previous coverage losses. https://aspe.hhs.gov/sites/default/files/documents/77d7cc41648a371e0b5128f0dec2470e/aspe-childrens-health-coverage.pdf

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