Author Archives: Kristin Catena

Child Health and Health Care Access

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Many celebrated outside the Supreme Court two weeks ago following SCOTUS’s decision to allow health care subsidies through the Affordable Care Act (ACA). I was among those who breathed a sigh of relief at home after reading that our coverage through the Marketplace would be continued. Now as life returns to normal and we no longer have to worry for the time being, let’s not forget the importance of health care access, especially for children, and the fact that there are still children who don’t have it. Exactly how important is health care access? Lindsey Leininger and Helen Levy joined forces in the latest Future of Children issue to tell us about the influence access has on child health.

Research on this question has had varying results, but Leininger and Levy argue that, overall, access to care does improve child health and that the influence is often more significant for those who are marginalized. The classic RAND Health Insurance Experiment, for instance, suggested that in the population as a whole, the generosity of insurance coverage did not significantly determine overall health. However for high-risk (meaning low-income) children, generosity of coverage did affect health.

Studies on Medicaid eligibility show further evidence: in the year after implementation, mortality fell among nonwhite infants, and this effect persisted for at least 10 years. Also, among children in low-income families, those who experienced more years of Medicaid eligibility were in better health. A variety of other studies have associated expansions of Medicaid eligibility with reductions in child mortality. With regard to Medicaid enrollment, positive effects have also been seen, such as increased enrollment leading to decreases in hospital admissions for conditions that could be well-managed by primary care.

Leininger’s own research has shown that lack of coverage can be a strong detriment to child health. Her study showed that each additional month without coverage was associated with a small, statistically significant decline in the probably of a child seeing a doctor for a well-visit or any other visit. A four-month spell of being uninsured, for example, resulted in a 4 percent decrease in the likelihood of any visit and a 9 percent decrease in the likelihood of a well-visit.

So insurance coverage is good for child health, especially for marginalized children. But according to our authors, although “the ACA builds on the earlier successes of Medicaid expansion and CHIP to promote children’s access to care… challenges remain.” Access to care improves child health, but it is not the only factor. For example one study cited by Leininger and Levy estimates that lack of access to medical care explains only about 10% of early mortality in the population as a whole; less than genetics (30%), social circumstances (15%), and behavioral factors (40%). To improve children’s health overall and consider policies that may do so, we must also consider the larger picture. To learn more about other factors that influence children’s health, read the full Future of Children issue on Child Health.

Child and Public Health in a Libertarian Legal Framework

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Earlier this year the West Coast saw a measles outbreak, another recurrence in a string of previously eradicated childhood illnesses. Stories of parents’ various objections to vaccination quickly flooded the news, underscoring the main question: who is responsible for these public health crises, families or the state? While some people may have been surprised or confused to see such illnesses return, Clare Huntington and Elizabeth Scott’s explanation of children’s health in a legal framework for The Future of Children provides valuable context.

The U.S. legal system, say Huntington and Scott, “gives parents the authority and responsibility to make decisions about their children’s health care, and favors parental rights over society’s collective responsibility to provide for children’s welfare” or, in the case of vaccination, overall public health. They call this a libertarian legal framework as a way to describe the legal context in which parents are permitted to make their own decisions about child health. There are exceptions, such as when a child’s life is in danger or when a child is in juvenile justice custody; however, since parental rights are constitutionally protected, a high standard of harm must be met before intervention can occur.

In public health cases such as vaccination, where can the line of “harm” be drawn? Currently, all healthy children are required to receive vaccinations in order to attend school. However, almost all states offer exemptions for religious beliefs and many also offer them for other philosophical convictions. The balance between the libertarian argument and public health theoretically rests on the understanding that those with strong beliefs both deserve their right to decide and are a small enough segment of the population that the overall public interest of immunity is still met. However the return of some childhood illnesses shows that this balance is no longer being maintained.

Now many states are tightening their exemption policies. For example, California (origin of the measles outbreak) is on the verge of eliminating philosophical exemptions. For some states, making these adjustments may be more difficult. As Huntingdon and Scott put it, “without an affirmative legal obligation to promote children’s [or public] health, governmental investment is optional.” In this context, public health policy is often reactive rather than proactive or preventative.

Recent shifts in both cultural and legal views of vaccination deliver an immediate and crucial example of the libertarian legal context for child health policy and its limits. To read further on current issues in children’s health, see our latest issue of The Future of Children, “Policies to Promote Child Health.”

Evidence for Supporting Military Families

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Following our discussion of the evidence-based movement, I would like to highlight the recent work of Future of Children contributor Col. Stephen Cozza (U.S. Army, retired) and the National Military Family Bereavement Study. In a recent interview, Cozza, who is a professor of psychiatry and associate director of the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences, explained that the study aims to guide policy by creating a greater base of empirical data on how immediate family members are affected when a service member passes away.

In the interview, Cozza argued that basing policy on research is important for these families, whose needs vary based on relationship to the deceased, the type of death, geographic location, and other factors. By gathering data on these scenarios, Cozza hopes to better advise policy makers on how to help these families.

Even before the study began, Cozza established the importance of this research in his Future of Children article with Allison Holmes and Paula Rauch. A parent’s death in combat not only brings immediate grief, it can also mean that survivors lose their identity within the military community, especially if they have been living on base and need to leave. Additionally, sudden, violent deaths—such as suicides, accidents, and combat-related deaths—are more common among service members than in the general population, and such deaths have been shown to bring a greater risk of PTSD and other emotional issues for surviving loved ones.

Another Future of Children article suggested building communities of care for military families and pointed to a need for further research on how to best do so. In the article, communities of care are defined as complex systems that work across individual, parent/child, family, community, military, and national levels of organization to promote the health and development of military children and families. The authors highlighted the tensions that exist in creating these interdisciplinary care communities. When we attempt to create collaborative communities of care and run into conflicts between the training of clinicians and public health professionals, research evidence could create an objective common ground on which to base programs and policy. Cozza’s National Military Family Bereavement Study is an example of the evidence-based movement in action.

For more Future of Children articles on military families, see our Fall 2013 issue, Military Children and Families. For more on the evidence-based movement, check out this interview with Future of Children senior editor Ron Haskins.

Childhood Food Insecurity: Especially Vulnerable Populations

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If you’ve read our recent posts, you now know that a number of factors besides household income influence childhood food insecurity, including caretakers’ mental and physical health, parents’ marital status, and childcare arrangements. However, even when these factors are taken into account, children of immigrant parents and children of incarcerated parents remain especially at risk for childhood food insecurity, according to the Future of Children‘s Fall 2014 research report.

For example, writes John Cook, after controlling for other risk factors, “children of foreign-born mothers were three times as likely to experience very low food security as were children of U.S.-born mothers.” And a study by Kelly Balistreri found that 40 percent of children experiencing very low food security are children of immigrants, even though they constitute less than 25 percent of all children in the US.

When children have one or more parents incarcerated, this factor also decreases food security, however the reasons for the effect of incarceration are unclear. The research report highlights several theoretical explanations, but none have been thoroughly investigated. For example, incarcerating a parent might theoretically improve a household’s food security because of decreased demands on resources or by removing a negative influence in the household. On the other hand, incarceration might reduce food security because that parent’s financial, child care, and other contributions are removed. Given these conflicting theories, you might think that other factors correlated with incarceration, such as drug use or mental illness (which I discussed in a previous blog), are causing the effects we see. However, Wallace and Cox found that children with an incarcerated parent are more likely to be food insecure even after controlling for correlated factors.

We need to better understand exactly how these populations are affected, but it’s clear from the research report that children of immigrant or incarcerated parents may need additional support to obtain stable nutrition. Given that these are often two difficult-to-reach populations, policy makers should consider how to best serve these children within existing programs or with new possibilities. For more information about these vulnerable populations, see the Future of Children‘s Fall 2014 research report. For more about children of immigrants in the U.S., see Volume 21 on Immigrant Children.

Food insecurity and child care for low-income families

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So far, we’ve written several blogs about how characteristics of children’s parents can influence food security. As the authors of our Fall 2014 research report remind us, however, three-quarters of children spend some portion of their preschool years in the care of people other than their parents, so we need to look at how child-care arrangements may also influence food insecurity among children. This is especially important given that children in center-based care may receive a majority of their nutritional needs at their center rather than in the home.

The research report highlights a study by Heflin, Arteaga, and Gable that compared child care by parents to child care by someone else, among low-income families. Specifically, they examined five types of child-care arrangements: child-care by parents, by a relative, by someone unrelated to the child in a home care setting, in a child-care center, and in Head Start. They found that compared with children cared for exclusively by their parents, low-income preschoolers attending a child-care center had lower levels of both food insecurity in general and of very low food security. Children cared for by a relative were less likely to experience food insecurity in general but equally likely to experience very low food security and children cared for by an unrelated adult were more likely to experience very low food security.

The finding that low-income preschoolers attending child-care centers had lower levels of food insecurity and very low food security compared to those cared for by their parents has several theoretical explanations. First, parents of these children may be better able to work while their children attend the center, which increases household income. Second, these children may receive some of their nutritional needs directly through the child-care center.

While school-based nutrition programs have proven to help alleviate food insecurity for some children, this research reminds us that preschool children must also be considered in policy discussions. Improving access to child-care services for low-income parents of preschool children may improve food security within this age group.

Health of Caregivers and Childhood Food Insecurity

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We often assume that low household income causes children’s food insecurity. But the Future of Children’s recent research report highlights a number of additional factors that contribute to food insecurity. One notable risk factor is a caregiver who faces mental or physical health problems.

The latest research shows that even when we account for income level, caregivers’ health is still central to children’s food security. For example, a recent paper in the Journal of Children and Poverty found that mothers in food-secure families had better overall health and were less likely to report substance use compared with mothers in food-insecure households. Craig Gunderson and James Ziliak‘s Future of Children report cites a number of health factors that can contribute to children’s food insecurity, including parental depression, parental drug use, or living with an adult with a disability.

What can we do to help children in these situations? The authors point out that the effect of caregiver’s mental and physical health on family food security raises concerns about families’ ability to navigate the welfare system. A caregiver’s health problems may also be exacerbated by lack of access to services. While the authors argue that improved access to services could improve food security, they also state that we need further research on how policy makers can create more accessible systems. The authors offer one suggestion to address the risk factor of substance use: ensuring that mothers who seek substance use treatment are enrolled in SNAP and WIC, if they are eligible. Perhaps a similar idea could be implemented in other contexts where caregivers receive medical or mental health treatment.

As more researchers explore the relationship between food security and health, new policy possibilities may come to light. However, the research highlighted in the Future of Children report makes us aware that health contributes to food security, and low income is not the only indicator of risk. In following blog posts, we will explore additional factors that influence food security. To learn more about health and food insecurity, see the Future of Children‘s Fall 2014 research report.