PRIMARY CARE: PSYCHOSOCIAL ISSUES, POSTPARTUM CARE, AMBULATORY CARE AND HOSPITALIZATION, VIOLENCE Uninsured Children With Psychosocial Problems: Primary Care Management

Objective. Nearly 14% of children in the United States are uninsured. We compared the prevalence of psychosocial problems and mental health services received by insured and uninsured children in primary care practices. Methods. The Child Behavior Study was a cohort study conducted by Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network. Four hundred one primary care clinicians enrolled an average sample of 55 consecutive children (4–15 years old) per clinician. Results. Of the 13 401 visits to clinicians with 3 or more uninsured patients, 12 518 were by insured children (93.4%) and 883 were by uninsured children (6.6%). A higher percentage of adolescents, Hispanic children, those with unmarried parents, and those with less educated parents were uninsured. According to clinicians, uninsured children and insured children had similar rates of psychosocial problems (19%) and severe psychosocial problems (2%). For children with a clinician-identified psychosocial problem, we found no differences in clinician-reported counseling, medication use, or referral to mental health professionals. Conclusions. Among children served in primary care practices, uninsured children have similar prevalence of clinician-identified psychosocial and mental health problems compared with insured children. Within their practices, clinicians managed uninsured children much the same way as insured children. Pediatrics 2000;106:930– 936; psychosocial problems, uninsured children, pediatrics, family medicine, primary care. ABBREVIATIONS. CBS, Child Behavior Study; PROS, Pediatric Research in Office Settings; ASPN, Ambulatory Sentinel Practice Network; WRen, Wisconsin Research Network; MAFPRN, Minnesota Academy of Family Physicians Research Network; AAP, American Academy of Pediatrics; PSC, Pediatric Symptom Checklist. Nearly 14% of children in the United States (between 9 and 11 million) are uninsured.1–4 Studies have documented that uninsured children are more likely than insured children to lack access to health care,5–11 to use fewer needed health services,6,7,9–16 to have poorer quality of care,17,18 to have worse reported health status,7,12,19 and in some cases to have potentially avoidable hospitalizations.20 However, little is known about mental and behavioral health care for uninsured children. It is not clear if these differences in access and quality of care are attributable to different settings and places at which uninsured children receive health care, or if they are attributable to different types of care received from their primary care providers. Uninsured children are less likely to have a regular source of care than insured children,7,9,16 and by inference, less likely to experience the benefits associated with a regular source of care. Alternatively, clinicians in primary care settings may provide different diagnoses and treatment to uninsured children than they do to insured children either because they have concerns about the affordability of certain treatments or because they lack familiarity with uninsured children because of less frequent contact. Prior studies have found differences in primary care providers’ management and referrals for children covered by managed care, compared with children not covered by managed care, suggesting that differences in patients’ health insurance status can influence provider decisions.21 Thus, it is important to assess whether these differences extend to uninsured children. However, prior studies have had insufficient sample sizes, regional variation, and clinician variability to examine whether diagnosis and management of childhood illnesses are different for uninsured children. The Child Behavior Study (CBS) examined the management of child psychosocial problems in primary care practices for 24 183 children seen by 401 clinicians. The large number of children, clinicians, and sites provided sufficient opportunity to explore whether different diagnoses and management are provided to insured and uninsured chilFrom the *Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York; ‡University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and §University of Vermont, Burlington, Vermont. Drs McInerny and Kelleher are both with Pediatric Research in Office