Journals > Journal: School Readiness: Closing Racial and Ethnic Gaps > Article: Health Disparities and Gaps in School Readiness
Journal Issue: School Readiness: Closing Racial and Ethnic Gaps Volume 15 Number 1 Spring 2005
Potential Policy Responses
Potential policy responses considered here include measures aimed at reducing disparities in access to health care, early intervention programs, family services, and WIC (the Supplemental Nutrition Program for Women, Infants, and Children).
Reducing Disparities in Access to Health Care
Disadvantaged children are not only more likely than better-off children to have particular health conditions, they are also less likely to be treated for them. Could differences in access to care be responsible for differences in use of care? Although lack of insurance coverage remains a serious problem for many children, past expansions of public health insurance under Medicaid and the State Children's Health Insurance Program (SCHIP) mean that most poor and near-poor children are already eligible for public health insurance. This journal devoted its spring 2003 issue to a discussion of health insurance for children and concluded that “programs already in place have the potential to virtually eliminate uninsurance among low-income children.”36
Making more children eligible for care is unlikely to reduce health disparities greatly because the most disadvantaged children are already eligible (though reductions in eligibility in many states could undo recent progress). More to the point, many eligible children are not signed up for public health insurance until they have an urgent medical problem. Thus they do not get preventive care. A Medicaid- eligible child suffering an asthma attack will be treated, but if she is not enrolled, she may not receive the monitoring and medication needed to prevent another attack. The children with the poorest access to specialists are those in families with incomes between 125 percent and 200 percent of poverty, even though many are eligible for SCHIP.37
One way to improve access to care among children eligible for public health insurance may be to make it easier to sign up for, and to maintain, Medicaid coverage. When Jeffrey Grogger and I examined several state efforts to streamline the Medicaid application process, such as shortening application forms and allowing mail-in applications, we found little evidence that they were effective. By contrast, Anna Aizer found that paying community organizations to help families sign up for public health insurance in California increased enrollments among Hispanic and Asian families and reduced preventable hospitalizations. Because take-up of social programs is highest when enrollment is automatic, the best approach to the problem of eligible, unenrolled children may be to make all children eligible for Medicaid services and charge premiums on a sliding scale.38
But further expanding public health insurance is unlikely ever to eliminate all socioeconomic disparities in health. The famous 1980 Black report in Great Britain concluded that links between socioeconomic status and health became more pronounced following the advent of national health insurance in 1948—although it is possible that the socioeconomic gap would have widened even further in the absence of the National Health Service. Moreover, despite universal take-up of national health insurance in Britain, the rich receive more services than the poor, conditional on their health status. Health is also linked to household income in Canada, even though Canadians have universal health insurance.39
A final consideration is that health care providers are not always trained to offer the services that children and their mothers require. A recent study found that pediatricians rarely recognized depressive symptoms in most mothers, suggesting that increasing access to these providers would not necessarily help children whose problems were linked to maternal depression.40
Early Childhood Intervention Programs
Most early intervention programs include a significant health component, in the belief that they cannot address educational needs without also addressing health problems. Because many different children's programs already address specific health problems (for example, by screening for lead poisoning or by focusing on child nutrition), it may seem irrational to make health a major focus of educationally oriented early intervention programs. But to take advantage of existing health programs, parents must be knowledgeable and tireless advocates for their children. And parents who are struggling to put bread on the table may not have the time or energy to get all the services their children need. Hence the potential value of quality infant and preschool programs that offer “onestop shopping” for these services. Staff members in such programs may be better than parents at spotting problems and also more knowledgeable about community resources. But researchers have not yet systematically assessed the importance and effectiveness of the health services component of early intervention programs.41
Head Start, the federal program serving disadvantaged three- to five-year-old children, mandates that children receive the health assessments and services that they need. A 1984 Abt Associates study, now quite dated, randomly assigned children in four sites to Head Start treatments and non–Head Start controls and evaluated the health services the children received. The children entering Head Start had many and serious health problems. They had an average of 4.6 unfilled cavities; 34 percent scored below the 10th percentile for fine and gross motor skills for their age; 63 percent had a speech or language problem; and one-third failed the hearing test. Fourteen percent had active otitis media.42
Although the Abt study found that compliance with Head Start health performance standards was imperfect, the Head Start children were significantly more likely than the control children to have received medical screenings and necessary services. It is also worth stressing that Head Start has detailed performance standards for health services and that programs are regularly evaluated with respect to indicators such as the fraction of children who have received dental examinations, hearing and vision screenings, and immunizations. Using data from Head Start budgets and from the National Longitudinal Survey of Youth, Matthew Neidell and I found that Head Start programs that spend a larger share of their budgets on health and education raise future child test scores more than do programs that spend higher shares on other types of programming, such as programs for parents.43
Given the large socioeconomic disparities in health in the United States, it may well be that the health services offered by early intervention programs play an important role in improving the cognitive functioning and future schooling attainments of impoverished children. The programs do not seem to duplicate services, but rather to help children get the services for which they are eligible through other programs.
Family-Based Services
Offering health services through programs such as Head Start will not reach all needy children, both because not all eligible children enroll and because not all needy children are eligible. Home visiting programs and other family-centered programs offer an alternative model for service delivery. The most successful of these programs are those associated with David Olds.44
Olds's programs, which focus on families at risk because the mother is young, poor, uneducated, and unmarried, involve nurse visits from the prenatal period until the child turns two. Evaluators have documented many positive effects on both maternal behavior and children's health. As of age two, children in one study site were much less likely than control children to have visited a hospital emergency room for unintentional injuries or ingestion of poisonous substances, although this finding was not replicated at other study sites. As of age fifteen, children of visited mothers were less likely to have been arrested or run away from home, had fewer sexual partners, and smoked and drank less. These children were also less likely to have been involved in verified incidents of child maltreatment. There was little evidence of effects on cognition at four years of age (except among children of initially heavy smokers), though the reduction in delinquent behavior among teens could be expected to improve their school achievement. These studies suggest that locating children at risk and ensuring that they receive necessary services would be a useful complement to other strategies for reducing disparities in child health.
The Special Supplemental Nutrition Program for Women, Infants, and Children
The WIC program probably already plays a large role in remediating health disparities that could lead to gaps in school readiness. It has, for example, been credited with the dramatic decline in the incidence of anemia among young children between 1975 (shortly after it was introduced) and 1985. Several studies indicate that these improvements in nutrition affect children's behavior and ability to learn. Children whose mothers were on WIC during the prenatal period score higher than children not on WIC on the Peabody Picture Vocabulary Test, a good predictor of future scholastic achievement.45
In any given month in 1998, 58 percent of all infants were eligible for WIC and roughly 45 percent of all infants received benefits. Among children aged one to four, 57 percent were eligible for WIC and 38 percent of eligible children received benefits. Participation tends to drop off sharply after a child's first birthday, when WIC stops providing valuable infant formula.46
The program offers participants coupons that can be used only to purchase specific commodities that meet the nutritional needs of pregnant or nursing women, infants, and children under five. It is a promising vehicle for addressing health disparities in other respects as well. First, WIC agencies have frequent contact with participants, who typically come in at least once quarterly to pick up coupons and get nutritional counseling. Second, the agencies are required to help participants get preventive health care by providing services on-site or through referrals. Third, agencies teach pregnant women that “breast is best,” although they may undermine this message by providing free infant formula to women who choose not to breast feed.
Because WIC already serves many children who receive inadequate health care and because it is strongly linked to the provision of health services, it is worth considering whether WIC could do more to reduce health disparities. Further promoting breast feeding would be particularly worthwhile, as would offering screenings and referrals for maternal depression. Keeping children in the program beyond their first year could increase access to health screenings and reduce nutritional problems such as low iron levels.
