We found that race/ethnicity, health insurance coverage, and family income and mother's education (as proxies for SES) are associated with differences in all categories of health service utilization for children with asthma. In general, minority children, poor children, children who lack health insurance, and children whose mothers are less educated use more emergency department care and less preventive care.
Consistent with past studies of race/ethnicity, emergency department utilization for asthma is significantly higher for black and Hispanic children than for white children, even after controlling for other socioeconomic factors (10
). Part of the explanation may be that black and Hispanic (especially Puerto Rican) children have more asthma attacks than do whites (as supported by trend data [3
]), but the explanation may also lie with the lack of a usual source of care, with level of home asthma management skills, or with attitudes (13
). If parents rely on emergency department care for children who are having acute asthma episodes because they lack home management skills, then intervention programs designed to improve caregivers' asthma management skills or attitudes would be useful. However, if parents seek emergency department care for asthma episodes because they lack access to usual care, then more systems-oriented changes may be needed.
Our findings do not show significant differences in prescription filling by race/ethnicity. This finding is in contrast to those of previous studies of children on Medicaid (9
), which reported that minority children are less likely to use antiinflammatory or controller medications to prevent asthma exacerbations. The discrepancies between these findings may come from differences in the samples (national vs Medicaid). We do not report the analyses of antiinflammatory or controller medications alone because MEPS provides data only on which medications were prescribed, not which medications were used.
We found that Hispanic children have a significantly higher level of office visits than do children of other racial/ethnic groups. Puerto Ricans have a much higher prevalence of asthma than do other racial/ethnic groups or Hispanic subgroups (6
), which may explain why Hispanic children have more office visits for asthma than do white or black children. We tested this explanation in a separate analysis by including Puerto Ricans as a separate ethnic group, but we found that non-Puerto Rican Hispanic groups had significantly more office visits than did other groups (data not shown). The small sample sizes of other Hispanic subgroups prohibited further investigation of subgroup differences.
The associations with family income are less straightforward, and most of the associations in multivariate analysis did not reach significance. Only children in low-income families (125%-199% of the poverty level) had significantly fewer checkups. Nevertheless, the overall pattern suggests that children from families at less than 200% of the poverty level use less preventive and urgent care than do children from high-income families. Low-income families may lack the resources needed to manage their children's asthma and prevent exacerbations.
Children with health insurance are more likely to use health services and use more services than children without insurance, although the association usually reached or approached significance in children with only public insurance. The reasons for this finding may be complex. Some children in low-income families who do not have private insurance are likely to be ineligible for public insurance. Consequently, they may not use health services as much as children of poor or near-poor families who have public insurance. In our sample, approximately 17% of children in low-income families were uninsured, compared with 9% in poor families and 10% in near-poor families. Approximately 65% of children in poor families and 40% in near-poor families had only public insurance, compared with 20% of children in low-income families. Public health insurance appears to provide support for poor families, which suggests that children with asthma in low-income families that lack insurance may be in the most vulnerable position.
Children whose mothers had the most education received more preventive care and had fewer emergency department visits than children whose mothers had less education. This finding reinforces the idea that mothers with more education focus more on prevention and rely less on urgent care (15
A strength of our study is that we used nationally representative data from MEPS. MEPS provides extensive information on health care utilization during 2 complete calendar years and concurrent socioeconomic and health insurance information for children with asthma.
We conclude that minority children of socioeconomically disadvantaged families use more urgent care and less preventive care for asthma, and families without health insurance use fewer health services overall. Providing health insurance to children who do not have it may be crucial to managing asthma, especially for preventive services such as filling prescriptions and having general checkups. To meet the needs of more uninsured children, the federal government should support public insurance programs for underserved children, such as the State Children's Health Insurance Program. Future research should address how additional factors — such as caregiver time, skills, and attitudes — relate to health services utilization in children with asthma.