Preventive
Care
Use by School-Aged
Children:
Differences
by Socioeconomic
Status
Paul W. Newacheck,
MPP,
and
Neal
Halfon,
MD, MPH
From the Institute for Health Policy Studies, University of California, San Francisco, and The Center for the Vulnerable Child, Children’s Hospital, Oakland, California
ABSTRACT. Use of ambulatory care services by children
from low-income families has increased substantially
since the early 1960s. However, in few studies have
at-tempts been made to disaggregate physician visits
ac-cording to type (eg, preventive v diagnosis and
treat-ment). In this study, receipt of preventive care (including
physical, vision, and dental examinations), based on a
sample of 16,838 children aged 5 to 16 years from the
1982 National Health Interview Survey, was examined.
The results indicate that children in families with
in-comes below the poverty level, especially those without
Medicaid insurance, are much less likely to receive
rou-tine preventive care on a timely basis. Poor school-aged
children with Medicaid are much more likely to receive
timely preventive care than their counterparts without
Medicaid coverage. The effectiveness of preventive care
for children is discussed and suggestions for improving
access to routine preventive care are presented. Pediatrics
1988;82(pt 2):462-468; preventive health care,
socioeco-nomic status, poverty.
Use of ambulatory care services by children from
low-income families has increased substantially
since the “War on Poverty” was initiated in the
middle 1960s. As a result of Medicaid, neighborhood
health centers, children and youth projects, and
other efforts to increase access and availability of care, poor children now use about equal numbers
of physician services as nonpoor children. Although
poor children continue to trail behind their nonpoor
counterparts in use of physician services after ad-justing for their depressed health status, gains in use of ambulatory care services since the middle
1960s are impnessivc.13
Received for publication Oct 20, 1986; accepted Dec 15, 1987.
The views expressed here are those of the authors and do not
necessarily reflect those of funding or data collection agencies. Reprint requests to (P.W.N.) Institute for Health Policy Studies,
University of California, San Francisco, 1326 Third Aye, San
Francisco, CA 94143.
PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the
American Academy of Pediatrics.
Most studies in which use of physician services
among poor children and adults have been
exam-med have focused on overall volume of visits and have not disaggregated visits according to type (eg,
preventive care v diagnosis and treatment). Given that children from low-income families are more frequently reported in worse health than their peers
from higher income families, poor children could conceivably benefit disproportionately from appro-pniate use of preventive care. Hence, an important
question concerns whether children from
low-in-come families make adequate use of preventive health care services. Those studies in which use of
preventive health services for adult populations
have been examined generally conclude that poor
adults use fewer preventive services.4’5 For example,
results from a 1982 national survey of access to
health care services revealed that low-income
women were less likely than high-income women to obtain Papanicolaou smear tests or breast
exami-nations by physicians.4 Unfortunately, little
infor-mation has been published concerning use of pre-ventive cane services among poor children. The
information that is available suggests that poor children receive fewer preventive care services. For
example, Aday et al4 found that children from low-income families were less likely to have tuberculin
skin tests than children from high-income families.
Based on a survey of preponderantly black children
in Washington, DC, conducted in 1970/1971,
Dutton6 found income-related differentials in the
frequency of children’s medical checkups. Using
data from the 1982 National Health Interview Sun-vey, Bloom7 found that frequency of routine vision examinations and dental examinations was
in-versely related to a child’s reported family income level.
Children’s access to preventive services is not uniform but depends on several different factors.6
by health insurance and the type of preventive services that are insured by that insurance. Not all health insurance plans pay for all preventive serv-ices. Most US children arc insured by some form of
private health insurance, but even when insured
these children arc often not insured for preventive health care services. When preventive health serv-ices are included, first-dollar deductibles or other copayments may limit the use of these services.
Indeed, a recent analysis of insurance claims from the Rand Health Insurance Experiment indicated
that higher levels of copayments were associated
with fewer immunizations for children younger than 7 years of age.8
For poor children, the problem of access to pre-ventive cane is somewhat different. Few children in
families with incomes below the poverty level have
private health insurance.3’4 Medicaid is the primary
insurer for impoverished children, even though only
about one half of all poor children receive Medicaid
services.3 The poor child who is eligible for
Medic-aid should also be eligible for preventive services
through the Early and Periodic Screening,
Diag-nosis and Treatment program (EPSDT). However,
availability of EPSDT services differs both between
and within states.9 Furthermore, for the poor child, EPSDT may pay the cost of initial screening, yet
the availability of providers for referral services may be severely restricted.’0
In this paper we present recently collected
na-tional data concerning the use of several preventive
cane services for school-aged children, including physical, visual, and dental examinations. We cx-amined differences by poverty status in receipt of each of these preventive care services. Because we are interested in the role that financial barriers play in influencing use of preventive care services
by impoverished children, we also examined differ-ences in use of preventive care among poor children
with and without Medicaid. Together, these
anal-yses should provide an improved understanding of
how use of preventive care varies according to in-come level and how publicly financed health care coverage influences use of these services.
METHODS
Source
of Data
Data for this study came from the Preventive Care Supplement to the 1982 National Health In-terview Survey.7 The Preventive Cane Supplement
was designed specifically to measure the use of various preventive cane services at the national level. The survey was administered to a random
sample of 41,000 households in all 50 states and the
District of Columbia by Bureau of the Census
in-terviewers working with the National Center for
Health Statistics. In general, parents, and most often mothers, served as the respondent for the interview. The overall response rate exceeded 95%. In total, approximately 19,819 school-aged children
(5 to 16 years old) were included in the survey.1’ Based on reported income from all sources and reported family size, sample children were catego-nized as being above or below the federal poverty level. Medicaid insurance was established by an affirmative response to questionnaire probes con-cerning whether Medicaid paid for any health cane
services for the child during the previous year or
whether the child had a current Medicaid card at the time of the survey.
Of the original 19,819 children aged 5 to 16 years in the sample, 1,749 were excluded because their
family’s income was unknown on not reported. An
additional 1,232 children were excluded because of
missing information about their last use of
preven-tive care. Excluding these children resulted in an
analysis sample of 16,838 children aged 5 to 16 years including 19.4% classified as below the
pov-erty level and 80.6% classified as above the poverty level. In this report, sample observations were weighted by the inverse of their sampling
probabil-ities to reflect national population totals.
Preventive
Care Measures
The Preventive Cane Supplement contained three sets of questions regarding use of preventive care services for children. Specifically, respondents were asked how recently the child had received a routine physical examination (including those pro-vided at school) and a routine eye examination (also including examinations performed at school). In addition, respondents were asked when the child first visited a dentist for an examination. Based on these questions and professionally accepted stand-ards concerning how often children should receive physical, vision, and dental examinations, we crc-ated several measures of preventive care use.
In 1967, the American Academy of Pediatrics developed age-specific guidelines for child health supervisory visits. These guidelines were subse-quently revised in 1972, 1975, and 1981 to accom-modate perceived changes in children’s health
needs.’2 The original peniodicity schedule was
es-tablished on the basis of what were then current standards of practice by most pediatricians, and subsequent revisions have included similar cnite-na.’3 Currently, the American Academy of Pediat-nics recommends that children 3 to 6 years of age receive at least one supervisory visit annually; one
chil-dren and adolescents 7 through 21 years of age.’2
In our analysis of the school-aged population, we
then categorized children 5 and 6 years of age
according to whether they had received a routine physical examination within the previous year. Children 7 to 16 years of age were categorized
according to whether they had received an
exami-nation in the previous 2 years.
The American Optometric Association issued
recommendations regarding appropriate use of
vi-sion examination services. According to their nec-ommendations, children should receive a
compre-hensive examination prior to entering school and
annually during the school years.’4 The American
Academy of Ophthalmology also developed
guide-lines concerning frequency of vision examinations
and similarly recommends that school-aged chil-drcn receive vision screening annually.’5 Based on
these recommendations, we then categorized
school-aged children according to whether or not
they had received a vision examination during the
previous year.
The American Academy of Pediatric Dentistry,
which is affiliated with the American Dental
As-sociation, recommended that a child’s first dental
visit should occur no later than 12 months of age.’6
However, because less than one half of 1% of the
National Health Interview Survey sample reported
having a dental examination during the first year
of life, we categorized children according to whether
or not they had received a dental examination
before 5 years of age.
Using information from all three preventive care
services, we developed an index of preventive care
use similar to that of Bloom.7 In this index, we classified children as nonusers of preventive care services if they had not received physical and eye
examinations during the recommended time
inter-vals and did not obtain a dental examination before
5 years of age. Children were classified as infrequent
users of preventive care services if they met only
one of the criteria (ie, had a physical on eye exam-ination during the recommended interval or a
den-tal examination before 5 years ofage). We classified
children as moderate users of preventive services if they met at least two of the criteria. Children
meeting all of the criteria were classified as frequent
users of preventive services.
Our characterization of use of preventive care
services is not meant to directly approximate the recommendations and guidelines issued by the
American Academy of Pediatrics, American
Opto-metric Association, American Academy of
Oph-thalmology, or American Academy of Pediatric
Dentistry. Rather, the official guidelines were used
only to establish general benchmarks for when
pre-ventive care services should be obtained. To fully
approximate the professional standards and
guide-lines would require a knowledge of the content of
preventive care examinations. Each of the profes-sional organizations provide suggestions or
guide-lines for content as well as frequency of visits. For
example, the American Academy of Pediatrics’
guidelines for supervisory cane indicate that all supervisory visits should include an interval
his-tory, height and weight measurements, develop-mental and behavioral assessments, a physical cx-amination, and anticipatory guidance.’2 Similarly, rather than simply screening for distance acuity,
the American Optometric Association recommends routine testing for refractive error, binocular coon-dination, vision development, and eye disease.’4
The Preventive Care Supplement collected no in-formation concerning the content of physical,
vi-sion, and dental examinations, making it impossible
to fully approximate the professional guidelines.
RESULTS
Overall, 69% of US school age children met our criteria for receipt of routine physical examinations (Table 1). Similarly, 67% met the criteria for eye examinations, whereas only 45% of children were reported to have received an initial dental visit before age 5 years. For income, some interesting
results are apparent in Table 1. First, no significant
differences were apparent in receipt of routine
physical examinations according to the child’s
fam-ily income level. Second, only a small difference favoring children from families with incomes above the poverty level was apparent for receipt of eye examinations (P < .05). Third, the largest
differ-ence in use of preventive services by income was
found for dental examinations; children from fam-ilies with incomes below the poverty level were 40% less likely than their counterparts from families with incomes above poverty to have initiated a dental examination prior to age 5 years (P < .01).
The associations between income and receipt of preventive care services could be spurious. This would be the case if other variables, correlated with both income and use of preventive care services, were actually the causal agents. To test such an
assumption, we assessed the relationship between
poverty status and receipt of the three preventive cane services while controlling for other demo-graphic variables that have been shown to be as-sociated with use of health care services, including the child’s age, sex, and race. The results of these multivaniate analyses (not shown) were similar to
the simple bivaniate results described before.
TABLE 1. Preventive Care Service Use by C hildren Aged 5 to 16 Ye ars: United States, 1982*
Family Income Physical
Examination in the Recommended
Interval
Eye Examination in Last Year
Dental Examination
Before Age 5 yr
All incomes, including unknown 69.1 ± 0.5 67.1 ± 0.4 44.7 ± 0.5
Below poverty 69.8 ± 1.3 64.6 ± 1.3 29.5 ± 1.1
Above poverty 68.5 ± 0.5 67.5 ± 0.5 49.0 ± 0.5
* Results are mean percentages ± SE of children receiving service. Microdata from the Preventive Care Supplement
to the 1982 National Health Interview Survey.
TABLE 2. Preventive Care Use Scale for Children Aged 5 to 16 Years: United States, 1982*
Family Income Use Scale
Nonuser Infrequent Moderate Frequent
All incomes, including unknown 8.7 ± 0.3 26.1 ± 0.4 40.3 ± 0.5 24.9 ± 0.4
Below poverty 12.0 ± 0.8 29.2 ± 1.1 41.9 ± 1.2 17.0 ± 1.1
Above poverty 7.9 ± 0.3 25.6 ± 0.5 39.8 ± 0.5 26.8 ± 0.5
* Results are mean percentages ± SE of children. Microdata from the Preventive Care Supplement to the 1982
National Health Interview Survey.
scale, 9% of school-aged children were nonusers of preventive services, 26% used preventive services infrequently, 40% were moderate users, and 25% were frequent users of preventive care services. Given that low-income children were less likely to meet our criteria for receipt of vision and dental examinations, they should fare worse than children from high-income families on the preventive care
use scale. In fact, children in families with incomes below poverty were 52% more likely to be nonusens of preventive care (P < .01) and 37% less likely to be frequent users of preventive cane (P < .01) than children in families with incomes above the poverty
level.
We would expect that financial barriers play a role in receipt of preventive cane. Given the many competing demands for the limited resources avail-able to low-income families, preventive health care might be considered a low priority. However, if the family is eligible for Medicaid, such financial ban-niers should be greatly reduced. Indeed, all state Medicaid programs are nequired to offer EPSDT services to Medicaid-eligible children. EPSDT serv-ices can include physical, vision, and dental exam-inations and follow-up cane. Hence, Medicaid
should affect receipt of preventive care services for
children in low-income families.
In Table 3 such a positive affect of Medicaid on use of preventive care services is demonstrated. Impoverished children with Medicaid were 33% more likely to meet our criteria for receipt of phys-ical examinations (P < .01), 7% more likely to meet the criteria for vision examinations (P < .05), and
30% more likely to meet the criteria for initial
dental examinations (P < .01) than children
with-out Medicaid but still in families with incomes below poverty. Low-income children with Medicaid were also 67% more likely to be classified as fre-quent users of preventive care services (P < .01) when compared with other children with family incomes below poverty but without Medicaid insur-ance.
Children in impoverished families with Medicaid continue to lag behind children from more affluent families in receipt of preventive dental care (P <
.01). However, the same children were about equally likely to obtain vision examinations and were ac-tually more likely to have obtained physical exam-inations at the recommended intervals (P < .01). In contrast, children from low-income families without Medicaid lagged behind their more affluent counterparts in receipt of all three preventive care services (physical examination P < .05; eye exami-nation P < .05; dental examination P < .01).
DISCUSSION
Results from this analysis of data from the Na-tional Health Interview Survey indicate that school-aged children in families with incomes below poverty were more likely to be nonusers of preven-tive care and were less likely than children from more affluent families to be frequent users of pre-ventive care. Among the three preventive services analyzed, the largest disparity in use was found for initial dental examinations; a modest disparity was apparent for routine vision examinations, and no income difference was found for receipt of routine physical examinations.
TABLE 3. Medicaid Effect on Reducing Differential
Years: United States, 1982*
Use of Preventive Care Services for Children Aged 5 to 16
Income and Physical Eye Dental Frequent
Medicaid Status Examination
in the Recommended
Interval
Examination in Last
Year
Examination Before Age
5 yr
Use of Preventive
Care Services
Above poverty 68.5 ± 0.5 67.5 ± 0.5 49.0 ± 0.8 26.8 ± 0.5
Below poverty 69.9 ± 1.3 64.6 ± 1.3 29.5 ± 1.1 17.0 ± 1.1
With Medicaid 82.7 ± 1.3 67.5 ± 1.9 34.5 ± 1.9 22.4 ± 1.6
Without Medicaid 62.2 ± 1.4 62.9 ± 1.4 26.6 ± 1.3 13.7 ± 1.1
* Results are mean percentages ± SE of children receiving service. Microdata from the Preventive Care Supplement
to the 1982 National Health Interview Survey.
poverty. The “Medicaid effect” was especially
dna-matic for physical examinations; impoverished
chil-dren with Medicaid cards were more likely to have received a recent physical examination than
chil-dren from families with incomes above the poverty
level. However, children in low-income families
without Medicaid were significantly less likely to have received a recent physical examination when compared with other low-income school age
chil-dren with Medicaid or children from higher income
households. Hence, Medicaid appears to greatly influence the likelihood that a low-income child will receive a timely physical examination.
The effect of Medicaid on use ofprcvcntivc vision
and dental care by impoverished school-aged
chil-dren was less pronounced but still significant. Un-like the case for physical examinations, for which Medicaid was associated with a 20% increase in the
probability that the child would receive an
exami-nation at the recommended interval, Medicaid was
associated with a modest 5-point increase in the
probability of receiving a vision examination within
the recommended interval and an 8-point increase
in the probability that a child would obtain a dental
examination by age 5 years.
A key assumption implicit in this analysis is that child health supervisory care-including routine
screening physical, vision and dental
examina-tions-is effective for school-aged children.
Unfor-tunately, the evidence available to assess
effective-ness of supervisory care is problematic.’7 The phys-ical examination can be used for either diagnostic
or screening purposes. Screening usually refers to
procedures that identify potential problems in
asymptomatic individuals, whereas diagnostic
pro-cedures are used to confirm the existence of
prob-lems to propose treatment or nemediation.’8
Screen-ing physical examinations are a component of
well-child care and health care supervision, whereas diagnostic physical examinations arc usually asso-ciated with sick visits. Several studies have
at-tempted to evaluate the efficacy of routine
screen-ing physical examinations. Most all of these studies
are fraught with methodologic problems and fail to
show clear utility of routine screening physical
cx-aminations. The positive yield from these studies
varied from 3% to 33%, but each study used
differ-ent populations, criteria for abnormality, and
sup-plemcntary screening tests to detect
abnormali-tics.’924
Other components of routine well-child cane in-cluding developmental screening assessments, hearing screening, anticipatory guidance for injury prevention, and screening for iron deficiency have
all recently been reviewed with similarly equivocal
results.’7 Vision screening, on the other hand, has
been shown to be an effective procedure for
iden-tifying potential abnormalities.25 Therefore, even
though some screening procedures have been proven to be of definite efficacy, the overall efficacy of well-child care has not been unequivocally estab-lished in the general pediatric population.
None-theless, several authors using the same collection
of studies of effectiveness of well-child cane reached
startling different conclusions that range from
full-fledged endorsement to extreme doubt.24’2629
Almost all studies of the efficacy of routine
su-pervisory care have been based on relatively
low-risk populations. Questions remain as to whether
routine preventive care might be more efficacious for high-risk children, especially those from low-income households. None of the studies in which the efficacy of well-child care was evaluated directly addressed this question. Yet, among children who have received little cane in the past, or in a more extreme case, been abused or neglected, much higher yields from routine evaluations have been demonstrated.30’31 Because it is well established that
low-income children receive fewer ambulatory
study of a sample of Medicaid-eligible children re-ceiving EPSDT screening demonstrated substan-tial reductions in prevalence of abnormalities
ne-quining care upon subsequent screening. The
authors concluded that “periodic screening” is
as-sociated with a decrease in the prevalence of
ab-normalitics requiring care.33 Although definitive
evidence was not provided, these data suggest that
supervisory care for low-income children may be
efficacious, even if it is not for children of more
advantaged upbringing.
Through its mandatory payment of routine
phy-sician services and its EPSDT program, the federal
and state Medicaid program has the potential to
ensure that children from low-income families
re-ceive preventive care at appropriate intervals. How-ever, the majority of children in families with
in-comes below the poverty level are not currently
covered by Medicaid.34 Our results indicate that
low-income school-aged children without Medicaid
arc at much greater risk of not receiving routine
physical, vision, and dental examinations. We
es-timate that at least 800,000 school-aged children in
families with incomes below the poverty level did
not receive physical, dental, or vision examinations
at the suggested intervals in 1982. Nearly 75% of
these children who went without preventive cane
had no Medicaid. Hence, one public policy avenue
that might be pursued to alleviate the current
in-come-related gaps in receipt of periodic preventive
care would be to extend Medicaid to additional
low-income children.
During the last decade, federal and state cutbacks
in eligibility standards have resulted in a large
decrease in the number of poor children with
Mcd-icaid. For example, in 1977 it was estimated that about two thirds of poor children had Medicaid, but
by 1984 less than half of children below poverty had such insurance.9 Recent actions at the state
level suggest the outlook for Medicaid may now be
changing. Since 1984, changes in federal law have
permitted states to expand their Medicaid programs to provide improved coverage of pregnant women and children. These state efforts should eventually
result in substantially better health care for
low-income children, but whether they will fully
com-pensate for the cutbacks of the late 1970s and early
1980s is unclear.
A second policy direction would be for states to adopt new programs to insure low-income children
who are currently ineligible for Medicaid. The
Om-nibus Budget Reconciliation Acts of 1986 and 1987
now permits states to offer Medicaid benefits on a
phased-in basis to pregnant women and children
up to age 5 years whose incomes are above existing
Medicaid eligibility thresholds but below the federal
poverty level. The costs of providing services to additional children older than 8 years of age would have to be met by the states because federal finan-cial participation is limited to the Medicaid-eligible population. The advantages of such programs are considerable, however. First, such a state-financed program could ensure that all needy children have
insurance and are not discriminated against
be-cause their incomes are slightly above the Medicaid
cutoffs. Second, such a program could greatly
in-crease continuity of cane if linked to the state’s Medicaid program. A 1981 study of Medicaid
cligi-bility patterns in San Francisco revealed that 63%
of a sample of children eligible for Medicaid through
the Aid to Families With Dependent Children pro-gram had previously experienced multiple eligibility
spells (case closings and neopenings) and 78% of
children eligible for Medicaid under the Medically Indigent Children program experienced such turn-over.35 When poor children lose Medicaid eligibility, continuity of care is often disrupted, and, as a
result, these children may have to forego needed
care. The prospects for these children arc greatly improved because of legislative changes under the Consolidated Omnibus Budget Reconciliation Act of 1985 that require states to extend Medicaid
eligibility for at least 9 months to mothers and
children who lose eligibility for Aid to Families With Dependent Children benefits because of small changes in income. A state-sponsored program in-terfaced with Medicaid would further reduce such
risks and ensure continuity for care for these
chil-dren.
One final public policy avenue that might be pursued is strengthening the existing EPSDT
pro-gram. Federal regulations require that states offer
and take affirmative action to ensure that Medic-aid-eligible children receive EPSDT services. How-ever, states vary widely in how they operate their EPSDT programs. Some states have aggressively implemented their programs, whereas others have lagged behind.9 According to a 1985 survey con-ducted by the Children’s Defense Fund, many states
use less complete peniodicity and content protocols
than the suggested guidelines of the American
Academy of Pediatrics. The same survey revealed
that six states reported using no provider protocols
at all.9 A useful model may be provided by Indiana, which recently contracted with Automated Health
Systems Inc to manage the EPSDT program and
to organize a resource network of primary care
physicians throughout the state. A case
manage-ment approach is used and referrals are coordi-nated, and families are notified when subsequent periodic examinations are due.36
Medicaid services. First, EPSDT service packages can include a more comprehensive set of services than would ordinarily be available under a state’s Medicaid program. For example, states may offer an augmented service package under EPSDT that includes vision, hearing, dental, and developmental services even if those services would not ordinarily be covered. Second, EPSDT services can be di-rected at specific high-risk groups, with specific
augmentations to meet the particular health needs
of those groups. EPSDT services targeted at tech-nology-dependent children, foster children,
high-risk adolescents, and other groups with unique
needs may represent a more efficacious approach to health care supervision.
The potential benefits of strengthening the EPSDT program are indicated by the results of this
study that show only 22% of all Medicaid-eligible
school age children made frequent use of preventive care. Movement toward a more uniform set of standards for peniodicity and content of supervisory health care, as originally intended by the Congress in passing the EPSDT legislation, could be of great benefit to the nation’s economically disadvantaged children.
ACKNOWLEDGMENTS
This work was supported, in part, by the Division of
Maternal and Child Health (MCJ-063468) (DHHS).
Data were provided by the National Center for Health
Statistics. The authors appreciate helpful comments from
Helen Gonzales and Barbara Starfield.
REFERENCES
1. Davis K, Gold M, Makuc D: Access to health care for the
poor: Does the gap remain? Annu Rev Public Health
1981;2:159
2. Starfield B, Budetti PB: Child health status and risk factors.
Health Serv Res 1985;19:817
3. Newacheck PW, Halfon N: Access to ambulatory care
serv-ices for economically disadvantaged children. Pediatrics
1986;78:813-819
4. Aday L, Fleming GV, Andersen R: Access to medical care in
the US: Who has it, who doesn’t. Chicago, Pluribus Press,
1984
5. Rundall TG, Wheeler JRC: The effect of income on use of
preventive care: an evaluation of alternative explanations.
J Health Soc Behav 1979;20:397
6. Dutton DB: Explaining the low use of health services by the
poor: costs, attitudes, or delivery systems? Am Sociol Rev
1978;43:348
7. Bloom B: Use of selected preventive care procedures, United States, 1982, Vital and Health Statistics, series 10, No. 157,
US Department of Health and Human Services publication
No. (PHS) 86-1585. Government Printing Office, September 1986
8. Lurie N, Manning WG, Peterson C, et al: Preventive care:
Do we practice what we preach? Am J Public Health
1987;77:801
9. Rosenbaum 5, Johnson K: Providing health care for
low-income children: Reconciling child health goals with child health financing realities. Milbank Q 1986;64:442
10. McManus M: Medicaid services and delivery settings for
maternal and child health, in Curtis R, Hill I (eds): Affording Access to Quality Care: Strategies for State Medicaid Cost
Management. Washington, DC, National Governors’ Asso-ciation Center for Policy Research, July 1986
11. 1982 Computer Processing Public Use Record, tape. National
Health Interview Survey. National Center for Health
Sta-tistics, 1983
12. Guidelines for Health Supervision. Evanston, IL, American Academy of Pediatrics, 1985
13. Strain JE: American Academy of Pediatrics Periodicity
Guidelines: A framework for educating patients. Pediatrics
1984;74(suppl):924
14. Optometry and the Nation’s Health. Washington, DC,
Amer-ican Optometric Association, February 1982
15. Infant and children’s eye care, in Information About Eye
Care. Presented to the Select Panel for the Promotion of
Child Health, US Department of Health and Human
Serv-ices. San Francisco, American Academy of Ophthalmology, April 1980
16. Policy Statement on Infant Dental Care. Chicago, American
Academy of Pediatric Dentistry, May 1986
17. Healthy children: Investing in the future, US Congress,
Of-fice of Technology, OTA-H-345. Government Printing
Of-fice, February 1988
18. Meisels SJ: Prediction, prevention and developmental
screening in the EPSDT program, in Stevenson HW, Siegel
AE (eds): Child Development Research and Social Policy
Chicago, University Press, vol 1, pp 267-317
19. Anderson FP: Evaluation of the routine physical
examina-tion of infants in the first year oflife. Pediatrics 1970;45:950
20. O’Connell EJ, Friesen CD: The preschool physical
exami-nation. Clin Pediatr 1976;15:930
21. Welch NM, Saulsbury FT, Kesler RW: The value of the
preschool examination in screening for health problems. J
Pediatr 1982;100:232
22. Grant WW, Fearnow RG, Hebertson LM, et al: Health
screening in school age children. Am J Di.s Child 1973;
125:520
23. DeAngelis C, Berman B, Oda D, et al: Comparative value of
school physical exams and mass screening tests. J Pediatr 1983;102:477
24. Yankauer A: Child health supervision-Is it worth it?
Pe-diatrics 1973;52:272
25. Feldman W, Milner RA, Sackett B, et al: Effects of preschool screening for vision and hearing on prevalence of vision and hearing problems 6-12 months later. Lancet 1980;2:1014
26. Charney E (ed): Well child care as axiom, in Well Child
Care. Presented at the 17th Ross Roundtable on Critical
Approaches to Common Pediatric Problems. Columbus, OH,
Ross Laboratories, 1986
27. Korsch BM: Issues in evaluating child health supervision. J
Pediatr 1985;75:942
28. Shadish WR: A review and critique of controlled studies of
the effectiveness of preventive child health care. Health
Policy Q 1982;2:24
29. Casey P, Sharp M, Loda F: Child-health supervision for
children under 2 years of age: a review of its content and effectiveness. J Pediatr 1979:95:1
30. Kavaler F, Swire MR: Foster Child Health Care. Lexington,
MA, DK Heath, 1983
31. Schor EL: The foster care system and health status of foster children. Pediatrics 1982;69:521-528
32. The Medicare and Medicaid Data Book, 1981. Baltimore,
Office of Research and Demonstrations, Health Care
Fi-nancing Administration, Health Care Financing Program
Statistics, April 1982
33. Irwin PH, Conroy-Hughes R: EPSDT impact on health
status: Estimates based on secondary analysis of adminis-tratively generated data. Med Care 1982;20:216
34. US Bureau of the Census, Current Population Reports, series
P-60, No. 150: Characteristics of Households and Persons
Receiving Selected Noncash Benefits: 1984. Government Printing Office, 1985
35. Celum C, Newacheck PW, Showstack JA: Patterns of
Med-icaid eligibility: A sample of 408 Medi-Cal eligibles in San Francisco, California. Health Care Finan Rev 1981;2:1
36. Manning WI: The EPSDT program: A progress report.
