Barriers to children in a midwestern college town having a medical home

Background Providing a medical home for every child is an unmet public health objective. In Iowa 70.7% of children who qualify for Title XIX or Title V services have a medical home, but in Iowa City only 54.0% of these children have one. Objectives  Identify barriers to access to medical homes for children who use Johnson County Public Health (JCPH) services and develop strategies to increase medical home access. Methods Families attending JCPH well-child and WIC clinics were randomly selected to be interviewed using a semi-structured 38 item questionnaire. Families with and without medical homes were compared. Results Among 71 families interviewed, 41 did not have a medical home for their children and 87% cited financial barriers.  Lack of U.S citizenship status accounted for 59% without health insurance. A recent move to Iowa City contributed to 29% not having a medical home. Forty one percent of all parents interviewed had never had their own primary care provider. Nine different languages were spoken among the No Medical Home group.  Overall, a less than favorable view of physicians was expressed by 29%.  Parents expressed the child's psychological comfort, e.g., being “less afraid” and feeling “more secure”, and the physician knowing the child's medical history as benefits of a Medical Home.

	No MH (n 41)	MH (n 30)	p values
Lack health insurance	30 (73%)	4 (13%)	<0.001
Non-English at home	28 (68%)	6 (20%)	<0.001
Less favorable view MD	13 (32%)	7 (23%)	ns
ER more convenient	10 (28%)	4 (13%)	ns
Parent never had primary care provider	19 (46%)	10 (33%)	ns

Conclusions The single greatest barrier to children at JCPH clinics not having a medical home is lack of health insurance, which is due primarily to citizenship status. The mobile nature of our society and marked cultural diversity are additional barriers to accessing medical homes. Recommendations 1. Title XIX should be transferable between states to prevent gaps in children's health insurance coverage. 2. States should require private insurance policies to provide well-child coverage. 3. To promote buy-in to the Medical Home, the psychological benefits to the child should be emphasized to parents. 4. The national health care debate regarding universal health insurance should address coverage for all children residing in the U.S.