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a. Job security and Job Stability – have higher rates of employment and less likely to get laid off of work.

b. Living Arrangements – More likely to live in their own apartment or home (rather then living with parents)

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College graduates are half as likely to lose their jobs as compared with people who have just a high school diploma.

Unemployment data from the Bureau of Labor Statistics (BLS) shows that among workers age 25 and older, college graduates with at least a Bachelor's degree had an unemployment rate of 8.4%, which is about half the 17.3% unemployment rate for people with just a high school diploma.

This table also shows that unemployment rates in April 2020 are more than triple the unemployment rates in March 2020 at all levels of educational attainment. (This data is seasonally adjusted, which might skew the unemployment rates about 0.2 percentage points higher.)

Female college graduates have a higher unemployment rate than male college graduates. Among Bachelor's degree recipients, 8.9% of women are unemployed in April 2020, compared with 7.5% of men. Among people with just a high school diploma or the equivalent, 19.4% of women are unemployed, compared with 15.4% of men.

Except for Asian college graduates, minority college graduates have higher unemployment rates than white college graduates, as shown in this table.

A Savingforcollege.com survey showed that job loss during the pandemic is much greater for low-income families than high-income families. Almost half of low-income families lost a job or experienced a decrease in income, compared with a third of middle-income families and a quarter of high-income families.

If you lost your job and have student loan debt, you can apply for an unemployment deferment. There are many resources available if you lost your job due to the coronavirus pandemic.

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College graduates are half as likely to lose their jobs as compared with people who have just a high school diploma. Unemployment data from the Bureau of Labor Statistics (BLS) shows that among workers age 25 and older, college graduates with at least a Bachelor's degree had an unemployment rate of 8.4%, which is about half the 17.3% unemployment rate for people with just a high school diploma.

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a. Lower Levels of Anxiety

b. Greater Self-esteem

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a. Are more open to new ideas

b. Make more effective consumer choices and decisions

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How often do you consider the possibility that you could be wrong about your most cherished beliefs? How much time have you spent thinking through arguments you deeply disagree with? How often do you seek to engage intellectually with those who hold opposing views?

I raise these questions because I value intellectual exchange and would like to see it flourish, not flounder, in the face of heated disagreement.

Many can agree that open-mindedness-a willingness to consider new ideas and arguments-is a positive characteristic of an active mind. Thus, students should be encouraged to be open-minded. However, I do not want my argument to rest here. Rather, I want to delineate some of the short and long-term benefits of practising open-mindedness in order to strengthen my recommendation that educators put more effort into exposing students to different perspectives.

What are the short-term benefits?

1. Pluralism:open-mindedness allows for a wider range of intellectual discourse on campus.

2. Thoughtful consideration of differing opinions can promote understanding of the reasoning underlying oppositional arguments, so that students can effectively controvert them.

3. Thinking through the logical argumentation of those with whom we disagree can help us strengthen our own arguments and improve our ability to effectively communicate differences of opinion.

4. Students who would otherwise be reluctant to express their opinions might be more likely to do so in an open-minded interaction.

5. Open-mindedness can advance mutual understanding, which accommodates the ideal of students working constructively and cohesively toward achieving common goals, despite intense disagreement.

What are the long-term benefits?

1. Open-minded interaction in college prepares students to have more constructive conversations about sensitive issues after they graduate.

2. Entertaining opinions on all sides of various issues can help students come to understand the intellectual value and democratic significance of political tolerance in their future work-place.

3. Cosmopolitanism: fostering open-mindedness can be a way of educating students on the importance of maintaining a universal respect for legitimate differences.

4. Exposure to and sustained engagement with a wider range of perspectives on pressing issues can better enable students to be informed critical thinkers and problem solvers, in various fields of human endeavor.

5. Students are more likely to be open to trying out new things and taking critical (potentially rewarding) risks once they graduate from college and embark on various career paths.

I think many teachers can do more to help their students potentially reap these benefits. In many classes in the social sciences and humanities, even the best professors will tell students their personal understanding of a particular thinker, issue, or event. Personally, I do not think that professors should necessarily self-censor, be apolitical, or refrain from expressing their opinions. However, I do think that students would learn more if professors put more effort into presenting multiple perspectives on topics of discussion.

For example, if the issue being discussed in a political science course is affirmative action, I think students would benefit from having their professor present and explain arguments on all sides of the issue, not just for and against, but also those perspectives in between for and against that might endorse affirmative action under a different guise or altered institutional framework. While professors should feel free to express their viewpoints, they should be mindful of the degree to which doing so can influence the thinking and understanding of their students.

Further, professors can encourage students who seem swayed one way or the other to consider different understandings of the topic being discussed. To be sure, this pedagogical approach does not apply just to social sciences. If, in an English course, students are reading Moby Dick by Herman Melville, a classic text often taught at universities, they should not just be presented with one interpretation or reading of the text. Rather, they should be presented with contrasting interpretations from various critics that challenge them to interrogate their own ideas and challenge those being discussed.

Needless to say, professors should not expect students to agree with them. Respectful disagreement should be understood as a legitimate, meaningful, and instructive intellectual outcome of any discussion. In these respects, the goal of class seminars and lectures is not to leave students with or convinced of the professor's opinion. While the professor should feel free to express and defend their opinions, the goal should be to challenge students to think critically about opinions on all sides of issues on which people substantively disagree.

Taking this approach toward open-mindedness, as the great American pragmatic philosopher, John Dewey suggests, "includes an active desire to listen to more sides than one; to give heed to facts from whatever source they come; to give full attention to alternative possibilities; to recognize the possibility of error even in the beliefs that are dearest to us."

I encourage all students and teachers to consider this approach precisely because it is one that aims to be charitable and compassionate toward any perspective from which we can gain insight and wisdom in our efforts at making a positive difference in the lives of others.

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The benefits of intellectual open-mindedness

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How often do you consider the possibility that you could be wrong about your most cherished beliefs? How much time have you spent thinking through arguments you deeply disagree with? How often do you seek to engage intellectually with those who hold opposing views?

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a. Less likely to get incarcerated
b. Higher rate of voter participation

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a. Have better dietary habits

b. Exercise more regularly

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Nutrients. 2018 Dec; 10(12): 1823.

Abstract

Overweightness and obesity rates have increased dramatically over the past few decades and they represent a health epidemic in the United States (US). Unhealthy dietary habits are among the factors that can have adverse effects on weight status in young adulthood. The purpose of this explorative study was to use a qualitative research design to analyze the factors (barriers and enablers) that US college students perceived as influencing healthy eating behaviors. A group of Cornell University students ( n = 35) participated in six semi-structured focus groups. A qualitative software, CAQDAS Nvivo11 Plus, was used to create codes that categorized the group discussions while using an Ecological Model. Common barriers to healthy eating were time constraints, unhealthy snacking, convenience high-calorie food, stress, high prices of healthy food, and easy access to junk food. Conversely, enablers to healthy behavior were improved food knowledge and education, meal planning, involvement in food preparation, and being physically active. Parental food behavior and friends' social pressure were considered to have both positive and negative influences on individual eating habits. The study highlighted the importance of consulting college students when developing healthy eating interventions across the campus (e.g., labeling healthy food options and information campaigns) and considering individual-level factors and socio-ecological aspects in the analysis.

Keywords: young adults, focus group, USA, interventions, overweight, qualitative studies

1. Introduction

Overweightness and obesity rates have dramatically increased over the past few decades and they represent a health epidemic in the United States, as well as in many other areas of the world [ 1, 2, 3]. According to a scoping review of risk behavior interventions in young men, Ashton, Hutchesson, Rollo, Morgan & Collins [ 4] identified obesity as a serious health risk with an incidence rate of obesity reaching 29% of the population aged 20-39 years old [ 5, 6]. Physical inactivity and unhealthy dietary habits are among the main behaviors that potentially have adverse effects on weight status in young adulthood, and consequently, the future health of adults [ 3, 7].

As reported by the World Health Organization (WHO) [ 8], the adult disease burden is due to health risk behaviors that start during adolescence (e.g., unhealthy eating practices). For example, most of the United States (US) population does not consume the recommended daily amount of fruit and vegetables, nuts, and seeds. On the other hand, the consumption of added sugars, processed meats, and trans fats is higher than the recommended daily intake [ 9]. It has been shown that after the transition from adolescence to young adulthood, when independency increases, young adults are continuously challenged to make healthful food choices [ 2, 10]. Along with unhealthy eating behaviors, a new series of weight-related behavioral patterns begins throughout this period, such as excessive alcohol consumption and a low level of physical activity.

Recently, the so-called Ecological Model has been considered as an acceptable framework to link individual and social behaviors with environmental determinants, to reduce serious and prevalent health problems [ 22].

The aim of this study is to explore the barriers and enablers of healthy eating behaviors among US college students, using focus groups that foster open discussion between a small number of participants. This study is the first stage of a larger research project called "CONSUMEHealth. Using consumer science to improve healthy eating habits", funded bythe European Union's Horizon 2020 research and Innovation programme (Marie Sklodowska-Curie grant agreement No 749514).

2. Materials and Methods

2.1. Focus Groups

We selected focus group interviewing as a key methodology for the study, the elements of which include participant observation, formal and informal interviewing, filming, and recording, among others [ 23]. Focus groups are used to obtain insights and in-depth information on why and how people think (perceptions, attitude, opinions, experience) about a topic of interest [ 24] used to unlock the complexity of the decision-making process [ 25] and unencumbered by what we expect to find [ 26]. In our study, a focus group was suitable, since we were aiming to obtain cultural insights from a group of individuals, and to explore their beliefs and behaviors [ 27], allowing for us to examine the context of healthy eating behaviors [ 16, 28]. Various studies have demonstrated that focus groups are an appropriate research method to study eating habits, particularly among students [ 2, 29]. Since the definition of this population was not just a matter of age, but of lifestyle and identity, a focus group could help us to better understand the meanings of healthy eating behaviors and its contexts.

2.2. Participants

Eligible participants were college students aged 18 to 25 years, who were transitioning from adolescence to young adulthood, who lived in the USA, and who were enrolled at Cornell University in the town of Ithaca (New York, NY, USA). Similar to previous studies [ 29], no first-year university students were included in the study, due to their limited college experience. In addition, we excluded students from nutrition classes or any other disciplines that might transmit a greater overall knowledge or awareness of healthy eating. The final group consisted of students from different disciplines (humanistic and scientific). These young adults were recruited via flyers that were distributed across the University facilities, and via email using a college student database. In the advertisement sheet, a link to an online survey was provided to facilitate recruitment, and to give subjects the essential statement outline of the study (aim, benefits, and risks that are associated with time, incentives, other). One advantage of our approach was that it allowed us to recruit participants from different disciplines and years of study. In addition, we chose to have mixed-gender groups, which could produce a greater variety of responses and better discussion [ 29]. The interview guideline was designed to take participants on a journey, starting from a broader concept of health, to more specific questions on past, present, and future diet behavior practices.

2.3. Procedure

The recruitment of participants was carried out using an online system at Cornell University. A recruitment rate of between six and eight participants per focus group session was planned, in order to have at least four people in each focus group session, therefore, an over-recruitment of two students was planned in the case of 'no-shows'.

Following the literature [ 29], a semi-structured question guide was developed to identify the key questions for the research problem (eating habits, physical activity levels, and weight change). Enough flexibility and side-questions allowed for open discussions within the group, to obtain more in-depth information from participants.

Projective techniques were used both at the beginning of the sessions for "ice-breaking", and later on to understand better emotional connections and cognitions towards the topic of interest [ 30]. Specifically, the photograph response test technique was used, which consists of showing a series of photographs that are related to the topic under investigation. A stimulus (images of obese/overweight individuals) was presented to the group, and the participants were asked to answer with the first words that came to their mind.

As reported by Guerrero and Xicola [ 24], the integration of different qualitative techniques (e.g., projective stimuli as in this study) within the same focus group was considered to be a mixed approach. The study was approved by the Institutional Review Board (IRB) of the Office of Research Integrity and Assurance of Cornell University (Protocol ID: 1709007406).

2.4. Data Collection Outline

During the online prescreening registration, all of the participants completed a short questionnaire, providing self-reported socio-demographic information, physical activity, height, weight status, and perceived body image.

Before beginning the focus group, an information sheet about the study and a consent form for anonymity and confidentiality were signed by each participant. Drinks and a few snacks were provided in order to make the environment as much comfortable as possible. In addition, the room that was used to carry out the discussions was modified to look like a living room of a house.

As suggested in the literature [ 28], each focus group lasted around 90 min, and it was held in a comfortable and quiet place. The sessions were video-audio recorded with the permission of the participants, and were facilitated by a well-trained and experienced moderator (female moderator with five years of experience in focus groups in the field of food, both in the public and private context). The principal investigator was an observer, and stayed in another room that was connected with audio and video recording systems during the focus group discussion. The moderator directed the flow of the discussion, and ensured that all of the important issues were covered. We opted for small groups (4-6 people), which was considered to be more appropriate when the topic of investigation is seen as complex and personal [ 31]. Both the principal investigator and the moderator did not have any type of relationship with the participants; we strongly believe that no bias or conflict of interest exist between the research team, the subjects, and the focus of the study.

The semi-structured questions guide ( Table 1 ), as developed following Krueger and Casey [ 27], aimed to investigate the main factors influencing eating behaviors among college students. First, a projective technique was first used for "ice breaking", and to facilitate the group discussion. At the beginning, all of the participants were asked to list "five healthy eating habits" and "five unhealthy eating habits", and afterwards to read the list out and share it with group. In this way, the whole group was actively involved in the discussion, and participants became acquainted with, and felt connected with each other. The main questions focused on factors influencing students' health and weight-related behaviors. Before ending each of the focus group sessions, the moderator and principal investigator decided whether further questions were needed. At the very end of the focus group, all of the subjects chose to either receive a monetary payment ($ 15) or university course credit (1.5) for their participation.

Table 1

Question Type

Questions

Opening and warm-up questions

Presentation of the research topic and participants (demographic characteristics and some general eating habits like "what do you have for breakfast?)

Introduction/Projective techniques

Could you list five habits related to healthy and unhealthy eating?
Could you mention the first types of food/food products you consider healthy?

Transition questions (to move into and between key questions)

How do you think the concept of healthy eating has changed?
Were you involved in cooking preparations in the past?
What changes happened in your cooking habits since you started college?

Main key questions

What different eating behaviors do you have between eating out and at home?
What is for you the meanings of the word "healthy" and "unhealthy"?
What is your eating behavior to stay healthy?
What are the consequences of having a healthy eating behavior?
How may have the community (e.g., colleges) impacted on your healthy and unhealthy habits?
How can a parent/guardian positively/negatively influence on children's eating behavior?

Projective technique (i.e., showing images of overweight/underweight adults/children)

What comes into your mind (e.g., thoughts) when you see these images on obesity, overweightness, and a healthy body weight?

Ending

Are there any other opinions related to the topic? Is there anything else you would like to share?

2.5. Data Analysis

In the field of health studies, the use of focus groups for research is a relatively recent phenomena [ 28]. The information resulting from focus groups is usually analyzed throughout a process of categorizing and coding the data in a systematic manner.

At the end of the six focus group sessions, the audio tapes were transcribed verbatim in Microsoft Word by an independent transcription agency, and they were double-reviewed by two researchers. Second, the data collected were analyzed by the principal investigator and two research assistants who were trained in qualitative analysis. All quotes were encoded using the computer-assisted qualitative data analysis software Nvivo11 Plus Version 11 (QSR International Pty Ltd., Melbourne, Australia) [ 32]. This software helped the researchers at the stage of data analysis, marking, and coding the transcription, and helped them to identify the relations between categories (concepts, themes, and ideas) and individuals [ 28].

An inductive thematic approach, which is useful for identifying core meanings that were relevant to the research objects, was used for data analysis, in which quotes were coded and categorized into themes and subthemes [ 25, 33]. These themes were organized into individual, social, and environmental categories using an Ecological Model framework [ 16, 22], and were successively described. A Microsoft Excel package was used to analyze the characteristics of the sample using responses from the questionnaire (descriptive statistics).

3. Results

3.1. Descriptive Results

In our study, six focus group discussions were conducted until saturation of new information was reached. The final sample consisted of 35 students (23 females), with a mean age of 20.4 ± 1.5 years and a mean body mass index (BMI) of 23.2 (SD ± 4.52), which was calculated as weight (kg) divided by height squared (m ²). Most participants considered themselves to have a healthy weight status, and few of them indicated current or past eating disorders. The characteristics of the sample are summarized in Table 2 . Participants were also from a variety of study disciplines and different college years (from junior to senior). This variety in participant characteristics enormously contributed to gather more insights (e.g., diverse experiences and opinions) into the relationship between behaviors and healthy eating.

Table 2

Group Characteristics

Responses

%

Mean ± SD

Race/ethnicity

White/Caucasian
Asian (excluding South Asian)
African American
South Asian

80
11
6
3

Field of study

Business
Scientific
Humanistic
Info not provided

42.9
34.3
14.3
8.5

Students with an extra job

Job
No job
Info not provided

42.9
40
17.1

3.2. Qualitative Results

Following the literature [ 31], the researchers reviewed the transcript line-by-line encoding and classified the text. As a first step, the questions that were enclosed in the script were used as initial categories, then during a rigorous and systematic reading of the transcript, the main categories started to emerge [ 33]. The researchers used an inductive coding method to find meaningful messages to categorize into main themes and sub-themes.

The information was then analyzed in conjunction with the Ecological Model conceptual framework. The importance of the Ecological Model in the social sciences is the consideration of interactions between the people's behavior and the environment (sociocultural, policy, and physical) [ 16, 29].

With the results from this model, we developed a list of factors influencing healthy eating behaviors among college students, based on content analysis of the focus groups ( Figure 1 ). We adapted a model by Deliens, Clarys, Bourdeaudhuij & Deforche [ 29], and then developed the following main levels for the analysis: individual (intrapersonal), social (interpersonal relationship), and university environment (community settings), and some main attributes of the students (e.g., gender). The most significant quotes by respondents were reported to illustrate each (sub)theme. We also decided to incorporate some basic information of the participants by using an ID for the quotes: e.g., FG1_F21 (Focus Group 1, Female, age 21 years old).

3.2.1. Individual Level (Intrapersonal)

Intrapersonal factors are represented mainly by attitude, behavior, self-concepts, and skills [ 16].

Healthy Eating: Meaning, Perception, and Consequences

They also considered "eating healthy" as something that was related to a lifestyle with positive consequences to the general mindset of the individual: " I think healthy is feeling good about yourself, having energy, and not being exhausted all day" (FG2_F18); " I think healthy goes beyond just food, you have to be mentally healthy and physically healthy" (FG2_F19); " I tend to like healthy food, it makes me feel better" (FG6_M22). More generally, people related the concept of being healthy to both physical and psychological status: " I think being healthy is both your physical appearance and your mindset... exercised and eating food, as well as balancing it out with your mental state " (F2_M20).

We used a projective technique to create more interaction and interest on the topic. Images of overweight/obese people were shown, and participants were then asked what thoughts came into their mind. Most participants felt uncomfortable with describing these images. Some of them thought that being heavily overweight or obese could be attributed to not having control over their own lifestyle: " I feel bad for them, because I know the probably inside, they are not happy with themselves, but it's all your personal choice" (FG3_M19). At the same time, there was a feeling both of sadness for them, but also a willingness to not judge other people's weight status. Only one person mentioned that body image was a motivator in maintaining healthy eating: " I want to be in a good shape, and I think that's what motivates me " (FG4_M21).

Eating Habits (Healthy and Unhealthy)

Every participant was asked to list five healthy and five unhealthy eating habits on post-it notes and then share it among the groups ( Table 3 ). First, snacking was associated most of the time with unhealthy eating, as mentioned by several participants: " I'm trying to eat a heavier breakfast so that I snack less throughout the day" (FG1_F21); " I have snacks late night, mostly, if I'm going to snack at all, it's generally junk food" (FG4_M19). Only a few of them tried snacking with an healthy option: " I don't mindlessly snack, but when I do snack, it's always something healthy like nuts or fruit" (FG4_F19). Some participants did not seem conscious of having three meals a day, but preferred to have smaller snacks consistently throughout the day and being portion-aware: " I try to eat like four to five times a day like smaller meals as opposed to just like breakfast, lunch and dinner" (FG3_M23). Regarding drinking habits, surprisingly, alcohol consumption was not mentioned as an unhealthy drinking habit; but more attention was focused on the most common daily drinks (i.e., water, coffee, and soda). One female participant said: " I like carbonated drinks, like sugary drinks that I should probably stay away from " (FG1_F21). Many people were aware that a high sugar-sweetened beverage intake was associated with greater weight gain.

Healthy Activities

Almost all of the participants mentioned that they had been very busy since they started tertiary education, and that this was a barrier to maintaining a healthy lifestyle. They remembered that exercising was as a big part of family time: "... me and my two brothers and my dad, we started going to the gym. So we'd go to the gym like every weekend" (FG2_M20); " I play a lot of soccer with my dad" (FG3_M19). It is clear the role of parents in incentiving activities to stay healthy: " my parents were also very encouraging of me and my other siblings with doing sports" (FG6_M21). Nowadays, due to time constraints associated with being a college student, it was more difficult to stay active. The statement " not keeping junk food in the house" was repeated by several students as a way to avoid the temptation of eating unhealthy foods, as was having small snacks throughout the day rather than designated meals. They were also aware about overeating, and few of them believed themselves to be good at controlling portion sizes: " I try to get individual packages, so I have portion control " (FG2_F18).

Food Preparation and Knowledge

In order to eat healthy, consumers must have some knowledge about food, healthful products, and the composition of a meal, among others. During the focus groups, participants were asked about changes that they had made in their cooking habits since they had moved from home. Some of them realized how negative the changes were in terms of eating healthy: " the first time I lived outside of home wasn't good. I ate out twice a day, every day, which is really unhealthy and really expensive. So now I'm trying to cook more, which is good. I feel like I'm healthier when I'm cooking it myself" (FG1_F21). Others confirmed how expensive it is to eat out frequently: " Well I didn't cook at all when I was at home. So just off campus, it's cheaper to cook than eating out every night, so I'm just trying to cook more " (FG1_F21).

Students were asked their involvement in preparing food when living with their parents, the majority declared to have never helped in the kitchen or only during holiday meals. One participant shared a personal experience: " Only for Thanksgiving or Christmas I would usually make a dessert or something like that. Cake or cookies " (FG6_M21).

When asked to elaborate more on a healthy diet and give examples, few students had a vague idea of what the Mediterranean diet was about: " I've definitely heard of it before, but I don't ... is it like, only eating certain Greek, Mediterranean ingredients? " (FG2_F19), and most of them had not even heard of the term before.

Time, Price and State of Mind

The transition from living at home to the college experience was considered to be stressful. Most of the participants mentioned a problem with stress eating, especially when studying; as one participant said: " ... I definitely snack too much when I'm stressed" (FG4_F19). Another one: " I work too much. I don't take the down time to exercise. I like to snack a lot. I use food to regulate my mood" (FG6_M22). Almost all participants believed that they did not have enough time to prepare healthy meals. The "lack of time" appeared to be an important barrier: " I don't have time to be going to the grocery store to just get fruit and healthy things" (FG1_F20). Time constraints also made students skip meals: " ...then sometimes I will eat at random hours during the day, including sometimes I'll have to skip lunch if I just don't have enough time, which I can see the effects, it just makes me really tired, it's not good for working out " (FG4_F19).

Also, the relative perception of the high costs of buying healthy food (i.e., fruits and vegetables) was one of the main barriers to a varied diet [ 2, 34]. For many students: " junk food is way cheaper than getting healthy food"; as one female participant specified: " it can be hard to afford healthy food, because no matter what healthy eaters say about how easy is to find cheap, healthy food, it's always probably gonna be cheaper to find heavily processed junk food" (FG1_F20). Another female participant with Asian origin confirmed with her personal experience that: " it's very abnormal in America that the fruit and the vegetables are much expensive than the meat, because back in China the vegetables and fruits are very cheap, so everyone can have access to that " (FG5_F24).

3.2.2. Social Level (Interpersonal Relationships)

Social relationships in early adulthood are predominantly formed with roommates and friends at college, as well as with family members, even if with a lower frequency with the latter. The perception of social pressure was a strong determinant in supporting and maintaining a healthy diet [ 35]. As one participant said in relation to healthy eating: " What you eat and who you're around is really influential" (FG2_F20). Another one confirmed this point: " Seeing if someone's eating really unhealthy, you can be like: "I'm going to be the one to eat healthy tonight", or if everyone's eating healthy, you feel more inclined to eat healthy " (FG2_F20). Sometimes, it was also the influence of the partner that could make a person change their dietary habits.

Parental Feeding Behavior

Respondents were asked about how parents can negatively and positively impact a child's eating behavior. They agreed that it was difficult for kids and adolescents to learn about eating healthy if their parents did not influence and teach them: " I think as a child, you look up to your parents a lot, so instead of verbally saying, "Eat healthy, blah blah blah..." you actually have to show it " (FG2_F19).

One student explained that sometimes there was a risk that the parents were too busy to take care of their children's diet: " If parents are too busy or they don't have the income and also the time, if they're working too many jobs, you know, they'll just get packaged food or processed foods and that could definitely have a very negative effect" (FG6_M21). As a result, the parents prefer to give them money to buy food away from home and most of them choose junk food or fast food: " if I'm with my friends, I can kind of get away with my mom not knowing what I'm eating. So I tend to eat what I can't eat at home, so always unhealthy " (FG1_F21).

These young adults believed that parents should give a good example (i.e., not going to a fast food place). Most of the students mentioned the role of the mother as a relevant figure for giving good recommendations: " my mom has always ingrained the healthy eating thing in me" (FG1_F20); " when I was younger ... even now, my mom only has healthy food available for me. And if I ever shop with her, she doesn't let me buy snacks or sweets" (FG1_F21). The participants who mentioned that their parents were good at cooking, and liked preparing foods from different cultures, also realized that they should not be really picky in their food choices. Others reported that their parents used some tricks to make their children to eat healthy food: " I think my parents just seasoned my vegetables so it would taste better. And that way I wouldn't really have to think about me eating vegetables" (FG4_M20). Other students experienced a more ambiguous and controversial approach with food: " We weren't allowed to leave the table until I finished my food " (FG4_F21); in this case, sometimes their mothers were part of the "Clean Plate Club", a club where parents are used to asking their children to finish everything on their plates.

Dietary Aspects of Home, School, and Eating Out

Respondents were asked what different eating behaviors they had between eating out and at home. Even if young adults ate in a variety of different settings, especially after living with their parents, the number of times eating out strongly increased. For instance, eating at home was usually correlated with higher fruit and vegetable intakes. However, many participants said that eating out was a kind of relief where all food desires could be satisfied: " I tend to eat what I can't eat at home, so always unhealthy" (FG1_F21); " when I'm eating out "I might as well treat myself" and treat myself for nothing" (FG4_F21); " when I lived at home, I would always eat really healthy, so whenever I go out, I tend to eat a lot of junk food" (FG1_F21). One participant's personal experience confirmed that: " usually when I go out with my friends or family, I eat just such trash food. And restaurant food to begin with is already so caloric, and then you just add on top of it, let's get appetizers and desserts " (FG4_F19).

Friends and Media Pressure

Young adults are often influenced by their peers for many habits, and also when eating behaviors are involved [ 29]; as one male participant, who had a high frequency in activity level and played in a team, said: " there is just so much social pressure to eat healthy around other people" (FG3_M23). As one female student reported: " I think every girl has this kind of thing and you have some pressure from your friends and if you will see them wearing beautiful dresses you want to lose weight or something" (FG5_F24). Another explained: " I think general rule of thumb, if you see people [friends] that look healthy, that we tend to ask someone, what do you eat? How do you do that?" (FG5_M21). Usually, meals with friends tended to be not healthy: " when I'm with my friends in the evening we do tend to eat heavier meals, which make me feel pretty sick the next morning". However, for someone else, the experience was the opposite: " I think the big thing that changed for me was when I came here at Cornell, I saw other people and their eating habits, and some of them were eating lean or eating healthier, and I tried to pick up on some of those too " (FG4_M21).

Many participants raised concerns about the role of television and other mass media on how an adolescent or young adult should look: " I just feel like in the media, you see all these images of celebrities and their body type is glorified, so you just want to eat healthier to look like that" (FG4_F19). In addition, they also considered advertisement on TVs for candies and other sweet foods to be negative communication on what to eat, as one participant said: "...there's all these ads on TVs for candies and stuff like that... kids would rather have the bright colors, the fun candies and stuff that aren't necessarily healthy" (FG1_F21).

3.2.3. University Environment and Student Life

Besides human physiology, the physical environment is also another element that can strongly shape our food choices [ 36]. In general the surroundings where you are living can strongly determine your diet: " I also think like your environment that you're in and that like you're constantly in really affects how you eat " (FG3_M19).

The university environment could have both a positive and negative influence on eating habits, as one participant explained: " I think if the community is driven to be healthier, then I think once you're in that environment, it tries to influence you to be healthier. And seeing other people around you eat healthy and want to be healthier is a big influencer on changing your habits. And vice versa" (FG2_F20). For example, most of the students thought that the dining halls strongly influenced their eating habits. Some students started to eat irregularly when starting college: " I eat irregularly, like sometimes for dinner I just don't want anything in the dining halls and I'll just eat cookies or the ice cream" (FG5_F19); " I probably eat more meat at college, I don't know, just a lot of food" (FG5_F19). When asked what events could make a person gain or lose lots of weight, someone said that going to college made people gain weight: " having that sort of unrestricted freedom of being able to choose whatever you want to eat, and also having a meal plan where it's like an "all-you-can eat" buffet" (FG1_F20). One participant shared a personal experience and said: " I need to go eat every meal at the dining hall. And once you're at the dining hall, you have unlimited food, so I feel like I overate a lot in the dining halls. And now living off campus, I'm able to just buy what I want to cook, and sometimes I cook all my food at once. So I can plan, this is for lunch, this is for dinner. So I can do better with portion control " (FG1_F21).

For some other students, especially athletes, having the dining hall always available and close to the dormitory or workplace was instead an advantage: " it was good to have the dining halls right there so you could kind of eat whenever you wanted to. So it helped me stay healthy and had a good eating pattern for that kind of lifestyle. And then, I think once when I got off campus, it's like harder to keep up with good eating patterns" (FG6_M21). Student life could be a critical period regarding unhealthy changes in lifestyle behaviors: " I also sometimes skip lunch when I have class or studying to do, and a lot of times when I'm studying I also eat junk food, try to keep myself awake " (FG4_M21).

Table 4 summarizes the main barriers and enablers that are associated with health decisions during college life.

Table 4

BARRIERS

ENABLERS

Individual-level
Not exercising
Not eating healthful food
Time constraints
Unhealthy snacking
Convenience food
Bad mood & stress
High prices
Junk food home availability

Individual-level
Maintenance of healthy lifestyle
Healthy eating habits
Food knowledge and education
Meal planning
Involvement in food preparation
Physical activity
Being portion-aware

Social-level
Parental food behavior and influence
Friends pressure and influence
Low food culture

Social-level
Friends pressure and influence
Parental food behavior and influence

University Environment
College's dining services
Availability of high-calorie food and fast food

Environmental-level
College's dining services

4. Discussion

Among the social enablers, students found that having the support of friends to be active in healthy eating was an important stimulus. We also observed that students who have a higher frequency of physical activity believe that social pressure helps them to stay healthy. Parents also have a crucial role, both positive and negative, in shaping the concept of healthy eating and in encouraging children in healthy activities, both related to eating (e.g., food preparation) or more physical (e.g., sport, outdoor activities). We noticed how perceived benefits of healthy eating also influence the intention to consume healthier food [ 41], which seems to be more easily achieved if students start planning their meals (self-control technique). Moreover, university characteristics, such as living arrangements (i.e., dormitory, off-campus, with parents) or academic schedules (e.g., classes, exams, etc.), also influence the relationships between individuals and their eating behaviors [ 18, 29, 42], and they should be taken into account when designing effective and tailored multilevel intervention programs.

Finally, it should be noted that some barriers for certain individuals, might be perceived as potential drivers by others. For instance, and not surprisingly, some students stated that "all-you-can-eat" formulas have a negative impact on the amount and quality of food consumed, whereas others believed that these types of dining halls facilitated their ability to have a healthy diet.

The focus groups confirmed that both lifestyle and behavioral factors are strongly associated with dietary patterns among college students: participants were aware that "being a healthy person" was not just exercising and eating healthy foods, but also taking time for yourself and being an overall happy individual.

One of the methodological limitations to the current study is that these results cannot be automatically generalized to the whole population of university students, when considering the specific and limited sample of participants (i.e., US college environment, healthy BMI status, other). Another limitation is related to the presence of students who might have been more interested in this topic, and decided to participate at the focus group, leading to "selection bias".

5. Implications

More precision in the relationship between food and health is a topic of growing importance on the public agenda [ 43]. Nevertheless, even with wide recognition that the food that we consume has a strong impact on our health, consumers' food preferences do not always lead to the best nutritional choices. A better understanding of the link between diet and health among college students is important for developing programs and behavioral change strategies to improve their lifestyle in general, and to reduce diet-related diseases in particular [ 9].

This study highlights the importance of consulting college students when developing healthy eating interventions across the campus for dining services or programs. As suggested by Stok et al., [ 10], researchers in the food and nutrition field should not only focus on individual-level factors, but they should also integrate socio-ecological aspects into the analysis. Dining halls and other University facilities should ensure the availability of healthy food choices, as well as promoting physical activity practices regularly. They should also provide food education and food preparation classes, to make students more knowledgeable on how to cook and better plan meals.

Giving college students the necessary skills to be more aware of what a healthy diet style means would empower them to make better food choices throughout their life. As suggested by many authors [ 4, 44], interventions should be specific for the targeted population (i.e., young adults) in order to help individuals to behave accordingly with their healthy intentions. For instance, social media facilitates the interaction between individuals and organizations (e.g., university administrators and food researchers), in order to provide tailor-made information [ 29, 45]. This aspect can be helpful in promoting healthy diets without creating eating disorders. In addition, price reductions for high-cost foods in campus facilities, such as dining halls and cafeterias, should also facilitate the purchase of more healthy options (e.g., fruits and vegetables). Environmental modifications can include changing and/or labeling healthy food options to make them more appealing, while creating a point of nutrition information where students can see healthy food options.

6. Conclusions

The aim of this study was to identify factors driving healthy lifestyle behaviors among US college students. Opinions and recommendations for effective and tailored-made intervention programs or environmental modifications that support healthy eating were presented, using an ecological framework that combined psychological, social, and environmental strategies.

Consumer behavior scientists typically do not contribute to the scientific debate about what is best to eat from a nutritional point of view or give recommendations about dietary components for the specific amounts and limits for food groups. In this study, we instead tried to understand the individual, social, and environmental factors that influenced students' healthy eating choices. Our results suggest that participants were influenced by individual, social, and university environmental factors.

The Ecological Model can help university communities to gain more insights into how and why students make certain food choices, and support them in staying healthy.

Colleges and dining halls on campuses should acknowledge their crucial role in guiding healthy eating behaviors, and be the first subjects to be interested in creating a healthy environment for the students. Unless they start understanding the reasons behind unhealthy eating behaviors of young adults, effective policies and managerial strategies to fight malnutrition (obesity, anorexia, micro-deficiency) cannot be developed.

The next step of this research will include the collection of a larger and more representative sample size, especially when taking into consideration the socio-cultural differences of college students between the US and other Western countries. Considering that the same negative trend of overweightness and unhealthy eating behavior among children, adolescents, and young adults is emerging in Europe, and also in Mediterranean countries [ 46], discussions on potential and future studies addressing this problem in a national context are advised. In addition, further research should evaluate whether specific tailor-made interventions are effective in changing behaviors towards a healthy lifestyle.

Acknowledgments

This study, which is part of a wider project called "CONSUMEHealth. Using consumer science to improve healthy eating habits", has received funding from the European Union's Horizon 2020 research and Innovation programme under the Marie Sklodowska-Curie grant agreement No 749514. We appreciate the assistance of Liam Wickes-Do and Zekun Ma, two research assistants, for the contribution in data collection, cleaning and transcription of the focus groups. The authors also thank all students participating in this study and the staff members of the Cornell Institute for Social and Economic Research (CISER). We also sincerely appreciate the feedbacks and insightful comments of the anonymous reviewers who helped improve and clarify this manuscript.

Author Contributions

G.S. took lead in writing the manuscript and was overall responsible for the study design, data collection and analysis. C.V.-A. has contributed in the study design and in the data collection (Focus Group moderator). C.M. and M.I.G. contributed in the result interpretation and made suggestions and comments of the final version of the manuscript. All authors read and approved the final manuscript.

Conflicts of Interest

None of the authors or affiliated institutions associated with this manuscript submission has any financial or personal relationship or affiliation that could influence the present work.

References

26. Creswell J.W. Qualitative inquiry and research design: Choosing among five approaches. Health Promot. Pract. 1998;16:473-475. [ Google Scholar]

Articles from Nutrients are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

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College Students and Eating Habits: A Study Using An Ecological Model for Healthy Behavior

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Overweightness and obesity rates have increased dramatically over the past few decades and they represent a health epidemic in the United States (US). Unhealthy dietary habits are among the factors that can have adverse effects on weight status in young ...

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When I graduated from college, I remember the relief of never having to take another final exam or sit through another boring lecture and the utter terror at finding a job and figuring out the rest of my life. With those big decisions to deal with, the last thing I worried about was staying fit and exercising, something I eventually regretted.

What I learned is that going from a relatively active college life to a sedentary full-time job leads to weight gain, something you can avoid if you establish a healthy routine now.

Exercise can relieve stress, easing you through this difficult transition, while boosting your confidence at a time you need it the most. You'll also have a big advantage going into the workforce. It's easier to work in exercise from the beginning than to squeeze it into a stressful work schedule later on.

Figuring out how to do that can be a challenge, but all it takes is a little knowledge and planning to get started on the right foot.

How to Exercise in a Post-College World

When you leave college, everything changes - especially your exercise habits. With your energy spent finding a job or starting a job, your activity drops and your stress levels spike. Below, you'll find out about the most common pitfalls and how you can prepare for them:

1. No More Free Workouts

If you had access to a free campus gym or discounted membership elsewhere, you now have to pay full price or find other ways to exercise.
The Fix: Where to Exercise - If you're on a budget, as many graduates are, you may need to be creative about where and how you exercise. Some options include:

At home: Set up a home gym with basic equipment such as dumbbells, resistance bands, and a stability ball. If money is an issue, there are ways to save money by buying secondhand equipment or even making your own weights. You can read about more ideas for home exercise and workouts you can do at home.

Outside: Running and walking are great ways to stay fit and manage your weight and only require a good pair of shoes. You can also try cycling, playing tennis or pick-up basketball games at your local park or meet up with fitness groups in your area. To get started, try an outdoor circuit workout.

At the Gym: To save money, look for small local gyms that charge lower fees (some are just $19.95 a month, such as Cardinal Fitness in Illinois), community centers, or your local YMCA, which usually aren't as expensive as larger health clubs.

At the Office: If you have a job, take advantage of your on-site fitness center, if you have one, or any health club discounts your company offers.

2. Your Schedule

In college, you may have more freedom and time to exercise. A full-time job will take up most of your day, leaving less time and energy to workout.
The Fix: Fitting It In - With that free time gone, you'll have to work a little harder to make time for exercise. It's important to establish your exercise routine as soon as you can. If you're looking for a job, make exercise part of your daily routine - it will boost your mood, give you the energy to keep going and build confidence. If you're already working, look at your schedule and carve out some exercise time each day. Even if you start with just 10 minutes or split your workouts, you can build on that over time:

3. Less Move, More Sit

Walking from class to class or from party to party can burn calories. Sitting in front of a computer for 8 hours a day doesn't, which can quickly lead to weight gain, backaches, and other aches and pains.
The Fix: Staying Fit at the Office: You have to be creative if you want to stay active at work. Set an alarm to go off every hour and stretch or do a few exercises. Other ideas:

Walk the stairs on your breaks or walk during your lunch hour

Walk, run or bike to work

Park further away or leave things in the car so you have a reason to get up

Avoid office junk food and eating out for lunch every day, which can quickly pile on the pounds

Try an office staircase workout

You can also try some lunch hour workouts

4. Changing Priorities

Graduating and going out into a different world can be overwhelming and it's hard to set your priorities. You may be tempted to skip exercise because you need all your energy to find a job or deal with the tiny nervous breakdowns that occur during big life changes.
The Fix: Make Exercise a Priority - Remind yourself that exercise adds energy to your day rather than feeling that it's taking something away. Other benefits to remember:

Whether you ease into post-college life without worry or you freak out all the way, exercise is an important part of the transition process. Be aware that moving into the workforce means you have to get used to working on someone else's schedule and take control of the time you do have to fit in as much exercise as you can. Starting now will help keep your weight in check and your stress at manageable levels.

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4 Tips to Stay Fit and Keep up Your Exercise Routine After College

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When I graduated from college, I remember the relief of never having to take another final exam or sit through another boring lecture and the utter terror at finding a job and figuring out the rest of my life. With those big decisions to deal with, the last thing I worried about was staying fit and exercising, something I eventually regretted.

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a. Better Leadership Skills

b. Higher levels of marital satisfaction

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Professions W/ Higher or Lower Divorce Rates

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The class of 2020, one of the largest graduating classes in U.S. history, is facing a far tougher job market than they expected due to the coronavirus pandemic's impact on the economy.

Even so, there is some good news for career starters: 1.5 million entry-level jobs are open in the U.S. right now, according to LinkedIn data, which shows a real-time picture of the global job market based on insights from millions of members, jobs, companies and schools.

What's more, there are certain skills in demand across all industries that can help grads stand out from the crowd, start their careers on the right foot and position themselves for advancement as the economy recovers. Having the right skills can make all the difference, even in difficult times.

During the Great Recession, for example, a large subset of the class of 2009 chose to forgo an immediate job search to pursue additional education and upskilling, setting themselves up to be better positioned for opportunities as the economy began to recover the year following. Importantly, data suggest that did not delay those grads' career progression.

The same might be even more true for today's grads, who have far greater access to a larger variety of upskilling programs than their predecessors. Acquiring new and relevant skills is no longer limited to going back to school to earn a graduate degree. From short-term credential programs to skill-specific online courses, graduates can choose from many paths to pick up the skills necessary for success in a rapidly changing workforce.

According to LinkedIn's new "Grad's Guide to Getting Hired," many of the most in-demand competencies - the ones most requested in job postings across every industry - are soft skills, like communication and leadership. While colleges may not offer courses called "Leadership 101" or degrees in critical thinking, these are skills that can be learned. Maybe you've acquired them while volunteering or participating in school clubs and organizations. Like technical skills, all of them can be developed, polished and leveraged to make yourself stand out in a crowded post-Covid market, no matter your original area of study.

Here are six of the most in-demand skills you should have in your career toolkit.

As Covid-19 continues to impact the way companies do business, strong customer service skills remain vital. Employees who know how to ensure that customers feel valued, especially as many services are conducted online without that face-to-face element, are in high demand. In fact, we found the role of customer service specialist to be one of our top entry-level jobs right now.

Those that know how to innovate and foster customer loyalty are even more in demand. Whether you plan to go into this space or not, it doesn't hurt to learn the foundations, finer techniques and the power of creating customer value.

Leadership is not just a skill for managers. It's a sign of self-awareness and authenticity and one that can take your career to new heights when honed.

Opportunities to lead present themselves every day, and that's never been more clear as employees lose the in-person mentorship they might have grown accustomed to and workers must make difficult decisions when confronted with situations that could endanger the health and safety of their colleagues and customers.

Being able to project clarity, credibility and self-confidence - the characteristics of a well-developed executive presence - amid stressful and uncertain circumstances is quickly becoming table stakes in our new world of work.

Communication skills are even more important as Covid-19 has led to a dramatic increase in employees working remotely, a change that is likely to stick around after the pandemic fades.

Effective communication foundations will always be an asset in the workplace, no matter your function or industry. Start by learning how to better pitch yourself to employers, helping you stand out from the crowd at a time when so many will be applying for the same jobs. Also, brushing up on your body-language skills will help you more effectively communicate, and empathize, with your colleagues and managers in a newly digital workspace.

Even before the pandemic, the pace of change and volume of information employees encounter each day made it difficult to make the right decisions.

The result: People largely rely on biases and uninformed gut feelings that cloud their judgment and draw them to the wrong conclusions. The world is now more confusing and overwhelming than ever, and well-developed problem-solving skills - like critical thinking and rational analysis - will be vital in navigating the demands of a post-Covid workplace.

Successful employees and leaders know to foster curiosity within themselves and their colleagues, and how and when to ask the right questions to better understand our increasingly complex world.

How is it that some brands are able to stand the test of time, enduring fluctuating market and consumer demands?

Covid-19 has started to reveal which of today's brands have this staying power and which do not, which brands are so well-defined and executed they can outlast even a pandemic that has dramatically altered how customers view and interact with the products and services they use.

Marketing plays a large role in this, and companies are looking for employees who understand how they can best connect with consumers even in challenging times.

Spending time learning these skills, which will be necessary to thrive in today's ever changing world of work, will help career starters get ahead as the economy recovers. And consider making it a habit. Lifelong learning can bolster your resilience in economic downturns as well as advance your career.
-By Emily Poague, vice president, LinkedIn Learning
For more on the convergence of new technology and the future of work, request a ticket to join the CNBC @ Work Spotlight virtual event on June 18, featuring VMware's Pat Gelsinger, Honeywell Connected Enterprise's Que Dallara and Genpact's "Tiger" Tyagarajan.

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Emily Poague, guest contributor and vice president, LinkedIn Learning

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These are the 6 skills college grads need to compete in the post-Covid jobs market: LinkedIn

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The class of 2020, one of the largest graduating classes in U.S. history, is facing a far tougher job market than they expected due to the coronavirus pandemic's impact on the economy. Even so, there is some good news for career starters: 1.5 million entry-level jobs are open in the U.S.

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a. Provide better health care to their children

b. Spend more time with their child

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Abstract

It might seem strange to ask whether increasing access to medical care can improve children's health. Yet Lindsey Leininger and Helen Levy begin by pointing out that access to care plays a smaller role than we might think, and that many other factors, such as those discussed elsewhere in this issue, strongly influence children's health.

Nonetheless, they find that, on the whole, policies to improve access indeed improve children's health, with the caveat that context plays a big role-medical care "matters more at some times, or for some children, than others." Focusing on studies that can plausibly show a causal effect between policies to increase access and better health for children, and starting from an economic framework, they consider both the demand for and the supply of health care. On the demand side, they examine what happens when the government expands public insurance programs (such as Medicaid), or when parents are offered financial incentives to take their children to preventive appointments. On the supply side, they look at what happens when public insurance programs increase the payments that they offer to health-care providers, or when health-care providers are placed directly in schools where children spend their days. They also examine how the Affordable Care Act is likely to affect children's access to medical care.

Leininger and Levy reach three main conclusions. First, despite tremendous progress in recent decades, not all children have insurance coverage, and immigrant children are especially vulnerable. Second, insurance coverage alone doesn't guarantee access to care, and insured children may still face barriers to getting the care they need. Finally, as this issue of Future of Children demonstrates, access to care is only one of the factors that policy makers should consider as they seek to make the nation's children healthier.

What role does access to medical care play in protecting and promoting children's health? Although it might seem self-evident that medical care improves children's health, evidence for the population as a whole suggests that medical care is less important than we might have thought. One widely cited study estimates that lack of access to medical care explains only about 10 percent of early mortality in the population as a whole; the remainder is attributed to genetics (30 percent), social circumstances (15 percent), environmental exposure (5 percent), and behavioral factors (40 percent). Compared with its effect on overall mortality, medical care may be more or less important as a determinant of children's health. Medical care's role also depends on time, place, and context; for example, screening children for exposure to lead may be much more valuable in an environment with older housing stock. Similarly, access to medical care is critically important during infectious disease outbreaks. Nonetheless, the fact that, on average, medical care may matter less than we think is a useful starting point as we consider how access to care affects children's health.

In this article, we review what is known about how policies that promote access to medical care affect children's health. We consider a range of such policies, including government-provided insurance coverage, increased payments to health-care providers who care for publicly insured children, cash payments to parents who take their children to get care, and the placement of health-care providers in schools. We organize our discussion using an economic framework, categorizing policies to promote access according to whether they affect primarily the demand side of the market (children and their families) or the supply side (doctors, hospitals, clinics, and other providers of medical care). The aspect that we care about-actual use of services, or what sociologist Ronald Andersen calls "realized access"-is, of course, the result of the interaction between supply and demand. But policies to promote access tend to focus on one side of the market or the other, and so we structure our discussion accordingly.

Ultimately, we conclude that access to medical care does affect children's health, and that an array of policies to improve access-expanding coverage, increasing reimbursement to providers, placing nurses or counselors in schools-can improve children's health. We can't say which of these policies yields the most bang for the buck in terms of improved health, nor can we say whether they are more effective than policies that focus on domains beyond access to medical care, such as those discussed in other articles in this issue. At the same time, we can say with some certainty that access to care is not the whole reason some kids are healthier than others, a point that is reinforced by the fact that socioeconomic disparities in child health exist in countries like Canada that have more equal access to health care. Nonmedical inputs into children's health, like those discussed elsewhere in this issue, as well as the quality of medical care, are important pieces of the puzzle.

Finally, we close by discussing how the Affordable Care Act is likely to affect children's access to care, the policy questions that may arise as this landmark legislation is implemented against an already complex backdrop of public insurance programs for children, and the challenges that will remain to ensure children's access to care.

Standards for Inclusion in This Review

At the outset, we need to acknowledge that it's hard to identify true causation when it comes to how access to medical care affects health. Simply comparing people with and without insurance, for example, or those who have public versus private coverage, tells us little about how insurance affects health. We can't necessarily solve this problem by using statistical models that control for observed differences between the two groups; such an analysis might even yield the paradoxical result that Medicaid appears to make health worse, when in fact the worse health of Medicaid enrollees may be driven by other dimensions of disadvantage that are not necessarily measured in the data. Evaluating the experience over time of new enrollees in public programs may also be misleading, since the decision to enroll in the program may have been driven by declining health-a phenomenon first identified in the context of job training programs, where those who enroll are more likely to have experienced a dip in earnings beforehand.

With these considerations in mind, we focus on studies that have an effective strategy for dealing with such problems. In practice, this means we favor studies that rely either on randomized trials-relatively rare, but not unknown, in social policy-or on "natural experiment" methods that rely on changes in policy that are close to random (such as a federally imposed requirement that all states expand their Medicaid programs for children-more on this later) and therefore can teach us something about how the policy in question affects the outcomes we want to study. The trade-off associated with relying on randomized trials or natural experiments is that they give us good information about a relatively narrow range of situations. For example, most of our evidence on the impact of health insurance on children's health relates to low-income children who are on the margin of Medicaid eligibility, with much less information about those who are privately insured, even though, judging by the 2012 American Community Survey, the privately insured represent 55 percent of all children.

In terms of what outcomes to look for, we focus on studies that measure either health or the use of preventive services; use of preventive services includes whether a child makes any visit to a doctor during the year, since the American Academy of Pediatrics recommends that all children have at least one visit per year, even if it is only a well-child visit. We don't consider studies that review only how policy affects, for example, the total amount of medical care that children use (which would include sick visits and hospitalizations). Our rationale for singling out preventive services is that health benefits from prevention may occur far down the road; a necessary although not sufficient step for policy to improve health through preventing illness would be to increase the use of preventive services.

Finally, this article does not consider two special groups, not because they are unimportant but because they are discussed elsewhere. In this issue of Future of Children, Maya Rossin-Slater discusses how access to prenatal care affects infants' health. And health insurance for children with disabilities-how it affects their access to care and their health outcomes-was reviewed by Peter Szilagyi in a recent issue of the journal.

Demand-Side Policies

The primary demand-side policy to promote children's access to medical care is providing free or subsidized health insurance. The past 25 years have seen dramatic expansions of Medicaid, as well as the creation of the State Children's Health Insurance Program (formerly known as SCHIP and now as CHIP) in 1997. describes selected milestones in the history of public health insurance coverage for U.S. children, and shows how enrollment in these programs has grown. In 1988, approximately 16 percent of all children were covered by Medicaid; in 2010, Medicaid and CHIP together covered half of all children under age 19 for at least some part of the year, as well as 45 percent of all births. This growth both increases the importance of public insurance as a way of promoting access to care and provides an opportunity to evaluate how public coverage affects the health of infants and children. In this section, we review the evidence on the effects of these large expansions in public health insurance. In addition to considering the consequences of whether children have coverage at all, we consider the continuity, type, and generosity of coverage for those who have it. We examine how insurance "churning"-moving in and out of coverage-may affect children's health, and we look at the relatively limited evidence on how HMO or high-deductible plans affect health compared with more traditional insurance coverage. Finally, we discuss two studies that evaluate what happens to children's health when parents receive direct financial incentives to obtain preventive care for their children.

Table 1

1965

Medicaid is established to provide health insurance coverage to children in families receiving
welfare.

1986-90

Congress requires gradual increases in income eligibility threshold for Medicaid until all
children living below the poverty level are covered by Medicaid.

1997

Congress enacts the State Children's Health Insurance Program (SCHIP), providing funds for
states to expand insurance coverage to low-income children above the poverty level, either
through their existing Medicaid programs or through new state-sponsored programs.

2009

Congress reauthorizes the State Children's Health Insurance Program and changes its
acronym from SCHIP to CHIP.

2014

Major coverage provisions of the ACA take effect: health insurance expansions, premium tax
credits, individual coverage mandate, and Medicaid expansions for adults in some states.

How Insurance Affects Child Health

With a few exceptions, most of the evidence on how health insurance-and the improvement in access to care that it affords-affects children's health and use of preventive services comes from expansions of Medicaid in the late 1980s and early 1990s and the establishment of SCHIP in 1997. One of the important exceptions is the RAND Health Insurance Experiment (HIE), conducted between 1971 and 1986.

The RAND Health Insurance Experiment

The RAND HIE has been extensively described elsewhere. In a nutshell, the experimenters randomly assigned approximately 6,000 people to insurance plans with different levels of cost sharing. At one extreme was a plan in which all care was free; at the other, a plan in which participants had to pay 95 percent of the cost of their care, up to an out-of-pocket maximum of $1,000, at which point care was free. Note that because of inflation, $1,000 in 1971 would be almost $6,000 in today's dollars, so the RAND participants with the least generous coverage had what we now think of as a high-deductible health plan. After tracking the participants for three to five years, the researchers compared their health-care use and health status. The results for adults have been well publicized; on average, the RAND HIE found no difference in health among adults across the different insurance plans, despite large differences in health-care use. Low-income adults who received free care experienced some measurable improvements in health; in particular, the researchers found improvements in corrected vision and, for those who began the study with hypertension, significant reductions in blood pressure.

The results of the RAND HIE for the approximately 1,000 children who completed the study are similar. There were no differences across insurance plans, on average, in physiologic measures of health such as anemia and hearing or vision problems, or in parental assessments of children's overall health-again, despite large differences in the use of medical care. Among children, anemia (for low-income children) and dental care (for all children) seemed to be exceptions. Eight percent of low-income children in the free care group had anemia at the end of the study, compared with 22 percent in cost-sharing plans, although the relatively small number of low-income children in the study makes it hard to say with confidence that this difference did not occur by chance. For children between the ages of six and 17, although the overall rate of decayed, missing, and filled teeth did not vary by insurance plan, children on the free care plan were more likely than those in the cost-sharing plans to have filled teeth rather than decayed or missing ones (on average, a difference of about one tooth). Among children ages three to five, those in the free care plan were less likely than those in the cost-sharing plans to have decayed teeth. Both of these effects were largest for children in low-income families; in fact, for preschoolers in high-income families, the number of decayed teeth did not vary significantly for those covered by cost-sharing plans (0.44 teeth) versus the free plan (0.19 teeth).

The chief criticisms of the RAND results related to the health of children center on the fact that there were relatively few low-income children in the study-possibly too few to detect important effects of coverage on health; the fact that the study excluded infants; and the relatively high proportion of children who left during the course of the study. For our purposes, an additional consideration is that RAND didn't compare insured versus uninsured people but rather estimated the effect of the generosity of coinsurance in an insured population. Notwithstanding these caveats, the RAND results for children-like those for adults-suggest that in the population as a whole, the generosity of insurance coverage does not significantly determine overall health. For high-risk children, however, which in this case means low-income children, the RAND experiment suggests that the generosity of coverage does affect health (again, mirroring the results for adults).

Medicaid

Next, we consider how Medicaid affects children's health. Two recent studies analyzed Medicaid's impact after its inception in 1965. Both found positive health effects. One study used variation across states in both the timing of Medicaid adoption and the fraction of children receiving welfare (who were automatically eligible for Medicaid) to identify how coverage affected infant and child mortality. It found that, in the year after implementation, mortality fell among nonwhite infants (although not among white infants), and that this effect persisted for at least 10 years. The second study exploited variation across states in the timing of Medicaid adoption to estimate how exposure to Medicaid in childhood affected health in adulthood. It found that among children from low-income families, those who experienced more years of Medicaid eligibility were in better health, measured using an index of chronic conditions, than were those with less exposure to Medicaid. This finding supports the rationale we offered above for focusing on the use of preventive services in addition to health outcomes; the effects of investments in health may take a while to reveal themselves.

More recently, the expansions of Medicaid eligibility in the late 1980s and early 1990s have proved to be a powerful natural experiment shedding light on how coverage affects infants' and children's health. Several influential studies have documented significant positive effects. One pair of researchers used mortality data, combined with a measure of the generosity of coverage expansions, and concluded that expanding eligibility significantly decreased child mortality. Using a similar strategy, the same researchers focused on expansions of eligibility among pregnant women; they found that these expansions significantly increased women's use of prenatal care and reduced the incidence of low birth weight and infant mortality. Another set of researchers used data from the National Hospital Discharge Survey to document that eligibility expansions led to increased hospitalization among children. These researchers also looked at why the children were hospitalized, to see whether improved access to care might have succeeded in reducing hospitalizations for conditions like asthma that should ideally be managed with adequate primary care, while increasing hospitalizations for truly serious conditions. On the contrary, they found no decline in hospitalizations for conditions like asthma, suggesting, somewhat surprisingly, that the expansion in coverage did not improve children's access to primary care. And a third set of researchers used data from the National Health Interview Survey to show that expansions of Medicaid eligibility increased use of preventive care. Though there was no immediate effect on children's health, their health improved later in childhood, further bolstering the case for focusing on use of preventive services.

Exploiting the fact that an expansion of coverage meant that many more children born after September 30, 1983, were eligible for Medicaid than were children born before that date, another study measured how coverage affected adolescents. It found significant reductions in mortality for black children ages 15 to 18 but no reduction for whites (echoing the results for infants after Medicaid's 1965 inception). However, using the differences across states in the income level at which children are eligible for Medicaid, another study analyzed data from the Panel Study of Income Dynamics-Child Development Supplement, and found that Medicaid eligibility had no significant effect on three aspects of children's health: the probability of being in excellent health, obesity, and school days missed because of illness.

The Medicaid studies we've discussed so far focus primarily on the impact of expanding eligibility, rather than on actual enrollment. In contrast, one researcher exploited California's variation in the placement of outreach centers for Medicaid enrollment to estimate the effect of actual enrollment on child health. She found that increases in enrollment led to significant decreases in hospital admissions for conditions that could, in theory, be well-managed in a primary care setting and should not result in hospitalization if children's access to primary care is adequate.

Taken as a whole, the evidence from studies of Medicaid expansion-and, in one case, actual enrollment-suggest that coverage has large and significant impacts on children's physical health. To this firm conclusion, however, we would add several more nuanced observations. First, although the preponderance of evidence supports the view that access is important for children's health, not all studies find this to be so. This reinforces a point we made earlier: the importance of medical care depends on context. It matters more at some times, or for some children, than others. Access may matter more, for example, for the typical low-income child made newly eligible for Medicaid coverage than for the average child in the RAND experiment gaining access to more rather than less generous private coverage. Second, some programs-such as those that offer access to preventive services-may not yield any effect for months or even years, meaning that the available data, typically measured at one point in time, may understate their effects on children's health in the long run. Third, researchers have paid relatively little attention to how coverage affects children's mental health, even though some of coverage's most striking effects on low-income adults are in the domain of mental health.

How Continuity and Type of Coverage Affect Health

Insurance coverage among low-income children is strikingly dynamic; such children frequently move between having public insurance, being uninsured, and having private insurance. For example, one nationally representative study took a snapshot of child enrollees in Medicaid and tracked their enrollment one year later. Over one-quarter had left the Medicaid program; among those who left, approximately half had become uninsured. State-specific studies have found similarly high Medicaid dropout rates and have also found that many dropouts reenter the program in fairly short order, a phenomenon known as "churn." Unfortunately, this pattern is likely to continue in the post-ACA era; low-income families' incomes and employment trajectories are quite volatile, and this volatility is projected to mean that children's eligibility for coverage will frequently churn between Medicaid, subsidized coverage from health insurance market-places, and employer-based coverage. And although the ACA's individual mandate now imposes a fine on families if their children are uninsured, a grace period allows a lapse in coverage of up to three months in any given year. Moreover, children in families under the tax filing threshold ($20,000 for a married couple in 2013) are not subject to the mandate and consequently could face longer coverage gaps.

Insurance volatility is especially likely for children in families with income that is just above or below the Medicaid eligibility threshold. For families with income just below the threshold, an increase in income may mean that they have to begin making a premium contribution even for public insurance; this has repeatedly been shown to increase the likelihood that they will lose coverage and experience uninsured spells. Additionally, this group of children is the one most likely to experience across-year and even within-year shifts in eligibility for public coverage versus publicly subsidized exchange coverage.

Two studies use data that track children's insurance coverage and health-care use over time to demonstrate compellingly that coverage gaps, even those of short duration, reduce children's access to and use of care. One of the authors of this article, Lindsey Leininger, examined how the number of months children spent uninsured affected the likelihood that they would experience any doctor's visit and any well-child visit in a given year. She found that each additional month without coverage was associated with a small, statistically significant decline in the probability of both outcomes; four months without insurance-the typical length of an uninsured spell for this group-was associated with a 4 percent decrease in the likelihood of any visit to a doctor and a 9 percent decrease in the likelihood of a well-child visit. The study found that one reason even short gaps in coverage reduced doctor visits is that interruptions in coverage may lead children to lose their usual source of care.

A recent study expanded on Leininger's work, exploring how the types of coverage held over the course of a year (that is, public versus private), in addition to the duration of coverage, affected the likelihood of any visit to a doctor. Interestingly, it was not the type of coverage children held over the year-public, private, or a mix of public and private-that affected their use of health care, but solely the total amount of time for which the children had coverage. These findings offer some reassurance that children who churn among different types of insurance coverage are likely to retain sufficient access to care, as long as the transitions are not punctuated by spells without insurance. Accordingly, we need policies that make such seamless transitions possible.

Finally, there has been some concern that the cost-sharing in high-deductible health plans might discourage children's use of preventive services. A recent study examined this question. Using data from a single health plan, the researchers analyzed the experience of 1,598 children whose parents' employer switched their families from a standard insurance plan to a high-deductible plan. Although the fraction of these children who received well-child visits over the course of a year decreased slightly (from 84.6 percent to 84.1 percent), this decrease was no larger than that of a control group of 10,093 children who remained in traditional insurance plans throughout the study period (from 86.1 percent to 85.5 percent). For this population, at least, there is no evidence that the increase in cost-sharing associated with the switch to a high-deductible health plan reduced children's use of preventive services. Because the switch to a high-deductible plan was made by the employer on behalf of all employees, the study avoided potential concerns that families might have chosen a high-deductible plan precisely because they don't place much value on preventive services.

Financial Incentives for Use of Preventive Services

Medicaid agencies have recently begun adopting financial incentive programs to promote healthy behaviors and use of preventive care among members. Most of these programs, including a series of demonstration projects created and funded as part of the ACA, focus on promoting healthy behaviors such as quitting smoking among adults, but a few have focused on well-child visits. Encouragingly, the results from the well-child visit pilot programs are the most positive among all of the burgeoning Medicaid incentive programs.

A financial incentive program launched by a Medicaid managed-care insurer in Minnesota has also been positively associated with well-child visits. In October 2000, the insurer, Medica Health Plans, introduced a $10 Target gift card as an incentive for member children. The incentive was implemented via a voucher program-network physicians gave vouchers to parents during well-child visits that could be redeemed by mailing them back to the insurer. No control group was available, so a study of the program exploited differences in distance from the children's homes to the nearest Target store to estimate the program's impact. The study found that children who lived within the sample's median distance to a Target store (2.5 miles) saw a 6 percent relative increase in the likelihood of having a well-child visit, compared with children who lived further away (before the study began, 37 percent of children in the near-to-Target group were receiving well-child visits, compared with 28 percent in the distant-from-Target group). Unfortunately, there is no easy way to use this "distance-to-Target" effect to estimate the incentive program's actual impact, so it's hard to compare these findings to those from Idaho. Importantly, however, the Idaho and Minnesota programs both showed positive impacts, albeit within opposite contexts: during the study period in Idaho, rates of well-child visits among Medicaid-enrolled comparison-group children were generally rising, while during the Minnesota study they were falling.

The four studies we've just discussed consistently demonstrated that financial incentive programs can appreciably increase use of preventive care, including dental care, among low-income children. This finding mirrors similar work on adults, which has found that financial incentives are more effective when they target use of preventive care than when they aim to bring about more sustained health behavior changes, such as quitting smoking and exercising.

Supply-Side Policies

Turning now to the supply side, we review what is known about how provider reimbursement from Medicaid affects children's health, since low payments to providers are one of the reasons that some providers simply do not see Medicaid patients. We also review evidence on policies that focus on providing care directly, including Federally Qualified Health Centers, the Vaccines for Children program, and school-based health centers. These policies have received less research attention than has public insurance, but they could nonetheless be important for improving children's health.

How Medicaid Reimbursement Rates Affect Child Health

An important early study, now somewhat dated, assessed the relationship between Medicaid's physician fees and infant health. This study examined changes in individual states' fee levels over time to assess how the ratio of Medicaid fees to private fees for obstetricians and gynecologists affected infant mortality rates. Its findings indicate that when the Medicaid-to-private fee ratio doubled (the ratio ranged from 0.45 to 0.60 over the study period, according to the working paper version of the manuscript), infant mortality fell by 0.56 deaths per 1,000 live births (mean infant mortality rate in the study was 9 deaths per 1,000 births). Weighing the costs of increased reimbursement rates against the benefit of better health, the authors concluded that it cost about $260,000 (in 1986 dollars, or about $560,000 in 2014 dollars) in increased Medicaid fees to save one additional infant's life. An important limitation of this study is that, unlike the others we review in this article, it analyzed state-level aggregate data as opposed to using person-level observations. Accordingly, we can't know for which groups of women the changes in Medicaid fee ratios affected infant mortality.

Recent research documents that elementary school counselors can have beneficial behavioral effects on children

Using the same research design, but with data covering a longer study period and a larger set of dental procedures, a later study produced very similar results, though the effects were somewhat smaller. However, this study used an additional calculation to show that the improvements in the public-private gap in dental-care use came at great cost, because the large fee changes required to induce marginal improvements in dental-care use among publicly insured children would be applied toward all visits the children made, not just those induced by the changing fee schedule. Thus, they calculated, the implied cost of one additional visit was approximately eight times the amount of the current Medicaid payment rate for a single visit.

Taken together, these compelling studies suggest that for prenatal care and children's dental care, increasing Medicaid provider fees is an important way to improve access. Unfortunately, to our knowledge, no studies of how Medicaid reimbursement levels affect children's access to medical care or behavioral health care have research designs that meet our criteria for inclusion in this article.

How Policies that Provide Direct Medical Care Affect Child Health

In recent decades, promoting access to insurance coverage has been the primary policy to improve children's access to medical care. But policies that provide medical care directly have also improved children's health. These policies include placing counselors or health-care workers in schools, funding community health centers, and subsidizing vaccinations.

Elementary School Counselors

Recent research documents that elementary school counselors can have beneficial behavioral effects on children. In contrast to counselors serving older children, who require intensive academic advising, elementary school counselors-there are more than 40,000 of them across the country-spend most of their time focusing on students' mental and behavioral health.

One study examined the effect of counselors by exploiting the differences within academic years in a Florida school district's student-to-counselor ratios that arose from the placement schedule of University of Florida graduate student counseling interns. The researchers found that fewer students per counselor meant fewer discipline problems in schools. A decrease in the student-to-counselor ratio from the sample mean level of 544 students per counselor to the ratio of 250 students per counselor recommended by the American School Counselor Association (ASCA) was associated with a 7.4 percent decrease in the probability that a given student would repeat a disciplinary problem. These effects were the most pronounced for black male students, who saw a 10 percent decrease. A school-level analysis suggests that a drop from the mean student-counselor ratio to the ASCA-recommended ratio is associated with an 11.8 percent decrease in the mean share of students with a disciplinary occurrence. A potential problem with the study design is that interns were more likely to be placed in schools with lower levels of discipline problems in the previous semester; to the extent that this occurred, however, it means that the study's findings are conservative and may underestimate the true effect.

Similar findings emerge from two companion studies. The first exploited the fact that Alabama has strict enrollment cutoffs for financing elementary school counselors, meaning that schools with almost the same number of students could have different numbers of counselors. Importantly, there is no evidence-either in the data, or based on conversations with Alabama school officials-that schools were strategically manipulating their enrollment levels to get more resources the following school year, which could have biased the findings. The findings suggest that although the student-to-counselor ratio had no meaningful relationship to academic outcomes (measured by math, reading, and language test scores), it did have a statistically significant and qualitatively important influence on rates of suspension and weapons-related incidents. The estimated effect of having more counselors was somewhat sensitive to the assumptions used in different statistical analyses; the study's best estimates indicated that an increase of one half-time counselor decreased the likelihood that the school would have at least one student suspension per school year by 20 percent compared to the mean rate of suspension and decreased the likelihood of at least one student weapons-related incident per school year by 26 percent. However, the study found that additional counselors had no effect on other behaviors, including rates of attendance, expulsions, and drug-related incidents.

In a later study, the same author explored how changes in state-level elementary school counselor policies affected a variety of teacher-reported measures of behavioral issues. The research design took advantage of the fact that different states adopted minimum student-counselor ratios and/or subsidies for schools to hire more counselors at different times. The study consistently found that additional counselors were associated with decreases in the likelihood that teachers would report that a series of seven out of eight behavioral issues presented at least a minor problem. The decrease in likelihood typically ranged from 5 to 9 percent, with one outlier of 19 percent for the measure "students cutting class." Interestingly, effects on the likelihood that teachers would report a given behavioral issue as a moderate or severe problem were much weaker-only two measures, "student drug abuse" and "physical conflicts among the students," consistently showed significant effects.

Taken as a whole, these studies offer powerful evidence that public policies to reduce student-to-counselor ratios have meaningful effects on elementary school students' behavioral health. Such policies seem even more important when considered in the context of the high prevalence of mental and behavioral health problems among children and the damage that they inflict, which Alison Cuellar discusses in detail in this issue.

School-Based Health Centers

A national network of approximately 2,000 school-based health centers (SBHCs)-distributed across elementary, middle, and high schools-provides preventive services to an estimated 2 million children and adolescents each year. Though the SBHCs date back to the 1930s, the vast majority of existing centers (over 85 percent) were established after 1990, and 20 percent were established after 1999. The SBHCs serve a strikingly diverse student population; the racial/ethnic profile of host schools is fairly evenly divided among non-Hispanic white, Hispanic/Latino, and black students. The SBHCs are more prevalent in underserved communities, and over two-thirds of them explicitly seek to serve the broader community in addition to the host schools' student population. Under the Affordable Care Act, the SBHCs recently entered a period of great expansion. Specifically, the ACA appropriated $200 million over the years 2010-13 both to increase the number of SBHCs and to increase service levels at the existing SBHCs.

A recent working paper constitutes the first empirical study of the SBHCs with a research design that can plausibly show causation. Based on the variation arising from openings, closings, and changes in per-student service levels in different counties over time, the authors estimated how the SBHCs affected teenage birthrates and high school dropout rates. Though they found no effect on dropout rates, they discovered large, statistically significant effects on teen birthrates. Specifically, they found that opening an average-size SBHC was associated with a 20 percent decline in the birthrate among teens less than 15 years old (from an average of 0.56 births per 1,000 teens) and a 7 percent decline in the birthrate among teens ages 16-19 (from an average of 45.6 births per 1,000 teens). Moreover, they found that these results were driven entirely by the 85 percent of the SBHCs that offered birth control services (either directly or through referral), underscoring the SBHCs' important role in providing access to reproductive health services, an issue around which there has been considerable controversy.

Other Direct Provision Policies

The Affordable Care Act has appropriated over $10 billion to expand Federally Qualified Health Centers (FQHCs), also commonly referred to as community health centers, a network of 9,000 clinics that provide primary care to underserved populations, including an estimated 7 million low-income children each year. A 2010 study found that increases in federal funding for the FQHCs directly translate into meaningful increases in the services offered by the clinics-including, importantly, increases in behavioral health services. Thus the new ACA funding should increase access to preventive and mental health services among low-income children. Although extensive correlational evidence suggests that the FQHCs achieve impressive health benefits, no research that focuses specifically on the FQHCs and children's health meets our criteria for inclusion in this review. A study of the early years of the FQHCs, beginning in the mid-1960s, found that the clinics were associated with declines in mortality among older adults, but no data suitable for analyzing outcomes among children were available.

Another major policy to directly provide health care is Vaccines for Children (VFC), the federal program that offers free vaccines to participating pediatricians' offices for uninsured and publicly insured children. VFC pays for almost half of pediatric vaccines administered in the United States. As with the FQHCs, the research evidence behind VFC is mostly correlational. Studies suggest that VFC's introduction was associated with increases in immunization rates and, among inner-city children, decreases in fragmentation of care. However, these findings should not be taken as conclusive, because these studies were not designed in a way that can show causation.

The ACA and Children's Access to Medical Care

The passage and implementation of the Affordable Care Act (ACA) mark a new era for the health-care system. The law's hallmark provisions provide new pathways to insurance coverage for populations that have historically been at high risk of being uninsured. These provisions were crafted largely with adults in mind because, before the ACA, children were much more likely than adults to be eligible for public coverage and less likely to be uninsured. Nonetheless, some of the coverage provisions targeting adults or low-income families will have spillover effects on children's coverage and access to care. Moreover, some provisions of the ACA do focus on children or young adults. In this section, we outline how the ACA is likely to affect children's access to care.

Coverage Impacts

Box 1

Under the ACA, the typical income range for CHIP eligibility-from 150 percent to 250 percent of the federal poverty line-now overlaps with the income eligibility levels for coverage through subsidized exchanges. Many current CHIP enrollees will be ineligible for this subsidized coverage, however, since their parents have offers of coverage under their employer-sponsored plans. Dependent coverage is typically very expensive, and its cost isn't considered when determining eligibility for exchange subsidies (a feature called the "family glitch"); thus many children covered by CHIP might become uninsured if the program is discontinued, unless the regulations governing eligibility for exchange subsidies are revised to fix the "family glitch." With this in mind, the Medicaid and CHIP Payment and Access Commission (MACPAC), an independent agency that advises Congress, has recommended funding CHIP for an additional two years, until adequate provisions for covering these children can be made. MACPAC is also concerned about potential differences in the generosity of children's benefits between exchange coverage and CHIP. Its preliminary analysis suggests that, on average, CHIP plans have more generous coverage than exchange plans; MACPAC was to continue to monitor the issue and report back to Congress in spring 2015.

The ACA also offers states the option of establishing and administering a Basic Health Program (BHP), which would mitigate the problem of differential benefit generosity. BHPs are intended to provide a subsidized coverage option, with benefits and provider networks similar to Medicaid's, to Medicaid-ineligible people with incomes up to 200 percent of the federal poverty line. Such a program could reduce the potentially damaging effects of coverage churn among such people. Moreover, it would provide an option for low-income parents who are eligible for neither Medicaid nor CHIP to have an insurance plan with the same provider networks as those available to their Medicaid- or CHIP-enrolled children. Though states have the option to establish a BHP beginning in 2015, as of this writing, very few states have signaled an interest in doing so.

Because it mandates increases in the scope or generosity of private coverage, the ACA may also improve access for children who are already insured. For example, the ACA prohibits annual or lifetime limits on coverage, and people can't be denied coverage because of preexisting conditions. The act also requires that all private insurance, including employer-sponsored plans, cover the full cost of preventive services, such as childhood immunizations and well-child visits. The ACA may also increase the scope of coverage for private individual health insurance plans by introducing minimum benefit standards called Essential Health Benefits. These standards encompass a wide range of preventive, acute, and rehabilitative services and, for children, vision and dental services. It is unclear how many children will be affected by these provisions, since many plans are likely to have covered most of these benefits already.

The ACA also includes some smaller-scale supply-side provisions that are likely to affect children's access to care, although exactly how is hard to predict. These provisions include the expansion of funding for the SBHCs and the FQHCs, both of which are important sources of medical care for vulnerable children, as well as a temporary Medicaid reimbursement increase (in 2013-14) for primary care providers, including pediatricians, to achieve parity with Medicare. Additionally, several small-scale workforce initiatives are designed to increase the supply of providers serving vulnerable populations, including underserved children. These expansions in supply may not be enough to meet projected demand increases likely to be induced by the ACA's coverage provisions. Accordingly, it will be important to watch for barriers to access for newly insured children and their families. The first studies of the issue provide some reassurance that existing capacity in the health-care sector has been able to absorb the increased demand.

Finally, the ACA contains a series of health-care system delivery reforms designed to tackle two problems: the high cost and fragmentation of medical care. Specifically, the ACA introduces and supports a series of pilot demonstrations involving financing changes that accelerate the existing trend away from payments based on quantity of services toward a fixed, global per-patient payment, with payment bonuses for providing higher-quality care (for example, ensuring that patients receive annual flu shots). Additionally, the ACA pilot demonstrations involve initiatives to enhance the coordination of care, which are expected to increase the continuity and integration of care across primary care providers and specialists. The two most notable reform models tested in these pilots are the Accountable Care Organization, a new type of multiprovider network that coordinates care across providers (primary care and specialty) and settings (hospital, outpatient, and in-home), and the Patient-Centered Medical Home (PCMH), a primary care-focused model providing enhanced payments to primary care providers to promote "whole patient" care. These pilots overwhelmingly focus on adult populations, so very few children are likely to benefit directly from them in the short run. But they indicate broader health-care system trends that are shaping changes in pediatric practice. Indeed, the concept of the medical home originated in pediatrics, and the American Academy of Pediatrics continues to advocate for pediatric-focused PCMHs. A key aim of such efforts is to integrate behavioral health care into primary care, which is vital given the high prevalence of behavioral health problems among children.

Conclusions

The ACA builds on the earlier successes of Medicaid expansion and CHIP to promote children's access to care, but challenges remain. We close by summarizing the three most significant challenges facing policy makers and policy-oriented researchers when it comes to the relationship between children's access to care and their health.

Not All Children Have Coverage

The country has made tremendous progress in increasing insurance coverage among children, but some groups have been left behind. In particular, undocumented children have very few affordable coverage options. Immigrant children, including the undocumented, are less likely to have access to employer-sponsored insurance than are citizen children. Moreover, undocumented children are ineligible for both Medicaid/CHIP and exchange coverage. Many of these children will continue to rely on free and/or greatly reduced-price care from safety net providers such as the FQHCs, free clinics, and public hospitals. Federal payments to safety net hospitals for uncompensated care are slated to decrease substantially under the ACA, further reducing the medical resources available to this vulnerable group.

Coverage Does Not Guarantee Access

Other Inputs Are Critical

Our review of the evidence suggests that, without question, access to care plays an important role in promoting children's health. Moreover, improving children's access to care represents a relatively straight-forward problem in the sense that, if the political will exists, we know which policies will work: expanding coverage, promoting continuous coverage, and increasing reimbursement rates. At the same time, as we noted at the outset, access to care is not the whole reason that some kids are healthier than others. It is worth repeating a point from the RAND Health Insurance Experiment: even in the free care plan, 30 percent of children had uncorrected vision problems in spite of receiving an average of more than three office visits per year. Nonmedical inputs into children's health, such those discussed in the other articles in this issue, as well as the quality of the medical care that children can access, are also important pieces of the puzzle.

Acknowledgments

Levy acknowledges financial support from the National Institute on Aging (grant number NIA K01AG034232).

Footnotes

Jeannette Rogowski of Rutgers University reviewed and critiqued a draft of this article.

* In some cases, large groups may adopt a temporary preexisting condition exclusion period.

Contributor Information

Lindsey Leininger, Mathematica Policy Research.

Helen Levy, Institute for Social Research, the Ford School of Public Policy, and the Department of Health Management and Policy of the School of Public Health at the University of Michigan.

ENDNOTES

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53. Decker Medicaid Payment Levels.

55. Buchmueller, Orzol, Shore-Sheppard Medicaid Payment Rates.

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It might seem strange to ask whether increasing access to medical care can improve children's health. Yet Lindsey Leininger and Helen Levy begin by pointing out that access to care plays a smaller role than we might think, and that many other ...