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SPECIAL

ARTICLES

Medically

Uninsured

Children

in the United

States:

A Challenge

to Public

Policy

Charles

N. Oberg,

MD, FAAP

From the Department of Pediatrics, University of Minnesota and the Department of Pediatrics, Hennepin County Medical Center, Minneapolis, Minnesota

ABSTRACT. This article is an examination of the nature

and extent of the problem presented by medically unin-sured children in the United States. First, the

character-istics of the uninsured population are explored with a

description of how age, family income, and employment status disproportionately affect families with children. Second, the Medicaid program and its historically

mad-equate response to this growing problem of uninsured

children is examined. Third, the relationship between

insurance status and the health and development of children is discussed. Finally, recent public policy initia-tives that have been enacted or proposed to address this inequity in the present health care system are reviewed with a recommendation to establish a “Universal Mater-nal and Child Health Program.” Pediatrics 1990;85:824-833; Uninsured, Medicaid, low birth weight, universal access.

As we proceed into the 1990s we are faced with a

health care trend which is affecting an increasing

proportion of children in the United States. It is

estimated that there are over 37 million Americans

who lack health insurance coverage, and children

represent the largest segment of the uninsured pop-ulation.1 This article is an examination of the na-ture and extent of the problem presented by medi-cally uninsured children. The characteristics of the uninsured population are discussed with a descrip-tion of how age, family income, and employment status disproportionately affect families with

chil-dren resulting in their overrepresentation among

the uninsured. The Medicaid program, or Title

XIX

of the Social Security Act, and its historically

in-Received for publication Jan 27, 1989; accepted Jul 10, 1989. Reprint requests to (C. N. 0.) Dept of Pediatrics, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN 55415.

PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the American Academy of Pediatrics.

adequate response to this growing problem is ex-amined and the relationship between insurance sta-tus and children’s health and development is dis-cussed. Finally, recent public policy initiatives that

have been either enacted or proposed to address

this inequity in the health care system are reviewed.

The article concludes with a recommendation

call-ing for the establishment of a “Universal Maternal

and Child Health Program” to assure access to this vulnerable population.

CHARACTERISTICS OF MEDICALLY

UNINSURED

The number of uninsured Americans has

in-creased an estimated 30% during the past decade.2

The uninsured are not a homogenous group of

individuals, but rather a diverse population that is becoming increasingly alienated and disenfran-chised from the health care system. This section is

an exploration of the key factors that characterize

the uninsured, specifically age, income, and em-ployment status.

The age distribution of the uninsured demon-strates the inequity faced by children. It is esti-mated that the largest segment of the uninsured population are the 12.2 million children less than

18 years of age.3 Another 7 million children may be insured for only part of the year.4 If the age limit is

extended to include young adults, more than 56% of the uninsured are under 24 years of age.5

Inequi-ties in coverage are particularly evident for children

between the ages of 0 and 2 years and for adoles-cents and young adults aged 18 to 24 years.4 The

lack of insurance among 18- to 24-year-olds is of

particular concern for young women in need of maternity care. Quality comprehensive prenatal

care is becoming less accessible to a large and

growing proportion of women because they lack

(2)

Whereas the uninsured rate for the general popu-lation is 17%, it

is estimated

that three women in five (59%) 15 to 19 years old and one third of women

20 to 24 years old have no insurance for maternity care during these prime childbearing years.8 The

issue of inadequate access to prenatal care during this age period is critical, because it may result in increased neonatal morbidity and mortality.

Income is another key demographic variable that provides information on the uninsured and the relationship between health insurance and families

with children. Before 1965 and the creation of Med-icaid, access to health insurance was best charac-terized as a linear function with increasing family

income assuring a greater likelihood of health

in-surance coverage.7 That pattern of availability,

however, has changed. The poorest poor are at least partially covered by Medicaid. In addition, the fi-nancially secure families of the middle- and upper-income strata typically have an employer-subsi-dized health care plan or individually financed health coverage. However, there is a large segment of the population who are poor or near poor who

lack health insurance coverage.

Americans living below the federal poverty level still represent the largest segment of the uninsured, accounting for 12.6 million or 35.6% of uncovered persons.8 Because children account for the largest segment ofall Americans in poverty (40%), the link between income and health insurance coverage for children is particularly significant.8 If all families with incomes below 200% of the federal poverty level are included, close to 65% of all uninsured persons can be accounted for. Being uninsured, however, is not solely a low-income phenomenon; the income of 35% of the uninsured is above 200%

of the poverty threshold.8

Private health insurance coverage obtained through employment is by far the most common source of health insurance. In 1985, two thirds of all those under age 65 and 75.9% of all workers

received their health coverage through

employ-ment.’#{176} Therefore, any major disruption in the workforce environment is likely to have

ramifica-tions on access to health care benefits unless alter-natives are available. Several significant events and trends since 1980 have affected directly the availa-bility of health care coverage in the workplace.

The slow erosion of employer-based health care

coverage began with the severe recession of 1981 to

1982 and the substantial loss of employment-re-lated health benefits. The United States

Congres-sional Budget Office estimated that, of the 12

mil-lion persons out of work in December 1982, about

5.3

million had lost coverage under an employer-based health plan. If dependents were included, an

estimated 10.7 million joined the ranks of the un-insured because of lost employment.”

Since the recession, the United States has expe-rienced a prolonged recovery spanning two admin-istrations. However, the growth in jobs has occurred primarily in the service industries, such as retail trade and personal services, which have much lower rates of health insurance coverage than industries

such as mining and manufacturing. The latter in-dustries have had very limited growth in jobs since

1981 to 1982. While there are approximately twice as many workers in the high-coverage industries as in the low-coverage industries, employment growth during the recovery has been four times faster in the low-coverage industries, thereby increasing the number of uninsured.12

The 1981 to 1982 recession also changed employ-ers’ attitudes toward health insurance as a fringe benefit. The combination of the aftermath of the recession and the continued escalation of health care costs led employers to reduce offered benefits, typically by increasing the workers’ cost-sharing requirements. This has led to a reduction in family

or dependent coverage. Between 1980 and 1986, the

proportion ofemployees in medium- and large-sized

firms receiving the full cost for family coverage

declined to 35%, down from 51% in 1981.’ An

increase in the number of indirectly uninsured

chil-then, where the adult worker is covered and the

children

are not,

is a serious

problem.

Almost

87% of all medically uninsured children were in families in which at least one member was employed. In addition, 53% of uninsured children lived in fami-lies where a parent was employed full-time, full-year, and over 43% of these parents where covered by an employer-based health plan.’4

Finally, many children are underinsured. Current health insurance coverage frequently provides for only major medical and catastrophic coverage. That

is, they will pay for the child if he or she is acutely ill, but may not cover recommended well-child care visits during which growth and development are

monitored and children receive routine

immuniza-tion. In addition, in some cases preventive care may

be covered, but deductibles are so high that parents defer such care because they are unable to pay the cost-sharing requirements. It has been demon-strated that the higher the cost-sharing require-ments for families, the greater the reduction in

ambulatory care for children of all ages, especially

among low-income families.’5

MEDICAID:

AN INADEQUATE

RESPONSE

FOR

CHILDREN

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to health care for low-income people. Enacted in

1965,

it mandated the creation of a jointly funded federal-state partnership to help eliminate the fi-nancial barriers to medical care for the poor. The federal government matches state expenditures based on a formula using a state’s per capita in-come. This federal contribution ranges from 50%

to 78%.16 States, however, have a great deal of latitude and flexibility in setting Medicaid policies, which results in substantial state-by-state

varia-tions in the benefits and reimbursement rates of

the Medicaid program. This section is an

exami-nation the Medicaid program in terms of eligibility, expenditures, and its historical inability to cover all poor children.

Medicaid was initially envisioned as a small pro-gram designed to consolidate several smaller cate-gorical grant programs. However, in the first year of operation, the combined federal and state outlays

reached $1.5 billion. By 1975, outlays had increased

to $12 billion. In 1989, Medicaid expenditures are expected to exceed $58 billion for 25 million

recip-ients.17 The two major groups entitled to Medicaid benefits are those who receive Aid to Families with Dependent Children and persons on Supplemental Security Income. Supplemental Security Income is

for low-income individuals who are aged, blind, and/or disabled. Medicaid has grown tremendously

since its inception in terms of expenditures, enroll-ment, and expansion of benefits. In 1967, the Early

Periodic Screening, Diagnosis and Treatment

pro-gram was enacted to provide preventive screening

and health services for children receiving Medicaid

benefits. The next major change came with the passage ofthe Social Security Amendments of 1972. These amendments federalized the Supplemental Security Income program, establishing national standards for Supplemental Security Income ben-efits for low-income, aged, and disabled persons, but allowed the continued state-by-state variations that characterize the Aid to Families with Depend-ent Children program. This statutory change dis-rupted the equilibrium between the two eligible groups and has had an impact on the subsequent

growth of the Medicaid program.’8

A trend analysis of Medicaid expenditures for Aid to Families with Dependent Children children

vs Supplemental Security Income recipients from 1972 to 1987 is shown in Table 1. In 1972, 18.1%

of Medicaid expenditures went to Aid to Families with Dependent Children children under 21 years

of age. By 1984, this percentage declined to 11.7%

and recently increased slightly to 12.3%. The share used by the Supplemental Security Income

popu-lation, on the other hand, increased from 52.8% in 1972 to 73.0% in 1987.19 These two divergent trends

exemplify the shift in direction for the Medicaid

program following the passage of the Social

Secu-rity Amendments of 1972. Although Medicaid was

enacted to finance and improve access to health care for the poor, it has developed into the largest public funder of long-term care for the elderly.

TABLE 1. Medicaid Expenditure for Children Receiving Aid to Families with Dependent

Children (AFDC) vs Recipients of Supplemental Security Income (551) for the Years 1972

to 1987 (Expenditures in Millions of Dollars)*

Years Total AFDC Children <21 y 551 Recipients

E:nthtures Expenditures % of Expenditures % of

Total Total

1972 6 300 1 139 18.1 3 324 52.8

1973 8639 1426 16.5 5315 61.5

1974 9983 1694 17.0 6159 61.7

1975 12 242 2 186 17.9 7 503 61.3

1976 14091 2431 17.3 8830 62.7

1977 16239 2610 16.1 10382 63.9

1978 17992 2748 15.3 11929 66.3

1979 20472 2884 14.1 13928 68.0

1980 23311 3123 13.4 16360 70.2

1981 27204 3508 12.9 19381 71.2

1982 29 399 3 473 11.8 21 144 71.9

1983 32391 3836 11.8 23321 72.0

1984 33895 3979 11.7 24795 73.2

1985 37508 4412 11.8 27548 73.4

1986 40872 5096 12.5 29943 73.3

1987 45170 5536 12.3 32963 73.0

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When nursing home care is needed, the elderly “spend down” to a level of poverty so as to qualify

for Supplemental Security Income and Medicaid.

The inadequacy of coverage by Medicare and pri-vate insurance for long-term care services forces

many older Americans onto Medicaid. This shift of funds toward the aged and disabled has contributed

to the erosion of Medicaid coverage for uninsured

children in poverty.

The Robert Wood Johnson Foundation

exam-med the extent to which Medicaid was able to provide coverage for individuals whose income is

below or near the poverty level. The program

reached its peak in 1975 when 63% of low-income individuals were covered by Medicaid. By 1985, the program served less than half (46%) of those living

in or near poverty.20 In addition, the proportion of poor children who actually receive Medicaid bene-fits declined 18% from 1980 to 1983.21 In 1984, the

10 states with the lowest Aid to Families with Dependent Children income levels covered only

38% of their children living below the poverty threshold.22 The states’ failure to increase income eligibility ceilings to deal with inflation caused coy-erage for poor families to decline. The average state

Aid to Families with Dependent Children eligibility

threshold used for Medicaid fell from 71% of pov-erty in 1975 to 48% in 1986.23 This retrenchment was accentuated in the early 1980s under the Rea-gan Administration and the passage of Public Law 97-35, the Omnibus Budget Reconciliation Act of 1981. The Ominbus Budget Reconciliation Act of 1981 mandated reductions in the federal Medicaid match to states for a 3-year period.24 The Omnibus Budget Reconciliation Act of 1981 also modified

provisions of the “work incentive” program within

the Aid to Families with Dependent Children pro-gram, which eliminated close to half a million work-ing families and 700 000 children from the Medicaid

program and expanded the ranks ofthe uninsured.25 In summary, this inability to cover low-income

families and children has been due to the shift of Medicaid to long-term care services, governmental efforts to constrain programmatic costs, and the persistent inequity found in state-by-state varia-tions in eligibility standards.

CORRELATES

TO CHILDREN’S

HEALTH

AND

DEVELOPMENT

Financial access to care correlates with the uti-lization of health services. This section is an explo-ration of how this relates to the health and well-being of infants and children. In that regard, both uninsured women in need of prenatal care and uninsured children are discussed. The difficulties

faced by each group in obtaining care potentially affect the overall growth and development of

chil-dren.

The birth of a healthy infant is associated with

early and appropriate prenatal care. A recent Insti-tute of Medicine report on the prevention of low-birth-weight infants indicated that prenatal care was particularly beneficial to socioeconomically and

medically high-risk women.26 The Institute of Med-icine study also noted, however, that the proportion

of women receiving inadequate prenatal care stopped decreasing and, in fact, recently increased.

The United States Government Accounting Office

recently conducted a survey of 1157 women in 32 communities from eight states and examined the use of prenatal care by Medicaid recipients and

uninsured women. The results demonstrated that 63% of these women obtained insufficient prenatal

care, and that most of the women in that group were uninsured, young, poorly educated, and from

a minority background.27

The consequences of inadequate prenatal care may be profound, with a direct relationship to an increased incidence of low-birth-weight infants and

perinatal and infant mortality. The Infant

Mortal-ity Rate remains a serious problem in the United States. This country made significant progress in reducing infant deaths over the 30-year span from 1950 to 1980. However, it appears that the

subse-quent rate of decline in the 1980s has been dis-tinctly slower than that of the 19705.28 In addition to this slowing of the aggregate national rate, a

number of states and cities have experienced an increase in their overall and ethnic-specific

mortal-ity rates. In 1985, the Infant Mortality Rate among whites actually increased in 19 states, and the In-fant Mortality Rate among blacks increased in 12 states.29 Data from the National Center for Health Statistics revealed that 15% ofthe 54 largest United States cities experienced an increase in infant mor-tality for all races from 1979 through 1984, and 35% reported higher nonwhite rates.3#{176}The Chil-dren’s Defense Fund recently reported that the international standing of the United States for

infant mortality had declined to where the United States was now tied for last place among 20 other

industrialized nations.31

Low birth weight is a major determinant of infant

mortality. A low-birth-weight infant is almost 40 times more likely to die in the first 4 weeks of life as a normal-birth-weight infant, and two thirds of all deaths during the first month are attributable to low birth weight.26 Researchers recently demon-strated a sixfold increase in the risk of low birth

weight associated with financial problems during

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eth-nicity, health habits, and complication of preg-nancy.32 The presence of low birth weight, in addi-tion to increasing the risk of mortality, can have major consequences for those who survive. These infants appear to be at increased risk of serious illness, developmental disorders, and life-long handicapping conditions. Birth defects, mental

re-tardation, seizure disorders, and cerebral palsy are

more prevalent among these infants.33 The most

distressing fact is that low birth weight and its consequence for infant mortality and health is largely a preventable disorder. According to the

Department of Health and Human Services, with

adequate risk assessment, 80% of women at risk of having a low-birth-weight baby can be identified at

the first prenatal visit, and intervention can be started to reduce the risk.27

Medically uninsured children also face barriers to health care services that may affect their overall

health and development. An analysis of physician visits revealed that the uninsured had 15% fewer physician visits than privately insured individuals

and 33% fewer than Medicaid recipients.34 In

ad-dition, according to the 1977 National Medical Care

Expenditure Survey, the uninsured had 50% fewer

physician visits and hospital days than did full-year

Medicaid recipients.35

The 1980 National Medical Care Utilization and

Expenditure Survey revealed similar results.

In-sured children averaged 1.3 more physician visits

than the uninsured and incurred more than twice the total medical charges.36 This persistent differ-entiation in the availability of services is also seen in preventive services. Uninsured children received

fewer childhood immunizations than those with a

public and/or private source of coverage.37 The

Robert Wood Johnson Foundation prepared a

se-ries of special reports investigating access to medi-cal care during the past decade. Its 1986 report

states that despite rapid changes in the health care system, the plight of those traditionally under-served, such as poor uninsured children, may have worsened since the last survey in 1982. The report investigated ambulatory visits as a key indicator of access to care, and the poor, despite their worse

health and their greater likelihood of having a

chronic or serious illness, fared worse than the more affluent. While the number of ambulatory visits has declined for both insured and uninsured persons, the gap has widened. In 1982, the insured had 4.7 and the uninsured had 3.8 ambulatory visits. The

insured in 1986 had 4.4 visits and the uninsured had 3.2. In addition, it was estimated that over a million families were refused or did not seek care

because of an inability to pay.38

This inadequate access to health-related services

for uninsured children may contribute to poor health outcomes in later childhood and adolescence. Although researchers have had difficulty establish-ing the predictive value of the frequency of well-child visits on better health outcomes, the efficacy of preventive care becomes evident when specific aspects of such visits are examined. The data are particularly clear for immunizations, good nutri-tion, and various forms of other early childhood screening; for example, vision and hearing, lead poisoning, and iron-deficiency anemia.3#{176} Each of these aspects of well-child visits has also been shown to have an impact on subsequent health,

development, cognitive functioning, and school

achievement. Furthermore, certain health condi-tions make a statistically significant contribution to explaining variations in school performance and cognitive functioning. Low birth weight, poor hear-ing, uncorrected or poor vision, and school absences because of illness are among the major correlates of below-average achievement and IQ.4#{176}

Low-in-come children also have a greater prevalence of

iron-deficiency anemia, lead poisoning, recurrent

infections, and school absence.41 Lead poisoning is

a particularly insidious problem. Low to moderately elevated lead levels, which clinically are frequently

asymptomatic, can exert significant and lasting ef-fects on cognitive ability. A recent study showed that such levels affected motor skills, memory,

con-centration, language development, and spatial

func-tioning.42 Lead poisoning may in part be linked to

poor access to health care services and the absence of early detection.

A

number of preventive expenditures have been

shown to be dramatically cost-effective.

Further-more, these savings from the additional costs for more intense medical services or developmental

interventions can be considered proxies for

im-proved health and developmental outcomes for chil-dren. The United States House of Representative’s

Select Committee on Children, Youth and Families

released a report on the cost-effectiveness of se-lected preventive programs for children.43 The re-port estimated that for every dollar spent on quality prenatal care, over $3 can be saved by reducing the number of low-birth-weight infants. The

cost-effec-tiveness of childhood immunizations is also clear.

For every dollar spent on the Childhood Immuni-zation Program, over $10 is saved in future medical

costs. A Centers for Disease Centers Control study

revealed that the $180 million spent on measles

vaccination saved $1.3 billion in acute medical and

long-term care by reducing hearing impairment and

mental retardation.43 Yet because of inadequate

ac-cess to care and reductions in funding for the

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TABLE 2. Medically Uninsured Children in the United States

Legislative Initiatives Medicaid Eligibility Changes

(CHAP Amendments)

*DEFRA, Deficit Reduction Act; CHAP, Child Health Assurance Program; COBRA,

Consolidated Omnibus Budget Reconciliation Act; AFDC, Aid to Families with Dependent

Children; SOBRA, Sixth Omnibus Budget Reconciliation Act; OBRA87, Omnibus Budget

Reconciliation Act of 1987.

increase in the reported cases of measles, mumps, and pertussis and a decrease in the number of fully immunized children between 1981 and 1985.

Despite the documentation of decreased utiliza-tion and the increased prevalence of poor health

indices among poor and uninsured children, re-search has been equivocal on the benefits of well child visits on health outcomes. In fact, the Rand Insurance Study failed to show a relationship

be-tween the availability and utilization of medical care services to improved health outcomes for

chil-dren.451t is therefore critical that research on access

and health outcomes continue to better delineate the relationship between these various parameters.

RECENT PUBLIC POLICY INITIATIVES

Numerous public policy initiatives have

at-tempted to address the inadequate financial access

to care for the uninsured. Some of these proposals

address the entire uninsured population, while

oth-ers have targeted high-risk populations that appear most vulnerable, such as expectant mothers, in-fants, and young children. Some proposals have

called for the creation of new federal and state programs; others have attempted to broaden the

scope of the existing health care system by expand-ing employer-sponsored health care. In addition, the recent incremental expansion of the Medicaid

program could extend coverage to more low-income

families and children and shrink the pool of the uninsured. This section is an examination of recent

Medicaid changes which should reduce the number of uninsured children as well as major legislative

proposals introduced to address the problem of the uninsured.

Medicaid

Expansion

for Uncovered

Women.

Infants and Children

As previously noted, recent changes in the

Med-icaid program directly affect uninsured women and children. Despite significant budgetary difficulties faced by this nation and the continued need to find

domestic savings, Medicaid has not only been

pro-tected from further cuts but has been expanded to

reach a larger portion of uninsured women and

children. Table 2 provides a brief summary of the

DEFRA* 1984

COBRA 1985

SOBRA 1986

OBRA87

1987

Medicare Catastrophic

1988

Family Support Act 1988

OBRA89 1989

Mandates expansion to include first time

pregnant women and women in two-parent families.

Mandates coverage for all children aged 0-5 meeting state financial eligibility critiera.

Financial eligibility standards remain unchanged and vary state by state based on AFDC eligibility.

States may increase coverage for

preg-nant women and children up to 5 y of age with family incomes less than 100% federal poverty level.

States may provide coverage to pregnant

women and infants with family in-comes up to 185% of federal poverty

level.

Expansion of CHAP Amendments to

in-dude children up to 8 y of age.

Mandates cover age of pregnant women and infants with family incomes less than 100% of federal poverty level.

Mandates Medicaid coverage for 6 mo

for working families leaving AFDC.

Allows states an additional 6-mo

ex-tension of benefits.

Mandates coverage of all pregnant and

children under 6 y of age with family incomes less than 133% of the federal

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recent changes in the Medicaid program which have loosened categorical and financial eligibility

re-quirements. Toward the end of the 98th Congress,

Public Law 98-356, the Deficit Reduction Act of 1984, was enacted and contained certain provisions called “The Child Health Assurance Program”.46 The Child Health Assurance Program altered Med-icaid’s eligibility criteria to include a larger number

of women in need of prenatal care services. It

expanded coverage to include first-time pregnant

women and pregnant women from two-parent

households in which the main wage earner is un-employed. The Deficit Reduction Act also extended

Medicaid coverage to all children less than 5 years

of age born after October 31, 1983, whose family income falls below the state’s income eligibility floor. The Child Health Assurance Program

amend-ments were completed by Public Law 99-272, the

Consolidated Omnibus Budget Reconciliation Act

of 1985, which extended coverage to the last group of low-income expectant mothers: those pregnant women in families where the parents may be

work-ing but whose income is insufficient to raise the family income above the state’s asset and income

requirements for Aid to Families with Dependent Children eligibility.47

In the 99th Congress, Public Law 99-509, the

Sixth Omnibus Budget Reconciliation Act of 1986 was passed. It gave the states the option to raise eligibility to 100% of the federal poverty level for

this vulnerable group of expectant mothers, infants,

and children less than 5 years of age. This effort was an attempt to federalize partially the Aid to Families with Dependent Children portion of the Medicaid program to reduce state-by-state varia-tions. The National Governors’ Association

esti-mates that as of January 1, 1988, 24 states had

opted this 48 program expansion.

The 100th Congress produced three major legis-lative initiatives that would allow states to continue to separate Aid to Families with Dependent Chil-then from Medicaid eligibility and would extend care to a large number of families who make up a significant portion of the uninsured. First, Public Law 100-203, the Omnibus Budget Reconciliation Act of 1987, provided Medicaid benefits to addi-tional working poor families. It permitted states the option of expanding Medicaid coverage to the large number of uninsured pregnant women and infants whose family income falls between 100% and 185% of the federal poverty level. This bill would also accelerate the phase-in for children who were ex-tended care in the previous bills and would include children through 8 years of age.49 The Children’s Defense Fund recently estimated that full imple-mentation of Sixth Omnibus Budget Reconciliation

Act and Omnibus Budget Reconcilation Act of 1987 by all states could reduce the number of uninsured

pregnant women and infants by two thirds, and the number of uninsured children aged 1 to 8 years by one third.5#{176}Secondly, Public Law 100-360, the re-cently passed Medicare Catastrophic legislation

contained Medicaid provisions that mandated

states to cover all pregnant women and infants less

than one with income less than 100% of poverty.5’ Finally, Public Law 100-435, the Family Support Act of 1988 passed at the close of the 100th

Con-gress enacting major welfare reform. One provision

addresses the issue of working poor families making the transition from welfare to self-sufficiency. The law mandates an extension of Medicaid coverage

for a minimum of 6 months following the loss of

Aid to Families with Dependent Children benefits due to employment and allows states to provide benefits for an additional 6 months.52 This Medic-aid extension is considered a vital component of welfare reform and the need to address the insuffi-cient health coverage of working poor families. This

effort to decouple Medicaid from the welfare system

continues with Medicaid expansion proposals in

the 101st Congress. Senator Lloyd Bentsen (D-TX) and John Chafee (R-RI) introduced 5.1201 which would mandate states to cover any pregnant women and children up to age 6 years in families with incomes below 185% of the federal poverty level. It

is estimated that the expansion would ensure

300 000 pregnant women and 2.5 million children.53

The Omnibus Budget Reconciliation Act of 1989

increased coverage for this group up to 133% of the

poverty threshold.

Expansion

of Private

Sector

Alternatives

“The Basic Health Benefits for All Americans Act,” was first introduced in 1987, by Senator Ken-nedy (D-MA) and would require companies to offer a minimum level of health benefits to their employ-ees.54 This legislation was crafted to use the present

health care system in which 75% of Americans

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Small businesses are strongly opposed and feel that

the cost of providing coverage to all workers is prohibitive and that it is unreasonable to expect small businesses to provide the same coverage as

medium and large firms. Somewhat surprisingly, a

number of large employers have provided their

sup-port; they contend that larger employers with

health care coverage pick up the costs of uninsured

workers when hospitals and providers pass costs

onto payers through higher charges to insured pa-tients. There is a growing sentiment among large employers that a minimum level of coverage should

be shared equitably by all employers. Although not

passed in the 100th Congress, the proposal was

reintroduced and will be debated vigorously in the 101st Congress.

The “Child Health Incentive Reform Plan” has

been introduced by Senator Chaffee (R-RI) in the past and was also reintroduced in the 101st

Con-gress. This legislation addresses the large number

of children who are underinsured. It would provide coverage for those children currently insured for acute illnesses and major medical expenses but not

for preventive well-child care. This bill would

re-quire all traditional insurers who offer dependent coverage to include comprehensive well-child care coverage at a reasonable cost with appropriate

cost-sharing requirements. This proposal with the strong support from the American Academy of Pe-diatrics has been enacted by seven states with sim-ilar legislation pending in several other states.56

CONCLUSION

The nature and extent of medically uninsured children provides us with a public policy challenge. How do we reverse the deleterious trends which

have resulted in the growing number of uncovered children? The public policy initiatives discussed

above provide the first step and acknowledge the realization that financial access to quality health care ought to be available to all Americans. In the near future new proposals will surface and they

must be examined, discussed, and analyzed. These will range from local and state initiatives to a

restructuring of how health care is delivered and

financed in the United States. This process has already begun. The Intergovernmental Health

Pol-icy Project estimates that, in 1988, 29 states and

the District of Columbia enacted measures designed

to extend care to selected segments of medically uninsured population.57 Several proposals have re-cently appeared in the medical literature which

advocate a fundamental restructuring of the health care in the United States in response to the growing number of uninsured persons.58’59 In addition, the

American Academy of Pediatrics has undertaken as a priority an active role in the development and formulation of a proposal which will hopefully re-duce or eliminate the problem of uninsured chil-dren.

The Presidential Commission for the Study of

Ethical Problems in Medicine concluded that,

“So-ciety has an ethical obligation to ensure equitable access to health care for all.”#{176}We must proceed to

broaden the scope of the present patchwork of

private and public programs and transform the

restrictive, categorical programs of the past toward

a “Universal Maternity and Child Health

Pro-gram.” This program must be universal to assure that women in need of maternity care and children

have equitable access to health services

independ-ent of age, income, family composition, and/or em-ployment status. Equitable access implies that

women and children are able to secure an adequate level of care without an excessive financial burden. Finally an adequate level of care will require coy-erage of not only acute and catastrophic services

but the full array of preventive services necessary to promote the growth and development of our children. This obligation must be met, and the

present inequity characterized by the dispropor-tionate representation of children among the

un-insured must be reversed and eliminated.

ACKNOWLEDGMENTS

This work was supported, in part, by a grant from

Hennepin Faculty Associates, Minneapolis, MN Grant

P-951G.

The author would like to express gratitude to Becky

Westergren for manuscript editing and preparation.

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(10)

Uni-versity; 1988:17. Intergovernmental Health Policy Project. 58. Himmelstein D, Woolhandler S. A national health program for the United States. A physician’s proposal. N EnglJ Med. 1989;320;102-108

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CHEATING

IN SCHOOL

A 50-state study released in September by Friends for Education, an

Albu-querque, NM, school-research group, concluded that “outright cheating by

American educators” is “common.” The group says standardized achievement

test scores are greatly inflated because teachers often “teach the test”...

Evidence of widespread cheating has surfaced in several states in the last year or so. California’s education department suspects adult responsibility for

erasures at 40 schools that changed wrong answers to right ones on a statewide test. After numerous occurrences of questionable teacher help to students,

Texas is revising its security practices.

. . .sales of test-coaching booklets for classroom instruction are booming.

These materials, including Macmillan/McGraw-Hill School Publishing Co.’s

Scoring High and Learning Materials-are nothing short of sophisticated crib sheets, according to some recent academic research. By using them,

teachers-with administrative blessing-telegraph to students beforehand the precise areas to which a test will concentrate, and sometimes give away a few exact

questions and answers. ...

Putka G. The Wall Street Journal. November 2, 1989.

“COMITTOLOGY”

(Pediatrics.

1 989;84:A1

18)

The European Commission that coined that word to describe its policy of

leaving decisions to the appropriate committees evidently forgot the definition

of a committee: A group of the inept, chosen from the unwilling, by the

incompetent, to do the impossible.

(11)

1990;85;824

Pediatrics

Charles N. Oberg

Medically Uninsured Children in the United States: A Challenge to Public Policy

Services

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http://pediatrics.aappublications.org/content/85/5/824

including high resolution figures, can be found at:

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entirety can be found online at:

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(12)

1990;85;824

Pediatrics

Charles N. Oberg

Medically Uninsured Children in the United States: A Challenge to Public Policy

http://pediatrics.aappublications.org/content/85/5/824

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

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