Children's Medicaid Entitlement: What Have We Got to Lose?

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The details provided in the article indicate that the

mothers were primiparous, older (28 to 38 years old),

had prepared themselves for breastfeeding, four of

five had vaginal deliveries, and four of five had

full-term infants (1 was 36 weeks). If one examines Table 2 in the article and assigns a risk score to the

negative points (such as 38 years old, delivered by

caesarean section receiving pain medication, sent

home at 48 hours), one can identify situations that

deserve extra attention. No mention in the case

de-scriptions is made of the percentage of weight loss on

discharge from the hospital or when all the

meco-nium was passed (should have milk stools by day 3),

or the ability of the infant to latch onto the breast or the quality of the breastfeeding at discharge from the

newborn nursery. The information provided does

not prove the relationship between serious

compli-cations and breastfeeding. Other causes of thrombo-sis are not ruled out.

The American Academy of Pediatrics has already

stated that all infants should be seen by their practi-tioner within 7 days of discharge from the hospital as all infants are at risk for complications in the early

weeks regardless of feeding mode. When

complica-tions develop such as cerebral infarction, the feeding mode is not necessarily cause and effect. A

practitio-ner must not become blinded by breastfeeding and

fail to completely assess the picture of an infant

with a problem in the same thorough manner that

the problem would be reviewed if the infant was

bottle-fed.

Early discharge was the single common theme in

the patients described and none of these infants were

seen by a physician. Had the infants been observed

in the hospital another day or two, important

mile-stones could have been checked.1 By the third day, the infant should: . stop losing weight;

. have lost no more than 7% of birth weight;

. be passing milk stools;

. have at least three stools (minimum) a day;

. wet at least six diapers a day (cloth diapers are

preferred for accurate assessment in the first 6

weeks); and

. latch on to breast well. The mother should:

. experience some breast engorgement;

. notice dripping of milk from opposite breast; and

. expect the infant to feed every 3 hours or a

mini-mum of 8 times a day.

In the event of early discharge, the pediatrician

should provide within 3 days of discharge in the

office or in the home a weight check, observation of

the infant for physical status, jaundice, hydration, and successful breastfeeding.

The infant must be assessed by an experienced

practitioner who knows a sick baby when he/she

sees one. Hospital nurseries must instruct patients to contact their practitioner directly when there is

trou-ble and urge them to see their infant’s physician

when they call the nursery with problems.

RUTH A. LAWRENCE, MD

University of Rochester School of Medicine Department of Pediatrics, Box 777 Rochester, NY 14642

REFERENCE

1 Lawrence RA, Breastfeeding: A Guide for the Medical Profession, 4th ed, St. Louis: CV Mosby; 1994

Children’s

Medicaid

Entitlement:

What

Have

We

Got

to Lose?

ABBREVIATIONS. AAP, American Academy of Pediatrics;

EPSDT, Early and Periodic Screening, Diagnosis and Treatment;

HCFA, Health Care Financing Administration.

Medicaid’s efficacy as a safety net for children has

been lost in the heated health policy debates of the

last 2 years. The second year of the last Congress was

dominated by competing proposals that would have

cast aside Medicaid and assured universal coverage

through comprehensive private health insurance

plans. The first year of the current Congress has been

spent debating legislation designed to reduce the

federal government’s role in the provision of health

care services through constrained funding,

regula-tory rollback, and broadened latitude for state

pro-grams dependent on federal dollars, (eg, Medicaid).

Over the past 2 years, taking the position that the

Medicaid program should be exempt from proposed

changes (at least with respect to children) has not

been in vogue. Although defending the status quo

may be de rigueur, policymakers ought to review the

data before the next realignment in health policy

thinking.

Medicaid-Children’s Largest Health Insurer

Over one fourth of U.S. children and adolescents

who have health insurance are covered by Medicaid.

(See Table.) The child Medicaid rolls grew by one

third during the first 4 years of the decade, and if the program is left as it is at the time of this writing, both

the absolute number and the proportion of the child

population covered by Medicaid will continue to

increase substantially.

The erosion in employer-based, private health

in-surance coverage for children is accelerating at an

alarming rate. In 1993 nearly 5% of privately insured

children lost coverage. (See Table.) This is due

pri-manly to the unaffordability of private insurance

premiums, particularly for small firms that

dispro-portionately hire young adults who have children.

The views expressed in this article are solely those of the authors. Proposed

policies and opinions should not be interpreted as those of the American Academy of Pediatrics,

Received for publication Aug 14, 1995; accepted Aug 14, 1995,

Correspondence to: Samuel S. flint, PhD, Associate Executive Director, American Academy of Pediatrics, 141 Northwest Point Blvd. Elk Grove

Village, IL 60007

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968 COMMENTARIES

To contain their escalating costs, the last 10 years

have witnessed companies either dropping

depen-dent coverage outright or requiring workers to pay

most or all of the premium.1 As a result nearly one

fourth of uninsured children have parents with

em-ployer-paid health coverage.2

Coinciding with the loss of private insurance, a

series of Medicaid eligibility expansions targeted to

children and pregnant women were enacted during

the latter half of the 1980s. The new laws broke the

historic tie between Medicaid and welfare by

elimi-nating children’s “categorical” requirements. They

also expanded family income ceilings during a

pe-nod of sharp increases in the number of low-income

families with children.3 Thus, the number of children

eligible for and needing Medicaid coverage rose.

Absent changes in Medicaid law, this trend will

con-tinue unabated for the foreseeable future according to both government and private researchers.4

Medicaid’s Potential to Provide Insurance

Although Medicaid insures more of America’s

children than any other public or private entity, it

could make an even larger dent in the uninsured

child population. According to our analysis of

Cur-rent Population Survey data, an additional 2.6

mil-lion low-income children (22% of the uninsured child

population) are eligible for Medicaid now. It is

un-clear why there is such poor beneficiary participa-tion. Unawareness of eligibility, aversion to the com-plicated application process, or resistance to accept a

means-tested program due to its welfare stigma are

three hypotheses. In addition to eligible nonpartici-pants, another 1.6 million poor 12- to 18-year-olds

will become eligible over the next 6 years during a

gradual phase-in.

Also, states can use federal Medicaid funds (which

average three fifths of total program costs) to make

children eligible who reside in families with incomes

substantially above the poverty line. Minnesota,

Vermont, Connecticut, New Mexico, New

Hamp-shire, and Michigan are already doing so to varying

degrees. If all states chose to maximize eligibility for

children, another 4 million uninsured children could

gain financial access to the health care system. Our data indicate that Medicaid has the potential

to insure 25 million of the 30 million children not

covered by private health insurance. If the political

constituencies were there to optimize Medicaid,

95% of children and adolescents could have health

insurance.

Nonfinancial Access Issues

Even if all the expanded eligibility standards were

adopted, the Medicaid program would still have its

well-known problems: complex beneficiary

enroll-ment procedures, poor provider participation, and

wide variability in benefits among states. However, even these nettlesome access barriers can be amelio-rated through existing legislation.

The Medicaid enrollment process, which often

dis-courages families from applying, has been improved

by several states through newly permitted outreach

strategies, such as presumptive, expedited, and

TABLE. Healt

cents Through A

h Insurance Status of

ge 21 in Millions (Wit US h P Children ercentage and Adoles-of Group)

1990 1991 1992 1993

Private 54.0 53.0 52.4 49.9

Insurance (68.1%) (66.5%) (65.2%) (62.4%)

Medicaid 13.4 15.1

(16.9%) (18.9%)

16.1 (20.1%)

17.8 (22.3%)

Uninsured 1 1 .9 1 1 .7

(15.0%) (14.6%)

1 1 .8

(14.7%)

12.2

(15.3%)

Source: AAP Department of Research analysis of March 1991-1994 Current Population Surveys.

mail-in eligibility. These procedures simplify and

streamline the application process and encourage

beneficiary participation.

Low provider participation resulting from

made-quate Medicaid reimbursement, slow Medicaid

claims processing, and burdensome paperwork

re-quirements are well-documented . However, since

1990 states have been required to either increase

reimbursement to market rates for pediatric and

ob-stetrical care or demonstrate sufficient provider

par-ticipation to assure adequate delivery of services to

children and pregnant women. This legislation has

been the basis for legal action initiated by

pediatri-cians, often in concert with other child advocates, in

a number of states, eg, Pennsylvania, North Carolina,

Illinois, New Jersey, and Arkansas. Because states

recognize that they must comply with federal law to

receive federal Medicaid matching funds, these suits

have all been settled favorably pretrial. A recent AAP report6 has detected the first increase in pediatrician

participation in Medicaid since the late 1970s when

the AAP began tracking this issue. We believe this is

attributable at least in part to the federal scrutiny of reimbursement rates.

Children’s Medicaid benefits are also buttressed

by unique protections. Regulations promulgated to

enforce amendments enacted in 1989 to the Early and

Periodic Screening, Diagnosis and Treatment

(EPSDT) program require states to provide all

“med-ically necessary” services needed to treat medical

problems diagnosed during an EPSDT screening,

even if these services are not covered as part of the

state’s federally approved scope of benefits. These

regulations also mandate states to include: 1) the

participation of partial screening providers; 2)

coy-erage for interperiodic screening; and 3) screening at

least 80% of eligible children by this year. Clearly, all these standards have not and are not likely to ever be achieved fully throughout the states. Nonetheless,

the current entitlement law provides advocates with

the tools to address nearly all access issues and craft

a solid program.

Block Grant or Chopping Block

Congress is now debating enactment of state block

grants to replace Medicaid’s entitlement status.

Un-restricted block grants (ie, federal funds to be used at state discretion with no regulatory requirements)

would allow for the dismantling of the Medicaid

program’s funding, eligibility, and benefits package.

We may have a glimpse into the dicey future for

low-income children that could occur under

at Viet Nam:AAP Sponsored on September 1, 2020 www.aappublications.org/news

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stricted block grants if we observe current

demon-stration projects allowed under the Health Care

Fi-nancing Administration’s (HCFA’s) “waiver”

process.

In an effort to expand health care coverage to

vulnerable populations, HCFA has permitted states

to adopt new standards that waive federal eligibility

and benefits standards through a complex approval

process. If Medicaid waivers are the precursor to

block grants, some predictions can be made. First,

states with waivers no longer need to limit their

eligibility expansions to children in order to receive

additional federal Medicaid funds. Under the

waiv-ers granted to Tennessee, Oregon, and elsewhere,

states are drawing federal dollars to cover poor

adults rather than near-poor children. Considering the fact that children cannot vote, the substitution risk is real.

Second, children’s unique benefits protections

rooted in the EPSDT regulation would be lost,

per-haps through an Oregon-type rationing system.

Fi-nally, provider morale has been damaged severely in

waivered states (eg, Tennessee) due to mandatory

patient service requirements and low reimbursement

rates. The special protections afforded pediatric and

obstetrical care are universally ignored in waivered state programs.

The Extent of the Risk

Congress has proposed reducing federal Medicaid

funding over the next 7 years by $182 billion from

what it is projected to be if the program is left intact. This “reduction in program growth” is characterized

by some as a modest contribution to deficit

reduc-tion. We are far less sanguine.

The block grants under discussion, unlike those

enacted in 1981, require no state match. We agree

with most observers who expect states to continue to

support Medicaid at their current levels in the

near-term. However, half of the total reduction to take

place over 7 years will occur during the sixth and

seventh years.4 Thus, the sacrifice required by these budget proposals will not be a one-time adjustment;

the federal underfunding will accelerate. As the

trends cited earlier increase children’s dependence on Medicaid, we fear there will not be the political

will to meet children’s needs at the state level to

offset flagging federal support.

Further, the health insurance status analysis above implies a static population to simplify the presenta-tion, but the situation is dynamic and therefore more

critical. While the number of uninsured children at

any given point in time has remained approximately

12 million (with an ominous uptick for the most

recent year), this is only part of the story. Children,

like adults, flow in and out of private and public

insurance plans. Employing one respected

algo-rithm,7 the number of children uninsured for at least

1 month during the year is roughly 19 million.

Mil-lions of children counted as insured by private plans today are likely to be on Medicaid and/or uninsured at some point. Over one third of all US births are now

Medicaid paid.4 Arguably half of US children and

adolescents may need Medicaid at some time during

their childhood.

Alternatives

Handing a crushing public debt to the next

gener-ation is unambiguously anti-child. Thus, child

advo-cates should only debate how to bring the federal

budget in balance, not if it is necessary. But, due to the relatively low cost for their care, millions of

chil-dren would have to lose Medicaid to reduce the

federal budget deficit significantly.

Children (under age 21) comprise 57% of the

Med-icaid program population, but account for just 23%

of program expenditures.8 Therefore, even modest

budget cuts translate into large numbers of children

losing coverage. Using fiscal year 1993 costs, each

billion dollar reduction in federal Medicaid

appro-priations eliminates the federal Medicaid share for

over 1 .5 million children. As our data demonstrate,

employer-based private insurance coverage for

chil-dren continues to shrink. A reduction in federal

Medicaid support of the magnitude under discussion

would lead to a dismal scenario: millions of children with no safety net.

Humanitarian concerns and fiscal common sense

point to cost-containment strategies other than

tam-pering with children’s Medicaid entitlement.

How-ever, the financing of some high-cost Medicaid

ser-vices could be restructured. A rollback in the Boren

amendment (which requires full cost reimbursement

for hospital care), or alternative payment

mecha-nisms for nursing home services, could yield savings

without forcing large numbers of beneficiaries from

the program or compromising their access too

severely.

An alternative avenue to ease Medicaid cost

pres-sures is to fashion policies that reduce the need for

Medicaid rather than excluding beneficiaries from

coverage when they need it. Requiring private

insur-ers to pay for preexisting conditions, prohibiting

“cherry-picking” strategies, such as occupational

redlining, and allowing for insurance portability are

legislative options that should be pursued.

Finally, we believe it is in the country’s best

inter-est to reexamine the proposed 7 year tax cut of $245

billion, considering each billion dollars provides

fed-eral funds for over a million children for an entire

year. Balancing the budget is intended to make our

nation stronger; it is contradictory to disinvest in our children’s health.

SAMUEL S. FLINT PhD

BETH K. YUDKOWSKY, MPH

SUK-FONG S. TANG, BA

American Academy of Pediatrics

Elk Grove Village, IL 60007

REFERENCES

1. Congressional Research Service. Health Insurance and the U;,ins:red:

Background Data and Analysis. Washington, DC: US Government Print-ing Office; 1988

2. Employee Benefit Research Institute. Sources of Health Insurance and Characteristics of the Uninsirt’d-Analysis of the Marc/i 1993 Current Poii-lation Surz’ei. EBRI Issue Brief #145, SR-20. Washington, DC: Employee Benefit Research Institute; January 1994

(4)

970 COMMENTARIES

Public Health. Young Children in Poverty: A Statistical Update. Neu’s and Issues. Winter/Spring 1995;5:1-2

4. Holahan J, Liska D. The Impact of the House and Senate Budget Committees’ Proposals on Medicaid Expenditures. Washington, DC: Kaiser Commission on the Future of Medicaid; May 1995

5. Yudkowsky BK, Cartland JD, Flint 55. Pediatrician participation in Medicaid: 1978 to 1989. Pediatrics. 1990;85:567-577

6. American Academy of Pediatrics. Pediatrician Participation in Medicaid: A

1993 Survey ofAAP Members. Elk Grove Village, IL: American Academy

of Pediatrics; 1994

7. Swartz K. Dynamics of people without health insurance-don’t let the numbers fool you. JAMA. 1994;271:64-66

8. American Academy of Pediatrics. Medicaid State Reports: FT 1993. Elk Grove Village, IL: American Academy of Pediatrics; 1995

New

Developments

With

Pertussis

Vaccines

ABBREVIATIONS. NIH, National Institutes of Health; DTaP,

multiple acellular pertussis vaccines combined with tetanus and

diphtheria toxoids; DTP, diphtheria, tetanus, and pertussis vaccine; FDA, Food and Drug Administration; AAP, American Academy of Pediatrics.

Extensive efforts on the part of the National

Insti-tutes of Health (NIH), vaccine manufacturers, and

other investigators in the United States and Europe

have generated important new information

regard-ing the efficacy of several acellular and whole-cell pertussis vaccines administered to infants. Multiple

acellular pertussis vaccines combined with tetanus,

and diphtheria toxoids (DTaP) have been tested in

European trials and compared with whole-cell

diph-theria, tetanus, and pertussis (DTP) preparations.

The results of most trials have been released to the

press and formal manuscripts will be published in

scientific journals within the next few weeks.1’3 The

data from these studies indicate variable efficacy of

both acellular and whole-cell pertussis vaccines,

re-flecting differences in manufacturing processes and

the number and type of vaccine components in the

new acellular vaccines. In addition, these studies

further confirm the safety of acellular vaccines.

The two acellular products currently available in

the United States for use at 15 months of age and

older for the fourth and fifth doses were not

evalu-ated in the trials in Sweden and Italy that were

reported in the recent NIH press release. The results

of infant studies with these vaccines in Germany

should become available in the near future.

One study of a monocomponent acellular pertussis

vaccine administered at 3, 5, and 12 months of age to

Swedish infants revealed an efficacy of 71%#{149}3No

comparison was conducted with whole-cell pertussis

vaccine in this trial. In other studies conducted in

Sweden and Italy, acellular products administered in

Received for publication Aug 31, 1995; accepted Sep 4, 1995.

Reprints are not available. Address correspondence to: (N.A.H.) Depart-ments of International Health and Pediatrics, Johns Hopkins University, 615 North Wolfe St. Baltimore, MD 21205.

Acad-emy of Pediatrics.

the schedule used in the United States for primary

immunization with whole-cell vaccines (2, 4, and 6

months of age) resulted in vaccine efficacy of 58% for

one acellular vaccine and 84% to 85% for three other

acellular vaccines.1’2 These vaccine preparations con-tamed different antigen concentrations.

The only whole-cell product tested in these trials that

was produced in the United States had an efficacy of

36%

in

Italy and 48% in Sweden for children who were

followed up until approximately 28 months of age.

These results underestimate the likely efficacy of the whole-cell vaccines given in the United States. In the

European trials, no booster doses were administered at

12 to 18 months of age as is the recommendation in the United States. The efficacy of the whole-cell product

was 85% when evaluated shortly after completion of

the three-dose series in children at 6 to 9 months of age and was comparable to that of the acellular vaccines. However, the efficacy of the whole-cell vaccine waned faster than that of the acellular products so that by 28

months of age the efficacy was 48%. In the United

States, where booster doses are recommended at 12 to

18 months of age, the efficacy of this whole-cell product

is

undoubtedly higher than the overall efficacy

ob-served in the European studies in which no booster

dose was administered. The effectiveness of the whole-cell vaccines is reflected in the greater than 90% reduc-tion in the incidence of pertussis in the United States

associated with the widespread use of whole-cell

vac-cines.4

The results of the NIH-sponsored trials confirmed the previously reported lower rates of fever and local adverse reactions associated with acellular pertussis

vaccines as compared with whole cell vaccine. There

is insufficient data regarding differences in rates of

the rarer complications following use of acellular or

whole cell vaccine preparations.

Differences in immunogenicity of whole-cell

vac-cines have been observed in several studies. For

ex-ample the whole-cell vaccine used in Sweden and

Italy was significantly less immunogenic than

an-other whole-cell product used in the United States.5’6

The differences in whole-cell preparations are

fur-ther emphasized by the very high efficacy associated

with a German-produced whole-cell DTP that had

96% protective efficacy in a recent trial.7 Therefore, we should not generalize the results from the whole-cell vaccine evaluated in these trials to all whole-cell

vaccines. Similarly, we cannot generalize about all

acellular vaccines. Differences in these products need to be carefully reviewed and taken into consideration

when formulating any changes in immunization

recommendations for children.

What do the data from the recent European studies

mean for providers of health care to children? In

addition to emphasizing the importance of timely

immunization against pertussis beginning at 2

months of age, one or more of the acellular vaccines

will be approved by the Food and Drug

Administra-tion

(FDA) for administration to infants in the United

States. The FDA is committed to expediting the

re-view of these efficacious and safe vaccines. The

American Academy of Pediatrics (AAP) Committee

on

Infectious Disease will be carefully reviewing the

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1995;96;967

Pediatrics

Samuel S. Flint, Beth K. Yudkowsky and Suk-fong S. Tang