Two worlds, two futures

The hidden competition for U.S. health-care resources

Anita Kunz


In the early 1960s, more than one in three draftees failed the physical and mental exams required to enter military service. An investigation ordered by President John F. Kennedy revealed that many had conditions that could have been prevented or treated during childhood — tuberculosis, rheumatic heart disease and psychiatric disorders, for example. Children’s access to health care had become an issue of national security, and Congress acted decisively. In 1967 it authorized an expansion of Medicaid to require the screening and treatment of a variety of illnesses and developmental problems in eligible low-income children.

Fast-forward nearly 40 years. More than 25 million children — nearly one-third the nation’s total — are covered by Medicaid. While tremendous strides have been made in improving kids’ health, experts across the nation are warning that the pendulum is slowing and even reversing in several key areas. Infant mortality and prematurity rates are increasing and more children than ever before live with chronic diseases such as asthma, obesity and diabetes. At the same time, the budgetary gun is now taking aim at children’s health care, threatening to further reinforce a shameful status quo that effectively doles out medical services based on the size of a family’s pocketbook and the color of their skin.

It might seem ironic that our nation’s most comprehensive system of health care for children is rooted in wartime. But the fact that it took a dearth of young, able-bodied soldiers to spark positive change highlights the tug-of-war between older adults and children that has colored health-care policies for the past century — from the passage of child labor laws in the early 1900s to the inception of Social Security in 1935 and passage of the Medicare and Medicaid bills in 1965.

When push comes to shove in the hallways of Congress, it seems that the walking, talking and voting grandparents are winning. The Deficit Reduction Act, passed by the House of Representatives on Feb. 1, aims to save $16 billion over the next 10 years by increasing Medicaid co-payments and premiums while reducing benefits — a move that some experts speculate will reduce or eliminate coverage for millions of children — at the same time the new Medicare Prescription Drug plan for seniors, with an estimated 10-year cost of about $700 billion, is kicking into gear.

“There is a profound and startling inattention to the special health-care needs of kids throughout the country and across all political spectrums,” says Stanford and Lucile Packard Children’s Hospital’s health policy expert Paul Wise, MD, MPH. “Policies meant to protect children aren’t just ‘not holding their own.’ They’re not just ‘out of date’ — as some say. They are actually unraveling.”

Nine million — or about 12 percent — of U.S. children, primarily low-income minorities, lack health insurance. Another 3 to 4 million are underinsured by policies with high deductibles or limited coverage. Many families also struggle with additional barriers to health-care access: unreliable transportation, too few doctors or dentists in their neighborhoods or work schedules that conflict with medical office hours.

It’s apparent that the already fragile tissue of health-care access for kids is fraying. Tug gently on any one of several interwoven strands — race, income, geography or politics — and you’ll get a handful of statistics that might change the way you think about America’s reputation as the land of equal opportunity. The infant mortality rate for African-Americans is twice that of whites, for example, and minority children are far more likely to undergo traumatic injury or die.

Anita Kunz

Few people would argue that such disparities are acceptable. But, like stopping the Titanic, reversing the course of a health-care delivery system that many believe is fatally flawed isn’t going to be easy. And whose job is it to fix, anyway?

“We all need to accept responsibility for children’s health,” says U.S. Surgeon General and Vice Admiral Richard H. Carmona, MD, MPH, who designated 2005 the Year of the Healthy Child. “The situation is pretty good across the board; for example, four out of five kids get fully immunized. But we can’t become complacent. There are still several areas where we can make a difference.”

The surgeon general’s office partnered with advocacy groups, parents and schools, as well as the public and private sector, to focus on ways to prevent common causes of injury and sickness in children: improving prenatal care for pregnant women, increasing immunization rates, reducing childhood obesity and preventing traumatic injuries and child abuse.

Individual pediatricians and philanthropic organizations are also realizing the importance of rolling up their sleeves to deliver care to all kids wherever they are. Many believe that these outreach efforts have to be coupled not only with legislative change but also with a transformation of how most people think about kids and their health.

“If we as a society are committed to the health and well-being of children,” says Packard’s chief of staff Harvey Cohen, MD, PhD, “it wouldn’t cost that much to deliver preventive care to children. It comes down to the will and the desire to help these kids.”

So, do we have it?

It’s the economy, stupid (or is it?)

To many, access to health care is all about health insurance, which is all about money. In some ways they’re right. Thirteen million American children live in poverty — many of them minorities — and the number is increasing steadily. Not surprisingly, these kids are significantly more likely to be uninsured than are kids in higher income brackets. They are also five times more likely to have an unmet medical need and are more likely to be hospitalized for a condition that could have originally been treated through a simple doctor visit.

Even middle-income families struggle to pay the now-skyrocketing costs of private or employer-sponsored health insurance. The number of children covered by these types of plans has decreased dramatically during the past several years, while the number of children on Medicaid or the federally subsidized State Children’s Health Insurance Program (implemented in 1997 to cover uninsured kids who don’t qualify for Medicaid) has increased correspondingly.

Although together the two programs provide coverage to about 30 million children, ongoing re-enrollment requirements coupled with income restrictions that can render a child eligible one month but ineligible the next have discouraged millions more qualifying families. In 2004 about one in five Hispanic or Latino children were uninsured, compared with about one in 15 white children.

“Health insurance is being priced out of reach for people who are just getting by, such as many families with small children,” says Stanford professor of medicine Alan Garber, MD, PhD, director of Stanford’s Center for Health Policy. “But it can be difficult to find out about the public programs and sign up, and coverage varies across states.”

Providing coverage to these kids is only one part of the solution, though, says pediatrician and child advocate Irwin Redlener, MD. Redlener and singer/songwriter Paul Simon founded the Children’s Health Fund in 1987 to provide comprehensive health care to medically underserved children, first in New York, and then across the nation.

“Many politicians seem to think that if children have an insurance card and can get to an emergency room, they have full access to health care. But there’s much more to it,” says Redlener, who points out that 4 million, mostly rural, U.S. children lack reliable transportation to get to and from doctor appointments. In addition, about 45 million Americans live in health-professional shortage areas, or HPSAs — a federal designation awarded to areas with fewer than one primary care physician for every 3,500 people. Communities with a shortage of dentists, nurses and mental health professionals can also qualify.

“For these families, insurance is not even an issue,” says Redlener. “If they have to travel 20 miles to bring a child with a severe ear infection to a doctor, that’s a really big problem.” The Children’s Health Fund supports more than 30 mobile medical units, including Packard Children’s Hospital’s Teen Health Van, in 20 sites around the country, which bring the care and the caregivers directly to the kids who need it most.

These vans serve as stand-ins for true “medical homes” — a term coined by pediatricians to describe a situation in which a few familiar places and faces provide all of a child’s health care, from routine checkups to midnight consultations. Physicians and nurses get to know young patients well, delivering preventive medicine and health education, managing acute and chronic illnesses, and coordinating any special services the child needs.

Unfortunately, the vans roll away at the end of the day, often not to return for a week or more. Redlener believes a better solution would be to increase the numbers of federally funded community health centers in HPSA communities and expand the National Health Service Corps — a federal program that offers educational loan repayment and scholarships to primary care physicians, nurse-midwives, dentists and mental health professionals who agree to practice in underserved areas.

“We’re performing stop-gap duties for a country that has the resources to do much better,” says Redlener. “The challenge is to get elected officials to make these issues a high priority. We need to finish the job of getting all kids insured, and then address these additional barriers to care.”

Many believe that physicians have a responsibility to help make this happen.

“Pediatricians need to be heard at the national level on the importance of universal access to care and to medical homes for children,” says former U.S. Surgeon General David Satcher, MD, PhD, who is now president of the Morehouse School of Medicine. “This is critical since pediatricians are expert, trusted and respected voices in this arena.”

The American Academy of Pediatrics favors automatic, universal health care that covers every child in the country from birth to age 22. Eligibility requirements would be eliminated; parents would pay an income-adjusted premium. Low-income families would pay no premium or out-of-pocket expenses. Don’t hold your breath, though. The MediKids Health Insurance Act has been introduced in Congress unsuccessfully every year for the past five, despite clear evidence that children are less expensive to cover than adults.

“If you added up all the money spent on health care for kids, you’d find that it’s much less than what is being spent on health services for the elderly,” says Wise, the Packard health policy expert. The American Academy of Pediatrics has estimated that 7.5 children could be covered by Medicaid for the cost of a single senior citizen. Children, who account for about one-quarter of our population, use only 10 to 20 percent of our total hospital resources.

“Cost just isn’t the issue, despite the rhetoric that’s generated,” says Wise. “Kids are basically healthy. What’s required is a commitment to elevate the needs of children above those of other special-interest groups.”

What’s in it for the grown-ups?

It’s becoming obvious that, despite lip service from politicians and voters, America’s children often lose out at the polls.

“Society in general has not paid adequate attention to kids,” says Alan Krensky, MD, the Shelagh Galligan Professor at the medical school and executive director of Packard’s recently completed $500 million fundraising campaign. “It’s a chronic clash. Kids don’t vote, and there are fewer parents with young children than there are elderly voters, who have very different priorities.”

Anita Kunz

Priorities such as ensuring access to long-term care and expensive prescription drugs. To many of these older Americans, mentally stacking their dwindling resources against the oncoming years, children must seem impossibly healthy.

“The health-care dollars in this country are more and more being spent on adults, particularly during the last few days of life,” says Krensky. “While this population has important needs, one could argue that we’re being penny wise and pound foolish by directing our resource use in this way.”

But it’s going to be a hard sell to convince the American public they have to choose between their children and their elderly parents. A more compelling reason to focus on children’s health might be strictly economic. Investing in preventive care for children now is far cheaper than paying — in the form of higher health insurance premiums or increased federal spending — to care for the chronically ill adults they may become. Treatment of obesity-related diseases in adults and children, for example, cost more than $100 billion each year, according to the American Academy of Pediatrics.

“Obesity is destroying our children and our culture by robbing them of healthy years of life,” says Surgeon General Carmona. “The cost to us is tremendous.” It’s also not likely to decrease anytime soon. The number of overweight or obese American children has more than doubled during the past 20 years to about 9 million, and pediatricians nationwide are struggling to treat diseases that used to affect primarily adults: hypertension, type-2 diabetes and orthopedic problems. Researchers estimate that preventing obesity in one person would save at least $39,000 in future health-care costs.

The annual roster of premature and low-birth-weight infants is also increasing. Nearly 500,000 infants, or about 12 percent of all babies, were born prematurely in 2003 — each racking up medical costs nearly 15 times that of a full-term baby. The March of Dimes estimates that caring for these infants costs more than $15 billion each year. Those who survive can require lifelong care to overcome associated vision, movement, learning and breathing difficulties. Although the causes of prematurity are unclear, timely prenatal visits can tip the balance in favor of healthier, less expensive babies.

Immunizations are also a relative bargain. The American Academy of Pediatrics estimates that every dollar spent to vaccinate children saves over $18 in costs to society.

Although the dollar amounts are compelling, the indirect costs to society are no less important. A nation of chronically ill workers or soldiers is likely to end up at a serious global disadvantage.

“Healthy children become healthy, productive adults who advance who we are as a society,” says Cohen. “Caring for older people has less of an impact on the number of years that can be given to our world.”

A gift of decades isn’t that uncommon any more. Medical advances have conquered many cases of pediatric cancer, congenital defects and other formerly fatal conditions. But unless every child benefits equally, the triumph is bittersweet.

“The central paradox is that at the very moment medical capacity has never been greater, we’re seeing an increasing failure of public policies to provide access to this care,” says Wise. “We can’t just keep throwing clinical improvements out there and expect to reduce disparities in health outcomes. Each new intervention must be accompanied by programs to ensure it’s reaching those kids who need it most.”

“The biggest challenge we have is translating robust cutting-edge science in a culturally competent manner into a package that the average person can take action on,” says Surgeon General Carmona.

This kind of outreach is even more critical for the complex chronic diseases that increasingly affect kids. Conditions like asthma, diabetes, obesity and mental health problems require ongoing management, preferably by a provider who knows the child well. Medical advances have also created populations of medically fragile children that require special, sometimes unique types of lifelong care.

Many pediatricians worry that charging co-payments or premiums for formerly free Medicaid coverage will price many of these children out of needed checkups or treatments.

“A $3 co-pay for one prescription may not sound like a lot, but for children with asthma or diabetes, for example, each prescription adds up quickly,” wrote American Academy of Pediatrics president Eileen Ouellette, MD, JD, in a 2005 statement protesting the then-proposed changes to Medicaid.

In fact, the new law allows states to charge those with incomes between 100 and 150 percent of the poverty level co-payments up to 10 percent of the cost of the medical service; those with higher incomes could pay 20 percent, plus a monthly premium. Although the total amount collected is limited to 5 percent of a family’s income, ample evidence has shown that this type of cost-sharing increases the likelihood that low-income populations will forego needed care and eventually require more expensive medical interventions.

The lowdown

Like a willful toddler, children’s health care in America is a mass of contradictions. Most children are basically healthy, but the numbers of chronically ill and medically fragile children are increasing dramatically — a result of the failure of preventive medicine and the success of medical advances that add years to sick children’s lives. Access to health care hangs by a thread for most kids, threatened by inadequate health insurance, the financial status of their parents, the state or county that they live in and their racial or ethnic group.

Many pediatricians believe that the solution lies in providing universal health care coverage for children, building the number of physicians and clinics in underserved areas, and working to prevent childhood causes of adult disease like obesity and prematurity. They are increasingly going to bat for their young patients. Packard Children’s Hospital was one of the first in the nation to begin teaching pediatric residents how to advocate effectively for children at a local and national level — both within their local communities and in the halls of Congress. Many other medical schools are now following suit.

Their efforts come at a time when budget cuts have compromised health insurance coverage for many of our neediest kids and may even reduce their access to the very screening and treatment services mandated in 1967. Even if these services are spared, deeply ingrained failings in the way children access health care may demand a complete overhaul.

“I feel strongly that our health-care system needs a total fix,” says Satcher. “We need a community health system that balances health promotion, disease prevention, early detection and universal access to health care. Currently we are just moving the chairs around on the deck of the Titanic.”

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