1. National: Seriously, What Is a Child?
An intriguing question to which I have sought the answer ever since coming to these shores is what Americans think of children. Do they view children as the human analogues of pets? Or do they view them, as do most Europeans and Asians, as precious national treasures? Perhaps a mixture of both?
This is not meant to be a frivolous question. Its answer informs the nation's health policy. If one views children primarily as the human analogue of their owners' (i.e., the parents') pets, then it follows that children's health care is primarily the parents' financial responsibility, although one might extend public subsidies to very poor parents to help them care for their children adequately. On this view it is just and proper that, of two households with identical incomes, the one with children will have substantially less discretionary income after necessities than does the childless household.
On the other hand, if one views children as national treasures--and the nation's economic future--then it makes sense to make the health care of children the financial responsibility of society as a whole, just as is the financing of public elementary and secondary education. Why treat children's education as a social good, but their health care as a private consumption good?
I developed renewed interest in this question after observing the torturous debate in Congress during the last two years over CHIP, the Children's Health Insurance Program. The debate was over how high up the income scale the public subsidies inherent in Chip should be extended to American families.
At the time, about nine million American children remained uninsured, most of them in low-income or poor households. Of these, however, close to seven million children actually were entitled to CHIP, but not enrolled. Parental ignorance about this program and the often vexing bureaucratic hurdles that must be scaled to enter CHIP have been the main barriers of entry. Worse still, unlike Canadians, Europeans, Taiwanese and Japanese, Americans seem to impute different social values to the health care of children, depending on their socioeconomic status, even if they have health insurance. In New Jersey, for example, Medicaid pays a pediatrician about $30 or so for a pediatric office visit. The comparable fee for commercially insured children is somewhere between $100 to $120 a visit.
Evidently, through their legislative representatives the good burghers of New Jersey tell pediatricians that their professional work has only about a third or a quarter of the social value that New Jersey citizens impute to an office visit by a child from a middle- or upper-income family. This differential valuation is uncommon in other industrialized nations, where physicians typically are paid the same fee for a given service, regardless of the patient's socioeconomic status.
Physicians in New Jersey, and in analogous situations in other states, have perceived this differential-value signal only too clearly. So informed by the citizenry, many of them refuse to treat children on Medicaid altogether. Blame not the physicians, however. The Hippocratic Oath does not mandate ignoring such powerful economic signals. If Americans want to blame anyone for this circumstance, they'll find the culprit in the mirror.
As an American who grew up in Europe and lived for years in Canada, I still have the habit of regarding children as national treasures. In that frame of mind, I recommend to the president and to Congress an alternative approach to health insurance for children. Just as merely being born on American soil entitles even the child of illegal immigrants to American citizenship and with it a whole battery of publicly financed services--notably elementary and secondary education--so should any child in this country be entitled to tax-financed public health insurance until age 22. Parents who wish to opt out of this public program would receive a risk-adjusted, actuarially equivalent voucher to procure at least equally good coverage from a private insurer. But coverage of children would be mandatory.
The purchasing function under this public program, that is organizing and managing care, could be delegated to private for-profit or nonprofit insurers, as in Medicaid Managed Care. Private insurers would then compete over the quality of their disease-management programs, not through judicious risk selection. Finally, the fees paid providers under the public program would be set equal to the average of fees paid by the largest two or three private insurers in the state, lest the professional work of physicians caring for poor children continue to be relatively undervalued.
Gone would be the presence of uninsured children in our midst. Gone would be the haggling over how high up the income scale CHIP eligibility should go. Gone would be the relative undervaluation of professional work for poor children. School-based programs for primary health care, staffed by local, self-employed physicians and nurses under contract, would be financially feasible. And American health-services researchers would no longer have to blush over this country's spotty health insurance for children when attending health-care conferences abroad.
We have about 3.3 working-age Americans per elderly American in this country now. According to the Social Security Trustees, that ratio will decline to close to about 2 by the 2030. In light of this trend alone, can anyone doubt that children really are precious? We should give medals to parents who have them, not penalize them financially. [Uwe Reinhardt, The New York Times, 04/24/09]
2. Iowa: All Kids Should Get Health Insurance
How can anyone justify denying children health care? Whether their parents brought them to this country illegally--or whether they are legal immigrants who fall short of the required five years to qualify for government health-insurance benefits--health care should be a basic right for all children. It's a moral obligation. It also would provide public-health benefits for everyone, such as reducing chances classmates will get sick from a student who has not been treated for strep throat or another contagious illness.
Some states, including Illinois, already have changed state law to do this. Iowa should join them. State Sen. Jack Hatch has introduced proposals to cover immigrant children and make other changes to strengthen the health-care infrastructure, but it is most urgent to pass the initiatives that look out for kids.
Senate File 48 includes guaranteed funding for covering all children eligible for Medicaid, Medicaid expansion and Hawk-I--programs serving lower-income families--by Dec. 31, 2009. And it calls for the state to give all remaining uninsured children under age 19 subsidized coverage on a sliding scale based on family income "as funding becomes available." "This is about children," said Hatch, a Des Moines Democrat who chairs the Senate Health and Human Services Budget Committee. "This is not about people jumping a fence and coming over here illegally. We don't want to make children pay for the crimes of their parents."
The state would have to pick up the entire cost of coverage for undocumented children. Hatch said he does not know what that cost would be, but a letter he shared from Leighton Ku, director of the Center for Health Policy Research at George Washington University Medical Center, estimates at 2,600 the number of uninsured noncitizen children in Iowa with family incomes under 300 percent of the poverty line. Some of them may have legal status.
Based on his experience, Ku said, perhaps a third of those children would participate if eligible for public insurance. Congress is considering legislation to let states restore health-insurance benefits to legal immigrants who are pregnant or under age 21, eliminating the five-year wait put in place in 1996. The U.S. Senate passed a bill Thursday that would make that change as part of a broader expansion of government-sponsored health insurance to 4 million additional uninsured children, not just legal immigrants. The House already passed similar legislation. If the legislation is signed into law, as expected, Iowa would get federal dollars to help with this expense.
Hatch said last year it would cost an estimated $20 million to $25 million annually to cover all uninsured Iowa children, but federal assistance with legal immigrant children excluded now would reduce that amount somewhat.
Gov. Chet Culver's proposed 2010 budget released Wednesday does not include new money for insuring more children, Hatch said. The $10 million that had been slated by the 2008 Legislature was de-appropriated, he said. But Hatch is committed to coverage for all currently eligible children, even if Congress does not come through. "The Democratic caucus just today reaffirmed its total commitment to funding children's health care," Hatch said Wednesday.
Hatch also said he thinks Iowa can find funding for legal immigrant children now prevented from receiving benefits for five years. As for funding to take care of undocumented children this year, given the economic crisis, "That is an unknown right now. I will be pushing it." The budget should be trimmed elsewhere to offset the costs.
In Illinois, the All Kids program ensures health-care coverage for all children who don't have it otherwise, including undocumented children. Concern about protecting U.S.-born children from illnesses and the use of expensive emergency rooms for nonemergencies helped build support, said Joshua Hoyt, executive director of the Illinois Coalition for Immigrant and Refugee Rights. "If it's about kids...we feel like they ought to get a decent shot. The decisions of the parents are not a reason to treat the kids badly," Hoyt said.
It will take a lot of political courage for Iowa legislators to make sure all children have health-care coverage. The Latino vote is not as significant as it is in Illinois, and the anti-illegal immigrant backlash is probably stronger. Still, it's the right thing to do. [Iowa Register Editorial, 01/31/09]
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