WASHINGTON, D.C.--Passage of a law last year that expands health insurance for children by $24 billion offers an unprecedented opportunity to improve children's health, but Congress and the federal government must take immediate steps to ensure that states are held accountable for meeting the goals of the new programs, according to two new reports from a committee of the Institute of Medicine. Congress must devote adequate funding to track the effectiveness of the state programs, and federal and state officials must develop new tools to monitor the programs' impact on access to care, use of medical services, and health outcomes and status.
America's Children: Health Insurance and Access to Care examines the relationship between children's health and access to care; a companion report, Systems of Accountability: Implementing Children's Health Insurance Programs, makes recommendations for state and federal officials who are implementing the new and expanded insurance plans.
"This historic new commitment to children's health holds the promise of improving the lives of millions of children," said committee chair Molly Joel Coye, director, West Coast office, The Lewin Group, San Francisco. "As the federal government, the states, and the private sector work to implement the new programs, it is critical that we learn what works and what doesn't. If we do not have reliable, consistent ways of collecting information, we will never know--and we will miss a critical opportunity to improve accountability in health care. The time for action is now, while these new plans are being established."
The five-year insurance expansion was passed as part of the Balanced Budget Act of 1997. It allocates $20.3 billion for states to use in expanding private insurance for children and another $3.6 billion to improve coverage under Medicaid. While the states have been given great latitude under the act, they must apply for federal funds through the U.S. Department of Health and Human Services (HHS), which approves and funds each state's plan.
While the committee supported the versatility under the act, it is concerned about how to evaluate the results. Performance measures should be established by HHS to provide comparable information for all approaches used to implement the programs, and a new national survey is needed to track these measures, the committee said. Moreover, the agency should develop systems to improve the availability of information on the national and state levels about how many children are covered by insurance, their use of health care services, and the status of their health. Presently, these data are not available for most states.
11 Million Uninsured
More than 11 million children, or one in seven, are estimated to be uninsured in the United States. Most are in families with working parents who have jobs that do not provide insurance and who cannot afford to buy it on their own. Nationally, one out of six African-American children and one out of four Hispanic children is uninsured, compared with one in 10 white children.
The problem has been exacerbated in the last decade by changes in the benefits that employers provide for their workers. The percentage of children who are covered by employer-based insurance has declined in the past decade; this decline has been partially offset by an increase in the number of children enrolled in Medicaid, which now reaches a quarter of all children in the United States.
The committee's examination of the relationship between insurance coverage and health revealed that uninsured children are more likely to be sick as newborns, less likely to be immunized as preschoolers, and less likely to receive medical treatment for injuries or for illnesses such as acute or recurrent ear infections, asthma, and tooth decay. Untreated illnesses and injuries can have lifelong consequences. Untreated ear infections, for example, can lead to hearing loss or deafness. Language or other developmental delays resulting from untreated neurological problems can inhibit normal development and social interactions.
Uninsured and underinsured children presently receive a patchwork of care from "safety-net" providers at hospitals, clinics, public health departments, community and school-based health centers, and individual practitioners. In the wake of shrinking government support and pressures brought by the market's transition to managed care, these safety-net providers face increasing financial challenges. Safety-net providers are taking a variety of steps to adapt to the competitive health care marketplace, but this is a period of major transition and uncertainty.
Guarding Against Underenrollment
Expanding access to insurance alone is not likely to eliminate all of the barriers that keep some children from getting appropriate health care services, the committee said. Even insured children must rely on their parents to identify problems and seek treatment. Parents whose families are insured may delay getting care because of out-of-pocket expenses, the difficulty of scheduling appointments, cultural differences with providers, or a lack of easily accessible care. For this reason, states may also need to provide assistance with child care and transportation, culturally appropriate services, and better use of information technology to improve access and utilization of service.
Presently, more than 3 million children who are eligible for Medicaid are not enrolled. Such underenrollment also will be a problem with the new state plans, unless states improve outreach to eligible families, simplify procedures for determining eligibility, or provide new programs to insure children. All state efforts should be designed to achieve the highest possible enrollment, the committee said. States should coordinate their initiatives with other state and private programs to maximize children's opportunities to receive access to care. States also must provide adequate reimbursement rates to maintain and improve provider participation, and quality standards must be enforced for all providers.
A committee roster follows. The study was funded by the Robert Wood Johnson Foundation. The Institute of Medicine is a private, non-profit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences.
Pre-publication copies of America's Children: Health Insurance and Access to Care are available from the National Academy Press at the mailing address in the letterhead; tel. (202) 334-3313 or 1-800-624-6242. The cost of the report is $45.00 (prepaid) plus shipping charges of $4.00 for the first copy and $.50 for each additional copy.
Pre-publication copies of Systems of Accountability: Implementing Children's Health Insurance Programs are available free from the IOM's Division of Health Care Services; tel. (202) 334-2184.
Reporters may obtain a copy of both reports from the Office of News and Public Information at the letterhead address (contacts listed above).