AMA Journal of Ethics^®

In 1997, Congress enacted the State Children's Health Insurance Plan (SCHIP), committing $40 billion dollars over 10 years to protect more than 10 million children who were uninsured and not eligible for Medicaid.¹ Today, most American children without private health coverage are enrolled either in SCHIP or Medicaid. Approximately 23.9 million children—nearly 1 in 4—are covered under Medicaid and another 5.4 million children are enrolled in SCHIP.^2,3 Clearly, Medicaid and SCHIP have improved child health by providing the coverage needed to effectively promote regular care; data support claims that children covered by one of these programs are more likely than uninsured children both to access the care to which they are entitled and to seek out preventive care, possibly preventing more costly medical procedures down the line.^4,5 Children enrolled in Medicaid are 4 times more likely to access a regular source of care than unenrolled, Medicaid-eligible children.⁴ If free or reduced-cost pediatric services are available, uninsured families are still less likely to use them than families whose children are enrolled in Medicaid or SCHIP. Even uninsured children who attend urban public schools with free in-school primary care clinics use those services less frequently and are also more likely to visit an emergency room than peers enrolled in SCHIP.⁵ What is unclear, however, is whether and how these programs can be more effective in reaching those who are eligible but not enrolled. Although SCHIP enrollment has nearly doubled since the program began, there are still 7 million children eligible for federal health coverage but not enrolled—4.7 million for Medicaid and 2.3 million for SCHIP.⁶ Further, data provided by the Centers for Medicare and Medicaid Services (CMS), the most accurate count of enrollees, only indicates whether a child was enrolled at some point during the year, potentially missing large populations of transient children who aren't consistently covered over the entire year.³

What research does exist discusses only general barriers to enrollment. A report by the Urban Institute shows that large proportions of Medicare and SCHIP applications are denied for largely procedural reasons.⁷ However, the report doesn't describe the demographics of the 7 million eligible for federal health coverage but unenrolled, nor does it offer any commentary about the possible needs of those who are not covered. Reforming these programs to capture more eligible children may be difficult without clearer research on who is being left out. Two studies (with very limited data sets) do exist suggesting that Medicaid and SCHIP are leaving out a disproportionate high number of Hispanic children (a group with historically significant disease burden) without a regular source of care or recent insurance.^8,9 That data also hint that those likely to enroll in federal health insurance are those who have been previously insured and likely to be receiving medical care already. Additionally, while there is evidence that increasing children's health coverage leads to better health outcomes, little data exist on how many enrollees actually take advantage of their coverage (ie, utilize primary care personnel). The General Accounting Office (GAO) notes that states have very poor monitoring systems to determine who is accessing care and how often.¹⁰ Children enrolled at some point, while healthier than unenrolled children, could still be using the system more effectively. Thus, the problem is identifying who is without coverage and reforming the federal children's health insurance system to increase enrollment. Physicians, in particular pediatricians, can play an important role.

Nearly 80 percent of Americans believe the government should guarantee health care for all children.¹¹ Likely, the percentage of pediatricians, de facto advocates for children's health, who believe in guaranteed coverage for children is even higher. Groups like the American Academy of Pediatrics (AAP) continue to call upon their members to push for more and better care in state and federal legislatures, public policy forums, and the media.¹² Pediatricians have been a driving force behind the creation of SCHIP and efforts to maintain its funding. However, states are reluctant to expand SCHIP coverage to more children because SCHIP suffers from an uneven funding structure. As the law was originally written, funds unspent within 3 years were to be returned and reallocated to states that had spent all their funds and needed more. Funds still unspent after a fourth year would be returned to the US Treasury. To meet congressional budget limits, federal funding was designed to decline from $4.3 billion in 2001 to $3.1 billion in 2002, and then gradually increase to $4.1 billion in 2005.¹³

Budget crises in almost every state have further jeopardized funding for health coverage, pressuring lawmakers to significantly alter the administration of Medicaid and SCHIP dollars which states have broad discretionary authority to administer.¹⁴ There are now strong incentives to trim "fill-in" programs, like California's Children's Health and Disability Prevention Program, a wholly state-funded program that provides health, vision, and dental screenings each year to more than 1 million children, including undocumented immigrants.¹⁵ Additionally, while work is being done to help states keep unspent SCHIP funds, they will be reluctant to expand coverage without the certainty of more federal funding.¹⁶

Because of this increased budget scrutiny, many health policy experts believe the time is ripe for children's health coverage reform, and pediatricians can play a key role in this process. First, as clinicians, pediatricians are in the best position to observe whether children who most need the care are enrolled in federally funded programs. One of the top problems reported by pediatricians is lack of consistent care—children enroll, then drop out.¹⁷ Pediatricians can make sure children whose families can't pay for care know how to enroll in programs for which they may qualify. The AAP has gone so far as to request that pediatricians be placed on SCHIP monitoring and advisory panels involved in developing and reviewing changes, annual reports, and evaluations.¹⁸

Second, those pediatricians who engage in public health research have the prerogative to investigate how and why effective coverage is or is not delivered and distribute those findings to the entire pediatrician community.¹⁸ Current research methodologies, although they give us a glimpse of the problem, are still imperfect. We have no information about the health status of the millions of children who have no coverage. Researchers could focus more attention on the demographics of unenrolled children and their incidence of health problems. With this information, policy makers could reformulate these programs to increase enrollment.

Third, as advocates for children's health, pediatricians should think about what types of reform would best serve America's children, whether that means improving existing programs or a complete system overhaul. Being well-informed enough about current policy initiatives to advocate for their patients is a part of a physician professionalism. Besides those eligible for federal programs, 2.5 million children lack coverage but don't qualify.¹⁹ Although the number of so-called "gap children" has shrunk significantly since SCHIP was established, there are still many who aren't poor enough to qualify for federal assistance but are too poor to afford private insurance. The current child health coverage system thus shares many of the access and financing problems that characterize US health care delivery in general. Plans have been proposed by policy institutes and Congress to cover all children, regardless of financial status. For example, the "Leave No Child Behind" Act proposed in Congress includes a plan to require parents to provide health insurance to their children either through an employer or "buy-in" to federally funded insurance. The political difficulties in enacting such a program are obvious; similar initiatives have been bandied around Washington for years to no avail. The 2004 elections have already begun drawing attention to improved health coverage, and calls for more extensive coverage are likely to increase. Pediatricians have a role in advising both policy makers and the general public as to what steps are necessary to insure the health and well-being of America's children.