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Problem of Uninsured Children Gets Renewed Interest

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Efforts to provide health care for uninsured children have assumed a prominent profile at both the federal and state level.

Last month, the issue was put into the spotlight when President Bush, in his State of the Union Address, said Secretary of Health and Human Services Louis W. Sullivan would head a Cabinet-level study on the status of health care nationally.

One of the areas to be included in the study is how to best address the insurance needs of the estimated 31 to 37 million Americans who lack any form of health coverage, one-third of whom are children.

The issue is also being studied by the U.S. Bipartisan Commission on Comprehensive Health Care, which is made up primarily of members of the Congress. Its recommendations for health-insurance reform, to be announced by March 1, are expected to generate federal legislation.

The renewed interest in providing health care to poor children has been largely fueled by economics, experts said last week. National health costs are expected to exceed $600 billion this year, or almost 12 percent of the gross national product.

Far too much of this money, they said, will be spent on financing emergency-room visits and hospital stays for common childhood conditions, such as ear infections and asthma attacks, which could have been treated more cheaply if detected during a routine medical appointment.

While children from the nation's poorest families receive medical care under the federal Medicaid program, millions more from "working poor" families lack any form of health coverage.

Many employers, reacting to skyrocketing premiums, have either eliminated their health plans or modified them to exclude their workers' dependents. But lower-income families can rarely afford to purchase insurance on their own, health-policy experts said.

"Despite the rise in health-care costs, the [national] health indicators are poor," said Aileen Whitfill, a senior health specialist with the Children's Defense Fund. "We know that the system is no longer working adequately for children."

Medicaid Expansion

Although there is a growing sentiment that more children must have access to health care, and especially to preventative services, there has been no agreement on how this should be paid for, health experts said last week.

Many said the best short-term solution is to continue to expand the Medicaid program to include more children from higher family-income levels. The federal government pays for at least half of the cost of the Medicaid program, with the states responsible for the rest.

States have traditionally been allowed to set their own eligibility levels for Medicaid recipients, which are often well below the federal poverty line: $12,100 for a family of four.

Last year, however, the Congress amended the program to require states to provide benefits to all pregnant women, infants, and children up to the age of 6 whose family income is less than 133 percent of the federal poverty rate, about $16,000 for a family of four. About one million children are expected to benefit from this change.

States also have the option of covering pregnant women and infants whose family income is up to 185 percent of the federal poverty level, about $22,000 for a four-member family.

Health-care advocates said they expect the Congress this year to consider measures to expand the program to include older children, and to include children and pregnant women from families with higher incomes.

Under Medicaid, a child is entitled to receive a full range of health services, including hearing aids and eye glasses, free of charge. Despite these benefits, many health-care experts said they believe the program is not as effective as it could be. Potentially eligible children are often not enrolled in the program because the application process is too complex for many families to complete, observers said.

Doctors and hospitals have also claimed that they receive inadequate reimbursement rates from the state for treating Medicaid patients, forcing them to limit the number they serve.

"We clearly do not view Medicaid as the model for health-care delivery to children and pregnant women, but it's an interim measure," said Elizabeth J. Noyes, director of government liaison for the American Academy of Pediatrics.

This fall, the AAP unveiled its own draft plan for providing health insurance for poor children and pregnant women. Under the plan, health care would be covered by a state fund that would be financed, in part, by a tax on employers who do not provide insurance for their workers. (See Education Week, Nov. 8, 1989.)

As part of the Medicaid bill last fall, the Congress also authorized, but did not appropriate, $5 million for demonstration projects to provide insurance for "medically uninsurable children." The law specified that this could include school-based insurance plans.

One such plan is being developed by Institute for Child Health Policy at the University of Florida. Organizers of the program, which is being funded by HHS and the Robert Wood Johnson Foundation, hope to offer a districtwide school-enrollment-based insurance plan by September 1991.

State Initiatives

Meanwhile, a growing number of states have either enacted or are considering adopting plans that would help the children of the working poor:

In Minnesota, children up to the age of 8 who come from families that earn up to 185 percent of the federal poverty level, can receive a full range of preventive health services for $25 a year. The two-year-old program, which does not cover in-patient hospital fees, will include children up to age 18 as of July 1, 1991. (See Education Week, Dec. 14, 1988.)

Since July, pregnant women in households that earn up to 200 percent of the poverty level, and children from families with incomes up to 225 percent of the poverty level can qualify for Vermont's prenatal and children's health program. Participants receive the same services as Medicaid recipients. The state estimates that half of the 3,700 eligible children will use it.

Beginning this July in Maine, children up to age 18 from families with incomes up to 125 percent of the poverty line will receive Medicaid services. Families with incomes above the poverty level will have to pay a portion of the premium. Officials estimate that about 5,750 children will participate in the first year.

The Governors of both Michigan and New York used their state-of-the-state addresses this year to launch a campaign to provide health care for poor children. Under the Michigan program, which must be approved by the legislature, Medicaid benefits would be extended to children up to the age of 10 who come from families that have incomes up to 200 percent of the poverty level.

According to a detailed draft proposal released by New York officials last week, the state would help provide health insurance to every uninsured child through age 17. Participation would be on a sliding-fee basis. Families with net incomes below 130 percent of the poverty line would have their insurance premiums paid in full by the state, while those above 185 percent would be able to purchase it at a premium cost. The program, which would cost the state $10 million, must be passed by the legislature.

Iowa lawmakers last year earmarked $300,000 to pay for preventative services offered free of charge to uninsured poor children through the Caring Program for Children, a public-private partnership administered by the local Blue Cross and Blue Shield organizations.

The program, which is modeled after a Caring Program started by Blue Cross of Western Pennsylvania and Pennsylvania Blue Shield in 1985, covers most medical services except in-patient hospital fees. The program, now in 10 states, requires private donations to cover the child's medical costs. Doctors also accept lower reimbursement rates. Iowa is the only state to contribute to the program so far.

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