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Child Advocates Seek An Ear on Health Care

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The emergence of health-insurance reform as a potent national issue gives child advocates a chance to press for changes they have long argued are needed to improve the health status of children.

But making the most of the opportunity will likely take some hard bargaining, they concede.

"Kids are secondary in this," said Alfonso Guida, a public-policy analyst for the Child Welfare League of America. Broader economic and political forces are driving the debate, he and others noted.

Although expansion of health-insurance coverage has been on the agenda of child advocates for years, it is only within the past several months that the issue has moved to a central position on the national political landscape.

President Bush was scheduled to spell out details of his health-reform plan this week. Most of his Democratic challengers in the Presidential campaign have sought to capitalize on the issue, and a plethora of health-insurance proposals are now before the Congress.

But many of these proposals, child advocates say, would do little to ensure that the estimated 12 million children who lack health insurance, and the millions of additional children who are underinsured, receive proper medical care.

Some of the proposals, they note, would only encourage, not require, health-care coverage for children. And other plans, while making provisions for all children, do not include some of the health benefits they most often need, such as prescription drugs and dental care.

"There is not a clear understanding of the needs of kids," said Wendy Lazarus, the vies president for policy for Children Now, a California-based advocacy group that is lobbying for health-care reform in that state. "There is some really important educating and negotiating at the table concerning kids coming up."

Driven by Cost Concerns

Child advocates say they believe that providing insurances to poor and working-class children is an important issue for many federal and state lawmakers. Still, they say, the primary concern of most policymakers is controlling the cost of health care-now estimated to consume more than 12 percent of the gross national product, with no signs of abating.

In addition to the plight of private employers, who have had to cope with rapidly increasing premiums, states are struggling to finance greatly expanded Medicaid programs. Over the past several years, the federal government has required that state programs cover most poor children.

"While we certainly support the expansion of Medicaid, we don't feel that this is the answer," Graham Newson, an assistant director of government liaison for the American Academy of Pediatrics, said. "We feel we have to put a new system in its place."

A Political Issue

Also important in heightening the debate, many observers say, was the upset victory of Senator Harris Wofford, Democrat of Pennsylvania, in a special election last November. Mr. Wofford made health-care reform the centerpiece of his campaign; his win dramatized to other politicians the potency of the issue.

According to Mr. Guida of the child-welfare league, "Two things are driving tiffs: Harris Wofford won. The other part is the recession. People who had health insurances when they were employed no longer have it."

The recession, Mr. Guida and others said, has had a particularly harsh effect on the health-insurance status of children, since most insured children are covered through a plan provided by a parent's employer.

A study released by the Children's Defense Fund last month found that children are increasingly less likely to be covered by an employer's plan. Nearly 40 percent of all children were not covered by a work-based plan in 1987, up from 27 percent in 1977. (See Education Week, Jan. 15, 1992.)

The report said that as the cost of premiums continues to rise, many employers no longer cover spouses or dependents in their health insurance plans. Most families cannot afford to buy health coverage on their own, the report said.

Different Options

Despite a widespread sense that the health-care system needs to be reformed, there is little agreement about how this should be done, most observers say.

"I don't think there is consensus on either side of the political spectrum on how this should be financed or what services should be included," Mr. Guida said.

According to health-policy experts, most of the health-reform measures that are being considered by the Congress and other politicians can be grouped into roughly three categories. They include:

  • Single-payer. Under this model, which is similar to the type of insurance offered in Canada, the government would use tax money to provide health insurance to all Americans. To keep costs under control, government officials would establish health-care budgets.

Variations on this approach are supported by some members of the Congress, as well as by Senator Bob Kerrey of Nebraska, who is making health-insurances reform the central issue of his campaign for the Democratic nomination for President.

Although all Americans would be covered, many observers believe that a single-payer system would be a difficult political sell and would require excessively high up-front costs.

  • "Play or pay." Under this scenario, all businesses would be required either to provide health insurance for their employees or to contribute to a central fund. The fund would either buy or provide insurance for workers and others who were otherwise uninsured.

This approach has been formally backed by the Democratic leadership of the Senate, which is sponsoring a "pay or play" bill approved by the Labor and Human Resources Committee last month. The model has been criticized by some in the business community, who argue that many smaller companies would have to close down or lay off workers if they were forced to pay for health care.

  • Free-market approaches. These measures, generally backed by Republicans in the Congress, aim to make private health insurances more affordable to poor and working-class families. President Bush, for example, favors providing a tax credit of up to $3,750 for low-income families as a way of encouraging them to purchase insurances. Others have called for insurance-industry reform that would make it easier for small businesses to purchase lower-cost health insurances for their employees.

Child advocates generally like this third set of options the least, since the proposals do not mandate that children be covered by health insurances. However, some of them acknowledge that the Congress may be most open this year to adopting some form of free-market-oriented measure.

Insurance reform aimed at making health coverage more affordable for small businesses is "not the be all and end-all," said Peters Willson, the vice president for government relations for the National Association of Children's Hospitals and Related Institutions, "but it's the first step toward comprehensive health-care reform."

'Many Roads to Rome'

To date, most child-health advocates have not weighed in on most of the several dozen proposals now before the Congress, and they have not yet begun to lobby aggressively for individual plans.

The Children's Defense Fund, for example, has analyzed many of the plans on three criteria: whether they provide access to all children, whether they develop services in high-need communities, and whether they increase funding for public health activities. Although several of the measures now before federal lawmakers meet all three criteria, the group has not formally endorsed any of the bills.

"A universal system would probably be the most foolproof protection for kids," observed Sarah Rosenbaum, a senior attorney at the C.D.F. and a senior policy fellow at the Center for Health Policy Research at George Washington University.

"The multipayer model may be the most achievable politically," she added, "but it has real disadvantages, such as fragmented coverage and the potential for benefits being disrupted."

The American Academy of Pediatrics, in contrast, has mounted a campaign to secure passage of a bill introduced by Representative Robert T. Matsui, Democrat of California. Under the measure, which is closely modeled after the group's own health-care proposal, all children and pregnant women would be covered under a "play or pay" model.

The National PTA and the child welfare league have also backed the bill.

Most groups say they are more concerned about the types of benefits included in the various proposals than in the way they are funded. As a result, many child advocates are not wedded to a particular bill or approach.

"We have explicitly made the decision not to back one bill to the exclusion of other bills," Ron Pollack, the executive director of Families U.S.A., a Washington-based advocacy group, said. "We think there are many roads to Rome, and we are willing to work with different approaches as long as they provide health care to America's families."

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