CHILDREN’S HEALTH: NEJM Study Underlines Need
President Clinton's efforts to expand Medicaid to cover more of the nation's uninsured children came on "the same day that a key study was released showing that children without health insurance frequently go without proper medical care," USA Today reports (Findlay, 2/19). Published in today's New England Journal of Medicine, the University of California-San Francisco study looked at data on more than 49,000 children "under 18 years of age from the 1993-1994 National Health Interview Survey." The study found that 13% of the nation's children were uninsured in 1993-1994 and these children were less likely than insured children to have a "usual source of care" (75.9% compared with 96.2%). Insured status also affected "needed medical, dental or other health care"; only 6.1% of insured children went without such care compared to 22.2% of uninsured children. Even when all factors "such as family income and children's health status" were taken into consideration and controlled, the study found the "effect of insurance remained substantial and statistically significant." The authors, led by Dr. Paul Newacheck of UCSF, conclude: "Simply put, health insurance is a powerful predictor of children's degree of access to and use of primary care."
Watching The States
The authors call for close monitoring of how states implement the federal Kiddiecare, or Children's Health Insurance Program (CHIP). "[T]he specific steps taken by states in implementing the new programs will need to be vigilantly monitored in order to assess the breadth and depth of the expansion in children's health insurance coverage. More important, beyond raw numbers of children for whom coverage is provided, the effects of the new programs under this initiative will need to be monitored closely. Ideally, such a monitoring program should include ongoing measurement of indicators of processes and outcomes such as population-based measures of children's access to care and their health status. Only in this way will our nation be able to realize the return on this important new investment," the authors conclude (Newacheck et al, 2/19 issue).
The Incremental Model
An accompanying editorial in today's New England Journal of Medicine concludes that, while states should seize federal Kiddiecare dollars to expand access to children, such efforts will not "eliminate the inequities in access to care among children." The editorial notes that there are 11 million uninsured children in the U.S., but the new federal law will expand coverage to "only some 3.4 million children, of whom 1.4 million would have had private coverage without the new legislation, and that only 55% of eligible children will be enrolled." The editorial's author, Peter Budetti of Northwestern University's Institute for Health Services Research and Policy Studies, notes that the Kiddiecare statute "attempts to ensure new health insurance coverage for a 'clean increment' of uninsured, low-income children. But its implementation is likely to illustrate the complexity and costs of pursuing such an outreach." He concludes, "[I]t remains to be seen whether [Kiddiecare] is an important incremental reform, or whether it is another example of legislation that has high visibility and perhaps brief political value but, like the Kassebaum-Kennedy legislation of one year earlier, has little practical value for many of the vast and growing number of persons without health insurance" (2/19 issue).