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COMMENTARY |
Abbreviations: SCHIP, State Children’s Health Insurance Program
Pediatric health services research has documented that uninsured children are less likely to receive needed medical, mental health, and dental services and are more likely to experience adverse health outcomes.1 Uninsured children can be defined in 1 of the following 3 ways: 1) lacking insurance during a specified period of time, usually the most recent calendar year or past 12 months; 2) lacking insurance at any time during a specified period of time; or 3) lacking insurance at the specific point in time when a survey is done. During the first 3 years of life about one quarter of our nation’s children have at least 1 month when they are uninsured and over one half of these children remain uninsured for >6 months.2
The rate of uninsured children is constantly changing with the state of the economy, increases in employer insurance premiums, and changes in access to public insurance programs. Current economic conditions suggest that the number of uninsured children is rising from 
8.5 million reported from 1998 to 2000 to perhaps more than the 11 million reported for 1997.3 However, there is a great deal of confusion associated with estimating the number of uninsured children because of differences among surveys with respect to when and how often they are administered, numbers of survey respondents and their geographic distribution, insurance definitions, age classifications, and other measurement issues.4
Using the 1999 National Survey of America’s Families survey, the Urban Institute estimated that among the country’s 72 million children, 51.2% were eligible for a publicly financed health plan, 33.4% were eligible for Medicaid, and 17.8% were eligible for the State Children’s Health Insurance Program (SCHIP).5 During this time period only 20.4% of children were enrolled in Medicaid and SCHIP based on Current Population Survey survey data. This means that only 39.8% of the children eligible for these public programs were enrolled. As a result, at a given point in time three fourths of our uninsured children are eligible for Medicaid or SCHIP. It appears that <4% of children who remain uninsured for most of the year are ineligible for Medicaid or SCHIP.5
The passage of new state and or federal child health legislation to reduce the number of uninsured children requires a comprehensive understanding of the number of uninsured children, the reasons these children remain uninsured, and the consequences and costs of the available child health policy options.
Why are we having so much difficulty enrolling children eligible for these programs? In 1999, Kempe and colleagues6 surveyed a random sample of families with uninsured children as well as families who requested a SCHIP application but did not complete it. Among families with uninsured children, only 41.7% had heard of the SCHIP. The most common reasons for not completing the application among families requesting an application were thinking that their income was too high despite evidence that over half of the these families would have qualified, complicated paperwork, and having obtained other insurance. In this issue of Pediatrics, Kempe and her colleagues publish a study comparing the health status, health care service utilization, and sociodemographic characteristics of children who have enrolled in the Colorado title XXI SCHIP with children who were likely eligible but remained uninsured (see page XXX).7 This information has important child health policy implications. The findings profile a "hard to reach population" that is more likely to be Hispanic, more likely to be uninsured for a longer time, and more likely to be considered to have fair or poor health and/or have behavioral problems. Not surprisingly the "hard to reach" uninsured population was less likely to have a usual source of preventive care. The children easiest to enroll in the Colorado SCHIP were more recently insured, more often had a usual source of primary care, and were more often non-Hispanic. These findings suggest that we are failing to enroll those children who have the greatest need for these programs. These findings are similar to the experience from the state of Washington where eligible adults failing to enroll in Basic Health Plan were generally less well-off, with less education, lower income, worse health, and less likely to have had prior health insurance.8 An analysis of the national Survey of America’s Families found that while one third of low-income uninsured families were not aware of Medicaid and SCHIP and another 10% were unwilling or unable to overcome administrative hassles, 22% of families with uninsured children did not want health insurance from public programs.9
These findings suggest that the goal of health care coverage and a medical home for every child is not possible if our system is voluntary within the existing health care structure. The Robert Wood Johnson Foundation’s "Covering Kids" initiative has spent many hundreds of millions of dollars on marketing and enrollment of SCHIP and Medicaid throughout the country. In Colorado, despite reducing Colorado SCHIP premiums to $25 per year, adding dental benefits, having an aggressive "Covering Kids" SCHIP and Medicaid marketing campaign, and implementing a single streamlined application process for Medicaid and SCHIP, almost two thirds of the state’s 150 000 uninsured children remain eligible but are not enrolled in these public programs.
Is our current voluntary approach fundamentally flawed? Because 96% of uninsured children are now eligible for Medicaid or SCHIP coverage, there appears to be a public policy consensus that all children should be enrolled in a public or private health plan that provides high-quality, needed services. What can be done to ensure that we reach this goal using the existing public and private child health care systems? If we look at our experiences with preventing childhood ingestions, improving vaccination rates, decreasing the frequency of uninsured motorists, and operating the Social Security system, I believe we can find the appropriate answers to this question. Requiring that potentially harmful medications and household chemicals be stored in containers with child-proof tops is by far the most effective way to reduce the frequency of childhood ingestions. Requiring that children be fully immunized before entering school while making vaccine available to uninsured and underinsured children has been an effective way to ensure that almost all children are vaccinated. Requiring proof of automobile insurance when registering a car or being stopped for a traffic violation is an effective way to ensure that almost all motorists carry insurance. Requiring employers to deduct Social Security payments from the employee salary and pay the federal government has maintained our Social Security system for the public good of our society. All of these requirements or mandates are in the public interest and promote the public good of our society. Promoting and maintaining the development and health of our children is also in the public interest and public good. If we are not prepared to restructure and finance a new health care system for our children, then an approach that deserves consideration is to introduce new mandates into the existing system, mandates on parents to enroll their kids in health plans, mandates on insurers and health plans to provide high-quality needed services, and mandates on employers for employee payroll deductions when employee children are enrolled in public plans. Personally, I suggest we consider the following 10-point approach:
Our post 9/11 experience has shown when there is the national will to address an important problem; there is a way to get it done. How long can our uninsured children wait for the national will to address their problem?
Department of Pediatrics
Children’s Hospital
University of Colorado School of Medicine
Denver, CO 80218
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FOOTNOTES
Received for publication Oct 17, 2002; Accepted Oct 17, 2002.
Address correspondence to Stephen Berman, MD, Children’s Hospital, 1056 E 19th Ave, B032, Denver, CO 80218. E-mail: berman.stephen{at}tchden.org
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  S. G. Federico, J. F. Steiner, B. Beaty, L. Crane, and A. Kempe Disruptions in Insurance Coverage: Patterns and Relationship to Health Care Access, Unmet Need, and Utilization Before Enrollment in the State Children's Health Insurance Program Pediatrics, October 1, 2007; 120(4): e1009 - e1016. [Abstract] [Full Text] [PDF]
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 S. E. Rushing and M. Genel Our Porous Safety Net for Children Arch Pediatr Adolesc Med, November 1, 2005; 159(11): 1080 - 1081. [Full Text] [PDF]
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A. Kempe, B. L. Beaty, L. A. Crane, J. Stokstad, J. Barrow, S. Belman, and J. F. Steiner Changes in Access, Utilization, and Quality of Care After Enrollment Into a State Child Health Insurance Plan Pediatrics, February 1, 2005; 115(2): 364 - 371. [Abstract] [Full Text] [PDF]
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