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COMMENTARY |
National Association of Children's Hospitals, Alexandria, Virginia
As it approached the end of 2005, Congress debated how to save billions of dollars in federal spending for Medicaid, the federal state program that provides health coverage to low-income and disabled children and adults. Although the mechanisms for these cuts were advanced as "reforms," it was no secret that the driver of these cuts was the federal deficit.
With the deficit mounting and states calling for greater flexibility, Medicaid reform remains squarely on Congress' agenda, aided by a federal Medicaid commission that will make longer-term reform recommendations by the end of 2006.
Children are uniquely vulnerable in any push that makes savings the focus of Medicaid reform. Although children constitute >50% of Medicaid enrollees, they account for only 22% of Medicaid spending, which includes spending for children with disabilities. Reform driven by spending would affect children disproportionately but achieve comparatively little savings.
In 2006 we again will see reforms debated that could either harm children's health care coverage or help provide more children with access to quality health care services that meet their needs.
As pediatricians, we share a common vision that all children deserve access to health care. The reality, however, is that the United States is the only industrialized nation that does not guarantee health coverage to all children, although it makes that promise to its seniors. Medicaid is the closest that we come to providing health coverage to large numbers of children (26 million, or 1 in 4, of our country's children). Medicaid reforms must take into account children's unique health care needs.
For many in Congress, Medicaid is seen largely as a budget issue, not as the largest payer of children's health coverage. For children, it is the financial backbone of the pediatric health care infrastructure because it pays for the health care of 1 in 4 children, nearly 1 in 3 children with special needs, and 1 in 3 infants. It also pays, on average, for nearly one third of the patient care provided by private-practice pediatricians and half of the care provided by children's hospitals.
When Medicaid for children is cut, such as through new cost-sharing or benefit restrictions, it directly affects millions of children, most of whom have working families. Cuts also affect children's providers' ability to serve all children, not just those covered by Medicaid.
Children's hospitals are a perfect illustration of the impact that Medicaid cuts would have on all children. Less than 5% of all hospitals, they deliver 40% of all hospital care for children and the large majority of hospital care for children with serious or chronic conditions. They train the majority of all pediatricians, most pediatric subspecialists, and virtually all pediatric research scientists. They also house our premier pediatric research centers.
Medicaid pays, on average, for half of children's hospitals' patient care and seldom covers even close to the cost of that care. When Medicaid funding is cut, children's hospitals can't close the door to just Medicaid patients. They must limit services to all children, which could result in longer wait times and delay the start of pediatric research, training, or building initiatives.
Ironically, even if there were no budget pressures, there still would be compelling arguments for Congress to undertake real reform of Medicaid for children, provided it addressed the big challenges that children on Medicaid face.
First, real reform would focus on the fact that >70% of uninsured children are currently eligible but not enrolled in Medicaid or the State Children's Health Insurance Program. Real reform would enroll all children who are eligible, which would result finally in nearly every child in the United States having health coverage.
Second, real reform would recognize that Medicaid payment for children's providers is abysmally low in many states. It drives pediatricians to limit their practices or move to more affluent areas, leaving poor children behind. For all that physicians complain about how badly Medicare pays, pediatricians would be thrilled if Medicaid paid Medicare rates for identical services.
Third, real reform would lead to substantial federal leadership and investment in child health quality and performance measurement. Federal investment under Medicare has resulted in significant advances in quality measurement for seniors. There has been no comparable investment in quality measurement for children. Instead, the federal government defers to states and individual children's providers despite the dearth of measures for children's health and the fact that most states and institutions have too few children to develop meaningful quality measures.
Real Medicaid reform for children means better enrollment, increased access to care, and a federal investment in quality improvement for children. Our voices as providers of care to children can send a powerful message to Congress to achieve reforms that children uniquely need.
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FOOTNOTES |
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Address correspondence to David Alexander, MD, FAAP, National Association of Children's Hospitals, 401 Wythe St, Alexandria, VA 22314. E-mail: david.alexander4{at}comcast.net
The author has indicated he has no financial relationships relevant to this article to disclose.
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  J. Jimenez and M. I. Romero Reducing Infant Mortality In Chile: Success In Two Phases Health Aff., March 1, 2007; 26(2): 458 - 465. [Abstract] [Full Text] [PDF]
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