- ACA —
- Affordable Care Act
Critics of the Affordable Care Act (ACA) predicted dire consequences: massive job loss, large decreases in employer-sponsored insurance, and huge increases in health care costs. In fact, none of these predictions has come true, as job growth has increased with unemployment falling,1 employer-sponsored insurance has been stable,2 and the rate of increasing health care costs has moderated.3 Overall, the uninsured rate has declined from 16% in 2010 to 9.1% in 2015,4 and there is evidence that quality of care is improving.5 How have children fared with the implementation of the ACA and what needs to be done in the future with respect to child health policy?
The article entitled “Trends in Access to Health Care Services for US Children, 2004–2014” by Larson et al6 in this issue of Pediatrics addresses both of these questions. Analyzing data from the National Health Interview Survey, the authors documented a steep decline in the percentage of children aged <18 years without insurance, as well as an associated improvement in 5 health care access measures: no well-child care in the past year, no physician office visits, no dental visits, no usual source of care, and having unmet health needs. The uninsured rate declined from 12.1% in 2000 to 5.3% in 2014. This outcome was accompanied by an increase in public coverage (18.9% to 38.9%) and a decrease in private coverage (69.0% to 55.8%). Larson et al also analyzed how race/ethnicity and income affected uninsurance rates and the 5 health care access measures. Poor and near-poor children had steeper declines in uninsurance rates than children who were not poor. A gap in uninsured rates according to income still persists, but it is now considerably smaller between the poor, near-poor, and not poor (5.9%–8.8% to 3.5%). Similarly, Hispanic, black, and other nonwhite children had steeper declines in uninsurance rates than white children. Although the gap in insurance coverage has been eliminated between black, white, and other children, a small but persistent gap still remains for Hispanic children compared with white children (8.2% to 4.0%).
Gaps in the 5 health care access measures also narrowed considerably between Hispanic, black, and other children compared with white children as well as for poor and near-poor children compared with not poor children. These findings provide reassurance that regardless of having a public or private coverage plan, children had improved access to needed medical and dental services.
The findings of this study6 have important implications for future child health care policy decisions. First, all children should have coverage, and strong efforts must be made to reach the 5.3% who remain uninsured. These efforts should target the near-poor and Hispanic families because the gap is greatest for these populations. Second, the reauthorization and continued funding of the Children’s Health Insurance Plan, due to terminate in 2019, is essential and should be addressed sooner rather than later. The large shift from private to public coverage for children reported in the study, as well as the finding that near-poor children are more likely to be uninsured than poor children, suggests that the “family glitch” is a serious flaw in the ACA. The family glitch is a result of language specifying that the eligibility determination for subsidies is based on the cost of individual-only coverage and does not take into consideration the higher cost of a family plan. This finding means that some low-to-moderate-income families may be locked out of receiving federal financial assistance to purchase health coverage through the health insurance exchanges. Without access to a federal subsidy, the only affordable coverage for a family’s children may be the Children’s Health Insurance Plan. Therefore, the Children’s Health Insurance Plan, which currently has >6 million children enrolled, must be reauthorized because it plays an important fail-safe role in ameliorating the negative impact of the family glitch. Third, exchange plans must become more affordable to near-poor and middle-class families. One way to help would be to fix the family glitch and make more families eligible for subsidies. However, fixing the family glitch is not enough as premium costs and out-of-pocket expenses for family coverage in the exchanges are too high with existing subsidy levels.
Although this study6 focuses our attention on health care access measures, advocates and policy makers need to address having meaningful health outcomes. To reach this goal, we need to have a national child health policy with a population health focus. Because health care only contributes 10% to 20% to maximizing population health,7,8 a new child health policy should focus on addressing the social determinants of health and the reduction of behaviors that compromise health (smoking, excessive alcohol intake, substance abuse, and poor nutrition). Because education creates opportunity (better jobs, higher incomes, and skills needed for upward social mobility), it is a powerful social determinant for health. Income and racial/ethnic gaps in education must be narrowed. To be successful, we need to fund programs that encourage “responsive parenting” (talking, reading, playing, and praise) to better prepare young children to enter preschool and kindergarten and commit to helping every child learn in school. Community initiatives are also needed to reduce adverse childhood experiences. Our child health policy should stimulate community partnerships with hospitals, health plans/accountable care organizations, academic institutions, foundations, social service agencies, juvenile justice systems, schools, behavioral health organizations, urban planners, and the business community. We need a new vision and national commitment to the health of our children that goes beyond improving access to care.
- Accepted September 19, 2016.
- Address correspondence to Stephen Berman, MD, FAAP, 13199 E Montview Blvd, Suite 310, A090, Aurora, CO 80045. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2016-2176.
- ↵United States Department of Labor, Bureau of Labor Statistics. Databases, tables & calculators by subject. Available at: www.bls.gov/data/#employment. Accessed August 16, 2016
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- Copyright © 2016 by the American Academy of Pediatrics