Congress Should Adopt a “Do No Harm to Children” Standard in Changes to Public Health Insurance

In 2015, 21% of children, 15 000 000, were living in poverty (<100% of the federal poverty level).¹ Forty-three percent of children, 31 000 000, were living below 200% of the federal poverty level, which is a better measure of economic hardship for families in the United States. Children are the poorest age group in our society and more than twice as poor as older adults. It is well documented that poor children are more likely to have poor health outcomes, including chronic conditions such as asthma. They are also at greater risk for poor social, emotional, and behavioral problems, including disobedience, impulsivity, and anxiety.² Behavioral and mental health problems are common comorbidities of chronic conditions in children living in poverty.

In this issue of Pediatrics, Pulcini et al³ present the results of their secondary analyses of the National Survey of Children’s Health for the years 2003, 2007, and 2011–12. Their purpose was to identify trends in parent-reported lifetime prevalence and comorbidity among children with asthma, attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorder (ASD). They found that poor and near poor children had a higher lifetime prevalence of asthma and ADHD, but not ASD, as well as higher rising prevalence rates of asthma from 2003 to 2011–12. ADHD rose in all income groups from 2003 to 2011–12, and ASD rose significantly from 2007 to 2011–12 only in the higher income groups. In multivariate regression analyses, poor children had higher than average comorbid conditions in 2011–12 for asthma and ADHD, but not ASD, and children on public health insurance had higher comorbid conditions for all 3 conditions.

Although these results are not surprising, they substantiate the burden of chronic disease in poor children and the importance of access to health care for this vulnerable population. The contrasting findings for asthma and ADHD versus ASD are likely multifactorial but possibly due to community and family factors that influence asthma and ADHD and are more prevalent in poor children, whereas ASD prevalence is not increased by those factors. Even for ASD, however, children on public insurance were burdened with more comorbidities.

These results raise important health policy considerations. More children are covered by health insurance today than ever before. In 2015, 95% of children were covered by health insurance, due primarily to the expansion of public health insurance through Medicaid and the Children’s Health Insurance Program (CHIP).⁴

However, the Affordable Care Act (ACA), although primarily insuring nonelderly adults and young adults (19- to 25-year-olds), did help to drive the increases in child health insurance coverage. Parents were offered sign up to public health insurance for their children when they sought insurance for themselves, and some children received health insurance through the ACA marketplace. An additional 1.7 million children received health insurance during the period that the major provisions of the ACA were implemented.⁴ The major advances in health insurance coverage occurred for poor and near poor children, although they still lag behind those at higher income, primarily due to higher uninsured rates among Latino children.

The association of poverty and chronic disease among children is due to more than just health insurance status. As described in a recent American Academy of Pediatrics (AAP) policy on poverty and child health and an accompanied technical report, family, economic, and community factors are powerful social determinants of health outcomes in poor children.^5,6 Nevertheless, all children, especially children with chronic diseases, require access to quality health care, for which health insurance is a prerequisite.

Forty-two percent of children, and virtually all poor children, are ensured through public plans, primarily Medicaid and CHIP.⁷ This year, Congress is deliberating the fate of public health insurance that is essential for the health of children, such as potential cuts or block-granting of Medicaid to the states and an uncertain reauthorization of CHIP. As described here, dramatic changes to the ACA also have the potential to negatively affect children.

We in the AAP, and pediatricians throughout the country, urge Congress to take a “do no harm to children” standard. Any changes in the ACA must not leave children worse off than they are today; there must be no structural changes to Medicaid; and CHIP must be reauthorized and strengthened. As described in the AAP Blueprint for Children,⁸ anything less will leave the most vulnerable children, who have an increased burden of chronic disease, without access to the essential, comprehensive health services they need to survive and thrive.

• Copyright © 2017 by the American Academy of Pediatrics