Insuring Children's Health Care: A Call for Papers

Letter From the Editor Insuring Children’s Health Care: A Call for Papers Insurance plays a critical role in helping children and youth access needed and appropriate health services. Most health insurance for children arises from their parents’ workplace, where employee benefits include dependent health insurance. Nonetheless, large numbers of children in the United States lack access to employer-based health insurance, and public programs—especially Medicaid and the State Children’s Health Insurance Program (SCHIP)—fill the gap and provide coverage to very large numbers of American children. Both public and private coverage face potential major changes in the next few years. Having health insurance improves children’s access to health care. Children without health insurance have decreased immunizations and other preventive services, fewer visits for children with chronic conditions,1,2 higher rates of morbidity as newborns, and less treatment for otitis media and other acute illnesses.3 Parents of children with chronic conditions who have health insurance typically report fewer unmet health care needs and better access to ongoing primary and subspecialty care. Recent work from the Institute of Medicine4 documents the importance of health care insurance for the population in general, with some new information arising regarding the impact of parental uninsurance on child and adolescent health.5 And other work has documented that many children have intermittent coverage, with lapses associated with poorer care.6 Most reports comparing children who have private insurance with those who have public insurance also indicate that they have comparable rates of these indicators, with uninsured children having less good care.7 Given the higher burden of chronic health conditions among children and youth with public insurance, an unanswered question is whether publicly insured children with chronic conditions have enough access to care—that is, whether having similar rates of use as those with private insurance adequately covers the need of children with chronic conditions for more services. Recent studies provide conflicting findings: Some studies indicate major differences when Medicaid beneficiaries are compared with those with private insurance, whereas other studies do not indicate such differences.8,9 Many employers see major advantages in providing employees benefits that enhance worker morale and productivity—including dependent health care coverage—although coverage varies greatly across employers.10 Nonetheless, the growing cost of health care has led to major cutbacks in coverage for many employees and their dependents11—and erosion in the private health insurance market accounts for most of the increase in uninsurance among children and youth in the United States (from about 74% in 1989 to 66% in 1995). At least 2 important trends in health insurance may have particular relevance to children and adolescents. First, among employers who have continued coverage for employees, there is increasing interest in improving the quality of care received. Recent attention has focused on ‘‘pay for performance’’ strategies, which provide financial incentives for clinicians and health care systems to meet certain standards of care. Much of this interest has come from several Institute of Medicine studies that have noted gaps in the quality of care and recommended financial incentives to enhance quality.12 How extensive this movement will become and what focus it will have on children’s health care remains open for debate (and study).13,14 Another concept attracting much attention is consumer-driven health care.15 Many analysts assume that the lack of awareness of consumers of the costs of the care they receive—and their limited participation in direct payment for this care—has fueled excessive growth in costs. They view giving more control of health care expenditures directly to consumers as a means of limiting growth. Consumer-driven health care could greatly limit children’s access to needed services by providing incentives to limit, for example, preventive care. Financially strapped young families could potentially choose to limit health care expenditures for their children to acute illness or catastrophic needs. Again, the specifics of consumer-driven health care have received little attention, and studies of such care and implications and opportunities in child health will help raise the level of the debate. Related efforts to provide employment-based coverage through small employers (Association Health Plans) could face similar issues, without the assurance of coverage of preventive services. SCHIP came with much fanfare as a method for covering large numbers of children who were not eligible for Medicaid and whose parents did not receive employment-based dependent health care coverage. Indeed, it has insured large numbers of children and youth in the United States while also documenting major gaps in the enrollment of children eligible for Medicaid in that program. Ambulatory Pediatrics has published a number of important articles about SCHIP and other studies of public insurance.16,17 With growing information about this program and with its renewal up for public consideration, we look forward to more studies that document how this program works and ways AMBULATORY PEDIATRICS Copyright q 2005 by Ambulatory Pediatric Association

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Volume 5, Number 4 July–August 2005

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Letter From the Editor

AMBULATORY PEDIATRICS

to improve its operations and coverage. Medicaid has also received much attention in recent months, with discussions of various ways to curb the continuing speedy rise in Medicaid expenditures. We plan a special section on insuring children’s health tentatively scheduled for the November–December 2006 issue of the journal. For this issue, manuscripts will be due in the editorial office by February 1, 2006. We have particular interest in manuscripts that provide insight into public health insurance for children and potential changes or enhancements to public insurance, newer ideas regarding incentives in private health insurance for improved quality or consumer involvement in health care, specialized benefits for children with and without chronic conditions, and alternative mechanisms to improve children’s access to health care. Comparative studies providing insight from other industrialized countries are also encouraged. James M. Perrin, MD Editor in Chief REFERENCES 1. Huang ZJ, Kogan MD, Yu SM, Strickland B. Delayed or forgone care among children with special health care needs: An analysis of the 2001 National Survey of Children With Special Health Care Needs. Ambul Pediatr. 2005;5:60–67. 2. Dusing SC, Skinner AC, Mayer ML. Unmet need for therapy services, assistive devices, and related services: data from the National Survey of Children With Special Health Care Needs. Ambul Pediatr. 2004;4:448–454. 3. Institute of Medicine. America’s Children: Health Insurance and Access to Care. Washington, DC: National Academy Press; 1998. 4. Institute of Medicine. Insuring America’s Health: Principles and Recommendations. Washington, DC: National Academies Press; 2004. 5. Fairbrother G. Commentary on IOM report: health insurance is a family matter. Ambul Pediatr. 2003;3:66–67. 6. Aiken KD, Freed GL, Davis MM. When insurance status is not static: insurance transitions of low-income children and implications for health and health care. Ambul Pediatr. 2004;4:237–243. 7. Simpson L, Owens PL, Zodet MW, et al. Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by income. Ambul Pediatr. 2005;5:6–44. 8. Newacheck PW, Lieu T, Kalkbrenner AE, et al. A comparison of health care experiences for Medicaid and commercially enrolled children in a large, nonprofit health maintenance organization. Ambul Pediatr. 2001;1:28–35. 9. Cabana M, Bruckman D, Rushton JL, et al. Receipt of asthma subspecialty care by children in a managed care organization. Ambul Pediatr. 2002;2:456–461. 10. Rolett A, Parker JD, Heck KE, Makuc DM. Parental employment, family structure, and child’s health insurance. Ambul Pediatr. 2001; 1:306–313. 11. Gabel J, Claxton G, Gil I, et al. Health benefits in 2004: four years of double-digit premium increases take their toll on coverage. Health Aff. 2004;23:200–209. 12. Institute of Medicine. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Corrigan JM, Eden J, Smith BM, eds. Washington DC: National Academy Press; 2002. 13. McInerny TK, Meurer JR, Lannon C. Incorporating quality improvement into pediatric practice management. Pediatrics. 2003;112:1163– 1165. 14. Berman S. Challenge of transforming our private and public pediatric health care systems to emphasize value. Pediatrics. 2005;115: 1068–1070. 15. Sturm MG. Can the rise of consumerism control increasing healthcare costs? Milliman Benefits Perspectives. Winter 2003–2004:4–8. Available at: http://www.milliman.com/pubs/Wint0304pfin.pdf. Accessed June 20, 2005. 16. Kempe A, Renfrew BL, Barrow J, et al. Barriers to enrollment in a state child health insurance program. Ambul Pediatr. 2001;1:169– 177. 17. Kempe A, Beaty BL, Crane LA, et al. Disenrollment from a state child health insurance plan: are families jumping S(c)HIP? Ambul Pediatr. 2004;4:154–161.